Datasets:

dmacres

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mimiciii-hospitalcourse-meta

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[ { "category": "ECG", "chartdate": "2176-03-01 00:00:00.000", "description": "Report", "row_id": 220342, "text": "Sinus tachycardia, rate 129. Low voltage in the standard leads. Compared to the\nprevious tracing of sinus bradycardia has given way to sinus\ntachycardia and ventricular ectopy is no longer evident.\n\n" }, { "category": "Radiology", "chartdate": "2176-02-26 00:00:00.000", "description": "O L-SPINE (AP & LAT) IN O.R.", "row_id": 1122473, "text": " 8:53 AM\n L-SPINE (AP & LAT) IN O.R. Clip # \n Reason: ANT FUSION T10-L4\n Admitting Diagnosis: SCOLIOSIS/SDA\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Anterior fusion T10-L4.\n\n Single AP portable view of the lumbar spine obtained in the OR. The lower\n thoracic and much of the lumbar spine are included. Surgical instrumentation\n and materials overlie the spine. Laminectomy and fusion seen in the lower\n lumbar spine. Correlation with real-time findings is recommended for further\n assessment.\n\n" }, { "category": "Radiology", "chartdate": "2176-02-29 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1123030, "text": " 10:31 AM\n CHEST (PA & LAT) Clip # \n Reason: r/o pneumothorax\n Admitting Diagnosis: SCOLIOSIS/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old woman with chest tube removal\n REASON FOR THIS EXAMINATION:\n r/o pneumothorax\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Evaluation of the patient after chest tube removal.\n\n Portable AP chest radiograph was compared to prior study obtained on .\n\n The current study demonstrates thoracic spine orthopedic hardware.\n Cardiomediastinal silhouette is stable. There is questionable minimal lucency\n at the left lung base that might represent small pneumothorax or small amount\n of intraperitoneal air and should be closely followed on repeated radiograph.\n The left basal opacity is most likely consistent with atelectasis. Small\n right pleural effusion and right basal atelectasis are present.\n\n" }, { "category": "Radiology", "chartdate": "2176-02-27 00:00:00.000", "description": "O L-SPINE (AP & LAT) IN O.R.", "row_id": 1122703, "text": " 11:46 AM\n L-SPINE (AP & LAT) IN O.R. Clip # \n Reason: T2-L5 POST FUSION, SCOLIOSIS\n Admitting Diagnosis: SCOLIOSIS/SDA\n ______________________________________________________________________________\n FINAL REPORT\n\n STUDY: Lumbar spine intraoperative study, .\n\n HISTORY: Patient anticipating spinal fusion.\n\n FINDINGS: Comparison is made to prior study from .\n\n Seven intraoperative radiographs of the spine demonstrates placement of\n multiple pedicle screws as well as left-sided spinal rod spanning from\n approximately T3 down to L5. Intervertebral disc spacer at L4-L5 is\n visualized. Please refer to the operative note for additional details.\n\n\n\n\n\n\n" } ]

[ { "category": "Respiratory ", "chartdate": "2157-01-01 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 361436, "text": "Pt received orally intubated and vented on PSV. Pt placed on SBT,\n passed\n" }, { "category": "Nursing", "chartdate": "2157-01-01 00:00:00.000", "description": "Nursing Progress Note", "row_id": 361415, "text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n Pain control (acute pain, chronic pain)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Respiratory ", "chartdate": "2157-01-01 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 361439, "text": "Pt received orally intubated and vented on PSV. Pt placed on SBT,\n passed SBT. Pt the extubated, good cuff leak heard prior to extubation.\n Lung sounds clear with diminished bases. Pt with a strong congested\n cough.\n" }, { "category": "Nursing", "chartdate": "2157-01-01 00:00:00.000", "description": "Nursing Progress Note", "row_id": 361385, "text": "This is a 76 yr old male who presented to the EW with one week history\n of malaise and lower back pain. Room air sat found to be 90% on room\n air. Reports taking oxycodone for back pain. Became agitated\n pulling out IV\ns and pulling off 02 .Was given .5 mg of iv ativan and\n had a ct scan of chest . Upon return, he rapidly decompensated and\n required intubation.\n PMHX\n Sarcoidosis on chronic prednisone\n GERD\n Afib ( on coumadin)\n CVA resulting in memory difficulties and dysphagia\n Hx of falls\n Lumbar surgery\n HTN\n Allergies PCN\n Received patient on 40 mcgs of propofol ..Unresponsive to sternal rub\n ..not following commands .. Localizing to IV sticks ..Pupils 2 mm and\n briskly responsive to light\nAbsent gag. Propofol weaned to 10 mcgs at\n 0600\n Vent settings 450/40%/18/5 peep..lungs diminished at the bases\n secretions via ett\nABG 7.42/42/81/2/28\n GI abd distended with hypoactive bowel sounds ..No output via OGT. No\n stool\n ID afebrile Bld/Urine cultures obtained. MRSA swab pndg.\n Placed on pressure support at 0700. Patient moving all extremities\n ..sitting up in bed. MRI pndg rounds ..MRI checklist.\n Need Flu culture\n Anticipate extubation when more awake\n Placed on Droplet precautions at 0700\n" }, { "category": "Nursing", "chartdate": "2157-01-01 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 361486, "text": "This is a 76 yr old male who presented to EW for Senior Life\n with a one week history of malaise and increased lower back pain. In\n the EW, room air sat found to be 90%. Patient reports to have taken ~~\n 10 percocets twenty four hours PTA\n ( serum/urine tox screen negative ) Became acutely agitated in the\n EW..pulling out IV\ns/off 02 and was given .5 mg of iv Ativan and had a\n head ct. Upon return to the EW bay, he had resp decompensation and\n required intubation.\n PMHX\n Sarcoidosis on chronic prednisone\n GERD\n Afib ( on coumadin)\n CVA resulting in memory difficulties and dysphagia\n HX of falls\n Lumbar surgery\n Right hip pain from recent fall\n HTN\n Allergy PCN\n Propofol was weaned at 0600 ..Patient more awake ..extubated at\n 0900\n.Head ct negative. Ruled out for flu. MRSA swab pndg. Urine and\n bld cultures pndg. MRI of chest /torso ruled out structural problem.\n Family concerned that patient has been increasing his dose of\n oxycodone for back pain. He is followed at the Pain clinic ( On\n lyrica 150 mg qam/ 225 mg q pm ) and fentanyl patch 100 mcgs q 72.\n Team suspects progressive narcotic overdose. He needs chronic pain\n eval for a cohesive med regimen. He is on scale\n Altered mental status (not Delirium)\n Assessment:\n Sleeping post extubation\n conversant but perseverating on lyrica\nArouses to name when called .. Oriented to name ..unable to state\n year or place. Intermit restless. scale evaluation q4 hours\n Action:\n Continue to re-orient. Side rails up for safety\n Response:\n Plan:\n Continue to monitor for narcotic withdrawal\n Pain control (acute pain, chronic pain)\n Assessment:\n Hx of recent fall to right hip/small head lac. Small old fx to left hip\n acetabulem. Bed rest maintained. Chronic pain meds re-initiated. Denies\n abd pain\n Action:\n Ambulates with walker at home\n Response:\n PT consult would be helpful for gait evaluation\n Plan:\n Social work consult to address post discharge needs\n" }, { "category": "Nursing", "chartdate": "2157-01-02 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 361487, "text": "This is a 76 yr old male who presented to EW for Senior Life\n with a one week history of malaise and increased lower back pain. In\n the EW, room air sat found to be 90%. Patient reports to have taken ~~\n 10 percocets twenty four hours PTA\n ( serum/urine tox screen negative ) Became acutely agitated in the\n EW..pulling out IV\ns/off 02 and was given .5 mg of iv Ativan and had a\n head ct. Upon return to the EW bay, he had resp decompensation and\n required intubation.\n PMHX\n Sarcoidosis on chronic prednisone\n GERD\n Afib ( on coumadin)\n CVA resulting in memory difficulties and dysphagia\n HX of falls\n Lumbar surgery\n Right hip pain from recent fall\n HTN\n Allergy PCN\n Propofol was weaned at 0600 ..Patient more awake ..extubated at\n 0900\n.Head ct negative. Ruled out for flu. MRSA swab pndg. Urine and\n bld cultures pndg. MRI of chest /torso ruled out structural problem.\n Family concerned that patient has been increasing his dose of\n oxycodone for back pain. He is followed at the Pain clinic ( On\n lyrica 150 mg qam/ 225 mg q pm ) and fentanyl patch 100 mcgs q 72.\n Team suspects progressive narcotic overdose. He needs chronic pain\n eval for a cohesive med regimen. He is on scale\n Altered mental status (not Delirium)\n Assessment:\n Sleeping post extubation\n conversant but perseverating on lyrica\nArouses to name when called .. Oriented to name ..unable to state\n year or place. Intermit restless. scale evaluation q4 hours\n Action:\n Continue to re-orient. Side rails up for safety\n Response:\n Plan:\n Continue to monitor for narcotic withdrawal\n Pain control (acute pain, chronic pain)\n Assessment:\n Hx of recent fall to right hip/small head lac. Small old fx to left hip\n acetabulem. Bed rest maintained. Chronic pain meds re-initiated. Denies\n abd pain\n Action:\n Ambulates with walker at home\n Response:\n PT consult would be helpful for gait evaluation\n Plan:\n Social work consult to address post discharge needs\n Demographics\n Attending MD:\n C.\n Admit diagnosis:\n PNEUMONIA\n Code status:\n Full code\n Height:\n Admission weight:\n 76.2 kg\n Daily weight:\n 76 kg\n Allergies/Reactions:\n Penicillins\n Hives;\n Precautions:\n PMH:\n CV-PMH:\n Additional history: Pulmonary darcoidosis\n Hx of afib\n Hx of stroke with memory difficulty and esophageal dismotility\n lumbar spinal stenosis in with chronic back pain\n Recent viral pneumonia\n Htn\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:129\n D:68\n Temperature:\n 97.4\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 15 insp/min\n Heart Rate:\n 83 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n Nasal cannula\n O2 saturation:\n 100% %\n O2 flow:\n 4 L/min\n FiO2 set:\n 0% %\n 24h total in:\n 24h total out:\n 0 mL\n Pertinent Lab Results:\n Sodium:\n 138 mEq/L\n 05:54 AM\n Potassium:\n 4.4 mEq/L\n 05:54 AM\n Chloride:\n 102 mEq/L\n 05:54 AM\n CO2:\n 27 mEq/L\n 05:54 AM\n BUN:\n 16 mg/dL\n 05:54 AM\n Creatinine:\n 0.9 mg/dL\n 05:54 AM\n Glucose:\n 156 mg/dL\n 05:54 AM\n Hematocrit:\n 33.8 %\n 05:54 AM\n Valuables / Signature\n Patient valuables:\n Other valuables: clothes/dentures\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: ccu\n Transferred to: cc709\n Date & time of Transfer: midnight\n" }, { "category": "Nursing", "chartdate": "2157-01-01 00:00:00.000", "description": "Nursing Progress Note", "row_id": 361416, "text": "This is a 76 yr old male who presented to the EW with one week history\n of malaise and lower back pain. Room air sat found to be 90% on room\n air. Reports taking oxycodone for back pain. Became agitated\n pulling out IV\ns and pulling off 02 .Was given .5 mg of iv ativan and\n had a ct scan of chest . Upon return, he rapidly decompensated and\n required intubation.\n PMHX\n Sarcoidosis on chronic prednisone\n GERD\n Afib ( on coumadin)\n CVA resulting in memory difficulties and dysphagia\n Hx of falls\n Lumbar surgery\n HTN\n Allergies PCN\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n Pain control (acute pain, chronic pain)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2157-01-01 00:00:00.000", "description": "Nursing Progress Note", "row_id": 361419, "text": "This is a 76 yr old male who presented to the EW with one week history\n of malaise and lower back pain. Room air sat found to be 90% on room\n air. Reports taking oxycodone for back pain. Became agitated\n pulling out IV\ns and pulling off 02 .Was given .5 mg of iv ativan and\n had a ct scan of chest . Upon return, he rapidly decompensated and\n required intubation.\n PMHX\n Sarcoidosis on chronic prednisone\n GERD\n Afib ( on coumadin)\n CVA resulting in memory difficulties and dysphagia\n Hx of falls\n Lumbar surgery\n HTN\n Allergies PCN\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n Pain control (acute pain, chronic pain)\n Assessment:\n Action:\n Response:\n Plan:\n Altered mental status (not Delirium)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Physician ", "chartdate": "2157-01-01 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 361349, "text": "Chief Complaint: respiratory distress\n HPI:\n This is a 76 year-old male with a history of sarcoid and recent\n admission who presents with altered mental status.\n .\n In the ED, the patient had initial vitals of 100.1 with BP 137/100 HR\n 80s rr 100% RA. While in the ED the patient was treated empirically\n for pneumonia with levofloxacin and vancomycin. O2 sats ranged from\n 90-100% eventually being placed on 100% NRB. He was given 0.5 mg\n ativan at 23:40. Due to hypoxia to 74% and increased work of breathing\n the patient was intubated at 1AM. He was sedated on propofol. The ED\n attempted to contact the nursing home without success to address code\n status.\n There is mention in the ED note that the patient may have taken\n oxycodone prior to presentation.\n .\n Upon discussion with the family the patient has not been feeling well\n for the last 1 week. He was not specific about his discomfort, but has\n been increasing his pain medications. The family is concerned that he\n has been increasing his intake of oxycodone and has become more\n confused as a result. The reason for his increased intake of oxycodone\n (i.e. the location of increased pain) is unclear. The family reports\n that he took at least 8 percocets in the last 36 hours. The do not\n recall any localizing symptoms including no fever, chills, chest pain,\n shortness of breath, diarrhea. The family was concerned about his\n general health such that they took him to his PCP on thursday and he\n saw his nurse practitioner . Both health care practitioners\n were not concerned for any acute change in his health and are well\n known to the patient.\n .\n ROS: unable to be obtained as the patient is intubated and sedated.\n Patient admitted from: ER\n History obtained from Family / Medical records\n Allergies:\n Penicillins\n Hives;\n Last dose of Antibiotics:\n Infusions:\n Propofol - 40 mcg/Kg/min\n Other ICU medications:\n Other medications:\n Discharge meds as of 11.24, family believes them to be correct\n 1. Percocet 2.5-325 mg up to 8/day per family\n 2. Lidocaine 5 %(700 mg/patch)\n 3. Pregabalin 75 mg Capsule Sig: Two (2) Capsule PO QAM (once a\n day (in the morning)).\n 4. Pregabalin 75 mg Capsule Sig: Three (3) Capsule PO QPM (once\n a day (in the evening)).\n 5. Fentanyl 100 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr\n Transdermal Q48H (every 48 hours).\n 6. Fentanyl 25 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr\n Transdermal Q48H (every 48 hours).\n 7. Prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).\n 8. Warfarin 5 mg\n 9. Docusate Sodium 100 mg\n 10. Senna 8.6 mg .\n 11. Omeprazole 20 mg Capsule, \n 12. Donepezil 5 mg Tablet Sig: One (1) Tablet PO HS (at\n bedtime).\n 13. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2\n times a day).\n 14. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY\n (Daily).\n 15. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO at bedtime.\n 16. Fluticasone-Salmeterol 100-50 mcg/Dose Disk with Device Sig:\n One (1) Inhalation Inhalation (2 times a day).\n 17. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol\n 18. Calcitrate-Vitamin D 315-200 mg-unit Tablet Sig: Two (2)\n Past medical history:\n Family history:\n Social History:\n 1) Sarcoidosis\n 2) GERD\n 3) Paroxysmal atrial fibrillation\n 4) CVA with resulting memory difficulty\n 5) Hypertension\n 6) Anemia\n 7) Chronic Back Pain (post-herpetic neuralgia)on chronic prednisone\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: Retired physician, , 2 grandchildren. Son-in-law \n very supportive. Divorced from wife, who recently died. Patient\n has never smoked. Patient rarely consumes alcohol. Patient lives\n alone at Senior Life. His meals are provided for him, he\n does go shopping on his own and is quite active. He ambulates\n with a walker since fracturing his acetabulum recently.\n Review of systems:\n Flowsheet Data as of 05:41 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 37.1\nC (98.8\n Tcurrent: 37.1\nC (98.8\n HR: 72 (68 - 72) bpm\n BP: 117/56(62) {107/56(62) - 117/56(69)} mmHg\n RR: 18 (18 - 18) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 76 kg (admission): 76.2 kg\n Total In:\n 46 mL\n PO:\n TF:\n IVF:\n 46 mL\n Blood products:\n Total out:\n 0 mL\n 70 mL\n Urine:\n 70 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -24 mL\n Respiratory\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST\n Vt (Set): 450 (450 - 450) mL\n RR (Set): 18\n PEEP: 5 cmH2O\n FiO2: 40%\n PIP: 30 cmH2O\n Plateau: 16 cmH2O\n Compliance: 40.9 cmH2O/mL\n SpO2: 100%\n ABG: 7.42/42/81.//2\n Ve: 8.3 L/min\n PaO2 / FiO2: 203\n Physical Examination\n General Appearance: Thin\n Eyes / Conjunctiva: constricted pupils, mildly reactive\n Head, Ears, Nose, Throat: Normocephalic, Poor dentition, Endotracheal\n tube, OG tube\n Lymphatic: Cervical WNL, Supraclavicular WNL\n Cardiovascular: (S1: Normal), (S2: Normal), No(t) Rub\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ),\n (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Absent, Left: Absent\n Musculoskeletal: Muscle wasting, Unable to stand\n Skin: Warm\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Sedated,\n Tone: Not assessed\n Labs / Radiology\n 233\n 107\n 1.2\n 18\n 33\n 99\n 4.1\n 141\n 39.5\n 10.7\n [image002.jpg]\n \n 2:33 A1/17/ 02:21 AM\n \n 10:20 P1/17/ 03:40 AM\n \n 1:20 P\n \n 11:50 P\n \n 1:20 A\n \n 7:20 P\n 1//11/006\n 1:23 P\n \n 1:20 P\n \n 11:20 P\n \n 4:20 P\n TC02\n 28\n 28\n Other labs: CK / CKMB / Troponin-T:222/10/0.1, Differential-Neuts:87.8,\n Lymph:5.9, Mono:5.2, Ca++:9.2, Mg++:2.3, PO4:2.2\n Fluid analysis / Other labs: 141 99 18 107 AGap=13\n 4.1 33 1.2\n estGFR: 59/71 (click for details)\n CK: 222 MB: 10 MBI: 4.5 Trop-T: 0.10\n Comments: cTropnT: Ctropnt > 0.10 Ng/Ml Suggests Acute Mi\n Ca: 9.2 Mg: 2.3 P: 2.2 D\n ALT: 27 AP: 96 Tbili: 1.1 Alb:\n AST: 32 LDH: Dbili: TProt:\n : Lip: 33\n 84\n 10.7 13.7 233\n 39.5\n N:87.8 L:5.9 M:5.2 E:0.8 Bas:0.4\n Assessment and Plan\n Assesment: This is a 76 year-old male with a history of sarcoid and\n atrial fibrillation who presents with 1 week of malaise and worsening\n respiratory status.\n # Altered mental status: unclear etiology though increased pain meds\n seem at least partly the cause. Other causes including delirium\n secondary to infection, or toxic injestion. At this point, it is still\n unclear, will attempt to extubate. If unable, will consider doing\n repeat head CT v. MRI. Cardiac event possible as well, though less\n likely given the patient's ECG. Will trend cardiac enzymes\n - wean sedation\n - serial neuro exams\n - consider additional head imaging\n - cardiac enzymes\n # Respiratory failure: brief period of hypoxia. be secondary to\n oversedation secondary to medications. Will wean sedation and evaluate\n respiratory status. Does have slight worsening of appearance of lung\n parenchyma on CT, thus could be worsening of the patient's underlying\n sarcoid\n - increase steroids?\n - wean from vent\n # Atrial fibrilation: Currently rate controlled. Likely will restart\n metoprolol in AM, will hold anticoagulation for now.\n ICU Care\n Nutrition:\n Glycemic Control: Blood sugar well controlled\n Lines:\n 22 Gauge - 02:59 AM\n 18 Gauge - 03:00 AM\n 20 Gauge - 03:13 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Need for restraints reviewed\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n" }, { "category": "Physician ", "chartdate": "2157-01-01 00:00:00.000", "description": "MICU Attending Progress Note", "row_id": 361444, "text": "TITLE: MICU ATTENDING PROGRESS NOTE\n I saw and examined the patient, and was physically present with the ICU\n team for the key portions of the services provided. I agree with the\n resident note, including the assessment and plan. I would emphasize and\n add the following points: 76M HSL resident sarcoidosis, CVA, HTN, PAF,\n GERD and chronic pain p/w respiratory failure after ? narcotic overdose\n / aspiration event on floor. Sent to ED for generalized malaise,\n developed hypoxemic respiratory failure following ativan. CTA c hilar\n fullness and no PE. Treated with broad abx coverage, extubated this AM.\n Exam notable for Tm 99.1 BP 130/60 HR 70 RR 25 with sat 98 on 3LNC.\n Drowsy, c/o pain. Coarse BS. RRR s1s2. Soft +BS. No edema. Labs notable\n for WBC 10K, HCT 39, Cr 1.2, INR 1.7. CT with chronic perihilar\n changes.\n Agree with plan to monitor in MICU off abx following extubation; CT\n without clear change. Suspect progressive narcotic overdose, given\n recovery and negative head CT (suboptimal quality). Will obtain MRI to\n r/o structural problem; has ruled out for MI. Needs chronic pain eval\n for a cohesive med regimen; will add back fent patch with low dose MSO4\n PRN. Hold coumadin in the setting of elevated INR but can restart BBL\n for PAF. Remainder of plan as outlined above.\n Patient is critically ill\n Total time: 35 min\n" }, { "category": "Physician ", "chartdate": "2157-01-01 00:00:00.000", "description": "Physician Attending Admission Note - MICU", "row_id": 361363, "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 76 yo male with sarcoidosis. For the past week has been feeling poorly\n per family, with confusion and difficulty speaking clearly. During this\n time he also took more pain medication with at least 8 oxycodone over\n the past day. Yesterday he went to his PCP and NP with no concerning\n findings. As of 4:30 pm in the afternoon, pt felt poorly but still was\n functioning ok. However, son was called by facility 2\n hours later and told pt was getting sent to hospital.\n To ED around 9 pm with SBP 130's, 100% RA, Temp 100.1. Received LVQ.\n Down there, MS worsened with desats to 74% and increased WOB eventually\n prompting addition of NRB followed by intubation. ABG prior to\n intubation: 7.33/57/134 on 6 liters oxygen. Received LVQ/Vanco\n CTA negative for PNA or PE.\n Head CT: limited due to mov't artifact, but no obvious hemorrhage\n Patient admitted from: ER\n History obtained from Medical records, ICU housestaff\n Patient unable to provide history: Sedated\n Allergies:\n Penicillins\n Hives;\n Last dose of Antibiotics:\n Infusions:\n Propofol - 40 mcg/Kg/min\n Other ICU medications:\n Other medications:\n probably unchanged from hospitalization: percocet, lidocaine\n patch, pregabalin, fentanyl, prednisone, coumadin, prilosec, aricept,\n simvastatin, senna, colace, metoprolol, thiamine, advair, combivent\n Past medical history:\n Family history:\n Social History:\n Sarcoidosis on prednisone 10mg\n Atrial fibrillation\n HTN\n Hx CVA\n Chronic back pain s/p surgery \n post herpetic neuralgia\n Hx viral PNA \n no family hx of sarcoidosis\n Unable to obtain ROS from pt due to his being intubated\n Occupation: Retired physician, 1 daughter, divorced\n Drugs:\n Tobacco: remote smoking\n Alcohol:\n Other:\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: 37.1\nC (98.8\n Tcurrent: 37.1\nC (98.8\n HR: 72 (68 - 72) bpm\n BP: 117/56(62) {107/56(62) - 117/56(69)} mmHg\n RR: 18 (18 - 18) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 76 kg (admission): 76.2 kg\n Total In:\n 34 mL\n PO:\n TF:\n IVF:\n 34 mL\n Blood products:\n Total out:\n 0 mL\n 70 mL\n Urine:\n 70 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -36 mL\n Respiratory\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST\n Vt (Set): 450 (450 - 450) mL\n RR (Set): 18\n PEEP: 5 cmH2O\n FiO2: 40%\n PIP: 30 cmH2O\n Plateau: 16 cmH2O\n Compliance: 40.9 cmH2O/mL\n SpO2: 100%\n ABG: 7.42/42/81.//2\n Ve: 8.3 L/min\n PaO2 / FiO2: 203\n Physical Examination\n General Appearance: Well nourished, No(t) No acute distress, No(t)\n Overweight / Obese, No(t) Thin, No(t) Anxious, No(t) Diaphoretic\n Eyes / Conjunctiva: No(t) Pupils dilated, No(t) Conjunctiva pale, No(t)\n Sclera edema, pupils pinpoint and minimally reactive\n Head, Ears, Nose, Throat: Normocephalic, No(t) Poor dentition,\n Endotracheal tube, No(t) NG tube, OG tube\n Lymphatic: Cervical WNL\n Cardiovascular: (PMI Normal, No(t) Hyperdynamic), (S1: Normal, No(t)\n Absent), (S2: Normal, No(t) Distant), No(t) S3, No(t) S4, No(t) Rub,\n (Murmur: No(t) Systolic, No(t) Diastolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric, No(t) Paradoxical),\n (Percussion: No(t) Resonant : , Hyperresonant: ), (Breath Sounds: Clear\n : )\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended,\n No(t) Tender: , No(t) Obese\n Extremities: Right: 1+, Left: 1+, No(t) Cyanosis, No(t) Clubbing\n Skin: Warm, No(t) Rash: , No(t) Jaundice\n Neurologic: No(t) Attentive, No(t) Follows simple commands, Responds\n to: Unresponsive, Movement: No spontaneous movement, Sedated, No(t)\n Paralyzed, Tone: Normal, no gag or corneals. Previously responsive to\n Labs / Radiology\n 107\n 1.2\n 18\n 33\n 99\n 4.1\n 141\n [image002.jpg]\n 02:21 AM\n 03:40 AM\n WBC\n 10.7\n Hct\n 39.5\n Plt\n 233\n TC02\n 28\n 28\n Other labs: CK / CKMB / Troponin-T:222/10/4.5/0.1, ALT / AST:27/22, Alk\n Phos / T Bili:1.1, Amylase / Lipase:/33, Differential-Neuts:87.8,\n Lymph:5.9, Mono:5.2, Ca++:9.2, Mg++:2.3, PO4:2.2\n Fluid analysis / Other labs: Urine and serum tox negative\n ABG 7.33/57/134 on 6 liters oxygen\n ABG 7.48/36/492 vent\n ABG 7.42/42/81 vent\n Imaging: CTA: hilar fullness/right minor fissure scarring (chronic); no\n PE, increased air-space disease esp. right base\n Head CT: no obvious abnormalities\n Microbiology: U/A negative except for ketones\n Urine cultures positive\n ECG: NSR with ectopy, old RBBB\n Assessment and Plan\n 76 yo male with sarcoidosis, chronic back pain admitted with malaise\n and MS changes\n (1) MS changes: Development over several days of unclear etiology.\n Excessive pain meds superimposed on chronic dementia could contribute.\n Other possibilities would include stroke not visualized by CT. Patient\n currently minimally reactive which represents a distinct change from\n his arrival to the CCU; though propofol was subsequently increased\n *Wean propofol and-reevaluate MS\n *If mental status doesn't improve would proceed with neuro-imaging (MR)\n +/- LP\n (2) Respiratory failure: Pt arrived in the ED with O2 sats in the mid\n 90's on RA but subsequently decompensated, with no PE by CTA. Rapid\n onset might suggest MS/sedation/aspiration a factor. Has adequate\n ventilation and oxygenation- As MS permits will wean vent and assess\n for extubation\n (3) Elevated CK's - r/o MI\n (4) Hx afib: currently in SR, no changes\n Rest of plan per ICU team\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines / Intubation:\n 22 Gauge - 02:59 AM\n 18 Gauge - 03:00 AM\n 20 Gauge - 03:13 AM\n Comments:\n Prophylaxis:\n DVT: Boots\n Stress ulcer:\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 60 minutes\n Patient is critically ill\n" }, { "category": "Nursing", "chartdate": "2157-01-01 00:00:00.000", "description": "Nursing Progress Note", "row_id": 361459, "text": "This is a 76 yr old male who presented to the EW with one week history\n of malaise and lower back pain. Room air sat found to be 90% on room\n air. Reports taking oxycodone for back pain. Became agitated,\n pulling out IV\ns and pulling off 02; given 0.5 mg iv ativan and had\n a ct scan of head/chest . Upon return, he rapidly decompensated and\n required intubation.\n PMHX :\n Sarcoidosis on chronic prednisone\n GERD\n Afib ( on coumadin)\n CVA resulting in memory difficulties and dysphagia\n Hx of falls\n Lumbar surgery\n HTN\n Allergies: PCN\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Ready to extubate with good abg on AC10/5; RSBI 87; propofol at 10mcgs\n off at 1100\n Action:\n Successfully extubated at 1100 to 40% mask\n Response:\n Sats remains 99-100% w/O2 weaned to 3-4l nc; episodes tachypnea later\n in day w/sats remaining 99-100%; probably related to narcotic\n withdrawl; lungs clear to few exp wheezes with exertion\n Plan:\n Follow sats, inhalers prn as ordered; assess RR and effort esp\n w/episodes agitation.\n Pain control (acute pain, chronic pain)\n Assessment:\n Complaining of pain throughout day; multiple sites including R hip,\n lower back, 1 episode chest pain after MRI\n Action:\n Withholding usual narcotics initially secondary to respiratory\n compromise requiring intubation overnight; lido patch placed on R hip\n removed by pt and replaced again by RN with minimal change in pain;\n after team consulted with pain service, fentanyl patch/Lyrica ordered;\n to MRI at 1500 w/o receiving meds as not yet available; 1600 pt out of\n MRI machine anxious, restless, w/nausea, dry heaves, tachycardia, HTN,\n tachypnic to 35, diaphoretic\n CCU team called\n transported back to\n CCU\n received Morphine 2mg iv x3\n total 6mg, Zofran 8mg IV, Lyrica\n total 150mg po, fentanyl patch placed\n Response:\n scale improved to 3 from 12 after medical interventions, pt calm,\n resting more comfortably\n Plan:\n Continue scale, assess response to meds/assess pain level, follow\n sats, to re-consult pain service in AM to develop long-term plan.\n Altered mental status (not Delirium)\n Assessment:\n Pt alert and oriented x2-3 after extubation, pt at times\n restless/agitated, requesting pain meds throughout day\n Action:\n Head MRI done secondary to confusion in ED last night;\n Morphine sulfate iv, fentanyl patch, Lyrica po given for pain\n Response:\n Pt much calmer, less agitated post-meds; scale improved\n Plan:\n Continue to assess changes in mental status; pain meds as ordered and\n follow scale; emotional support for pt; Keep daughter, son-in-law\n informed of condition, plan of care.\n" }, { "category": "Physician ", "chartdate": "2157-01-01 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 361366, "text": "Chief Complaint: respiratory distress\n HPI:\n This is a 76 year-old male with a history of sarcoid and recent\n admission who presents with altered mental status.\n .\n In the ED, the patient had initial vitals of 100.1 with BP 137/100 HR\n 80s rr 100% RA. While in the ED the patient was treated empirically\n for pneumonia with levofloxacin and vancomycin. O2 sats ranged from\n 90-100% eventually being placed on 100% NRB. He was given 0.5 mg\n ativan at 23:40. Due to hypoxia to 74% and increased work of breathing\n the patient was intubated at 1AM. He was sedated on propofol. The ED\n attempted to contact the nursing home without success to address code\n status.\n There is mention in the ED note that the patient may have taken\n oxycodone prior to presentation.\n .\n Upon discussion with the family the patient has not been feeling well\n for the last 1 week. He was not specific about his discomfort, but has\n been increasing his pain medications. The family is concerned that he\n has been increasing his intake of oxycodone and has become more\n confused as a result. The reason for his increased intake of oxycodone\n (i.e. the location of increased pain) is unclear. The family reports\n that he took at least 8 percocet in the last 36 hours. The do not\n recall any localizing symptoms including no fever, chills, chest pain,\n shortness of breath, diarrhea. The family was concerned about his\n general health such that they took him to his PCP on Thursday and he\n saw his nurse practitioner . Both health care practitioners\n were not concerned for any acute change in his health and are well\n known to the patient.\n .\n ROS: unable to be obtained as the patient is intubated and sedated.\n Patient admitted from: ER\n History obtained from Family / Medical records\n Allergies:\n Penicillins\n Hives;\n Last dose of Antibiotics:\n Infusions:\n Propofol - 40 mcg/Kg/min\n Other ICU medications:\n Other medications:\n Discharge meds as of 11.24, family believes them to be correct\n 1. Percocet 2.5-325 mg up to 8/day per family\n 2. Lidocaine 5 %(700 mg/patch)\n 3. Pregabalin 75 mg Capsule Sig: Two (2) Capsule PO QAM (once a\n day (in the morning)).\n 4. Pregabalin 75 mg Capsule Sig: Three (3) Capsule PO QPM (once\n a day (in the evening)).\n 5. Fentanyl 100 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr\n Transdermal Q48H (every 48 hours).\n 6. Fentanyl 25 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr\n Transdermal Q48H (every 48 hours).\n 7. Prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).\n 8. Warfarin 5 mg\n 9. Docusate Sodium 100 mg\n 10. Senna 8.6 mg .\n 11. Omeprazole 20 mg Capsule, \n 12. Donepezil 5 mg Tablet Sig: One (1) Tablet PO HS (at\n bedtime).\n 13. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2\n times a day).\n 14. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY\n (Daily).\n 15. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO at bedtime.\n 16. Fluticasone-Salmeterol 100-50 mcg/Dose Disk with Device Sig:\n One (1) Inhalation Inhalation (2 times a day).\n 17. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol\n 18. Calcitrate-Vitamin D 315-200 mg-unit Tablet Sig: Two (2)\n Past medical history:\n Family history:\n Social History:\n 1) Sarcoidosis\n 2) GERD\n 3) Paroxysmal atrial fibrillation\n 4) CVA with resulting memory difficulty\n 5) Hypertension\n 6) Anemia\n 7) Chronic Back Pain (post-herpetic neuralgia)on chronic prednisone\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: Retired physician, , 2 grandchildren. Son-in-law \n very supportive. Divorced from wife, who recently died. Patient\n has never smoked. Patient rarely consumes alcohol. Patient lives\n alone at Senior Life. His meals are provided for him, he\n does go shopping on his own and is quite active. He ambulates\n with a walker since fracturing his acetabulum recently.\n Review of systems:\n Flowsheet Data as of 05:41 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 37.1\nC (98.8\n Tcurrent: 37.1\nC (98.8\n HR: 72 (68 - 72) bpm\n BP: 117/56(62) {107/56(62) - 117/56(69)} mmHg\n RR: 18 (18 - 18) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 76 kg (admission): 76.2 kg\n Total In:\n 46 mL\n PO:\n TF:\n IVF:\n 46 mL\n Blood products:\n Total out:\n 0 mL\n 70 mL\n Urine:\n 70 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -24 mL\n Respiratory\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST\n Vt (Set): 450 (450 - 450) mL\n RR (Set): 18\n PEEP: 5 cmH2O\n FiO2: 40%\n PIP: 30 cmH2O\n Plateau: 16 cmH2O\n Compliance: 40.9 cmH2O/mL\n SpO2: 100%\n ABG: 7.42/42/81.//2\n Ve: 8.3 L/min\n PaO2 / FiO2: 203\n Physical Examination\n General Appearance: Thin\n Eyes / Conjunctiva: constricted pupils approx , mildly reactive\n Head, Ears, Nose, Throat: Normocephalic, Poor dentition, Endotracheal\n tube, OG tube\n Lymphatic: Cervical WNL, Supraclavicular WNL\n Cardiovascular: (S1: Normal), (S2: Normal), No(t) Rub\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ),\n (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Absent edema , Left: Absent edema\n Skin: small faruncle on left leg, no surrounding erythema\n Musculoskeletal:\n Skin: Warm\n Neurologic: Sedated, Tone: Not assessed, down going plantar reflexes,\n withdraws all extremities to pain\n Labs / Radiology\n 233\n 107\n 1.2\n 18\n 33\n 99\n 4.1\n 141\n 39.5\n 10.7\n [image002.jpg]\n \n 2:33 A1/17/ 02:21 AM\n \n 10:20 P1/17/ 03:40 AM\n \n 1:20 P\n \n 11:50 P\n \n 1:20 A\n \n 7:20 P\n 1//11/006\n 1:23 P\n \n 1:20 P\n \n 11:20 P\n \n 4:20 P\n TC02\n 28\n 28\n Other labs: CK / CKMB / Troponin-T:222/10/0.1, Differential-Neuts:87.8,\n Lymph:5.9, Mono:5.2, Ca++:9.2, Mg++:2.3, PO4:2.2\n Fluid analysis / Other labs:\n Assessment and Plan\n Assesment: This is a 76 year-old male with a history of sarcoidosis and\n atrial fibrillation who presents with 1 week of malaise and worsening\n respiratory status.\n # Altered mental status: unclear etiology though increased pain meds\n seem at least partly the cause. Other causes including delirium\n secondary to infection, or toxic ingestion. The patient\ns mental\n status seemed to worsen while in the ED which could be partly explained\n by the medications that he received. Will wean sedation and however,\n if persistently sedated, will consider doing repeat head CT v. MRI.\n Cardiac event possible as well, though less likely given the patient's\n ECG. Will trend cardiac enzymes.\n - wean sedation\n - serial neuro exams\n - MRI, with stat head CT prn\n - cardiac enzymes\n - may also need LP if mental status continues to be poor, or if febrile\n # Respiratory failure: brief period of hypoxia. be secondary to\n oversedation secondary to medications. Will wean sedation and evaluate\n respiratory status. Does have slight worsening of appearance of lung\n parenchyma on CT, thus could be worsening of the patient's underlying\n sarcoid\n - empirically treat with levofloxacin and metronidazole for CAP/asp pna\n - wean from vent\n # Sarcoidosis: Not currently treated (except for inhalers as prednisone\n is not for sarcoid per pulmonologist). Will continue inhalers\n # Atrial fibrillation: Currently rate controlled. Likely will restart\n metoprolol in AM, will hold anticoagulation for now, await INR.\n # History CVA: will get MRI as above as INR is unknown and patient is\n high risk for stroke.\n # GERD: continue pantoprazole\n ICU Care\n Nutrition:\n Glycemic Control: Blood sugar well controlled\n Lines:\n 22 Gauge - 02:59 AM\n 18 Gauge - 03:00 AM\n 20 Gauge - 03:13 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Need for restraints reviewed\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n" }, { "category": "Respiratory ", "chartdate": "2157-01-01 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 361355, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 0\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: 21 cm at upper lip.\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: Diminished\n Comments:\n Secretions\n Sputum color / consistency: /\n Sputum source/amount: Suctioned / None\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support:\n Comments: No RSBI at this time. Pt has no spont. Resp at this time.\n" }, { "category": "Radiology", "chartdate": "2157-01-03 00:00:00.000", "description": "MR L SPINE W/O CONTRAST", "row_id": 1057636, "text": " 3:29 PM\n MR L SPINE W/O CONTRAST Clip # \n Reason: Please evaluate L-spine for an etiology for pain of right hi\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with right hip pain, ROM in hip intact, concern for referred\n pain from L-spine.\n REASON FOR THIS EXAMINATION:\n Please evaluate L-spine for an etiology for pain of right hip.\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): FBr 2:23 PM\n 1. Multilevel spondylosis of the lumbar spine which is most severe at level\n of L4-L5.\n\n 2. Grade 1 anterolisthesis of L4 over L5 associated with mild canal narrowing\n and bilateral moderate neural foraminal narrowing at this level.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 76-year-old man with right hip pain.\n\n Comparison is made to the plain radiograph of the lumbar spine performed on\n and .\n\n TECHNIQUE: Sagittal T1, T2 and axial T2-weighted images of the lumbar spine\n were obtained.\n\n FINDINGS: The signal intensity of the bone marrow is normal. The vertebral\n body heights are well preserved. The distal spinal cord and nerve roots have\n normal appearance. The conus terminates at the upper level of L1.\n\n There are multilevel disc degenerative changes.\n\n Above the level of L1-L2, there is a left paracentral disc bulge with no\n definite canal or neural foraminal narrowing.\n\n At the Level of L2-L3, there is diffuse disc bulge with no definite canal or\n neural foraminal narrowing.\n\n At the level of L3-L4, there is mild diffuse disc bulge and facet joint\n hypertrophy with no canal or neural foraminal narrowing.\n\n At the level of L4-L5, there is grade 1 anterolisthesis and moderate diffuse\n disc bulge and central annular tear which is associated with facet joint\n hypertrophy with mild canal narrowing noted at this level. There is also\n bilateral moderate neural foraminal narrowing. There are Schmorl's nodes and\n type 2 changes at the inferior endplate of L4 and superior endplate of\n L5.\n\n At the level of L5-S1, there is mild left paracentral disc bulge with mild\n left neural foraminal narrowing. No canal narrowing is noted.\n\n (Over)\n\n 3:29 PM\n MR L SPINE W/O CONTRAST Clip # \n Reason: Please evaluate L-spine for an etiology for pain of right hi\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n IMPRESSION:\n\n 1. Multilevel spondylosis of the lumbar spine which is most severe at level\n of L4-L5.\n\n 2. Grade 1 anterolisthesis of L4 over L5 is associated with mild canal\n narrowing and bilateral moderate neural foraminal narrowing.\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2157-01-03 00:00:00.000", "description": "MR L SPINE W/O CONTRAST", "row_id": 1057637, "text": ", B. MED CC7A 3:29 PM\n MR L SPINE W/O CONTRAST Clip # \n Reason: Please evaluate L-spine for an etiology for pain of right hi\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with right hip pain, ROM in hip intact, concern for referred\n pain from L-spine.\n REASON FOR THIS EXAMINATION:\n Please evaluate L-spine for an etiology for pain of right hip.\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n 1. Multilevel spondylosis of the lumbar spine which is most severe at level\n of L4-L5.\n\n 2. Grade 1 anterolisthesis of L4 over L5 associated with mild canal narrowing\n and bilateral moderate neural foraminal narrowing at this level.\n\n" }, { "category": "Radiology", "chartdate": "2156-12-31 00:00:00.000", "description": "CTA CHEST W&W/O C&RECONS, NON-CORONARY", "row_id": 1057285, "text": " 8:58 PM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \n Reason: eval for pe\n Field of view: 39 Contrast: OPTIRAY Amt: 85\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with hypoxia and shortness of breath\n REASON FOR THIS EXAMINATION:\n eval for pe\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: DSsd 11:16 PM\n sl. limited by resp motion. no central/segmental PE\n\n similar chronic lung changes related to sarcoidosis, possibly worse at L\n hilum.\n\n small bilateral pleural effusions.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Hypoxia and shortness of breath.\n\n COMPARISON: , and multiple recent chest radiographs.\n\n TECHNIQUE: Volumetric CT acquisition of the chest was performed before and\n after administration of intravenous contrast per non-gated chest pain CTA\n technique.\n\n CTA CHEST: Evaluation is slightly limited by respiratory motion artifact.\n Allowing for this, there is no central or segmental pulmonary embolism.\n Thoracic aorta is normal in caliber and contour throughout. There is mild-to-\n moderate atherosclerotic calcification of the aortic arch and descending\n aorta. There is moderate-to-severe three-vessel coronary artery\n calcification.\n\n Bilateral areas of fibrosis, scarring, and architectural distortion related to\n the patient's known diagnosis of sarcoidosis are not significantly changed\n since previous exam. However, there is slightly increased airspace opacity in\n the vicinity of the left hilum, which is somewhat difficult to evaluate due to\n respiratory motion, but could represent a superimposed infectious process.\n Lungs are otherwise grossly unchanged. There is no focal pulmonary nodule or\n mass. Central airways are patent to the subsegmental level, but again show\n some narrowing, and distortion, likely related to underlying fibrotic change.\n\n There is slightly increased airspace opacity at the left hilum, which could\n represent areas of atelectasis, or possibly early infection. -apical\n pleural thickening is slightly increased since previous exam, particularly at\n the right lung apex.\n\n Limited views of the upper abdomen are unremarkable. Previously noted left\n adrenal myelolipoma, and pancreatic cystic lesions are not visualized on this\n examination.\n\n (Over)\n\n 8:58 PM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \n Reason: eval for pe\n Field of view: 39 Contrast: OPTIRAY Amt: 85\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n Multilevel degenerative changes in the visualized thoracic spine are stable.\n\n IMPRESSION:\n\n 1. No pulmonary embolism.\n\n 2. Bilateral parenchymal distortion, with areas of scarring consistent with\n known sarcoidosis, again most severe in the right upper lobe, with increased\n right apical pleural thickening, and associated architectural distortion.\n\n 3. Slightly increased left perihilar airspace opacity, could represent\n atelectasis, aspiration, or early infection.\n\n 4. Small bilateral pleural effusions, new since previous exam.\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2156-12-31 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1057282, "text": " 8:18 PM\n CHEST (PA & LAT) Clip # \n Reason: eval for pna\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with cough and shortness of breath\n REASON FOR THIS EXAMINATION:\n eval for pna\n ______________________________________________________________________________\n FINAL REPORT\n Study was performed on . Images now become available for\n interpretation.\n\n HISTORY: 76-year-old man with cough and shortness of breath. Evaluate for\n pneumonia.\n\n STUDY: Portable upright AP and lateral views.\n\n COMPARISON: Chest radiograph on .\n\n FINDINGS: The study is limited by patient's positioning and low lung volumes.\n There is a moderately enlarged cardiac silhouette, unchanged compared to\n prior. The slightly tortuous aortic contour is again noted with vascular\n calcification. The prominent hilar regions are unchanged, compatible with the\n underlying sarcoidosis. The lungs are clear, without pleural effusion or\n pneumothorax. The significant thoracic kyphosis is unchanged.\n\n IMPRESSION: No acute cardiopulmonary process. Stable cardiomegaly. Chronic\n fibrosis of the perihilar area compatible with the known sarcoidosis.\n\n" }, { "category": "Radiology", "chartdate": "2157-01-05 00:00:00.000", "description": "VIDEO OROPHARYNGEAL SWALLOW", "row_id": 1057968, "text": " 9:49 AM\n VIDEO OROPHARYNGEAL SWALLOW Clip # \n Reason: Eval for pharyngeal aspiration\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with evidence of aspiration on speech and swallow eval\n REASON FOR THIS EXAMINATION:\n Eval for pharyngeal aspiration\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Dysphagia.\n\n FINDINGS: A swallowing video fluoroscopy study was done in conjunction with\n the speech pathology service. The oral phase of swallowing was notable for\n moderate deficits in bolus formation, control and AP tongue movement. Oral\n transit time was also moderately increased. There was a mild amount of oral\n cavity residue. The pharyngeal phase of swallowing was notable for mild\n deficit in upper esophageal relaxation. Aspiration was noted prior to\n swallowing with thin liquids and a cued cough was ineffective at clearing this\n aspirated material. There was no spontaneous cough. The patient's notable\n kyphosis prevented any posturing treatment techniques.\n\n IMPRESSION: Moderate oral and mild pharyngeal dysphagia with silent\n aspiration not cleared with cued cough. Further details can be found in the\n online medical record and the speech pathology note from .\n\n\n" }, { "category": "Radiology", "chartdate": "2157-01-01 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1057294, "text": " 12:08 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: eval for ICH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with changes in MS\n REASON FOR THIS EXAMINATION:\n eval for ICH\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: DXAe SAT 1:29 AM\n Moderately limited by motion but no gross ICH.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 76-year-old man with change in mental status, for evaluation of\n intracranial hemorrhage.\n\n COMPARISON: Multiple prior exams, the most recent dating .\n\n TECHNIQUE: Non-contrast axial images were obtained from the skull vertex to\n the skull base. Exam was repeated due to patient motion.\n\n FINDINGS: Exam is moderately limited by motion, although there is no gross\n intracranial abnormality. There is no evidence of shift of normally midline\n structures, large hemorrhage or fracture. The paranasal sinuses and mastoid\n air cells are grossly clear except to note persistent mucosal retention cyst\n in the right anterior ethmoid sinus.\n\n IMPRESSION: Moderately limited exam without large intracranial hemorrhage or\n fracture.\n\n" }, { "category": "ECG", "chartdate": "2157-01-01 00:00:00.000", "description": "Report", "row_id": 217899, "text": "Sinus tachycardia with ventricular premature depolarizations. Compared to the\nprevious tracing no diagnostic change.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2156-12-31 00:00:00.000", "description": "Report", "row_id": 217900, "text": "Sinus rhythm with ventricular premature depolarizations. Right bundle-branch\nblock. Left axis deviation. Left anterior fascicular block. Possible\nseptal myocardial infarction. Compared to the previous tracing of \nmultiple abnormalities as noted persist without major change.\nTRACING #1\n\n" }, { "category": "Radiology", "chartdate": "2157-01-02 00:00:00.000", "description": "L-SPINE (AP & LAT)", "row_id": 1057537, "text": ", V. MED CC7A 3:54 PM\n L-SPINE (AP & LAT) Clip # \n Reason: Please eval for possible etiology of pain that could be radi\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with chronic hip pain that worsened over past 5 days.\n REASON FOR THIS EXAMINATION:\n Please eval for possible etiology of pain that could be radiating to hip.\n ______________________________________________________________________________\n PFI REPORT\n Multilevel degenerative joint and disc disease, most severe at L4-L5.\n\n" }, { "category": "Radiology", "chartdate": "2157-01-01 00:00:00.000", "description": "MR HEAD W/O CONTRAST", "row_id": 1057394, "text": " 2:32 PM\n MR HEAD W/O CONTRAST; MRA BRAIN W/O CONTRAST Clip # \n Reason: evaluate for infarction\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with new AMS, hx of CVA, unclear etiology of current MS.\n FOR THIS EXAMINATION:\n evaluate for infarction\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: CXWc SAT 7:39 PM\n No evidence of acute ischemia or infarction. Moderate degree of chronic small\n vessel ischemia again seen. No gross vascular abnormalities. Major vessels\n patent and well perfused.\n ______________________________________________________________________________\n FINAL REPORT\n MRI AND MRA BRAIN, \n\n HISTORY: Altered mental status with history of infarction.\n\n TECHNIQUE: Sagittal short TR, short TE spin-echo imaging was performed\n through the brain. Axial imaging was performed with gradient-echo, long TR,\n long TE fast spin-echo, FLAIR, three-dimensional time-of-flight MRA, and\n diffusion technique. Comparison to a head CT of .\n\n FINDINGS: There is no evidence of infarction. The FLAIR images demonstrate\n periventricular and deep white matter hyperintensity suggesting chronic small\n vessel ischemia. The MRA examination is somewhat limited by motion artifact.\n However, it raises the possibility of stenoses in the M1 segment of the right\n middle cerebral artery. There is also a possible stenosis in the A2 segment\n of the right anterior cerebral artery.\n\n CONCLUSION: No evidence of infarction. Findings suggesting chronic small\n vessel ischemic disease. Possible stenoses of the right middle and anterior\n cerebral arteries; MRA examination is technically limited by motion artifact.\n\n\n" }, { "category": "Radiology", "chartdate": "2157-01-02 00:00:00.000", "description": "R HIP UNILAT MIN 2 VIEWS RIGHT", "row_id": 1057535, "text": ", V. MED CC7A 3:53 PM\n HIP UNILAT MIN 2 VIEWS RIGHT Clip # \n Reason: Please evaluate for etiology of acute on chronic hip pain\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with chronic hip pain that worsened over past 5 days.\n REASON FOR THIS EXAMINATION:\n Please evaluate for etiology of acute on chronic hip pain\n ______________________________________________________________________________\n PFI REPORT\n No fracture.\n\n\n" }, { "category": "Radiology", "chartdate": "2157-01-02 00:00:00.000", "description": "L-SPINE (AP & LAT)", "row_id": 1057536, "text": " 3:54 PM\n L-SPINE (AP & LAT) Clip # \n Reason: Please eval for possible etiology of pain that could be radi\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with chronic hip pain that worsened over past 5 days.\n REASON FOR THIS EXAMINATION:\n Please eval for possible etiology of pain that could be radiating to hip.\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): PMB 5:42 PM\n Multilevel degenerative joint and disc disease, most severe at L4-L5.\n ______________________________________________________________________________\n FINAL REPORT\n LUMBAR SPINE SERIES, , WITH COMPARISON LUMBAR SPINE CT,\n .\n\n INDICATION: Hip pain.\n\n Scoliosis is present with major convexity at the left at approximately the L3\n vertebral body level. There has been previous surgery, presumably laminectomy\n at the L4-L5 level. Multilevel degenerative changes are present with multiple\n anterior osteophytes throughout the spine, as well as degenerative disc\n disease, most prominent at L4-L5 and L5-S1 with adjacent subchondral\n sclerosis. No acute fracture or dislocation is identified.\n\n" }, { "category": "Radiology", "chartdate": "2157-01-01 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1057320, "text": " 4:03 AM\n CHEST (PORTABLE AP); -59 DISTINCT PROCEDURAL SERVICE Clip # \n Reason: evaluate placement of ET , OGT\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with respiratory failure, now intubated with OGT\n REASON FOR THIS EXAMINATION:\n evaluate placement of ET , OGT\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): DLnc SAT 9:37 AM\n Too proximal position of the NG tube which should be advanced at least \n cm. Interval improvement in pulmonary edema.\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Evaluation of ET and OG tube position.\n\n Portable AP chest radiograph was compared to .\n\n The ET tube tip is 6 cm above the carina. The NG tube tip terminates at the\n gastroesophageal junction and might be advanced at least 10-15 cm. There is\n interval improvement in previously seen perihilar opacity and interstitial\n engorgement suggesting improvement in pulmonary edema.\n\n\n" }, { "category": "Radiology", "chartdate": "2157-01-01 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1057321, "text": ", V. MED CCU 4:03 AM\n CHEST (PORTABLE AP); -59 DISTINCT PROCEDURAL SERVICE Clip # \n Reason: evaluate placement of ET , OGT\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with respiratory failure, now intubated with OGT\n REASON FOR THIS EXAMINATION:\n evaluate placement of ET , OGT\n ______________________________________________________________________________\n PFI REPORT\n Too proximal position of the NG tube which should be advanced at least \n cm. Interval improvement in pulmonary edema.\n\n\n" }, { "category": "Radiology", "chartdate": "2157-01-02 00:00:00.000", "description": "R HIP UNILAT MIN 2 VIEWS RIGHT", "row_id": 1057534, "text": " 3:53 PM\n HIP UNILAT MIN 2 VIEWS RIGHT Clip # \n Reason: Please evaluate for etiology of acute on chronic hip pain\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with chronic hip pain that worsened over past 5 days.\n REASON FOR THIS EXAMINATION:\n Please evaluate for etiology of acute on chronic hip pain\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): PMB 5:45 PM\n No fracture.\n ______________________________________________________________________________\n FINAL REPORT\n RIGHT HIP STUDY, \n\n COMPARISON: Left hip radiographs of .\n\n Bones are diffusely demineralized. Mild degenerative changes are present at\n both hips without change since the recent study of about one month earlier.\n If strong clinical suspicion for fracture persists, MRI may be considered.\n With regard to the left hip, the cortical margin of the medial femoral head is\n less clearly delineated than on prior studies. If there are symptoms\n referable to the left hip, additional imaging such as MRI may be helpful to\n exclude avascular necrosis in the appropriate clinical setting. Remainder of\n exam is remarkable for ankylosis of the SI joints and diffuse vascular\n calcifications.\n\n\n" }, { "category": "Radiology", "chartdate": "2157-01-02 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1057500, "text": " 11:36 AM\n CHEST (PA & LAT) Clip # \n Reason: Eval for infiltrate or edema\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with hypoxia and cough\n REASON FOR THIS EXAMINATION:\n Eval for infiltrate or edema\n ______________________________________________________________________________\n FINAL REPORT\n AP AND LATERAL CHEST \n\n COMPARISON: Portable chest radiograph .\n\n INDICATION: Hypoxia and cough.\n\n FINDINGS: Interval removal of endotracheal tube and nasogastric tube. Lung\n volumes are low. Heart is upper limits of normal in size. Marked enlargement\n of pulmonary arteries with adjacent lymphadenopathy and parenchymal scarring\n seen to better detail on recent chest CTA and consistent with the known\n diagnosis of sarcoidosis likely complicated by pulmonary arterial\n hypertension. Small left pleural effusion and adjacent atelectasis.\n\n\n" }, { "category": "Radiology", "chartdate": "2157-01-01 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1057298, "text": " 1:22 AM\n CHEST (PA & LAT) Clip # \n Reason: eval ETT\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with ET intubation for resp failure\n REASON FOR THIS EXAMINATION:\n eval ETT\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Hypoxia.\n\n COMPARISON: Chest radiograph .\n\n PA AND LATERAL VIEWS OF THE CHEST: Evaluation of the study is due to patient\n rotation and low inspiratory volumes. The heart remains enlarged with\n calcification of the aortic knob. Perihilar areas of fibrosis and distortion\n are likely chronic, and appear unchanged. Prominence of the hilar regions\n also likely reflects underlying mild lymphadenopathy. No new areas of focal\n consolidation are demonstrated. No pleural effusions or pneumothorax is seen.\n Lateral view is limited due to patient positioning. Degenerative changes are\n again noted within the thoracic spine. Pulmonary vascularity is not engorged.\n No pneumothorax.\n\n IMPRESSION: Little change when compared to previous chest radiograph from\n .\n DFDdp\n\n" } ]

[ { "category": "Radiology", "chartdate": "2198-06-16 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1190348, "text": " 2:07 PM\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \n Reason: location of left basilic picc line 52 cm\n Admitting Diagnosis: AORTIC STENOSIS\\AORTIC VALVE REPLACEMENT /SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old woman with iv needs\n REASON FOR THIS EXAMINATION:\n location of left basilic picc line 52 cm\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: PICC line placement.\n\n Portable AP chest radiograph was reviewed in comparison to \n obtained at 08:44 a.m.\n\n The left PICC line tip is at the level of the atrium and should be pulled back\n for approximately 4 cm. The right internal jugular line is unremarkable.\n Cardiomediastinal silhouette is stable. Bilateral opacities are unchanged\n including the right upper lobe opacity, slightly asymmetric compared to the\n rest of the imaging. It might be worrisome for developing infectious process\n and should be closely monitored.\n\n\n" }, { "category": "Radiology", "chartdate": "2198-06-15 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1190149, "text": " 12:30 AM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p AVR w/hypoxia r/o PTX\n Admitting Diagnosis: AORTIC STENOSIS\\AORTIC VALVE REPLACEMENT /SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old woman with as above\n REASON FOR THIS EXAMINATION:\n s/p AVR w/hypoxia r/o PTX\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Evaluation of the patient after aortic valve\n replacement with hypoxia.\n\n Portable AP chest radiograph was reviewed in comparison to prior study\n obtained on at 8:40 p.m.\n\n There is new small-to-moderate right apical pneumothorax. Patient is in\n interstitial pulmonary edema. Bilateral pleural effusions are noted, left\n more than right. Aortic valve, Swan-Ganz catheter, and mediastinal drain are\n in expected positions.\n\n\n" }, { "category": "Radiology", "chartdate": "2198-06-16 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1190319, "text": " 8:40 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for ptx\n Admitting Diagnosis: AORTIC STENOSIS\\AORTIC VALVE REPLACEMENT /SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old woman s/p ct pull\n REASON FOR THIS EXAMINATION:\n eval for ptx\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Evaluation of the patient after chest tube pulling\n for the presence of pneumothorax.\n\n Portable AP chest radiograph was reviewed in comparison to .\n\n Right internal jugular line tip is at the level of superior SVC.\n Cardiomediastinal silhouette is stable. There are bilateral areas of basal\n atelectases. There is no evidence of pneumothorax. Small pleural effusion\n cannot be excluded.\n\n\n" }, { "category": "Radiology", "chartdate": "2198-06-18 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1190526, "text": " 9:47 AM\n CHEST (PA & LAT) Clip # \n Reason: eval for effusion\n Admitting Diagnosis: AORTIC STENOSIS\\AORTIC VALVE REPLACEMENT /SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old woman s/p avr\n REASON FOR THIS EXAMINATION:\n eval for effusion\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post AVR.\n\n COMPARISON: .\n\n CHEST RADIOGRAPH, PA AND LATERAL VIEWS: There are low lung volumes. Anterior\n mediastinal wires and aortic prosthesis are again noted.\n\n Bibasilar atelectasis has decreased from prior study. No pneumothorax is\n seen. Left retrocardiac opacity is less prominent than prior study of , , likely atelectasis.\n\n The cardiomediastinal and hilar contours are stable.\n\n IMPRESSION: Post-operative changes with interval increase in bilateral lung\n aeration and decreased bibasilar atelectasis since prior study of .\n\n" }, { "category": "Radiology", "chartdate": "2198-06-14 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1190080, "text": " 11:39 AM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: CARDIAC SURGERY FAST TRACK EXTUBATION, FOR PTX AND EFFU\n Admitting Diagnosis: AORTIC STENOSIS\\AORTIC VALVE REPLACEMENT /SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old woman with s/p AVR\n REASON FOR THIS EXAMINATION:\n CARDIAC SURGERY FAST TRACK EXTUBATION, FOR PTX AND EFFUSIONS. icu provider\n is , please page her if there is concern with findings\n ______________________________________________________________________________\n FINAL REPORT\n TYPE OF EXAMINATION: Chest AP portable single view.\n\n INDICATION: 77-year-old female patient status post aortic valve replacement,\n cardiac surgery fast track extubation, evaluate.\n\n FINDINGS: AP single view of the chest has been obtained with patient in\n supine position. The patient is now intubated, the ETT terminating in the\n trachea some 3 cm above the level of the carina. Sternotomy wires in place,\n right internal jugular approach sheath carries Swan-Ganz catheter the tip of\n which reaches central portion of the right pulmonary artery. An NG tube\n reaches well below the diaphragm. Mediastinal drainage tubes from below in\n place. No pneumothorax is seen. The pulmonary vasculature is now more\n distended than it was on the pre-operative chest examination but there is no\n evidence of pulmonary edema and no pleural effusion as the lateral pleural\n sinuses are free. No pneumothorax.\n\n IMPRESSION: Satisfactory first post-operative chest findings.\n\n\n" }, { "category": "Radiology", "chartdate": "2198-06-17 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1190425, "text": " 7:26 AM\n CHEST (PORTABLE AP) Clip # \n Reason: f/u effusions, atx\n Admitting Diagnosis: AORTIC STENOSIS\\AORTIC VALVE REPLACEMENT /SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old woman with s/p cardiac surgery\n REASON FOR THIS EXAMINATION:\n f/u effusions, atx\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST RADIOGRAPH OF \n\n COMPARISON: .\n\n FINDINGS: Following removal of right internal jugular vascular sheath, there\n is no visible pneumothorax. Heart size remains normal. Crowding of\n bronchovascular structures is present related to low lung volumes, limiting\n assessment of cardiovascular status of the patient.\n\n Left retrocardiac opacity has worsened and is probably a combination of\n atelectasis and effusion. Otherwise, no relevant changes since recent study.\n\n\n" }, { "category": "Radiology", "chartdate": "2198-06-15 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1190161, "text": " 2:12 AM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: s/p AVR w/?R apical PTX-evaluate size\n Admitting Diagnosis: AORTIC STENOSIS\\AORTIC VALVE REPLACEMENT /SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old woman with as above\n REASON FOR THIS EXAMINATION:\n s/p AVR w/?R apical PTX-evaluate size\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Evaluation of the patient after aortic valve\n replacement with right apical pneumothorax.\n\n Portable AP chest radiograph was reviewed in comparison to \n obtained at 00:37 a.m.\n\n Current study redemonstrates the presence of small right apical pneumothorax\n that appears to be decreased since the prior study. There is overall improved\n aeration of the right lung with still present bibasal opacities and right\n paramediastinal opacity that might represent developing atelectasis and should\n be closely followed to exclude the possibility of developing infection. The\n Swan-Ganz catheter tip is at the level of right ventricular outflow tract.\n The replaced aortic valve is in expected position. Bilateral pleural\n effusions are present.\n\n\n" }, { "category": "Echo", "chartdate": "2198-06-14 00:00:00.000", "description": "Report", "row_id": 89573, "text": "PATIENT/TEST INFORMATION:\nIndication: Aortic valve disease.\nHeight: (in) 63\nWeight (lb): 200\nBSA (m2): 1.94 m2\nBP (mm Hg): 150/90\nHR (bpm): 99\nStatus: Inpatient\nDate/Time: at 17:06\nTest: TEE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Mild LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. Normal interatrial septum.\n\nLEFT VENTRICLE: Mild symmetric LVH with normal cavity size.\n\nLV WALL MOTION: basal anterior - normal; mid anterior - normal; basal\nanteroseptal - normal; mid anteroseptal - normal; basal inferoseptal - normal;\nmid inferoseptal - normal; basal inferior - normal; mid inferior - normal;\nbasal inferolateral - normal; mid inferolateral - normal; basal anterolateral\n- normal; mid anterolateral - normal; anterior apex - normal; septal apex -\nnormal; inferior apex - normal; lateral apex - normal; apex - normal;\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Complex (mobile) atheroma in the descending aorta.\n\nAORTIC VALVE: Severely thickened/deformed aortic valve leaflets. Critical AS\n(area <0.8cm2).\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Mild to moderate (+)\nMR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS.\nPhysiologic PR.\n\nPERICARDIUM: No pericardial effusion.\n\nConclusions:\nPREBYAPSS: Preserved LV systolic function with LVEF>55%, no swma. The left\natrium is mildly dilated. There is mild symmetric left ventricular hypertrophy\nwith normal cavity size. Right ventricular chamber size and free wall motion\nare normal. There are complex (mobile) atheroma in the descending aorta. The\naortic valve leaflets are severely thickened/deformed. There is critical\naortic valve stenosis (valve area <0.8cm2). The mitral valve leaflets are\nmildly thickened. Mild to moderate (+) mitral regurgitation is seen. There\nis no pericardial effusion.\nPOSTBYPASS: normally functioning AV bioprosthesis. No AI No AS. MV unchanged.\nLVEF > 55%\n\n\n" }, { "category": "ECG", "chartdate": "2198-06-14 00:00:00.000", "description": "Report", "row_id": 242436, "text": "Sinus rhythm. Within normal limits.\n\n" } ]

[ { "category": "Radiology", "chartdate": "2147-10-20 00:00:00.000", "description": "DISTINCT PROCEDURAL SERVICE", "row_id": 984941, "text": " 8:10 AM\n RENAL U.S. PORT; -59 DISTINCT PROCEDURAL SERVICE Clip # \n DUPLEX DOP ABD/PEL LIMITED\n Reason: Renal ultrasound with doplers of renal arteries\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old woman with endocarditis, worsening creatinine and decreased urine\n output.\n REASON FOR THIS EXAMINATION:\n Renal ultrasound with doplers of renal arteries\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 64-year-old woman with endocarditis and worsening creatinine and\n decreased urine output.\n\n COMPARISONS: .\n\n RENAL DOPPLER ULTRASOUND:\n SCALE ULTRASOUND: The right kidney measures 10.4 cm in length. It\n contains a 7 mm nonobstructing stone in the mid portion. The left kidney\n measures 10.2 cm in length and appears normal. No hydronephrosis is seen in\n either kidney. No renal mass or perirenal fluid.\n DOPPLER EXAM: The Doppler study is very limited due to patient motion. The\n main renal arteries bilaterally are visualized and demonstrate normal\n waveforms with good systolic acceleration and flow throughout the diastole.\n The interrogation of the intrarenal arteries was very limited. One intrarenal\n artery is visualized in the mid portion of the right kidney demonstrating a\n normal waveform and an RI of 0.54. No intrarenal arteries are visualized in\n the left kidney. Venous waveforms are demonstrated in both main renal veins.\n\n IMPRESSION:\n 1. No hydronephrosis.\n\n 2. Nonobstructing 7-mm stone in the mid portion of the right kidney.\n\n 3. Technically limited Doppler exam due to respiratory motion, with\n demonstration of flow in both main renal arteries and veins.\n\n\n\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2147-10-16 00:00:00.000", "description": "CTA NECK W&W/OC & RECONS", "row_id": 984485, "text": " 11:22 PM\n CTA HEAD W&W/O C & RECONS; CTA NECK W&W/OC & RECONS Clip # \n Reason: Evaluate for aneurysm\n Field of view: 26 Contrast: OPTIRAY Amt: 80\n ______________________________________________________________________________\n FINAL ADDENDUM\n ADDENDUM:\n\n Upon review of this study and ancillary examinations, we cannot duplicate any\n abnormality within the thyroid gland in the accompanying cervical spine\n imaging study. Therefore, is not necessary as a followup procedure.\n\n\n\n\n 11:22 PM\n CTA HEAD W&W/O C & RECONS; CTA NECK W&W/OC & RECONS Clip # \n Reason: Evaluate for aneurysm\n Field of view: 26 Contrast: OPTIRAY Amt: 80\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old woman with SAH\n REASON FOR THIS EXAMINATION:\n Evaluate for aneurysm\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: AKSb TUE 12:49 AM\n Several foci of sub-arachnoid hemorrhage - in the high right frontal, left\n frontal, left parieto-occipital (dominant bleed). Pattern of distribution is\n atypical for aneurysal source. Per Neurosurg. Dr. , bleed is\n \"relatively stable compared to OSH CT\" (I have not seen this CT for direct\n comparison)\n\n CTA source and reformats (recons pending) demonstrate patency of the COW and\n its major branches, with no definite aneurysm.\n\n 5 mm extra-axial lesion along left parieto-temporal cortex with mild erosion\n of underlying bone - ?meningioma. Recc. MRI w/ gad on a non-emergent basis for\n further eval.\n\n ______________________________________________________________________________\n FINAL REPORT (REVISED)\n CLINICAL INDICATION: 64-year-old woman with subarachnoid hemorrhage, evaluate\n for aneurysm.\n\n TECHNIQUE: Contiguous axial images were obtained through the brain without\n contrast material. Subsequently, coronal images were obtained from the aortic\n arch through the brain during infusion of intravenous contrast. Reformatted\n images were reviewed.\n\n COMPARISON: Outside studies demonstrated \"Several foci of subarachnoid\n hemorrhage - high right frontal, left frontal, and left parietooccipital, not\n significantly changed compared to outside CT.\"\n\n FINDINGS:\n\n HEAD CT: Several foci of subarachnoid hemorrhage in the right frontal, left\n frontal, left parietooccipital lobe regions are noted. There is minimal\n associated edema without evidence of mass effect. No major vascular\n territorial infarct is identified. A 5- mm extra-axial lesion (2, 18) along\n the left parietotemporal lobe region may represent a meningioma, unchanged.\n There is no shift of the normally midline structures.\n\n Also noted is a 2cm wedge shaped area of infarction in the left parietal\n lobe, subacute to chronic in age.\n\n HEAD AND NECK CTA: The carotid and vertebral arteries and their major\n branches are patent with no evidence of stenosis. There is a 2-mm aneurysm\n (Over)\n\n 11:22 PM\n CTA HEAD W&W/O C & RECONS; CTA NECK W&W/OC & RECONS Clip # \n Reason: Evaluate for aneurysm\n Field of view: 26 Contrast: OPTIRAY Amt: 80\n ______________________________________________________________________________\n FINAL REPORT (REVISED)\n (Cont)\n directed inferiorly from the posterior margin of the left supraclinoid\n internal carotid artery. Irregularity along the left upper pole of the thyroid\n suggests ill defined mass.\n\n IMPRESSION:\n\n 1. 2-mm aneurysm from the supraclinoid left internal carotid artery is\n unlikley to relate to patient's symptoms, or account for the subarachnoid\n hemorrhage, given its distribution.\n\n 2. Several foci of subarachnoid hemorrhage as noted above. Left parietal\n lobe infarct, subacute to chronic.\n\n 3. Stable subcentimeter lesion along the left parietal temporal lobe region\n likely represents a meningioma.\n\n 4. Irregularity along the left upper pole of the thyroid may represent\n thyroid mass. obtain thyroid ultrasound if clinically indicated.\n\n\n All findings discussed with neurosurgery service by telephone on .\n\n\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2147-10-19 00:00:00.000", "description": "BY DIFFERENT PHYSICIAN", "row_id": 984892, "text": " 5:59 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: Evaluate NG tube placement.\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old woman with ICH, s/p itubation, replacement of NG tube.\n\n REASON FOR THIS EXAMINATION:\n Evaluate NG tube placement.\n ______________________________________________________________________________\n WET READ: 6:59 PM\n NG tube appropriately positioned.\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 6:25 p.m. on \n\n HISTORY: Intracerebral hemorrhage. Replaced NG tube.\n\n IMPRESSION: AP chest compared to at 3:25 a.m.:\n\n ET tube and nasogastric tube in standard placements. Lungs clear. Heart size\n normal.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2147-10-20 00:00:00.000", "description": "Report", "row_id": 1615176, "text": "MICU 6 Nursing Progress Note (0700-1900)\n\nPlease see flowsheet for all objective data. Mrs. is a 64 year old woman admitted to MICU from the SICU. Originally presented at OSH after her husband noted confusion, groaning and inability to follow commands.Head CT showed bilateral SAH. Transferred to , neurosurgery. Repeat head CT showed new left thalamic hemorrhage. +WBC on LP...triple antibiotics started. Blood and sputum grew staph aureus and a new systolic murmur was noted. TTE showed MV vegetation and severe MR. +thrombocytopenia with platelet count of 50. Vascular surgery consulted due to cool, cyanotic right hand. Probable septic emboli related to endocarditis. Pt unable to be anticoagulated due to recent head bleed. Pt underwent right radial thrombectomy and patch emergently , which was unsuccessful. Pt is now unresponsive and in renal failure. Dr. has met with husband to update him on his wife's condition and of her grave prognosis.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2147-10-20 00:00:00.000", "description": "Report", "row_id": 1615177, "text": "NPN (cont'd)\n\nREVIEW OF SYSTEMS\n\nCNS: Pt. is basically unresponsive. She has a minimal gag, no cough. She does clench her teeth when oral care attempted, but no other spontaneous movement noted. Pupils are equal and sluggishly reactive to light. +corneals per neuro. She has not received any sedation/analgesia today.\n\nRESP: Lungs are clear, no secretions via ETT. Sats of 100% on A/C 40% 450 x 30 with 5 of PEEP. She has become increasingly tachypneic (45) late this afternoon and is most likely becoming more acidotic...ABG pending. Serum bicarb of 12.\n\nVASCULAR: Please see flowsheet for hourly pulse checks. Feet are cold and mottled, no DP or PT's bilaterally, +popliteal pulses bilaterally per doppler. RUE is increasingly mottled/cyanotic without DP/PT pulses present, +brachial per doppler. The appearance of her RUE has worsened quickly throughout the day. LUE is cool and pale with ulnar/brachial/radial pulses present by doppler.\n\nCVS: Initially able to wean neo off, but pt again became hypotensive. Received 500cc NS IVB without improvement and neo has been restarted to maintaim MAP > 65 (2.5mcg/kg/min). Tachycardic with heart rate 110-120.\n\nGI: Abdomen soft with hypoactive bowel sounds throughout. No stool this shift. Tube feedings on hold due to continued high residuals.\n\nID: T max of 101 po, 500mg tylenol given per NGT. Standing gent has been dc'ed and level to be checked in AM. Continues on nafcillin.\n\nRENAL: Increasing BUN and creatinine. No urine output >12hr. +3.5L.\n\nSKIN: Abrasion over coccyx, barrier cream applied. Pt should have therapeutic bed.\n\nSOCIAL: Husband in and met with nursing and Dr. . Need for amputation of RUE at the elbow discussed and Mr. feels his wife would not accept this. Due to MSOF at this point and minimal hope for meaningful recovery, he wishes to make pt. DNR. Dr. currently speaking with pt's son. Pt also has a mother and 2 daughters, at least one of whom lives out of state.\n\nPLAN: Continue to follow neuro exam.\n Continue to follow hemodynamic parameters. Re-evaluate with housestaff re? increasing pressors\n Support to family as they deal with this devastating diagnosis and as they consider withdrawal.\n" }, { "category": "Nursing/other", "chartdate": "2147-10-20 00:00:00.000", "description": "Report", "row_id": 1615178, "text": "Addendum: ABG of 7.35 16 131 -13 9. Pt given 2mg MSO4 due to persistent tachycardia. Increased metabolic acidosis, as lactate is also up to 4.8. Ionized calcium .98, to receive 3 amps. Neo to be titrated up as needed, will not add another pressor. Son, , is aware of pt's continued decline and will notify various family members.\n" }, { "category": "Nursing/other", "chartdate": "2147-10-20 00:00:00.000", "description": "Report", "row_id": 1615179, "text": "Resp Care\nPt remains intubated on CMV, no vent changes. Pt remains tachypnic, met acidosis, abg's as noted. Worsening status, now DNR. Will continue with current tx.\n" }, { "category": "Nursing/other", "chartdate": "2147-10-20 00:00:00.000", "description": "Report", "row_id": 1615180, "text": "MICU Nursing Note 1900-2330\nEVENTS: pt unresponsive during evening with HR= 80-110 SR/ST with occasional PVC's, BP 90/40-50's with IV Neosynephrine infusing at 5mcgs/kg/min, RR 30's, Temp 100.1. Family (son , mother , stepfather, brother, niece) in to visit and had family meeting with MICU intern---all questions answered and pt remained DNR/DNI. Medicated with 4mg. IV Morphine at 2200 for increased tachypnea with good effect. STsegment elevation noted on tele monitor in V lead at approx. 2230--EKG confirmed ST segment elevation and shortly after pt went into idioventricular rhythm and then VT and asystole with Neosynephrine gtt infusing wide open. MICU team aware and assessed pt, pt with no heart rate, no pulse, no spontaneous respirations and MICU team pronounced pt at 2330. MICU resident called pt's son and pt's son asked that we allow him to tell pt's husband . MICU resident had contact pt's husband with initial EKG changes and he was aware that pt's condition was deteriorating at that time and he advised that he would not be in to visit. Pt expired at 2330.\n" }, { "category": "Nursing/other", "chartdate": "2147-10-17 00:00:00.000", "description": "Report", "row_id": 1615163, "text": "status\nD: FEBRILE..PROPOFOL DC'D..PT UNRESPONSIVE WITHDRAWS TO PAINFUL STIMULI DOESN'T FOLLOW COMMANDS..P=RL..RT HAND COLD FINGERS BLUE\nA: RT RADIAL A-LINE DC'D WITH SOME IMPROVEMENT IN HAND COLOR BUT STILL COLD..RT FEM A-LINE INSERTED..PAN CULTURED..HEAD & NECK CT DONE..LP DONE FLUID CLEAR PRESSURE 11(PROTEIN & WBC'S ELEVATED) ? MENINGITIS PLACED ON DROPLET PERCAUTIONS..VENT CHANGES & ABG'S SEE FLOW SHEET BORDERLINE HUO'S HO AWARE..STARTED ON TF'S\nR: UNRESPONSIVE\nP: AWAITING CULTURE RESULTS..REMAIN ON DROPLET PRECAUTIONS UNTIL RESULTS BACK..Q1H NEURO SIGNS..CHECK TF RESIDUALS Q4-6H HOLD FOR >100CC\n" }, { "category": "Nursing/other", "chartdate": "2147-10-17 00:00:00.000", "description": "Report", "row_id": 1615164, "text": "Resp Care\n\nPt remains intubated and currently vented on PSV 10/5 tol well with Vt around 300-400cc and MV 8-10L. BS essentially clear sxing for small amts of thick white secretions. Pt transported to and from ct scan without any incident. Will cont to follow and wean when appropriate.\n" }, { "category": "Nursing/other", "chartdate": "2147-10-18 00:00:00.000", "description": "Report", "row_id": 1615165, "text": "Resp Care Note\nReceived pt from SICU on PSV with RR in high 20's. RR increased to 35 and did not change with increases in PSV. Placed on AC 450/20/+5/40%. RR now 27-32. Changed circuit to heated wire due to high VE. Suctioning small amts of thick white secretions. Rotated and retaped OETT at 23cms. Pt on droplet precautions to rule out meningitis. Ambu bag and mask at bedside.\nPlan: cont on current settings.\n" }, { "category": "Nursing/other", "chartdate": "2147-10-18 00:00:00.000", "description": "Report", "row_id": 1615166, "text": "REVIEW CAREVUE FOR DETAILS.\n\nEVENTS :\n\nFLUID BOLUSED FOR LOW URINE OUTPUT & BORDERLINE BP WITH MINIMAL EFFECT, CRITICAL PHOS LEVEL - REPLETED WITH NEUTRAPHOS. TACHYPNOIC, VENT MODE CHANGED FROM CPAP TO AC WITH VERY LITTLE EFFECT.\n\nNEURO : NEURO CHECKS Q 1 HRLY. UNRESPONSIVE, RESPONDS TO NAILBED PRESSURE BY WITHDRAWING MILDLY, NO SPONTANEOUS MOVEMENT SEEN TO UPPER & LOWER EXTREMITIES. BIL PUPILS 4MM IN SIZE EQUAL & REACTING TO LIGHT BRISKLY. ORDERS FOR PROPOFOL GTT IF PATIENT IS TACHYPNOIC. HAS A J COLLAR. NO FRACTURES PRESENT AS MD. S/P FOR SUB ARACHNOID & THALAMIC BLEED. THERE IS A 2MM ANEURYSM IN THE POST MARGIN OF THE SUPRACLINOID INTERNAL CAROTID ARTERY. NO SIZURES SEEN TILL TIME NOTED. CONTINUED ON IV PHENYTOIN DOSES.\n\nRESP : REMAINS VENTED,VENT MODE CHANGED AS MENTIONED ABOVE - CONTINUES TO BE IN RESP ALKALOSIS. LS CLEAR.\n\nCVS : NSR, NO ECTOPY NOTED. SBP 90'S TO 120'S, MAP'S 60'S TO 80'S. RT. FEM A-LINE IN PLACE. PIV X 2 . RIGHT HAND MOTTLED & COLD WITH CYANOTIC FINGER TIPS. WEAK PULSES AUDIBLE WITH DOPPLER.BIL LEXTREMITIES HAS A DUSKY LOOK & IS COLD. PULSES AUDIBLE WEAKLY ON DOPPLER. COAGULATION PROFILE & CBC & LYTES MONITORED & REPLETED AS MENTIONED ABOVE. S/P ? TTP, NO PLAN TO DO PLASMA PHORESIS AT PRESENT.\n\nGI : ABDOMEN SOFT, HYPOACTIVE BS, ON TF WITH REPLETE WITH FIBER AT 10 MLS/HR, NOT TO INCREASE THE RATE TILL FURTHER ORDERS. BNO.\n\nGU : DRAINING MINIMAL AMTS OF URINE, FLUID BOLUSED WITH LITTLE EFFECT.\n\nID : ON DROPLET PRECAUTIONS FOR ? BACTERIAL MENINGITIS. FEBRILE, BC POSITIVE FOR GRAM POSITIVE COCCI. CONTINUED ON AMPICILLIN, ACYCLOVIR,\nGENTAMYCIN & VANCO.\n\nSKIN : HAS LESIONS ON THE RIGHT SIDE OF THE FACE & UPPER BACK, NO PRESSURE SORES NOTED BELOW THE DEPENDANT SITES OF THE COLLAR OR BACK.\n\nENDO : FS Q 6 HRLY, ON S/S.\n\nSOCIAL : SON CALLED, UPDATED ON PATIENT'S CURRENT STATUS , PHONE NOS. GIVEN & RECORDED IN THE CHART. HE IS NOT SURE IF THE HUSBAND HAS ANY RECORDS OF HEALTH PROXY OFFICIAL PAPERS, THIS NEEDS TO BE FOLLOWED UP.\n\nPLAN :\n\nCONTINUE NEURO CHECKS Q 1 HRLY.\nCONTINUE MONITORING ABG / LYTES/ HEMATOLOGY PROFILES.\n? START PROPOFOL IF TACHYPNOIC & BP STABLE.\n?CENTRAL LINE INSERTION.\nEMOTIONAL SUPPORT TO FAMILY.\n\n" }, { "category": "Nursing/other", "chartdate": "2147-10-18 00:00:00.000", "description": "Report", "row_id": 1615167, "text": "Nursing Progress Note 0700-1900\n\nEvents: Echo done showing + MR Vegetation on valve, Repeat CT scan showing no extension of hemoragic areas, no new areas of hemmorhage. EEG without seizure activity, + for metabolic encephalopathy. US of abdomen done results pending. Mental status continues to decline, extremties increasingly cold and mottled.\n\nNeuro: Grimaces when gag reflex tested, does not withdraw any extremities to nailbed pressure. PEERLA, corneal, cough and gag reflex impaired but present. Head CT & EEG done results as previously noted. Continues on Dilanting TID for seizure prophalaxis. Given 1 mg Versed this AM without effect on RR, HR. Given 1 mg morphine at 1830 without change in vitals.\n\nResp: Vent settings decreased to AC 14/40%/450/+5, continues to breath at a rate of 28-35. Trailed on PS briefly RR up to 50's. ABGs as noted in carevue. Lung sounds clear, suctioned for minimal amounts of clear secretions\n\nCardiac: HR increasing all day currently 120-130's Sinus Tachy. Hemodynamically stable. RUE with cyantoic fingertips, mottling of the way up arm. Radial pulse by dopplear only, unable to appreciate ulnar pulse. LUE Warm, pulses by dopplear. Bilaterally lower extremities increasingly dusky and cool through day, Unable to dopplear DP, PT by dopplear.\n\nGI: Abdomen soft distended, + BS in 4 quadrents although hypoactive. TF infusing at 10 ml/hr (replete with fiber) without orders to increase. TF residuals 20-30 ml. No BM this shift on Senna/colace\n\nRenal: UOP marginal all day 20-30 cc/hr, last tow hours 10 cc team aware. Urine clear amber in color\n\nHeme: Given 1 unit plts for PLT count of 29, PLTup to 62 post transfusion. To get second unit of PLTS when available. Goal PLT above 80\n\nID: T-max 101, BC x 2 sent from a-line. Continues on Genta (peak & trough due over night with 3 am dose), Vanco, Nafacillin and Acyclovir. Continues on Droplet precautions\n\nSkin: Grossly intact, extremities as noted above\n\nFEN: FS 137-156, treated per RISS. Phos 1.1 currently being repleted with neutra-phos.\n\nSocial: Husband and Son in to visit, Updated by Dr. re: severity of situation\n\nAccess: Team hesitant to place central line D/T likely MSSA bactermia and vegitation two new PIVS placed today, Right fem art line\n\nPlan:\n\n1. Continue with Q 1 hour neuro and extremitie checks\n2. Monitor temp curve, culture data ANBX as ordered\n3. Routine ICU monitoring and care\n4. Emotional Support to family\n" }, { "category": "Nursing/other", "chartdate": "2147-10-19 00:00:00.000", "description": "Report", "row_id": 1615168, "text": "This is a 64 y old woman who was adm from OSH with multiple sml SAH via head CT, and was intubated for airway protection D/T agitation. Pt was also adm with NSTEMI, thrombocytopenia (?source) and ARF (pre renal). AT , Head CT showed Rt frontal, Lt parieto-occipital and Lt Thalmic bleed. Ech done showed EF of 55% and mod veg on MV with +4 MR. with GPC (via BC) endocarditis (? source of sepsis). Pt now has motteling to bil feet and Rt hand/arm with sml black spots to finger and toes (arterial vs septic emboli). Vascular srgery is following pt. No anticoagulation to be given. ? need for F/U head CT vs MRI of brain.\n\nROS:\n\nNeuro) Pt remains intubated (OETT) on NO sedation. Pt only opens eyes when she is turned side to side in bed. Pupils = and reactive to light. Rt arm and LLE flaccid. RLE with + babinski. LUE w/d to nail bed stimuli. NO spon movements noted. Impaired gag. Pt on dilantin TID. No contact from family over night. ? need for family meeting for POC.\n\nID) WBC NL. Tmax 99.8. F/U BC x 2 done. Bc, sputum and urine culture pending. Pt on precaution for bacterial meningitis (LP results due back today). Gentamycin for GPC endocarditis. Pt is also on vanco and Nafcillin.\n\nCV) Pt found at 8 pm to be in ST (120-130's). Hr back in NSR (80-90's) after IVF given in setting of sepsis. Total 1 liter given. SBP 95-120 with MAP > 65. PLT level 35 last night and 1 unit PLTs given with good effect. PLT level now stable at 72->62. Ica also replaced and now stable. No edema noted. Pulses + as noted in care vue. Aline with good wave form. Hct dropping slowly 26->24, but no s/s of bleed.\n\nResp) No vent changes made over night. Pt remains in Resp alkalosis via ABG's. Pt found to be over breathing the vent. No sedation to be given overnight MD. ABGs slight improved. LS CTA. NO secretions via deep sx.\n\nGI) Abd soft with now + BS. TF with residuals 40-50 cc. TF at 10 cc/hr. NO BM. RISS with stable BS.\n\nGU) Low U/O via catheter. U/O did improve as noted after IVF.\n\nSkin) see care vue for details.\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2147-10-19 00:00:00.000", "description": "Report", "row_id": 1615169, "text": "Resp Care Note\nPt remains on AC 14/450/+5/40%. ABG on current settings 7.49/26/172/20. Pt overbreathing set rate by . Breath sounds essent clear. Suctioning no secretions. RSBI 112. Ambu bag and mask at bedside. OETT patent and secure.\nPlan: cont on current vent settings.\n" }, { "category": "Nursing/other", "chartdate": "2147-10-19 00:00:00.000", "description": "Report", "row_id": 1615170, "text": "resp. care\npt. remains intubated/vented/sedated. no vent changes\nthis shift. to o.r. for embilzation of hand. ? wean\nin a.m.\n" }, { "category": "Nursing/other", "chartdate": "2147-10-19 00:00:00.000", "description": "Report", "row_id": 1615171, "text": "Nursing Progress Note 0700-1900\n\nEvents: Down to the OR for emergent thrombectomy and of right radial artery after US showed no flow to hand post pt remains without dopplearable pulses. TEE showing large vegetation on Mitral valve\n\nNeuro: Remains unresponsive despite being off sedation. Slight movement of LUE to pain, no movement of LUE, or lower extremities to pain. No response to sternal rub. Gag relfex but weak, does bit down on catheter when suctioned. PERLLA. Eyes open when being turned.\n\nCardiac: Tele remains in ST 110-120's. Hemodynamically stable with BP 100-120/60-70's. LUE with + 2 edema, warm to touch..pulses by dopplear. RUE cold cynanotic, pulse found in brachial artery only. Bilateral lower extremities cold to touch and mottled. right PT dopplearable otherwise pulses absent. Mutiple small hemmorages to extremities noted. Needs daily EKG\n\nResp: Remains intubated on A/C 40%/450/x14/+5, overbreathing vent 14-16 BPM, remains in a respiratory alkalosis. Lungs clear, no secretions noted ? transitioning to PS\n\nGI: TF held this AM D/T TEE and OR, OGT replaced after TEE, X-ray done awaiting verification of placement before restarting TF (replete with fiber) at 10 cc/hr. Abodmen soft + BS in 4 quadrents, no stool this shift\n\nRenal: Foley draining minimal amounts of amber urine with sediment. Creat continues to rise. Repeat urine lytes sent this evening. + 2 liters for day\n\nID: droplet precautions D/C'd. Am vanco level 22.9 so AM dose held, evening level pending. Acyclovir D/C'd. Gent peak and trough due with AM dose. Nafacillin Q 4 hours. Continues on daily BC\n\nHeme: Small amount of bleeding from gums noted after TEE, repeat CBC pending. HIT antibody sent.\n\nSkin: grossly . Extremities as noted in above RIght radial DRSG with a small amount of blood but , Left fem DRSG from harvest site\n\nSocial: Husband, son & Mother in to visit Updated by multiple teams re: POC....Remains full code\n\nFEN: FS have remain well controlled on RISS but has not needed coverage.\n\nPlan:\n\n1. Daily BC, ANBX as ordered\n2. Hourly neuro checks, Follow extremity exam\n3. Restart TF once OGT placement confirmed\n4. Monitor cardiac status, daily EKG's\n5. For MRI 2-3 days to further evaluate SAH\n6. Routine ICU monitoring and care\n7. Emotional support to family\n\n" }, { "category": "Nursing/other", "chartdate": "2147-10-20 00:00:00.000", "description": "Report", "row_id": 1615172, "text": "REVIEW CAREVUE FOR DETAILS.\n\nALLERGIC TO FENTANYL, DILAUDID & COMPAZINE.\n\nFULL CODE.\n\nEVENTS :\nPATIENT TACHYPNEIC RR 37 TO 42 ON THE VENT & TACHYCARDIC GRADUALLY INCREASED FROM 115 TO 135. EKG SHOWED ST. DYSYNCHROUS WITH THE VENT, TRIED ON PS, RR UP TO 55, CHANGED IMMEDIATELY TO CMV MODE ON THE VENT. STARTED ON PROPOFOL GTT & GIVEN MORPHINE 1 MG IV WITH NO EFFECT, FLUID BOLUSED FOR TACHYCARDIA OF 135 WITH TEMPORARY DECREASE IN HR TO 128. SEEN BY ATTENDING, MORPHINE 2 MGS IV REPEATED , FLUID BOLUSED & VENT SET RR INCREASED TO 30. MORPHINE 2MGS IV REPEATED AFTER 30 MINS, MULTIPLE FLUID BOLUSES GIVEN FOR SYSTOLIC BP'S IN 90'S & ALMOST NIL URINE OUTPUT WITH NO EFFECT ON THE URINE OUTPUT. BUN / CREAT RISING. RENAL TEAM TO SEE IN AM AS MD.\n RESPONDED WELL TO MORPHINE. HR REDUCED TO 115. RR AT 30. NOTED P/M/H - S/P FOR FIBROMYALGIA, HAS BEEN ON PRESCRIPTION DOSES OF PAIN MEDS AT HOME. IONIZED CALCIUM LOW, IV CALCIUM GLUCONATE 2 GRAMS GIVEN. FEBRILE- BLOOD CULTURED. PLATELET COUNT AT MN REDUCED TO 51. NO PLAN TO TRANSFUSE THEN. AM LABS PENDING. NO PT & DP PULSES APPRECIATED ON BIL LOWER EXTREMITIES, SEEN BY INTERN, POPLITEAL PULSES PRESENT ON BLE. RN DISCUSSED ABOUT THE RT FEMORAL LINE ,? BENEFITS OF THE A-LINE VERSUS AGGRAVATIING PATIENT'S LIMB CONDITION, AS MD TO DISCUSS IN ROUNDS IN AM. RT HAND IS CYANOTIC WITH NO RADIAL OR ULNAR PULSES, SEEN BY VASCULAR MD & NEUROSURGERY MD, NO PLANS TO TAKE TO OR , ? NEEDS ANTICOAGULATION WITH RISKS OF INTRACRANIAL BLEED, NO PLANS TO START ON ANY ANTICOAGULATION AT PRESENT ? HIT +, STARTED ON ASPIRIN 325 MGS.\n\nNEURO : NEURO CHECKS CONTINUED Q 1 HRLY. UNRESPONSIVE, BIL PUPILS REACTING TO LIGHT BRISKLY 3-4 MM, SEE CAREVUE FOR NEURO ASSESSMENT DETAILS. RESPONDED WELL TO MORPHINE AS MENTIONED ABOVE. CONTINUED ON LOW DOSE PROPOFOL.\n\nRESP : REMAINS VENTED ON CMV MODE, LS CLEAR, SCANT ETT SECRETIONS.\n\nCVS : ST ,NO ECTOPY SEEN. SBP 90'S TO 120'S, MAPS 60'S TO 80'S. HR 113 TO 130'S. PLAN TO INSERT CENTRAL LINE IN AM AS ATTENDING MD. ALMOST 2.5 LITS FLUID BOLUSED OVERNIGHT. PLATELETS UP TO 50, LACTIC ACID IS 2.6 IN AM LABS. GENTAMYCIN TROUGH LEVELS SENT, RESULTS PENDING. THEREFORE DOSE NOT GIVEN YET.\n\nGI : ABD SOFT, HYPOACTIVE BS, TF RESIDUALS 100. FEEDS HELD FOR 4 HRS & RESTARTED AS RESIDUALS 10 MLS. NO BM THIS SHIFT.\n\nGU : SILICON CATHETER PRESENT, URINE OUTPUT NIL TO 10 MLS/HR ,TOTAL 25 MLS SINCE 8PM TILL TIME NOTED. BUN/ CREAT RISING.\n\nID : FEBRILE, BLOOD CULTURED, TYLENOL GIVEN WITH MILD EFFECT, VANCO & ACYCLOVIR DC'D, CONTINUED ON NAFICCILIN & GENTA. OFF DROPLET PRECAUTIONS. POSITIVE FOR MSSA.\n\nSKIN : AS MENTIONED IN CAREVUE. HAS CYANOTIC RT HAND, MOTTLED BLE, WARM NORMAL LEFT UE. RASHES ON FACE & BACK, HAS MINIMAL ORAL BLEEDING ? BLEEDING GUMS.\n\nSCD'S DC'D TO LOWER LIMBS, HAS MULTIPODUS BOOTS ON.\n\nENDO : ON RISS, NO COVERAGE REQUIRED TILL TIME NOTED.\n\nSOCIAL : NO CALLS OR VISITS FROM FAMILY TILL TIME NOTED.\n\nPLAN :\nCONTINUE NEUROCHECKS Q 1 HRLY.\n? DC FEMORAL A-LINE .\nCONTINUE VASCULAR CHECKS.\nADEQUATE\n" }, { "category": "Nursing/other", "chartdate": "2147-10-20 00:00:00.000", "description": "Report", "row_id": 1615173, "text": "(Continued)\nPAIN MANAGEMENT.\nDAILY EKG'S TO BE DONE AS PER CARDIOLOGY.\nMONITOR HCT/ PLATELETS/ LYTES/ HEME, MONITOR FOR BLEEDING.\nMONITOR I/O- FOLLOW UP WITH RENAL.\n? CENTRAL LINE INSERTION.\nFOLLOW TEMP CURVE ,FOLLOW UP ON CULTURES, ADEQUATE ANTIBIOTIC COVERAGE. FOLLOW UP ON GENTAMYCIN TROUGH LEVELS, IF DOSE ADMINISTERED- TO SEND FOR PEAK LEVEL\n" }, { "category": "Nursing/other", "chartdate": "2147-10-20 00:00:00.000", "description": "Report", "row_id": 1615174, "text": "resp care\nPt initially on a/c 450x14 -overbreathing to a rate of 30-40. Pt out of phase with vent. Sedation and fluid bolus started with no effect. RR inc on the vent md to match spont rr but pt continued to look uncomfortable and out of phase. Sedation inc and pt finally stopped overbreathing. ABG reveal a compensated met acidosis.RSBI attempted=120.Current settings are a/c 450x30 40% 5peep.Will cont to follow.\n" }, { "category": "Nursing/other", "chartdate": "2147-10-20 00:00:00.000", "description": "Report", "row_id": 1615175, "text": "Addendum :\n\nSBP IN LOW 90'S MAP'S IN LOW 60'S, 500MLS IV BOLUSED AS PER ORDERS, ATTENDING AT BEDSIDE, ORDERS TO START NEOSYNEPHRINE VIA PERIPHERAL IV IF NEEDED, UNTIL A CENTRAL LINE IS PLACED.\nPATIENT TURNED ON TO HER LEFT SIDE TO GIVE BACK CARE , SBP IN 80'S, STARTED ON NEOSYNEPHRINE AS PER ORDERS WITH GOOD EFFECT. MD INFORMED. I\n" }, { "category": "Nursing/other", "chartdate": "2147-10-17 00:00:00.000", "description": "Report", "row_id": 1615161, "text": "Resp: pt intubated #7.5, taped @ 23 lip via ER with vent settings. a/c 14/500/+5/100%. CT scan results in SAH. Suctioned for small amounts of tan thick secretions. BS are clear bilaterally. AM ABG 7.50/28/?/23. 02 sats @ 100%. Vent changes to present a/c 12/500/+5/60%. No rsbi=^ fio2 Plan to wean as tolerated.\n" }, { "category": "Nursing/other", "chartdate": "2147-10-17 00:00:00.000", "description": "Report", "row_id": 1615162, "text": "Nursing Progress Note:\nPlease see CareVue for details.\n Pt is a 64yo female who was admitted to ED from OSH with CT evidence of bialteral subarachnoid hemorrhage. husband brought the pt to after 2 days of agitation and confusion. Pt intubated in ED and went for repeat head CT. Transferred to SICU-B at approximately 0045 for close neuro and BP monitoring. PMH: hepatitis C, fibromyalgia, anemia, s/t tubal ligation, s/p D&C, and tonsillectomy.\n Neuro exam q1hr. Ppf gtt AT 10Mmcg/kg/min. Pt does not open eyes to command or to pain. PERRLA. Pt localizes pain. Withdraws extremities to nailbed pressure. Pt can lift/hold LUE. Moves RUE and BLE in bed. Absent gag/cough reflex. +corneal reflex. No seizures noted. Repeat head CT today. Tmax 99.7. HR 70-90s (NSR). Pt with PVCs upon arrival to SICU, but no further ectopy. Goal SBP <140. A-line placed. NS 500mL IVB x1 given for hypotension with +effect. SBP increased to low 100s after IVB. PIV x2. IVF: D5 1/2 NS with 20meq KCl @ 75cc/hr. Potassium, magnesium, and calcium repleted. Fingers on right hand mottled; Dr. aware. Left hand cold. Venodyne boots on BLE. Lungs clear. ABG showed respiratory alkalosis. Current vent setting: CMV 40%, Vt 450 x 10, PEEP 5. See CareVue for vent changes. Pt suctioned for small amount thick, tan secretions. Abdomen soft with hypoactive bowel sound. OGT to low continuous suction with green, bilious output. No bowel movement. FS q6hr; treated with sliding scale. Foley intact with clear, yellow urine. Urine output low for 1hr (5cc), but then increased to 30cc/hr after IVB. Urine culture, UA, urine lytes sent. No pressure sores noted. Cervical collar changed to -J collar. No calls/visits from family overnight.\n Plan: Monitor VS, I's and O's, labs. Monitor neuro and respiratory status. Neuro exam q1hr; notify HO with any changes. Head CT today. Wean vent setting as tolerated. Wean Ppf gtt. Keep SBP <140. Update pt and family on plan of care; provide emotional support. Continue ICU care and treatment.\n" }, { "category": "Echo", "chartdate": "2147-10-19 00:00:00.000", "description": "Report", "row_id": 86028, "text": "PATIENT/TEST INFORMATION:\nIndication: Endocarditis.\nHeight: (in) 65\nWeight (lb): 120\nBSA (m2): 1.59 m2\nBP (mm Hg): 114/72\nHR (bpm): 109\nStatus: Inpatient\nDate/Time: at 16:30\nTest: Portable TEE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Lipomatous hypertrophy of the interatrial\nseptum. No ASD by 2D or color Doppler.\n\nLEFT VENTRICLE: Symmetric LVH. Overall normal LVEF (>55%).\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Simple atheroma in aortic arch. Simple atheroma in descending aorta.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). Trace AR.\n\nMITRAL VALVE: Abnormal mitral valve. Large vegetation on mitral valve. No\nmitral valve abscess. Eccentric MR jet. Moderate (2+) MR.\n\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Mild [1+] TR.\n\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.\n\nPERICARDIUM: Trivial/physiologic pericardial effusion.\n\nGENERAL COMMENTS: A TEE was performed in the location listed above. I certify\nI was present in compliance with HCFA regulations. The patient was monitored\nby a nurse throughout the procedure. No TEE related\ncomplications.\n\nConclusions:\nNo atrial septal defect is seen by 2D or color Doppler. There is symmetric\nleft ventricular hypertrophy. Overall left ventricular systolic function is\nnormal. Right ventricular chamber size and free wall motion are normal. There\nare simple atheroma in the aortic arch. There are simple atheroma in the\ndescending thoracic aorta. The aortic valve leaflets (3) are mildly thickened.\nTrace aortic regurgitation is seen. The mitral valve is abnormal. There is a\nlarge mobile vegetation on the posterior mitral valve leaflet measuring at\nleast 2.5cm in length and approximately 0.7cm in width. The posteriorly\nleaflet is severly deformed/thickened. The aniteror mitral leaflet is mildly\ndeformed. No mitral valve abscess is seen. Moderate (2+) mitral regurgitation\nis seen. The tricuspid valve leaflets are mildly thickened.\n\nIMPRESSION: Very large mobile vegetation on posterior mitral valve leaflet. No\nabscess seen. Moderate mitral regurgitation.\n\n\n" }, { "category": "Echo", "chartdate": "2147-10-18 00:00:00.000", "description": "Report", "row_id": 86029, "text": "PATIENT/TEST INFORMATION:\nIndication: Endocarditis.\nHeight: (in) 64\nWeight (lb): 147\nBSA (m2): 1.72 m2\nBP (mm Hg): 113/65\nHR (bpm): 123\nStatus: Inpatient\nDate/Time: at 15:45\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. Normal IVC diameter\n(1.5-2.5cm) with >50% decrease during respiration (estimated RAP 5-10 mmHg).\n\nLEFT VENTRICLE: Mild symmetric LVH with normal cavity size and systolic\nfunction (LVEF>55%). [Intrinsic LV systolic function likely depressed given\nthe severity of valvular regurgitation.]\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.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Moderate-sized\nvegetation on mitral valve. Mild mitral annular calcification. Calcified tips\nof papillary muscles. Severe (4+) MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR. Mild PA\nsystolic hypertension.\n\nPERICARDIUM: Small pericardial effusion.\n\nGENERAL COMMENTS: Resting tachycardia (HR>100bpm). Cardiology fellow involved\nwith the patient's care was notified by telephone.\n\nConclusions:\nThe left atrium is normal in size. The estimated right atrial pressure is \nmmHg. There is mild symmetric left ventricular hypertrophy with normal cavity\nsize and systolic function (LVEF>55%). [Intrinsic left ventricular systolic\nfunction is likely more depressed given the severity of mitral regurgitation.]\nRight ventricular chamber size and free wall motion are normal. The aortic\nvalve leaflets (3) are mildly thickened but aortic stenosis is not present. No\naortic regurgitation is seen. The mitral valve leaflets are mildly thickened.\nThere is a moderate-sized, 1cm long/elongated, mobile echodensity that appears\nto be attached to the posterior annulus and herniates into the left\nventricular cavity in diastole and into the left atrium in ventricualr systole\nc/w a vegetation vs. torn leaflet. Severe (4+) mitral regurgitation is seen.\nThere is mild pulmonary artery systolic hypertension. There is a small\nprimarily anterior pericardial effusion without evidence for hemodynamic\ncompromise.\n\nIMPRESSION: Likely mitral valve vegetation vs. torn leaflet with severe mitral\nregurgitation. Mild pulmonary artery systolic hypertension. Mild symmetric\nleft ventricular hypertrophy with preserved global and regional biventricular\nsystolic function.\nIf clinically indicated, a TEE would be better able to define the mitral valve\nmorphology.\n\n\n" }, { "category": "ECG", "chartdate": "2147-10-20 00:00:00.000", "description": "Report", "row_id": 219500, "text": "Compared to prior tracing the cardiac mechanism is unclear but is probably\nstill sinus with a markedly widened QRS complex and peaked T waves in the\nanterior precordium. The tracing is highly suggestive of hyperkalemia.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2147-10-20 00:00:00.000", "description": "Report", "row_id": 219501, "text": "Normal sinus rhythm, rate 78, with variable sinus rate and occasional\natrial premature beats. Left anterior hemiblock. Intraventricular conduction\ndelay. Non-specific lateral repolarization changes. Compared with tracing\nof left anterior hemiblock and intraventricular conduction delay\nare new, and sinus tachycardia has given way to normal sinus rhythm.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2147-10-20 00:00:00.000", "description": "Report", "row_id": 219502, "text": "Sinus tachycardia. Occasional atrial premature beats. Diffuse non-specific\nST-T wave changes. Low QRS voltage in limb leads. Compared to tracing\nof there is no significant diagnostic change.\n\n" }, { "category": "ECG", "chartdate": "2147-10-19 00:00:00.000", "description": "Report", "row_id": 219503, "text": "Sinus tachycardia\nInferior/lateral T changes are nonspecific\nLow QRS voltages in limb leads\nNo previous tracing available for comparison\n\n" } ]

[ { "category": "Echo", "chartdate": "2193-04-26 00:00:00.000", "description": "Report", "row_id": 91347, "text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function.\nHeight: (in) 71\nWeight (lb): 169\nBSA (m2): 1.97 m2\nBP (mm Hg): 132/61\nHR (bpm): 72\nStatus: Inpatient\nDate/Time: at 15:51\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Elongated LA.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. Normal interatrial septum.\nNo ASD by 2D or color Doppler.\n\nLEFT VENTRICLE: Mild symmetric LVH. Normal LV cavity size. Mild-moderate\nregional LV systolic dysfunction. No LV mass/thrombus. No resting LVOT\ngradient. No VSD.\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: basal inferior\n- hypo; basal inferolateral - hypo; mid inferolateral - hypo; basal\nanterolateral - hypo; mid anterolateral - hypo; anterior apex - hypo; septal\napex - hypo; apex - hypo;\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal diameter of aorta at the sinus, ascending and arch levels.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. Mild (1+) AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. No MS. Mild (1+)\nMR.\n\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. No TS. Mild [1+]\nTR. Indeterminate PA systolic pressure.\n\nPULMONIC VALVE/PULMONARY ARTERY: No PS.\n\nPERICARDIUM: No pericardial effusion.\n\nConclusions:\nThe left atrium is elongated. No atrial septal defect is seen by 2D or color\nDoppler. There is mild symmetric left ventricular hypertrophy. The left\nventricular cavity size is normal. There is mild to moderate regional left\nventricular systolic dysfunction with basal to mid lateral hypokinesis and\ndistal septal/distal anterior and apical septal hypokinesis. No masses or\nthrombi are seen in the left ventricle. There is no ventricular septal defect.\nRight ventricular chamber size and free wall motion are normal. The diameters\nof aorta at the sinus, ascending and arch levels are normal. The aortic valve\nleaflets (3) are mildly thickened but aortic stenosis is not present. Mild\n(1+) aortic regurgitation is seen. The mitral valve leaflets are mildly\nthickened. There is no mitral valve prolapse. Mild (1+) mitral regurgitation\nis seen. The tricuspid valve leaflets are mildly thickened. The pulmonary\nartery systolic pressure could not be determined. There is no pericardial\neffusion.\n\n\n" }, { "category": "ECG", "chartdate": "2193-04-27 00:00:00.000", "description": "Report", "row_id": 256176, "text": "Sinus rhythm with increase in rate as compared with previous tracing\nof . There are more prominent T wave abnormalities in leads I and aVL.\nST segment elevation previously recorded in the anterolateral leads persists.\nThe ST-T wave changes are less prominent. This may represent\npseudonormalization or further evolution of anteroseptal and lateral\nmyocardial infarction. Followup and clinical correlation are suggested.\nTRACING #3\n\n" }, { "category": "ECG", "chartdate": "2193-04-26 00:00:00.000", "description": "Report", "row_id": 256177, "text": "Sinus rhythm. Left atrial abnormality. Prior anteroseptal myocardial\ninfarction. Compared to the previous tracing of no diagnostic interim\nchange.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2193-04-26 00:00:00.000", "description": "Report", "row_id": 256178, "text": "Sinus arrhythmia. Left atrial abnormality. Left axis deviation. Prior\nanteroseptal myocardial infarction. ST segment elevation in leads V1-V5 with\nbiphasic to inverted T waves in leads V2-V6. Q-T interval prolongation.\nThere is left ventricular hypertrophy. Rule out myocardial infarction.\nFollowup and clinical correlation are suggested.\nTRACING #1\n\n" } ]

[ { "category": "Radiology", "chartdate": "2174-05-11 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1239023, "text": " 11:58 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate for ptx\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\CORONARY ARTERY BYPASS GRAFT /SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old man with s/p CABG, CTs to waterseal\n REASON FOR THIS EXAMINATION:\n evaluate for ptx\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Chest tube on waterseal.\n\n FINDINGS: In comparison with study of , the monitoring and support devices\n have been removed except for the right IJ catheter and right and left chest\n tube. With the chest tube on waterseal, there is no evidence of pneumothorax.\n\n Relatively low lung volumes with continued prominence of the cardiomediastinal\n silhouette. No definite vascular congestion. The apparent pneumomediastinum\n on the right has substantially decreased.\n\n\n" }, { "category": "Echo", "chartdate": "2174-05-09 00:00:00.000", "description": "Report", "row_id": 104634, "text": "PATIENT/TEST INFORMATION:\nIndication: Intraoperative CABG. Evaluate wall function\nStatus: Inpatient\nDate/Time: at 11:28\nTest: TEE (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: Lipomatous hypertrophy of the interatrial\nseptum. No ASD by 2D or color Doppler.\n\nLEFT VENTRICLE: Mild symmetric LVH. Low normal LVEF.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic diameter at the sinus level. Normal ascending aorta\ndiameter. No atheroma in ascending aorta. Normal aortic arch diameter. Simple\natheroma in aortic arch. Normal descending aorta diameter. Complex (>4mm)\natheroma in the descending thoracic aorta.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MS. Mild (1+) MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets. Physiologic\n(normal) PR.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: No TEE related complications.\n\nConclusions:\nPre Bypass: The left atrium is elongated. No atrial septal defect is seen by\n2D or color Doppler. There is mild symmetric left ventricular hypertrophy.\nOverall left ventricular systolic function is low normal (LVEF 50-55%). Right\nventricular chamber size and free wall motion are normal. There are simple\natheroma in the aortic arch. There are complex (>4mm) atheroma in the\ndescending thoracic aorta. The aortic valve leaflets (3) are mildly thickened.\nThere is no aortic valve stenosis. No aortic regurgitation is seen. The mitral\nvalve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen.\nThere is no pericardial effusion.\n\nPost Bypass: Patient is A paced on phenylepherine infusion. Preserved\nbiventricular funciton. LVEF 55%. Aortic countours intact. Remaining exam is\nunchanged. All findings discussed witih surgeons at the time of the exam.\n\n\n" }, { "category": "Radiology", "chartdate": "2174-05-11 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1239033, "text": " 2:29 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: evaluate for ptx\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\CORONARY ARTERY BYPASS GRAFT /SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old man with s/p CABG, CTs d/c'd\n REASON FOR THIS EXAMINATION:\n evaluate for ptx\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Chest tube removal.\n\n FINDINGS: In comparison with the study of earlier in this date, the left\n chest tube has been removed, and there is no convincing evidence of\n pneumothorax.\n\n\n" }, { "category": "Radiology", "chartdate": "2174-05-12 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1239224, "text": " 2:42 PM\n CHEST (PA & LAT) Clip # \n Reason: eval effusion\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\CORONARY ARTERY BYPASS GRAFT /SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old man\n REASON FOR THIS EXAMINATION:\n eval effusion\n ______________________________________________________________________________\n FINAL REPORT\n PA AND LATERAL VIEWS OF THE CHEST\n\n REASON FOR EXAM: Evaluate pleural effusion.\n\n Comparison is made with prior study, .\n\n Moderate cardiomegaly and widened mediastinum are stable. Small bilateral\n pleural effusions, larger on the left side and probably unchanged allowing the\n difference in positioning of the patient. Bibasilar atelectases are improved\n on the left. There are no new lung abnormalities, pneumothorax or pulmonary\n edema.\n\n\n" }, { "category": "Radiology", "chartdate": "2174-05-09 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1238753, "text": " 12:51 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: FAST TRACK EXTUBATION CARDIAC SURGERY, ?line placement, r/o\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\CORONARY ARTERY BYPASS GRAFT /SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old man with CAD s/p CABG. Please page at with\n abnormalities\n REASON FOR THIS EXAMINATION:\n FAST TRACK EXTUBATION CARDIAC SURGERY, ?line placement, r/o PTX/Effusion\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 68-year-old male with coronary artery disease status post CABG,\n question line placement, rule out pneumothorax.\n\n COMPARISON: PA and lateral chest radiograph from .\n\n FINDINGS: An ET tube is seen 5.2 cm above the carina. An NG tube courses\n below the diaphragm and terminates in the proximal stomach. A left chest tube\n is in place. A right IJ central line tip is in the lower SVC. Median\n sternotomy wires are intact. There is no pneumothorax or focal consolidation.\n There is a small left pleural effusion and retrocardiac opacity, compatible\n with atelectasis in the left lower lobe. The cardiomediastinal silhouette is\n notable for widened mediastinum, pneumomediastinum on the right as well as\n pneumopericardium expected postoperatively.\n\n IMPRESSION:\n 1. Lines and tubes as above. Small left pleural effusion and left lower lobe\n atelectasis.\n 2. Post-operative pneumomediastinum and pneumopericardium.\n\n" }, { "category": "ECG", "chartdate": "2174-05-09 00:00:00.000", "description": "Report", "row_id": 304769, "text": "Sinus rhythm. Wandering baseline with baseline artifact. Non-specific\ninferior ST-T wave changes. Compared to the previous tracing of \nthe rate has increased. Otherwise, no diagnostic interim change.\n\n" } ]

[ { "category": "Radiology", "chartdate": "2161-10-04 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 980722, "text": " 8:47 AM\n CHEST (PA & LAT) Clip # \n Reason: f/u cxr from pt with left apical pnuemo\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\CORONARY ARTERY BYPASS GRAFT /SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50 year old man with CAD for CABG\n\n REASON FOR THIS EXAMINATION:\n f/u cxr from pt with left apical pnuemo\n ______________________________________________________________________________\n FINAL REPORT\n PA AND LATERAL CHEST, .\n\n HISTORY: 50-year-old man with coronary artery disease and CABG. With left\n apical pneumothorax.\n\n FINDINGS: Comparison is made to previous study from .\n\n No pneumothoraces are seen. There is atelectasis at both lung bases, most\n prominent on the left side. There are low lung volumes due to poor\n inspiratory effort. Very tiny bilateral pleural effusions are present. There\n is no focal consolidation or overt pulmonary edema.\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2161-10-01 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 980372, "text": " 4:40 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: postop film-contact NP # if abnormal\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\CORONARY ARTERY BYPASS GRAFT /SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50 year old man s/p cabg x4\n REASON FOR THIS EXAMINATION:\n postop film-contact NP # if abnormal\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Status post CABG.\n\n FINDINGS: In comparison with the study of , the patient has undergone a\n CABG procedure with surgical clips and sternal wires in place. The\n endotracheal tube lies less than 2 mm above the carina and should be pulled\n back somewhat. This information has been telephoned to at .\n\n The right internal jugular Swan-Ganz catheter extends to the pulmonary outflow\n tract. The nasogastric tube extends to the body of the stomach and then is\n lost at the bottom of the film. Left chest tube is in place and there is no\n pneumothorax. Mediastinal tubes are in place. Low lung volumes but no acute\n pneumonia.\n\n IMPRESSION: Standard appearance following coronary artery bypass procedure.\n The relatively low endotracheal tube position has been conveyed to .\n\n\n DR. \n" }, { "category": "Radiology", "chartdate": "2161-10-03 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 980634, "text": " 12:48 PM\n CHEST (PA & LAT) Clip # \n Reason: post ct emoveal / evaluate for pneumo\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\CORONARY ARTERY BYPASS GRAFT /SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50 year old man with CAD for CABG\n REASON FOR THIS EXAMINATION:\n post ct emoveal / evaluate for pneumo\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Pneumothorax.\n\n Three radiographs of the chest demonstrate interval removal of the support\n lines seen on . There is a very small left apical pneumothorax. The\n trachea is midline. The patient is status post CABG. There is mild bibasilar\n atelectasis. Lung volumes are low. Linear markings involving the bilateral\n mid and upper lungs represent atelectasis as well.\n\n IMPRESSION:\n\n Interval removal of support lines.\n\n Very small left apical pneumothorax.\n\n\n" }, { "category": "Echo", "chartdate": "2161-10-01 00:00:00.000", "description": "Report", "row_id": 82925, "text": "PATIENT/TEST INFORMATION:\nIndication: Intraoperative TEE for CABG\nHeight: (in) 67\nWeight (lb): 213\nBSA (m2): 2.08 m2\nBP (mm Hg): 134/67\nHR (bpm): 78\nStatus: Inpatient\nDate/Time: at 12:21\nTest: TEE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Moderate LA enlargement. Elongated LA.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in the RA\nand extending into the RV. No ASD by 2D or color Doppler.\n\nLEFT VENTRICLE: Moderately depressed LVEF.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal ascending aorta diameter. Simple atheroma in ascending aorta.\nSimple atheroma in aortic arch. Normal descending aorta diameter. Simple\natheroma 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 thickening of\nmitral valve chordae. Mild (1+) MR.\n\nTRICUSPID VALVE: Tricuspid valve not well visualized. Mild [1+] TR.\n\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen. Physiologic\n(normal) PR.\n\nGENERAL COMMENTS: A TEE was performed in the location listed above. I certify\nI was present in compliance with HCFA regulations. The patient was under\ngeneral anesthesia throughout the procedure. No TEE related complications.\nSuboptimal image quality. The patient appears to be in sinus rhythm. Results\nwere personally reviewed with the MD caring for the patient.\n\nConclusions:\nPRE-CPB\n\n1.The left atrium is moderately dilated. The left atrium is elongated. No\natrial septal defect is seen by 2D or color Doppler.\n\n2. Overall left ventricular systolic function is moderately depressed (LVEF=\n40 %).\n\n3.Right ventricular chamber size and free wall motion are normal.\n\n4.There are simple atheroma in the ascending aorta. There are simple atheroma\nin the aortic arch. There are simple atheroma in the descending thoracic\naorta.\n\n5. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is\nnot present. No aortic regurgitation is seen.\n\n6.The mitral valve leaflets are mildly thickened. There is moderate thickening\nof the mitral valve chordae. Mild (1+) mitral regurgitation is seen.\n\nPost bypass\n\n1. Patient is in sinus rhythm.\n\n2. Biventricular systolic function is slightly improved.\n\n3. Mild mitral regurgitation persists.\n\n4. Aorta intact post decannulation.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2161-10-01 00:00:00.000", "description": "Report", "row_id": 1665999, "text": "resp care - Pt received from OR intubated with #7.5 ETT. BLBS clear. Pt on fast-track wean. See carevue for details.\n" }, { "category": "Nursing/other", "chartdate": "2161-10-01 00:00:00.000", "description": "Report", "row_id": 1666000, "text": "labile bp with low filling pressures,brisk huo treated with neo titration & volume,see flow sheet. cardiac parameters remain stable. reversed,propofol wean started. called,abusive on phone to secretary-\" you f ing people\" etc. spoke at length with her concerning visitor guidelines & plan of care. sounded agitated/inebriated vascillating from crying & swearing with slurred speech to vocal gratitudes concering care.did not visit patient post op therefore was provided with phone # & calling restrictions but did not receive visitor booklet. seemed in better spirits/control after updated about patient's condition.\n" }, { "category": "Nursing/other", "chartdate": "2161-10-01 00:00:00.000", "description": "Report", "row_id": 1666001, "text": "RESPIRATORY CARE NOTE\n\nPatient received intubated and on full AC ventilation. Changed to PS at . Cuff leak present. Extubated. No stridor noted after extubation. Placed on nasal cannula 4 lpm.\n\n , RRT\n" }, { "category": "Nursing/other", "chartdate": "2161-10-01 00:00:00.000", "description": "Report", "row_id": 1666002, "text": "extubated to np's w/o incident. cooperative with pulmonary toilet. occasional snoring noted when sleeping with mild co2 retention. pain controlled with morphine,see flow sheet. glucoses rising despite increased gtt & bolus dosing,will follow closely. no family contact.\n" }, { "category": "Nursing/other", "chartdate": "2161-10-02 00:00:00.000", "description": "Report", "row_id": 1666003, "text": "neuro: awake alert follows commands- mae- perc's and morphine for pain with good effect-\nresp: ls clear to dim- sats good on 2l- ct dng wnl- starting to dump more with movement-\ncv: st to nsr- filling pressures good- remains on neo for b/p support lytes repleted prn- wires attached and work-\ngi/gu: abd soft- bs hypo- foley to gravity- uo good-\nendo: bg - very labile up to 12u gtt- off when bg down to 80's tx last bg with sliding scale\nplan: cont to monitor- ?\n" }, { "category": "ECG", "chartdate": "2161-10-02 00:00:00.000", "description": "Report", "row_id": 198195, "text": "Sinus rhythm. Inferior myocardial infarction. Compared to previous tracing\nof no major change.\n\n" } ]

[ { "category": "Nursing/other", "chartdate": "2122-01-29 00:00:00.000", "description": "Report", "row_id": 1509237, "text": "FOCUS; STATUS UPDATE\nDATA;\nPT ALERT AND ORIENTED X3. COMPLAINS OF ABDOMINAL PAIN WHICH IMPROVES WITH MORPHINE SULFATE IVP AS NEEDED.\n\nLUNGS CLEAR BILATERALLY, DIMINISHED AT BASES. SATS 97-100% ON 4LNC. DENIES SOB.\n\nL RADIAL ARTERIAL LINE PLACED WITH DIFFICULTY. LINE IS VERY POSITIONAL AND NOT ACCURATE FOR BP READINGS WHICH ARE LOWER THAN , ALTHOUGH PT DOES HAVE HX/O AXILLARY BIFEM ON THAT SIDE. BLOOD DRAWS WITH DIFFICULTY VIA A-LINE.\n\nBOLUSED WITH X4 FOR LOW URINE OUTPUTS. CVP NORMALLY , AFTER BOLUSED. CONTINUES WITH LR MAINTENANCE FLUID.\n\nPLS SEE CONTINUED NOTE LATER.\n" }, { "category": "Nursing/other", "chartdate": "2122-01-29 00:00:00.000", "description": "Report", "row_id": 1509238, "text": "Note Continued\nDATA;\nFAMILY MEETING HELD WITH DR AND DR . WHOLE FAMILY PRESENT, INCLUDING (SON) WHO IS PATIENT'S PROXY. POOR PROGNOSIS WAS DISCUSSED WITH OR WITHOUT SURGERY, DUE TO PATIENT'S COMPLICATED HISTORY. ALL DECIDED TO HONOR MRS. WISHES AND SHE WAS SENT TO THE OR AT 1700.\n" }, { "category": "Nursing/other", "chartdate": "2122-01-29 00:00:00.000", "description": "Report", "row_id": 1509239, "text": "Respiratory Care Note\nPt received from OR intubated. Pt placed on AC as noted. BS are clear and equal. Plan to continue on current settings at this time.\n" }, { "category": "Nursing/other", "chartdate": "2122-01-29 00:00:00.000", "description": "Report", "row_id": 1509240, "text": "Nursing Progress Note:\nPt is . Ppf gtt stopped at and pt extubated at 2100. Morphine gtt titrated for comfort (see CareVue for specifics). son, daughter, and many other family members visited; family aware of plan of care.\n Plan: Pt is . Titrate morphine gtt to keep pt comfortable. Provide emotional care to family.\n" }, { "category": "Nursing/other", "chartdate": "2122-01-29 00:00:00.000", "description": "Report", "row_id": 1509236, "text": "Nursing Progress Note:\nPlease refer to CareVue for details.\n Pt admitted at 0500 from ED w/ ischemic bowel and small bowel obstruction. (See FHP for PMH). Upon admission to SICU-B, Dr. placed left subclavian triple lumen central line. CXR done to confirm placement; per Dr. , okay to use central line. Dr. attempted to place A-line, but unable to. Will attempt A-line placement again today after AM rounds. Afebrile. HR 90s (NSR; no ectopty noted). NBP 110s-150s/30-80s. CVP 5-8. Per Dr. , goal CVP 15. LR @ 125cc/hr. RR 17-21. O2 sat on room air was 89%. O2 sat increased to >/= 98% on 4L nasal cannula. Weak, nonproductive cough. Lungs clear, diminished at bases. Abdomen softly distended w/ absent bowel sounds. NPO. NGT to low continuous suction w/ yellow drainage. Negative flatus. Pt c/o nausea w/ turning and repositioning, but nausea subsided without any meds. Pt c/o dull abdominal pain; morphine 2mg IV given at 0615 w/ +effect. Pt stated that abd pain improved when pt was turned onto her right side. Foley intact w/ clear, yellow urine. UO 40-60cc/hr. son and daughter visited; updated on plan of care.\n Plan: Monitor VS, I's and O's, labs. Cardiac enzymes q8hr. Monitor neuro and respiratory status. Goal CVP 15. Pt needs A-line. Offer pain med when needed. Update pt and family on plan of care. Continue ICU care and treatment.\n" }, { "category": "ECG", "chartdate": "2122-01-29 00:00:00.000", "description": "Report", "row_id": 300719, "text": "Sinus tachycardia. Intraventricular conduction delay. Prior inferior wall\nmyocardial infarction. Possible prior anterior wall myocardial infarction as\nwell. Compared to the previous tracing of the rate has increased.\nOtherwise, no diagnostic interim change.\n\n" }, { "category": "ECG", "chartdate": "2122-01-28 00:00:00.000", "description": "Report", "row_id": 300720, "text": "Sinus arrhythmia\nInferior infarct - age undetermined\nPoor R wave progression - ? old anterior myocardial infarction\nNonspecific T wave flattening\nIntraventricular conduction delay\nSince previous tracing of , QRS changes in leads V5-V6 - ? lead\nplacement\n\n" } ]

[ { "category": "Radiology", "chartdate": "2161-04-26 00:00:00.000", "description": "SEL CATH 3RD ORDER THOR", "row_id": 961888, "text": " 12:31 PM\n CAROT/CEREB Clip # \n Reason: ?aneurysm/AVM\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\n Contrast: OPTIRAY Amt: 350\n ********************************* CPT Codes ********************************\n * SEL CATH 3RD ORDER SEL CATH 2ND ORDER *\n * -59 DISTINCT PROCEDURAL SERVICE SEL CATH 1ST ORDER *\n * -59 DISTINCT PROCEDURAL SERVICE ADD'L 2ND/3RD ORDER *\n * CAROTID/CERVICAL BILAT CAROTID/CEREBRAL BILAT *\n * EXT CAROTID UNILAT VERT/CAROTID A-GRAM *\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 80 year old woman with L arm numbness and bilat leg weakness\n REASON FOR THIS EXAMINATION:\n ?aneurysm/AVM\n ______________________________________________________________________________\n FINAL REPORT\n CEREBRAL ANGIOGRAM\n\n DATE OF STUDY: .\n\n HISTORY: 80 year old female with right frontal subarachnoid hemorrhage,\n assess for cause of hemorrhage.\n\n TECHNIQUE:\n\n Informed written consent was obtained from the patient and the patient's\n family after an extensive discussion of the risks, benefits, and alternative\n management therapies. The risks discussed included cerebral infarction,\n blindness both temporary and permanent, and possible use of stenting and\n 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 for local anesthesia.\n Using a 19-gauge needle, a single wall puncture of the right common femoral\n artery was performed and an 035 wire was placed through the needle\n into the aorta. The wire was removed and a 4 French vascular sheath was\n placed. The vascular sheath was connected to continuous saline infusion with\n 500 units of heparin and 500 cc of saline. A 4 French Berenstein II catheter\n was then placed over the wire and connected to a continuous saline infusion\n containing 1000 units of heparin and 1000 cc of saline. The wire was\n exchanged for a guide wire. The following selective arteriograms were then\n performed.\n\n 1. AP, lateral, and oblique views of the right common carotid artery.\n 2. AP, lateral, and rotational views of the right internal carotid artery.\n (Over)\n\n 12:31 PM\n CAROT/CEREB Clip # \n Reason: ?aneurysm/AVM\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\n Contrast: OPTIRAY Amt: 350\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n 3. AP and lateral views of the right common carotid artery.\n 4. AP and lateral views of the right external carotid artery.\n 5. AP and lateral views of the left common carotid artery.\n 6. AP, lateral, and rotational views of the left internal carotid artery.\n 7. AP and lateral views of the left vertebral artery and basilar system via a\n left subclavian artery injection with a manual blood pressure cuff in place.\n\n The right vertebral artery and the left vertebral artery were not directly\n catheterized due to tortuosity and patient motion.\n\n There were no complications.\n\n OPERATORS: Drs. and \n\n Moderate sedation was provided by administering divided doses of Versed and\n fentanyl throughout a total intraservice time of 1 hour and 15 minutes during\n which the patient's hemodynamic parameters were continuously monitored.\n\n A total of 350 cc of Optiray-240 was used.\n\n FINDINGS: The current study is somewhat limited by patient motion.\n\n No aneurysms, vascular malformations, or evidence of vasculitis are seen.\n\n The right common carotid artery injection shows an ulcerated plaque of the\n right internal carotid artery bulb which is causing mild-to-moderate stenosis.\n There is a large right posterior communicating artery supplying the right\n posterior cerebral artery.\n\n The left internal carotid artery is tortuous. There is minimal irregularity\n of the M2 segment of the left middle cerebral artery, which likely represents\n atherosclerotic disease.\n\n IMPRESSION: No aneurysms, vascular malformations, or evidence of vasculitis.\n\n Ulcerated plaque of the right internal carotid artery bulb causing mild-to-\n moderate stenosis and some mild irregularity of the M2 segment of the left\n middle cerebral artery which likely represents atherosclerotic disease.\n\n A repeat angiogram could be performed in three to five days under general\n anesthesia if clinically indicated.\n\n Dr. , the attending neuroradiologist, was present and supervising the\n entire procedure\n\n (Over)\n\n 12:31 PM\n CAROT/CEREB Clip # \n Reason: ?aneurysm/AVM\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\n Contrast: OPTIRAY Amt: 350\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2161-04-26 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 961839, "text": " 12:31 AM\n CHEST (PA & LAT) Clip # \n Reason: Cardiac size/lung fields clear? Pre-procedure film\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old woman with SAH.\n REASON FOR THIS EXAMINATION:\n Cardiac size/lung fields clear? Pre-procedure film\n ______________________________________________________________________________\n FINAL REPORT\n PA AND LATERAL CHEST AT 0030 HOURS.\n\n HISTORY: Pre-operative chest radiograph.\n\n COMPARISON: None.\n\n FINDINGS: The lungs are clear. The mediastinum is unremarkable. The cardiac\n silhouette is borderline enlarged. There is a tiny right pleural effusion\n layering posteriorly. No pneumothorax is evident.\n\n IMPRESSION: Tiny right pleural effusion. Otherwise no acute pulmonary\n process.\n\n\n" }, { "category": "Radiology", "chartdate": "2161-04-25 00:00:00.000", "description": "MR HEAD W & W/O CONTRAST", "row_id": 961822, "text": " 8:01 PM\n MR HEAD W & W/O CONTRAST; MRA BRAIN W/O CONTRAST Clip # \n Reason: eval mass/bleed\n Contrast: MAGNEVIST Amt: 10CC\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old woman with ?SAH R superior temporal lobe on OSH CT, sudden onset L\n numbness, now dizzy.\n REASON FOR THIS EXAMINATION:\n eval mass/bleed\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: JJMl SAT 11:58 PM\n Study severely limited by motion.\n No evidence of acute infarction.\n Fetal-type right PCA.\n\n Possible area of high FLAIR signal in a right superior frontal lobe sulcus\n that consistent with subarachnoid hemorrhage.\n\n Post-gado images of brain are limited by motion and artifact.\n\n WET READ VERSION #1 JJMl SAT 11:57 PM\n Study severely limited by motion.\n No evidence of acute infarction.\n Fetal-type right PCA.\n Possible area of high FLAIR signal in a right superior frontal lobe sulcus\n that could suggest subarachnoid hemorrhage without associated susceptibility\n artifact on GRE images to confirm.\n Post-gado images of brain are limited by motion and artifact.\n\n ______________________________________________________________________________\n FINAL REPORT\n ROUTINE MRI OF THE BRAIN WITHOUT AND WITH GADOLINIUM. ROUTINE MRA USING 3D\n TIME-OF-FLIGHT TECHNIQUE.\n\n HISTORY: Subarachnoid hemorrhage on outside hospital.\n\n There is a focus of FLAIR sulcal hyperintensity in the central sulcus on the\n right with associated enhancement. This could represent a focus of\n subarachnoid hemorrhage or less likely, leptomeningeal metastasis in this\n patient with remote history of breast cancer. Although the images are limited\n by motion, no significant abnormal T2 signal is seen in the pre or post-\n central gyrus.\n\n There are scattered small vessel ischemic sequela in the subcortical and\n periventricular white matter.\n\n Evaluation of the MRA demonstrates no aneurysm or hemodynamically significant\n stenosis within limits of this exam.\n\n There was a large left maxillary sinus mucus retention cyst.\n\n (Over)\n\n 8:01 PM\n MR HEAD W & W/O CONTRAST; MRA BRAIN W/O CONTRAST Clip # \n Reason: eval mass/bleed\n Contrast: MAGNEVIST Amt: 10CC\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n No acute ischemia is seen on the diffusion-weighted images.\n\n Ventricles and sulci are age appropriate.\n\n IMPRESSION:\n\n Probable subarachnoid hemorrhage in the right central sulcus, less likely,\n leptomeningeal metastasis given the acuity of symptoms. Occasionally,\n cortical venous thrombosis may present with focal subarachnoid hemorrhage. No\n findings suggestive of cortical venous thrombosis are seen on this examination\n although this diagnosis may be occult on routine cross-sectional imaging.\n\n" }, { "category": "Radiology", "chartdate": "2161-04-25 00:00:00.000", "description": "CTA HEAD W&W/O C & RECONS", "row_id": 961837, "text": " 10:52 PM\n CTA HEAD W&W/O C & RECONS Clip # \n Reason: NUMBNESS, RT FRONTAL SAH\n Contrast: OPTIRAY Amt: 70\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old woman with L sided numbness and R frontal SAH on CT.\n REASON FOR THIS EXAMINATION:\n ?R SAH and aneurysm/AVM\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: JJMl SUN 12:11 AM\n No aneurysm or AVM seen.\n Hyperdensity in right superior frontal lobe sulcus consistent with\n subarachnoid hemorrhage.\n Left maxillary air/fluid level may suggest acute sinusitis.\n WET READ VERSION #1 JJMl SAT 11:58 PM\n ______________________________________________________________________________\n FINAL REPORT\n CTA OF THE HEAD\n\n Routine CTA of the circle of is performed with contrast.\n\n HISTORY: Subarachnoid hemorrhage right central sulcus.\n\n On the unenhanced head CT, note is made of hypodensity in the right central\n sulcus compatible with subarachnoid hemorrhage.\n\n On the CTA, no aneurysm or stenosis is seen. There is a right fetal PCA.\n\n There is a large fluid level in the left maxillary sinus. There is\n retropharyngeal deviation of the right distal cervical ICA.\n\n IMPRESSION: No evidence for aneurysm or hemodynamically significant stenosis.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2161-04-26 00:00:00.000", "description": "Report", "row_id": 1592399, "text": "NURSING ADMISSION\nNEURO: THIS 80YR OLD FEMALE WAS ADMITTED VIA ED FROM OSH AFTER ACUTE ONSET OF DIZZYNESS AND NUMBNESS EXTENDING FROM LEFT FINGERS->ARM->NECK. CT @ OSH AND MRI @ SHOWED FRONTAL SAH, NO ANEURSM OR AVM. ON ARRIVAL IN SICU, PT NEUROLOGICALLY INTACT, SL DIZZINESS INITIALLY BUT THIS ALSO RESOLVED. NO CHANGE IN NEURO EXAM OVERNOC, HAS REMAINED ALERT AND ORIENTED X3, THOUGH DISPLAYING MOOD SWINGS RANGING FROM PLEASANT/JOKING/COOPERATIVE TO WITHDRAWN/HOSTILE/ UNCOOPERATIVE. PUPILS EQUAL IN SIZE AND REACTIVITY, NO DRIFT/DROOP. MAE NORMAL STRENGTH.\n\nCV: HR NSR, NO ECTOPY. HYDRALAZINE 10MG IV ON ADMISSION FOR SBP 160-180, (GOAL SBP<130). HAS BEEN NORMOTENSIVE SINCE. HYDRALAZINE HELD THIS AM. ARTERIAL LINE PLACED BY DR WITHOUT DIFFICULTY.\n\nGI: SOFT, BOWEL SOUNDS+, NPO EXCEPT FOR MEDS AT THIS TIME.\n\nGU: REFUSED INSERTION OF FOLEY CATH DUE TO HX OF UTI'S, VOIDED IN BEDPAN X1, U/A SENT.\n\nENDO: NO HX OF DIABETES. SLIDING SCALE IN EFFECT BUT NO INSULIN REQUIRED THIS SHIFT.\n\nSOCIAL: DAUGHTERS ACCOMPANIED PT ON ADMISSION AND WILL BE RETURNING TODAY. PT LIVES IN OWN HOME AND IS FULLY INDEPENDANT AT BASELINE.\n\nPLAN: CONTINUE TO CLOSELY MONITOR NEURO EXAM Q1H. MAINTAIN SBP<130. FOLLOW UP RADIOLOGY EXAM.\n\nPT MONITORED CONTINUOUSLY.\nDR IN ICU ATTENDANCE. FOLLOWED ALSO BY N/ AND NEUROLOGY.\nSEE CAREVUE FLOWSHEETS FOR DETAILED DATA.\n\n" }, { "category": "Nursing/other", "chartdate": "2161-04-26 00:00:00.000", "description": "Report", "row_id": 1592400, "text": "Condition Update\nD: See carevue flowsheet for specifics\n This am pt sleeping in naps. A little upset due to no sleep overnight and confused as to people who were talking to her and placing lines and giving meds. But able to answer questions of orientation and sequence of events correctly. Pt assisted OOB to chair and after a couple of discussions with neurology service pt voiced relief with prognosis of current status. Neuro status stable throughout the day with no deficits noted. Awaiting angio. Angio done from 2p-4p angio RN no significant findings. See angio note for specifics.\n Patient . SBP goal per nsurg <130-no prn meds required. Pt receiving nimodipine/hydralazine scheduled and tolerating well. In am pt voided on BSC with supervised assist with transfer. Pt gait a little unsteady when walking around the bed. Pt remained NPO throughout the day with IVF @60 but no further urge to void. Foley placed prior to angio with 650cc out upon insertion. IVF changed to include bicarb for 1hr prior to angio and will continue for 6hrs after procedure.\n Patient's daughter in to visit and present during discussion with Dr. re: angiogram.\nPLAN:\n Frequent neuro checks\n Right groin angio site checks per protocol\n Raise head of bed as ordered\n Keep SBP<130\n Continue IVFx6hrs post-angio\n Notify H.O. with any changes\n" }, { "category": "Nursing/other", "chartdate": "2161-04-27 00:00:00.000", "description": "Report", "row_id": 1592401, "text": "NURSING UPDATE\nCV: HR NSR, NO ECTOPY, BP WITHIN ACCEPTABLE PARAMETERS, HYDRALAZINE HELD X1.\nNEURO: ALERT AND ORIENTED X3, ANSWERING QUESTIONS CORRECTLY WHEN COOPERATING, BUT PT OFTEN HOSTILE DURING NEURO CHECKS, AT ONE TIME THREATENED TO PUNCH NURSE AND ATTEMPTED TO KICK NURSE WHEN ASKED NOT TO GET OUT OF BED WITHOUT ASSISTANCE. REFUSING TO TAKE MEDS INITIALLY, BEING HOSTILE BECAUSE NURSE ASKED IF SHE WOULD LIKE JUICE INSTEAD OF WATER, THEN CALMED DOWN AND TOOK MEDS. GOOD STRENGTH ALL EXTREMITIES, PUPILS EQUAL IN SIZE AND REACTIVITY. NO DRIFT OR DROOP. DENIES HEADACHE, NUMBNESS OR VERTIGO. ANGIO SITE D&I, PULSES PALPABLE, FEET PINK/WARM BILATERALLY.\nGI: ABDOMEN SOFT, BOWEL SOUNDS ACTIVE, REFUSED DINNER.\nGU: ADEQUATE HUO CLEAR YELLOW URINE PER FOLEY CATH.\nHYGIENE: REFUSED ALL ASPECTS OF HYGIENE CARE - OFFERED Q2-4H.\nPLAN: CONTINUE PLAN PER NEUROLOGY TEAM. MAINTAIN BP<130. CONTINUE Q1-2H NEURO CHECK PER PT LEVEL OF COOPERATION.\nPT MONITORED .\nSEE CAREVUE FLOWSHEET FOR DETAILED DATA.\n" }, { "category": "Nursing/other", "chartdate": "2161-04-27 00:00:00.000", "description": "Report", "row_id": 1592402, "text": "Condition Update A:\nPlease refr to careview and remarks for details.\n\nPt alert and oriented x3. Pt very HOH per family. Pt's mood variable, to anxious to irritable. Pt's baseline per family. LP done at bedside. Pt flat in bed for one hour per Dr. . Site C/D/I. Pt premedicated with Ativan with good effect. Pt's neuro exam stable, PERL bilat 2mm brisk, denies HA, dizziness, nubness/tingling. Pt voided good amount urine at 1700. Good PO intake. Pt very determined to go home.\n\nPLAN: Cont to monitor. Neuro exam every four hours. Transfer to floor when bed available.\n" }, { "category": "Nursing/other", "chartdate": "2161-04-28 00:00:00.000", "description": "Report", "row_id": 1592403, "text": "Condition Update\nD: See carevue flowsheet for specifics\n Patient's vital signs stable. SBP 90-120 overnight no hydralazine given or required to keep SBP<140. HR 60-70 NSR with no ectopy. Pt slept for most of night. No neuro deficits or changes noted overnight. Pt took a few sips of water overnight and did not void thus far.\n Patient is called out to 5-awaiting a bed. If no bed available today pt may be discharged home from SICU. Pt voiced no complaints overnight. No contact with family overnight.\n" }, { "category": "Nursing/other", "chartdate": "2161-04-28 00:00:00.000", "description": "Report", "row_id": 1592404, "text": "Discharge Note:\nPt discharged to home with daughter, , and son-in-law at 1220PM. Discharge teaching performed and questions answered by this RN; pt's daughter and son-in-law present during discharge teaching. Prescriptions for lorazepam and phenytoin given. Pt aware of necessary follow-up appointments, angio, and blood-draw (for dilantin level). Peripheral IV d/c'd prior to discharge. . Neuro exam unchanged; alert and oriented x3. Pt denied any pain, dizziness, nausea, numbness/tingling. Pt brought to Clinical Center lobby via wheelchair by PCT without any incident. All discharge paperwork given to pt and copies filed in pt's chart.\n" }, { "category": "ECG", "chartdate": "2161-04-25 00:00:00.000", "description": "Report", "row_id": 226537, "text": "Baseline artifact. Sinus rhythm. Right bundle-branch block. Non-specific\ninferior T wave changes. No previous tracing available for comparison.\n\n" } ]

[ { "category": "Nursing/other", "chartdate": "2155-01-12 00:00:00.000", "description": "Report", "row_id": 1962754, "text": "NPN 1900-0700\n\n\n#3 FEN: Weight 1310, down 15g. TF 140c/k/d. 40cc/k of\nPE20/BM; 9.2cc q 4hrs. 100cc/k of TPN D12.5 w/ IL by PIV.\nABd benign, BS active. No spits or asps. Voiding and\nstooling. Tolerating feeds well, con't per plan to advance\nfeeds 10cc/k at 0500 and 1700.\n\n#4 G&D: and active, irritable. Sucks on pacifier\nvigorously. Maintaining temps nested in sheepskin in servo\ncontrolled isolette. Stable, con't to support dev needs.\n\n#5 Par: Parents up after 9pm cares, visited, updated by RN.\nMom still on postpartum floor, will be up in a.m. Con't to\nsupport and update as needed. Begin planning family meeting.\n\n#6 Bili: Infant remains jaundice under single phototherapy.\nCoombs neg. See flowsheet for last bili level, check next\nlevel tomorrow. Con't per plan.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2155-01-12 00:00:00.000", "description": "Report", "row_id": 1962755, "text": "Newborn Med Attending\n\nDOL#3. Cont in RA, no spells. AF flat, clear BS, no murmur, abd soft, MAE. Wt=1310 down 15. TF=140 on PE20 advancing 10 . On phototherapy.\nA/P: Infant working up on PG feeds. Monitor for spells. Check bili in AM.\n" }, { "category": "Nursing/other", "chartdate": "2155-01-12 00:00:00.000", "description": "Report", "row_id": 1962756, "text": "#6 BILI\ns/o: Remains under single phototx. A/p: bili in AM\n#5 PARENt\ns/o: Both parents in and updated at bedside. Mom scheduled\nfor d/c in AM A: Invested family. P: Attempt scheduling of\nfamily mtg prior to mom's d/c home\n#4 G&D\ns/o: Temp stable in heated isolette, on servo. with\ncares. Calms well. Nested in sheepskin in heated isolette on\nservo. A: Dev AGA. P: cont dev supportive cares\n#3 FEN\ns/o: Adv to 150cc/k/d-- enteral feeds at 65 cc/k/d while IVF\nat 85 cc/k. PN and IL d/c'd and D12 with 2 NaCL and 1 KCl\ninfusing via PIV. DS x1-88. A: Tol adv of enterals with\nbenign abd exam. P: cont to adv 15cc/k 5A-5 P as tolerated\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2155-01-15 00:00:00.000", "description": "Report", "row_id": 1962767, "text": "NICU Fellow Physical Exam\nGen: active, \nHEENT: AFLF, OP clear, mmm, no nasal flare\nCV: RRR no murmur\nLungs: clear\nAbd: soft, +BS, no loops\nExt: mae\nSkin: no rash\n" }, { "category": "Nursing/other", "chartdate": "2155-01-15 00:00:00.000", "description": "Report", "row_id": 1962768, "text": "Nursing NICU Note\n\n\n#3. FEN O: TF 150cc/kg/d of PE24 w/polycose =26cc Q 3hrs,\ngavage over 30min. Abdomen is soft, pink, no loops/ small\nspit x1 noted. Abdominal girth 20.5cm. He is voiding/\nstooling guiac-. D-sticks 84/57 prior to feeds. A: Pt. is\ntolerating current nutritional plan. P: Continue w/\ncurrent feeding plan. Monitor for s/s of intolerance.\nContinue to monitor D-sticks Q 3hrs.\n\n#4. Growth/Development O: Pt. remains on servo control\nisolette w/ stable temps. He is and active w/ cares,\nsleeps well between. Fontanelle soft/flat. A: AGA P:\nContinue to provide environment appropriate for growth and\ndevelopment.\n\n#5. Parenting O: Parents in to visit throughout the\nshift. They participate in cares, asking appropriate\nquestions. A: Parents are very and involved. P:\nContinue to support and educate.\n\n#6. Hyperbilirubinemia O: Pt. remains under single photo\ntherapy. He is ruddy, well perfused. A: Alteration in\n. P: Continue w/ single photo therapy. Check \nin am.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2155-01-16 00:00:00.000", "description": "Report", "row_id": 1962769, "text": "#3FEN\nHep lock in R hand unable to flush and removed at 0200. Wt.\nunchanged. Baby cont on 3h feeds, PE20 with 4 cal polycose.\nDstick 48 prior to 0200 feed. At 0300 Dstick was 70. Prior\nto 0500 feed, Dstick 77. Abd soft. active bowel sounds. void\nand stooling green. Abd girth stable at 20.5.\nA. Tol feeds. Adequate dstick on polycose.\nP. Cont to monitor\n#4Dev\nTemp stable on servo. Active with cares. resting on a\nsheepskin with boundaries.\n#5Parent\nMom called for an update\n#6 Bili\nBaby remains under single phototherapy with mask. Bili sent.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2155-01-16 00:00:00.000", "description": "Report", "row_id": 1962770, "text": "Neonatology\nDoing well. Remains in RA. Comfortable apeparing. Spells not a problem.\n\nWT 1305 unchanged. Abdomen benign. Tolerating feeds of 24 cal (polycose). Single preprandial BS of 48. Rest iun 70s. Will increase cals to 26 and monitor tolerance and BS.\n\nUnder phototherapy for bili of 6. WIll continue lites and check in am.\n\nContinue as at present.\n\nPotential transfer to for am.\n" }, { "category": "Nursing/other", "chartdate": "2155-01-16 00:00:00.000", "description": "Report", "row_id": 1962771, "text": "NPN 7a-7p\n\n\n#3: TF150cc/kg/d. Remains on q3 hr feeds. Formula changed\ntoday to PE24w/2polycose. D/S have been stable throughout\nshift-please see flow sheet. abdomen is benign, voiding and\nstooling, no spits. AG stable. Min aspirates. Started on FE\ntoday. A: Tolerating feeds, D/S stable.P: cont with plan.\n#4: Temp stable in servo isolette, fontanelles are soft and\nflat. and active with cares, sleeping well. Infant\nbrings hands to face, likes pacifier. A: AGa. P: cont to\nsupport .\n#5: Mom called for an update, she will be in later tonight\nwith Dad for PM cares. A: parnets. P:cont to support.\n\n#6: Remains under single phototherapy, eye shields on at all\ntimes. A/P: cont to monitor.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2155-01-19 00:00:00.000", "description": "Report", "row_id": 1962781, "text": "Neonatology Attending\nDOL 10\n\nRemains in room air with no cardiorespiratory events. Wt 1375 (+10) on TFI 150 cc/kg/day PE26/BM26 with polycose and promod. History of hypoglycemia but >45 consistently over the past 12 hours (60-47-85-77). Voiding and stooling appropriately. Bottling almost full volume. On Vit E and Ferinsol.\n\nA&P\nStable. For transfer to today. Auditory screening to be completed there prior to final discharge home.\n" }, { "category": "Nursing/other", "chartdate": "2155-01-19 00:00:00.000", "description": "Report", "row_id": 1962782, "text": "Nursing D/C Note 0900\nBaby #2 \"\" ready for transfer to today at 12pm. Parents notified this AM, consent for transfer present in chart. Infant's ID tag on.\nCurrent issues:\nCVR: Stable in RA, no spells. HR 150-160's, no murmur, color pink. RR 38-50's. Lungs clear, no resp. distress.\nF/N: Current wt. 1375gms, increase of 10gms, BW 1385gms. Infant receiving 150cc/kg/d Pe/BM 26 cals polycose and promod added, 35cc q 3 hrs. Infant has had a hx of hypoglycemia last glucose at 0500 this AM 77. Abd soft, bowel snds active. AG 22-23cms. Voiding and stooling adequately. Baby is , spit up this AM after the 8am feeding. Gavage fed over 40 mins. Taking po's fairly well X1-2/day. Mom hopes to breast feed and is putting the babies to breast when she visits.\nParents: Private pedi is Dr. . Parents pleased w/ transfer to . Invested and involved.\nDev.: remains in an isolette on air mode 27.0C. Temp 99.7ax this AM, iso. weaned. Awake and , swaddled.\n" }, { "category": "Nursing/other", "chartdate": "2155-01-19 00:00:00.000", "description": "Report", "row_id": 1962783, "text": "Nursing Note: Correction\nBaby #2 is to receive 26cc q 3 hrs PE26/br. milk 26.\n" }, { "category": "Nursing/other", "chartdate": "2155-01-10 00:00:00.000", "description": "Report", "row_id": 1962748, "text": "Clinical Nutrition:\nO/\nFormer 33 weeker, BB (twin #2)now on DOL #1\nMaternal history/chart reviewed.\nBirth wt: 1385g (~10th%ile)\nCurrent wt: 1340g (+45)\nBirth LN: 39.5cm (~10th%ile)\nBirth HC: 28cm (~10th%ile)\nLabs: 24 hr lytes note\nAccess: PIV\nTF: 120 cc/kg/day\nNutrition: PN (D10 w/ 1.0g% protein conc.)\nEN: BM/PE20 @ 20 cc/kg/day\nProjected 24 intake: ~59 Kcals/kg & ~1.5 g/kg of protein\nGI: +BS, no stool\n\nA/goals:\n#2 of set of twins, IUGR- to begin trial of enteral feeds later today w/ PN. Decided to initiate PN d/t anticipation of slow advancement w/ feeds. Dsticks initially low- have since stabilized. 24 hr lytes wnl. Acetate in PN. +BS, no meconium stool yet. PN goals: ~90-110 Kcals/kg, ~3.0-3.5 g/kg of protein & ~3.0 g/kg of IL. conc. w/ PIV access= D10 w/ 3.0g% protein OR D12.5 w/ 2.0g%. Growth goals: ~15-20 g/kg/day, ~0.5-1.0 cm/wk for HC & ~1.0 cm/wk for LN. Will cont. to follow feeding tolerance/growth w/ team & participate in nutrition plans.\n" }, { "category": "Nursing/other", "chartdate": "2155-01-10 00:00:00.000", "description": "Report", "row_id": 1962749, "text": "NPN 7a-7p\n\n\n#1: ABx DC's this afternoon, resolved.\n#2: Conts in room air, breathing 30-50s. Breath sounds are\nclear and equal, with mild IC/SC retractions. Color is ruddy\npink. No spells or desats noted this shift. A:Stable in room\nair. P :cont to monitor.\n#3: TF120cc/kg/d. FEeds of PE20 started today with plan to\nadvance by 10cc/kg/d , next increase due at 0100. Feeds\nare currently at 20cc/kg/d. IVF is at\n100cc/kg/d(D10w/2NAcl/1Kcl). PN to be hung tonight. Abdomen\nis benign, voiding and having mec stool. AG 20.5 cms. No\nspits, min aspirates. A: Intro to feeds, tolerating well. P:\nCont to monitor.\n#4: Temp stable in servo isolette, fontanelles are soft and\nflat. and active with cares, irritable at times.\nSleeping for good stretches. Brings hands to face, likes\nbinky. A: AGA. P: cont to support.\n#5: MOM and Dad in during the day, plan to visit and hold\nthis evening.\n#6: Conts under single phototherapy, eye shields on at all\ntimes. Level to be check in am with lytes.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2155-01-11 00:00:00.000", "description": "Report", "row_id": 1962750, "text": "NPN 1900-0700\n\n1 Infant with Potential Sepsis\n\n#2 Resp: RA, sats >94%. Pink, RR 20-50s, LS clear, IC/SC\nretractions. No spells. Stable, con't to monitor.\n\n#3 FEN: Weight 1325, down 15g. TF 120cc/k/d. 30cc/k of PE20;\n6.9cc q4hrs. 90cc/k of TPN D12.5 running in a PIV at\n5.2cc/hr. DS 61-72. Abd benign, BS active. Girth stable.\nVoiding, no stools. Tolerating feeds well, con't per plan,\nadvance feeds by 10cc/k at 01 & 13.\n\n#4 G&D: and active w/ cares, sleeps well. Irritable.\nSucks on pacifier vigorously. maintaining stable temps\nnested in sheepskin in servo controlled isolette. Con't to\nsupport dev needs.\n\n#5 Par: Parents up at 2100 for cares, changed diaper adn\ntook temps, needed assist from RN. Asking questions. Con't\nto support and update as needed. Plan family meeting.\n\n#6 Bili: Infant remains jaundice. See flowsheet for last\nbili. Under single phototherapy w/ eye shields on. Sent bili\nlevel at 0530, results pending.\n\nREVISIONS TO PATHWAY:\n\n 1 Infant with Potential Sepsis; d/c'd\n\n" }, { "category": "Nursing/other", "chartdate": "2155-01-11 00:00:00.000", "description": "Report", "row_id": 1962751, "text": "NICU Attending Note\nPEx: AFSOF, lungs clear, BSE, RRR with no murmur, abd benign, skin pink and well perfused. and comfortable in NAD.\n" }, { "category": "Nursing/other", "chartdate": "2155-01-14 00:00:00.000", "description": "Report", "row_id": 1962762, "text": "NPN\n\n\n\n FEN: Infant on TF 150cc/k/d. He is advancing on enteral\nfeeds presently at 125cc/k BM/PE20 (29cc pg'd over 30min).\nPIV at 25cc/k D12.5 w/lytes infusing well. DS at 1300 48\n( Zacagnini aware, repeat DS at 1700 83. Abd soft, +BS,\nAG stable, min asp, no spits, UO 4.8cc/k/hrx12hrs. Mec\nstooled x2. A: Tol adv feeds. P: Cont to adv 15cc/k and\nassess tolerance.\n\n G+D: Temp stable in servo isolette. and active\nw/cares. Sucks on pacifier. , . A: AGA P: Cont to\nsupport dev.\n\n Parents: Mom in for all cares today. Asking approp\nquestions. Updates on infants progress given at bedside. Mom\nindependent w/cares. Dad in for 1300 cares. He is\nindependent as well. A: Involved parents. P: Cont teaching\nand support.\n\n Hyperbili: Infant remains slightly jaundiced. Remains\nunder single phototherapy, eyes are protected. P: Repeat\nbili as ordered.\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2155-01-15 00:00:00.000", "description": "Report", "row_id": 1962763, "text": "NICU NPN 1900-0700\n\n\n#3 FEN O: TF REMAIN AT 150CC/K/DAY. FEEDS ADVANCED TO\n140CC/K/D. TOLERATING ADVANCING FEEDS. D STICK AT 1AM 34.\n AWARE. RECHECKED AFTER FEED, AND IT HAD INCREASED TO 65.\nCURRENTLY IVF AT 20CC/K, WITH DECREASE TO 10CC/K, IF D STICK\nSTABLE AT 4AM. VOIDING AND STOOLING, ABDOMEN IS SOFT, NO\nLOOPS, AG STABLE, NO SPITS, MIN NGT ASPIRTAES. A: LOW D\nSTICK. P: FOLLOW D STICKS CLOSELY, MONITOR FEEDING\nTOLERANCE.\n\n#4 G&D O: TEMPS ARE STABLE, NESTED ON SHEEPSKIN, IN SERVO\nISOLETTE. IS AND ACTIVE WITH CARES, SLEEPS WELL IN\nBETWEEN CARES, SUCKS ON PACIFIER. FONTANELLS ARE SOFT AND\nFLAT. A: AGA P: CONTINUE TO SUPPORT DEVELOPMENT.\n\n#5 PARENTING O: MOM X1 FOR UPDATE, ASKING APPROPRIATE\nQUESTIONS. A: INVOLVED, LOVING PARENTS. P: CONTINUE TO KEEP\nPARENTS INFORMED.\n\n#6 BILI O: BABY REMAINS UNDER SINGLE PHOTOTHERAPY, WEARING\nEYE SHIELDS. A: STABLE. P: CONTINUE TO MONIITOR.\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2155-01-15 00:00:00.000", "description": "Report", "row_id": 1962764, "text": "NICU NPN ADDENDUM\nD STICK AT 430AM WAS 49. AWARE. FORMULA CHANGED TO PE20, WITH 4CAL. OF POLYCOSE ADDED TO MAKE 24CAL. IVF NOW INFUSING AT 30CC/K/D. WILL REPEAT D STICK IN 2HRS.\n" }, { "category": "Nursing/other", "chartdate": "2155-01-15 00:00:00.000", "description": "Report", "row_id": 1962765, "text": "Neonatology\nRA. No spells. Comfortable appearing.\n\nWt 1385 up 65. Tolerating feeds at 120 cc/k/d out of TF =150 cc/k/d. Up to 24 cal (Polycose) last noc becuase of BS of 42. WIll continue to monitor BS during day. WIll advance to full feeds on 24 cal.\n\nBili in range under phototherrapy. Will repeat in am.\n\nCOntinue as at present.\n\n transfer to at parents request once BS stable.\n" }, { "category": "Nursing/other", "chartdate": "2155-01-15 00:00:00.000", "description": "Report", "row_id": 1962766, "text": "NPN Days\n\n\n#3: TF!50cc/kg/d. REcieved infant on IVF at 20cc/kg/d, has\nsince been heplocked for D/S >55 per order. Now conts on q3\nhr feeds of PE24 made with 4cal polycose. D/S 91,57. Abdomen\nis benign, voiding, no stool this shift. One small spit\nnoted. AG stable. A: Tolerating feeds, D/S stable at\npresent. P: cont to monitor closely.\n#4: Temp stable in servo isolette, fontanelles are soft and\nflat. and active wtih cares, irritable at times.\nSleeping well. Brings hands to face, likes pacifier. A: AGA.\nP: Cont to support.\n#5: Mom in today to visit, participated in cares. Will be\nback tonight with Dad to hold. A: mom. P: cont to\nsupport .\n#6: cont under single phototherapy, eye shields on at all\ntimes. Level to be checked in am. A/P Cont to monitor.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2155-01-18 00:00:00.000", "description": "Report", "row_id": 1962776, "text": "NPN\n\n\n3. TF@ 150/kg/d of PE/BM 26, ds 38 x1, fed and rpt. ds wnl,\nall ac ds wnl, see flow sheet. Feeds q 3 hrs., min.\naspirates, spit x1 small. Voiding qs. Abd. benign, soft,\nag stable. A: Tolerating feeds, ds mostly wnl. P: Cont. to\ncheck ac ds. Follow for s&sx of fdg. intolerance.\n4. Stable temp in air isolette, and active. Swaeddled\nin isolette. A: AGA P: Cont. to support developmentally.\n5. Mom called last evening, updated on cares. A: Involved\nparents P: Cont. to support.\n6. Rebound bili pending.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2155-01-09 00:00:00.000", "description": "Report", "row_id": 1962742, "text": "Neonatology Attending Admit Note:\n\n33 week male twin #2 IUGR admitted for observation due to prematurity.\n\nInfant born to a 43 year old G4P0 mother blood type O positive, antibody negative, HepBSAg negative, RPR NR, RI. Prenatal course noteable for\n1) IVF donor egg\n2) di/di twins\n3) discordant growth (twin A-- 85% and 50% compared with twin B-- 57% and 18%)\n4) normal AFP, declined amnio\n5) mother admitted due to possible preterm labor. Received betamethasone x 2 with last dose 1/16 at 4:45pm . Due to persistence of variables in this twin with decel to 90's lasting < 1 minute, returning to baseline, elected to delivery by C/S today.\n\nno ROM, unknown GBS, no maternal fever, no maternal antibiotics\nOB: Dr. \nPEDI: Dr. \n\nInfant born at 0127 on by C/S. This twin emerged crying and active. Noted to have initial central cyanosis requiring oxygen and due to decreased air entry, received intermittent PPV. Color and respiratory status improved and infant transported to NICU receiving BB oxygen. APGARS of 8 (1min) and 9 (5min)\n\nPE: weight=1385g, L=39.5cm, HC=28 cm (all parameters between 10th and 25th %); HR=160, RR=48, oxygen saturation=100% on RA\nwell appearing infant, slightly ruddy. AFOF, normal palate, normal facies. normal S1S2, no murmur. breath sounds clear bilaterally, no ic/sc retx. abdomen soft, nontender, nondistended. ext warm, well perfused, tone aga. testes palpable in canal. patent anus. spine intact. hips stable\n\nImp/Plan: 33 week male IUGR twin (probably due to placental insufficiency) admitted for observation and sepsis evaluation.\n\nRESP--monitor respiratory status closely. monitor for apnea over next few days.\nCOR--stable, continue to monitor\nFEN-- IV D10 W at 80 cc/kg/d, monitor dstx.\nID-- due to sepsis risk factors of unknown GBS status, PTL and prematurity, will start ampicillin and gentamicin. length of treatment to be determined by clinical course and blood culture results\nSOCIAL-- will update family\n" }, { "category": "Nursing/other", "chartdate": "2155-01-09 00:00:00.000", "description": "Report", "row_id": 1962743, "text": "NICU nursing admit note\n\n\nMale infant 33 wk discordant twin/ IUGR delivered by C-sect\nwith apgar 8 and 9. See above note for delivery room course\nand maternal history. Infant admitted to NICU in r/a with\nmild sc/Ic retractions with diminished bs bilaterally which\nimproved over the course of the next couple of hours. Sat's\nin high 90's to 100%. BSCE , slightly diminished at bases\nbilaterally with mild sc retractions. BP stable well\nperfused with good cap. refill. No murmur. Dstick initially\n29, received 2cc/kg bolus of D10w, TF begun at 80cc/kg/day\nwith dstick improved to 58. TF increased to 100cc/kg/day\nafter dstick of 49. Voided no stool. Active bs x 4 quads.\nCBC blood cx drawn, abx started, diff. unshifted. temp\nstable on warmer. active and alert with cares, sleeps in\nbetween. Dad visit x2, Mom visit x1, updated and verbalizing\nunderstanding.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2155-01-13 00:00:00.000", "description": "Report", "row_id": 1962757, "text": "NPN 1900-0700\n\n\n#3 FEN: Weight 1310g, no change. TF 150cc/k/d. Currently\n70cc/k of D12.5 through PIV and 80cc/k of PE20; 18.5cc\ngavaged over 40min. ABd benign, BS active, girth stable. No\nspits or aspirates. Voiding and stooling mec. Tolerating\nfeeds well, con't per plan, increase feeds 15cc/k at 01\n& 13.\n\n#4 G&D: and active w/ cares, sleeping well this shift.\nSucks on pacifier. Maintaining stable temps nested in\nsheepskin in servo controlled isolette. Con't to support dev\nneeds.\n\n#5 Parents: Parents up for 2100 cares, asking appropriate\nquestions. Mom drew picture for isolette. Mom being d/c'd\ntomorrow, may stay in parent room. Con't to support and\nudpate as needed, need family meeting tomorrow.\n\n#6 Bili: Infant remains jaundice under single phototherapy.\nWill recheck bili level this a.m. See flowsheet.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2155-01-18 00:00:00.000", "description": "Report", "row_id": 1962777, "text": "NEONATOLOGY ATTENDING\n\nDay 9 for .\n\nRESP: RA, good RR, no apneas or bradys.\n\nCV: No murmur, no perfusion, MBP 54.\n\nFEN: BW was 1385, now +45 to 1365. On 150/kg, 26 cal HBM/PE (with 2 cals of polycose). Problems with hypoglycemia. Dropped to 38 once last night. DS since then all acceptable. On Q3h feeds, coping. Girth stable, belly benign. Spit once. Voiding, stooling. Will add promod today. Will add Vit E today. Is on Fe.\n\nDVLP: Weaning headed incubator, air mode.\n\nBILI: Rebound 5.8/0.2 this AM. Off lights yesterday.\n\nEXAM: Small, bright-eyed baby. AF soft. Slightly mottled skin. Belly soft. +BS. Lungs clear, no murmur, good pulses.\n\n" }, { "category": "Nursing/other", "chartdate": "2155-01-18 00:00:00.000", "description": "Report", "row_id": 1962778, "text": "NICU Nursing Progress Note\n\nNUTRITION\nO: Remains on 150cc/kg/day and added Promod to 26 cal BM/PE.\nInfant took entire volume required for one feeding this\nmorning using volufeed and red nipple. Abd exam benign.\nVoiding and passing heme neg stool. Attempted BF with Mom\nand infant latched on briefly and sucked in very short\nbursts.\nA: No evidenceof intolerance to additon of promod. Beginning\nto tolerate increase in po attempts.\nP: Continue plan of care.\n\nHYPERBILI\nO: Rebound bili this a.m. 5.2/0.8 off phototherapy for 24\nhrs.\nA: Resolved problem.\nP: D/C problem.\n\nDEVELOPMENT\nO: Sleeps between cares. Active and during cares. Temp\n low degree air controlled isolette.\nA: Appropriate behavior. Good temp control.\nP: Leave in isolette until weight progresses a bit further.\n\nPARENTING\nO: Mom and Dad in to visit. Dad independent in temp taking\nand diaper change. Updated regarding infant's plan of care.\nMom independent in puttinginfant to breast with verbal cues.\n\nA: Involved parents.\nP: Support and keep informed.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2155-01-19 00:00:00.000", "description": "Report", "row_id": 1962779, "text": "NPN\n\n\n3. TF@ 150/kg/d of PE/BM 26 with PM, min. aspirates, abd.\nbenign, spit x1, small, ag stable, all Ds wnl with the\nexception of one at 2300, was 47, rpt. after fdg. 77. PO\nx1, took 26cc's. Voiding qs, no stool. A: Continue to have\nsmall glucose instability.P:Continue to check ds ac.\nObserve for fdg. intolerance.\n4. Stable temp in air isloette. with cares, sleeps\nwell b/w. PO fed well. A: AGA P: Continue to suppoort\ndevelopmentally.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2155-01-19 00:00:00.000", "description": "Report", "row_id": 1962780, "text": "Neonatology Attending\nPhysical Examination\n\nwell appearing infant\nHEENT AFSF; no nasal flaring; buccal mucousa normal\nCHEST no retractins; good bs bilat; no crackles\nCVS well perfused; RRR; PPP, symm; S1S2 normal; no murmur\nABD soft, non-distended; no organomegaly; no masses; bs present; normal male genitalia with testes in canal; small left intermittent reducible inguinal hernia\nCNS active, ; AGA; MAE symm; suck/root/Moro/grasp/gag present\nINTEG normal\n\n" }, { "category": "Nursing/other", "chartdate": "2155-01-13 00:00:00.000", "description": "Report", "row_id": 1962758, "text": "Neonatology\nRA. No spells.\n\nWt 1310 no change. On 80 cc/k/d of feeds. All gavage. TF at 150 cc/k/d. Rest via D10. Abdomen benign.\n\nBili 7.2. Underphotorx to conitnue and recheck in am.\n\nContinue as at present.\n" }, { "category": "Nursing/other", "chartdate": "2155-01-13 00:00:00.000", "description": "Report", "row_id": 1962759, "text": "Nrsg Progress Note-0700-1500\n\n\nReport from night RN at 0700.\n#3O/A-Tf of 150 cc's/kg/day of bm 20 cal with adancemtn of\nabove from 80 cc'/skg to 95 cc's/kg all pg with no intol\nnoted. Piv of d10w with 55 cc's (3.2 cc's/hr) infusing well\nthrough Piv in rt foot. Dstix of 68 prefeeding at 0900.A-Fen\nneeds wnl this shift with no fdg issues.P-Cont to assess fen\nneeds.\n#4O/A-Rem nested in heated isol with servo mode. Awake with\nfdgs with minimal stressors. A-g&d needs wnl this shift.\nP-Cont to assess g&d needs.\n#5O/A-Mom and dad here with complete udpate given. Plans for\nfamily meeting at 1400 today. A-Parents coping with\nhsopitalization. P-Cont to assess parenting needs.\n#6O/A-Rem jaundiced with bili masks in place. Removed with\ncares with replacement after cares. Plans for bili in am\ntomorrow. A-Bili issues remain stable.P-Cont to assess bili\nneeds and monitor results.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2155-01-14 00:00:00.000", "description": "Report", "row_id": 1962760, "text": "NICU NPN 1900-0700\n\n\n#3 FEN O: Tf remain at 150cc/k/day. Weight 1240g, down 70g.\nTolerating advancing feeds of bm/pe20 well, feeds currently\nat 100cc/k/day. PIV of d12.5, infusing through piv well.\nVoiding and stooling. Abdomen soft, slightly distended, with\nsoft loops, at 4am care. by , no changes\nmade in feeding plan. Min aspirates, active bs, no spits. A:\nstable. P: Continue feeding plan.\n\n#4 G&D O: Temps are stable, nested on sheepskin, on servo,\nin isolette. Baby is , active, sometimes irritable with\ncares, sleeps well in between cares. Fontanells are soft and\nflat. Takes pacifier for comfort. A: aga P: Continue to\nsupport development.\n\n#5 Parenting O: Mom in for cares x2, asking questions. A:\nInvolved. P: Continue to keep informed, offer support.\n\n#6 Bili O: Baby remains under single phototherapy, wearing\neye shields. Bili to be checked this am. A: stable. P:\nFollow up with am bili.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2155-01-14 00:00:00.000", "description": "Report", "row_id": 1962761, "text": "NEONATOLOGY\nCOMFORTABLE APEPARING. SPELLS NOT A PROBLEM.\n\nWT DOWN 70. FEEDS AT 110 CC/K/D OUT OF TF = 150 CC/K/D.\n\nBILI UNDER PHOTORX FOR BILI IN 7 RANGE. WILL FOLLOW.\n\nCONTINUE AS AT PRESENT.\n" }, { "category": "Nursing/other", "chartdate": "2155-01-17 00:00:00.000", "description": "Report", "row_id": 1962772, "text": "NURSING PROGRESS NOTE\n\n\n3. F/N\nTONIGHT'S WEIGHT UP 15 GRAMS TO 1.32KG. TOLERATING 150CC/KG\nOF BM/PE26, ADDED CALS ARE POLYCOSE. ABD BENIGN, NO\nASPIRATES. STOOLING. ONE TOUCH AC AT 0500 57.\n4. G&D\nSWADDLED AFTER PHOTOTHERAPY DC'D AT 0500. QUIET UNLESS\nDISTURBED. LOVES PACIFIER.\n5. PARENTING\nNO CONTACT.\n6. HYPERBILI\nPHOTOTHERAPY . TO CHECK REBOUND TOMORROW AM.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2155-01-17 00:00:00.000", "description": "Report", "row_id": 1962773, "text": "Neonatology Attending\nDOL 8\n\n remains in room air with no apnea/bradycardia. Wt 1320 (+15) on TFI 150 cc/kg/day on PE26/BM26. Glucose acceptable (>55). Voiding and stooling appropriately. Phototherapy discontinued today.\n\nA&P\nDoing well. Continue to await maturation of oral feeding skills and thermoregulation. Rebound bilirubin check in am. For transfer to today.\n" }, { "category": "Nursing/other", "chartdate": "2155-01-17 00:00:00.000", "description": "Report", "row_id": 1962774, "text": "Clinical Nutrition:\nO/\n34 wks, BB now on DOL #8\nWt: 1320g (+15)-(<10th%ile); current wt down ~7% from birth wt.\nLN: 40.25cm (39.5)-(10-25th%ile)\nHC: 27.5cm (28)-(<10th%ile)\nMeds: Iron (total from suppl.&feeds= ~4.1 mg/kg/day) & vit E\nLabs: none recent\nNutrition: BM/PE26 @ 150 cc/kg/day\nProjected 24 hr intake: ~130 Kcals/kg & ~3.3-3.6 g/kg of protein\n\nA/Goals:\nTolerating feeds, no spits noted. H/O hypoglycemia, current formuala includes 2 Kcals from Polycose. Dsticks slightly low: 57, 61. need to increase length of feeding times. Would cont. to advance Kcals/protein to BM30/PE30 w/ promod until baby boy is gaining ~15-20 g/kg/day. Check nutrition labs Qweek & cont. to monitor Dsticks closely. Suggest starting vit E. Noted transfer pending to this afternoon, please call w/ any questions.\n" }, { "category": "Nursing/other", "chartdate": "2155-01-17 00:00:00.000", "description": "Report", "row_id": 1962775, "text": "NICu Nursing Progress Note\n\nRESP\nO: No apnea, bradycardia, or spontanoeus desat noted. Pulse\noximeter d/c'd after discussion on rounds this a.m.\nA: No evidence of compromise.\nP: D/C problem.\n\nNUTRITION\nO: Remains on 150cc/kg of BM/PE26 mostly by gavage. Remains\non q3 hr feeds. Abd exam benign. Voiding and passing heme\nneg stool. Infant attempted BF with Mom and latched on for\nbrief bursts of sucking. Dextrostix 55 and above.\nA: Remains euglycemic. Slow to po feed.\nP: Attempt BF when Mom visits.\n\nDEVELOPMENT\nO: Temp elevated due to environmental isolette issues. Air\ncontrol temp weaned significantly today. during cares.\nSleeps between. Sucking on pacifier.\nA: Appropriate behavior.\nP: Maintain neutral thermal environment.\n\nPARENTING\nO: MOm in for most of the afternoon. Held infant and put him\nto breast. Updated regarding infant's status and plan of\ncare. Plan to attempt transfer to NWH tomorrow if bedspace\navailable.\nA: Involved parent.\nP: Support and keep informed.\n\nHYPERBILI\nO: Remains out of phototherapy since 0500 this morning.\nA: Resolving hyperbilirubinemia.\nP: Rebound bili in a,.m.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2155-01-09 00:00:00.000", "description": "Report", "row_id": 1962744, "text": "Neonatology\nCOMFORTABLE APPEARING SPELLS NOT PROBLEM.\nNO EVIDENCE OF PDA.\n\nWT . ABDOMEN BENIGN. NPO AT PRESENT. TF AT 100 CC/K/D. BS IN HIGH 40S. BS STABLE ON IJNCREASED GIR.\n\nON ABX FOR 48 H R/O.\n\nSPOKE WITH MOTHER.\n\n" }, { "category": "Nursing/other", "chartdate": "2155-01-09 00:00:00.000", "description": "Report", "row_id": 1962745, "text": "NURSING PROGRESS NOTES.\n\n\n#1 O: BABY REMAINS ON IV AMPI AND GENT. A: ON 48 HOUR\nSEPSIS RULE OUT. P: FOLLOW CULTURE RESULTS.\n#2 O: BABY REMAINS IN ROOM AIR. BREATH SOUNDS CLEAR AND\nEQUAL, MILD RETRACTIONS. NO SPELLS NOTED. A: DOING WELL.\nP: CONTINUE TO MONITOR.\n#3 O: TOTAL FLUIDS 100CC/KG/DAY OF D10W VIA PERIPHERAL IV.\nD/STIX 69 AND 66. VOIDING WELL. NO STOOL TODAY. ABDOMEN\nSOFT, BOWEL SOUNDS ACTIVE, NO LOOPS. A: BABY REMAINS NPO.\nP: CHECK LYTES AND BILI IN AM AND CHANGE IV FLUIDS AS\nNEEDED.\n#4 O: TEMP STABLE ON WARMER, WEANED SLIGHTLY TODAY. BABY IS\n AND ACTIVE WHEN AWAKE AND SUCKS HIS PACIFIER AND\nSLEEPS WELL BETWEEN CARES. A: APPORPRIATE FOR AGE. P:\nCONTINUE TO SUPPORT DEVELOPMENT.\n#5 O: PARENTS UP TO VISIT BABY TODAY. MOTHER HELD BABY. A:\nINVOLVED FAMILY. P: CONTINUE TO KEEP INFORMED.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2155-01-10 00:00:00.000", "description": "Report", "row_id": 1962746, "text": "NPN\n\n\nNPN#1 O= cont on IV Abxampi & gent as ordered, irritable but\nsettles, stable temp on servo..good , blood cx remain\npnd in computer A= r/o sepsis P= cont per plan, monitor for\nS&S of sepsis, ? 48hr r/o\n\nNPN#2 O= remains in RA with O2 sats >97%, no spells, RR\n30's-40's< lS clear & equal with mild IC/SCR, no murmer,\nwell perfused MAP =50 A= stable in RA P= cont to assess\nWOB..monitor for spells\n\nNPN#3 O= remains NPO WT down 45gms to 1340, TF increased to\n120cc/kg at 0200, IVF changed to D10W with 2NaCl and 1 meq\nKCL infusing well via PIV, DS= 47 ^ 55 and TF increased Abd\nexam soft + active BS, no stool, uo good, lytes 140/ 4.3/\n104/ 20 A=DS improving P= consult team re; start of feeds,\nfollow DS, cont per plan\n\nNPN#4 O= received on warmer transferred into heated isolette\non servo with stable temp, irritable with cares settles with\ncontainment, good , , nested in sheepskin\nwithboundaries in place, A= irritable at times P+ cont to\nassess & support dev needs\n\nNPN#5 O= dad at ..updated, both parents returned at\n2100..both watched temp/ diaper change will try later\ntoday..asking alot of questions..needing alot of\nreinforcement re; clustering of cares..both held for\nabout 30min each..tol well , mom called x1 for update A=\ninvolved new parents P= cont to teach/ update & support\n\nNPN#6 O= infant increasingly jaundiced..bili\n7.6/.3/7.3..started on single phototherapy with protective\neye patches in place A= hyperbili P= cont to follow levels,\n skin exposure to lights\n\n\n" }, { "category": "Nursing/other", "chartdate": "2155-01-10 00:00:00.000", "description": "Report", "row_id": 1962747, "text": "Neonatology\nDoing well. RA. No spells. Comfortable appearing.\nSpells not a problem. evidence of PDA.\n\nWt 134-0 down 45. TF incresaed to 120 cc/k/d last noc for BS. BS in 60s. Lytes in good range. Feeds to begin today. AAbdomen benign\n\nTemp stable in isollette.\n\nAbx to be dced.\n\nBili in 7 range. Photorx started last noc. To be repeated tonoc.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2155-01-11 00:00:00.000", "description": "Report", "row_id": 1962752, "text": "NICU Attending Note\n\nDOL # 2, IUGR, with issues of growth and nutrition, hyperbili.\n\nCVR/RESP: RA, no A/B, no active issues. Will continue to monitor.\n\nFEN: Weight today down 15 gm to 1325 gm, on TF of 120 cc/kg/d, 30 cc/kg/d of which is enteral, remainder as D12.5 with lytes, D sticks in normal range after problems with hypoglycemia. Lytes this am: 147/4.5/107/18. Will increase enteral volume by 10 cc/kg/ as tolerated, start PN, increase TF to 140 cc/kg/d, continue to follow lytes.\n\nBILI: today's bili up to 8.1/0.4, from 7.6/0.3 yesterday, under single phototx. Maternal blood type O+, will check type and coombs for baby, if +, will start second phototx light, otherwise, will leave single light and recheck bili in am.\n\nID: s/p 48 hour rule out, no active concerns.\n" }, { "category": "Nursing/other", "chartdate": "2155-01-11 00:00:00.000", "description": "Report", "row_id": 1962753, "text": "#6 BILI\ns/o: Cont under single phototx- am bili-- 8.1/0.4. Type and\ncoombs ordered from mom's cord blood- pending. A: Hyperbili\nof prematurity. P: Labs as ordered\n#5 PARENTS\ns/o: Both parents in. Dad held son. also participating\nin cares. A: Involved parents asking appropriate questions.\n#4 G&D\ns/o: Nested in sheepskin in heated isolette on servo. \ngood. with cares. A: Dev AGA. P: cont Dev supp. cares\n#3 FEN\ns/o: Adv to 40cc/k of enteral feeds today. Tol well. voiding\nqs. DS x1-82. IVF D12.5 cont via PIV. IL started this eve.\nA: Hyperal and PE20 for TF of 140cc/k/d. P: Lytes in Am,\ncont to mtr IVF, DS and wt.\n#2 RESP\ns/o: Stable in RA - BS clear and equal. No spells. A/p:\nResolved.\n\n\n" } ]

[ { "category": "Radiology", "chartdate": "2164-09-14 00:00:00.000", "description": "BY SAME PHYSICIAN", "row_id": 1149826, "text": " 8:08 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: lines/tubes in right position\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\CORONARY ARTERY BYPASS GRAFT WITH ATRIAL VALVE REPLACEMENT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old man with avr/cabg\n REASON FOR THIS EXAMINATION:\n lines/tubes in right position\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE AP PORTABLE VIEW OF THE CHEST\n\n REASON FOR EXAM: Status post AVR.\n\n ET tube tip is 4 cm above the carina. There is a catheter sheath in the right\n IJ. There are mediastinal and bilateral chest tubes. Bilateral pleural\n effusions are small, right greater than left, probably decreased on the left,\n and associated with bibasilar atelectasis. There is no evident pneumothorax.\n Sternal wires are aligned. There is cardiomegaly and mediastinal widening.\n\n" }, { "category": "Echo", "chartdate": "2164-09-14 00:00:00.000", "description": "Report", "row_id": 86192, "text": "PATIENT/TEST INFORMATION:\nIndication: Coronary artery disease. H/O cardiac surgery. Aortic valve disease.\nStatus: Inpatient\nDate/Time: at 19:01\nTest: TEE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT VENTRICLE: Mildly depressed LVEF.\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: basal\nanteroseptal - hypo; mid anteroseptal - hypo; basal inferoseptal - akinetic;\nmid inferoseptal - akinetic; basal inferior - akinetic; mid inferior -\nakinetic; inferior apex - akinetic;\n\nRIGHT VENTRICLE: Normal RV chamber size. Normal RV systolic function.\n\nAORTIC VALVE: Bioprosthetic aortic valve prosthesis (AVR). AVR well seated,\nnormal leaflet/disc motion and transvalvular gradients. 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.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: A TEE was performed in the location listed above. I certify\nI was present in compliance with HCFA regulations. The patient was under\ngeneral anesthesia throughout the procedure. The TEE probe was passed with\nassistance from the anesthesioology staff using a laryngoscope. No TEE related\ncomplications. Results were personally reviewed with the MD caring for the\npatient.\n\nConclusions:\nOverall left ventricular systolic function is mildly depressed (LVEF= 40-45%).\nThere is severe inferior and inferoseptal hypokinesis/akinesis. Right\nventricular chamber size is normal with normal free wall contractility. A\nbioprosthetic aortic valve prosthesis is present. The aortic valve prosthesis\nappears well seated, with normal leaflet/disc motion and transvalvular\ngradients (peak/mean 16/7 mmHg). There is no aortic valve stenosis. No aortic\nregurgitation is seen. The mitral valve leaflets are mildly thickened.\nModerate (2+) mitral regurgitation is seen. There is no pericardial effusion.\nThere is a right pleural effusion which decreased in size after removal by\nsurgical team.\n\nDr. was notified in person of the results at the time of the study.\n\n\n" }, { "category": "Echo", "chartdate": "2164-09-12 00:00:00.000", "description": "Report", "row_id": 86193, "text": "PATIENT/TEST INFORMATION:\nIndication: Aortic valve disease. Congestive heart failure. Shortness of breath.\nStatus: Inpatient\nDate/Time: at 14:33\nTest: TEE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Mild LA enlargement. Elongated LA. No spontaneous echo contrast\nin the body of the LAA. Good (>20 cm/s) LAA ejection velocity.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal interatrial septum.\n\nLEFT VENTRICLE: Moderate symmetric LVH. Normal LV cavity size. Mildly\ndepressed LVEF.\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: basal\ninferoseptal - hypo; mid inferoseptal - hypo; septal apex - hypo;\n\nRIGHT VENTRICLE: Normal RV systolic function.\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: Severely thickened/deformed aortic valve leaflets. Critical AS\n(area <0.8cm2). Moderate (2+) AR.\n\nMITRAL VALVE: Moderately thickened mitral valve leaflets. Severe mitral\nannular calcification. Calcified tips of papillary muscles. Moderate (2+) MR.\n\nTRICUSPID VALVE: Tricuspid valve not well visualized. Mild [1+] TR.\n\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen. Physiologic\n(normal) PR.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: A TEE was performed in the location listed above. I certify\nI was present in compliance with HCFA regulations. The patient was under\ngeneral anesthesia throughout the procedure. No TEE related complications. The\npatient appears to be in sinus rhythm.\n\nConclusions:\nPREBYPASS\nThe left atrium is mildly dilated. The left atrium is elongated. No\nspontaneous echo contrast is seen in the body of the left atrium or left\natrial appendage.\nThere is moderate symmetric left ventricular hypertrophy. The left ventricular\ncavity size is normal. Overall left ventricular systolic function is mildly\ndepressed (LVEF= 40-45%) with global mild hypokinesis and severe hypokinesis\nof the inferolateral septum.\nRight ventricular systolic function is normal with good free wall\ncontractility.\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 are severely thickened/deformed. Number of leaflets\ncannot be determined. There is critical aortic valve stenosis (valve area <0.5\ncm2). Moderate (2+) aortic regurgitation is seen.\nThe mitral valve leaflets are moderately thickened. There is severe mitral\nannular calcification. Moderate (2+) mitral regurgitation is seen.\nThere is no pericardial effusion.\n\nPOSTBYPASS\nThe patient is AV-paced on a phenylephrine infusion.\nLeft ventricular systolic function is slightly improved (LVEF = 50-55%) with\nsome septal dyskinesis consistent with ventricular pacing.\nThe new bioprosthetic aortic valve is well-seated without perivalvular leaks\nor aortic regurgitation. Peak/mean gradients across the new valve are 14/9\nmmHg.\nMitral regurgitation is now mild (1+).\nThe thoracic aorta is intact.\n\nDr. was informed of the results at the time of the study.\n\n\n" }, { "category": "ECG", "chartdate": "2164-09-12 00:00:00.000", "description": "Report", "row_id": 220051, "text": "Sinus rhythm with A-V conduction delay. Consider left atrial abnormality.\nIntraventricular conduction delay with left axis deviation may be left anterior\nfascicular block and additional intraventricular conduction delay. ST-T wave\nabnormalities may be due to intraventricular conduction delay or possible\nischemia. Clinical correlation is suggested. Since the previous tracing\nof the rate is faster and late precordial QRS transition is less\nprominent.\n\n" } ]

[ { "category": "Radiology", "chartdate": "2188-08-17 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 795432, "text": " 4:07 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: please eval for hemorrhage\n Admitting Diagnosis: LEFT LEG WEAKNESS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 29 year old man with le paraparesis, now with headache woke him up from sleep\n REASON FOR THIS EXAMINATION:\n please eval for hemorrhage\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT (REVISED)\n HISTORY: Lower extremity paraparesis, now with headache that woke him up from\n sleep.\n\n COMPARISON: None.\n\n TECHNIQUE: Non-contrast head CT.\n\n CT HEAD W/O CONTRAST: There is no parenchymal or extra-axial hemorrhage. There\n is no shift of normally midline structures or mass effect. The /white\n distinction is preserved and the ventricles, cisterns and sulci are within\n normal limits. The bones and visualized paranasal sinuses are unremarkable.\n\n IMPRESSION: Normal non-contrast head CT.\n MRI of the brain is recomended to exclude subtle abnormality\n\n\n" }, { "category": "Radiology", "chartdate": "2188-08-14 00:00:00.000", "description": "MR-ANGIO HEAD", "row_id": 795186, "text": " 7:08 PM\n MR-ANGIO HEAD; MR HEAD W/O CONTRAST Clip # \n MR-ANGIO NECK WITHOUT CONTRAST\n Reason: Following Exams:MRI-BrainMRA-Brain & NeckDWI-BrainThanks\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 29 year old man with\n REASON FOR THIS EXAMINATION:\n Following Exams:MRI-BrainMRA-Brain & NeckDWI-BrainThanks\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Leg weakness after motor vehicle accident. Evaluate for stroke.\n\n TECHNIQUE: Multiplanar T1 and T2 weighted imaging of the brain was performed.\n Diffusion weighted scans are provided.\n\n 3D time of flight MR angiography of the circle of was performed. 3D\n and 2D time of flight MR angiography of the cervical vasculature was also\n performed. Multiplanar reformatted images and source image data are reviewed.\n\n FINDINGS:\n\n MRI of the brain demonstrates no focal signal abnormalities within the\n parenchyma. There is no susceptibility artifact detected. Diffusion weighted\n scans show no restricted diffusion to indicate acute infarction. The overall\n focal and gyri pattern of the brain is normal. The ventricles are normal in\n size and configuration.\n\n MRA OF THE CIRCLE OF :\n\n Flow signal is identified within both intracranial internal carotid arteries\n and in the anterior and middle arterial branches. Flow is seen in the\n posterior communicating arteries as well. Flow signal is identified in both\n intracranial vertebral arteries, the basilar artery, the posterior cerebral\n arteries and the proximal portions of the superior cerebellar and posterior\n inferior cerebellar arteries. No abnormal vascularity or aneurysm formation\n is identified.\n\n MR OF THE CERVICAL VASCULATURE:\n\n Motion artifact limits evaluation of MIP images due to flap artifacts.\n However, there is no evidence of flow limiting stenosis involving the carotid\n or vertebral arteries within the neck. Continuous flow signal is identified\n throughout both cervical vertebral and carotid arteries, including internal\n and external branches.\n\n IMPRESSION:\n\n 1. MRI of the brain reveals no evidence of infarction or signal abnormality.\n There is no intracranial structural abnormality observed.\n\n 2. MRA of the circle of is within normal limits.\n\n (Over)\n\n 7:08 PM\n MR-ANGIO HEAD; MR HEAD W/O CONTRAST Clip # \n MR-ANGIO NECK WITHOUT CONTRAST\n Reason: Following Exams:MRI-BrainMRA-Brain & NeckDWI-BrainThanks\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n 3. MRA of the cervical vasculature demonstrates flow in the carotid and\n vertebral arteries.\n\n" }, { "category": "Radiology", "chartdate": "2188-08-14 00:00:00.000", "description": "MR CERVICAL SPINE", "row_id": 795175, "text": " 4:58 PM\n MR CERVICAL SPINE; MR THORACIC SPINE Clip # \n MR L SPINE SCAN\n Reason: s/p MCC with LLE weakness and numbness, urinary incontinence\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 29 year old man with\n REASON FOR THIS EXAMINATION:\n s/p MCC with LLE weakness and numbness, urinary incontinence.\n ______________________________________________________________________________\n WET READ: 7:32 PM\n NORMAL\n ______________________________________________________________________________\n FINAL REPORT\n MRI OF THE TOTAL SPINE, \n\n HISTORY: Motor vehicle accident. Delayed onset of back pain. Lower\n extremity weakness, incontinence.\n\n TECHNIQUE: Cervical and thoracic MR imaging was performed with sagittal T1,\n T2 and inversion recovery scans, as well as axial gradient echo images through\n the cervical spine.\n\n Lumbosacral spine MRI was performed with sagittal T1, T2 and inversion\n recovery sagittal images of the lower spine with axial T2-weighted images\n through the upper lumbar region and conus.\n\n FINDINGS: The cervicothoracic images demonstrate normal cervical and thoracic\n vertebral alignment. Vertebral body height is maintained. Signal is normal.\n There is no evidence of edema in the immediate pre- or post- vertebral spaces.\n\n Axial images through the cervical spine demonstrate a wide spinal canal. There\n are mild degenerative osteophytic ridges at the C4-5 and C3-4 levels. There\n is no definite impingement on the cord and the spinal canal is not narrowed.\n There is probably mild to moderate narrowing of both the left C3-4 and C4-5\n neuroforamina.\n\n Cervical cord signal is difficult to assess due to artifact. The thoracic\n spinal cord appears normal in caliber and signal intensity. There is no\n evidence of a bony or soft tissue mass impinging on the thoracic spinal cord.\n The conus has a normal appearance.\n\n The lumbosacral spine images reveal normal vertebral alignment. There is no\n evidence of compression deformity. Vertebral signal is maintained. The\n intervertebral discs are normal. No edema is evident in the adjacent soft\n tissues. The conus has normal signal. The cauda equina has a normal\n appearance.\n\n IMPRESSION:\n 1. Cervicothoracic MR images reveal no evidence of a mass impinging on the\n spinal cord. There is no spinal stenosis. There is limited visualization of\n the cervical spinal cord, but the thoracic cord appears normal in signal\n intensity and caliber.\n (Over)\n\n 4:58 PM\n MR CERVICAL SPINE; MR THORACIC SPINE Clip # \n MR L SPINE SCAN\n Reason: s/p MCC with LLE weakness and numbness, urinary incontinence\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n 2. Lumbosacral MRI reveals no disc herniations or impingement on the conus or\n quada equina.\n\n" }, { "category": "Radiology", "chartdate": "2188-08-14 00:00:00.000", "description": "CT C-SPINE W/O CONTRAST", "row_id": 795170, "text": " 4:37 PM\n CT C-SPINE W/O CONTRAST; CT RECONSTRUCTION Clip # \n Reason: s/p ejection MCC, plain films negative at OSH, now with incr\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 29 year old man with\n REASON FOR THIS EXAMINATION:\n s/p ejection MCC, plain films negative at OSH, now with increasing pain and\n radiculopathy symptoms, evaluate for fx/dislocation.\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: 5:20 PM\n no fractures or malalignment\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post trauma now with increasing pain and \"radiculopathy\".\n Assess for fracture or dislocation.\n\n TECHNIQUE: Contiguous axial images were obtained through the cervical spine\n without the administration of IV contrast. Coronal and sagittal reformatted\n images were also obtained.\n\n CT OF CERVICAL SPINE WITHOUT IV CONTRAST: There are no fractures, areas of\n malalignment, bone destruction or prevertebral soft tissue swelling. The\n vertebral body heights are well preserved. The intervertebral disc spaces are\n within normal limits. There is no central canal stenosis. The visualized\n paravertebral soft tissues are unremarkable. Incidentally noted is a probable\n retention cyst within the posterior portion of the right maxillary sinus.\n\n Multiplanar reformatted images confirm the above findings.\n\n IMPRESSION: No evidence of fractures or malalignment.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2188-08-14 00:00:00.000", "description": "CT ABDOMEN W/CONTRAST", "row_id": 795173, "text": " 4:45 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n CT 150CC NONIONIC CONTRAST\n Reason: s/p sig trauma yesterday, abdominal tender, evaluate with IV\n Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 29 year old man with MCC yesterday.\n REASON FOR THIS EXAMINATION:\n s/p sig trauma yesterday, abdominal tender, evaluate with IV contrast for\n traumatic injury, please scan high enough to evaluate L-spine.\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: 5:08 PM\n NEGATIVE\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Thrown through windshield of car yesterday and evaluated and\n discharged home with a cervical spine collar at outside hospital. Now\n presenting with abdominal pain and lower extremity symptoms. Please evaluate\n abdomen and pelvis and scan high enough to include the lumbar spine.\n\n TECHNIQUE: Contrast enhanced CT of the abdomen and pelvis.\n\n CONTRAST: 150 cc of Optiray secondary to trauma.\n\n CT OF THE ABDOMEN WITH IV CONTRAST: The lung bases reveal respiratory motion\n artifact and atelectasis. The liver, gallbladder, pancreas, spleen, adrenal\n glands and kidneys are unremarkable and without evidence of traumatic injury.\n The unopacified bowel is normal for technique. The aorta is of normal\n caliber. Retroperitoneal tissues are unremarkable.\n\n CT OF THE PELVIS WITH IV CONTRAST: There is no free fluid or free air. A\n Foley catheter is contained within the bladder and there is gas within the\n bladder. There are no inflammatory changes in the lower abdomen. There is no\n evidence of mesenteric or bowel hematoma. The distal ureters are\n unremarkable. There is no adenopathy. There is a small amount of\n stranding in the right buttock deep subcutaeous fat, probable a\n minor contusion. Examination of the bone reveals no findings suspicious for\n fracture in the lumbar spine or elsewhere.\n\n IMPRESSION: No evidence of traumatic intra-abdominal injury.\n\n" }, { "category": "Radiology", "chartdate": "2188-08-15 00:00:00.000", "description": "MR CERVICAL SPINE", "row_id": 795224, "text": " 5:19 AM\n MR CERVICAL SPINE Clip # \n Reason: include MRI/MRA/IR of the neck and spine, per attendin\n Admitting Diagnosis: LEFT LEG WEAKNESS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 29 year old man with LLE weakness and anesthesia, bowel and bladder\n incontinence s/p motorcycle vs. mvc yesterday.\n REASON FOR THIS EXAMINATION:\n include MRI/MRA/IR of the neck and spine, per attending.Thank you.\n ______________________________________________________________________________\n FINAL REPORT\n CERVICAL SPINE MRI, \n\n INDICATION: Lower extremity weakness following trauma.\n\n TECHNIQUE: Sagittal T1, T2 and inversion recovery scans of the cervical spine\n were obtained and axial gradient echo images are provided through the cervical\n levels. A sagittal T2-weighted image of the cervical and thoracic spinal cord\n was also obtained.\n\n FINDINGS: Compared to the study of , the cervical cord is well\n visualized and appears normal. No signal intensity abnormalities are detected\n within the cervical portion of the spinal cord on any of the imaging sequences\n obtained. The cervicomedullary junction appears normal. The foramen magnum\n is normally wide and the cerebellar tonsils are in normal position.\n\n Axial images demonstrate spondylosis on the left at C3-4 and C4-5 levels with\n mild to moderate foraminal stenosis. There is no spinal canal narrowing.\n\n Inversion recovery images reveal no prevertebral edema or edema within the\n posterior soft tissues.\n\n Sagittal T2-weighted scans through the entire spinal cord demonstrate normal\n signal throughout. There is no cord swelling or deformity. The conus has a\n normal appearance and so does the proximal cauda equina.\n\n IMPRESSION: Normal-appearing cervical spinal cord. No evidence of edema in\n the cord or adjacent structures of the spinal. The findings were discussed\n with Dr. .\n\n" }, { "category": "Radiology", "chartdate": "2188-08-15 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 795269, "text": " 11:42 AM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p central line placement; r/o ptx\n Admitting Diagnosis: LEFT LEG WEAKNESS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 29 year old man with\n REASON FOR THIS EXAMINATION:\n s/p central line placement; r/o ptx\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 29 y/o man s/p line placement.\n\n FRONTAL VIEW OF THE CHEST: A right IJ line is present with its tip in the\n lower SVC. There is no pneumothorax. The cardiomediastinal contour is\n unchanged allowing for differences in technique. The lungs are clear, without\n pleural effusions, focal areas of consolidation or pulmonary nodules.\n\n IMPRESSION: Right IJ line with tip in the lower SVC. No pneumothorax.\n\n" }, { "category": "Radiology", "chartdate": "2188-08-16 00:00:00.000", "description": "C-SPINE (PORTABLE)", "row_id": 795355, "text": " 11:00 AM\n C-SPINE (PORTABLE) Clip # \n Reason: Please do flex-extension views to clear C-spine.\n Admitting Diagnosis: LEFT LEG WEAKNESS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 29 year old man post MVA.\n REASON FOR THIS EXAMINATION:\n Please do flex-extension views to clear C-spine.\n ______________________________________________________________________________\n FINAL REPORT\n CERVICAL SPINE, 2 VIEWS, FLEXION AND EXTENSION:\n\n HISTORY: Trauma.\n\n C1-C5 and a portion of C6 are included. No evidence of instability to the C6\n level. C7-T1 are not evaluated in these films.\n\n\n" }, { "category": "Radiology", "chartdate": "2188-08-14 00:00:00.000", "description": "T-SPINE", "row_id": 795201, "text": " 9:53 PM\n T-SPINE; L-SPINE (AP & LAT) Clip # \n Reason: PLEASE DO T/L SPINE AP/LATERAL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 29 year old man with LLE weakness post trauma.\n REASON FOR THIS EXAMINATION:\n PLEASE DO T/L SPINE AP/LATERAL\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Left lower extremity weakness, status post trauma.\n\n FOUR VIEWS T SPINE: The alignment is unremarkable, and no fractures are\n identified. No focal bone destruction is seen.\n\n TWO VIEWS L SPINE: No fractures are identified. The alignment is anatomic.\n On the lateral view, the posterior elements are not fully included on all the\n levels. If clinically warranted, a repeat lateral view could be obtained at\n no additional charge to the patient.\n\n\n" }, { "category": "Radiology", "chartdate": "2188-08-14 00:00:00.000", "description": "CHEST (SINGLE VIEW)", "row_id": 795203, "text": " 10:27 PM\n CHEST (SINGLE VIEW) Clip # \n Reason: s/p trauma\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 29 year old man with\n REASON FOR THIS EXAMINATION:\n s/p trauma\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Trauma.\n\n SINGLE VIEW CHEST: The heart size is mildly prominent, which may be due to\n technical factors. The mediastinal contours are unremarkable. The lungs are\n clear and there are no pleural effusions. The pulmonary vasculature is\n normal. No fractures are identified.\n\n IMPRESSION: No significant abnormalities identified.\n\n\n" }, { "category": "Radiology", "chartdate": "2188-08-14 00:00:00.000", "description": "PELVIS (AP ONLY)", "row_id": 795204, "text": " 10:27 PM\n PELVIS (AP ONLY) Clip # \n Reason: s/p MCC evaluate for traumatic injury\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 29 year old man with\n REASON FOR THIS EXAMINATION:\n s/p MCC evaluate for traumatic injury\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Trauma, status post MVC.\n\n SINGLE VIEW PELVIS: There is no evidence for fracture, dislocation, focal\n bone destruction, or soft tissue abnormality. A Foley catheter is in place.\n There is contrast in the bladder, secondary to recent contrast enhanced CT.\n\n\n" }, { "category": "Radiology", "chartdate": "2188-08-15 00:00:00.000", "description": "MR THORACIC SPINE", "row_id": 795296, "text": " 2:59 PM\n MR THORACIC SPINE Clip # \n Reason: WEAKNESS AND MULT-MODALITY SENSORY LOSS FROM T6 DOWN\n Admitting Diagnosis: LEFT LEG WEAKNESS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 29 year old man s/p mva has left lower extremity weakness and mult-modality\n sensory loss from t6 down (except for perserved propioception on right foot).\n we expect infarction or contusion at level of t6\n REASON FOR THIS EXAMINATION:\n please obtain axial and longitudinal views of spinal cord from t4-t10\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Continued signs of lower extremity weakness and sensory loss from\n T6 inferiorly suspicious for infarction or contusion of the cord.\n\n TECHNIQUE: Sagittal T1, T2 and inversion recovery scans of the thoracic spine\n were obtained and axial T2 weighted images are provided T9-10.\n\n FINDINGS\n\n The cervical and thoracic spinal canal is wide. Signal intensity in the\n visualized spinal cord appears normal. The caliber of the cord is normal.\n Axial images through the thoracic spine are somewhat limited by patient\n motion, but there is no evidence of cord swelling or discrete signal\n abnormality within the cord substance. No disk herniations are appreciated in\n this area.\n\n IMPRESSION: No evidence of spinal cord edema or signal abnormality that might\n reflect hemorrhage.\n\n" }, { "category": "Radiology", "chartdate": "2188-08-15 00:00:00.000", "description": "CT CHEST W/O CONTRAST", "row_id": 795241, "text": " 8:37 AM\n CT CHEST W/O CONTRAST Clip # \n Reason: please focus on aorta r/o aortic dissection\n Admitting Diagnosis: LEFT LEG WEAKNESS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 29 year old man with\n REASON FOR THIS EXAMINATION:\n please focus on aorta r/o aortic dissection\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n \n\n HISTORY: Motorcycle accident, back pain.\n\n CT OF THE CHEST WITHOUT CONTRAST:\n\n FINDINGS: There is no direct or secondary signs to suggest any thoracic injury\n in this patient. In particular, there are no pulmonary contusions, no bony\n abnormalities, the aorta and great neck vessels all appear intact without\n evidence of contour abnormality. There is no evidence of effusion. The lung\n windows demonstrate no abnormalities.\n\n IMPRESSION: Normal CT scan of the chest and in particular, no primary or\n secondary signs to suggest any evidence of thoracic or great neck vessel\n injury.\n\n" }, { "category": "Radiology", "chartdate": "2188-08-16 00:00:00.000", "description": "C-SPINE FLEX AND EXT ONLY 2 VIEWS", "row_id": 795416, "text": " 8:00 PM\n C-SPINE FLEX AND EXT ONLY 2 VIEWS Clip # \n Reason: assess flexion/extension views; please pull arms down to vis\n Admitting Diagnosis: LEFT LEG WEAKNESS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 29 year old man with\n REASON FOR THIS EXAMINATION:\n assess flexion/extension views; please pull arms down to visualize C7 (previous\n films inadequate)\n ______________________________________________________________________________\n FINAL REPORT\n CERVICAL SPINE 2 VIEWS LATERAL IN FLEXION & EXTENSION:\n\n HISTORY: Trauma.\n\n C1 to C7 are included. No evidence of instability on lateral flexion and\n extension. No fracture.\n\n" }, { "category": "Nursing/other", "chartdate": "2188-08-15 00:00:00.000", "description": "Report", "row_id": 1563533, "text": "MICUB 4P-7P RN Note\n\n29yo male involvd in MCA brought to NH TX and released with multiple aches back, neck, no fx @ home Tx with cold and heat. ON presented to ED with acute onset right leg numbness and R/L foot parathesia, inc of stool/urine. Upon presentation to pt stated felt like golf size ball mid back, Pain recieved MSO4 and Ativan, Evaluated by Neuro, Received 4 MRI and spinal xrays which upon priliminary report no fx or significant findings. R/O spinal Infarction. Levophed goal SBP 160-180, Solumedrol Infusion, HeparinIV.\nRIJ place, CXR confirmed placement, c/o left sided chest pain post central line placement EKG:no acute changes.\n\nAdmitted to MICUB @ 1600\nNeuro: Awake alert oriented, Pupils 4mm equal react brisk, Grasps right hand grasp weaker, tingling sensation R/L foot moves right leg randomly, Left leg numbness, minimal movement. decrease tactile sensation left. MRI Neg for Spinal infarction Heparin D/c @1815.\nLevo titrated to sustain SBP 160-180 refer to carevue. Solumedrol infusion to be D/c @.\n\nCV: HR 78-88 NSR no ectopy, SBP 145-188 Levo titrated to sustain SBP 160-180. Peripherally warm and dry 3+DP&DT. RIJ multilumen.\n\nResp: RR 14-22 O2 sat 96-98 RA , Lungs: Clear.\n\nGI: Abd Soft nontender + BS, Reg diet to well, No N/V.\nGU: u/o 85-150ccc/hr.\nPain: c/o Back, Neck pain Medicated with MSO4 2mg IV x2. Plan to start PCA for Pain Management.\n\nPLan: EMG \n" }, { "category": "Nursing/other", "chartdate": "2188-08-16 00:00:00.000", "description": "Report", "row_id": 1563534, "text": "NSG PROGRESS NOTE 7P-7A\nNEURO: NEURO CHECKS DONE Q1HR WITH LITTLE CHANGES. PUPILS AT START OF SHIFT 5MM, THIS AM 7MM EQUAL AND BRISK. UPPER EXTREMITY EQUAL AND STRONG. LEFT JUST VERY SLIGHTLY WEAKER BUT ABLE TO RAISE AND HOLD STEADY. GOOD SENSATION IN UPPER EXTREMITIES. RIGHT LOWER EXTREMITY IMPROVED PER PT. STRONG AND ABLE TO LIFT OFF BED. SLIGHT DECREASE IN SENSATION NEAR GROIN. LEFT LE ABLE TO RAISE OFF THE BED BUT WEAKER THAN RIGHT. STATES HE FEELS TINGLING IN FOOT AND AWARE OF TOUCH BUT UNALBE TO FEEL UP HIS WHOLE LEFT LEG. SWALLOW AND COUGH INTACT.\n\nPAIN: PAIN CONTROL MAJOR ISSUE. AT START OF SHIFT HE WAS C/O SIGN. AMOUNT OF PAIN , GRIMACING, C/O BACK PAIN AND NECK PAIN. MSO4 IVP GIVEN PER ORDERS WHILE DILAUDID PCA BEING INITIATED. STARTED DILAUDID PCA @ DOSE .25MG Q6MIN NO BASAL RATE LOCKOUT 2.5MG. PT NEVER GOT ADEQUATE PAIN CONTROL ON THIS DOSE AND WAS FREQUENTLY REQUESTING MSO4. DR. NOTIFIED AND PCA DOSE INCREASE TO .37MG LOCKOUT 3.7MG.\n PT AGAIN CONT TO STATE HIS \"BACK WAS KILLING HIM\" AT 2300 PT'S PAIN WAS UNCHANGED AND HIS DOSE WAS AGAIN INCREASED TO .45MG Q6MIN LOCKOUT 4.5MG. PT CONT TO REQUEST MSO4 STATING \"IT TAKES THE EDGE OFF\". OVER THE NEXT SEVERAL HRS PT WAS FOUND TO BE CONSTANTLY TAKING NECK BRACE OFF, CARDIAC LEADS OFF AND WAS CONSIDERABLY MORE RESTLESS AND ANXIOUS. PT WOULD REQUEST MSO4 AND WHEN TOLD THE DOCTOR WAS GOING TO BE CALLED TO DISCUSS HIS PCA AND PAIN, HE WOULD STATE THAT \"I THINK I\"M FINE FOR NOW\" FINALLY DR. CALLED AND SPOKE WITH PT. NO FURTHER MSO4 WAS GIVEN AND DOSE STAYED THE SAME. PT'S MOOD AND ATTITUDE CHANGED AND HE BECAME VAGUE REGARDING HIS PAIN WHEN ASKED. PT APPEARED VERY LETHARGIC AND CONT TO BE SO. SHORTLY AFTER HIS MEETING WITH THE DOCTOR HE FELL ASLEEP AND NO ATTEMPTS ON PCA WERE MADE FOR 1.5HRS UNTIL HE WAS AWAKENED FOR LABS. PT CURRENTLY SLEEPING AND SNORING. HR HAS BECOME BRADYCARDIC. AND PT HAS NOT CALLED FOR NURSE OR ASKED FOR MORE PAIN MED. WHEN ASKED HE STATES HIS NECK PAIN HAS IMPROVED BUT BACK PAIN STILL \n\nCV: GOAL TO KEEP BP 160-180 ON NOREPINEPHERIN 0.075MCG/KG/MIN BP 156-170. PT'S HR HAS BECOME BRADYCARDIC 44-55 SINCE 0400 WHILE SLEEPING. NO ECTOPY. GOOD PEDAL PULSES.\n\nRESP: LUNGS CLEAR, ON RA SATS 95-96%\nGI: REG DIET. ATE 3 SANDWICHES AND SEVERAL SNACKS. GOOD PO INTACT. ABD SOFT. DIST. + BOS ON SENNA AND COLACE.\n\nGU: FOLEY, CLEAR, EXCELLENT URINE OUPUT SEE CAREVIEW. NS @150CC/HR X2 LITERS (CURRENTLY ON SECOND LITER)\nSKIN: INTACT.\nLABS: PENDING.\nMISC: PT HEPARIN GTT D/C'D LAST EVE 1815 AND SOLUMEDROL GTT OFF @ .\nDISPO: FULL CODE.\n" }, { "category": "Nursing/other", "chartdate": "2188-08-16 00:00:00.000", "description": "Report", "row_id": 1563535, "text": " RN NOTE--0700-1900--S/P MVC (MOTORCYCLE)\nPAIN: MR SEEMS TO HAVE HAD A BETTER DAY TODAY THAN LAST NOC. WITH TLC, TURNING, PILLOWS TO BACK, PCA, AND SUPPLEMENTAL TYLENOL PO HAVE HELPED. HE DOZED INTERMITTENTLY AND SLEPT FOR A TOTAL OF 4 HOURS IN 2-INSTALLMENTS.\n\nCV: LEVOPHED TO MAINTAIN SBP 160-180. OVERALL BADYCARDIC--THIS IS NOT NEW. PPP.\n\nRESP: BBS: CTA, SLIGHTLY DIM BILAT BASES, ENCOURAGING C+DB.\n\nGI/GU: NO ISSUES. FOLEY, TOL HOUSE DIET IN SMALL AMOUNTS.\n\nNEURO: IVF INFUSING AND GOAL SBP TO MAINTAIN SPINAL PERFUSION. NO CHANGES IN Q1 HOUR CHECKS. PUPILS ABOUT 4MM AND BRISK. UPPER EXTREMITIES =, STRONG. LOWER EXTREMITIES WEAK, (+) SENSATION TO BOTH FEET AS EVIDENCED BY TICKLING, WITHDRAWS WITH TICKLING. LEFT LEG WEAKER THAN RT. CONTINUES TO HAVE SENSATIONS OF NOT BEING ABLE TO FEEL UP HIS LEG.\n" }, { "category": "Nursing/other", "chartdate": "2188-08-17 00:00:00.000", "description": "Report", "row_id": 1563536, "text": "Nsg Progress note 7p-7a\nNeuro: Until 0300 pt neuro status remained unchanged. PERLA 6mm/ brisk, MAE's (left side very slightly weaker than right) Pt states no sensation in left LE however when tickled unannounced he pulls back. A+O X3. These assessments remain unchanged however @ 0300 he awoke screaming in pain stating \"my head is killing me!\". Pt also tossing around in bed unable to sit still. Stated some tingling down his arms. Neuro , neurology, and SICU covering called. Pts head ache went away for a few minutes and then returned \"worse\". Pt taken to Head CT STAT. No abnormal findings but still awaiting final report. During this time pt received a bolus of Dilaudid 1mg IV, valium 2mg IV and a total of Lorazepam 2mg IV with no effect. 2 1/2hrs later pt cont to c/o of considerable amount of pain despite using PCA Dilaudid 0.6mg Q6min Lockout 6mg (which was increased @ 2200 after Ativan failed to calm pt down and his pain cont to be ). Initially it was thought that his headache may be a rebound since he did not use his PCA for several hrs since he was sleeping. O2 applied per doctors . Pt also brought to radiology for Cspine which were neg and pt cleared to remove cervical collar however pt had already removed collar despite explanation of safety. Awaiting LP.\n\nCV: Cont on Levophed gtt, no changes made overnoc as Bp remained mostly in the 160's with an occassional dip to 140's. Currently receiving 0.076mcg/kg/min. Pt constantly taking Bp cuff and leads off. Reminded of importance. HR NSR 70's no ectopy. Am K+ 2.6 currently being repleted with KCL. Needs total of KCl 40meq IV and 40meq po however d/t pt condition he will likely not be able to tolerate po's.Please f/u. CVP 6-9\n\nRESP: lungs clear, placed on nc per neuro does not tolerate it and keeps taking it off stating it hurts.\n\nGu: Requested foley to be d/c'd. OK per Dr. . Pt voiding in urinal QS. see careview. Received a total of 1.5L NS at start of shift and remains on NS @150cc/hr maitenance.\n\nGI: Abd soft, +bos, pt had lg BM guaic neg. Reg diet. Did not tolerate dinner d/t c/o back pain.\n\nDISPO: Pt is a full code. Awaiting LP. Needs K+repletion. cont with frequent neuro checks\n\n" }, { "category": "Nursing/other", "chartdate": "2188-08-17 00:00:00.000", "description": "Report", "row_id": 1563537, "text": "MICU B RN\nPLEASE SEE MICU TRANSFER NOTE\n" }, { "category": "ECG", "chartdate": "2188-08-15 00:00:00.000", "description": "Report", "row_id": 180602, "text": "Sinus rhythm\nBorderline first degree A-V block\nClinical correlation is suggested\n\n" } ]

[ { "category": "Echo", "chartdate": "2174-05-30 00:00:00.000", "description": "Report", "row_id": 59687, "text": "PATIENT/TEST INFORMATION:\nIndication: Aortic valve disease. Left ventricular function.\nHeight: (in) 60\nWeight (lb): 117\nBSA (m2): 1.49 m2\nBP (mm Hg): 113/53\nHR (bpm): 89\nStatus: Inpatient\nDate/Time: at 13:00\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT ATRIUM: Mild LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. A catheter or pacing wire is\nseen in the RA and extending into the RV. Lipomatous hypertrophy of the\ninteratrial septum.\n\nLEFT VENTRICLE: Normal LV wall thickness and cavity size. Mild-moderate\nregional LV systolic dysfunction. No LV mass/thrombus. No resting LVOT\ngradient.\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: basal inferior\n- hypo; mid inferior - akinetic; basal inferolateral - akinetic; mid\ninferolateral - hypo;\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic diameter at the sinus level. Normal ascending aorta\ndiameter.\n\nAORTIC VALVE: Severely thickened/deformed aortic valve leaflets.\nModerate-severe AS (area 0.8-1.0cm2). Mild (1+) AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Mild mitral annular\ncalcification. Mild thickening of mitral valve chordae. Calcified tips of\npapillary muscles. Mild (1+) MR. [Due to acoustic shadowing, the severity of\nMR may be significantly UNDERestimated.]\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR. Borderline PA\nsystolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS.\nPhysiologic PR.\n\nPERICARDIUM: Small pericardial effusion. Effusion is loculated. No RV\ndiastolic collapse.\n\nGENERAL COMMENTS: Right pleural effusion.\n\nConclusions:\nThe left atrium is mildly dilated. Left ventricular wall thicknesses and\ncavity size are normal. There is mild to moderate regional left ventricular\nsystolic dysfunction with near akinesis of the inferior and inferolateral\nwalls and mild-moderate hypokinesis of the remaining segments (LVEF = 30-35%).\nNo masses or thrombi are seen in the left ventricle. Right ventricular chamber\nsize and free wall motion are normal. The aortic valve leaflets are severely\nthickened/deformed. There is moderate to severe aortic valve stenosis (area\n0.9cm2). Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are\nmildly thickened. At least mild (1+) mitral regurgitation is seen. [Due to\nacoustic shadowing, the severity of mitral regurgitation may be significantly\nUNDERestimated.] There is borderline pulmonary artery systolic hypertension.\nThere is a small, primarily anterior (?loculated) pericardial effusion without\nevidence of hemodynamic compromise with a prominent anterior fat pad.\n\nCompared with the prior study (images reviewed) of , left ventricular\nsystolic function is slightly improved.\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": "Echo", "chartdate": "2174-05-29 00:00:00.000", "description": "Report", "row_id": 59688, "text": "PATIENT/TEST INFORMATION:\nIndication: Pericardial effusion. Left ventricular function. Aortic valve disease. S/p aortic valvuloplasty\nHeight: (in) 58\nWeight (lb): 115\nBSA (m2): 1.44 m2\nBP (mm Hg): 115/55\nHR (bpm): 112\nStatus: Inpatient\nDate/Time: at 10:22\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 ATRIUM: Normal LA size.\n\nLEFT VENTRICLE: Severe global LV hypokinesis.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTIC VALVE: Severely thickened/deformed aortic valve leaflets. Significant\nAS is present (not quantified) Mild (1+) AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Mild mitral annular\ncalcification. Mild thickening of mitral valve chordae. Calcified tips of\npapillary muscles. Mild (1+) MR. [Due to acoustic shadowing, the severity of\nMR may be significantly UNDERestimated.]\n\nPERICARDIUM: Small to moderate pericardial effusion. No RV diastolic collapse.\n\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows. Emergency\nstudy performed by the cardiology fellow on call.\n\nConclusions:\nThe left atrium is normal in size. There is severe global left ventricular\nhypokinesis (LVEF = 25-30 %). Right ventricular chamber size and free wall\nmotion are normal. The aortic valve leaflets are severely thickened/deformed.\nSignificant aortic stenosis is present (not quantified). Mild (1+) aortic\nregurgitation is seen. The mitral valve leaflets are mildly thickened. Mild\n(1+) mitral regurgitation is seen. [Due to acoustic shadowing, the severity of\nmitral regurgitation may be significantly UNDERestimated.] There is a small to\nmoderate ?loculated pericardial effusion, most prominent (1.5cm) around the\nright atrium and (0.5-1cm) right ventricle with minimal elsewhere. No right\nventricular diastolic collapse is seen.\n\nCompared with the prior study (images reviewed) of , the pericardial\neffusion is more prominent (previously trivial). Left ventricular systolic\nfunction and the severity of aortic regurgitation are similar.\n\n\n" }, { "category": "Radiology", "chartdate": "2174-05-29 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1017640, "text": " 8:10 AM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: Please eval for interval change.\n Admitting Diagnosis: RESPIRATORY FAILURE;CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old woman with AS, CHF here with shortness of breath intubated for\n ?PNA/CHF.\n REASON FOR THIS EXAMINATION:\n Please eval for interval change.\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Aortic stenosis. SOB.\n\n CHEST: Comparison is made to prior chest x-ray of five hours previous. The\n position of the various lines and tubes is unchanged, severe scoliosis is\n again noted. There has been some mild improvement in the degree of\n interstitial edema, though it persists.\n\n IMPRESSION: Some improvement in pulmonary edema.\n\n\n" }, { "category": "Radiology", "chartdate": "2174-05-31 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1018011, "text": " 4:57 PM\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \n Reason: please assess placement of right internal jugular central li\n Admitting Diagnosis: RESPIRATORY FAILURE;CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old woman extubated for respiratory distress, now s/p right IJ for\n access\n REASON FOR THIS EXAMINATION:\n please assess placement of right internal jugular central line\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): PSS WED 1:11 PM\n Lines and tubes including new right IJ line are in standard placements. No\n pneumothorax or mediastinal widening. Small right pleural effusion\n increasing, but probably unrelated. Left lower lobe atelectasis stable.\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 5:17 \n\n HISTORY: 80-year-old woman intubated for respiratory distress. Right IJ\n line.\n\n IMPRESSION: AP chest compared to through 17:\n\n Tip of the new right IJ central vascular line is obscured by the indwelling\n dual-channel right internal jugular hemodialysis catheter, but probably ends\n in the SVC. No pneumothorax or mediastinal widening has developed. Increase\n in small right pleural effusion is probably unrelated. Left lower lobe\n atelectasis is chronic, probably related to a longstanding hiatus hernia.\n Heart size is normal.\n\n\n" }, { "category": "Radiology", "chartdate": "2174-06-02 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1018232, "text": " 8:00 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for signs of volume overload/interval change\n Admitting Diagnosis: RESPIRATORY FAILURE;CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old woman intubated for respiratory distress d/t CHF/overload and PNA,\n now extubated doing well.\n REASON FOR THIS EXAMINATION:\n eval for signs of volume overload/interval change\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): 12:44 PM\n Increasing signs of overhydration, increasing retrocardiac opacities.\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n COMPARISON: .\n\n As compared to the previous radiograph, the endotracheal tube has been\n removed, the other monitoring and support devices are in unchanged position.\n The lung volumes have decreased, the interstitial structures are better\n visible than on the previous radiograph. In addition, there is newly occurred\n atelectasis of the left retrocardiac areas of the lung.\n\n\n" }, { "category": "Radiology", "chartdate": "2174-05-30 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1017759, "text": " 8:06 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for interval change\n Admitting Diagnosis: RESPIRATORY FAILURE;CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old woman with AS, CHF here with shortness of breath intubated for\n ?PNA/CHF.\n REASON FOR THIS EXAMINATION:\n eval for interval change\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE PORTABLE AP CHEST RADIOGRAPH\n\n INDICATION: 80-year-old female with aortic stenosis and CHF with shortness of\n breath, intubated.\n\n COMPARISON: and .\n\n FINDINGS: Right central venous catheter tip terminates at the cavoatrial\n junction. Pulmonary edema and right lower lobe opacity demonstrate interval\n improvement. Cardiomediastinal silhouette and scoliosis are unchanged.\n Endotracheal tube remains in standard position. Lungs are clear aside from\n left retrocardiac opacity consistent with atelectasis.\n\n A rounded calcified density overlying the left upper lung corresponds to a\n bone island in a left posterior rib on comparison CT chest from .\n\n IMPRESSION:\n 1. Interval improvement of pulmonary edema and probable aspiration.\n\n 2. Mild left lower lobe atelectasis remains.\n\n" }, { "category": "Radiology", "chartdate": "2174-06-01 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1018082, "text": " 8:06 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please assess for pulmonary edema, consolidation, interval c\n Admitting Diagnosis: RESPIRATORY FAILURE;CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old woman s/p intubation for respiratory distress, with CHF\n exacerbation versus pneumonia\n REASON FOR THIS EXAMINATION:\n please assess for pulmonary edema, consolidation, interval change\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 80-year-old woman with intubation for respiratory distress.\n Please evaluate interval change.\n\n Comparison is made to the prior study of .\n\n PORTABLE UPRIGHT RADIOGRAPH OF THE CHEST: The right dialysis catheter and NG\n tube are unchanged in position. The endotracheal tube projects approximately\n 2.2 cm above the carina which is approximately 1-2 cm below the optimal level.\n The cardiomediastinal silhouette and hilar contours are normal. The lungs are\n clear with no focal consolidation or pneumothorax. Small left pleural\n effusion. The patient has severe levoconvex scoliosis. Large hiatal hernia\n with surrounding atelectasis.\n\n IMPRESSION:\n 1. The low lying ETT is unchanged.\n 2. No focal consolidation and no pulmonary edema.\n\n" }, { "category": "Radiology", "chartdate": "2174-05-31 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1017914, "text": " 8:10 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please assess for interval change, pulmonary edema, consodli\n Admitting Diagnosis: RESPIRATORY FAILURE;CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old woman s/p intubation for respiratory distress, suspected CHF\n exacerbation\n REASON FOR THIS EXAMINATION:\n please assess for interval change, pulmonary edema, consodliation\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 8:45 \n\n HISTORY: Respiratory distress. Suggest CHF exacerbation.\n\n IMPRESSION: AP chest compared to and 16.\n\n Pulmonary edema has not recurred, but left lower lobe collapse persists,\n accompanied by a small clinically insignificant left pleural effusion. Heart\n size is normal. ET tube is in standard placement. Dual-channel right\n transjugular dialysis catheter tips are in the SVC and superior cavoatrial\n junction respectively. No pneumothorax. Nasogastric tube passes into the\n stomach and out of view.\n\n\n" }, { "category": "Radiology", "chartdate": "2174-05-31 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1017957, "text": " 11:41 AM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: eval for interval change\n Admitting Diagnosis: RESPIRATORY FAILURE;CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old woman s/p intubation for respiratory distress, with CHF\n exacerbation versus pneumonia, with desat to mid 80's and increased rhonchi on\n exam c/w flash pulmonary edema.\n REASON FOR THIS EXAMINATION:\n eval for interval change\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: Single portable AP chest radiograph.\n\n INDICATION: Status post intubation with respiratory distress.\n\n COMPARISON: ; , 8:45 a.m.\n\n FINDINGS: Endotracheal tube is in standard position 3.5 cm from the carina.\n Right dual-chamber dialysis catheter TIPS are at the mid SVC and cavoatrial\n junction respectively. Feeding tube courses through the mediastinal with side\n port in the stomach and tip out of the field of view. Surgical clips are\n noted within the right upper quadrant.\n\n There is leftward shift of the mediastinum secondary to known scoliosis. There\n is interval development of mild interstitial pulmonary edema. Retrocardiac\n opacity is most consistent with mild atelectasis.\n\n IMPRESSION:\n\n 1. Interval development of mild interstitial pulmonary edema.\n\n 2. Continued left lower lobe mild atelectatic change.\n\n\n\n\n\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2174-06-01 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1018120, "text": " 11:09 AM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: evaluate for worsening CHF vs mucous plug (interval change?)\n Admitting Diagnosis: RESPIRATORY FAILURE;CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old woman with CHF and pneumonia now concern for flash vs mucous plug\n b/c acute respiratory distress/hypoxia\n REASON FOR THIS EXAMINATION:\n evaluate for worsening CHF vs mucous plug (interval change?)\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 80-year-old woman with heart failure and pneumonia and\n respiratory distress. Evaluate interval change.\n\n Comparison is made to prior radiograph performed three hours earlier.\n\n The right dialysis catheter , NG tube, and baby dialysis catheter, NG tube,\n and endotracheal tubes are nchanged in position. The cardiomediastinal\n silhouette and hilar contours are normal. The lungs are clear with no focal\n consolidation or pneumothorax. Small left pleural effusion. Severe lecoconvex\n scoliosis. Large hiatal hernia with surrounding atelectasis.\n\n IMPRESSION: No interval change. No pneumonia or heart failure.\n\n" }, { "category": "Radiology", "chartdate": "2174-05-31 00:00:00.000", "description": "BY DIFFERENT PHYSICIAN", "row_id": 1018012, "text": ", H. 4:57 PM\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \n Reason: please assess placement of right internal jugular central li\n Admitting Diagnosis: RESPIRATORY FAILURE;CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old woman extubated for respiratory distress, now s/p right IJ for\n access\n REASON FOR THIS EXAMINATION:\n please assess placement of right internal jugular central line\n ______________________________________________________________________________\n PFI REPORT\n Lines and tubes including new right IJ line are in standard placements. No\n pneumothorax or mediastinal widening. Small right pleural effusion\n increasing, but probably unrelated. Left lower lobe atelectasis stable.\n\n\n" }, { "category": "Radiology", "chartdate": "2174-06-02 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1018233, "text": ", H. 8:00 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for signs of volume overload/interval change\n Admitting Diagnosis: RESPIRATORY FAILURE;CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old woman intubated for respiratory distress d/t CHF/overload and PNA,\n now extubated doing well.\n REASON FOR THIS EXAMINATION:\n eval for signs of volume overload/interval change\n ______________________________________________________________________________\n PFI REPORT\n Increasing signs of overhydration, increasing retrocardiac opacities.\n\n\n" }, { "category": "Radiology", "chartdate": "2174-06-06 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1018816, "text": " 4:43 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Please evaluate for pna vs mucous plug\n Admitting Diagnosis: RESPIRATORY FAILURE;CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old woman with acute onset SOB\n REASON FOR THIS EXAMINATION:\n Please evaluate for pna vs mucous plug\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): JWK MON 11:02 AM\n PFI: Increased interstitial edema bilaterally and increased lingular\n atelectasis.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 80-year-old female with acute shortness of breath. Evaluate for\n pneumonia and mucus plug.\n\n COMPARISON: .\n\n SEMI-UPRIGHT CHEST RADIOGRAPH: A right-sided dual-lumen internal jugular\n central venous line is in unchanged position. There is no pneumothorax. The\n heart is at the upper limits of normal with a left ventricular configuration.\n There is calcification of the aortic knob.\n\n A retrocardiac opacity represents the known hiatal hernia. There are\n increased interstitial markings bilaterally consistent with worsening mild\n pulmonary edema. A lingular opacity likely reflects atelectasis.\n\n IMPRESSION:\n 1. Increasing mild interstitial edema.\n 2. Lingular atelectasis.\n\n\n" }, { "category": "Radiology", "chartdate": "2174-06-05 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1018730, "text": " 8:47 AM\n CHEST (PA & LAT) Clip # \n Reason: eval for interval change/infiltrate\n Admitting Diagnosis: RESPIRATORY FAILURE;CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old woman with CHF and pneumonia with course c/b acute respiratory\n distress/hypoxia, intubation (extubated since ), with copious sputum.\n Afebrile with stable WBC.\n REASON FOR THIS EXAMINATION:\n eval for interval change/infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n TWO VIEW CHEST, \n\n COMPARISON: .\n\n INDICATION: Elevated white blood cell count.\n\n Heart is upper limits of normal in size with left ventricular configuration.\n Moderate hiatal hernia is again demonstrated. Previously present interstitial\n edema has resolved, and improving aeration is noted within the left\n retrocardiac region. Minimal linear atelectasis is present at the right lung\n base, and small pleural effusions are present bilaterally. Calcified\n granuloma incidentally noted in left upper lobe.\n\n IMPRESSION:\n 1. Resolution of interstitial edema.\n\n 2. Improving left lower lobe opacity, likely due to atelectasis.\n\n 3. Persistent small pleural effusions.\n\n" }, { "category": "Radiology", "chartdate": "2174-05-29 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1017617, "text": " 3:10 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ETT, NGT PLACEM. CHECK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 88 year old woman with recent aortic valvuloplasty now with acute onset of SOB\n with hypoxia and crackles bilaterally\n REASON FOR THIS EXAMINATION:\n fluid status? cardiac silhouette?\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INDICATION: Recent aortic valvuloplasty presenting with acute onset\n shortness of breath.\n\n COMPARISON: .\n\n SUPINE PORTABLE CHEST: A right internal jugular catheter with its tip in the\n cavoatrial junction is unchanged. Mild cardiomegaly is unchanged. Aortic\n calcifications are unchanged. There is markedly worsened pulmonary edema\n bilaterally, most prominent in the lower lobes.\n\n IMPRESSION:\n 1. Markedly increased pulmonary edema.\n\n 2. Endotracheal tube terminates just above the carina, and can be pulled back\n 3 cm.\n\n" }, { "category": "Radiology", "chartdate": "2174-06-06 00:00:00.000", "description": "RENAL U.S.", "row_id": 1018987, "text": " 3:46 PM\n RENAL U.S.; -59 DISTINCT PROCEDURAL SERVICE Clip # \n DUPLEX DOP ABD/PEL LIMITED\n Reason: Please check renal arterial ultrasound with dopplers.\n Admitting Diagnosis: RESPIRATORY FAILURE;CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old woman with AS and renal failure.\n REASON FOR THIS EXAMINATION:\n Please check renal arterial ultrasound with dopplers.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 80-year-old woman with aortic stenosis and renal failure.\n\n COMPARISON: Renal ultrasound from .\n\n RENAL ULTRASOUND: The left kidney measures 10.6 cm. The patient is status\n post right nephrectomy. There is no evidence of hydronephrosis,\n nephrolithiasis, or renal mass. The main renal artery and vein are patent\n with normal waveforms, and a sharp arterial upstroke. The resistive indices\n in the upper, mid, and lower pole are 0.73, 0.56, and 0.61 respectively.\n\n IMPRESSION: Patent left renal vasculature as above. No evidence of renal\n artery stenosis.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2174-06-06 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1018817, "text": ", H. 4:43 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Please evaluate for pna vs mucous plug\n Admitting Diagnosis: RESPIRATORY FAILURE;CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old woman with acute onset SOB\n REASON FOR THIS EXAMINATION:\n Please evaluate for pna vs mucous plug\n ______________________________________________________________________________\n PFI REPORT\n PFI: Increased interstitial edema bilaterally and increased lingular\n atelectasis.\n\n" }, { "category": "Radiology", "chartdate": "2174-06-02 00:00:00.000", "description": "P RENAL U.S. PORT", "row_id": 1018247, "text": " 9:14 AM\n RENAL U.S. PORT Clip # \n Reason: please assess for evidence of obstruction, hydronephrosis\n Admitting Diagnosis: RESPIRATORY FAILURE;CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old woman with history of renal insufficiency, worsening renal function\n REASON FOR THIS EXAMINATION:\n please assess for evidence of obstruction, hydronephrosis\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 80-year-old woman with history of renal insufficiency, now with\n worsening renal function.\n\n RENAL ULTRASOUND: The study is compared to an MR of the abdomen from and renal ultrasound from .\n\n The right nephrectomy bed appears unremarkable. The left kidney measures 11.4\n cm. There is no evidence of hydronephrosis, nephrolithiasis, or renal mass.\n The kidney is normal in size and echogenicity. The incompletely distended\n bladder appears unremarkable.\n\n IMPRESSION: No hydronephrosis.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2174-05-31 00:00:00.000", "description": "Report", "row_id": 1663701, "text": "Nursing Note 7a-7p\nNeuro- Alert, cooperative but anxious @ times. MAE, no c/o c-pain/ sob. Conts to receive prn fentanyl for chronic back pain w/ effect.\nCV- SR w/ LBBB, rare PVCs. HR 70s-80s. HO placed A-line in L radial, ABPs 100-123/40s-50s, NBPs corrolate. Team decided to place PA line to r/o sepsis & better monitor fluid status. Cordis inserted into R IJ, PA insertion attempt was aborted d/t inducing a CHB (in setting of LBBB, paced via life-pac for <2min) Cordis remains, TLCL was inserted, CXR confirmed.\nResp- Extubation postponed, currently vented on AC 400x12 8peep, sats >98%, Tv >450, overbreathing 4-8bpm. Flash episode while on PS 5/5, responed well to AC. See careview for ABG.\nCRRT- Started on CVVHDF w/ fluid removal goal 100hr, set rates blood flow 120, PFR 100, Dialysis 500, Replacement 1500. CalGluconate gtt started @ 30cc/hr & Potassium gtt @ 10cc/hr.\nGI/GU- NPO, NGT for meds, +bs no bm. Remains oliguric, ^Cre 4.3\nID- Afeb, conts on broad abx coverage.\nA/P- Remains intubated, Swan attempt unsuccessful, has TLCL via cordis. Started on CVVHDF w/ goal PFR 100. Cont plan of care, support pt/ family, monitor BPs has Dopa if needed, I+Ca, K+, Cre.\n" }, { "category": "Nursing/other", "chartdate": "2174-05-30 00:00:00.000", "description": "Report", "row_id": 1663695, "text": "Resp Care\nPt remains on vent. Intubated with 7.5 ett @ 23, patent and secure. low Pco2 rr weaned. Suctioned for mod amt of thick blood tinged secretions. Rsbi 55. Will continue to monitor.\n" }, { "category": "Nursing/other", "chartdate": "2174-06-03 00:00:00.000", "description": "Report", "row_id": 1663708, "text": "CCU progress note 7p-7a\n\nUneventful night. CRRT off since yesterday morning.\n\nNEURO: slept in naps overnite. given vicodin 1 tab prn for chronic back pain. ice pack for neck pain with relief. husband stayed in room overnite on cot. both patient and husband anxious at times, emotional support/reassurance given.\n\nID: afebrile. abx: ceftaz.\n\nSKIN: no breakdown. barrier cream to skin. sarna lotion to belly (itchy).\n\nACCESS: RIJ TLC. R s/c dialysis line. Lt radial aline. 1PIV.\n\nCARDIAC: SR 80s-100s. SBP 90-120s. tolerated coreg last evening (due ). due to restart daily losartin this morning. heparin s/q TID. daily asprin and plavix.\n\nRESP: LS diminished. given incentive spirometer - able to get TV 500-700cc. con't IS today. productive strong cough - productive whitish clear secretions - using yankhaur and kleenex. sats 95% on room air - using cool mist face tent for humidity to loosen secretions. pt can get bronchospastic and becomes anxious, but sats remains 95% - emotional support given and pt calms coughing. given popsicles w/ good effect. robitussin given for expectorant w/ little effect last evening.\n\nGI/GU: foley patent, cloudy urine in small amts - specimin sent last shift for culture. abd soft distended. +BS. no BM for several days - started last evening on colace and senna. burping. given maalox 30cc this morning w/ some relief. poor appetite. protonix IV BID - coffee grounds noted on NGT when removed yesterday (HCT 24-25 currently). guiac stool.\n\n\nPLAN: plan for hemodialysis today. ?c/o to floor. con't cardiac meds. emotional support. pain meds. pulmonary toliet/incentive spirometry. con't abx. encourage PO diet today.\n" }, { "category": "Nursing/other", "chartdate": "2174-05-30 00:00:00.000", "description": "Report", "row_id": 1663696, "text": "Resp Care\n\nPt remainds intubated on full support. ABG stable. BS with crackles in the bases. Having 1.5L removed. Possibel extubation in am.\n" }, { "category": "Nursing/other", "chartdate": "2174-05-30 00:00:00.000", "description": "Report", "row_id": 1663697, "text": "CCU NPN\n\n0700-1900\n\nPlease see carevue for all objective data\nneuro: alert, following commands, MAE, cooperative. given bolus doses of fentanyl and versed for comfort and c/o back pain.\ncv: bp labile 80-123/46-58, on dopamine 3-5 mcg to maintain maps >60. HR 83-123, rate increasing thru day. Lopressor held at 1200 d/t sbp 90's, ECHO done results pnd.\nresp: remains intubated, on AC 500/12/5 peep/40% abg done 7.43/29/122. Sx for sm-mod amts thick white secretions, lungs coarse, w/ bilateral basilar crackles.\ngi: NPO at this time, no stool\ngu: u/o 10-20cc/hr. cr 2.9 up from 1.9 on admission. Ultrafiltered for 1.5 liters.\nid: afebrile, wbc 8.0, cont on vanc, levo, ceftazadine.\nheme: hct this am 22.8, f/u 23.4 down from 29 . No stool to guiac. Clot in BB,\nsocial: husband with pt all day, asking many questions, anxious, supportive to pt.\nskin: intact, heels, elbows coccyx red. Aloe Vesta applied, turned frequently.\naccess: 2 PIV,RSC quinton HD catheter. No aline (unable to place)\nA: Poor u/o in setting of rising cr. Ultrafiltered for 1.5 liters. Labile bp requiring low dose dopamine. Hct drop ? cause. Afebrile, nl wbc.\nP: Monitor bp, d/c dopamine as able, monitor renal fx, u/o,. ? ultrafiltrate again tomorrow, ? extubate.Follow hct. Turn frequently.\nEmotional support to pt and famil6y.\nP: Follow\n\n\n" }, { "category": "Nursing/other", "chartdate": "2174-05-31 00:00:00.000", "description": "Report", "row_id": 1663698, "text": "Resp Care,\nPt. remains intubated on A/C overnoc. Suctioned x 1 for thick tan sputum. Sent for sputum spec. RSBI 58 this am, changed to IPS . Possible extubation this am.\n" }, { "category": "Nursing/other", "chartdate": "2174-05-29 00:00:00.000", "description": "Report", "row_id": 1663691, "text": "CCU ADMIT NOTE\nPlease see ICU Admit/FHP note for details of Pmhx, events leading to hospitalization and transfer to CCU,\nPt. arrived to CCU approx. 0600 via stretcher, intubated, eyes opening and attempting to talk. Tachypneic and discoordinate on vent.\nCVS; HR 120'S NST, no vea. BP ranges initially 80's/40's after 2mg IV Versed and 20mg IV Lasix given in ER. BP now 97/54 via non-invasive cuff\nRESP; Orally intubated with vent settings as per carevue, lungs coarse with rales upper . CCU intern attempting to draw abg at present. Discoordinate on vent, attempting to overbreath, RT adjusting mode. Sedated with 2mg IV Versed and 25mcg IV Fentanyl at 0700.\nGI:GU: NGT placed in ER, good auscultation, awaiting CXR confirmation. Drained 25cc brown bilious solution. Abdomen soft with active bowel sounds, no stool. Foley to drainage with minimal yellow urine.\nID; Temp 98.8 rectally WBC 17.0. Pt. received IV antibxs in EW, need to confirm with chart.\nNeuro: Pt. arrived with eyes open, tracking nurse, attempting to talk, moving upper extremities, soft hand restraints applied. Responding with painful stimuli (abg attempt)\nA; CHF with probable pneumonia per CCU team, requiring emergent intubation.\nP: Cont to monitor hemodynamics, resp. status, follow up with abg and labs, awaiting orders. POC per CCU team\n" }, { "category": "Nursing/other", "chartdate": "2174-05-29 00:00:00.000", "description": "Report", "row_id": 1663692, "text": "Resp Care\n\nPt remains intubated on full vent support. Spo2 100%. Fio2 to 60%. BS with crackles in the bases. Suctioning blood tinged sputum.\n" }, { "category": "Nursing/other", "chartdate": "2174-05-29 00:00:00.000", "description": "Report", "row_id": 1663693, "text": "ccu nursing progress note\ns; alert, mouthing words. pointing to communicate.\no: pls see carevue flowsheet for complete vs/data/events\ncv: initially hypotensive at start of shift. bp to 60s/ via nbp. discussed w team, started levophed w good response, titrated off in a few hours. since has remained stable. bp avg 110/60. unsuccessful aline attempt this am. have not retried.\nhr 100 at rest, to 120s when uncomfortable, sxn'ing, etc. ordered for iv lopressor, then asked to hold by team as hr then under 100 and wanted better bp for diuresis. losaartan and carvedilol also on hold per parameters.\nrec'd 40mg iv lasix this am w sm bump in uop but no effective diuresis. rec'd additional 40mg iv lasix and started lasix gtt first at 5mg/hr then ^'d to 10mg/hr. goal uop >100cc/hr.\nresp: ac 500x24. fio2 decreased to 60% from 100%. sxn'd for scant tan, thin. bs scatt coarse w basialr cxs.\nid: afeb. rec'd vanco dose this afternoon. no lab data back.\ngi: ngt clamped. cxr confirmed placement. meds given. no stool.\nendo: bs 95-140. no coverage required.\nskin: intact. dry. freq repositioned w skin care.\nms: alert, able to follow commands. c/o pain at lle, sciatica per husband. also takes oxycodone for scoliosis/back pain. rec'ing prn versed and fentanyl w good effect.\nsocial: husband here until late afternoon when son arrived to take him home to retrieve some belongings and take a shower. he will return this eve and plans to stay overnoc. he and son updated.\naccess: has 2 peripheral lines. did briefly access quinton line (withdrawing 5cc to discard before flushing). this has now stopped and line is marked as having indwelling heparin.\na: chf vs pna. hypotension.\np: attemtping to achieve diuresis. follow hemodynamics. wean vent as indicated,?abg. cont to med for comfort. support to pt, husband and family. consult sw in am for family support.\n" }, { "category": "Nursing/other", "chartdate": "2174-05-30 00:00:00.000", "description": "Report", "row_id": 1663694, "text": "CCU NPN 1900-0700\nS: orally intubated\nO:Please see carevue for VS and objective data\nNeuro: Pt. alert and responsive, following simple commands, MAE, hand grasps equal and strong. PERLA. Mouthing words, attempting to speak, gagging at times on ETT and gets quite anxious, resopnds well to verbal support and 0.5mg IV Versed q1-2 hours. Pt. admits to left leg and lower back pain which her husband states is from scoliosis/siatica, responds well to 25-50mcgs IV Fentanyl q2-3 hours. Soft hand restaints in place overnight for safety of ETT.\nCVS; Hemodynamically stable with HR initially 100's NST, down to 70-80's after 25mg po Lopressor. Carvedilol dc'd. BP ranges via non-invasive cuff 97-120's/40-60. CPKs neg.\nResp; Orally intubated and mechanically ventilated, abgs drawn by RT, initially with resp. alkalosis now with metabolic alkalosis, current vent settings 500x12, with occ. spont. breathes over vent. Fio2 weaned 60-40%, 5 peep with good oxygenation. Sats 95-100%. Lungs coarse with scattered rhonchi and rales in bases. Suctioned q2-3hours for small amount thick, blood tinged sputum. VAP protocol in effect. HOB>30deg.\nIV Lasix at 10mg/hour with u/o 50-100cc/hour then down to 30-10cc/hr. Given 250mg IV Chlorothiazide at 2315 without response, discussed with CCU team increasing IV Lasix drip, decision made to D/C IV Lasix in setting of rising creatine and no response.\nGI:GU: NPO, NGT in good placement with minimal residuals. Abdomen soft/distended with active bs, no stool. Foley with u/o as above then down to <5cc/hour, sterile flush to catheter without blockage or clots noted, minimal to no u/o. CCU team aware. Urine lytes sent, pre-renal per CCU team. I/O +200cc at MN.\nRenal: BUN/CREAT 48/2.4 on eves, am pnd.\nEndo; glucose in low 100 range\nID; Tmax 100.4 rectally , pancultured this shift. WBC pnd. Started IV Ceftazadime 1gm, conts on IV Levofloxacin and IV Vanco as ordered.\nSocial: Husband very involved in her care, pleasant and appreciative of care, slept on cot in room as he did not wish to leave her side. His son brought dinner in to him.\nA: hemodynamically stable, good oxygentation on vent. Minimal response to diuretics in setting of rising creatine\nP: Cont to monitor hemodynamics, resp. status. Follow up with am labs and cultures pnd. Renal consult in am, may need HD again. Cont. antibxs as ordered. Prn sedation/pain meds. Comfort and emotional support to Pt. and family\n" }, { "category": "Nursing/other", "chartdate": "2174-06-01 00:00:00.000", "description": "Report", "row_id": 1663704, "text": "Resp care\n\nPT REMAINS INTUBATED AND CURRENTLY VENTED ON PSV 5/5 TOL WELL WITH VT RANGING FROM 400-500ML AND MV 6-10L. BS COURSE SXING FOR MOD AMTS OF THICK WHITE SECRETIONS. PT DECOMPENSATED ON PS WEAN EARLIER IN THE SHIFT AND WAS BAGGED,SXED, AND LAVAGED FOR MOD SIZE PLUGS WITH NOTICEABLE DECREASE IN WOB AND PEAK AIRWAY PRESSURES. WILL CONT WITH PS WEAN AND MAKE CHANGES ACCORDINGLY.\n" }, { "category": "Nursing/other", "chartdate": "2174-05-29 00:00:00.000", "description": "Report", "row_id": 1663690, "text": "Resp Care\nPt presented in ed diaphorietic and in resp distress, sats in 80% on nrb. Intubated with 7.5 ett @ 23, patent and secure. Transfered to unit. Abg pending. Will continue to monitor.\n" }, { "category": "Nursing/other", "chartdate": "2174-06-01 00:00:00.000", "description": "Report", "row_id": 1663702, "text": "Resp Care\nRemains intubated and ventilated on assist/control with no remarkable changes overnight. A.M. rsbi =55. Pt did not tolerate psv yesterday requiring increased peep. Currently on dialysis, possible wean attempt later this morning.\n" }, { "category": "Nursing/other", "chartdate": "2174-06-01 00:00:00.000", "description": "Report", "row_id": 1663705, "text": "Nursing Note 7a-7p\nNeuro- Alert, cooperative but anxious. No c/o c-pain/ sob, MAE in bed. Received fentanyl boluses & x1 vicodin for chronic back pain w/ effect.\nCV- SR/ST rare PVCs, HR 80s-134. ABPs 104-157/50s-80, Dopamine gtt used for approx 1hr p getting hypotensive from fentanyl boluses (BP 79). Lopressor held by parameters, losartin d/c'd.\n Pt on CVVHDF w/ goal fluid removal @ 100hr until 5pm. Renal satisfied w/ achieving -2L off, switched order to CVVHD & running pt even. CCU team can use CRRT for fluid removal if needed. Blood flow rate w/ citrate confirmed @ 100hr, PFR @ 220 (intake approx 215/hr) Ca+Glu @ 35/hr, K+ @ 10/hr. Filter pressures wnl. 5am Cre 2.5, 2pm (Cre) was sent ?not reported. Bair hugger remains on, dialysis fluids under warmer.\nResp- Put on 40% PS 8/5, tol well but mucus plugged causing resp distress. RT cleared plug & placed back on AC to recover. Received fentanyl boluses to calm. Later again placed back on PS -> tol well, no change in ABG. Successfully extubated @ 6pm-> 50% Hi-Flow mask. Tol well w/ sats >98%, no gas done. Strong productive cough, using yankawer.\nGI/GU- Still NPO, has NGT for meds, no bm yet. Remains anuric, foley patent.\nID- Tmax 98.7po, Vanco d/c'd conts on Ceftaz for PNA. C/o feeling cold d/t dialysis fluids.\nA/P- Successfully extubated, conts on CVVHD p 2L fluid removed. Cont to monitor K+/Ca+ q4, follow up Cre level. Pulmonary toilet, monitor resp status, BPs. Support pt/ family.\n" }, { "category": "Nursing/other", "chartdate": "2174-06-02 00:00:00.000", "description": "Report", "row_id": 1663706, "text": "CCU progress note 7p-7a\n\nEvents: Remains extubated since last evening, weaned off face tent to nasal canula sats >99%. no resp distress. some hypotension overnite - given 250cc NS bolus after decreasing PFR did not help increase BP. goal even overnite per renal.\n\nNEURO: A+Ox3. sleeps for 2-3 hrs after pain meds given for back pain, then dozing itermittently. recieving vicodin 1 tab q6h for back pain. also c/o of neck pain this morning, given padded warm pack to neck w/ relief. husband stayed in room overnite, sleeping in chair and cot. SR up x 3. call light in reach. bed low and locked.\n\nID: afebrile. bair hugger on. abx: ceftazadime. vanco and levo d/c'd yesterday.\n\nSKIN: no skin breakdown. heels elevated off bed. barrier cream applied to elbows, heels/feet and back/coccyx.\n\nRESP: LS clear, dim. weaned off face tent 50% to NC - currently at 2L n/c with sats 99-100%. expectorating small amts clear/whitish secretions using yankhaur.\n\nCARDIAC: SR 80-90s. small run SVT this morning when c/o of neck pain after turning in bed. Lt radial Aline patent - good waveform - SBP 90-120s overnite. slightly hypotensive last evening to 78-85 - turned down PFR to 0 w/ no increase in BP, given 250cc NS via rescue line on CRRT w/ good effect. R IJ TLC patent. lines flushed last evening.\n\nCRRT: ultrafiltration goal even overnite - currently positive 200cc at 5am. Citrate @ 150cc/hr, blood flow 100cc/hr. Prismasate dialysate @ 500cc/hr, Prismasate replacement @ 1500cc/hr. Ca and KCL gtts infusing per protocols w/ q6h lytes/labs. R s/c quinton site D+I.\n\nGI/GU: foley patent, scant amt urine - yellow cloudy w/ sediment noted. abd soft distended. +BS. no BM. NGT patent - using for meds overnite since pt was extubated last evening. taking icechips well overnite. advance diet as tolerated today. FS wnl - no insulin required overnite.\n\nPLAN: con't CRRT - labs q6h - next due 8am, adjust CA + KCL gtts per protocol. advance diet as tolerated. emotional support. monitor skin integrity, freq turns/barrier cream for skin protection. pain medication as required.\n" }, { "category": "Nursing/other", "chartdate": "2174-06-02 00:00:00.000", "description": "Report", "row_id": 1663707, "text": "Nursing Note 7a-7p\nNeuro- A+Ox3, pleasant/ cooperative. No c/o sob, c-pain. Required prn vicodin x1 this shift for back & neck pain. Declined offer to sit in chair.\nCV- SR/ST rare PVCs, HR 80s->112 w/ exertion & coughing, ABPs 98-140. Lopressor d/c'd & started on carvedilol & losartan. R IJ Cordis dsg changed, 2 piv's d/c'd & new R AC placed. CVVHD tx was stopped @ 10am, Quentin flushed w/ heparin & kerlex wrapped.\nResp- LS diminished bibasilary, CXR showed ^L lower lobe atelectasis now less airated post extubation. Freq prod coughing thick white secretions, using 70% Hi-Flow mask occ. Sats on r/a >96%.\nGI/GU- NGT removed w/ residue + for gastric bleeding, team aware, Hct steady 24.9-> 24.4 Started on Cardiac diet, tol sm bites w/ liquids, no c/o nausea. Still no bm, started on bowel regimen. UOP picking up, approx 280cc this shift. Very milky looking, u/a c&s sent. Sugars below RISS.\nID- Remains afeb, wbc 7.3, conts on ceftaz for pna. MRSA precautions.\nSkin- Sarna lotion for back & L ankle itch.\nA/P- CVVHD stopped, next HD tx ?tomorrow. Conts expectorating thick secretions, using Hi-Flow mask adlib. Cont to monitor resp status/BP over noc. Started bowel regimen, prob will pass black tarry stools. ?call-out tomorrow.\n\n" }, { "category": "Nursing/other", "chartdate": "2174-06-01 00:00:00.000", "description": "Report", "row_id": 1663703, "text": "CCU nursing note\nS-Intubated.\nO-see flowsheet. 80y.o female admitted c Resp Failure, pna, volume overload. Hx significant for severe AS c recent valvuloplasty and stent to Lcx, CKD now c acute on chornic Kidney failure requiring CVVHDF. EF 30-35%.\n\nN-remains alert and cooperative c care. No need for wrist restraints. No focal deficits. Neuro assessment unchanged. Low dose fentanyl gtt 12.5mcg started for comfort as pt c hx of siatica/scoliosis=back pain.\n\nCV-HR NSR 70s-90s, c SBP stable 100-125, CVP 6-10 (currently 7). Lopressor held MD so as to save BP for fluid removal. 2 pivs. Right IJ c TLC through cortis. Am labs pending. please adjust K/Ca gtts appropriatly. 1 unit prbc given-f/u am Hct. pulses palp. L radial aline.\n\nResp-LS clear to dim. no vent changes, am RISBI 54.8. RR 15-20 (set @ 12). +8peep, 40%.\n\nCRRT-CVVHDF. Tolerating goal 100cc/hr fluid removal as ordered. K @ 20, CA @ 35, dialysis @ 500, and Replacement @ 1500. Line site intact. See carevue for presssures and current fluid balance.\n\nID-afebrile. bear Hugger c recent temp 97.0. IV abxs as ordred.\n\nskin-intact. Turned frequently. Score 13-consider specialty bed. Also disscuss nutritional needs if pt not extubating soon.\n\nGI-NPO. +BS. no BM. NGT placement wnl.\nGU-very scant UO. f/u am labs.\n\nsocial-husband again sleeping at pt's bedside overnight. Son also into visit.\nDispo-full code.\n\nplan-Renal following-tolerating current goals of fluid removal. F/U am labs and adjust e-lyte gtts per protocol. Monitor Hct s/p transfusion. Disscuss POC in multi-disiplanary rounds.\n" }, { "category": "Nursing/other", "chartdate": "2174-05-31 00:00:00.000", "description": "Report", "row_id": 1663699, "text": "CCU nursing note\nS-intubated. Mouthing and writting.\nO-see flowsheet. 80y.o female c CAD, severe AS-s/p recent admit for valvuloplasty and stent to Lcx. Acute on CKD on HD. Admitted c respitory failure, fever, elevated WBC=volume overload c ?pna. Tx'd c abxs.\nEcho EF 30-35%, known Severe AS, 1+AR, 1+MR, c known right atrial loculated effusion. cxray c improvement in pulm edema and right lower lobe opacity. UF for 1.1L.\n\nN-Fent/versed prn for comfort c effect-see . Back pain scoliosis and siatica. , , consistent c commands. Very cooperative c care and very comfortable c lines-no wrist restraints. No focal deficits.\n\nCV-Weaned off Dopamine. HR from ST to NSR (QTC 0.51). SBP 90s-110 c MAP >60 off dopamine. 2 pivs-22g slightly leaky-monitor. Very difficult access. HD line right subclavian. +palp pulses. Hct continues to trend down, 21.6 (23, 24, and 29 on admit) c no obvious source of bleeding. Thus far not transfused. Echo as above. unable to draw coags-if HD today consider getting off of line.\n\nResp-Weaned to CPAP 5/5 40%. No aline. ABGs per MDs. sats >98% throughout night. LS clear to diminished/coarse. Thick/white pm sputum cx sent. No other significant secreations sx'd. RISBI 58.3.\n\nGI-NPO. soft abd, +BS. ?last bm.\nGU- Urine remains poor c further decrease in UO and increase in Crt to 3.9 (2.9, 1.9 admit). Renal following pt. ?ultrafiltrate +dialysis today.\n\nID-afebrile. broad abx coverage. pan cultures pending.\n\nskin-intact aside from skin tear on left anterior elbow-aproximated. Barrier cream c turning.\n\nsocial-very supportive husband. Stayed overnight c pt and seems to lessen pt's anxiety.\ndispo-full code.\n\nplan-Renal consulting-?HD today prior to ?extubation. Monitor HDs off Dopa. pain control.\n" }, { "category": "Nursing/other", "chartdate": "2174-05-31 00:00:00.000", "description": "Report", "row_id": 1663700, "text": "Resp Care\nPt remains intubated currently on CMV. Had been on PSV, ^WOB, fluid. Required ^peep. Plan for dialysis and wean as tolerated.\n" }, { "category": "ECG", "chartdate": "2174-06-06 00:00:00.000", "description": "Report", "row_id": 106150, "text": "Sinus tachycardia. Left atrial abnormality. Left bundle-branch block.\nLeft axis deviation. Secondary repolarization abnormalities. Compared to the\nprevious tracing of heart rate has increased. Otherwise, no major\nchange.\n\n" }, { "category": "ECG", "chartdate": "2174-06-04 00:00:00.000", "description": "Report", "row_id": 106151, "text": "Sinus rhythm. Left bundle-branch block. Compared to the previous tracing\nof there is no significant diagnostic change.\n\n" }, { "category": "ECG", "chartdate": "2174-06-02 00:00:00.000", "description": "Report", "row_id": 106152, "text": "Normal sinus rhythm with left bundle-branch block and secondary ST-T wave\nabnormalities. Compared to the previous tracing of no diagnostic\ninterval change.\n\n" }, { "category": "ECG", "chartdate": "2174-06-01 00:00:00.000", "description": "Report", "row_id": 106153, "text": "Baseline artifact. Sinus rhythm. Short P-R interval. Left axis deviation.\nLeft bundle-branch block. Marked ST-T wave abnormalities. Since the previous\ntracing of at a faster rate ST-T wave abnormalities are more marked.\nClinical correlation is suggested.\n\n" }, { "category": "ECG", "chartdate": "2174-05-30 00:00:00.000", "description": "Report", "row_id": 106154, "text": "Sinus rhythm. Left axis deviation. Left bundle-branch block. Compared to the\nprevious tracing there is no significant change.\n\n" }, { "category": "ECG", "chartdate": "2174-05-29 00:00:00.000", "description": "Report", "row_id": 106155, "text": "Sinus tachycardia with left bundle-branch block with secondary ST-T wave\nabnormalities. No diagnostic change from tracing #1.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2174-05-29 00:00:00.000", "description": "Report", "row_id": 106156, "text": "Sinus tachycardia with left bundle-branch block and secondary ST-T wave\nabnormalities. Compared to the previous tracing of the rate has\nincreased.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2174-05-24 00:00:00.000", "description": "Report", "row_id": 106157, "text": "Sinus tachycardia. Left bundle branch block. Possible left ventricular\nhypertrophy. Possible prior inferior myocardial infarction. Compared to the\nprevious tracing of the QRST change in lead V5 is probably positional.\n\n" } ]

[ { "category": "Radiology", "chartdate": "2185-05-02 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1242254, "text": " 12:58 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: 45 cm right Picc \n Admitting Diagnosis: GASTROINTESTINAL BLEEDING\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old man with new Picc\n REASON FOR THIS EXAMINATION:\n 45 cm right Picc \n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 74-year-old male with new PICC line.\n\n FINDINGS: A right-sided PICC line tip has been inserted to the mid SVC. The\n evaluation of the lungs is limited by hardware overlying the right lower lobe\n and exclusion of the left costophrenic angle from the field of view. Despite\n these limitations, the lungs appear well inflated. No focal consolidation,\n effusion, or pneumothorax is present. The cardiac and mediastinal contours\n are normal.\n\n IMPRESSION:\n\n Limited chest radiograph. Right PICC line in the mid SVC.\n\n" }, { "category": "Radiology", "chartdate": "2185-05-02 00:00:00.000", "description": "EMBO NON NEURO", "row_id": 1242274, "text": " 2:56 PM\n MESSENERTIC Clip # \n Reason: assess UGIB\n Admitting Diagnosis: GASTROINTESTINAL BLEEDING\n Contrast: OPTIRAY Amt: 115\n ********************************* CPT Codes ********************************\n * EMBO NON NEURO INITAL 3RD ORDER ABD/PEL/LOWER *\n * -59 DISTINCT PROCEDURAL SERVICE VISERAL SEL/SUPERSEL A-GRAM *\n * -59 DISTINCT PROCEDURAL SERVICE EA ADD'L VESSEL AFTER BASIC A- *\n * -59 DISTINCT PROCEDURAL SERVICE TRANCATHETER EMBOLIZATION *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old man with UGIB, visible bleeding vessel in duodenal bulb\n REASON FOR THIS EXAMINATION:\n assess UGIB\n ______________________________________________________________________________\n FINAL REPORT\n PROCEDURES:\n 1. DSA angiogram of the celiac artery.\n 2. Selective DSA angiogram of the gastroduodenal artery with a microcatheter\n in three non-orthogonal projections.\n 3. Coil embolization of the gastroduodenal artery.\n\n PHYSICIANS: Dr. , fellow; Dr. ,\n resident and Dr. , attending physician.\n\n CLINICAL INDICATION: 74-year-old man with upper gastrointestinal bleeding and\n active visible submucosal bleeding artery in the duodenal bulb.\n\n Informed consent for the procedure was obtained after risks, benefits, and\n potential complications had been discussed. The patient was placed on the\n angiographic table in supine position. The skin of the right inguinal region\n was prepped and draped in a sterile fashion. Timeout protocol was carried out\n prior to the procedure according to the Hospital policy.\n\n ANESTHESIA: Local, 1% lidocaine.\n\n MONITORED CONSCIOUS SEDATION: The procedure was performed under monitored\n conscious sedation. The patient received a total quantity of 3 mg of Versed\n and 100 mcg of fentanyl intravenously during the total procedural time of 120\n minutes, while his hemodynamic parameters and pulse oximetry were continuously\n monitored by a trained radiology nurse.\n\n Using a combination of palpatory and fluoroscopic landmarks and after generous\n infiltration of subcutaneous soft tissues by 1% lidocaine, the right common\n femoral artery was punctured using 21-gauge micropuncture needle. Over a\n 0.018 guidewire, micropuncture needle was exchanged for a 4 French\n micropuncture sheath. A 0.035 Bentson guidewire was then advanced into the\n abdominal aorta through the 4 French micropuncture sheath and 4 French\n micropuncture sheath was exchanged for 5 French endovascular sheath.\n Selective celiac arteriogram was performed through a 5 French C2 glide\n catheter. The arteriogram demonstrated standard trifurcation of the celiac\n (Over)\n\n 2:56 PM\n MESSENERTIC Clip # \n Reason: assess UGIB\n Admitting Diagnosis: GASTROINTESTINAL BLEEDING\n Contrast: OPTIRAY Amt: 115\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n artery with normal appearance of the splenic artery, left gastric artery and\n common hepatic artery. Gastroduodenal artery origin was delineated slightly\n distal to the origin of the left hepatic artery. Using a combination of\n Renegade Hi- microcatheter in tandem with a Transcend guidewire, selective\n catheterization of the gastroduodenal artery was expedient.\n\n Multiple selective DSA injections of the gastroduodenal artery in three\n non-orthogonal projections demonstrated no perceptible active arterial\n extravasation. Microcatheter was advanced around the bend of the\n gastroduodenal artery to the vicinity of the endoscopically deployed mucosal\n clip and retrograde coil embolization of the gastroduodenal artery was\n performed using initially a 5-mm profile coil followed by 4 mm coils. At the\n conclusion of the embolization, stasis of flow/occlusion of the gastroduodenal\n artery was demonstrated.\n\n Microcatheter was removed and follow up DSA angiogram with the tip of the C2\n glide catheter in the common hepatic artery demonstrated effective occlusion\n of the gastroduodenal artery by coil embolization.\n\n Hemostasis was achieved by manual compression.\n\n CONCLUSION:\n\n 1. No evidence of active arterial extravasation from the gastroduodenal\n artery or its branches on DSA arteriogram of the gastroduodenal artery.\n\n 2. Successful retrograde coil embolization of the gastroduodenal artery,\n resulting in occlusion/flow stasis.\n\n\n" } ]

[ { "category": "ECG", "chartdate": "2139-09-02 00:00:00.000", "description": "Report", "row_id": 281547, "text": "Sinus rhythm. Left atrial enlargement. Low precordial lead voltage. The ECG is\nsimilar to that recorded on . The right precordial recordings may\nrepresent high lead placement. There is no apparent diagnostic interim change.\n\n" } ]

[ { "category": "Nursing/other", "chartdate": "2109-04-05 00:00:00.000", "description": "Report", "row_id": 1327491, "text": "MICU NURSING ADMIT NOTE:\n Pt is a 51 yr old NH resident who was brought to OSH yesterday with c/o ab pain, N/V and was found on floor of bathroom at NH (no report of LOC or trauma sustained). Of note, pt with PMH significant for DM, schizophrenia, CHF, and HTN. In EW of OsH, pt noted to be in DKA (fsbs 933, K+ 6.2, Na 129, chloride 95, bicarb 14, bun 55, creat 3.8.. also of note, wbc 19.8). pt received ivf 1L and 10units ivp insulin x 2. She also received a dose of Levaquin, Zosyn and Vanco. she was hemodynamically stable, and maintained sats high 90's on RA. CXR was clear. Ab CT negative except for thickening in colon. Pt was transferred to MICU at for further care.\n UPon arrival to MICU pt had 1 20g piv. several unsuccessful attempts were made to draw bloodwork and start a second IV. The MICU team placed a R sublcavian TLC and cxr confirmed placement. Blood work was sent and revealed blood sugar 671, K+ 4.9, Na 140, , chloride 107, bicarb 20, bun 53, creat 3.1. anion gap (corrected for hypoalbuminemia) was 16. ABG on RA: 7.37/33/74/20, lactic acid 1.9. pt was started on insulin gtt titrated 5-13units regular insulin/hr based on fsbs. A CVP was transduced at 4-5, and ivf was ordered to be bolused until cvp 12. pt currently receiving liter # 4 of NS.\n REview of Systems:\nNuero: pt pleasant, cooperative, answering questions in one-two word answers. able to state her name. intermittently follows commands. lethargic, sleeping when not disturbed. opens eyes to voice.\nCV: sbp 113-120. HR 120's ST on admit down to 106 ST. pt initially orthostatic, dropping sbp to 85 when sitting upright in bed.\nRESP: LS cta, sats 96% RA. rr 16-20.\nGI: ab soft, nontender, bs +. last bm .\nGU: foley intact. UO light yellow, 120-180cc's/hr.\nFE: titrating insuling gtt scale to fsbs. please see careview.\nID: blood cx sent x 2, and urine cx sent. no abx to be ordered at this time per team. tmax 100.2 pr.\nSocial: pt is a NH resident. her spokesperson is her daughter who spoke with team and gave consent for placement of central line.\n A/P: pt is a 51 yr old pt admit with DKA, resulting in volume depletion, and also with elevated wbc. Plan to continue iv insulin and volume rescusitation. will recheck labs at 4 am. hourly fsbs. follow cx.\n" }, { "category": "Nursing/other", "chartdate": "2109-04-05 00:00:00.000", "description": "Report", "row_id": 1327492, "text": "neuro: pt lethargic/sleeping throughout day but easily aroused...a+ox2. +mae noted and follows simple ocmmnads. Cough/gag intact. denies pain or discomfort.\ncv: monitor shows nsr-st with no ectopy noted. cvp 8-11.\nresp: lscta. no sob or resp distress noted. O2 @ 2 lnp applied this afternoon 2/2 drop in Sao2 to 88 on ra while sleeping soundly.\ngi-f/e/n: abd soft and distended. +bs noted. no stools this shift. appetite fair. 1/2 ns decreased to 150 cc/hr x3l (2nd L up).\ngu: foley intact and patent draining yellow urine with no sedimentation noted. urine lytes sent as ordered.\nskin: d+i with no open areas noted.\nm-s: oob-c x4hr and tol well. pt has slow steady gait.\nendo: pt received 10 unit nph this am and covered with riss x2. bs's continued to trend up therefore insulin gtt resumed this afternoon and titrated per scale. consulted...pt to receive 25 unit nph this eve and attempt to wean gtt to off o/n. plan for tighter bs control with humalog recommendations with fingersticks q6hr when off gtt. ? need for oral hypoglycemic in future.\ni-d: afebrile. off abx. cx's with no growth to date. cxr from - and RUQ us revealed 2 g-bldr stones but no cholecystitis.\nheme: 1400 chem 7 revealed na 141, k 5.6, cl 116, co2 16, bun/cr 40/2.5 and glu 379. Dr notified and insulin gtt resumed. Plan for chem 7 q6hr with next lab draw due @ .\npsy-soc: dtr at bedside througout day...updated on status and plan of care by this rn and dr. . pt remains full code on micu service.\n\n" }, { "category": "Nursing/other", "chartdate": "2109-04-07 00:00:00.000", "description": "Report", "row_id": 1327496, "text": "Nursing Progress Note 0700-1200 noon :\n** full code\n\n** access: right SC TLC\n\n** NKDA\n\n** precautions: universal\n\nNEURO: pt alert and oriented x 2 -can't remember where she is-also not good recollection of the events leading up to transfer to BIMDC. Able to answer all other questions and follow all commands and participate in care. Has been ambulating to the toilet without difficulty with steady gait and assist of one.\n\n\nCARDIAC: NSR with HR 70's and no ectopy. Pulses all easily palpable. SBP >100. DC'd right radial aline without event-no bleeding, no hematoma, dressing c, d and intact. Denies any cardiac or related symptoms.\n\nRESP: Received pt on 2l NC with sats of 100%. Removed o2 and pt sats have been >97% sice-no c/o SOB or other resp distress. No cough.\n\nGI/GU: abd softly distended (obese) , positive BS, small smear-no BM today; receives colace as ordered. Had a small amt of breakfast-did not have much appetite. Taking adequate fluids. Pt receives diet. Foley dc'd this am -has voided since that time-adequate yellow urine.\n\nID: pt on levofloxacin, metronidazole and levofloxacin for abx coverage. Afebrile. WBC down to 12.\n\nENDO: pt sugars under much better control with slide scale and fixed dose but pt not taking in much food yet. Apparently was not on any DM medication or having sugars checked at nursing home and this will need to be addressed.\n\nPSYCHOSOCIAL: daughter supportive and in to visit today; spoke with md in regards to need for social work/care coordination to assist with possible new place for pt to live.\n\nPLAN: Tx to 712. Daughter is aware of transfer. Cont med regimen, glucose control and supportive care.\n" }, { "category": "Nursing/other", "chartdate": "2109-04-07 00:00:00.000", "description": "Report", "row_id": 1327497, "text": "addendum:\n** All pt abx dc'd -no source of infection was ever found-she was placed on abx due to elevated wbc and hypotension for coverage.\n" }, { "category": "Nursing/other", "chartdate": "2109-04-06 00:00:00.000", "description": "Report", "row_id": 1327493, "text": "NPN 7p-7a:\n Review of systems:\n Nuero: pt lethargic this shift. sleeping when not disturbed. requiring sternal rub during 1 check to awaken, but then answering questions appropriately (cont A+ O x ). Otherwise opens eyes to voice. Perrla. MAE. Seroquel, haldol dc'd as pt lethargic. remains on Depakote.\n CV/ID: pt developed hypotension to 70's at 10pm. HO notified. fluid bolus up. 12 lead ekg revealed pt with ? anterior lead ST elevations vs wandering baseline. pt denied CP throughout. Pt given ASA 325mg po and heparin gtt started after bolus as per careview/. Cardiology into eval. ECHO revealed normal LV/RV function and showed pt remained intravascularly dry. CVP 9 at the time. cardiac enzymes cycled. flat so far. Per cardiology, pt did not appear to be having an acute coronary syndrome, so heparin dc'd. Pt then with sbp drop to 60's despite total 3L ivf. nbp recycled and measured on both arms with same result. tmax 100.6 pr. Pt started on levophed with map up to 90's. blood cx sent x 2 and urine cx sent. pt started on levaquin, flagyl, vanco. other cx ngtd. a cortisol stim test was completed. MVo2 was 86%. aline placed. aline and nbp initially not correlating. now correlating. after 3L ivf levophed weaned to off and maps remained in 70's. at the present moment, sbp has fallen to 80's so levophed back on.\n RESP: sats 98-100% on 2L O2NC. LS cta, bronchial L base. rr 16-20.\n fE: cont on q 4-6 hr lab checks please see careview. receiving phos repletion at this time. bun 33/creat 2.2. received nph insulin 25 units at 8pm, now ssi and nph dosing dc'd in favor of insulin gtt. insulin gtt on now at 2u/hr with fsbs 140's.\n GU: urine light yellow to yellow. uo was 35-60cc's/hr before sbp dropped at 10pm. now up to 200-400cc's/hr.\n GI: ab soft, bs +, no bm. report of ab discomfort in evening, resolved without intervention.\n social: no calls o/n.\n integ: intact.\n access: tlc to R subclavian and piv x 1, and aline.\n A/P: 51 yr old who initially presented with DKA picture, now with hypotension, ? sepsis. will cont abx, follow cx and cont to cycle cpk's, last due at 2 pm. cont to follow hemodynamics. follow fsbs and titrate insulin gtt prn.\n" }, { "category": "Nursing/other", "chartdate": "2109-04-06 00:00:00.000", "description": "Report", "row_id": 1327494, "text": "S I am at it is don't know the year\no. Neuro very lethagic this am difficult to arouse, inattentive oriented x 2 became increasingly alert toward afternoon oob to chair min amt of assist\no. cvs hr 70- without ectopy qtc .42, k+ 4.7, Na 145, phosphorus 2.80 bp 70/-135/90 taken off levophed did well bp dropped to 70/ placed back on levophed x 2 hrs then d/c ck 27 skin w+d pp+3\n+ 2 pedal edema\nresp on room air o2 sat 100% lungs cta\ngu u/0 > 45cc bun 26 cr 2.0\ngi fair appetite abd snt bs+ no stool\nendo given 25 u nph this am insulin gtt weaned to off\naccess rtsc, lt periph\na. hyperglcemia\nhypotension\nms change\np. ss insulin monitor q 6 hr give fixed dose nph q am and q pm, monitor cr urine output\nmonitor bp\nmonitor ms, orient prn psychiatry consulted saw the pt, hold sequel and haldol cont to give deprakote level drawn\noob to chair as tol\n" }, { "category": "Nursing/other", "chartdate": "2109-04-07 00:00:00.000", "description": "Report", "row_id": 1327495, "text": "NPN-MICU\nMs. has been comfortable all night.\nNeuro:pt cont to be calm and coooperative, very alert but still unable to remember date.She MAE and able to get OOB to chair with one assist, no changes noted. She got some sleep.\nEndo:pt cont on NPH and humalog insulin, BS check q2hrs to follow trend.She will get increased NPH this am.\nCV: her BP has been improved, 100-120/70's, hr in the 70-80's. She denies any pain.Her u/o has been good at 100cc/hr.\nID:she remains afebrile on 3 IVAB, neg cx\nGI: no c/o, no stool but passing flatus.\nA/P:Will cont to asses mental status and restart meds once she is more awake.\n Will follow BS and adjust Clinics recommendations\n Follow BP and u/o, awiat final cx results\n" }, { "category": "Echo", "chartdate": "2109-04-05 00:00:00.000", "description": "Report", "row_id": 99829, "text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. Epigastric pain and ST changes.\nHeight: (in) 68\nWeight (lb): 210\nBSA (m2): 2.09 m2\nBP (mm Hg): 96/37\nHR (bpm): 100\nStatus: Inpatient\nDate/Time: at 23:40\nTest: Portable TTE (Complete)\nDoppler: Limited doppler and color doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Normal LA size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.\n\nLEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size. Suboptimal\ntechnical quality, a focal LV wall motion abnormality cannot be fully\nexcluded. Overall normal LVEF (>55%).\n\nRIGHT VENTRICLE: Normal RV wall thickness. Normal RV chamber size. Normal RV\nsystolic function.\n\nAORTA: Normal aortic root diameter.\n\nAORTIC VALVE: ?# aortic valve leaflets. No AR.\n\nMITRAL VALVE: Normal mitral valve leaflets. No MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality.\n\nConclusions:\n1. The left atrium is normal in size.\n2.Left ventricular wall thicknesses are normal. The left ventricular cavity\nsize is normal. Due to suboptimal technical quality, a focal wall motion\nabnormality cannot be fully excluded. Overall left ventricular systolic\nfunction is normal (LVEF>55%).\n3.Right ventricular chamber size is normal. Right ventricular systolic\nfunction is normal.\n4. The aortic valve is not well seen. The number of aortic valve leaflets\ncannot be determined. No aortic regurgitation is seen.\n5.The mitral valve leaflets are structurally normal. No mitral regurgitation\nis seen.\n6.There is no pericardial effusion.\n\n\n" }, { "category": "ECG", "chartdate": "2109-04-06 00:00:00.000", "description": "Report", "row_id": 285058, "text": "Sinus tachycardia\nPoor R wave progression - probable normal variant\nLateral ST changes are nonspecific\nLow QRS voltages in precordial leads\nPrevious anterior ST elevation have resolved\n\n" }, { "category": "ECG", "chartdate": "2109-04-05 00:00:00.000", "description": "Report", "row_id": 285059, "text": "Sinus tachycardia\nPoor R wave progression - probable normal variant\nLow QRS voltages in precordial leads\nAnterior ST elevation\nProbable repolarization but can not rule out myocardial ischemia\nSuggest repeat tracing\nClinical correlation is suggested\n\n" }, { "category": "ECG", "chartdate": "2109-04-05 00:00:00.000", "description": "Report", "row_id": 285060, "text": "Sinus tachycardia\nPoor R wave progression - probable normal variant\nGeneralized low QRS voltages\n\n" } ]

[ { "category": "Radiology", "chartdate": "2192-11-05 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1154375, "text": " 2:15 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: FAST TRACK EXTUBATION CARDIAC SURGERY, r/o PTX/Effusion, ?li\n Admitting Diagnosis: ST ELEVATED MYOCARDIAL INFARCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old man with CAD s/p CABG. Please at with\n abnormalities.\n REASON FOR THIS EXAMINATION:\n FAST TRACK EXTUBATION CARDIAC SURGERY, r/o PTX/Effusion, ?line placement\n ______________________________________________________________________________\n FINAL REPORT\n CHEST LINE PLACEMENT\n\n COMPARISON: .\n\n HISTORY: Status post CABG.\n\n FINDINGS: Patient is status post CABG. An ET tube is approximately 4.8 cm\n above the carina. An NG tube has its tip within the stomach. The side port\n is likely just beyond the GE junction. A Swan-Ganz catheter terminates in the\n main pulmonary artery. Left-sided chest tubes are identified. Postoperative\n mediastinal widening is identified. Left mid lung zone and retrocardiac\n atelectasis with a small layering pleural effusion is noted on the left. No\n evidence of pneumothorax.\n\n IMPRESSION: Postoperative appearance consistent with recent CABG. Lines and\n tubes as described above. Small left pleural effusion with left mid and lower\n lung zone atelectasis.\n\n\n" }, { "category": "Radiology", "chartdate": "2192-11-11 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1155382, "text": " 4:14 PM\n CHEST (PA & LAT) Clip # \n Reason: evaluate effusions/atx\n Admitting Diagnosis: ST ELEVATED MYOCARDIAL INFARCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old man with s/p CABG\n REASON FOR THIS EXAMINATION:\n evaluate effusions/atx\n ______________________________________________________________________________\n FINAL REPORT\n CHEST, TWO VIEWS, \n\n CLINICAL INFORMATION: Evaluate effusion.\n\n FINDINGS:\n\n Two views of the chest demonstrate marked cardiomegaly. Status post CABG.\n Left lower lobe atelectasis, small left pleural effusion. Essentially no\n change since prior study. Upper lung zones are clear.\n\n\n" }, { "category": "Radiology", "chartdate": "2192-11-08 00:00:00.000", "description": "P ABDOMEN (SUPINE & ERECT) PORT", "row_id": 1154975, "text": " 10:11 PM\n ABDOMEN (SUPINE & ERECT) PORT Clip # \n Reason: s/p CABG w/abdominal distention r/o ileus/obstruction\n Admitting Diagnosis: ST ELEVATED MYOCARDIAL INFARCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old man with as above\n REASON FOR THIS EXAMINATION:\n s/p CABG w/abdominal distention r/o ileus/obstruction\n ______________________________________________________________________________\n WET READ: 10:51 PM\n DIlated loops of small bowel measuring up to 3.5cm with colonic air noted in\n the region of the cecum, which would be abnormally dilated, suggest ileus,\n though early obstruction is not excluded. Rectum not completely imaged.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 77-year-old male status post CABG with abdominal distention.\n\n COMPARISON: None available.\n\n ABDOMINAL RADIOGRAPH, SUPINE UPRIGHT VIEWS: There are multiple loops of\n dilated large and small bowel seen overlying the mid abdomen. A single loop\n of small bowel in the left lower quadrant measures 3.5 cm which is above the\n normal limit. There is diffuse dilatation of the cecum which measures\n approximately 11 cm. No free air is seen in upright film to suggest\n perforation. These findings are concerning for postoperative ileus.\n Sternotomy wires are visualized overlying the midline thoracic vertebral\n bodies and degenerative changes of the lumbar spine are evident.\n\n IMPRESSION: Diffusely dilated loops of small bowel and colon. Significantly\n dilated cecum measuring approximately 11 cm in largest diameter. No free air\n to suggest perforation. These findings are concerning for postoperative\n ileus.\n\n\n" }, { "category": "Radiology", "chartdate": "2192-11-09 00:00:00.000", "description": "ABDOMEN (SUPINE & ERECT)", "row_id": 1155042, "text": " 10:09 AM\n ABDOMEN (SUPINE & ERECT) Clip # \n Reason: s/p CABG w/distended abdomen r/o ileus/obstruction\n Admitting Diagnosis: ST ELEVATED MYOCARDIAL INFARCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old man with as above****please do after 7am******\n REASON FOR THIS EXAMINATION:\n s/p CABG w/distended abdomen r/o ileus/obstruction\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 77-year-old male status post CABG with increasing abdominal\n distention. Prior radiograph suggestive of ileus versus early partial small-\n bowel obstruction.\n\n COMPARISON: Abdominal radiographs from .\n\n ABDOMINAL RADIOGRAPH, SUPINE AND LATERAL DECUBITUS VIEWS: On the lateral\n view, there is no evidence of free air to suggest perforation. Multiple air-\n fluid levels are seen within the large and small bowel. Again seen are\n dilated loops of small bowel throughout the abdomen and the cecum is markedly\n distended. The largest diameter of the cecum measures about 12 cm on the\n current study which is slightly larger than the prior. These findings are\n most consistent with continued postoperative ileus; however, partial small-\n bowel obstruction cannot be excluded. There has been no other significant\n change compared to prior study.\n\n IMPRESSION: Diffusely dilated loops of large and small bowel with multiple\n air-fluid level seen. No evidence of free air to suggest perforation.\n Markedly dilated cecum measuring 12 cm on the current study. These findings\n are suggestive of underlying postoperative ileus. No significant change\n compared to prior.\n\n\n" }, { "category": "Radiology", "chartdate": "2192-11-10 00:00:00.000", "description": "ABDOMEN (SUPINE & ERECT)", "row_id": 1155213, "text": " 9:43 AM\n ABDOMEN (SUPINE & ERECT) Clip # \n Reason: interval chnage in air fluid levels and cecum diameter.\n Admitting Diagnosis: ST ELEVATED MYOCARDIAL INFARCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old man with ileus and dilated cecum\n REASON FOR THIS EXAMINATION:\n interval chnage in air fluid levels and cecum diameter.\n ______________________________________________________________________________\n FINAL REPORT\n ABDOMEN TWO VIEWS \n\n CLINICAL INFORMATION: Interval change in air-fluid levels or cecum diameter.\n\n FINDINGS:\n\n Two views of the abdomen demonstrate multiple radiopaque densities in the mid\n abdomen likely representing pills. Since the prior study, there has been\n interval decompression of the cecum. On the prior study, it measured 12 cm.\n Currently it measures approximately 8.1 cm. There are multiple dilated small\n bowel segments and air is seen throughout the transverse colon and in the\n rectum. These findings likely represent the sequela of postoperative ileus.\n\n\n" }, { "category": "Radiology", "chartdate": "2192-11-07 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1154665, "text": " 7:18 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? ptx after CT removal\n Admitting Diagnosis: ST ELEVATED MYOCARDIAL INFARCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old man with CABG\n REASON FOR THIS EXAMINATION:\n ? ptx after CT removal\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE AP PORTABLE VIEW OF THE CHEST\n\n REASON FOR EXAM: Assess for pneumothorax after chest tube removal.\n\n Comparison is made with prior study performed a day earlier.\n\n There is no evident pneumothorax.\n\n Mild cardiomegaly is stable. Left lower lobe retrocardiac opacity consistent\n with atelectasis has improved. Right lower lobe atelectasis is unchanged.\n There are lower lung volumes. There are no pleural effusions. The sternal\n wires are aligned.\n\n\n" }, { "category": "Radiology", "chartdate": "2192-11-03 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1154072, "text": " 7:27 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Please evaluate for acute cardiopulmonary abnormality.\n Admitting Diagnosis: ST ELEVATED MYOCARDIAL INFARCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old man with acute STEMI. Intraortic balloon pump.\n REASON FOR THIS EXAMINATION:\n Please evaluate for acute cardiopulmonary abnormality.\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE AP PORTABLE VIEW OF THE CHEST\n\n REASON FOR EXAM: Acute STEMI with intra-aortic balloon pump.\n\n Cardiomediastinal contours are normal. The intra-aortic balloon pump tip is 3\n cm from the top of the aortic arch. Cardiac size is normal. The lungs are\n clear. There is no pneumothorax or large pleural effusions. The left lateral\n CP angle was not included on the field.\n\n\n" }, { "category": "Radiology", "chartdate": "2192-11-06 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1154455, "text": " 5:35 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess fluid vs atelectasis\n Admitting Diagnosis: ST ELEVATED MYOCARDIAL INFARCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old man s/p CABG x5 ; dropping sats and hct\n REASON FOR THIS EXAMINATION:\n assess fluid vs atelectasis\n ______________________________________________________________________________\n WET READ: SBNa TUE 10:41 AM\n 1. Worsening retrocardiac opacity, likely representing atelectasis. New\n small left pleural effusion.\n 2. Although no significant change in cardiac silhoutte between post operative\n radiographs, the increase between pre-operative and postoperative films is\n dramatic and may represent pericardial effusion. Consider echocardiogram.\n ______________________________________________________________________________\n FINAL REPORT\n CHEST PORTABLE AP\n\n COMPARISON: .\n\n HISTORY: Status post CABG with dropping saturations and hematocrit, evaluate\n for fluid versus atelectasis.\n\n FINDINGS: The patient has been extubated since prior exam. There is severe\n cardiomegaly, increased when compared to remote prior exams. The patient is\n status post CABG. A right-sided Swan-Ganz catheter is identified with tip in\n main pulmonary artery. Left-sided chest tubes are unchanged in position.\n There is worsening retrocardiac opacity likely representing atelectasis.\n Small left pleural effusion has increased when compared to prior exam. Right\n mid lung zone atelectasis is also noted. No evidence of pneumothorax.\n\n IMPRESSION:\n 1. Worsening retrocardiac opacity, likely representing atelectasis. New\n small left pleural effusion.\n 2. Although no significant change in cardiac silhoutte between post operative\n radiographs, the increase between pre-operative and postoperative films is\n dramatic and may represent pericardial effusion. Consider echocardiogram.\n\n" }, { "category": "Radiology", "chartdate": "2192-11-08 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1154941, "text": " 4:06 PM\n CHEST (PA & LAT) Clip # \n Reason: eval for pleural effusions\n Admitting Diagnosis: ST ELEVATED MYOCARDIAL INFARCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old man s/p CABG\n REASON FOR THIS EXAMINATION:\n eval for pleural effusions\n ______________________________________________________________________________\n FINAL REPORT\n\n TWO-VIEW CHEST, \n\n COMPARISON: .\n\n FINDINGS: The patient is status post median sternotomy and coronary artery\n bypass surgery. Cardiac silhouette is enlarged, without change compared to\n postoperative radiograph of , but increased since the\n baseline of preoperative radiograph. Pulmonary vascularity\n is normal. Improving bibasilar atelectasis and small bilateral pleural\n effusions. Distended loops of bowel in imaged upper abdomen are incompletely\n evaluated.\n\n IMPRESSION:\n 1. Postoperative enlargement of cardiac silhouette which may reflect\n pericardial effusion.\n 2. Improving bibasilar atelectasis.\n 3. Small bilateral pleural effusions.\n\n" }, { "category": "Radiology", "chartdate": "2192-11-08 00:00:00.000", "description": "PORTABLE ABDOMEN", "row_id": 1154978, "text": " 11:16 PM\n PORTABLE ABDOMEN; -59 DISTINCT PROCEDURAL SERVICE Clip # \n Reason: s/p CABG w/abdominal distention***please obtain view of low\n Admitting Diagnosis: ST ELEVATED MYOCARDIAL INFARCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old man with as above\n REASON FOR THIS EXAMINATION:\n s/p CABG w/abdominal distention***please obtain view of low abdomen/rectum not\n visible on previous study***\n ______________________________________________________________________________\n WET READ: JMGw FRI 1:20 AM\n prominent dilated loops of small bowel and dilated cecum similar to earlier\n study with air in the rectum. findings suggest illeus, but partial obstruction\n no excluded. d/w dr. at 1:20am via phone.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 77-year-old male with increasing abdominal distention status post\n CABG.\n\n COMPARISON: Abdominal radiograph from at 22:24.\n\n ABDOMINAL RADIOGRAPH, SINGLE SUPINE PORTABLE VIEW: This single image of the\n mid lower abdomen and pelvis continues to show dilated loops of small bowel\n and significantly distended cecum. Coarse calcifications are visualized in\n the right mid abdomen and may represent calcifications within stool. No\n significant osseous abnormalities are seen within the pelvis. Air is\n visualized within the rectum.\n\n IMPRESSION: Prominent dilated loops of small bowel and significantly dilated\n cecum. No significant change compared to prior. These findings continue to\n suggest postoperative ileus\n\n" }, { "category": "Echo", "chartdate": "2192-11-05 00:00:00.000", "description": "Report", "row_id": 90025, "text": "PATIENT/TEST INFORMATION:\nIndication: Intraoperative TEE for CABG on IABP.\nHeight: (in) 71\nStatus: Inpatient\nDate/Time: at 14:02\nTest: Portable TEE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThere are mobile echos seen in the descending thoracic aorta c/w IABP.\nLEFT ATRIUM: Moderate LA enlargement. No mass/thrombus in the LAA. Good\n(>20 cm/s) LAA ejection velocity.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in the RA.\nNormal interatrial septum.\n\nLEFT VENTRICLE: Normal LV wall thickness and cavity size. Normal regional LV\nsystolic function. Low normal LVEF.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal diameter of aorta at the sinus, ascending and arch levels. Focal\ncalcifications in aortic root. Normal ascending aorta diameter. Simple\natheroma in descending aorta.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). Mild (1+) AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Moderate mitral annular\ncalcification. Calcified tips of papillary muscles. Mild (1+) MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.\n\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen. No PR.\n\nGENERAL COMMENTS: A TEE was performed in the location listed above. I certify\nI was present in compliance with HCFA regulations. The patient was under\ngeneral anesthesia throughout the procedure. The TEE probe was passed with\nassistance from the anesthesioology staff using a laryngoscope. No TEE related\ncomplications.\n\nConclusions:\nPRE-CPB:\nThe left atrium is moderately dilated. No mass/thrombus is seen in the left\natrium or left atrial appendage.\n\nLeft ventricular wall thicknesses and cavity size are normal. Regional left\nventricular wall motion is normal. Overall left ventricular systolic function\nis low normal (LVEF 50-55%).\n\nRight ventricular chamber size and free wall motion are normal.\n\nThe diameters of aorta at the sinus, ascending and arch levels are normal.\nThere is evidence of intimal thickening in the descending thoracic aorta. The\naortic valve leaflets (3) are mildly thickened. Mild (1+) aortic regurgitation\nis seen. There is calcification of the commisure between the non- and\nright-coronary cusps.\n\nThe mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation\nis seen. There is moderate posterior mitral annular calcification.\n\nPOST-CPB:\nThe LV function appears unchanged from pre-op. No wall motion abnormalities\nare noted. LV chamber size is small, consistent with hypovolemic state. The\nmitral regurgitation is now mild-moderate. There were no significant changes\nin the function of other valves. The IABP is again seen the the descending\nthoracic aorta. There is no evidence of dissection.\n\n\n" }, { "category": "Echo", "chartdate": "2192-11-03 00:00:00.000", "description": "Report", "row_id": 90026, "text": "PATIENT/TEST INFORMATION:\nIndication: Coronary artery disease. S/p stemi\nHeight: (in) 71\nWeight (lb): 170\nBSA (m2): 1.97 m2\nBP (mm Hg): 130/83\nHR (bpm): 79\nStatus: Inpatient\nDate/Time: at 10:39\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Normal LA size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.\n\nLEFT VENTRICLE: Normal LV wall thickness and cavity size. Mild regional LV\nsystolic dysfunction.\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: basal inferior\n- hypo;\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Mildly dilated aortic sinus. Normal ascending aorta diameter. Normal\naortic arch diameter.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. Trace AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Mild mitral annular\ncalcification. Mild thickening of mitral valve chordae. Calcified tips of\npapillary muscles. Trivial MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Normal PA\nsystolic pressure.\n\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not visualized. No PS.\nPhysiologic PR.\n\nPERICARDIUM: No pericardial effusion.\n\nConclusions:\nThe left atrium is normal in size. Left ventricular wall thicknesses and\ncavity size are normal. There is mild regional left ventricular systolic\ndysfunction with basal inferior hypokinesis. The remaining segments contract\nnormally (LVEF = 50-55%). Right ventricular chamber size and free wall motion\nare normal. The aortic root is mildly dilated at the sinus level. The aortic\nvalve leaflets (3) are mildly thickened but aortic stenosis is not present.\nTrace aortic regurgitation is seen. The mitral valve leaflets are mildly\nthickened. Trivial mitral regurgitation is seen. The estimated pulmonary\nartery systolic pressure is normal. There is no pericardial effusion.\n\nIMPRESSION: Mild regional left ventricular systolic dysfunction, c/w CAD. No\nsurgically-significant valvular or proximal aortic disease.\n\n\n" }, { "category": "ECG", "chartdate": "2192-11-03 00:00:00.000", "description": "Report", "row_id": 239235, "text": "Sinus rhythm. Normal tracing. No previous tracing available for comparison.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2192-11-05 00:00:00.000", "description": "Report", "row_id": 239232, "text": "Sinus rhythm. Baseline artifact. Left atrial abnormality. Prior inferior\nmyocardial infarction. Compared to the previous tracing of no\ndiagnostic interim change.\n\n" }, { "category": "ECG", "chartdate": "2192-11-04 00:00:00.000", "description": "Report", "row_id": 239233, "text": "Sinus rhythm. Non-specific ST-T wave changes. Compared to the previous tracing\nST-T wave changes are new.\nTRACING #3\n\n" }, { "category": "ECG", "chartdate": "2192-11-03 00:00:00.000", "description": "Report", "row_id": 239234, "text": "Sinus rhythm. Normal tracing. Compared to the previous tracing there is no\nsignificant change.\nTRACING #2\n\n" } ]

[ { "category": "Radiology", "chartdate": "2142-02-12 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 999620, "text": " 3:35 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: ptx\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59 year old man with s/p CABG\n REASON FOR THIS EXAMINATION:\n ptx\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST OF \n\n COMPARISON: .\n\n INDICATION: Status post coronary artery bypass surgery.\n\n There has been interval median sternotomy and coronary artery bypass surgery.\n Endotracheal tube is in standard position 4.4 cm above the carina, Swan-Ganz\n catheter terminates in the right pulmonary artery, and nasogastric tube\n terminates below the diaphragm. Mediastinal drain and low lying chest tube\n are also present with no pneumothorax visible. Cardiomediastinal contours are\n slightly widened compared to the preoperative study, likely due to a\n combination of postoperative change and accentuation by technical factors.\n Patchy and linear left basilar atelectasis are present as well as a probable\n layering small left pleural effusion.\n\n\n" }, { "category": "Radiology", "chartdate": "2142-02-14 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 999938, "text": " 1:19 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for pneumo s/p chest tube removal\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59 year old man with s/p CABGx3\n REASON FOR THIS EXAMINATION:\n eval for pneumo s/p chest tube removal\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: Status post CABG. Question pneumothorax.\n\n CHEST, AP UPRIGHT: Comparison is made to two days earlier. The patient has\n been extubated, and all lines, tubes, and drains have been removed. Except\n for minor residual left basilar atelectasis, the lungs are clear. There are\n no pleural effusions or pneumothorax. No pulmonary edema is present.\n\n IMPRESSION: No pneumothorax. Status post removal of lines, tubes, and\n drains.\n\n" }, { "category": "Echo", "chartdate": "2142-02-12 00:00:00.000", "description": "Report", "row_id": 63917, "text": "PATIENT/TEST INFORMATION:\nIndication: Intra-op TEE for CABG\nHeight: (in) 69\nWeight (lb): 188\nBSA (m2): 2.01 m2\nBP (mm Hg): 111/68\nHR (bpm): 68\nStatus: Inpatient\nDate/Time: at 13:38\nTest: TEE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Normal LA and RA cavity sizes.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal interatrial septum. No ASD by 2D or\ncolor Doppler.\n\nLEFT VENTRICLE: Normal LV wall thickness, cavity size, and systolic function\n(LVEF>55%).\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic diameter at the sinus level. Focal calcifications in\naortic root. Normal ascending aorta diameter. Normal aortic arch diameter.\nSimple atheroma in aortic arch. Normal descending aorta diameter. Simple\natheroma in descending aorta.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MS. Mild (1+) MR.\n\nTRICUSPID VALVE: Mild [1+] TR.\n\nPULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR.\n\nGENERAL COMMENTS: A TEE was performed in the location listed above. I certify\nI was present in compliance with HCFA regulations. The patient was under\ngeneral anesthesia throughout the procedure. No TEE related complications. The\npatient appears to be in sinus rhythm. Results were personally reviewed with\nthe MD caring for the patient. See Conclusions for post-bypass data The\npost-bypass study was performed while the patient was receiving vasoactive\ninfusions (see Conclusions for listing of medications).\n\nConclusions:\nPRE-BYPASS:\n1. The left atrium and right atrium are normal in cavity size. No atrial\nseptal defect is seen by 2D or color Doppler.\n2. Left ventricular wall thickness, cavity size, and systolic function are\nnormal (LVEF>55%).\n3. Right ventricular chamber size and free wall motion are normal.\n4. There are simple atheroma in the aortic arch. There are simple atheroma in\nthe descending thoracic aorta.\n5. The aortic valve leaflets (3) appear structurally normal with good leaflet\nexcursion and no aortic regurgitation. 6. The mitral valve leaflets are mildly\nthickened. Mild (1+) mitral regurgitation is seen.\n\nPOST-BYPASS: For the post-bypass study, the patient was receiving vasoactive\ninfusions including phenylephrine and is being A paced.\n1. Biventricular function is preserved.\n2. Aorta is intact post decannulation\n3. Other findings are unchanged.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2142-02-12 00:00:00.000", "description": "Report", "row_id": 1645979, "text": "Nursing Admission Note: S/P CABG X3, LIMA->LAD, SVG->Ramus,SVG->diag\n\nPt arrived from OR at 1550pm. Orally intubated and placed on ventilater. Out of OR on Neo .3 and propofol 40. CT's placed to suction-no airleak and small sanginous drainage. CXR and EKG done.\nTemp 35.1 on arrival-warmed with bair hugger.\n\nNeuro: Now weaned off propofol and awakening. Following commands and moving all extremities. PERRL.\nID: Received 2 doses of kefsol in OR. Warmed to 36.9 core. WBC-18.7\nCV: Out of OR A paced at 80 with underlying 50 SB. Now in SR 70-80's.\nK 4.4-4.2. Ran high in OR. Hct 31.7. Palpable pedal pulses. CI>2.4. PAD 13-16 with CVP 6-11. Now HTN-requiring NTG.\nRes: Intubated. ABG's WNL-weaned to CPAP/50%/ with RR 16-24. CT's to suction-small sanginous output. No airleak.\nGU: Foley to gd. UO>100cc/hr. Creat 1.3.\nGI: Abdomen obese,soft, NT, ND with OGT-scant bilious output. Carafate given.\nEndo: Glucoses WNL. No treatment needed.\nComfort: Morphine sulfate 2-4mg q 1 hr with good effect. Now denies pain.\nIncisisions: Sternum and mediastinal with DSD-D/I. L leg ace wrap intact.\nActivity: Bedrest-turned side to side.\nA: Stable-awakening and weaning\nP: Wean and extubate, Neo/NTG as needed. Carefully replete K r/t baseline creat 1.4. Pain mangement.\n" }, { "category": "Nursing/other", "chartdate": "2142-02-12 00:00:00.000", "description": "Report", "row_id": 1645980, "text": "Respiratory Care Note\nPt received from OR intubated and placed on SIMV as noted. BS clear and equal. Pt weaned according to ABGs and fast track protocol. Pt weaned to PSV as noted. Plan to extubate as soon as pt will tolerate.\n" }, { "category": "Nursing/other", "chartdate": "2142-02-13 00:00:00.000", "description": "Report", "row_id": 1645981, "text": "Neuro: pt awake following commands oriented x3.\nResp: pt extubated at 2130 without difficulty. Placed on Np 4 l with O2 sats 95-98%. Pt cughs and deep breaths well Pulling 1000 on IS.\nC/V: Heart rate in the 80's sinus no ectopy CO 6.6 and CI >3.0 pt received a total of 1 L of LR at begining of shift for metabolic acidosis with improvement. N o further fluid needed. Chest tubes patent draining serous sangunious drainage sm-mod amounts. No air leak detected.\nGI: pt tolerating ice chips advanced to clear liquids Bowel sounds hypo active.\nEndo: Insulin gtt started for borderline blood sugars.\nGU: adequate urine outputs\nPain: pt medicated with morphine 2mg sc for mild pain repeat dose need after 1 hour. switched to percocets this am with good effect so far.\nPlan: Deline, out of bed to chair. Transfer to floor.\n" }, { "category": "ECG", "chartdate": "2142-02-12 00:00:00.000", "description": "Report", "row_id": 124506, "text": "Sinus rhythm. Compared to the previous tracing of the rate has\nincreased.\n\n" } ]

[ { "category": "Radiology", "chartdate": "2144-05-05 00:00:00.000", "description": "ABDOMEN (SUPINE & ERECT)", "row_id": 1016966, "text": " 2:29 PM\n ABDOMEN (SUPINE & ERECT) Clip # \n Reason: r/o obstruction\n Admitting Diagnosis: RULE-OUT MYOCARDIAL INFARCTION;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old man with hx of pyloric stenosis as a child s/p surgery, now\n admitted with abdominal pain and vomiting\n REASON FOR THIS EXAMINATION:\n r/o obstruction\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 74-year-old man with history of pyloric stenosis, now abdominal\n pain and vomiting, query obstruction.\n\n COMPARISON: .\n\n ABDOMEN, TWO VIEWS: Nonspecific bowel gas pattern with stool and gas seen in\n the large bowel. Interval verteboplasty. There is an anterior fixation\n device at L5-S1. Otherwise, no gross osseous abnormality. There is linear\n atelectasis versus scarring at the left lung base. Phleboliths are seen in the\n pelvis.\n\n IMPRESSION: No radiographic evidence for obstruction.\n\n" }, { "category": "Radiology", "chartdate": "2144-05-14 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1018331, "text": " 2:36 PM\n CHEST (PA & LAT) Clip # \n Reason: Evaluate for interval change, effusion, consolidation\n Admitting Diagnosis: RULE-OUT MYOCARDIAL INFARCTION;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old man with increasing O2 requirement\n REASON FOR THIS EXAMINATION:\n Evaluate for interval change, effusion, consolidation\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): PMB 4:38 PM\n Worsening right pleural effusion and adjacent parenchymal opacification in\n right lower lobe.\n ______________________________________________________________________________\n FINAL REPORT\n TWO-VIEW CHEST, \n\n COMPARISON: and earlier studies dating back to .\n\n INDICATION: Increasing oxygen requirement.\n\n Right internal jugular vascular catheter is unchanged in position, but new\n right internal jugular dialysis catheter has been placed, with tip terminating\n in expected location of proximal right atrium. No pneumothorax. Moderate\n right pleural effusion has slightly increased in size, with adjacent\n increasing consolidation at right lung base. Small left pleural effusion is\n also evident as well as minor atelectasis at the left base. High-density\n material is present adjacent to the right hemidiaphragm, likely due to\n aspirated barium, as reported on earlier radiograph of .\n\n Deformity of proximal left humerus is likely due to old injury.\n\n IMPRESSION:\n 1. Increasing right effusion and adjacent right basilar consolidation. The\n latter may potentially be due to an evolving infection, possibly secondary to\n aspiration.\n 2. Small left pleural effusion.\n\n\n" }, { "category": "Radiology", "chartdate": "2144-05-14 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1018332, "text": ", P. MED FA2 2:36 PM\n CHEST (PA & LAT) Clip # \n Reason: Evaluate for interval change, effusion, consolidation\n Admitting Diagnosis: RULE-OUT MYOCARDIAL INFARCTION;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old man with increasing O2 requirement\n REASON FOR THIS EXAMINATION:\n Evaluate for interval change, effusion, consolidation\n ______________________________________________________________________________\n PFI REPORT\n Worsening right pleural effusion and adjacent parenchymal opacification in\n right lower lobe.\n\n\n" }, { "category": "Radiology", "chartdate": "2144-05-13 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1018134, "text": " 12:14 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: Confirm placement\n Admitting Diagnosis: RULE-OUT MYOCARDIAL INFARCTION;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old man s/p central line placement.\n REASON FOR THIS EXAMINATION:\n Confirm placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 74-year-old man with central line placement.\n\n Comparison is made to the prior study of .\n\n UPRIGHT RADIOGRAPH OF THE CHEST: The left CV line distal tip projects in the\n cavoatrial junction. There are new bibasilar atelectasis. An increased\n opacity of the right hemithorax might be related to patient positioning or\n moderate right pleural effusion, repeated radiograph is recommended. The\n cardiomedistineal and hilar countours are normal.\n\n These findings were discussed with Dr. at time of dictation.\n\n" }, { "category": "Radiology", "chartdate": "2144-05-07 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1017257, "text": " 1:56 PM\n CHEST (PORTABLE AP) Clip # \n Reason: assess placement\n Admitting Diagnosis: RULE-OUT MYOCARDIAL INFARCTION;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old man with NG tube placement\n REASON FOR THIS EXAMINATION:\n assess placement\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Nasogastric tube placement.\n\n FINDINGS: In comparison with the study of , there has been placement of a\n nasogastric tube that extends to the upper portion of the stomach. Allowing\n for some obliquity of the patient, there is little change in the appearance of\n the cardiac silhouette. No evidence of acute pneumonia.\n\n There has been aspiration of barium into the right lower lung zone.\n\n\n" }, { "category": "Radiology", "chartdate": "2144-05-12 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1018030, "text": " 7:52 PM\n CHEST (PORTABLE AP) Clip # \n Reason: NGT placement\n Admitting Diagnosis: RULE-OUT MYOCARDIAL INFARCTION;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old man with recent NGT placement for persistent emesis.\n REASON FOR THIS EXAMINATION:\n NGT placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 47-year-old man with recent NG tube placement for persistent\n emesis. Please evaluate NG tube location.\n\n Single AP radiograph of the abdomen has been provided. NG tube projects at\n the expected location of the stomach. The visualized portions of the lung\n bases appear normal.\n\n IMPRESSION: Standard position of the NG tube.\n\n" }, { "category": "Radiology", "chartdate": "2144-05-08 00:00:00.000", "description": "CT ABDOMEN W/O CONTRAST", "row_id": 1017460, "text": " 4:50 PM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: Please eval for obstruction.\n Admitting Diagnosis: RULE-OUT MYOCARDIAL INFARCTION;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old man with h/o CAD, a. fib, hemetemesis and nausea vomiting concern\n for gastric outlet obstruction.\n REASON FOR THIS EXAMINATION:\n Please eval for obstruction.\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 74-year-old man with nausea, vomiting and hematemesis with\n concern for gastric outlet obstruction. Additional history of DM, CAD and\n AFIB.\n\n COMPARISON: Abdominal radiograph of , upper GI study of and\n abdominal radiograph of .\n\n TECHNIQUE: MDCT-acquired axial images were obtained through the abdomen and\n pelvis without intravenous contrast administration. Multiplanar reformatted\n images were also obtained.\n\n FINDINGS:\n\n At the lung bases, multiple high attenuation foci are present, ? aspiration of\n barium are present. Additionally, there is bibasilar atelectasis and very\n small bilateral pleural effusions. The heart is slightly enlarged, and there\n is extensive calcification of the coronary arteries. Within the thorax, the\n esophagus is dilated, measuring approximately 2 cm at its greatest diameter,\n and contains oral contrast material as well as a nasogastric tube.\n\n In the abdomen, a large amount of retained oral contrast material is present\n within a somewhat distended stomach. The most dense concentration of barium\n is along the posterior wall of the stomach. A small amount of contrast\n material is seen in both small and large bowel, indicating the absence of a\n complete obstruction.\n\n There is a moderate amount of ascites in the abdomen, greatest surrounding the\n liver and in the dependent portions of the intraperitoneal cavity, and\n tracking along the mesentery into the pelvis. Mesenteric stranding is present\n diffusely. Streak artifact from retained contrast material in the stomach,\n and the absence of intravenous contrast material somewhat limits evaluation of\n intra- abdominal organs. However, the liver, kidneys, pancreas and adrenal\n glands are largely unremarkable. Within the gallbladder, small gallstones are\n seen layering along the dependent wall. The abdominal aorta and its branches\n are heavily calcified, without evidence of dilatation.\n\n In the pelvis, the bladder, prostate gland and rectum are largely\n unremarkable. Extensive calcification is noted of the seminal vesicles, and\n the branches of the internal and external iliac arteries. Within the sigmoid\n colon, there are scattered diverticuli, and stool of increased density, likely\n (Over)\n\n 4:50 PM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: Please eval for obstruction.\n Admitting Diagnosis: RULE-OUT MYOCARDIAL INFARCTION;TELEMETRY\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n resulting from mixing with oral barium.\n\n Evaluation of bony structures reveals posterior fixation hardware of the lower\n lumbar spine, spanning L4 through S1. The patient is post-vertebroplasty at\n L1 and L2, where extensive compression deformities are present, and the\n posterior aspect of the L2 vertebral body has retropulsed into the spinal\n canal. Degenerative disc disease is noted at multiple levels. There is no\n acute fracture.\n\n IMPRESSIONS:\n\n 1. Contrast material has progressed to the colon, indicating the absence of a\n complete obstruction. However, the large amount of retained barium in the\n stomach reflects a significant delay in gastric emptying. Diagnostic\n considerations include severe gastroparesis or partial gastric outlet\n obstruction.\n 2. Possible precipitation of retained barium in the stomach, with refluxed\n contrast material in the esophagus. Nasogastric suctioning is recommended.\n 3. Moderate ascites.\n 4. Small layering gallstones.\n 5. Extensive atherosclerotic calcification of coronary arteries, aorta and\n major branches.\n 6. Aspirated barium at the right lung base.\n 7. Upper lumbar vertebroplasty with retropulsed fragment of L2 into the\n spinal canal.\n\n Dr. was paged at the time of dictation.\n\n\n" }, { "category": "Radiology", "chartdate": "2144-05-13 00:00:00.000", "description": "TUNNELED W/O PORT", "row_id": 1018161, "text": " 3:08 PM\n TUNNELLED CATH PLACE SCH Clip # \n Reason: tunneled dialysis line\n Admitting Diagnosis: RULE-OUT MYOCARDIAL INFARCTION;TELEMETRY\n ********************************* CPT Codes ********************************\n * TUNNELED W/O FLUORO GUID PLCT/REPLCT/REMOVE *\n * US GUID FOR VAS. ACCESS *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old man with esrd\n REASON FOR THIS EXAMINATION:\n tunneled dialysis line\n ______________________________________________________________________________\n FINAL REPORT\n PROCEDURE: Tunneled hemodialysis catheter placement.\n\n INDICATION: A 74 year man with ESRD and re-throbosis of arm a-v fistula needs\n placement of tunneled HD catheter.\n\n Radiologists:This procedure was performed by Dr , Dr and Dr\n , the attending radiologist, who was present and supervised throughout\n the entire procedure.\n\n PROCEDURE AND FINDINGS: Written informed consent obtained from the patient and\n his son by the clinical team at the time of thrombectomy consent was in the\n patient's chart. The patient's primary care physicain was also present prior\n to the procedure and wrote a note indicating necessity of procedure in this\n now sedated (post-op) patient.\n The patient was placed supine on the angiographic table and right neck and\n right upper chest were prepped and draped in standard sterile fashion. After\n injection of local anesthesia and using ultrasound guidance, access was gained\n into the right internal jugular vein with a 21- gauge micropuncture needle.\n Hard copy image of ultrasound were obtained before and after venous puncture\n documenting vessel patency. A 0.018 guidewire was advanced with a needle into\n the SVC under fluoroscopic guidance, and the needle was exchanged for a 4.5\n French micropuncture sheath. A 0.035 guidewire was advanced through the\n sheath into the IVC under fluoroscopic guidance. After injection of local\n anesthesia, a subcutaneous tunnel was created using blunt dissection in the\n left upper chest. A tunneled hemodialysis catheter was pulled through the\n tunnel into the neck incision site. The tract was serially dilated with 8\n French, 12 French, and 14 French dilators. A 16 French peel- away sheath was\n advanced over the wire into the SVC under fluoroscopic guidance and inner\n portion and guidewire were removed and a tunneled hemodialysis catheter with\n 19 cm tip-to-cuff length was advanced into the peel-away sheath with its tip\n positioned at right atrium. The neck incision was closed with #2 Vicryl\n sutures and the catheter was secured to the skin with 0 Prolene sutures. A\n catheter was flushed, heplocked and sterile dressing was applied.\n\n Fluoroscopic images show previously placed left IJ triple lumen catheter\n tip at the level of the SVC/RA junction. The heart has a configuration of\n left ventricular hypertrophy. Radiodensities at the right lung base are\n consistent with known aspirated barium.\n (Over)\n\n 3:08 PM\n TUNNELLED CATH PLACE SCH Clip # \n Reason: tunneled dialysis line\n Admitting Diagnosis: RULE-OUT MYOCARDIAL INFARCTION;TELEMETRY\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n The patient tolerated the procedure well and there were no immediate\n complications.\n\n IMPRESSION: Successful placement of a 15.5 French tunneled hemodialysis\n catheter with 19 cm tip-to-cuff length via right internal jugular vein and\n with its tip positioned in the proximal right atrium. The catheter is ready\n to use.\n\n\n" }, { "category": "Radiology", "chartdate": "2144-05-13 00:00:00.000", "description": "RO HUMERUS (AP & LAT) RIGHT IN O.R.", "row_id": 1018117, "text": " 10:59 AM\n HUMERUS (AP & LAT) RIGHT IN O.R.; UPPER EXTREMITY FLUORO WITHOUT RADIOLOGIST RIGHTClip # \n Reason: FISTULOGRAM THROMBECTOMY\n Admitting Diagnosis: RULE-OUT MYOCARDIAL INFARCTION;TELEMETRY\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Fistulogram. Thrombectomy.\n\n A single intraoperative fluoroscopic view of a fistulogram was obtained\n without a radiologist present. This demonstrates iodinated contrast within a\n fistula. For additional details, please consult the operative report.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2144-05-08 00:00:00.000", "description": "Report", "row_id": 1351462, "text": "MICU Nurse Admission/progress note 0000-0700\npt is a 74yo M PMH:DM I; CRI on HD; HTN; aortic stenosis; GIB; BPH dilated cardiomypathy EF 60%; who was admitted to on w/ N/V CG emesis. and increased confusion. evening, while being treated on the floor pt developed new A-fib w/ RVR HR in the 140's-170's. SBP dropped into the 70's-80's. pt triggered, was given MgSO4 4g and IV KCL and transferred to the MICU as a CCU boarder.\n\nUpon arrival to the MICU pt was in a-fib HR 130's-150's, sbp in the low 90's. pt started on amiodarone gtt at 1mg/min per protocol. converted to NSR after ~45min on amiodarone gtt. b/p remained somewhat low 80's-90's/40's-50's, bolused w/ 250ml N/S w/ immediate improvement. b/p now 100-120/40's. of note pt missed his am dose of amiodarone r/t N/V. also pt had HD on . currently pt is in NSR w/ HR 70's-80's and b/p as above.\n\nROS:\n\nNeuro: A/Ox2-3, following commands, MAE. PEARRLS, no c/o pain or SOB since transfer.\n\nPulm: LS clear bilat, slight crackles noted initially in the bases, now resolved. 02 sat 92-98% on RA\n\nCVS: NSR w/ no ectopy at this time, HR 70's-80's, b/p as above. +1 edema noted in all ext. pt has R A-V Fistula for HD access. also PIV x2 in L upper arm.\n\nGI: NGT in R nare initially to low intermittent suction, draining sm- mod amt bilious drainage. abd soft distended w/ hypoactive BS. pt has not had BM since admit on . NPO except meds/ ice chips.\n\nGU: per report pt voids sm amt, no urine noted this shift. R A-V fistula w/ +B/T.\n\nskin: W/D, intact.\n\nsocial: pt son called, updated by RN/MD r/t pt cond and . at time of last update pt was still in a-fib.\n\nplan: cont amiodarone gtt per protocol, transition back to PO amiodarone.\nmonitor/ replete lytes as needed.\nf/u w/ bowel regimen/ ngt to . vs Low intermittent suction.\nroutine ICU monitoring and care\nsupport pt and family\nc/o to floor when off amiodarone gtt.\n" }, { "category": "Nursing/other", "chartdate": "2144-05-08 00:00:00.000", "description": "Report", "row_id": 1351463, "text": "addendum\nNeuro: as pt more awake it is clear that he is confused, oriented to self only. still following commands and MAE. reorient to place/ time w/ little effect.\n" }, { "category": "Nursing/other", "chartdate": "2144-05-15 00:00:00.000", "description": "Report", "row_id": 1351464, "text": "CCU Nursing Progress Note 1145-1730\nS:\n\nO: 74yom w/ extensive pmh, tx from 2 at 1145 this am for rapid HR (afib 160), which did not resolve w/ Lopressor and Dilt. 45 minutes after arrival to CCU, pt converted to NSR in 90's which continued throughout shift. BP 87-100/30-40's. pt on 1350units heparin which was dc'd at 1530.\n\nResp - ls are dimished at l base and bronchial on r. pt on 2lnp which was increased to 5ln/p d/t o2 sat of 89%. Sat increased to 99-100%.\n\nGU - DNV\n\nGI - Tolerating sips of clear liqs.\n\nID - low grade temp of 99.7\n\nAccess - r tunnel cath, l tlc which was dc'd by house staff at 1630.\n\nPain - pt describes generalized pain, but is reluctant to inform staff. Pt rec'd 2mg IVP Morphine w/ good effect.\n\nSocial - family vss w/ pt throughout day. Family meeting w/ Dr. . Family agrees to CMO and discharge to home today.\n\nA/P: 74yom w/ extensive pmh, made cmo and was discharged to home.\n" }, { "category": "Radiology", "chartdate": "2144-05-11 00:00:00.000", "description": "L UNILAT UP EXT VEINS US LEFT", "row_id": 1017854, "text": " 4:07 PM\n UNILAT UP EXT VEINS US LEFT Clip # \n Reason: EVAL FOR DVT, SWELLING\n Admitting Diagnosis: RULE-OUT MYOCARDIAL INFARCTION;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old man with L arm edema, no pain/redness\n REASON FOR THIS EXAMINATION:\n Eval for superficial vs deep VT\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INDICATION: Left arm edema.\n\n TECHNIQUE: Two-dimensional -scale, color, and pulse Doppler evaluation\n using a linear array transducer.\n\n FINDINGS: There is thrombus located within one of the patient's brachial\n veins as well as the basilic vein. There is no evidence of thrombus within\n internal jugular, subclavian, or axillary veins in which compressibility,\n flow, and augmentation is maintained throughout. These findings are discussed\n with Dr. at the time of dictation.\n\n IMPRESSION:\n 1. Thrombus identified within brachial and basilic veins as noted.\n\n\n" }, { "category": "Radiology", "chartdate": "2144-05-03 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1016698, "text": " 3:31 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: eval for hemorrhage, chronic changes\n Admitting Diagnosis: RULE-OUT MYOCARDIAL INFARCTION;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old man with ESRD on HD, p/w GIB and mental status changes.\n REASON FOR THIS EXAMINATION:\n eval for hemorrhage, chronic changes\n CONTRAINDICATIONS for IV CONTRAST:\n ESRD\n ______________________________________________________________________________\n FINAL REPORT\n CT HEAD WITHOUT CONTRAST\n\n COMPARISON: None.\n\n HISTORY: Altered mental status changes.\n\n TECHNIQUE: MDCT axially acquired images through the skull were obtained. IV\n contrast was not administered.\n\n FINDINGS: The ventricles and sulci are prominent consistent with age-\n appropriate atrophy. Periventricular white matter hypodensities are noted,\n consistent with chronic small vessel ischemic changes. There is no shift of\n normally midline structures. Calcifications of the carotid arteries are\n noted. The visualized paranasal sinuses are clear. There is no evidence of\n hemorrhage.\n\n IMPRESSION: No evidence of hemorrhage or shift of normally midline\n structures. Chronic small vessel ischemic changes.\n\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2144-05-02 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1016576, "text": " 10:59 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? acute cardiopulm\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old man with vomiting x 1 week, ? UGIB\n REASON FOR THIS EXAMINATION:\n ? acute cardiopulm\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Vomiting for one week, query upper GI bleed, query acute\n cardiopulmonary process.\n\n COMPARISON: .\n\n CHEST, THREE VIEWS: There has been interval placement of an OG tube with tip\n and side hole projecting below the diaphragm. The heart size is top normal\n and unchanged as are mediastinal and hilar contours. There is no pneumothorax\n or pleural effusion. Right superior mediastinal fullness likely relates to\n tortuous vessels. No airspace opacification identified. The pulmonary\n vasculature is normal. No gross osseous abnormality.\n\n IMPRESSION: No acute cardiopulmonary process.\n\n" }, { "category": "Radiology", "chartdate": "2144-05-07 00:00:00.000", "description": "ABDOMEN (SUPINE & ERECT)", "row_id": 1017236, "text": " 11:11 AM\n ABDOMEN (SUPINE & ERECT) Clip # \n Reason: eval transit of barium through gut\n Admitting Diagnosis: RULE-OUT MYOCARDIAL INFARCTION;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old man with DM, ESRD here with N/V concerning for gastroparesis\n REASON FOR THIS EXAMINATION:\n eval transit of barium through gut\n ______________________________________________________________________________\n FINAL REPORT\n SUPINE AND ERECT ABDOMEN:\n\n INDICATION: 74-year-old man with diabetes, end-stage renal disease with\n nausea and vomiting, concerning for gastroparesis. Evaluate transition of\n barium through the gut after upper GI study on .\n\n COMPARISON: radiograph and upper GI study.\n\n FINDINGS: There are scattered flecks of barium within the lung bases. The\n barium is retained within the stomach. There is also a small amount of barium\n to the right of L1 and L2 vertebrae, likely in small bowel. The dense material\n overlying T12 and L1 vertebrae is consistent with prior vertebroplasty as\n noted on prior radiographs from . There is anterior fixation\n hardware in the spine from L3 through S1. There are calcifications of the vas\n deferens bilaterally.\n\n IMPRESSION: No evidence of significant progression of the barium, which is\n for the most part retained within the stomach, as discussed with Dr. on\n the day of the study.\n\n\n" }, { "category": "Radiology", "chartdate": "2144-05-06 00:00:00.000", "description": "UGI AIR W/O KUB", "row_id": 1017116, "text": " 2:48 PM\n UGI AIR W/O KUB Clip # \n Reason: eval esophagus, r/o delayed contrast transit or slowed gastr\n Admitting Diagnosis: RULE-OUT MYOCARDIAL INFARCTION;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old man with tortuous esophagus, hx of pyloric stenosis s/p\n pyloroplasty. Has had N/V with mult EGD's with retained food in stomach\n REASON FOR THIS EXAMINATION:\n eval esophagus, r/o delayed contrast transit or slowed gastric motility.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Query delayed transit of contrast.\n\n COMPARISON: .\n\n BARIUM UPPER GI STUDY\n\n The study was limited due to patient factors and aspiration. Barium passes\n freely through the esophagus into the stomach, and there is no demonstration\n of mucosal abnormality or stricture. In the 50 minutes of the exam, barium\n did not pass into the small bowel. Barium is seen in the tracheal tree\n secondary to regurgitation and aspiration. Limited views of the stomach do\n not demonstrate a mucosal abnormality. There is an anterior fixation device,\n and there has been a vertebroplasty.\n\n IMPRESSION: No transit of barium from the stomach: gastroparesis versus\n gastric outlet obstruction; recommend nuclear medicine gastric emptying study.\n\n" }, { "category": "ECG", "chartdate": "2144-05-15 00:00:00.000", "description": "Report", "row_id": 164168, "text": "Atrial fibrillation with rapid ventricular response. Inferior wall myocardial\ninfarction of indeterminate age. Non-specific ST-T wave changes. Compared to\nthe previous tracing of there is no significant diagnostic change.\n\n" }, { "category": "ECG", "chartdate": "2144-05-15 00:00:00.000", "description": "Report", "row_id": 164169, "text": "Atrial fibrillation with rapid ventricular response. Inferior wall myocardial\ninfarction, age indeterminate. Non-specific anterolateral ST-T wave changes.\nProlonged QTc interval. Compared to the previous tracing of the rhythm\nis now atrial fibrillation.\n\n" }, { "category": "ECG", "chartdate": "2144-05-11 00:00:00.000", "description": "Report", "row_id": 164170, "text": "Sinus rhythm. The Q-T interval is prolonged. There are Q waves in the\ninferior leads consistent with prior myocardial infarction. Non-specific\nST-T wave changes. Compared to the previous tracing ST-T wave changes are\nless marked.\n\n" }, { "category": "ECG", "chartdate": "2144-05-10 00:00:00.000", "description": "Report", "row_id": 164171, "text": "Normal sinus rhythm. ST segment depressions in leads V2-V5 are more prominent\nand new compared to tracing #2 and suggestive of anterior myocardial ischemia.\nClinical correlation is suggested. The Q-T interval prolongation persists.\nTRACING #3\n\n" }, { "category": "ECG", "chartdate": "2144-05-09 00:00:00.000", "description": "Report", "row_id": 164172, "text": "Normal sinus rhythm with Q-T interval prolongation. Prior inferior myocardial\ninfarction. Non-specific ST-T wave abnormalities. No change from tracing #1.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2144-05-09 00:00:00.000", "description": "Report", "row_id": 164173, "text": "Normal sinus rhythm. Q-T interval prolongation. Q waves in leads III and aVF\nconsistent with prior inferior myocardial infarction. T wave inversions in\nlead V2. Slight ST segment depressions in leads V3-V4 suggest possible\nanterior ischemia. Compared to the previous tracing of there has been\nno diagnostic interval change.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2144-05-03 00:00:00.000", "description": "Report", "row_id": 164174, "text": "Sinus rhythm. Long Q-T interval. Old inferior myocardial infarction.\nNon-specific diffuse T wave flattening with slight ST segment changes.\nCompared to the previous tracing of baseline artifact is resolved.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2144-05-02 00:00:00.000", "description": "Report", "row_id": 164175, "text": "Sinus rhythm. Prolonged Q-T interval. Baseline artifact. Non-specific\ndiffuse T wave flattening. Possible prior inferior myocardial infarction.\nCompared to the previous tracing of the QRS voltage has decreased.\nArtifact is more pronounced.\nTRACING #1\n\n" } ]

[ { "category": "Echo", "chartdate": "2111-02-20 00:00:00.000", "description": "Report", "row_id": 70537, "text": "PATIENT/TEST INFORMATION:\nIndication: Endocarditis.\nHeight: (in) 63\nWeight (lb): 100\nBSA (m2): 1.44 m2\nBP (mm Hg): 172/70\nStatus: Inpatient\nDate/Time: at 10:55\nTest: TTE (Complete)\nDoppler: Complete pulse and color flow\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: The left atrium is normal in size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: The right atrium is normal in size. A\ncatheter or pacing wire is seen in the right atrium and/or right ventricle.\n\nLEFT VENTRICLE: Left ventricular wall thicknesses are normal. The left\nventricular cavity size is top normal/borderline dilated. There is mild global\nleft ventricular hypokinesis.\n\nRIGHT VENTRICLE: Right ventricular chamber size is normal. There is focal\nhypokinesis of the apical free wall of the right ventricle.\n\nAORTA: The aortic root is normal in diameter.\n\nAORTIC VALVE: The number of aortic valve leaflets cannot be determined. No\nmasses or vegetations are seen on the aortic valve. There is no aortic valve\nstenosis. No aortic regurgitation is seen.\n\nMITRAL VALVE: The mitral valve leaflets are structurally normal. No mass or\nvegetation is seen on the mitral valve. Mild (1+) mitral regurgitation is\nseen.\n\nTRICUSPID VALVE: The tricuspid valve leaflets are normal. There is no mass or\nvegetation detected on the tricuspid valve. Physiologic 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. No vegetation/mass is seen on the pulmonic valve.\n\nPERICARDIUM: There is no pericardial effusion.\n\nConclusions:\nThe left atrium is normal in size. Left ventricular wall thicknesses are\nnormal. The left ventricular cavity size is top normal/borderline dilated.\nThere is mild global left ventricular hypokinesis (ejection fraction 40%). The\nbasal inferio wall is more markedly hypokinetic compared to the other\nsegments. Right ventricular chamber size is normal. There is focal hypokinesis\nof the apical free wall of the right ventricle. The number of aortic valve\nleaflets cannot be determined. No masses or vegetations are seen on the aortic\nvalve. There is no aortic valve stenosis. No aortic regurgitation is seen. The\nmitral valve leaflets are structurally normal. No mass or vegetation is seen\non the mitral valve. Mild (1+) mitral regurgitation is seen. The tricuspid\nvalve is normal with no vegetations. There is trace tricuspid regurgitaiton.\nThere is mild pulmonic regurgitation. The pulmonary artery systolic pressure\ncould not be determined. No vegetation/mass is seen on the pulmonic valve.\nThere is no pericardial effusion.\n\nCompared with the findings of the prior report (tape unavailable for review)\nof , there are no significant changes. No vegetations were identified.\n\n\n" }, { "category": "Radiology", "chartdate": "2111-02-22 00:00:00.000", "description": "MRI ABDOMEN W/O & W/CONTRAST", "row_id": 821172, "text": " 12:52 PM\n MRI ABDOMEN W/O & W/CONTRAST; MR RECONSTRUCTION IMAGING Clip # \n MR CONTRAST GADOLIN\n Reason: Please eval for intrabd. masses, pancreas, liver.\n Admitting Diagnosis: DIABETIC KETOACIDOSIS\n Contrast: MAGNEVIST Amt: 9CC]\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old woman with chronic wasting, CAD, poorly controlled DM, previous h/o\n heavy tob use ,CRI, and RUQ pain, please eval for LAD/masses,pancreatic CA etc.\n REASON FOR THIS EXAMINATION:\n Please eval for intrabd. masses, pancreas, liver.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Right upper quadrant pain and chronic wasting. Evaluate for\n pancreatic cancer or lymphadenopathy.\n\n TECHNIQUE: Multiplanar T1- and T2-weighted and gadolinium-enhanced MR imaging\n of the abdomen. Non-breath hold technique was used due to limited ability of\n the patient to suspend respiration.\n\n MRI ABDOMEN WITH CONTRAST: There are pleural effusions bilaterally, right\n greater than left, as on the CT of . Cholecystectomy clips are noted.\n No focal lesions are seen in the liver, spleen, pancreas or adrenal glands.\n There are cysts in both kidneys. No enlarged retroperitoneal lymph nodes are\n seen.\n\n IMPRESSION: Bilateral pleural effusions, right greater than left. No liver\n or pancreatic masses identified. No enlarged retroperitoneal lymph nodes\n seen.\n\n" }, { "category": "Radiology", "chartdate": "2111-02-20 00:00:00.000", "description": "CT CHEST W/O CONTRAST", "row_id": 821024, "text": " 3:20 PM\n CT CHEST W/O CONTRAST Clip # \n Reason: any evidence of masses or lymphadenopathy\n Admitting Diagnosis: DIABETIC KETOACIDOSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old woman with diabetes, hypertension, h/o lung scar/mass?, chf, now\n with fevers and weight loss.\n REASON FOR THIS EXAMINATION:\n any evidence of masses or lymphadenopathy\n CONTRAINDICATIONS for IV CONTRAST:\n renal function\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Diabetes hypertension and recent chest CT with question mass versus\n resolving pneumonia or edema.\n\n Evaluate for mass or evidence of adenopathy.\n\n COMPARISON: .\n\n TECHNIQUE: Noncontrast chest CT.\n\n FINDINGS: There are persistent bilateral pleural effusions and persistent mild\n pulmonary edema manifested as some septal thickening toward the bases and\n ground glass opacity. More focal patchy opacity in the right lower lobe has\n decreased in intensity since the prior exam suggesting a resolving area of\n edema or infection. There are no new areas of abnormality demonstrated. There\n is extensive emphysema. The heart is enlarged and the patient is post CABG.\n There is a left sided PICC line terminating in the lower SVC. There is a small\n hiatal hernia. The bones reveal degenerative changes but no suspicious\n findings. The imaged organs of the upper abdomen demonstrate a right renal\n stone and a right sided kidney cyst. There is a small left renal stone as\n well. The adrenal glands are not abnormal. There is subcutaneous edema.\n\n IMPRESSION: 1. Improvement in appearance of more focal irregular opacity in\n the right lower lobe suggesting resolving area of infection or edema.\n\n 2. Improving but persistent pulmonary edema with effusions bilaterally.\n\n 3. Emphysema.\n\n Recommendation: One more followup chest CT after the patient's pulmonary edema\n and effusions have resolved on chest radiograph is suggested to assure\n continued resolution of the right lower lobe finding.\n\n\n" }, { "category": "Radiology", "chartdate": "2111-02-16 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 820462, "text": " 8:03 AM\n CHEST (PORTABLE AP) Clip # \n Reason: 61 year old woman with CAD/s/p CABG with chest pain and DKA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old woman with CAD/s/p CABG with chest pain and DKA\n REASON FOR THIS EXAMINATION:\n 61 year old woman with CAD/s/p CABG with chest pain and DKA\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Chest pain and diabetic ketoacidosis.\n\n VIEWS: Upright AP view compared with upright AP view from .\n\n FINDINGS: The patient is s/p median sternotomy and CABG. There is stable\n cardiac enlargement. There has been interval resolution of the previously\n identified left ventricular heart failure. The pulmonary vascularity now is\n within normal limits. The lungs are clear without evidence of pleural\n effusions of pneumothorax. The soft tissues and osseous structures are\n unremarkable.\n\n IMPRESSION: Resolution of left ventricular heart failure.\n\n" }, { "category": "Radiology", "chartdate": "2111-02-19 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 820857, "text": " 9:07 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please check placement l bas picc for abx, call beeper 3-760\n Admitting Diagnosis: DIABETIC KETOACIDOSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old woman with CAD/s/p CABG with chest pain and DKA\n\n REASON FOR THIS EXAMINATION:\n please check placement l bas picc for abx, call beeper with wet read\n thanks\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post CABG with chest pain and diabetic ketoacidosis.\n Status post PICC line placement.\n\n VIEWS: Upright AP view of the chest compared with an upright AP view from\n .\n\n FINDINGS: A left sided PICC line has been placed with tip at the cavoatrial\n junction. The patient is status post median sternotomy and CABG. The heart\n is stablely enlarged. The mediastinal and hilar contours remain unchanged.\n There is mild upper zone vascular redistribution and vascular indistinctness,\n findings consistent with mild pulmonary edema. Patchy opacity is present\n within both lung bases which may represent atelectasis. No pneumothorax is\n identified.\n\n IMPRESSION:\n\n 1) Satisfactory placement of PICC line.\n 2) Slight interval worsening of pulmonary edema.\n 3) Bibasilar patchy atelectasis.\n\n" }, { "category": "ECG", "chartdate": "2111-02-18 00:00:00.000", "description": "Report", "row_id": 157755, "text": "Sinus bradycardia\nLeft ventricular hypertrophy with ST-T changes\nSince last ECG, no significant change\n\n" }, { "category": "ECG", "chartdate": "2111-02-17 00:00:00.000", "description": "Report", "row_id": 157756, "text": "Normal sinus rhythm\nLong QTc interval\nLeft ventricular hypertrophy with ST-T wave changes\nSince last ECG, no significant change\n\n" }, { "category": "ECG", "chartdate": "2111-02-17 00:00:00.000", "description": "Report", "row_id": 157757, "text": "Sinus bradycardia\nLeft ventricular hypertrophy with ST-T changes\nSince last ECG, no significant change\n\n" }, { "category": "ECG", "chartdate": "2111-02-16 00:00:00.000", "description": "Report", "row_id": 157976, "text": "Sinus rhythm\nLeft ventricular hypertrophy with ST-T wave changes\nSince last ECG, no significant change\n\n" }, { "category": "ECG", "chartdate": "2111-02-16 00:00:00.000", "description": "Report", "row_id": 157977, "text": "Sinus rhythm\nPossible left atrial abnormality\nLeft ventricular hypertrophy\nSince last ECG, no significant change\n\n" }, { "category": "Nursing/other", "chartdate": "2111-02-17 00:00:00.000", "description": "Report", "row_id": 1428687, "text": "NPN (NOC): PT HAD AN OK NIGHT. IVF CHANGED TO 1/2 NS W/ 20 KCL. PT ALSO HAD INSULIN DRIP RUNNING AT 1 U/HR. AFTER A FEW HRS DROPPED BS TO 54. ONE AMP D50 GIVEN W/ INCREASE IN BS TO 154. IVF CHANGED TO D51/2 AT 100/HR. INSULIN DRIP RESTARTED ONCE BS'S ~ 150 CONSISTANTLY, BUT OFF AGAIN AT 6AM FOR BS OF 79. WHEN BS WAS 54, I ASKED HER HOW SHE FELT AND SHE SAID THAT SHE HAD CP. ONE MG IVMS GIVEN W/ RELEIF. CK'S/MB'S FLAT, BUT MN TROPONIN .21. DR. AWARE. 3RD SET OF CK'S/TROPONIN DONE AT 6AM. IN FOR AM ECG. HR'S HAVE BEEN IN 50'S, NSR W/O ECTOPY. SBP'S 130'S. TOOK ALL BP MEDS. OTHERWISE HAS BEEN NPO EXCEPT ICE CHIPS D/T AMYLASE/LIPASE UP (BUT HO THINKS THIS BE DKA INSTEAD OF PANCREATITIS.) UO AT LEAST 30 CC'S/HR. LATEST K+ 3.8, AM K PND. PM HCT 27 (DOWN FROM 37- PROBABLY DILUTIONAL). RPT 29%. CLOT SENT TO BB BUT NO PLAN TO TRANSFUSE FOR NOW.\n" }, { "category": "Nursing/other", "chartdate": "2111-02-17 00:00:00.000", "description": "Report", "row_id": 1428688, "text": "NPN 0700-1900\nGeneral: Pt A&Ox3,talkative no c/o abd pain since this am at which time pt was tx'd with 2mg MSo4 IV for +3 abd pain. After eating breakfast pt was nauseated and given 10mg Compazine IV, no nausea or pain since am, pt ate lunch and dinner without complaints. No insulin gtt today, pt started on SS insulin, FBS 153- FBS was 302 after dinner HO called 4u Humalog given SQ. BCX2 sent. Troponin elevated, CPK flat, discussed with HO, likely d/t to poor renal fx.\n\nNeuro: Talkative, MAEW, able to turn self, PERLA X2, no neuro deficit.\n\nCV: HR 50-60 SB-SR no ectopy, BP's 129-145/45-50's, no edema, T max 97.7, no c/o CP.\n\nResp: Lungs clear but diminished throughout, no c/o SOB, O2sat 95-99% RR 18-22.\n\nGI: BS (+) x 4 quad., no BM's, tolerating diabetic diet, eating 60% of meal, if pt has vomiting after meals she is to be made NPO.\n\nGU:Foley cath intact draining clear urine with scant sediment, UO=30cc/hr.\n\nAccess: 20g R FA with D51/2NS at 100cc/hr infusing, 20g L FA.\n\nSocial: Pt lives with mother who does not drive, she talked to mother over the phone, has one son in the military, and one daughter, no calls from family members.\n\nPlan: Continue to monitor and tx elevated FBS, monitor VS, UO, assess pain and nausea, continue nutrition as tolerated, call out to floor when bed available.\n" }, { "category": "Nursing/other", "chartdate": "2111-02-16 00:00:00.000", "description": "Report", "row_id": 1428686, "text": "MSICU NSG ADMIT/PROGRESS NOTE\n\nSee FHPA for more details.\n\n61 yo w/~ day h/o n/v and elevated FSs presented to EU in DKA w/FS >700. Transferred to MSICU for furhter mgmt. A&o x3 on arrival to ICU. FS 330 on Insulin gtt @8u/hr. Initailly on NS @100/hr. Currently on D5.45NS at 100/hr and Insulin gtt at 6u but decreased to 2u/hr for FS 100. Repeat FS as well as electrolytes pnd.\n\nC/O stomach ache and nausea ( pain scale) as well as CP (). ECG done with flipped Ts laterally. Pt fell asleep when undisturbed. Stated she did not take any of her meds today because of nausea. Plan to r/o MI. Also given compazine for nausea. Plan to try and give her her meds this eve if nausea subsides.\n\nLives with her mother who she says is her spokesperson but her Proxy is someone else (see FHPA). MD called her mother.\n\nPlan to cont R/O MI protocol and follow FSs closely.\n" } ]

[ { "category": "Radiology", "chartdate": "2127-09-20 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1254398, "text": " 9:00 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for acute pulmonary process\n Admitting Diagnosis: ANGIOEDEMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 23 year old woman with angioedema; now spiking fevers\n REASON FOR THIS EXAMINATION:\n eval for acute pulmonary process\n ______________________________________________________________________________\n FINAL REPORT\n CHEST ON \n\n HISTORY: Angioedema, spiking fevers.\n\n FINDINGS: Compared to the study from two days prior. The heart size is\n mildly larger, but there is no focal infiltrate or effusion. ET tube and NG\n tube are unchanged.\n\n\n" }, { "category": "Radiology", "chartdate": "2127-09-18 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1254135, "text": " 8:07 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? plament\n ______________________________________________________________________________\n MEDICAL CONDITION:\n History: 23F with ett\n REASON FOR THIS EXAMINATION:\n ? plament\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 22-year-old female with ET tube placement, evaluate for ETT\n placement.\n\n COMPARISON: None.\n\n FRONTAL VIEW OF THE CHEST: Frontal view of the chest demonstrates an ET tube\n approximately 2.2 cm from the carina and should be repositioned, withdraw\n approximately 1 cm. Bilateral low lung volumes are noted with mild crowding\n of bronchovascular markings. Cardiac silhouette appears accentuated by low\n lung volumes. There is no focal consolidation, pleural effusion or\n pneumothorax.\n\n Findings discussed with Dr. at 9:57a.m. on via\n telephone.\n\n" }, { "category": "ECG", "chartdate": "2127-09-18 00:00:00.000", "description": "Report", "row_id": 305939, "text": "Sinus rhythm. High precordial voltage consistent with possible left\nventricular hypertrophy. Lateral ST segment elevations consistent with\nnormal early repolarization pattern. No previous tracing available for\ncomparison.\n\n" } ]

[ { "category": "Radiology", "chartdate": "2168-01-28 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 779608, "text": " 7:37 PM\n CHEST (PORTABLE AP) Clip # \n Reason: check line placement s/p or\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old man with renal insufficiency s/p central line placement\n REASON FOR THIS EXAMINATION:\n check line placement s/p or\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post central line placement. Check position.\n\n Comparison is made to prior exam of .\n\n FINDINGS: Surgical staples are seen in the midline consistent with the\n patient's very recent thoracic laminectomy. There is no pneumothorax. A\n right internal jugular approach Swan-Ganz catheter is seen coiled within the\n main pulmonary artery and bent back on itself approximately 6 cm towards the\n right ventricle. An ET tube is in good position. The cardiomediastinal\n borders are unchanged. The pulmonary vasculature is normal. There is\n evidence of bilateral lower lobe densities consistent with atelectasis,\n greater on the left. An NG tube is coursing through the stomach and exits the\n field of view. There are no pleural effusions. A left shoulder prosthesis is\n noted.\n\n IMPRESSION:\n\n 1. Positioning of a Swan-Ganz catheter as described. The house staff caring\n for the patient was informed of this finding at the time of interpretation.\n\n 2. No pneumothorax. Bibasilar atelectasis.\n\n" }, { "category": "Radiology", "chartdate": "2168-01-27 00:00:00.000", "description": "CHEST (PRE-OP PA & LAT)", "row_id": 779522, "text": " 9:37 PM\n CHEST (PRE-OP PA & LAT) Clip # \n Reason: HERNIATED DISC\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old man with\n REASON FOR THIS EXAMINATION:\n 57yr old male preop for thoracic laminecotomy \n ______________________________________________________________________________\n FINAL REPORT\n\n CHEST, TWO VIEWS, PA AND LATERAL.\n\n HISTORY: Preop for thoracic laminectomy.\n\n Allowing for low lung volumes, heart size is borderline. There is tortuosity\n of the thoracic aorta. There are coronary calcifications. There is slight\n flattening of the diaphragms with elevation of the left hemidiaphragm.\n Minimal linear atelectasis at the left lung base. No pulmonary consolidation\n or pleural effusion. S/P left shoulder hemiarthroplasty and\n calcified/ossified soft tissue density in region of left axilla. Hiatal\n hernia.\n\n IMPRESSION: No evidence for chf or pneumonia. Minimal linear atelectasis.\n Small hiatal hernia.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2168-01-27 00:00:00.000", "description": "MR L SPINE SCAN", "row_id": 779513, "text": " 7:39 PM\n MR L SPINE SCAN; MR THORACIC SPINE Clip # \n Reason: 57 yr old male with T8-T9 and T9-T10 stenosis will need sagg\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old man with hx thoracic stenosis. left leg weakness.\n REASON FOR THIS EXAMINATION:\n 57 yr old male with T8-T9 and T9-T10 stenosis will need saggital T2 views from\n mid-sacrum to T6 and axial T2 through any areas of cord compression Patient is\n Preop for \n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Thoracic spinal canal stenosis rule out cord compression.\n\n Multiplanar T1 and T2 weighted images of the thoracic and the lumbar spine are\n obtained. Comparison is made to the prior examination of . Sagittal\n images reveals multilevel disk degenerations of the thoracic spine extending\n from T4 through T10 levels. There is borderline stenosis of the spinal canal\n at T5-T6 level due to degenerative spurring. Mild spinal canal stenosis is\n seen at T6-T7 level and T7-T8 level due to paracentral disk protrusions and\n ligamental hypertrophy. Both disk spaces have severely desiccated. There is\n moderate to severe stenosis of the spinal canal at T8-T9 and T9-T10 levels due\n to disk protrusions, degenerative spurring and ligamental hypertrophy.\n Increased T2 signal is seen within the cord at T8, T9 and T10 levels probably\n related to myelomalacia.\n\n There is mild stenosis of the canal at T12-L1 level due to central disk\n protrusion resulting in minimal compression of the conus ventrally. The upper\n lumbar spine is unremarkable. There is degenerative grade 1 anterolisthesis\n of L5 in relation to S1 with uncovering of the posterior aspect of the disk\n space along with discogenic changes. The patient has undergone surgical\n fusion by metallic plates and mulitple screws noted along the pedicles of L5\n and S1. Severe narrowing of the exit neural foraminal is seen at L5-S1 level.\n\n IMPRESSION: Multilevel spinal canal stenosis involving the mid and lower\n thoracic spine as described above. The degree of stenosis is worst at T8-T9\n and T9-T10 levels. Mild spinal stenosis is seen at T6-T7 and T7-T8 levels.\n Scattered foci of myelomalacia within the thoracic cord.\n\n Mild spinal stenosis is seen at the thoracolumbar junction at T12-L1 level\n compounded by a small central disk herniation.\n\n Post-surgical changes and effusion at L5-S1 level with grade 1 anterolisthesis\n of L5 in relation to S1.\n\n" }, { "category": "Radiology", "chartdate": "2168-01-28 00:00:00.000", "description": "O LUMBAR SP,SINGLE FILM IN O.R.", "row_id": 779591, "text": " 3:43 PM\n LUMBAR SP,SINGLE FILM IN O.R. Clip # \n Reason: DECOMPRESSIVE THORACIC LAMINECTOMY\n ______________________________________________________________________________\n FINAL REPORT\n\n\n INDICATION: Decompressive thoracic laminectomy.\n\n FINDINGS: Single intraoperative lateral view of the lumbar spine is grossly\n underpenetrated. There appears to be posterior fusion of the lower lumbar\n vertebral bodies with bone graft material posteriorly. There is an unusual\n lucency through an upper lumbar vertebral body, which extends beyond the\n anterior aspect of the vertebral body. Two surgical clips are seen overlying\n this area. Full AP and lateral exam is recommended for complete evaluation.\n\n" }, { "category": "Radiology", "chartdate": "2168-01-29 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 779670, "text": " 12:43 PM\n CHEST (PORTABLE AP) Clip # \n Reason: pneumothorax\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old man with renal insufficiency s/p central line placement\n\n REASON FOR THIS EXAMINATION:\n pneumothorax\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Evaluate position of central line.\n\n COMPARISON: \n\n CHEST, PORTABLE: The heart is slightly enlarged even allowing for the AP\n projection. What is shown of the lungs is clear. There is a right sided\n internal jugular line in situ with the tip in the distal SVC. No\n pneumothorax.\n\n IMPRESSION: No pneumothorax.\n\n\n" }, { "category": "ECG", "chartdate": "2168-01-28 00:00:00.000", "description": "Report", "row_id": 105958, "text": "Sinus rhythm with one ventricular premature beat. Abnormal left axis deviation.\nSince the previous tracing of the ventricular ectopy is less.\n\n" }, { "category": "ECG", "chartdate": "2168-01-27 00:00:00.000", "description": "Report", "row_id": 105959, "text": "Normal sinus rhythm\nFrequent premature ventricular contractions\nProbable prior inferior infarct - age undetermined - may be old\nLeft atrial abnormality\nConsider left ventricular hypertrophy\nNonspecific ST-T wave changes\nSince previous tracing of : no significant change\n\n" } ]

[ { "category": "Radiology", "chartdate": "2123-04-23 00:00:00.000", "description": "RENAL U.S.", "row_id": 1131656, "text": ", R. MED MICU 8:59 AM\n RENAL U.S. Clip # \n Reason: Please evaluate for hydronephrosis, hematoma\n Admitting Diagnosis: ANEMIA/THROMBOCYTOPNEIA/FEVER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old woman with renal failure.\n REASON FOR THIS EXAMINATION:\n Please evaluate for hydronephrosis, hematoma\n ______________________________________________________________________________\n PFI REPORT\n IMPRESSION: Unremarkable renal ultrasound with no evidence of hydronephrosis\n or perinephric fluid collections.\n\n\n" }, { "category": "Radiology", "chartdate": "2123-04-22 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1131561, "text": " 2:14 PM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o infiltrate\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old woman with sob\n REASON FOR THIS EXAMINATION:\n r/o infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Shortness of breath.\n\n COMPARISON: Chest radiograph .\n\n UPRIGHT AP VIEW OF THE CHEST: Cardiac silhouette remains mildly enlarged.\n The aorta is tortuous. The mediastinal and hilar contours are otherwise\n unremarkable. Lungs are clear without pleural effusion. No pneumothorax. No\n acute osseous abnormality is seen.\n\n IMPRESSION: No acute cardiopulmonary process.\n\n\n" }, { "category": "Radiology", "chartdate": "2123-04-23 00:00:00.000", "description": "RENAL U.S.", "row_id": 1131655, "text": " 8:59 AM\n RENAL U.S. Clip # \n Reason: Please evaluate for hydronephrosis, hematoma\n Admitting Diagnosis: ANEMIA/THROMBOCYTOPNEIA/FEVER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old woman with renal failure.\n REASON FOR THIS EXAMINATION:\n Please evaluate for hydronephrosis, hematoma\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): DLrc FRI 11:31 AM\n IMPRESSION: Unremarkable renal ultrasound with no evidence of hydronephrosis\n or perinephric fluid collections.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Patient is a 79-year-old female with renal failure. Evaluate for\n hydronephrosis or perinephric hematoma.\n\n EXAMINATION: Renal ultrasound.\n\n COMPARISONS: Comparison is made to MR examination from .\n\n FINDINGS: The right kidney measures 9.4 cm.\n\n Left kidney measures 9.6 cm.\n\n Both kidneys are symmetric in size. Located arising from the upper pole of\n the right kidney, there is a 2.4 x 2.3 x 2.7 cm simple cyst and located\n arising from the interpolar region of the left kidney, there is a 2.6 x 1.7 x\n 2.4 cm simple cyst. These are little changed since examination from .\n The kidneys are otherwise unremarkable with no evidence of hydronephrosis,\n nephrolithiasis, or discrete masses. The bladder is collapsed about a Foley\n catheter, limiting evaluation.\n\n IMPRESSION: Unremarkable renal ultrasound with no evidence of hydronephrosis\n or perinephric fluid collections.\n\n\n" }, { "category": "Radiology", "chartdate": "2123-04-23 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1131664, "text": ", R. MED MICU 9:25 AM\n CHEST (PA & LAT) Clip # \n Reason: eval for infiltrate/pneumonia\n Admitting Diagnosis: ANEMIA/THROMBOCYTOPNEIA/FEVER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old woman with thrombocytopenia, hypoxia\n REASON FOR THIS EXAMINATION:\n eval for infiltrate/pneumonia\n ______________________________________________________________________________\n PFI REPORT\n No evidence of pneumonia.\n\n" }, { "category": "Radiology", "chartdate": "2123-04-23 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1131663, "text": " 9:25 AM\n CHEST (PA & LAT) Clip # \n Reason: eval for infiltrate/pneumonia\n Admitting Diagnosis: ANEMIA/THROMBOCYTOPNEIA/FEVER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old woman with thrombocytopenia, hypoxia\n REASON FOR THIS EXAMINATION:\n eval for infiltrate/pneumonia\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): YGd FRI 12:34 PM\n No evidence of pneumonia.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 79-year-old female with thrombocytopenia and hypoxia here for\n evaluation of pneumonia.\n\n COMPARISON: .\n\n CHEST, PA AND LATERAL: Moderate cardiomegaly is unchanged since .\n Mediastinal and hilar contours are unremarkable. With the exception of trace\n left bassilar atelectasis, the lungs are clear. There is no pleural effusion\n or pneumothorax.\n\n IMPRESSION: No evidence of pneumonia.\n\n" }, { "category": "ECG", "chartdate": "2123-04-22 00:00:00.000", "description": "Report", "row_id": 151961, "text": "Baseline artifact. Regular rhythm, probably sinus. ST-T wave abnormalities.\nSince the previous tracing of there may well be no difference but\nST-T waves cannot be directly compared. Clinical correlation is suggested.\n\n" } ]

[ { "category": "Echo", "chartdate": "2195-04-27 00:00:00.000", "description": "Report", "row_id": 104643, "text": "PATIENT/TEST INFORMATION:\nIndication: TIPS candidate Left ventricular function.\nHeight: (in) 63\nWeight (lb): 192\nBSA (m2): 1.90 m2\nBP (mm Hg): 108/46\nHR (bpm): 60\nStatus: Inpatient\nDate/Time: at 14:50\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\nLEFT VENTRICLE: Normal LV wall thickness, cavity size, and global systolic\nfunction (LVEF>55%). Suboptimal technical quality, a focal LV wall motion\nabnormality cannot be fully excluded. Estimated cardiac index is normal\n(>=2.5L/min/m2). No resting LVOT gradient.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTIC VALVE: Normal aortic valve leaflets (?#). Trace AR.\n\nMITRAL VALVE: Normal mitral valve leaflets. No MVP. Mild (1+) MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Normal PA\nsystolic pressure.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows. Suboptimal\nimage quality as the patient was difficult to position. Suboptimal image\nquality - patient unable to cooperate.\n\nConclusions:\nThe left atrium is mildly dilated. Left ventricular wall thickness, cavity\nsize, and global systolic function are normal (LVEF>55%). Due to suboptimal\ntechnical quality, a focal wall motion abnormality cannot be fully excluded.\nThe estimated cardiac index is normal (>=2.5L/min/m2). Right ventricular\nchamber size and free wall motion are normal. The aortic valve leaflets (?#)\nappear structurally normal with good leaflet excursion. Trace aortic\nregurgitation is seen. The mitral valve leaflets are structurally normal.\nThere is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. The\nestimated pulmonary artery systolic pressure is high normal. There is no\npericardial effusion.\n\nIMPRESSION: Suboptimal image quality. Normal biventricular cavity sizes with\npreserved global biventricular systolic function. Mild mitral regurgitation.\nHigh normal pulmonary artery systolic pressure.\n\nCLINICAL IMPLICATIONS:\nBased on AHA endocarditis prophylaxis recommendations, the echo findings\nindicate prophylaxis is NOT recommended. Clinical decisions regarding the need\nfor prophylaxis should be based on clinical and echocardiographic data.\n\n\n" }, { "category": "Radiology", "chartdate": "2195-04-26 00:00:00.000", "description": "P LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT", "row_id": 1236883, "text": " 12:43 PM\n LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT; -59 DISTINCT PROCEDURAL SERVICEClip # \n DUPLEX DOP ABD/PEL LIMITED\n Reason: UGIB,EVALPV THOMBOSIS\n Admitting Diagnosis: GASTROINTESTINAL BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old woman with cirrhosis p/w UGIB. Please eval with doppler.\n REASON FOR THIS EXAMINATION:\n ?thrombus\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Cirrhosis and upper GI bleed.\n\n No comparison studies available.\n\n TECHNIQUE: Ultrasonography, including Color Doppler spectral analysis, of the\n liver.\n\n FINDINGS:\n The liver is coarse and echogenic, denoting hepatic steatosis. No focal\n intrahepatic lesion or intrahepatic bile duct dilation is seen. The CBD is\n not dilated, measuring 3 mm. The gallbladder is surgically absent. The\n spleen is enlarged, measuring 14.0 cm. There is no ascites.\n\n Wall-to-wall color flow is seen within the left, mid, right hepatic veins,\n left, right anterior and posterior portal veins, main portal vein, and main\n hepatic artery, all demonstrating appropriate waveforms and flow direction.\n\n IMPRESSION:\n 1. Patent hepatic and portal veins, and main hepatic arteries, demonstrating\n appropriate waveforms and flow directions.\n 2. Echogenic liver denotes hepatic steatosis. More advanced disease such as\n cirrhosis or fibrosis cannot be excluded with this technique.\n 3. Splenomegaly.\n\n" } ]

[ { "category": "Nursing/other", "chartdate": "2164-08-05 00:00:00.000", "description": "Report", "row_id": 1828814, "text": "NICU NPN 0500-0700 ADMIT NOTE\nBaby admitted to the NICU from L&D for prematurity at 33 2/7 weeks. Please see attending note for history and details. Baby delivered vaginally, with apgars 8,9.\nVSS on arrival to the NICU. D stick was 38. PIV placed and baby started on d10 at 80cc/k. D stick to be rechecked at 0630. Vss (Please see flowsheet), baby meds given. Dad in to visit with grandparents of baby and updated at the bedside. Mom remains in L&D on mgso4.\n" }, { "category": "Nursing/other", "chartdate": "2164-08-05 00:00:00.000", "description": "Report", "row_id": 1828815, "text": "Neo Attend\nDay 0 now 33.2 wk pma\nmat severe PIH, increased lft's, nvd.\n\nrespr ra, clear=bs, rr 40-60s.\nCV: no murmur now. bp 67/36, hr 130-160s, pink, well perfused,\nwt 1715 gm\n80 cc/kg/day piv.\nglu 38 increased to 59, 70.\none void, no stool yet.\nwill be formula fed.\n\nAssess: 33.2 wk, wll on RA, monitor for s/sx of increased Mg.\n\nPlan: continue plan as noted above.\n\n" }, { "category": "Nursing/other", "chartdate": "2164-08-05 00:00:00.000", "description": "Report", "row_id": 1828816, "text": "NPN DAYS\n\n1 Alt in FEN\n2 Alt in Growth and Dev\n3 Parenting\n\nAlt in FEN: Currently NPO. TF 80cc/kg/day D10 infusing via\nPIV in left foot. D/S 70. Voiding. No stool. Belly benign.\nNo spits. Soft bowel sounds. To have 24hr lytes and bili.\n start feeds tonight or tomorrow.\n\nALt in Growth and Dev: Temp stable while nested on warmer.\nWarmer temp weaned a bit this shift. Awake and alert with\ncares. Likes her pacifier. AGA. Continue to provide for\ndevelopmental needs.\n\nParenting: Dad in to visit and updated at the bedside by\nthis RN. Mom remains in L&D and has not been able to see the\nbaby in the NICU yet. Will provide teaching and support\nthroughout the NICU stay.\n\nREVISIONS TO PATHWAY:\n\n 1 Alt in FEN; added\n Start date: \n 2 Alt in Growth and Dev; added\n Start date: \n 3 Parenting; added\n Start date: \n\n" }, { "category": "Nursing/other", "chartdate": "2164-08-06 00:00:00.000", "description": "Report", "row_id": 1828817, "text": "NPN\n\n\n#1-O: on tf 80cc/k/d, started enteral feeds of 30cc/k/d,\nincreasing 20/k . SSC 20 = 9cc q 4 hrs, po'd x 2 , no\nspits, abd soft, benign, voided 4.4cc/k/hr this shift. no\nstools. d/s = 74 IVF D10 at 50cc/k/d infusing well via\nPIV. wt down 10 gms today to 1.705 kg.\n\n#2-O; temps 98.6-99.5 on servo warmer, will transfer to\nisolette when heated, active alert and awake for feedings,\npo'd well x 2 for initial amts feeding, AFOF, MAE, no\nspells, cont to assess.\n\n#3-O; no contact this shift.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2164-08-05 00:00:00.000", "description": "Report", "row_id": 1828813, "text": "NICU Attending Admission Note\nID: 33 week gestation girl, induced vaginal delivery secondary to severe pre-eclampsia.\n\nPre/perinatal Hx: Mother is 27 y.o.G2 P now 2, EDC . PNS: O+, Ab-, RPRNR, RI, HepBSAg-, GBS?. Pregnancy complicated by severe PIH including proteinuria prompting admission for evaluation and betamethasone course, complete . Due to rising LFT's, started on MgSO4 as well as pitocin for induction last night. No maternal fever, AROM 3.5 hours PTD, + intrapartum antibiotic prophylaxis to oprematurity. Uncomplicated vaginal delivery early this am. Spontaneous cry, routine care in DR, apgars 8 and 9. Transferred to NICU secondary to prematurity.\n\nPEx: Weight: 1715 gm (35%), L: 43 cm (35%), HC: 29.5 cm (25%), overall appearance c/w EGA, nondysmorphic, AFSOF, + RR bilaterally, palate intact, mild retractions, BS clear/=, RRR without murmur, 2+ peripheral pulses including femorals, abd benign without HSM or masses, small umbilical cord with 3 vessels, normal female external genitalia for g.a. normal back and ext with stable hips, skin pink and well perfused, appropriate tone and strength.\n\nA/P: 33 2/7 weeks gestation, AGA female delivered preterm due to maternal indications, beta complete with apparently mature pulmonary function. No perinatal risk factors for sepsis. At risk for other complications of moderate prematurity including A/B, electrolytes imbalance, hypoglycemia, hyperbilirubinemia, suck swallow dyscoordination, thermal dysregulation. At low risk for IVH and ROP.\n\n-monitor on CVR and O2 sat monitor\n-NPO for now, D10W at 80 ml/kg/day, follow D stick, lytes, bili, treat as indicated.\n- If resp status remains stable, start enteral feeds, advance as tolerated\n- CBC and blood cx, consider antibiotics if develops any s/s concerning for sepsis\n- No head U/S or eye exam unless warranted based on severity of illness or specifica clinical concners\n- I spoke with parents in DR, will continue to inform/support, contact office when name identified.\n" }, { "category": "Nursing/other", "chartdate": "2164-08-06 00:00:00.000", "description": "Report", "row_id": 1828818, "text": "Neonatology Attending\n\nDay 1 PMA 33 wks\n\nRemains in RA. RR 40-50s. No murmur. BP mean 47. Pink. Weight 1705 g (-10). TF at 80 ml/kg/d. On SC 20 at 30 ml/kg/d. IV dextrose supplement. Lytes 141/4.4/105/26. Bilirubin 14.9. Taking po feeds. No stool passed. Benign abdomen. Stable temperature in servo-controlled incubator. Held by parents yesterday.\n\nDoing well. Will continue to monitor closely. Metabolically fine. Significant hyperbilirubinemia noted. Starting phototherapy and repeating bili. Will continue to advance feeds.\n\n" }, { "category": "Nursing/other", "chartdate": "2164-08-06 00:00:00.000", "description": "Report", "row_id": 1828819, "text": "Case Management Note\nChart has been reviewed and events noted. EIP & VNA options placed in record. I will be providing clinical updates to insurance and will assist w/any d'c planning needs along with team & family inputs\n" }, { "category": "Nursing/other", "chartdate": "2164-08-14 00:00:00.000", "description": "Report", "row_id": 1828857, "text": "Neonatology Attending\n\nDay 9 PMA 34 wks\n\nRemains in RA. Sats 95-100%. Clear breath sounds. RR 30-60s. No bradycardia. No murmur. HR 130-160s. Pale, pink. Weight 1665g (-5). TF at 150 ml/kg/d- SC 26 with Propass. Attempting po feeding. Supplemented with gavage feeds. Benign abdomen. Stable girth. No spits. Minimal aspirates. Rebound bilirubin 5.5. Stable temperature in air-mode incubator. , active.\n\nAcceptable breathing control. Will continue to monitor closely. Tolerating feeds. Encouraging po feeds. up to date.\n\n" }, { "category": "Nursing/other", "chartdate": "2164-08-12 00:00:00.000", "description": "Report", "row_id": 1828849, "text": "Neonatology Attending\n\nDay 7 PMA 34 wks\n\nRemains in RA. RR 30-50s. No bradycardia. No murmur. HR 140-160s. Pale, pink. Mottles with care. BP mean 42. Weight 1655g (+40). TF at 150 ml/kg/d- SC 24. Taking about half of volume po. Gavage supplementation started yesterday. Benign abdomen. Passing stool. Continues on phototherapy. Stable temperature in incubator.\n\nAcceptable breathing control. Monitoring. Immature feeding. Will supplement as needed. Changing over to SeoSure 26. Will recheck bilirubin tomorrow. Family up to date.\n\n" }, { "category": "Nursing/other", "chartdate": "2164-08-12 00:00:00.000", "description": "Report", "row_id": 1828850, "text": "NPN 7A-7P\n\n\n#1 TF at 150cc/k/d, cal's increased to 26 of SCF. Bottled\n15-20cc's and remainder gavaged. No spits today, \nresiduals, girth steady, voiding and stooling. Gained wt\nlast night. Con't to monitor.\n\n#2,4 Under Neoblue photo tx (in servo-isolette for this\nreason) with eye and genital protection in place. Has\nhigh-boundaries in place and extremities brought to midline\n(until infant can be swaddled) due to hyper-reflexive\nstartle. Though bottles well, working on stamina. Increased\ncal's today. Very alert during and after cares. Con't\npresent interventions.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2164-08-11 00:00:00.000", "description": "Report", "row_id": 1828844, "text": "NPN 7A-7P\n\n\n#1 TF increased to 150cc/k/d (infant lost 5 gms last noc and\nng tube placed for sluggish feeds). Bottled 40cc's eagerly\nat first this AM and got tired, then only bottled 10cc's at\n12n feed, remainder gavaged. Is voiding, stooled small\nguiaic neg. Had moderate spit approx 1 hr after 12n feed\n(partially digested formula), but otherwise exam\nunremarkable: is soft and pink. Mom in attendance ans was\nupdated that we'd continue to closely for\ntoleration. Will con't to po as tolerated. Monitor.\n\n#2 In air-isolette since NeoBlue phototx started (changed\nfrom triple photo tx last noc). Is very active and alert\nwith cares, eager to feed but gets tired and slows. Spit\nmoderate amount, prior to increased TF volume. Monitor\nclosely since mom reports this is the first time infant has\nspit. Con't present interventions.\n\n#4 Under NeoBlue, eye and genital protection in place. Is\nstooling, TF incraesed, infant pale-pink and very slightly\njaundiced. Will recheck bili early Monday AM.\n\n#3 Mom called this AM and was in to visit, along with\ninfant's grandfather. updated at bedside on plan at\nbedside to assess closely (was present during\ninfant's spit). Mom visits daily, con't to support.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2164-08-11 00:00:00.000", "description": "Report", "row_id": 1828845, "text": "Neonatology - NNP Progress Note\n\nInfant is active with good tone. AFOF. she is pink, well perfused, no murmur auscultated. She is comfortable in room air, breath sounds clear and equal. She is tolerating enteral feeds, abd soft, active bowel sounds, voiding and stooling. Stable temp in servo isolette. Remains under phototherapy. Please refer to neonatology attending note for detailed plan.\n" }, { "category": "Nursing/other", "chartdate": "2164-08-11 00:00:00.000", "description": "Report", "row_id": 1828846, "text": "NPN Addendum:\nInfant remains alert with cares, is pale-pink/sl jaundiced but mottles with cares. Placed infant on servo-control heat because infant seemed to cool quickly during cares. Bottled 25cc's quickly but tired out and remainder gavaged. Abdomen is soft, active bowel sounds. NNP informed of earlier spit and change to servo. Will con't to monitor closely.\n" }, { "category": "Nursing/other", "chartdate": "2164-08-12 00:00:00.000", "description": "Report", "row_id": 1828847, "text": "NPN 07p-07a\n\n\nFEN\nCurrent weight 1655g (40g). TF 150cc/kg/day, SSC24. PO/PG.\nTolerating well. No spits. . aspirates. Bottled 20 & 30cc\nthis shift thus far. Gavaged remaining volume. BS active.\nAbd. soft, round. No loops. AG 22-22.5cm. Voiding, stooling\nheme negative. Cont. monitor PO/PG feeding tolerance &\nweight.\nG&D\nIn servo isolette, temps stable. Alert & active with cares.\nResting comfortably inbetween. Loves pacifier. Brings hands\nto face. Fontanels soft, flat. Cont. jittery with cares,\nsettling with boundaries. MAEs. PPPx4ext. Cont. monitor\ngrowth & developm. patterns.\nBILI\nCont. under neoblue bank, eye shields in place. VS stable.\nVoiding, stooling. Alert & active with cares. Recheck bili\nMonday am. Cont. monitor for changes.\n\nNo contact this shift thus far. Cont. support & educate.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2164-08-12 00:00:00.000", "description": "Report", "row_id": 1828848, "text": "Neonatology Attending\n\nExam remarkable for well-appearing preterm infant in no distress with pink color, soft af, no gfr, clear breath sounds, no murmur, flat soft n-t abdomen, nl tone/activity.\n" }, { "category": "Nursing/other", "chartdate": "2164-08-13 00:00:00.000", "description": "Report", "row_id": 1828851, "text": "NPN 07p-07a\n\n\nFEN\nCurrent weight 1670g (^15). TF 150cc/kg/day, SSC26. PO/PG.\nBottled 10-15cc this shift thus far. Coordinated, tiring\neasily. D-stick 67. One small spit. Max. aspirate 3cc. BS\nactive. Abd. soft, round. No loops. AG 22.5-23cm. Voiding,\nstooling heme negative. Cont. monitor PO/PG feeding\ntolerance & weight.\nBILI\nCont. under neoblue bank, eye shields in place. Alert &\nactive with cares. VS stable. Voiding, stooling. Recheck\nbili pending. Cont. monitor for changes.\nG&D\nIn servo isolette, temps stable. Alert & active with cares.\nResting comfortably with boundaries inbetween. Cont.\njittery/^active startle - needing boundaries. Fontanels\nsoft, flat. MAEs. +PPPx4ext. Cont. monitor growth &\ndevelopm. patterns.\n\nNo contact this shift thus far. Cont. support & educate.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2164-08-13 00:00:00.000", "description": "Report", "row_id": 1828852, "text": "NP NOTE\nPE: small preterm infant neslted in isolette. Phototherapy off. AFOF sutures overriding, eyes clear, ng in place, MMMP\nChest is clear, equal bs\nCV: RRR, no murmur, nl S1 prominent S2\nAbd: soft,flat, active bs, cord drying\nGU: immature female\nEXT: , \nNeuro: active, mottles with exam, tremulous,improves with boundaries. Symmetric reflexes\n" }, { "category": "Nursing/other", "chartdate": "2164-08-13 00:00:00.000", "description": "Report", "row_id": 1828853, "text": "Neonatology Attending\n\nDay 8 PMA 34 wks\n\nRemains in RA. Clear breath sounds. RR 30-50s. Mild retractions. No bradycardia. No murmur. HR 140-170s. Pale, pink. BP mean 53. Weight 1670g (+15). TF at 150 ml/kg/d- SC 26. Taking only partial bottles with gavage supplementation. Passing heme negative stool. On iron. Benign abdomen. Bilirubin 5.3. Phototherapy discontinued. Stable temperature in air-mode incubator.\n\nAcceptable breathing control under monitoring. Gaining weight but immature feeding evident. Will check rebound bilirubin tomorrow. Family up to date.\n\n" }, { "category": "Nursing/other", "chartdate": "2164-08-10 00:00:00.000", "description": "Report", "row_id": 1828840, "text": "NNP On-Call\nPlease see Dr. note for overall summary and plan.\n\nPhysical Exam\nGeneral: infant in isolette, on phototherapy\nSkin: warm and dry; color pink\nHEENT: anterior fontanel open, level; sutures opposed\nChest: breath sounds clear/=\nCV: RRR, no murmur; normal S1 S2; pulses +2\nAbd: soft; no masses; + bowel sounds; cord on/drying\nGU: preterm female\nExt: moving all\nNeuro: jittery, + suck; + grasps; no elicitable clonus, tone appropriate\n" }, { "category": "Nursing/other", "chartdate": "2164-08-10 00:00:00.000", "description": "Report", "row_id": 1828841, "text": "NICu Nursing Progress Note\n\nRemains in roomair with O2 sats >95. Breath sounds, resp\nrate and WOB are at baseline. No apnea or bradycardia\nobserved.\n\nRemains under triple phototherapy with eyes covered. Today's\nbili down to 7.0/0.3. Slightly jaundiced. Will check another\nbili in am\n\nWaking every 4 hrs to feed. Just taking minimum volume\nrequirement. Abd exam benign. Voiding and passing heme neg\nstool.\n\nInfant has rapid state changes and marked jitteriness.\nUnable to self-console. Sucking strongly on pacifier. \nBumper placed in infant's isolette and Mom instructed in\nsome developmental strategies she can do daily daily. Mom\nspoke with PT today.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2164-08-09 00:00:00.000", "description": "Report", "row_id": 1828836, "text": "NPN days\n\n\nFEN: TF MIN of 140cc/k/d of SC24. All PO feedings (took in\n162/k yesterday), trial AD lib with min of 140cc/k/d , so if\nfeeding Q3 infant needs to take 30cc, or if Q4hours 40cc to\nmeet min. Today has been waking Q3-3.5 hours and\nhas taken 38cc and 30cc. Abdomen is soft and pink, AG\nstable, no loops, voiding and stooling. No spits.\nTolerating feeds well. Will continue to monitor closely for\nsigns or symptoms of feeding intol. Continue to encourage\nPO intake.\n\nG/D: Temps stable in servo isolette, temp weaned. Infant\nis nested in sheepskin. Active and alert w/ cares, moving\nall extremties, brings hands to face, sucks on pacifier at\ntimes. Waking Q3-3.5 hours. Will continue to support\ndevelomental needs.\n\nParenting: Mother and Father in today, participating in\ncares, holding and feeding infant. ASking appropriate\nquestions. Eager for baby to come home, discussed discharge\ncriteria with family. Discussed with also that\nsince infant is trialing Adlib PO feeds with min, that if\nshe does not meet the minimum amt that she will need an ngt\nagain. are loving and involved. Will continue to\nsupport and update family.\n\nHyperbili: Under triple phototherapy (High intensity\nneoblue and single light combined) current level 8.6/.3\nfrom this morning. will check level in am.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2164-08-11 00:00:00.000", "description": "Report", "row_id": 1828842, "text": "NPN 2300-0700\n\n\nFEN: BW 1715g CW 1615g (down 5g). TF 140cc/k/day PO\nSC24. Infant noted to be eager initially with feeds, then\ntires. PO intake notably less this shift than previously.\nWill monitor for need of NGT for supplementation. Pt woke\nQ4H and bottled 26-27cc each feed (40cc Q4H). Total 24H\nintake: 134cc/k. Abd benign. Voiding QS, stooling heme\nnegative. DS= 84.\n\nDEV: pt nested in off isolette. Isolette changed to\nairmode at 2400 due to removal of spot light photoRx (which\ngives off some heat). Pt temps stable. A/a with cares,\nwakes Q4H for feeds. Pt remains jittery. Boundries in\nplace. Likes pacifier, moves hands to face. , ,\nAGA.\n\nPAR: No contact with thus far this shift.\n\nBILI: Pt moved from triple photoRx to neoblue bank at 2300.\n Pt appears sl jaundiced, WP. Eye mask in place. Repeat\nbili sent: 7.0/0.2 (no change). Continue to monitor.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2164-08-11 00:00:00.000", "description": "Report", "row_id": 1828843, "text": "Neonatology Attending Progress Note\n\nNow day of life 6, CA 1/7 weeks.\nRR30-60s in RA.\nHR 150-180s BP 76/41 55\n\nWt. 1615gm down 5gm on ad feedings of SSC24 - though required a gavage tube this morning because of inability to take full volume.\nNormal urine and stool output.\n\nBili 7.0/0.2 - on phototherapy\n\nAssessment/plan:\nPremature infant with immature feeding skills.\nWill increase to 150ml/kg/d today.\n\n" }, { "category": "Nursing/other", "chartdate": "2164-08-10 00:00:00.000", "description": "Report", "row_id": 1828837, "text": "NPN\n\n\n#1 Min TF 140cc/k/d=40cc Q4hrs of SC24. Infant waking\nQ4hrs and taking 38-42cc. Infant took in 130cc/k/d x24hrs\nyesterday(infant had taken in 160cc/k/d the day before).\nAbd soft, +BS, no loops. AG 22-23cm. No spits. Voiding\nand stooling. Wt 1620(+20gms).\n\n#2 Infant nested on sheepskin in servo isolette. Infant\nactive and alert with cares. Waking Q4hrs for feedings.\nInfant settles nicely between cares.\n\n#3 No contact from overnight.\n\n#4 Infant remains under Neoblue+single phototherapy with\neye shields in place. Bili to be sent this am.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2164-08-10 00:00:00.000", "description": "Report", "row_id": 1828838, "text": "Neonatology Attending Note\nDay 5, PMA 34w\n\nRA. RR30-50s. Mild ic rtxns. No murmur. Pale/pink. HR 130-160s. BP 58/33, 43. Wt 1620, up 10 gms. PO ad , 140. SC24. Tol well. Nl voiding and stooling. In open crib.\n\nUnder photot.\n\nA/P:\nGrowing preterm infant with hyperbilirubinemia. Cont photot and follow bili levels. Cont CVR monitoring.\n" }, { "category": "Nursing/other", "chartdate": "2164-08-10 00:00:00.000", "description": "Report", "row_id": 1828839, "text": "PT/Rehab Services\nBaby born 33 adn gestation induced vaginal delivery severe pre-eclampsia. Apgars 8 and 9. Transferred to NICU for prematurity, on photo for increased bili.\nO: RN reporting disorganization and decreased state regulation c/w prematurity. Observed part of cares performed by RN. Baby active and frequent shaking/flailing of extremities. Responds well to firm boundaries.\nMet with mother and issued dev care handout and discussed dev care and role of therapy. She demonstrated good understanding of all education.\nA: Presentation c/w prematurity. Mother demonstrating good understanding of developmental care education. Will benefity from PT follow-up for developmental play and further parent education once appropriate.\nP: Follow up when ready for play plan.\n" }, { "category": "Nursing/other", "chartdate": "2164-08-08 00:00:00.000", "description": "Report", "row_id": 1828831, "text": "Neonatology Attending\n\nDay 3 PMA 33 wks\n\nRemains in RA. Clear breath sounds. No bradycardia. No murmur. HR 130-150s. BP mean 56. Bilirubin 9.1 on phototherapy. Weight 1600g (-20). TF at 120 ml/kg/d. Blood glucose 69. On BM/SC20- all po overnight. Stable temperature in incubator.\n\nDoing well. No evidence of breathing control immaturity. Monitoring. Will increase fluids to 140 ml/kg/d. Following bilirubin.\n\n" }, { "category": "Nursing/other", "chartdate": "2164-08-08 00:00:00.000", "description": "Report", "row_id": 1828832, "text": "NPN days\n\n\nFEN: TF 140cc/k/d of SC20. Abdomen is soft, pink, active\nbowel sounds, no loops, voiding and stooling\nmeconium/transitional stools. No spits, min residuals.\nInfant eagerly rooting prior to feedings, bottling well\ntaking full volumes (40cc Q4hours). No apnea/bradycardias\nw/ feeds, no choking, very well coordinated feeding.\nTolerating feeds well, all po feedings. Will continue to\noffer PO feeds by cues, and monitor closely for signs or\nsymptoms of feeding intolerance.\n\nG/D: Temps are stable in servo controlled isolette, nested\nin sheepskin while under phototherapy. Infant is active and\nalert with cares, moving all extremities, wakes and demands\nfeedings ~q4hours. Sleeps well between cares. Fontonelles\nare soft and flat. AGA. Will continue to support\ndevelopmental needs.\n\nParenting: Mother / Father and grandparents in today ,\nmother taking temp, changing diaper, and bottling infant.\nHandles infant well. Asking appropriate questions about\ninfants care/status. Loving and involved family. Will\ncontinue to support and update family.\n\nHyperbilirubinemia: Currently under triple phototherapy,\nlevel this am 9.1/0.4, plan to recheck bilirubin level\n in am.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2164-08-08 00:00:00.000", "description": "Report", "row_id": 1828833, "text": "NNP Physical Exam\nPE: pink, under phototherapy, breath sounds clear/equal with comfortable WOB, no murmur, abd soft, + bowel sounds, active with good tone.\n" }, { "category": "Nursing/other", "chartdate": "2164-08-09 00:00:00.000", "description": "Report", "row_id": 1828834, "text": "NPN\n\n\n#1 TF 140cc/k/d of SC20=40cc Q4hrs. Infant waking Q3\n1/2-4hrs for feedings and has been all PO tonight. Abd\nsoft, +BS, no loops. AG 22-23cm. No spits. DS 58.\nVoiding and stooling. Took in 162cc/k/d x24hrs yesterday.\nWt 1610(+10gms).\n\n#2 Infant nested on sheepskin in servo isolette with stable\ntemp. Infant active and alert with cares, irritable at\ntimes. She is waking early for feeds. She tends to be\njittery with cares. Sucks on pacifier.\n\n#3 No contact from overnight.\n\n#4 Infant remains under neoblue + single phototherapy with\neye shields in place. Bili sent this morning and results\nare pending.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2164-08-09 00:00:00.000", "description": "Report", "row_id": 1828835, "text": "Neonatology Attending\n\nDay 4 PMA 33 wks\n\nRemains in RA. RR 30-50s. No apnea. Clear breath sounds. Mild retractions. No murmur. HR 130-150s. BP mean 62. Weight 1610g (+10). TF at 140 ml/kg/d- SC. Taking 40-50 ml per feed. Feeding well. Took total of 162 ml/kg yesterday. Benign abdomen. Bilirubin 8.6 on phototherapy. Servo-controlled incubator with stable temperature. in and out.\n\nDoing well. Mature breathing control. Will continue to monitor closely. Remarkably good feeding. Ad lib schedule. Will place on 24 cal/oz feeds. Will repeat bilirubin tomorrow.\n\n" }, { "category": "Nursing/other", "chartdate": "2164-08-17 00:00:00.000", "description": "Report", "row_id": 1828875, "text": "NICU fellow PE note\nWell appearing premature infant in NAD, slleping in the open crib.\nVSS\nAFOF, MMM, nares patent, oropharing clear,\nRRR, no murmur, S1 and S2 normal\nCTA bilaterally, no g/f/r\nAbdomen soft NT/ND, no masses\nGU normal female.\nNeuro: appropriate for age, normal suck, swallow and tone.\n" }, { "category": "Nursing/other", "chartdate": "2164-08-17 00:00:00.000", "description": "Report", "row_id": 1828876, "text": "NPN 7A-7P\n\n\n#1 TF at 150cc/k/d, formula changed to Sim24 in preparation\nfor going home. Taking in , bottling 45-55cc's q 4hrs.\nVoiding and stooling. Abdominal exam unremarkable. Con't to\nassess wt on lower cal.\n\n#2 Passed car seat screen, maintaining temp in crib, waking\nfor feeds (sometimes early). Bottling all feeds, no brady's.\nCon't to monitor. To have hearing screen this\nafternoon/evening.\n\n#3 Mom in this afternoon for discharge teaching. Is very\nexcited to have infant going home tomorrow (if status\nremains unchanged). Reviewed Discharge Instruction Sheet, 24\ncal formula preparation, Fe dosing and administration, and\nmom will make pedi 't for Tues (VNA will visit ).\nMom will call in AM to check on status prior to coming in.\nCon't to support/inform.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2164-08-18 00:00:00.000", "description": "Report", "row_id": 1828877, "text": "PCA note 1900-0700\n\n\n1. FEN: TF 150cc/kg 24. New weight 1.840 kg up 70g. At\n bottled 50cc. At 00 bottled 50cc. Tolerating feeds\nwell; abdomen benign, good BS, no spits. Voiding and\nstooling heme negative. P: Continue to support nutritional\nneeds.\n\n2. G/D: Temps stable and swaddled in crib. and active\nwith cares. Wakes for feeds. MAE well. AFSF. AGA. Desitin\napplied to bottom. P: Continue to support developmental\nneeds.\n\n3. Parenting: in for feed. and involved.\nUpdated on infant's condition at bedside by RN. P: Continue\nto support and update .\n\n\n" }, { "category": "Nursing/other", "chartdate": "2164-08-18 00:00:00.000", "description": "Report", "row_id": 1828878, "text": "Have read and agree with note of PCA above. cont to do well with feeds and weight gain. will need hearing screen before DC. PKU done. A: stable P: cont plan for discharge later today.\n" }, { "category": "Nursing/other", "chartdate": "2164-08-18 00:00:00.000", "description": "Report", "row_id": 1828879, "text": "Neonatology Attending Note\nDay 13, 35 1\n\nRA. RR30-50s. Soft murmur. HR 130-150s. BP 75/36, 50. Wt 1840, up 70. PO ad , Sim24. Nl voiding and stooling. In open crib.\n\nPlan:\nWill proceed with plan for discharge to home. Please see dictation and bedside chart for further details.\nd/c t>30'.\n" }, { "category": "Nursing/other", "chartdate": "2164-08-18 00:00:00.000", "description": "Report", "row_id": 1828880, "text": "NICU nursing note\n\n\n1. FEN=O/Bottlefeeding very well-exceeding TF of\n150cc/k/d of Sim24. Waking Q3-4hrs. Abd benign. (Refer to\nflowsheet for assessments and po vols.) No spits.\nVoiding/stooling. Will cont on iron at home.\n\n2. G&D=O/Temp stable swaddled in open crib. and\nactive with cares. Sleeping well between feed. MAE. Font\nS/F. Passed hearing screen. AGA.\n\n3. Parent=O/ arrived at 1200. Independent with\ncares. Dishcharge teaching and paperwork completed.\n\nDischarge exam completed by Attending. Pedi appt scheduled\nfor tues, . VNA scheduled to visit . Baby \nhome in car seat with at 1310. (Please refer to\nAttending's note for further details.)\n\n\n" }, { "category": "Nursing/other", "chartdate": "2164-08-07 00:00:00.000", "description": "Report", "row_id": 1828826, "text": "Clinical Nutrition\nO:\n33 wk gestational age BG, AGA, now on DOL 2.\nBirth wt: 1715 g (~25th %Ile); current wt: 1620 g (-85)(down ~6% from birth wt)\nHC: 29.5 cm (~10th to 25th %Ile)\nLN: 43 cm (~25th to 50th %Ile)\nNutrition: Minimum 120 cc/kg/day, SSC 20. Infant taking all po feeds so far, although minimum was just increased. Projected minimum intake for next 24hrs ~80 kcal/kg/day, ~2.2 g pro/kg/day.\nGI: Abdomen benign. No spits. Passing meconium.\n\nA/Goals:\nTolerating feeds so far without GI problems, advancing slowly and monitoring closely for tolerance. All po feeds so far. Labs not needed. INitial goal for feeds is ~150 cc/kg/day SSC 24, providing ~120 kcal/kg/day and ~3.6 g pro/kg/day. Appropriate to start Fe supps when feeds reach initial goal. FUrther increases in feeds as per growth and tolerance. Growth goals after initial diuresis are ~15 to 20 g/kg/day for wt gain, ~0.5 to 1 cm/wk for HC gain, and ~1 cm/wk for LN gain. WIll follow w/ team and participate in nutrition plans.\n" }, { "category": "Nursing/other", "chartdate": "2164-08-07 00:00:00.000", "description": "Report", "row_id": 1828827, "text": "NPN 7a7p\n\n\nFen\nInfant on TF increased to 120 today. Po/PG SC20. Had bottled\nfull amts historicaly, but needed gavage tube with 2nd cares\ntoday after fluids increased. Infant tired out with bottle,\nunable to finish. understand it would not benefit\nher to push. Abd soft round with active BS. DS Voiding and\nmec stools. No loops or spits. Cont on present plan .\nMonitor weight and exam.\nG/D\nInfant in servo isolette, nested. Temps stable. A/A for\ncares. Very jittery when upset. Settles well between cares.\nMAEs. FS&F. AGA. Cont to monitor and support G/D.\nParenting\nBoth up for visit and cares. Experienced ,\nfairly independent with cares. Had family mtg today before\nMom dcd home. Asking appropriate questions. Mom \nupset leaving here without infant. Plan to be in for\ntomorrow cares. Will call for updates.\nBili\nInfant recieved under quad lights. Repeat bili this am\ndecreased some from 4 am. see careview. Bili blanket dcd.\nInfant presently under single spot and blue bank. Infant\njaundice. Eating,voiding, stooling and active. Monitor labs.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2164-08-07 00:00:00.000", "description": "Report", "row_id": 1828828, "text": "NNP On-Call\nPlease see Dr. note for overall summary and plan.\n\nPhysical Exam\nGeneral: infant in isolette, under phototherapy, room air\nSkin: warm and dry; color pink/jaundiced\nHEENT: anterior fontanel open, level; sutures opposed\nChest: breath sounds clear/=\nCV: RRR, no murmur; normal S1 S2; pulses +2\nAbd: soft; no masses; active bowel sounds; cord on/drying\nExt: moving all\nNeuro: jittery, no elicitable clonus at ankles; + suck; + grasps\n" }, { "category": "Nursing/other", "chartdate": "2164-08-07 00:00:00.000", "description": "Report", "row_id": 1828829, "text": "Family Meeting Note\nFamily Meeting held with , both and myself. course discussed and current clinical issues reviewed. Discharge criteria explained. Primary pediatrician identified. All parental questions answered. Checklist completed and placed in chart.\n" }, { "category": "Nursing/other", "chartdate": "2164-08-08 00:00:00.000", "description": "Report", "row_id": 1828830, "text": "#1 TF 120CC/KG OF SC20. PT PO FEEDING OVERNIGHT. BOTTLES\nWELL. ABD BENIGN. VOIDING AND STOOLING. WEIGHT DECREASE\n20GM.\n#3 TEMPS ARE STABLE NESTED IN SERVO ISO. ALERT AND ACTIVE.\nJITTERY, DSTIX 69 PRIOR TO FEEDING.\n#3 NO CONTACT FROM FAMILY THIS SHIFT.\n#4 PT CONT UNDER TRIPLE PHOTO. BILI SENT THIS A.M., PENDING.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2164-08-06 00:00:00.000", "description": "Report", "row_id": 1828820, "text": "SOCIAL WORK\nTouched base with parents this pm, and arranged for family meeting Tues, at 3pm. Parents appear to be managing well. Informed dad about reduced parking stickers.\nWill attend family meeting with note to follow.\n" }, { "category": "Nursing/other", "chartdate": "2164-08-06 00:00:00.000", "description": "Report", "row_id": 1828821, "text": "NPN Days\n\n4 hyperbilirubinemia\n\n#1 FEN- TF=100cc/kg/d of SC20. abd benign. weaned off IV\nfluids this shift and all po feeds. voiding, no stool so far\nthis shift. ag-22cm. no spits. d-stcik 89 and 83. P- Will\ncont to encourage po feeding and monitor FEN.\n#2 G&D- Temp stable in servo isolette. alert and active with\ncares. sleeps well b/w cares. tP- Will cont to monitor G&D.\n#3 Parenting- Parents and grandparents visiting this shift.\nMom held pt. Loving and caring towards pt. updates given.\nFamily meeting scheduled for tomorrow @ 2:45pm. P- Will cont\nto support and educate parents.\n#4 Hyperbili- Bili this am 14.9/0.4. repeat bili drawn\n9.6/0.3. Pt placed under triple phototherapy. type and\ncoombs sent. eye shields on. pt jaund. P- Will cont to\nmonitor hyperbili.\nSee flowsheet for further details.\n\nREVISIONS TO PATHWAY:\n\n 4 hyperbilirubinemia; added\n Start date: \n\n" }, { "category": "Nursing/other", "chartdate": "2164-08-07 00:00:00.000", "description": "Report", "row_id": 1828822, "text": "NPN (1900-0700)\nNPN addendum: Infant placed on bili blanket at 0615 in addition to triple PT already in place. Bili to be re-checked at 0800 as per M. St., NNP.\n" }, { "category": "Nursing/other", "chartdate": "2164-08-07 00:00:00.000", "description": "Report", "row_id": 1828823, "text": "NPN (1900-0700)\n\n\n1. F/N: Weight down 85gm to 1620. Tf's continue at\n100cc/kg/d of SC20. Infant has been able to take in\nadequate amounts by bottle. D/S 58 ac. Hep-lock in place.\nVdg 4.8cc//kg/hr over last 24 hours, passed first mec stool.\nAbd exam benign. Will continue to support po feeeding.\n\n2. Dev: Nested in servo control isolette, temp stable.\nJittery with stress, but settles with pacifier. AGA\nbehavior.\n\n3. Parenting: Mom and Dad in last evening, updated, Mom fed\ninfant...confidence increasing. Dad held. have\nmany questions, including potential length of stay. Family\nmeeting to be held this afternoon. may come up for\n0600 feeding.\n\n4. Bili: Bili this am up to 12.7/0.4, remains under triple\nphototherapy. Will continue to follow.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2164-08-07 00:00:00.000", "description": "Report", "row_id": 1828824, "text": "NPN (1900-0700)\nNPN addendum: Infant placed on bili blanket at 0615 in addition to triple PT already in place. Bili to be re-checked at 0800 as per M. St., NNP.\n" }, { "category": "Nursing/other", "chartdate": "2164-08-15 00:00:00.000", "description": "Report", "row_id": 1828863, "text": "Neo Attending Addendum\nDay 10, now 34.5 wk pma\nRR 30-60s,\nno bradys\nCV: hr 140-170s, no murmur, 65/33 bp\nwt; 1685 gm, up 20 gm\nSC26 all po I=162 cc/kg/day.\nabd wnl. stool wnl.\nbili resolved.\ntemp stable in open crib.\n involved.\nRx Fe\n\nAssessment: As noted before, clinically stable.\nPlan: Continue with same regimen and nutrition orders.\nIf good intake and wt gain, will begin to adjust caloric intake.\n\nPt examined and discussed with team.\n\n" }, { "category": "Nursing/other", "chartdate": "2164-08-16 00:00:00.000", "description": "Report", "row_id": 1828868, "text": "NPN 07p-07a\nI have examined this infant and agree with the above written note by , PCA. updated. Independent with feeding & diaper change. To be in later today. Cont. support & educate.\n" }, { "category": "Nursing/other", "chartdate": "2164-08-16 00:00:00.000", "description": "Report", "row_id": 1828869, "text": "Neo Attending\nDay 11, now 34.6 wk pma\nRespr: ra, no spells, rr=30-50s clear\ncv: no murmur, 150-160s, bp 62/30\nwt 1695, up 10 gm\nIntake = 170 cc/kg/day SC26 +Pro po all feeds.\nabd wnl, uop and stool wnl.\nOn Rx Fe\ntemp stable.\n\nAssessment: SGA premature infant now feeding all feeds po but with added protein and enhanced calories.\nPlan: If infant continues to po consistently well and gain wt, we will begin to reduce supplemental protein and caloric density within the next few days. Continue current regimen.\n\n" }, { "category": "Nursing/other", "chartdate": "2164-08-16 00:00:00.000", "description": "Report", "row_id": 1828870, "text": "NICU FELLOW PE NOTE\nGen- WD/WN F in NAD\nHEENT- NCAT, AFOF, nares patent, oropharynx clear, MMM\nCardiac- RRR, nl s1,s2, no murmur\nLungs- CTAB, no retractions\nAbdomen- +BS, mild distension\nExtrem- FROM x4\nNeuro- nl suck, nl grasp, nl suck\n" }, { "category": "Nursing/other", "chartdate": "2164-08-16 00:00:00.000", "description": "Report", "row_id": 1828871, "text": "NPN 7A-7P\n\n\n#1 Remains on SCF26 w/beneproteine, bottling all feeds well\nq 4hrs. Has been all bottles for almost 48hrs and taking in\n of 150cc/k/d. Plan to monitor wt, and possibly\ndiscontinue protein over next couple of days in preparation\nof discharge. Abdominal exam unremarkable, is voiding and\nstooling.\n\n#2 Maintaining temp, gaining wt on 26 cal w/protein. Waking\nfor feeds, is very and active, settling well\nafterward. Rec'd Hep B vaccine today. No brady's or desat's.\nCon't to assess for discharge readiness.\n\n#3 Mom called this AM and was updated on possible plan for\nD/C Sunday or Monday, depending on wt, continuance of\nfeeding stamina, and continued no brady's. Mom will be in\ntomorrow for teaching. Con't to update/support.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2164-08-17 00:00:00.000", "description": "Report", "row_id": 1828872, "text": "NPN 1900-0700\n\n\nFEN: Tolerating ad PO feeds well, no spits. Abdomen\nsoft/round, good bs, voiding, no stool thus far. Continues\non Iron.\n\nG/D: Temp stable swaddled in open crib. A&A w/cares, sleeps\nwell in between. Waking for all feeds, settles well with\ncontainment.\n\n: Mom in for first cares. Updated by this RN, asking\nappropriate questions. Becoming more independent with cares.\nDischarge teaching discussed for potential discharge of\ninfant this weekend.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2164-08-07 00:00:00.000", "description": "Report", "row_id": 1828825, "text": "Neonatology Attending\n\nDay 2 PMA 33 wks\n\nRemains in RA. RR 40-60s. Mild retractions. Clear breath sounds. No bradycardia. No murmur. HR 130-150s. Pink. BP mean 41. Bilirubin 10.7 under maximal phototherapy. Blood types O+/B+/DAT-. Blood glucose 55. Weight 1620 g (-85). TF at 100 ml/kg/d. On SC20. Taking all bottles. Passing meconium stool. Stable temperature in servo-controlled incubator. in.\n\nMature respiratory status. Monitoring. Feeding exceedlingly well. Will put on ad lib schedule with minimum daily volume of 120 ml/kg. Will recheck bilirubin tomorrow. Family meeting this afternoon.\n" }, { "category": "Nursing/other", "chartdate": "2164-08-14 00:00:00.000", "description": "Report", "row_id": 1828858, "text": "Nursing Note 0700-1900\n\n\n#1FEN: TF 150cc/kg/day of SC62 w/ beneprotein, Q 4 hrs\nPO/PG. Pt is well-coordinated and eager w/ PO's, but tires\neasily. Tolerating feedings, AG stable, asp, no spits so\nfar this shift. And benign. Pt voiding and stooling, guiac\nneg. Pt cont on her iron. Please refer to flow chart for PO\nvolumes and assessment.\n\n#2G/D: Temps remain stable, pt swaddled in weaning air\nisolette. Pt sometimes wakes for feedings. Remains and\nactive during cares. Settles and sleeps well in between care\ntimes. MAE. AFSF. Brings hands to mouth. P: cont to support\ndev needs.\n\n#3PAR: Mom and grandmother in for noontime cares. \nmother, asking questions. Participated in feeding and\ncares. Updates given. P: cont to support and update .\n\n#4Bili: Hyperbilirubinemia resolved.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2164-08-14 00:00:00.000", "description": "Report", "row_id": 1828859, "text": "4 hyperbilirubinemia\n\nREVISIONS TO PATHWAY:\n\n 4 hyperbilirubinemia; d/c'd\n\n" }, { "category": "Nursing/other", "chartdate": "2164-08-15 00:00:00.000", "description": "Report", "row_id": 1828864, "text": "CLinical Nutrition\nO:\n~34 wk CGA BG on DOL 10.\nWT: 1685 g (+20)(~10th to 25th %Ile); birth wt: 1715 g. WT currently down ~2% from birth wt\nHC: 30 cm (~10th to 25th %Ile); last: 29.5 cm\nLN: 43.5 cm (~25th %Ile); last: 43 cm\nMeds include Fe\nLabs not due yet\nNutrition: 150 minimum SSC26 w/ beneprotein, all po since midnight. Projected minimum intake for next 24hrs ~130 kcal/kg/day and ~4.1 g pro/kg/day.\nGI: Abdomen benign.\n\nA/Goals:\nTolerating feeds without GI problems. TAking all po feeds overnight; will monitor intake closely. Labs not due yet. CUrrent feeds + supps meeting recs for kcals/pro/vits and mins. Growth is meeting recs for HC gain. Wt gain and LN gain should improve now that feeds are meeting recs. WIll continue to follow w/ team and participate in nutrition plans.\n" }, { "category": "Nursing/other", "chartdate": "2164-08-15 00:00:00.000", "description": "Report", "row_id": 1828865, "text": "NICU FELLOW PE NOTE\nGen- WD/WN F in NAD\nHEENT- NCAT, AFOF, nares patent, oropharynx clear, MMM\nCardiac- RRR, nl s1,s2, no murmur appreciated\nLungs- CTAB, no retractions\nAbdomen- +BS, soft, ND, no mass\nExtrem- FROM x4\nSkin- mottled, no rash\nNeuro- nl tone, nl suck, nl grasp\n" }, { "category": "Nursing/other", "chartdate": "2164-08-15 00:00:00.000", "description": "Report", "row_id": 1828866, "text": "NPN \n\n\n\n #1. TF 150cc/k SC 26 w/BP (44cc q4h). She has cont on po\nfeeds. Taking more than req. (55cc each feed.) Abd benign.\nNo spits. V+S heme neg. A: Tol current feeding plan. Gaining\nwt. P: Cont to support nutritional needs.\n\n #2. Temp stable swaddled in OC. Wakes for feeds.\nCoordinated w/bottling. AFSF MAEW. A: AGA P: cont to support\nG+D.\n\n #3. Mom called x1. Updated over the phone. Will try and\nvisit sometime today, depending on big brother's schedule.\nA: Involved . P: cont support, keep updated and\neducate.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2164-08-16 00:00:00.000", "description": "Report", "row_id": 1828867, "text": "PCA Progress Note 7900-700\n\n\n#1 FEN: New weight 1695g up 10g. TF 150cc/kg/day of SC26\nwith BeneProtein (44cc q4hrs). 24hr intake of 173cc/kg. All\nPOs. Infant feeding 45-60cc with each feed. Coordinated with\nbottling. Abd benign, girth 23, no loops, +BS. Voiding. No\nstools so far this shift. No spits. Tolerating feeds.\nContinue to follow nutritional plan.\n\n#2 DEV: Stable temps swaddled in OAC. Brings hands to face.\nMAE. AFSF. and active with cares, sleeping well\nbetween. AGA. Continue to support developmental needs.\n\n#3 : Both in for cares. Independent with\ncares, asking appropriate questions. Mom wants to give\ninfant bath tomorrow. Updated at bedside by RN. Very \ntowards daughter. Continue to update and support .\n\nSee flowsheet for further details.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2164-08-17 00:00:00.000", "description": "Report", "row_id": 1828873, "text": "Neonatology Attending\n\nDay 12 PMA 35 0/7 wks\n\nRemains in RA. Sats > 98%. Pink. No murmur. No bradycardia. BP mean 47. Weight 1770g (+75). TF at 150 cc/kg/d. Took 168 ml/kg/d SC 26 with Beneprotein. Stable temperature. Received hepatitis B vaccine.\n\nMature breathing control. Much improved feeding with all po feeds for the last 3 days. Final discharge teaching underway. Will do car seat position study and check hearing screen. Hope to send home tomorrow- will determine discharge formula preparation. Will contact pediatrician today and complete discharge summary.\n\n" }, { "category": "Nursing/other", "chartdate": "2164-08-17 00:00:00.000", "description": "Report", "row_id": 1828874, "text": "Neonatology Attending\n\nWill discharge home on 24.\n\n" }, { "category": "Nursing/other", "chartdate": "2164-08-13 00:00:00.000", "description": "Report", "row_id": 1828854, "text": "0700- PCA Prgoress Note\n\n\nFEN:\nO: TF 150cc/kg/day SSC26 =43cc Q4 hours. Infant bottled 3-12\ncc this shift. The last feed was gavaged over 1 hour.\nAbdomenal exam is benign, +BS. Infant had a max aspirate\n11.0 cc, RN and NNP aware. Partially digested, nonbilious\nrefed and subtracted from feed NNP. Infant had aspirate\nof 6.0cc of partially digested, nonbilious formula. Refed\nand subtracted from feed RN. At last care infant had an\naspirate of .8cc. No spits. AG stable. Infant\nvoiding/stooling heme negative this shift. Continues on\niron. A: Infant had large aspirates, tolerating feeds at\nthis time. P: Continue to monitor and support nutritional\nneeds.\n\nDEV:\nO: Infant remains swaddled in air isolette (weaned x2)\nmaintaining stable temps. Fontanels are soft and flat, MAE.\nInfant wakes for some cares, alert anda ctive throughout.\nSleeps well between cares with boundaries. Enjoys pacifier,\nbrings hands to face. A: AGA. P: Continue to support\ndevelopmental needs.\n\n:\nO: Mom came in briefly between cares and held infant.\nUpdated by this PCA and RN. Mom plans to come in for \ncare time. A: Loving family. P: Continue to support, update\nand teach.\n\nBILI:\nO: Photo therapy remains off at this time. A: Infant appears\nto be pale pink in color. P: Plan for bili in the am.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2164-08-13 00:00:00.000", "description": "Report", "row_id": 1828855, "text": "0700- PCA Prgoress Note\nAddendum to above: I have examined this infant and agree with the above note by . Mother updated at bedside. Plans to be in tonight at 8p feeding. Will continue to update and support.\n" }, { "category": "Nursing/other", "chartdate": "2164-08-14 00:00:00.000", "description": "Report", "row_id": 1828856, "text": "NICU NPN 1900-0700\n\n\nFEN O: Weight 1665g, down 5g. Tolerating po/pg feeds of sc\n26 well. Abdomen is soft, round, bs are active, voiding and\nstooling, no spits, minimal ngt aspirates.\n\nDEV O: Temps are stable, swaddled in low air isolette. baby\nis and active with cares, sleeps well in between\ncares, takes pacifier for comfort. Fontanells are soft and\nflat.\n\nParenting O: Mom and dad in for cares.\n\nBili O: Rebound bili 5.5/0.3 this am.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2164-08-14 00:00:00.000", "description": "Report", "row_id": 1828860, "text": "NNP On-Call\nPhysical Exam\nGeneral: infant in isolette, room air\nSkin: warm and dry; color pink\nHEENT: anterior fontanel open, level; sutures opposed\nCHest: breath sounds clear/=\nCV:RRR, no murmur; normal S1 S2; pulses +2\nABd: soft; no masses; + bowel sounds\nExt: moving all\nNeuro: appropriate tone and reflexes\n" }, { "category": "Nursing/other", "chartdate": "2164-08-15 00:00:00.000", "description": "Report", "row_id": 1828861, "text": "1: npn 1900-0700\n\n\n1: fen\ncurrent weight 1685gms up 20. total fluids remain at\n150cc/kilo/day of sc 26 with beneprotein = 43cc's q 4 hours.\n. infant tolerating feeds well. taking all po feeds. infant\ntaking 50cc with each feeding. infant abd exam benign.\nvoiding and stooling. stool hem negative. no spits. minimal\naspirates. infant pulled ngt out with last feeding. remains\nout as of this time. continue to encurage po feeds.\n\n2: growth and development:\ntemps stable in an off isolette. and active with\ncares. sleeps well inbetween. brings hands to face. sucks\nvigorously on pacifier. aga. continue to monitor for\ndevelopmental milestones.\n\n3: :\nmom,dad, and brother in for visit. and\ninvested. asking appropriate questions. updated by this rn.\nmom and dad held infant and participated in care. continue\nto support while infant in the nicu environment.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2164-08-15 00:00:00.000", "description": "Report", "row_id": 1828862, "text": "Neo Attending\nGA 33.2 wk\nday 9, now 34.5 wk pma\n\nPremature issues:\nbili: off photoRx. Bili rebound yesterday was stable. 5.5/0.3.\nRespr: always RA, nl rr, clear=bs. regular rhythm.\nCV: no murmur, heart sounds wnl. pink, premie vaso-mottling appearance.\nNutrition: PO/PG, SC26+Beneprotein. On 150 cc/kg/day.\ntemp stable in crib.\nabd wnl. uop and stool wnl. be developing monilial rash around perianal area (two erythematous spots.)\n, active, healthy appearing.\n\nStatus:Stable premature infant. Learning to feed. Possible evolving moniliat perianal rash.\n\nPlan: Continue current regimen. Monitor perianal area and treat accordingly.\n\nPt examined and discussed with team.\n" } ]

[ { "category": "Nursing/other", "chartdate": "2177-09-27 00:00:00.000", "description": "Report", "row_id": 1559999, "text": "nursing progress note 7p-7a\nS: \"THEY TOOK OFF ALOT OF FLUID\"\n\nO: NEURO: PT. AND ORIENTED X3. SLIGHTLY ANXIOUS AT TIMES CONCERNING MEDS, INSULIN, BP. GIVEN TRAZADONE FOR SLEEP. SLEPT IN LONG NAPS OVERNIGHT. TAKING OWN MEDS WITH RN SUPERVISION. MOVING ALL EXTREMITIES. OOB TO BATHROOM, GAIT STEADY. ANXIOUS FOR D/C HOME.\n\nCV: BP STABLE 130-140/ 70'S CONT ON LOPRESSOR AND HYDRALAZINE. DENIES C/O CP. DR. IN TO SEE PT. LATE LAST EVE. PLAN TO D/C HOME AND TO RETURN TO OUTPT. CLINIC FOR NATRECOR INFUSION. PT. AGREEABLE TO OUTPT. TREATMENT. HR 78 VPACED. LOWER EXTREMITY EDEMA 2+.\n\nRESP: OFF O2. O2 SAT 98%. DENIES C/O SOB. LUNGS CLEAR.\n\nGU: OOB TO BR, VOIDING IN TOILET. I/O (-) 14L LOS.\n\nGI: APPETITE EXCELLENT. + BOWEL SOUNDS. NO BM\n\nENDO: SUGARS ELEVATED. 2200 317, REFUSED SSRI COVERAGE. RECEIVED 50 UNITS NPH PER PT. REQUEST.\n\nA: STABLE NOC. S/P CHF ULTRAFILTRATION\n\nP: PLAN D/C HOME THIS AFTERNOON, TO RETURN TO CLINIC ON TUESDAY FOR NATRECOR INFUSION\n" }, { "category": "Nursing/other", "chartdate": "2177-09-24 00:00:00.000", "description": "Report", "row_id": 1559992, "text": "CCU NSG ADMIT\nPlease see FHPA for allergy and PMH\n\nPt w/ decompensated heart failure admitted directly from home for ultrafiltration.\nPt arrived ~ 1600 in NAD\nhr 75-80 a paced, bp 140/75,\nno c/o SOB, SATS 88-95% on RA, lungs w/ basilar crackles.\nabd soft, obese.\nDTV, bun/cr 75/3.6\nafebrile\nbs 80\n, oriented, pleasant, cooperative w/ care.\nA: elective admission for ultrafiltration\nP: place catheter, initiate ultrafiltration. monitor bs, resp status, emotional support to pt.\n" }, { "category": "Nursing/other", "chartdate": "2177-09-25 00:00:00.000", "description": "Report", "row_id": 1559993, "text": "RESP CARE\nPt placed on bipap 10/5 with 4l o2. Pt using his own full face mask and tubing. O2 inc to 6l due to sats to 89%. Will cont to follow.\n" }, { "category": "Nursing/other", "chartdate": "2177-09-25 00:00:00.000", "description": "Report", "row_id": 1559994, "text": "CCU Nursing Progress Note 7p-7a\nS: \" Is it okay for me to sit up?\"\n\nO: Please see careview for complete VS/additional objective data\n\nMS: AAOx3. Pleasant and cooperative. Pt denies pain. Pt taking own meds w/ the exception of prn meds and insulin NPH. Pt given Trazadone HCL 50mg x1 w/ gd effect.\n\nCV: Vpaced/ NSR. DDD PPM placed . Pt denies CP. HR 59-77. No ectopy. NIBP 136-165/65-86. Pt took pm dose Nifedical XL but Norvasc was held per HO. Pt was given 10 mg IV Hydralazine for SBP>160. Pt SBP remains labile 140-160s remainder of noc. Heparin gtt started at 1000 units/hr. PTT this am subtherapeutic at 43.7. Goal rate 50-70. Pt was given additional 2500 unit bolus as well as an increased in infusion rate by 250u/hr to 1250 units/hr. HCT last pm 28.2. Pt is anemic at baseline and receives EPO per HO. Repeat this am 29.0. No acute ACS so transfusion was held overnoc.\n\nResp: Bibasilar crackles upon auscultation. Pt denies SOB. Pt resistent to use of NC. O2 sats on RA 88-90%. Encouraged pt to utilize face tent. Sats improved to 94%. BIPAP used at home which was applied overnoc for sleep apnea. O2 sats initially 94% but noted to be 90% in middle of noc. ^ O2 to 6L and sats 96-100% overnoc. RR 12-25.\n\nGI/GU: Abd obese. +BS. Tolerating po meds/ clr liquids and Italian ice w/o difficulty. No stool. Pt voiding via urinal w/o difficulty. Pt is receiving ultrafiltration via CHF solutions. Initially, 500 cc were removed for two hours then ultrafiltration rate was decreased to 300cc/hr for remainder of noc. Between UO and ultrafiltration pt is currently -3L.\n\nID: Afebrile. No abx.\n\nEndo: IDDM. Receives NPH doses q am and q pm. BS last pm 128. Per pt's at home sliding scale pt instructed RN that dose would be 43U NPH.\n\nSkin: No breakdown noted on back. Dry skin bilaterally on LE. Significant peripheral edema w/ blistering noted. Two areas of blisters/ulcers dressed w/ adaptic and DSD. Sm amt of drainage noted. Cont to follow.\n\nA/P: Significant CHF. Electively admitted for ultrafiltration for decompensated heart failure. Successful removal of fluid overnoc. Hypertensive overnoc. Cont current regimen of filtration while SBP remains elevated. Cont po antihypertensives and address need for prn as indicated. Cont to follow strict I/Os and weights. Ptt therapeutic. Increased infusion per sliding scale. Recheck PTT at 1300. Recheck electrolytes/CBC at that time. Ambulate pt to chair as tolerated. Encourage po intake. Cont to support pt and family as indicated.\n" }, { "category": "Nursing/other", "chartdate": "2177-09-25 00:00:00.000", "description": "Report", "row_id": 1559995, "text": "Neuro: Pt and oriented X3. PERRL. Moves all extremities and equal strength. Tongue midline and speech clear.\n\nCV: HR sinus paced with BBB, 60-90. Some PVC'c present. BP stable HCTZ started on a daily dose. SBP 130-150. Pt denies chest pain, lightheadedness or dizziness. Continues on CHF solutions and tolerating well. Pulling off 300-400cc/hr MD orders. Lower extremities decreased edema 1+ edema. Pt still SOB with ambulation and movement but pt states he has less SOB than yesterday. Removed roughly 7L per CHF solutions machine today so far.\n\nRESP: Pt uses Bipap when sleeping at home and was used last night. On RA oxygen saturation 92-97%. Pt denies SOB at rest. RR 10-24. No sputum production or cough.\n\nGI: Abdomen distended soft. Positive BS in all four quadrants. Tolerating diet well.\n\nGU: Pt urinating roughly Q6 hrs. Urinated 1500 of clear amber urine.\nCreatine 3.6. PCP was here today and states that creatine has been in the 3 range and rising the past few months.\n\nEndocrine: BS all over the place. This am 61-83 pt wanted to hold insulin this am and took his 43 units of 70/30 at 1200. BS the rest of the day were in the low 200's but pt refused insulin at this time due to the peaks of the insulin he has taken. Pt seems educated on own endocrine system, and medications. clininc to be consulted to evaluate and form plan for better diabetic contorl.\n\nSkin: Lower extremities less swelling some reddness and a few open areas on bilateral legs due to fluid blisters that popped yesterday. Dressings dry and . No other skin breakdown.\n\nA/P: Will continue with CHF diuresis on CHF solutions machine. Goal at least 10L will closely monitor pt's response to diuresis. Watch closely for signs of hypovolemia, hypervolemia. Watch urine output and renal functions closely. Monior BS as ordered and watch for signs and symptoms of hyper/hypo glycemia. Wife in today and updated on pt status and plan.\n\n" }, { "category": "Nursing/other", "chartdate": "2177-09-26 00:00:00.000", "description": "Report", "row_id": 1559996, "text": "CCU Nursing Progress Note 7p-7a\nS: \"Have you ever experienced this pain before?\"\n\nO: Please see careview for complete VS/additional objective data\n\nMS: AAOx3. Pleasant and cooperative. PEARL. MAE. Pt able to change position and ambulate w/out assistance. Pt denied discomfort until 0300 when pt awoke w/ left leg calf pain. Pt stood at side of bed and then encourage to sit dangling legs w/ improved effect. No analgesic administered. Pt taking own meds from home which are located at bedside in canvas bag with the exception of prn meds and insulin. Pt cont on Nortriptyline and Gabapentin as ordered. Trazadone 50 mg given w/ moderate effect.\n\nCV: VSS. Apaced w/ HR 60-68. No VEA. NBP 134-156/54-76. MAPs>85. Pt cont on at home regimen of Zetia and Metoprolol XL. Pt has been started on Hydralazine po every 6 hours for ^BP. Norvasc and Nifedipine dc'd during hospitalization. Pt cont on Heparin gtt. Received pt w/ infusion set at 1300 units/hr. PTT at 2100 returned at 125.5. Goal rate during ultrafiltration is 50-70. Held Heparin gtt x 1hr and decreased by 500 units to 800units per sliding scale. Resent PTT in the interim which returned at 141. Next Ptt due at 0700.\n\nResp: Pt denies SOB. He states that breathing feels better. RR 13-19. ^ while off all supplemental O2. Pt was placed on BIPAP at 00 for sleep apnea. RR decreased to 13 bpm and O2 sats improved to 97-100%. O2 sats 89-93% on RA. Bibasilar crackles auscultated in bases. CXR reveals mild CHF.\n\nGI/GU: Abd soft. +BS. No stool. Awaiting orders for bowel meds. Tolerating po meds/ liquids w/out difficulty. Good appetite per report. Pt voiding lg amounts of cyu q 6-8 hrs via urinal. Ultrafiltration continues at 300cc per hour. Pt is currently -2.3L for 24hrs and remains -9.8L for LOS. Goal is 10L per Dr. .\n^ Cr past few months per PCP. ? secondary to hypoperfusion vs DM. Renal team consulted and felt that CRF is secondary to DM neuropathy. The renal team had a lengthy conversation w/ pt about probable need for HD/PD in the near future. Pt very fearful of such treatment and not open to this treatment at this time.\n\nID: Afebrile. No abx regimen\n\nEndo: Pt well educated on management of insulin. BS remain labile during hospitalization. consulted and plan to address today. Pt receives 70/30 on days based on sliding scale and NPH at noc based on scale. BS 340 at 2300. Per pt request given 43 units NPH. (Less was given since pt BS decreased to 60-80 this past am w/ same dose). At home diuretic regimen currently on hold per HO.\n\nSkin: Peripheral edema markedly improved. DSD applied to blisters opened up prior to admission r/t fluid overload. Lower legs also very dry but hasn't taken prescribed skin ointment since he was told that his legs didn't need to retain any additional moisture. Pt cont to have gloves on for mgmt of Raynauds.\n\nA/P: Electively admitted for ultrafiltration for decompensated heart failure. Pt has effectively been on CHF solution treatment for over 33hrs and is almost at goal fluid status of 10L negative. ? c\n" }, { "category": "Nursing/other", "chartdate": "2177-09-26 00:00:00.000", "description": "Report", "row_id": 1559997, "text": "CCU Nursing Progress Note 7p-7a\n(Continued)\nontinuing ultrafiltration as long as pt remains slightly hypertensive. Cont to follow PTT and adjust per sliding scale as indicated. Awaiting orders from HO for bowel meds and cont Epogen injections for anemia while hospitalized. Renal consulted ? CRF secondary to DM neuropathy. Cont to follow. ? future need for PD/HD. Awaiting consult for labile sugars while hospitalized. Cont to support pt and family as indicated.\n" }, { "category": "Nursing/other", "chartdate": "2177-09-26 00:00:00.000", "description": "Report", "row_id": 1559998, "text": "Nursing Progress Note\n\nS: \" How much fluid has been taken off so far?\"\n\nO: Please see flow sheet for objective data. Tele remains V paced. SBP>120 throughout the day. Hemodynamically tolerating UF well. Conts on hydralzine 10mg Q 6hrs.\n\nResp: Lungs clear with few scattered rales. O2 sat 94-98% on RA. BIPAP off since early this am. Denies shortness of breath.\n\nNeuro: Pt is and oriented. Able to MAE. Voicing concerns over how much fluid is going to be removed. Refusing to be started on Natrecor. Pt has spoken with Dr regarding POC. Pt conts to take his own meds with nursing staff present.\n\nGU/GI: Pt tolerating diet well. Abd is soft with bowel sounds present. UF at rate of 300/hr until 1pm. Rate decreased to 200/hr d/t rise in Creat to 4.2. Dr called asking that UF be stopped d/t possible over diuresis. UF dc'd at 5pm Repeat creat still pending. Pt is neg 13,000 cc LOS. Pt conts to void large amts of clear yellow urine several times a day.\n\nEndo: Conts on Fixed dose of insulin . Better control of bld sugar today. No need for SS coverage.\n\nA&P: 59 yo man admitted to CCU on for UF. RSC line placed and UF successfully removed 13 liters of fluid. Hemodynamics stable. Stopped UF d/t increase in creat. Recheck labs. Hold diuretics tonite. Possible dc home late tomorrow.\n\n\n" }, { "category": "Radiology", "chartdate": "2177-09-24 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 842568, "text": " 7:54 PM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate right SC line, r/o PTX\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59 year old man with CHF here for ultrafiltration\n REASON FOR THIS EXAMINATION:\n evaluate right SC line, r/o PTX\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: CHF; evaluate for right subclavian line; rule/out pneumothorax.\n\n COMPARISON: .\n\n TECHNIQUE: Single AP portable upright chest.\n\n FINDINGS: A right subclavian line is in place, with tip crossing the midline\n and terminating in the left upper mediastinum. A left-sided pacemaker is in\n unchanged position, with dual electrodes. The electrode leads also course to\n the left of the mediastinum. These findings are suggestive of a left-sided\n SVC. The heart size and mediastinal contours are unchanged, with mild\n cardiomegaly. There is bibasilar atelectasis and a small right pleural\n effusion. The left costophrenic angle is excluded from the radiograph.\n Minimal haziness of the interstitial markings, consistent with mild congestive\n heart failure. The osseous structures appear unchanged. No pneumothorax.\n IMPRESSION\n\n 1. Right subclavian venous access catheter with tip terminating in the upper\n portion of a left-sided SVC. No pneumothorax.\n\n 2. Mild cardiomegaly and mild congestive heart failure, slightly improved.\n Small right pleural effusion.\n\n 3. Bibasilar atelectasis.\n\n\n\n" }, { "category": "ECG", "chartdate": "2177-09-25 00:00:00.000", "description": "Report", "row_id": 142970, "text": "Sinus rhythm. First degree A-V delay. Left atrial abnormality. Left\nbundle-branch block. Since the previous tracing of atrial pacing is not\nevident.\n\n" } ]

[ { "category": "Echo", "chartdate": "2201-02-17 00:00:00.000", "description": "Report", "row_id": 96045, "text": "PATIENT/TEST INFORMATION:\nIndication: Aortic valve disease.\nHeight: (in) 63\nWeight (lb): 169\nBSA (m2): 1.80 m2\nBP (mm Hg): 88/57\nHR (bpm): 92\nStatus: Outpatient\nDate/Time: at 16:13\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 report of the prior study (tape not available)\nof .\n\n\nLEFT ATRIUM: Mild LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.\n\nLEFT VENTRICLE: Wall thickness and cavity dimensions were obtained from 2D\nimages. Normal LV wall thickness, cavity size, and systolic function\n(LVEF>55%). Suboptimal technical quality, a focal LV wall motion abnormality\ncannot be fully excluded.\n\nRIGHT VENTRICLE: RV not well seen. Normal RV chamber size. Paradoxic septal\nmotion consistent with prior cardiac surgery.\n\nAORTA: Mildly dilated aortic root. Normal ascending aorta diameter.\n\nAORTIC VALVE: Mechanical aortic valve prosthesis (AVR). Normal AVR gradient.\nTrace AR. [The amount of AR is normal for this AVR.]\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Mitral valve\nannuloplasty ring. Mild mitral annular calcification. Mnimally increased\ngradient consistent with trivial MS. MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Moderate [2+] TR. Moderate\nPA systolic hypertension.\n\nPERICARDIUM: Trivial/physiologic 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.\nCardiology fellow involved with the patient's care was notified by telephone.\n\nConclusions:\nThe left atrium is mildly dilated. Left ventricular wall thickness, cavity\nsize, and systolic function are normal (LVEF>50%). Due to suboptimal technical\nquality, a focal wall motion abnormality cannot be fully excluded. Right\nventricular chamber size is grossly normal. Free wall motion could not be\nassessed. The aortic root is mildly dilated. A mechanical aortic valve\nprosthesis is present. The transaortic gradient is normal for this prosthesis.\nTrace aortic regurgitation is seen. [The amount of regurgitation present is\nnormal for this prosthetic aortic valve.] The mitral valve leaflets are mildly\nthickened. A mitral valve annuloplasty ring is present. There is a minimally\nincreased gradient consistent with trivial mitral stenosis. No mitral\nregurgitation is seen. Moderate [2+] tricuspid regurgitation is seen. There is\nmoderate pulmonary artery systolic hypertension. There is a\ntrivial/physiologic pericardial effusion.\n\nCompared with the report of the prior study (tape unavailable for review) of\n, moderate pulmonary artery systolic hypertension is now identified\n(not quantified on the prior report, but the severity of tricuspid\nregurgitation is unchanged - moderate).\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": "ECG", "chartdate": "2201-02-16 00:00:00.000", "description": "Report", "row_id": 259358, "text": "Sinus tachycardia\nRight bundle branch block\nSince previous tracing, right bundle branch block is complete\n\n" }, { "category": "Nursing/other", "chartdate": "2201-02-17 00:00:00.000", "description": "Report", "row_id": 1412604, "text": "MICU/SICU Nursing acceptance\n54yo F with significant PMH admitted throuhg the Ew 2 days ago s/p fall transferred to ICU today after becoming acutely hypotensive requiring 2L crystalloid volume resuscitation.\n\nROS:\n\n\nNeuro: Pt is A&Ox3, MAEW, denies pain at present\n\nPulm: LS diminished, SpO2 95% RA\n\nCV: VSS on arrival to ICU, please see flowsheet\n\nInteg: C/W/D/I\n\nGI/GU: abd softly distended, BS present, FOley patent for clear yellow urine\n\nLines: right femoral TLCL, #20 angio RLA\n\nPlan: r/o UGIB by NG lavage, transfuse to keep Hct > 28, monitor hemodynamic status\n\n\n" }, { "category": "Nursing/other", "chartdate": "2201-02-18 00:00:00.000", "description": "Report", "row_id": 1412605, "text": "NPN 1900-0700\nGeneral: 54 y/o to ER after a fall followed with inability to amb., hx CAD, MVR, AVR on coumandin, transferred to flr where she had hypotn. and HCT drop, ransferred to MICU for observationa and transfusion. Attempted transfusion of 1st unit of bld at 2215, pt temp increased to 103, no other s/s, bld transfusion stopped, team notified, remaining bld. sent to lab for analysis. Given a second 1unit of PRBC's with no s/s of transfusion rxn. Cortisol level drawn.\n\nNeuro: A&O x 3, no c/o pain, follows commands appropriately, answers questions appropriately, MAE in bed.\n\nResp: Lungs Diminished to Coarse A&P chest, RR 16-20, O2@2L NC intact, O2 sats 94-100%.\n\nCV: HR 99-118 ST no ectopy, BP 98-127/30-60's, 1+ edema to lower exremities, pedal pulses palpable bilat. Temps 99-103, started on Levaquin d/t MVR and risk of sepsis.\n\nGI: BS (+) x 4 quad., no bm, abd softly distended.\n\nGU: Foley intact draining adequate amts of clear light yellow urine.\n\nSkin: W/D/I. scant amt of bld drying to R groin CVL.\n\nSocial: Dauther and Sister called and aware of current medical mgt.\n\nPlan: Continue to follw HCT, monitor VS.\n\n\n" } ]

[ { "category": "Radiology", "chartdate": "2105-09-18 00:00:00.000", "description": "SEL CATH 3RD ORDER THOR", "row_id": 769918, "text": " 10:32 AM\n CAROT/CEREB Clip # \n Reason: HEADACHES\n Contrast: OPTIRAY Amt: 52\n ********************************* CPT Codes ********************************\n * SEL CATH 3RD ORDER SEL CATH 2ND ORDER *\n * -59 DISTINCT PROCEDURAL SERVICE ADD'L 2ND/3RD ORDER *\n * CAROTID/CEREBRAL BILAT CAROTID/CEREBRAL BILAT *\n * VERT/CAROTID A-GRAM EXT UNILAT A-GRAM *\n * -52 REDUCED SERVICES *\n ****************************************************************************\n ______________________________________________________________________________\n FINAL REPORT (REVISED)\n PREOPERATIVE DIAGNOSIS: Subarachnoid hemorrhage with a previous angiogram\n which revealed two small irregularities at the level of the left internal\n carotid artery in the supraclinoid segment. This angiogram is being performed\n as a follow-up procedure prior to considering discharge of the patient.\n\n POSTOPERATIVE DIAGNOSIS: Interval rapid growth of the two small aneurysmal\n dilatations of the left supraclinoid segment into full-fledged aneurysms of\n that same location measuring for the proximal one 3 mm and for the distal one\n approximately 4 mm in widest dimension. No evidence of other intracranial\n aneurysm.\n\n ANESTHESIA: Conscious sedation and local infiltration of the right groin\n using lidocaine and administration of Versed and fentanyl in divided doses\n during the entirety of the procedure.\n\n INDICATION: This patient suffered a sudden onset of headache approximately\n ten days prior to this angiogram. An angiogram performed six days prior\n revealed no frank aneurysmal dome but suggested a possible site of irregular\n contour at the left supraclinoid internal carotid artery. This angiogram is\n being performed to follow up on these lesions and to determine whether the\n initial angiogram may have missed any potential thrombosed rupture sites.\n\n Consent was obtained from the patient and her mother after explanation of the\n details of the procedure including the risks, benefits and possible\n complications.\n\n PROCEDURE IN DETAIL: The patient was brought into the Endovascular Suite and\n placed on the table in supine position. The right and left groin areas were\n prepped and draped in the usual sterile fashion and 4-French vascular sheath\n was inserted into the right common femoral artery and kept on a heparinized\n saline flush. At this point, a 4-French dialysis catheter was used to\n selectively catheterize the following vessels in succession: right common\n carotid artery, right internal carotid artery, right subclavian artery then\n right vertebral artery then left common carotid artery, then left internal\n carotid artery. With the catheter in each of these positions, a series of\n biplane and three-dimensional rotational angiograms was performed in various\n projections. At this point, the catheter was withdrawn from the patient and\n the vascular sheath was removed and hemostasis was achieved using application\n of a Syvek patch with manual compression.\n\n (Over)\n\n 10:32 AM\n CAROT/CEREB Clip # \n Reason: HEADACHES\n Contrast: OPTIRAY Amt: 52\n ______________________________________________________________________________\n FINAL REPORT (REVISED)\n (Cont)\n RESULTS: Injection of the right and left common carotid artery reveals no\n evidence of stenosis or disease at the bifurcation. Injection of the right\n internal carotid artery reveals no evidence of intracranial aneurysm or\n arteriovenous malformation and shows it to lack a sizable anterior cerebral\n artery segment. Injection of the left internal carotid artery reveals that\n the previously noted irregularities in the contour of the left internal\n carotid artery segment have blossomed and grown rapidly now into a 3 and a 4\n mm aneurysm in the appearance of a camel hump which are pointing medially.\n This finding is consistent with a blister-type aneurysm of the anterior wall\n of the internal carotid artery and has been previously reported to be a highly\n unstable lesion. Accordingly, recommendation is to proceed with urgent\n craniotomy for clipping of this aneurysm. Injection of the right and left\n subclavian artery fails to reveal any injury or stenosis at the origin of the\n vertebral arteries and rotational angiography of the right vertebral artery\n reveals no evidence of aneurysms of the posterior circulation with clear\n visualization of the vertebrobasilar junction.\n\n IMPRESSION: Rapid interval growth of previously noted irregularities of the\n left supraclinoid internal carotid artery into 3 and 4 mm tandem superiorly-\n pointing aneurysms of the anterior wall of the carotid artery.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2105-09-21 00:00:00.000", "description": "SEL CATH 2ND ORDER", "row_id": 770191, "text": " 3:31 PM\n CAROT/CEREB Clip # \n Reason: S/P CLIPPING, R/O VASOSPASM\n Contrast: OPTIRAY Amt: 40\n ********************************* CPT Codes ********************************\n * SEL CATH 2ND ORDER CAROTID/CEREBRAL UNILAT *\n * CAROTID/CEREBRAL UNILAT *\n ****************************************************************************\n ______________________________________________________________________________\n FINAL REPORT (REVISED)\n PREOPERATIVE DIAGNOSIS: Left internal carotid artery supraclinoid blister-\n like aneurysm status post clipping.\n\n POSTOPERATIVE DIAGNOSIS: Clipped aneurysm with no evidence of residual\n aneurysm and no evidence of stenosis of the supraclinoid internal carotid\n artery.\n\n INDICATION: This patient presented with subarachnoid hemorrhage and was noted\n to have a rapidly growing pair of aneurysms of the blister type involving the\n left internal carotid artery in the supraclinoid segment. She underwent a\n left pterional craniotomy for clipping of her aneurysm. Angiogram is being\n performed to document the position of the clips.\n\n ANESTHESIA: Conscious sedation with local infiltration of the right groin and\n administration of Versed and fentanyl in divided doses during the entirety of\n the procedure.\n\n CONSENT: The patient was given a full and complete explanation of the\n procedure including risks, benefits and possible complications. These include\n but are not limited to stroke, infection, coma, death, vessel rupture, vessel\n injury, as well as other unforeseen problems. She understood and wished to\n proceed.\n\n PROCEDURE IN DETAIL: The patient was brought into the Endovascular Suite and\n placed on the table in supine position. The right and left groin areas were\n prepped and draped in the usual sterile fashion. A 4-French vascular sheath\n was inserted into the right common femoral artery over a wire and kept on a\n heparinized saline flush. At this point, a 4-French Berenstein catheter was\n used to selectively catheterize the left common carotid artery, followed by\n the left internal carotid artery. With the catheter in this position, a\n series of angiographic runs was performed in single plane, biplane and three-\n dimensional angiography with reconstruction. The catheter was then withdrawn\n from the patient and manual compression was used to control and achieve\n hemostasis of the right common femoral artery with the assistance of a Syvek\n patch. Injection of the left common carotid artery reveals no evidence of\n injury, stenosis or dissection, and injection of the left internal carotid\n artery reveals in position the two square-angled clips and shows no evidence\n of aneurysmal dome filling and a reconstruction of the left internal carotid\n artery without significant stenosis. Specifically, the bilateral distal A2\n segments of the anterior cerebral arteries fill as documented previously, and\n again is noted the presence of a fenestration in the proximal right A2 segment\n of the anterior cerebral artery. There are no identified branch occlusions.\n\n (Over)\n\n 3:31 PM\n CAROT/CEREB Clip # \n Reason: S/P CLIPPING, R/O VASOSPASM\n Contrast: OPTIRAY Amt: 40\n ______________________________________________________________________________\n FINAL REPORT (REVISED)\n (Cont)\n IMPRESSION: Clipped bilateral blister-type aneurysm with no evidence of\n residual aneurysm filling and no significant stenosis of the parent vessel.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2105-09-14 00:00:00.000", "description": "CT EMERGENCY HEAD W/O CONTRAST", "row_id": 769621, "text": " 12:43 PM\n CT EMERGENCY HEAD W/O CONTRAST Clip # \n Reason: change in ct w/ incr. bp and worsening ha\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 32 year old woman with h/a x 1 week\n REASON FOR THIS EXAMINATION:\n change in ct w/ incr. bp and worsening ha\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INFORMATION: Persistent headache, evidence of subarachnoid\n hemorrhage on lumbar puncture.\n\n Exam is compared to the prior head CT of .\n\n Non-contrast head CT:\n\n There is no mass effect, hemorrhage, displacement of normally midline\n structures or extraaxial accumulation. Ventricles and sulci are not\n remarkable and unchanged from the previous examination. The and white\n matter are not unusual. The visualized paranasal sinuses are not remarkable.\n\n IMPRESSION: Continued negative head CT.\n\n" }, { "category": "Radiology", "chartdate": "2105-09-12 00:00:00.000", "description": "SEL CATH 3RD ORDER THOR", "row_id": 769500, "text": " 8:16 AM\n CAROT/CEREB Clip # \n Reason: ?SAH\n Contrast: OPTIRAY Amt: 225\n ********************************* CPT Codes ********************************\n * SEL CATH 3RD ORDER SEL CATH 2ND ORDER *\n * -59 DISTINCT PROCEDURAL SERVICE SEL CATH 2ND ORDER *\n * -59 DISTINCT PROCEDURAL SERVICE ADD'L 2ND/3RD ORDER *\n * ADD'L 2ND/3RD ORDER ADD'L 2ND/3RD ORDER *\n * ADD'L 2ND/3RD ORDER ADD'L 2ND/3RD ORDER *\n * CAROTID/CEREBRAL BILAT CAROTID/CEREBRAL BILAT *\n * EXT CAROTID BILAT VERT/CAROTID A-GRAM *\n * VERT/CAROTID A-GRAM -59 DISTINCT PROCEDURAL SERVICE *\n * EXT BILAT A-GRAM -52 REDUCED SERVICES *\n * SEL EA ADD'L SEL EA ADD'L *\n ****************************************************************************\n ______________________________________________________________________________\n FINAL ADDENDUM (REVISED)\n ADDENDUM:\n\n Selective injections of the left thyrocervical and costocervical trunk are\n normal without evidence of AV shunting.\n\n\n 8:16 AM\n CAROT/CEREB Clip # \n Reason: ?SAH\n Contrast: OPTIRAY Amt: 225\n ______________________________________________________________________________\n FINAL REPORT (REVISED)\n PREOPERATIVE DIAGNOSIS: Sudden onset of severe headache 5 days prior to\n admission with evidence of a positive lumbar puncture and xanthochromia.\n\n POSTOPERATIVE DIAGNOSIS: Two foci of irregular contour on the left\n supraclinoid ICA measuring approximately 1 to 2 mm in height, but no frank\n evidence of aneurysmal dilatation. Diffuse mild vasospasm.\n\n PROCEDURE PERFORMED: Cerebral angiogram.\n\n ANESTHESIA: Conscious sedation provided by divided doses of Fentanyl and\n Versed during the entirety of the procedure with continuous hemodynamic\n monitoring.\n\n CONSENT: The patient was given a full and complete explanation of the\n procedure. The indication, risks, as well as the possible complications.\n These include but not limit to vessel injury, vessel dissection, stroke,\n death, as well as puncture site complications which is hematoma or\n pseudoaneurysm. The patient understood and wished to proceed with the\n operation.\n\n PROCEDURE IN DETAIL: The patient was brought to the endovascular suite and\n placed on the table in supine position. The right and left groin areas were\n prepped and draped in the usual sterile fashion and a 19 gauge single wall\n needle was used to puncture the right common femoral artery. Upon the return\n of brisk arterial blood, a 5 FR vascular sheath was inserted into the right\n common femoral artery and kept on a heparinized saline flush. At this point,\n a 5 FR Berenstein type 2 catheter was used to selectively catheterize the\n vessels in the following succession: The right common carotid artery, right\n internal carotid artery, right external carotid artery, left common carotid\n artery, left internal carotid artery, left external carotid artery, left\n subclavian artery, left vertebral artery, right subclavian artery, right\n vertebral artery, and then left paracervical trunk, and then left\n costocervical trunk. With the catheter in each of these positions, a series\n of angiographic runs were performed in single plane, biplane, and three-\n dimensional rotational angiography. The catheter was then withdrawn from the\n patient and a 5 FR vascular sheath was withdrawn and the puncture site was\n compressed manually with successful results.\n\n RESULTS: Injection of the right common carotid artery and the left common\n carotid artery reveals a smooth contour of the bifurcation with no evidence of\n stenosis or dissection. Injection of the right subclavian and left subclavian\n reveal a smooth contour of the origin of the vertebral arteries with no\n evidence of stenosis or injury. Injection of the right and left external\n carotid artery fails to reveal any significant dural arteriovenous shunting or\n abnormal anatomy. Injection of the right internal carotid artery reveals an\n atretic right A1 segment and shows no evidence of aneurysm or arteriovenous\n malformation. Injection of the left internal carotid artery reveals a\n (Over)\n\n 8:16 AM\n CAROT/CEREB Clip # \n Reason: ?SAH\n Contrast: OPTIRAY Amt: 225\n ______________________________________________________________________________\n FINAL REPORT (REVISED)\n (Cont)\n dominant left A1 segment of the anterior cerebral artery with a duplicated\n right A2 fenestration. There is, however, no evidence of aneurysm at the\n anterior communicating artery segment. Evaluation of the supraclinoid segment\n reveals two areas of irregularity pointing superiorly with a height of\n approximately 1 to 2 mm. There is no aneurysmal dilatation or dome associated\n with the focal sites of ectasia. Injection of the right and left vertebral\n arteries fails to reveal any evidence of intracranial aneurysm or\n arteriovenous malformation.\n\n IMPRESSION: Focal sites of ectatic dilatation in the left supraclinoid\n internal carotid artery and a fenestration into the right A2 segment near its\n origin. Recommend that the patient undergo a follow up angiogram as\n clinically indicated.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2105-09-15 00:00:00.000", "description": "Report", "row_id": 1337887, "text": "7p-7a; Full assessment in flow sheet.\n\nneuro: A+oX3. Follow commands. Clear speech. tongue midline. Equal smile. no arms drift. MAE - strong, bilaterally. PERLA - 2 mm - brisk. Pain - c/o headache in back, relief wih morphine ivp. Nausea - relief with zofran. Appropriate respond.\n\ncv: NSR/SB without ectopy. BP 90-114/56-70. Nipride off. A-line very positional - Flush line, adjust arm rest, +cmst, cool hands (bilaterally). Warm, dry, no edema.\n\nresp; lung sound clear bilaterally. Room air. SaO2 >96%.\n\ngu/gi: soft abd, +BS X4. no BM. Void - yellow/clear urine >100 cc/hr.\n\nint: skin intact.\n\nPlan: continue to monitor neurological. MRI head AM? AM lab.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2105-09-20 00:00:00.000", "description": "Report", "row_id": 1337888, "text": "NEURO; A&O X3, SPEECH CLEAR, MAE, FOLLOWS COMMANDS, NO PRONATOR DRIFT, NO FACIAL DROOP NOTED, LEFT TEMPORAL-PARIETAL DSG D/I, PERL #3, BRISK TO LIGHT, EOMS INTACT, NIPRIDE BEING WEANED DOWN, PRESENTLY AT 0.4 MCG/KG/MIN TO KEEP SYS GOAL < 130\n\nCARDIOVASCULAR; HR 60'S-70'S SR, EXTREMITIES WARM, PEDAL AND PT PULSES PALPABLE, RT GROIN SITE HAS BANDAID, NO OOZING OR HEMATOMA, SOME ECCHYMOSIS, LEFT RADIAL A LINE INTACT,\n\nRESPIR; LUNGS CLEAR, PT ON NASAL PRONGS AT 3 L/MIN AND NOW ON R/A WITH 02 SATS 98%, EXPECTORATED SMALL AMT LIGHT GREY PHLEGM,\n\nLABS; HCT 26 BEFORE ARRIVAL TO SICU, RPT LABS PENDING THIS AM,\n\nPLAN CLOSE NEURO MONITORING, POTENTIAL VASOSPASM, MAINTAIN RECOMMENED BP AND HYDRATION\n" }, { "category": "Nursing/other", "chartdate": "2105-09-20 00:00:00.000", "description": "Report", "row_id": 1337889, "text": "FOCUS: STATUS UPDATE\nDATA:\nALERT AND ORIENTED X3. MAE WITH EQUAL STRENGTH. SLIGHTLY WEAK ALL OVER BUT NO OBVIOUS DEFICITS NOTED. PERL. C/O HA--INCISIONAL. OXYCODONE AND ICE PACK WITH EFFECT. VSS. CONTINUES OFF NIPRIDE. TOL PO FLUIDS W/0 PROBLEM. DENIES NAUSEA. U/O VERY LARGE. IVF INCREASED.\n\nPLAN:\nMONITOR NEURO STATUS.\n" }, { "category": "Nursing/other", "chartdate": "2105-09-21 00:00:00.000", "description": "Report", "row_id": 1337890, "text": "NEURO: PT X3. PUPILS EQUAL AT 3MM AND BRISKLY REACTIVE. SPEECH CLEAR AND APPROPRITATE. FACE SYMMETRICAL. MAEW. NORMAL STRENGTH 5/5 X 4 EXTREMITIES. C/O INTERMITTENT \"BRUISING\" LIKE PAIN AT INCISION. RELIEVED WITH PRN OXYCODONE X2 OVERNOC.\nRESP: LSCTA. STRONG BUT NONPRODUCTIVE COUGH.\nCV: NSR 50S TO 70S. SBP 100S TO 110S. IVF NS AT 150CC/HOUR CONTINUES VIA PERIPHERAL IV. PALPABLE PULSES. MODERATE FACIAL SWELLING LEFT > RIGHT.\nGI: ABD SOFT, NONTENDER. NO N/V. TOL CL AND PILLS WELL.\nGU: FOLEY INTACT AND PATENT FOR ADEQUATE AMTS CLEAR, YELLOW U/O. PT APPROX 150CC NEG SINCE MN.\nENDO: FSBS COVERED PER RISS.\nPLAN: INCREASE ACTIVITY AS TOLERATED. CONTINUE CLOSE NEURO MONITORING. MONITOR FOR ANY S/S VASOSPASM. ADVANCE DIET.\n" }, { "category": "Nursing/other", "chartdate": "2105-09-21 00:00:00.000", "description": "Report", "row_id": 1337891, "text": "transfer note\nD: pt doing well post angio. site is clean and dry. positive palable pulses. tolerating diet well and making good urine foley to be dc'd at 2400. pt may be out of bed at midnight. iv fluid decreased to 60cc/hr. oxycodone 5mg effective in controlling pain.\na: ready for transfer to floor at 2200.\nr: well post clipping and angio.\n" }, { "category": "Nursing/other", "chartdate": "2105-09-14 00:00:00.000", "description": "Report", "row_id": 1337885, "text": "CONDITION UPDATE\nD.AFEBRILE,SR,RR=,O2 SAT ON RM AIR=98,SBP INITIALLY 120'S ON 4MCQ OF NIPRIDE. PT WAS STARTED ON HYDRALAZINE PER DR. TO MAINTAIN SBP 100-110. THRU THE COARSE OF THE NITE SBP IN 90'S ENABLING NIPRIDE TO BE WEANED DOWN TO 2.5 MCQ.\n NEURO SIGNS STABLE.\n PT REQUESTED MSO4 SHORTLY AFTER ONSET OF PULSATION IN HEAD WITH # HA WHICH RESOLVED WITH 5MG MSO4 X2.\n A. MAINTAIN SBP <110 PER DR. .\n R. STABLE\n" }, { "category": "Nursing/other", "chartdate": "2105-09-14 00:00:00.000", "description": "Report", "row_id": 1337886, "text": "NURSING PROGRESS NOTE\n-1900\n\nS/O\nNEURO: Alert & oriented x3, PERLA as noted, tongue midline, speech clear and audible, grasps equal. Sudden onset excrutiating h/a (30 min after Lopressor) with increasing BP, HR from 58 ->117 after hydralazine 10 mg IV given.\nMSO4 5 mg IV followed by 2mg IV x2 and Zofran 2 mg IV for continuing pain and nausea. Nipride restarted, titrated from 0.5 -> 3.0 mcg/kg-min. To head CT, results negative.\nMSO4 5 mg IV given again, Zofran 2 mg IV given a second time four hours after first dose with resolution of nausea. H/A resolved, VSS, nipride weaned back to 0.5 mcg/kg-min.\n\nCV: See neuro re: pressors. Pressors titrated to maintain cuff SBP 90-110. Left radial a-line d/c'd this a.m., awaiting transfer. After sudden onset of h/a and restart of nipride gtt, a-line placed in right radial artery with one stick by MD. Cuff and occlusion pressures correlate; transduced arterial pressure inconsistent with cuff and occlusion pressures; left hand cool, ?arterial spasm -> warm packs applied and cuff pressures followed to titrate gtt.\n\nRESP: SpO2 decreased to 80's on RA during above incidence. Placed on 2 LPM nc with SpO2 87-89; O2 increased to 4 LPM with SpO2 95%. Weaned back to room air with SPO2 97-99%.\n\nGI: Nausea as noted, resolved after second dose of Zofran. BS decreased, abd soft and non-tender.\n\nFEN: BS 143 -> no insulin given. Continues on Decadron.\n\nGU: U/O qs, voids without issue.\n\nPSYCHSOC: Approp questions, responses.\n\nA/P\nContinue care as ordered. Moniter after pm dose of Lopressor for any adverse signs/symptoms.\n" }, { "category": "Nursing/other", "chartdate": "2105-09-13 00:00:00.000", "description": "Report", "row_id": 1337883, "text": "7p-7a: Full assessment in flow sheet.\n\nneuro: A+OX3. Clear speech. Good cough. Good gag. MAE - strong bilaterally. No drift arms. Able to read near and far. Headache - Left back of head, forehead, then back of head - relief with morphine ivp. Follow commands. Calm. Appropriate questions and understanding.\nAble to take off contact lenses, and put them on in AM. Swallow water and pill without difficulty.\n\ncv: NSR without ectopy. Maintain SBP 90-100 with Nipride drip. A-line dampen with pt movement. Warm, dry, no edema.\n\nresp: Clear lung sound. Room air. 96-100%. RR 14-20.\n\ngu/gi: Soft abd. +BSX4. Pt refuse foley. Void without difficulty, >200 cc q2 hrs - yellow, clear urine. no BM.\n\nint: Skin intact.\n\nExplain all procedures and answer all pt questions.\n\nPlan: Continue to monitor neurology and hemodynamic. AM lab done.\n" }, { "category": "Nursing/other", "chartdate": "2105-09-13 00:00:00.000", "description": "Report", "row_id": 1337884, "text": "SICU NSG PROG NOTE: DAYS\nRemains stable awaiting decision re: aneurysm repair. Remains on nipride gtt w/ increasing required dosing to manage spb 90-100/.\n(She has elevating b/p w/ visitors or \" stressful\" situations. (i.e. when we needed to place a new a-line). Neuro intact w/out deficit. Has persistent headaches that are well managed w/ mso4 5mg iv q2hr. HOB flat, remains npo. No nausea. Converses appropriately. She refused antianxiants. Bedrest.\n\nA-line changed over wire for damped/nonfunctioning line. Works well now. Has new L peripheral line that functions well. Voids w/out difficulty .\n\nMaintenance fluid ns w/ 20meq kcl @ 100cc/hr cont.\n\nVisited today by close friends. Brief visits.\n\nASSESS:s table, no noted neuro changes, good pain control, increasing Nipride requirements for b/p management.\n\nPlan: cont to titrate nipride, keep npo....plan per neuro team,./\n" } ]

[ { "category": "Nursing/other", "chartdate": "2191-11-13 00:00:00.000", "description": "Report", "row_id": 1341686, "text": "MICU NPN 3p to 7p:\n\nIV RN unable placed PICC at bedside. Will need PICC placement on Monday via IR. Order in place. Foley will remain in place overnight as agreed by RN and MICU resident Dr. .\n" }, { "category": "Nursing/other", "chartdate": "2191-11-13 00:00:00.000", "description": "Report", "row_id": 1341687, "text": "RESPIRATORY CARE: PT GIVEN ALBUTEROL/ATROVENT\nSVN THIS SHIFT AS PER CV. MUCH IMPROVED TOWARDS\nEND OF SHIFT. COUGH PRODUCTIVE FOR YELLOW SPUTUM\nAND WHEEZING HAS DECREASED.\n" }, { "category": "Nursing/other", "chartdate": "2191-11-14 00:00:00.000", "description": "Report", "row_id": 1341688, "text": "NPN 1900-0700\nResp: LS rhonchorus c occ wheezing. Lge amt wheezing and coughing this am, improved c nebs. productive cough, clear, thick sputum, will attempt to get sputum cx. cxr this am. sats good >96,rr 15-19.\n\nCV: sbp 138-153, starting back on antihypertensives. HR 70-90,ns, no ectopy. To have picc placed in IR today, once placed can remove L subclavian, did not change dsg due to planned removal. Tmax99.4 po, cont on mirepenem.\n\nNeuro: A&Ox3. mae. No c/o pain. Was up in chair yest c PT but was unable to stand on own.\n\nGI: Abd obese, +BS. Soft stools x1, one huge, incontinent. Poor appetite but drinking liquids well.\n\nEndo: Now on qid sliding scale on humalog plus am fixed dose. FS ~ 200.\n\nGu: Excellent u/o clear, yellow urine.\n\nSocial: No calls from family o/n.\n\nPlan: Probably will be called out. IR for picc line. Cont nebs for wheezing, abx. Mag 1.6, will need repletion.\n" }, { "category": "Nursing/other", "chartdate": "2191-11-14 00:00:00.000", "description": "Report", "row_id": 1341689, "text": "Nursing Day Note\nNeuro: Alert, oriented to self, intermittently forgetful re:place, time, conversation. Pleasant and cooperative but becomes anxious at times. Rec'd Ativan 1mg IV x1 for anxiety @1300 with very good effect. ***Difficulty tolerating lying flat for PICC placement, c/o anxiety, req'd frequent reassurance. Good cough. Moves all extremities but still requires 2person assist to turn, for OOB. Requires some assistance to feed decreased eye-hand coord. OOB to chair x1 for ~2h, v. well tol'd. Afebrile today.\n\nCV: HR 70's to 90's. NSR w/rare PAC's, denies CP/palps. AM SBP 97, Norvasc held until 10a. BP throughout day 140's-160's., Dr. aware. Lasix 20mg IV, awaiting effect. Skin warm, dry. +pedal pulses.\n\nResp: O2 sats >96% on 2L NC. Tolerated RA through am w/sats >93% but desat to 88% when sleeping, NC reapplied. RT administered MDI w/ very good effect, UL's CTA @this time. Will practice deep breathing techniques if prompted. Denies SOB/distress.\n\nGI: Obese abd NT, +BS in 4quadrants. BM medium, v. loose x1 this shift, Colace held. Tolerating PO's. Continues on RISS for glucose control, see and Carevue for additional doc.\n\nGU: Foley patent, draining clear, yellow urine @ >60cc/hr. Urology by to see today, MRI of ?abcess scheduled for .\n\nSkin: Notable for fungal impair. @ groin creases and inside thighs B/L, Miconazole pwdr applied. C/O perineal tenderness after loose stool last noc and today, Doubleguard applied. Neg pressure ulcers on sacrum. Healing lesions on face past intubation, applying abx ointment prn.\n\nLines: CVL d/c'd today. To IR today for PICC placement in R brachial. Single lumen, flushes well, draws.\n\nID: Continuing only IV Meropenem 1000mg q 8.\n\nPlan: Monitor and support hemodynamics, respiratory status. Monitor u/o. IV Meropenem as ordered. MRI of kidney in am, pt will require anxiolytic. Encourage turn,cough,deep breathe. OOB w/PT scheduled for . Emotional support. F/U w/ team re: cont'd POC.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2191-11-21 00:00:00.000", "description": "Report", "row_id": 1341709, "text": "NPN 7P-7A:\n\nNEURO: THE PT IS A/OX1. SHE IS ABLE TO FOLLOW COMMANDS. I DID NOTE THAT SHE WAS SMACKING HER LIPS FREQUENTLEY. BOTH HER ARMS WERE UP IN A FLEXED POSITION. AT ONE POINT SHE FLEXED HER RIGHT ARM, AND THE LEFT LEG. THE ICU TEAM WENT IN TO EXAM HER. NOTED CLONUS. THEY ALSO NOTED THAT SHE IS HYPER-REFLEXIVE. BENADRY WAS GIVNE, AND LABS WERE DREWN.HER CA 9.7, CK 34, CK/MB 2. HER PUPILS ARE 4MM AND BRISK. AT THE START OF THE SHIFT SHE WAS MORE LETHARGIC. BUT NOW SHE IS ALERT. SHE HAS NOT SLET TONIGHT.\n\nRESP: SHE WAS EXTUBATED ON , AND RE-INTUBATED ON BRONCHOSPASM. SHE WAS BRONCHED ON , WHICH SHOWED FRIABLE MUCOSE, AND MUCOSAL BLEEDING. SHE WAS AGAIN EX-TUBATED ON . NOW SHE IS ON NC 2L W/ O2 SAT >96%. HER LS ARE DIMINSHED W/ WHEEZING AT TIMES. HHN WERE GIVEN W/ GOOD EFFECT NOTED.\n\nID: TEMP MAX IS 100.0 RECTAL. BLOOD CULTURES X2 AND UA WERE SENT. SHE IS ON MEROPENEM/VANCO FOR PNEUMONIA. SHE ALSO HAD A UTI.\n\nCV: NSR W/ PAC NOTED. HR 85-90'S.\n\nSKIN: HER GROIN IS PINK. SHE HAS MICONAZOLE POWDER. SHE ALSO HAS THURSH. NYSTATIN ORAL WAS GIVEN.\n\nGI/GU: SHE WAS COUGHING TONIGHT WITH CRUSHE PILLS, AND SIPS OF FLUID. SHE WAS GIVNE A NS FB FOR LOW UA OUT PUT. SHE IS NOW PUTS OUT\n80-100CC/HR OF CLEAR YELLOW URINE W/ OCCASIONAL CLOTS NTOED.\n\nPOC: MONITOR PT NEURO STATUS. THEIR IS A QUESTION OF ACUTE DYSTONIC REACTION VS TARDIVE DYSKINESIA VS SEIZURE. NEURO IS QUESTIONING ON GOING DELIRIUM. SEROQUIL AND HALDOL WAS D/C ON . EEG TODAY. QUESTION HEAD CT. IV ABX.\n" }, { "category": "Nursing/other", "chartdate": "2191-11-07 00:00:00.000", "description": "Report", "row_id": 1341661, "text": "Nursing Assessment Note 1900-0700\nNEURO: Pt sedated on mcg/kg/min, pt not opening eyes or following commands, but does withdraw to painful stimuli, MD's felt pt was too sedated so I turned Propofol down to 5 mcg's, but after short time pt became more agitated trying to pull at ETT, I am slowly trying to increse Propofol to obtain adequate sedation and is current infusing at 15 mcg/kg/min\n\nCV: Pt febrile to 104.4, Pan cultured, 1 gram tylenol given and pt packed with ice and then cold bath given, temp at 0400 was 101.4, but then increased to 101.8 at 0530 and cooling blanket was started and given 650 mg tylenol pogt, skin is pale, warm, and dry, pp + & =, with trace to +1 edema, Pt has #18 and #22 in left lower arm, with Propfol infusing via #22 and NS @ KVO via #18, pt also has #20 in right wrist, new right Radial A-line was placed and waveform is sharp and wnl, MD's also wanted pt to have 1000 cc NS bolus for ? of being dry\n\nRESP: Pt intubated initially on CMV, but changed to CPAP PS-15, PEEP-5, FIo2-40%, see carevue for ABG's and exact vent changes, lung sounds revealed Ins/Exp whez and diminished in bases, pt suctioned for moderate amount thick yellow sputum with blood spots\n\nGI: Pt npo with OGT, placement confirmed via air bolus and by x-ray, bowel sounds are positive, with huge soft obese abd\n\nGU: Pt's foley was original from OSH, specimen sent on arrival and continued to remain + for UTI, so new #16 fr foley was placed, pt draining clear amber urine qs\n\nPLAN:\n-Continue with antibiotics as ordered\n-Monitor Urine output and temp closely\n-Try to wean pt for possible extubation today?\n" }, { "category": "Nursing/other", "chartdate": "2191-11-07 00:00:00.000", "description": "Report", "row_id": 1341662, "text": "resp care note\n\nPt placed on PSV in preparation to wean vent support and possibly extubae. Pt getting atrv Q 6 hrs, alb MDI Q 6 PRN. She has had some wheezing but this improved P she received bronchodilators.\n\n" }, { "category": "Nursing/other", "chartdate": "2191-11-07 00:00:00.000", "description": "Report", "row_id": 1341663, "text": "Respiratory Care\nPt weaned and extubated this am. Placed on 40% face Tent. BS coarse with faint exp wheezing.\n" }, { "category": "Nursing/other", "chartdate": "2191-11-07 00:00:00.000", "description": "Report", "row_id": 1341664, "text": " 4 ICU nursing progress note:\n Respiratory: Pt remained on c-pap thru early am..extubated and placed on 60% face tent. rr 20-40 depending on level of agitation. With increased rr has increased wheezing and more agitation. By 1730..pt very bronchospastic..team decided pt needs to be intubated and sedated thru the noc. Awaiting neuro exam before pt intubated.\n Neuro: Once pt extubated..continued to be very agitated..flailing arms and legs..pt tends to favor left side. Often found sideways in bed. Does not respond to name..nor does she open her eyes..though at times seems to try. Will yell when pain inflicted..ie needle sticks/moving pt. Per sister..pt has very bad arthritis and takes motrin at home. Tried multiple meds in attempt to calm pt..5mgmx5mgm IM haldol given. Fentanyl 50mic x2 sc. Mso42mgm iv and ativan 2mgmx2mgm iv. ??reliability of IVs..Pt has shown no change in behavior despite above meds. House staff wants neuro to see pt before being intubated and sedated?\n Cardiac: BP 170-210/ most of day with hr 100-120'sst..attempted dose of iv diltizian with no effect. IV gtt started..up to 15mgm..??reliability of IVs. Dilt dc'd d/t lack of access.\n Access: Pts peripheral IVs have blown..mostly d/t agitation..house staff unable to get central line in d/t agitation. IVRN able to place #22..Pt still not responsive to anti-anxiety meds. ??ask anesthesia to assist with central line.\n ID: Pt febrile to 103po..given tylenol suppository and on cooling blanket. Added azithromycin to regiem. Another BC from a-line sent.\n GI: +bs..abdomen obese..distended. no stool..ng/og needs to be replaced once intubated.\n GU: Recieved x1 1000cc ns bolus this am..??pt dry. Has good u/o most of day.\n Skin: Small skin tears noted on elbows from pt rubbing arms back and forth on sheets\n AODM: Following bs q6hrs..running high 180-270..\n Social: Sister and husband in to visit..is spokesperson along with pt husband. Pt husband is undergoing for prostate cancer..is not supposed to drive and probably wont be down to see pt. Sister is keeping him updated. Pt also has stepdaughter..who has not called today.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2191-11-12 00:00:00.000", "description": "Report", "row_id": 1341682, "text": "NPN\nNeuro: Lightly sedated w/Fentanyl @ 45mcg/kg/min and Versed @ 2mg/hr. Frequent awakenings/restlessness required additional boluses. PERRL,remain sluggish, sometimes follows command, often responds appropriately to yes/no ?'s. Became alert to sound of husband's voice via phone call. gag reflex is + but diminished. Afebrile this shift.\n\nCV: HR 70's-90's. NSR w/occasional PAC's. K+ 4.1, Mg 2.1 @ 0200. AM labs pending, see Carevue for further documentation. Skin warm/dry. Pneumo boots in place.\n\nResp: RR teens and 20's with sats>94% for most of shift. Intermittent but frequent wheezing/rales noted upon auscultation, rec'd several doses of MDI w/ +effect. RT sxn q2-4h w/scant-small amts thick, bld-tinged secretions. Overall improved respiratory status over 12/7-8. PSV: PEEP = 8, PS = 15, 40% FiO2. Pt could not tolerate RSBI trial this am\n\nGI: TF running @ 10cc/hr. Residual of 70cc overnoc, TF stopped for ~2hrs, restarted @0000. +BS in all 4 quadrants, obese abd firm, nt. No BM this shift, may need to institute bowel regimen.\n\nEndo: Continues on regular insulin drip to support bld glucose WNL. See Carevue for q1h FS documentation\n\nGU: Patent foley draining clear yellow urine @ >50cc/hr. Goal for shift was to have 0 balance. ?abcess/lesion on L kidney, ID to follow up.\n\nID: Vanco IV q 12h, Meropenem IV q8h, Levaquin PO q24h.\n\nLines: CVL on L chest-all lines patent, skin WNL. Art line on R wrist will not draw, waveform position dependent. Drsg noc.\n\nSocial: Husband undergoing for prostate cancer, unable to visit regularly from home in VT. Called early in shift, encouraged to speak to pt. Pt spontaneously opened eyes and moved extremities @ sound of his voice. He hopes to come visit this wkend.\n\nPlan: Monitor and support hemodynamic and respiratory status. Evaluate efficacy of sedation doses. Abx as ordered. Cont. reg insulin gtt. TF to maintain gut motility, monitor residuals. Continue soft restraints. Bowel regimen prn. F/U w/ team re: ?abcess and cont'd POC.\n" }, { "category": "Nursing/other", "chartdate": "2191-11-12 00:00:00.000", "description": "Report", "row_id": 1341683, "text": "events of day pt extubated at 1500, temp to 101.8 orally and paqn cultured.\n\nneuro: A&O off sedation a bit anxious. MAE lt hand is less reactive when asked to move it but spontaniously moves appropriatly.\n\ncard: a line needs to be pulled and please send tip for culture NBP is 150/70 range. NSR no ectopy noted . pulses by and eatremities warm upper extrem 3+ edema.\n\nresp: extubated at 1500 and sat 95-98 on humidifed mask o2. good cough bringing up thick blood tinged sputum with yelllow mucus. wheezing post extuvbation and recieved neb txs resp 18-24\n\ngi: given po meds per ogt and supp this am and has had 3 stools green black with mucus and spec in room to be sent for c-diff cult. taking po ice and tol well will advance to cl/ full liquids\n\ngu: good output > 60 cc/ hr and just given 1000 cc d5w for rehydration.\n\nID: no change in antibx; temp spike to 101.8 pan cultured and needs 1 more set blood cults, stick if poss. pt given motrin for fever and currently 98.8 oral. maqss on kidney needs MRI to further eval for poss abcess.\n\nendo: steroids decreased and iv insulin upped for 4-5 hr for glucose in 200-205 reang and currently on 1 unit /hr glu 149 x2 and now is 179. poss could move to sc dosing soon\n\nlines: aline not drawing and needs to be pulled . triple is functioning well\n\nsocial: several phone calls and husband and son aware of being extubated\n\nplan : resp toilet and . fluid status and iv glucose control, advance diet as tol.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2191-11-13 00:00:00.000", "description": "Report", "row_id": 1341684, "text": "NPN 1900-0700\nREsp: Pt did well on 2Lnc most of noc c sats >95 until ~ 0530 when noted to have ^ wheezing, turned to L side, desatted to 88. Neb given by RT, turned pt supine c head ^ then placed pt back on cool neb at 50%. sat currently 93, improving. LS diminished. RR 16-23. Freq productive cough, only noted clear sputum.\n\nCV: HR 71-84, nsr, no ectopy. SBP 126-172 by nbp, a-line removed and tip sent for cx. Repleted mag and Kphos o/n, needs more K repletion, now 3.6. Afebrile.\n\nNeuro: A&Ox3. mae. Did not sleep at all until 0600, wide awake watching TV all noc. Did not appear restless or anxious.\n\nGI: +BS, abd obese. 3 soft, dark brown stools, came quickly for pt, incontinent. OB neg. Pt swallowing well. Drinking water easily, had toast and milk, is hungry.\n\nEndo: FSq1hr. currently on 3 units/hr.\n\nGU: Excellent u/o, clear urine c sediment.I&O last 24 hrs + 158mls.\n\nSocial: Pt excited about pending visit from husband today.\n\nPlan: Monitor resp status, ls, encourage C&DB. FS q1hr, ? change to NPH today and SS. Advance diet.\n" }, { "category": "Nursing/other", "chartdate": "2191-11-20 00:00:00.000", "description": "Report", "row_id": 1341707, "text": "NPN 7P-7A:\n\nNEURO: PT ALERT AND CONFUSED (A/OX1 OR 2). SHE WILL FOLLOW COMMANDS AT TIME. HER PUPILS ARE 3MM AND BRISK. SHE IS ABLE TO MAE.\n\nRESP: LS DIMINSHED BILAT. O2 SAT ON 4L NC >96%. SHE HAS A NON-PRODUCTIVE CONGESTED COUGH.\n\nCV: NSR W/ HR 85-110'S. NO ECTOPY NOTED. SHE IS ON DILT/LOPRESSOR PO FOR HER HR AND B/P.\n\nGI/GU: SHE IS ABLE TO SWALLOW PILLS WHOLE. HER ABD IS LARGE ROUND NON TENDER. + BS NO BM. FOLEY CATH WITH 80-120CC/HR OF CLEAR YELLOW URINE.\n\nENDO: SHE IS ON RISS.\n\nPOC: HEAD CT/MRI NEG. NO BENZO. SEROQUEL. HALDOL WAS D/ IV ABX. HTN MEDS.\n" }, { "category": "Nursing/other", "chartdate": "2191-11-20 00:00:00.000", "description": "Report", "row_id": 1341708, "text": " 4 ICU nursing progress note:\n Respiratory: Extubated ..abg on room air= 73/33/7.51..rr 20's..slight exp wheeze early am. Cleared with neb treatment. Repeat abg on 3l (is mouth breather) 80/34/7.52..Non-productive..congested cough. ??some aspiration with liqs. Per daughter..pt would cough after drinking at home. ??Speech and swollow study at later date.\n Neuro: Very lethargic..unfocused..dazed affect today. Confused to time and place..voice just a whisper. MAE..with prodding..will follow commands. OOB to chair with 2 assist. Haldol decreased to 2.5mgm tid. By late afternoon pt noted to have both arms/hands tucked under chin..??dystonia and lip smacking..??tardive dyskinesia...??r/t Haldol. Haldol has since been dc'd as has seroquel. Will continue to observe.\n GU/Renal: Decreased u/o by late afternoon..remains neg..??more fluid boluses..\n GI: Ate breakfast and lunch with assist from daughter..tolerated well..(was up in chair) Will hold diner d/t lethargy.\nNo stool today.\n AODM: Rise in bs..covered with ssri\n ID: Afebrile..no change in antibiotics..slight rise in WBC..steroids decreased.\n Cardiac: Lopressor dc'd and dilt increased..bp 130-160/\nHR 100-105sr/st.\n Social: Daughter in most of day. Updated.\n\n" }, { "category": "Nursing/other", "chartdate": "2191-11-09 00:00:00.000", "description": "Report", "row_id": 1341668, "text": "NPN\nNeuro: Pt continues sedation on Propofol, currently @70mcg/kg/min. Required freqent titration of sedative overnoc, now appears v. comfortable. Pinpoint pupil equal,minimal rxn to light, neg spontaneous eye opening. Does not follow commands, neg response to painful stimuli. Increased facial grimace observed when experiencing incr work of brthing. Occasional gag w/sxning. Afebrile w/ T=97.9-99.7.\n\nCV: HR 80's to low 90's, SR w/o alarms or ectopy. SBP's 140-160 throughout most of shift, occasionally <110 in response to increased sedation. R. art line and L chest CVL patent, all flushing well. Set #2 of BLCx sent, results pending. Skin warm, damp, +pedal pulses. See Carevue for lab documentation.\n\nResp: On CPAP &PS for most of shift with O2 sats in the high 90's, RR in high 30's. Diminished LS in LLL, otherwise coarse w/intermittent wheezing. Experienced significant increased work of breathing @ 0400 w/ no relief after increase of sedative and suctioning, some response to MDI tx. Placed on A/C with immediate decrease in RR, use of accessory muscles and improved overall appearance. Remains on A/C: FiO2=40, Vt=500, PEEP=5. RR high 20's.\n\nGI: Obese abd soft, distended w/hypoactive bowel sounds. No BM this shift. TF stopped for ?extubation today. Titrating insulin drip with FS q1h. See Carevue for documentation. Insulin currently stopped for recent FS of 68. Rec'd 1/2amp D50 x1 on eves for diaphoretic appearance and FS of 60.\n\nGU: Patent foley draining clear yellow urine @ 40+ cc/hr.\n\nSkin: Neg for pressure ulcers. Old lesion noted on R elbow, healing well. Turned q2h.\n\nSocial: Son in to visit last noc. POC explained.\n\nPlan: Closely monitor respiratory status, u/o and FS. Monitor and support hemodynamic status. Continue abx as ordered. VAP q4h; turn, assess restraints q2h,prn.\n" }, { "category": "Nursing/other", "chartdate": "2191-11-09 00:00:00.000", "description": "Report", "row_id": 1341669, "text": "Respiratory Care Note:\n\nPt received orally intubated & sedated on spontaneous ventilation. We were able to wean PEEP, and lastly earlier this morning, we had to switch to vent support due to increased WOB, uses of acc muscles. BS are dim midly and low pitch insp< exp wheezes, respond well to MDI,s this morning. We are sxtn for small to mod rhick tan to bloody secretions from ETT & clear micoid orally. Plan: Continue present ICU minitoring & wean as tol. Will folllow.\n" }, { "category": "Nursing/other", "chartdate": "2191-11-09 00:00:00.000", "description": "Report", "row_id": 1341670, "text": "Resp. Care Note\nPt remains intubated and vented on AC settings as charted on resp flowsheet. Pt remains tachypneic to 30's with minute ventilation of 16-18L. Attempted to change to PSV but on PSV 20 RR to 40 and TV's 350-400 after a few minutes. No ABG's this shift but sats >95%. Plan to cont current support. Fever w/u in progress.\n" }, { "category": "Nursing/other", "chartdate": "2191-11-17 00:00:00.000", "description": "Report", "row_id": 1341695, "text": "Resp Care\n1900-0700 shift note\nPt was intubated early in the shift. Placed on vent, (see carevue for settings). Pt went to ctscan without incident. Suctioned out large amt of blood tinged plugs. Placed on heated circuit. Mdis given. Rsbi 58. Currently on SBT. Awaiting abgs. Will continue to monitor.\n" }, { "category": "Nursing/other", "chartdate": "2191-11-17 00:00:00.000", "description": "Report", "row_id": 1341696, "text": "MICU NPN\nAt the change of shift, pt was intubated due to becoming more sob and increased rr.\n\nNeuro: Is now sedated with fentanyl 75mcg/hr and versed 5mg with good effect. Reponds to painful stimuli. Wrists restrained for pt. safety.\n\nResp: Intubated, vent settings changed this am was on a/c is now on pressure support see carevue for most updated vent settings and abg results.\n\nCV: hr and bp stable, see carevue for details. Originally was on propofol when first intubated but became hypotenive, sedation switched from propofol to versed/fent, received 500cc ns bolus during this time for hypotension. cvp 4-7. went for cta last night to r/o PE results are pending.\n\ngi: ogt in place and clamped. abd. obese + bs, no bm overnight.\n\ngu: u/o 50-70cc/hr light yellow, was duiresed yest. ? if dry now, cvp 4-7.\n\nsocial: family aware that pt. was reintubated last evening, husband called this am and was updated on pt's condition.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2191-11-17 00:00:00.000", "description": "Report", "row_id": 1341697, "text": "Nursing Note:\n\nNeuro: pt remains sedated versed and fentanyl drips, pt sedated deeply for bronchoscopy this PM, sedation off following bronch, pt had to be put on CMV settings, pt awoke at approx 1600 attempting to pull ETT, sedated currently versed 1.5mg/hr, fentaynl 75mcs/hr. pt moves extremities well, nods appropriatly when awake, opens eyes to voice.\n\nResp: pt currently on CPAP Psupp 5, PEEP 5, FIO2 40, RR 12-17, sats 92-96. bronchoscopy done today, sputum sampes sent, airways appeared red and extremely irriated, lungs coarse and diminished, suction brown blood tinge, lungs coarse upper, diminished lower. pt nearly self extubated at approx 1600, repeat CXR done and confirmed placement on ETT and OGT. remains on levoquin, vanco, and merempenem for antibiotic coverage.\n\nCV: HR 60-80's when sedated, up to 110 when agitated, sinus rhythm no ectopy, ABP when sedated 100-115/40-50, up to 150 systolic when awake. pos distal pulses, minimal extremity edema, SCDs on.\n\nRenal: foley output 40-100cc/hr, clear yellow, 500cc NS bolus given this AM for low CVP ()\n\nGI/endo: pos bowel sounds, sm smear brown stool this AM, tube feeds initiated via OGT at 10cc hr, tube feeds ordered to be held at 0400 for possible AM extubation. remains on insulin slide scale.\n\nSocial: husband called during shift, update given.\n\nSkin: pt turned and repositioned, no skin breakdown noted, barrier cream applied to coccyx.\n\nPlan: tube feeds off at 0400 for possible extubation tommorow, cont to monitor resp status, sedation level, vitals. update pt and family as neccesary.\n" }, { "category": "Nursing/other", "chartdate": "2191-11-17 00:00:00.000", "description": "Report", "row_id": 1341698, "text": "Respiratory Care\n\n Pt continues on PSV 5/5 in NARD. On A/C briefly during and after bronch. BAL sample obtained and sent. B/S ess clear dim in bases Sx'ing small amounts of pluggy brown secretions. MDI's as documented. Will continue to follow closely.\n" }, { "category": "Nursing/other", "chartdate": "2191-11-06 00:00:00.000", "description": "Report", "row_id": 1341660, "text": "pmicu nursing admission and progress note\n61 yr old woman that was transferred from an outside hospital in , where she had been admitted on for onset of confusion and found to be septic from a UTI--on cipro and ceftriaxone. ??whether pt had pneumonia. neg lp and neg head c-scan. gnr noted in blood. yest pt responsive to name and would open eyes, knew family but last evening became more unresponsive, not following commands, or opening eyes. today pt became more agitated requiring haldol and morphine. an abg was obtained on 4l nasal prongs(sats of 92-93%)----o2 74 co2 40 and ph 7.3. heart rate newly elevated to 120-130's, with bp of 140-188/76. temp of 38.5C.\n\npmh: fibromyalgia, asthma, iddm, hypercholesterolemia, lbbb, tachycardia, pud, s/p hernia, s/p bil knee replacements, s/p tah\nanxiety\n\nall: ?codeine\n\nsystems review:\n\nresp: pt arrived intubated---pt intub by the emts--and it was stated that pt had many mucus \"pockets\" noted. tube is a #7.5, 21 at the lip. vent settings are ac 100% tv 450 x14 vented breathes 5peep (for intub pt rec'd etom, succs, fent, vec, and versed). lung sounds are clear, but deminished in the LLL. suctioned for a small amt of thick yellow sputum. propofol drip started and is infusing at 10.25mcg/kg/min. a cxr done to check for placement of ettube and og tube here in 4.\n\ncardiac: bp 135-145/58-64 with a pulse of 110-120 st, no ectopy noted. k+ this morning in Vt was 4.0. while pt being intubated she required an amp of atropine as pt became bradycardic--??vagal.\n\nid: temps 100.4 po. urine and sputum sent for culture.\n\ngi: abdomin obese, very distended, but soft. emts stated that abdomin not distended from bagging. placed on constant suction for a few!!no stool passed in VT, but pt had large amt of flatus. og tube placed by emts---advanced by nurse 4---small amt of bilious residuals.\n\ngu: foley in place. urine sent. septic from UTI.\n\nheme: pt rec'd 2uprbcs on \n\naccess: three peripherals in place.\n\nsocial: health care proxy is husband. husband is sickly and receiving radiation treatments.\n" }, { "category": "Nursing/other", "chartdate": "2191-11-10 00:00:00.000", "description": "Report", "row_id": 1341676, "text": " 4 ICU nursing progress note:\n Respiratory: Remains intubated and vented..still with high respiratory rate (vent=14) pt rate 20-30. Sats high 90's. Suctioned for mod amt bloody sputum..sent for culture. No changes to vent. Added bicarb gtt to get serum bicarb up..and aid in tacypnea.\n ID: Still with high temps..up to 102 today. Tylenol doesnt seem to help with temp. Given motrin liquid. Followed by ID..changed antibiotics to meropenum..continues with vanco. TEE post-poned until tomorrow.\n Neuro: Opens eyes spontaneously..appears to hear you when her name is called..not tracking or following commands..but appears to be lighter. Also..does not seem to be uncomfortable when more awake. rr not higher. Responds to suctioning by turning head and moving arms. Propofol at 90mic/kg/min. Pt appears adequately sedated. Followed by neuro:\n Cardiac: Short periods when bp up..ususally when propofol running low. NSR 80-100. bp 130-150/60-70\n GU: Urine output adequate.\n GI: TF restarted Passing small amts liquid green stool ob-\n Skin: Double guard applied to broken areas on buttocks.\n Endo: BS labile..D5W started with bicarb..continue to follow closely.\n Social: Son called and updated..\n" }, { "category": "Nursing/other", "chartdate": "2191-11-10 00:00:00.000", "description": "Report", "row_id": 1341677, "text": " 4 nursing addendum note:\n GI: Per nutrition..pt is recieving 2700 calories with propofol gtt.\nTF decreased to 10/hr..will make NPO after 12m for TEE tomorrow\n" }, { "category": "Nursing/other", "chartdate": "2191-11-11 00:00:00.000", "description": "Report", "row_id": 1341678, "text": "Respiratory CAre\nPt. intubated on ventilatory support. Pt experienced episode of desaturation, very diminished BS with fine end exp. wheezes and coarse rales. Pt treated aggressively with inhaled bronchodilators and suctioning. Sx'd for thick blood tinged secretions, BS greatly improved with marked increase in aeration but remains very wheezy. Oxygen saturation improved with increase in FiO2 from 30% to 40%. RSBI not performed due to medical instability.\n" }, { "category": "Nursing/other", "chartdate": "2191-11-11 00:00:00.000", "description": "Report", "row_id": 1341679, "text": "NPN\nNeuro: Pt remains on IV Propofol @90mcg/kg/min. Very lightly sedated for early part of shift as assessed by spontaneous eye opening, movement of extremities and grimace,required several 20-40mcg boluses.\nPERRL,sluggish; withdraws from neg stimuli, + but diminished gag reflex. Tmax of 101.4, responded positively to liquid Tylenol 650mg and liquid Ibuprofen 800 mg @ . Afebrile for remainder of evening.\n\nCV: HR avg in 90's w/ episode of tachycardia up to 157 x1 and subsequent PAC's which spontaneously resolved. K+ 2.8 Mg 1.9 Repleted w/60mEq KCl IV, 4gm Mg sulfate IV and 150mEq sodium bicarb. See Carevue for lab data. Pt also experienced increased BP's w/MAP of ~ 100; rec'd IV Hydral 5mg x1 followed by additional 10mg x1 with good effect. BP's 140's-150's/50's-60's for remainder of shift. AM labs, and BLCx x2 pnding.\n\nResp: Pt desat'd to 92% w/ I/E wheezing @ ~0315. RT notified, MDI's administered. LS cont. to be coarse with I/E wheezing but improved sats to 97%. RR 20-30. CXR done, ? early ARDS. IV Lasix 20mg. Rec'd first 2 doses of Meropenem this shift, new orders for Levaquin, Vanco now q12.\n\nGI: Obese abd NT w/+BS in 4 quadrants. Large, very loose stool x1, fecal collection bag placed. NPO since 0000 for anticipated TEE today.\n\nEndo: Pt remains on Reg insuling gtt for glucose control.\n\nGU: Patent foley draining gold colored, clear urine w/ decreasing u/o overnoc. pt rec'd IV Lasix as noted above, now draining light colored urine @ ~200cc/hr.\n\nLines: R art line, L CVL all patent, site appearance WNL.\n\nSkin: Scabbed lesion on elbows B/L, neg drainage, open to air. Skin on buttocks intact, lesions @ thigh creases B/L ~ 3cmx1cm. Powder applied to keep dry.\n\nPlan: Monitor and support hemodynamic status. Closely monitor respiratory status, MDI's prn and additional Lasix IV if u/o not ~200cc/hr. Monitor sedation status; ?medication chng to Versed and Fentanyl frequent Propofol boluses. Monitor FS, insulin gtt. VAP care q4h, turn q2h. F/U w/team re: cont'd POC.\n" }, { "category": "Nursing/other", "chartdate": "2191-11-11 00:00:00.000", "description": "Report", "row_id": 1341680, "text": "NPN\n\nNeuro: The Propofol was shut off prior to rounds this morning, she was awake and alert, answering some questions, able to gather that she felt SOB on A/C and was more comfortable on PSV. She is now sedated on 2.5 mcg/hr of fent and 1 mg/hr of versed, she has required boluses of 2.5mcg of fent and 1 mg of versed, she has done well with this sedation, easily arousible, following commands, usually appears comfortable.\n\nCV: BP stable 100-150s/70s, HR 80s. She had a TEE done today, no vegitation was found. Given 20 meq og KCl today, no ectopy noted, pm lytes were WNL, her bicarb was d/ced since she was alkalotic on her ABG.\n\nResp: She is on PSV 20/8,.4 VTs 500-600cc, rate 10-20, ABG 7.45/34/116. LS were very wheezy this morning, not so at noon but were again becoming more wheezy by 4 pm, she conts on steroids 10mg IV q8hr, the team discussed increasing this if she conts to be bronchospastic.\n\nGI: TF were restarted this afternoon, no stool today.\n\nGU: She is about even today with u/o 40-80cc/hr, team to talk with urology to discuss options.\n\nEndo: Conts on an insulin gtt, her BS have ranged from 200s-60, gtt titrated to keep her 80-120.\n\nSoc: Her family has called, no visitors today.\n" }, { "category": "Nursing/other", "chartdate": "2191-11-11 00:00:00.000", "description": "Report", "row_id": 1341681, "text": "RESPIRATORY CARE: PT W/ A 7.5 ORAL ETT IN PLACE.\nCHANGED TO PS 18/5 .40 TODAY. SX FOR YELLOW\nSPUTUM. ALBUTEROL AND ATROVENT MDI'S GIVEN.\nWILL C/W PS 18/5 AS TOLERATED.\n" }, { "category": "Nursing/other", "chartdate": "2191-11-19 00:00:00.000", "description": "Report", "row_id": 1341703, "text": "Respiratory Care:\nPatient remains on MMV ventilatory support with no parameter changes made throughout the night. No morning abg results at this time. Received mdi therapy with albuterol and atrovent with each vent check, as well as flovent, as documented in CareVue. SX'd for small amounts of secretions, with bright red results at 0430.\n\nRSBI = 72 on 0-PEEP and 5 cm PSV. No SBT due to increasing BP and HR during RSBI.\n" }, { "category": "Nursing/other", "chartdate": "2191-11-19 00:00:00.000", "description": "Report", "row_id": 1341704, "text": "MICU NSG NOTE.\nO:NEURO=SEDATED W PROPOFOL GTT @ 50MCG/KG/MIN W GD EFFECT. ALSO RECEIVING HALDOL 5MG IV TID. EASILY AROUSABLE, BUT DOES NOT FOLLOW COMMANDS. WHEN STIMULATED BECOMES VERY RESTLESS/MOVING ALL EXTREM, APPEARS TO BE STARING OFF INTO SPACE, DOES NOT TRACT/FOLLOW, & DOES NOT RESPOND TO VERBAL STIMULI. SOFT RESTRAINTS TO UPPER EXTREM.\n PULM=INTUBATED/VENTED W PRESENT SETTING--MMV-FIO2 40%-PEEP/PRESSURE SUPPORT -STV 700-800-RR 8-30. BREATH SOUNDS=COURSE THROUGHOUT. SX-THICK TANNISH SECRETIONS & LAST SX FOR THICKTANNISH/BLOODY SECRETIONS.\n CV=HEMODY STABLE. BECOMES TACHYCARDIC & HYPERTENSIVE WHEN AGITATED.\n GI=TF DCED @ 0400. MINIMAL RESIDUALS. WO STOOL.\n GU=EXCELLENT UO. PERIODIC DIURESIS OF GREATER THAN 400ML/HR-NOT RELATED TO ANYTHING.\n ID=AFEBRILE. REMAINS ON ABX X2.\n ENDO=2300 FSBS 154 COVERED W 2U RISS. AM BS PENDING.\n\nA:QUESTIONABLE NEURO STATUS. CONTIN SIGNIF AMTS THICK SECRETIONS.\n\nP:?WEAN DC PROPOFOL W GOAL EXTUBATION (?ABILITY TO CLEAR SECRETIONS WO ETT). RESUME TF POST EXTUBATION OR IF EXTUBATION NOT DONE. CK AM LABS-REPLACE AS INDICATED. SUPPORT PT/FAMILY (?HUSBAND & DAUGHTER TO VISIT TODAY ).\n" }, { "category": "Nursing/other", "chartdate": "2191-11-19 00:00:00.000", "description": "Report", "row_id": 1341705, "text": "Resp Care\n\nPt was extubated this shift without incident. Though small cuff leak present no stridor noted after extubation. BS with occ scattered wheezes but generally diminished. Bronchodilators changed to nebs\n" }, { "category": "Nursing/other", "chartdate": "2191-11-19 00:00:00.000", "description": "Report", "row_id": 1341706, "text": " 4 ICU nursing progress note:\n Respiratory: Pt placed on MMV mode this am..propofol dc'd..pt successfully extubated late . Prior to extubation had very minimal air leak..order for decadron for ?swelling x24hrs. No stridor heard. Was on 50% face tent but pt kept taking it off..changed to 3l nc..abg= 113/39/7.45. Has congested cough..needs encouragement to do so.\n Neuro: Pt remains confused to time and place. Follows commands and MAE. Is less agitated. Recieving haldol tid.\n Cardiac: Less tachycardic today..88-105st.sr. BP 140-170/60-70. Started on dilt for bp/hr control. Increased dose to 60 qid. Dc'd hydrochlorthiazide d/t diuresis.\n GU: U/O 200-300cc hr..Given 2 fluid boluses..When asked pt says she thirsty. CVP 2-6. ??cause of auto diuresis.\n GI: Will advance diet as tolerated..no stool..hypoactive bs.\n AODM: Recieving glargine in am and on ssri..bs seem to be in better control.\n Skin: No active issues. Thrush in mouth.\n" }, { "category": "Nursing/other", "chartdate": "2191-11-08 00:00:00.000", "description": "Report", "row_id": 1341667, "text": "NPN: Review of Systems\nEvents: MRI of head\n Cardiac Echo\n EEG\n Renal Ultrasound\n Pan Cultured\n\nNeuro: Pt sedated most of the day w/ propofol. High dose of 100mcg/kg/min during MRI, turned off for EEG->Pt opened eyes to voice, moved arms purposefully, but did not follow commands. Propofol now being titrated back to dose which will provide the most comfort..\n\nResp: Pt breathing comfortably when sedated-> abg=7.38/31/95 and 19/-5 when fiO2 decreased to 40% and PEEP increased to 8. Pt breathing over the vent. CPAP trial: RR in 30s, Pt appears labored. Sxning small amts of thick tan secretions.\n\nCV: NSR. HR70s-90s. No ectopy. BP=120s-140s/70-80s, while sedated. BP 170s/70s when not sedated adequately. Skin warm. Palpable DP/PT pulses bilaterally. Mg++ repleted.\n\nGI: Obese. OGT clamped. Plan to start tubefeeds when pump available.\n\nEndo: Insulin drip titrated w/ goal being a BS=80-150. Following protocol. Please see flowsheet for further data and assessment.\n\nGU: Clear yellow urine via foley.\n\nID: Afebrile today. Steroid dose decreased. Above tests done to try to find source of mental status change and fevers. Awaiting results. Continues on antibiotics.\n\nSkin: Intact. Multipodus boots placed on PT.\n\nSocial: sister and brother-in-law in to visit w/ Pt. Aware of pending results from above tests. Social Worker consulted to provide additional support to family. husband is ill and her father past away recently.\n\nA: Pt hemodynamically stable for multiple tests today. No change in neuro exam.\n\nP: F/U w/ tests results. Continue to check Blood sugar q1hr and titrate insulin accordingly. Start tubefeeds. One more set of blood cultures needed. Obtain ABG on CPAP.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2191-11-16 00:00:00.000", "description": "Report", "row_id": 1341693, "text": "NPN 1900-0700:\nNeuro: Pt is disoriented, confused, at times agitated tried to pull Foley and PICC line, MRI negative for abscess, opening eyes spontaneously and tries to get out of bed, not following commands, localizes pain.\n\nResp: Tachypneac, looks labored at times, but comfortable breathing most of the time, RR 18=38, SPO2 93-99 on O2 NC 2 L/min. LS coarse to diminished at beses, ABGs at 20: 7.51, 32, 70.\n\nCV: NSR-ST HR 72-112, BP 110-160/54-70, with a peripheral 22 G IV in lt hand and PICC in Rt AC, site echymotic, started on insulin drip at 5 units per hour, FS was stable up to 242 then suddenly dropped to 50, insulin has been OFF since 4 a.m. FS improved to 100s, receiving meropenam, K and Mg repleted at night. morning labs after repletion pending.\n\nGI/GU: abdomen obese, BS present, passed small BM, at risk for aspiration due to decreased mentation, PO meds not given, MD aware, with Foley draining 90-200 cc/hr clear yellow U/O, Foley catheter changed.\n\nInteg: With re3dness over perineal area, double guard applied, T max 99.8.\n\nSocial: No visits/calls from family over night, pt is full code.\n\nPlan: Continue monitoring LOC, monitor FS and ? resume insulin drip if needed, continue antibiotics, monitor electrolytes and replete accordingly.\n" }, { "category": "Nursing/other", "chartdate": "2191-11-16 00:00:00.000", "description": "Report", "row_id": 1341694, "text": " 4 nursing progress note:\n Respiratory: Increased rr all day..up to 40's. CXR done..??new pneumonia vs CHF. At times has paradoxical breathing pattern. Given 40 lasix with good u/o. Has had increased 02 requirements..now on 70% face tent..sats 89-96%. Pt re-evaluated by house staff late evening..??PE with persistant tachycardia and hypoxia..given x1 dose lovenox. Possible intubation later this evening.\n ID: Afebrile..however ??new pneumonia on cxr..started on levofloxicin and vanco. Last pm MRI neg for abcess..but GU service wants it repeated..??when.\n Cardiac: When pt asleep hr 80's..awake and confused..hr 110-120st..persistantly. bp 160-140/70. Was able to take po meds this am.\n GI: Incontinent of large amt liquid ob- stool..pt currently npo d/t mental status. Was able to take oatmeal and banana and some juice this am.\n GU: Good u/o to lasix..\n AODM: Dc'd insulin gtt this am..tightened ss and increased glargine.\nFollowing bs q6hrs..Now with new gap..\n Neuro: Lethargic this am..??d/t ativan and haldol from trip to MRI..pt fidgety and restlesss most of afternoon with increased rr. Legs over side rails. Trying to sit up..pulling o2 mask of. Hands restrained at times for saftey. Confused to time and place..knows name and name of sister. 2.5mgm haldol iv..with slight decrease in agitation.\n Social: Husband and sister called..updated..both aware pt doing worse today.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2191-11-08 00:00:00.000", "description": "Report", "row_id": 1341665, "text": "NPN 1900-0700\nEvents: Pt extubated yest during days, reintubated at for increased work of breathing, mod resp distress, ongoing severe delirium, dim gag. 7.5mm tube inserted without problem. L subclavian central line placed.\n\nNeuro: Prior to intubation and sedation, pt extremely agitated, pulling out IVs, flailing arms and legs in bed but did not open her eyes or respond to name. Sedated on Propofol after intubation, team didn't want versed/fent. Increased propofol up to 80mcg/kg/min to keep sedated adequately for vent. PERRL at 2mm bsk. moves extrem non purposefully.\n\nCV: HR 97-106, ns/st no ectopy. BP 107/49 - 161/63. +PP. K repleted c 40meq for K 3.3 yest. Started on D5W at 250mls/hr, changed to 150mls/hr for 3L, second L hanging. Na 150, down to 146 at midnoc, am labs pending.\n\nResp: Intubated as above, AC 500x14, 5peep, 50%. ABG in am 7.42/30/90/-. LS coarse, occ wheezing, cl with MDIs. Sats 96-99. ? pna. Sx for sm-mod amts thick, tan/bldy secretions. coughs occ/ gag dim.\n\nID: Tmax 101.7, tylenol 650 x2, on cooling blanket. On vanco, cefapime, azithro.\n\nGI: Abd obese, +BS, nt, no stool, +flatus. NPO, OG placed, conf by cxr. FSBS high, 396, 462. Reported to team, gave 10 units reg ins at 0400 for 462, team to evaluate for insulin gtt.\n\nGU: U?O 45-60mls/hr, dark, cl yellow urine. Pt + 1.1L los.\n\nSkin: Skin tear/eschar on elbows.\n\nAccess: TL subclav placed on L, placement confirmed by xray.\n\nSocial: Sister visited, making decisions for pt since husband is unable to come in due to prostate ca/radiation therapy.\n\nPlan: MRI as soon as possible. Monitor neuro status, resp status, BP, sedate for comfort. FSBS per team. Cont iv flds, abx, f/u on am labs.\n" }, { "category": "Nursing/other", "chartdate": "2191-11-08 00:00:00.000", "description": "Report", "row_id": 1341666, "text": "resp care\nPt intubated for inc resp distress, gag, and altered mental status.Placed on a/c 500x14 100% 5peep. Fio2 weaned to 50% with sats >95%.BS coarse rhonchi with few wheeze. Suct for thick brown blood tinged sput. ABG reveal a compensated met acidosis. Pt has episodes of inc rr >30 relieved with inc sedation.Alb/atro mdi given as ordered. RSBI attempted but rr inc > 40. MRI planned for today.Will cont to follow.\n" }, { "category": "Nursing/other", "chartdate": "2191-11-15 00:00:00.000", "description": "Report", "row_id": 1341690, "text": "MICU NPN\nNEURO: VERY AGITATED AND CONFUSED AT TIMES SEEMED TO GET WORSE AS THE NIGHT WENT ON. RECEIVED 1 MG OF IV ATIVAN WITH NO EFFECT, PULLED OFF O2, DESATED, WRIST RESTRAINTS WERE APPLIED FOR PT.SAFETY, BED ALARM ON.\n\nRESP: CONTINUES IN O2 AT 2L N/C, DESATS VERY QUICKLY TO LOW-MID 80'S IF O2 IS OFF. SOB WITH EXERTION..\n\nCV: BP AND HR STABLE SEE CAREVUE FOR DETAILS, CHANGES WER WITH PT'S BP MEDS DUE TO PT.BECOMONG MORE HYPERTENSION.\n\nGI: INC. OF LARGE AMTS OF STOOL X2.\n\nGU: FOLEY IN PLACE URINE OUTPUT 50-100CC/HR.\n\nSOCIAL: FAMILY IN VISITING YESTERDAY AFTERNOON.\n\nPLAN: CONTINUE TO MONITOR, IF CALLED OUT TO FLOOR NEED A SITTER.\n" }, { "category": "Nursing/other", "chartdate": "2191-11-15 00:00:00.000", "description": "Report", "row_id": 1341691, "text": "RESPIRATORY CARE:\n\nFollowing pt for bronchodilator therapy Q4-6. BS's diminished with some coarse exp wheezes, mainly with exertion. No changes overnight, see flowsheet for further pt data. Will follow.\n" }, { "category": "Nursing/other", "chartdate": "2191-11-09 00:00:00.000", "description": "Report", "row_id": 1341671, "text": " 4 ICU nursing progress note:\n Resiratory: Remains intubated and vented. Requireing AC/500/14/40%/5peep..over breathing by 20-25bbm. Has minimal secretions. Attempted brief C-pap trial..pt immediately had increased rr..and was uncomfortable. Per house staff..??worsening pneumonia.\n Neuro: Continues on propofol @80 mic/kg. Pt responds to noxious stimuli. If lightened attempts to open eyes. Does not follow commands or move extremities. Neuro still following.\n ID: Spiked to 102.5 this afternoon..was previously 101 most of am. Given tylenol BC x2 done. Still waiting for previous cultures. To have TEE tomorrow to r/o pericarditis. No change in antibiotics.\n Cardiac: BP 130-150/ tachycardic most of day to 115 with fevers.,\n GU: Fair u/o 10-50cc hr..no further fluid given..??reassess this evening..could become dry.\n GI: Small amt of liquid brown stool..ob -..Mushroom catheter placed.\nTF restarted 25hr.. Will shut off at 4am in preperation for TEE.\n Skin: No new issues.\n Social: No contact with family today.. Spoke to social service..she will follow up with family tomorrow.\n" }, { "category": "Nursing/other", "chartdate": "2191-11-09 00:00:00.000", "description": "Report", "row_id": 1341672, "text": " 4 ICU nursing note addendum:\n AODM: Continues on insulin gtt..bs as low as 52 and high of 200.\nAdjusting gtt accordingly. With TF on ??help keep bs up..will follow closely.\n" }, { "category": "Nursing/other", "chartdate": "2191-11-21 00:00:00.000", "description": "Report", "row_id": 1341710, "text": "Neuro: Alert most of the day yet very slow with communication, no garbled speech. Able to state name, type of place and month/year. Needs encouragement and time for her make a statement. Able to identify her sister and brother in-laws name. Patient sleeping intermittently. Tremors of R arm noted, stiff upper extremeties. No seizures noted. Neuro in to assess patient ? seizure or encephalopathy. Pupils equal briskly reactive to light. Follows simple commands. Denies pain, got out of bed to chair for 4 hrs tolerating well. EEG done, no result yet. CT scan of head no remarkable findings.\n\nCV: SBP 110-130's SR-ST without ectopy. denies any achest pain, no edema noted, easily palpable pedal pulses. PICC line and L subclavian multilumen functioning well.\n\nRespi: satting 98-100% at 2 lpm, lung sounds clear diminished at bases. cough out tan sticky secretions x 1; started on incentive spirometry, got tired easily.\n\nGI: speech and swallow eval, patient coughing / choking with water. on aspiration precaution thickened liquids with supervision. Patient spits her PO meds, unable to tolerate ( refusing ) crushed meds with applesauce, pudding, jeloo after several tries. bowel sounds present, no bowel movement, given bisacodyl supp x 1, no effect.\n\nGU: urine output > 50cc/hr goal euvolemic. No clots noted with her urine.\n\nEndo: on insulin sliding scale and glargine 35 units. FS 218 with 8 humalog coverage.\n\nID: meropenem dc'd ? contributory to ? seizure activity. Started on ciprofloxacin PO yet patient spits meds. Shifted to IV 400 mgs q12hrs. Continues on vancomycin. Tmax 97.7\n\nSocial: patient's husband and daughter called for updates, sister and brother-in-law in for a visit.\n\nplan:\n\nPIV insertion and plan to dc central line if patient will have another temp spike. follow-up blood cultures sent last night. encourage incentive spirometry when awake. monitor patient's mental status, reorient consistently. Provides sleep and rest tonight.\n\n" }, { "category": "Nursing/other", "chartdate": "2191-11-22 00:00:00.000", "description": "Report", "row_id": 1341711, "text": "NPN 1900 -0700\n\nNEURO: AWAKE AND ALERT, KNOWS SHE IS AT A HOSPITAL ,DOESN'T KNOW WHICH, DOESN'T KNOW YEAR.PLEASANT AND COOPERTIVE, FOLLOWS COMMANDS, ALTHOUGH SHE CONT TO BE SOMEHAT \"SLOW \" TO RESPOND.\n\nRESP: LCTA DIM AT BASES MAINT SATS 97-100 ON 2L NC.\n\nC/V: ST NO PVC'S , BP STABLE.\n\nF/E/N: UO ~ 50 CCHR, RECIEVED ONE 500 CC BOLUS FOR LOW UO AND TEAMS CONCERN PT WAS - 800CC/DRY. ABLE TO SWALLOW PILLS W/ PUDDING.\n\nPLAN: CONT TO MONITOR HEMODYNAMICS, ASPIRATION PRECAUTIONS, EMOTIONAL SUPPORT FOR FAMILY.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2191-11-22 00:00:00.000", "description": "Report", "row_id": 1341712, "text": "Neuro: patient very alert making sensible conversations and following news. denies any pain, oriented x 3; got out of bed for 4 hrs tolerating well, starts to gain normal power on upper extremeties., stands with supervision.\n\nCV: BP 130-150's on diltiazem, hctz and norvasc; SR-ST without ectopy; no edema\n\nRespi: sat's > 95% at room air, lung sounds clear, dim at bases still, uses incentive spirometry well\n\nAccess: new PIV at LFA; PICC line intact, central line pulled out today.\n\nGI: tolerating sofft solid, on aspiratio precaution. no bowel movement today. bowel sounds present.\n\nGU: urine output > 50cc/hr; -2L for LOS\n\nSocial: husband called for updates\n\nEndo: on RISS FS 241 with coverage\n\nID: afebrile, continues on cipro and vancomycin\n\nplan: called out to floor, waiting for room, monitor mental status, continue to reorient, provide encouragement, insert another PIV and pull out PICC line\n" }, { "category": "Nursing/other", "chartdate": "2191-11-15 00:00:00.000", "description": "Report", "row_id": 1341692, "text": " 4 ICU nursing progress note:\n Respiratory: rr 18-22 O2 sats 95-99%..02 off while up in chair. Maintained adequate sats in high 90's. Once back in bed placed back on 2l nc. Has dry cough. Less wheezing.\n Neuro: Awake and restless this am. Confused to time and place..knows name and town she lives in. Has been un-restrained thruough-out day..does not seem to pick at things. Will attempt to get oob. Alarm set. OOB to chair with assist of 2. Tolerated well.\n ID: Afebrile. No change in antibiotic regime. Housestaff insist on MRI of kidney to r/o abcess..awaiting time.\n GI: Incontinent of loose ob- green stool x5 today. Taking po liqs and food. Able to feed self ..needs to be feed other foods..\n GU: Maintaining good u/o.\n Cardiac: Tachycardic most of day 100-115st EKG done. ??dry/pt also agitated. Given 500ns x2 today. Slight decrease in hr. BP as high as 170's..continues on antihypertensives.\n AODM: BS consistantly above 200's despite ssri..glargine and po meds.\nTo start IV insulin gtt.\n Skin: Excoriated buttocks and inner thighs..d/t constant diarrhea...Using double . Ordered for desitin and lido.\n Access: Only has single lumen PICC..IVRN attempting to place another peripheral line for IV insulin.\n Social: Spoke to husband and updated.\n" }, { "category": "Nursing/other", "chartdate": "2191-11-10 00:00:00.000", "description": "Report", "row_id": 1341673, "text": "NPN 1900-0700\nEvents: CT scan abdomen.\n\nResp: RR up > 40 when temp up to 103.1 and MVs >21, using abd musc to breath. Propofol up to 100mcg/kg/min with additional boluses during this time. Pt improved once temp down and 500ml bolus given, but rr remained in 30s all noc while on AC c no changes to vent. Team aware and discussed pt many times. Sx when coughing ~q1-3hrs for sm-mod amt thick, tan sputum c bldy plugs. LS coarse, dim bases, occ wheezes. ABG 7.38/24/156, receiving po na bicarb for alkalosis.\n\nCV: HR 94-111, ns,no ectopy. sbp 132-155 except when RR up in 40s, then >160. Tmax 103.1, 1gm tylenol given, iced pt, temp grad down, last 99.9 po.\n\nNeuro: Opened eyes x2 while on 100 propofol. no response to commands, responds to painful stimuli. moves upper extrem.\n\nGI: TF off at 0400 for TEE. Highest residual 60mls. Med black stool, OB neg, soft/formed. Mushroom cath removed c stool. +BS.\nInsulin gtt cont, FS up and down.\n\nGU: Adequate u/o.\n\nSkin: Some redness and sm open area between skin folds of groin, antifungal ordered.\n\nSocial: Sister and brother in law visited on eves. Daughter called and updated.\n" }, { "category": "Nursing/other", "chartdate": "2191-11-10 00:00:00.000", "description": "Report", "row_id": 1341674, "text": "pt transported to CT for image of abdomen, pt tollerated without incidence.She was sx'd for moderate secretions.plan is let pt stabilize before further weaning is attempted. AM RSBI not done due to high RR.\n" }, { "category": "Nursing/other", "chartdate": "2191-11-10 00:00:00.000", "description": "Report", "row_id": 1341675, "text": "pt was on CMV with set rate of 14 but with actual rate of 32. B/S were slightly diminished at the bases with some wheezes noted. MDI'S given as ordered. Sx moderate amount of pink, tinged thick sputum.\n Plan is to correct metabolic acidoisis to see if this will correct respiratory alkalosis. Will continue to follow closely.\n\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2191-11-18 00:00:00.000", "description": "Report", "row_id": 1341699, "text": "MICU NPN\nNEURO: CONTINUES TO BE SEDATED WITH FENTANYL 75MCG/HR AND VERSED WHICH WAS INCREASED 2.5MG/HR DUE TO PT. BECOMING VERY RESTLESS, THRASHING IN BED, THROWING FEET OVER SIDERAILS. SHE ALSO RECEIVED ADDITIONAL BOLUS OF FENT/VERSED DURING THIS TIME.\n\nRESP: PLACE ON MMV AROUND MID. DUE TO INCREASED NEED FOR SEDATION. SETTINGS ARE 450X8 WITH PEEP OF 5 AND P/S OF 5. PT. ALSO HAS LARGE AMTS. OF BLOODY/PINK TINGED SECREATIONS, ? IF SHE SHOULD BE EXTUBATED TODAY DUE TO INCREASE SECREATIONS, ? IF PT. WILL BE ABLE TO CLEAR OWN SECREATIONS ONCE EXTUBATED. SEE CAREVUE FOR MOST UP TO DATE ABG RESULTS.\n\nCV: HR AND BP STABLE SEE CAREVUE FOR MOST UP TO DATE INFO.\n\nGI: TUBE FEEDS WERE SHUT OFF IN ANTICIPATION OF EXTUBATION THIS AM. OGT IN PLACE, + BS NO STOOL OVERNIGHT.\n\nGU: U/O 30-70CC/HR VIA FOLEY.\n\nSOCIAL: FAMILY WAS UPDATED BY TEAM YESTERDAY, NO VISITORS LAST NIGHT.\n\nPLAN: TO EXTUBATE TODAY, OHERWISE CONT. WITH PRESENT TREATMENT.\n" }, { "category": "Nursing/other", "chartdate": "2191-11-18 00:00:00.000", "description": "Report", "row_id": 1341700, "text": "RESPIRATORY CARE:\n\nPt remains intubated, vent supported overnight on MMV for increasing periods of apnea and hypoventilation. BS's coarse, with scattered wheezing. Sxing thick blood tinged secretions. Administering Albuterol, Atrovent, and Flovent MDIs as ordered. See flowsheet for further pt data. Will follow.\n" }, { "category": "Nursing/other", "chartdate": "2191-11-18 00:00:00.000", "description": "Report", "row_id": 1341701, "text": "Resp Care\nPt remains intubated on MMV, RR/pattern erratic. RR 5-25. Sx for mod bloody secretions. Plan to eval for extubation in AM.\n" }, { "category": "Nursing/other", "chartdate": "2191-11-18 00:00:00.000", "description": "Report", "row_id": 1341702, "text": "Nursing Note:\n\nNeuro: pt switched from midaz/fentanyl to propofol drip in anticipation of extubation tomorrow. propofol currently at 20mcs/kg/min. haldol 5mg IV TID, pt opens eyes to stimulation, appears agitated when awake, moving extremities in bed, attempting to put legs over side of bed, does not appear to follow or track with eyes when awake, neuro consult today, ? unknown neurological process.\n\nResp: pt on MMV Psupp 5, PEEP 5, FIO2 40, VT 300-500's, irreglar resp pattern, RR 8-20, sats 97-100, suction mod/copious brown blood tinged thick secretions, plan to extubate today but concern over airways secretions and mental status, plan to attempt extubation tomorrow.\n\nCV: HR 65-85 NSR when asleep, up to 110 ST when agitated, no ectopy, r radial aline, ABP 100-140/45-65, afebrile, minimal extrem edema.\n\nGI: pt NPO since 0400 for planned extubation, resumption of tube feedings ordered to be turned off at 0400 tonight for ?extubation, OGT intact. abd soft and obese, no BM today.\n\nGU: UO 100-120cc/hr clear yellow, pts fluid status negative, 500cc NS bolus ordered at 1700.\n\nSkin: no active skin breakdown noted, barrier cream applied to coccyx, repositioned q4h.\n\nIV: left SC TLC dressing changed, r PICC line flushed dsg due to be changed, r radial aline.\n\nSocial: pts sister and husband called for update, pts husband coming down from VT to visit tomorrow.\n\nPlan: cont to evaluate for possible extubation tomorrow AM, cont to monitor resp status, secretion volume. neuro status, sedation level. update famliy as appropriate.\n" }, { "category": "Nursing/other", "chartdate": "2191-11-13 00:00:00.000", "description": "Report", "row_id": 1341685, "text": "61 yr old admitted to hospital in confusion agitation urosepsis, fever spiked, was intubated by . Head Ct was negative, LP negative. HX asthma, DM\n\nNeuro pt alert oriented sitting inchair conversing with staff and family. speaking appropriately answers questions and follows commands.\n\nCV Hr in 70-80's BP 160/70 at times rec'd 1dose of norvasc 10mg. at noon . Pt has central line in which team wants to D/C In is for PICC line placement perIV approval. Iv up to see if possible for PIV x2 placment but unable to place.\n\nResp pt become wheezy this AM had neb treatment but felt as though she needed another one, RT gave her 2nd treatment with good results. Had prodcutive cough this am with somall amts of white sputum. Pt on n/c 2 l but has not had any o2 on since OOB to chair.\n\nGi/GU changed from insulin drip to sliding scale 1300 blood sugar 201 rec'd 4 u humlog Did have small breakfast/lunch. Diet to be advanced Eating and rinking easily Foley inplace draining clear yellow urine. Pt incontinenet of brown liquid stool x1. Order for foley to be removed. Will need to use bedpan. Pt unable to stand and held up with 2 assist and pivot to chair.\n\nSocial husband and daughter into visit. Pt very happy to see husband unable to sleep last night since she was awaiting his visit. Husband said to shut TV at night so that pt will sleep\n\nCOnt on meripenum other Abx d/c'd\n" }, { "category": "Echo", "chartdate": "2191-11-11 00:00:00.000", "description": "Report", "row_id": 68662, "text": "PATIENT/TEST INFORMATION:\nIndication: Endocarditis.\nHeight: (in) 66\nWeight (lb): 200\nBSA (m2): 2.00 m2\nBP (mm Hg): 128/78\nHR (bpm): 80\nStatus: Inpatient\nDate/Time: at 14:31\nTest: Portable TEE (Congenital)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: No spontaneous echo contrast or thrombus in the LA/LAA or the\nRA/RAA.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: PFO is present. Left-to-right shunt across\nthe interatrial septum at rest.\n\nLEFT VENTRICLE: Overall normal LVEF (>55%).\n\nAORTA: Simple atheroma in aortic arch. Simple atheroma in descending aorta.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No masses or vegetations on\naortic valve. No AS. No AR.\n\nMITRAL VALVE: Normal mitral valve leaflets with trivial MR. mass or\nvegetation on mitral valve.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. No mass or\nvegetation on tricuspid valve.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with\nphysiologic PR.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: The patient was monitored by a nurse \nthroughout the procedure. Local anesthesia was provided by benzocaine topical\nspray. The patient was sedated for the TEE. Medications and dosages are listed\nabove (see Test Information section). No TEE related complications. 0.2 mg of\nIV glycopyrrolate was given as an antisialogogue prior to TEE probe insertion.\n\nConclusions:\nNo spontaneous echo contrast or thrombus is seen in the body of the left\natrium/left atrial appendage or the body of the right atrium/right atrial\nappendage. A patent foramen ovale is present with slight left-to-right shunt\nacross the interatrial septum at rest. There are probably complex nonmobile\natheroma in the aortic arch. There are simple atheroma in the descending\nthoracic aorta. Biventricullar systolic function appears normal. The aortic\nvalve leaflets (3) appear structurally normal with good leaflet excursion. No\nmasses or vegetations are seen on the aortic valve. There is no aortic valve\nstenosis. No aortic regurgitation is seen. The mitral valve appears\nstructurally normal with trivial mitral regurgitation. No mass or vegetation\nis seen on the mitral valve. There is no pericardial effusion.\n\nIMPRESSION: No perivalvular abscess or vegetation seen. Patent foramen ovale\nwith left to right shunt. Aortic atheroma.\n\n\n" }, { "category": "Echo", "chartdate": "2191-11-08 00:00:00.000", "description": "Report", "row_id": 68663, "text": "PATIENT/TEST INFORMATION:\nIndication: Evaluate for endocarditis.\nHeight: (in) 61\nWeight (lb): 175\nBSA (m2): 1.79 m2\nBP (mm Hg): 147/64\nHR (bpm): 84\nStatus: Inpatient\nDate/Time: at 15:06\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the report of the prior study (images not\navailable) of .\n\n\nLEFT ATRIUM: Normal LA size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: RA not well visualized.\n\nLEFT VENTRICLE: Normal LV wall thickness, cavity size, and systolic function\n(LVEF>55%). Suboptimal technical quality, a focal LV wall motion abnormality\ncannot be fully excluded.\n\nRIGHT VENTRICLE: RV not well seen.\n\nAORTA: Normal aortic root diameter. Normal ascending aorta diameter.\n\nAORTIC VALVE: Normal aortic valve leaflets. ?# aortic valve leaflets. No\nmasses or vegetations on aortic valve. No AS. No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No mass or vegetation on\nmitral valve. Mild thickening of mitral valve chordae. No MR. Normal LV inflow\npattern for age.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.\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 normal in size. Left ventricular wall thickness, cavity\nsize, and systolic function are normal (LVEF>55%). Due to suboptimal technical\nquality, a focal wall motion abnormality cannot be fully excluded. The aortic\nvalve leaflets appear structurally normal with good leaflet excursion. The\nnumber of aortic valve leaflets cannot be determined. No masses or vegetations\nare seen on the aortic valve. There is no aortic valve stenosis. No aortic\nregurgitation is seen. The mitral valve leaflets are mildly thickened. No mass\nor vegetation is seen on the mitral valve. No mitral regurgitation is seen.\nThere is no pericardial effusion.\n\nCompared with the report of the prior study (images unavailable for review) of\n, the previously described focal inferior hypokinesis is not well\nvisualized. There are no obvious vegetations on the mitral or aortic valves,\nbut due to poor echo windows, endocarditis cannot be fullly excluded.\n\n\n" }, { "category": "ECG", "chartdate": "2191-11-16 00:00:00.000", "description": "Report", "row_id": 149796, "text": "Sinus rhythm\nLeft axis deviation\nPoor R wave progression\nSince previous tracing, slower rate noted\n\n" }, { "category": "ECG", "chartdate": "2191-11-07 00:00:00.000", "description": "Report", "row_id": 149797, "text": "Sinus tachycardia. Consider left anterior fascicular block and prior inferior\nwall myocardial infarction. Delayed R wave progression with late precordial\nQRS transition could be due in part to left axis deviation/left anterior\nfascicular block. Non-specific ST-T wave changes. Since the previous tracing\nof left axis deviation with suggestion of inferior wall\nmyocardial infarction is present, QRS voltage is less prominent and ST-T wave\nabnormalities have decreased.\n\n" }, { "category": "Radiology", "chartdate": "2191-11-15 00:00:00.000", "description": "MR 3D RENDERING W/POST PROCESSING ON INDEPENDENT WS", "row_id": 939704, "text": " 6:28 PM\n MRI ABDOMEN W/O & W/CONTRAST; MR 3D RENDERING W/POST PROCESSING ON INDEPENDENT WSClip # \n Reason: please eval L kidney for abscess vs tumor vs other\n Admitting Diagnosis: ALTERED MENTAL STATUS\n Contrast: MAGNEVIST Amt: 20\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old woman with UTI, pyelonephritis?, altered mental status, fever and\n evidence of pyelonephrosis on CT abd\n REASON FOR THIS EXAMINATION:\n please eval L kidney for abscess vs tumor vs other\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Mass-like appearance of left kidney on prior imaging.\n Persistently altered mental status, with fever and evidence of pyelonephritis\n on prior CT. Evaluate for renal abscess, tumor.\n\n TECHNIQUE: Multiplanar MR imaging of the abdomen was performed, including\n dynamically acquired images of the abdomen obtained before, during, and after\n the administration of 0.1 millimoles per kilogram of gadolinium-DTPA.\n\n 3D postprocessed images were also reviewed at time of interpretation, although\n of limited utility given the gross motion throughout the examination.\n\n Of note, non-breathhold technique was performed for this entire examination,\n as the patient was unable to cooperate for this examination. Gross motion was\n seen throughout the examination degrading both image quality as well as\n registration of images.\n\n COMPARISONS: None. Correlation is made to the prior CT dated .\n\n FINDINGS:\n\n The right kidney measures approximately 12.5 cm in size. The left kidney is\n enlarged, measuring approximately 14.5 cm in size. The degree of cortical-\n medullary differentiation seen in the left kidney is decreased when compared\n to the right. In addition, the left kidney shows a diffusely heterogeneous\n signal intensity when compared to the right. Regions of wedge-shaped signal\n abnormalities are seen extending to the periphery of the kidney in multiple\n locations, showing both areas which are of greater T2 signal than the\n background parenchyma, as well as others which appear somewhat decreased in\n signal. Some of these lesions are hypoperfusing after the administration of IV\n gadolinium when compared to the background renal parenchyma. There is no\n evidence of frank abscess or drainable collection of the left kidney. Minimal\n left-sided perinephric fat stranding remains present. There is no evidence of\n hydronephrosis. Within the limits of this motion degraded examination, no mass\n lesion is identified within the left kidney.\n\n The remainder of the visualized abdominal viscera are unremarkable, again\n given the limitations of the examination.\n\n IMPRESSION:\n (Over)\n\n 6:28 PM\n MRI ABDOMEN W/O & W/CONTRAST; MR 3D RENDERING W/POST PROCESSING ON INDEPENDENT WSClip # \n Reason: please eval L kidney for abscess vs tumor vs other\n Admitting Diagnosis: ALTERED MENTAL STATUS\n Contrast: MAGNEVIST Amt: 20\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n 1. Markedly motion-limited.\n\n 2. Diffusely enlarged left kidney, with regions of wedge-shaped signal\n intensity abnormalities extending to the periphery of the kidneys. These\n findings may be consistent with pyelonephritis, and the differential diagnosis\n also includes bland versus septic embolic disease.\n\n 3. No evidence of drainable abscess.\n\n 4. Within the limits of this examination, no mass lesion is identified.\n However, greater sensitivity for detection of mass can be obtained if a MRI is\n performed when the patient is able to cooperate and performed multiple breath\n holds.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2191-11-09 00:00:00.000", "description": "CT PELVIS W/CONTRAST", "row_id": 938992, "text": " 11:52 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: please eval for necrotizing pyelonephritis\n Admitting Diagnosis: ALTERED MENTAL STATUS\n Field of view: 50 Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old woman with known UTI, persistent fever and altered mental status;\n perinephric stranding on CT Abd from OSH several days ago\n REASON FOR THIS EXAMINATION:\n please eval for necrotizing pyelonephritis\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: 12:40 AM\n left pyelonephrosis. no evidence of abscess, gas, or perirenal fluid\n collection. no renal vein or ovarian vein thrombosis. bowel looks normal.\n bibasilar atelectasis.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 61-year-old female with known UTI, persistent fever, and altered\n mental status, with perinephric stranding on CT from outside hospital.\n Evaluate for necrotizing pyelonephritis.\n\n COMPARISON: renal ultrasound and CT abdomen and pelvis\n (reference) .\n\n TECHNIQUE: MDCT acquired axial images of the abdomen and pelvis were\n performed with IV contrast. Multiplanar reformations were obtained.\n\n CT ABDOMEN WITH IV CONTRAST: There is bibasilar atelectasis. The liver,\n gallbladder, pancreas, spleen, adrenal glands, and right kidney are\n unremarkable. The left kidney is slightly enlarged diffusely and\n heterogeneous in appearance with some perinephric stranding similar to prior\n study from . Noted on today's contrast-enhanced exam is\n heterogeneous enhancement as well as a focal area of both enhancement and mass\n effect measuring 5.8 x 4.4 cm within the mid portion anteriorly. There is no\n definite fluid collection present. These findings are very suspicious for\n renal neoplasm. However, this could represent focal superimposed area of\n phlegmonous tissue. There is no evidence of hydronephrosis or hydroureter. The\n small and large bowel are unremarkable. There is no free fluid or free air.\n There is no retroperitoneal or mesenteric lymphadenopathy. Diffuse aortic and\n iliac artery calcifications. The urinary bladder is catheterized contains a\n small of contrast.\n\n There are no suspicious lytic or sclerotic bony lesions.\n\n IMPRESSION:\n\n 1. Heterogeneous enhancement of the left kidney with focal 4.4 x 5.8 cm area\n of increased heterogeneity within the mid pole. These findings are concerning\n for renal neopasm. DDx includes diffuse pyelonephritis with underlying\n phlegmonous change. There is no specific fluid collection present. There is\n some surrounding perinephric stranding. There is no hydronephrosis or\n (Over)\n\n 11:52 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: please eval for necrotizing pyelonephritis\n Admitting Diagnosis: ALTERED MENTAL STATUS\n Field of view: 50 Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n hydroureter.\n\n These findings were discussed with Dr. on .\n\n\n" }, { "category": "Radiology", "chartdate": "2191-11-11 00:00:00.000", "description": "BY DIFFERENT PHYSICIAN", "row_id": 939229, "text": " 2:31 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: Please evaluate tube placement\n Admitting Diagnosis: ALTERED MENTAL STATUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old woman s/p intubation now with bronchospasm and increasing oxygen\n requirement now s/p TEE\n REASON FOR THIS EXAMINATION:\n Please evaluate tube placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post intubation with bronchospasm and increasing oxygen\n requirement.\n\n PORTABLE AP CHEST\n\n The ET tube is about 4 cm above the carina. The NG tube tip overlies the\n stomach. The cardiomediastinal silhouette is unchanged. Bilateral vascular\n congestion is noted and probably is secondary to CHF and volume overload.\n There are no pleural effusions. There is no pneumothorax.\n\n The right subclavian catheter tip overlies the upper SVC.\n\n IMPRESSION: No significant change from the prior radiograph obtained 10 hours\n earlier\n\n\n" }, { "category": "Radiology", "chartdate": "2191-11-08 00:00:00.000", "description": "MR HEAD W & W/O CONTRAST", "row_id": 938717, "text": " 8:17 AM\n MRA BRAIN W/O CONTRAST; MR HEAD W & W/O CONTRAST Clip # \n Reason: eval for acute stroke, temporal lobe enhancement, evidence f\n Admitting Diagnosis: ALTERED MENTAL STATUS\n Contrast: MAGNEVIST Amt:\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old woman with\n REASON FOR THIS EXAMINATION:\n eval for acute stroke, temporal lobe enhancement, evidence for encephalopy\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: NPw TUE 4:56 PM\n Chronic microvessel disease; no acute infarct.\n Mild, smooth, benign appearing diffuse pachymeningeal enhancement, which could\n be related to recent LP and unlikely to explain the pt's presentation. No\n leptomeningeal endhancement.\n Right fetal equivalent PCA; Right A1 absent with both A2 being supplied by\n left ACA, which is very tortuous.\n Irreularity of basilar artery.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 61-year-old woman with urosepsis, pyelonephritis, altered mental\n status, possible drug overdosage, to evaluate for any intracranial structural\n lesion.\n\n PRIOR STUDY: CT of the head without contrast done on .\n\n TECHNIQUE: Multiplanar T1- and T2-weighted imaging of the brain was performed\n with IV contrast. 3D TOF MR angiogram of the circle of was also\n performed.\n\n FINDINGS:\n\n The posterior fossa structures are unremarkable. There are several small\n areas of increased signal intensity on the FLAIR images and bilateral cerebral\n white matter, which are nonspecific but could most likely represent chronic\n microvascular disease. No abnormality is noted on the diffusion-weighted\n images to suggest acute infarcts. The ventricles and extra-axial CSF spaces\n are unremarkable. There is mild smooth enhancement of the pachymeninges\n diffusely, is likely benign, related to the recent lumbar puncture procedure\n and is unlikely to explain the patient's presentation. There is no\n leptomeningeal enhancement. The osseous and the soft tissues structures and\n visualized portions of the paranasal sinuses and the orbits are unremarkable.\n\n MR ANGIOGRAM OF THE CIRCLE OF : Bilateral cavernous ICA and MCA are\n patent and normal in caliber. The A1 segment of right ACA is not visualized.\n Bilateral A2 segments are supplied by single left ACA which is tortuous in\n course. Visualized segments of bilateral distal vertebral arteries are\n unremarkable. The basilar artery has an irregular contour, likely due to\n atherosclerosis. Right fetal equivalent PCA is noted; left PCA appears normal.\n\n IMPRESSION:\n (Over)\n\n 8:17 AM\n MRA BRAIN W/O CONTRAST; MR HEAD W & W/O CONTRAST Clip # \n Reason: eval for acute stroke, temporal lobe enhancement, evidence f\n Admitting Diagnosis: ALTERED MENTAL STATUS\n Contrast: MAGNEVIST Amt:\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n 1. No acute infarcts.\n 2. Chronic microvascular disease.\n 3. Benign appearing pachymeningeal enhancement, most likely related to the\n recent LP and unlikely to explain the patient's presentation.\n 4. No leptomeningeal enhancement.\n 5. Absent A1; bilateral A2 segments supplied by single left ACA; fetal\n equivalent of right PCA.\n\n 6.Atherosclerotic disease overlying the basilar artery with no evidence of\n stenosis or occlusion.\n\n\n" }, { "category": "Radiology", "chartdate": "2191-11-16 00:00:00.000", "description": "BY DIFFERENT PHYSICIAN", "row_id": 939846, "text": " 7:33 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: ETT placement\n Admitting Diagnosis: ALTERED MENTAL STATUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old woman with asthma,having increased difficulty breathing\n\n REASON FOR THIS EXAMINATION:\n ETT placement\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 61-year-old woman with asthma, having difficulty breathing status\n post ETT placement.\n\n COMPARISON: at 10:36 a.m.\n\n CHEST AP: Accounting for the rotation on the film, cardiac, mediastinal, and\n hilar contours are stable. Pulmonary vasculature is unchanged. There\n continues to be a retrocardiac consolidation. A right infrahilar opacity is\n more prominent on this exam. No pleural effusions are identified.\n Endotracheal tube, nasogastric tube, and right-sided PICC appear in\n satisfactory position. Osseous and soft tissue structures are unremarkable.\n\n IMPRESSION:\n 1. Satisfactory positioning of endotracheal tube.\n 2. Retrocardiac consolidation and depression of the left mainstem bronchus\n consistent with left lower lobe collapse, possibly due to mucous plugging.\n Right infrahilar opacity could represent a developing pneumonia or additional\n mucous plugging.\n\n" }, { "category": "Radiology", "chartdate": "2191-11-14 00:00:00.000", "description": "FLUOR GUID PLCT/REPLCT/REMOVE", "row_id": 939504, "text": " 10:57 AM\n PICC LINE PLACMENT SCH Clip # \n Reason: Please place PICC line for Abx.\n Admitting Diagnosis: ALTERED MENTAL STATUS\n ********************************* CPT Codes ********************************\n * PICC W/O FLUOR GUID PLCT/REPLCT/REMOVE *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old woman with Sepsis and MS change, now resolving requiring PICC\n placed by IR\n REASON FOR THIS EXAMINATION:\n Please place PICC line for Abx.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 61-year-old woman with sepsis, requiring PICC line for\n antibiotics.\n\n RADIOLOGISTS: Drs. and Dr. , the attending radiologist,\n was present and supervising throughout.\n\n TECHNIQUE/FINDINGS: Using sterile technique and 1% Lidocaine for local\n anesthesia, the right basilic vein was localized with ultrasound and punctured\n under direct ultrasound guidance using a micropuncture set. A peel-away\n sheath was then placed over the wire and a single lumen PICC was then placed\n through the peel-away sheath with its tip positioned in the SVC under constant\n fluoroscopic guidance. Position of the catheter was confirmed with subsequent\n single fluoroscopic spot view. Peel-away sheath was then removed and the\n catheter was secured to the skin. The patient tolerated the procedure well\n with no immediate complications.\n\n IMPRESSION: Uncomplicated ultrasound and fluoroscopically guided PICC\n placement via the right basilic venous approach, with tip positioned in the\n SVC.\n\n" }, { "category": "Radiology", "chartdate": "2191-11-14 00:00:00.000", "description": "BY DIFFERENT PHYSICIAN", "row_id": 939552, "text": " 3:59 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: please ensure PICC line position is unchanged after removal\n Admitting Diagnosis: ALTERED MENTAL STATUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old woman with asthma, s/p PICC line placement and CVL removal\n REASON FOR THIS EXAMINATION:\n please ensure PICC line position is unchanged after removal of central line\n ______________________________________________________________________________\n FINAL REPORT\n CHEST, SINGLE AP FILM\n\n History of asthma and PICC line placement.\n\n Tip of right-sided PICC line overlies proximal SVC. A left-sided subclavian\n CV line has been removed. No pneumothorax.\n\n\n" }, { "category": "Radiology", "chartdate": "2191-11-16 00:00:00.000", "description": "BY SAME PHYSICIAN", "row_id": 939855, "text": " 9:15 PM\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \n Reason: eval for line placemet\n Admitting Diagnosis: ALTERED MENTAL STATUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old woman s/p Left subclavian line placemet\n REASON FOR THIS EXAMINATION:\n eval for line placemet\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: New line placement.\n\n COMPARISON: Chest x-ray from the same day.\n\n FRONTAL CHEST: An endotracheal tube terminates 3.8 cm above the carina. The\n tip of the nasogastric tube is not visualized, but is below the diaphragm.\n There is a right-sided PICC with its tip over the superior vena cava. There\n is a new left subclavian central venous catheter with its tip in the central\n superior vena cava. Again seen are prominent pulmonary vessels as well as\n retrocardiac left lower lobe opacification. The previously identified opacity\n in the right lower lung has improved, and therefore was likely in part due to\n mucus plugging. No pneumothorax is seen.\n\n IMPRESSION: Satisfactory positioning of lines and tubes. No pneumothorax.\n Mild pulmonary edema. Improved aeration of the lungs.\n\n" } ]

[ { "category": "Radiology", "chartdate": "2194-07-11 00:00:00.000", "description": "BABYGRAM (CHEST & ABDOMEN)", "row_id": 766589, "text": " 9:21 PM\n BABYGRAM (CHEST & ABDOMEN) Clip # \n Reason: ett ua uvc placment\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Infant with\n 28 triplet\n REASON FOR THIS EXAMINATION:\n ett ua uvc placment\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Infant who is one of triplets.\n\n FINDINGS: Endotracheal tube reaches T2. Umbilical arterial catheter reaches\n T7-8. Umbilical venous catheter reaches low right atrium. The lungs are hazy\n with a fine granularity in keeping with hyaline membrane disease. The lung\n volumes are low. The bowel gas pattern is normal. Esophagoenteric catheter\n reaches stomach. The bones are normal.\n\n" }, { "category": "Nursing/other", "chartdate": "2194-07-11 00:00:00.000", "description": "Report", "row_id": 1877065, "text": "Newborn Med Attending Admit/Transfer Note\n\n1210g IVF triplet #3 born by C/S for advanced PTL and breech presentation at 28 2/7 weeks EGA to a 38 yo G1. Pregnancy complicated by PTL since ~23 weeks. Mother rx with Mg, , indocin and nifedipine. PROM this afternoon.\n\nPNS: O+/HBSAg-/Ab-/RPRNR\n\nDR: Infant emerged with good cry. Given BBO2 and facial CPAP. Apgars .\n\nExam: see newborn exam sheet, but notable for G/F/Ring and isp crackles.\n\nA: Preterm femal infant presents with resp distress. Most likely RDS but can't r/o infection at this time.\n\nP: Intubate, PPV and survanta rx. Obtain CBC and blood cx. Start IV amp and gent pending 48h culture results and clinical course. Monitor DS. StartIV D10W @80 cc/kg/d. Keep family informed of plans and progress. Transfer to TCH.\n" }, { "category": "Nursing/other", "chartdate": "2194-07-11 00:00:00.000", "description": "Report", "row_id": 1877066, "text": "Nursing Admission Note\n Refer to above notes for history and physical of triplet #3. Infant intubated by NNP on arrival. 2.5ETT taped at 7.5cm's. DLUVC and UAV placed under sterile conditions by NNP. BP unstable with MAP's 26-27. NSB x2 given thus far. Initial d/s 25, 2.5cc's of D10W bolus given. D/S now 52. Breath sounds are coarse. IC/SC retractions noted. Survanta x1 given. No murmur heard at this time. Infant ruddy. NPO. TF's of 80cc/k/d. D10W infusing via DLUVC, and 1.2NS with hep infusing well via UAC. Infant voided on table. No mec's thus far. Abd soft and flat. Non audible bowel sounds. CBCD and blood cultures sent. Infant started on ampicillin and gentamicin. PKU sent. Erthryomycin and vitamin K given. Infant on radiant warmer with stable temp. Bruising noted on extremities and on bottom of both feet. Dad in to visit several times. Updated at bedside. Infant to be transfered to .\n" }, { "category": "Nursing/other", "chartdate": "2194-07-11 00:00:00.000", "description": "Report", "row_id": 1877067, "text": "Neonatology-NNP Progress Note\n\nN/S bolus X2 for marginal bp's, started on dopamine gtt 5 mg/kg/h prior to transfer\n\n" }, { "category": "Nursing/other", "chartdate": "2194-07-11 00:00:00.000", "description": "Report", "row_id": 1877062, "text": "Neonatology-NNP PRocedure Note\nIngnore this note, written on wrong pt\n" }, { "category": "Nursing/other", "chartdate": "2194-07-11 00:00:00.000", "description": "Report", "row_id": 1877063, "text": "Neonatology-NNP PRocedure Note\nProcedure Intubation\nIndication: Prematurity\nRDS\n\nInfant on warmer with oxymetry & cardiac monitoring in place. Infant in midline position, using # 0 laryngopscope, vocal cords visualized 2.5 ett inserted & taped at 7 cm mark at lip. X-ray to confirm placement.\n\nProcedure: DLUVC, UAC\nIndication: Prematurity\n\nInfant as above, using sterile technique, prepped & drapped, 3.5 DLUVC inserted & sutured at 7.5 cm mark, UAC inserted & sutured at 12 cm mark. X-ray to confirm placement in progress\n\nInfant tolerated procedures well\n" }, { "category": "Nursing/other", "chartdate": "2194-07-11 00:00:00.000", "description": "Report", "row_id": 1877064, "text": "NNP Procedure Note\n\nProcedure: Tracheal Intubation\nIndication: respiratlry failure\n\nthe vocal cords were visualized and a 2.5 ETT was passed orally into the trachea and taped at 7.5cm at the upper lip with equal breath sounds. Infant tolerated the procedure. x-ray for placement pending.\n\nProcedure: Umbilical artery and venous lines\nIndication: Continuous BP monitoring and frequent blood sampling and nutritian and fluids\n\nUnder sterily conditions the umbilical cord and periumbilical area was prepped with betadine and alcohol, cord tie placed, sterile drapes placed, and the umbilical cord cut. A 3.5 single lumen umbilical catheter was placed to 13.5 cm with blood return. A 3.5 double lumen umbilical catheter was placed in the vein to 7.75 cm with good blood return. x-ray for placement pending.\n" } ]

[ { "category": "Radiology", "chartdate": "2132-04-13 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 823120, "text": " 1:33 PM\n CHEST (PA & LAT) Clip # \n Reason: assess for pneumonia\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\CORONARY ARTERY BYPASS GRAFT/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with s/p CABG now s/p removal of CT and pacing wires\n\n REASON FOR THIS EXAMINATION:\n assess for pneumonia\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post CABG. Now status post removal of chest tube and\n pacing wires. ? pneumonia.\n\n CHEST TWO VIEWS:\n\n Status post sternotomy, with mild to moderate cardiomegaly. There is biapical\n left greater than right pleural parenchymal scarring. The diaphragms are\n flattened. There is blunting of the left costophrenic angle posteriorly, new\n compared with one day earlier, consistent with a small left pleural effusion.\n There is no CHF, focal infiltrate or right-sided effusion.\n\n IMPRESSION: Small left pleural effusion. No pneumothorax or pneumonia\n detected.\n\n" }, { "category": "Radiology", "chartdate": "2132-04-14 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 823182, "text": " 10:22 AM\n CHEST (PA & LAT) Clip # \n Reason: r/o 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 now s/p removal of CT and pacing wires\n\n REASON FOR THIS EXAMINATION:\n r/o effusion\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 66-year-old male status post CABG.\n\n PA and lateral views of the chest are compared to .\n\n FINDINGS: The patient is status post recent median sternotomy and CABG. There\n is a left pleural effusion, which is most likely unchanged. No evidence of CHF\n or pneumonia.\n\n IMPRESSION: Small left pleural effusion, which is most likely unchanged.\n\n" }, { "category": "Radiology", "chartdate": "2132-04-12 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 823063, "text": " 12:34 PM\n CHEST (PA & LAT) Clip # \n Reason: eval post removal of ct and pacing wires\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\CORONARY ARTERY BYPASS GRAFT/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with s/p CABG now s/p removal of CT and pacing wires\n REASON FOR THIS EXAMINATION:\n eval post removal of ct and pacing wires\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 66 y/o man with status post CABG and removal of chest tube.\n\n COMMENT: PA & lateral radiographs of the chest are reviewed and compared to\n the previous study of .\n\n Patient is status post CABG and median sternotomy. The patient has been\n extubated. The left chest tube, NG tube and right IJ line have been removed.\n\n Again, note is made of right apical scar. The lungs are clear otherwise.\n There is no evidence of CHF. The heart is normal in size. There are probably\n small bilteral pleural effusions.\n\n IMPRESSION: Satisfactory postoperative status post-CABG. No pneumothirax.\n\n" }, { "category": "Radiology", "chartdate": "2132-04-09 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 822718, "text": " 3:40 PM\n CHEST (PORTABLE AP) Clip # \n Reason: postop film\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\CORONARY ARTERY BYPASS GRAFT/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man s/p cabg x3\n REASON FOR THIS EXAMINATION:\n postop film\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 66 year old man status post CABG.\n\n Post op film.\n\n AP supine single view of the chest is compared to .\n\n FINDINGS: There are postoperative changes status post median sternotomy and\n CABG. There is an ET tube in good position. There is a right IJ central line\n with the tip in the mid SVC. There is a left chest tube. There is an NG tube\n with the tip extending beyond the limits of the radiograph in the stomach.\n There is no evidence of pneumothorax. The pulmonary vascularity is within\n normal limits. There is no evidence of CHF. The lung fields are remarkable\n for minimal linear atelectasis in the mid and lower lung zones, but there are\n no focal consolidations. There is no evidence of pleural effusion.\n\n IMPRESSION:\n 1) Lines and tubes in adequate position. There is no evidence for\n pneumothorax.\n 2) There is no evidence of aspiration or CHF.\n\n" }, { "category": "Radiology", "chartdate": "2132-04-09 00:00:00.000", "description": "O CHEST (PORTABLE AP) IN O.R.", "row_id": 822684, "text": " 9:35 AM\n CHEST (PORTABLE AP) IN O.R. Clip # \n Reason: GRAFT BYPASS, FORIEGN BODY\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\CORONARY ARTERY BYPASS GRAFT/SDA\n ______________________________________________________________________________\n FINAL REPORT\n CHEST, PORTABLE FILM FROM THE O.R.:\n\n Bypass graft, looking for foreign body.\n\n View of the chest shows an ETT to be present and positioned above the carina.\n There is no evidence of a radiopaque foreign body within the field of view.\n\n CONCLUSION: No evidence of a radiopaque foreign body within the field of\n view.\n\n" }, { "category": "Nursing/other", "chartdate": "2132-04-10 00:00:00.000", "description": "Report", "row_id": 1394200, "text": "NPN: S/P CABG X3\n\nNEURO: ALERT AND ORIENTED TO PLACE, OR AND SELF. MAE WITH EQUAL STRENGTH. OCC SL ANXIOUS..EVERYTHING IS TERRIBLE BUT DOING WELL.\nCV: 80-60'S NSR WITH NO VEA SEEN. REQUIRING NEO .2-.3 FOR LOW BP. K AND CA BEING REPLETED THIS AM. HCT 29.2. PACER AT A DEMAND -NOW 60. PALP PEDAL PULSES. SKIN WARM AND DRY.\nRESP: LUNGS DIM AT BASES BUT OTHERWISE CTA. O2 SATS> 96% ON 3L NC O2. COUGH FAIR SL PROD CLEAR SPUTUM. CT/MT TO SXN WITH 20-40CC SEROSANG PER 1-2 HRS. DUMPED 120CC WHEN OOB TO CHAIR.\nGU: FOLEY TO GD WITH UO 40-25CC/HR. CR STABLE .8.\nGI: ABD SOFT,NT, ND WITH HYPO BS, +BELCHING,- FLATUS. TOL CLEARS. NO N/V.\nENDO: ON INSULIN GTT PER CTS PROTOCOL FOR GLUCOSES 110'S TO 84.\nINCISION: STERNUM AND CT/MT WITH DSD-D/I. L LEG ACE WRAP CHANGED-STERISTRIPPED WITHOUT DNG-C/D.\nCOMFORT: C/O INCISIONAL CHEST AND BACK PAIN..C/O ARTHRITIS. MEDICATED WITH TORADOL AND MSO4 WITH EFFECT.\nACTIVITY: TURNED SIDE TO SIDE IN BED. OOB TO CHAIR WITH 2 ASSISTS AT 6AM. TOL WELL-LESS PAIN PER PT.\nA: STABLE ON LOW DOSE NEO..TOL ^ PO'S/ACTIVITY\nP: WEAN NEO, ADVANCE ACTIVITY. ^ DIET. POSSIBLE TRANSFER TO 2. EVALUATE NEED TO RESTART ATIVAN-PT TAKES .\n" }, { "category": "Nursing/other", "chartdate": "2132-04-09 00:00:00.000", "description": "Report", "row_id": 1394198, "text": "~1505 Patient admitted from or s/p cabg x 3. Patient intubated and sedated with iv propofol. Pserl. Ct's patent for minimsl sero-sang. Palpable pulses.\n" }, { "category": "Nursing/other", "chartdate": "2132-04-09 00:00:00.000", "description": "Report", "row_id": 1394199, "text": "NEURO: MAE BUT SLOW TO WAKE, NOW AWAKE, ALERT, ORIENTED X3.\nCARDIAC: MP SR WITHOUT ECTOPY. CT'S PATENT FOR MINIMAL SERO-SANG. PACER OFF, SENSES/CAPTURES. PALPABLE PULSES.\nRESP: EXTUBATED AT 2055, NP'S 3 LITERS, SUCTIONED PRIOR TO EXTUBATION FOR SMALL AMT THICK TAN. PATIENT RECENTLY HAD URI WITH COUGH, NONPRODUCTIVE, LOW GRADE TEMP PRESENT AT THIS TIME.\nGI: OG TUBE DC'D WITH EXTUBATION.\nGU: FOLEY IN PLACE, PATENT FOR CLEAR YELLOW URINE.\nENDO: INSULIN GTT ^, FOLLOWING PROTOCOL.\nFAMILY IN, WIFE AWARE OF INCIDENT WITH CROWNS, CROWNS PER ANESTHESIA IN SAFE.\n" }, { "category": "ECG", "chartdate": "2132-04-10 00:00:00.000", "description": "Report", "row_id": 186609, "text": "Atrial paced rhythm\nST-T wave abnormalities suggestive of early repolarization\nSince previous tracing of , paced rhythm seen\n\n" }, { "category": "ECG", "chartdate": "2132-04-09 00:00:00.000", "description": "Report", "row_id": 186610, "text": "Sinus rhythm.\nLateral ST elevation suggests early repolarization\nInferior T wave changes are nonspecific or may be due to ischemia\nSince previous tracing of , no significant change\n\n" } ]

[ { "category": "Physician ", "chartdate": "2146-03-11 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 516987, "text": "Chief Complaint: PCP: \n .\n CHIEF COMPLAINT: s/p cystectomy for bladder cancer\n REASON FOR MICU ADMISSION: post-op monitoring\n .\n HPI:\n Pt is an 82 y.o male with recently dx invasive transitional cell\n bladder cancer, HTN, DM, HL who is s/p ileal loop cystectomy with\n radial prostectomy. Pt also underwent placement of a thoracic epidural\n for pain control. Pt's BP was 84/39 upon arrival to the PAC and neo at\n 0.5mcg/kg/min was started at 1330. Neo off at 1430. Vitals prior to\n transfer T 97.4, BP 135/60, HR 90, RR 12, sat 99 on 3L. He received\n 4350 of fluids and put out 180 from the urostomy and 105 from the\n foley. EBL 1200.\n .\n Currently, Pt reports lower abd pain, belching, and thirst.\n He denies chills, headache, blurred vision, ST/cough/cp/sob/abd\n pain/n/v/d/c/skin rash/joint pain/paresthesias.\n Patient admitted from: OR / PACU\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 Medications - Prescription\n ECONAZOLE [SPECTAZOLE] - 1 % Cream - apply to toenails as\n directed twice a day\n HYDROCHLOROTHIAZIDE - 25 mg Tablet - 1 Tablet(s) by mouth once a\n day\n LISINOPRIL - 40 mg Tablet - 1 Tablet(s) by mouth once a day\n LORAZEPAM - 1 mg Tablet - 1 Tablet(s) by mouth at bedtime as\n needed for insomnia\n NIFEDIPINE - 90 mg Tablet Extended Rel 24 hr - 1 Tab(s) by mouth\n once a day\n SILDENAFIL [VIAGRA] - 100 mg Tablet - 1 Tablet(s) by mouth as\n needed\n SIMVASTATIN - 40 mg Tablet - 1 Tablet(s) by mouth once a day for\n chol\n NPH 50 units \n viagra.\n Past medical history:\n Family history:\n Social History:\n *invasive muscular bladder cancer-gross hematuria . Cystoscopy\n showing atypical urothelial cells. CT showing enhancing soft tissue\n mass on posterior medial wall of bladder. -large bladder tumor\n found. No metastatic disease found. TURBT difficult, resulting in\n dysuria.\n *Hypertension.\n *Diabetes mellitus, diagnosed over 10 years ago, now\n insulin-dependent, with retinopathy and nephropathy.\n *Hyperlipidemia.\n *Polyneuritis.\n .\n The patient's father died in his 70s from\n myocardial infarction. His mother died in her 60s from\n myocardial infarction. He has five sisters, many of whom have\n diabetes. One sister has a blood disorder (question\n myelodysplasia). There are no other malignancies in the family.\n Occupation:\n Drugs:\n Tobacco: quit 35 yrs ago.\n Alcohol:\n Other: The patient is married and lives with his wife,\n who has disease. He has a daughter and a son who are\n with him here today. He is a former plasterer and also worked in\n a high asbestos exposure area. He is a former smoker and drinks\n alcohol rarely. He is a US naval veteran.\n .\n Review of systems:\n Flowsheet Data as of 07:47 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since AM\n Tmax: 36.2\nC (97.1\n Tcurrent: 36.2\nC (97.1\n HR: 101 (101 - 101) bpm\n BP: 136/57(81) {136/57(81) - 142/61(87)} mmHg\n RR: 20 (20 - 21) insp/min\n SpO2: 96%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 218 mL\n PO:\n TF:\n IVF:\n 218 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 218 mL\n Respiratory\n SpO2: 96%\n Physical Examination\n =VS: T. 97.1, BP 142/61, HR 101, RR 21 sat 96% on 2L\n GEN:The patient is in no distress and appears comfortable\n SKIN:No rashes or skin changes noted\n HEENT:Dry MM, EOMI, No JVD, neck supple, No lymphadenopathy in\n cervical, posterior, or supraclavicular chains noted. NGT in place.\n CHEST:Lungs are clear without wheeze, rales, or rhonchi anteriorly\n CARDIAC: Regular rhythm; no murmurs, rubs, or gallops.\n ABDOMEN: +surgical vertical wound-covered, serous drainage, with ileal\n drain, +Bs, soft,\n EXTREMITIES:no peripheral edema, warm without cyanosis\n NEUROLOGIC: Alert and appropriate. CN II-XII grossly intact, no TREMOR.\n Labs / Radiology\n [image002.jpg]\n Fluid analysis / Other labs: 140 106 14 92 AGap=13\n 3.9 25 1.6\n estGFR: 42/50 (click for details)\n Ca: 7.9 Mg: 1.5 P: 5.6 &#8710;\n Source: Line-radial artery line\n 79\n 9.6 8.6 233\n 26.2\n .\n Imaging: KUB-NG tube tip at the GE junction, recommded advancement to\n atleast 8 cm for optimal position.\n 2. Proximal ureteric stents in position. dital portion not included.\n .\n Stress -\n IMPRESSION: Normal myocardial perfusion. The calculated left\n ventricular ejection fraction is 60% at rest and 65% with stress\n ECG: NSR @75. RBBB. normal intervals.\n Assessment and Plan\n ASSESSMENT & PLAN:\n Pt is an 82 y.o male with h.o transitional cell invasive bladder ca,\n HTN, HL, who is s/p ileal loop cystectomy with radial prostectomy.\n .\n #s/p post-op hypotension-Pt with reported intraoperative hypotension\n requiring pressors. Pt normotensive in the PACU and currently\n normotensive. Likely related to loss of volume or intraoperative blood\n loss. Anesthetics and epidural also likely a possibility. Other\n considerations include sepsis or cardiogenic, but doubtful at this\n time.\n -monitor BP-goal map >65\n -abx as per urology\n -2 units PRBcs\n -post transfusion HCT\n -8hr HCT\n -active T+S\n -IVF\n -can consider infectious w/u if symptoms arise.\n -EKG\n .\n #Transitional cell bladder ca-s/p resection in . Now s/p ileal\n loop cystectomy with radical prostectomy.\n -foley and urostomy drain\n -post op abx\n -urology recs.\n -pain control with epidural.\n .\n #acute renal failure-baseline 1.0. Could be related to underlying\n cancer vs. prerenal process given blood loss in OR. Could be intrarenal\n vs. post-obstructive from new anatomy/procedure.\n -u/a and cx\n -ulytes\n -renally dose meds.\n .\n #HTN-hold anti-hypertensives at this time. Will likely resume in am.\n .\n #HL-home statin.\n .\n #DM-HISS for now, DM diet when able.\n .\n # FEN: IVFs / replete lytes prn / regular diet\n # PPX: PPI, heparin SQ, bowel regimen\n # ACCESS: PIV\n # CODE: Full, discussed\n # CONTACT: Pt's daugther\n # DISPOSITION: ICU o/n to floor-urology if BP stable.\n urology p \n ICU Care\n Nutrition: npo for now\n Glycemic Control: insulin ss\n Lines:\n Arterial Line - 07:00 PM\n 20 Gauge - 07:00 PM\n 18 Gauge - 07:01 PM\n Prophylaxis:\n DVT: pneumoboots\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: icu o/n\n" }, { "category": "Physician ", "chartdate": "2146-03-11 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 516988, "text": "Chief Complaint: PCP: \n .\n CHIEF COMPLAINT: s/p cystectomy for bladder cancer\n REASON FOR MICU ADMISSION: post-op monitoring\n .\n HPI:\n Pt is an 82 y.o male with recently dx invasive transitional cell\n bladder cancer, HTN, DM, HL who is s/p ileal loop cystectomy with\n radial prostectomy. Pt also underwent placement of a thoracic epidural\n for pain control. Pt's BP was 84/39 upon arrival to the PAC and neo at\n 0.5mcg/kg/min was started at 1330. Neo off at 1430. Vitals prior to\n transfer T 97.4, BP 135/60, HR 90, RR 12, sat 99 on 3L. He received\n 4350 of fluids and put out 180 from the urostomy and 105 from the\n foley. EBL 1200.\n .\n Currently, Pt reports lower abd pain, belching, and thirst.\n He denies chills, headache, blurred vision, ST/cough/cp/sob/abd\n pain/n/v/d/c/skin rash/joint pain/paresthesias.\n Patient admitted from: OR / PACU\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 Medications - Prescription\n ECONAZOLE [SPECTAZOLE] - 1 % Cream - apply to toenails as\n directed twice a day\n HYDROCHLOROTHIAZIDE - 25 mg Tablet - 1 Tablet(s) by mouth once a\n day\n LISINOPRIL - 40 mg Tablet - 1 Tablet(s) by mouth once a day\n LORAZEPAM - 1 mg Tablet - 1 Tablet(s) by mouth at bedtime as\n needed for insomnia\n NIFEDIPINE - 90 mg Tablet Extended Rel 24 hr - 1 Tab(s) by mouth\n once a day\n SILDENAFIL [VIAGRA] - 100 mg Tablet - 1 Tablet(s) by mouth as\n needed\n SIMVASTATIN - 40 mg Tablet - 1 Tablet(s) by mouth once a day for\n chol\n NPH 50 units \n viagra.\n Past medical history:\n Family history:\n Social History:\n *invasive muscular bladder cancer-gross hematuria . Cystoscopy\n showing atypical urothelial cells. CT showing enhancing soft tissue\n mass on posterior medial wall of bladder. -large bladder tumor\n found. No metastatic disease found. TURBT difficult, resulting in\n dysuria.\n *Hypertension.\n *Diabetes mellitus, diagnosed over 10 years ago, now\n insulin-dependent, with retinopathy and nephropathy.\n *Hyperlipidemia.\n *Polyneuritis.\n .\n The patient's father died in his 70s from\n myocardial infarction. His mother died in her 60s from\n myocardial infarction. He has five sisters, many of whom have\n diabetes. One sister has a blood disorder (question\n myelodysplasia). There are no other malignancies in the family.\n Occupation:\n Drugs:\n Tobacco: quit 35 yrs ago.\n Alcohol:\n Other: The patient is married and lives with his wife,\n who has disease. He has a daughter and a son who are\n with him here today. He is a former plasterer and also worked in\n a high asbestos exposure area. He is a former smoker and drinks\n alcohol rarely. He is a US naval veteran.\n .\n Review of systems:\n Flowsheet Data as of 07:47 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since AM\n Tmax: 36.2\nC (97.1\n Tcurrent: 36.2\nC (97.1\n HR: 101 (101 - 101) bpm\n BP: 136/57(81) {136/57(81) - 142/61(87)} mmHg\n RR: 20 (20 - 21) insp/min\n SpO2: 96%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 218 mL\n PO:\n TF:\n IVF:\n 218 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 218 mL\n Respiratory\n SpO2: 96%\n Physical Examination\n =VS: T. 97.1, BP 142/61, HR 101, RR 21 sat 96% on 2L\n GEN:The patient is in no distress and appears comfortable\n SKIN:No rashes or skin changes noted\n HEENT:Dry MM, EOMI, No JVD, neck supple, No lymphadenopathy in\n cervical, posterior, or supraclavicular chains noted. NGT in place.\n CHEST:Lungs are clear without wheeze, rales, or rhonchi anteriorly\n CARDIAC: Regular rhythm; no murmurs, rubs, or gallops.\n ABDOMEN: +surgical vertical wound-covered, serous drainage, with ileal\n drain, +Bs, soft,\n EXTREMITIES:no peripheral edema, warm without cyanosis\n NEUROLOGIC: Alert and appropriate. CN II-XII grossly intact, no TREMOR.\n Labs / Radiology\n [image002.jpg]\n Fluid analysis / Other labs: 140 106 14 92 AGap=13\n 3.9 25 1.6\n estGFR: 42/50 (click for details)\n Ca: 7.9 Mg: 1.5 P: 5.6 &#8710;\n Source: Line-radial artery line\n 79\n 9.6 8.6 233\n 26.2\n .\n Imaging: KUB-NG tube tip at the GE junction, recommded advancement to\n atleast 8 cm for optimal position.\n 2. Proximal ureteric stents in position. dital portion not included.\n .\n Stress -\n IMPRESSION: Normal myocardial perfusion. The calculated left\n ventricular ejection fraction is 60% at rest and 65% with stress\n ECG: NSR @75. RBBB. normal intervals.\n Assessment and Plan\n ASSESSMENT & PLAN:\n Pt is an 82 y.o male with h.o transitional cell invasive bladder ca,\n HTN, HL, who is s/p ileal loop cystectomy with radial prostectomy.\n .\n #s/p post-op hypotension-Pt with reported intraoperative hypotension\n requiring pressors. Pt normotensive in the PACU and currently\n normotensive. Likely related to loss of volume or intraoperative blood\n loss. Anesthetics and epidural also likely a possibility. Other\n considerations include sepsis or cardiogenic, but doubtful at this\n time.\n -monitor BP-goal map >65\n -abx as per urology\n -2 units PRBcs\n -post transfusion HCT\n -8hr HCT\n -active T+S\n -IVF\n -can consider infectious w/u if symptoms arise.\n -EKG\n .\n #Transitional cell bladder ca-s/p resection in . Now s/p ileal\n loop cystectomy with radical prostectomy.\n -foley and urostomy drain\n -post op abx\n -urology recs.\n -pain control with epidural.\n .\n #acute renal failure-baseline 1.0. Could be related to underlying\n cancer vs. prerenal process given blood loss in OR. Could be intrarenal\n vs. post-obstructive from new anatomy/procedure.\n -u/a and cx\n -ulytes\n -renally dose meds.\n .\n #HTN-hold anti-hypertensives at this time. Will likely resume in am.\n .\n #HL-home statin.\n .\n #DM-HISS for now, DM diet when able.\n .\n # FEN: IVFs / replete lytes prn / regular diet\n # PPX: PPI, heparin SQ, bowel regimen\n # ACCESS: PIV\n # CODE: Full, discussed\n # CONTACT: Pt's daugther\n # DISPOSITION: ICU o/n to floor-urology if BP stable.\n urology p \n ICU Care\n Nutrition: npo for now\n Glycemic Control: insulin ss\n Lines:\n Arterial Line - 07:00 PM\n 20 Gauge - 07:00 PM\n 18 Gauge - 07:01 PM\n Prophylaxis:\n DVT: pneumoboots\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: icu o/n\n ------ Protected Section ------\n ICU Attending Overnight Coverage\n I saw and examined the patient with the medical resident in the ICU,\n assessment and plan discussed in detail. I would highlight and add the\n following.\n 82 yo man w/ h/o HTN, AODM, recent dx w/bladder cancer now s/p radical\n cystectomy/protastectomy w/creation of neobladder and ileoconduit.\n Transiently required Neosynephrine gtt in the PACU (EBL 1200, received\n 4 L IVFs in perioperatively); pressors weaned off prior to transfet to\n the ICU for overnight monitoring.\n BP 140/70, off pressors since ~2 pm NGT in place\n Lungs clear anteriolaterally\n Cor: RRR Abdomen: Dressing clean and dry, occ. Bowel sound, soft\n Labs notable for mildly elevated Cr 1.6, BUN 14, glucose 92, HCT 26.2\n (pre-op Hcct 36.4). Plt 233K\n Intraoperative and postop hypotension transiently requiring neo in the\n PACU. Now hemodynamically stable off pressors for past several hours.\n Agree with assessment and plan as above. Also would check\n postoperative ECG. Agree with blood transfusion (ICU consent signed).\n Check coags and follow serial CBC. Antibiotics per surgical service,\n check to be sure dosed per renal function. Follow urine output, serial\n labs. Likely prerenal. UA, culture, check urine lytes. Pain control\n with epidural.\n Patient is critically ill given labile blood pressure postoperatively\n Time spent: 40 minutes\n ------ Protected Section Addendum Entered By: , MD\n on: 20:03 ------\n" }, { "category": "Nursing", "chartdate": "2146-03-12 00:00:00.000", "description": "Nursing Progress Note", "row_id": 517002, "text": "82 yo man w/ h/o HTN, AODM, polynephritis, neuropathy, recent dx\n w/bladder cancer. Today he underwent radical cystectomy/protastectomy\n w/creation of neobladder and ileoconduit. Required Neosynephrine gtt\n which has been weaned off. Transferred to ICU for overnight monitoring\n" }, { "category": "Nursing", "chartdate": "2146-03-12 00:00:00.000", "description": "Nursing Progress Note", "row_id": 517003, "text": "82 yo man w/ h/o HTN, AODM, polynephritis, neuropathy, recent dx\n w/bladder cancer. Today he underwent radical cystectomy/protastectomy\n w/creation of neobladder and ileoconduit. Required Neosynephrine gtt\n which has been weaned off. Transferred to ICU for overnight monitoring\n Cancer (Malignant Neoplasm), Other\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2146-03-12 00:00:00.000", "description": "Nursing Progress Note", "row_id": 517035, "text": "82 yo man w/ h/o HTN, AODM, polynephritis, neuropathy, recent dx\n w/bladder cancer. Today he underwent radical cystectomy/protastectomy\n w/creation of neobladder and ileoconduit. Required Neosynephrine gtt\n which has been weaned off. Transferred to ICU for overnight monitoring\n Cancer (Malignant Neoplasm), Other\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2146-03-12 00:00:00.000", "description": "Nursing Progress Note", "row_id": 517036, "text": "82 yo man w/ h/o HTN, AODM, polynephritis, neuropathy, recent dx\n w/bladder cancer. Today he underwent radical cystectomy/protastectomy\n w/creation of neobladder and ileoconduit. Required Neosynephrine gtt\n which has been weaned off. Transferred to ICU for overnight monitoring\n Cancer (Malignant Neoplasm), Other\n Assessment:\n Pt s/p radical\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2146-03-12 00:00:00.000", "description": "Nursing Progress Note", "row_id": 517205, "text": "82 yo man w/ h/o HTN, AODM, polynephritis, neuropathy, recent dx\n w/bladder cancer. On he underwent radical\n cystectomy/protastectomy w/creation of neobladder and ileoconduit.\n Required Neosynephrine gtt which has been weaned off. Transferred to\n ICU for overnight monitoring\n Cancer (Malignant Neoplasm), Other\n Assessment:\n Pt with thoracic epidural catheter, pain not relieved, anesthesia\n checked location of catheter, in too far, readjusted, pt bolused with\n 5 cc lidocaine via epidural catheter, pt received additional bolus 5\n cc x 1, pain relieved, level at inguinal area pain on a\n scale of ( ) , esp with coughing. Epidural continues\n Hydormorphone 10 mcg/cc with 0.1% Bupivacaine at 1mg/cc at 10\n cc/hr. Pt using IS every 1 hours, enc to cough, deep breath, pt\n sat on side of bed for\n, unable to stand\n epidural was too low.\n (legs numb- ) temp max 100.7 po, down to 100.1 axillary,\n HR 90\ns SR BP 140/60 on 4 liters n/c, rr~20, O2 sats 94%. Pt\n with crackles at bases, IVF LR @ 150 cc/hr decreased to 75 cc/hr.\n foley inserted in penis ( just a pelvic drain)\n draining small amounts\n serous fluid. Ileoconduit draining 60-100 cc/hr of seroussang\n urine. Bun 21 crt 1.7 abd dsg intact\n old blood on\n dsg, (surgeon did not change dsg) repeat Hct 28.4 (pt received 2\n units PRBC on nights) 3^rd unit on hold for now secondary to temp\n Action:\n Pt post op day 1, thoracic epidural catheter continues for pain\n control\n Response:\n Stable, VSS, pain relieved with epidural catheter.\n Plan:\n Call pain service if you need to adjust epidural catheter. Pain\n service Pirzadey beeper . encourage turn, cough, deep\n breath. Do not have pt lie on left side\n catheter will not drain.\n Pneumoboots continue continue to monitor urine output via ileo\n conduit, monitor output from penis. Check dsg . surgery following,\n pain service following.\n ENDO: FS qid, at 6 pm FS 215 pt received 4 units regular insulin\n (according to sliding scale)\n GI: NPO, right nare NG tube hooked up to low cont. suction\n drained\n >600 cc\ns clear fluid. Pt taking few ice chips, swab\n Mouth constantly, feels dry, wants NG tube out. + bowel sounds, no\n gas yet, pt continues to burb.\n CV: bp elevated >160/70 Lopressor increased to 7.5 mg IV qid from\n 5 mg\n ID: t max 100.7 po, pt on Cefazolin 2 grams q 8 hrs x 2 days, need\n 10 pm dose, 6 am and 2 pm dose. received Gent x 2.\n" }, { "category": "Physician ", "chartdate": "2146-03-12 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 517124, "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: 82 yo man w/ h/o HTN, AODM, recent dx w/bladder cancer now s/p\n radical cystectomy/protastectomy w/creation of neobladder and\n ileoconduit. Transiently required Neosynephrine gtt in the PACU (EBL\n 1200, received 4 L IVFs in perioperatively); pressors weaned off prior\n to transfer to the ICU. Admitted for overnight monitoring.\n 24 Hour Events:\n A-line inserted, transfused 2 units prbc\n Low grade fever 100.3\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Gentamicin - 04:45 AM\n Cefazolin - 06:20 AM\n Infusions:\n Other ICU medications:\n Metoprolol - 06:20 AM\n Other medications: reviewed\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 08:23 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.9\nC (100.3\n Tcurrent: 37.9\nC (100.3\n HR: 96 (93 - 108) bpm\n BP: 138/53(84) {91/35(54) - 142/61(87)} mmHg\n RR: 16 (11 - 21) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 1,146 mL\n 2,060 mL\n PO:\n TF:\n IVF:\n 984 mL\n 1,473 mL\n Blood products:\n 162 mL\n 588 mL\n Total out:\n 90 mL\n 1,035 mL\n Urine:\n 90 mL\n 785 mL\n NG:\n 250 mL\n Stool:\n Drains:\n Balance:\n 1,056 mL\n 1,025 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 97%\n ABG: ///22/\n Physical Examination\n Lungs clear ant/lat\n CVS\n HSM\n NG tube, Abd with ostomy bag, 2 drains, PPP\n Skin: warm, Neurologic: awake, alert, oriented\n Labs / Radiology\n 9.9 g/dL\n 193 K/uL\n 152 mg/dL\n 1.7 mg/dL\n 22 mEq/L\n 4.6 mEq/L\n 21 mg/dL\n 107 mEq/L\n 139 mEq/L\n 28.6 %\n 11.0 K/uL\n [image002.jpg]\n 09:44 PM\n 03:38 AM\n WBC\n 11.0\n Hct\n 28.6\n Plt\n 193\n Cr\n 1.6\n 1.7\n TropT\n <0.01\n <0.01\n Glucose\n 134\n 152\n Other labs: PT / PTT / INR:13.7/25.7/1.2, CK / CKMB /\n Troponin-T:6463/17/<0.01, Ca++:7.6 mg/dL, Mg++:1.5 mg/dL, PO4:4.6\n mg/dL. Baseline creat ~ 1.0\n Assessment and Plan\n 82 yo man w/ h/o HTN, AODM, recent dx w/bladder cancer now s/p radical\n cystectomy/protastectomy w/creation of neobladder and ileoconduit.\n Transiently required Neosynephrine gtt in the PACU (EBL 1200, received\n 4 L IVFs in perioperatively); pressors weaned off prior to transfet to\n the ICU for overnight monitoring.\n Intraoperative and postop hypotension transiently requiring neo in the\n PACU. Remains hemodynamically stable off pressors. Follow Hct, renal\n function closely.\n Acute renal failure\n Antibiotics per surgical service, check to be sure dosed per renal\n function. Follow urine output, serial labs. Likely prerenal. UA,\n culture, check urine lytes. Pain control with epidural.\n Patient is critically ill given labile blood pressure postoperatively\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Arterial Line - 07:00 PM\n 20 Gauge - 07:00 PM\n 18 Gauge - 07:01 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 30 minutes\n Patient is critically ill\n" }, { "category": "Physician ", "chartdate": "2146-03-12 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 517127, "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: 82 yo man w/ h/o HTN, AODM, recent dx w/bladder cancer now s/p\n radical cystectomy/protastectomy w/creation of neobladder and\n ileoconduit. Transiently required Neosynephrine gtt in the PACU (EBL\n 1200, received 4 L IVFs in perioperatively); pressors weaned off prior\n to transfer to the ICU. Admitted for overnight monitoring.\n 24 Hour Events:\n A-line inserted, transfused 2 units prbc\n Low grade fever 100.3\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Gentamicin - 04:45 AM\n Cefazolin - 06:20 AM\n Infusions:\n Other ICU medications:\n Metoprolol - 06:20 AM\n Other medications: reviewed\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 08:23 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.9\nC (100.3\n Tcurrent: 37.9\nC (100.3\n HR: 96 (93 - 108) bpm\n BP: 138/53(84) {91/35(54) - 142/61(87)} mmHg\n RR: 16 (11 - 21) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 1,146 mL\n 2,060 mL\n PO:\n TF:\n IVF:\n 984 mL\n 1,473 mL\n Blood products:\n 162 mL\n 588 mL\n Total out:\n 90 mL\n 1,035 mL\n Urine:\n 90 mL\n 785 mL\n NG:\n 250 mL\n Stool:\n Drains:\n Balance:\n 1,056 mL\n 1,025 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 97%\n ABG: ///22/\n Physical Examination\n Lungs clear ant/lat\n CVS\n HSM\n NG tube, Abd with ostomy bag, 2 drains, PPP\n Skin: warm, Neurologic: awake, alert, oriented\n Labs / Radiology\n 9.9 g/dL\n 193 K/uL\n 152 mg/dL\n 1.7 mg/dL\n 22 mEq/L\n 4.6 mEq/L\n 21 mg/dL\n 107 mEq/L\n 139 mEq/L\n 28.6 %\n 11.0 K/uL\n [image002.jpg]\n 09:44 PM\n 03:38 AM\n WBC\n 11.0\n Hct\n 28.6\n Plt\n 193\n Cr\n 1.6\n 1.7\n TropT\n <0.01\n <0.01\n Glucose\n 134\n 152\n Other labs: PT / PTT / INR:13.7/25.7/1.2, CK / CKMB /\n Troponin-T:6463/17/<0.01, Ca++:7.6 mg/dL, Mg++:1.5 mg/dL, PO4:4.6\n mg/dL. Baseline creat ~ 1.0\n Assessment and Plan\n 82 yo man w/ h/o HTN, AODM, recent dx w/bladder cancer now s/p radical\n cystectomy/protastectomy w/creation of neobladder and ileoconduit.\n Transiently required Neosynephrine gtt in the PACU (EBL 1200, received\n 4 L IVFs in perioperatively); pressors weaned off prior to transfer to\n the ICU for overnight monitoring.\n Hypotension resolved, now hypertensive, would continue with metoprolol\n IV.\n Acute renal failure\n renally dose meds, hydration +/- prbc prn given\n long surgery, follow Hct, renal function closely.\n Antibiotics\n gent completed, cefazolin x 2 d per surgical service\n Pain control with epidural.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Arterial Line - 07:00 PM\n 20 Gauge - 07:00 PM\n 18 Gauge - 07:01 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 35 minutes\n Patient is critically ill\n" }, { "category": "Nursing", "chartdate": "2146-03-12 00:00:00.000", "description": "Nursing Progress Note", "row_id": 517192, "text": "82 yo man w/ h/o HTN, AODM, polynephritis, neuropathy, recent dx\n w/bladder cancer. Today he underwent radical cystectomy/protastectomy\n w/creation of neobladder and ileoconduit. Required Neosynephrine gtt\n which has been weaned off. Transferred to ICU for overnight monitoring\n Cancer (Malignant Neoplasm), Other\n Assessment:\n Pt with epidural catheter, pain not relieved, anesthesia checked\n location of catheter, in too far, readjusted, pt bolused with\n lidocaine, pt received additional bolus 5 cc x 2, pain relieved, level\n at pain on a scale of , esp with coughing.\n Epidural continues Hydormorphone 10 mcg/cc with 0.1% Bupivacaine at 10\n cc/hr. Pt using IS every 1 hours, enc to cough, deep breath, pt\n sat on side of bed for\n, unable to stand\n epidural was too low.\n (legs numb) temp max 100.7 po, HR 90\ns SR BP 140/60 on 4\n liters n/c, rr~20, O2 sats 94%. Pt with crackles at bases, IVF LR @\n 150 cc/hr decreased to 75 cc/hr. foley inserted in penis ( just a\n pelvic drain)\n draining small amounts serous fluid. Ileoconduit\n draining 60-100 cc/hr of seroussang urine. 21 crt 1.7\n abd dsg intact\n old blood on dsg, (surgeon did not change dsg)\n Action:\n Response:\n Plan:\n Call pain service if you need to adjust epidural catheter. Pain\n service Pirzadey beeper . encourage turn, cough, deep\n breath. Do not have pt lie on left side\n catheter will not drain.\n ENDO: FS qid, at 6 pm FS 215 pt received 4 units regular insulin\n (according to sliding scale)\n" }, { "category": "Nursing", "chartdate": "2146-03-12 00:00:00.000", "description": "Nursing Progress Note", "row_id": 517196, "text": "82 yo man w/ h/o HTN, AODM, polynephritis, neuropathy, recent dx\n w/bladder cancer. On he underwent radical\n cystectomy/protastectomy w/creation of neobladder and ileoconduit.\n Required Neosynephrine gtt which has been weaned off. Transferred to\n ICU for overnight monitoring\n Cancer (Malignant Neoplasm), Other\n Assessment:\n Pt with epidural catheter, pain not relieved, anesthesia checked\n location of catheter, in too far, readjusted, pt bolused with\n lidocaine, pt received additional bolus 5 cc x 2, pain relieved, level\n at pain on a scale of , esp with coughing.\n Epidural continues Hydormorphone 10 mcg/cc with 0.1% Bupivacaine at 10\n cc/hr. Pt using IS every 1 hours, enc to cough, deep breath, pt\n sat on side of bed for\n, unable to stand\n epidural was too low.\n (legs numb) temp max 100.7 po, HR 90\ns SR BP 140/60 on 4\n liters n/c, rr~20, O2 sats 94%. Pt with crackles at bases, IVF LR @\n 150 cc/hr decreased to 75 cc/hr. foley inserted in penis ( just a\n pelvic drain)\n draining small amounts serous fluid. Ileoconduit\n draining 60-100 cc/hr of seroussang urine. Bun 21 crt\n 1.7 abd dsg intact\n old blood on dsg, (surgeon did not\n change dsg)\n Action:\n Response:\n Plan:\n Call pain service if you need to adjust epidural catheter. Pain\n service Pirzadey beeper . encourage turn, cough, deep\n breath. Do not have pt lie on left side\n catheter will not drain.\n ENDO: FS qid, at 6 pm FS 215 pt received 4 units regular insulin\n (according to sliding scale)\n" }, { "category": "Nursing", "chartdate": "2146-03-12 00:00:00.000", "description": "Nursing Progress Note", "row_id": 517198, "text": "82 yo man w/ h/o HTN, AODM, polynephritis, neuropathy, recent dx\n w/bladder cancer. On he underwent radical\n cystectomy/protastectomy w/creation of neobladder and ileoconduit.\n Required Neosynephrine gtt which has been weaned off. Transferred to\n ICU for overnight monitoring\n Cancer (Malignant Neoplasm), Other\n Assessment:\n Pt with thoracic epidural catheter, pain not relieved, anesthesia\n checked location of catheter, in too far, readjusted, pt bolused with\n 5 cc lidocaine via epidural catheter, pt received additional bolus 5\n cc x 1, pain relieved, level at inguinal area pain on a\n scale of , esp with coughing. Epidural continues\n Hydormorphone 10 mcg/cc with 0.1% Bupivacaine at 1mg/cc at 10 cc/hr.\n Pt using IS every 1 hours, enc to cough, deep breath, pt sat on\n side of bed for\n, unable to stand\n epidural was too low. (legs\n numb) temp max 100.7 po, HR 90\ns SR BP 140/60 on 4\n liters n/c, rr~20, O2 sats 94%. Pt with crackles at bases, IVF LR @\n 150 cc/hr decreased to 75 cc/hr. foley inserted in penis ( just a\n pelvic drain)\n draining small amounts serous fluid. Ileoconduit\n draining 60-100 cc/hr of seroussang urine. Bun 21 crt\n 1.7 abd dsg intact\n old blood on dsg, (surgeon did not\n change dsg) repeat Hct 28\n Action:\n Response:\n Plan:\n Call pain service if you need to adjust epidural catheter. Pain\n service Pirzadey beeper . encourage turn, cough, deep\n breath. Do not have pt lie on left side\n catheter will not drain.\n ENDO: FS qid, at 6 pm FS 215 pt received 4 units regular insulin\n (according to sliding scale)\n" }, { "category": "Physician ", "chartdate": "2146-03-12 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 517115, "text": "Chief Complaint: s/p ileal loop cystectomy with radial prostectomy with\n intraoperative hypotension\n 24 Hour Events:\n ARTERIAL LINE - START 07:00 PM\n transfused 2 units pRBCs\n epidural anesthesia increased\n This am still requesting ice chips and for NGT to be removed.\n History obtained from Medical records\n Allergies:\n History obtained from Medical recordsNo Known Drug Allergies\n Last dose of Antibiotics:\n Gentamicin - 04:45 AM\n Cefazolin - 06:20 AM\n Infusions:\n Other ICU medications:\n Metoprolol - 06:20 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 Nutritional Support: NPO\n Gastrointestinal: Abdominal pain\n Genitourinary: Foley\n Flowsheet Data as of 08:32 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.9\nC (100.3\n Tcurrent: 37.9\nC (100.3\n HR: 96 (93 - 108) bpm\n BP: 138/53(84) {91/35(54) - 142/61(87)} mmHg\n RR: 16 (11 - 21) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 1,146 mL\n 2,081 mL\n PO:\n TF:\n IVF:\n 984 mL\n 1,493 mL\n Blood products:\n 162 mL\n 588 mL\n Total out:\n 90 mL\n 1,035 mL\n Urine:\n 90 mL\n 785 mL\n NG:\n 250 mL\n Stool:\n Drains:\n Balance:\n 1,056 mL\n 1,046 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 97%\n ABG: ///22/\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Head, Ears, Nose, Throat: NG tube\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Breath Sounds: Clear : )\n Abdominal: Soft, No(t) Bowel sounds present, Tender: diffuse, dressing\n CDI\n Skin: Not assessed\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 193 K/uL\n 9.9 g/dL\n 152 mg/dL\n 1.7 mg/dL\n 22 mEq/L\n 4.6 mEq/L\n 21 mg/dL\n 107 mEq/L\n 139 mEq/L\n 28.6 %\n 11.0 K/uL\n [image002.jpg]\n 09:44 PM\n 03:38 AM\n WBC\n 11.0\n Hct\n 28.6\n Plt\n 193\n Cr\n 1.6\n 1.7\n TropT\n <0.01\n <0.01\n Glucose\n 134\n 152\n Other labs: PT / PTT / INR:13.7/25.7/1.2, CK / CKMB /\n Troponin-T:6463/17/<0.01, Ca++:7.6 mg/dL, Mg++:1.5 mg/dL, PO4:4.6 mg/dL\n Assessment and Plan\n Pt is an 82 y.o male with h.o transitional cell invasive bladder ca,\n HTN, HL, who is s/p ileal loop cystectomy with radial prostectomy.\n HYPOTENSION (NOT SHOCK)\n Admitted to ICU for intraoperative hypotension requiring pressors. Now\n resolved and normotensive. Likely related to loss of volume or\n intraoperative blood loss. Anesthetics and epidural also likely a\n possibility. Other considerations include sepsis or cardiogenic, but\n doubtful at this time. Transfused 2 units pRBCs. EKG from baseline.\n -transfuse additional unit for crit 28 from 26 s/p 2 units\n -continue IVF\n -f/u urology recs\n DIABETES MELLITUS (DM), TYPE II\n -HISS for now, DM diet when able.\n CANCER (MALIGNANT NEOPLASM), OTHER\n Transitional cell bladder ca-s/p resection in . Now s/p ileal loop\n cystectomy with radical prostectomy.\n -foley and urostomy drain\n -post op abx: gent x 24h\n -urology recs.\n -pain control with epidural\n baseline 1.0. Could be related to underlying cancer vs. prerenal\n process given blood loss in OR. Also possible intrinsic vs.\n post-obstructive from new anatomy/procedure.\n -u/a and cx\n -ulytes\n -renally dose meds.\nHTN-hold anti-hypertensives at this time. Will likely resume in am.\nHL-home statin.\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 07:00 PM\n 20 Gauge - 07:00 PM\n 18 Gauge - 07:01 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": "Nursing", "chartdate": "2146-03-12 00:00:00.000", "description": "Nursing Progress Note", "row_id": 517185, "text": "82 yo man w/ h/o HTN, AODM, polynephritis, neuropathy, recent dx\n w/bladder cancer. Today he underwent radical cystectomy/protastectomy\n w/creation of neobladder and ileoconduit. Required Neosynephrine gtt\n which has been weaned off. Transferred to ICU for overnight monitoring\n Cancer (Malignant Neoplasm), Other\n Assessment:\n Pt with epidural catheter, pain not relieved, anesthesia checked\n location of catheter, in too far, readjusted, pt bolused with\n lidocaine, pt received additional bolus 5 cc x 2, pain relieved, level\n at pain on a scale of , esp with coughing.\n Epidural continues Hydormorphone 10 mcg/cc with 0.1% Bupivacaine at 10\n cc/hr. Pt using IS every 1 hours, enc to cough, deep breath, pt\n sat on side of bed for\n, unable to stand\n epidural was too low.\n (legs numb) temp max 100.7 po, HR 90\ns SR BP 140/60 on 4\n liters n/c, rr~20, O2 sats 94%. Pt with crackles at bases, IVF LR @\n 150 cc/hr decreased to 75 cc/hr. foley inserted in penis ( just a\n pelvic drain)\n draining small amounts serous fluid. Ileoconduit\n draining 60-100 cc/hr of seroussang urine. crt abd\n dsg intact\n old blood on dsg, (surgeon did not change dsg)\n Action:\n Response:\n Plan:\n Call pain service if you need to adjust epidural catheter. Pain\n service Pirzadey beeper . encourage turn, cough, deep\n breath. Do not have pt lie on left side\n catheter will not drain.\n" }, { "category": "Physician ", "chartdate": "2146-03-12 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 517095, "text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n ARTERIAL LINE - START 07:00 PM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Gentamicin - 04:45 AM\n Cefazolin - 06:20 AM\n Infusions:\n Other ICU medications:\n Metoprolol - 06:20 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 08:23 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.9\nC (100.3\n Tcurrent: 37.9\nC (100.3\n HR: 96 (93 - 108) bpm\n BP: 138/53(84) {91/35(54) - 142/61(87)} mmHg\n RR: 16 (11 - 21) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 1,146 mL\n 2,060 mL\n PO:\n TF:\n IVF:\n 984 mL\n 1,473 mL\n Blood products:\n 162 mL\n 588 mL\n Total out:\n 90 mL\n 1,035 mL\n Urine:\n 90 mL\n 785 mL\n NG:\n 250 mL\n Stool:\n Drains:\n Balance:\n 1,056 mL\n 1,025 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 97%\n ABG: ///22/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 9.9 g/dL\n 193 K/uL\n 152 mg/dL\n 1.7 mg/dL\n 22 mEq/L\n 4.6 mEq/L\n 21 mg/dL\n 107 mEq/L\n 139 mEq/L\n 28.6 %\n 11.0 K/uL\n [image002.jpg]\n 09:44 PM\n 03:38 AM\n WBC\n 11.0\n Hct\n 28.6\n Plt\n 193\n Cr\n 1.6\n 1.7\n TropT\n <0.01\n <0.01\n Glucose\n 134\n 152\n Other labs: PT / PTT / INR:13.7/25.7/1.2, CK / CKMB /\n Troponin-T:6463/17/<0.01, Ca++:7.6 mg/dL, Mg++:1.5 mg/dL, PO4:4.6 mg/dL\n Assessment and Plan\n CANCER (MALIGNANT NEOPLASM), OTHER\n 82 yo man w/ h/o HTN, AODM, recent dx w/bladder cancer now s/p radical\n cystectomy/protastectomy w/creation of neobladder and ileoconduit.\n Transiently required Neosynephrine gtt in the PACU (EBL 1200, received\n 4 L IVFs in perioperatively); pressors weaned off prior to transfet to\n the ICU for overnight monitoring.\n BP 140/70, off pressors since ~2 pm NGT in place\n Lungs clear anteriolaterally\n Cor: RRR Abdomen: Dressing clean and dry, occ. Bowel sound, soft\n Labs notable for mildly elevated Cr 1.6, BUN 14, glucose 92, HCT 26.2\n (pre-op Hcct 36.4). Plt 233K\n Intraoperative and postop hypotension transiently requiring neo in the\n PACU. Now hemodynamically stable off pressors for past several hours.\n Agree with assessment and plan as above. Also would check\n postoperative ECG. Agree with blood transfusion (ICU consent signed).\n Check coags and follow serial CBC. Antibiotics per surgical service,\n check to be sure dosed per renal function. Follow urine output, serial\n labs. Likely prerenal. UA, culture, check urine lytes. Pain control\n with epidural.\n Patient is critically ill given labile blood pressure postoperatively\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Arterial Line - 07:00 PM\n 20 Gauge - 07:00 PM\n 18 Gauge - 07:01 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 30 minutes\n Patient is critically ill\n" }, { "category": "Physician ", "chartdate": "2146-03-12 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 517098, "text": "Chief Complaint: s/p ileal loop cystectomy with radial prostectomy with\n intraoperative hypotension\n 24 Hour Events:\n ARTERIAL LINE - START 07:00 PM\n transfused 2 units pRBCs\n epidural anesthesia increased\n History obtained from Medical records\n Allergies:\n History obtained from Medical recordsNo Known Drug Allergies\n Last dose of Antibiotics:\n Gentamicin - 04:45 AM\n Cefazolin - 06:20 AM\n Infusions:\n Other ICU medications:\n Metoprolol - 06:20 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 Nutritional Support: NPO\n Gastrointestinal: Abdominal pain\n Genitourinary: Foley\n Flowsheet Data as of 08:32 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.9\nC (100.3\n Tcurrent: 37.9\nC (100.3\n HR: 96 (93 - 108) bpm\n BP: 138/53(84) {91/35(54) - 142/61(87)} mmHg\n RR: 16 (11 - 21) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 1,146 mL\n 2,081 mL\n PO:\n TF:\n IVF:\n 984 mL\n 1,493 mL\n Blood products:\n 162 mL\n 588 mL\n Total out:\n 90 mL\n 1,035 mL\n Urine:\n 90 mL\n 785 mL\n NG:\n 250 mL\n Stool:\n Drains:\n Balance:\n 1,056 mL\n 1,046 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 97%\n ABG: ///22/\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Head, Ears, Nose, Throat: NG tube\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Breath Sounds: Clear : )\n Abdominal: Soft, No(t) Bowel sounds present, Tender: diffuse, dressing\n CDI\n Skin: Not assessed\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 193 K/uL\n 9.9 g/dL\n 152 mg/dL\n 1.7 mg/dL\n 22 mEq/L\n 4.6 mEq/L\n 21 mg/dL\n 107 mEq/L\n 139 mEq/L\n 28.6 %\n 11.0 K/uL\n [image002.jpg]\n 09:44 PM\n 03:38 AM\n WBC\n 11.0\n Hct\n 28.6\n Plt\n 193\n Cr\n 1.6\n 1.7\n TropT\n <0.01\n <0.01\n Glucose\n 134\n 152\n Other labs: PT / PTT / INR:13.7/25.7/1.2, CK / CKMB /\n Troponin-T:6463/17/<0.01, Ca++:7.6 mg/dL, Mg++:1.5 mg/dL, PO4:4.6 mg/dL\n Assessment and Plan\n HYPOTENSION (NOT SHOCK)\n DIABETES MELLITUS (DM), TYPE II\n CANCER (MALIGNANT NEOPLASM), OTHER\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 07:00 PM\n 20 Gauge - 07:00 PM\n 18 Gauge - 07:01 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": "2146-03-12 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 517101, "text": "Chief Complaint: s/p ileal loop cystectomy with radial prostectomy with\n intraoperative hypotension\n 24 Hour Events:\n ARTERIAL LINE - START 07:00 PM\n transfused 2 units pRBCs\n epidural anesthesia increased\n History obtained from Medical records\n Allergies:\n History obtained from Medical recordsNo Known Drug Allergies\n Last dose of Antibiotics:\n Gentamicin - 04:45 AM\n Cefazolin - 06:20 AM\n Infusions:\n Other ICU medications:\n Metoprolol - 06:20 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 Nutritional Support: NPO\n Gastrointestinal: Abdominal pain\n Genitourinary: Foley\n Flowsheet Data as of 08:32 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.9\nC (100.3\n Tcurrent: 37.9\nC (100.3\n HR: 96 (93 - 108) bpm\n BP: 138/53(84) {91/35(54) - 142/61(87)} mmHg\n RR: 16 (11 - 21) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 1,146 mL\n 2,081 mL\n PO:\n TF:\n IVF:\n 984 mL\n 1,493 mL\n Blood products:\n 162 mL\n 588 mL\n Total out:\n 90 mL\n 1,035 mL\n Urine:\n 90 mL\n 785 mL\n NG:\n 250 mL\n Stool:\n Drains:\n Balance:\n 1,056 mL\n 1,046 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 97%\n ABG: ///22/\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Head, Ears, Nose, Throat: NG tube\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Breath Sounds: Clear : )\n Abdominal: Soft, No(t) Bowel sounds present, Tender: diffuse, dressing\n CDI\n Skin: Not assessed\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 193 K/uL\n 9.9 g/dL\n 152 mg/dL\n 1.7 mg/dL\n 22 mEq/L\n 4.6 mEq/L\n 21 mg/dL\n 107 mEq/L\n 139 mEq/L\n 28.6 %\n 11.0 K/uL\n [image002.jpg]\n 09:44 PM\n 03:38 AM\n WBC\n 11.0\n Hct\n 28.6\n Plt\n 193\n Cr\n 1.6\n 1.7\n TropT\n <0.01\n <0.01\n Glucose\n 134\n 152\n Other labs: PT / PTT / INR:13.7/25.7/1.2, CK / CKMB /\n Troponin-T:6463/17/<0.01, Ca++:7.6 mg/dL, Mg++:1.5 mg/dL, PO4:4.6 mg/dL\n Assessment and Plan\n HYPOTENSION (NOT SHOCK)\n DIABETES MELLITUS (DM), TYPE II\n CANCER (MALIGNANT NEOPLASM), OTHER\n Pt is an 82 y.o male with h.o transitional cell invasive bladder ca,\n HTN, HL, who is s/p ileal loop cystectomy with radial prostectomy.\n .\n #s/p post-op hypotension-Pt with reported intraoperative hypotension\n requiring pressors. Pt normotensive in the PACU and currently\n normotensive. Likely related to loss of volume or intraoperative blood\n loss. Anesthetics and epidural also likely a possibility. Other\n considerations include sepsis or cardiogenic, but doubtful at this\n time.\n -monitor BP-goal map >65\n -abx as per urology\n -2 units PRBcs\n -post transfusion HCT\n -8hr HCT\n -active T+S\n -IVF\n -can consider infectious w/u if symptoms arise.\n -EKG\n .\n #Transitional cell bladder ca-s/p resection in . Now s/p ileal\n loop cystectomy with radical prostectomy.\n -foley and urostomy drain\n -post op abx\n -urology recs.\n -pain control with epidural.\n .\n #acute renal failure-baseline 1.0. Could be related to underlying\n cancer vs. prerenal process given blood loss in OR. Could be intrarenal\n vs. post-obstructive from new anatomy/procedure.\n -u/a and cx\n -ulytes\n -renally dose meds.\n .\n #HTN-hold anti-hypertensives at this time. Will likely resume in am.\n .\n #HL-home statin.\n .\n #DM-HISS for now, DM diet when able.\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 07:00 PM\n 20 Gauge - 07:00 PM\n 18 Gauge - 07:01 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": "Nursing", "chartdate": "2146-03-11 00:00:00.000", "description": "Nursing Progress Note", "row_id": 516980, "text": "82 yo man w/ h/o HTN, AODM, polynephritis, neuropathy, recent dx\n w/bladder cancer. Today he underwent radical cystectomy/protastectomy\n w/creation of neobladder and ileoconduit. Required Neosynephrine gtt\n which has been weaned off. Transferred to ICU for overnight monitoring.\n A&O x3 on admit. Pain increased during transport from with\n T9-10 epidural in place. Sensation at umbilicus area with L >R. Given\n 5cc bolus and pain is now down to 3/10. Followed by pain service.\n Abd distended w/hypoactive bowel sds. Incisional dsd with dried blood\n soaked through, small amt. Ileoconduit drained 90cc pink urine. Foley\n cath via penis into pelvis draining small amt frank blood.\n Gd O2sats on 3L N/C.\n Art line in place.\n NGT-LCS w/ no output at present.\n Family spoke with MD and have gone home for the night. is\n HCP.\n" }, { "category": "Nursing", "chartdate": "2146-03-12 00:00:00.000", "description": "Nursing Progress Note", "row_id": 517061, "text": "82 yo man w/ h/o HTN, AODM, polynephritis, neuropathy, recent dx\n w/bladder cancer. Today he underwent radical cystectomy/protastectomy\n w/creation of neobladder and ileoconduit. Required Neosynephrine gtt\n which has been weaned off. Transferred to ICU for overnight monitoring\n Cancer (Malignant Neoplasm), Other\n Assessment:\n Pt s/p radical cystectomy / prostectomy with neobladder and ileoconduit\n , post op day #1 , off pressor,VSS, aline in place, abd incision\n dressing soaked with old drainage ,looks same, c/o pain when coughing\n or with any activity, other wise comfortable on bed. Slept well , EBL\n 1200CC\n Action:\n Monitored ABP, neo bladder urine output 40-50c/hr ,amber /pink in\n colour. Ileoconduit drained 175cc sero sanguinous drainage. Transfused\n 2 unit blood during the shift ,. gentamycin T 1.0,due dose 80mg given\n at 4.30am. continued with cefazolin 2gm q 8h. FS q6h ,covered with\n sliding scale insulin. Continued with epidural infusion hydromorphone\n 10mcg/ml + bupivaccine 0/1% 1mg/ml @ 7cc/hr. pt pain free ,moving\n all extremities, feeling sensation on LE. Tmax F .\n Response:\n Stable now, pain free, comfortable. Crit 28 with am lab\n Plan:\n f/u with urologist , monitor VS, urine output, am labs,continue with\n antibiotics as ordered.\n" }, { "category": "Nursing", "chartdate": "2146-03-12 00:00:00.000", "description": "Nursing Progress Note", "row_id": 517059, "text": "82 yo man w/ h/o HTN, AODM, polynephritis, neuropathy, recent dx\n w/bladder cancer. Today he underwent radical cystectomy/protastectomy\n w/creation of neobladder and ileoconduit. Required Neosynephrine gtt\n which has been weaned off. Transferred to ICU for overnight monitoring\n Cancer (Malignant Neoplasm), Other\n Assessment:\n Pt s/p radical cystectomy / prostectomy with neobladder and ileoconduit\n , post op day #1 , off pressor,VSS, aline in place, abd incision\n dressing soaked with old drainage ,looks same, c/o pain when coughing\n or with any activity, other wise comfortable on bed. Slept well , crit\n 23 from yesterday.\n Action:\n Monitored ABP, neo bladder urine output 40-50c/hr ,amber /pink in\n colour. Ileoconduit drained 175cc sero sanguinous drainage. Transfused\n 2 unit blood during the shift ,. gentamycin T 1.0,due dose 80mg given\n at 4.30am. continued with cefazolin 2gm q 8h. FS q6h ,covered with\n sliding scale insulin. Continued with epidural infusion hydromorphone\n 10mcg/ml + bupivaccine 0/1% 1mg/ml @ 7cc/hr. pt pain free ,moving\n all extremities, feeling sensation on LE. Tmax F .\n Response:\n Stable now, pain free, comfortable. Crit 28 with am lab\n Plan:\n f/u with urologist , monitor VS, urine output, am labs,continue with\n antibiotics as ordered.\n" }, { "category": "Nursing", "chartdate": "2146-03-12 00:00:00.000", "description": "Nursing Progress Note", "row_id": 517055, "text": "82 yo man w/ h/o HTN, AODM, polynephritis, neuropathy, recent dx\n w/bladder cancer. Today he underwent radical cystectomy/protastectomy\n w/creation of neobladder and ileoconduit. Required Neosynephrine gtt\n which has been weaned off. Transferred to ICU for overnight monitoring\n Cancer (Malignant Neoplasm), Other\n Assessment:\n Pt s/p radical\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2146-03-12 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 517207, "text": "82 yo man w/ h/o HTN, AODM, polynephritis, neuropathy, recent dx\n w/bladder cancer. On he underwent radical\n cystectomy/protastectomy w/creation of neobladder and ileoconduit.\n Required Neosynephrine gtt which has been weaned off. Transferred to\n ICU for overnight monitoring\n Cancer (Malignant Neoplasm), Other\n Assessment:\n Pt with thoracic epidural catheter, pain not relieved, anesthesia\n checked location of catheter, in too far, readjusted, pt bolused with\n 5 cc lidocaine via epidural catheter, pt received additional bolus 5\n cc x 1, pain relieved, level at inguinal area pain on a\n scale of ( ) , esp with coughing. Epidural continues\n Hydormorphone 10 mcg/cc with 0.1% Bupivacaine at 1mg/cc at 10\n cc/hr. Pt using IS every 1 hours, enc to cough, deep breath, pt\n sat on side of bed for\n, unable to stand\n epidural was too low.\n (legs numb- ) temp max 100.7 po, down to 100.1 axillary,\n HR 90\ns SR BP 140/60 on 4 liters n/c, rr~20, O2 sats 94%. Pt\n with crackles at bases, IVF LR @ 150 cc/hr decreased to 75 cc/hr.\n foley inserted in penis ( just a pelvic drain)\n draining small amounts\n serous fluid. Ileoconduit draining 60-100 cc/hr of seroussang\n urine. Bun 21 crt 1.7 abd dsg intact\n old blood on\n dsg, (surgeon did not change dsg) repeat Hct 28.4 (pt received 2\n units PRBC on nights) 3^rd unit on hold for now secondary to temp\n Action:\n Pt post op day 1, thoracic epidural catheter continues for pain\n control\n Response:\n Stable, VSS, pain relieved with epidural catheter.\n Plan:\n Call pain service if you need to adjust epidural catheter. Pain\n service Pirzadey beeper . encourage turn, cough, deep\n breath. Do not have pt lie on left side\n catheter will not drain.\n Nothing per rectum or po either\n Pneumoboots continue\n continue to monitor urine output via ileo conduit, monitor output from\n penis. Check dsg . surgery following, pain service following.\n ENDO: FS qid, at 6 pm FS 215 pt received 4 units regular insulin\n (according to sliding scale)\n GI: NPO, right nare NG tube hooked up to low cont. suction\n drained\n >600 cc\ns clear fluid. Pt taking few ice chips, swab\n Mouth constantly, feels dry, wants NG tube out. + bowel sounds, no\n gas yet, pt continues to burb.\n CV: bp elevated >160/70 Lopressor increased to 7.5 mg IV qid from\n 5 mg HR 80-90 SR no vea noted. No chest pain.\n ID: t max 100.7 po, pt on Cefazolin 2 grams q 8 hrs x 2 days, need\n 10 pm dose, 6 am and 2 pm dose. received Gent x 2.\n Demographics\n Attending MD:\n F.\n Admit diagnosis:\n BLADDER CANCER/SDA\n Code status:\n Full code\n Height:\n Admission weight:\n 103 kg\n Daily weight:\n Allergies/Reactions:\n No Known Drug Allergies\n PMH: Diabetes - Oral \n CV-PMH: Hypertension\n Additional history: polynephritis, neuropathy, recent dx bladder ca\n Surgery / Procedure and date: see above\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:133\n D:57\n Temperature:\n 100.1\n Arterial BP:\n S:142\n D:60\n Respiratory rate:\n 16 insp/min\n Heart Rate:\n 96 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n Nasal cannula\n O2 saturation:\n 94% %\n O2 flow:\n 4 L/min\n FiO2 set:\n 24h total in:\n 3,775 mL\n 24h total out:\n 2,485 mL\n Pertinent Lab Results:\n Sodium:\n 139 mEq/L\n 03:38 AM\n Potassium:\n 4.6 mEq/L\n 03:38 AM\n Chloride:\n 107 mEq/L\n 03:38 AM\n CO2:\n 22 mEq/L\n 03:38 AM\n BUN:\n 21 mg/dL\n 03:38 AM\n Creatinine:\n 1.7 mg/dL\n 03:38 AM\n Glucose:\n 152 mg/dL\n 03:38 AM\n Hematocrit:\n 28.4 %\n 01:40 PM\n Finger Stick Glucose:\n 215\n 06:00 PM\n Valuables / Signature\n Patient valuables: Glasses\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Transferred from: 4 \n Transferred to: 12R\n Date & time of Transfer: 2230\n" }, { "category": "ECG", "chartdate": "2146-03-16 00:00:00.000", "description": "Report", "row_id": 246477, "text": "Sinus rhythm with ventricular premature beats in a trigeminal pattern. Right\nbundle-branch block with left anterior fascicular block. Non-specific T wave\nchanges. Compared to the previous tracing of left anterior fascicular\nblock is present.\n\n" }, { "category": "ECG", "chartdate": "2146-03-15 00:00:00.000", "description": "Report", "row_id": 246478, "text": "Sinus rhythm with premature beats that may be ventricular. Right bundle-branch\nblock. Leftward axis is non-specific. Since the previous tracing of \nectopy is now present.\n\n" }, { "category": "Radiology", "chartdate": "2146-03-17 00:00:00.000", "description": "ABDOMEN (SUPINE & ERECT)", "row_id": 1121014, "text": " 5:59 PM\n ABDOMEN (SUPINE & ERECT) Clip # \n Reason: r/o Ileus.\n Admitting Diagnosis: BLADDER CANCER/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old man with Bladder Ca s/p Radical cystectomy now with abdominal\n distention concerning for Ileus\n REASON FOR THIS EXAMINATION:\n r/o Ileus.\n ______________________________________________________________________________\n WET READ: 7:45 PM\n Coiled OGT incompletely eval Distended SB&LB c/w ileus No free air GWlms\n d/ 7:40p\n WET READ VERSION #1 7:42 PM\n Distendedt SB&LB c/w ileus No free air GWlms d/ 7:40p\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 82-year-old man with bladder cancer status post radical\n cystectomy, now with abdominal distention, concerning for ileus.\n\n COMPARISON: Abdominal radiograph .\n\n SUPINE AND UPRIGHT ABDOMEN RADIOGRAPHS: Diffuse gaseous distention of the\n small bowel and large bowel loops are noted throughout the abdomen. The\n -gastric tube is coiled in the gastric fundus. No free air is identified.\n Bilateral ureter extends are again noted.\n\n IMPRESSION: Findings consistent with ileus.\n\n" }, { "category": "Radiology", "chartdate": "2146-03-11 00:00:00.000", "description": "P ABDOMEN (SUPINE ONLY) PORT", "row_id": 1119996, "text": " 1:45 PM\n ABDOMEN (SUPINE ONLY) PORT Clip # \n Reason: uretral stent and ngt position\n Admitting Diagnosis: BLADDER CANCER/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old man with lines as above\n REASON FOR THIS EXAMINATION:\n uretral stent and ngt position\n ______________________________________________________________________________\n WET READ: KKgc FRI 4:10 PM\n 1.NG tube tip at the GE junction, recommded advancement to atleast 8 cm for\n optimal position.\n 2. Proximal ureteric stents in position. dital portion not included.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 82-year-old man with ureteral stent and NG tube, to assess the\n position.\n\n COMPARISON: No recent post-op studies available for comparison.\n\n FINDINGS: Single supine AP abdomen radiograph is obtained. An NG tube tip\n terminates at the level of the gastroesophageal junction, recommended\n advancement of at least 8 cm. The proximal portion of bilateral ureteric\n stents are visualized at expected location in the region of the renal\n pelvices; however, the distal portions are not included in the image.\n Multiple surgical clips and skin staples are noted in the pelvis relating to\n the patient's radical cystectomy with ileal loop conduit. Bowel gas pattern\n appears unremarkable. An epidural spinal catheter is noted. No\n pneumoperitoneum is identified.\n\n IMPRESSION:\n\n 1. NG tube terminates at the level of gastroesophageal junction, recommended\n advancement of at least 8 cm.\n 2. Proximal portion of bilateral ureteric stents noted, in expected location.\n The distal portions are not included in the study, presumably in ileal\n conduit.\n\n" } ]

[ { "category": "ECG", "chartdate": "2147-03-22 00:00:00.000", "description": "Report", "row_id": 255151, "text": "Sinus rhythm. Inferolateral T wave changes which are non-specific. No\nprevious tracing available for comparison.\n\n" } ]

[ { "category": "Nursing/other", "chartdate": "2125-11-28 00:00:00.000", "description": "Report", "row_id": 1532401, "text": "MICU NPN 3PM-11PM:\nNeuro: Pt awake, restless most of the time. Pulss at groin lines and trach when able so requires soft wrist restraints. Sometimes assists with turning. Follows simple commands and nods head appropriately to questions.\n\nCardiac: VSS. Off pressors and IVF at this point with good UO.\n\nResp: Doing well on PSV 10 with 5cm peep. Lungs are clear at times, other times coarse when in need of suctioning. Suctioned twice for mod amt thick pale yellow secretions. SRR 12-20 at rest. When needs to be suctioned her RR goes up to 30's.\n\nGI: Advancing tube feeds slowly to goal rate of 40cc/hr. Currently at 30cc/hr with no residuals. Passed stool at the end of day shift. +BS heard. Pt denies c/o pain.\n\nGU: UO good 40-80cc/hr.\n\nID: Temp up to 100.6 at 9PM. Given a dose of tylenol via the NGT.\n\nSocial: Phone call from pt's sister-in-law tonight. I did give her brief update.\n\nSkin: Buttocks decubitus dressing changed. Minimal drainage noted. Pt now on 1st step mattress. Turned off buttocks as much as possible but she does tend to squirm herself back to her back shortly after I turn her.\n" }, { "category": "Nursing/other", "chartdate": "2125-11-29 00:00:00.000", "description": "Report", "row_id": 1532402, "text": "Respiratory Care:\n8.0 trach patent/secure. B/S course>>ETS for moderate, thick, yellow. Pt. bronchospastic to SXN>>started on albuterol MDI's with good effect. No ABG's available, SPO2 high 90's to 100%. VT's 400-500cc. Pt. appears well sedated and synchronous at present. Will continue pulmonary hygiene. ? TM trial soon.\n" }, { "category": "Nursing/other", "chartdate": "2125-11-29 00:00:00.000", "description": "Report", "row_id": 1532403, "text": "NPN 11p-7a:\n CV: pt with episode of hypotension to 70/p after receiving 1 mg iv ativan for sleep... pt had tolerated .5mg iv x 2 o/n.. team aware, treated with total of 1L IVF... (500CC'S NS X 2) with resolution.. see careview of objective data.. pt to sternal rub/loud voice at the time. hct 25 this am (27).. no s/s bleeding. HR remained 50's SB/60's nrs with occasional pvc's/pac's.\n RESP: cont on PSV 10/5 with adequate volumes/mv... rate 12-20... tachypneic, low volumes x 1, sx'd and med with aforementioned ativan with good effect. sputum cont yellow, thick.\n GI: TF's advanced to 40cc's/hr.. no apparent difficulty.. ab soft, no stool. ngt placement checked.\n Id: low grade temps o/n.. wbc wnl today. abx unchanged o/n. cx pending.\n F/e: fsbs wnl. fb 1L + so far today.\n Integument: cont with stage 2 decube on buttocks. cleansed with wound cleanser and dsd applied.. on first step mattress.\n A/P: pt with episode hypotension o/n.. ? r/t sedation vs sepsis or other?. cont to follow hemodynamics.. ? Transfusion today? cont to follow for s/s bleeding. cont to follow cx.\n" }, { "category": "Nursing/other", "chartdate": "2125-12-02 00:00:00.000", "description": "Report", "row_id": 1532413, "text": "pmicu nsg progress note-\n\nNeuro- received haldol 1-2 mg q 4 hours for continuous restlesness and agitation with some effect. given MS 1mg at 5am for comfort during AM care with good effect. Pt much more interactive and cooperative with care, assisting in turning and responding to commands. BP stable with all meds for rrestlessnes.\n\nResp- rested on rate of 10 during night, toleratied well. rate was 13-16 and satsa 97% or above. suctioned q 4 hours for small amounts. Lungs with diminished breath sounds.\n\nCardiac- VSS, no hypotension. NSR with very short runs of A fib.\n\nGI-toleratin Tube feeds well. No stool,\n\nGU- urine output fair, 30-40 hourly with only tube feeds and meds intake.\n\nMisc-Picc line found to be red and echymotic, draining serosang fluid from insertion site. Flushed with NS and fluid fushed returned via insertion site. Resident in to check line and line dc'd due to erythema, serosang drainage from site and flushing showed infiltrate, therefore line dc'd upon request.\n\nID-received vanco forlast time yesterday and started on cipro IV.\n\nPlan- follow culures and fevers. continue to encourage to wean as able. sedate for comfort and management.\n" }, { "category": "Nursing/other", "chartdate": "2125-12-03 00:00:00.000", "description": "Report", "row_id": 1532419, "text": "MICU NPN 11AM-11PM:\nNeuro: awake and restless on/off throughout the day. Sedated with fentanyl 50mcg and versed 1mg for the PEG placementat 3PM and has been sleeping since then. MAE Pt turned and positioned every two to three hours.\n\nCardiac: VSS\n\nResp: Pt on PSV 10 with 5cm peep until she developed apnea post PEG insertion from getting the sedation. Put back on IMV at this point for the rest of the day. Lungs are coarse prior to suctioning improve after suctioning. Suctioned thick pale yellow secretions.\n\nGI: Pt underwent PEG insertion without complications. We can use the tube for meds tonight. Not free water boluses. We can restart tube feeds tomorrow afternoon. Pt with +BS No stool. Site looks clean and dry.\n\nGU: Foley with small UO most of the shift despite two fluid boluses of 500cc's 1/2NS. UO 20-40/hr.\n\nIV's: Pt still has the left groin triple lumen.The left arm is swollen and today's US shows clot in every major vessel in the shoulder and upper arm including subclavian vein, axillary vein and brachiocephalic veins. Jugular veins look open at this point. She needs to start on a heparin drip but the team has decided to hold off on this until tomorrow due to the new PEG that had to be inserted. GI did not want the heparin to be started tonight if possible. If they do decide to start it for some reason they would want no heparin bolus. The ored is written for it to start tomorrow at 11AM after the team discusses it on rounds.\n\nID: low grade fever today 99.3\n\nSocial: I spoke to pt's brother today. Told him about the clot that was found and filled him in on the PEG insertion.\n" }, { "category": "Nursing/other", "chartdate": "2125-12-04 00:00:00.000", "description": "Report", "row_id": 1532420, "text": "Pmicu nsg progress\nNeuro- Sleeping in naps. Appears to understand when spoken to.\nResp- remains on imv rate thoughout night with stable sats. Will need to wean to psv in am. Suctioned for mod amts clear secretions q3-4hrs.\nGI- Remains npo s/p peg. Can restart tube feeds at 3pm today. Passing mod amt soft brown stool.\nSkin- Lt arm remains swollen(us with clot). Will need to start heparin at 11am today.\n" }, { "category": "Nursing/other", "chartdate": "2125-12-04 00:00:00.000", "description": "Report", "row_id": 1532421, "text": "Micu Nursing Progress Note\nResp: Vent settings changed from IMV to PSV around 9am with O2 sats 95-96%. RR 26-32. She has been suctioned for large amount of white/yellow secretions.\n\nCardiac: B/P 120-140/80's, HR 80-90's.\n\nGI: Peg site without reddness or irritation. GI stated it was OK to start tube feedings at 12n so promote with fiber at 30cc/hr and will increase to tolerance to goal of 60cc/hr. Pt has had 2 lg golden loose stools.\n\nHeme: Pt was started on heparin due to the blood clots in the major blood veins in her left arm. She was started on 1100u/hr with no bolus at 12noon. Lovenox on hold until IR is consulted for PICC placement.\n\nGU: Urine output has been ~40cc/hr.\n\nNeuro: Pt has had periods of calm where she will be able to mouth words that made sense but they she will have period of aggitation where she will be throwing her legs over the side rails and mouthing words that did not make sense. She was able to talked down so that she was calm.\n\nSkin: dressing changed on buttock due to contamination with stool. The skin breakdown on right buttock almost healed and the skin breadkown on left buttock healing well, it was cleaned with wound cleanser and duoderm replaced.\n\nIV lines: Groin line has to be D/C'ed due to possible contamination from stool. IR contact and she will take down for PICC line placement at 1600. Heparin gtt stopped at 1430.\n" }, { "category": "Nursing/other", "chartdate": "2125-11-30 00:00:00.000", "description": "Report", "row_id": 1532408, "text": "PMICU NURSING PROGRESS 7A-7P\nreview of systems\nID-has been afebrile. wbc=10.2. on same antibx. no new cultures sent.\nGI-tube feeds infusing.unable to do PEG today because pt was not npo after 12m-will try and do PEG on monday.has positive bowel sounds.no stool today.\nNEURO-has been restless most of the day, pulling at groin line and monitor leads.throwing legs over siderails.does not follow commands consistently.opens eyes but does not make eye contact.family thinks her mental status is worse than baseline and that she does not recognize them.no sedatives given today until probably in IR.\nCV-vs have been stable, little change with agitation.\nRESP-we switched pt to PSV, with PS 10 and 5 peep.she did well for a while, with tvs ~ 500 and resp rate 20. later in day her resp rate went up to 32, and tvs were ~250 ccs-resps looked labored.team aware.sats ~93.lungs sound slightly coarse anteriorally.was sx multiple times for thick clear secretions.has a good cough.now -pt in interventional radiology-pt placed on an IMV rate so she could be sedated for picc line placement.\nF/E-has had a good urinary output, no peripheral edema noted.please see labs as listed in carevue.\nSKIN-seen by skin rehab nurse who detailed some recommendations in the chart.pt turned , but she always twists onto her back.\nIV Access- has the triple lumen groin line. currently down in interventional radiology for pICC line placement.\na-relatively uneventful day.tolerated PSV for several hrs.\np-will leave on a rate overnight.continue with good pulm, skin care.\nprovide safe environment-keep all side rails up, hand restraints in place.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2125-11-30 00:00:00.000", "description": "Report", "row_id": 1532409, "text": "resp. care note\npt remains and vented. changed to ps of tolerating well this a.m. and afternoon, but resp. rate is increasing with lower vols. ets'd for thick tan secretions. mdi's given. pt transported to I.R. for picc placement. versed given for procedure. plan for re-screen for rehab on monday after peg placement. see rt flowsheet for more.\n" }, { "category": "Nursing/other", "chartdate": "2125-12-01 00:00:00.000", "description": "Report", "row_id": 1532410, "text": "Respiratory Care:\n\nPatient remins intubated on mechanical support. Vent settings Vt 550, Simv 14, Fio2 40%, Peep 5, Psv 10 and Flowby 6/3. PAP/Plateau 22/17. Bs coarse bilaterally. Albuterol MDI given Q4hr. Sx'd for sm-moderate amounts of thick yellow sputum. Increased temp. Sputum Cx sent via nurse. No further changes made. Continue with mechanical support weaning to Psv during the day.\n" }, { "category": "Nursing/other", "chartdate": "2125-12-02 00:00:00.000", "description": "Report", "row_id": 1532414, "text": "P-MICU NURSING NOTE\nADDENDUM-PT'S PICC LINE WAS MEASURED TO BE 25 CM. NOT DOCUMENTED IN THE CHART HOW LONG IT WAS WHEN IT WAS PLACED. PER IV THERAPY THOSE LINES ARE GENERALLY 55 CM IN LENGTH. THE LINE LOOKED LIKE IT HAD BEEN CUT. CXR AND ARM X RAYS DONE. MONITOR.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2125-12-02 00:00:00.000", "description": "Report", "row_id": 1532415, "text": "P-MICU NURSING NOTE\nS-VENTED\nO-PLEASE SEE CAREVUE FOR ALL OBJECTIVE DATA.\n ALERT. ABLE TO NOD HEAD APPROPRIATELY TO SOME SIMPLE QUESTIONS. IS CONFUSED AS TO WHERE SHE IS/DATE OR TIME. FOLLOWS SIMPLE COMMANDS. CONTINUES TO PULL ON TRACH AND LINES. RECEIVED HALDOL 1 MG PO. HAS SETTLED DOWN AFTER THAT. OOB TO CHAIR FOR 2 1/2 HRS. TOTAL LIFT- WELL.\n AFEBRILE ON CURRENT ANTIBIOTICS. AWAITING RESULTS OF FURTHER CULTURES.\n NA-148-STARTED ON FREE WATER BOLUSES. GLUC LESS THAN 200.\n ON TUBE FEEDS-AT GOAL. NO BM.\n DEBUB ON BUTT-AREA CLEAN. DUODERM APPLIED AS DSG FELL OFF.\nA-AGITATION\n INFECTION\n ALT IN FLUID/LYTES.\n ALT IN SKIN INTEGRITY\nP-KEEP IN A SAFE ENVIRONMENT. HALDOL . CONTINUE RESTRAINTS FOR SAFETY.\n FOLLOW TEMP CURVE AND WBC'S. CONTINUE ANTIBIOTICS. AWAIT RESULTS OF CULTURES.\n FOLLOW NA AND SUGAR.\n PT NEEDS TO BE NPO AFTER MIDNIGHT FOR PEG PLACEMENT. GO BACK TO REHAB AFTER THAT. F/UP WITH CASE MANAGEMENT.\n CONTINUE SKIN CARE.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2125-12-03 00:00:00.000", "description": "Report", "row_id": 1532416, "text": "Respiratory Care:\n\nPatient remains intubated on mechanical support. Vent settings Vt 550, Simv 10, Fio2 40%, Peep 5, Psv 10, with Flowby 6/3. PAP/Plateau 21/16. Spont vols 300's with RR 5-10. Bs with few expiratory wheezes L lung otherwise lungs clear. Sx'd for sm amounts of thick white sputum. Albuterol MDI given q4hr. No further changes made. Continue with Psv trials during the day resting on Simv as above.\n" }, { "category": "Nursing/other", "chartdate": "2125-11-27 00:00:00.000", "description": "Report", "row_id": 1532396, "text": "MICU Nursing Admission Note:\n77 y.o. female admitted today from the EW with hypotension, changes in MS Rehab.\n\nPMH: S/P AAA repair in complicated by ARDS, failure to wean, vent dependent. UTI, Aspiration pneumonia, CAD, A-fib, HTN\n\nAllergies: Sulfa\n\nPt is at rehab, vent dependent. Today found unresponsive without audible BP. EMT's were called and BP found to be 90/50. Transported to EW where BP was only 60 palp. Pt minimally responsive. Given 1.5 liters IVF. Poor access, finally central line left groin inserted and pt started on dopamine which was increased to 20mcg/kg/min. Transported for head CT which was negative. Pt was fully all but for sputum and sent to MICU for further care.\n\nNeuro: Pt awake, does not follow commands. Minimally responsive but tries to pull at her trach tube so hands are restained loosely for safety.\n\nCardiac: BP 80's on admission off the dopamine. 500cc's NS bolus given then pt began on Neo drip to keep MAP>60. HR in the 80's.\n\nResp: Lungs are clear but decreased at the bases. On AC 14, 550, 40% with 5cm peep. Suctioned for thick white secretions.\n\nID: Febrile on admission to 101 rectal. Given tylenol 650mg PR.\nWill start antibiotics once she is fully .\n\nGI: NGT in place. Pt given a bottle of barocat for abdominal CT but it is on hold for now. Pt with loud bowel sounds throughout.\n\nGU: Foley in place draining sedimented yellow urine.\n\nSkin: Pt with red buttocks with open stage II decubitus noted on admission. Needs 1st step mattress.\n\nSocial: Daughter is spokesperson. . Pt also has brother who is involved .\n\n\n" }, { "category": "Nursing/other", "chartdate": "2125-11-27 00:00:00.000", "description": "Report", "row_id": 1532397, "text": "MICU Admission Note addendum:\nID: Pt was on IV Vanco at rehab for MRSA and needs levels drawn with next dose. I drew a trough before I hung the 10PM dose which will run over one hour and she will need a peak one hour after the dose finishes tonight. This should be at about midnight.\n" }, { "category": "Nursing/other", "chartdate": "2125-11-28 00:00:00.000", "description": "Report", "row_id": 1532398, "text": "Resp Care Note:\n\nPt cont on mech vent as per Carevue. Lung sounds coarse suct sm-mod th pale yellow. Pt placed on PSV from A/C and has very well overnoc. Begin weaning with PSV as .\n" }, { "category": "Nursing/other", "chartdate": "2125-12-04 00:00:00.000", "description": "Report", "row_id": 1532422, "text": "MICU NPN 11AM-11PM:\nNeuro: Pt awake, restless, picking at things constantly. I found the trach in her hand and she was pulling on it at one point. Also pt trying to get legs out of the bed. She does not know what she is doing. Restraints on for safety. Given haldol 2mg IV times one and ativan 1mg PO with minimal relief.\n\nCardiac: Vitalsigns are stable.Still with someAPC's.No a-fib noted. She has clot in her left upper arm and started on a heparin drip with no bolus at 6PM this eve.Needs to have level checked at midnight. Pt ordered to start on levonox but this will be done tomorrow after they discuss it on rounds.\n\nResp: Thick yellow secretions via the ETT suctioned every hour or two, could be morefrequent if I had the time. Lungs clear after suctioning. Remainson PSV 10 with 5cm peep through the day. SRR 14-20's.\n\nGI: Tube feeds restarted at noon.Slowly advanced to goal of60cc/hr.Pt passing sticky thick stool which seems too thick for bag or tube. PEG looks good.\n\nGU: UO adequate via the foley.\n\nID: Left groin line d/c'd and tipsent for culture at 8PM. New PICC inserted in right arm in IR this afternoon. Draws back well and site is oozing small amt serous sang dng. All antibiotics have been stopped. She will need to be if she spikes tonight. So farpt temp99.2.\n" }, { "category": "Nursing/other", "chartdate": "2125-12-05 00:00:00.000", "description": "Report", "row_id": 1532423, "text": "NPN nocs:\n S/O: pt remains hemodynamcially stable, see careview for objective data. hep gtt therapeutic, with ptt 99.9.. picc line cont to ooze blood, draws well. cont on TF's at goal.. loose stool x 1.. may need different formula or immodium if stool persists.. duoderm replaced to stage 2 decube to L buttock.. uo adequate but marginal. pt afebrile. am labs pending. sx for small amts yellow secretions.\n A/P: stable o/n.. only active issue remains diarrhea, and heparin gtt.. ? if will need to be coumadinized before transfer to rehab.\n" }, { "category": "Nursing/other", "chartdate": "2125-12-05 00:00:00.000", "description": "Report", "row_id": 1532424, "text": "MICU Nursing Discharge Note:\nPt. stable for discharge back to rehab.\n\nNeuro: Pt. restless, and not happy. She fights when being turned and with pt. care. Bilateral soft restraints on becuase pt. keeps pulling on tubes and lines.\n\nResp: Remains stable on PS 10 +5. Rate in the teens, her rate does increase when she is agitated. Lungs are coarse, suctioned for thick white secretions.\n\nCV: BP stable, NSr, with occ pac.\n\nGI: tolerating tube feeds, continues to pass soft brown stool.\nGU:Urine output marginal, has received a 250cc NS bolus and a 250cc 1/2ns bolus.\n\nHEME: ptt theraputic, however ptt reported from add an lab 150. Dr. aware, heparin at 1100u/hr, and ptt is currently being sent.\nSee carevue for further details.\n" }, { "category": "Nursing/other", "chartdate": "2125-11-29 00:00:00.000", "description": "Report", "row_id": 1532404, "text": "NPN 7a-3p\n\nReview of Systems:\n\nNeuro: Pt. given 0.5mg of Ativan for aggitation, tachpnea w/low TV and slight desaturation; good effect; TV increased, RR slowed and pt. sleeping X 2 hours.\n\nResp: No TM trials thus far today d/t hyperventilation and low TV. Sx'd several times (bagged) for yellow plugs. Sat's maintained >96% (93% with desaturation). LS- coarse throughout. Plan- TM trial when appropriate.\n\nCV: HR 70-80's A-fib to NSR. BP 100-130/70. Pt. conts to be edemedous throughout. + pedal pulses.\n\nSkin: Wound RN consulted, will be by tom'row. Cont. with Damp to Dry dsg changes with wound cleanser . On 1st Matress.\n\nGI: TF advanced to 50cc with min. residuals. 60cc of Promote with fiber. Large, golden stool X1. . soft.\n\nGU: F/C draining clear, yellow urine. U/A sent.\n\nID: Pt. conts on Vanco, flagyl PO, ceftaz. Mildly febrile today.\n\nHeme: 1 of 2 units of PRBC hanging; tolerated thus far. Will repeat HCT after 2 u. Hemetology and other studies sent this afternoon.\n\nAccess: Awaiting PICC placement at bedside or in IR tom'row. Then will d/c femoral line.\n" }, { "category": "Nursing/other", "chartdate": "2125-11-29 00:00:00.000", "description": "Report", "row_id": 1532405, "text": "NPN 3P-11P:\nPt was given 2nd unit of blood. During tx she became tachypneic, relatively and hypertensive, with exp wheezing. She appeared to be in and out of AF on the monitor at this time as well. She was suctioned for thick plugs, given albuterol MDI's, treated with Lasix, and given 0.5mg IV Ativan with good effect. She has settled down nicely, with HR, RR, BP returning to baseline. She is now resting comfortably.\nTF's advanced to goal of 60 cc/hr with minimal residuals. She had several loose stools early in the shift, none for several hours.\nA: ? CHF with blood, now resolved\nP: continue to follow resp status and U/O; pulmonary toilet; Ativan ; Recheck Hct in AM.\n" }, { "category": "Nursing/other", "chartdate": "2125-11-30 00:00:00.000", "description": "Report", "row_id": 1532406, "text": "PMICU Nursing Progress Note\nReview of Systems:\n\n Pt is awake, inconsisitently responsive to commands and experiencing periods of agitation. She was given MSO4(2mg) and Ativan (.5mg) w/ good effect for these periods of agitation which were accompanied by s+s of CHF (crackles at bases of lungs, tachypnea, tachycardia, flushing). When agitated, her HR and BP increasesd and she pulls at all her tubes. Safety concern-continue w/ wrist restraints!\n\nC-V- VSS currently. Pt completed 2nd unit prbc's.. 2 hrs into this transfusion, pt developed tachypnea(rate30's), tachycardia(90's nsr), flushing, and course breathe sounds.. HO notified, pt med with 20mg iv lasix with good effect.. UO about 500cc's.. pt settled out thereafter and tx completed without event.. 1.5 hrs after tx complete, pt again with s/s chf.. 20mg lasix repeated and also med with 2mg iv mso4 with good effect... Rested o/n on simv mode of ventilation. Tx w/u sent per HO. w/u pending. HR a 80's up to 90's when in distress, NSR with Frequent PAC's. Maintained BP's in 140's/ 70's.\n\nResp- Current Vent settings SIMV, 550x10, PEEP 5, pt over breathing to 21. Pt. suctioned q 2 hrs for thick, yellow secretions. Three episodes of desaturation to the low 90's, high 80's. After suctioning, Sat's resumed normal in high 90's. LS coarse bilaterally with an expiratory wheeze. Last ABG 77/43/7.47. per team to retrial psv this am.\n\nGI- TF (Promote w/ Fiber) @ 60 cc/hr for most of the night, after periods of desaturation HO ordered TF turned down to 20 cc/hr. Abddomen soft, nondistended, pos.BS, 3 loose BM early in shift.\n\nGU- Good U/O, average 100 cc/hr after lasix. Clear, yellow. fluid balance -200 since mn... yesterday 24 hr fluid balance +1730.\n\nID- Afebrile, continues on antibiotics-Vanco, Flagyl, Ceftaz.\n\nSkin- Wound specialist in to see decubitus ulcer (stage II) today. Duoderm applied last night. Pt on first step mattress and continued frequent position changes.\n\nHeme/Endocrine- Received second unit of PRBC, significant bump in HCT from 28.3 to 39.8. Last FSBG was 159, pt received 2 U of Insulin.\n\nA/P- Continue to monitor pt's resp status; suction as needed and continue antibiotics. Cardiac status needs also to be carefully followed; appears to be a direct relationship w/ fluid balance. Follow up w/ wound care nurse ulcer. Treat agitation as needed ativan as ordered.\n" }, { "category": "Nursing/other", "chartdate": "2125-11-30 00:00:00.000", "description": "Report", "row_id": 1532407, "text": "pmicu nursing\na Dr called inquiring about mrs . he is the infectious disease doc from who covers Rehab-was taking care of Mrs .his phone # is if he can be of any help.\n" }, { "category": "Nursing/other", "chartdate": "2125-11-28 00:00:00.000", "description": "Report", "row_id": 1532399, "text": "NPN 11P-7A:\n S/O: Review of systems:\n CV: pt with sbp >100 all noc off Neo. No fluid boluses required.. cont on NS at 100cc/hr all noc.. HR 80's-90's NSR, occ pvc's. cpk's flat so far.\n ID: wbc 15 this am.. low grade temps all noc.. cont on vanco, pk and tr pending. also on flagyl pngt. UA with elevated wbc's.. all cx ngtd.\n RESP: PSV 15/5 all noc.. mv , rr 16-20 x 500. sx for small amts of thick yellow sputum. Trach site benign.. trache care done\n Integ: pt with stage 2 decube on R buttock.. site cleansed with wound cleanser and dsd applied.. needs first step mattress.\n F/E: fb 2L + yesterday.. 200cc's + today. ivf as noted in careview.\n MS: perrla.. pt inconsistently follows commands.. alert all noc.. MAE.. picks and pulls at iv tubing and trach, so therefore remains restrained.\n Social: no calls from family o/n.\n GI: ab soft, BS +.. ngt to lis without output, so clamped.. + flatus.. no stool.. initially nodding yes to ab discomfort, then nodding no.\n A/P: pt with likely sepsis.. hemodynamically stable o/n.. cont abx and follow cx. needs special care mattress.\n" }, { "category": "Nursing/other", "chartdate": "2125-12-03 00:00:00.000", "description": "Report", "row_id": 1532417, "text": "rn progress note\n 545am\nneuro: pt awake most of the night. sometimes will follow commands nods yes and no apporpriately and then several minutes later pt will look petrifried. denies that she is frighten. will take her several seconds to respond to staff as she previously had done. ? hoh or does not comprehend situation. reported by rehab that pt usually is unrsponsive.\n\ncad: hr afib with occass. pvc 80-90 b/p 90-teens/ 50-60's\n\nresp: no vent changes remains on imv 10x40%fio2l peep . overbreathes by breahts. occass. breahting in 30's ? hiccuping and setting off vent or pt was mouthing tube or pt had inc. oral secretions. happened several times thru out shift. pt suctioned for thick whiteish secretions. ls coarse with some scattered wheeezing.\n\ngi: tf off at mn for peg placement. no bm this shift .bs+ no tf resid.\n\ngu: uo30cc/hr currently 160+. rec 1/2 ns 500cc bolus with little effect on ouput.\n\nid: afebrile. cipro dc'd . ceftaz given. pt has slight oral thrush.\n\nskin: both arms weeping left at aline sighjt and right at picc line site. duoderm of l eft buttocks. continuously coming off do to gel.\n\nplan: peg placemnt, follow fluid status. ? attempt at weaning poss. inc activity as tolerated.\n" }, { "category": "Nursing/other", "chartdate": "2125-12-03 00:00:00.000", "description": "Report", "row_id": 1532418, "text": "7a-11a\n\nPt. stable on vent. No vent. changes made. FB 1/2 NS 500cc given X 1 for low u/o and decreasing BP. Haldol PO/ IV 2mg given for increased aggitation and tachypnea. Sx'd for sm. amounts of yellow plugs with no changes in ventilation (still rapid resp. rate). Pt. remain NPO for PEG placement today. SKin on coccyx looks improved; duoderm applied. Left arm old PICC site is of concern with new area of infiltration, bruising and redness. Area is not warmer to touch in comparison to right; not too much suspicion for cellulitus. Area to be u/s today to rule out clot. Area is marked and wrapped d/t weeping of stick site. Plan- increased frequency of FB PGT to QID for increasing serum Na+, get pt. OOB to chair, follow left arm circumference/ area of infiltration, u/s.\n" }, { "category": "Nursing/other", "chartdate": "2125-11-28 00:00:00.000", "description": "Report", "row_id": 1532400, "text": "NEURO: Opens eyes spont. and follows simple commands. Spont movement of extremities by four noted. Pt does attempt to self D/C trach when unrestrained therefore bilat soft hand restraints. +PERRLA 3+ noted.\nCV: Monitor shows NSR with occ PAC's and multifocal PVC's. Repeat lab work K, Mg, and Phos sent. Hct down to 27 this am (33 yest) and repeat Hct sent and stable @ 27. Increased ectopy noted with sxn and activity.\nRESP: LS bronchial RUL. Requiring frequent sxn Q2hr with thick yellow secretions. Pt ambued and lavaged by 1 for multiple thick mucous plugs. Prior to this pt with tacypnea(RR 30,s) and decreased tidal volumes(TV 180). Immed. following this RR down to 20 and TV 580. Cont with mod amts of clear oral secretions. R.T. attempted to decrease PS this am, however pt did not tolerate.\nGI: soft and nontender. + b.s. noted. Attempted to replace NGT from rehab by 2RN attempts with no success. Housestaff aware and will attempt later. + placement. Pt started on promote with fiber @ 10 cc/hr with residuals of 5. (goal 40 cc/hr). No stools.\nGU: New foley placed as ordered without difficulty and draining clear yellow urine with no sedimentation noted.\nM/S: Passive r.o.m. given and Ble slightly stiff. Remains restrained for ETT protection.\nI/D: Reamains febrile. Diflucan d/c'd and cont on po Flagyl.\nEND: Cont on fingersticks Q6 and required no s/s coverage.\nSKIN: Stage 2 OA on R glut with small amount serous/yellow dng. Wash with NS and DSD applied.\nNEURO-VASC: +csm +pp bilat SDC boots intact.\nPLAN: Cont to treat for sepsis and wean for PS as tolerated.\n\n" }, { "category": "Nursing/other", "chartdate": "2125-12-01 00:00:00.000", "description": "Report", "row_id": 1532411, "text": "NPN 7p-7a:\n ID: tmax 100.8..rectal. team aware. blood cx sent x 1 via picc, ua, c+s and sputum sent. restarted on diflucan as urine cx on admit showed >100,000 yeast. cont on vanco/flagyl/ceftaz for gnr and staph aureus in sputum.\n CV: pt with hypotension to 70/p after receiving mso4 1mg x 2 for aggitation. resolved with total 1L NS as ordered by team. hr cont 60's-90's nsr.\n Integ: wound cleanser then duoderm with paper tape border appled to stage 2-3 decube on L buttock as per skin care specialist. aloe vesta cream to r buttock. cont on first step mattress. also cont on vitamins to promote wound healing, as ordered.\n REsp; cotn on simv o/n.. see careview for details. sats 99-100% on 40% fio2. no changes o/n.. sx for thick yellow secretions.\n GI: tf's advanced as tolerated o/n.. no residuals noted.. to go for peg monday am... npo after mn monday.\n ACCESS: pt with Picc line placed last eve... to L brachial site.. site noted to be swollen (pt with bilateral upper body edema), red, and warm to touch.. per wincing x 1 when arm lifted, then shaking head \"no \" when asked if painful.\n Mental status: pt cont restless, pulling at lines, trach unless restrained. at times appears to understand conversation, but not following simple commands. pt required med for sleep, but dropped pressure to morphine as noted.\n a/P: pt cont with low grade temps.. diflucan added. aggitation cont to pose a challenge, as pt seems to become hypotensive to sedation.. ? trying haldol? cont with skin care as outlined. team aware of picc line, to f/u.. also unable to draw enough blood for chem 7... tlc not drawing blood, picc line stopped drawing after cx and cbc, and both this rn and another micu rn attempted to draw peripheral bloods.. unable. follow cx, cont abx.. to start on epogen d/t chronc low hct.\n" }, { "category": "Nursing/other", "chartdate": "2125-12-01 00:00:00.000", "description": "Report", "row_id": 1532412, "text": "P-MICU NURSING NOTE\nS-\nO-PLEASE SEE CAREVUE FOR ALL OBJECTIVE DATA.\n TEMP-100; WBC-9.3. REMAINS ON FLAGYL, CEFTAZ AND DIFLUC. UNABLE TO GIVE IV VANCO AS PT HAS RECEIVED HER MEDS FOR 72 HRS AND NOW NEEDS ID APPROVAL. INTERN, RESIDENT AND ID FELLOW AWARE. PRESENTLY RECEIVING ID CONSULT.\n ON VENT-CHANGED FROM IMV TO CPAP-PSV-10 AND 5 PEEP. MOVING 450-660 IN TV'S WITH A RR OF 14-24. RR INCREASES WITH AGITATION. O2 SAT> 94. SUCTIONED Q 3-4 HRS FOR THICK YELLOW SPUTUM.\n ON PROMOTE WITH FIBER-INCREASED TO 60/HR. SOFT-BS PRESENT. NO BM. GLUC IN THE 130'S-NO INSULIN GIVEN.\n 2-DECUBS ON BOTTOM-NO CHANGE. DSG DONE.\n PT WITH PERIODS OF AGITATION. ALERT. ABLE TO NOD HEAD APPROPRIATELY TO SOME QUESTIONS. DOES NOT FOLLOW ALL COMMANDS. PULLING OFF TRACHE TUBING, FOLEY, LINES. THROWING LEGS OVER THE SIDE OF THE BED. UNABLE TO CALM PT WITH ANY INTERVENTION. GAVE HALDOL WITH FAIR EFFECT.\nA-INFECTION\n IMP GAS EXCHANGE\n ALT IN NUTRITION\n ALT IN MENTAL STATUS.\nP-FOLLOW TEMP CURVE, WBC. CONTINUE ANTIBIOTIC THERAPY. AWAIT ID CONSULT FOR VANCO TO CONTINUE.\n KEEP ON PSV FOR NOW. PLAN IS TO PLACE BACK ON IMV LATER TONIGHT TO REST PT.\n CONTINUE TUBE FEEDS.\n HALDOL FOR AGITATION. EVALUATE EFFECTIVENESS OF MED. CONTINUE CARE. KEEP IN A SAFE ENVIRONMENT.\n\n" }, { "category": "ECG", "chartdate": "2125-11-27 00:00:00.000", "description": "Report", "row_id": 142375, "text": "Ectopic atrial tachycardia with new P wave morpholoy\nIncreased lateral ST-T changes suggest myocardial injury/ischemia\nSince last ECG, R wave progression more normal\n\n" }, { "category": "Radiology", "chartdate": "2125-11-27 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 744704, "text": " 1:43 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: EVAL FOR BLEED // MENTAL STATUS CHANGES\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old woman with MS changes. Chronic vent.\n REASON FOR THIS EXAMINATION:\n r/o bleed\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: Change in mental status.\n\n Comparisons: none.\n\n TECHNIQUE: Noncontrast axial images were obtained from the skull base to the\n vertex.\n\n FINDINGS: Moderate generalized age appropriate involutional changes are\n noted. The ventricles, basal cisterns and sulci are unremarkable. Diffuse\n hypoattenuation is seen throughout the periventricular white matter,\n consistent with chronic microvascular infarction in patient of this age. There\n is no mass lesion, acute intra-axial or extra-axial hemorrhage, shift of the\n normally midline structures, or hydrocephalus. Extensive intracranial\n vascular calcifications are noted along with a dilated basilar artery segment\n just superior to the vertebral artery junction point. The bony structures are\n intact. The paranasal sinuses and mastoid air cells are clear.\n\n IMPRESSION:\n 1) Diffuse hypoattenuation is seen throughout the periventricular white\n matter, consistent with chronic microvascular infarction.\n 2) Extensive vascular calcifications in a dilated segment of the basilar\n artery. This likely represents a dolichoectatic basilar artery segment;\n however, a focal aneurysm cannot be entirely excluded.\n 3) There is no evidence of acute intracranial hemorrhage or infarction.\n\n" }, { "category": "Radiology", "chartdate": "2125-11-30 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 744850, "text": " 12:49 AM\n CHEST (PORTABLE AP) Clip # \n Reason: e/f failure, edema, infiltrate\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old woman s/p trach placement. acute SOB, wheezes, inc crackles\n REASON FOR THIS EXAMINATION:\n e/f failure, edema, infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Acute shortness of breath. Wheezing.\n\n FRONTAL CHEST: Comparison with . Tracheostomy remains in good\n position. NGT extends below the level of the diaphragm off the film.\n Previously noted opacity in the right upper lobe is more confluent in the\n interval. In addition there has been slight increase in intensity of right\n middle lobe opacities. There is increased left retrocardiac density which may\n relate to atelectasis. Patchy opacity in the left mid lung has developed. No\n pleural effusions are identified. Superior mediastinum remains widened,\n consistent with history of aortic aneurysm. The heart is shifted towards the\n left in the interval.\n\n IMPRESSION: Worsening multifocal air space opacities concerning for\n multifocal pneumonia. Atelectasis of left lower lobe with shift of heart\n toward left.\n\n" }, { "category": "Radiology", "chartdate": "2125-12-02 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 744994, "text": " 2:35 PM\n CHEST (PORTABLE AP); HUMERUS (AP & LAT) LEFT PORT LEFT PORT Clip # \n Reason: PICC pulled this am, unsure as to length of PICC that was pl\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old woman s/p trach placement. PICC placed in IR and then pulled this\n am.\n REASON FOR THIS EXAMINATION:\n PICC pulled this am, unsure as to length of PICC that was placed\n please e/f PICC remnant in Left arm\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: ?PICC placement.\n\n Single view of the chest and left arm were submitted and compared to films\n from the PICC line placement of . Patient has an NG tube in place\n and a tracheostomy. There is tortuosity and calcification of the aorta. The\n heart is normal in size. There is an opacity in the retrocardiac region which\n may represent atelectasis although infection cannot be excluded. There is\n also blunting of the left costophrenic angle which may represent pleural\n effusion. There is linear opacification of the right apex, which is decreased\n in comparison to the prior examination. This may represent a resolving\n pneumonia. The osseous structures are normal. There is no portion of the\n PICC line visualized. The two views of the arm do not demonstrate any\n residual catheter.\n\n IMPRESSION: Retrocardiac density as well as a right upper lobe opacity, which\n are decreased in comparison to the prior examination and probably representing\n resolving pneumonia.\n\n No residual catheter is seen.\n\n" }, { "category": "Radiology", "chartdate": "2125-12-03 00:00:00.000", "description": "LP UPPER EXTREM VEINS US LEFT PORT", "row_id": 745038, "text": " 12:51 PM\n UPPER EXTREM VEINS US LEFT PORT Clip # \n Reason: Swelling, warmth, s/p Picc placement on Friday. Picc now dc'\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old woman with s/p thoracoabdominal aneyrsym repair, c/b by asp\n pna/ards, trach'd, transfered to rehab, returned for unresponsiveness,\n hypotension, and fever.\n REASON FOR THIS EXAMINATION:\n Swelling, warmth, s/p Picc placement on Friday. Picc now dc'd\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Swelling, warmth of the left upper extremity status post PICC\n placement on Friday.\n\n LEFT UPPER EXTREMITY DUPLEX VENOUS ULTRASOUND: -scale and color Doppler\n images of the left jugular, subclavian, axillary, brachial and basilic veins\n were performed. The left jugular vein is patent. However, no flow is\n demonstrated in the left subclavian, axillary, brachial or basilic veins.\n\n IMPRESSION: Extensive deep venous thrombosis of the left upper extremity\n involving the left subclavian, axillary, brachial and basilic veins. This\n finding was relayed to the medical team upon completion of the study.\n\n" }, { "category": "Radiology", "chartdate": "2125-12-04 00:00:00.000", "description": "CVL/PICC", "row_id": 745130, "text": " 3:40 PM\n PICC LINE PLACMENT SCH Clip # \n Reason: PICC placement in right arm\n Contrast: OPTIRAY Amt: 20\n ********************************* CPT Codes ********************************\n * CVL/PICC -22 EXTRA CHARGE *\n * UD GUID FOR NEEDLE PLACMENT CHEST AP ONLY *\n * EXTREM UNILAT VENOGRAPHY *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old woman with cad, htn, afib, s/p aaa, trach'd, presented with septic\n shock. Will need long term antibiotics. PICC placed on Friday in left arm. On\n Sat, was not drawing back blood. Dc'd on Sun. Site is swollen and warm.\n REASON FOR THIS EXAMINATION:\n PICC placement in right arm\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 77 YEAR OLD FEMALE WITH COMPLEX MEDICAL HISTORY, NEEDS LONG TERM\n ANTIBIOTICS. THE PATIENT HAS HISTORY OF CENTRAL VEIN OCCLUSIONS. A PICC LINE\n COULD NOT BE ADVANCED INTO THE SVC FROM THE LEFT ARM ON FRIDAY.\n\n PROCEDURE: The patient was placed on the angiographic table and right upper\n extremity was prepped and draped in the usual fashion. Using ultrasound\n guidance, the right basilic vein was punctured with a micropuncture needle.\n Ultrasound guidance was used due to non-visualization of the superficial veins\n in the right upper extremity. A 0.018 wire was advanced into the right\n subclavian vein, but could not be passed into the superior vena cava.\n Subsequently, a 4 FR introducer sheath was placed into the basilic vein and a\n right upper extremity venogram was performed, which showed almost complete\n occlusion of the right subclavian vein with various size collaterals in the\n right lower neck, draining into the patent superior vena cava. The right\n subclavian occlusion was then successfully negotiated using a 4 FR Berenstein\n catheter and a 0.035 stiff guidewire into the superior vena cava.\n Subsequently, a 36.5 cm single lumen 4 FR PICC was placed over the wire into\n the superior vena cava. A single chest radiograph was obtained to confirm the\n catheter's position. The catheter was secured to the skin with sutures. The\n patient left the department in satisfactory condition.\n\n IMPRESSION:\n\n 1. Right upper extremity venogram showed almost complete occlusion of the\n right subclavian vein with multiple various size collaterals in the right\n lower neck and a patent SVC.\n\n 2. The right subclavian occlusion was successfully crossed and a 36.5 cm\n single lumen PICC was placed with the tip in the lower SVC.\n\n 3. If PICC needs to be removed and/or recanalization of the right subclavian\n vein is indicated, please contact the intervention radiologist service.\n\n\n (Over)\n\n 3:40 PM\n PICC LINE PLACMENT SCH Clip # \n Reason: PICC placement in right arm\n Contrast: OPTIRAY Amt: 20\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n DR. \n" }, { "category": "Radiology", "chartdate": "2125-11-30 00:00:00.000", "description": "CVL/PICC", "row_id": 744872, "text": " 11:25 AM\n PICC LINE PLACMENT SCH Clip # \n Reason: PICC line placement by interventional radiology\n Contrast: OPTIRAY Amt: 40\n ********************************* CPT Codes ********************************\n * CVL/PICC UD GUID FOR NEEDLE PLACMENT *\n * CHEST AP ONLY EXTREM UNILAT VENOGRAPHY *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old woman with cad, htn, afib, s/p aaa, trach'd, presented with septic\n shock. Will need long term antibiotics. PICC may be placed in either arm.\n REASON FOR THIS EXAMINATION:\n PICC line placement by interventional radiology\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 77 year old female with multiple medical problems and septic shock,\n requiring parenteral antibiotic therapy.\n\n RADIOLOGISTS: Drs. and . The attending radiologist, Dr. ,\n was present throughout the procedure. DR. reviewed the case.\n\n TECHNIQUE: The left arm was prepped and draped in the usual sterile manner.\n Since no superficial veins were visible, ultrasound examination of the left\n arm was performed.\n\n Under ultrasound guidance, and following the administration of 1% lidocaine\n for local anesthesia, the left basilic vein was accessed using a micropuncture\n needle. A 0.018 guide wire was subsequently advanced into the left subclavian\n vein under fluroscopic guidance, and the needle was exchanged for a 4-French\n peel- away sheath. Multiple attempts at advancing the guide wire into the\n superior vena cava were unsuccessful. The guide wire was therefore exchanged\n for a 0.018 Glidewire, then a 0.035 stiff Glidewire, and multiple attempts at\n advancing the guide wires were still unsuccessful. A 4-French Berenstein\n catheter was therefore advanced over the guide wire and positioned in the left\n subclavian vein. A hand injected digital subtraction venogram was performed\n with the catheter in that location to demonstrate the central venous anatomy.\n\n The guide wire was then removed and the 0.018 guide wire was advanced under\n fluoroscopic guidance into the left subclavian vein. The 4-French Berenstein\n catheter was then removed and a single-lumen 4-French PICC was trimmed to 25\n cm and advanced over the guide wire. The guide wire and peel-away sheath were\n removed, and the PICC hub was affixed to the skin using a Stat-Lock system.\n The catheter was flushed and a sterile dressing was applied. A chest\n radiograph was obtained to demonstrate catheter position.\n\n The patient tolerated the procedure without complication. She received 0.5 mg\n of Versed intravenously for sedation. This was followed by a transient\n episode of bradycardia and hypotension which was treated with Ambu bagging and\n intravenous fluids. The MICU housestaff were called into the procedure room\n for management, and the patient was taken back to the MICU in stable\n condition.\n\n (Over)\n\n 11:25 AM\n PICC LINE PLACMENT SCH Clip # \n Reason: PICC line placement by interventional radiology\n Contrast: OPTIRAY Amt: 40\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n FINDINGS: Ultrasound examination of the left arm demonstrated a patent\n basilic vein with normal surrounding anatomy.\n\n Digital subtraction venogram with catheter tip in the left subclavian vein\n demonstrated reflux of contrast into a patient left internal jugular vein and\n complete occlusion of the left brachiocephalic vein. Multiple collaterals in\n the upper chest and neck were opacified. Contrast was seen in the region of\n the superior vena cava on delayed imaging.\n\n Post PICC placement radiograph demonstrated tip in the central left subclavian\n vein.\n\n IMPRESSION:\n\n 1) Complete occlusion of the left brachiocephalic vein, with multiple\n collaterals filling the superior vena cava.\n\n 2) Single lumen 4 Fr. PICC placed with the tip of the catheter in the left\n subclavian vein.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2125-11-27 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 744710, "text": " 2:53 PM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p R subclav attempt\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old woman s/p R SQ attempt. From NH with MS changes and R pneumonia.\n REASON FOR THIS EXAMINATION:\n s/p R subclav attempt\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: STATUS POST RIGHT SUBCLAVIAN LINE PLACEMENT ATTEMPT. PATIENT\n WITH KNOWN PNEUMONIA.\n\n Comparison is made to the prior study of .\n\n FINDINGS: There is no evidence of a central line. There is no pneumothorax.\n There is a tracheostomy tube with its tip well positioned in the trachea.\n There is an NG tube with its tip well positioned within the stomach.\n\n In the interval since the prior study, there is near complete resolution of\n the infiltrate in the left lower and mid lung zones. There is partial\n resolution of the infiltrate and collapse in the right upper and right lower\n lung zones. A small residual effusion on the right.\n\n There is left ventricular enlargement and a prominent aortic knob. The\n pulmonary vasculature is unremarkable.\n\n IMPRESSION: There is no evidence of pneumothorax or hematoma status post\n attempted central line placement.\n\n Interval improvement in both left and right-sided consolidation seen on the\n prior film.\n\n" } ]

[ { "category": "Radiology", "chartdate": "2179-07-17 00:00:00.000", "description": "L UNILAT LOWER EXT VEINS LEFT", "row_id": 1194535, "text": " 5:57 AM\n UNILAT LOWER EXT VEINS LEFT Clip # \n Reason: PT W/ SWELLING, EVAL FOR DVT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old woman with LLE swelling and hx of multiple DVTs. Had a positve D\n Dimer at the OSH\n REASON FOR THIS EXAMINATION:\n eval for DVT\n ______________________________________________________________________________\n WET READ: SAT 6:34 AM\n no dvt in left lower extremity.\n\n WET READ VERSION #1\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 63-year-old woman with left lower extremity swelling and history\n of multiple DVTs with a positive D-dimer at an outside hospital.\n\n COMPARISON: None.\n\n LEFT LOWER EXTREMITY VENOUS ULTRASOUND: Grayscale and Doppler son of\n the left common femoral, left superficial femoral and left popliteal veins\n show normal compressibility, flow and augmentation. Left posterior tibial and\n peroneal veins show normal flow.\n\n IMPRESSION: No evidence of DVT in left lower extremity veins.\n\n\n" }, { "category": "Radiology", "chartdate": "2179-07-17 00:00:00.000", "description": "CTA CHEST W&W/O C&RECONS, NON-CORONARY", "row_id": 1194536, "text": " 6:58 AM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \n Reason: eval for PE\n Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old woman with hx of multiple DVTs now w/ CP and low BPs. tx pt\n REASON FOR THIS EXAMINATION:\n eval for PE\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: SAT 8:36 AM\n no central pe or acute aortic injury\n small-mod hiatal hernia.\n trace b/l atelectasis.\n WET READ VERSION #1\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 62-year-old woman with history of multiple DVTs, now with chest\n pain.\n\n COMPARISON: None.\n\n TECHNIQUE: MDCT axial images were obtained through the chest with the\n administration of IV contrast. Multiplanar reformats were generated and\n reviewed.\n\n CT OF THE CHEST: The visualized lungs show trace bibasilar atelectasis, but\n no focal consolidation, pleural effusion or pneumothorax. The visualized\n heart and pericardium are unremarkable. Mediastinal, axillary and hilar lymph\n nodes do not meet CT size criteria for pathologic enlargement. No filling\n defects are noted within the pulmonary vasculature to suggest pulmonary\n embolism. The abdominal aorta shows normal caliber. No intramural hematoma\n or dissection is noted.\n\n This study is not optimized for subdiaphragmatic evaluation. Within this\n limitation, there is a small hiatal hernia noted. The upper abdominal\n structures are otherwise unremarkable.\n\n Multilevel degenerative changes are noted but no focal lytic or sclerotic\n lesion suspicious for malignancy are identified.\n\n IMPRESSION:\n\n 1. No acute pulmonary embolism or acute aortic injury.\n\n 2. Small-to-moderate hiatal hernia.\n\n 3. Bibasilar atelectasis.\n (Over)\n\n 6:58 AM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \n Reason: eval for PE\n Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2179-07-17 00:00:00.000", "description": "CT ABD & PELVIS W/O CONTRAST", "row_id": 1194555, "text": " 11:41 AM\n CT ABD & PELVIS W/O CONTRAST Clip # \n Reason: r/o bleed/acute process\n Admitting Diagnosis: CHEST PAIN;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old woman with hypotenstion and abdominal pain\n REASON FOR THIS EXAMINATION:\n r/o bleed/acute process\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: JMGw SAT 12:20 PM\n no acute findings in the ab/pelvis, although the low pelvis is difficult to\n evaluate due to extensive streak from right hip fixation hardware. colonic\n diverticulae, but without diverticulitis.\n\n WET READ VERSION #1\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Hypotension and abdominal pain. Evaluate for bleed or other\n acute process.\n\n CT ABDOMEN AND PELVIS: MDCT imaging was performed from the lung bases to the\n pubic symphysis without oral or IV contrast. Sagittal and coronal reformats\n were performed.\n\n COMPARISON: CTA chest .\n\n ABDOMEN: The visualized lung bases demonstrate minimal dependent atelectasis.\n There are pacing wires within the heart. There is a small hiatal hernia but\n the stomach and abdominal bowel loops are otherwise normal in their\n appearance. The spleen, adrenals and pancreas appear within normal limits\n given the lack of IV contrast. The liver and gallbladder appear normal.\n Contrast is being excreted from the kidneys related to the earlier\n contrast-enhanced CT the patient received but otherwise the kidneys appear\n normal. The aorta and its branches appear normal in caliber. No free air or\n free fluid or adenopathy is present.\n\n PELVIS: No free air or free fluid or adenopathy is present, although the deep\n low pelvis is difficult to evaluate due to extensive streak artifact from the\n right hip fixation hardware. Contrast is present within the bladder. Colonic\n diverticula are present without diverticulitis.\n\n BONE WINDOWS: There is right femoral and acetabular fixation hardware which\n appears intact. One of the acetabular fixation screws, however, traverses\n through the acetabulum with its tip within the expected location of the\n iliacus muscle (2:63) which is atrophied. Scoliosis is present with\n degenerative changes but no suspicious bone lesions are present.\n\n IMPRESSION:\n\n 1. No acute findings in the abdomen or pelvis although low pelvic evaluation\n is limited by streak.\n (Over)\n\n 11:41 AM\n CT ABD & PELVIS W/O CONTRAST Clip # \n Reason: r/o bleed/acute process\n Admitting Diagnosis: CHEST PAIN;TELEMETRY\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n 2. Diverticulosis without diverticulitis.\n\n 3. Intact right hip fixation hardware with an acetabular fixation screw\n traversing through the acetabulum into the pelvic musculature but no hematoma.\n\n" }, { "category": "Echo", "chartdate": "2179-07-19 00:00:00.000", "description": "Report", "row_id": 100804, "text": "PATIENT/TEST INFORMATION:\nIndication: Valvular heart disease. Hypotension. Chest pain\nHeight: (in) 64\nWeight (lb): 215\nBSA (m2): 2.02 m2\nBP (mm Hg): 107/59\nHR (bpm): 62\nStatus: Inpatient\nDate/Time: at 15:50\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. A catheter or pacing wire\nis seen in the RA.\n\nLEFT VENTRICLE: Normal LV wall thickness and cavity size. Mild regional LV\nsystolic dysfunction. No resting LVOT gradient.\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: basal\ninferoseptal - hypo; mid inferoseptal - hypo; basal inferior - hypo; mid\ninferior - hypo; remaining LV segments contract normally.\n\nRIGHT VENTRICLE: Moderately dilated RV cavity. Borderline normal RV systolic\nfunction. Abnormal diastolic septal motion/position consistent with RV volume\noverload.\n\nAORTA: Normal aortic diameter at the sinus level. Normal ascending aorta\ndiameter. Mildly dilated aortic arch.\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. Trivial MR.\n\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Moderate to severe\n[3+] TR. Normal PA systolic pressure.\n\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - body habitus.\n\nConclusions:\nThe left atrium is elongated. Left ventricular wall thicknesses and cavity\nsize are normal. There is mild regional left ventricular systolic dysfunction\nwith focal hypokinesis of the basal to mid inferior wall and inferior septum.\nThe remaining segments contract normally (LVEF = 50 %). The remaining left\nventricular segments contract normally. The right ventricular cavity is\nmoderately dilated with borderline normal free wall function. There is\nabnormal diastolic septal motion/position consistent with right ventricular\nvolume overload. The aortic arch is mildly dilated. The aortic valve leaflets\n(3) are mildly thickened but aortic stenosis is not present. No aortic\nregurgitation is seen. The mitral valve leaflets are mildly thickened. There\nis no mitral valve prolapse. Trivial mitral regurgitation is seen. The\ntricuspid valve leaflets are mildly thickened. Moderate to severe [3+]\ntricuspid regurgitation is seen. The estimated pulmonary artery systolic\npressure is normal. There is no pericardial effusion.\n\nIMPRESSION: Suboptimal image quality. Mild regional systolic dysfunction c/w\nCAD. Moderate right ventricular enlargement with borderline normal function.\nModerate to severe tricuspid regurgitation.\n\n\n" }, { "category": "ECG", "chartdate": "2179-07-17 00:00:00.000", "description": "Report", "row_id": 295517, "text": "Atrial paced rhythm. Left axis deviation. Low limb lead voltage. ST-T wave\nabnormalities. Since the previous tracing of no significant change.\n\n" }, { "category": "ECG", "chartdate": "2179-07-17 00:00:00.000", "description": "Report", "row_id": 295518, "text": "Sinus rhythm. Compared to the previous tracing no definite change.\nTRACING #4\n\n" }, { "category": "ECG", "chartdate": "2179-07-17 00:00:00.000", "description": "Report", "row_id": 295519, "text": "Sinus rhythm. Compared to the previous tracing pacer spikes are not seen.\nTRACING #3\n\n" }, { "category": "ECG", "chartdate": "2179-07-17 00:00:00.000", "description": "Report", "row_id": 295520, "text": "Atrial paced rhythm versus artifact. Compared to the previous tracing possible\natrial spikes are now seen. However, baseline artifact creates uncertainty.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2179-07-17 00:00:00.000", "description": "Report", "row_id": 295521, "text": "Sinus rhythm. Non-specific ST-T wave changes. Possible old anterior\nmyocardial infarction. No previous tracing available for comparison.\nTRACING #1\n\n" } ]

[ { "category": "Radiology", "chartdate": "2161-09-28 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1210904, "text": " 11:52 AM\n CHEST (PORTABLE AP) Clip # \n Reason: aspiration, new infiltrates.\n Admitting Diagnosis: FEVERS;TACHYCARDIA;\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old woman with respiratory oxygen need. pseudomonas bacteremia, h/o\n MRSA, septic emboli on head imaging. on abx.\n REASON FOR THIS EXAMINATION:\n aspiration, new infiltrates.\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST AT 12:33 HOURS\n\n COMPARISON: AT 17:53.\n\n HISTORY: Aspiration, question new infiltrates.\n\n NG tube extends to the stomach. Right IJ line is at the cavoatrial junction.\n Left PICC line is no longer visualized. Lung volumes are low. No definite\n airspace consolidation noted. Minimal streaky atelectasis in the right mid\n lung zone, unchanged.\n\n IMPRESSION: Suboptimal inspiration. No new findings.\n\n\n" }, { "category": "Radiology", "chartdate": "2161-09-30 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1211242, "text": " 5:05 PM\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \n Reason: Eval PICC placement\n Admitting Diagnosis: FEVERS;TACHYCARDIA;\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old woman with PSA bacteremia. New PICC line placed. Not visualized on\n previous Xray\n REASON FOR THIS EXAMINATION:\n Eval PICC placement\n ______________________________________________________________________________\n WET READ: LLTc WED 5:51 PM\n Magnified view of the right upper chest, demonstrating a right PICC\n terminating within the upper SVC. Right IJ terminates at the caval atrial\n junction.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Evaluate PICC placement.\n\n FRONTAL VIEW OF THE CHEST.\n\n COMPARISON: Chest radiograph .\n\n FINDINGS: On this limited view of the right hemithorax the tip of the PIC\n catheter is visualized within the upper SVC. The right IJ catheter terminates\n near the cavoatrial junction. A nasogastric catheter is seen coursing towards\n the stomach but is not fully visualized on this study. Lung evaluation is\n limited on this study which was dedicated for PICC line evaluation.\n\n IMPRESSION:\n\n Right PIC catheter tip in the upper SVC. Right IJ at the cavoatrial junction.\n These findings were discussed between Dr. and of the\n IV access team via telephone at 5:50 p.m. on .\n\n\n" }, { "category": "Radiology", "chartdate": "2161-09-29 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1211098, "text": " 6:50 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for ET tube and NG tube placement\n Admitting Diagnosis: FEVERS;TACHYCARDIA;\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old woman now with intubation and with new NG tube\n REASON FOR THIS EXAMINATION:\n eval for ET tube and NG tube placement\n ______________________________________________________________________________\n WET READ: LLTc TUE 7:34 PM\n RIght IJ at the caval atrial junction. ET tube 3 cm above the carina.\n Orogastric tube terminating at least to the level of the stomach. Low lung\n volumes, with bibasilar atelectasis. No pneumothorax.\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, AT 7:22 P.M.\n\n HISTORY: 66-year-old woman, newly intubated. Check NG and ET tube\n placements.\n\n IMPRESSION: AP chest compared to and 11:\n\n Endotracheal tube in standard placement. Nasogastric tube passes into the\n stomach and out of view. Right jugular line ends close to the estimated\n location of the superior cavoatrial junction, difficult to assess because of\n unavoidable patient rotation. Lungs are very low in volume, but the only\n discrete atelectasis is at the right lung base unchanged, and the upper lungs\n are entirely clear. Pleural effusion is small if any. Cardiac size cannot be\n assessed because of patient rotation.\n\n\n" }, { "category": "Radiology", "chartdate": "2161-09-30 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1211237, "text": " 4:13 PM\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \n Reason: Please eval PICC placement\n Admitting Diagnosis: FEVERS;TACHYCARDIA;\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old woman with psa bacteremia. New PICC line\n REASON FOR THIS EXAMINATION:\n Please eval PICC placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 66-year-old woman with bacteremia. New PICC line.\n\n COMPARISONS: . . .\n\n FINDINGS: Frontal view of the chest was obtained. A new right PICC is traced\n to the junction of the superior vena cava and the right brachiocephalic vein,\n but the tip is not visualized. Patient has been extubated. The remainder of\n the exam is unchanged with bibasilar atelectasis, low lung volumes, calcified\n gallstones, NG tube coursing below the diaphragm and across the midline, and\n right IJ line at superior cavoatrial junction.\n\n IMPRESSION: New right PICC traced to right brachiocephalic - SVC junction,\n but unable to determine location of tip.\n\n Findings were communicated to PICC nurse at 16:45 by\n .\n\n" }, { "category": "Radiology", "chartdate": "2161-09-22 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1210194, "text": " 11:33 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Hypoxemea\n Admitting Diagnosis: FEVERS;TACHYCARDIA;\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old woman with Hypoxemea\n REASON FOR THIS EXAMINATION:\n Hypoxemea\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Hypoxemia.\n\n FINDINGS: No previous images. Extremely low lung volumes may account for\n some of the prominence of the transverse diameter of the heart and engorgement\n of pulmonary vessels. There is elevation of what appears to be the right\n hemidiaphragmatic contour. Left subclavian catheter extends to lower portion\n of the SVC. No definite acute focal pneumonia.\n\n Repeat study with the patient having a better inspiration and additional\n lateral view would be most helpful for further evaluation.\n\n\n" }, { "category": "Radiology", "chartdate": "2161-09-30 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1211133, "text": " 5:09 AM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o intrathoracic process, interval change, ETT placement.\n Admitting Diagnosis: FEVERS;TACHYCARDIA;\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old woman with FUO, AMS and pancytopenia. Currently intubated.\n REASON FOR THIS EXAMINATION:\n r/o intrathoracic process, interval change, ETT placement.\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 5:12 A.M. ON \n\n HISTORY: 66-year-old woman with FUO and pancytopenia.\n\n IMPRESSION: AP chest compared to through 11:\n\n Lungs are very low in volume. Bibasilar infrahilar consolidation is likely\n atelectasis, though pneumonia is not excluded. An elliptical opacity\n projecting over the anterior right first rib could be a new mucoid impaction\n or just sclerosis in the costosternal junction. There are obvious\n difficulties in positioning this patient. I would recommend reverse\n Trendelenburg position for the patient in bed to improve aeration at the lung\n bases.\n\n ET tube is at the upper margin of the clavicles, no less than 2 cm from the\n carina. Right jugular line ends in the mid SVC. The heart is mildly\n enlarged. Pleural effusions are small, if any. No pneumothorax.\n\n\n" }, { "category": "Radiology", "chartdate": "2161-09-29 00:00:00.000", "description": "CAROTID SERIES COMPLETE", "row_id": 1211075, "text": " 3:44 PM\n CAROTID SERIES COMPLETE Clip # \n Reason: please eval for carotid source of emboli. bilateral\n Admitting Diagnosis: FEVERS;TACHYCARDIA;\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old woman with embolic lesions in the brain. psudomonas bacteremia on\n abx. h/o MRSA.\n REASON FOR THIS EXAMINATION:\n please eval for carotid source of emboli. bilateral\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: Carotid series limited.\n\n REASON: Embolic brain lesions, bacteremia.\n\n FINDINGS: Duplex was performed of the left carotid system, but the right side\n could not be imaged due to the placement of central line. Heterogeneous\n plaque is seen in the ICA and CCA. Peak velocities are 73, 68, and 203 in the\n ICA, CCA, and ECA. This is consistent with less than 40% left ICA stenosis.\n There is antegrade flow in left vertebral.\n\n IMPRESSION: Less than 40% left carotid stenosis. Right side could not be\n imaged.\n\n\n" }, { "category": "Radiology", "chartdate": "2161-09-24 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1210365, "text": " 5:02 AM\n CHEST (PORTABLE AP) Clip # \n Reason: new infiltrates?\n Admitting Diagnosis: FEVERS;TACHYCARDIA;\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old woman with worsening breathing, fever, hypotension requiring\n levophed\n REASON FOR THIS EXAMINATION:\n new infiltrates?\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 5:26 A.M.\n\n HISTORY: Worsening breathing, fever and hypotension.\n\n IMPRESSION: AP chest submitted for review on compared to :\n\n Marked elevation of the right hemidiaphragm is longstanding. The patient is\n rotated severely to the right, distorting the architecture of the left lung.\n Enlargement of the left hilus is probably due to vascular engorgement. The\n heart is top normal size. There is no pulmonary edema.\n\n Left-sided central venous line ends in the region of the superior cavoatrial\n junction. No pneumothorax.\n\n\n" }, { "category": "Radiology", "chartdate": "2161-09-26 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1210731, "text": " 5:41 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: Please eval placement of RIJ central line and NG tube. Also\n Admitting Diagnosis: FEVERS;TACHYCARDIA;\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old woman with pseudomonal bacteremia and multiple embolic infarcts and\n hypoxia. New RIJ placement and NG tube.\n REASON FOR THIS EXAMINATION:\n Please eval placement of RIJ central line and NG tube. Also with continued\n hypoxia\n ______________________________________________________________________________\n WET READ: SHSf SAT 7:51 PM\n Right IJ catheter appears to terminate in the lower SVC or cavoatrial\n junction, but is somwhat obscured by the left subclavian line. NG tube courses\n into the stomach. Markedly low lung volumes again seen. No pneumothorax.\n\n WET READ VERSION #1\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST\n\n HISTORY: RIJ central line and NG tube placements, compare at 0526.\n\n NG tube courses to the stomach and the RIJ catheter terminates at or near the\n cavoatrial junction. There is no evidence of pneumothorax. Low lung volumes\n make evaluation of the lungs difficult. A few streaky densities are seen in\n the right middle lobe suggesting atelectasis. No other significant findings.\n\n\n" }, { "category": "Radiology", "chartdate": "2161-10-03 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1211695, "text": " 3:57 PM\n CHEST (PORTABLE AP) Clip # \n Reason: R/o PNA or aspiration\n Admitting Diagnosis: FEVERS;TACHYCARDIA;\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old woman with pseudomonal bacteremia, multiple brain infarcts\n concerning for septic emboli, dysphagia with new temp 103.3.\n REASON FOR THIS EXAMINATION:\n R/o PNA or aspiration\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Evaluation of the patient with pseudomonas bacteremia\n and multiple brain infarcts, suspicious for pneumonia.\n\n AP radiograph of the chest was compared to .\n\n The lung volumes remain very low with bilateral linear opacities most likely\n representing atelectasis with no worsening of consolidation to suggest\n interval progression of infection. The NG tube tip is in the stomach. There\n is additional line projecting over the mid mediastinum. Its location is\n unclear.\n\n Right PICC line tip is not clearly seen and potentially is at the low SVC,\n correlation with lateral imaging is recommended.\n\n\n" }, { "category": "Radiology", "chartdate": "2161-09-25 00:00:00.000", "description": "MR HEAD W & W/O CONTRAST", "row_id": 1210613, "text": " 3:59 PM\n MR HEAD W & W/O CONTRAST Clip # \n Reason: r/o intracranial abnormality\n Admitting Diagnosis: FEVERS;TACHYCARDIA;\n Contrast: MAGNEVIST Amt: 25\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old woman with pancytopenia and FUO. Pt has remained altered.\n REASON FOR THIS EXAMINATION:\n r/o intracranial abnormality\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: JBRe SAT 9:36 AM\n 1. No acute infarct.\n 2. Moderate small vessel disease.\n ______________________________________________________________________________\n FINAL REPORT\n EXAM: MRI of the brain.\n\n CLINICAL INFORMATION: Patient with pancytopenia, rule out intracranial\n abnormality.\n\n TECHNIQUE: T1 sagittal and axial and FLAIR T2 susceptibility and diffusion\n axial images of the brain were acquired. Following gadolinium, T1 axial and\n MP-RAGE sagittal images were acquired.\n\n COMPARISON: No prior similar examinations for comparison.\n\n FINDINGS: There are several foci of increased signal on diffusion images some\n of which appear to have low intensity on ADC map but evaluation of the ADC map\n is limited secondary to small size of the abnormality seen on diffusion\n images. These lesions are seen in both occipital lobes and also in the left\n frontal and parietal regions. None of this foci demonstrate definite\n enhancement. There is no meningeal enhancement mass effect, midline shift or\n hydrocephalus seen. There is mild prominence of sulci. There is no evidence\n of acute or chronic blood products.\n\n IMPRESSION: Multiple foci of signal abnormalities on diffusion images with\n occipital lobe with questionable low ADC changes and could suggest acute\n infarcts. Some of these infarcts are likely subacute in nature seen in the\n left frontal and parietal region. None of this foci demonstrate enhancement.\n No MRI signs of an abscess formation or meningeal enhancement seen. No\n epidural or subdural fluid collection or enhancement seen. Findings were\n discussed with Dr. at the time of interpretation of this study on\n at 11 a.m.\n\n" }, { "category": "Radiology", "chartdate": "2161-09-24 00:00:00.000", "description": "US PERC NEEDLE BX MUSCLE", "row_id": 1210439, "text": " 1:37 PM\n LUMBAR PUNCTURE Clip # \n Reason: L4-5 disk biopsy/aspiration and CSF fluid sampling.\n Admitting Diagnosis: FEVERS;TACHYCARDIA;\n ********************************* CPT Codes ********************************\n * LUMBAR SPINAL PUNCTURE US PERC NEEDLE BX MUSCLE *\n * FLUORO GUID FOR SPINE DIAG/THE *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old woman with L4/L5 discitis, pancytopenia, increasing confusion and\n fevers.\n REASON FOR THIS EXAMINATION:\n L4-5 disk biopsy/aspiration and CSF fluid sampling.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Case of L4-L5 osteomyelitis and discitis with high fever.\n\n OPERATORS: Dr. , and Dr . The attending\n radiologist, Dr., performed the entire procedure.\n\n PROCEDURE: L4-L5 disc biopy and lumbar puncture.\n\n TECHNIQUE: The risks, benefits, and alternatives of the procedure were\n explained to the patient's sister, and informed consent was obtained. The\n patient was transported to the neuro-angiography suite and placed on the table\n in prone position. The lower back was prepared and draped in the standard\n sterile fashion. Timeout was performed per protocol.\n\n The L4-L5 disc space level was localized with fluoroscopy. The skin overlying\n the disc space was anesthetized with 1% lidocaine. Using 22-gauge needle as a\n guide, a 11-gauge needle was introduced into the left paraspinal space\n and the stylet was taken out. Through the needle 200\n needle was introduced and multiple samples of the L4-L5 disc were obtained.\n The needle was subsequently removed.\n\n The L4-L5 disc space was again confirmed with fluoroscopy. The skin overlying\n the disc space was anesthetized with 1% lidocaine. A spinal needle was\n positioned perpendicularly to the interspace, and position was confirmed with\n AP fluoroscopy. The needle was slowly advanced. Position was monitored by\n fluoroscopy in the lateral projection. After passing through the dura, the\n inner stylet of the needle was removed, and clear CSF flowed out. A total of\n 25 cc of CSF was collected. The needle was subsequently removed and a sterile\n bandage was applied.\n\n The samples of the disc biopsy and CSF were sent to the laboratory for\n analysis. The procedure was uneventful. The patient tolerated the procedure\n well and there were no immediate complications. The patient was sent to the\n floor with orders.\n\n Moderate sedation was provided by administrating divided doses of Versed 0.5\n mg and 1 mg Dilaudid with a total intraservice time of 30 minutes. The\n patient's hemodynamic parameters were continuously monitored.\n (Over)\n\n 1:37 PM\n LUMBAR PUNCTURE Clip # \n Reason: L4-5 disk biopsy/aspiration and CSF fluid sampling.\n Admitting Diagnosis: FEVERS;TACHYCARDIA;\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n IMPRESSION: Successful biopsy of L4-L5 intervertebral disc and lumbar\n puncture. Samples of the disc and CSF were sent to the laboratory for\n analysis.\n\n\n" }, { "category": "Echo", "chartdate": "2161-09-29 00:00:00.000", "description": "Report", "row_id": 93761, "text": "PATIENT/TEST INFORMATION:\nIndication: Cerebrovascular event/TIA. Endocarditis.\nHeight: (in) 67\nWeight (lb): 287\nBSA (m2): 2.36 m2\nBP (mm Hg): 107/37\nHR (bpm): 65\nStatus: Inpatient\nDate/Time: at 16:23\nTest: Portable TEE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nSedation via titration of IV propofol gtt by ICU RN.\nThis study was compared to the prior study of .\n\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Lipomatous hypertrophy of the interatrial\nseptum. PFO is present.\n\nLEFT VENTRICLE: Overall normal LVEF (>55%).\n\nRIGHT VENTRICLE: Normal RV systolic function.\n\nAORTA: Complex (>4mm) atheroma in the aortic arch. Complex (>4mm) atheroma in\nthe descending thoracic aorta.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No masses or\nvegetations on aortic valve. No AR.\n\nMITRAL VALVE: Normal mitral valve leaflets with trivial MR. mass or\nvegetation on mitral valve. Mild mitral annular calcification.\n\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. No mass or\nvegetation on tricuspid valve. Mild [1+] TR.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets. No\nvegetation/mass on pulmonic valve.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: 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. No glycopyrrolate was\nadministered. No TEE related complications. The patient appears to be in sinus\nrhythm.\n\nConclusions:\nA very small left to right shunt is seen across a stretched patent foramen\novale. Overall left ventricular systolic function is normal (LVEF>55%). Right\nventricular systolic function is normal. There are complex (>4mm), nonmobile\natheroma in the aortic arch and the descending thoracic aorta. The aortic\nvalve leaflets (3) are mildly thickened. No masses or vegetations are seen on\nthe aortic valve. No aortic regurgitation is seen. The mitral valve appears\nstructurally normal with trivial mitral regurgitation. No mass or vegetation\nis seen on the mitral valve. The tricuspid valve leaflets are mildly\nthickened. No vegetation/mass is seen on the pulmonic valve. No mass or\nvegetation is seen on the pulmonic valve. There is no pericardial effusion.\n\nIMPRESSION: No abscess or vegetations seen. Complex, nonmobile atheroma of the\ndescending aorta and arch.\n\nCompared with the prior study (images reviewed) of , the findings are\nsimilar.\n\n\n" }, { "category": "Echo", "chartdate": "2161-09-23 00:00:00.000", "description": "Report", "row_id": 93762, "text": "PATIENT/TEST INFORMATION:\nIndication: Endocarditis.\nHeight: (in) 66\nWeight (lb): 280\nBSA (m2): 2.31 m2\nBP (mm Hg): 111/79\nHR (bpm): 114\nStatus: Inpatient\nDate/Time: at 12:10\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Normal LA size.\n\nLEFT VENTRICLE: Normal LV wall thickness and cavity size. Suboptimal technical\nquality, a focal LV wall motion abnormality cannot be fully excluded.\nHyperdynamic LVEF >75%.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No masses or vegetations\non mitral valve, but cannot be fully excluded due to suboptimal image quality.\nMild mitral annular calcification. Mild thickening of mitral valve chordae.\nTrivial MR.\n\nTRICUSPID VALVE: Indeterminate PA systolic pressure.\n\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not visualized. No PS.\nPhysiologic PR.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows. Suboptimal\nimage quality - body habitus.\n\nConclusions:\nThe left atrium is normal in size. Left ventricular wall thicknesses and\ncavity size are normal. Due to suboptimal technical quality, a focal wall\nmotion abnormality cannot be fully excluded. Left ventricular systolic\nfunction is hyperdynamic (EF>75%). Right ventricular chamber size and free\nwall motion are normal. The aortic valve leaflets (3) are mildly thickened but\naortic stenosis is not present. No aortic regurgitation is seen. The mitral\nvalve leaflets are mildly thickened. No masses or vegetations are seen on the\nmitral valve, but cannot be fully excluded due to suboptimal image quality.\nTrivial mitral regurgitation is seen. The pulmonary artery systolic pressure\ncould not be determined. There is no pericardial effusion.\n\nIMPRESSION: No echocardiographic evidence of endocarditis. Hyperdynamic LV\nsystolic function. No significant valvular regurgitation seen. If clinically\nindicated, a transesophageal echocardiogram may better assess for valvular\nvegetations.\n\n\n" }, { "category": "ECG", "chartdate": "2161-09-24 00:00:00.000", "description": "Report", "row_id": 249549, "text": "Sinus rhythm. Non-specific ST-T wave changes, probably normal variant.\nCompared to the previous tracing the rate is slower.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2161-09-23 00:00:00.000", "description": "Report", "row_id": 249550, "text": "Baseline artifact. Sinus tachycardia suggested. No previous tracing available\nfor comparison.\nTRACING #1\n\n" } ]

[ { "category": "Echo", "chartdate": "2179-07-23 00:00:00.000", "description": "Report", "row_id": 59886, "text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function.\nHeight: (in) 71\nWeight (lb): 180\nBSA (m2): 2.02 m2\nBP (mm Hg): 132/82\nStatus: Inpatient\nDate/Time: at 10:38\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: There is mild symmetric left ventricular hypertrophy. The left\nventricular cavity size is normal. Overall left ventricular systolic function\nis low normal (LVEF 50-55%).\n\nLV WALL MOTION: The following resting regional left ventricular wall motion\nabnormalities are seen: basal inferior - hypokinetic; mid inferior -\nhypokinetic;\n\nRIGHT VENTRICLE: Right ventricular chamber size and free wall motion are\nnormal.\n\nAORTA: The aortic root is normal in diameter. The ascending aorta is normal in\ndiameter.\n\nMITRAL VALVE: The mitral valve appears structurally normal with trivial mitral\nregurgitation.\n\nTRICUSPID VALVE: The tricuspid valve appears structurally normal with trivial\ntricuspid regurgitation. No tricuspid regurgitation is seen. There is\nborderline pulmonary artery systolic hypertension.\n\nPERICARDIUM: There is no pericardial effusion.\n\nConclusions:\nThe left atrium is normal in size. There is mild symmetric left ventricular\nhypertrophy. The left ventricular cavity size is normal. Overall left\nventricular systolic function is low normal (LVEF 50-55%). Resting regional\nwall motion abnormalities include mid and basal inferior hypokinesis. Right\nventricular chamber size and free wall motion are normal. The mitral valve\nappears structurally normal with trivial mitral regurgitation. There is\nborderline pulmonary artery systolic hypertension. There is no pericardial\neffusion.\n\n\n" }, { "category": "ECG", "chartdate": "2179-07-22 00:00:00.000", "description": "Report", "row_id": 106974, "text": "Sinus rhythm\n Inferior T wave changes are nonspecific - Cannot exclude ischemia - Clinical\ncorrelation is suggested\n Since previous tracing of same date: Inferior ST segment changes decreased\nand T wave changes seen - consider evolution of myocardial infarction\n\n" }, { "category": "ECG", "chartdate": "2179-07-22 00:00:00.000", "description": "Report", "row_id": 106975, "text": "Baseline artifact\nNormal sinus rhythm\n- frequent premature ventricular contractions\nSlight inferior ST segment elevation - consider acute injury/ myocardial\n infarction\nSince previous tracing of same date: ST-T changes decreased & ventricular\n premature complexes seen\n\n" }, { "category": "ECG", "chartdate": "2179-07-22 00:00:00.000", "description": "Report", "row_id": 106976, "text": "Sinus rhythm\nInferior ST segment elevation & depression in V1+V2 Consistent with inferior\n posteriorinjury/ myocardial infarction\nNo previous report available for comparison\n\n" }, { "category": "ECG", "chartdate": "2179-07-23 00:00:00.000", "description": "Report", "row_id": 106971, "text": "Normal sinus rhythm. Marked left axis deviation. Non-specific T wave flattening\nin leads V5-V6. Inferior T wave inversions. No previous tracing available for\ncomparison. Clinical correlation is suggested.\n\n" }, { "category": "ECG", "chartdate": "2179-07-24 00:00:00.000", "description": "Report", "row_id": 106972, "text": "Sinus rhythm\nMarked left axis deviation\nInferior infarct - age undetermined - may be acute/recent\n Since previous tracing of : inferior T wave changes slightly more\nprominent\n\n" }, { "category": "ECG", "chartdate": "2179-07-23 00:00:00.000", "description": "Report", "row_id": 106973, "text": "Sinus rhythm\nLeft axis deviation\nInferior infarct - age undetermined - may be acute/recent\n Since previous tracing of : inferior Q waves and further T wave changes\npresent\n\n" }, { "category": "Nursing/other", "chartdate": "2179-07-23 00:00:00.000", "description": "Report", "row_id": 1297711, "text": "CCU NPN 1900-0700\nS: \" by back hurts \"\nO: remains Painfree since cath. 2200 CK 648/54, plts 277. AM labs pnd. integrilin at 2mcq/kg/min.\ngoal temp. reached at , therefore nasal temp. probe d/c'd and warming blanket removed.\nleft groin sheaths d/c'd by Dr. at 2300, tol. well. VSS during sheath pull. pulses 2+/2+. extrem. warm. both groin sites D/I.\nplts 277\nstarted on po lopressor 25mg at 2200. HR 80's -> 70 SR. BP 1-2-117/50-60's.\n\nLS clear. sats 96-97% on RA.\n\nate tol. well. taking fluids freely.\n\nfoley draining 100-150cc/hr.\n\npt. c/o lower back pain after sheath pull, good relief with percocet (1). slept well\n\nA: stable s/p IMI/cool Mi study\nP: EKG in AM. d/c integrilin at 0900. d/c IVF 10am.\ncardiac diet. ? dangle at bedside today. follow lytes,\n" }, { "category": "Nursing/other", "chartdate": "2179-07-23 00:00:00.000", "description": "Report", "row_id": 1297712, "text": "CCU progress note 7a - 3p\nVSS today. Foley removed, voiding well in urinal. Integrillin d/c'd at 9am, IVF d/c'd at 10am.\nEpisode of L chest pressure @ 2pm, EKG done, relieved by 1 NTG s/l.\nWife in visiting.\n\nSee Transfer note. Careview for graphics and assessments.\n" }, { "category": "Nursing/other", "chartdate": "2179-07-22 00:00:00.000", "description": "Report", "row_id": 1297710, "text": "imi, s/p stent rca, cool mi study\nccu npn (see fhpa for admit note)\nto ccu 3:15pm.\nid- temp low on cool mi study, lowest 34.1, up to 36.1 at 6:30pm with rewarming. wbc 9.5. Demerol drip on, given 25mg x1 for shivering with effect. Demerol d/c'd with rewarming.\ncv- hr 70-80s sr with occ-freq pvcs. bp 100s-120s/. denies cpain/other pain. k- 3.9, replace po after takes some solids. mg pnd. ck 176. plts 301 to 256. recheck plts, ck 10pm. check labs in am- see study labs, post intervention and ccu labs. r groin d+i, sheaths pulled by c. tech. dsd with tegaderm on d+i. l groin with study sheath- scant ooze under dsg. pulses dp/pt bilat. cont. on integrilin until 9am . ivf on d/c 10am.\ncool mi study- protocol followed. temp. probe not towards end of study, all connections secure. console troubleshooted, study rn t. bishop , company rep also with further trouble shooting done. probe still not registering. pt cont. to be rewarmed with warming blanket. temp rising as above. study sheath to be d/c'd when temp reaches 36.5. pt temp probe saved/labeled for study rn, along with temp sheet and study ekgs.\nresp- on n/c 4l. sats 95-98. l/s clear, dim with few scat. cxs lower . no sob. foley with dilute urine, lge u/o.\nms- a+o, anxious, occ. forgetful. states feels dizzy, denies room spinning, seasickness or feeling foggy. unable to qualify his feelings of dizziness. dizziness subsided quickly after demerol d/c'd. seemed calmer also after demerol d/c'd.\nsocial- wife in, supportive to pt. pt status, mi, study, plan explained to pt/wife, understand. reinforce, update prn. wife will be in tomorrow, phone numbers in chart, room. wife prefers no one else visits pt in am.\n" } ]

[ { "category": "Radiology", "chartdate": "2127-04-18 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1238409, "text": " 2:56 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Please evaluate for pneumonia\n Admitting Diagnosis: PANCREATIC MASS/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old woman with temp and crackles on lung exam\n REASON FOR THIS EXAMINATION:\n Please evaluate for pneumonia\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE FRONTAL VIEW OF THE CHEST\n\n REASON FOR EXAM: Fever and crackles.\n\n Comparison is made with prior study, .\n\n Mild cardiomegaly is stable. Bibasilar opacities, larger on the right side,\n are unchanged, consistent with atelectasis. The upper lungs are grossly\n clear. There is no pneumothorax. If any, there is a small left pleural\n effusion. Right PICC tip is in the lower SVC.\n\n\n" }, { "category": "Radiology", "chartdate": "2127-04-13 00:00:00.000", "description": "ABDOMEN (SUPINE & ERECT)", "row_id": 1237845, "text": " 2:33 PM\n ABDOMEN (SUPINE & ERECT) Clip # \n Reason: any intraabd explanation of current new symptoms that can be\n Admitting Diagnosis: PANCREATIC MASS/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76F with pancreatitis, distal CBD stricutre with cytology +adenoca, on TPN for\n past 1week to aid cooling off pancreatitis, s/p Whipple with PV recon and jtube\n placement now w increased abd pain and distention\n REASON FOR THIS EXAMINATION:\n any intraabd explanation of current new symptoms that can be seen on KUB?\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: Abdomen supine and erect views .\n\n CLINICAL HISTORY: 76-year-old woman with pancreatitis and distal CBD. Now\n with new symptoms. Increased abdominal pain.\n\n FINDINGS: Comparison is made to the radiographs from .\n\n No definite free intra-abdominal air is seen. There is a surgical clip seen\n within the mid abdomen. Multiple surgical tacks are seen in a circular\n pattern in the mid abdomen suggestive of hernia mesh. There is a nonspecific\n bowel gas pattern with air and stool seen throughout the colon. No definite\n dilated loops of small bowel are seen. There is also no free intra-abdominal\n gas identified.\n\n" }, { "category": "Radiology", "chartdate": "2127-04-08 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1237075, "text": " 1:11 AM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: eval new CVL\n Admitting Diagnosis: PANCREATIC MASS/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old woman s/p whipple\n REASON FOR THIS EXAMINATION:\n eval new CVL\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 12:58 AM, \n\n HISTORY: New central venous line. Whipple procedure.\n\n IMPRESSION: AP chest compared to pre-operative chest radiograph :\n\n Mild cardiomegaly and borderline pulmonary vascular congestion have developed.\n Pleural effusion is small on the left, if any. No pulmonary edema or\n consolidation. No pneumothorax. Nasogastric tube ends in the mid stomach.\n Right internal jugular line tip is at the level of the mid SVC, and a right\n PIC line passes just beyond to the low SVC.\n\n\n" }, { "category": "Radiology", "chartdate": "2127-04-14 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1237952, "text": " 11:39 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate placement of right picc line\n Admitting Diagnosis: PANCREATIC MASS/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old woman s/p whipple\n REASON FOR THIS EXAMINATION:\n evaluate placement of right picc line\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 76-year-old female post-Whipple procedure and right PICC\n placement.\n\n COMPARISON: .\n\n CHEST, AP: Right internal jugular catheter and nasogastric tube have been\n removed. Right PICC terminates in the upper-to-mid SVC. There is no\n significant pneumothorax. Moderate cardiomegaly, central venous congestion,\n and mild interstitial edema are unchanged. The aorta is tortuous and\n calcified. Midline abdominal staples from recent surgery, with trace residual\n pneumoperitoneum.\n\n IMPRESSION:\n 1. Right PICC in upper-to-mid SVC.\n 2. Postoperative volume overload.\n\n" } ]

[ { "category": "Physician ", "chartdate": "2145-01-11 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 558856, "text": "Chief Complaint:\n 24 Hour Events:\n - extubated in the morning\n - mental status at level he was pre-code\n - low dose ativan for aggitation\n - started mitodrine, octreotide, albumin for HRS\n - art line pulled\n - had acute respiratory distress around 4 am with desat to 80s,\n required intense suctioning of bloody secretions, gas 7.38/51/108; did\n slightly better with frequent nebs\n Allergies:\n Demerol (Oral) (Meperidine Hcl)\n Confusion/Delir\n Last dose of Antibiotics:\n Vancomycin - 08:00 PM\n Piperacillin/Tazobactam (Zosyn) - 12:26 AM\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 08:01 AM\n Lorazepam (Ativan) - 04:01 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 07:01 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: 86 (75 - 86) bpm\n BP: 111/60(71) {102/53(65) - 130/80(89)} mmHg\n RR: 18 (14 - 26) insp/min\n SpO2: 92%\n Heart rhythm: SR (Sinus Rhythm)\n CVP: 11 (5 - 19)mmHg\n Total In:\n 2,126 mL\n 237 mL\n PO:\n TF:\n 350 mL\n IVF:\n 1,061 mL\n 237 mL\n Blood products:\n 400 mL\n Total out:\n 3,885 mL\n 680 mL\n Urine:\n 3,185 mL\n 680 mL\n NG:\n Stool:\n 700 mL\n Drains:\n Balance:\n -1,759 mL\n -443 mL\n Respiratory support\n O2 Delivery Device: Face tent\n Ventilator mode: CPAP/PSV\n Vt (Set): 550 (550 - 550) mL\n Vt (Spontaneous): 665 (665 - 665) mL\n PS : 5 cmH2O\n RR (Set): 14\n RR (Spontaneous): 16\n PEEP: 5 cmH2O\n FiO2: 100%\n PIP: 14 cmH2O\n SpO2: 92%\n ABG: 7.38/51/108/31/4\n Ve: 12 L/min\n PaO2 / FiO2: 108\n Physical Examination\n Eyes / Conjunctiva: PERRL, opens eyes, makes eye contact\n , Ears, Nose, Throat: , Poor dentition, Endotracheal\n tube, NG tube\n Cardiovascular: (S1: Normal), (S2: Normal), No(t) S3, No(t) S4, No(t)\n Rub\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : ,\n Rhonchorous: )\n Abdominal: Soft, Bowel sounds present, Distended, palpable fluid wave\n Neurologic: arousable to voice, opens eyes no purposeful movements,\n withdraws to pain, non-verbal\n Labs / Radiology\n 52 K/uL\n 9.5 g/dL\n 100 mg/dL\n 1.4 mg/dL\n 31 mEq/L\n 3.7 mEq/L\n 59 mg/dL\n 112 mEq/L\n 148 mEq/L\n 29.6 %\n 5.6 K/uL\n [image002.jpg]\n 05:46 PM\n 03:23 AM\n 03:38 AM\n 10:22 AM\n 01:38 PM\n 02:25 AM\n 03:39 AM\n 04:55 AM\n 12:53 PM\n 04:02 AM\n WBC\n 16.3\n 6.1\n 6.1\n 5.6\n Hct\n 31.4\n 24.9\n 26.4\n 26.3\n 29.6\n Plt\n 118\n 63\n 73\n 52\n Cr\n 2.5\n 2.4\n 2.1\n 1.4\n TCO2\n 27\n 27\n 28\n 30\n 31\n Glucose\n 103\n 108\n 108\n 100\n Other labs: PT / PTT / INR:18.5/50.8/1.7, CK / CKMB /\n Troponin-T:447/26/0.24, ALT / AST:79/200, Alk Phos / T Bili:105/2.9,\n Amylase / Lipase:93/30, Differential-Neuts:74.5 %, Lymph:14.1 %,\n Mono:8.1 %, Eos:2.9 %, Lactic Acid:1.8 mmol/L, LDH:418 IU/L, Ca++:8.7\n mg/dL, Mg++:2.8 mg/dL, PO4:2.3 mg/dL\n Assessment and Plan\n This is a 63 y/o M with Hepatitis C cirrhosis hepatorenal syndrome, s/p\n PEA arrest, body cooling and rewarming, concern for PNA covering with\n Vanc/Zosyn.\n .\n # s/p Shock/PEA Arrest: After PEA, was initially hemodynamically stable\n but has had episodes of hypotension non-responsive to IVF boluses,\n levofed started, currently off. Echo showed no evidence of cardiogenic\n shock. s/p cooling and rewarming.\n - continue goal MAP >65\n - stable now after off pressors\n .\n # Respiratory/Ventilation: Assist control. Low tidal volumes to avoid\n unneeded injury, with pH goal of above 7.25. Acute desats overnight\n agitation -> improved with sedation and nebs. Will likely continue\n to aspirate mental status, may need to re-intubate depending on\n respiratory status.\n - extubated yesterday\n - cont 5-day total course of ABX\n - cont local care\n .\n # Pneumonia\n on CXR has RLL infiltrate and bronch with thick yellow\n secretions, leukocytosis starting to resolve\n - on vanco/zosyn for total 5-day course\n - follow up cultures, NGTD\n .\n # Mental Status: With slowly resolving delerium prior to this event,\n and now with unclear hypoxic insult to brain. GCS of on admission\n to ICU. Considering head CT to evaluate for anoxic brain injury\n post-cooling. Neuro eval for possible seizure. EEG neg for seizure,\n severe encephalopathy likely in setting of sedation. Back to pre-code\n MS per wife.\n - off sedation, waking up, mouthing words\n - LP done earlier that was negative gram stain/culture, no whites,\n negative HSV PCR\n - would not cooperate with CT at this time, will hold off for now\n - cont lactulose\n .\n # Renal Failure: Unclear Etiology. Renal following given concern for\n HRS. given 2 days of albumin per hepatology recs.\n - likely in setting of hypoperfusion v. HRS, starting to improve,\n making good urine output\n - f/u renal rec's.\n - giving mitodrine and octreotide and albumin\n .\n # Hypernatremia: Likely hypovolemic hypernatremia in the setting of\n recent ATN and current HRS. Free water deficit ~ 2-3L.\n - correct slowly today with IVF, 150cc/hr\n - check lytes Q6H\n .\n # Metabolic Acidosis: s/p arrest to tissue hypoxia. Continue IVF's\n and trend lactate. Will need to increase minute ventilation for CO2.\n - resolved, likely in setting of post code hypoperfusion\n - lactates normalized\n .\n # Cardiac: Anticipate some elevation in CE's post-arrest, will trend.\n Echo hyperdynamic, no cardiogenic shock.\n - CK and Trop trending downward,\n .\n # Cirrhosis: Hep C Cirrhosis, with concern for HRS.\n - pre-code mental status likely related to encephalopathy v. delirium\n - will follow s/p extubation, continue lactulose, unclear etiology at\n this time\n - will f/u with liver re: long-term prognosis\n .\n # Leukocytosis: Unclear etiology. Negative tap for SBP on .\n Urine growing E. Coli. Pan-culture.\n - likely from pneumonia\n .\n # Parotid mass. Incidental finding of L parotid mass on MRI, 1.6cm. --\n Will require OP ENT followup.\n .\n # Access: PIV, Central Line, d/c\ned art line today\n .\n # FEN: IVF, replete electrolytes, tube feeds resuming \n .\n # Prophylaxis: holding HSQ since elevated PTT, famotidine\n .\n # Code: full\n .\n # Communication: Wife is HCP -> will need to readdress long-term goals\n .\n # Disposition: ICU for now.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 12:48 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": "2145-01-13 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 559300, "text": "Chief Complaint:\n 24 Hour Events:\n Events:\n patient on max dose bolus fent/versed sedation and agitated, moving\n constantly but no purposeful movements, hypertensive, and fighting\n vent, placed on propofol drip sedation\n off rifaximin while on vanc/zosyn\n increased free water boluses through feeding tube\n IP will do trach at bedside on thursday\n Allergies:\n Demerol (Oral) (Meperidine Hcl)\n Confusion/Delir\n Last dose of Antibiotics:\n Vancomycin - 08:16 PM\n Piperacillin/Tazobactam (Zosyn) - 06:27 AM\n Infusions:\n Propofol - 6 mcg/Kg/min\n Other ICU medications:\n Pantoprazole (Protonix) - 08:00 AM\n Fentanyl - 11:30 PM\n Midazolam (Versed) - 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 06:54 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: 36.4\nC (97.5\n HR: 60 (57 - 82) bpm\n BP: 130/59(79) {109/52(68) - 156/69(91)} mmHg\n RR: 18 (7 - 20) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 73 Inch\n CVP: 15 (8 - 18)mmHg\n Total In:\n 2,510 mL\n 939 mL\n PO:\n TF:\n 868 mL\n 369 mL\n IVF:\n 802 mL\n 70 mL\n Blood products:\n 200 mL\n Total out:\n 1,280 mL\n 580 mL\n Urine:\n 1,280 mL\n 580 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,230 mL\n 359 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 550 (550 - 550) mL\n RR (Set): 18\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 40%\n PIP: 26 cmH2O\n Plateau: 18 cmH2O\n SpO2: 99%\n ABG: 7.52/36/164/29/6\n Ve: 9.3 L/min\n PaO2 / FiO2: 410\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 8.2 g/dL\n 117 mg/dL\n 0.8 mg/dL\n 29 mEq/L\n 3.8 mEq/L\n 31 mg/dL\n 114 mEq/L\n 146 mEq/L\n 24.1 %\n 4.6 K/uL\n [image002.jpg]\n 05:56 PM\n 06:13 PM\n 07:31 PM\n 09:57 PM\n 01:37 AM\n 04:43 AM\n 03:24 PM\n 02:42 AM\n 03:30 AM\n 06:33 AM\n WBC\n 5.8\n 4.9\n 4.6\n Hct\n 26.1\n 25.3\n 24.1\n Plt\n 48\n 47\n 50\n Cr\n 1.1\n 1.1\n 1.0\n 1.0\n 1.0\n 0.8\n TCO2\n 30\n 29\n 30\n 30\n Glucose\n 167\n 170\n 176\n 133\n 125\n 117\n Other labs: PT / PTT / INR:20.2/57.1/1.9, CK / CKMB /\n Troponin-T:447/26/0.24, ALT / AST:53/134, Alk Phos / T Bili:78/3.0,\n Amylase / Lipase:93/30, Differential-Neuts:84.1 %, Lymph:10.6 %,\n Mono:2.3 %, Eos:2.7 %, Lactic Acid:1.6 mmol/L, Albumin:3.3 g/dL,\n LDH:298 IU/L, Ca++:8.5 mg/dL, Mg++:1.9 mg/dL, PO4:1.6 mg/dL\n Assessment and Plan\n ELECTROLYTE & FLUID DISORDER, OTHER\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n HYPOTENSION (NOT SHOCK)\n CARDIAC ARREST\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n BACTEREMIA\n ICU Care\n Nutrition:\n Nutren Renal (Full) - 04:58 AM 60 mL/hour\n Glycemic Control:\n Lines:\n Multi Lumen - 12:48 PM\n Arterial Line - 11:00 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": "2145-01-13 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 559301, "text": "Chief Complaint:\n 24 Hour Events:\n Events:\n patient on max dose bolus fent/versed sedation and agitated, moving\n constantly but no purposeful movements, hypertensive, and fighting\n vent, placed on propofol drip sedation\n off rifaximin while on vanc/zosyn\n increased free water boluses through feeding tube\n IP will do trach at bedside on thursday\n Allergies:\n Demerol (Oral) (Meperidine Hcl)\n Confusion/Delir\n Last dose of Antibiotics:\n Vancomycin - 08:16 PM\n Piperacillin/Tazobactam (Zosyn) - 06:27 AM\n Infusions:\n Propofol - 6 mcg/Kg/min\n Other ICU medications:\n Pantoprazole (Protonix) - 08:00 AM\n Fentanyl - 11:30 PM\n Midazolam (Versed) - 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 06:54 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: 36.4\nC (97.5\n HR: 60 (57 - 82) bpm\n BP: 130/59(79) {109/52(68) - 156/69(91)} mmHg\n RR: 18 (7 - 20) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 73 Inch\n CVP: 15 (8 - 18)mmHg\n Total In:\n 2,510 mL\n 939 mL\n PO:\n TF:\n 868 mL\n 369 mL\n IVF:\n 802 mL\n 70 mL\n Blood products:\n 200 mL\n Total out:\n 1,280 mL\n 580 mL\n Urine:\n 1,280 mL\n 580 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,230 mL\n 359 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 550 (550 - 550) mL\n RR (Set): 18\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 40%\n PIP: 26 cmH2O\n Plateau: 18 cmH2O\n SpO2: 99%\n ABG: 7.52/36/164/29/6\n Ve: 9.3 L/min\n PaO2 / FiO2: 410\n Physical Examination\n Eyes / Conjunctiva: PERRL, opens eyes, makes eye contact\n , Ears, Nose, Throat: , Poor dentition, Endotracheal\n tube, NG tube\n Cardiovascular: (S1: Normal), (S2: Normal), No(t) S3, No(t) S4, No(t)\n Rub\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : ,\n Rhonchorous: )\n Abdominal: Soft, Bowel sounds present, Distended, palpable fluid wave\n Neurologic: arousable to voice, opens eyes no purposeful movements,\n withdraws to pain, non-verbal\n Labs / Radiology\n 50 K/uL\n 8.2 g/dL\n 117 mg/dL\n 0.8 mg/dL\n 29 mEq/L\n 3.8 mEq/L\n 31 mg/dL\n 114 mEq/L\n 146 mEq/L\n 24.1 %\n 4.6 K/uL\n [image002.jpg]\n 05:56 PM\n 06:13 PM\n 07:31 PM\n 09:57 PM\n 01:37 AM\n 04:43 AM\n 03:24 PM\n 02:42 AM\n 03:30 AM\n 06:33 AM\n WBC\n 5.8\n 4.9\n 4.6\n Hct\n 26.1\n 25.3\n 24.1\n Plt\n 48\n 47\n 50\n Cr\n 1.1\n 1.1\n 1.0\n 1.0\n 1.0\n 0.8\n TCO2\n 30\n 29\n 30\n 30\n Glucose\n 167\n 170\n 176\n 133\n 125\n 117\n Other labs: PT / PTT / INR:20.2/57.1/1.9, CK / CKMB /\n Troponin-T:447/26/0.24, ALT / AST:53/134, Alk Phos / T Bili:78/3.0,\n Amylase / Lipase:93/30, Differential-Neuts:84.1 %, Lymph:10.6 %,\n Mono:2.3 %, Eos:2.7 %, Lactic Acid:1.6 mmol/L, Albumin:3.3 g/dL,\n LDH:298 IU/L, Ca++:8.5 mg/dL, Mg++:1.9 mg/dL, PO4:1.6 mg/dL\n Assessment and Plan\n ELECTROLYTE & FLUID DISORDER, OTHER\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n HYPOTENSION (NOT SHOCK)\n CARDIAC ARREST\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n BACTEREMIA\n ICU Care\n Nutrition:\n Nutren Renal (Full) - 04:58 AM 60 mL/hour\n Glycemic Control:\n Lines:\n Multi Lumen - 12:48 PM\n Arterial Line - 11:00 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": "2145-01-16 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 559885, "text": "Chief Complaint:\n 24 Hour Events:\n Events:\n was able to lighten propofol sedation\n psych c/s done and did not think that it was likely that he had NMS\n from haldol but still recommend giving only seroquel\n i/o negative 2L\n Allergies:\n Demerol (Oral) (Meperidine Hcl)\n Confusion/Delir\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 06:36 AM\n Vancomycin - 08:00 AM\n Penicillin G potassium - 04:00 AM\n Infusions:\n Propofol - 15 mcg/Kg/min\n Other ICU medications:\n Pantoprazole (Protonix) - 08:04 AM\n Furosemide (Lasix) - 12:54 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 07:06 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.1\nC (100.6\n Tcurrent: 36.9\nC (98.4\n HR: 80 (80 - 114) bpm\n BP: 151/67(91) {128/49(68) - 191/81(113)} mmHg\n RR: 14 (9 - 29) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 73 Inch\n CVP: 18 (7 - 21)mmHg\n Total In:\n 4,016 mL\n 1,465 mL\n PO:\n TF:\n 1,268 mL\n 427 mL\n IVF:\n 549 mL\n 168 mL\n Blood products:\n Total out:\n 5,960 mL\n 760 mL\n Urine:\n 4,960 mL\n 760 mL\n NG:\n Stool:\n 1,000 mL\n Drains:\n Balance:\n -1,944 mL\n 705 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 445 (402 - 860) mL\n PS : 15 cmH2O\n RR (Spontaneous): 29\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 83\n PIP: 21 cmH2O\n SpO2: 99%\n ABG: 7.47/45/106/32/7\n Ve: 16.3 L/min\n PaO2 / FiO2: 212\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 51 K/uL\n 8.9 g/dL\n 114 mg/dL\n 0.7 mg/dL\n 32 mEq/L\n 4.0 mEq/L\n 16 mg/dL\n 110 mEq/L\n 147 mEq/L\n 26.3 %\n 5.7 K/uL\n [image002.jpg]\n 01:26 PM\n 03:23 PM\n 09:24 PM\n 10:04 PM\n 03:29 AM\n 03:46 AM\n 01:02 PM\n 01:03 PM\n 04:28 AM\n 04:45 AM\n WBC\n 5.0\n 5.5\n 5.8\n 5.7\n Hct\n 28.7\n 28.4\n 27.7\n 26.3\n Plt\n 59\n 55\n 59\n 51\n Cr\n 0.7\n 0.7\n 0.7\n 0.7\n 0.7\n TCO2\n 32\n 34\n 34\n 34\n Glucose\n 115\n 122\n 114\n 110\n 114\n Other labs: PT / PTT / INR:17.0/47.3/1.5, CK / CKMB /\n Troponin-T:447/26/0.24, ALT / AST:59/138, Alk Phos / T Bili:120/2.4,\n Amylase / Lipase:93/30, Differential-Neuts:80.0 %, Band:0.0 %,\n Lymph:16.0 %, Mono:0.0 %, Eos:4.0 %, Lactic Acid:1.6 mmol/L,\n Albumin:3.3 g/dL, LDH:398 IU/L, Ca++:8.9 mg/dL, Mg++:1.6 mg/dL, PO4:2.9\n mg/dL\n Assessment and Plan\n AEROBIC CAPACITY / ENDURANCE, IMPAIRED\n AROUSAL, ATTENTION, AND COGNITION, IMPAIRED\n RESPIRATION / GAS EXCHANGE, IMPAIRED\n HEPATIC ENCEPHALOPATHY\n ELECTROLYTE & FLUID DISORDER, OTHER\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n HYPOTENSION (NOT SHOCK)\n CARDIAC ARREST\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n BACTEREMIA\n ICU Care\n Nutrition:\n Nutren Pulmonary (Full) - 03:10 AM 60 mL/hour\n Glycemic Control:\n Lines:\n Multi Lumen - 12:48 PM\n Arterial Line - 11:00 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": "2145-01-16 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 559887, "text": "Chief Complaint:\n 24 Hour Events:\n Events:\n was able to lighten propofol sedation\n psych c/s done and did not think that it was likely that he had NMS\n from haldol but still recommend giving only seroquel\n i/o negative 2L\n Allergies:\n Demerol (Oral) (Meperidine Hcl)\n Confusion/Delir\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 06:36 AM\n Vancomycin - 08:00 AM\n Penicillin G potassium - 04:00 AM\n Infusions:\n Propofol - 15 mcg/Kg/min\n Other ICU medications:\n Pantoprazole (Protonix) - 08:04 AM\n Furosemide (Lasix) - 12:54 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 07:06 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.1\nC (100.6\n Tcurrent: 36.9\nC (98.4\n HR: 80 (80 - 114) bpm\n BP: 151/67(91) {128/49(68) - 191/81(113)} mmHg\n RR: 14 (9 - 29) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 73 Inch\n CVP: 18 (7 - 21)mmHg\n Total In:\n 4,016 mL\n 1,465 mL\n PO:\n TF:\n 1,268 mL\n 427 mL\n IVF:\n 549 mL\n 168 mL\n Blood products:\n Total out:\n 5,960 mL\n 760 mL\n Urine:\n 4,960 mL\n 760 mL\n NG:\n Stool:\n 1,000 mL\n Drains:\n Balance:\n -1,944 mL\n 705 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 445 (402 - 860) mL\n PS : 15 cmH2O\n RR (Spontaneous): 29\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 83\n PIP: 21 cmH2O\n SpO2: 99%\n ABG: 7.47/45/106/32/7\n Ve: 16.3 L/min\n PaO2 / FiO2: 212\n Physical Examination\n Eyes / Conjunctiva: PERRL, opens eyes, makes eye contact\n , Ears, Nose, Throat: , Poor dentition, NG tube, trach\n (Bloody )\n Cardiovascular: (S1: Normal), (S2: Normal), No(t) S3, No(t) S4, No(t)\n Rub\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not\n assessed), has a-line\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : ,\n Rhonchorous: )\n Abdominal: Soft, Bowel sounds present, Distended, palpable fluid wave\n Neurologic: arousable to voice, opens eyes no purposeful movements,\n withdraws to pain, non-verbal\n Labs / Radiology\n 51 K/uL\n 8.9 g/dL\n 114 mg/dL\n 0.7 mg/dL\n 32 mEq/L\n 4.0 mEq/L\n 16 mg/dL\n 110 mEq/L\n 147 mEq/L\n 26.3 %\n 5.7 K/uL\n [image002.jpg]\n 01:26 PM\n 03:23 PM\n 09:24 PM\n 10:04 PM\n 03:29 AM\n 03:46 AM\n 01:02 PM\n 01:03 PM\n 04:28 AM\n 04:45 AM\n WBC\n 5.0\n 5.5\n 5.8\n 5.7\n Hct\n 28.7\n 28.4\n 27.7\n 26.3\n Plt\n 59\n 55\n 59\n 51\n Cr\n 0.7\n 0.7\n 0.7\n 0.7\n 0.7\n TCO2\n 32\n 34\n 34\n 34\n Glucose\n 115\n 122\n 114\n 110\n 114\n Other labs: PT / PTT / INR:17.0/47.3/1.5, CK / CKMB /\n Troponin-T:447/26/0.24, ALT / AST:59/138, Alk Phos / T Bili:120/2.4,\n Amylase / Lipase:93/30, Differential-Neuts:80.0 %, Band:0.0 %,\n Lymph:16.0 %, Mono:0.0 %, Eos:4.0 %, Lactic Acid:1.6 mmol/L,\n Albumin:3.3 g/dL, LDH:398 IU/L, Ca++:8.9 mg/dL, Mg++:1.6 mg/dL, PO4:2.9\n mg/dL\n Assessment and Plan\n This is a 63 y/o M with Hepatitis C cirrhosis, s/p PEA arrest, body\n cooling and rewarming, with Fusobacterium sepsis covering with IV Pen G\n until .\n .\n # bleeding from trach site- Procedure done , 8-0 Portex .lost\n 150cc. Patient was given giving 2u platelets, given 1u FFP after the\n procedure. ENT was consulted on for concern of posterior pharynx\n bleed, which they did not find any evidence of.\n - will consider bronch to eval for source of bleed from trach site,\n continues to have red congealed blood oozing from site\n .\n # Respiratory/Ventilation: Pt re-intubated secondary to\n respiratory distress and inability to handle secretions. Unlikely to\n tolerate extubation given that underlying problem is inability to\n handle secretions which is unlikely to change. CXR from showed\n evidence of pulmonary edema. Patient getting trach in OR. Patient\n completed treatment for empire HAP for 5day with vanc/zosyn starting\n . Stopped vanc , continuing zosyn until sensitivities of\n fusobacterium.\n - giving Lasix 40mg IV with goal -2L\n .\n # Fusobacterium sepsis: Will treat for two-week course, awaiting\n sensitivities on Fusobacterium -> likely responsive to penicillin. Dx\n on , will need 14d course until . Covering with zosyn until\n sensitivies obtained.\n - surveillance blood cxs NTD\n .\n # thrombocytopenia\n platlets 171, now 44. Switched from H2 to\n PPI. Considering HIT vs. splenic sequestration\n - obtaining smear\n -\n # Mental Status: With slowly resolving delerium prior to this event,\n and now with unclear hypoxic insult to brain. GCS of on admission\n to ICU. Considering head CT to evaluate for anoxic brain injury\n post-cooling. Neuro eval for possible seizure. EEG neg for seizure,\n severe encephalopathy likely in setting of sedation. LP done earlier\n that was negative gram stain/culture, no whites, negative HSV PCR. Back\n to pre-code MS per wife. CT scan did not show any focal lesions.\n - patient is following commands, off propofol sedation, psych saw\n patient on and felt that the patient was very unlikely to have had\n NMS and recommended seroquel to be used for agitation.\n - likely will need MRI in the future but can not tolerate now \n mental status/respiratory status\n - increase lactulose\n .\n # Resolved Renal Failure: Unclear etiology, likely combination of ATN\n in the setting of code and HRS. Renal following given concern for HRS.\n Off albumin, mitodrine and octreotide\n - f/u renal and liver recs\n .\n # Hypernatremia: Likely hypovolemic hypernatremia in the setting of\n recent ATN and current HRS. Corrected , free water deficit ~ 2-3L.\n - switching antibiotics to be made with D5W\n .\n # Cardiac: CE's trended post-arrest. Echo hyperdynamic, no cardiogenic\n shock. CK and Trop trended down\n - will consider repeat echo\n .\n # Cirrhosis: Hep C Cirrhosis, with concern for HRS.\n - pre-code mental status likely related to encephalopathy v. delirium\n - titrate up lactulose\n - liver recs -> non suitable for tx at this point, in the very small\n chance that pt improves could possibly be candidate in the future\n .\n # s/p Shock/PEA Arrest: After PEA, was initially hemodynamically stable\n but has had episodes of hypotension non-responsive to IVF boluses,\n levofed started, currently off. Echo showed no evidence of cardiogenic\n shock. s/p cooling and rewarming. Trended cardiac enzymes, came down\n and no evidence of cardiogenic shock on rewarmed echo.\n # Parotid mass. Incidental finding of L parotid mass on MRI, 1.6cm. --\n Will require ENT followup as outpt.\n .\n # Metabolic Acidosis: s/p arrest to tissue hypoxia. Lactates now\n normalized, now resolved.\n # Access: PIV, Central Line\n .\n # FEN: TF running at goal, 60cc/hr\n .\n # Prophylaxis: holding HSQ since elevated PTT, PPI\n .\n # Code: full\n .\n # Communication: Wife is HCP -> will readdress long-term goals re:\n long-term prognosis\n .\n # Disposition: ICU for now.\n ICU Care\n Nutrition:\n Nutren Pulmonary (Full) - 03:10 AM 60 mL/hour\n Glycemic Control:\n Lines:\n Multi Lumen - 12:48 PM\n Arterial Line - 11:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Echo", "chartdate": "2145-01-08 00:00:00.000", "description": "Report", "row_id": 64732, "text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function.\nHeight: (in) 72\nWeight (lb): 180\nBSA (m2): 2.04 m2\nBP (mm Hg): 96/54\nHR (bpm): 54\nStatus: Inpatient\nDate/Time: at 13:53\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT VENTRICLE: Hyperdynamic LVEF >75%.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows. Suboptimal\nimage quality - bandages, defibrillator pads or electrodes. Suboptimal image\nquality - body habitus. Suboptimal image quality - ventilator. Ascites.\n\nConclusions:\nVery limited study. Left ventricular systolic function is grossly hyperdynamic\n(EF>75%). Right ventricular chamber size and free wall motion are grossly\nnormal.\n\n\n" }, { "category": "Echo", "chartdate": "2144-12-21 00:00:00.000", "description": "Report", "row_id": 64733, "text": "PATIENT/TEST INFORMATION:\nIndication: Cirrhosis, encephalopathic. Persistent murmur, ?endocarditis.\nHeight: (in) 72\nWeight (lb): 180\nBSA (m2): 2.04 m2\nBP (mm Hg): 148/93\nHR (bpm): 78\nStatus: Inpatient\nDate/Time: at 11:15\nTest: TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Normal LA and RA cavity sizes.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. Normal IVC diameter\n(<2.1cm) with <35% decrease during respiration (estimated RA pressure\nindeterminate).\n\nLEFT VENTRICLE: Mild symmetric LVH with normal cavity size and regional/global\nsystolic function (LVEF>55%). Estimated cardiac index is normal\n(>=2.5L/min/m2). No resting LVOT gradient.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal diameter of aorta at the sinus, ascending and arch levels.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No masses or\nvegetations on aortic valve. No AR.\n\nMITRAL VALVE: Normal mitral valve leaflets with trivial MR. No MVP. No mass or\nvegetation on mitral valve.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Normal PA\nsystolic pressure.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS.\nPhysiologic PR. No masses or vegetations on pulmonic valve, but cannot be\nfully excluded due to suboptimal image quality.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor apical views. Suboptimal\nimage quality as the patient was difficult to position.\n\nConclusions:\nThe left atrium and right atrium are normal in cavity size. The right atrial\npressure is indeterminate. There is mild symmetric left ventricular\nhypertrophy with normal cavity size and regional/global systolic function\n(LVEF>55%). The estimated cardiac index is normal (>=2.5L/min/m2). Right\nventricular chamber size and free wall motion are normal. The diameters of\naorta at the sinus, ascending and arch levels are normal. The aortic valve\nleaflets (3) are mildly thickened but aortic stenosis is not present. No\nmasses or vegetations are seen on the aortic valve. No aortic regurgitation is\nseen. The mitral valve appears structurally normal with trivial mitral\nregurgitation. There is no mitral valve prolapse. No mass or vegetation is\nseen on the mitral valve. The estimated pulmonary artery systolic pressure is\nnormal. No masses or vegetations are seen on the pulmonic valve, but cannot be\nfully excluded due to suboptimal image quality. There is no pericardial\neffusion.\n\nIMPRESSION: Normal biventricular systolic function with mild symmetric left\nventricular hypertrophy. Mild aortic valve sclerosis without discrete\nvegetation or pathologic flow.\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.\nIf clinically suggested, the absence of a vegetation by 2D echocardiography\ndoes not exclude endocarditis.\n\n\n" }, { "category": "Nursing", "chartdate": "2145-01-20 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 560794, "text": "Pt admitted to on s/p fall for spinal fusion. Per pt\ns wife\n pt has been confused since surgery. Did have known UTI however post\n treatment continues to have MS changes. Team questioning\n encephalopathy vs. infection. pt had episode of respiratory\n distress then became unresponsive and went into PEA arrest, intubated\n during code. Pt had been on Arctic sun for post VT arrest cooling. CT\n negative for PE or bleed. Pt was successfully extubated on ,\n however unable to tolerate and reintubated . Trached .\n Repeat head CT negative for any acute changes. Pt has been stable last\n few days.\n Note: this patient needs 1:1 sitter at night.\n Altered mental status (not Delirium)\n Assessment:\n Pt restless, confused, trying to get out of bed, pulling at tubes, hx\n of dc\ning NGT. Pt on seroquell overnoc with minimal result. Orients\n quickly but then forgets limitations. A&O x .\n Action:\n OOBTC facing nurse\ns station, a.m. seroquel, soft restraints.\n Response:\n Pt calm and appropriate while in chair.\n Plan:\n Keep pt in chair as tolerated. Re-orient frequently, provide calm, safe\n environment, initiate interventions to keep pt safe and to minimize\n interference with treatments. Pt must have a sitter at night.\n Aerobic Capacity / Endurance, Impaired\n Assessment:\n Pt on trache collar on 50%, breathing regular, strong productive cough,\n clears own secretions, exp wheeze/diminished, pt down flat in bed.\n Action:\n Pt boosted numerous times, does not maintain position at 30 degrees.\n OOBTC on Passe Muir valve, session with PT.\n Response:\n Tolerated well, maintained sat > 95%.\n Plan:\n Keep HOB at 30 degrees, boost often, OOBTC or bed as chair as\n tolerated, increase Passe Muir valve duration as tolerated, increase\n activity as tolerated.\n Hepatic encephalopathy\n Assessment:\n Pt confused, A & O to self and sometimes to place (\nhospital\n), forgets\n limitations, pulls at tube.\n Action:\n Lactulose q 4 hours, reorient frequently.\n Response:\n Amonia levels WNL\n Plan:\n Continue with lactulose therapy, continue collaboration with liver\n team.\n Demographics\n Attending MD:\n F.\n Admit diagnosis:\n HEPATIC ENCEPHALOPATHY\n Code status:\n Full code\n Height:\n 73 Inch\n Admission weight:\n 107.5 kg\n Daily weight:\n Allergies/Reactions:\n Demerol (Oral) (Meperidine Hcl)\n Confusion/Delir\n Precautions: No Additional Precautions\n PMH: ETOH, Hepatitis, Liver Failure\n CV-PMH:\n Additional history: Hep C, ETOH, cirrhosis, hepatic cell CA, Bipolar\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:125\n D:69\n Temperature:\n 99.3\n Arterial BP:\n S:158\n D:71\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 Trach mask\n O2 saturation:\n 100% %\n O2 flow:\n 12 L/min\n FiO2 set:\n 50% %\n 24h total in:\n 3,676 mL\n 24h total out:\n 2,680 mL\n Pertinent Lab Results:\n Sodium:\n 144 mEq/L\n 05:46 AM\n Potassium:\n 3.8 mEq/L\n 05:46 AM\n Chloride:\n 112 mEq/L\n 05:46 AM\n CO2:\n 26 mEq/L\n 05:46 AM\n BUN:\n 14 mg/dL\n 05:46 AM\n Creatinine:\n 0.6 mg/dL\n 05:46 AM\n Glucose:\n 95 mg/dL\n 05:46 AM\n Hematocrit:\n 25.5 %\n 05:46 AM\n Finger Stick Glucose:\n 125\n 12:00 PM\n Valuables / Signature\n Patient valuables: none\n Other valuables: none\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: MICU 6\n Transferred to: 10\n Date & time of Transfer: 1700\n" }, { "category": "Physician ", "chartdate": "2145-01-14 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 559508, "text": "Chief Complaint:\n 24 Hour Events:\n OR SENT - At 10:20 PM\n OR RECEIVED - At 12:30 AM\n trach place, 8 portex, pt received 2 units ffp in OR\n Events:\n - around 10 pm, got trach - had some mild bleeding around the trach\n site (150cc), but otherwise without complications\n - want to keep INR low over next few days, FFP PRN\n - mildly hypernatremic, getting D5W but held during procedure, will\n finish IVFs and start TFs with free water flushes\n - continues to be on propofol sedation\n Allergies:\n Demerol (Oral) (Meperidine Hcl)\n Confusion/Delir\n Last dose of Antibiotics:\n Vancomycin - 08:30 PM\n Piperacillin/Tazobactam (Zosyn) - 06:36 AM\n Infusions:\n Propofol - 20 mcg/Kg/min\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 07:15 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.3\nC (99.2\n Tcurrent: 35.7\nC (96.3\n HR: 67 (59 - 81) bpm\n BP: 142/65(86) {106/48(63) - 165/68(96)} mmHg\n RR: 11 (0 - 27) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 73 Inch\n CVP: 8 (6 - 16)mmHg\n Total In:\n 3,425 mL\n 1,360 mL\n PO:\n TF:\n 467 mL\n 180 mL\n IVF:\n 1,486 mL\n 1,180 mL\n Blood products:\n 621 mL\n Total out:\n 3,890 mL\n 710 mL\n Urine:\n 3,890 mL\n 710 mL\n NG:\n Stool:\n Drains:\n Balance:\n -465 mL\n 650 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 550 (550 - 550) mL\n RR (Set): 12\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 100\n PIP: 19 cmH2O\n Plateau: 16 cmH2O\n Compliance: 50 cmH2O/mL\n SpO2: 100%\n ABG: 7.47/40/94./30/4\n Ve: 8.6 L/min\n PaO2 / FiO2: 235\n Physical Examination\n Eyes / Conjunctiva: PERRL, opens eyes, makes eye contact\n , Ears, Nose, Throat: , Poor dentition, Endotracheal\n tube, NG tube\n Cardiovascular: (S1: Normal), (S2: Normal), No(t) S3, No(t) S4, No(t)\n Rub\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : ,\n Rhonchorous: )\n Abdominal: Soft, Bowel sounds present, Distended, palpable fluid wave\n Neurologic: arousable to voice, opens eyes no purposeful movements,\n withdraws to pain, non-verbal\n Labs / Radiology\n 44 K/uL\n 9.2 g/dL\n 112 mg/dL\n 0.6 mg/dL\n 30 mEq/L\n 3.8 mEq/L\n 23 mg/dL\n 111 mEq/L\n 147 mEq/L\n 27.8 %\n 4.1 K/uL\n [image002.jpg]\n 04:43 AM\n 03:24 PM\n 02:42 AM\n 03:30 AM\n 06:33 AM\n 03:37 PM\n 04:02 PM\n 09:03 PM\n 03:15 AM\n 03:29 AM\n WBC\n 5.8\n 4.9\n 4.6\n 4.1\n 4.1\n Hct\n 26.1\n 25.3\n 24.1\n 28.6\n 27.8\n Plt\n 48\n 47\n 50\n 46\n 44\n Cr\n 1.0\n 1.0\n 0.8\n 0.7\n 0.8\n 0.6\n TCO2\n 30\n 30\n 32\n 30\n Glucose\n 133\n 125\n 117\n 95\n 120\n 112\n Other labs: PT / PTT / INR:17.2/48.4/1.6, CK / CKMB /\n Troponin-T:447/26/0.24, ALT / AST:53/127, Alk Phos / T Bili:73/3.7,\n Amylase / Lipase:93/30, Differential-Neuts:84.1 %, Lymph:10.6 %,\n Mono:2.3 %, Eos:2.7 %, Lactic Acid:1.6 mmol/L, Albumin:3.3 g/dL,\n LDH:298 IU/L, Ca++:8.2 mg/dL, Mg++:1.7 mg/dL, PO4:2.6 mg/dL\n Assessment and Plan\n This is a 63 y/o M with Hepatitis C cirrhosis, s/p PEA arrest, body\n cooling and rewarming, concern for PNA covering with Vanc/Zosyn.\n .\n # s/p Shock/PEA Arrest: After PEA, was initially hemodynamically stable\n but has had episodes of hypotension non-responsive to IVF boluses,\n levofed started, currently off. Echo showed no evidence of cardiogenic\n shock. s/p cooling and rewarming. Trended cardiac enzymes, came down\n and no evidence of cardiogenic shock on rewarmed echo.\n .\n # Respiratory/Ventilation: Pt re-intubated secondary to\n respiratory distress and inability to handle secretions. Unlikely to\n tolerate extubation given that underlying problem is inability to\n handle secretions which is unlikely to change. CXR from showed\n evidence of pulmonary edema. Patient getting trach in OR.\n - cont 5-day total course of vanc/zosyn\n - giving Lasix 40mg IV with goal -1L (will need to give addition dose\n in setting of getting 1u PRBC and 2u FFP)\n .\n # Pneumonia\n on CXR has RLL infiltrate and bronch with thick yellow\n secretions, leukocytosis starting to resolve\n - on vanco/zosyn for total 5-day course\n - follow up cultures\n .\n # Gram negative bacteremia: Will treat for two-week course, awaiting\n sensitivities on Fusobacterium -> likely responsive to penicillin.\n - will continue surveillance blood cxs\n .\n # Mental Status: With slowly resolving delerium prior to this event,\n and now with unclear hypoxic insult to brain. GCS of on admission\n to ICU. Considering head CT to evaluate for anoxic brain injury\n post-cooling. Neuro eval for possible seizure. EEG neg for seizure,\n severe encephalopathy likely in setting of sedation. LP done earlier\n that was negative gram stain/culture, no whites, negative HSV PCR. Back\n to pre-code MS per wife.\n - patient is following commands, on propofol sedation\n - CT scan did not show any focal lesions\n - likely will need MRI in the future but can not tolerate now \n mental status/respiratory status\n - increase lactulose\n .\n # Resolved Renal Failure: Unclear etiology, likely combination of ATN\n in the setting of code and HRS. Renal following given concern for HRS.\n Off albumin, mitodrine and octreotide\n - f/u renal and liver recs\n .\n # Hypernatremia: Likely hypovolemic hypernatremia in the setting of\n recent ATN and current HRS. Corrected , free water deficit ~ 2-3L.\n .\n # Cardiac: CE's trended post-arrest. Echo hyperdynamic, no cardiogenic\n shock. CK and Trop trended down\n - will consider repeat echo\n .\n # Cirrhosis: Hep C Cirrhosis, with concern for HRS.\n - pre-code mental status likely related to encephalopathy v. delirium\n - titrate up lactulose\n - liver recs -> non suitable for tx at this point, in the very small\n chance that pt improves could possibly be candidate in the future\n .\n # Parotid mass. Incidental finding of L parotid mass on MRI, 1.6cm. --\n Will require ENT followup as outpt.\n .\n # Metabolic Acidosis: s/p arrest to tissue hypoxia. Lactates now\n normalized, now resolved.\n # Access: PIV, Central Line\n .\n # FEN: NPO for trach in OR, resume TF\n .\n # Prophylaxis: holding HSQ since elevated PTT, famotidine\n .\n # Code: full\n .\n # Communication: Wife is HCP -> will readdress long-term goals today\n re: long-term prognosis\n .\n # Disposition: ICU for now.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 12:48 PM\n Arterial Line - 11:00 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": "2145-01-15 00:00:00.000", "description": "Nursing Progress Note", "row_id": 559785, "text": "63 y/o M with Hepatitis C cirrhosis, s/p PEA arrest, body cooling and\n rewarming, with Fusobacterium sepsis covering with Zosyn until .\n Altered mental status (not Delirium)\n Assessment:\n More awake, however does not follow commands, tracks or tries to\n communicate. Pupils 2-3mm equal and reactive. Remains slightly rigid.\n On propofol sedation, possibly encephalopathic\n Action:\n Propofol d/c if agitated will try haldol or zyprexa per psych consult .\n If in pain treat pain, lactulose increased to 60 q4hr.\n Response:\n Per wife more awake, however still non communicable and does not\n follows commands.\n Plan:\n Continue top monitor patient\ns neuro status, may need MRI later on,\n meds \n Respiratory failure, acute (not ARDS/)\n Assessment:\n Remains trached and vented on PSV 40% 5/5. Bil LS clear, RRR, copious\n amnt of bloody secretions w/suctioning and around trach. Periods of\n low MV.\n Action:\n Weaned to trach mask, suction prn, trach care and frequent mouth care,\n ENT consulted, lasix 40mg X1 given w/goal of -2L\n Response:\n pending\n Plan:\n Continue to monitor resp status, meds , need bronch later on.\n Mouth care and trach care as needed.\n Cardio: normotensive hr at 90\ns SR no ectopy, upper extr edema,\n peripheral pulses present.\n GI: abd soft distended positive for BS, on lactulose q4hr, brown loose\n stool in flexiseal. TF at goal of 60/hr tolerates it well.\n GU: clear yellow urine via foley. Adequate amnt. Got lasix 40mg X1\n given.\n IV access: LT subclavian, LT a - line.\n Social: patient is a FULL CODE> family in to visit updated by RN and\n MD.\n At 1700 patient agitated, thrashing in bed, tachypneic to 40\ns, B/P at\n 180\ns-190, desats to mid 80\ns. Sedation restarted, and patient was put\n back on PSV 50% 15/5 w/sats at 97%. B/P down 130\n" }, { "category": "General", "chartdate": "2145-01-07 00:00:00.000", "description": "ICU Event Note", "row_id": 558111, "text": "Clinician: Attending\n Patient has been cooled to target pressure. O2 sats 94% on FIO2=0.6.\n On exam, patient intubated and sedated. Chest clear anterior and\n lateral lung fields. Heart sounds soft. No gallop. Abdomen distended,\n mildly firm. Bowel sounds present. Capillary refill delayed.\n CVP transduced; pressure is on PEEP=6. Patient is not making urine.\n SVR likely high with cooling. Despite this, the low CVP suggests volume\n depleted. be in ATN or hepatorenal but should at least try volume\n challenge to see if there is any urinary response. Check bladder\n pressure for possible abdominal compartment syndrome although by exam\n my suspicion is low.\n Total time spent: 35 minutes\n Patient is critically ill.\n" }, { "category": "Physician ", "chartdate": "2145-01-08 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 558186, "text": "Chief Complaint:\n 24 Hour Events:\n Events:\n - bronch showing thick, yellow secretions concerning for infection,\n started vanco and zosyn for HAP\n - cooling protocol initiated, plan for rewarming around noon tomorrow\n - renal team following, sent urine lytes and UA; pt remaining basically\n anuric overnight\n - CVPs in 8-10s, likely fluid down; to test kidneys, gave 500 cc fluid\n challenge. UO improved slightly from about 20 cc/hr up to 80 cc/hr for\n short time\n - Around 2 am, after repositioning patients SBP dropped to 70s, came up\n to 80s with fluids but needed to start levophed; titrated up to 0.07\n and then stable overnight\n INVASIVE VENTILATION - START 10:55 AM\n MULTI LUMEN - START 12:48 PM\n BRONCHOSCOPY - At 04:23 PM\n ARTERIAL LINE - START 05:00 PM\n Allergies:\n Demerol (Oral) (Meperidine Hcl)\n Confusion/Delir\n Last dose of Antibiotics:\n Ceftriaxone - 04:00 PM\n Vancomycin - 08:00 PM\n Piperacillin/Tazobactam (Zosyn) - 01:57 AM\n Infusions:\n Fentanyl - 50 mcg/hour\n Midazolam (Versed) - 2 mg/hour\n Norepinephrine - 0.05 mcg/Kg/min\n Other ICU medications:\n Midazolam (Versed) - 11:30 AM\n Fentanyl - 11:30 AM\n Heparin Sodium (Prophylaxis) - 10:02 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:38 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 3.1\nC (37.5\n Tcurrent: 3.1\nC (37.5\n HR: 60 (59 - 156) bpm\n BP: 114/68(82) {85/51(62) - 114/77(82)} mmHg\n RR: 19 (17 - 27) insp/min\n SpO2: 97%\n CVP: 15 (7 - 18)mmHg\n Bladder pressure: 9 (9 - 9) mmHg\n Total In:\n 2,497 mL\n 855 mL\n PO:\n TF:\n IVF:\n 2,497 mL\n 855 mL\n Blood products:\n Total out:\n 410 mL\n 154 mL\n Urine:\n 410 mL\n 154 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,087 mL\n 701 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 550 (550 - 550) mL\n RR (Set): 18\n RR (Spontaneous): 0\n PEEP: 12 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10\n PIP: 22 cmH2O\n Plateau: 20 cmH2O\n SpO2: 97%\n ABG: 7.46/34/92./25/0\n Ve: 10.3 L/min\n PaO2 / FiO2: 186\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 134 K/uL\n 12.7 g/dL\n 114 mg/dL\n 2.2 mg/dL\n 25 mEq/L\n 4.2 mEq/L\n 85 mg/dL\n 102 mEq/L\n 138 mEq/L\n 38.5 %\n 26.5 K/uL\n [image002.jpg]\n 11:21 AM\n 01:24 PM\n 03:41 PM\n 06:56 PM\n 09:04 PM\n 10:13 PM\n 11:06 PM\n 11:47 PM\n 03:38 AM\n 04:01 AM\n WBC\n 13.4\n 26.5\n Hct\n 39.6\n 38.5\n Plt\n 152\n 134\n Cr\n 2.1\n 2.0\n 1.9\n 2.2\n TropT\n 0.27\n 0.24\n TCO2\n 33\n 27\n 28\n 27\n 27\n 25\n Glucose\n 105\n 92\n 117\n 114\n Other labs: PT / PTT / INR:17.2/54.3/1.6, CK / CKMB /\n Troponin-T:447/26/0.24, Differential-Neuts:74.5 %, Lymph:14.1 %,\n Mono:8.1 %, Eos:2.9 %, Lactic Acid:2.0 mmol/L, Ca++:7.7 mg/dL, Mg++:3.1\n mg/dL, PO4:5.5 mg/dL\n Assessment and Plan\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n HYPOTENSION (NOT SHOCK)\n CARDIAC ARREST\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 22 Gauge - 11:30 AM\n 20 Gauge - 11:45 AM\n Multi Lumen - 12:48 PM\n Arterial Line - 05:00 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": "2145-01-13 00:00:00.000", "description": "Nursing Progress Note", "row_id": 559267, "text": "PMH: Pt admitted to on s/p fall for back spinal fusion. Has\n been confused since surgery according to pt's wife later developed UTI.\n Unknown cause of MS changes. ? encephalopathy vs. infection.Pt had\n resp distress, became unresponsive and went into PEA arrest on .Pt\n has been on Arctic sun.CT neg for PE or bleed.Pt was succefully\n extubated on .But developed acute respiratory distress on that\n night with increasing agitation and confusion.Was reintubated on\n .Head CT neg for any acute changes.\n Events:\n Electrolyte & fluid disorder, other\n Assessment:\n Pt\ns Na was elevated at 146, phosphate low at 1.6.\n Action:\n FWB increased\n Response:\n Plan:\n Altered mental status (not Delirium)\n Assessment:\n Action:\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Social Work", "chartdate": "2145-01-13 00:00:00.000", "description": "Social Work Progress Note", "row_id": 559324, "text": "Pt known to this worker since on Fa10. Continuing to follow\n case to monitor pt\ns progress and ongoing assessment of wife\ns coping;\n also to provide emotional support. Wife has been at the bedside for\n the entire admission during which time pt has been non-commuacative\n secondary to ?NMS. Wife has been able to provide comfort to pt in\n ongoing agitated state; wife has worked well with medical team and\n support services and has helped us to know her husband.\n Wife continues to be at the bedside, is coping well, she has a good\n support system through her church and through her job at the VNA. Wife\n will be applying for Family leave which will allow her more time with\n pt and her two adolescent children. Pt\ns 16 yr old son visited the ICU\n and attended meeting with Dr. last week and seemed to process\n the medical information appropriately. Son appears to be coping well.\n Attended meeting with Dr. and pt\ns wife yesterday, goals of care\n where discussed. Wife asking to review both short and long term\n goals.\n Will continue to follow and provide counseling and support to this\n family.\n" }, { "category": "Respiratory ", "chartdate": "2145-01-14 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 559603, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 4\n Ideal body weight: 83.5 None\n Ideal tidal volume: mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type:\n Size:\n Tracheostomy tube:\n Type: Standard\n Manufacturer: Portex\n Size: 8.0mm\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Bloody / 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 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 Underlying illness not resolved\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n" }, { "category": "Nursing", "chartdate": "2145-01-08 00:00:00.000", "description": "Nursing Progress Note", "row_id": 558287, "text": "Synopsis per prior nursing note:\n Pt admitted to on s/p fall for back spinal fusion.\n According to pt's wife, who is health care proxy, pt has been confused\n since coming out of anesthesia and later developed a UTI. According to\n floor RN, pt has had MS changes over the past few weeks where he has\n been agitated and unresponsive. Neuro and psych have consulted.\n Unknown cause of MS changes. ? encephalopathy vs. infection. Today pt\n had resp distress, became unresponsive and went into PEA arrest. Large\n plug suctioned from pt. Chest compressions done, 1mg Atropine given\n along with Epi. Pulse returned and pt transferred to MICU for further\n management.\n Cardiac arrest\n Assessment:\n HR 55-68 SR w/rare PVC\ns. ABP 95-109/48-66. MAP\ns 60\ns-70\n Eyes-PERRL, 2mm, brisk. Not moving extremities. Not following commands.\n Not responding to painful stimuli. Temp 34C rectal. QT 505milliseconds\n (Resident aware). No shivering noted.\n Action:\n Continues on artic sun. Temp monitored-rectal and bladder. Started\n rewarming protocol @ 1215.\n Response:\n Monitoring of ECG for changes, AM labs: K (4.1), glucose levels WNL.\n Plan:\n Close monitoring of QTc as hypothermia may mask hypo/hyperkalemic\n changes on the ECG.Monitor lytes closely. Administer nimbex for\n shivering or excessive drops in Artic Sun water temperature. Begin\n re-warming at 12:20 at 0.5C/hr per protocol - monitor for\n hyperglycemia, hyperkalemia, and seizure activity. Monitor pan cultures\n pending.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Assumed care AC 18/50% x 550/5, pH 7.50, pO2 54. Lung sounds\n diminished in the lower fields and rhonchorous in the upper\n bilaterally. Suctioning scant amounts of tan tenacious secretions.\n Brief periods of desaturation to 90% relieved by increasing FiO2 to\n 100%.WCC this am 26.5,almost doubled from yesterday.\n Action:\n Repeat pH 7.49, pO2 53, RT lavaged ETT with little to no increase in\n secretions, vent changes to 18/70% x 550/12. Lung sounds diminished in\n all fields. CXR showing probable PNA. HOB 30 degrees.\n Response:\n ABG = 7.44, pO2 77, FiO2 60%, breathing approx. 10 L/min. Zosyn and\n Vanco per . WBC (13.4).\n Plan:\n Monitor ABG, ween FiO2 and PEEP as appropriate. ABX, T&R and CPT as\n tolerated. Monitor for signs of distress.F/u culture report.\n Hypotension (not Shock)\n Assessment:\n Normotensive at commencement of shift, MAP high 60\ns, CVP 9.\n Fentanyl/Versed at 50mcg/2mg. Urine output approx. 20cc/hr.\n Action:\n 500 cc bolus fluid challenge given. Fentanyl/Versed d/c\nd and Propofol\n started at 25 mcg/kg/min, with immediate hypotensive effect, decreased\n to 10 mcg/kg/min, MAP of high 40\ns. 500 cc bolus given and Propofol\n d/c\nd, Fentanyl/Versed restarted at 50mcg/2mg.\n Response:\n BP returned to MAP of 60. Hypotensive episode with T&R, 500 cc bolus\n given with poor effect on BP and urine output, Levophed started,\n increased in increments to 0.09 mcg/kg/min with MAP goal >70 for brain\n perfusion.\n Plan:\n Titrate Levophed for MAP >70. Monitor fluid balance, LOS about +3000\n mL. Assess for BP lability during rewarming r/t vasodilation.\n" }, { "category": "Respiratory ", "chartdate": "2145-01-13 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 559268, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 3\n Ideal body weight: 83.5 None\n Ideal tidal volume: mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: 25 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Diminished\n LUL Lung Sounds: Diminished\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Blood Tinged /\n Sputum source/amount: Suctioned / Scant\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Underlying illness\n not resolved\n" }, { "category": "Nursing", "chartdate": "2145-01-13 00:00:00.000", "description": "Nursing Progress Note", "row_id": 559368, "text": "Synopsis per prior nursing note:\n Pt admitted to on s/p fall for back spinal fusion. Has been\n confused since surgery according to pt's wife later developed UTI.\n Unknown cause of MS changes. ? encephalopathy vs. infection.Pt had\n resp distress, became unresponsive and went into PEA arrest on .Pt\n has been on Arctic sun.CT neg for PE or bleed.Pt was succefully\n extubated on .But developed acute respiratory distress on that\n night with increasing agitation and confusion.Was reintubated on\n .Head CT neg for any acute changes.\n Altered mental status (not Delirium)\n Assessment:\n Arouses to voice/stimuli. Inconsistantly follows simple commands.\n Occasionally has non-purposeful movements of upper and lower\n extremities. At times becomes extremely restless (pulling arms toward\n face, lifting legs and moving them towards edge of bed, fighting vent).\n Action:\n Continued on propofol gtt. Reorientation attempted frequently.\n Lactulose held d/t NPO status.\n Response:\n Continues to be restless when less sedated.\n Plan:\n Continue neuro checks. Continue to reorient. Continue Lactulose when no\n longer NPO, ?lactulose PR.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Vent settings CMV 12/550/40%/PEEP8. LS diminished. Tmax 99.2 PO.\n Action:\n PEEP decreased to 5. Continued on vanco/zosyn. Suctioned small amt of\n blood tinged secretions. Frequent position changes. Chest PT done.\n Response:\n Appears comfortable on vent settings. O2 sats 95-100%. ABG\n 7.48/42/77/32.\n Plan:\n Wean vent as tolerated. Suction as needed. Continue chest PT. Continue\n antibiotics. ?trach Thursday.\n Electrolyte & fluid disorder, other\n Assessment:\n K 3.8. Phos 1.6. Mg 1.6. HCt 24.1.\n Action:\n Given 2 pks of neutra phos. K repleted on prior shift. Lasix 40mEq IV\n given. 1unit PRBC given.\n Response:\n UOP ~2.5L to lasix. Repeat labs, Hct 28.\n Plan:\n Monitor electrolytes.\n" }, { "category": "Nursing", "chartdate": "2145-01-13 00:00:00.000", "description": "Nursing Progress Note", "row_id": 559369, "text": "Synopsis per prior nursing note:\n Pt admitted to on s/p fall for back spinal fusion. Has been\n confused since surgery according to pt's wife later developed UTI.\n Unknown cause of MS changes. ? encephalopathy vs. infection.Pt had\n resp distress, became unresponsive and went into PEA arrest on .Pt\n has been on Arctic sun.CT neg for PE or bleed.Pt was succefully\n extubated on .But developed acute respiratory distress on that\n night with increasing agitation and confusion.Was reintubated on\n .Head CT neg for any acute changes.\n Altered mental status (not Delirium)\n Assessment:\n Arouses to voice/stimuli. Inconsistantly follows simple commands.\n Occasionally has non-purposeful movements of upper and lower\n extremities. At times becomes extremely restless (pulling arms toward\n face, lifting legs and moving them towards edge of bed, fighting vent).\n Action:\n Continued on propofol gtt. Reorientation attempted frequently.\n Lactulose held d/t NPO status.\n Response:\n Continues to be restless when less sedated.\n Plan:\n Continue neuro checks. Continue to reorient. Continue Lactulose when no\n longer NPO, ?lactulose PR.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Vent settings CMV 12/550/40%/PEEP8. LS diminished. Tmax 99.2 PO.\n Action:\n PEEP decreased to 5. Continued on vanco/zosyn. Suctioned small amt of\n blood tinged secretions. Frequent position changes. Chest PT done.\n Response:\n Appears comfortable on vent settings. O2 sats 95-100%. ABG\n 7.48/42/77/32.\n Plan:\n Wean vent as tolerated. Suction as needed. Continue chest PT. Continue\n antibiotics. ?trach Thursday.\n Electrolyte & fluid disorder, other\n Assessment:\n K 3.8. Phos 1.6. Mg 1.6. HCt 24.1. Na 147.\n Action:\n Given 2 pks of neutra phos. K repleted on prior shift. Lasix 40mEq IV\n given. 1unit PRBC given. Given potassium phosphate 15mmol. Started on\n 1L D5w @100cc/hr for Na.\n Response:\n UOP ~2.5L to lasix. Repeat labs, Hct 28.6, k 4.0, phos 2.9, Mg 1.6\n (given 2gm magnesium IV).\n Plan:\n Monitor electrolytes/UOP.\n" }, { "category": "Physician ", "chartdate": "2145-01-15 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 559688, "text": "Chief Complaint:\n 24 Hour Events:\n Events:\n - spoke to ID, fusobacterium is pan-sensitive and will give IV\n penicillin -> d/c zosyn\n - ENT eval for bleeding source -> no pharyngeal source\n - peripheral smear showed no evidence of DIC\n Allergies:\n Demerol (Oral) (Meperidine Hcl)\n Confusion/Delir\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 06:36 AM\n Vancomycin - 08:00 AM\n Penicillin G potassium - 04:00 AM\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 08:30 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:24 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.3\nC (99.1\n Tcurrent: 37.1\nC (98.8\n HR: 78 (63 - 85) bpm\n BP: 136/62(84) {125/57(76) - 161/81(109)} mmHg\n RR: 8 (8 - 25) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 73 Inch\n CVP: 9 (6 - 12)mmHg\n Total In:\n 4,647 mL\n 1,068 mL\n PO:\n TF:\n 637 mL\n 280 mL\n IVF:\n 2,346 mL\n 198 mL\n Blood products:\n 574 mL\n Total out:\n 6,290 mL\n 1,020 mL\n Urine:\n 5,990 mL\n 1,020 mL\n NG:\n 200 mL\n Stool:\n Drains:\n Balance:\n -1,643 mL\n 48 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 550 (500 - 550) mL\n Vt (Spontaneous): 580 (361 - 651) mL\n PS : 10 cmH2O\n RR (Set): 12\n RR (Spontaneous): 8\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 63\n PIP: 17 cmH2O\n Plateau: 13 cmH2O\n Compliance: 68.7 cmH2O/mL\n SpO2: 99%\n ABG: 7.48/45/86/31/8\n Ve: 8.1 L/min\n PaO2 / FiO2: 215\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 55 K/uL\n 9.6 g/dL\n 114 mg/dL\n 0.7 mg/dL\n 31 mEq/L\n 3.9 mEq/L\n 18 mg/dL\n 110 mEq/L\n 146 mEq/L\n 28.4 %\n 5.5 K/uL\n [image002.jpg]\n 03:15 AM\n 03:29 AM\n 08:58 AM\n 01:09 PM\n 01:26 PM\n 03:23 PM\n 09:24 PM\n 10:04 PM\n 03:29 AM\n 03:46 AM\n WBC\n 4.1\n 4.6\n 4.8\n 5.0\n 5.5\n Hct\n 27.8\n 27.0\n 27.0\n 28.7\n 28.4\n Plt\n 44\n 46\n 60\n 59\n 55\n Cr\n 0.6\n 0.7\n 0.7\n 0.7\n TCO2\n 30\n 32\n 34\n 34\n Glucose\n 112\n 115\n 122\n 114\n Other labs: PT / PTT / INR:16.6/46.5/1.5, CK / CKMB /\n Troponin-T:447/26/0.24, ALT / AST:58/126, Alk Phos / T Bili:95/2.8,\n Amylase / Lipase:93/30, Differential-Neuts:80.0 %, Band:0.0 %,\n Lymph:16.0 %, Mono:0.0 %, Eos:4.0 %, Lactic Acid:1.6 mmol/L,\n Albumin:3.3 g/dL, LDH:298 IU/L, Ca++:8.9 mg/dL, Mg++:1.6 mg/dL, PO4:3.1\n mg/dL\n Assessment and Plan\n HEPATIC ENCEPHALOPATHY\n ELECTROLYTE & FLUID DISORDER, OTHER\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n HYPOTENSION (NOT SHOCK)\n CARDIAC ARREST\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n BACTEREMIA\n ICU Care\n Nutrition:\n Nutren Pulmonary (Full) - 12:47 AM 40 mL/hour\n Glycemic Control:\n Lines:\n Multi Lumen - 12:48 PM\n Arterial Line - 11:00 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": "2145-01-15 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 559689, "text": "Chief Complaint:\n 24 Hour Events:\n Events:\n - spoke to ID, fusobacterium is pan-sensitive and will give IV\n penicillin -> d/c zosyn\n - ENT eval for bleeding source -> no pharyngeal source\n - peripheral smear showed no evidence of DIC\n Allergies:\n Demerol (Oral) (Meperidine Hcl)\n Confusion/Delir\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 06:36 AM\n Vancomycin - 08:00 AM\n Penicillin G potassium - 04:00 AM\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 08:30 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:24 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.3\nC (99.1\n Tcurrent: 37.1\nC (98.8\n HR: 78 (63 - 85) bpm\n BP: 136/62(84) {125/57(76) - 161/81(109)} mmHg\n RR: 8 (8 - 25) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 73 Inch\n CVP: 9 (6 - 12)mmHg\n Total In:\n 4,647 mL\n 1,068 mL\n PO:\n TF:\n 637 mL\n 280 mL\n IVF:\n 2,346 mL\n 198 mL\n Blood products:\n 574 mL\n Total out:\n 6,290 mL\n 1,020 mL\n Urine:\n 5,990 mL\n 1,020 mL\n NG:\n 200 mL\n Stool:\n Drains:\n Balance:\n -1,643 mL\n 48 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 550 (500 - 550) mL\n Vt (Spontaneous): 580 (361 - 651) mL\n PS : 10 cmH2O\n RR (Set): 12\n RR (Spontaneous): 8\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 63\n PIP: 17 cmH2O\n Plateau: 13 cmH2O\n Compliance: 68.7 cmH2O/mL\n SpO2: 99%\n ABG: 7.48/45/86/31/8\n Ve: 8.1 L/min\n PaO2 / FiO2: 215\n Physical Examination\n Eyes / Conjunctiva: PERRL, opens eyes, makes eye contact\n , Ears, Nose, Throat: , Poor dentition, NG tube, trach\n (Bloody )\n Cardiovascular: (S1: Normal), (S2: Normal), No(t) S3, No(t) S4, No(t)\n Rub\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not\n assessed), has a-line\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : ,\n Rhonchorous: )\n Abdominal: Soft, Bowel sounds present, Distended, palpable fluid wave\n Neurologic: arousable to voice, opens eyes no purposeful movements,\n withdraws to pain, non-verbal\n Labs / Radiology\n 55 K/uL\n 9.6 g/dL\n 114 mg/dL\n 0.7 mg/dL\n 31 mEq/L\n 3.9 mEq/L\n 18 mg/dL\n 110 mEq/L\n 146 mEq/L\n 28.4 %\n 5.5 K/uL\n [image002.jpg]\n 03:15 AM\n 03:29 AM\n 08:58 AM\n 01:09 PM\n 01:26 PM\n 03:23 PM\n 09:24 PM\n 10:04 PM\n 03:29 AM\n 03:46 AM\n WBC\n 4.1\n 4.6\n 4.8\n 5.0\n 5.5\n Hct\n 27.8\n 27.0\n 27.0\n 28.7\n 28.4\n Plt\n 44\n 46\n 60\n 59\n 55\n Cr\n 0.6\n 0.7\n 0.7\n 0.7\n TCO2\n 30\n 32\n 34\n 34\n Glucose\n 112\n 115\n 122\n 114\n Other labs: PT / PTT / INR:16.6/46.5/1.5, CK / CKMB /\n Troponin-T:447/26/0.24, ALT / AST:58/126, Alk Phos / T Bili:95/2.8,\n Amylase / Lipase:93/30, Differential-Neuts:80.0 %, Band:0.0 %,\n Lymph:16.0 %, Mono:0.0 %, Eos:4.0 %, Lactic Acid:1.6 mmol/L,\n Albumin:3.3 g/dL, LDH:298 IU/L, Ca++:8.9 mg/dL, Mg++:1.6 mg/dL, PO4:3.1\n mg/dL\n Assessment and Plan\n HEPATIC ENCEPHALOPATHY\n ELECTROLYTE & FLUID DISORDER, OTHER\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n HYPOTENSION (NOT SHOCK)\n CARDIAC ARREST\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n BACTEREMIA\n ICU Care\n Nutrition:\n Nutren Pulmonary (Full) - 12:47 AM 40 mL/hour\n Glycemic Control:\n Lines:\n Multi Lumen - 12:48 PM\n Arterial Line - 11:00 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": "2145-01-15 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 559690, "text": "Chief Complaint:\n 24 Hour Events:\n Events:\n - spoke to ID, fusobacterium is pan-sensitive and will give IV\n penicillin -> d/c zosyn\n - ENT eval for bleeding source -> no pharyngeal source\n - peripheral smear showed no evidence of DIC\n Allergies:\n Demerol (Oral) (Meperidine Hcl)\n Confusion/Delir\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 06:36 AM\n Vancomycin - 08:00 AM\n Penicillin G potassium - 04:00 AM\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 08:30 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:24 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.3\nC (99.1\n Tcurrent: 37.1\nC (98.8\n HR: 78 (63 - 85) bpm\n BP: 136/62(84) {125/57(76) - 161/81(109)} mmHg\n RR: 8 (8 - 25) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 73 Inch\n CVP: 9 (6 - 12)mmHg\n Total In:\n 4,647 mL\n 1,068 mL\n PO:\n TF:\n 637 mL\n 280 mL\n IVF:\n 2,346 mL\n 198 mL\n Blood products:\n 574 mL\n Total out:\n 6,290 mL\n 1,020 mL\n Urine:\n 5,990 mL\n 1,020 mL\n NG:\n 200 mL\n Stool:\n Drains:\n Balance:\n -1,643 mL\n 48 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 550 (500 - 550) mL\n Vt (Spontaneous): 580 (361 - 651) mL\n PS : 10 cmH2O\n RR (Set): 12\n RR (Spontaneous): 8\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 63\n PIP: 17 cmH2O\n Plateau: 13 cmH2O\n Compliance: 68.7 cmH2O/mL\n SpO2: 99%\n ABG: 7.48/45/86/31/8\n Ve: 8.1 L/min\n PaO2 / FiO2: 215\n Physical Examination\n Eyes / Conjunctiva: PERRL, opens eyes, makes eye contact\n , Ears, Nose, Throat: , Poor dentition, NG tube, trach\n (Bloody )\n Cardiovascular: (S1: Normal), (S2: Normal), No(t) S3, No(t) S4, No(t)\n Rub\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not\n assessed), has a-line\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : ,\n Rhonchorous: )\n Abdominal: Soft, Bowel sounds present, Distended, palpable fluid wave\n Neurologic: arousable to voice, opens eyes no purposeful movements,\n withdraws to pain, non-verbal\n Labs / Radiology\n 55 K/uL\n 9.6 g/dL\n 114 mg/dL\n 0.7 mg/dL\n 31 mEq/L\n 3.9 mEq/L\n 18 mg/dL\n 110 mEq/L\n 146 mEq/L\n 28.4 %\n 5.5 K/uL\n [image002.jpg]\n 03:15 AM\n 03:29 AM\n 08:58 AM\n 01:09 PM\n 01:26 PM\n 03:23 PM\n 09:24 PM\n 10:04 PM\n 03:29 AM\n 03:46 AM\n WBC\n 4.1\n 4.6\n 4.8\n 5.0\n 5.5\n Hct\n 27.8\n 27.0\n 27.0\n 28.7\n 28.4\n Plt\n 44\n 46\n 60\n 59\n 55\n Cr\n 0.6\n 0.7\n 0.7\n 0.7\n TCO2\n 30\n 32\n 34\n 34\n Glucose\n 112\n 115\n 122\n 114\n Other labs: PT / PTT / INR:16.6/46.5/1.5, CK / CKMB /\n Troponin-T:447/26/0.24, ALT / AST:58/126, Alk Phos / T Bili:95/2.8,\n Amylase / Lipase:93/30, Differential-Neuts:80.0 %, Band:0.0 %,\n Lymph:16.0 %, Mono:0.0 %, Eos:4.0 %, Lactic Acid:1.6 mmol/L,\n Albumin:3.3 g/dL, LDH:298 IU/L, Ca++:8.9 mg/dL, Mg++:1.6 mg/dL, PO4:3.1\n mg/dL\n Assessment and Plan\n This is a 63 y/o M with Hepatitis C cirrhosis, s/p PEA arrest, body\n cooling and rewarming, with Fusobacterium sepsis covering with Zosyn\n until .\n .\n # bleeding from trach site- lost 150cc intraop. surgery following,\n continue sedation to prevent movement, giving 2u platelets, given 1u\n FFP\n - will not give additional FFP since INR 1.6\n - ENT consult to eval for concern of posterior pharynx, giving\n affirm, lidocaine spray\n .\n # Respiratory/Ventilation: Pt re-intubated secondary to\n respiratory distress and inability to handle secretions. Unlikely to\n tolerate extubation given that underlying problem is inability to\n handle secretions which is unlikely to change. CXR from showed\n evidence of pulmonary edema. Patient getting trach in OR. Patient\n completed treatment for empire HAP for 5day with vanc/zosyn starting\n . Stopped vanc , continuing zosyn until sensitivities of\n fusobacterium.\n - giving Lasix 40mg IV with goal -1L\n .\n # Fusobacterium sepsis: Will treat for two-week course, awaiting\n sensitivities on Fusobacterium -> likely responsive to penicillin. Dx\n on , will need 14d course until . Covering with zosyn until\n sensitivies obtained.\n - surveillance blood cxs NTD\n .\n # thrombocytopenia\n platlets 171, now 44. Switched from H2 to\n PPI. Considering HIT vs. splenic sequestration\n - obtaining smear\n -\n # Mental Status: With slowly resolving delerium prior to this event,\n and now with unclear hypoxic insult to brain. GCS of on admission\n to ICU. Considering head CT to evaluate for anoxic brain injury\n post-cooling. Neuro eval for possible seizure. EEG neg for seizure,\n severe encephalopathy likely in setting of sedation. LP done earlier\n that was negative gram stain/culture, no whites, negative HSV PCR. Back\n to pre-code MS per wife. CT scan did not show any focal lesions.\n - patient is following commands, on propofol sedation\n - likely will need MRI in the future but can not tolerate now \n mental status/respiratory status\n - increase lactulose\n .\n # Resolved Renal Failure: Unclear etiology, likely combination of ATN\n in the setting of code and HRS. Renal following given concern for HRS.\n Off albumin, mitodrine and octreotide\n - f/u renal and liver recs\n .\n # Hypernatremia: Likely hypovolemic hypernatremia in the setting of\n recent ATN and current HRS. Corrected , free water deficit ~ 2-3L.\n - switching antibiotics to be made with D5W\n .\n # Cardiac: CE's trended post-arrest. Echo hyperdynamic, no cardiogenic\n shock. CK and Trop trended down\n - will consider repeat echo\n .\n # Cirrhosis: Hep C Cirrhosis, with concern for HRS.\n - pre-code mental status likely related to encephalopathy v. delirium\n - titrate up lactulose\n - liver recs -> non suitable for tx at this point, in the very small\n chance that pt improves could possibly be candidate in the future\n .\n # s/p Shock/PEA Arrest: After PEA, was initially hemodynamically stable\n but has had episodes of hypotension non-responsive to IVF boluses,\n levofed started, currently off. Echo showed no evidence of cardiogenic\n shock. s/p cooling and rewarming. Trended cardiac enzymes, came down\n and no evidence of cardiogenic shock on rewarmed echo.\n # Parotid mass. Incidental finding of L parotid mass on MRI, 1.6cm. --\n Will require ENT followup as outpt.\n .\n # Metabolic Acidosis: s/p arrest to tissue hypoxia. Lactates now\n normalized, now resolved.\n # Access: PIV, Central Line\n .\n # FEN: NPO for trach in OR, resume TF\n .\n # Prophylaxis: holding HSQ since elevated PTT, PPI\n .\n # Code: full\n .\n # Communication: Wife is HCP -> will readdress long-term goals today\n re: long-term prognosis\n .\n # Disposition: ICU for now.\n ICU Care\n Nutrition:\n Nutren Pulmonary (Full) - 12:47 AM 40 mL/hour\n Glycemic Control:\n Lines:\n Multi Lumen - 12:48 PM\n Arterial Line - 11:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Respiratory ", "chartdate": "2145-01-17 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 560031, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 7\n Ideal body weight: 83.5 None\n Ideal tidal volume: mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type: Not applicable\n Size: Not applicable\n Tracheostomy tube:\n Type: Standard, Cuffed, Inner Cannula\n Manufacturer: Portex\n Size: 8.0mm\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 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: Clear\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: Intermittent 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: Periodic SBT's for conditioning; Comments: Trach\n collars trial s as tolerated. Pt remained on TC yesterday for about 15\n hrs. Had some desaturations to 80's ~ 0300.resing on vent for a few\n hrs.\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n Pt was on TC yesterday for ~ 14 hrs, desaturation to 80 last night,\n Plan to resume trach collar wean this morning. RSBI was 70\n" }, { "category": "Nursing", "chartdate": "2145-01-17 00:00:00.000", "description": "Nursing Progress Note", "row_id": 560033, "text": "PMH: Pt admitted to on s/p fall for back spinal fusion. Has\n been confused since surgery according to pt's wife later developed UTI.\n Unknown cause of MS changes. ? encephalopathy vs. infection.Pt had\n resp distress, became unresponsive and went into PEA arrest on .Pt\n has been on Arctic sun.CT neg for PE or bleed.Pt was successfully\n extubated on . Reintubated . Trached . Head CT neg for any\n acute changes.\n 63 y/o M with Hepatitis C cirrhosis, s/p PEA arrest, body cooling and\n rewarming, with Fusobacterium sepsis covering with Zosyn until .\n Altered mental status (not Delirium)\n Assessment:\n More awake, however does not follow commands, tracks or tries to\n communicate. Pupils 3mm equal and reactive. Remains slightly rigid. On\n propofol sedation, possibly encephalopathic\n Action:\n Propofol d/c if agitated will try haldol or zyprexa per psych consult .\n If in pain treat pain, lactulose increased to 60 q4hr.\n Response:\n Per wife more awake, however still non communicable and does not\n follows commands.\n Plan:\n Continue top monitor patient\ns neuro status, may need MRI later on,\n meds \n Respiratory failure, acute (not ARDS/)\n Assessment:\n Remains trached and vented on PSV 50% 15/5. Bil LS clear, RRR, moderate\n amt of bloody secretions w/suctioning and around trach. Periods of low\n MV.\n Action:\n Weaned to trach mask, suction prn, trach care and frequent mouth care,\n ENT consulted.\n Response:\n pending\n Plan:\n Continue to monitor resp status, meds , need bronch later on,\n possible today. Mouth care and trach care as needed.\n Cardio: normotensive hr at 90\ns SR no ectopy, upper extr edema,\n peripheral pulses present.\n GI: abd soft distended positive for BS, on lactulose q4hr, brown loose\n stool in flexiseal. TF at goal of 60/hr tolerates it well.\n GU: clear yellow urine via foley. Adequate amnt.\n IV access: LT subclavian, LT a - line.\n Social: patient is a FULL CODE> family in to visit updated by RN and\n MD.\n Patient frequently agitated, thrashing in bed, tachypneic to 40\ns, B/P\n at 160\ns. Sedation of Propofol remains infusing.\n Respiration / Gas Exchange, Impaired\n Assessment:\n Action:\n Response:\n Plan:\n Altered mental status (not Delirium)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2145-01-10 00:00:00.000", "description": "Nursing Progress Note", "row_id": 558646, "text": "Pt admitted to on s/p fall for back spinal fusion.\n According to pt's wife, who is health care proxy, pt has been confused\n since coming out of anesthesia and later developed a UTI. According to\n floor RN, pt has had MS changes over the past few weeks where he has\n been agitated and unresponsive. Neuro and psych have consulted.\n Unknown cause of MS changes. ? encephalopathy vs. infection. pt\n had resp distress, became unresponsive and went into PEA arrest. Large\n plug suctioned from pt. Chest compressions done, 1mg Atropine given\n along with Epi. Pulse returned and pt transferred to MICU for further\n management.\n Events: pt more awake restless\n Hct 24.9 down from 31.4, repeat 26.4\n K+ 3.3 repleted w/ 60 meq KCL Via NGT\n TF @ 40cc/hr (goal). Minimal residuals. Bag on abd @ site of old tap\n for oozing.\n Altered mental status (not Delirium)\n Assessment:\n Eyes open to verbal stimuli. Localizing to pain. MAE, restless.\n Eyes-PERRLA, brisk 3mm. Not following commands.\n Action:\n . Soft wrist restraints in place. Lactulose administered x2 for\n encephalopathy. Neuro assessed frequently. Reoriented frequently.\n Neuro following. Psych following. Q 2hr turns.\n Response:\n More responsive to stimuli throughout shift. Tracking, increasing\n restlessness.\n Plan:\n Monitor neuro assessment. Assess/treat pain. Continue Lactulose.\n Hypotension (not Shock)\n Assessment:\n Rec\nd pt off prressors w/ sbp 110\ns and MAP 58-62\n Action:\n Remains off pressors, albumin given a/o.\n Response:\n b/p improving as pt becomes more awake/ restless, SBP now 130-140\n w/ MAP >70\n Plan:\n Monitor ABP, goal MAP >60. Monitor UOP/CVP. Continue to monitor QT.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Tmax 98.6 rectal. Vent AC 550x14 40% /PEEP 8. ABG this am\n 7.47/40/121. O2 sats 99-100%. LS clear/dim bilat.\n Action:\n Suctioned for sm to mod amt thick tan secretions\n Response:\n O2 sats remained 99-100%. RSBI 23 this am. Overbreathing the vent as pt\n becomes more awake/\n Plan:\n Wean vent as tolerated. Suction as needed. ? extubation\n" }, { "category": "Nursing", "chartdate": "2145-01-12 00:00:00.000", "description": "Nursing Progress Note", "row_id": 558988, "text": "Pt admitted to on s/p fall for back spinal fusion. Has been\n confused since surgery according to pt's wife later developed UTI.\n Unknown cause of MS changes. ? encephalopathy vs. infection.Pt had\n resp distress, became unresponsive and went into PEA arrest on .Pt\n has been on Arctic sun.CT neg for PE or bleed.Pt was succefully\n extubated on .But developed acute respiratory distress on that\n night with increasing agitation and confusion.Was reintubated on\n .Head CT neg for any acute changes.\n" }, { "category": "Nursing", "chartdate": "2145-01-11 00:00:00.000", "description": "Nursing Progress Note", "row_id": 558951, "text": "Altered mental status (not Delirium)\n Assessment:\n Received pt in mod agitation/restlessness; confused; not following\n simple commands nor recognizing name\n Action:\n Remained in 3pt soft restraints/side rails elevated x4; med with 0.5mg\n ativan IVp; continuous monitoring of pt for safety as well as\n respiratory compromise\n Response:\n Min effects with ativan\npt decompensated- intubated/sedated; head CT\n Plan:\n Bil wrist restraints for line safety; sedated on fent/versed gtts;\n opening eyes with calling of name; withdrawing to pain; f/u with team\n for final head Ct results\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received pt on 100% aerosol FM; pt agitated/restless and unable to keep\n pt upright in bed\ndesaturating to mid 80\ns; min secretions obtained\n with NT suctioning and deep oral suctioning; increased work of\n breathing; CXR with increased opacity to RLL\n Action:\n intubated\n Response:\n Initially maintaining saturation in low 90\ns; small amts thick blood\n tinged sputum; presently maintaining saturations >96%; ABG wnl\n Plan:\n VAp protocol; monitor ABg\ns, vent changes prn. IV antibx\n Cardiac arrest\n Assessment:\n Received succ/propofol for intubation meds ; given by anesthesia. K 3.7\n Action:\n Pt soon after developed a wide complex tachycardia\nV-tach;\n Response:\n 1 gm calcium given IVP with good results; converted to SR. Post K\n 6.3, repeat K <4.\n Plan:\n Monitor lytes; cont D5W at 125cc/hr for Hypernatremia;\n" }, { "category": "Nursing", "chartdate": "2145-01-16 00:00:00.000", "description": "Nursing Progress Note", "row_id": 559843, "text": "PMH: Pt admitted to on s/p fall for back spinal fusion. Has\n been confused since surgery according to pt's wife later developed UTI.\n Unknown cause of MS changes. ? encephalopathy vs. infection.Pt had\n resp distress, became unresponsive and went into PEA arrest on .Pt\n has been on Arctic sun.CT neg for PE or bleed.Pt was successfully\n extubated on . Reintubated . Trached . Head CT neg for any\n acute changes.\n" }, { "category": "Physician ", "chartdate": "2145-01-17 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 560144, "text": "Chief Complaint:\n 24 Hour Events:\n - started seroquel per psych\n - still remained very aggitated, needed to stay on low dose propofol\n - MRI completed yesterday:\n did not show signs of anoxic brain injury\n Allergies:\n Demerol (Oral) (Meperidine Hcl)\n Confusion/Delir\n Last dose of Antibiotics:\n Vancomycin - 08:00 AM\n Penicillin G potassium - 03:58 AM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:00 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 06:58 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.1\nC (100.6\n Tcurrent: 38.1\nC (100.6\n HR: 74 (74 - 102) bpm\n BP: 104/55(70) {104/51(68) - 175/134(129)} mmHg\n RR: 23 (16 - 33) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 73 Inch\n CVP: 12 (7 - 16)mmHg\n Total In:\n 3,610 mL\n 1,195 mL\n PO:\n TF:\n 1,312 mL\n 418 mL\n IVF:\n 643 mL\n 217 mL\n Blood products:\n Total out:\n 4,620 mL\n 370 mL\n Urine:\n 2,720 mL\n 370 mL\n NG:\n Stool:\n 850 mL\n Drains:\n Balance:\n -1,010 mL\n 825 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 443 (443 - 507) mL\n PS : 10 cmH2O\n RR (Spontaneous): 22\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 71\n PIP: 15 cmH2O\n SpO2: 96%\n ABG: ///28/\n Ve: 9.9 L/min\n Physical Examination\n Eyes / Conjunctiva: PERRL, opens eyes, makes eye contact\n , Ears, Nose, Throat: , Poor dentition, NG tube, trach\n (Bloody )\n Cardiovascular: (S1: Normal), (S2: Normal), No(t) S3, No(t) S4, No(t)\n Rub\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not\n assessed), has a-line\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : ,\n Rhonchorous: )\n Abdominal: Soft, Bowel sounds present, Distended, palpable fluid wave\n Neurologic: arousable to voice, opens eyes no purposeful movements,\n withdraws to pain, non-verbal\n Labs / Radiology\n 63 K/uL\n 9.3 g/dL\n 97 mg/dL\n 0.7 mg/dL\n 28 mEq/L\n 4.2 mEq/L\n 15 mg/dL\n 112 mEq/L\n 146 mEq/L\n 27.6 %\n 6.0 K/uL\n [image002.jpg]\n 03:23 PM\n 09:24 PM\n 10:04 PM\n 03:29 AM\n 03:46 AM\n 01:02 PM\n 01:03 PM\n 04:28 AM\n 04:45 AM\n 02:55 AM\n WBC\n 5.0\n 5.5\n 5.8\n 5.7\n 6.0\n Hct\n 28.7\n 28.4\n 27.7\n 26.3\n 27.6\n Plt\n 59\n 55\n 59\n 51\n 63\n Cr\n 0.7\n 0.7\n 0.7\n 0.7\n 0.7\n 0.7\n TCO2\n 34\n 34\n 34\n Glucose\n 115\n 122\n 114\n 110\n 114\n 97\n Other labs: PT / PTT / INR:17.3/46.8/1.6, CK / CKMB /\n Troponin-T:447/26/0.24, ALT / AST:60/136, Alk Phos / T Bili:129/2.5,\n Amylase / Lipase:38/42, Differential-Neuts:80.0 %, Band:0.0 %,\n Lymph:16.0 %, Mono:0.0 %, Eos:4.0 %, Lactic Acid:1.6 mmol/L,\n Albumin:3.3 g/dL, LDH:341 IU/L, Ca++:8.9 mg/dL, Mg++:1.6 mg/dL, PO4:2.9\n mg/dL\n Assessment and Plan\n This is a 63 y/o M who has continued AMS to point where not\n communicating at all; with hx Hepatitis C cirrhosis, s/p PEA arrest,\n body cooling and rewarming, with Fusobacterium sepsis covering with IV\n Pen G until .\n .\n # Mental Status: With slowly resolving delerium prior to this event,\n and now with unclear hypoxic insult to brain. GCS of on admission\n to ICU. Considering head CT to evaluate for anoxic brain injury\n post-cooling. Neuro eval for possible seizure. EEG neg for seizure,\n severe encephalopathy likely in setting of sedation. LP done earlier\n that was negative gram stain/culture, no whites, negative HSV PCR. Back\n to pre-code MS per wife. CT scan did not show any focal lesions. MRI\n () was unremarkable.\n - patient not responding to pain or consistently following commands,\n off propofol sedation, psych saw patient on and felt that the\n patient was very unlikely to have had NMS and recommended seroquel to\n be used for agitation.\n - d/c propofol (still intermittently using)\n - continue max dose of lactulose and rifaximin\n .\n # bleeding from trach site- Procedure done , 8-0 Portex .lost\n 150cc. Patient was given giving 2u platelets, given 1u FFP after the\n procedure. ENT was consulted on for concern of posterior pharynx\n bleed, which they did not find any evidence of.\n - bleeding has improved\n - ENT found small bite on back of tongue, but no evidence of posterior\n pharynx bleed\n .\n # Respiratory/Ventilation: Pt re-intubated secondary to\n respiratory distress and inability to handle secretions. Unlikely to\n tolerate extubation given that underlying problem is inability to\n handle secretions which is unlikely to change. CXR from showed\n evidence of pulmonary edema. Patient getting trach in OR. Patient\n completed treatment for empiric HAP for 5day with vanc/zosyn starting\n .\n - giving Lasix 40mg IV with goal -2L\n - tolerating trach collar very well\n .\n # Fusobacterium sepsis: Will treat for two-week course, awaiting\n sensitivities on Fusobacterium -> likely responsive to penicillin. Dx\n on , will need 14d course until . Covered with zosyn until\n sensitivies obtained.\n - surveillance blood cxs NTD\n - complete course of PCN on \n .\n # Thrombocytopenia\n platelets 171, slowly declining. Switched\n from H2 to PPI. Considering HIT vs. splenic sequestration\n - f/u smear\n - no current evidence of DIC\n - plts starting to improve slightly after switch from H2 to PPI\n .\n # Resolved Renal Failure: Unclear etiology, likely combination of ATN\n in the setting of code and HRS. Renal following given concern for HRS.\n Off albumin, mitodrine and octreotide\n - renal function stable\n - f/u renal and liver recs\n .\n # Hypernatremia: Likely hypovolemic hypernatremia in the setting of\n recent ATN and current HRS. Corrected , free water deficit ~ 2-3L.\n - switching antibiotics to be made with D5W\n - increase free water boluses through G-tube\n .\n # Cardiac: CE's trended post-arrest. Echo hyperdynamic, no cardiogenic\n shock. CK and Trop trended down\n - will consider repeat echo\n .\n # Cirrhosis: Hep C Cirrhosis, with concern for HRS.\n - pre-code mental status likely related to encephalopathy v. delirium\n - titrate up lactulose\n - liver recs -> non suitable for tx at this point, in the very small\n chance that pt improves could possibly be candidate in the future\n .\n # s/p Shock/PEA Arrest: After PEA, was initially hemodynamically stable\n but has had episodes of hypotension non-responsive to IVF boluses,\n levofed started, currently off. Echo showed no evidence of cardiogenic\n shock. s/p cooling and rewarming. Trended cardiac enzymes, came down\n and no evidence of cardiogenic shock on rewarmed echo.\n # Parotid mass. Incidental finding of L parotid mass on MRI, 1.6cm. --\n Will require ENT followup as outpt.\n .\n # Metabolic Acidosis: s/p arrest to tissue hypoxia. Lactates now\n normalized, now resolved.\n # Access: PIV, Central Line\n .\n # FEN: TF running at goal, 60cc/hr\n .\n # Prophylaxis: holding HSQ since elevated PTT, PPI\n .\n # Code: full\n .\n # Communication: Wife is HCP -> will readdress long-term goals re:\n long-term prognosis\n .\n # Disposition: ICU for now.\n ICU Care\n Nutrition:\n Nutren Pulmonary (Full) - 02:20 AM 60 mL/hour\n Glycemic Control:\n Lines:\n Multi Lumen - 12:48 PM\n Arterial Line - 11:00 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": "2145-01-18 00:00:00.000", "description": "Nursing Progress Note", "row_id": 560284, "text": "Pt admitted to on s/p fall for spinal fusion. Per pt\ns wife\n pt has been confused since surgery. Did have known UTI however post\n treatment continues to have MS changes. Team questioning\n encephalopathy vs. infection. pt had episode of respiratory\n distress then became unresponsive and went into PEA arrest, intubated\n during code. Pt had been on Arctic sun for post VT arrest cooling, now\n off. CT negative for PE or bleed. Pt was successfully extubated on\n , however unable to tolerate and reintubated . Trached .\n Repeat head CT negative for any acute changes.\n Altered mental status (not Delirium)\n Assessment:\n Propofol gtt off since 1100 , delirium/confusion continues, pt\n inconsistently following commands, withdraws to pain, tracks to voice,\n seems to be slowly improving.\n Action:\n Seroquel dose increased for agitation, continues on ATC lactulose,\n oriented to time and place as needed, mental status assessed\n frequently, bilateral arms and left leg restrained for pt safety.\n Response:\n Some effect from increased Seroquel dose, pt stooling moderate amounts\n of liquid, green stool, flexiseal in place, pt occasionally able to get\n legs over side rail.\n Plan:\n Continue PRN Seroquel q8h and lactulose, continue to assess mental\n status, maintain pt safety.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt on cool mist neb trach mask 70% at 10L, RR 20-30, sats >95%, lungs\n clear to rhonchrous.\n Action:\n Expectorating/suctioned for small amounts of thick, tan/pink\n secretions.\n Response:\n Able to tolerate trach mask overnight, ABG this AM 7.44/47/127.\n Plan:\n Wean O2 as tolerated by pt, pulmonary toilet, maintain sats >90%.\n" }, { "category": "Physician ", "chartdate": "2145-01-09 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 558463, "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 63 PEA arrest 2 days ago\n was in hospital for cervical cord compression - decompressed \n post-op encephalopathy - improving\n worsening renal insufficiency\n arrest on the floor\n 24 Hour Events:\n History obtained from HO\n Allergies:\n Demerol (Oral) (Meperidine Hcl)\n Confusion/Delir\n Last dose of Antibiotics:\n Ceftriaxone - 04:00 PM\n Vancomycin - 08:07 PM\n Piperacillin/Tazobactam (Zosyn) - 10:00 AM\n Infusions:\n Norepinephrine - 0.05 mcg/Kg/min\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:07 PM\n Other medications:\n Changes to medical and family history:\n warmed yesterday\n EEG severe encephalopathy\n receiving albumin for HRS\n opening eyes\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 11:28 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: 66 (55 - 73) bpm\n BP: 127/55(69) {95/48(61) - 147/60(80)} mmHg\n RR: 17 (17 - 18) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n CVP: 14 (9 - 22)mmHg\n Mixed Venous O2% Sat: 94 - 94\n Total In:\n 4,422 mL\n 1,745 mL\n PO:\n TF:\n 190 mL\n IVF:\n 4,222 mL\n 1,355 mL\n Blood products:\n 200 mL\n 100 mL\n Total out:\n 641 mL\n 865 mL\n Urine:\n 641 mL\n 865 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,781 mL\n 880 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 550 (550 - 550) mL\n RR (Set): 16\n RR (Spontaneous): 0\n PEEP: 10 cmH2O\n FiO2: 40%\n RSBI Deferred: PEEP > 10\n PIP: 20 cmH2O\n Plateau: 15 cmH2O\n Compliance: 183.3 cmH2O/mL\n SpO2: 100%\n ABG: 7.48/35/121/24/3\n Ve: 8.3 L/min\n PaO2 / FiO2: 303\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 10.3 g/dL\n 118 K/uL\n 108 mg/dL\n 2.4 mg/dL\n 24 mEq/L\n 3.9 mEq/L\n 91 mg/dL\n 104 mEq/L\n 137 mEq/L\n 31.4 %\n 16.3 K/uL\n [image002.jpg]\n 09:04 PM\n 10:13 PM\n 11:06 PM\n 11:47 PM\n 03:38 AM\n 04:01 AM\n 05:46 PM\n 03:23 AM\n 03:38 AM\n 10:22 AM\n WBC\n 26.5\n 16.3\n Hct\n 38.5\n 31.4\n Plt\n 134\n 118\n Cr\n 1.9\n 2.2\n 2.5\n 2.4\n TropT\n 0.24\n TCO2\n 28\n 27\n 27\n 25\n 27\n 27\n Glucose\n 117\n 114\n 103\n 108\n Other labs: PT / PTT / INR:18.2/70.4/1.7, CK / CKMB /\n Troponin-T:447/26/0.24, ALT / AST:119/282, Alk Phos / T Bili:154/3.3,\n Amylase / Lipase:93/30, Differential-Neuts:74.5 %, Lymph:14.1 %,\n Mono:8.1 %, Eos:2.9 %, Lactic Acid:1.3 mmol/L, LDH:635 IU/L, Ca++:7.8\n mg/dL, Mg++:3.2 mg/dL, PO4:4.4 mg/dL\n Fluid analysis / Other labs: 7.48/35/121\n Assessment and Plan\n ALTERED MENTAL STATUS (NOT DELIRIUM) - now opening eyes, continue\n lactulose,? anoxic brain injury, if no further improvement - will image\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF) - stable creatinine,\n receiving albuimin and IVF prn\n HYPOTENSION (NOT SHOCK) - received fluid, wean levophed as tolerated\n CARDIAC ARREST - thought to be due to mucuc plug/resp arrest, follow\n rhythm\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/) - continue current settings\n until he awakens\n cirrhosis - continue lactulose, receiving albumin\n effusion, infiltrate - being covered for pna with vanco and zosyn\n ICU Care\n Nutrition:\n Nutren Renal (Full) - 12:26 AM 30 mL/hour\n Glycemic Control:\n Lines:\n 20 Gauge - 11:45 AM\n Multi Lumen - 12:48 PM\n Arterial Line - 05:00 PM\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: 37 minutes\n Patient is critically ill\n" }, { "category": "Physician ", "chartdate": "2145-01-09 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 558484, "text": "Chief Complaint:\n 24 Hour Events:\n Events:\n - rewarmed per protocol\n - EEG -> Overall, the tracing indicates an extremely severe\n encephalopathy. If not due to sedating agents such as barbiturate or\n benzodiazepines, and if due to the cardiac arrest, this tracing offers\n a very poor prognosis\n - liver rec'd albumin for HRS\n - ECHO hyperdynamic\n - started TFs\n - opening eyes voice, added lactulose for hepatic encephalopathy\n Allergies:\n Demerol (Oral) (Meperidine Hcl)\n Confusion/Delir\n Last dose of Antibiotics:\n Vancomycin - 08:07 PM\n Piperacillin/Tazobactam (Zosyn) - 02:06 AM\n Infusions:\n Midazolam (Versed) - 2 mg/hour\n Norepinephrine - 0.14 mcg/Kg/min\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:07 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:49 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.4\nC (97.5\n Tcurrent: 36.4\nC (97.5\n HR: 66 (55 - 73) bpm\n BP: 147/60(80) {95/48(61) - 147/66(80)} mmHg\n RR: 18 (18 - 18) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n CVP: 15 (9 - 22)mmHg\n Mixed Venous O2% Sat: 94 - 94\n Total In:\n 4,422 mL\n 1,331 mL\n PO:\n TF:\n 112 mL\n IVF:\n 4,222 mL\n 1,119 mL\n Blood products:\n 200 mL\n 100 mL\n Total out:\n 641 mL\n 555 mL\n Urine:\n 641 mL\n 555 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,781 mL\n 776 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 550 (550 - 550) mL\n RR (Set): 18\n RR (Spontaneous): 0\n PEEP: 12 cmH2O\n FiO2: 40%\n RSBI Deferred: PEEP > 10\n PIP: 23 cmH2O\n Plateau: 20 cmH2O\n Compliance: 68.8 cmH2O/mL\n SpO2: 100%\n ABG: 7.49/35/144/24/4\n Ve: 9.4 L/min\n PaO2 / FiO2: 360\n Physical Examination\n Eyes / Conjunctiva: PERRL, dysconjugate gaze\n Head, Ears, Nose, Throat: Normocephalic, Poor dentition, Endotracheal\n tube, NG tube\n Cardiovascular: (S1: Normal), (S2: Normal), No(t) S3, No(t) S4, No(t)\n Rub\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : ,\n Rhonchorous: )\n Abdominal: Soft, Bowel sounds present, Distended, palpable fluid wave\n Neurologic: arousable to voice, opens eyes no purposeful movements,\n withdraws to pain, non-verbal\n Labs / Radiology\n 118 K/uL\n 10.3 g/dL\n 108 mg/dL\n 2.4 mg/dL\n 24 mEq/L\n 3.9 mEq/L\n 91 mg/dL\n 104 mEq/L\n 137 mEq/L\n 31.4 %\n 16.3 K/uL\n [image002.jpg]\n 06:56 PM\n 09:04 PM\n 10:13 PM\n 11:06 PM\n 11:47 PM\n 03:38 AM\n 04:01 AM\n 05:46 PM\n 03:23 AM\n 03:38 AM\n WBC\n 26.5\n 16.3\n Hct\n 38.5\n 31.4\n Plt\n 134\n 118\n Cr\n 1.9\n 2.2\n 2.5\n 2.4\n TropT\n 0.24\n TCO2\n 27\n 28\n 27\n 27\n 25\n 27\n Glucose\n 117\n 114\n 103\n 108\n Other labs: PT / PTT / INR:18.2/70.4/1.7, CK / CKMB /\n Troponin-T:447/26/0.24, ALT / AST:119/282, Alk Phos / T Bili:154/3.3,\n Amylase / Lipase:93/30, Differential-Neuts:74.5 %, Lymph:14.1 %,\n Mono:8.1 %, Eos:2.9 %, Lactic Acid:2.0 mmol/L, LDH:635 IU/L, Ca++:7.8\n mg/dL, Mg++:3.2 mg/dL, PO4:4.4 mg/dL\n Assessment and Plan\n This is a 63 y/o M with Hepatitis C cirrhosis hepatorenal syndrome, s/p\n PEA arrest, body cooling and rewarming, concern for PNA covering with\n Vanc/Zosyn.\n .\n # s/p Shock/PEA Arrest: After PEA, was initially hemodynamically stable\n but overnight had hypotension non-responsive to IVF boluses, levofed\n started, currently off. Echo showed no evidence of cardiogenic shock.\n s/p cooling and rewarming.\n - continue goal MAP >65\n .\n # Respiratory/Ventilation: Assist control. Low tidal volumes to avoid\n unneeded injury, with pH goal of above 7.25.\n - required increased FiO2 and PEEP overnight due to low oxygenation\n - likely has early ARDS, based on P:F ratio, CXR; continue ARDS net\n protocol with low Vt and high PEEPs\n .\n # Pneumonia\n on CXR has RLL infiltrate and bronch with thick yellow\n secretions, increasing leukocytosis today\n - on vanco/zosyn for HAP\n - follow up cultures\n .\n # Mental Status: With slowly resolving delerium prior to this event,\n and now with unclear hypoxic insult to brain. GCS of on admission\n to ICU. Consider cooling protocol. Head CT to evaluate for anoxic\n brain injury post-cooling. Neuro eval for possible seizure. EEG neg\n for seizure\n - off sedation\n - LP done earlier this admit that was negative gram stain/culture, no\n whites, negative HSV PCR.\n - will need head CT\n . .\n # Renal Failure: Unclear Etiology. Renal following given concern for\n HRS. given 2 days of albumin per hepatology recs.\n - likely in setting of hypoperfusion, still has some urine output. Will\n consider mitodrine and octreotride.\n - f/u renal rec's.\n .\n # Metabolic Acidosis: s/p arrest to tissue hypoxia. Continue IVF's\n and trend lactate. Will need to increase minute ventilation for CO2.\n - resolved, likely in setting of post code hypoperfusion\n - continue to trend lactate, are normalizing\n .\n # Cardiac: Anticipate some elevation in CE's post-arrest, will trend.\n Echo hyperdynamic, no cardiogenic shock.\n - CK and Trop trending downward,\n .\n # Cirrhosis: Hep C Cirrhosis, with concern for HRS.\n - pre-code mental status likely related to encephalopathy v. delerium\n .\n # Leukocytosis: Unclear etiology. Negative tap for SBP on .\n Urine growing E. Coli. Pan-culture.\n - likely from pneumonia\n .\n # Parotid mass. Incidental finding of L parotid mass on MRI, 1.6cm. --\n Will require OP ENT followup.\n .\n # Access: PIV, Central Line, arterial line.\n .\n # FEN: IVF, replete electrolytes, tube feeds resuming \n .\n # Prophylaxis: holding HSQ since elevated PTT, famotidine\n .\n # Code: full\n .\n # Communication: Wife is HCP\n .\n # Disposition: ICU for now.\n ICU Care\n Nutrition:\n Nutren Renal (Full) - 12:26 AM 20 mL/hour\n Glycemic Control:\n Lines:\n 20 Gauge - 11:45 AM\n Multi Lumen - 12:48 PM\n Arterial Line - 05:00 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": "2145-01-10 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 558653, "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 more awake this morning\n changed to PSV\n pressors weaned\n 24 Hour Events:\n Patient unable to provide history: intubated\n Allergies:\n Demerol (Oral) (Meperidine Hcl)\n Confusion/Delir\n Last dose of Antibiotics:\n Ceftriaxone - 04:00 PM\n Vancomycin - 08:00 PM\n Piperacillin/Tazobactam (Zosyn) - 09:20 AM\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 08:01 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 10:39 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.8\n Tcurrent: 36.6\nC (97.8\n HR: 79 (67 - 81) bpm\n BP: 158/60(79) {116/41(58) - 158/61(82)} mmHg\n RR: 14 (12 - 18) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n CVP: 14 (6 - 19)mmHg\n Total In:\n 3,236 mL\n 1,207 mL\n PO:\n TF:\n 576 mL\n 335 mL\n IVF:\n 2,170 mL\n 488 mL\n Blood products:\n 300 mL\n 200 mL\n Total out:\n 1,680 mL\n 1,185 mL\n Urine:\n 1,680 mL\n 1,185 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,556 mL\n 22 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): 665 (665 - 665) mL\n PS : 5 cmH2O\n RR (Set): 14\n RR (Spontaneous): 16\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 23\n PIP: 14 cmH2O\n Plateau: 16 cmH2O\n SpO2: 95%\n ABG: 7.47/40/121/28/5\n Ve: 12 L/min\n PaO2 / FiO2: 303\n Physical Examination\n General Appearance: No(t) Thin\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Clear : )\n Abdominal: Distended\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 8.9 g/dL\n 73 K/uL\n 108 mg/dL\n 2.1 mg/dL\n 28 mEq/L\n 3.3 mEq/L\n 92 mg/dL\n 106 mEq/L\n 140 mEq/L\n 26.4 %\n 6.1 K/uL\n [image002.jpg]\n 03:38 AM\n 04:01 AM\n 05:46 PM\n 03:23 AM\n 03:38 AM\n 10:22 AM\n 01:38 PM\n 02:25 AM\n 03:39 AM\n 04:55 AM\n WBC\n 26.5\n 16.3\n 6.1\n 6.1\n Hct\n 38.5\n 31.4\n 24.9\n 26.4\n Plt\n 134\n 118\n 63\n 73\n Cr\n 2.2\n 2.5\n 2.4\n 2.1\n TropT\n 0.24\n TCO2\n 25\n 27\n 27\n 28\n 30\n Glucose\n 114\n 103\n 108\n 108\n Other labs: PT / PTT / INR:18.5/67.4/1.7, CK / CKMB /\n Troponin-T:447/26/0.24, ALT / AST:76/202, Alk Phos / T Bili:134/1.5,\n Amylase / Lipase:93/30, Differential-Neuts:74.5 %, Lymph:14.1 %,\n Mono:8.1 %, Eos:2.9 %, Lactic Acid:1.0 mmol/L, LDH:635 IU/L, Ca++:8.1\n mg/dL, Mg++:3.3 mg/dL, PO4:3.1 mg/dL\n Imaging: CXR stable bilateral infiltrates\n Assessment and Plan\n ALTERED MENTAL STATUS (NOT DELIRIUM) - now following commands,\n continue lactulose,? anoxic brain injury\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF) - creatinine\n improving, receiving albuimin and IVF prn, renal requesting midodrine\n and octreotide - will start\n HYPOTENSION, SHOCK - received fluid, levophed off, follow BP\n CARDIAC ARREST - thought to be due to mucus plug/resp arrest, follow\n rhythm\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/) - RSBI 24 on PSV 5/5, will\n work towards extubation\n hospital acquired pneumonia - CXR stable, complete 10 days of abx\n cirrhosis - continue lactulose, receiving albumin\n anemia - has fallen over past few days though now stable, follow,\n guaiac\n thrombocytopenia - also stable\n ICU Care\n Nutrition:\n Nutren Renal (Full) - 12:26 AM 40 mL/hour\n Glycemic Control:\n Lines:\n Multi Lumen - 12:48 PM\n Arterial Line - 05:00 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: 39 minutes\n Patient is critically ill\n" }, { "category": "Nursing", "chartdate": "2145-01-12 00:00:00.000", "description": "Nursing Progress Note", "row_id": 558989, "text": "Pt admitted to on s/p fall for back spinal fusion. Has been\n confused since surgery according to pt's wife later developed UTI.\n Unknown cause of MS changes. ? encephalopathy vs. infection.Pt had\n resp distress, became unresponsive and went into PEA arrest on .Pt\n has been on Arctic sun.CT neg for PE or bleed.Pt was succefully\n extubated on .But developed acute respiratory distress on that\n night with increasing agitation and confusion.Was reintubated on\n .Head CT neg for any acute changes.\n Altered mental status (not Delirium)\n Assessment:\n Pt is now sedated on fent/versed.Withdraws to painful stimuli.PEARL\n size 3.\n Action:\n Cont on fent/versed.\n Response:\n Pt comfortable on current sedation.Head CT neg for bleed.\n Plan:\n Frequent neuro checks.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received the pt on ac 60%/550/18/10.LS clear with diminished\n base.Suctioned for small amount of bld stained secretions.Pt with GNR\n in bld from .\n Action:\n Weaned O2 to 40%.\n Response:\n Bld gases good on 40%.Started on vanc/zosyn.\n Plan:\n VAp protocol; monitor ABg\ns, vent changes prn. IV antibx\n" }, { "category": "Physician ", "chartdate": "2145-01-12 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 559067, "text": "Chief Complaint:\n 24 Hour Events:\n - re-intubated resp. distress and inability to protect airway\n - peri-intubation had episode of AF with RVR and aberrancy, responded\n to Ca2+ (?increased K+ use of sux for intubation)\n - replaced a-line\n - decreased albumin to 50mg daily\n - Head CT with no focal findings -> recommend MRI at later date\n Allergies:\n Demerol (Oral) (Meperidine Hcl)\n Confusion/Delir\n Last dose of Antibiotics:\n Vancomycin - 08:16 PM\n Piperacillin/Tazobactam (Zosyn) - 06:27 AM\n Infusions:\n Fentanyl - 50 mcg/hour\n Midazolam (Versed) - 2 mg/hour\n Other ICU medications:\n Lorazepam (Ativan) - 08:26 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 12 AM\n Tmax: 36.5\nC (97.7\n Tcurrent: 35.8\nC (96.4\n HR: 59 (57 - 98) bpm\n BP: 128/58(74) {111/50(66) - 212/84(126)} mmHg\n RR: 18 (18 - 27) insp/min\n SpO2: 100%\n Heart rhythm: SB (Sinus Bradycardia)\n CVP: 11 (11 - 17)mmHg\n Total In:\n 3,092 mL\n 1,043 mL\n PO:\n TF:\n 69 mL\n 191 mL\n IVF:\n 2,663 mL\n 781 mL\n Blood products:\n 200 mL\n 12 mL\n Total out:\n 2,660 mL\n 530 mL\n Urine:\n 1,960 mL\n 530 mL\n NG:\n Stool:\n 700 mL\n Drains:\n Balance:\n 432 mL\n 513 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 550 (550 - 550) mL\n RR (Set): 18\n RR (Spontaneous): 0\n PEEP: 10 cmH2O\n FiO2: 40%\n RSBI Deferred: PEEP > 10\n PIP: 26 cmH2O\n Plateau: 20 cmH2O\n SpO2: 100%\n ABG: 7.44/42/109/32/3\n Ve: 8.8 L/min\n PaO2 / FiO2: 273\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 48 K/uL\n 8.5 g/dL\n 133 mg/dL\n 1.0 mg/dL\n 32 mEq/L\n 3.6 mEq/L\n 43 mg/dL\n 110 mEq/L\n 145 mEq/L\n 26.1 %\n 5.8 K/uL\n [image002.jpg]\n 04:02 AM\n 11:01 AM\n 11:21 AM\n 01:03 PM\n 05:56 PM\n 06:13 PM\n 07:31 PM\n 09:57 PM\n 01:37 AM\n 04:43 AM\n WBC\n 5.6\n 7.7\n 5.8\n Hct\n 29.6\n 30.0\n 26.1\n Plt\n 52\n 61\n 48\n Cr\n 1.4\n 1.3\n 1.1\n 1.1\n 1.0\n 1.0\n TCO2\n 31\n 29\n 29\n 30\n 29\n Glucose\n 100\n 136\n 167\n 170\n 176\n 133\n Other labs: PT / PTT / INR:19.1/51.4/1.8, CK / CKMB /\n Troponin-T:447/26/0.24, ALT / AST:60/144, Alk Phos / T Bili:72/3.4,\n Amylase / Lipase:93/30, Differential-Neuts:84.1 %, Lymph:10.6 %,\n Mono:2.3 %, Eos:2.7 %, Lactic Acid:2.2 mmol/L, LDH:303 IU/L, Ca++:8.8\n mg/dL, Mg++:2.3 mg/dL, PO4:1.7 mg/dL\n Assessment and Plan\n ELECTROLYTE & FLUID DISORDER, OTHER\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n HYPOTENSION (NOT SHOCK)\n CARDIAC ARREST\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ICU Care\n Nutrition:\n Nutren Renal (Full) - 06:16 AM 30 mL/hour\n Glycemic Control:\n Lines:\n Multi Lumen - 12:48 PM\n Arterial Line - 11:00 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": "2145-01-12 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 559070, "text": "Chief Complaint:\n 24 Hour Events:\n - re-intubated resp. distress and inability to protect airway\n - peri-intubation had episode of AF with RVR and aberrancy, responded\n to Ca2+ (?increased K+ use of sux for intubation)\n - replaced a-line\n - decreased albumin to 50mg daily\n - Head CT with no focal findings -> recommend MRI at later date\n Allergies:\n Demerol (Oral) (Meperidine Hcl)\n Confusion/Delir\n Last dose of Antibiotics:\n Vancomycin - 08:16 PM\n Piperacillin/Tazobactam (Zosyn) - 06:27 AM\n Infusions:\n Fentanyl - 50 mcg/hour\n Midazolam (Versed) - 2 mg/hour\n Other ICU medications:\n Lorazepam (Ativan) - 08:26 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 12 AM\n Tmax: 36.5\nC (97.7\n Tcurrent: 35.8\nC (96.4\n HR: 59 (57 - 98) bpm\n BP: 128/58(74) {111/50(66) - 212/84(126)} mmHg\n RR: 18 (18 - 27) insp/min\n SpO2: 100%\n Heart rhythm: SB (Sinus Bradycardia)\n CVP: 11 (11 - 17)mmHg\n Total In:\n 3,092 mL\n 1,043 mL\n PO:\n TF:\n 69 mL\n 191 mL\n IVF:\n 2,663 mL\n 781 mL\n Blood products:\n 200 mL\n 12 mL\n Total out:\n 2,660 mL\n 530 mL\n Urine:\n 1,960 mL\n 530 mL\n NG:\n Stool:\n 700 mL\n Drains:\n Balance:\n 432 mL\n 513 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 550 (550 - 550) mL\n RR (Set): 18\n RR (Spontaneous): 0\n PEEP: 10 cmH2O\n FiO2: 40%\n RSBI Deferred: PEEP > 10\n PIP: 26 cmH2O\n Plateau: 20 cmH2O\n SpO2: 100%\n ABG: 7.44/42/109/32/3\n Ve: 8.8 L/min\n PaO2 / FiO2: 273\n Physical Examination\n Eyes / Conjunctiva: PERRL, opens eyes, makes eye contact\n , Ears, Nose, Throat: , Poor dentition, Endotracheal\n tube, NG tube\n Cardiovascular: (S1: Normal), (S2: Normal), No(t) S3, No(t) S4, No(t)\n Rub\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : ,\n Rhonchorous: )\n Abdominal: Soft, Bowel sounds present, Distended, palpable fluid wave\n Neurologic: arousable to voice, opens eyes no purposeful movements,\n withdraws to pain, non-verbal\n Labs / Radiology\n 48 K/uL\n 8.5 g/dL\n 133 mg/dL\n 1.0 mg/dL\n 32 mEq/L\n 3.6 mEq/L\n 43 mg/dL\n 110 mEq/L\n 145 mEq/L\n 26.1 %\n 5.8 K/uL\n [image002.jpg]\n 04:02 AM\n 11:01 AM\n 11:21 AM\n 01:03 PM\n 05:56 PM\n 06:13 PM\n 07:31 PM\n 09:57 PM\n 01:37 AM\n 04:43 AM\n WBC\n 5.6\n 7.7\n 5.8\n Hct\n 29.6\n 30.0\n 26.1\n Plt\n 52\n 61\n 48\n Cr\n 1.4\n 1.3\n 1.1\n 1.1\n 1.0\n 1.0\n TCO2\n 31\n 29\n 29\n 30\n 29\n Glucose\n 100\n 136\n 167\n 170\n 176\n 133\n Other labs: PT / PTT / INR:19.1/51.4/1.8, CK / CKMB /\n Troponin-T:447/26/0.24, ALT / AST:60/144, Alk Phos / T Bili:72/3.4,\n Amylase / Lipase:93/30, Differential-Neuts:84.1 %, Lymph:10.6 %,\n Mono:2.3 %, Eos:2.7 %, Lactic Acid:2.2 mmol/L, LDH:303 IU/L, Ca++:8.8\n mg/dL, Mg++:2.3 mg/dL, PO4:1.7 mg/dL\n Assessment and Plan\n ELECTROLYTE & FLUID DISORDER, OTHER\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n HYPOTENSION (NOT SHOCK)\n CARDIAC ARREST\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ICU Care\n Nutrition:\n Nutren Renal (Full) - 06:16 AM 30 mL/hour\n Glycemic Control:\n Lines:\n Multi Lumen - 12:48 PM\n Arterial Line - 11:00 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": "2145-01-16 00:00:00.000", "description": "Nursing Progress Note", "row_id": 559847, "text": "PMH: Pt admitted to on s/p fall for back spinal fusion. Has\n been confused since surgery according to pt's wife later developed UTI.\n Unknown cause of MS changes. ? encephalopathy vs. infection.Pt had\n resp distress, became unresponsive and went into PEA arrest on .Pt\n has been on Arctic sun.CT neg for PE or bleed.Pt was successfully\n extubated on . Reintubated . Trached . Head CT neg for any\n acute changes.\n 63 y/o M with Hepatitis C cirrhosis, s/p PEA arrest, body cooling and\n rewarming, with Fusobacterium sepsis covering with Zosyn until .\n Altered mental status (not Delirium)\n Assessment:\n More awake, however does not follow commands, tracks or tries to\n communicate. Pupils 3mm equal and reactive. Remains slightly rigid. On\n propofol sedation, possibly encephalopathic\n Action:\n Propofol d/c if agitated will try haldol or zyprexa per psych consult .\n If in pain treat pain, lactulose increased to 60 q4hr.\n Response:\n Per wife more awake, however still non communicable and does not\n follows commands.\n Plan:\n Continue top monitor patient\ns neuro status, may need MRI later on,\n meds \n Respiratory failure, acute (not ARDS/)\n Assessment:\n Remains trached and vented on PSV 50% 15/5. Bil LS clear, RRR, moderate\n amt of bloody secretions w/suctioning and around trach. Periods of low\n MV.\n Action:\n Weaned to trach mask, suction prn, trach care and frequent mouth care,\n ENT consulted.\n Response:\n pending\n Plan:\n Continue to monitor resp status, meds , need bronch later on,\n possible today. Mouth care and trach care as needed.\n Cardio: normotensive hr at 90\ns SR no ectopy, upper extr edema,\n peripheral pulses present.\n GI: abd soft distended positive for BS, on lactulose q4hr, brown loose\n stool in flexiseal. TF at goal of 60/hr tolerates it well.\n GU: clear yellow urine via foley. Adequate amnt.\n IV access: LT subclavian, LT a - line.\n Social: patient is a FULL CODE> family in to visit updated by RN and\n MD.\n Patient frequently agitated, thrashing in bed, tachypneic to 40\ns, B/P\n at 160\ns. Sedation of Propofol remains infusing.\n" }, { "category": "Nursing", "chartdate": "2145-01-17 00:00:00.000", "description": "Nursing Progress Note", "row_id": 560212, "text": "Pt admitted to on s/p fall for back spinal fusion. Has been\n confused since surgery according to pt's wife later developed UTI.\n Unknown cause of MS changes. ? encephalopathy vs. infection.Pt had\n resp distress, became unresponsive and went into PEA arrest on .Pt\n has been on Arctic sun.CT neg for PE or bleed.Pt was successfully\n extubated on . Reintubated . Trached . Head CT neg for any\n acute changes.\n Events day shift: Tolerated Trach mask 70% Fio2 with o2 sat\ns high 90\n Altered mental status (not Delirium)/Agitation\n Assessment:\n Off Propofol this am. Increase agitation, throwing legs over side rail,\n squirming in bed. Not following commands does not tracks or try to\n communicate. Pupils 3mm. Slightly rigid with turning. Lactulose held\n at 16:00 d/t increase stool.\n Action:\n Given Seroquel 50mg, continues on Lactulose\n Response:\n Only slightly less agitated\n Plan:\n Continue to monitor patient\ns neuro status, meds ASDIR\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Tolerated Trach mask this shift 70% fio2, O2 sat\ns high 90\ns, RR~20\n Given Lasix 40mg IV x1 with good effect. LS clear upper diminished\n lower\n Action:\n Suction prn, trach care and frequent mouth care\n Response:\n Tolerated trach mask\n Plan:\n Continue to monitor resp status, meds ASDIR, Mouth care and trach care\n as needed.\n" }, { "category": "Physician ", "chartdate": "2145-01-18 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 560275, "text": "Chief Complaint:\n 24 Hour Events:\n - propofol sedation weaned off\n - seroquel uptitrated -> pt still agitated\n - psych recommended staying away from zyprexa/haldol (?NMS) and adding\n ativan PRN (would like to limit liver disease)\n - hypernatremia not improving (tried increasing free water flushes to\n 500cc q3h) -> called , try to mix all meds in D5W\n Allergies:\n Demerol (Oral) (Meperidine Hcl)\n Confusion/Delir\n Last dose of Antibiotics:\n Penicillin G potassium - 04:00 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:07 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.6\nC (99.6\n Tcurrent: 37.3\nC (99.2\n HR: 92 (73 - 103) bpm\n BP: 153/62(89) {120/53(73) - 175/77(106)} mmHg\n RR: 25 (14 - 31) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 73 Inch\n CVP: 8 (3 - 36)mmHg\n Total In:\n 3,319 mL\n 1,111 mL\n PO:\n TF:\n 1,109 mL\n IVF:\n 639 mL\n 191 mL\n Blood products:\n Total out:\n 4,330 mL\n 550 mL\n Urine:\n 3,630 mL\n 550 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,011 mL\n 561 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n Ventilator mode: Standby\n FiO2: 70%\n SpO2: 99%\n ABG: 7.44/47/127/31/7\n PaO2 / FiO2: 254\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 55 K/uL\n 9.0 g/dL\n 90 mg/dL\n 0.6 mg/dL\n 31 mEq/L\n 3.8 mEq/L\n 15 mg/dL\n 112 mEq/L\n 148 mEq/L\n 26.9 %\n 5.0 K/uL\n [image002.jpg]\n 03:46 AM\n 01:02 PM\n 01:03 PM\n 04:28 AM\n 04:45 AM\n 02:55 AM\n 04:00 PM\n 01:01 AM\n 04:22 AM\n 05:38 AM\n WBC\n 5.8\n 5.7\n 6.0\n 5.0\n Hct\n 27.7\n 26.3\n 27.6\n 26.9\n Plt\n 59\n 51\n 63\n 55\n Cr\n 0.7\n 0.7\n 0.7\n 0.7\n 0.7\n 0.6\n TCO2\n 34\n 34\n 33\n Glucose\n 110\n 114\n 97\n 111\n 94\n 90\n Other labs: PT / PTT / INR:16.2/45.6/1.4, CK / CKMB /\n Troponin-T:447/26/0.24, ALT / AST:60/136, Alk Phos / T Bili:129/2.5,\n Amylase / Lipase:38/42, Differential-Neuts:80.0 %, Band:0.0 %,\n Lymph:16.0 %, Mono:0.0 %, Eos:4.0 %, Lactic Acid:1.6 mmol/L,\n Albumin:3.3 g/dL, LDH:341 IU/L, Ca++:8.9 mg/dL, Mg++:1.6 mg/dL, PO4:2.8\n mg/dL\n Assessment and Plan\n AEROBIC CAPACITY / ENDURANCE, IMPAIRED\n AROUSAL, ATTENTION, AND COGNITION, IMPAIRED\n RESPIRATION / GAS EXCHANGE, IMPAIRED\n HEPATIC ENCEPHALOPATHY\n ELECTROLYTE & FLUID DISORDER, OTHER\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n HYPOTENSION (NOT SHOCK)\n CARDIAC ARREST\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n BACTEREMIA\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 12:48 PM\n Arterial Line - 11:00 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": "2145-01-18 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 560276, "text": "Chief Complaint:\n 24 Hour Events:\n - propofol sedation weaned off\n - seroquel uptitrated -> pt still agitated\n - psych recommended staying away from zyprexa/haldol (?NMS) and adding\n ativan PRN (would like to limit liver disease)\n - hypernatremia not improving (tried increasing free water flushes to\n 500cc q3h) -> called , try to mix all meds in D5W\n Allergies:\n Demerol (Oral) (Meperidine Hcl)\n Confusion/Delir\n Last dose of Antibiotics:\n Penicillin G potassium - 04:00 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:07 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.6\nC (99.6\n Tcurrent: 37.3\nC (99.2\n HR: 92 (73 - 103) bpm\n BP: 153/62(89) {120/53(73) - 175/77(106)} mmHg\n RR: 25 (14 - 31) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 73 Inch\n CVP: 8 (3 - 36)mmHg\n Total In:\n 3,319 mL\n 1,111 mL\n PO:\n TF:\n 1,109 mL\n IVF:\n 639 mL\n 191 mL\n Blood products:\n Total out:\n 4,330 mL\n 550 mL\n Urine:\n 3,630 mL\n 550 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,011 mL\n 561 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n Ventilator mode: Standby\n FiO2: 70%\n SpO2: 99%\n ABG: 7.44/47/127/31/7\n PaO2 / FiO2: 254\n Physical Examination\n Eyes / Conjunctiva: PERRL, opens eyes, makes eye contact\n , Ears, Nose, Throat: , Poor dentition, NG tube, trach\n (Bloody )\n Cardiovascular: (S1: Normal), (S2: Normal), No(t) S3, No(t) S4, No(t)\n Rub\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not\n assessed), has a-line\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : ,\n Rhonchorous: )\n Abdominal: Soft, Bowel sounds present, Distended, palpable fluid wave\n Neurologic: arousable to voice, opens eyes no purposeful movements,\n withdraws to pain, non-verbal\n Labs / Radiology\n 55 K/uL\n 9.0 g/dL\n 90 mg/dL\n 0.6 mg/dL\n 31 mEq/L\n 3.8 mEq/L\n 15 mg/dL\n 112 mEq/L\n 148 mEq/L\n 26.9 %\n 5.0 K/uL\n [image002.jpg]\n 03:46 AM\n 01:02 PM\n 01:03 PM\n 04:28 AM\n 04:45 AM\n 02:55 AM\n 04:00 PM\n 01:01 AM\n 04:22 AM\n 05:38 AM\n WBC\n 5.8\n 5.7\n 6.0\n 5.0\n Hct\n 27.7\n 26.3\n 27.6\n 26.9\n Plt\n 59\n 51\n 63\n 55\n Cr\n 0.7\n 0.7\n 0.7\n 0.7\n 0.7\n 0.6\n TCO2\n 34\n 34\n 33\n Glucose\n 110\n 114\n 97\n 111\n 94\n 90\n Other labs: PT / PTT / INR:16.2/45.6/1.4, CK / CKMB /\n Troponin-T:447/26/0.24, ALT / AST:60/136, Alk Phos / T Bili:129/2.5,\n Amylase / Lipase:38/42, Differential-Neuts:80.0 %, Band:0.0 %,\n Lymph:16.0 %, Mono:0.0 %, Eos:4.0 %, Lactic Acid:1.6 mmol/L,\n Albumin:3.3 g/dL, LDH:341 IU/L, Ca++:8.9 mg/dL, Mg++:1.6 mg/dL, PO4:2.8\n mg/dL\n Assessment and Plan\n AEROBIC CAPACITY / ENDURANCE, IMPAIRED\n AROUSAL, ATTENTION, AND COGNITION, IMPAIRED\n RESPIRATION / GAS EXCHANGE, IMPAIRED\n HEPATIC ENCEPHALOPATHY\n ELECTROLYTE & FLUID DISORDER, OTHER\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n HYPOTENSION (NOT SHOCK)\n CARDIAC ARREST\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n BACTEREMIA\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 12:48 PM\n Arterial Line - 11:00 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": "2145-01-18 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 560277, "text": "Chief Complaint:\n 24 Hour Events:\n - propofol sedation weaned off\n - seroquel uptitrated -> pt still agitated\n - psych recommended staying away from zyprexa/haldol (?NMS) and adding\n ativan PRN (would like to limit liver disease)\n - hypernatremia not improving (tried increasing free water flushes to\n 500cc q3h) -> called , try to mix all meds in D5W\n Allergies:\n Demerol (Oral) (Meperidine Hcl)\n Confusion/Delir\n Last dose of Antibiotics:\n Penicillin G potassium - 04:00 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:07 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.6\nC (99.6\n Tcurrent: 37.3\nC (99.2\n HR: 92 (73 - 103) bpm\n BP: 153/62(89) {120/53(73) - 175/77(106)} mmHg\n RR: 25 (14 - 31) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 73 Inch\n CVP: 8 (3 - 36)mmHg\n Total In:\n 3,319 mL\n 1,111 mL\n PO:\n TF:\n 1,109 mL\n IVF:\n 639 mL\n 191 mL\n Blood products:\n Total out:\n 4,330 mL\n 550 mL\n Urine:\n 3,630 mL\n 550 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,011 mL\n 561 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n Ventilator mode: Standby\n FiO2: 70%\n SpO2: 99%\n ABG: 7.44/47/127/31/7\n PaO2 / FiO2: 254\n Physical Examination\n Eyes / Conjunctiva: PERRL, opens eyes, makes eye contact\n , Ears, Nose, Throat: , Poor dentition, NG tube, trach\n (Bloody )\n Cardiovascular: (S1: Normal), (S2: Normal), No(t) S3, No(t) S4, No(t)\n Rub\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not\n assessed), has a-line\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : ,\n Rhonchorous: )\n Abdominal: Soft, Bowel sounds present, Distended, palpable fluid wave\n Neurologic: arousable to voice, opens eyes no purposeful movements,\n withdraws to pain, non-verbal\n Labs / Radiology\n 55 K/uL\n 9.0 g/dL\n 90 mg/dL\n 0.6 mg/dL\n 31 mEq/L\n 3.8 mEq/L\n 15 mg/dL\n 112 mEq/L\n 148 mEq/L\n 26.9 %\n 5.0 K/uL\n [image002.jpg]\n 03:46 AM\n 01:02 PM\n 01:03 PM\n 04:28 AM\n 04:45 AM\n 02:55 AM\n 04:00 PM\n 01:01 AM\n 04:22 AM\n 05:38 AM\n WBC\n 5.8\n 5.7\n 6.0\n 5.0\n Hct\n 27.7\n 26.3\n 27.6\n 26.9\n Plt\n 59\n 51\n 63\n 55\n Cr\n 0.7\n 0.7\n 0.7\n 0.7\n 0.7\n 0.6\n TCO2\n 34\n 34\n 33\n Glucose\n 110\n 114\n 97\n 111\n 94\n 90\n Other labs: PT / PTT / INR:16.2/45.6/1.4, CK / CKMB /\n Troponin-T:447/26/0.24, ALT / AST:60/136, Alk Phos / T Bili:129/2.5,\n Amylase / Lipase:38/42, Differential-Neuts:80.0 %, Band:0.0 %,\n Lymph:16.0 %, Mono:0.0 %, Eos:4.0 %, Lactic Acid:1.6 mmol/L,\n Albumin:3.3 g/dL, LDH:341 IU/L, Ca++:8.9 mg/dL, Mg++:1.6 mg/dL, PO4:2.8\n mg/dL\n Assessment and Plan\n This is a 63 y/o M who has continued AMS to point where not\n communicating at all; with hx Hepatitis C cirrhosis, s/p PEA arrest,\n body cooling and rewarming, with Fusobacterium sepsis covering with IV\n Pen G until .\n .\n # Mental Status: With slowly resolving delerium prior to this event,\n and now with unclear hypoxic insult to brain. GCS of on admission\n to ICU. Considering head CT to evaluate for anoxic brain injury\n post-cooling. Neuro eval for possible seizure. EEG neg for seizure,\n severe encephalopathy likely in setting of sedation. LP done earlier\n that was negative gram stain/culture, no whites, negative HSV PCR. Back\n to pre-code MS per wife. CT scan did not show any focal lesions. MRI\n () was unremarkable.\n - patient not responding to pain or consistently following commands,\n off propofol sedation, psych saw patient on and felt that the\n patient was very unlikely to have had NMS and recommended seroquel to\n be used for agitation.\n - d/c propofol (still intermittently using)\n - continue max dose of lactulose and rifaximin\n .\n # bleeding from trach site- Procedure done , 8-0 Portex .lost\n 150cc. Patient was given giving 2u platelets, given 1u FFP after the\n procedure. ENT was consulted on for concern of posterior pharynx\n bleed, which they did not find any evidence of.\n - bleeding has improved\n - ENT found small bite on back of tongue, but no evidence of posterior\n pharynx bleed\n .\n # Respiratory/Ventilation: Pt re-intubated secondary to\n respiratory distress and inability to handle secretions. Unlikely to\n tolerate extubation given that underlying problem is inability to\n handle secretions which is unlikely to change. CXR from showed\n evidence of pulmonary edema. Patient getting trach in OR. Patient\n completed treatment for empiric HAP for 5day with vanc/zosyn starting\n .\n - giving Lasix 40mg IV with goal -2L\n - tolerating trach collar very well\n .\n # Fusobacterium sepsis: Will treat for two-week course, awaiting\n sensitivities on Fusobacterium -> likely responsive to penicillin. Dx\n on , will need 14d course until . Covered with zosyn until\n sensitivies obtained.\n - surveillance blood cxs NTD\n - complete course of PCN on \n .\n # Thrombocytopenia\n platelets 171, slowly declining. Switched\n from H2 to PPI. Considering HIT vs. splenic sequestration\n - f/u smear\n - no current evidence of DIC\n - plts starting to improve slightly after switch from H2 to PPI\n .\n # Resolved Renal Failure: Unclear etiology, likely combination of ATN\n in the setting of code and HRS. Renal following given concern for HRS.\n Off albumin, mitodrine and octreotide\n - renal function stable\n - f/u renal and liver recs\n .\n # Hypernatremia: Likely hypovolemic hypernatremia in the setting of\n recent ATN and current HRS. Corrected , free water deficit ~ 2-3L.\n - switching antibiotics to be made with D5W\n - increase free water boluses through G-tube\n .\n # Cardiac: CE's trended post-arrest. Echo hyperdynamic, no cardiogenic\n shock. CK and Trop trended down\n - will consider repeat echo\n .\n # Cirrhosis: Hep C Cirrhosis, with concern for HRS.\n - pre-code mental status likely related to encephalopathy v. delirium\n - titrate up lactulose\n - liver recs -> non suitable for tx at this point, in the very small\n chance that pt improves could possibly be candidate in the future\n .\n # s/p Shock/PEA Arrest: After PEA, was initially hemodynamically stable\n but has had episodes of hypotension non-responsive to IVF boluses,\n levofed started, currently off. Echo showed no evidence of cardiogenic\n shock. s/p cooling and rewarming. Trended cardiac enzymes, came down\n and no evidence of cardiogenic shock on rewarmed echo.\n # Parotid mass. Incidental finding of L parotid mass on MRI, 1.6cm. --\n Will require ENT followup as outpt.\n .\n # Metabolic Acidosis: s/p arrest to tissue hypoxia. Lactates now\n normalized, now resolved.\n # Access: PIV, Central Line\n .\n # FEN: TF running at goal, 60cc/hr\n .\n # Prophylaxis: holding HSQ since elevated PTT, PPI\n .\n # Code: full\n .\n # Communication: Wife is HCP -> will readdress long-term goals re:\n long-term prognosis\n .\n # Disposition: ICU for now.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 12:48 PM\n Arterial Line - 11:00 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": "2145-01-09 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 558473, "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 63 PEA arrest 2 days ago\n was in hospital for cervical cord compression - decompressed \n post-op encephalopathy - improving\n worsening renal insufficiency\n arrest on the floor\n stable overnight, sedation stopped this morning, opening eyes\n History obtained from HO\n Allergies:\n Demerol (Oral) (Meperidine Hcl)\n Confusion/Delir\n Last dose of Antibiotics:\n Ceftriaxone - 04:00 PM\n Vancomycin - 08:07 PM\n Piperacillin/Tazobactam (Zosyn) - 10:00 AM\n Infusions:\n Norepinephrine - 0.05 mcg/Kg/min\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:07 PM\n Other medications:\n Changes to medical and family history:\n warmed yesterday\n EEG severe encephalopathy\n receiving albumin for HRS\n opening eyes\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 11:28 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: 66 (55 - 73) bpm\n BP: 127/55(69) {95/48(61) - 147/60(80)} mmHg\n RR: 17 (17 - 18) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n CVP: 14 (9 - 22)mmHg\n Mixed Venous O2% Sat: 94 - 94\n Total In:\n 4,422 mL\n 1,745 mL\n PO:\n TF:\n 190 mL\n IVF:\n 4,222 mL\n 1,355 mL\n Blood products:\n 200 mL\n 100 mL\n Total out:\n 641 mL\n 865 mL\n Urine:\n 641 mL\n 865 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,781 mL\n 880 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 550 (550 - 550) mL\n RR (Set): 16\n RR (Spontaneous): 0\n PEEP: 10 cmH2O\n FiO2: 40%\n RSBI Deferred: PEEP > 10\n PIP: 20 cmH2O\n Plateau: 15 cmH2O\n Compliance: 183.3 cmH2O/mL\n SpO2: 100%\n ABG: 7.48/35/121/24/3\n Ve: 8.3 L/min\n PaO2 / FiO2: 303\n Physical Examination\n Comfortable on vent, opening eyes to voice, not following commands\n Hrt rrr\n Lungs scattered rhonchi\n Abd beign\n Extreme- thin\n Labs / Radiology\n 10.3 g/dL\n 118 K/uL\n 108 mg/dL\n 2.4 mg/dL\n 24 mEq/L\n 3.9 mEq/L\n 91 mg/dL\n 104 mEq/L\n 137 mEq/L\n 31.4 %\n 16.3 K/uL\n [image002.jpg]\n 09:04 PM\n 10:13 PM\n 11:06 PM\n 11:47 PM\n 03:38 AM\n 04:01 AM\n 05:46 PM\n 03:23 AM\n 03:38 AM\n 10:22 AM\n WBC\n 26.5\n 16.3\n Hct\n 38.5\n 31.4\n Plt\n 134\n 118\n Cr\n 1.9\n 2.2\n 2.5\n 2.4\n TropT\n 0.24\n TCO2\n 28\n 27\n 27\n 25\n 27\n 27\n Glucose\n 117\n 114\n 103\n 108\n Other labs: PT / PTT / INR:18.2/70.4/1.7, CK / CKMB /\n Troponin-T:447/26/0.24, ALT / AST:119/282, Alk Phos / T Bili:154/3.3,\n Amylase / Lipase:93/30, Differential-Neuts:74.5 %, Lymph:14.1 %,\n Mono:8.1 %, Eos:2.9 %, Lactic Acid:1.3 mmol/L, LDH:635 IU/L, Ca++:7.8\n mg/dL, Mg++:3.2 mg/dL, PO4:4.4 mg/dL\n Fluid analysis / Other labs: 7.48/35/121\n Assessment and Plan\n ALTERED MENTAL STATUS (NOT DELIRIUM) - now opening eyes, continue\n lactulose,? anoxic brain injury, if no further improvement - will image\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF) - stable creatinine,\n receiving albuimin and IVF prn\n HYPOTENSION, SHOCK - received fluid, wean levophed as tolerated\n CARDIAC ARREST - thought to be due to mucus plug/resp arrest, follow\n rhythm\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/) - continue current settings\n until he awakens\n cirrhosis - continue lactulose, receiving albumin\n effusion, infiltrate - being covered for pna with vanco and zosyn\n ICU Care\n Nutrition:\n Nutren Renal (Full) - 12:26 AM 30 mL/hour\n Glycemic Control:\n Lines:\n 20 Gauge - 11:45 AM\n Multi Lumen - 12:48 PM\n Arterial Line - 05:00 PM\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: 37 minutes\n Patient is critically ill\n" }, { "category": "Physician ", "chartdate": "2145-01-10 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 558621, "text": "Chief Complaint:\n 24 Hour Events:\n Events:\n - weaned levophed\n - off sedation, responding to name\n Allergies:\n Demerol (Oral) (Meperidine Hcl)\n Confusion/Delir\n Last dose of Antibiotics:\n Ceftriaxone - 04:00 PM\n Vancomycin - 08:00 PM\n Piperacillin/Tazobactam (Zosyn) - 02:00 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:16 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.8\n Tcurrent: 36.6\nC (97.8\n HR: 73 (66 - 79) bpm\n BP: 142/57(74) {116/41(58) - 149/61(79)} mmHg\n RR: 15 (12 - 18) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n CVP: 14 (6 - 16)mmHg\n Total In:\n 3,236 mL\n 646 mL\n PO:\n TF:\n 576 mL\n 218 mL\n IVF:\n 2,170 mL\n 318 mL\n Blood products:\n 300 mL\n 110 mL\n Total out:\n 1,680 mL\n 720 mL\n Urine:\n 1,680 mL\n 720 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,556 mL\n -74 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 550 (550 - 550) mL\n RR (Set): 14\n RR (Spontaneous): 0\n PEEP: 8 cmH2O\n FiO2: 40%\n RSBI: 23\n PIP: 18 cmH2O\n Plateau: 16 cmH2O\n SpO2: 99%\n ABG: 7.47/40/121/28/5\n Ve: 8.1 L/min\n PaO2 / FiO2: 303\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 73 K/uL\n 8.9 g/dL\n 108 mg/dL\n 2.1 mg/dL\n 28 mEq/L\n 3.3 mEq/L\n 92 mg/dL\n 106 mEq/L\n 140 mEq/L\n 26.4 %\n 6.1 K/uL\n [image002.jpg]\n 03:38 AM\n 04:01 AM\n 05:46 PM\n 03:23 AM\n 03:38 AM\n 10:22 AM\n 01:38 PM\n 02:25 AM\n 03:39 AM\n 04:55 AM\n WBC\n 26.5\n 16.3\n 6.1\n 6.1\n Hct\n 38.5\n 31.4\n 24.9\n 26.4\n Plt\n 134\n 118\n 63\n 73\n Cr\n 2.2\n 2.5\n 2.4\n 2.1\n TropT\n 0.24\n TCO2\n 25\n 27\n 27\n 28\n 30\n Glucose\n 114\n 103\n 108\n 108\n Other labs: PT / PTT / INR:18.5/67.4/1.7, CK / CKMB /\n Troponin-T:447/26/0.24, ALT / AST:76/202, Alk Phos / T Bili:134/1.5,\n Amylase / Lipase:93/30, Differential-Neuts:74.5 %, Lymph:14.1 %,\n Mono:8.1 %, Eos:2.9 %, Lactic Acid:1.0 mmol/L, LDH:635 IU/L, Ca++:8.1\n mg/dL, Mg++:3.3 mg/dL, PO4:3.1 mg/dL\n Assessment and Plan\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n HYPOTENSION (NOT SHOCK)\n CARDIAC ARREST\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ICU Care\n Nutrition:\n Nutren Renal (Full) - 12:26 AM 30 mL/hour\n Glycemic Control:\n Lines:\n 20 Gauge - 11:45 AM\n Multi Lumen - 12:48 PM\n Arterial Line - 05:00 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": "2145-01-10 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 558622, "text": "Chief Complaint:\n 24 Hour Events:\n Events:\n - weaned levophed\n - off sedation, responding to name\n Allergies:\n Demerol (Oral) (Meperidine Hcl)\n Confusion/Delir\n Last dose of Antibiotics:\n Ceftriaxone - 04:00 PM\n Vancomycin - 08:00 PM\n Piperacillin/Tazobactam (Zosyn) - 02:00 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:16 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.8\n Tcurrent: 36.6\nC (97.8\n HR: 73 (66 - 79) bpm\n BP: 142/57(74) {116/41(58) - 149/61(79)} mmHg\n RR: 15 (12 - 18) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n CVP: 14 (6 - 16)mmHg\n Total In:\n 3,236 mL\n 646 mL\n PO:\n TF:\n 576 mL\n 218 mL\n IVF:\n 2,170 mL\n 318 mL\n Blood products:\n 300 mL\n 110 mL\n Total out:\n 1,680 mL\n 720 mL\n Urine:\n 1,680 mL\n 720 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,556 mL\n -74 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 550 (550 - 550) mL\n RR (Set): 14\n RR (Spontaneous): 0\n PEEP: 8 cmH2O\n FiO2: 40%\n RSBI: 23\n PIP: 18 cmH2O\n Plateau: 16 cmH2O\n SpO2: 99%\n ABG: 7.47/40/121/28/5\n Ve: 8.1 L/min\n PaO2 / FiO2: 303\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 73 K/uL\n 8.9 g/dL\n 108 mg/dL\n 2.1 mg/dL\n 28 mEq/L\n 3.3 mEq/L\n 92 mg/dL\n 106 mEq/L\n 140 mEq/L\n 26.4 %\n 6.1 K/uL\n [image002.jpg]\n 03:38 AM\n 04:01 AM\n 05:46 PM\n 03:23 AM\n 03:38 AM\n 10:22 AM\n 01:38 PM\n 02:25 AM\n 03:39 AM\n 04:55 AM\n WBC\n 26.5\n 16.3\n 6.1\n 6.1\n Hct\n 38.5\n 31.4\n 24.9\n 26.4\n Plt\n 134\n 118\n 63\n 73\n Cr\n 2.2\n 2.5\n 2.4\n 2.1\n TropT\n 0.24\n TCO2\n 25\n 27\n 27\n 28\n 30\n Glucose\n 114\n 103\n 108\n 108\n Other labs: PT / PTT / INR:18.5/67.4/1.7, CK / CKMB /\n Troponin-T:447/26/0.24, ALT / AST:76/202, Alk Phos / T Bili:134/1.5,\n Amylase / Lipase:93/30, Differential-Neuts:74.5 %, Lymph:14.1 %,\n Mono:8.1 %, Eos:2.9 %, Lactic Acid:1.0 mmol/L, LDH:635 IU/L, Ca++:8.1\n mg/dL, Mg++:3.3 mg/dL, PO4:3.1 mg/dL\n Assessment and Plan\n This is a 63 y/o M with Hepatitis C cirrhosis hepatorenal syndrome, s/p\n PEA arrest, body cooling and rewarming, concern for PNA covering with\n Vanc/Zosyn.\n .\n # s/p Shock/PEA Arrest: After PEA, was initially hemodynamically stable\n but overnight had hypotension non-responsive to IVF boluses, levofed\n started, currently off. Echo showed no evidence of cardiogenic shock.\n s/p cooling and rewarming.\n - continue goal MAP >65\n .\n # Respiratory/Ventilation: Assist control. Low tidal volumes to avoid\n unneeded injury, with pH goal of above 7.25.\n - required increased FiO2 and PEEP overnight due to low oxygenation\n - likely has early ARDS, based on P:F ratio, CXR; continue ARDS net\n protocol with low Vt and high PEEPs\n .\n # Pneumonia\n on CXR has RLL infiltrate and bronch with thick yellow\n secretions, increasing leukocytosis today\n - on vanco/zosyn for HAP\n - follow up cultures\n .\n # Mental Status: With slowly resolving delerium prior to this event,\n and now with unclear hypoxic insult to brain. GCS of on admission\n to ICU. Consider cooling protocol. Head CT to evaluate for anoxic\n brain injury post-cooling. Neuro eval for possible seizure. EEG neg\n for seizure\n - off sedation\n - LP done earlier this admit that was negative gram stain/culture, no\n whites, negative HSV PCR.\n - will need head CT\n . .\n # Renal Failure: Unclear Etiology. Renal following given concern for\n HRS. given 2 days of albumin per hepatology recs.\n - likely in setting of hypoperfusion, still has some urine output. Will\n consider mitodrine and octreotride.\n - f/u renal rec's.\n .\n # Metabolic Acidosis: s/p arrest to tissue hypoxia. Continue IVF's\n and trend lactate. Will need to increase minute ventilation for CO2.\n - resolved, likely in setting of post code hypoperfusion\n - continue to trend lactate, are normalizing\n .\n # Cardiac: Anticipate some elevation in CE's post-arrest, will trend.\n Echo hyperdynamic, no cardiogenic shock.\n - CK and Trop trending downward,\n .\n # Cirrhosis: Hep C Cirrhosis, with concern for HRS.\n - pre-code mental status likely related to encephalopathy v. delerium\n .\n # Leukocytosis: Unclear etiology. Negative tap for SBP on .\n Urine growing E. Coli. Pan-culture.\n - likely from pneumonia\n .\n # Parotid mass. Incidental finding of L parotid mass on MRI, 1.6cm. --\n Will require OP ENT followup.\n .\n # Access: PIV, Central Line, arterial line.\n .\n # FEN: IVF, replete electrolytes, tube feeds resuming \n .\n # Prophylaxis: holding HSQ since elevated PTT, famotidine\n .\n # Code: full\n .\n # Communication: Wife is HCP\n .\n # Disposition: ICU for now.\n ICU Care\n Nutrition:\n Nutren Renal (Full) - 12:26 AM 30 mL/hour\n Glycemic Control:\n Lines:\n 20 Gauge - 11:45 AM\n Multi Lumen - 12:48 PM\n Arterial Line - 05:00 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": "2145-01-10 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 558623, "text": "Chief Complaint:\n 24 Hour Events:\n Events:\n - weaned levophed\n - off sedation, responding to name\n Allergies:\n Demerol (Oral) (Meperidine Hcl)\n Confusion/Delir\n Last dose of Antibiotics:\n Ceftriaxone - 04:00 PM\n Vancomycin - 08:00 PM\n Piperacillin/Tazobactam (Zosyn) - 02:00 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:16 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.8\n Tcurrent: 36.6\nC (97.8\n HR: 73 (66 - 79) bpm\n BP: 142/57(74) {116/41(58) - 149/61(79)} mmHg\n RR: 15 (12 - 18) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n CVP: 14 (6 - 16)mmHg\n Total In:\n 3,236 mL\n 646 mL\n PO:\n TF:\n 576 mL\n 218 mL\n IVF:\n 2,170 mL\n 318 mL\n Blood products:\n 300 mL\n 110 mL\n Total out:\n 1,680 mL\n 720 mL\n Urine:\n 1,680 mL\n 720 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,556 mL\n -74 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 550 (550 - 550) mL\n RR (Set): 14\n RR (Spontaneous): 0\n PEEP: 8 cmH2O\n FiO2: 40%\n RSBI: 23\n PIP: 18 cmH2O\n Plateau: 16 cmH2O\n SpO2: 99%\n ABG: 7.47/40/121/28/5\n Ve: 8.1 L/min\n PaO2 / FiO2: 303\n Physical Examination\n Eyes / Conjunctiva: PERRL, dysconjugate gaze\n Head, Ears, Nose, Throat: Normocephalic, Poor dentition, Endotracheal\n tube, NG tube\n Cardiovascular: (S1: Normal), (S2: Normal), No(t) S3, No(t) S4, No(t)\n Rub\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : ,\n Rhonchorous: )\n Abdominal: Soft, Bowel sounds present, Distended, palpable fluid wave\n Neurologic: arousable to voice, opens eyes no purposeful movements,\n withdraws to pain, non-verbal\n Labs / Radiology\n 73 K/uL\n 8.9 g/dL\n 108 mg/dL\n 2.1 mg/dL\n 28 mEq/L\n 3.3 mEq/L\n 92 mg/dL\n 106 mEq/L\n 140 mEq/L\n 26.4 %\n 6.1 K/uL\n [image002.jpg]\n 03:38 AM\n 04:01 AM\n 05:46 PM\n 03:23 AM\n 03:38 AM\n 10:22 AM\n 01:38 PM\n 02:25 AM\n 03:39 AM\n 04:55 AM\n WBC\n 26.5\n 16.3\n 6.1\n 6.1\n Hct\n 38.5\n 31.4\n 24.9\n 26.4\n Plt\n 134\n 118\n 63\n 73\n Cr\n 2.2\n 2.5\n 2.4\n 2.1\n TropT\n 0.24\n TCO2\n 25\n 27\n 27\n 28\n 30\n Glucose\n 114\n 103\n 108\n 108\n Other labs: PT / PTT / INR:18.5/67.4/1.7, CK / CKMB /\n Troponin-T:447/26/0.24, ALT / AST:76/202, Alk Phos / T Bili:134/1.5,\n Amylase / Lipase:93/30, Differential-Neuts:74.5 %, Lymph:14.1 %,\n Mono:8.1 %, Eos:2.9 %, Lactic Acid:1.0 mmol/L, LDH:635 IU/L, Ca++:8.1\n mg/dL, Mg++:3.3 mg/dL, PO4:3.1 mg/dL\n Assessment and Plan\n This is a 63 y/o M with Hepatitis C cirrhosis hepatorenal syndrome, s/p\n PEA arrest, body cooling and rewarming, concern for PNA covering with\n Vanc/Zosyn.\n .\n # s/p Shock/PEA Arrest: After PEA, was initially hemodynamically stable\n but overnight had hypotension non-responsive to IVF boluses, levofed\n started, currently off. Echo showed no evidence of cardiogenic shock.\n s/p cooling and rewarming.\n - continue goal MAP >65\n .\n # Respiratory/Ventilation: Assist control. Low tidal volumes to avoid\n unneeded injury, with pH goal of above 7.25.\n - required increased FiO2 and PEEP overnight due to low oxygenation\n - likely has early ARDS, based on P:F ratio, CXR; continue ARDS net\n protocol with low Vt and high PEEPs\n .\n # Pneumonia\n on CXR has RLL infiltrate and bronch with thick yellow\n secretions, increasing leukocytosis today\n - on vanco/zosyn for HAP\n - follow up cultures\n .\n # Mental Status: With slowly resolving delerium prior to this event,\n and now with unclear hypoxic insult to brain. GCS of on admission\n to ICU. Consider cooling protocol. Head CT to evaluate for anoxic\n brain injury post-cooling. Neuro eval for possible seizure. EEG neg\n for seizure\n - off sedation\n - LP done earlier this admit that was negative gram stain/culture, no\n whites, negative HSV PCR.\n - will need head CT\n . .\n # Renal Failure: Unclear Etiology. Renal following given concern for\n HRS. given 2 days of albumin per hepatology recs.\n - likely in setting of hypoperfusion, still has some urine output. Will\n consider mitodrine and octreotride.\n - f/u renal rec's.\n .\n # Metabolic Acidosis: s/p arrest to tissue hypoxia. Continue IVF's\n and trend lactate. Will need to increase minute ventilation for CO2.\n - resolved, likely in setting of post code hypoperfusion\n - continue to trend lactate, are normalizing\n .\n # Cardiac: Anticipate some elevation in CE's post-arrest, will trend.\n Echo hyperdynamic, no cardiogenic shock.\n - CK and Trop trending downward,\n .\n # Cirrhosis: Hep C Cirrhosis, with concern for HRS.\n - pre-code mental status likely related to encephalopathy v. delerium\n .\n # Leukocytosis: Unclear etiology. Negative tap for SBP on .\n Urine growing E. Coli. Pan-culture.\n - likely from pneumonia\n .\n # Parotid mass. Incidental finding of L parotid mass on MRI, 1.6cm. --\n Will require OP ENT followup.\n .\n # Access: PIV, Central Line, arterial line.\n .\n # FEN: IVF, replete electrolytes, tube feeds resuming \n .\n # Prophylaxis: holding HSQ since elevated PTT, famotidine\n .\n # Code: full\n .\n # Communication: Wife is HCP\n .\n # Disposition: ICU for now.\n ICU Care\n Nutrition:\n Nutren Renal (Full) - 12:26 AM 30 mL/hour\n Glycemic Control:\n Lines:\n 20 Gauge - 11:45 AM\n Multi Lumen - 12:48 PM\n Arterial Line - 05:00 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": "2145-01-10 00:00:00.000", "description": "Nursing Progress Note", "row_id": 558726, "text": "Pt admitted to on s/p fall for back spinal fusion.\n According to pt's wife, who is health care proxy, pt has been confused\n since coming out of anesthesia and later developed a UTI. According to\n floor RN, pt has had MS changes over the past few weeks where he has\n been agitated and unresponsive. Neuro and psych have consulted.\n Unknown cause of MS changes. ? encephalopathy vs. infection. pt\n had resp distress, became unresponsive and went into PEA arrest. Large\n plug suctioned from pt. Chest compressions done, 1mg Atropine given\n along with Epi. Pulse returned and pt transferred to MICU for further\n management.\n Altered mental status (not Delirium)\n Assessment:\n Pt extremely restless/agitated today; opening eyes to stimuli; w/d to\n pain; MAE; PERRLA; pt following commands inconsistently.\n Action:\n Soft wrist restraints in place for pt safety; Lactulose administered x\n 2 this shift for presumed encephalopathy; pt reoriented frequently.\n Ativan (0.25mg) given x 2 for restlessness/agitation.\n Response:\n More responsive to stimuli throughout shift; pt remains\n restless/agitated; minimal response to Ativan.\n Plan:\n Monitor neuro assessment. Assess/treat pain. Continue Lactulose.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received pt intubated on ACV this am. ABG this am 7.47/40/121. O2 sats\n 99-100%. LS clear/diminished, w/ occasional ronchi. Placed on PSV in\n early am.\n Action:\n Pt tolerated PSV well; successfully extubated ~ 14:00. C&DB encouraged;\n oral and NT sxn prn.\n Response:\n O2 sats remain > 95% on face tent. LS coarse, pt with weak/congested\n cough; however, non-productive at this time.\n Plan:\n Monitor resp status closely; oral/NT sxn prn; encourage C&DB.\n" }, { "category": "Respiratory ", "chartdate": "2145-01-12 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 559043, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 2\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Tube Type\n ETT:\n Position: 25 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 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: Blood Tinged / Thick\n Sputum source/amount: Suctioned / Small\n Ventilation Assessment\n Visual assessment of breathing pattern: Normal quiet breathing\n Plan\n Next 24-48 hours: Reduce PEEP as tolerated\n Respiratory Care Shift Procedures\n Bedside Procedures: FIO2 decreased to 40%. Latest abg results\n determined a very mild metabolic alkalosis with very good oxygenaton.\n No RSBI measured due the level of PEEP required at this time.\n Comments:\n" }, { "category": "Respiratory ", "chartdate": "2145-01-16 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 559968, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 6\n Ideal body weight: 83.5 None\n Ideal tidal volume: mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type:\n Size:\n Tracheostomy tube:\n Type: Standard, Cuffed, Inner Cannula\n Manufacturer: Portex\n Size: 8.0mm\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Tan / Thick\n Sputum source/amount: Suctioned / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Intermittent invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing, Active\n exhalations\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: trach mask trials\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n MRI\n 1530\n Bedside Procedures:\n Comments:\n Placed on trach mask in mid am, presently tolerating fine. Rr somewhat\n erratic with agitation.,nard.\n" }, { "category": "Physician ", "chartdate": "2145-01-18 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 560280, "text": "Chief Complaint:\n 24 Hour Events:\n - propofol sedation weaned off\n - seroquel uptitrated -> pt still agitated\n - psych recommended staying away from zyprexa/haldol (?NMS) and adding\n ativan PRN (would like to limit liver disease)\n - hypernatremia not improving (tried increasing free water flushes to\n 500cc q3h) -> called , try to mix all meds in D5W\n Allergies:\n Demerol (Oral) (Meperidine Hcl)\n Confusion/Delir\n Last dose of Antibiotics:\n Penicillin G potassium - 04:00 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:07 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.6\nC (99.6\n Tcurrent: 37.3\nC (99.2\n HR: 92 (73 - 103) bpm\n BP: 153/62(89) {120/53(73) - 175/77(106)} mmHg\n RR: 25 (14 - 31) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 73 Inch\n CVP: 8 (3 - 36)mmHg\n Total In:\n 3,319 mL\n 1,111 mL\n PO:\n TF:\n 1,109 mL\n IVF:\n 639 mL\n 191 mL\n Blood products:\n Total out:\n 4,330 mL\n 550 mL\n Urine:\n 3,630 mL\n 550 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,011 mL\n 561 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n Ventilator mode: Standby\n FiO2: 70%\n SpO2: 99%\n ABG: 7.44/47/127/31/7\n PaO2 / FiO2: 254\n Physical Examination\n Eyes / Conjunctiva: PERRL, opens eyes, makes eye contact\n , Ears, Nose, Throat: , Poor dentition, NG tube, trach\n (Bloody )\n Cardiovascular: (S1: Normal), (S2: Normal), No(t) S3, No(t) S4, No(t)\n Rub\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not\n assessed), has a-line\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : ,\n Rhonchorous: )\n Abdominal: Soft, Bowel sounds present, Distended, palpable fluid wave\n Neurologic: arousable to voice, opens eyes no purposeful movements,\n withdraws to pain, non-verbal\n Labs / Radiology\n 55 K/uL\n 9.0 g/dL\n 90 mg/dL\n 0.6 mg/dL\n 31 mEq/L\n 3.8 mEq/L\n 15 mg/dL\n 112 mEq/L\n 148 mEq/L\n 26.9 %\n 5.0 K/uL\n [image002.jpg]\n 03:46 AM\n 01:02 PM\n 01:03 PM\n 04:28 AM\n 04:45 AM\n 02:55 AM\n 04:00 PM\n 01:01 AM\n 04:22 AM\n 05:38 AM\n WBC\n 5.8\n 5.7\n 6.0\n 5.0\n Hct\n 27.7\n 26.3\n 27.6\n 26.9\n Plt\n 59\n 51\n 63\n 55\n Cr\n 0.7\n 0.7\n 0.7\n 0.7\n 0.7\n 0.6\n TCO2\n 34\n 34\n 33\n Glucose\n 110\n 114\n 97\n 111\n 94\n 90\n Other labs: PT / PTT / INR:16.2/45.6/1.4, CK / CKMB /\n Troponin-T:447/26/0.24, ALT / AST:60/136, Alk Phos / T Bili:129/2.5,\n Amylase / Lipase:38/42, Differential-Neuts:80.0 %, Band:0.0 %,\n Lymph:16.0 %, Mono:0.0 %, Eos:4.0 %, Lactic Acid:1.6 mmol/L,\n Albumin:3.3 g/dL, LDH:341 IU/L, Ca++:8.9 mg/dL, Mg++:1.6 mg/dL, PO4:2.8\n mg/dL\n Assessment and Plan\n This is a 63 y/o M who has continued AMS to point where not\n communicating at all; with hx Hepatitis C cirrhosis, s/p PEA arrest,\n body cooling and rewarming, with Fusobacterium sepsis covering with IV\n Pen G until .\n .\n # Mental Status: With slowly resolving delerium prior to this event,\n and now with unclear hypoxic insult to brain. GCS of on admission\n to ICU. Considering head CT to evaluate for anoxic brain injury\n post-cooling. Neuro eval for possible seizure. EEG neg for seizure,\n severe encephalopathy likely in setting of sedation. LP done earlier\n that was negative gram stain/culture, no whites, negative HSV PCR. Back\n to pre-code MS per wife. CT scan did not show any focal lesions. MRI\n () was unremarkable.\n - patient not responding to pain or consistently following commands,\n off propofol sedation, psych saw patient on and felt that the\n patient was very unlikely to have had NMS and recommended seroquel to\n be used for agitation.\n - d/c propofol (still intermittently using)\n - continue max dose of lactulose and rifaximin\n .\n # bleeding from trach site- Procedure done , 8-0 Portex .lost\n 150cc. Patient was given giving 2u platelets, given 1u FFP after the\n procedure. ENT was consulted on for concern of posterior pharynx\n bleed, which they did not find any evidence of.\n - bleeding has improved\n - ENT found small bite on back of tongue, but no evidence of posterior\n pharynx bleed\n .\n # Respiratory/Ventilation: Pt re-intubated secondary to\n respiratory distress and inability to handle secretions. Unlikely to\n tolerate extubation given that underlying problem is inability to\n handle secretions which is unlikely to change. CXR from showed\n evidence of pulmonary edema. Patient getting trach in OR. Patient\n completed treatment for empiric HAP for 5day with vanc/zosyn starting\n .\n - giving Lasix 40mg IV with goal -2L\n - tolerating trach collar very well\n .\n # Fusobacterium sepsis: Will treat for two-week course, awaiting\n sensitivities on Fusobacterium -> likely responsive to penicillin. Dx\n on , will need 14d course until . Covered with zosyn until\n sensitivies obtained.\n - surveillance blood cxs NTD\n - complete course of PCN on \n .\n # Thrombocytopenia\n platelets 171, slowly declining. Switched\n from H2 to PPI. Considering HIT vs. splenic sequestration\n - f/u smear\n - no current evidence of DIC\n - plts starting to improve slightly after switch from H2 to PPI\n .\n # Resolved Renal Failure: Unclear etiology, likely combination of ATN\n in the setting of code and HRS. Renal following given concern for HRS.\n Off albumin, mitodrine and octreotide\n - renal function stable\n - f/u renal and liver recs\n .\n # Hypernatremia: Likely hypovolemic hypernatremia in the setting of\n recent ATN and current HRS. Corrected , free water deficit ~ 2-3L.\n - switching antibiotics to be made with D5W\n - increase free water boluses through G-tube\n .\n # Cardiac: CE's trended post-arrest. Echo hyperdynamic, no cardiogenic\n shock. CK and Trop trended down\n - will consider repeat echo\n .\n # Cirrhosis: Hep C Cirrhosis, with concern for HRS.\n - pre-code mental status likely related to encephalopathy v. delirium\n - titrate up lactulose\n - liver recs -> non suitable for tx at this point, in the very small\n chance that pt improves could possibly be candidate in the future\n .\n # s/p Shock/PEA Arrest: After PEA, was initially hemodynamically stable\n but has had episodes of hypotension non-responsive to IVF boluses,\n levofed started, currently off. Echo showed no evidence of cardiogenic\n shock. s/p cooling and rewarming. Trended cardiac enzymes, came down\n and no evidence of cardiogenic shock on rewarmed echo.\n # Parotid mass. Incidental finding of L parotid mass on MRI, 1.6cm. --\n Will require ENT followup as outpt.\n .\n # Metabolic Acidosis: s/p arrest to tissue hypoxia. Lactates now\n normalized, now resolved.\n # Access: PIV, Central Line\n .\n # FEN: TF running at goal, 60cc/hr\n .\n # Prophylaxis: holding HSQ since elevated PTT, PPI\n .\n # Code: full\n .\n # Communication: Wife is HCP -> will readdress long-term goals re:\n long-term prognosis\n .\n # Disposition: ICU for now.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 12:48 PM\n Arterial Line - 11:00 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": "2145-01-09 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 558427, "text": "Chief Complaint:\n 24 Hour Events:\n Events:\n - rewarmed per protocol\n - EEG -> Overall, the tracing indicates an extremely severe\n encephalopathy. If not due to sedating agents such as barbiturate or\n benzodiazepines, and if due to the cardiac arrest, this tracing offers\n a very poor prognosis\n - liver rec'd albumin for HRS\n - ECHO hyperdynamic\n - started TFs\n Allergies:\n Demerol (Oral) (Meperidine Hcl)\n Confusion/Delir\n Last dose of Antibiotics:\n Ceftriaxone - 04:00 PM\n Vancomycin - 08:07 PM\n Piperacillin/Tazobactam (Zosyn) - 02:06 AM\n Infusions:\n Midazolam (Versed) - 2 mg/hour\n Norepinephrine - 0.14 mcg/Kg/min\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:07 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:49 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.4\nC (97.5\n Tcurrent: 36.4\nC (97.5\n HR: 66 (55 - 73) bpm\n BP: 147/60(80) {95/48(61) - 147/66(80)} mmHg\n RR: 18 (18 - 18) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n CVP: 15 (9 - 22)mmHg\n Mixed Venous O2% Sat: 94 - 94\n Total In:\n 4,422 mL\n 1,331 mL\n PO:\n TF:\n 112 mL\n IVF:\n 4,222 mL\n 1,119 mL\n Blood products:\n 200 mL\n 100 mL\n Total out:\n 641 mL\n 555 mL\n Urine:\n 641 mL\n 555 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,781 mL\n 776 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 550 (550 - 550) mL\n RR (Set): 18\n RR (Spontaneous): 0\n PEEP: 12 cmH2O\n FiO2: 40%\n RSBI Deferred: PEEP > 10\n PIP: 23 cmH2O\n Plateau: 20 cmH2O\n Compliance: 68.8 cmH2O/mL\n SpO2: 100%\n ABG: 7.49/35/144/24/4\n Ve: 9.4 L/min\n PaO2 / FiO2: 360\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 118 K/uL\n 10.3 g/dL\n 108 mg/dL\n 2.4 mg/dL\n 24 mEq/L\n 3.9 mEq/L\n 91 mg/dL\n 104 mEq/L\n 137 mEq/L\n 31.4 %\n 16.3 K/uL\n [image002.jpg]\n 06:56 PM\n 09:04 PM\n 10:13 PM\n 11:06 PM\n 11:47 PM\n 03:38 AM\n 04:01 AM\n 05:46 PM\n 03:23 AM\n 03:38 AM\n WBC\n 26.5\n 16.3\n Hct\n 38.5\n 31.4\n Plt\n 134\n 118\n Cr\n 1.9\n 2.2\n 2.5\n 2.4\n TropT\n 0.24\n TCO2\n 27\n 28\n 27\n 27\n 25\n 27\n Glucose\n 117\n 114\n 103\n 108\n Other labs: PT / PTT / INR:18.2/70.4/1.7, CK / CKMB /\n Troponin-T:447/26/0.24, ALT / AST:119/282, Alk Phos / T Bili:154/3.3,\n Amylase / Lipase:93/30, Differential-Neuts:74.5 %, Lymph:14.1 %,\n Mono:8.1 %, Eos:2.9 %, Lactic Acid:2.0 mmol/L, LDH:635 IU/L, Ca++:7.8\n mg/dL, Mg++:3.2 mg/dL, PO4:4.4 mg/dL\n Assessment and Plan\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n HYPOTENSION (NOT SHOCK)\n CARDIAC ARREST\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ICU Care\n Nutrition:\n Nutren Renal (Full) - 12:26 AM 20 mL/hour\n Glycemic Control:\n Lines:\n 20 Gauge - 11:45 AM\n Multi Lumen - 12:48 PM\n Arterial Line - 05:00 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": "2145-01-09 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 558428, "text": "Chief Complaint:\n 24 Hour Events:\n Events:\n - rewarmed per protocol\n - EEG -> Overall, the tracing indicates an extremely severe\n encephalopathy. If not due to sedating agents such as barbiturate or\n benzodiazepines, and if due to the cardiac arrest, this tracing offers\n a very poor prognosis\n - liver rec'd albumin for HRS\n - ECHO hyperdynamic\n - started TFs\n Allergies:\n Demerol (Oral) (Meperidine Hcl)\n Confusion/Delir\n Last dose of Antibiotics:\n Ceftriaxone - 04:00 PM\n Vancomycin - 08:07 PM\n Piperacillin/Tazobactam (Zosyn) - 02:06 AM\n Infusions:\n Midazolam (Versed) - 2 mg/hour\n Norepinephrine - 0.14 mcg/Kg/min\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:07 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:49 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.4\nC (97.5\n Tcurrent: 36.4\nC (97.5\n HR: 66 (55 - 73) bpm\n BP: 147/60(80) {95/48(61) - 147/66(80)} mmHg\n RR: 18 (18 - 18) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n CVP: 15 (9 - 22)mmHg\n Mixed Venous O2% Sat: 94 - 94\n Total In:\n 4,422 mL\n 1,331 mL\n PO:\n TF:\n 112 mL\n IVF:\n 4,222 mL\n 1,119 mL\n Blood products:\n 200 mL\n 100 mL\n Total out:\n 641 mL\n 555 mL\n Urine:\n 641 mL\n 555 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,781 mL\n 776 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 550 (550 - 550) mL\n RR (Set): 18\n RR (Spontaneous): 0\n PEEP: 12 cmH2O\n FiO2: 40%\n RSBI Deferred: PEEP > 10\n PIP: 23 cmH2O\n Plateau: 20 cmH2O\n Compliance: 68.8 cmH2O/mL\n SpO2: 100%\n ABG: 7.49/35/144/24/4\n Ve: 9.4 L/min\n PaO2 / FiO2: 360\n Physical Examination\n Eyes / Conjunctiva: PERRL, dysconjugate gaze\n Head, Ears, Nose, Throat: Normocephalic, Poor dentition, Endotracheal\n tube, NG tube\n Cardiovascular: (S1: Normal), (S2: Normal), No(t) S3, No(t) S4, No(t)\n Rub\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : ,\n Rhonchorous: )\n Abdominal: Soft, Bowel sounds present, Distended, palpable fluid wave\n Extremities: Right: Absent, Left: Absent\n Skin: Not assessed\n Neurologic: No(t) Attentive, No(t) Follows simple commands, Responds\n to: Noxious stimuli, Movement: Not assessed, Tone: Not assessed,\n Patient not arousable to voice, no purposeful movements, withdraws to\n pain, non-verbal\n Labs / Radiology\n 118 K/uL\n 10.3 g/dL\n 108 mg/dL\n 2.4 mg/dL\n 24 mEq/L\n 3.9 mEq/L\n 91 mg/dL\n 104 mEq/L\n 137 mEq/L\n 31.4 %\n 16.3 K/uL\n [image002.jpg]\n 06:56 PM\n 09:04 PM\n 10:13 PM\n 11:06 PM\n 11:47 PM\n 03:38 AM\n 04:01 AM\n 05:46 PM\n 03:23 AM\n 03:38 AM\n WBC\n 26.5\n 16.3\n Hct\n 38.5\n 31.4\n Plt\n 134\n 118\n Cr\n 1.9\n 2.2\n 2.5\n 2.4\n TropT\n 0.24\n TCO2\n 27\n 28\n 27\n 27\n 25\n 27\n Glucose\n 117\n 114\n 103\n 108\n Other labs: PT / PTT / INR:18.2/70.4/1.7, CK / CKMB /\n Troponin-T:447/26/0.24, ALT / AST:119/282, Alk Phos / T Bili:154/3.3,\n Amylase / Lipase:93/30, Differential-Neuts:74.5 %, Lymph:14.1 %,\n Mono:8.1 %, Eos:2.9 %, Lactic Acid:2.0 mmol/L, LDH:635 IU/L, Ca++:7.8\n mg/dL, Mg++:3.2 mg/dL, PO4:4.4 mg/dL\n Assessment and Plan\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n HYPOTENSION (NOT SHOCK)\n CARDIAC ARREST\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ICU Care\n Nutrition:\n Nutren Renal (Full) - 12:26 AM 20 mL/hour\n Glycemic Control:\n Lines:\n 20 Gauge - 11:45 AM\n Multi Lumen - 12:48 PM\n Arterial Line - 05:00 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": "2145-01-09 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 558429, "text": "Chief Complaint:\n 24 Hour Events:\n Events:\n - rewarmed per protocol\n - EEG -> Overall, the tracing indicates an extremely severe\n encephalopathy. If not due to sedating agents such as barbiturate or\n benzodiazepines, and if due to the cardiac arrest, this tracing offers\n a very poor prognosis\n - liver rec'd albumin for HRS\n - ECHO hyperdynamic\n - started TFs\n Allergies:\n Demerol (Oral) (Meperidine Hcl)\n Confusion/Delir\n Last dose of Antibiotics:\n Ceftriaxone - 04:00 PM\n Vancomycin - 08:07 PM\n Piperacillin/Tazobactam (Zosyn) - 02:06 AM\n Infusions:\n Midazolam (Versed) - 2 mg/hour\n Norepinephrine - 0.14 mcg/Kg/min\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:07 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:49 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.4\nC (97.5\n Tcurrent: 36.4\nC (97.5\n HR: 66 (55 - 73) bpm\n BP: 147/60(80) {95/48(61) - 147/66(80)} mmHg\n RR: 18 (18 - 18) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n CVP: 15 (9 - 22)mmHg\n Mixed Venous O2% Sat: 94 - 94\n Total In:\n 4,422 mL\n 1,331 mL\n PO:\n TF:\n 112 mL\n IVF:\n 4,222 mL\n 1,119 mL\n Blood products:\n 200 mL\n 100 mL\n Total out:\n 641 mL\n 555 mL\n Urine:\n 641 mL\n 555 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,781 mL\n 776 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 550 (550 - 550) mL\n RR (Set): 18\n RR (Spontaneous): 0\n PEEP: 12 cmH2O\n FiO2: 40%\n RSBI Deferred: PEEP > 10\n PIP: 23 cmH2O\n Plateau: 20 cmH2O\n Compliance: 68.8 cmH2O/mL\n SpO2: 100%\n ABG: 7.49/35/144/24/4\n Ve: 9.4 L/min\n PaO2 / FiO2: 360\n Physical Examination\n Eyes / Conjunctiva: PERRL, dysconjugate gaze\n Head, Ears, Nose, Throat: Normocephalic, Poor dentition, Endotracheal\n tube, NG tube\n Cardiovascular: (S1: Normal), (S2: Normal), No(t) S3, No(t) S4, No(t)\n Rub\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : ,\n Rhonchorous: )\n Abdominal: Soft, Bowel sounds present, Distended, palpable fluid wave\n Extremities: Right: Absent, Left: Absent\n Skin: Not assessed\n Neurologic: No(t) Attentive, No(t) Follows simple commands, Responds\n to: Noxious stimuli, Movement: Not assessed, Tone: Not assessed,\n Patient not arousable to voice, no purposeful movements, withdraws to\n pain, non-verbal\n Labs / Radiology\n 118 K/uL\n 10.3 g/dL\n 108 mg/dL\n 2.4 mg/dL\n 24 mEq/L\n 3.9 mEq/L\n 91 mg/dL\n 104 mEq/L\n 137 mEq/L\n 31.4 %\n 16.3 K/uL\n [image002.jpg]\n 06:56 PM\n 09:04 PM\n 10:13 PM\n 11:06 PM\n 11:47 PM\n 03:38 AM\n 04:01 AM\n 05:46 PM\n 03:23 AM\n 03:38 AM\n WBC\n 26.5\n 16.3\n Hct\n 38.5\n 31.4\n Plt\n 134\n 118\n Cr\n 1.9\n 2.2\n 2.5\n 2.4\n TropT\n 0.24\n TCO2\n 27\n 28\n 27\n 27\n 25\n 27\n Glucose\n 117\n 114\n 103\n 108\n Other labs: PT / PTT / INR:18.2/70.4/1.7, CK / CKMB /\n Troponin-T:447/26/0.24, ALT / AST:119/282, Alk Phos / T Bili:154/3.3,\n Amylase / Lipase:93/30, Differential-Neuts:74.5 %, Lymph:14.1 %,\n Mono:8.1 %, Eos:2.9 %, Lactic Acid:2.0 mmol/L, LDH:635 IU/L, Ca++:7.8\n mg/dL, Mg++:3.2 mg/dL, PO4:4.4 mg/dL\n Assessment and Plan\n This is a 63 y/o M with Hepatitis C cirrhosis, a to ICU w/ PEA arrest\n to mucous plug.\n .\n # Shock/PEA Arrest: Witness arrest to mucous plug.\n - initially hemodynamically stable\n - overnight with repositioning had hypotension non-responsive to IVF\n boluses, levofed started. Etiology of hypotension is cardiogenic shock\n s/p PEA vs. septic shock secondary to pneumonia\n - check central venous O2 today; if high, likely in septic shock, would\n continue levofed; if low, could consider adding extra inotropic pressor\n like dopamine\n - echo today if possible over arctic sun suit\n - continue goal MAP >65\n .\n # Respiratory/Ventilation: Assist control. Low tidal volumes to avoid\n unneeded injury, with pH goal of above 7.25.\n - required increased FiO2 and PEEP overnight due to low oxygenation\n - likely has early ARDS, based on P:F ratio, CXR; continue ARDS net\n protocol with low Vt and high PEEPs\n .\n # Pneumonia\n on CXR has RLL infiltrate and bronch with thick yellow\n secretions, increasing leukocytosis today\n - on vanco/zosyn for HAP; add double coverage of GN with cipro after\n checking EKG for QT prolongation this morning\n - follow up cultures\n .\n # Neuro: With slowly resolving delerium prior to this event, and now\n with unclear hypoxic insult to brain. GCS of on admission to ICU.\n Consider cooling protocol. Head CT to evaluate for anoxic brain injury\n post-cooling. Neuro eval for possible seizure.\n - Continue cooling protocol, will rewarm around noon today\n - Low dose fentanyl/versed for sedation for now; failed trial of\n propofol overnight.\n - LP done earlier this admit that was negative gram stain/culture, no\n whites, negative HSV PCR.\n - EEG prelim report neg for seizure, f/u final read\n - head CT after warmed\n .\n .\n # Renal Failure: Unclear Etiology. Renal following given concern for\n HRS.\n - likely in setting of hypoperfusion, still has some urine output\n - avoid fluid boluses if possible per renal recs\n - Send urine lytes, repeat Ua post-arrest\n - Appreciate renal rec's.\n .\n # Metabolic Acidosis: s/p arrest to tissue hypoxia. Continue IVF's\n and trend lactate. Will need to increase minute ventilation for CO2.\n - resolved, likely in setting of post code hypoperfusion\n - continue to trend lactate, are normalizing\n .\n # Cardiac: Anticipate some elevation in CE's post-arrest, will trend.\n - CK and Trop trending downward,\n - echo today if possible to evaluate for function post PEA\n .\n # Cirrhosis: Hep C Cirrhosis, with concern for HRS.\n - Appreciate liver rec's, no tx at this time\n - pre-code mental status likely related to encephalopathy v. delerium\n .\n # Leukocytosis: Unclear etiology. Negative tap for SBP on .\n Urine growing E. Coli. Pan-culture.\n - likely from pneumonia\n .\n # Parotid mass. Incidental finding of L parotid mass on MRI, 1.6cm. --\n Will require OP ENT followup.\n .\n # Access: PIV, Central Line, arterial line.\n .\n # FEN: IVF, replete electrolytes, tube feeds after rewarming\n .\n # Prophylaxis: Subcutaneous heparin, famotidine\n .\n # Code: full\n .\n # Communication: Wife is HCP\n .\n # Disposition: ICU for now.\n ICU Care\n Nutrition:\n Nutren Renal (Full) - 12:26 AM 20 mL/hour\n Glycemic Control:\n Lines:\n 20 Gauge - 11:45 AM\n Multi Lumen - 12:48 PM\n Arterial Line - 05:00 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": "2145-01-12 00:00:00.000", "description": "Nursing Progress Note", "row_id": 559210, "text": "Synopsis per prior nursing note:\n Pt admitted to on s/p fall for back spinal fusion. Has been\n confused since surgery according to pt's wife later developed UTI.\n Unknown cause of MS changes. ? encephalopathy vs. infection.Pt had\n resp distress, became unresponsive and went into PEA arrest on .Pt\n has been on Arctic sun.CT neg for PE or bleed.Pt was succefully\n extubated on .But developed acute respiratory distress on that\n night with increasing agitation and confusion.Was reintubated on\n .Head CT neg for any acute changes.\n Altered mental status (not Delirium)\n Assessment:\n Arouses to strong stimuli. Not following commands. Occasionally has\n non-purposeful movements of upper and lower extremities. At times\n becomes agitated (pulling arms toward face, lifting legs and moving\n them towards edge of bed, fighting vent).\n Action:\n Sedation turned off @0800. Given bolus sedation for agitation.\n Reorientation attempted frequently. Continued on lactulose TID.\n Response:\n Becomes less agitated w/ bolus sedation.\n Plan:\n Continue neuro checks. Continue to reorient. Bolus sedation PRN.\n Continue lactulose.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Vent settings CMV 18/550/40%/PEEP10. LS clear w/ diminished bases.\n Action:\n PEEP decreased to 8. Continued on vanco/zosyn. Suctioned small amt of\n blood tinged secretions. Frequent position changes. Chest PT done.\n Response:\n Appears comfortable on vent settings. O2 sats 98-100%.\n Plan:\n Wean vent as tolerated. Suction as needed. Continue chest PT. Continue\n antibiotics. ?trach Thursday.\n Electrolyte & fluid disorder, other\n Assessment:\n K 3.6. Phos 1.7.\n Action:\n Given 2 pks of neutra phos and 20mEq potassium IV.\n Response:\n Repeat K 3.9, phos 1.6 (Intern aware).\n Plan:\n Monitor electrolytes.\n" }, { "category": "Nursing", "chartdate": "2145-01-12 00:00:00.000", "description": "Nursing Progress Note", "row_id": 559056, "text": "Pt admitted to on s/p fall for back spinal fusion. Has been\n confused since surgery according to pt's wife later developed UTI.\n Unknown cause of MS changes. ? encephalopathy vs. infection.Pt had\n resp distress, became unresponsive and went into PEA arrest on .Pt\n has been on Arctic sun.CT neg for PE or bleed.Pt was succefully\n extubated on .But developed acute respiratory distress on that\n night with increasing agitation and confusion.Was reintubated on\n .Head CT neg for any acute changes.\n Altered mental status (not Delirium)\n Assessment:\n Pt is now sedated on fent/versed.Withdraws to painful stimuli.PEARL\n size 3.\n Action:\n Cont on fent/versed.\n Response:\n Pt comfortable on current sedation.Head CT neg for bleed.\n Plan:\n Frequent neuro checks.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received the pt on ac 60%/550/18/10.LS clear with diminished\n base.Suctioned for small amount of bld stained secretions.Pt with GNR\n in bld from .\n Action:\n Weaned O2 to 40%.\n Response:\n Bld gases good on 40%.Started on vanc/zosyn.\n Plan:\n VAp protocol; monitor ABg\ns, vent changes prn. IV antibx\n Electrolyte & fluid disorder, other\n Assessment:\n Sodium 146.\n Action:\n Pt getting D5W 175cc/hr.\n Response:\n Sodium this am 145.\n Plan:\n Recheck lytes.\n" }, { "category": "Physician ", "chartdate": "2145-01-17 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 560136, "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 63 yo man with HCV cirrhosis. s/p PEA arrest post laminectomy, with\n persistently poor MS. MRI yesterday unremarkable. Required placement\n back on vent overnight for desaturation for 4 hours, now back on TM.\n 24 Hour Events:\n Allergies:\n Demerol (Oral) (Meperidine Hcl)\n Confusion/Delir\n Last dose of Antibiotics:\n Penicillin G potassium - 08:30 AM\n Infusions:\n Propofol - 10 mcg/Kg/min\n Other ICU medications:\n Other medications:\n folate\n thiamine\n vitamin D\n atrovent\n protonix\n levoxyl\n pen G\n lactulose\n rifaxamin\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 Heme / Lymph: Anemia\n Neurologic: No(t) Numbness / tingling, No(t) Seizure\n Psychiatric / Sleep: Agitated\n Pain: No pain / appears comfortable\n Flowsheet Data as of 11:35 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.1\nC (100.6\n Tcurrent: 37.3\nC (99.2\n HR: 81 (73 - 102) bpm\n BP: 145/64(87) {104/51(68) - 175/134(129)} mmHg\n RR: 26 (16 - 33) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 73 Inch\n CVP: 11 (7 - 15)mmHg\n Total In:\n 3,610 mL\n 1,732 mL\n PO:\n TF:\n 1,312 mL\n 690 mL\n IVF:\n 643 mL\n 362 mL\n Blood products:\n Total out:\n 4,620 mL\n 675 mL\n Urine:\n 2,720 mL\n 675 mL\n NG:\n Stool:\n 850 mL\n Drains:\n Balance:\n -1,010 mL\n 1,057 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n Ventilator mode: Standby\n Vt (Spontaneous): 443 (443 - 443) mL\n RR (Spontaneous): 22\n PEEP: 5 cmH2O\n FiO2: 70%\n RSBI: 71\n PIP: 15 cmH2O\n SpO2: 98%\n ABG: ///28/\n Ve: 9.9 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)\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: )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Absent, Left: Absent\n Skin: Warm\n Neurologic: No(t) Follows simple commands, Responds to: Noxious\n stimuli, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 9.3 g/dL\n 63 K/uL\n 97 mg/dL\n 0.7 mg/dL\n 28 mEq/L\n 4.2 mEq/L\n 15 mg/dL\n 112 mEq/L\n 146 mEq/L\n 27.6 %\n 6.0 K/uL\n [image002.jpg]\n 03:23 PM\n 09:24 PM\n 10:04 PM\n 03:29 AM\n 03:46 AM\n 01:02 PM\n 01:03 PM\n 04:28 AM\n 04:45 AM\n 02:55 AM\n WBC\n 5.0\n 5.5\n 5.8\n 5.7\n 6.0\n Hct\n 28.7\n 28.4\n 27.7\n 26.3\n 27.6\n Plt\n 59\n 55\n 59\n 51\n 63\n Cr\n 0.7\n 0.7\n 0.7\n 0.7\n 0.7\n 0.7\n TCO2\n 34\n 34\n 34\n Glucose\n 115\n 122\n 114\n 110\n 114\n 97\n Other labs: PT / PTT / INR:17.3/46.8/1.6, CK / CKMB /\n Troponin-T:447/26/0.24, ALT / AST:60/136, Alk Phos / T Bili:129/2.5,\n Amylase / Lipase:38/42, Differential-Neuts:80.0 %, Band:0.0 %,\n Lymph:16.0 %, Mono:0.0 %, Eos:4.0 %, Lactic Acid:1.6 mmol/L,\n Albumin:3.3 g/dL, LDH:341 IU/L, Ca++:8.9 mg/dL, Mg++:1.6 mg/dL, PO4:2.9\n mg/dL\n Assessment and Plan\n Poor MS: still unresponsive. Moving all extremeties. Was placed on\n propofol during ventilation overnight. Will try to limit drip sedation\n and stick ot boluses.\n Fusobacterium sepsis: continue Pen G until .\n Thrombocytopenia: plts improved today.\n Hypernatremia: replete free water while diuresing.\n ICU Care\n Nutrition:\n Nutren Pulmonary (Full) - 10:07 AM 60 mL/hour\n Glycemic Control:\n Lines:\n Multi Lumen - 12:48 PM\n Arterial Line - 11:00 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 35 minutes\n" }, { "category": "Respiratory ", "chartdate": "2145-01-19 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 560574, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation:\n Ideal body weight: 83.5 None\n Ideal tidal volume: mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type: Not applicable\n Size: Not applicable\n Tracheostomy tube:\n Type: Standard, Cuffed, Inner Cannula\n Manufacturer: Portex\n Size: 8.0mm\n PMV: Yes\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Tan / Thick\n Sputum source/amount: Suctioned / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern:\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours:\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n Patient remains on cool-aerosol neb, wearing a cuffed 8 Portex DIC,\n breath sounds bilaterally clear and diminished at the bases, suctioned\n intermittently for moderate to small amounts of thick tan secretions,\n treated with Albuterol and atrovent inhalers, had transtracheal\n measurement and PMV trial done by SLP, measurements were good, patient\n , so far, tolerates PMV well, spoke clearly, sat in a chair for a while\n saturation mid to upper 90s on 50% cool neb, will continues to be\n followed.\n" }, { "category": "Respiratory ", "chartdate": "2145-01-12 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 559223, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 2\n Ideal body weight: 83.5 None\n Ideal tidal volume: mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: 25 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Diminished\n LUL Lung Sounds: Diminished\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Bloody / Thick\n Sputum source/amount: Suctioned / Scant\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Tracheostomy planned\n Reason for continuing current ventilatory support: Cannot protect\n airway, Cannot manage secretions\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n" }, { "category": "Rehab Services", "chartdate": "2145-01-19 00:00:00.000", "description": "Physical Therapy Progress Note", "row_id": 560566, "text": "Subjective:\n Im doing pretty good\n Objective:\n Follow up PT visit to address goals of: . Patient seen today\n for patient education, other:\n Updated medical status: CXR - Persistent low lung volumes.\n Opacification at the right base is increasing and the hemidiaphragm is\n not sharply seen, consistent with pleural effusion and atelectasis\n Activity\n Clarification\n I\n S\n CG\n Min\n Mod\n Max\n Rolling:\n\n\n T\n\n\n Supine/\n Sidelying to Sit:\n\n\n\n\n T\n Transfer:\n\n\n\n T\n\n Sit to Stand:\n\n\n\n\n T\n Ambulation:\n\n\n\n\n\n Stairs:\n\n\n\n\n\n Aerobic Activity Response:\n Position\n HR\n BP\n RR\n O[2] sat\n RPE\n Rest\n Supine\n 82\n 152/70\n 96% on TM\n Activity\n Sit\n 94\n see/below\n 95% on TM\n Recovery\n /\n Total distance walked: 0\n Minutes:\n Gait: able to take several steps from edge of bed to chair with mod A\n of 1 and min A of 2nd person.\n Balance: CG static/dynamic sitting at edge of bed, mod A static/dynamic\n standing activities.\n Education / Communication: Reviewed safety with patient and PT with\n patient and wife. Communicated with nsg re: status\n Other: Pt on 50% FIO2 via trach mask\n Patient lethargic but following most simple commands and several 2-step\n commands\n BP's:\n supine 152/70 -> sitting at EOB 89/58 -> recovery at EOB 120/73 ->\n sitting in chair 98/39 -> recovery in chair 103/60\n Assessment: 63 yo M s/p PEA arrest making good progress in PT in that\n he is able to tolerate functional mobility training and out-of-bed\n transfer. He is limited by general weakness a/w prolonged\n bedrest/hospitalization but is now following commands and showing good\n rehab potential. Will continue to benefit from daily PT and OOB as\n tolerated\n Anticipated Discharge: Rehab\n Plan: Continue with \n" }, { "category": "Respiratory ", "chartdate": "2145-01-10 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 558704, "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: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Tan / Thick\n Sputum source/amount: Suctioned / Copious\n :\n Ventilation Assessment\n Level of breathing assistance: Unassisted spontaneous breathing\n Visual assessment of breathing pattern: Normal quiet breathing,\n Accessory muscle use, Prolonged exhalation\n Respiratory Care Shift Procedures\n Bedside Procedures:\n Comments: Pt extubated without complications\n" }, { "category": "Physician ", "chartdate": "2145-01-13 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 559302, "text": "Chief Complaint:\n 24 Hour Events:\n Events:\n patient on max dose bolus fent/versed sedation and agitated, moving\n constantly but no purposeful movements, hypertensive, and fighting\n vent, placed on propofol drip sedation\n off rifaximin while on vanc/zosyn\n increased free water boluses through feeding tube\n IP will do trach at bedside on thursday\n Allergies:\n Demerol (Oral) (Meperidine Hcl)\n Confusion/Delir\n Last dose of Antibiotics:\n Vancomycin - 08:16 PM\n Piperacillin/Tazobactam (Zosyn) - 06:27 AM\n Infusions:\n Propofol - 6 mcg/Kg/min\n Other ICU medications:\n Pantoprazole (Protonix) - 08:00 AM\n Fentanyl - 11:30 PM\n Midazolam (Versed) - 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 06:54 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: 36.4\nC (97.5\n HR: 60 (57 - 82) bpm\n BP: 130/59(79) {109/52(68) - 156/69(91)} mmHg\n RR: 18 (7 - 20) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 73 Inch\n CVP: 15 (8 - 18)mmHg\n Total In:\n 2,510 mL\n 939 mL\n PO:\n TF:\n 868 mL\n 369 mL\n IVF:\n 802 mL\n 70 mL\n Blood products:\n 200 mL\n Total out:\n 1,280 mL\n 580 mL\n Urine:\n 1,280 mL\n 580 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,230 mL\n 359 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 550 (550 - 550) mL\n RR (Set): 18\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 40%\n PIP: 26 cmH2O\n Plateau: 18 cmH2O\n SpO2: 99%\n ABG: 7.52/36/164/29/6\n Ve: 9.3 L/min\n PaO2 / FiO2: 410\n Physical Examination\n Eyes / Conjunctiva: PERRL, opens eyes, makes eye contact\n , Ears, Nose, Throat: , Poor dentition, Endotracheal\n tube, NG tube\n Cardiovascular: (S1: Normal), (S2: Normal), No(t) S3, No(t) S4, No(t)\n Rub\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : ,\n Rhonchorous: )\n Abdominal: Soft, Bowel sounds present, Distended, palpable fluid wave\n Neurologic: arousable to voice, opens eyes no purposeful movements,\n withdraws to pain, non-verbal\n Labs / Radiology\n 50 K/uL\n 8.2 g/dL\n 117 mg/dL\n 0.8 mg/dL\n 29 mEq/L\n 3.8 mEq/L\n 31 mg/dL\n 114 mEq/L\n 146 mEq/L\n 24.1 %\n 4.6 K/uL\n [image002.jpg]\n 05:56 PM\n 06:13 PM\n 07:31 PM\n 09:57 PM\n 01:37 AM\n 04:43 AM\n 03:24 PM\n 02:42 AM\n 03:30 AM\n 06:33 AM\n WBC\n 5.8\n 4.9\n 4.6\n Hct\n 26.1\n 25.3\n 24.1\n Plt\n 48\n 47\n 50\n Cr\n 1.1\n 1.1\n 1.0\n 1.0\n 1.0\n 0.8\n TCO2\n 30\n 29\n 30\n 30\n Glucose\n 167\n 170\n 176\n 133\n 125\n 117\n Other labs: PT / PTT / INR:20.2/57.1/1.9, CK / CKMB /\n Troponin-T:447/26/0.24, ALT / AST:53/134, Alk Phos / T Bili:78/3.0,\n Amylase / Lipase:93/30, Differential-Neuts:84.1 %, Lymph:10.6 %,\n Mono:2.3 %, Eos:2.7 %, Lactic Acid:1.6 mmol/L, Albumin:3.3 g/dL,\n LDH:298 IU/L, Ca++:8.5 mg/dL, Mg++:1.9 mg/dL, PO4:1.6 mg/dL\n Assessment and Plan\n This is a 63 y/o M with Hepatitis C cirrhosis hepatorenal syndrome, s/p\n PEA arrest, body cooling and rewarming, concern for PNA covering with\n Vanc/Zosyn.\n .\n # s/p Shock/PEA Arrest: After PEA, was initially hemodynamically stable\n but has had episodes of hypotension non-responsive to IVF boluses,\n levofed started, currently off. Echo showed no evidence of cardiogenic\n shock. s/p cooling and rewarming.\n - continue goal MAP >65\n - stable now after off pressors\n .\n # Respiratory/Ventilation: Pt re-intubated secondary to\n respiratory distress and inability to handle secretions. Unlikely to\n tolerate extubation given that underlying problem is inability to\n handle secretions which is unlikely to change.\n - pt will likely need trach if long-term care is the goal\n - cont 5-day total course of vanc/zosyn\n - cont local care\n .\n # Pneumonia\n on CXR has RLL infiltrate and bronch with thick yellow\n secretions, leukocytosis starting to resolve\n - on vanco/zosyn for total 5-day course\n - follow up cultures\n .\n # Mental Status: With slowly resolving delerium prior to this event,\n and now with unclear hypoxic insult to brain. GCS of on admission\n to ICU. Considering head CT to evaluate for anoxic brain injury\n post-cooling. Neuro eval for possible seizure. EEG neg for seizure,\n severe encephalopathy likely in setting of sedation. Back to pre-code\n MS per wife.\n - off sedation, still not following commands or making purposeful\n movements\n - LP done earlier that was negative gram stain/culture, no whites,\n negative HSV PCR\n - CT scan did not show any focal lesions\n - likely will need MRI in the future but can not tolerate now \n mental status/respiratory status\n - increase lactulose to TID, continue rifaximin\n .\n # Renal Failure: Unclear etiology, likely combination of ATN in the\n setting of code and HRS. Renal following given concern for HRS. On\n albumin, mitodrine and octreotide per liver/renal.\n - urine output improving\n - giving mitodrine, octreotide and albumin\n - f/u renal and liver recs\n .\n # Hypernatremia: Likely hypovolemic hypernatremia in the setting of\n recent ATN and current HRS. Corrected , rree water deficit ~ 2-3L.\n - lytes\n .\n # Metabolic Acidosis: s/p arrest to tissue hypoxia. Lactates now\n normalized, now resolved.\n .\n # Cardiac: CE's trended post-arrest. Echo hyperdynamic, no cardiogenic\n shock.\n - CK and Trop trended down\n .\n # Cirrhosis: Hep C Cirrhosis, with concern for HRS.\n - pre-code mental status likely related to encephalopathy v. delirium\n - titrate up lactulose\n - liver recs -> non suitable for tx at this point, in the very small\n chance that pt improves could possibly be candidate in the future\n ..\n # Gram negative bacteremia: Will treat for two-week course, awaiting\n sensitivities on Fusobacterium -> likely responsive to penicillin.\n - will continue surveillance blood cxs\n .\n # Parotid mass. Incidental finding of L parotid mass on MRI, 1.6cm. --\n Will require ENT followup as outpt.\n .\n # Access: PIV, Central Line\n .\n # FEN: IVF, replete electrolytes, tube feeds\n .\n # Prophylaxis: holding HSQ since elevated PTT, famotidine\n .\n # Code: full\n .\n # Communication: Wife is HCP -> will readdress long-term goals today\n re: long-term prognosis\n .\n # Disposition: ICU for now.\n ICU Care\n Nutrition:\n Nutren Renal (Full) - 04:58 AM 60 mL/hour\n Glycemic Control:\n Lines:\n Multi Lumen - 12:48 PM\n Arterial Line - 11:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "General", "chartdate": "2145-01-13 00:00:00.000", "description": "Generic Note", "row_id": 559338, "text": "TITLE: Critical Care\n Present for the key portions of resident\ns history and exam. Agree\n substantially with assessment and plan. Have discontinued benzos and\n narcotics. Somewhat agitated overnight and started on low dose\n propofol for behavioral control. Continuing lactulose.\n Family meeting\n plan for trache with withdrawal of meds that may be\n clouding sensorium.\n Chest\n diffusse mid insp crackels\n CXR\n worsening pulmonary edema\n Creat\n down to 0.7\n Not clear why he should have pulm edema. Echo immed post arrest showed\n hyperdynamic LV. Troponin did incr, however, and he likely had episode\n of ATN suggesting signif hypoperfusion. We have d/c\nd drugs for HRS and\n we are starting gentle diuresis\n Time spent\n 40 min\n Critically ill\n" }, { "category": "Physician ", "chartdate": "2145-01-13 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 559344, "text": "Chief Complaint:\n 24 Hour Events:\n Events:\n patient on max dose bolus fent/versed sedation and agitated, moving\n constantly but no purposeful movements, hypertensive, and fighting\n vent, placed on propofol drip sedation\n off rifaximin while on vanc/zosyn\n increased free water boluses through feeding tube\n IP will do trach at bedside on thursday\n Allergies:\n Demerol (Oral) (Meperidine Hcl)\n Confusion/Delir\n Last dose of Antibiotics:\n Vancomycin - 08:16 PM\n Piperacillin/Tazobactam (Zosyn) - 06:27 AM\n Infusions:\n Propofol - 6 mcg/Kg/min\n Other ICU medications:\n Pantoprazole (Protonix) - 08:00 AM\n Fentanyl - 11:30 PM\n Midazolam (Versed) - 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 06:54 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: 36.4\nC (97.5\n HR: 60 (57 - 82) bpm\n BP: 130/59(79) {109/52(68) - 156/69(91)} mmHg\n RR: 18 (7 - 20) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 73 Inch\n CVP: 15 (8 - 18)mmHg\n Total In:\n 2,510 mL\n 939 mL\n PO:\n TF:\n 868 mL\n 369 mL\n IVF:\n 802 mL\n 70 mL\n Blood products:\n 200 mL\n Total out:\n 1,280 mL\n 580 mL\n Urine:\n 1,280 mL\n 580 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,230 mL\n 359 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 550 (550 - 550) mL\n RR (Set): 18\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 40%\n PIP: 26 cmH2O\n Plateau: 18 cmH2O\n SpO2: 99%\n ABG: 7.52/36/164/29/6\n Ve: 9.3 L/min\n PaO2 / FiO2: 410\n Physical Examination\n Eyes / Conjunctiva: PERRL, opens eyes, makes eye contact\n , Ears, Nose, Throat: , Poor dentition, Endotracheal\n tube, NG tube\n Cardiovascular: (S1: Normal), (S2: Normal), No(t) S3, No(t) S4, No(t)\n Rub\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : ,\n Rhonchorous: )\n Abdominal: Soft, Bowel sounds present, Distended, palpable fluid wave\n Neurologic: arousable to voice, opens eyes no purposeful movements,\n withdraws to pain, non-verbal\n Labs / Radiology\n 50 K/uL\n 8.2 g/dL\n 117 mg/dL\n 0.8 mg/dL\n 29 mEq/L\n 3.8 mEq/L\n 31 mg/dL\n 114 mEq/L\n 146 mEq/L\n 24.1 %\n 4.6 K/uL\n [image002.jpg]\n 05:56 PM\n 06:13 PM\n 07:31 PM\n 09:57 PM\n 01:37 AM\n 04:43 AM\n 03:24 PM\n 02:42 AM\n 03:30 AM\n 06:33 AM\n WBC\n 5.8\n 4.9\n 4.6\n Hct\n 26.1\n 25.3\n 24.1\n Plt\n 48\n 47\n 50\n Cr\n 1.1\n 1.1\n 1.0\n 1.0\n 1.0\n 0.8\n TCO2\n 30\n 29\n 30\n 30\n Glucose\n 167\n 170\n 176\n 133\n 125\n 117\n Other labs: PT / PTT / INR:20.2/57.1/1.9, CK / CKMB /\n Troponin-T:447/26/0.24, ALT / AST:53/134, Alk Phos / T Bili:78/3.0,\n Amylase / Lipase:93/30, Differential-Neuts:84.1 %, Lymph:10.6 %,\n Mono:2.3 %, Eos:2.7 %, Lactic Acid:1.6 mmol/L, Albumin:3.3 g/dL,\n LDH:298 IU/L, Ca++:8.5 mg/dL, Mg++:1.9 mg/dL, PO4:1.6 mg/dL\n Assessment and Plan\n This is a 63 y/o M with Hepatitis C cirrhosis, s/p PEA arrest, body\n cooling and rewarming, concern for PNA covering with Vanc/Zosyn.\n .\n # s/p Shock/PEA Arrest: After PEA, was initially hemodynamically stable\n but has had episodes of hypotension non-responsive to IVF boluses,\n levofed started, currently off. Echo showed no evidence of cardiogenic\n shock. s/p cooling and rewarming. Trended cardiac enzymes, came down\n and no evidence of cardiogenic shock on rewarmed echo.\n .\n # Respiratory/Ventilation: Pt re-intubated secondary to\n respiratory distress and inability to handle secretions. Unlikely to\n tolerate extubation given that underlying problem is inability to\n handle secretions which is unlikely to change. CXR from showed\n evidence of pulmonary edema. Patient getting trach in OR.\n - cont 5-day total course of vanc/zosyn\n - giving Lasix 40mg IV with goal -1L (will need to give addition dose\n in setting of getting 1u PRBC and 2u FFP)\n .\n # Pneumonia\n on CXR has RLL infiltrate and bronch with thick yellow\n secretions, leukocytosis starting to resolve\n - on vanco/zosyn for total 5-day course\n - follow up cultures\n .\n # Gram negative bacteremia: Will treat for two-week course, awaiting\n sensitivities on Fusobacterium -> likely responsive to penicillin.\n - will continue surveillance blood cxs\n .\n # Mental Status: With slowly resolving delerium prior to this event,\n and now with unclear hypoxic insult to brain. GCS of on admission\n to ICU. Considering head CT to evaluate for anoxic brain injury\n post-cooling. Neuro eval for possible seizure. EEG neg for seizure,\n severe encephalopathy likely in setting of sedation. LP done earlier\n that was negative gram stain/culture, no whites, negative HSV PCR. Back\n to pre-code MS per wife.\n - patient is following commands, on propofol sedation\n - CT scan did not show any focal lesions\n - likely will need MRI in the future but can not tolerate now \n mental status/respiratory status\n - increase lactulose\n .\n # Resolved Renal Failure: Unclear etiology, likely combination of ATN\n in the setting of code and HRS. Renal following given concern for HRS.\n Off albumin, mitodrine and octreotide\n - f/u renal and liver recs\n .\n # Hypernatremia: Likely hypovolemic hypernatremia in the setting of\n recent ATN and current HRS. Corrected , free water deficit ~ 2-3L.\n .\n # Cardiac: CE's trended post-arrest. Echo hyperdynamic, no cardiogenic\n shock. CK and Trop trended down\n - will consider repeat echo\n .\n # Cirrhosis: Hep C Cirrhosis, with concern for HRS.\n - pre-code mental status likely related to encephalopathy v. delirium\n - titrate up lactulose\n - liver recs -> non suitable for tx at this point, in the very small\n chance that pt improves could possibly be candidate in the future\n .\n # Parotid mass. Incidental finding of L parotid mass on MRI, 1.6cm. --\n Will require ENT followup as outpt.\n .\n # Metabolic Acidosis: s/p arrest to tissue hypoxia. Lactates now\n normalized, now resolved.\n # Access: PIV, Central Line\n .\n # FEN: NPO for trach in OR, resume TF\n .\n # Prophylaxis: holding HSQ since elevated PTT, famotidine\n .\n # Code: full\n .\n # Communication: Wife is HCP -> will readdress long-term goals today\n re: long-term prognosis\n .\n # Disposition: ICU for now.\n ICU Care\n Nutrition:\n Nutren Renal (Full) - 04:58 AM 60 mL/hour\n Glycemic Control:\n Lines:\n Multi Lumen - 12:48 PM\n Arterial Line - 11:00 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": "2145-01-20 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 560699, "text": "Chief Complaint:\n 24 Hour Events:\n - NGT replaced after patient pulled it out\n ARTERIAL LINE - STOP 08:00 PM\n Allergies:\n Demerol (Oral) (Meperidine Hcl)\n Confusion/Delir\n Last dose of Antibiotics:\n Penicillin G potassium - 04:30 AM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:00 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 07:17 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: 36.8\nC (98.3\n HR: 83 (78 - 109) bpm\n BP: 126/67(80) {98/39(53) - 169/84(94)} mmHg\n RR: 18 (14 - 25) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 73 Inch\n CVP: 13 (6 - 13)mmHg\n Total In:\n 3,827 mL\n 1,670 mL\n PO:\n TF:\n 77 mL\n IVF:\n 790 mL\n 245 mL\n Blood products:\n Total out:\n 3,230 mL\n 1,240 mL\n Urine:\n 2,130 mL\n 240 mL\n NG:\n Stool:\n 1,000 mL\n Drains:\n Balance:\n 597 mL\n 430 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n SpO2: 100%\n ABG: ///26/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 69 K/uL\n 8.5 g/dL\n 95 mg/dL\n 0.6 mg/dL\n 26 mEq/L\n 3.8 mEq/L\n 14 mg/dL\n 112 mEq/L\n 144 mEq/L\n 25.5 %\n 2.9 K/uL\n [image002.jpg]\n 02:55 AM\n 04:00 PM\n 01:01 AM\n 04:22 AM\n 05:38 AM\n 02:41 PM\n 09:01 PM\n 03:15 AM\n 04:16 PM\n 05:46 AM\n WBC\n 6.0\n 5.0\n 3.9\n 2.9\n Hct\n 27.6\n 26.9\n 26.1\n 25.5\n Plt\n 63\n 55\n 59\n 69\n Cr\n 0.7\n 0.7\n 0.7\n 0.6\n 0.5\n 0.5\n 0.6\n 0.6\n TCO2\n 33\n 30\n Glucose\n 97\n 111\n 94\n 90\n 111\n 85\n 109\n 95\n Other labs: PT / PTT / INR:17.9/44.4/1.6, CK / CKMB /\n Troponin-T:104/26/0.24, ALT / AST:60/136, Alk Phos / T Bili:129/2.5,\n Amylase / Lipase:38/42, Differential-Neuts:80.0 %, Band:0.0 %,\n Lymph:16.0 %, Mono:0.0 %, Eos:4.0 %, Lactic Acid:1.0 mmol/L,\n Albumin:3.3 g/dL, LDH:341 IU/L, Ca++:8.4 mg/dL, Mg++:1.5 mg/dL, PO4:2.6\n mg/dL\n Assessment and Plan\n AEROBIC CAPACITY / ENDURANCE, IMPAIRED\n AROUSAL, ATTENTION, AND COGNITION, IMPAIRED\n RESPIRATION / GAS EXCHANGE, IMPAIRED\n HEPATIC ENCEPHALOPATHY\n ELECTROLYTE & FLUID DISORDER, OTHER\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n HYPOTENSION (NOT SHOCK)\n CARDIAC ARREST\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n BACTEREMIA\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 12:48 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": "2145-01-20 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 560700, "text": "Chief Complaint:\n 24 Hour Events:\n - NGT replaced after patient pulled it out\n ARTERIAL LINE - STOP 08:00 PM\n Allergies:\n Demerol (Oral) (Meperidine Hcl)\n Confusion/Delir\n Last dose of Antibiotics:\n Penicillin G potassium - 04:30 AM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:00 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 07:17 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: 36.8\nC (98.3\n HR: 83 (78 - 109) bpm\n BP: 126/67(80) {98/39(53) - 169/84(94)} mmHg\n RR: 18 (14 - 25) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 73 Inch\n CVP: 13 (6 - 13)mmHg\n Total In:\n 3,827 mL\n 1,670 mL\n PO:\n TF:\n 77 mL\n IVF:\n 790 mL\n 245 mL\n Blood products:\n Total out:\n 3,230 mL\n 1,240 mL\n Urine:\n 2,130 mL\n 240 mL\n NG:\n Stool:\n 1,000 mL\n Drains:\n Balance:\n 597 mL\n 430 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n SpO2: 100%\n ABG: ///26/\n Physical Examination\n Eyes / Conjunctiva: PERRL, opens eyes, makes eye contact\n , Ears, Nose, Throat: , Poor dentition, NG tube, trach\n (Bloody )\n Cardiovascular: RRR, (S1: Normal), (S2: Normal), No(t) S3, No(t) S4,\n No(t) Rub\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear )\n Abdominal: Soft, Bowel sounds present, Distended, palpable fluid wave,\n non-tender\n Neurologic: arousable to voice, opens eyes, non-verbal, follows some\n basic commands\n Labs / Radiology\n 69 K/uL\n 8.5 g/dL\n 95 mg/dL\n 0.6 mg/dL\n 26 mEq/L\n 3.8 mEq/L\n 14 mg/dL\n 112 mEq/L\n 144 mEq/L\n 25.5 %\n 2.9 K/uL\n [image002.jpg]\n 02:55 AM\n 04:00 PM\n 01:01 AM\n 04:22 AM\n 05:38 AM\n 02:41 PM\n 09:01 PM\n 03:15 AM\n 04:16 PM\n 05:46 AM\n WBC\n 6.0\n 5.0\n 3.9\n 2.9\n Hct\n 27.6\n 26.9\n 26.1\n 25.5\n Plt\n 63\n 55\n 59\n 69\n Cr\n 0.7\n 0.7\n 0.7\n 0.6\n 0.5\n 0.5\n 0.6\n 0.6\n TCO2\n 33\n 30\n Glucose\n 97\n 111\n 94\n 90\n 111\n 85\n 109\n 95\n Other labs: PT / PTT / INR:17.9/44.4/1.6, CK / CKMB /\n Troponin-T:104/26/0.24, ALT / AST:60/136, Alk Phos / T Bili:129/2.5,\n Amylase / Lipase:38/42, Differential-Neuts:80.0 %, Band:0.0 %,\n Lymph:16.0 %, Mono:0.0 %, Eos:4.0 %, Lactic Acid:1.0 mmol/L,\n Albumin:3.3 g/dL, LDH:341 IU/L, Ca++:8.4 mg/dL, Mg++:1.5 mg/dL, PO4:2.6\n mg/dL\n Assessment and Plan\n This is a 63 y/o M who has continued AMS to point where not\n communicating at all; with hx Hepatitis C cirrhosis, s/p PEA arrest,\n body cooling and rewarming, with Fusobacterium sepsis covering with IV\n Pen G until .\n .\n # Mental Status: With slowly resolving delerium prior to this event,\n and now with unclear hypoxic insult to brain. GCS of on admission\n to ICU. Considering head CT to evaluate for anoxic brain injury\n post-cooling. Neuro eval for possible seizure. EEG neg for seizure,\n severe encephalopathy likely in setting of sedation. LP done earlier\n that was negative gram stain/culture, no whites, negative HSV PCR. Back\n to pre-code MS per wife. CT scan did not show any focal lesions. MRI\n () was unremarkable. Mental status is somewhat improved today.\n - off propofol sedation,\n - psych saw patient on and felt that the patient was very unlikely\n to have had NMS and recommended seroquel for agitation (uptitrate per\n Psych recs\n standing Seroquel TID with prns)\n - lactulose increased to 60mg q4hr for stool ouput goal of 1000cc and\n cont rifaximin; ammonia not elevated\n - Thyroid studies wnl\n .\n # Respiratory/Ventilation: Pt re-intubated secondary to\n respiratory distress and inability to handle secretions. Unlikely to\n tolerate extubation given that underlying problem is inability to\n handle secretions which is unlikely to change. CXR from showed\n evidence of pulmonary edema. Patient getting trach in OR. Patient\n completed treatment for empiric HAP for 5day with vanc/zosyn starting\n .\n - tolerating trach collar very well\n .\n # Fusobacterium bacteremia: Will treat for two-week course, awaiting\n sensitivities on Fusobacterium -> likely responsive to penicillin. Dx\n on , will need 14d course until .\n - surveillance blood cxs NTD\n - complete course of PCN on \n .\n # bleeding from trach site- Procedure done , 8-0 Portex .lost\n 150cc. Patient was given giving 2u platelets, given 1u FFP after the\n procedure. ENT was consulted on for concern of posterior pharynx\n bleed, which they did not find any evidence of.\n - bleeding has improved, tr blood at site, but controlled\n - ENT found small bite on back of tongue, but no evidence of posterior\n pharynx bleed\n .\n # Hypernatremia: Likely hypovolemic hypernatremia in the setting of\n recent ATN and current HRS. Corrected , free water deficit 3.5L on\n and now corrected again as TF were held overnight except for FW\n boluses..\n - increase free water boluses through G-tube\n - will discuss with nutrition to see if there is a way to decrease\n sodium in TF or dilute TF to prevent hypernatremia\n .\n # Thrombocytopenia\n platelets 171, slowly declining. Switched\n from H2 to PPI. Considering HIT vs. splenic sequestration\n - no current evidence of DIC\n - plts stable after switch from H2 to PPI\n .\n # Resolved Renal Failure: Unclear etiology, likely combination of ATN\n in the setting of code and HRS. Renal following given concern for HRS.\n Off albumin, mitodrine and octreotide\n - renal function stable\n - f/u renal and liver recs\n .\n # Cardiac: CE's trended post-arrest. Echo hyperdynamic, no cardiogenic\n shock. CK and Trop trended down\n - will consider repeat echo\n .\n # Cirrhosis: Hep C Cirrhosis, with concern for HRS.\n - pre-code mental status likely related to encephalopathy v. delirium\n - lactulose increased\n - liver recs -> non suitable for tx at this point, in the very small\n chance that pt improves could possibly be candidate in the future\n .\n # s/p Shock/PEA Arrest: Now stable. After PEA, was initially\n hemodynamically stable but has had episodes of hypotension\n non-responsive to IVF boluses, levofed started, currently off. Echo\n showed no evidence of cardiogenic shock. s/p cooling and rewarming.\n Trended cardiac enzymes, came down and no evidence of cardiogenic shock\n on rewarmed echo.\n # Parotid mass. Incidental finding of L parotid mass on MRI, 1.6cm. --\n Will require ENT followup as outpt.\n .\n # Metabolic Acidosis: s/p arrest to tissue hypoxia. Lactates now\n normalized, now resolved.\n # Access: Central Line and A-line; will remove A-line today and request\n PICC placement.\n .\n # FEN: were stopped due to patient positioning, will try restarting\n today for goal, 60cc/hr\n Speech/swallow c/s for consideration of passy-muir valve.\n .\n # Prophylaxis: holding HSQ since elevated PTT, PPI\n .\n # Code: full\n .\n # Communication: Wife is HCP -> will readdress long-term goals re:\n long-term prognosis\n .\n # Disposition: ICU for now. be able to transition to floor vs.\n rehab soon.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 12:48 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": "2145-01-13 00:00:00.000", "description": "Nursing Progress Note", "row_id": 559391, "text": "Synopsis per prior nursing note:\n Pt admitted to on s/p fall for back spinal fusion. Has been\n confused since surgery according to pt's wife later developed UTI.\n Unknown cause of MS changes. ? encephalopathy vs. infection.Pt had\n resp distress, became unresponsive and went into PEA arrest on .Pt\n has been on Arctic sun.CT neg for PE or bleed.Pt was succefully\n extubated on .But developed acute respiratory distress on that\n night with increasing agitation and confusion.Was reintubated on\n .Head CT neg for any acute changes.\n Altered mental status (not Delirium)\n Assessment:\n Arouses to voice/stimuli. Inconsistently follows simple commands.\n Occasionally has non-purposeful movements of upper and lower\n extremities. At times becomes extremely restless (pulling arms toward\n face, lifting legs and moving them towards edge of bed, fighting vent).\n Action:\n Continued on propofol gtt. Reorientation attempted frequently.\n Lactulose held d/t NPO status.\n Response:\n Continues to be restless when less sedated.\n Plan:\n Continue neuro checks. Continue to reorient. Continue Lactulose when no\n longer NPO, ?lactulose PR.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Vent settings CMV 12/550/40%/PEEP8. LS diminished. Tmax 99.2 PO.\n Action:\n PEEP decreased to 5. Continued on vanco/zosyn. Suctioned small amt of\n blood tinged secretions. Frequent position changes. Chest PT done.\n Lasix 40mEq IV given.\n Response:\n Appears comfortable on vent settings. O2 sats 95-100%. ABG\n 7.48/42/77/32. UOP ~2.5L to lasix.\n Plan:\n Wean vent as tolerated. Suction as needed. Continue chest PT. Continue\n antibiotics. ?trach Thursday. Monitor UOP.\n Electrolyte & fluid disorder, other\n Assessment:\n K 3.8. Phos 1.6. Mg 1.6. HCt 24.1. Na 147.\n Action:\n Given 2 pks of neutra phos. K repleted on prior shift. 1unit PRBC\n given. Given potassium phosphate 15mmol. Started on 1L D5w @100cc/hr\n for Na.\n Response:\n Repeat labs, Hct 28.6, k 4.0, phos 2.9, Mg 1.6 (given 2gm magnesium\n IV).\n Plan:\n Monitor electrolytes.\n" }, { "category": "Physician ", "chartdate": "2145-01-12 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 559081, "text": "Chief Complaint:\n 24 Hour Events:\n - re-intubated resp. distress and inability to protect airway\n - peri-intubation had episode of AF with RVR and aberrancy, responded\n to Ca2+ (?increased K+ use of sux for intubation)\n - replaced a-line\n - decreased albumin to 50mg daily\n - Head CT with no focal findings -> recommend MRI at later date\n Allergies:\n Demerol (Oral) (Meperidine Hcl)\n Confusion/Delir\n Last dose of Antibiotics:\n Vancomycin - 08:16 PM\n Piperacillin/Tazobactam (Zosyn) - 06:27 AM\n Infusions:\n Fentanyl - 50 mcg/hour\n Midazolam (Versed) - 2 mg/hour\n Other ICU medications:\n Lorazepam (Ativan) - 08:26 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 12 AM\n Tmax: 36.5\nC (97.7\n Tcurrent: 35.8\nC (96.4\n HR: 59 (57 - 98) bpm\n BP: 128/58(74) {111/50(66) - 212/84(126)} mmHg\n RR: 18 (18 - 27) insp/min\n SpO2: 100%\n Heart rhythm: SB (Sinus Bradycardia)\n CVP: 11 (11 - 17)mmHg\n Total In:\n 3,092 mL\n 1,043 mL\n PO:\n TF:\n 69 mL\n 191 mL\n IVF:\n 2,663 mL\n 781 mL\n Blood products:\n 200 mL\n 12 mL\n Total out:\n 2,660 mL\n 530 mL\n Urine:\n 1,960 mL\n 530 mL\n NG:\n Stool:\n 700 mL\n Drains:\n Balance:\n 432 mL\n 513 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 550 (550 - 550) mL\n RR (Set): 18\n RR (Spontaneous): 0\n PEEP: 10 cmH2O\n FiO2: 40%\n RSBI Deferred: PEEP > 10\n PIP: 26 cmH2O\n Plateau: 20 cmH2O\n SpO2: 100%\n ABG: 7.44/42/109/32/3\n Ve: 8.8 L/min\n PaO2 / FiO2: 273\n Physical Examination\n Eyes / Conjunctiva: PERRL, opens eyes, makes eye contact\n , Ears, Nose, Throat: , Poor dentition, Endotracheal\n tube, NG tube\n Cardiovascular: (S1: Normal), (S2: Normal), No(t) S3, No(t) S4, No(t)\n Rub\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : ,\n Rhonchorous: )\n Abdominal: Soft, Bowel sounds present, Distended, palpable fluid wave\n Neurologic: arousable to voice, opens eyes no purposeful movements,\n withdraws to pain, non-verbal\n Labs / Radiology\n 48 K/uL\n 8.5 g/dL\n 133 mg/dL\n 1.0 mg/dL\n 32 mEq/L\n 3.6 mEq/L\n 43 mg/dL\n 110 mEq/L\n 145 mEq/L\n 26.1 %\n 5.8 K/uL\n [image002.jpg]\n 04:02 AM\n 11:01 AM\n 11:21 AM\n 01:03 PM\n 05:56 PM\n 06:13 PM\n 07:31 PM\n 09:57 PM\n 01:37 AM\n 04:43 AM\n WBC\n 5.6\n 7.7\n 5.8\n Hct\n 29.6\n 30.0\n 26.1\n Plt\n 52\n 61\n 48\n Cr\n 1.4\n 1.3\n 1.1\n 1.1\n 1.0\n 1.0\n TCO2\n 31\n 29\n 29\n 30\n 29\n Glucose\n 100\n 136\n 167\n 170\n 176\n 133\n Other labs: PT / PTT / INR:19.1/51.4/1.8, CK / CKMB /\n Troponin-T:447/26/0.24, ALT / AST:60/144, Alk Phos / T Bili:72/3.4,\n Amylase / Lipase:93/30, Differential-Neuts:84.1 %, Lymph:10.6 %,\n Mono:2.3 %, Eos:2.7 %, Lactic Acid:2.2 mmol/L, LDH:303 IU/L, Ca++:8.8\n mg/dL, Mg++:2.3 mg/dL, PO4:1.7 mg/dL\n Assessment and Plan\n This is a 63 y/o M with Hepatitis C cirrhosis hepatorenal syndrome, s/p\n PEA arrest, body cooling and rewarming, concern for PNA covering with\n Vanc/Zosyn.\n .\n # s/p Shock/PEA Arrest: After PEA, was initially hemodynamically stable\n but has had episodes of hypotension non-responsive to IVF boluses,\n levofed started, currently off. Echo showed no evidence of cardiogenic\n shock. s/p cooling and rewarming.\n - continue goal MAP >65\n - stable now after off pressors\n .\n # Respiratory/Ventilation: Pt re-intubated secondary to\n respiratory distress and inability to handle secretions.\n - pt will likely need trach\n - cont 5-day total course of ABX\n - cont local care\n .\n # Pneumonia\n on CXR has RLL infiltrate and bronch with thick yellow\n secretions, leukocytosis starting to resolve\n - on vanco/zosyn for total 5-day course\n - follow up cultures, NGTD\n .\n # Mental Status: With slowly resolving delerium prior to this event,\n and now with unclear hypoxic insult to brain. GCS of on admission\n to ICU. Considering head CT to evaluate for anoxic brain injury\n post-cooling. Neuro eval for possible seizure. EEG neg for seizure,\n severe encephalopathy likely in setting of sedation. Back to pre-code\n MS per wife.\n - off sedation, still not following commands or making purposeful\n movements\n - LP done earlier that was negative gram stain/culture, no whites,\n negative HSV PCR\n - CT scan did not show any focal lesions\n - likely will need MRI in the future but can not tolerate now \n mental status/respiratory status\n - continue lactulose\n .\n # Renal Failure: Unclear etiology, likely combination of ATN in the\n setting of code and HRS. Renal following given concern for HRS. On\n albumin, mitodrine and octreotide per liver.\n - urine output improving\n - giving mitodrine, octreotide and albumin\n - f/u renal and liver recs\n .\n # Hypernatremia: Likely hypovolemic hypernatremia in the setting of\n recent ATN and current HRS. Corrected , rree water deficit ~ 2-3L.\n - continue to check lytes\n .\n # Metabolic Acidosis: s/p arrest to tissue hypoxia. Continue IVF's\n and trend lactate. Will need to increase minute ventilation for CO2.\n - resolved, likely in setting of post code hypoperfusion\n - lactates normalized\n .\n # Cardiac: Anticipate some elevation in CE's post-arrest, will trend.\n Echo hyperdynamic, no cardiogenic shock.\n - CK and Trop trended down\n .\n # Cirrhosis: Hep C Cirrhosis, with concern for HRS.\n - pre-code mental status likely related to encephalopathy v. delirium\n - continue lactulose\n - will f/u with liver re: long-term management/prognosis\n .\n # Leukocytosis: Unclear etiology. Negative tap for SBP on .\n Urine growing E. Coli. Pan-culture.\n - likely from pneumonia\n .\n # Parotid mass. Incidental finding of L parotid mass on MRI, 1.6cm. --\n Will require ENT followup as outpt.\n .\n # Access: PIV, Central Line\n .\n # FEN: IVF, replete electrolytes, tube feeds\n .\n # Prophylaxis: holding HSQ since elevated PTT, famotidine\n .\n # Code: full\n .\n # Communication: Wife is HCP -> will need to readdress long-term goals\n .\n # Disposition: ICU for now.\n ICU Care\n Nutrition:\n Nutren Renal (Full) - 06:16 AM 30 mL/hour\n Glycemic Control:\n Lines:\n Multi Lumen - 12:48 PM\n Arterial Line - 11:00 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": "2145-01-12 00:00:00.000", "description": "Nursing Progress Note", "row_id": 558990, "text": "Pt admitted to on s/p fall for back spinal fusion. Has been\n confused since surgery according to pt's wife later developed UTI.\n Unknown cause of MS changes. ? encephalopathy vs. infection.Pt had\n resp distress, became unresponsive and went into PEA arrest on .Pt\n has been on Arctic sun.CT neg for PE or bleed.Pt was succefully\n extubated on .But developed acute respiratory distress on that\n night with increasing agitation and confusion.Was reintubated on\n .Head CT neg for any acute changes.\n Altered mental status (not Delirium)\n Assessment:\n Pt is now sedated on fent/versed.Withdraws to painful stimuli.PEARL\n size 3.\n Action:\n Cont on fent/versed.\n Response:\n Pt comfortable on current sedation.Head CT neg for bleed.\n Plan:\n Frequent neuro checks.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received the pt on ac 60%/550/18/10.LS clear with diminished\n base.Suctioned for small amount of bld stained secretions.Pt with GNR\n in bld from .\n Action:\n Weaned O2 to 40%.\n Response:\n Bld gases good on 40%.Started on vanc/zosyn.\n Plan:\n VAp protocol; monitor ABg\ns, vent changes prn. IV antibx\n Electrolyte & fluid disorder, other\n Assessment:\n Sodium 147.\n Action:\n Pt getting D5W 175cc/hr.\n Response:\n Plan:\n Recheck lytes.\n" }, { "category": "Nursing", "chartdate": "2145-01-12 00:00:00.000", "description": "Nursing Progress Note", "row_id": 558991, "text": "Pt admitted to on s/p fall for back spinal fusion. Has been\n confused since surgery according to pt's wife later developed UTI.\n Unknown cause of MS changes. ? encephalopathy vs. infection.Pt had\n resp distress, became unresponsive and went into PEA arrest on .Pt\n has been on Arctic sun.CT neg for PE or bleed.Pt was succefully\n extubated on .But developed acute respiratory distress on that\n night with increasing agitation and confusion.Was reintubated on\n .Head CT neg for any acute changes.\n Altered mental status (not Delirium)\n Assessment:\n Pt is now sedated on fent/versed.Withdraws to painful stimuli.PEARL\n size 3.\n Action:\n Cont on fent/versed.\n Response:\n Pt comfortable on current sedation.Head CT neg for bleed.\n Plan:\n Frequent neuro checks.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received the pt on ac 60%/550/18/10.LS clear with diminished\n base.Suctioned for small amount of bld stained secretions.Pt with GNR\n in bld from .\n Action:\n Weaned O2 to 40%.\n Response:\n Bld gases good on 40%.Started on vanc/zosyn.\n Plan:\n VAp protocol; monitor ABg\ns, vent changes prn. IV antibx\n Electrolyte & fluid disorder, other\n Assessment:\n Sodium 146.\n Action:\n Pt getting D5W 175cc/hr.\n Response:\n Plan:\n Recheck lytes.\n" }, { "category": "Respiratory ", "chartdate": "2145-01-11 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 558939, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 1\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: 25 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Blood Tinged / Thick\n Sputum source/amount: Suctioned / Moderate\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Intermittent invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing,\n Tachypneic (RR> 35 b/min); Comments: pt intuabted this morning for\n increased wob and decreased sats once placed on vent pt suctioned for\n mod amt thick brown/blood tinged sputum\n Assessment of breathing comfort: No claim of dyspnea)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Maintain PEEP at current level and reduce FiO2 as\n tolerated\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n CT\n 1600\n pt went for head ct without incident\n Bedside Procedures:\n Comments:\n" }, { "category": "Physician ", "chartdate": "2145-01-19 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 560549, "text": "TITLE:\n Chief Complaint: PEA/asystole\n 24 Hour Events:\n - Hypernatremia corrected to 143 today. Free water deficit calculated\n to be 3.7 L, getting D5W 500 cc q3hrs.\n - ABG/VBG showing good correlation\n - Made Seroquel around the clock and PRN per psych recs\n Allergies:\n Demerol (Oral) (Meperidine Hcl)\n Confusion/Delir\n Last dose of Antibiotics:\n Penicillin G potassium - 04:15 AM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:19 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 06:54 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: 35.9\nC (96.7\n HR: 87 (78 - 102) bpm\n BP: 120/70(82) {120/70(82) - 120/70(82)} mmHg\n RR: 18 (17 - 29) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 73 Inch\n CVP: 7 (7 - 16)mmHg\n Total In:\n 5,362 mL\n 1,498 mL\n PO:\n TF:\n IVF:\n 1,057 mL\n 238 mL\n Blood products:\n Total out:\n 2,915 mL\n 1,910 mL\n Urine:\n 1,915 mL\n 810 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,447 mL\n -412 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n SpO2: 99%\n ABG: 7.41/46/170/27/4\n PaO2 / FiO2: 425 / 40%\n Physical Examination\n Eyes / Conjunctiva: PERRL, opens eyes, makes eye contact\n , Ears, Nose, Throat: , Poor dentition, NG tube, trach\n (Bloody )\n Cardiovascular: RRR, (S1: Normal), (S2: Normal), No(t) S3, No(t) S4,\n No(t) Rub\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear )\n Abdominal: Soft, Bowel sounds present, Distended, palpable fluid wave,\n non-tender\n Neurologic: arousable to voice, opens eyes, non-verbal, follows some\n basic commands\n Labs / Radiology\n 59 K/uL\n 8.6 g/dL\n 85 mg/dL\n 0.5 mg/dL\n 27 mEq/L\n 3.7 mEq/L\n 13 mg/dL\n 110 mEq/L\n 143 mEq/L\n 26.1 %\n 3.9 K/uL\n [image002.jpg]\n 04:28 AM\n 04:45 AM\n 02:55 AM\n 04:00 PM\n 01:01 AM\n 04:22 AM\n 05:38 AM\n 02:41 PM\n 09:01 PM\n 03:15 AM\n WBC\n 5.7\n 6.0\n 5.0\n 3.9\n Hct\n 26.3\n 27.6\n 26.9\n 26.1\n Plt\n 51\n 63\n 55\n 59\n Cr\n 0.7\n 0.7\n 0.7\n 0.7\n 0.6\n 0.5\n 0.5\n TCO2\n 34\n 33\n 30\n Glucose\n 114\n 97\n 111\n 94\n 90\n 111\n 85\n Other labs: PT / PTT / INR:17.4/44.6/1.6, Ca++:8.4 mg/dL, Mg++:1.7\n mg/dL, PO4:2.2 mg/dL; TSH 3.7, T4 5.7; Lactate 1.0, ammonia 31\n CXR : FINDINGS: In comparison with the study of , the\n monitoring and support devices remain in place. Persistent low lung\n volumes. Opacification at the right base is increasing and the\n hemidiaphragm is not sharply seen. This is consistent with pleural\n effusion and atelectasis, though in the absence of a lateral view. A\n superimposed pneumonia cannot be excluded. The left hemidiaphragm is\n more sharply seen, suggesting some improvement in atelectasis and\n effusion in this region.\n Assessment and Plan\n This is a 63 y/o M who has continued AMS to point where not\n communicating at all; with hx Hepatitis C cirrhosis, s/p PEA arrest,\n body cooling and rewarming, with Fusobacterium sepsis covering with IV\n Pen G until .\n .\n # Mental Status: With slowly resolving delerium prior to this event,\n and now with unclear hypoxic insult to brain. GCS of on admission\n to ICU. Considering head CT to evaluate for anoxic brain injury\n post-cooling. Neuro eval for possible seizure. EEG neg for seizure,\n severe encephalopathy likely in setting of sedation. LP done earlier\n that was negative gram stain/culture, no whites, negative HSV PCR. Back\n to pre-code MS per wife. CT scan did not show any focal lesions. MRI\n () was unremarkable. Mental status is somewhat improved today.\n - off propofol sedation,\n - psych saw patient on and felt that the patient was very unlikely\n to have had NMS and recommended seroquel for agitation (uptitrate per\n Psych recs\n standing Seroquel TID with prns)\n - lactulose increased to 60mg q4hr for stool ouput goal of 1000cc and\n cont rifaximin; ammonia not elevated\n - Thyroid studies wnl\n .\n # Respiratory/Ventilation: Pt re-intubated secondary to\n respiratory distress and inability to handle secretions. Unlikely to\n tolerate extubation given that underlying problem is inability to\n handle secretions which is unlikely to change. CXR from showed\n evidence of pulmonary edema. Patient getting trach in OR. Patient\n completed treatment for empiric HAP for 5day with vanc/zosyn starting\n .\n - tolerating trach collar very well\n .\n # Fusobacterium bacteremia: Will treat for two-week course, awaiting\n sensitivities on Fusobacterium -> likely responsive to penicillin. Dx\n on , will need 14d course until .\n - surveillance blood cxs NTD\n - complete course of PCN on \n .\n # bleeding from trach site- Procedure done , 8-0 Portex .lost\n 150cc. Patient was given giving 2u platelets, given 1u FFP after the\n procedure. ENT was consulted on for concern of posterior pharynx\n bleed, which they did not find any evidence of.\n - bleeding has improved, tr blood at site, but controlled\n - ENT found small bite on back of tongue, but no evidence of posterior\n pharynx bleed\n .\n # Hypernatremia: Likely hypovolemic hypernatremia in the setting of\n recent ATN and current HRS. Corrected , free water deficit 3.5L on\n and now corrected again as TF were held overnight except for FW\n boluses..\n - increase free water boluses through G-tube\n - will discuss with nutrition to see if there is a way to decrease\n sodium in TF or dilute TF to prevent hypernatremia\n .\n # Thrombocytopenia\n platelets 171, slowly declining. Switched\n from H2 to PPI. Considering HIT vs. splenic sequestration\n - no current evidence of DIC\n - plts stable after switch from H2 to PPI\n .\n # Resolved Renal Failure: Unclear etiology, likely combination of ATN\n in the setting of code and HRS. Renal following given concern for HRS.\n Off albumin, mitodrine and octreotide\n - renal function stable\n - f/u renal and liver recs\n .\n # Cardiac: CE's trended post-arrest. Echo hyperdynamic, no cardiogenic\n shock. CK and Trop trended down\n - will consider repeat echo\n .\n # Cirrhosis: Hep C Cirrhosis, with concern for HRS.\n - pre-code mental status likely related to encephalopathy v. delirium\n - lactulose increased\n - liver recs -> non suitable for tx at this point, in the very small\n chance that pt improves could possibly be candidate in the future\n .\n # s/p Shock/PEA Arrest: Now stable. After PEA, was initially\n hemodynamically stable but has had episodes of hypotension\n non-responsive to IVF boluses, levofed started, currently off. Echo\n showed no evidence of cardiogenic shock. s/p cooling and rewarming.\n Trended cardiac enzymes, came down and no evidence of cardiogenic shock\n on rewarmed echo.\n # Parotid mass. Incidental finding of L parotid mass on MRI, 1.6cm. --\n Will require ENT followup as outpt.\n .\n # Metabolic Acidosis: s/p arrest to tissue hypoxia. Lactates now\n normalized, now resolved.\n # Access: Central Line and A-line; will remove A-line today and request\n PICC placement.\n .\n # FEN: were stopped due to patient positioning, will try restarting\n today for goal, 60cc/hr\n Speech/swallow c/s for consideration of passy-muir valve.\n .\n # Prophylaxis: holding HSQ since elevated PTT, PPI\n .\n # Code: full\n .\n # Communication: Wife is HCP -> will readdress long-term goals re:\n long-term prognosis\n .\n # Disposition: ICU for now. be able to transition to floor vs.\n rehab soon.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 12:48 PM\n Arterial Line - 11:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "General", "chartdate": "2145-01-14 00:00:00.000", "description": "Generic Note", "row_id": 559540, "text": "TITLE: Critical Care\n Present for the key portions of the resident\ns history and exam. Agree\n substantially with assessment and plan. Trache done w/o complications\n continuing to have oozing at site. Supporting INR and plts with\n blood products.\n Sedated. Chest few mid insp crackles\n Hct stable at 27\n RSBI 100\n Remains on propofol. When oozing stops will d/c propofol and hold all\n sedation for better assessment of neuro status. Given his ATN post\n arrest seems increasingly likely he has had some anoxic injury\n Need to review meds as decr plt ct has occurred in ~ last week\n Time spent 40 min\n Critically ill\n" }, { "category": "Nutrition", "chartdate": "2145-01-14 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 559543, "text": "Objective\n Pertinent medications: Meds and repletions noted\n Labs:\n Value\n Date\n Glucose\n 112 mg/dL\n 03:15 AM\n Glucose Finger Stick\n 104\n 04:02 PM\n BUN\n 23 mg/dL\n 03:15 AM\n Creatinine\n 0.6 mg/dL\n 03:15 AM\n Sodium\n 147 mEq/L\n 03:15 AM\n Potassium\n 3.8 mEq/L\n 03:15 AM\n Chloride\n 111 mEq/L\n 03:15 AM\n TCO2\n 30 mEq/L\n 03:15 AM\n PO2 (arterial)\n 94. mm Hg\n 03:29 AM\n PO2 (venous)\n 33 mm Hg\n 11:15 AM\n PCO2 (arterial)\n 40 mm Hg\n 03:29 AM\n PCO2 (venous)\n 57 mm Hg\n 11:15 AM\n pH (arterial)\n 7.47 units\n 03:29 AM\n pH (venous)\n 7.34 units\n 11:15 AM\n pH (urine)\n 5.0 units\n 12:42 PM\n CO2 (Calc) arterial\n 30 mEq/L\n 03:29 AM\n CO2 (Calc) venous\n 32 mEq/L\n 11:15 AM\n Albumin\n 3.3 g/dL\n 02:42 AM\n Calcium non-ionized\n 8.2 mg/dL\n 03:15 AM\n Phosphorus\n 2.6 mg/dL\n 03:15 AM\n Ionized Calcium\n 1.12 mmol/L\n 03:29 AM\n Magnesium\n 1.7 mg/dL\n 03:15 AM\n ALT\n 53 IU/L\n 03:15 AM\n Alkaline Phosphate\n 73 IU/L\n 03:15 AM\n AST\n 127 IU/L\n 03:15 AM\n Amylase\n 93 IU/L\n 03:38 AM\n Total Bilirubin\n 3.7 mg/dL\n 03:15 AM\n WBC\n 4.1 K/uL\n 03:15 AM\n Hgb\n 9.2 g/dL\n 03:15 AM\n Hematocrit\n 27.0 %\n 08:58 AM\n Current diet order / nutrition support: NPO, FS Nutren Pulmonary\n @60cc/hr\n GI: Abd soft/dist/ (+) BS, (-) flatus\n Assessment of Nutritional Status\n 63 y/o M with Hepatitis C cirrhosis, s/p PEA arrest, body cooling and\n rewarming, PNA.\n Pt s/p trach yesterday, team monitoring INR closely. TF were held for\n procedure, restarted and currently @ 20cc/hr (via NGT).\n Possible head CT to r/o anoxic brain injury.\n Noted pt w/ high Na.\n .\n Medical Nutrition Therapy Plan - Recommend the Following\n 1. Advance TF to goal of 60cc/hr to provide 2160kcals and 98g\n prot/day to meet 100% est. nutrition needs\n 2. Check residuals q 4-6 hrs, hold TF if >150cc\n 3. c/w lyte mngt as you are, Phos low- noted repletions from\n today.\n 4. Monitor hydration status.\n 5. Free H2O flushes 50-100cc q 4 hrs and adjust prn.\n Following closely, please pge w/ questions #\n 11:43\n" }, { "category": "Physician ", "chartdate": "2145-01-14 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 559548, "text": "Chief Complaint:\n 24 Hour Events:\n OR SENT - At 10:20 PM\n OR RECEIVED - At 12:30 AM\n trach place, 8 portex, pt received 2 units ffp in OR\n Events:\n - around 10 pm, got trach - had some mild bleeding around the trach\n site (150cc), but otherwise without complications\n - want to keep INR low over next few days, FFP PRN\n - mildly hypernatremic, getting D5W but held during procedure, will\n finish IVFs and start TFs with free water flushes\n - continues to be on propofol sedation\n Allergies:\n Demerol (Oral) (Meperidine Hcl)\n Confusion/Delir\n Last dose of Antibiotics:\n Vancomycin - 08:30 PM\n Piperacillin/Tazobactam (Zosyn) - 06:36 AM\n Infusions:\n Propofol - 20 mcg/Kg/min\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 07:15 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.3\nC (99.2\n Tcurrent: 35.7\nC (96.3\n HR: 67 (59 - 81) bpm\n BP: 142/65(86) {106/48(63) - 165/68(96)} mmHg\n RR: 11 (0 - 27) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 73 Inch\n CVP: 8 (6 - 16)mmHg\n Total In:\n 3,425 mL\n 1,360 mL\n PO:\n TF:\n 467 mL\n 180 mL\n IVF:\n 1,486 mL\n 1,180 mL\n Blood products:\n 621 mL\n Total out:\n 3,890 mL\n 710 mL\n Urine:\n 3,890 mL\n 710 mL\n NG:\n Stool:\n Drains:\n Balance:\n -465 mL\n 650 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 550 (550 - 550) mL\n RR (Set): 12\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 100\n PIP: 19 cmH2O\n Plateau: 16 cmH2O\n Compliance: 50 cmH2O/mL\n SpO2: 100%\n ABG: 7.47/40/94./30/4\n Ve: 8.6 L/min\n PaO2 / FiO2: 235\n Physical Examination\n Eyes / Conjunctiva: PERRL, opens eyes, makes eye contact\n , Ears, Nose, Throat: , Poor dentition, NG tube, trach\n (Bloody )\n Cardiovascular: (S1: Normal), (S2: Normal), No(t) S3, No(t) S4, No(t)\n Rub\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not\n assessed), has a-line\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : ,\n Rhonchorous: )\n Abdominal: Soft, Bowel sounds present, Distended, palpable fluid wave\n Neurologic: arousable to voice, opens eyes no purposeful movements,\n withdraws to pain, non-verbal\n Labs / Radiology\n 44 K/uL\n 9.2 g/dL\n 112 mg/dL\n 0.6 mg/dL\n 30 mEq/L\n 3.8 mEq/L\n 23 mg/dL\n 111 mEq/L\n 147 mEq/L\n 27.8 %\n 4.1 K/uL\n [image002.jpg]\n 04:43 AM\n 03:24 PM\n 02:42 AM\n 03:30 AM\n 06:33 AM\n 03:37 PM\n 04:02 PM\n 09:03 PM\n 03:15 AM\n 03:29 AM\n WBC\n 5.8\n 4.9\n 4.6\n 4.1\n 4.1\n Hct\n 26.1\n 25.3\n 24.1\n 28.6\n 27.8\n Plt\n 48\n 47\n 50\n 46\n 44\n Cr\n 1.0\n 1.0\n 0.8\n 0.7\n 0.8\n 0.6\n TCO2\n 30\n 30\n 32\n 30\n Glucose\n 133\n 125\n 117\n 95\n 120\n 112\n Other labs: PT / PTT / INR:17.2/48.4/1.6, CK / CKMB /\n Troponin-T:447/26/0.24, ALT / AST:53/127, Alk Phos / T Bili:73/3.7,\n Amylase / Lipase:93/30, Differential-Neuts:84.1 %, Lymph:10.6 %,\n Mono:2.3 %, Eos:2.7 %, Lactic Acid:1.6 mmol/L, Albumin:3.3 g/dL,\n LDH:298 IU/L, Ca++:8.2 mg/dL, Mg++:1.7 mg/dL, PO4:2.6 mg/dL\n Assessment and Plan\n This is a 63 y/o M with Hepatitis C cirrhosis, s/p PEA arrest, body\n cooling and rewarming, with Fusobacterium sepsis covering with Zosyn\n until .\n .\n # bleeding from trach site- lost 150cc intraop. surgery following,\n continue sedation to prevent movement, giving 2u platelets, given 1u\n FFP\n - will not give additional FFP since INR 1.6\n - ENT consult to eval for concern of posterior pharynx, giving\n affirm, lidocaine spray\n .\n # Respiratory/Ventilation: Pt re-intubated secondary to\n respiratory distress and inability to handle secretions. Unlikely to\n tolerate extubation given that underlying problem is inability to\n handle secretions which is unlikely to change. CXR from showed\n evidence of pulmonary edema. Patient getting trach in OR. Patient\n completed treatment for empire HAP for 5day with vanc/zosyn starting\n . Stopped vanc , continuing zosyn until sensitivities of\n fusobacterium.\n - giving Lasix 40mg IV with goal -1L\n .\n # Fusobacterium sepsis: Will treat for two-week course, awaiting\n sensitivities on Fusobacterium -> likely responsive to penicillin. Dx\n on , will need 14d course until . Covering with zosyn until\n sensitivies obtained.\n - surveillance blood cxs NTD\n .\n # thrombocytopenia\n platlets 171, now 44. Switched from H2 to\n PPI. Considering HIT vs. splenic sequestration\n - obtaining smear\n -\n # Mental Status: With slowly resolving delerium prior to this event,\n and now with unclear hypoxic insult to brain. GCS of on admission\n to ICU. Considering head CT to evaluate for anoxic brain injury\n post-cooling. Neuro eval for possible seizure. EEG neg for seizure,\n severe encephalopathy likely in setting of sedation. LP done earlier\n that was negative gram stain/culture, no whites, negative HSV PCR. Back\n to pre-code MS per wife. CT scan did not show any focal lesions.\n - patient is following commands, on propofol sedation\n - likely will need MRI in the future but can not tolerate now \n mental status/respiratory status\n - increase lactulose\n .\n # Resolved Renal Failure: Unclear etiology, likely combination of ATN\n in the setting of code and HRS. Renal following given concern for HRS.\n Off albumin, mitodrine and octreotide\n - f/u renal and liver recs\n .\n # Hypernatremia: Likely hypovolemic hypernatremia in the setting of\n recent ATN and current HRS. Corrected , free water deficit ~ 2-3L.\n - switching antibiotics to be made with D5W\n .\n # Cardiac: CE's trended post-arrest. Echo hyperdynamic, no cardiogenic\n shock. CK and Trop trended down\n - will consider repeat echo\n .\n # Cirrhosis: Hep C Cirrhosis, with concern for HRS.\n - pre-code mental status likely related to encephalopathy v. delirium\n - titrate up lactulose\n - liver recs -> non suitable for tx at this point, in the very small\n chance that pt improves could possibly be candidate in the future\n .\n # s/p Shock/PEA Arrest: After PEA, was initially hemodynamically stable\n but has had episodes of hypotension non-responsive to IVF boluses,\n levofed started, currently off. Echo showed no evidence of cardiogenic\n shock. s/p cooling and rewarming. Trended cardiac enzymes, came down\n and no evidence of cardiogenic shock on rewarmed echo.\n # Parotid mass. Incidental finding of L parotid mass on MRI, 1.6cm. --\n Will require ENT followup as outpt.\n .\n # Metabolic Acidosis: s/p arrest to tissue hypoxia. Lactates now\n normalized, now resolved.\n # Access: PIV, Central Line\n .\n # FEN: NPO for trach in OR, resume TF\n .\n # Prophylaxis: holding HSQ since elevated PTT, PPI\n .\n # Code: full\n .\n # Communication: Wife is HCP -> will readdress long-term goals today\n re: long-term prognosis\n .\n # Disposition: ICU for now.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 12:48 PM\n Arterial Line - 11:00 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": "2145-01-14 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 559550, "text": "Chief Complaint:\n 24 Hour Events:\n OR SENT - At 10:20 PM\n OR RECEIVED - At 12:30 AM\n trach place, 8 portex, pt received 2 units ffp in OR\n Events:\n - around 10 pm, got trach - had some mild bleeding around the trach\n site (150cc), but otherwise without complications\n - want to keep INR low over next few days, FFP PRN\n - mildly hypernatremic, getting D5W but held during procedure, will\n finish IVFs and start TFs with free water flushes\n - continues to be on propofol sedation\n Allergies:\n Demerol (Oral) (Meperidine Hcl)\n Confusion/Delir\n Last dose of Antibiotics:\n Vancomycin - 08:30 PM\n Piperacillin/Tazobactam (Zosyn) - 06:36 AM\n Infusions:\n Propofol - 20 mcg/Kg/min\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 07:15 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.3\nC (99.2\n Tcurrent: 35.7\nC (96.3\n HR: 67 (59 - 81) bpm\n BP: 142/65(86) {106/48(63) - 165/68(96)} mmHg\n RR: 11 (0 - 27) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 73 Inch\n CVP: 8 (6 - 16)mmHg\n Total In:\n 3,425 mL\n 1,360 mL\n PO:\n TF:\n 467 mL\n 180 mL\n IVF:\n 1,486 mL\n 1,180 mL\n Blood products:\n 621 mL\n Total out:\n 3,890 mL\n 710 mL\n Urine:\n 3,890 mL\n 710 mL\n NG:\n Stool:\n Drains:\n Balance:\n -465 mL\n 650 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 550 (550 - 550) mL\n RR (Set): 12\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 100\n PIP: 19 cmH2O\n Plateau: 16 cmH2O\n Compliance: 50 cmH2O/mL\n SpO2: 100%\n ABG: 7.47/40/94./30/4\n Ve: 8.6 L/min\n PaO2 / FiO2: 235\n Physical Examination\n Eyes / Conjunctiva: PERRL, opens eyes, makes eye contact\n , Ears, Nose, Throat: , Poor dentition, NG tube, trach\n (Bloody )\n Cardiovascular: (S1: Normal), (S2: Normal), No(t) S3, No(t) S4, No(t)\n Rub\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not\n assessed), has a-line\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : ,\n Rhonchorous: )\n Abdominal: Soft, Bowel sounds present, Distended, palpable fluid wave\n Neurologic: arousable to voice, opens eyes no purposeful movements,\n withdraws to pain, non-verbal\n Labs / Radiology\n 44 K/uL\n 9.2 g/dL\n 112 mg/dL\n 0.6 mg/dL\n 30 mEq/L\n 3.8 mEq/L\n 23 mg/dL\n 111 mEq/L\n 147 mEq/L\n 27.8 %\n 4.1 K/uL\n [image002.jpg]\n 04:43 AM\n 03:24 PM\n 02:42 AM\n 03:30 AM\n 06:33 AM\n 03:37 PM\n 04:02 PM\n 09:03 PM\n 03:15 AM\n 03:29 AM\n WBC\n 5.8\n 4.9\n 4.6\n 4.1\n 4.1\n Hct\n 26.1\n 25.3\n 24.1\n 28.6\n 27.8\n Plt\n 48\n 47\n 50\n 46\n 44\n Cr\n 1.0\n 1.0\n 0.8\n 0.7\n 0.8\n 0.6\n TCO2\n 30\n 30\n 32\n 30\n Glucose\n 133\n 125\n 117\n 95\n 120\n 112\n Other labs: PT / PTT / INR:17.2/48.4/1.6, CK / CKMB /\n Troponin-T:447/26/0.24, ALT / AST:53/127, Alk Phos / T Bili:73/3.7,\n Amylase / Lipase:93/30, Differential-Neuts:84.1 %, Lymph:10.6 %,\n Mono:2.3 %, Eos:2.7 %, Lactic Acid:1.6 mmol/L, Albumin:3.3 g/dL,\n LDH:298 IU/L, Ca++:8.2 mg/dL, Mg++:1.7 mg/dL, PO4:2.6 mg/dL\n Assessment and Plan\n This is a 63 y/o M with Hepatitis C cirrhosis, s/p PEA arrest, body\n cooling and rewarming, with Fusobacterium sepsis covering with Zosyn\n until .\n .\n # bleeding from trach site- lost 150cc intraop. surgery following,\n continue sedation to prevent movement, giving 2u platelets, given 1u\n FFP\n - will not give additional FFP since INR 1.6\n - ENT consult to eval for concern of posterior pharynx, giving\n affirm, lidocaine spray\n .\n # Respiratory/Ventilation: Pt re-intubated secondary to\n respiratory distress and inability to handle secretions. Unlikely to\n tolerate extubation given that underlying problem is inability to\n handle secretions which is unlikely to change. CXR from showed\n evidence of pulmonary edema. Patient getting trach in OR. Patient\n completed treatment for empire HAP for 5day with vanc/zosyn starting\n . Stopped vanc , continuing zosyn until sensitivities of\n fusobacterium.\n - giving Lasix 40mg IV with goal -1L\n .\n # Fusobacterium sepsis: Will treat for two-week course, awaiting\n sensitivities on Fusobacterium -> likely responsive to penicillin. Dx\n on , will need 14d course until . Covering with zosyn until\n sensitivies obtained.\n - surveillance blood cxs NTD\n .\n # thrombocytopenia\n platlets 171, now 44. Switched from H2 to\n PPI. Considering HIT vs. splenic sequestration\n - obtaining smear\n -\n # Mental Status: With slowly resolving delerium prior to this event,\n and now with unclear hypoxic insult to brain. GCS of on admission\n to ICU. Considering head CT to evaluate for anoxic brain injury\n post-cooling. Neuro eval for possible seizure. EEG neg for seizure,\n severe encephalopathy likely in setting of sedation. LP done earlier\n that was negative gram stain/culture, no whites, negative HSV PCR. Back\n to pre-code MS per wife. CT scan did not show any focal lesions.\n - patient is following commands, on propofol sedation\n - likely will need MRI in the future but can not tolerate now \n mental status/respiratory status\n - increase lactulose\n .\n # Resolved Renal Failure: Unclear etiology, likely combination of ATN\n in the setting of code and HRS. Renal following given concern for HRS.\n Off albumin, mitodrine and octreotide\n - f/u renal and liver recs\n .\n # Hypernatremia: Likely hypovolemic hypernatremia in the setting of\n recent ATN and current HRS. Corrected , free water deficit ~ 2-3L.\n - switching antibiotics to be made with D5W\n .\n # Cardiac: CE's trended post-arrest. Echo hyperdynamic, no cardiogenic\n shock. CK and Trop trended down\n - will consider repeat echo\n .\n # Cirrhosis: Hep C Cirrhosis, with concern for HRS.\n - pre-code mental status likely related to encephalopathy v. delirium\n - titrate up lactulose\n - liver recs -> non suitable for tx at this point, in the very small\n chance that pt improves could possibly be candidate in the future\n .\n # s/p Shock/PEA Arrest: After PEA, was initially hemodynamically stable\n but has had episodes of hypotension non-responsive to IVF boluses,\n levofed started, currently off. Echo showed no evidence of cardiogenic\n shock. s/p cooling and rewarming. Trended cardiac enzymes, came down\n and no evidence of cardiogenic shock on rewarmed echo.\n # Parotid mass. Incidental finding of L parotid mass on MRI, 1.6cm. --\n Will require ENT followup as outpt.\n .\n # Metabolic Acidosis: s/p arrest to tissue hypoxia. Lactates now\n normalized, now resolved.\n # Access: PIV, Central Line\n .\n # FEN: NPO for trach in OR, resume TF\n .\n # Prophylaxis: holding HSQ since elevated PTT, PPI\n .\n # Code: full\n .\n # Communication: Wife is HCP -> will readdress long-term goals today\n re: long-term prognosis\n .\n # Disposition: ICU for now.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 12:48 PM\n Arterial Line - 11:00 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": "2145-01-13 00:00:00.000", "description": "Nursing Progress Note", "row_id": 559361, "text": "Synopsis per prior nursing note:\n Pt admitted to on s/p fall for back spinal fusion. Has been\n confused since surgery according to pt's wife later developed UTI.\n Unknown cause of MS changes. ? encephalopathy vs. infection.Pt had\n resp distress, became unresponsive and went into PEA arrest on .Pt\n has been on Arctic sun.CT neg for PE or bleed.Pt was succefully\n extubated on .But developed acute respiratory distress on that\n night with increasing agitation and confusion.Was reintubated on\n .Head CT neg for any acute changes.\n Altered mental status (not Delirium)\n Assessment:\n Arouses to voice/stimuli. Inconsistantly follows simple commands.\n Occasionally has non-purposeful movements of upper and lower\n extremities. At times becomes extremely restless (pulling arms toward\n face, lifting legs and moving them towards edge of bed, fighting vent).\n Action:\n Continued on propofol gtt. Reorientation attempted frequently.\n Lactulose held d/t NPO status.\n Response:\n Continues to be restless when less sedated.\n Plan:\n Continue neuro checks. Continue to reorient. Continue Lactulose when no\n longer NPO, ?lactulose PR.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Vent settings CMV 12/550/40%/PEEP8. LS diminished. Tmax 99.2 PO.\n Action:\n PEEP decreased to 5. Continued on vanco/zosyn. Suctioned small amt of\n blood tinged secretions. Frequent position changes. Chest PT done.\n Response:\n Appears comfortable on vent settings. O2 sats 95-100%. ABG\n 7.48/42/77/32.\n Plan:\n Wean vent as tolerated. Suction as needed. Continue chest PT. Continue\n antibiotics. ?trach Thursday.\n Electrolyte & fluid disorder, other\n Assessment:\n K 3.8. Phos 1.6.\n Action:\n Given 2 pks of neutra phos. K repleted on prior shift. Lasix 40mEq IV\n given.\n Response:\n Plan:\n Monitor electrolytes.\n" }, { "category": "Rehab Services", "chartdate": "2145-01-19 00:00:00.000", "description": "PMV Evaluation", "row_id": 560556, "text": "TITLE: PASSY MUIR SPEAKING VALVE EVALUATION / DISPENSE\n Pt was seen at bedside for PMV trial. Tolerated well for brief\n period. PMV left at bedside for placement at RN/RT discretion. Please\n see note in OMR/paper chart for full details and recs. Please\n reconsult when pt\ns MS and ability to maintain upright positioning\n would be appropriate for swallow evaluation.\n Whitmill, MS, CCC-SLP\n Pager #\n" }, { "category": "Nutrition", "chartdate": "2145-01-19 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 560557, "text": "Subjective\n Unable to speak w/ pt\n Objective\n :\n Value\n Date\n Glucose\n 85 mg/dL\n 03:15 AM\n Glucose Finger Stick\n 125\n 12:00 PM\n BUN\n 13 mg/dL\n 03:15 AM\n Creatinine\n 0.5 mg/dL\n 03:15 AM\n Sodium\n 143 mEq/L\n 03:15 AM\n Potassium\n 3.7 mEq/L\n 03:15 AM\n Chloride\n 110 mEq/L\n 03:15 AM\n TCO2\n 27 mEq/L\n 03:15 AM\n PO2 (arterial)\n 170 mm Hg\n 02:41 PM\n PO2 (venous)\n 33 mm Hg\n 11:15 AM\n PCO2 (arterial)\n 46 mm Hg\n 02:41 PM\n PCO2 (venous)\n 57 mm Hg\n 11:15 AM\n pH (arterial)\n 7.41 units\n 02:41 PM\n pH (venous)\n 7.34 units\n 11:15 AM\n pH (urine)\n 5.0 units\n 12:42 PM\n CO2 (Calc) arterial\n 30 mEq/L\n 02:41 PM\n CO2 (Calc) venous\n 32 mEq/L\n 11:15 AM\n Albumin\n 3.3 g/dL\n 02:42 AM\n Calcium non-ionized\n 8.4 mg/dL\n 03:15 AM\n Phosphorus\n 2.2 mg/dL\n 03:15 AM\n Ionized Calcium\n 1.17 mmol/L\n 05:38 AM\n Magnesium\n 1.7 mg/dL\n 03:15 AM\n ALT\n 60 IU/L\n 02:55 AM\n Alkaline Phosphate\n 129 IU/L\n 02:55 AM\n AST\n 136 IU/L\n 02:55 AM\n Amylase\n 38 IU/L\n 02:55 AM\n Total Bilirubin\n 2.5 mg/dL\n 02:55 AM\n Triglyceride\n 143 mg/dL\n 02:55 AM\n WBC\n 3.9 K/uL\n 03:15 AM\n Hgb\n 8.6 g/dL\n 03:15 AM\n Hematocrit\n 26.1 %\n 03:15 AM\n Current diet order / nutrition support: NPO, TF Rx: FS Nutren Pulmonary\n @ 60cc/hr\n GI: Abd soft/ dist/(+) BS\n Assessment of Nutritional Status\n 63 y/o M who has continued AMS to point where not communicating at all;\n with hx Hepatitis C cirrhosis, s/p PEA arrest, body cooling and\n rewarming, with Fusobacterium sepsis.\n Pt trached , now tolerating PMV.\n MRI unremarkable, MS slowly improving\n Pt TF held O/N d/t positioning issues/ ? of aspiration. Paged by MD\n this afternoon, that safe to re-start TF later this evening.\n Rec changing TF given pt w/ hypovolemic hypernatremia.\n Medical Nutrition Therapy Plan - Recommend the Following\n 1. Change TF Rx to FS Fibersource HN @ goal 75cc/hr to provide\n 2160kcals and 95g prot/day\n 2. Start w/ 10cc/hr and adv slowly, HOB elevated to 30 degrees\n 3. Check residuals q 4-6hrs, hold TF if >150cc\n 4. c/w free H2O flushes and adjust prn.\n Following closely, please pge w/ questions #\n 14:37\n" }, { "category": "Nursing", "chartdate": "2145-01-14 00:00:00.000", "description": "Nursing Progress Note", "row_id": 559619, "text": "Pt admitted to on s/p fall for back spinal fusion. Has been\n confused since surgery according to pt's wife later developed UTI.\n Unknown cause of MS changes. ? encephalopathy vs. infection.Pt had\n resp distress, became unresponsive and went into PEA arrest on .Pt\n has been on Arctic sun.CT neg for PE or bleed.Pt was succefully\n extubated on . Reintubated . Trached . Head CT neg for any\n acute changes.\n Events: Given 1unit FFP and 1unit platelets. Moderate amt of bloody\n secretions suctioned from mouth and suc cath. ENT eval done.\n Electrolyte & fluid disorder, other\n Assessment:\n Action:\n Response:\n Plan:\n Hepatic encephalopathy\n Assessment:\n Action:\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "General", "chartdate": "2145-01-12 00:00:00.000", "description": "Generic Note", "row_id": 559214, "text": "TITLE: Critical Care\n Present for the key portions of resident\ns history and exam. Agree\n substantially with assessment and plan.\n He is now stable on the ventilator. He is unresponsive this am and we\n are decreasing his sedation. Secretions are not copious. Awaiting\n sputum cx.\n We are continuing rx of hepatic encephalopathy. Na corrected. Neuro\n is recommending an MR\n is likely to require trache if plan is to continue aggressive care.\n Will lighten sedation, change vent to PSV, arrange family meeting.\n Time spent 35 min\n Critically ill\n ------ Protected Section ------\n Critical Care\n Met with patient\ns wife to discuss goals of care. He currently is too\n delirious to protect airway, yet we cannot eliminate sedation and care\n for him. Best approach may be to trache him and stop all meds we can.\n If no signif improvement in MS she is of the opinion her husb would not\n want to pursue aggressive care.\n Time spent 40 min\n Critically ill\n ------ Protected Section Addendum Entered By: , MD\n on: 18:08 ------\n" }, { "category": "Nursing", "chartdate": "2145-01-19 00:00:00.000", "description": "Nursing Progress Note", "row_id": 560618, "text": "HPI: Pt admitted to on s/p fall for spinal fusion. Per pt\n wife pt has been confused since surgery. Did have known UTI however\n post treatment continues to have MS changes. Team questioning\n encephalopathy vs. infection. pt had episode of respiratory\n distress then became unresponsive and went into PEA arrest, intubated\n during code. Pt had been on Arctic sun for post VT arrest cooling, now\n off. CT negative for PE or bleed. Pt was successfully extubated on\n , however unable to tolerate and reintubated . Trached .\n Repeat head CT negative for any acute changes.\n TF restarted at 10 ml/hr for 5 hrs, pt removed NGT at 1700. Team\n does not want to place post-pyloric dophoff at this time, pt will need\n access for TF/ FWBs for hypernatremia.\n Hepatic encephalopathy\n Assessment:\n Ammonia level from yesterday WNL, pt A + O x 2. Pt has known\n cirrohsis, hep C. Ascites present.\n Action:\n Pt conts on 60 ml lactulose qid.\n Response:\n Pt putting out approx 2 L / day liquid stool.\n Plan:\n Maintain aggressive lactulose tx.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Trach in place, inner cannula changed today. Trach mask on w/ Fi02 at\n 40%, Spo2 95-100%.\n Action:\n PMV applied today for 3.5 hrs, pt OOB in stretcher chair for 2.5 hrs.\n Response:\n Sp02 remains 95-100%, PMV removed when pt became increasingly agitated\n and tachycardic, trach mask on again.\n Plan:\n Cont to wean pt from trach mask as tol. Case mgt is screening pt for\n rehab placement.\n Electrolyte & fluid disorder, other\n Assessment:\n Pt conts w/ FWB of 500 ml q 3 h for hx of hypernatremia. Na this AM\n was 143.\n Action:\n Cont w/ FWB and fluids in D5.\n Response:\n Na this afternoon 144.\n Plan:\n Monitor lytes.\n" }, { "category": "General", "chartdate": "2145-01-15 00:00:00.000", "description": "Generic Note", "row_id": 559727, "text": "TITLE: Critical Care\n Present for the key portions of the resident\ns history and exam. Agree\n substantially with assessment and plan.\n Remains on low dose of propofol. Appears alert but not following\n commands, akesthetic.\n Producing bloody secretions but oozing at trache site diminishing\n SaO2 good on trache collar\n Lack of improvement in MS . We are increasing lactulose\n Time spent\n 35 min\n Critically ill\n" }, { "category": "Nursing", "chartdate": "2145-01-15 00:00:00.000", "description": "Nursing Progress Note", "row_id": 559734, "text": "63 y/o M with Hepatitis C cirrhosis, s/p PEA arrest, body cooling and\n rewarming, with Fusobacterium sepsis covering with Zosyn until .\n Altered mental status (not Delirium)\n Assessment:\n More awake, however does not follow commands, tracks or tries to\n communicate. Pupils 2-3mm equal and reactive. Remains slightly rigid.\n On propofol sedation, possibly encephalopathic\n Action:\n Propofol d/c if agitated will try halidol or zyprexa. If in pain treat\n pain, lactolose increased to 60 q4hr.\n Response:\n Per wife more awake, however still no communicable and does not follows\n commands.\n Plan:\n Continue top monitor patient\ns neuro status, may need MRI later on,\n meds \n Respiratory failure, acute (not ARDS/)\n Assessment:\n Remains trached and vented on PSV 40% 5/5. Bil LS clear, RRR, copious\n amnt of bloody secretions w/suctioning and around trach. Periods of\n low MV.\n Action:\n Weaned to trach mask, suction prn, trach care and frequent mouth care,\n ENT consulted, lasix 40mg X1 given w/goal of -2L\n Response:\n pending\n Plan:\n Continue to monitor resp status, meds , need bronch later on.\n Mouth care and trach care as needed.\n Cardio: normotensive hr at 90\ns SR no ectopy, upper extr edema,\n peripheral pulses present.\n GI: abd soft distended positive for BS, on lactolose q4hr, brown stool\n in flexiseal. TF at goal of 60/hr tolerates it well.\n GU: clear yellow urine via foley. Adequate amnt. Got lasix 40mg X1\n given.\n I\n IV access: LT subclavian, LT aline.\n Social: patient is a FULL CODE> family in to visit updated by RN.\n" }, { "category": "General", "chartdate": "2145-01-11 00:00:00.000", "description": "Generic Note", "row_id": 558900, "text": "TITLE: Critical Care Note\n Present for key portions of the resident\ns history and exam. Agree\n substantially with assessment and plan Agitated, desaturating\n overnight. MS remains poor, intermittently agitated, confused. C/o\n thirst. Spontaneous diuresis over day yesterday\n resolving ATN.\n MS remains problem. weak. Not clear if this is primarily\n hepatic encephalopathy, hypernatremia, or post arrest. Not stable\n enough for CT without intubation. Will correct free water, continue\n lactulose, review with Neuro.\n Will discuss long term prognosis with Hepatology\n Time spent 40 min\n Critically Ill\n ------ Protected Section ------\n Critical Care\n Apparent VT arrest immediately after intubation for progressive resp\n failure. Maintained pulse. Got Ca for ? of hyperkalemia due to\n succinylcholine. Converted spontaneously as we were preparing to\n cardiovert. K later returned > 6 making suc likely cause. Now hemodyn\n stable and oxygenation has returned\n derecruited very rapidly\n Time spent 60 min\n Critically ill\n ------ Protected Section Addendum Entered By: , MD\n on: 13:20 ------\n" }, { "category": "Nutrition", "chartdate": "2145-01-12 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 559145, "text": "Subjective\n Pt intubated/sedated\n Objective\n Pertinent medications: Noted\n Labs:\n Value\n Date\n Glucose\n 133 mg/dL\n 04:43 AM\n Glucose Finger Stick\n 182\n 10:00 AM\n BUN\n 43 mg/dL\n 04:43 AM\n Creatinine\n 1.0 mg/dL\n 04:43 AM\n Sodium\n 145 mEq/L\n 04:43 AM\n Potassium\n 3.6 mEq/L\n 04:43 AM\n Chloride\n 110 mEq/L\n 04:43 AM\n TCO2\n 32 mEq/L\n 04:43 AM\n PO2 (arterial)\n 109 mm Hg\n 09:57 PM\n PO2 (venous)\n 33 mm Hg\n 11:15 AM\n PCO2 (arterial)\n 42 mm Hg\n 09:57 PM\n PCO2 (venous)\n 57 mm Hg\n 11:15 AM\n pH (arterial)\n 7.44 units\n 09:57 PM\n pH (venous)\n 7.34 units\n 11:15 AM\n pH (urine)\n 5.0 units\n 12:42 PM\n CO2 (Calc) arterial\n 29 mEq/L\n 09:57 PM\n CO2 (Calc) venous\n 32 mEq/L\n 11:15 AM\n Calcium non-ionized\n 8.8 mg/dL\n 04:43 AM\n Phosphorus\n 1.7 mg/dL\n 04:43 AM\n Ionized Calcium\n 1.01 mmol/L\n 10:22 AM\n Magnesium\n 2.3 mg/dL\n 04:43 AM\n ALT\n 60 IU/L\n 04:43 AM\n Alkaline Phosphate\n 72 IU/L\n 04:43 AM\n AST\n 144 IU/L\n 04:43 AM\n Amylase\n 93 IU/L\n 03:38 AM\n Total Bilirubin\n 3.4 mg/dL\n 04:43 AM\n WBC\n 5.8 K/uL\n 04:43 AM\n Hgb\n 8.5 g/dL\n 04:43 AM\n Hematocrit\n 26.1 %\n 04:43 AM\n Current diet order / nutrition support: FS Novasource Renal@ 40cc/hr\n GI: Abd soft/ dist/ hypo BS/ (+) BM\n Assessment of Nutritional Status\n Estimated Nutritional Needs based on adj BW 88kg\n Calories:2200-2460kcals/day (25-28kcal/kg)\n Protein: 70-106g/day (0.8-1.2 g/kg)\n Fluid: per team\n Specifics:\n 63 y/o M with Hepatitis C cirrhosis hepatorenal syndrome, s/p PEA\n arrest, body cooling and rewarming, concern for HRS, unclear hypoxic\n insult to brain/anoxic injury post-cooling.\n Currently off the liver transplant list, pending family meeting to\n address goals of care, possible need for trach.\n Pt receiving TF at the above goal to provide 1920kcals and 71g\n prot/day, underfeeding calories and protein.\n .\n Medical Nutrition Therapy Plan - Recommend the Following\n 1. Change TF Rx to FS Nutren Pulmonary @ 60cc/hr to provide\n 2160kcals and 98g protein/day to meet est. nutrition needs. Possible\n that Novasource Renal may be contributing to decreasing Phos.\n 2. Check residuals q 4-6hrs, hold TF if >150cc\n 3. c/w lyte mngt as you are, replete Phos today.\n Following closely, will adj TF Rx prn based on progress/ labs\n Please pge w/ questions #\n 11:31\n" }, { "category": "Nursing", "chartdate": "2145-01-12 00:00:00.000", "description": "Nursing Progress Note", "row_id": 559215, "text": "Synopsis per prior nursing note:\n Pt admitted to on s/p fall for back spinal fusion. Has been\n confused since surgery according to pt's wife later developed UTI.\n Unknown cause of MS changes. ? encephalopathy vs. infection.Pt had\n resp distress, became unresponsive and went into PEA arrest on .Pt\n has been on Arctic sun.CT neg for PE or bleed.Pt was succefully\n extubated on .But developed acute respiratory distress on that\n night with increasing agitation and confusion.Was reintubated on\n .Head CT neg for any acute changes.\n Altered mental status (not Delirium)\n Assessment:\n Arouses to strong stimuli. Not following commands. Occasionally has\n non-purposeful movements of upper and lower extremities. At times\n becomes extremely restless (pulling arms toward face, lifting legs and\n moving them towards edge of bed, fighting vent).\n Action:\n Sedation turned off @0800. Given bolus sedation for sustained\n restlessness. Reorientation attempted frequently. Continued on\n lactulose TID.\n Response:\n Becomes less agitated w/ bolus sedation.\n Plan:\n Continue neuro checks. Continue to reorient. Bolus sedation PRN.\n Continue lactulose.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Vent settings CMV 18/550/40%/PEEP10. LS clear w/ diminished bases.\n Action:\n PEEP decreased to 8. Continued on vanco/zosyn. Suctioned small amt of\n blood tinged secretions. Frequent position changes. Chest PT done.\n Response:\n Appears comfortable on vent settings. O2 sats 98-100%.\n Plan:\n Wean vent as tolerated. Suction as needed. Continue chest PT. Continue\n antibiotics. ?trach Thursday.\n Electrolyte & fluid disorder, other\n Assessment:\n K 3.6. Phos 1.7.\n Action:\n Given 2 pks of neutra phos and 20mEq potassium IV.\n Response:\n Repeat K 3.9, phos 1.6 (Intern aware).\n Plan:\n Monitor electrolytes.\n" }, { "category": "Nursing", "chartdate": "2145-01-12 00:00:00.000", "description": "Nursing Progress Note", "row_id": 559221, "text": "Synopsis per prior nursing note:\n Pt admitted to on s/p fall for back spinal fusion. Has been\n confused since surgery according to pt's wife later developed UTI.\n Unknown cause of MS changes. ? encephalopathy vs. infection.Pt had\n resp distress, became unresponsive and went into PEA arrest on .Pt\n has been on Arctic sun.CT neg for PE or bleed.Pt was succefully\n extubated on .But developed acute respiratory distress on that\n night with increasing agitation and confusion.Was reintubated on\n .Head CT neg for any acute changes.\n Altered mental status (not Delirium)\n Assessment:\n Arouses to strong stimuli. Not following commands. Occasionally has\n non-purposeful movements of upper and lower extremities. At times\n becomes extremely restless (pulling arms toward face, lifting legs and\n moving them towards edge of bed, fighting vent).\n Action:\n Sedation turned off @0800. Given bolus sedation for sustained\n restlessness. Reorientation attempted frequently. Continued on\n lactulose TID.\n Response:\n Becomes less agitated w/ bolus sedation.\n Plan:\n Continue neuro checks. Continue to reorient. Bolus sedation PRN.\n Continue lactulose.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Vent settings CMV 18/550/40%/PEEP10. LS clear w/ diminished bases.\n Action:\n PEEP decreased to 8. Continued on vanco/zosyn. Suctioned small amt of\n blood tinged secretions. Frequent position changes. Chest PT done.\n Response:\n Appears comfortable on vent settings. O2 sats 98-100%.\n Plan:\n Wean vent as tolerated. Suction as needed. Continue chest PT. Continue\n antibiotics. ?trach Thursday.\n Electrolyte & fluid disorder, other\n Assessment:\n K 3.6. Phos 1.7.\n Action:\n Given 2 pks of neutra phos and 20mEq potassium IV.\n Response:\n Repeat K 3.9, phos 1.6 (Intern aware).\n Plan:\n Monitor electrolytes. Replete phos.\n" }, { "category": "Nursing", "chartdate": "2145-01-14 00:00:00.000", "description": "Nursing Progress Note", "row_id": 559608, "text": "Synopsis per prior nursing note:\n Pt admitted to on s/p fall for back spinal fusion. Has been\n confused since surgery according to pt's wife later developed UTI.\n Unknown cause of MS changes. ? encephalopathy vs. infection.Pt had\n resp distress, became unresponsive and went into PEA arrest on .Pt\n has been on Arctic sun.CT neg for PE or bleed.Pt was succefully\n extubated on . Reintubated . Trached . Head CT neg for any\n acute changes.\n Events: Given 1unit FFP and 1unit platelets. Moderate amt of bloody\n secretions suctioned from mouth and suc cath. ENT eval done.\n Altered mental status\n Assessment:\n Continued on propofol gtt. Moving extremities on bed. Not following\n commands. Non-purposeful movements. PERRLA, sluggish.\n Action:\n Continued on propofol gtt. Reorientation attempted frequently.\n Lactulose PO and PR given.\n Response:\n Continues to be restless when less sedated.\n Plan:\n Continue neuro checks. Continue to reorient. Continue Lactulose.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Vent settings CMV 12/550/40%/PEEP8. LS clear w/ diminished bases. O2\n sats >98%. INR 1.6, platelets 44.\n Action:\n Changed to PS, PEEP 5, PS 10. Vanco/zosyn d/c\nd and PCN started.\n Suctioned moderate amt of bloody secretions from mouth and suc cath.\n Frequent position changes. Lasix 40mEq IV given. ENT eval bleeding.\n 1unit FFP and 1unit platelets given. Vitamin K given.\n Response:\n Appears comfortable on vent settings. O2 sats 98-100%. ABG\n 7.45/44/100/32. Continues to diurese from lasix. INR 1.5, platelets 60,\n Hct 27-28.\n Plan:\n Wean vent as tolerated. Suction as needed. Continue antibiotics.\n Monitor UOP. ?additional dose of lasix if UOP decreases (goal 1L neg).\n Monitor hct, INR, platelets, electrolytes.\n Electrolyte & fluid disorder, other\n Assessment:\n Na 147. Received w/ TF off.\n Action:\n Free water boluses restarted q4hrs. TF restarted (goal 60cc/hr). Pharm\n called to have meds in D5W instead of NS.\n Response:\n Repeat Na 145. K 3.7 (given 20mEq potassium IV given). Minimal\n residuals.\n Plan:\n Monitor electrolytes. Increase TF to goal as tolerated.\n" }, { "category": "Physician ", "chartdate": "2145-01-07 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 558048, "text": "Chief Complaint: s/p Cardiac Arrest\n HPI:\n History of Present Illness: Patient is a 63 year-old man w/ history of\n Hepatitis C and cirrhosis, hepatocellular carcinoma who initially\n presented on with unsteadiness, tremor, and fall. His hospital\n course is significant for hepatic encephalopathy, treated with\n lactulose, cervical cord compresson, OR on , MS change\n ?delirium treated with haldol, ?NMS due to rigidity and fever and\n elevated CK, broad Abx for possible infection (UTI). Poor MS never\n recovered. Also guestion of HRS.\n .\n On the floor, this AM patient was verbal and otherwise alert. Nurse\n was present in room when patient suddently became unresponsive and\n pulseless. CPR was initiated promptly. Initial rhythm demonstrated\n PEA/bradycardia, patient was intubated and given epi/atropine. A large\n mucous plug was suctioned from the ET tube, with subsequent restoration\n of perfusing rhythm. Patient was transfered to ICU for managment.\n Patient admitted from: \n History obtained from Family / Medical records\n Patient unable to provide history: Sedated, Encephalopathy,\n Unresponsive\n Allergies:\n Demerol (Oral) (Meperidine Hcl)\n Confusion/Delir\n Last dose of Antibiotics:\n Infusions:\n Fentanyl - 50 mcg/hour\n Midazolam (Versed) - 2 mg/hour\n Other ICU medications:\n Midazolam (Versed) - 11:30 AM\n Fentanyl - 11:30 AM\n Other medications:\n Past medical history:\n Family history:\n Social History:\n 1. Bipolar disorder.\n 2. HCV - unclear genotype. Grade 1 esophageal varices on EGD in 4/.\n Liver biopsy in with Stage 4 cirrhosis and small\n well-differentiated hepatocellular carcinoma.\n 3. Hypothyroidism.\n 4. Suicide attempt in the past.\n Non-contributory\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: He lives w/ wife, who is a nurse. \n beverage for 30 years. No tobacco use ever.\n Review of systems:\n Flowsheet Data as of 03:45 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n HR: 92 (92 - 156) bpm\n BP: 108/48(60) {87/48(60) - 146/84(77)} mmHg\n RR: 18 (18 - 27) insp/min\n SpO2: 98%\n Total In:\n 1,027 mL\n PO:\n TF:\n IVF:\n 1,027 mL\n Blood products:\n Total out:\n 0 mL\n 225 mL\n Urine:\n 225 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 802 mL\n Respiratory\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 550 (550 - 550) mL\n RR (Set): 18\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 12 cmH2O\n SpO2: 98%\n ABG: 7.33/60/30/27/3\n Ve: 15.3 L/min\n PaO2 / FiO2: 60\n Physical Examination\n Eyes / Conjunctiva: PERRL, dysconjugate gaze\n Head, Ears, Nose, Throat: Normocephalic, Poor dentition, Endotracheal\n tube, NG tube\n Cardiovascular: (S1: Normal), (S2: Normal), No(t) S3, No(t) S4, No(t)\n Rub\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : ,\n Rhonchorous: )\n Abdominal: Soft, Bowel sounds present, Distended, palpable fluid wave\n Extremities: Right: Absent, Left: Absent\n Skin: Not assessed\n Neurologic: No(t) Attentive, No(t) Follows simple commands, Responds\n to: Noxious stimuli, Movement: Not assessed, Tone: Not assessed,\n Patient not arousable to voice, no purposeful movements, withdraws to\n pain, non-verbal\n Labs / Radiology\n 152 K/uL\n 13.0 g/dL\n 105 mg/dL\n 2.1 mg/dL\n 75 mg/dL\n 27 mEq/L\n 98 mEq/L\n 4.3 mEq/L\n 140 mEq/L\n 39.6 %\n 13.4 K/uL\n [image002.jpg]\n \n 2:33 A2/19/ 11:21 AM\n \n 10:20 P2/19/ 01:24 PM\n \n 1:20 P\n \n 11:50 P\n \n 1:20 A\n \n 7:20 P\n 1//11/006\n 1:23 P\n \n 1:20 P\n \n 11:20 P\n \n 4:20 P\n WBC\n 13.4\n Hct\n 39.6\n Plt\n 152\n Cr\n 2.1\n TropT\n 0.27\n TC02\n 33\n Glucose\n 105\n Other labs: PT / PTT / INR:16.2/42.3/1.4, CK / CKMB /\n Troponin-T:1287/31/0.27, Differential-Neuts:74.5 %, Lymph:14.1 %,\n Mono:8.1 %, Eos:2.9 %, Lactic Acid:5.2 mmol/L, Ca++:8.3 mg/dL, Mg++:3.4\n mg/dL, PO4:6.0 mg/dL\n Imaging: CXR no significant change from prior. Some asymmetry to\n lungs suggesting differential blood flow\n Microbiology: Urine: E. Coli - pan sensitive\n ECG: Sinus tach with normalization of T-waves in inferior leads.\n Assessment and Plan\n Assessment and Plan: This is a 63 y/o M with Hepatitis C cirrhosis, a\n to ICU w/ PEA arrest to mucous plug.\n .\n # Shock/PEA Arrest: Witness arrest to mucous plug.\n - Now hemodynamically stable, access achieved.\n - Culture broadly to guid further care but would not cover with\n antibiotics at this time\n - Rule out for MI with serial enzymes\n - follow-UOP and bolus IVF's PRN.\n - Opt for dopamine or levo as initial pressor of choice.\n - frequent suctioning and bronch to evaluate airways for retained food.\n .\n # Neuro: With slowly resolving delerium prior to this event, and now\n with unclear hypoxic insult to brain. GCS of on admission to ICU.\n Consider cooling protocol. Head CT to evaluate for anoxic brain injury\n post-cooling. Neuro eval for possible seizure.\n - Will need sedation and paralysis for cooling.\n - Low dose fentanyl/versed for sedation for now.\n - LP done earlier this admit that was negative gram stain/culture, no\n whites, negative HSV PCR.\n - Dysconjugate gaze c/w possible seizure consult neuro for EEG.\n .\n # Respiratory/Ventilation: Assist control. Low tidal volumes to avoid\n unneeded injury, with pH goal of above 7.25.\n - Repeat ABG now and titrate oxygen/PEEP, minute vent to effect.\n .\n # Metabolic Acidosis: s/p arrest to tissue hypoxia. Continue IVF's\n and trend lactate. Will need to increase minute ventilation for CO2.\n - Blood cultures, urine cultures for infectious source given white\n blood cell count, but do not suspect sepsis at this time.\n .\n # Cardiac: Anticipate some elevation in CE's post-arrest, will trend.\n .\n # Cirrhosis: Hep C Cirrhosis, with concern for HRS.\n - Appreciate liver rec's\n .\n # Renal Failure: Unclear Etiology. Renal following given concern for\n HRS.\n - Send urine lytes, repeat Ua post-arrest\n - Appreciate renal rec's.\n .\n # Leukocytosis: Unclear etiology. Negative tap for SBP on .\n Urine growing E. Coli. Pan-culture.\n .\n # Parotid mass. Incidental finding of L parotid mass on MRI, 1.6cm. --\n Will require OP ENT followup.\n .\n # Access: PIV, Central Line, arterial line.\n .\n # FEN: IVF, replete electrolytes\n .\n # Prophylaxis: Subcutaneous heparin\n .\n # Code: full\n .\n # Communication: Wife is HCP\n .\n # Disposition: ICU for now.\n .\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 22 Gauge - 11:30 AM\n 20 Gauge - 11:45 AM\n Multi Lumen - 12:48 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP: HOB elevation, Mouth care\n Comments:\n Communication: Family meeting held , ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n" }, { "category": "Physician ", "chartdate": "2145-01-07 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 558049, "text": "Chief Complaint: s/p Cardiac Arrest\n HPI:\n History of Present Illness: Patient is a 63 year-old man w/ history of\n Hepatitis C and cirrhosis, hepatocellular carcinoma who initially\n presented on with unsteadiness, tremor, and fall. His hospital\n course is significant for hepatic encephalopathy, treated with\n lactulose, cervical cord compresson, OR on , MS change\n ?delirium treated with haldol, ?NMS due to rigidity and fever and\n elevated CK, broad Abx for possible infection (UTI). Poor MS never\n recovered. Also guestion of HRS.\n .\n On the floor, this AM patient was verbal and otherwise alert. Nurse\n was present in room when patient suddently became unresponsive and\n pulseless. CPR was initiated promptly. Initial rhythm demonstrated\n PEA/bradycardia, patient was intubated and given epi/atropine. A large\n mucous plug was suctioned from the ET tube, with subsequent restoration\n of perfusing rhythm. Patient was transfered to ICU for managment.\n Patient admitted from: \n History obtained from Family / Medical records\n Patient unable to provide history: Sedated, Encephalopathy,\n Unresponsive\n Allergies:\n Demerol (Oral) (Meperidine Hcl)\n Confusion/Delir\n Last dose of Antibiotics:\n Infusions:\n Fentanyl - 50 mcg/hour\n Midazolam (Versed) - 2 mg/hour\n Other ICU medications:\n Midazolam (Versed) - 11:30 AM\n Fentanyl - 11:30 AM\n Other medications:\n Past medical history:\n Family history:\n Social History:\n 1. Bipolar disorder.\n 2. HCV - unclear genotype. Grade 1 esophageal varices on EGD in 4/.\n Liver biopsy in with Stage 4 cirrhosis and small\n well-differentiated hepatocellular carcinoma.\n 3. Hypothyroidism.\n 4. Suicide attempt in the past.\n Non-contributory\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: He lives w/ wife, who is a nurse. \n beverage for 30 years. No tobacco use ever.\n Review of systems:\n Flowsheet Data as of 03:45 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n HR: 92 (92 - 156) bpm\n BP: 108/48(60) {87/48(60) - 146/84(77)} mmHg\n RR: 18 (18 - 27) insp/min\n SpO2: 98%\n Total In:\n 1,027 mL\n PO:\n TF:\n IVF:\n 1,027 mL\n Blood products:\n Total out:\n 0 mL\n 225 mL\n Urine:\n 225 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 802 mL\n Respiratory\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 550 (550 - 550) mL\n RR (Set): 18\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 12 cmH2O\n SpO2: 98%\n ABG: 7.33/60/30/27/3\n Ve: 15.3 L/min\n PaO2 / FiO2: 60\n Physical Examination\n Eyes / Conjunctiva: PERRL, dysconjugate gaze\n Head, Ears, Nose, Throat: Normocephalic, Poor dentition, Endotracheal\n tube, NG tube\n Cardiovascular: (S1: Normal), (S2: Normal), No(t) S3, No(t) S4, No(t)\n Rub\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : ,\n Rhonchorous: )\n Abdominal: Soft, Bowel sounds present, Distended, palpable fluid wave\n Extremities: Right: Absent, Left: Absent\n Skin: Not assessed\n Neurologic: No(t) Attentive, No(t) Follows simple commands, Responds\n to: Noxious stimuli, Movement: Not assessed, Tone: Not assessed,\n Patient not arousable to voice, no purposeful movements, withdraws to\n pain, non-verbal\n Labs / Radiology\n 152 K/uL\n 13.0 g/dL\n 105 mg/dL\n 2.1 mg/dL\n 75 mg/dL\n 27 mEq/L\n 98 mEq/L\n 4.3 mEq/L\n 140 mEq/L\n 39.6 %\n 13.4 K/uL\n [image002.jpg]\n \n 2:33 A2/19/ 11:21 AM\n \n 10:20 P2/19/ 01:24 PM\n \n 1:20 P\n \n 11:50 P\n \n 1:20 A\n \n 7:20 P\n 1//11/006\n 1:23 P\n \n 1:20 P\n \n 11:20 P\n \n 4:20 P\n WBC\n 13.4\n Hct\n 39.6\n Plt\n 152\n Cr\n 2.1\n TropT\n 0.27\n TC02\n 33\n Glucose\n 105\n Other labs: PT / PTT / INR:16.2/42.3/1.4, CK / CKMB /\n Troponin-T:1287/31/0.27, Differential-Neuts:74.5 %, Lymph:14.1 %,\n Mono:8.1 %, Eos:2.9 %, Lactic Acid:5.2 mmol/L, Ca++:8.3 mg/dL, Mg++:3.4\n mg/dL, PO4:6.0 mg/dL\n Imaging: CXR no significant change from prior. Some asymmetry to\n lungs suggesting differential blood flow\n Microbiology: Urine: E. Coli - pan sensitive\n ECG: Sinus tach with normalization of T-waves in inferior leads.\n Assessment and Plan\n Assessment and Plan: This is a 63 y/o M with Hepatitis C cirrhosis, a\n to ICU w/ PEA arrest to mucous plug.\n .\n # Shock/PEA Arrest: Witness arrest to mucous plug.\n - Now hemodynamically stable, access achieved.\n - Culture broadly to guid further care but would not cover with\n antibiotics at this time\n - Rule out for MI with serial enzymes\n - follow-UOP and bolus IVF's PRN.\n - Opt for dopamine or levo as initial pressor of choice.\n - frequent suctioning and bronch to evaluate airways for retained food.\n .\n # Neuro: With slowly resolving delerium prior to this event, and now\n with unclear hypoxic insult to brain. GCS of on admission to ICU.\n Consider cooling protocol. Head CT to evaluate for anoxic brain injury\n post-cooling. Neuro eval for possible seizure.\n - Will need sedation and paralysis for cooling.\n - Low dose fentanyl/versed for sedation for now.\n - LP done earlier this admit that was negative gram stain/culture, no\n whites, negative HSV PCR.\n - Dysconjugate gaze c/w possible seizure consult neuro for EEG.\n .\n # Respiratory/Ventilation: Assist control. Low tidal volumes to avoid\n unneeded injury, with pH goal of above 7.25.\n - Repeat ABG now and titrate oxygen/PEEP, minute vent to effect.\n .\n # Metabolic Acidosis: s/p arrest to tissue hypoxia. Continue IVF's\n and trend lactate. Will need to increase minute ventilation for CO2.\n - Blood cultures, urine cultures for infectious source given white\n blood cell count, but do not suspect sepsis at this time.\n .\n # Cardiac: Anticipate some elevation in CE's post-arrest, will trend.\n .\n # Cirrhosis: Hep C Cirrhosis, with concern for HRS.\n - Appreciate liver rec's\n .\n # Renal Failure: Unclear Etiology. Renal following given concern for\n HRS.\n - Send urine lytes, repeat Ua post-arrest\n - Appreciate renal rec's.\n .\n # Leukocytosis: Unclear etiology. Negative tap for SBP on .\n Urine growing E. Coli. Pan-culture.\n .\n # Parotid mass. Incidental finding of L parotid mass on MRI, 1.6cm. --\n Will require OP ENT followup.\n .\n # Access: PIV, Central Line, arterial line.\n .\n # FEN: IVF, replete electrolytes\n .\n # Prophylaxis: Subcutaneous heparin\n .\n # Code: full\n .\n # Communication: Wife is HCP\n .\n # Disposition: ICU for now.\n .\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 22 Gauge - 11:30 AM\n 20 Gauge - 11:45 AM\n Multi Lumen - 12:48 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP: HOB elevation, Mouth care\n Comments:\n Communication: Family meeting held , ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n ------ Protected Section ------\n Medications on Transfer:\n Ceftriaxone 1 g IV q 24 hrs\n Vitamin D 400 IU daily\n Bengay\n Heparin SC 5000 U TID\n Lansoprazole 30 mg daily\n Tylenol 325-650 prn\n Gelclair\n Spironolactone 50 mg daily\n Lactulose 60 mL qid\n Levothyroixine 37.5 mcg daily\n Rifaxamin 400 mg tid\n Folate 1 mg daily\n Thiamine 100 mg daily\n Caphsol 30 ml oral qid\n Bactrim 1 DS tab daily (given yesterday)\n .\n Home Medications:\n . Bupropion XL 150mg TID, but not taken as prescribed. Will need to\n verify with psychiatrist in AM\n #. Esomeprazole 40mg daily\n #. Lactulose 10mg/15mL TID, not taking as prescribed.\n #. Levothyroxine 75mcg daily\n #. Lithium 600mg per pharmacy, but 450 CR in OMR, which is a\n more appropriate for dosing.\n #. Spironolactone 50mg daily\n #. Vitamin D daily\n #. Milk Thistle 400mg daily\n #. Omega-3 Fatty acids daily\n ------ Protected Section Addendum Entered By: , MD\n on: 15:47 ------\n" }, { "category": "Physician ", "chartdate": "2145-01-07 00:00:00.000", "description": "Resident / Attending Admission Notes", "row_id": 558052, "text": "Chief Complaint: s/p Cardiac Arrest\n HPI:\n History of Present Illness: Patient is a 63 year-old man w/ history of\n Hepatitis C and cirrhosis, hepatocellular carcinoma who initially\n presented on with unsteadiness, tremor, and fall. His hospital\n course is significant for hepatic encephalopathy, treated with\n lactulose, cervical cord compresson, OR on , MS change\n ?delirium treated with haldol, ?NMS due to rigidity and fever and\n elevated CK, broad Abx for possible infection (UTI). Poor MS never\n recovered. Also guestion of HRS.\n .\n On the floor, this AM patient was verbal and otherwise alert. Nurse\n was present in room when patient suddently became unresponsive and\n pulseless. CPR was initiated promptly. Initial rhythm demonstrated\n PEA/bradycardia, patient was intubated and given epi/atropine. A large\n mucous plug was suctioned from the ET tube, with subsequent restoration\n of perfusing rhythm. Patient was transfered to ICU for managment.\n Patient admitted from: \n History obtained from Family / Medical records\n Patient unable to provide history: Sedated, Encephalopathy,\n Unresponsive\n Allergies:\n Demerol (Oral) (Meperidine Hcl)\n Confusion/Delir\n Last dose of Antibiotics:\n Infusions:\n Fentanyl - 50 mcg/hour\n Midazolam (Versed) - 2 mg/hour\n Other ICU medications:\n Midazolam (Versed) - 11:30 AM\n Fentanyl - 11:30 AM\n Other medications:\n Past medical history:\n Family history:\n Social History:\n 1. Bipolar disorder.\n 2. HCV - unclear genotype. Grade 1 esophageal varices on EGD in 4/.\n Liver biopsy in with Stage 4 cirrhosis and small\n well-differentiated hepatocellular carcinoma.\n 3. Hypothyroidism.\n 4. Suicide attempt in the past.\n Non-contributory\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: He lives w/ wife, who is a nurse. \n beverage for 30 years. No tobacco use ever.\n Review of systems:\n Flowsheet Data as of 03:45 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n HR: 92 (92 - 156) bpm\n BP: 108/48(60) {87/48(60) - 146/84(77)} mmHg\n RR: 18 (18 - 27) insp/min\n SpO2: 98%\n Total In:\n 1,027 mL\n PO:\n TF:\n IVF:\n 1,027 mL\n Blood products:\n Total out:\n 0 mL\n 225 mL\n Urine:\n 225 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 802 mL\n Respiratory\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 550 (550 - 550) mL\n RR (Set): 18\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 12 cmH2O\n SpO2: 98%\n ABG: 7.33/60/30/27/3\n Ve: 15.3 L/min\n PaO2 / FiO2: 60\n Physical Examination\n Eyes / Conjunctiva: PERRL, dysconjugate gaze\n Head, Ears, Nose, Throat: Normocephalic, Poor dentition, Endotracheal\n tube, NG tube\n Cardiovascular: (S1: Normal), (S2: Normal), No(t) S3, No(t) S4, No(t)\n Rub\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : ,\n Rhonchorous: )\n Abdominal: Soft, Bowel sounds present, Distended, palpable fluid wave\n Extremities: Right: Absent, Left: Absent\n Skin: Not assessed\n Neurologic: No(t) Attentive, No(t) Follows simple commands, Responds\n to: Noxious stimuli, Movement: Not assessed, Tone: Not assessed,\n Patient not arousable to voice, no purposeful movements, withdraws to\n pain, non-verbal\n Labs / Radiology\n 152 K/uL\n 13.0 g/dL\n 105 mg/dL\n 2.1 mg/dL\n 75 mg/dL\n 27 mEq/L\n 98 mEq/L\n 4.3 mEq/L\n 140 mEq/L\n 39.6 %\n 13.4 K/uL\n [image002.jpg]\n \n 2:33 A2/19/ 11:21 AM\n \n 10:20 P2/19/ 01:24 PM\n \n 1:20 P\n \n 11:50 P\n \n 1:20 A\n \n 7:20 P\n 1//11/006\n 1:23 P\n \n 1:20 P\n \n 11:20 P\n \n 4:20 P\n WBC\n 13.4\n Hct\n 39.6\n Plt\n 152\n Cr\n 2.1\n TropT\n 0.27\n TC02\n 33\n Glucose\n 105\n Other labs: PT / PTT / INR:16.2/42.3/1.4, CK / CKMB /\n Troponin-T:1287/31/0.27, Differential-Neuts:74.5 %, Lymph:14.1 %,\n Mono:8.1 %, Eos:2.9 %, Lactic Acid:5.2 mmol/L, Ca++:8.3 mg/dL, Mg++:3.4\n mg/dL, PO4:6.0 mg/dL\n Imaging: CXR no significant change from prior. Some asymmetry to\n lungs suggesting differential blood flow\n Microbiology: Urine: E. Coli - pan sensitive\n ECG: Sinus tach with normalization of T-waves in inferior leads.\n Assessment and Plan\n Assessment and Plan: This is a 63 y/o M with Hepatitis C cirrhosis, a\n to ICU w/ PEA arrest to mucous plug.\n .\n # Shock/PEA Arrest: Witness arrest to mucous plug.\n - Now hemodynamically stable, access achieved.\n - Culture broadly to guid further care but would not cover with\n antibiotics at this time\n - Rule out for MI with serial enzymes\n - follow-UOP and bolus IVF's PRN.\n - Opt for dopamine or levo as initial pressor of choice.\n - frequent suctioning and bronch to evaluate airways for retained food.\n .\n # Neuro: With slowly resolving delerium prior to this event, and now\n with unclear hypoxic insult to brain. GCS of on admission to ICU.\n Consider cooling protocol. Head CT to evaluate for anoxic brain injury\n post-cooling. Neuro eval for possible seizure.\n - Will need sedation and paralysis for cooling.\n - Low dose fentanyl/versed for sedation for now.\n - LP done earlier this admit that was negative gram stain/culture, no\n whites, negative HSV PCR.\n - Dysconjugate gaze c/w possible seizure consult neuro for EEG.\n .\n # Respiratory/Ventilation: Assist control. Low tidal volumes to avoid\n unneeded injury, with pH goal of above 7.25.\n - Repeat ABG now and titrate oxygen/PEEP, minute vent to effect.\n .\n # Metabolic Acidosis: s/p arrest to tissue hypoxia. Continue IVF's\n and trend lactate. Will need to increase minute ventilation for CO2.\n - Blood cultures, urine cultures for infectious source given white\n blood cell count, but do not suspect sepsis at this time.\n .\n # Cardiac: Anticipate some elevation in CE's post-arrest, will trend.\n .\n # Cirrhosis: Hep C Cirrhosis, with concern for HRS.\n - Appreciate liver rec's\n .\n # Renal Failure: Unclear Etiology. Renal following given concern for\n HRS.\n - Send urine lytes, repeat Ua post-arrest\n - Appreciate renal rec's.\n .\n # Leukocytosis: Unclear etiology. Negative tap for SBP on .\n Urine growing E. Coli. Pan-culture.\n .\n # Parotid mass. Incidental finding of L parotid mass on MRI, 1.6cm. --\n Will require OP ENT followup.\n .\n # Access: PIV, Central Line, arterial line.\n .\n # FEN: IVF, replete electrolytes\n .\n # Prophylaxis: Subcutaneous heparin\n .\n # Code: full\n .\n # Communication: Wife is HCP\n .\n # Disposition: ICU for now.\n .\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 22 Gauge - 11:30 AM\n 20 Gauge - 11:45 AM\n Multi Lumen - 12:48 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP: HOB elevation, Mouth care\n Comments:\n Communication: Family meeting held , ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n ------ Protected Section ------\n Medications on Transfer:\n Ceftriaxone 1 g IV q 24 hrs\n Vitamin D 400 IU daily\n Bengay\n Heparin SC 5000 U TID\n Lansoprazole 30 mg daily\n Tylenol 325-650 prn\n Gelclair\n Spironolactone 50 mg daily\n Lactulose 60 mL qid\n Levothyroixine 37.5 mcg daily\n Rifaxamin 400 mg tid\n Folate 1 mg daily\n Thiamine 100 mg daily\n Caphsol 30 ml oral qid\n Bactrim 1 DS tab daily (given yesterday)\n .\n Home Medications:\n . Bupropion XL 150mg TID, but not taken as prescribed. Will need to\n verify with psychiatrist in AM\n #. Esomeprazole 40mg daily\n #. Lactulose 10mg/15mL TID, not taking as prescribed.\n #. Levothyroxine 75mcg daily\n #. Lithium 600mg per pharmacy, but 450 CR in OMR, which is a\n more appropriate for dosing.\n #. Spironolactone 50mg daily\n #. Vitamin D daily\n #. Milk Thistle 400mg daily\n #. Omega-3 Fatty acids daily\n ------ Protected Section Addendum Entered By: , MD\n on: 15:47 ------\n CRITICL CARE STAFF ADDENDUM\n 4p\n I saw and examined Mr. with Dr. , whose note above\n reflects my input. I would add/emphasize that he is a 63-year-old man\n with a past history most notable for HCV-associated cirrhosis and a\n complicated, long hospitalization most notable for laminectomy for cord\n compression and prolonged encephalopathy of uncertain etiology. Today\n during suctioning he had a witnessed arrest. During intubation, a\n mucus plug (vs. food\n though seems less likely given prolonged NPO\n status) was removed. Had ROSC and brought to MICU, where he was\n unresponsive with GCS~8. CVL and art line placed for borderline\n hypotension, tachycardia to 140s.\n On exam now he is sedated with dysconjugate gaze. 92 108/48 A/C 550\n x 18 x 0.5 x P5. Heart is regular. Lungs are clear. Abdomen is\n protuberant. Edema.\n CXR with ET in place. Elevated right hemi. EKG with some inferior\n pseudonormalization.\n Labs reviewed in note above.\n Assessment and Plan\n 63-year-old man with cirrhosis and prolonged delirium/encephalopathy\n now s/p PEA arrest with ROSC but continued depressed mental status.\n Post-arrest care\n Hemodynamic management as needed (currently normotense)\n Hypothermia per protocol\n Dysconjugate gaze\n Discuss with neuro re: possibility of nonconvulsive status\n Respiratory failure\n Given findings at intubation, will bronch to exclude\n retained foreign material\n Leave intubated during hypothermia\n No clear evidence of infection at present\n Acute renal failure\n Expect ATN post-arrest; may have underlying HRS or other\n issues\n Renal following\n Other issues as per ICU team note above. Our team has d/w pt\ns wife.\n 50 minutes\n ------ Protected Section Addendum Entered By: , MD\n on: 16:07 ------\n" }, { "category": "Physician ", "chartdate": "2145-01-08 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 558188, "text": "Chief Complaint:\n 24 Hour Events:\n Events:\n - bronch showing thick, yellow secretions concerning for infection,\n started vanco and zosyn for HAP\n - cooling protocol initiated, plan for rewarming around noon tomorrow\n - renal team following, sent urine lytes and UA; pt remaining basically\n anuric overnight\n - CVPs in 8-10s, likely fluid down; to test kidneys, gave 500 cc fluid\n challenge. UO improved slightly from about 20 cc/hr up to 80 cc/hr for\n short time\n - Around 2 am, after repositioning patients SBP dropped to 70s, came up\n to 80s with fluids but needed to start levophed; titrated up to 0.07\n and then stable overnight\n INVASIVE VENTILATION - START 10:55 AM\n MULTI LUMEN - START 12:48 PM\n BRONCHOSCOPY - At 04:23 PM\n ARTERIAL LINE - START 05:00 PM\n Allergies:\n Demerol (Oral) (Meperidine Hcl)\n Confusion/Delir\n Last dose of Antibiotics:\n Ceftriaxone - 04:00 PM\n Vancomycin - 08:00 PM\n Piperacillin/Tazobactam (Zosyn) - 01:57 AM\n Infusions:\n Fentanyl - 50 mcg/hour\n Midazolam (Versed) - 2 mg/hour\n Norepinephrine - 0.05 mcg/Kg/min\n Other ICU medications:\n Midazolam (Versed) - 11:30 AM\n Fentanyl - 11:30 AM\n Heparin Sodium (Prophylaxis) - 10:02 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:38 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 3.1\nC (37.5\n Tcurrent: 3.1\nC (37.5\n HR: 60 (59 - 156) bpm\n BP: 114/68(82) {85/51(62) - 114/77(82)} mmHg\n RR: 19 (17 - 27) insp/min\n SpO2: 97%\n CVP: 15 (7 - 18)mmHg\n Bladder pressure: 9 (9 - 9) mmHg\n Total In:\n 2,497 mL\n 855 mL\n PO:\n TF:\n IVF:\n 2,497 mL\n 855 mL\n Blood products:\n Total out:\n 410 mL\n 154 mL\n Urine:\n 410 mL\n 154 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,087 mL\n 701 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 550 (550 - 550) mL\n RR (Set): 18\n RR (Spontaneous): 0\n PEEP: 12 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10\n PIP: 22 cmH2O\n Plateau: 20 cmH2O\n SpO2: 97%\n ABG: 7.46/34/92./25/0\n Ve: 10.3 L/min\n PaO2 / FiO2: 186\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 134 K/uL\n 12.7 g/dL\n 114 mg/dL\n 2.2 mg/dL\n 25 mEq/L\n 4.2 mEq/L\n 85 mg/dL\n 102 mEq/L\n 138 mEq/L\n 38.5 %\n 26.5 K/uL\n [image002.jpg]\n 11:21 AM\n 01:24 PM\n 03:41 PM\n 06:56 PM\n 09:04 PM\n 10:13 PM\n 11:06 PM\n 11:47 PM\n 03:38 AM\n 04:01 AM\n WBC\n 13.4\n 26.5\n Hct\n 39.6\n 38.5\n Plt\n 152\n 134\n Cr\n 2.1\n 2.0\n 1.9\n 2.2\n TropT\n 0.27\n 0.24\n TCO2\n 33\n 27\n 28\n 27\n 27\n 25\n Glucose\n 105\n 92\n 117\n 114\n Other labs: PT / PTT / INR:17.2/54.3/1.6, CK / CKMB /\n Troponin-T:447/26/0.24, Differential-Neuts:74.5 %, Lymph:14.1 %,\n Mono:8.1 %, Eos:2.9 %, Lactic Acid:2.0 mmol/L, Ca++:7.7 mg/dL, Mg++:3.1\n mg/dL, PO4:5.5 mg/dL\n Assessment and Plan\n Assessment and Plan: This is a 63 y/o M with Hepatitis C cirrhosis, a\n to ICU w/ PEA arrest to mucous plug.\n .\n # Shock/PEA Arrest: Witness arrest to mucous plug.\n - Now hemodynamically stable, access achieved.\n - Culture broadly to guid further care but would not cover with\n antibiotics at this time\n - Rule out for MI with serial enzymes\n - follow-UOP and bolus IVF's PRN.\n - Opt for dopamine or levo as initial pressor of choice.\n - frequent suctioning and bronch to evaluate airways for retained food.\n .\n # Neuro: With slowly resolving delerium prior to this event, and now\n with unclear hypoxic insult to brain. GCS of on admission to ICU.\n Consider cooling protocol. Head CT to evaluate for anoxic brain injury\n post-cooling. Neuro eval for possible seizure.\n - Will need sedation and paralysis for cooling.\n - Low dose fentanyl/versed for sedation for now.\n - LP done earlier this admit that was negative gram stain/culture, no\n whites, negative HSV PCR.\n - Dysconjugate gaze c/w possible seizure consult neuro for EEG.\n .\n # Respiratory/Ventilation: Assist control. Low tidal volumes to avoid\n unneeded injury, with pH goal of above 7.25.\n - Repeat ABG now and titrate oxygen/PEEP, minute vent to effect.\n .\n # Metabolic Acidosis: s/p arrest to tissue hypoxia. Continue IVF's\n and trend lactate. Will need to increase minute ventilation for CO2.\n - Blood cultures, urine cultures for infectious source given white\n blood cell count, but do not suspect sepsis at this time.\n .\n # Cardiac: Anticipate some elevation in CE's post-arrest, will trend.\n .\n # Cirrhosis: Hep C Cirrhosis, with concern for HRS.\n - Appreciate liver rec's\n .\n # Renal Failure: Unclear Etiology. Renal following given concern for\n HRS.\n - Send urine lytes, repeat Ua post-arrest\n - Appreciate renal rec's.\n .\n # Leukocytosis: Unclear etiology. Negative tap for SBP on .\n Urine growing E. Coli. Pan-culture.\n .\n # Parotid mass. Incidental finding of L parotid mass on MRI, 1.6cm. --\n Will require OP ENT followup.\n .\n # Access: PIV, Central Line, arterial line.\n .\n # FEN: IVF, replete electrolytes\n .\n # Prophylaxis: Subcutaneous heparin\n .\n # Code: full\n .\n # Communication: Wife is HCP\n .\n # Disposition: ICU for now.\n .\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 22 Gauge - 11:30 AM\n 20 Gauge - 11:45 AM\n Multi Lumen - 12:48 PM\n Arterial Line - 05:00 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": "2145-01-13 00:00:00.000", "description": "Nursing Progress Note", "row_id": 559277, "text": "PMH: Pt admitted to on s/p fall for back spinal fusion. Has\n been confused since surgery according to pt's wife later developed UTI.\n Unknown cause of MS changes. ? encephalopathy vs. infection.Pt had\n resp distress, became unresponsive and went into PEA arrest on .Pt\n has been on Arctic sun.CT neg for PE or bleed.Pt was succefully\n extubated on .But developed acute respiratory distress on that\n night with increasing agitation and confusion.Was reintubated on\n .Head CT neg for any acute changes.\n Events: Hematuria noted in pt\ns urine, cont to monitor. Hct drop to\n 24.1 from 25.3. INR up to 1.9 from 1.8.\n Electrolyte & fluid disorder, other\n Assessment:\n Received pt w/ Na elevated at 146, phosphate low at 1.6.\n Action:\n FWB increased to 250 ml q 4 hr. 3 pkts neutraphos given.\n Response:\n Na and phos unchanged on this AM labs. K at 3.8, 20 MEq\ns given.\n Plan:\n Follow NA levels, request phos repletion.\n Altered mental status (not Delirium)\n Assessment:\n Received pt w/bolus sedation PRN. Pt became agitated, w/ spontaneous\n and non-purposeful movts. Not following any commands, ABPS increased\n to 170 sys, HR elevated to 80. PERRL, MAEs.\n Action:\n Pt required max dose of bolus fent /versed w/o good effect. Propofol\n gtt started.\n Response:\n Pt appears comfortable w/ prop gtt at mcg/kg/min, very lightly\n sedated. Arouses to verbal / tactile stimulation. ABPs now\n 126/57(76), HR 60.\n Plan:\n Intern able to assess pt\ns neuro status before prop started, will cont\n to assess MS.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2145-01-13 00:00:00.000", "description": "Nursing Progress Note", "row_id": 559280, "text": "PMH: Pt admitted to on s/p fall for back spinal fusion. Has\n been confused since surgery according to pt's wife later developed UTI.\n Unknown cause of MS changes. ? encephalopathy vs. infection.Pt had\n resp distress, became unresponsive and went into PEA arrest on .Pt\n has been on Arctic sun.CT neg for PE or bleed.Pt was succefully\n extubated on .But developed acute respiratory distress on that\n night with increasing agitation and confusion.Was reintubated on\n .Head CT neg for any acute changes.\n Events: Hematuria noted in pt\ns urine, cont to monitor. Hct drop to\n 24.1 from 25.3. INR up to 1.9 from 1.8. Pt afebrile.\n Electrolyte & fluid disorder, other\n Assessment:\n Received pt w/ Na elevated at 146, phosphate low at 1.6.\n Action:\n FWB increased to 250 ml q 4 hr. 3 pkts neutraphos given.\n Response:\n Na and phos unchanged on this AM labs. K at 3.8, 20 MEq\ns given.\n Plan:\n Follow NA levels, request phos repletion.\n Altered mental status (not Delirium)\n Assessment:\n Received pt w/bolus sedation PRN. Pt became agitated, w/ spontaneous\n and non-purposeful movts. Not following any commands, ABPS increased\n to 170 sys, HR elevated to 80. PERRL, MAEs.\n Action:\n Pt required max dose of bolus fent /versed w/o good effect. Propofol\n gtt started.\n Response:\n Pt appears comfortable w/ prop gtt at mcg/kg/min, very lightly\n sedated. Arouses to verbal / tactile stimulation. ABPs now\n 126/57(76), HR 60.\n Plan:\n Intern able to assess pt\ns neuro status before prop started, will cont\n to assess MS.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received pt on AC 40%/550/18/10PEEP. Sp02 99-100%. Pt producing mod\n amt blood tinged sputum. LS course and dim at bases. ABG at 0400\n 7.52/36/97/5/30.\n Action:\n Pt was overbreathing vent prior to gtt sedation, poss cause of\n increased pH. No action taken.\n Response:\n Will recheck ABG to see if pH normalizes w/ better sedation.\n Plan:\n Follow resp status, plan still to trach pt this Thurs.\n" }, { "category": "Nursing", "chartdate": "2145-01-20 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 560792, "text": "Pt admitted to on s/p fall for spinal fusion. Per pt\ns wife\n pt has been confused since surgery. Did have known UTI however post\n treatment continues to have MS changes. Team questioning\n encephalopathy vs. infection. pt had episode of respiratory\n distress then became unresponsive and went into PEA arrest, intubated\n during code. Pt had been on Arctic sun for post VT arrest cooling. CT\n negative for PE or bleed. Pt was successfully extubated on ,\n however unable to tolerate and reintubated . Trached .\n Repeat head CT negative for any acute changes. Pt has been stable last\n few days.\n Note: this patient needs 1:1 sitter at night.\n Altered mental status (not Delirium)\n Assessment:\n Pt restless, confused, trying to get out of bed, pulling at tubes, hx\n of dc\ning NGT. Pt on seroquell overnoc with minimal result. Orients\n quickly but then forgets limitations. A&O x .\n Action:\n OOBTC facing nurse\ns station, a.m. seroquel, soft restraints.\n Response:\n Pt calm and appropriate while in chair.\n Plan:\n Keep pt in chair as tolerated. Re-orient frequently, provide calm, safe\n environment, initiate interventions to keep pt safe and to minimize\n interference with treatments. Pt must have a sitter at night.\n Aerobic Capacity / Endurance, Impaired\n Assessment:\n Pt on trache collar on 50%, breathing regular, strong productive cough,\n clears own secretions, exp wheeze/diminished, pt down flat in bed.\n Action:\n Pt boosted numerous times, does not maintain position at 30 degrees.\n OOBTC on Passe Muir valve, session with PT.\n Response:\n Tolerated well, maintained sat > 95%.\n Plan:\n Keep HOB at 30 degrees, boost often, OOBTC or bed as chair as\n tolerated, increase Passe Muir valve duration as tolerated, increase\n activity as tolerated.\n Hepatic encephalopathy\n Assessment:\n Pt confused, A & O to self and sometimes to place (\nhospital\n), forgets\n limitations, pulls at tube.\n Action:\n Lactulose q 4 hours, reorient frequently.\n Response:\n Amonia levels WNL\n Plan:\n Continue with lactulose therapy, continue collaboration with liver\n team.\n" }, { "category": "Physician ", "chartdate": "2145-01-14 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 559503, "text": "Chief Complaint:\n 24 Hour Events:\n OR SENT - At 10:20 PM\n OR RECEIVED - At 12:30 AM\n trach place, 8 portex, pt received 2 units ffp in OR\n Events:\n - around 10 pm, got trach - had some mild bleeding around the trach\n site (150cc), but otherwise without complications\n - want to keep INR low over next few days, FFP PRN\n - mildly hypernatremic, getting D5W but held during procedure, will\n finish IVFs and start TFs with free water flushes\n - continues to be on propofol sedation\n Allergies:\n Demerol (Oral) (Meperidine Hcl)\n Confusion/Delir\n Last dose of Antibiotics:\n Vancomycin - 08:30 PM\n Piperacillin/Tazobactam (Zosyn) - 06:36 AM\n Infusions:\n Propofol - 20 mcg/Kg/min\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 07:15 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.3\nC (99.2\n Tcurrent: 35.7\nC (96.3\n HR: 67 (59 - 81) bpm\n BP: 142/65(86) {106/48(63) - 165/68(96)} mmHg\n RR: 11 (0 - 27) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 73 Inch\n CVP: 8 (6 - 16)mmHg\n Total In:\n 3,425 mL\n 1,360 mL\n PO:\n TF:\n 467 mL\n 180 mL\n IVF:\n 1,486 mL\n 1,180 mL\n Blood products:\n 621 mL\n Total out:\n 3,890 mL\n 710 mL\n Urine:\n 3,890 mL\n 710 mL\n NG:\n Stool:\n Drains:\n Balance:\n -465 mL\n 650 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 550 (550 - 550) mL\n RR (Set): 12\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 100\n PIP: 19 cmH2O\n Plateau: 16 cmH2O\n Compliance: 50 cmH2O/mL\n SpO2: 100%\n ABG: 7.47/40/94./30/4\n Ve: 8.6 L/min\n PaO2 / FiO2: 235\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 44 K/uL\n 9.2 g/dL\n 112 mg/dL\n 0.6 mg/dL\n 30 mEq/L\n 3.8 mEq/L\n 23 mg/dL\n 111 mEq/L\n 147 mEq/L\n 27.8 %\n 4.1 K/uL\n [image002.jpg]\n 04:43 AM\n 03:24 PM\n 02:42 AM\n 03:30 AM\n 06:33 AM\n 03:37 PM\n 04:02 PM\n 09:03 PM\n 03:15 AM\n 03:29 AM\n WBC\n 5.8\n 4.9\n 4.6\n 4.1\n 4.1\n Hct\n 26.1\n 25.3\n 24.1\n 28.6\n 27.8\n Plt\n 48\n 47\n 50\n 46\n 44\n Cr\n 1.0\n 1.0\n 0.8\n 0.7\n 0.8\n 0.6\n TCO2\n 30\n 30\n 32\n 30\n Glucose\n 133\n 125\n 117\n 95\n 120\n 112\n Other labs: PT / PTT / INR:17.2/48.4/1.6, CK / CKMB /\n Troponin-T:447/26/0.24, ALT / AST:53/127, Alk Phos / T Bili:73/3.7,\n Amylase / Lipase:93/30, Differential-Neuts:84.1 %, Lymph:10.6 %,\n Mono:2.3 %, Eos:2.7 %, Lactic Acid:1.6 mmol/L, Albumin:3.3 g/dL,\n LDH:298 IU/L, Ca++:8.2 mg/dL, Mg++:1.7 mg/dL, PO4:2.6 mg/dL\n Assessment and Plan\n ELECTROLYTE & FLUID DISORDER, OTHER\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n HYPOTENSION (NOT SHOCK)\n CARDIAC ARREST\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n BACTEREMIA\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 12:48 PM\n Arterial Line - 11:00 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": "2145-01-14 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 559506, "text": "Chief Complaint:\n 24 Hour Events:\n OR SENT - At 10:20 PM\n OR RECEIVED - At 12:30 AM\n trach place, 8 portex, pt received 2 units ffp in OR\n Events:\n - around 10 pm, got trach - had some mild bleeding around the trach\n site (150cc), but otherwise without complications\n - want to keep INR low over next few days, FFP PRN\n - mildly hypernatremic, getting D5W but held during procedure, will\n finish IVFs and start TFs with free water flushes\n - continues to be on propofol sedation\n Allergies:\n Demerol (Oral) (Meperidine Hcl)\n Confusion/Delir\n Last dose of Antibiotics:\n Vancomycin - 08:30 PM\n Piperacillin/Tazobactam (Zosyn) - 06:36 AM\n Infusions:\n Propofol - 20 mcg/Kg/min\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 07:15 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.3\nC (99.2\n Tcurrent: 35.7\nC (96.3\n HR: 67 (59 - 81) bpm\n BP: 142/65(86) {106/48(63) - 165/68(96)} mmHg\n RR: 11 (0 - 27) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 73 Inch\n CVP: 8 (6 - 16)mmHg\n Total In:\n 3,425 mL\n 1,360 mL\n PO:\n TF:\n 467 mL\n 180 mL\n IVF:\n 1,486 mL\n 1,180 mL\n Blood products:\n 621 mL\n Total out:\n 3,890 mL\n 710 mL\n Urine:\n 3,890 mL\n 710 mL\n NG:\n Stool:\n Drains:\n Balance:\n -465 mL\n 650 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 550 (550 - 550) mL\n RR (Set): 12\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 100\n PIP: 19 cmH2O\n Plateau: 16 cmH2O\n Compliance: 50 cmH2O/mL\n SpO2: 100%\n ABG: 7.47/40/94./30/4\n Ve: 8.6 L/min\n PaO2 / FiO2: 235\n Physical Examination\n Eyes / Conjunctiva: PERRL, opens eyes, makes eye contact\n , Ears, Nose, Throat: , Poor dentition, Endotracheal\n tube, NG tube\n Cardiovascular: (S1: Normal), (S2: Normal), No(t) S3, No(t) S4, No(t)\n Rub\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : ,\n Rhonchorous: )\n Abdominal: Soft, Bowel sounds present, Distended, palpable fluid wave\n Neurologic: arousable to voice, opens eyes no purposeful movements,\n withdraws to pain, non-verbal\n Labs / Radiology\n 44 K/uL\n 9.2 g/dL\n 112 mg/dL\n 0.6 mg/dL\n 30 mEq/L\n 3.8 mEq/L\n 23 mg/dL\n 111 mEq/L\n 147 mEq/L\n 27.8 %\n 4.1 K/uL\n [image002.jpg]\n 04:43 AM\n 03:24 PM\n 02:42 AM\n 03:30 AM\n 06:33 AM\n 03:37 PM\n 04:02 PM\n 09:03 PM\n 03:15 AM\n 03:29 AM\n WBC\n 5.8\n 4.9\n 4.6\n 4.1\n 4.1\n Hct\n 26.1\n 25.3\n 24.1\n 28.6\n 27.8\n Plt\n 48\n 47\n 50\n 46\n 44\n Cr\n 1.0\n 1.0\n 0.8\n 0.7\n 0.8\n 0.6\n TCO2\n 30\n 30\n 32\n 30\n Glucose\n 133\n 125\n 117\n 95\n 120\n 112\n Other labs: PT / PTT / INR:17.2/48.4/1.6, CK / CKMB /\n Troponin-T:447/26/0.24, ALT / AST:53/127, Alk Phos / T Bili:73/3.7,\n Amylase / Lipase:93/30, Differential-Neuts:84.1 %, Lymph:10.6 %,\n Mono:2.3 %, Eos:2.7 %, Lactic Acid:1.6 mmol/L, Albumin:3.3 g/dL,\n LDH:298 IU/L, Ca++:8.2 mg/dL, Mg++:1.7 mg/dL, PO4:2.6 mg/dL\n Assessment and Plan\n ELECTROLYTE & FLUID DISORDER, OTHER\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n HYPOTENSION (NOT SHOCK)\n CARDIAC ARREST\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n BACTEREMIA\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 12:48 PM\n Arterial Line - 11:00 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": "2145-01-07 00:00:00.000", "description": "procedure note", "row_id": 558112, "text": "TITLE:\n A-line placement\n Standard sterile technique used. Left arm of pt sterile prepared with\n chlorhexidine, sterile towels, gloves etc, used. 20g angio cath used to\n locate the radial artery. Guide wire used after successful location,\n and 20g angio cath placed for transduction. Access shortly after\n procedure lost, and new cath was inserted under sterile condition and\n use of guide wire. New cath obtained from regular a-line kit.\n No immediate complication\n" }, { "category": "General", "chartdate": "2145-01-12 00:00:00.000", "description": "Generic Note", "row_id": 559125, "text": "TITLE: Critical Care\n Present for the key portions of resident\ns history and exam. Agree\n substantially with assessment and plan.\n He is now stable on the ventilator. He is unresponsive this am and we\n are decreasing his sedation. Secretions are not copious. Awaiting\n sputum cx.\n We are continuing rx of hepatic encephalopathy. Na corrected. Neuro\n is recommending an MR\n is likely to require trache if plan is to continue aggressive care.\n Will lighten sedation, change vent to PSV, arrange family meeting.\n Time spent 35 min\n Critically ill\n" }, { "category": "Physician ", "chartdate": "2145-01-12 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 559128, "text": "Chief Complaint:\n 24 Hour Events:\n - re-intubated resp. distress and inability to protect airway\n - peri-intubation had episode of AF with RVR and aberrancy, responded\n to Ca2+ (?increased K+ use of sux for intubation)\n - replaced a-line\n - decreased albumin to 50mg daily\n - Head CT with no focal findings -> recommend MRI at later date\n Allergies:\n Demerol (Oral) (Meperidine Hcl)\n Confusion/Delir\n Last dose of Antibiotics:\n Vancomycin - 08:16 PM\n Piperacillin/Tazobactam (Zosyn) - 06:27 AM\n Infusions:\n Fentanyl - 50 mcg/hour\n Midazolam (Versed) - 2 mg/hour\n Other ICU medications:\n Lorazepam (Ativan) - 08:26 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 12 AM\n Tmax: 36.5\nC (97.7\n Tcurrent: 35.8\nC (96.4\n HR: 59 (57 - 98) bpm\n BP: 128/58(74) {111/50(66) - 212/84(126)} mmHg\n RR: 18 (18 - 27) insp/min\n SpO2: 100%\n Heart rhythm: SB (Sinus Bradycardia)\n CVP: 11 (11 - 17)mmHg\n Total In:\n 3,092 mL\n 1,043 mL\n PO:\n TF:\n 69 mL\n 191 mL\n IVF:\n 2,663 mL\n 781 mL\n Blood products:\n 200 mL\n 12 mL\n Total out:\n 2,660 mL\n 530 mL\n Urine:\n 1,960 mL\n 530 mL\n NG:\n Stool:\n 700 mL\n Drains:\n Balance:\n 432 mL\n 513 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 550 (550 - 550) mL\n RR (Set): 18\n RR (Spontaneous): 0\n PEEP: 10 cmH2O\n FiO2: 40%\n RSBI Deferred: PEEP > 10\n PIP: 26 cmH2O\n Plateau: 20 cmH2O\n SpO2: 100%\n ABG: 7.44/42/109/32/3\n Ve: 8.8 L/min\n PaO2 / FiO2: 273\n Physical Examination\n Eyes / Conjunctiva: PERRL, opens eyes, makes eye contact\n , Ears, Nose, Throat: , Poor dentition, Endotracheal\n tube, NG tube\n Cardiovascular: (S1: Normal), (S2: Normal), No(t) S3, No(t) S4, No(t)\n Rub\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : ,\n Rhonchorous: )\n Abdominal: Soft, Bowel sounds present, Distended, palpable fluid wave\n Neurologic: arousable to voice, opens eyes no purposeful movements,\n withdraws to pain, non-verbal\n Labs / Radiology\n 48 K/uL\n 8.5 g/dL\n 133 mg/dL\n 1.0 mg/dL\n 32 mEq/L\n 3.6 mEq/L\n 43 mg/dL\n 110 mEq/L\n 145 mEq/L\n 26.1 %\n 5.8 K/uL\n [image002.jpg]\n 04:02 AM\n 11:01 AM\n 11:21 AM\n 01:03 PM\n 05:56 PM\n 06:13 PM\n 07:31 PM\n 09:57 PM\n 01:37 AM\n 04:43 AM\n WBC\n 5.6\n 7.7\n 5.8\n Hct\n 29.6\n 30.0\n 26.1\n Plt\n 52\n 61\n 48\n Cr\n 1.4\n 1.3\n 1.1\n 1.1\n 1.0\n 1.0\n TCO2\n 31\n 29\n 29\n 30\n 29\n Glucose\n 100\n 136\n 167\n 170\n 176\n 133\n Other labs: PT / PTT / INR:19.1/51.4/1.8, CK / CKMB /\n Troponin-T:447/26/0.24, ALT / AST:60/144, Alk Phos / T Bili:72/3.4,\n Amylase / Lipase:93/30, Differential-Neuts:84.1 %, Lymph:10.6 %,\n Mono:2.3 %, Eos:2.7 %, Lactic Acid:2.2 mmol/L, LDH:303 IU/L, Ca++:8.8\n mg/dL, Mg++:2.3 mg/dL, PO4:1.7 mg/dL\n Assessment and Plan\n This is a 63 y/o M with Hepatitis C cirrhosis hepatorenal syndrome, s/p\n PEA arrest, body cooling and rewarming, concern for PNA covering with\n Vanc/Zosyn.\n .\n # s/p Shock/PEA Arrest: After PEA, was initially hemodynamically stable\n but has had episodes of hypotension non-responsive to IVF boluses,\n levofed started, currently off. Echo showed no evidence of cardiogenic\n shock. s/p cooling and rewarming.\n - continue goal MAP >65\n - stable now after off pressors\n .\n # Respiratory/Ventilation: Pt re-intubated secondary to\n respiratory distress and inability to handle secretions. Unlikely to\n tolerate extubation given that underlying problem is inability to\n handle secretions which is unlikely to change.\n - pt will likely need trach if long-term care is the goal\n - cont 5-day total course of vanc/zosyn\n - cont local care\n .\n # Pneumonia\n on CXR has RLL infiltrate and bronch with thick yellow\n secretions, leukocytosis starting to resolve\n - on vanco/zosyn for total 5-day course\n - follow up cultures, NGTD\n .\n # Mental Status: With slowly resolving delerium prior to this event,\n and now with unclear hypoxic insult to brain. GCS of on admission\n to ICU. Considering head CT to evaluate for anoxic brain injury\n post-cooling. Neuro eval for possible seizure. EEG neg for seizure,\n severe encephalopathy likely in setting of sedation. Back to pre-code\n MS per wife.\n - off sedation, still not following commands or making purposeful\n movements\n - LP done earlier that was negative gram stain/culture, no whites,\n negative HSV PCR\n - CT scan did not show any focal lesions\n - likely will need MRI in the future but can not tolerate now \n mental status/respiratory status\n - increase lactulose to TID, continue rifaximin\n .\n # Renal Failure: Unclear etiology, likely combination of ATN in the\n setting of code and HRS. Renal following given concern for HRS. On\n albumin, mitodrine and octreotide per liver/renal.\n - urine output improving\n - giving mitodrine, octreotide and albumin\n - f/u renal and liver recs\n .\n # Hypernatremia: Likely hypovolemic hypernatremia in the setting of\n recent ATN and current HRS. Corrected , rree water deficit ~ 2-3L.\n - lytes\n .\n # Metabolic Acidosis: s/p arrest to tissue hypoxia. Lactates now\n normalized, now resolved.\n .\n # Cardiac: CE's trended post-arrest. Echo hyperdynamic, no cardiogenic\n shock.\n - CK and Trop trended down\n .\n # Cirrhosis: Hep C Cirrhosis, with concern for HRS.\n - pre-code mental status likely related to encephalopathy v. delirium\n - titrate up lactulose\n - liver recs -> non suitable for tx at this point, in the very small\n chance that pt improves could possibly be candidate in the future\n ..\n # Gram negative bacteremia: Will treat for two-week course, awaiting\n sensitivities on Fusobacterium -> likely responsive to penicillin.\n - will continue surveillance blood cxs\n .\n # Parotid mass. Incidental finding of L parotid mass on MRI, 1.6cm. --\n Will require ENT followup as outpt.\n .\n # Access: PIV, Central Line\n .\n # FEN: IVF, replete electrolytes, tube feeds\n .\n # Prophylaxis: holding HSQ since elevated PTT, famotidine\n .\n # Code: full\n .\n # Communication: Wife is HCP -> will readdress long-term goals today\n re: long-term prognosis\n .\n # Disposition: ICU for now.\n ICU Care\n Nutrition:\n Nutren Renal (Full) - 06:16 AM 30 mL/hour\n Glycemic Control:\n Lines:\n Multi Lumen - 12:48 PM\n Arterial Line - 11:00 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": "2145-01-12 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 559129, "text": "Chief Complaint:\n 24 Hour Events:\n - re-intubated resp. distress and inability to protect airway\n - peri-intubation had episode of AF with RVR and aberrancy, responded\n to Ca2+ (?increased K+ use of sux for intubation)\n - replaced a-line\n - decreased albumin to 50mg daily\n - Head CT with no focal findings -> recommend MRI at later date\n Allergies:\n Demerol (Oral) (Meperidine Hcl)\n Confusion/Delir\n Last dose of Antibiotics:\n Vancomycin - 08:16 PM\n Piperacillin/Tazobactam (Zosyn) - 06:27 AM\n Infusions:\n Fentanyl - 50 mcg/hour\n Midazolam (Versed) - 2 mg/hour\n Other ICU medications:\n Lorazepam (Ativan) - 08:26 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 12 AM\n Tmax: 36.5\nC (97.7\n Tcurrent: 35.8\nC (96.4\n HR: 59 (57 - 98) bpm\n BP: 128/58(74) {111/50(66) - 212/84(126)} mmHg\n RR: 18 (18 - 27) insp/min\n SpO2: 100%\n Heart rhythm: SB (Sinus Bradycardia)\n CVP: 11 (11 - 17)mmHg\n Total In:\n 3,092 mL\n 1,043 mL\n PO:\n TF:\n 69 mL\n 191 mL\n IVF:\n 2,663 mL\n 781 mL\n Blood products:\n 200 mL\n 12 mL\n Total out:\n 2,660 mL\n 530 mL\n Urine:\n 1,960 mL\n 530 mL\n NG:\n Stool:\n 700 mL\n Drains:\n Balance:\n 432 mL\n 513 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 550 (550 - 550) mL\n RR (Set): 18\n RR (Spontaneous): 0\n PEEP: 10 cmH2O\n FiO2: 40%\n RSBI Deferred: PEEP > 10\n PIP: 26 cmH2O\n Plateau: 20 cmH2O\n SpO2: 100%\n ABG: 7.44/42/109/32/3\n Ve: 8.8 L/min\n PaO2 / FiO2: 273\n Physical Examination\n Eyes / Conjunctiva: PERRL, opens eyes, makes eye contact\n , Ears, Nose, Throat: , Poor dentition, Endotracheal\n tube, NG tube\n Cardiovascular: (S1: Normal), (S2: Normal), No(t) S3, No(t) S4, No(t)\n Rub\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : ,\n Rhonchorous: )\n Abdominal: Soft, Bowel sounds present, Distended, palpable fluid wave\n Neurologic: arousable to voice, opens eyes no purposeful movements,\n withdraws to pain, non-verbal\n Labs / Radiology\n 48 K/uL\n 8.5 g/dL\n 133 mg/dL\n 1.0 mg/dL\n 32 mEq/L\n 3.6 mEq/L\n 43 mg/dL\n 110 mEq/L\n 145 mEq/L\n 26.1 %\n 5.8 K/uL\n [image002.jpg]\n 04:02 AM\n 11:01 AM\n 11:21 AM\n 01:03 PM\n 05:56 PM\n 06:13 PM\n 07:31 PM\n 09:57 PM\n 01:37 AM\n 04:43 AM\n WBC\n 5.6\n 7.7\n 5.8\n Hct\n 29.6\n 30.0\n 26.1\n Plt\n 52\n 61\n 48\n Cr\n 1.4\n 1.3\n 1.1\n 1.1\n 1.0\n 1.0\n TCO2\n 31\n 29\n 29\n 30\n 29\n Glucose\n 100\n 136\n 167\n 170\n 176\n 133\n Other labs: PT / PTT / INR:19.1/51.4/1.8, CK / CKMB /\n Troponin-T:447/26/0.24, ALT / AST:60/144, Alk Phos / T Bili:72/3.4,\n Amylase / Lipase:93/30, Differential-Neuts:84.1 %, Lymph:10.6 %,\n Mono:2.3 %, Eos:2.7 %, Lactic Acid:2.2 mmol/L, LDH:303 IU/L, Ca++:8.8\n mg/dL, Mg++:2.3 mg/dL, PO4:1.7 mg/dL\n Assessment and Plan\n This is a 63 y/o M with Hepatitis C cirrhosis hepatorenal syndrome, s/p\n PEA arrest, body cooling and rewarming, concern for PNA covering with\n Vanc/Zosyn.\n .\n # s/p Shock/PEA Arrest: After PEA, was initially hemodynamically stable\n but has had episodes of hypotension non-responsive to IVF boluses,\n levofed started, currently off. Echo showed no evidence of cardiogenic\n shock. s/p cooling and rewarming.\n - continue goal MAP >65\n - stable now after off pressors\n .\n # Respiratory/Ventilation: Pt re-intubated secondary to\n respiratory distress and inability to handle secretions. Unlikely to\n tolerate extubation given that underlying problem is inability to\n handle secretions which is unlikely to change.\n - pt will likely need trach if long-term care is the goal\n - cont 5-day total course of vanc/zosyn\n - cont local care\n .\n # Pneumonia\n on CXR has RLL infiltrate and bronch with thick yellow\n secretions, leukocytosis starting to resolve\n - on vanco/zosyn for total 5-day course\n - follow up cultures\n .\n # Mental Status: With slowly resolving delerium prior to this event,\n and now with unclear hypoxic insult to brain. GCS of on admission\n to ICU. Considering head CT to evaluate for anoxic brain injury\n post-cooling. Neuro eval for possible seizure. EEG neg for seizure,\n severe encephalopathy likely in setting of sedation. Back to pre-code\n MS per wife.\n - off sedation, still not following commands or making purposeful\n movements\n - LP done earlier that was negative gram stain/culture, no whites,\n negative HSV PCR\n - CT scan did not show any focal lesions\n - likely will need MRI in the future but can not tolerate now \n mental status/respiratory status\n - increase lactulose to TID, continue rifaximin\n .\n # Renal Failure: Unclear etiology, likely combination of ATN in the\n setting of code and HRS. Renal following given concern for HRS. On\n albumin, mitodrine and octreotide per liver/renal.\n - urine output improving\n - giving mitodrine, octreotide and albumin\n - f/u renal and liver recs\n .\n # Hypernatremia: Likely hypovolemic hypernatremia in the setting of\n recent ATN and current HRS. Corrected , rree water deficit ~ 2-3L.\n - lytes\n .\n # Metabolic Acidosis: s/p arrest to tissue hypoxia. Lactates now\n normalized, now resolved.\n .\n # Cardiac: CE's trended post-arrest. Echo hyperdynamic, no cardiogenic\n shock.\n - CK and Trop trended down\n .\n # Cirrhosis: Hep C Cirrhosis, with concern for HRS.\n - pre-code mental status likely related to encephalopathy v. delirium\n - titrate up lactulose\n - liver recs -> non suitable for tx at this point, in the very small\n chance that pt improves could possibly be candidate in the future\n ..\n # Gram negative bacteremia: Will treat for two-week course, awaiting\n sensitivities on Fusobacterium -> likely responsive to penicillin.\n - will continue surveillance blood cxs\n .\n # Parotid mass. Incidental finding of L parotid mass on MRI, 1.6cm. --\n Will require ENT followup as outpt.\n .\n # Access: PIV, Central Line\n .\n # FEN: IVF, replete electrolytes, tube feeds\n .\n # Prophylaxis: holding HSQ since elevated PTT, famotidine\n .\n # Code: full\n .\n # Communication: Wife is HCP -> will readdress long-term goals today\n re: long-term prognosis\n .\n # Disposition: ICU for now.\n ICU Care\n Nutrition:\n Nutren Renal (Full) - 06:16 AM 30 mL/hour\n Glycemic Control:\n Lines:\n Multi Lumen - 12:48 PM\n Arterial Line - 11:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Respiratory ", "chartdate": "2145-01-13 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 559374, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 3\n Ideal body weight: 83.5 None\n Ideal tidal volume: mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: 25 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Diminished\n LUL Lung Sounds: Diminished\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Blood Tinged / Thin\n Sputum source/amount: Suctioned / Scant\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n 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: Tracheostomy planned\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n" }, { "category": "Respiratory ", "chartdate": "2145-01-18 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 560295, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 8\n Ideal body weight: 83.5 None\n Ideal tidal volume: mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type:\n Size:\n Tracheostomy tube:\n Type: Standard, Cuffed, Inner Cannula\n Manufacturer: Portex\n Size: 8.0mm\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: Exp Wheeze\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Exp Wheeze\n Comments:\n Secretions\n Sputum color / consistency: Bloody / Thick\n Sputum source/amount: Suctioned / Moderate\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Unassisted spontaneous breathing\n Visual assessment of breathing pattern:\n Assessment of breathing comfort: No claim of dyspnea)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\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 is on trach collar, Vent D/C this morning after 23 hours on TC, Fio2\n @ 70%\n" }, { "category": "Nursing", "chartdate": "2145-01-14 00:00:00.000", "description": "Nursing Progress Note", "row_id": 559481, "text": "PMH: Pt admitted to on s/p fall for back spinal fusion. Has\n been confused since surgery according to pt's wife later developed UTI.\n Unknown cause of MS changes. ? encephalopathy vs. infection. Pt had\n resp distress, became unresponsive and went into PEA arrest on .\n Pt has been on Arctic sun. CT neg for PE or bleed. Pt was\n successfully extubated on , but developed acute respiratory\n distress on that night with increasing agitation and confusion. Was\n reintubated on . Head CT neg for any acute changes.\n Events: Pt taken to OR at 2130 for trach. Per surgery pt bled a fair\n amt during procedure, received 1 unit FFP in MICU prior and 2 unit FFP\n in OR. INR at 2100 1.7. Trach sutured in place w/ thrombin infused\n gel foam around surgical site. Per thoracic surgery will leave\n dressing in place until their follow up post-op day 1 (). Pt\n afebrile throughout shift.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received pt on AC 40%/550/12/5PEEP. LS course and dim at bases, mod\n amts blood-tinged sputum w/ suction. Sp02 96-99%.\n Action:\n Pt taken to OR for trach.\n Response:\n #8 portex trach in place, vent settings same as prior to procedure.\n Sp02 100%. Pt sedated on 20 mcg/kg/min propofol, pt breathing over\n vent at approx 16 bpm. ABG 7.47/40/94. Mod amts blood-tinged oral and\n bronchotracheal secretions.\n Plan:\n Monitor resp status. Extra trach kit and inner cannula in pt room.\n Electrolyte & fluid disorder, other\n Assessment:\n Pt diuresed yesterday and NPO prior to procedure. Na cont\ns to be\n elevated (147) and K, Mg, Ca, Phos low.\n Action:\n Finishing 1 L 5% Dextrose at 100 ml/hr now, TF restarted w/ 250 ml FWB\n q 4 hr, repleting lytes now.\n Response:\n Plan:\n Follow lytes, recheck labs.\n Altered mental status (not Delirium)\n Assessment:\n Pt sedated and opens eyes inconsistently to voice, noxious stimuli.\n PERRL, does not track. MAEs, does not follow commands, no purposeful\n movts.\n Action:\n Freq neuro checks.\n Response:\n No changes noted in MS. Pt remains sedated.\n Plan:\n Monitor, maintain pt\ns comfort.\n" }, { "category": "Physician ", "chartdate": "2145-01-20 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 560769, "text": "Chief Complaint:\n 24 Hour Events:\n - NGT replaced after patient pulled it out\n ARTERIAL LINE - STOP 08:00 PM\n Allergies:\n Demerol (Oral) (Meperidine Hcl)\n Confusion/Delir\n Last dose of Antibiotics:\n Penicillin G potassium - 04:30 AM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:00 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 07:17 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: 36.8\nC (98.3\n HR: 83 (78 - 109) bpm\n BP: 126/67(80) {98/39(53) - 169/84(94)} mmHg\n RR: 18 (14 - 25) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 73 Inch\n CVP: 13 (6 - 13)mmHg\n Total In:\n 3,827 mL\n 1,670 mL\n PO:\n TF:\n 77 mL\n IVF:\n 790 mL\n 245 mL\n Blood products:\n Total out:\n 3,230 mL\n 1,240 mL\n Urine:\n 2,130 mL\n 240 mL\n NG:\n Stool:\n 1,000 mL\n Drains:\n Balance:\n 597 mL\n 430 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n SpO2: 100%\n ABG: ///26/\n Physical Examination\n Gen: sitting in chair, NAD\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, Poor dentition, NG tube, trach\n in place\n Cardiovascular: RRR, (S1: Normal), (S2: Normal), No(t) S3, No(t) S4,\n No(t) Rub\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear )\n Abdominal: Soft, Bowel sounds present, Distended, palpable fluid wave,\n non-tender\n Neurologic: alert and oriented x 3, answering questions appropriately.\n Labs / Radiology\n 69 K/uL\n 8.5 g/dL\n 95 mg/dL\n 0.6 mg/dL\n 26 mEq/L\n 3.8 mEq/L\n 14 mg/dL\n 112 mEq/L\n 144 mEq/L\n 25.5 %\n 2.9 K/uL\n [image002.jpg]\n 02:55 AM\n 04:00 PM\n 01:01 AM\n 04:22 AM\n 05:38 AM\n 02:41 PM\n 09:01 PM\n 03:15 AM\n 04:16 PM\n 05:46 AM\n WBC\n 6.0\n 5.0\n 3.9\n 2.9\n Hct\n 27.6\n 26.9\n 26.1\n 25.5\n Plt\n 63\n 55\n 59\n 69\n Cr\n 0.7\n 0.7\n 0.7\n 0.6\n 0.5\n 0.5\n 0.6\n 0.6\n TCO2\n 33\n 30\n Glucose\n 97\n 111\n 94\n 90\n 111\n 85\n 109\n 95\n Other labs: PT / PTT / INR:17.9/44.4/1.6, CK / CKMB /\n Troponin-T:104/26/0.24, ALT / AST:60/136, Alk Phos / T Bili:129/2.5,\n Amylase / Lipase:38/42, Differential-Neuts:80.0 %, Band:0.0 %,\n Lymph:16.0 %, Mono:0.0 %, Eos:4.0 %, Lactic Acid:1.0 mmol/L,\n Albumin:3.3 g/dL, LDH:341 IU/L, Ca++:8.4 mg/dL, Mg++:1.5 mg/dL, PO4:2.6\n mg/dL\n Assessment and Plan\n This is a 63 y/o M with hx Hepatitis C cirrhosis, s/p PEA arrest, body\n cooling and rewarming, with Fusobacterium sepsis covering with IV Pen G\n until .\n .\n # Mental Status: Much better this morning. Cirrhosis and PEA arrest\n (and anoxic brain injury to unknown extent) contributing.\n - Seroquel dosing tweaked yesterday per Psych recs.\n - continue lactulose, which was uptitrated to 60 mg Q4 hrs yesterday\n with goal stool output of 1 L. Continue rifaximin.\n .\n # Respiratory/Ventilation: Pt was re-intubated secondary to\n respiratory distress and inability to handle secretions. Unlikely to\n tolerate extubation given that underlying problem is inability to\n handle secretions which is unlikely to change. CXR from showed\n evidence of pulmonary edema. Patient got trach in OR. Patient\n completed treatment for empiric HAP for 5day with vanc/zosyn starting\n .\n - tolerating trach collar very well; has passy-muir valve\n .\n # Fusobacterium bacteremia: Will treat for two-week course, awaiting\n sensitivities on Fusobacterium -> likely responsive to penicillin. Dx\n on .\n - no new micro data\n - completed 14 day course of PCN today\n .\n # Hypernatremia, resolved: Likely hypovolemic hypernatremia in the\n setting of recent ATN and current HRS. Resolved with free water\n boluses\n - continue free water boluses through G-tube.\n .\n # Thrombocytopenia\n stable. Considering HIT vs. splenic sequestration\n - no current evidence of DIC\n - switched from H2 to PPI\n .\n # Resolved Renal Failure: Unclear etiology, likely combination of ATN\n in the setting of code and HRS.; Renal function stable\n Currently.\n .\n # Cardiac: CE's trended post-arrest. Echo hyperdynamic, no cardiogenic\n shock. CK and Trop trended down\n - will consider repeat echo\n .\n # Cirrhosis: Hep C; stable\n - lactulose increased\n - liver recs -> non suitable for tx at this point, in the very small\n chance that pt improves could possibly be candidate in the future; will\n discuss this again since pt\ns mental status much better now\n .\n # Parotid mass. Incidental finding of L parotid mass on MRI, 1.6cm. --\n Will require ENT followup as outpt.\n # Access: A line removed yesterday; will try PIV today then d/c central\n line.\n # FEN: were stopped due to patient\ns inability to maintain upright\n posture; will speak with liver nutritionist to discuss tube feed\n bolusing rather than continuous feed. Speech and swallow c/s to\n evaluate swallowing fxn.\n .\n # Prophylaxis: holding HSQ since elevated PTT, PPI\n .\n # Code: full\n .\n # Communication: Wife is HCP\n .\n # Disposition: call out to floor today\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 12:48 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": "2145-01-20 00:00:00.000", "description": "Physician Resident/Attending Progress Note - MICU", "row_id": 560779, "text": "Chief Complaint:\n 24 Hour Events:\n - NGT replaced after patient pulled it out\n ARTERIAL LINE - STOP 08:00 PM\n Allergies:\n Demerol (Oral) (Meperidine Hcl)\n Confusion/Delir\n Last dose of Antibiotics:\n Penicillin G potassium - 04:30 AM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:00 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 07:17 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: 36.8\nC (98.3\n HR: 83 (78 - 109) bpm\n BP: 126/67(80) {98/39(53) - 169/84(94)} mmHg\n RR: 18 (14 - 25) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 73 Inch\n CVP: 13 (6 - 13)mmHg\n Total In:\n 3,827 mL\n 1,670 mL\n PO:\n TF:\n 77 mL\n IVF:\n 790 mL\n 245 mL\n Blood products:\n Total out:\n 3,230 mL\n 1,240 mL\n Urine:\n 2,130 mL\n 240 mL\n NG:\n Stool:\n 1,000 mL\n Drains:\n Balance:\n 597 mL\n 430 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n SpO2: 100%\n ABG: ///26/\n Physical Examination\n Gen: sitting in chair, NAD\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, Poor dentition, NG tube, trach\n in place\n Cardiovascular: RRR, (S1: Normal), (S2: Normal), No(t) S3, No(t) S4,\n No(t) Rub\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear )\n Abdominal: Soft, Bowel sounds present, Distended, palpable fluid wave,\n non-tender\n Neurologic: alert and oriented x 3, answering questions appropriately.\n Labs / Radiology\n 69 K/uL\n 8.5 g/dL\n 95 mg/dL\n 0.6 mg/dL\n 26 mEq/L\n 3.8 mEq/L\n 14 mg/dL\n 112 mEq/L\n 144 mEq/L\n 25.5 %\n 2.9 K/uL\n [image002.jpg]\n 02:55 AM\n 04:00 PM\n 01:01 AM\n 04:22 AM\n 05:38 AM\n 02:41 PM\n 09:01 PM\n 03:15 AM\n 04:16 PM\n 05:46 AM\n WBC\n 6.0\n 5.0\n 3.9\n 2.9\n Hct\n 27.6\n 26.9\n 26.1\n 25.5\n Plt\n 63\n 55\n 59\n 69\n Cr\n 0.7\n 0.7\n 0.7\n 0.6\n 0.5\n 0.5\n 0.6\n 0.6\n TCO2\n 33\n 30\n Glucose\n 97\n 111\n 94\n 90\n 111\n 85\n 109\n 95\n Other labs: PT / PTT / INR:17.9/44.4/1.6, CK / CKMB /\n Troponin-T:104/26/0.24, ALT / AST:60/136, Alk Phos / T Bili:129/2.5,\n Amylase / Lipase:38/42, Differential-Neuts:80.0 %, Band:0.0 %,\n Lymph:16.0 %, Mono:0.0 %, Eos:4.0 %, Lactic Acid:1.0 mmol/L,\n Albumin:3.3 g/dL, LDH:341 IU/L, Ca++:8.4 mg/dL, Mg++:1.5 mg/dL, PO4:2.6\n mg/dL\n Assessment and Plan\n This is a 63 y/o M with hx Hepatitis C cirrhosis, s/p PEA arrest, body\n cooling and rewarming, with Fusobacterium sepsis covering with IV Pen G\n until .\n .\n # Mental Status: Much better this morning. Cirrhosis and PEA arrest\n (and anoxic brain injury to unknown extent) contributing.\n - Seroquel dosing tweaked yesterday per Psych recs.\n - continue lactulose, which was uptitrated to 60 mg Q4 hrs yesterday\n with goal stool output of 1 L. Continue rifaximin.\n .\n # Respiratory/Ventilation: Pt was re-intubated secondary to\n respiratory distress and inability to handle secretions. Unlikely to\n tolerate extubation given that underlying problem is inability to\n handle secretions which is unlikely to change. CXR from showed\n evidence of pulmonary edema. Patient got trach in OR. Patient\n completed treatment for empiric HAP for 5day with vanc/zosyn starting\n .\n - tolerating trach collar very well; has passy-muir valve\n .\n # Fusobacterium bacteremia: Will treat for two-week course, awaiting\n sensitivities on Fusobacterium -> likely responsive to penicillin. Dx\n on .\n - no new micro data\n - completed 14 day course of PCN today\n .\n # Hypernatremia, resolved: Likely hypovolemic hypernatremia in the\n setting of recent ATN and current HRS. Resolved with free water\n boluses\n - continue free water boluses through G-tube.\n .\n # Thrombocytopenia\n stable. Considering HIT vs. splenic sequestration\n - no current evidence of DIC\n - switched from H2 to PPI\n .\n # Resolved Renal Failure: Unclear etiology, likely combination of ATN\n in the setting of code and HRS.; Renal function stable\n Currently.\n .\n # Cardiac: CE's trended post-arrest. Echo hyperdynamic, no cardiogenic\n shock. CK and Trop trended down\n - will consider repeat echo\n .\n # Cirrhosis: Hep C; stable\n - lactulose increased\n - liver recs -> non suitable for tx at this point, in the very small\n chance that pt improves could possibly be candidate in the future; will\n discuss this again since pt\ns mental status much better now\n .\n # Parotid mass. Incidental finding of L parotid mass on MRI, 1.6cm. --\n Will require ENT followup as outpt.\n # Access: A line removed yesterday; will try PIV today then d/c central\n line.\n # FEN: were stopped due to patient\ns inability to maintain upright\n posture; will speak with liver nutritionist to discuss tube feed\n bolusing rather than continuous feed. Speech and swallow c/s to\n evaluate swallowing fxn.\n .\n # Prophylaxis: holding HSQ since elevated PTT, PPI\n .\n # Code: full\n .\n # Communication: Wife is HCP\n .\n # Disposition: call out to floor today\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 12:48 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n ------ Protected Section ------\n MICU ATTENDING ADDENDUM\n I saw and examined the patient, and was physically present with the ICU\n team for the key portions of the services provided. I agree with the\n note above, including the assessment and plan. I would emphasize and\n add the following points: 63M HCV, HCC, ESLD, PEA arrest likely due to\n airway plugging, fusobacterium sepsis. Mental status improved,\n tolerated PMV.\n Exam notable for Tm 98.9 BP 126/60 HR 70-100 RR 18 with sat 100 on 50%\n TM 7.41/46/170. Interactive, appropriate, mildly encephalopathic.\n Coarse BS B. RRR s1s2. Soft +BS. 2+ edema. Labs notable for WBC 3K, HCT\n 25, K+ 3.8, Cr 0.6.\n Agree with plan to manage multifactorial encephalopathy with ongoing\n lactulose / rifaximin for component of hepatic encephalopathy (NH3\n 30s), PCN for fusobacterium sepsis/bacteremia x2w (ends today), PGT FW\n repletion for hypernatremia, continuing IV synthroid for\n hypothyroidism, and supportive care with minimal sedation (seroquel\n only); he is much better today. Can uptitrate ACEI as BP allows. Will\n resume low sodium TFs via bolus when upright, check S+S eval. PT eval,\n OOB, continue PMV trials today. Will continue close communication with\n family. Remainder of plan as outlined above.\n Total time: 35 min\n ------ Protected Section Addendum Entered By: , MD\n on: 04:00 PM ------\n" }, { "category": "Nursing", "chartdate": "2145-01-14 00:00:00.000", "description": "Nursing Progress Note", "row_id": 559584, "text": "PMH: Pt admitted to on s/p fall for back spinal fusion. Has\n been confused since surgery according to pt\ns wife later developed\n UTI. Unknown cause of MS changes. ? encephalopathy vs. infection.\n Pt. had resp distress, became unresponsive and went into PEA arrest on\n . PT. has been on Artic sun. CT neg for PE or bleed. Pt. was\n successfully extubated on . Reintubated on . PT. taken to OR\n on for trach. Head CT neg for any acute changes.\nfrom previous\n nursing note.\n Events: Thoracic visit to assess tach dressing. Changed and reinforced\n r/t bleeding at site. ENT up to assess mod amounts bloody secretions\n from mouth and suction cath. 1unit FFP and 1unit of platelets given.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n CMV 12/550/41%/5PEEP. LS clear w/ dim bases bilat. Mod amt of bloody\n secretions suctioned from mouth and suction cath. Sat 99-100%.\n Platelets 44, INR 1.6.\n Action:\n Vent changed to PS-5PEEP and PS 10. Suctioned as needed. Frequent\n position changes. Continued on albuterol and atrovent by RT. ENT\n evaluated for bleeding site. Given 1unit FFP, 1unit platelets, and vit\n K. Given 40mg of lasix IV.\n Response:\n Abg: 7.45/44/100. RR 12-21. O2 sats >98%. Amt of secretions suctioned\n from mouth/cath significantly decreased throughout shift. ENT found no\n source of bleeding. Repeat INR 1.5 and platelets 60. Continues to\n diurese from lasix- goal 1L neg.\n Plan:\n Wean vent as tolerated. Suction as needed. Monitor bleeding. Monitor\n INR, platelets (goal >50), Hct. Monitor UOP/electrolytes.\n Electrolyte & fluid disorder, other\n Assessment:\n Received patient w/ TF off, Na 147.\n Action:\n Restarted on free water boluses @ 250mL q4hr. Antibiotics ordered from\n pharm in D5W. TF restarted (goal 60cc/hr). Lytes monitored.\n Response:\n Minimal residuals. Repeat lytes- Na 145, K 3.7 (20mEq potassium given).\n Plan:\n Monitor electrolytes. Continue to increase TF as tolerated. Continue\n free water boluses.\n Hepatic encephalopathy\n Assessment:\n On propofol gtt. Arouseable to pain. Not following commands. Fine\n tremors in arms, legs, and jaw. Flexiseal in place draining mod amount\n brown liquid stools. PERRLA, sluggish. No purposeful movement.\n Action:\n Propofol titrated for sedation. Continued Lactulose qid. Lactulose PR\n given.\n Response:\n No significant mental status change. Continues to be agitated (pulling\n arms towards head, sliding down bed, moving legs up in air) when\n sedation weaned down. Less agitated w/ propofol titrated higher.\n Plan:\n Continue neuro assessments. Monitor and maintain comfort. Continue\n Lactulose.\n" }, { "category": "Respiratory ", "chartdate": "2145-01-20 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 560777, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 10\n Ideal body weight: 83.5 None\n Ideal tidal volume: mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type: Not applicable\n Size: Not applicable\n Tracheostomy tube:\n Type: Standard, Cuffed, Inner Cannula\n Manufacturer: Portex\n Size: 8.0mm\n PMV: No\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Tan / Thick\n Sputum source/amount: Suctioned / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern:\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours:\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n Patient remains on 50% cool neb/trach collar, breath sounds bilaterally\n clear and diminished, suctioned intermittently for small amounts of\n thick tan secretions, treated with Albuterol and atrovent inhalers,\n SPO2 remained upper 90s, sat in a chair for a while, spent about 4\n hours with PMV on, no distress occurred, will continues to be followed.\n" }, { "category": "Respiratory ", "chartdate": "2145-01-14 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 559478, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 4\n Ideal body weight: 83.5 None\n Ideal tidal volume: mL/kg\n Tracheostomy tube:\n Type: Standard\n Manufacturer: Portex\n Size: 8.0mm\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Bloody / 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:\n Assessment of breathing comfort: No response (sleeping / sedated)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment: Frequent alarms (High pressure, High rate)\n Comments:\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Underlying illness\n not resolved\n :\n Comments:\n Taken to the o.r. tonight and trached. #8 Portex. Moderate amount of\n bleeding around the site.\n" }, { "category": "Respiratory ", "chartdate": "2145-01-15 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 559666, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 5\n Ideal body weight: 83.5 None\n Ideal tidal volume: mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type: Not applicable\n Size: Not applicable\n Tracheostomy tube:\n Type: Standard, Cuffed, Inner Cannula\n Manufacturer: Portex\n Size: 8.0mm\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Bronchial\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Bronchial\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Bloody / Thick\n Sputum source/amount: Suctioned / Moderate\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Gasping efforts, High flow\n demand\n Assessment of breathing comfort: No response (sleeping / sedated)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment: Abnormal trigger efforts (efforts during\n inspiratory)\n Dysynchrony assessment: Vigorous inspiratory efforts\n Comments:\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated,\n Increase ventilatory support at night\n Reason for continuing current ventilatory support: Intolerant of\n weaning attempts, Cannot manage secretions\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n ABG showing fair oxygenation on PSV with partially compensated\n metabolic alkalosis. RSBI 63. Pt has remained on PSV 10/+5 almost all\n night but towards breathing became increasingly erratic, with\n frequent coughing and hyperventilation immediately followed by hypopnea\n and low MV. Cycle continued to repeat for more than an hour. Tried MMV\n without satisfactory result, changed back to AC mode to give pt a rest.\n Pt appears uncomfortable t/o most of night although objective measures\n were reasonable on PSV.\n" }, { "category": "Nursing", "chartdate": "2145-01-14 00:00:00.000", "description": "Nursing Progress Note", "row_id": 559587, "text": "PMH: Pt admitted to on s/p fall for back spinal fusion. Has\n been confused since surgery according to pt\ns wife later developed\n UTI. Unknown cause of MS changes. ? encephalopathy vs. infection.\n Pt. had resp distress, became unresponsive and went into PEA arrest on\n . PT. has been on Artic sun. CT neg for PE or bleed. Pt. was\n successfully extubated on . Reintubated on . PT. taken to OR\n on for trach. Head CT neg for any acute changes.\nfrom previous\n nursing note.\n Events: Thoracic visit to assess tach dressing. Changed and reinforced\n r/t bleeding at site. ENT up to assess mod amounts bloody secretions\n from mouth and suction cath. 1unit FFP and 1unit of platelets given.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n CMV 12/550/41%/5PEEP. LS clear w/ dim bases bilat. Mod amt of bloody\n secretions suctioned from mouth and suction cath. Sat 99-100%.\n Platelets 44, INR 1.6.\n Action:\n Vent changed to PS-5PEEP and PS 10. Suctioned as needed. Frequent\n position changes. Continued on albuterol and atrovent by RT. ENT\n evaluated for bleeding site. Given 1unit FFP, 1unit platelets, and vit\n K. Given 40mg of lasix IV.\n Response:\n Abg: 7.45/44/100. RR 12-21. O2 sats >98%. Amt of secretions suctioned\n from mouth/cath significantly decreased throughout shift. ENT found no\n source of bleeding. Repeat INR 1.5 and platelets 60. Continues to\n diurese from lasix- goal 1L neg. HCT 27-28.\n Plan:\n Wean vent as tolerated. Suction as needed. Monitor bleeding. Monitor\n INR, platelets (goal >50), Hct. Monitor UOP/electrolytes.\n Electrolyte & fluid disorder, other\n Assessment:\n Received patient w/ TF off, Na 147.\n Action:\n Restarted on free water boluses @ 250mL q4hr. Antibiotics ordered from\n pharm in D5W. TF restarted (goal 60cc/hr). Lytes monitored.\n Response:\n Minimal residuals. Repeat lytes- Na 145, K 3.7 (20mEq potassium given).\n Plan:\n Monitor electrolytes. Continue to increase TF as tolerated. Continue\n free water boluses.\n Hepatic encephalopathy\n Assessment:\n On propofol gtt. Arouseable to pain. Not following commands. Fine\n tremors in arms, legs, and jaw. Flexiseal in place draining mod amount\n brown liquid stools. PERRLA, sluggish. No purposeful movement.\n Action:\n Propofol titrated for sedation. Continued Lactulose qid. Lactulose PR\n given.\n Response:\n No significant mental status change. Continues to be agitated (pulling\n arms towards head, sliding down bed, moving legs up in air) when\n sedation weaned down. Less agitated w/ propofol titrated higher.\n Plan:\n Continue neuro assessments. Monitor and maintain comfort. Continue\n Lactulose.\n" }, { "category": "Physician ", "chartdate": "2145-01-19 00:00:00.000", "description": "Physician Resident/Attending Progress Note - MICU", "row_id": 560587, "text": "TITLE:\n Chief Complaint: PEA/asystole\n 24 Hour Events:\n - Hypernatremia corrected to 143 today. Free water deficit calculated\n to be 3.7 L, getting D5W 500 cc q3hrs.\n - ABG/VBG showing good correlation\n - Made Seroquel around the clock and PRN per psych recs\n Allergies:\n Demerol (Oral) (Meperidine Hcl)\n Confusion/Delir\n Last dose of Antibiotics:\n Penicillin G potassium - 04:15 AM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:19 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 06:54 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: 35.9\nC (96.7\n HR: 87 (78 - 102) bpm\n BP: 120/70(82) {120/70(82) - 120/70(82)} mmHg\n RR: 18 (17 - 29) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 73 Inch\n CVP: 7 (7 - 16)mmHg\n Total In:\n 5,362 mL\n 1,498 mL\n PO:\n TF:\n IVF:\n 1,057 mL\n 238 mL\n Blood products:\n Total out:\n 2,915 mL\n 1,910 mL\n Urine:\n 1,915 mL\n 810 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,447 mL\n -412 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n SpO2: 99%\n ABG: 7.41/46/170/27/4\n PaO2 / FiO2: 425 / 40%\n Physical Examination\n Eyes / Conjunctiva: PERRL, opens eyes, makes eye contact\n , Ears, Nose, Throat: , Poor dentition, NG tube, trach\n (Bloody )\n Cardiovascular: RRR, (S1: Normal), (S2: Normal), No(t) S3, No(t) S4,\n No(t) Rub\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear )\n Abdominal: Soft, Bowel sounds present, Distended, palpable fluid wave,\n non-tender\n Neurologic: arousable to voice, opens eyes, non-verbal, follows some\n basic commands\n Labs / Radiology\n 59 K/uL\n 8.6 g/dL\n 85 mg/dL\n 0.5 mg/dL\n 27 mEq/L\n 3.7 mEq/L\n 13 mg/dL\n 110 mEq/L\n 143 mEq/L\n 26.1 %\n 3.9 K/uL\n [image002.jpg]\n 04:28 AM\n 04:45 AM\n 02:55 AM\n 04:00 PM\n 01:01 AM\n 04:22 AM\n 05:38 AM\n 02:41 PM\n 09:01 PM\n 03:15 AM\n WBC\n 5.7\n 6.0\n 5.0\n 3.9\n Hct\n 26.3\n 27.6\n 26.9\n 26.1\n Plt\n 51\n 63\n 55\n 59\n Cr\n 0.7\n 0.7\n 0.7\n 0.7\n 0.6\n 0.5\n 0.5\n TCO2\n 34\n 33\n 30\n Glucose\n 114\n 97\n 111\n 94\n 90\n 111\n 85\n Other labs: PT / PTT / INR:17.4/44.6/1.6, Ca++:8.4 mg/dL, Mg++:1.7\n mg/dL, PO4:2.2 mg/dL; TSH 3.7, T4 5.7; Lactate 1.0, ammonia 31\n CXR : FINDINGS: In comparison with the study of , the\n monitoring and support devices remain in place. Persistent low lung\n volumes. Opacification at the right base is increasing and the\n hemidiaphragm is not sharply seen. This is consistent with pleural\n effusion and atelectasis, though in the absence of a lateral view. A\n superimposed pneumonia cannot be excluded. The left hemidiaphragm is\n more sharply seen, suggesting some improvement in atelectasis and\n effusion in this region.\n Assessment and Plan\n This is a 63 y/o M who has continued AMS to point where not\n communicating at all; with hx Hepatitis C cirrhosis, s/p PEA arrest,\n body cooling and rewarming, with Fusobacterium sepsis covering with IV\n Pen G until .\n .\n # Mental Status: With slowly resolving delerium prior to this event,\n and now with unclear hypoxic insult to brain. GCS of on admission\n to ICU. Considering head CT to evaluate for anoxic brain injury\n post-cooling. Neuro eval for possible seizure. EEG neg for seizure,\n severe encephalopathy likely in setting of sedation. LP done earlier\n that was negative gram stain/culture, no whites, negative HSV PCR. Back\n to pre-code MS per wife. CT scan did not show any focal lesions. MRI\n () was unremarkable. Mental status is somewhat improved today.\n - off propofol sedation,\n - psych saw patient on and felt that the patient was very unlikely\n to have had NMS and recommended seroquel for agitation (uptitrate per\n Psych recs\n standing Seroquel TID with prns)\n - lactulose increased to 60mg q4hr for stool ouput goal of 1000cc and\n cont rifaximin; ammonia not elevated\n - Thyroid studies wnl\n .\n # Respiratory/Ventilation: Pt re-intubated secondary to\n respiratory distress and inability to handle secretions. Unlikely to\n tolerate extubation given that underlying problem is inability to\n handle secretions which is unlikely to change. CXR from showed\n evidence of pulmonary edema. Patient getting trach in OR. Patient\n completed treatment for empiric HAP for 5day with vanc/zosyn starting\n .\n - tolerating trach collar very well\n .\n # Fusobacterium bacteremia: Will treat for two-week course, awaiting\n sensitivities on Fusobacterium -> likely responsive to penicillin. Dx\n on , will need 14d course until .\n - surveillance blood cxs NTD\n - complete course of PCN on \n .\n # bleeding from trach site- Procedure done , 8-0 Portex .lost\n 150cc. Patient was given giving 2u platelets, given 1u FFP after the\n procedure. ENT was consulted on for concern of posterior pharynx\n bleed, which they did not find any evidence of.\n - bleeding has improved, tr blood at site, but controlled\n - ENT found small bite on back of tongue, but no evidence of posterior\n pharynx bleed\n .\n # Hypernatremia: Likely hypovolemic hypernatremia in the setting of\n recent ATN and current HRS. Corrected , free water deficit 3.5L on\n and now corrected again as TF were held overnight except for FW\n boluses..\n - increase free water boluses through G-tube\n - will discuss with nutrition to see if there is a way to decrease\n sodium in TF or dilute TF to prevent hypernatremia\n .\n # Thrombocytopenia\n platelets 171, slowly declining. Switched\n from H2 to PPI. Considering HIT vs. splenic sequestration\n - no current evidence of DIC\n - plts stable after switch from H2 to PPI\n .\n # Resolved Renal Failure: Unclear etiology, likely combination of ATN\n in the setting of code and HRS. Renal following given concern for HRS.\n Off albumin, mitodrine and octreotide\n - renal function stable\n - f/u renal and liver recs\n .\n # Cardiac: CE's trended post-arrest. Echo hyperdynamic, no cardiogenic\n shock. CK and Trop trended down\n - will consider repeat echo\n .\n # Cirrhosis: Hep C Cirrhosis, with concern for HRS.\n - pre-code mental status likely related to encephalopathy v. delirium\n - lactulose increased\n - liver recs -> non suitable for tx at this point, in the very small\n chance that pt improves could possibly be candidate in the future\n .\n # s/p Shock/PEA Arrest: Now stable. After PEA, was initially\n hemodynamically stable but has had episodes of hypotension\n non-responsive to IVF boluses, levofed started, currently off. Echo\n showed no evidence of cardiogenic shock. s/p cooling and rewarming.\n Trended cardiac enzymes, came down and no evidence of cardiogenic shock\n on rewarmed echo.\n # Parotid mass. Incidental finding of L parotid mass on MRI, 1.6cm. --\n Will require ENT followup as outpt.\n .\n # Metabolic Acidosis: s/p arrest to tissue hypoxia. Lactates now\n normalized, now resolved.\n # Access: Central Line and A-line; will remove A-line today and request\n PICC placement.\n .\n # FEN: were stopped due to patient positioning, will try restarting\n today for goal, 60cc/hr\n Speech/swallow c/s for consideration of passy-muir valve.\n .\n # Prophylaxis: holding HSQ since elevated PTT, PPI\n .\n # Code: full\n .\n # Communication: Wife is HCP -> will readdress long-term goals re:\n long-term prognosis\n .\n # Disposition: ICU for now. be able to transition to floor vs.\n rehab soon.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 12:48 PM\n Arterial Line - 11:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n ------ Protected Section ------\n 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: 63M HCV, HCC, ESLD, PEA arrest likely due to\n airway plugging, fusobacterium sepsis. Ongoing titration of sedating\n meds; sodium down to 143.\n Exam notable for Tm 98.4 BP 128/70 HR 70-100 RR 14-25 with sat 99 on\n 40% TM 7.41/46/170. Minimally response, moves x4 spontaneously. Not\n interactive, non-verbal. Coarse BS B. RRR s1s2. Soft +BS. 2+ edema.\n Labs notable for WBC 4K, HCT 26, K+ 3.8, Cr 0.5. R effusion on CXR\n Agree with plan to manage multifactorial encephalopathy with ongoing\n lactulose / rifaximin for component of hepatic encephalopathy (NH3\n 30s), PCN for fusobacterium sepsis/bacteremia x2w (ends ), PGT FW\n repletion for hypernatremia, continuing IV synthroid for\n hypothyroidism, and supportive care with minimal sedation (seroquel\n only) for component of med effects and possible hypoxic injury. Can\n uptitrate ACEI as BP allows. Will resume low sodium TFs and d/c\n arterial line today. Will try PMV today. Will continue close\n communication with family. Remainder of plan as outlined above.\n Total time: 35 min\n ------ Protected Section Addendum Entered By: , MD\n on: 05:25 PM ------\n" }, { "category": "Nursing", "chartdate": "2145-01-20 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 560766, "text": "Altered mental status (not Delirium)\n Assessment:\n Action:\n Response:\n Plan:\n Aerobic Capacity / Endurance, Impaired\n Assessment:\n Action:\n Response:\n Plan:\n Hepatic encephalopathy\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2145-01-20 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 560768, "text": "Pt admitted to on s/p fall for spinal fusion. Per pt\ns wife\n pt has been confused since surgery. Did have known UTI however post\n treatment continues to have MS changes. Team questioning\n encephalopathy vs. infection. pt had episode of respiratory\n distress then became unresponsive and went into PEA arrest, intubated\n during code. Pt had been on Arctic sun for post VT arrest cooling. CT\n negative for PE or bleed. Pt was successfully extubated on ,\n however unable to tolerate and reintubated . Trached .\n Repeat head CT negative for any acute changes.\n Altered mental status (not Delirium)\n Assessment:\n Pt restless, confused, trying to get out of bed, pulling at tubes, hx\n of dc\ning NGT. Pt on seroquell overnoc with minimal result. Orients\n quickly but then forgets limitations. A&O x .\n Action:\n OOBTC facing nurse\ns station, a.m. seroquel, soft restraints.\n Response:\n Pt calm and appropriate while in chair.\n Plan:\n Keep pt in chair as tolerated. Re-orient frequently, provide calm, safe\n environment, initiate interventions to keep pt safe and to minimize\n interference with treatments.\n Aerobic Capacity / Endurance, Impaired\n Assessment:\n Action:\n Response:\n Plan:\n Hepatic encephalopathy\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Rehab Services", "chartdate": "2145-01-15 00:00:00.000", "description": "Physical Therapy Evaluation Note", "row_id": 559768, "text": "Attending Physician: \n Referral date: \n Medical Diagnosis / ICD 9: /\n Reason of referral: Re-eval\n History of Present Illness / Subjective Complaint: 63M with HepC\n cirrhosis, underwent C3-T1 laminectomies on , and\n postoperatively went into cardiac arrest, secondary to a mucous plug\n seen on subsequent bronchoscopy. He was intubated from but\n failed extubation secondary to increased respiratory distress, hypoxia,\n and mental status changes\n Past Medical / Surgical History: See initial eval\n Medications:\n Radiology: Cxr: 2/25Discoid atelectasis of the right lung base is\n visualized. There are low lung volumes bilaterally. Small bilateral\n pleural effusions are seen EEG : Overall, the tracing indicates an\n extremely severe encephalopathy. If not due to sedating agents such as\n barbiturate or benzodiazepines, and if due to the cardiac arrest, this\n tracing offers a very poor prognosis\n Labs:\n 27.7\n 9.3\n 59\n 5.8\n [image002.jpg]\n Other labs:\n Activity Orders: bedrest\n Social / Occupational History: see intial eval\n Living Environment: see initial eval\n Prior Functional Status / Activity Level: see initial eval\n Objective Test\n Arousal / Attention / Cognition / Communication: Pt not following\n commands, eyes open t/o eval, no eye contact or visual tracking. does\n not responde to name, tactile cues. Pt appears agitated\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 103\n 164/68\n 97% 40% TM\n Rest\n /\n Sit\n /\n Activity\n /\n Stand\n /\n Recovery\n /\n Total distance walked:\n Minutes:\n Pulmonary Status: Trach, strong cough productive of thick bloody\n secretions cleared via yankaur\n Integumentary / Vascular: B LE edema, aline, areas of ecchymosis on B\n UE and LE, trach, NGT\n Sensory Integrity: No response to pain\n Pain / Limiting Symptoms: Pts mental status was limiting factor to\n evaluation\n Posture: unable to formally assess\n Range of Motion\n Muscle Performance\n grossly \n Pt spontaneously moving all extremities in bed LE > UE\n Motor Function: Pt demonstrates inconsistent purposeful movement in all\n extremities, attempting to move B LE over bed rails consistently t/o\n eval.\n Functional Status:\n Activity\n Clarification\n I\n S\n CG\n Min\n Mod\n Max\n Gait, Locomotion:\n Rolling:\n N/A\n\n\n\n\n\n\n Supine /\n Sidelying to Sit:\n N/A\n\n\n\n\n\n\n Transfer:\n N/A\n\n\n\n\n\n\n Sit to Stand:\n N/A\n\n\n\n\n\n\n Ambulation:\n N/A\n\n\n\n\n\n\n Stairs:\n\n\n\n\n\n Balance: NA mental status\n Education / Communication: Pt status discussed with RN and pts wife.\n Made recommendations for pt positioning in bed\n Intervention:\n Other:\n Diagnosis:\n 1.\n Aerobic Capacity / Endurance, Impaired\n 2.\n Arousal, Attention, and Cognition, Impaired\n 3.\n Respiration / Gas Exchange, Impaired\n Clinical impression / Prognosis: 63 yo m c MMP c hep C s/p multiple\n spinal sx with hospital course sx for PEA arrest. Pt perents with above\n impairments c/w CNS dysfunction. Pt is currently functioning well below\n baseline. At this time he is not able to activity participate with\n therapy due to mental status. We will continue to f/u as appropriate\n to make recommendations and assess functional status as indicated. Pt\n will need rehab upon d/c, his potential is guarded presently however if\n his altered mental status is related to severe encephalopathy he does\n have potential for improvement, also the fact that he has active\n movement in all extremities is a positive contributor to his potential\n to participate with PT.\n Goals\n Time frame: 2wk\n 1.\n follow > 10 % of 1 step commands\n 2.\n make eye contact 50% of the time\n 3.\n Track to stimuli\n 4.\n 5.\n 6.\n Anticipated Discharge: Rehab\n Treatment Plan:\n Frequency / Duration: 2-3x/wk\n f/u cognitive stimulation, mobility assessment to follow\n no pts mental status. Pt agrees with the above goals and is\n willing to participate in the rehabilitation program.\n" }, { "category": "Nursing", "chartdate": "2145-01-19 00:00:00.000", "description": "Nursing Progress Note", "row_id": 560458, "text": "Altered mental status (not Delirium)\n Assessment:\n Pt very restless. He tracks to voice, follows commands inconsistently\n and makes non-purposeful movements. PERL brisk. Hand grasp equal\n bilaterally, tongue midline. Pt able to mouth his name.\n Action:\n Pt oriented to surroundings frequently. All meds and procedures\n explained. Pt restrained for safety and in bed in low, locked position\n with bed alarm on. Pt was repositioned frequently. Pt also given\n lactulose q8hour this shift. 2 doses held stool output at 1000cc\n in less than 24 hours.\n Response:\n No improvement in mental status. Pt continues to make liquid stool.\n Plan:\n Continue to monitor mental status, reorient pt frequently. Continue to\n lactulose for stool output 1000cc/day.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt received on trach mask at 70% and ABG 7.41/46/170 so FiO2 decreased\n to 40%. LS clear, was occasionally rhonchorous, but cleared with\n suctioning.\n Action:\n Pt suctioned for small amounts of blood tinged secretions.\n Response:\n On 40%, RR 20s and sats 97-100%. Weak cough occasionally clearing his\n secretions.\n Plan:\n Continue to monitor resp status, suction as needed.\n Electrolyte & fluid disorder, other\n Assessment:\n PM Na 148.\n Action:\n Pt with 500cc free water flushes q3hour.\n Response:\n AM Na 143.\n Plan:\n Continue to monitor electrolytes.\n" }, { "category": "Nursing", "chartdate": "2145-01-19 00:00:00.000", "description": "Nursing Progress Note", "row_id": 560459, "text": "Pt admitted to on s/p fall for spinal fusion. Per pt\ns wife\n pt has been confused since surgery. Did have known UTI however post\n treatment continues to have MS changes. Team questioning\n encephalopathy vs. infection. pt had episode of respiratory\n distress then became unresponsive and went into PEA arrest, intubated\n during code. Pt had been on Arctic sun for post VT arrest cooling, now\n off. CT negative for PE or bleed. Pt was successfully extubated on\n , however unable to tolerate and reintubated . Trached .\n Repeat head CT negative for any acute changes.\n Altered mental status (not Delirium)\n Assessment:\n Pt very restless. He tracks to voice, follows commands inconsistently\n and makes non-purposeful movements. PERL brisk. Hand grasp equal\n bilaterally, tongue midline. Pt able to mouth his name.\n Action:\n Pt oriented to surroundings frequently. All meds and procedures\n explained. Pt restrained for safety and in bed in low, locked position\n with bed alarm on. Pt was repositioned frequently. Pt also given\n lactulose q8hour this shift. 2 doses held stool output at 1000cc\n in less than 24 hours.\n Response:\n No improvement in mental status. Pt continues to make liquid stool.\n Plan:\n Continue to monitor mental status, reorient pt frequently. Continue to\n lactulose for stool output 1000cc/day.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt received on trach mask at 70% and ABG 7.41/46/170 so FiO2 decreased\n to 40%. LS clear, was occasionally rhonchorous, but cleared with\n suctioning.\n Action:\n Pt suctioned for small amounts of blood tinged secretions.\n Response:\n On 40%, RR 20s and sats 97-100%. Weak cough occasionally clearing his\n secretions.\n Plan:\n Continue to monitor resp status, suction as needed.\n Electrolyte & fluid disorder, other\n Assessment:\n PM Na 148.\n Action:\n Pt with 500cc free water flushes q3hour.\n Response:\n AM Na 143.\n Plan:\n Continue to monitor electrolytes.\n" }, { "category": "Nursing", "chartdate": "2145-01-15 00:00:00.000", "description": "Nursing Progress Note", "row_id": 559775, "text": "63 y/o M with Hepatitis C cirrhosis, s/p PEA arrest, body cooling and\n rewarming, with Fusobacterium sepsis covering with Zosyn until .\n Altered mental status (not Delirium)\n Assessment:\n More awake, however does not follow commands, tracks or tries to\n communicate. Pupils 2-3mm equal and reactive. Remains slightly rigid.\n On propofol sedation, possibly encephalopathic\n Action:\n Propofol d/c if agitated will try haldol or zyprexa per psych consult .\n If in pain treat pain, lactulose increased to 60 q4hr.\n Response:\n Per wife more awake, however still non communicable and does not\n follows commands.\n Plan:\n Continue top monitor patient\ns neuro status, may need MRI later on,\n meds \n Respiratory failure, acute (not ARDS/)\n Assessment:\n Remains trached and vented on PSV 40% 5/5. Bil LS clear, RRR, copious\n amnt of bloody secretions w/suctioning and around trach. Periods of\n low MV.\n Action:\n Weaned to trach mask, suction prn, trach care and frequent mouth care,\n ENT consulted, lasix 40mg X1 given w/goal of -2L\n Response:\n pending\n Plan:\n Continue to monitor resp status, meds , need bronch later on.\n Mouth care and trach care as needed.\n Cardio: normotensive hr at 90\ns SR no ectopy, upper extr edema,\n peripheral pulses present.\n GI: abd soft distended positive for BS, on lactulose q4hr, brown loose\n stool in flexiseal. TF at goal of 60/hr tolerates it well.\n GU: clear yellow urine via foley. Adequate amnt. Got lasix 40mg X1\n given.\n IV access: LT subclavian, LT a - line.\n Social: patient is a FULL CODE> family in to visit updated by RN and\n MD.\n At 1700 patient agitated, thrashing in bed, tachypneic to 40\ns, B/P at\n 180\ns-190, desats to mid 80\ns. Sedation restarted, and patient was put\n back on PSV 50% 15/5 w/sats at 97%. B/P down 130\n" }, { "category": "Respiratory ", "chartdate": "2145-01-15 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 559776, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 5\n Ideal body weight: 83.5 None\n Ideal tidal volume: mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location:\n Reason:\n Tracheostomy tube:\n Type: Standard\n Manufacturer: Portex\n Size: 8.0mm\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Cuff volume: mL /\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Bloody / 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 Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Intolerant of\n weaning attempts\n Pt spent 5 hours on trach collar tolerated well. When sedation is off\n pt becomes extremely agitated desating to the 80\ns required being\n placed back on vent.\n" }, { "category": "Nursing", "chartdate": "2145-01-15 00:00:00.000", "description": "Nursing Progress Note", "row_id": 559659, "text": "Pt admitted to on s/p fall for back spinal fusion. Has been\n confused since surgery according to pt's wife later developed UTI.\n Unknown cause of MS changes. ? encephalopathy vs. infection.Pt had\n resp distress, became unresponsive and went into PEA arrest on .Pt\n has been on Arctic sun.CT neg for PE or bleed.Pt was succefully\n extubated on . Reintubated . Trached . Head CT neg for any\n acute changes.\n Events: Given 1unit FFP and 1unit platelets. Moderate amt of bloody\n secretions suctioned from mouth and suc cath. ENT eval done.\n Electrolyte & fluid disorder, other\n Assessment:\n Pt chronically hypernatremic, AM labs show Na of 146. Pt diuresed\n yesterday, AM K 3.9, Mg 1.6.\n Action:\n Cont w/ TF and q 4 h 250 ml FWB. All KVO fluids D5 when possible.\n Repleted w/ 20 Meq\ns of K.\n Response:\n Cont to follow labs closely.\n Plan:\n As above follow labs and will request order to replete Mg.\n Hepatic encephalopathy\n Assessment:\n Pt recent hx of MS changes. Pt cont\ns to display rigid extremities,\n tongue fasicullations, not following commands, PERRL, no tracking, MAEs\n Action:\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received pt on PS 40%/. ABG this AM 7.48/45/86. Sp02 98-100%.\n SRR approx 16, but w/ periods of apnea and low minute volumes. RSBI\n this AM 63. LS clear and dim, scant amts blood tinged drainage w/\n suction.\n Action:\n Vent changed to AC at 0530 d/t apnea / low MV.\n Response:\n Vent currently on AC 40%/500/12/5.\n Plan:\n Re-attempt to wean vent today.\n" }, { "category": "Nursing", "chartdate": "2145-01-15 00:00:00.000", "description": "Nursing Progress Note", "row_id": 559660, "text": "PMH: Pt admitted to on s/p fall for back spinal fusion. Has\n been confused since surgery according to pt's wife later developed UTI.\n Unknown cause of MS changes. ? encephalopathy vs. infection.Pt had\n resp distress, became unresponsive and went into PEA arrest on .Pt\n has been on Arctic sun.CT neg for PE or bleed.Pt was successfully\n extubated on . Reintubated . Trached . Head CT neg for any\n acute changes.\n Electrolyte & fluid disorder, other\n Assessment:\n Pt chronically hypernatremic, AM labs show Na of 146. Pt diuresed\n yesterday, AM K 3.9, Mg 1.6.\n Action:\n Cont w/ TF and q 4 h 250 ml FWB. All KVO fluids D5 when possible.\n Repleted w/ 20 Meq\ns of K.\n Response:\n Cont to follow labs closely.\n Plan:\n As above follow labs and will request order to replete Mg.\n Hepatic encephalopathy\n Assessment:\n Pt recent hx of MS changes. Pt cont\ns to display rigid extremities,\n tongue fasicullations, not following commands, PERRL, no tracking,\n MAEs.\n Action:\n Cont w/ propofol gtt for comfort until trach site heals. Freq neuron\n checks.\n Response:\n Pt remains lightly sedated.\n Plan:\n Wean sedation to assess MS.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received pt on PS 40%/. ABG this AM 7.48/45/86. Sp02 98-100%.\n SRR approx 16, but w/ periods of apnea and low minute volumes. RSBI\n this AM 63. LS clear and dim, scant amts blood tinged drainage w/\n suction. Scant amts serosanguinos drainage around trach.\n Action:\n Vent changed to AC at 0530 d/t apnea / low MV.\n Response:\n Vent currently on AC 40%/500/12/5.\n Plan:\n Re-attempt to wean vent today.\n" }, { "category": "General", "chartdate": "2145-01-15 00:00:00.000", "description": "Generic Note", "row_id": 559766, "text": "TITLE: Critical Care\n Present for the key portions of the resident\ns history and exam. Agree\n substantially with assessment and plan.\n Remains on low dose of propofol. Appears alert but not following\n commands, akesthetic.\n Producing bloody secretions but oozing at trache site diminishing\n SaO2 good on trache collar\n Lack of improvement in MS . We are increasing lactulose\n Time spent\n 35 min\n Critically ill\n ------ Protected Section ------\n Family meeting\n Discussed Mr. \ns condition at length with his wife. This is his\n third day without benzodiazepines. He is awake without being aware, is\n still profoundly delirious, moving back and forth in bed. We repeated\n our plan to try to manage his behavior with drugs that will not\n accumulate and will not cloud his sensorium. We are increasing his\n lactulose even more for the possibility we can reverse some component\n of hepatic encephalopathy. We will reassess him early next week but I\n warned her that it seems increasingly unlikely that his mental staus\n will improve.\n Time spent 50 min\n Critically ill\n ------ Protected Section Addendum Entered By: , MD\n on: 16:57 ------\n" }, { "category": "Rehab Services", "chartdate": "2145-01-15 00:00:00.000", "description": "Physical Therapy Evaluation Note", "row_id": 559758, "text": "Attending Physician: \n Referral date: \n Medical Diagnosis / ICD 9: /\n Reason of referral: Re-eval\n History of Present Illness / Subjective Complaint: 63M with HepC\n cirrhosis, underwent C3-T1 laminectomies on , and\n postoperatively went into cardiac arrest, secondary to a mucous plug\n seen on subsequent bronchoscopy. He was intubated from but\n failed extubation secondary to increased respiratory distress, hypoxia,\n and mental status changes\n Past Medical / Surgical History: See intial eval\n Medications:\n Radiology: Cxr: 2/25Discoid atelectasis of the right lung base is\n visualized. There are low lung volumes bilaterally. Small bilateral\n pleural effusions are seen EEG : Overall, the tracing indicates an\n extremely severe encephalopathy. If not due to sedatingagents such as\n barbiturate or benzodiazepines, and if due to the cardiac arrest, this\n tracing offers a very poor prognosis\n Labs:\n 27.7\n 9.3\n 59\n 5.8\n [image002.jpg]\n Other labs:\n Activity Orders: bedrest\n Social / Occupational History: see intial eval\n Living Environment: see inital eval\n Prior Functional Status / Activity Level: see intial eval\n Objective Test\n Arousal / Attention / Cognition / Communication: Pt not following\n commands, eyes open t/o eval, no eye contact or tracking. does\n not responde to name, tactile cues. Pt appears agitated\n Hemodynamic Response\n Aerobic Capacity\n HR\n BP\n RR\n O[2 ]sat\n HR\n BP\n RR\n O[2] sat\n RPE\n Supine\n /\n Rest\n /\n Sit\n /\n Activity\n /\n Stand\n /\n Recovery\n /\n Total distance walked:\n Minutes:\n Pulmonary Status: Trach, strong cough productive of thick bloody\n secretions cleared via yankaur\n Integumentary / Vascular: B LE edema, aline, areas of ecchymosis on B\n UE and LE, trach, NGT\n Sensory Integrity: No response to pain\n Pain / Limiting Symptoms: Pts mental status was limiting factor to\n evaluation\n Posture: unable to formally assess\n Range of Motion\n Muscle Performance\n grossly \n Pt spontanously moving all extremties in bed LE > UE\n Motor Function: Pt demonstrate inconsisitent purposeful movement in all\n extremities\n Functional Status:\n Activity\n Clarification\n I\n S\n CG\n Min\n Mod\n Max\n Gait, Locomotion:\n Rolling:\n\n\n\n\n\n\n Supine /\n Sidelying to Sit:\n\n\n\n\n\n Transfer:\n\n\n\n\n\n Sit to Stand:\n\n\n\n\n\n Ambulation:\n\n\n\n\n\n Stairs:\n\n\n\n\n\n Balance: NA mental status\n Education / Communication: Pt status discussed with RN and pts wife.\n Made recommendations for pt positioning in bed\n Intervention:\n Other:\n Diagnosis:\n 1.\n Aerobic Capacity / Endurance, Impaired\n 2.\n Arousal, Attention, and Cognition, Impaired\n 3.\n Respiration / Gas Exchange, Impaired\n Clinical impression / Prognosis: 63 yo m c MMP c hep C s/p mulitpe\n spinal sx with hospital course sx for PEA arrest. Pt perents with above\n impairments c/w CNS dysfunciton. Pt is currenlty funcitoining well\n below baseline. At this time he is not able to activity participate\n with therapy due to mental status. We will continue to f/u as\n appropriate to make recommendations and assess fucntional status as\n indicated. Pt will need rehab upon d/c, his potential is gaurded\n presently however if his altered mental status is related to severe\n enchepathy he does have potential for improvement, also the fact that\n he has active movement in all extremties is a positive contributer to\n his potential to particpate with PT.\n Goals\n Time frame: 2wk\n 1.\n follow > 10 % of 1 step commands\n 2.\n make eye contact 50% of the time\n 3.\n Track to stimuli\n 4.\n 5.\n 6.\n Anticipated Discharge: Rehab\n Treatment Plan:\n Frequency / Duration: 2-3x/wk\n f/u cogntive stimulation, mobitly assessment to follow\n Patient agrees with the above goals and is willing to participate in\n the rehabilitation program.\n" }, { "category": "Rehab Services", "chartdate": "2145-01-20 00:00:00.000", "description": "Physical Therapy Progress Note", "row_id": 560751, "text": "Subjective:\n Someone needs to take out this foley\n Objective:\n Follow up PT visit to address goals of: . Patient seen today\n for patient education, other:\n Updated medical status: CXR - Persistent low lung volumes.\n Opacification at the right base is increasing and the hemidiaphragm is\n not sharply seen, consistent with pleural effusion and atelectasis\n Activity\n Clarification\n I\n S\n CG\n Min\n Mod\n Max\n Rolling:\n\n\n\n\n\n Supine/\n Sidelying to Sit:\n\n\n\n\n\n Transfer:\n\n\n\n\n\n Sit to Stand:\n\n\n\n\n X2\n Ambulation:\n\n\n\n\n\n Stairs:\n\n\n\n\n\n Aerobic Activity Response:\n Position\n HR\n BP\n RR\n O[2] sat\n RPE\n Rest\n Sit\n 84\n 125/68\n 98% on TM\n Activity\n Sit\n 90\n 107/70\n 88% on TM\n Recovery\n /\n Total distance walked: 0\n Minutes:\n Gait: unable to take steps at this time multiple lines/tubes.\n Sit-to-stand with max A x2\n Balance: mod A x2 to maintain static standing, 2 x 30 seconds.\n Education / Communication: REviewed PT with patient and wife,\n discussed d/c planning. Communicated with nsg re: status\n Other: On 50% FIO2 via trach mask\n Denies pain, but c/o discomfort at foley site\n Mild-mod lethargy, following most simple commands\n Assessment: 63 yo M making good progress in PT and able to tolerate\n mobility training and standing balance. He continues to be limited by\n decreased strength as well as some cognitive deficits, anticipate he\n will be good rehab candidate as he demonstrates daily improvements and\n motivation. PT to continue to follow.\n Anticipated Discharge: Rehab\n Plan: Continue with \n" }, { "category": "Nursing", "chartdate": "2145-01-14 00:00:00.000", "description": "Nursing Progress Note", "row_id": 559463, "text": "PMH: Pt admitted to on s/p fall for back spinal fusion. Has\n been confused since surgery according to pt's wife later developed UTI.\n Unknown cause of MS changes. ? encephalopathy vs. infection. Pt had\n resp distress, became unresponsive and went into PEA arrest on .\n Pt has been on Arctic sun. CT neg for PE or bleed. Pt was\n successfully extubated on , but developed acute respiratory\n distress on that night with increasing agitation and confusion. Was\n reintubated on . Head CT neg for any acute changes.\n Events: Pt taken to OR at 2130 for trach. Per surgery pt bled a fair\n amt during procedure, received 1 unit FFP in MICU prior and 2 unit FFP\n in OR. INR at 2100 1.7. Trach sutured in place w/ thrombin infused\n gel foam around surgical site. Per thoracic surgery will leave\n dressing in place until their follow up post-op day 1 (). Pt\n afebrile throughout shift.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received pt on AC 40%/550/12/5PEEP. LS course and dim at bases, mod\n amts blood-tinged sputum w/ suction. Sp02 96-99%.\n Action:\n Pt taken to OR for trach.\n Response:\n #8 portex trach in place, vent settings same as prior to procedure.\n Sp02 100%. Pt sedated on 15 mcg/kg/min propofol, pt breathing over\n vent at approx 16 bpm. ABG 7.47/40/94. Mod amts blood-tinged oral and\n bronchotracheal secretions.\n Plan:\n Monitor resp status. Extra trach kit and inner cannula in pt room.\n Electrolyte & fluid disorder, other\n Assessment:\n Pt diuresed yesterday and NPO prior to procedure. Na cont\ns to be\n elevated (147) and K, Mg, Ca, Phos low.\n Action:\n Finishing 1 L 5% Dextrose at 100 ml/hr now, TF restarted w/ 250 ml FWB\n q 4 hr, repleting lytes now.\n Response:\n Plan:\n Follow lytes, recheck labs.\n Altered mental status (not Delirium)\n Assessment:\n Pt sedated and opens eyes to voice, noxious stimuli. PERRL, does not\n track. MAEs, does not follow commands, no purposeful movts.\n Action:\n Freq neuro checks.\n Response:\n No changes noted in MS.\n :\n Monitor, maintain pt\ns comfort.\n" }, { "category": "Physician ", "chartdate": "2145-01-15 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 559812, "text": "Chief Complaint:\n 24 Hour Events:\n Events:\n - spoke to ID, fusobacterium is pan-sensitive and will give IV\n penicillin -> d/c zosyn\n - ENT eval for bleeding source -> no pharyngeal source\n - peripheral smear showed no evidence of DIC\n Allergies:\n Demerol (Oral) (Meperidine Hcl)\n Confusion/Delir\n Last dose of Antibiotics:\n Penicillin G potassium - 04:00 AM\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 08:30 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:24 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.3\nC (99.1\n Tcurrent: 37.1\nC (98.8\n HR: 78 (63 - 85) bpm\n BP: 136/62(84) {125/57(76) - 161/81(109)} mmHg\n RR: 8 (8 - 25) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 73 Inch\n CVP: 9 (6 - 12)mmHg\n Total In:\n 4,647 mL\n 1,068 mL\n PO:\n TF:\n 637 mL\n 280 mL\n IVF:\n 2,346 mL\n 198 mL\n Blood products:\n 574 mL\n Total out:\n 6,290 mL\n 1,020 mL\n Urine:\n 5,990 mL\n 1,020 mL\n NG:\n 200 mL\n Stool:\n Drains:\n Balance:\n -1,643 mL\n 48 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 550 (500 - 550) mL\n Vt (Spontaneous): 580 (361 - 651) mL\n PS : 10 cmH2O\n RR (Set): 12\n RR (Spontaneous): 8\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 63\n PIP: 17 cmH2O\n Plateau: 13 cmH2O\n Compliance: 68.7 cmH2O/mL\n SpO2: 99%\n ABG: 7.48/45/86/31/8\n Ve: 8.1 L/min\n PaO2 / FiO2: 215\n Physical Examination\n Eyes / Conjunctiva: PERRL, opens eyes, makes eye contact\n , Ears, Nose, Throat: , Poor dentition, NG tube, trach\n (Bloody )\n Cardiovascular: (S1: Normal), (S2: Normal), No(t) S3, No(t) S4, No(t)\n Rub\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not\n assessed), has a-line\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : ,\n Rhonchorous: )\n Abdominal: Soft, Bowel sounds present, Distended, palpable fluid wave\n Neurologic: arousable to voice, opens eyes no purposeful movements,\n withdraws to pain, non-verbal\n Labs / Radiology\n 55 K/uL\n 9.6 g/dL\n 114 mg/dL\n 0.7 mg/dL\n 31 mEq/L\n 3.9 mEq/L\n 18 mg/dL\n 110 mEq/L\n 146 mEq/L\n 28.4 %\n 5.5 K/uL\n [image002.jpg]\n 03:15 AM\n 03:29 AM\n 08:58 AM\n 01:09 PM\n 01:26 PM\n 03:23 PM\n 09:24 PM\n 10:04 PM\n 03:29 AM\n 03:46 AM\n WBC\n 4.1\n 4.6\n 4.8\n 5.0\n 5.5\n Hct\n 27.8\n 27.0\n 27.0\n 28.7\n 28.4\n Plt\n 44\n 46\n 60\n 59\n 55\n Cr\n 0.6\n 0.7\n 0.7\n 0.7\n TCO2\n 30\n 32\n 34\n 34\n Glucose\n 112\n 115\n 122\n 114\n Other labs: PT / PTT / INR:16.6/46.5/1.5, CK / CKMB /\n Troponin-T:447/26/0.24, ALT / AST:58/126, Alk Phos / T Bili:95/2.8,\n Amylase / Lipase:93/30, Differential-Neuts:80.0 %, Band:0.0 %,\n Lymph:16.0 %, Mono:0.0 %, Eos:4.0 %, Lactic Acid:1.6 mmol/L,\n Albumin:3.3 g/dL, LDH:298 IU/L, Ca++:8.9 mg/dL, Mg++:1.6 mg/dL, PO4:3.1\n mg/dL\n Assessment and Plan\n This is a 63 y/o M with Hepatitis C cirrhosis, s/p PEA arrest, body\n cooling and rewarming, with Fusobacterium sepsis covering with IV Pen G\n until .\n .\n # bleeding from trach site- Procedure done , 8-0 Portex .lost\n 150cc. Patient was given giving 2u platelets, given 1u FFP after the\n procedure. ENT was consulted on for concern of posterior pharynx\n bleed, which they did not find any evidence of.\n - will consider bronch to eval for source of bleed from trach site,\n continues to have red congealed blood oozing from site\n .\n # Respiratory/Ventilation: Pt re-intubated secondary to\n respiratory distress and inability to handle secretions. Unlikely to\n tolerate extubation given that underlying problem is inability to\n handle secretions which is unlikely to change. CXR from showed\n evidence of pulmonary edema. Patient getting trach in OR. Patient\n completed treatment for empire HAP for 5day with vanc/zosyn starting\n . Stopped vanc , continuing zosyn until sensitivities of\n fusobacterium.\n - giving Lasix 40mg IV with goal -2L\n .\n # Fusobacterium sepsis: Will treat for two-week course, awaiting\n sensitivities on Fusobacterium -> likely responsive to penicillin. Dx\n on , will need 14d course until . Covering with zosyn until\n sensitivies obtained.\n - surveillance blood cxs NTD\n .\n # thrombocytopenia\n platlets 171, now 44. Switched from H2 to\n PPI. Considering HIT vs. splenic sequestration\n - obtaining smear\n -\n # Mental Status: With slowly resolving delerium prior to this event,\n and now with unclear hypoxic insult to brain. GCS of on admission\n to ICU. Considering head CT to evaluate for anoxic brain injury\n post-cooling. Neuro eval for possible seizure. EEG neg for seizure,\n severe encephalopathy likely in setting of sedation. LP done earlier\n that was negative gram stain/culture, no whites, negative HSV PCR. Back\n to pre-code MS per wife. CT scan did not show any focal lesions.\n - patient is following commands, off propofol sedation, psych saw\n patient on and felt that the patient was very unlikely to have had\n NMS and recommended seroquel to be used for agitation.\n - likely will need MRI in the future but can not tolerate now \n mental status/respiratory status\n - increase lactulose\n .\n # Resolved Renal Failure: Unclear etiology, likely combination of ATN\n in the setting of code and HRS. Renal following given concern for HRS.\n Off albumin, mitodrine and octreotide\n - f/u renal and liver recs\n .\n # Hypernatremia: Likely hypovolemic hypernatremia in the setting of\n recent ATN and current HRS. Corrected , free water deficit ~ 2-3L.\n - switching antibiotics to be made with D5W\n .\n # Cardiac: CE's trended post-arrest. Echo hyperdynamic, no cardiogenic\n shock. CK and Trop trended down\n - will consider repeat echo\n .\n # Cirrhosis: Hep C Cirrhosis, with concern for HRS.\n - pre-code mental status likely related to encephalopathy v. delirium\n - titrate up lactulose\n - liver recs -> non suitable for tx at this point, in the very small\n chance that pt improves could possibly be candidate in the future\n .\n # s/p Shock/PEA Arrest: After PEA, was initially hemodynamically stable\n but has had episodes of hypotension non-responsive to IVF boluses,\n levofed started, currently off. Echo showed no evidence of cardiogenic\n shock. s/p cooling and rewarming. Trended cardiac enzymes, came down\n and no evidence of cardiogenic shock on rewarmed echo.\n # Parotid mass. Incidental finding of L parotid mass on MRI, 1.6cm. --\n Will require ENT followup as outpt.\n .\n # Metabolic Acidosis: s/p arrest to tissue hypoxia. Lactates now\n normalized, now resolved.\n # Access: PIV, Central Line\n .\n # FEN: TF running at goal, 60cc/hr\n .\n # Prophylaxis: holding HSQ since elevated PTT, PPI\n .\n # Code: full\n .\n # Communication: Wife is HCP -> will readdress long-term goals re:\n long-term prognosis\n .\n # Disposition: ICU for now.\n ICU Care\n Nutrition:\n Nutren Pulmonary (Full) - 12:47 AM 40 mL/hour\n Glycemic Control:\n Lines:\n Multi Lumen - 12:48 PM\n Arterial Line - 11:00 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": "2145-01-17 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 560084, "text": "Chief Complaint:\n 24 Hour Events:\n - started seroquel per psych\n - still remained very aggitated, needed to stay on low dose propofol\n - MRI completed yesterday:\n did not show signs of anoxic brain injury\n Allergies:\n Demerol (Oral) (Meperidine Hcl)\n Confusion/Delir\n Last dose of Antibiotics:\n Vancomycin - 08:00 AM\n Penicillin G potassium - 03:58 AM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:00 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 06:58 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.1\nC (100.6\n Tcurrent: 38.1\nC (100.6\n HR: 74 (74 - 102) bpm\n BP: 104/55(70) {104/51(68) - 175/134(129)} mmHg\n RR: 23 (16 - 33) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 73 Inch\n CVP: 12 (7 - 16)mmHg\n Total In:\n 3,610 mL\n 1,195 mL\n PO:\n TF:\n 1,312 mL\n 418 mL\n IVF:\n 643 mL\n 217 mL\n Blood products:\n Total out:\n 4,620 mL\n 370 mL\n Urine:\n 2,720 mL\n 370 mL\n NG:\n Stool:\n 850 mL\n Drains:\n Balance:\n -1,010 mL\n 825 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 443 (443 - 507) mL\n PS : 10 cmH2O\n RR (Spontaneous): 22\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 71\n PIP: 15 cmH2O\n SpO2: 96%\n ABG: ///28/\n Ve: 9.9 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 63 K/uL\n 9.3 g/dL\n 97 mg/dL\n 0.7 mg/dL\n 28 mEq/L\n 4.2 mEq/L\n 15 mg/dL\n 112 mEq/L\n 146 mEq/L\n 27.6 %\n 6.0 K/uL\n [image002.jpg]\n 03:23 PM\n 09:24 PM\n 10:04 PM\n 03:29 AM\n 03:46 AM\n 01:02 PM\n 01:03 PM\n 04:28 AM\n 04:45 AM\n 02:55 AM\n WBC\n 5.0\n 5.5\n 5.8\n 5.7\n 6.0\n Hct\n 28.7\n 28.4\n 27.7\n 26.3\n 27.6\n Plt\n 59\n 55\n 59\n 51\n 63\n Cr\n 0.7\n 0.7\n 0.7\n 0.7\n 0.7\n 0.7\n TCO2\n 34\n 34\n 34\n Glucose\n 115\n 122\n 114\n 110\n 114\n 97\n Other labs: PT / PTT / INR:17.3/46.8/1.6, CK / CKMB /\n Troponin-T:447/26/0.24, ALT / AST:60/136, Alk Phos / T Bili:129/2.5,\n Amylase / Lipase:38/42, Differential-Neuts:80.0 %, Band:0.0 %,\n Lymph:16.0 %, Mono:0.0 %, Eos:4.0 %, Lactic Acid:1.6 mmol/L,\n Albumin:3.3 g/dL, LDH:341 IU/L, Ca++:8.9 mg/dL, Mg++:1.6 mg/dL, PO4:2.9\n mg/dL\n Assessment and Plan\n AEROBIC CAPACITY / ENDURANCE, IMPAIRED\n AROUSAL, ATTENTION, AND COGNITION, IMPAIRED\n RESPIRATION / GAS EXCHANGE, IMPAIRED\n HEPATIC ENCEPHALOPATHY\n ELECTROLYTE & FLUID DISORDER, OTHER\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n HYPOTENSION (NOT SHOCK)\n CARDIAC ARREST\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n BACTEREMIA\n ICU Care\n Nutrition:\n Nutren Pulmonary (Full) - 02:20 AM 60 mL/hour\n Glycemic Control:\n Lines:\n Multi Lumen - 12:48 PM\n Arterial Line - 11:00 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": "2145-01-17 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 560085, "text": "Chief Complaint:\n 24 Hour Events:\n - started seroquel per psych\n - still remained very aggitated, needed to stay on low dose propofol\n - MRI completed yesterday:\n did not show signs of anoxic brain injury\n Allergies:\n Demerol (Oral) (Meperidine Hcl)\n Confusion/Delir\n Last dose of Antibiotics:\n Vancomycin - 08:00 AM\n Penicillin G potassium - 03:58 AM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:00 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 06:58 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.1\nC (100.6\n Tcurrent: 38.1\nC (100.6\n HR: 74 (74 - 102) bpm\n BP: 104/55(70) {104/51(68) - 175/134(129)} mmHg\n RR: 23 (16 - 33) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 73 Inch\n CVP: 12 (7 - 16)mmHg\n Total In:\n 3,610 mL\n 1,195 mL\n PO:\n TF:\n 1,312 mL\n 418 mL\n IVF:\n 643 mL\n 217 mL\n Blood products:\n Total out:\n 4,620 mL\n 370 mL\n Urine:\n 2,720 mL\n 370 mL\n NG:\n Stool:\n 850 mL\n Drains:\n Balance:\n -1,010 mL\n 825 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 443 (443 - 507) mL\n PS : 10 cmH2O\n RR (Spontaneous): 22\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 71\n PIP: 15 cmH2O\n SpO2: 96%\n ABG: ///28/\n Ve: 9.9 L/min\n Physical Examination\n Eyes / Conjunctiva: PERRL, opens eyes, makes eye contact\n , Ears, Nose, Throat: , Poor dentition, NG tube, trach\n (Bloody )\n Cardiovascular: (S1: Normal), (S2: Normal), No(t) S3, No(t) S4, No(t)\n Rub\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not\n assessed), has a-line\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : ,\n Rhonchorous: )\n Abdominal: Soft, Bowel sounds present, Distended, palpable fluid wave\n Neurologic: arousable to voice, opens eyes no purposeful movements,\n withdraws to pain, non-verbal\n Labs / Radiology\n 63 K/uL\n 9.3 g/dL\n 97 mg/dL\n 0.7 mg/dL\n 28 mEq/L\n 4.2 mEq/L\n 15 mg/dL\n 112 mEq/L\n 146 mEq/L\n 27.6 %\n 6.0 K/uL\n [image002.jpg]\n 03:23 PM\n 09:24 PM\n 10:04 PM\n 03:29 AM\n 03:46 AM\n 01:02 PM\n 01:03 PM\n 04:28 AM\n 04:45 AM\n 02:55 AM\n WBC\n 5.0\n 5.5\n 5.8\n 5.7\n 6.0\n Hct\n 28.7\n 28.4\n 27.7\n 26.3\n 27.6\n Plt\n 59\n 55\n 59\n 51\n 63\n Cr\n 0.7\n 0.7\n 0.7\n 0.7\n 0.7\n 0.7\n TCO2\n 34\n 34\n 34\n Glucose\n 115\n 122\n 114\n 110\n 114\n 97\n Other labs: PT / PTT / INR:17.3/46.8/1.6, CK / CKMB /\n Troponin-T:447/26/0.24, ALT / AST:60/136, Alk Phos / T Bili:129/2.5,\n Amylase / Lipase:38/42, Differential-Neuts:80.0 %, Band:0.0 %,\n Lymph:16.0 %, Mono:0.0 %, Eos:4.0 %, Lactic Acid:1.6 mmol/L,\n Albumin:3.3 g/dL, LDH:341 IU/L, Ca++:8.9 mg/dL, Mg++:1.6 mg/dL, PO4:2.9\n mg/dL\n Assessment and Plan\n AEROBIC CAPACITY / ENDURANCE, IMPAIRED\n AROUSAL, ATTENTION, AND COGNITION, IMPAIRED\n RESPIRATION / GAS EXCHANGE, IMPAIRED\n HEPATIC ENCEPHALOPATHY\n ELECTROLYTE & FLUID DISORDER, OTHER\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n HYPOTENSION (NOT SHOCK)\n CARDIAC ARREST\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n BACTEREMIA\n ICU Care\n Nutrition:\n Nutren Pulmonary (Full) - 02:20 AM 60 mL/hour\n Glycemic Control:\n Lines:\n Multi Lumen - 12:48 PM\n Arterial Line - 11:00 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": "2145-01-17 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 560086, "text": "Chief Complaint:\n 24 Hour Events:\n - started seroquel per psych\n - still remained very aggitated, needed to stay on low dose propofol\n - MRI completed yesterday:\n did not show signs of anoxic brain injury\n Allergies:\n Demerol (Oral) (Meperidine Hcl)\n Confusion/Delir\n Last dose of Antibiotics:\n Vancomycin - 08:00 AM\n Penicillin G potassium - 03:58 AM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:00 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 06:58 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.1\nC (100.6\n Tcurrent: 38.1\nC (100.6\n HR: 74 (74 - 102) bpm\n BP: 104/55(70) {104/51(68) - 175/134(129)} mmHg\n RR: 23 (16 - 33) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 73 Inch\n CVP: 12 (7 - 16)mmHg\n Total In:\n 3,610 mL\n 1,195 mL\n PO:\n TF:\n 1,312 mL\n 418 mL\n IVF:\n 643 mL\n 217 mL\n Blood products:\n Total out:\n 4,620 mL\n 370 mL\n Urine:\n 2,720 mL\n 370 mL\n NG:\n Stool:\n 850 mL\n Drains:\n Balance:\n -1,010 mL\n 825 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 443 (443 - 507) mL\n PS : 10 cmH2O\n RR (Spontaneous): 22\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 71\n PIP: 15 cmH2O\n SpO2: 96%\n ABG: ///28/\n Ve: 9.9 L/min\n Physical Examination\n Eyes / Conjunctiva: PERRL, opens eyes, makes eye contact\n , Ears, Nose, Throat: , Poor dentition, NG tube, trach\n (Bloody )\n Cardiovascular: (S1: Normal), (S2: Normal), No(t) S3, No(t) S4, No(t)\n Rub\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not\n assessed), has a-line\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : ,\n Rhonchorous: )\n Abdominal: Soft, Bowel sounds present, Distended, palpable fluid wave\n Neurologic: arousable to voice, opens eyes no purposeful movements,\n withdraws to pain, non-verbal\n Labs / Radiology\n 63 K/uL\n 9.3 g/dL\n 97 mg/dL\n 0.7 mg/dL\n 28 mEq/L\n 4.2 mEq/L\n 15 mg/dL\n 112 mEq/L\n 146 mEq/L\n 27.6 %\n 6.0 K/uL\n [image002.jpg]\n 03:23 PM\n 09:24 PM\n 10:04 PM\n 03:29 AM\n 03:46 AM\n 01:02 PM\n 01:03 PM\n 04:28 AM\n 04:45 AM\n 02:55 AM\n WBC\n 5.0\n 5.5\n 5.8\n 5.7\n 6.0\n Hct\n 28.7\n 28.4\n 27.7\n 26.3\n 27.6\n Plt\n 59\n 55\n 59\n 51\n 63\n Cr\n 0.7\n 0.7\n 0.7\n 0.7\n 0.7\n 0.7\n TCO2\n 34\n 34\n 34\n Glucose\n 115\n 122\n 114\n 110\n 114\n 97\n Other labs: PT / PTT / INR:17.3/46.8/1.6, CK / CKMB /\n Troponin-T:447/26/0.24, ALT / AST:60/136, Alk Phos / T Bili:129/2.5,\n Amylase / Lipase:38/42, Differential-Neuts:80.0 %, Band:0.0 %,\n Lymph:16.0 %, Mono:0.0 %, Eos:4.0 %, Lactic Acid:1.6 mmol/L,\n Albumin:3.3 g/dL, LDH:341 IU/L, Ca++:8.9 mg/dL, Mg++:1.6 mg/dL, PO4:2.9\n mg/dL\n Assessment and Plan\n This is a 63 y/o M who has continued AMS to point where not\n communicating at all; with hx Hepatitis C cirrhosis, s/p PEA arrest,\n body cooling and rewarming, with Fusobacterium sepsis covering with IV\n Pen G until .\n .\n # Mental Status: With slowly resolving delerium prior to this event,\n and now with unclear hypoxic insult to brain. GCS of on admission\n to ICU. Considering head CT to evaluate for anoxic brain injury\n post-cooling. Neuro eval for possible seizure. EEG neg for seizure,\n severe encephalopathy likely in setting of sedation. LP done earlier\n that was negative gram stain/culture, no whites, negative HSV PCR. Back\n to pre-code MS per wife. CT scan did not show any focal lesions. MRI\n () was unremarkable.\n - patient is following commands, off propofol sedation, psych saw\n patient on and felt that the patient was very unlikely to have had\n NMS and recommended seroquel to be used for agitation.\n - continue max dose of lactulose and rifaximin\n .\n # bleeding from trach site- Procedure done , 8-0 Portex .lost\n 150cc. Patient was given giving 2u platelets, given 1u FFP after the\n procedure. ENT was consulted on for concern of posterior pharynx\n bleed, which they did not find any evidence of.\n - bleeding has improved\n - ENT found small bite on back of tongue, but no evidence of posterior\n pharynx bleed\n .\n # Respiratory/Ventilation: Pt re-intubated secondary to\n respiratory distress and inability to handle secretions. Unlikely to\n tolerate extubation given that underlying problem is inability to\n handle secretions which is unlikely to change. CXR from showed\n evidence of pulmonary edema. Patient getting trach in OR. Patient\n completed treatment for empire HAP for 5day with vanc/zosyn starting\n . Stopped vanc , continuing zosyn until sensitivities of\n fusobacterium.\n - giving Lasix 40mg IV with goal -2L\n - tolerating trach collar very well\n .\n # Fusobacterium sepsis: Will treat for two-week course, awaiting\n sensitivities on Fusobacterium -> likely responsive to penicillin. Dx\n on , will need 14d course until . Covered with zosyn until\n sensitivies obtained.\n - surveillance blood cxs NTD\n - complete course of PCN until \n .\n # Thrombocytopenia\n platlets 171, now 44. Switched from H2 to\n PPI. Considering HIT vs. splenic sequestration\n - f/u smear\n - plts starting to improve slightly after switch\n .\n # Resolved Renal Failure: Unclear etiology, likely combination of ATN\n in the setting of code and HRS. Renal following given concern for HRS.\n Off albumin, mitodrine and octreotide\n - renal function stable\n - f/u renal and liver recs\n .\n # Hypernatremia: Likely hypovolemic hypernatremia in the setting of\n recent ATN and current HRS. Corrected , free water deficit ~ 2-3L.\n - switching antibiotics to be made with D5W\n - cont free water flushes q3 hr through G tube\n .\n # Cardiac: CE's trended post-arrest. Echo hyperdynamic, no cardiogenic\n shock. CK and Trop trended down\n - will consider repeat echo\n .\n # Cirrhosis: Hep C Cirrhosis, with concern for HRS.\n - pre-code mental status likely related to encephalopathy v. delirium\n - titrate up lactulose\n - liver recs -> non suitable for tx at this point, in the very small\n chance that pt improves could possibly be candidate in the future\n .\n # s/p Shock/PEA Arrest: After PEA, was initially hemodynamically stable\n but has had episodes of hypotension non-responsive to IVF boluses,\n levofed started, currently off. Echo showed no evidence of cardiogenic\n shock. s/p cooling and rewarming. Trended cardiac enzymes, came down\n and no evidence of cardiogenic shock on rewarmed echo.\n # Parotid mass. Incidental finding of L parotid mass on MRI, 1.6cm. --\n Will require ENT followup as outpt.\n .\n # Metabolic Acidosis: s/p arrest to tissue hypoxia. Lactates now\n normalized, now resolved.\n # Access: PIV, Central Line\n .\n # FEN: TF running at goal, 60cc/hr\n .\n # Prophylaxis: holding HSQ since elevated PTT, PPI\n .\n # Code: full\n .\n # Communication: Wife is HCP -> will readdress long-term goals re:\n long-term prognosis\n .\n # Disposition: ICU for now.\n ICU Care\n Nutrition:\n Nutren Pulmonary (Full) - 02:20 AM 60 mL/hour\n Glycemic Control:\n Lines:\n Multi Lumen - 12:48 PM\n Arterial Line - 11:00 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": "2145-01-16 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 559934, "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 63 yo man with hep C cirrhosis, with samll HCC, admitted for falls, had\n cervical laminextomy and never recovered MS. had PEA arrest one week\n ago due to mucous plug. Intubated and failured extubation once. Has\n had episodic agitation, required uping of propofol. Psych rec. giving\n seroquel instead of haldol with ? of NMS previously.\n 24 Hour Events:\n Allergies:\n Demerol (Oral) (Meperidine Hcl)\n Confusion/Delir\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 06:36 AM\n Vancomycin - 08:00 AM\n Penicillin G potassium - 04:00 AM\n Infusions:\n Propofol - 15 mcg/Kg/min\n Other ICU medications:\n Furosemide (Lasix) - 12:54 PM\n Other medications:\n protonix\n folate\n thiamine\n levoxyl\n pen G\n lactulose\n rifaxamin\n Changes to medical and family history:\n PMH, SH, FH and ROS are from Admission except where noted\n above and below\n Review of systems is from admission except as noted below\n Review of systems:\n Respiratory: No(t) Dyspnea\n Psychiatric / Sleep: No(t) Delirious, unresponsive\n Flowsheet Data as of 11:57 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.1\nC (100.6\n Tcurrent: 37.4\nC (99.4\n HR: 86 (80 - 114) bpm\n BP: 163/66(96) {128/49(68) - 191/81(113)} mmHg\n RR: 27 (9 - 29) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 73 Inch\n CVP: 16 (7 - 21)mmHg\n Total In:\n 4,016 mL\n 2,138 mL\n PO:\n TF:\n 1,268 mL\n 671 mL\n IVF:\n 549 mL\n 212 mL\n Blood products:\n Total out:\n 5,960 mL\n 2,100 mL\n Urine:\n 4,960 mL\n 1,050 mL\n NG:\n Stool:\n 1,000 mL\n Drains:\n Balance:\n -1,944 mL\n 38 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 507 (445 - 860) mL\n PS : 10 cmH2O\n RR (Spontaneous): 16\n PEEP: 5 cmH2O\n FiO2: 70%\n RSBI: 83\n PIP: 22 cmH2O\n SpO2: 100%\n ABG: 7.47/45/106/32/7\n Ve: 8.6 L/min\n PaO2 / FiO2: 212\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: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Absent, Left: Absent\n Musculoskeletal: No(t) Muscle wasting\n Skin: Warm\n Neurologic: No(t) Attentive, No(t) Follows simple commands, Responds\n to: Noxious stimuli, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 8.9 g/dL\n 51 K/uL\n 114 mg/dL\n 0.7 mg/dL\n 32 mEq/L\n 4.0 mEq/L\n 16 mg/dL\n 110 mEq/L\n 147 mEq/L\n 26.3 %\n 5.7 K/uL\n [image002.jpg]\n 01:26 PM\n 03:23 PM\n 09:24 PM\n 10:04 PM\n 03:29 AM\n 03:46 AM\n 01:02 PM\n 01:03 PM\n 04:28 AM\n 04:45 AM\n WBC\n 5.0\n 5.5\n 5.8\n 5.7\n Hct\n 28.7\n 28.4\n 27.7\n 26.3\n Plt\n 59\n 55\n 59\n 51\n Cr\n 0.7\n 0.7\n 0.7\n 0.7\n 0.7\n TCO2\n 32\n 34\n 34\n 34\n Glucose\n 115\n 122\n 114\n 110\n 114\n Other labs: PT / PTT / INR:17.0/47.3/1.5, CK / CKMB /\n Troponin-T:447/26/0.24, ALT / AST:59/138, Alk Phos / T Bili:120/2.4,\n Amylase / Lipase:93/30, Differential-Neuts:80.0 %, Band:0.0 %,\n Lymph:16.0 %, Mono:0.0 %, Eos:4.0 %, Lactic Acid:1.6 mmol/L,\n Albumin:3.3 g/dL, LDH:398 IU/L, Ca++:8.9 mg/dL, Mg++:1.6 mg/dL, PO4:2.9\n mg/dL\n Microbiology: : Fusobacterium from blood.\n Assessment and Plan\n Encephalopathy: MS g well on lactulose. Seroquel\n for agitation.\n Respiratory failure: doing well on Trach mask.\n Acute renal failure: improved\n HCV cirrhosis:\n ICU Care\n Nutrition:\n Comments: TFs\n Glycemic Control:\n Lines:\n Multi Lumen - 12:48 PM\n Arterial Line - 11:00 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 35 minutes\n" }, { "category": "Physician ", "chartdate": "2145-01-16 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 559943, "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 63 yo man with hep C cirrhosis, with samll HCC, admitted for falls, had\n cervical laminextomy and never recovered MS. had PEA arrest one week\n ago due to mucous plug. Intubated and failured extubation once. Has\n had episodic agitation, required uping of propofol. Psych rec. giving\n seroquel instead of haldol with ? of NMS previously.\n 24 Hour Events:\n Allergies:\n Demerol (Oral) (Meperidine Hcl)\n Confusion/Delir\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 06:36 AM\n Vancomycin - 08:00 AM\n Penicillin G potassium - 04:00 AM\n Infusions:\n Propofol - 15 mcg/Kg/min\n Other ICU medications:\n Furosemide (Lasix) - 12:54 PM\n Other medications:\n protonix\n folate\n thiamine\n levoxyl\n pen G\n lactulose\n rifaxamin\n Changes to medical and family history:\n PMH, SH, FH and ROS are from Admission except where noted\n above and below\n Review of systems is from admission except as noted below\n Review of systems:\n Respiratory: No(t) Dyspnea\n Psychiatric / Sleep: No(t) Delirious, unresponsive\n Flowsheet Data as of 11:57 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.1\nC (100.6\n Tcurrent: 37.4\nC (99.4\n HR: 86 (80 - 114) bpm\n BP: 163/66(96) {128/49(68) - 191/81(113)} mmHg\n RR: 27 (9 - 29) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 73 Inch\n CVP: 16 (7 - 21)mmHg\n Total In:\n 4,016 mL\n 2,138 mL\n PO:\n TF:\n 1,268 mL\n 671 mL\n IVF:\n 549 mL\n 212 mL\n Blood products:\n Total out:\n 5,960 mL\n 2,100 mL\n Urine:\n 4,960 mL\n 1,050 mL\n NG:\n Stool:\n 1,000 mL\n Drains:\n Balance:\n -1,944 mL\n 38 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 507 (445 - 860) mL\n PS : 10 cmH2O\n RR (Spontaneous): 16\n PEEP: 5 cmH2O\n FiO2: 70%\n RSBI: 83\n PIP: 22 cmH2O\n SpO2: 100%\n ABG: 7.47/45/106/32/7\n Ve: 8.6 L/min\n PaO2 / FiO2: 212\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: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Absent, Left: Absent\n Musculoskeletal: No(t) Muscle wasting\n Skin: Warm\n Neurologic: No(t) Attentive, No(t) Follows simple commands, Responds\n to: Noxious stimuli, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 8.9 g/dL\n 51 K/uL\n 114 mg/dL\n 0.7 mg/dL\n 32 mEq/L\n 4.0 mEq/L\n 16 mg/dL\n 110 mEq/L\n 147 mEq/L\n 26.3 %\n 5.7 K/uL\n [image002.jpg]\n 01:26 PM\n 03:23 PM\n 09:24 PM\n 10:04 PM\n 03:29 AM\n 03:46 AM\n 01:02 PM\n 01:03 PM\n 04:28 AM\n 04:45 AM\n WBC\n 5.0\n 5.5\n 5.8\n 5.7\n Hct\n 28.7\n 28.4\n 27.7\n 26.3\n Plt\n 59\n 55\n 59\n 51\n Cr\n 0.7\n 0.7\n 0.7\n 0.7\n 0.7\n TCO2\n 32\n 34\n 34\n 34\n Glucose\n 115\n 122\n 114\n 110\n 114\n Other labs: PT / PTT / INR:17.0/47.3/1.5, CK / CKMB /\n Troponin-T:447/26/0.24, ALT / AST:59/138, Alk Phos / T Bili:120/2.4,\n Amylase / Lipase:93/30, Differential-Neuts:80.0 %, Band:0.0 %,\n Lymph:16.0 %, Mono:0.0 %, Eos:4.0 %, Lactic Acid:1.6 mmol/L,\n Albumin:3.3 g/dL, LDH:398 IU/L, Ca++:8.9 mg/dL, Mg++:1.6 mg/dL, PO4:2.9\n mg/dL\n Microbiology: : Fusobacterium from blood.\n Assessment and Plan\n Encephalopathy: MS g well on lactulose. Seroquel\n for agitation. Consider MRI to work up anoxic brain injury\n Respiratory failure: doing well on Trach mask.\n Acute renal failure: improved\n HCV cirrhosis:\n ICU Care\n Nutrition:\n Comments: TFs\n Glycemic Control:\n Lines:\n Multi Lumen - 12:48 PM\n Arterial Line - 11:00 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 35 minutes\n" }, { "category": "Physician ", "chartdate": "2145-01-16 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 559953, "text": "Chief Complaint:\n 24 Hour Events:\n Events:\n was able to lighten propofol sedation\n psych c/s done and did not think that it was likely that he had NMS\n from haldol but still recommend giving only seroquel\n i/o negative 2L\n Allergies:\n Demerol (Oral) (Meperidine Hcl)\n Confusion/Delir\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 06:36 AM\n Vancomycin - 08:00 AM\n Penicillin G potassium - 04:00 AM\n Infusions:\n Propofol - 15 mcg/Kg/min\n Other ICU medications:\n Pantoprazole (Protonix) - 08:04 AM\n Furosemide (Lasix) - 12:54 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 07:06 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.1\nC (100.6\n Tcurrent: 36.9\nC (98.4\n HR: 80 (80 - 114) bpm\n BP: 151/67(91) {128/49(68) - 191/81(113)} mmHg\n RR: 14 (9 - 29) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 73 Inch\n CVP: 18 (7 - 21)mmHg\n Total In:\n 4,016 mL\n 1,465 mL\n PO:\n TF:\n 1,268 mL\n 427 mL\n IVF:\n 549 mL\n 168 mL\n Blood products:\n Total out:\n 5,960 mL\n 760 mL\n Urine:\n 4,960 mL\n 760 mL\n NG:\n Stool:\n 1,000 mL\n Drains:\n Balance:\n -1,944 mL\n 705 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 445 (402 - 860) mL\n PS : 15 cmH2O\n RR (Spontaneous): 29\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 83\n PIP: 21 cmH2O\n SpO2: 99%\n ABG: 7.47/45/106/32/7\n Ve: 16.3 L/min\n PaO2 / FiO2: 212\n Physical Examination\n Eyes / Conjunctiva: PERRL, opens eyes, makes eye contact\n , Ears, Nose, Throat: , Poor dentition, NG tube, trach\n (Bloody )\n Cardiovascular: (S1: Normal), (S2: Normal), No(t) S3, No(t) S4, No(t)\n Rub\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not\n assessed), has a-line\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : ,\n Rhonchorous: )\n Abdominal: Soft, Bowel sounds present, Distended, palpable fluid wave\n Neurologic: arousable to voice, opens eyes no purposeful movements,\n withdraws to pain, non-verbal\n Labs / Radiology\n 51 K/uL\n 8.9 g/dL\n 114 mg/dL\n 0.7 mg/dL\n 32 mEq/L\n 4.0 mEq/L\n 16 mg/dL\n 110 mEq/L\n 147 mEq/L\n 26.3 %\n 5.7 K/uL\n [image002.jpg]\n 01:26 PM\n 03:23 PM\n 09:24 PM\n 10:04 PM\n 03:29 AM\n 03:46 AM\n 01:02 PM\n 01:03 PM\n 04:28 AM\n 04:45 AM\n WBC\n 5.0\n 5.5\n 5.8\n 5.7\n Hct\n 28.7\n 28.4\n 27.7\n 26.3\n Plt\n 59\n 55\n 59\n 51\n Cr\n 0.7\n 0.7\n 0.7\n 0.7\n 0.7\n TCO2\n 32\n 34\n 34\n 34\n Glucose\n 115\n 122\n 114\n 110\n 114\n Other labs: PT / PTT / INR:17.0/47.3/1.5, CK / CKMB /\n Troponin-T:447/26/0.24, ALT / AST:59/138, Alk Phos / T Bili:120/2.4,\n Amylase / Lipase:93/30, Differential-Neuts:80.0 %, Band:0.0 %,\n Lymph:16.0 %, Mono:0.0 %, Eos:4.0 %, Lactic Acid:1.6 mmol/L,\n Albumin:3.3 g/dL, LDH:398 IU/L, Ca++:8.9 mg/dL, Mg++:1.6 mg/dL, PO4:2.9\n mg/dL\n Assessment and Plan\n This is a 63 y/o M who has continued AMS to point where not\n communicating at all; with hx Hepatitis C cirrhosis, s/p PEA arrest,\n body cooling and rewarming, with Fusobacterium sepsis covering with IV\n Pen G until .\n .\n # Mental Status: With slowly resolving delerium prior to this event,\n and now with unclear hypoxic insult to brain. GCS of on admission\n to ICU. Considering head CT to evaluate for anoxic brain injury\n post-cooling. Neuro eval for possible seizure. EEG neg for seizure,\n severe encephalopathy likely in setting of sedation. LP done earlier\n that was negative gram stain/culture, no whites, negative HSV PCR. Back\n to pre-code MS per wife. CT scan did not show any focal lesions.\n - patient is following commands, off propofol sedation, psych saw\n patient on and felt that the patient was very unlikely to have had\n NMS and recommended seroquel to be used for agitation.\n - starting seroquel today\n - plan for MRI today\n - continue max dose of lactulose and rifaximin\n .\n # bleeding from trach site- Procedure done , 8-0 Portex .lost\n 150cc. Patient was given giving 2u platelets, given 1u FFP after the\n procedure. ENT was consulted on for concern of posterior pharynx\n bleed, which they did not find any evidence of.\n - bleeding has improved\n - ENT found small bite on back of tongue, but no evidence of posterior\n pharynx bleed\n .\n # Respiratory/Ventilation: Pt re-intubated secondary to\n respiratory distress and inability to handle secretions. Unlikely to\n tolerate extubation given that underlying problem is inability to\n handle secretions which is unlikely to change. CXR from showed\n evidence of pulmonary edema. Patient getting trach in OR. Patient\n completed treatment for empire HAP for 5day with vanc/zosyn starting\n . Stopped vanc , continuing zosyn until sensitivities of\n fusobacterium.\n - giving Lasix 40mg IV with goal -2L\n - tolerating trach collar today very well\n .\n # Fusobacterium sepsis: Will treat for two-week course, awaiting\n sensitivities on Fusobacterium -> likely responsive to penicillin. Dx\n on , will need 14d course until . Covered with zosyn until\n sensitivies obtained.\n - surveillance blood cxs NTD\n - complete course of PCN until \n .\n # thrombocytopenia\n platlets 171, now 44. Switched from H2 to\n PPI. Considering HIT vs. splenic sequestration\n - obtaining smear\n - plts starting to improve slightly after switch\n .\n # Resolved Renal Failure: Unclear etiology, likely combination of ATN\n in the setting of code and HRS. Renal following given concern for HRS.\n Off albumin, mitodrine and octreotide\n - renal function stable\n - f/u renal and liver recs\n .\n # Hypernatremia: Likely hypovolemic hypernatremia in the setting of\n recent ATN and current HRS. Corrected , free water deficit ~ 2-3L.\n - switching antibiotics to be made with D5W\n - cont free water flushes q3 hr through G tube\n .\n # Cardiac: CE's trended post-arrest. Echo hyperdynamic, no cardiogenic\n shock. CK and Trop trended down\n - will consider repeat echo\n .\n # Cirrhosis: Hep C Cirrhosis, with concern for HRS.\n - pre-code mental status likely related to encephalopathy v. delirium\n - titrate up lactulose\n - liver recs -> non suitable for tx at this point, in the very small\n chance that pt improves could possibly be candidate in the future\n .\n # s/p Shock/PEA Arrest: After PEA, was initially hemodynamically stable\n but has had episodes of hypotension non-responsive to IVF boluses,\n levofed started, currently off. Echo showed no evidence of cardiogenic\n shock. s/p cooling and rewarming. Trended cardiac enzymes, came down\n and no evidence of cardiogenic shock on rewarmed echo.\n # Parotid mass. Incidental finding of L parotid mass on MRI, 1.6cm. --\n Will require ENT followup as outpt.\n .\n # Metabolic Acidosis: s/p arrest to tissue hypoxia. Lactates now\n normalized, now resolved.\n # Access: PIV, Central Line\n .\n # FEN: TF running at goal, 60cc/hr\n .\n # Prophylaxis: holding HSQ since elevated PTT, PPI\n .\n # Code: full\n .\n # Communication: Wife is HCP -> will readdress long-term goals re:\n long-term prognosis\n .\n # Disposition: ICU for now.\n ICU Care\n Nutrition:\n Nutren Pulmonary (Full) - 03:10 AM 60 mL/hour\n Glycemic Control:\n Lines:\n Multi Lumen - 12:48 PM\n Arterial Line - 11:00 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": "2145-01-17 00:00:00.000", "description": "Nursing Progress Note", "row_id": 560082, "text": "Pt admitted to on s/p fall for back spinal fusion. Has been\n confused since surgery according to pt's wife later developed UTI.\n Unknown cause of MS changes. ? encephalopathy vs. infection.Pt had\n resp distress, became unresponsive and went into PEA arrest on .Pt\n has been on Arctic sun.CT neg for PE or bleed.Pt was successfully\n extubated on . Reintubated . Trached . Head CT neg for any\n acute changes.\n Events over night: Dropped O2 sat mom to 90%, placed back on\n PSV 10/ 5 peep.\n Altered mental status (not Delirium)\n Assessment:\n Remains on propafol, not following commands, tracks or tries to\n communicate. Pupils 3mm. Slightly rigid with turning. Earlier dose of\n lactulose held, 0400 given due to stool amt slowing down\n Action:\n Requiring propafol in order to control agitation\n Response:\n Per with increased agitation with any tactile stimulation\n Plan:\n Continue to monitor patient\ns neuro status, meds ASDIR\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Remained on trach mask over night until ~0300, placed back on PSV 10\n with 5 peep to rest. Small amt s of blood tinged\n Action:\n Suction prn, trach care and frequent mouth care\n Response:\n Tolerated trach mask, on PSV to rest due to Sat drop\n Plan:\n Continue to monitor resp status, meds ASDIR, Mouth care and trach care\n as needed.\n" }, { "category": "Respiratory ", "chartdate": "2145-01-16 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 559879, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 6\n Ideal body weight: 83.5 None\n Ideal tidal volume: mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type: Not applicable\n Size: Not applicable\n Tracheostomy tube:\n Type: Standard\n Manufacturer: Portex\n Size: 8.0mm\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Bloody / Thick\n Sputum source/amount: Suctioned / Moderate\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Accessory muscle use, Gasping\n efforts, High flow demand\n Assessment of breathing comfort: No response (sleeping / sedated)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment: Abnormal trigger efforts (efforts during\n inspiratory)\n Dysynchrony assessment: Vigorous inspiratory efforts\n Comments:\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n Pt becomes agitated W/O sedation\n" }, { "category": "Physician ", "chartdate": "2145-01-16 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 559886, "text": "Chief Complaint:\n 24 Hour Events:\n Events:\n was able to lighten propofol sedation\n psych c/s done and did not think that it was likely that he had NMS\n from haldol but still recommend giving only seroquel\n i/o negative 2L\n Allergies:\n Demerol (Oral) (Meperidine Hcl)\n Confusion/Delir\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 06:36 AM\n Vancomycin - 08:00 AM\n Penicillin G potassium - 04:00 AM\n Infusions:\n Propofol - 15 mcg/Kg/min\n Other ICU medications:\n Pantoprazole (Protonix) - 08:04 AM\n Furosemide (Lasix) - 12:54 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 07:06 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.1\nC (100.6\n Tcurrent: 36.9\nC (98.4\n HR: 80 (80 - 114) bpm\n BP: 151/67(91) {128/49(68) - 191/81(113)} mmHg\n RR: 14 (9 - 29) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 73 Inch\n CVP: 18 (7 - 21)mmHg\n Total In:\n 4,016 mL\n 1,465 mL\n PO:\n TF:\n 1,268 mL\n 427 mL\n IVF:\n 549 mL\n 168 mL\n Blood products:\n Total out:\n 5,960 mL\n 760 mL\n Urine:\n 4,960 mL\n 760 mL\n NG:\n Stool:\n 1,000 mL\n Drains:\n Balance:\n -1,944 mL\n 705 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 445 (402 - 860) mL\n PS : 15 cmH2O\n RR (Spontaneous): 29\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 83\n PIP: 21 cmH2O\n SpO2: 99%\n ABG: 7.47/45/106/32/7\n Ve: 16.3 L/min\n PaO2 / FiO2: 212\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 51 K/uL\n 8.9 g/dL\n 114 mg/dL\n 0.7 mg/dL\n 32 mEq/L\n 4.0 mEq/L\n 16 mg/dL\n 110 mEq/L\n 147 mEq/L\n 26.3 %\n 5.7 K/uL\n [image002.jpg]\n 01:26 PM\n 03:23 PM\n 09:24 PM\n 10:04 PM\n 03:29 AM\n 03:46 AM\n 01:02 PM\n 01:03 PM\n 04:28 AM\n 04:45 AM\n WBC\n 5.0\n 5.5\n 5.8\n 5.7\n Hct\n 28.7\n 28.4\n 27.7\n 26.3\n Plt\n 59\n 55\n 59\n 51\n Cr\n 0.7\n 0.7\n 0.7\n 0.7\n 0.7\n TCO2\n 32\n 34\n 34\n 34\n Glucose\n 115\n 122\n 114\n 110\n 114\n Other labs: PT / PTT / INR:17.0/47.3/1.5, CK / CKMB /\n Troponin-T:447/26/0.24, ALT / AST:59/138, Alk Phos / T Bili:120/2.4,\n Amylase / Lipase:93/30, Differential-Neuts:80.0 %, Band:0.0 %,\n Lymph:16.0 %, Mono:0.0 %, Eos:4.0 %, Lactic Acid:1.6 mmol/L,\n Albumin:3.3 g/dL, LDH:398 IU/L, Ca++:8.9 mg/dL, Mg++:1.6 mg/dL, PO4:2.9\n mg/dL\n Assessment and Plan\n This is a 63 y/o M with Hepatitis C cirrhosis, s/p PEA arrest, body\n cooling and rewarming, with Fusobacterium sepsis covering with IV Pen G\n until .\n .\n # bleeding from trach site- Procedure done , 8-0 Portex .lost\n 150cc. Patient was given giving 2u platelets, given 1u FFP after the\n procedure. ENT was consulted on for concern of posterior pharynx\n bleed, which they did not find any evidence of.\n - will consider bronch to eval for source of bleed from trach site,\n continues to have red congealed blood oozing from site\n .\n # Respiratory/Ventilation: Pt re-intubated secondary to\n respiratory distress and inability to handle secretions. Unlikely to\n tolerate extubation given that underlying problem is inability to\n handle secretions which is unlikely to change. CXR from showed\n evidence of pulmonary edema. Patient getting trach in OR. Patient\n completed treatment for empire HAP for 5day with vanc/zosyn starting\n . Stopped vanc , continuing zosyn until sensitivities of\n fusobacterium.\n - giving Lasix 40mg IV with goal -2L\n .\n # Fusobacterium sepsis: Will treat for two-week course, awaiting\n sensitivities on Fusobacterium -> likely responsive to penicillin. Dx\n on , will need 14d course until . Covering with zosyn until\n sensitivies obtained.\n - surveillance blood cxs NTD\n .\n # thrombocytopenia\n platlets 171, now 44. Switched from H2 to\n PPI. Considering HIT vs. splenic sequestration\n - obtaining smear\n -\n # Mental Status: With slowly resolving delerium prior to this event,\n and now with unclear hypoxic insult to brain. GCS of on admission\n to ICU. Considering head CT to evaluate for anoxic brain injury\n post-cooling. Neuro eval for possible seizure. EEG neg for seizure,\n severe encephalopathy likely in setting of sedation. LP done earlier\n that was negative gram stain/culture, no whites, negative HSV PCR. Back\n to pre-code MS per wife. CT scan did not show any focal lesions.\n - patient is following commands, off propofol sedation, psych saw\n patient on and felt that the patient was very unlikely to have had\n NMS and recommended seroquel to be used for agitation.\n - likely will need MRI in the future but can not tolerate now \n mental status/respiratory status\n - increase lactulose\n .\n # Resolved Renal Failure: Unclear etiology, likely combination of ATN\n in the setting of code and HRS. Renal following given concern for HRS.\n Off albumin, mitodrine and octreotide\n - f/u renal and liver recs\n .\n # Hypernatremia: Likely hypovolemic hypernatremia in the setting of\n recent ATN and current HRS. Corrected , free water deficit ~ 2-3L.\n - switching antibiotics to be made with D5W\n .\n # Cardiac: CE's trended post-arrest. Echo hyperdynamic, no cardiogenic\n shock. CK and Trop trended down\n - will consider repeat echo\n .\n # Cirrhosis: Hep C Cirrhosis, with concern for HRS.\n - pre-code mental status likely related to encephalopathy v. delirium\n - titrate up lactulose\n - liver recs -> non suitable for tx at this point, in the very small\n chance that pt improves could possibly be candidate in the future\n .\n # s/p Shock/PEA Arrest: After PEA, was initially hemodynamically stable\n but has had episodes of hypotension non-responsive to IVF boluses,\n levofed started, currently off. Echo showed no evidence of cardiogenic\n shock. s/p cooling and rewarming. Trended cardiac enzymes, came down\n and no evidence of cardiogenic shock on rewarmed echo.\n # Parotid mass. Incidental finding of L parotid mass on MRI, 1.6cm. --\n Will require ENT followup as outpt.\n .\n # Metabolic Acidosis: s/p arrest to tissue hypoxia. Lactates now\n normalized, now resolved.\n # Access: PIV, Central Line\n .\n # FEN: TF running at goal, 60cc/hr\n .\n # Prophylaxis: holding HSQ since elevated PTT, PPI\n .\n # Code: full\n .\n # Communication: Wife is HCP -> will readdress long-term goals re:\n long-term prognosis\n .\n # Disposition: ICU for now.\n ICU Care\n Nutrition:\n Nutren Pulmonary (Full) - 03:10 AM 60 mL/hour\n Glycemic Control:\n Lines:\n Multi Lumen - 12:48 PM\n Arterial Line - 11:00 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": "2145-01-16 00:00:00.000", "description": "Nursing Progress Note", "row_id": 559994, "text": "PMH: Pt admitted to on s/p fall for back spinal fusion. Has\n been confused since surgery according to pt's wife later developed UTI.\n Unknown cause of MS changes. ? encephalopathy vs. infection.Pt had\n resp distress, became unresponsive and went into PEA arrest on .Pt\n has been on Arctic sun.CT neg for PE or bleed.Pt was successfully\n extubated on . Reintubated . Trached . Head CT neg for any\n acute changes.\n 63 y/o M with Hepatitis C cirrhosis, s/p PEA arrest, body cooling and\n rewarming, with Fusobacterium sepsis covering with Zosyn until .\n Altered mental status (not Delirium)\n Assessment:\n Pt responsive to painful stimuli only, no response to verbal stimuli.\n Very restless in bed, attempting to put L leg over siderail and freq\n scooting self down in bed so that it is difficult to keep head\n elevated>30degrees. Pt does not appear to be in pain. Rec\nd pt on\n Propofol qtt @ 15mcg/kg/min.\n Action:\n Pt remained on Propofol qtt until after going to head MRI. He then\n rec\nd PRN Seroquel via GT.\n Response:\n Pt cont to be very restless, attempting to exit bed but unresponsive to\n verbal redirection.\n Plan:\n Restart Propofol and rest pt on PS ventilation overnight. Re-eval re po\n med alternatives.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Rec\nd pt on vent settings CPAP/PS 15/+5/50% with SRR 20-31 and irreg\n with periods apnea. Lung snds clear, diminished in bases. Pt with\n erratic strong cough, productive of small-mod amts thick, tan,\n blood-tinged sputum. Tmax 99.4, presently afebrile. Mouth with multiple\n scabs on lips, tongue.\n Action:\n Pt cont on PCN antibiotic. Requring infreq sxn\ning of small amts\n sputum.\n Response:\n No change.\n Plan:\n Cont present antibiotic course. Monitor temp. Cont aggressive oral\n care.\n" }, { "category": "Respiratory ", "chartdate": "2145-01-17 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 560188, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 7\n Ideal body weight: 83.5 None\n Ideal tidal volume: mL/kg\n Airway\n Tracheostomy tube:\n Type: Standard, Cuffed, Inner Cannula\n Manufacturer: Portex\n Size: 8.0mm\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 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: Blood Tinged / Thin\n Sputum source/amount: Expectorated / Moderate\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 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: Increase ventilatory support at night; Comments: if\n needed\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Bedside Procedures:\n Comments:\n" }, { "category": "Physician ", "chartdate": "2145-01-18 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 560366, "text": "Chief Complaint:\n 24 Hour Events:\n - propofol sedation weaned off\n - seroquel uptitrated -> pt still agitated\n - psych recommended staying away from zyprexa/haldol (?NMS) and adding\n ativan PRN (would like to limit liver disease)\n - hypernatremia not improving (tried increasing free water flushes to\n 500cc q3h) -> called pharmacy, will try to mix all meds in D5W\n Allergies:\n Demerol (Oral) (Meperidine Hcl)\n Confusion/Delir\n Last dose of Antibiotics:\n Penicillin G potassium - 04:00 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:07 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.6\nC (99.6\n Tcurrent: 37.3\nC (99.2\n HR: 92 (73 - 103) bpm\n BP: 153/62(89) {120/53(73) - 175/77(106)} mmHg\n RR: 25 (14 - 31) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 73 Inch\n CVP: 8 (3 - 36)mmHg\n Total In:\n 3,319 mL\n 1,111 mL\n PO:\n TF:\n 1,109 mL\n IVF:\n 639 mL\n 191 mL\n Blood products:\n Total out:\n 4,330 mL\n 550 mL\n Urine:\n 3,630 mL\n 550 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,011 mL\n 561 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n Ventilator mode: Standby\n FiO2: 70%\n SpO2: 99%\n ABG: 7.44/47/127/31/7\n PaO2 / FiO2: 254\n Physical Examination\n Eyes / Conjunctiva: PERRL, opens eyes, makes eye contact\n , Ears, Nose, Throat: , Poor dentition, NG tube, trach\n (Bloody )\n Cardiovascular: (S1: Normal), (S2: Normal), No(t) S3, No(t) S4, No(t)\n Rub\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not\n assessed), has a-line\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : ,\n Rhonchorous: )\n Abdominal: Soft, Bowel sounds present, Distended, palpable fluid wave\n Neurologic: arousable to voice, opens eyes, non-verbal, follows some\n basic commands\n Labs / Radiology\n 55 K/uL\n 9.0 g/dL\n 90 mg/dL\n 0.6 mg/dL\n 31 mEq/L\n 3.8 mEq/L\n 15 mg/dL\n 112 mEq/L\n 148 mEq/L\n 26.9 %\n 5.0 K/uL\n [image002.jpg]\n 03:46 AM\n 01:02 PM\n 01:03 PM\n 04:28 AM\n 04:45 AM\n 02:55 AM\n 04:00 PM\n 01:01 AM\n 04:22 AM\n 05:38 AM\n WBC\n 5.8\n 5.7\n 6.0\n 5.0\n Hct\n 27.7\n 26.3\n 27.6\n 26.9\n Plt\n 59\n 51\n 63\n 55\n Cr\n 0.7\n 0.7\n 0.7\n 0.7\n 0.7\n 0.6\n TCO2\n 34\n 34\n 33\n Glucose\n 110\n 114\n 97\n 111\n 94\n 90\n Other labs: PT / PTT / INR:16.2/45.6/1.4, CK / CKMB /\n Troponin-T:447/26/0.24, ALT / AST:60/136, Alk Phos / T Bili:129/2.5,\n Amylase / Lipase:38/42, Differential-Neuts:80.0 %, Band:0.0 %,\n Lymph:16.0 %, Mono:0.0 %, Eos:4.0 %, Lactic Acid:1.6 mmol/L,\n Albumin:3.3 g/dL, LDH:341 IU/L, Ca++:8.9 mg/dL, Mg++:1.6 mg/dL, PO4:2.8\n mg/dL\n Assessment and Plan\n This is a 63 y/o M who has continued AMS to point where not\n communicating at all; with hx Hepatitis C cirrhosis, s/p PEA arrest,\n body cooling and rewarming, with Fusobacterium sepsis covering with IV\n Pen G until .\n .\n # Mental Status: With slowly resolving delerium prior to this event,\n and now with unclear hypoxic insult to brain. GCS of on admission\n to ICU. Considering head CT to evaluate for anoxic brain injury\n post-cooling. Neuro eval for possible seizure. EEG neg for seizure,\n severe encephalopathy likely in setting of sedation. LP done earlier\n that was negative gram stain/culture, no whites, negative HSV PCR. Back\n to pre-code MS per wife. CT scan did not show any focal lesions. MRI\n () was unremarkable.\n - patient not consistently following commands, off propofol sedation,\n psych saw patient on and felt that the patient was very unlikely\n to have had NMS and recommended seroquel to be used for agitation\n will uptitrate per Psych recs\n standing Seroquel TID\n - propofol off\n - increase lactulose to 60mg q2hr for stool ouput goal of 1000cc and\n cont rifaximin\n - Will check thyroid studies and ammonia as cause of AMS\n .\n # bleeding from trach site- Procedure done , 8-0 Portex .lost\n 150cc. Patient was given giving 2u platelets, given 1u FFP after the\n procedure. ENT was consulted on for concern of posterior pharynx\n bleed, which they did not find any evidence of.\n - bleeding has improved, tr blood at site, but controlled\n - ENT found small bite on back of tongue, but no evidence of posterior\n pharynx bleed\n .\n # Respiratory/Ventilation: Pt re-intubated secondary to\n respiratory distress and inability to handle secretions. Unlikely to\n tolerate extubation given that underlying problem is inability to\n handle secretions which is unlikely to change. CXR from showed\n evidence of pulmonary edema. Patient getting trach in OR. Patient\n completed treatment for empiric HAP for 5day with vanc/zosyn starting\n .\n - tolerating trach collar very well\n .\n # Fusobacterium bacteremia: Will treat for two-week course, awaiting\n sensitivities on Fusobacterium -> likely responsive to penicillin. Dx\n on , will need 14d course until .\n - surveillance blood cxs NTD\n - complete course of PCN on \n .\n # Thrombocytopenia\n platelets 171, slowly declining. Switched\n from H2 to PPI. Considering HIT vs. splenic sequestration\n - no current evidence of DIC\n - plts stable after switch from H2 to PPI\n .\n # Resolved Renal Failure: Unclear etiology, likely combination of ATN\n in the setting of code and HRS. Renal following given concern for HRS.\n Off albumin, mitodrine and octreotide\n - renal function stable\n - f/u renal and liver recs\n .\n # Hypernatremia: Likely hypovolemic hypernatremia in the setting of\n recent ATN and current HRS. Corrected , free water deficit 3.5L on\n \n - increase free water boluses through G-tube to provide 3.5L by\n tomorrow PM\n .\n # Cardiac: CE's trended post-arrest. Echo hyperdynamic, no cardiogenic\n shock. CK and Trop trended down\n - will consider repeat echo\n .\n # Cirrhosis: Hep C Cirrhosis, with concern for HRS.\n - pre-code mental status likely related to encephalopathy v. delirium\n - titrate up lactulose\n - liver recs -> non suitable for tx at this point, in the very small\n chance that pt improves could possibly be candidate in the future\n .\n # s/p Shock/PEA Arrest: Now stable. After PEA, was initially\n hemodynamically stable but has had episodes of hypotension\n non-responsive to IVF boluses, levofed started, currently off. Echo\n showed no evidence of cardiogenic shock. s/p cooling and rewarming.\n Trended cardiac enzymes, came down and no evidence of cardiogenic shock\n on rewarmed echo.\n # Parotid mass. Incidental finding of L parotid mass on MRI, 1.6cm. --\n Will require ENT followup as outpt.\n .\n # Metabolic Acidosis: s/p arrest to tissue hypoxia. Lactates now\n normalized, now resolved.\n # Access: PIV, Central Line\n .\n # FEN: TF running at goal, 60cc/hr\n .\n # Prophylaxis: holding HSQ since elevated PTT, PPI\n .\n # Code: full\n .\n # Communication: Wife is HCP -> will readdress long-term goals re:\n long-term prognosis\n .\n # Disposition: ICU for now.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 12:48 PM\n Arterial Line - 11:00 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": "2145-01-17 00:00:00.000", "description": "Nursing Progress Note", "row_id": 560180, "text": "Pt admitted to on s/p fall for back spinal fusion. Has been\n confused since surgery according to pt's wife later developed UTI.\n Unknown cause of MS changes. ? encephalopathy vs. infection.Pt had\n resp distress, became unresponsive and went into PEA arrest on .Pt\n has been on Arctic sun.CT neg for PE or bleed.Pt was successfully\n extubated on . Reintubated . Trached . Head CT neg for any\n acute changes.\n Events day shift: Tolerated Trach mask 70% Fio2 with o2 sat\ns high 90\n Altered mental status (not Delirium)/Agitation\n Assessment:\n Off Propofol this am. Increase agitation, throwing legs over side rail,\n squirming in bed. Not following commands does not tracks or try to\n communicate. Pupils 3mm. Slightly rigid with turning. Lactulose held\n at 16:00 d/t increase stool.\n Action:\n Given Seroquel 50mg, continues on Lactulose\n Response:\n Only slightly less agitated\n Plan:\n Continue to monitor patient\ns neuro status, meds ASDIR\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Tolerated Trach mask this shift 70% fio2, O2 sat\ns high 90\ns, RR~20\n Action:\n Suction prn, trach care and frequent mouth care\n Response:\n Tolerated trach mask\n Plan:\n Continue to monitor resp status, meds ASDIR, Mouth care and trach care\n as needed.\n" }, { "category": "Nursing", "chartdate": "2145-01-17 00:00:00.000", "description": "Nursing Progress Note", "row_id": 560181, "text": "Pt admitted to on s/p fall for back spinal fusion. Has been\n confused since surgery according to pt's wife later developed UTI.\n Unknown cause of MS changes. ? encephalopathy vs. infection.Pt had\n resp distress, became unresponsive and went into PEA arrest on .Pt\n has been on Arctic sun.CT neg for PE or bleed.Pt was successfully\n extubated on . Reintubated . Trached . Head CT neg for any\n acute changes.\n Events day shift: Tolerated Trach mask 70% Fio2 with o2 sat\ns high 90\n Altered mental status (not Delirium)/Agitation\n Assessment:\n Off Propofol this am. Increase agitation, throwing legs over side rail,\n squirming in bed. Not following commands does not tracks or try to\n communicate. Pupils 3mm. Slightly rigid with turning. Lactulose held\n at 16:00 d/t increase stool.\n Action:\n Given Seroquel 50mg, continues on Lactulose\n Response:\n Only slightly less agitated\n Plan:\n Continue to monitor patient\ns neuro status, meds ASDIR\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Tolerated Trach mask this shift 70% fio2, O2 sat\ns high 90\ns, RR~20\n Given Lasix 40mg IV x1 with good effect. LS clear upper diminished\n lower\n Action:\n Suction prn, trach care and frequent mouth care\n Response:\n Tolerated trach mask\n Plan:\n Continue to monitor resp status, meds ASDIR, Mouth care and trach care\n as needed.\n" }, { "category": "Nursing", "chartdate": "2145-01-17 00:00:00.000", "description": "Nursing Progress Note", "row_id": 560182, "text": "Pt admitted to on s/p fall for back spinal fusion. Has been\n confused since surgery according to pt's wife later developed UTI.\n Unknown cause of MS changes. ? encephalopathy vs. infection.Pt had\n resp distress, became unresponsive and went into PEA arrest on .Pt\n has been on Arctic sun.CT neg for PE or bleed.Pt was successfully\n extubated on . Reintubated . Trached . Head CT neg for any\n acute changes.\n Events day shift: Tolerated Trach mask 70% Fio2 with o2 sat\ns high 90\n Altered mental status (not Delirium)/Agitation\n Assessment:\n Off Propofol this am. Increase agitation, throwing legs over side rail,\n squirming in bed. Not following commands does not tracks or try to\n communicate. Pupils 3mm. Slightly rigid with turning. Lactulose held\n at 16:00 d/t increase stool.\n Action:\n Given Seroquel 50mg, continues on Lactulose\n Response:\n Only slightly less agitated\n Plan:\n Continue to monitor patient\ns neuro status, meds ASDIR\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Tolerated Trach mask this shift 70% fio2, O2 sat\ns high 90\ns, RR~20\n Given Lasix 40mg IV x1 with good effect. LS clear upper diminished\n lower\n Action:\n Suction prn, trach care and frequent mouth care\n Response:\n Tolerated trach mask\n Plan:\n Continue to monitor resp status, meds ASDIR, Mouth care and trach care\n as needed.\n" }, { "category": "Physician ", "chartdate": "2145-01-18 00:00:00.000", "description": "MICU Attending Progress Note", "row_id": 560367, "text": "TITLE: MICU Attending Progress Note\n I saw and examined the patient, and was physically present with the ICU\n team for the key portions of the services provided. I agree with Dr.\n \ns note above, including the assessment and plan. I would\n emphasize and add the following points: 63M HCV, HCC, ESLD, PEA arrest\n likely due to airway plugging, fusobacterium sepsis. Ongoing titration\n of sedating meds; rising sodium.\n Exam notable for Tm 98.3 BP 148/70 HR 70 RR 14-25 with sat 99 on 70%\n TM. Minimally response, moves x4 spontaneously. Not interactive,\n non-verbal. Coarse BS B. RRR s1s2. Soft +BS. 2+ edema. Labs notable for\n WBC 5K, HCT 26, K+ 3.8, Cr 0.6.\n Agree with plan to manage multifactorial encephalopathy with ongoing\n lactulose / rifaximin for component of hepatic encephalopathy (will\n check NH3 today), PCN for fusobacterium sepsis/bacteremia, IV/PGT FW\n repletion for hypernatremia, continuing IV synthroid for\n hypothyroidism, and supportive care with minimal sedation for component\n of med effects and possible hypoxic injury. Can uptitrate ACEI as BP\n allows. Will resume TFs today. Will continue close communication with\n family. Remainder of plan as outlined above.\n Patient is critically ill\n Total time: 35 min\n" }, { "category": "Nursing", "chartdate": "2145-01-18 00:00:00.000", "description": "Nursing Progress Note", "row_id": 560243, "text": "Pt admitted to on s/p fall for spinal fusion. Per pt\ns wife\n pt has been confused since surgery. Did have known UTI however post\n treatment continues to have MS changes. Team questioning\n encephalopathy vs. infection. pt had episode of respiratory\n distress then became unresponsive and went into PEA arrest, intubated\n during code. Pt had been on Arctic sun for post VT arrest cooling, now\n off. CT negative for PE or bleed. Pt was successfully extubated on\n , however unable to tolerate and reintubated . Trached .\n Repeat head CT negative for any acute changes.\n Altered mental status (not Delirium)\n Assessment:\n Propofol gtt off since 1100 , delirium/confusion continues, pt\n inconsistently following commands, withdraws to pain, occasionally\n tracks to voice\n Action:\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2145-01-19 00:00:00.000", "description": "Nursing Progress Note", "row_id": 560481, "text": "Pt admitted to on s/p fall for spinal fusion. Per pt\ns wife\n pt has been confused since surgery. Did have known UTI however post\n treatment continues to have MS changes. Team questioning\n encephalopathy vs. infection. pt had episode of respiratory\n distress then became unresponsive and went into PEA arrest, intubated\n during code. Pt had been on Arctic sun for post VT arrest cooling, now\n off. CT negative for PE or bleed. Pt was successfully extubated on\n , however unable to tolerate and reintubated . Trached .\n Repeat head CT negative for any acute changes.\n Altered mental status (not Delirium)\n Assessment:\n Pt very restless. He tracks to voice, follows commands inconsistently\n and makes non-purposeful movements. PERL brisk. Hand grasp equal\n bilaterally, tongue midline. Pt able to mouth his name.\n Action:\n Pt oriented to surroundings frequently. All meds and procedures\n explained. Pt restrained for safety and in bed in low, locked position\n with bed alarm on. Pt was repositioned frequently. Pt also given\n lactulose q8hour this shift. 2 doses held stool output at 1000cc\n in less than 24 hours.\n Response:\n No improvement in mental status. Pt continues to make liquid stool.\n Plan:\n Continue to monitor mental status, reorient pt frequently. Continue to\n lactulose for stool output 1000cc/day.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt received on trach mask at 70% and ABG 7.41/46/170 so FiO2 decreased\n to 40%. LS clear, was occasionally rhonchorous, but cleared with\n suctioning.\n Action:\n Pt suctioned for small amounts of blood tinged secretions.\n Response:\n On 40%, RR 20s and sats 97-100%. Weak cough occasionally clearing his\n secretions.\n Plan:\n Continue to monitor resp status, suction as needed.\n Electrolyte & fluid disorder, other\n Assessment:\n PM Na 148.\n Action:\n Pt with 500cc free water flushes q3hour. Pt also given 40mEq KCL for AM\n K 3.7.\n Response:\n AM Na 143.\n Plan:\n Continue to monitor electrolytes.\n" }, { "category": "Nursing", "chartdate": "2145-01-20 00:00:00.000", "description": "Nursing Progress Note", "row_id": 560669, "text": "Pt admitted to on s/p fall for spinal fusion. Per pt\ns wife\n pt has been confused since surgery. Did have known UTI however post\n treatment continues to have MS changes. Team questioning\n encephalopathy vs. infection. pt had episode of respiratory\n distress then became unresponsive and went into PEA arrest, intubated\n during code. Pt had been on Arctic sun for post VT arrest cooling, now\n off. CT negative for PE or bleed. Pt was successfully extubated on\n , however unable to tolerate and reintubated . Trached .\n Repeat head CT negative for any acute changes.\n Events: NGT placed and confirmed by CXR.\n Altered mental status (not Delirium)\n Assessment:\n Pt very restless. He tracks to voice, follows commands consistently\n and makes non-purposeful movements. PERL brisk. Hand grasp equal\n bilaterally, tongue midline. Pt able to mouth his name.\n Action:\n Pt oriented to surroundings frequently. All meds and procedures\n explained. Pt restrained for safety and in bed in low, locked position\n with bed alarm on. Pt was repositioned frequently. Pt also given\n lactulose q4hour this shift. Pt\ns seroquel order change per psych\n recs.\n Response:\n No improvement in mental status. Pt continues to make liquid stool.\n Plan:\n Continue to monitor mental status, reorient pt frequently. Continue to\n lactulose for stool output 1000cc/day. Per day shift, pt\ns restlessness\n improved when pt was OOB to chair.\n" }, { "category": "Nursing", "chartdate": "2145-01-18 00:00:00.000", "description": "Nursing Progress Note", "row_id": 560412, "text": "HPI: Pt admitted to on s/p fall for spinal fusion. Per pt\n wife pt has been confused since surgery. Did have known UTI however\n post treatment continues to have MS changes. Team questioning\n encephalopathy vs. infection. pt had episode of respiratory\n distress then became unresponsive and went into PEA arrest, intubated\n during code. Pt had been on Arctic sun for post VT arrest cooling, now\n off. CT negative for PE or bleed. Pt was successfully extubated on\n , however unable to tolerate and reintubated . Trached .\n Repeat head CT negative for any acute changes.\n Events: TF off today d/t position of pt in bed, risk of aspiration. ?\n need for post-pyloric dophoff.\n Arousal, Attention, and Cognition, Impaired\n Assessment:\n Pt opens eyes to voice, does not follow commands, PERRL, MAEs,\n nonpurposeful movt. Very restless.\n Action:\n Assess neuro status freq, limiting meds that will alter MS: seroquel\n given for agitation. Tx w/ lactulose for hepatic encephalopathy.\n Response:\n Pt remains restless, restraints in place. Ammonia levels WNL today at\n 31. MS unchanged throughout day.\n Plan:\n Cont to monitor.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n LS course and dim at bases. ABG 7.41/46/170. Pt on trach mask fi02\n 50%. Sp02 98-100%. Min amt blood tinged sputum w/ suction.\n Action:\n Cont pulm toilet, suction prn, abx for bacteremia.\n Response:\n Resp status remains unchanged.\n Plan:\n Wean trach mask as tol.\n Electrolyte & fluid disorder, other\n Assessment:\n Pt has had elevated Na levels, 148 this AM.\n Action:\n Increase FWB to 500 ml q 3 h. 1 L D5 at 75 ml / hr running.\n Response:\n Na this after noon correcting to 144.\n Plan:\n Cont to monitor, cont FWB, maintenance fluid.\n" }, { "category": "Physician ", "chartdate": "2145-01-19 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 560489, "text": "TITLE:\n Chief Complaint: PEA/asystole\n 24 Hour Events:\n - Hypernatremia corrected to 143 today. Free water deficit calculated\n to be 3.7 L, getting D5W 500 cc q3hrs.\n - ABG/VBG showing good correlation\n - Made Seroquel around the clock and PRN per psych recs\n Allergies:\n Demerol (Oral) (Meperidine Hcl)\n Confusion/Delir\n Last dose of Antibiotics:\n Penicillin G potassium - 04:15 AM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:19 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 06:54 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: 35.9\nC (96.7\n HR: 87 (78 - 102) bpm\n BP: 120/70(82) {120/70(82) - 120/70(82)} mmHg\n RR: 18 (17 - 29) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 73 Inch\n CVP: 7 (7 - 16)mmHg\n Total In:\n 5,362 mL\n 1,498 mL\n PO:\n TF:\n IVF:\n 1,057 mL\n 238 mL\n Blood products:\n Total out:\n 2,915 mL\n 1,910 mL\n Urine:\n 1,915 mL\n 810 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,447 mL\n -412 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n SpO2: 99%\n ABG: 7.41/46/170/27/4\n PaO2 / FiO2: 425\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 59 K/uL\n 8.6 g/dL\n 85 mg/dL\n 0.5 mg/dL\n 27 mEq/L\n 3.7 mEq/L\n 13 mg/dL\n 110 mEq/L\n 143 mEq/L\n 26.1 %\n 3.9 K/uL\n [image002.jpg]\n 04:28 AM\n 04:45 AM\n 02:55 AM\n 04:00 PM\n 01:01 AM\n 04:22 AM\n 05:38 AM\n 02:41 PM\n 09:01 PM\n 03:15 AM\n WBC\n 5.7\n 6.0\n 5.0\n 3.9\n Hct\n 26.3\n 27.6\n 26.9\n 26.1\n Plt\n 51\n 63\n 55\n 59\n Cr\n 0.7\n 0.7\n 0.7\n 0.7\n 0.6\n 0.5\n 0.5\n TCO2\n 34\n 33\n 30\n Glucose\n 114\n 97\n 111\n 94\n 90\n 111\n 85\n Other labs: PT / PTT / INR:17.4/44.6/1.6, CK / CKMB /\n Troponin-T:104/26/0.24, ALT / AST:60/136, Alk Phos / T Bili:129/2.5,\n Amylase / Lipase:38/42, Differential-Neuts:80.0 %, Band:0.0 %,\n Lymph:16.0 %, Mono:0.0 %, Eos:4.0 %, Lactic Acid:1.0 mmol/L,\n Albumin:3.3 g/dL, LDH:341 IU/L, Ca++:8.4 mg/dL, Mg++:1.7 mg/dL, PO4:2.2\n mg/dL\n Assessment and Plan\n This is a 63 y/o M who has continued AMS to point where not\n communicating at all; with hx Hepatitis C cirrhosis, s/p PEA arrest,\n body cooling and rewarming, with Fusobacterium sepsis covering with IV\n Pen G until .\n .\n # Mental Status: With slowly resolving delerium prior to this event,\n and now with unclear hypoxic insult to brain. GCS of on admission\n to ICU. Considering head CT to evaluate for anoxic brain injury\n post-cooling. Neuro eval for possible seizure. EEG neg for seizure,\n severe encephalopathy likely in setting of sedation. LP done earlier\n that was negative gram stain/culture, no whites, negative HSV PCR. Back\n to pre-code MS per wife. CT scan did not show any focal lesions. MRI\n () was unremarkable.\n - patient not consistently following commands, off propofol sedation,\n psych saw patient on and felt that the patient was very unlikely\n to have had NMS and recommended seroquel to be used for agitation\n will uptitrate per Psych recs\n standing Seroquel TID\n - propofol off\n - increase lactulose to 60mg q2hr for stool ouput goal of 1000cc and\n cont rifaximin\n - Will check thyroid studies and ammonia as cause of AMS\n .\n # bleeding from trach site- Procedure done , 8-0 Portex .lost\n 150cc. Patient was given giving 2u platelets, given 1u FFP after the\n procedure. ENT was consulted on for concern of posterior pharynx\n bleed, which they did not find any evidence of.\n - bleeding has improved, tr blood at site, but controlled\n - ENT found small bite on back of tongue, but no evidence of posterior\n pharynx bleed\n .\n # Respiratory/Ventilation: Pt re-intubated secondary to\n respiratory distress and inability to handle secretions. Unlikely to\n tolerate extubation given that underlying problem is inability to\n handle secretions which is unlikely to change. CXR from showed\n evidence of pulmonary edema. Patient getting trach in OR. Patient\n completed treatment for empiric HAP for 5day with vanc/zosyn starting\n .\n - tolerating trach collar very well\n .\n # Fusobacterium bacteremia: Will treat for two-week course, awaiting\n sensitivities on Fusobacterium -> likely responsive to penicillin. Dx\n on , will need 14d course until .\n - surveillance blood cxs NTD\n - complete course of PCN on \n .\n # Thrombocytopenia\n platelets 171, slowly declining. Switched\n from H2 to PPI. Considering HIT vs. splenic sequestration\n - no current evidence of DIC\n - plts stable after switch from H2 to PPI\n .\n # Resolved Renal Failure: Unclear etiology, likely combination of ATN\n in the setting of code and HRS. Renal following given concern for HRS.\n Off albumin, mitodrine and octreotide\n - renal function stable\n - f/u renal and liver recs\n .\n # Hypernatremia: Likely hypovolemic hypernatremia in the setting of\n recent ATN and current HRS. Corrected , free water deficit 3.5L on\n \n - increase free water boluses through G-tube to provide 3.5L by\n tomorrow PM\n .\n # Cardiac: CE's trended post-arrest. Echo hyperdynamic, no cardiogenic\n shock. CK and Trop trended down\n - will consider repeat echo\n .\n # Cirrhosis: Hep C Cirrhosis, with concern for HRS.\n - pre-code mental status likely related to encephalopathy v. delirium\n - titrate up lactulose\n - liver recs -> non suitable for tx at this point, in the very small\n chance that pt improves could possibly be candidate in the future\n .\n # s/p Shock/PEA Arrest: Now stable. After PEA, was initially\n hemodynamically stable but has had episodes of hypotension\n non-responsive to IVF boluses, levofed started, currently off. Echo\n showed no evidence of cardiogenic shock. s/p cooling and rewarming.\n Trended cardiac enzymes, came down and no evidence of cardiogenic shock\n on rewarmed echo.\n # Parotid mass. Incidental finding of L parotid mass on MRI, 1.6cm. --\n Will require ENT followup as outpt.\n .\n # Metabolic Acidosis: s/p arrest to tissue hypoxia. Lactates now\n normalized, now resolved.\n # Access: PIV, Central Line\n .\n # FEN: TF running at goal, 60cc/hr\n .\n # Prophylaxis: holding HSQ since elevated PTT, PPI\n .\n # Code: full\n .\n # Communication: Wife is HCP -> will readdress long-term goals re:\n long-term prognosis\n .\n # Disposition: ICU for now.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 12:48 PM\n Arterial Line - 11:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Respiratory ", "chartdate": "2145-01-19 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 560480, "text": "Demographics\n Day of intubation: NOT VENTED\n Day of mechanical ventilation: 9\n Ideal body weight: 83.5 None\n Ideal tidal volume: mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location:\n Reason:\n Tube Type\n Tracheostomy tube:\n Type: Standard, Cuffed, Inner Cannula\n Manufacturer: Portex\n Size: 8.0mm\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: cmH2O\n Cuff volume: 8 mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Rhonchi\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Rhonchi\n Comments:\n Secretions\n Sputum color / consistency: Blood Tinged / Thick\n Sputum source/amount: Suctioned / Moderate\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Unassisted spontaneous breathing\n Plan\n Next 24-48 hours: Continue current support\n" }, { "category": "Nursing", "chartdate": "2145-01-09 00:00:00.000", "description": "Nursing Progress Note", "row_id": 558502, "text": "Synopsis per prior nursing note:\n Pt admitted to on s/p fall for back spinal fusion.\n According to pt's wife, who is health care proxy, pt has been confused\n since coming out of anesthesia and later developed a UTI. According to\n floor RN, pt has had MS changes over the past few weeks where he has\n been agitated and unresponsive. Neuro and psych have consulted.\n Unknown cause of MS changes. ? encephalopathy vs. infection. Today pt\n had resp distress, became unresponsive and went into PEA arrest. Large\n plug suctioned from pt. Chest compressions done, 1mg Atropine given\n along with Epi. Pulse returned and pt transferred to MICU for further\n management.\n Events: fentanyl and versed stopped. Levophed weaned and stopped.\n Altered mental status (not Delirium)\n Assessment:\n Eyes open to sternal stimuli and voice. Localizing to pain.\n Un-purposeful movement RUE & RLE upon turning. Pupils brisk 2mm.\n Action:\n Fentanyl and versed stopped. Soft wrist restraints in place. Lactulose\n administered for ?encephalopathy. NG feed rate titrated up to 40mL/hr\n Response:\n Arouse to stimulation, eye opening to pain, up-purposeful movement of\n limbs. Residuals < 10 mL\n Plan:\n Continue to monitor neurologically , assess changes in vital signs for\n pain\n Hypotension (not Shock)\n Assessment:\n ABP >70. urine output >30 mL clear yellow q hour.\n Action:\n Levephed weaned and stopped, ECG to monitor wave forms\n Response:\n ABP> 62. QT interval urine output >30 yellow w/ sediments q hour\n Plan:\n Continue to monitor ABP, maintain map >62. continue to monitor urine\n output. continue to obtain ECG q shift\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Sat 95-100. Initial vent: FiO2 40% tidal volume 550 respirations18\n PEEP 12 not over breathing. ABG: pH 7.49 pC02 35 P02 144 arterial base\n excess 4 TC02 27. LS clear/dim. Gag reflex absent. Cough absent\n Action:\n Vent changed: FiO2 40% tidal volume 550 respirations 16 PEEP 8. Lung\n percussion R side. Suctioned prn mod amt thick green\n Response:\n Sating >95% rarely breathing over vent. ABG: pH 7.47 pC02 38 P02 106\n arterial base excess 3 TC02 28 Sa02 98. LS clear w/ dim bases. Gag\n reflex impaired. Weak non productive cough\n Plan:\n Wean vent as tolerated. Continue to monitor ABG. continue to monitor\n LS\n" }, { "category": "Physician ", "chartdate": "2145-01-08 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 558214, "text": "Chief Complaint: respiratory/cardiac arrest\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 INVASIVE VENTILATION - START 10:55 AM\n MULTI LUMEN - START 12:48 PM\n BRONCHOSCOPY - At 04:23 PM\n ARTERIAL LINE - START 05:00 PM\n Hypothermia tolerated with paralysis but developed hypotension\n requiring norepinephrine\n Oliguria unresponsive to volume challenge\n Didn't tolerate propofol (hypotension)\n EEG formal read pending, but prelim negative for status epilepticus\n Required increased respiratory support (PEEP, FiO2)\n Patient unable to provide history: Sedated\n Allergies:\n Demerol (Oral) (Meperidine Hcl)\n Confusion/Delir\n Last dose of Antibiotics:\n Ceftriaxone - 04:00 PM\n Vancomycin - 08:00 PM\n Piperacillin/Tazobactam (Zosyn) - 01:57 AM\n Infusions:\n Fentanyl - 50 mcg/hour\n Midazolam (Versed) - 2 mg/hour\n Norepinephrine - 0.05 mcg/Kg/min\n Other ICU medications:\n Midazolam (Versed) - 11:30 AM\n Fentanyl - 11:30 AM\n Heparin Sodium (Prophylaxis) - 10:02 PM\n Other medications:\n versed @ 2, fent @ 50, vit d, thiamine, folate, rifaxamin, synthroid,\n famotidine, chg, sqh , zosyn, vanco, propofol, levophed @ .05\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 09:01 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 3.1\nC (37.5\n Tcurrent: 3.1\nC (37.5\n HR: 59 (59 - 156) bpm\n BP: 107/66(78) {85/51(62) - 114/77(82)} mmHg\n RR: 18 (17 - 27) insp/min\n SpO2: 97%\n CVP: 14 (7 - 18)mmHg\n Bladder pressure: 9 (9 - 9) mmHg\n Total In:\n 2,497 mL\n 932 mL\n PO:\n TF:\n IVF:\n 2,497 mL\n 932 mL\n Blood products:\n Total out:\n 410 mL\n 186 mL\n Urine:\n 410 mL\n 186 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,087 mL\n 746 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 550 (550 - 550) mL\n RR (Set): 18\n RR (Spontaneous): 0\n PEEP: 12 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10\n PIP: 23 cmH2O\n Plateau: 22 cmH2O\n Compliance: 55 cmH2O/mL\n SpO2: 97%\n ABG: 7.46/34/92./25/0\n Ve: 10.3 L/min\n PaO2 / FiO2: 186\n Physical Examination\n General Appearance: Well nourished\n Eyes / Conjunctiva: dysconjugate\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n Respiratory / Chest: (Breath Sounds: Clear : ), limited by arctic sun\n Abdominal: Soft, protuberant; exam limited by arctic sun\n Extremities: Right: 1+, Left: 1+\n Skin: Cool\n Neurologic: Responds to: Unresponsive, Movement: Not assessed, Sedated,\n No(t) Paralyzed, Tone: Decreased\n Labs / Radiology\n 12.7 g/dL\n 134 K/uL\n 114 mg/dL\n 2.2 mg/dL\n 25 mEq/L\n 4.2 mEq/L\n 85 mg/dL\n 102 mEq/L\n 138 mEq/L\n 38.5 %\n 26.5 K/uL\n [image002.jpg]\n 11:21 AM\n 01:24 PM\n 03:41 PM\n 06:56 PM\n 09:04 PM\n 10:13 PM\n 11:06 PM\n 11:47 PM\n 03:38 AM\n 04:01 AM\n WBC\n 13.4\n 26.5\n Hct\n 39.6\n 38.5\n Plt\n 152\n 134\n Cr\n 2.1\n 2.0\n 1.9\n 2.2\n TropT\n 0.27\n 0.24\n TCO2\n 33\n 27\n 28\n 27\n 27\n 25\n Glucose\n 105\n 92\n 117\n 114\n Other labs: PT / PTT / INR:17.2/54.3/1.6, CK / CKMB /\n Troponin-T:447/26/0.24, Differential-Neuts:74.5 %, Lymph:14.1 %,\n Mono:8.1 %, Eos:2.9 %, Lactic Acid:2.0 mmol/L, Ca++:7.7 mg/dL, Mg++:3.1\n mg/dL, PO4:5.5 mg/dL\n Microbiology: BAL: oral flora\n Assessment and Plan\n 63-year-old man with respiratory arrest\n cardiac arrest after a\n prolonged and complicated hospital course, now receiving therapeutic\n hypothermia. Now will probable HAP (acquired on floor or at\n intubation) and hypotension requiring vasopressors.\n Post-arrest care\n Hemodynamic management as needed (currently normotense)\n Hypothermia per protocol\n Respiratory failure\n P:F ratio now <200; bilateral infiltrates. Although may be\n cardiac, also reasonable to consider ARDS\n Ventilae per ARDSnet\n Shock\n be cardiac or vasodilatory. CVP argues against\n hypovolemia.\n Check pulse pressure variation\n Ask echo if they are technically able to do echo with arctic\n sun in place\n Acute renal failure\n Expect some ATN\n Intra-abdominal hypertension excluded by low bladder\n pressure\n Neurologic status\n Assess clinically after rewarming\n Will likely need brain imaging after rewarming\n Await EEG\n Appreciate neurology\ns help\n Other issues as per ICU team note above. Our team has d/w pt\ns wife.\n ICU \n Nutrition: NPO\n Glycemic Control:\n Lines:\n 22 Gauge - 11:30 AM\n 20 Gauge - 11:45 AM\n Multi Lumen - 12:48 PM\n Arterial Line - 05:00 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP: HOB elevation, Mouth care\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 45 min\n Patient is critically ill\n" }, { "category": "Physician ", "chartdate": "2145-01-08 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 558216, "text": "Chief Complaint:\n 24 Hour Events:\n Events:\n - bronch showing thick, yellow secretions concerning for infection,\n started vanco and zosyn for HAP\n - cooling protocol initiated, plan for rewarming around noon tomorrow\n - renal team following, sent urine lytes and UA; pt remaining basically\n anuric overnight\n - CVPs in 8-10s, likely fluid down; to test kidneys, gave 500 cc fluid\n challenge. UO improved slightly from about 20 cc/hr up to 80 cc/hr for\n short time\n - Around 2 am, after repositioning patients SBP dropped to 70s, came up\n to 80s with fluids but needed to start levophed; titrated up to 0.07\n and then stable overnight\n INVASIVE VENTILATION - START 10:55 AM\n MULTI LUMEN - START 12:48 PM\n BRONCHOSCOPY - At 04:23 PM\n ARTERIAL LINE - START 05:00 PM\n Allergies:\n Demerol (Oral) (Meperidine Hcl)\n Confusion/Delir\n Last dose of Antibiotics:\n Ceftriaxone - 04:00 PM\n Vancomycin - 08:00 PM\n Piperacillin/Tazobactam (Zosyn) - 01:57 AM\n Infusions:\n Fentanyl - 50 mcg/hour\n Midazolam (Versed) - 2 mg/hour\n Norepinephrine - 0.05 mcg/Kg/min\n Other ICU medications:\n Midazolam (Versed) - 11:30 AM\n Fentanyl - 11:30 AM\n Heparin Sodium (Prophylaxis) - 10:02 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:38 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 3.1\nC (37.5\n Tcurrent: 3.1\nC (37.5\n HR: 60 (59 - 156) bpm\n BP: 114/68(82) {85/51(62) - 114/77(82)} mmHg\n RR: 19 (17 - 27) insp/min\n SpO2: 97%\n CVP: 15 (7 - 18)mmHg\n Bladder pressure: 9 (9 - 9) mmHg\n Total In:\n 2,497 mL\n 855 mL\n PO:\n TF:\n IVF:\n 2,497 mL\n 855 mL\n Blood products:\n Total out:\n 410 mL\n 154 mL\n Urine:\n 410 mL\n 154 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,087 mL\n 701 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 550 (550 - 550) mL\n RR (Set): 18\n RR (Spontaneous): 0\n PEEP: 12 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10\n PIP: 22 cmH2O\n Plateau: 20 cmH2O\n SpO2: 97%\n ABG: 7.46/34/92./25/0\n Ve: 10.3 L/min\n PaO2 / FiO2: 186\n Physical Examination\n Eyes / Conjunctiva: PERRL, dysconjugate gaze\n Head, Ears, Nose, Throat: Normocephalic, Poor dentition, Endotracheal\n tube, NG tube\n Cardiovascular: (S1: Normal), (S2: Normal), No(t) S3, No(t) S4, No(t)\n Rub\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : ,\n Rhonchorous: )\n Abdominal: Soft, Bowel sounds present, Distended, palpable fluid wave\n Extremities: Right: Absent, Left: Absent\n Skin: Not assessed\n Neurologic: No(t) Attentive, No(t) Follows simple commands, Responds\n to: Noxious stimuli, Movement: Not assessed, Tone: Not assessed,\n Patient not arousable to voice, no purposeful movements, withdraws to\n pain, non-verbal\n Labs / Radiology\n 134 K/uL\n 12.7 g/dL\n 114 mg/dL\n 2.2 mg/dL\n 25 mEq/L\n 4.2 mEq/L\n 85 mg/dL\n 102 mEq/L\n 138 mEq/L\n 38.5 %\n 26.5 K/uL\n [image002.jpg]\n 11:21 AM\n 01:24 PM\n 03:41 PM\n 06:56 PM\n 09:04 PM\n 10:13 PM\n 11:06 PM\n 11:47 PM\n 03:38 AM\n 04:01 AM\n WBC\n 13.4\n 26.5\n Hct\n 39.6\n 38.5\n Plt\n 152\n 134\n Cr\n 2.1\n 2.0\n 1.9\n 2.2\n TropT\n 0.27\n 0.24\n TCO2\n 33\n 27\n 28\n 27\n 27\n 25\n Glucose\n 105\n 92\n 117\n 114\n Other labs: PT / PTT / INR:17.2/54.3/1.6, CK / CKMB /\n Troponin-T:447/26/0.24, Differential-Neuts:74.5 %, Lymph:14.1 %,\n Mono:8.1 %, Eos:2.9 %, Lactic Acid:2.0 mmol/L, Ca++:7.7 mg/dL, Mg++:3.1\n mg/dL, PO4:5.5 mg/dL\n Assessment and Plan\n Assessment and Plan: This is a 63 y/o M with Hepatitis C cirrhosis, a\n to ICU w/ PEA arrest to mucous plug.\n .\n # Shock/PEA Arrest: Witness arrest to mucous plug.\n - initially hemodynamically stable\n - overnight with repositioning had hypotension non-responsive to IVF\n boluses, levofed started. Etiology of hypotension is cardiogenic shock\n s/p PEA vs. septic shock secondary to pneumonia\n - check central venous O2 today; if high, likely in septic shock, would\n continue levofed; if low, could consider adding extra inotropic pressor\n like dopamine\n - echo today if possible over arctic sun suit\n - continue goal MAP >65\n .\n # Respiratory/Ventilation: Assist control. Low tidal volumes to avoid\n unneeded injury, with pH goal of above 7.25.\n - required increased FiO2 and PEEP overnight due to low oxygenation\n - likely has early ARDS, based on P:F ratio, CXR; continue ARDS net\n protocol with low Vt and high PEEPs\n .\n # Pneumonia\n on CXR has RLL infiltrate and bronch with thick yellow\n secretions, increasing leukocytosis today\n - on vanco/zosyn for HAP; add double coverage of GN with cipro after\n checking EKG for QT prolongation this morning\n - follow up cultures\n .\n # Neuro: With slowly resolving delerium prior to this event, and now\n with unclear hypoxic insult to brain. GCS of on admission to ICU.\n Consider cooling protocol. Head CT to evaluate for anoxic brain injury\n post-cooling. Neuro eval for possible seizure.\n - Continue cooling protocol, will rewarm around noon today\n - Low dose fentanyl/versed for sedation for now; failed trial of\n propofol overnight.\n - LP done earlier this admit that was negative gram stain/culture, no\n whites, negative HSV PCR.\n - EEG prelim report neg for seizure, f/u final read\n - head CT after warmed\n .\n .\n # Renal Failure: Unclear Etiology. Renal following given concern for\n HRS.\n - likely in setting of hypoperfusion, still has some urine output\n - avoid fluid boluses if possible per renal recs\n - Send urine lytes, repeat Ua post-arrest\n - Appreciate renal rec's.\n .\n # Metabolic Acidosis: s/p arrest to tissue hypoxia. Continue IVF's\n and trend lactate. Will need to increase minute ventilation for CO2.\n - resolved, likely in setting of post code hypoperfusion\n - continue to trend lactate\n .\n # Cardiac: Anticipate some elevation in CE's post-arrest, will trend.\n - CK and Trop trending downward,\n - echo today if possible to evaluate for function post PEA\n .\n # Cirrhosis: Hep C Cirrhosis, with concern for HRS.\n - Appreciate liver rec's\n .\n # Leukocytosis: Unclear etiology. Negative tap for SBP on .\n Urine growing E. Coli. Pan-culture.\n .\n # Parotid mass. Incidental finding of L parotid mass on MRI, 1.6cm. --\n Will require OP ENT followup.\n .\n # Access: PIV, Central Line, arterial line.\n .\n # FEN: IVF, replete electrolytes\n .\n # Prophylaxis: Subcutaneous heparin\n .\n # Code: full\n .\n # Communication: Wife is HCP\n .\n # Disposition: ICU for now.\n .\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 22 Gauge - 11:30 AM\n 20 Gauge - 11:45 AM\n Multi Lumen - 12:48 PM\n Arterial Line - 05:00 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": "2145-01-07 00:00:00.000", "description": "Nursing Progress Note", "row_id": 558099, "text": "Pt admitted to on s/p fall for back spinal fusion.\n According to pt's wife, pt has been confused since coming out of\n anesthesia and later developed a UTI. According to floor RN, pt has\n had MS changes over the past few weeks where he has been agitated and\n unresponsive. Neuro and psych have consulted. Unknown cause of MS\n changes. ? encephalopathy vs. infection. Today pt had resp distress,\n became unresponsive and went into PEA arrest. Large plug suctioned\n from pt. Chest compressions done, 1mg Atropine given along with Epi.\n Pulse returned and pt transferred to MICU for further management.\n Cardiac arrest\n Assessment:\n Pt went into PEA arrest on floor as stated above. Upon arriving to the\n MICU pt was in sinus tach with HR in 130\ns. Currently on 2mg/hr Versed\n and 50mcg/hr Fentanyl. HR in the 60\ns in NSR.\n Action:\n Arctic Sun started around 1540. Goal temp of 34 reached at 1820.\n Given 16mg Cicatricurium x 1 for shivering. EEG done. Results\n pending. TOF done before giving paralytic. Basline at 50 with 4/4\n using left ulnar site.\n Response:\n Pt currently at goal temp of 34 degrees C. No shivering present.\n Plan:\n Continue with artic sun at current temp until 1220 on before\n re-warming.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt received intubated on CMV/100%/18/550/5 PEEP. Thick tan secretions\n suctioned from ETT. O2 sats 100%. LS rhocherous, cleared with\n suctioning.\n Action:\n Bronchoscopy done and large amts of puss noted in lung. Started on\n Ceftriaxone, Vanco and Zosyn for pna.\n Response:\n No changes\n Plan:\n Continue to monitor. Continue to administer abx as ordered. Suction\n prn.\n" }, { "category": "Physician ", "chartdate": "2145-01-07 00:00:00.000", "description": "Resident / Attending Admission Notes", "row_id": 558101, "text": "Chief Complaint: s/p Cardiac Arrest\n HPI:\n History of Present Illness: Patient is a 63 year-old man w/ history of\n Hepatitis C and cirrhosis, hepatocellular carcinoma who initially\n presented on with unsteadiness, tremor, and fall. His hospital\n course is significant for hepatic encephalopathy, treated with\n lactulose, cervical cord compresson, OR on , MS change\n ?delirium treated with haldol, ?NMS due to rigidity and fever and\n elevated CK, broad Abx for possible infection (UTI). Poor MS never\n recovered. Also guestion of HRS.\n .\n On the floor, this AM patient was verbal and otherwise alert. Nurse\n was present in room when patient suddently became unresponsive and\n pulseless. CPR was initiated promptly. Initial rhythm demonstrated\n PEA/bradycardia, patient was intubated and given epi/atropine. A large\n mucous plug was suctioned from the ET tube, with subsequent restoration\n of perfusing rhythm. Patient was transfered to ICU for managment.\n Patient admitted from: \n History obtained from Family / Medical records\n Patient unable to provide history: Sedated, Encephalopathy,\n Unresponsive\n Allergies:\n Demerol (Oral) (Meperidine Hcl)\n Confusion/Delir\n Last dose of Antibiotics:\n Infusions:\n Fentanyl - 50 mcg/hour\n Midazolam (Versed) - 2 mg/hour\n Other ICU medications:\n Midazolam (Versed) - 11:30 AM\n Fentanyl - 11:30 AM\n Other medications:\n Past medical history:\n Family history:\n Social History:\n 1. Bipolar disorder.\n 2. HCV - unclear genotype. Grade 1 esophageal varices on EGD in 4/.\n Liver biopsy in with Stage 4 cirrhosis and small\n well-differentiated hepatocellular carcinoma.\n 3. Hypothyroidism.\n 4. Suicide attempt in the past.\n Non-contributory\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: He lives w/ wife, who is a nurse. \n beverage for 30 years. No tobacco use ever.\n Review of systems:\n Flowsheet Data as of 03:45 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n HR: 92 (92 - 156) bpm\n BP: 108/48(60) {87/48(60) - 146/84(77)} mmHg\n RR: 18 (18 - 27) insp/min\n SpO2: 98%\n Total In:\n 1,027 mL\n PO:\n TF:\n IVF:\n 1,027 mL\n Blood products:\n Total out:\n 0 mL\n 225 mL\n Urine:\n 225 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 802 mL\n Respiratory\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 550 (550 - 550) mL\n RR (Set): 18\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 12 cmH2O\n SpO2: 98%\n ABG: 7.33/60/30/27/3\n Ve: 15.3 L/min\n PaO2 / FiO2: 60\n Physical Examination\n Eyes / Conjunctiva: PERRL, dysconjugate gaze\n Head, Ears, Nose, Throat: Normocephalic, Poor dentition, Endotracheal\n tube, NG tube\n Cardiovascular: (S1: Normal), (S2: Normal), No(t) S3, No(t) S4, No(t)\n Rub\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : ,\n Rhonchorous: )\n Abdominal: Soft, Bowel sounds present, Distended, palpable fluid wave\n Extremities: Right: Absent, Left: Absent\n Skin: Not assessed\n Neurologic: No(t) Attentive, No(t) Follows simple commands, Responds\n to: Noxious stimuli, Movement: Not assessed, Tone: Not assessed,\n Patient not arousable to voice, no purposeful movements, withdraws to\n pain, non-verbal\n Labs / Radiology\n 152 K/uL\n 13.0 g/dL\n 105 mg/dL\n 2.1 mg/dL\n 75 mg/dL\n 27 mEq/L\n 98 mEq/L\n 4.3 mEq/L\n 140 mEq/L\n 39.6 %\n 13.4 K/uL\n [image002.jpg]\n \n 2:33 A2/19/ 11:21 AM\n \n 10:20 P2/19/ 01:24 PM\n \n 1:20 P\n \n 11:50 P\n \n 1:20 A\n \n 7:20 P\n 1//11/006\n 1:23 P\n \n 1:20 P\n \n 11:20 P\n \n 4:20 P\n WBC\n 13.4\n Hct\n 39.6\n Plt\n 152\n Cr\n 2.1\n TropT\n 0.27\n TC02\n 33\n Glucose\n 105\n Other labs: PT / PTT / INR:16.2/42.3/1.4, CK / CKMB /\n Troponin-T:1287/31/0.27, Differential-Neuts:74.5 %, Lymph:14.1 %,\n Mono:8.1 %, Eos:2.9 %, Lactic Acid:5.2 mmol/L, Ca++:8.3 mg/dL, Mg++:3.4\n mg/dL, PO4:6.0 mg/dL\n Imaging: CXR no significant change from prior. Some asymmetry to\n lungs suggesting differential blood flow\n Microbiology: Urine: E. Coli - pan sensitive\n ECG: Sinus tach with normalization of T-waves in inferior leads.\n Assessment and Plan\n Assessment and Plan: This is a 63 y/o M with Hepatitis C cirrhosis, a\n to ICU w/ PEA arrest to mucous plug.\n .\n # Shock/PEA Arrest: Witness arrest to mucous plug.\n - Now hemodynamically stable, access achieved.\n - Culture broadly to guid further care but would not cover with\n antibiotics at this time\n - Rule out for MI with serial enzymes\n - follow-UOP and bolus IVF's PRN.\n - Opt for dopamine or levo as initial pressor of choice.\n - frequent suctioning and bronch to evaluate airways for retained food.\n .\n # Neuro: With slowly resolving delerium prior to this event, and now\n with unclear hypoxic insult to brain. GCS of on admission to ICU.\n Consider cooling protocol. Head CT to evaluate for anoxic brain injury\n post-cooling. Neuro eval for possible seizure.\n - Will need sedation and paralysis for cooling.\n - Low dose fentanyl/versed for sedation for now.\n - LP done earlier this admit that was negative gram stain/culture, no\n whites, negative HSV PCR.\n - Dysconjugate gaze c/w possible seizure consult neuro for EEG.\n .\n # Respiratory/Ventilation: Assist control. Low tidal volumes to avoid\n unneeded injury, with pH goal of above 7.25.\n - Repeat ABG now and titrate oxygen/PEEP, minute vent to effect.\n .\n # Metabolic Acidosis: s/p arrest to tissue hypoxia. Continue IVF's\n and trend lactate. Will need to increase minute ventilation for CO2.\n - Blood cultures, urine cultures for infectious source given white\n blood cell count, but do not suspect sepsis at this time.\n .\n # Cardiac: Anticipate some elevation in CE's post-arrest, will trend.\n .\n # Cirrhosis: Hep C Cirrhosis, with concern for HRS.\n - Appreciate liver rec's\n .\n # Renal Failure: Unclear Etiology. Renal following given concern for\n HRS.\n - Send urine lytes, repeat Ua post-arrest\n - Appreciate renal rec's.\n .\n # Leukocytosis: Unclear etiology. Negative tap for SBP on .\n Urine growing E. Coli. Pan-culture.\n .\n # Parotid mass. Incidental finding of L parotid mass on MRI, 1.6cm. --\n Will require OP ENT followup.\n .\n # Access: PIV, Central Line, arterial line.\n .\n # FEN: IVF, replete electrolytes\n .\n # Prophylaxis: Subcutaneous heparin\n .\n # Code: full\n .\n # Communication: Wife is HCP\n .\n # Disposition: ICU for now.\n .\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 22 Gauge - 11:30 AM\n 20 Gauge - 11:45 AM\n Multi Lumen - 12:48 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP: HOB elevation, Mouth care\n Comments:\n Communication: Family meeting held , ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n ------ Protected Section ------\n Medications on Transfer:\n Ceftriaxone 1 g IV q 24 hrs\n Vitamin D 400 IU daily\n Bengay\n Heparin SC 5000 U TID\n Lansoprazole 30 mg daily\n Tylenol 325-650 prn\n Gelclair\n Spironolactone 50 mg daily\n Lactulose 60 mL qid\n Levothyroixine 37.5 mcg daily\n Rifaxamin 400 mg tid\n Folate 1 mg daily\n Thiamine 100 mg daily\n Caphsol 30 ml oral qid\n Bactrim 1 DS tab daily (given yesterday)\n .\n Home Medications:\n . Bupropion XL 150mg TID, but not taken as prescribed. Will need to\n verify with psychiatrist in AM\n #. Esomeprazole 40mg daily\n #. Lactulose 10mg/15mL TID, not taking as prescribed.\n #. Levothyroxine 75mcg daily\n #. Lithium 600mg per pharmacy, but 450 CR in OMR, which is a\n more appropriate for dosing.\n #. Spironolactone 50mg daily\n #. Vitamin D daily\n #. Milk Thistle 400mg daily\n #. Omega-3 Fatty acids daily\n ------ Protected Section Addendum Entered By: , MD\n on: 15:47 ------\n CRITICL CARE STAFF ADDENDUM\n 4p\n I saw and examined Mr. with Dr. , whose note above\n reflects my input. I would add/emphasize that he is a 63-year-old man\n with a past history most notable for HCV-associated cirrhosis and a\n complicated, long hospitalization most notable for laminectomy for cord\n compression and prolonged encephalopathy of uncertain etiology. Today\n during suctioning he had a witnessed arrest. During intubation, a\n mucus plug (vs. food\n though seems less likely given prolonged NPO\n status) was removed. Had ROSC and brought to MICU, where he was\n unresponsive with GCS~8. CVL and art line placed for borderline\n hypotension, tachycardia to 140s.\n On exam now he is sedated with dysconjugate gaze. 92 108/48 A/C 550\n x 18 x 0.5 x P5. Heart is regular. Lungs are clear. Abdomen is\n protuberant. Edema.\n CXR with ET in place. Elevated right hemi. EKG with some inferior\n pseudonormalization.\n Labs reviewed in note above.\n Assessment and Plan\n 63-year-old man with cirrhosis and prolonged delirium/encephalopathy\n now s/p PEA arrest with ROSC but continued depressed mental status.\n Post-arrest care\n Hemodynamic management as needed (currently normotense)\n Hypothermia per protocol\n Dysconjugate gaze\n Discuss with neuro re: possibility of nonconvulsive status\n Respiratory failure\n Given findings at intubation, will bronch to exclude\n retained foreign material\n Leave intubated during hypothermia\n No clear evidence of infection at present\n Acute renal failure\n Expect ATN post-arrest; may have underlying HRS or other\n issues\n Renal following\n Other issues as per ICU team note above. Our team has d/w pt\ns wife.\n 50 minutes\n ------ Protected Section Addendum Entered By: , MD\n on: 16:07 ------\n Addendum\n 6:50p\n Has tolerated induction of hypothermia\n shivering required\n pharmacologic paralysis.\n Preliminary EEG review (discussed with neurology) does not show status\n epilepticus. Background is very diminished.\n Art line is damped and will need replacement.\n Met with patients wife and reviewed events. All questions answered.\n 45 minutes\n ------ Protected Section Addendum Entered By: , MD\n on: 18:58 ------\n" }, { "category": "Respiratory ", "chartdate": "2145-01-08 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 558127, "text": "Demographics\n Day of intubation: \n Day of mechanical ventilation: 0\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n Tube Type\n ETT:\n Position: 25 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Cuff volume: mL /\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: Tan / Thick\n Sputum source/amount: Suctioned / Scant\n Comments: At beginning of shift, copious amount of very tan, thick,\n chunky 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 response (sleeping / sedated)\n Plan\n Next 24-48 hours:\n Reason for continuing current ventilatory support: Underlying illness\n not resolved\n Comments: Pt had sats in mid 90\ns and progressively worsening Pao2\n values. Peep increased along with FiO2. Values improved. Will re-wean\n Fio2 slowly.\n" }, { "category": "Nursing", "chartdate": "2145-01-08 00:00:00.000", "description": "Nursing Progress Note", "row_id": 558129, "text": "Pt admitted to on s/p fall for back spinal fusion.\n According to pt's wife, who is health care proxy, pt has been confused\n since coming out of anesthesia and later developed a UTI. According to\n floor RN, pt has had MS changes over the past few weeks where he has\n been agitated and unresponsive. Neuro and psych have consulted.\n Unknown cause of MS changes. ? encephalopathy vs. infection. Today pt\n had resp distress, became unresponsive and went into PEA arrest. Large\n plug suctioned from pt. Chest compressions done, 1mg Atropine given\n along with Epi. Pulse returned and pt transferred to MICU for further\n management.\n Cardiac arrest\n Assessment:\n HR 60\ns SR. Artic sun maintaining pt. in range of goal temp of 34.0 C,\n continuous monitoring with rectal and bladder probes. Goal temp\n reached at 18:20 . Cool to the touch, adequate peripheral\n perfusion, skin not compromised. Abd. soft and distended, hypoactive\n BS. Withdrawing to oral care, brief eye opening on turns.\n Action:\n TOF at 50 MA on L ulnar site. Bladder pressure 9 mm Hg, site\n marked on R groin for repeat measurements. QTc 400 milliseconds. No\n Nimbex required.\n Response:\n Monitoring of ECG for changes, AM labs: K (4.1), glucose levels not\n requiring insulin coverage.\n Plan:\n Close monitoring of QTc as hypothermia may mask hypo/hyperkalemic\n changes on the ECG. Administer nimbex for shivering or excessive drops\n in Artic Sun water temperature. Begin re-warming at 12:20 at\n 0.5C/hr per protocol - monitor for hyperglycemia, hyperkalemia, and\n seizure activity.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Assumed care AC 18/50% x 550/5, pH 7.50, pO2 54. Lung sounds\n diminished in the lower fields and rhonchorous in the upper\n bilaterally. Suctioning scant amounts of tan tenacious secretions.\n Brief periods of desaturation to 90% relieved by increasing FiO2 to\n 100%.\n Action:\n Repeat pH 7.49, pO2 53, RT lavaged ETT with little to no increase in\n secretions, vent changes to 18/70% x 550/12. Lung sounds diminished in\n all fields. CXR showing probable PNA. HOB 30 degrees.\n Response:\n ABG = 7.44, pO2 77, FiO2 60%, breathing approx. 10 L/min. Zosyn and\n Vanco per .\n Plan:\n Monitor ABG, ween FiO2 and PEEP as appropriate. ABX, T&R and CPT as\n tolerated. Monitor for signs of distress.\n Hypotension (not Shock)\n Assessment:\n Normotensive at commencement of shift, MAP high 60\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2145-01-08 00:00:00.000", "description": "Nursing Progress Note", "row_id": 558130, "text": "Pt admitted to on s/p fall for back spinal fusion.\n According to pt's wife, who is health care proxy, pt has been confused\n since coming out of anesthesia and later developed a UTI. According to\n floor RN, pt has had MS changes over the past few weeks where he has\n been agitated and unresponsive. Neuro and psych have consulted.\n Unknown cause of MS changes. ? encephalopathy vs. infection. Today pt\n had resp distress, became unresponsive and went into PEA arrest. Large\n plug suctioned from pt. Chest compressions done, 1mg Atropine given\n along with Epi. Pulse returned and pt transferred to MICU for further\n management.\n Cardiac arrest\n Assessment:\n HR 60\ns SR. Artic sun maintaining pt. in range of goal temp of 34.0 C,\n continuous monitoring with rectal and bladder probes. Goal temp\n reached at 18:20 . Cool to the touch, adequate peripheral\n perfusion, skin not compromised. Abd. soft and distended, hypoactive\n BS. Withdrawing to oral care, brief eye opening on turns.\n Action:\n TOF at 50 MA on L ulnar site. Bladder pressure 9 mm Hg, site\n marked on R groin for repeat measurements. QTc 400 milliseconds. No\n Nimbex required.\n Response:\n Monitoring of ECG for changes, AM labs: K (4.1), glucose levels not\n requiring insulin coverage.\n Plan:\n Close monitoring of QTc as hypothermia may mask hypo/hyperkalemic\n changes on the ECG. Administer nimbex for shivering or excessive drops\n in Artic Sun water temperature. Begin re-warming at 12:20 at\n 0.5C/hr per protocol - monitor for hyperglycemia, hyperkalemia, and\n seizure activity.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Assumed care AC 18/50% x 550/5, pH 7.50, pO2 54. Lung sounds\n diminished in the lower fields and rhonchorous in the upper\n bilaterally. Suctioning scant amounts of tan tenacious secretions.\n Brief periods of desaturation to 90% relieved by increasing FiO2 to\n 100%.\n Action:\n Repeat pH 7.49, pO2 53, RT lavaged ETT with little to no increase in\n secretions, vent changes to 18/70% x 550/12. Lung sounds diminished in\n all fields. CXR showing probable PNA. HOB 30 degrees.\n Response:\n ABG = 7.44, pO2 77, FiO2 60%, breathing approx. 10 L/min. Zosyn and\n Vanco per .\n Plan:\n Monitor ABG, ween FiO2 and PEEP as appropriate. ABX, T&R and CPT as\n tolerated. Monitor for signs of distress.\n Hypotension (not Shock)\n Assessment:\n Normotensive at commencement of shift, MAP high 60\ns, CVP 9.\n Fentanyl/Versed at 50mcg/2mg. Urine output approx. 20cc/hr.\n Action:\n 500 cc bolus fluid challenge given. Fentanyl/Versed d/c\nd and Propofol\n started at 25 mcg/kg/min, with immediate hypotensive effect, decreased\n to 10 mcg/kg/min, MAP of high 40\ns. 500 cc bolus given and Propofol\n d/c\nd, Fentanyl/Versed restarted at 50mcg/2mg.\n Response:\n BP returned to MAP of 60. Hypotensive episode with T&R, 500 cc bolus\n given with poor effect on BP and urine output, Levophed started,\n increased in increments to 0.09 mcg/kg/min with MAP goal >70 for brain\n perfusion.\n Plan:\n Titrate Levophed for MAP >70. Monitor fluid balance, LOS about +3000\n mL. Assess for BP lability during rewarming r/t vasodilation.\n" }, { "category": "Nursing", "chartdate": "2145-01-08 00:00:00.000", "description": "Nursing Progress Note", "row_id": 558131, "text": "Pt admitted to on s/p fall for back spinal fusion.\n According to pt's wife, who is health care proxy, pt has been confused\n since coming out of anesthesia and later developed a UTI. According to\n floor RN, pt has had MS changes over the past few weeks where he has\n been agitated and unresponsive. Neuro and psych have consulted.\n Unknown cause of MS changes. ? encephalopathy vs. infection. Today pt\n had resp distress, became unresponsive and went into PEA arrest. Large\n plug suctioned from pt. Chest compressions done, 1mg Atropine given\n along with Epi. Pulse returned and pt transferred to MICU for further\n management.\n Cardiac arrest\n Assessment:\n HR 60\ns SR. Artic sun maintaining pt. in range of goal temp of 34.0 C,\n continuous monitoring with rectal and bladder probes. Goal temp\n reached at 18:20 . Cool to the touch, adequate peripheral\n perfusion, skin not compromised. Abd. soft and distended, hypoactive\n BS. Withdrawing to oral care, brief eye opening on turns.\n Action:\n TOF at 50 MA on L ulnar site. Bladder pressure 9 mm Hg, site\n marked on R groin for repeat measurements. QTc 400 milliseconds. No\n Nimbex required.\n Response:\n Monitoring of ECG for changes, AM labs: K (4.1), glucose levels not\n requiring insulin coverage.\n Plan:\n Close monitoring of QTc as hypothermia may mask hypo/hyperkalemic\n changes on the ECG. Administer nimbex for shivering or excessive drops\n in Artic Sun water temperature. Begin re-warming at 12:20 at\n 0.5C/hr per protocol - monitor for hyperglycemia, hyperkalemia, and\n seizure activity. Monitor pan cultures pending.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Assumed care AC 18/50% x 550/5, pH 7.50, pO2 54. Lung sounds\n diminished in the lower fields and rhonchorous in the upper\n bilaterally. Suctioning scant amounts of tan tenacious secretions.\n Brief periods of desaturation to 90% relieved by increasing FiO2 to\n 100%.\n Action:\n Repeat pH 7.49, pO2 53, RT lavaged ETT with little to no increase in\n secretions, vent changes to 18/70% x 550/12. Lung sounds diminished in\n all fields. CXR showing probable PNA. HOB 30 degrees.\n Response:\n ABG = 7.44, pO2 77, FiO2 60%, breathing approx. 10 L/min. Zosyn and\n Vanco per . WBC (13.4).\n Plan:\n Monitor ABG, ween FiO2 and PEEP as appropriate. ABX, T&R and CPT as\n tolerated. Monitor for signs of distress.\n Hypotension (not Shock)\n Assessment:\n Normotensive at commencement of shift, MAP high 60\ns, CVP 9.\n Fentanyl/Versed at 50mcg/2mg. Urine output approx. 20cc/hr.\n Action:\n 500 cc bolus fluid challenge given. Fentanyl/Versed d/c\nd and Propofol\n started at 25 mcg/kg/min, with immediate hypotensive effect, decreased\n to 10 mcg/kg/min, MAP of high 40\ns. 500 cc bolus given and Propofol\n d/c\nd, Fentanyl/Versed restarted at 50mcg/2mg.\n Response:\n BP returned to MAP of 60. Hypotensive episode with T&R, 500 cc bolus\n given with poor effect on BP and urine output, Levophed started,\n increased in increments to 0.09 mcg/kg/min with MAP goal >70 for brain\n perfusion.\n Plan:\n Titrate Levophed for MAP >70. Monitor fluid balance, LOS about +3000\n mL. Assess for BP lability during rewarming r/t vasodilation.\n" }, { "category": "Nursing", "chartdate": "2145-01-08 00:00:00.000", "description": "Nursing Progress Note", "row_id": 558132, "text": "Pt admitted to on s/p fall for back spinal fusion.\n According to pt's wife, who is health care proxy, pt has been confused\n since coming out of anesthesia and later developed a UTI. According to\n floor RN, pt has had MS changes over the past few weeks where he has\n been agitated and unresponsive. Neuro and psych have consulted.\n Unknown cause of MS changes. ? encephalopathy vs. infection. Today pt\n had resp distress, became unresponsive and went into PEA arrest. Large\n plug suctioned from pt. Chest compressions done, 1mg Atropine given\n along with Epi. Pulse returned and pt transferred to MICU for further\n management.\n Cardiac arrest\n Assessment:\n HR 60\ns SR. Artic sun maintaining pt. in range of goal temp of 34.0 C,\n continuous monitoring with rectal and bladder probes. Goal temp\n reached at 18:20 . Cool to the touch, adequate peripheral\n perfusion, skin not compromised. Abd. soft and distended, hypoactive\n BS. Withdrawing to oral care, brief eye opening on turns.\n Action:\n TOF at 50 MA on L ulnar site. Bladder pressure 9 mm Hg, site\n marked on R groin for repeat measurements. QTc 400 milliseconds. No\n Nimbex required.\n Response:\n Monitoring of ECG for changes, AM labs: K (4.1), glucose levels WNL.\n Plan:\n Close monitoring of QTc as hypothermia may mask hypo/hyperkalemic\n changes on the ECG. Administer nimbex for shivering or excessive drops\n in Artic Sun water temperature. Begin re-warming at 12:20 at\n 0.5C/hr per protocol - monitor for hyperglycemia, hyperkalemia, and\n seizure activity. Monitor pan cultures pending.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Assumed care AC 18/50% x 550/5, pH 7.50, pO2 54. Lung sounds\n diminished in the lower fields and rhonchorous in the upper\n bilaterally. Suctioning scant amounts of tan tenacious secretions.\n Brief periods of desaturation to 90% relieved by increasing FiO2 to\n 100%.\n Action:\n Repeat pH 7.49, pO2 53, RT lavaged ETT with little to no increase in\n secretions, vent changes to 18/70% x 550/12. Lung sounds diminished in\n all fields. CXR showing probable PNA. HOB 30 degrees.\n Response:\n ABG = 7.44, pO2 77, FiO2 60%, breathing approx. 10 L/min. Zosyn and\n Vanco per . WBC (13.4).\n Plan:\n Monitor ABG, ween FiO2 and PEEP as appropriate. ABX, T&R and CPT as\n tolerated. Monitor for signs of distress.\n Hypotension (not Shock)\n Assessment:\n Normotensive at commencement of shift, MAP high 60\ns, CVP 9.\n Fentanyl/Versed at 50mcg/2mg. Urine output approx. 20cc/hr.\n Action:\n 500 cc bolus fluid challenge given. Fentanyl/Versed d/c\nd and Propofol\n started at 25 mcg/kg/min, with immediate hypotensive effect, decreased\n to 10 mcg/kg/min, MAP of high 40\ns. 500 cc bolus given and Propofol\n d/c\nd, Fentanyl/Versed restarted at 50mcg/2mg.\n Response:\n BP returned to MAP of 60. Hypotensive episode with T&R, 500 cc bolus\n given with poor effect on BP and urine output, Levophed started,\n increased in increments to 0.09 mcg/kg/min with MAP goal >70 for brain\n perfusion.\n Plan:\n Titrate Levophed for MAP >70. Monitor fluid balance, LOS about +3000\n mL. Assess for BP lability during rewarming r/t vasodilation.\n" }, { "category": "Physician ", "chartdate": "2145-01-08 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 558190, "text": "Chief Complaint:\n 24 Hour Events:\n Events:\n - bronch showing thick, yellow secretions concerning for infection,\n started vanco and zosyn for HAP\n - cooling protocol initiated, plan for rewarming around noon tomorrow\n - renal team following, sent urine lytes and UA; pt remaining basically\n anuric overnight\n - CVPs in 8-10s, likely fluid down; to test kidneys, gave 500 cc fluid\n challenge. UO improved slightly from about 20 cc/hr up to 80 cc/hr for\n short time\n - Around 2 am, after repositioning patients SBP dropped to 70s, came up\n to 80s with fluids but needed to start levophed; titrated up to 0.07\n and then stable overnight\n INVASIVE VENTILATION - START 10:55 AM\n MULTI LUMEN - START 12:48 PM\n BRONCHOSCOPY - At 04:23 PM\n ARTERIAL LINE - START 05:00 PM\n Allergies:\n Demerol (Oral) (Meperidine Hcl)\n Confusion/Delir\n Last dose of Antibiotics:\n Ceftriaxone - 04:00 PM\n Vancomycin - 08:00 PM\n Piperacillin/Tazobactam (Zosyn) - 01:57 AM\n Infusions:\n Fentanyl - 50 mcg/hour\n Midazolam (Versed) - 2 mg/hour\n Norepinephrine - 0.05 mcg/Kg/min\n Other ICU medications:\n Midazolam (Versed) - 11:30 AM\n Fentanyl - 11:30 AM\n Heparin Sodium (Prophylaxis) - 10:02 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:38 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 3.1\nC (37.5\n Tcurrent: 3.1\nC (37.5\n HR: 60 (59 - 156) bpm\n BP: 114/68(82) {85/51(62) - 114/77(82)} mmHg\n RR: 19 (17 - 27) insp/min\n SpO2: 97%\n CVP: 15 (7 - 18)mmHg\n Bladder pressure: 9 (9 - 9) mmHg\n Total In:\n 2,497 mL\n 855 mL\n PO:\n TF:\n IVF:\n 2,497 mL\n 855 mL\n Blood products:\n Total out:\n 410 mL\n 154 mL\n Urine:\n 410 mL\n 154 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,087 mL\n 701 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 550 (550 - 550) mL\n RR (Set): 18\n RR (Spontaneous): 0\n PEEP: 12 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10\n PIP: 22 cmH2O\n Plateau: 20 cmH2O\n SpO2: 97%\n ABG: 7.46/34/92./25/0\n Ve: 10.3 L/min\n PaO2 / FiO2: 186\n Physical Examination\n Eyes / Conjunctiva: PERRL, dysconjugate gaze\n Head, Ears, Nose, Throat: Normocephalic, Poor dentition, Endotracheal\n tube, NG tube\n Cardiovascular: (S1: Normal), (S2: Normal), No(t) S3, No(t) S4, No(t)\n Rub\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : ,\n Rhonchorous: )\n Abdominal: Soft, Bowel sounds present, Distended, palpable fluid wave\n Extremities: Right: Absent, Left: Absent\n Skin: Not assessed\n Neurologic: No(t) Attentive, No(t) Follows simple commands, Responds\n to: Noxious stimuli, Movement: Not assessed, Tone: Not assessed,\n Patient not arousable to voice, no purposeful movements, withdraws to\n pain, non-verbal\n Labs / Radiology\n 134 K/uL\n 12.7 g/dL\n 114 mg/dL\n 2.2 mg/dL\n 25 mEq/L\n 4.2 mEq/L\n 85 mg/dL\n 102 mEq/L\n 138 mEq/L\n 38.5 %\n 26.5 K/uL\n [image002.jpg]\n 11:21 AM\n 01:24 PM\n 03:41 PM\n 06:56 PM\n 09:04 PM\n 10:13 PM\n 11:06 PM\n 11:47 PM\n 03:38 AM\n 04:01 AM\n WBC\n 13.4\n 26.5\n Hct\n 39.6\n 38.5\n Plt\n 152\n 134\n Cr\n 2.1\n 2.0\n 1.9\n 2.2\n TropT\n 0.27\n 0.24\n TCO2\n 33\n 27\n 28\n 27\n 27\n 25\n Glucose\n 105\n 92\n 117\n 114\n Other labs: PT / PTT / INR:17.2/54.3/1.6, CK / CKMB /\n Troponin-T:447/26/0.24, Differential-Neuts:74.5 %, Lymph:14.1 %,\n Mono:8.1 %, Eos:2.9 %, Lactic Acid:2.0 mmol/L, Ca++:7.7 mg/dL, Mg++:3.1\n mg/dL, PO4:5.5 mg/dL\n Assessment and Plan\n Assessment and Plan: This is a 63 y/o M with Hepatitis C cirrhosis, a\n to ICU w/ PEA arrest to mucous plug.\n .\n # Shock/PEA Arrest: Witness arrest to mucous plug.\n - Now hemodynamically stable, access achieved.\n - Culture broadly to guid further care but would not cover with\n antibiotics at this time\n - Rule out for MI with serial enzymes\n - follow-UOP and bolus IVF's PRN.\n - Opt for dopamine or levo as initial pressor of choice.\n - frequent suctioning and bronch to evaluate airways for retained food.\n .\n # Neuro: With slowly resolving delerium prior to this event, and now\n with unclear hypoxic insult to brain. GCS of on admission to ICU.\n Consider cooling protocol. Head CT to evaluate for anoxic brain injury\n post-cooling. Neuro eval for possible seizure.\n - Will need sedation and paralysis for cooling.\n - Low dose fentanyl/versed for sedation for now.\n - LP done earlier this admit that was negative gram stain/culture, no\n whites, negative HSV PCR.\n - Dysconjugate gaze c/w possible seizure consult neuro for EEG.\n .\n # Respiratory/Ventilation: Assist control. Low tidal volumes to avoid\n unneeded injury, with pH goal of above 7.25.\n - Repeat ABG now and titrate oxygen/PEEP, minute vent to effect.\n .\n # Metabolic Acidosis: s/p arrest to tissue hypoxia. Continue IVF's\n and trend lactate. Will need to increase minute ventilation for CO2.\n - Blood cultures, urine cultures for infectious source given white\n blood cell count, but do not suspect sepsis at this time.\n .\n # Cardiac: Anticipate some elevation in CE's post-arrest, will trend.\n .\n # Cirrhosis: Hep C Cirrhosis, with concern for HRS.\n - Appreciate liver rec's\n .\n # Renal Failure: Unclear Etiology. Renal following given concern for\n HRS.\n - Send urine lytes, repeat Ua post-arrest\n - Appreciate renal rec's.\n .\n # Leukocytosis: Unclear etiology. Negative tap for SBP on .\n Urine growing E. Coli. Pan-culture.\n .\n # Parotid mass. Incidental finding of L parotid mass on MRI, 1.6cm. --\n Will require OP ENT followup.\n .\n # Access: PIV, Central Line, arterial line.\n .\n # FEN: IVF, replete electrolytes\n .\n # Prophylaxis: Subcutaneous heparin\n .\n # Code: full\n .\n # Communication: Wife is HCP\n .\n # Disposition: ICU for now.\n .\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 22 Gauge - 11:30 AM\n 20 Gauge - 11:45 AM\n Multi Lumen - 12:48 PM\n Arterial Line - 05:00 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": "2145-01-08 00:00:00.000", "description": "Nursing Progress Note", "row_id": 558303, "text": "Synopsis per prior nursing note:\n Pt admitted to on s/p fall for back spinal fusion.\n According to pt's wife, who is health care proxy, pt has been confused\n since coming out of anesthesia and later developed a UTI. According to\n floor RN, pt has had MS changes over the past few weeks where he has\n been agitated and unresponsive. Neuro and psych have consulted.\n Unknown cause of MS changes. ? encephalopathy vs. infection. Today pt\n had resp distress, became unresponsive and went into PEA arrest. Large\n plug suctioned from pt. Chest compressions done, 1mg Atropine given\n along with Epi. Pulse returned and pt transferred to MICU for further\n management.\n Cardiac arrest\n Assessment:\n HR 55-68 SR w/rare PVC\ns. ABP 95-109/48-66. MAP\ns 60\ns-70\n Eyes-PERRL, 2mm, brisk. Not moving extremities. Not following commands.\n Not responding to painful stimuli. Temp 34C rectal. QT 505milliseconds\n (Resident aware). No shivering noted. Continues on fentanyl and versed\n gtts. FS 119-124. CVP 13-14.\n Action:\n Continues on arctic sun. Temp monitored-rectal and bladder. Started\n rewarming protocol @ 1215. Arctic sun set to rewarm 0.5degrees C/hr.\n EKG done. Fentanyl gtt weaned to 25mcg/hr.\n Response:\n Temp increased accordingly. SBP decreased to 70\ns w/ turns.\n Plan:\n Monitor QT. Monitor lytes. Monitor for shivering. Monitor for\n hyperglycemia, hyperkalemia, and seizure activity. Monitor pan cultures\n pending.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n AC 18/550/50%/PEEP12. LS clear to rhonchi w/ diminished bases. Not\n breathing over vent. Central venous O2 was 80.\n Action:\n Suctioned scant amt of tan secretions. HOB 30 degrees. Continued on\n antibiotics.\n Response:\n O2 sats remained 98-100%. Desats to high 80\ns-low 90\ns w/ turns.\n Plan:\n Monitor ABG, o2 sats. Wean vent as tolerated. Continue antibiotics.\n Suction as needed.\n Hypotension (not Shock)\n Assessment:\n ABP 95-109/48-66. MAP\ns 60\ns to 70\ns. UOP ~15-40cc/hr.\n Action:\n 500 cc bolus fluid challenge given. Fentanyl/Versed d/c\nd and Propofol\n started at 25 mcg/kg/min, with immediate hypotensive effect, decreased\n to 10 mcg/kg/min, MAP of high 40\ns. 500 cc bolus given and Propofol\n d/c\nd, Fentanyl/Versed restarted at 50mcg/2mg.\n Response:\n BP returned to MAP of 60. Hypotensive episode with T&R, 500 cc bolus\n given with poor effect on BP and urine output, Levophed started,\n increased in increments to 0.09 mcg/kg/min with MAP goal >70 for brain\n perfusion.\n Plan:\n Titrate Levophed for MAP >70. Monitor fluid balance, LOS about +3000\n mL. Assess for BP lability during rewarming r/t vasodilation.\n" }, { "category": "Physician ", "chartdate": "2145-01-08 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 558305, "text": "Chief Complaint: respiratory/cardiac arrest\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 INVASIVE VENTILATION - START 10:55 AM\n MULTI LUMEN - START 12:48 PM\n BRONCHOSCOPY - At 04:23 PM\n ARTERIAL LINE - START 05:00 PM\n Hypothermia tolerated with paralysis but developed hypotension\n requiring norepinephrine\n Oliguria unresponsive to volume challenge\n Didn't tolerate propofol (hypotension)\n EEG formal read pending, but prelim negative for status epilepticus\n Required increased respiratory support (PEEP, FiO2)\n Patient unable to provide history: Sedated\n Allergies:\n Demerol (Oral) (Meperidine Hcl)\n Confusion/Delir\n Last dose of Antibiotics:\n Ceftriaxone - 04:00 PM\n Vancomycin - 08:00 PM\n Piperacillin/Tazobactam (Zosyn) - 01:57 AM\n Infusions:\n Fentanyl - 50 mcg/hour\n Midazolam (Versed) - 2 mg/hour\n Norepinephrine - 0.05 mcg/Kg/min\n Other ICU medications:\n Midazolam (Versed) - 11:30 AM\n Fentanyl - 11:30 AM\n Heparin Sodium (Prophylaxis) - 10:02 PM\n Other medications:\n versed @ 2, fent @ 50, vit d, thiamine, folate, rifaxamin, synthroid,\n famotidine, chg, sqh , zosyn, vanco, propofol, levophed @ .05\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 09:01 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 3.1\nC (37.5\n Tcurrent: 3.1\nC (37.5\n HR: 59 (59 - 156) bpm\n BP: 107/66(78) {85/51(62) - 114/77(82)} mmHg\n RR: 18 (17 - 27) insp/min\n SpO2: 97%\n CVP: 14 (7 - 18)mmHg\n Bladder pressure: 9 (9 - 9) mmHg\n Total In:\n 2,497 mL\n 932 mL\n PO:\n TF:\n IVF:\n 2,497 mL\n 932 mL\n Blood products:\n Total out:\n 410 mL\n 186 mL\n Urine:\n 410 mL\n 186 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,087 mL\n 746 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 550 (550 - 550) mL\n RR (Set): 18\n RR (Spontaneous): 0\n PEEP: 12 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10\n PIP: 23 cmH2O\n Plateau: 22 cmH2O\n Compliance: 55 cmH2O/mL\n SpO2: 97%\n ABG: 7.46/34/92./25/0\n Ve: 10.3 L/min\n PaO2 / FiO2: 186\n Physical Examination\n General Appearance: Well nourished\n Eyes / Conjunctiva: dysconjugate\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n Respiratory / Chest: (Breath Sounds: Clear : ), limited by arctic sun\n Abdominal: Soft, protuberant; exam limited by arctic sun\n Extremities: Right: 1+, Left: 1+\n Skin: Cool\n Neurologic: Responds to: Unresponsive, Movement: Not assessed, Sedated,\n No(t) Paralyzed, Tone: Decreased\n Labs / Radiology\n 12.7 g/dL\n 134 K/uL\n 114 mg/dL\n 2.2 mg/dL\n 25 mEq/L\n 4.2 mEq/L\n 85 mg/dL\n 102 mEq/L\n 138 mEq/L\n 38.5 %\n 26.5 K/uL\n [image002.jpg]\n 11:21 AM\n 01:24 PM\n 03:41 PM\n 06:56 PM\n 09:04 PM\n 10:13 PM\n 11:06 PM\n 11:47 PM\n 03:38 AM\n 04:01 AM\n WBC\n 13.4\n 26.5\n Hct\n 39.6\n 38.5\n Plt\n 152\n 134\n Cr\n 2.1\n 2.0\n 1.9\n 2.2\n TropT\n 0.27\n 0.24\n TCO2\n 33\n 27\n 28\n 27\n 27\n 25\n Glucose\n 105\n 92\n 117\n 114\n Other labs: PT / PTT / INR:17.2/54.3/1.6, CK / CKMB /\n Troponin-T:447/26/0.24, Differential-Neuts:74.5 %, Lymph:14.1 %,\n Mono:8.1 %, Eos:2.9 %, Lactic Acid:2.0 mmol/L, Ca++:7.7 mg/dL, Mg++:3.1\n mg/dL, PO4:5.5 mg/dL\n Microbiology: BAL: oral flora\n Assessment and Plan\n 63-year-old man with respiratory arrest\n cardiac arrest after a\n prolonged and complicated hospital course, now receiving therapeutic\n hypothermia. Now will probable HAP (acquired on floor or at\n intubation) and hypotension requiring vasopressors.\n Post-arrest care\n Hemodynamic management as needed (currently normotense)\n Hypothermia per protocol\n Respiratory failure\n P:F ratio now <200; bilateral infiltrates. Although may be\n cardiac, also reasonable to consider ARDS\n Ventilae per ARDSnet\n Shock\n be cardiac or vasodilatory. CVP argues against\n hypovolemia.\n Check pulse pressure variation\n Ask echo if they are technically able to do echo with arctic\n sun in place\n Acute renal failure\n Expect some ATN\n Intra-abdominal hypertension excluded by low bladder\n pressure\n Neurologic status\n Assess clinically after rewarming\n Will likely need brain imaging after rewarming\n Await EEG\n Appreciate neurology\ns help\n Other issues as per ICU team note above. Our team has d/w pt\ns wife.\n ICU \n Nutrition: NPO\n Glycemic Control:\n Lines:\n 22 Gauge - 11:30 AM\n 20 Gauge - 11:45 AM\n Multi Lumen - 12:48 PM\n Arterial Line - 05:00 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP: HOB elevation, Mouth care\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 45 min\n Patient is critically ill\n ------ Protected Section ------\n Addendum\n 5:30p\n Case discussed with neurology\n no prognostication feasible until after\n rewarming (which I agree with)..\n Met with family, including wife , along with SW. Discussed events\n of day and expected course over next 24\n 72 hours\n that we will\n rewarm him then assess neurological exam and potentially ancillary\n tests. All questions answered.\n Norepinephrine requirement is increasing. Echo suggests hyperdynamic\n LVEF (though limited study). CVP is decreasing. Pattern suggest\n vasodilation or hypovolemia. Will volume challenge.\n 30 minutes\n ------ Protected Section Addendum Entered By: , MD\n on: 17:45 ------\n" }, { "category": "Nursing", "chartdate": "2145-01-08 00:00:00.000", "description": "Nursing Progress Note", "row_id": 558315, "text": "Synopsis per prior nursing note:\n Pt admitted to on s/p fall for back spinal fusion.\n According to pt's wife, who is health care proxy, pt has been confused\n since coming out of anesthesia and later developed a UTI. According to\n floor RN, pt has had MS changes over the past few weeks where he has\n been agitated and unresponsive. Neuro and psych have consulted.\n Unknown cause of MS changes. ? encephalopathy vs. infection. Today pt\n had resp distress, became unresponsive and went into PEA arrest. Large\n plug suctioned from pt. Chest compressions done, 1mg Atropine given\n along with Epi. Pulse returned and pt transferred to MICU for further\n management.\n Cardiac arrest\n Assessment:\n HR 55-68 SR w/rare PVC\ns. ABP 95-109/48-66. MAP\ns 60\ns-70\n Eyes-PERRL, 2mm, brisk. Not moving extremities. Not following commands.\n Not responding to painful stimuli. Temp 34C rectal. QT 505milliseconds\n (Resident aware). No shivering noted. Continues on fentanyl and versed\n gtts. FS 119-124. CVP 13-14.\n Action:\n Continues on arctic sun. Temp monitored-rectal and bladder. Started\n rewarming protocol @ 1215. Arctic sun set to rewarm 0.5degrees C/hr.\n EKG done. Fentanyl gtt weaned to 25mcg/hr.\n Response:\n Temp increased accordingly. SBP decreased to 70\ns w/ turns.\n Plan:\n Monitor QT. Monitor lytes. Monitor for shivering. Monitor for\n hyperglycemia, hyperkalemia, and seizure activity. Monitor pan cultures\n pending.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n AC 18/550/50%/PEEP12. LS clear to rhonchi w/ diminished bases. Not\n breathing over vent. Central venous O2 was 80.\n Action:\n Suctioned scant amt of tan secretions. HOB 30 degrees. Continued on\n antibiotics.\n Response:\n O2 sats remained 98-100%. Desats to high 80\ns-low 90\ns w/ turns.\n Plan:\n Monitor ABG, o2 sats. Wean vent as tolerated. Continue antibiotics.\n Suction as needed.\n Hypotension (not Shock)\n Assessment:\n ABP 95-109/48-66. MAP\ns 60\ns to 70\ns. UOP ~15-40cc/hr.\n Action:\n Continues on levophed gtt. Slowly required levophed titration up to\n maintain MAP 65-70 as rewarming occurred. Given 1L NS bolus. Albumin\n order for 2days.\n Response:\n Continued to become hypotensive w/ turns.\n Plan:\n Titrate Levophed gtt for MAP >65-70. ?more fluid bolus\n for increasing\n hypotension.\n" }, { "category": "General", "chartdate": "2145-01-07 00:00:00.000", "description": "Generic Note", "row_id": 558023, "text": "TITLE:\n Procedure Note\n Left Subclavian Line Placement\n Patient was prepped and draped in a sterile fashion. A time out was\n performed. Insertion site was identified. 3cc of sterile lidocaine\n was injected at the clavicle and subcutaneously. Finder needle was\n used to identify the subclavian vein. Two insertion sites were\n required, and after 3 passes at the second insertion site the\n subclavian vein was cannulated. Finder wire was then introduced\n without any arrhythmia present on monitors. Dilation and insertion of\n the line was performed without difficulty and wire was removed. Line\n was sutured into place. There were no apparent complications during\n the procedure. Estimated blood loss was 15-20cc. Dr. \n was present for the entirety of the procedure.\n Chest x-ray post-insertion is pending at time of this note.\n" }, { "category": "Nursing", "chartdate": "2145-01-08 00:00:00.000", "description": "Nursing Progress Note", "row_id": 558171, "text": "Pt admitted to on s/p fall for back spinal fusion.\n According to pt's wife, who is health care proxy, pt has been confused\n since coming out of anesthesia and later developed a UTI. According to\n floor RN, pt has had MS changes over the past few weeks where he has\n been agitated and unresponsive. Neuro and psych have consulted.\n Unknown cause of MS changes. ? encephalopathy vs. infection. Today pt\n had resp distress, became unresponsive and went into PEA arrest. Large\n plug suctioned from pt. Chest compressions done, 1mg Atropine given\n along with Epi. Pulse returned and pt transferred to MICU for further\n management.\n Cardiac arrest\n Assessment:\n HR 60\ns SR. Artic sun maintaining pt. in range of goal temp of 34.0 C,\n continuous monitoring with rectal and bladder probes. Goal temp\n reached at 18:20 . Cool to the touch, adequate peripheral\n perfusion, skin not compromised. Abd. soft and distended, hypoactive\n BS. Withdrawing to oral care, brief eye opening on turns.\n Action:\n TOF at 50 MA on L ulnar site. Bladder pressure 9 mm Hg, site\n marked on R groin for repeat measurements. QTc 400 milliseconds. No\n Nimbex required.\n Response:\n Monitoring of ECG for changes, AM labs: K (4.1), glucose levels WNL.\n Plan:\n Close monitoring of QTc as hypothermia may mask hypo/hyperkalemic\n changes on the ECG.Monitor lytes closely. Administer nimbex for\n shivering or excessive drops in Artic Sun water temperature. Begin\n re-warming at 12:20 at 0.5C/hr per protocol - monitor for\n hyperglycemia, hyperkalemia, and seizure activity. Monitor pan cultures\n pending.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Assumed care AC 18/50% x 550/5, pH 7.50, pO2 54. Lung sounds\n diminished in the lower fields and rhonchorous in the upper\n bilaterally. Suctioning scant amounts of tan tenacious secretions.\n Brief periods of desaturation to 90% relieved by increasing FiO2 to\n 100%.WCC this am 26.5,almost doubled from yesterday.\n Action:\n Repeat pH 7.49, pO2 53, RT lavaged ETT with little to no increase in\n secretions, vent changes to 18/70% x 550/12. Lung sounds diminished in\n all fields. CXR showing probable PNA. HOB 30 degrees.\n Response:\n ABG = 7.44, pO2 77, FiO2 60%, breathing approx. 10 L/min. Zosyn and\n Vanco per . WBC (13.4).\n Plan:\n Monitor ABG, ween FiO2 and PEEP as appropriate. ABX, T&R and CPT as\n tolerated. Monitor for signs of distress.F/u culture report.\n Hypotension (not Shock)\n Assessment:\n Normotensive at commencement of shift, MAP high 60\ns, CVP 9.\n Fentanyl/Versed at 50mcg/2mg. Urine output approx. 20cc/hr.\n Action:\n 500 cc bolus fluid challenge given. Fentanyl/Versed d/c\nd and Propofol\n started at 25 mcg/kg/min, with immediate hypotensive effect, decreased\n to 10 mcg/kg/min, MAP of high 40\ns. 500 cc bolus given and Propofol\n d/c\nd, Fentanyl/Versed restarted at 50mcg/2mg.\n Response:\n BP returned to MAP of 60. Hypotensive episode with T&R, 500 cc bolus\n given with poor effect on BP and urine output, Levophed started,\n increased in increments to 0.09 mcg/kg/min with MAP goal >70 for brain\n perfusion.\n Plan:\n Titrate Levophed for MAP >70. Monitor fluid balance, LOS about +3000\n mL. Assess for BP lability during rewarming r/t vasodilation.\n" }, { "category": "Respiratory ", "chartdate": "2145-01-08 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 558295, "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 Position: cm at teeth\n Route: L 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: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: /\n Sputum source/amount: /\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Maintain PEEP at current level and reduce FiO2 as\n tolerated\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n" }, { "category": "Nursing", "chartdate": "2145-01-09 00:00:00.000", "description": "Nursing Progress Note", "row_id": 558492, "text": "Synopsis per prior nursing note:\n Pt admitted to on s/p fall for back spinal fusion.\n According to pt's wife, who is health care proxy, pt has been confused\n since coming out of anesthesia and later developed a UTI. According to\n floor RN, pt has had MS changes over the past few weeks where he has\n been agitated and unresponsive. Neuro and psych have consulted.\n Unknown cause of MS changes. ? encephalopathy vs. infection. Today pt\n had resp distress, became unresponsive and went into PEA arrest. Large\n plug suctioned from pt. Chest compressions done, 1mg Atropine given\n along with Epi. Pulse returned and pt transferred to MICU for further\n management.\n Events: fentanyl and versed stopped. Levophed weaned and stopped.\n Altered mental status (not Delirium)\n Assessment:\n Eyes open to sternal stimuli and voice. Localizing to pain.\n Un-purposeful movement RUE & RLE upon turning. Pupils brisk 2mm.\n Action:\n Fentanyl and versed stopped. Soft wrist restraints in place. Lactulose\n ordered for ?encephalophthy. NG feed rate titrated up to 40mL/hr\n Response:\n Arouse to stimulation, eye opening to pain, up-purposeful movement of\n limbs.\n Plan:\n Continue to monitor neurologically , assess changes in vital signs for\n pain\n Hypotension (not Shock)\n Assessment:\n Action:\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Physician ", "chartdate": "2145-01-11 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 558831, "text": "Chief Complaint:\n 24 Hour Events:\n - extubated in the morning\n - mental status at level he was pre-code\n - low dose ativan for aggitation\n - started mitodrine, octreotide, albumin for HRS\n - art line pulled\n - had acute respiratory distress around 4 am with desat to 80s,\n required intense suctioning of bloody secretions, gas 7.38/51/108; did\n slightly better with frequent nebs\n Allergies:\n Demerol (Oral) (Meperidine Hcl)\n Confusion/Delir\n Last dose of Antibiotics:\n Vancomycin - 08:00 PM\n Piperacillin/Tazobactam (Zosyn) - 12:26 AM\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 08:01 AM\n Lorazepam (Ativan) - 04:01 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 07:01 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: 86 (75 - 86) bpm\n BP: 111/60(71) {102/53(65) - 130/80(89)} mmHg\n RR: 18 (14 - 26) insp/min\n SpO2: 92%\n Heart rhythm: SR (Sinus Rhythm)\n CVP: 11 (5 - 19)mmHg\n Total In:\n 2,126 mL\n 237 mL\n PO:\n TF:\n 350 mL\n IVF:\n 1,061 mL\n 237 mL\n Blood products:\n 400 mL\n Total out:\n 3,885 mL\n 680 mL\n Urine:\n 3,185 mL\n 680 mL\n NG:\n Stool:\n 700 mL\n Drains:\n Balance:\n -1,759 mL\n -443 mL\n Respiratory support\n O2 Delivery Device: Face tent\n Ventilator mode: CPAP/PSV\n Vt (Set): 550 (550 - 550) mL\n Vt (Spontaneous): 665 (665 - 665) mL\n PS : 5 cmH2O\n RR (Set): 14\n RR (Spontaneous): 16\n PEEP: 5 cmH2O\n FiO2: 100%\n PIP: 14 cmH2O\n SpO2: 92%\n ABG: 7.38/51/108/31/4\n Ve: 12 L/min\n PaO2 / FiO2: 108\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 52 K/uL\n 9.5 g/dL\n 100 mg/dL\n 1.4 mg/dL\n 31 mEq/L\n 3.7 mEq/L\n 59 mg/dL\n 112 mEq/L\n 148 mEq/L\n 29.6 %\n 5.6 K/uL\n [image002.jpg]\n 05:46 PM\n 03:23 AM\n 03:38 AM\n 10:22 AM\n 01:38 PM\n 02:25 AM\n 03:39 AM\n 04:55 AM\n 12:53 PM\n 04:02 AM\n WBC\n 16.3\n 6.1\n 6.1\n 5.6\n Hct\n 31.4\n 24.9\n 26.4\n 26.3\n 29.6\n Plt\n 118\n 63\n 73\n 52\n Cr\n 2.5\n 2.4\n 2.1\n 1.4\n TCO2\n 27\n 27\n 28\n 30\n 31\n Glucose\n 103\n 108\n 108\n 100\n Other labs: PT / PTT / INR:18.5/50.8/1.7, CK / CKMB /\n Troponin-T:447/26/0.24, ALT / AST:79/200, Alk Phos / T Bili:105/2.9,\n Amylase / Lipase:93/30, Differential-Neuts:74.5 %, Lymph:14.1 %,\n Mono:8.1 %, Eos:2.9 %, Lactic Acid:1.8 mmol/L, LDH:418 IU/L, Ca++:8.7\n mg/dL, Mg++:2.8 mg/dL, PO4:2.3 mg/dL\n Assessment and Plan\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n HYPOTENSION (NOT SHOCK)\n CARDIAC ARREST\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 12:48 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": "2145-01-11 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 558832, "text": "Chief Complaint:\n 24 Hour Events:\n - extubated in the morning\n - mental status at level he was pre-code\n - low dose ativan for aggitation\n - started mitodrine, octreotide, albumin for HRS\n - art line pulled\n - had acute respiratory distress around 4 am with desat to 80s,\n required intense suctioning of bloody secretions, gas 7.38/51/108; did\n slightly better with frequent nebs\n Allergies:\n Demerol (Oral) (Meperidine Hcl)\n Confusion/Delir\n Last dose of Antibiotics:\n Vancomycin - 08:00 PM\n Piperacillin/Tazobactam (Zosyn) - 12:26 AM\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 08:01 AM\n Lorazepam (Ativan) - 04:01 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 07:01 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: 86 (75 - 86) bpm\n BP: 111/60(71) {102/53(65) - 130/80(89)} mmHg\n RR: 18 (14 - 26) insp/min\n SpO2: 92%\n Heart rhythm: SR (Sinus Rhythm)\n CVP: 11 (5 - 19)mmHg\n Total In:\n 2,126 mL\n 237 mL\n PO:\n TF:\n 350 mL\n IVF:\n 1,061 mL\n 237 mL\n Blood products:\n 400 mL\n Total out:\n 3,885 mL\n 680 mL\n Urine:\n 3,185 mL\n 680 mL\n NG:\n Stool:\n 700 mL\n Drains:\n Balance:\n -1,759 mL\n -443 mL\n Respiratory support\n O2 Delivery Device: Face tent\n Ventilator mode: CPAP/PSV\n Vt (Set): 550 (550 - 550) mL\n Vt (Spontaneous): 665 (665 - 665) mL\n PS : 5 cmH2O\n RR (Set): 14\n RR (Spontaneous): 16\n PEEP: 5 cmH2O\n FiO2: 100%\n PIP: 14 cmH2O\n SpO2: 92%\n ABG: 7.38/51/108/31/4\n Ve: 12 L/min\n PaO2 / FiO2: 108\n Physical Examination\n Eyes / Conjunctiva: PERRL, opens eyes, makes eye contact\n , Ears, Nose, Throat: , Poor dentition, Endotracheal\n tube, NG tube\n Cardiovascular: (S1: Normal), (S2: Normal), No(t) S3, No(t) S4, No(t)\n Rub\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : ,\n Rhonchorous: )\n Abdominal: Soft, Bowel sounds present, Distended, palpable fluid wave\n Neurologic: arousable to voice, opens eyes no purposeful movements,\n withdraws to pain, non-verbal\n Labs / Radiology\n 52 K/uL\n 9.5 g/dL\n 100 mg/dL\n 1.4 mg/dL\n 31 mEq/L\n 3.7 mEq/L\n 59 mg/dL\n 112 mEq/L\n 148 mEq/L\n 29.6 %\n 5.6 K/uL\n [image002.jpg]\n 05:46 PM\n 03:23 AM\n 03:38 AM\n 10:22 AM\n 01:38 PM\n 02:25 AM\n 03:39 AM\n 04:55 AM\n 12:53 PM\n 04:02 AM\n WBC\n 16.3\n 6.1\n 6.1\n 5.6\n Hct\n 31.4\n 24.9\n 26.4\n 26.3\n 29.6\n Plt\n 118\n 63\n 73\n 52\n Cr\n 2.5\n 2.4\n 2.1\n 1.4\n TCO2\n 27\n 27\n 28\n 30\n 31\n Glucose\n 103\n 108\n 108\n 100\n Other labs: PT / PTT / INR:18.5/50.8/1.7, CK / CKMB /\n Troponin-T:447/26/0.24, ALT / AST:79/200, Alk Phos / T Bili:105/2.9,\n Amylase / Lipase:93/30, Differential-Neuts:74.5 %, Lymph:14.1 %,\n Mono:8.1 %, Eos:2.9 %, Lactic Acid:1.8 mmol/L, LDH:418 IU/L, Ca++:8.7\n mg/dL, Mg++:2.8 mg/dL, PO4:2.3 mg/dL\n Assessment and Plan\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n HYPOTENSION (NOT SHOCK)\n CARDIAC ARREST\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 12:48 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": "2145-01-11 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 558834, "text": "Chief Complaint:\n 24 Hour Events:\n - extubated in the morning\n - mental status at level he was pre-code\n - low dose ativan for aggitation\n - started mitodrine, octreotide, albumin for HRS\n - art line pulled\n - had acute respiratory distress around 4 am with desat to 80s,\n required intense suctioning of bloody secretions, gas 7.38/51/108; did\n slightly better with frequent nebs\n Allergies:\n Demerol (Oral) (Meperidine Hcl)\n Confusion/Delir\n Last dose of Antibiotics:\n Vancomycin - 08:00 PM\n Piperacillin/Tazobactam (Zosyn) - 12:26 AM\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 08:01 AM\n Lorazepam (Ativan) - 04:01 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 07:01 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: 86 (75 - 86) bpm\n BP: 111/60(71) {102/53(65) - 130/80(89)} mmHg\n RR: 18 (14 - 26) insp/min\n SpO2: 92%\n Heart rhythm: SR (Sinus Rhythm)\n CVP: 11 (5 - 19)mmHg\n Total In:\n 2,126 mL\n 237 mL\n PO:\n TF:\n 350 mL\n IVF:\n 1,061 mL\n 237 mL\n Blood products:\n 400 mL\n Total out:\n 3,885 mL\n 680 mL\n Urine:\n 3,185 mL\n 680 mL\n NG:\n Stool:\n 700 mL\n Drains:\n Balance:\n -1,759 mL\n -443 mL\n Respiratory support\n O2 Delivery Device: Face tent\n Ventilator mode: CPAP/PSV\n Vt (Set): 550 (550 - 550) mL\n Vt (Spontaneous): 665 (665 - 665) mL\n PS : 5 cmH2O\n RR (Set): 14\n RR (Spontaneous): 16\n PEEP: 5 cmH2O\n FiO2: 100%\n PIP: 14 cmH2O\n SpO2: 92%\n ABG: 7.38/51/108/31/4\n Ve: 12 L/min\n PaO2 / FiO2: 108\n Physical Examination\n Eyes / Conjunctiva: PERRL, opens eyes, makes eye contact\n , Ears, Nose, Throat: , Poor dentition, Endotracheal\n tube, NG tube\n Cardiovascular: (S1: Normal), (S2: Normal), No(t) S3, No(t) S4, No(t)\n Rub\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : ,\n Rhonchorous: )\n Abdominal: Soft, Bowel sounds present, Distended, palpable fluid wave\n Neurologic: arousable to voice, opens eyes no purposeful movements,\n withdraws to pain, non-verbal\n Labs / Radiology\n 52 K/uL\n 9.5 g/dL\n 100 mg/dL\n 1.4 mg/dL\n 31 mEq/L\n 3.7 mEq/L\n 59 mg/dL\n 112 mEq/L\n 148 mEq/L\n 29.6 %\n 5.6 K/uL\n [image002.jpg]\n 05:46 PM\n 03:23 AM\n 03:38 AM\n 10:22 AM\n 01:38 PM\n 02:25 AM\n 03:39 AM\n 04:55 AM\n 12:53 PM\n 04:02 AM\n WBC\n 16.3\n 6.1\n 6.1\n 5.6\n Hct\n 31.4\n 24.9\n 26.4\n 26.3\n 29.6\n Plt\n 118\n 63\n 73\n 52\n Cr\n 2.5\n 2.4\n 2.1\n 1.4\n TCO2\n 27\n 27\n 28\n 30\n 31\n Glucose\n 103\n 108\n 108\n 100\n Other labs: PT / PTT / INR:18.5/50.8/1.7, CK / CKMB /\n Troponin-T:447/26/0.24, ALT / AST:79/200, Alk Phos / T Bili:105/2.9,\n Amylase / Lipase:93/30, Differential-Neuts:74.5 %, Lymph:14.1 %,\n Mono:8.1 %, Eos:2.9 %, Lactic Acid:1.8 mmol/L, LDH:418 IU/L, Ca++:8.7\n mg/dL, Mg++:2.8 mg/dL, PO4:2.3 mg/dL\n Assessment and Plan\n This is a 63 y/o M with Hepatitis C cirrhosis hepatorenal syndrome, s/p\n PEA arrest, body cooling and rewarming, concern for PNA covering with\n Vanc/Zosyn.\n .\n # s/p Shock/PEA Arrest: After PEA, was initially hemodynamically stable\n but has had episodes of hypotension non-responsive to IVF boluses,\n levofed started, currently off. Echo showed no evidence of cardiogenic\n shock. s/p cooling and rewarming.\n - continue goal MAP >65\n - stable now after off pressors\n .\n # Respiratory/Ventilation: Assist control. Low tidal volumes to avoid\n unneeded injury, with pH goal of above 7.25.\n - required increased FiO2 and PEEP overnight due to low oxygenation,\n will try to wean as tolerated\n - likely has early ARDS, based on P:F ratio, CXR; continue ARDS net\n protocol with low Vt and high PEEPs\n - seems to have improved, cont tx with abx\n - extubated yesterday\n .\n # Pneumonia\n on CXR has RLL infiltrate and bronch with thick yellow\n secretions, leukocytosis starting to resolve\n - on vanco/zosyn for HAP\n - follow up cultures\n .\n # Mental Status: With slowly resolving delerium prior to this event,\n and now with unclear hypoxic insult to brain. GCS of on admission\n to ICU. Considering head CT to evaluate for anoxic brain injury\n post-cooling. Neuro eval for possible seizure. EEG neg for seizure,\n severe encephalopathy likely in setting of sedation\n - off sedation, waking up, mouthing words\n - LP done earlier this admit that was negative gram stain/culture, no\n whites, negative HSV PCR.\n - would not cooperate with CT at this time, will hold off for now\n . .\n # Renal Failure: Unclear Etiology. Renal following given concern for\n HRS. given 2 days of albumin per hepatology recs.\n - likely in setting of hypoperfusion v. HRS, starting to improve,\n making good urine output\n - f/u renal rec's.\n - giving mitodrine and octreotide and albumin\n .\n # Metabolic Acidosis: s/p arrest to tissue hypoxia. Continue IVF's\n and trend lactate. Will need to increase minute ventilation for CO2.\n - resolved, likely in setting of post code hypoperfusion\n - lactates normalized\n .\n # Cardiac: Anticipate some elevation in CE's post-arrest, will trend.\n Echo hyperdynamic, no cardiogenic shock.\n - CK and Trop trending downward,\n .\n # Cirrhosis: Hep C Cirrhosis, with concern for HRS.\n - pre-code mental status likely related to encephalopathy v. delirium\n - will follow s/p extubation, continue lactulose, unclear etiology at\n this time\n .\n # Leukocytosis: Unclear etiology. Negative tap for SBP on .\n Urine growing E. Coli. Pan-culture.\n - likely from pneumonia\n .\n # Parotid mass. Incidental finding of L parotid mass on MRI, 1.6cm. --\n Will require OP ENT followup.\n .\n # Access: PIV, Central Line, d/c\ned art line today\n .\n # FEN: IVF, replete electrolytes, tube feeds resuming \n .\n # Prophylaxis: holding HSQ since elevated PTT, famotidine\n .\n # Code: full\n .\n # Communication: Wife is HCP\n .\n # Disposition: ICU for now.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 12:48 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Rehab Services", "chartdate": "2145-01-07 00:00:00.000", "description": "Deferred Evaluation", "row_id": 558018, "text": "TITLE: DEFERRED BEDSIDE SWALLOWING EVALUATION\n Plan was to attempt bedside swallow evaluation on this patient on \n 10 today. Before we arrived to the floor, pt had code blue, intubated,\n and was transferred to MICU. Given current intubation and\n inappropriate MS x1 week for PO trials (unable to maintain appropriate\n positioning for PO intake), we will sign off. Please reconsult when pt\n is extubated, stable, and MS is appropriate for PO evaluation.\n Whitmill, MS, CCC-SLP\n Pager #\n" }, { "category": "Nursing", "chartdate": "2145-01-09 00:00:00.000", "description": "Nursing Progress Note", "row_id": 558357, "text": "Cardiac arrest\n Assessment:\n HR in NSR 60-70.Warming completed at .Temp since then 36.5-37\n rectally.QTc 0.53.\n Action:\n Arctic sun d/ced at .Pads taken off.Temp taken orally and rectally.\n Response:\n Temp stable at 36.5 rectally overnight.Oral temp 97.5.BS stable.No\n seizure activity noticed.\n Plan:\n Monitor QTc,lytes and BS.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n No vent changes overnight.On AC 50%/550/18/12.Not overbreathing.LS\n rhonchorus/diminished.\n Action:\n Minimal secretion on suction.Cont on ABx for pna.\n Response:\n Sats 98-100.Afebrile.\n Plan:\n Monitor ABG, o2 sats. Wean vent as tolerated. Continue antibiotics.\n Suction as needed.\n Hypotension (not Shock)\n Assessment:\n ABP mean 65-80.On levophed gtt.CVP 8-14.U/O 40-100c/hr.\n Action:\n Titrated levophed for MAP >70.Had total of 1.5 lit FB overnight.\n Response:\n CVP upto 12 after FB. U/O improved after the FB.Levophed at 0.16 at the\n time of report.\n Plan:\n Titrate Levophed gtt for MAP >70. FB as needed.\n Altered mental status (not Delirium)\n Assessment:\n Pt is on fent/versed 25/2 for comfort with the tubes.Pt was not\n responding to any kind of stimulus, this am pt opening eyes to voice\n and localizing to pain.\n Action:\n Lactulose added for ?encephalopathy.Feed started.Minimal residual from\n NGT.\n Response:\n Needs cont assessment.\n Plan:\n Turn off sedation in the am to see if wakes up.?CT scan after if\n doesn\nt wake up.\n" }, { "category": "Nursing", "chartdate": "2145-01-09 00:00:00.000", "description": "Nursing Progress Note", "row_id": 558490, "text": "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 Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Physician ", "chartdate": "2145-01-10 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 558674, "text": "Chief Complaint:\n 24 Hour Events:\n Events:\n - weaned levophed\n - off sedation, responding to name\n Allergies:\n Demerol (Oral) (Meperidine Hcl)\n Confusion/Delir\n Last dose of Antibiotics:\n Ceftriaxone - 04:00 PM\n Vancomycin - 08:00 PM\n Piperacillin/Tazobactam (Zosyn) - 02:00 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:16 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.8\n Tcurrent: 36.6\nC (97.8\n HR: 73 (66 - 79) bpm\n BP: 142/57(74) {116/41(58) - 149/61(79)} mmHg\n RR: 15 (12 - 18) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n CVP: 14 (6 - 16)mmHg\n Total In:\n 3,236 mL\n 646 mL\n PO:\n TF:\n 576 mL\n 218 mL\n IVF:\n 2,170 mL\n 318 mL\n Blood products:\n 300 mL\n 110 mL\n Total out:\n 1,680 mL\n 720 mL\n Urine:\n 1,680 mL\n 720 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,556 mL\n -74 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 550 (550 - 550) mL\n RR (Set): 14\n RR (Spontaneous): 0\n PEEP: 8 cmH2O\n FiO2: 40%\n RSBI: 23\n PIP: 18 cmH2O\n Plateau: 16 cmH2O\n SpO2: 99%\n ABG: 7.47/40/121/28/5\n Ve: 8.1 L/min\n PaO2 / FiO2: 303\n Physical Examination\n Eyes / Conjunctiva: PERRL, opens eyes, makes eye contact\n , Ears, Nose, Throat: , Poor dentition, Endotracheal\n tube, NG tube\n Cardiovascular: (S1: Normal), (S2: Normal), No(t) S3, No(t) S4, No(t)\n Rub\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : ,\n Rhonchorous: )\n Abdominal: Soft, Bowel sounds present, Distended, palpable fluid wave\n Neurologic: arousable to voice, opens eyes no purposeful movements,\n withdraws to pain, non-verbal\n Labs / Radiology\n 73 K/uL\n 8.9 g/dL\n 108 mg/dL\n 2.1 mg/dL\n 28 mEq/L\n 3.3 mEq/L\n 92 mg/dL\n 106 mEq/L\n 140 mEq/L\n 26.4 %\n 6.1 K/uL\n [image002.jpg]\n 03:38 AM\n 04:01 AM\n 05:46 PM\n 03:23 AM\n 03:38 AM\n 10:22 AM\n 01:38 PM\n 02:25 AM\n 03:39 AM\n 04:55 AM\n WBC\n 26.5\n 16.3\n 6.1\n 6.1\n Hct\n 38.5\n 31.4\n 24.9\n 26.4\n Plt\n 134\n 118\n 63\n 73\n Cr\n 2.2\n 2.5\n 2.4\n 2.1\n TropT\n 0.24\n TCO2\n 25\n 27\n 27\n 28\n 30\n Glucose\n 114\n 103\n 108\n 108\n Other labs: PT / PTT / INR:18.5/67.4/1.7, CK / CKMB /\n Troponin-T:447/26/0.24, ALT / AST:76/202, Alk Phos / T Bili:134/1.5,\n Amylase / Lipase:93/30, Differential-Neuts:74.5 %, Lymph:14.1 %,\n Mono:8.1 %, Eos:2.9 %, Lactic Acid:1.0 mmol/L, LDH:635 IU/L, Ca++:8.1\n mg/dL, Mg++:3.3 mg/dL, PO4:3.1 mg/dL\n Assessment and Plan\n This is a 63 y/o M with Hepatitis C cirrhosis hepatorenal syndrome, s/p\n PEA arrest, body cooling and rewarming, concern for PNA covering with\n Vanc/Zosyn.\n .\n # s/p Shock/PEA Arrest: After PEA, was initially hemodynamically stable\n but overnight had hypotension non-responsive to IVF boluses, levofed\n started, currently off. Echo showed no evidence of cardiogenic shock.\n s/p cooling and rewarming.\n - continue goal MAP >65\n - stable now after off pressors yesterday\n .\n # Respiratory/Ventilation: Assist control. Low tidal volumes to avoid\n unneeded injury, with pH goal of above 7.25.\n - required increased FiO2 and PEEP overnight due to low oxygenation,\n will try to wean as tolerated\n - likely has early ARDS, based on P:F ratio, CXR; continue ARDS net\n protocol with low Vt and high PEEPs\n - seems to have improved, cont tx with abx\n - extubate today\n .\n # Pneumonia\n on CXR has RLL infiltrate and bronch with thick yellow\n secretions, leukocytosis starting to resolve\n - on vanco/zosyn for HAP\n - follow up cultures\n .\n # Mental Status: With slowly resolving delerium prior to this event,\n and now with unclear hypoxic insult to brain. GCS of on admission\n to ICU. Considering head CT to evaluate for anoxic brain injury\n post-cooling. Neuro eval for possible seizure. EEG neg for seizure,\n severe encephalopathy likely in setting of sedation\n - off sedation, waking up, mouthing words\n - LP done earlier this admit that was negative gram stain/culture, no\n whites, negative HSV PCR.\n - would not cooperate with CT at this time, will hold off for now\n . .\n # Renal Failure: Unclear Etiology. Renal following given concern for\n HRS. given 2 days of albumin per hepatology recs.\n - likely in setting of hypoperfusion v. HRS, starting to improve,\n making good urine output\n - f/u renal rec's.\n - giving mitodrine and octreotide and albumin today\n .\n # Metabolic Acidosis: s/p arrest to tissue hypoxia. Continue IVF's\n and trend lactate. Will need to increase minute ventilation for CO2.\n - resolved, likely in setting of post code hypoperfusion\n - lactates normalized\n .\n # Cardiac: Anticipate some elevation in CE's post-arrest, will trend.\n Echo hyperdynamic, no cardiogenic shock.\n - CK and Trop trending downward,\n .\n # Cirrhosis: Hep C Cirrhosis, with concern for HRS.\n - pre-code mental status likely related to encephalopathy v. delirium\n - will follow s/p extubation, continue lactulose, unclear etiology at\n this time\n .\n # Leukocytosis: Unclear etiology. Negative tap for SBP on .\n Urine growing E. Coli. Pan-culture.\n - likely from pneumonia\n .\n # Parotid mass. Incidental finding of L parotid mass on MRI, 1.6cm. --\n Will require OP ENT followup.\n .\n # Access: PIV, Central Line, d/c\ned art line today\n .\n # FEN: IVF, replete electrolytes, tube feeds resuming \n .\n # Prophylaxis: holding HSQ since elevated PTT, famotidine\n .\n # Code: full\n .\n # Communication: Wife is HCP\n .\n # Disposition: ICU for now.\n ICU Care\n Nutrition:\n Nutren Renal (Full) - 12:26 AM 30 mL/hour\n Glycemic Control:\n Lines:\n 20 Gauge - 11:45 AM\n Multi Lumen - 12:48 PM\n Arterial Line - 05:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "General", "chartdate": "2145-01-11 00:00:00.000", "description": "Generic Note", "row_id": 558850, "text": "TITLE: Critical Care Note\n Present for key portions of the resident\ns history and exam. Agree\n substantially with assessment and plan Agitated, desaturating\n overnight. MS remains poor, intermittently agitated, confused. C/o\n thirst. Spontaneous diuresis over day yesterday\n resolving ATN.\n MS remains problem. weak. Not clear if this is primarily\n hepatic encephalopathy, hypernatremia, or post arrest. Not stable\n enough for CT without intubation. Will correct free water, continue\n lactulose, review with Neuro.\n Will discuss long term prognosis with Hepatology\n Time spent 40 min\n Critically Ill\n" }, { "category": "Physician ", "chartdate": "2145-01-10 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 558661, "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 24 Hour Events:\n more awake this morning\n changed to PSV\n pressors weaned\n Patient unable to provide history: intubated\n Allergies:\n Demerol (Oral) (Meperidine Hcl)\n Confusion/Delir\n Last dose of Antibiotics:\n Ceftriaxone - 04:00 PM\n Vancomycin - 08:00 PM\n Piperacillin/Tazobactam (Zosyn) - 09:20 AM\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 08:01 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 10:39 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.8\n Tcurrent: 36.6\nC (97.8\n HR: 79 (67 - 81) bpm\n BP: 158/60(79) {116/41(58) - 158/61(82)} mmHg\n RR: 14 (12 - 18) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n CVP: 14 (6 - 19)mmHg\n Total In:\n 3,236 mL\n 1,207 mL\n PO:\n TF:\n 576 mL\n 335 mL\n IVF:\n 2,170 mL\n 488 mL\n Blood products:\n 300 mL\n 200 mL\n Total out:\n 1,680 mL\n 1,185 mL\n Urine:\n 1,680 mL\n 1,185 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,556 mL\n 22 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): 665 (665 - 665) mL\n PS : 5 cmH2O\n RR (Set): 14\n RR (Spontaneous): 16\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 23\n PIP: 14 cmH2O\n Plateau: 16 cmH2O\n SpO2: 95%\n ABG: 7.47/40/121/28/5\n Ve: 12 L/min\n PaO2 / FiO2: 303\n Physical Examination\n General Appearance: No(t) Thin\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Respiratory / Chest: (Breath Sounds: Clear : )\n Abdominal: Distended\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 8.9 g/dL\n 73 K/uL\n 108 mg/dL\n 2.1 mg/dL\n 28 mEq/L\n 3.3 mEq/L\n 92 mg/dL\n 106 mEq/L\n 140 mEq/L\n 26.4 %\n 6.1 K/uL\n [image002.jpg]\n 03:38 AM\n 04:01 AM\n 05:46 PM\n 03:23 AM\n 03:38 AM\n 10:22 AM\n 01:38 PM\n 02:25 AM\n 03:39 AM\n 04:55 AM\n WBC\n 26.5\n 16.3\n 6.1\n 6.1\n Hct\n 38.5\n 31.4\n 24.9\n 26.4\n Plt\n 134\n 118\n 63\n 73\n Cr\n 2.2\n 2.5\n 2.4\n 2.1\n TropT\n 0.24\n TCO2\n 25\n 27\n 27\n 28\n 30\n Glucose\n 114\n 103\n 108\n 108\n Other labs: PT / PTT / INR:18.5/67.4/1.7, CK / CKMB /\n Troponin-T:447/26/0.24, ALT / AST:76/202, Alk Phos / T Bili:134/1.5,\n Amylase / Lipase:93/30, Differential-Neuts:74.5 %, Lymph:14.1 %,\n Mono:8.1 %, Eos:2.9 %, Lactic Acid:1.0 mmol/L, LDH:635 IU/L, Ca++:8.1\n mg/dL, Mg++:3.3 mg/dL, PO4:3.1 mg/dL\n Imaging: CXR stable bilateral infiltrates\n Assessment and Plan\n ALTERED MENTAL STATUS (NOT DELIRIUM) - now following commands,\n continue lactulose,? anoxic brain injury\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF) - creatinine\n improving, receiving albuimin and IVF prn, renal requesting midodrine\n and octreotide - will start\n HYPOTENSION, SHOCK - received fluid, levophed off, follow BP\n CARDIAC ARREST - thought to be due to mucus plug/resp arrest, follow\n rhythm\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/) - RSBI 24 on PSV 5/5, will\n work towards extubation\n hospital acquired pneumonia - CXR stable, complete 10 days of abx\n cirrhosis - continue lactulose, receiving albumin\n anemia - has fallen over past few days though now stable, follow,\n guaiac\n thrombocytopenia - also stable\n ICU Care\n Nutrition:\n Nutren Renal (Full) - 12:26 AM 40 mL/hour\n Glycemic Control:\n Lines:\n Multi Lumen - 12:48 PM\n Arterial Line - 05:00 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: 39 minutes\n Patient is critically ill\n" }, { "category": "Physician ", "chartdate": "2145-01-10 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 558671, "text": "Chief Complaint:\n 24 Hour Events:\n Events:\n - weaned levophed\n - off sedation, responding to name\n Allergies:\n Demerol (Oral) (Meperidine Hcl)\n Confusion/Delir\n Last dose of Antibiotics:\n Ceftriaxone - 04:00 PM\n Vancomycin - 08:00 PM\n Piperacillin/Tazobactam (Zosyn) - 02:00 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:16 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.8\n Tcurrent: 36.6\nC (97.8\n HR: 73 (66 - 79) bpm\n BP: 142/57(74) {116/41(58) - 149/61(79)} mmHg\n RR: 15 (12 - 18) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n CVP: 14 (6 - 16)mmHg\n Total In:\n 3,236 mL\n 646 mL\n PO:\n TF:\n 576 mL\n 218 mL\n IVF:\n 2,170 mL\n 318 mL\n Blood products:\n 300 mL\n 110 mL\n Total out:\n 1,680 mL\n 720 mL\n Urine:\n 1,680 mL\n 720 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,556 mL\n -74 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 550 (550 - 550) mL\n RR (Set): 14\n RR (Spontaneous): 0\n PEEP: 8 cmH2O\n FiO2: 40%\n RSBI: 23\n PIP: 18 cmH2O\n Plateau: 16 cmH2O\n SpO2: 99%\n ABG: 7.47/40/121/28/5\n Ve: 8.1 L/min\n PaO2 / FiO2: 303\n Physical Examination\n Eyes / Conjunctiva: PERRL, dysconjugate gaze\n Head, Ears, Nose, Throat: Normocephalic, Poor dentition, Endotracheal\n tube, NG tube\n Cardiovascular: (S1: Normal), (S2: Normal), No(t) S3, No(t) S4, No(t)\n Rub\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : ,\n Rhonchorous: )\n Abdominal: Soft, Bowel sounds present, Distended, palpable fluid wave\n Neurologic: arousable to voice, opens eyes no purposeful movements,\n withdraws to pain, non-verbal\n Labs / Radiology\n 73 K/uL\n 8.9 g/dL\n 108 mg/dL\n 2.1 mg/dL\n 28 mEq/L\n 3.3 mEq/L\n 92 mg/dL\n 106 mEq/L\n 140 mEq/L\n 26.4 %\n 6.1 K/uL\n [image002.jpg]\n 03:38 AM\n 04:01 AM\n 05:46 PM\n 03:23 AM\n 03:38 AM\n 10:22 AM\n 01:38 PM\n 02:25 AM\n 03:39 AM\n 04:55 AM\n WBC\n 26.5\n 16.3\n 6.1\n 6.1\n Hct\n 38.5\n 31.4\n 24.9\n 26.4\n Plt\n 134\n 118\n 63\n 73\n Cr\n 2.2\n 2.5\n 2.4\n 2.1\n TropT\n 0.24\n TCO2\n 25\n 27\n 27\n 28\n 30\n Glucose\n 114\n 103\n 108\n 108\n Other labs: PT / PTT / INR:18.5/67.4/1.7, CK / CKMB /\n Troponin-T:447/26/0.24, ALT / AST:76/202, Alk Phos / T Bili:134/1.5,\n Amylase / Lipase:93/30, Differential-Neuts:74.5 %, Lymph:14.1 %,\n Mono:8.1 %, Eos:2.9 %, Lactic Acid:1.0 mmol/L, LDH:635 IU/L, Ca++:8.1\n mg/dL, Mg++:3.3 mg/dL, PO4:3.1 mg/dL\n Assessment and Plan\n This is a 63 y/o M with Hepatitis C cirrhosis hepatorenal syndrome, s/p\n PEA arrest, body cooling and rewarming, concern for PNA covering with\n Vanc/Zosyn.\n .\n # s/p Shock/PEA Arrest: After PEA, was initially hemodynamically stable\n but overnight had hypotension non-responsive to IVF boluses, levofed\n started, currently off. Echo showed no evidence of cardiogenic shock.\n s/p cooling and rewarming.\n - continue goal MAP >65\n .\n # Respiratory/Ventilation: Assist control. Low tidal volumes to avoid\n unneeded injury, with pH goal of above 7.25.\n - required increased FiO2 and PEEP overnight due to low oxygenation\n - likely has early ARDS, based on P:F ratio, CXR; continue ARDS net\n protocol with low Vt and high PEEPs\n .\n # Pneumonia\n on CXR has RLL infiltrate and bronch with thick yellow\n secretions, increasing leukocytosis today\n - on vanco/zosyn for HAP\n - follow up cultures\n .\n # Mental Status: With slowly resolving delerium prior to this event,\n and now with unclear hypoxic insult to brain. GCS of on admission\n to ICU. Consider cooling protocol. Head CT to evaluate for anoxic\n brain injury post-cooling. Neuro eval for possible seizure. EEG neg\n for seizure\n - off sedation\n - LP done earlier this admit that was negative gram stain/culture, no\n whites, negative HSV PCR.\n - will need head CT\n . .\n # Renal Failure: Unclear Etiology. Renal following given concern for\n HRS. given 2 days of albumin per hepatology recs.\n - likely in setting of hypoperfusion, still has some urine output. Will\n consider mitodrine and octreotride.\n - f/u renal rec's.\n .\n # Metabolic Acidosis: s/p arrest to tissue hypoxia. Continue IVF's\n and trend lactate. Will need to increase minute ventilation for CO2.\n - resolved, likely in setting of post code hypoperfusion\n - continue to trend lactate, are normalizing\n .\n # Cardiac: Anticipate some elevation in CE's post-arrest, will trend.\n Echo hyperdynamic, no cardiogenic shock.\n - CK and Trop trending downward,\n .\n # Cirrhosis: Hep C Cirrhosis, with concern for HRS.\n - pre-code mental status likely related to encephalopathy v. delerium\n .\n # Leukocytosis: Unclear etiology. Negative tap for SBP on .\n Urine growing E. Coli. Pan-culture.\n - likely from pneumonia\n .\n # Parotid mass. Incidental finding of L parotid mass on MRI, 1.6cm. --\n Will require OP ENT followup.\n .\n # Access: PIV, Central Line, arterial line.\n .\n # FEN: IVF, replete electrolytes, tube feeds resuming \n .\n # Prophylaxis: holding HSQ since elevated PTT, famotidine\n .\n # Code: full\n .\n # Communication: Wife is HCP\n .\n # Disposition: ICU for now.\n ICU Care\n Nutrition:\n Nutren Renal (Full) - 12:26 AM 30 mL/hour\n Glycemic Control:\n Lines:\n 20 Gauge - 11:45 AM\n Multi Lumen - 12:48 PM\n Arterial Line - 05:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Respiratory ", "chartdate": "2145-01-09 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 558532, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 3\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Unknown\n Procedure location: Floor\n Reason:\n Tube Type\n ETT:\n Position: 25 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Tan / Thick\n Sputum source/amount: Suctioned / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n 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: Hemodynimic\n instability\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n Improving abgs, able to wean Ve and peep.\n" }, { "category": "Nursing", "chartdate": "2145-01-10 00:00:00.000", "description": "Nursing Progress Note", "row_id": 558595, "text": "Pt admitted to on s/p fall for back spinal fusion.\n According to pt's wife, who is health care proxy, pt has been confused\n since coming out of anesthesia and later developed a UTI. According to\n floor RN, pt has had MS changes over the past few weeks where he has\n been agitated and unresponsive. Neuro and psych have consulted.\n Unknown cause of MS changes. ? encephalopathy vs. infection. pt\n had resp distress, became unresponsive and went into PEA arrest. Large\n plug suctioned from pt. Chest compressions done, 1mg Atropine given\n along with Epi. Pulse returned and pt transferred to MICU for further\n management.\n Events: pt more awake restless\n Hct 24.9 down from 31.4, repeat 26.4\n K+ 3.3 repleted w/ 60 meq KCL Via NGT\n TF @ 40cc/hr (goal). Minimal residuals. Bag on abd @ site of old tap\n for oozing.\n Altered mental status (not Delirium)\n Assessment:\n Eyes open to verbal stimuli. Localizing to pain. MAE, restless.\n Eyes-PERRLA, brisk 3mm. Not following commands.\n Action:\n . Soft wrist restraints in place. Lactulose administered x2 for\n encephalopathy. Neuro assessed frequently. Reoriented frequently.\n Neuro following. Psych following. Q 2hr turns.\n Response:\n More responsive to stimuli throughout shift. Tracking, increasing\n restlessness.\n Plan:\n Monitor neuro assessment. Assess/treat pain. Continue Lactulose.\n Hypotension (not Shock)\n Assessment:\n Rec\nd pt off prressors w/ sbp 110\ns and MAP 58-62\n Action:\n Remains off pressors, albumin given a/o.\n Response:\n b/p improving as pt becomes more awake/ restless, SBP now 130-140\n w/ MAP >70\n Plan:\n Monitor ABP, goal MAP >60. Monitor UOP/CVP. Continue to monitor QT.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Tmax 98.6 rectal. Vent AC 550x14 40% /PEEP 8. ABG this am\n 7.47/40/121. O2 sats 99-100%. LS clear/dim bilat.\n Action:\n Suctioned for sm to mod amt thick tan secretions\n Response:\n O2 sats remained 99-100%. RSBI 23 this am. Overbreathing the vent as pt\n becomes more awake/\n Plan:\n Wean vent as tolerated. Suction as needed. ? extubation\n" }, { "category": "Nursing", "chartdate": "2145-01-09 00:00:00.000", "description": "Nursing Progress Note", "row_id": 558528, "text": "Synopsis per prior nursing note:\n Pt admitted to on s/p fall for back spinal fusion.\n According to pt's wife, who is health care proxy, pt has been confused\n since coming out of anesthesia and later developed a UTI. According to\n floor RN, pt has had MS changes over the past few weeks where he has\n been agitated and unresponsive. Neuro and psych have consulted.\n Unknown cause of MS changes. ? encephalopathy vs. infection. Today pt\n had resp distress, became unresponsive and went into PEA arrest. Large\n plug suctioned from pt. Chest compressions done, 1mg Atropine given\n along with Epi. Pulse returned and pt transferred to MICU for further\n management.\n Events: Fentanyl and Versed off. Levophed off. Responding to\n stimuli. SBP decreased to 80\ns w/ turns.\n TF @ 40cc/hr (goal). Minimal residuals. Bag placed on abd @ site of old\n tap for oozing. ICa 1.01, given 2gm calcium gluconate.\n Altered mental status (not Delirium)\n Assessment:\n Eyes open to sternal stimuli. Localizing to pain. Non purposeful\n movement of all extremities, although appears to reach for ET tube when\n suctioned/turned. Eyes-PERRLA, brisk 2mm. Not following commands.\n Action:\n Fentanyl and versed stopped. Soft wrist restraints in place. Lactulose\n administered for encephalopathy. Neuro assessed frequently. Reoriented\n frequently. Neuro following. Psych following.\n Response:\n More responsive to stimuli throughout shift. Originally absent gag and\n cough but now has weak cough w/ no gag.\n Plan:\n Monitor neuro assessment. Assess/treat pain. Continue Lactulose. ?CT if\n neuro status does not improve.\n Hypotension (not Shock)\n Assessment:\n ABP 116-149/45-59. MAPs>70. UOP 45-110, clear yellow. CVP 14-16.\n Action:\n Levophed weaned off, EKG done, QT 0.46 (0.53). UOP monitored.\n Response:\n MAPs >60. SBP decreased to 80\ns when turned. UOP ~40cc/hr.\n Plan:\n Monitor ABP, goal MAP >60. Monitor UOP/CVP. Continue to monitor QT.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Tmax 98.6 rectal. Vent CMV 18/550/40%/PEEP 12. ABG pH 7.49/ pC02 35/\n P02 144/ TC02 27. O2 sats 99-100%. LS clear/dim bilat. No secretions\n when suctioning. Rarely breathing over vent.\n Action:\n PEEP decreased to 8 and rate decreased to 14. Chest PT done.\n Suctioned as needed. ABG followed. Frequent position changes.\n Response:\n O2 sats remained 99-100%. Repeat ABG pH 7.47/ pC02 38/ P02 106/TC02 28.\n Suctioned small amt of thick, tan secretions.\n Plan:\n Wean vent as tolerated. Suction as needed.\n" }, { "category": "Respiratory ", "chartdate": "2145-01-10 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 558598, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 4\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 Tube Type\n ETT:\n Position: 24 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Cuff volume: mL /\n Lung sounds\n RLL Lung Sounds: 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 Visual assessment of breathing pattern: Normal quiet breathing\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Underlying illness\n not resolved\n Respiratory Care Shift Procedures\n Bedside Procedures: Latest abg results determined a mild metabolic\n alkalemia with very good oxygenation on the current settings.\n RSBI = 23 on 0-PEEP and 5 cm PSV.\n" }, { "category": "Nursing", "chartdate": "2145-01-08 00:00:00.000", "description": "Nursing Progress Note", "row_id": 558145, "text": "Pt admitted to on s/p fall for back spinal fusion.\n According to pt's wife, who is health care proxy, pt has been confused\n since coming out of anesthesia and later developed a UTI. According to\n floor RN, pt has had MS changes over the past few weeks where he has\n been agitated and unresponsive. Neuro and psych have consulted.\n Unknown cause of MS changes. ? encephalopathy vs. infection. Today pt\n had resp distress, became unresponsive and went into PEA arrest. Large\n plug suctioned from pt. Chest compressions done, 1mg Atropine given\n along with Epi. Pulse returned and pt transferred to MICU for further\n management.\n Cardiac arrest\n Assessment:\n HR 60\ns SR. Artic sun maintaining pt. in range of goal temp of 34.0 C,\n continuous monitoring with rectal and bladder probes. Goal temp\n reached at 18:20 . Cool to the touch, adequate peripheral\n perfusion, skin not compromised. Abd. soft and distended, hypoactive\n BS. Withdrawing to oral care, brief eye opening on turns.\n Action:\n TOF at 50 MA on L ulnar site. Bladder pressure 9 mm Hg, site\n marked on R groin for repeat measurements. QTc 400 milliseconds. No\n Nimbex required.\n Response:\n Monitoring of ECG for changes, AM labs: K (4.1), glucose levels WNL.\n Plan:\n Close monitoring of QTc as hypothermia may mask hypo/hyperkalemic\n changes on the ECG.Monitor lytes closely. Administer nimbex for\n shivering or excessive drops in Artic Sun water temperature. Begin\n re-warming at 12:20 at 0.5C/hr per protocol - monitor for\n hyperglycemia, hyperkalemia, and seizure activity. Monitor pan cultures\n pending.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Assumed care AC 18/50% x 550/5, pH 7.50, pO2 54. Lung sounds\n diminished in the lower fields and rhonchorous in the upper\n bilaterally. Suctioning scant amounts of tan tenacious secretions.\n Brief periods of desaturation to 90% relieved by increasing FiO2 to\n 100%.\n Action:\n Repeat pH 7.49, pO2 53, RT lavaged ETT with little to no increase in\n secretions, vent changes to 18/70% x 550/12. Lung sounds diminished in\n all fields. CXR showing probable PNA. HOB 30 degrees.\n Response:\n ABG = 7.44, pO2 77, FiO2 60%, breathing approx. 10 L/min. Zosyn and\n Vanco per . WBC (13.4).\n Plan:\n Monitor ABG, ween FiO2 and PEEP as appropriate. ABX, T&R and CPT as\n tolerated. Monitor for signs of distress.\n Hypotension (not Shock)\n Assessment:\n Normotensive at commencement of shift, MAP high 60\ns, CVP 9.\n Fentanyl/Versed at 50mcg/2mg. Urine output approx. 20cc/hr.\n Action:\n 500 cc bolus fluid challenge given. Fentanyl/Versed d/c\nd and Propofol\n started at 25 mcg/kg/min, with immediate hypotensive effect, decreased\n to 10 mcg/kg/min, MAP of high 40\ns. 500 cc bolus given and Propofol\n d/c\nd, Fentanyl/Versed restarted at 50mcg/2mg.\n Response:\n BP returned to MAP of 60. Hypotensive episode with T&R, 500 cc bolus\n given with poor effect on BP and urine output, Levophed started,\n increased in increments to 0.09 mcg/kg/min with MAP goal >70 for brain\n perfusion.\n Plan:\n Titrate Levophed for MAP >70. Monitor fluid balance, LOS about +3000\n mL. Assess for BP lability during rewarming r/t vasodilation.\n" }, { "category": "Nursing", "chartdate": "2145-01-09 00:00:00.000", "description": "Nursing Progress Note", "row_id": 558346, "text": "Cardiac arrest\n Assessment:\n HR in NSR 60-70.Warming completed at .Temp since then 36.5-37\n rectally.QTc 0.53.\n Action:\n Arctic sun d/ced at .Pads taken off.Temp taken orally and rectally.\n Response:\n Temp stable at 36.5 rectally overnight.Oral temp 97.5.BS stable.No\n seizure activity noticed.\n Plan:\n Monitor QTc,lytes and BS.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n No vent changes overnight.On AC 50%/550/18/12.Not overbreathing.LS\n rhonchorus/diminished.\n Action:\n Minimal secretion on suction.Cont on ABx for pna.\n Response:\n Sats 98-100.Afebrile.\n Plan:\n Monitor ABG, o2 sats. Wean vent as tolerated. Continue antibiotics.\n Suction as needed.\n Hypotension (not Shock)\n Assessment:\n ABP mean 65-80.On levophed gtt.CVP 8-14.U/O 40-100c/hr.\n Action:\n Titrated levophed for MAP >70.Had total of 1.5 lit FB overnight.\n Response:\n CVP upto 12 after FB. U/O improved after the FB.Levophed at 0.16 at the\n time of report.\n Plan:\n Titrate Levophed gtt for MAP >70. FB as needed.\n Altered mental status (not Delirium)\n Assessment:\n Pt is fent/versed 25/2 for comfort with the tubes.Pt not responding to\n any kind of stimulus.\n Action:\n Lactulose added for ?encephalopathy.Feed started.Minimal residual from\n NGT.\n Response:\n Remains same.Needs cont assessment.\n Plan:\n Turn off sedation in the am to see if wakes up.?CT scan after if\n doesn\nt wake up.\n" }, { "category": "Nursing", "chartdate": "2145-01-09 00:00:00.000", "description": "Nursing Progress Note", "row_id": 558520, "text": "Synopsis per prior nursing note:\n Pt admitted to on s/p fall for back spinal fusion.\n According to pt's wife, who is health care proxy, pt has been confused\n since coming out of anesthesia and later developed a UTI. According to\n floor RN, pt has had MS changes over the past few weeks where he has\n been agitated and unresponsive. Neuro and psych have consulted.\n Unknown cause of MS changes. ? encephalopathy vs. infection. Today pt\n had resp distress, became unresponsive and went into PEA arrest. Large\n plug suctioned from pt. Chest compressions done, 1mg Atropine given\n along with Epi. Pulse returned and pt transferred to MICU for further\n management.\n Events: Fentanyl and Versed off. Levophed off. Responding to\n stimuli. SBP decreased to 80\ns w/ turns.\n TF @ 40cc/hr (goal). Minimal residuals. Bag placed on abd @ site of old\n tap for oozing. ICa 1.01, given 2gm calcium gluconate.\n Altered mental status (not Delirium)\n Assessment:\n Eyes open to sternal stimuli. Localizing to pain. Non purposeful\n movement of all extremities, although appears to reach for ET tube when\n suctioned/turned. Eyes-PERRLA, brisk 2mm. Not following commands.\n Action:\n Fentanyl and versed stopped. Soft wrist restraints in place. Lactulose\n administered for encephalopathy. Neuro assessed frequently. Reoriented\n frequently. Neuro following. Psych following.\n Response:\n More responsive to stimuli throughout shift. Originally absent gag and\n cough but now has weak cough w/ no gag.\n Plan:\n Monitor neuro assessment. Assess/treat pain. Continue Lactulose. ?CT if\n neuro status does not improve.\n Hypotension (not Shock)\n Assessment:\n ABP 116-149/45-59. MAPs>70. UOP 45-110, clear yellow. CVP 14-16.\n Action:\n Levophed weaned off, EKG done, QT 0.46 (0.53). UOP monitored.\n Response:\n MAPs >60. SBP decreased to 80\ns when turned. UOP ~40cc/hr.\n Plan:\n Monitor ABP, goal MAP >60. Monitor UOP/CVP. Continue to monitor QT.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Tmax 98.6 rectal. Vent CMV 18/550/40%/PEEP 12. ABG pH 7.49/ pC02 35/\n P02 144/ TC02 27. O2 sats 99-100%. LS clear/dim bilat. No secretions\n when suctioning. Rarely breathing over vent.\n Action:\n PEEP decreased to 8 and rate decreased to 14. Chest PT done.\n Suctioned as needed. ABG followed. Frequent position changes.\n Response:\n O2 sats remained 99-100%. Repeat ABG pH 7.47/ pC02 38/ P02 106/TC02 28.\n Suctioned small amt of thick, tan secretions.\n Plan:\n Wean vent as tolerated. Suction as needed.\n" }, { "category": "Nursing", "chartdate": "2145-01-11 00:00:00.000", "description": "Nursing Progress Note", "row_id": 558770, "text": "Pt admitted to on s/p fall for back spinal fusion.\n According to pt's wife, who is health care proxy, pt has been confused\n since coming out of anesthesia and later developed a UTI. According to\n floor RN, pt has had MS changes over the past few weeks where he has\n been agitated and unresponsive. Neuro and psych have consulted.\n Unknown cause of MS changes. ? encephalopathy vs. infection. pt\n had resp distress, became unresponsive and went into PEA arrest. Large\n plug suctioned from pt. Chest compressions done, 1mg Atropine given\n along with Epi. Pulse returned and pt transferred to MICU for further\n management.\n Significant Events: pt desatted to the mid 80%\ns, RR 28-36 bpm LS\n wheezes bilat, increased restlessness, HR 80\ns b/p consistent w/\n baseline. given albuterol, atrovent nebs, NT suctioned for mod amt\n thick bloody sputum, Fi02 increased to 100% face tent, and medicated\n w/ ativan 0.5mg w/ good effect. Pt now w/ RR 14, 02 sat 100% ABG\n following episode 7.38/51/108\n Altered mental status (not Delirium)\n Assessment:\n Pt cont to be restless/agitated; opening eyes to verb stimuli; PERRLA;\n following commands inconsistently. Pt receiving Lactulose, Flexiseal\n in place draining loose brown stool, guiac neg.\n Action:\n Soft restraints in place for pt safety; Lactulose administered this\n shift for presumed encephalopathy; pt reoriented frequently. Ativan\n 0.5mg q4hr for agitation. Pt restless, disloged flexiseal, replaced and\n flushed to keep patent\n Response:\n More responsive to stimuli throughout shift; pt remained\n restless/agitated until after receiving 3^rd dose of ativan after above\n episode. Pt now calm/ sleeping w/ HR 70\ns RR 14-16, 02 sat 100%,\n flexiseal remains intact and draining loose brown stool.\n Plan:\n Monitor neuro assessment. Assess/treat pain. Continue Lactulose.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received pt on 70% face tent , LS rhochi bilat w/ dim bases, 02 sat\n 96-100% RR 16-20 even with periods of restlessness. Cough weak\n congested and non productive., 4am desatted to the mid 80%\ns, RR 28-36\n bpm LS wheezes bilat, increased restlessness, HR 80\ns b/p consistent w/\n baseline.\n Action:\n NT suctioned for mod amt thick bloody secretions. PRN nebs ordered\n given following above episode of resp[ distress. Fi02 increased to 100%\n face tent, and medicated w/ ativan 0.5mg\n Response:\n Pt now w/ RR 14, 02 sat 100% ABG following episode 7.38/51/108 lactate\n 1.8 LS remain coarse bilat,\n Plan:\n Monitor resp status closely; oral/NT sxn prn; encourage C&DB. Neb tx\n prn\n" }, { "category": "Respiratory ", "chartdate": "2145-01-09 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 558391, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 3\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Unknown\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: 24 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Cuff volume: mL /\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Diminished\n Ventilation Assessment\n Plan\n Next 24-48 hours:\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Bedside Procedures: Latest abg results reveal a respiratory alkalemia\n with very good oxygenation. No RSBI measured due to the allotment of\n time. No RSBI measured due to the level of peep.\n" }, { "category": "Respiratory ", "chartdate": "2145-01-07 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 558064, "text": "Demographics\n Day of intubation: \n Day of mechanical ventilation: 1\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location: Floor\n Reason: Emergent (1st time)\n Tube Type\n ETT:\n Position: 25 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Lung sounds\n RLL Lung Sounds: 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 / Copious\n Comments: via bedside bronchoscopy\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Gasping efforts; Comments: pt\n remains on A/C ventilation w/ \"gasping\" like inspiratory efforts.\n Assessment of breathing comfort: No response (sleeping / sedated)\n Comments: occasionally triggers\n Plan\n Next 24-48 hours: maintain support\n Reason for continuing current ventilatory support: Cannot protect\n airway\n Respiratory Care Shift Procedures\n Bedside Procedures:\n Bronchoscopy (1600)\n Comments: moderate thick tan secretions - sample sent to lab of R and L\n lung.\n" }, { "category": "Physician ", "chartdate": "2145-01-08 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 558228, "text": "Chief Complaint:\n 24 Hour Events:\n Events:\n - bronch showing thick, yellow secretions concerning for infection,\n started vanco and zosyn for HAP\n - cooling protocol initiated, plan for rewarming around noon tomorrow\n - renal team following, sent urine lytes and UA; pt remaining basically\n anuric overnight\n - CVPs in 8-10s, likely fluid down; to test kidneys, gave 500 cc fluid\n challenge. UO improved slightly from about 20 cc/hr up to 80 cc/hr for\n short time\n - Around 2 am, after repositioning patients SBP dropped to 70s, came up\n to 80s with fluids but needed to start levophed; titrated up to 0.07\n and then stable overnight\n INVASIVE VENTILATION - START 10:55 AM\n MULTI LUMEN - START 12:48 PM\n BRONCHOSCOPY - At 04:23 PM\n ARTERIAL LINE - START 05:00 PM\n Allergies:\n Demerol (Oral) (Meperidine Hcl)\n Confusion/Delir\n Last dose of Antibiotics:\n Ceftriaxone - 04:00 PM\n Vancomycin - 08:00 PM\n Piperacillin/Tazobactam (Zosyn) - 01:57 AM\n Infusions:\n Fentanyl - 50 mcg/hour\n Midazolam (Versed) - 2 mg/hour\n Norepinephrine - 0.05 mcg/Kg/min\n Other ICU medications:\n Midazolam (Versed) - 11:30 AM\n Fentanyl - 11:30 AM\n Heparin Sodium (Prophylaxis) - 10:02 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:38 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 3.1\nC (37.5\n Tcurrent: 3.1\nC (37.5\n HR: 60 (59 - 156) bpm\n BP: 114/68(82) {85/51(62) - 114/77(82)} mmHg\n RR: 19 (17 - 27) insp/min\n SpO2: 97%\n CVP: 15 (7 - 18)mmHg\n Bladder pressure: 9 (9 - 9) mmHg\n Total In:\n 2,497 mL\n 855 mL\n PO:\n TF:\n IVF:\n 2,497 mL\n 855 mL\n Blood products:\n Total out:\n 410 mL\n 154 mL\n Urine:\n 410 mL\n 154 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,087 mL\n 701 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 550 (550 - 550) mL\n RR (Set): 18\n RR (Spontaneous): 0\n PEEP: 12 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10\n PIP: 22 cmH2O\n Plateau: 20 cmH2O\n SpO2: 97%\n ABG: 7.46/34/92./25/0\n Ve: 10.3 L/min\n PaO2 / FiO2: 186\n Physical Examination\n Eyes / Conjunctiva: PERRL, dysconjugate gaze\n Head, Ears, Nose, Throat: Normocephalic, Poor dentition, Endotracheal\n tube, NG tube\n Cardiovascular: (S1: Normal), (S2: Normal), No(t) S3, No(t) S4, No(t)\n Rub\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : ,\n Rhonchorous: )\n Abdominal: Soft, Bowel sounds present, Distended, palpable fluid wave\n Extremities: Right: Absent, Left: Absent\n Skin: Not assessed\n Neurologic: No(t) Attentive, No(t) Follows simple commands, Responds\n to: Noxious stimuli, Movement: Not assessed, Tone: Not assessed,\n Patient not arousable to voice, no purposeful movements, withdraws to\n pain, non-verbal\n Labs / Radiology\n 134 K/uL\n 12.7 g/dL\n 114 mg/dL\n 2.2 mg/dL\n 25 mEq/L\n 4.2 mEq/L\n 85 mg/dL\n 102 mEq/L\n 138 mEq/L\n 38.5 %\n 26.5 K/uL\n [image002.jpg]\n 11:21 AM\n 01:24 PM\n 03:41 PM\n 06:56 PM\n 09:04 PM\n 10:13 PM\n 11:06 PM\n 11:47 PM\n 03:38 AM\n 04:01 AM\n WBC\n 13.4\n 26.5\n Hct\n 39.6\n 38.5\n Plt\n 152\n 134\n Cr\n 2.1\n 2.0\n 1.9\n 2.2\n TropT\n 0.27\n 0.24\n TCO2\n 33\n 27\n 28\n 27\n 27\n 25\n Glucose\n 105\n 92\n 117\n 114\n Other labs: PT / PTT / INR:17.2/54.3/1.6, CK / CKMB /\n Troponin-T:447/26/0.24, Differential-Neuts:74.5 %, Lymph:14.1 %,\n Mono:8.1 %, Eos:2.9 %, Lactic Acid:2.0 mmol/L, Ca++:7.7 mg/dL, Mg++:3.1\n mg/dL, PO4:5.5 mg/dL\n Assessment and Plan\n Assessment and Plan: This is a 63 y/o M with Hepatitis C cirrhosis, a\n to ICU w/ PEA arrest to mucous plug.\n .\n # Shock/PEA Arrest: Witness arrest to mucous plug.\n - initially hemodynamically stable\n - overnight with repositioning had hypotension non-responsive to IVF\n boluses, levofed started. Etiology of hypotension is cardiogenic shock\n s/p PEA vs. septic shock secondary to pneumonia\n - check central venous O2 today; if high, likely in septic shock, would\n continue levofed; if low, could consider adding extra inotropic pressor\n like dopamine\n - echo today if possible over arctic sun suit\n - continue goal MAP >65\n .\n # Respiratory/Ventilation: Assist control. Low tidal volumes to avoid\n unneeded injury, with pH goal of above 7.25.\n - required increased FiO2 and PEEP overnight due to low oxygenation\n - likely has early ARDS, based on P:F ratio, CXR; continue ARDS net\n protocol with low Vt and high PEEPs\n .\n # Pneumonia\n on CXR has RLL infiltrate and bronch with thick yellow\n secretions, increasing leukocytosis today\n - on vanco/zosyn for HAP; add double coverage of GN with cipro after\n checking EKG for QT prolongation this morning\n - follow up cultures\n .\n # Neuro: With slowly resolving delerium prior to this event, and now\n with unclear hypoxic insult to brain. GCS of on admission to ICU.\n Consider cooling protocol. Head CT to evaluate for anoxic brain injury\n post-cooling. Neuro eval for possible seizure.\n - Continue cooling protocol, will rewarm around noon today\n - Low dose fentanyl/versed for sedation for now; failed trial of\n propofol overnight.\n - LP done earlier this admit that was negative gram stain/culture, no\n whites, negative HSV PCR.\n - EEG prelim report neg for seizure, f/u final read\n - head CT after warmed\n .\n .\n # Renal Failure: Unclear Etiology. Renal following given concern for\n HRS.\n - likely in setting of hypoperfusion, still has some urine output\n - avoid fluid boluses if possible per renal recs\n - Send urine lytes, repeat Ua post-arrest\n - Appreciate renal rec's.\n .\n # Metabolic Acidosis: s/p arrest to tissue hypoxia. Continue IVF's\n and trend lactate. Will need to increase minute ventilation for CO2.\n - resolved, likely in setting of post code hypoperfusion\n - continue to trend lactate, are normalizing\n .\n # Cardiac: Anticipate some elevation in CE's post-arrest, will trend.\n - CK and Trop trending downward,\n - echo today if possible to evaluate for function post PEA\n .\n # Cirrhosis: Hep C Cirrhosis, with concern for HRS.\n - Appreciate liver rec's, no tx at this time\n - pre-code mental status likely related to encephalopathy v. delerium\n .\n # Leukocytosis: Unclear etiology. Negative tap for SBP on .\n Urine growing E. Coli. Pan-culture.\n - likely from pneumonia\n .\n # Parotid mass. Incidental finding of L parotid mass on MRI, 1.6cm. --\n Will require OP ENT followup.\n .\n # Access: PIV, Central Line, arterial line.\n .\n # FEN: IVF, replete electrolytes, tube feeds after rewarming\n .\n # Prophylaxis: Subcutaneous heparin, famotidine\n .\n # Code: full\n .\n # Communication: Wife is HCP\n .\n # Disposition: ICU for now.\n .\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 22 Gauge - 11:30 AM\n 20 Gauge - 11:45 AM\n Multi Lumen - 12:48 PM\n Arterial Line - 05:00 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": "2145-01-08 00:00:00.000", "description": "Nursing Progress Note", "row_id": 558331, "text": "Synopsis per prior nursing note:\n Pt admitted to on s/p fall for back spinal fusion.\n According to pt's wife, who is health care proxy, pt has been confused\n since coming out of anesthesia and later developed a UTI. According to\n floor RN, pt has had MS changes over the past few weeks where he has\n been agitated and unresponsive. Neuro and psych have consulted.\n Unknown cause of MS changes. ? encephalopathy vs. infection. Today pt\n had resp distress, became unresponsive and went into PEA arrest. Large\n plug suctioned from pt. Chest compressions done, 1mg Atropine given\n along with Epi. Pulse returned and pt transferred to MICU for further\n management.\n Cardiac arrest\n Assessment:\n HR 55-68 SR w/rare PVC\ns. ABP 95-109/48-66. MAP\ns 60\ns-70\n Eyes-PERRL, 2mm, brisk. Not moving extremities. Not following commands.\n Not responding to painful stimuli. Temp 34C rectal. QT 505milliseconds\n (Resident aware). No shivering noted. Continues on fentanyl and versed\n gtts. FS 119-124. CVP 13-14.\n Action:\n Continues on arctic sun. Temp monitored-rectal and bladder. Started\n rewarming protocol @ 1215. Arctic sun set to rewarm 0.5degrees C/hr.\n EKG done. Fentanyl gtt weaned to 25mcg/hr.\n Response:\n Temp increased accordingly. SBP decreased to 70\ns w/ turns.\n Plan:\n Monitor QT. Monitor lytes. Monitor for shivering. Monitor for\n hyperglycemia, hyperkalemia, and seizure activity. Monitor pan cultures\n pending.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n AC 18/550/50%/PEEP12. LS clear to rhonchi w/ diminished bases. Not\n breathing over vent. Central venous O2 was 80.\n Action:\n Suctioned scant amt of tan secretions. HOB 30 degrees. Continued on\n antibiotics.\n Response:\n O2 sats remained 98-100%. Desats to high 80\ns-low 90\ns w/ turns.\n Plan:\n Monitor ABG, o2 sats. Wean vent as tolerated. Continue antibiotics.\n Suction as needed.\n Hypotension (not Shock)\n Assessment:\n ABP 95-109/48-66. MAP\ns 60\ns to 70\ns. UOP ~15-40cc/hr.\n Action:\n Continues on levophed gtt. Slowly required levophed titration up to\n maintain MAP 65-70 as rewarming occurred. Given 1L NS bolus. Albumin\n order for 2days.\n Response:\n Continued to become hypotensive w/ turns.\n Plan:\n Titrate Levophed gtt for MAP >65-70. ?more fluid bolus\n for increasing\n hypotension.\n" }, { "category": "Nursing", "chartdate": "2145-01-09 00:00:00.000", "description": "Nursing Progress Note", "row_id": 558385, "text": "Cardiac arrest\n Assessment:\n HR in NSR 60-70.Warming completed at .Temp since then 36.5-37\n rectally.QTc 0.53.\n Action:\n Arctic sun d/ced at .Pads taken off.Temp taken orally and rectally.\n Response:\n Temp stable at 36.5 rectally overnight.Oral temp 97.5.BS stable.No\n seizure activity noticed.\n Plan:\n Monitor QTc,lytes and BS.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n No vent changes overnight.On AC 50%/550/18/12.Not overbreathing.LS\n rhonchorus/diminished.\n Action:\n Minimal secretion on suction.Cont on ABx for pna.\n Response:\n Sats 98-100.Afebrile.\n Plan:\n Monitor ABG, o2 sats. Wean vent as tolerated. Continue antibiotics.\n Suction as needed.\n Hypotension (not Shock)\n Assessment:\n ABP mean 65-80.On levophed gtt.CVP 8-14.U/O 40-100c/hr.\n Action:\n Titrated levophed for MAP >70.Had total of 1.5 lit FB overnight.\n Response:\n CVP upto 12 after FB. U/O improved after the FB.Levophed at 0.16 at the\n time of report.\n Plan:\n Titrate Levophed gtt for MAP >70. FB as needed.\n Altered mental status (not Delirium)\n Assessment:\n Pt is on fent/versed 25/2 for comfort with the tubes.Pt was not\n responding to any kind of stimulus, this am pt opening eyes to voice\n and localizing to pain.\n Action:\n Lactulose added for ?encephalopathy.Feed started.Minimal residual from\n NGT.\n Response:\n Needs cont assessment.\n Plan:\n Turn off sedation in the am to see if wakes up.?CT scan after if\n doesn\nt wake up.\n" }, { "category": "ECG", "chartdate": "2144-12-18 00:00:00.000", "description": "Report", "row_id": 135379, "text": "Baseline artifact. Sinus rhythm. Left axis deviation. Consider\nleft anterior fascicular block. Intraventricular conduction delay of\nright bundle-branch block type. Low voltage in the precordial leads.\nSince the previous tracing of probably no significant change.\n\n" }, { "category": "ECG", "chartdate": "2144-12-17 00:00:00.000", "description": "Report", "row_id": 135380, "text": "Compared to the previous tracing probably no significant change apart from\nbaseline artifact. The rhythm is sinus.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2144-12-14 00:00:00.000", "description": "Report", "row_id": 135381, "text": "Normal sinus rhythm, rate 99. Left anterior hemiblock. Right bundle-branch\nblock. Compared to the previous tracing of no significant change.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2144-12-15 00:00:00.000", "description": "Report", "row_id": 135382, "text": "Baseline artifact. Sinus rhythm. Left axis deviation. Consider left anterior\nfascicular block. Intraventricular conduction delay of right bundle-branch\nblock type. Since the previous tracing of voltage is decreased.\n\n" }, { "category": "ECG", "chartdate": "2144-12-10 00:00:00.000", "description": "Report", "row_id": 135434, "text": "Baseline artifact. Sinus rhythm. Left anterior fascicular block. RSR' pattern\nin lead VI. ST-T wave abnormalities. Since the previous tracing of \nno significant change.\n\n" }, { "category": "ECG", "chartdate": "2144-12-05 00:00:00.000", "description": "Report", "row_id": 135435, "text": "Sinus rhythm\nLeft atrial abnormality\nLeft anterior fascicular block\nLow amplitude anterolateral T waves\nProminent U waves\nFindings are nonspecific but clinical correlation is suggested for possible in\npart drug/metabolic/electrolyte effect\nNo previous tracing available for comparison\n\n" }, { "category": "ECG", "chartdate": "2145-01-11 00:00:00.000", "description": "Report", "row_id": 135373, "text": "Sinus rhythm. Left anterior fascicular block. Delayed R wave progression\nwith late precordial QRS transition is non-specific. Since the previous\ntracing of sinus bradycardia is absent and the QTc interval appears\nshorter.\n\n" }, { "category": "ECG", "chartdate": "2145-01-08 00:00:00.000", "description": "Report", "row_id": 135374, "text": "Sinus bradycardia. Left axis deviation consistent with left anterior fascicular\nblock. Delayed R wave transition across the anterior precordial leads.\nProlonged QTc interval. Compared to the previous tracing of the\nventricular rate is slower. Findings are otherwise similar.\n\n" }, { "category": "ECG", "chartdate": "2145-01-07 00:00:00.000", "description": "Report", "row_id": 135375, "text": "Sinus tachycardia. Compared to the previous tracing the heart rate is\nincreased. Otherwise, no major change.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2145-01-06 00:00:00.000", "description": "Report", "row_id": 135376, "text": "Sinus rhythm with baseline artifact. Left axis deviation. Left anterior\nfascicular block. Leftward precordial R wave transition point. Cannot exclude\nprior anterior myocardial infarction. Compared to the previous tracing\nof multiple abnormalities persist without major change.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2145-01-01 00:00:00.000", "description": "Report", "row_id": 135377, "text": "Sinus rhythm. The Q-T interval is prolonged. Left axis deviation. Left\nanterior fascicular block. There is an RSR' pattern in lead V1 which is\nprobably normal. There is a late transition consistent with possible\nprior anterior myocardial infarction. Compared to the previous tracing\nthere is no significant change.\n\n" }, { "category": "ECG", "chartdate": "2144-12-21 00:00:00.000", "description": "Report", "row_id": 135378, "text": "Sinus rhythm. Baseline artifact. Left anterior fascicular block. Delayed\nprecordial R wave transition. Compared to the previous tracing of \nno diagnostic interim change.\n\n" }, { "category": "Radiology", "chartdate": "2145-01-07 00:00:00.000", "description": "BY DIFFERENT PHYSICIAN", "row_id": 1063620, "text": " 12:56 PM\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \n Reason: Please evaluate Left subclavian position\n Admitting Diagnosis: HEPATIC ENCEPHALOPATHY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with aspiration event, now s/p PEA arrest.\n REASON FOR THIS EXAMINATION:\n Please evaluate Left subclavian position\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): JRld 10:06 AM\n PFI: Left subclavian catheter tip is in the upper SVC.\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAM: Assess left subclavian catheter.\n\n Left subclavian catheter tip is in the upper SVC. There is no pneumothorax.\n There is no opacity in the left perihilar region. There are persistent low\n lung volumes. ET tube is in standard position. NG tube tip is out of view\n below the diaphragm.\n\n jr\n\n\n DR. \n" }, { "category": "Radiology", "chartdate": "2145-01-07 00:00:00.000", "description": "BY DIFFERENT PHYSICIAN", "row_id": 1063621, "text": ", D. MED MICU 12:56 PM\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \n Reason: Please evaluate Left subclavian position\n Admitting Diagnosis: HEPATIC ENCEPHALOPATHY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with aspiration event, now s/p PEA arrest.\n REASON FOR THIS EXAMINATION:\n Please evaluate Left subclavian position\n ______________________________________________________________________________\n PFI REPORT\n PFI: Left subclavian catheter tip is in the upper SVC.\n\n" }, { "category": "Radiology", "chartdate": "2145-01-11 00:00:00.000", "description": "BY DIFFERENT PHYSICIAN", "row_id": 1064282, "text": " 12:02 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: et tube placement, interval change\n Admitting Diagnosis: HEPATIC ENCEPHALOPATHY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with resp distress\n REASON FOR THIS EXAMINATION:\n et tube placement, interval change\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 63-year-old man with respiratory distress.\n\n Comparison is made to the same day radiograph performed eight hours earlier.\n\n Findings: There has been interval placement of the endotracheal tube which\n projects approximately 6.2 cm above the carina. The left subclavian line is\n unchanged. Interval progression of bibasilar consolidation is noted. No\n pneumothorax is seen. The remainder of the study appears unchanged.\n\n\n" }, { "category": "Radiology", "chartdate": "2145-01-07 00:00:00.000", "description": "BY SAME PHYSICIAN", "row_id": 1063708, "text": " 10:32 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: evaluate tube placement, lungs\n Admitting Diagnosis: HEPATIC ENCEPHALOPATHY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with PEA arrest today, continued hypoxemia\n REASON FOR THIS EXAMINATION:\n evaluate tube placement, lungs\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): JRld 10:31 AM\n Worsened left perihilar and left lower lobe opacities and new right lower lobe\n opacities are consistent with aspiration.\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAM: PEA arrest, continued hypoxemia.\n\n ET tube is in standard position. Left subclavian catheter tip is in the upper\n SVC. NG tube tip is out of view below the diaphragm. New right lower lobe\n opacity and worsened left lower lobe opacities are consistent with aspiration.\n There is no pneumothorax.\n\n jr\n\n DR. \n" }, { "category": "Radiology", "chartdate": "2145-01-07 00:00:00.000", "description": "BY SAME PHYSICIAN", "row_id": 1063709, "text": ", D. MED MICU 10:32 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: evaluate tube placement, lungs\n Admitting Diagnosis: HEPATIC ENCEPHALOPATHY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with PEA arrest today, continued hypoxemia\n REASON FOR THIS EXAMINATION:\n evaluate tube placement, lungs\n ______________________________________________________________________________\n PFI REPORT\n Worsened left perihilar and left lower lobe opacities and new right lower lobe\n opacities are consistent with aspiration.\n\n" }, { "category": "Radiology", "chartdate": "2145-01-24 00:00:00.000", "description": "BY SAME PHYSICIAN", "row_id": 1066754, "text": " 6:40 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: ? NG tube position\n Admitting Diagnosis: HEPATIC ENCEPHALOPATHY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with new NG tube that was way too high\n REASON FOR THIS EXAMINATION:\n ? NG tube position\n ______________________________________________________________________________\n WET READ: RSRc SUN 10:52 PM\n Right chest incompletely imaged. Left atelectasis/effusion may be slightly\n improved. Dobhoff advanced, satisfactory. 9:40 pm .\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: New nasogastric tube placement.\n\n FINDINGS: In comparison with the earlier study of this date, the Dobbhoff\n tube has been pushed forward and is now in the lower body or antrum of the\n stomach. Otherwise, little change.\n\n\n" }, { "category": "Radiology", "chartdate": "2145-01-19 00:00:00.000", "description": "BY DIFFERENT PHYSICIAN", "row_id": 1065904, "text": " 10:57 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: NGT placement\n Admitting Diagnosis: HEPATIC ENCEPHALOPATHY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with encephalopathy needed GI access\n REASON FOR THIS EXAMINATION:\n NGT placement\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 11:05 p.m. on :\n\n HISTORY: Encephalopathy. New nasogastric tube.\n\n IMPRESSION: AP chest compared to 3:49 a.m. on :\n\n Nasogastric tube is looped in the stomach. Tracheostomy tube in standard\n placement. Persistent consolidation in the left lower lobe could be\n pneumonia, alternatively atelectasis. Marked elevation of the right lung base\n is longstanding. Increase in basal atelectasis. Pulmonary vascular\n congestion and mediastinal venous engorgement indicate volume overload.\n Minimal edema persists in the right lung. No pneumothorax.\n\n\n" }, { "category": "Radiology", "chartdate": "2144-12-30 00:00:00.000", "description": "BY SAME PHYSICIAN", "row_id": 1062066, "text": " 2:21 AM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: Please confirm NGT placement, again. Thank you very much!\n Admitting Diagnosis: HEPATIC ENCEPHALOPATHY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with cirrhosis, now post new NGT placement\n REASON FOR THIS EXAMINATION:\n Please confirm NGT placement, again. Thank you very much!\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): MPtb WED 12:38 PM\n Nasogastric tube terminates in the stomach in good position.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 63-year-old male with cirrhosis, now after NG tube placement.\n\n COMPARISON: Study at 00:09 today.\n\n FINDINGS: This study is comprised of a single view of the lung bases and\n upper abdomen which demonstrates a nasogastric tube with sidehole and tip in\n the stomach in good position.\n\n\n" }, { "category": "Radiology", "chartdate": "2144-12-30 00:00:00.000", "description": "BY SAME PHYSICIAN", "row_id": 1062067, "text": ", V. MED FA10 2:21 AM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: Please confirm NGT placement, again. Thank you very much!\n Admitting Diagnosis: HEPATIC ENCEPHALOPATHY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with cirrhosis, now post new NGT placement\n REASON FOR THIS EXAMINATION:\n Please confirm NGT placement, again. Thank you very much!\n ______________________________________________________________________________\n PFI REPORT\n Nasogastric tube terminates in the stomach in good position.\n\n\n" }, { "category": "Radiology", "chartdate": "2144-12-20 00:00:00.000", "description": "GUIDANCE FOR THORA/ABD/PARA CENTESIS US", "row_id": 1060190, "text": ", V. MED FA10 2:17 PM\n PARACENTESIS DIAG. OR THERAPEUTIC; GUIDANCE FOR /ABD/PARA CENTESIS USClip # \n Reason: Please perform dx paracentesis and send labs (in POE).\n Admitting Diagnosis: HEPATIC ENCEPHALOPATHY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with cirrhosis, s/p laminectomy,spinal fusion, encephalopathic,\n unresponsive now w/ new ascites.\n REASON FOR THIS EXAMINATION:\n Please perform dx paracentesis and send labs (in POE).\n ______________________________________________________________________________\n PFI REPORT\n Successful paracentesis. Fluid sent for labs and microbiology as requested.\n\n" }, { "category": "Radiology", "chartdate": "2144-12-20 00:00:00.000", "description": "GUIDANCE FOR THORA/ABD/PARA CENTESIS US", "row_id": 1060189, "text": " 2:17 PM\n PARACENTESIS DIAG. OR THERAPEUTIC; GUIDANCE FOR /ABD/PARA CENTESIS USClip # \n Reason: Please perform dx paracentesis and send labs (in POE).\n Admitting Diagnosis: HEPATIC ENCEPHALOPATHY\n ********************************* CPT Codes ********************************\n * PARACENTESIS DIAG. OR THERAPEUTIC GUIDANCE FOR /ABD/PARA CENTESIS *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with cirrhosis, s/p laminectomy,spinal fusion, encephalopathic,\n unresponsive now w/ new ascites.\n REASON FOR THIS EXAMINATION:\n Please perform dx paracentesis and send labs (in POE).\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): CJMt SUN 6:51 PM\n Successful paracentesis. Fluid sent for labs and microbiology as requested.\n ______________________________________________________________________________\n FINAL REPORT\n ULTRASOUND-GUIDED PARACENTESIS\n\n INDICATION: Cirrhosis, encephalopathy. New ascites. Poorly responsive.\n\n TECHNIQUE: The procedure was performed following obtaining written informed\n consent from the patient next of (patient's wife). Risks of bleeding,\n infection, and organ injury were described. Prior to commencing the\n procedure, a preprocedure timeout was also carried out.\n\n Pre-procedure ultrasound demonstrated the presence of mild-to-moderate ascites\n A suitable pocket for aspiration was identified in the right lower quadrant.\n Aseptic technique was used. The skin was prepped with Betadine. 1% lidocaine\n was used to anesthetize the skin and subcutaneous tissues. Under direct\n ultrasound visualization, a 20 gauge spinal needle was advanced into the fluid\n pocket in the right lower quadrant. 40 cc approximately of straw-colored\n fluid was aspirated. This fluid was sent for microbiology, cell count and\n biochemistry as requested by the referring physician.\n\n The procedure was well tolerated. There were no immediate complications.\n\n The attending radiologist, Dr. , was present and available\n throughout the procedure.\n\n IMPRESSION: Successful aspiration of peritoneal fluid.\n\n\n" }, { "category": "Radiology", "chartdate": "2144-12-18 00:00:00.000", "description": "CT ABDOMEN W/CONTRAST", "row_id": 1059930, "text": " 1:51 PM\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: Evaluate for source of fever PNA, abcess, coilitis etc.\n Admitting Diagnosis: HEPATIC ENCEPHALOPATHY\n Field of view: 36 Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with Cirrhosis, s/p Laminectomy and spinal fusion, now w/\n persistent and worsening encephalopathy, low grade fevers of unclear source.\n REASON FOR THIS EXAMINATION:\n Evaluate for source of fever PNA, abcess, coilitis etc.\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): JLLW 6:50 PM\n Moderately distended and edematous gallbladder, possibly secondary to\n third-spacing, given the amount of ascites and pleural effusions. No source\n of infection.\n ______________________________________________________________________________\n FINAL REPORT\n CT CHEST W/CONTRAST ; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: Evaluate for source of fever PNA, abcess, coilitis etc.\n\n Field of view: 36 Contrast: OPTIRAY Amt: 130\n 63 year old man with Cirrhosis, s/p Laminectomy and spinal fusion, now w/\n persistent and worsening encephalopathy, low grade fevers of unclear source.\n Evaluate for source of fever PNA, abcess, coilitis etc.\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CT TORSO WITH IV CONTRAST.\n\n CLINICAL HISTORY: Laminectomy, spinal fusion, cirrhosis, with persistent and\n worsening encephalopathy, low-grade fever of unclear source. Evaluate source\n of fever such as pneumonia, abscess, colitis.\n\n TECHNIQUE: CT of the torso was performed after the administration of oral and\n IV contrast. 130 cc of Optiray nonionic contrast was administered without\n complications.\n\n COMPARISONS: .\n\n FINDINGS:\n\n CT CHEST WITH IV CONTRAST: There is no axillary, mediastinal, or hilar\n lymphadenopathy. Heart and pericardium are grossly unremarkable. Note is made\n of bilateral moderate atelectasis and trace pleural effusions. No clear\n consolidation. No definite pulmonary nodules or masses are seen. Coronary\n artery calcifications are also noted.\n\n CT OF THE ABDOMEN WITH ORAL AND IV CONTRAST: Moderate ascites is present. No\n focal hepatic mass is seen. The gallbladder is moderately distended with some\n (Over)\n\n 1:51 PM\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: Evaluate for source of fever PNA, abcess, coilitis etc.\n Admitting Diagnosis: HEPATIC ENCEPHALOPATHY\n Field of view: 36 Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n gallbladder wall edema, although it is unclear whether this may be secondary\n to third spacing/NPO status. Please correlate clinically. The spleen,\n adrenal glands, and kidneys appear unremarkable aside from multiple low-\n density lesions seen within the left kidney, the largest of which measures\n approximately 4.5 cm with appearances consistent with cysts, and the smaller\n ones are too small for accurate characterization, particularly given the\n motion artifact during the study. A post-pyloric enteric tube is seen, with\n the tip at the junction of the third-fourth portions of the duodenum. Spleen\n and pancreas appear grossly unremarkable. There is diffuse edema within the\n mesentery and omentum. Left gastric varices are seen. No abdominal\n lymphadenopathy is evident.\n\n CT OF THE PELVIS WITH ORAL AND IV CONTRAST: Rectal tube and Foley catheter\n are present, with a decompressed appearance to the bladder. Small-to-moderate\n pelvic free fluid, tracks down from the abdomen. Assessment of the large\n bowel is grossly unremarkable.\n\n Examination of osseous structures does not show lytic or sclerotic lesions\n concerning for malignancy. Upper thoracic pedicle screws are seen, but not\n clearly visualized or characterized on this study. Degenerative changes of the\n lumbar spine are seen, with a focal scoliosis with an S-shape in the lumbar\n spine, left convex at L3 and right convex at L4-5, with transitional vertebral\n body anatomy and slight anterolisthesis of L3 on L4.\n\n Multiplanar reformatted images were also reviewed in our interpretation,\n supporting these findings.\n\n IMPRESSION:\n\n 1. Moderately distended gallbladder with mild edema. This may be secondary\n to third spacing, given the moderate amount of ascites and mesenteric edema\n seen. Please correlate clinically.\n\n 2. Moderate bilateral atelectasis.\n\n 3. No other focal infectious source identified.\n\n JLLW\n DR. \n Approved: SUN 8:41 PM\n (Over)\n\n 1:51 PM\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: Evaluate for source of fever PNA, abcess, coilitis etc.\n Admitting Diagnosis: HEPATIC ENCEPHALOPATHY\n Field of view: 36 Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2144-12-18 00:00:00.000", "description": "CT ABDOMEN W/CONTRAST", "row_id": 1059931, "text": ", V. MED FA10 1:51 PM\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: Evaluate for source of fever PNA, abcess, coilitis etc.\n Admitting Diagnosis: HEPATIC ENCEPHALOPATHY\n Field of view: 36 Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with Cirrhosis, s/p Laminectomy and spinal fusion, now w/\n persistent and worsening encephalopathy, low grade fevers of unclear source.\n REASON FOR THIS EXAMINATION:\n Evaluate for source of fever PNA, abcess, coilitis etc.\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n Moderately distended and edematous gallbladder, possibly secondary to\n third-spacing, given the amount of ascites and pleural effusions. No source\n of infection.\n\n" } ]

[ { "category": "Radiology", "chartdate": "2159-05-16 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 761527, "text": " 3:44 PM\n CHEST (PA & LAT) Clip # \n Reason: baseline CXR in patient being started on Amiodarone\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old man with paroxysmal atrial fibrillation presenting with wide\n complex tachycardia, now being loaded on PO Amiodarone.\n REASON FOR THIS EXAMINATION:\n baseline CXR in patient being started on Amiodarone\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INDICATION: Baseline radiograph prior to beginning Amiodarone\n therapy.\n\n A permanent pace maker is present with leads in the right atrium and right\n ventricle. The heart size is within normal limits. The mediastinal and hilar\n contours are also normal. The lungs demonstrate no evidence of interstitial\n fibrosis or alveolar consolidation. No pleural effusions are evident. The\n bones demonstrate diffuse demineralization.\n\n Mild symmetric biapical thickening is noted.\n\n IMPRESSION: No radiographic evidence of congestive heart failure or\n interstitial fibrosis.\n\n\n" }, { "category": "ECG", "chartdate": "2159-05-15 00:00:00.000", "description": "Report", "row_id": 177686, "text": "Regular A-V sequential pacing\nPacemaker rhythm - no further analysis\n\n" }, { "category": "Nursing/other", "chartdate": "2159-05-15 00:00:00.000", "description": "Report", "row_id": 1464571, "text": " ADMISSION NOTE:\n\n68 year old male transferred here from Hospital to cath lab. Pt went to OSH with syncope,rapid aflutter,wide complex tachycardia. He had been at a party drinking the previous night and had developed chest pain radiating to shoulders the next day which did not subside. He stated he took an extra dig and an extra lopressor to try to stop the pain with no effect. He was cardioverted in ED at OSH.\nPt has No Allergies. PMH: Htn,hypercholesterolemia,gout,CAD,PPM-DDD, previous episodes of VT,SVT,AFib,etc requiring cardioversion, new DM, slightly HOH,Sick Sinus Syndrome,Rt BBB. He has been on flecanide since which is thought to be contributing to his ectopy. This is now d/c'd. His cardiac cath showed clean coronaries. His cardiac enzymes from Hospital were positivex2. He is admitted to CCU tonight to wait for EP studies tomorrow. During the cardiac cath today the patient had Episodes of VT,SVT,Afib,Junctional rhythm and a very short episode of pulseless VT. EP fellow interrogated his PPM at this time. He is now 100% asensed/vpaced at 70.\n\nCVS: Pt is afebrile, HR 70 vpaced. SBP148-161 He was on 20mcgs/hr of IV NTG in cath lab which has been d/c'd. He received a total of 175mg IV Lidocaine boluses in cath lab and is currently on an IV Lidocaine drip at 2mg/min. IV fluid=1/2 NS at 125cc/h. Pulses are easily palpable, feet are warm, Rt Femoral cath site is clean and dry with no bleeding or ecchymosis noted.\n\nResp: RA sats=96-98%. Lungs are clear, no distress noted. No SOB or Chest pain noted.\n\nGU: Pt has condom cath and has voided 550cc since arrival here.\n\nGI: Pt ate small ,fruit cup and juice for supper and is NPO after MN for EP studies tomorrow. +bowel sounds.\n\nSKIN: No open or red areas.\n\nNeuro: No deficits noted. Alert and orientedx3.\n\nPlan: EP studies/procedures in AM. Maintain on IV Lido tonight.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2159-05-16 00:00:00.000", "description": "Report", "row_id": 1464572, "text": "NEURO: A&O X3. PLEASANT & COOPERATIVE.\nRESP: BS CLEAR. RR 13-15. O2 SAT 96-98% ON RM. AIR.\nCARDIAC: HR 70 VP. BP 145-154/83-87. LIDO GTT INFUSING AT 2MG/HR.\n DENIES CP/SOB. R. GROIN SITE C&D. +BPPP. FOR EP TESTING IN\n AM.\nGI: ABD. SOFT. BS+. NPO AFTER MIDNOC->EP LAB.\nGU: CONDOM CATH ON & VOIDING QS. URINE IS CLEAR YELLOW.\nID: AFEBRILE.\nAM LABS PENDING.\n" } ]

[ { "category": "Echo", "chartdate": "2151-03-01 00:00:00.000", "description": "Report", "row_id": 81790, "text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function.\nHeight: (in) 66\nWeight (lb): 175\nBSA (m2): 1.89 m2\nBP (mm Hg): 73/50\nHR (bpm): 100\nStatus: Inpatient\nDate/Time: at 15:45\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Normal LA size.\n\nLEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size. Normal\nregional LV systolic function. Overall normal LVEF (>55%).\n\nRIGHT VENTRICLE: Normal RV wall thickness. Normal RV chamber size. Normal RV\nsystolic function.\n\nAORTA: Normal aortic root diameter. Normal ascending aorta diameter.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Trivial MR.\n\nTRICUSPID VALVE: Moderate [2+] TR. Mild PA systolic hypertension.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor apical views.\n\nConclusions:\n1. The left atrium is normal in size.\n2. Left ventricular wall thicknesses are normal. The left ventricular cavity\nsize is normal. Regional left ventricular wall motion is normal. Overall left\nventricular systolic function is normal (LVEF>55%).\n3. The aortic valve leaflets (3) appear structurally normal with good leaflet\nexcursion. No aortic regurgitation is seen.\n4.The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation\nis seen.\n5. Moderate [2+] tricuspid regurgitation is seen.\n6. There is mild pulmonary artery systolic hypertension.\n7.There is no pericardial effusion.\n8. Normal right ventricular size and function with and echolucent mass in the\nright ventricle consistent with a Swan -Ganz catheter.\n\nIMPRESSION;\nNo echocardiographic evidence of endocarditis. Would recommend a TEE if\nclinically indicated.\n\n\n" }, { "category": "ECG", "chartdate": "2151-02-28 00:00:00.000", "description": "Report", "row_id": 197974, "text": "Sinus rhythm. Diffuse low QRS voltage. Compared to the previous tracing\nof sinus tachycardia is absent.\n\n" }, { "category": "ECG", "chartdate": "2151-02-25 00:00:00.000", "description": "Report", "row_id": 197975, "text": "Sinus tachycardia\nLateral T wave changes are nonspecific - could be rate related\nLow QRS voltages\nNo previous tracing available for comparison\n\n" }, { "category": "ECG", "chartdate": "2151-02-28 00:00:00.000", "description": "Report", "row_id": 201730, "text": "Sinus rhythm. Generalized low QRS voltage. Compared to the previous tracing\nof no significant change.\n\n" }, { "category": "ECG", "chartdate": "2151-03-02 00:00:00.000", "description": "Report", "row_id": 201728, "text": "Masrked widening of the QRS interval and inapparent atrial activity. These\nfindings are consistent with hyperkalemia, metabolic abnormality. Followup and\nclinical correlation are suggested.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2151-03-01 00:00:00.000", "description": "Report", "row_id": 201729, "text": "Sinus rhythm. The rate is 98. P-R interval 0.20. QRS duration 0.12. Diffuse low\nvoltage and left atrial abnormality. Non-specific ST-T wave abnormalities.\nCompared to the previous tracing of there is apparent variation in\nprecordial lead placement. The ST-T wave abnormalities are more prominent.\nOtherwise, no diagnostic interim change.\nTRACING #1\n\n" }, { "category": "Radiology", "chartdate": "2151-03-01 00:00:00.000", "description": "R UNILAT BREAST US RIGHT", "row_id": 906369, "text": " 3:55 PM\n UNILAT BREAST US RIGHT Clip # \n Reason: please have breast ultrasonographer RE-eval right breast for\n Admitting Diagnosis: NECROTIC MASTITIS OF THE RIGHT BREAST\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 43 year old woman with right breast mastitis s/p partial tissue resection.\n REASON FOR THIS EXAMINATION:\n please have breast ultrasonographer RE-eval right breast for ? abcess (request\n of primary breast surgery team; if ?'s please ); thanks\n ______________________________________________________________________________\n FINAL REPORT\n ULTRASOUND SCAN OF RIGHT BREAST (PORTABLE)\n\n CLINICAL DETAILS: Evaluate for breast abscess.\n\n FINDINGS:\n\n No subcutaneous abscess collection demonstrated.\n\n Ultrasound directly over the open right breast at the 12 o'clock position\n towards the nipple shows a small (sub-5-mm wide) anechoic structure which may\n represent a mildly dilated duct or some subcutaneous tracking fluid .\n\n CONCLUSION:\n\n No collection demonstrated on ultrasound.\n\n" }, { "category": "Radiology", "chartdate": "2151-02-28 00:00:00.000", "description": "P UNILAT BREAST US PORT", "row_id": 906216, "text": " 10:02 AM\n UNILAT BREAST US PORT Clip # \n Reason: eval for occult abscess formation\n Admitting Diagnosis: NECROTIC MASTITIS OF THE RIGHT BREAST\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 43 year old woman with breast cellulitis s/p debridement\n REASON FOR THIS EXAMINATION:\n eval for occult abscess formation\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 43-year-old woman with breast cellulitis status post debridement.\n\n PORTABLE UNILATERAL BREAST ULTRASOUND: Please note the patient has a large\n open surgical wound over the lower half of the right breast. Targeted\n ultrasound adjacent to the open wound was performed. There is no evidence of\n focal fluid collection. Edematous subcutaneous tissues are noted.\n\n IMPRESSION: No evidence of fluid collection.\n\n" }, { "category": "Radiology", "chartdate": "2151-03-01 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 906272, "text": " 5:18 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please re-eval\n Admitting Diagnosis: NECROTIC MASTITIS OF THE RIGHT BREAST\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 43F w/ bilateral interstitial opacities.\n REASON FOR THIS EXAMINATION:\n please re-eval\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 5:52 A.M. .\n\n HISTORY: Bilateral interstitial opacities.\n\n IMPRESSION: AP chest compared to and 26:\n\n Consolidation in the right lung has improved while interstitial abnormality in\n the left lung and more pronounced perihilar opacification has worsened on the\n left. Overall findings are most consistent with pulmonary edema. A component\n of aspiration may have been present earlier. Heart size is top normal and\n there is no appreciable mediastinal vascular engorgement. Pleural effusion if\n any on the left is small.\n\n Tip of the endotracheal tube, 2.5 cm from the carina with the chin flexed is\n in standard. Nasogastric tube passes into the stomach and out of view. No\n radiopaque central venous catheter is seen.\n\n\n" }, { "category": "Radiology", "chartdate": "2151-02-28 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 906243, "text": " 3:51 PM\n CHEST (PORTABLE AP) Clip # \n Reason: please eval\n Admitting Diagnosis: NECROTIC MASTITIS OF THE RIGHT BREAST\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 43F w/ decreased o2 sats on vent.\n REASON FOR THIS EXAMINATION:\n please eval\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST .\n\n COMPARISON: .\n\n INDICATION: Decreased oxygen saturation.\n\n Endotracheal tube has been repositioned and is now in satisfactory position.\n Nasogastric tube continues to terminate below the diaphragm. Cardiac and\n mediastinal contours are stable. Bilateral alveolar opacities show slight\n interval improvement particularly in the lung bases. There are bilateral\n small layering pleural effusions.\n\n IMPRESSION: Slight improvement in bilateral alveolar opacities, likely due to\n pulmonary edema from fluid overload. Differential diagnoses include\n aspiration pneumonia, ARDS and hemorrhage.\n\n\n" }, { "category": "Radiology", "chartdate": "2151-03-01 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 906337, "text": " 12:52 PM\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \n Reason: PA line placement\n Admitting Diagnosis: NECROTIC MASTITIS OF THE RIGHT BREAST\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 43F w/ bilateral interstitial opacities.\n\n REASON FOR THIS EXAMINATION:\n PA line placement\n ______________________________________________________________________________\n FINAL REPORT\n TYPE OF EXAMINATION: Chest AP portable single view.\n\n INDICATION: PA catheter placement. Previous chest examination with bilateral\n interstitial opacities.\n\n Check catheter position.\n\n FINDINGS: AP single view of the chest is obtained with the patient in supine\n position. Comparison is made with a similar previous study obtained seven\n hours earlier of the same date. The patient remains intubated, the ETT in\n unchanged appropriate position terminating in the trachea some 4 cm above the\n level of the carina. During the latest interval, a left internal jugular vein\n sheath has been placed through which a Swan-Ganz catheter has been advanced,\n seen to terminate in the central portion of the right pulmonary artery. No\n pneumothorax or any other complication has occurred with the placement. NG\n tube still in place and reaches below diaphragm, but termination point not\n identified. Previously described bilateral parenchymal densities mostly in\n central position remain and are consistent with pulmonary edema.\n\n\n" }, { "category": "Radiology", "chartdate": "2151-02-27 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 906087, "text": " 6:30 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval effusions\n Admitting Diagnosis: NECROTIC MASTITIS OF THE RIGHT BREAST\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 43F s/p I&D breast abscess\n REASON FOR THIS EXAMINATION:\n eval effusions\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST DATED \n\n INDICATION: Status post breast abscess drainage.\n\n The patient's neck is in a flexed position which likely accentuates the\n relatively low position of the endotracheal tube, which is approximately 1.2\n cm above the carina. Nasogastric tube terminates in the region of the\n gastroduodenal junction. Cardiac silhouette is upper limits of normal in\n size. There are bilateral alveolar opacities, most pronounced in the\n perihilar and basilar regions, and there are also small bilateral pleural\n effusions. No pneumothorax is evident.\n\n IMPRESSION:\n 1. Low position of endotracheal tube, likely accentuated by flexed position\n of the neck. Attention to this position on repeat radiograph with the neck in\n a neutral position may be helpful to confirm appropriate level of placement.\n 2. Perihilar and basilar alveolar opacities likely due to pulmonary edema\n from fluid overload, but differential diagnosis includes a massive aspiration\n event.\n\n" }, { "category": "Radiology", "chartdate": "2151-03-01 00:00:00.000", "description": "P EMERGENCY PELVIC U.S. PORT", "row_id": 906386, "text": " 4:35 PM\n EMERGENCY PELVIC U.S. PORT Clip # \n Reason: SEPSIS ? SOURCE\n Admitting Diagnosis: NECROTIC MASTITIS OF THE RIGHT BREAST\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 43 year old woman with hypotension, septic with source unknown, ID service\n suggests U/S to assess for IUD\n REASON FOR THIS EXAMINATION:\n question of IUD\n ______________________________________________________________________________\n FINAL REPORT\n PELVIC ULTRASOUND (TRANSABDOMINAL).\n\n CLINICAL DETAILS: Assess for intrauterine contraceptive device.\n\n FINDINGS:\n\n The uterus is normal in size measuring 9.2 cm sagittal x 4.9 cm transverse. No\n evidence of intrauterine contraceptive device on ultrasound.\n\n Small amount of free pelvic fluid around the uterus and adnexa, appears simple\n on ultrasound. No adnexal masses are demonstrated.\n\n CONCLUSION:\n\n 1. No IUD demonstrated.\n\n 2. Small amount of free pelvic fluid.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2151-02-27 00:00:00.000", "description": "Report", "row_id": 1487587, "text": "Resp Care Note:\n\nPt cont intub with OETT after receiving pt from PACU placed on mech vent as per Carevue. Lung sounds coarse suct sm th yellow sput. ABGs metabolic acidosis with marginal oxygenation; will attempt to manipulate vent settings to optimize gas exchange. Cont mech vent support.\n" }, { "category": "Nursing/other", "chartdate": "2151-02-27 00:00:00.000", "description": "Report", "row_id": 1487588, "text": "NPM\nreceived from PACU 2330, , dx: sepsis R/T right mastitis/cellulitis. Has been in PACU x 3days, awaiting bed. I/D x 2, & . Extubated , failed and re-intubated.\n\nneuro: sedate on propofol. Arouses to voice, follows commands. , . No focal deficits. Med w/ fentanyl 50mcg x 1.\n\nCV: NSR, ST, no ectopy, 70's-90's. MAP >65 on levo and vasopressin. Tol slow levo wean. Pulse paplpable throughout.\n\nPulm: IMV 16 x 550 x PEEP 8 x PS 10 x 50%. Has been acidostic throughout stay. Oxygentation has been marginal, requiring slowly incresing cent support. ETT secretions are thick yellow. BS are course throughout.\n\nGU: F/C urine clear amber; O/P 0-50cc/hr. Cr up to 2.1 from 2\nScant ruddy menstrual flow.\n\nGI: abd soft, hypo BS. NPO. OGT draining yellow bile.\n\nSkeletal: skin grossly intact except for cellulitic area and right breast wound. Large area of erythema and edema right breast spreading to neck over shoulder and to scapula (borders marked). Breast is open, w NS packing TID. Right femoral T/L site wnl.\n\nID: on antibx x 4. Cx show staph, further tissue cxs pending. Afebrile.\n\nEndo: RISS, none required\n\nSocial : husband at home w/ children. Has not called this shift.\n\nP: maintain vent support, adjusting to optimize oxygenation and correct for acidosis. Aggressive bronchial hygeine. Titrate levo to MAP>65; vaso @ 2.4u/hr. Right breast wound packing w/ NS TID (by surgical team). Monitor cellulitic area, notify team of worsening edema of spreading erythema. ? start TPN vs enteral feeding.\n\n" }, { "category": "Nursing/other", "chartdate": "2151-03-01 00:00:00.000", "description": "Report", "row_id": 1487594, "text": "resp care\nPt currently on a/c 500x16 60% 12 peep with peak/plat 40/34. BS coarse bil. Suct for sml amt of thick yellow sput. Alb mdi given q6. Peep weaned to 12 with acceptable oxygenation.Met acidosis persists. Will cont to follow and wean as tolerated.\n" }, { "category": "Nursing/other", "chartdate": "2151-03-01 00:00:00.000", "description": "Report", "row_id": 1487595, "text": "Respiratory Care\nPt placed on ards net protocol this am a/c 400 x 30 peep increased to 15 from 12 60% . Pt required 1 recruitment breath for 30sec for desats to 80\"s under department protocol. last abg on 15cm 726/37/101/17/-. MDI as ordered.\n" }, { "category": "Nursing/other", "chartdate": "2151-03-01 00:00:00.000", "description": "Report", "row_id": 1487596, "text": "T/SICU Nursing \nEvents today:\nProtective ventilation strategy initiated.\nPlacement of left IJ PA line.\nPlacement of left radial arterial line.\nTransthoracic echo.\nRight breast ultrasound.\nPelvic ultrasound.\nDiuresed x2.\nEKG x2.\n\nSee CareVue for specific data.\n\nNeuro: Propofol and fentanyl drips infusing for sedation, comfort, and pain managment. When lightened, begins to cough and gag , sedation never completely turned off. Unable to assess orientation, does not follow commands, withdraws to pain. Pupils equal, round, reactive to light. Moves all extremities non-purposefully, withdraws to nail bed stimuli even when lightened.\n\nPain: Fentanyl gtt increased to 25mcg/hr for comfort, appears not to be in pain at rest; bolused intermittently for procedures, turning, etc.\n\nResp: Intubated, ventilator on assist control mode FiO260% RR30 PEEP15 Vt400. ABGs reveal ongoing metabolic acidosis with excellent oxygenation. SPO2 fell to high 80's once in afternoon when on left side, returned to 94-96% after repositioning on back and recruitment breaths as delivered by respiratory therapy in the presence of Dr - see RRT note for further details. Suctioned intermittently for moderate amounts of thick yellow or thin white secretions. Lung sounds coarse, equal bilaterally, diminished at bases. Does overbreathe vent somewhat. SVO2 70's-low 80's.\n\nCV: Sinus rhythm/sinus tachy 90's-low 100's. EKGs obtained x2 today. Cardiac enzymes drawn x1 as ordered. Palpable pulses in wrists, dopplerable in lower extremities. Generalized pitting edema. Norepinephrine drip titrated to MAP>60, increasing dose through shift. Vasopressin drip continues as ordered. Right radial arterial line d/c'd, new arterial line in left radial artery by MD, transducing sharply. Left IJ PA/CCO line placed today by MD, PAP and CVP transduce sharply, wedges well. CO approx .\n\nGI: Abdomen obese vs slightly distended, faint hypoactive bowel sounds, tube feeds have moderate residuals. Reglan begun, given x1. No BM. OGT in place, tube feeds at goal.\n\nGU: Foley to gravity, minimal amber cloudy urine out. Diuresed with lasix x2, did not respond to first dose of 10mg, effects of second dose pending.\n\nEndo/Lytes: RISS coverage as ordered, BGs in 100's. No repletions of electrolytes this shift. Stress dose steroids administered as ordered.\n\nSkin: Generally edematous, however back intact. Weeps serous fluid from skin puncture sites. Right breast dressing W->D done x2 (08&16), seen by breast surgery team both times. Back intact. Placed on triadyne rotating bed with air mattress for oxygenation & skin.\n\nSocial: Husband visited in evening. Cousin called, very persistently asked for information regarding patient, referred to HCP (husband). Social services following.\n\nPlan:\nMaintain safety\nPain management\nTitrate pressors to goal MAP>60\nPulmonary toileting, mouth care\nOngoing emotional support\n" }, { "category": "Nursing/other", "chartdate": "2151-03-02 00:00:00.000", "description": "Report", "row_id": 1487597, "text": "RESPIRATORY CARE:\n\nPt remains intubated, fully vent supported on AC mode. Pt continues to require higher levels of FiO2 and peep to maintain adequate oxygenation. BS's coarse. Sxing thick pale yellow. Administering Albuterol MDI in line Q6prn. See flowsheet for rx times and further pt data. Will follow.\n" }, { "category": "Nursing/other", "chartdate": "2151-03-02 00:00:00.000", "description": "Report", "row_id": 1487598, "text": "Death Note\n Neurologically decreasing propofol and planning to wean to off and use ativan PRN if needed. Was tolerating propofol wean without any ativan needed but remained very sedate.\n No resp changes made and am labs without any sign change in ABGs. Cont with metabolic acidosis. Lungs coarse with diminished bases. Scant secretions.\n Pt overnight had been requiring increased dose of levophed. In evening HR into 60s when had been consistently in 80-90s. SBP dropped to MAP 50s. Levo titrated up to .25. Atropine 0.5mg given per Dr and rate returned to 90-100s. Able to decrease levo from .25 to .2. Around 0415 EKG with widening QRS complex. 12 lead EKG done and Dr called to bedside. PA and BP unchanged. Complex progressing to wide complex Vtach with BP and pulse present. Lidocaine given and about to draw blood and repeat 12 lead when pt arrested. Rythmn ?fine v-fib veruses asystole. No BP. CPR intitated, RT at bedside intiated BMV and code blue called. Pt recieved pt recieved several epi doses, shocked, Bicarb, hypercalcium treated with insulin, D50W and CaCL, atropine and override pacing per ACLS. See code blue sheet for specifics. Pt not responding to any treatment, never regaining meaningful heart rate or BP. Time of death called at 0534 after 35 minutes of resusitation attempt. Husband notified and is coming from NH.\n" }, { "category": "Nursing/other", "chartdate": "2151-02-28 00:00:00.000", "description": "Report", "row_id": 1487592, "text": "T/SICU Nursing Progress Note\n7A-7P: s/p right breast I/D for mastitis/cellulitis\nNeuro: remains sedated on propofol gtt. Grimaces to noxious stimuli. Started on fentanyl gtt: 12.5 mcg/hr w/ some relief. Able to MAE when lightened.\nCV: Cont on vasopressin/levo to maintain MAP >65. No adjustments made in gtt rate.\nResp: placed on PS 20 for several hours w/ TV 300-400 RR 20s. Required lots of pulmonary suctioning due to increased thick tenatious secretions. Dropped O2 sat to 80s, placed back on A/C: abg cont show acidosis. CXR: lots of pulmonary infiltrates / ? chf.\nGI: abd soft non-distended. TFs started: FS Promode w/ fiber at 10cc/hr via OGT.\nGU: u/o marginal: switched IVF to NS 100cc/hr, received 500 cc NS bolus x2 w/ little response in u/o.\nSkin: right breast u/s performed at bedside. Drsg : breast tissue pale pink in color. No odor noted. Draining serrous fluid. Backside unremarkable.\nID: remains afebrile. Cont on triple antibx as ordered. BC x2 obtained\n(one set from aline other set from fem line due to lack of peripheral access). Will need to re-establish CL and send right Fem line tip for culture per ID recommendation.\nEndo: no requirement needed per SS.\nSocial: husband and close relative in most of the afternoon. Able to speak w/ HO to get update on patient's condition.\nA: septic picture continues\nP: re-establish CL and send right fem cath tip for culture. Cont pressors to maintain MAP > 65. Monitor u/o closely. Titrated TF's until goal rate achieved. Drsg as ordered. As per NCP.\n\n" }, { "category": "Nursing/other", "chartdate": "2151-03-01 00:00:00.000", "description": "Report", "row_id": 1487593, "text": "NPN 1900-0700\n Pt is a 43 yo female who presented with sepsis from breast infection secondary to bite when breastfeeding son. Group A staph in blood cx for outside hospital. Fasciotomy/debridement of R breast on .\n\nNeuro- Sedated on propofol and fent gtt for pain. Pt doesn't open eyes to , . Withdraws to pain and occ weak movements of BUEs noted. When propofol lightened begins coughing continuously, does open eyes.\n\nResp- PEEP decreased to 12 and paO2 low 100s. Metabolic acidosis persists. Lungs coarse with diminished bases. Infiltrates on previous CXR. Awaiting results of am CXR. Pt suctioned several times for small tpo scant thick yellow. ETT rotated and retaped.\n\nCV- SR with MAP maintained greater than 60 on vasopressin and levophed GTTs. Able to titrate levophed down. Afebrile. Rectal temp more accurate than oral (95.8O vs 98.8R). Hct stable. Hyponatremic at 129. WBCs 18.1. CA repleted. BG <120. Anbx cont. Vanco trough pending. Skin w/d. R breast wound oozing large amts serous fluid. Dressing changed and 0400. Tissue pale pink and yellow adipose tissue, with dry appearance. TLC resited to L groin. Old line tip sent for CX. Both old and new sites oozing serosang drainage.\n\nGI/GU- Abd obese with +BS. TF advanced to 30cc/h, goal 80cc. However residuals increasing with last 110cc. Mostly gastric secretions, very little obvious tf. Started on bowel regimen. Colace and dulcolax given. Foley patent with amber slightly cloudy urine.\n\nSocial- No contact with family overnight.\n\nPlan- Wean pressors as tolerated. Review results of cortisol stem test. ECHO today.\n" }, { "category": "Nursing/other", "chartdate": "2151-02-27 00:00:00.000", "description": "Report", "row_id": 1487589, "text": "7a-7p\nneuro: sedated on propofol gtt, attempts to open eyes to voice, grimaces to painful stimuli, perl\n\ncv: hr nsr(76-86), no ectopy, sbp 94-103, continues on levophed & vassopressin gtts to keep map > 60\n\nresp: on 50% fio2, imv 16, 10 peep, 10 ps, no vent changes today, bs+ all lobes & course, sux sm amt loose white/yellow sputum, sat 95-100, abg sent(7.32/37/87/20)\n\ngi: npo, ogt to low wall sux draining sm amt green bilious material, no stool, iv pepcid\n\ngu: foley patent, clear yellow urine, low uo, < 30 cc/hr most of day, ho aware, urine lytes sent, 500 cc LR bolus x 2 today\n\nother: R breast dsg D&I, dsg changed by ho , ivf continue @ 100cc/hr, husband in & updated on pt's condition\n\nplan: continue with ventilatory support, wean vent as tolerated, titrate levo/pitressin gtts to keep map > 60-65, antibiotics as ordered, support husband, assist with R breast dsg change\n" }, { "category": "Nursing/other", "chartdate": "2151-02-28 00:00:00.000", "description": "Report", "row_id": 1487590, "text": "NPN 1900-0700\n Pt sedated on propofol and prn fentanyl. Withdraws and grimaces to pain. No spont movement. PERLA.\n\n Pt PEEP increased to 12 due to paO2 in 80s and sats 92-94%. RR in 20-30s which decreased after fent IVP for suspected pain as cause of RR. Repeat ABGs with improved paO2 but persistant metabolic acidosis.\n\nCV- SR with MAP maintained greater than 65 on vasopressin and levophed gtt. Pt inadvertantly recieved faster rate on Levo with change in carrier rate pt BP into 170s and had PVcs and ST depression (returned to w/i minutes). Dr aware. troponin this am 0.5, CKs normal range. Afebrile. Skin w/d/. Breast dressing oozing large amt serous fluid. Poor UO. IVF at 100cc/h. NA dropping. HCT 25.5.\n\nGI/GU- OGT to LWS with bilous drainage in small amts. Abd soft, obese with +BS. Foley patent with average 20cc/h.\n\nPlan- Maintain anbx. Cont to wean pressors as tolerated. Supportive care to family. dressing changes per team.\n" }, { "category": "Nursing/other", "chartdate": "2151-02-28 00:00:00.000", "description": "Report", "row_id": 1487591, "text": "Resp. care note - Pt. remaines intubated and vented, weaned to PSV tol ok at this time.\n" } ]

[ { "category": "Radiology", "chartdate": "2130-02-15 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1226183, "text": " 5:17 AM\n CHEST (PORTABLE AP) Clip # \n Reason: intubated\n Admitting Diagnosis: RESPIRATORY DISTRESS;PNEUMONIA;CHRONIC PULM DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old woman with respiratory failure\n REASON FOR THIS EXAMINATION:\n intubated\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 5:36 A.M.\n\n HISTORY: 58-year-old woman with respiratory failure.\n\n IMPRESSION: AP chest compared to through 31:\n\n Since , previous moderate right pleural effusion has improved. Mild\n peribronchial opacification at the lung bases is probably atelectasis. There\n is no pulmonary edema or good evidence for pneumonia. Heart size is normal.\n ET tube is in standard placement, right jugular line ends in the mid to low\n SVC and a nasogastric tube passes into the stomach and out of view.\n\n\n" }, { "category": "Radiology", "chartdate": "2130-02-13 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1225870, "text": " 4:41 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please eval for interval changes\n Admitting Diagnosis: RESPIRATORY DISTRESS;PNEUMONIA;CHRONIC PULM DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old woman with copd, pna, like to eval for interval changes.\n REASON FOR THIS EXAMINATION:\n please eval for interval changes\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: COPD and pneumonia, to assess for change.\n\n FINDINGS: In comparison with the study of , the monitoring and support\n devices remain in place. Cardiac silhouette remains at the upper limits of\n normal in size. Some indistinctness of pulmonary vessels raises the\n possibility of elevated pulmonary venous pressure. The left hemidiaphragm is\n more sharply seen. Mild bibasilar atelectatic change. No definite acute\n focal pneumonia.\n\n\n" }, { "category": "Radiology", "chartdate": "2130-02-12 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1225786, "text": " 4:27 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: RESPIRATORY DISTRESS;PNEUMONIA;CHRONIC PULM DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old woman with pneumonia, intubated\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 4:48 A.M., \n\n HISTORY: Pneumonia, intubated patient.\n\n IMPRESSION: AP chest compared to through 28:\n\n Relatively mild peribronchial opacification in the lower lungs has worsened.\n Whether this represents progression of the presumed location of pneumonia or\n instead a decrease in positive pressure ventilation support, is\n radiographically indeterminate. Pleural effusions are small if any. Heart\n size is normal. ET tube and right internal jugular line are in standard\n placements and a nasogastric tube passes below the diaphragm and out of view.\n No pneumothorax.\n\n\n" }, { "category": "Radiology", "chartdate": "2130-02-09 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1225469, "text": " 3:04 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: evaluate support structures, interval change\n Admitting Diagnosis: RESPIRATORY DISTRESS;PNEUMONIA;CHRONIC PULM DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old woman with pneumonia s/p intubation\n REASON FOR THIS EXAMINATION:\n evaluate support structures, interval change\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST \n\n COMPARISON: Study of earlier the same date.\n\n FINDINGS: Interval placement of endotracheal tube, with tip terminating about\n 5.4 cm above the carina. Nasogastric tube terminates below the diaphragm.\n Previously reported right upper lobe opacity has resolved, but there is now\n worsening heterogeneous consolidation in the right lower lobe which may\n correspond to the clinical history of pneumonia. Heart is mildly enlarged and\n accompanied by pulmonary vascular congestion. No definite pleural effusion.\n\n" }, { "category": "Radiology", "chartdate": "2130-02-09 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1225432, "text": " 10:40 AM\n CHEST (PORTABLE AP) Clip # \n Reason: pna\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old woman with ams favwr\n REASON FOR THIS EXAMINATION:\n pna\n ______________________________________________________________________________\n FINAL REPORT\n EXAM: Chest frontal views.\n\n COMPARISON: .\n\n HISTORY: 58-year-old female with history of altered mental status.\n\n FINDINGS: AP upright portable view of the chest was obtained. Moderate\n pulmonary vascular congestion is seen. There is no large pleural effusion or\n pneumothorax. The patient's chin overlies the medial lung apices, partially\n obscuring the view. In the lateral right upper lung, there is an area of more\n increased opacity which may relate to vascular structures and overlying\n osseous structures, although consolidation in this location may be present,\n due to aspiration and/or pneumonia. The cardiac silhouette is top normal to\n mildly enlarged. Old bilateral rib deformities are again seen.\n\n IMPRESSION:\n 1. Pulmonary vascular congestion.\n 2. Area of increased opacity lateral right upper lung could be due to\n overlying vascular and osseous structures, although underlying consolidation\n may be present, due to infection or aspiration.\n\n\n" }, { "category": "Radiology", "chartdate": "2130-02-14 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1226110, "text": " 1:59 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: s/p aspiration\n Admitting Diagnosis: RESPIRATORY DISTRESS;PNEUMONIA;CHRONIC PULM DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old woman with aspiration pna\n REASON FOR THIS EXAMINATION:\n s/p aspiration\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Aspiration pneumonia.\n\n FINDINGS: In comparison with the study of earlier in this date, the\n endotracheal tube is difficult to see. The tip of the tube appears to be\n about 5.6 cm above the carina. Nasogastric tube is lost within the\n mediastinum and cannot be followed into the stomach. Continued hyperexpansion\n of the lungs with hazy opacification at the bases consistent with pleural\n effusions and compressive atelectasis. Again, the possibility of supervening\n pneumonia would have to be considered in the appropriate clinical setting.\n\n\n" }, { "category": "Radiology", "chartdate": "2130-02-11 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1225679, "text": " 4:52 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for interval change, support structures\n Admitting Diagnosis: RESPIRATORY DISTRESS;PNEUMONIA;CHRONIC PULM DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old woman with respiratory failure secondary to COPD/pneumonia\n REASON FOR THIS EXAMINATION:\n eval for interval change, support structures\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE FRONTAL VIEW OF THE CHEST\n\n REASON FOR EXAM: Respiratory failure, sequela to COPD and pneumonia,\n intubated patient.\n\n Comparison is made with prior study performed a day earlier.\n\n Cardiomegaly and mediastinal silhouette are unchanged. A large main pulmonary\n artery is again noted. There is no pneumothorax. Lines and tubes are in\n standard positions. Right lower lobe opacities consistent with pneumonia are\n unchanged. There are no new lung opacities.\n\n\n" }, { "category": "Radiology", "chartdate": "2130-02-10 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1225537, "text": " 5:02 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for interval change\n Admitting Diagnosis: RESPIRATORY DISTRESS;PNEUMONIA;CHRONIC PULM DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old woman with respiratory failure from COPD/PNA, intubated\n REASON FOR THIS EXAMINATION:\n eval for interval change\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 5:44 A.M., \n\n HISTORY: COPD and pneumonia, intubated.\n\n IMPRESSION: AP chest compared to :\n\n Heterogeneous opacification in the right lower lung has not worsened since\n and could be resolving pneumonia. There is no pulmonary edema.\n Heart size is top normal. ET tube and right internal jugular line are in\n standard placements, and a nasogastric tube passes below the diaphragm and out\n of view. Right pleural effusion is small, if any. No pneumothorax.\n\n\n" }, { "category": "Radiology", "chartdate": "2130-02-10 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1225553, "text": " 8:50 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: evaluate for acute process, ? subdural hematoma\n Admitting Diagnosis: RESPIRATORY DISTRESS;PNEUMONIA;CHRONIC PULM DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old woman with respiratory failure pneumonia, ? toxidrome with ?\n fall\n REASON FOR THIS EXAMINATION:\n evaluate for acute process, ? subdural hematoma\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Respiratory failure due to pneumonia. Possible fall and possible\n toxidrome.\n\n COMPARISON: Head CT, . MRI head, .\n\n TECHNIQUE: Contiguous axial MDCT images were obtained through the brain\n without administration of IV contrast.\n\n FINDINGS: Subtle hypodensities in the frontal lobe, inferior putamen, and\n subinsular region are new from the prior exam. This is of unclear\n significance and could be due to hypoxic injury. Would recommend MRI for\n further evaluation. There is no mass, hemorrhage, or mass effect. The\n ventricles and sulci are normal in size and configuration. The basal cisterns\n are patent. There is loss of -white matter differentiation.\n\n No fracture is identified. There is a small air-fluid level in the right\n maxillary sinus and patchy opacification of the ethmoid air cells. There is\n also an air-fluid level in the sphenoid sinuses. The mastoid air cells and\n middle ear cavities are clear. Soft tissues are unremarkable.\n\n IMPRESSION:\n 1. Loss of -white matter differentiation and subtle hypodensities in the\n left frontal lobe, inferior putamen, and subinsular region . The etiology is\n unclear . Would recommend MRI for further evaluation.\n 2. Small air-fluid levels in the right maxillary sinus and sphenoid sinuses\n may be related to intubation.\n\n Results were discussed with at 11:45 a.m. on via\n telephone by Dr. .\n\n" }, { "category": "Radiology", "chartdate": "2130-02-17 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1226469, "text": " 5:24 AM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p extubation, PNA f/u\n Admitting Diagnosis: RESPIRATORY DISTRESS;PNEUMONIA;CHRONIC PULM DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old woman with PNA\n REASON FOR THIS EXAMINATION:\n s/p extubation, PNA f/u\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Pneumonia with extubation.\n\n FINDINGS: In comparison with the study of , the endotracheal tube and\n nasogastric tube have been removed. Continued hyperexpansion of the lungs\n with substantial decrease in opacification at the right base. Pulmonary\n vascularity is within normal limits, and there is no definite pneumonia. Mild\n atelectatic changes at the bases.\n\n\n" }, { "category": "Radiology", "chartdate": "2130-02-09 00:00:00.000", "description": "BY DIFFERENT PHYSICIAN", "row_id": 1225506, "text": " 8:02 PM\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \n Reason: placement confirmation.\n Admitting Diagnosis: RESPIRATORY DISTRESS;PNEUMONIA;CHRONIC PULM DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old woman with cvl newly placed, like to get placement confirmation.\n REASON FOR THIS EXAMINATION:\n placement confirmation.\n ______________________________________________________________________________\n WET READ: 9:37 PM\n\n R IJ CVL ends in the cavo-atrial junction. No pneumothorax. Interval worsening\n of patchy RLL opacities, ? aspiration vs worsening pneumonia KKaliannan d/w\n Dr. at 8:30 P.M on \n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 8:10 P.M. .\n\n HISTORY: New central venous line placed.\n\n IMPRESSION: AP chest compared to , 3:18 p.m.:\n\n Tip of the new right internal jugular line is partially obscured by an EKG\n lead, but is in the mid to low SVC. There is no mediastinal widening, new\n pleural effusion or pneumothorax. Heterogeneous opacification of the right\n lower lung is probably pneumonia, unchanged since the earlier study. Heart\n size is normal. Pleural effusion is small if any.\n\n ET tube is in standard placement. Feeding tube passes into the stomach and\n out of view.\n\n\n" }, { "category": "Radiology", "chartdate": "2130-02-18 00:00:00.000", "description": "MRA NECK W&W/O CONTRAST", "row_id": 1226667, "text": " 4:12 PM\n MR HEAD W/O CONTRAST; -59 DISTINCT PROCEDURAL SERVICE Clip # \n MRA BRAIN W/O CONTRAST; MRA NECK W&W/O CONTRAST\n -52 REDUCED SERVICES\n Reason: evaluate for stroke\n Admitting Diagnosis: RESPIRATORY DISTRESS;PNEUMONIA;CHRONIC PULM DISEASE\n Contrast: GADAVIST Amt: 2CC\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old woman with likely seizure, want to r/o stroke\n REASON FOR THIS EXAMINATION:\n evaluate for stroke\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n MRI AND MRA OF THE BRAIN AND MRA OF THE NECK (INCOMPLETE), \n\n HISTORY: 58-year-old female with likely seizure; evaluate for stroke.\n\n TECHNIQUE: Routine non-enhanced cranial MRI and MRA, with review of\n both axial source and rotational targeted MIP-reconstructed images from the\n MRA on the workstation. Note: Though a contrast-enhanced MRA of the cervical\n vessels was requested and attempted, according to the technologist's note \"the\n patient cooperate(d) only with 'timing run' and then refused to continue.\"\n\n FINDINGS: The study is compared with the cranial MRI of . There is\n background multifocal and confluent FLAIR-hyperintensity in periventricular\n and central pontine white matter, unchanged, representing the sequelae of\n chronic small vessel ischemic disease. However, there is now relatively\n symmetric /FLAIR-hyperintensity in bihemispheric parietal and occipital\n subcortical white matter. This demonstrates only mild mass effect and\n allowing for T2- \"shine-through\" effect, there is no definite evidence of slow\n diffusion at these sites, or elsewhere in the brain. There is no intra- or\n extra-axial hemorrhage, the midline structures are in the midline and the\n ventricles and cisterns are normal and unchanged in size and configuration.\n The remainder of the examination is notable only for a small mucus-retention\n cyst in the right sphenoid air cell, unchanged.\n\n There is normal flow-related enhancement in the included intracranial portions\n of both internal carotid and proximal middle and anterior cerebral arteries,\n with normal, symmetric arborization of MCA branches, bilaterally and no\n significant mural irregularity or flow-limiting stenosis. There is normal\n flow-related enhancement in the distal vertebral arteries with dominant left\n vessel, as well as the basilar and bilateral superior cerebellar and posterior\n cerebral arteries, with no significant mural irregularity or flow-limiting\n stenosis. There is no aneurysm larger than 3 mm in diameter.\n\n IMPRESSION:\n 1. Findings involving the parieto-occipital subcortical white matter,\n bilaterally, without significant mass effect or associated diffusion\n abnormality or hemorrhage. These findings are most suggestive of so-called\n PRES (posterior reversible encephalopathy syndrome) and should be closely\n correlated with history of significant hypertension (including \"relative\"\n (Over)\n\n 4:12 PM\n MR HEAD W/O CONTRAST; -59 DISTINCT PROCEDURAL SERVICE Clip # \n MRA BRAIN W/O CONTRAST; MRA NECK W&W/O CONTRAST\n -52 REDUCED SERVICES\n Reason: evaluate for stroke\n Admitting Diagnosis: RESPIRATORY DISTRESS;PNEUMONIA;CHRONIC PULM DISEASE\n Contrast: GADAVIST Amt: 2CC\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n hypertension) and/or implicated pharmaceutical agents.\n 2. Discrete and confluent FLAIR-hyperintensity in bihemispheric subcortical\n and periventricular and central pontine white matter, unchanged since\n , and likely representing chronic small vessel ischemic disease,\n perhaps related to underlying hypertension.\n 3. Unremarkable cranial MRA, with no flow-limiting stenosis. N.B. The\n cervical MRA could not be completed.\n\n COMMENT: These findings were discussed with Dr. (HMFP hospitalist,\n caring for the patient), via telephone, at 1350H, , who informed me\n that the patient is being treated for the clinical diagnosis of PRES.\n\n" }, { "category": "Radiology", "chartdate": "2130-02-18 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1226651, "text": " 1:30 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: evaluate for acute bleed\n Admitting Diagnosis: RESPIRATORY DISTRESS;PNEUMONIA;CHRONIC PULM DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old woman with code stroke\n REASON FOR THIS EXAMINATION:\n evaluate for acute bleed\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: LLTc SAT 2:31 PM\n Previously seen vague hypodensities near the left insular region are less\n apparent today. no ICH. No acute intracranial process detected.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Code Stroke.\n\n COMPARISON: CT available from .\n\n TECHNIQUE: MDCT-acquired 5-mm axial images of the head were obtained without\n the use of IV contrast.\n\n FINDINGS: Previously seen subtle hypodensities along the insular region are\n less apparent on the current study. The -white matter differentiation\n appears grossly preserved. There is no evidence of acute intracranial\n hemorrhage, edema, mass, or mass effect. No acute fracture is detected. The\n middle ear cavities, mastoid air cells, and included views of the paranasal\n sinuses remain clear.\n\n IMPRESSION: Previously seen vague hypodensities in the left insular region\n are less apparent on today's examination. No acute hemorrhage detected.\n\n\n" }, { "category": "Radiology", "chartdate": "2130-02-14 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1226029, "text": " 1:52 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for support structures, interval changes\n Admitting Diagnosis: RESPIRATORY DISTRESS;PNEUMONIA;CHRONIC PULM DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old woman with respiratory distress on vent\n REASON FOR THIS EXAMINATION:\n eval for support structures, interval changes\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Respiratory distress.\n\n FINDINGS: In comparison with the study of , the endotracheal tube lies\n about 5.7 cm above the level of the carina. Some enlargement of the cardiac\n silhouette persists with indistinctness of pulmonary vessels consistent with\n elevated pulmonary venous pressure. The hemidiaphragms are not well seen, and\n there is hazy opacification at the bases consistent with pleural effusion and\n compressive atelectasis. The possibility of supervening pneumonia would have\n to be considered in the appropriate clinical setting.\n\n\n" }, { "category": "Echo", "chartdate": "2130-02-13 00:00:00.000", "description": "Report", "row_id": 96281, "text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. COPD.\nWeight (lb): 185\nBP (mm Hg): 118/68\nHR (bpm): 81\nStatus: Outpatient\nDate/Time: at 10:38\nTest: TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nPatient intubated.\nLEFT ATRIUM: Elongated LA.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. Lipomatous hypertrophy of\nthe interatrial septum. The IVC is dilated (>2.5cm)\n\nLEFT VENTRICLE: Normal LV cavity size. Overall normal LVEF (>55%).\n\nRIGHT VENTRICLE: RV not well seen.\n\nAORTA: Normal aortic diameter at the sinus level. Normal ascending aorta\ndiameter.\n\nAORTIC VALVE: ?# aortic valve leaflets. No AS. No AR.\n\nMITRAL VALVE: Normal mitral valve leaflets with trivial MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.\n\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not visualized. No PS.\nPhysiologic PR.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - ventilator.\n\nConclusions:\nThe left atrium is elongated. The left ventricular cavity size is normal.\nRegional wall motion abnormalities could not be excluded due to suboptimal\nimaging. However, overall left ventricular systolic function is probably\nnormal (LVEF>55%). The number of aortic valve leaflets cannot be determined.\nThere is no aortic valve stenosis. No aortic regurgitation is seen. The mitral\nvalve appears structurally normal with trivial mitral regurgitation. There is\nno pericardial effusion.\n\nIMPRESSION: Suboptimal image quality. Regional wall motion abnormalities could\nnot be excluded due to suboptimal imaging. However, overall left ventricular\nsystolic function is probably normal. No significant valvular\nregurgitation/stenosis.\n\nCompared with the findings of the prior study (images reviewed) of ,\nthe findings are similar.\n\n\n" }, { "category": "ECG", "chartdate": "2130-02-21 00:00:00.000", "description": "Report", "row_id": 264867, "text": "Sinus rhythm. Left axis deviation. Non-specific ST-T wave changes. There is a\nlate transition that is probably normal. Compared to the previous tracing\nof there is no significant change.\n\n" }, { "category": "ECG", "chartdate": "2130-02-10 00:00:00.000", "description": "Report", "row_id": 264868, "text": "Sinus rhythm. Left axis deviation. There is a late transition with tiny\nR waves in the anterior leads consistent with possible infarction.\nNon-specific ST-T wave changes. Compared to the previous tracing of the same\ndate there is no significant change.\nTRACING #3\n\n" }, { "category": "ECG", "chartdate": "2130-02-10 00:00:00.000", "description": "Report", "row_id": 264869, "text": "Sinus rhythm. Left axis deviation. There is a late transition with small\nR waves in the anterior leads consistent with possible infarction.\nNon-specific ST-T wave changes. Compared to the previous tracing of the same\ndate there is no significant change.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2130-02-09 00:00:00.000", "description": "Report", "row_id": 264870, "text": "Sinus rhythm. Left atrial abnormality. Left axis deviation. There is a late\ntransition with tiny R waves in the anterior leads consistent with possible\ninfarction. Non-specific ST-T wave changes. Compared to the previous tracing\nof ST-T wave changes are more significant.\nTRACING #1\n\n" } ]

[ { "category": "Radiology", "chartdate": "2126-09-21 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 977568, "text": " 2:12 PM\n CHEST (PORTABLE AP) Clip # \n Reason: assess for ETT placement\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 47 year old woman with s/p intubation\n REASON FOR THIS EXAMINATION:\n assess for ETT placement\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH.\n\n INDICATION: 47-year-old woman status post intubation. Assess for ET tube\n placement.\n\n COMPARISON: .\n\n FINDINGS: ET tube terminates 3.8 cm above the carina. There is a left\n subclavian venous catheter with its tip projecting over the superior SVC.\n There is no pneumothorax.\n\n Cardiomediastinal silhouette is probably unchanged, given differences in\n technique. There is no focal consolidation or pneumothorax. There is a small\n left-sided pleural effusion with atelectasis at the left base.\n\n The tip of the NG tube is reviewed, with side port projecting below the\n expected location of the gastroesophageal junction.\n\n IMPRESSION:\n 1. Status post intubation, with ET tube 3.8 cm above the carina.\n 2. Small left pleural effusion.\n\n\n" }, { "category": "Radiology", "chartdate": "2126-09-23 00:00:00.000", "description": "CT CHEST W/CONTRAST", "row_id": 977855, "text": " 5:16 PM\n CT CHEST W/CONTRAST; CT ABD W&W/O C Clip # \n CT PELVIS W/CONTRAST\n Reason: please evaluate disease progression or response\n Admitting Diagnosis: OVERDOSE\n Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 46 year old woman with met breast ca, known liver and bone mets\n\n REASON FOR THIS EXAMINATION:\n please evaluate disease progression or response\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Known metastatic breast cancer, evaluate for progression or\n response. History of UC.\n\n Comparison is made to , CT torso.\n\n TECHNIQUE: MDCT-acquired axial images obtained through the chest, abdomen,\n and pelvis with intravenous and oral contrast. Coronal and sagittal\n reformations were evaluated.\n\n CT OF THE CHEST WITH INTRAVENOUS CONTRAST: No new suspicious parenchymal\n lesions are identified with stable subpleural right middle lobe opacity (3:36)\n and now clearly calcified right lower lobe granuloma (3:31). There has been\n interval development of a few nonspecific peribronchovascular predominantly\n ground-glass opacities within the right upper and right middle lobe, with a\n slightly more nodular opacity noted within the right apex (3:17). Remaining\n lungs displaying mild bilateral dependent atelectasis adjacent to small simple\n bilateral pleural effusions along with a band of linear atelectasis within the\n left lower lobe. The airways appear patent to the segmental level and there is\n no evidence of pericardial effusion. Calcific atherosclerotic disease within\n the intrathoracic aorta is stable as is slight enlargement of the heart with\n probable underlying LVH and left atrial enlargement. Slightly increased\n densities within the right breast consistent with patient's known right breast\n cancer are stable as is a small non-pathologically enlarged 6-mm right\n axillary lymph node. No pathologically enlarged lymph nodes are identified.\n\n CT OF THE ABDOMEN WITHOUT AND WITH INTRAVENOUS CONTRAST: Multiple small\n hypoattenuating hepatic lesions appear stable to decreased in size from prior\n examination; for example, target lesion #1 has decreased in size to 11 x 11 mm\n from prior measurement of 14 x 19 mm (3:44). Target lesion #2 has decreased\n in size from prior measurement of 15 x 16 mm, currently measuring 11 x 9 mm\n (3:47) Target lesion #3 has also decreased in size measuring 7 x 22 mm with\n prior measurement of 11 x 25 mm (3:46). No new hepatic lesions are\n identified, and the spleen, stomach, intra-abdominal bowel, gallblader,\n kidneys, adrenal, and pancreas all appear normal. No free air or free fluid is\n noted within the abdominal cavity. No pathologically enlarged retroperitoneal\n lymph nodes are identified with stable appearance to slightly prominent\n pericecal lymph node measuring approximately 6 mm in short axis.\n\n (Over)\n\n 5:16 PM\n CT CHEST W/CONTRAST; CT ABD W&W/O C Clip # \n CT PELVIS W/CONTRAST\n Reason: please evaluate disease progression or response\n Admitting Diagnosis: OVERDOSE\n Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n CT OF THE PELVIS WITH INTRAVENOUS CONTRAST: Post-surgical changes from prior\n hemicolectomy are again identified with no evidence of bowel obstruction.\n There is stable appearance to an 8-mm left pelvic sidewall lymph node with no\n free fluid is noted within the pelvic cavity. The urinary bladder, uterus,\n and adnexa appear unremarkable.\n\n BONE WINDOWS: There is stable appearance to multiple predominantly sclerotic\n osseous lesions within the right ribs, thoracic/lumbar spine, sacrum, and\n right inferior pubic rami. No new osseous lesions are identified.\n\n IMPRESSION:\n\n 1. Continued slight improvement to multiple hepatic lesions with no new\n metastatic foci identified. Stable osseous tumor burden.\n\n 2. New bilateral small simple pleural effusions with bibasilar atelectasis.\n Peribronchovascular right upper and right middle lobe ground-glass opacities\n are nonspecific and may be infectious or inflammatory etiology. Drug reaction\n alos within the differential. Slightly more nodular right apical opacity can\n be followed up after treatment with repeat chest CT in 3 months.\n\n Oncology table updated in CareWeb.\n\n\n" }, { "category": "Radiology", "chartdate": "2126-09-23 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 977742, "text": " 3:01 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: OVERDOSE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 47 year old woman with s/p intubation\n\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST RADIOGRAPH\n\n CLINICAL HISTORY: Status post extubation, evaluation for interval change.\n\n COMPARISON: Chest radiograph and and CT chest\n .\n\n TECHNIQUE: Single portable upright chest radiograph.\n\n FINDINGS: There has been interval removal of endotracheal tube. The left\n subclavian venous catheter is unchanged in position. Cardiomediastinal\n silhouette is unchanged. There is a small left pleural effusion. Small\n amount of fluid is also noted along the left fissure. Left basal atelectasis\n is noted, unchanged.\n\n IMPRESSION:\n 1. Interval removal of endotracheal tube.\n 2. Small left pleural effusion.\n\n" }, { "category": "Radiology", "chartdate": "2126-09-21 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 977572, "text": " 3:14 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: assess for ICH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 47 year old woman with altered mental status, TCA overdose, ? trauma\n REASON FOR THIS EXAMINATION:\n assess for ICH\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: ARHb SAT 5:33 PM\n No intracranial hemorrhage. Previosuly noted left cerebellar lesion on MRI not\n well characterized on noncontrast head ct.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Altered mental status.\n\n COMPARISON: Multiple priors, most recent MR head dated .\n\n TECHNIQUE: Non-contrast axial images of the head were obtained at 5-mm\n section thickness.\n\n CT HEAD WITHOUT CONTRAST: There is no intracranial hemorrhage, shift of\n normally midline structures, or evidence of acute major vascular territorial\n infarct. Subtle focal left cerebellar hypodensity is not well characterized\n on noncontrast CT and better evaluated on prior MRI exams. Surrounding osseous\n structures are unremarkable. Imaged portions of the paranasal sinuses and\n mastoid air cells are well aerated.\n\n IMPRESSION: No intracranial hemorrhage. Known left cerebellar lesion seen on\n previous MR, which may represent leptomeningeal tumor with sub-pial\n parenchymal extension, is not well characterized on this non- contrast head\n CT.\n\n" }, { "category": "Nursing/other", "chartdate": "2126-09-23 00:00:00.000", "description": "Report", "row_id": 1613187, "text": "correction- Porta-cath is accessed.\n" }, { "category": "Nursing/other", "chartdate": "2126-09-24 00:00:00.000", "description": "Report", "row_id": 1613188, "text": "19:00-07:00\n\nNEURO:PT IS ALERT ORIENTED X3.SLEEPING ON AND OFF IN B/W GOING TO BATHROOM.MOBILISING UNDER SUPERVISION.PT IS 1:1 SITTER ON SUICIDAL PRECAUTIONS.\n\nPULM:LUNG SOUND CLEAR ALL REGIONS.SATURATING FINE ON RA.\n\nCVS:IN NSR WITH HR 80-110.NO ECTOPY.NBP WITHIN LIMITS.LT PORTCATH FOR ACCESS.\n\nGI: SOFT WITH POS BS.LOOSE BROWN STOOL NUMEROUS TIME OVERNIGHT.\n\nGU:PASSING SMALL AMOUNT OF CLEAR YELOW URINE.\n\nID:AFEBRILE.\n\nPLAN:TRANSFER TO FLOOR WHEN BED AVAILABLE.IF STABLE FOR 24 ON FLOOR TO TRANSFER TO PSYCH UNIT. NURSE WITH FLOOR NURSE EITHER TUE/WED.\n\n" }, { "category": "Nursing/other", "chartdate": "2126-09-24 00:00:00.000", "description": "Report", "row_id": 1613189, "text": "MICU Nursing D/C note\nPt seen by case management this afternoon and bed is available on Deaconness 4. D/C summary, page 1 and 2 ready to be sent with patient when unit is ready.\n\nPt spoke openly throughout shift of anxiety related to involunatary admission to psych unit. She regrets having attempted suicide. Emotional support provided. Pt also expressed anxiety related to being d/c'd back to her home where she is without supports. She expressed interest in being placed in a \"rest home\" at the time of discharge. Social work saw patient and will continue to follow her.\n\nVSS, temp 99.4. POC to be de-accessed at time of transfer. Belongings sent with patient. She still has a wallet and pill bottles locked in security.\n" }, { "category": "Nursing/other", "chartdate": "2126-09-21 00:00:00.000", "description": "Report", "row_id": 1613181, "text": "MICU NPN ADMIT NOte\n\nPt admitted to MICU from EW for TCA OD. Pt reported taking 28, 75mg amitriptyline this morning. She called 911 to report ingestion and also stated that she immediately vomited. Pt arrived in EW, alert, oreinted, hemodynamically stable. IN ew, pt became delerious and hemodynamically unstable so she was intubated for airway protection. She was given charcoal via ETT. She was given a total of 3 amps bicarb in EW and started on bicarb gtt. She was taken for head CT which results are pending. Pt brought to MICU for furhter monitoring.\n\nPMH: Metastatic breast CA to liver and bone, psychiatric illness, personality disorder vs schizophrenia vs bipolar disorder (pt has been hospitalized in the past for suicide attempts), h/o PTSD, ulcerative colitis s/p hemicolectomy.\n\nEvents: Upon arrival to MICU, EKG showed widdening QRS 110. Pt was given 1 amp NA Bicarb and continued on gtt. Labs sent and pt found t be hypokalemic. Bicarb gtt stopped and KCL repletion started. Please see carevue for all objective data.\n\nNeuro: Sedated on 34mcg of propofol (dose she arrived on from EW). Pt with minimal response. PERRL, sluggish. No spontaneous movement of extremities noted. Pt does withdraw to painful stimuli. Propofol gtt decreased per med. team. Pt is at high risk for seizures. soft wrist restraints on for pt safety.\n\nResp: Received pt on ACx12/550/50/5. ABG7.62/40/204/43. Vent changes made- RR decreased to 8 and fio2 decreased to 40%. LS coarse. Oral secretions blood tinged. pt has not been ETT suctioned since arrival to MICU. GOal PH 7.5-7.55\n\nCV: Hemodynamically stable. HR 80's NSR, no ectopy noted. Frequent EKG checks needed. Pt's K 2.3. Pt is being repleted with 60meq KCL at this time (first 20meq infusing). Bicarb gtt shut off while increasing serum potassium. Plan is to recheck EKG/K+ once repletion is completed. Pt has Rt SC portacath which we are using. She has 1 peripheral IV.\n\nGI: Pt has OGT. In place per CXR read by Dr.. Plan is to give another dose of charcoal if pt does not stool by 8pm. Abdomen soft, BS present.\n\nGU: large u/o via foley.\n\nSkin: perineum area slightly reddened.\n\nSocial: unknown if pt has support system available to her. There have been no phone calls since admission to MICU. Full Code\n" }, { "category": "Nursing/other", "chartdate": "2126-09-23 00:00:00.000", "description": "Report", "row_id": 1613185, "text": "NPN 7p-7a\nEVENTS: Pt remains c/o to the floor. Psych in to eval and determined pt meets section 12 criteria and requires 1:1 sitter. Pt will need in-patient psych facility once medically able.\n\nNEURO: Pt has slept on/off most of shift. Pt is oriented x3, pleasant, soft spoken, and appears withdrawn/depressed. No c/o pain. Pt OOB to commode, supervised and tolerating well.\n\nCV: NSR/ST 90s-100s. BO 1teens-130s/70s-80s. Pt has easily palpable pulses. EKG obtained this am for comparison purposes only.\n\nRESP: Sats>94% on RA. LS cta. No cough or sputum. RR 12-20s.\n\nGI/GU: ABD is softly distended. + BS. Pt having black liquid stool from charcoal. Pt tolerating small amounts of POs. No nausea/vomitting. Pt voiding via commode.\n\nSOCIAL: Pt lives alone, no social contacts or person supports. Pt states she is estranged from her family.\n\nPLAN: C/O to floor. 1:1 sitter.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2126-09-23 00:00:00.000", "description": "Report", "row_id": 1613186, "text": "0700-1900 MICU NURSING NOTE:\n\n47 yo female admitted on after ingesting 28 tabs of Amytriptline. Pt has had multi hospital and ER visits related to increasing depression. Pt has outpatient pyschiatrist and sees OP social worker. PMH includes: Breast CA with mets to bone and liver. Pt currently undergoing weekly chemo treatments(due today) Hemo/Onc called today, spoke w/ - will reschedule for Tues/Wed. She will contact floor with time and date of chemo Tx. Long psych history of schizophrenia, depression/anxiety, BiPolar, and PTSD. At this time she is REFUSING her clonopin. At this time patient has NO social supports, only outpatient therapist. Pt was seen by her Onc/Hemo MD, plan to continue chemo, cancer is responding well to current TX. CT of Torso completes today for routine F/U of cancer. Pt meets criteria for section 12 and continues to have 1:1.\n\n Pt alert, vague, flat affect. Followed by psych, plan admission to psych floor once stable. Able to follow commands. Pt c/o slight dizziness when standing, one assist to commode.\n\nC/ Pt has no edema, no CP. HR 90-116, ST w/ no ectopy. HCT stable 30.\n\nResp- Lungs clear, no SOB. POx 97-99% on RA\n\nG/ Pt had CT of Torso, results pending. Abd soft, +BS. Pt having loose dark greenish/black stool. Pt refusing colace. Denies N/V. Diet advanced to Reg, well. Eating 30-50% meals.\n\nSkin- Skin intact, perineum reddened\n\nAccess- Porta-Cath L chest wall, not accessed\n\n Pt states she has no social support(see psych note for complete history)\n\n\n Pt C/O-- needs to be stable on floor bed for 24hr, prior to admission to Psych floor\n 1:1 sitter/suicide precautions\n Chemo Tues or Wednesday\n\n" }, { "category": "Nursing/other", "chartdate": "2126-09-22 00:00:00.000", "description": "Report", "row_id": 1613182, "text": "NPN 7P-7A:\n\nTHE PT IS A 47Y/O WOMAN WHO WAS ADMIT ON FROM THE ED TO MICU 6 W/ A OVERDOSE ON AMITRIPTYLIN 75MG TABS. SHE TOOK 28 TABS, AND THAN CALL EMS.\n\nPMH: STAGE IV BREAST CAN ON GEMCITABINE/HERCEPTIN LAST INFUSION ON , METASTASES TO LIVER AND BONE, PERSONALITY D/O VS SCHIZOPHRENIA VS BIPOLAR D/O, MULTIPLE PHYSIC HOSPITALIZATIONS W/ PRIOR SUCIDE ATTEMPTS,ULCERATIVE COLLITIS S/P HEMICOLECTOMY,MELANOMA ON BACK 7 YEARS AGO, PARTIAL THYROIDECTOMY FOR GOITER, PORTA CATH PLACED .\n\nALLERGIES: ZOLOFT,PAXIL,LORAZEPAM,HALDOL.\n\nNEURO: AT THE START OF THE SHIFT. THE PROPOLFOL 35MCG/KG/MIN. IT WAS DECREASED TO 15MCG/KG/MIN. SHE WAS ABLE TO FOLLOW COMMANDS, BUT NOT CONSISTENTLY. HER PUPIL ARE 3MM AND SLUGGISH. SHE HAS PURPOSEFUL MOVEMENTS TO PULL THE ET TUBE OUT. BOTH WRIST HAS SOFT RESTRAINTS ON. SHE CAN MOVE ALL FOUR EXT. NOW THE PORPOFOL 35MCG/KG/MIN. AT TIMES SHE WILL REACH FOR THE TUBE.\n\nRESP: VENT SETTINGS 40%X50X10X5PEEP. LS RONCHII RIGHT, AND COURSE LEFT. VBG PH 7.46. ICU TEAM AWARE.\n\nCV: NSR HR 80 W/ OT ECTOPY NOTED. QTC .46. POTASSIUM LEVEL 2.9. POTASSIUM 40MEQ GIVEN. SODIUM DICAR GTT AT 125CC/HR. LACTATE 1.7. PH 7.46.\n\nGI/GU: CHARCOAL 50GM WAS GIVEN. NO BM W/ OUT RESULTS. SHE DID VOMIT UP 100ML OF THE CHARCOAL A 1/2 HOUR AFTER I ADMINISTRATION. FOLEY CATH W/ GOOD OUT PUT NOTED.\n\nPOC: WEAN TO EXTUBATE THIS AM. AT 0400 THE PROPOFOL GTT TO OBTAIN A RISBI. ICU TEAM WANTS TO PH >= 7.50 TO MAINTAIN THE QTC WNL. MONITOR EKG QTC. TO MONITOR PH/POTASSIUM LEVEL/LACTATE LABS Q 4 HOURS. REPLETE POTASSIUM. CONT SODIUM BICARB GTT FOR THIS 1L.\n\n" }, { "category": "Nursing/other", "chartdate": "2126-09-22 00:00:00.000", "description": "Report", "row_id": 1613183, "text": "Resp Care Note, Pt remains on current vent settings. See vent flow sheet for details. MD wants to maintain ABG'S as alkalotic to stabilize cardiac status.Suctioned for sml amts thick yellow secretions.Sedated with propofol.RSBI done on 0 PEEP/5 IPS 57.9. will cont to monitor resp sattus.\n" }, { "category": "Nursing/other", "chartdate": "2126-09-22 00:00:00.000", "description": "Report", "row_id": 1613184, "text": "MICU NPN 0700-1900\n\nEvents: Pt extubated and doing well. C/O to floor. 1:1 sitter at this time.\n\nNeuro: AA&Ox3. Pleasant and cooperative. Pt asking for plan of care. Awaitng Psychiatry to come and evaluate pt at this time. 1:1 sitter at bedside for pt safety. No seizures noted.\n\nResp: Pt extubated and quickly weaned to RA. LS CTA, diminished @ bases. Pt has non productive cough. SAts 96-100%. Hoarseness improving. Denies SOB.\n\nCV: Hemodynamically stable. HR, 89-107, SR/ST. No ectopy noted. Pt's repleted 40meq KCL for K 3.1. Evening K pending at this time. BP 118-134/71-81. Pt has port-a-cath for access. It is currently heparin locked.\n\nGI: Pt passing liquid black (charcoal) stool. Diet advanced to liquids. No s/s aspiration noted. Pt reporting slight nausea after eating small amount of tray. No vomiting at this time noted.\n\nGU: foley catheter out. Pt voiding as needed.\n\nSocial: no social support per pt report. She is followed by SW here at . SW consult ordered.\n\nDispo: Called out to floor. Full Code\n" }, { "category": "ECG", "chartdate": "2126-09-23 00:00:00.000", "description": "Report", "row_id": 294329, "text": "Sinus rhythm\nLeft axis deviation\nBorderline prolonged/upper limits of normal Q-Tc interval - is nonspecific\nclinical correlation is suggested\nSince previous tracing of , no significant change\n\n" }, { "category": "ECG", "chartdate": "2126-09-22 00:00:00.000", "description": "Report", "row_id": 294330, "text": "Sinus rhythm\nLeftward axis\nBorderline prolonged/upper limits of normal Q-Tc interval - is nonspecific\nclinical correlation is suggested\nSince previous tracing of the same date, probably no significant change\n\n" }, { "category": "ECG", "chartdate": "2126-09-22 00:00:00.000", "description": "Report", "row_id": 294331, "text": "Sinus tachycardia\nLeftward axis\nBorderline prolonged/upper limits of normal Q-Tc interval - is nonspecific\nclinical correlation is suggested\nSince previous tracing of , sinus tachycardia present and QRS duration\nappears slightly less\n\n" }, { "category": "ECG", "chartdate": "2126-09-21 00:00:00.000", "description": "Report", "row_id": 294332, "text": "Sinus rhythm\nBorderline nonspecific intraventricular conduction delay\nBorderline prolonged/upper limits of normal Q-Tc interval\nThese findings are nonspecific but clinical correlation is suggested\nSince previous tracing of , probably no significant change\n\n" }, { "category": "ECG", "chartdate": "2126-09-21 00:00:00.000", "description": "Report", "row_id": 294333, "text": "Sinus rhythm. Compared to tracing #1 there is no significant diagnostic\nchange.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2126-09-21 00:00:00.000", "description": "Report", "row_id": 294334, "text": "Sinus rhythm. Electrocardiographic findings are within normal limits.\nCompared to tracing of there is no significant diagnostic change.\nTRACING #1\n\n" } ]

[ { "category": "Nursing", "chartdate": "2132-10-09 00:00:00.000", "description": "Nursing Progress Note", "row_id": 418395, "text": "AD. EF 55%. PVD, S/P ILIAC AND RENAL PCI. S/P CEA ~10Y AGO. CVA-LACUNAR\n CONFIRMED BY MRI ON . SPINAL STENOSIS. STENT .\n ANXIETY.\n Impaired Physical Mobility\n Assessment:\n Action:\n Response:\n Plan:\n .H/O of cerebrovascular disease, other\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2132-10-09 00:00:00.000", "description": "Nursing Progress Note", "row_id": 418396, "text": "AD. EF 55%. PVD, S/P ILIAC AND RENAL PCI. S/P CEA ~10Y AGO. CVA-LACUNAR\n CONFIRMED BY MRI ON . SPINAL STENOSIS. STENT .\n ANXIETY.\n Assessment:\n Action:\n Response:\n Plan:\n .H/O of cerebrovascular disease, other\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2132-10-09 00:00:00.000", "description": "Nursing Progress Note", "row_id": 418392, "text": "Impaired Physical Mobility\n Assessment:\n Action:\n Response:\n Plan:\n .H/O of cerebrovascular disease, other\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2132-10-10 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 418480, "text": "PMH: CAD. EF 55%. PVD, S/P ILIAC AND RENAL PCI. S/P CEA ~10Y AGO.\n CVA-LACUNAR CONFIRMED BY MRI ON . SPINAL STENOSIS. STENT\n . ANXIETY, -polar.\n PT l SIDED WEAKNESS 10/05. HE WAS ADMITTED TO AND\n W/U SHOWED R ICA NARROWING. HE HAS BEEN SYMPTOM FREE SINCE ADMISSION\n AND WENT FOR R ICA STENTING TODAY.\n IN LAB HE RECEIVED 2 CAROTID STENTS. PRIOR STENT WAS STILL OPEN, NEW\n ONES PLACED DISTAL TO IT. HE HAD NO SEDATION WITH PROCEEDURE. HE WAS\n STARTYED ON IV NITRO AT 100MIC/MIN. HE WAS ALSO STARTED ON NABICARB\n DRIP AT 100CC/HR x 1 LITER. MINX DEVICE DEPLOYED IN R GROIN AND FAILED.\n PRESSURE HELD x 40MIN. HEMOSTASIS ACHIEVED. ALL PULSES DOPPLERABLE. BP\n GOAL 100-140 SYSTOLIC.\n Alteration in Nutrition\n Assessment:\n Pt NPO prior to procedure; restarted on food last eve, FS 160\ns done a\n couple hours after supper\ntherefore post-prandriol. Pt w/o hx DM.\n Action:\n No SSI given.\n Response:\n 03:00 FS 110\n Plan:\n Cont to follow prn\n Carotid artery stenosis (Occlusion)\n Assessment:\n Pt s/p carotid stenting; completed 1 L IVF\ns w/ NaBicarb as ordered to\n protect kidneys;\n Action:\n Neuro checks done post-procedure at least q 2 hrs;\n Sbp maintained 120-140, and at least 100-140;\n Response:\n Pt w/out return of symptoms of carotid occlusion\nleft sided defecits;\n a.m. serum creatinine 1.2, up from 1.0; urine output average 50 cc/hr;\n Plan:\n Cont per plan, to ensure adequate brain and tissue perfusion;\n Follow urine output, serum creatinine;\n Impaired Physical Mobility\n Assessment:\n Pt bedrest post-procedure; Rt leg maintained straight until 22:00\n (ordered time);\n Action:\n Pedal pulses checked q 1 hr x4, then q 2 hrs\n Response:\n Pedal pulses w/out change from previous; asymptomatic for\n clot/occlusion;\n Plan:\n Cont to follow q 4 hrs; per plan, reportedly pt can get OOB today\n 06:45 Dr. in to see pt at this time, stated pt can\n get OOB this a.m., and get ready for discharge/return to nursing home.\n" }, { "category": "Echo", "chartdate": "2132-10-07 00:00:00.000", "description": "Report", "row_id": 81520, "text": "PATIENT/TEST INFORMATION:\nIndication: Cerebrovascular event/TIA.\nHeight: (in) 68\nWeight (lb): 174\nBSA (m2): 1.93 m2\nBP (mm Hg): 166/85\nHR (bpm): 73\nStatus: Inpatient\nDate/Time: at 15:26\nTest: TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Mild LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: 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%). No LV mass/thrombus. Transmitral Doppler and\nTVI c/w Grade I (mild) LV diastolic dysfunction. No resting LVOT gradient.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic diameter at the sinus level. Normal ascending aorta\ndiameter.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. Mild mitral\nannular calcification. Trivial MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.\nIndeterminate PA systolic pressure.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS.\nPhysiologic PR.\n\nPERICARDIUM: No pericardial effusion. There is an anterior space which most\nlikely represents a fat pad, though a loculated anterior pericardial effusion\ncannot be excluded.\n\nConclusions:\nThe left atrium is mildly dilated. No atrial septal defect is seen by 2D or\ncolor Doppler. Left ventricular wall thickness, cavity size and\nregional/global systolic function are normal (LVEF >55%). No masses or thrombi\nare seen in the left ventricle. Transmitral Doppler and tissue velocity\nimaging are consistent with Grade I (mild) LV diastolic dysfunction. 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 regurgitation is seen. The mitral valve leaflets are mildly thickened.\nThere is no mitral valve prolapse. Trivial mitral regurgitation is seen. The\npulmonary artery systolic pressure could not be determined. There is no\npericardial effusion. There is an anterior space which most likely represents\na fat pad.\n\nIMPRESSION: No ASD or cardiac source of embolism seen. Normal global and\nregional biventricular systolic function. Aortic sclerosis without frank\nvalvular stenosis.\n\n\n" }, { "category": "Radiology", "chartdate": "2132-10-07 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1038443, "text": " 1:38 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: 48 after 1st event of numbness and weakness. look for bleed\n Admitting Diagnosis: LT ARM WEAKNESS;R/P CVA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old man with PVD s/ bilaterally and R ICA stent now with evidence\n of L hand weakness and stuttering L hand numbness & upper lip/tongue numbness\n REASON FOR THIS EXAMINATION:\n 48 after 1st event of numbness and weakness. look for bleed or tumor. had\n previous CT at OSH\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 78-year-old male with right ICA stent and evidence of left hand\n weakness and numbness.\n\n COMPARISON: CTA .\n\n TECHNIQUE: Non-contrast axial images of the head are obtained with 5-mm\n section thickness.\n\n FINDINGS: There is no intracranial hemorrhage, edema, shift of normally\n midline structures, or evidence of acute major vascular territorial\n infarction. A chronic right parietal subcortical white matter lacunar\n infarction appears unchanged. Mild periventricular hypodensities are\n consistent with small vessel ischemic changes. Minimal cavernous carotid\n atherosclerotic calcification is noted bilaterally. The surrounding osseous\n structures are unremarkable, and the imaged portion of the paranasal sinuses\n and mastoid air cells are well aerated.\n\n IMPRESSION: Unchanged appearance of the brain without evidence of acute\n intracranial abnormalities.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2132-10-07 00:00:00.000", "description": "CTA NECK W&W/OC & RECONS", "row_id": 1038332, "text": " 5:06 AM\n CTA NECK W&W/OC & RECONS Clip # \n Reason: S/P STENT IN , LT ARM NUMBNESS.\n Admitting Diagnosis: LT ARM WEAKNESS;R/P CVA\n Contrast: OPTIRAY Amt: 90\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old man with intermittent left arm numbness s/p stent in .\n REASON FOR THIS EXAMINATION:\n flow limiting lesion?\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): JXRl TUE 7:44 PM\n No significant interval change from . Patent right internal carotid\n artery. Bilateral carotid flaps, unchanged.\n ______________________________________________________________________________\n FINAL REPORT\n CTA NECK\n\n HISTORY: 78-year-old male with intermittent left arm numbness, status post\n right internal carotid artery stenting, . Evaluate for flow-limiting\n lesion.\n\n COMPARISON: Neck CTA .\n\n TECHNIQUE: Rapid axial imaging was performed from the aortic arch through the\n skull base during infusion of intravenous contrast. Images are multiplanar\n coronal, sagittal and axial MIP reformatted images, as well as curved and 3D\n reformatted images were generated.\n\n FINDINGS: Findings are unchanged in comparison to .\n\n There is approximately 30% stenosis of the left common carotid artery.\n Inferior to this, there is stable dissection flap/atherosclerotic ulcerating\n plaque. Small calcific plaque at the carotid bulb is not hemodynamically\n significant. There is no significant stenosis of the left internal carotid\n artery.\n\n The right internal carotid artery stent is patent. Mural thickening within\n the stented segment is unchanged, although there is no significant stenosis.\n The right common carotid artery at the level of the origin of the external\n carotid artery is unchanged, may represent a dissection flap. There is\n approximately 40% stenosis of the right common carotid artery due to mural\n plaque.\n\n The vertebral arteries are patent. There is mild stenosis of the origin and\n plaque proximally within the left vertebral artery, without stenosis.\n\n There is plaque without stenosis of the right vertebral artery. The right\n vertebral artery origin is patent.\n\n The circle of is not completely imaged on this study.\n\n (Over)\n\n 5:06 AM\n CTA NECK W&W/OC & RECONS Clip # \n Reason: S/P STENT IN , LT ARM NUMBNESS.\n Admitting Diagnosis: LT ARM WEAKNESS;R/P CVA\n Contrast: OPTIRAY Amt: 90\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n There is atherosclerotic plaque of the petrous, cavernous and supraclinoid\n segments of the right and left internal carotid arteries.\n\n Degenerative changes of the cervical spine are unchanged. Atherosclerosis\n with calcified mural plaque of the aortic arch is unchanged.\n\n IMPRESSION:\n 1. Findings are unchanged in comparison to CTA neck .\n 2. Patent right internal carotid artery stent without hemodynamically\n significant stenosis.\n 3. Unchanged intimal flaps of the left common carotid artery and of the right\n common carotid artery at the level of the origin of the external carotid\n artery.\n 4. Mild stenosis of the right carotid bulb of the right and left carotid\n bulbs.\n\n Findings were discussed with Dr. at 11:00 a.m. on .\n\n\n" }, { "category": "Radiology", "chartdate": "2132-10-07 00:00:00.000", "description": "CTA NECK W&W/OC & RECONS", "row_id": 1038333, "text": ", J. 5:06 AM\n CTA NECK W&W/OC & RECONS Clip # \n Reason: S/P STENT IN , LT ARM NUMBNESS.\n Admitting Diagnosis: LT ARM WEAKNESS;R/P CVA\n Contrast: OPTIRAY Amt: 90\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old man with intermittent left arm numbness s/p stent in .\n REASON FOR THIS EXAMINATION:\n flow limiting lesion?\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n No significant interval change from . Patent right internal carotid\n artery. Bilateral carotid flaps, unchanged.\n\n" }, { "category": "Radiology", "chartdate": "2132-10-07 00:00:00.000", "description": "CAROTID SERIES COMPLETE", "row_id": 1038431, "text": " 1:09 PM\n CAROTID SERIES COMPLETE Clip # \n Reason: patency of stent and R ICA\n Admitting Diagnosis: LT ARM WEAKNESS;R/P CVA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old man with R carotid stent now with transient L hand numbness\n REASON FOR THIS EXAMINATION:\n patency of stent and R ICA\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): BNq TUE 9:49 PM\n Findings consistent with intimal flap/carotid dissection, right common carotid\n artery, likely unchanged but difficult to compare to previous CT from of\n this year.\n ______________________________________________________________________________\n FINAL REPORT\n CAROTID ULTRASOUND DATED \n\n CLINICAL HISTORY: Status post right and left carotid endarterectomy and right\n ICA stent placement, history of right-sided common carotid artery intimal\n flap.\n\n TECHNIQUE: -scale imaging supplemented by duplex ultrasonography was\n performed of the extracranial carotid system bilaterally.\n\n This study is compared to a previous study dated .\n\n FINDINGS: There is an echogenic line traversing the lumen of the distal\n common carotid artery consistent with an intimal flap and previous dissection.\n This is noticed on the prior CTA of the neck from . It is difficult\n to compare between these two modalities, but it is likely unchanged. Clinical\n correlation is advised. The ICA is widely patent on both sides with mild\n intimal thickening consistent with atherosclerotic plaque formation, but no\n significant stenosis on either side consistent with satisfactory followup\n imaging after reported prior performance of carotid endarterectomy\n bilaterally. There are findings consistent with a right-sided ICA stent. The\n following peak systolic flow velocities were obtained in m/sec:\n\n RIGHT SIDE: CCA 0.38, proximal ICA 0.84, mid ICA 0.55 and distal ICA 0.57.\n\n LEFT SIDE: CCA 0.72, proximal ICA 0.41, mid ICA 0.69 and distal ICA 1.07.\n\n Antegrade flow was recorded in both vertebral arteries.\n\n IMPRESSION:\n 1. Widely patent ICA bilaterally with findings consistent with prior ICA\n stent placement on the right.\n 2. Findings consistent with an intimal flap on the right, likely unchanged\n compared to prior CT imaging, but difficult to compare as discussed above and\n clinical correlation advised. Notably, the flow velocities in the common\n carotid artery on the right are substantially diminished when compared to the\n left.\n 3. Antegrade flow in both vertebral arteries\n (Over)\n\n 1:09 PM\n CAROTID SERIES COMPLETE Clip # \n Reason: patency of stent and R ICA\n Admitting Diagnosis: LT ARM WEAKNESS;R/P CVA\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n Telephone report was given at 5:20 p.m. to the resident taking care of this\n patient.\n\n" }, { "category": "Radiology", "chartdate": "2132-10-07 00:00:00.000", "description": "CAROTID SERIES COMPLETE", "row_id": 1038432, "text": ", J. 1:09 PM\n CAROTID SERIES COMPLETE Clip # \n Reason: patency of stent and R ICA\n Admitting Diagnosis: LT ARM WEAKNESS;R/P CVA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old man with R carotid stent now with transient L hand numbness\n REASON FOR THIS EXAMINATION:\n patency of stent and R ICA\n ______________________________________________________________________________\n PFI REPORT\n Findings consistent with intimal flap/carotid dissection, right common carotid\n artery, likely unchanged but difficult to compare to previous CT from of\n this year.\n\n" }, { "category": "ECG", "chartdate": "2132-10-11 00:00:00.000", "description": "Report", "row_id": 202704, "text": "Sinus rhythm. Compared to tracing #1 there is no significant diagnostic\nchange.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2132-10-11 00:00:00.000", "description": "Report", "row_id": 202705, "text": "Sinus rhythm. Prominent early R wave progression. Non-specific modest\nST-T wave changes. Compared to the previous tracing of there is no\nsignificant diagnostic change.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2132-10-10 00:00:00.000", "description": "Report", "row_id": 202706, "text": "Normal sinus rhythm. Early R wave transition. No change from tracing #1.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2132-10-09 00:00:00.000", "description": "Report", "row_id": 202707, "text": "Normal sinus rhythm with early R wave transition. Non-specific ST-T wave\nabnormalities. Compared to the previous tracing of no diagnostic\ninterval change.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2132-10-07 00:00:00.000", "description": "Report", "row_id": 202708, "text": "Normal sinus rhythm. Borderline A-V conduction delay. Early R wave\ntransition. Compared to the previous tracing of no diagnostic interval\nchange.\n\n" }, { "category": "ECG", "chartdate": "2132-10-07 00:00:00.000", "description": "Report", "row_id": 202709, "text": "Normal sinus rhythm. Early R wave transition. Consider right ventricular\nhypertrophy. No diagnostic change from tracing of .\n\n" }, { "category": "Nursing", "chartdate": "2132-10-10 00:00:00.000", "description": "Nursing Progress Note", "row_id": 418445, "text": "PMH: CAD. EF 55%. PVD, S/P ILIAC AND RENAL PCI. S/P CEA ~10Y AGO.\n CVA-LACUNAR CONFIRMED BY MRI ON . SPINAL STENOSIS. STENT\n . ANXIETY, -polar.\n PT l SIDED WEAKNESS 10/05. HE WAS ADMITTED TO AND\n W/U SHOWED R ICA NARROWING. HE HAS BEEN SYMPTOM FREE SINCE ADMISSION\n AND WENT FOR R ICA STENTING TODAY.\n IN LAB HE RECEIVED 2 CAROTID STENTS. PRIOR STENT WAS STILL OPEN, NEW\n ONES PLACED DISTAL TO IT. HE HAD NO SEDATION WITH PROCEEDURE. HE WAS\n STARTYED ON IV NITRO AT 100MIC/MIN. HE WAS ALSO STARTED ON NABICARB\n DRIP AT 100CC/HR x 1 LITER. MINX DEVICE DEPLOYED IN R GROIN AND FAILED.\n PRESSURE HELD x 40MIN. HEMOSTASIS ACHIEVED. ALL PULSES DOPPLERABLE. BP\n GOAL 100-140 SYSTOLIC.\n Alteration in Nutrition\n Assessment:\n Pt NPO prior to procedure; restarted on food last eve, FS 160\ns done a\n couple hours after supper\ntherefore post-prandriol. Pt w/o hx DM.\n Action:\n No SSI given.\n Response:\n 03:00 FS 110\n Plan:\n Cont to follow prn\n Carotid artery stenosis (Occlusion)\n Assessment:\n Pt s/p carotid stenting; completed 1 L IVF\ns w/ NaBicarb as ordered to\n protect kidneys;\n Action:\n Neuro checks done post-procedure at least q 2 hrs;\n Sbp maintained 120-140, and at least 100-140;\n Response:\n Pt w/out return of symptoms of carotid occlusion\nleft sided defecits;\n a.m. serum creatinine 1.2, up from 1.0; urine output average 50 cc/hr;\n Plan:\n Cont per plan, to ensure adequate brain and tissue perfusion;\n Follow urine output, serum creatinine;\n Impaired Physical Mobility\n Assessment:\n Pt bedrest post-procedure; Rt leg maintained straight until 22:00\n (ordered time);\n Action:\n Pedal pulses checked q 1 hr x4, then q 2 hrs\n Response:\n Pedal pulses w/out change from previous; asymptomatic for\n clot/occlusion;\n Plan:\n Cont to follow q 4 hrs; per plan, reportedly pt can get OOB today\n" }, { "category": "Nursing", "chartdate": "2132-10-09 00:00:00.000", "description": "Nursing Progress Note", "row_id": 418409, "text": "PMH: CAD. EF 55%. PVD, S/P ILIAC AND RENAL PCI. S/P CEA ~10Y AGO.\n CVA-LACUNAR CONFIRMED BY MRI ON . SPINAL STENOSIS. STENT\n . ANXIETY.\n PT l SIDED WEAKNESS 10/05. HE WAS ADMITTED TO AND\n W/U SHOWED R ICA NARROWING. HE HAS BEEN SYMPTOM FREE SINCE ADMISSION\n AND WENT FOR R ICA STENTING TODAY.\n IN LAB HE RECEIVED 2 CAROTID STENTS. PRIOR STENT WAS STILL OPEN, NEW\n ONES PLACED DISTAL TO IT. HE HAD NO SEDATION WITH PROCEEDURE. HE WAS\n STARTYED ON IV NITRO AT 100MIC/MIN. HE WAS ALSO STARTED ON NABICARB\n DRIP AT 100CC/HR x 1 LITER. MINX DEVICE DEPLOYED IN R GROIN AND FAILED.\n PRESSURE HELD x 40MIN. HEMOSTASIS ACHIEVED. ALL PULSES DOPPLERABLE. BP\n GOAL 100-140 SYSTOLIC.\n Impaired physical mobility\n Assessment:\n PT HAD L SIDED WEAKNESS PRIOR TO ADMISSION.\n Action:\n W/U SHOWED R CAROTID NARROWING\n Response:\n IN R ICA. PT SYMPTOM FREE. HE WAS ADMITTED TO CCU 1800\n PAIN FREE. GROIN SITE DRY AND IN TACT. ALL PULSES DOPPLERABLE. NO NEURO\n DEFICITS. ~40 MINS AFTER ADMISSON HE C/O OF L SIDED WEAKNESS THAT\n RESOLVED QUICKLY. HE CONTINUES ON IV NITRO AND BICARB GTT FOR 1 LITER.\n PT TO REMAINS FLAT UNTIL 10PM\n Plan:\n Wean OFF IV NITRO AS TOLERATED. MONITOR GROIN SITE FOR OOZING. MONITOR\n FOR NEURO CHANGES. ASSIST PT WITH POSITION CHANGES.\n" }, { "category": "Nursing", "chartdate": "2132-10-10 00:00:00.000", "description": "Nursing Progress Note", "row_id": 418540, "text": "Pt stable post stenting . Pt returned to extended care\n facility by ambulance and feels ready to leave. See discharge material\n for complete D/C information.\n Carotid artery stenosis (Occlusion)\n Assessment:\n Pt had 2 stents placed in yesterday. Groin site stable. BP within\n accepted range.\n Action:\n IV nitro turned off in am. None of his anti-hypertensives started yet.\n Pt went for monitored walks.\n Response:\n HR and bp remain stable off nitro. BP within accepted range off\n anti-hypertensives. Tolerated walking without problems. Groin site\n stable with all pulses dopplerable. Pt feeling very good.\n Plan:\n Pt returns to nsg home at 1345\n" }, { "category": "Nursing", "chartdate": "2132-10-09 00:00:00.000", "description": "Nursing Progress Note", "row_id": 418398, "text": "PMH: CAD. EF 55%. PVD, S/P ILIAC AND RENAL PCI. S/P CEA ~10Y AGO.\n CVA-LACUNAR CONFIRMED BY MRI ON . SPINAL STENOSIS. STENT\n . ANXIETY.\n IN LAB HE RECEIVED 2 CAROTID STENTS. PRIOR STENT WAS STILL OPEN, NEW\n ONES PLACED DISTAL TO IT. HE HAD NO SEDATION WITH PROCEEDURE. HE WAS\n STARTYED ON IV NITRO AT 100MIC/MIN. HE WAS ALSO STARTED ON NABICARB\n DRIP AT 100CC/HR x 1 LITER. MINX DEVICE DEPLOYED IN R GROIN AND FAILED.\n PRESSURE HELD x 40MIN. HEMOSTASIS ACHIEVED. ALL PULSES DOPPLERABLE. BP\n GOAL 100-140 SYSTOLIC.\n Impaired physical mobility\n Assessment:\n Action:\n Response:\n Plan:\n .H/O of cerebrovascular disease, other\n Assessment:\n Action:\n Response:\n Plan:\n" } ]

[ { "category": "Radiology", "chartdate": "2171-09-03 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 797638, "text": " 4:45 PM\n CHEST (PA & LAT) Clip # \n Reason: r/o effusion\n Admitting Diagnosis: CHEST PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man s/p cabg\n REASON FOR THIS EXAMINATION:\n r/o effusion\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post CABG, rule out effusion.\n\n COMPARISON: .\n\n PA AND LATERAL CHEST: There are small bilateral pleural effusions. Also\n noted is bibasilar atelectasis, greater on the left than on the right. The\n right subclavian catheter terminates in the right atrium. There is no\n evidence for pneumothorax. The patient is status post median sternotomy. The\n pulmonary vasculature appears normal. No osseous abnormalities are\n appreciated.\n\n IMPRESSION:\n\n 1) Small bilateral pleural effusions with bibasilar atelectasis.\n\n" }, { "category": "Radiology", "chartdate": "2171-08-29 00:00:00.000", "description": "VIDEO OROPHARYNGEAL SWALLOW", "row_id": 797236, "text": " 2:36 PM\n VIDEO OROPHARYNGEAL SWALLOW Clip # \n Reason: r/o aspiration\n Admitting Diagnosis: CHEST PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man with s/p trach , s/p cabg\n REASON FOR THIS EXAMINATION:\n r/o aspiration\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: S/P tracheostomy and CABG. Evaluate for aspiration.\n\n Fluoroscopic assistance was provided for the speech and language pathology\n service for video oropharyngeal swallow study.\n\n The patient was able to swallow liquids of varying consistencies without\n evidence of aspiration. There is slight penetration during consecutive straw\n sips of thin liquids, which cleared during the swallow. This may be due to\n lack of epiglottic deflection, which appears to be secondary to the presence\n of NG tube. During attempts to swallow a 13 mm barium tablet, the patient was\n unable to swallow the tablet due to impaired AP transit of the pill.\n Additionally, during repeated swallows with water, a small amount of water was\n seen trapped within the laryngeal vestibule, although the time of penetration\n is unclear.\n\n Please see the speech and language pathology service report in the Notes\n portion of OMR for full details, assessment, and recommendations.\n\n" }, { "category": "Radiology", "chartdate": "2171-09-13 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 798527, "text": " 11:29 AM\n CHEST (PORTABLE AP) Clip # \n Reason: To assess location of PICC tip inserted in patient's left ar\n Admitting Diagnosis: CHEST PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 yo man s/p cabg and sternal rewiring with sternal wound infection.\n\n REASON FOR THIS EXAMINATION:\n To assess location of PICC tip inserted in patient's left arm. Please notify IV\n nurse T beeper number 9-2439. Thank you.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Assess location of PICC tip.\n\n VIEWS: Single AP portable upright view, comparison dated .\n\n FINDINGS: There has been interval placement of a left-sided PICC line, with\n tip located at the SVC/RA junction, in satisfactory position. The previously\n seen tracheostomy is in unchanged position. Sternal wires and metallic skin\n staples are again noted. The heart size, mediastinal contour, and pulmonary\n vasculature appear unchanged from the prior study without cardiac failure.\n There is unchanged bilateral lower lobe collapse/consolidation, left greater\n than right, and a possible small left pleural effusion. No pneumothorax is\n detected.\n\n IMPRESSION: 1) Left-sided PICC line in satisfactory position without\n pneumothorax.\n\n 2) No change in examination of the chest, with persistent bibasilar\n atelectasis/consolidation and possible small left pleural effusion.\n\n" }, { "category": "Radiology", "chartdate": "2171-09-04 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 797684, "text": " 8:22 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Please assess for infiltrate, volume overload.\n Admitting Diagnosis: CHEST PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man s/p CABG.\n REASON FOR THIS EXAMINATION:\n Please assess for infiltrate, volume overload.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post CABG.\n\n AP CHEST: Despite the mild rightward rotation on this study, deviation of the\n four lower sternal wires to the right of midline appears to be unrelated to\n technique. There is mild cardiac enlargement. Small bibasilar effusions have\n decreased slightly since the prior study of . Lung volumes remain low.\n Allowing for the low lung volumes, there is no pulmonary vasculature\n engorgement. There are no focal lung opacities to suggest pneumonia.\n\n IMPRESSION: Mal-alignment of lower sternal wires raising the suspicion for\n dehiscence. This has already been determined clinically, by report from the\n referring physician.\n\n" }, { "category": "Radiology", "chartdate": "2171-09-11 00:00:00.000", "description": "CT CHEST W/CONTRAST", "row_id": 798339, "text": " 9:55 AM\n CT CHEST W/CONTRAST; CT 100CC NON IONIC CONTRAST Clip # \n Reason: assess for fluid collections/nonunion of sternum\n Admitting Diagnosis: CHEST PAIN\n Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old man s/p cabg and sternal rewiring,now with sternal drainage\n REASON FOR THIS EXAMINATION:\n assess for fluid collections/nonunion of sternum\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Recent sternal rewiring after dehiscence.\n\n TECHNIQUE: Helical CT of the chest was performed at 5 mm collimation after the\n administration of intravenous contrast.\n\n CONTRAST: 100 cc of Optiray were administered secondary to cardiac\n dysfunction; there were no complications.\n\n CT CHEST WITH INTRAVENOUS CONTRAST: The soft tissue windows demonstrate\n tracheostomy tube within the mid trachea. Multiple intact sternotomy wires are\n seen passing through the sternum; there is no significant callus formation. A\n small amount of retrosternal soft tissue stranding is likely a combination of\n post surgical granulation and possibly a small amount of hemorrhage. A tiny\n focus of gas is seen anterior to the pericardium at the level of the main\n pulmonary artery. There is also a small focus of gas overlying the left\n pectoralis major muscle. No areas of bone destruction are identified. There is\n mild cardiac enlargement and a small pericardial effusion is seen.\n\n Lung windows demonstrate diffuse ground glass opacities within both lungs,\n small bilateral pleural effusions and fluid lying within the major fissures.\n There is a small amount of bibasilar atelectasis. No obstructing endobronchial\n lesions are identified.\n\n Within the visualized portion of the upper abdomen, the superior liver,\n gallbladder, pancreas, adrenal glands and left kidney are normal in\n appearance. A small area of low attenuation within the anterior mid right\n kidney could represent a cyst, but is too small to characterize fully on this\n single phase study. A dense calcification within the spleen is likely a\n granuloma.\n\n Degenerative anterior osteophytosis of the thoracic spine is seen on bone\n windows.\n\n IMPRESSION: Small amount of soft tissue density retrosternally is likely post\n surgical in nature. No large fluid collection or continued sternal dehiscence\n is identified. A tiny focus of gas attenuation anterior to the main pulmonary\n artery also likely reflects the recent surgery.\n\n 2. Mild left heart failure.\n\n (Over)\n\n 9:55 AM\n CT CHEST W/CONTRAST; CT 100CC NON IONIC CONTRAST Clip # \n Reason: assess for fluid collections/nonunion of sternum\n Admitting Diagnosis: CHEST PAIN\n Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n\n" }, { "category": "Radiology", "chartdate": "2171-09-05 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 797775, "text": " 7:20 AM\n CHEST (PORTABLE AP) Clip # \n Reason: R/O EFFUSION\n Admitting Diagnosis: CHEST PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man s/p CABG.\n\n REASON FOR THIS EXAMINATION:\n R/O EFFUSION\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST:\n\n CLINICAL INDICATION: S/P coronary artery bypass surgery. Evaluate for\n effusion.\n\n A tracheostomy tube remains in satisfactory position. The lung volumes are\n low, accentuating the cardiac silhouette and bronchovascular structures.\n Allowing for this factor, the heart size and mediastinal contours are stable.\n There are persistent areas of increased opacity in both lung bases, and there\n are also persistent small bilateral pleural effusions.\n\n Within the imaged portion of the upper abdomen, note is made of development of\n moderate gastric distention.\n\n Note is also made of a drain or catheter overlying the mid abdomen. This has\n a relatively low position for a mediastinal drain.\n\n Overall, as compared to the recent study, the bibasilar opacities appear\n slightly worse.\n\n IMPRESSION:\n 1) Slight worsening of bibasilar opacities, most likely due to atelectasis in\n this recently post operative patient. Aspiration or pneumonia cannot be\n excluded in the appropriate clinical setting.\n\n 2) Slight worsening of bilateral pleural effusions.\n\n 3) Moderate gastric distention.\n\n 4) Drainage catheter overlying mid abdomen extending to inferior sternal\n region, possibly due to a low positioned mediastinal drain. Clinical\n correlation suggested.\n\n" }, { "category": "Radiology", "chartdate": "2171-08-26 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 796911, "text": " 11:48 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ro ptx\n Admitting Diagnosis: CHEST PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man with cad, s/p iabp placement\n\n REASON FOR THIS EXAMINATION:\n ro ptx\n ______________________________________________________________________________\n FINAL REPORT\n\n HISTORY: Assessment of intra-aortic balloon pump.\n\n CHEST AP PORTABLE: Comparison is made to .\n\n Again noted, is an intra-aortic balloon pump with the tip at the level of\n T6/T7 vertebral body, 3 cm below the aortic arch, in satisfactory position.\n There are low lung volumes noted bilaterally. Again noted is a tracheostomy\n tube and SG catheter both of which are in good position. There is interval\n development of patchy opacities bilaterally, especially at the lung bases,\n which most likely represents atelectasis. There are bilateral small pleural\n effusions.\n\n IMPRESSION: The intra-aortic balloon pump is about 3 cm below the aortic arch\n in satisfactory position. There is interval development of bibasilar\n atelectasis.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2171-08-25 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 796830, "text": " 7:02 AM\n CHEST (PORTABLE AP) Clip # \n Reason: hypoxia\n Admitting Diagnosis: CHEST PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man with cad, s/p iabp placement\n\n REASON FOR THIS EXAMINATION:\n hypoxia\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 61 year old man with CAD status post IABP placement now with hypoxia.\n Portable supine chest at 7:35 AM: Comparison is made to previous exam\n dated there appears to be some clearing of the patchy opacities that\n were present bilaterally in that study. This exam shows bilateral pleural\n effusions. No evidence of pulmonary edema. Stable external support tubes.\n\n IMPRESSION: Resolving patchy pulmonary opacities. Bilateral pleural effusions\n remain.\n\n" }, { "category": "Radiology", "chartdate": "2171-09-10 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 798231, "text": " 8:24 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate wire placement\n Admitting Diagnosis: CHEST PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 yo man s/p cabg and sternal rewiring\n REASON FOR THIS EXAMINATION:\n evaluate wire placement\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Status post CABG and sternal rewiring. Followup bibasilar opacities\n and pleural effusion.\n\n Compared to the prior study the patient has taken a much improved inspiratory\n effort. Tracheostomy remains in adequate position. There is persistent opacity\n between the left side of the heart likely representing atelectasis or\n infiltrate with blunting of the left costophrenic angle consistent with left\n pleural effusion. However the degree of opacity at the right base particularly\n in the cardiophrenic angle has improved greatly.\n\n IMPRESSION: Much improved inspiratory effort with improved appearance of the\n right and left bases. Likely persistent left pleural effusion and some degree\n of left lower lobe atelectasis or infiltrate with right lower lobe atelectasis\n persisting as well.\n\n" }, { "category": "Radiology", "chartdate": "2171-08-27 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 797067, "text": " 4:03 PM\n CHEST (PORTABLE AP) Clip # \n Reason: S/P r sc CVL\n Admitting Diagnosis: CHEST PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man with cad, s/p iabp placement\n\n REASON FOR THIS EXAMINATION:\n S/P r sc CVL\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Status post right subclavian central line.\n\n CHEST, AP PORTABLE: There is interval placement of right subclavian central\n line, with the tip in the IVC. There is no evidence of pneumothorax. The\n remaining lines and tubes remain unchanged. There is no significant change\n from the prior study otherwise. Discussed with the surgical team.\n\n" }, { "category": "Radiology", "chartdate": "2171-08-21 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 796450, "text": " 7:07 AM\n CHEST (PA & LAT) Clip # \n Reason: c/o cp, sob over night\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man with asthma, high cholesterol\n REASON FOR THIS EXAMINATION:\n c/o cp, sob over night\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 61-year-old man with asthma, high cholesterol, chest pain and\n shortness of breath.\n\n COMPARISON: .\n\n Portable AP chest radiograph demonstrates a stable left ventricular\n configuration to the heart. There are low lung volumes on the current study.\n In the left retrocardiac region there is patchy opacity. Given the low lung\n volumes it cannot be ascertained whether this represents an infiltrate versus\n atelectasis. There is no evidence of failure.\n\n IMPRESSION: Low lung volumes with a patchy opacity in the left lung base.\n This could represent an early pneumonia versus atelectasis. When the patient\n is able, a PA and lateral radiograph is suggested.\n\n" }, { "category": "Radiology", "chartdate": "2171-08-21 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 796526, "text": " 6:22 PM\n CHEST (PORTABLE AP) Clip # \n Reason: check iabp/pa placement\n Admitting Diagnosis: CHEST PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man with cad, s/p iabp placement\n REASON FOR THIS EXAMINATION:\n check iabp/pa placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: IABP placement.\n\n AP bedside chest: Comparison is made to study from earlier today. There has\n been interval placement of a tracheostomy tube. Air is seen in subcutaneous\n tissues of the neck. A PA catheter inserted via the left subclavian route\n terminates in the right main pulmonary artery. An IABP is seen with tip 4 cm\n from the aortic knob. The heart size is normal. There are new perihilar\n opacities and bibasilar atelectasis. There is no effusion or pneumothorax.\n\n IMPRESSION: Interval placement of tracheosteomy, PA catheter, and IABP. All\n are in appropriate position. Perihilar opacities probably represent vascular\n congestion though evaluation is difficult due to overlying subcutaneous\n emphysema.\n\n" }, { "category": "Radiology", "chartdate": "2171-08-22 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 796569, "text": " 8:20 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess for infiltrates\n Admitting Diagnosis: CHEST PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man with cad, s/p iabp placement\n\n REASON FOR THIS EXAMINATION:\n assess for infiltrates\n ______________________________________________________________________________\n FINAL REPORT\n\n HISTORY: S/P intraaortic balloon pump placement.\n\n CHEST, AP PORTABLE: Comparison is made to .\n\n Again noted, is an intra-aortic balloon pump, with the tip about 4 cm below\n the aortic arch. Again noted, is a tracheostomy tube, as well as a subclavian\n PA catheter, both of which are unchanged in position. There is no significant\n change in overall pulmonary pattern.\n\n IMPRESSION: The tip of the intra-aortic balloom pump is currently 4 cm below\n the aortic arch in satisfactory position.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2171-08-22 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 796630, "text": " 3:54 PM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p trach w/tracheobronchitis-evaluate infiltrate\n Admitting Diagnosis: CHEST PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man with cad, s/p iabp placement\n\n REASON FOR THIS EXAMINATION:\n s/p trach w/tracheobronchitis-evaluate infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INDICATION: Intra-aortic balloon pump placement. Tracheobronchitis.\n\n The examination is limited by respiratory motion and marked rotation of the\n patient. An intra-aortic balloon pump remains in place. The radiodense tip is\n likely unchanged in position allowing for differences in patient position,\n currently terminating about 4.7 cm below the superior aspect of the aortic\n knob. A Swan-Ganz catheter is also present, terminating in the proximal right\n pulmonary artery and a tracheostomy tube is unchanged in position. Note is\n made of slight overdistention of the cuff of the tube. Cardiac and mediastinal\n contours are stable. Bibasilar areas of atelectasis are noted as well as a\n probable left pleural effusion.\n\n Previously noted patchy area of right upper lobe opacity is less prominent in\n the interval but may be partially obscured by the degree of rotation.\n\n IMPRESSION:\n 1. Intra-aortic balloon terminates approxiately 4.5 cm below the superior\n aspect of the aortic knob.\n 2. Apparent overdistention of endotracheal tube cuff.\n\n" }, { "category": "Radiology", "chartdate": "2171-09-04 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 797712, "text": " 1:18 PM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p sternal rewire-r/o effusion/ptx\n Admitting Diagnosis: CHEST PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man s/p CABG.\n\n REASON FOR THIS EXAMINATION:\n s/p sternal rewire-r/o effusion/ptx\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post CABG. Status post sternal rewiring.\n\n FINDINGS: AP supine view is compared to AP upright view done earlier on the\n same day. The previously noted sternal sutures are now vertically aligned,\n and additional sternal sutures are present. There is also a new vertical line\n of skin staples overlying the mediastinum and the epigastrium. A new\n tracheostomy tube is in place.\n\n The heart remains enlarged. Upper zone redistribution is present within the\n pulmonary vasculature, which may be due to supine position. However, mild\n congestive heart failure cannot be excluded. There are new bilateral upper\n lobe opacities. There is also a persistent left lower lobe opacity. The\n bilateral pleural effusions are unchanged.\n\n IMPRESSION:\n\n 1) Satisfactory alignment of sternal sutures.\n\n 2) Bilateral opacities most consistent with aspiration. Pulmonary edema is\n less likely.\n\n 3) Bilateral small pleural effusions, unchanged.\n\n 4) Status post tracheostomy.\n\n" }, { "category": "Radiology", "chartdate": "2171-08-25 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 796837, "text": " 9:48 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: decreased mental status\n Admitting Diagnosis: CHEST PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man with\n REASON FOR THIS EXAMINATION:\n decreased mental status\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INDICATION: Altered mental status.\n\n TECHNIQUE: CT of the brain without intravenous contrast.\n\n COMPARISON: None.\n\n FINDINGS: There is no intracranial hemorrhage. There is no mass effect or\n shift of the normally midline structures. The ventricles and sulci are\n slightly prominent but symmetric, compatible with involutional change. There\n are minor patchy areas of low attenuation adjacent to the lateral ventricles,\n compatible with chronic microvascular infarction. The -white matter\n differentiation is grossly preserved. There is no evidence of an acute major\n vascular territorial infarction.\n\n Visualized osseous structures are unremarkable. There is fluid and mucosal\n thickening within the frontal, ethmoid, and sphenoid sinuses, right greater\n than left.\n\n IMPRESSION: No acute intracranial hemorrhage, mass effect, or edema. Please\n note that if there is clinical concern for an acute infarct, an MRI with\n diffusion-weighted imaging would be the modality of choice.\n\n" }, { "category": "Echo", "chartdate": "2171-08-25 00:00:00.000", "description": "Report", "row_id": 68899, "text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. S/P aborted CABG surgery c/b respiratory arrest at induction\nHeight: (in) 60\nWeight (lb): 195\nBSA (m2): 1.85 m2\nBP (mm Hg): 88/50\nHR (bpm): 77\nStatus: Inpatient\nDate/Time: at 01:12\nTest: Portable TTE(Complete)\nDoppler: Focused pulse and color flow\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: The left atrium is dilated.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: The right atrium is normal in size. The\ninteratrial septum is normal.\n\nLEFT VENTRICLE: The left ventricular cavity size is normal. Overall left\nventricular systolic function is normal (LVEF>55%).\n\nRIGHT VENTRICLE: Right ventricular chamber size is normal. Regional right\nventricular systolic function cannot be reliably assessed.\n\nAORTIC VALVE: No aortic regurgitation is seen.\n\nMITRAL VALVE: The mitral valve leaflets are structurally normal. Mild (1+)\nmitral regurgitation is seen.\n\nPERICARDIUM: There is no pericardial effusion.\n\nConclusions:\nLimited study. The left atrium is dilated. The left ventricular cavity size is\nnormal. Overall left ventricular systolic function is normal (LVEF>55%). There\nis basal and mid inferior wall hypokinesis/akinesis. Right ventricular chamber\nsize is normal. No aortic regurgitation is seen. The mitral valve leaflets are\nstructurally normal. Mild (1+) mitral regurgitation is seen. There is no\npericardial effusion. A linear echogenic structure is seen in the right\nventricle consistent with a pacemaker wire.\n\nCompare to the report (no study available) there is no significant\nchange in findings.\n\n\n" }, { "category": "Echo", "chartdate": "2171-08-21 00:00:00.000", "description": "Report", "row_id": 69138, "text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. Mitral valve disease. ? Myocardial infarction.\nHeight: (in) 66\nWeight (lb): 195\nBSA (m2): 1.98 m2\nBP (mm Hg): 118/69\nHR (bpm): 53\nStatus: Inpatient\nDate/Time: at 09:37\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 mildly dilated.\n\nLEFT VENTRICLE: The left ventricular cavity size is normal. There is mild\nregional left ventricular systolic dysfunction.\n\nRIGHT VENTRICLE: Right ventricular chamber size and free wall motion are\nnormal.\n\nAORTA: The aortic root is normal in diameter.\n\nAORTIC VALVE: The aortic valve leaflets (3) appear structurally normal with\ngood leaflet excursion. There is no aortic valve stenosis. No aortic\nregurgitation is seen.\n\nMITRAL VALVE: The mitral valve leaflets are mildly thickened. Mild to moderate\n(+) mitral regurgitation is seen.\n\nTRICUSPID VALVE: The tricuspid valve leaflets are mildly thickened. Mild\ntricuspid [1+] regurgitation is seen. There is borderline pulmonary artery\nsystolic hypertension.\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. The left ventricular cavity size is normal.\nThere is mild regional left ventricular systolic dysfunction with basal to mid\ninferior hypokinesis/akinesis. Right ventricular chamber size and free wall\nmotion are normal. The aortic valve leaflets (3) appear structurally normal\nwith good leaflet excursion. There is no aortic valve stenosis. No aortic\nregurgitation is seen. The mitral valve leaflets are mildly thickened. Mild to\nmoderate (+) mitral regurgitation is seen. The tricuspid valve leaflets are\nmildly thickened. There is borderline pulmonary artery systolic hypertension.\nThere is no pericardial effusion.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2171-08-31 00:00:00.000", "description": "Report", "row_id": 1678271, "text": "Update\nO: Neuro status: a&o x3 w some stm deficit . at 4mm. Mae spont and to command. Ambulated in Icu w 1 assist w/o difficulty\n\nCV status: sr to transient at times. Sbp stable.\n\nResp status: Bbs diminished bilat throughout.Dbc w/o raising any sput.O2 via np at 2lpm. Trach remains in place(#4 portex uncuffed) w passe muir valve. Inhalers per orders.\n\nGi status: po food and flds well. + bowel snds. Abd distended, firm, no bm today.\n\nGu status: foley to gd dc'd @ 11am -> dtv 1900.\n\nHeme/Id: hct stable. Remains on levaquin po for pulm prophylax.\n\nTubes/Lines: rsc dble lumen patent. rt radial art line. Epicardial wires dc'd @13:30 w/o incident,pt on bedrest x1hr & heparin gtt off x 3+hrs before dc->restarted after wires out at prior rate 1500units/hr. Pt to start coumadin this pm,check w ho re: dose.\n\nA/P: Stable . Progress w cardiac rehab ^ diet and activ as -> per Dr may go to 2 on Monday if remains stable over weekend.\n\n" }, { "category": "Nursing/other", "chartdate": "2171-08-31 00:00:00.000", "description": "Report", "row_id": 1678272, "text": "Resp care\nPt remains on 2 l/min o2 NC, w/ o2 sats > 96%. Pt remains\non PMV well. B/S dim clear, Pt treated w/ mdi flovent\nPt has strong cough & stated he has been able to clear\nsecretions on his own. Plan: continue treatments\n" }, { "category": "Nursing/other", "chartdate": "2171-09-01 00:00:00.000", "description": "Report", "row_id": 1678273, "text": "RN Progress note\nNeuro: AAO x 3; cooperative, calm. Slept in long naps dur noc.\n\nCV: In & out of afib, HR 70-110, rare VEA. BPS >90.\n\nPulm: Bibasilar crackles, scattered I/E wheezing. SpO2 93 on RA, 95+\non 2L/NP. DOE. Wheezy, non-productive cough. IS to 750cc.\n\nGI: cl liqs, no N/V. BS hypo, no BM\n\nGU: voiding. Poor output from lasix 20mg 2200\n\nMS/derm: wounds C/D. groins eccymotic, no hematoma. A-line extremely positional.\n\nLabs: all essentially normal. PTT 50.1, Heparin increase to 1600 units/he @ 0600. INR 2.5 this am after coumadin 2.5mg last eve.\n\nP: P: D/C a-line. OOB, ambulate. Work on pulm toilet, ? nebs for wheeze despite MDI's. ?transfer to F2. Follow PTT, adjust heparin. Dose w/ coumadin this pm.\n\n\n\n\n\n\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2171-09-05 00:00:00.000", "description": "Report", "row_id": 1678285, "text": "RESP CARE NOTE\nPT REMAINS , #8.0 SHILEY TUBE, INNER CANNULA IN PLACE, CUFF INFLATED. CHANGED FROM VENT TO TRACH COLLAR EARLY IN SHIFT. WELL. PERSISTANT COUGHING, HOWEVER, W/MOD AMTS FROTHY BLOOD-TINGED SEC. BS ESSENTIALLY CLEAR, OCCAS UPPER AIRWAY WHEEZES, RELIEVED AFTER NEB TX. NO CRACKLES NOTED. PT FEBRILE, AWAKE, AGITATED THRU MOST OF SHIFT. VOMITED IN AM, NO EVIDENCE OF ASPIRATION TO AIRWAY. AM ABG REFLECTS UNCOMPENSATED RESP ALKALOSIS W/HYPEROXIA. PLAN TO CONTINUE TRACH COLLAR AS , FOLLOW CLOSELY.\n" }, { "category": "Nursing/other", "chartdate": "2171-09-01 00:00:00.000", "description": "Report", "row_id": 1678274, "text": "addendum, RN progress note of , 0630\nPTT 28 last eve, . Gtt remained @ 1500 units. 1 unit FFP transfused for probable anti-thrombin 3. PTT 50.1 this am.\n" }, { "category": "Nursing/other", "chartdate": "2171-09-01 00:00:00.000", "description": "Report", "row_id": 1678275, "text": "update\nD: pt with uneventful day, awaiting trach/valve removal by MD.\nneuro: wnl, pt still speaking about \"thing\" that he think happen that he must have dreamed while under - ie: roaming the unit, people selling bananas etc. mae, approp answers to questions when asked, oriented x 3.\n\ncardiac: pt remains in nsr with rare pac- sbp 90's/, palp pedal pulses bilat.\n\nresp: pt weaned to 2l np with sat >97%, on r/a sat 97% then dipped to 94%, when back to bed placed o2 back on. bs dim in bases, intermittent wheezes noted bilat- clear with coughing, pt cont with loose cough raising small amt clear-white secretions.\n\ngi: po's well, appetite fair- abd soft none tender, + bs no bm today. cont on po colace.\n\ngu: pt voiding in small (100cc amt) clear to amber urine. cont on po lasix.\n\nactivity: amb in with pt- 3 times around unit. oob to chair most of day- back to bed to rest.\n\nhem: hct 25.5- started po iron and vit c.\n\nplan: thoracic to d/c valve and pt to be transfered to floor in am.\n" }, { "category": "Nursing/other", "chartdate": "2171-09-05 00:00:00.000", "description": "Report", "row_id": 1678286, "text": "PT UPDATE\n PT IS S/P STERNAL REWIRING AND I&D YEST.\n\n NEURO: PT IS A&O X3. DOES NOT SEEM AS ANXIOUS AT HE WAS LAST NIGHT. WIFE IN WITH PT.\n\n RESP: BS CLEAR, SATS 98 ON 50% TRACH COLLAR. MUCH LESS SPUTUM TODAY THAN LAST NIGHT. SPEECH THERAPIST BY; TO PUT PASSE-MUIR VALVE ON PT THIS TO WAIT 24HR AFTER SURGERY BEFORE PUTTING IT ON.\nABG IMPROVED-THOUGH STILL SLIGHTLY ALKYLOTIC. OXYGENATION GOOD.\n\n CV: PT CHANGED INTO SR AROUND CHANGE OF SHIFT-REMAINS IN SR. PT ON PO AMIODARONE. BP STABLE ON 100MG PO LOPRESSOR TID. ALINE D/C'D. SBP BY CUFF 100-120/40'S.\n\n GU: PT ON PO LASIX-FAIR RESPONSE FROM LASIX THIS AM. PT IS BELOW WT. U/O ADEQUATE. IVF STOPPED-H.L.\n\n GI: PT TAKING FLUIDS W/O DIFFICULTY. POOR APPETITE-JUST FEW BITES. PT HAS BS AND HAD VERY LARGE BM THIS AM.\n\n LAB: K 3.2 THIS AM-KCL IN MAINTENANCE IV AND GIVEN PO K-NOW UP TO 4.3. INR THIS AM 1.9. HCT STABLE-29. GIVEN SS REG COVERAGE FOR BS.\n\n OTHER: PT DENIES PAIN. WIFE IN TO VISIT-HAS LEFT FOR NOW. PT UP IN CHAIR FOR FEW HOURS-BACK TO BED. DR. BY TO SEE PT THIS AM.\n\n A/P:SEEMS VERY FATIGUED-DID NOT SLEEP AT ALL LAST NIGHT. SEEMS TO BE IN FAIRLY GOOD SPIRITS. WIFE STILL SOMEWHAT ANXIOUS RE: ALL OF EVENTS THAT HAVE OCCURED. PT IS DOING WELL. TO STAY IN CSRU FOR TODAY.\n" }, { "category": "Nursing/other", "chartdate": "2171-09-05 00:00:00.000", "description": "Report", "row_id": 1678287, "text": "PT UPDATE\n ADDENDUM TO ABOVE NOTE: AS STATED INR 1.9-HEP D/C'D EARLY AM AND COUMADIN ON HOLD FOR TODAY. PT STILL RUNNING LOW-GRADE TEMP. FULLY CULTURED LAST NIGHT. STARTED ON IV VANCO TODAY.\n" }, { "category": "Nursing/other", "chartdate": "2171-09-05 00:00:00.000", "description": "Report", "row_id": 1678288, "text": "Resp Care: Pt remains intubated via #8 Shiley trach.Trach care done. Inner cannula cleaned. BS sl coarse w/ gd aeration bilat. Sx'd for mod amt thick white sputum. Cuff deflated, PMV placed, plan to use as . Taking slow sips of apple juice w/o coughing. Good strong voice. Nebs/Mdi's given as ordered. Remains on .50 trach collar t/o shift. ABG's WNL. Please see carevue for further resp. inquiries.\n" }, { "category": "Nursing/other", "chartdate": "2171-09-05 00:00:00.000", "description": "Report", "row_id": 1678289, "text": "CSRU PROGRESS\nS/O: Passey-muir vaalve placed. RR 19, SAO2 >95% on 50% face mask. Nebs given with trach open. Coumadin given.\nA: Stable.\nP: rehab. ?smaller trach in am. F2.\n" }, { "category": "Nursing/other", "chartdate": "2171-08-23 00:00:00.000", "description": "Report", "row_id": 1678240, "text": "ALTERED CARDIAC STATUS CONT.\n GI: TF OFF @ 0715 IN PREPARATION FOR BRONCH. RESTARTED TF @ 1000 RESIDUALS <15MLS. TOLERATING TF @ 30 MLS- OFF @ 1830 DUE TO HYPOTENSION- HO AWARE. ABD SOFT NO STOOL, + BOWEL SOUNDS.\n GU: GOOD UO\n ENDO: 3 UNITS REGULAR HUMALIN INSULIN X1 FOR GLUCOSE OF 128\n PAIN: RECIEVED 1 MG MSO4 X2\n SKIN: INTACT\n SOCIAL: WIFE INTO VISIT THROUGHOUT THE DAY, SPOKE WITH DR ,, AND .AND UPDATED.\nA: LABILE BP WITH LEVEL OF SEDATION,MAE NOT TO COMMAND, PAC'S, NO FURTHER BLEEDING FROM IABP SITE. DECREASED RATE AND TV WITH BETTER ABG.CONTINUES WITH BLOODY SECRETIONS. TOLERATING TF, DIURESING,\nP: MONITOR COMFORT, HR AND RYTHYM, SBP, RESP STATUS, NEURO STATUS, I+O- TF + RESIDUALS, LABS, IABP, PP, AS PER ORDERS. CI.\n" }, { "category": "Nursing/other", "chartdate": "2171-08-24 00:00:00.000", "description": "Report", "row_id": 1678241, "text": "agitation\nrecieved 1 mgx1 and .5 mg iv ativan x2 for agitation and hypertension however sbp 80's - recieved 500 ml ns bolus with sbp 90. with pm care pt sbp 140's and propofol increased from 55 to 75 . continues to diurese.iabp with fair augmentation p: monitor comfort, hr and rythym,iabp, sbp-keep sbp>100, resp status, neuro status,i+o, labs. as per orders. ? or sunday or monday.\n" }, { "category": "Nursing/other", "chartdate": "2171-08-24 00:00:00.000", "description": "Report", "row_id": 1678242, "text": "Resp Care Note, Pt remains on current vent settings. See vent flow sheet for further details. Sustion sml amts thick bld tinged secretions. Propofol increased.MDI'S given\n" }, { "category": "Nursing/other", "chartdate": "2171-08-24 00:00:00.000", "description": "Report", "row_id": 1678243, "text": "PT UPDATE\n PT IS S/P CRYCOTHYROIDOTOMY ON .\n\n NEURO: PT AT CHANGE OF SHIFT AND VERY AGITATED WHEN PROP DOSE DECREASED. DR. IN TO SEE PT AND ORDERED PT BACK UP TO 70MCG PROP OR DOSE IT TAKES TO KEEP PT CALM AND SEDATED. PT WAS MAE, THOUGH NOT TO COMMAND. PROP BACK UP TO 65-75MCG DURING NIGHT; AND MOSTLY BP HAS BEEN 110-120 RANGE. SBP> 90 IS ACCEPTABLE. OCCAS. BP DOWN TO 80'S AND PROP DOSE DECREASED. EVEN AT THIS DOSE; PT DOES STILL OCCAS. MOVE SLIGHTLY IN BED. PERL.\n\n RESP: BS CLEAR, DECREASED IN BASES. ABG GOOD THIS AM-MIN CHANGE FROM YEST AFTERNOON. PT SX FEW TIMES FOR SM AMTS BL TINGE. AFTER GIVING PT .T. GOT UP THICK BL. TINGE PLUG; BUT OVERALL LESS SPUTUM THAN REPORTED EARLIER IN DAY. NO BLEEDING NOTED AROUND TRACH.\n\n CV: CI REMAINS EXCELLENT. IABP CONT ON 1:1 WITH ONLY FAIR UNLOADING SECOND. TO FREQUENT PAC'S. NTG REMAINS OFF. HR 70'S. SR . CONT ON 900U HEPARIN-PT/PTT FROM THIS AM PENDING. BPPP WITH FEET WARM.\n\n GU: GOOD AMTS URINE.\n\n GI: NGT-FEEDING. NO STOOL.\n\n LAB: K REPLACEMENT. HCT STABLE AT 30. ALL AM LABS PENDING.\n\n OTHER: SKIN COND GOOD. NO BREAKDOWN OR REDNESS. PT Q 2 1/2 HR. TOL WELL. KNEE IMMOB. AND WAFFLE BOOT RT LEG REMOVED AND LEG CHECKED-NO REDNESS-REAPPLIED. MED WITH OCCAS DOSE MSO4 FOR PAIN.\n\n A/P: PT RELATIVELY STABLE; BP LESS LABILE THAN ON EVE SHIFT; BP FAIRLY EASILY MAINTAINED WITH SBP>90 WITH MIN. TITRATION OF PROP. PT VERY AGITATED WHEN MORE AWAKE. TO REMAIN SEDATED IN CSRU UNTIL OR FOR CABG.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2171-08-22 00:00:00.000", "description": "Report", "row_id": 1678236, "text": "CSRU Progress Note\nS/O: Neuro: Followed commands and nodded head appropriately. Kept sedated with propofol and lorazepam.\n CV: NTG .2, HR 80s with apcs. BP 120/70, IABP 1:1.\n Resp: Fully ventilated. Bronch early am showed tracheobronchitis. Small amt bloody secretions. Trach site bleeds intermittently.\n Renal: Lg uo despite slowing IV fluids. K repleted.\n Heme: Heparin 900u/hr with PTT 51. Bleeding at trach site, sm amt oozing at IABP site.\n ID: Afebrile. Begun on enteral levoflox and flagyl.\n GI: Sm amt brown drg ngt. On lansoprzole. Begun of impact tf.\n Endo: GLu 120-134.\n SKin: Intact.\n Family: Wife present most of day.\nA: Stable, sedated.\nP: Eval lungs tomorrow, ?CABG Saturday. Advance tf as tol. Watch trach site. Supportive care.\n" }, { "category": "Nursing/other", "chartdate": "2171-08-30 00:00:00.000", "description": "Report", "row_id": 1678267, "text": "CSRU NPN\n\nNeuro: Awake all night. Stating he couldn't fall asleep. Anxious regarding trach change in morning per patient. Appropriate most of the time in conversation but then will make statements that indicate he is still confused at times. Oriented to self and place but confused to date unless looks at calendar. Thought it was morning last evening. MAE with good strength.\n\nCV: Occasional PAC's. Lytes repleted. BP stable. BP will occasionally go up briefly for no obvious reason then return to baseline. Heparin gtt increased to 900u/hr for PTT of approx 30. Repeat PTT pnd.\n\nResp: Passey muir valve in all night with stable O2sats. Suctioned x 2 for thick white secretions. BS diminished at lower lobes. Pt requiring much encouragement to cough and deep breathe.\n\nGI: NGT clamped all night with residual of 10-20cc. Abd soft. Asked to bedpan x 1 with no BM at that time. Sips of water without difficulty.\n\nGU: u/o adequate.\n\nEndo: SSRI per orders.\n\nID: Afebrile.\n\nSkin: Intact. Large eccymosis noted left groin. Incisions clean and dry.\n\nComfort: c/o incisional pain with pulm hygiene. Low dose morphine given.\n\nA: Slightly confused. Tolerating passey muir valve. Hemodynamically stable.\n\nP: Monitor mental status and reorient prn. Heparin adjustment until PTT therapeutic. Pulmonary hygiene. Trach change by Dr. this morning. ? plans for advancing diet today. Increase activity as tolerated.\n" }, { "category": "Nursing/other", "chartdate": "2171-08-30 00:00:00.000", "description": "Report", "row_id": 1678268, "text": "Shift Note\nNeurologically pt is intact, MAE to command. Pt is confused at times but reorients easily. Hemodynamically, brief run of Afib this am, metoprolol 5mg IVP given with effect. Pt has maintained SR with frequent PAC's. Trach changed to a #4 by Dr. . Pt oob to chair for 5 hours today, mobility is improved from yesterday. U/O is qs, +bowel sounds, large heme + BM today. See flowsheet for details.\n" }, { "category": "Nursing/other", "chartdate": "2171-08-30 00:00:00.000", "description": "Report", "row_id": 1678269, "text": "Resp Care: Pt had trach changed from no#7 to no#4 shiely without incident. Pt has had trach button all shift and is wearing N/C with sat's of 95% or greater.Pt also had PT and was walking around unit.Alb and flovent given x 1.\n" }, { "category": "Nursing/other", "chartdate": "2171-08-31 00:00:00.000", "description": "Report", "row_id": 1678270, "text": "CSRU Nursing Progress Note\nNeuro: Pt remains S&O x3 however remains off and talking about odd things that don't exist.\n\nCardiac: Pt in SR HR 72-88 with occ PAC's. BP 119-151/59-65. Pt on 1300u/hr heparin, PTT drawn at 0700, tell team and adjust heparin accordingly.\n\nResp: Pts trach remains capped. Pt on 2L via NC with O2 sat 98-99%. BS clear in upper airway decreased in bases. Pt encouraged to use IS.\n\nGI: Pt started on diet, large BM on day shift. However still requires pills be curshed to swallow.\n\nGU: Pt has f/c wihth good u/o.\n" }, { "category": "Nursing/other", "chartdate": "2171-09-04 00:00:00.000", "description": "Report", "row_id": 1678283, "text": "NPN0700-1900;\nCONTINUED TO DRAIN SEOUS DRAINAGE FROM LOWER END OF STERNAL WOUND WHEN COUGHING STERNUM UNSTABLE . THEREFORE WENT TO TO OR AT 0930, AFTER UNSUCCESSFUL ATTEMPT TO PLACE ALINE AND TRACH.\nRETURNED FROM OR AT 1230 AFTER HAVING HAD STERNAL REWIRING WITH I + D. WITH CHEST CLOSED AND MED CHEST TUBE . CONNECTED TO 20 CM. SUCTION. SEDATED ON AND INTUBATED WITH TRACH TUBE INPLACED AND VENT 600X10 ON FIO2 50%. LUNG SOUNDS CLEAR, DIMINISHED AT BASES. WIFE AND SON UPDATED BY DR .\n\nNEURO; WEANED OFF . BY 1800 AOOX3 MAE TO COMMAND NODS APPROPRIATELY. APPEARS ANXIOUS AT TIMES.\n\nRESP; WEANED TO PS 5 PEEP5 ABG SENT SUCTIONED SEVERAL TIMES FOR THICK BLOODY SECRETIONS. LUNG SOUNDS COARSE WITH AUDIBLE WHEEZE GIVEN NEBS BY RESP AND IMPROVED TO CLEAR UPPER DIMINISHED AT BASES.SATS 100% THROUGHOUT.\n\nCVS; T MAX 100.6 PO, NRS 80-90 WITH BOUT OF AFIB TO 130,S GIVEN LOPRESSOR 5MGS I,,V, AND CONVERTED BACK TO NSR 98 WITH BP 107-125 UP TO 160 AFTER OFF.\n\n GU; DRAINING GOOD QUANTITIES CLEAR YELLOW URINE.\n\nGI NPO NO NGT. BELLY SOFT DISTENDED DENIES PAIN .\n\nWOUND WITH DSD AND TRANSPARENCY WITH SMALL AMOUNT PINK TINGED STAIN UNCHANGED SINCE RETURN FROM OR. CT DRAINING SCANT AMOUNTS SANQUINOUS DRAINAGE.NO LEAK .POS FLUCT NO S/C EMPHYSEMA NOTED.\n\n REMAIN WWITH ECCHYMOTIC AREA OVER LT AND AROUND BACK OF THIGH EXTENDING TO THIGH TO KNEE.\nLABS WNL EXCEPT K 4.9 REPEAT DOWN TO 4.2 AT 1800. ABGS SATS.\nHEPARIN RESTARTED AT 1800 AT 1400 U/HR.\n\nFAMILY UPDATED WITH CURRENT PLAN OF CARE.AND HAVE GONE HOME WIFE ANXIOUS OFFERED EMOTIONAL SUPPORT.SON ACCOMPANIED WIFE.\n" }, { "category": "Nursing/other", "chartdate": "2171-09-05 00:00:00.000", "description": "Report", "row_id": 1678284, "text": " CSRU 7P-7A SHIFT SUMMARY;\n\nNEURO; ALERT, ANXIOUS, FOLLOWS COMMANDS AND MAE'S WELL. AWAKE ALL NOC. NODS HEAD YES OR NO TO SIMPLE QUESTIONS AND WRITES FOR FURTHER COMMUNICATION. PT NODS HEAD YES WHEN ASKED IF HE IS ANXIOUS. DR NOTIFIED AND PT GIVEN BENADRYL 25MG IVP WITH NO EFFECT.\n\nRESP; PT AT BEGGINNING OF SHIFT ON CPAP 5/5 WITH ABG'S WNL. PT CHANGED TO TRACH MASK OVER NOC WITH ABG,RR AND 02 SAT'S WNL. PT SUCTIONED FOR BLOODY SECREATIONS BUT NOW WITH GOOD STRONG COUGH AND C+R THICK PINK TO WHITISH SECREATIONS. LUNG COARSE TO WHEEZY WITH ALOT OF COUGHING BUT IMPROVES AFTER SUCTIONING. PT RECEIVING ALBUTEROL NEBS FROM RESP ATC.\n\nCARDIOVAS; IN AND OUT OF AFIB TO NSR ALL NOC. AFIB RATES 120'S TO 140'S TX WITH SEVERAL DOSES LOPRESSOR 5MG IVP THRUOUT THE SHIFT. PT DOES CONVERT TO NSR 90'S OFF AND ON WITH LOPRESSOR AND AT TIMES SPONT. BP STABLE BUT DOES BECOME HYPERTENSIVE WITH SBP 140'S 160'S WITH COUGHING AND SUCTIONING. TEMP SPIKE UP TO 101.8 DR NOTIFIED BLD CULTURE X1, SPUTUM, AND URINE CULTURES ,SENT AND PT GIVEN TYLENOL PER ORDERS. HEPARIN GTT CONT'S AT 1400U HR PTT PENDING THIS AM.\n\nGI; NPO OVER NOC D/T TRACH. BS ABSENT NOW HYPOACTIVE. ON BEDPAN X1 NO BM BUT DID PASS FLATUS. C/O NAUSEA ONCE TX WITH REGLAN 5MG IVP X1 WITH GOOD EFFECT.\n\nGU; HOURLY URINE OP WNL.\n\nCOMFORT; C/O INCISIONAL DISCOMFORT. MED WITH 1MG IVP MS04 WITH GOOD EFFECT. NODDED HEAD NO REST OF NOC WHEN ASKED IF HE WAS IN PAIN.\n\nENDO; BLD SUGARS TX WITH REG INSULIN SQ SS PER PROTOCOL.\n\nPLAN; CONT TO MONITOR AND ASSESS. POSS. DC OF TRACH THIS AM IS RESP STATUS REMAINS STABLE\n\n\n" }, { "category": "Nursing/other", "chartdate": "2171-08-23 00:00:00.000", "description": "Report", "row_id": 1678237, "text": "csru update\nneuro: remains sedated on propofol though does occas \"lighten\" lifting arms/legs slightly off bed. perl.\n\ncv: vs/hemo stable as per flowsheet. anticoagulated on heparin, awaiting am ptt. iabp 1:1, w/ good waveform and unloading. ci~2.6. iabp site w/ mod amt bldy oozing early in shift resolving w/ sm pressure dsg. feet warm much of time, dp easily palped. ntg on much of shift. frequent pac. k+ repleted freq.\n\nresp: sx for thick bloody secretions several times. pao2 to 79 on .40 fio2->increased to 50. o2 sats mid-high 90's. lungs coarse at times, dim bases this am. remains full vent support. bldty dng at trach site.\n\ngi: abd soft, hypo bs. ngt w/ impact at 10cc/hr. resids minimal.\n\ngu: uop qs via foley.\n\nassess: stable pm. marginal pao2. oozy at trach/iabp.\n\nplan: bronch this am. monitor abg. monitor ptt, watch blding. cont aggessive support.\n" }, { "category": "Nursing/other", "chartdate": "2171-08-23 00:00:00.000", "description": "Report", "row_id": 1678238, "text": "Resp Care Note, Pt remains on current vent settings. See vent flow sheet for further details.Suctioned lrg amts thick bldy secretions.Sedated with lrg amts propofol. RSBI not done due to no spont resp.MDI'S given IABP @ 1:1. FI02 was increased during noc for PaO2'S in the 70'S.\n" }, { "category": "Nursing/other", "chartdate": "2171-08-23 00:00:00.000", "description": "Report", "row_id": 1678239, "text": "ALTERED CARDIAC STATUS\nO: CARDAIC: SR80'S WITH PAC'S NOTED @ TIMES MORE FREQUENT THAN OTHERS- MAG SO4 2 GM X1. WHEN PT LIGHT HR 100 WITHOUT PAC'S . NO VEA NOTED. K 3.5 RECIEVED 40 MEQ X1-REPEAT K 4.2 RECIEVING 20 MEQ KCL PRESENTLY. SBP 130'S WITH MAP 90'S WHEN \"LIGHT\" WHEN SEDATE SBP 80'S. RECIEVED 500 ML NS TO ATTEMPT TO KEEP SBP >100. PAD'S HIGH TEENS WITH CVP 7-11. CI>2.2 SVR DECREASING. IABP WITH FAIR AUGMENTATION. FEET WARM TO TOUCH,PALP PP, KNEE IMMOBILIZER INTACT, RIGHT FEM SITE C+D-SOFT. HCT 33- PA-NIILLSON AWARE.\n RESP: BRONCH THIS AM PER DR. LEFT BRONCHUS AND MAINSTEM MUCH IMPROVED RIGHT BRONCHUS REMAINS REDDENED. SX FOR THICK BLOODY SPUTUM X 3 LAVAGED. VENT CHANGES PER FLOW WITH GOOD ABG. BS COURSE UPPER WHICH CLEARS WITH SUCTIONING. RR HIGH TEENS LO TWENTIES. O2 SAT > 96%. TRACHE CARE X 2, LESS BLEEDING NOTED, INNER CANNULA CHANGED X2- CLEAN NOT ALOT OF SECRETIONS NOTED.\n NEURO: PROPOFOL @ 75 -DECREASED TO 30 WITH PT LIFTING TORSO OFF BED, MAE-NOT TO COMMAND, DID OPEN EYES WHEN ASKED TO DO SO HOWEVER WAS NOT FOCUSED AND HAS NOT DONE AGAIN, PERL, THE LIGHTER THE SEDATION THE LARGER HIS PUPILS-5MM,\n GI:\n" }, { "category": "Nursing/other", "chartdate": "2171-08-21 00:00:00.000", "description": "Report", "row_id": 1678231, "text": "Resp. Care Note\nPt received from OR after emergent trache done for difficult airway. Pt was to have CABG. Pt with #7 cricothyroid trache. Vented on settings as per resp. flowsheet. Plan to keep vented overnight and return to OR for his CABG on or .\n" }, { "category": "Nursing/other", "chartdate": "2171-08-21 00:00:00.000", "description": "Report", "row_id": 1678232, "text": "Nursing Admission Note\nPresented to ER with chest heaviness. Sent to cath lab, results positive for mvd. IABP placed and pt sent to OR for CABG. Loss of airway during induction. Unable to ventilate pt. Emergent crycothyroidotomy performed by anesthesia. Pt sent to CSRU to remain sedated until OR.\nNeuro: Pt has awakened x 2 and followed commands. MAE equally. PERRL. Dangerously agitated, gagging on trach. Was seen by and decision was made to keep pt sedated. Family is aware of plan.\nCV: sr with frequent pac's and occ pvc. hemodynamics stable. see flowsheet.\nresp: ls coarse, clearing with sxn. Sxn brb from trach. +crepitus felt around trach site. CXR obtained. vent adjusted acc to abg's.\ngi: benign\ngu: foley to cont drg.\nplan: cont sedated in ICU.\n" }, { "category": "Nursing/other", "chartdate": "2171-08-22 00:00:00.000", "description": "Report", "row_id": 1678233, "text": "Resp Care Note, Pt remains on current vent settings. See vent flow sheet for further details. Started on MDI'S prn for wheezes. IABP @1:1. Increased propofol, increased PA pressures 50's.RSBI not done due to no spont respirations. Will cont to monitor ABG'S.\n" }, { "category": "Nursing/other", "chartdate": "2171-08-29 00:00:00.000", "description": "Report", "row_id": 1678263, "text": "NPN:\n\nNEURO: APPEARS ORIENTED TO PLACE AND SELF. FOLLOWS COMMANDS AND NODS APPROPRIATELY TO QUESTIONS. MAE WITH EQUAL STRENGTH.\nCV: 90-100'S SR-ST WITH FREQ TO OCC APC'S. LOPRESSOR 50 MG GIVEN DOWN NGT. BP STABLE. PALP PEDAL PULSES. K REQUIRING FREQ REPLETION. ON HEPARIN GTT ^ 800U/HR FOR PTT OF 30-AWAITING AM PTT-SENT 6AM.\nRESP: LUNGS WITH OCC WHEEZES TREATED WITH COMBIVENT INHALER AS ORDERED. ON 40% TRACH COLLAR WITH O2 SATS>98%. SUCTIONED FOR SMALL AMTS THICK CLEAR TO WHITE SECRETIONS-COUGHING AND RAISING THICK CLEAR WHITE SPUTUM. ABG'S WNL.\nGU: FOLEY TO GD WITH STABLE CR .7. UO WITH OCC DIPS TO 15-25CC/HR BUT MOSTLY > 30.\nGI: ABD SOFTLY DISTENDED WITH FAINT TO ABSENT BS. NGT TO LCS WITH LG BILIOUS DNG. MEDS VIA NGT. NO N/V. REGLAN GIVEN AT 645AM.\nENDO: STABLE ON INSULIN GTT AT 1U/HR WITH GLUCOSES 105-120.\nACTIVITY: REMAINED IN BED OVERNIGHT-TURNED SIDE TO SIDE.\nCOMFORT: MEDICATED WITH 2MG IV MSO4 X2 WITH EFFECT.\nINCISIONS: SEE CAREVUE.\nA: STABLE EXTUBATED ON 40% TRACH COLLAR.\nP: ASSESS GI FXN AND TOLERANCE OF MEDS VIA NGT, DISCUSS PLAN FOR TRACH-PASSE MUIR, ?DECANNULATE. CONT HEPARIN -GOAL PTT> 40. CARDIAC REHAB.\n" }, { "category": "Nursing/other", "chartdate": "2171-08-29 00:00:00.000", "description": "Report", "row_id": 1678264, "text": "Shift NOTE\nPt is neurologicaly intact, confused at times but easily reoriented. Hemodynamics as per flowsheet. lungs CTA but course. U/O qs, + bowel sounds, small smears on pad, less drainage from NGT. Pt oob to chair. To and from barium swallow without incident. See flowsheet for details.\n" }, { "category": "Nursing/other", "chartdate": "2171-08-29 00:00:00.000", "description": "Report", "row_id": 1678265, "text": "Resp Care: Pt received on 40% trach mask.B/S fair air movement some rhonchi, HR 97, sat 97% and RR 20. Pt remains on 40% trach mask at this time.\n" }, { "category": "Nursing/other", "chartdate": "2171-08-29 00:00:00.000", "description": "Report", "row_id": 1678266, "text": "UPDATE FROM 3PM TO 7PM.AWAKE,ALERT,FOLLOWS COMMANDS USUALLY ORIENTED,SOMETIMES APPEARS SLIGHTLY CONFUSED.HEPARIN WAS RESTARTED AT 800UNITS/HR AFTER BEING HELD FOR ONE HR.SEEN AND EVALUATED BY PHYSICAL THERAPY.AMBULATED WITH THE ASSISTANCE OF TWO PEOPLE.MEDICATED FOR COMPLAINT OF CHEST INCISIONAL PAIN.TOLERATING PO FLUIDS NOW WILL GET 4 DOSES OF REGLAN Q6HRS THEN PRN.NGT TUBE TO REMAIN IN OVERNIGHT CLAMPED AND HAVE RESIDUALS CHECKED Q6HR.SMALLER TRACH TUBE TO BE PUT IN DURING AM BY DR IN AM.PT REMAINS OOB IN CHAIR TOLERATING WELL. BY WIFE.\n" }, { "category": "Nursing/other", "chartdate": "2171-08-22 00:00:00.000", "description": "Report", "row_id": 1678234, "text": "update\nCV: NSR W/ OCC TO FREQ PAC,S W/ LITTLE CHANGE AFTER LYTES REPLACED. HAD ~8 BEAT VT THIS A.M. 0630 AFTER 40 MEQ KCL FINISHED IV. ADD'L MGSO4 GIVEN AND EKG DONE. NO OBVIOUS CHANGES. CK AND MB RISING HOWEVER. CT TEAM NOTIFIED ON ROUNDS. IABP 1:1. DISTAL PULSES EASILY PALP. C.I. CONSISTENTLY > 2 W/ NL SVR. SBP 100-110'S RANGE ON .2 MCG/KG/MIN OF IV NTG. IV HEPARIN TITRATED UP FOR SUBTHERAPEUTIC PTT.\n\nRESP: COARSE BS INITIALLY , CLEARING AFTER SUX. SUX FOR SM AMTS THIS BLOODY SECRETIONS. ASTHMA MEDS RESTARTED. NO VENT WEAN O/N. SM AMT BLOODY DRNG FROM TRACH SITE.\n\nNEURO: PT WAKING VERY AGITATED AND SITTING UP IN BED WHILE ON 50 MCG/KG/MIN OF PROPOFOL.PT MAE BUT UNABLE TO RESPOND TO COMMANDS. DOSE TITRATED UP SL FOR BETTER SEDATION.\n\nG.I.: NTG PLACED L NARE AND POSITION CONFIRMED BY AUSCULTATION. SM AMT OF COFFEE GRND DRNG OUT WHEN PLACED TO SUX. PLACED TO SUX AGAIN THIS A.M. FOR SAME DRNG BRIEFLY, OTHERWISE USED FOR MEDS AND KEPT CLAMPED.\n\nG.U.: CONT ON MAINTENANCE IV @ 125ML/HR. UO >100 MOST OF NIGHT.\n\nSKIN: INTACT EXCEPT FOR SM AMT OOZING @ TRACH SITE(SEE ABOVE) AND MOD AMT @ IAB SITE DUE TO PT TRYING TO SIT UP IN BED.\n\nA/P: UNSTABLE HR THIS A.M. EKG UNREMARKABLE BUT PT STILL @ RISK FOR ISCHEMIC CHANGES. MONITOR AND ADJUST HEPARIN PER PROTOCOL. CONT IV NTG. ASSESS NEURO STATUS IF ABLE TO TOL LESS SEDATION W/O AGITATION. KEEP FAMILY INFORMED-WIFE VERY ANXIOUS ABOUT PT. ?O.R. .\n" }, { "category": "Nursing/other", "chartdate": "2171-08-22 00:00:00.000", "description": "Report", "row_id": 1678235, "text": "the pt remained stable throughout the shift.a bronchoscopt was\nperformed and showed a small amount of bloody secretion.no changes on the vent.\n" }, { "category": "Nursing/other", "chartdate": "2171-08-28 00:00:00.000", "description": "Report", "row_id": 1678259, "text": "NEURO~WHEN OFF. PT IS ALERT. FC. MAE. DOES NOT RESPOND TO YES AND NO QUESTIONING. PT HAS A BLANK STARE WILL MAKE EYE CONTACT BUT MOSTLY STARES AT CEILING. WEANED THROUGHOUT THE NIGHT FROM 25 UCG/KG/MIN TO CURRENT RATE OF 10 UCG/KG/MIN. T-MAX 101.1 GIVEN ELIX 650 MG VIA NGT.\n\nCARDIAC~0230 BURST OF AFIB 130'S. GIVEN LOPRESSOR 5 MG IVP X 1. CONT IN CONTROLLED AFIB IN 80'S-90'S. CONVERTED TO SR 86 W/ OCC PAC'S @ 0545. PACER OFF. FIRING INAPPROPRIATELY. MAINTAINING SBP >100 W/ MAP'S 60-90. CONT ON AMIODARONE DRIP @.5 MG/MIN. ELECTROLYTES REPLENISHED. POS PAL PEDAL PULSES BILAT. LOWER EXTREMITIES COOL. GOOD CAP REFILL.\n\nRESP~CONT ON CPAP THROUGHOUT THE NIGHT. WELL. BS~COARSE UPPER/COARSE & DIMINISHED IN BASES. SX FOR SMALL AMTS OF THICK CLEAR /SL BLOOD TINGED SPUTUM. ABG~MET ALKALOSIS.\n\nGI/GU~NPO. NGT LCS~BILIOUS DRAINAGE. PO MEDS FINE. NYSTATIN ORAL SUSPENISON FOR THRUSH. ADEQUATE DIURESIS.\n\nENDO~CONT ON INSULIN DRIP. TITIRATING TO MAINTAIN BG LEVEL W/IN CSRU PROTOCOL.\n\nA/P~IRREGULAR HR. CONVERTED BACK TO NSR W/ OCC PAC'S. QUESTIONING CONT AMIODARONE DRIP. STARTED ON PO LOPRESSOR. CONT TO ATTEMPT SLOW VENT WEAN AS BY PT. ALSO CONT TO WEAN PT OFF MED AS NEED FOR AGITATION AND DISCOMFORT.\n" }, { "category": "Nursing/other", "chartdate": "2171-08-28 00:00:00.000", "description": "Report", "row_id": 1678260, "text": "PT REMAINED ON PSV T/O THE NOC RSBI DONE 103 NO SBT DONE ALB GIVEN AS ORDERED WILL CONT TO TRY TO WEEN TO T/C\n" }, { "category": "Nursing/other", "chartdate": "2171-08-28 00:00:00.000", "description": "Report", "row_id": 1678261, "text": "PROB: S/P CABG\n\nCV: PT BACK IN AFIB WITH HR 90-100. LOPRESSOR DOSE INCREASED, ELECTROLTYES REPLACED. PACER WIRES SENSE AND CAPTURE. AMIODARONE CHANGED TO PO.\n\nRESP: WEANED OFF VENT, TOLERATING TRACH COLLAR-49%. SUCTIONED FOR THIN CLEAR SPUTUM. RESTATED ON LEVOQUIN. PT SEEN BY SPEECH AND SWALLOW, TRIED PASSEY MUIR VALVE FOR 23-30 MIN, TOLERATED WELL.\n\nGU: FOLEY DRAINING YELLOW URINE WITH SEDIMENT.\n\nGI: NGT DRAINING BILIOUS, PLACEMENT GOOD.\n\nNEURO: ALERT ALL DAY, SEEMED TO BE NODDING APPROPRIATELY. WITH PASSEY MUIR VALVE ON, PT TOLD US IT\"S , AND THAT HE WAS IN HOSPITAL. PT SEEMED TO CLEAR AS HE CONTINUED TO TALK.\n\nENDO: BS PER FLOW SHEET, TREATED WITH S/S INSULIN.\n\nSOCIAL: WIFE IN TO VISIT MOST OF DAY.\n\nASSESSMENT: TOLERATING TRACH COLLAR, ABLE TO COUGH AND RAISE SPUTUM.\n\nPLAN: CONT.\nMONITOR ELECTROLYTES.\nPULMONARY TOILET.\nTRACH COLLAR AS TOLERATED.\nPASSEY-MUIR VALVE AS TOLERATED.\nSPEECH AND SWALLOW TO FOLLOW PT.\n" }, { "category": "Nursing/other", "chartdate": "2171-08-28 00:00:00.000", "description": "Report", "row_id": 1678262, "text": "Respiratory note:\nPt is awake and responsive. Trached, weaned off vent support and placed on trach collar, well. passy-muir valve with speech was well too, spo2 remained above 96% the whole time. Lungs clear, sx'd some blood tinged sec. Received flovent and combivent.\n" }, { "category": "Nursing/other", "chartdate": "2171-08-27 00:00:00.000", "description": "Report", "row_id": 1678255, "text": "NEURO~SEDATED ON CURRENTLY @ 35UCG/KG/MIN. ALSO GIVEN MIDAZOLAM .5 MG IV X2 AND MSO4 2MG X1 AND 4 MG X1 THROUGHOUT THE NIGHT FOR DISCOMFORT AND AGITATION. EFFECTIVE. FOLLOW COMMANDS WHEN IS OFF. MAE. GRIMACES TO PAINFIL STIMULI. DID NOT RESPOND TO YES AND NO QUESTIONING. TYLENOL 650 MG ELIX X2 FOR TEMP 101.5. EFFECTIVE AFTER SECOND DOSE.\n\nCARDIAC~IN AFIB NO ECTOPY NOTED. GIVEN LOPRESSOR 5 MG IVP FOLLOWED BY 2.5 MG IVP FOR HR 130/101. ALSO GIVEN AMIODARONE BOLUS AND STARTED ON AMIODARONE DRIP @ 1 MG/MIN. TO DECREASE DOSE TO .5 MG/MIN @ 1000. CI>2. IABP 1:1 W/ GOOD AUGUMENTATION. HAS WEAK POS PAL PEDAL PULSES BILAT. FEET COOL & PALE. CAP REFILL<3 SEC. CONT ON NEO CURRENTLY @ 1 UCG/KG/MIN. MAINTAINING MAP'S 60-90.\n\nRESP~SEE FLOW SHEET FOR VENT SETTINGS. MAINTANING SATS OF 98%. SX FOR SM AMTS OF THIN SL BLOOD TINGED SPUTUM. SPUTUM CX SENT.\nLUNGS COARSE AND DIMINISHED BILAT. TRACH CARE DONE.\n\nGI/GU~NGT LCS~BILIOUS DRAINAGE. ADEQUATE DIURESIS.\n\nENDO~CONT ON INSULIN DRIP TITRATING TO MAINTAIN BG LEVELS WITHIN CSRU PROTOCOL. CURRENTLY @ 4 UNITS/HR.\n\nA/P~IRREGULATR HR. AFIB VS AFLUTTER. CONT ON AMIODARONE DRIP TO DECREASE TO .5 MG/MIN @ 1000. LABILE BP~CONT ON NEO TO MAINTAIN MAP'S 60-90. ATTEMPT TO WEAN TODAY. TO WEAN PT OFF BALLOON PUMP SOMETIME TODAY. QUESTIONING IF ABLE TO START WEANING FROM VENT. MED AS NEEDED FOR ANXIETY ANF DISCOMFORT.\n" }, { "category": "Nursing/other", "chartdate": "2171-08-27 00:00:00.000", "description": "Report", "row_id": 1678256, "text": "Resp care\nPt remains trached & supported via PB 7200 in SIMV mode.\nPt continues to have ^ temp 101. Pt had IABP w/drawn.\nB/S course, w/ diffuse exp. wheezes treated w/ alb/flovent\nMDI's. Sx mod amount of thick yellow secretions.\nPlan: continue support, wean to extubation\n" }, { "category": "Nursing/other", "chartdate": "2171-08-27 00:00:00.000", "description": "Report", "row_id": 1678257, "text": "PROB: S/P CABG\n\nCV: IABP D/CD, CO/CI UNCHANGED. NO HEMATOMA AT SITE NOTED, DRESSING CLEAN AND DRY. CT D/CD, DRAINING S/S DRAINAGE. PACER INTACT, BOTH A AND V WIRES SENSE AND CAPTURE. PT WENT INTO AFIB/FLUTTER AT 18:00 WITH RATE 130-140, GIVEN LOPRESSOR 5MG IV WITH RATE DOWN TO 90'S. AMIO BOLUS 150MG GIVEN BUT PT REMAINS IN AFIB. MAG REPLACED X2, K AND CA REPLACED. CENTRAL LINE CHANGED TO MULTILUMEN, MOVED TO RIGHT SUBCLAVIAN.\n\nRESP: PT WAKING, CHANGED TO CPAP WITH PS. SUCTION FOR BLOOD TINGED SPUTUM. SPUTUM CULTURE -GRAM POSITIVE.\n\nGU: UOP ADEQUATE.\n\nGI: NGT DRAINING BILIOUS DRAINAGE.\n\nNEURO: AGITATED WHEN WAKING. MAE. . INTERMITTENTLY OPENS EYES WHEN NAME CALLED.\n\nASSESSMENT: AFIB NOT RESPONDING TO AMIO BOLUS. TOLERATING IABP D/C.\n\nPLAN: CONT TO MONIRO\nCHECK BS Q 1HR\nREPLACE LYTES PRN\nCHECK IABP SITE.\n\n" }, { "category": "Nursing/other", "chartdate": "2171-08-27 00:00:00.000", "description": "Report", "row_id": 1678258, "text": " 7PM TO 11PM:\nNEURO: WEANED PROP SLOWLY AND TOLERATING, MAE, NOT YET FOLLOWING COMMANDS.\n\nCARDIAC: NSR IN THE 80'S NO ECTOPY,SBP'S ALL WNL, RUNNING LOW GRADE TEMPS TYLENOL GIVEN WILL FOLLOW, PALPIBLE PEDIAL PULSES, SKIN WARM DRY AND INTACT, 2 A AND 2 V WIRES TO BOX THAT IS A SENSING.\n\nRESP: DIM IN BASES BILAT ON CPAP AND PRESSURE SUPPORT, ABG'S GOOD, SCANT TAN THICK SECRETIONS WHEN SXNED.\n\nSKIN: CHEST WITH DSD THAT IS CDI, LEFT LEG WITH ACE THAT IS CDI, ABD WITH CT DSD THAT IS CDI, RIGHT FEM DSD CDI.\n\nGI/GU: NG TUBE TO LWS WITH BILLEOUS DRAINAGE, NPO MEDS VIA NG-TUBE, ABD SOFT AND ROUND WITH HYPOACTIVE BOWEL SOUNDS, MAKING GREATER THAN 30CC/HR OF URINE, ON RISS GTT.\n\nPLAN: WEAN FROM VENT, WEAN PROP IF TOLERATES, MONITOR FOR ECTOPY OR ARRYTHMIAS, MONITOR BLOOD SUGARS Q 1 HR.\n" }, { "category": "Nursing/other", "chartdate": "2171-08-26 00:00:00.000", "description": "Report", "row_id": 1678249, "text": "EKG NSR, OCC PACS. SBP STABLE WHILE SEDATE, HTN WHEN LIGHTER. FP, CO/CI ACCEPTABLE. IABP ON 1:1, NO PROBLEMS WITH TRIGGER OR TIMING, OOZING AT INSERTION SITE. REMAINS ON HEPARIN, INCREASED TO 1200U AT 2100, PTT IN THERAPEUTIC RANGE THIS AM. 2 UNTS FFP TRANSFUSED PER ORDER. LOWGRADE TEMP, 99.5. EXCELLENT UO, CLEAR, YELLOW. BREATH SOUNDS CLEAR BILAT, ETT SUCTIONED FOR MOD AMTS THICK BLOODY SECRETIONS, SEVERAL PLUGS NOTED PER RESP RX. VENT SETTINGS PER FLOW SHEET, NO CHANGES OVERNIGHT, ACCEPTABLE ABGS. ABD SOFT, TF AT 50CC/HR UNTIL MN, THEN NPO FOR OR. BOWEL SOUNDS PRESENT, NO FLATUS OR STOOL TONIGHT. SEDATED WITH PROPOFOL AND INTERMITTENT MSO4. OCC LIGHTENS, MAE SPONT, BUT NOT TO COMMAND, OPENS EYES OCC. PREOP SCRUB DONE, CHECKLIST COMPLETED, READY FOR OR.\n" }, { "category": "Nursing/other", "chartdate": "2171-08-26 00:00:00.000", "description": "Report", "row_id": 1678250, "text": "Respiratory Care:\nPatient remains on ventilatory support in SIMV/PSV mode, with no changes made throughout the night. Morning ABG's show a compensated metabolic alkalemia with good oxygenation on 40% and 5cm PEEP.\n\nAnesthesia in with patient, preparing him for surgery. RSBI unable to be performed at this time. Received MDI albuterol and flovent inline.\n\nSX'd for blood-tinged plugs X 2.\n" }, { "category": "Nursing/other", "chartdate": "2171-08-26 00:00:00.000", "description": "Report", "row_id": 1678251, "text": "~1215 Patient arrived from or s/p cabg x 4, lima to lad, vein to diag, om1, om2. Trach in place and sedated with iv . I v neo ^. ct's minimal drainage, no leak. Foley to cd, clear urine. Palpable pulses.\n\nNeuro: remains sedated on iv , after reversal patient mae, following simple commands but restless. Resedated with iv ms .\n\nCardiac: Mp sr without. Iabp 1:1 rt groin, augmenting well. Pulses palpable. Pacer attached, not on, attempted to test for capture and ma's, hr ^, pacer off. iv neo ^, titrated to keep sb/p ^ 90. Ct's patent for small amt sero-sang. drainage.\n\nResp: Remains on ventilator, plan is to wean after Iabp dc'd in am. Cs clear, suctioned for moderate thick sl bld tinged secretions.\n\nGi: Ng in place, patent for bilious drainage.\n\nGu: Foley in place, adequate amts clear yellow urine.\n\nEndo: Insulin gtt ^, following protocol.\n\nPain: Medicated with iv ms with effect.\n\nFamily in, aware of events and plan.\n" }, { "category": "Nursing/other", "chartdate": "2171-08-26 00:00:00.000", "description": "Report", "row_id": 1678252, "text": "Resp care\nPt remains on vent support via PB 7200 in SIMV/PS mode.\nPt went to OR in the AM for CABG x 4, w/ no complications\nB/S dim, w/ exp. wheezes treated w/ alb & flovent.\nSx mod thick sl. bld. tinged secretions.\nPlan: continue support, wean in the AM after IABP is w/drawn\n" }, { "category": "Nursing/other", "chartdate": "2171-08-26 00:00:00.000", "description": "Report", "row_id": 1678253, "text": "Temperature ^ despite crushed tylenol down ng tube and liquid tylenol. Blood c/s drawn from radial aline and IABP a line as well as cvp port of swan. Urine for c/s sent also. Needs sputum c/s.\nRemains sedated with iv ms, iv as well as iv , mae, restless at times. Plan is to keep sedated till IABP is dc'd in am.\n" }, { "category": "Nursing/other", "chartdate": "2171-08-27 00:00:00.000", "description": "Report", "row_id": 1678254, "text": "RESPIRATORY CARE:\n\nPt remains trached, vent supported. Trache intermittently leaking throughout shift, requiring manipulation and some addition of air to cuff. Sxing mod amts of tan secretions from trache, spec sent. Administering Albuterol and Flovent MDI's in line with vent. No vent changes made thru noc. See flowsheet for further pt data.\nPlan: Maintain vent support.\n" }, { "category": "Nursing/other", "chartdate": "2171-08-24 00:00:00.000", "description": "Report", "row_id": 1678244, "text": "PROB: TRACHEOSTOMY, IABP\n\nCV: SR-ST WITH FREQ PACS NOTED. BP LABILE 90-160/SYS, ELEVATED WITH LIGHTENING OF SEDATION. IABP 1:1 WITH GOOD AUGMENTATION, FEET WARM AND PEDAL PULSES PALPABLE. HEPARIN CONT AT 900U/HR. TYPE AND CROSS DONE FOR OR. K REPLACED.\n\nRESP: LUNGS CLEAR, DIM AT BASES. O2 SAT ADEQUATE. ABGS GOOD. SUCTIONED FOR THICK BLOOD TINGED SPUTUM. DIFFICULT TO VENTILATE PT WITH SEDATION OFF DUE TO HIGH PIPS AND COUGHING.\n\nGU: CLEAR YELLOW URINE.\n\nGI: TOLERATING TF WITH LOW RESIDUALS. BOWEL SOUNDS HYPERACTIVE, REGLAN HELD.\n\nNEURO: PROPOFOL WEANED TO 20MCG, PT BECAME AGITATED AND RESTLESS. THRASHING LEGS IN BEDS. COUGHING WITH RESPIRATORY RATE OF 30, PIPS 50-60. PT WEANED TO EVALUATE NEURO STATUS. PT OPENING EYES WHEN NAME CALLED, AND INTERMITTENTLY SQUEEZING HAND WHEN ASKED. PT GIVEN HALDOL PER DR. WITH SOME IMPROVEMENT. NEURO CAME TO EVALUATE PT. PT FOLLOWING SIMPLE COMMANDS AT THAT TIME ALTHOUGH STILL AGITATED. NEURO MD SPOKE WITH PT'S WIFE. MAE, .\n\nASSESSMENT: AGITATED WHEN NOT SEDATED.\n\nPLAN: OR ON MONDAY.\nCONT TF-GOAL RATE 80CC/HR\nMONITOR LABS/ABGS/COAGS\nHALDOL AND PROP FOR SEDATION.\nIABP 1:1\n" }, { "category": "Nursing/other", "chartdate": "2171-08-24 00:00:00.000", "description": "Report", "row_id": 1678245, "text": "resp care\npatient remains trached and vented and sedated. decreased sedation for neuro exam today and pt. became very aggitated. sx for bloody secretions. no vent changes. good abg. plan o.r. on monday for cabg. see rt flowsheet for more.\n" }, { "category": "Nursing/other", "chartdate": "2171-08-25 00:00:00.000", "description": "Report", "row_id": 1678246, "text": "ekg nsr, occ pacs. sbp labile, 90s when more sedated, 140s when lighter. fp and co/ci acceptable, iabp at 1:1, no problems with trigger or timing. cardiac echo showed good lv function, ef > 50%. afebrile. adequate uo, clear, yellow, has occ auto diuresis. electrolytes repleted, glucose rx per sliding scale. breath sounds clear, decreased at bases, ett suctioned for small to mod amts thick bloody secretions. vent settings per flow sheet, no changes overnight, abgs acceptable. small amt sang drainage at trach site.h site, small amt at r fem iabp site, dressing changed. abd soft, distended, bowel sounds present. tolerating tf at 50cc/hr, scant residuals, no stool overnight. sedated with propofol, occ doses of haldol. occ becomes light, and opens eyes to voice, mae restlessly, did not follow commands. awaiting cab, probably monday.\n" }, { "category": "Nursing/other", "chartdate": "2171-08-25 00:00:00.000", "description": "Report", "row_id": 1678247, "text": "RESP CARE\nPT REMAINS INTUBATED & SUPPORTED VIA PB 7200 IN THE SIMV\nMODE. B/S CLEAR, W/ OCC. EXP WHEEZES TX W/ MDI ALB &\nFLOWVENT. PT TRANSPORTED TO CT FOR HEAD SCAN WAITING\nON RESULTS. PT TODAY FOR POSS. ASPIRATION,\nSAMPLE SENT TO LAB. NO CHANGES MADE\nPLAN: CONTINUE SUPPORT\n" }, { "category": "Nursing/other", "chartdate": "2171-08-25 00:00:00.000", "description": "Report", "row_id": 1678248, "text": "PROB: PRE-OP CABG\n\nCV: SR OCC PAC NOTED, MAG AND K REPLACED. VSS. IABP 1:1 WITH GOOD AUGMENTATION. FEET WARM, PEDALS PALPABLE.\n\nRESP: LUNGS CLEAR, DIM IN BASES. BRONCH DONE TODAY, LUNGS IMPROVING, LESS SECRETIONS. SPUTUM SENT FOR C&S, GRAM STAIN. O2 SATS ADEQUATE. ABGS GOOD.\n\nGU: UOP ADEQUATE. FOLEY DRAINING CLEAR YELLOW URINE.\n\nGI: TOLERATING TF, BOWEL SOUNDS PRESENT. ABD SOFT. CONT ON REGLAN.\n\nNEURO: HEAD CT DONE TODAY-NORMAL. SEEN BY NEUROLOGY. MAE. . CONT ON PROPOFOL 50MCG/KG.\n\nENDO: BS ELEVATED, SEE FLOW SHEET.\n\nSOCIAL: FAMILY IN TO VISIT.\n\nASSESSMENT: PT IMPROVING.\n\nPLAN: OR IN AM\nNPO AFTER MIDNOC.\nLABS PENDING.\n" }, { "category": "Nursing/other", "chartdate": "2171-09-01 00:00:00.000", "description": "Report", "row_id": 1678276, "text": "ptt\nD: pt cont on 1600u/hr heparin\nR: ptt 70\nA: drip left at present rate- pt to recive coumadin 2.5mg po tonight\n" }, { "category": "Nursing/other", "chartdate": "2171-09-01 00:00:00.000", "description": "Report", "row_id": 1678277, "text": "Resp care\nPt remains on PMV on 2 l/m o2 w/ o2 sats > 94%.\nB/S dim bases w/ exp wheezes treated w/ alb/flovent mdi's\nPt raising white secretions on his own.\nPlan: Continue therapy\n" }, { "category": "Nursing/other", "chartdate": "2171-09-02 00:00:00.000", "description": "Report", "row_id": 1678278, "text": "NURSING PROGRESS NOTE\nPT CONTINUES TO IMPROVE.\nNEURO: INTACT, PERCOCET WITH EFFECT.\nCV: SR WITH STABLE BP. FIRST DOSE OF COUMADIN GIVEN TONIGHT.\nPULM: PASSY MUIR VALVE IN PLACE WITHOUT DIFFICULTY. STRONG PROD COUGH.\nGI: WNL\nGU: VOIDING.\nPLAN: TX TO FLOOR.\n" }, { "category": "Nursing/other", "chartdate": "2171-09-02 00:00:00.000", "description": "Report", "row_id": 1678279, "text": "A+OX3, pleasant, cooperative. Medicated with 1 percocet once for incision pain. Continues with PAF. 100-145's. Breaks to NSR. Sbp 90's after lopressor 100mg po. Lungs are clear bilat, diminished bases. Good spo2's on 2L. Voiding in urinal. No Bm yet. Appetite improved. po's. Repleted K+ and Mg. Bs wnl. No coverage needed. Heparin @ 1500u/hr. Next ptt due @ . Ambulated to 5 and back w/o difficulty. Ready for when bed available.\n" }, { "category": "Nursing/other", "chartdate": "2171-09-04 00:00:00.000", "description": "Report", "row_id": 1678280, "text": "PT READMITTED TO CSRU FROM AT 2300. PT READMITTED PER TEAM SECONDARY TO STERNAL WOUND DRNG AND ? PARANOIA/CONFUSION NOTED ON FLOOR. PT ARRIVED IN BED. APPROPRIATE W/ HEPARIN IV AT 1400U/HR. LABS DRAWN PRIOR TO LEAVING THE FLOOR. VSS ON ARRIVAL SEE FLOWSHEET.\nNEURO: PT AWAKE AND ALERT. ORIENTED X3. PT AWARE ON REASONS FOR TRANSFER. AFFECT ODD.\nCV: SR W/ FREQUENT PAC'S. HR 80-90'S. IN AFIB BRIEFLY X1 HR. TX W/ MAG 2GM SPONTANEOUSLY CONVERTED. AF RATE 80-120. BP 105-140/60'S. PALP PULSES. RT CVL DC'D - TIP CX. LT PIV 18G PLACED BY IV TEAM. PERIPHERAL BLOOD CX DRAWN AND SENT. HEPARIN AT 1400 U/HR- BE DC'D AT 0600 FOR ? OR. TYPE AND CROSS SENT. D5/12 W/ 20KCL AT 40CC/HR UP AT 0100 FOR MAINTANCE FLUIDS.\n RESP: TRACH SITE REDRESSED FOR SMALL AMT MUCOUS DRNG. 02 SATS RA >92%. ON 2L NC 94-97%. LUNGS W/ SCATTERED CRACKLES AT BASE.\nGI/GU: NPO FOR ? OR. ABD SOFT +BS. NO N/V. PT VOIDING IN URINAL FAIR AMTS. UA SENT.\nID: WBC ELEV 15. STERANL DSG CHNG MN. FOR SMALL AMT SEROSANG DRNG.INCISION APPROXIMATED W/ STERIS. STERNUM SLIGHTLY UNSTABLE W/ COUGH. CX AS SENT AS ABOVE. AFEBRILE. PT DIAPHORETIC AFTER IBUPROFEN/TYLENOL ? MASKING FEVER.\nPLAN: CONT ASSESS HEMODYNAMICS/RESP/ MENTAL STATUS. CHNG STERNAL DSG TID. FOLLOW CX. CONT NPO FOR ? OR IN AM. D/C HEPARING 0600.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2171-09-04 00:00:00.000", "description": "Report", "row_id": 1678281, "text": "ADDENDUM: IN AND OUT AF. SECOND EPISODE TACHY W/ RATE 130'S/ TREATED W/ 7MG IV LOPRESSOR CONVERTED BACK TO SR. BACK IN AF AT 0600 PO LOPRESSOR DOSE GIVEN/ STERNAL DSG SATURATED W/ SEROSANG DRNG. TEAM INTO SEE. CLEANED W/ BETADINE NEW DSD APPLIED. CONT TO BE NPO EXCEPT MEDS. HEPARIN OFF AT 0600. PLAN: CXR THIS AM. ? OR FOR STERNAL EXPLORATION.\n" }, { "category": "Nursing/other", "chartdate": "2171-09-04 00:00:00.000", "description": "Report", "row_id": 1678282, "text": "Resp Care\npt arrived from or with new 8.0 shiley trach in place. s/p sternal debridement,trach revision d/t prior emerg.cricothyroidotomy. initially on simv mode, not waking up and changed to psv mode. anticipate pt will wean to trach collar this evening. mdi's given inline. wheeze with sxn but not at rest. mod amt bldy thick secretions.\n" }, { "category": "ECG", "chartdate": "2171-09-03 00:00:00.000", "description": "Report", "row_id": 154683, "text": "Sinus rhythm. Atrial premature beats. Modest non-specific T wave changes. Since\nthe previous tracing of ST-T wave abnormalities have decreased.\n\n" }, { "category": "ECG", "chartdate": "2171-08-21 00:00:00.000", "description": "Report", "row_id": 154689, "text": "Sinus bradycardia\nSupraventricular extrasystoles\nInferior T wave changes are nonspecific\nSince previous tracing of : atrial premature complexes are seen\n\n" }, { "category": "ECG", "chartdate": "2171-08-21 00:00:00.000", "description": "Report", "row_id": 154690, "text": "Sinus bradycardia\nNormal ECG except for rate\nSince previous tracing of : ST-T wave abnormalities are less marked\n\n" }, { "category": "ECG", "chartdate": "2171-08-21 00:00:00.000", "description": "Report", "row_id": 154691, "text": "Sinus rhythm\nLeft atrial abnormality\nAnterolateral ST-T changes may be due to myocardial ischemia\nNo previous tracing\n\n" }, { "category": "ECG", "chartdate": "2171-08-28 00:00:00.000", "description": "Report", "row_id": 154684, "text": "Sinus rhythm. Diffuse ST-T wave abnormalities with anterolateral ST segment\nelevations - cannot exclude in part acute injury/ischemia and/or possible\nregional pericarditis. Clinical correlation is suggested. Since the previous\ntracing of further ST-T wave changes are present including ST segment\nelevations.\n\n" }, { "category": "ECG", "chartdate": "2171-08-26 00:00:00.000", "description": "Report", "row_id": 154685, "text": "Sinus rhythm. Modest non-specific inferolateral ST-T wave abnormalities. Since\nthe previous tracing of ST-T wave changes have decreased.\n\n" }, { "category": "ECG", "chartdate": "2171-08-23 00:00:00.000", "description": "Report", "row_id": 154686, "text": "Sinus arrhythmia. Inferior/lateral ST-T changes may be due to myocardial\nischemia. Since the previous tracing no significant change.\n\n" }, { "category": "ECG", "chartdate": "2171-08-23 00:00:00.000", "description": "Report", "row_id": 154687, "text": "Sinus rhythm\nInferior/lateral ST-T changes may be due to myocardial ischemia\nSince previous tracing, atrial ectopy no longer present; ST-T wave changes are\nslightly more pronounced\n\n" }, { "category": "ECG", "chartdate": "2171-08-22 00:00:00.000", "description": "Report", "row_id": 154688, "text": "Sinus rhythm\nSupraventricular extrasystoles\nInferior ST-T changes are nonspecific\nSince previous tracing of : no significant change\n\n" } ]

[ { "category": "Radiology", "chartdate": "2150-05-14 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1240137, "text": " 11:58 AM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: FAST TRACK EXTUBATION CARDIAC SURGERY, ?line placement, r/o\n Admitting Diagnosis: AORTIC STENOSIS\\AORTIC VALVE REPLACEMENT; ? ASCENDING AORTA REPLACEMENT; ? CORONARY ARTERY BYPASS GRAFT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old man s/p AVR, Asc. Aorta Replacement. Please at\n with abnormalities.\n REASON FOR THIS EXAMINATION:\n FAST TRACK EXTUBATION CARDIAC SURGERY, ?line placement, r/o PTX/Effusion\n ______________________________________________________________________________\n FINAL REPORT\n TYPE OF EXAMINATION: Chest AP portable single view.\n\n INDICATION: Status post aortic valve replacement and ascending aorta repair.\n First postoperative chest examination.\n\n FINDINGS: AP single view of the chest has been obtained with patient in\n supine position. The patient is now intubated, the ETT terminating in the\n trachea 6 cm above the level of the carina. Row of midline sternal suture\n wires is seen. A right internal jugular approach sheath carries a Swan-Ganz\n catheter, the tip of which reaches the central portion of the pulmonary\n artery. An NG tube has been passed and reaches well below the diaphragm. One\n mediastinal drainage tube is advanced from below terminating in the upper\n mediastinum. The lungs are well aerated and no pneumothorax can be\n identified. A circular metallic structure representing the metallic component\n of the aortic valve prosthesis is seen in place.\n\n IMPRESSION: Very satisfactory first postoperative findings, no pneumothorax\n or advanced pulmonary congestion.\n\n\n" }, { "category": "Radiology", "chartdate": "2150-05-13 00:00:00.000", "description": "CHEST (PRE-OP PA & LAT)", "row_id": 1240056, "text": " 8:16 PM\n CHEST (PRE-OP PA & LAT) Clip # \n Reason: AORTIC STENOSIS\\AORTIC VALVE REPLACEMENT; ? ASCENDING AORTA REPLACEMENT; ? CORONARY ARTERY BYPASS GRAFT\n Admitting Diagnosis: AORTIC STENOSIS\\AORTIC VALVE REPLACEMENT; ? ASCENDING AORTA REPLACEMENT; ? CORONARY ARTERY BYPASS GRAFT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old man with preop AVR\n REASON FOR THIS EXAMINATION:\n evaluate for acute process\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 57-year-old male preop for aortic valve replacement and possible\n ascending aortic replacement.\n\n COMPARISONS: None.\n\n TWO VIEWS OF THE CHEST: The lungs are mildly hyperinflated. No focal\n consolidation is seen. Mild pulmonary vascular congestion is seen without\n pleural effusion, pneumothorax or overt pulmonary edema. The heart is normal\n in size with a slightly prominent bulge of the right heart border, likely\n reflecting a tortuous or dilated ascending aorta.\n\n IMPRESSION: No acute intrathoracic process.\n\n" }, { "category": "Echo", "chartdate": "2150-05-14 00:00:00.000", "description": "Report", "row_id": 94184, "text": "PATIENT/TEST INFORMATION:\nIndication: Intraop AVR, possible Ascending Aorta replacement\nHeight: (in) 71\nWeight (lb): 240\nBSA (m2): 2.28 m2\nBP (mm Hg): 140/70\nHR (bpm): 63\nStatus: Inpatient\nDate/Time: at 09:35\nTest: TEE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Mild LA enlargement. Elongated LA.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. Normal interatrial septum.\nNo ASD by 2D or color Doppler.\n\nLEFT VENTRICLE: Mild symmetric LVH with normal cavity size and global systolic\nfunction (LVEF>55%). Normal LV cavity size. Normal regional LV systolic\nfunction. Overall normal LVEF (>55%).\n\nRIGHT VENTRICLE: Mild global RV free wall hypokinesis.\n\nAORTA: Focal calcifications in aortic root. Mildly dilated ascending aorta.\nFocal calcifications in ascending aorta. Mildly dilated aortic arch. Simple\natheroma in aortic arch. Normal descending aorta diameter. Complex (>4mm)\natheroma in the descending thoracic aorta.\n\nAORTIC VALVE: Bicuspid aortic valve. Severely thickened/deformed aortic valve\nleaflets. Critical AS (area <0.8cm2).\n\nMITRAL VALVE: Normal mitral valve leaflets. No MS. Trivial MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR.\n\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.\n\nPERICARDIUM: No pericardial effusion.\n\nConclusions:\nPre Bypass: The left atrium is mildly dilated. The left atrium is elongated.\nNo atrial septal defect is seen by 2D or color Doppler. There is mild\nsymmetric left ventricular hypertrophy with normal cavity size and global\nsystolic function (LVEF>55%). The left ventricular cavity size is normal.\nRegional left ventricular wall motion is normal. Overall left ventricular\nsystolic function is normal (LVEF>55%). with mild global free wall\nhypokinesis. The ascending aorta is mildly dilated. The aortic arch is mildly\ndilated. There are simple atheroma in the aortic arch. There are complex\n(>4mm) atheroma in the descending thoracic aorta. The aortic valve is\nbicuspid. The aortic valve leaflets are severely thickened/deformed. There is\ncritical aortic valve stenosis (valve area <0.8cm2). The mitral valve leaflets\nare structurally normal. Trivial mitral regurgitation is seen. There is no\npericardial effusion.\n\nPost Bypass: Preserved biventricular function. LVEF >55% Aortic conturs\nintact. There is a mechanical aortic valve prosthetis (#23 regent per\nsurgeons). Peak gradients 20-26 mm Hg, mean 9-13 mm Hg at cardaic outputs of\n lpm. Remaining exam is unchanged. All findings discussed with surgeons at\nthe time of the exam.\n\n\n" }, { "category": "Radiology", "chartdate": "2150-05-16 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1240407, "text": " 9:33 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate for PTX/effusion\n Admitting Diagnosis: AORTIC STENOSIS\\AORTIC VALVE REPLACEMENT; ? ASCENDING AORTA REPLACEMENT; ? CORONARY ARTERY BYPASS GRAFT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old man with POD2 AVR CT removal\n REASON FOR THIS EXAMINATION:\n evaluate for PTX/effusion\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 9:46 A.M., \n\n HISTORY: 67-year-old man after chest tube removal following AVR.\n\n IMPRESSION: AP chest compared to :\n\n Lung volumes are well maintained after removal of the endotracheal tube.\n There is no pneumothorax and only a minimal left pleural effusion if any\n following removal of drainage tubes. Previous vascular engorgement in the\n lungs has cleared.\n\n\n" }, { "category": "Radiology", "chartdate": "2150-05-18 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1240623, "text": " 1:49 PM\n CHEST (PA & LAT) Clip # \n Reason: r/o inf., eff.\n Admitting Diagnosis: AORTIC STENOSIS\\AORTIC VALVE REPLACEMENT; ? ASCENDING AORTA REPLACEMENT; ? CORONARY ARTERY BYPASS GRAFT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old man s/p avr\n REASON FOR THIS EXAMINATION:\n r/o inf., eff.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 67-year-old male post-aortic valve replacement.\n\n COMPARISON: .\n\n CHEST, PA AND LATERAL: Again seen are changes of median sternotomy and aortic\n valve replacement. Small bilateral pleural effusions persist, left greater\n than right. Increased pulmonary aeration, with mild residual left lower lobe\n atelectasis. Heart size is top normal.\n\n IMPRESSION:\n 1. Improved left lower lobe atelectasis.\n 2. Persistent small pleural effusion.\n\n\n" }, { "category": "ECG", "chartdate": "2150-05-14 00:00:00.000", "description": "Report", "row_id": 243766, "text": "Artifact is present. The rhythm is initially atrial pacing followed by sinus\nbradycardia at a rate of 50 beats per minute. Non-specific ST-T wave changes.\nNo previous tracing available for comparison.\n\n" } ]

[ { "category": "Radiology", "chartdate": "2196-11-25 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1222630, "text": " 9:55 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please evaluate interval change in lung pathology\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old woman with CHF exacerbation\n REASON FOR THIS EXAMINATION:\n please evaluate interval change in lung pathology\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 10:03 A.M., \n\n HISTORY: CHF exacerbation. Rule out pulmonary pathology.\n\n IMPRESSION: AP chest compared to :\n\n Patient has had median sternotomy and coronary bypass grafting. Cardiomegaly\n is severe with a large right heart component. Perihilar opacification\n predominantly in the upper lungs persists, but has improved in the lower\n lungs. I think this is probably pulmonary edema, since there is accompanying\n small left pleural effusion. It will be very helpful to have conventional\n views including a lateral.\n\n Thoracic aorta is heavily calcified, but at least in the upper descending\n portion, not dilated.\n\n\n" }, { "category": "Radiology", "chartdate": "2196-11-23 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1222270, "text": " 1:46 AM\n CHEST (PORTABLE AP) Clip # \n Reason: pna chf\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old woman with dyspnea on bipap\n REASON FOR THIS EXAMINATION:\n pna chf\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: -year-old female with dyspnea, on BiPAP.\n\n COMPARISON: None available.\n\n TECHNIQUE: Single frontal chest radiograph was obtained portably with the\n patient in an upright position.\n\n FINDINGS: Heart size is enlarged. There is mild interstitial pulmonary\n edema. Left pleural effusion may be present. No pneumothorax is seen.\n Sternal wires appear intact.\n\n IMPRESSION: Mild pulmonary edema and cardiomegaly.\n\n" }, { "category": "Radiology", "chartdate": "2196-11-23 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1222294, "text": " 8:27 AM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: ?edema vs infiltrate\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old woman with hypoxia\n REASON FOR THIS EXAMINATION:\n ?edema vs infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 8:15 A.M., \n\n HISTORY: Hypoxia, possible edema.\n\n IMPRESSION: AP chest compared to 1:30 a.m.:\n\n Somewhat asymmetric pulmonary edema has improved in the perihilar regions\n since earlier in the day. Severe cardiomegaly and at least a small left\n pleural effusion persist. Conventional radiographs would be required to see\n if the pulmonary findings are more extensive than just edema.\n\n\n" }, { "category": "ECG", "chartdate": "2196-11-23 00:00:00.000", "description": "Report", "row_id": 244694, "text": "No significant change compared to tracing #1.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2196-11-23 00:00:00.000", "description": "Report", "row_id": 244695, "text": "Atrial fibrillation with a controlled ventricular response. Probable left\nventricular hypertrophy with repolarization changes. Intraventricular\nconduction delay. Poor R wave progression across the precordium. There are\nT wave inversions in leads I and aVL with ST segment depressions in leads V4-V5\nraising the possibility of active myocardial ischemia. Clinical correlation is\nsuggested. No previous tracing available for comparison.\nTRACING #1\n\n" } ]

[ { "category": "Echo", "chartdate": "2154-03-27 00:00:00.000", "description": "Report", "row_id": 71923, "text": "PATIENT/TEST INFORMATION:\nIndication: Intraop CABG. Eval aortic atheroma, IABP placement, valvular function\nHeight: (in) 70\nWeight (lb): 251\nBSA (m2): 2.30 m2\nBP (mm Hg): 138/56\nHR (bpm): 64\nStatus: Inpatient\nDate/Time: at 12:36\nTest: TEE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Mild LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Markedly dilated RA. Lipomatous hypertrophy\nof the interatrial septum. No ASD by 2D or color Doppler.\n\nLEFT VENTRICLE: Mild symmetric LVH. Normal regional LV systolic function. Low\nnormal LVEF.\n\nLV WALL MOTION: basal anterior - normal; mid anterior - normal; basal\nanteroseptal - normal; mid anteroseptal - normal; basal inferoseptal - normal;\nmid inferoseptal - normal; basal inferior - normal; mid inferior - normal;\nbasal inferolateral - normal; mid inferolateral - normal; basal anterolateral\n- normal; mid anterolateral - normal; anterior apex - normal; septal apex -\nnormal; inferior apex - normal; lateral apex - normal;\n\nRIGHT VENTRICLE: Borderline normal RV systolic function.\n\nAORTA: Normal aortic root diameter. Focal calcifications in aortic root.\nNormal ascending aorta diameter. Normal aortic arch diameter. There are\ncomplex (>4mm) atheroma in the aortic arch.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. Trace AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MS. Moderate (2+) MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Moderate to severe [3+] TR.\n\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen. No PR. Dilated\nmain PA.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: A TEE was performed in the location listed above. I certify\nI was present in compliance with HCFA regulations. No TEE related\ncomplications. The patient was under general anesthesia throughout the\nprocedure.\n\nConclusions:\nPre bypass: Technically limited study due to rotated heart and poor image\nquality. The left atrium is mildly dilated. The right atrium is markedly\ndilated. No atrial septal defect is seen by 2D or color Doppler. There is mild\nsymmetric left ventricular hypertrophy. Overall left ventricular systolic\nfunction is low normal (LVEF 50-55%). Right ventricular systolic function is\nborderline normal. There are complex (>4mm) atheroma in the mid aortic arch.\nThere is focal calcification of the sinotubular junction- no other discrete\nplaques seen in proximal ascending aorta. Intraortic balloon pump is The\naortic valve leaflets (3) appear structurally normal with good leaflet\nexcursion. There is no aortic valve stenosis. Trace aortic regurgitation is\nseen. The mitral valve leaflets are mildly thickened. Moderate (2+) mitral\nregurgitation is seen. Moderate to severe [3+] tricuspid regurgitation is\nseen. The main pulmonary artery is dilated. There is no pericardial effusion.\n\nPost bypass: Improved biventricular function LVEF > 55% no gross wall motion\nabnormalities. Mitral regrugitation is now trace to mild. Tricuspid\nregurgitation is now mild. AI remains trace. Aortic contours intact. Remaining\nexam unchanged. Results discussed with surgeons at time of the exam.\n\n\n" }, { "category": "Echo", "chartdate": "2154-03-25 00:00:00.000", "description": "Report", "row_id": 71924, "text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. Hypertension. Myocardial infarction.\nHeight: (in) 70\nWeight (lb): 252\nBSA (m2): 2.30 m2\nBP (mm Hg): 139/56\nHR (bpm): 60\nStatus: Inpatient\nDate/Time: at 10:15\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Moderate LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Moderately dilated RA.\n\nLEFT VENTRICLE: Normal LV wall thickness. Top normal/borderline dilated LV\ncavity size. Normal regional LV systolic function. Overall normal LVEF (>55%).\nNo resting LVOT gradient.\n\nRIGHT VENTRICLE: Moderately dilated RV cavity. Cannot assess RV systolic\nfunction.\n\nAORTA: Focal calcifications in aortic root. Normal ascending aorta diameter.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). Trace AR.\n\nMITRAL VALVE: Normal mitral valve leaflets with trivial MR. Mild mitral\nannular calcification.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR. Mild PA\nsystolic 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: Trivial/physiologic pericardial effusion.\n\nGENERAL COMMENTS: Based on AHA endocarditis prophylaxis recommendations,\nthe echo findings indicate a moderate risk (prophylaxis recommended). Clinical\ndecisions regarding the need for prophylaxis should be based on clinical and\nechocardiographic data.\n\nConclusions:\nThe left and right atrium are moderately dilated. Left ventricular wall\nthicknesses are normal. The left ventricular cavity size is top\nnormal/borderline dilated. Regional left ventricular wall motion is normal.\nOverall left ventricular systolic function is normal (LVEF>55%). The right\nventricular cavity is moderately dilated. Free wall motion could not be\nadequately assessed. The aortic valve leaflets (3) appear structurally normal\nwith good leaflet excursion. No aortic stenosis is seen. Trace aortic\nregurgitation is seen. The mitral valve leaflets appear structurally normal\nwith trivial mitral regurgitation., There is mild pulmonary artery systolic\nhypertension. The end-diastolic pulmonic regurgitation velocity is increased\nsuggesting pulmonary artery diastolic hypertension. There is a\ntrivial/physiologic pericardial effusion.\n\nIMPRESSION: Mild left ventricular cavity enlargement with preserved global and\nregional systolic function. Right ventricular cavity enlargement. Pulmonary\nartery hypertension.\n\nBased on AHA endocarditis prophylaxis recommendations, the echo findings\nindicate a moderate risk (prophylaxis recommended). Clinical decisions\nregarding the need for prophylaxis should be based on clinical and\nechocardiographic data.\n\n\n" }, { "category": "ECG", "chartdate": "2154-04-08 00:00:00.000", "description": "Report", "row_id": 179942, "text": "Baseline artifact\nSinus rhythm\nRight bundle branch block\nLow QRS voltage\nDiffuse ST-T wave abnormalities with probable QT interval prolonged although is\ndifficult to measure - baseline artifact makes assessment difficult\nSince previous tracing of , rapid atrial fibrillation now absent\n\n" }, { "category": "ECG", "chartdate": "2154-03-30 00:00:00.000", "description": "Report", "row_id": 179943, "text": "Atrial fibrillation with uncontrolled ventricular response\nIndeterminate frontal QRS axis\nRight bundle branch block\nConsider anteroseptal infarct - age undetermined\nInferior ST-T changes are nonspecific\nRepolarization changes may be partly due to rate/rhythm\nLow QRS voltages in precordial leads\nSince previous tracing of earlier , atrial fibrillation recurrance with\nrapid ventricular response\n\n" }, { "category": "ECG", "chartdate": "2154-03-30 00:00:00.000", "description": "Report", "row_id": 179944, "text": "Sinus rhythm with atrial premature complexes\nRight bundle branch block\nConsider inferior infarct - age undetermined\nIndeterminate QRS axis\nLateral T wave changes offer additional evidence of ischemia\nRepolarization changes may be partly due to rhythm\nLow QRS voltages\nSince previous tracing of , sinus rhythm restored\n\n" }, { "category": "ECG", "chartdate": "2154-03-27 00:00:00.000", "description": "Report", "row_id": 179945, "text": "Atrial fibrillation\nRight bundle branch block\nConsider prior inferior myocardial infarction although is nondiagnostic\nDiffuse T wave abnormalities - cannot exclude in part ischemia - clinical\ncorrelation is suggested\nSince previous tracing of , ST-T wave abnormalities decreased and Q-Tc\ninterval appears short\n\n" }, { "category": "ECG", "chartdate": "2154-03-25 00:00:00.000", "description": "Report", "row_id": 179946, "text": "Submitted late and out of sequence\nNearly regular tachycardia - mechanism uncertain - may be rapid atrial\nfibrillation\nRight bundle branch block\nProbable inferior infarct, age indeterminate\nDiffuse ST-T wave abnormalities - Cannot exclude in part ischemia\nClinical correlation is suggested\nSince previous tracing of , tachycardia present\n\n" }, { "category": "ECG", "chartdate": "2154-03-24 00:00:00.000", "description": "Report", "row_id": 180192, "text": "Irregular rhythm - may be atrial fibrillation although low amplitude atrial\nwaveforms are suggested\nProbable right sided chest leads - no ST segment elevation\nRight bundle branch block\nPossible prior inferior myocardial infarction\nDiffuse nonspecific T wave changes\nClinical correlation is suggested\nSince previous tracing of , ventricular response is now irregular\n\n" }, { "category": "ECG", "chartdate": "2154-03-26 00:00:00.000", "description": "Report", "row_id": 180191, "text": "Atrial fibrillation with a controlled ventricular response. Right bundle-branch\nblock with secondary ST-T wave abnormalities. Compared to the previous tracing\nof no diagnostic interim change.\n\n" }, { "category": "Radiology", "chartdate": "2154-04-01 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 909321, "text": " 10:53 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Please assess for infiltrates, etc\n Admitting Diagnosis: STEMYOCARDIAL INFARCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old woman with HTN, DM2, lymphoma s/p CABG worsening hypoxia\n\n REASON FOR THIS EXAMINATION:\n Please assess for infiltrates, etc\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Hypertension, diabetes, Lymphoma, status post CABG.\n\n COMPARISON: .\n\n AP CHEST RADIOGRAPH.\n\n Endotracheal tube, NG tube, and right-sided central line appear in unchanged\n position. Tip of the right IJ catheter is again seen in the proximal right\n atrium. Median sternotomy wires are also again seen.\n\n Cardiac and mediastinal silhouettes again appear enlarged. Accurate\n assessment of the mediastinum is limited secondary to patient rotation. There\n is again evidence of mild CHF. No focal consolidations are seen. Basilar\n atelectasis and effusions appear unchanged.\n\n" }, { "category": "Radiology", "chartdate": "2154-03-29 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 909058, "text": " 7:54 AM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p CABG w/fever-r/o infiltrate\n Admitting Diagnosis: STEMYOCARDIAL INFARCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old woman with HTN, DM2, lymphoma s/p CABG and ct removal\n\n REASON FOR THIS EXAMINATION:\n s/p CABG w/fever-r/o infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Lymphoma with recent CABG and now fever.\n\n COMPARISON: .\n\n AP UPRIGHT PORTABLE CHEST: Tip of the endotracheal tube is in a high lying\n position at the superior clavicular margin less than 9 cm above the carina.\n Right subclavian catheter sheath tip is in the brachiocephalic vein.\n Nasogastric tube courses over the left upper abdomen out of view. There is\n slight decrease in postoperative mediastinal widening. Heart size remains\n moderately enlarged. There is slight worsening of bibasilar airspace\n opacities concerning for developing pneumonia with superimposed congestive\n heart failure. No pneumothorax. The prominent right mediastinal border is\n unchanged and may represent lymphadenopathy.\n\n IMPRESSION: Interval worsening of bibasilar opacity concerning for developing\n pneumonia with superimposed congestive failure. High lying endotracheal tube.\n Advancing 4 cm is suggested.\n\n This was discussed with at 11:30 a.m. on .\n\n\n" }, { "category": "Radiology", "chartdate": "2154-04-08 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 910270, "text": " 3:09 PM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o inf., eff\n Admitting Diagnosis: STEMYOCARDIAL INFARCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old woman s/p PEG/Trach.\n\n REASON FOR THIS EXAMINATION:\n r/o inf., eff\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 72-year-old female with PEG, trach placement. Evaluate for\n infiltrate or effusion.\n\n COMPARISON .\n\n AP CHEST RADIOGRAPH: The tip of the right internal jugular catheter is within\n the right atrium likely due to positional changes. Heart size, mediastinal\n contours are unchanged. Diffuse opacities bilaterally, particularly at the\n bases. Bilateral pleural effusions. Not completely evaluated given lack of\n inclusions of lung bases.\n\n\n" }, { "category": "Radiology", "chartdate": "2154-04-02 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 909509, "text": " 5:19 PM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p CABG\n Admitting Diagnosis: STEMYOCARDIAL INFARCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old woman with HTN, DM2, lymphoma s/p CABG worsening\n hypoxia\n REASON FOR THIS EXAMINATION:\n s/p CABG\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 72-year-old female with hypertension, diabetes mellitus and\n lymphoma status post CABG with worsening hypoxia.\n\n COMPARISON: , 11:15 a.m.\n\n AP SUPINE CHEST RADIOGRAPH:\n Endotracheal tube is at the thoracic inlet. Nasogastric tube is no longer\n clearly visualized. Right IJ catheter tip is seen in the mid SVC, however,\n difficult to appreciate tip. The patient again significantly rotated making\n assessment of the cardiac, mediastinal, and hilar contours difficult. Global\n cardiac enlargement versus pericardial effusion. Lung volumes appear similar\n and no definite focal opacities are present. No pleural effusions. No\n pneumothorax.\n\n IMPRESSION: No significant change in lung volumes or definite opacities.\n Multichamber cardiomegaly versus pericardial effusion. Clinically correlate.\n\n" }, { "category": "Radiology", "chartdate": "2154-04-04 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 909785, "text": " 5:56 PM\n CHEST (PORTABLE AP) Clip # \n Reason: confirm trach position, r/o PTX, r/o obstructive ATX.\n Admitting Diagnosis: STEMYOCARDIAL INFARCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old woman s/p PEG/Trach.\n REASON FOR THIS EXAMINATION:\n confirm trach position, r/o PTX, r/o obstructive ATX.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 72-year-old woman with status post PEG, tracheostomy.\n\n TECHNIQUE: Portable AP chest radiograph.\n\n COMPARISON: Chest radiograph dated .\n\n FINDINGS: The patient is status post tracheostomy, with tracheostomy tube\n terminating approximately 5 cm above the carina. Right IJ line is unchanged\n compared to the prior study. The patient is status post CABG with median\n sternotomy. Again, note is made of marked rotation of the patient\n positioning, with overall unchanged appearance of mediastinal contour, with\n tortuous aorta. As noted previously, precise evaluation of the cardiac and\n mediastinal contours are difficult due to positioning. Bilateral pleural\n effusions are increased, with bibasilar atelectasis, especially in left lower\n lobe. The opacity in left lower lobe may represent atelectasis, however, the\n presence of pneumonia cannot be excluded.\n\n IMPRESSION:\n 1. Tubes and lines as described above. Limited study due to positioning,\n especially for the assessment of mediastinal contours. Increased bilateral\n pleural effusion, with opacity in bilateral lower lobes, especially in left\n lower lobe. The opacities can represent atelectasis, however, pneumonia\n cannot be totally excluded. Clinical correlation is recommended.\n\n\n" }, { "category": "Radiology", "chartdate": "2154-04-08 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 910310, "text": " 7:25 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: evaluate tracheostomy position and lung field (r/o PTX/ effu\n Admitting Diagnosis: STEMYOCARDIAL INFARCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old woman s/p PEG/Trach.\n\n REASON FOR THIS EXAMINATION:\n evaluate tracheostomy position and lung field (r/o PTX/ effusion) s/p emergent\n bedside bronch for repositioning of pulled trach\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 72-year-old female status post PEG/trach.\n\n COMPARISON: Prior study here from earlier the same day at 15:29 hours.\n\n AP SUPINE CHEST: The tip of the tracheostomy tube is unchanged in position.\n The tip of the right internal jugular catheter is seen within the region of\n the right atrium. The heart size and mediastinal contours are unchanged.\n Bibasilar opacities with obscuration of both hemidiaphragms are stable. There\n is no pneumothorax. There is otherwise no significant change in appearance of\n the chest since approximately four hours prior.\n\n IMPRESSION: Unchanged position of the tracheostomy tube. Stable bibasilar\n opacities.\n\n\n" }, { "category": "Radiology", "chartdate": "2154-04-04 00:00:00.000", "description": "VEN DUP EXTEXT BIL (MAP/DVT)", "row_id": 909795, "text": " 8:09 PM\n DUP EXTEXT BIL (MAP/DVT) Clip # \n Reason: LOW PLATELETS\n Admitting Diagnosis: STEMYOCARDIAL INFARCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old woman with s/p cabg, new CMML\n REASON FOR THIS EXAMINATION:\n r/o DVT\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Evaluate for lower extremity deep venous thrombosis.\n\n COMPARISON: None.\n\n LOWER EXTREMITY ULTRASOUND: Grayscale and color Doppler son of the left\n and right common femoral, superficial femoral, and popliteal veins were\n performed. There was normal flow, augmentation, compressibility and waveforms\n demonstrated. No intraluminal thrombus is identified. Exam was somewhat\n limited by patient body habitus.\n\n IMPRESSION: No evidence of deep vein thrombosis in the right or left lower\n extremity.\n\n\n" }, { "category": "Radiology", "chartdate": "2154-04-01 00:00:00.000", "description": "P RENAL U.S. PORT", "row_id": 909342, "text": " 11:16 AM\n RENAL U.S. PORT Clip # \n Reason: PLease perform renal ultrasound bilaterally with duplex U/S\n Admitting Diagnosis: STEMYOCARDIAL INFARCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old woman with rising creatinine post CABG\n REASON FOR THIS EXAMINATION:\n PLease perform renal ultrasound bilaterally with duplex U/S to assess for blood\n flow to kidneys, and/or anatomic abnormality\n ______________________________________________________________________________\n FINAL REPORT\n RENAL ULTRASOUND SCAN (PORTABLE).\n\n CLINICAL DETAILS: Post-CABG raised creatinine.\n\n FINDINGS:\n\n The kidneys are normal in size.\n\n Doppler assessment of the renal vasculature with Doppler is technically\n limited. However, bilateral intrarenal arterial waveform is demonstrable at\n the segmental level with good systolic upstroke.\n\n Bladder is empty at the time of scanning.\n\n CONCLUSION:\n\n 1. Normal-sized kidneys, no hydronephrosis.\n\n\n" }, { "category": "Radiology", "chartdate": "2154-04-05 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 909824, "text": " 7:01 AM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o inf\n Admitting Diagnosis: STEMYOCARDIAL INFARCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old woman s/p PEG/Trach.\n\n REASON FOR THIS EXAMINATION:\n r/o inf\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 72-year-old with lymphoma post-CABG.\n\n TWO FRONTAL VIEWS OF THE CHEST. Comparison is made to several radiographs\n dating back to , most recent yesterday.\n\n Again mediastinal contours are unchanged with mild cardiomegaly. Bibasilar\n opacities with obscuration of both hemidiaphragms are stable compared to\n yesterday, but have increased compared to . There is also likely a\n mild element of congestive failure with upper zone redistribution of the\n pulmonary vasculature. Lines and tubes are unchanged.\n\n IMPRESSION:\n\n Stable bibasilar opacities and pleural effusions. Probable mild associated\n CHF.\n\n\n" }, { "category": "Radiology", "chartdate": "2154-03-28 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 908909, "text": " 12:00 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ett advanced, check position\n Admitting Diagnosis: STEMYOCARDIAL INFARCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old woman with HTN, DM2, lymphoma, with NSTEMI and hypoxia, with\n IABP s/p CABG\n REASON FOR THIS EXAMINATION:\n ett advanced, check position\n ______________________________________________________________________________\n FINAL REPORT\n\n REASON FOR EXAMINATION: Evaluation of the ETT tube position.\n\n Portable AP radiograph was compared to the previous film from .\n\n The ET tube tip is projecting 0.56 cm above the carina instead of 8.2 seen on\n the previous film.\n\n Post-surgical changes with widened cardiac and mediastinal silhouettes are\n again noted, stable. Left lower lobe atelectasis is unchanged. Mild increase\n in the right pleural effusion is demonstrated which may be due to patient's\n position.\n\n Less prominence of the pulmonary vasculature is present representing the\n slight improvement of the mild congestive heart failure seen on the previous\n chest x-ray.\n\n IMPRESSION: Satisfactory position of the ET tube and Swan-Ganz catheter.\n\n 2) Stable enlarged cardiomediastinal silhouette.\n\n 3) Enlarged right pleural effusion.\n\n 4) Improvement of the mild congestive heart failure.\n\n" }, { "category": "Radiology", "chartdate": "2154-03-28 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 909019, "text": " 6:52 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: r/o ptx\n Admitting Diagnosis: STEMYOCARDIAL INFARCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old woman with HTN, DM2, lymphoma s/p CABG and ct removal\n\n REASON FOR THIS EXAMINATION:\n r/o ptx\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 72-year-old with lymphoma status post CABG, with chest tube out.\n Evaluate for pneumothorax.\n\n SINGLE AP SEMI-UPRIGHT PORTABLE CHEST: Compared to study of 19 hours prior.\n Endotracheal tube remains unchanged in position. Enteric feeding tube tip\n courses off the inferior aspect of the screen. Right IJ Cordis remains in,\n the Swan-Ganz catheter has been removed. No chest tube is visualized on the\n current or prior study. No significant pneumothorax is seen. There are\n subtle opacities at the lung bases likely relating to known pleural effusions.\n be a component of mild congestive heart failure. Cardiomegaly.\n\n IMPRESSION:\n 1) No pneumothorax identified.\n 2) Subtle bibasilar opacities likely relate to a combination of atelectasis\n and effusion on this semi-upright study.\n 3) Cardiomegaly with a likely mild component of congestive heart failure.\n\n\n" }, { "category": "Radiology", "chartdate": "2154-03-25 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 908666, "text": " 1:00 PM\n CHEST (PORTABLE AP) Clip # \n Reason: ? worsening edema\n Admitting Diagnosis: STEMYOCARDIAL INFARCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old woman with HTN, DM2, lymphoma, with NSTEMI and hypoxia\n\n REASON FOR THIS EXAMINATION:\n ? worsening edema\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Hypertension, lymphoma and hypoxia.\n\n COMPARISON: .\n\n CHEST AP: There is stable cardiomegaly. There is mild left ventricular\n failure. There is prominence of the superior mediastinum. This could be\n consistent with given history of lymphoma. There is no pneumonia.\n\n IMPRESSION: Mild failure. Soft tissue density in the superior mediastinum,\n which could be consistent with given history of lymphoma. PA and lateral\n examination would be helpful for further evaluation.\n\n" }, { "category": "Radiology", "chartdate": "2154-03-24 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 908581, "text": " 7:15 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please eval for edema\n Admitting Diagnosis: STEMYOCARDIAL INFARCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old woman with HTN, DM2, lymphoma, with NSTEMI and hypoxia\n REASON FOR THIS EXAMINATION:\n please eval for edema\n ______________________________________________________________________________\n FINAL REPORT\n CHEST SINGLE VIEW\n\n HISTORY: Lymphoma, hypoxia.\n\n FINDINGS: There are no old films available for comparison. This is a single\n AP view of the chest. The heart is moderately enlarged. There is pulmonary\n vascular redistribution and patchy areas of increased alveolar infiltrate. It\n is unclear how much of this appearance is due to fluid overload or if an\n underlying infectious infiltrate is also present.\n\n\n" }, { "category": "Radiology", "chartdate": "2154-03-26 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 908729, "text": " 10:08 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: STEMYOCARDIAL INFARCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old woman with HTN, DM2, lymphoma, with NSTEMI and hypoxia, with IABP\n awaiting CABG\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 72-year-old female with myocardial infarction and lymphoma, awaiting\n CABG.\n\n COMPARISON: .\n\n AP UPRIGHT PORTABLE CHEST: Tip of the intraaortic balloon pump overlies the\n aortic knob. There is stable cardiomegaly. Also unchanged is mediastinal\n widening which may represent involvement of lymphoma. There is prominent\n pulmonary vasculature consistent with congestive heart failure. No\n pneumothorax.\n\n IMPRESSION: IABP at the level of the aortic knob. Persistent congestive\n failure.\n\n" }, { "category": "Radiology", "chartdate": "2154-03-27 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 908880, "text": " 4:15 PM\n CHEST (PORTABLE AP) Clip # \n Reason: pleural effusion, pulmonary edema, tamponade, pneumothorax.P\n Admitting Diagnosis: STEMYOCARDIAL INFARCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old woman with HTN, DM2, lymphoma, with NSTEMI and hypoxia, with\n IABP s/p CABG\n REASON FOR THIS EXAMINATION:\n pleural effusion, pulmonary edema, tamponade, pneumothorax.Page or call\n with issues./\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post CABG, question pleural effusion, pulmonary edema,\n tamponade, pneumothorax.\n\n Comparison is made to a preop film of .\n\n AP SUPINE RADIOGRAPH OF THE CHEST: The endotracheal tube is positioned with\n the tip approximately 7.8 cm above the carina. Advancement of approximately 3\n cm is recommended. An NG tube courses over the stomach with the tip not being\n included in this study. A Swan-Ganz catheter is seen with the tip projecting\n over the main pulmonary artery. Two mediastinal tubes are seen. The cardiac\n silhouette and mediastinum appear wider than on the preop film which may be\n explained by post-surgical changes, however, a pericardial effusion cannot be\n excluded. There are median sternotomy wires in place. The lungs appear\n grossly clear given supine technique. There is a band-like opacity in the\n left retrocardiac region which most likely represents left lower lobe\n atelectasis. There is an additional area atelectasis at the left lung base.\n\n IMPRESSION: Post-surgical changes with widened cardiac and mediastinal\n silhouette which most likely represent expected post-surgical changes.\n However, a pericardial effusion cannot be excluded. Left lower lobe\n atelectasis. Endotracheal tube positioned approximately 8 cm above the\n carina, advancement of approximately 3 cm is recommended.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2154-04-11 00:00:00.000", "description": "PICC W/O PORT", "row_id": 910606, "text": " 8:52 AM\n PICC LINE PLACMENT SCH Clip # \n Reason: IV access\n Admitting Diagnosis: STEMYOCARDIAL INFARCTION\n ********************************* CPT Codes ********************************\n * PICC W/O FLUOR GUID PLCT/REPLCT/REMOVE *\n * US GUID FOR VAS. ACCESS C1751 CATH ,/CENT/MID(NOT D *\n * C1769 GUID WIRES INCL INF *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old woman with\n REASON FOR THIS EXAMINATION:\n IV access\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 72-year-old female with lymphoma requiring TPN and chemotherapy.\n\n RADIOLOGISTS: Doctors , , and . The attending\n radiologist, Dr. was present and supervising throughout the\n procedure.\n\n TECHNIQUE/FINDINGS: The patient was brought to the angiography suite and\n placed supine on the angiography table. Using ultrasound guidance, the left\n basilic vein was found to be patent and compressible. The left arm was\n prepped and draped in the usual sterile fashion. Local anesthesia was\n administered with 1% lidocaine subcutaneously. Using real-time ultrasound\n guidance, 21-gauge needle was advanced into the left basilic vein. A 0.018-\n inch guide wire was advanced through the needle into the superior vena cava\n under fluoroscopic guidance. The needle was exchanged for an introducer\n sheath and 5-French double-lumen PICC was cut to a length of 53 cm based on\n the markings on the wire. The PICC was placed over the wire through the\n sheath and the wire and sheath were removed. Pre- and post-line placement\n ultrasound images were obtained to document vessel patency. Both ports\n flushed and aspirated well, were capped and heplocked. Pre- and post-PICC\n placement ultrasound images were obtained to document vessel patency. The\n catheter was fixed in place using a small StatLock device and sterile\n transparent dressing was applied. A final limited chest radiograph confirmed\n catheter tip position within the mid SVC. There were no procedural or\n immediate postprocedural complications. The catheter is ready for use.\n\n MEDICATIONS: 1% lidocaine for local anesthesia.\n\n IMPRESSION: Successful placement of a 5-French double-lumen 53-cm PICC by way\n of the left basilic vein, with the tip in the mid SVC. The line is ready for\n use.\n\n" }, { "category": "Radiology", "chartdate": "2154-03-29 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 909148, "text": " 9:49 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: ? effusion ? chf\n Admitting Diagnosis: STEMYOCARDIAL INFARCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old woman with HTN, DM2, lymphoma s/p CABG worsening hypoxia\n REASON FOR THIS EXAMINATION:\n ? effusion ? chf\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Lymphoma, status post CABG with worsening hypoxia.\n\n COMPARISON: at 8:33.\n\n SEMI-UPRIGHT AP VIEW OF THE CHEST: Patient is status post median sternotomy\n and CABG. Cardiac silhouette remains enlarged. Endotracheal tube,\n nasogastric tube, and left-sided chest tube remain in unchanged positions.\n Right internal jugular vascular sheath has been replaced with a central venous\n catheter with tip in the proximal right atrium. There has been improvement in\n the previously seen pattern of pulmonary edema. Patchy opacities are\n demonstrated within the lung bases bilaterally consistent with atelectasis.\n Probable small bilateral pleural effusions persist. There is no pneumothorax.\n\n IMPRESSION:\n 1. Interval improvement in congestive heart failure.\n 2. Bibasilar atelectasis with probable small bilateral pleural effusions.\n 3. Right central venous catheter tip within the proximal right atrium.\n DFDdp\n\n" }, { "category": "Radiology", "chartdate": "2154-04-02 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 909518, "text": " 6:41 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: r/o cva/bleed\n Admitting Diagnosis: STEMYOCARDIAL INFARCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old woman with s/p CABG\n REASON FOR THIS EXAMINATION:\n r/o cva/bleed\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 72-year-old woman status post CABG and respiratory arrest, rule\n out CVA bleed.\n\n TECHNIQUE: Noncontrast axial head CT.\n\n FINDINGS: The ventricles are prominent secondary to involutional changes.\n There is no mass effect or shift of normally midline structures. There is no\n evidence for hemorrhage. The -white matter junction is distinct. The\n sulci and cisterns demonstrate no effacement.\n\n Osseous structures are unremarkable. The right maxillary sinuses are mostly\n opacified. Fluid is also present in the sphenoid sinuses. The osseous\n structures are unremarkable. Atherosclerotic calcification of the cavernous\n carotids is present.\n\n IMPRESSION:\n\n 1. No evidence for intracranial hemorrhage. MR is more sensitive for the\n evaluation of ischemia.\n\n 2. Partial opacification of right maxillary sinus and sphenoid sinuses.\n\n Note added at attending review: I do not think there is any free fluid in the\n sphenoid sinus.\n\n\n\n\n\n" } ]

[ { "category": "Radiology", "chartdate": "2149-04-27 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1014920, "text": " 10:20 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for PNA, Pulm edema\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 89 year old man with resp distress\n REASON FOR THIS EXAMINATION:\n eval for PNA, Pulm edema\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 89-year-old man with respiratory distress. Please evaluate for\n pneumonia or pulmonary edema.\n\n No comparison is available.\n\n PORTABLE AP RADIOGRAPH OF THE CHEST: The heart size is moderately enlarged.\n There are perihilar opacities and increased interstitial markings,\n bilaterally, consistent with pulmonary edema. Moderate bilateral pleural\n effusions are also noted. Left retrocardiac density may represent a\n combination of atelectasis and effusion. The overlying soft tissue and osseous\n structures appear unremarkable.\n\n IMPRESSION:\n 1. Moderate cardiomegaly and pulmonary edema, with bilateral pleural\n effusions.\n 3. Left retrocardiac density may represent atelectasis and\n effusion; underlying pneumonia cannot be excluded.\n\n" }, { "category": "ECG", "chartdate": "2149-04-27 00:00:00.000", "description": "Report", "row_id": 178763, "text": "Regularized ventriciular rhythm with underlying atrial which is difficult to\ndiscern. This could be regularized atrial fibrillation, given patient's history\nof atrial fibrillation. This could also be accelerated junctional rhythm.\nRight axis deviation. Right bundle-branch block. Lateral myocardial infarction\nand anterior and inferior ST segment depressions which could be due to\nmyocardial ischemia. Compared to the previous tracing of the lateral\nmyocardial infarction is new.\n\n" } ]

[ { "category": "ECG", "chartdate": "2141-04-21 00:00:00.000", "description": "Report", "row_id": 155289, "text": "Normal sinus rhythm, rate 72\nBorderline low voltage in frontal leads\nDiffuse Nonspecific T wave abnormalities\nSince last ECG, T wave amplitude lower\nBorderline ECG\n\n" }, { "category": "ECG", "chartdate": "2141-04-14 00:00:00.000", "description": "Report", "row_id": 155290, "text": "Normal sinus rhythm, rate 63\nPoor R wave progression V1-3 - ? lead placement\nBorderline ECG\n\n" }, { "category": "ECG", "chartdate": "2141-04-14 00:00:00.000", "description": "Report", "row_id": 155291, "text": "Normal sinus rhythm, rate 80\nBorderline low voltage in frontal leads\nPoor R wave progression\nNondiagnostic T changes\nABNORMAL ECG\n\n" }, { "category": "Radiology", "chartdate": "2141-04-14 00:00:00.000", "description": "CHEST (PRE-OP PA & LAT)", "row_id": 739373, "text": " 9:41 AM\n CHEST (PRE-OP PA & LAT) Clip # \n Reason: Please evaluate for infiltrates and effusions. PRE-OP. Pleas\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 49 year old man with CAD, awaiting CABG \n Thanks\n \n \n REASON FOR THIS EXAMINATION:\n Please evaluate for infiltrates and effusions. PRE-OP. Please do in AM on\n Friday .\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: CAD, awaiting CABG. Preoperative.\n\n CHEST, PA AND LATERAL: Heart size and mediastinal contour are normal. There\n is no pleural effusion or focal consolidation. Pulmonary vascularity is\n normal. Multiple surgical clips are noted in the left abdomen. No\n pneumothorax or fracture is identified.\n\n IMPRESSION: No acute cardiopulmonary process.\n\n" }, { "category": "Radiology", "chartdate": "2141-04-25 00:00:00.000", "description": "CVL/PICC", "row_id": 739480, "text": " 3:37 PM\n PIC CHECK/REPO Clip # \n Reason: STERNAL INFECTION, LONG-TERM ANTIBIOTICS\n ********************************* CPT Codes ********************************\n * CVL/PICC UD GUID FOR NEEDLE PLACMENT *\n * CHEST AP ONLY *\n ****************************************************************************\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Long-term antibiotics requiring PICC status post sternal\n infection.\n\n RADIOLOGISTS: Drs. , and supervising radiologist Dr.\n performed the procedure.\n\n PROCEDURE: The patient was explained risks and benefits of the procedure and\n informed written consent was obtained. The patient was placed on the\n angiographic table in a supine position with left arm extended. The left arm\n was prepped and draped in sterile fashion. Ultrasound was utilized as no\n suitable superficial vein was identified visually. A left basilic vein was\n identified and accessed utilizing a micropuncture set after 1% Lidocaine was\n administered. Utilizing the Seldinger technique, a wire was inserted through\n the needle and was documented to travel in a straight trajectory on\n fluoroscopy. This was exchanged for a peel-away 5 French sheath and a longer\n wire was exchanged and documented to be placed within the lower superior vena\n cava. Subsequently a 4 French single lumen catheter was advanced over the\n wire.\n\n A follow-up chest X-ray was performed which demonstrated placement of the PICC\n with tip in the lower SVC.\n\n CONTRAST: No contrast was administered.\n\n COMPLICATIONS: No immediate complications.\n\n IMPRESSION: Status post successful placement of a left single lumen Vaxcel\n PICC.\n\n\n" }, { "category": "Radiology", "chartdate": "2141-04-16 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 739388, "text": " 7:37 AM\n CHEST (PORTABLE AP) Clip # \n Reason: S/P OPEN HEART SURGERY-?PNEUMONITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 49 year old man with cad\n REASON FOR THIS EXAMINATION:\n S/P OPEN HEART SURGERY-?PNEUMONITIS\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Recent open heart surgery, fever.\n\n Sternal sutures and skin staples are present. The patient has taken a\n suboptimal inspiration. The heart is at the upper limits of normal in size.\n There are no overt signs of failure. Bilateral areas of subsegmental\n atelectasis and a faint density adjacent to the right hilum are present since\n . A right IJ line is present terminating in the proximal SVC at the\n level of the thoracic inlet. There is no pneumothorax.\n\n IMPRESSION: Bilateral perihilar and lower lobe subsegmental atelectasis.\n Recent post surgical changes and IJ line insertion.\n\n" }, { "category": "Radiology", "chartdate": "2141-04-20 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 739429, "text": " 2:13 PM\n CHEST (PA & LAT) Clip # \n Reason: please eval pt s/p CABG w/ increased WBC and h/o lymphoma, p\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 49 year old man with CAD, see above\n \n REASON FOR THIS EXAMINATION:\n please eval pt s/p CABG w/ increased WBC and h/o lymphoma, previous MI\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Elevated white blood cell count. History of lymphoma.\n\n The patient is S/P median sternotomy and coronary bypass surgery. The cardiac\n and mediastinal contours are stable compared to the recent post-operative\n study, but there has been some mediastinal widening compared to the pre-\n operative film of . Moreover the cardiac contour appears significantly\n larger than on the pre-operative film. The pulmonary vascularity is normal.\n The lungs reveal no focal areas of consolidation to suggest the presence of\n pneumonia. Small bilateral pleural effusions are identified. There is no\n evidence of pneumothorax.\n\n IMPRESSION: Marked interval widening of cardiac and mediastinal contour as\n compared to pre-operative radiographs but stable in the post-operative. This\n may reflect post-operative pericardial fluid and/or hematoma, as discussed\n with the clinical service caring for the patient.\n\n" }, { "category": "Radiology", "chartdate": "2141-04-23 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 739456, "text": " 9:17 AM\n CHEST (PA & LAT) Clip # \n Reason: PLEASE PT S/P CABG W/ PERSISTENT wbc ELEVATIONS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 49 year old man with CAD, see above\n REASON FOR THIS EXAMINATION:\n PLEASE PT S/P CABG W/ PERSISTENT wbc ELEVATIONS\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Persistent elevated white count status post CABG.\n\n PA/LATERAL VIEWS: Compared with 5/24, lung volumes are slightly lower, with\n secondary crowding of lung markings at both bases. Allowing for this, no\n definite consolidating pulmonary infiltrates are seen. Bilateral small\n pleural effusions appear essentially unchanged. No CHF.\n\n" }, { "category": "Radiology", "chartdate": "2141-04-17 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 739400, "text": " 10:49 AM\n CHEST (PORTABLE AP) Clip # \n Reason: R/O INFILTRATES,EFFUSIONS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 49 year old man with S/P CABG WITH ELEVATED WBC\n REASON FOR THIS EXAMINATION:\n R/O INFILTRATES,EFFUSIONS\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Post-CABG. Leukocytosis.\n\n CHEST, ONE VIEW: Compared to , the lung volumes are improved. The\n right IJ central venous catheter has been removed. There is no pneumothorax.\n There is decreased atelectasis in the bilateral lung bases. Scattered\n bilateral subsegmental atelectasis persists, greatest in the right upper lobe.\n There is no gross CHF. No pleural effusions. Recent sternotomy changes are\n noted.\n\n IMPRESSION: Improved lung volumes with decreased atelectasis, but no other\n significant interval change from .\n\n" } ]

[ { "category": "Radiology", "chartdate": "2120-07-04 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1141339, "text": " 6:09 PM\n CHEST (PORTABLE AP) Clip # \n Reason: assess for infiltrate, fluid\n Admitting Diagnosis: FAILURE TO THRIVE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old woman with CLL and reaction to IVIG, hypoxia\n REASON FOR THIS EXAMINATION:\n assess for infiltrate, fluid\n ______________________________________________________________________________\n WET READ: 7:51 PM\n No evidence of pneumonia or edema. No pleural effusion or pneumothorax.\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 7:01 P.M. ON \n\n HISTORY: CLL. Hypoxia.\n\n IMPRESSION: AP chest compared to :\n\n Normal heart, lungs, hila, mediastinum and pleural surfaces.\n\n\n" }, { "category": "Radiology", "chartdate": "2120-07-05 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1141390, "text": " 5:02 AM\n CHEST (PORTABLE AP) Clip # \n Reason: underlying pulmomary process to explain chronic cough?\n Admitting Diagnosis: FAILURE TO THRIVE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old woman with acute on chronic cough, Richters transformation,\n tachypnea, neutropenic fever\n REASON FOR THIS EXAMINATION:\n underlying pulmomary process to explain chronic cough?\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 70-year-old woman with acute on chronic cough and with tachypnea and\n neutropenic fever and underlying pulmonary process.\n\n TECHNIQUE: AP portable upright chest radiograph, single view.\n\n COMPARISON: , at 7 p.m.\n\n FINDINGS: There are low lung volumes. There is no focal lung consolidation.\n Hilar, mediastinal, and cardiac silhouette are within normal limits. No\n pleural effusion, or pneumothorax.\n\n IMPRESSION: No pneumonia.\n\n" }, { "category": "Radiology", "chartdate": "2120-07-02 00:00:00.000", "description": "CT CHEST W/CONTRAST", "row_id": 1140868, "text": " 12:44 PM\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: Pl evaluate for source of infection, enlarged LNs, etc.\n Admitting Diagnosis: FAILURE TO THRIVE\n Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old woman with CLL, now pancytopenic and febrile.\n REASON FOR THIS EXAMINATION:\n Pl evaluate for source of infection, enlarged LNs, etc.\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: JXKc TUE 4:53 PM\n 1. Marked retroperitoneal lymphadenopathy and lymphadenopathy along the iliac\n chains and pelvic sidewalls, significantly progressed from .\n 2. Splenomegaly, measuring approx. 20 cm, also increased in size.\n 3. Small hypodensities in the liver, which are too small to characterize.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: CLL, pancytopenia and febrile, assess for source of infection,\n enlarged lymph nodes.\n\n COMPARISON: .\n\n TECHNIQUE: MDCT axial images were obtained from the thoracic inlet to the\n symphysis pubis with administration of IV and oral contrast. Coronal and\n sagittal reformations were obtained.\n\n CT OF THE CHEST WITH IV CONTRAST: The heart and pericardium are normal,\n without pericardial effusion. The great vessels are within normal limits. No\n pathologically enlarged mediastinal, hilar, or axillary lymph nodes by CT size\n criteria are identified.\n\n There is paraseptal emphysema. Sub-4-mm nodular opacities, pleural based, in\n the left upper and lower lobes peripherally are unchanged from prior studies.\n The lungs are otherwise clear. There is no pleural effusion.\n\n CT OF THE ABDOMEN WITH IV CONTRAST: A hypodensity measuring approximately 1.4\n cm within segment VII (2:51) is indeterminant. Additional smaller\n hypodensities in the right lobe are all too small to characterize. The liver\n is otherwise unremarkable. The gallbladder, pancreas, and adrenal glands are\n unremarkable. There are bilateral parapelvic cysts in the kidneys, without\n evidence for hydronephrosis. The kidneys are otherwise unremarkable.\n\n The spleen is markedly enlarged, measuring up to 19 cm in craniocaudad\n dimensions. Additionally, there are numerous retroperitoneal lymph nodes,\n which are enlarged, and significantly progressed from . For\n example, a conglomerate of periaortic lymph nodes (2:80) measure up to 24 mm x\n 16 mm. There are additional lymph nodes along the iliac chains bilaterally,\n with the largest along the right iliac chain (2:87) measuring 17 mm x 19 mm.\n\n A small hiatal hernia is noted. Otherwise, the stomach, small, and large\n (Over)\n\n 12:44 PM\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: Pl evaluate for source of infection, enlarged LNs, etc.\n Admitting Diagnosis: FAILURE TO THRIVE\n Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n bowel are unremarkable. There is no free air or free fluid.\n\n CT OF THE PELVIS WITH IV CONTRAST: The urinary bladder and rectum are\n unremarkable. A calcified fibroid is seen within the uterus. There are bulky\n lymph nodes, particularly along the left pelvic sidewall, (2:103), measuring\n 40 mm x 16 mm, previously measured 38 mm x 18 mm.\n\n OSSEOUS STRUCTURES: There is a heterogeneous attenuation of the L5 vertebral\n body, with areas of rarefaction intermixed with areas of sclerosis, which are\n new from prior study. A similar-appearing lesion is also present within the\n T8 and T9 vertebral bodies.\n\n IMPRESSION:\n 1. Marked retroperitoneal lymphadenopathy, which are increased in size and\n number from , with additional bulky lymphadenopathy along the\n iliac chains and pelvic side walls bilaterally.\n 2. Splenomegaly, which is also increased in size from prior study.\n 3. Multiple small hypodensities in the liver, which are incompletely\n characterized.\n 4. New areas of rarefaction and lucencies in T8, T9, and L5 vertebral bodies.\n Attention on follow-up studies.\n\n\n" }, { "category": "Radiology", "chartdate": "2120-07-01 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1140762, "text": " 7:30 PM\n CHEST (PA & LAT) Clip # \n Reason: evaluate for pneumonia\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old woman with fatigue and cough\n REASON FOR THIS EXAMINATION:\n evaluate for pneumonia\n ______________________________________________________________________________\n FINAL REPORT\n EXAM: Chest frontal and lateral views.\n\n CLINICAL INFORMATION: 70-year-old female with history of fatigue and cough,\n evaluate for pneumonia.\n\n COMPARISON: .\n\n FINDINGS: Frontal and lateral views of the chest were obtained. The\n previously seen left-sided PICC is no longer seen. No focal consolidation,\n pleural effusion, or pneumothorax is seen. There is mild biapical pleural\n thickening. The cardiac and mediastinal silhouettes are unremarkable.\n\n IMPRESSION: No acute cardiopulmonary abnormality.\n\n" }, { "category": "Radiology", "chartdate": "2120-07-07 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1141745, "text": " 6:15 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: 47 cm Picc placed in right basilic vein, need Picc tip place\n Admitting Diagnosis: FAILURE TO THRIVE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old woman with new Picc\n REASON FOR THIS EXAMINATION:\n 47 cm Picc placed in right basilic vein, need Picc tip placement\n ______________________________________________________________________________\n WET READ: SUN 8:58 PM\n R picc tip extends well below the cavoatrial junction and should be\n repositioned. d/ at 1900 on .\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: New PICC line, assessment for line placement.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous examination, a new PICC line has been\n inserted over the right upper extremity. The course of the line is\n unremarkable. The tip of the line projects over the bases of the right\n atrium, the line should be pulled back by at least 5-6 cm. There is no\n evidence of complication, notably no pneumothorax. The IV nurse \n by the time of the wet read.\n\n\n" }, { "category": "Echo", "chartdate": "2120-07-04 00:00:00.000", "description": "Report", "row_id": 90891, "text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. Pre-Chemo Evaluation\nHeight: (in) 64\nWeight (lb): 143\nBSA (m2): 1.70 m2\nBP (mm Hg): 143/66\nHR (bpm): 113\nStatus: Outpatient\nDate/Time: at 11:22\nTest: TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Mild LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: 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: Normal RV chamber size and free wall motion.\n\nAORTA: Normal diameter of aorta at the sinus, ascending and arch levels.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Normal mitral valve leaflets with trivial MR. No MVP.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.\nIndeterminate PA systolic pressure.\n\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Resting tachycardia (HR>100bpm).\n\nConclusions:\nThe left atrium is mildly dilated. Left ventricular wall thickness, cavity\nsize and regional/global systolic function are normal (LVEF >55%). Right\nventricular chamber size and free wall motion are normal. The diameters of\naorta at the sinus, ascending and arch levels are normal. The aortic valve\nleaflets (3) appear structurally normal with good leaflet excursion and no\naortic regurgitation. The mitral valve appears structurally normal with\ntrivial mitral regurgitation. There is no mitral valve prolapse. The pulmonary\nartery systolic pressure could not be determined. There is no pericardial\neffusion.\n\nIMPRESSION: Normal global and regional biventricular systolic function. No\nclinically-significant valvular disease seen.\n\n\n" }, { "category": "ECG", "chartdate": "2120-07-01 00:00:00.000", "description": "Report", "row_id": 229272, "text": "Sinus rhythm. Delayed precordial R wave transition. Compared to the previous\ntracing of there is variation in precordial lead placement. No\ndiagnostic interim change.\n\n" } ]

[ { "category": "Nursing", "chartdate": "2161-05-24 00:00:00.000", "description": "Nursing Progress Note", "row_id": 467982, "text": "Aortic stenosis\n Assessment:\n Action:\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt remains intubated on CMV mode with 40% FIO2 with acceptable ABGs;\n breath sounds clear & equal bilaterally; minimal blood tinged\n secretions suctioned.\n Action:\n Vent mode changed to CPAP/PSV 5/5\n Spontaneous breathing trial done (PSV 5, 0 PEEP)\n Response:\n Tolerated CPAP/PSV with acceptable ABG and NAD noted.\n Failed SBT with flash pulmonary edema: increased WOB, tachypnea, HTN,\n desaturation to 90, coarse breath sounds throughout and ABG revealing\n inadequate ventilation with pH of 7.15. Pt returned to CMV mode for\n rest. Medications provided: lopressor 5mg ivp, 1 inch nitropaste,\n Lasix 20mg ivp\n Plan:\n Rest and attempt PSV mode again with gradual wean as tolerated.\n Diurese and manage hemodynamics.\n Subdural hemorrhage (SDH)\n Assessment:\n Action:\n Response:\n Plan:\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Respiratory ", "chartdate": "2161-05-25 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 468134, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 3\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Tube Type\n ETT:\n Position: 24 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 28 cmH2O\n Cuff volume: 8 mL /\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Diminished\n LUL Lung Sounds: Diminished\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Tan / Thick\n Sputum source/amount: Suctioned / Moderate\n Comments:\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern: Normal quiet breathing\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Underlying illness\n not resolved\n Respiratory Care Shift Procedures\n Bedside Procedures:\n Comments: Patient so far remains intubated and on mechanical\n ventilation, breath sounds bilaterally diminished, suctioned\n intermittently for moderate amounts of thick tan secretions, had\n successful SBT for 10 minutes, plan is to travel to CT for head scan,\n probably OR then be considered for extubation, SPO2 remained upper 90s,\n no distress occurred, will continues to be followed.\n" }, { "category": "Echo", "chartdate": "2161-05-25 00:00:00.000", "description": "Report", "row_id": 89480, "text": "PATIENT/TEST INFORMATION:\nIndication: Hypertension. Murmur. Syncope.\nHeight: (in) 63\nWeight (lb): 138\nBSA (m2): 1.65 m2\nBP (mm Hg): 154/57\nHR (bpm): 90\nStatus: Inpatient\nDate/Time: at 09:18\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: The patient is mechanically ventilated.\nCannot assess RA pressure.\n\nLEFT VENTRICLE: Mild symmetric LVH with normal cavity size and regional/global\nsystolic function (LVEF>55%). Estimated cardiac index is normal\n(>=2.5L/min/m2). No resting LVOT gradient.\n\nRIGHT VENTRICLE: Normal RV chamber size. Borderline normal RV systolic\nfunction.\n\nAORTA: Normal aortic diameter at the sinus level. Mildly dilated ascending\naorta.\n\nAORTIC VALVE: Severely thickened/deformed aortic valve leaflets. Critical AS\n(area <0.8cm2). Mild (1+) AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Mild mitral annular\ncalcification. Moderate (2+) MR. [Due to acoustic shadowing, the severity of\nMR may be significantly UNDERestimated.]\n\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Mild to moderate\n[+] TR. Moderate PA systolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Echocardiographic results were reviewed by telephone with\nthe houseofficer caring for the patient.\n\nConclusions:\nThe left atrium is mildly dilated. There is mild symmetric left ventricular\nhypertrophy with normal cavity size and regional/global systolic function\n(LVEF>55%). The estimated cardiac index is normal (>=2.5L/min/m2). Right\nventricular chamber size is normal with borderline normal free wall function.\nThe ascending aorta is mildly dilated. The aortic valve leaflets are severely\nthickened/deformed. There is critical aortic valve stenosis (valve area\n0.6cm2). Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are\nmildly thickened. Moderate (2+) mitral regurgitation is seen. [Due to acoustic\nshadowing, the severity of mitral regurgitation may be significantly\nUNDERestimated.] The tricuspid valve leaflets are mildly thickened. There is\nmoderate pulmonary artery systolic hypertension. There is no pericardial\neffusion.\n\nIMPRESSION: Severe/critical aortic stenosis. At least moderate mitral\nregurgitation. Pulmonary artery systolic hypertension. Mild symmetric left\nventricular hypertrophy with preserved global and regional biventricular\nsystolic function.\n\nCLINICAL IMPLICATIONS:\nThe patient has severe aortic stenosis. Based on ACC/AHA Valvular Heart\nDisease Guidelines, if the patient is symptomatic (angina, syncope, CHF) and a\nsurgical candidate, surgical intervention has been shown to be beneficial.\n\n\n" }, { "category": "Nursing", "chartdate": "2161-05-26 00:00:00.000", "description": "Nursing Progress Note", "row_id": 468195, "text": "Shift events:\n -Repeat head CT (routine)\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Patient orally intubated on CPAP 10 PS, 5 PEEP, 40% FiO2. LS clear to\n diminished, sats 100%.\n Action:\n PS decreased to 5, ABG drawn.\n Response:\n ABG WNL. Around midnight, patient desaturated to 91%, became\n Tachypneic in low 30\ns. Patient suctioned for thick, tan plugs. Sats\n returned to , however, patient remained Tachypneic. Ventilator\n settings changed to A/C, 16 x 500, 40% FiO2.\n Plan:\n Subdural hemorrhage (SDH)\n Assessment:\n Patient sedated on propofol. Patient alert, unable to assess\n orientation. Pupils 4mm, equal, reactive. +gag/cough/corneal\n reflexes. MAE spontaneously. Follows commands, able to give thumbs\n up, wiggle toes and stick out tongue.\n Action:\n Q2h neuro exam. Repeat head CT at 0500.\n Response:\n Neuro exam unchanged. Propofol titrated as indicated.\n Plan:\n Continue to monitor neuro exam. Follow up w/ pending CT results. ?\n change q2h to q4h neuro exams.\n" }, { "category": "Nutrition", "chartdate": "2161-05-26 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 468303, "text": "Subjective\n intubated\n Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 165 cm\n 62.3 kg\n 64 kg ( 04:00 AM)\n 22.8\n Ideal body weight\n % Ideal body weight\n Adjusted weight\n Usual body weight\n % Usual body weight\n 56.7 kg\n 110%\n Diagnosis: acute SDH\n PMH :\n Food allergies and intolerances: mag sulfate (2g), IV abx, RISS,\n colace, lansoprazole, lasix, others noted\n Pertinent medications:\n Labs:\n Value\n Date\n Glucose\n 127 mg/dL\n 01:17 AM\n Glucose Finger Stick\n 153\n 08:00 AM\n BUN\n 19 mg/dL\n 01:17 AM\n Creatinine\n 1.0 mg/dL\n 01:17 AM\n Sodium\n 143 mEq/L\n 01:17 AM\n Potassium\n 4.6 mEq/L\n 01:17 AM\n Chloride\n 108 mEq/L\n 01:17 AM\n TCO2\n 26 mEq/L\n 01:17 AM\n PO2 (arterial)\n 158 mm Hg\n 02:50 AM\n PCO2 (arterial)\n 38 mm Hg\n 02:50 AM\n pH (arterial)\n 7.46 units\n 02:50 AM\n pH (urine)\n 7.0 units\n 05:29 PM\n CO2 (Calc) arterial\n 28 mEq/L\n 02:50 AM\n Albumin\n 3.6 g/dL\n 05:42 AM\n Calcium non-ionized\n 9.3 mg/dL\n 01:17 AM\n Phosphorus\n 3.7 mg/dL\n 01:17 AM\n Ionized Calcium\n 1.15 mmol/L\n 10:13 PM\n Magnesium\n 1.9 mg/dL\n 01:17 AM\n ALT\n 8 IU/L\n 05:42 AM\n Alkaline Phosphate\n 50 IU/L\n 05:42 AM\n AST\n 24 IU/L\n 05:42 AM\n Total Bilirubin\n 0.5 mg/dL\n 05:42 AM\n WBC\n 14.4 K/uL\n 01:17 AM\n Hgb\n 8.1 g/dL\n 01:17 AM\n Hematocrit\n 24.6 %\n 01:17 AM\n Current diet order / nutrition support: Replete with fiber Full\n strength;\n Starting rate: 20 ml/hr; Advance rate by 10 ml q4h Goal rate: 60 ml/hr\n = 1440 kcals/ 89 g protein\n Residual Check: q4h Hold feeding for residual >= : 200 ml\n GI: soft, distended, +bowel sounds\n Assessment of Nutritional Status\n At risk for malnutrition\n Pt at risk due to: trauma\n Estimated Nutritional Needs\n Calories: 1558-1744 (BEE x or / 25-28 cal/kg)\n Protein: 62-75 (1-1.2 g/kg)\n Fluid: per team\n Estimation of previous intake: Inadequate\n Estimation of current intake: Inadequate\n Specifics:\n Medical Nutrition Therapy Plan - Recommend the Following\n Multivitamin / Mineral supplement: via tube feeding\n Check chemistry 10 panel daily\n Comments:\n" }, { "category": "Nursing", "chartdate": "2161-05-23 00:00:00.000", "description": "Nursing Progress Note", "row_id": 467847, "text": "Subdural hemorrhage (SDH) s/p fall \n Assessment:\n Pt sedated on propofol. When sedation lightened, pt MAEs and follows\n commands & nods head to questions inconsistently. PERRL @ 3-4mm/brisk\n with positive corneal reflexes. Cough & gag are intact.\n Action:\n Response:\n Plan:\n" }, { "category": "Physician ", "chartdate": "2161-05-24 00:00:00.000", "description": "Intensivist Note", "row_id": 467955, "text": "SICU\n Chief complaint:\n head trauma\n HPI:\n 82yo female who reports having tripped on the curb and falling. Hit her\n right side of face on the ground. Event reported to happen @ approx.\n 7:15pm on . Pts daughter witnessed event and brought her to OSH for\n evaluation, INR 2.97. Denies pain, acute respiratory decompensation in\n ED requiring intubation, found to have SDH.\n PMHx:\n CAD s/p stent placement, filter, MI, PE, Mitral Regurg,\n GERD, Anxiety, Anemia, HOH\n Current medications:\n 24 Hour Events:\n TRANSTHORACIC ECHO - At 08:00 AM\n MULTI LUMEN - START 11:24 AM\n URINE CULTURE - At 06:20 PM\n FEVER - 101.6\nF - 04:00 AM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ciprofloxacin - 06:25 AM\n Infusions:\n Phenylephrine - 0.8 mcg/Kg/min\n Propofol - 25 mcg/Kg/min\n Other ICU medications:\n Famotidine (Pepcid) - 08:20 AM\n Metoprolol - 08:20 AM\n Fentanyl - 05:39 PM\n Other medications:\n Pepcid\n NTP\n metoprolol\n Flowsheet Data as of 05:00 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.7\nC (101.6\n T current: 38.7\nC (101.6\n HR: 95 (60 - 96) bpm\n BP: 120/58(84) {97/36(2) - 165/73(112)} mmHg\n RR: 21 (10 - 25) insp/min\n SPO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 66 kg (admission): 62.3 kg\n Total In:\n 3,276 mL\n 520 mL\n PO:\n Tube feeding:\n IV Fluid:\n 2,022 mL\n 520 mL\n Blood products:\n 284 mL\n Total out:\n 1,520 mL\n 211 mL\n Urine:\n 1,190 mL\n 211 mL\n NG:\n 200 mL\n Stool:\n Drains:\n Balance:\n 1,756 mL\n 309 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 16\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 40%\n PIP: 27 cmH2O\n Plateau: 16 cmH2O\n Compliance: 50 cmH2O/mL\n SPO2: 98%\n ABG: 7.47/41/121/26/6\n Ve: 7.2 L/min\n PaO2 / FiO2: 303\n Physical Examination\n General Appearance: No acute distress, Well nourished\n HEENT: EOMI, MMs moist, nasal abrasion unchnaged\n Cardiovascular: (Rhythm: Regular), (Murmur: Systolic), (Distant heart\n sounds: Absent) diamond shaped systolic murmur, no heave\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: No(t)\n Resonant : ), (Breath Sounds: CTA bilateral : ), (Sternum: Stable )\n Abdominal: Soft, Non-distended, Non-tender\n Left Extremities: (Edema: Absent), (Temperature: Warm)\n Right Extremities: (Edema: Absent), (Temperature: Warm)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: Follows simple commands, (Responds to: Verbal stimuli),\n Moves all extremities, Sedated, GCS 10T\n Labs / Radiology\n 281 K/uL\n 8.3 g/dL\n 124 mg/dL\n 1.0 mg/dL\n 26 mEq/L\n 3.9 mEq/L\n 16 mg/dL\n 108 mEq/L\n 143 mEq/L\n 24.5 %\n 16.3 K/uL\n [image002.jpg]\n 05:42 AM\n 07:11 AM\n 07:22 AM\n 09:29 AM\n 11:16 AM\n 01:45 PM\n 04:01 PM\n 08:45 PM\n 01:13 AM\n WBC\n 12.7\n 16.3\n Hct\n 21.6\n 22.5\n 24.5\n 24.5\n Plt\n 290\n 281\n Creatinine\n 1.1\n 1.0\n TCO2\n 35\n 30\n 30\n 31\n 31\n Glucose\n 125\n 117\n 103\n 124\n Other labs: PT / PTT / INR:13.4/23.9/1.1, ALT / AST:, Alk-Phos / T\n bili:50/0.5, Differential-Neuts:77.3 %, Lymph:16.4 %, Mono:4.9 %,\n Eos:1.1 %, Lactic Acid:0.8 mmol/L, Albumin:3.6 g/dL, Ca:9.6 mg/dL,\n Mg:1.8 mg/dL, PO4:2.9 mg/dL\n Assessment and Plan\n AORTIC STENOSIS, SUBDURAL HEMORRHAGE (SDH)\n Assessment and Plan: 82F with SDH coumadin, stable neuro exam\n Neurologic: 1- SDH- repeat head ct this am shows decreased midline\n shift and organization of hematoma, exam symmetric. Neuro checks Q: 2\n hr, wean sedation with propofol, no current indication for\n intervention, will discuss with neurosurgery, .\n Cardiovascular: 1- CAD and Aortic stenosis -PRN nitro paste + beta\n blocker for hypertension, keep MAP > 80 using neo if needed, holding\n ASA + Plavix for now, follow up final cardiology recs, has known A.S.\n Re-assess cardiac med status after extubation and weaned from neo.\n Pulmonary: 1- Vent-dependent respiratory insufficiency\n wean to\n extubate.\n Gastrointestinal / Abdomen: no acute issues\n Nutrition: NPO\n Renal: 1-euvolemic\n leave on NS @ 75 cc/hr. Fix hypomagnesemia and\n hypokalemia. Mild metabolic alkalosis now unmasked by relative\n hypocapnia. CXR this AM\n is diuretic dependent at home and may\n need mild diuresis.\n Hematology: stable\n Endocrine: RISS\n Infectious Disease: 1- ? Early sepsis - check cultures, febrile, known\n bacteriuria\n follow up repeat cultures, restart cipro, not septic\n Lines / Tubes / Drains: Foley, ETT, CVL, arterial line\n Wounds: Dry dressings\n Imaging:\n Fluids: NS, 75/hr\n Consults: Neuro surgery,\n Billing Diagnosis: SDH and Vent-dependent respiratory insufficiency\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 07:00 AM\n 18 Gauge - 09:15 AM\n Multi Lumen - 11:24 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 38 min\n" }, { "category": "Physician ", "chartdate": "2161-05-26 00:00:00.000", "description": "Intensivist Note", "row_id": 468269, "text": "TSICU\n HPI:\n 82yo female here for Right-sided SDH who reports having tripped on the\n curb and falling. Hit her right side of face on the ground. Event\n reported to happen @ approx. 7:15pm on . Pts daughter witnessed\n event and brought her to OSH for evaluation, INR 2.97. Denies pain.\n Chief complaint:\n subdural hematoma\n PMHx:\n CAD s/p stent placement, filter, MI, PE, Mitral Regurg,\n GERD, Anxiety, Anemia, HOH, aflutter\n Current medications:\n . 2. 1000 mL NS 3. Acetaminophen (Liquid) 4. Albuterol Inhaler 5.\n Bisacodyl 6. Calcium Gluconate\n 7. Chlorhexidine Gluconate 0.12% Oral Rinse 8. Docusate Sodium (Liquid)\n 9. Fentanyl Citrate 10. Insulin\n 11. Ipratropium Bromide MDI 12. Lansoprazole Oral Disintegrating Tab\n 13. Levofloxacin 14. Levofloxacin\n 15. Magnesium Sulfate 16. Metoprolol Tartrate 17. Phenylephrine 18.\n Pneumococcal Vac Polyvalent 19. Potassium Chloride\n 20. Potassium Phosphate 21. Propofol 22. Sertraline 23. Senna 24.\n Simvastatin 25. Sodium Chloride 0.9% Flush\n 24 Hour Events:\n ARTERIAL LINE - STOP 12:26 PM\n ARTERIAL LINE - START 03:15 PM\n A-line placed on L, tube feeds started, levoflox started for PNA/UTI\n (replaced Cipro). MAPs ranging from 60-80 throughout PM.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ciprofloxacin - 04:15 PM\n Levofloxacin - 08:33 PM\n Infusions:\n Propofol - 10 mcg/Kg/min\n Other ICU medications:\n Famotidine (Pepcid) - 08:14 AM\n Metoprolol - 12:00 AM\n Other medications:\n Flowsheet Data as of 06:31 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.1\nC (100.6\n T current: 38.1\nC (100.6\n HR: 81 (78 - 120) bpm\n BP: 125/48(78) {107/39(62) - 145/74(98)} mmHg\n RR: 19 (13 - 31) insp/min\n SPO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 64 kg (admission): 62.3 kg\n CVP: 15 (3 - 22) mmHg\n Total In:\n 1,272 mL\n 487 mL\n PO:\n Tube feeding:\n 188 mL\n 239 mL\n IV Fluid:\n 1,024 mL\n 158 mL\n Blood products:\n Total out:\n 1,761 mL\n 430 mL\n Urine:\n 1,761 mL\n 430 mL\n NG:\n Stool:\n Drains:\n Balance:\n -489 mL\n 57 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 386 (327 - 553) mL\n PS : 10 cmH2O\n RR (Set): 16\n RR (Spontaneous): 23\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 98\n PIP: 15 cmH2O\n SPO2: 100%\n ABG: 7.46/38/158/26/3\n Ve: 9.6 L/min\n PaO2 / FiO2: 395\n Physical Examination\n General Appearance: No acute distress, Anxious\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular), (Murmur: Systolic, Diastolic),\n Murmur of AS\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: No(t) CTA\n bilateral : , Crackles : On R)\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: Absent), (Pulse - Dorsalis pedis: Present)\n Right Extremities: (Edema: Absent), (Pulse - Dorsalis pedis: Present),\n (Pulse - Posterior tibial: Present)\n Skin: Facial bruising\n Neurologic: (Responds to: No(t) Verbal stimuli, Tactile stimuli, No(t)\n Noxious stimuli), Moves all extremities, Sedated\n Labs / Radiology\n 288 K/uL\n 8.1 g/dL\n 127 mg/dL\n 1.0 mg/dL\n 26 mEq/L\n 4.6 mEq/L\n 19 mg/dL\n 108 mEq/L\n 143 mEq/L\n 24.6 %\n 14.4 K/uL\n [image002.jpg]\n 02:41 PM\n 05:10 PM\n 06:21 PM\n 06:27 PM\n 01:25 AM\n 01:37 AM\n 10:13 PM\n 12:54 AM\n 01:17 AM\n 02:50 AM\n WBC\n 17.3\n 14.4\n Hct\n 24.7\n 24.6\n Plt\n 261\n 288\n Creatinine\n 0.9\n 1.0\n 1.0\n TCO2\n 29\n 30\n 28\n 29\n 27\n 28\n 28\n Glucose\n 120\n 170\n 124\n 127\n Other labs: PT / PTT / INR:12.9/22.4/1.1, ALT / AST:, Alk-Phos / T\n bili:50/0.5, Differential-Neuts:77.3 %, Lymph:16.4 %, Mono:4.9 %,\n Eos:1.1 %, Lactic Acid:1.0 mmol/L, Albumin:3.6 g/dL, Ca:9.3 mg/dL,\n Mg:1.9 mg/dL, PO4:3.7 mg/dL\n Assessment and Plan\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/), FEVER, UNKNOWN ORIGIN (FUO,\n HYPERTHERMIA, PYREXIA), AORTIC STENOSIS, SUBDURAL HEMORRHAGE (SDH)\n Assessment and Plan: 82 yo F w/ h/o CAD, AS, Afib on coumadin, s/p fall\n with rt SDH.\n Neurologic: sedation with propofol; rpt CT head with no sig change\n Neuro checks Q: 2\n - CT head sched 5am .\n Pain: fentanyl PRN\n Cardiovascular: - MAPs low normal. If stay in 60s, start pressors.\n - Critical AS. Nitro d/c'd. Metoprolol for hypertension, keep MAP > 80,\n holding ASA + Plavix for now, follow up final cardiology recs, has\n known A.S.\n Pulmonary: ? R-sided PNA\n Cont cipro and add Vanco and f/u with sputum\n cx\ns. SBT and trial of extubation this AM\n Gastrointestinal / Abdomen: NPO; H2B, swallow eval after extubated,\n Place NGT prior to extubation.\n Nutrition: Tube feeding\n on hold for extubation this AM.\n Renal: Adeq UOP, cont to follow and give lasix prn for goal euvolemia\n today.\n Hematology: Mod anemia unchanged\n cont to follow.\n Endocrine: RISS\n Infectious Disease: Antbx for VAP and UTI\n f/u with cx\n Lines / Tubes / Drains: L A-line, foley, PIV - CVL\n Imaging: CT scan head today\n Fluids: KVO\n Consults: Neuro surgery\n Billing Diagnosis: (Hemorrhage, NOS: Subdural)\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 09:15 AM\n Multi Lumen - 11:24 AM\n Arterial Line - 03:15 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP bundle:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: TSICU\n Total time spent: 33\n" }, { "category": "Respiratory ", "chartdate": "2161-05-23 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 467842, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 0\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Tube Type\n ETT:\n Position: cm at teeth\n Route: Oral\n Type: Standard\n Size: 7mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: cmH2O\n Cuff volume: 8 mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Clear\n Comments:\n Secretions\n Sputum color / consistency: Tan / Thick\n Sputum source/amount: Suctioned / Scant\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n :\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 Reason for continuing current ventilatory support: Underlying illness\n not resolved\n" }, { "category": "Nursing", "chartdate": "2161-05-24 00:00:00.000", "description": "Nursing Progress Note", "row_id": 468032, "text": "Aortic stenosis\n Assessment:\n + Systolic murmur, known AS, CHF, & 3 vessel CAD, s/p stent to LAD in\n , & HTN. TTE @ bedside confirms EF ~ 45%. Pt need MAP ~ 80\n for adequate coronary perfusion. Sedation softens BP; Neosynephrine\n available to maintain MAP.\n Action:\n Lopressor & nitropaste for HTN> 160 systolic\n Titration of sedation; neo weaned to off\n Lasix for positive fluid balance\n Electrolyte repletion to maintain acid/base balance\n Response:\n MAP maintained within goal range with nitropaste, prn lopressor,\n minimal propofol, prn fentanyl while remaining off neo infusion.\n Currently in running ~ 300cc negative for the day with LOS balance\n positive ~ 1200cc.\n Electrolytes wnl\n Plan:\n Continuous hemodynamic monitoring with goal of MAP ~ 80\n Goal fluid balance: even of slightly negative to prepare for wean\n &extubation\n Replete electrolytes prn; monitor pH.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt remains intubated on CMV mode & 40% FIO2 with acceptable ABGs;\n breath sounds clear & equal bilaterally; minimal blood tinged\n secretions suctioned. Goal is for PCO2 ~ 40 to avoid cerebral edema in\n setting of SDH.\n Action:\n Vent mode changed to CPAP/PSV 5/5\n Spontaneous breathing trial done (PSV 5, 0 PEEP)\n Response:\n Tolerated CPAP/PSV with acceptable ABG and NAD noted.\n Failed SBT with flash pulmonary edema: increased WOB, tachypnea, HTN,\n desaturation to 90, coarse breath sounds throughout and ABG revealing\n inadequate ventilation with pH of 7.15 & PCO2 >80. Pt returned to CMV\n mode for rest. Medications provided: lopressor 5mg ivp, 1 inch\n nitropaste, Lasix 20mg ivp\n Plan:\n Rest and attempt PSV mode again with gradual wean as tolerated. PSV\n adequate to maintain PCO2~ 40\n Diurese and manage Hemodynamics with pharmacology\n Subdural hemorrhage (SDH)\n Assessment:\n Pt is lightly sedated with propofol. Pt responds to voice &\n stimulation but is not following commands (? By choice). Spontaneously\n MAEs with purpose & against gravity and equal bilaterally. PERRL @\n 4-5mm/brisk; corneal, cough, & gag reflexes present. Pt remains\n restless when lightened from sedation.\n Action:\n Head CT repeated this morning.\n Neuro checks Q 2 hours\n Sedation titrated to effect. PRN Fentanyl provided to assist in\n sedation & comfort with ETT.\n Neosynephrine utilized as needed to maintain adequate BP while sedated\n Response:\n Repeat CT reported as no significant change\n Neuro exam is unchanged\n Pt remains restless when awake and continues to NOT follow commands;\n minimal eye contact or tracking noted.\n Propofol maintained @ 18-30mcg/kg/min; Fentanyl x2 with effect.\n Neo weaned off\n Plan:\n Neuro checks Q 2 hours\n Maintain sedation for tolerance of ETT & ventilation support.\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n S/P temp spike to 101.6 on nights & WBC elevated to 16; cultures\n pending. Vital signs & O2 saturations adequate. Pt warm & well\n perfused. Urine is clear & yellow now absent of foul odor; sputum is\n pale yellow.\n Action:\n Temperature checked Q 2-4 hours\n Urine culture sent\n Ciprofloxacin therapy reordered today.\n Response:\n Temp 99 currently with T max 100.2; pt remains warm, dry with normal\n skin coloring and palpable peripheral pulses. Hemodynamics with\n acceptable ranges; O2 saturations 100%\n All cultures are pending.\n No change in character of urine or sputum\n Plan:\n Follow temp trend and daily WBC; not changes in urine or sputum.\n Monitor for hypotension & evidence of decreased tissue perfusion.\n Antibiotics as ordered.\n" }, { "category": "Nursing", "chartdate": "2161-05-24 00:00:00.000", "description": "Nursing Progress Note", "row_id": 468033, "text": "Aortic stenosis\n Assessment:\n + Systolic murmur, known AS, CHF, & 3 vessel CAD, s/p stent to LAD in\n , & HTN. TTE @ bedside confirms EF ~ 45%. Pt needs MAP ~ 80\n for adequate coronary perfusion. Sedation softens BP; Neosynephrine\n available to maintain MAP.\n Action:\n Lopressor for HTN> 160 systolic and tachycardia >100\n Nitropaste for coronary perfusion, afterload reduction\n Titration of sedation; neo weaned to off\n Lasix for positive fluid balance\n Electrolyte repletion to maintain acid/base balance\n Response:\n MAP maintained within goal range with nitropaste, prn lopressor,\n minimal propofol, prn fentanyl while remaining off neo infusion.\n Currently in running ~ 400cc negative for the day with LOS balance\n positive ~ 1200cc.\n Electrolytes wnl\n Plan:\n Continuous hemodynamic monitoring with goal MAP ~ 80\n Goal fluid balance: even or slightly negative to prepare for wean &\n extubation\n Replete electrolytes prn; monitor pH.\n Continue sedation to limit hyperdynamic effects of agitation (pt has\n significant h/o anxiety)\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt remains intubated on CMV mode & 50% FIO2 with acceptable ABGs;\n breath sounds clear & equal bilaterally; minimal blood tinged to yellow\n secretions suctioned. Goal is for PCO2 ~ 40 to avoid cerebral edema in\n setting of SDH.\n Action:\n Vent mode changed to CPAP/PSV 5/5\n Spontaneous breathing trial done (PSV 5, 0 PEEP)\n Response:\n Tolerated CPAP/PSV 5/5 with acceptable ABG and NAD noted.\n Failed SBT with flash pulmonary edema: increased WOB, tachypnea, HTN,\n SVT to 140, desaturation to 90, coarse breath sounds throughout without\n much air movement, and ABG revealing inadequate ventilation with pH of\n 7.15 & PCO2 >80. Pt returned to CMV mode for rest. Medications\n provided: lopressor 5mg ivp, 1 inch nitropaste, Lasix 20mg ivp,\n fentanyl & propofol for sedation.\n Plan:\n Rest and attempt PSV mode again with gradual wean as tolerated. PSV\n adequate to maintain PCO2~ 40\n Diurese and manage Hemodynamics with pharmacology\n **NB: pt returned to PSV/CPAP 8/5 with PCO2 of 50: PSV increased to 10.\n During sedation suspension for neuro exam @ 1600, pt again experienced\n dyspnea, tachypnea, tachycardia & HTN, with coarse breath sounds, and\n required intervention with Lopressor, fentanyl & propofol bolusing, &\n increase in PSV to 15cm. Pt eventually settled. ABG following settling\n & vent changes is acceptable (pH 7.37 & PCO2 45). Additional diuresis\n is planned for this evening; currently fluid balance remains negative\n with adequate hourly urine output.\n Subdural hemorrhage (SDH)\n Assessment:\n Pt is lightly sedated with propofol. Pt responds to voice &\n stimulation but is not following commands (? By choice). Spontaneously\n MAEs with purpose & against gravity and equal bilaterally. PERRL @\n 4-5mm/brisk; corneal, cough, & gag reflexes present. Pt remains\n restless when lightened from sedation.\n Action:\n Head CT repeated this morning.\n Neuro checks Q 2 hours\n Sedation titrated to effect. PRN Fentanyl provided to assist in\n sedation & comfort with ETT.\n Neosynephrine utilized as needed to maintain adequate BP while sedated\n Response:\n Repeat CT reported as no significant change\n Neuro exam is unchanged\n Pt remains restless when awake and continues to NOT follow commands;\n minimal eye contact or tracking noted.\n Propofol maintained @ 18-30mcg/kg/min; Fentanyl x2 with effect.\n Neo weaned off\n Plan:\n Neuro checks Q 2 hours\n Maintain sedation for tolerance of ETT & ventilation support.\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n S/P temp spike to 101.6 on nights & WBC elevated to 16; cultures\n pending. Vital signs & O2 saturations adequate. Pt warm & well\n perfused. Urine is clear & yellow now absent of foul odor; sputum is\n pale yellow.\n Action:\n Temperature checked Q 2-4 hours\n Urine culture sent\n Ciprofloxacin therapy reordered today.\n Response:\n Temp 99 currently with T max 100.2; pt remains warm, dry with normal\n skin coloring and palpable peripheral pulses. Hemodynamics with\n acceptable ranges; O2 saturations 100%\n All cultures are pending.\n No change in character of urine or sputum\n Plan:\n Follow temp trend and daily WBC; not changes in urine or sputum.\n Monitor for hypotension & evidence of decreased tissue perfusion.\n Antibiotics as ordered.\n SOCIAL: Both daughters have been in contact by phone today; lengthy\n updates have been provided with explanations of plan of care for\n weaning and what has occurred today in that regard. Daughters\n demonstrate understanding of today\ns events and are aware that weaning\n from ventilator support may be a slow process for their mother due to\n her baseline cardiac issues. They both are appropriate in their\n concerns and remain hopeful for the best outcome.\n" }, { "category": "Physician ", "chartdate": "2161-05-25 00:00:00.000", "description": "Intensivist Note", "row_id": 468085, "text": "TSICU\n HPI:\n 82yo female who reports having tripped on the curb and\n falling. Hit her right side of face on the ground. Event reported\n to happen @ approx. 7:15pm on . Pts daughter witnessed event\n and brought her to OSH for evaluation, INR 2.97. Denies pain.\n Chief complaint:\n SDH s/p fall\n PMHx:\n CAD s/p stent placement, filter, MI, PE, Mitral Regurg,\n GERD, Anxiety, Anemia, HOH, aflutter\n Current medications:\n 24 Hour Events:\n URINE CULTURE - At 09:00 AM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ciprofloxacin - 05:00 PM\n Infusions:\n Propofol - 60 mcg/Kg/min\n Other ICU medications:\n Fentanyl - 04:50 PM\n Propofol - 04:50 PM\n Famotidine (Pepcid) - 08:00 PM\n Metoprolol - 08:00 PM\n Furosemide (Lasix) - 08:36 PM\n Other medications:\n Flowsheet Data as of 07:25 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.2\nC (100.7\n T current: 37.3\nC (99.2\n HR: 88 (65 - 144) bpm\n BP: 145/65(98) {95/41(62) - 180/79(119)} mmHg\n RR: 16 (8 - 27) insp/min\n SPO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 62.5 kg (admission): 62.3 kg\n CVP: 9 (4 - 16) mmHg\n Total In:\n 2,117 mL\n 269 mL\n PO:\n Tube feeding:\n IV Fluid:\n 1,877 mL\n 269 mL\n Blood products:\n Total out:\n 3,078 mL\n 1,085 mL\n Urine:\n 2,978 mL\n 1,085 mL\n NG:\n 100 mL\n Stool:\n Drains:\n Balance:\n -961 mL\n -816 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 415 (343 - 505) mL\n PS : 10 cmH2O\n RR (Set): 16\n RR (Spontaneous): 17\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 75\n PIP: 18 cmH2O\n Plateau: 15 cmH2O\n SPO2: 100%\n ABG: 7.43/43/116/26/4\n Ve: 6.7 L/min\n PaO2 / FiO2: 290\n Physical Examination\n General Appearance: No acute distress, intubated, sedated\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular), (Murmur: Systolic), SEM @ LSB\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Neurologic: No(t) Follows simple commands, Moves all extremities,\n Sedated\n Labs / Radiology\n 261 K/uL\n 8.4 g/dL\n 124 mg/dL\n 1.0 mg/dL\n 26 mEq/L\n 4.0 mEq/L\n 15 mg/dL\n 106 mEq/L\n 144 mEq/L\n 24.7 %\n 17.3 K/uL\n [image002.jpg]\n 01:13 AM\n 05:21 AM\n 08:35 AM\n 09:08 AM\n 02:41 PM\n 05:10 PM\n 06:21 PM\n 06:27 PM\n 01:25 AM\n 01:37 AM\n WBC\n 16.3\n 17.3\n Hct\n 24.5\n 24.7\n Plt\n 281\n 261\n Creatinine\n 1.0\n 0.9\n 1.0\n TCO2\n 30\n 29\n 31\n 29\n 30\n 28\n 29\n Glucose\n 124\n 116\n 120\n 170\n 124\n Other labs: PT / PTT / INR:12.9/22.4/1.1, ALT / AST:, Alk-Phos / T\n bili:50/0.5, Differential-Neuts:77.3 %, Lymph:16.4 %, Mono:4.9 %,\n Eos:1.1 %, Lactic Acid:1.0 mmol/L, Albumin:3.6 g/dL, Ca:9.3 mg/dL,\n Mg:2.3 mg/dL, PO4:3.9 mg/dL\n Assessment and Plan\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/), FEVER, UNKNOWN ORIGIN (FUO,\n HYPERTHERMIA, PYREXIA), AORTIC STENOSIS, SUBDURAL HEMORRHAGE (SDH)\n Assessment and Plan: 82 yo F w/ h/o CAD, AS, Afib on coumadin, s/p fall\n with rt SDH.\n Neurologic: Neuro checks Q: 2 hr, propofol for sedation; prn fentanyl\n for pain.\n Cardiovascular: hemodynamically stable off pressors; PRN nitro paste,\n metoprolol for hypertension, keep MAP > 80, holding ASA + Plavix for\n now, follow up final cardiology reccs, has known A.S., surface echo\n today (ordered)\n Pulmonary: (Ventilator mode: CPAP + PS), tolerating CPAP/PS s/p\n diureses yesterday; ABG improved this am. try to wean to extubate\n today, f/u this am CXR\n Gastrointestinal / Abdomen: NPO; H2B, swallow eval after extubated\n Nutrition: NPO, Speech and Swallow eval\n Renal: Foley, Adequate UO, acid base status improved (prior resp\n acidosis); s/p lasix 20 mg IV x 2 yesterday with appropriate diuresis;\n takes lasix at home, restart home po lasix if able to tol po after\n extubation\n Hematology: chronic stable anemia\n Endocrine: RISS\n Infectious Disease: febrile, known bacteriuria/GNR - followup repeat\n cx's, restarted cipro\n Lines / Tubes / Drains: Foley, ETT, art line, PIV, CVL\n Wounds:\n Imaging: CXR today\n Fluids: KVO\n Consults: Neuro surgery, Trauma surgery, Cardiology\n Billing Diagnosis: (Hemorrhage, NOS: Subdural), (Respiratory distress)\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 07:00 AM\n 18 Gauge - 09:15 AM\n Multi Lumen - 11:24 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n Total time spent:\n" }, { "category": "Physician ", "chartdate": "2161-05-25 00:00:00.000", "description": "Intensivist Note", "row_id": 468108, "text": "TSICU\n HPI:\n 82yo female who reports having tripped on the curb and\n falling. Hit her right side of face on the ground. Event reported\n to happen @ approx. 7:15pm on . Pts daughter witnessed event\n and brought her to OSH for evaluation, INR 2.97. Denies pain.\n Chief complaint:\n SDH s/p fall\n PMHx:\n CAD s/p stent placement, filter, MI, PE, Mitral Regurg,\n GERD, Anxiety, Anemia, HOH, aflutter\n Current medications:\n Acetaminophen (Liquid) 4. Albuterol Inhaler 5. Bisacodyl 6. Calcium\n Gluconate\n 7. Chlorhexidine Gluconate 0.12% Oral Rinse 8. Ciprofloxacin 9.\n Docusate Sodium (Liquid) 10. Famotidine\n 11. Fentanyl Citrate 13. Furosemide 14. Insulin 16. Metoprolol Tartrate\n 17. Metoprolol Tartrate 18. Nitroglycerin Ointment 2% 19. Phenylephrine\n 23. Propofol 24. Sertraline 25. Senna 26. Simvastatin\n 24 Hour Events:\n URINE CULTURE - At 09:00 AM\n --Remains intubated with poor mental exam.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ciprofloxacin - 05:00 PM\n Infusions:\n Propofol - 60 mcg/Kg/min\n Other ICU medications:\n Fentanyl - 04:50 PM\n Propofol - 04:50 PM\n Famotidine (Pepcid) - 08:00 PM\n Metoprolol - 08:00 PM\n Furosemide (Lasix) - 08:36 PM\n Other medications:\n Flowsheet Data as of 07:25 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.2\nC (100.7\n T current: 37.3\nC (99.2\n HR: 88 (65 - 144) bpm\n BP: 145/65(98) {95/41(62) - 180/79(119)} mmHg\n RR: 16 (8 - 27) insp/min\n SPO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 62.5 kg (admission): 62.3 kg\n CVP: 9 (4 - 16) mmHg\n Total In:\n 2,117 mL\n 269 mL\n PO:\n Tube feeding:\n IV Fluid:\n 1,877 mL\n 269 mL\n Blood products:\n Total out:\n 3,078 mL\n 1,085 mL\n Urine:\n 2,978 mL\n 1,085 mL\n NG:\n 100 mL\n Stool:\n Drains:\n Balance:\n -961 mL\n -816 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 415 (343 - 505) mL\n PS : 10 cmH2O\n RR (Set): 16\n RR (Spontaneous): 17\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 75\n PIP: 18 cmH2O\n Plateau: 15 cmH2O\n SPO2: 100%\n ABG: 7.43/43/116/26/4\n Ve: 6.7 L/min\n PaO2 / FiO2: 290\n Physical Examination\n General Appearance: No acute distress, intubated, sedated\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular), (Murmur: Systolic), SEM @ LSB\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Neurologic: No(t) Follows simple commands, Moves all extremities,\n Sedated, +cough and gag.\n Labs / Radiology\n 261 K/uL\n 8.4 g/dL\n 124 mg/dL\n 1.0 mg/dL\n 26 mEq/L\n 4.0 mEq/L\n 15 mg/dL\n 106 mEq/L\n 144 mEq/L\n 24.7 %\n 17.3 K/uL\n [image002.jpg]\n 01:13 AM\n 05:21 AM\n 08:35 AM\n 09:08 AM\n 02:41 PM\n 05:10 PM\n 06:21 PM\n 06:27 PM\n 01:25 AM\n 01:37 AM\n WBC\n 16.3\n 17.3\n Hct\n 24.5\n 24.7\n Plt\n 281\n 261\n Creatinine\n 1.0\n 0.9\n 1.0\n TCO2\n 30\n 29\n 31\n 29\n 30\n 28\n 29\n Glucose\n 124\n 116\n 120\n 170\n 124\n Other labs: PT / PTT / INR:12.9/22.4/1.1, ALT / AST:, Alk-Phos / T\n bili:50/0.5, Differential-Neuts:77.3 %, Lymph:16.4 %, Mono:4.9 %,\n Eos:1.1 %, Lactic Acid:1.0 mmol/L, Albumin:3.6 g/dL, Ca:9.3 mg/dL,\n Mg:2.3 mg/dL, PO4:3.9 mg/dL\n Assessment and Plan\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/), FEVER, UNKNOWN ORIGIN (FUO,\n HYPERTHERMIA, PYREXIA), AORTIC STENOSIS, SUBDURAL HEMORRHAGE (SDH)\n Assessment and Plan: 82 yo F w/ h/o CAD, AS, Afib on coumadin, s/p fall\n with right SDH.\n Neurologic: Neuro checks Q: 2 hr, propofol for sedation\n wean as\n tolerated, fent prn pain. Discuss sz prophylaxis with neurosurgery.\n Cardiovascular: Hemodynamically stable off pressors; PRN nitro paste,\n metoprolol for hypertension and heart rate control, keep MAP > 80,\n holding ASA + Plavix for now, follow up final cardiology rec\ns, has\n known A.S., surface echo today (ordered)\n Pulmonary: (Ventilator mode: CPAP + PS), tolerating CPAP/PS s/p\n diureses yesterday; ABG improved this am, SBT for possible extubation\n trial today, f/u this am CXR\n Gastrointestinal / Abdomen: NPO; H2B, swallow eval after extubated\n Nutrition: NPO, Place NGT and start TF if tolerates extubation.\n Renal: Foley, Adequate UO, acid base status improved (prior resp\n acidosis); s/p lasix 20 mg IV x 2 yesterday with appropriate diuresis;\n takes lasix at home, restart home po lasix if able to tolerate po after\n extubation\n Hematology: chronic stable anemia\n Endocrine: RISS\n Infectious Disease: febrile, known bacteruria/GNR\n follow-up repeat\n cx's, restarted cipro\n Lines / Tubes / Drains: Foley, ETT, art line, PIV, CVL\n Imaging: CXR today\n Fluids: KVO\n Consults: Neuro surgery, Trauma surgery, Cardiology\n Billing Diagnosis: (Hemorrhage, NOS: Subdural), (Respiratory failure)\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 07:00 AM\n 18 Gauge - 09:15 AM\n Multi Lumen - 11:24 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: TSICU\n Total time spent: 31\n" }, { "category": "Nursing", "chartdate": "2161-05-27 00:00:00.000", "description": "Nursing Progress Note", "row_id": 468401, "text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt remains vented d/t failed spontaneous breathing trials over the past\n few days, possibly d/t fluid status. Pt started on home dose lasix PO,\n continues to be diuresed, negative for the day, negative for LOS. Lung\n sounds clear/diminished as documented in metavision. Vent settings\n unchanged overnight: CPAP 10 PS/5 PEEP/40% FiO2. O2 sat 98-100%. Pt has\n strong gag/cough, suctioned for minimal secretions. Pt afebrile, had\n 3^rd dose of ceftazidime overnight, continues on vancomycin daily.\n Action:\n 3^rd/last dose of ceftazidime given overnight. VAP care provided per\n protocol, pt repositioned frequently. Suctioned as needed. Albumin 25%\n given x2 overnight, pt continues to be diuresed, lytes repleted.\n Response:\n Pt rested well overnight, minimal oral secretions. ABG WNL.\n Plan:\n Plan to extubate pt in the AM, monitor for pulmonary edema, continue to\n support pt and family. Consider transfer to floor as tolerated\n tomorrow?\n Subdural hemorrhage (SDH)\n Assessment:\n Q4 hr neuro checks continued, neuro exam improved: pt alert with\n 10mcg/kg/min propofol gtt on. Pt opens eyes spontaneously, MAE\n (lift/holds), follows all commands, communicates by nodding/mouthing\n words/gesturing. Pupils 3-4mm, equal, briskly reactive. Pt acting\n appropriately, rested well overnight, intermittently awake. Pt denies\n pain, appears comfortable. Difficult to assess orientation d/t ET\n tube.\n Action:\n Q4 hr neuro checks done overnight. Restful environment promoted to\n allow pt to sleep.\n Response:\n Pt slept well overnight, neuro exam unchanged, intact.\n Plan:\n Continue Q4 hr neuro checks, continue to support pt and family. Plan to\n extubated pt this AM.\n" }, { "category": "Physician ", "chartdate": "2161-05-27 00:00:00.000", "description": "Intensivist Note", "row_id": 468402, "text": "SICU\n HPI:\n 82yo female here for Right-sided SDH who reports having tripped on the\n curb and falling. Hit her right side of face on the ground. Event\n reported to happen @ approx. 7:15pm on . Pts daughter witnessed\n event and brought her to OSH for evaluation. Found to have SDH and INR\n of 3.\n Chief complaint:\n sub dural hematoma\n PMHx:\n PMH: CAD s/p stent placement, filter, MI, PE, Mitral Regurg,\n GERD, Anxiety, Anemia, HOH, aflutter\n PSH: hernia repair, left vein stripping.\n Current medications:\n 24 Hour Events:\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Levofloxacin - 08:33 PM\n Vancomycin - 10:39 AM\n Ciprofloxacin - 11:30 AM\n Ceftazidime - 12:00 AM\n Infusions:\n Propofol - 10 mcg/Kg/min\n Other ICU medications:\n Furosemide (Lasix) - 05:57 PM\n Other medications:\n Flowsheet Data as of 05:41 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.5\nC (99.5\n T current: 36.9\nC (98.5\n HR: 74 (69 - 107) bpm\n BP: 129/46(76) {94/33(54) - 158/88(99)} mmHg\n RR: 19 (15 - 30) insp/min\n SPO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 62.1 kg (admission): 62.3 kg\n Height: 65 Inch\n CVP: 8 (6 - 19) mmHg\n Total In:\n 2,270 mL\n 602 mL\n PO:\n Tube feeding:\n 1,044 mL\n 240 mL\n IV Fluid:\n 856 mL\n 272 mL\n Blood products:\n 100 mL\n Total out:\n 2,535 mL\n 1,040 mL\n Urine:\n 2,535 mL\n 1,040 mL\n NG:\n Stool:\n Drains:\n Balance:\n -265 mL\n -438 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 415 (371 - 498) mL\n PS : 10 cmH2O\n RR (Spontaneous): 16\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 98\n PIP: 15 cmH2O\n SPO2: 100%\n ABG: 7.40/45/136/30/2\n Ve: 7 L/min\n PaO2 / FiO2: 340\n Physical Examination\n General Appearance: No acute distress\n HEENT: EOMI\n Cardiovascular: (Rhythm: Regular), (Murmur: Systolic)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles :\n scattered, Diminished: right base), (Sternum: Stable )\n Abdominal: Soft, Non-distended, Non-tender\n Left Extremities: (Edema: Absent), (Temperature: Warm)\n Right Extremities: (Edema: Absent), (Temperature: Warm)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: Follows simple commands, Moves all extremities, Sedated\n Labs / Radiology\n 294 K/uL\n 8.3 g/dL\n 159\n 0.9 mg/dL\n 30 mEq/L\n 3.5 mEq/L\n 28 mg/dL\n 104 mEq/L\n 143 mEq/L\n 25.7 %\n 12.7 K/uL\n [image002.jpg]\n 10:13 PM\n 12:54 AM\n 01:17 AM\n 02:50 AM\n 03:10 PM\n 03:14 PM\n 08:00 PM\n 01:48 AM\n 01:59 AM\n 02:00 AM\n WBC\n 14.4\n 12.7\n Hct\n 24.6\n 25.7\n Plt\n 288\n 294\n Creatinine\n 1.0\n 0.9\n 0.9\n TCO2\n 27\n 28\n 28\n 29\n 29\n Glucose\n 127\n 148\n 153\n 141\n 159\n Other labs: PT / PTT / INR:13.5/22.4/1.2, ALT / AST:, Alk-Phos / T\n bili:50/0.5, Differential-Neuts:77.3 %, Lymph:16.4 %, Mono:4.9 %,\n Eos:1.1 %, Lactic Acid:0.6 mmol/L, Albumin:3.6 g/dL, Ca:9.5 mg/dL,\n Mg:1.9 mg/dL, PO4:3.7 mg/dL\n Assessment and Plan\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/), FEVER, UNKNOWN ORIGIN (FUO,\n HYPERTHERMIA, PYREXIA), AORTIC STENOSIS, SUBDURAL HEMORRHAGE (SDH)\n Assessment and Plan: 82 yo F w/ h/o CAD, AS, Afib on coumadin, s/p fall\n with rt SDH.\n Neurologic: Neuro checks Q: 4 hr, SDH: repeat head CT showed no change,\n no OR per NSG, sedation\n Pain/sedation - propofol as needed\n Cardiovascular: Aspirin, (1) Critical AS: keep MAP 60s to 70s, HR<90,\n avoid dehydration (2) HTN: lopressor TID + PRN, narrow pulse pressure\n and SBP in 90s suggests dry (3) CAD: aspirin restarted for existing BMS\n Pulmonary: Extubate today, Spontaneous breathing trial, (Ventilator\n mode: CPAP + PS), (1) Pneumonia - on vanco + ceftazidime for empiric\n VAP, f/u cultures (2) ventilator dependence - SBT today, wean as\n tolerated\n Gastrointestinal / Abdomen: speech and swallow post extubation\n Nutrition: Tube feeding\n Renal: Foley, Adequate UO, (1) Acid/base: slight resp acidosis w/\n metabolic compensation (2) fluid status: at baseline weight, on home\n lasix\n Hematology: stable\n Endocrine: RISS\n Infectious Disease: (1) PNA: GPC on sputum, vanco+ceftaz for empiric\n PNA (2) UTI: ceftaz covering cipro-R ecoli\n Lines / Tubes / Drains: NGT, ETT, pIV, CVL, a-line\n Wounds:\n Imaging: CXR today\n Fluids: KVO\n Consults: Neuro surgery, Cardiology\n Billing Diagnosis:\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Multi Lumen - 11:24 AM\n Arterial Line - 03:15 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent:\n" }, { "category": "Nursing", "chartdate": "2161-05-26 00:00:00.000", "description": "Nursing Progress Note", "row_id": 468229, "text": "Shift events:\n -Repeat head CT (routine)\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Patient orally intubated on CPAP 10 PS, 5 PEEP, 40% FiO2. LS clear to\n diminished, sats 100%.\n Per HO, patient has ? beginning of RLL pna per CXR.\n Action:\n PS decreased to 5, ABG drawn. Cipro discontinued, levofloxacin ordered\n and administered. Tmax 100.2F. Tylenol given.\n Response:\n ABG WNL. Around midnight, patient desaturated to 91%, became\n Tachypneic in low 30\ns. Patient suctioned for thick, tan plugs. Sats\n returned to , however, patient remained Tachypneic. Ventilator\n settings changed to A/C, 16 x 500, 40% FiO2. ABG drawn, WNL.\n Plan:\n Wean ventilator as tolerated. Follow ABGs. Administer abx as\n ordered. ? extubate if patient is not going to OR/able to wean\n ventilator.\n Subdural hemorrhage (SDH)\n Assessment:\n Patient sedated on propofol. Patient alert, unable to assess\n orientation. Pupils 4mm, equal, reactive. +gag/cough/corneal\n reflexes. MAE spontaneously. Follows commands, able to give thumbs\n up, wiggle toes and stick out tongue.\n Action:\n Q2h neuro exam. Repeat head CT at 0500.\n Response:\n Neuro exam unchanged. Propofol titrated as indicated.\n Plan:\n Continue to monitor neuro exam. Follow up w/ pending CT results. ?\n change q2h to q4h neuro exams.\n" }, { "category": "Respiratory ", "chartdate": "2161-05-26 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 468230, "text": "Demographics\n Day of intubation: 4\n Day of mechanical ventilation: 4\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: 24 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7mm\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: 8 mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Bronchial\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Yellow / Tenacious\n Sputum source/amount: Suctioned / Moderate\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Intermittent invasive ventilation\n Visual assessment of breathing pattern: High flow demand\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: Vigorous inspiratory efforts\n Comments:\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Sedated / Paralyzed,\n Cannot manage secretions\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n RSBI today is 98. At times pt was tachypenic on PSV, rested on AC at\n night, CT early A.M.\n" }, { "category": "Physician ", "chartdate": "2161-05-26 00:00:00.000", "description": "Intensivist Note", "row_id": 468236, "text": "TSICU\n HPI:\n 82yo female here for Right-sided SDH who reports having tripped on the\n curb and falling. Hit her right side of face on the ground. Event\n reported to happen @ approx. 7:15pm on . Pts daughter witnessed\n event and brought her to OSH for evaluation, INR 2.97. Denies pain.\n Chief complaint:\n subdural hematoma\n PMHx:\n CAD s/p stent placement, filter, MI, PE, Mitral Regurg,\n GERD, Anxiety, Anemia, HOH, aflutter\n Current medications:\n . 2. 1000 mL NS 3. Acetaminophen (Liquid) 4. Albuterol Inhaler 5.\n Bisacodyl 6. Calcium Gluconate\n 7. Chlorhexidine Gluconate 0.12% Oral Rinse 8. Docusate Sodium (Liquid)\n 9. Fentanyl Citrate 10. Insulin\n 11. Ipratropium Bromide MDI 12. Lansoprazole Oral Disintegrating Tab\n 13. Levofloxacin 14. Levofloxacin\n 15. Magnesium Sulfate 16. Metoprolol Tartrate 17. Phenylephrine 18.\n Pneumococcal Vac Polyvalent 19. Potassium Chloride\n 20. Potassium Phosphate 21. Propofol 22. Sertraline 23. Senna 24.\n Simvastatin 25. Sodium Chloride 0.9% Flush\n 24 Hour Events:\n ARTERIAL LINE - STOP 12:26 PM\n ARTERIAL LINE - START 03:15 PM\n A-line placed on L, tube feeds started, levoflox started for PNA/UTI\n (replaced Cipro). MAPs ranging from 60-80 throughout PM.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ciprofloxacin - 04:15 PM\n Levofloxacin - 08:33 PM\n Infusions:\n Propofol - 10 mcg/Kg/min\n Other ICU medications:\n Famotidine (Pepcid) - 08:14 AM\n Metoprolol - 12:00 AM\n Other medications:\n Flowsheet Data as of 06:31 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.1\nC (100.6\n T current: 38.1\nC (100.6\n HR: 81 (78 - 120) bpm\n BP: 125/48(78) {107/39(62) - 145/74(98)} mmHg\n RR: 19 (13 - 31) insp/min\n SPO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 64 kg (admission): 62.3 kg\n CVP: 15 (3 - 22) mmHg\n Total In:\n 1,272 mL\n 487 mL\n PO:\n Tube feeding:\n 188 mL\n 239 mL\n IV Fluid:\n 1,024 mL\n 158 mL\n Blood products:\n Total out:\n 1,761 mL\n 430 mL\n Urine:\n 1,761 mL\n 430 mL\n NG:\n Stool:\n Drains:\n Balance:\n -489 mL\n 57 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 386 (327 - 553) mL\n PS : 10 cmH2O\n RR (Set): 16\n RR (Spontaneous): 23\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 98\n PIP: 15 cmH2O\n SPO2: 100%\n ABG: 7.46/38/158/26/3\n Ve: 9.6 L/min\n PaO2 / FiO2: 395\n Physical Examination\n General Appearance: No acute distress, Anxious\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular), (Murmur: Systolic, Diastolic),\n Murmur of AS\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: No(t) CTA\n bilateral : , Crackles : On R)\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: Absent), (Pulse - Dorsalis pedis: Present)\n Right Extremities: (Edema: Absent), (Pulse - Dorsalis pedis: Present),\n (Pulse - Posterior tibial: Present)\n Skin: Facial bruising\n Neurologic: (Responds to: No(t) Verbal stimuli, Tactile stimuli, No(t)\n Noxious stimuli), Moves all extremities, Sedated\n Labs / Radiology\n 288 K/uL\n 8.1 g/dL\n 127 mg/dL\n 1.0 mg/dL\n 26 mEq/L\n 4.6 mEq/L\n 19 mg/dL\n 108 mEq/L\n 143 mEq/L\n 24.6 %\n 14.4 K/uL\n [image002.jpg]\n 02:41 PM\n 05:10 PM\n 06:21 PM\n 06:27 PM\n 01:25 AM\n 01:37 AM\n 10:13 PM\n 12:54 AM\n 01:17 AM\n 02:50 AM\n WBC\n 17.3\n 14.4\n Hct\n 24.7\n 24.6\n Plt\n 261\n 288\n Creatinine\n 0.9\n 1.0\n 1.0\n TCO2\n 29\n 30\n 28\n 29\n 27\n 28\n 28\n Glucose\n 120\n 170\n 124\n 127\n Other labs: PT / PTT / INR:12.9/22.4/1.1, ALT / AST:, Alk-Phos / T\n bili:50/0.5, Differential-Neuts:77.3 %, Lymph:16.4 %, Mono:4.9 %,\n Eos:1.1 %, Lactic Acid:1.0 mmol/L, Albumin:3.6 g/dL, Ca:9.3 mg/dL,\n Mg:1.9 mg/dL, PO4:3.7 mg/dL\n Assessment and Plan\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/), FEVER, UNKNOWN ORIGIN (FUO,\n HYPERTHERMIA, PYREXIA), AORTIC STENOSIS, SUBDURAL HEMORRHAGE (SDH)\n Assessment and Plan: 82 yo F w/ h/o CAD, AS, Afib on coumadin, s/p fall\n with rt SDH.\n Neurologic: sedation with propofol; rpt CT head with no sig change\n Neuro checks Q: 2\n - CT head sched 5am .\n Pain: fentanyl PRN\n Cardiovascular: - MAPs low normal. If stay in 60s, start pressors.\n - Critical AS. Nitro d/c'd. Metoprolol for hypertension, keep MAP > 80,\n holding ASA + Plavix for now, follow up final cardiology recs, has\n known A.S.\n Pulmonary: ? R-sided PNA - changed Cipro to Levo. on PS 10/5; keep pCO2\n 35-40, HCO3 28-29, may wean to extubate in AM if no planned\n neurosurgical intervention\n Gastrointestinal / Abdomen: NPO; H2B, swallow eval after extubated\n Nutrition: Tube feeding\n Renal: ABG normalizing fr chronic respiratory acidosis with\n compensatory metabolic alkalosis now unmasked by relative hypocapnia.\n Hematology: Stable\n Endocrine: RISS\n Infectious Disease: stable\n Lines / Tubes / Drains: L A-line, foley, PIV - CVL\n Wounds:\n Imaging: CT scan head today\n Fluids:\n Consults: Neuro surgery\n Billing Diagnosis: (Hemorrhage, NOS: Subdural)\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 09:15 AM\n Multi Lumen - 11:24 AM\n Arterial Line - 03:15 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP bundle:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n Total time spent:\n" }, { "category": "Nursing", "chartdate": "2161-05-28 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 468673, "text": "Subdural hemorrhage (SDH)\n Assessment:\n Pt is A&O x3, MAE\ns without focal deficits noted & follows commands.\n PERRL. Pt is s/p multiple head CTs this admission that are stable.\n Action:\n Q 4 hour neuro assessments followed.\n Response:\n No change in neuro exam\n Plan:\n Continue to monitor neuro assessments.\n Pneumonia, bacterial, ventilator acquired (VAP)\n Assessment:\n VAP PNA by CXR with bibasilar opacities and thick yellow secretions.\n Action:\n Antibiotic coverage with vancomycin 1 gram daily, started \n Successful extubation \n Pulmonary toileting measures provided\n Response:\n Pt remains Afebrile with WBC wnl\n Strong congested cough with pt swallowing secretions. O2 saturations\n maintained on 2L NC and pt has no subjective complaints of respiratory\n distress. Regular breathing pattern observed.\n Plan:\n Continue antibiotic therapy; continue pulmonary toileting measures and\n mobilize pt as tolerated.\n Vancomycin trough level due before 0800 dose\n Urinary tract infection (UTI)\n Assessment:\n Confirmed UTI on admission testing. Multi drug resistant E.Coli\n confirmed; pt requires contact precautions.\n Action:\n Antibiotic therapy with ceftazidine continues\n Order to d/c foley today\n Response:\n Pt is Afebrile with WBC trending to WNL now.\n Urine is clear yellow\n Will d/c foley prior to transfer to floor.\n Plan:\n Continue antibiotics for UTI, continue contact precautions; D/C foley\n before transfer.\n PT will be DTV this evening.\n Atrial fibrillation (Afib)\n Assessment:\n Episode of a. fib/flutter with RVR to 120-145. Episode treated with\n diltiazem IVP & infusion, and increase in scheduled Lopressor dosing.\n Pt converted to NSR and remains in NSR with HR in 70\ns. Pt has known\n baseline of APC & PVC activity. PT has recent h/o PE () & is s/p\n IVC filter and takes coumadin at home.\n Action:\n Diltiazem therapy weaned & discontinued pm\n Lopressor dose increased to 50mg TID today\n Electrolytes replete to wnl\n sc heparin started ; compression boots in use\n Response:\n Heart rhythm continues in NS in 70\ns with rare to occasional PVC & APC\n activity\n Plan:\n Continue with current medical management and monitor for recurrence of\n a. fib\n Continue with heparin sc and compression boot therapy.\n Aortic stenosis\n Assessment:\n Pt with known AS with valve area of .8 per cardiac cath in ; also #\n vessel CAD & s/p BMS to LAD in . EF ~ 45%. Pt with episodes of\n flash pulmonary edema this admission during attempts to wean from vent\n support & related to fluid overload. Pt known hypertensive. BP\n 170-/systolic this morning with MAP >90.\n No c/o cheat pain\n Action:\n Pt diuresed and home medications restarted\n lasix resumed; home doses of Lopressor & ace inhibitor started;\n daily ASA continues. Home dose of isordil started today but\n discontinued per recommendation of medical team now in charge of pt\n care.\n Aggressive potassium repletion continued\n Goal MAP >70 during ICU stay.\n Per cardiology consult: no need for plavix at this time.\n Response:\n Current fluid balance is negative ~ 1200cc for LOS\n Blood pressure currently 140\ns/ 58 with MAP in 70s; adequate peripheral\n CSM\n Adequate urine response to lasix\n No c/o chest pain\n Plan:\n Continue with home medication regimen; monitor fluid balance; &\n provide potassium repletion to maintain >4.0\n Monitor blood pressure & peripheral perfusion\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt extubated from mechanical ventilation 7/1 @1600. Supplemental oxygen\n support by humidified face tent @ 50% with saturations >95% unless\n asleep, then ~ 90%. Breathing pattern in NAD & no subjective\n complaints.\n Strong congested cough, nonproductive (? swallows). Breath sounds:\n clear with basilar crackles to scattered rhonchi.\n Action:\n O2 support changed to NC\n Activity advanced to OOB with ambulation\n Coughing encouraged.\n PT consult obtained\n Response:\n Respiratory failure resolved\n O2 saturations >95% on NC @ 2L\n Strong congested cough continues\n Pt OOB to chair with assist of 1; ambulated in unit with assist of 1;\n pt very independent with activities.\n Plan:\n Continue with advanced physical activities as tolerated.\n Encourage C&DB exercises\n Maintain O2 saturations >92%; assess breath sounds for changes\n" }, { "category": "Nursing", "chartdate": "2161-05-26 00:00:00.000", "description": "Nursing Progress Note", "row_id": 468338, "text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Patient orally intubated on vent settings as charted. LS clear to\n diminished, sats 100%.\n Per HO, patient has ? beginning of RLL pna per CXR. Failed SBT this\n morning (tachycardic & tachypneic) . ? pulmonary edema\n Action:\n Placed back on CPAP 5/5 after SBT this am. Restarted home lasix dose PO\n and gave one time IV dose Antibiotics changed this morning.\n Response:\n Patient tolerating CPAP with PS. Sats 100%, HR and RR returned to\n baseline.\n Plan:\n Wean ventilator as tolerated. Follow ABGs. Continue home lasix, add\n another dose if indicated. Repeat SBT in am and attempt extubation.,\n Subdural hemorrhage (SDH)\n Assessment:\n Patient lightly sedated on propofol. Patient alert, unable to assess\n orientation. Pupils 4mm, equal, reactive. +gag/cough/corneal\n reflexes. MAE spontaneously. Follows commands, able to give thumbs\n up, wiggle toes and stick out tongue.\n Action:\n Q4h neuro exam.\n Response:\n Neuro exam unchanged. Propofol titrated as indicated.\n Plan:\n Continue to monitor neuro exam.\n" }, { "category": "Physician ", "chartdate": "2161-05-28 00:00:00.000", "description": "Intensivist Note", "row_id": 468623, "text": "SICU\n HPI:\n 82yo female here for Right-sided SDH who reports having tripped on the\n curb and falling. Hit her right side of face on the ground. Event\n reported to happen @ approx. 7:15pm on . Pts daughter witnessed\n event and brought her to OSH for evaluation, INR 2.97. Denies pain.\n Chief complaint:\n PMHx:\n .\n PMH: CAD s/p stent placement, filter, MI, PE, Mitral Regurg,\n GERD, Anxiety, Anemia, HOH, aflutter\n PSH: hernia repair, left vein stripping.\n : Zocor 40mg QD, KCL 20Meq QD,Coumadin 4mg , 325mg QD, Plavix\n 75mg QD, ?Iron 325mg QD, fosinopril 10mg QD, Isordil 60', Ativan 0.5mg\n TID, Toprol XL 100 QD, Zoloft 75mg QD, Lasix 40''\n Current medications:\n 24 Hour Events:\n went into A.Fib, rate controlled on Dilt gtt, spontaneously converted\n to sinus. Cards consulted - if A.Fib recurs, will amio load. Extubated,\n A-line replaced on right\n EKG - At 09:12 AM\n ARTERIAL LINE - STOP 01:30 PM\n ARTERIAL LINE - START 02:30 PM\n EXTUBATION - At 04:00 PM\n INVASIVE VENTILATION - STOP 04:00 PM\n pt admitteed from ED\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Levofloxacin - 08:33 PM\n Ciprofloxacin - 11:30 AM\n Vancomycin - 08:45 AM\n Ceftazidime - 12:45 AM\n Infusions:\n Other ICU medications:\n Metoprolol - 09:15 AM\n Diltiazem - 11:35 AM\n Heparin Sodium (Prophylaxis) - 10:00 PM\n Other medications:\n Flowsheet Data as of 06:37 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37\nC (98.6\n T current: 36.1\nC (96.9\n HR: 78 (64 - 110) bpm\n BP: 178/61(106) {73/37(-3) - 178/70(106)} mmHg\n RR: 21 (15 - 24) insp/min\n SPO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 59.3 kg (admission): 62.3 kg\n Height: 65 Inch\n CVP: 8 (5 - 13) mmHg\n Total In:\n 1,827 mL\n 306 mL\n PO:\n Tube feeding:\n 240 mL\n IV Fluid:\n 1,097 mL\n 246 mL\n Blood products:\n Total out:\n 2,555 mL\n 1,240 mL\n Urine:\n 2,555 mL\n 1,240 mL\n NG:\n Stool:\n Drains:\n Balance:\n -728 mL\n -934 mL\n Respiratory support\n O2 Delivery Device: Aerosol-cool\n Ventilator mode: PSV/SBT\n Vt (Spontaneous): 362 (362 - 447) mL\n PS : 5 cmH2O\n RR (Spontaneous): 20\n PEEP: 0 cmH2O\n FiO2: 50%\n PIP: 5 cmH2O\n SPO2: 100%\n ABG: 7.42/48/91./29/5\n Ve: 8 L/min\n PaO2 / FiO2: 184\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular), holosystolic, diastolic\n murmur\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : , Wheezes : )\n Abdominal: Soft, Non-distended\n Labs / Radiology\n 379 K/uL\n 8.5 g/dL\n 105 mg/dL\n 0.9 mg/dL\n 29 mEq/L\n 3.5 mEq/L\n 28 mg/dL\n 102 mEq/L\n 144 mEq/L\n 26.5 %\n 10.5 K/uL\n [image002.jpg]\n 02:50 AM\n 03:10 PM\n 03:14 PM\n 08:00 PM\n 01:48 AM\n 01:59 AM\n 02:00 AM\n 03:38 PM\n 02:12 AM\n 02:28 AM\n WBC\n 12.7\n 10.5\n Hct\n 25.7\n 26.5\n Plt\n 294\n 379\n Creatinine\n 0.9\n 0.9\n 0.9\n TCO2\n 28\n 29\n 29\n 29\n 32\n Glucose\n 148\n 153\n 141\n 159\n 105\n Other labs: PT / PTT / INR:13.5/22.4/1.2, ALT / AST:, Alk-Phos / T\n bili:50/0.5, Differential-Neuts:77.3 %, Lymph:16.4 %, Mono:4.9 %,\n Eos:1.1 %, Lactic Acid:0.7 mmol/L, Albumin:3.6 g/dL, Ca:10.3 mg/dL,\n Mg:1.9 mg/dL, PO4:3.9 mg/dL\n Assessment and Plan\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/), AORTIC STENOSIS, URINARY\n TRACT INFECTION (UTI), PNEUMONIA, BACTERIAL, VENTILATOR ACQUIRED (VAP),\n ATRIAL FIBRILLATION (AFIB)\n Assessment and Plan: 82 yo F w/ h/o CAD, AS, Afib on coumadin, s/p\n fall with rt SDH.\n Neurologic: Neuro checks Q: 4 hr, Pain controlled, stable MS. Please\n re-start home dose ativan for anxiety\n Cardiovascular: Aspirin, 1) Critical AS: keep MAP 60s to 70s, HR<90,\n avoid dehydration (2) HTN: lopressor TID\n increase to 50 mg tid for\n better BP and HR control, + PRN, (3) CAD: aspirin restarted for\n existing BMS (4) A-Fib - spontaneously converted to sinus, increased\n metoprolol dose as above, will amio load if A. Fib returns. Please\n re-start all anti-hypertensive home meds\n Pulmonary: Successfully extubated, pneumonia - on vanco + ceftazidime\n for empiric VAP, f/u cultures. Stable resp status post-extubation.\n Please check vanco level\n Gastrointestinal / Abdomen: H2B, speech and swallow post extubation\n Nutrition: Advance diet as tolerated\n Renal: Foley, adequate u/o. Please d/c foley\n Hematology: Serial Hct, stable anemia, HCt at 26\n Endocrine: RISS with adequate glucose control. Keep < 150\n Infectious Disease: (1) PNA: GPC on sputum, vanco+ceftaz for empiric\n PNA (2) UTI: ceftaz covering cipro-R ecoli\n Lines / Tubes / Drains: Foley, NGT\n Wounds:\n Imaging: CXR today\n Fluids:\n Consults:\n Billing Diagnosis: SDH, Respiratory insufficiency\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Multi Lumen - 11:24 AM\n Arterial Line - 02:30 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP bundle: HOB elevation, Mouth care\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition: Transfer to floor\n Total time spent: 20 minutes\n" }, { "category": "Rehab Services", "chartdate": "2161-05-28 00:00:00.000", "description": "Physical Therapy Evaluation Note", "row_id": 468648, "text": "Attending Physician: , \n Referral date: \n Medical Diagnosis / ICD 9: SDH / 432.1\n Reason of referral: Eval and treat\n History of Present Illness / Subjective Complaint: 82 y/o F s/p\n tripping on a curb leaving a restaurant c dtr and falling forward. Pt\n hit face on the ground c (+) facial bleeding, (-) LOC. Dtr drove pt to\n outside hospital where she was intubated agitation, per dtr. Pt\n transferred to for treatment of SDH. Head CT revealed R SDH c 6mm\n midline shift that has since decreased minimally in size. Pt also\n experiencing bibasilar opacities.\n Past Medical / Surgical History: CAD s/p stent placement, \n filter, MI, HTN, PE, GERD, Anemia, Anxiety\n Medications: Insulin, Acetaminophen, Albuterol, Simvastatin,\n Sertraline, Ipratropium Bromide, Metoprolol, Vancomycin, Furosemide,\n ASA, Heparin, Diltiazem, Isosorbide Mononitrate, Lisinopril, Lorazepam\n Radiology: Head CT : Right subdural hematoma with 6mm midline\n shift and associated mass effect and leftward subfalcine herniation.\n Head CT : Minimal decrease in R SDH. CXR :Bibasilar opacities,\n left greater than right, upper lungs clear.\n Labs:\n 26.5\n 8.5\n 379\n 10.5\n [image002.jpg]\n Other labs:\n Activity Orders: Ambulate, HOB always >30 degrees.\n Social / Occupational History: Lives alone in (husband\n passed 2 yr ago), RN friend helps c cleaning/chores, dtr does grocery\n shopping, frequently visits dtr and grandson in \n Living Environment: 1 level home\n Prior Functional Status / Activity Level: I PTA c ADLs/IADLs, some A\n from dtr and friend for chores/shopping.\n Objective Test\n Arousal / Attention / Cognition / Communication: A+Ox2 (self and time).\n Refused to answer place question because \"5 people have already asked\n that this morning\". Pt able to correctly verbalize her fall/injury. Pt\n pleasant and cooperative c PT, able to follow 100% of simple commands,\n 75% of multi-step commands.\n Hemodynamic Response\n Aerobic Capacity\n HR\n BP\n RR\n O[2 ]sat\n HR\n BP\n RR\n O[2] sat\n RPE\n Supine\n /\n Rest\n 94\n 178/55\n 24\n 92\n Sit\n /\n Activity\n /\n 24\n 97\n Stand\n /\n Recovery\n 95\n 173/62\n 21\n 97\n Total distance walked: 2 ft\n Minutes:\n Pulmonary Status: Breathing even and coordinated c no signs of obvious\n respiratory distress. Pt demonstrates wet, non-productive cough\n although ? of productive but pt unable to expectorate secretions.\n Currently on humidified FM c no supplemental O2.\n Integumentary / Vascular: R radial A-line, L subclavian multi-lumen,\n telemetry, foley catheter, (+) B DPP, (+) ecchymosis throughout entire\n face c minimal swelling, on 50% humidified O2 via face mask\n Sensory Integrity: Pt denies parasthesias.\n Pain / Limiting Symptoms: Pt reports no pain.\n Posture: Pt supine c HOB at 30 degrees. FH, B rounded shoulders, slight\n thoracic kyphosis\n Range of Motion\n Muscle Performance\n B UE/LE WFL grossly\n B UE/LE > grossly\n Motor Function: Able to move all extremities in isolation.\n Functional Status:\n Activity\n Clarification\n I\n S\n CG\n Min\n Mod\n Max\n Gait, Locomotion: Pt able to go sit to/from stand c min A for balance\n and obtaining full, upright posture. Pt required min A c amb 2 ft to\n chair. Demonstrated steady gait c decr ground clearance and decr step\n length. Overall pt did well, but required additional A to manage\n multiple lines.\n Rolling:\n\n T\n\n\n\n\n Supine /\n Sidelying to Sit:\n T\n\n\n\n\n Transfer:\n\n\n x\n\n\n Sit to Stand:\n\n\n T\n\n\n Ambulation:\n\n\n\n Stairs:\n\n\n\n\n\n Balance: Pt able to sit EOB using B UE on bed with no LOB. In standing,\n pt required verbal and tactile cues to maintain upright standing a\n tendency to stand in slight trunk flexion c min post lean. Dynamic\n balance c amb was good, able to negotiate multiple lines and turn\n towards chair effectively with no LOB.\n Education / Communication: Pt Education: Role of rehab process,\n importance of OOB to chair, importance of coughing/expectorating\n secretions, DC planning. Consult with RN re: pt status.\n Intervention: PT evaluation, stand/amb transfer bed to chair, pt\n education\n Other:\n Diagnosis:\n 1.\n Impaired bed mobility\n 2.\n Impaired transfers\n 3.\n Impaired functional mobility\n 4.\n Knowledge deficit re: fall risk/fall prevention\n Clinical impression / Prognosis: 82 y/o F s/p fall resulting in R SDH\n with 6mm midline shift on . Pt presents with above impairments c/w\n fall risk pattern. Pt is functioning well below her baseline limited by\n pain and unstable HDR. If SDH continues to decrease, no additional\n midline shifts occurs, and pt becomes medically stable, pt has very\n good prognosis to return to her prior level of function. Pt has great\n support system and was mostly I PTA, so pt should be able to D/C home c\n support. Pt is unsafe for home at this time, however following more\n PT tx anticipate she will be able to be D/C home, and would benefit\n from home PT and a home safety evaluation to maximize her functional\n return and prevent future falls.\n Goals\n Time frame: 1 week\n 1.\n I c bed mobility\n 2.\n I sit to/from stand\n 3.\n Amb >50ft c least restrictive AD c S\n 4.\n Demonstrates adherence to safe amb practices 100% of the time\n Anticipated Discharge: Home with Home PT\n Treatment :\n Frequency / Duration: 2-3x\n Continued bed mobility, transfer training\n Gait training (assessing if pt requires AD)\n Assess needs for chest PT if pt continues to have secretions\n Pt education re: fall prevention\n T Patient agrees with the above goals and is willing to participate in\n the rehabilitation program.\n Evaluation performed by , PT/S x31293\n" }, { "category": "Nutrition", "chartdate": "2161-05-28 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 468650, "text": "Subjective\n \"I know i can swallow well, can I have more ice?\" patient reports good\n pos PTA denies nausea and vomiting\n Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 165 cm\n 62.3 kg\n 59.3 kg ( 01:00 AM)\n -3 kg due to diuresing\n 22.8\n Ideal body weight\n % Ideal body weight\n Adjusted weight\n Usual body weight\n % Usual body weight\n 56.7 kg\n Pertinent medications: RISS, normal saline, lansoprazole, IV abx,\n heparin, lasix, KCl (40mEq), Mag Sulfate (2g), others noted\n Labs:\n Value\n Date\n Glucose\n 105 mg/dL\n 02:12 AM\n Glucose Finger Stick\n 164\n 09:00 AM\n BUN\n 28 mg/dL\n 02:12 AM\n Creatinine\n 0.9 mg/dL\n 02:12 AM\n Sodium\n 144 mEq/L\n 02:12 AM\n Potassium\n 3.5 mEq/L\n 02:12 AM\n Chloride\n 102 mEq/L\n 02:12 AM\n TCO2\n 29 mEq/L\n 02:12 AM\n PO2 (arterial)\n 91. mm Hg\n 02:28 AM\n PCO2 (arterial)\n 48 mm Hg\n 02:28 AM\n pH (arterial)\n 7.42 units\n 02:28 AM\n pH (urine)\n 7.0 units\n 05:29 PM\n CO2 (Calc) arterial\n 32 mEq/L\n 02:28 AM\n Albumin\n 3.6 g/dL\n 05:42 AM\n Calcium non-ionized\n 10.3 mg/dL\n 02:12 AM\n Phosphorus\n 3.9 mg/dL\n 02:12 AM\n Ionized Calcium\n 1.29 mmol/L\n 02:28 AM\n Magnesium\n 1.9 mg/dL\n 02:12 AM\n ALT\n 8 IU/L\n 05:42 AM\n Alkaline Phosphate\n 50 IU/L\n 05:42 AM\n AST\n 24 IU/L\n 05:42 AM\n Total Bilirubin\n 0.5 mg/dL\n 05:42 AM\n WBC\n 10.5 K/uL\n 02:12 AM\n Hgb\n 8.5 g/dL\n 02:12 AM\n Hematocrit\n 26.5 %\n 02:12 AM\n Current diet order / nutrition support: cardiac, heart healthy\n GI: soft, +bowel sounds\n Assessment of Nutritional Status\n Specifics: 82 year old female presented to outside hospital after\n tripping on curbe and fell hit right side of face on ground. Head Ct\n showed right sided SDH with midline shift. Patient extubated and\n tube feedings discountinued. Diet advanced to regular, SLP consulted.\n RN patient has only been taking custard and ice chips until formal\n SLP eval.\n Medical Nutrition Therapy Plan - Recommend the Following\n 1. Implement any SLP recs\n 2. Monitor needs for supplements\n 3. Multiviamin via po\n 4. Will follow page with questions\n" }, { "category": "Rehab Services", "chartdate": "2161-05-28 00:00:00.000", "description": "Physical Therapy Evaluation Note", "row_id": 468639, "text": "Attending Physician: , \n Referral date: \n Medical Diagnosis / ICD 9: SDH / 432.1\n Reason of referral: Eval and treat\n History of Present Illness / Subjective Complaint: 82 y/o F s/p\n tripping on a curb leaving a restaurant c dtr and falling forward. Pt\n hit face on the ground c (+) facial bleeding, (-) LOC. Dtr drove pt to\n outside hospital where she was intubated agitation, per dtr. Pt\n transferred to for treatment of SDH. Head CT revealed R SDH c 6mm\n midline shift that has since decreased minimally in size. Pt also\n experiencing bibasilar opacities.\n Past Medical / Surgical History: CAD s/p stent placement, \n filter, MI, HTN, PE, GERD, Anemia, Anxiety\n Medications: Insulin, Acetaminophen, Albuterol, Simvastatin,\n Sertraline, Ipratropium Bromide, Metoprolol, Vancomycin, Furosemide,\n ASA, Heparin, Diltiazem, Isosorbide Mononitrate, Lisinopril, Lorazepam\n Radiology: Head CT : Right subdural hematoma with 6mm midline\n shift and associated mass effect and leftward subfalcine herniation.\n Head CT : Minimal decrease in R SDH. CXR :Bibasilar opacities,\n left greater than right, upper lungs clear.\n Labs:\n 26.5\n 8.5\n 379\n 10.5\n [image002.jpg]\n Other labs:\n Activity Orders: Ambulate, HOB always >30 degrees.\n Social / Occupational History: Lives alone in (husband\n passed 2 yr ago), RN friend helps c cleaning/chores, dtr does grocery\n shopping, frequently visits dtr and grandson in \n Living Environment: 1 level home\n Prior Functional Status / Activity Level: I PTA c ADLs/IADLs, some A\n from dtr and friend for chores/shopping.\n Objective Test\n Arousal / Attention / Cognition / Communication: A+Ox2 (self and time).\n Refused to answer place question because \"5 people have already asked\n that this morning\". Pt able to correctly verbalize her fall/injury. Pt\n pleasant and cooperative c PT, able to follow 100% of simple commands,\n 75% of multi-step commands.\n Hemodynamic Response\n Aerobic Capacity\n HR\n BP\n RR\n O[2 ]sat\n HR\n BP\n RR\n O[2] sat\n RPE\n Supine\n /\n Rest\n 94\n 178/55\n 24\n 92\n Sit\n /\n Activity\n /\n 24\n 97\n Stand\n /\n Recovery\n 95\n 173/62\n 21\n 97\n Total distance walked: 2 ft\n Minutes:\n Pulmonary Status: Breathing even and coordinated c no signs of obvious\n respiratory distress. Pt demonstrates wet, non-productive cough\n although ? of productive but pt refusing to expectorate secretions.\n Currently on humidified FM c no supplemental O2.\n Integumentary / Vascular: R radial A-line, L subclavian multi-lumen,\n telemetry, foley catheter, (+) B DPP, (+) ecchymosis throughout entire\n face c minimal swelling, humidified FM\n Sensory Integrity: Pt denies parasthesias.\n Pain / Limiting Symptoms: Pt reports no pain.\n Posture: Pt supine c HOB at 30 degrees. FH, B rounded shoulders, slight\n thoracic kyphosis\n Range of Motion\n Muscle Performance\n B UE/LE WFL grossly\n B UE/LE > grossly\n Motor Function: Able to move all extremities in isolation.\n Functional Status:\n Activity\n Clarification\n I\n S\n CG\n Min\n Mod\n Max\n Gait, Locomotion: Pt able to go sit to/from stand c min A for balance\n and obtaining full, upright posture. Pt required CG A c amb 2 ft to\n chair. Demostrated steady gait c decr ground clearance and decr step\n length. Overall pt did well, but required additional A to manage\n multiple lines.\n Rolling:\n\n T\n\n\n\n\n Supine /\n Sidelying to Sit:\n T\n\n\n\n\n Transfer:\n\n\n\n\n\n Sit to Stand:\n\n\n T\n\n\n Ambulation:\n\n T\n\n\n\n Stairs:\n\n\n\n\n\n Balance: Pt able to sit EOB using B UE on bed with no LOB. In standing,\n pt required verbal and tactile cues to maintain upright standing a\n tendency to stand in slight trunk flexion c min post lean. Dynamic\n balance c amb was good, able to negotiate multiple lines and turn\n towards chair effectively with no LOB.\n Education / Communication: Pt Education: Role of rehab process,\n importance of OOB to chair, importance of coughing/expectorating\n secretions, DC planning. Consult with RN re: pt status.\n Intervention: PT evaluation, stand/amb transfer bed to chair, pt\n education\n Other:\n Diagnosis:\n 1.\n Impaired bed mobility\n 2.\n Impaired transfers\n 3.\n Impaired functional mobility\n 4.\n Knowledge deficit re: fall risk/fall prevention\n Clinical impression / Prognosis: 82 y/o F s/p fall resulting in R SDH\n with 6mm midline shift on . Pt presents with above impairments c/w\n fall risk pattern. Pt is functioning well below her baseline limited by\n pain and unstable HDR. If SDH continues to decrease, no additional\n midline shifts occurs, and pt becomes medically stable, pt has very\n good prognosis to return to her prior level of function. Pt has great\n support system and was mostly I PTA, so pt should be able to D/C home c\n support. Pt would benefit from continued PT until able to be D/C, and\n would benefit from home PT and a home safety evaluation to maximize her\n functional return and prevent future falls.\n Goals\n Time frame: 1 week\n 1.\n I c bed mobility\n 2.\n I sit to/from stand\n 3.\n Amb >50ft c least restrictive AD c S\n 4.\n Demostrates adherence to safe amb practices 100% of the time\n Anticipated Discharge: Home with Home PT\n Treatment :\n Frequency / Duration: 3-5x/wk\n Continued bed mobility, transfer training\n Gait training (assessing if pt requires AD)\n Assess needs for chest PT if pt continues to have secretions\n Pt education re: fall prevention\n T Patient agrees with the above goals and is willing to participate in\n the rehabilitation program.\n Evaluation performed by , PT/S x31293\n" }, { "category": "Nursing", "chartdate": "2161-05-24 00:00:00.000", "description": "Nursing Progress Note", "row_id": 467911, "text": "Aortic stenosis\n Assessment:\n Pt with + systolic murmur, AS by , 45%. Pt needs estimated MAP of\n 80 for adequate coronary perfusion. Aline pressures adequate, decreased\n on sedation.\n Action:\n Phenylephrine started to maintain MAP~80\n Response:\n BP adequate, no signs of ischemia on monitor, extremities warm, well\n perfused\n Plan:\n Wean sedation after CT(if CT stable)- wean Neo as able\n Subdural hemorrhage (SDH)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Respiratory ", "chartdate": "2161-05-24 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 467992, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 2\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Tube Type\n ETT:\n Position: 24 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7mm\n :\n Cuff Management:\n Vol/Press:\n Cuff pressure: 28 cmH2O\n Cuff volume: 8 mL /\n :\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Clear\n Comments:\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Scant\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No claim of dyspnea)\n Non-invasive ventilation assessment:\n :\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Underlying illness\n not resolved\n Comments: Attempted sbt this am. Pt with increase rr, hr and wob.\n Dropping peep increased venous return and caused pt to flash. Will\n attempt weaning slowly\n" }, { "category": "Nursing", "chartdate": "2161-05-24 00:00:00.000", "description": "Nursing Progress Note", "row_id": 467994, "text": "Aortic stenosis\n Assessment:\n Action:\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt remains intubated on CMV mode & 40% FIO2 with acceptable ABGs;\n breath sounds clear & equal bilaterally; minimal blood tinged\n secretions suctioned.\n Action:\n Vent mode changed to CPAP/PSV 5/5\n Spontaneous breathing trial done (PSV 5, 0 PEEP)\n Response:\n Tolerated CPAP/PSV with acceptable ABG and NAD noted.\n Failed SBT with flash pulmonary edema: increased WOB, tachypnea, HTN,\n desaturation to 90, coarse breath sounds throughout and ABG revealing\n inadequate ventilation with pH of 7.15 & PCO2 >80. Pt returned to CMV\n mode for rest. Medications provided: lopressor 5mg ivp, 1 inch\n nitropaste, Lasix 20mg ivp\n Plan:\n Rest and attempt PSV mode again with gradual wean as tolerated.\n Diurese and manage Hemodynamics with pharmacology\n Subdural hemorrhage (SDH)\n Assessment:\n Pt is lightly sedated with propofol. Pt responds to voice and\n stimulation but is not following commands (? By choice). Spontaneous\n MAEs with purpose & against gravity and equal bilaterally. PERRL @\n 4-5mm/brisk; corneal, cough, & gag reflexes present. Pt remains\n restless when lightened from sedation.\n Action:\n Head CT repeated this morning.\n Neuro checks Q 2 hours\n Sedation titrated to effect. PRN Fentanyl provided to assist in\n sedation & comfort with ETT.\n Neosynephrine utilized as needed to maintain adequate BP while sedated\n Response:\n Repeat CT reported as no significant change\n Neuro exam is unchanged\n Pt remains restless when awake and continues to NOT follow commands;\n minimal eye contact or tracking noted.\n Propofol maintained @ 18-30mcg/kg/min; Fentanyl x2 with effect.\n Neo weaned off\n Plan:\n Neuro checks Q 2 hours\n Maintain sedation for tolerance of ETT & ventilation support.\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n S/P temp spike to 101.6 on nights & WBC elevated to 16; cultures sent\n on night shift. T max today 100. Vital signs & O2 saturations adequate.\n Pt warm & well perfused.\n Action:\n Temperature checked Q 2-4 hours\n Urine culture sent\n Ciprofloxacin therapy reordered today.\n Response:\n Temp 99 currently; pt remains warm, dry with normal skin coloring and\n palpable peripheral pulses. Hemodynamics with acceptable ranges; O2\n saturations 100%\n All cultures are pending.\n Plan:\n Follow temp trend and daily WBC\n Cipro as ordered.\n Monitor for hypotension & evidence of decreased tissue perusion.\n" }, { "category": "Nursing", "chartdate": "2161-05-24 00:00:00.000", "description": "Nursing Progress Note", "row_id": 467995, "text": "Aortic stenosis\n Assessment:\n Action:\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt remains intubated on CMV mode & 40% FIO2 with acceptable ABGs;\n breath sounds clear & equal bilaterally; minimal blood tinged\n secretions suctioned.\n Action:\n Vent mode changed to CPAP/PSV 5/5\n Spontaneous breathing trial done (PSV 5, 0 PEEP)\n Response:\n Tolerated CPAP/PSV with acceptable ABG and NAD noted.\n Failed SBT with flash pulmonary edema: increased WOB, tachypnea, HTN,\n desaturation to 90, coarse breath sounds throughout and ABG revealing\n inadequate ventilation with pH of 7.15 & PCO2 >80. Pt returned to CMV\n mode for rest. Medications provided: lopressor 5mg ivp, 1 inch\n nitropaste, Lasix 20mg ivp\n Plan:\n Rest and attempt PSV mode again with gradual wean as tolerated.\n Diurese and manage Hemodynamics with pharmacology\n Subdural hemorrhage (SDH)\n Assessment:\n Pt is lightly sedated with propofol. Pt responds to voice &\n stimulation but is not following commands (? By choice). Spontaneously\n MAEs with purpose & against gravity and equal bilaterally. PERRL @\n 4-5mm/brisk; corneal, cough, & gag reflexes present. Pt remains\n restless when lightened from sedation.\n Action:\n Head CT repeated this morning.\n Neuro checks Q 2 hours\n Sedation titrated to effect. PRN Fentanyl provided to assist in\n sedation & comfort with ETT.\n Neosynephrine utilized as needed to maintain adequate BP while sedated\n Response:\n Repeat CT reported as no significant change\n Neuro exam is unchanged\n Pt remains restless when awake and continues to NOT follow commands;\n minimal eye contact or tracking noted.\n Propofol maintained @ 18-30mcg/kg/min; Fentanyl x2 with effect.\n Neo weaned off\n Plan:\n Neuro checks Q 2 hours\n Maintain sedation for tolerance of ETT & ventilation support.\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n S/P temp spike to 101.6 on nights & WBC elevated to 16; cultures\n pending. Vital signs & O2 saturations adequate. Pt warm & well\n perfused. Urine is clear & yellow now absent of foul odor; sputum is\n pale yellow.\n Action:\n Temperature checked Q 2-4 hours\n Urine culture sent\n Ciprofloxacin therapy reordered today.\n Response:\n Temp 99 currently with T max 100.2; pt remains warm, dry with normal\n skin coloring and palpable peripheral pulses. Hemodynamics with\n acceptable ranges; O2 saturations 100%\n All cultures are pending.\n No change in character of urine or sputum\n Plan:\n Follow temp trend and daily WBC; not changes in urine or sputum.\n Monitor for hypotension & evidence of decreased tissue perfusion.\n Antibiotics as ordered.\n" }, { "category": "Nursing", "chartdate": "2161-05-24 00:00:00.000", "description": "Nursing Progress Note", "row_id": 467996, "text": "Aortic stenosis\n Assessment:\n + Systolic murmur, known AS & 3 vessel CAD, s/p stent to LAD in , &\n HTN. TTE @ bedside confirms EF ~ 45%. Pt need MAP ~ 80 to perfuse\n coronaries.\n Action:\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt remains intubated on CMV mode & 40% FIO2 with acceptable ABGs;\n breath sounds clear & equal bilaterally; minimal blood tinged\n secretions suctioned.\n Action:\n Vent mode changed to CPAP/PSV 5/5\n Spontaneous breathing trial done (PSV 5, 0 PEEP)\n Response:\n Tolerated CPAP/PSV with acceptable ABG and NAD noted.\n Failed SBT with flash pulmonary edema: increased WOB, tachypnea, HTN,\n desaturation to 90, coarse breath sounds throughout and ABG revealing\n inadequate ventilation with pH of 7.15 & PCO2 >80. Pt returned to CMV\n mode for rest. Medications provided: lopressor 5mg ivp, 1 inch\n nitropaste, Lasix 20mg ivp\n Plan:\n Rest and attempt PSV mode again with gradual wean as tolerated.\n Diurese and manage Hemodynamics with pharmacology\n Subdural hemorrhage (SDH)\n Assessment:\n Pt is lightly sedated with propofol. Pt responds to voice &\n stimulation but is not following commands (? By choice). Spontaneously\n MAEs with purpose & against gravity and equal bilaterally. PERRL @\n 4-5mm/brisk; corneal, cough, & gag reflexes present. Pt remains\n restless when lightened from sedation.\n Action:\n Head CT repeated this morning.\n Neuro checks Q 2 hours\n Sedation titrated to effect. PRN Fentanyl provided to assist in\n sedation & comfort with ETT.\n Neosynephrine utilized as needed to maintain adequate BP while sedated\n Response:\n Repeat CT reported as no significant change\n Neuro exam is unchanged\n Pt remains restless when awake and continues to NOT follow commands;\n minimal eye contact or tracking noted.\n Propofol maintained @ 18-30mcg/kg/min; Fentanyl x2 with effect.\n Neo weaned off\n Plan:\n Neuro checks Q 2 hours\n Maintain sedation for tolerance of ETT & ventilation support.\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n S/P temp spike to 101.6 on nights & WBC elevated to 16; cultures\n pending. Vital signs & O2 saturations adequate. Pt warm & well\n perfused. Urine is clear & yellow now absent of foul odor; sputum is\n pale yellow.\n Action:\n Temperature checked Q 2-4 hours\n Urine culture sent\n Ciprofloxacin therapy reordered today.\n Response:\n Temp 99 currently with T max 100.2; pt remains warm, dry with normal\n skin coloring and palpable peripheral pulses. Hemodynamics with\n acceptable ranges; O2 saturations 100%\n All cultures are pending.\n No change in character of urine or sputum\n Plan:\n Follow temp trend and daily WBC; not changes in urine or sputum.\n Monitor for hypotension & evidence of decreased tissue perfusion.\n Antibiotics as ordered.\n" }, { "category": "Nursing", "chartdate": "2161-05-24 00:00:00.000", "description": "Nursing Progress Note", "row_id": 467998, "text": "Aortic stenosis\n Assessment:\n + Systolic murmur, known AS, CHF, & 3 vessel CAD, s/p stent to LAD in\n , & HTN. TTE @ bedside confirms EF ~ 45%. Pt need MAP ~ 80\n for adequate coronary perfusion. Sedation softens BP; Neosynephrine\n available to maintain MAP.\n Action:\n Lopressor & nitropaste for HTN> 160 systolic\n Titration of sedation; neo weaned to off\n Lasix for positive fluid balance\n Electrolyte repletion to maintain acid/base balance\n Response:\n MAP maintained within goal range with nitropaste, prn lopressor,\n minimal propofol, prn fentanyl while remaining off neo infusion.\n Currently in running ~ 300cc negative for the day with LOS balance\n positive ~ 1200cc.\n Electrolytes wnl\n Plan:\n Continuous hemodynamic monitoring with goal of MAP ~ 80\n Goal fluid balance: even of slightly negative to prepare for wean\n &extubation\n Replete electrolytes prn; monitor pH.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt remains intubated on CMV mode & 40% FIO2 with acceptable ABGs;\n breath sounds clear & equal bilaterally; minimal blood tinged\n secretions suctioned. Goal is for PCO2 ~ 40 to avoid cerebral edema in\n setting of SDH.\n Action:\n Vent mode changed to CPAP/PSV 5/5\n Spontaneous breathing trial done (PSV 5, 0 PEEP)\n Response:\n Tolerated CPAP/PSV with acceptable ABG and NAD noted.\n Failed SBT with flash pulmonary edema: increased WOB, tachypnea, HTN,\n desaturation to 90, coarse breath sounds throughout and ABG revealing\n inadequate ventilation with pH of 7.15 & PCO2 >80. Pt returned to CMV\n mode for rest. Medications provided: lopressor 5mg ivp, 1 inch\n nitropaste, Lasix 20mg ivp\n Plan:\n Rest and attempt PSV mode again with gradual wean as tolerated. PSV\n adequate to maintain PCO2~ 40\n Diurese and manage Hemodynamics with pharmacology\n Subdural hemorrhage (SDH)\n Assessment:\n Pt is lightly sedated with propofol. Pt responds to voice &\n stimulation but is not following commands (? By choice). Spontaneously\n MAEs with purpose & against gravity and equal bilaterally. PERRL @\n 4-5mm/brisk; corneal, cough, & gag reflexes present. Pt remains\n restless when lightened from sedation.\n Action:\n Head CT repeated this morning.\n Neuro checks Q 2 hours\n Sedation titrated to effect. PRN Fentanyl provided to assist in\n sedation & comfort with ETT.\n Neosynephrine utilized as needed to maintain adequate BP while sedated\n Response:\n Repeat CT reported as no significant change\n Neuro exam is unchanged\n Pt remains restless when awake and continues to NOT follow commands;\n minimal eye contact or tracking noted.\n Propofol maintained @ 18-30mcg/kg/min; Fentanyl x2 with effect.\n Neo weaned off\n Plan:\n Neuro checks Q 2 hours\n Maintain sedation for tolerance of ETT & ventilation support.\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n S/P temp spike to 101.6 on nights & WBC elevated to 16; cultures\n pending. Vital signs & O2 saturations adequate. Pt warm & well\n perfused. Urine is clear & yellow now absent of foul odor; sputum is\n pale yellow.\n Action:\n Temperature checked Q 2-4 hours\n Urine culture sent\n Ciprofloxacin therapy reordered today.\n Response:\n Temp 99 currently with T max 100.2; pt remains warm, dry with normal\n skin coloring and palpable peripheral pulses. Hemodynamics with\n acceptable ranges; O2 saturations 100%\n All cultures are pending.\n No change in character of urine or sputum\n Plan:\n Follow temp trend and daily WBC; not changes in urine or sputum.\n Monitor for hypotension & evidence of decreased tissue perfusion.\n Antibiotics as ordered.\n" }, { "category": "Nursing", "chartdate": "2161-05-28 00:00:00.000", "description": "Nursing Progress Note", "row_id": 468606, "text": "Urinary tract infection (UTI)\n Assessment:\n e.coli UTI multi drug resistant organism. Adequate clear, light yellow\n urine. Continue to diurese pt with home dose lasix. Pt negative for\n LOS. Afebrile, WBC WNL. Neuro exam intact, unchanged.\n Action:\n Ceftazidime and vanco continues. Pt on contact precautions.\n Response:\n Pt remains afebrile, antibiotics continued.\n Plan:\n Vanco level tomorrow morning before 4^th dose (6a-8a). Pt on contact\n precautions.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt on 50% aerosol cool mask, O2 sats WNL while awake. Lung sounds\n clear/diminished. Pt has strong, productive/congested cough. Pt does\n not spit out secretions despite encouragement, seems to swallow\n secretions. O2 sats lower when pt sleeping.\n Action:\n Pt encouraged to cough/deep breathe, spit out secretions. Chest PT\n done. Pt repositioned frequently. Pt given minimal PO\ns, tube feeds\n not restarted d/t pt tolerating PO\ns well.\n Response:\n Coughing/breathing well. Pt tolerating Po\n Plan:\n Speech and swallow eval ordered to officially clear pt to eat. PT\n consult to assist with OOB to chair/increased activity as tolerated.\n Transfer to floor today? Continue diuresing/pulmonary toileting.\n" }, { "category": "Respiratory ", "chartdate": "2161-05-26 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 468326, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 4\n Ideal body weight: 56.7 None\n Ideal tidal volume: 226.8 / 340.2 / 453.6 mL/kg\n 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: 7mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 28 cmH2O\n Cuff volume: 8 mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Clear / Thick\n Sputum source/amount: Suctioned / Moderate\n Comments:\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern: Normal quiet breathing\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Underlying illness\n not resolved\n Respiratory Care Shift Procedures\n Bedside Procedures:\n Comments: Patient so far, remains intubated and on mechanical\n ventilation, breath sounds bilaterally clear and diminished, suctioned\n intermittently for small to moderate amounts of thick clear secretions,\n had SBT for passed 1 hour, got tired, is back on PSV, SPO2 remained\n upper 90s, will continues to be followed.\n" }, { "category": "Physician ", "chartdate": "2161-05-27 00:00:00.000", "description": "Intensivist Note", "row_id": 468427, "text": "SICU\n HPI:\n 82yo female here for Right-sided SDH who reports having tripped on the\n curb and falling. Hit her right side of face on the ground. Event\n reported to happen @ approx. 7:15pm on . Pts daughter witnessed\n event and brought her to OSH for evaluation. Found to have SDH and INR\n of 3.\n Chief complaint:\n sub dural hematoma\n PMHx:\n PMH: CAD s/p stent placement, filter, MI, PE, Mitral Regurg,\n GERD, Anxiety, Anemia, HOH, aflutter\n PSH: hernia repair, left vein stripping.\n Current medications:\n 24 Hour Events:\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Levofloxacin - 08:33 PM\n Vancomycin - 10:39 AM\n Ciprofloxacin - 11:30 AM\n Ceftazidime - 12:00 AM\n Infusions:\n Propofol - 10 mcg/Kg/min\n Other ICU medications:\n Furosemide (Lasix) - 05:57 PM\n Other medications:\n Flowsheet Data as of 05:41 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.5\nC (99.5\n T current: 36.9\nC (98.5\n HR: 74 (69 - 107) bpm\n BP: 129/46(76) {94/33(54) - 158/88(99)} mmHg\n RR: 19 (15 - 30) insp/min\n SPO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 62.1 kg (admission): 62.3 kg\n Height: 65 Inch\n CVP: 8 (6 - 19) mmHg\n Total In:\n 2,270 mL\n 602 mL\n PO:\n Tube feeding:\n 1,044 mL\n 240 mL\n IV Fluid:\n 856 mL\n 272 mL\n Blood products:\n 100 mL\n Total out:\n 2,535 mL\n 1,040 mL\n Urine:\n 2,535 mL\n 1,040 mL\n NG:\n Stool:\n Drains:\n Balance:\n -265 mL\n -438 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 415 (371 - 498) mL\n PS : 10 cmH2O\n RR (Spontaneous): 16\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 98\n PIP: 15 cmH2O\n SPO2: 100%\n ABG: 7.40/45/136/30/2\n Ve: 7 L/min\n PaO2 / FiO2: 340\n Physical Examination\n General Appearance: No acute distress\n HEENT: EOMI\n Cardiovascular: (Rhythm: Regular), (Murmur: Systolic)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles :\n scattered, Diminished: right base), (Sternum: Stable )\n Abdominal: Soft, Non-distended, Non-tender\n Left Extremities: (Edema: Absent), (Temperature: Warm)\n Right Extremities: (Edema: Absent), (Temperature: Warm)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: Follows simple commands, Moves all extremities, Sedated\n Labs / Radiology\n 294 K/uL\n 8.3 g/dL\n 159\n 0.9 mg/dL\n 30 mEq/L\n 3.5 mEq/L\n 28 mg/dL\n 104 mEq/L\n 143 mEq/L\n 25.7 %\n 12.7 K/uL\n [image002.jpg]\n 10:13 PM\n 12:54 AM\n 01:17 AM\n 02:50 AM\n 03:10 PM\n 03:14 PM\n 08:00 PM\n 01:48 AM\n 01:59 AM\n 02:00 AM\n WBC\n 14.4\n 12.7\n Hct\n 24.6\n 25.7\n Plt\n 288\n 294\n Creatinine\n 1.0\n 0.9\n 0.9\n TCO2\n 27\n 28\n 28\n 29\n 29\n Glucose\n 127\n 148\n 153\n 141\n 159\n Other labs: PT / PTT / INR:13.5/22.4/1.2, ALT / AST:, Alk-Phos / T\n bili:50/0.5, Differential-Neuts:77.3 %, Lymph:16.4 %, Mono:4.9 %,\n Eos:1.1 %, Lactic Acid:0.6 mmol/L, Albumin:3.6 g/dL, Ca:9.5 mg/dL,\n Mg:1.9 mg/dL, PO4:3.7 mg/dL\n Assessment and Plan\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/), FEVER, UNKNOWN ORIGIN (FUO,\n HYPERTHERMIA, PYREXIA), AORTIC STENOSIS, SUBDURAL HEMORRHAGE (SDH)\n Assessment and Plan: 82 yo F w/ h/o CAD, AS, Afib on coumadin, s/p fall\n with rt SDH.\n Neurologic: Neuro checks Q: 4 hr, SDH: repeat head CT showed no change,\n no OR per NSG, sedation\n Pain/sedation - propofol as needed\n Cardiovascular: Aspirin, (1) Critical AS: keep MAP 60s to 70s, HR<90,\n avoid dehydration (2) HTN: lopressor TID + PRN, narrow pulse pressure\n suggests dry (3) CAD: aspirin restarted for existing BMS\n Pulmonary: Extubate today, Spontaneous breathing trial, (Ventilator\n mode: CPAP + PS), (1) Pneumonia - on vanco + ceftazidime for empiric\n VAP, f/u cultures (2) ventilator dependence - SBT today, wean as\n tolerated\n Gastrointestinal / Abdomen: speech and swallow post extubation\n Nutrition: Tube feeding\n Renal: Foley, Adequate UO, (1) Acid/base: slight resp acidosis w/\n metabolic compensation (2) fluid status: at baseline weight, on home\n lasix\n Hematology: stable\n Endocrine: RISS\n Infectious Disease: (1) PNA: GPC on sputum, vanco+ceftaz for empiric\n PNA (2) UTI: ceftaz covering cipro-R ecoli\n Lines / Tubes / Drains: NGT, ETT, pIV, CVL, a-line\n Wounds:\n Imaging: CXR today\n Fluids: KVO\n Consults: Neuro surgery, Cardiology\n Billing Diagnosis:\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Multi Lumen - 11:24 AM\n Arterial Line - 03:15 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent:\n" }, { "category": "Physician ", "chartdate": "2161-05-27 00:00:00.000", "description": "Intensivist Note", "row_id": 468434, "text": "SICU\n HPI:\n 82yo female here for Right-sided SDH who reports having tripped on the\n curb and falling. Hit her right side of face on the ground. Event\n reported to happen @ approx. 7:15pm on . Pts daughter witnessed\n event and brought her to OSH for evaluation. Found to have SDH and INR\n of 3.\n Chief complaint:\n sub dural hematoma\n PMHx:\n PMH: CAD s/p stent placement, filter, MI, PE, Mitral Regurg,\n GERD, Anxiety, Anemia, HOH, aflutter\n PSH: hernia repair, left vein stripping.\n Current medications:\n 24 Hour Events:\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Levofloxacin - 08:33 PM\n Vancomycin - 10:39 AM\n Ciprofloxacin - 11:30 AM\n Ceftazidime - 12:00 AM\n Infusions:\n Propofol - 10 mcg/Kg/min\n Other ICU medications:\n Furosemide (Lasix) - 05:57 PM\n Other medications:\n Flowsheet Data as of 05:41 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.5\nC (99.5\n T current: 36.9\nC (98.5\n HR: 74 (69 - 107) bpm\n BP: 129/46(76) {94/33(54) - 158/88(99)} mmHg\n RR: 19 (15 - 30) insp/min\n SPO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 62.1 kg (admission): 62.3 kg\n Height: 65 Inch\n CVP: 8 (6 - 19) mmHg\n Total In:\n 2,270 mL\n 602 mL\n PO:\n Tube feeding:\n 1,044 mL\n 240 mL\n IV Fluid:\n 856 mL\n 272 mL\n Blood products:\n 100 mL\n Total out:\n 2,535 mL\n 1,040 mL\n Urine:\n 2,535 mL\n 1,040 mL\n NG:\n Stool:\n Drains:\n Balance:\n -265 mL\n -438 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 415 (371 - 498) mL\n PS : 10 cmH2O\n RR (Spontaneous): 16\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 98\n PIP: 15 cmH2O\n SPO2: 100%\n ABG: 7.40/45/136/30/2\n Ve: 7 L/min\n PaO2 / FiO2: 340\n Physical Examination\n General Appearance: No acute distress\n HEENT: EOMI\n Cardiovascular: (Rhythm: Regular), (Murmur: Systolic)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles :\n scattered, Diminished: right base), (Sternum: Stable )\n Abdominal: Soft, Non-distended, Non-tender\n Left Extremities: (Edema: Absent), (Temperature: Warm)\n Right Extremities: (Edema: Absent), (Temperature: Warm)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: Follows simple commands, Moves all extremities, Sedated\n Labs / Radiology\n 294 K/uL\n 8.3 g/dL\n 159\n 0.9 mg/dL\n 30 mEq/L\n 3.5 mEq/L\n 28 mg/dL\n 104 mEq/L\n 143 mEq/L\n 25.7 %\n 12.7 K/uL\n [image002.jpg]\n 10:13 PM\n 12:54 AM\n 01:17 AM\n 02:50 AM\n 03:10 PM\n 03:14 PM\n 08:00 PM\n 01:48 AM\n 01:59 AM\n 02:00 AM\n WBC\n 14.4\n 12.7\n Hct\n 24.6\n 25.7\n Plt\n 288\n 294\n Creatinine\n 1.0\n 0.9\n 0.9\n TCO2\n 27\n 28\n 28\n 29\n 29\n Glucose\n 127\n 148\n 153\n 141\n 159\n Other labs: PT / PTT / INR:13.5/22.4/1.2, ALT / AST:, Alk-Phos / T\n bili:50/0.5, Differential-Neuts:77.3 %, Lymph:16.4 %, Mono:4.9 %,\n Eos:1.1 %, Lactic Acid:0.6 mmol/L, Albumin:3.6 g/dL, Ca:9.5 mg/dL,\n Mg:1.9 mg/dL, PO4:3.7 mg/dL\n Assessment and Plan\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/), FEVER, UNKNOWN ORIGIN (FUO,\n HYPERTHERMIA, PYREXIA), AORTIC STENOSIS, SUBDURAL HEMORRHAGE (SDH)\n Assessment and Plan: 82 yo F w/ h/o CAD, AS, Afib on coumadin, s/p fall\n with rt SDH.\n Neurologic: Neuro checks Q: 4 hr, SDH: repeat head CT showed no change,\n no OR per NSG, sedation\n Pain/sedation - propofol as needed\n Cardiovascular: Aspirin, (1) Critical AS: keep MAP 60s to 70s, HR<90,\n avoid dehydration (2) HTN: lopressor TID + PRN, narrow pulse pressure\n suggests dry (3) CAD: aspirin restarted for existing BMS\n Pulmonary: Extubate today, Spontaneous breathing trial, (Ventilator\n mode: CPAP + PS), (1) Pneumonia - on vanco + ceftazidime for empiric\n VAP, f/u cultures (2) ventilator dependence - SBT today, wean as\n tolerated\n Gastrointestinal / Abdomen: speech and swallow post extubation\n Nutrition: Tube feeding\n Renal: Foley, Adequate UO, (1) Acid/base: slight resp acidosis w/\n metabolic compensation (2) fluid status: at baseline weight, on home\n lasix\n Hematology: stable\n Endocrine: RISS\n Infectious Disease: (1) PNA: GPC on sputum, vanco+ceftaz for empiric\n PNA (2) UTI: ceftaz covering cipro-R ecoli\n Lines / Tubes / Drains: NGT, ETT, pIV, CVL, a-line\n Wounds:\n Imaging: CXR today\n Fluids: KVO\n Consults: Neuro surgery, Cardiology\n Billing Diagnosis:\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Multi Lumen - 11:24 AM\n Arterial Line - 03:15 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent:\n" }, { "category": "Physician ", "chartdate": "2161-05-27 00:00:00.000", "description": "Intensivist Note", "row_id": 468445, "text": "SICU\n HPI:\n 82yo female here for Right-sided SDH who reports having tripped on the\n curb and falling. Hit her right side of face on the ground. Event\n reported to happen @ approx. 7:15pm on . Pts daughter witnessed\n event and brought her to OSH for evaluation. Found to have SDH and INR\n of 3.\n Chief complaint:\n sub dural hematoma\n PMHx:\n PMH: CAD s/p stent placement, filter, MI, PE, Mitral Regurg,\n GERD, Anxiety, Anemia, HOH, aflutter\n PSH: hernia repair, left vein stripping.\n Current medications:\n 24 Hour Events:\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Levofloxacin - 08:33 PM\n Vancomycin - 10:39 AM\n Ciprofloxacin - 11:30 AM\n Ceftazidime - 12:00 AM\n Infusions:\n Propofol - 10 mcg/Kg/min\n Other ICU medications:\n Furosemide (Lasix) - 05:57 PM\n Other medications:\n Flowsheet Data as of 05:41 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.5\nC (99.5\n T current: 36.9\nC (98.5\n HR: 74 (69 - 107) bpm\n BP: 129/46(76) {94/33(54) - 158/88(99)} mmHg\n RR: 19 (15 - 30) insp/min\n SPO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 62.1 kg (admission): 62.3 kg\n Height: 65 Inch\n CVP: 8 (6 - 19) mmHg\n Total In:\n 2,270 mL\n 602 mL\n PO:\n Tube feeding:\n 1,044 mL\n 240 mL\n IV Fluid:\n 856 mL\n 272 mL\n Blood products:\n 100 mL\n Total out:\n 2,535 mL\n 1,040 mL\n Urine:\n 2,535 mL\n 1,040 mL\n NG:\n Stool:\n Drains:\n Balance:\n -265 mL\n -438 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 415 (371 - 498) mL\n PS : 10 cmH2O\n RR (Spontaneous): 16\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 98\n PIP: 15 cmH2O\n SPO2: 100%\n ABG: 7.40/45/136/30/2\n Ve: 7 L/min\n PaO2 / FiO2: 340\n Physical Examination\n General Appearance: No acute distress\n HEENT: EOMI\n Cardiovascular: (Rhythm: Regular), (Murmur: Systolic)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles :\n scattered, Diminished: right base), (Sternum: Stable )\n Abdominal: Soft, Non-distended, Non-tender\n Left Extremities: (Edema: Absent), (Temperature: Warm)\n Right Extremities: (Edema: Absent), (Temperature: Warm)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: Follows simple commands, Moves all extremities, Sedated\n Labs / Radiology\n 294 K/uL\n 8.3 g/dL\n 159\n 0.9 mg/dL\n 30 mEq/L\n 3.5 mEq/L\n 28 mg/dL\n 104 mEq/L\n 143 mEq/L\n 25.7 %\n 12.7 K/uL\n [image002.jpg]\n 10:13 PM\n 12:54 AM\n 01:17 AM\n 02:50 AM\n 03:10 PM\n 03:14 PM\n 08:00 PM\n 01:48 AM\n 01:59 AM\n 02:00 AM\n WBC\n 14.4\n 12.7\n Hct\n 24.6\n 25.7\n Plt\n 288\n 294\n Creatinine\n 1.0\n 0.9\n 0.9\n TCO2\n 27\n 28\n 28\n 29\n 29\n Glucose\n 127\n 148\n 153\n 141\n 159\n Other labs: PT / PTT / INR:13.5/22.4/1.2, ALT / AST:, Alk-Phos / T\n bili:50/0.5, Differential-Neuts:77.3 %, Lymph:16.4 %, Mono:4.9 %,\n Eos:1.1 %, Lactic Acid:0.6 mmol/L, Albumin:3.6 g/dL, Ca:9.5 mg/dL,\n Mg:1.9 mg/dL, PO4:3.7 mg/dL\n Assessment and Plan\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/), FEVER, UNKNOWN ORIGIN (FUO,\n HYPERTHERMIA, PYREXIA), AORTIC STENOSIS, SUBDURAL HEMORRHAGE (SDH)\n Assessment and Plan: 82 yo F w/ h/o CAD, AS, Afib on coumadin, s/p fall\n with rt SDH.\n Neurologic: Neuro checks Q: 4 hr, SDH: repeat head CT showed no change,\n no OR per NSG, sedation\n Pain/sedation - propofol as needed\n Cardiovascular: Aspirin, (1) Critical AS: keep MAP 60s to 70s, HR<90,\n avoid dehydration (2) HTN: lopressor TID + PRN, (3) AF CAD: aspirin\n restarted for existing BMS. PO lopressor 12.5 mg tid\n increase to 25\n mg tid. Start Diltiazem drip and PO later on PO dilt for rate control\n Pulmonary: Extubate today, Spontaneous breathing trial, (Ventilator\n mode: CPAP + PS), (1) Pneumonia - on vanco + ceftazidime for empiric\n VAP, f/u cultures (2) ventilator dependence - SBT today, wean as\n tolerated. RSBI\n Gastrointestinal / Abdomen: speech and swallow post extubation\n Nutrition: Tube feeding held. Resume TF if does not get extubated today\n Renal: Foley, Adequate UO, (1) Acid/base: slight resp acidosis w/\n metabolic compensation (2) fluid status: at baseline weight, on home\n lasix PO\n Hematology: stable anemia\n Endocrine: RISS with adequate glucose control. Keep < 150\n Infectious Disease: (1) PNA: GPC on sputum, vanco+ceftaz for empiric\n PNA (2) UTI: ceftaz covering cipro-R ecoli. Please check vanco level\n Lines / Tubes / Drains: NGT, ETT, pIV, CVL, a-line. Please re-wire\n a-line or re-site it.\n Wounds:\n Imaging: CXR today\n Fluids: KVO\n Consults: Neuro surgery, Cardiology\n Billing Diagnosis:\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Multi Lumen - 11:24 AM\n Arterial Line - 03:15 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 32 min\n" }, { "category": "Nursing", "chartdate": "2161-05-27 00:00:00.000", "description": "Nursing Progress Note", "row_id": 468531, "text": "Subdural hemorrhage (SDH)\n Assessment:\n Pt intubated & on propofol infusion @ 10mcg/kg/min: pt alert and\n following commands. PERRL @ 4mm/brisk. Cough, gag, corneal reflexes are\n intact. Pt MAEs equally & with normal strength.\n Action:\n Q 4 hour neuro assessments done.\n Response:\n No change in neuro exam: pt remains alert & now oriented x2 since\n extubation. She continues to MAEs without deficit & follow commands\n consistently. PERRL.\n Plan:\n Continue Q 4 hour neuro checks.\n Atrial fibrillation (Afib)\n Assessment:\n NSR with baseline PAC & PVC activity; at 0900, pt converted to atrial\n fibrillation/flutter with VR of 110 to 145.\n MAP was sustained >60 & pt remained alert without complaints of chest\n pain or respiratory distress.\n Action:\n Lopressor total 15mg ivp; diltiazem 15mg ivp with infusion started @\n 10mg per hour.\n 12 lead EKG obtained\n Cardiology was re-consulted\n Response:\n Ventricular response was controlled to 70-90 range. Re-bolused with\n diltiazem 15mg & drip dose increased to 15mg for HR to 145 > with\n effect.\n Oral dose of Lopressor was increased to 37.5mg\n Pt converted to NSR @1400; MAP maintained >60\n Plan:\n Administer higher dose Lopressor TID per order\n Wean diltiazem & discontinue as tolerated\n Maintain electrolytes wnl\n If returns to a. fib, dose with ammioderone per cardiology\n recommendations.\n Pneumonia, bacterial, ventilator acquired (VAP)\n Assessment:\n Bilateral opacifications per CXR; sputum gram stain with GPC. Pt\n suctioned for moderate amounts of tenacious yellow sputum. Afebrile\n with WBC trending downward. Breath sounds coarse to clear after\n suctioning.\n Action:\n Retained secretions cleared prn with suctioning\n Routine pulmonary toileting measures\n Antibiotics provided\n Response:\n Pt remains Afebrile. Breath sounds remain coarse; cough is congested &\n nonproductive at this time.\n Plan:\n Continue pulmonary toileting & NTS if pt unable to clear retained\n secretions.\n Follow temp trends and daily WBC\n Continue antibiotic\n Urinary tract infection (UTI)\n Assessment:\n UTI documented on admission testing; antibiotics provided. Today, call\n from Infectious disease to report that E.Coli UTI is a multi-drug\n resistant organism and requires contact precautions. Pt positive for\n urinary discomfort per nonverbal communication.\n Action:\n Current antibiotic is appropriate for resistant organism.\n Contact precautions applied\n Temps followed; daily WBC obtained.\n Response:\n Pt remains Afebrile. Urine remains clear & yellow; local urinary\n discomfort continues.\n Plan:\n Continue with antibiotic coverage\n Maintain contact precautions\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt intubated with CPAP/PSV @ with 40% fio2\n Action:\n Spontaneous breathing trial performed\n Abg obtained\n Response:\n Pt tolerated SBT with appropriate RSBI and gas exchange per abg; no c/o\n respiratory distress; O2 saturations adequate. Pt extubated @ 1600.\n Plan:\n Monitor for respiratory distress\n Provide supplemental O2 support\n Pulmonary toilet per routine\n Advance OOB as tolerated\n Assess swallow ability & consider po diet\n" }, { "category": "Nutrition", "chartdate": "2161-05-26 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 468306, "text": "Subjective\n intubated\n Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 165 cm\n 62.3 kg\n 64 kg ( 04:00 AM)\n 22.8\n Ideal body weight\n % Ideal body weight\n Adjusted weight\n Usual body weight\n % Usual body weight\n 56.7 kg\n 110%\n Diagnosis: acute SDH\n PMH : CAD s/p stent placement, filter, MI, PE, Mitral\n Regurg, GERD, Anxiety, Anemia, HOH, aflutter\n Food allergies and intolerances: no known food allergies\n Pertinent medications: mag sulfate (2g), IV abx, RISS, colace,\n lansoprazole, lasix, propofol, others noted\n Labs:\n Value\n Date\n Glucose\n 127 mg/dL\n 01:17 AM\n Glucose Finger Stick\n 153\n 08:00 AM\n BUN\n 19 mg/dL\n 01:17 AM\n Creatinine\n 1.0 mg/dL\n 01:17 AM\n Sodium\n 143 mEq/L\n 01:17 AM\n Potassium\n 4.6 mEq/L\n 01:17 AM\n Chloride\n 108 mEq/L\n 01:17 AM\n TCO2\n 26 mEq/L\n 01:17 AM\n PO2 (arterial)\n 158 mm Hg\n 02:50 AM\n PCO2 (arterial)\n 38 mm Hg\n 02:50 AM\n pH (arterial)\n 7.46 units\n 02:50 AM\n pH (urine)\n 7.0 units\n 05:29 PM\n CO2 (Calc) arterial\n 28 mEq/L\n 02:50 AM\n Albumin\n 3.6 g/dL\n 05:42 AM\n Calcium non-ionized\n 9.3 mg/dL\n 01:17 AM\n Phosphorus\n 3.7 mg/dL\n 01:17 AM\n Ionized Calcium\n 1.15 mmol/L\n 10:13 PM\n Magnesium\n 1.9 mg/dL\n 01:17 AM\n ALT\n 8 IU/L\n 05:42 AM\n Alkaline Phosphate\n 50 IU/L\n 05:42 AM\n AST\n 24 IU/L\n 05:42 AM\n Total Bilirubin\n 0.5 mg/dL\n 05:42 AM\n WBC\n 14.4 K/uL\n 01:17 AM\n Hgb\n 8.1 g/dL\n 01:17 AM\n Hematocrit\n 24.6 %\n 01:17 AM\n Current diet order / nutrition support: Replete with fiber Full\n strength;\n Starting rate: 20 ml/hr; Advance rate by 10 ml q4h Goal rate: 60 ml/hr\n = 1440 kcals/ 89 g protein\n Residual Check: q4h Hold feeding for residual >= : 200 ml\n GI: soft, distended, +bowel sounds\n Assessment of Nutritional Status\n At risk for malnutrition\n Pt at risk due to: trauma\n Estimated Nutritional Needs based on admit wt\n Calories: 1558-1744 (BEE x or / 25-28 cal/kg)\n Protein: 62-75 (1-1.2 g/kg)\n Fluid: per team\n Estimation of previous intake: \n Estimation of current intake: Inadequate\n Specifics: 82 year old female presented to outside hospital after\n tripping on curb and fell hit right side of face on ground went to\n outside hospital. Head CT showed right sided SDH with midline shift.\n Patient intubated with poor mental exam. Tube feeding started on \n currently tolerating at 60 ml/hr RN. Tube feeding order exceed\n patients protein needs. Recommend changing tube feeding formula to\n better meet needs and more concentrated formula due to fluid issues.\n Propofol is running at 7/5 ml/hr providing ~198 kcals/day. Will need to\n adjust tube feeding if rate increases, RN patient may be extubated\n tomorrow. Noted mag repletion.\n Medical Nutrition Therapy Plan - Recommend the Following\n Change tube feeding to Nutren Pulmonary @ 45 ml/hr = 1620 kcals/ 73 g\n protein\n Will adjust tube feeding if propofol rate increases\n Multivitamin / Mineral supplement: via tube feeding\n Check chemistry 10 panel daily and replete prn\n Will follow page with questions\n" }, { "category": "Physician ", "chartdate": "2161-05-28 00:00:00.000", "description": "Intensivist Note", "row_id": 468602, "text": "SICU\n HPI:\n 82yo female here for Right-sided SDH who reports having tripped on the\n curb and falling. Hit her right side of face on the ground. Event\n reported to happen @ approx. 7:15pm on . Pts daughter witnessed\n event and brought her to OSH for evaluation, INR 2.97. Denies pain.\n Chief complaint:\n PMHx:\n .\n PMH: CAD s/p stent placement, filter, MI, PE, Mitral Regurg,\n GERD, Anxiety, Anemia, HOH, aflutter\n PSH: hernia repair, left vein stripping.\n : Zocor 40mg QD, KCL 20Meq QD,Coumadin 4mg , 325mg QD, Plavix\n 75mg QD, ?Iron 325mg QD, fosinopril 10mg QD, Isordil 60', Ativan 0.5mg\n TID, Toprol XL 100 QD, Zoloft 75mg QD, Lasix 40''\n Current medications:\n 24 Hour Events:\n went into A.Fib, rate controlled on Dilt gtt, spontaneously converted\n to sinus. Cards consulted - if A.Fib recurs, will amio load. Extubated,\n A-line replaced on right\n EKG - At 09:12 AM\n ARTERIAL LINE - STOP 01:30 PM\n ARTERIAL LINE - START 02:30 PM\n EXTUBATION - At 04:00 PM\n INVASIVE VENTILATION - STOP 04:00 PM\n pt admitteed from ED\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Levofloxacin - 08:33 PM\n Ciprofloxacin - 11:30 AM\n Vancomycin - 08:45 AM\n Ceftazidime - 12:45 AM\n Infusions:\n Other ICU medications:\n Metoprolol - 09:15 AM\n Diltiazem - 11:35 AM\n Heparin Sodium (Prophylaxis) - 10:00 PM\n Other medications:\n Flowsheet Data as of 06:37 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37\nC (98.6\n T current: 36.1\nC (96.9\n HR: 78 (64 - 110) bpm\n BP: 178/61(106) {73/37(-3) - 178/70(106)} mmHg\n RR: 21 (15 - 24) insp/min\n SPO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 59.3 kg (admission): 62.3 kg\n Height: 65 Inch\n CVP: 8 (5 - 13) mmHg\n Total In:\n 1,827 mL\n 306 mL\n PO:\n Tube feeding:\n 240 mL\n IV Fluid:\n 1,097 mL\n 246 mL\n Blood products:\n Total out:\n 2,555 mL\n 1,240 mL\n Urine:\n 2,555 mL\n 1,240 mL\n NG:\n Stool:\n Drains:\n Balance:\n -728 mL\n -934 mL\n Respiratory support\n O2 Delivery Device: Aerosol-cool\n Ventilator mode: PSV/SBT\n Vt (Spontaneous): 362 (362 - 447) mL\n PS : 5 cmH2O\n RR (Spontaneous): 20\n PEEP: 0 cmH2O\n FiO2: 50%\n PIP: 5 cmH2O\n SPO2: 100%\n ABG: 7.42/48/91./29/5\n Ve: 8 L/min\n PaO2 / FiO2: 184\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 : , Wheezes : )\n Abdominal: Soft, Non-distended\n Labs / Radiology\n 379 K/uL\n 8.5 g/dL\n 105 mg/dL\n 0.9 mg/dL\n 29 mEq/L\n 3.5 mEq/L\n 28 mg/dL\n 102 mEq/L\n 144 mEq/L\n 26.5 %\n 10.5 K/uL\n [image002.jpg]\n 02:50 AM\n 03:10 PM\n 03:14 PM\n 08:00 PM\n 01:48 AM\n 01:59 AM\n 02:00 AM\n 03:38 PM\n 02:12 AM\n 02:28 AM\n WBC\n 12.7\n 10.5\n Hct\n 25.7\n 26.5\n Plt\n 294\n 379\n Creatinine\n 0.9\n 0.9\n 0.9\n TCO2\n 28\n 29\n 29\n 29\n 32\n Glucose\n 148\n 153\n 141\n 159\n 105\n Other labs: PT / PTT / INR:13.5/22.4/1.2, ALT / AST:, Alk-Phos / T\n bili:50/0.5, Differential-Neuts:77.3 %, Lymph:16.4 %, Mono:4.9 %,\n Eos:1.1 %, Lactic Acid:0.7 mmol/L, Albumin:3.6 g/dL, Ca:10.3 mg/dL,\n Mg:1.9 mg/dL, PO4:3.9 mg/dL\n Assessment and Plan\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/), AORTIC STENOSIS, URINARY\n TRACT INFECTION (UTI), PNEUMONIA, BACTERIAL, VENTILATOR ACQUIRED (VAP),\n ATRIAL FIBRILLATION (AFIB)\n Assessment and Plan: 82 yo F w/ h/o CAD, AS, Afib on coumadin, s/p\n fall with rt SDH.\n Neurologic: Neuro checks Q: 4 hr, Pain controlled, stable\n Cardiovascular: Aspirin, 1) Critical AS: keep MAP 60s to 70s, HR<90,\n avoid dehydration (2) HTN: lopressor TID + PRN, narrow pulse pressure\n and SBP in 90s suggests dry (3) CAD: aspirin restarted for existing BMS\n (4) A-Fib - spontaneously converted to sinus, increased dose og\n metoprolol, will amio load if A. Fib returns.\n Pulmonary: Successfully extubated, pneumonia - on vanco + ceftazidime\n for empiric VAP, f/u cultures\n Gastrointestinal / Abdomen: H2B, speech and swallow post extubation\n Nutrition: Advance diet as tolerated\n Renal: Foley\n Hematology: Serial Hct, stable HCt at 26\n Endocrine: RISS\n Infectious Disease: (1) PNA: GPC on sputum, vanco+ceftaz for empiric\n PNA (2) UTI: ceftaz covering cipro-R ecoli\n Lines / Tubes / Drains: Foley, NGT\n Wounds:\n Imaging: CXR today\n Fluids:\n Consults:\n Billing Diagnosis:\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Multi Lumen - 11:24 AM\n Arterial Line - 02:30 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP bundle: HOB elevation, Mouth care\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition: Transfer to floor\n Total time spent: 30 minutes\n" }, { "category": "Respiratory ", "chartdate": "2161-05-27 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 468403, "text": "Demographics\n Day of intubation: 5\n Day of mechanical ventilation: 5\n Ideal body weight: 56.7 None\n Ideal tidal volume: 226.8 / 340.2 / 453.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location: OR\n Reason: Elective\n Tube Type\n ETT:\n Position: 24 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Clear / Thin\n Sputum source/amount: Suctioned / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No claim of dyspnea)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated;\n Comments: Plan to extubate today\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 has been getting dieresis overnight, plan is to extubate today\n" }, { "category": "Nursing", "chartdate": "2161-05-27 00:00:00.000", "description": "Nursing Progress Note", "row_id": 468515, "text": "Subdural hemorrhage (SDH)\n Assessment:\n Pt intubated & on propofol infusion @ 10mcg/kg/min: pt alert and\n following commands. PERRL @ 4mm/brisk. Cough, gag, corneal reflexes are\n intact. Pt MAEs equally & with normal strength.\n Action:\n Q 4 hour neuro assessments done.\n Response:\n No change in neuro exam: pt remains alert & now oriented x2 since\n extubation. She continues to MAEs without deficit & follow commands\n consistently. PERRL.\n Plan:\n Continue Q 4 hour neuro checks.\n Atrial fibrillation (Afib)\n Assessment:\n NSR with baseline PAC & PVC activity; at 0900, pt converted to atrial\n fibrillation/flutter with VR of 110 to 145.\n MAP was sustained >60 & pt remained alert without complaints of chest\n pain or respiratory distress.\n Action:\n Lopressor total 15mg ivp; diltiazem 15mg ivp with infusion started @\n 10mg per hour.\n 12 lead EKG obtained\n Cardiology was re-consulted\n Response:\n Ventricular response was controlled to 70-90 range. Re-bolused with\n diltiazem 15mg & drip dose increased to 15mg for HR to 145 > with\n effect.\n Oral dose of Lopressor was increased to 37.5mg\n Pt converted to NSR @1400; MAP maintained >60\n Plan:\n Administer higher dose Lopressor TID per order\n Wean diltiazem & discontinue as tolerated\n Maintain electrolytes wnl\n If returns to a. fib, dose with ammioderone per cardiology\n recommendations.\n Pneumonia, bacterial, ventilator acquired (VAP)\n Assessment:\n Bilateral opacifications per CXR; sputum gram stain with GPC. Pt\n suctioned for moderate amounts of tenacious yellow sputum. Afebrile\n with WBC trending downward. Breath sounds coarse to clear after\n suctioning.\n Action:\n Retained secretions cleared prn with suctioning\n Routine pulmonary toileting measures\n Antibiotics provided\n Response:\n Pt remains Afebrile. Breath sounds remain coarse; cough is congested &\n nonproductive at this time.\n Plan:\n Continue pulmonary toileting & NTS if pt unable to clear retained\n secretions.\n Follow temp trends and daily WBC\n Continue antibiotic\n Urinary tract infection (UTI)\n Assessment:\n UTI documented on admission testing; antibiotics provided. Today, call\n from Infectious disease to report that E.Coli UTI is a multi-drug\n resistant organism and requires contact precautions. Pt positive for\n urinary discomfort per nonverbal communication.\n Action:\n Current antibiotic is appropriate for resistant organism.\n Contact precautions applied\n Temps followed; daily WBC obtained.\n Response:\n Pt remains Afebrile. Urine remains clear & yellow; local urinary\n discomfort continues.\n Plan:\n Continue with antibiotic coverage\n Maintain contact precautions\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt intubated with CPAP/PSV @ with 40% fio2\n Action:\n Spontaneous breathing trial performed\n Abg obtained\n Response:\n Pt tolerated SBT with appropriate RSBI and gas exchange per abg; no c/o\n respiratory distress; O2 saturations adequate. Pt extubated @ 1600.\n Plan:\n Monitor for respiratory distress\n Provide supplemental O2 support\n Pulmonary toilet per routine\n Advance OOB as tolerated\n Assess swallow ability & consider po diet\n" }, { "category": "Nursing", "chartdate": "2161-05-27 00:00:00.000", "description": "Nursing Progress Note", "row_id": 468506, "text": "Subdural hemorrhage (SDH)\n Assessment:\n Pt intubated & on propofol infusion @ 10mcg/kg/min: pt alert and\n following commands. PERRL @ 4mm/brisk. Cough, gag, corneal reflexes are\n intact. Pt MAEs equally & with normal strength.\n Action:\n Q 4 hour neuro assessments done.\n Response:\n No change in neuro exam: pt remains alert & now oriented x2 since\n extubation. She continues to MAEs without deficit & follow commands\n consistently. PERRL.\n Plan:\n Continue Q 4 hour neuro checks.\n Atrial fibrillation (Afib)\n Assessment:\n NSR with baseline PAC & PVC activity; at 0900, pt converted to atrial\n fibrillation/flutter with VR of 110 to 145.\n MAP was sustained >60 & pt remained alert without complaints of chest\n pain or respiratory distress.\n Action:\n Lopressor total 15mg ivp; diltiazem 15mg ivp with infusion started @\n 10mg per hour.\n 12 lead EKG obtained\n Cardiology was re-consulted\n Response:\n Ventricular response was controlled to 70-90 range. Re-bolused with\n diltiazem 15mg & drip dose increased to 15mg for HR to 145 > with\n effect.\n Oral dose of Lopressor was increased to 37.5mg\n Pt converted to NSR @1400; MAP maintained >60\n Plan:\n Administer higher dose Lopressor TID per order\n Wean diltiazem & discontinue as tolerated\n Maintain electrolytes wnl\n If returns to a. fib, dose with ammioderone per cardiology\n recommendations.\n Pneumonia, bacterial, ventilator acquired (VAP)\n Assessment:\n RLL opacification per CXR\n Action:\n Response:\n Plan:\n Urinary tract infection (UTI)\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": "2161-05-28 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 468683, "text": "Subdural hemorrhage (SDH)\n Assessment:\n Pt is A&O x3, MAE\ns without focal deficits noted & follows commands.\n PERRL. Pt is s/p multiple head CTs this admission that are stable.\n Action:\n Q 4 hour neuro assessments followed. NGT removed and able to eat\n regular lunch and take clears without any signs of aspirations.\n Response:\n No change in neuro exam\n Plan:\n Continue to monitor neuro assessments.\n Pneumonia, bacterial, ventilator acquired (VAP)\n Assessment:\n VAP PNA by CXR with bibasilar opacities and thick yellow secretions.\n Action:\n Antibiotic coverage with vancomycin 1 gram daily, started \n Successful extubation \n Pulmonary toileting measures provided\n Response:\n Pt remains Afebrile with WBC wnl\n Strong congested cough with pt swallowing secretions. O2 saturations\n maintained on 2L NC and pt has no subjective complaints of respiratory\n distress. Regular breathing pattern observed.\n Plan:\n Continue antibiotic therapy; continue pulmonary toileting measures and\n mobilize pt as tolerated.\n Vancomycin trough level due before 0800 dose\n Urinary tract infection (UTI)\n Assessment:\n Confirmed UTI on admission testing. Multi drug resistant E.Coli\n confirmed; pt requires contact precautions.\n Action:\n Antibiotic therapy with ceftazidine continues\n Foley d/c\nd at 1400.\n Response:\n Pt is Afebrile with WBC trending to WNL now.\n Urine is clear yellow.\n Plan:\n Continue antibiotics for UTI, continue contact precautions;\n PT will be DTV this evening at .\n Atrial fibrillation (Afib)\n Assessment:\n Episode of a. fib/flutter with RVR to 120-145. Episode treated with\n diltiazem IVP & infusion, and increase in scheduled Lopressor dosing.\n Pt converted to NSR and remains in NSR with HR in 70\ns. Pt has known\n baseline of APC & PVC activity. PT has recent h/o PE () & is s/p\n IVC filter and takes coumadin at home.\n Action:\n Diltiazem therapy weaned & discontinued pm\n Lopressor dose increased to 50mg TID today\n Electrolytes replete to wnl\n sc heparin started ; compression boots in use\n Response:\n Heart rhythm continues in NS in 70\ns with rare to occasional PVC & APC\n activity\n Plan:\n Continue with current medical management and monitor for recurrence of\n a. fib\n Continue with heparin sc and compression boot therapy.\n Aortic stenosis\n Assessment:\n Pt with known AS with valve area of .8 per cardiac cath in ; also #\n vessel CAD & s/p BMS to LAD in . EF ~ 45%. Pt with episodes of\n flash pulmonary edema this admission during attempts to wean from vent\n support & related to fluid overload. Pt known hypertensive. BP\n 170-/systolic this morning with MAP >90.\n No c/o cheat pain\n Action:\n Pt diuresed and home medications restarted\n lasix resumed; home doses of Lopressor & ace inhibitor started;\n daily ASA continues. Home dose of isordil started today but\n discontinued per recommendation of medical team now in charge of pt\n care.\n Aggressive potassium repletion continued\n Goal MAP >70 during ICU stay.\n Per cardiology consult: no need for plavix at this time.\n Response:\n Current fluid balance is negative ~ 1200cc for LOS\n Blood pressure currently 140\ns/ 58 with MAP in 70s; adequate peripheral\n CSM\n Adequate urine response to lasix\n No c/o chest pain\n Plan:\n Continue with home medication regimen; monitor fluid balance; &\n provide potassium repletion to maintain >4.0\n Monitor blood pressure & peripheral perfusion\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt extubated from mechanical ventilation 7/1 @1600. Supplemental oxygen\n support by humidified face tent @ 50% with saturations >95% unless\n asleep, then ~ 90%. Breathing pattern in NAD & no subjective\n complaints.\n Strong congested cough, nonproductive (? swallows). Breath sounds:\n clear with basilar crackles to scattered rhonchi.\n Action:\n O2 support changed to NC\n Activity advanced to OOB with ambulation\n Coughing encouraged.\n PT consult obtained\n Response:\n Respiratory failure resolved\n O2 saturations >95% on NC @ 2L\n Strong congested cough continues\n Pt OOB to chair with assist of 1; ambulated in unit with assist of 1;\n pt very independent with activities.\n Plan:\n Continue with advanced physical activities as tolerated.\n Encourage C&DB exercises\n Maintain O2 saturations >92%; assess breath sounds for changes\n Demographics\n Attending MD:\n W.\n Admit diagnosis:\n ACUTE SUBDURAL HEMATOMA\n Code status:\n Full code\n Height:\n 65 Inch\n Admission weight:\n 62.3 kg\n Daily weight:\n 59.3 kg\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions: Contact\n PMH: Anemia\n CV-PMH: CAD, MI\n Additional history: s/p stent placement, filter, htn, pe,\n gerd, anxiety\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:133\n D:47\n Temperature:\n 96.7\n Arterial BP:\n S:166\n D:49\n Respiratory rate:\n 19 insp/min\n Heart Rate:\n 85 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n Nasal cannula\n O2 saturation:\n 99% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 50% %\n 24h total in:\n 1,270 mL\n 24h total out:\n 2,035 mL\n Pertinent Lab Results:\n Sodium:\n 144 mEq/L\n 02:12 AM\n Potassium:\n 3.5 mEq/L\n 02:12 AM\n Chloride:\n 102 mEq/L\n 02:12 AM\n CO2:\n 29 mEq/L\n 02:12 AM\n BUN:\n 28 mg/dL\n 02:12 AM\n Creatinine:\n 0.9 mg/dL\n 02:12 AM\n Glucose:\n 105 mg/dL\n 02:12 AM\n Hematocrit:\n 26.5 %\n 02:12 AM\n Finger Stick Glucose:\n 164\n 09:00 AM\n Valuables / Signature\n Patient valuables:\n Other valuables:\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: \n Transferred to: 224\n Date & time of Transfer: 1700\n" }, { "category": "Nursing", "chartdate": "2161-05-24 00:00:00.000", "description": "Nursing Progress Note", "row_id": 467929, "text": "Aortic stenosis\n Assessment:\n Pt with + systolic murmur, AS by , 45%. Pt needs estimated MAP of\n 80 for adequate coronary perfusion. Aline pressures adequate, decreased\n on sedation.\n Action:\n Phenylephrine started to maintain MAP~80\n Response:\n BP adequate, no signs of ischemia on monitor, extremities warm, well\n perfused, LS essentially clear\n Plan:\n Wean sedation after CT(if CT stable)- wean Neo as able\n Subdural hemorrhage (SDH)\n Assessment:\n Pt sedated on Propofol, responds appropriately when lightened, PERL,MAE\n with equal strengths. Intact gag, cough and corneals, follows commands\n most of the time, occ mouths\n instead. Consistently denies pain.\n Maintained on CMV mode overnight to correct resp acidosis/ met\n alkalosis, tolerates settings well.LS clear, crackles R base, clears\n later in shift.\n Action:\n Fentanyl stopped, Propofol titrated for sedation/ETT tolerance.\n Neuro\ns q2h overnight to promote sleep\n Lytes repleted to optimize metabolic status\n Head CT early this am- awaiting call\n Soft restraints for safety\n Turn and reposition q2h for comfort\n Response:\n Lytes WNL, abg indicates met alkalosis, new results pending\n Plan:\n Await CT results, ? extubate if stable. Maintain safe environment,\n monitor neuro signs q2h.\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Temp to 101.6 orally, WBC^ 16 from 12. Urine cx sent previous shift.\n ABX x1 in ED, none since admit. Scant bloody secretions from ETT, urine\n clear yellow but with foul odor\n Action:\n Blood cx x2, sputum cx\n Tylenol 650mg via OG\n Response:\n VSS, sputum w/frank blood, unable to further assess\n Plan:\n Monitor cx, temp curve, change in sputum or urine\n" }, { "category": "Nursing", "chartdate": "2161-05-24 00:00:00.000", "description": "Nursing Progress Note", "row_id": 467931, "text": "HPI:\n 82yo female who reports having tripped on the curb and falling. Hit her\n right side of face on the ground. Event reported to happen @ approx.\n 7:15pm on . Pts daughter witnessed event and brought her to OSH for\n evaluation, INR 2.97. Denies pain, acute respiratory decompensation in\n ED requiring intubation, found to have SDH.\n Chief complaint:\n head trauma\n PMHx:\n CAD s/p stent placement, filter, MI, PE, Mitral Regurg,\n GERD, Anxiety, Anemia, HOH\n Aortic stenosis\n Assessment:\n Pt with + systolic murmur, AS by , 45%. Pt needs estimated MAP of\n 80 for adequate coronary perfusion. Aline pressures adequate, decreased\n on sedation.\n Action:\n Phenylephrine started to maintain MAP~80\n Response:\n BP adequate, no signs of ischemia on monitor, extremities warm, well\n perfused, LS essentially clear\n Plan:\n Wean sedation after CT(if CT stable)- wean Neo as able\n Subdural hemorrhage (SDH)\n Assessment:\n Pt sedated on Propofol, responds appropriately when lightened, PERL,MAE\n with equal strengths. Intact gag, cough and corneals, follows commands\n most of the time, occ mouths\n instead. Consistently denies pain.\n Maintained on CMV mode overnight to correct resp acidosis/ met\n alkalosis, tolerates settings well.LS clear, crackles R base, clears\n later in shift.\n Action:\n Fentanyl stopped, Propofol titrated for sedation/ETT tolerance.\n Neuro\ns q2h overnight to promote sleep\n Lytes repleted to optimize metabolic status\n Head CT early this am- awaiting call\n Soft restraints for safety\n Turn and reposition q2h for comfort\n Response:\n Lytes WNL, abg indicates met alkalosis, new results pending\n Plan:\n Await CT results, ? extubate if stable. Maintain safe environment,\n monitor neuro signs q2h.\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Temp to 101.6 orally, WBC^ 16 from 12. Urine cx sent previous shift.\n ABX x1 in ED, none since admit. Scant bloody secretions from ETT, urine\n clear yellow but with foul odor\n Action:\n Blood cx x2, sputum cx\n Tylenol 650mg via OG\n Response:\n VSS, sputum w/frank blood, unable to further assess\n Plan:\n Monitor cx, temp curve, change in sputum or urine\n" }, { "category": "Nursing", "chartdate": "2161-05-25 00:00:00.000", "description": "Nursing Progress Note", "row_id": 468158, "text": "82yo female s/p fall on witnessed trip on curb, hit her face on\n the ground. Pt has hx of anemia, CAD/MI, stent placement, IVC filter,\n HTN, critical AS, PE, GERD, anxiety/depression; on coumadin, ASA,\n plavix- INR 2.9. Injuries include: nasal fx and SDH with 8mm midline\n shift with compression of right lateral ventricle. Pt was intubated in\n ED for hypoxia most likely related to cardiac dysfunction not neuro\n injury.\n Subdural hemorrhage (SDH)\n Assessment:\n Continues with Q2H neuro checks. When lightened from propofol patient\n will intermittently follow commands and open eyes. Moves all\n extremities with equal strength. PERLA.\n Action:\n Propofol weaned slightly (downto 20) and continuing Q2H neuro checks.\n Response:\n Intermittantly restless after stimulation. Seems to settle down\n quickly. Reoriented with neuro exams\n Plan:\n Continue to monitor neuro exam Q2, change to Q4? Repeat head CT for\n tomorrow to assess need for OR. Assess for pain, treat as needed.\n Continue to support pt and family.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Lung sounds clear/diminished. Remains orally intubated & vented on\n settings as charted.\n Action:\n PSV decreased as tolerated, O2 sat WNL. Pulmonary toileting, frequent\n repositioning, VAP care per protocol.\n Response:\n Pt tolerating vent wean thus far, strong cough/gag.\n Plan:\n Needs repeat head CT in am, will likely extubated post CT if surgery\n not indicated.\n" }, { "category": "Respiratory ", "chartdate": "2161-05-24 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 467923, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 2\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: 24 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: cmH2O\n Cuff volume: 8 mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: 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 Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated,\n Periodic SBT's for conditioning, Maintain PEEP at current level and\n reduce FiO2 as tolerated\n Reason for continuing current ventilatory support: Sedated / Paralyzed,\n Cannot protect airway, Cannot manage secretions, Underlying illness not\n resolved; Comments: Pt remains on full support with no spontaneous\n respirations, and stable on vent on current vent settings. Pt has\n clear lung sounds and required small amount of suctioning this shift.\n Pt is not responsive. Pt to be assessed by MD team for possible\n extubation.\n" }, { "category": "Nursing", "chartdate": "2161-05-25 00:00:00.000", "description": "Nursing Progress Note", "row_id": 468065, "text": "82yo female s/p fall on witnessed trip on curb, hit her face on\n the ground. Pt has hx of anemia, CAD/MI, stent placement, IVC filter,\n HTN, PE, GERD, anxiety/depression; on coumadin, ASA, plavix- INR 2.9.\n Injuries include: nasal fx and SDH with 8mm midline shift with\n compression of right lateral ventricle. Pt was intubated in ED for\n hypoxia most likely related to cardiac dysfunction not neuro injury.\n Subdural hemorrhage (SDH)\n Assessment:\n Pt continues on Q2 hr neuro checks, unchanged throughout the day/night.\n Pt lightly sedated on propofol-was restless, moving unsafely in bed in\n the evening. When sedation is lightened, pt does not follow commands,\n does not open eyes to voice, MAE\ns with adequate strength, localizes to\n pain. Pupils 3-4mm, briskly reactive, equal. Pt appears comfortable\n based on grimace scale even when restless. Goal MAP >80 to perfuse d/t\n cardiac history.\n Action:\n Propofol gtt increased to achieve adequate sedation for pt\n safety/comfort, HO aware. Lytes repleted. Pt restrained with 4 rails\n d/t brisk activity/turning on own in bed. MAP 80-90 with current\n sedation.\n Response:\n Pt appears more comfortable once propofol gtt increased, less restless,\n rested well throughout the night. Pt seems pain free throughout the\n shift. Pt tolerating current sedation, no need for pressors.\n Plan:\n Continue to monitor neuro exam Q2, change to Q4? Consider repeat CT\n scan today/ tomorrow? Assess for pain, treat as needed. Continue to\n support pt and family. SW consult recommended.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Lung sounds clear/diminished. Pt has ++oral secretions, small amount\n of secretions in lungs (tan, thick). Pt has +cough/gag. CPAP , 40%\n FiO2.\n Action:\n PSV decreased as tolerated, O2 sat WNL. Pulmonary toileting, frequent\n repositioning, VAP care per protocol.\n Response:\n Pt tolerating vent wean thus far, strong cough/gag.\n Plan:\n Daily AM CXR recommended since pt being diuresed, difficulty weaning\n off ventilation. Continue to support pt and family. SW consult\n recommended.\n" }, { "category": "Physician ", "chartdate": "2161-05-24 00:00:00.000", "description": "Intensivist Note", "row_id": 467916, "text": "SICU\n HPI:\n 82yo female who reports having tripped on the curb and falling. Hit her\n right side of face on the ground. Event reported to happen @ approx.\n 7:15pm on . Pts daughter witnessed event and brought her to OSH for\n evaluation, INR 2.97. Denies pain, acute respiratory decompensation in\n ED requiring intubation, found to have SDH.\n Chief complaint:\n head trauma\n PMHx:\n CAD s/p stent placement, filter, MI, PE, Mitral Regurg,\n GERD, Anxiety, Anemia, HOH\n Current medications:\n 24 Hour Events:\n TRANSTHORACIC ECHO - At 08:00 AM\n MULTI LUMEN - START 11:24 AM\n URINE CULTURE - At 06:20 PM\n FEVER - 101.6\nF - 04:00 AM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ciprofloxacin - 06:25 AM\n Infusions:\n Phenylephrine - 0.8 mcg/Kg/min\n Propofol - 25 mcg/Kg/min\n Other ICU medications:\n Famotidine (Pepcid) - 08:20 AM\n Metoprolol - 08:20 AM\n Fentanyl - 05:39 PM\n Other medications:\n Flowsheet Data as of 05:00 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.7\nC (101.6\n T current: 38.7\nC (101.6\n HR: 95 (60 - 96) bpm\n BP: 120/58(84) {97/36(2) - 165/73(112)} mmHg\n RR: 21 (10 - 25) insp/min\n SPO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 66 kg (admission): 62.3 kg\n Total In:\n 3,276 mL\n 520 mL\n PO:\n Tube feeding:\n IV Fluid:\n 2,022 mL\n 520 mL\n Blood products:\n 284 mL\n Total out:\n 1,520 mL\n 211 mL\n Urine:\n 1,190 mL\n 211 mL\n NG:\n 200 mL\n Stool:\n Drains:\n Balance:\n 1,756 mL\n 309 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 16\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 40%\n PIP: 27 cmH2O\n Plateau: 16 cmH2O\n Compliance: 50 cmH2O/mL\n SPO2: 98%\n ABG: 7.47/41/121/26/6\n Ve: 7.2 L/min\n PaO2 / FiO2: 303\n Physical Examination\n General Appearance: No acute distress, Well nourished\n HEENT: EOMI\n Cardiovascular: (Rhythm: Regular), (Murmur: Systolic), (Distant heart\n sounds: Absent)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: No(t)\n Resonant : ), (Breath Sounds: CTA bilateral : ), (Sternum: Stable )\n Abdominal: Soft, Non-distended, Non-tender\n Left Extremities: (Edema: Absent), (Temperature: Warm)\n Right Extremities: (Edema: Absent), (Temperature: Warm)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: Follows simple commands, (Responds to: Verbal stimuli),\n Moves all extremities, Sedated, GCS 10T\n Labs / Radiology\n 281 K/uL\n 8.3 g/dL\n 124 mg/dL\n 1.0 mg/dL\n 26 mEq/L\n 3.9 mEq/L\n 16 mg/dL\n 108 mEq/L\n 143 mEq/L\n 24.5 %\n 16.3 K/uL\n [image002.jpg]\n 05:42 AM\n 07:11 AM\n 07:22 AM\n 09:29 AM\n 11:16 AM\n 01:45 PM\n 04:01 PM\n 08:45 PM\n 01:13 AM\n WBC\n 12.7\n 16.3\n Hct\n 21.6\n 22.5\n 24.5\n 24.5\n Plt\n 290\n 281\n Creatinine\n 1.1\n 1.0\n TCO2\n 35\n 30\n 30\n 31\n 31\n Glucose\n 125\n 117\n 103\n 124\n Other labs: PT / PTT / INR:13.4/23.9/1.1, ALT / AST:, Alk-Phos / T\n bili:50/0.5, Differential-Neuts:77.3 %, Lymph:16.4 %, Mono:4.9 %,\n Eos:1.1 %, Lactic Acid:0.8 mmol/L, Albumin:3.6 g/dL, Ca:9.6 mg/dL,\n Mg:1.8 mg/dL, PO4:2.9 mg/dL\n Assessment and Plan\n AORTIC STENOSIS, SUBDURAL HEMORRHAGE (SDH)\n Assessment and Plan: 82F with SDH coumadin, stable neuro exam\n Neurologic: Neuro checks Q: 2 hr, sedation with propofol, repeat CT in\n AM, stable exam, no current indication for intervention, will discuss\n with neurosurgery\n Cardiovascular: PRN nitro paste + beta blocker for hypertension, keep\n MAP > 80 using neo if needed, holding ASA + Plavix for now, follow up\n final cardiology recs, has known A.S.\n Pulmonary: keep pCO2 35-40, HCO3 28-29, may wean to extubate in AM if\n no planned neurosurgical intervention and no CT or mental status\n changes\n Gastrointestinal / Abdomen: no acute issues\n Nutrition: NPO\n Renal: chronic respiratory acidosis with compensatory metabolic\n alkalosis now unmasked by relative hypocapnia\n Hematology: stable\n Endocrine: RISS\n Infectious Disease: Check cultures, febrile, known bacteriuria -\n followup repeat cultures may restart cipro, not septic\n Lines / Tubes / Drains: Foley, ETT, CVL, arterial line\n Wounds: Dry dressings\n Imaging: CT scan head today\n Fluids: NS, 75/hr\n Consults: Neuro surgery, Trauma surgery\n Billing Diagnosis:\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 07:00 AM\n 18 Gauge - 09:15 AM\n Multi Lumen - 11:24 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent:\n" }, { "category": "Respiratory ", "chartdate": "2161-05-25 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 468052, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 3\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n Tube Type\n ETT:\n Position: 24 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 28 cmH2O\n Cuff volume: 8 mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Tan / Thick\n Sputum source/amount: Suctioned / Moderate\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort:\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 Reduce PEEP as tolerated, Adjust Min. ventilation to control pH\n Reason for continuing current ventilatory support: Cannot protect\n airway, Cannot manage secretions, Underlying illness not resolved;\n Comments: Pt reamians stable on CPAP/PSV settings with changes made on\n vent to accommadate her respiratory drive. Pt has clear to diminished\n lung sounds and suctioned for small to moderate amounts of sputum. Pt\n is awake but responsiveness is weak. Pt to be assessed by MD team and\n to be continued on current support\n" }, { "category": "Physician ", "chartdate": "2161-05-23 00:00:00.000", "description": "Intensivist Note", "row_id": 467808, "text": "TSICU\n Chief complaint:\n Subdural hematoma\n HPI:\n HPI: 82yo female who reports having tripped on the curb and\n falling. Hit her right side of face on the ground. Event reported\n to happen @ approx. 7:15pm on . Pts daughter witnessed event\n and brought her to OSH for evaluation, INR 2.97. Denies pain. Head CT\n shows right-sided SDH with mild midline shift. Pt received FFP in ER\n with correction of INR to 1.2.\n PMHx:\n PMH: CAD s/p stent placement, filter, MI, PE, Mitral Regurg,\n GERD, Anxiety, Anemia, HOH\n Current medications:\n 1. 1000 mL NS 2. Bisacodyl 3. Calcium Gluconate 4. Chlorhexidine\n Gluconate 0.12% Oral Rinse 5. Docusate Sodium (Liquid)\n 6. Famotidine 7. Insulin 8. Magnesium Sulfate 9. Metoprolol Tartrate\n 10. Nitroglycerin Ointment 2%\n 11. Pneumococcal Vac Polyvalent 12. Potassium Chloride 13. Potassium\n Phosphate 14. Propofol 15. Senna\n 24 Hour Events:\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ciprofloxacin - 06:25 AM\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 08:20 AM\n Metoprolol - 08:20 AM\n Other medications:\n Flowsheet Data as of 11:34 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.9\nC (100.2\n T current: 37.9\nC (100.2\n HR: 69 (69 - 82) bpm\n BP: 131/42(72) {131/42(2) - 165/60(99)} mmHg\n RR: 19 (10 - 20) insp/min\n SPO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 1,966 mL\n PO:\n 20 mL\n Tube feeding:\n IV Fluid:\n 742 mL\n Blood products:\n 284 mL\n Total out:\n 0 mL\n 380 mL\n Urine:\n 250 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 1,586 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 18\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 25 cmH2O\n SPO2: 100%\n ABG: 7.48/39/159/30/6\n Ve: 7.3 L/min\n PaO2 / FiO2: 318\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular), (Murmur: Systolic) 4/6 SEM loudest\n in mitral area. No heave.\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Non-distended, Non-tender\n Left Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Posterior tibial: Present)\n Right Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Neurologic: Moves all extremities spontaneously with non-focal neuro\n exam.\n Labs / Radiology\n 290 K/uL\n 7.4 g/dL\n 117 mg/dL\n 1.1 mg/dL\n 30 mEq/L\n 3.2 mEq/L\n 23 mg/dL\n 100 mEq/L\n 141 mEq/L\n 22.5 %\n 12.7 K/uL\n [image002.jpg]\n 05:42 AM\n 07:11 AM\n 07:22 AM\n 09:29 AM\n WBC\n 12.7\n Hct\n 21.6\n 22.5\n Plt\n 290\n Creatinine\n 1.1\n TCO2\n 35\n 30\n Glucose\n 125\n 117\n Other labs: PT / PTT / INR:13.4/23.9/1.1, ALT / AST:, Alk-Phos / T\n bili:50/0.5, Differential-Neuts:77.3 %, Lymph:16.4 %, Mono:4.9 %,\n Eos:1.1 %, Lactic Acid:0.8 mmol/L, Albumin:3.6 g/dL, Ca:9.0 mg/dL,\n Mg:1.6 mg/dL, PO4:3.3 mg/dL\n Assessment and Plan\n SUBDURAL HEMORRHAGE (SDH)\n Assessment and Plan: 82 yo F s/ SDH on coumadin, plavix, asa and with\n increase interval size now with vent dependent respiratory failure\n Neurologic: 1- SDH with symmetric neuro exam despite midline shift -\n Neuro checks Q: 1 hr, - Initial increase in SDH size, now stabilized on\n third CT head\n - Neuro exam currently not unilateral- no indication for OR emergently\n - plan for repeat head CT in morning.\n Cardiovascular: - 1- Aortic stenosis\n use nitropaste an\\d beta blocker\n to enhance myocardial perfusion and reduce afterload. Will obtain\n cardiology consult to evaluate valve area and gradient. Bedside\n ultrasound/echo shows significant AS as well as moderate MR \nned leaflets c/w prior rheumatic disease but formal echo needed.\n 2- HTN here- use low dose beta blocker\n Pulmonary: 1- Vent-dependent respiratory insufficiency - Cont ETT, -\n plan to increase rate to decreased CO2, but complicated by admission\n ABGs consistent with chronic respiratory acidosis and likely COPD. To\n limit cerebral vasodilation, will try to keep CO2 35-45, and will treat\n the resulting\nmetabolic alkalosis\n-like state by using HCl to reduce\n bicarb. We\nll need to keep this in mind when we eventually try to\n extubate her by allowing her CO2 to rise prior to extubation.\n - likely COPD undiagnosed\n Gastrointestinal / Abdomen: - no aucte issues\n Nutrition: NPO\n Renal: 1- Probably euvolemic. - Foley, Adequate UO. 2- hypokalemic-\n will replete, mag >2 goal\n - has a pre-existing respiratory acidosis, will appear like a met\n alkalosis as we correct chronic resp acidosis\n Hematology: -hct 22, give 1 u prbcs- likely dilutional bc no other\n source bleed\n - s/p 1 uffp and profilnine- INR 1.2\n Endocrine: RISS, - no acute issues\n Infectious Disease: - no acute issues\n Lines / Tubes / Drains: Foley\n Wounds:\n Imaging: CT scan head today\n Fluids: NS\n Consults: Neuro surgery, Trauma surgery\n Billing Diagnosis: Closed head injury\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 20 Gauge - 05:32 AM\n Arterial Line - 07:00 AM\n 18 Gauge - 09:15 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 74 min\n Patient is critically ill\n" }, { "category": "Physician ", "chartdate": "2161-05-23 00:00:00.000", "description": "Intensivist Note", "row_id": 467804, "text": "TSICU\n HPI:\n HPI: 82yo female who reports having tripped on the curb and\n falling. Hit her right side of face on the ground. Event reported\n to happen @ approx. 7:15pm on . Pts daughter witnessed event\n and brought her to OSH for evaluation, INR 2.97. Denies pain.\n .\n Chief complaint:\n sepsis\n PMHx:\n PMH: CAD s/p stent placement, filter, MI, PE, Mitral Regurg,\n GERD, Anxiety, Anemia, HOH\n Current medications:\n 1. 1000 mL NS 2. Bisacodyl 3. Calcium Gluconate 4. Chlorhexidine\n Gluconate 0.12% Oral Rinse 5. Docusate Sodium (Liquid)\n 6. Famotidine 7. Insulin 8. Magnesium Sulfate 9. Metoprolol Tartrate\n 10. Nitroglycerin Ointment 2%\n 11. Pneumococcal Vac Polyvalent 12. Potassium Chloride 13. Potassium\n Phosphate 14. Propofol 15. Senna\n 24 Hour Events:\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ciprofloxacin - 06:25 AM\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 08:20 AM\n Metoprolol - 08:20 AM\n Other medications:\n Flowsheet Data as of 11:34 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.9\nC (100.2\n T current: 37.9\nC (100.2\n HR: 69 (69 - 82) bpm\n BP: 131/42(72) {131/42(2) - 165/60(99)} mmHg\n RR: 19 (10 - 20) insp/min\n SPO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 1,966 mL\n PO:\n 20 mL\n Tube feeding:\n IV Fluid:\n 742 mL\n Blood products:\n 284 mL\n Total out:\n 0 mL\n 380 mL\n Urine:\n 250 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 1,586 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 18\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 25 cmH2O\n SPO2: 100%\n ABG: 7.48/39/159/30/6\n Ve: 7.3 L/min\n PaO2 / FiO2: 318\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular), (Murmur: Systolic)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Non-distended, Non-tender\n Left Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Posterior tibial: Present)\n Right Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Neurologic: Moves all extremities\n Labs / Radiology\n 290 K/uL\n 7.4 g/dL\n 117 mg/dL\n 1.1 mg/dL\n 30 mEq/L\n 3.2 mEq/L\n 23 mg/dL\n 100 mEq/L\n 141 mEq/L\n 22.5 %\n 12.7 K/uL\n [image002.jpg]\n 05:42 AM\n 07:11 AM\n 07:22 AM\n 09:29 AM\n WBC\n 12.7\n Hct\n 21.6\n 22.5\n Plt\n 290\n Creatinine\n 1.1\n TCO2\n 35\n 30\n Glucose\n 125\n 117\n Other labs: PT / PTT / INR:13.4/23.9/1.1, ALT / AST:, Alk-Phos / T\n bili:50/0.5, Differential-Neuts:77.3 %, Lymph:16.4 %, Mono:4.9 %,\n Eos:1.1 %, Lactic Acid:0.8 mmol/L, Albumin:3.6 g/dL, Ca:9.0 mg/dL,\n Mg:1.6 mg/dL, PO4:3.3 mg/dL\n Assessment and Plan\n SUBDURAL HEMORRHAGE (SDH)\n Assessment and Plan: 82 yo F s/ SDH on coumadin, plavix, asa and with\n increase interval size now with vent dependent respiratory failure\n Neurologic: Neuro checks Q: 1 hr, - Initial increase in SDH size, now\n stabilized on third CT head\n - Neuro exam currently not unilateral- no indication for OR emergently\n - plan for repeat head CT in morning\n Cardiovascular: - htn here- use low dose beta blocker\n - would pefer nitro paste but cannot use since pre-load dependent (AS)\n - AS- not previously diagnosed, needs cards consult and echo\n - htn here- use low dose beta blocker\n - would pefer nitro paste but cannot use since pre-load dependent (AS)\n - AS- not previously diagnosed, needs cards consult and echo\n - htn here- use low dose beta blocker\n - would pefer nitro paste but cannot use since pre-load dependent (AS)\n - AS- not previously diagnosed, needs cards consult and echo\n Pulmonary: Cont ETT, - plan to increase rate to decreased CO2, pt\n likely with baseline resp acidosis\n - likely COPD undiagnosed\n Gastrointestinal / Abdomen: - no aucte issues\n Nutrition: NPO\n Renal: Foley, Adequate UO, -euvolemic, hypokalemic- will replete, mag\n >2 goal\n - has a pre-existing respiratory acidosis, will appear like a met\n alkalosis as we correct chronic resp acidosis\n Hematology: -hct 22, give 1 u prbcs- likely dilutional bc no other\n source bleed\n - s/p 1 uffp and profilnine- INR 1.2\n Endocrine: RISS, - no acute issues\n Infectious Disease: - no acute issues\n Lines / Tubes / Drains: Foley\n Wounds:\n Imaging: CT scan head today\n Fluids: LR\n Consults: Neuro surgery, Trauma surgery\n Billing Diagnosis: Closed head injury\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 20 Gauge - 05:32 AM\n Arterial Line - 07:00 AM\n 18 Gauge - 09:15 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer:\n VAP bundle:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent:\n Patient is critically ill\n" }, { "category": "Nursing", "chartdate": "2161-05-23 00:00:00.000", "description": "Nursing Progress Note", "row_id": 467758, "text": "82 year old woman who tripped on the curb and hit her head (while on\n coumadin, aspirin and plavix) and now with SDH and nasal fracture. Pt.\n intubated in ED for hypoxia. Repeat CT at shows increasing right\n sided SDH with a shift. INR corrected with ffp, vit K, factor 9\n PMH: s/p stent placement, MI, filter, htn,pe, gerd, anemia,\n anxiety.\n Subdural hemorrhage (SDH)\n Assessment:\n Sedated on propofol, when lightened, moves all extremities, perrla. BP\n 130-140, nsr. Last INR 1.2\n Action:\n Admitted at 05:45, transported to CT for repeat head CT, labs drawn,\n neuro assessment done. Family updated\n Response:\n Moving all extremities, await repeat inr results as well as repeat head\n CT results\n Plan:\n Hob 30, follow q 1 hour neuro exams, follow inr results,?? Need for\n dilantin\n" }, { "category": "Nursing", "chartdate": "2161-05-23 00:00:00.000", "description": "Nursing Progress Note", "row_id": 467872, "text": "HPI:\n HPI: 82yo female who reports having tripped on the curb and\n falling. Hit her right side of face on the ground. Event reported\n to happen @ approx. 7:15pm on . Pts daughter witnessed event\n and brought her to OSH for evaluation, INR 2.97. Denies pain. Head CT\n shows right-sided SDH with mild midline shift. Pt received FFP in ER\n with correction of INR to 1.2.\n PMHx:\n PMH: CAD s/p stent placement, filter, MI, PE, Mitral Regurg,\n GERD, Anxiety, Anemia, HOH\n Subdural hemorrhage (SDH) s/p fall \n Assessment:\n Pt sedated on propofol. When sedation lightened, pt MAEs and follows\n commands & nods head to questions inconsistently; occasionally mouthing\n word.. PERRL @ 3-4mm/brisk with positive corneal reflexes. Cough & gag\n are intact. No seizure activity noted. Intubated & vented on CMV with\n metabolic alkalosis & respiratory acidosis per ABG. serum\n potassium, magnesium, and calcium. HCT 21.5 Hemodynamics within\n acceptable range (MAP 80).\n Action:\n Q hour neuro checks\n Bedside TTE done by ICU fellow.\n Vent changes made & fio2 weaned: see metavision; abg\ns followed.\n Electrolytes repleted & monitored prn\n I unit PRBCs transfused.\n Pt daughters provided with condition updates and POC goals; all\n questions answered.\n Response:\n PERRL @ 3-4mm/brisk with positive corneal reflexes, positive cough &\n gag. Pt continues to MAEs equally against gravity, and open eyes to\n voice. Pt currently not actively following commands or nodding her head\n to questions; pt noted to mouth words:\nstop it\n when questions to\n follow commands made earlier. Propofol titrated to effect: pt restless\n and fidgety when lightened (pt has known h/o anxiety with ativan &\n Zoloft therapy daily). No seizure activity observed.\n TTE reported to show tight aortic stenosis and inferior wall motion\n abnormality; EF ~ 45% (pt with know RCA stent & HTN; pt assessed to\n need MAP ~ 80 to perfuse coronaries). ** Recent BP in low 100 systolic\n range with MAP dipping below 60. Fentanyl infusion ordered so propofol\n could be decreased; Neosynephrine ordered if needed to maintain BP\n within goal parameters with MAP ~ 80**\n FIO2 weaned to 40% with adequate PaO2 and saturations. RR increased\n then decreased per ABG values to maintain PCO2 35-40 and TCO2 25-30.\n Current settings are providing acceptable results.\n Electrolytes repleted & followed: see metavision & .\n Post transfusion HCT: 24.5\n Family demonstrates understanding of pt\ns condition and POC.\n Plan:\n Q 1 hour neuro checks\n Maintain MAP~ 80; utilize sedation, analgesia, vasopressors as needed.\n Monitor & replete electrolytes to wnl\n Follow ABG values and adjust ventilator settings to maintain desired\n goals (see above).\n Continue to orient and reassure pt and provide family updates and POC\n changes.\n" }, { "category": "Nursing", "chartdate": "2161-05-23 00:00:00.000", "description": "Nursing Progress Note", "row_id": 467881, "text": "HPI:\n HPI: 82yo female who reports having tripped on the curb and\n falling. Hit her right side of face on the ground. Event reported\n to happen @ approx. 7:15pm on . Pts daughter witnessed event\n and brought her to OSH for evaluation, INR 2.97. Denies pain. Head CT\n shows right-sided SDH with mild midline shift. Pt received FFP in ER\n with correction of INR to 1.2.\n PMHx:\n PMH: CAD s/p stent placement, filter, MI, PE, Mitral Regurg,\n GERD, Anxiety, Anemia, HOH\n Subdural hemorrhage (SDH) s/p fall \n Assessment:\n Pt sedated on propofol. When sedation lightened, pt MAEs and follows\n commands & nods head to questions inconsistently; occasionally mouthing\n words. PERRL @ 3-4mm/brisk with positive corneal reflexes. Cough & gag\n are intact. No seizure activity noted. Intubated & vented on CMV with\n metabolic alkalosis & respiratory acidosis per ABG. Low serum\n potassium, magnesium, and calcium. HCT 21.5 Hemodynamics within\n acceptable range (MAP 80). Malodorous urine; positive UA in ED, given\n cipro x1 dose.\n Action:\n Q hour neuro checks\n Bedside TTE done by ICU fellow.\n Vent changes made & fio2 weaned: see metavision; abg\ns followed.\n Electrolytes repleted & monitored prn\n I unit PRBCs transfused.\n Pt daughters provided with condition updates and POC goals; all\n questions answered.\n Urine culture sent.\n Response:\n PERRL @ 3-4mm/brisk with positive corneal reflexes, positive cough &\n gag. Pt continues to MAEs equally against gravity, and open eyes to\n voice. Pt currently not actively following commands or nodding her head\n to questions; pt noted to mouth words:\nstop it\n when questions to\n follow commands made earlier. Propofol titrated to effect: pt restless\n and fidgety when lightened (pt has known h/o anxiety with ativan &\n Zoloft therapy daily). No seizure activity observed.\n TTE reported to show tight aortic stenosis and inferior wall motion\n abnormality; EF ~ 45% (pt with know RCA stent & HTN; pt assessed to\n need MAP ~ 80 to perfuse coronaries). ** Recent BP in low 100 systolic\n range with MAP dipping below 60. Fentanyl infusion ordered so propofol\n could be decreased; Neosynephrine ordered if needed to maintain BP\n within goal parameters with MAP ~ 80**\n FIO2 weaned to 40% with adequate PaO2 and saturations. RR increased\n then decreased per ABG values to maintain PCO2 35-40 and TCO2 25-30.\n Current settings are providing acceptable results.\n Electrolytes repleted & followed: see metavision & .\n Post transfusion HCT: 24.5\n Family demonstrates understanding of pt\ns condition and POC.\n Foley is positional; urine is clear & yellow; 1 small clot noted. Foley\n irrigated- no obstruction note. Culture pending. T max 100.2\n Plan:\n Q 1 hour neuro checks\n Maintain MAP~ 80; utilize sedation, analgesia, vasopressors as needed.\n Monitor & replete electrolytes to wnl\n Follow ABG values and adjust ventilator settings to maintain desired\n goals (see above).\n Continue to orient and reassure pt and provide family updates and POC\n changes.\n" }, { "category": "Nursing", "chartdate": "2161-05-23 00:00:00.000", "description": "Nursing Progress Note", "row_id": 467737, "text": "82 year old woman who tripped on the curb and hit her head (while on\n coumadin, aspirin and plavix) and now with SDH and nasal fracture. Pt.\n intubated in ED for hypoxia. Repeat CT at shows increasing right\n sided SDH with a shift.\n PMH: s/p stent placement, MI, filter, htn,pe, gerd, anemia,\n anxiety.\n Subdural hemorrhage (SDH)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "ECG", "chartdate": "2161-06-07 00:00:00.000", "description": "Report", "row_id": 233047, "text": "Atrial fibrillation with a rapid ventricular response. Possible left\nventricular hypertrophy. Diffuse non-specific ST-T wave changes.\nCompared to the previous tracing atrial fibrillation is new and ST-T wave\nchanges are more marked.\n\n" }, { "category": "ECG", "chartdate": "2161-06-03 00:00:00.000", "description": "Report", "row_id": 233048, "text": "Sinus rhythm. Left ventricular hypertrophy. Compared to the previous tracing\nof the rhythm has changed.\n\n" }, { "category": "ECG", "chartdate": "2161-05-27 00:00:00.000", "description": "Report", "row_id": 233049, "text": "Atrial fibrillation with rapid ventricular response. Left ventricular\nhypertrophy with secondary ST-T wave changes. Compared to the previous tracing\nof no diagnostic interim change.\n\n" }, { "category": "ECG", "chartdate": "2161-05-22 00:00:00.000", "description": "Report", "row_id": 233050, "text": "Sinus rhythm. Occasional ventricular premature beats. Possible left\nventricular hypertrophy with repolarization change. No previous tracing\navailable for comparison.\n\n" }, { "category": "Radiology", "chartdate": "2161-06-03 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1087463, "text": ", K. MED FA2 3:36 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: 82 year old woman with SDH.\n Admitting Diagnosis: ACUTE SUBDURAL HEMATOMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old woman with SDH.\n REASON FOR THIS EXAMINATION:\n 82 year old woman with SDH.\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n PFI: Slight increase in midline shift from 11 mm, now 14 mm. More subfalcine\n herniation (2:17). More transtentorial herniation with effacement of the\n right ambient cistern (2:11). No new areas of hemorrhage. The size of\n right-sided subdural hematoma appears grossly stable. No new bleed.\n\n" }, { "category": "Radiology", "chartdate": "2161-05-22 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1085855, "text": " 11:31 PM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate for traumatic injury\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old woman with fall, hypoxic\n REASON FOR THIS EXAMINATION:\n evaluate for traumatic injury\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 82 year-old woman with fall onto face with multiple facial\n lacerations.\n\n COMPARISON: None.\n\n AP UPRIGHT CHEST: There is mild cardiomegaly. The lungs are clear without\n effusion, consolidation or pneumothorax. There is vascular engorgement\n without overt CHF. An IVC filter is incompletely imaged. The remaining upper\n abdomen is unremarkable. There is no displaced rib fracture.\n\n IMPRESSION: Vascular engorgement without overt CHF.\n\n" }, { "category": "Radiology", "chartdate": "2161-05-23 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1085856, "text": " 12:42 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Patient currently in . ET placement\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old women s/p intubation\n REASON FOR THIS EXAMINATION:\n Patient currently in . ET placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 82 year-old post-intubation.\n\n COMPARISON: 1 hour prior.\n\n AP UPRIGHT CHEST: The endotracheal tube terminates 4.5 cm above the carina.\n Nasogastric tube terminates in the mid stomach with the side port in the\n proximal stomach. Mild cardiomegaly persists. There is diffuse increased\n vascularity with a prominent right perihilar streaky opacity which is new\n since 1 hour prior. There is no effusion or pneumothorax.\n\n IMPRESSION:\n\n 1. Increased right perihilar opacity may represent worsening vascular\n engorgement (mild CHF) or aspiration pneumonia.\n\n 2. Endotracheal tube terminates 4.5 cm above the carina.\n\n" }, { "category": "Radiology", "chartdate": "2161-05-25 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1086148, "text": " 1:59 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: ? PNA, pulm edema\n Admitting Diagnosis: ACUTE SUBDURAL HEMATOMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old woman with critical aortic stenosis, subdural hematoma, now w\n respiratory distress on vent\n REASON FOR THIS EXAMINATION:\n ? PNA, pulm edema\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 82-year-old female with critical aortic stenosis, subdural\n hematoma now with respiratory distress. Evaluate for pneumonia and pulmonary\n edema.\n\n Single AP chest radiograph compared to nine hours prior shows increased right\n basilar opacity likely due to aspiration or pneumonia. Left retrocardiac\n opacity persists. The cardiomediastinal contour is stable. There are small\n bilateral pleural effusions. There is no pneumothorax. Left- sided central\n venous catheter tip terminates in the upper SVC. ET tube terminates 3.7 cm\n above the carina.\n\n IMPRESSION: Worsening right lower lobe pneumonia or aspiration.\n\n" }, { "category": "Radiology", "chartdate": "2161-05-24 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1085992, "text": " 6:29 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: evaluate for changes***Please do by 6a****\n Admitting Diagnosis: ACUTE SUBDURAL HEMATOMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old woman with SDH\n REASON FOR THIS EXAMINATION:\n evaluate for changes***Please do by 6a****\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CT OF THE HEAD WITHOUT CONTRAST\n\n INDICATION: Followup of subdural hemorrhage.\n\n COMPARISON: , 05:50.\n\n TECHNIQUE: Non-contrast head CT.\n\n FINDINGS: Large right convexity acute subdural hematoma is not significantly\n changed in size or configuration. Mass effect on subjacent sulci is stable,\n as is roughly 5 mm of leftward subfalcine herniation. Slight effacement of\n the right lateral ventricle is unchanged. Basilar cisterns remain intact.\n\n There is no sign of new intracranial hemorrhage. Slightly more subdural blood\n is seen along the right tentorium on current study, likely representing\n redistribution. Minimal layering hyperdensity in the occipital of the\n left lateral ventricle is unchanged. There is no sign of vascular territorial\n infarction. Visualized paranasal sinuses and mastoid air cells remain\n normally aerated.\n\n IMPRESSION: No significant interval change in right acute subdural hematoma,\n and associated mass effect and leftward subfalcine herniation.\n Close f/u as clinically indicated.\n\n" }, { "category": "Radiology", "chartdate": "2161-05-24 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1085996, "text": " 7:52 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess for pulm edema.\n Admitting Diagnosis: ACUTE SUBDURAL HEMATOMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old woman with SDH, AS, intubated, crackles.\n REASON FOR THIS EXAMINATION:\n assess for pulm edema.\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: AP chest, .\n\n HISTORY: 82-year-old woman with subdural hemorrhage. Assess for pulmonary\n edema.\n\n FINDINGS: Comparison is made to previous study from .\n\n The left-sided central venous catheter, endotracheal tube, nasogastric tube\n are unchanged in position. There has been worsening of the left hepatic\n opacity. There is some mild prominence of the pulmonary interstitial markings\n without overt pulmonary edema.\n\n\n" }, { "category": "Radiology", "chartdate": "2161-06-03 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1087462, "text": " 3:36 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: 82 year old woman with SDH.\n Admitting Diagnosis: ACUTE SUBDURAL HEMATOMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old woman with SDH.\n REASON FOR THIS EXAMINATION:\n 82 year old woman with SDH.\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): JMGw WED 8:39 PM\n PFI: Slight increase in midline shift from 11 mm, now 14 mm. More subfalcine\n herniation (2:17). More transtentorial herniation with effacement of the\n right ambient cistern (2:11). No new areas of hemorrhage. The size of\n right-sided subdural hematoma appears grossly stable. No new bleed.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: An 82-year-old woman with subdural hematoma.\n\n HEAD CT: Axial imaging was performed through the brain without IV contrast\n administration.\n\n COMPARISON: Head CT, .\n\n FINDINGS: There is a 14 mm of leftward shift of midline (2:14) where there\n was previously 11 mm leftward shift. There is increased subfalcine herniation\n (2:17). There is minimal change in the degree of transtentorial herniation\n (2:11). The frontal of the right lateral ventricle (2:11) appears more\n effaced and displaced than on the previous study. The size of the right-sided\n subdural hematoma with acute-on-chronic components appears grossly stable\n without new areas of hemorrhage. There are subinsular hypodensities on the\n left side, which appear stable, likely representing chronic infarcts. There\n is effacement of the sulci and gyri along the right convexity; however, sulci\n and gyral pattern along the left convexity appear stable. There is no\n evidence for uncal herniation. The osseous structures appear intact. The\n paranasal sinuses and the ethmoidal and mastoid air cells appear clear.\n\n IMPRESSION:\n 1. Increased leftward shift of midline structures, with increased subfalcine\n and stable transtentorial herniation. There is increased effacement of the\n frontal of the right lateral ventricle.\n 2. Stable appearance to right convexity subdural hematoma without evidence\n for new foci of hemorrhage.\n\n COMMENT: These findings were communicated by telephone to Dr. at\n 04:30 p.m. on .\n\n (Over)\n\n 3:36 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: 82 year old woman with SDH.\n Admitting Diagnosis: ACUTE SUBDURAL HEMATOMA\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2161-05-27 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1086396, "text": " 5:51 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for interval change\n Admitting Diagnosis: ACUTE SUBDURAL HEMATOMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old woman with PNA, prolonged vent dependence\n REASON FOR THIS EXAMINATION:\n eval for interval change\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 82-year-old female with pneumonia and prolonged ventilator\n dependence. Assess change.\n\n COMPARISONS: Several priors, most recent .\n\n PORTABLE AP CHEST: Left subclavian central venous catheter, endotracheal\n tube, and nasogastric tube are unchanged in position. The side port of the\n nasogastric tube is near the gastroesophageal junction, as before. The NG\n tube could be advanced further for optimal positioning. The cardiomediastinal\n contours are stable. Bibasilar opacities, left greater than right, are\n unchanged. The upper lungs are clear.\n\n IMPRESSION: No interval change. NG tube could be advanced 5-10 cm for\n optimal positioning.\n\n Findings discussed with Dr. on morning of by Dr. over\n the telephone.\n\n" }, { "category": "Radiology", "chartdate": "2161-05-25 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1086083, "text": " 5:40 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for pulm edema\n Admitting Diagnosis: ACUTE SUBDURAL HEMATOMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old woman with severe aortic stenosis, s/p fall w/ SDH, intubated, with\n wheezing\n REASON FOR THIS EXAMINATION:\n eval for pulm edema\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 82-year-old female with severe aortic stenosis status post fall\n with subdural hematoma. Evaluate for pulmonary edema.\n\n Single AP chest radiograph compared to show increased right\n peribronchial opacity. There is continued clearing of the left lower lobe\n opacity. There is no pneumothorax or pleural effusion. ET tube terminates 5.2\n cm above the carina. Left subclavian central venous catheter terminates in\n the mid SVC. NG tube enters the stomach, the tip has been excluded.\n\n IMPRESSION: Increased right peribronchial opacity, which may be due to edema\n or aspiration.\n\n" }, { "category": "Radiology", "chartdate": "2161-05-29 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1086764, "text": " 1:48 PM\n CHEST (PA & LAT) Clip # \n Reason: 82 year old woman with non-productive cough. Extubated recen\n Admitting Diagnosis: ACUTE SUBDURAL HEMATOMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old woman with non-productive cough. Extubated recently.\n REASON FOR THIS EXAMINATION:\n 82 year old woman with non-productive cough. Extubated recently.\n ______________________________________________________________________________\n FINAL REPORT\n CHEST\n\n HISTORY: Productive cough, extubated.\n\n PA and lateral views. Comparison with . There is interval\n improvement in bibasilar atelectasis or consolidation. Small bilateral\n pleural effusions are no longer apparent. The heart appears enlarged as\n before. The aorta is tortuous and calcified. Mediastinal structures are\n stable. A left subclavian catheter remains in place. A nasogastric tube has\n been withdrawn.\n\n IMPRESSION: Interval improvement in bibasilar atelectasis or consolidation,\n and pleural fluid.\n\n\n" }, { "category": "Radiology", "chartdate": "2161-05-23 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1085909, "text": " 12:00 PM\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \n Reason: central line placement\n Admitting Diagnosis: ACUTE SUBDURAL HEMATOMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old woman with right SDH\n REASON FOR THIS EXAMINATION:\n central line placement\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Central line placement.\n\n A single portable radiograph of the chest demonstrates interval placement of a\n left subclavian central venous catheter. The catheter tip is in the SVC. The\n remaining support lines are unchanged when compared with the chest radiograph\n obtained 12 hours prior. Increased airspace opacity involving both lungs\n persists. No effusion is detected. The aorta is calcified. No pneumothorax.\n Trachea is midline.\n\n IMPRESSION:\n\n Interval placement of left subclavian central venous catheter with catheter\n tip in the SVC. No pneumothorax. Remaining support lines are unchanged.\n\n Persistent airspace opacity involving both lungs, unchanged. Diagnostic\n considerations again include CHF.\n\n\n" }, { "category": "Radiology", "chartdate": "2161-05-23 00:00:00.000", "description": "CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST", "row_id": 1085862, "text": " 1:38 AM\n CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST Clip # \n Reason: S/P FALL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old woman with SDH on coumadin, not reversed presenting as transfer\n REASON FOR THIS EXAMINATION:\n eval for facial fractures\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: DXAe SAT 2:28 AM\n Minimally displaced nasal bone fx.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: An 82-year-old woman with right orbital and nasal and revelation\n of facial fractures.\n\n COMPARISON: None.\n\n TECHNIQUE: Non-contrast axial images were obtained through the facial bones.\n\n There is a mildly displaced comminuted nasal bone fracture. The paranasal\n sinuses and mastoid air cells are clear. There is minimal swelling over the\n right orbit without evidence of intraconal extension. The left orbit is\n grossly unremarkable except to note likely post-surgical changes. The orbits\n are intact without evidence of fracture at right subdural hematoma is better\n evaluated on concurrent CT head.\n\n IMPRESSION: Minimally displaced comminuted nasal bone fracture. No other\n evidence of acute fracture.\n\n Large right subdural hematoma is better evaluated on a concurrent CT head.\n\n\n" }, { "category": "Radiology", "chartdate": "2161-05-26 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1086256, "text": " 9:19 AM\n CHEST (PORTABLE AP) Clip # \n Reason: verify NG tube position, show diaphragm on film\n Admitting Diagnosis: ACUTE SUBDURAL HEMATOMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old woman with SDH, s/p placement of NG tube\n REASON FOR THIS EXAMINATION:\n verify NG tube position, show diaphragm on film\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: NG tube placement.\n\n FINDINGS: In comparison with the study of , the right hemidiaphragm is\n slightly better seen. Nevertheless, there is bibasilar opacification\n consistent with atelectasis, though _____.\n\n\n" }, { "category": "Radiology", "chartdate": "2161-05-23 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1085860, "text": " 1:37 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: S/P FALL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old woman with SDH on coumadin, not reversed presenting as transfer\n REASON FOR THIS EXAMINATION:\n eval for interval change of subdural\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: DXAe SAT 2:31 AM\n Increasing acute right subdural hematoma, now measuring up to 15 mm from the\n inner table with increasing mas effect and 8 mm midline shift. Short interval\n followup is recommended.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: An 82-year-old woman with subdural hematoma on Coumadin for\n evaluation of increasing size.\n\n CONTRAST CT HEAD: There is a large right acute subdural hematoma with high-\n density material which measures up to 15 mm from the inner table. The\n hematoma extends from temporal ro frontal and parietal regions. There is\n evidence of shift of normally midline structures as well as compression of the\n right lateral ventricle. There is no evidence of parenchymal hemorrhage. The\n ventricles and cisterns are normal in caliber. The paranasal sinuses and\n mastoid air cells are clear. The bony calvarium are intact.\n\n IMPRESSION: Right subdural hematoma with mild midline shift. Recommend short\n interval followup.\n\n Findings were discussed with Dr. by phone at the time of\n dictation.\n\n" }, { "category": "Radiology", "chartdate": "2161-05-23 00:00:00.000", "description": "CT C-SPINE W/O CONTRAST", "row_id": 1085861, "text": " 1:38 AM\n CT C-SPINE W/O CONTRAST Clip # \n Reason: S/P FALL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old woman with SDH on coumadin, not reversed presenting as transfer\n REASON FOR THIS EXAMINATION:\n eval for fracture or subluxation\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: DXAe SAT 2:28 AM\n No fx.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: -year-old woman on Coumadin with fall and ecchymoses over the\n right orbit nasal bone and lower lip, for evaluation of fractures.\n\n TECHNIQUE: Non-contrast axial images were obtained from the skull base to T1.\n\n There is no evidence of acute fracture or malalignment. Moderate multilevel\n degenerative changes worst at C5-6 and C6-7 are noted. The prevertebral soft\n tissues are grossly unremarkable. An endotracheal tube and a nasogastric tube\n are both noted. The imaged lung apices show atelectetic changes left upper\n lung incompletely evaluated. Small low density lesions are seen in right lobe\n of thyroid.\n\n IMPRESSION: No evidence of acute fracture or malalignment.\n\n" }, { "category": "Radiology", "chartdate": "2161-05-31 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1086942, "text": " 9:29 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: 82 year old woman with acute on chronic SDH.\n Admitting Diagnosis: ACUTE SUBDURAL HEMATOMA\n ______________________________________________________________________________\n FINAL ADDENDUM\n The official findings of the study were promptly discussed by Dr. \n with the neurosurgery team, . The patient has clinically improved\n despite the interval increase of SDH in the right cranial fossa, and the team\n opted for close interval observation at this point.\n\n\n 9:29 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: 82 year old woman with acute on chronic SDH.\n Admitting Diagnosis: ACUTE SUBDURAL HEMATOMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old woman with acute on chronic SDH\n REASON FOR THIS EXAMINATION:\n 82 year old woman with acute on chronic SDH.\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: ENYa SUN 11:38 AM\n Appearance of minimally increase left-sided SDH, effacement of right lateral\n ventricle, and leftward shift. The change can be partially secondary to the\n difference in technique, but cannot rule out small interval worsening of the\n known acute on chronic right SDH. No new hemorrhagic site.\n ______________________________________________________________________________\n FINAL REPORT (REVISED)\n HISTORY: An 82-year-old woman, with acute-on-chronic subdural hemorrhage,\n evaluate for interval change.\n\n COMPARISON: Multiple CT head without contrast, with the latest on .\n\n TECHNIQUE: Contiguous MDCT images were acquired through the brain without\n contrast.\n\n FINDINGS: Again noted is a large subdural hematoma overling the right\n convexity, mostly seen in the frontal region, but extending to the parietal\n region, measuring approximately 1.7 cm, and causing a midline shift of roughly\n 11 mm. The overall appearance suggests a mild interval mass effect, with\n possibly minimal increase of effacement of the right lateral ventricle and\n leftward shift; however, this could be secondary to the differences in\n technique between the studies. New acute hemorrhage cannot be excluded.\n However, this increased mass effect can be secondary to evolving vasogenic\n edema from the hemorrhage. There is no evidence of new hemorrhagic site.\n There is unchanged periventricular white matter hypodensity, consistent with\n chronic small vessel ischemic disease. The paranasal sinuses are clear. The\n mastoid air cells are clear. The underlying soft tissues are unremarkable.\n\n IMPRESSION: Appearance of minimal interval increase of mass effect from the\n known acute on chronic subdural hematoma on the right convexity. The\n difference between the studies can be secondary to technique, or evolving\n vasogenic edema from the known hemorrhage; cannot rule out interval small\n acute bleed.\n\n NOTE AT ATTENDING REVIEW: I believe the right middle cranial fossa portion of\n this subdural hemorrhage has increased in size, as has the degree of leftward\n subfalcine herniation. The more anterior portion of the subdural hemorrhage is\n less dense, however. Nevertheless, prompt review of this study by neurosurgery\n is advised.\n\n I spoke with Dr. , our resident who read this study, who will be contacting\n (Over)\n\n 9:29 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: 82 year old woman with acute on chronic SDH.\n Admitting Diagnosis: ACUTE SUBDURAL HEMATOMA\n ______________________________________________________________________________\n FINAL REPORT (REVISED)\n (Cont)\n neurosurgery.\n\n\n" }, { "category": "Radiology", "chartdate": "2161-05-29 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1086789, "text": " 5:34 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: pls assess tip of RUE 50cm PICC, call with wet read\n Admitting Diagnosis: ACUTE SUBDURAL HEMATOMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old woman with newly placed picc\n REASON FOR THIS EXAMINATION:\n pls assess tip of RUE 50cm PICC, call with wet read # \n ______________________________________________________________________________\n WET READ: RSRc FRI 5:59 PM\n New RUE PICC terminates at lower SVC, otherwise unchanged. 6p .\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 82-year-old woman after PICC placement.\n\n COMPARISON: at 13:51.\n\n AP PORTABLE CHEST: New right PICC terminates in the lower SVC. Otherwise,\n there is no appreciable change in the chest on this radiograph that does not\n include the left costophrenic sulcus. Mild central vasculature\n engorgement consistent with mild failure. There is mild atelectasis at the\n lung bases. Heart size remains mildly enlarged. Left subclavian central\n catheter tip unchanged in the upper SVC.\n\n" }, { "category": "Radiology", "chartdate": "2161-06-09 00:00:00.000", "description": "ABDOMEN U.S. (COMPLETE STUDY)", "row_id": 1088407, "text": " 10:33 AM\n ABDOMEN U.S. (COMPLETE STUDY); -59 DISTINCT PROCEDURAL SERVICE Clip # \n DUPLEX DOPP ABD/PEL\n Reason: Source of RUQ tenderness, liver enlargement?, reduced flow i\n Admitting Diagnosis: ACUTE SUBDURAL HEMATOMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old woman with subdural bleed, s/p craniotomy with AF. Transaminitis\n (100s-300s) developed over 48 hrs. Tender RUQ. Likely drug reaction, but query\n ischemic.\n REASON FOR THIS EXAMINATION:\n Source of RUQ tenderness, liver enlargement?, reduced flow in hepatic/portal\n veins? (Doppler).\n ______________________________________________________________________________\n FINAL REPORT\n ABDOMEN ULTRASOUND\n\n COMPARISON: None.\n\n HISTORY: Right upper quadrant tenderness with transaminitis. Patient is\n status post subdural bleed with craniotomy.\n\n FINDINGS: The liver demonstrates normal echotexture. There are no focal\n liver lesions identified. A 3-mm calcification near the porta hepatis within\n the liver is identified. The pancreas is unremarkable. The tail is obscured\n by overlying bowel gas. There is no intrahepatic or extrahepatic biliary\n dilatation. The common bile duct measures 2 mm. The portal vein is patent\n with normal hepatopetal flow. There is a small right pleural effusion. The\n gallbladder demonstrates mild gallbladder wall edema likely due to third\n spacing. There is no evidence of stones.\n\n There is appropriate color flow and waveforms within the right, left, and\n middle hepatic vein, IVC, main hepatic arteries and right and left portal\n veins.\n\n The right kidney measures 10.8 cm. The left kidney measures 9.8 cm. The\n spleen measures 8.4 cm. There is no evidence of hydronephrosis, renal masses,\n or renal calculi. The abdominal aorta demonstrates mild-to-moderate amount of\n atherosclerotic calcifications. There is no focal aneurysm identified.\n\n IMPRESSION:\n\n 1. Normal Doppler study.\n\n 2. Small right pleural effusion.\n\n 3. Mild calcifications of the abdominal aorta, without aneurysmal dilatation.\n\n 4. Calcified granuloma within the liver.\n\n (Over)\n\n 10:33 AM\n ABDOMEN U.S. (COMPLETE STUDY); -59 DISTINCT PROCEDURAL SERVICE Clip # \n DUPLEX DOPP ABD/PEL\n Reason: Source of RUQ tenderness, liver enlargement?, reduced flow i\n Admitting Diagnosis: ACUTE SUBDURAL HEMATOMA\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2161-06-05 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1087839, "text": " 8:07 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: 82 year old woman s/p right frontal craniotomy SDH drainage.\n Admitting Diagnosis: ACUTE SUBDURAL HEMATOMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old woman s/p right frontal craniotomy SDH drainage. please evaluate\n for acute post op bleed, please perform within 4hrs.\n REASON FOR THIS EXAMINATION:\n 82 year old woman s/p right frontal craniotomy SDH drainage. please evaluate\n for acute post op bleed, please perform within 4hrs.\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Patient is an 82-year-old female status post right frontal\n craniotomy for subdural hemorrhage. Please evaluate for acute postoperative\n bleed performed within four hours.\n\n EXAMINATION: Non-contrast head CT.\n\n COMPARISONS: Comparison to non-contrast head CT from .\n\n TECHNIQUE: Contiguous axial images were obtained through the brain. No\n intravenous contrast was administered.\n\n FINDINGS: The patient is status post right frontal craniotomy with interval\n drainage of previously noted subdural hemorrhage. There are expected\n postoperative changes with extensive pneumocephalus adjacent to the right\n frontal lobe. No acute hemorrhage, edema, masses, or acute infarction. The\n -white matter differentiation is preserved. There is persistent mass\n effect with a 9 mm leftward midline shift, slightly improved since examination\n from . There is improvement in previously noted transtentorial\n herniation best seen on (2A:12). There is persistent effacement of the right\n lateral ventricle though there is interval improvement since examination from\n with the frontal demonstrating increased patency. There is a\n stable appearance of subinsular hypodensity which likely represent areas of\n chronic infarction. The -white matter differentiation is preserved. There\n is a right frontal cephalohematoma that is likely post-surgically related. The\n visualized portions of the mastoid air cells and paranasal sinuses are well\n aerated.\n\n IMPRESSION: Status post evacuation of right frontal subdural hematoma with\n improvement in mass effect with reduction in subfalcine herniation with an\n improvement in leftward midline shift, now 9 mm. No evidence of acute\n hemorrhage.\n\n" }, { "category": "Radiology", "chartdate": "2161-06-08 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1088227, "text": " 10:19 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: Rebleed of right sided subdural s/p craniotomy\n Admitting Diagnosis: ACUTE SUBDURAL HEMATOMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old woman s/p craniotomy for subdural. Mental status and neuro exam\n change this morning\n REASON FOR THIS EXAMINATION:\n Rebleed of right sided subdural s/p craniotomy\n CONTRAINDICATIONS for IV CONTRAST:\n Renal insufficiency and poor PO. Has not been fluid loaded or given bicarb or NAC.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Patient is an 80-year-old woman, status post recent craniotomy for\n subdural hematoma, now with mental status changes and neuro exam changes this\n morning; study performed to assess rebleed of right-sided subdural.\n\n TECHNIQUE: Contiguous axial images were obtained through the brain, and no\n contrast was administered.\n\n COMPARISON STUDY: , non-contrast head CT.\n\n FINDINGS: Compared to the previous study, there is inprovement in left\n midline herniation. The subdural fluid collection is stable in size. The\n skull shows changes consistent with right-sided craniotomy. There is right-\n sided scalp swelling over the site of the craniotomy, unchanged from the\n previous study. There is marked decrease in pneumocephalus compared with\n previous study. There is small vessel ischemic disease in the left frontal\n lobe. The ventricles are stable in size.\n\n IMPRESSION: Status post right craniotomy for evacuation of right frontal\n subdural hematoma, now with improvement of midline shift, now only 4 mm in\n leftward direction. There is no evidence of an acute hemorrhage.\n\n" }, { "category": "Radiology", "chartdate": "2161-06-10 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1088709, "text": " 11:01 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: S/P CRANI\n Admitting Diagnosis: ACUTE SUBDURAL HEMATOMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old woman with CAD, Afib, s/p craniotomy on SDH from a fall.\n With new onset left arm weakness.\n REASON FOR THIS EXAMINATION:\n please evaluate her for acute intracranial process\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): 12:40 AM\n 1. Stable leftward shift of midline with stable right subdural collection.\n No new areas of hemorrhage.\n 2. If there is concern for acute ischemia, MRI would be more sensitive for\n evaluation.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 82-year-old woman with status post craniotomy secondary to a\n subdural hematoma from a fall. Now with new onset left arm weakness. Evaluate\n for acute intracranial process.\n\n HEAD CT: Axial imaging was performed through the brain without IV contrast.\n\n COMPARISON: CT head .\n\n FINDINGS: There is stable 3-mm leftward shift of normally midline structures.\n There is unchanged appearance to a linear area of hyperdensity along the right\n frontal convexity as well as a hypodense subdural fluid collection along the\n right calvarium, unchanged. The size and configuration of the ventricles\n appears stable. The basilar cisterns are widely patent without evidence for\n herniation. There are hypodensities in the periventricular or subinsular\n white matter bilaterally consistent with small vessel ischemic disease and\n chronic microvascular changes. -white matter differentiation is well\n preserved and there is no sign of acute vascular territorial infarction.\n Patient is status post right frontal craniotomy with interval resolution of\n pneumocephalus and decreased soft tissue swelling along the right\n frontoparietal scalp. Otherwise, osseous structures remain intact. Paranasal\n sinuses, ethmoid, and mastoid air cells are clear. There is calcification of\n bilateral carotid siphons and bilateral vertebral arteries.\n\n IMPRESSION:\n 1. Stable leftward shift of midline with stable right subdural collection. No\n new areas of hemorrhage.\n 2. If there is concern for acute ischemia, MRI would be more sensitive for\n evaluation.\n\n (Over)\n\n 11:01 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: S/P CRANI\n Admitting Diagnosis: ACUTE SUBDURAL HEMATOMA\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2161-06-10 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1088710, "text": ", B. MED FA6A 11:01 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: S/P CRANI\n Admitting Diagnosis: ACUTE SUBDURAL HEMATOMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old woman with CAD, Afib, s/p craniotomy on SDH from a fall.\n With new onset left arm weakness.\n REASON FOR THIS EXAMINATION:\n please evaluate her for acute intracranial process\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n 1. Stable leftward shift of midline with stable right subdural collection.\n No new areas of hemorrhage.\n 2. If there is concern for acute ischemia, MRI would be more sensitive for\n evaluation.\n\n" }, { "category": "Radiology", "chartdate": "2161-05-23 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1085882, "text": " 5:50 AM\n CT HEAD W/O CONTRAST; -76 BY SAME PHYSICIAN # \n Reason: Interval comparison Please do for 6:00am\n Admitting Diagnosis: ACUTE SUBDURAL HEMATOMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old woman with acute rt SDH\n REASON FOR THIS EXAMINATION:\n Interval comparison Please do for 6:00am\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: DXAe SAT 6:27 AM\n Minimally increased size and midline shift of right convexity subdural\n hematoma without evidence of herniation.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: For followup of right acute subdural hematoma.\n\n COMPARISON: Four hours prior.\n\n NON-CONTRAST CT HEAD: There is a large subdural hematoma covering the entire\n right convexity, which measures up to 2 cm from the inner table, which causes\n 6 mm shift of normally midline structures, unchanged since . There is\n mild compression of the right lateral ventricle without evidence of subfalcine\n or uncal herniation. The bony calvarium is intact. The paranasal sinuses and\n mastoid air cells are clear.\n\n IMPRESSION: Increased size of right subdural hematoma and minimally increased\n midline shift without evidence of herniation.\n\n" }, { "category": "Radiology", "chartdate": "2161-05-26 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1086223, "text": " 4:47 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: eval for progression / evolution of right acute on chronic s\n Admitting Diagnosis: ACUTE SUBDURAL HEMATOMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old woman with right sdh\n REASON FOR THIS EXAMINATION:\n eval for progression / evolution of right acute on chronic sdh. Please perform\n CT at 05:00 on . Thx!\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n EXAM: CT of the head without contrast, .\n\n INDICATION: Please evaluate for progression or evolution of right acute on\n chronic subdural hemorrhage.\n\n COMPARISON: Multiple priors, most recently at 06:48.\n\n TECHNIQUE: Non-contrast head CT.\n\n FINDINGS: Right convexity acute on chronic subdural hematoma is again not\n significantly changed in configuration, and may be slightly decreased in size,\n now measuring 13 mm in greatest AP dimension. Mass effect on subjacent sulci\n is not significantly changed. Leftward subfalcine herniation has minimally\n decreased, now 3 mm (previously 5 mm). Effacement of the occipital of\n the right lateral ventricle is unchanged. Basal cisterns remain intact.\n\n There is no new intracranial hemorrhage. Two tiny foci of extra-axial\n hyperdensity overlying the left occipitoparietal cortex (2, 16 and 2, 17) are\n unchanged. Hyperdensity in the occipital of the left lateral ventricle\n is unchanged.\n\n IMPRESSION: Minimal decrease in size of right convexity acute on chronic\n subdural hematoma, associated mass effect, and leftward subfalcine herniation.\n Continued followup as clinically indicated.\n\n NOTE ON ATTENDING REVIEW: It is equivocal whether any meaningful interval\n change is present.\n\n DFDkq\n\n" }, { "category": "Radiology", "chartdate": "2161-05-28 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1086569, "text": " 6:12 AM\n CHEST (PORTABLE AP) Clip # \n Reason: f/u VAP\n Admitting Diagnosis: ACUTE SUBDURAL HEMATOMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old woman with vent acquired PNA, now extubated\n REASON FOR THIS EXAMINATION:\n f/u VAP\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Ventilator-acquired pneumonia, now extubated.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, the patient has now been\n extubated. The nasogastric tube is still in place. Unchanged superior vena\n cava filter and left-sided central venous access line. Unchanged moderate\n cardiomegaly, the retrocardiac lung areas and the medial basal right-sided\n lung appears slightly denser than before, presumably caused by atelectasis.\n Otherwise, no newly occurred focal parenchymal opacities are seen. Blunting\n of the left costophrenic sinus could suggest the presence of a minimal\n pneumothorax. The mediastinal contours are unremarkable.\n\n\n" } ]

[ { "category": "Echo", "chartdate": "2148-12-09 00:00:00.000", "description": "Report", "row_id": 79961, "text": "PATIENT/TEST INFORMATION:\nIndication: Endocarditis.\nHeight: (in) 70\nWeight (lb): 250\nBSA (m2): 2.30 m2\nBP (mm Hg): 111/69\nHR (bpm): 104\nStatus: Inpatient\nDate/Time: at 11:31\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: Definity\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT ATRIUM: 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. Normal interatrial septum. No ASD\nby 2D or color Doppler.\n\nLEFT VENTRICLE: Mild symmetric LVH. Moderately dilated LV cavity. Severe\nglobal LV hypokinesis. No LV mass/thrombus. No resting LVOT gradient.\n\nRIGHT VENTRICLE: RV function depressed.\n\nAORTA: Normal aortic root diameter. Normal ascending aorta diameter.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR. No masses or\nvegetations on aortic valve.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. No mass or\nvegetation on mitral valve. Moderate (2+) MR. LV inflow pattern c/w\nrestrictive filling abnormality, with elevated LA pressure.\n\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. No mass or\nvegetation on tricuspid valve. Moderate [2+] TR. Moderate PA systolic\nhypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with\nphysiologic PR.\n\nPERICARDIUM: No pericardial effusion.\n\nConclusions:\nA pacemaker lead is seen in the RA/RV. No large mass/vegetation is seen on the\nlead (cannot exclude). The left atrium is moderately dilated. No atrial septal\ndefect is seen by 2D or color Doppler. There is mild symmetric left\nventricular hypertrophy. The left ventricular cavity is moderately dilated.\nThere is severe global left ventricular hypokinesis. No masses or thrombi are\nseen in the left ventricle. Right ventricular systolic function appears\ndepressed. The aortic valve leaflets (3) appear structurally normal with good\nleaflet excursion and no aortic regurgitation. No masses or vegetations are\nseen on the aortic valve. The mitral valve leaflets are mildly thickened.\nThere is no mitral valve prolapse. No mass or vegetation is seen on the mitral\nvalve. Mild to moderate (2+) mitral regurgitation is seen. The tricuspid valve\nleaflets are mildly thickened. Moderate [2+] tricuspid regurgitation is seen.\nThere is moderate pulmonary artery systolic hypertension. There is no\npericardial effusion.\n\nCompared with the prior study (images reviewed) of , no change.\n\n\n" }, { "category": "ECG", "chartdate": "2148-12-10 00:00:00.000", "description": "Report", "row_id": 210222, "text": "Sinus rhythm\nVentricular premature complexes with couplets and 3 beat run, rate 104\nPrior apicolateral myocardial infarction\nSince previous tracing of , no significant change\n\n" }, { "category": "ECG", "chartdate": "2148-12-08 00:00:00.000", "description": "Report", "row_id": 210224, "text": "Sinus rhythm. The sinus rhythm is interrupted by runs of wide complex rhythm at\napproximately the same rate as the sinus mechanism. The ectopic rhythm does not\ninterfere with the sinus node suggesting this is an idioventricular rhythm.\nThis a new finding since the previous tracing of .\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2148-12-07 00:00:00.000", "description": "Report", "row_id": 210225, "text": "Sinus tachycardia. Since the previous tracing of the rate is more\nrapid. There is no other significant change.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2148-12-09 00:00:00.000", "description": "Report", "row_id": 210223, "text": "Sinus rhythm\nVentricular premature complex\nPrior apicolateral myocardial infarction\nSince previous tracing of , ventricular ectopy absent\n\n" }, { "category": "Nursing/other", "chartdate": "2148-12-10 00:00:00.000", "description": "Report", "row_id": 1294797, "text": "3PM-7PM Nsg Progress Note\nsee Nsg transfer note written @ 3:30 pm (days)\n\nCV: bp stable 115/63, HR 80's SR w/ occ to frequent PVC's, no runs noted. pt started on Amiodarone HCL 400 mg po bid x 7 days, then change to 400 mg qd on D8. Metoprolol increased to 50 mg po bid, on , no edema, +pulses.\n\nRESP: on 2 l n/p P2 sats 98% lungs clear bilat.\n\nGI: diet changed to regular, pt w/ good appetite. on 1500 cc fluid restriction. no stool.\n\nGU: foley intact, draining clear, yellow urine.\n\nSKIN: left shoulder dsg changed, no drainage, site looks clean, NS wet to dry (change tid) Ortho to aspirate left shoulder this evening.\n\nACCESS: intern removed right femoral A-line, and venous line, pressure held, dsd applied, no bleeding from site. per Cardiology, pt to keep right leg straight for 4 hrs, HOB @ 30 degrees. pt with one peripheral line.\n\nID: afebrile. on Gent, Vanco, Flagyl po. check Vanco level at 12 midnight.\n\n\nPLAN: Ortho to aspirate left shoulder. XRAY to take left shoulder XRAY at bedside. continue antibx, monitor CV status. pt called out to floor (transfer note done)\n" }, { "category": "Nursing/other", "chartdate": "2148-12-09 00:00:00.000", "description": "Report", "row_id": 1294793, "text": "CCU NPN 1900-0700\n\nS/O: 38 y/o male w/ sig. cardiac hx. Now w/ infected aicd pocket.\nNeuro: Alert & Oriented x3, becomes lethargic but arousable w/ temp increase.\nCV: NSR hr 91, bp 104/68 (76). Amio off, no VT/. To have Echo in AM.\nResp: LSCTA, strong cough! No productive sputum. O2 sat 95 % RA, periods of apnea when sleep. O2 sat drop to low 90's-80's.\nGI: NPO after MN for OR. Vomitted x1 after strong cough. Denies nausea.\nGU: voiding w/ urinal.\nID: Triple IVABX: Flagyl, Vanco, Gentamycin. Temp max this shift 102.7. Treated w/ tylenol q4hrs. Pt spiking temps through Tylenol. Replaced cooling blanket (under upper torso for pt comfort).\n+ bld cx's from previous shift as well as osh.\n\nA: Infected aicd, febrile on abx and tylenol. + blood cx's. BP stable. Cooling blanket effective in bringing down temp's. No Ectopy. + sleep apnea.\n P: OR in am to remove icd and wires. Echo prior to OR. Treat temp, IV ABX, tylenol, cooling device.\n\n" }, { "category": "Nursing/other", "chartdate": "2148-12-09 00:00:00.000", "description": "Report", "row_id": 1294794, "text": "CCU NSG NOTE: ALT IN CV/INFECTED AICD\nS: \"That shoulder is really sore.\"\nO: For complete VS see CCU flow sheet.\nThis 38y old male with extensive cardiac PMH including 6 MI's,CABG,multiple caths- last cath , EF 25%, inducible VT with 2 syncopal episodes and AICD placement , transfered in from OSH with infected AICD pouch and high fevers. He has been on IV ABX since and went to OR for removal of AICD and wires.\nCV: Pt went to OR at ~1230. He had AICD and all wires removed. A large amt of pus came from site when opened and wound was not closed. He will be receiving NS wet to dry dsgs TID to start at 0100 tonight. He went into a-fib during OR and was cardioverted. He recieved 1200cc fluid and started wheezing upon arriving here.\nID: Pt remains febrile, up to 102.2 Oral post OR. He received tylenol and conts on triple ABX. BC sent.\nCV: HR in 120s intially now down to 90s with increasing amts of VEA-runs of VT in low 100s. Lytes sent early. BP 100-150/50-60s. Both arterial and venous sheaths remain in R groin. THe site is clean and dry. Sheaths will remain in over night. DP on R dopplerable, all other pulses palpable. Feet are warm, CSM nl. Dsg on old AICD site clean and dry. Area around wound reddened and tender.\nRESP: Pt extubated before returning to CCU. Pt intially had exp wheezes, but since neb his breath sounds are clear and he is sating 98% on 4L NP. Gas upon returning was 7.38/ 33/ 87/ -4.\nGI: Pt had light dinner and tolerated it well. He remains very thirsty and drinking lg amts.\nRENAL: Pt received 40mg lasix in OR at ~1500 and diureses well. He still remains ~350cc pos for the day. Urine clear.\nENDO: Finger stick 80 at 1700.\nCOMFORT: Pt c/o of infection site pain in am and received dilaudid 2mg po with good results. Since returning he has been sleeping when not stimulated and has not required further pain med.\nMS: Pt A & O X 3, pleasant and cooperative. Of note pt want his roomate and close friend to be his next of and it has been so changed thru admitting. Pt wants any information requested to be given to his friend.Health care proxy will be discussed with pt tomorrow.\nA: Stable post AICD removal.\nP: Monitor for ectopy. CHeck results of lytes. Follow results of cultures. Assist pt with position changes. Keep careful I & O and diuress as necessary. ANalgesia for pain.\n\n" }, { "category": "Nursing/other", "chartdate": "2148-12-09 00:00:00.000", "description": "Report", "row_id": 1294795, "text": "Nursing Progress Note 0700-1900\nS: \"My shoulder is killing me\"\n\nO: Please see admit note and flowsheet for complete objective data.\n\nCV: Pt had infected AICD removed in OR today. Pt went into A-fib and was cardioverted. Pt in NSR c many episodes of VEA. NSVT lasting ~30sec. HR 90-100's, SBP 100-120's. Gave 12.5 metoprolol.\n\nResp: RR teens-20's, exp wheezes, gave flovent inhaler. strong cough.\n\nGI/GU/Endo: on Full liq diet, taking po's well. foley draining CYU, had lasix @ 1500. gave 4u reg ins per ss for FS 244.\n\nID/Skin: temp 99.5, gave tylenol 650mg @ . Rec'd PM doses of Vanco/gent/flagyl. Gent and Vanco troughs sent. Lactate 1.1.\n\nNeuro/social: A&O x 3, copp with care. Has pain in Left chest r/t wound. gave dilaudid 2mg po @ c effect. sleepy, but maintaining SBP. Pt does not have HCP, but allows his friend to receive information. Has 9yo daughter that lives c his sister, does not want them contact.\n\nA/P: Follow labs and replete lytes. Monitor tele-?amio. wet to dry dressing this evening-TID. Emotionally support pt and keep updated on plan\n" }, { "category": "Nursing/other", "chartdate": "2148-12-08 00:00:00.000", "description": "Report", "row_id": 1294791, "text": "CCU NPN 1900-0700\n\n38 y/o male w/ sig. cardiac hx, including: 6 MI's from past cocaine use, CM w/ EF 20-25%, CABG x2, occ svg to Rpda, VT, PM upgraded to BiV . Presents w/ infected ICD Pocket. See admit note or full detail.\n\nS/O:\nArrived to unit lethargic and febrile, responding to voice, oriented x3. Pt would c/o pain , but then fall asleep.\n\nID: Temp 104.8 on rectal temp. Pt diaphoretic. Rec'd one gm of tylenol in EW. Cooling blanket applied. Gent given in ew. Next dose at , to start q8hrs. Vanco q12hrs. Blood cx's sent in ew. Temp down to 98.6 po at 0200-0230, pt more alert & conversive c/o being to cold. Tylenol given 650mg, cooling blanket removed. Temp 101.7 po at 0500. Vanco hung. AICD pocket red and inflammed. Lactate 1.5. WBC 13.5.\n\nCV: Wide complex ST, w/ Frequent PVC's. On Amio gtt at .5mg/min (started at 00). BP 118/78 (86). Trop and CK flat. Repeat K 4.4. Mag 1.7, repleted w/ 2gm.\n\nResp: LS cta upper, decreased bs at bases. O2 Sat 97 on 4lnc. Occ drop in sat w/ sleep apnea. No cough/no distress.\n\nGI/GU: creat 1.1, bun 9. voided x1 w/ urinal 600cc.\n\nSkin: No open areas, psoariasis areas.\n\nA: Febrile, not responsive to tylenol thus far. Cooling blanket w/ good effect. Bld cx's pending, on iv abx. No VT on Amio gtt. BP stable, Lactate wnl.\nP: Iv Abx, Control Fever w/ tylenol and cooling blanket, EP to remove icd on Monday. Amio gtt, Monitor for VT. Check w/ team on D/C time.\n\n" }, { "category": "Nursing/other", "chartdate": "2148-12-08 00:00:00.000", "description": "Report", "row_id": 1294792, "text": "CCU NPN: MICU border see flowsheet for objective data\n\nCardiac: EP examined pt early am recommended d/c amiodorone which was done. HR 84-110 NSR- ST rare to occ PVC's. BP 87-116/66-78 lopressor 12.5 and dig .0125 started on both at home.\n\nResp: rr 4-20 when sleeping deeply has periods of apnea. sats 93-99 on RA,occ wears 2l NP.\n\nID: 2 blood culture bottles +gram positive clusters.temp down to as low as 97.9 then increased to 101.6 now 101.5.received tylenol at 10 and 3pm. flagyl started at 12 and to receive gent at 8pm.\n\nPain: c/o left CP stabbing and received dilaudid 2 mg twice last time at 5pm. has also c/o stabbing head pain when he coughs.\n\nGU: voiding 350-400cc at a time. +470\n\nGI: +BS, drinking lot of fluids and at some for dinner,NPO after midnight\n\nEndocrine: blood sugar in 200's started on SSI covered at 12 for FS 227 then 141 at 5pm.\n\nNeuro: sleeping quite deeply most of day,needing a loud voice and some stimulation to wake up. alert and oriented x3 when awake.\n\nA/P: infected ICD pocket with + blood cultures. echo in am then OR late morning/early afternoon for removal of ICD and pacer.cont to closely follow temps,tylenol q4 and abx.\n" }, { "category": "Nursing/other", "chartdate": "2148-12-11 00:00:00.000", "description": "Report", "row_id": 1294798, "text": "NPN 7p-7a\nNEURO: Pt has been alert and oriented x3. Pt slept most of shift. Pt has been medicated Q2-4H with Dilaudid for incisional/shoulder pain. Pt is pleasant and cooperative with care, MAE ad lib but needs help with turning.\n\nCV: NSR 80s, with frequent ectopy. Runs of PVCs and vent trigeminy observed. BP 90s/60s with MAPs >60, lower BP probably pain meds. Palpable pulses bilaterally. Old AICD site in LUQ clean with pink tissue, small amount of serous dng. DSD changed. Right groin angio site is clean and dry, no bleeding observed.\n\nRESP: Sats 96-98% on 2L NC. LS coarse in upper, diminshed in lower. RR 20s. Pt has junky productive cough.\n\nGI/GU: ABD is softly distended, +BS. Pt has good appetite, tolerating house diet well. No BM this shift. U/O ample 50-160cc/hr. Pt on 1500cc/day fluid restriction. Pt covered on ss insulin, no coverage needed this shift.\n\nID: Pt has been afebrile. Covered on Gentamycin, Vanco, and Flagyl.\n\nSOCIAL: No contacts overnight.\n\nPLAN: Pt is c/o and awaiting a bed. Continue to monitor HR/BP. DSG changes. Pain management. F/U with am labs.\n" }, { "category": "Nursing/other", "chartdate": "2148-12-11 00:00:00.000", "description": "Report", "row_id": 1294799, "text": "npn 0700-1500;\nneuro;neuro intact steady on transfer to chair c/o lightheaded ness on transfer orthostatic but bp quickly returned to .\n\nresp;lungs coarse diminished at bases encouraged to cdb. sats 93-95% on ra rr 14-18.strong productive junky cough.\n\ncvs; tmax 99.3 po nsr with frequent pvc's couplets and triplets but no runs. bp 84-105/56 .lopressor given but lisinopril held.team aware.\n\ngu ;passing good amounts of clear yellow urine via foley.foley d/c'd at 1130 dtv @ pm.\n\ngi; obese belly pos bs pos flatus no stool. taking good diet. on 1500 mls fluid restiction.bs covered on riss.\n\nsoc; no family phone calls or visits.pt communicating by phone with friends.\n\nskin. psoriasis unchanged. aidc pocket pink with serous drainage. skin and shoulder markedly less inflamed and swollen .pain also improved. @ with dilaudid po q4-6.\n\na/p improving.sepsis resolving.\nresp maintain 02 sats greater than 92%. encourage to cdb.\nfollow blood cultures .encourage gentle ambulation as tolerated.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2148-12-11 00:00:00.000", "description": "Report", "row_id": 1294800, "text": "npn 3pm to 7pm\npt received 3 pm- planning transfer to 3- awaiting transfer orders. On attempt to give iv vanco iv found to have clotted - iv team unable to place piv due to difficult stick. medical team receiving pt to 3 aware of iv need and attempting to contact IR for picc under fluro. angio nurse spoke with me and stated pts attending would need to order picc as emergent to get picc done tonight. team transfering pt to 3 gave ok to transfer w/o iv access as planning picc- on arrival to 3 Dr stated that angio unable to do picc to noc and pt needed to return to micu for ctr line. pt brought back to micu and ctr line placed plan return 3 after line in/cxr done.\n" }, { "category": "Nursing/other", "chartdate": "2148-12-10 00:00:00.000", "description": "Report", "row_id": 1294796, "text": "NPN 7P-7A\nTHIS IS A 38YO MICU PT. TRANSFERRED FROM CCU LAST EVENING. HE WAS ADMITTED FOR AN INFECTED AICD. THE AICD AND WIRES WAS REMOVED IN OR YESTERDAY. HE HAS AN EXTENSIVE CARDIAC PMH INCLUDING: 6 MI'S, CABG, MULTIPLE CATHS - LAST CATH (EF 25%), INDUCIBLE VT WITH 2 SYNCOPAL EPISODES WITH AICD PLACEMENT . PT. ALSO HAS A HISTORY OF COCAINE USE.\n\nNEURO: PT. ALERT AND ORIENTED X3. MAE. FOLLOWS COMMANDS. PT. C/O PAIN AT INCISION SITE. PT. MEDICATED WITH 2MG DILAUDID PO Q2-4 HRS WITH GOOD EFFECT.\n\nRESP: PT. ON 2L NASAL CANNULA. SATS 95-100%. BREATH SOUNDS CLEAR BILAT. EXP. WHEEZES NOTED AT TIMES WHICH CLEAR WITH COUGHING. NO C/O SOB. NO COUGH NOTED.\n\nCV: PT. NSR/ST. HE CONTINUES TO HAVE LOTS OF VENTRICULAR ECTOPY. HE IS NOTED TO HAVE RUNS OF 1-2MIN VTACH. PT. ASYMPTOMATIC WITH THESE EPISODES. BP REMAINS WNL. SBP LOW 100'S TO MID 110'S. PT. DID RECEIVE 3GM MAG SULFATE AT 2300 WHICH SEEMED TO DECREASE THE AMOUNT OF ECTOPY NOTED. WILL CONT. TO MONITOR CLOSELY. MD'S TO DISCUSS STARTING PT. ON AMIO GTT THIS AM. + PULSES. NO EDEMA NOTED. TMAX 99.2\n\nGI: PT. ON FULL LIQUID DIET AT THIS TIME AND TOLERATING WELL. ABD. SOFT/DISTENDED. + BS. NO BM THIS SHIFT.\n\nGU: FOLEY CATH IN PLACE DRAINING CLEAR YELLOW URINE. GOOD UO.\n\nSKIN: INCISION SITE WITH WET TO DRY DRESSING CHANGED AT 0100. TO BE CHANGED Q8H. WOUND LEFT OPEN D/T LARGE AMOUNT OF PUS IN AICD POCKET. AREA AROUND INCISION SITE WARM TO TOUCH. SOME SWELLING NOTED AROUND SITE AS WELL.\n\nACCESS: R FEMORAL AV SHEATH\n 2 PIVS PATENT\n\nPSYCHOSOCIAL: PT. HAS 2 CHILDREN WHO LIVE WITH HIS SISTER. HE DOES NOT WANT THEM TO BE GIVEN ANY INFORMATION REGUARDING HIS CONDITION. PT.'S HCP IS A FRIEND, , AND HE IS THE ONLY ONE TO BE GIVEN ANY INFORMATION.\n\nPLAN: ? START AMIO GTT THIS AM IF PT. CONTINUES TO HAVE RUNS OF VTACH. CONTINUE TO MONITOR CV STATUS CLOSELY. PT. REMAINS FULL CODE AT THIS TIME.\n" }, { "category": "Radiology", "chartdate": "2148-12-09 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 935701, "text": " 4:04 PM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p ICD removal, ? hemothorax, no sob.\n Admitting Diagnosis: INFECTED AICD\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 38 year old man with fever, sob and hypotension w/apparent infected AICD\n site.\n REASON FOR THIS EXAMINATION:\n s/p ICD removal, ? hemothorax, no sob.\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: 38-year-old man with fever, SOB and hypertension.\n\n CHEST: The ICD device has been removed. The heart remains enlarged and some\n mediastinal widening is present. Pulmonary plethora is again seen consistent\n with failure.\n\n\n" }, { "category": "Radiology", "chartdate": "2148-12-07 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 935473, "text": " 8:45 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for chf\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 38 year old man with fever, sob and hypotension w/apparent infected AICD site.\n REASON FOR THIS EXAMINATION:\n eval for chf\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Fever, shortness of breath, and hypotension.\n\n COMPARISON: X-ray dated .\n\n PORTABLE SEMI-UPRIGHT VIEW OF THE CHEST: Heart size is stable, allowing for\n differences in technique. The position of the AICD leads appears unchanged.\n There is mild perivascular haze and perihilar fullness. No definite pleural\n effusion is seen. There is a possible subtle opacity at both lung bases. No\n evidence of pneumothorax.\n\n IMPRESSION:\n 1. Perihilar fullness and perivascular haze, consistent with mild fluid\n overload.\n 2. Possible subtle patchy bibasilar opacities could represent atelectasis or\n consolidation.\n\n\n" }, { "category": "Radiology", "chartdate": "2148-12-08 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 935511, "text": " 8:08 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate for infiltrate, pulmonary edema\n Admitting Diagnosis: INFECTED AICD\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 38 year old man with fever, sob and hypotension w/apparent infected AICD\n site.\n REASON FOR THIS EXAMINATION:\n evaluate for infiltrate, pulmonary edema\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: AP chest, .\n\n HISTORY: 38-year-old man with fever, shortness of breath and hypotension.\n Patient with apparent infected AICD site. Evaluate for infiltrate or\n pulmonary edema.\n\n FINDINGS: Compared to prior study from .\n\n There is an artifact across the left side of the image which limits\n examination. There is a median sternotomy and a left-sided dual-lead\n pacemaker which is unchanged in position allowing for the technical artifact.\n The cardiac silhouette remains prominent. There is a mild prominence of\n pulmonary vascular congestion without overt pulmonary edema or focal\n consolidation. Overall the findings are stable.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2148-12-11 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 936076, "text": " 6:58 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: Please confirm CL placement, rule out Pneumothorax\n Admitting Diagnosis: INFECTED AICD\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 38 year old man with fever, sob and hypotension w/infected AICD site s/p\n placement of right subclavian CL\n REASON FOR THIS EXAMINATION:\n Please confirm CL placement, rule out Pneumothorax\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 38-year-old male with fever, shortness of breath, infected AICD,\n status post right subclavian central venous catheter placement.\n\n Portable AP view of the chest dated is compared to the prior from\n . Patient is status post median sternotomy. Clips are seen overlying\n the left chest probably the site of the patient's prior AICD. The right\n subclavian venous catheter terminates in the mid SVC. The cardiac silhouette\n is stable. There has been interval improvement of aeration within the lung\n fields. There is no pleural effusion or pneumothorax.\n\n IMPRESSION:\n 1. Right subclavian line terminating in the proximal SVC without evidence for\n pneumothorax.\n\n 2. Improved aeration of the lungs consistent with improving congestive heart\n failure.\n\n" }, { "category": "Radiology", "chartdate": "2148-12-12 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 936147, "text": " 9:05 AM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: L picc\n Admitting Diagnosis: INFECTED AICD\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 38 year old man with fever, sob and hypotension w/infected AICD site s/p\n placement of right subclavian CL\n REASON FOR THIS EXAMINATION:\n L picc\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Fever and shortness breath, status post left PICC line placement.\n\n COMPARISON: CXR .\n\n FINDINGS: Upright radiograph of the chest. Left-sided PICC line is seen with\n its tip terminating either at the atriocaval junction or just within the right\n atrium. Right-sided subclavian line is unchanged in position.\n Cardiomediastinal silhouette is again stable. Lung fields do not appear to be\n grossly changed compared to yesterday. No left-sided pleural effusion is\n seen. The right costophrenic angle was cut off on this film. No pneumothorax\n is identified.\n\n IMPRESSION: Left-sided PICC line with tip terminating at the atriocaval\n junction or just within the right atrium. Recommend pulling back a few cm for\n more optimal placement. Otherwise, stable radiograph.\n\n\n" }, { "category": "Radiology", "chartdate": "2148-12-10 00:00:00.000", "description": "LP SHOULDER (AP, NEUTRAL & AXILLARY) TRAUMA LEFT PORT", "row_id": 935886, "text": " 10:38 PM\n SHOULDER (AP, NEUTRAL & AXILLARY) TRAUMA LEFT PORT Clip # \n Reason: eval for fx, other pathology\n Admitting Diagnosis: INFECTED AICD\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 38 year old man with left shoulder pain\n REASON FOR THIS EXAMINATION:\n eval for fx, other pathology\n ______________________________________________________________________________\n FINAL REPORT\n LEFT SHOULDER, TWO VIEWS.\n\n INDICATION: Shoulder pain. Evaluate for fracture or other pathology.\n\n FINDINGS: No fracture or dislocation is seen. No lucent or sclerotic lesion\n is noted. More complete evaluation for a dislocation would require axillary\n or scapular Y view. Visualized portion of the left long apex demonstrates two\n metallic clips.\n\n IMPRESSION:\n\n No evidence of fracture or lucent lesion. No definite evidence of\n dislocation, although a more definitive evaluation would require axillary or\n scapular Y view.\n\n" } ]

[ { "category": "Nursing/other", "chartdate": "2122-10-25 00:00:00.000", "description": "Report", "row_id": 2039258, "text": "#5Parents\n had not been in contact with staff during the day.\n arrived at 2300. The importance of visiting at care\ntimes was stresed to . It was explained that if baby\nis to gain weight and grow, he needs to be allowed to rest\nin between. Also encouraged to call and inform staff\nof their visit time so we can plan the day so he can be held\nwhen they visit. This nurse was unaware that they would be\nin to visit and thus baby was out to weigh previos to\n visit. informed that care times could be\naltered if a particular scheduce was more conducive for\ntheir visits. Also asked them to think about what day would\nbe good for family meeting.Toward end of visit, stated\nthat he was not feeling well. mom asked to wait\noutside.Mom plans to visit at 1200 later today.\nP. Plan to inform and update.\n#3FEN\nWt up5g to 665g. TF remains at 150cc/kg. Feed advanced at\n2400 to 80cc/kg or 9.2cc BM20 q4. Abd soft, active bowel\nsounds. Voi, transitional stool. Max asp 1cc with tinge\nbile. However, at 2400 asp .4 with no bile. Bruise in R\ngroin unchanged. IVF at 70cc/kg. TPN D8 with lipids at\ninfusing via PIC.\nA. Tol slowly advancing feed.\nP. Low threshold to obtain KUB. Cont to advance feed\n10cc/kg/ . Check lytes gas Hct today.\n#4DEv\nTemp stable nested in servo control . Sleeps well\nbetween cares.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2122-10-25 00:00:00.000", "description": "Report", "row_id": 2039259, "text": "RESPIRATORY CARE NOTE\nBaby received intubated on vent settings 15/5 Rate 12 FiO2 21%. Suctioned ETT for sm amt of white secretions. Breath sounds are clear. ABg PO2 58 CO2 43 PH 7.40 28 0. No vent changes made. Stable on current vent settings cont to follow.\n" }, { "category": "Nursing/other", "chartdate": "2122-11-23 00:00:00.000", "description": "Report", "row_id": 2039434, "text": "Nursing progress note\n\n\n#2 O: Remains on 5cm prong CPAP, 26-29% O2. Breath sounds\nequal & clear with mild IC/SC retractions. Suctioned X's 1\nfor mod secretions. Remains on caffeine. Baby had 2 bradys\nwith apnea & desats. Occasional sat drifts. A: Unchanged. P:\nCont to assess.\n#3 O: Wgt up 30 gms. remains on 150cc/k/d 30 cal PE/BM.\nfeeds given q4h pg over 90 . Abd soft full with active\nbowel sounds & no loops. Sm spit X's 1. Voiding & stooling.\nA: Tolerating feeds & gaining wgt. P: Cont to assess.\n#4 O: Remains in air controlled . Swaddled on\nsheepskin. Weaning temp. Alert with cares. A:\nStable. P: Cont to assess.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2122-11-23 00:00:00.000", "description": "Report", "row_id": 2039435, "text": "Respiratory Care\nBaby remains on cpap 5 26-29%.BS clear throughout.Sx x 1 for mod cldy secs.RR 40-70. 2 spells documented this shift,continues to have drifts in o2 sats.\n" }, { "category": "Nursing/other", "chartdate": "2122-11-23 00:00:00.000", "description": "Report", "row_id": 2039436, "text": "Newborn Med Attending\n\n Cont on CPAP5, 26% O2, occ spells. AF flat, clear BS, no murmur, abd soft, MAE. WT=1305 up 30, on 150 cc/kg/d BM30.\nA/P: Growing infant with CLD and AOP. Monitor for spells.\n" }, { "category": "Nursing/other", "chartdate": "2122-12-10 00:00:00.000", "description": "Report", "row_id": 2039524, "text": "npn 1900-0700\n\n\n2: resp\nremains in nasal cannula 500cc flow 40-50% fio2. infant\nhaving occational drifts to mid 80%. RR 30-90's. Infant with\nmild to moderate subcostal retractions. Np aware of increase\nin resp rate. Continuing to trial off of cpap. Continues on\ncaffeine. no spells thus far this shift. Continue to monitor\nfor changes in resp status\n\n3: fen\ncurrent weight 2025gms up 35gms. total fluids remain at\n150cc/kilo/day of pe/bm 31 cals. infant feeds tolerated by\ngavage. no spits. minimal aspirates. voiding and no stool\nthus far this shift. girth stable. no loops. infant with\nmoderate edema. continues on iron and vit e.\n\n4: g/d\ntemps stable in an open crib. alert and active with cares.\nsleeps well inbetween. sucks vigorously on pacifier.\nbrings hands to mouth. aga. continue to monitor for\ndevelopmental milestones.\n\n5: \nmom and in for care. very loving and involved.\n both participating in care. mom held infant during\nfeeding. updated by this rn. continue to support family\nneeds.\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2122-12-10 00:00:00.000", "description": "Report", "row_id": 2039525, "text": "Newborn Med Attending\n\nDOL#54. Cont in O2 per NC, no spells. AF flat, clear BS, some retractions, no murmur, abd soft, MAE. WT= up 35, TF=150 cc/kg/d PE31 with PM.\nA/P: Growing infant with CLD. Wean O2 as tolerated. Cont current feeding plan.\n" }, { "category": "Nursing/other", "chartdate": "2122-10-25 00:00:00.000", "description": "Report", "row_id": 2039260, "text": "Neonatology Attending\n\nDOL 9 CGA 29 weeks\n\nContinues on low vent settings 21%/15/5/12. R 30s-60s. ABG 7.40/43/58/28/0. No A/B. On caffeine.\n\nBP 59/33 mean 41\n\nOn 150 cc/kg/d with 70 cc/kg/d PN8/IL via central PICC and 80 cc/kg/d BM20. Tolerating feeds well. Voiding. Stooling (heme neg). 133/4.2/98/27 DS 127. Wt 665 grams (up 5).\n\nBlood out 11.5 Hct 26.8\n\n visiting and up to date.\n\nA: Stable on low vent settings with control of apnea. Tolerating feed advance. Anemic with significant blood out.\n\nP Continue current vent settings\n Advance feeds 10 cc/kg q 12\n D/C IL, continue PN for one more day\n Transfuse prbc\n Formal family meeting soon\n\n" }, { "category": "Nursing/other", "chartdate": "2122-10-25 00:00:00.000", "description": "Report", "row_id": 2039261, "text": "Neonatology-NNP PROgress Note\n\nPE: remains in his , on 15/5 X12 .21, bbs cl=, rrr s1s 2no murmur, abd soft,nontender, voiding, non stool today, afs, sutures approximated, pale, pink, activew with care, picc line in place\n\nSee attending note for plan\n" }, { "category": "Nursing/other", "chartdate": "2122-10-25 00:00:00.000", "description": "Report", "row_id": 2039262, "text": "Neonatology-NNP PROgress Note\nBruise in right groin area\n" }, { "category": "Nursing/other", "chartdate": "2122-11-06 00:00:00.000", "description": "Report", "row_id": 2039339, "text": "NPN DAYS\n\n\nAlt in Resp: Remains on NP with FiO2 22-26%. LS clear\nand equal. Mild IC/SC retractions noted. Sxn'd q4hrs. RRT\nchanged NP tube. Spell x1 so far this shift. Continues on\ncaffeine. Will continue to monitor closely.\n\nAlt in FEN: TF 150cc/kg/day BM30PM, gavaging feeds over\n50mins. Minimal aspirates. No spits. Belly full and soft\nwith active bowel sounds. No loops noted. Trace amounts\nyellow stool. will continue with current plan of care.\n\nGrowth and Dev: Temp stable in servo . Nested on\nsheepskin with boundaries in place. Likes his pacifier.\nActive and alert with cares. Sleeps well between cares. Will\ncontinue to provide for developmental needs.\n\n: No contact as of yet this shift.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2122-11-06 00:00:00.000", "description": "Report", "row_id": 2039340, "text": "NPN DAYS\nMom called for update. She voiced that she was upset for personal reasons. She wanted to know when she and the visited on . Info given to mom. Told mom to call back if she needed emotional support from myself or social work.\n" }, { "category": "Nursing/other", "chartdate": "2122-11-06 00:00:00.000", "description": "Report", "row_id": 2039341, "text": "Respiratory Care\nPt recieved on NP-CPAP +6cm's with the fio2 21 to 28%. Pt got new NP tube this shift and was suctioned for a mod amt of thick yellow secretions. Respiartory rates 30's to 60's. Plan is to follow on CPAP.\n" }, { "category": "Nursing/other", "chartdate": "2122-11-07 00:00:00.000", "description": "Report", "row_id": 2039342, "text": "#2 PT CONT ON CPAP6, 23-26%. LS ARE CLEAR. SX WITH CARES FOR\nLARGE CLEAR VIA MOUTH, MOD YELLOW VIA TUBE. NO SPELLS AT\nTHIS TIME IN SHIFT.\n#3 TF 150CC/KG BM30C/PRO. FEEDS TOLERATED WELL OVER 50MIN.\nNO SPITS, ASP, ABD BENIGN. VOIDING, NO STOOL THIS SHIFT.\n#4 TEMPS ARE STABLE IN SERV0 ISO. ALERT AND ACTIVE. SLEEPING\nWELL BETWEEN CARES.\n#5 MOM AND IN FOR MIDNIGHT CARES. ASSISTING WITH\nCARES. OARENTS UPDATED AT BEDSIDE.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2122-11-07 00:00:00.000", "description": "Report", "row_id": 2039343, "text": "Respiratory Care\nBaby remains on cpap 6 21-26%.BS clear throughout.Sx for mod yellow->bld tinged secsreom nptube.lg thick clear from mouth.On caffeine no spells documented this shift.\n" }, { "category": "Nursing/other", "chartdate": "2122-12-10 00:00:00.000", "description": "Report", "row_id": 2039526, "text": "NPN 0700-1900\n\n\n2.Resp: Infant remains in NC 500cc flow with Fi02\nrequirement mostly 42-50%, increasing to 60% with cares.\nLung sounds are clear and equal with mild SC retractions,\nRRs 40s-100s. He remains on caffeine with no spells. He\ndoes drift to the low 80s, which is self resolved and\noccasionally drifts to the 60s-70s%, needing an increase in\n02. /MD aware of increased Fi02 requirement and\noccasional drifts. Infant does not appear to be distressed.\n Continue to monitor respiratory status and work of\nbreathing.\n\n3.FEN: Infant remains on TF 150cc/kg/day of PE/BM 30cal/oz.\n He is tolerating feeds well with no spits, minimal\naspirates. 0800 aspirate was remarkable for a small amount\nof fresh red blood, accompanied by a small amount of nasal\nbleeding following suctioning. 1200 aspirate then also had\nsome old dried blood. /MD aware. Aspirate discarded.\nAbomden is soft and full with active bowel sounds, no loops.\n He has consistent abdominal girths between 25-26cm. He is\nvoiding, no stool thus far this shift. Moderate amount of\ngeneralized edema. Continue to monitor FEN status.\n\n4.DEV: Infant is swaddled in an open crib with stable\ntemps. He is alert and active with cares. He brings hands\nto face, calms with containment and pacifier. Small\nstrawberry hemangioma present on left lower arm. Small\numbilical hernia is soft and reducable. Continue to support\ngrowth and development.\n\n5.: No contact from thus far this shift.\nContinue to support and keep informed.\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2122-12-10 00:00:00.000", "description": "Report", "row_id": 2039527, "text": "Addendum NPN\n and extended family in to visit with infant. Plan to visit tomorrow.\n" }, { "category": "Nursing/other", "chartdate": "2122-12-29 00:00:00.000", "description": "Report", "row_id": 2039600, "text": "NPN\n\n\n#2 S. O. Received infant on a nasal cannula with fio2 at\n100%,flow at 100cc. Flow has ranged from 75cc to 100cc.\nBreath sounds clear and equal. Suctioned x 1 for thick\nsecretions. A. Infant requiring a small amount of fio2. P.\n Team to discuss continued diuretic therapy.\n\n#3 S. O. Weight up 55 grams. Infant continues on breast\nmilk/premie enfamil 29 cal . Infant is taking all po feeds.\n Infant breast fed well at care and took 45cc pc. A.\nInfant acting hungry. P. Assess\n\n#5 S. O. very comfortable in care of infant. in to update on eye exam. A. Loving\n,concerned . P. Support and keep updated.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2122-12-29 00:00:00.000", "description": "Report", "row_id": 2039601, "text": "Neonatology\nDoing well. Remains in 75 cc NC flow. Comfortable appearing. Diuril to be restarted. Will monitor response.\n\nWt 2775 up 75. Tolerating feeds at 1309 cc/k/d of 29 cal. Abdomen bneign. All pos.\n\nContinue as at present.\n\n" }, { "category": "Nursing/other", "chartdate": "2122-11-07 00:00:00.000", "description": "Report", "row_id": 2039344, "text": "Neonatology Attending Progress Note\n\nNow day of life 22, CA 5/7 weeks.\nCurrently on CPAP of 6 and in FIO2 21-26%.\n2 episodes of apnea and bradycardia in the past 24 hours.\nRR 30-60 HR 160-170s\nOn caffeine.\n\nWt. 781gm up 21gm on 150cc/kg/d of MM30 with Promod\nFeedings well tolerated by gavage.\nNormal urine and stool output\n\nAssessment/plan:\nVery nice progress continues.\nWill try wean on vent support to CPAP of 5.\n\n" }, { "category": "Nursing/other", "chartdate": "2122-11-07 00:00:00.000", "description": "Report", "row_id": 2039345, "text": "Neonatal NP-Exam\n\nSee Dr. note for details and plan of care as discussed in rounds this am.\n\nAFOF, sutures split. Breath sounds clear and equal. Nl S1S2, no audible murmur. Pink and well perfused. Abd benign,\n" }, { "category": "Nursing/other", "chartdate": "2122-11-22 00:00:00.000", "description": "Report", "row_id": 2039431, "text": "Neonatology- Physical Exam\n\n remains on CPAP. Active, alert in an , AFOF, sutures opposed, good tone. BBS clear and equal with good air entry. No murmur, pulses +2, pink, RRR. Abdomen soft, non-distended with active bowel sounds, no HSM, left inguinal hernia, tolerating feeds. Please refer to attending progress note for detailed plan.\n" }, { "category": "Nursing/other", "chartdate": "2122-11-22 00:00:00.000", "description": "Report", "row_id": 2039432, "text": "Nursing NICU Note\n\n\n2. Resp. O/Pt remains on bubble CPAP 5, FiO2 primarily\n26-29% this shift. Occasional desaturations noted to the mid\n80s. One sat drift noted as low as 78%, requring increase in\nFiO2. No A/B noted thus far. REmains on caffeine. A/Requires\nCPAP to maintain adequate oxygenation. P/Cont. to supply and\nwean FiO2 as pt needs/tolerates. Cont. to monitor for resp\ndistress and A/B and intervene as pt needs.\n\n3. F/N. O/TF remain at 150cc/k/d of BM30PM PNGT. Please\nrefer to flowsheet for examinations of pt from this shift.\nVoiding. L inguinal hernia firm and this nurse was unable to\nreduce. Scrotal area remains pink and well perfused.\nAttending and made aware of in to examine\nand no changes in plan made at this time. A/Appears to be\ntolerating present feeding regimen. P/Cont. to monitor for\ns/s of feeding intolerance. Cont. to monitor hernia for\nevidence of incarceration.\n\n3. G/D. O/Pt remains in an air controled . Temp\nstable. Awake and alert at care times and sleeping well in\nbetween. Sucks on pacifier. Brings hands to face. A/Alt. in\nG/D. P/Cont. to support pt's growth and dev. needs.\n\n5. . O/Father called this afternoon. UPdated on\npatient's status and plan of care. Father aware of hernia.\nA/ are known to be actively involved in pt's care.\nP/Cont. to support and educate .\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2122-11-22 00:00:00.000", "description": "Report", "row_id": 2039433, "text": "Respiratory Care Note\nPt. remains on +5 Prong CPAP, FiO2 26-29%. BS clear. RR 30-70. Sm amount bloody secretions from nares. No bradys this shift. Pt drops O2 Sat precipitiously when CPAP prongs removed.\n" }, { "category": "Nursing/other", "chartdate": "2122-12-29 00:00:00.000", "description": "Report", "row_id": 2039602, "text": "PCA note:\n\n\nAlt in Resp: NC 50-75cc @ 100%FiO2. Mild intercostal\nretractions. Mottles with cares but otherwise well perfused\n(pale pink). Increased work of breathing with bottling. No\ndrifts, no spells. Continue to monitor respiratory status.\n\nAlt in FEN: TF 130cc/kg restriction. BM 28 or PE 28 po (q\n4h). Generalized edema. Small reducable umbilical hernia.\nStrawberry hemangioma on left upper arm unchanged. Voiding,\nstooling (neg. heme). Continue with plan of care.\n\nGrowth and Dev: Swaddled in open crib. Alert and active\nwith cares. Sleeps well. Temps stable. Eyes stage 2 zone\n2 (recheck next week). Continue to support developmental\nneeds.\n\n: in to visit this morning. will return\nfor 8pm cares. Continue to support and teach where\napplicable.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2122-12-29 00:00:00.000", "description": "Report", "row_id": 2039603, "text": "Neonatology- Physical Exam\n\n remains on NC. Active, alert in an open crib, AFOF, sutures opposed, good tone. BBS clear and equal with good air entry, mild SC retractions. Gr murmur, pulses +2, pink, RRR. Abdomen soft, non-distended with active bowel sounds, no HSM, small umbilical hernia, left hydrocele, tolerating feeds. Please refer to attending progress note for detailed plan.\n" }, { "category": "Nursing/other", "chartdate": "2122-12-29 00:00:00.000", "description": "Report", "row_id": 2039604, "text": "NPN DAYS\nI have examined - and agree with above note by , PCA. He was restarted on Diuril today. He will have nutrition on the 15th. called and was updated re: Diuril. Will continue to wean O2 if tolerated.\n" }, { "category": "Nursing/other", "chartdate": "2122-12-30 00:00:00.000", "description": "Report", "row_id": 2039605, "text": "NPN 1900-0700\n\n\nRESP: Continues on NC, 100% FiO2, 50-100cc of flow. RR\n40-70. LS clear and equal. Mild SC rtx. Some UAC noted.\nOccasional sat drifts to hi 80%'s/low 90%'s. No spells.\nStarted on diuril.\n\nFEN: wt 2860g (up 85g). TF restricted at 130cc/kg/d of\nBM/PE28. Equals 62cc q4hrs. All PO. BF X1 well. Abdomen\nsoft, +BS, no loops, voiding and stooling. On vit E and Fe.\nPlan to take nutrition tomorrow.\n\nG&D: Temps stable, swaddled in open crib. Wakes for feeds.\nAlert and active with cares. Takes paci well.\n\n: Both in earlier this shift. Independent\nwith cares and feeding.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2123-01-12 00:00:00.000", "description": "Report", "row_id": 2039678, "text": "PCA Note:\n\n\nAlt in Resp: NC 100%FiO2, 50cc. Lung sounds clear and\nequal, mild subcostal retractions. Respiratory rates\nincrease with feedings. Infant \"head bobbing\" illustrates\nincreased work of breathing with bottling. O2sats remain\nstable with no drifts. Continue to monitor respiratory\nstatus. Decrease flow rate as tolerated.\n\nAlt in FEN: TF 130cc/kg/day E20 or BM ad lib demand.\nInfant bottling q 3-4hrs, taking well over suggested volume.\nInfant somewhat gassy, but voiding and stooling (neg.heme).\nNo spits. Continue with plan of care.\n\nAlt in G&D: Infant is swaddled in an open crib, maintaining\nstable temps. Infant is and active with cares.\nSleeping intermittantly throughout the day, but awake for\nthe most part. Infant enjoys bouncy seat and music.\nContinue to support developmental needs of infant.\n\n: in this morning @9am. Held and read to baby.\n called and spoke to RN. plan on returning for\nevening cares and breastfeeding. Continue to support and\nteach when possible.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2123-01-12 00:00:00.000", "description": "Report", "row_id": 2039679, "text": "NPN DAYS\nI agree with above note by , PCA.\n" }, { "category": "Nursing/other", "chartdate": "2123-01-12 00:00:00.000", "description": "Report", "row_id": 2039680, "text": "NPN DAYS\nReviewed FeSO4, Diuril, and KCL with . Gave them teaching sheets to take home and review on their own. Will start having draw up meds and give them.\n" }, { "category": "Nursing/other", "chartdate": "2123-01-13 00:00:00.000", "description": "Report", "row_id": 2039681, "text": "PCA Note\n\n\nRESP: Infant on 100% FiO2 at 50cc flow via NC; O2 sat >97%.\nRR 30-50's while sleeping but occassionaly increases to low\n70's while bottling. LS clear bilat. with mild subcostal\nretractions. Continue to assess respiratory status and wean\nO2 NC as tolerated.\n\nFEN: Infant is on ad lib demand schedule bottling BM or\nE20. TF of 130cc/kg/day; 73cc Q4 or 55cc Q3. Current\nweight 3315, down 45g. Abd benign - soft, round, good bowel\nsounds, no loops; soft umb hernia noted. Infant is voiding;\nno stool thus far. Continue to encourage PO's and assess.\n\nDEV: Infant swaddled in OAC. Temps have been stable. \nand active with cares, MAE. Sleeping well between cares.\nIrritable at times but easily consolable. Continue to\nsupport developmental needs.\n\n: Mom and in earlier this evening. holding\ninfant while mom read book to . Very caring. Continue\nto update and support .\n\n\n" }, { "category": "Nursing/other", "chartdate": "2123-01-13 00:00:00.000", "description": "Report", "row_id": 2039682, "text": "NPN\nAgree with above note by PCA Tran.\n\nQuestionable hernia noted on left side. notified. Plan to examine furthe today.\n\n" }, { "category": "Nursing/other", "chartdate": "2123-01-13 00:00:00.000", "description": "Report", "row_id": 2039683, "text": "Neonatology\nDOing well. REmains in low flow NCo2. Comfortable apepairng. Will attempt to wean flow as tolerated.\n\nWt 3315 down 45. Taking ad lib feeds. REasonable voluems. Abdomen benign. Good weight gain over time. Lytes to be checked.\n\nContinue to await maturation of pulm function.\nSynagis to be arranged.\n" }, { "category": "Nursing/other", "chartdate": "2122-10-24 00:00:00.000", "description": "Report", "row_id": 2039253, "text": "Respiratory Care Note\nPt remains intubated on IMV settings of 15/5 RR 12 FIO2 21%. B.S. ess. clear with good air entry. ETT sx'ed for mod amt white secretions.\n" }, { "category": "Nursing/other", "chartdate": "2122-10-24 00:00:00.000", "description": "Report", "row_id": 2039254, "text": "Nsg Addendum\nBaby noted to have a round circular bruise in R groin area. by NNP.\nFeed not advanced due to procedures tonight as well as 1cc asp and appearnce of belly being full. Feed remain at 60cc/kg. Urine Output only 0.83cc/kg/hr this shift. Urine output 1.49cc/kg/hr for 24h. NNP informed. Baby placed back in at 0400.\n" }, { "category": "Nursing/other", "chartdate": "2122-10-24 00:00:00.000", "description": "Report", "row_id": 2039255, "text": "Neonatology\nDoing well. REmains on 15/5 Low Fio2. Comfortable apeparing.\n\nWt 660 up 40. TF at 150 cc/k/d. feeds being tolerated at 60 cc/k/d. Rest via PN. feed advancement held last night with bilious apsirate. belly looks good this am. Will examine during am and determine erstart of feed advancement. NA in low 130s. result of 125 earlier eysterday appears to be artefactual. Will dcerease NA supplementation in PN slightly.\n\nLytes HCt and CBG to be checked later today.\n\nTemp stable in isollette.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2122-10-24 00:00:00.000", "description": "Report", "row_id": 2039256, "text": "NPN DAYS\n\n6 Alt. C/V\n\nAlt in Resp: Remains intubated on settings of 15/5 rate 12\nin room air. LS coarse. Sxn'd for moderated amts from ETT\nand large amounts of secretions orally. No spells. Remains\non caffeine. To check gas tonight. Continue to monitor.\n\nAlt in FEN: TF 150cc/kg/day. Enteral feeds of BM20 are at\n70cc/kg/day and IV fluids of PND7.5 and lipids infusing via\nPICC line at 80cc/kg/day. D/S 100. Minimal aspirates are\ngreen tinged. Team is aware. Belly benign. Urine out\n4.4cc/kg/hr. Stool x1. AG 15.5-16cm. Tolerating increased\nfeeds without problems. continue to increase feeds by\n10cc/kg/ as tolerated. To check lytes and HCT tonight.\n\nGrowth and Dev: Temp stable in servo . Awake and\nalert with cares. Sleeps soundly between cares. Nested on\nsheepskin with boundaries in place. Continue to support\ndevelopmental needs.\n\n: No calls yet this shift.\n\nAlt C/V: No alteration in cardiac status noted. Problem\nresolved.\n\n\n\nREVISIONS TO PATHWAY:\n\n 6 Alt. C/V; resolved\n\n" }, { "category": "Nursing/other", "chartdate": "2122-10-24 00:00:00.000", "description": "Report", "row_id": 2039257, "text": "Respiratory Care\nPt remains on IMV, rate of 12, pressures of 15/5, with the fio2 21. Pt's respiratory rates 30's to 70's. Pt suctioned for a mod amt of cloudy secretions. Plan is to follow pm PPV, wean as tolerated.\n" }, { "category": "Nursing/other", "chartdate": "2122-11-05 00:00:00.000", "description": "Report", "row_id": 2039334, "text": "Clinical Nutrition\nO:\n~30 wk CGA BB on DOL 20.\nWT: 834g(+24)(<10th %ile); birth wt: 695g. Average wt gain over past wk ~26g/kg/d.\nHC: 25cm(<10th %ile); last: 22cm()\nLN: 33cm(<10th %ile); last: 32cm()\nMeds include: Fe & Vit.E\n due next week.\nNutrition: 150cc/kg/d as BM 30 w/ promod; pg. Average of past 3d intake ~150cc/kg/d, providing ~150kcals/kg/d and ~4.1g pro/kg/d.\nGI: Abdomen benign.\n\nA/Goals:\nTolerating feeds w/o GI problems, pg. due next week. Current feeds & supps meeting recommendations for kcals/pro/vits/mins. Growth is exceeding recs for WT/HC gains of ~15-20g/kg/d for WT and of ~0.5-1cm/wk for HC(HC average gain of past 2 wks). Average of past 2-week LN gain is not meeting recs of ~1cm/wk. If infant continues to exceed recommended wt gain for the next 1-2 days, would recommend decreasing the calorie level to BM 28 w/ promod. Will continue to follow w/ team & participate in nutrition plans.\n" }, { "category": "Nursing/other", "chartdate": "2122-11-06 00:00:00.000", "description": "Report", "row_id": 2039335, "text": "Nursing Progress Note\n\n\nRESP O/A: Infant remains on NP CPAP 6cm; FiO2 27-30%. RR\n30-60s, LS clear/=, ic/sc rtxns. Occasional drifts to the\n80s noted overnight. No spells thus far; continues on\ncaffiene. P: Cont monitor resp status.\n\nFEN O/A: Current Wt: 850, ^16g. TF @ 150cc/k/d; BM30 w/\nPromod. Infant receives 21cc q4h pg; tolerating well.\nAbdomen soft/full, active BS. Girth stable. Voiding/stooling\n(heme neg). P: Cont to monitor for s/s of feeding\nintolerance.\n\nG&D O/A: - is nested on sheepskin in a servo\n. Ax temp @ 2400: 97.3, temp increased &\n placed under warming lights. F/U temp 98. Infant is\nquietly A/A with cares. Likes pacifier. FSF, sutures spread.\nP: Cont to support developmental needs.\n\nPAR O/A: Mom in for cares. is very independent\nwith temp/diaper & overall handling. Asking appropriate\nquestions. P: Cont to support NICU family.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2122-11-06 00:00:00.000", "description": "Report", "row_id": 2039336, "text": "Respiratory Care\nBaby remains on np cpap 6 27-30%.BS clear throughout.sx for mod->lg cldy->yellow secs.On caffeine no spells documented this shift.RR 30-60's.\n" }, { "category": "Nursing/other", "chartdate": "2122-11-06 00:00:00.000", "description": "Report", "row_id": 2039337, "text": "Neonatology Attending Progress Note\nNow day of life 21.\nRemains on CPAP - 6cm and in FIO2 27-30%\nRR 30-60s.\nNo true apnea and bradycardia - only occasional desaturations.\nHR 160-180s - BP 67/47 53\n\nWt. 850gm up 16gm on 150cc/kg/d of MM30 with Promod\nFeedings well tolerated by gavage.\nNormal urine and stool output(heme neg)\n\nAssessment/plan:\nVery nice progress continues.\nWill continue with current management.\nMother - lactation consult next week.\n\n" }, { "category": "Nursing/other", "chartdate": "2122-11-06 00:00:00.000", "description": "Report", "row_id": 2039338, "text": "Neonatal NP-Exam\n\nSee Dr. note for details and plan of care as discussed in rounds this am.\n\naFOF, sutures split wide. Breath sounds clear and equall. Nl S1S2, no audible murmur. Pale, pink and well perfused. Abd benign, no HSM. Active bowel sound. Infant active with exam.\n" }, { "category": "Nursing/other", "chartdate": "2122-11-21 00:00:00.000", "description": "Report", "row_id": 2039425, "text": "Nursing NICU Note.\n\n\n2. Resp. O/Pt remains on nasal prong bubble CPAP of 5, FiO2\n21-30%. Infrequent desaturations noted as low as 78% and\noccasional brief sat drifts noted as low as 86%. FiO2\nadjusted as neeed. No A/B noted thus far. On caffeine.\nA/Requiring nasal prong CPAP to maintatin adequate\noxygenation. P/Cont. to supply and wean FiO2 as pt\nneeds/tolerates. Cont. to monitor for evidence of resp\ndistress.\n\n3. F/N. O/TF remain at 150cc/k/d of BM30PM/PE30PM PNGT.\nPlease refer to flowsheet for examinations of pt from this\nshift. Voiding. One sm spit noted. A/Occasional spits,\notherwise appears to be tolerating present feeding regimen\nat this time. P/Cont. to monitor for evidence of feeding\nintolerance.\n\n4. G/D. O/Temp remains stable swaddled in an air controled\n. Awake and very alert with cares and sleeping well\ninbetween. Rooting and sucking on pacifier. A/Alt. in G/D.\nP/Cont. to support pt's growth and dev. needs.\n\n5. . O/This nurse called and spoke with pt's mother\nthis morning. Mother updated on pt's status and was made\naware of changes in plan of care. Mother aware of blood\ntransfusion. Mother had no objections to blood transfusion.\n have not visited this shift thus far. Snow storm\nnoted. A/ are involved in pt's care. P/Cont. to\nsupport and educate .\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2122-11-21 00:00:00.000", "description": "Report", "row_id": 2039426, "text": "Respiratory Care Note\nPt. remains on +5 Prong CPAP, FiO2 21-30%. RR 40-60. On caffeine. No spells noted. BS clear. Given PRBC's today\n" }, { "category": "Nursing/other", "chartdate": "2122-11-21 00:00:00.000", "description": "Report", "row_id": 2039427, "text": "Nursing NICU Note addendum\nPt recieved 1st alloquot of 20cc/k PRBC transfusion: TW.\n" }, { "category": "Nursing/other", "chartdate": "2122-11-22 00:00:00.000", "description": "Report", "row_id": 2039428, "text": "Nursing progress note\n\n\n#2 O: Remains on 5cm prong, bubble CPAP, 24-29% O2. Breath\nsounds equal & clear with IC/SC retractions. Suctioned for\nlg from nares & mod OP. No A's or B's, occasional drifts. A:\nStable on CPAP. P: Cont to assess.\n#3 O: Wgt up 55gms. Remains on 30 cal BM/PE w/PM at\n150cc/k/d. Feeds given PG q4h over 70 . Abd soft full\nwith active bowel sounds & no loops. Baby had lg soft gr\nstool. No spits, minimal aspirates. A: Tolerating feeds &\ngaining wgt. P: Cont to assess.\n#4 O: Temp stable in air controlled . Alert with\ncares. Sucks on pacifier. A: AGA. P: Cont to assess.\n#5 O: Mom phoned for update. A: Involved . P:\nSupport.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2122-11-22 00:00:00.000", "description": "Report", "row_id": 2039429, "text": "Respiratory Crae\nBaby remains on cpap 5 28%.RR 40-80's.BS clear throughout.Sx x 1 for lg. cldy,from nares and mouth.On caffeine,no spells documented this shift,occ drifts in sats.\n" }, { "category": "Nursing/other", "chartdate": "2122-11-22 00:00:00.000", "description": "Report", "row_id": 2039430, "text": "NICU Attending Note\n\nDOL # 36 = 32 5/7 weeks CGA with CLD, issues of growth and nutrition, anemia.\n\nPlease see full .\n\nCVR/RESP: RRR without murmur, BS clear/=, CPAP @ 5, 28% FiO2, no A/B in last 24 hours, on caffeine. Will continue caffeine, CPAP, monitors.\n\nHEME: Transfused PRBC yest for hct of 27.\n\nFEN: Weight today 1275 gm, up 55 gm, on TF of 150 MM/PE 30 with PM. Will continue current diet.\n\nGI: Left inguinal hernia, slightly firm, difficult to reduce yesterday. If remains difficult to reduce, will call surgery.\n\nENV'T: Stable temp in , eyes immature zone 2, f/u 2 weeks after last exam.\n" }, { "category": "Nursing/other", "chartdate": "2122-12-09 00:00:00.000", "description": "Report", "row_id": 2039520, "text": "Respiratory Care\nbaby remains on cpap 5 21-26%BS clear throughout.RR 30-70's,no spells documented this shift.On caffeine.\n" }, { "category": "Nursing/other", "chartdate": "2122-12-09 00:00:00.000", "description": "Report", "row_id": 2039521, "text": "NPN 7p7a\n\n\nResp\nInfant on NP CPAP 5 needing 21-28% fi02. RR 40-70. LSC. Suc\nx 1 for plugs. S/C rtxs. Off CPAP for a few minutes during\nweighing with BBo2 at side, desating without good recovery.\nNo issues when on CPAP. Infant with little reserves off\nCPAP. No bradys overnight. Moniotor and support resp status.\nFen\nInfant on TF 150 cc/k/d of BM or PE 31 gavaged 1 hr. Abd\nfull, distended this am. AG stable 27cm. Active BS. Has not\nstooled overnight but very gassy. No spits, no loops. \nbenign asps, asps of air. Placed on abd after this am cares\nto see if it will relieve some CPAP distention. Mild\ngeneralized and dependent edema. Wt 1.995 (+80). Monitor\nweight and exam.\nG/D\nInfant with stable temps in OAC swaddled. A/A with cares,\nsleeping well between. MAEs. Some clonis noted. FS&F. AGA.\nSupport G/D.\n\nBoth in last eve. They complained of being exhausted\nas they were in the process of moving and closing on their\nhouse. They participated in cares and asked appropite\nquestions. Interactive with infant. Invested and loving.\nSupport and educate.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2122-12-09 00:00:00.000", "description": "Report", "row_id": 2039522, "text": "Newborn Med Attending\n\nCont on CPAP5, 25% o2. No spells. AF flat, clear BS, no murmur, abd soft, MAE. WT= up 80 on Bm31 with Pm PG.\nA/P: Growing infant with CLD. CONT TO WEAN FROM CPAP AS TOLERATED. CONT CURRENT FEEDING PLAN.\n" }, { "category": "Nursing/other", "chartdate": "2122-12-09 00:00:00.000", "description": "Report", "row_id": 2039523, "text": "NPN 0700-1900\n\n\n2.Resp: Infant trialled on NC 500cc flow beginning at 10am\nthis morning. Lung sounds are clear and equal with RRs\n50s-70s, occasionally up into the 80s and 90s when active.\nHe remains on caffeine with no spontaneous bradys today.\nInfant has tolerated NC well with 02 sats 90-97%. Fi02\nrequirement has increased to 36-48%. Mild SC retractions\npersistent. Continue to monitor respiratory status.\n\n3.FEN: Infant remains on TF 150cc/kg/day of PE/BM 31cal/oz.\n He is tolerating feeds well with no spits, minimal\naspirates. Abdomen is soft and full with active bowel\nsounds, no loops. AG consistent at 25.5-26.5cm. He is\nvoiding and stooling (heme neg). He has a moderate amount\nof generalized edema. Continue to monitor FEN status.\n\n4.DEV: Infant is swaddled in an open crib with stable\ntemps. He is alert and active with cares, wakes for feeds.\nHe sucks vigorously on pacifier and brings hands to face.\nContinue to support growth and development.\n\n5.: No contact from thus far this shift.\nContinue to support and keep informed.\n\nSkin: Infant has two small, white, raised areas on right\ncheek under the Tegaderm holding NGT in place. MD/ made\naware. Continue to monitor.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2122-12-28 00:00:00.000", "description": "Report", "row_id": 2039595, "text": "NICU NURSING PROGRESS NOTE:\n\nRESP.O: Infant conts on NCO2 with 75-100cc flow, 100%. Sats>\n94%, RR:40-70. Slightly working hard to breath.\nMod subcostal retractions. Lungs sound clear and equal. No\nspells. Desats on occasion after feeds. Continue to monitor\nfor apnea/ and assess.\n\nFen.O: Weight=2720kg, ^30gm. TF restricted to 130cc/k/d of\nBM/PE 29+promod. Bottling full volume, 58cc each time. Abd\nexam is soft, no loops. BS active and alert. Umbilical\nhernia remains soft. Voiding and stooling. No spits.\nA: Tolerating feeds and gaining weight.\nP: Cont to support feeding plan.\n\nG/D.O: is swaddled in open crib. Temps stable. Active\nand alert with cares. sleeps well in between cares.\nOccasionally wakes for feeds. Sucks on pacifier.\nA: AGA. P: Continue to support devep needs.\n\nParenting: in at 8pm. Updated at bedside regarding\n weight, feeds and cares by RN . are very\nhappy that is 6 lb tonight. Mom breast fed and bottled\nhim. Loving and involving . Continue to support.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2122-12-28 00:00:00.000", "description": "Report", "row_id": 2039596, "text": "NPN NIGHTS\nI have examined - and agree with above note by , PCA.\n" }, { "category": "Nursing/other", "chartdate": "2122-12-28 00:00:00.000", "description": "Report", "row_id": 2039597, "text": "NPN 0700-1900\n\n\n#2: O: Infant remains on 100% nasal cannula O2 with a flow\nof 75-100cc. Saturations greater than 91%. Respiratory rate\n40's-60's, occasionally goes up to the 80's. Lung sounds\nclear and equal with moderate subcostal retractions. Some\ndrifts, quickly self resolving. No spells. A: Infant stable\nin nasal cannula O2. P: Continue to monitor respiratory\nstatus and reassess need for oxygen.\n\n#3: O: Total fluids restricted to 130ml/kg/d. of BM or PE\n29, 58cc q4 hours. Taking all bottles, abdomen benign, soft\numbi hernia, no spits, voiding and stooling. Stools heme\nnegative. Bowel sounds active. A: Infant tolerating feeds.\nP: Continue with current feeding plan.\n\n#4: O: Temperature stable in OAC. Alert and active, wakes\nfor feeds. Sucks pacifier when offered, brings hands to face\nfor comfort. Infant had eye exam today. A: AGA. P: Continue\nto support growth and development.\n\n#5: O: in to visit briefly this afternoon.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2122-12-28 00:00:00.000", "description": "Report", "row_id": 2039598, "text": "NEONATOLOGY\nCONTINUES IN NCO2 WITH SL INCREASED FLOW. WEANED FROM DIRUIL OVER WEKEND. WILL MONITOR FOE NEED TO RESTART.\n\nPO FEEDS CONTINUE TO IMPROVE. ASBDOMEN BENIGN.,\n\nCONTINUE TO MONITOR INTAKE.\n" }, { "category": "Nursing/other", "chartdate": "2122-12-28 00:00:00.000", "description": "Report", "row_id": 2039599, "text": "Neonatology NP Note\nPE\n swaddled in open crib\nAFOF, suturse opposed\nmild subcostal retractions and mild head bobbing at rest in NCO2, lungs with few scattered crackles, bases clear, some nasal congestion\nRRR, no murmur, pink and well perfused\nabdomen soft, nontender and nondistended, hernia not appreciated\ngood tone\n" }, { "category": "Nursing/other", "chartdate": "2123-01-11 00:00:00.000", "description": "Report", "row_id": 2039673, "text": "Nursing PRogress Note\n\n\n#2 O: NC O2 100% 30-50cc to keep sats >93. Lungs cl/equal\nw/upper airway congestion noted. RR 50's-70's w/baseline sc\nretractions. Diuril/KCL as ordered. Inc O2 for feeds but no\nfurther /bradys. A: low flow O2 P: wean as tol.\n#3 O: ad lib demand feeds, now E20/BM20. waking q3-4h,\ntaking 50-80cc well. Abd benign, vdg qdiaper. vit E/Ferinsol\nas ordered. A: doing well w/feeds P: per present care.\n#4 O: temp stable in open crib, waking own own for feeds as\nnoted above. w/cares, sleeping well in between. A: AGA\nP: cont to assess and support developmentally.\n#5 O: here this morning, updated on last nights\nchoking/ episode and plan to keep baby for 5more days\nas a result. disappointed but understands. very loving\nw/, a book and holding after feed. A: loving\nfamily anxious to take baby home. P: cont to support.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2123-01-11 00:00:00.000", "description": "Report", "row_id": 2039674, "text": "Neonatology- Physical Exam\n\n remains on NC. Active, in an open crib, AFOF, sutures opposed, good tone. BBS clear and equal with good air entry. No murmur, pulses +2, pink, RRR. Abdomen soft, non-distended with active bowel sounds, no HSM, tolerating feeds, small ubilical hernia. Please refer to attending progress note for detailed plan.\n" }, { "category": "Nursing/other", "chartdate": "2123-01-12 00:00:00.000", "description": "Report", "row_id": 2039675, "text": "2. Resp: O: Received infant in O2 via nc, 100% FiO2 and in\n50cc flow when sleeping and up to 75-100cc during bottle\nfeeds. Ls clear, RR 40-60s when quiet and up to 80s when\nbottling. He is on diuril and KCl. No spells tonight. A:\nStable in nc O2. P: Monitor. Meds as ordered. Wean O2 as\ntol.\n\n3. F/N: O: Infant is on an ad lib demand schedule, 130cc/k/d\n. Abd is benign, w/ a small, soft umbi hernia. He bottled\n132cc/k/d yesterday in 24 hours. He bottles well, though can\nget out of sinc at times which can cause him to choke. He is\nfine if paced. He is voiding and had a large, g- stool. He\ngained 120g ( he had lost 45g yesterday). He is on 20cal\nEnfamil. He breast fed for at least 20 w/ Mom tonight.\nA: Bottling well, though needs to be paced at times. P:\nContinue w/ plan.\n\n4. G/d: O: Infant's temp is stable in the open crib. He is\nactive w/ cares and waking @ q 4 hours to feed. A/P:\nContinue to support infant needs.\n\n5. : O: were in in the evening and took care\nof . Mom breast fed and bottled. A: Loving, involved\n. P: Med teaching is still needed before d/c.\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2123-01-12 00:00:00.000", "description": "Report", "row_id": 2039676, "text": "Neonatology\nRemaisn in RA. Comfortable apeparing. STill on diuil. dose increased yesterday.\n\nWt 3360 up 120. Tolerating feeds at ad lib with good intake. Abdomen benign.\n\nAwaiitng weaning from O2.\n" }, { "category": "Nursing/other", "chartdate": "2123-01-12 00:00:00.000", "description": "Report", "row_id": 2039677, "text": "Neonatology NP Progress Note\nPhysical Exam:\nActive and in open crib. Pale pinkon NC O2. AFOF, sutures opposed. Mild dolilcocephaly. Eyes clear, nares patent, skin with neonatal acne. MMMP\nChest is clear with shallow, rapid resp in state.\nEqual BS. CV: RRR, no murmur. Pulses plus 2 equal. Abdomen is soft protruberant, active BS. LIH noted.\nEXt: normal bulk, mildly hypertonic with exam, state.\nSymmetric reflexes present.\n\n" }, { "category": "Nursing/other", "chartdate": "2122-10-25 00:00:00.000", "description": "Report", "row_id": 2039263, "text": "NPN DAYS\n\n\nAlt in Resp: Remains on vent settings of 15/5 rate 12 FiO2\n21-25%. Needs increased O2 with cares. LS clear. Sxn'd ETT\nfor small white secretions. Sxn'd orally for large amounts\nsecretions. Mild IC/SC retractions. No spells. Remains on\ncaffeine. 1st alloquot of PRBC's infusing for HCT 26.8. Will\ncontinue to follow closely. To get 2nd alloquot blood 1hyr\nafter 1st infusion finished.\n\nAlt in FEN: TF 150cc/kg/day. Feeds of BM 20 are at\n90cc/kg/day q4hrs. PND10 infusing via PICC line at\n60cc/kg/day. Feeds are increased 10cc/kg/ as tolerated.\nMinimal aspirates. Voiding and stooling, heme - stool. No\nspits. Will continue with advancement of feeds as tolerated.\n\nGrowth and Dev: Temp stable in servo . Awake and\nalert with cares. Tolerated kangarooing with mom x90mins.\nWill continue to provide for developmental needs.\n\n: Mom in to visit and kangaroo'd. Updated her on\n- status. MOm and will be in tomorrow for\nfamily meeting at 3pm. Will continue to provide teaching and\nsupport. called and will delay visit r/t coming down\nwith a cold.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2122-10-25 00:00:00.000", "description": "Report", "row_id": 2039264, "text": "Respiratory Care\nPt recieved on IMV, rate of 12, pressures of 15/5 with the fio2 21%. PT suctioned for a sm amt of thick white secretions. No change on ventilator settings this shift. Plan is to follow.\n" }, { "category": "Nursing/other", "chartdate": "2122-10-26 00:00:00.000", "description": "Report", "row_id": 2039265, "text": "#5Parents\nMom and called for an update. called at 2400 asking\nif baby was OK. He said he had a bad feeling that something\nwas wrong. Reassured that baby was stable.\nP. Family Meeting tomorrow at 1500.\n#2Resp\nLungs clear. Suctioned for mod amt secretions from ETT as\nwell as orally. Baby remains intubated. Settings unchanged.\nBaby has been in RA for the most part but has occ needed\nsmall amt O2. FIO2 21- 24%. Baby has had one spell so far\ntonight. He cont on caffeine. Mild IC/Sc retactions.\nRR50-70.\nA. Stable. Minimal O2 requirement\nP. Cont to monitor.\n#3FEN\nWt up 26g. TF at 150cc/kg. Enteral feed currently at 90cc/kg\nor 10.4ccq4. Plan to advance at 0400. Abd soft, active bowel\nsounds. Large stool guiac neg. Voiding in larger quantities.\nTPN D10 infusing via PIC at 50cc/kg. Hep lock patent in L\nleg. Baby received 2nd blood 7cc over 4 hours and\ntol well. Color pinker since transfusion.\nA. Tol advancing feed\nP. Cont to advance 10cc/kg q12.\n#4Dev\nTemp stable in a servo control . Active with cares.\nNested on sheepskin.\nP. Cont to monitor.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2122-10-26 00:00:00.000", "description": "Report", "row_id": 2039266, "text": "RESPIRATORY CARE NOTE\nBaby received intubated on vent settings 15/5 Rate 12 FiO2 21-24%. Suctioned ETT for sm-mod amt of white secretions. Breath sounds are clear. One spell so far tonight. Stable on current vent settings cont to follow.\n" }, { "category": "Nursing/other", "chartdate": "2122-10-26 00:00:00.000", "description": "Report", "row_id": 2039267, "text": "Nsg Addendum\nOver the course of latter part of night, FIO2 has increased to 25-28%. Slight increased work of breath noted. Will reassess after time allowed to settle after cares. Breath sounds clear but squeaky. Discussed with NNP need for Lasix, but will ho;d off for now due to low Na recently.\nP. Cont to monitor FIO2 requirement as well as work of breath.\n" }, { "category": "Nursing/other", "chartdate": "2122-11-23 00:00:00.000", "description": "Report", "row_id": 2039437, "text": "0700- NPN\n\n\nRESP: Cont on Prong CPAP of 5 with FiO2 mainly 24-27%. RR\n40's-60's. LS clear/=. Mild IC/SC retractions. A/B spell\nx 1 requiring mild stim and increase in O2. Occasional\ndrifts in O2 sats to high 70-low 80%'s. On Caffeine. P:\nCont to monitor and wean O2 as tolerated.\n\nFEN: TF=150cc/kg/d of BM32 with PM (33cc Q4hr) PG. No\nspits. Max aspirate of 1cc. Abdomen benign, girth stable\nat 22.5-23cm. Pt is voiding, trace stools x 2. On Ferinsol\nand Vit E. P: Cont to monitor.\n\nDEV: Temps stable in air-controlled , pt\ndressed/swaddled. MAE, alert/active with cares. Sleeps\nbetween cares. Sucks pacifier and brings hands to face for\ncomfort. Fontanels soft/flat. AGA. P: Cont to support\ngrowth and development.\n\nPARENTING: called x 1, updated by RN, asking\nappropriate questions. plan to visit this evening\nfor care. P: Cont to support/educate .\n\n\n" }, { "category": "Nursing/other", "chartdate": "2122-11-23 00:00:00.000", "description": "Report", "row_id": 2039438, "text": "Respiratory Care\nBaby continues on prong CPAP 5 with 02 req 24-33% this shift. BS clear. Nares sxn x1 for mod amt cldy secretions. RR 50's-70's. One mild stim with desat as of this writing. On caffeine. Will cont CPAP.\n" }, { "category": "Nursing/other", "chartdate": "2122-11-24 00:00:00.000", "description": "Report", "row_id": 2039439, "text": "NPN\n\n\n2.Resp: Infant remains on prong CPAP 5, 24-33% Fi02. Lung\nsounds are clear and equal with mild SC/IC retractions.\nInfant is breathing comfortably with RR 30s-70s, 02 sats\n93-99%. He has been suctioned q care for small-moderate\nclowdy secretions from mouth and moderate yellow secretions\nfrom nares. He remains on caffeine with one spell thus far\nthis shift. Continue to monitor respiratory status.\n\n3.FEN: Infant's weight tonight 1360 grams (increased 55g).\nHe remains on TF 150cc/kg/day of BM/PE 30cal/oz with Promod.\n He is tolerating feeds well with no spits, max aspirate\n0.8cc. Abdomen is pink and soft, no loops, with abdominal\ngirth 23-24cm. He is voiding and stooling (large yellow\nstool). He remains on vitamin E and Fe+ dietary\nsupplements. Continue to monitore FEN status.\n\n4.DEV: Infant remains swaddled on sheepskin in an air\n. He is alert and active with cares, wakes for\nfeeds. He brings hands to face and sucks vigorously on\npacifier. Continue to support growth and development.\n\n5.: Both in this evening for care time.\n are loving and appropriate. Mom held infant for 60\nminutes, infant tolerated very well. Continue to support\n and keep informed.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2122-11-24 00:00:00.000", "description": "Report", "row_id": 2039440, "text": "RESPIRATORY CARE NOTE\nBaby remains on bubble CPAP 5 via Prongs FiO2 24-33%. Suctioned nares for mod-lg amt of yellow secretions. Breath sounds are clear. RR 30-70's stable on CPAP cont to follow.\n" }, { "category": "Nursing/other", "chartdate": "2122-11-24 00:00:00.000", "description": "Report", "row_id": 2039441, "text": "Newborn Med Attending\n\nCont on CPAP%, 25-305 O2. Occ spells. AF flat, clear BS, no murmur, abd soft, MAE. WT= up 55, on 150 cc/kg/d BM30 with PM, PG.\nA/P: Growing infant with CLD and AOP. Wean O2 as tolerated. Monitor for spells.\n" }, { "category": "Nursing/other", "chartdate": "2122-11-24 00:00:00.000", "description": "Report", "row_id": 2039442, "text": "Respiratory Care Note\nPt remains on +5 prong CPAP, FiO2 26-34% t/o shift. BS clear. RR 30-50's. Suctioned for sm amount cloudy secretions. No spells thus far this shift. Will continue on CPAP and will monitor.\n" }, { "category": "Nursing/other", "chartdate": "2122-11-07 00:00:00.000", "description": "Report", "row_id": 2039346, "text": "NPN DAYS\n\n\nAlt in Resp: Remains on NP with FiO2 21% most of the\nshift. LS clear and equal. Mild IC/SC retractions. Sxn'd\nq4hrs. Spell x1. Remains on caffeine. Will try to wwean baby\nti today.\n\nAlt in FEN: TF 150cc/kg/day BM30PM. Tolerating feeds without\nproblems. spits. Minimal aspirates. Voiding and stooling.\nBelly soft and full with active bowel sounds. Will continue\nwith current plan of care.\n\nGrowth and Dev: Temp stable in servo . Awake and\nalert with cares. Nested on sheepskin with boundaries in\nplace. Will continue to provide for developmental needs.\n\n: No contact so far this shift.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2122-11-07 00:00:00.000", "description": "Report", "row_id": 2039347, "text": " Care\nPt recieved on NP CPAP +6cm's with 21% fio2. Pt suctioned for a sm amt of thick yellow secretions. CPAP decreased from 6 to 5cm's with no increase in fio2. Plan is to follow on CPAP.\n" }, { "category": "Nursing/other", "chartdate": "2122-11-08 00:00:00.000", "description": "Report", "row_id": 2039348, "text": "2. ResP: O: Received infant on np CPAP of 5cm, FiO2 @ 26%,\nRR 30-50s. Around mn, infant was desatting, needing more O2,\nand was sxned w/ his cares. It was impossible to pass the\nsxn cathether all the way down the np tube and infant\nstarting exhibiting increased WOB. Np tube was pulled and\nwas found to be clogged w/ secretions at the end. Infant was\nsxned for a large amt of secretions and placed on a nc,\nlow-flow, 100% FiO2 and in 50cc flow. So far he seems\ncomfortable, lying on his side and vigorously sucking on a\nbinkie. No a/bs so far tonight. Infant remains on caffeine.\nA: Trialling nasal cannulla. P: Monitor. Meds as ordered.\nSxn prn.\n\n3. F/N: O: Infant is on 150cc/k/d of 30cal BM/PE w/ promod,\ndelivered q 4 hours via gavage. Abd is benign, he is voiding\nand stooling g- stools. No spits, asps. He gained 7g. A:\nTol feeds, gaining a bit of wt. P: Monitor. Continue w/\nplan.\n\n4. G/d: O: Infant was kangarooed for @ 90 and did very\nwell, sucking on his binkie most of the time. He is active\nw/ cares and loves that binkie. He sleeps well inbetween\ncares. A/P: Continue to support infant needs.\n\n5. : O: Mom was in to visit and do cares. She\nkangarooed and both infant and Mom did well. Later, infant's\nAunt visited as well. called for an update too. A:\nLoving, involved Mom. P: Continue to support.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2122-11-08 00:00:00.000", "description": "Report", "row_id": 2039349, "text": "RESPIRATROY CARE NOTE\nBaby received on NP CPAP 5 FiO2 26%. At 1am NP tube pulled, nares suctioned for lg amt of yellow secretions. Breath sounds clear. Decision made to try off CPAP. Started on nasal cannula low flow 50cc FiO2 100%. Sat's were high Changed to nasal cannula 300cc FiO2 40%. Baby looks comfortable off CPAP. Will cont to monitor closely.\n" }, { "category": "Nursing/other", "chartdate": "2122-11-08 00:00:00.000", "description": "Report", "row_id": 2039350, "text": "Neonatology Attending\n\nDay 23- CGA 31 0/7 weeks\n\nRemains on nasal cannula at 300 cc/ flow with 40% oxygen. RR 30-50s. Clear breath sounds. Had one bradycardia episode over last 24 hours. No murmur. HR 160s. Weight 878 gms (+7). TF at 150 cc/kg/d- BM/PE 30 with Promod. Stable temperature in incubator. Passing stool.\n\nTransitioned from CPAP. Will continue to monitor closely. Hope to wean flow. Tolerating feeds with good weight gain overall. No changes for now.\n\n" }, { "category": "Nursing/other", "chartdate": "2122-12-11 00:00:00.000", "description": "Report", "row_id": 2039528, "text": "Nursing progress note\n\n\n #2 O: Remains on 500cc flow nasal cannula, 45-70% O2.\nBreath sounds equal & clear at bases but has some UA\nstuffiness. Nares sx'd X's 1 for thick pale yel plug form L\nnares & small pale yel R nares. Tachypneic, 84-100. Remains\non caffeine. Baby had 1 with apnea & desat requiring\nmild stim & inc O2. O2 sats labile requiring inc O2 at\ntimes. A: Labile O2 requirement. P: Suction nares prn, cont\nto assess.\n#3 O: Wgt up 75 gms. Cont to receive 150cc/k/d PE 31 cal pg,\nq4h. Feeds given over 50 . ABd soft with active bowel\nsounds & no loops. Voiding with diaper changes. No stool\nthis shift. No spits, minimal aspirates. A: Tolerating feeds\n& gaining wgt. P: Cont to assess.\n#4 O: Temp stable swaddled in crib. Alert with cares. Sucks\non pacifier. A: Stable. P: Cont to assess.\n#5 O: phoned for update.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2122-12-11 00:00:00.000", "description": "Report", "row_id": 2039529, "text": "Newborn Med Attending\n\n Cont in o2 per NC. Occ spells. AF flat, clear BS, no murmur, abd soft, MAE. WT=2100 up 75, on 150 cc/kg/d PE31 with PM PG.\nA/P: Infant with CLD and AOP. Wean o2 as tolerated. monitor for spells.\n" }, { "category": "Nursing/other", "chartdate": "2122-12-11 00:00:00.000", "description": "Report", "row_id": 2039530, "text": "NPN DAYS\n\n\nAlt in Resp: Remains on NC 500cc flow, 60-65% FiO2. LS clear\nand equal. Mild UAC. Tachypneic at times. One time dose of\n4mg lasix given this am. Will continue to monitor closely.\n\nAlt in FEN: TF 150cc/kg/day PE31/BM31, gavaged over 50mins.\nBelly benign. Voiding, no stool. Minimal aspirates. No\nspits. Remains on VitE and FeSO4. Will continue with current\nfeeding plan.\n\nGrowth and Dev: Temp stable in open crib. Baby sleeping most\nof the shift, wakes with cares. ? inguinal hernia vs. edema.\nWill cotninue to provide for developmental needs.\n\n: in for quick visit this morning. Updated him on\n- status. Will continue to offer support and\nteaching.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2122-12-12 00:00:00.000", "description": "Report", "row_id": 2039531, "text": "NPN 1900-0700\n\n\n1. Resp: Infant remains in NC 500cc flow and 50-70% FiO2.\n(Mostly 55-60%). Baseline SCR. LS clear. RR=60-90's.\nInfant continues to be tachypneic, but appears comfortable.\n aware of RR and fiO2 requirement. No spells. Rec'd\nlasix yesterday am, but continues to have mod generalized\nedema.\n\n2. FEN: WT=2090gms (down 10gms s/p lasix yesterday).\nTF=150cc/k/day PE/BM 31. Gavaged 52cc over 50\". Max asp =\n2cc. No spits. U/O for past 12hrs = 2.6cc/k/hr. Had 2\nsmall brown stools o/n. Abd is soft and round with active\nbs.\n\n3. G&D: is quietly alert and active with cares.\nSleeps well between cares. Uses pacifier to comfort self.\nBrings hands to face. Temps stable swaddled in open crib.\nAFSF.\n\n4. : in at . Independent with cares.\n held throughout gavage feeding. were\nupdated at bedside.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2122-12-30 00:00:00.000", "description": "Report", "row_id": 2039606, "text": "Neonatology Attending\n\nDay 75\n\nRemains on nasal cannula oxygen at 50-100 cc/ oxygen. Restarted on Diuril. RR 40-70s. Mild subcostal retractions. Murmur heard. HR 140-170s. Pale, pink. BP mean 60. Weight 2860 gms (+85). TF at 130 cc/kg/d- PE 28- all po. Breast fed last night. Passing stool. On vitamin E and iron. Stable temperature in open crib. Active, alert.\n\nMild chronic lung disease. Will continue to monitor closely. Will adjust Diuril dose. Gaining weight well. Will reduce caloric concentration to 26/oz. Feeding improving.\n\n" }, { "category": "Nursing/other", "chartdate": "2122-12-30 00:00:00.000", "description": "Report", "row_id": 2039607, "text": "PCA 0700-1900\n\n\n#2 O: Infant on 75cc NC @ 100% o2; maintaining 94-98% sats.\nLungs are clear and =, with upper airway congestion.\nSubcostal retractions noted and no spells thus far. Remains\non Diuril. A: Infant maintaining adequate o2 sats with NC.\nP: Continue to monitor infant for A's and B's.\n\n#3 O: Total fluids= restricted at 130cc/k/day of BM26 or\nPE26. Taking 62cc q4 hours; all PO feeds. No drifts or spits\nthus far. Abdomen benign; no loops noted. Voiding and trace\nstools with cares. A: Infant tolerating PO feeds well. P:\nContinue to encourage PO feeds.\n\n#4 O: Temps stable. Wakes and is alert for cares; sleeps\nwell in between. Brings hands to face for comfort. Umbi\nhernia remains soft and pink. A: AGA. P: Continue to monitor\ndevelopment.\n\n#5 O: in to visit at 1000. Mom and plan to visit for\n1600 cares. A: are involved. P: Continue to support\nand update family.\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2122-12-30 00:00:00.000", "description": "Report", "row_id": 2039608, "text": "Neonatology- Physical Exam\n\nInfant remains in NC. Active, alert in an open crib, AFOF, sutures opposed, good tone. BBS clear and equal with good air entry, mild SC retractions. Gr murmur, pulses +2, pink, RRR. Abdomen soft, non-distended with active bowel sounds, no HSM, tolerating feeds. Please refer to attending progress note for detailed plan.\n" }, { "category": "Nursing/other", "chartdate": "2122-12-30 00:00:00.000", "description": "Report", "row_id": 2039609, "text": "Agree with above assessment and plan written by , PCA. Meds given as ordered. I have also examined this infant.\n" }, { "category": "Nursing/other", "chartdate": "2122-12-31 00:00:00.000", "description": "Report", "row_id": 2039610, "text": "NPN 1900-0700\n\n\nRESP: Continues on NC 100%, 75-125cc of flow. O2sat 92-99%.\nOccasional drifts, QSR. Had one dusky spell with bottling,\nrequiring removal of bottle, mild stim and increase in O2.\nRR 50-70. Mild SC rtx. LS clear and equal. Some UAC noted.\nOn diuril.\n\nFEN: wt=2855g (down 5g). TF restricted at 130cc/kg/d of\nBM/PE26. Equals 62cc q4hrs. All PO's. Bottling well, taking\nadequate amts. Belly soft, +BS, no loops, voiding, stooling.\nOn vit E and Fe. Plan to send nutrition with next\ncares.\n\nG&D: Temps stable, swaddled with hat. Alert and active with\ncares. Sleeps well between. Given bath.\n\n: Called X1, left message that they were not feeling\nwell and would not be in to visit tonight.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2122-12-31 00:00:00.000", "description": "Report", "row_id": 2039611, "text": "Neonatology\nRemains in NCO2. Comfortable appearing. Back on diruil.\nInetrmittent dseats with choking overnight.\n\nWt 2855 down 5. Tolerating feeds at 130 cc/k/d of 26 cal. Abdomen benign. Lytes in good range.\n\nAwaiting wean from O2.\n" }, { "category": "Nursing/other", "chartdate": "2122-12-31 00:00:00.000", "description": "Report", "row_id": 2039612, "text": "Neonatology\nDiruil dose to be titrated upward.\n" }, { "category": "Nursing/other", "chartdate": "2123-01-13 00:00:00.000", "description": "Report", "row_id": 2039684, "text": "NPN \n\n\n\n #2. O: Rec infant in NC 100% 50cc flow. Weaned flow to 25cc\nat 1100 w/sats >94%. Had 1 w/bottling to 69% and HR\nwent down to 88. QSR w/removal of bottle. Had a few drifts\nto the 80's after that w/bottling, again QSR. RR 50-70. Mild\nSC retractions. LS cl/=. Mild upper airway congestion. Conts\non diuril and KCL supps. A: Stable in NC. P: Cont to\nevaluate infant in lower flow settings w/bottling. req\nincrease flow rate just for pos.\n\n #3. O: TF 130cc/k ad lib demand schedule BM/E20. Waking\nevery 3-4hrs and taking 60-85cc. Abd soft w/active BS, no\nspits, no loops, voiding in gd amts, stooled x1 heme-. A:\nTol current feeding plan. P: Cont to nutritional needs.\n\n #4. O: Temp stable swaddled in OC. Wakes for feeds. sleeps\nwell between. MAEW. Loves pacifier. AF soft and flat. A: AGA\nP: cont to support G&D.\n\n #5. O: in for 0900 cares. Gave a bottle and\nchanged diaper. Asking approp questions. updates given at\nthe bedside. Mom called for updates. She will be in at\n-2100. They are closing on their house on friday and\nmoving this w/e. Pot d/c will be next week. A: Involved\nloving . P: Cont support, keep updated and educate.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2123-01-13 00:00:00.000", "description": "Report", "row_id": 2039685, "text": "Neonatology- Physical Exam\n\n remains in NC. Active, in an open crib, AFOF, sutures opposed, good tone. BBS clear and equal with good air entry. No murmur, pulses +2, pink, RRR. Abdomen soft, non-distended with active bowel sounds, no HSM, tolerating feeds, small umbilical hernia, mild scrotal edema. Please refer to attending progress note for detailed plan.\n" }, { "category": "Nursing/other", "chartdate": "2123-01-14 00:00:00.000", "description": "Report", "row_id": 2039686, "text": "PCA Note\n\n\nRESP: Infant requiring 100% FiO2 25-50cc flow via NC. O2\nsat. >94% with occassional drifts to mid-high 80's when\nbottling and needs 50cc flow during feeds. RR 40-60'S while\ncalm but can increase to 70's when bottling. No attempt to\nwean O2 flow tonight. LS clear bilat. with mild subcostal\nretractions. Continue to monitor respiratory issues closely\nand wean O2 NC as tolerated.\n\nFEN: Infant is on an ad lib/demand schedule. Bottles q4-5h.\nPresent weight tonight 3310g, down 5g. TF 130cc/kg/day\nof BM or E20; 73cc Q4 or 55cc Q3. TF 147cc/kg tonight.\nAbd. benign. Infant is voiding, large stool x1. No spits\nthus far. Continue to encourage PO's.\n\nDEV: Infant is swaddled in OAC. Temps have been stable.\n and active with cares. MAE. Very irritable at times\nbut easily consolable. Needs help with pacing himself while\nbottling. Enjoys his binky. Sleeps well after a good\nfeeding. Continue to support developmental issues.\n\n: Mom and in tonight at . Mom held infant.\nVery loving and asking appropriate questions. Continue to\nsupport and update.\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2123-01-14 00:00:00.000", "description": "Report", "row_id": 2039687, "text": "NPN\nAgree with above note by PCA Tran.\n\nD-stick 80 @ 0515. Lytes sent; results pending.\n" }, { "category": "Nursing/other", "chartdate": "2123-01-14 00:00:00.000", "description": "Report", "row_id": 2039688, "text": "Neonatology\nSpent much of eysterday in 25 and even 13 cc of flow. Back up to\nWill attempt to wean from O2.\n\nWt 3310. Bottling well. Needing increased O2 flow with feeds. Lytes in good range.\n\nStage 2 Zone 2 bilaterally.\nSynagis given on 28th.\n\nAwaiting maturation of resp function.\n" }, { "category": "Nursing/other", "chartdate": "2122-10-26 00:00:00.000", "description": "Report", "row_id": 2039271, "text": "NPN 7a-7p\n\n\n#2: remains orally intubated on settings: 15/5x12.\nFIO2 mostly 21-25%. ^'ed 30-40% with cares. RR stable.\nThis am BBS dim and ? few crackles on right. After retaping\nETT aeration greatly improved. BBS now coarse-clear/=.\nSWx'ed for red-old blood tinged secretions. Team aware. No\napnea/brady spells noted. Caffiene given as ordered. A:\nstable on current vent settings P:Cont to monitor and\nprovide support as needed.\n\n#3: TF: 150cc/k/d. Currently on D10W with 2meq NaCl &\n2meqKCl with 1/2uhep/cc infusing via patent PICC at\n35cc/k/d. D/S stable. Enteral feeds adv'ed at 17care to\n115cc/k/d. Now tol'ing 13cc q4hrs gavaged over 40mins. Sm\nspit x1. Min asp, essentially benign. Few pale green specs\nnoted. aware. Abd soft, +, no loops. Ag stable.\nVoiding qs. Stooling- heme negative. Sm bruise noted in\nright groin. assessed, states better. A:\nadv'ing enteral feeds P:Cont to adv EF's by 15cc/k/ as\ntol'ed. Follow wt and exam. Monitor tol to feeds.\n\n#4: Temps stable in servo . is alert/active\nwith cares. MAE. Fonts soft/flat. Settles easily. A: AGA\nP:Cont to support dev needs.\n\n#5: Mom in at 15 for family meeting. Stayed for 16care and\nlearned to take temp and change diaper. called for\nupdate. A: Involved family P:Cont to support and educate.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2122-11-08 00:00:00.000", "description": "Report", "row_id": 2039351, "text": "Neonatolopgy- Progress Note\nPE: remains in his , in nasal cannula O@, bb cl=, mild subcostal retreactions, rrr soft systolyc murmur, pulses 2++, abd soft, nontender, V&S, afs sutures split\n\nSee attending note for plan\n" }, { "category": "Nursing/other", "chartdate": "2122-11-08 00:00:00.000", "description": "Report", "row_id": 2039352, "text": "NPN 1730\n\n\n#2 Resp: Infant remains on a nasal cannula of 300cc flow,\n35-40%. RR 30-60. Br. snds clear. Suctioned X1 w/ tb syringe\nfor small amt secretions. spells X3 today 52, 68, 71,\nw/ apnea and mod stim X1. Remains on caffeine. O2sat 90-97.\nA: Occ spells.\nP: Cont w/ plan, assess for increasing # spells.\n#3 F/N: Infant remains on 150cc/kg/d PE30/BM30 + PM, 22cc q\n4 hrs over 50 mins. Abd full and soft, bowel snds active.\nTrace amts of stool passed. No spits today.\nA: Tolerating feeds.\nP: Cont to monitor for feeding intolerance.\n#4 G/D: Infant remains on servo heat control w/i a nested\nsheepskin. Extremities to midline. Awake and alert w/ cares.\nA: AGA 31 wks.\nP: Cont dev. supports.\n#5 : No contact this shift but they are expected this\neve to kangaroo.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2122-11-09 00:00:00.000", "description": "Report", "row_id": 2039355, "text": "Nursing Progress Note\n\n\nRESP: Infant remains in NC; 400cc flow, FiO2 33-40%. RR\n40-60s, occasionally in the 70s. LS clear/= & slightly\ndiminished, baseline ic/sc rtxns. 3 documented spells today;\ncaffiene dose increased in response to ~8spells in\nyesterday's 24h period. P: Cont to monitor for As & Bs.\nMonitor need for addtional resp support.\n\nFEN O/A: TF @ 150cc/k/d. BM 30 w/ Promod. Infant receives\n23cc q4h pg. Tolerating feeds gavaged over 50 minutes, no\nspits, minimal aspirates. Abdomen soft/full, girths stable,\nactive BS. Voiding/stooling (heme neg). Continues on Vit E &\nFe. P: Cont to monitor for s/s of feeding intolerance.\n\nG&D O/A: Temps stable in an servo , weaning heat\nsupport as tolerated. - is quietly A/A with cares,\nlikes pcacifer. Opens eyes, grabs Mom's finger. AFSF,\nsutures spread. P: Cont to support developmental needs. 30\nday HUS nest week.\n\nPAR O/A: Mom & each called x1. Mom in for 1600 cares.\nIndependent with diaper changes & temp. Asking apprpriate\nquestions. Mom concerned that her milk supply is tapering\noff. Lactation consult scheduled for 1:30 pm tomorrow. P:\nCont to support NICU family.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2122-11-09 00:00:00.000", "description": "Report", "row_id": 2039356, "text": "NPN Adendum\nInfant placed on Bubble prong CPAP 6cm @ 1800 for increased WOB, sl. diminished LS & increased FiO2 requirement. Spoke with Mother this afternoon re: resp status & spells. Discussed the possibility that infant may need CPAP sometime this evening or overnight. Mom verbalized her understanding to this RN & asked appropriate questions.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2122-11-09 00:00:00.000", "description": "Report", "row_id": 2039357, "text": "Neonatology NP note\nnested in \nAFOF, sutures opposed\nmild subcostal retractions , lungs clear/=, slughtly decreased at bases\nl/Vl SEM at LUSB only, pink and well perfused\nabdomen soft\ngood tone.\n" }, { "category": "Nursing/other", "chartdate": "2122-11-10 00:00:00.000", "description": "Report", "row_id": 2039358, "text": "Nursing Progress Note 1900-0700\n\n\nResp:Infant in NP-CPAP-6,FIO2 21-28%.RR30-60's with\nIC/SC retractions.LS remain clear and equal.Infant with no\nA's and B's thus far.Cont's on Caffiene as ordered.A:Alt.\nResp. d/t Prematurity P:Cont. to assess resp.\n\nF/E/N:Infant cont's on TF 150cc's/kg/day,rec.BM30 with\nPromode 23cc's q 4 hrs. gavaged over 50 .Weight=0.924kg\nup 14 grams.Abd. soft and full,pos bs,no loops or\nspits,minimal aspirates,girth=20.Infant voiding and stooling\nheme negative stool.A:Stable P:Cont. to assess tolerance of\nfeeds and monitor weight gain.\n\nG/D:AFSF.Sutures spread.Infant alert and active with cares\nhowever intermitently irritable b/t cares.Calms with\npacifier and containment.Infant remains in Servo\n,temp stable.Infant in flex position with nested\nboundaries.Bringing hands to face and mouth.A:AGA P:Cont. to\nsupport growth and dev.\n\n:No contact from thus far.A/P:Cont. to\nupdate,support,and educate.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2122-11-10 00:00:00.000", "description": "Report", "row_id": 2039359, "text": "RESPIRATORY CARE NOTE\nBaby was placed back on bubble CPAP 6 FiO2 21-28% @ 1800 hrs. Baby was was having increased work of breathing. Suctioned nares for mod amt of yellow secretion. Breath sounds are clear. RR 30-60's stable on CPAP cont to follow.\n" }, { "category": "Nursing/other", "chartdate": "2123-01-01 00:00:00.000", "description": "Report", "row_id": 2039623, "text": "Neonatology Progress Note\nPatient examined and discussed with team. Evaluation and plan per Dr. note.\n\nPhysical exami:\nGeneral: alert and vigorously rooting. Pale pink.\nSkin: small hemangioma on left arm.\nHEENT: AFOF sutures split. Eyes clear. NC in place. MMMP\nChest is clear with comfortable resp pattern.\nCV RRR Gr murmur radiatiating to axilla. Pulses plus 2 and equal.\nAbd: sogt, protruberant. Active BS.\nGU. L hydrocele. testes palpable.\nEXt: MAE, symmetric tone and reflexes.\n\n" }, { "category": "Nursing/other", "chartdate": "2123-01-02 00:00:00.000", "description": "Report", "row_id": 2039624, "text": "PCA 1900-0700\n\n\n2 infant remains in NC FIO2 100% 50-75cc flow, RR 40-80,\nSATing 93-100%, lung sounds cl=, sc retractions, no spells,\nno deSATs. P:cont. to monitor.\n\n3 infant's current weight 2940 up 70g, infant is on an\nadlib feeding schedule with a TF . 130cc/kg/d, infant\nbottling 65-77cc q3.5-4 hours. abd. soft, bs+, no loops,\nvoiding qs, large stool X1 heme. neg., no spits. P:cont. to\nsupport nutritional needs.\n\n4 infant remains swaddled in OAC, temp. stable, a/a with\ncares, settles well in between, wakes for feeds, brings\nhands to face. P:cont. to support dev. needs.\n\n5 mom and in to visit, independant with care.\nP:cont. to update on infant's progress.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2123-01-02 00:00:00.000", "description": "Report", "row_id": 2039625, "text": "NPN7P7A\nAGREE WITH THE ABOVE NOTE WRITTEN BY COWORKER.\nADD,\nTF INCREASED TO 130CC/K/D ADLIB. INFANT APPEARS MORE SETTLED BETWEEN CARES, SLEEPING 3-4 HRS BETWEEN FEEDINGS. KCL ADDED TO MED REGIME . OBTAIN LITES ON MON AM.\n" }, { "category": "Nursing/other", "chartdate": "2123-01-17 00:00:00.000", "description": "Report", "row_id": 2039701, "text": "Nursing\n\n\n#1O: Continues in room air with O2 sats> than 92% with rare\nquick . br. sounds clear with some upper airway\ncongestion, mild retractions. Diuril and KCl given as\nordered.\n#3O: Wt. up 5 g on 20cal Enfamil. Breast feeds once a day\nwell then bottles well with a yellow nipple, no spits.\nVoids qs, sm. stool, belly soft.\n#4O: Wakes for feeds, responsive to voice, loves pacifier\nand being snuggled.\n#5O: in last eve. after moving all day into new\nhouse. Talked about meds son is on and showed how to draw\nup the Diril and KCl. Told d/c could be soon if all\ngoes well. very excited about this.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2123-01-17 00:00:00.000", "description": "Report", "row_id": 2039702, "text": "Neonaotlogy Attending\nDOL 92 / CGA 40-6/7\n\nIn room air for 24 hours! Still some increase wob with bottling but otherwise in no distress. On diuril.\n\nSoft murmur, not noted overnight. BP 79/43 (57).\n\nWt 3295 (+5) on ad lib dmeand with intake BM/E20 148 cc/kg/day yesterday. Voiding and stooling normally. Abd benign. On diuril, vit E and ferrous sulfate.\n\nTemeprature stable in open crib.\n\nA&P\n27-3/7 week GA infant with CLD\n-Continue to monitor oxygen saturations in room air\n-Will recheck hct/retic this week.\n-Follow murmur clinically\n-Discontinue vitamin E and start vidaylin\n" }, { "category": "Nursing/other", "chartdate": "2123-01-18 00:00:00.000", "description": "Report", "row_id": 2039707, "text": "NPN 7A-7P\n\n\n#2 Remains in RA, Sao2's low 90's. Transient 's to 80's\nduring bottling (is very vigorous to eat)with color change\nbut returns to baseline once bottle removed. No spontaneous\n's or 's. Con't to monitor.\n\n#3 On ad lib amounts/demand schedule. Bottling frequently q\n3 hrs today, usually taking 90cc's (+ snacks). Awake b/t\nfeeds but may take an occasional light nap . in and\npicked him up to visit a bit, also gave him a 20cc \"snack\".\nIs voiding, stooled med/lge this AM. (Usually strains to\nstool and can disrupt sleep). Will con't to assess\ncoodination of feeds/toleration.\n\n#4 Maintaining temp in crib, very and can be irritable\nunless held. Bottling successfully but \"sputters\" at times.\nSao2's low-mid 90's on day of RA. Monitor.\n\n#5 in this afternoon to visit; have moved in to\ntheir new home in Hubberston,MA and are settling in.\nVisiting daily. Will be in again this evening. Informed of\nDiuril dose change and will need to teach administration.\nCon't to inform.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2123-01-18 00:00:00.000", "description": "Report", "row_id": 2039708, "text": "Neonatology- Progress Note\nPE: in his open crib, in room air, bbs cl=, periods of tachypnea, rrr systolyc murmur soft, abd soft, nontender, (deferred genial exam) afso, active with interventions\n\n\nSee attending note for plan\n" }, { "category": "Nursing/other", "chartdate": "2123-01-19 00:00:00.000", "description": "Report", "row_id": 2039709, "text": "PCA Note\n\n\nRESP: Infant remains in RA; O2 sat>95%. RR 30-70's. LS\nclear bilat. with mild intercostal retractions. Infant\noccassionally drifts to the 80's during bottling but is\nquickly self-resolved. Infant displays increased WOB with\nbottling. Continue to monitor respiratory status.\n\nFEN: Present weight tonight 3435g; up 25g. Infant is on PO\nad lib schedule bottling 80-114cc Q4-5h of E20 or BM. \ntook in 197cc/kg. Abd benign - soft, round, good bowel\nsounds, no loops. He is voiding; tr. stool x1. Continue to\nencourage PO's.\n\nDEV: Infant is swaddled in OAC. Temps have been stable.\nHe is and active with cares, MAE. He enjoys sucking\non his fingers and binky. Infant sleeps well in between\ncares. Continue to support developmental needs.\n\n: No contact thus far tonight from mom or .\nContinue to update, support and teach for discharge.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2123-01-19 00:00:00.000", "description": "Report", "row_id": 2039710, "text": "PCA Note\nNursing Progress Note\n Agree with above note and assessments.\n" }, { "category": "Nursing/other", "chartdate": "2122-10-20 00:00:00.000", "description": "Report", "row_id": 2039226, "text": "Rehab/ OT\n\n observed at the bedside during afternoon cares. Plan posted including infant strengths, stress signals, and ways to optimize infant comfort. Parents unavailable during observation. To meet with them next week. OT to follow.\n" }, { "category": "Nursing/other", "chartdate": "2122-10-21 00:00:00.000", "description": "Report", "row_id": 2039227, "text": "Respiratory Care\nBaby remains on cpap 6 21%.BS clear throughout.Sx for mod yellow secs.CBG drawn,7.28/47,with no change at this time.No spells documented,on caffeine.\n" }, { "category": "Nursing/other", "chartdate": "2122-10-21 00:00:00.000", "description": "Report", "row_id": 2039228, "text": "Respiratory Care\nHad 2 spells,sx after 2nd spell for copious thick yellow in back of throat.\n" }, { "category": "Nursing/other", "chartdate": "2122-10-21 00:00:00.000", "description": "Report", "row_id": 2039229, "text": "Nursing Progress Note\n\n\nRESP O/A: Infant remains on NP CPAP 7; FiO2 21% w/ increased\nO2 w/ cares. RR 40-70s, LS clear/=, ic/sc rtxns. Sxn for\nlarge amnts thick yellow secretions. Two spells noted\novernight w/ apnea, increased O2 & stim needed for resolve.\nContinues on caffeine. P: Cont to monitor resp status.\nMonitor for As & Bs.\n\nFEN O/A: BW: 695g, Current Wt: 575g (down 20g) TF @\n150cc/k/d. Enteral feeds @ 20cc/k/d; BM20. Tolerating 2.3cc\nq4h pg. Max aspirate .4cc, bilious. IVF @ 130cc/k/d, PN D8 &\nIL running through a DLUVC. Catheter site appears slightly\nred & moist. D-sticks 81 & 91. Abdomen soft/flat, soft\nhypoactive. Voiding/no stool. Lytes drawn @ 0500: results\npending. P: Cont to monitor for s/s of feeding intolerance.\nMonitor UVC site. Monitor I&O.\n\nPAR O/A: Dad called x1 for an update.\n\nC/V O/A: Infant appears pale, BPs stable. Brisk cap refill &\npulses WNL. No audible murmur. P: Cont to monitor for PDA.\n\nBILI O/A: Continues under sigle phototherapy. Bili drawn @\n0500: results pending. P: Cont to montior.\n\nG&D O/A: is nested on sheepskin in a servo .\nTemps stable. A/A with cares, opens eyes. Settles well b/t\ncare times. AFSF, PFSF, sutures OR. P: Cont to support\ndevelopmental needs.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2122-10-31 00:00:00.000", "description": "Report", "row_id": 2039299, "text": "PE: well appearing, AFOF, normal S1S2, no murmur, breath sounds coarse bilaterally equal, mild ic/sc retx. abdomen soft, nontender, nondistended, ext warm, well perfused\n" }, { "category": "Nursing/other", "chartdate": "2122-10-31 00:00:00.000", "description": "Report", "row_id": 2039300, "text": "Neonatology Attending Progress Note:\nDOL #15\non 15/5 x 12 25-30%, large amount oral secretions\nno spells, on caffeine, RR=30-50's\n150-170's HR, TF=150cc/kg/d BM 26 with Promod, wt=757 (inc 19)\nheme negative stool, minimal aspirates, 1 spit this am\nPE: see addendum\nImp/Plan:x-27 week infant with apnea, advancing on feeds.\n--continue intubation, attempt trial off early this week\n--monitor for spells\n--increase to 28 calories\n" }, { "category": "Nursing/other", "chartdate": "2122-12-02 00:00:00.000", "description": "Report", "row_id": 2039485, "text": "NPN DAYS\n\n\nAlt in Resp: Received baby on NC 500cc 40%FiO2. RR up to\n100's, moderate SC retractions and lung sounds diminished\neven more so at 12pm than at 8am. Sxn'd x1 for mod\nsecretions. Because of tachynea and increased WOB, baby\nplaced back on prong . Weaned to CPAP5 2hrs later. Baby\nis much more comfortable now. No more increased WOB noted.\nRR now in the 60's. Spell x1. Remains on caffeine. Will\ncontinue to monitor closely.\n\nAlt in FEN: TF 150cc/kg/day BM31, gavaging feeds over 1hour.\nNo spits, minimal aspirates. Belly benign. Stool x1, heme -.\nMoerate generalized edema. Continue with current feeding\nplan.\n\nGrowth and Dev: Temp stable in off . Awake and\nquietly alert wtih cares. Resting well between cares. Will\ncontinue to provide for developmental needs.\n\n: Mom and both called for updates. notified\nthat - was placed back on CPAP. visit daily\nat 8pm. Will continue to provide support and updates.\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2122-12-02 00:00:00.000", "description": "Report", "row_id": 2039486, "text": "Respiratory Care\nBaby placed back on cpap 6 for ^ wob and diminished bs.Weaned down to cpap 5 after 2 hrs.Fio2 ranges from 25-30%.Appears comfortable on cpap.\n" }, { "category": "Nursing/other", "chartdate": "2122-12-02 00:00:00.000", "description": "Report", "row_id": 2039487, "text": "Newborn Med Attending\n\nPlaced back on CPAP for increased work of breathing.\n" }, { "category": "Nursing/other", "chartdate": "2122-12-03 00:00:00.000", "description": "Report", "row_id": 2039488, "text": "Respiratory Care Note\nPt. continues on 5cmH2O of nasal prong CPAP and 21-29% FIO2. BS clear. To follow.\n" }, { "category": "Nursing/other", "chartdate": "2122-12-03 00:00:00.000", "description": "Report", "row_id": 2039489, "text": "NPN 11p-7a\n\n\n#2: Infant conts on NPCPAP of 5cms, FIO2 21-29%. RR 40-70s,\nclear and equal with some UAC. Sx'd x1 for mod amt of pale\nyellow secretions. Mild IC/SC retractions noted. Color is\npink and well perfused. No spells or desats noted at this\nwriting. Conts on caffiene. A: STable on CPAP. P: cont with\nplan.\n#3: TF150cc/kg/d of BM/PE31 PG. Abdomen is benign, voiding,\nno stool this shift. No spits, aspirates. On VitE and\nFe. A: Tolerating feeds. P: cont with plan.\n#4: Temp stable in off , fontanelles are soft and\nflat. Alert and active with cares, sleeping well. Infant\nbrings hands to face, likes pacifier. a: AGA> P> cont to\nsupport.\n#5: NO contact from at this writing.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2122-12-03 00:00:00.000", "description": "Report", "row_id": 2039490, "text": "Newborn Med Attending\n\nCont on CPAP5, 25% O2. No spells. AF flat, clear BS, no murmur, abd soft, MAE. Wt=1700 up 30, on 150 cc/kg/d PE31 with PM.\nA/P: Infant with CLD , failed trial off CPAP. Wean O2 as tolerated.\n" }, { "category": "Nursing/other", "chartdate": "2122-12-03 00:00:00.000", "description": "Report", "row_id": 2039491, "text": "Respiratory Care Note\nPt remains on +5 prong CPAP, FiO2 25-29% this shift. BS clear. SubC retractions. RR 40-80's. On caffeine. No bradys this shift as of this writing.\n" }, { "category": "Nursing/other", "chartdate": "2123-01-08 00:00:00.000", "description": "Report", "row_id": 2039659, "text": "PCA Note:\n\n\nAlt in Resp: NC 100%FiO2 50cc (occasionally turned up to\n75cc). Lung sounds clear and equal. Mild upper airway\ncongestion. Mild subcostal retractions. Increased work of\nbreathing while bottling as evidenced by head bobbing. No\ndrifts, no spells thus far. Continue to monitor respiratory\nstatus.\n\nAlt in FEN: TF . 130cc/kg/day PE24. PO ad lib. Infant\nwaking to feed every 3-4hrs. Taking well over suggested\nintake. Breathing while bottling has improved greatly.\nBelly is soft and nontender, no loops. Infant is voiding\nand stooling. Small spit this morning after 10am feed.\nContinue with plan of care.\n\nAlt in G&D: Swaddled in open crib. Infant and active\nwith cares. Sleeps intermittantly between cares. Does well\nin bouncy seat and enjoys music. Temps stable. Continue to\nsupport developmental needs.\n\n: No contact with thus far. Continue to\nsupport and teach when needed\n\n\n" }, { "category": "Nursing/other", "chartdate": "2123-01-08 00:00:00.000", "description": "Report", "row_id": 2039660, "text": "NPN DAYS\nI have examined - and agree with above note by , PCA.\n" }, { "category": "Nursing/other", "chartdate": "2123-01-09 00:00:00.000", "description": "Report", "row_id": 2039661, "text": "NPN 2300-0700\n\n\n2. O: Infant remains in his nasal cannula 25-50cc in\n100%fio2. RR 60's with mild retractions noted. Head bobbing\nnoted during bottling without desaturations. LS clear\nbilaterally. Remains on diuril & KCLA: weaned Fio2\nslightly. P: Continue to wean Fio2 as tolerated.\n\n3. O: Wt.+25g 3175g. Yesterday received 146cc/kg/d Infant\nbottling PE 24 80cc about every 4 hours. No spits noted.\nAbdomen soft. +b.s. Vdg q.s. No stool noted. A: Bottling\nwell. P: Continue to assess daily weight.\n\n4. O: maintaining temperature swaddled in open crib.\nMAE. with cares. Repeat eye exam next week. Wakes for\nfeeds. A: AGA P: Continue to support development.\n\n5. No parental contact noted thus far.\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2123-01-09 00:00:00.000", "description": "Report", "row_id": 2039662, "text": "Neonatology Attending\nDOL 85\n\nIn NC 25-50 cc/ of 100% FiO2. No distress. Now day without bradycardias. Remains on diuril.\n\nIntermittent murmur, not noted today. BP pending.\n\nWt 3175 (+25) on ad lib demand with intake 146 cc/kg/day PE24/BM24. Voiding and stooling normally. On KCl.\n\nA&P\n25-5/7 week GA infant with CLD, respiratory immaturity, hydrocele.\n-Continue to wean oxygen as tolerated\n-For repeat ophthalmology examination early this week\n-Discharge planning in progress.\n" }, { "category": "Nursing/other", "chartdate": "2123-01-09 00:00:00.000", "description": "Report", "row_id": 2039663, "text": "Neonatology- Physical Exam\n\n remains in NC. Active, in an open crib, AFOF, sutures opposed, good tone. BBS clear and equal with good air entry, mild SC retractions. No murmur, pulses +2, pink, RRR. Abdomen soft, non-distended with active bowel sounds, no HSM, small umbilical hernia, tolerating feeds. Please refer to attending progress note for detailed plan.\n" }, { "category": "Nursing/other", "chartdate": "2123-01-09 00:00:00.000", "description": "Report", "row_id": 2039664, "text": "NPN 7a-7p\n\n\n#2: remains in NC 100%, 25-50cc flow. 25cc when\nsleeping in crib, 50cc flow needed for bottling and when\nsitting up in bouncy seat. RR stable. Conts with baseline\nSC retractions. BBS cl/, with mild upper airway congestion.\nTB sx'ed x1 for lg yel plug from right nare, and sm yel.\nsecretions from left. No apnea/ spells noted. Conts on\nDiuril and KCl supps as ordered. A: stable on low flow NC.\nP:Cont to monitor. Wean O2 as tol'ed. Provide support as\nneeded.\n\n#3: TF: min130cc/k/d. Conts on ad lib demand feeding\nschedule. Infant has been waking q4-5hrs for feeds,\nbottling with good coordination. Taking 70-90cc. Breastfed\nvery well this evening, ~45mins with consistent and\neager suck. Abd exam stable. Sm spit x1. Voiding qs. No\nstool thus far. ? hydrocele on left-Team aware, has been\neval'ed. A: feeding well P:Cont with current feeding plan.\nMonitor tol to feeds. Follow wt and exam.\n\n#4: Temps stable while swaddled in an open crib. Sleeping\nwell in btw cares. MAE. Fonts soft/flat. Settles with\npacifier. Brings hands to face. Sat up in bouncy seat for\nhrs- tol'ed well. A: AGA P:Cont to support dev needs.\n\n#5: in for 16care. Both participated in care and\nfeeding. Indep. Mom breastfed and bottled. Asking\nappropr. questions. Team had discussed possible transfer to\n with . will be closing on a home\nnext week which makes further away for them.\nInfant will not transfer. A: Involved family P:Cont to\nsupport and educate.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2123-01-10 00:00:00.000", "description": "Report", "row_id": 2039665, "text": "NPN 7p7a\n\n\nRESP\nInfant in NC 100% at 25-75 cc flow. Generally only needing\n25-50 cc. LSC. Upper airway congestion. Suc produced only\nvery small white green secretions. RR 40-70s with some short\noccasions of tachapenia, 80-90s. No bradys. Day on \ncountdown. Infant with o2 needs. Plan for DC on o2. Monitor\nand support resp status.\nFen\nInfant on TF 130 cc/k/d adlib/demand. PE 22. Abd soft,\nround with active BS. Has had only trace stool this shift.\nWaking for feeds overnight q 4-4.5 hrs. Taking 60-110 at\neach bottling. Wt 3285 (+110). Monitor weight and exam.\nG/D\nInfant in OAC with stable temps. Engaging with caregiver.A/A\nwith cares and waking for feeds. MAEs. FS&F.\n\nBoth in late last eve, participated in care.\nInvested and loving. Support and educate.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2123-01-10 00:00:00.000", "description": "Report", "row_id": 2039666, "text": "Neonatology Attending\n\nDOL 86 CGA 40 weeks\n\nStable in NCO2 25-75 cc. Sats 94-98%. No A/B. On diuril.\n\nBP 73/48 mean 57\n\nOn 130 cc/kg PE 24 + BF x1 yest. Voiding. Stooling. Wt 3285 grams (up 110).\n\nEye exam due tomorrow.\n\n in and up to date. Plan to close on house tomorrow.\n\nA: Stable. CLD with small O2 requirement. All po feeding.\n\nP: Monitor\n Change to E 24\n Eye exam tomorrow\n\n" }, { "category": "Nursing/other", "chartdate": "2122-11-09 00:00:00.000", "description": "Report", "row_id": 2039353, "text": "2. Resp: O: Infant received in nc, 300cc flow and in 40%\nFiO2. He has had a number of bradys w/ apnea tonight while\notherwise appearing well. (He has only been off CPAP for\nbarely 24 hours.) His nc flow was raised to 400cc. Rr\n30-50s, ls clear. Sxned x2 for a small amt of nasal\nsecretions. He is on caffeine. A: Having spells w/ apnea. P:\nMonitor. Consider putting infant back on CPAP if spells\ncontinue to be too frequent.\n\n3. F/N: O: Infant is on 150cc/k/d of 30cal BM/PE + promod, q\n4 hour gavage feeds. Abd is benign, he is voiding and having\nsmall stools. He gained 32g. No spits, asps. A: Tol\nfeeds, gaining wt. P: Monitor. Continue w/ plan.\n\n4. G/d: O: Infant is active w/ cares, and sucks vigorously\non a pacifier. His temp is stable on servo in the heated\n. A/P: Continue to support infant needs.\n\n5. : O: were in for the 8p cares and \nkangarooed for @ 90 . Both infant and did well.\nA: Loving, involved . P: Continue to support.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2122-11-09 00:00:00.000", "description": "Report", "row_id": 2039354, "text": "Neonatology Attending Note\nDay 24\nCGA 31\n\nIn NC 400cc, 35-40%. 8 A&BS past 24 h. On caffeine. Cl and = BS exc for mild UA congestion. HR 160-180s. No murmur. Pale/pink. BP 56/43, 47.\n\nWt 910, up 32 gms. TF 150 cc/k/day of BM30 w promod. Tol well. Nl voiding and stooling (g-).\n\nOn Vit E and Fe.\n\nIn .\n\nA/P:\nwean nc o2 flow as tol\nmonitor aop on caffeine, adjust caffeine dose to current weight, may need to consider returning to CPAP if A&Bs increase\nno change to nutritional plan\nnext HUS d30\n" }, { "category": "Nursing/other", "chartdate": "2122-11-24 00:00:00.000", "description": "Report", "row_id": 2039443, "text": "0700-1900 NPN\n\n\nRESP: Cont on Prong CPAP of 5 with FiO2 26-28%. RR\n30's-40's. LS clear/=. Mild IC/SC retractions. TB\nsuctioned x 1 for mod cloudy secretions. No A/B spells this\nshift. Occasional drifts in O2 sats to low 80%'s. On\nCaffeine. P: Cont to monitor and wean O2 as tolerated.\n\nFEN: TF=150cc/kg/d of BM/PE30 with PM PG over 50 mins. No\nspits. Max aspirate of 3cc. Abdomen benign, girth stable\nat 21-22.5cm. Pt is voiding, stools x 2 (heme-). On\nFerinsol and Vit E. P: Cont to monitor feeding tolerance.\n\nDEV: Temps stable in air controlled , pt\ndressed/swaddled. MAE, alert/active with cares. Sleeps\nbetween cares. Sucks pacifier and brings hands to face for\ncomfort. Fontanels soft/flat. AGA. P: Cont to support\ngrowth and development.\n\nPARENTING: No contact this shift. P: Cont to\nsupport/educate .\n\n\n" }, { "category": "Nursing/other", "chartdate": "2122-11-25 00:00:00.000", "description": "Report", "row_id": 2039448, "text": "Respiratory Care\nBaby continues on prong CPAP 5, 21%. BS clear. Nares sxn x1 for mod amt pale yellow blood-streaked secretions. RR 50's-60's with baseline retractions. On caffeine. No spells noted. Plan cont present management.\n" }, { "category": "Nursing/other", "chartdate": "2122-11-26 00:00:00.000", "description": "Report", "row_id": 2039449, "text": "NPN 11p-7a\n\n\n#2 Remains on bubble CPAP @ 5cm. FiO2 28-34%. BBS clear and\n=. Mild IC/SCR present. Labile at times with sat drifts to\nthe low to mid 80's. No bradys. On caffeine. A: alt in resp\nstatus P:Monitor closely\n\n#3 TF's 150cc/k. Received 36cc of BM30+PM on a pump over 50\nmins. q 4hrs. Small spit x 1. 2.5cc blood flecked aspirate x\n1. Hx of being suctioned on days for some bloody secretions.\nAspirate discarded after shown to . Abdomen\nfull but soft with active BS. Passed a lg yellow stool-heme\nneg. AG 23-24.5cm. A: tolerating feeds P: follow weight and\nexam closely\n\n#4 Temps stable in off . Alert and fiesty with\ncares. Sleeps well swaddled on sheepskin. Sucks on binkie\nwhen offered. A: AGA P: support developmental needs\n\n#5 No parental contact thus far in shift.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2122-11-26 00:00:00.000", "description": "Report", "row_id": 2039450, "text": "Respiratory Care\nBaby on cpap 5 28-32%.1 spelll documented this shift.changed to larger prongs.BS clear throughout.Sx x 1 for sm from nares and kg white from mouth.\n" }, { "category": "Nursing/other", "chartdate": "2122-11-26 00:00:00.000", "description": "Report", "row_id": 2039451, "text": "Newborn Med Attending\n\nCont on CPAP5, 28-34% O2. Occ spells. AF flat, clear BS, no murmur, abd soft, MAE. WT=1440 up 65, on 150 cc/kg/d BM30 with PM, PG.\nA/P: Growing infant with CLD and AOP. Wean O2 as tolerated. Monitor for spells.\n" }, { "category": "Nursing/other", "chartdate": "2122-11-26 00:00:00.000", "description": "Report", "row_id": 2039452, "text": "Clinical Nutrition\nAddendum:\nCurrent formula (BM/PE 30 w/ promod) @ 151cc/kg/d based on average 3d intake provides ~4.0-4.4g protein/kg/d.\n" }, { "category": "Nursing/other", "chartdate": "2122-11-26 00:00:00.000", "description": "Report", "row_id": 2039453, "text": "Clinical Nutrition\nO:\n~33 wk CGA BB on DOL 41.\nWT: 1440g(+65)(~10 %ile); birth wt: 695g. Average wt gain over past wk ~26g/kg.\nHC: 27.5cm(<10 %ile); last wk: 26cm\nLN: 37cm(<10 %ile); last wk: 34cm\nMeds include Fe & Vit.E\n due this week.\nNutrition: 150cc/kg/d as BM/PE 30 w/ promod, pg over 50 mins. Average of past 3d intake ~151cc/kg/d, providing ~151kcals/kg/d and ~3.2-3.6g pro/kg/d.\nGI: Abdomen benign; 2.5cc w/blood flecked residuals, X1 small spit, BM guiac neg.\n\nA/Goals:\nTolerating feeds w/o GI probs except as noted above; pg over extended feeding time. due this week. Current feeds & supps meeting recs for kcals/pro/vits/mins. Growth is exceeding recs for WT/HC/LN of ~15-20g/kg/d for WT, ~0.5-1cm/wk for HC, & ~1cm/wk for LN. Will monitor growth trends & may decrease kcals next week if he continues to exceed growth gains. Will continue to follow w/ team & participate in nutrition plans.\n" }, { "category": "Nursing/other", "chartdate": "2123-01-17 00:00:00.000", "description": "Report", "row_id": 2039703, "text": " On-Call\nPlease see Dr. note for overall summary and plan.\n\nPhysical Exam\nGeneral: infant in open crib, room air\nSkin: warm and dry; color pale/pink\nHEENT: anterior fontanel open, level; sutures open/opposed\nChest: breath sounds euqal, slightly coarse; intercostal retractions, intermittently tachypneic with shallow breaths\nCV: Gr II/VI high-pitched systolic murmur left upper sternal border consistent with PPS; normal S1 S2; pulses +2\nAbd: soft; no masses; + bowel sounds cord healed\nGU: left hydrocele; testes descending\nExt: moving all; normal tone\nNeuro: + suck; + grasps; +moro\n" }, { "category": "Nursing/other", "chartdate": "2123-01-17 00:00:00.000", "description": "Report", "row_id": 2039704, "text": "NPN DAYS\n\n\nAlt in Resp: Remains in room air. O2 sats >93%, occasional\ndrifts to the 80's but quickly self resolves. LS clear and\nequal. Mild SC retractions. Mild upper airway congestion.\nRemains on Diuril and KCl. Continue to closely monitor.\n\nAlt in FEN: Ad lib demand schedule. Minimum intake\nrequirement of 130cc/kg/day. Taking over his minimum.\nVoiding and stooling. No spits. Started on Multivitamins\ntoday. Will continue with current plan of care.\n\nGrowth and dev: Temp stable while swaddled in open crib.\nAwake and with cares. Not sleeping very well between\ncares today. Will continue to support developmental needs.\n\n: No contact so far this shift.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2123-01-18 00:00:00.000", "description": "Report", "row_id": 2039705, "text": "Nursing\n\n\n#2O: In room air with O2 sats >92 with rare quick\nself-resolved into the upper 80's. Br. sounds clear\nwith mild retractions.\n#3O: Wt. up 110g on E20, demand feeds. wakes q 2 - 5 hr.\nand bottles and nurses very well. Took in 153cc/kg. .\nBelly soft, no spits, voids qs.\n#4O: Stable temp in crib, with cares. Loves being\nheld and pacifier. Brings hands to mouth.\n#4O: Mom in and had her draw up the meds which included\niron, multivits, Diuril, and Potassium. Mom needs a bit\nmore practice with the syringes. Knows that son will be\nhaving an eye exam today and that d/c may be at end of week.\nTold mom to call pedi's office for an appt. . Mom\nexcited about pending d/c.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2122-10-31 00:00:00.000", "description": "Report", "row_id": 2039301, "text": "Nursing NICU Note.\n\n\n2. Resp. O/PT remains on IMV settings of 15/5, rate X12.\nFiO2 ranging between 24-35% this shift. 2 desaturations\nnoted to 77% this shift thus far, requiring increase in\nFiO2. Occasional desaturations noted to the mid 80%s\nrequiring increase in FiO2 or QSR. A/Occasional sat drifts\nnoted on vent. Requiring vent support to maintain adequate\noxygenation. P/Cont. to monitor. Cont. to supply and wean\nFiO2 as pt needs/tolerates.\n\n3. F/N. O/TF remain at 150cc/k/d of BM26PM pngt over 50min.\nPlease refer to flowsheet for examinations of pt from this\nshift. Voiding. Passed heme neg stool. A/Appears to be\ntolerating present feeding regimen at this time. P/Cont. to\nmonitor for s/s of feeding intolerance.\n\n4. G/D. O/Temp stable thus far while on servo control.\nAwake, very alert and active with cares. Sleeping well in\nbetween care times. Occasionally wake prior to being fed.\nBrings hands to mouth. Briefly sucks on pacifier. Good\nmuscle tone. A/Alt. in G/D. P/Cont. to support pt's growth\nand dev needs.\n\n5. . O/No contact made from this shift thus\nfar. A/Unable to fully assess parental involvement at this\ntime. P/Cont. to support and educate.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2122-10-31 00:00:00.000", "description": "Report", "row_id": 2039302, "text": "Respiratory Care Note\nPt. remains on vent on 15/5, RR 12, FiO2 26-34%. BS clear. RR 30-60. On caffeine. One spell today.\n" }, { "category": "Nursing/other", "chartdate": "2122-11-01 00:00:00.000", "description": "Report", "row_id": 2039303, "text": "Nursing progress note\n\n\n#2 O: Remains orally intubated in 26-33% O2 15/5 X's 12.\nBreath sounds equal & clear with mild IC/SC retractions.\nSuctioned X's 3 for mod cldy secretions. No A's or B's.\nOccasional sat drifts requiring inc O2. A; Stable on present\nvent settings. P: Cont to assess.\n#3 O: Wgt up 3gms. Remains on 150cc/k/d 28 cal BM w/PM.\nFeeds given PG, q4h over 50 . Abd soft with active bowel\nsounds & no loops. Sm spit X's 1. Max aspirate 2cc. Voiding\n& sm yel stool X's 2. Stools neg. A: Tolerating feeds. P:\nCont to assess.\n#4 O: Temp stable in servo . Nested in sheepskin\nwith H2O pillow. Alert with cares. A: AGA. P: Cont to\nassess.\n#5 O: Mom in for kangaroo care. Mom held baby for 90 . A:\nInvolved . P: Support.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2122-11-01 00:00:00.000", "description": "Report", "row_id": 2039304, "text": "Respiratory Care Note\nPt. continues on 15/5 R 12 and 26-33% FIO2. BS are clear. Pt. sx'd for sm. cloudy from ett and mod. oral secretions. Pt. out to kangaroo. To follow.\n" }, { "category": "Nursing/other", "chartdate": "2122-11-15 00:00:00.000", "description": "Report", "row_id": 2039394, "text": "Neonatology- Physical Exam\n\n remains on CPAP. Active, alert in an , AFOF. BBS clear and equal with good air entry. No murmur, pulses +2, pink, RRR. Abdomen soft, non-distended with active bowel sounds, no HSM, tolerating feeds. Please refer to attending progress note for detailed plan.\n" }, { "category": "Nursing/other", "chartdate": "2122-11-16 00:00:00.000", "description": "Report", "row_id": 2039395, "text": "Respiratory Care\nBaby continues on prong CPAP 5 with 02 req 21-26%, except during kangaroo care up to 39%. BS clear. Nares sxn x1 for sm amt old bloody secretions. RR 40's-70's. On caffeine. No bradys noted, but having sat drifts. Will cont current management.\n" }, { "category": "Nursing/other", "chartdate": "2122-12-22 00:00:00.000", "description": "Report", "row_id": 2039570, "text": "NPN\n\n\n#2 Remains in NC O2, 500cc flow, 45-50% O2. Lungs clear with\nupper airway congestion, large secretions suctioned 4 q\nhours. Resp rate stable, sats stable with infrequent drifts\nto the 70's QSR. Continues on Duiril. No bradycardia.\n\n#3 Continues on 130cc/kg/day of BM/PE 31. No spits, minimal\nasp. Voiding, no stool as yet this shift, abd soft and\nbenign. Gavage feeds, bottled x1 took entire volume.\nContinues on KCL supps, Vit e and iron. Lytes to be checked\n.\n\n#4 Active and alert with cares, awake beyond cares. Bottling\nfairly well, uncoordinated at times with inadequate seal.\nSwaddled with temp stable, open crib.\n\n#5 No contact with as yet this shift.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2122-12-22 00:00:00.000", "description": "Report", "row_id": 2039571, "text": "Neonatology - Progress note\n\n is active with good tone. AFOF. He is pink, well perfused, soft murmur auscultated. He remains in NCO2, 500ccs/45-60%. Comfortable resp pattern, scattered rales auscultated @ bases. He is tolerating feeds. Abd soft, active bowel sounds, no loops. Voiding and stooling. Stable temp in open crib. Please refer to neonatology attending note for detailed plan.\n" }, { "category": "Nursing/other", "chartdate": "2122-12-23 00:00:00.000", "description": "Report", "row_id": 2039572, "text": "NPN 1900-0700\n\n\n2.Resp: Infant remains in NC 500cc flow, Fi02 requirement\n48-55%. Lung sounds are clear and equal with mild-mod nasal\ncongestion. Infant has not been suctioned thus far this\ncare secondary to stable respiratory status and irritation\nof nasal tissue. Infant is breathing comfortably with\nmild-mod SC/IC retractions, RR 40s-50s (occasionally in the\n70s when active and with feeds), and 02 sats > 92%. He has\noccasional drifts to the high 70s-low 80s with QSR or\nresolved with increased 02. He remains on 1 week trial of\nDiuril and KCl. No spells thus far this shift. Continue to\nmonitor respiratory status.\n\n3.FEN: Infant's weight tonight 2460g (up 5g). Infant\nremains on TF 130cc/kg/day of BM/PE 31cal/oz. He is\nbottling q shift and breastfeeding q day when mom visits.\n is tolerating feeds well with no spits, minimal\naspirates. Abdomen is soft and round with active bowel\nsounds, no loops. He is voiding, no stool thus far this\nshift. Remains on vitamin E and Fe+. Infant BF at \nwith appropriate latch on, but sleepy behavior. Mother\nreports poor milk supply, thus full gavage feeding done at\ntime. Plan to check electrolytes and repeat PKU morning of\n. Continue to monitor FEN status and weight\ngain/loss.\n\n4.DEV: Infant remains swaddled in open crib with HOB raised\n45 degrees. He is alert and active with stable temps. He\nbrings hands to face and sucks vigorously on pacifier. He\nis coordinated with breastfeeding, achieves appropriate\nlatch on and is able to maintain 02 sats. Infant has\nmoderate amount of generalized edema. Small umbilical\nhernia remains soft and reducable. Continue to support\ngrowth and development.\n\n5.: Mom and in this evening at for CPR\nclass, then care time. are loving and\nappropriate, independent with cares. Plan to visit\ntomorrow. Continue to support and keep informed.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2122-12-23 00:00:00.000", "description": "Report", "row_id": 2039573, "text": "Neonatology\nRemains in NCO2 at 500 cc. Resp similar to before. WIll attempt to weans to low flow and provide 100% as needed.monitor spells.\n\nWt 2460 up 5. Tolerating feeds at 130 cc/k/d of 31 cal. Abdomen benign. Bottling/bottling once per feed. Improving slightly over time.\n\nCOntinue with mild peripheral edema.\n\nContinue current nutritional regimen and resp monitoring.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2122-12-23 00:00:00.000", "description": "Report", "row_id": 2039574, "text": "NPN DAYS\n\n\nAlt in Resp: Received on NC 500cc flow, 50-55% flow. Changed\nto low flow NC at 1115. Has been in 100%FiO2, 50-100cc flow\nsince the change. Mild UAC. No spells. Desats to the 70's\nbut self resolves. Remains on Diuril and KCl. Will continue\nto wean O2 as tolerated.\n\nAlt in FEN: TF 130cc/kg/day BM31/PE31. Gavaging feeds over\n1hr. took 60cc x1 po today. Offering po's QS. Voiding.\nNo stool. Belly benign. No spits. To have lytes in am. \nstart to offer bottles/BF every other feed if tolerated.\n\nGrowth and Dev: Temp stable in open crib. Awake and alert\nwith cares. Small umbilical hernia is soft and reducible.\nWill have PKU done tonight.\n\n: No contact so far this shift.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2122-12-24 00:00:00.000", "description": "Report", "row_id": 2039575, "text": "NPN 1900-0700\n\n\n2.Resp: Infant remains in NC, 25-75cc flow, 100%Fi02. Lung\nsounds are clear and equal with mild upper airway\ncongestion. He is breathing comfortably with RRs 40s-70s,\n02 sats > 91%, and mild SC retractions. He has occasional\ndrifts to the 70s- low 80s, QSR. He remains on Diruil and\nKCl. No spells thus far this shift. Continue to monitor\nrespiratory status and wean 02 as tolerated.\n\n3.FEN: Infant's weight tonight 2485g (up 25g). Infant\nremains on TF 130cc/kg/day of BM/PE 31cal/oz. He is\nbottling or breastfeeding once per shift with bottles being\noffered based on infant's behavioral cues. Infant breastfed\nat for 5-10 minutes with latch on, sleepy and\nirritable. Mother has poor milk supply, thus entire feeding\ngavaged in addition to BF. Infant is tolerating feeds well\nwith no spits, minimal aspirates. Abdomen is soft and round\nwith active bowel sounds, no loops. He is voiding, no stool\nthus far this shift. He remains on vitamin E and Fe+.\nLytes drawn this morning, please see laboratory for details.\n Continue to monitor FEN status, weight gain, and encourage\npo feeding as tolerated.\n\n4.DEV: Infant remains swaddled in open crib with HOB at 15\ndegrees, stable temps. He is alert and active with cares,\nbrings hands to face. Mild amount of generalized edema.\nSmall umbilical hernia remains soft and reducable. He does\nhave a small strawberry hemangioma on left forearm that\nappears to be increasing in size. Repeat PKU drawn and\nplaced in utility room to dry. Continue to support growth\nand development.\n\n5.: Mom and in for care time. are\nloving and appropriate, very independent with cares. Mom\nbreastfed for 5-10 minutes, then held infant for 30 minutes.\n then held infant for 30 minutes, well tolerated.\n updated at bedside. Consent for PKU done. Continue\nto support and keep informed.\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2122-12-24 00:00:00.000", "description": "Report", "row_id": 2039576, "text": "Neonatology\nDoing well. Remains in NCO2 at 25 cc 100%. generally comforable appearing. Will continue diruil for now and consider need for continuation vs trial off.\n\nWt up 25. Tolerating feeds at 130 cc/k/d of 31. Abdomen benign.\nLytes in good range on diuril.\n" }, { "category": "Nursing/other", "chartdate": "2122-12-24 00:00:00.000", "description": "Report", "row_id": 2039577, "text": "Neonatology - Progress Note\n\n is active with good tone. AFOF. He is pink, well perfused, soft murmur auscultated. He is comfortable in NCO2 75cc/100%. Appears sl tachypneic with mild retractions. Breath sounds clear and equal. She is tolerating full volume feeds. Abd soft, active bowel sounds, no loops. Voiding and stooling. Stable temp in open crib. Please refer to neonatology attending note for detailed plan.\n" }, { "category": "Nursing/other", "chartdate": "2122-11-25 00:00:00.000", "description": "Report", "row_id": 2039444, "text": "NPN\n\n\n2.Resp: Infant remains on prong CPAP 5, 23-28% Fi02. Lung\nsounds are clear and equal with mild SC/IC retractions, RR\n30s-60s. He remains on caffeine with no spells thus far\nthis shift. Continue to monitor respiratory status.\n\n3.FEN: Wt tonight 1375 grams (increased 15g). He remains\non TF 150cc/kg/day of BM/PE 30cal/oz with Promod. He is\ntolerating feeds well with no spits, max. aspirate 3.4cc of\nnon-bilious undigested formula. Abdomen is pink and soft,\nno loops, abdominal girths 22.5-23.5. He is voiding and\nstooling (guiac neg). Continue to monitor FEN status.\n\n4.DEV: Infant is swaddled on sheepskin in an air \n(27.6 degrees). He is alert and active with cares, sucks on\npacifier. He has a left inguinal hernia that remains soft\nand reducable. Plan to follow up eye exam next week.\nContinue to support growth and development.\n\n5.: Mom and in this evening to visit with infant\nat cares. held infant for 60 minutes, well\ntolerated. are loving and appropriate. Continue to\nsupport growth and development.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2122-11-25 00:00:00.000", "description": "Report", "row_id": 2039445, "text": "RESPIRATORY CARE NOTE\nBaby remains on Prong CPAP 5 FiO2 23-28%. Suctioned nares for mod amt of yellow secretions. Breath sounds are clear. RR 30-60's stable on CPAP cont to follow.\n" }, { "category": "Nursing/other", "chartdate": "2122-11-25 00:00:00.000", "description": "Report", "row_id": 2039446, "text": "Newborn Med Attending\n\nCont on CPAP5, 28% O2, no spells. AF flat, clear BS, no murmur,abd soft, MAE. WT=1375 up 15, on 150 cc/kg/d BM30 with PM, PG.\nA/P: Growing infant with CLD and AOP. Wean O2 as tolerated. Monitor for spells.\n" }, { "category": "Nursing/other", "chartdate": "2122-11-25 00:00:00.000", "description": "Report", "row_id": 2039447, "text": "0700- NPN\n\n\nRESP: Remains on prong CPAP 5, 26-37% fiO2. O2 sats 92-97%.\nRR=50-70's. Breath sounds clear and equal, mild SC/IC\nretractions noted. No bradys. Continues on caffeine. Will\ncontinue to monitor resp status.\n\nFEN: TF= 150cc/kg/d of BM30/PE30 with promod gavaged q4hr.\nAbdomen pink, soft, round, +BS, no loops, AG=23.5 cm. Small\nspits, minimal aspirates. Voiding, no stool. Continues on Fe\nand Vit E. Will continue to monitor FEN status.\n\nG&D: Infant nested in . Temp this am 99.1-99.6(air\ncontrolled turned off/blankets removed), most\ncurrent temp=98.8. Active and alert with cares, sleeps\nbetween. Brings hands to face. Sucks on pacifier for\ncomfort. Will continue to support G&D.\n\n: Mom here for 1200 care, independent, involved, and\nloving. Will continue to support/answer questions.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2122-12-12 00:00:00.000", "description": "Report", "row_id": 2039532, "text": "Neonatology Attending\nDOL 57\n\nIn NC 500 cc/ of 50-75% FiO2. Intermittently tachypneic, especially with handling. Lasix yesterday. One bradycardia in 24 hours, on caffeine.\n\nIntermittent murmur. BP 77/37 (53).\n\nWt 2090 (-10) on TFI 150 cc/kg/day BM31/PE31, tolerating well. Abdomen benign. Voiding 2.6 cc/kg/hr and stooling. On vitamin E and ferinsol.\n\nA&P\n27-5/7 week GA infant with CLD, feeding immaturity\n-Continue with NC for now, with plan to restart CPAP if FiO2 requirement increases or if frequency/severity of apneas worsens\n-Lytes with nutrition this week\n-We will obtain consent for two-month immunizations\n-Follow murmur clinically\n" }, { "category": "Nursing/other", "chartdate": "2122-12-13 00:00:00.000", "description": "Report", "row_id": 2039537, "text": "NPN 0700-1900\n\n\n#2 O: Infant remains in NC o2 500cc's of flow at 50-70% o2.\nRR 30's-80's with mild SC retractions. LS clear and =. Nasal\ncongestion noted; suctioned with TB syringe for mod amounts\nof white secretions. No spells. On caffeine as ordered. A:\nStable in NC; tachypneic. P: Cont to monitor.\n\n#3 O: TF= 150cc/kg/d. Infant taking 54cc's of BM31/PE31 q 4h\nvia gavage. Abdomen benign; voiding, no stool. No spits,\nminimal aspirates. Remains on vit E and iron. A: Tolerating\nfeeds. P: Cont to monitor.\n\n#4 O: Infant maintaining temp in oac. Awake and alert with\ncares; sleeping well between. Sucking on pacifier when\noffered. AFSF. A: AGA. P: Cont to support development.\n\n#5 O: No contact as yet this shift. A/P: Cont to support and\nupdate.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2122-12-13 00:00:00.000", "description": "Report", "row_id": 2039538, "text": "Neonatology - Progress Note\n\n is active with good tone. AFOF. He is pink, well perfused, no murmur auscultated. He remains in NCO2 500cc/40-70%. Transient tachypnea, + retractions. Breath sounds clear and equal. He is tolerating full volume feeds. Abd soft, active bowel sounds, no loops. Voiding and stooling. LIH warm, pink, reduceable. Stable temp in open crib. Please refer to neonatology attending note for detailed plan.\n" }, { "category": "Nursing/other", "chartdate": "2122-12-14 00:00:00.000", "description": "Report", "row_id": 2039539, "text": "NURSING PROGRESS NOTE\n\n\n2. RESPIRATORY\nCONTINUES TO REQUIRE NASAL CANNULA O2 @ 500CC, 50-70%. BBS\nCLEAR WITH BASELINE SUBCOSTAL RETRACTIONS. RR 50-70'S. NO\nSPONTANEOUS DESATS, OCCAISIONAL DRIFTS TO MID 80'S.\n3. F/N\nTONIGHT'S WEIGHT DOWN 15 GRAMS TO 2.130KG. TOLERATING\n150CC/KG OF PE/BM31. ABD BENIGN. PASSED HUGE STOOL AT\n.\n4. G&D\nWAKING FOR SOME FEEDINGS. SUCKING ON PACIFIER.\n5. \nMOM AND IN FOR CARE. HELD FOR FEEDING.\n ASKED WHEN BABY WILL BE ABLE TO BREAST FEED.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2122-12-14 00:00:00.000", "description": "Report", "row_id": 2039540, "text": "Newborn Med Attending\n\n Cont in O2 per NC, no spells. AF flat, clear BS, no murmur, abd soft, MAE. Wt=2130 up 15, on 150 cc/kg/d Bm31 with PM.\nA/P: Growing infant with CLD. Wean O2 as tolerated. Encourage PO feeds.\n" }, { "category": "Nursing/other", "chartdate": "2122-12-14 00:00:00.000", "description": "Report", "row_id": 2039541, "text": "NPN DAYS\n\n\nAlt in Resp: Remains in NC 500cc flow, 40-70% FiO2 (mostly\n50-60%). RR 60-100. LS clear and equal. Mild SC retractions.\nMild generalized edema. On caffeine. No spells. Frequent\ndrifts of sats, self resolving.\n\nAlt in FEN: TF 150cc/kg/day PE31/BM31. All gavage feeds. No\nspits, aspirates. Voiding. No stool. Belly benign. On VitE\nand FeSO4. try bottling tomorrow.\n\nGrowth and Dev: Temp stable in open crib. Awake and alert\nwith cares. Eye exam today showed mild ROP, see consult\nsheet. consented to 60day immunizations. Will\ncontinue to support developmental needs.\n\n: in for brief visit this am. Will return tonight\nfor 8pm cares and to hold. Continue to provide support and\nteaching.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2122-11-16 00:00:00.000", "description": "Report", "row_id": 2039396, "text": "NPN NIGHTS\n\n\nAlt in Resp: Remains on prong CPAP5 with FiO2 21-39%. Needs\nincreased O2 while being held. LS clear and equal. Sxn'd\nnares x1. Mild IC/SC retractions. No spells. Occasional\ndrifting of sats. On caffeine. Continue with current plan of\ncare.\n\nAlt in FEN: Weight 1085gm up20. TF 150cc/kg/day BM30/PE30PM,\ngavaging over 50mins. Minimal aspirates. No spits. Voiding\nand stooling. On VitE and FeSO4. Continue with current plan.\n\nGrowth and Dev: Temp stable in servo nested on\nsheespkin with boundaries in place. Awake and alert with\ncares. Tolerated kangarooing wtih x90mins. To have HUS\nWednesday and eye exam this am.\n\n: In to visit and held. Asking appropriate\nquestions. Verly loving towards the baby. are\nlooking for housing. Will continue to provide support and\nteaching.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2122-11-16 00:00:00.000", "description": "Report", "row_id": 2039397, "text": "Newborn Med Attending\n\n Cont on CPAP5, 21-26% O2. No spells, on caffeine. AF flat, clear BS, no murmur, abd soft, MAE. WT=1085 up 20. On 150 cc/kg/d BM30 with PM.\nA/P: Growing infant with residual CLD. Wean CPAP as tolerated. Monitor for spells. Cont current feeding plan.\n" }, { "category": "Nursing/other", "chartdate": "2122-11-16 00:00:00.000", "description": "Report", "row_id": 2039398, "text": "Respiratory Care Note\nPt off CPAP this pm after eye exam. Placed on 200 cc nasal cannula with FiO2 30-45%. No spells this shift. RR 40-60's.\n" }, { "category": "Nursing/other", "chartdate": "2122-11-16 00:00:00.000", "description": "Report", "row_id": 2039399, "text": "0700- NPN\n\n\nRESP: Received pt on Prong CPAP of 5 with FiO2 21-30%. Pt\nplaced on NC 200cc flow rate at 1600, FiO2 30-55%. RR\n40's-60's. LS clear/=. Mild IC/SC retractions. No A/B\nspells or desats. On Caffeine.\n\nFEN: TF=150cc/kg/d of BM30/PE30 with PM PG over 50 mins.\nSmall spit x 1. Minimal aspirates. Abdomen benign. Pt is\nvoiding, stools x 2 (heme-). On Ferinsol and Vit E.\n\nDEV: Temps stable in servo-controlled .\nAlert/active with cares. Sleeps between cares. Sucks\npacifier and brings hands to face for comfort. Fontanels\nsoft/flat. AGA.\n\nPARENTING: No contact from .\n\n\n" }, { "category": "Nursing/other", "chartdate": "2122-12-01 00:00:00.000", "description": "Report", "row_id": 2039482, "text": "NPN 0700-1900\n\n\n#2 RESP S/O: Infant in NC, 500cc, FiO2 40-70% today. Lungs\nare clear, subcostal retractions. RR 20-60, up to 100 with\ncares. No spells yet this shift. Frequent drifts into the\n80's. On caffeine. Suctioned x1 for mod, thick white\nsecretions. A: Stable P: Continue to monitor.\n\n#3 FEN S/O: TF 150cc/k/d. Infant to get pe31 or bm31, 41cc\nq4h pg. Infants abdomen is benign, voiding, no stools today.\nAbdomen is full, AG stable 24cm. No spits, minimal\naspirates. A: Tolerating feeds. P: Continue to monitor.\n\n#4 DEV S/O: Infant in off , maintaining temps.\nSwaddled with one blanket. Alert and active with cares,\nsleeping in between. A: AGA P: Continue to support dev.\n\\\n#5 S/O: No contact with yet this shift. A:\nUnable to assess. P: Continue to support.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2123-01-07 00:00:00.000", "description": "Report", "row_id": 2039652, "text": "Clinical Nutrition\nO:\n~39 wk CGA BB on DOL 83.\nWT: 3145g(+60)(~50 %ile); birth WT: 695g. Average wt gain over past wk ~41g/d.\nHC: 34.5cm(~75 %ile); last wk:34cm\nLN: 45cm(~10 %ile); last wk: 44.5cm\nMeds include Fe, Vit.E, KCl, & Diuril\n not needed.\nNutrition: Adlib w/ . 130cc/kg/d as PE 24, all po's. Breast fed x1. Average of past 3d intake ~144cc/kg/d, providing ~115kcal/kg/d and ~3.5g pro/kg/d.\nGI: Abdomen benign.\n\nA/Goals:\nTolerating feeds w/o GI problems, all po's. not needed. Current feeds & supps meeting weaned recs for kcal/pro/vits/mins. HC gain is meeting recs. Growth is exceeding recs for WT gain of ~15-20g/kg/d. LN gain is not meeting rec of ~1cm/wk. Will monitor trends. Will continue to follow w/ team & participate in nutrition plans.\n" }, { "category": "Nursing/other", "chartdate": "2123-01-07 00:00:00.000", "description": "Report", "row_id": 2039653, "text": "NPN DAYS\nI have examined - and agree with above note by , PCA.\n" }, { "category": "Nursing/other", "chartdate": "2123-01-08 00:00:00.000", "description": "Report", "row_id": 2039654, "text": "PCA NOTE\ninfant o2 has been 50-75cc's this shift, 100%this rn has assessed this infant and agrees with the above note and the assessments done by PCA. infant continue on diuril and kcl.\n" }, { "category": "Nursing/other", "chartdate": "2123-01-08 00:00:00.000", "description": "Report", "row_id": 2039655, "text": "PCA NOTE\ninfant o2 has been 50-75cc's this shift, 100%this rn has assessed this infant and agrees with the above note and the assessments done by PCA. infant continue on diuril and kcl.\n" }, { "category": "Nursing/other", "chartdate": "2123-01-08 00:00:00.000", "description": "Report", "row_id": 2039656, "text": "PCA NOTE\n\n\nRESP: In NC 100% fiO2, 25-75cc flow. Breathing 40-70's. Sats\nmid 90's. Lungs are CL/=. UA Congest noted. No spells or\ndesats. Some drfiting QSR. P-Continue to closely monitor.\n\nFEN: Current weight 3150, ^5gm. TF 130 cc/k/d of PE 24.\nPO. is voiding and stooling. Hem neg. +. Abdomen is\nunremarkable. No spits. P-Continue to follow current regimen\nas ordered.\n\nDEV: In OAC. Temp stable. Waking for feeds. and\nactive, Sleeping peacefully. MAE. Paci for comfort. Adorable\ndisposition.\n\n: Mom and in this shift. Updated at bedside.\nInde. with cares. Loving and invested. P-Continual support\nand encouragment\n\n\n" }, { "category": "Nursing/other", "chartdate": "2123-01-08 00:00:00.000", "description": "Report", "row_id": 2039657, "text": "Neonatology\nDoing well. Remains in NCO2. Comfortable apeparing.\n\nWt 3150 up 5. Tolerating feeds at ad lib with of 130. Abdomen benign.\n\ntem,p stable in open crib.\n\nAwaiting wean from O2.\n" }, { "category": "Nursing/other", "chartdate": "2123-01-08 00:00:00.000", "description": "Report", "row_id": 2039658, "text": "Neonatology NP Note\nPE:\nswaddled in open crib\nAFOF, suturs opposed\nmild subcostal retraction and head bobbing in NCO2, lungs with transmitted upper airway sounds from nasal congestion, lung bases clear\nRRR, no murmur, pink and well perfused\nabdomen soft, nontender and nondistended, small umbilical hernia\ninguinal edema\ngood tone vigorous with exam\n" }, { "category": "Nursing/other", "chartdate": "2122-12-12 00:00:00.000", "description": "Report", "row_id": 2039533, "text": "NICU nursing note\n\n\n2. Resp=O/cont in NCO2 500cc/ flow FIO2 55-70%. No\nspells. Occas self-resolving drifts to 70-80's. (Please\nrefer to flowsheet for resp assessment and sxning.)\nA/Stable in NCO2. Cont with periods of tachypnea. P/Cont\nto monitor for resp distress.\n\n3. FEN=O/TF cont at 150cc/k/d of BM/PE31 gavaged over\n50min. Abd benign. (Please refer to flowsheet for\nassessment.) No spits. Voiding. Sm stool x3. Cont on\nVitE and iron. A/Tolerating current regime. P/cont to\nmonitor for feeding intolerance.\n\n4. G&D=O/Temp stable swaddled in open crib. Alert and\nactive with cares. Sleeping well between cares. A/Alt in\nG&D. P/cont to monitor and support G&D.\n\n5. =O/ called x1. Updated by this nurse.\nA/Appropriate and actively involved. P/cont to support and\neducate .\n\n\n" }, { "category": "Nursing/other", "chartdate": "2122-12-12 00:00:00.000", "description": "Report", "row_id": 2039534, "text": "Neonatology Progress note\n\n is active with good tone. AFOF. He is pink, well perfused, no murmur auscultated. He appears comfortable in NCO2 500ccs/50-75% fio2. Breath sounds clear and equal. He si tolerating full volume feeds. Abd soft, active bowel sounds, no loops. Voiding and stooling. Stable temp in open crib. Please refer to neonatology attending note for detailed plan.\n" }, { "category": "Nursing/other", "chartdate": "2122-12-13 00:00:00.000", "description": "Report", "row_id": 2039535, "text": "NURSING PROGRESS NOTE\n\n\n2. RESPIRATORY\nCONTINUES TO REQUIRE NASAL CANNULA O2 AT 500CC, 50-70%. BBS\nCLEAR, RR 40-70'S. NO DESATS, FREQUENT DRIFTS TO MID 80'S,\nSELF RESOLVED.\n3. F/N\nTONIGHT'S WEIGHT UP 55 GRAMS TO 2.145KG. APPEARS GENERALLY\nEDEMATOUS. TOLERATING 150CC/KG OF BM/PE31. ABD BENIGN.\nPASSING STOOL.\n4. G&D\nNOT WAKING FOR ALL FEEDINGS. LOVES TO BE HELD.\n5. \nMOM AND IN, ASSISTED WITH WEIGHT/CARE. MOM HELD FOR\nFEEDING.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2122-12-13 00:00:00.000", "description": "Report", "row_id": 2039536, "text": "Attending Note\nDay of life 58 CGA 36\nNC 500 cc 50-70% FiO2 RR 40-60\nno spells\ns/p lasix on friday.\ngeneralized edema HR 140 up to 180\n2145 up 55 grams on 150 cc/kg/day\nBM 31/PE 31 gavage over 50 \nvoiding and stooling\non Vit E and iron\nPlan will close monitor resp status\nwill consent for immunization\n up to date\n\n" }, { "category": "Nursing/other", "chartdate": "2122-12-31 00:00:00.000", "description": "Report", "row_id": 2039613, "text": "Clinical Nutrition\nO:\n~38 wk CGA BB on DOL 76.\nWt: 2855 g (-5)(~25th to 50th %ile); birth wt: 695 g. Average wt gain over past wk ~53 g/d.\nHC: 34 cm (~50th to 75th %ile); last: 32.5 cm\nLN: 44.5 cm (~10th to 25th %ile); last: 43 cm\nMeds include Fe, diuril, and Vit E\n not needed\nNutrition: 130 cc/kg/d PE 26, all po. Average of past 3 d intake ~126 cc/kg/d. Feeds just decreased yesterday due to good wt gain; projected intake for next 24 hrs based on 130 cc/kg/d is ~113 kcal/kg/d and ~3.1 g pro/kg/d.\nGI: Abdomen benign; generalized edema.\n\nA/Goals:\nTolerating feeds without GI problems. not needed. Current feeds + supps meeting weaned recs for kcals/pro/vits and mins. Growth is exceeding recs for all parameters; kcals and pro decreased in response. Will continue to follow w/ team and participate in nutrition plans.\n" }, { "category": "Nursing/other", "chartdate": "2123-01-01 00:00:00.000", "description": "Report", "row_id": 2039618, "text": "NPN 7p7a\n\n\nResp\nInfant in NC 50-75cc @ 100% to maintain sats between 94-98.\nLSC. S/C rtxs. RR in the 70 and 80s at times. No bradys. Rec\ndiuril, increased dose yesterday. Infant weaning on 02.\nWOB.Monitor and support resp status.\nFen\nInfant on fluid rest 130 cc/k/d of pe/bm 26. Bottled or\nbreast q feeding. Mom BF this evening, good , time\non breast. Abd soft, benign. Active BS. No spits. Gassy. Wt\n2.870 (+ 15). Infant learning to PO. Monitor weight and\nexam.\nG/D\nInfant in OAC with stable temps. A/A with cares. Had\ndifficulty settling between #1 + 2 cares, acting hungry.\n in to check on/evaluate infant. Will not begin OT\nexercises yet as infant is not ready. MAEs. Some clonis.\nFS&F. AGA. Monitor and support G/D.\n\nBoth in for cares and BF. Independent and competent.\nAsking appropiate questions. Father to infant. Both\n expressing stress re home buying experience. Loving\nand invested. Support and educate.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2123-01-01 00:00:00.000", "description": "Report", "row_id": 2039619, "text": "Neonatology Attending\n\nWill liberalize fluids today and adjust diuretic management as needed.\n\n" }, { "category": "Nursing/other", "chartdate": "2123-01-01 00:00:00.000", "description": "Report", "row_id": 2039620, "text": "Neonatology Attending\n\nDay 77\n\nRemains on nasal cannula at 50-100 cc/. Clear breath sounds. Mild retractions. Diuril dose increased yesterday. HR 130-180s. BP mean 65. Weight 2870 gms (+15). TF at 130 cc/kg/d- BM/PE 26. Feeding every four hours. Benign abdomen. On iron and vitamin E. Waking for feeds. Stable temperature in open crib.\n\nMild residual chronic lung disease. Monitoring and weaning oxygen as allowed. Gaining weight well. No changes in management for today.\n\n" }, { "category": "Nursing/other", "chartdate": "2123-01-01 00:00:00.000", "description": "Report", "row_id": 2039621, "text": "I have read and agree with the above note written by .\n bottle fed baby and was reluctant to let me increase baby's oxygen when he was alarming for low sats saying that he was not correlating and that baby was doing well in 25cc. Baby did breastfed well in 25cc. I explained to the that it is always important to look at their baby and to note his color rather than just to go by the monitor and that sometimes baby could need oxygen even if it was not correlated, if he was not pink.\n" }, { "category": "Nursing/other", "chartdate": "2123-01-15 00:00:00.000", "description": "Report", "row_id": 2039695, "text": "PCA Note:\n\n\nAlt in Resp: NC 100%FiO2 35-50cc flow. Infant tolerates\nlow flow better at rest, requires 50cc during feeds to\nmaintain stable sat range. Lung sounds are clear and equal.\nMild subcostal retractions. Drifts to low 80's while\nbottling, but self resolves. Continue to monitor\nrespiratory status. Wean flow as tolerated.\n\nAlt in FEN: TF 130cc/kg/day BM or E20 ad lib demand.\nAbdomen is soft, nontender, no loops. Infant is voiding,\nstooling (heme neg.) Continue with plan of care.\n\nAlt in G&D: Infant is swaddled in an open crib.\nMaintaining stable temps. Infant is and active with\ncares. Has slept well between cares today. Continue to\nsupport developmental needs of children.\n\n: No contact with today thus far.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2123-01-15 00:00:00.000", "description": "Report", "row_id": 2039696, "text": "NPN DAYS\nI AGREE WITH THE ABOVE NOTE BY , PCA.\n" }, { "category": "Nursing/other", "chartdate": "2122-10-19 00:00:00.000", "description": "Report", "row_id": 2039216, "text": "Respiratory Care Note\n\nPt remains on IMV 14, 15/5, FiO2 21-25% today. BS clear. RR 50-60. IC/SubC retractions noted. Plan CBG this pm. On caffeine. Will follow and support as necessary.\n" }, { "category": "Nursing/other", "chartdate": "2122-10-19 00:00:00.000", "description": "Report", "row_id": 2039217, "text": "Respiratory Care Note\nCBG:7.26/54/49/25/-3. No vent changes at this time.\n" }, { "category": "Nursing/other", "chartdate": "2122-10-19 00:00:00.000", "description": "Report", "row_id": 2039218, "text": "Nursing Progress Note\n\n\nRESP O/A: Infant received on SIMV: 15/5, R14. CBG @ 1530:\n7.26/54/49/25/-3, no changes made today. FiO2 21-25% w/ a\nmild increase in O2 with cares & suctioning. RR 50-60s, LS\ncoarse to clear, ic/sc rtxns. Continues on IV caffeine. P:\nCont to monitor resp status.\n\nFEN O/A: TF @ 130cc/k/d. IVF @ 120cc/k/d: PND5 w/ IL running\nthrough a DLUVC. Enteral feeds started @ 10cc/k/d; BM20.\nInfant receives 1.2cc q4h pg, tolerating well thus far.\nAbdomen soft/flat, soft BS audible. Voiding/trace mec\nstooling. P: Cont to monitor I&O. Monitor for s/s of feeding\nintolerance.\n\nG&D O/A: is nested on sheepskin in a servo ;\ntemps stable. A/A with cares, opens eyes, sucks on pacifier.\nP: Cont to support developmental needs.\n\nPAR O/A: Dad in times today w/ visitors. Updated @\nthe bedside by this RN. No contact from mother thus far. P:\nCont to support NICU family.\n\nC/V O/A: No audible murmur. HR 120-140s. BP: 66/36 (48).\nInfant is sl. jaund/well perfused. P: Cont to monitor CV\nstatus.\n\nBili O/A: remains under single phototherapy. Eye\nshields in place. P: Cont to monitor.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2122-10-20 00:00:00.000", "description": "Report", "row_id": 2039219, "text": "RESPIRATORY CARE NOTE\nBaby received intubated on vent settings 15/5 Rate 14 Fio2 21%. Suctioned ETT for mod amt of white secretions. Breath sounds clear after suctioning. Stable on current vent settings cont to follow.\n" }, { "category": "Nursing/other", "chartdate": "2122-12-02 00:00:00.000", "description": "Report", "row_id": 2039483, "text": "NPN 1900-0700\n\n\n1. Resp: Rec'd infant in NC 500cc flow and 70% FiO2.\nInfant had increased FiO2 to 80% during feeding (and\nholding). Returned to and was placed prone\nsecondary to head bobbing and increased wob. Infant quickly\nweaned fiO2 to 40-45%, where he remained most of the rest of\nthe night. RR up to 70's to 90's at times, especially when\nbeing held. However, RR decreased to 50's to 60's at rest.\nMild SCR at baseline. LS clear. + upper airway congestion.\nHad 1 spell while being held. See flowsheet for details.\nTotal is 2 in 24hrs. On caffeine.\n\n2. FEN: WT=1670gms (up 30gms). TF=150cc/k/day BM/PE31.\nGavaged 42cc over 1hr. Max asp = 4cc partially digested\nformula. Refed. No spits. AG=24.5-25cm. Abd is soft and\nslightly full. Active bs. V&S with each diaper change.\n\n3. G&D: Infant is quietly alert and active with cares.\nSleeps well between cares. Uses pacifier to comfort self.\nBrings hands to face. Temps stable swaddled in off\n. AFSF. AGA.\n\n4. : in at and participated in cares.\nUpdated at bedside. Asked appropriate questions. Mom held\nfor ~ 45\". Both were very concerned about infant's increase\nin fiO2 requirement. Mom called later and was pleased that\n had decreased fiO2 requirement and decreased wob. Cont\nto offer updates and support.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2122-12-21 00:00:00.000", "description": "Report", "row_id": 2039564, "text": "Neonatology\nRemains in high flow NCO2. Generally comfortable apeparing.\nReceiving trial of Diuril rx. SLightly improved over past few days.\n\nWt 2430 up 25. Tolerating feeds at 130 cc/k/d of 30 cal. Abdomen benign.\n\nContinue to monitor resp status. Continue current nutritional regimen.\n\n" }, { "category": "Nursing/other", "chartdate": "2122-12-21 00:00:00.000", "description": "Report", "row_id": 2039565, "text": "Neonatology NP Note\nPE\nswaddled in open crib\nAFOF, sutures opposed\nmild subcostal retractions in NCO2, lungs clear/=\nRRR, no murmur appreciated, pink/well perfused\nabdomen soft, nontender, nondistended, small umbilical hernia, left inguinal hernia not appreciated, active with good tone.\n" }, { "category": "Nursing/other", "chartdate": "2122-12-21 00:00:00.000", "description": "Report", "row_id": 2039566, "text": "NPN 0700-1900\n\n\n#2 RESP\nO: Infant remains on NC 500cc, 45-60%. RR=30-80's. O2\nsats>92%. Mild IC/SC retractions. LS are clr/=. Occasional\ndrifts to 70-80%'s with QSR. No A/B's thus far. Remains on\nDiuril and KCl. A: Stable on NC. P: Cont to monitor.\n#3 FEN\nO: TF=130cc/kg/day of PE31=53cc q4hr gavaged over 1hr. PO\nonce a shift. No spits. Aspirates=3.2-5.0cc. Voiding. Trace\nstools. Abdomen benign. Active bowel sounds. A: Tolerating\nfeeds. P: Cont to monitor and encourage PO feeds.\n#4 G&D\nO: Infant remains in OAC. Swaddled. Temp stable. A/A with\ncares. Sucks on pacifier. Brings hands to mouth. Sleeps well\nin between cares. Eye exam done. AFOF. MAE. A: AGA. P: Cont\nto monitor and support G&D.\n#5 \nNo contact with thus far.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2122-12-31 00:00:00.000", "description": "Report", "row_id": 2039614, "text": "Neonatology- Physical Exam\n\n remains in NC. Active, alert in an open crib, AFOF, sutures opposed, good tone. BBS clear and equal with good air entry, mild SC retractions. Gr murmur LLSB, pink, RRR. Abdomen soft, non-distended with active bowel sounds, no HSM, small umbilical hernia, tolerating feeds. Please refer to attending progress note for detailed plan.\n" }, { "category": "Nursing/other", "chartdate": "2122-12-31 00:00:00.000", "description": "Report", "row_id": 2039615, "text": "npn 0700-1530\n\n\nRESP: Infant remains on 50-100cc of 100% FiO2 via NC.\nSats=>94% with occassional drifts to high 80's, QSR.\nRR=50-70's with occassional episodes of tachypnea, mild subc\nretractions noted upon exam. Upper airway congestion\naudible, TB sx q nostril removed thick green secretions. No\nspells thus far. P: Continue to monitor respiratory status\nand continue to wean O2 as tolerated.\n\nFEN: Infant remains on restricted TF's of 130cc/kg/d of\nPE/BM26= 62cc q 4hrs all po. Infant tolerating feeds well,\nhad x1 small spit. Abd benign, soft, no loops, +bs, soft\nreducible umbi hernia. Infant voiding and stooling, trace\npositive, infant does have anal fissure which was , RN\naware. Infant has generalized edema. P: Continue to monitor\nnutritional status.\n\nDEV: Temp stable in OAC, while dressed and swaddled. Alert\nand active with cares. Wakes for feeds. Easily consolable.\nEnjoys sucking vigorously on pacificer when offered.\nBecoming aware of surroundings. Enjoys being held and talked\ntoo. . MAE. AGA. P: Continue to monitor and support\ndevelopmental needs.\n\nPAR: No contact from thus far, unable to assess at\nthis time. P: Continue to update and support .\n\n\n" }, { "category": "Nursing/other", "chartdate": "2122-12-31 00:00:00.000", "description": "Report", "row_id": 2039616, "text": "nursing note\nAgree with above note by co-worker. was elevated at 45 degress today. Also Father came in at 1600 for brief visit. given update. Stated that he would be back with mom for the cares. P: will continue to update and support.\n" }, { "category": "Nursing/other", "chartdate": "2122-12-31 00:00:00.000", "description": "Report", "row_id": 2039617, "text": "Rehab/OT\n\nObserved during evening cares. Continues to require increased O2 during cares, increased WOB noted. Tremors when awake, periods of hyperalert. Not ready for increased stimulation at this time. Will re-assess next week. to continue to stimulate with holding and to him.\n" }, { "category": "Nursing/other", "chartdate": "2123-01-14 00:00:00.000", "description": "Report", "row_id": 2039689, "text": "NICU nursing progress note\n\n\nPlease refer to flowsheet for specific info.\nResp\nO: remains with NC 100% 13-50cc flow. RR 40-60's, sat's\n>93%. BSCE bilat. Mild upper airway congestion noted. A:\nbreathing comfortably, 's with feeds to low 80% then\nrequiring dialing of 02, quickly returning to baseline. P:\ncont to wean 02 as tolerated, keeping sat's 92-98%.\nFEN\nO: TF of 130cc/k/d of E20 or bm on an ad lib schedule.\nBottling q 4 hours at present. Abd pink, no loops, active\nbs. Voiding/ no stool thus far today. asp. No spits. A:\nstable. P: cont to follow.\nGD\nO: Temp stable in oac, active and with cares. MAE.\nFont soft, flat. Calms with containment and pacifier. A: AGA\nP: cont to support dev. milestones.\nParenting\nO: in and updated at bedside, verbalizing understanding.\nA: Involved, invested, and loving . P: cont to\nupdate, support, educate.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2123-01-16 00:00:00.000", "description": "Report", "row_id": 2039697, "text": "PCA 1900 - 0700\n\n\nResp\n#2 O: Infant currently on NC 100% fiO2, flow of 13-50cc.\nMaintaing adequate sats above 92%. Occasionally drifts to\nmid-high 80's while bottling; O2 flow increased to 50cc\nwhile feeding. Mild subcostal retractions noted. Lung sounds\nare clear/= bilaterally. A: Infant is sustaining adequate\nsats with NC O2. P: Continue to monitor infant for A's and\nB's and wean O2 as tolerated.\n\nFEN\n#3 O: Current weight= 3290 (^40). Total fluids= minimum\n130cc/k/day of BM20 or E20. Adlib diet on demand; PO's q2-4\nhours. Abdomen is round, soft and benign; no loops noted.\nVoiding with cares; X1 lg stool (-) thus far. BS+. A: Infant\nis tolerating adlib feedings well. P: Continue to encourage\nadlib on demand feeing schedule.\n\nG&D\n#4 O: Temps stable. Infant swaddled in OAC. Brings hands to\nface for comfort. Wakes and is for cares; has slept\nwell so far in between cares. . A: AGA. P: Cotinue to\nmonitor and support infants growth and development.\n\n\n#5 O: Mom and in at 2100. Mom BF for 25 ; infant\nlatched on well and was eager to feed. A: are\ninvolved. P: Continue to update and support family.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2123-01-16 00:00:00.000", "description": "Report", "row_id": 2039698, "text": "NICU NPN\n I agree with above note written by PCA.\n" }, { "category": "Nursing/other", "chartdate": "2123-01-16 00:00:00.000", "description": "Report", "row_id": 2039699, "text": "Newborn Med Attending\n\nDOL#91. Cont in low flow O2 per NC. No spells. AF flat, clear BS, soft murmur, abd soft, MAE. Wt=3290 up 40, on ad lib Bm.\nA/P: Growing infant with CLD. Wean O2 as tolerated. Eye exam on Monday, mild ROP.\n" }, { "category": "Nursing/other", "chartdate": "2123-01-16 00:00:00.000", "description": "Report", "row_id": 2039700, "text": "NPN DAYS\n\n\nAlt in Resp: LS clear and equal. + nasal congestion. No\nsuctioning needed. Mild SC retractions. Baby has mostly been\nin room air at rest and requiring O2 during feeds. Continues\non Diuril and KCl. Continue to monitor closely.\n\nAlt in FEN: TF 130cc/kg/day ad lib demand schedule\nE20/BM20. Baby taking plenty po, see flow sheet. No spits.\nBelly benign. Stool x1 small. Continue to offer feeds ad\nlib.\n\nGrowth and Dev: Temp stable while swaddled in open crib.\nWakes for feeds. Sleeping fairly well between feeds. Will\ncontinue to support developmental needs.\n\n: No contact yet this shift.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2122-10-20 00:00:00.000", "description": "Report", "row_id": 2039220, "text": "NURSING PROGRESS NOTE\n\nRESP/CV: REMAINS ON UNCHANGED VENT SETTINGS IN 21%FIO2 ALL NIGHT. BS\nCSE/CL&= WITH BASELINE RETRACTIONS. RR 30-70. SX'D Q4HRS FOR SM-MOD SECRETIONS. COLOR PALE/PINK AND ADEQUATELY PERFUSED. NO A&B'S OR DESATS TONIGHT. REMAINS ON CAFFEINE IV. SINGLE PHOTOTHERAPY MAINTAINED WITH EYE PROTECTION. NO BILI LEVEL ORDERED.\n\nFEN: TOTAL FLUIDS REMAIN AT 150CC/KG/D. PN6%/D10W & IL INFUSING VIA DOUBLE LUMEN UVC AT 140CC/KG/D. RECEIVED ONE D10 BOLUS FOR D-STICK OF 50. PRESENTLY D-STICK 62. ENTERAL FEEDS OF BM AT 10CC/KG/D. ABD SOFT, PINK WITH STABLE GIRTH AND HYPOACTIVE BS. 0.8CC SLIGHTLY BILIOUS RESIDUAL DISCARDED AT 2400 NNP AND FEEDS CONTINUED. NO RESIDUAL AT 0400. VOIDING 3.6CC/KG/D PRESENTLY.\n\nDEV: ACTIVE AND ALERT WITH INTERVENTIONS, MOVING ALL EXTREMITIES AND SUCKING VIGOROUSLY ON PACIFIER. SLEEPING QUIETLY BETWEEN CARES.\n\nSOCIAL: PARENTS VISITED X2, ASKING APPROPRIATE QUESTIONS. VERY PLEASED WITH HIS PROGRESS BUT AWARE OF HIS POTENTIAL PROBLEMS. MOM PUMPING SUCCESSFULLY.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2122-10-20 00:00:00.000", "description": "Report", "row_id": 2039221, "text": "Neonatology Attending Note\nDay 4\n\n15/5 x 14, RA. CBG 7.26/54. No A&Bs. On caffeine. RR40-50s.\n\nPale/pink. HR 130-140s. Mean BP 44. No murmur.\n\nUnder single photot.\n\nWt 595, down 7 gms. TF 150 cc/k/d. PND6/IL. Trophic feedings at 10 cc/k/d.\nu/o 3.6\nNo stool\nd/s 50\n\nIn servo .\n\nA/P:\n-- resp: try CPAP, monitor AOP\n-- Heme:con't photot, check bili in am\n-- FEN: Adv enteral feedings\n-- HUS Thurs.\n-- labs lytes and bili in am\n" }, { "category": "Nursing/other", "chartdate": "2122-10-30 00:00:00.000", "description": "Report", "row_id": 2039292, "text": "Neonatology Attending Note\nDay 14\n\nIMV 15/5 x 12, 24-28%. RR30-60s. Sm to mod secretions, +oral secretions. On caffeine. No A&Bs.\n\nNo murmur. HR 140-170s. BP 71/58,62.\n\nWt 738, up 56. TF 150 cc/k/day BM26 pg. Tol well w/ no spits and min aspirates. Nl voiding and stooling.\n\nDrainage in left eye.\n\nIn .\n\nA/P:\nDoing well on low vent settings. Will consider another trial of CPAP early next week. Remains on caffeine.\n\nWil add promod to nutritional content.\n\nEvaluate eye drainage.\n\nd/c PICC.\n\nHUS - nl, next day 30.\n" }, { "category": "Nursing/other", "chartdate": "2122-10-30 00:00:00.000", "description": "Report", "row_id": 2039293, "text": "Neonatology- Physical Exam\n\n remains intubated on low vent settings. Active, alert in an , AFOF,sutures split, good tone. BBS clear and equal with good air entry. No murmur, pulses +2, pink, RRR. Abdomen soft, non-distended with active bowel sounds, no HSM, tolerating feeds. Please refer to attending progress note for detailed plan.\n" }, { "category": "Nursing/other", "chartdate": "2122-10-30 00:00:00.000", "description": "Report", "row_id": 2039294, "text": "Neonatology- Physical Exam\nPICC line removed without incident.\n" }, { "category": "Nursing/other", "chartdate": "2122-12-21 00:00:00.000", "description": "Report", "row_id": 2039567, "text": "NPN 7a7p\n\n\nAgree with the above note by coworker. In addition..\nFEN\nInfant with lrger benign asps, active BS. Has been trying to\nstool x 2 days, only traces. No loops, no spits. Await\nstool. Infant learning to PO. Reported to do better with BF.\nBottles aggressively but is uncoordinated, air hungry and\ndesats. Encourage BF. Assess WOB and need to bottle. Monitor\nweight and exam.\n\nFather in this am for short visit prior to eye exam.\nAppropiate with infant. Expressing some stress over property\nhe and Mom are trying to purchase. Will be in for this eves\ncares and BF. Involved, stressed and loving Father. Support\nand educate .\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2122-12-22 00:00:00.000", "description": "Report", "row_id": 2039568, "text": "NPN\n\n\n#2\nInfant remains in N/C 500cc flow; 45-60% and is maintaining\nsats low 90s. Occasional drifts in sats-SR. BS clear= with\nmild retractions at rest--increased to moderate after\nbottling. Continues on Diurel and KCL as ordered. Color is\npink; soft intermittent murmer. No spells noted.\n\n#3\nInfant remains on TF=130cc/k of PE/BM31 q4 hours. Infant\nhas tolerated gavage feeds well without spits and only scant\naspirates. Infant nursed x1 last eve with mom and did well.\nHe bottled this am x1 and also did well, but a little\nuncoordinated at times. Abd is soft and round; voiding and\nstooling. Wt is up 25gms-2455.\n\n#4\nInfant remains in an open crib swaddled with boundaries.\nInfant is alert with cares; temp is stable. Does very well\nwith breastfeeding; continues to be a little uncoordinated\nwith bottling.\n\n#5\n were in last evening-both independent with cares.\nMom nursed infant and then held after.\n\n\n\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2122-12-22 00:00:00.000", "description": "Report", "row_id": 2039569, "text": "Neonatology\nStable in NCO2. Stable flow. Generally comfortable apeparing. On trial of diuril. Intermittent murmur.\n\nWt 2455 up 25 . Tolerating feeds at 130 cc/k/d of 32 cal. Abdomen benign. Taking one bottle per shift.\n\nCOntinue to assess resp status.\n" }, { "category": "Nursing/other", "chartdate": "2123-01-07 00:00:00.000", "description": "Report", "row_id": 2039647, "text": "Co-worker note 11p-7a\n\n\n#2. RES: Infant remains in 100% NC at 50cc- 75cc flow. O2 is\nweaned to maintain O2 sats between 93-98%. LS cl/= with mild\nupper resp congestion. Mild sc retractions noted during\ncares. No episodes of bradycardia or apnea during this\nshift.\n\n#3. FEN: Weight 3145, ^ 60g. TF: 130cc/k/d of PE 24= 67c\nq4hr. Infant cont to be an ad lib demand feeder waking q3-4\nhours to bottle. TF over 24 hrs= 145cc/k. Abd benign, no\nloops, +BS. No spits. Voiding qs/ no stool this shift.\n\n#4. G&D: Infant is swaddled in an OAC with stable temps.\nWakes for feeds and is and active with cares. Brings\nhands to face. Will cont to monitor growth and development.\n\n#5. PAR: No contact with during this shift.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2123-01-07 00:00:00.000", "description": "Report", "row_id": 2039648, "text": "NPN 7p7a\nAgree with the above note written by coworker.\nADD\n\nBoth in for cares and feeding at beginning of shift. Independent with cares. Engaging with infant. Mom BF x 20 and then bottled while read stories to . Both comp of exhaustion, stating their house plans are still in the works and they look forward to closing on the property soon. Asking appropiate questions. Invested and loving. Support and educate.\n" }, { "category": "Nursing/other", "chartdate": "2123-01-14 00:00:00.000", "description": "Report", "row_id": 2039690, "text": "Rehab/OT\n\nMet at the bedside. Reviewed tummy time and developmental play positions. Discussed EI transition. Recommend EI 1x week if possible.\n" }, { "category": "Nursing/other", "chartdate": "2123-01-15 00:00:00.000", "description": "Report", "row_id": 2039691, "text": "PCA Note\n\n\nRESP: Infant remains on O2 NC 100% FiO2 13-25cc flow. O2\nsat >92%. Infant drifts to mid-high 80's while bottling;\nneeds 50cc during feeds. RR 30-70's, occassionally\nincreasing to 80's during feeds. LS cl/= with mild\nsubcostal retractions. Continue to monitor resp. status\nclosely and wean O2 as tolerated.\n\nFEN: Present weight 3250g, down 60g. TF of\n130cc/kg/day. Infant is on an ad lib/demand schedule of BM\nor E20; infant bottles Q4-5hrs. TF 145cc/kg/day for 24\nintake. Abd benign. Infant is voiding and stooling.\nContinue to encourage PO's.\n\nDEV: Infant is swaddled in OAC. Temps have been stable\ntonight. and active with cares. Sleeps well after a\ngood bottle. Sleepy tonight. Continue to support\ndevelopmental needs.\n\n: Mom and in tonight at 2200. Mom participated\nwith cares. Mom held and BF infant for 15 and bottled\n. Both showing enthusiasm and asking\nappropriate questions. Continue to update and support.\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2123-01-15 00:00:00.000", "description": "Report", "row_id": 2039692, "text": "NPN\nAgree with above note by PCA Tran.\n\nBrief trial off nasal cannula unsuccessful. Will cont to assess need for O2 support & wean as tolerated.\n\n independent with cares. Will be moving into their home over the weekend. Brought in a carseat for -.\n" }, { "category": "Nursing/other", "chartdate": "2123-01-15 00:00:00.000", "description": "Report", "row_id": 2039693, "text": "Neonatology\nAttempted to wena O2 yetserday. Transiently down to 13 cc. Will continue to attempt weaning.\n\nWt 3250 down 60. Took in good volumes. Ad lib of E20. Abdomen benign.\n\nCOntinue current attempt to wean from O2. Will arrange family meeting.\n\n" }, { "category": "Nursing/other", "chartdate": "2123-01-15 00:00:00.000", "description": "Report", "row_id": 2039694, "text": "Neonatology- Physical Exam\n\n remains on NC. Active, in an open crib, AFOF, sutures opposed, good tone. BBS clear and equal with good air entry. No murmur, pulses +2, pink, RRR, strawverry hemaingioma on left arm. Abdomen soft, non-distended, small umbilical hernia, tolerating feeds. Please refer to attending progress note for detailed plan.\n" }, { "category": "Nursing/other", "chartdate": "2122-10-30 00:00:00.000", "description": "Report", "row_id": 2039295, "text": "NPN DAYS\n\n\nAlt in Resp: Remains on IMV 15/5 rate 12 with FiO2 23-30%.\nLS clear and equal. Mild IC/SC retractions. Sxn'd q4hrs, see\nflow sheet. No spells. Has occasional desats to the 70's\nneeding increased O2. try on CPAP again next week.\n\nAlt in FEN: TF 150cc/kg/day BM26PM, gavaging feeds over\n50mins. No spits. No aspirates. Belly benign. Voiding. Trace\nstool x1. to d/c PICC line today. Continue with current\nplan of care.\n\nGrowth and Dev: Temp stable in servo . Nested on\nsheepskin with boundaries in place. Sutures remain flat,\nsoft, moveable and spread. HUS normal thus far. Awake and\nalert with cares. + root relex but not yet taking a\npacifier. Will continue to provide for developmental needs.\n\n: Mom called for an update. She will be in tonight\nfor the 8pm cares. Will continue to provide support and\nteaching.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2122-10-30 00:00:00.000", "description": "Report", "row_id": 2039296, "text": "Respiratory Care Note\nPt. remains vented on 15/5, RR 12, 21-30%. BS clear. RR 30-60. Suctioned for mod amount cloudy secretions. On caffeine. No spells but occ. O2 Sat drifts. Plan to extubate on Mon.\n" }, { "category": "Nursing/other", "chartdate": "2122-10-31 00:00:00.000", "description": "Report", "row_id": 2039297, "text": "2. Resp: O: Received infant on the vent at settings of 15/5\nX 12. FiO2 has been 25-30%, RR 30-50s, ls clear. Sxned q 4\nhours for a mod amt of white secretions from his ETT and a\nmod-large amt of oral secretions. No spells. He is on\ncaffeine. A: Stable on low settings on the vent. P: Monitor.\nSxn prn. Meds as ordered.\n\n3. F/N: O: Infant is on 26cal BM + promod, delivered via\ngavage q 4 hours over 50min. Abd is benign, he is voiding\nand stooling g- stools. No spits, min asps. He gained 19g.\nA: Tol feeds, gaining wt. P: Monitor.\n\n4. G/d: O: Temp is stable on servo in the heated .\nInfant sucks vigorously on a binkie, though he will desat w/\nit if he falls asleep w/ a binkie in his mouth. A/P:\nContinue to support infant needs.\n\n5. : O: Mom came in for the 8p cares and held infant\nbriefly after he was weighed while I changed his bed.\n(Saturday is kangaroo day.) A: Loving, involved Mom. P:\nContinue to support.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2122-10-31 00:00:00.000", "description": "Report", "row_id": 2039298, "text": "Respiratory Care Note\nPt. continues on 15/5 R12 and FIO2 25-30%. BS are clear. Pt. sx'd for mod. cloudy secretions. To follow.\n" }, { "category": "Nursing/other", "chartdate": "2122-11-14 00:00:00.000", "description": "Report", "row_id": 2039388, "text": "NPNOte;\n\n\n#2.Remains on nasal prong CPAP of 5cm, Fio2 21-28%, BBS\nclear, equal, mild intercostal/subcostal retractions\npresent, on caffine, spell x1, needed mild stim, yellowish\nnasal secretions suctioned. Occassional sat drifts noted.\nPcell transfusion 10cc x 2 alliqots, 2nd alliqot in\nprogress.A; required CPAP support. P; cont resp support as\nneeded.\n\n#3. Tf=150cc/kg/day,PE30 pg fed over 30mts, BS+, no loops,\nvoided, stooled guaic negative. Team aware of todays\n,PIV P cells infusing.A; Feeds tolerated.P; cont current\nfeeding plan.\n\n#4.Alert, active with care, temp stable in a servo control\n,nested in sheepskin,MAE.A; AGA P; cont dev support.\n\n#5. informed about P cells transfusion and\nupdated over the phone. P; cont update an dteaching, \ndid not visit thus far this shift.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2123-01-07 00:00:00.000", "description": "Report", "row_id": 2039649, "text": "Neonatology\nDoing well. Remains in NCO2. 50 - 75 cc flow. Mild upper airway congestion. On diuril.\n\nWt 3145 up 60. Tolearting feeds at ad lib voluems 24 cal. Took in 145 cc/k/d yesterday. Abdomen bneign.\n\nTemp stable in crib.\n\nAwaiting maturation of resp control and feeds.\n" }, { "category": "Nursing/other", "chartdate": "2123-01-07 00:00:00.000", "description": "Report", "row_id": 2039650, "text": "Neonatology NP Note\n examined, care discussed with team. Evaluation and plan per DR. note.\n\nPhysical exam:\nAwake, fussy in open crib, receiving NC O2.\nAFOF, sutures split. eyes clear. MMMP.\nResp with mild tachypnea while active, BS with fine crackels, gfod excursion. RRR, no murmur. Pulses plus 2 equal.\nAbdomen protruberant, active BS.\nleft hydroclele palapble. small area of perianal excoriation.\nMAE, LE mildy hypertonic during exam.\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2123-01-07 00:00:00.000", "description": "Report", "row_id": 2039651, "text": "PCA Note:\n\n\nAlt in Resp: NC 100%FiO2 50-75cc (increase to 75cc with\nfeedings). Lung sounds clear and equal with mild upper\nrespiratory congestion. Mild subcostal retractions.\nIncreased work of breathing with feedings as evidenced by\nhead bobbing. to 57% with 8am bottling. Seems to be\nresult of poor coordination. Infant became pale, resolved\nwith blow by O2. Continue to monitor respiratory status\nclosely especially while feeding.\n\nAlt in FEN: TF minimum 130cc/kg/day. PE24 ad lib. Infant\nwakes for feedings about every 3 hours. Voiding, stooling,\nheme neg. No spits. Continue with plan of care.\n\nGrowth and Development: Swaddled in open crib. Temps\nstable. Infant has been somewhat irritable today. Sleeps\non and off between cares. Happy in bouncy seat. ROP stage\n2 zone 2 bilaterally (to be rechecked next week). Continue\nto support developmental needs.\n\n: in today before work to drop off breast milk.\nWoke infant to say hello. Will return this evening.\nContinue to support and teach.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2122-11-15 00:00:00.000", "description": "Report", "row_id": 2039389, "text": "NPN NIGHTS\n\n\nAlt in Resp: Remains on prong CPAP5 with FiO2 mainly 25%\nthis shift. LS clear and equal. Sxn'd nares x1. Mild IC/SC\nretractions. No spells. Remains on caffeine. Continue to\nmonitor.\n\nAlt in FEN: TF 150cc/kg/day PE30/BM30PM, gavaging over\n40mins. Tolerating feeds without problems. Belly benign.\nWeight 1065 up 65gm. Continue with current plan of care.\n\nGrowth and Dev: Temp stable in servo . Nested on\nsheepskin with boundaries in place. Awake and alert with\ncares. Tolerated kangarooing with mom x90mins. Will continue\nto support appropriate development for his age.\n\n: called x1. Mom in to visit and participated in\ncares, then held. Gave mom HepB info sheet. Updated her and\n on day. Will continue to provide teaching\nand support.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2122-11-15 00:00:00.000", "description": "Report", "row_id": 2039390, "text": "Respiratory Care Note\nPt. continues on 5cmH2O of nasal prong CPAP and 25%. Pt. on caffeine, no spells thus far. To follow.\n" }, { "category": "Nursing/other", "chartdate": "2122-11-15 00:00:00.000", "description": "Report", "row_id": 2039391, "text": "Neonatology Attending Note\nDay 30\n\nCPAP5, 25%. RR40-60s. BS cl and =. 1 A&B/24h. HR 170-180. Pink and well perfused. BP 72/40, 53.\n\ns/p PRBCs yest.\n\nWt 1065, up 65 gms. TF 150 cc/k/day PE/BM30 w promod. Tol well. Nl voiding and stooling (g-).\nFe and Vit E\n\nIn .\n\nA/P:\nmaintain CPAP\nmonitor aop on caffeine\nHUS check d30 Weds.\n\n" }, { "category": "Nursing/other", "chartdate": "2122-11-15 00:00:00.000", "description": "Report", "row_id": 2039392, "text": "Respiratory Care\nBaby continues on cpap5, fio2 22-25%, bs clear, rr 40-60's, on caffeine, no spells noted on this shift thus far. Will continue to follow.\n" }, { "category": "Nursing/other", "chartdate": "2122-11-15 00:00:00.000", "description": "Report", "row_id": 2039393, "text": "NPNOte;\n\n\n#2.Remains on Nasal prong buble CPAp of 5cm, Fio2 22-25%,BBs\nclear, equal, mild intercostal/subcostal retractions\npresent,mod amount cloudy nasal secretions suctioned. on\ncaffine, no spells thus far this shift.H. rate 170-180 team\naware.A; no spells thus far this shift.P; cont resp support\nas needed.\n\n#3. Tf=150cc/kg/day, Pe30/BM30 with promod, pg fed,\ntolerated, BS+, no loops, voided, no stool. On Vit E and\nIron supps.A; feds tolerated. P; cont current feeding plan.\n\n#4. Alert, active with care, temp stable in a servo control\n, .nested in sheepskin. A; aga P; cont dev\nsupport.\n\n#5.Mom called for a update, asking app questions, planing to\nvisit this pm.A; unable to assess.P; cont update and\nteaching.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2122-12-01 00:00:00.000", "description": "Report", "row_id": 2039480, "text": "Newborn Med Attending\n\n off CPAP yest. Now in O2 per NC, occ spells. AF flat, clear BS, no murmur, abd soft, MAE. Wt=1640 up 55, on 150 cc/kg/d PE331 with PM, PG.\nA/P: Growing infant with AOP. Monitor fopr spells.\n" }, { "category": "Nursing/other", "chartdate": "2122-10-23 00:00:00.000", "description": "Report", "row_id": 2039247, "text": "NPN DAYS\n\n7 Hyperbili\n\nAlt in Resp: Received baby on in room air. Baby had\n9 spells between 7a-1:30p. Reintubated by MD and placed on\nvent settings of 15/5 rate 15 FiO2 21%. No spells since\nintubation. LS clear. Sxn'd for large amounts oral\nsecretions. Remains on caffeine. To check blood gas this\nafternoon.\n\nAlt in FEN: TF 150cc/kg/day. 90cc/kg/day is PND8 and lipids\nvia DUVC. 60cc/kg/day is BM20 via gavage feedings.\nIncreasing feeds by 10cc/kg/. Minimal aspirates, green\ntinged, refed and continued with feeds. NNP aware. Belly\nbenign. Stool x1 mec. Will check lytes this afternoon.\nContinue to increase feeds as tolerated.\n\nGrowth and Dev: Temp stable in servo and on warmer.\nAwake and alert with cares. Rests well between cares. Nested\non sheepskin with boundaries in place. Will continue to\nprovide for developmental needs.\n\n: No contact yet this shift.\n\nAlt C/V: No murmur noted. TBO 9.25cc. Will check HCT this\nafternoon.\n\nHyperbili: Resolved r/t rebound bili 1.8/0.5.\n\nREVISIONS TO PATHWAY:\n\n 7 Hyperbili; resolved\n\n" }, { "category": "Nursing/other", "chartdate": "2122-10-23 00:00:00.000", "description": "Report", "row_id": 2039248, "text": "Respiratory Care\nBaby reintubated for increased apnea and bradycardia, intubated with a 3.0ett taped at 7cm, currently on imv 15/5 x 12, fio2 21, bs clear, on caffeine, abg on f of 15, 7.35/36/151/21/-4, f decreased. Will continue to follow.\n" }, { "category": "Nursing/other", "chartdate": "2122-10-23 00:00:00.000", "description": "Report", "row_id": 2039249, "text": "Neonatology-NNP PRogress Note\n\nPE: is curently intubated in oroma ir, bbs cl=, rrr s1s2no murmur, bd soft, nontender, gavage tube in V&S, afs, sutures slightly split, pale, pink, mottles with care\n\nSee attending note for plan\n" }, { "category": "Nursing/other", "chartdate": "2122-10-24 00:00:00.000", "description": "Report", "row_id": 2039250, "text": "Procedure Note: P-CVL\nIndication: long-term central venous access\n\n#1.9 Neo-Picc catheter inserted to 12 cm via introducer in left arm vein. Cathter pre-cut to 12 cm. Line draws and flushes easily. Secured with sterile occlusive dressing. Aspetic technique with Betadine/alcohol skin prep. Infant tolerated procedure well, no complications. Chest x-ray shows tip in SVC.\n" }, { "category": "Nursing/other", "chartdate": "2122-10-24 00:00:00.000", "description": "Report", "row_id": 2039251, "text": "#2Resp\nLungs clear. Minimal amt secretions from ETT but large thick\nwhite oral secreions. Baby remains on same settings. 15/5\nwith rate of 15. Baby has remained in RA entire night with\nsat 100. Mild IC/SC retractions. RR40-70's. No spells.\nA. No spells since reintubation.\nP. Cont to monitor.\n#3FEN\nTF cont at 150cckg. Feed currently at 60cc/kg. Not advanced\nat 2400 due to placement on new PICC line. Baby receiving\n7cc BM20 q4, At , 1.2cc bilious tinged asp noted. \nto NNP and discarded. Feed continued. At 2400, .4cc asp\nnoted. Bowel sounds heard. AG 16-16.5. Small round bruise\nnoted in r lower quandrant. New PIC placed in L arm. Chest\nxray confirmed central placement. TPN D7.5 inusing with\nlipids at 90cc/kg. UVC clamped and then removed by NNP.\nVoiding, but only trace stool.\nA.Feed continued.\nP. Cont to monitor abd exam. Plan to increase feed with next\ncare.\n#5Parents\n here and updated at . Hope to hold tomorrow. Not\nheld tonight due to intubation and line placement.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2122-10-24 00:00:00.000", "description": "Report", "row_id": 2039252, "text": "#4Dev\nBaby on a radiant warmer for PIC line placement. Nested on\nsheepskin with boundaries. temp stable. Awake and alert with\ncares. Calm during procedures.\nP. Plan to return baby to with next care.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2122-10-19 00:00:00.000", "description": "Report", "row_id": 2039211, "text": "NPN\n\n\n#2Ressp O- Infant remains on vent settings of 15/5 X 12 O2\nneed 21-26%. RR 50-70. Lungs clear. Cap gas 7.23/54 Mild\nincrease in FIO2 with cares. A-Stable on minimal vent\nsettings P- As per team.\n#3F/N O- remains NPO with total fluids at 130cc/kg.(\nPN5% and lipids)D-stick 106. Voiding well. Abdomen is soft\nwith active bs. Girth 16-17cm. trace mec. passed. Lytes and\nbili sent with PKU. Wt 602. A- Doing well be ready for\ninitiation of feeds. P-As per team.\n#5Family Parents in to vsiit and MOm held infant for first\ntime. Family updated with status. Mom pumping and storing\nBM. A- Updated P- Continue to teach and support. Arrange\nfamily meeting for this week.\n#6C/V No issues. No murmur heard. HR 120-130.\n#7Bili Bili pending. Remains under single spot light.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2122-10-19 00:00:00.000", "description": "Report", "row_id": 2039212, "text": "Nursing Addendum\nVent rate increased to 14 after cap gas. Follow cap gas later today.\n\n" }, { "category": "Nursing/other", "chartdate": "2122-10-19 00:00:00.000", "description": "Report", "row_id": 2039213, "text": "Neonatology Attending Note\nDay 3\n\nSIMV 15/5 x14, 21-25%. On caffeine. CBG 7.23/54. HR 120-130s. BP 66/36, 48.\n\nUnder single photo. Bili 2.5/0.3.\n\nWt 602, down 33 gms. TF 130 cc/k/day. NPO. DL UVC. d/s 106.\n140/5.6/105/24.\nNl voiding, tr stools.\n\nIn .\n\nA/P:\n - Maintain current low vent settings\n - Start trophic feedings\n - HUS planned for day 7\n" }, { "category": "Nursing/other", "chartdate": "2122-10-19 00:00:00.000", "description": "Report", "row_id": 2039214, "text": "Neonatology-NNP Physical Exam\n\nInfant remains orally intubated on low vent wettings. AFOF, sutures slightly split, active, alert, good tone. BBS clear and equal with good air entry. No murmur, pulses +2 and equal, no palmar pulses, precordium not active. Abdomen soft, non-distended, hypoactive bowel sounds, no HSM. Please refer to attending progress note for detailed plan.\n" }, { "category": "Nursing/other", "chartdate": "2122-10-19 00:00:00.000", "description": "Report", "row_id": 2039215, "text": "Clinical Nutrition\nO:\n27 wk gestational age BB, SGA, now on DOL 3.\nBirth wt: 695 g (slightly below 10th %ile); current wt: 602 g (-33); wt currently down ~13% from birth wt.\nHC at birth: 23.5 cm (~10th %ile); current HC: 22 cm (<10th %ile)\nLN at birth: 32 cm (~10th %ile); current LN: 32 cm (<10th %ile)\nLabs noted.\nNutrition: TF @ 130 cc/kg/d. NPO; plan to start feeds today @ 10 cc/kg/d BM 20. PN started on DOL 1; lipids added on DOL 2. Remainder of fluids as PN via DUVC; projected intake for next 24 hrs from PN ~47 kcal/kg/d, ~2.5 g pro/kg/d, and ~1.4 g fat/kg/d. From EN: ~7 kcal/kg/d, ~0.1 g pro/kg/d, and ~0.4 g fat/kg/d. Glucose infusion rate from PN ~4.8 mg/kg/min.\nGI: Trace meconium stool. Soft bowel sounds.\n\nA/Goals:\nTolerating PN with some hyperglycemia yesterday to ~160's range, but now well controlled to ~100. Will slowly advance GIR. Plan to start trophic feeds today and monitor closely for tolerance. Labs noted and PN adjusted accordingly. Initial goal for PN is ~90 to 110 kcal/kg/d, ~3.0 to 3.5 g pro/kg/d, and ~3.0 g fat/kg/d. When able to advance enteral feeds, initial goal is ~150 cc/kg/d PE/BM 24, providing ~120 kcal/kg/d and ~3.3 to 3.6 g pro/kg/d. Expect PN to taper when enteral feeds are advanced. Appropriate to add Fe and Vit E supps when feeds reach initial goal. Further increases in feeds as per growth and tolerance. Growth goals after initial diuresis are ~15 to 20 g/kg/d for wt gain, ~0.5 to 1 cm/wk for HC gain, and ~ 1 cm/wk for LN gain. Will follow w/ team and participate in nutrition plans.\n" }, { "category": "Nursing/other", "chartdate": "2122-12-01 00:00:00.000", "description": "Report", "row_id": 2039481, "text": "Clinical Nutrition\nO:\n~34 wk CGA BB on DOL 46.\nWT: 1640 g (+55)(~10th to 25th %ile); birth wt: 695 g. Average wt gain over past wk ~24 g/kg/d.\nHC: 29 cm (~10th to 25th %ile); last: 27.5 cm\nLN: 36 cm (<10th %ile); last: 37 cm\nMeds include Fe and Vit E.\n noted.\nNutrition: 150 cc/kg/d PE/BM 31, w/ 5 pkts HMF/100 cc BM or 1 pkt HMF per 90 cc PE 24. Feeds just increased recently due to results of nutrition . Projected intake for next 24 hrs ~155 kcal/kg/d, ~3.6 to 4.1 g pro/kg/d, ~211 to 238 mg Ca/kg/d, ~104 to 120 mg PO4/kg/d, ~284 to 392 iu Vit D/kg/d, ~ to 2116 iu Vit A/kg/d, ~12.1 to 12.6 iu Vit E/kg/d, and ~4.3 mg Fe/kg/d.\nGI: Abdomen benign. Hx guiac + stools. One sm. spit.\n\nA/Goals:\nTolerating feeds without GI problems except spit and hx of guiac + stool as noted above. Monitoring closely for feeding intolerance. noted and within acceptable range except elevated alk phos to 518 and low PO4 to 3.9. Decision made by team to add additional packet of HMF to q 100 cc BM or 90 cc formula to increase Ca/ PO4 and Vit D intake. All nutrients remain within concensus recs except for Vit A (concensus recs is 700 to 1500 iu/kg.) This nutrient discussed w/ team and not felt to be of concern. Promod d/c'd from feedings to avoid overfeeding protein. Will recheck nutrition ~1 wk after initiating this regimen. Current feeds meeting recs for kcals/pro/vits and mins with exception of Vit A as noted above. Growth is exceeding recommended ~15 to 20 g/kg/d for wt gain and ~0.5 to 1 cm/wk for HC gain; represents catch up growth. LN shows loss of 1 cm over past wk, but question accuracy of measurements. Will continue to follow w/ team and participate in nutrition plans.\n" }, { "category": "Nursing/other", "chartdate": "2122-12-20 00:00:00.000", "description": "Report", "row_id": 2039562, "text": "NPN 7a7p\n\n\nAgree with the above assessment by co-worker.\nIn addition,\nResp. Infant began on 1 week trial of diuril and KCL hoping\nto decrease o2 need. Has been in NC 500 cc flow @ 55-60%\nmost of the day. Req increase for cares and bottling. LSC.\nS/C I/C rtx and head bobbing at times. No bradys or\nprolonged desats today. Monitor and support resp status.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2122-11-05 00:00:00.000", "description": "Report", "row_id": 2039328, "text": "Nursing Progress Note\n\n\nRESP O/A: Infant remains on NP CPAP 6cm; FiO2 28-30%. RR\n30-60s, LS clear/=, baseline ic/sc rtxns. Sxn w/ cares for\nmod secretions. Remains on caffiene, no spells noted thus\nfar. P: Cont to monitor resp status.\n\nFEN O/A: Current Wt: 834, ^24g. TF @ 150cc/k/d; BM30 w/\nPromod. Infant recives 21cc q4h pg. Tolerating feeds well,\nminimal aspirates, no spits. Abdomen soft/round, active BS.\nGirth stable. Voiding/stooling (heme neg). P: Cont to\nmonitor for s/s of feeding intolerance.\n\nG&D O/A: - is nested on sheepskin in a servo\n, Temps 98.9-99.2. Infant is A/A w/ cares, MAE, AGA.\nSutures spread, FSF. Tolerated kangaroo care for 2 hours. P:\nCont to support developmental needs.\n\nPAR O/A: Mom in for cares; independent with temp &\ndiaper change. Held - for 2 hours. Mom in @ 0030 for\na brief visit. Mom is very loving & affectionate with son.\nP: Cont to support NICU family.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2122-11-05 00:00:00.000", "description": "Report", "row_id": 2039329, "text": "Respiratory care Note\nPt. continues on 6cmH2O of NPCPAP and 27-30% FIO2. BS are clear. Pt. sx'd for mod. white secretions. Pt. is on caffeine. To follow.\n" }, { "category": "Nursing/other", "chartdate": "2122-11-05 00:00:00.000", "description": "Report", "row_id": 2039330, "text": "Neonatology Attending Progress Note\n\nNow day of life 20, CA 4/7 weeks.\nContinues on support with CPAP of 6 and FIO2 27-30%\nHR 160-170 BP 68/34 47\n\nWt. 834gm up 24gm on MM30 with Promod\nFeedings well tolerated, noted to have mild abdominal distension on CPAP.\nNormal urine and stool output.\n\nAssessment/plan:\nSteady course.\nWill continue with current management.\nUrine CMV sent because of growth restriction.\n" }, { "category": "Nursing/other", "chartdate": "2122-11-05 00:00:00.000", "description": "Report", "row_id": 2039331, "text": "Respiratory Care Note\nPt. remains on +6 NP CPAP, FiO2 25-30%. Suctioned for mod amount yellow secretions. BS coarse to clear. RR 40-60. On caffeine. No spells documented today as of this writing.\n" }, { "category": "Nursing/other", "chartdate": "2122-11-05 00:00:00.000", "description": "Report", "row_id": 2039332, "text": "Neonatology- Physical Exam\n\n remains on CPAP. Active, alert in an , AFOF, sutures split, good tone. BBS clear and equal with good air entry. No murmur, pulses +2, pink, RRR. Abdomen soft, non-distended with active bowel sounds, no HSM, tolerating feeds. Please refer to attending progress note for detailed plan.\n" }, { "category": "Nursing/other", "chartdate": "2122-11-05 00:00:00.000", "description": "Report", "row_id": 2039333, "text": "NPN \n\n\n\n #2. RESP: Infant conts on NP CPAP 6cms. FIO2 req 25-30%. RR\n40-60 w/baseline IC/SC retractions. Sux w/cares for mod amts\nthick secretions. LS coarse->clear after sux. No spells\nnoted today. Conts on caffeine. A: Doing well on CPAP w/\namt of O2. P: Cont to monitor for spells and document.\n\n #3 FEN: Infant remains on TF 150cc/k BM30w/PM (21cc q4hr\nover 50 ). Abd soft w/active BS, AG up this am to 20cms\nbut had lg stool and AG back down to 18. Max asp 1cc\nnonbilious, partially digested BM. No loops, no spits,\nvoiding and stooling heme-. A: Tol current feeding plan. P:\nCont to assess abd and tol to feeds.\n\n #4. DEV: Temp slightly labile nested in servo control\n. Acting A&A w/cares. AF soft and flat. MAEW. Sucks\non pacifier. A: Temp lability prob environmental Infant\nacting well. P: Cont to support dev needs.\n\n #5. : No contact thus far this shift.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2122-10-18 00:00:00.000", "description": "Report", "row_id": 2039205, "text": "NICU\n\nID: 2 days old = 28 weeks CGA with resolving HMD, issues of fluid and nutrition, hyperbili,\n\nPlease see full NNP Rivers\n\nCVR/RESP: No murmur, BS clear/=. Weaned to 15/5 rate of 12, 22-30%, CBG: 7.28/53, no changes made. No A/B, not on caffeine. Will load with caffeine, trial of CPAP.\n\nFEN: Abd benign, BW 695 gm, weight this am down 60 gm to 635 gm, on TF of 130 cc/kg/d, NPO PN/IL, adjusting glucose concentration due to hyperglycemia. Lytes this am: 139/4.6/106/25. u/o 3.4 cc/kg/hr. Will leave TF at 130 cc/kg, consider trophic feeds if extubation to CPAP goes well. Will check lytes again tomorrow.\n\nGI:Under double phototx, for 5.7/0.2, down to 3.8/0.3 this am. Will d/c one phototx light, check rebound tomorrow.\n\nID: On amp/gent with blood cx negative at 48 hours. Clinical course consistent with prematurity/HMD. Will d/c antibiotics and monitor closely off.\n\nNEURO: Head U/S next week. (1 week of age)\n" }, { "category": "Nursing/other", "chartdate": "2122-10-18 00:00:00.000", "description": "Report", "row_id": 2039206, "text": "Nursing Progress Note\n\n\nSEPSIS O/A: BC negative to date. No overt s/s of sepsis\nnoted throughout the day. Ampi & Gent d/c'd. P: Problem\nresolved.\n\nRESP O/A: Infant remains on SIMV 15/5, R12. FiO2 22-28%. RR\n40-70s, LS clear/=, mild ic/sc rtxns. Sxn q4h for sm cloudy\nsecretions. Caffeine loading dose given today in preparation\nfor extubation. P: Cont to monitor resp status.\n\nFEN O/A: TF @ 130cc/k/d. Infant remains NPO. IVF PN D5 & IL\nrunning through primary & secondary ports of the DLUVC.\nD-stick 108. Voiding/trace stooling; Urine output: 1.7cc/k/h\nfor 12h. Abdomen soft/flat, active BS. P: Cont to monitor\nI&O.\n\nG&D O/A: is nested on sheepskin in a servo ;\ntemps stable. A/A with cares; opens eyes. AFSF, PFSF. P:\nCont to support developmental needs.\n\nPAR O/A: Dad in multiple times throughout the day with\nvisitors. Updated by this RN @ the bedside. Asking\nappropriate questions. P: Cont to support NICU family.\n\nCV O/A: Infant is well perfused, brisk cap refil. No audible\nmurmur. BP: 44/28 (34). P: Cont to monitor.\n\nBILI O/A: bili: 3.8/0.3/3.5; double phototherapy reduced to\nsingle today. P: Check bili in the am.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2122-10-18 00:00:00.000", "description": "Report", "row_id": 2039207, "text": "1 Infant with Potential Sepsis\n\nREVISIONS TO PATHWAY:\n\n 1 Infant with Potential Sepsis; resolved\n\n" }, { "category": "Nursing/other", "chartdate": "2122-10-18 00:00:00.000", "description": "Report", "row_id": 2039208, "text": "Respiratory Care\nPt recieved on SIMV, rate of 12, pressures of 15/5 with the fio2 21 to 25%. Pt's resp rate 30s' to 60's. Pt started on caffine for a possible trial on CPAP. Plan is to monitor resp status and support patient.\n" }, { "category": "Nursing/other", "chartdate": "2122-10-19 00:00:00.000", "description": "Report", "row_id": 2039209, "text": "Respiratory Care Note\nPt. continues on SIMV 15/5 R 12 and 21-28% FIO2. BS are clear. Mom held baby for the first time--was tolerated well by pt. Cap gas overnight was 7.23/54/44/24/-5. To follow.\n" }, { "category": "Nursing/other", "chartdate": "2122-10-19 00:00:00.000", "description": "Report", "row_id": 2039210, "text": "Respiratory Care Note\nPt.'s rate increased to 14 in response to cbg.\n" }, { "category": "Nursing/other", "chartdate": "2122-10-29 00:00:00.000", "description": "Report", "row_id": 2039289, "text": "NPN 7a-7p\n\n\n#2: remains orally intubated on settings: 15/5x12.\nFIO2 23-27%. ^'ed to ~35% with cares at times. Labile in\nsats. RR stable. Breathing with mild IC/SC retractions.\nBBS cl/slightly dim/=. Sx'ed x2 for sm white-cloudy\nsecretions. Sm amt oral secretions. No apnea/brady spells\nnoted. Caffiene given as ordered. A: stable on current\nvent settings. P:Cont on current vent settings. Plan to\ntrial off when infant is bigger. Provide support as needed.\n\n#3: TF: 150cc/k/d. Conts on BM24. Tol'ing feeds q4hrs\ngavaged over 50mins. Med spit x1- pale green noted in it.\nMin benign asps. Abd soft, +, no loops. AG stable.\nVoiding qs. Stooled- heme negative. PICC patent, flushing\neasily. Started on FeSO4 & Vit E. A: tol'ing feeds.\nP:Cont to follow wt and exam. ^ to BM26 tonight.\n\n#4: Temps stable while nested on sheepskin in servo\n. Infant is alert and active with cares. MAE. Sm\namt yellow eye drainage noted from left eye. Cleansed with\nsterile water and gentle massage applied to tear duct. HUS\ndone this am. A: AGA P:Cont to support dev needs.\n\n#5 Mom and each called today for updates. Both pleased\nto hear that HUS nml. Mom will be in for 20care. A:\nInvolved family P:Cont to support and educate.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2122-10-30 00:00:00.000", "description": "Report", "row_id": 2039290, "text": "RESPIRATORY CARE NOTE\nBaby received intubated on vent settings 15/5 Rate 12 FIO2 24-28%. Suctioned ETT for sm-mod amt of cloudy secretions and lg amt of oral secretions also suctioned. Breath sounds are clear. Stable on current vent settings cont to follow.\n" }, { "category": "Nursing/other", "chartdate": "2122-10-30 00:00:00.000", "description": "Report", "row_id": 2039291, "text": "NPN 1900-0700\n\n\nRESP\n2. O: Remains intubated on settings 15/5 R12. FiO2 24-28%.\nBreathing 30-60s w/mild IC/SCR noted. Sats kept in 87-94%\nrange. Can be labile @ times. LS clr/= but sl.diminished\nbilaterally @ bases. Suctioned x2 thus far for sm-mod amt\ncldy secretions. Infant has lg amts cldy oral secretions. No\nspells. Receiving caffeine. A: Stable in current resp\nsupport. P: Cont to monitor for s/s resp distress, wean O2\nas tolerated.\n\n3. FEN\nO: BW 695g. Current wgt= 738g (+56). TF 150cc/kg/day. On\nfull feeds of BM26 (18.5cc q4h over 50 mins). D/S 71. Abd\nsoft, +BS, no loops. A/G 18-19cm. No spits. Asps 0.7-1cc of\nnonbilious BM. PICC remains intact, hep flushed, ?D/C today.\nVoiding and stooling (heme-). UO x8hrs= 3.9cc/kg/hr. A:\nTolerating full feeds. P: Cont to monitor for s/s feeding\nintolerance, monitor for changes in exam.\n\n4. G&D\nO: is alert/active with cares. Temps stable in servo\n. Nested in sheepskin. Fonts remain spread, but soft\nand flat. MAE. Sleeping well b/w care times. Kangaroo'ed x90\nmins @ and tolerated it very well. PKU done. A: AGA. P:\nCont to provide dev appropriate care.\n\n5. \nO: Mom in for care. Participated in temp and diaper\nchanges. Kangaroo'ed w/. Updated @ bedside by this RN.\nPleased w/his progress. Very loving and appropriate. A:\nAttentive, loving family. P: Cont to support and educate\nfamily.\n\nSee flowsheet for details.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2122-12-21 00:00:00.000", "description": "Report", "row_id": 2039563, "text": "NPN 1900-0700\n\n\n2.Resp: Infant remains in NC 500cc flow with Fi02\nrequirement 50-60%. Lung sounds are clear and equal with\nmild upper airway congestion. RRs 50s-60s with mild-mod\nSC/IC retractions, 02 sats > 90%. Occasional drifts to the\nlow-mid 80s requiring increased 02. No spells thus far this\nshift. Diuril and KCl given. Continue to monitor\nrespiratory status.\n\n3.FEN: Infant's weight tonight 2430g (down 25g). Infant\nremains on TF 130cc/kg/day of BM/PE 31cal/oz. He is\ntolerating feeds well with no spits, max. aspirate 2.0cc of\nnon-bilious undigested formula/breastmilk. Aspirate present\nfollowing breastfeeding in addition to full gavage feeding.\nInfant breastfed for greater than 10 minutes with latch on,\neager suck. Abdomen is soft and full with active bowel\nsounds, no loops. He is voiding, no stool thus far this\nshift. Infant has moderate amount of generalized edema.\nContinue to monitor FEN status and weight gain/loss.\n\n4.DEV: Infant remains swaddled in an open crib with stable\ntemps. HOB raised 45 degrees. Infant is alert and active,\nwakes for feeds. Plan for eye exam in the morning, eye\ndrops due at 0800. Continue to support growth and\ndevelopment.\n\n5.: Mom and in this evening at for care\ntime. are loving and appropriate, very independent\nwith cares. Father participated in cares and measures.\nMother breastfed and held for 1 hour, well tolerated by\ninfant. Continue to support and keep informed.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2123-01-05 00:00:00.000", "description": "Report", "row_id": 2039641, "text": "Neonatology - Progress Note\n\n is active with good tone. AFOF. He is pink, well perfused, soft murmur auscultated. He is comfortable on low flow NCO2. Breath sounds clear and equal. Mild retractions. One spell last night down to 60 with associated to 60, self resolved. He is tolerating full volume, po feeds. Abd soft, active bowel sounds, no loops. Voiding and stooling. Stable temp in open crib. Family meeting scheduled for today @ 5pm. Please refer to neonatology attending note for detailed plan.\n" }, { "category": "Nursing/other", "chartdate": "2123-01-06 00:00:00.000", "description": "Report", "row_id": 2039642, "text": "NPN 1900-0700\n\n\nRESP: Continues on NC, 75cc of flow, 100% FiO2. O2sat\n94-100%. RR mostly 30-60's. Mild SC rtx. Some head-bobbing\nnoted with bottling. LS clear and equal. Some UAC, sxn'd X1\nfor sm amt of secretions. On KCl and diuril. Day of\n countdown.\n\nFEN: wt=3085g (up 25g). PO ad lib. PE 24. Yest TFI=157cc/kg.\nBottling 40-70cc q2-5hrs. Abdomen soft, +BS, no loops,\nvoiding and stooling. On vit E and Fe.\n\nG&D: Temps stable, swaddled in open crib. Occasionally wakes\nfor feeds. Had one period of quiet awake time ~3hrs. Likes\nswing and paci.\n\n: Both in for bath and feeding. Independent\nwith infant.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2123-01-06 00:00:00.000", "description": "Report", "row_id": 2039643, "text": "Neonatology\nContinues in low flow NCO2. Comfortable. Attempting to wean as tolerated. Remains on diuril.\n\nWt 3085 up 25. Tolerating feeds well. TAking po slowly. Went to breast last night. Abdomen benign.\n\nContinue to await weaning and maturation of resp control and feeds\n" }, { "category": "Nursing/other", "chartdate": "2122-11-20 00:00:00.000", "description": "Report", "row_id": 2039419, "text": "NPN DAYS\n\n\nAlt in Resp: Remains on prong CPAP5 with FiO2 25-30%. LS\nclear and equal. Mild SC retractions. No spells. Does have\nsat drifts that are self resolving. Sxn'd nares x2. On\ncaffeine. Continue with current plan of care.\n\nAlt in FEN: TF 150cc/kg/day BM30PM/PE30PM gavaging feeds\nover 50mins. Small spit x1. Minimal aspirates. Voiding, no\nstool. Belly benign. HOB elevated. On VitE and FeSO4. Will\ncontinue with current plan of care.\n\nGrowth and Dev: Temp stable in air , swaddled. Awake\nand alert with cares. Sleeping well between cares. Likes his\npacifier. will continue to support developmental needs.\n\n: No contact so far this shift.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2122-11-20 00:00:00.000", "description": "Report", "row_id": 2039420, "text": "Respiratory Care\nBaby continues on prong CPAP 5 with 02 req 25-30%. BS clear. Nares sxn for mod amt pale yellow secretions with old bloody plugs and some small fresh blood streaks. RR 30's-80's. Having some sat drifts. Septic w/u done. Hct 27.9, retic pending. Plan cont CPAP.\n" }, { "category": "Nursing/other", "chartdate": "2122-11-20 00:00:00.000", "description": "Report", "row_id": 2039421, "text": "Nursing Addendum\nBaby needing increased O2 and having multiple desats. Septic w/u done as . CBC benign. HCT 27.9, retic is pending. Will continue to monitor closely.\n" }, { "category": "Nursing/other", "chartdate": "2122-11-21 00:00:00.000", "description": "Report", "row_id": 2039422, "text": "NURSING PROGRESS NOTE\n\nRESP/CV: REMAINS ON NASAL PRONG CPAP OF 5 IN 25-30% FIO2. NO A&B'S TONIGHT AND ONLY OCCAS. QUICK DESAT NOTED. BS CL&= WITH NO INCREASE IN WORK OF BREATHING. RR 40-70'S, HR 150-180 WITHOUT MURMER. COLOR PALE/PINK AND ADEQUATELY PERFUSED.\n\nFEN: TOTAL FLUIDS REMAIN AT 150CC/KG/D OF BM30/PE30CAL. WEIGHT UP 20GMS TO 1220GMS. ABD SOFT, PINK WITH STABLE GIRTH AND +BS. NO EMESIS OR RESIDUALS NOTED. VOIDING AND STOOLING WNL.\n\nDEV: TEMP STABLE IN 29 DEGREE , LIGHTLY SWADDLED FOR COMFORT. ALERT AND ACTIVE WITH INTERVENTIONS AND SLEEPING QUIETLY BETWEEN CARES.\n\nSOCIAL: IN FOR VISIT TONIGHT. MOM HELD INFANT SWADDLED FOR FIRST TIME AND ENJOYED THE INTERACTION WITH HIM.\n" }, { "category": "Nursing/other", "chartdate": "2122-11-21 00:00:00.000", "description": "Report", "row_id": 2039423, "text": "Respiratory Care\nBaby remains on cpap 5 24-30%.No spells documented this shift.On caffeine.sx x 1 for sm cldy secs.\n" }, { "category": "Nursing/other", "chartdate": "2122-11-21 00:00:00.000", "description": "Report", "row_id": 2039424, "text": "Newborn Med Attending\n\nDOL#35. Cont on CPAP5, 30% O2. Occ desats. AF flat, clear BS, no murmur, abd soft, MAE. Wt=1220 up 20, on 150 cc/kg/d Bm30 with PM, PG.\nA/P: Growing infant with AOP and residual CLD. Wean O2 as tolerated. Monitor for spells. Tx for hct=27.\n" }, { "category": "Nursing/other", "chartdate": "2122-12-07 00:00:00.000", "description": "Report", "row_id": 2039513, "text": "NPN DAYS\n\n\nAlt in Resp: Remains on prong CPAP5 with FiO2 24-26%. LS\nclear and equal. Mild SC retractions. No spells. Remains on\ncaffeine. Will trial on NC Wednesday.\n\nAlt in FEN: Tf 150cc/kg/day BM31/PE31. Gavaging feeds over\n50mins. Voiding and stooling. Belly benign. Minimal\naspirates. No spits. On VitE and FeSO4. Continue with\ncurrent feeding plan.\n\nGrowth and Dev: Temp stable in open crib. Awake and alert\nwith cares, sleeps well between cares. Great suck on\npacifier. Will ask to bring in some music.\n\n: No contact so far this shift.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2122-12-07 00:00:00.000", "description": "Report", "row_id": 2039514, "text": "Respiratory Care\nPt recieved on nasal prong CPAP +5 cm's with the fio2 21 to 25%. Pt respiratory rates 40's to 70's. Plan is to follow on CPAP.\n" }, { "category": "Nursing/other", "chartdate": "2122-10-17 00:00:00.000", "description": "Report", "row_id": 2039200, "text": "NPN DAYS\n\n7 Hyperbili\n\nInfant with Potential Sepsis: Cx remains negative to date.\nRemains on Ampi and Gent.\n\nAlt in Resp: Current vent settings 15/5 rate 12 FiO2 22-24%.\nLS coarse to clear. Sxn'x small amounts white secretions.\nIC/SC retractions. No spells . To check blood gas in the am.\n\nAlt in FEN: TF currently 100cc/kg/day D10 with hep and D5\nwith hep via DUVC. Will be changed to 120cc/kg/day PND7.5\nwith change of fluids. Voiding. No stool. Belly benign. D/S\n162. Lytes 137/3.9/105/24. Continue with current plan of\ncare.\n\nGrowth and Dev: Temp stable on warmer. Awake and active with\ncares. Resting well between cares. Nested on sheepskin.\nLikes pacifier. Will transfer baby into this\nafternoon.\n\nParents: Dad up to visit and updated at the bedside. Asking\nappropriate questions. Will continue to provide updates and\nsupport.\n\nAlt C/V: No murmur noted. Color ruddy and jaundice. BP\nstable with M 32-35. Good perfusion. Will continue to\nmonitor for any changes.\n\nHyperbili: Bili last night 3.9/0.2. Started under single\nphotherapy this am. Repeat bili this am 5.7/0.2. Double\nphototherapy started. Will check another bili in the am.\n\nREVISIONS TO PATHWAY:\n\n 7 Hyperbili; added\n Start date: \n\n" }, { "category": "Nursing/other", "chartdate": "2122-10-29 00:00:00.000", "description": "Report", "row_id": 2039285, "text": "NPN\n\n\n\nNPN#2 O= received intubated on settings of 15/5 x12, FIO2\nmostly 24-27%..infant with frequent drifts in sat..no\nbradys,. cont on caffeine as ordered, RR 50's-60's, LS\ncoarse to diminished with mild IC/SCR, sxn'd q4hrs for sm\namts cloudy from ETT, but large amts OP, A=min settings/\nliable sats\n\nNPN#3 O= WT down 13gms to 682, TF at 150cc/kg/d of BM24\ncals q4hrs..tol well gavaged over 40min, min asp .4-.6cc,no\nspits, Abd exam softly rounded + active BS, no loops, AG\n18-18.5,bruising noted in RLQ/groin region..team aware/ no\nchange, uo=3.7cc/kg/hr x2 sm/ mod sys stools G-, PIC- HL'd,\nflushes well q4-6hrs A= tol feeds/ P= cont to monitor tol of\nfeeds, ? ^ cals today, follow abd bruising, please keep\ninfant on -4 times per parent's request\n\nNPN#4 O= temp stable on servo in heated , nested in\nsheepskin nest with boundaries in place, active & alert with\ncares, tone GA appropriate, AF soft & flat but sutures\nspread, HC=24.5cm..no change from yesterday..will obtain HUS\ntodat to eval.. A=spread sutures P= HUS to evaluate, cont to\nassess & support dev needs\n\nNPN#5 O= in at 2330 after got out of\nwork..several attempts to remind of need of\nundisturbed sleep between cares.. upset to learn infant's\nfeeding times had been changed ( were changed over 2 days\nago)..discussed etio on why times were possibly\nchanged..informed him that we would adjust feeding\ntimes overnight back to 8-12-4 times as per requested..will\ncall in am for update A=invested/ sl anxious new P=\ncont to teach/ update & support\n\n\n" }, { "category": "Nursing/other", "chartdate": "2122-10-29 00:00:00.000", "description": "Report", "row_id": 2039286, "text": "Neonatology Attending Note\nDay 13\n\n15/5 x 12, 24-27%. Small tan secretions. 2 A&Bs/24h. On caffeine. HR 160-170s. BP 54/29, 37.\n\nWt 682, down 13 gms. TF 150 cc/k/day BM24. Tol well. Min aspirates. u/o 3.7. +Stool overnight (g-).\n\nHUS today normal.\n\nIn servo .\n\nA/P:\nMaintain minimal vent settings\nMonitor AOP on caffeine\nInc cals to 26, start Fe and Vit E\n\n" }, { "category": "Nursing/other", "chartdate": "2122-10-29 00:00:00.000", "description": "Report", "row_id": 2039287, "text": "Neonatal NP-Exam\n\nSee Dr. note for details and plan of care as discussed in rounds this am.\n\nAFOF. Breath sounds clear and equal. NL S1S2, no audible murmur. pink and well perfused. Abd , no HSM. Activ ebowel sounds. Infnat active with exam. PICC dressing intact.\n" }, { "category": "Nursing/other", "chartdate": "2122-10-29 00:00:00.000", "description": "Report", "row_id": 2039288, "text": "Respiratory Care Note\nBaby remains vented on settings of 15/5, rate of 12 and 22-28%. Sx for mod amts of secretions. BS = and clear, continue to follow.\n" }, { "category": "Nursing/other", "chartdate": "2122-11-12 00:00:00.000", "description": "Report", "row_id": 2039372, "text": "Respiratory care Note\nPt. continues on 6cmH2O of nasal prong CPAP and 23-25%. Pt. sx'd for mod. thick white secretions. BS are clear. No spells thus far. To follow.\n" }, { "category": "Nursing/other", "chartdate": "2122-11-12 00:00:00.000", "description": "Report", "row_id": 2039373, "text": "Neonatology Attending Note\nDay 27\n\nCPAP6, 21%. No A&Bs. RR30-60s. On caffeine. BS cl and =. No murmur. HR 160-180s. BP 65/32, 43.\n\nWt 968, up 23 gms. TF 150 cc/k/day PE30/BM30 w promod. Tol well. Nl voiding and stooling.\n\nIn .\n\nA/P:\ntry to wean cpap to 5 peep\nno change to nutritional plan\n" }, { "category": "Nursing/other", "chartdate": "2122-11-12 00:00:00.000", "description": "Report", "row_id": 2039374, "text": "Neonatology Attending Note\nOn exam:\nResting in . +CPAP. Lungs CTA, =. CV RRR, no murmur heard. CV RRR, no murmur, 2+FP. Abd soft, +BS. Skin mottled, but pink and well perfused.\n" }, { "category": "Nursing/other", "chartdate": "2122-11-13 00:00:00.000", "description": "Report", "row_id": 2039381, "text": "NPN Days\n\n\n#2Resp: Continues on nasal prong CPAP 5. RR 30-70's. FiO2\n21-23%. No spells. Lungs clear & equal. No sxn needed so\nfar this shift. Continues on caffeine. P: Continue to\nmonitor.\n#3FEN: TF=150cc/kg/day of BM 30 or PE 30 w/ promod NG Q\n4hrs. No spits. .2-.5cc asp. Asp X1 had greenish color.\n aware. Abd rounded & soft. AG 21.5-23.5. No loops. +\nBS. Voiding. No stool so far this shift. P: continue to\nmonitor AG & aspirates. Needs nutrition sent tonight.\n#4G&D: Temps stable in servo . Alert & active w/\ncares. Sucking on pacifier. AGA. P: continue to monitor.\n Needs consent for Hep B.\n#5Parents: Mom called today asking approp questions.\nUpdates given. Mom will be in for 4pm cares. P: cont to\nsupport & educate.\nSee flowsheet for further details.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2122-11-13 00:00:00.000", "description": "Report", "row_id": 2039382, "text": "Respiratory Care Note\nPt. remains on +5 prong CPAP, FiO2 21-23%. BS clear. RR 40-60's. On caffeine. No spells. Has some difficulty maintaining CPAP due to mouth open.\n" }, { "category": "Nursing/other", "chartdate": "2122-11-14 00:00:00.000", "description": "Report", "row_id": 2039383, "text": "Respiratory Care\nBaby continues on prong CPAP 5, 21-23%. BS clear. RR 40's-60's. On caffeine. No spells recorded as of this writing, fer sat drifts noted. Plan cont present management.\n" }, { "category": "Nursing/other", "chartdate": "2122-11-14 00:00:00.000", "description": "Report", "row_id": 2039384, "text": "1900-0730 NPN\n\n\nRESP: Cont on Prong CPAP of 5 with FiO2 21-24%. RR\n40's-50's. LS clear/=. Mild IC/SC retractions. No A/B\nspells. Occasional drifts in O2 sats to 70-80%'s. On\nCaffeine.\n\nFEN: Wgt tonight is 1000g, up 14g. TF=150cc/kg/d of\nBM30/PE30 with PM PG over 20 mins. No spits. Minimal\naspirates. Abdomen benign. Pt is voiding, med stool x 1\n(heme-). On Ferinsol and Vit E.\n\nDEV: Temps stable in servo-controlled .\nAlert/active with cares. Sleeps between cares. Sucks\npacifier and brings hands to face for comfort. Fontanels\nsoft/flat. AGA.\n\nPARENTING: Both in to visit, updated by RN, asking\nappropriate questions. Both participated in care.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2122-11-14 00:00:00.000", "description": "Report", "row_id": 2039385, "text": "Neonatology Attending\nDOL\n\nOn CPAP 5 cm H2O in 21-28% FIO2. On caffeine with no bradycardia.\n\nNo murmur. BP 69/39 (50).\n\nHct 23. retic pending. Transfusion in progress.\n\nWt 1000g (+14g) on TFI 150 cc/kg/day PE30/BM30, tolerating well. Abdomen benign. Voiding and stooling normally. On ferinsol and vitamin E. Lytes 135/4.3/100/25. ALP 209. Ca 10.2. PO4 5.2 BUN 4 Cr 0.3.\n\nA&P\n27-5/7 weeks GA infant with respiratory adn feeding immaturity, anemia of prematurity\n-Continue with CPAP given recent unsuccessful trial of NC\n-Cranial ultrasound this week\n-Otherwise continue current management as detailed above\n" }, { "category": "Nursing/other", "chartdate": "2122-11-14 00:00:00.000", "description": "Report", "row_id": 2039386, "text": "Neonatology- Physical Exam\n\n remains on CPAP. Active, alert in an , AFOF, sutures opposed, good tone. BBS clear and equal with good air entry. No murmur, pulses +2, pink/pale. Abdomen soft, non-distended with active bowel sounds, no HSM, tolerating feeds. Please refer to attending progress note for detailed plan.\n" }, { "category": "Nursing/other", "chartdate": "2122-11-14 00:00:00.000", "description": "Report", "row_id": 2039387, "text": "Respiratory Care\nBaby continues on prong CPAP 5, 21%. BS clear. Nares sxn x1 for mod amt yellow secretions. RR mostly 40's-60's. Receiving PRBCs for hct 23. One mild stim noted, some sat drifts. On caffeine. Will cont CPAP @ present.\n" }, { "category": "Nursing/other", "chartdate": "2123-01-06 00:00:00.000", "description": "Report", "row_id": 2039644, "text": "PCA 0700-1900\n\n\n2 infant remains on NC FIO2 100%, 75cc flow, SATing 95-98%,\nRR 40-70. infant has m sc retractions, lung sounds cl=. no\nspells. P:cont. to monitor.\n\n3 infant remains on an ad lib feeding schedule, all PO\nfeeds. infant waking q4-4.5h bottling 65-72cc. infant does\nsome head bobbing with feeds. abd. soft and round, bs+, no\nloops, voiding/stooling qs, no spits. P:cont. to support\nnutritional needs.\n\n4 infant remains in OAC, temp. stable, quietly with\ncares, wakes for feeds, brings hands to mouth. P:cont. to\nsupport dev. needs.\n\n5 in today at 1000, bottled infant, will return this\nevening. P:cont. to update on infant's progress.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2123-01-06 00:00:00.000", "description": "Report", "row_id": 2039645, "text": "NPN 7a-7p\nAssessed infant and agree with above note by PCA .\n\n conts breathing comfortably in O2 req 100%/75cc flow. As discussed with Team, wean O2 as tol'ed to keep sats 95-99%. Unable to wean thus far. Does have mild upper airway congestion- will TB sx at next care. Mild head bobbing noted with PO feeds, but no need for ^'ed O2. Diuril given as ordered. HR stable. No murmur. Ad lib PO feeding PE24. Bottles with good coordinaion. Abd exam stable. in for am feed. Indep with bottling. Update given. plan to visit this evening.\n" }, { "category": "Nursing/other", "chartdate": "2123-01-06 00:00:00.000", "description": "Report", "row_id": 2039646, "text": "Neonatology NP Note\nPE\nswaddled in open crib\nAFOF, sutures opposed\nmild subcostal retractions and minimal head bobbing in NCO2\nlungs clear/=\nRRR, no murmur appreciated,pink and well perfused\nabdomen soft\nactive with good tone\n" }, { "category": "Nursing/other", "chartdate": "2123-01-21 00:00:00.000", "description": "Report", "row_id": 2039718, "text": "PCA Note:\n\n\nAlt in Resp: RA, breathing comfortably. Mild subcostal\nretractions. Infants work of breathing increases with\nbottling. Maintaining stable sat range. No spells, no\ndrifts. Continue to monitor respiratory status.\n\nAlt in FEN: Today's weight 3.540kg (^40g). TF \n130cc/kg/day BM or E20. Bottling every 2-5hrs. Intake\nmeeting requirements. Infant's abdomen is soft, nontender,\nno loops, pos. bowel sounds. Infant is voiding and\nstooling. No spits. Continue with plan of care.\n\nAlt in G&D: Infant is swaddled in an open crib.\nMaintaining stable temps. Infant was somewhat fussy earlier\nthis evening, but sleeping well between cares this morning.\nInfant wakes for feeds, remains and active throughout\ncares. Settles with pacifier. Continue to support\ndevelopmental needs of infant.\n\n: in to visit last night, left at change of\nshift. Brief interaction with showed excitement for\nson's discharge tomorrow. Continue to support and teach\n when possible.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2123-01-21 00:00:00.000", "description": "Report", "row_id": 2039719, "text": "NPN 1900-0700\nI have examined this infant and agree with note and assessment of PCA, .\n" }, { "category": "Nursing/other", "chartdate": "2123-01-21 00:00:00.000", "description": "Report", "row_id": 2039720, "text": "Neonatology Attending Progress Note\n\nNow day of life 97.\nCA 2/7 weeks.\nIn RA RR 30-70s with O2 sat >93%.\nOn Diuril and KCl\nHR 1301-80s\n\nECHO yesterday - revealed normal anatomy and\n\nWt. 3540gm up 40gm on ad lib feedings - took in 209cc/kg/d yesterday\nFeedings quite well tolerated.\nNormal urine and stool output.\n\nAssessment/plan:\nVery nice progress continues.\nDischarge to home today.\nFU appointments arranged with Pulmonary, Ophthalmology, Surgery, IFUP, VNA , EI all set.\n\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2122-10-23 00:00:00.000", "description": "Report", "row_id": 2039242, "text": "NPN 11p-7a\n\n\n#2 NPCPAP ^ from 5cm to 6cm d/t infant with ^ frequency of\nspells. Pls see flow sheet for details. Remains in RA.\nCaffeine bolus given as ordered. BBS clear and =. Mild\nretractions present. Sats consistently 98-100%. A: spells\ndecreased P:Follow resp status closely\n\n#3 TF's 150cc/k. PN and IL infusing via DLUVC @ 100cc/k.\nwithout evidence of difficulty. Feeds of BM20 @ 50cc/k.\nInfant has received 5.8cc of BM q 4hrs on a pump over 30\nmins. Feeds not advanced as ordered d/t infant w/some small\nyellowish/green aspirates which have been discarded. NNP\nBuck made aware. No spits. UOP ~ 2cc/k overnoc. Lg mec\npassed-heme neg. AG stable at 17cm. DS 160. Am lytes\npending. A: feeds holding steady for now P: Cont to follow\ntolerance to feeds& advance feeds 10cc/k when ready\n\n#4 Temps stable in servo control . Nested within\nboundaries. Very interested in binkie. Calm with open eyes\nduring interventions. Settles with ease. A: AGA P: support\ndevelopmental needs\n\n#5 No parental contact thus far in shift.\n\n#6 Color pink. BP means 34-36. Blood out 9.25cc. ^ spells\n1st part of noc. HR's stable. Plts sent-results pending. A:\n? blood transfusion in near future P: F/u with team\n\n#7 Am bili pending. Passed lg amt meconium. P: f/u w/labs\n\n\n\n\n\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2122-10-23 00:00:00.000", "description": "Report", "row_id": 2039243, "text": "Respiratory Care Note\nPt. began shift on 5cmH2O of CPAP. Pt. had several spells. CPAP increased to 6cmH2O. BS are clear. Pt. sx'd for mod.-lrg. pale yellow secretions. Lrg. oral secretions. To follow.\n" }, { "category": "Nursing/other", "chartdate": "2122-10-23 00:00:00.000", "description": "Report", "row_id": 2039244, "text": "Neonatology-NNP Progress Note\n\nPE: remains his , pale, pink, on CPAP in .21 bbs cl=, rrr s1s2no murmur, abd soft, nontender, uvc secured in place, slightly red, no drainage around site, afs, sutures split, active with exam\n\nSee attending note for plan\n" }, { "category": "Nursing/other", "chartdate": "2122-10-23 00:00:00.000", "description": "Report", "row_id": 2039245, "text": "Neonatology Attending Note\nDay 7\n\nNPCPAP5 to 6 for inc A&Bs. RA. On caffeine. Recd caffeine bolus. RR30-50s. No murmur. HR 140-160s. BP means 34-56. 44/32, 34.\n\nPlts 164\n\nRebound bili 1.8/0.5.\n\nWt 620, up 23 gms. TF 150 cc/k/day of 50 cc/k/day BM20 and PNd8/IL at 100. Sm green aspirates, o/w abd benign. Passing mec. u/o 1.5.\nd/s 160\n125/4.6/93/16\n\nIn servo .\n\nHUS wnl.\n\nA/P:\n-- continued A&Bs despite CPAP, will reintubate and provide as low as settings as possible\n-- Follow gases\n-- Inc Na in PN, check lytes\n-- Check crit for anemia\n-- Place PICC line\n" }, { "category": "Nursing/other", "chartdate": "2122-10-23 00:00:00.000", "description": "Report", "row_id": 2039246, "text": "Neonatology Fellow Procedure Note\nIntubation performed for increased apnea of prematurity.\n\nPatient pre-oxgenated to 100% by bag-mask ventilation. Cords visualized and intubated on 3rd attempt with 2.5 ETT to 7 cm. Good breath sounds and saturation subsequently. CXR pending to confirm tube placement. Patient tolerated procedure well. No complications.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2122-11-03 00:00:00.000", "description": "Report", "row_id": 2039320, "text": "Respiratory Care\nBaby continues on cpap 6, fio2 21-23%, bs clear, rr 30-60's, on caffeine, no spells recorded on this shift thus far. Will continue to follow.\n" }, { "category": "Nursing/other", "chartdate": "2122-11-03 00:00:00.000", "description": "Report", "row_id": 2039321, "text": "Rehab/OT\n\nDropped off bumper for . RN to place at next care session. bumper increasing comfort through containment. OT to follow for developmental care interventions.\n" }, { "category": "Nursing/other", "chartdate": "2122-12-08 00:00:00.000", "description": "Report", "row_id": 2039515, "text": "npn 1900-0700\n\n\n#2 resp\npt continues on nprong cpap5 with fio2 21-28%. lsc=. rr\n30-70's, occationally seen in 90's to low 100's. sux x1 for\nsmall clear. no spells thus far this shift. occational\ndrift to high 80's that usually qsr.\n#3 fen\ntf 150cc/kg of bm31/pe31 gavaged q4hours. wt. 1.915kg\n(+25gms). abd benign, full. ag stable 26cm. no spits,\nminimal aspirates.\n#4 g&d\npt in open crib with stable temps. alert and active with\ncares. maew. sucking on binki, calming well with binki.\nfontanelles soft and flat.\n#5 parenting\n came in around 2200pm. asking appropriate\nquestions. loving and caring towards infant. updated at\nbedside.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2122-12-08 00:00:00.000", "description": "Report", "row_id": 2039516, "text": "Respiratory Care Note\nPt. continues on 5cmH2O of nasal prong CPAP and 21-28% FIO@. BS are clear. Pt. sx'd for clear nasal secretions. Pt. is on caffeine. To follow.\n" }, { "category": "Nursing/other", "chartdate": "2122-12-08 00:00:00.000", "description": "Report", "row_id": 2039517, "text": "Newborn Med Attending\n\nCont on CPAP5, 25-30% O2. No spells. AF flat, clear BS, soft murmur, abd soft, MAE. WT= up 25, on 140 cc/kg/d Bm31 with Pm.\nA/P: Growing infant with CLD. Consider trial off CPAP. Cont current feeeding plan.\n" }, { "category": "Nursing/other", "chartdate": "2122-12-08 00:00:00.000", "description": "Report", "row_id": 2039518, "text": "NPN 1400\n\n\n#2 Resp: infant remains on NCPAP=5. FiO2 Sat dependent\nranging 25-29% with desired sats 88-94%. BBS clear/=, sl\nupper airway congestion and old blood tinged secretions on\nnasal prongs. RR 30-70's. Occasional drifts into 80's with\nself recovery. no spells.\nA: infant stable on NCPAP\nP: cont to closely monitor resp status and plan to trial off\nNCPAP -> NC tomorrow\n#3 FEN: Remains at 150cc/kg/d PE31/Br31. Taking 48cc NG Q4h.\nTolerating well, abd full and soft, +BS, girth=27cm. smear\nstool heme negative. aspirate this AM =1cc tinged with old\nblood. No residuals this afternoon. no spits.\nA: infant tolerating full NG feeds.\nP: cont to closely monitor for feeding intolerance and plan\nto encourage PO feeds once stable on NC.\n#4 G&D: infant with stable temps in OC. Bundled with\nextremeties midline. cries appropriately with diaper change\nand temp. calms with pacifier. Awake and alert at times.\nA: AGA 35 weeker\nP: cont to provide developmental support\n#5 : no contact from so far this shift.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2122-12-08 00:00:00.000", "description": "Report", "row_id": 2039519, "text": "Respiratory Care\nBaby continues on prong CPAP 5, 22-29%. BS clear. Nares sxn x1 for sm amt bloody secretions. RR 50's-80's with mild retractions. No spells noted. On caffeine. Plan try off CPAP Wed.\n" }, { "category": "Nursing/other", "chartdate": "2122-12-27 00:00:00.000", "description": "Report", "row_id": 2039591, "text": "NPN NIGHTS\nI have examined baby and agree with above note by , PCA. I reviewed teaching with re: when to call the doctor, bowel and bladder pattern, infection prevention, bulb suctioning. have taken CPR. Will continue with d/c teaching and answer any questions the may have.\n" }, { "category": "Nursing/other", "chartdate": "2122-10-16 00:00:00.000", "description": "Report", "row_id": 2039195, "text": "Nursing Admit Note\nThis is a 27 week baby boy to a 35yo G2P0 mom. above MD note for details and Hx. Initially tried on CPAp and failed. Intubated and surf'd. Blood gas done and was WNL, initial vent settings weaned. Currently on 20/5 rate 20 in room air. LS coarse to clear. IC/SC retractions. Sxn'd x1 after intubation for no secretions. No murmur. Pink and well perfused. BP stable. TF 100cc/kg/day DUVC D10 with 1/2u hep/cc. Voiding. No stool yet. Belly benign. BW 695gm. CBC and blood cx sent. See flow sheet for results. Amp and Gent started. Temp has stabilized since admission. Nested on sheepskin with boundaries in place. Dad up to visit several times and has been updated at the bedside. Mom still up in L&D.\n" }, { "category": "Nursing/other", "chartdate": "2122-10-17 00:00:00.000", "description": "Report", "row_id": 2039201, "text": "Respiratory Care\nPt remains on SIMV, rate of 12, pressures of 15/5 with the fio2 21%. Pt suctioned for a sm amt of cloudy secretions. Respiratory rates 50's to 70's with good B/S. Plan is to move to , concider trial on CPAP if respiratory status remains good.\n" }, { "category": "Nursing/other", "chartdate": "2122-10-18 00:00:00.000", "description": "Report", "row_id": 2039202, "text": "Respiratory Care Note\nPt. continues on SIMV 15/5 R 12 FIO2 <30%. BS are clear. Plan is to continue on minimal settings. Cap gas overnight was 7.28/53/43/26/-2. To follow.\n" }, { "category": "Nursing/other", "chartdate": "2122-10-18 00:00:00.000", "description": "Report", "row_id": 2039203, "text": "NPN\n\n\n#1Sepsis No change.\n#2Resp O- Infant continues on vent settings of 15/5 x 12 O2\nneed 22-30% RR 40-70. Breath sounds coarse. Sx. for small\namounts. Cap gas at 0400 53/7.28. A- Stable on minimal\nsettings. P- As per team.\n#3F/N O- Total fluids increased to 130cc/kg at 2200. Blood\nglucose over 200 at and secondary port of UVL changed\nto D5W. Blood sugar now 140-160. Infant remains NPO . He is\nvoiding well. Passed small smear of mec. X2. Abdomen is soft\nwith some faint bowel sounds. Wt .635. A-Stable P_ Follow\nlabs per team.\n#4Dev. No change.\n#5Family Dad in to visit x1 and updated at bedside.\n#6C/V No murmur heard. BP stable. HR 140-150.\n#7Bili Remains under double phototherapy. Bili sent at 0400.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2122-10-18 00:00:00.000", "description": "Report", "row_id": 2039204, "text": "Neonatology - NNP Progress Note\n\nInfant is active with tone appropriate for GA. AFOF. She is pink, well perfused, no murmur auscultated. She is comfortable on low vent settings of 15/5 x 12 x 21-24% fio2. Breath sounds clear and equal. She remains NPO. IV fluids infusing via intact UVC @ 120cc/kg/day. Abd soft, soft bowel sounds, no loops, voiding and stooling. Stable temp in servo . Please refer to neonatology attending note for detailed plan.\n" }, { "category": "Nursing/other", "chartdate": "2122-11-12 00:00:00.000", "description": "Report", "row_id": 2039375, "text": "NPN DAYS\n\n\nAlt in Resp: Received on prong CPAP6, decreased to CPAP5 at\n11am. FiO2 21-25%. LS clear and equal. Mild IC/SC\nretractions. No spells so far this shift. Remains on\ncaffeine. Continue to monitor closely.\n\nAlt in FEN: TF 150cc/kg/day PE30/BM30PM. No spits. Minimal\naspirates. Belly soft and full. No loops. Large stool x1. AG\n19.5-20cm. Continue with current plan of care.\n\nGrowth and Dev: Temp stable in servo . Awake and\nalert with cares. Nested on sheepskin with boundaries in\nplace. Will continue to support developmental needs.\n\n: No contact as of yet this shift.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2122-11-12 00:00:00.000", "description": "Report", "row_id": 2039376, "text": "Respiratory Care Note\nPt decreased to +5 prong CPAP from +6, FiO2 21-25% today. BS clear. RR 30-60. On caffeine. No spells thus far today.\n" }, { "category": "Nursing/other", "chartdate": "2122-11-13 00:00:00.000", "description": "Report", "row_id": 2039377, "text": "NPN\n\n\n#2 Resp- Remains on Prong CPAP of 5cms in 23-26%. BS clear.\nMild retractions.Sxn x1 for mod amts.RR= 40-60.\n#3 F/N- Abd soft+ full,+bs, no loops. Tolerating ng feeds of\nBM/Pe 30 cals w/o spits. Minimal asps. Feeds given on a pump\nover 50 mins q 4 hrs.Wt up 18gms.Voiding+ stooling in adeq\namts.Tf= 150cc/kg/day.\n#5 -Mom and here to visit and hold.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2122-11-13 00:00:00.000", "description": "Report", "row_id": 2039378, "text": "Respiratory care\nBaby remains on cpap 5 23-26%.BS clear throughout.sx x 1 for sm cldy secs.No spe;;s documented this shift.RR 30-60's.\n" }, { "category": "Nursing/other", "chartdate": "2122-11-13 00:00:00.000", "description": "Report", "row_id": 2039379, "text": "Neonatology\nDoing well. On CPAP. Increased from 5->6 yesterday. No spells.\nNo murmur.\n\nWt 986 up 15 Tolerating feeds at 150 cc/k/d of 30 cal. Abdomen benign. All gavage.\n\nTemp stable in isollette.\n\nContinue as at present. Monitor resp status and continue nutritional managment.\n\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2122-11-13 00:00:00.000", "description": "Report", "row_id": 2039380, "text": " On-Call\nPlease see Dr. note for overall summary and plan.\n\nPhysical Exam\nGeneral: infant on prong CPAP, in \nSkin: warm and dry; color pink\nHEENT: anterior fontanel open, level\nChest: breath sounds equal, well-aerated\nCV: RRR without murmur; normal S1 S2; pulses +2/=\nAbd: soft, full; no masses; active bowel sounds; non-tender; umbilicus healed\nGU: preterm male, testes descending\nExst: moving all\nNeuro: alerts; + grasps; + suck\n" }, { "category": "Nursing/other", "chartdate": "2122-11-29 00:00:00.000", "description": "Report", "row_id": 2039468, "text": "#5 PARENT\ns/o: Mom in and participating in cares. Asking appropriate\nquestions and handling son safely. called for updates.\nA: invested . P: Cont support/ reinforce teaching\n#4 G&D\ns/o: nested and swaddled in off . Calmed well with\ncontainment and postioning support. Visually alert and\nfixing on faces. A: Dev CGA- 33-5/7 P: cont dev supp cares\nScheduled for eye exam today.\n#3 FEN\ns/o: Wt up 50 gms to 1530 gms today. Cont tol feeds -all pg.\nNon -nutritive sucking eagerly. Abd- full soft . Void and\nstool tonight. A: Gaining on cal dense feedings, remains pg\n2' to CPAP. P: cont to mtr tolerance, wt and positive oral\nexperiences.\n#2 RESP\ns/o:Cont on prong CPAP of 5 with FiO2 mainly 25% this shift.\nColor pink. BS c&e. RR 50-60-comfortable. Upper airway\ncongestion - sx x 1 -mod thick. Gently cleansed nasal\ncrustiness with cares q 4. A: Stable on CPAP with low O2\nrequirement. P: Cont to assess BS, wob . FiO2 to maintain\nsats, report changes.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2122-11-29 00:00:00.000", "description": "Report", "row_id": 2039469, "text": "Respiratory Care Note\nPt remains on Prong CPAP +5 FIO2 25-30%. B.S. clear. Without apnea or bradys noted as of this note.\n" }, { "category": "Nursing/other", "chartdate": "2122-11-30 00:00:00.000", "description": "Report", "row_id": 2039474, "text": "2. Resp: O: Infant received on nasal prong CPAP of 5cm in\nRA. Ls clear, sxned X 1 for mod amt of white secretions. RR\n30-50s, no spells. FiO2 is mostly RA, occasionally as high\nas 27%. He is on caffeine. A: Stable on prong CPAP. P:\nMonitor. Meds as ordered. Sxn prn.\n\n3. F/N: O: Infant is on 31cal PE/BM w/ promod, delivered via\ngavage q 4 hours over 50 for TF = 150cc/k/d. Abd is\nbenign, he is voiding and having stool smears so far this\nshift. asps, very small spit X 1. He gained 55g. A: Tol\nfeeds, gaining wt. P: Continue w/ plan.\n\n4. G/d: O: Temp is stable in the w/ the heat off.\nHe is swaddled and nestled in bumper. He sucks\nvigorously on a binkie. He is alert w/ cares and sleeps well\ninbetween. A/P: Continue to support infant needs.\n\n5. : O: called for an update. They were\ntrying to visit but were unable to due to bad road\nconditions due to the weather. A: Loving, involved .\nP: Continue to support.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2122-11-30 00:00:00.000", "description": "Report", "row_id": 2039475, "text": "Respiratory Care Note\nPt. continues on 5cmH2O of nasal prong CPAP and 21-27% FIO2. BS are clear. On caffeine. To follow.\n" }, { "category": "Nursing/other", "chartdate": "2122-11-30 00:00:00.000", "description": "Report", "row_id": 2039476, "text": "Newborn Med Attending\n\nCont on CPAP5, RA, no spells overnight. AF flat, clear BS, no murmur, abd soft, MAE. Wt=1585 up 55, on 150 cc/kg/d BM31 with PM.\nA/P: Growing infant with AOP. Monitor for spells.\n" }, { "category": "Nursing/other", "chartdate": "2122-11-30 00:00:00.000", "description": "Report", "row_id": 2039477, "text": "0700- NPN\n\n\nRESP: Infant received in prong CPAP 5, 25% fiO2. Infant\ntransitioned to NC this am as MD. Infant currently in NC\n500cc, 40% fiO2. O2 sats 95-99%. RR=40-60's. Breath sounds\nclear and equal. Mild SC/IC retractions noted. No desats, no\nbradys. Continues on caffeine.\n\nFEN: TF= 150cc/kg/d of PE31/BM31 with promod gavaged via NG\nq4hr. Abdomen pink, soft, full, +BS, no loops, AG=24-25cm.\nNo spits, minimal aspirates. Voiding, no stool. Continues on\nIron and Vit E.\n\nG&D: Temps stable, swaddled in off . Active and\nalert with cares, sleeps between. Sucks on pacifier for\ncomfort. Left inguinal hernia noted, soft and pink.\n\n: No contact with thus far.\n\nWill continue to monitor infant.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2122-11-30 00:00:00.000", "description": "Report", "row_id": 2039478, "text": "Respiratory Care Note\nPt off CPAP at 0900 today. Placed on 500cc nasal cannula with FiO2 range 30-45%. Plan to adjust FiO2 as necessary and leave flow at 500CC. RR 40-60's. One cluster of bradys (with feed) off CPAP as of this writing.\n" }, { "category": "Nursing/other", "chartdate": "2122-12-01 00:00:00.000", "description": "Report", "row_id": 2039479, "text": "Nursing NOte\n\n\n2. COntinues in NC 500cc flow, 40-50% with ^ O2with cares. 2\nspells at end of feeds. Sats otherwise >92%, RRR, bls c/=.\nCOntinue to monitor.\n3. TF 150ml/kg/d of PE31cPM gavaged over 40-50min. Has had\none spit thus far. +bs, stable girth, v/s x2, abd\nunremarkable. COntinue to monitor and support FEN\nrequirements.\n4. Temps stable in off iso, swaddled, wearing t-shirt. A/A\nwith cares, sleeps well between. Sucks binki eagerly, brings\nhands to face. MAE, AFOSF, . COntinue to support GD.\n5. in at . Asking appropriate questions.\nIndependent and eager for care time. Updated at bedside.\nCOntiune to educate, update, and support family.\n\nPls see flowsheet for additional details.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2123-01-21 00:00:00.000", "description": "Report", "row_id": 2039721, "text": "Nursing Discharge Note\n\n\nAlt in Resp: Baby remains in room air with O2 sats >93%.\nMild SC retractions noted. LS clear and equal. Baby will f/u\nwith pulmonary outpatient. to call for appointment.\nAlt in FEN: Taking in over required amount E20. Voiding and\nstooling. No spits. Remains on Diuril, KCl and FeSO4.\nContinue with meds at home.\nGrowth and Dev: Temp stable in open crib. Waking on his own\nfor feeds. Loves his pacifier. Settles easily with holding.\nHep B #2 given in right thigh. Will be followed by EIP and\nInfant f/u program at home.\n: in for discharge. Picked up meds from CVS\nand reviewed dosing with them. Reviewed d/c teaching and f/u\nappointments. Will f/u with opthomology, pulmonary, and\nsurgery (for hernia vs. hydrocele). VNA to contact \nfor visit time and they are aware of baby's d/c today.\nBaby in at time of d/c with . Condition\nstable at time of d/c.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2123-01-21 00:00:00.000", "description": "Report", "row_id": 2039722, "text": "Nsg addendum\nBaby also had CXR and HUS today. CXR sent to Dr. and a copy sent home with the .\n" }, { "category": "Nursing/other", "chartdate": "2122-11-04 00:00:00.000", "description": "Report", "row_id": 2039322, "text": "2. ResP: O: Infant received on np CPAP of 6cm. RR 30-60s, Ls\nclear, FiO2 24-28%, no spells. Sxned q 4 hours for a small\namt of secretions via his np tube and a large amt of oral\nsecretions. He is on caffeine. A: on np CPAP. P:\nMonitor. Meds as ordered. Sxn prn.\n\n3. F/N: O: Infant is on 150cc/k/d of BM30 + promod,\ndelivered q 4 hours via ngt over 50 . Abd is benign, he\nis voiding, no stool so far tonight. No spits, asps. He\ngained 13g. A: Tol feeds, gaining wt. P: Continue w/ plan.\n\n4. G/d: O: Infant's temp is stable in a heated . He\nis nestled in a sheepskin w/ bumper and a gel\npillow. He is active w/ cares and sucks vigorously on his\nbinkie. A/P: Continue to support infant needs.\n\n5. : O: Mom stopped by to visit briefly. They will\nkangaroo later today (Wed.) A: Loving, involved . P:\nContinue to support.\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2122-11-04 00:00:00.000", "description": "Report", "row_id": 2039323, "text": "Respiratory Care\nBaby continues on NPCPAP 6 with 02 req 24-30%. BS clear. NPT sxn for sm amts clear/white sec. RR 40's-60's with baseline mild IC/SCR. No bradys recorded, noted to have sat drifts. On caffeine. Will follow closely, cont CPAP.\n" }, { "category": "Nursing/other", "chartdate": "2122-11-04 00:00:00.000", "description": "Report", "row_id": 2039324, "text": "Neonatology Attending Progress Note\nNow day of life 19, CA 3/7 weeks.\nOn CPAP of 6 and 24-30% - RR 40-60s.\nOn caffeine.\nOnly 1 episode\nHR 160-180s\nBP 64/48 53\n\nWt. 810 up 13gm on 150cc/kg/d of MM30 with Promod\nFeedings are well tolerated.\nNormal urine and stool output.\n\nAssessment/plan:\nVery nice progress continues.\nWill continue with CPAP support and current feedings.\n" }, { "category": "Nursing/other", "chartdate": "2122-11-04 00:00:00.000", "description": "Report", "row_id": 2039325, "text": "Neonatal NP-Exam\n\nSee Dr. note for details and plan of care as discussed in rounds this am.\n\nAFOF, sutures widened. Breath sounds clear and equal with good CPAP. Nl S1S2, no audible murmur. Pink and well perfused. Abd benign, no HSM. Active bowel sounds. Infant active with exam.\n" }, { "category": "Nursing/other", "chartdate": "2122-11-04 00:00:00.000", "description": "Report", "row_id": 2039326, "text": "Respiratory Care\nBaby continues on cpap 6, fio2 24-26%, rr 30-60's, bs clear, on caffeine, had one spell on this shift thus far. Will continue to follow.\n" }, { "category": "Nursing/other", "chartdate": "2122-11-04 00:00:00.000", "description": "Report", "row_id": 2039327, "text": "NPN DAYS\n\n\nAlt in Resp: Remains on NP FiO2 24-26%. LS clear and\nequal. Mild IC/SC retractions. Spell x1, see flow sheet.\nSxn'd every 4hrs. Will continue to wean O2 as tolerated.\n\nAlt in FEN: TF 150cc/kg/day BM30PM. Tolerating feeds without\nproblems. Belly benign. AG 18-18.5cm. 0.4cc greenish tinged\naspirate x1. No spits. Stool x1.\n\nGrowth and Dev: Temp stable in servo . Awake and\nalert with cares. Likes his pacifier. Nested on sheepskin\nwith boundaries in place. Will continue to provide for\ndevelopmental needs.\n\n: No contact yet this shift.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2122-12-27 00:00:00.000", "description": "Report", "row_id": 2039592, "text": "Neonatology Attending Note\nDay 72\n\nNC 75-100cc, 100%. RR60-90s. Some sat drifts post feedings. BS cl and =. SC rtxns. Some UA congestion. s/p diuril. +murmur. HR 140s. BP 72/30, 46.\n\nWt 2690, up 60 gms. TF 130 cc/k/day BM/PE31. All po. Nl voiding and stooling.\n\nIn open crib.\n\nA/P:\nGrowing preterm infant w/ CLD, F&G, ROP\n - wean fiO2 as tol\n - no change to nutritional plan, good overall growth, will begin to wean cals by decreasing polycose\n - next eye check Monday\n" }, { "category": "Nursing/other", "chartdate": "2122-12-27 00:00:00.000", "description": "Report", "row_id": 2039593, "text": "Nursing Progress notes.\n\n\n#2 O: Baby remains in nasal cannula oxygen, 100%, 75 to\n125cc. Breath sound clear and equal, mild to moderate\nretractions with increased work of breathing with feeding.\nNo apnea or bradycardia noted. A: slight increase in nasal\ncannula oxygen noted today. P: Continue to monitor and\nprovide support as required.\n#3 O: total fluids restricted to 130cc/kg/day of BM/PE29\nwith promod. Feeds offered every 4 hours and were taken\nwithin 20 . 1 spit, abdomen benign, voiding well, trace\nstools. A: Po feeding well, calories weaned today. P:\nContinue to encourage PO feeding.\n#4 O: Temp stable in open crib. Baby did not wake for feeds\nbut was alert once woken up. Baby sleeps well between feeds\nswaddled in a flat crib. A: Appropriate for age. P:\nContinue to support development.\n#5 O: No contact from to time of report.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2122-12-27 00:00:00.000", "description": "Report", "row_id": 2039594, "text": " On-Call\nPlease see Dr. note for overall sumamry and plan.\n\nPhysical Exam\nGeneral: non-distressed infant in open crib, nasal cannula O2\nSkin: warm and dry; color pink\nHEENT: anterior fontanel open, level; sutures opposed\nChest: breath sounds equal, fine crackles\nCV: RRR; murmur consistent with PPS; S1 S2; femoral pulses +2\nAbd: soft small umbilical hernia; no masses; + bowel sounds\nGU: left hydrocele; testes descended\nExt: moving all\nNeuro: + suck; + grasps; symmetric tone\n" }, { "category": "Nursing/other", "chartdate": "2123-01-11 00:00:00.000", "description": "Report", "row_id": 2039670, "text": "NPN 7p7a\n\n\n Resp\nInfant in NC 100%, 30-50 cc flow to keep sats 93-99. LCS,\nupper airway congestion. TB suc produced small white\nsecretion. S/C rtxs. Had been on day for \ncountdown. Did have x 1 this am during bottling,\ninduced by a choke. HR drop to 40s and to 70s, turned\ndusky, needed some stim and increased o2 to recover. Infant\nwith 02 flow needs and x 1. Monitor and support resp\nstatus.\nFen\nInfant on TF 130 cc/k/d BM or E 24, adlib, demand. Took\n158 cc/k/24 hrs. Waking to feed q 3-4 hrs. Abd soft, no\nloops, active BS. Stooled lrg amts yesterday and this shift.\nWt 3240 (-45). Maintaining minimum. Monitor weight and exam.\nG/D\nInfant in OAC with stable temps. A/A with cares, waking for\nall feeds. Engaging with caregiver. Sucks on hands, pacifier\nwith support. MAES.Mild clonis noted at times. FS&F. Due for\neye exam this am. Monitor and support G/D.\n\nReported parent visit early in evening. This writter had no\ncontact with this shift.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2123-01-11 00:00:00.000", "description": "Report", "row_id": 2039671, "text": "Neonatology\nRemains in low flow NCO2. Able to wean slightly over course of weekend. Will titrate dose of diuril. Chokign episode with \n\nWT 3240 down 45 after being up 110 previously. Tolerating feeds at ad lib voluems of 24 cla. Abdomen benign.\n\nContinue to await maturation of resp control and weaning from O2.\n" }, { "category": "Nursing/other", "chartdate": "2122-10-16 00:00:00.000", "description": "Report", "row_id": 2039196, "text": "Respiratory Care\nPt this day brought to nicu on blow by O2. Pt had poor air exchange requiring O2. Pt intubated with 2.5 ett placed at the 6.5cm mark, pushed in cm per CXR. Pt given 1st and 2nd dose of 2.3cc of surfactant this shift and weaned down on ventilator. Pt remains on SIMV, rate of 18, pressures of 18/5 and the fio2 21%. Plan is to wean as tolerated.\n" }, { "category": "Nursing/other", "chartdate": "2122-10-17 00:00:00.000", "description": "Report", "row_id": 2039197, "text": "NPN\n\n\n#1Sepsis No change. Infant remains on antibiotics.\n#2Resp O-Infant weaned on vent settings to 15/5 X 12 O2\n21-25% with sats 90-94. Cap gas at 0400 35/7.42. RR 40-70.\nBreath sounds coarse to clear. Sx. x1 for small white.\nA-Weaned to minimal settings P- Follow cap gases as needed.\n#3F/N O- Infant remains on total fluids of 100cc/kg. Blood\nglucose 204 and secondary port of UVL switched to D5W\nw/heparin. Current D-sticks 146-147.Repeat lytes\n136/3.9/104/23. U/O 2.3cc/kg/hr over last 12 hrs. Abdomen\nsoft with hypoactive bowel sounds. No stool passed. A-blood\nglucose improved. P- Follow lytes and bili per team.\n#4Dev. O- infant on open radient warmer. He required set\npoint increased x1 for low temp 97.3 ax. Infant opens eyes\nwith cares and is active. AF soft slightly full. A- AGA P-\nMove to heated isolette this AM.\n#5Family O-Parents in to visit when Mom to . Parents updated at bedside by RN. Mom touching infant\nand asking some questions. A-Family understand current plan.\nP-Continue to update and support.\n#6C/V O- Color ruddy/pink. HR 130-140. No murmur heard. NS\nbolus given at 0500 for mean less 30. A-No signs PDA. P-\nContinue to follow closely.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2122-10-17 00:00:00.000", "description": "Report", "row_id": 2039198, "text": "Respiratory Care\nBaby rec'd on 18/5, R 16, 21%. BS coarse-> clear. Sxn for sm amt white secretions. CBG: 7.41/32; rate to 14, PIP to 16. Follow-up CBG: 7.42/35; further weaned to 15/5, R 12, 21%. No spells noted. Baby rec'd NSS bolus this am for decrease BP. Will cont to follow closely, support as indicated.\n" }, { "category": "Nursing/other", "chartdate": "2122-10-17 00:00:00.000", "description": "Report", "row_id": 2039199, "text": "Newborn Med Attending\n\nDOL#1. Cont on SIMV 15/5 x 12, RA. Last CBG =7.42/35. AF flat, clear BS< no murmur, abd soft, MAE. WT=695, 100 cc/kg/d D5W due to high DS, now ~140. Na=136, K=3.9. Bili=3.9.\nA/P: Critically-ill infant with RDS. Consider trial of CPAP in AM. Start PN, increase to 120 cc/kg/d. Start phototherapy. Repaeat lytes and bili in AM. Cont amp and gent for 48h r/o.\n" }, { "category": "Nursing/other", "chartdate": "2122-10-28 00:00:00.000", "description": "Report", "row_id": 2039282, "text": "NPN 0700-1900\n\n\n2.Resp: Infant remains vented on settings of 15/5 with a\nrate of 12. Fi02 requirement today mostly 23-28%,\nincreasing to 40% with cares. Lung sounds are coarse on the\nright and diminished on the left, do not improve with\nsuctioning. Infant has been suctioned q care for a small\namount of tan secretions from ETT. RRs 30s-60s with SC/IC\nretractions. He has had 2 spontaneous spells thus far this\nshift and has occasional desats to the mid-low 80s that are\nquickly self resolved with increased 02. Capillary gas\ntoday was 7.31/56/29/30/-1. No changes were made. Continue\nto monitor respiratory status.\n\n3.FEN: Infant remains on TF 150cc/kg/day of BM 24cal/oz.\nHe is on full feeds and tolerating well. PICC line in left\narm hep-locked. Abdomen is soft and full with a small\namount of bruising in the lower right quadrant. Abdominal\ngirths today 17.0. He has had no spits, max aspirate 1.4cc\nwith a small amount of green bilious. He is voiding\n3.8cc/kg/hr for 8 hrs, and stooling trace amount of yellow\nstool. Continue to monitor FEN status.\n\n4.DEV: Infant is nested on sheepskin and a water pillow in\na covered servo with stable temps. He is alert and\nactive with cares, sucks vigorously on pacifier. He had a\nnormal head u/s done at 7 days of life. On exam this\nmorning, his sutures were spread and his head circumference\nwas increased to 24.5 (from previously measured at 22.0). A\nhead u/s was scheduled for tomorrow. Continue to support\ngrowth and development.\n\n5.: Mom and in the morning to visit with infant,\nplan to visit again later today. informed of head\nultrasound tomorrow, spoke to regarding\nconcerns. are concerned and appropriate with\ninfant. Continue to support and keep informed.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2122-10-28 00:00:00.000", "description": "Report", "row_id": 2039283, "text": "Respiratory Care\nPt recieved on IMV, rate of 12, pressures of 15/5, with the fio2 21 to 34%. Pt suctioned for a sm amt of thickish cloudy, brown tinge secretions. Pt's respiratory rates 30's to 70's. Blood gas obtained this shift with good results. Plan is to follow on PPV, wean as tolerated.\n" }, { "category": "Nursing/other", "chartdate": "2122-10-29 00:00:00.000", "description": "Report", "row_id": 2039284, "text": "RESPIRATORY CARE NOTE\nBaby received intubated on vent settings 15/5 rate 12 FiO2 24-27%. Suctioned ETT for sm amt of cloudy secretions. Breath sounds clear after suctioning. Stable on current vent settings cont to follow.\n" }, { "category": "Nursing/other", "chartdate": "2122-11-29 00:00:00.000", "description": "Report", "row_id": 2039470, "text": "Neonatology Attending\n\nDOL 43 CGA 33 6/7 weeks\n\nStable on prong CPAP 5 25-30%. R 40s-60s. No A/B. On caffeine.\n\nBP 71/44 mean 54\n\nOn 150 cc/kg/d BM31 with promod. Voiding. Stooling. Wt 1530 grams (up 50).\n\nLIH present.\n\nEyes immature Zone 2 f/u 2 weeks\n\nA: Stable. Still requiring CPAP. Gaining wt.\n\nP: Monitor\n Continue CPAP\n f/u eye exam\n\n" }, { "category": "Nursing/other", "chartdate": "2122-11-29 00:00:00.000", "description": "Report", "row_id": 2039471, "text": "Respiratory Care Note\nPt remains on + 5 prong CPAP, FiO2 21%. RR 40-60's. BS clear. On caffeine. No bradys noted. Will trial off CPAP again this week.\n" }, { "category": "Nursing/other", "chartdate": "2122-11-29 00:00:00.000", "description": "Report", "row_id": 2039472, "text": "0700- NPN\n\n\nRESP: Cont on Prong CPAP of 5 with FiO2 at 21%. RR\n40's-60's. LS clear/=. Mild SC retractions. No A/B spells\nor desats. On Caffeine. P: Cont to monitor and wean O2 if\nnot in RA.\n\nFEN: TF=150cc/kg/d of BM/PE31 with PM (38cc Q4hr) PG over\n50 mins. Med spit x 1. Minimal aspirates. Abdomen benign,\ngirth stable at 24-25cm. Pt is voiding, trace stool x 1.\nOn Ferinsol and Vit E. P: Cont to monitor feeding\ntolerance.\n\nDEV: Temps stable in off , pt dressed/swaddled.\nMAE, alert/active with cares. Sleeps between cares. Sucks\npacifier and brings hands to face for comfort. Fontanels\nsoft/flat. Pt has left sided inguinal hernia, soft and\nreducable. AGA. P: Cont to support growth and development.\n\nPARENTING: No contact from yet this shift. P: Cont\nto support/educate \n\n\n" }, { "category": "Nursing/other", "chartdate": "2122-11-29 00:00:00.000", "description": "Report", "row_id": 2039473, "text": "Neonatology- Progress Note\n\nPE; remains in his , on CPAPP, bbs cl=, rrr s1s2 no murmur,a bd softm nontender, V&S, afso, active with care\nleft inguinal hernia soft\n\nSee attending note for plan\n" }, { "category": "Nursing/other", "chartdate": "2122-12-17 00:00:00.000", "description": "Report", "row_id": 2039551, "text": "2. continues in nasal cannula 50cc flow 50-60%,\nRR50-80's, sc/ic retractions, BBS clear, equal, mild-mod\nperipheral edema P: continue to monitor/wean as tolerated,\nTF decreased to 130cc/k/d.\n3. TF 130cc/k/d BM31 51cc q4h pg, abd full, soft, active\nbowel sounds, voiding, sm stool x1, no spits, minimal\naspirates, soft umbi hernia.\n4. temps stable swadled in open crib, active with cares,\nsucking well on pacifier, received hep b vaccine and\ntylenol.\n5. no contact from yet today.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2122-12-17 00:00:00.000", "description": "Report", "row_id": 2039552, "text": "Neonatology- Physical Exam\n\n remains in NC 500cc. Active, alert in an open crib, AFOF, sutures opposed, good tone. BBS clear and equal with good air entry, mild SC retractions. Gr murmur, pulses +2, pink, RRR. Abdomen soft, non-distended with active bowel sounds,, left inguinal hernia, tolerating feeds. Please refer to attending progress note for detailed plan.\n" }, { "category": "Nursing/other", "chartdate": "2122-12-19 00:00:00.000", "description": "Report", "row_id": 2039556, "text": "#2 PT CONT ON NC02 500CC OF 60%. LS ARE CLEAR. RR 40-70 WITH\nSOME HEAD BOBBING WITH CARES. UPPER AIRWAY CONG NOTED. MOD\nGENERALIZED EDEMA.\n#3 TV 130CC/KG PE/BM31 WITH HMF. FEEDS TOLERATED WELL. NO\nSPITTING, NO ASP, ABD BENIGN. VOIDING, TRACE STOOL X1.\nWEIGHT UNCHANGED.\n#4 TEMPS ARE STABLE IN OPEN CRIB. ALERT WITH CARES. HERNIAS\nSOFT AND WARM.\nMOM AMD TO VISIT IN EVENING, NO CONTACT FROM FAMILY\nOVERNIGHT.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2122-12-19 00:00:00.000", "description": "Report", "row_id": 2039557, "text": "Newborn Med Attending\n\nDOL#64. Cont in high flow O2 per NC. No spells. AF flat, clear BS, soft murmur, abd soft, MAE. WT=2410 no change, on 130 cc/kg/d Bm31 with PM.\nA/P: Infant with CLD. Wean O2 as tolerated. Cont on current feeding plan.\n" }, { "category": "Nursing/other", "chartdate": "2122-12-19 00:00:00.000", "description": "Report", "row_id": 2039558, "text": "npn 7a7p\n\n\nResp\nInfant on NC 500cc flow @ 58-62%. RR 50-70s, LSC with some\nupper airway congestion. S/C I/C rtxs. Head bobbing and\npanting with cares and bottle. Mod generalized edema. Unable\nto wean further on O2. Recieved 1 of 2 doses of lasix this\nam. O2 needs unchanged. No spells. Monitor and support resp\nstatus.\nFen\nInfant on TF 130 cc/k/d BM or PE 31. Gavaged and PO x 1\nevery shift. Abd soft, full, round with active BS. Trace\nstool. Bottled entire amt at midday. Needs pacing, strong\nsuck, some desating. Infant learning to PO. Monitor weight\nand exam.\nG/D\nInfant in OAC with stable temps. A/A with cares. Wakes for\nfeeds q 3-4 hrs. Uses pacifier. Clonis present. MAEs. FS&F.\nAGA. Monitor and support G/D.\n\nHave had no contact from today.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2122-12-20 00:00:00.000", "description": "Report", "row_id": 2039559, "text": "NPN 1900-0700\n\n\n2.Resp: Infant remains in NC 500 cc with Fi02 requirement\n50-68% (increasing to 70% with cares). Lung sounds are\nclear and equal with mild upper airway congestion. Infant\nis now s/p 2 doses of Lasix (last dose given at 2200). RRs\n40s-70s with mild IC/SC (occasionally substernal)\nretractions and occasional head bobbing. 02 sats mostly >\n90% with occasional drifts to the low-mid 80s, QSR. Infant\ndid have one prolonged desat after 15cc of feeding gavaged\nwith a low sat of 77%, remaining in the high 70s to mid 80s\nfor approximately 3-5 minutes. Infant resolved after\nincreasing 02, repositioning. Continue to monitor\nrespiratory status.\n\n3.FEN: Infant's weight tonight 2455g (up 45g). Infant\nremains on TF 130cc/kg/day of BM/PE 31cal/oz. He is\nbottling q shift, no bottles thus far this shift secondary\nto bath. Infant is tolerating feeds with no spits, max.\naspirate 1.2cc. Abdomen is soft and full with active bowel\nsounds, no loops. Infant has moderate generalized edema.\nPlan to check electrolytes in the am following 2 doses of\nLasix. Continue to monitor FEN status.\n\n4.DEV: Infant remains swaddled in an open crib with head of\nbed raised 45degrees, stable temps. He is alert and active\nwith cares, wakes for feeds. Small umbilical hernia remains\nsoft and reducable. called to bedside to assess left\ninguinal hernia. Scrotum is moderately edematous making\npalpation of hernia difficult. stated probable\nhydrocele instead of hernia. Scrotum is soft, pink,\nnontender. Continue to monitor, support growth and\ndevelopment, and plan to repeat eye exam next week.\n\n5.: Mom and in at for cares. gave\ninfant bath, then held for 1 hour, well tolerated. \nare loving and appropriate, very independent with cares.\nUpdated at bedside. Continue to support and keep\ninformed.\n\nCV: Infant has soft intermittent murmur heard on\nauscultation. He is pink and well perfused with normal\npulses, BP 85/37(53). Continue to monitor.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2122-12-20 00:00:00.000", "description": "Report", "row_id": 2039560, "text": "NEONATOLOGY\nREMAINS IN NCO2 500-600 CC. IN 50 -60%. RECEIVING SECOND DOSE OF LASIX LAST NIGHT. Single desat overnight. Will begin on trial of diruil rx in attempt to decrease O2 need.\n\nWt 2555 up 45. Tolearting feeds at 130 cc/k/d of 31 cal. Abdomen benign without masses.\n\nNeuro non-focal and age appropriate. Moving all 4 well. Hips normal. Skins w/o lesions. ? LIH on exam although not apparent on exam today.\n\nRepeat eye exam this week.\n\nCOntinue to monitor resp status and nutritional regimen.\n" }, { "category": "Nursing/other", "chartdate": "2122-12-20 00:00:00.000", "description": "Report", "row_id": 2039561, "text": "NICU NURSING PROGRESS NOTE:\n\nRESP.O: Infant remains on NCO2 500cc, 50-62 flow with sats\n89-97%. Occasional drifting O2 into 70-80's with quick\nrecovery or control of O2 flow. RR 40-60's. Lungs sound\nclear and equal. Mod IC/subc retarctions. No spells.\nContinue to monitor resp status and assess.\n\nFen.O: Infant conts remains on 130cc/k/d of BM 31 or PE31,\n53cc Q4 hrs. Offered bottle once. Bottled full volume, took\n62cc. Bottled well, coordinated, but worked very hard to\nbreath. Abd exam is soft, no loops. BS active. Voiding and\nstooling. No spits. aspirates. Umbilical hernia is soft\nand warm. Feeding tube is replaced. Tolerating feeds.P:\nContinue to support feeding plan.\n\nG/D.O: Baby is in open crib. Swaddled. Temps stable.\nMod/Gen edema. Active and alert with cares. Sleeps in\nbetween cares. Wakes for feeds every 4 hrs. Able to suck on\npacifier. Head of the bed is elevated at a 45 degree.\nLifting head side to side in prone position.\nA: Appropriate behavior. P: Continue to support\ndevelopmentally needs.\n\nParenting: No contact from to the time of note.\nContinue to support and keep informed.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2122-10-22 00:00:00.000", "description": "Report", "row_id": 2039234, "text": "2. Resp: O: Infant is on CPAP of 6cm, delivered via np tube.\nHe is in RA. RR 20-50s, ls clear. Sxned q 4 hours for a\nsmall to mod amt of oral secretions, scant from his np tube.\nHe has had a brady per hour at least since 8p. He gets pale,\nand is totally apneic. He is otherwise active and vigorous\nand tolerates cares well. He is on caffeine. A: Infant has\nno O2 need but has been having a/bs. P: Monitor. Check labs\nat next care time.\n\n3. F/N: O: Infant is on 150cc/k/d TF, working up on feeds of\nBM20. He has just been advanced to 40cc/k/d of pg feeds. Abd\nis benign, he has been stooling w/ each diaper so far,\nthough his u/o is down. No spits and very small asps of\nslightly green-tinged secretions. He gained 22g. PIC line\nattempted but no central line was established. He still has\na DUV w/ his TPN and lipids infusing via this. A: Tol w/u on\nfeeds, u/o is down. P: Monitor. Labs at next care time.\nCheck d/s.\n\n4. G/d: O: Infant's temp is stable on servo in a heated\n under phototx. He is active and alert w/ cares and\ntolerated being held by Mom while his bed was being changed.\nHe opens his eyes during cares. He also has been tolerating\nhis cares well w/o any O2 need. A/P: Continue to support\ninfant needs.\n\n5. Parents: O: Parents were in to visit and Mom held on\na blanket against her under warming lights. He did very well\nw/ this and also maintained his temp well. Parents signed\nconsents for PIC and blood products. A: Loving, involved\nparents. P: Continue to support.\n\n6. CV: O: HR is 120-140s. No murmur. Color is pink when\ninfant is not under the phototx lights. A: Stable. P: Check\nlabs at next care time.\n\n7. Bili: O: Infant is under single phototx w/ his eyes\ncovered. He is pink and he is stooling tonight. A:\nHyperbilirubinemia. P: Phototx as ordered. Check bili at\nnext care time.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2122-10-22 00:00:00.000", "description": "Report", "row_id": 2039235, "text": "NPN addendum:\n\n2. Resp: O: Infant has had 5 bradys in 8 hours so far. ABG\nsent was 126/28/7.25/13/-13. His PEEP was turned down from 6\nto 5cm after speaking to , NNP. Infant is otherwise\nwell-appearing w/ VSS. His hct is 38.6. A: Infant is\nacidotic. He is well appearing. P: Monitor. Gas prn.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2122-10-22 00:00:00.000", "description": "Report", "row_id": 2039238, "text": "Neonatology-NNP Physical Exam\n\n remains on CPAP. Active, alert in an , AFOF, sutures slightly spilt, good tone. BBS clear and equal with good air entry. No murmur, pulses +2, pink, RRR. Abdomen soft, non-distended with active bowel sounds, no HSM, tolerating feeds. Please refer to attending progress note for detailed plan.\n" }, { "category": "Nursing/other", "chartdate": "2122-10-22 00:00:00.000", "description": "Report", "row_id": 2039239, "text": "Nursing Note\n\n\n2. Recieved infant on NP CPAP of 5, 21% O2. COntinues on\nthese settings today. TOlerating well with no increased O2\nrequirement as of yet. Has had 2bradys without desats. BLS\nc/=, RRR, no ^WOB. TOlerates cares without ^O2 requirements.\nSee flowsheet for last ABG results. Check CBG this\nafternoon. Plan to recheck Plt, lytes and bili tomorrow AM.\nCOntinue to monitor.\n3.TF at 150cc/kg/d. 100cc/kg/d TPN/IL via DLUVC, 50cc/kg/d\nBM20 via NG tube. TOlerating well with sustained dsticks\nabove 100. V/S qdiaper change. See flowsheet for I&O values\nand dstick values. Abd unremarkable, min asp. Working up on\nfeeds. COntinue to monitor. See flowsheet for further\ndetails.\n4. Temps stable in servo iso. a/a with all cares, sleeps\nwell between. Likes binki. AFOSF, PFOSF, MAE. Had head\nultrasound today. Will continue to monitor.\n5. No contact with thus far.\n6. Pink, well perfused. See flowsheet for HR. No murmur.\nGood cap refill. 2 bradys thus far this shift. QSR. Refer to\nflowsheet for additional details. COntinue to assess and\nmonitor.\n7. Phototherapy d/c'd for bili of 1.2,0.5,1.7.Plan to\nrecheck bili in AM. COntinue to monitor.\n\nSee flowsheet for further details.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2122-10-22 00:00:00.000", "description": "Report", "row_id": 2039240, "text": "Respiratory Care\nBaby continues on cpap5, fio2 21%, bs clear, rr 30-50's, on caffeine, had one spell on this shift thus far. Will contnue to follow.\n" }, { "category": "Nursing/other", "chartdate": "2122-10-22 00:00:00.000", "description": "Report", "row_id": 2039241, "text": "Nursing Note 1900-2300\nRESP: Pt remains on NP, requiring 21% FiO2. Pt has had 4 spells so far this shift which require mild stim but no increase in FiO2. NNP Buck and Dr. made aware. Caffeine bolus ordered. RR 20-60's. Lung sounds are clear. Baseline retractions. Sxn for mod clear secretions via NP tube. Will report to next RN that caffeine be given when it arrives from pharmacy. Will monitor closely.\n" }, { "category": "Nursing/other", "chartdate": "2122-11-19 00:00:00.000", "description": "Report", "row_id": 2039414, "text": "NPN 0700-1900\n\n\nRESP: remains on Prong CPAP-5cm, FIO2 22-35%.\nAttempted off CPAP (but w/ BBO2) during cares, but he\nrequired the CPAP to maintain his sats. Breath sounds are\nclear and equal. + mild intercostal and subcostal\nretractions noted. Occasionally tachypneic, RR 50-90's.\nSuctioned x 1 for a small amount of blood tinged secretions.\n Nares are becoming excoriated- ? tachypneic due to pain.\n On Caffeine- has had one this shift ( HR39, sats 61)\nneeded mild stim and increased FIO2 to resolve.\nA/P: Monitor spells on CPAP, monitor nares clsoely. ?\nTylenol.\n\nF&N: TF-150cc/kg/d of PE/BM30 w/ promod. Tolerating feeds\nover 50minutes w/o spits. MAx aspirate-.8cc. Abd is round\nand soft w/ active bowel sounds and no loops. ag is stable\nat 21-22cm.\n\n\nG&D: Temp is stable in servo-.( temp weaned\nx 1). He is active and alert. Appropriate w/ cares.\nEAgerly takes pacifier. HUS done today-wnl. Brings hands\nto face.\n\n: No contact yet.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2122-11-19 00:00:00.000", "description": "Report", "row_id": 2039415, "text": "Respiratory Care\nBaby continues on prong CPAP 5 with 02 req 23-30% this shift. BS clear. Sxn x1 as per flowsheet. RR mostly 50's-60's. One mild stim A & B during feed. On caffeine. Plan cont CPAP.\n" }, { "category": "Nursing/other", "chartdate": "2122-11-20 00:00:00.000", "description": "Report", "row_id": 2039416, "text": "1900-0730 NPN\n\n\nRESP: Cont on Prong CPAP of 5 with FiO2 24-28%. RR\n30's-60's. O2 sats 95-98%. LS clear/=. Mild IC/SC\nretractions. No A/B spells thus far this shift. Occasional\ndrifts in O2 sats to 70-80%'s. On Caffeine. P: Cont to\nmonitor and wean O2 as tolerated.\n\nFEN: Wgt tonight is 1200g, up 20g. TF=150cc/kg/d of\nBM30/PE30 with PM (30cc Q4hr PG over 50 mins). No spits.\nMinimal aspirates. Abdomen benign, girth stable at 21.5cm.\nPt is voiding, no stool. On Ferinsol and Vit E. P: Cont to\nmonitor feeding tolerance.\n\nDEV: Temps stable in servo-controlled , pt is\nnested on sheepskin. MAE, alert/active with cares. Sleeps\nbetween cares. Sucks pacifier and brings hands to face for\ncomfort. Fontanels soft/flat. AGA. P: Cont to support\ngrowth and development.\n\nPARENTING: Both in to visit for care, updated\nby RN, asking appropriate questions. Mom participated in\ncare and kangaroo'd infant x 45 mins. Family is loving\nand invested. P: Cont to support/educate .\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2122-11-20 00:00:00.000", "description": "Report", "row_id": 2039417, "text": "RESPIRATORY CARE NOTE\nBaby remains on Prong CPAP 5 FiO2 24-28%. RR 30-60's breath sounds are clear. Occasional drifts on the sat monitor requiring increased FiO2. Stable on CPAP cont to follow.\n" }, { "category": "Nursing/other", "chartdate": "2122-11-20 00:00:00.000", "description": "Report", "row_id": 2039418, "text": "Newborn Med Attending\n\nCont on CPAP5 24-28% O2. no spells overnight. AF flat, clear BS, no murmur, abd soft, MAE. WT=1200 up 20, on 150 cc/kg/d BM30 with PM, PG.\nA/P: Growing infant with residual CLD and AOP. Monitor for spells.\n" }, { "category": "Nursing/other", "chartdate": "2123-01-11 00:00:00.000", "description": "Report", "row_id": 2039672, "text": "Clinical Nutrition\nO:\n~40 wk CGA BB on DOL 87.\nWT: 3240 g (-45)(~50th to 75th %ile); birth wt: 695 g. Average wt gain over past wk ~29 g/d.\nHC: 36 cm (>90th %ile); last: 34.5 cm\nLN: 47.5 cm (~25th to 50th %ile); last: 45 cm\nMeds include Vit E, Fe, KCl, and diuril.\n not needed\nNutrition: Ad lib demand feeds, minimum 130 cc/kg/d, E/ BM 20. Average of past 3 d intake ~148 cc/kg/d. Feeds just decreased today for good wt gain. Projected intake for next 24 hrs based on average intake is ~99 kcal/kg/d, ~1.6 to 2.1 g pro/kg/d.\nGI: Abdomen benign.\n\nA/Goals:\nTolerating feeds without GI problems. not needed. Current feeds + supps not quite meeting weaned recs of ~108 kcal/kg/d and ~2.2 g pro/kg/d. Infant takes primarily formula; therefore, intake is at higher end of range stated above. Anticipate infant will increase intake as kcal content of feeds decreases. Will monitor intake and amount of BM available. Infant will require ViDaylin supps if more Breastmilk becomes available. Will continue to follow w/ team and participate in nutrition plans.\n" }, { "category": "Nursing/other", "chartdate": "2122-10-28 00:00:00.000", "description": "Report", "row_id": 2039278, "text": "2. Resp: O: Infant received on the vent at settings of 15/5\nX 12. Ls coarse/clear, RR 40-60s. Infant is active and\nvigorous. No spells. FiO2 21-26% for the most part, 30% max.\nHe is on caffeine. Sxned X 2, once for scant clear\nsecretions and once for a mod amt of blood- tinged\nsecretions. ( aware.) A: Stable on the vent at low\nsettings. P: Continue as per plan.\n\n3. F/N: O: Infant is on full feeds at 150cc/k/d of BM20, q 4\nhour feeds via gavage over 40 min each. No asps. no spits.\nAbd is benign. He voided 4.3cc/k/hr over the last 8 hours\nand stooled a g- stool. He lost 5g. A: Tol full feeds so\nfar. P: Continue as per NICU protocol.\n\n4. G/d: O: Infant's temp is stable on servo in the heated\n. He sucks vigorously on a binkie and generally\ntolerates cares well. He kangarooed w/ Mom for 80min and did\nvery well. A/P: Continue to support infant needs.\n\n5. : O: Mom was in to visit, do cares and kangaroo.\nBoth Mom and Baby did very well. called also and talked\nto Mom for an update. A: Loving, involved . P:\nContinue to support.\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2122-10-28 00:00:00.000", "description": "Report", "row_id": 2039279, "text": "Respiratory Care\nBaby remains on imv 12 15/5 21-34%.Sx x 2 for mod-lg bld tinged->brown secs.BS coarse throughout.On caffeine no spells documented this shift.\n" }, { "category": "Nursing/other", "chartdate": "2122-10-28 00:00:00.000", "description": "Report", "row_id": 2039280, "text": "Neonatology Attending Note\nDay 12\n\n15/5 x 12, 21-35%. 1 A&B past 24 hr. On caffeine. No murmur. HR 140-160s.\n\nWt 695, down 5 gms. TF 150 cc/k/day BM20. HL PICC.\n\nInitial HUS (d6) wnl.\n\nIn .\n\nA/P:\nMaintain low vent settings\nMonitor AOP\nInc cals to 24\nRepeat HUS in am\n\n" }, { "category": "Nursing/other", "chartdate": "2122-10-28 00:00:00.000", "description": "Report", "row_id": 2039281, "text": "Neonatal NP-Exam\n\nSee dr. note for details and plan of care as discussed in rounds this am.\n\nAFOF, sutures split. Breath sounds clear and equal. NL S1S2, no audible murmur. Pale, pink and well perfused. Abd benign, no HSM. Active bowel sounds. Infant active with exam.\n" }, { "category": "Nursing/other", "chartdate": "2122-11-10 00:00:00.000", "description": "Report", "row_id": 2039360, "text": "Clinical Nutrition\nO:\n~31 wk CGA BB on DOL 25.\nWT: 924 g (+14)(<10th %ile); birth wt: 695 g. Average wt gain over past wk ~20 g/kg/d.\nHC: 25.75 cm (<10th %ile); last: 25 cm\nLN: 33 cm (<10th %ile); last: 33 cm\nMeds include Fe and Vit E\n not due yet\nNutrition: 150 cc/kg/d BM 30 w/ promod, pg over 50 feeds due to hx of spits. Average of past 3 d intake ~154 cc/kg/d, providing ~154 kcal/kg/d and ~4.1 g pro/kg/d.\nGI: Abdomen benign.\n\nA/Goals:\nTolerating feeds over extended feeding times without GI problems. not due. Current feeds + supps meeting recs for kcals/pro/vits and mins. Growth is meeting recs for wt gain and HC gain. LN shows no change over past wk; will follow long term trends. Will continue to follow w/ team and participate in nutrition plans.\n" }, { "category": "Nursing/other", "chartdate": "2122-11-10 00:00:00.000", "description": "Report", "row_id": 2039361, "text": "Neonatology Attending Note\nDay 25\nCGA 31 2\n\nPalced on CPAP last pm for inc work of breathing. CPAP6, RA. RR40-60s. No murmur. HR 160-180s. BP 68/59, 62.\nOn caffeine.\n\nWt 924, up 14. TF 150 cc/k/dat BM30 w promod. PG. Tol well. Nl voiding and stooling. On Fe and Vit E.\n\nIn .\n\nA/P:\ncont cpap, monitor aop on caffeine\nno change to nutritional plan\nnext hus day 30\n" }, { "category": "Nursing/other", "chartdate": "2122-11-10 00:00:00.000", "description": "Report", "row_id": 2039362, "text": "Respiratory Care\nBaby continues on cpap 6, fio2 21-25%, bs clear, rr 30-60's, on caffeine, no spells noted on this shift thus far. Will continue to follow.\n" }, { "category": "Nursing/other", "chartdate": "2122-11-11 00:00:00.000", "description": "Report", "row_id": 2039365, "text": "Nursing Progress Note 1900-0700\n\n\nResp:Infant remains in Nasal Prong CPAP-6,FIO2 21-28%.RR\n30-50's with IC/SC retractions.LS remain clear and equal\nb/l.Sxn'd for moderate white secretions orally and lg white\nnasally.Infant cont's on Caffiene no spells thus\nfar.A:Alt.in Resp. d/t Prematurity P:Cont. to assess resp.\nstatus.\n\nF/E/N:Infant cont's on TF 150cc's/kg/day.Rec.BM 30 or PE 30\nwith Promode 24cc's gavaged over 50 .Weight=0.945 kg up\n21 grams.Abd soft and full with pos bs,no loops or\nspits,minimal aspirates.Infant voiding and stooling heme\nnegative.A:Stable P:Cont. to assess tolerance of feeds.\n\nG/D:AFSF.Infant appears alert and active with cares at times\nirritable b/t cares but calms with containment and\npacifier.Remains in Servo control ;temp.\nmaintained.A:AGA P:Cont. to support growth and dev.\n\n: in tonight appear very loving and\ninvested.Mom kangarooed infant for 45-50 ,infant\ntolerated well.A/P:Cont. to update,support,and educate.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2122-11-11 00:00:00.000", "description": "Report", "row_id": 2039366, "text": "Respiratory Care Note\nPt. continues on 6cmH2O of nasal prong CPAP and 21-28% FIO@. BS are clear. Pt. sx'd for lrg. white secretions. To follow.\n" }, { "category": "Nursing/other", "chartdate": "2122-11-11 00:00:00.000", "description": "Report", "row_id": 2039367, "text": "Neonatology Attending Note\nDay 26\n\nCPAP6, 21-28%. BS clear. On caffeine. 2 A&Bs/24 hours. No murmur. HR 160-170s. Pale/pink. BP 67/34, 47.\n\nWt 945, up 21. TF 150 cc/k/day BM30/PE30 w promod. PG over 50 minutes. Tol well. Left inguinal hernia.\n\nIn servo .\n\nA/P:\ndoing well on CPAP\nmonitor AOP, mild and well controlled on caffeine\nno change to nutritional plan\n" }, { "category": "Nursing/other", "chartdate": "2122-11-11 00:00:00.000", "description": "Report", "row_id": 2039368, "text": "Neonatal NP-Exam\n\nSee Dr. note for details and plan of care as discussed in rounds this am.\n\nAFOF, sutures widened. Breath sounds clear and equal with good CPAP transmission> nl S1S2, no audible murmru. Pulses full/4. Abd benign, no HSM. active bowel sounds. L inguinal hernia easily reduced. Infant active with exam.\n" }, { "category": "Nursing/other", "chartdate": "2122-11-11 00:00:00.000", "description": "Report", "row_id": 2039369, "text": "Respiratory Care\nBaby continues on cpap 6, fio2 21-27%, bs clear, rr 40-60's, on caffeine, no spells noted thus far on this shift. Will continue to follow.\n" }, { "category": "Nursing/other", "chartdate": "2122-11-11 00:00:00.000", "description": "Report", "row_id": 2039370, "text": "NPN DAYS\n\n\nAlt in Resp: Remains on prong CPAP6 with FiO2 23-26%. LS\nclear and equal. Mild IC/SC retractions. No spells so far\nthis shift. Remains on caffeine. Continue to monitor\nclosely.\n\nAlt in FEN: TF 150cc/kg/day BM30PM/PE30PM, gavaging over\n50mins. Belly full, slightly firm, no loops. Minimal\naspirates. AG 19.5-20cm. Will continue with current plan of\ncare.\n\nGrowth and Dev: Temp stable in servo . Awake and\nalert with cares. Sleeps well between cares. Will continue\nto provide developmental needs.\n\n: Mom called x1. be in to visit tonight.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2122-11-12 00:00:00.000", "description": "Report", "row_id": 2039371, "text": "NPN\n\n\n#2 Resp= Remains on Prong CPAP of 6cms in 21-26% o2. BS\nclear. Mild retractions.RR= 30-60.Sxn sor mod amts.Remains\non caffeine.No A's or B's yet tonight. see flowsheet.\n#3 F/N- Abd soft+ very full,+bs, no loops.Tolerating ng\nfeeds of BM/Pe 30 cals w/o spits. Minimal\nasps.Voiding+stooling in adeq amts.Wt up 23gms.Tf=\n150cc/kg/day.Feeds given on a pump over 50 mins q 4 hrs.\n#5 Mom and here to visit. Took temp+ changed\ndiaper.Called x1.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2122-12-18 00:00:00.000", "description": "Report", "row_id": 2039553, "text": "NPN\n\n\n#2\nInfant remains in N/C 500cc flow; 50-60% maintaining sats\nmid 90s. Occasional drifts in sats; no spells. BS clear=\nwith mild/mod retractions. Color is pink; soft murmer\naudible.\n\n#3\nInfant remains on TF=130cc/k of PE/BM31 q4 hours. Infant is\ntolerating gavage feeds well with scant aspirates and no\nspits. Abd is soft and round; voiding and stooling. Infant\nbottled x1 and took the whole feeding well with . Wt is\nup 75gms-2410.\n\n#4\nInfant continues in an open crib swaddled with boundaries.\nInfant is alert with cares; sucks eagerly on the pacifier;\ntemps have been stable.\n\n#5\n were in last evening for cares. Independent with\nweighing and caring for infant. was very eager to\nbottle infant--infant took the bottle well.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2122-12-18 00:00:00.000", "description": "Report", "row_id": 2039554, "text": "Neonatology\nREMAINS IN NCO@ FLOW AT APPROX 500 CC 50-60%. OFF CAFFEINE.\nSOFT MURMUR AS BEFORE. GENERALLY comfortabel apeparing.\n\nWt 2410 UP 75. TF decreased to 130 cc/k/d. Abdomen benign.\nTaking some bottle but mainly gavage.\n\nTemp stable in open crib.\n\n60 d Immunizations given.\n\nAwiting maturation of resp control and feeds.\n\n" }, { "category": "Nursing/other", "chartdate": "2122-12-18 00:00:00.000", "description": "Report", "row_id": 2039555, "text": "NPN 0700-1900\n\n\n#2 O: Infant remains in NC 02 500cc's of flow at 55-60% o2.\nRR mainly 40's-70's but can be higher at times. LS clear and\n=. Upper airway congestion noted. Mild-mod SC retractions.\nNo spells. Infant noted to be working hard with bottle feed;\nbreathing faster and retracting more. A: Stable in NC. P:\nCont to monitor.\n\n#3 O: TF= 130cc/kg/d. Infant taking 52cc's of PE31 q 4h via\npo/pg feeds. Bottled at 0800 taking 12cc's before tiring.\nAbdomen benign; voiding, no stool. No spits, minimal\naspirates. A: Tolerating feeds. P: Cont to monitor.\n\n#4 O: Infant maintaining temp in oac. Awake and alert with\ncares; sleeping well between. Sucks on pacifier and brings\nhands to face for comfort. A: AGA. P: Cont to support\ndevelopment.\n\n#5 O: Both in briefly between cares with relative to\nvisit. Given update at bedside by this RN. A: Involved. P:\nCont to support and update.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2123-01-03 00:00:00.000", "description": "Report", "row_id": 2039632, "text": "NPN 0700-1900\n\n\n#2 O: Infant remains in NC o2 100% at 75cc's of flow. RR\n40's-70's with mild SC retractions. LS clear and =. Upper\nairway congestion noted. No spells. On diuril and kcl as\nordered; diuril increased today. A: Stable on NC o2. P: Cont\nto monitor.\n\n#3 O: TF= 130cc/kg/d. Infant feeding ad lib amounts q\n4h; bottling 70-90cc's of PE26/BM26. Abdomen benign; voiding\nand stooling guaic neg. Sm spit after taking 90cc's. Lytes\nWNL. A: Tolerating feeds. P: Cont to monitor.\n\n#4 O: Infant maintaining temp in oac. Awake and alert with\ncares; sleeping well between. Waking on own for most cares.\n. Sucks on pacifier when offered. A: AGA. P: Cont to\nsupport development.\n\n#5 O: No conact as yet this shift. A: Involved. P: Cont to\nsupport and update.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2123-01-03 00:00:00.000", "description": "Report", "row_id": 2039633, "text": "Neonatology - PRogress Note\n\n is active with good tone. AFOF. He is pink, well perfused, no murmur auscultated. He is comfortable in low flow NCO2. Breath sounds clear and equal. Mild retractions. He is tolerating ad-lib feeds. Abd soft, active bowel sounds, voiding and stooling. Stable temp in open crib. Please refer to neonatology attending note for detailed plan.\n" }, { "category": "Nursing/other", "chartdate": "2123-01-04 00:00:00.000", "description": "Report", "row_id": 2039637, "text": "Nursing progress Notes.\n\n\n#2 O: Baby remains in nasal cannula oxygen, 75 to 100cc\nflow, 100%. Baby needed increased oxygen to maintain sats\nabove 90% after eyedrops and eye exam. Breath sounds clear\nand equal, mild to moderate subcostal retraction plus\nheadbobbing at times, even at rest. Baby had 1 to\n80's, no bradycardia. A: Continues to require nasal cannula\noxygen. P: Continue to monitor and provide support as\nrequired.\n#3 O: Baby continues on ad lib feeds, calories decreased to\nPE24 today. He woke about every 4 hours and fed well. 1\nspit, abdomen benign, voiding well, no stool today. A:\nFeeding well. P: Continue with ad lib feeds.\n#4 O: Temp stable in open crib. Baby woke for feeds and fed\nwell, baby also slept well between feedings. A: Appropriate\nfor age. P: Continue to support development.\n#5 O: Father in to visit and feed baby this morning. Mother\ncalled for an update. A: Involved family. P: Continue to\nkeep informed. Family meeting tomorrow at 5pm\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2123-01-05 00:00:00.000", "description": "Report", "row_id": 2039638, "text": "NICU nursing note\n\n\n2. Resp=O/Cont in NCO2 FIO2 100% 100cc/ flow. Spell x1.\n(Please refer to flowsheet for resp assessment and details\nof .) Cont on Diuril/KCl. A/Stable in NCO2. P/Cont\nto monitor for resp distress.\n\n3. FEN=O/Current wt=3060g (^20g). Cont on adlib feeding\nschedule of PE24 (with 130cc/k/d.) Abd benign. (Please\nrefer to flowsheet for assessement and po amts.) No spits.\nVoiding. Med stool x1, heme(-). Cont on Vit E.\nA/Tolerating current regime. Bottlefeeding well. P/Cont to\nmonitor for feeding intolerance.\n\n4. G&D=O/Temp stable swaddled in open crib. Alert and\nactive with cares. Sleeping well in between. Waking\nQ4-6hour. A/Alt in G&D. P/Cont to monitor and support G&D.\n\n5. =O/Mom and in to visit. Updated by this\nnurse. Mom BF then bottlefed baby at . \nindependent with care. A/appropriate and actively involved.\nP/Cont to support and educate .\n\n\n" }, { "category": "Nursing/other", "chartdate": "2123-01-05 00:00:00.000", "description": "Report", "row_id": 2039639, "text": "Nursing Progress Notes.\n\n\n#2 O: Baby remains in nasal cannula oxygen 100%, 75cc today,\nsats 94 to 97%, breath sounds clear and equal, mild\nretractions, no spells noted. A: Doing well in 75cc nasal\ncannula oxygen, Last on . P: Continue to monitor.\n#3 O: Baby feeding on demand every 3 to 4 hours today.\nAbdomen benign, voiding and stooling, no spits. A: Feeding\nwell. P: Continue to monitor.\n#4 O: Temp stable in open crib. Baby woke quietly for feeds\nand slept well between cares. Baby is and active with\ncares. A: Appropriate for age. P: continue to support\ndevelopment.\n#5 O: in to visit this morning and plans to visit again\ntonight to bath baby. A: Involved family. P: Continue to\nkeep informed.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2123-01-05 00:00:00.000", "description": "Report", "row_id": 2039640, "text": "Neonatology\nDoing well. Remains in NCO2. Single this am.\nContinues to await ability towean from O@. On diruil.\n\nWt 3060 up 20. Tolerating feeds at 130 cc/k/d . Changed to 24 cal yesterday given growth. Abdomen benign.\n\nCOntinue current resp rx and monitoring.\n" }, { "category": "Nursing/other", "chartdate": "2122-10-22 00:00:00.000", "description": "Report", "row_id": 2039236, "text": "Respiratory Care\nBaby rec'd on NPCPAP 5, 21%. BS clear. Sxn q4h as per flowsheet. RR 20's-40's with IC/SCR. ABG: 7.25/28/126/13/-13; CPAP decreased to 5. Six A's & B's this shift, QSR- mod stim. Will cont to follow closely, monitor spells, WOB.\n" }, { "category": "Nursing/other", "chartdate": "2122-10-22 00:00:00.000", "description": "Report", "row_id": 2039237, "text": "Neonatology Attending Note\nDay 6\nCGA 28 4\n\nNPCPA5, 21%. RR20-50s. Last ABG 7.25/28/-3. Rec'd bicarb. 6 A&Bs overnight. On caffeine.\n\nNo murmur. HR 130-150s. BP 57/33, 41.\n\nHct 45.4 -> 38.\nPlt count 36, but recheck 98.\n\nWt 595, up 22 gms. TF 150 cc/k/day - PNd7/IL at 110, enteral BM20 at 40. Tol well. Nl voiding and stooling.\n131/4.2/101/13\ntg 156\nd/s 133\n\nUnder single photot - bili 1.2/0.5\n\nIn .\n\nA/P:\n-- Good resp function on CPAP\n-- monitor AOP on caffeine\n-- Plt and Hct ok for now, will need to monitor trend and may need tx in future\n-- Advance enteral feedings\n-- Inc Na in PN to allow for more acetate\n-- d/c photo\n-- check lytes, bili in am\n" }, { "category": "Nursing/other", "chartdate": "2122-11-02 00:00:00.000", "description": "Report", "row_id": 2039310, "text": "Nursing progress note\n\n\n#2 O: Remains orally intubated in 27-35% O2 15/5 X's 12.\nBreath sounds equal 7 clear with mild IC/sc retractions.\nOccasional desats to the 70's requiring inc O2. Remains\ncaffeine. No A's or B's. CBG done. Suctioned q4h for mod th\ncldy from ETT & lg wh OP. A: Unchanged. P: COnt to assess.\n#3 O: Wgt up 20 gms. Remains on 150cc/k/d, 30 cal BM w/PM.\nAbd soft with active bowel sounds & no loops. Baby had\nmedium spit after midnoc feeding. Voiding & stooling. Stools\nare guaiac neg. A: Unchanged. P: Cont to assess.\n#4 O: Temp stable in servo nested in sheepskin.\nAlert with cares. Sucks on pacifier. A: AGA. P: Cont to\nassess.\n#5 O: in to visit. was concerned that baby's O2\nrequirement was up. was told that O2 requirement\nfluctuates. A: Involved . P: Support.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2122-11-02 00:00:00.000", "description": "Report", "row_id": 2039311, "text": "Neonatology Attending Progress Note\n\nNow day of life 17.\n\nOn vent support 16/5 12 and 27-37% FIO2\nRR - 30-60s.\nOn caffeine and Fe.\nNo apnea and bradycardia noted - occasional desaturations noted.\nCBG - 7.29/54\n\n65/41 50 HR 150-170s\n\nWt. 780gm up 20gm on 150cc/kg/d of MM30 with Promod\nFeedings of MM well tolerated.\nNormal urine and stool output.\n\nAssessment/plan:\nVery nice stability on low vent support.\nWill give trial of extubation today.\n\n" }, { "category": "Nursing/other", "chartdate": "2122-11-02 00:00:00.000", "description": "Report", "row_id": 2039312, "text": "Nursing Note\n\n\n2. REceived infant intubated with setting of 16/5 rate of\n12. Pt tolerating well. Pt NP CPAP of 5 in 23-28%\nO2. TOlerating well with no spells, sats >92%, 2 qsr drifts\nto high 70's low 80's thus far. Otherwise stable, c/=, RRR,\nmild sc/ic retractions. COntinues on caffine. Will continue\nto monitor for resp distress.\n3. TF continues at 150cc/kg/d of BM 30 with PM. Tolerating\nwell with no asp, no spits, stable girths, +BS, abd\nunremarkable. V q diaper change, no stool thus far on days.\nCOntinues on Fe, Vit E. COntinue to monitor for feeding\nintolerance and support FN requirements.\n4. Temps stable in servo iso, a/a with all cares, looking\naround while awake, sucks paci and fingers. Sleeps well\nbetween cares, settles well. Nested in sheepskin. AFOSF,\nPFOSF, MAE, AGA. Continue to support GD requirements.\n5. No contact thus far.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2122-11-03 00:00:00.000", "description": "Report", "row_id": 2039315, "text": "2. Resp: O: Infant received on np CPAP of 6 cm. RR 30-60s,\nFiO2 24-31% w/ a high at 41% X 1. Ls clear. Sxned X2 for a\nmod amt of yellow secretions via his np tube and mod-large\noral secretions. He had a couple of bradys while kangarooing\nbut none otherwise. He is labile, having frequent desats to\n80%, and sometimes needing more O2 to recover, sometimes\nrecovering w/o intervention. He is on caffeine. A: No real\nspells, but having multiple desats. P: Continue to monitor.\nMeds as ordered. Sxn prn.\n\n3. F/N: O: Infant is on 150cc/k/d of BM30 + promod,\ndelivered q 4 hours via gavage over 50 . Abd is benign,\nhe is voiding and having stool smears. No spits, asps.\nHe gained 17g. A: Tol feeds, gaining wt. P: Continue w/\nplan.\n\n4. G/d: O: Infant's temp is stable on servo in a heated\n. He sucks vigorously on a binkie and generally\ntolerates his cares. A/P: Continue to support infant needs.\n\n5. : O: were in to visit and Mom did cares\nand kangarooed for @ 1.5 hours. Infant had a couple\nbradys at the end but I believe he needed to be sxned. He\nmaintained his temp well kangarooing under warming lights.\nA: Loving, involved . P: Continue to support.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2122-11-03 00:00:00.000", "description": "Report", "row_id": 2039316, "text": "Respiratory Care\nBaby continues on NPCPAP 6, 22-31%. BS clear. Sxn for mod amts as per flowsheet. RR mostly 30's-50's with baseline IC/SCR. No bradys noted except during Kangaroo care, but frequent desats/sat drifts noted. On caffeine. Plan cont CPAP.\n" }, { "category": "Nursing/other", "chartdate": "2122-11-03 00:00:00.000", "description": "Report", "row_id": 2039317, "text": "Neonatology Attending Progress Note\n\nNow day of life 18\nExtubated to CPAP yesterday in 21-30% RR 30-60s.\nOn caffeine.\nOnly 2 episodes of apnea and bradycardia in the past 24 hours.\nHR 160-180s\n\nWt. 797gm up 17 on 150cc/kg/d of MM30 with Promod are well tolerated\nNormal urine and stool output.\n\nAssessment/plan:\nVery nice progress continues - very nice tolerance of extubation thus far.\nWill continue on support with CPAP and close monitoring.\n\n" }, { "category": "Nursing/other", "chartdate": "2122-11-03 00:00:00.000", "description": "Report", "row_id": 2039318, "text": "Neonatology- Physical Exam\n\n remains on CPAP. Active, alert in an , AFOF, sutures opposed, good tone. BBS clear and equal with good air entry. No murmur, pulses +2, pink, RRR. Abdomen soft, non-distended with active bowel sounds, no HSM, tolerating feeds. Please refer to attending progress note for detailed plan.\n" }, { "category": "Nursing/other", "chartdate": "2122-11-03 00:00:00.000", "description": "Report", "row_id": 2039319, "text": "1. COntinues on NP CPAP of 6 flow rate 8, FiO2 of 21%-29%..\nTOlerating well. Few qsr drifts to 80's. Otherwise, sats\nstable >93% with increased requirements at care times. RRR,\nc/=, sx x2 for mod. amt of think white secretions. COntinues\non caffine. Continue to monitor for resp distress.\n3. TF requirement remains at 150cc/kg/d of BM 30cPM\ngavaged over 50 . TOlerating well with no spits, asp,\n+BS, v/lg stool at 1300 guaic neg. Stable girth, abd\nunremarkable. Continues on Vit E, Fe. COntinue to support\nand monitor.\n4. Temp stable in servo iso , a/a with all cares, sleeps\nwell between, AFOSF, , , AGA. Holds hands to face,\nsucks fingers. Likes boundaries. Kangaroo's with \nqod.COntinue to supoort requirements.\n5. No sontact thus far. Will contiue to update and educate.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2122-12-06 00:00:00.000", "description": "Report", "row_id": 2039507, "text": "NPN DAYS\n\n\nAlt in Resp: Remains on prong CPAP5 FiO2 25-28%. LS clear\nand equal. Mild SC retractions. Sxn'd nares x1. No spells,\nremains on caffeine. Continue with CPAP for now.\n\nAlt in FEN: TF 150cc/kg/day BM31/PE31, gavaging fees over\n50mins. Belly full, soft, + BS. AG 26.5cm. No spits, minimal\naspirates. No stool. Voiding. Will continue with current\nplan of care.\n\nGrowth and Dev: Temp stable while swaddled in open crib.\nAwake and alert with cares, sleeps well between cares. Great\nsuck on pacifier. Will continue to support developmental\nneeds.\n\n: called for an update. to visit later.\nWill continue to provide support and teaching.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2122-12-06 00:00:00.000", "description": "Report", "row_id": 2039508, "text": "Respiratory Care\nPt recieved on nasal prong CPAP +5cm's with the fio2 21 to 25%. Pt respiratory rates 30's to 60's. Plan is to follow on CPAP, trial off later in the week.\n" }, { "category": "Nursing/other", "chartdate": "2122-12-07 00:00:00.000", "description": "Report", "row_id": 2039509, "text": "Respiratory Care\nBaby continues on bubble CPAP 5, 23-26% via INCA prongs. BS clear. RR 50's-80's with mild retractions. No spells recorded as of this writing. Will cont to follow closely.\n" }, { "category": "Nursing/other", "chartdate": "2122-12-07 00:00:00.000", "description": "Report", "row_id": 2039510, "text": "NPN\n\n\n#2-O: Remains in bubble prong CPAP 5, 23-25%, clear and\nequal RR 50's-70's, ic/sc retractions, suctioned nares x 1\nfor sm. white. on caffeine, int. murmur , audible x 2 . P:\nto trial in nasal cannula on Wednesday.\n\n#3-O: On tf 150cc/k/d PE/BM31 = 46cc q 4 hs PG over 50\" tol\nwell, aspirates, no spits, abd full soft, girths stable.\nactive bowel sounds. voiding, no stool this shift.\n\n#4-O; temps stable swaddled in crib, active and alert with\ncares, sucks well on pacifier, AFOF, MAE. cont to assess.\n\n#5-O: mom and in, independent with baby cares, held\nx 1 hr . loving supportive, visit daily\n\n\n" }, { "category": "Nursing/other", "chartdate": "2122-12-07 00:00:00.000", "description": "Report", "row_id": 2039511, "text": "Newborn Med Attending\n\nCont on CPAP5, 25% o2, no spells overnight. AF flat, clear BS, soft murmur, abd soft, MAE. Wt=1890 up 70, on 150 cc/kg/d Bm31 with PM.\nA/P: Infant with CLD. Wean O2 as tolerated. Cont current feediing plan. Monitor for spells.\n" }, { "category": "Nursing/other", "chartdate": "2122-12-07 00:00:00.000", "description": "Report", "row_id": 2039512, "text": "CLinical Nutrition\nO:\n~35 wk CGA BB on DOL 52.\nWT: 1890 g (+70)(~10th to 25th %ile); birth wt: 695 g. Average wt gain over past wk ~23 g/kg/d.\nHC: 30.5 cm (~10th to 25th %ile); last: 29 cm\nLN: 38.5 cm (<10th %ile); last: 36 cm\nMeds include Fe and Vit E\n noted\nNutrition: 150 cc/kg/d PE 31/BM 31, w/ 1 pkt HMF per 90 cc PE or 5 pkts HMF per 100 cc BM. Average intake over past 3 d ~150 cc/kg/d, providing ~155 kcal/kg/d and ~3.6 to 4.1 g pro/kg/d.\nGI: Abdomen benign.\n\nA/Goals:\nTolerating feeds without GI problems. noted and within acceptable range except elevated alk phos to 576 and borderline low PO4 to 4.5 (up from 3.9 one week prior, after adding the additional 1 kcal/oz of HMF to formula.) Current feeds + supps meeting recs for kcals/pro/vits and mins except Ca++ of 211 to 238 mg/kg/d, which is slightly above concensus recs of ~120 to 230 mg/kg/d, and Vit A of to 2116 iu/kg/d, which is above concensus rec of 700 to 1500 iu/kg/d. These nutrients were discussed w/ team and were not felt to be problem. Growth is exceeding recs for all parameters; represents catch up growth. Will continue to follow w/ team and participate in nutrition plans.\n" }, { "category": "Nursing/other", "chartdate": "2122-11-10 00:00:00.000", "description": "Report", "row_id": 2039363, "text": "Neonatology- Progress Note\n\nPE: remains in his on CPAP 6 .21, bbs cl=, rrr s1s 2no murmur, abd soft, full + bs, passing stool, left inguinal hernia, reduced by Dr. , afso, active with care\n\nSee attending note for plan\n" }, { "category": "Nursing/other", "chartdate": "2122-11-10 00:00:00.000", "description": "Report", "row_id": 2039364, "text": "Nursing Progress Note\n\n\nRESP O/A: Infant remains on Prong CPAP 6cm: FiO2 21-25%. RR\n30-60s, LS clear/=, baseline ic/sc rtxns. One & one\ndesat documented today. Continues on caffiene. P: Cont to\nmonitor resp status.\n\nFEN O/A: TF @ 150cc/k/d; BM30 w/ Promod. Infant receives\n~23cc q4h pg. Abdomen firm & distended @ 1200. KUB done;\nresults benign. Rectal stim & glycerin suppository given w/o\nresults yet. Voiding/Last stool @ . Active BS.\nLeft hernia noted @ 1200; MD & notified-firm, but\nreducable. Continues on Vit E & Fe. P: Cont to monitor for\ns/s of feeding intolerance.\n\nG&D O/A: - is nested on sheepskin in a servo\n. Temps 97.4 this am; warmed up under heating lamps.\nTemps warmer this afternoon. is quietly A/A with cares,\noccasionally drowsy. Likes pacifier. P: Cont to support\ndevelopmental needs.\n\nPAR O/A: Mom in for lactation consult @ 1330 in regards to\ndecreasing milk supply. Lactation nurse \netc with mom. very appropriate with son. will be\nin for evening kangaroo care. P: Cont to teach/support NICU\nfamily.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2122-11-26 00:00:00.000", "description": "Report", "row_id": 2039454, "text": "0700- NPN\n\n\nRESP: Infant currently in NC 400cc flow, 40% fiO2\n(transitioned from CPAP today at 1100 MD). O2 sats=\n91-99%. RR= 30-70's. Breath sounds clear and slightly\ndiminshed. Bulb suctioned at 0800 care, moderate amount red\ntinged secretions noted (MD aware). x 4 so far this\nshift (see flowsheet). Continues on caffeine. Plan to place\nback on CPAP if infant continues to have bradys.\n\nFEN: TF= 150cc/kg/d of BM30/PE30 with promod gavaged via NG\nq4hr. Abdomen soft, full, pink, +BS, no loops, AG=25.5-26cm.\nMinimal aspirates, small spits. Voiding and stooling, guiac\nneg.\n\nG&D: Temps stable, swaddled in off . Active and\nalert with cares, sleeps between. Brings hands to face,\nsucks on pacifier for comfort.\n\nParenting: No contact with thus far.\n\nWill continue to monitor infant.\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2122-11-26 00:00:00.000", "description": "Report", "row_id": 2039455, "text": "Respiratory Care Note\nPt off CPAP at 1100. Nares bloody. Placed on 400cc nasal cannula. Has had 3 bradys thus after after off CPAP, all with feeds.\n" }, { "category": "Nursing/other", "chartdate": "2122-11-27 00:00:00.000", "description": "Report", "row_id": 2039456, "text": "NPN 2300-0700\nResp addendum\nInfant noted to have increased work of breathing. Placed back on CPAP by RT. aware.\n\n" }, { "category": "Nursing/other", "chartdate": "2122-11-28 00:00:00.000", "description": "Report", "row_id": 2039462, "text": "Nursing Progress Note 1900-0700\n\n\nResp:Infant rec'd on NPCPAP-5,FIO2 31-41%.RR 50-70's with sc\nretractions.LS remain clear and equal.No A's and B's thus\nfar.Cont's on Caffiene as ordered.Infant orally sxn'd for\nmoderate white,attempted to sxn nasally however,nares\nswollen,noted blood tinged secretions.A:Alt Resp.P:Cont. to\nassess resp. status and wean as tolerated.\n\nF/E/N:Infant cont's on TF 150cc'/kg/day,rec.BM30/PE30 with\nPromode 37cc's gavaged over 50 .Weight=1.480kg up 35\ngrams.Abd. soft and full with pos bs,no loops or\nspits,minimal aspirates.Girth=24.5.Infant voiding and\nstooling heme negative stool.A:Stable P:Cont to assess\ntolerance of feeds and monitor weight gain.\n\nG/D:AFSF.Infant alert and active with cares.Sleeping well\nb/t cares.Infant remains in off ,swaddled with\nnested boundaries.Bringing hands to face and mouth.Temp.\nmaintained.A:AGA P:Cont. to support growth and dev.\n\n: in tonight asking appropriate\nquestions,appear very loving and invested.A/P:Cont. to\nupdate,support,and educate.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2122-11-28 00:00:00.000", "description": "Report", "row_id": 2039463, "text": "Respiratory Care Note\nPt. continues on 5cmH2O of nasal prong CPAP and 26-41%. BS clear. Pt. sx'd for thick yellow secretions. To follow.\n" }, { "category": "Nursing/other", "chartdate": "2122-11-28 00:00:00.000", "description": "Report", "row_id": 2039464, "text": "Neonatology\nDoing well. Remains on CPAP in Low fio2.. No spells. Comfortable appearing.\n\nWt 1430 up 85. Tolerating feeds at 150 cc/k/d of 30 cal. Abdomen benign. Nutrition notable for increased Alk Phos and low Phos. Will add 1 pack HMF to 90 cc of feeds to increase Ca and PO4 supplementation.\n\nContinue current resp management.\n" }, { "category": "Nursing/other", "chartdate": "2122-11-28 00:00:00.000", "description": "Report", "row_id": 2039465, "text": "NPN DAYS\n\n\nAlt in Resp: Remains on prong CPAP5 with FiO2 26-32%. LS\nclear and equal. Mild SC retractions. Sxn'd nares x1 for\nmoderate amount of secretions. Has sats drifts but no\nspells. Remains on caffeine. Will continue to monitor.\n\nAlt in FEN: TF 150cc/kg/day BM30/PE30PM, adding 1 more\npacket HMF as ordered for low Ca and Phos. Tolerating feeds.\nBelly soft and full with active bowel sounds. Voiding, no\nstool. Has soft left inguinal hernia.\n\nGrowth and Dev: Temp stable in off . Awake and alert\nwith cares. Sleeping well between cares. Will continue to\nprovide for developmental needs.\n\n: No contact so far this shift.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2122-11-28 00:00:00.000", "description": "Report", "row_id": 2039466, "text": "Respiratory Care\nBaby remains on cpap 5 fio2 ranges from 26-32%.BS clear throughout.RR with occ tachypnea.No spells documented this shift.On caffeine.Sx x 1 for mod yellow->bld tinged secs.\n" }, { "category": "Nursing/other", "chartdate": "2122-11-28 00:00:00.000", "description": "Report", "row_id": 2039467, "text": " On-call Note\nPlease see Dr. note for overall summary and plan.\n\nPhysical Exam\nGeneral: infant on prong CPAP in \nSkin: warm and dry; color pink\nHEENT: anterior fontanel open, level; sutures oppposed\nChest: breath sounds clear/=, well-aerated\nCV: RRR without murmur; normal S1 S2; pulses +2\nAbd: soft; no masses; + bowel sounds\nExt: moving all\nNeuro: appropriate tone and reflexes.\n" }, { "category": "Nursing/other", "chartdate": "2123-01-04 00:00:00.000", "description": "Report", "row_id": 2039634, "text": "NPN\n\n\n#2\nInfant remains in N/C 100%; 75cc all night maintaining sats\nmid/high 90s. Occasional quick drifts in sats to high\n80--all SR. BS clear= with mild upper airway congestion;\nmild retractions also noted. Color is pale pink; soft\nmurmer noted. No spells noted. Continues on Diurel as\nordered.\n\n#3\nInfant continues on ad lib schedule with 130cc/k.\nInfant is bottling ~q4-5 hours tonight and taking ~65cc of\nPE26. Infant nursed x1 and did well. Abd is soft and\nround; voiding and stooling. Small spit x1. Wt is up\n75gms-3040.\n\n#4\nInfant remains in an open crib swaddled with boundaries.\nInfant is alert with cares; slowly waking for feeds; but not\nvery vocal. Temp has bee stable. Eye exam this am.\n\n#5\n were in last evening for cares. Both are\nindependent--weighing and feeding infant with minimal\nassistance. Asking many questions re: going home with O2.\nAttempt to schedule a family meeting for Tuesday.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2123-01-04 00:00:00.000", "description": "Report", "row_id": 2039635, "text": "Neonatology Attending Note\nDay 80\nCGA 39 1\n\nNC 100%, 75cc. RR50-70s. +SC rtxns. On diuril and KCL. HR 130-160s. +Soft murmur. BP 79/32, 47. Pale/pink.\n\nWt 3040, up 75 gms. PO ad lib (152). PE26. Tol well. Nl voiding and stooling. On Fe and Vit E.\n\nIn open crib.\n\nA/P:\nPreterm infant w/ CLD, F&G\n- Discharge planning for home O2, ( are now in-between homes in a hotel)\n- Excellent growth, change to 24 cals\n" }, { "category": "Nursing/other", "chartdate": "2123-01-04 00:00:00.000", "description": "Report", "row_id": 2039636, "text": "Neonatology NP Note\nPE\nswaddled in open crib\nAFOF, sutures opposed\nvery mild head bobbing at rest, mild subcostal retractions in NCO2, lungs clear/=\nRRR, no murmur, pink and well perfused\nabdomen soft, nontender and nondistended\nmild edema of inguinal area,\ntremors of UE during exam\nsymmetric tone\n" }, { "category": "Nursing/other", "chartdate": "2123-01-19 00:00:00.000", "description": "Report", "row_id": 2039711, "text": "Neonatology Attending Progress Note\n\nNow day of life 95.\nCA 2/7 weeks.\n\nRR in RA with O2 sats>95%.\nMild increased work of breathing with feedings.\non Diuril.\nRR 30-70s\nHR 130-160s BP 78/29 47\n\nWt. 3435gm up 25gm on ad lib - took in 198cc/kg/d E20 yesterday\nNormal urine and stool output.\n\nAssessment/plan:\nVery nice progress continues off O2.\nDischarge teaching in progress.\nFU eye exam planned for tomorrow.\n\nPossible dc to home on Thursday or Friday.\n will be pediatrician in .\nPulmonary FU will be with Dr. .\nVNA and IFUP to be arranged.\n" }, { "category": "Nursing/other", "chartdate": "2123-01-19 00:00:00.000", "description": "Report", "row_id": 2039712, "text": "NPN DAYS\n\n\nAlt in Resp: Remains in room air with sats 94-100%. He does\nhave occasional drifts to the 80's with feeds, self\nresolves. LS clear and equal with mild SC retractions. Mild\nincreased WOB with feeds. Remains on Diuril and KCl. Will\ncontinue to monitor.\n\nAlt in FEN: Ad lib demand with 130cc/kg/day minimum E20.\nTaking over minimum po. Belly benign. Void. No stool. No\nspits. Continue with current plan of care.\n\nGrowth and Dev: Temp stable in open crib. Waking q3-6hrs for\nfeeds. Loves his pacifier. Awake, and active with\ncares. Will try to do carseat test today.\n\n: called for an update this am. States they will\nbe in later today. Will continue with d/c teaching.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2123-01-20 00:00:00.000", "description": "Report", "row_id": 2039716, "text": "Neonatology Attending\nNow day of life 96.\nCA 3/7 weeks.\nIn RA with O2 sats >93%. Occasional mild drifts to the 80s with feedings - resolve quickly when remove bottle.\nHR 130-150s\n\nWt. 3500gm up 65gm on ad lib feedings - took in 150cc/kg/d\nFeedings well tolerated.\nNormal urine and stool output.\n\nEye exam - ROP is regressing and vessels are now in Zone 3.\n\nAssessment/plan:\nVery nice progress continues.\nWill plan on discharge to home in the next few days if continues to do well.\nFU with Ophthalmology planned in 2 weeks.\nDr. will follow in Pulmonary.\nBaseline ECHO to evaluate for the presence of any pulmonary hypertension to be performed.\nDr. to follow hydrocoele.\nPediatrician to be updated on progress.\n\n" }, { "category": "Nursing/other", "chartdate": "2123-01-20 00:00:00.000", "description": "Report", "row_id": 2039717, "text": "NPN 7a7p\n\n\nResp\nInfant in RA since last Sat. Tolerating it well, sats 93 +.\nSome increased WOB when bottling and mild desats but\nrecovers when bottle removed. LSC. Nasal congestion. S/C\nrtxs. On max dose of Diuril and KCL. will pick up\nscript tonight from pharmacy. Lites obtained, pending.\nInfant had cardiac echo today prior to DC. He will also have\na chest x ray and head U/S prior to DC. Monitor and support\nresp status.\nFEN\nInfant on TF 130 . Bottling 90-110 q 4 hrs. X 1 sm spit.\nAbd soft. No stool today. Gaining wt. Monitor weight and\nexam.\nG/D\nInfant in OAC with stable temps. Had eye exam this am. ROP\nregressing. F/U scheduled @ for . A/A\nwith cares. Possible hernia in left inguinal area palpated\nby this writer and . Surgical F/U scheduled for @\n. MAEs. FS&F. Balding and mild shaping of head,\nattempt to have him lay his head to the left. AGA. Monitor\nand support G/D.\n\n in for cares and update re DC. Updated by RN and\n. Given scripts. Questions answered. They plan to be in\ntomorrow at 11 and DC after lunch. DC summary dictated.\nVNA called , need to be faxed. All F/U appts made except\npulmonary with Dr. , needs clarity re timing. \nanxious to get home. Attentive and loving. Support and\neducate.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2122-10-21 00:00:00.000", "description": "Report", "row_id": 2039230, "text": "Neonatology Attending Note\nDay 5\n\nCPAP6, 21%. 2 A&Bs/past 24 hours. CBG 7.28/47. On caffeine. No murmur. BP 48/34, 39. HR 120-150s.\n\nUnder single photo. Bili 2.5/0.4.\n\nWt 575, down 20 gms. TF 150 cc/k/day. Enteral at 20 of BM20. Remainder PND8/IL. Very sm bilious aspirates. Abd benign. u/o 2.6. No stool overnight.\nd/s 81, 91.\n\nIn servo .\n\nA/P:\n-- Maintain on CPAP but will try to maximize other measures to see if we can refrain from reintubation. Monitor AOP on caffeine. Inc caffeine dose to 8mg/k/d.\n-- Advance enteral feeding volume (10cc/k/).\n-- Con't photot.\n-- Check lytes and bili in am, TG. Will check Hct due to pale color and blood out.\n-- HUS Thurs.\n" }, { "category": "Nursing/other", "chartdate": "2122-10-21 00:00:00.000", "description": "Report", "row_id": 2039231, "text": "Respiratory Care Note\nPt. remains on +6 NP CPAP, FiO2 21% t/o shift. BS clear. RR 30-40. Suctioned for sm. amount yellow secretions. CBG:7.26/35/147/16/-10. No changes at this time. Caffeine dose increased today. 5 spells noted thus far this shift. HCT done but clotted. To be repeated. Pt. may need transfusion.\n" }, { "category": "Nursing/other", "chartdate": "2122-10-21 00:00:00.000", "description": "Report", "row_id": 2039232, "text": "NPN DAYS\n\n\nAlt in Resp: Remains on NP in room air with sats\n96-100%. LS clear and equal. Mild IC/SC retractions noted.\n NP tube for small amounts of secretions and orally for\nthick cloudy secretions. ABG today 7.26/35/147/16/-10. Spell\nx7today, see flow sheet. Caffeine dose increased. Will\ncontinue to monitor closely. Team is aware of spells and lab\nresults. To check CBC and blood cx tonight.\n\nAlt in FEN: TF 150cc/kg/day. Enteral feeds currently at\n30cc/kg/day BM20. PND7 and lipids infusing via DUVC at\n120cc/kg/day. Increasing feeds by 10cc/kg/ at 12/12.\nLytes 130/6.5/103/15. Triglycerides 180. Umbi site is\nreddened with small amount yellow drainage at site. Bilious\naspirate x1, refed and continued with feeds. Belly soft and\nflat with hypoactive bowel sounds. Glycerine sliver given PR\nfor no stools in 2 days. No results yet. AG 15-16cm. No\nloops. D/S 165, 125. No spits. Urine out 1.6cc/kg/hr for the\n12hr shift. Baby may have PIC line started tonight, need\nconsent.\n\nGrowth and Dev: Temp stable in servo . Awake and\nactive with cares. Nested on sheepskin with boundaries in\nplace. Due for HUS tomorrow. Likes his pacifier. Continue to\nprovide for developmental needs.\n\nParents: Dad called this afternoon. Updated him on the\nbaby's day. Dr. got telephone consent for blood. Need\nPICC line consent. Parents will be in for 8pm cares.\n\nAlt C/V: Color pale. No murmur heard. HCT 45.3, PLT 36 and\nthen repeated for 96. Will check again tonight. BP stable.\nWill continue to monitor.\n\nHyperbili: Remains under single phototherapy. To check bili\ntonight.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2122-10-21 00:00:00.000", "description": "Report", "row_id": 2039233, "text": "Neonatal NP-Procedure Note\n\nProcedure: PICC line placement\nIndication: long-term IV nutrition\n\nInformed consent obtained and placed in chart. Attempted to place PICC in right arm, unsucessful. Will continue with current regime and await another practitioner attempt in am.\n" }, { "category": "Nursing/other", "chartdate": "2122-11-01 00:00:00.000", "description": "Report", "row_id": 2039305, "text": "Attending Note\nDay of life 16\n15/5 rate 12 26-33% RR 40-60\non bradys but sat drifts on caffiene\nHR 160-180 59/34 43\nweight 760 up 3 BM 28 with promod\nlarge heme negative stool overnight\non iron and vit E\nservo controlled \n\nOverall making progress\nwill keep intubated today will consider\ntrial of CPAP tomorrow if stable\nwill advance to 30 cal/oz\n" }, { "category": "Nursing/other", "chartdate": "2122-11-02 00:00:00.000", "description": "Report", "row_id": 2039313, "text": "Respiratory Care Note\nBaby received ventilated this AM, extubated electively to NP cpap with 2.5 ETT and FI02 25-35%. RR 40-60, Baby had 2 spells this afternoon, cpap increased to 6. On caffeine, continue to follow closely.\n" }, { "category": "Nursing/other", "chartdate": "2122-11-02 00:00:00.000", "description": "Report", "row_id": 2039314, "text": "Neonatology- Physical Exam\n\n remains on CPAP. Active, alert in an , AFOF, sutures split, good tone. BBS clear and equal with good air entry, mild SC retractions. No murmur, pulses +2, pink, RRR. Abdomen soft, non-distended, active bowel sounds, no HSM, tolerating feeds. Please refer to attending progress note for detailed plan.\n" }, { "category": "Nursing/other", "chartdate": "2122-11-17 00:00:00.000", "description": "Report", "row_id": 2039404, "text": "0700- NPN\n\n\nRESP: Cont on Prong CPAP of 5 with FiO2 24-35%. RR\n30's-60's. LS clear/=. Mild IC/SC retractions. On\nCaffeine. A/B spells x 1 HR to 58 mod stim. Occasional O2\nsat drifts to 70-80%'s. TB suctioned x 2 for moderate\nyellow secretions from nares.\n\nFEN: TF=150cc/kg/d of BM/PE30 with PM PG over 50 mins. No\nspits. Minimal aspirates. Abdomen benign. Pt is voiding,\nmed stool x 1 (heme+, team aware). On Ferinsol and Vit E.\n\nDEV: Temps stable in servo-controlled .\nAlert/active with cares. Sleeps between cares. Sucks\npacifier and brings hands to face for comfort. Fontanels\nsoft/flat. AGA.\n\nPARENTING: called x 1, updated by RN, asking\nappropriate questions.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2122-11-18 00:00:00.000", "description": "Report", "row_id": 2039405, "text": "NICU Nursing Note 1900-0700\n\n\n#2 RESP\nRemains on Prong CPAP of 5, FiO2 23-36% at rest (increased\nto 50% while kangarooing). Clear and equal with good\naeration and mild IC/Sc retractions. Suctioned X2 for\nmoderate amounts of yellow secretions from the nares.\nDuoderm placed on nares by , RRT to prevent skin\nbreakdown. No spells this shift: total of 5 in the last 24\nhours, continues on caffeine.\n\n#3 FEN\nWeight tonight 1130gm (+30). TF 150ml/kg/day of BM/PE30PM.\nPG fed over 50minutes. Abd is benign as charted. No stool\nthis shift. No spits, minimal aspirates. Tolerating feeds\nwell. Continue to follow.\n\n#4 DEV\nTemp stable in servo , weaning slowly. Alert and\nactive with cares. Settles easily with pacifier and\npositioning. AFSF. MAE, symmetrical tone. AGA> contineu to\npromote developmental growth.\n\n#5 \nMom and were in for the cares. independently\nchanged the diaper and took the temp. kangarooed for 1\nhour with . are asking appropriate questions.\nPleased with how well looks on CPAP. Continue to\neducate and support.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2122-11-18 00:00:00.000", "description": "Report", "row_id": 2039406, "text": "RESPIRATORY CARE NOTE\nBaby remains on bubble CPAP 5 via Prongs FiO2 23-30%. Suctioned nares for mod amt of yellow secretions. Breath sounds are clear. Stable on CPAP cont to follow.\n" }, { "category": "Nursing/other", "chartdate": "2122-11-18 00:00:00.000", "description": "Report", "row_id": 2039407, "text": "Newborn Med Attending\n\nFailed trial off CPAP due to multiple spells. AF flat, clear BS, no murmur, abd soft, MAE. WT=1130 up 30, on 150 cc/kg/d BM30 with PM.\nA/P: Growing infant with AOP. Monitor for spells. Cont current feeding plan.\n" }, { "category": "Nursing/other", "chartdate": "2122-11-18 00:00:00.000", "description": "Report", "row_id": 2039408, "text": "Clinical Nutrition\nO:\n~32 wk CGA BB on DOL 33.\nWt: 1130 g (+30)(<10th %ile); birth wt: 695 g. Average wt gain over past wk ~23 g/kg/d.\nHC: 26 cm (<10th %ile); last: 25.75 cm\nLN: 34 cm (<10th %ile); last: 33 cm\nMeds include Fe and Vit E\n noted.\nNutrition: 150 cc/kg/d PE/BM 30 w/ promod, pg over 50 . due to hx of spits. Average of past 3 d intake ~150 cc/kg/d, providing ~150 kcal/kg/d, and ~4.0 to 4.4 g pro/kg/d.\nGI: Abdomen benign.\n\nA/Goals:\nTolerating feeds without GI problems on extended feeding times. noted and within acceptable range. Current feeds + supps meeting recs for kcals/pro/vits and mins. Growth is meeting recs for LN gain. Wt gain is exceeding recommended ~15 to 20 g/kg/d; represents catchup growth. HC gain is not meeting recommended ~0.5 to 1 cm/wk; will follow long term trends. Will continue to follow w/ team and participate in nutrition plans.\n" }, { "category": "Nursing/other", "chartdate": "2122-11-18 00:00:00.000", "description": "Report", "row_id": 2039409, "text": "Respiratory Care Note\nPt remains on +5 prong CPAP, FiO2 24-30%. RR 30-50. On caffeine. Occ O2 sat drifts.\n" }, { "category": "Nursing/other", "chartdate": "2122-11-18 00:00:00.000", "description": "Report", "row_id": 2039410, "text": "NPN DAYS\n\n\nAlt in Resp: Remains on CPAP5 26-31% FiO2. LC clear and\nequal. Sxn'd nares x1. Mild IC/SC retractions. No spells so\nfar this shift. Remains on caffeine. Continue to follow\nclosely.\n\nAlt in FEN: TF 150cc/kg/day BM30/PE30PM, gavaging feeds over\n50mins. Belly benign. No spits. AG 21.5-23cm. Minimal\naspirates. Stool x1, trace heme +. Will continue with\ncurrent plan of care.\n\nGrowth and Dev: Temp stable in servo . Awake and\nalert with cares. Nested on sheepskin with boundaries in\nplace. Occasionally sucks on pacifier. Continue to support\ndevelopmental needs.\n\n: called for an update. Informed him of need for\nHepB consent. to visit and kangaroo tonight. Will\ncontinue to provide support and teaching.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2122-11-19 00:00:00.000", "description": "Report", "row_id": 2039411, "text": "Nursing Progress Note\n\n\n2.O: Remains on nasal prong CPAP 5 mostly in 30% O2. O2 sats\nlow to mid 90's. Had a few brief desats due to periodic\nbreathing self resolved. No bradys thois shift. RR 50's-80's\nand breath sounds clear. Mild subcostal retractions noted.\nRR increased when he became warm. Remains on caffeine.\n A: Doing well on CPAP.\n P: Wean O2 as tolerated. Monitor RR. Document all spells.\n3.O: Weight 1180gms up 50gms. Fluids at 150cc/kg/d of PE\n30cal with promod or BM 30 cal. On 30cc's q4h. Gavaged and\ntolerated well. Abdomen benign, voiding and stooling. Stool\nheme negative. No spits or aspirates.\n A: Gaining weight and tolerating feeds.\n P: Monitor weight gain. Guiac all stools. Monitor for\nfeeding intolerance.\n4.O: In a heated on servo skin temp. Was warm and\n shut off briefly. Active and alert with cares.\nSucking on pacifier intermittently. Nested on sheepskin.\n A: Developmentally appropriate.\n P: Continue with interventions.\n5.O: No contact this shift.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2122-11-19 00:00:00.000", "description": "Report", "row_id": 2039412, "text": "Respiratory Care Note\nPt. continues on 5cmH2O of nasal prong CPAP and 30-37% FIO2. To follow.\n" }, { "category": "Nursing/other", "chartdate": "2122-11-19 00:00:00.000", "description": "Report", "row_id": 2039413, "text": "Newborn Med Attending\n\nCont on CPAP5, no spells. AF flat, clear BS, no murmur, abd soft, MAE.\nWt=1180 up 50 on 150 cc/kg/d BM30, PG.\nA/P: Growing infant with AOP. Monitor for spells.\n" }, { "category": "Nursing/other", "chartdate": "2122-12-26 00:00:00.000", "description": "Report", "row_id": 2039587, "text": "Neonatology Attending\nAddendum - Physical Examination\nwell-appearing infant\nHEENT AFSF\nCHEST minimal retractions; good bs bilat; few transmitted upper airway sounds but no crackles\nCVS well-perfused; RRR; femoral pulses normal; S1S2 normal; 1/6 SEM ULSB without radiation\nABD soft, non-distended; no organomegaly; no masses; bs active\nCNS active, resp to stim; tone AGA; moving all limbs symm; suck/root/gag normal; grasp/Moro symm\nINTEG normal\nMSK normal\n" }, { "category": "Nursing/other", "chartdate": "2122-12-26 00:00:00.000", "description": "Report", "row_id": 2039588, "text": "npn 0700-0730\n\n\nRESP: Recieved infant on 50cc of 100% FiO2; O2\nsupplementation was increased to 75cc of 100% FiO2 via NC to\nmaintain SAO2 btwn 94-98%. Infant sats= >92%, Before\nincrease in O2, has occassional desats to lower-mid 80's,\nQSR. RR=40-70's with episodes of tachypnea; mild subc\nretractions noted; LSC/= with audible upper airway\ncongestion, TB sx q nostril removing moderate amt of thick\ngreen secretions. Infant hasn't experienced any apnic or\nbradycardic spells thus far. P: Continue to monitor\nrespiratory status and continue to wean O2 as tolerated.\n\nFEN: Infant remains on Restricted TF's of 130cc/kg/d of\nBM/PE31= 57cc q 4hrs all po feeds. Infant tolerating feeds\nvery well, no spits, minimal aspirates(NG tube d/c at 1500\nthis afternoon). Abd benign, soft, no loops, +bs, notable\nsoft umbilical hernia, team aware. Infant voiding and\nstooling, guiac negative. Infant remains on Vit E, Fe, and\ndiuril. P: Continue to follow current regimen.\n\nDEV: Temp satble in OAC. Alert and active with cares; wakes\nfor feeds; enjoys sucking on pacificer when offered' brings\nhands to midline and face; easily consolable. Infant had\nbath today and really seemed to enjoy himself, has very\nsweet disposition. , ,AGA. P: Continue to monitor and\nsupport developmental needs.\n\nPAR: No contact from thus far, unable to asses at\nthis time. P: Continue to update and support .\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2122-12-26 00:00:00.000", "description": "Report", "row_id": 2039589, "text": "npn 0700-0730\nI have read and agree with the above note written by .\n" }, { "category": "Nursing/other", "chartdate": "2122-12-27 00:00:00.000", "description": "Report", "row_id": 2039590, "text": "NICU NURSING PROGRESS NOTE:\n\nRESP.O: Infant remains on NCO2 75-100cc with 100%. Sats\n92-98%, RR:50-70. Lungs sound clear and equal. Some upper\nairway conjections. Mild subcostal retractions. Occasionall\ndesats into 80's noted after feeds. No spells. P: Continue\nto monitor for desats and assess.\n\nFen.O: Weight=2690kg, 60gm. Infant is on restricted TF\n130cc/k/d of BM31 or PE 31, 57cc Q4 hrs. Feeds are all PO.\nBottling full volume of required. Bottling well and\ncoordinated. Abd exam is soft, no loops. BS active.\nUmbilical hernia is soft. Voiding, no stool. No spits. A:\nTolerating feeds and gaining weight. P: Continue to\nencourage PO feeds and support feeding plan.\n\nG/D.O: Baby is swaddled in open crib. Temps stable.\nActive and alert with cares. Sleeps well in between cares.\nWakes for feeds every 3.5-4 hrs. Liks his pacifier.\nA: Well appereance. P: Cont to support developmentally\nneeds.\nParenting: were in for the 8pm cares. Updated\nregarding infant's current weight and plan of care by RN\n. did the care and mom breast fed the baby, then\n bottled him. handle the cares well. Loving and\ncaring . Cont to support and keep informed.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2122-10-16 00:00:00.000", "description": "Report", "row_id": 2039191, "text": "Neonatology Attending Admission Note\n\nInfant is a 27 week, 695 gm male newborn who was admitted to the NICU for management of prematurity.\n\nInfant was born to a 35 y.o. G2P0 now 1 mother. Serologies: O+, ab negative, RPR NR, HBsAg negative, RI, GBS unknown. This pregnancy was complicated by pregnancy induced hypertension-preeclampsia. In addition, concerns for oligohydramnios and intrauterine growth restriction.\n\nMother was from for further management. At , fetal ultrasound demonstrated good amniotic fluid volume. Biophysical profile . Maternal with proteinuria and BPs 180s/100s and mother was started on Magnesium and labetolol with some good response. Mother betamethasone complete to .\n\n medical history:\n - Allergy to PCN, sulfa\n - H/o asthma maintained on provental and albuterol\n - Hyperthyroidism, h/o treatment with PTU (? this pregnancy)\n - H/o ulcer, migraines\n\nSocial: Father, , involved.\n\nDue to concerns of fetal deceleration and progressive maternal preeclampsia infant delivered and by Cesarean section. Neonatology present at delivery. Apgars 7,8.\n\nIn NICU, infant placed on radiant warmer, monitor leads placed, and initially started on CPAP. However, minimal aeration and increased work of breathing, so intubated and given surfactant.\n\nINTUBATION PROCEDURE:\nIndication: Respiratory Failure\nInfant suctioned, preoxygenated to saturations>93%. Vocal cords visualized and a 2.5F ETT passed to ~6.5 cm mark. Aeration improved, BS equal. Will obtain CXR for confirmation of placement.\n\nOn Exam:\nVS per CareView\nGrowth Parameters: Wt 695 gms (just < 10%), L 32 cm (10%), HC 23.5 cm (10%).\nSmall, hypotonic premature infant with respiratory distress. AFSF. RR x 2. Palate intact. Clavicles intact. Lungs w/ poor, crackly aeration, yet symmetrical. CV RRR, no murmur, 2+FP. Abd sl full, w/ min BS. GU nl preterm male. Testes right high in inguinal canal. Left not palpable. Patent anus. No sacral anomalies. Ext pink, well perfused. Tone hypotonic, yet symmetrical movements.\n\nImpression: This is a preterm male newborn born to a mother with preeclampsia. Infant is growth restricted and demonstrating clinical signs and symptoms consistent with hyaline membrane disease. No maternal/fetal sepsis risk factors exc. for GBS unknown status and prematurity.\n\nPlan:\n1. RESPIRATORY: Ventilatory support as needed, with aditional surfactant doses as needed. Monitor by exam, radiographs and blood gas monitoring. Wean from support as tolerated, and as infant is weaning, monitor for the development of apnea of prematurity.\n2. CV: Monitor blood pressures with volume and vasopressors as needed. Monitor for the development of a patent ductus arteriosus. Access: will place UVC and UAC.\n3. FEN: NPO for now. Provide maintenance IVFs initially at 100 cc/k/day.\n4. ID: Although infant delivered primary for maternal concerns, GBS status is unknown and infant premature. Will check CBC w diff and blood cx and begin ampicillin and gentamicin\n" }, { "category": "Nursing/other", "chartdate": "2122-10-16 00:00:00.000", "description": "Report", "row_id": 2039192, "text": "Neonatology Attending Admission Note\n(Continued)\n pending blood cx results and clinical course. Good maternal reasons for IUGR, doubt perinatal infectious concerns.\n5. NEURO: Will need HUS screening.\n\nPedi: Not yet identified.\nOB: Dr. \n" }, { "category": "Nursing/other", "chartdate": "2122-10-16 00:00:00.000", "description": "Report", "row_id": 2039193, "text": "Neonatal NP-Procedure\n\nUAC pulled back 2cm, UVC pulled back 1cm\n\nUA= 10cm\nUV=6cm\n\nAwaiting Xray confirmation.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2122-10-16 00:00:00.000", "description": "Report", "row_id": 2039194, "text": "Neonatology-NNP Procedure Note\n\nProcedure: Umbilical catheterization\nIndication: Continuous BP monitoring, IVF infusion\n\nInfant placed in supine position with cardio-respiratory monitor in place. Infant prepped and draped in sterile fashion. Using sterile technique, a 3.5 Fr double lumen umbilical catheter was inserted into the umbilical vein for positive blood return and sutured at 7 cm. A 3.5 Fr single lumen umbilical cathater was inserted into the umbilical artery for positive blood return and sutured at 12 cm. The infant tolerated the procedure without incident. An xray was obtained to confirm placment. The UVC was pulled back 1cm and secured at 6 cm. The UAC waws not in proper position in the vessel and was removed. The infant tolerated the procedure without incident.\n" }, { "category": "Nursing/other", "chartdate": "2122-11-27 00:00:00.000", "description": "Report", "row_id": 2039457, "text": "NPN 2300-0700\n\n\n2 Resp\nRemains in O2 via NC, currently 200cc flow with FiO2 of\n100%. RR 40-70's. Inter/subcostal retractions noted. Lung\nsounds cl/=. Continues on caffiene. No A's or B's noted.\n\n3 FEN\nCurrent weight 1.445 kg, up 5 grams. TF remain at\n150cc/kg/day of BM/PE 30. Tolerating gavage feedings well\nover 50 . No spits, asp. Abd soft, BS +. Girth\nstable. Voiding and stooling.\n\n4 G&D\nTemp stable in off . Awake and active with cares.\nSleeps well between cares. Brings hands to face.\n\n5 \nNo contact thus far this shift.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2122-11-27 00:00:00.000", "description": "Report", "row_id": 2039458, "text": "Respiratory Care\nbaby placed back on cpap 5 for increased wob.\n" }, { "category": "Nursing/other", "chartdate": "2122-11-27 00:00:00.000", "description": "Report", "row_id": 2039459, "text": "Newborn Med Attending\n\nFailed brief trial off CPAP. Cont CPAP5, 25-30% O2, no spells. AF flat, clear BS, no murmur, abd soft, MAE. WT=1445 up 5, on 150 cc/kg/d Bm30 with Pm PG.\nA/P: Infant with CLD. Wean O2 as tolerated. Cont curreent feeding plan.\n" }, { "category": "Nursing/other", "chartdate": "2122-11-27 00:00:00.000", "description": "Report", "row_id": 2039460, "text": "Respiratory Care Note\nPt remains on +5 prong CPAP, FiO2 29-34%. RR 50-60. BS clear. No spells as of this writing. On caffeine. Plan to leave on CPAP through w/e.\n" }, { "category": "Nursing/other", "chartdate": "2122-11-27 00:00:00.000", "description": "Report", "row_id": 2039461, "text": "NPN DAYS\n\n\nAlt in Resp: Received on prong CPAP5 where he remains with\nFiO2 requirements 29-33%. LS clear and equal. Sxn'd nares x1\nfor thick yellow secretions. Mild retractions noted. No\nspells. Does have some drifting of his sats which self\nresolves. Continues on caffeine. Will continue to monitor\nclosely.\n\nAlt in FEN: TF 150cc/kg/day BM30/PE30PM, gavaging over\n50mins. Belly benign. No spits, minimal aspirates. Voiding,\nno stools. On VitE and FeSO4. TO have nutrition \ntonight.\n\nGrowth and Dev: Temp stable in off while swaddled.\nAwake and alert with cares. Sleeps fairly well between\ncares. Needs PKU done with tonight's .\n\n: Mom in for and participated in baby's 12pm cares.\nShe held him briefly but he started having frequent desats\nand needed to be put back in . Mom and expected\nin for the 8pm cares. Will continue to provide support and\nteaching.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2122-12-15 00:00:00.000", "description": "Report", "row_id": 2039542, "text": "NPN 1900-0700\n\n\nRESP: NC 500cc, 50-55%. TB suction X1 for large/thick green\nsecretions from both nares. LS C/=, mild SCR. No spells, on\ncaffeine.\n\nFEN: Wt 2235gms ^105gms. PO @ 2100 (w/Mom) for the first\ntime taking more than full volume. Tolerated well, no spits\nor desats. NG feeds tolerated well also. Abdomen benign,\ngood bs. V&S (heme negative green stool).\n\nG/D: Temps stable swaddled in OAC. A&A w/cares, wakes for\nsome feeds, sleeps well in between. Prefers to be lying on\nbelly.\n\n: Mom and in for cares. Updated at bedside\nby this RN and (regarding ROP). Asking appropriate\nquestions.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2122-12-15 00:00:00.000", "description": "Report", "row_id": 2039543, "text": "Newborn Med Attending\n\nCont in O2 per NC, no spells. AF flat, clear BS, no murmur, abd soft, MAE. WT=2235 up 105, on 150 cc/kg/d Bm31 with PM, PO.\nA/P: Growing infant with CLD. Wean o2 as tolerated. Consider d/c caffeine. Cont to encouraqge PO feeds.\n" }, { "category": "Nursing/other", "chartdate": "2122-12-16 00:00:00.000", "description": "Report", "row_id": 2039546, "text": "1900-0730 NPN\n\n\nRESP: Cont on NC 500cc 50-60% FiO2. RR 40's-80's and\noccasionally as high as 90-100's when pt awake. O2 sats\n91-97%. LS clear/=. Mild SC retractions. No A/B spells.\nOccasional drifts in O2 sats to low 80%'s. Will wean O2 as\ntolerated.\n\nFEN: Wgt tonight is 2315g, up 80g. TF=150cc/kg/d of\nBM31/PE31. Pt gavaged all feedings this shift over 50 mins.\nNo spits. Max aspirate of 4cc. Abdomen benign. Voiding,\nno stool. On Ferinsol and Vit E.\n\nDEV: Temps stable OAC. Alert/active with cares. Sleeps\nbetween cares. Sucks pacifier and brings hands to face for\ncomfort. Fontanels soft/flat. AGA.\n\nPARENTING: Both in to visit this shift, updated by\nthis RN and aware of plan to transfuse pt with 2 aloquots of\nblood this shift. asking appropriate questions.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2122-12-16 00:00:00.000", "description": "Report", "row_id": 2039547, "text": "Newborn Med Attending\n\nCont in O2 per NC, no spells. AF flat, clear BS, no murmur, abd soft, MAE. WT=2315 up 80 on 150 cc/kg/d Bm31 with PM.\nA/P: Growing infant with CLD. Wean o2 as tolerated.\n" }, { "category": "Nursing/other", "chartdate": "2122-12-16 00:00:00.000", "description": "Report", "row_id": 2039548, "text": "NPN DAYS\n\n\nAlt in Resp: Remains on NC 500cc flow, 50-60%. LS clear and\nequal. Mild SC retractions. Tachypneic at times, see flow\nsheet. Caffeine dc'd. No spells. Occasional desats. Will\ncontinue to follow closely.\n\nAlt in FEN: TF 150cc/kg/day PE31/BM31. NO spits. Minimal\naspirates. Belly benign. On VitE and FeSO4. FeSO4 dose\nincreased today. To check phosphate and Alk phos levels\ntonight.\n\nGrowth and Dev: Temp stable in open crib. Awake and alert\nwith cares. Prevnar and IPV given today. Tylenol given as\nordered. Will continue with antibiotics.\n\n: Mom in to visit and held baby, updated her on\n day. They will be in tonight for 8pm cares. Will\ncontinue with updates and teaching.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2122-12-17 00:00:00.000", "description": "Report", "row_id": 2039549, "text": "NPN\n\n\n#2\nInfant remains in N/C 500cc flow;~60% maintaining sats\nlow/mid 90s. Occasional drifts in sats; no spells noted.\nBS clear= with mild/mod retractions; soft murmer audible.\nColor is pink; mild edema noted.\n\n#3\nInfant remains on TF=150cc/k of BM31 q4 hours. Feedings via\ngavage being well tolerated with minimal aspirates and no\nspits. Abd is soft and round; voiding and trace stool. Mom\nplaced to breast tonight and infant latched on eagerly for\n5-10 minutes. Wt is up 20gms-2335.\n\n#4\nInfant remains in an open crib swaddled with boundaries.\nInfant is alert with cares; sucks on the pacifier. Temp has\nbeen stable.\n\n#5\n were in to visit last evening. Both assisted with\nweighing and then mom placed infant to breast for the first\ntime.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2122-12-17 00:00:00.000", "description": "Report", "row_id": 2039550, "text": "Neonatology\nDoing well. Remains in NC flow.. No spells. Comfortable appearing.\nCaffeine dced yesterday.\n\nWt 2335 up 20. TF at 150 cc/k/d. Being tolerated via gavage. ABdomen benign. Will dcerease TF to 130 cc/k/d in attempt to improve resp status. Monitor growth and need for increased cals.\n\nHBV to be given.\n\nContinue to monitor resp status and wieght gain.\n" }, { "category": "Nursing/other", "chartdate": "2123-01-02 00:00:00.000", "description": "Report", "row_id": 2039626, "text": "Neonatology Attending Progress Note:\n\nDOL #78\nCGA 38 6/7 weeks\nremains in NC O2, 100% 50-75cc flow\nmild sc/ic retx, soft murmur\nDiuril and KCL\n79/48 BP,\nwt=2940g (inc 70g), ad lib minimum of 130cc/kg/d (took 133) PE 26\nvoiding, stool heme negative\nopen crib\n\nPE: see addendum\n\nImp/Plan: premie with CLD\n--wean oxygen as tolerated\n--monitor weight\n--check lytes tomorrow; if stable, increase to 40mg/kg/d\n--continue rest of present management\n" }, { "category": "Nursing/other", "chartdate": "2123-01-19 00:00:00.000", "description": "Report", "row_id": 2039713, "text": "NPN 1500-2300\n\n\n#2 RESP O: Infant remains on RA, 02 sats >95%, rr 40-70's\nwith mild subcostal retractions, BBS equal and clear,\nincreased WOB noted with po feeding. No desats or spells\nthis shift. Remains on Diuril and KCL. A: Alt in ResP P:\ncont to assess for increased resp distress, monitor and\ndocument for spells, cont with meds as ordered.\n#3 FEN O: Infant remains on ad lib demand E20 feedings,\ntaking large amts of feedings waking q 3 hours today. Infant\nbottles well, difficult to burp, one spit today, abd soft\nand nondistended, voiding well. Continues on KCL and Diuril.\nA: Stable FEN P Cont to encourage po feedings, monitor for\nfeeding intolerence, wt q day.\n#5 O: Mom and in to visit, asking appropriate\nquestions and updated on infant's progress. \nindependent with infant's care. P: cont to inform and\nsupport family as needed.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2123-01-20 00:00:00.000", "description": "Report", "row_id": 2039714, "text": "NPN\n\n\n#2\nInfant continues in RA with sats mid/high 90s. No spells\nnoted thus far tonight. BS clear= with mild retractions.\nIncreased WOB noted with/after bottling, but infant does not\nappear to be compromised by it. Color is pale pink; murmer\nnot audible.\n\n#3\nInfant remains on an ad lib feeding schedule with \n130cc/k. Infant has been taking ounces of E20 every 4-6\nhours tonight. Small spit x1. Abd is soft and round;\nvoiding and stooling. Wt is up 65gms-3500.\n\n#4\nInfant remains in an open crib swaddled with boundaries.\nTemp is stable. Infant is very with cares; sleeping\nwell in-between. Eye exam in the am.\n\n#5\nNo contact thus far from the tonight.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2123-01-20 00:00:00.000", "description": "Report", "row_id": 2039715, "text": "Neonatology- Progress Note\n\nPE: Remsins in his open crib, in room air, bbs cl=, rrr s1s 2no murmur, abd soft, nontedner, soft umbilical hernia, afso, molded head, nevus simplex on head and back of neck, afso, acitve with care\n\nSee attending note for plan\n" }, { "category": "Nursing/other", "chartdate": "2122-11-01 00:00:00.000", "description": "Report", "row_id": 2039306, "text": "Nursing NICU Note.\n\n\n2. Resp. O/Pt remains on IMV settings of 15/5, rate of 12\nb/. FiO2 ranging primarily between 27-43% this shift\n(team aware). Occasional sat drifts noted into the low 80%s,\nrequiring increase in FiO2 or QSR. One desaturation noted as\nlow as 71% requiring increase in FiO2 and 3 manual breaths.\nSee flowsheet. No A/B noted. Remains on caffeine.\nA/Desaturations noted on vent. Increase noted today in FiO2\nrequirement (team aware). P/cont. to monitor resp status.\nPlan to check blood gas in am.\n\n3. F/N. O/TF remain at 150cc/k/d of BM28PM PNGT. Please see\nflowsheet for examinations of pt from this shift. Voiding\nand passing stool. in to examine pt this am. A/Appears\nto be tolerating present feeding regimen. P/Cont. to monitor\nfor s/s of feeding intolerance.\n\n4. G/D. O/Temp remains stable on servo control in a covered\n. Awake and very alert with cares. Rooting at care\ntimes and actively sucking on pacifier. Brings hands and\nfinger to mouth. A/Alt. in G/D. P/Cont. to support pt's\ngrowth and dev. needs.\n\n5. . O/no contact made from this shift thus\nfar. A/Unable to fully assess parental involvement. P/Cont.\nto support and educate .\n\n\n" }, { "category": "Nursing/other", "chartdate": "2122-11-01 00:00:00.000", "description": "Report", "row_id": 2039307, "text": " On-Call\nPlease see Dr. note for overall summary and plan.\n\nPHYSICAL EXAM\nGeneral: intubated infant in \nSkin: warm and dry; color pink\nHEENT: anterior fontanel flat; orally intubated; symmetric facial features\nCHest: breath sounds equal, fine crackles\nCV:RRR without murmur; normal S1 S2; femoral pulses +2\nAbd: cord healed; full, soft; diastasis recti; + bowel sounds\nGU: preterm male testes undescended\nExt: moving all\nNeuro: fragile with exam; + grasps; + suck\n" }, { "category": "Nursing/other", "chartdate": "2122-11-01 00:00:00.000", "description": "Report", "row_id": 2039308, "text": "Respiratory Care Note\nPt. remains on vent on IMV 12, 15/5, FiO2 27-40% this shift. BS coarse to clear. Suctioned for mod amount white secretions. RR 40-60. Freq O2 Sat drifts. On caffeine.\n" }, { "category": "Nursing/other", "chartdate": "2122-11-02 00:00:00.000", "description": "Report", "row_id": 2039309, "text": "Respiratory Care Note\nPt. continues on 15/5 R 12 and 28-30% FIO@. BS are clear. Pt. sx'd for sm. cloudy secretions, mod. oral secretions. Pt. is on caffeine. Plan is to place pt. on CPAP today. To follow.\n" }, { "category": "Nursing/other", "chartdate": "2122-12-03 00:00:00.000", "description": "Report", "row_id": 2039492, "text": "NPN DAYS\n\n\nAlt in Resp: Remains on prong CPAP5 FiO2 24-29%. LS clear\nand equal. Mild SC retractions. No spells so far this shift.\nRemains on caffeine. Will continue to monitor closely.\n\nAlt in FEN: TF 150cc/kg/day BM/PE31, gavaging feeds over\n1hour. Belly soft and full. Stool x1 large. No loops. No\nspits, minimal aspirates. Continue with current plan of\ncare.\n\nGrowth and Dev: Temp stable while swaddled in off .\nQuietly alert and awake with cares. Sleeping well between\ncares. Will continue to support developmental needs.\n\n: No contact so far this shift.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2122-12-04 00:00:00.000", "description": "Report", "row_id": 2039493, "text": "npn 1900-0700\n\n\n#2 resp\npt continues on nasal prong cpap5 with fio2 21-27%. lsc=. rr\n30-80's. no spells. occational quick drift to 80's that\nusuall qsr.\n#3 fen\ntf 150cc/kg of pe31 gavaged q4hours. wt. 1.760kg (+60gms).\nabd benign. voiding qs. trace stool thus far this shift. ag\nstable 24cm. no spits and minimal aspirates.\n#4 g&d\npt continues in off with stable temps. alert and\nactive with cares. hands to face. sucking on binki.\nfontanelles soft and flat. maew.\n#5 parenting\n in for visit during 12a cares. asking appropriate\nquestions. involved and loving family. loving towards\ninfant.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2122-12-04 00:00:00.000", "description": "Report", "row_id": 2039494, "text": "Respiratory Care\nBaby continues on prong CPAP 5 with 02 req 25-27% this shift. BS clear. Nares sxn x1 for sm amt cldy secretions. RR 30's-70's with mild IC/SCR. On caffeine; no bradys noted, occ sat drifts. Plan cont present management, follow closely.\n" }, { "category": "Nursing/other", "chartdate": "2122-12-04 00:00:00.000", "description": "Report", "row_id": 2039495, "text": "Newborn Med Attending\n\nCont on CPAP5, 25% O2. No spells. AF flat, clear BS, no murmur, abd soft, MAE. WT=1760 up 60, on 150 cc/kg/d PE31 with PM, PG.\nA/P; Growing infant with CLD. Wean O2 as toleraated. Cont current feeding plan.\n" }, { "category": "Nursing/other", "chartdate": "2122-12-04 00:00:00.000", "description": "Report", "row_id": 2039496, "text": "NPN 0700-1900\n\n\n#2 RESP S/O: Infant in nasal prong Cpap 5, FiO2 25-30%.\nLungs are clear, rr30-60's. No spells, drifts to 80's\noccasionally. Infant has increasing gen. edema. Team aware.\nA: Stable in Cpap. P: Continue to support and monitor.\n\n#3 FEN S/O: TF 150cc/k/d. Infant to get bm or pe31, 44cc q4h\npg over one hour. Abdomen is benign, infant voiding. No\nstool today. No spits, minimal aspirates, no spits. A:\nStable P: Continue to monitor.\n\n#4 DEV S/O: Infant in off , maintaining temps. Alert\nand active with cares. Sucking on pacifier. A: AGA P:\nContinue to support development.\n\n#5 S/O: No contact from yet this shift. A:\nUnable to assess. P: Continue to support and update.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2122-12-05 00:00:00.000", "description": "Report", "row_id": 2039497, "text": "npn 1900-0700\n\n\n#2 resp\npt continues on nprong cpap5 with fio2 21-30%. lsc=. sc/ic\nretractions. rr 50-80's, mostly tachypneic in 80's t/o\nnight. occationally seen 90-low 100's for rr. tb sux for\nsmall cloudy. occational drift to 80's that usually self\nresolves. no spells.\n#3 fen\ntf 150cc/kg bm31/pe31 gavaged q4hours. wt. 1.800kg (+40gms).\nabd benign, full. voiding and stooling brown guiac neg\nstool. no spits or aspirates. ag 25cm.\n#4 g&d\npt in open crib with stable temps. alert and awake with\ncares, occationally waking prior to cares. maew. fontanelles\nsoft and flat. sucking on binki.\n#5 parenting\n in for evening cares. asking appropriate questions.\nbath done, guided through while did hands on\ncare. loving and caring towards infant.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2122-12-05 00:00:00.000", "description": "Report", "row_id": 2039498, "text": "Respiratory Care Note\nPt remains on Prong CPAP +5 FIO2 21-27%. B.S. ess. clear with good air entry. Without apnea or bradys noted this shift.\n" }, { "category": "Nursing/other", "chartdate": "2122-12-05 00:00:00.000", "description": "Report", "row_id": 2039499, "text": "Neonatology Attending Note\nDay 49\nCGA 35 weeks\n\nPrCPAP5, 21-30%. No A&Bs. Lungs Cl and =. Mild sc rtxns. RR50-80s. No murmur. HR 150-160s. Pale/pink. BP 68/36, 45. Mod edema.\n\nWt 1800, up 40 gms. TF 150 cc/k/day BM/PE 31.\nCa 9.2, P 4.5, Alk phos 576.\n\nIn open crib.\n\nA/P:\nDoing well on CPAP, another trial off anticipated next week.\nCheck gas today to r/o acidosis as cause to tachypnea.\nNo change to nutritional plan.\n" }, { "category": "Nursing/other", "chartdate": "2122-12-05 00:00:00.000", "description": "Report", "row_id": 2039500, "text": "NPN DAYS\n\n\nAlt in Resp: Remains on prong CPAP5 with FiO2 24-27%. LS\nclear and equal. Mild SC retractions. No spells. Occasional\nsat drifts. Remains on caffeine. ABG 7.41/47. No changes\nmade. Will continue with current plan.\n\nAlt in FEN: TF 150cc/kg/day PE31/BM31, gavaging feeds over\n50 mins. Belly full and soft with active bowel sounds.\nVoiding, no stool. AG 27cm. Continues with moderate\ngeneralized edema, team aware. Continue with current plan.\n\nGrowth and Dev: Temp stable while swaddled in open crib.\nAwake and alert with cares. Intermittently sucks on paci.\nWill continue to support developmental needs.\n\n: No contact so far this shift.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2122-12-05 00:00:00.000", "description": "Report", "row_id": 2039501, "text": "Neonatology NP note\nPE\nswaddled in open crib\nAFOF sutures approximated\nmild subcostal retractions on NPCPAP , tachypneac but lungs clear/=\nRRR, no murmur, pink and well perfused\nabdomen soft, nontender, nondistended, active bowel sounds\ngeneralized edema, increased in periorbital area\ngood tone.\n" }, { "category": "Nursing/other", "chartdate": "2122-12-05 00:00:00.000", "description": "Report", "row_id": 2039502, "text": "Respiratory Care\nbaby on cpap 5 24-27%.BS clear.No spells documented this shift,on caffeine.ABG 7.41/47/55/31/3.\n" }, { "category": "Nursing/other", "chartdate": "2122-12-06 00:00:00.000", "description": "Report", "row_id": 2039503, "text": "NPN\n\n\n#2-O: Remains on bubble prong CPAP 5, 25-28% this shift, occ\ndrifts, no spells, clear and equal, RR 50's-70's. on\ncaffeine as ordered.\n\n#3-O: on tf 150cc/k/d, = 46cc BM/PE 31 q 4 hrs PG tol well\nover 50\", aspirates, no spits. abd full but soft with\nactive bowel sounds, girth stable. voiding q.s. and stooled\nmod brown x 1 wt up 20 gms today to 1.820 kg.\n\n#4-O; temps stable swaddled in crib, active and alert with\ncares, sucks well on pacifier, afof MAE, cont to assess.\n\n#5-O; mom in , brought breastmilk, independent with baby\ncare, held x 1 hr. called x1 also.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2122-12-06 00:00:00.000", "description": "Report", "row_id": 2039504, "text": "Respiratory Care\nBaby continues on bubble CPAP 5, mostly 25-28% (range 23-32%). BS clear. Nares sxn x1 for mod amt as per flowsheet. RR 40's-70's with baseline SCR. On caffeine. No spells noted. Plan cont CPAP @ present.\n" }, { "category": "Nursing/other", "chartdate": "2122-12-06 00:00:00.000", "description": "Report", "row_id": 2039505, "text": "Neonatology Attending\n\nDay 50\n\nRemains on CPAP at 5 cm with fio2 in upper 20s. RR 50s. Suctioned for moderate secretions. No bradycardia. HR 150-170s. Weight 1820 gms (+20). On PE 31 at 150 cc/kg/d. Stable abdominal girth. Stable temperature in open crib.\n\nImproved breathing control on CPAP. Will continue to monitor closely. Gaining weight well. Tolerating feeds well. Family up to date.\n\n" }, { "category": "Nursing/other", "chartdate": "2122-12-06 00:00:00.000", "description": "Report", "row_id": 2039506, "text": "Neonatology NP Note\nPE\nswaddled in open crib\nAFOf\nmild head bobbing and tachypnea at rest on NPCPAP, lungs clear/=\nRRR, no murmur,pink and well perfused\nabdomen soft\ngeneralized edema\n" }, { "category": "Nursing/other", "chartdate": "2123-01-10 00:00:00.000", "description": "Report", "row_id": 2039667, "text": "NPN 7a-7p\n\n\n#2: remains in NC 100%, 25-50cc flow. RR stable.\nBreathing with mild baseline SC retractions. BBS cl/=. Occ\nmild upper airway congestion noted. Duiril and KCl given as\nordered. No apnea/ spells noted. A: stable on low flow\nO2. P:Cont to monitor and provide support as needed.\n\n#3: TF: 130cc/k/d. Conts on ad lib demand feeding\nschedule. Waking ~q4-5hrs for feeds. Changed to E24.\nBottled 90cc x2, with good coordination. No spits noted.\nAbd soft, +, no loops. Voiding qs. Huge thick brown\nstool, heme negative. Bottom slighty red, no open areas\nnoted. Desitin applied. A: tol'ing full feeds. Good PO\nskills P:Cont with current feeding plan. Monitor tol to\nfeeds. Follow wt and exam.\n\n#4: Temps remains stable while swaddled in an open crib.\nInfant is /active with cares. MAE. Fonts soft/flat.\nLoves to suck on pacifier. Waking on own for feeds. Sat up\nin bouncy seat for a little while. Sleeping well in btw\ncares. A: AGA P:Cont to support dev needs.\n\n#5: No contact with thus far in shift.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2123-01-10 00:00:00.000", "description": "Report", "row_id": 2039668, "text": "Neonatology- Physical Exam\n\n remains on NC. Active, in an open crib, AFOF, sutures opposed, good tone. BBS clear and equal with good air entry, mild SC retractions. No murmur, pulses +2, pink, RRR. Abdomen soft, non-distended with active bowel sounds, no HSM, tolerating feeds, small umbilical hernia. Please refer to attending progress note for detailed plan.\n" }, { "category": "Nursing/other", "chartdate": "2123-01-10 00:00:00.000", "description": "Report", "row_id": 2039669, "text": "Nursing Progress Note\n\n\n#2 Resp-- O: nc O2 100% 50-60cc with sats 93-99. No desats.\nBS clear and =. Upper airway cong. noted. Mild sc ret. Pale\npink. RR 40s-70s; HR 130s-150s. No murmer. On diuril, KCL.\nMild generalized edema. A: Stable in low flow O2 P: Cont\nwith O2 to keep sats 90s, meds per order. Monitor s/s\n\n#3 Nutrition-- O: Ad lib with 130cc/kg/d. Abd exam\nbenign. VQS, no stool. Woke at 1830 and po fed well taking\n120cc E24. No spits. A: Adequate intake and growth P: Cont\nto monitor growth\n\n#4 Development-- O: and active. In bouncy seat for\nawhile this eve. Woke for feed, and active and social.\nTemp stable in crib. Swaddled, with boundaries. Hands to\nmouth, sucking on pacifier. A: AGA P: Cont to support\ndevelopment\n\n#5 Parenting-- Called and visited at . Baby fed at 1845.\nHeld and read to baby. Disappointed that they missed feed.\nA: Involved and loving P: Cont to support and keep\ninformed/ planning\n\n\n" }, { "category": "Nursing/other", "chartdate": "2122-10-26 00:00:00.000", "description": "Report", "row_id": 2039268, "text": "Neonatology Attending Note\nDay 10\nCGA 28 3\n\n15/5 x 12, 21-30%. RR30-60s. Some bld tinged secretions (tube has play and was retaped). Before white cloudy secretions. 1 A&B. On caffeine.\n\nNo murmur. Transfused yest with PRBCs. Mean BP 40s. 63/39, 46.\n\nWt 691, up 26 gms.TF 150 cc/k/day of BM20 at 100 and rest PN. d/s 97. Tolerating feedings well. u/o 5.3 over night shift. Stooling (g-).\n\nIn servo .\n\nA/P:\n- Maintain low vent settings. Trial off CPAP perhaps in a week or two.\n- Cont feeding advance. d/c PN.\n- Family meeting today.\n" }, { "category": "Nursing/other", "chartdate": "2122-10-26 00:00:00.000", "description": "Report", "row_id": 2039269, "text": "Neonatology-NNP Progress Note\n\nPE: remains in his , on conv vent 16/5 X12, >21-.30, bbs cl=, rrr s1s2no murmur,abd soft,full, round, nontender, gavage tube in place, cord drying, small bruise in right groin (improving), afs, sutures approximated, active with care\n\nSee attending note for plan\n\n\n" }, { "category": "Nursing/other", "chartdate": "2122-10-26 00:00:00.000", "description": "Report", "row_id": 2039270, "text": "Respiratory Care\nBaby continues on imv 15/5 x 12, fio2 21-28%, bs clear, rr40-60's, sx'ing blood tinged secretions, on caffeine had one spell on this shift thus far, ett retaped. Will continue to follow.\n" }, { "category": "Nursing/other", "chartdate": "2122-10-27 00:00:00.000", "description": "Report", "row_id": 2039272, "text": "2. Resp: O: Received infant on the vent at settings of 15/5\nX 12. Ls coarse, RR 40-60s, Sxned for a small amt of white\nsecretions from his ETT and a large amt of white secretions\nfrom his mouth q 4 hours. FiO2 has ranged from 21% (briefly)\nto 35%. He has needed 40-50% FiO2 for cares at times. No\nbradys so far this shift. Infant is on caffeine. A: Stable\non low settings on the vent. P: Monitor. Sxn prn. Meds as\nordered.\n\n3. F/N: O: Infant is on TF = 150cc/k/d, working up on pg\nfeeds of BM20 delivered q 4 hours via gavage over 30 min.\nAbd is benign. No spits, no asps. He has voided 3.0cc/k/hr\nover the last 8 hours and has stooled a med, g- stool. He is\ncurrently at 115cc/k/d of pg feeds and his last d/s was 84\nat 9p. He is also on IVF infusing via a PIC line. He gained\n9g. A: Tol w/u on feeds so far. P: Monitor. Continue w/\nplan.\n\n4. G/d: O: Infant's temp has been stable on servo in the\nheated . Infant is active w/ cares and sucks\nvigorously on a binkie. A/P: Continue to support infant\nneeds.\n\n5. : No contact so far this shift.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2122-10-27 00:00:00.000", "description": "Report", "row_id": 2039273, "text": "Respiratory Care Note\nPt. continues on 15/5 R 12 and FIO2 39-50% FIO2. BS coarse. Pt. sx'd for sm. cloudy and lrg. thick oral secretions. To follow.\n" }, { "category": "Nursing/other", "chartdate": "2122-10-27 00:00:00.000", "description": "Report", "row_id": 2039274, "text": "Neonatology Attending Note\nDay 11\nCGA 28 4\n\nSIMV 15/5 x 12, 23-35%. Mod white secretions. On caffeine. No A&Bs. RR40-60s. No murmur. HR 140-160s. BP 61/44, 50.\n\nWt 700, up 9. TF 150 cc/k/day. BM20 at 130 cc/k/day. Rest IVFs. Tolerate feedings well. Nl voiding (3.0). +stools (g-).\nd/s 80\n\nServo .\n\nA/P:\n- Maintain low vent settings\n- Monitor AOP on caffeine\n- Adv feedings to full volume\n" }, { "category": "Nursing/other", "chartdate": "2122-10-27 00:00:00.000", "description": "Report", "row_id": 2039275, "text": "Neonatal NP-Exam\n\nSee Dr. note for details and plan of care as discussed in rounds this am.\n\nAFOF. Breath sounds clear and equal with good transmission. NL S1S2, no audible murmur. Pink and well perfused. Abd benign, no HSM. Active bowel sounds. Infant active with exam. PICC dressing intact.\n" }, { "category": "Nursing/other", "chartdate": "2122-10-27 00:00:00.000", "description": "Report", "row_id": 2039276, "text": "NPN 0700-1900\n\n\nRESP: Pt intubated on IMV 15/5 X12, FiO2 21-28%, RR 40-60's.\nLS clear/=, suctioned ETT X2 (produced nothing) & large\namount of cloudy secretions from oral cavity X2. Continues\non max dose of caffeine, no spells this shift. Plan to check\nblood gas in AM.\n\nFEN: TF=150cc/kg/day. Enteral feeds currently @ 130cc/kg/day\nand PICC infusing 20cc/kg/day of D10 w/2NaCl & 1KCl. Enteral\nfeeds to be increased to full feeds @ 1700 cares. PICC IV to\nbe Hep locked at that time. Abdomen benign, good BS, AG\nstable 15.5-16cms. No spits, minimal yellow aspirates (hx of\ngreen aspirates due to slow motility). U/O 3.4cc/kg/hr (8'),\nheme negative stool. D/S 80.\n\nG/D: Temps stable in servo . A&A w/cares, sleep well\nin between. Soothes well w/hand containment. AFSF, sutures\nspread. AGA.\n\n: called this am, updated by RN. Mom plans to\nkangaroo this evening @ 2100 cares, has had the flu and\nhasn't decided whether or not he will come to visit.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2122-10-27 00:00:00.000", "description": "Report", "row_id": 2039277, "text": "Respiratory Care Note\nPt remains on SIMV 12, 15/5, FiO2 21-28% this shift. RR 40-60. BS clear. Scant secretions from ETT. Lge amount oral secretions. On caffeine. No spells thus far this shift.\n" }, { "category": "Nursing/other", "chartdate": "2122-12-15 00:00:00.000", "description": "Report", "row_id": 2039544, "text": "Clinical Nutrition\nO:\n~36 wk CGA BB on DOL 60.\nWT: 2235g(+105)( %ile); birth WT: 695g. Average wt gain over past wk ~20g/kg/d.\nHC: 32.5cm(~50 %ile); last wk:30.5cm\nLN: 41cm(<10 %ile); last wk: 38.5cm\nMeds include Fe & vit.E\n due this week.\nNutrition: 150cc/kg/d as BM/PE 31 (w/ 5kcal/oz of HMF/BM or 1cal/oz of HMF/PE); po/pg. Average of past 3d intake ~158kcals/kg/d and ~3.7-4.2g pro/kg/d.\nGI: Abdomen benign; BM guiac neg.\n\nA/Goals:\nTolerating feeds w/o GI probs; po/pg. Taking > full volumes of po's. due this week. Current feeds & supps meeting recs for pro/vits/mins. Kcals exceeding recs of ~120-150kcals/kg/d due to additional HMF for a high Alk phos of 576(); due this week to reasses need for extra HMF. Growth is meeting recs for WT gain. HC/LN gains exceeding recs of ~0.5-1.0cm/wk for HC & of ~1cm/wk for LN. Will monitor growth trends. Will continue to follow w/ team & participate in nutrition plans.\n" }, { "category": "Nursing/other", "chartdate": "2122-12-15 00:00:00.000", "description": "Report", "row_id": 2039545, "text": "NPN DAYS\n\n\nAlt in Resp: Remains on NC 500cc flow, 50-55% FiO2. LS clear\nand equal. Mild SC retractions. Occasional desats. No\nspells. Remains on caffeine. HCT today 23, will transfuse\ntonight.\n\nAlt in FEN: TF 150cc/kg/day PE31/BM31, gavaging feeds over\n50mins. Belly benign., Voiding and stooling. No spits,\nminimal aspirates. On VitE and FeSO4. Lytes today were\nstable, see . Heplock started in right hand.Will\ncontinue with current plan of care.\n\nGrowth and Dev: Temp stable in open crib. 60 day\nimmunizations ordered, will start giving them tomorrow.\nAwake and alert with cares. Sleeping well between cares.\nWill continue to provide for developmental needs.\n\n: called x 1 today. Will encourage to\ntake CPR, choose a pediatrician and a carseat to prepare for\neventual d/c.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2123-01-01 00:00:00.000", "description": "Report", "row_id": 2039622, "text": "NICU NURSING PROGRESS NOTE:\n\nRESP.O: Infant is on NCO2 100% with 50-100cc flow. O2sats>\n94%. Occasional desats with feeds into 80's. RR:30-80. Lungs\nsound clear and equal. Mild subcostal retractions. No\nspells. Continue to monitor closely for apnea/bradys and\nassess.\nFen.O: TF is changed from stricted 130cc/k/d to \n130cc/k/d of BM26/PE26, 62cc Q4 hrs. All feeds are PO.\nBottling full volume of required. was breast fed for 15\n at noon time. Abd exam is soft, no loops. BS active.\nVoiding with each diaper change, no stools. No spits.\nTolerating feeds. Cont to support feeding plan.\n\nG/D.O: - is in open crib. Temps stable. Swaddled.\nactive and alert with cares. Sleeps well in between cares.\nWakes up for feeds. Likes his pacifeir.\nA: Well appereance. P: Continue to support developmentally\nneeds.\nPareing: Mom called this morning to update on . Updated\nregarding status and plan of cares by RN . Then,\nboth were in for the 12pm cares. Updated at bedside\nby and RN. did the care. Mom put the baby to\nbreast, and they bottled him and held him for .\n handle the care. Loving and involving .\nContinue to support and keep updated .\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2123-01-02 00:00:00.000", "description": "Report", "row_id": 2039627, "text": "PE; well appearing, AFOF, normal S1S2, soft I/VI systolic murmur LSB. abdomen soft, nontender, nondistended, ext warm, well perfused. tone aga.\n" }, { "category": "Nursing/other", "chartdate": "2123-01-02 00:00:00.000", "description": "Report", "row_id": 2039628, "text": "PCA 0700 - 1900\n\n\n#2 O: Infant on 100% NC @ 75 cc. Maintaining sats above 93%.\nLung sounds are clear and equal, with some upper airway\ncongestion. Mild subcostal retractions noted. No A's and B's\nnoted thus far. A: Infant currently stable with o2 via NC.\nP: Continue to monitor for drifts and spells.\n\n#3 O: TOTAL FLUIDS = 130cc/k/day minium, of PE26 or BM26.\nAll PO feedings; adlib (~q3-4 hours). Abdomen benign; no\nloops noted. No spits thus far. A: Infant is tolerating\nadlib PO feeds well. P: Continue to encourage adlib PO\nfeeding schedule.\n\n#4 O: Temps stable. In OAC. Infant wakes and is alert for\ncares; sleeps well in between. Brings hands to face for\ncomfort. A: AGA. P: Continue to monitor infants development.\n\n\n#5 O: called at 1200 and spoke with the nurse. Plans to\nvisit later tonight with mom. A: are involved. P:\nContinue to update .\n\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2123-01-02 00:00:00.000", "description": "Report", "row_id": 2039629, "text": "Agree with above assessment and plan written by , PCA. I have also examined this infant. Meds given as ordered. called and stated he and mom may be in later tonight.\n" }, { "category": "Nursing/other", "chartdate": "2123-01-03 00:00:00.000", "description": "Report", "row_id": 2039630, "text": "#2 PT CONT ON NC02 75CC OF 100%. LS ARE CLEAR WITH UPPER\nAIRWAY CONG. NO 'S, OCC SAT DRIFTS, SELF RESOLVING.\n#3 PT ON 130CC/KG . PT PO FEEDING AD LIB Q4HR. PO FEEDING\nWELL. BF WELL AT FEEDING. VOIDING AND STOOLING. WEIGHT\nINCREASE 25GM. LYTES TO BE SENT THIS A.M.\n#4 TEMPS STABLE IN OPEN CRIB. WAKING FOR FEEDS Q4HR. PO\nFEEDING WELL.\n#5 MOM AND IN FOR EVENING CARES. INDEPENDANT\nWITH ALL CARES.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2123-01-03 00:00:00.000", "description": "Report", "row_id": 2039631, "text": "NICU Attending Note\n\nDOL # 79 = 39 weeks CGA iwth CLD, still needing supplemental O2. ALso with issues of growth and nutrition.\n\nAgree wtih full Rivers\n\nCVR/RESP: RRR with baseline PPS murmur, mild subcostal retractions, NCO2, 75 cc/, 100% FiO2. Also on diuril. Will continue NCO2, increase diuril to 40 mg/kg/d.\n\nFEN: Abd benign, weight today 2965 gm, up 25 gm, on ad lib demand feeds, exceeding minimum of 130 cc/kg/d, 26 cal/oz, also on KCl, Vit E, Fe. Lytes this am: 138/5.3/100/32.\n\nSOCIAL: Family meeting Tuesday to discuss popssible d/c home on supplemental O2.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2123-01-18 00:00:00.000", "description": "Report", "row_id": 2039706, "text": "Neonatology Attending Progress Note\n\nNow day of life 93, CA weeks.\nIn RA for 2 days now.\nRR 40-50s up to 70s occasionally.\nOn Diuril, Fe and KCl, Vidaylin.\n\nNo apnea and bradycardia\nHR 110-130s\nBP 79/43 57\n\nWt. 3410gm up 110gm on E20 po ad lib - took in 153cc/kg/d\nFeedings continue to go very well.\nNormal urine and stool output.\n\nHct 29% retic 3.6%\n\nAssessment/plan:\nVery nice progress continues.\nDischarge preparations in progress.\nWill continue with teaching.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2122-10-20 00:00:00.000", "description": "Report", "row_id": 2039222, "text": "SOCIAL WORK\nMet with dad yesterday pm. Mum did not accompany him to unit. Appears to be managing well with much family support. Provided both reduced parking and SSI paperwork and let dad know I would continue to be available. Thank-you.\n" }, { "category": "Nursing/other", "chartdate": "2122-10-20 00:00:00.000", "description": "Report", "row_id": 2039223, "text": "Neonatology - NNP Progress Note\n\n is active with good tone. AFOF. He is pink, well perfused, no murmur auscultated. He is comfortable on low vent settings. Breath sounds clear and equal. FIo2 21%. No spells on caffeine. Total fluids @ 150cc/kg/day. PN/IL infusing via DLUVC. He is tolerating enteral feeds @ 10cc/kg/day. Abd soft, active bowel sounds, no loops. Does have occassional small brownish, green aspirates. DS in 50-60 range today. Remains under single phototherapy. Please refer to neonatology attending note for detailed plan.\n" }, { "category": "Nursing/other", "chartdate": "2122-10-20 00:00:00.000", "description": "Report", "row_id": 2039224, "text": "Respiratory Care Note\nPt extubated today and placed on +6 NP CPAP, FiO2 25-33%. RR 30-50. BS clear. Will continue to follow\n" }, { "category": "Nursing/other", "chartdate": "2122-10-20 00:00:00.000", "description": "Report", "row_id": 2039225, "text": "Nursing NICU Note\n\n\n#2. Respiratory O: Pt. received on IMV 15/5 @ rate of 14.\n He was onto NP CPAP 7 @ 1200 and has since remained\non NP CPAP. FIO2 21-33%. RR ~30-60's, no increase work of\nbreathing noted. He has mild IC/SC retractions noted. LS\nclear/=. No A&B's noted this shift thus far. He is on\nCaffeine. A: Pt. is stable on NP CPAP 7. P: Continue to\nmonitor respiratory status. Monitor for A&B's. Provide\nadditional O2 support as needed.\n\n#3. FEN O: TF 150cc/kg/d. IVF of D6 PN +IL are infuseing\nvia a DLUVC @ 110cc/kg/d without incident. D10W is\npiggybacked in to DLUVC and is infuseing @20cc/kg. Enteral\nfeeds of BM were advanced to 20cc/kg today =2.3cc Q 4hrs.\nAbdomen is soft, flat, hypoactive BS, no loops/spits noted.\nAbdominal girth is 15-15.5cm. He does continues to have gr.\nbilious aspirates- .6cc + 1cc that have been discarded \nNP/MD. He is voiding/ no stool noted this shift thus far.\nA: Potential alteration in FEN. P: Continue w/ current\nfeeding plan. Monitor for s/s of intolerance.\n\n#4. Growth/Development O: Pt. remains in servo-control\n, nested w/ stable temps. He is alert and active w/\ncares, sleeps well in between. Fontanelle soft/flat. He\nenjoys his hands by his face, side position. A: AGA P:\nContinue to provide environment appropriate for growth and\ndevelopment.\n\n#5. Parents O: Parents in to visit and were updated at\nbedside on pt's current status and daily plan of care.\nParents appropriately nervious, asking questions. A:\nParents appear loving and involved. P: Continue to update,\nsupport and educate.\n\n#6. CV O: Pt. is pale pink, warm and well perfused. HR\n~120-150's, no murmur noted. A: stable. P: Continue to\nmonitor CV status.\n\n#7. Hyperbillirubinemia O: Pt. remains under single photo\ntherapy. A: Alteration in . P: Continue to monitor.\nPlan to check in am.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2122-11-17 00:00:00.000", "description": "Report", "row_id": 2039400, "text": "NPN NIghts 7p-7a\n\n\n#2 O: Infant remains in nasal cannula O2 - in ~200cc of flow\nand needing mostly 40-55%, increased to 60-70% with feeds\n(infant appears to reflux while being gavage fed). Having\noccasional spontaneous drifting of sats, occuring more freq.\nwhile infant feeding. Resp rates 50s-70s. Lung sounds\nclear and equal with mild retractons. Sxn nares for large\nsecretions. Remains on q day dose of caffeine and has had 2\nepsiodes of bradys thus far this shift (X1 while feeding).\nA: infant having occasional desats and spells while on\ncannula, ? some may be r/t to reflux. P: Continue to\nmoniter closely. need consider retrun to bubble CPAP if\nnumber and severity of spells and desat increases.\n#3 O: Wgt 1100g, ^15g. Infant remains on Tf of 150cc/k/d of\nBM or Pe 30 cals. Abd remains softly full, +BS, no loops,\nAg stable, no spits. Infant does appear to have some reflux\nreactions while being gavage fed, with some drifting of sats\nat that time. Visible flecks of blood noted in stool and\nKUB was done that looked okay - ? if blood may\nbe r/t internal/non-visible anal fissure. Voiding adeq\namts. A: appears to be tolerating gavage feeds with no\nspits and minimal aspirates, with flecks of blood in stool\nas noted above. P: Will moniter abd closely and assess\ntolerance of feeds.\n#4 O: Infant is alert and active with cares. Temp in servo\ncontrolled with good skin temp probe contact.\nSucking occasionally on pacifier. Ant font soft, sutures\nwide. Tolerated kangaroo care well. A: AGA. P: Continue\nto moniter for milestones\n#5 O: infant's in this evening. They are indeond\nwith temp taking and diapering. asked appr.\nquestions and this RN explained the results of the eye exam\nto infant's mom. infant for ~1 hr.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2122-11-17 00:00:00.000", "description": "Report", "row_id": 2039401, "text": "RESPIRATORY CARE NOTE\nBaby received on nasal cannula 200cc FiO2 48-55%. Suctioned nares for mod amt of yellow secretions. Breath sounds are clear. At 5:30am due to increase work of breathing and spells baby was placed back on bubble CPAP via Prongs. CPAP 5 FiO2 30-40%. Weaning FiO2 as tolerated. Stable on CPAP cont to follow.\n" }, { "category": "Nursing/other", "chartdate": "2122-11-17 00:00:00.000", "description": "Report", "row_id": 2039402, "text": "Newborn Med Attending\n\nTrail off CPAP, now in NC O2. Occ spells. AF flat, clear BS, no murmur, abd soft, MAE. WT=1100 up 15, on 150 cc/kg/d PE30 with PM. Some flecks of blood in stool. KUB nl.\nA/P: Growing infant with AOP. No evidence of NEC. Most likley internal fissure but will follow by exam and KUBs as necessary.\n" }, { "category": "Nursing/other", "chartdate": "2122-11-17 00:00:00.000", "description": "Report", "row_id": 2039403, "text": "Respiratory Care Note\nPt remains on +5 prong CPAP, FiO2 24-35%. RR 40-60. Mod yellow secretions from nares. On caffeine. One spell documented after placed back on CPAP last shift.\n" }, { "category": "Nursing/other", "chartdate": "2122-12-02 00:00:00.000", "description": "Report", "row_id": 2039484, "text": "Newborn MEd Attending\n\n Cont inO2 per NC, occ spells. AF flat, clear BS, no murmur, abd soft, MAE. WT=1670 up 30, on Bm/PG 32 with Pm PG.\nA/P: Growing infant with CLD and AOP. Monitor for spells. Cont current feeding plan.\n" }, { "category": "Nursing/other", "chartdate": "2122-12-24 00:00:00.000", "description": "Report", "row_id": 2039578, "text": "NPN DAYS\n\n\nAlt in Resp: Remains on 25-50cc flow, 100% FiO2 via NC. LS\nclear and equal. Mild nasal congestion. Mild SC retractions.\nNO spells. Remains on Diuril and Caffeine. Continue to wean\nO2 as tolerated.\n\nAlt in FEN: TF 130cc/kg/day BM31/PE31. Took 54cc po x1 this\nshift. No spits. Minimal aspirates. Voiding. No stool. Belly\nbenign. Will offer po's every other feed as tolerated.\n\nGrowth and Dev: Temp stable in open crib, while swaddled.\nLoves his pacifier. Sleeping well between cares. Mild\ngeneralized edema. Hydrocele noted in left teste. Will\ncontinue to provide for developmental needs.\n\n: No contact so far this shift.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2122-12-25 00:00:00.000", "description": "Report", "row_id": 2039579, "text": "PCA NOTE\n\n\nRESP: In NC. 100% FIO2, 25-75cc flow. Lungs are clear. Upper\nairway congestion noted. No spells or desats. Minor drifting\nthat is QSR. P- Continue to monitor.\n\nFEN: Weight 2570, ^85gm. TF restriction 130cc/k/d of\nBM/PE31. PO/PG. is voiding, no stool. aspirates. No\nspits. P- Encourage PO feeds.\n\nG/D: Waking for feeds. Alert and active. Sleeping\npeacefully. Generalized edema noted. MAE.\n\n: Mom and in this shift. Updated at bedside.\nInde. with cares. Asking appropriate questions. Loving and\nvested. P- Continue to support.\n\n *****See flowsheet for specific information*****\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2122-12-25 00:00:00.000", "description": "Report", "row_id": 2039580, "text": "Neonatology\nREmains in low flow NCO2 25-50cc. Comfortable apeparing. WIll plan to leave on diuretics over weekend and decide re continuation at that point.\n\nWT 2570 up 85. Tolerating feeds at 130 cc/k/d of 31 cal. Abdomen benign. COnsider decreases in cals in coming days if continued good weight gain.\n\nContinue current reps managment and monitoring.\n" }, { "category": "Nursing/other", "chartdate": "2122-12-25 00:00:00.000", "description": "Report", "row_id": 2039581, "text": "Clinical Nutrition\nO:\n~37 wk CGA BB on DOL 70.\nWT: 2570g(+85)(~25th %ile); birth WT: 695g. Average wt gain over past wk ~23g/d.\nHC: 32.5cm(25-50th %ile); last wk:32.5cm\nLN: 43cm(<10th %ile); last wk: 41cm\nMeds include Fe, Vit.E, diuril, & KCl.\n noted.\nNutrition: 130cc/kg/d as PE/BM 31 (w/ 5kcal/oz of HMF in BM or w/ 1kcal/oz of HMF in PE); po/pg over 1hr. Po x1/shift. Average of past 3d intake ~138cc/kg/d, providing ~143kcal/kg/d and ~3.3-3.8g pro/kg/d.\nGI: Abdomen benign.\n\nA/Goals:\nTolerating feeds over extended feeding time w/o GI problems, po/pg. noted & within acceptable range except for low sodium; receiving Na+ supps. Current feeds & supps meeting recs for kcals/pro/vits/mins. Growth is meeting recs for wt gain. HC gain is not meeting recs of ~0.5-1.0cm/wk. LN gain is exceeding recs of ~1cm/wk. Will monitor trends. Will continue to follow w/ team & participate in nutrition plans.\n" }, { "category": "Nursing/other", "chartdate": "2122-12-25 00:00:00.000", "description": "Report", "row_id": 2039582, "text": "NPN 0700-1900\n\n\n#2 O: Infant remains in NC o2 100% 50cc's of flow. RR\n30's-80's with mild-mod SC retractions. LS clear and =.\nUpper airway congestion noted. Suctioned with bulb syringe\nx1 for mod amounts of thick yellow/greenish secretions. No\nspells. On diuril and Kcl as ordered. A: Stable in low flow\nNC. P: Cont to monitor.\n\n#3 O: TF= 130cc/kg/d. Infant taking 56cc's of PE31/BM31 q 4h\nvia po/pg feeds. Bottled at 1200 taking 60cc's well with\nyellow nipple after becoming coordinated and more awake.\nAbdomen benign; voiding, stooling lg amounts of guaic neg\nstools. NG tube replaced; dificult to place in right nare;\nreplaced again in left nare. No spits, minimal aspirates.\nUmbilical hernia remains soft. ? left hydrocele vs. inguinal\nhernia. On vit E and iron as ordered. A: Tolerating feeds.\nP: Cont to monitor and encourage po feeds.\n\n#4 O: Infant maintaining temp in oac. Awake and alert with\ncares; sleeping fairly well between. AFSF. Sucking on\npacifier when offered. Brings hands to face for comfort. A:\nAGA. P: Cont to support development.\n\n#5 O: No contact as yet from . A: Involved. P: Cont\nto support and update.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2122-12-25 00:00:00.000", "description": "Report", "row_id": 2039583, "text": "Nursing note\nAgree with note of from this AM.\n" }, { "category": "Nursing/other", "chartdate": "2122-12-26 00:00:00.000", "description": "Report", "row_id": 2039584, "text": "NICU NURSING PROGRESS NOTE:\n\nRESP.O: Infant remains on O2NC 100%, 50cc. O2sats are\n91-99%, RR:40-80. Lungs sound clear and equal. Mild\nsubcostal retractions. Occasional desats into 80's with\nquick recovery. No spells. P: Continue to monitor for\nspellls, desats, and assess.\n\nFen.O: Weight=2.630kg, ^60gm. Infant remains on 130cc/k/d of\nBM 31 or PE 31, 56cc Q4 hrs. Bottling full volume of\nrequired. Bottling well, coordinated. Abd exam is benign. BS\nactive. Voiding, no stool. No spits. aspirates.\nTolerating feeds and gaining weight.\nP: Continue to encourage PO feeds and support feeding plan.\n\nG/D.O: Baby is in open crib. Swaddled. Temps are\nstable. Active and alert with cares. Sleeps well in between\ncares. Wakes to eat every 4 hrs. Sucks on pacifier.\nA: AGA. P: Continue to support developmentally needs.\n\nParenting: were in for the 8pm cares. Updated\nregarding infant's status and feeds by RN . Mom breast\nfed the baby. They stayed in with the baby for . Loving\nand involving .\nP: Cont to support and keep informed.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2122-12-26 00:00:00.000", "description": "Report", "row_id": 2039585, "text": "Nursing note.\nAgree with above note of oc-worker.\n" }, { "category": "Nursing/other", "chartdate": "2122-12-26 00:00:00.000", "description": "Report", "row_id": 2039586, "text": "Neonatology Attending\nDOL 71 / CGA 37-6/7 weeks\n\nIn NC 50 cc/ of 100% FIO2, with intermittent tachypnea and desaturations to 80% range. Off caffeine. Now day 6 of planned 7-day course of diuril.\n\nIntermittent murmur persists. BP 72/26 (43).\n\nWt 2630 (+60) on TFI 130 cc/kg/day BM31, tolerating well orally (one gavage overnight after breastfeed). Voiding and stooling. Abdomen benign.\n\nTemperature stable.\n\nA&P\n27-5/7 week GA infant with CLD\n-Continue with oxygen supplementation to maintain SaO2 94-98%.\n-We will attempt to maintain full PO feeds and avoid gavage supplementation in anticipation of discharge\n-Otherwise continue current management as detailed above.\n" }, { "category": "Radiology", "chartdate": "2122-11-17 00:00:00.000", "description": "P BABYGRAM (ABD ANY SGL VIEW) (74000) PORT", "row_id": 809082, "text": " 1:03 AM\n BABYGRAM (ABD ANY SGL VIEW) () PORT Clip # \n Reason: r/o nec\n Admitting Diagnosis: NEWBORN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Infant with blood flecks in stool\n REASON FOR THIS EXAMINATION:\n r/o nec\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: Infant with blood flecks in stool.\n\n BABYGRAM: A single KUB compared to demonstrates a normal bowel gas\n pattern. The feeding tube terminates in the stomach. No pneumatosis, portal\n venous gas or pneumoperitoneum is identified. The lung bases are clear.\n\n" }, { "category": "Radiology", "chartdate": "2122-10-29 00:00:00.000", "description": "NEONATAL HEAD PORTABLE", "row_id": 807236, "text": " 7:25 AM\n NEONATAL HEAD PORTABLE Clip # \n Reason: head, , increased hc, full fontanel, sutures split , r/o iv\n Admitting Diagnosis: NEWBORN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Infant born at 27+ weeks, now a week old\n REASON FOR THIS EXAMINATION:\n head\n\n increased hc, full fontanel, sutures split\n r/o ivh\n ______________________________________________________________________________\n FINAL REPORT\n HEAD ULTRASOUND\n\n CLUSTERED: Ex-27 week infant, now one week of age with increasing head\n circumference.\n\n Compared to the prior examination of , there is no significant change.\n The sulci, gyri and ventricles remain symmetric and normal in size for the\n patient's age. Overall, there is a paucity of sulcation consistent with the\n patient's early gestationl age. No extraaxial collection or hemorrhage is\n identified. Incidental note is made of a thin septation within the posterior\n cavum of the cavum septum pellucidum et vergae.\n\n IMPRESSION: Stable head ultrasound without evidence of intracranial\n hemorrhage.\n\n" }, { "category": "Radiology", "chartdate": "2122-11-19 00:00:00.000", "description": "NEONATAL HEAD PORTABLE", "row_id": 809326, "text": " 7:17 AM\n NEONATAL HEAD PORTABLE Clip # \n Reason: INFANT BORN AT 27+ WEEKS, NOW 1 MONTH OLD, R/O PVL\n Admitting Diagnosis: NEWBORN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Infant born at 27+ weeks, now 1 month old\n REASON FOR THIS EXAMINATION:\n r/o pvl\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 27-week gestational age baby, now one month old.\n\n Comparison is made to the prior study performed on . There is no\n evidence of intracranial blood. There are no periventricular cystic changes.\n The ventricles, sulci and cisterns are normal for patient's age. There is no\n extraaxial fluid collection.\n\n IMPRESSION: Normal head ultrasound.\n\n" }, { "category": "Radiology", "chartdate": "2122-11-10 00:00:00.000", "description": "P BABYGRAM (ABD ANY SGL VIEW) (74000) PORT", "row_id": 808506, "text": " 12:32 PM\n BABYGRAM (ABD ANY SGL VIEW) () PORT Clip # \n Reason: on cpap, distended\n Admitting Diagnosis: NEWBORN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Infant with\n REASON FOR THIS EXAMINATION:\n on cpap, distended\n ______________________________________________________________________________\n FINAL REPORT\n On c-pap, abdominal distention.\n\n NGT reaches the level of the stomach. There are mildly distended loops of\n bowel with bubbly lucencies at the right lower quadrant likely representing\n fecal material. No convincing evidence of pneumatosis is seen. No portal\n venous gas is noted. There is a paucity of gas at the level of the rectum.\n The patient was noted to have a left inguinal hernia prior to exposure of this\n film which was reduced manually.\n\n IMPRESSION: Mildly dilated loops without convincing evidence of pneumatosis\n or portal venous gas.\n\n" }, { "category": "Radiology", "chartdate": "2123-01-21 00:00:00.000", "description": "NEONATAL HEAD PORTABLE", "row_id": 815670, "text": " 7:08 AM\n NEONATAL HEAD PORTABLE Clip # \n Reason: FOR , REPEAT FOLLOWING UP PREVIOUS STUDIES, INFANT BORN AT 27 WEEKS GESTATION, NOW TERM\n Admitting Diagnosis: NEWBORN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Infant born at 27 weeks gestation, now term\n REASON FOR THIS EXAMINATION:\n for \n repeat following up previous studies\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: This is a premature infant born at 27 weeks of gestation,\n who has now reached term age. This study is a follow up to evaluate for PVL.\n No new clinical symptoms.\n\n CRANIAL ULTRASOUND: Comparison is made with the most recent previous cranial\n ultrasound dated .\n\n Today's study shows appropriate interval maturation of the brain. The brain\n is normal in echogenicity and morphology. The ventricles are normal in size\n and there is no evidence of intraeventricular or intraparenchymal hemorrhage.\n\n There are no son findings to suggest development of PVL. The\n extraaxial fluid spaces are normal.\n\n No other abnormalities.\n\n IMPRESSION: Normal cranial ultrasound, with appropriate interval maturation\n of the brain.\n\n" }, { "category": "Radiology", "chartdate": "2123-01-21 00:00:00.000", "description": "P BABYGRAM (CHEST ONLY) PORT", "row_id": 815694, "text": " 8:48 AM\n BABYGRAM (CHEST ONLY) PORT Clip # \n Reason: former 27 + weeks with cld, getting ready for discharge\n Admitting Diagnosis: NEWBORN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Infant with\n REASON FOR THIS EXAMINATION:\n former 27 + weeks with cld, getting ready for discharge\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Former 27 week infant with chronic lung disease. This is a\n pre-discharge baseline evaluation.\n\n PORTABLE CHEST: Today's study is compared to the most recent prior exam from\n .\n\n The patient is extubated. Lung volumes are low. Even allowing for this,\n there is slight coarsening of the lung markings, probably related to the\n patient's chronic lung disease. These changes are most notable at the left\n lung base.\n\n Heart size is normal. Pulmonary vascularity is normal. Mild gasseous\n distention is present. No other abnormalities.\n\n IMPRESSION: Low lung volumes, with mild changes of chronic lung disease.\n\n" }, { "category": "Echo", "chartdate": "2123-01-20 00:00:00.000", "description": "Report", "row_id": 75343, "text": "PATIENT/TEST INFORMATION:\nIndication: Congenital heart disease.\nStatus: Inpatient\nDate/Time: at 08:15\nTest: Portable TTE (Congenital, complete)\nDoppler: Complete pulse and color flow\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\n\n\nConclusions:\nPediatric study. Report will be generated by .\n\n\n" }, { "category": "Radiology", "chartdate": "2122-10-16 00:00:00.000", "description": "P BABYGRAM (CHEST & ABDOMEN) PORT", "row_id": 805918, "text": " 11:14 AM\n BABYGRAM (CHEST & ABDOMEN) PORT Clip # \n Reason: line placement\n Admitting Diagnosis: NEWBORN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Infant with adjusted UA/UVC lines\n REASON FOR THIS EXAMINATION:\n line placement\n ______________________________________________________________________________\n FINAL REPORT\n BABYGRAM:\n\n HISTORY: Infant with adjusted umbilical arterial and umbilical venous\n catheters.\n\n FINDINGS: ETT has its tip at C7. Umbilical venous catheter reaches low right\n atrium. Umbilical arterial catheter coils in the aorta and its tip is at L2.\n Findings of hyaline membrane disease are stable. The bowel gas pattern is\n normal.\n\n" }, { "category": "Radiology", "chartdate": "2122-10-22 00:00:00.000", "description": "NEONATAL HEAD PORTABLE", "row_id": 806492, "text": " 7:03 AM\n NEONATAL HEAD PORTABLE Clip # \n Reason: PREMATURE INFANT, R/O IVH\n Admitting Diagnosis: NEWBORN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Infant born at 27+ weeks, now a week old\n REASON FOR THIS EXAMINATION:\n r/o ivh\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 27-week gestational age baby, now one week old. There is no prior\n study for comparison.\n\n The -white matter differentiation is appropriate for patient's age. There\n is no evidence of intracranial blood. The ventricles, sulci and cisterns are\n normal. There is no extraaxial fluid collection.\n\n IMPRESSION: No intracranial hemorrhage.\n\n" }, { "category": "Radiology", "chartdate": "2122-10-23 00:00:00.000", "description": "BABYGRAM (CHEST ONLY)", "row_id": 806672, "text": " 1:16 PM\n BABYGRAM (CHEST ONLY) Clip # \n Reason: Premature, intubation, confirm tube placement\n Admitting Diagnosis: NEWBORN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Infant with prematurity\n REASON FOR THIS EXAMINATION:\n Premature, intubation, confirm tube placement\n ______________________________________________________________________________\n FINAL REPORT\n\n HISTORY: Infant with prematurity, intubation, confirm tube placement.\n\n BABYGRAM, CHEST: The heart and mediastinal contours are normal. The ET tube\n is a few mm above the carina. The umbilical venous catheter tip projects over\n the expected position of the mid-right atrium. This position was discussed\n with the ICU team. The lungs are hyperinflated. There are very mild\n opacities, consistent with hyaline membrane disease. A pleural effusion is\n not seen. There are mildly dilated bowel loops seen in the upper abdomen.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2122-10-16 00:00:00.000", "description": "P BABYGRAM (CHEST & ABDOMEN) PORT", "row_id": 805911, "text": " 10:41 AM\n BABYGRAM (CHEST & ABDOMEN) PORT Clip # \n Reason: verify ETT placement, verify UAC/UVC placment\n Admitting Diagnosis: NEWBORN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Infant with prematurity, RDS\n REASON FOR THIS EXAMINATION:\n verify ETT placement\n verify UAC/UVC placment\n ______________________________________________________________________________\n FINAL REPORT\n BABYGRAM:\n\n HISTORY: Infant born prematurely.\n\n FINDINGS: The left lateral portion of the chest is not included on the film.\n ETT is seen with tip a few millimeters above the carina. Umbilical venous\n catheter reaches SVC. Umbilical arterial catheter coils in the aorta. The\n distal tip reaches T11. The lungs are hazy in keeping with hyaline membrane\n disease. Abdominal bowel gas pattern is normal.\n\n" }, { "category": "Radiology", "chartdate": "2122-10-24 00:00:00.000", "description": "BABYGRAM (CHEST ONLY)", "row_id": 806734, "text": " 12:18 AM\n BABYGRAM (CHEST ONLY) Clip # \n Reason: ? P-CVL tip position\n Admitting Diagnosis: NEWBORN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Infant with P-CVL originating left arm\n REASON FOR THIS EXAMINATION:\n ? P-CVL tip position\n ______________________________________________________________________________\n FINAL REPORT\n\n HISTORY: Infant with peripheral central venous line originating in left arm.\n ? tip position.\n\n BABYGRAM, CHEST: The left-sided central venous catheter tip projects over the\n expected position of the left brachial cephalic near its junction with the\n SVC. The ET tube has been pulled back somewhat since the study of one day\n prior. The new NG tube tip projects over the gastric bubble. Umbilical\n venous catheter tip is again noted to project over the expected position of\n the right atrium proximally. The lung volumes are slightly lower. The\n opacities of hyaline membrane disease and multifocal mild superimposed\n atelectasis are again noted and mediastinal contours are normal.\n\n\n\n" } ]

[ { "category": "ECG", "chartdate": "2201-05-26 00:00:00.000", "description": "Report", "row_id": 294772, "text": "Sinus rhythm. Normal ECG. No previous tracing available for comparison.\n\n" }, { "category": "Physician ", "chartdate": "2201-05-28 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 325575, "text": "Chief Complaint:\n 24 Hour Events:\n PICC LINE - START 12:30 PM\n ULTRASOUND - At 03:48 PM\n -Gave a 0.4mg dose of narcan, which she immediately responded to. She\n was very agitated, so the decision was made not to manage her on a drip\n and let her sleep through this as long as she remained hemodynamically\n stable.\n -Records from in the chart- she has NASH cirrhosis and has\n freqent admissions with volume overload and drug overdoses. She is not\n getting narcotics from her PCP or pain clinic doctors, so we are\n presuming she is getting them from outside sources. Her social\n situation appears to be very difficult.\n -Started scale, and gave her 10mg methadone for narcotic\n withdrawl\n -Osm gap 4\n -RUQ u/s c/w fatty liver, no ascites\n Allergies:\n Morphine\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:00 AM\n Haloperidol (Haldol) - 12:30 PM\n Naloxone (Narcan) - 02:15 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:32 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: 36.9\nC (98.5\n HR: 95 (85 - 111) bpm\n BP: 164/57(86) {141/57(78) - 200/80(109)} mmHg\n RR: 12 (12 - 22) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 469 mL\n 171 mL\n PO:\n TF:\n IVF:\n 349 mL\n 171 mL\n Blood products:\n Total out:\n 2,490 mL\n 515 mL\n Urine:\n 2,490 mL\n 515 mL\n NG:\n Stool:\n Drains:\n Balance:\n -2,021 mL\n -344 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 100%\n ABG: 7.33/48/69/24/-1\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 151 K/uL\n 9.7 g/dL\n 87 mg/dL\n 0.8 mg/dL\n 24 mEq/L\n 4.0 mEq/L\n 18 mg/dL\n 114 mEq/L\n 144 mEq/L\n 29.9 %\n 6.9 K/uL\n [image002.jpg]\n 10:38 PM\n 03:52 AM\n 10:35 AM\n 10:49 AM\n 04:48 AM\n WBC\n 6.8\n 5.8\n 7.3\n 6.9\n Hct\n 31.0\n 24.8\n 28.2\n 29.9\n Plt\n 175\n 115\n 149\n 151\n Cr\n 1.6\n 1.1\n 0.8\n TCO2\n 26\n Glucose\n 52\n 71\n 70\n 87\n Other labs: PT / PTT / INR:14.8/31.5/1.3, ALT / AST:20/39, Alk Phos / T\n Bili:320/0.7, Amylase / Lipase:44/11, Lactic Acid:0.8 mmol/L,\n Albumin:3.2 g/dL, LDH:256 IU/L, Ca++:9.0 mg/dL, Mg++:1.8 mg/dL, PO4:2.7\n mg/dL\n Imaging: Abdominal USD:\n IMPRESSION:\n 1. Coarsened echotexture of liver consistent with fatty liver.\n 2. No ascites.\n .\n CXR: IMPRESSION: Malpositioned right PICC in right atrium; results\n communicated.\n Microbiology: Ua: Negative\n CSF: NG\n BXx: NGTD\n Stool:\n FECAL CULTURE (Pending):\n CAMPYLOBACTER CULTURE (Pending):\n FECAL CULTURE - R/O E.COLI 0157:H7 (Pending):\n FECAL CULTURE - R/O YERSINIA (Pending):\n FECAL CULTURE - R/O VIBRIO (Pending):\n CLOSTRIDIUM DIFFICILE TOXIN ASSAY (Final ):\n FECES NEGATIVE FOR C. DIFFICILE TOXIN BY EIA.\n (Reference Range-Negative).\n OVA + PARASITES (Final ):\n NO OVA AND PARASITES SEEN.\n .\n This test does not reliably detect Cryptosporidium, Cyclospora or\n Microsporidium. While most cases of Giardia are detected by\n routine\n O+P, the Giardia antigen test may enhance detection when\n organisms\n are rare.\n Assessment and Plan\n 58 yof with history of CKD, Cirrhosis and history of multiple drug\n overdoses with opiates presented to ER with lethargy.\n .\n # Lethargy - Most likely secondary to opiates given the history and\n positive narcan test yesterday but is still extremely somnolent. Ddx\n includes infectious (low grade fever in ED, LP negative) vs. other\n toxins like benzo (tox screen negative other than benzo) vs. metabolic\n (?uremia from renal failure, not very impressive) vs. Hypoglycemia (low\n BS now but on presentation it was 157).\n - At this time, would consider scale and titrate as directed.\n Hold narcan unless non-responsive, or in resipratory distress.\n - CXR, UA negative for infection, LP negative. (received ceftriaxone in\n the ER). Given history of cirrhosis may have ascities and thus would\n be improtant to rule out SBP. Would check ultrasound for asicities.\n - F/u culture data\n - CIS\n - hold sedating medications (neurontin, citalaprom)\n - Will empirically give thimaine and folate for now eventhough daughter\n denies etoh , ask pt in AM.\n - If no improvement in lethargy by AM would consider gettign RPR, TSH,\n B12 in AM.\n .\n # Acute renal failure - Unclear baseline(daughter stated she has some\n kidney failure). Improved with IVF in ER.\n - Creatinine down to 0.8 this AM -> baseline.\n - Check urine lytes.\n - holding lasix, lisinpril for now. Goal I/O net even and lasix prn.\n Would hold Lasix/ACE until stable x24 hours.\n - Continue maitnence fluids. Need to be wary of volume overload.\n .\n # DM - hold glargine insulin for now and check fingersticks q2 given\n some low BS in the ER.\n - transition to q4H finger sticks\n - restart home insulin when taking PO's.\n .\n #Volume: H/o diastolic dysfunction and ARF leading to volume overload.\n - consider TTE for eval of cardiac function\n - Decreased fluids to 75cc/hr maintenence fluids while NPO.\n .\n # NASH - LFTs unremarkable but carries a diagnosis per history.\n - USD w/o e/o ascites, c/w NASH/fatty liver\n .\n # Chronic low back pain - would hold off on gabapentin and narcotics\n for now.\n - scale\n .\n # Anemia - hct 29.6, unclear baseline, maybe from liver disease (MCV\n 96) versus CKD\n - guaiac stools\n - B12 folate nml, Fe c/w ACD, stable from records.\n .\n # Chronic lung disease/BOOP - would continue prednisone at 5mg\n - nebs prn -> improved this AM with nebulizer. 95-96% on RA\n currently. Titrate O2 to sats = 90-95%.\n .\n # Hyperkalemia - resolved.\n # FEN - NPO for now until more arousable.\n # ppx - sc heparin, ppi (on it at home)\n # Communication/HCP - Daughter # .\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 12:30 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2201-05-29 00:00:00.000", "description": "Nursing Progress Note", "row_id": 325665, "text": "58F Spanish speaking with cirrhosis and renal failure, gets usual care\n at , presented to ER after taking some drugs off the street\n and lethargy. T 100.9, BP88/50 HR 69 O2 99%2L, she was initially given\n Narcan 0.4mg with some improvement in mental status and dose was\n repeated X 2. She had a low grade fever T 100.9 and LP was done.\n Prior to LP, she was given ceftriaxone 2 grams. She continued to be\n lethargic so received 2mg IV narcan X 2 and planned for narcan gtt,\n however, she was arousable to voice so this was not started. Last dose\n of Narcan was 10 AM . CT head and CXR in the ER were unremarkable.\n She also had a several BS in the 64-75 range and received Dextrose.\n Per ER notes additional history was obtained from family (2 daughters)\n who stated that patient abuses oxycodone, vicodin, T3 (no tyelnol in\n tox). Family denied that patient was on sulfonylureas for diabetes.\n .\n Hypertension, benign\n Assessment:\n BP up to 186/\n Action:\n Given 20mg IV labetolol @\n Response:\n Plan:\n Started 12.5mg lopressor po/NG tid\n" }, { "category": "Nursing", "chartdate": "2201-05-29 00:00:00.000", "description": "Nursing Progress Note", "row_id": 325666, "text": "58F Spanish speaking with cirrhosis and renal failure, gets usual care\n at , presented to ER after taking some drugs off the street\n and lethargy. T 100.9, BP88/50 HR 69 O2 99%2L, she was initially given\n Narcan 0.4mg with some improvement in mental status and dose was\n repeated X 2. She had a low grade fever T 100.9 and LP was done.\n Prior to LP, she was given ceftriaxone 2 grams. She continued to be\n lethargic so received 2mg IV narcan X 2 and planned for narcan gtt,\n however, she was arousable to voice so this was not started. Last dose\n of Narcan was 10 AM . CT head and CXR in the ER were unremarkable.\n She also had a several BS in the 64-75 range and received Dextrose.\n Per ER notes additional history was obtained from family (2 daughters)\n who stated that patient abuses oxycodone, vicodin, T3 (no tyelnol in\n tox). Family denied that patient was on sulfonylureas for diabetes.\n .\n Hypertension, benign\n Assessment:\n BP : 172/72-194/86\n Action:\n Given 20mg IV labetolol @\n Response:\n Plan:\n Started 12.5mg lopressor po/NG tid\n" }, { "category": "Physician ", "chartdate": "2201-05-29 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 325728, "text": "Chief Complaint: opiate od\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 htn--lasix, metop, lisinopril restarted\n History obtained from ho\n Allergies:\n Morphine\n Unknown;\n Last dose of Antibiotics:\n Fluconazole - 11:50 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:00 AM\n Other medications:\n per (reviewed)\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 12:22 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.2\nC (99\n Tcurrent: 37.1\nC (98.8\n HR: 86 (82 - 104) bpm\n BP: 183/80(108) {165/62(88) - 194/93(110)} mmHg\n RR: 19 (14 - 27) insp/min\n SpO2: 92% (RA)\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 714 mL\n 398 mL\n PO:\n TF:\n IVF:\n 474 mL\n 273 mL\n Blood products:\n Total out:\n 3,570 mL\n 975 mL\n Urine:\n 3,570 mL\n 975 mL\n NG:\n Stool:\n Drains:\n Balance:\n -2,856 mL\n -577 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 92%\n ABG: ///25/\n Physical Examination\n General Appearance: Well nourished, No acute distress, Overweight /\n Obese, lethargic\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Poor dentition, shoprt obese neck\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Diminished: )\n Abdominal: Soft, Non-tender, Bowel sounds present, Obese\n Extremities: Right: 2+, Left: 2+\n Skin: Not assessed\n Neurologic: Follows simple commands, Responds to: Not assessed,\n Movement: Not assessed, No(t) Sedated, No(t) Paralyzed, Tone: Not\n assessed\n Labs / Radiology\n 9.6 g/dL\n 169 K/uL\n 191 mg/dL\n 0.8 mg/dL (b/l)\n 25 mEq/L\n 3.7 mEq/L\n 16 mg/dL\n 108 mEq/L\n 143 mEq/L\n 28.9 %\n 9.2 K/uL\n [image002.jpg]\n 10:38 PM\n 03:52 AM\n 10:35 AM\n 10:49 AM\n 04:48 AM\n 05:41 PM\n 04:05 AM\n WBC\n 6.8\n 5.8\n 7.3\n 6.9\n 9.2\n Hct\n 31.0\n 24.8\n 28.2\n 29.9\n 28.9\n Plt\n 175\n 115\n 149\n 151\n 169\n Cr\n 1.6\n 1.1\n 0.8\n 0.8\n 0.8\n TCO2\n 26\n Glucose\n 52\n 71\n 70\n 87\n 171\n 191\n Other labs: PT / PTT / INR:15.7/36.4/1.4 (1.3), ALT / AST:16/28, Alk\n Phos / T Bili:295/0.9, Amylase / Lipase:44/11, Lactic Acid:0.8 mmol/L,\n Albumin:3.0 g/dL, LDH:260 IU/L, Ca++:8.8 mg/dL, Mg++:2.2 mg/dL, PO4:2.9\n mg/dL\n Fluid analysis / Other labs: rpr neg\n Imaging: no new film\n Microbiology: no new data\n Assessment and Plan\n 58 yo Spanish speaking F w/ h/o CKD, DM, depression, cirrhosis, boop\n and multiple prior admits for drug overdoses (opiates) presents with\n lethargy in setting of drug intoxication (street drugs), transient\n hypoglycemia (cs 64-75 range) and low grade temp.\n # Lethargy /delirium\n intoxication from opiates\n w/ clear response to narcan, signs of\n withdrawal on narcan drip, lethargy/delirium lingering\n Work up pursued to assess for metabolic component -Given\n underlying liver disease/ckd, possible obesity\n hypoventilation/hypoventilation from narcs, hypoglycemia\n (ABG without sig co2 retension, ruq without ascites for sbp, renal\n fx normalized, ammonia wnl, rpr, tsh, folate b12 wnl)\n Slightly more alert this am, but waxing and , nonfocal\n Repeat narcan dose\n Recheck abg for CO2\n No new s/sx of infection (af, stable wbc) but will recheck u/a,\n cx neg to date\n holding sedating meds\nmethadone , but has not required\n additional doses\n continue thiamine/folate\n trial of lactulaose, though low suspciion of HE\n # HTN\n Has h/o htn,\n withdrawal likely contributing\n diurese with lasix 9ggod response yesterday)\n continue metop, lisinopril\nincrease 40\n #DM\nnow with icnreasing BS, restart low dose glargine as NPO, freq\n cs/ssi\n # Nongap metabolic acidosis\nnormalized\n No osm gap, improved with hydration\n # Acute renal failure\nresolved to baseline with hydratio\n # Cirrhosis/nash\n LFTs remain stable/unremarkable, no ascitis\n RUQ c/w known NASH\n # Anemia\n hct stable at baseline\n # Chronic lung disease/BOOP\n continue prednisone at 5mg\n nebs prn\n # FEN\n NPO until more alert for asp risk\n Has NGT\n If no imrpovement consider starting TFs\n # Communication/HCP - Daughter # \n # Social issues: sw c/s, psych c/s, once more alert\n ICU Care\n Nutrition:\n NPO\n Glycemic Control: Regular insulin sliding scale\n Lines:\n PICC Line - 12:30 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition : stable for transfer to floor\n Total time spent: 40 minutes\n" }, { "category": "Physician ", "chartdate": "2201-05-29 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 325735, "text": "Chief Complaint: opiate od/somnolence\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: 58 yo Spanish speaking F w/ h/o CKD, DM, depression, cirrhosis,\n boop and multiple prior admits for drug overdoses (opiates) presents\n with lethargy in setting of drug intoxication (street drugs), transient\n hypoglycemia (cs 64-75 range) and low grade temp.\n 24 Hour Events:\n htn\n lasix, metop, lisinopril restarted\n History obtained from ho\n Allergies:\n Morphine\n Unknown;\n Last dose of Antibiotics:\n Fluconazole - 11:50 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:00 AM\n Other medications:\n per (reviewed)\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 12:22 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.2\nC (99\n Tcurrent: 37.1\nC (98.8\n HR: 86 (82 - 104) bpm\n BP: 183/80(108) {165/62(88) - 194/93(110)} mmHg\n RR: 19 (14 - 27) insp/min\n SpO2: 92% (RA)\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 714 mL\n 398 mL\n PO:\n TF:\n IVF:\n 474 mL\n 273 mL\n Blood products:\n Total out:\n 3,570 mL\n 975 mL\n Urine:\n 3,570 mL\n 975 mL\n NG:\n Stool:\n Drains:\n Balance:\n -2,856 mL\n -577 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 92%\n ABG: ///25/\n Physical Examination\n General Appearance: Well nourished, No acute distress, Overweight /\n Obese, lethargic\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Poor dentition, shoprt obese neck\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Diminished: )\n Abdominal: Soft, Non-tender, Bowel sounds present, Obese\n Extremities: Right: 2+, Left: 2+\n Skin: Not assessed\n Neurologic: Follows simple commands, Responds to: Not assessed,\n Movement: Not assessed, No(t) Sedated, No(t) Paralyzed, Tone: normal\n Labs / Radiology\n 9.6 g/dL\n 169 K/uL\n 191 mg/dL\n 0.8 mg/dL (b/l)\n 25 mEq/L\n 3.7 mEq/L\n 16 mg/dL\n 108 mEq/L\n 143 mEq/L\n 28.9 %\n 9.2 K/uL\n [image002.jpg]\n 10:38 PM\n 03:52 AM\n 10:35 AM\n 10:49 AM\n 04:48 AM\n 05:41 PM\n 04:05 AM\n WBC\n 6.8\n 5.8\n 7.3\n 6.9\n 9.2\n Hct\n 31.0\n 24.8\n 28.2\n 29.9\n 28.9\n Plt\n 175\n 115\n 149\n 151\n 169\n Cr\n 1.6\n 1.1\n 0.8\n 0.8\n 0.8\n TCO2\n 26\n Glucose\n 52\n 71\n 70\n 87\n 171\n 191\n Other labs: PT / PTT / INR:15.7/36.4/1.4 (1.3), ALT / AST:16/28, Alk\n Phos / T Bili:295/0.9, Amylase / Lipase:44/11, Lactic Acid:0.8 mmol/L,\n Albumin:3.0 g/dL, LDH:260 IU/L, Ca++:8.8 mg/dL, Mg++:2.2 mg/dL, PO4:2.9\n mg/dL\n Fluid analysis / Other labs: rpr neg\n Imaging: no new film\n Microbiology: no new data\n Assessment and Plan\n 58 yo Spanish speaking F w/ h/o CKD, DM, depression, cirrhosis, boop\n and multiple prior admits for drug overdoses (opiates) presents with\n lethargy in setting of opiate intoxication (street drugs), transient\n hypoglycemia (cs 64-75 range) and low grade temp.\n # Lethargy /delirium\n intoxication from opiates\n showed clear response to narcan, and\n later signs of withdrawal on narcan drip\n Work up pursued to assess for metabolic component -Given underlying\n liver disease/ckd, possible obesity hypoventilation/hypoventilation\n from narcs, hypoglycemia\n (ABG without sig co2 retension, ruq without ascites for sbp, renal\n fx normalized, ammonia wnl, rpr, tsh, folate b12 wnl)\n Slightly more alert this am, but waxing and , and lethargy is\n lingering, nonfocal exam\n -Repeat narcan dose\n -Recheck abg for CO2\n - No new s/sx of infection (af, stable wbc) but will recheck\n u/a, cx neg to date\n - hold sedating meds\nmethadone , but has not required\n additional doses\n - continue thiamine/folate\n - trial of lactulose, though low suspciion of HE\n # HTN\n Has h/o htn on lasix, metop, lisinopril\n withdrawal ? contributing\n diurese with lasix\n continue metop, lisinopril\n>increase to 40\n #DM\n BS increasing as holding glargine while NPO, restart low dose\n glargine , cs/ssi\n # Cirrhosis/nash\n LFTs remain stable/unremarkable,\n RUQ c/w known NASH, no ascitis\n # Anemia\n hct stable at baseline\n # Chronic lung disease/BOOP\n continue prednisone at 5mg\n nebs prn\n # FEN\n NPO until more alert for asp risk\n Has NGT\n If no improvement consider starting TFs in next 1-2 days\n # Communication/HCP - Daughter # \n # Social issues: sw c/s, psych c/s, once more alert\n ICU Care\n Nutrition:\n NPO advance when more alert\n Glycemic Control: Regular insulin sliding scale\n Lines:\n PICC Line - 12:30 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition : stable for transfer to floor\n Total time spent: 40 minutes\n" }, { "category": "Nursing", "chartdate": "2201-05-27 00:00:00.000", "description": "Nursing Progress Note", "row_id": 325508, "text": "58F Spanish speaking with cirrhosis and renal failure, gets usual care\n at , presented to ER after taking some drugs off the street\n and lethargy. T 100.9, BP88/50 HR 69 O2 99%2L, she was initially given\n Narcan 0.4mg with some improvement in mental status and dose was\n repeated X 2. She had a low grade fever T 100.9 and LP was done.\n Prior to LP, she was given ceftriaxone 2 grams. She continued to be\n lethargic so received 2mg IV narcan X 2 and planned for narcan gtt,\n however, she was arousable to voice so this was not started. Last dose\n of Narcan was 10 AM . CT head and CXR in the ER were unremarkable.\n She also had a several BS in the 64-75 range and received Dextrose.\n Per ER notes additional history was obtained from family (2 daughters)\n who stated that patient abuses oxycodone, vicodin, T3 (no tyelnol in\n tox). Family denied that patient was on sulfonylureas for diabetes.\n .\n At time of transfer to the ICU, she was easily arousable. She\n complained of lower back pain, which she's had for years. Otherwise\n denies any chest pain, shortness of breath. Denies any abdominal pain,\n fevers or chills at home. Daugther thinks she took altogether 34 pills\n (vicodin and tylenol #3) over past 2-3 days. She does not think her\n mom is depressed.\n Altered mental status (not Delirium)\n Assessment:\n Pt lethargic, unable to answer questions c interpreter, saying that she\n is in , not using many words moaning most of the time, not\n able to follow commands, yelling out when touched\n Action:\n AGB obtained this am, repeated am labs including ammonia level, abd u/s\n to evaluate for acites, Pt given narcan 0.4 mg and started on narcan\n gtt at 0.1mg/hr\n Response:\n Pt opening eyes and moaning loudly in response to narcan push and gtt,\n HR increased from 70s to 110s, BP up to 200 systolic, ABG 7.33/48/69,\n ammonia level 42\n Plan:\n Obtain repeat ABG with pt in more alert state, continue to follow neuro\n status frequently\n Diabetes Mellitus (DM), Type II\n Assessment:\n FSBS 66-93, pt NPO\n Action:\n Q2hr FSBS per order, pt to receive 1 amp D50, no IV access at the time,\n NGT placed given OJ and dextrose tab\n Response:\n FSBS trending up with treatment, has not required any D50\n Plan:\n Continue to follow FSBS\n" }, { "category": "Nutrition", "chartdate": "2201-05-29 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 325716, "text": "Patient has been NPO for 3 days. If patient's diet is not able to be\n advanced and tolerated in the next 48hrs, for\n nutrition support. Once able to start po\ns, advance as tolerated to\n cardiac heart healthy/Diabetic diet. Will follow po status.\n" }, { "category": "Nursing", "chartdate": "2201-05-27 00:00:00.000", "description": "Nursing Progress Note", "row_id": 325445, "text": "58F Spanish speaking with cirrhosis and renal failure, gets usual care\n at , presented to ER after taking some drugs off the street\n and lethargy. T 100.9, BP88/50 HR 69 O2 99%2L, she was initially given\n Narcan 0.4mg with some improvement in mental status and dose was\n repeated X 2. She had a low grade fever T 100.9 and LP was done.\n Prior to LP, she was given ceftriaxone 2 grams. She continued to be\n lethargic so received 2mg IV narcan X 2 and planned for narcan gtt,\n however, she was arousable to voice so this was not started. Last dose\n of Narcan was 10 AM . CT head and CXR in the ER were unremarkable.\n She also had a several BS in the 64-75 range and received Dextrose.\n Per ER notes additional history was obtained from family (2 daughters)\n who stated that patient abuses oxycodone, vicodin, T3 (no tyelnol in\n tox). Family denied that patient was on sulfonylureas for diabetes.\n .\n At time of transfer to the ICU, she was easily arousable. She\n complained of lower back pain, which she's had for years. Otherwise\n denies any chest pain, shortness of breath. Denies any abdominal pain,\n fevers or chills at home. Daugther thinks she took altogether 34 pills\n (vicodin and tylenol #3) over past 2-3 days. She does not think her\n mom is depressed.\n DISPO: FULL CODE\n ALLERIGIES: MORPHINE\n ACCESS: 1 20G PIV\n NEURO: PT AROUSES TO VOICE, CONSISTENTLY FOLLOWING COMMANDS. SPEECH\n IS GARBLED, INCOMPLETE WORDS. ORIENTED X1 - DIFFICULT TO ASSESS\n ORIENTATION PT IS PRIMARILY SPANISH SPEAKING. PT SLEEPING MOST OF\n SHIFT. DENIES PAIN. REC\nD 0.4 MG NARCAN X1 WITH LITTLE EFFECT IN MS,\n PT APPEARING MORE RESTLESS POST-NARCAN. CT IN ED, NEGATIVE.\n CV: HR 70-90S NSR WITH NO ECTOPY NOTED. NBP 120S-140S/50-60S. SBP\n INCREASED TO 170S AFTER IVP NARCAN WAS GIVEN. + WEAK PP BILATERALLY.\n PT ALSO NOTED TO HAVE TRACE BILATERAL UE EDEMA.\n RESP: PT SATING 100% ON 2L NC. LS CLEAR T/O. NO SOB/ INCREASED WOB\n NOTED. + COUGH, NO SPUTUM. RR 8-15. RR NOTED TO INCREASE WITH\n INCREASED LOC, RR 7-8 WHILE ASLEEP.\n GI/GU: AND OBESE, + BS, NO STOOL THIS SHIFT. PT STATING\n HUNGRY,\n - PT NPO, ALL PO MEDS TIMED FOR AM PT\nS AMS. FOLEY CATH.\n SECURE AND PATENT, DRAINING ADEQUATE AMOUNTS OF CLEAR YELLOW URINE.\n SKIN: WARM/DIAPHORETIC/INTACT. PT EXTREMELY DIFFICULT STICK.\n SOCIAL: NO CONTACT FM FAMILY THIS SHIFT.\n PLAN: CONT. Q2H NEURO EXAMS, CONT. TO MONITOR FOR WITHDRAWALS. F/U ON\n BLD/URINE CULTURES. ? MORE ACCESS, NEED TO CONTACT IV RN. CONT.\n PROVIDING SUPPORTIVE CARE.\n" }, { "category": "Nursing", "chartdate": "2201-05-29 00:00:00.000", "description": "Nursing Progress Note", "row_id": 325749, "text": "Hypertension, benign\n Assessment:\n Pt has been hypertensive since admission with high of ~200 systolic,\n restarted on home cardiac meds last evening lisinopril and also added\n lopressor, this shift BP 168-183/68-93, pt fluid over loaded with\n generalized 2+ pitting edema\n Action:\n Increased lisinopril and lopressor doses, given one time dose of IV\n lasix\n Response:\n No significant change in BP with changes in cardiac meds\n Plan:\n Continue to monitor BP, adjust meds as needed\n Altered mental status (not Delirium)\n Assessment:\n Pt continues to be lethargic, score 0-2, no clear signs of\n withdrawal, able to follow simple commands at times although largely\n unresponsive to questions with interpreter, arouses easily to voice and\n tracks and falls back to sleep\n Action:\n Given small dose of narcan to reassess pts responsiveness in the\n setting of persistant lethargy, started on lactulose given history of\n NASH and ?encephalopathy\n Response:\n Pt responded immediately to narcan administration, score\n persistently low, responding well to lactulose\n Plan:\n Continue to monitor MS, continue to follow liver enzymes, q4hrs,\n pt called out to floor\n" }, { "category": "Nursing", "chartdate": "2201-05-29 00:00:00.000", "description": "Nursing Progress Note", "row_id": 325750, "text": "58F Spanish speaking with cirrhosis and renal failure, gets usual care\n at , presented to ER after taking some drugs off the street\n and lethargy. T 100.9, BP88/50 HR 69 O2 99%2L, she was initially given\n Narcan 0.4mg with some improvement in mental status and dose was\n repeated X 2. She had a low grade fever T 100.9 and LP was done.\n Prior to LP, she was given ceftriaxone 2 grams. She continued to be\n lethargic so received 2mg IV narcan X 2 and planned for narcan gtt,\n however, she was arousable to voice so this was not started. CT head\n and CXR in the ER were unremarkable. She also had a several BS in the\n 64-75 range and received Dextrose. Per ER notes additional history was\n obtained from family (2 daughters) who stated that patient abuses\n oxycodone, vicodin, T3 (no tyelnol in tox). Family denied that patient\n was on sulfonylureas for diabetes.\n .\n Daugther thinks she took altogether 34 pills (vicodin and tylenol #3)\n over past 2-3 days. She does not think her mom is depressed. Daughter\n has been calling daily for updates however has not come in to visit.\n Very concerned with mother\n lethargy. Would like to speak\n with social work about ?rehab or detox following this admission.\n Hypertension, benign\n Assessment:\n Pt has been hypertensive since admission with high of ~200 systolic,\n restarted on home cardiac meds last evening lisinopril and also added\n lopressor, this shift BP 168-183/68-93, pt fluid over loaded with\n generalized 2+ pitting edema\n Action:\n Increased lisinopril and lopressor doses, given one time dose of IV\n lasix\n Response:\n No significant change in BP with changes in cardiac meds\n Plan:\n Continue to monitor BP, adjust meds as needed\n Altered mental status (not Delirium)\n Assessment:\n Pt continues to be lethargic, score 0-2, no clear signs of\n withdrawal, able to follow simple commands at times although largely\n unresponsive to questions with interpreter, arouses easily to voice and\n tracks and falls back to sleep\n Action:\n Given small dose of narcan to reassess pts responsiveness in the\n setting of persistant lethargy, started on lactulose given history of\n NASH and ?encephalopathy\n Response:\n Pt responded immediately to narcan administration, score\n persistently low, responding well to lactulose\n Plan:\n Continue to monitor MS, continue to follow liver enzymes, q4hrs,\n pt called out to floor\n" }, { "category": "Physician ", "chartdate": "2201-05-29 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 325753, "text": "Chief Complaint: Drug Overdose - opiate\n 24 Hour Events:\n - titrated up her BP meds by placing back on her lisinopril and\n metoprolol, still hypertensive, diuresed very well to 40mg oral lasix\n - scale less than 3 so no further methadone given\n Allergies:\n Morphine\n Unknown;\n Last dose of Antibiotics:\n Fluconazole - 11:50 AM\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 11:00 AM\n Heparin Sodium (Prophylaxis) - 04:00 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 07:24 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: 36.6\nC (97.9\n HR: 93 (88 - 104) bpm\n BP: 184/74(100) {163/57(83) - 194/83(110)} mmHg\n RR: 22 (14 - 27) insp/min\n SpO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 714 mL\n 175 mL\n PO:\n TF:\n IVF:\n 474 mL\n 130 mL\n Blood products:\n Total out:\n 3,570 mL\n 655 mL\n Urine:\n 3,570 mL\n 655 mL\n NG:\n Stool:\n Drains:\n Balance:\n -2,856 mL\n -478 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 93%\n ABG: ///25/\n Physical Examination\n General Appearance: Overweight / Obese\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: white discharge in oropharynx\n Cardiovascular: (S1: Normal), (S2: Normal), No(t) S3, No(t) S4, No(t)\n Rub, (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: transmitted upper airway sounds, poor respiratory\n effort\n Abdominal: Soft, Non-tender, Bowel sounds present, Obese\n Extremities: Right: 2+, Left: 2+\n Skin: Not assessed\n Neurologic: No(t) Attentive, No(t) Follows simple commands, Responds\n to: Not assessed, No(t) Oriented (to): , Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 169 K/uL\n 9.6 g/dL\n 191 mg/dL\n 0.8 mg/dL\n 25 mEq/L\n 3.7 mEq/L\n 16 mg/dL\n 108 mEq/L\n 143 mEq/L\n 28.9 %\n 9.2 K/uL\n [image002.jpg]\n 10:38 PM\n 03:52 AM\n 10:35 AM\n 10:49 AM\n 04:48 AM\n 05:41 PM\n 04:05 AM\n WBC\n 6.8\n 5.8\n 7.3\n 6.9\n 9.2\n Hct\n 31.0\n 24.8\n 28.2\n 29.9\n 28.9\n Plt\n 175\n 115\n 149\n 151\n 169\n Cr\n 1.6\n 1.1\n 0.8\n 0.8\n 0.8\n TCO2\n 26\n Glucose\n 52\n 71\n 70\n 87\n 171\n 191\n Other labs: PT / PTT / INR:15.7/36.4/1.4, ALT / AST:16/28, Alk Phos / T\n Bili:295/0.9, Amylase / Lipase:44/11, Lactic Acid:0.8 mmol/L,\n Albumin:3.0 g/dL, LDH:260 IU/L, Ca++:8.8 mg/dL, Mg++:2.2 mg/dL, PO4:2.9\n mg/dL\n Imaging: No New\n Microbiology: RPR: Negative\n No new micro\n Assessment and Plan\n 58 yof with history of CKD, Cirrhosis and history of multiple drug\n overdoses with opiates presented to ER with lethargy.\n .\n # Lethargy - Clearly responsive to narcan but taking long time to\n clear. ?secondary component of hepatic encephalopathy. No clear\n infectious source at this time, and metabolic distrubances are mild by\n laboratory data. Hypoglycemia resolved.\n - At this time, would continue scale and titrate as directed - has\n not needed further doses of opiates and is clearly still heavily\n sedated. Hold narcan unless non-responsive, or in resipratory failure.\n - CXR, UA negative for infection, USD w/o ascites, LP negative.\n (received ceftriaxone in the ER).\n - F/u culture data\n - CIS\n - hold sedating medications (neurontin, citalaprom)\n - Will empirically give thimaine and folate for now eventhough daughter\n denies etoh , ask pt in AM.\n - RPR, B12, folate normal.\n .\n # Acute renal failure\n Baseline 0.8\n improved with IVF\ns and now\n stable after restarting ACE and diuresis yesterday\n - Restarting lasix today, holding ACE. Restart ACE prn.\n - Redose 20mg lasix this AM, goal net out 1L\n .\n #Non-Gap Metabolic Acidosis: Osmolar gap normal\n - Resolved.\n .\n # DM - hold glargine insulin for now and check fingersticks q2 given\n some low BS in the ER.\n - Still not taking PO's, finger sticks trending upwards overnight\n .\n #Hypertension: to withdrawal but persistently hypertensive this AM\n and clearly not in withdrawal at this time. Will start with lasix, and\n treat with opiates PRN for withdrawal. Restart lisinopril PRN.\n - Continue with lisinopril, metoprolol - uptitrate as tolerated to\n 25mg PO TID today.\n .\n # Volume: H/o diastolic dysfunction and ARF leading to volume\n overload.\n - consider TTE for eval of cardiac function\n - Continue diuresis\n .\n # Withdrawal: On for narcotic withdrawal. Will redose with 8mg\n methadone at next time > 10.\n - Hypertension/tachycardia concerning for benzo withdrawal. Family\n reports only opiate abuse. Serum etoh negative on admit. Continue to\n follow. Consider low dose benzo trial if hypertension refractory to\n meds.\n .\n # NASH - LFTs unremarkable but carries a diagnosis per history.\n - USD w/o e/o ascites, c/w NASH/fatty liver\n .\n # Chronic low back pain - would hold off on gabapentin and narcotics\n for now.\n - scale\n .\n #Thrush: Continue fluconazole for 5 days.\n - Check HIV test once alert enough to consent.\n .\n # Anemia - hct 29.6, unclear baseline, maybe from liver disease (MCV\n 96) versus CKD\n - guaiac stools negative x3\n - B12 folate nml, Fe c/w ACD, stable from records.\n .\n # Chronic lung disease/BOOP - would continue prednisone at 5mg\n - nebs prn -> improved this AM with nebulizer. 95-96% on RA\n currently. Titrate O2 to sats = 90-95%.\n .\n # Hyperkalemia - resolved.\n # FEN - NPO for now until more arousable. NG tube in place\n # ppx - sc heparin, ppi (on it at home)\n # Communication/HCP - Daughter # .\n # Access: PICC placed - now day 2\n # Code: Presumed full\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 12:30 PM\n Prophylaxis:\n DVT: heparin SQ\n Stress ulcer: PPI\n VAP: none\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: Called out to floor yesterday\n" }, { "category": "Nursing", "chartdate": "2201-05-29 00:00:00.000", "description": "Nursing Progress Note", "row_id": 325671, "text": "58F Spanish speaking with cirrhosis and renal failure, gets usual care\n at , presented to ER after taking some drugs off the street\n and lethargy. T 100.9, BP88/50 HR 69 O2 99%2L, she was initially given\n Narcan 0.4mg with some improvement in mental status and dose was\n repeated X 2. She had a low grade fever T 100.9 and LP was done.\n Prior to LP, she was given ceftriaxone 2 grams. She continued to be\n lethargic so received 2mg IV narcan X 2 and planned for narcan gtt,\n however, she was arousable to voice so this was not started. Last dose\n of Narcan was 10 AM . CT head and CXR in the ER were unremarkable.\n She also had a several BS in the 64-75 range and received Dextrose.\n Per ER notes additional history was obtained from family (2 daughters)\n who stated that patient abuses oxycodone, vicodin, T3 (no tyelnol in\n tox). Family denied that patient was on sulfonylureas for diabetes.\n .\n Hypertension, benign\n Assessment:\n BP : 172/72-194/86 HR:\n Action:\n Given 20mg lisinopril per NGT @ 2100. Given 20mg IV labetolol @\n 0025.\n Response:\n No response to lisinopril. BP dropped from 194/83 to 174/80 after\n labetolol. Started 12.5mg lopressor po/NG tid. BP dropped to 165/67\n from 186/82.\n Plan:\n Monitor BP. Assess effectiveness of lopressor.\n" }, { "category": "Physician ", "chartdate": "2201-05-28 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 325586, "text": "Chief Complaint: opiate od\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 58 yo Spanish speaking F w/ h/o CKD, DM, depression, cirrhosis, boop\n and multiple prior admits for drug overdoses (opiates) presents with\n lethargy in setting of drug intoxication (street drugs), transient\n hypoglycemia (cs 64-75 range) and low grade temp.\n 24 Hour Events:\n PICC LINE - START 12:30 PM\n ULTRASOUND - At 03:48 PM\n osh records--h/o nash, multiple admits for opiate o/d\n narcan given--> responded , became fully awake and agitated\n overnight appeared to be withdrawing from opiates, methoadone started\n ruq u/s--c/w fatty liver\n History obtained from Medical records, HO\n Allergies:\n Morphine\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Haloperidol (Haldol) - 12:30 PM\n Naloxone (Narcan) - 02:15 PM\n Heparin Sodium (Prophylaxis) - 08:00 AM\n Other medications:\n per (reviewed)\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 10:02 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: 36.6\nC (97.8\n HR: 100 (88 - 111) bpm\n BP: 173/73(98) {144/57(83) - 200/80(109)} mmHg\n RR: 18 (12 - 22) insp/min\n SpO2: 95% (RA)\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 469 mL\n 252 mL\n PO:\n TF:\n IVF:\n 349 mL\n 252 mL\n Blood products:\n Total out:\n 2,490 mL\n 690 mL\n Urine:\n 2,490 mL\n 690 mL\n NG:\n Stool:\n Drains:\n Balance:\n -2,021 mL\n -438 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 95%\n ABG: 7.33/48/69/24/-1\n Physical Examination\n General Appearance: Well nourished, Overweight / Obese, lethargic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : ,\n Crackles : scant, Diminished: bases)\n Abdominal: Soft, Non-tender, Bowel sounds present, Distended\n Extremities: Right: 3+, Left: 3+, No(t) Cyanosis, No(t) Clubbing\n Musculoskeletal: No(t) Muscle wasting\n Skin: Warm, No(t) Rash: , No(t) Jaundice\n Neurologic: No(t) Attentive, No(t) Follows simple commands, Responds\n to: Not assessed, Movement: Purposeful, No(t) Sedated, Tone: Not\n assessed\n Labs / Radiology\n 9.7 g/dL\n 151 K/uL\n 87 mg/dL\n 0.8 mg/dL\n 24 mEq/L\n 4.0 mEq/L\n 18 mg/dL\n 114 mEq/L\n 144 mEq/L\n 29.9 %\n 6.9 K/uL\n [image002.jpg]\n 10:38 PM\n 03:52 AM\n 10:35 AM\n 10:49 AM\n 04:48 AM\n WBC\n 6.8\n 5.8\n 7.3\n 6.9\n Hct\n 31.0\n 24.8\n 28.2\n 29.9\n Plt\n 175\n 115\n 149\n 151\n Cr\n 1.6\n 1.1\n 0.8\n TCO2\n 26\n Glucose\n 52\n 71\n 70\n 87\n Other labs: PT / PTT / INR:14.8/31.5/1.3 , ALT / AST:20/39, Alk Phos /\n T Bili:320/0.7 (stable), Amylase / Lipase:44/11, Lactic Acid:0.8\n mmol/L, Albumin:3.2 g/dL, LDH:256 IU/L (211), Ca++:9.0 mg/dL, Mg++:1.8\n mg/dL, PO4:2.7 mg/dL\n Fluid analysis / Other labs: osm gap 4\n Imaging: cxr--no new film\n Microbiology: csf ngtd\n stool studies neg\n u/a neg\n Assessment and Plan\n 58 yo Spanish speaking F w/ h/o CKD, DM, depression, cirrhosis, boop\n and multiple prior admits for drug overdoses (opiates) presents with\n lethargy in setting of drug intoxication (street drugs), transient\n hypoglycemia (cs 64-75 range) and low grade temp.\n # Lethargy /delirium\n Most likely secondary to intoxication from opiates given hx and initial\n response to narcan then with signs of withdrawl\n Metabolic component possibly contributing initially --underlying liver\n disease/ckd, possible obesity hypoventilation/hypoventilation from\n narcs, hypoglycemia,\n No new s/sx of infection\n f/u cx\nneg to date/ruq unremarkable\n continue methadone taper scale\n - abg to eval CO2 level\n - Ammonia level (? HE)\n - RPR, TSH, B12 pending\n #HTN\nh/o htn, withdrawal may be continubtuing\n Restart lasix, monitor u/o cr and restart lisinopril if BP remains\n elevated\n # Nongap metabolic acidosis\ncompletely normalized tox screen + for\n opiates\n ? chronic kidney ds with RTA, ? diarrhea, dehydration\n No osm gap, improved with hydration\n # Acute renal failure\nresolved to baseline with hydration\n # DM - hold glargine while NPO/ given hypoglycemia in ed\n Chem. Sticks\n RSSI\n # Cirrhosis\n LFTs unremarkable\n RUQ c/w known NASH\n # Chronic LBP\n hold off on gabapentin and narcotics for now (methadone)\n # Anemia - hct 29.6, unclear baseline\n Anemia w/u and keep t and screen\n # Chronic lung disease/BOOP\n continue prednisone at 5mg\n nebs prn\n # FEN\n NPO, until more alert for asp risk\n d/c fluids with genbtle diuresis\n # Communication/HCP - Daughter # \n # Social issues: sw c/s, psych c/s, once more alert\n ICU Care\n Nutrition:\n Comments: NPO\n Glycemic Control: Regular insulin sliding scale\n Lines:\n PICC Line - 12:30 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition : stable for floor transfer\n Total time spent: 40 minutes\n" }, { "category": "Physician ", "chartdate": "2201-05-28 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 325591, "text": "Chief Complaint:\n 24 Hour Events:\n PICC LINE - START 12:30 PM\n ULTRASOUND - At 03:48 PM\n -Gave a 0.4mg dose of narcan, which she immediately responded to. She\n was very agitated, so the decision was made not to manage her on a drip\n and let her sleep through this as long as she remained hemodynamically\n stable.\n -Records from in the chart- she has NASH cirrhosis and has\n freqent admissions with volume overload and drug overdoses. She is not\n getting narcotics from her PCP or pain clinic doctors, so we are\n presuming she is getting them from outside sources. Her social\n situation appears to be very difficult.\n -Started scale, and gave her 10mg methadone for narcotic\n withdrawl\n -Osm gap 4\n -RUQ u/s c/w fatty liver, no ascites\n Allergies:\n Morphine\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:00 AM\n Haloperidol (Haldol) - 12:30 PM\n Naloxone (Narcan) - 02:15 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:32 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: 36.9\nC (98.5\n HR: 95 (85 - 111) bpm\n BP: 164/57(86) {141/57(78) - 200/80(109)} mmHg\n RR: 12 (12 - 22) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 469 mL\n 171 mL\n PO:\n TF:\n IVF:\n 349 mL\n 171 mL\n Blood products:\n Total out:\n 2,490 mL\n 515 mL\n Urine:\n 2,490 mL\n 515 mL\n NG:\n Stool:\n Drains:\n Balance:\n -2,021 mL\n -344 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 100%\n ABG: 7.33/48/69/24/-1\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 151 K/uL\n 9.7 g/dL\n 87 mg/dL\n 0.8 mg/dL\n 24 mEq/L\n 4.0 mEq/L\n 18 mg/dL\n 114 mEq/L\n 144 mEq/L\n 29.9 %\n 6.9 K/uL\n [image002.jpg]\n 10:38 PM\n 03:52 AM\n 10:35 AM\n 10:49 AM\n 04:48 AM\n WBC\n 6.8\n 5.8\n 7.3\n 6.9\n Hct\n 31.0\n 24.8\n 28.2\n 29.9\n Plt\n 175\n 115\n 149\n 151\n Cr\n 1.6\n 1.1\n 0.8\n TCO2\n 26\n Glucose\n 52\n 71\n 70\n 87\n Other labs: PT / PTT / INR:14.8/31.5/1.3, ALT / AST:20/39, Alk Phos / T\n Bili:320/0.7, Amylase / Lipase:44/11, Lactic Acid:0.8 mmol/L,\n Albumin:3.2 g/dL, LDH:256 IU/L, Ca++:9.0 mg/dL, Mg++:1.8 mg/dL, PO4:2.7\n mg/dL\n Imaging: Abdominal USD:\n IMPRESSION:\n 1. Coarsened echotexture of liver consistent with fatty liver.\n 2. No ascites.\n .\n CXR: IMPRESSION: Malpositioned right PICC in right atrium; results\n communicated.\n Microbiology: Ua: Negative\n CSF: NG\n BXx: NGTD\n Stool:\n FECAL CULTURE (Pending):\n CAMPYLOBACTER CULTURE (Pending):\n FECAL CULTURE - R/O E.COLI 0157:H7 (Pending):\n FECAL CULTURE - R/O YERSINIA (Pending):\n FECAL CULTURE - R/O VIBRIO (Pending):\n CLOSTRIDIUM DIFFICILE TOXIN ASSAY (Final ):\n FECES NEGATIVE FOR C. DIFFICILE TOXIN BY EIA.\n (Reference Range-Negative).\n OVA + PARASITES (Final ):\n NO OVA AND PARASITES SEEN.\n .\n This test does not reliably detect Cryptosporidium, Cyclospora or\n Microsporidium. While most cases of Giardia are detected by\n routine\n O+P, the Giardia antigen test may enhance detection when\n organisms\n are rare.\n Assessment and Plan\n 58 yof with history of CKD, Cirrhosis and history of multiple drug\n overdoses with opiates presented to ER with lethargy.\n .\n # Lethargy - Most likely secondary to opiates given the history and\n positive narcan test yesterday but is still extremely somnolent. Ddx\n includes infectious (low grade fever in ED, LP negative) vs. other\n toxins like benzo (tox screen negative other than benzo) vs. metabolic\n (?uremia from renal failure, not very impressive) vs. Hypoglycemia (low\n BS now but on presentation it was 157).\n - At this time, would continue scale and titrate as directed.\n Hold narcan unless non-responsive, or in resipratory failure.\n - CXR, UA negative for infection, USD w/o ascites, LP negative.\n (received ceftriaxone in the ER).\n - F/u culture data\n - CIS\n - hold sedating medications (neurontin, citalaprom)\n - Will empirically give thimaine and folate for now eventhough daughter\n denies etoh , ask pt in AM.\n - If no improvement in lethargy by AM would consider gettign RPR, TSH,\n B12 in AM.\n .\n # Acute renal failure\n Baseline 0.8\n improved with IVF\n - Creatinine down to 0.8 this AM -> baseline.\n - Check urine lytes.\n - Restarting lasix today, holding ACE. Restart ACE prn.\n .\n # DM - hold glargine insulin for now and check fingersticks q2 given\n some low BS in the ER.\n - transition to q4H finger sticks\n - restart home insulin when taking PO's.\n .\n #Hypertension: to withdrawal but persistently hypertensive this AM\n and clearly not in withdrawal at this time. Will start with lasix, and\n treat with opiates PRN for withdrawal. Restart lisinopril PRN.\n .\n #Volume: H/o diastolic dysfunction and ARF leading to volume overload.\n - consider TTE for eval of cardiac function\n - Decreased fluids to 75cc/hr maintenence fluids while NPO.\n .\n # NASH - LFTs unremarkable but carries a diagnosis per history.\n - USD w/o e/o ascites, c/w NASH/fatty liver\n .\n # Chronic low back pain - would hold off on gabapentin and narcotics\n for now.\n - scale\n .\n # Anemia - hct 29.6, unclear baseline, maybe from liver disease (MCV\n 96) versus CKD\n - guaiac stools\n - B12 folate nml, Fe c/w ACD, stable from records.\n .\n # Chronic lung disease/BOOP - would continue prednisone at 5mg\n - nebs prn -> improved this AM with nebulizer. 95-96% on RA\n currently. Titrate O2 to sats = 90-95%.\n .\n # Hyperkalemia - resolved.\n # FEN - NPO for now until more arousable.\n # ppx - sc heparin, ppi (on it at home)\n # Communication/HCP - Daughter # .\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 12:30 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2201-05-29 00:00:00.000", "description": "Nursing Progress Note", "row_id": 325669, "text": "58F Spanish speaking with cirrhosis and renal failure, gets usual care\n at , presented to ER after taking some drugs off the street\n and lethargy. T 100.9, BP88/50 HR 69 O2 99%2L, she was initially given\n Narcan 0.4mg with some improvement in mental status and dose was\n repeated X 2. She had a low grade fever T 100.9 and LP was done.\n Prior to LP, she was given ceftriaxone 2 grams. She continued to be\n lethargic so received 2mg IV narcan X 2 and planned for narcan gtt,\n however, she was arousable to voice so this was not started. Last dose\n of Narcan was 10 AM . CT head and CXR in the ER were unremarkable.\n She also had a several BS in the 64-75 range and received Dextrose.\n Per ER notes additional history was obtained from family (2 daughters)\n who stated that patient abuses oxycodone, vicodin, T3 (no tyelnol in\n tox). Family denied that patient was on sulfonylureas for diabetes.\n .\n Hypertension, benign\n Assessment:\n BP : 172/72-194/86\n Action:\n Given 20mg lisinopril per NGT @ 2100. Given 20mg IV labetolol @\n 0025.\n Response:\n No response to lisinopril.\n Plan:\n Started 12.5mg lopressor po/NG tid\n" }, { "category": "Nursing", "chartdate": "2201-05-29 00:00:00.000", "description": "Nursing Progress Note", "row_id": 325672, "text": "58F Spanish speaking with cirrhosis and renal failure, gets usual care\n at , presented to ER after taking some drugs off the street\n and lethargy. T 100.9, BP88/50 HR 69 O2 99%2L, she was initially given\n Narcan 0.4mg with some improvement in mental status and dose was\n repeated X 2. She had a low grade fever T 100.9 and LP was done.\n Prior to LP, she was given ceftriaxone 2 grams. She continued to be\n lethargic so received 2mg IV narcan X 2 and planned for narcan gtt,\n however, she was arousable to voice so this was not started. Last dose\n of Narcan was 10 AM . CT head and CXR in the ER were unremarkable.\n She also had a several BS in the 64-75 range and received Dextrose.\n Per ER notes additional history was obtained from family (2 daughters)\n who stated that patient abuses oxycodone, vicodin, T3 (no tyelnol in\n tox). Family denied that patient was on sulfonylureas for diabetes.\n .\n Hypertension, benign\n Assessment:\n BP : 172/72-194/86 HR: 88 SR -104 ST no ectopy\n Action:\n Given 20mg lisinopril per NGT @ 2100. Given 20mg IV labetolol @\n 0025.\n Response:\n No response to lisinopril. BP dropped from 194/83 to 174/80 after\n labetolol. Started 12.5mg lopressor po/NG tid. BP dropped to 165/67\n from 186/82. BP soon returns to 170\ns-180\ns/systolic after each\n antihypertensive.\n Plan:\n Monitor BP. Check w/ MD re: increasing lopressor dose.\n Altered mental status (not Delirium)\n Assessment:\n Patient slept all night. Easily arousable. Speaks Spanish only.\n Responded appropriately to phrases & questions in Spanish.\n Action:\n Response:\n Assessed scale @ overnight.\n Plan:\n Now checking scale q 4 hours. MD order if \n scale>10.\n" }, { "category": "Nursing", "chartdate": "2201-05-28 00:00:00.000", "description": "Nursing Progress Note", "row_id": 325553, "text": "Diabetes Mellitus (DM), Type II\n Assessment:\n Blood glucose 95-100s overnight and no insulin coverage needed.\n Action:\n Fingersticks q2hrs. On NS carrier only at this time. NPO.\n Response:\n No insulin needed.\n Plan:\n Continue q2hr fingersticks and monitor blood glucose closely. Monitor\n for signs and symptoms of hypoglycemia due to NPO status.\n Altered mental status (not Delirium)\n Assessment:\n Spanish speaking only. Per interpreter pt. confused and follows\n commands inconsistently. Oriented to self only. MAE in bed with equal\n strength. PERL 3mm and brisk. Agitated and moaning at beginning of\n shift stating she had abd. Pain. MDs notified and ? w/d symptoms- \n scale initiated with checks q2hr. Tachycardic and hypertensive as well\n leading to possible withdrawl signs.\n Action:\n One dose of 10mg po methadone via NGT given at .\n Response:\n Responded well to methadone and scale <10 since.\n Plan:\n scale q2hrs to monitor for signs and symptoms of narcotic\n withdrawl.\n No calls or visitors this shift.\n" }, { "category": "Physician ", "chartdate": "2201-05-28 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 325603, "text": "Chief Complaint: opiate od\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 58 yo Spanish speaking F w/ h/o CKD, DM, depression, cirrhosis, boop\n and multiple prior admits for drug overdoses (opiates) presents with\n lethargy in setting of drug intoxication (street drugs), transient\n hypoglycemia (cs 64-75 range) and low grade temp.\n 24 Hour Events:\n PICC LINE - START 12:30 PM\n ULTRASOUND - At 03:48 PM\n osh records--h/o nash, multiple admits for opiate o/d\n narcan given--> responded , became fully awake and agitated\n overnight appeared to be withdrawing from opiates, methoadone started\n ruq u/s--c/w fatty liver\n History obtained from Medical records, HO\n Allergies:\n Morphine\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Haloperidol (Haldol) - 12:30 PM\n Naloxone (Narcan) - 02:15 PM\n Heparin Sodium (Prophylaxis) - 08:00 AM\n Other medications:\n per (reviewed)\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 10:02 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: 36.6\nC (97.8\n HR: 100 (88 - 111) bpm\n BP: 173/73(98) {144/57(83) - 200/80(109)} mmHg\n RR: 18 (12 - 22) insp/min\n SpO2: 95% (RA)\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 469 mL\n 252 mL\n PO:\n TF:\n IVF:\n 349 mL\n 252 mL\n Blood products:\n Total out:\n 2,490 mL\n 690 mL\n Urine:\n 2,490 mL\n 690 mL\n NG:\n Stool:\n Drains:\n Balance:\n -2,021 mL\n -438 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 95%\n ABG: 7.33/48/69/24/-1\n Physical Examination\n General Appearance: Well nourished, Overweight / Obese, lethargic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : ,\n Crackles : scant, Diminished: bases)\n Abdominal: Soft, Non-tender, Bowel sounds present, Distended\n Extremities: Right: 3+, Left: 3+, No(t) Cyanosis, No(t) Clubbing\n Musculoskeletal: No(t) Muscle wasting\n Skin: Warm, No(t) Rash: , No(t) Jaundice\n Neurologic: No(t) Attentive, No(t) Follows simple commands, Responds\n to: Not assessed, Movement: Purposeful, No(t) Sedated, Tone: Not\n assessed\n Labs / Radiology\n 9.7 g/dL\n 151 K/uL\n 87 mg/dL\n 0.8 mg/dL\n 24 mEq/L\n 4.0 mEq/L\n 18 mg/dL\n 114 mEq/L\n 144 mEq/L\n 29.9 %\n 6.9 K/uL\n [image002.jpg]\n 10:38 PM\n 03:52 AM\n 10:35 AM\n 10:49 AM\n 04:48 AM\n WBC\n 6.8\n 5.8\n 7.3\n 6.9\n Hct\n 31.0\n 24.8\n 28.2\n 29.9\n Plt\n 175\n 115\n 149\n 151\n Cr\n 1.6\n 1.1\n 0.8\n TCO2\n 26\n Glucose\n 52\n 71\n 70\n 87\n Other labs: PT / PTT / INR:14.8/31.5/1.3 , ALT / AST:20/39, Alk Phos /\n T Bili:320/0.7 (stable), Amylase / Lipase:44/11, Lactic Acid:0.8\n mmol/L, Albumin:3.2 g/dL, LDH:256 IU/L (211), Ca++:9.0 mg/dL, Mg++:1.8\n mg/dL, PO4:2.7 mg/dL\n Fluid analysis / Other labs: osm gap 4\n Imaging: cxr--no new film\n Microbiology: csf ngtd\n stool studies neg\n u/a neg\n Assessment and Plan\n 58 yo Spanish speaking F w/ h/o CKD, DM, depression, cirrhosis, boop\n and multiple prior admits for drug overdoses (opiates) presents with\n lethargy in setting of drug intoxication (street drugs), transient\n hypoglycemia (cs 64-75 range) and low grade temp.\n # Lethargy /delirium\n intoxication from opiates --response to narcan/signs of withdrawl\n Work up pursued to assess for metabolic component -Given\n underlying liver disease/ckd, possible obesity\n hypoventilation/hypoventilation from narcs, hypoglycemia\n (ABG without sig co2 retension, ruq without ascites for sbp, renal\n fx normalized, ammonia wnl, rpr, tsh, folate b12 wnl)\n More alert this am\n No new s/sx of infection\n -f/u cx\nneg to date/ruq unremarkable\n - continue methadone taper scale for withdrawal\n # HTN\n Has h/o htn,\n withdrawal likely contributing\n -Restart home lasix,\n -monitor u/o cr\n -restart lisinopril if BP remains elevated\n # Nongap metabolic acidosis\nnormalized\n No osm gap, improved with hydration\n # Acute renal failure\nresolved to baseline with hydration\n # DM/transient hypoglycemia-resolved\n - holding glargine while NPO\n - follow chem. Sticks, rssi\n - RSSI\n # Cirrhosis\n LFTs remain stable/unremarkable\n RUQ c/w known NASH\n # Anemia\n hct stable at baseline\n # Chronic lung disease/BOOP\n continue prednisone at 5mg\n nebs prn\n # FEN\n NPO until more alert for asp risk\n d/c fluids and start gentle diuresis\n # Communication/HCP - Daughter # \n # Social issues: sw c/s, psych c/s, once more alert\n ICU Care\n Nutrition:\n Comments: NPO until more alert\n Glycemic Control: Regular insulin sliding scale\n Lines:\n PICC Line - 12:30 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition : stable for floor transfer\n Total time spent: 40 minutes\n" }, { "category": "Nursing", "chartdate": "2201-05-29 00:00:00.000", "description": "Nursing Progress Note", "row_id": 325670, "text": "58F Spanish speaking with cirrhosis and renal failure, gets usual care\n at , presented to ER after taking some drugs off the street\n and lethargy. T 100.9, BP88/50 HR 69 O2 99%2L, she was initially given\n Narcan 0.4mg with some improvement in mental status and dose was\n repeated X 2. She had a low grade fever T 100.9 and LP was done.\n Prior to LP, she was given ceftriaxone 2 grams. She continued to be\n lethargic so received 2mg IV narcan X 2 and planned for narcan gtt,\n however, she was arousable to voice so this was not started. Last dose\n of Narcan was 10 AM . CT head and CXR in the ER were unremarkable.\n She also had a several BS in the 64-75 range and received Dextrose.\n Per ER notes additional history was obtained from family (2 daughters)\n who stated that patient abuses oxycodone, vicodin, T3 (no tyelnol in\n tox). Family denied that patient was on sulfonylureas for diabetes.\n .\n Hypertension, benign\n Assessment:\n BP : 172/72-194/86\n Action:\n Given 20mg lisinopril per NGT @ 2100. Given 20mg IV labetolol @\n 0025.\n Response:\n No response to lisinopril. BP dropped from 194/83 to 174/80 after\n labetolol\n Plan:\n Started 12.5mg lopressor po/NG tid . BP dropped to 165/67 from 186/\n" }, { "category": "Nursing", "chartdate": "2201-05-29 00:00:00.000", "description": "Nursing Progress Note", "row_id": 325667, "text": "58F Spanish speaking with cirrhosis and renal failure, gets usual care\n at , presented to ER after taking some drugs off the street\n and lethargy. T 100.9, BP88/50 HR 69 O2 99%2L, she was initially given\n Narcan 0.4mg with some improvement in mental status and dose was\n repeated X 2. She had a low grade fever T 100.9 and LP was done.\n Prior to LP, she was given ceftriaxone 2 grams. She continued to be\n lethargic so received 2mg IV narcan X 2 and planned for narcan gtt,\n however, she was arousable to voice so this was not started. Last dose\n of Narcan was 10 AM . CT head and CXR in the ER were unremarkable.\n She also had a several BS in the 64-75 range and received Dextrose.\n Per ER notes additional history was obtained from family (2 daughters)\n who stated that patient abuses oxycodone, vicodin, T3 (no tyelnol in\n tox). Family denied that patient was on sulfonylureas for diabetes.\n .\n Hypertension, benign\n Assessment:\n BP : 172/72-194/86\n Action:\n Given 20mg IV labetolol @ 0025.\n Response:\n Plan:\n Started 12.5mg lopressor po/NG tid\n" }, { "category": "Nursing", "chartdate": "2201-05-29 00:00:00.000", "description": "Nursing Progress Note", "row_id": 325668, "text": "58F Spanish speaking with cirrhosis and renal failure, gets usual care\n at , presented to ER after taking some drugs off the street\n and lethargy. T 100.9, BP88/50 HR 69 O2 99%2L, she was initially given\n Narcan 0.4mg with some improvement in mental status and dose was\n repeated X 2. She had a low grade fever T 100.9 and LP was done.\n Prior to LP, she was given ceftriaxone 2 grams. She continued to be\n lethargic so received 2mg IV narcan X 2 and planned for narcan gtt,\n however, she was arousable to voice so this was not started. Last dose\n of Narcan was 10 AM . CT head and CXR in the ER were unremarkable.\n She also had a several BS in the 64-75 range and received Dextrose.\n Per ER notes additional history was obtained from family (2 daughters)\n who stated that patient abuses oxycodone, vicodin, T3 (no tyelnol in\n tox). Family denied that patient was on sulfonylureas for diabetes.\n .\n Hypertension, benign\n Assessment:\n BP : 172/72-194/86\n Action:\n Given 20mg lisinopril per NGT @ 2100. Given 20mg IV labetolol @\n 0025.\n Response:\n No response to lisinopril.\n Plan:\n Started 12.5mg lopressor po/NG tid\n" }, { "category": "Nursing", "chartdate": "2201-05-27 00:00:00.000", "description": "Nursing Progress Note", "row_id": 325494, "text": "Altered mental status (not Delirium)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2201-05-27 00:00:00.000", "description": "Nursing Progress Note", "row_id": 325495, "text": "58F Spanish speaking with cirrhosis and renal failure, gets usual care\n at , presented to ER after taking some drugs off the street\n and lethargy. T 100.9, BP88/50 HR 69 O2 99%2L, she was initially given\n Narcan 0.4mg with some improvement in mental status and dose was\n repeated X 2. She had a low grade fever T 100.9 and LP was done.\n Prior to LP, she was given ceftriaxone 2 grams. She continued to be\n lethargic so received 2mg IV narcan X 2 and planned for narcan gtt,\n however, she was arousable to voice so this was not started. Last dose\n of Narcan was 10 AM . CT head and CXR in the ER were unremarkable.\n She also had a several BS in the 64-75 range and received Dextrose.\n Per ER notes additional history was obtained from family (2 daughters)\n who stated that patient abuses oxycodone, vicodin, T3 (no tyelnol in\n tox). Family denied that patient was on sulfonylureas for diabetes.\n .\n At time of transfer to the ICU, she was easily arousable. She\n complained of lower back pain, which she's had for years. Otherwise\n denies any chest pain, shortness of breath. Denies any abdominal pain,\n fevers or chills at home. Daugther thinks she took altogether 34 pills\n (vicodin and tylenol #3) over past 2-3 days. She does not think her\n mom is depressed.\n Altered mental status (not Delirium)\n Assessment:\n Pt lethargic, unable to answer questions c interpreter, saying that she\n is in , not using many words moaning most of the time, not\n able to follow commands, yelling out when touched\n Action:\n AGB obtained this am, repeated am labs including ammonia level, abd u/s\n to evaluate for acites, Pt given narcan 0.4 mg and started on narcan\n gtt at 0.1mg/hr\n Response:\n Pt opening eyes and moaning loudly in response to narcan push and gtt,\n HR increased from 70s to 110s, BP up to 200 systolic, ABG 7.33/48/69,\n ammonia level 42\n Plan:\n Obtain repeat ABG with pt in more alert state, continue to follow neuro\n status frequently\n Diabetes Mellitus (DM), Type II\n Assessment:\n FSBS 66-93\n Action:\n Q2hr FSBS per order, pt to receive\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2201-05-27 00:00:00.000", "description": "Nursing Progress Note", "row_id": 325498, "text": "58F Spanish speaking with cirrhosis and renal failure, gets usual care\n at , presented to ER after taking some drugs off the street\n and lethargy. T 100.9, BP88/50 HR 69 O2 99%2L, she was initially given\n Narcan 0.4mg with some improvement in mental status and dose was\n repeated X 2. She had a low grade fever T 100.9 and LP was done.\n Prior to LP, she was given ceftriaxone 2 grams. She continued to be\n lethargic so received 2mg IV narcan X 2 and planned for narcan gtt,\n however, she was arousable to voice so this was not started. Last dose\n of Narcan was 10 AM . CT head and CXR in the ER were unremarkable.\n She also had a several BS in the 64-75 range and received Dextrose.\n Per ER notes additional history was obtained from family (2 daughters)\n who stated that patient abuses oxycodone, vicodin, T3 (no tyelnol in\n tox). Family denied that patient was on sulfonylureas for diabetes.\n .\n At time of transfer to the ICU, she was easily arousable. She\n complained of lower back pain, which she's had for years. Otherwise\n denies any chest pain, shortness of breath. Denies any abdominal pain,\n fevers or chills at home. Daugther thinks she took altogether 34 pills\n (vicodin and tylenol #3) over past 2-3 days. She does not think her\n mom is depressed.\n Altered mental status (not Delirium)\n Assessment:\n Pt lethargic, unable to answer questions c interpreter, saying that she\n is in , not using many words moaning most of the time, not\n able to follow commands, yelling out when touched\n Action:\n AGB obtained this am, repeated am labs including ammonia level, abd u/s\n to evaluate for acites, Pt given narcan 0.4 mg and started on narcan\n gtt at 0.1mg/hr\n Response:\n Pt opening eyes and moaning loudly in response to narcan push and gtt,\n HR increased from 70s to 110s, BP up to 200 systolic, ABG 7.33/48/69,\n ammonia level 42\n Plan:\n Obtain repeat ABG with pt in more alert state, continue to follow neuro\n status frequently\n Diabetes Mellitus (DM), Type II\n Assessment:\n FSBS 66-93, pt NPO\n Action:\n Q2hr FSBS per order, pt to receive 1 amp D50, no IV access at the time,\n NGT placed given OJ and dextrose tab\n Response:\n FSBS trending up with treatment, has not required any D50\n Plan:\n Continue to follow FSBS\n" }, { "category": "Physician ", "chartdate": "2201-05-27 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 325489, "text": "Chief Complaint: obtunded, drug od\n HPI:\n 58 yo Spanish speaking F w/ h/o CKD, DM, depression, cirrhosis, boop\n and multiple prior admits for drug overdoses (opiates) presents with\n lethargy in setting of drug intoxication (street drugs), hypoglycemia\n (cs 64-75 range) and low grade temp. .\n 24 Hour Events:\n head ct unremarkable\n cxr without infiltrate\n initial response to narcan\n transient hypoglycemia (ed)--improved with dextrose\n tox screen + opiates, o/w neg\n Allergies:\n Morphine\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:00 AM\n Other medications:\n per (reviewed)\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 10:02 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: 36.9\nC (98.5\n HR: 88 (74 - 92) bpm\n BP: 141/63(84) {122/53(73) - 177/90(96)} mmHg\n RR: 17 (9 - 21) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 40 mL\n 198 mL\n PO:\n TF:\n IVF:\n 40 mL\n 198 mL\n Blood products:\n Total out:\n 185 mL\n 760 mL\n Urine:\n 185 mL\n 760 mL\n NG:\n Stool:\n Drains:\n Balance:\n -145 mL\n -562 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 100%\n ABG: ///18/\n Physical Examination\n General Appearance: Well nourished, No acute distress, Overweight /\n Obese, lethargic\n Head, Ears, Nose, Throat: Normocephalic\n Lymphatic: No(t) Cervical WNL\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: diminshed:\n , No(t) Wheezes : ), unable to coop\n Abdominal: Soft, Non-tender, Bowel sounds present, Obese\n Extremities: Right: 3+, Left: 3+, No(t) Cyanosis, No(t) Clubbing\n Musculoskeletal: No(t) Muscle wasting,\n Skin: Warm, track marks\n Neurologic: Responds to: voice, confused, Movement:all 4 ext , unable\n to coop with exam\n Labs / Radiology\n 7.3 g/dL\n 115 K/uL\n 52 mg/dL\n 1.6 mg/dL (3.1)\n 18 mEq/L\n 4.3 mEq/L\n 27 mg/dL\n 116 mEq/L\n 144 mEq/L\n 24.8 %\n 5.8 K/uL\n [image002.jpg]\n 10:38 PM\n 03:52 AM\n WBC\n 6.8\n 5.8\n Hct\n 31.0\n 24.8\n Plt\n 175\n 115\n Cr\n 1.6\n Glucose\n 52\n Other labs: ALT / AST:50 ast, Alk Phos / T Bili:80/ 0.4, Albumin:3.1\n g/dL, Ca++:8.2 mg/dL, Mg++:1.8 mg/dL, PO4:3.9 mg/dL\n Fluid analysis / Other labs: b12 folate wnl\n ferritin 31\n retic 2.3\n abg: 7.33/38/74 (not clear how much fio2)\n Imaging: cxr--rotated, small volumes, increased interstitial markings,\n pulm edema, hazy right base but poor inspiratory effort\n Microbiology: bl cx pending\n csf cx pending\n stool cxs epdning, neg c diff\n Assessment and Plan\n 58 yo Spanish speaking F w/ h/o CKD, DM, depression, cirrhosis, boop\n and multiple prior admits for drug overdoses (opiates) presents with\n lethargy in setting of drug intoxication (street drugs), transient\n hypoglycemia (cs 64-75 range) and low grade temp.\n # Lethargy /delirium\n Most likely secondary to intoxication/opiates given hx and initial\n response to narcan (? Other ingestion)\n Metabolic component possibly contributing--underlying liver\n disease/ckd, possible obesity hypoventilation/hypoventilation from\n narcs, hypoglycemia, or infection\n Infection w/u unimpressive\n LP and cxr negative\n - u/a, cx\ns pending\n -RUQ ultrasound to assess ascitis ? SBP\n - abg to eval CO2 level\n - Ammonia level (? HE)\n - Repeat Narcan\n - RPR, TSH, B12\n - monitor for withdrawal\n # Nongap metabolic acidosis\ntox screen + for opiates\n ? chronic kidney ds with RTA, ? diarrhea\n - check osm gap\n - repeat abg\n - Osh labs to eval baseline\n # Acute renal failure\n - Unclear baseline cr but h/o CKD (check labs)\n - Cr improved w/ IVF\n - Check urine lytes.\n - hold lasix, lisinpril\n # DM - hold glargine while NPO/ given hypoglycemia in ed\n Chem. Sticks\n RSSI\n # Cirrhosis\n LFTs unremarkable\n ammonia level and RUQ u/s\n # Chronic LBP\n hold off on gabapentin and narcotics for now\n # Anemia - hct 29.6, unclear baseline\n Anemia w/u and keep t and screen\n # Chronic lung disease/BOOP\n continue prednisone at 5mg\n nebs prn\n # FEN\n NPO, until more alert for asp risk\n # Communication/HCP - Daughter # \n ICU Care\n Nutrition: NPO\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 20 Gauge - 09:05 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: 40 minutes\n critically ill\n" }, { "category": "Nursing", "chartdate": "2201-05-29 00:00:00.000", "description": "Nursing Progress Note", "row_id": 325694, "text": "58F Spanish speaking with cirrhosis and renal failure, gets usual care\n at , presented to ER after taking some drugs off the street\n and lethargy. T 100.9, BP88/50 HR 69 O2 99%2L, she was initially given\n Narcan 0.4mg with some improvement in mental status and dose was\n repeated X 2. She had a low grade fever T 100.9 and LP was done.\n Prior to LP, she was given ceftriaxone 2 grams. She continued to be\n lethargic so received 2mg IV narcan X 2 and planned for narcan gtt,\n however, she was arousable to voice so this was not started. Last dose\n of Narcan was 10 AM . CT head and CXR in the ER were unremarkable.\n She also had a several BS in the 64-75 range and received Dextrose.\n Per ER notes additional history was obtained from family (2 daughters)\n who stated that patient abuses oxycodone, vicodin, T3 (no tyelnol in\n tox). Family denied that patient was on sulfonylureas for diabetes.\n .\n Hypertension, benign\n Assessment:\n BP : 172/72-194/86 HR: 88 SR -104 ST no ectopy\n Action:\n Given 20mg lisinopril per NGT @ 2100. Given 20mg IV labetolol @\n 0025.\n Response:\n No response to lisinopril. BP dropped from 194/83 to 174/80 after\n labetolol. Started 12.5mg lopressor po/NG tid. BP dropped to 165/67\n from 186/82. BP soon returns to 170\ns-180\ns/systolic after each\n antihypertensive.\n Plan:\n Monitor BP. Awaiting rounds for team to decide re: increasing lopressor\n dose.\n Altered mental status (not Delirium)\n Assessment:\n Patient slept all night. Easily arousable. Speaks Spanish only.\n Responded appropriately to phrases & questions in Spanish.\n Action:\n Checking scale q 4 hrs\n Response:\n Assessed scale @ overnight.\n Plan:\n MD order if scale>10. Awaiting for patient to\n be called out soon.\n" }, { "category": "Physician ", "chartdate": "2201-05-29 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 325700, "text": "Chief Complaint: Drug Overdose - opiate\n 24 Hour Events:\n - titrated up her BP meds by placing back on her lisinopril and\n metoprolol, still hypertensive, diuresed very well to 40mg oral lasix\n - scale less than 3 so no further methadone given\n Allergies:\n Morphine\n Unknown;\n Last dose of Antibiotics:\n Fluconazole - 11:50 AM\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 11:00 AM\n Heparin Sodium (Prophylaxis) - 04:00 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 07:24 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: 36.6\nC (97.9\n HR: 93 (88 - 104) bpm\n BP: 184/74(100) {163/57(83) - 194/83(110)} mmHg\n RR: 22 (14 - 27) insp/min\n SpO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 714 mL\n 175 mL\n PO:\n TF:\n IVF:\n 474 mL\n 130 mL\n Blood products:\n Total out:\n 3,570 mL\n 655 mL\n Urine:\n 3,570 mL\n 655 mL\n NG:\n Stool:\n Drains:\n Balance:\n -2,856 mL\n -478 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 93%\n ABG: ///25/\n Physical Examination\n General Appearance: Overweight / Obese\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: white discharge in oropharynx\n Cardiovascular: (S1: Normal), (S2: Normal), No(t) S3, No(t) S4, No(t)\n Rub, (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: transmitted upper airway sounds, poor respiratory\n effort\n Abdominal: Soft, Non-tender, Bowel sounds present, Obese\n Extremities: Right: 2+, Left: 2+\n Skin: Not assessed\n Neurologic: No(t) Attentive, No(t) Follows simple commands, Responds\n to: Not assessed, No(t) Oriented (to): , Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 169 K/uL\n 9.6 g/dL\n 191 mg/dL\n 0.8 mg/dL\n 25 mEq/L\n 3.7 mEq/L\n 16 mg/dL\n 108 mEq/L\n 143 mEq/L\n 28.9 %\n 9.2 K/uL\n [image002.jpg]\n 10:38 PM\n 03:52 AM\n 10:35 AM\n 10:49 AM\n 04:48 AM\n 05:41 PM\n 04:05 AM\n WBC\n 6.8\n 5.8\n 7.3\n 6.9\n 9.2\n Hct\n 31.0\n 24.8\n 28.2\n 29.9\n 28.9\n Plt\n 175\n 115\n 149\n 151\n 169\n Cr\n 1.6\n 1.1\n 0.8\n 0.8\n 0.8\n TCO2\n 26\n Glucose\n 52\n 71\n 70\n 87\n 171\n 191\n Other labs: PT / PTT / INR:15.7/36.4/1.4, ALT / AST:16/28, Alk Phos / T\n Bili:295/0.9, Amylase / Lipase:44/11, Lactic Acid:0.8 mmol/L,\n Albumin:3.0 g/dL, LDH:260 IU/L, Ca++:8.8 mg/dL, Mg++:2.2 mg/dL, PO4:2.9\n mg/dL\n Imaging: No New\n Microbiology: RPR: Negative\n No new micro\n Assessment and Plan\n 58 yof with history of CKD, Cirrhosis and history of multiple drug\n overdoses with opiates presented to ER with lethargy.\n .\n # Lethargy - Clearly responsive to narcan but taking long time to\n clear. ?secondary component of hepatic encephalopathy. No clear\n infectious source at this time, and metabolic distrubances are mild by\n laboratory data. Hypoglycemia resolved.\n - At this time, would continue scale and titrate as directed - has\n not needed further doses of opiates and is clearly still heavily\n sedated. Hold narcan unless non-responsive, or in resipratory failure.\n - CXR, UA negative for infection, USD w/o ascites, LP negative.\n (received ceftriaxone in the ER).\n - F/u culture data\n - CIS\n - hold sedating medications (neurontin, citalaprom)\n - Will empirically give thimaine and folate for now eventhough daughter\n denies etoh , ask pt in AM.\n - RPR, B12, folate normal.\n .\n # Acute renal failure\n Baseline 0.8\n improved with IVF\ns and now\n stable after restarting ACE and diuresis yesterday\n - Restarting lasix today, holding ACE. Restart ACE prn.\n - Redose 20mg lasix this AM, goal net out 1L\n .\n #Non-Gap Metabolic Acidosis: Osmolar gap normal\n - Resolved.\n .\n # DM - hold glargine insulin for now and check fingersticks q2 given\n some low BS in the ER.\n - Still not taking PO's, finger sticks trending upwards overnight\n .\n #Hypertension: to withdrawal but persistently hypertensive this AM\n and clearly not in withdrawal at this time. Will start with lasix, and\n treat with opiates PRN for withdrawal. Restart lisinopril PRN.\n - Continue with lisinopril, metoprolol - uptitrate as tolerated to\n 25mg PO TID today.\n .\n # Volume: H/o diastolic dysfunction and ARF leading to volume\n overload.\n - consider TTE for eval of cardiac function\n - Continue diuresis\n .\n # Withdrawal: On for narcotic withdrawal. Will redose with 8mg\n methadone at next time > 10.\n - Hypertension/tachycardia concerning for benzo withdrawal. Family\n reports only opiate abuse. Serum etoh negative on admit. Continue to\n follow. Consider low dose benzo trial if hypertension refractory to\n meds.\n .\n # NASH - LFTs unremarkable but carries a diagnosis per history.\n - USD w/o e/o ascites, c/w NASH/fatty liver\n .\n # Chronic low back pain - would hold off on gabapentin and narcotics\n for now.\n - scale\n .\n #Thrush: Continue fluconazole for 5 days.\n - Check HIV test once alert enough to consent.\n .\n # Anemia - hct 29.6, unclear baseline, maybe from liver disease (MCV\n 96) versus CKD\n - guaiac stools negative x3\n - B12 folate nml, Fe c/w ACD, stable from records.\n .\n # Chronic lung disease/BOOP - would continue prednisone at 5mg\n - nebs prn -> improved this AM with nebulizer. 95-96% on RA\n currently. Titrate O2 to sats = 90-95%.\n .\n # Hyperkalemia - resolved.\n # FEN - NPO for now until more arousable. NG tube in place\n # ppx - sc heparin, ppi (on it at home)\n # Communication/HCP - Daughter # .\n # Access: PICC placed - now day 2\n # Code: Presumed full\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 12:30 PM\n Prophylaxis:\n DVT: heparin SQ\n Stress ulcer: PPI\n VAP: none\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: Called out to floor yesterday\n" }, { "category": "Case Management ", "chartdate": "2201-05-27 00:00:00.000", "description": "Case Managment Initial Patient Assessment", "row_id": 325472, "text": "Insurance information\n Primary insurance: MEDICAID - MASS. MEDICAID\n Secondary insurance:\n Insurance reviewer::\n Free Care application: N/A\n Status:\n Medicaid application: N/A\n Pre-Hospitalization services: None prior to admission\n DME / Home O[2]: None prior to admission\n Functional Status / Home / Family Assessment:\n Pt. lives with family in ; She is independent with her\n ADL's. Pt. has a history of oral pain medication abuse.\n Primary Contact(s): (dtr.) \n Health Care Proxy: .\n Dialysis: Yes\n Referrals Recommended: Social Work, Addictions\n Current plan: Home\n Home, when treatment completed, likely without services. Case\n Management will follow for DC needs.\n If VNA services needed can use:\n Multicultural Home Care - \n Americare at Home - \n Patient (s) to Discharge:\n None\n Patient discussed with multidisciplinary team: No\n" }, { "category": "Nursing", "chartdate": "2201-05-27 00:00:00.000", "description": "Nursing Progress Note", "row_id": 325420, "text": "58F Spanish speaking with cirrhosis and renal failure, gets usual care\n at , presented to ER after taking some drugs off the street\n and lethargy. T 100.9, BP88/50 HR 69 O2 99%2L, she was initially given\n Narcan 0.4mg with some improvement in mental status and dose was\n repeated X 2. She had a low grade fever T 100.9 and LP was done.\n Prior to LP, she was given ceftriaxone 2 grams. She continued to be\n lethargic so received 2mg IV narcan X 2 and planned for narcan gtt,\n however, she was arousable to voice so this was not started. Last dose\n of Narcan was 10 AM . CT head and CXR in the ER were unremarkable.\n She also had a several BS in the 64-75 range and received Dextrose.\n Per ER notes additional history was obtained from family (2 daughters)\n who stated that patient abuses oxycodone, vicodin, T3 (no tyelnol in\n tox). Family denied that patient was on sulfonylureas for diabetes.\n .\n At time of transfer to the ICU, she was easily arousable. She\n complained of lower back pain, which she's had for years. Otherwise\n denies any chest pain, shortness of breath. Denies any abdominal pain,\n fevers or chills at home. Daugther thinks she took altogether 34 pills\n (vicodin and tylenol #3) over past 2-3 days. She does not think her\n mom is depressed.\n DISPO: FULL CODE\n ALLERIGIES: MORPHINE\n ACCESS: 1 20G PIV\n NEURO: PT AROUSES TO VOICE, CONSISTENTLY FOLLOWING COMMANDS. SPEECH\n IS GARBLED, INCOMPLETE WORDS. ORIENTED X1 - DIFFICULT TO ASSESS\n ORIENTATION PT IS PRIMARILY SPANISH SPEAKING. PT SLEEPING MOST OF\n SHIFT. DENIES PAIN. REC\nD 0.4 MG NARCAN X1 WITH LITTLE EFFECT IN MS,\n PT APPEARING MORE RESTLESS POST-NARCAN. CT IN ED, NEGATIVE.\n CV: HR 70-90S NSR WITH NO ECTOPY NOTED. NBP 120S-140S/50-60S. SBP\n INCREASED TO 170S AFTER IVP NARCAN WAS GIVEN. + WEAK PP BILATERALLY.\n PT ALSO NOTED TO HAVE TRACE BILATERAL UE EDEMA.\n RESP: PT SATING 100% ON 2L NC. LS CLEAR T/O. NO SOB/ INCREASED WOB\n NOTED. + COUGH, NO SPUTUM. RR 8-15. RR NOTED TO INCREASE WITH\n INCREASED LOC, RR 7-8 WHILE ASLEEP.\n GI/GU: AND OBESE, + BS, NO STOOL THIS SHIFT. PT STATING\n HUNGRY,\n - PT NPO, ALL PO MEDS TIMED FOR AM PT\nS AMS. FOLEY CATH.\n SECURE AND PATENT, DRAINING ADEQUATE AMOUNTS OF CLEAR YELLOW URINE.\n SKIN: WARM/DIAPHORETIC/INTACT. PT EXTREMELY DIFFICULT STICK.\n SOCIAL: NO CONTACT FM FAMILY THIS SHIFT.\n PLAN: CONT. Q2H NEURO EXAMS, CONT. TO MONITOR FOR WITHDRAWALS. F/U ON\n BLD/URINE CULTURES. ? MORE ACCESS, NEED TO CONTACT IV RN. CONT.\n PROVIDING SUPPORTIVE CARE.\n" }, { "category": "Nursing", "chartdate": "2201-05-29 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 325772, "text": "58F Spanish speaking with cirrhosis and renal failure, gets usual care\n at , presented to ER after taking some drugs off the street\n and lethargy. T 100.9, BP88/50 HR 69 O2 99%2L, she was initially given\n Narcan 0.4mg with some improvement in mental status and dose was\n repeated X 2. She had a low grade fever T 100.9 and LP was done.\n Prior to LP, she was given ceftriaxone 2 grams. She continued to be\n lethargic so received 2mg IV narcan X 2 and planned for narcan gtt,\n however, she was arousable to voice so this was not started. CT head\n and CXR in the ER were unremarkable. She also had a several BS in the\n 64-75 range and received Dextrose. Per ER notes additional history was\n obtained from family (2 daughters) who stated that patient abuses\n oxycodone, vicodin, T3 (no tyelnol in tox). Family denied that patient\n was on sulfonylureas for diabetes.\n .\n Daugther thinks she took altogether 34 pills (vicodin and tylenol #3)\n over past 2-3 days. She does not think her mom is depressed. Daughter\n has been calling daily for updates however has not come in to visit.\n Very concerned with mother\n lethargy. Would like to speak\n with social work about ?rehab or detox following this admission.\n During ICU stay pt responsive to narcan bolus, on narcan gtt for ~2hrs\n unable to tolerate further therapy as became very agitated and\n hypertensive, initiated scale evening of , has received one\n dose of methadone score >10\n Hypertension, benign\n Assessment:\n Action:\n Response:\n Plan:\n Diabetes Mellitus (DM), Type II\n Assessment:\n Action:\n Response:\n Plan:\n Altered mental status (not Delirium)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2201-05-29 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 325773, "text": "58F Spanish speaking with cirrhosis and renal failure, gets usual care\n at , presented to ER after taking some drugs off the street\n and lethargy. T 100.9, BP88/50 HR 69 O2 99%2L, she was initially given\n Narcan 0.4mg with some improvement in mental status and dose was\n repeated X 2. She had a low grade fever T 100.9 and LP was done.\n Prior to LP, she was given ceftriaxone 2 grams. She continued to be\n lethargic so received 2mg IV narcan X 2 and planned for narcan gtt,\n however, she was arousable to voice so this was not started. CT head\n and CXR in the ER were unremarkable. She also had a several BS in the\n 64-75 range and received Dextrose. Per ER notes additional history was\n obtained from family (2 daughters) who stated that patient abuses\n oxycodone, vicodin, T3 (no tyelnol in tox). Family denied that patient\n was on sulfonylureas for diabetes.\n .\n Daugther thinks she took altogether 34 pills (vicodin and tylenol #3)\n over past 2-3 days. She does not think her mom is depressed. Daughter\n has been calling daily for updates however has not come in to visit.\n Very concerned with mother\n lethargy. Would like to speak\n with social work about ?rehab or detox following this admission.\n During ICU stay pt responsive to narcan bolus, on narcan gtt for ~2hrs\n unable to tolerate further therapy as became very agitated and\n hypertensive, initiated scale evening of , has received one\n dose of methadone score >10\n Hypertension, benign\n Assessment:\n Pt has been hypertensive since admission, with high of ~200 systolic,\n restarted home cardiac meds. Pt fluid overloaded w/ generalized +2\n edema.\n Action:\n Remains on standing lisinopril and lopressor\n Response:\n No sign. Change in BP with BP ranging 160-170s systolic this shift\n Plan:\n Cont. to monitor BP, adjust meds as needed.\n Diabetes Mellitus (DM), Type II\n Assessment:\n Initially in ICU pt was hypoglycemic, most recent FSBS ranging 170-202,\n NPO\n Action:\n FSBS q6h, SS humolog insulin\n Response:\n ongoing\n Plan:\n ? restarting home oral glycemic agents when able to eat, cont. ISS.\n Altered mental status (not Delirium)\n Assessment:\n Pt cont. to be lethargic, score 0-2, no clear signs of withdrawal,\n able to follow simple commands intermittently. Arouses easily to\n voice, but largely lethargic/ unresponsive to questions with\n interpreter. PERRLA 3mm/bsk bilaterally, tracks.\n Action:\n Rec\nd sm. Doses of narcan to assess pt\ns responsiveness t/o stay with\n little effect. Remains on standing dose lactulose for ? of\n encephalopathy.\n Response:\n Pt remains lethargic, has not rec\nd narcan this shift.\n Plan:\n Cont. to monitor MS, cont. to follow live enzymes, q4h.\n" }, { "category": "Nursing", "chartdate": "2201-05-29 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 325774, "text": "58F Spanish speaking with cirrhosis and renal failure, gets usual care\n at , presented to ER after taking some drugs off the street\n and lethargy. T 100.9, BP88/50 HR 69 O2 99%2L, she was initially given\n Narcan 0.4mg with some improvement in mental status and dose was\n repeated X 2. She had a low grade fever T 100.9 and LP was done.\n Prior to LP, she was given ceftriaxone 2 grams. She continued to be\n lethargic so received 2mg IV narcan X 2 and planned for narcan gtt,\n however, she was arousable to voice so this was not started. CT head\n and CXR in the ER were unremarkable. She also had a several BS in the\n 64-75 range and received Dextrose. Per ER notes additional history was\n obtained from family (2 daughters) who stated that patient abuses\n oxycodone, vicodin, T3 (no tyelnol in tox). Family denied that patient\n was on sulfonylureas for diabetes.\n .\n Daugther thinks she took altogether 34 pills (vicodin and tylenol #3)\n over past 2-3 days. She does not think her mom is depressed. Daughter\n has been calling daily for updates however has not come in to visit.\n Very concerned with mother\n lethargy. Would like to speak\n with social work about ?rehab or detox following this admission.\n During ICU stay pt responsive to narcan bolus, on narcan gtt for ~2hrs\n unable to tolerate further therapy as became very agitated and\n hypertensive, initiated scale evening of , has received one\n dose of methadone score >10\n Hypertension, benign\n Assessment:\n Pt has been hypertensive since admission, with high of ~200 systolic,\n restarted home cardiac meds. Pt fluid overloaded w/ generalized +2\n edema.\n Action:\n Remains on standing lisinopril and lopressor\n Response:\n No sign. Change in BP with BP ranging 160-170s systolic this shift\n Plan:\n Cont. to monitor BP, adjust meds as needed.\n Diabetes Mellitus (DM), Type II\n Assessment:\n Initially in ICU pt was hypoglycemic, most recent FSBS ranging 170-202,\n NPO\n Action:\n FSBS q6h, SS humolog insulin\n Response:\n ongoing\n Plan:\n ? restarting home oral glycemic agents when able to eat, cont. ISS.\n Altered mental status (not Delirium)\n Assessment:\n Pt cont. to be lethargic, score 0-2, no clear signs of withdrawal,\n able to follow simple commands intermittently. Arouses easily to\n voice, but largely lethargic/ unresponsive to questions with\n interpreter. PERRLA 3mm/bsk bilaterally, tracks.\n Action:\n Rec\nd sm. Doses of narcan to assess pt\ns responsiveness t/o stay with\n little effect. Remains on standing dose lactulose for ? of\n encephalopathy.\n Response:\n Pt remains lethargic, has not rec\nd narcan this shift.\n Plan:\n Cont. to monitor MS, cont. to follow live enzymes, q4h.\n Demographics\n Attending MD:\n S.\n Admit diagnosis:\n OPIATE OVERDOSE\n Code status:\n Full code\n Height:\n Admission weight:\n 94.6 kg\n Daily weight:\n Allergies/Reactions:\n Morphine\n Unknown;\n Precautions:\n PMH: Diabetes - Insulin, Liver Failure, Renal Failure\n CV-PMH:\n Additional history: CHRONIC LUNG DISEASE- BOOP, DEPRESSION,\n HYCHOLESTROLEMIA, MULT. OVERDOSE (STATES HAS BEEN ADMITTED -6X - LAST\n TIME 6MO AGO), CIRRHOSIS, DM, ARTHRITIS, HX OF SMOKING- 5PPD\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:157\n D:65\n Temperature:\n 100.3\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 19 insp/min\n Heart Rate:\n 85 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n None\n O2 saturation:\n 95% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 24h total in:\n 671 mL\n 24h total out:\n 2,715 mL\n Pertinent Lab Results:\n Sodium:\n 143 mEq/L\n 04:05 AM\n Potassium:\n 3.7 mEq/L\n 04:05 AM\n Chloride:\n 108 mEq/L\n 04:05 AM\n CO2:\n 25 mEq/L\n 04:05 AM\n BUN:\n 16 mg/dL\n 04:05 AM\n Creatinine:\n 0.8 mg/dL\n 04:05 AM\n Glucose:\n 191 mg/dL\n 04:05 AM\n Hematocrit:\n 28.9 %\n 04:05 AM\n Finger Stick Glucose:\n 202\n 06:00 PM\n Valuables / Signature\n Patient valuables:\n Other valuables:\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from:\n Transferred to:\n Date & time of Transfer:\n" }, { "category": "Nursing", "chartdate": "2201-05-29 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 325775, "text": "58F Spanish speaking with cirrhosis and renal failure, gets usual care\n at , presented to ER after taking some drugs off the street\n and lethargy. T 100.9, BP88/50 HR 69 O2 99%2L, she was initially given\n Narcan 0.4mg with some improvement in mental status and dose was\n repeated X 2. She had a low grade fever T 100.9 and LP was done.\n Prior to LP, she was given ceftriaxone 2 grams. She continued to be\n lethargic so received 2mg IV narcan X 2 and planned for narcan gtt,\n however, she was arousable to voice so this was not started. CT head\n and CXR in the ER were unremarkable. She also had a several BS in the\n 64-75 range and received Dextrose. Per ER notes additional history was\n obtained from family (2 daughters) who stated that patient abuses\n oxycodone, vicodin, T3 (no tyelnol in tox). Family denied that patient\n was on sulfonylureas for diabetes.\n .\n Daugther thinks she took altogether 34 pills (vicodin and tylenol #3)\n over past 2-3 days. She does not think her mom is depressed. Daughter\n has been calling daily for updates however has not come in to visit.\n Very concerned with mother\n lethargy. Would like to speak\n with social work about ?rehab or detox following this admission.\n During ICU stay pt responsive to narcan bolus, on narcan gtt for ~2hrs\n unable to tolerate further therapy as became very agitated and\n hypertensive, initiated scale evening of , has received one\n dose of methadone score >10\n Hypertension, benign\n Assessment:\n Pt has been hypertensive since admission, with high of ~200 systolic,\n restarted home cardiac meds. Pt fluid overloaded w/ generalized +2\n edema.\n Action:\n Remains on standing lisinopril and lopressor\n Response:\n No sign. Change in BP with BP ranging 160-170s systolic this shift\n Plan:\n Cont. to monitor BP, adjust meds as needed.\n Diabetes Mellitus (DM), Type II\n Assessment:\n Initially in ICU pt was hypoglycemic, most recent FSBS ranging 170-202,\n NPO\n Action:\n FSBS q6h, SS humolog insulin\n Response:\n ongoing\n Plan:\n ? restarting home oral glycemic agents when able to eat, cont. ISS.\n Altered mental status (not Delirium)\n Assessment:\n Pt cont. to be lethargic, score 0-2, no clear signs of withdrawal,\n able to follow simple commands intermittently. Arouses easily to\n voice, but largely lethargic/ unresponsive to questions with\n interpreter. PERRLA 3mm/bsk bilaterally, tracks.\n Action:\n Rec\nd sm. Doses of narcan to assess pt\ns responsiveness t/o stay with\n little effect. Remains on standing dose lactulose for ? of\n encephalopathy.\n Response:\n Pt remains lethargic, has not rec\nd narcan this shift.\n Plan:\n Cont. to monitor MS, cont. to follow live enzymes, q4h.\n Demographics\n Attending MD:\n S.\n Admit diagnosis:\n OPIATE OVERDOSE\n Code status:\n Full code\n Height:\n Admission weight:\n 94.6 kg\n Daily weight:\n Allergies/Reactions:\n Morphine\n Unknown;\n Precautions:\n PMH: Diabetes - Insulin, Liver Failure, Renal Failure\n CV-PMH:\n Additional history: CHRONIC LUNG DISEASE- BOOP, DEPRESSION,\n HYCHOLESTROLEMIA, MULT. OVERDOSE (STATES HAS BEEN ADMITTED -6X - LAST\n TIME 6MO AGO), CIRRHOSIS, DM, ARTHRITIS, HX OF SMOKING- 5PPD\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:157\n D:65\n Temperature:\n 100.3\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 19 insp/min\n Heart Rate:\n 85 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n None\n O2 saturation:\n 95% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 24h total in:\n 671 mL\n 24h total out:\n 2,715 mL\n Pertinent Lab Results:\n Sodium:\n 143 mEq/L\n 04:05 AM\n Potassium:\n 3.7 mEq/L\n 04:05 AM\n Chloride:\n 108 mEq/L\n 04:05 AM\n CO2:\n 25 mEq/L\n 04:05 AM\n BUN:\n 16 mg/dL\n 04:05 AM\n Creatinine:\n 0.8 mg/dL\n 04:05 AM\n Glucose:\n 191 mg/dL\n 04:05 AM\n Hematocrit:\n 28.9 %\n 04:05 AM\n Finger Stick Glucose:\n 202\n 06:00 PM\n Valuables / Signature\n Patient valuables:\n Other valuables:\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from:\n Transferred to:\n Date & time of Transfer:\n" }, { "category": "Physician ", "chartdate": "2201-05-27 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 325413, "text": "Chief Complaint: Somnolence\n HPI:\n 58F Spanish speaking with cirrhosis and renal failure, gets usual care\n at , presented to ER after taking some drugs off the street\n and lethargy. T 100.9, BP88/50 HR 69 O2 99%2L, she was initially given\n Narcan 0.4mg with some improvement in mental status and dose was\n repeated X 2. She had a low grade fever T 100.9 and LP was done.\n Prior to LP, she was given ceftriaxone 2 grams. She continued to be\n lethargic so received 2mg IV narcan X 2 and planned for narcan gtt,\n however, she was arousable to voice so this was not started. Last dose\n of Narcan was 10 AM . CT head and CXR in the ER were unremarkable.\n She also had a several BS in the 64-75 range and received Dextrose.\n Per ER notes additional history was obtained from family (2 daughters)\n who stated that patient abuses oxycodone, vicodin, T3 (no tyelnol in\n tox). Family denied that patient was on sulfonylureas for diabetes.\n .\n At time of transfer to the ICU, she was easily arousable. She\n complained of lower back pain, which she's had for years. Otherwise\n denies any chest pain, shortness of breath. Denies any abdominal pain,\n fevers or chills at home. Daugther thinks she took altogether 34 pills\n (vicodin and tylenol #3) over past 2-3 days. She does not think her\n mom is depressed.\n .\n History obtained from Patient, Family / Medical records\n Allergies:\n Morphine\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Medications at home:\n Citalaprom 40 mg daily\n Lisinopril 20 mg daily\n ASA 81 mg daily\n Iron 325 mg \n Metoprolol XL 50 mg daily\n Docusate 100 mg \n Senna \n Gabapentin 800mg tid\n Prednisone 5mg daily\n Lasix 40mg \n Omeprazole 20 mg daily\n Sulfatrin daily\n Simvastatin 20 mg daily\n Glargine daily dose unkown\n Aspart daily dose unknown\n Past medical history:\n Family history:\n Social History:\n Chronic lung disease - BOOP\n Depression\n Hypercholesterolemia\n Multiple overdose (states has been admitted ~6 times, last time 6\n months ago)\n Cirrhosis\n Diabetes\n Arthritis\n Kidney Failure\n not obtained\n Occupation:\n Drugs: denies ivda\n Tobacco: not currently previously upto 5 ppd\n Alcohol: denies etoh\n Other: lives with son\n Review of systems:\n Constitutional: No(t) Fever\n Ear, Nose, Throat: No(t) Dry mouth\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Orthopnea\n Respiratory: No(t) Cough, No(t) Dyspnea\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea\n Flowsheet Data as of 12:53 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: 92 (74 - 92) bpm\n BP: 177/69(84) {123/53(74) - 177/90(96)} mmHg\n RR: 21 (9 - 21) insp/min\n SpO2: 100%\n Total In:\n 40 mL\n 8 mL\n PO:\n TF:\n IVF:\n 40 mL\n 8 mL\n Blood products:\n Total out:\n 185 mL\n 70 mL\n Urine:\n 185 mL\n 70 mL\n NG:\n Stool:\n Drains:\n Balance:\n -145 mL\n -62 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 100%\n Physical Examination\n General Appearance: Well nourished\n Eyes / Conjunctiva: PERRL, Pupils dilated, reactive 3->1\n Head, Ears, Nose, Throat: Normocephalic\n Lymphatic: Cervical WNL\n Cardiovascular: (S1: Normal), (S2: Normal), No(t) S3, No(t) S4,\n (Murmur: No(t) Systolic, No(t) Diastolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: No(t)\n Crackles : , Wheezes : diffuse bilaterally)\n Abdominal: Soft, Non-tender, No(t) Distended, Obese\n Extremities: Right: 3+, Left: 3+\n Skin: Not assessed\n Neurologic: Responds to: Verbal stimuli, Oriented (to): place states\n , Movement: Purposeful, Tone: Not assessed\n Labs / Radiology\n 175 K/uL\n 9.6 g/dL\n 31.0 %\n 6.8 K/uL\n [image002.jpg]\n \n 2:33 A5/13/ 10:38 PM\n \n 10:20 P\n \n 1:20 P\n \n 11:50 P\n \n 1:20 A\n \n 7:20 P\n 1//11/006\n 1:23 P\n \n 1:20 P\n \n 11:20 P\n \n 4:20 P\n WBC\n 6.8\n Hct\n 31.0\n Plt\n 175\n Fluid analysis / Other labs: 10:31a\n #4 CSF WBC 3 RBC 560 Poly 44 Lymph 50 Mono 0\n EOs Macroph: 6\n .\n 10:30a\n #2 CSF\n Chemistry Protein 52 Glucose 51\n #1\n CSF WBC 5 RBC Poly 68 Lymph 25 Mono\n 0 EOs 1 Atyps: 3 Macroph: 3\n .\n 09:05a\n GROSS HEMOLYSIS.ADD-ONS @9;45\n 137 | 110 | 31 AGap=10\n -------------<123\n 6.6 | 18 | 2.6\n .\n Mg: 1.8 P: 4.7\n MCV 96\n 8.4 >---< 163\n ......29.6\n N:70.7 L:23.6 M:5.3 E:0.3 Bas:0.2\n 08:39a\n pH 7.33 pCO2 38 pO2 74 HCO3 21 BaseXS -5\n Na:140 K:3.7 Cl:112 TCO2:20 Glu:123 freeCa:1.11 Lactate:1.0\n .\n 01:55a\n Urine Opiates Pos\n Urine Benzos, Barbs, Cocaine, Amphet, Mthdne Negative\n Serum ASA, EtOH, Acetmnphn, Benzo, Barb, Tricyc Negative\n .\n Urinalysis:\n Color Yellow Appear Clear SpecGr 1.020 pH 5.0 Urobil Neg Bili\n Mod Leuk Neg Bld Neg Nitr Neg Prot Tr Glu Neg Ket Tr\n .\n ALT: 25 AP: 380 Tbili: 0.4 Alb:\n AST: 50 LDH: Dbili: TProt:\n : Lip: 13\n .\n MCV 97\n 11.1 >---< 182\n .... 3.7\n N:76.2 L:19.6 M:3.7 E:0.4 Bas:0.3\n Imaging: CXR: Low lung volumes. Likely mild pulmonary edema. If there\n is\n further concern, repeat evaluation with better inspiration is\n suggested.\n .\n CT Head: No definite intracranial hemorrhage.\n ECG: ECG: NSR at 68, nl axis, nl intervals, no signs of hypertrophy.\n twi III, no prior for comparison.\n Assessment and Plan\n 58 yof with history of CKD, Cirrhosis and history of multiple drug\n overdoses with opiates presented to ER with lethargy.\n .\n # Lethargy - Most likely secondary to opiates given the history. Ddx\n includes infectious (low grade fever in ED, LP negative) vs. other\n toxins like benzo (tox screen negative other than benzo) vs. metabolic\n (?uremia from renal failure, not very impressive) vs. Hypoglycemia (low\n BS now but on presentation it was 157).\n - CXR, UA negative for infection, LP negative. (received ceftriaxone in\n the ER). Given history of cirrhosis may have ascities and thus would\n be improtant to rule out SBP. Would check ultrasound for asicities.\n - F/u culture data\n - CIS\n - hold sedating medications (neurontin, citalaprom)\n - Narcan 0.4mg X 1 now to see if she improves\n - Will empirically give thimaine and folate for now eventhough daughter\n denies etoh , ask pt in AM.\n - If no improvement in lethargy by AM would consider gettign RPR, TSH,\n B12 in AM.\n .\n # Acute renal failure - Unclear baseline(daughter stated she has some\n kidney failure). Improved with IVF in ER.\n - Check urine lytes.\n - holding lasix, lisinpril for now. Will need to get baseline labs\n from in AM.\n .\n # DM - hold glargine insulin for now and check fingersticks q2 given\n some low BS in the ER.\n .\n # Hyperkalemia - last K 6.6 but hemolyzed (previously 3.7). will check\n new set of labs now.\n .\n # Cirrhosis - LFTs unremarkable but carries a diagnosis per history.\n Would hold lasix for now and reassess once we have baseline info from\n .\n - Check albumin\n - Would get abdominal ultrasound to evaluate for liver texture and\n ascities.\n .\n # Chronic low back pain - would hold off on gabapentin and narcotics\n for now.\n # Anemia - hct 29.6, unclear baseline, maybe from liver disease (MCV\n 96) versus CKD\n - Check B12, folate, iron studies, retic count.\n .\n # Chronic lund disease/BOOP - would continue prednisone at 5mg\n - nebs prn\n .\n # FEN - NPO for now until more arousable.\n # ppx - sc heparin, ppi (on it at home)\n # Communication/HCP - Daughter # .\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 20 Gauge - 09:05 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2201-05-28 00:00:00.000", "description": "Nursing Progress Note", "row_id": 325629, "text": "58F Spanish speaking with cirrhosis and renal failure, gets usual care\n at , presented to ER after taking some drugs off the street\n and lethargy. T 100.9, BP88/50 HR 69 O2 99%2L, she was initially given\n Narcan 0.4mg with some improvement in mental status and dose was\n repeated X 2. She had a low grade fever T 100.9 and LP was done.\n Prior to LP, she was given ceftriaxone 2 grams. She continued to be\n lethargic so received 2mg IV narcan X 2 and planned for narcan gtt,\n however, she was arousable to voice so this was not started. Last dose\n of Narcan was 10 AM . CT head and CXR in the ER were unremarkable.\n She also had a several BS in the 64-75 range and received Dextrose.\n Per ER notes additional history was obtained from family (2 daughters)\n who stated that patient abuses oxycodone, vicodin, T3 (no tyelnol in\n tox). Family denied that patient was on sulfonylureas for diabetes.\n .\n At time of transfer to the ICU, she was easily arousable. She\n complained of lower back pain, which she's had for years. Otherwise\n denies any chest pain, shortness of breath. Denies any abdominal pain,\n fevers or chills at home. Daugther thinks she took altogether 34 pills\n (vicodin and tylenol #3) over past 2-3 days. She does not think her\n mom is depressed.\n Altered mental status (not Delirium)\n Assessment:\n Pt alert, orientedx1 per HO, unable to reassess orientation throughout\n the shift d/t language barrier, following simple commands, pt is not\n displaying any signs of narcotic withdrawal, scale 0-4 with scores\n of 0 for the last several hours\n Action:\n Monitoring scale q2hrs\n Response:\n pt with low scale as noted above, no methadone required throughout\n the shift\n Plan:\n Continue scale q2hrs until then change to q4hr, pt can be\n called out to floor with change to q4hr checks, pt to receive methadone\n for \n Hypertension, benign\n Assessment:\n NBP: 163-185/62-83\n Action:\n pt given one time dose of lasix, is on home lasix and lisinipril\n Response:\n u/o with good response to lasix adm see flowsheet for objective data,\n BP continues to be high, afternoon lytes pending\n Plan:\n f/u afternoon lytes, ?restarting home lasix and lisinipril, htn dose\n not appear to be related to narcotic withdrawal given low scale as\n noted above\n Social: team in contact with daughter as next of , social work to\n follow up with daughter when available, OD is believed accidental\n daughter reiterating that pt is intermittently depressed but that she\n likes to get high and that this has happened before\n" }, { "category": "Physician ", "chartdate": "2201-05-27 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 325462, "text": "Chief Complaint: obtunded, drug od\n HPI:\n 58 yo f w/ h/o CKD, DM, depression, cirrhosis, boop and prior admits\n for drug overdoses with opiates presents with lethargy ins etting of\n drug intoxication\n 24 Hour Events:\n head ct unremarkable\n cxr without infiltrate\n transient hypoglycemia--improved with dextrose\n tox screen + opiates, o/w neg\n Allergies:\n Morphine\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:00 AM\n Other medications:\n per (reviewed)\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 10:02 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: 36.9\nC (98.5\n HR: 88 (74 - 92) bpm\n BP: 141/63(84) {122/53(73) - 177/90(96)} mmHg\n RR: 17 (9 - 21) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 40 mL\n 198 mL\n PO:\n TF:\n IVF:\n 40 mL\n 198 mL\n Blood products:\n Total out:\n 185 mL\n 760 mL\n Urine:\n 185 mL\n 760 mL\n NG:\n Stool:\n Drains:\n Balance:\n -145 mL\n -562 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 100%\n ABG: ///18/\n Physical Examination\n General Appearance: Well nourished, No acute distress, Overweight /\n Obese, lethargic\n Head, Ears, Nose, Throat: Normocephalic\n Lymphatic: No(t) Cervical WNL\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : ,\n No(t) Wheezes : ), unable to coop\n Abdominal: Soft, Non-tender, Bowel sounds present, Obese\n Extremities: Right: 3+, Left: 3+, No(t) Cyanosis, No(t) Clubbing\n Musculoskeletal: No(t) Muscle wasting, Unable to stand\n Skin: Warm\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed, unable to coop with exam\n Labs / Radiology\n 7.3 g/dL\n 115 K/uL\n 52 mg/dL\n 1.6 mg/dL (3.1)\n 18 mEq/L\n 4.3 mEq/L\n 27 mg/dL\n 116 mEq/L\n 144 mEq/L\n 24.8 %\n 5.8 K/uL\n [image002.jpg]\n 10:38 PM\n 03:52 AM\n WBC\n 6.8\n 5.8\n Hct\n 31.0\n 24.8\n Plt\n 175\n 115\n Cr\n 1.6\n Glucose\n 52\n Other labs: ALT / AST:50 ast, Alk Phos / T Bili:80/ 0.4, Albumin:3.1\n g/dL, Ca++:8.2 mg/dL, Mg++:1.8 mg/dL, PO4:3.9 mg/dL\n Fluid analysis / Other labs: b12 folate wnl\n ferritin 31\n retic 2.3\n abg: 7.33/38/74 (not clear how much fio2)\n Imaging: cxr--rotated, small volumes, increased interstitial arkings,\n pulm edema, hazy right base but poor inspiratory effort\n Microbiology: bl cx pending\n csf cx pending\n stool cxs epdning, neg c diff\n Assessment and Plan\n 58 yo f with dm,CKD, cirrhosis, obesity, PSA hx with prior admits for\n OD presents with lethargy/delirium with tox screen pos for opiates.\n # Lethargy /delirium/encephalopthy\n Most likely secondary to opiates given the history and did have initial\n response to narcan\n Metabolic component may be contributing with underlying liver\n disease/ckd, obesity and popssible obesity hypervenitaltion\n Infection w/u unimpressive\n Ddx includes infectious (low grade fever in ED, LP negative) vs.\n other toxins like benzo (tox screen negative other than benzo) vs.\n metabolic (?uremia from renal failure, not very impressive) vs.\n Hypoglycemia (low BS now but on presentation it was 157).\n CXR/UA negative for infection, LPunimpressive. (received ceftriaxone in\n the ER).\n Would check ultrasound for asicities.\n Stat abg to eval co2 level,\n Check ammonia level\n Narcan\n F/u culture data\n Ruq to eval for ascites /sbp given h/o cirrhosis\n RPR, TSH, B12 in AM.\n ? HE component, check ammonia\n # Nongap metabolic acidosis\ntox screen neg except for opiates,\n ? chronic kidney ds with RTA, diarrhea, check osm gap, repeat abg\n Osh labs to eval baseline\n # Acute renal failure\n Unclear baseline\n Creatinine improved with IVF in ER.\n - Check urine lytes.\n - holding lasix, lisinpril for now.\n get baseline labs from in AM.\n .\n # DM - hold glargine insulin while NPO and given hypoglycemia in ed\n Chem sticks,\n RSSI\n .\n # Cirrhosis\n LFTs unremarkable\n Check albumin/ammonia\n Ruq us as noted\n # Chronic low back pain - would hold off on gabapentin and narcotics\n for now.\n # Anemia - hct 29.6, unclear baseline, maybe from liver disease (MCV\n 96) versus CKD\n Anemia w/u and keep t and screen\n # Chronic lund disease/BOOP\n continue prednisone at 5mg\n nebs prn\n # FEN\n NPO, until more alert for asp risk\n # Communication/HCP - Daughter # .\n ICU Care\n Nutrition: NPO\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 20 Gauge - 09:05 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: 40 minutes, critically ill\n" }, { "category": "Nursing", "chartdate": "2201-05-28 00:00:00.000", "description": "Nursing Progress Note", "row_id": 325620, "text": "58F Spanish speaking with cirrhosis and renal failure, gets usual care\n at , presented to ER after taking some drugs off the street\n and lethargy. T 100.9, BP88/50 HR 69 O2 99%2L, she was initially given\n Narcan 0.4mg with some improvement in mental status and dose was\n repeated X 2. She had a low grade fever T 100.9 and LP was done.\n Prior to LP, she was given ceftriaxone 2 grams. She continued to be\n lethargic so received 2mg IV narcan X 2 and planned for narcan gtt,\n however, she was arousable to voice so this was not started. Last dose\n of Narcan was 10 AM . CT head and CXR in the ER were unremarkable.\n She also had a several BS in the 64-75 range and received Dextrose.\n Per ER notes additional history was obtained from family (2 daughters)\n who stated that patient abuses oxycodone, vicodin, T3 (no tyelnol in\n tox). Family denied that patient was on sulfonylureas for diabetes.\n .\n At time of transfer to the ICU, she was easily arousable. She\n complained of lower back pain, which she's had for years. Otherwise\n denies any chest pain, shortness of breath. Denies any abdominal pain,\n fevers or chills at home. Daugther thinks she took altogether 34 pills\n (vicodin and tylenol #3) over past 2-3 days. She does not think her\n mom is depressed.\n Altered mental status (not Delirium)\n Assessment:\n Pt alert, orientedx1 per HO, unable to reassess orientation throughout\n the shift d/t language barrier, following simple commands, pt is not\n displaying any signs of narcotic withdrawal, scale 0-4 with scores\n of 0 for the last several hours\n Action:\n Monitoring scale q2hrs\n Response:\n pt with low scale as noted above, no methadone required throughout\n the shift\n Plan:\n Continue scale q2hrs until then change to q4hr, pt can be\n called out to floor with change to q4hr checks, pt to receive methadone\n for \n Hypertension, benign\n Assessment:\n NBP: 163-185/62-83\n Action:\n pt given one time dose of lasix, is on home lasix and lisinipril\n Response:\n u/o with good response to lasix adm see flowsheet for objective data,\n BP continues to be high, afternoon lytes pending\n Plan:\n f/u afternoon lytes, ?restarting home lasix and lisinipril, htn dose\n not appear to be related to narcotic withdrawal given low scale as\n noted above\n Social: team in contact with daughter as next of , social work to\n follow up with daughter when available, OD is believed accidental\n daughter reiterating that pt is intermittently depressed but that she\n likes to get high and that this has happened before\n" }, { "category": "Nursing", "chartdate": "2201-05-28 00:00:00.000", "description": "Nursing Progress Note", "row_id": 325617, "text": "Altered mental status (not Delirium)\n Assessment:\n Pt alert, orientedx1 per HO, unable to reassess orientation throughout\n the shift d/t language barrier, following simple commands, pt is not\n displaying any signs of narcotic withdrawal, scale 0-4 with scores\n of 0 for the last several hours\n Action:\n Monitoring scale q2hrs\n Response:\n pt with low scale as noted above, no methadone required throughout\n the shift\n Plan:\n Continue scale q2hrs until then change to q4hr, pt can be\n called out to floor with change to q4hr checks, pt to receive methadone\n for \n Social: team in contact with daughter as next of , social work to\n follow up with daughter when available, OD is believed accidental\n daughter reiterating that pt is intermittently depressed but that she\n likes to get high and that this has happened before\n" }, { "category": "Nursing", "chartdate": "2201-05-29 00:00:00.000", "description": "Nursing Progress Note", "row_id": 325766, "text": "58F Spanish speaking with cirrhosis and renal failure, gets usual care\n at , presented to ER after taking some drugs off the street\n and lethargy. T 100.9, BP88/50 HR 69 O2 99%2L, she was initially given\n Narcan 0.4mg with some improvement in mental status and dose was\n repeated X 2. She had a low grade fever T 100.9 and LP was done.\n Prior to LP, she was given ceftriaxone 2 grams. She continued to be\n lethargic so received 2mg IV narcan X 2 and planned for narcan gtt,\n however, she was arousable to voice so this was not started. CT head\n and CXR in the ER were unremarkable. She also had a several BS in the\n 64-75 range and received Dextrose. Per ER notes additional history was\n obtained from family (2 daughters) who stated that patient abuses\n oxycodone, vicodin, T3 (no tyelnol in tox). Family denied that patient\n was on sulfonylureas for diabetes.\n .\n Daugther thinks she took altogether 34 pills (vicodin and tylenol #3)\n over past 2-3 days. She does not think her mom is depressed. Daughter\n has been calling daily for updates however has not come in to visit.\n Very concerned with mother\n lethargy. Would like to speak\n with social work about ?rehab or detox following this admission.\n During ICU stay pt responsive to narcan bolus, on narcan gtt for ~2hrs\n unable to tolerate further therapy as became very agitated and\n hypertensive, initiated scale evening of , has received one\n dose of methadone score >10\n Hypertension, benign\n Assessment:\n Pt has been hypertensive since admission with high of ~200 systolic,\n restarted on home cardiac meds last evening lisinopril and also added\n lopressor, this shift BP 168-183/68-93, pt fluid over loaded with\n generalized 2+ pitting edema\n Action:\n Increased lisinopril and lopressor doses, given one time dose of IV\n lasix\n Response:\n No significant change in BP with changes in cardiac meds\n Plan:\n Continue to monitor BP, adjust meds as needed\n Altered mental status (not Delirium)\n Assessment:\n Pt continues to be lethargic, score 0-2, no clear signs of\n withdrawal, able to follow simple commands at times although largely\n unresponsive to questions with interpreter, arouses easily to voice and\n tracks and falls back to sleep\n Action:\n Given small dose of narcan to reassess pts responsiveness in the\n setting of persistant lethargy, started on lactulose given history of\n NASH and ?encephalopathy\n Response:\n Pt responded immediately to narcan administration, score\n persistently low, responding well to lactulose\n Plan:\n Continue to monitor MS, continue to follow liver enzymes, q4hrs,\n pt called out to floor\n Diabetes Mellitus (DM), Type II\n Assessment:\n Intially in ICU stay pt hypoglycemic, this shift FSBS: 170-202, NPO\n Action:\n Following q6hr FSBS, SS humolog insulin, continues to be NPO awaiting\n decrease in lethargy\n Response:\n Ongoing\n Plan:\n ?restarting home oral glycemic agents when able to eat, continue to\n monitor FSBS q6hr and treat per SS\n" }, { "category": "Physician ", "chartdate": "2201-05-27 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 325449, "text": "Chief Complaint:\n 24 Hour Events:\n Allergies:\n Morphine\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:09 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: 37.4\nC (99.3\n HR: 86 (74 - 92) bpm\n BP: 144/63(83) {122/53(73) - 177/90(96)} mmHg\n RR: 12 (9 - 21) insp/min\n SpO2: 100%\n Total In:\n 40 mL\n 170 mL\n PO:\n TF:\n IVF:\n 40 mL\n 170 mL\n Blood products:\n Total out:\n 185 mL\n 520 mL\n Urine:\n 185 mL\n 520 mL\n NG:\n Stool:\n Drains:\n Balance:\n -145 mL\n -351 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 100%\n ABG: ///18/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 115 K/uL\n 7.3 g/dL\n 52 mg/dL\n 1.6 mg/dL\n 18 mEq/L\n 4.3 mEq/L\n 27 mg/dL\n 116 mEq/L\n 144 mEq/L\n 24.8 %\n 5.8 K/uL\n [image002.jpg]\n 10:38 PM\n 03:52 AM\n WBC\n 6.8\n 5.8\n Hct\n 31.0\n 24.8\n Plt\n 175\n 115\n Cr\n 1.6\n Glucose\n 52\n Other labs: Albumin:3.1 g/dL, Ca++:8.2 mg/dL, Mg++:1.8 mg/dL, PO4:3.9\n mg/dL\n Assessment and Plan\n 58 yof with history of CKD, Cirrhosis, BOOP and history of multiple\n drug overdoses with opiates presented to ER with lethargy.\n .\n # Lethargy - Most likely secondary to opiates given the history. Ddx\n includes infectious (low grade fever in ED, LP negative) vs. other\n toxins like benzo (tox screen negative other than benzo) vs. metabolic\n (?uremia from renal failure, not very impressive) vs. Hypoglycemia (low\n BS now but on presentation it was 157).\n - CXR, UA negative for infection, LP negative. (received ceftriaxone in\n the ER). Given history of cirrhosis may have ascities and thus would\n be improtant to rule out SBP. Would check ultrasound for asicities.\n - F/u culture data\n - CIS\n - hold sedating medications (neurontin, citalaprom)\n - Narcan 0.4mg X 1 overnight with minimal change but patient easily\n arousable at baseline. Can d/c q2 hour neuro checks.\n - Will empirically give thimaine and folate for now eventhough daughter\n denies etoh , ask pt in AM.\n - If no improvement in lethargy by AM would consider gettign RPR, TSH,\n B12 in AM and consider treatment with lactulose although Urea only\n 30's.\n .\n #Overdose: Chronic issue for this substance abusing patient.\n - social work consult this AM.\n - Obtain OSH records\n - Discuss with family.\n .\n # Acute renal failure - Unclear baseline(daughter stated she has some\n kidney failure). Improved with IVF in ER. Unclear baseline. clearly\n volume overloaded on exam.\n - Urine Lytes equivocal with FeUrea of 35%\n - holding lasix, lisinpril for now. Will need to get baseline labs\n from in AM.\n .\n # Anemia - hct 29.6, unclear baseline, maybe from liver disease (MCV\n 96) versus CKD\n - B12 and folate normal, Fe Sat 22%, Ferritin nml - Mixed picture with\n Anemia of chronic disease,\n - Continue PPI\n - Guaiac stools\n - Recheck AM labs as anticipate spurious value this AM.\n .\n #BOOP: Continue home prednisone dose, nebulizers PRN.\n - Follow oxygenation\n - Consider restarting lasix PRN.\n .\n # DM - hold glargine insulin for now and check fingersticks q2 given\n some low BS in the ER.\n .\n # Hyperkalemia - hemolysis. resolved.\n .\n # Cirrhosis - LFTs unremarkable but carries a diagnosis per history.\n Would hold lasix for now and reassess once we have baseline info from\n .\n - Check albumin\n - Would get abdominal ultrasound to evaluate for liver texture and\n ascities.\n .\n # Chronic low back pain - would hold off on gabapentin and narcotics\n for now.\n .\n # Chronic lund disease/BOOP - would continue prednisone at 5mg\n - nebs prn\n .\n # FEN - NPO for now until more arousable.\n # ppx - sc heparin, ppi (on it at home)\n # Communication/HCP - Daughter # .\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 09:05 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": "2201-05-29 00:00:00.000", "description": "Nursing Progress Note", "row_id": 325758, "text": "58F Spanish speaking with cirrhosis and renal failure, gets usual care\n at , presented to ER after taking some drugs off the street\n and lethargy. T 100.9, BP88/50 HR 69 O2 99%2L, she was initially given\n Narcan 0.4mg with some improvement in mental status and dose was\n repeated X 2. She had a low grade fever T 100.9 and LP was done.\n Prior to LP, she was given ceftriaxone 2 grams. She continued to be\n lethargic so received 2mg IV narcan X 2 and planned for narcan gtt,\n however, she was arousable to voice so this was not started. CT head\n and CXR in the ER were unremarkable. She also had a several BS in the\n 64-75 range and received Dextrose. Per ER notes additional history was\n obtained from family (2 daughters) who stated that patient abuses\n oxycodone, vicodin, T3 (no tyelnol in tox). Family denied that patient\n was on sulfonylureas for diabetes.\n .\n Daugther thinks she took altogether 34 pills (vicodin and tylenol #3)\n over past 2-3 days. She does not think her mom is depressed. Daughter\n has been calling daily for updates however has not come in to visit.\n Very concerned with mother\n lethargy. Would like to speak\n with social work about ?rehab or detox following this admission.\n During ICU stay pt responsive to narcan bolus, on narcan gtt for ~2hrs\n unable to tolerate further therapy as became very agitated and\n hypertensive, initiated scale evening of , has received one\n dose of methadone score >10\n Hypertension, benign\n Assessment:\n Pt has been hypertensive since admission with high of ~200 systolic,\n restarted on home cardiac meds last evening lisinopril and also added\n lopressor, this shift BP 168-183/68-93, pt fluid over loaded with\n generalized 2+ pitting edema\n Action:\n Increased lisinopril and lopressor doses, given one time dose of IV\n lasix\n Response:\n No significant change in BP with changes in cardiac meds\n Plan:\n Continue to monitor BP, adjust meds as needed\n Altered mental status (not Delirium)\n Assessment:\n Pt continues to be lethargic, score 0-2, no clear signs of\n withdrawal, able to follow simple commands at times although largely\n unresponsive to questions with interpreter, arouses easily to voice and\n tracks and falls back to sleep\n Action:\n Given small dose of narcan to reassess pts responsiveness in the\n setting of persistant lethargy, started on lactulose given history of\n NASH and ?encephalopathy\n Response:\n Pt responded immediately to narcan administration, score\n persistently low, responding well to lactulose\n Plan:\n Continue to monitor MS, continue to follow liver enzymes, q4hrs,\n pt called out to floor\n Diabetes Mellitus (DM), Type II\n Assessment:\n Intially in ICU stay pt hypoglycemic, this shift FSBS: 170-202, NPO\n Action:\n Following q6hr FSBS, SS humolog insulin, continues to be NPO awaiting\n decrease in lethargy\n Response:\n Ongoing\n Plan:\n ?restarting home oral glycemic agents when able to eat, continue to\n monitor FSBS q6hr and treat per SS\n" }, { "category": "Nursing", "chartdate": "2201-05-29 00:00:00.000", "description": "Nursing Progress Note", "row_id": 325748, "text": "Hypertension, benign\n Assessment:\n Pt has been hypertensive since admission with high of ~200 systolic,\n restarted on home cardiac meds last evening lisinopril and also added\n lopressor, this shift BP 168-183/68-93, pt fluid over loaded with\n generalized 2+ pitting edema\n Action:\n Increased lisinopril and lopressor doses, given one time dose of IV\n lasix\n Response:\n No significant change in BP with changes in cardiac meds\n Plan:\n Continue to monitor BP, adjust meds as needed\n Diabetes Mellitus (DM), Type II\n Assessment:\n Action:\n Response:\n Plan:\n Altered mental status (not Delirium)\n Assessment:\n Action:\n Response:\n Plan:\n" } ]

[ { "category": "Radiology", "chartdate": "2104-06-08 00:00:00.000", "description": "R ANKLE (AP, LAT & OBLIQUE) RIGHT", "row_id": 1142878, "text": " 9:06 AM\n ANKLE (AP, LAT & OBLIQUE) RIGHT Clip # \n Reason: r/o fracture\n Admitting Diagnosis: HEAD INJURY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 41 y.o. female intoxicated, unrestrained driver in MVC with ejection now\n intubated after mental status changes in the field.\n REASON FOR THIS EXAMINATION:\n r/o fracture\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Motor vehicle accident, to assess for fracture.\n\n FINDINGS: Three views show a mildly distracted intra-articular fracture of\n the medial malleolus.\n\n\n" }, { "category": "Radiology", "chartdate": "2104-06-08 00:00:00.000", "description": "R ELBOW (AP, LAT & OBLIQUE) RIGHT", "row_id": 1142879, "text": " 9:07 AM\n ELBOW (AP, LAT & OBLIQUE) RIGHT; WRIST(3 + VIEWS) RIGHT Clip # \n FOREARM (AP & LAT) RIGHT\n Reason: assess fracture\n Admitting Diagnosis: HEAD INJURY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 41 y.o. female intoxicated, unrestrained driver in MVC with ejection now\n intubated after mental status changes in the field.\n REASON FOR THIS EXAMINATION:\n assess fracture\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: MVC, to assess for fracture.\n\n FINDINGS: Overlying cast greatly obscures detail. In comparison with the\n study of , there is little overall change in the appearance of the\n horizontal fracture of the distal radius.\n\n\n" }, { "category": "Radiology", "chartdate": "2104-06-09 00:00:00.000", "description": "R TIB/FIB (AP & LAT) RIGHT", "row_id": 1143053, "text": " 2:46 PM\n TIB/FIB (AP & LAT) RIGHT; KNEE (2 VIEWS) RIGHT Clip # \n Reason: RT ANKLE FX; EVAL FOR FIBULA FX AND RT KNEE PAIN\n Admitting Diagnosis: HEAD INJURY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 41 year old woman with malleolar fracture.\n REASON FOR THIS EXAMINATION:\n Does patient have a fibular fracture.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Malleolar fracture, to assess for fibular fracture.\n\n FINDINGS: Views of the knee and leg show no evidence of proximal fibular\n fracture. The medial malleolar fracture is again seen.\n\n\n" }, { "category": "Radiology", "chartdate": "2104-06-06 00:00:00.000", "description": "TRAUMA #3 (PORT CHEST ONLY)", "row_id": 1142708, "text": " 9:56 PM\n TRAUMA #3 (PORT CHEST ONLY) Clip # \n Reason: TRAUMA\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Trauma.\n\n COMPARISON: No prior studies available.\n\n FINDINGS: Supine chest radiograph on the trauma board. Underlying trauma\n board limits evaluation. The cardiomediastinal and hilar contours are\n unremarkable. The lungs are well expanded and clear. No pleural effusions or\n pneumothorax is detected. Endotracheal tube is positioned 5.3 cm above the\n carina. The nasogastric tube ends at the level of the lower esophagus, not\n within the stomach.\n\n IMPRESSION:\n 1. Recommended further advancement of the nasogastric tube, which terminates\n at the level of the lower esophagus.\n 2. No other acute cardiopulmonary pathology detected.\n\n" }, { "category": "Radiology", "chartdate": "2104-06-06 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1142712, "text": " 10:18 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: Eval for trauma\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 37 year old woman with motorcycle crash\n REASON FOR THIS EXAMINATION:\n Eval for trauma\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: ENYa FRI 10:47 PM\n No acute intracranial injury. Calvarium intact. Minimally displaced right\n nasal bone fx, with a small AFL in the right maxillary sinus.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 41-year-old woman status post motor vehicle collision, ejected, and\n landed 30 feet away. Assess for acute trauma.\n\n COMPARISONS: None.\n\n TECHNIQUE: Non-contrast MDCT images were acquired through the head.\n Multiplanar reformatted images were obtained for evaluation.\n\n FINDINGS: There is no acute intracranial hemorrhage, edema, mass effect, or\n major vascular territorial infarct. The ventricles and sulci are normal in\n size and symmetric in configuration. There is no shift of the normally\n midline structures. The -white matter differentiation is well preserved.\n There is a minimally displaced right nasal bone fracture. An air-fluid level\n in the right maxillary sinus may be due to recent intubation. The visualized\n orbital floors and lamina papyracea are normal. There are scattered\n fluid-filled left mastoid air cells, but the remaining paranasal sinuses and\n right mastoid air cells are clear. Slight soft tissue swelling is noted in\n the left parietal region (image 2:11).\n\n IMPRESSION:\n 1. No acute intracranial traumatic injury.\n 2. Minimally displaced right nasal bone fracture.\n\n" }, { "category": "Radiology", "chartdate": "2104-06-06 00:00:00.000", "description": "CT C-SPINE W/O CONTRAST", "row_id": 1142713, "text": " 10:18 PM\n CT C-SPINE W/O CONTRAST Clip # \n Reason: eval for trauma\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 37 year old woman with motorcycle crash\n REASON FOR THIS EXAMINATION:\n eval for trauma\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: ENYa FRI 10:58 PM\n 1. No acute cervical fx or malalignment.\n 2. R maxillary sinus AFLs.\n 3. Bilateral subCM thyroid nodules.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 41-year-old woman, ejected 30 feet after motor vehicle collision.\n Assess for trauma.\n\n COMPARISON: None.\n\n TECHNIQUE: Non-contrast MDCT images were acquired from the skull base to the\n cervicothoracic junction. Multiplanar reformatted images were obtained for\n evaluation.\n\n FINDINGS: The patient is status post placement of endotracheal and NG tubes.\n The NG tube is seen coiling in the oropharynx.\n\n There is no acute cervical fracture or malalignment. The vertebral body\n heights are well preserved. The prevertebral soft tissues are unremarkable.\n There is straightening of the normal cervical lordosis, likely secondary to\n external cervical collar. The visualized lung apices demonstrate minimal\n bilateral atelectasis but no pneumothorax. The thyroid is slightly\n heterogeneous without a focal mass. There is minimal left paracentral disc\n bulging at C5-6 which indents the left ventral thecal sac. Again noted is an\n air-fluid level in the right maxillary sinus. Scattered fluid-filled left\n mastoids air cells are noted. The left maxillary sinus and the right mastoid\n air cells are clear.\n\n IMPRESSION:\n 1. No acute cervical fracture or malalignment.\n 2. NG tube coiled in the oropharynx.\n 3. Air-fluid level in the right maxillary sinus, likely due to recent\n intubation.\n\n" }, { "category": "Radiology", "chartdate": "2104-06-06 00:00:00.000", "description": "CT CHEST W/CONTRAST", "row_id": 1142714, "text": " 10:21 PM\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: trauma\n Field of view: 36 Contrast: OPTIRAY Amt:\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 37 year old woman with trauma\n REASON FOR THIS EXAMINATION:\n trauma\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: ENYa FRI 11:12 PM\n 1. R radius fracture and R elbow fracture.\n 2. No acute TORSO traumatic injury.\n 3. NGT tip in the distal esophageal. Distended stomach.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 41-year-old woman, with trauma from motor vehicle collision.\n\n COMPARISON: None.\n\n TECHNIQUE: MDCT images were acquired from the thoracic inlet to the pubic\n symphysis after the administration of IV contrast per CT trauma protocol.\n Multiplanar reformatted images were obtained for evaluation.\n\n SCOUT RADIOGRAPHS: A right distal radial fracture is noted, but incompletely\n assessed. There may be deformity of the right elbow, for which further\n radiographic assessment is recommended. The tip of nasogastric tube terminates\n in the distal esophagus.\n\n CT CHEST WITH IV CONTRAST: The patient is status post intubation where the\n endotracheal tube terminates approximately 2.3 cm above the carina. There are\n mild bibasilar atelectasis. The lungs are otherwise symmetrically expanded,\n without pneumothorax, pleural effusions, or focal airspace consolidations.\n There is no suspicious pulmonary mass or nodule. The heart is normal in size\n without pericardial effusion. The great mediastinal vessels are intact\n without evidence of acute vascular injury. There is no mediastinal, hilar, or\n axillary lymphadenopathy.\n\n CT ABDOMEN WITH CONTRAST: Mild periportal edema is compatible with IV fluid\n resuscitation. The liver is otherwise normally enhancing without focal\n lesions. The gallbladder, spleen, pancreas, adrenal glands, and kidneys are\n normal. There is prompt excretion of IV contrast into the collecting system\n and proximal ureters. The stomach is mildly distended. The duodenum and\n loops of small bowel are normal. Of note, there is a slight haziness of the\n fat about the celiac axis, which may represent lymphatic engorgement secondary\n to IV fluid resuscitation. The contour of the aorta and celiac axis are\n smooth, and no contrast extravasation is present. There is no free fluid,\n air, or lymphadenopathy in the abdomen. There are bilateral breast implants.\n\n CT PELVIS WITH CONTRAST: Apparent wall thickening of the right colon may be\n due to underdistention. The remainder of the colon is otherwise unremarkable.\n (Over)\n\n 10:21 PM\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: trauma\n Field of view: 36 Contrast: OPTIRAY Amt:\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n The urinary bladder is seen with an indwelling Foley catheter, but remains\n normally distended without focal abnormalities. The uterus is normal. There\n is no free fluid, air, or lymphadenopathy in the pelvis.\n\n BONE WINDOWS: Besides the right radial fracture noted in the scout\n radiographs, there is no acute fracture or dislocation. The cervical,\n thoracic, lumbar spines are normal in alignment. There is no suspicious lytic\n or sclerotic lesion.\n\n IMPRESSION:\n\n 1. Right distal radial fracture, incompletely assessed on this study.\n Possible deformity of the right elbow. Dedicated radiographs of these regions\n are recommended.\n\n 2. No acute traumatic injuries in the torso.\n\n 3. Nasogastric tube terminates in the distal esophagus for which advancement\n is recommended. Mildly distended stomach.\n\n" }, { "category": "Radiology", "chartdate": "2104-06-06 00:00:00.000", "description": "R WRIST(3 + VIEWS) RIGHT", "row_id": 1142716, "text": " 10:55 PM\n WRIST(3 + VIEWS) RIGHT Clip # \n Reason: fx\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 37 year old woman with fx\n REASON FOR THIS EXAMINATION:\n fx\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 37-year-old woman with trauma.\n\n COMPARISON: No prior studies available.\n\n TWO VIEWS OF THE RIGHT FOREARM: There is a transverse fracture through the\n distal radial diaphysis, with displacement and angulation of the fracture\n fragments with mild overriding. Assessment of the right wrist does not\n demonstrate obvious fracture or dislocation. Overlying fiber glass cast\n limits evaluation.\n\n IMPRESSION: Transverse fracture of the distal radial diaphysis with mild\n overlap of the fracture fragments.\n\n" }, { "category": "Radiology", "chartdate": "2104-06-07 00:00:00.000", "description": "RP ELBOW (AP, LAT & OBLIQUE) RIGHT PORT", "row_id": 1142753, "text": " 8:27 AM\n ELBOW (AP, LAT & OBLIQUE) RIGHT PORT Clip # \n Reason: FX OF FOREARM, CHECK ELBOW AREA\n Admitting Diagnosis: HEAD INJURY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 41 year old woman with elbow pain s/p trauma\n REASON FOR THIS EXAMINATION:\n Fracture\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Elbow pain status post trauma fracture.\n\n RIGHT ELBOW, THREE VIEWS: Technologist note is as follows: \"Patient in\n splint, positioning was limited.\"\n\n Detail slightly obscured by overlying splint. Allowing for this, the elbow\n joint appears congruent. The ulnar-trochlear and radio-capitellar\n articulations appear congruent on these views. No obvious fracture or effusion\n is identified. A fracture of the distal radius is demonstrated on the\n previous forearm film, but is not included on the current film. If there is\n continuing clinical suspicion for an abnormality involving the right elbow,\n then further assessment without the splint or by CT may be of help.\n\n\n" }, { "category": "Radiology", "chartdate": "2104-06-10 00:00:00.000", "description": "RO FOREARM (AP & LAT) RIGHT IN O.R.", "row_id": 1143190, "text": " 11:44 AM\n FOREARM (AP & LAT) RIGHT IN O.R.; UPPER EXTREMITY FLUORO WITHOUT RADIOLOGIST IN O.R. RIGHTClip # \n Reason: ORIF\n Admitting Diagnosis: HEAD INJURY\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: ORIF.\n\n Fluoroscopic assistance provided to surgeon in the OR without the radiologist\n present. Ten spot views obtained. These demonstrate steps related to surgery\n involving the right forearm. Fluoro time recorded as 13.2 seconds on the\n electronic requisition. Correlation with real-time findings and when\n appropriate conventional radiographs recommended for full assessment.\n\n\n" }, { "category": "Radiology", "chartdate": "2104-06-10 00:00:00.000", "description": "RO ANKLE (AP, LAT & OBLIQUE) RIGHT IN O.R.", "row_id": 1143191, "text": " 11:46 AM\n ANKLE (AP, LAT & OBLIQUE) RIGHT IN O.R.; LOWER EXTREMITY FLUORO WITHOUT RADIOLOGIST IN O.R. RIGHTClip # \n Reason: ORIF\n Admitting Diagnosis: HEAD INJURY\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Fracture. ORIF\n\n FINDINGS: Intraoperative study of the right ankle demonstrates interval\n placement of two lag screws through the medial malleolus. The fracture line\n is poorly seen. There are no signs of hardware-related complications. The\n total intraservice fluoroscopic time was 15.4 seconds.\n\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2104-06-08 00:00:00.000", "description": "R FOREARM (AP & LAT) SOFT TISSUE RIGHT", "row_id": 1142939, "text": " 4:55 PM\n FOREARM (AP & LAT) SOFT TISSUE RIGHT Clip # \n Reason: Post reduction\n Admitting Diagnosis: HEAD INJURY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 41 year old woman with right radial shaft fracture. Please image through mid\n forearm, as well as wrist.\n REASON FOR THIS EXAMINATION:\n Post reduction\n ______________________________________________________________________________\n WET READ: YGd SUN 5:43 PM\n No significant change since 8hs ago. Cast material obscures view. Displaced\n distal radial diaphyseal fracture redemonstrated with overriding fragments;\n extend of overriding similary to earlier today. x pg .\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Radial shaft fracture.\n\n FINDINGS: In comparison with the study of , there is better apposition and\n less overriding of the fracture fragments on the AP view. Cast again greatly\n obscures detail.\n\n\n" }, { "category": "Radiology", "chartdate": "2104-06-07 00:00:00.000", "description": "RP FOREARM (AP & LAT) RIGHT PORT", "row_id": 1142745, "text": " 5:08 AM\n FOREARM (AP & LAT) RIGHT PORT Clip # \n Reason: eval for interval change\n Admitting Diagnosis: HEAD INJURY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 41 year old woman with distal right radius fracture, now s/p closed reduction.\n REASON FOR THIS EXAMINATION:\n eval for interval change\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Distal right radial fracture status post closed reduction, question\n interval change.\n\n RIGHT FOREARM: Two portable views. A cast is in place, slightly limiting\n detail.\n\n Again seen is a fracture through the distal right radial diaphysis. Compared\n with , there has been shift in relative position of the 2 radius\n fracture fragments. On the lateral view, there has been considerable\n improvement in alignment and decrease of overriding. There is now cortical\n width dorsal displacement of the distal fragment and slightly more than\n cortical width lateral displacement of the distal fragment, with very minimal\n medial apex angulation. The distal radioulnar joint appears congruent on\n these views. Please see separate report of the right elbow.\n\n" }, { "category": "ECG", "chartdate": "2104-06-08 00:00:00.000", "description": "Report", "row_id": 232051, "text": "Sinus rhythm. Baseline artifact. Low precordial lead voltage. No previous\ntracing available for comparison.\n\n" } ]

[ { "category": "Radiology", "chartdate": "2159-11-28 00:00:00.000", "description": "P BABYGRAM (CHEST & ABDOMEN) PORT", "row_id": 778804, "text": " 10:50 AM\n BABYGRAM (CHEST & ABDOMEN) PORT Clip # \n Reason: RESP DISTRESS, S/P INDOCIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Infant with respiratory distress at 27 weeks\n REASON FOR THIS EXAMINATION:\n RESP DISTRESS, S/P INDOCIN\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE AP CHEST AND ABDOMEN:\n\n CLINICAL HISTORY: Respiratory distress and abdominal distention.\n\n A nasogastric tube is present with its tip in the fundus of the stomach.\n Minimal non-specific distention of multiple bowel loops. No evidence of\n pneumatosis or free peritoneal air identified. The lungs are markedly\n hypoinflated probably due to technique. No other significant abnormalities\n are identified.\n\n\n" }, { "category": "Radiology", "chartdate": "2159-11-16 00:00:00.000", "description": "NEONATAL HEAD PORTABLE", "row_id": 777728, "text": " 7:12 AM\n NEONATAL HEAD PORTABLE Clip # \n Reason: PREMATURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Infant former 27 week twin, now 6 do\n REASON FOR THIS EXAMINATION:\n r/o ivh\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: Infant former 27 week twin, now 6th day of life, r/o IVH.\n\n No prior studies are available for comparison.\n\n The ventricles are symmetric in appearance. There is no evidence of\n intraventricular or intraparenchymal hemorrhage. There is a cavum vergae and\n the gyral and sulcation pattern is normal for the baby's expected gestational\n age.\n\n The extra-axial CSF spaces are unremarkable.\n\n IMPRESSION: No evidence of intraventricular or intraparenchymal hemorrhage.\n\n" }, { "category": "Radiology", "chartdate": "2159-11-13 00:00:00.000", "description": "BABYGRAM (CHEST & ABDOMEN)", "row_id": 777547, "text": " 3:52 PM\n BABYGRAM (CHEST & ABDOMEN) Clip # \n Reason: PICC line placement.include left shoulder\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Infant with prematurity, PICC line\n REASON FOR THIS EXAMINATION:\n PICC line placement.include left shoulder\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST AND ABDOMEN, :\n\n CLINICAL HISTORY: Premature infant. Assess PICC line placement.\n\n FINDINGS: There is a left-sided PICC line with its tip in the right atrium.\n There is an NG tube with its tip in the stomach. The lungs are moderately\n hyperinflated. Heart size is normal. There is a moderate ground-glass\n appearance of the lung parenchyma in keeping with RDS.\n\n The abdominal bowel gas pattern demonstrates mild gaseous distention of bowel\n loops, slightly improved compared to the prior examination. No other\n abnormality is noted.\n\n" }, { "category": "Radiology", "chartdate": "2159-11-23 00:00:00.000", "description": "P BABYGRAM (CHEST ONLY) PORT", "row_id": 778363, "text": " 9:18 AM\n BABYGRAM (CHEST ONLY) PORT Clip # \n Reason: r/o cardiac anomaly\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Infant with prematurity, murmur, on cpap\n REASON FOR THIS EXAMINATION:\n r/o cardiac anomaly\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Rule out cardiac anomaly. Infant with prematurity, murmur on C-PAP.\n\n Study is limited due to overlying artifact. Heart size is within normal\n limits. No gross pulmonary abnormalities are seen. The vascularity is grossly\n within normal limits.\n\n NG tube terminates in the stomach.\n\n IMPRESSION: Limited study, normal chest.\n\n" }, { "category": "Radiology", "chartdate": "2159-11-23 00:00:00.000", "description": "BABYGRAM (CHEST ONLY)", "row_id": 778331, "text": " 4:57 AM\n BABYGRAM (CHEST ONLY) Clip # \n Reason: assess heart size\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Infant with new onset of heart murmur, 1 week old, 27 week infant\n REASON FOR THIS EXAMINATION:\n assess heart size\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Infant with new onset murmur.\n\n The heart size is slightly greater than on the previous examination performed\n on . The lungs are low volume with the right lower than the left.\n There is a suggestion of a right pleural effusion having developed. There is a\n nasogastric tube in the thigh. Diffuse bowel gas distention is also\n identified.\n\n" }, { "category": "Radiology", "chartdate": "2159-11-13 00:00:00.000", "description": "BABYGRAM (CHEST ONLY)", "row_id": 777557, "text": " 5:55 PM\n BABYGRAM (CHEST ONLY) Clip # \n Reason: s/p PICL readjustment.\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Infant with above.\n REASON FOR THIS EXAMINATION:\n s/p PICL readjustment.\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST, :\n\n CLINICAL HISTORY: PICC line readjustment.\n\n FINDINGS: The current study is compared to the preceding film dated earlier\n the same day. There is a left-sided PICC line with its tip now located in the\n region of the junction of the SVC with the right atrium. There is an NG tube\n with its tip in the stomach. There is persistent moderate hyperinflation of\n the lungs. The heart size is normal. There is a moderate ground-glass\n appearance of the lung parenchyma bilaterally, somewhat improved compared to\n the prior examination. No other abnormality is noted.\n\n" }, { "category": "Radiology", "chartdate": "2159-11-10 00:00:00.000", "description": "P BABYGRAM (CHEST & ABDOMEN) PORT", "row_id": 777312, "text": " 10:00 PM\n BABYGRAM (CHEST & ABDOMEN) PORT Clip # \n Reason: umbilical lines repositioned, ? tip postion\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Infant with respiratory distress at 27 weeks\n REASON FOR THIS EXAMINATION:\n umbilical lines repositioned, ? tip postion\n ______________________________________________________________________________\n FINAL REPORT\n\n\n CHEST AND ABDOMEN, :\n\n CLINICAL INDICATION: Respiratory distress at 27 weeks.\n\n FINDINGS: A single frontal portable view of the chest and abdomen was\n performed. Diffuse opacification throughout both lungs is again noted. This\n is consistent with surfactant deficiency. Since the prior study, UAC has been\n withdrawn several cm, now terminating at approximately the T7 level, in\n satisfactory position. ETT terminates at the thoracic inlet. Several\n nondilated gas-filled loops of bowel are again identified throughout the\n abdomen without evidence for focal obstruction. The demonstrated osseous\n structures are intact.\n\n" }, { "category": "Radiology", "chartdate": "2159-11-10 00:00:00.000", "description": "P BABYGRAM (CHEST & ABDOMEN) PORT", "row_id": 777304, "text": " 7:58 PM\n BABYGRAM (CHEST & ABDOMEN) PORT Clip # \n Reason: check lungs, ett, umbilical lines\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Infant with respiratory distress at 27 weeks\n REASON FOR THIS EXAMINATION:\n check lungs, ett, umbilical lines\n ______________________________________________________________________________\n FINAL REPORT\n CHEST, , AT 20:05 HOURS: There is no prior study for comparison. The\n cardiomediastinal silhouette is normal. There is hazy fine opacities\n throughout the lungs consistent with hyaline membrane disease. The ETT is\n half a cm above the carina. The umbilical venous line is in the right portal\n vein. The umbilical artery line is at the level of T2. The visualized bowel\n gas is normal.\n\n IMPRESSION:\n 1) Hyaline membrane disease.\n 2) The umbilical and arterial lines need to be repositioned.\n\n" }, { "category": "Radiology", "chartdate": "2159-11-12 00:00:00.000", "description": "P BABYGRAM (CHEST & ABDOMEN) PORT", "row_id": 777485, "text": " 10:07 PM\n BABYGRAM (CHEST & ABDOMEN) PORT Clip # \n Reason: check placement of newly placed PICC, assess lung expansion\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Infant with respiratory distress at 27 weeks\n please include left leg in film\n REASON FOR THIS EXAMINATION:\n check placement of newly placed PICC\n assess lung expansion on CPAP(increased fio2 requirement)\n ______________________________________________________________________________\n FINAL REPORT\n\n HISTORY: Infant with respiratory distress. Newly placed PICC line.\n\n PICC line in place from the left lower extremity can be followed to the left\n hemipelvis to the level of S1. Umbilical venous catheter reaches right\n atrium. There is diffuse gaseous distension of the abdomen. There is nothing\n to suggest obstruction or NEC.\n\n The lungs are diffusely hazy but show improved aeration compared to .\n Heart size is normal. The patient has been extubated on .\n\n\n" }, { "category": "Radiology", "chartdate": "2159-12-17 00:00:00.000", "description": "P BABYGRAM (CHEST ONLY) PORT", "row_id": 780435, "text": " 10:43 AM\n BABYGRAM (CHEST ONLY) PORT Clip # \n Reason: murmur\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Infant with prematurity, hx of PDA\n REASON FOR THIS EXAMINATION:\n murmur\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Patent ductus arteriosus.\n\n FINDINGS: This study was made available for interpretation on . There\n is hazy opacification throughout both lungs, in the setting of low lung\n volumes. This suggests at least some degree of surfactant deficiency. The\n cardiac silhouette is perhaps mildly enlarged. Co-existing edema may be\n present. Overall appearance of the chest is not significantly changed since\n , allowing for slight differences in technique. The patient's name\n badge partially obscures the left upper chest. There is a nasogastric tube,\n whose distal tip projects over the expected location of the stomach.\n\n" }, { "category": "Radiology", "chartdate": "2159-12-12 00:00:00.000", "description": "NEONATAL HEAD PORTABLE", "row_id": 780027, "text": " 7:28 AM\n NEONATAL HEAD PORTABLE Clip # \n Reason: 27 WEEK TWIN NOW 1 MO OLD R/O PVL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Infant former 27 week twin, now1 month old\n REASON FOR THIS EXAMINATION:\n r/o pvl\n ______________________________________________________________________________\n FINAL REPORT\n The patient is a former 27 week gestational age twin.\n\n Comparison is done to the exam of . The grey white matter\n differentiation is normal for the patient's age. There is no hydrocephalus.\n There is no evidence of hemorrhage. There is no evidence of periventricular\n leukomalacia.\n\n IMPRESSION: Normal head ultrasound.\n\n" }, { "category": "Echo", "chartdate": "2159-11-23 00:00:00.000", "description": "Report", "row_id": 74065, "text": "PATIENT/TEST INFORMATION:\nIndication: Congenital heart disease.\nStatus: Inpatient\nDate/Time: at 08:31\nTest: Portable TTE(Congenital, complete)\nDoppler: Complete pulse and color flow\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\n\n\nConclusions:\nPediatric study. Report will be generated by .\n\n\n" }, { "category": "Echo", "chartdate": "2159-11-28 00:00:00.000", "description": "Report", "row_id": 74011, "text": "PATIENT/TEST INFORMATION:\nIndication: Congenital heart disease.\nStatus: Inpatient\nDate/Time: at 08:41\nTest: Portable TTE(Congenital, complete)\nDoppler: Complete pulse and color flow\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\n\n\nConclusions:\nPediatric study. Report will be generated by .\n\n\n" }, { "category": "Nursing/other", "chartdate": "2159-11-27 00:00:00.000", "description": "Report", "row_id": 1699510, "text": "Neonatology Attending\nDOL 17\n\n is in NC 400 cc/min of 25-30% FIO2. Eight bradycardias in 24 hours, on caffeine.\n\nMurmur persists. BP 88/42 (54).\n\nWt 1190 (+20) on TFI 140 cc/kg/day, including enteral feeds PE20 at 80 cc/kg/day. Urine output 2.4 cc/kg/hr. Abdomen benign.\n\nTemperature stable in air isolette.\n\nA&P\nPreterm infant with respiratory and feeding immaturity, resolving surfactant deficiency, s/p indomethacin for PDA.\n\nWe will follow the murmur clinically for now and consider repeating echo if persistent.\n\nContinue to advance enteral feeds as tolerated (previously at full feeds).\n" }, { "category": "Nursing/other", "chartdate": "2159-11-27 00:00:00.000", "description": "Report", "row_id": 1699511, "text": "fellows exam note\ncomfortable\nHeent: Afof\nlungs: cta and equal with occ crackles\nheart: no murmur appreciated, nl s1/s2, equal and nl pulses throughout X 4\nabd: soft, mildly distended, NT\next: intact\nneuro; nonfocal\n" }, { "category": "Nursing/other", "chartdate": "2159-11-27 00:00:00.000", "description": "Report", "row_id": 1699512, "text": "NPn 7a-7p\n\n\nResp: Infant remains in NC 02 400cc flow fio232-40%. RR\n30-60's. Conts with ic/sc retractions. Infant had 4 bradys\nso far this shift. Conts on caffiene. Cont to wean 02 as\ntol.\n\nFen: Infant conts on tf 140cc/kg. Rec infant with pn d10w\ninfusing at 60cc/kg iv infiltated at 1200. Enteral feeds\nincreased to 100cc/kg and iv remains out. Will cont to\nadvance 40cc/kg at 04&16. Abd soft full. Active bs. NO\nstool thus far. Voiding lg amounts with each diaper change.\nmod spit x1 thus far. Minimal aspirates. Cont to advance\nfeeds at tol.\n\nDev: Temp stable in airmode isolette. Alert and active with\ncares. Swaddled with tshirt and hat. Irritable at times with\ncares. Sm amount of eye drainage noted in left eye. Cleansed\nwith sterile h20. Likes pacifier. Cont to support\ndevelopmental needs.\n\nParenting: Mom called x1 for update. will be in this\nevening. Cont to support and update.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2159-11-11 00:00:00.000", "description": "Report", "row_id": 1699412, "text": "Neonatology - NNP Progress Note\n\nInfant is active, responds appropriately to stimuli. AFOF. He is pink, well perfused, pulses of normal quality/character, sl active precordium, no murmur auscultated. He is stable on CMV with settings of 18/5 x 20 x 21% FIO2. Breath sounds clear and equal. Total fluids @ 100cc/kg/day. IV fluids of D10W infusing via UAC and PIV.DS increasing over course of day to 250 range. D5W piggybacked into IV D10W. UO 3.3cc/kg/day. No stool yet. Abd soft, hypoactive bowel sounds, no loops. Remains on amp/gent. Please refer to neonatology attending note for detailed plan.\n" }, { "category": "Nursing/other", "chartdate": "2159-11-11 00:00:00.000", "description": "Report", "row_id": 1699413, "text": "Respiratory Care\nBaby continues on vent settings of 17/5 x 16, fio2 21-30%, Bs coarse, sx mod cloudy secretions, rr 40-60, abg drawn 7.33/42/76/23/-3, rate decreased from 18 and pip decreased from 18. Will repeat another gas later this evening. Will wean as tolerated.\n" }, { "category": "Nursing/other", "chartdate": "2159-11-10 00:00:00.000", "description": "Report", "row_id": 1699407, "text": "Neonatology Attending\n\nPreterm infant admitted for NICU management.\n\nInfant born at 27 4/7 weeks to 28 yo G1 P0 O+, Ab-, GBS?, HBsAg-, RPR-NR woman. Antepartum remarkable for twin gestation with cerclage placed . Admitted at 24 6/7 weeks for contractions. Received betamethasone course at that time. Treated with MgSO4 and ampicillin. Readmitted to L&D on day of admission for new onset of contractions. Treated with ampicillin 6 hours prior to delivery. Decision made to deliver for possible chorio when WBC 26k noted. C/S under spinal anesthesia. Intubated at 5 min of age with # 3-0 ETT. Apgars 5, 7, 8.\n\nExam remarkable for pink preterm infant with ETT in place, with vital signs as noted, soft AF, nl facies, intact palate, moderate retractions with poor air entry, no murmur, present femoral pulses, flat soft n-t abdomen without hsm, nl phallus, stable hips, nl perfusion, nl tone/activity for GA.\n\nPreterm infant with respiratory course c/w HMD. Will administer surfactant. Will then obtain CXR. Will manage on simv. Plan umbilical vessel catheterization. Will require blood gas and non-invasive respiratory monitoring. Will also follow hemodynamic status closely.\n\nWill make NPO and infuse IV dextrose. Will require close monitoring of blood glucose, temperature, and bilirubin.\n\nGiven sepsis risk, will check cbc, blood culture. Will start ampicillin and gentamicin. Duration of antibiotic treatment to be determined by clinical course. Will likely require CSF examination.\n\nScreening studies of intracranium, retinae, hearing planned.\n\nParents aware of clinical status and immediate plan of care. Received antepartum consultation.\n\nPrimary pediatrician not currently identified. transfer from .\n\n" }, { "category": "Nursing/other", "chartdate": "2159-11-13 00:00:00.000", "description": "Report", "row_id": 1699429, "text": "Respiratory Care\nPt recieved on NP-CPAP +6cm's with the fio2 21 to 28%. Pt suctioned for a mod amt of thick white secretions. Plan is to remain on CPAP at this time.\n" }, { "category": "Nursing/other", "chartdate": "2159-11-13 00:00:00.000", "description": "Report", "row_id": 1699430, "text": "NPN 7a-7p\n\n\nREsp: Infant conts on NP cpap 6cm. Fi02 22-40%. RR 30-60's.\nConts on caffiene. Spell x1 thus far with apnea needing mild\nstim. Ls clr/=. Sxn x2 for scant white secretios. Ls clr/=.\nCont to wean 02 as tol.\n\nFen: Infant remains NPO. TF 140cc/kg. PN of d7.5 with lipids\ninfusing at 110cc/kg via picc line. D5w infusing at 30cc/kg\nd/t elevated Na today. Picc line replaced placement\nconfirmed by xray. Planned to start feeds, but infant had 1c\nof bilious apirate x2. Abd soft with loops. Ag stable 21cm.\nFellow aware. Kub done. Results pending. Will hold on\nfeeding until infant has two cares without aspirates. No\nstool. Lytes due in AM. Cont with above plan.\n\nSepsis: Cont amp and gent. Gent dose increased today.\n\nDev: Infant remains in servo isolette. Alert and irritable\nwith cares. Nested in sheepskin with boundries in place.\nSettles well in prone position. Loves pacifier. Head us\nplanned for FRi. Cont to support developmental milestones.\n\nParenting: Parnts in for 2 cares today. Mom with\ndiaper and temp. Dad still nervous with infants, but did\nsiblings temp. Family meeting todya with Fellow, \n and this RN. updated. Asking appropriate\nquestions. Cont to support and update.\n\nBili: Infant conts under single phototx. Eyes covered. Bili\nto be checked in AM.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2159-11-11 00:00:00.000", "description": "Report", "row_id": 1699414, "text": "NPN \n\n\n#1 Resp: Infant remains orally intubated w/ #2.5ETT,\nsettings initially 18/5 X20, ABG this AM 76/42/7.33/23/-3.\nVent weaned to 17/5 X16. Infant tol. vent setting well, no\nincreased work of breathing. RR 50-70. Lungs are coarse\nbefore and after suctioning. Secretions are mod. amts,\ncloudy. O2sat 94-99%.\nA: Stable on current vent settings.\nP: Cont to monitor resp status, wean from vent as\ntolerated.\n#2 F/N: Total fluids 100cc/kg/d. This am received infant w/\nUAC infusing D10 @ 4.7cc/hr. Bld. glucose 244 by 12pm. D5\nordered to infuse by PIV at 30cc/kg/d, then increased to\n50cc/kg/d. Bld. glucose to 190 by 6pm. Urine o/p 5.8cc/kg/hr\nin 18hrs. Passing mec. stools. UAC fluid to be changed to\n1/2NS w/ heparin this eve to infuse at 1cc/hr. PN now\ninfusing per PIV at 50cc/kg/d. Abd soft, full, hypoactive\nbowel snds.\nA: Hyperglycemia today, improved w/ decrease in D10. Remains\nNPO for now.\nP: Cont to monitor bld. glucose, continue fluids as ordered.\n#3 ID: Remains on Ampi/Gent as ordered. Will receive 7 days.\nWill need an LP. Bld. cultures pndg.\nA: Antibiotics for left shift and resp. distress and\nmaternal issues.\nP: Cont abx as ordered. Gent level on 3rd dose.\n#4 Dev.: Remains on an open warmer w/ stable temps. Nested\nsheepskin in place. Awake and alert w/ cares.\nA: AGA 27 .\nP: Cont dev. supports.\n#5 Parents: Mom and Dad up X2. Asking many appropriate\nquestions. Mom will br. milk for a few weeks, though\ndoes not intend to br. feed once the babies go home.\nA: Invested parents.\nP: Cont to provide dev. support.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2159-11-12 00:00:00.000", "description": "Report", "row_id": 1699415, "text": "RESPIRATORY CARE NOTE\nBaby boy #1 received intubated on vent settings 17/5 rate 16 FiO2 21-28%. Suctioned ETT for sm-mod amt of white secretions. Breath sounds are coarse. Abg PO2 82 CO2 51 PH 7.26 24 -4 no vent changes made. Stable on current vent settings cont to follow.\n" }, { "category": "Nursing/other", "chartdate": "2159-11-15 00:00:00.000", "description": "Report", "row_id": 1699440, "text": "Respiratory Care\nPt cont on NP CPAP. fio2 21. Weaned CPAP level to 5cmH20. bs clear, rr 40's. On caffeine. 1 spell noted this shift. Plan to support as needed. Will follow.\n" }, { "category": "Nursing/other", "chartdate": "2159-11-15 00:00:00.000", "description": "Report", "row_id": 1699441, "text": "NPN 0700-1900\n\n\nRESP: Received infant on NP CPAP 6, FiO2 21%. Weaned infant\nto NP CPAP 5. Continues to be in 21%. O2sat 94-98%. RR\n30-50's with mild IC/SC rtx. LS clear and equal. Sxn'd X2\nfor sm amt of white secretions via ETT and sm white oral\nsecretions. Infant had one spell, hr 59, sat 91%. Cont on\ncaffeine.\n\nFEN: bw=1135g. TF=150cc/kg/d. Currently receiving IVF at\n130cc/kg of PND8 and IL via central PICC, enteral feeds of\nBM/PE20 at 20cc/kg, advancing 10cc/kg . Tolerating well.\nBelly is soft and full. +BS, AG stable. No loops, no stools.\nInfant had two bilious aspirates, fellow aware. Continue to\nfeed as planned. UO=1.9cc/kg/hr x12hr.\n\nSepsis: VSS. Continues on amp and gent. Plan to check gent\nlevels tonight. Plan for LP tomorrow.\n\nDEV: AFSF. MAE. Temp stable, nested on sheepskin in\nservo-controlled isolette. Irritable at times, settles\neasily with containment and paci. Kangaroo'd today X45 min.\ntolerated well.\n\n: Mom and dad in to visit this afternoon. Updated at\nbedside. Providing cares. Mom requesting lactation consult.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2159-11-15 00:00:00.000", "description": "Report", "row_id": 1699442, "text": "addendum\n: continues on single phototherapy with eye shields on.\n" }, { "category": "Nursing/other", "chartdate": "2159-11-14 00:00:00.000", "description": "Report", "row_id": 1699431, "text": "Respiratory Care\nBaby remains on np cpap 6 28-39%.Sx npt for sm cldy secs.Stable night.\n" }, { "category": "Nursing/other", "chartdate": "2159-11-14 00:00:00.000", "description": "Report", "row_id": 1699432, "text": "NPN 1900-0730\n\n\n1. Remains in NP cpap 6, Fio2 21-35% with sats 94-99%.\nLungs clear, RR 30-50 with mild IC/SC retractions. Suction\nx1 for small cloudy secretions. On caffeine, no A&B's.\nCont to monitor need for cpap.\n\n2. Wt down 79gm to 946gm. TF 140/k/d; D7.5 PN and IL at\n110/k/d. D5 with lytes as orderd at 30/k/d. All IVF via\nPICC. Dstick 115. See flowsheet for lytes. Abd full,\ntransient soft loops, +BS. Aspirating 7-11cc air out from\nNGT. One small bilious aspirate. 24hr U/O 2.4cc/k/hr and\nno stool. Remains NPO. Cont to monitor abd closely and\nmonitor tolerance of IVF's.\n\n3. D4/7 amp and gent. VSS-see flowsheet. Dstick 115.\nAlert and irritable with cares, settles quickly after cares.\nNo apparent s/sx of sepsis. Cont to monitor for s/sx of\nsepsis and treat as per team.\n\n4. Temp stable nested in servo isolette. Awake, irritable\nwith cares, settles quickly after cares. Suckles well on\npacifier. MAE. Cont to promote development.\n\n5. No contact from .\n\n6. Remains under single phototherapy with eye shields on.\nBili this am 4.5/0.4/4.1. Color ruddy, no stool this shift.\nNPO. Cont to monitor bili as per team.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2159-11-14 00:00:00.000", "description": "Report", "row_id": 1699433, "text": "Newborn Med Attending\n\nCont on CPAP6, 26-38% O2. Occ spells. AF flat, clear BS, no murmur, abd soft, MAE. Bili=4.5, on phototherapy. WT=946 down 79 on 140 cc/kg/d Pn/Il and trophics.\nA/P: Infant with resolving RDS, As and Bs. Increase TF to 150 cc/kg/d. Cont amp and gent d . Cont phototherapy.\n" }, { "category": "Nursing/other", "chartdate": "2159-11-18 00:00:00.000", "description": "Report", "row_id": 1699459, "text": "NPN 7a-7p\n\n6 Hyperbilirubinemia\n7 CV:\n\nResp: Received infant this am on nasal prong cpap 5cm.\nRemains unchanged. Fi02 21%. Ls slightly coarse to clr with\nsxn. Sxn x1 for lg cloudy secretions orally and mod white\nnasally. Conts with ic/sc retractions. Remains on caffiene.\n3 spells so far this shift. Mild stim no desat hr 50's. Cont\nwith current plan.\n\nFen: Infant conts on tf 150cc/kg. IVF of pn d10w with Il\ninfusing at 70cc/kg via picc line. Enteral feeds of pe 20\nat 80cc/kg. Increasing 10cc/kg at 13&01. Abd full with\nsoft loops. NNP aware. Infant rec glycerin supp with lg mec\nstool. Ag stable 21.5-22cm. Voiding with each diaper change.\nSm spit x1. Minimal aspirates. Will check dsitck with next\ncares. Cont to increase feeds as tol.\n\nDev: Temp stable in servo isolette. Alert and active with\ncares. Settles easily with boundries in place. Sleeps well\nbetween cares. Sucks on pacifier. Brings hands to mouth.\nCont to support developmetnal milestones.\n\nParenting: Dad called x1 for update. still not\nfeeling well. Will plan to visit tommmorrw.\n\n: Rebound 2.7/0.3.\n\nCV: No murmur heard today. Hr 130-160's. Pink pulses wnl.\n\n\nREVISIONS TO PATHWAY:\n\n 6 Hyperbilirubinemia; resolved\n 7 CV:; resolved\n\n" }, { "category": "Nursing/other", "chartdate": "2159-11-18 00:00:00.000", "description": "Report", "row_id": 1699460, "text": "Respiratory Care\nPt recieved on nasal prong CPAP +5cm's with the fio2 21%. Pt's respiratory rates 30's to 60's. Plan is to follow on CPAP.\n" }, { "category": "Nursing/other", "chartdate": "2159-11-19 00:00:00.000", "description": "Report", "row_id": 1699461, "text": "RESPIRATORY CARE NOTE\nBaby #1 remains on Prong CPAP 5 FiO2 21%. Suctioned nares for mod amt of yellow secretions. Breath sounds are clear. RR 30-40's Stable on CPAP cont to follow.\n" }, { "category": "Nursing/other", "chartdate": "2159-11-16 00:00:00.000", "description": "Report", "row_id": 1699443, "text": "RESPIRATORY CARE NOTE\nBaby #1 remains on NP CPAP 6 FIO2 21-27%. Suctioned NP tube for mod amt of yellow secretions. Breath sounds are clear. RR 30-40's stable on CPAP cont to follow.\n" }, { "category": "Nursing/other", "chartdate": "2159-11-16 00:00:00.000", "description": "Report", "row_id": 1699444, "text": "Nursing progress note\n\n\n#1 O: Remains on 5cm NP CPAP, 21% O2. Breath sounds equal 7\nclear with mild IC/SC retractions. NP suctioned X's 2 for\nmod pale yel secretions. OP for sm white. Remains on\ncaffeine. Baby had 4 episodes of bradycardia with apnea\nrequiring mild stim. A: Stable. P: Suction q4h & cont to\nassess.\n#2 O: Wgt up 5gms. Total fluids remain 150cc/k/d. PN & IL\ninfusing well thru PICC @ 120cc/k/d. DS 108. UOP 1.9cc/k/h.\nNo stool. Abd soft with active bowel sounds & no loops.\nOccasional soft transient loops. PG feeds now at 30cc/k/d.\nBaby had 1.4cc aspirate of bilious secretions. Full feed\ngiven NNP. A: tolerating feed with minimal aspirates. P:\nCont to assess.\n#3 O: Blood cultures neg to date. Remains on antibiotics.\nGent levels drawn. A: Stable. P: Cont to assess.\n#4 O: Remains in servo controlled isolette. Temp stable.\nAlert with cares. Nested in sheepskin. A: AGA. P: Cont to\nassess.\n#6 O: Remains under single photo tx with eye patches on.\nAlert with cares. P: Cont to assess.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2159-11-16 00:00:00.000", "description": "Report", "row_id": 1699445, "text": "Newborn Med Attending\n\nCont on CPAP6, RA-27% O2, several spells. AF flat, clear BS, no murmur, abd soft, MAE. WT=965 up 5, on 150 cc/kg/d PE20 and PN/IL.\nA/P: Infant with residual RDS, hyperbili and As and Bs. Cont phototherapy, check . Monitor for spells. Cont to advance feeds. Cont amp and gent d .\n" }, { "category": "Nursing/other", "chartdate": "2159-11-16 00:00:00.000", "description": "Report", "row_id": 1699446, "text": "Respiratory Care\nPt cont on CPAP. Fi02 .21, rr 40's, bs clear. sx for mod amt. On caffeine. 1 spell noted thus far this shift. Plan to support as needed. Will follow.\n" }, { "category": "Nursing/other", "chartdate": "2159-11-20 00:00:00.000", "description": "Report", "row_id": 1699470, "text": "Clinical Nutrition:\nO:\n29 CGA, BB now on DoL #10\nWt: 1050g (no change o/n)- (~25th%ile); current wt is down ~7% from birth wt.\nLN: 39cm (35)-(50-75th%ile)\nHC: 26cm (26)-(~25th%ile)\nLabs: noted\nDsticks: 98, 105, 124 over the previous 24hrs\nTF: 150 cc/kg/day\nNutrition: BM/PE20 @ 150 cc/kg/day\nProjected 24hr nutrition: ~100Kcals/kg & ~1.6-3 g/kg of protein\nGI: +BS, small meconium stool noted yesterday; no stool noted yet today & x1 small spit this am\n\nA/goals:\n advanced to full volume enteral feeds o/n, tolerating well thus far. All gavage. Holding feeds @ 20Kcals/oz for 24hrs before beginning to advance Kcals. Voiding & stooling. No wt gain o/n, although did gain wt the previous 5days. Once feeds are advanced to 24Kcals/oz can begin iron/vit E. Once @ 26Kcals/oz w/ , check nutrition labs post one week. No other changes to nutrition plans, will cont. to follow w/team.\n" }, { "category": "Nursing/other", "chartdate": "2159-11-20 00:00:00.000", "description": "Report", "row_id": 1699471, "text": "Respiratory Care\nPt CPAP. Fio2 .21, rr 40's, bs clear. On caffeine. 1 spell noted thus far this shift. Plan to support as needed.\n" }, { "category": "Nursing/other", "chartdate": "2159-11-19 00:00:00.000", "description": "Report", "row_id": 1699462, "text": "NURSING PROGRESS NOTE\n\nRESP/CV: Infant remains on nasal prong CPAP of 5 in RA all night. Two A&B's noted requiring mild-mod stim. BS cl&=, color pale/pink with adequate perfusion. Sx'd for mod-lg secretions. HR 140-150's without murmer.\n\nFEN: Advanced by 10cc/kg to 17cc PE20 at 12am and PN decreased accordingly. Presently at 90cc/kg/d enterally and 60cc/kg/d of TPN. Abd soft, pink with stable girth and +BS. Sm emesis x1 and minimal residuals. Weight up 20gms to 1050gms.\n" }, { "category": "Nursing/other", "chartdate": "2159-11-19 00:00:00.000", "description": "Report", "row_id": 1699463, "text": "Newborn Med Attending\n\nCont on CPAP5, RA. Occ spells. AF flat, clear BS, no murmur, abd soft, MAE. WT=1050 up 20, on 150 cc/kg/d PN/IL and PG feeds.\nA/P: Growing infant with residual RDS and As and Bs. Monitor for spells. Cont to advance feeds.\n" }, { "category": "Nursing/other", "chartdate": "2159-11-26 00:00:00.000", "description": "Report", "row_id": 1699504, "text": "Clinical Nutrition\nO:\n~30 wk CGA BB on DOL 16.\nWt: 1170 g (+25)(~25th %ile); birth wt: 1130 g. Average wt gain over past wk ~17 g/kg/d.\nHC: n/a\nLN: n/a\nMeds : s/p indocin\nLabs not due\nNutrition: TF @ 140 cc/kg/d. EN @ 20 cc/kg/d PE 20, advancing to 50 cc/kg/d now, then advancing 40 cc/kg/. Remainder of fluids as PN via PIV. Projected intake for next 24 hrs from PN ~23 kcal/kg/d, ~1.5 g pro/kg/d; lipids d/c'd today. From EN: ~60 kcal/kg/d, ~1.8 g pro/kg/d, and ~3.1 g fat/kg/d. Glucose infusion rate from PN ~3.4 mg/kg/min.\nGI: Abdomen benign; max aspirate 1 cc--refed.\n\nA/Goals:\nTolerating feeds without GI problems except aspirate as noted above. Plan to advance feedings quickly now s/p indocin as was previously tolerating at goal volumes. Labs not due. Current feeds + PN not meeting recommendations for kcals/vits or mins; protein recommendations are being met. Expect feedings to advance quickly to initial goal of ~150 cc/kg/d PE 24, when full needs will be met. Growth is meeting recommendations for wt gain, but question if this is volume related. HC and LN n/a for comparison. Will continue to follow w/ team and participate in nutrition plans.\n" }, { "category": "Nursing/other", "chartdate": "2159-11-26 00:00:00.000", "description": "Report", "row_id": 1699505, "text": "NPN 7-7p\n\n\nResp: Infant remains in NC 400cc flow. Fi02 30%. RR 40-60's.\n2 spells so far this shift. QSR and mild stim. Mild ic/sc\nreractions. Ls clr/=. Cont with current plan.\n\nFen: Infnat conts on tf 140cc/kg. Enteral feeds @20cc/kg of\npe 20. IVF at 130cckg. Enteral feeds to be increased 40cc/kg\n. Infant had 1cc light green aspirate. Discarded and cont\nwith feed. Unable to advance this feeding. Wil cont to\nmonitor aspirates. Abd soft, full. No loops noted. No spits\nnoted. AG stable 19.5-20.5cm Cont to advance as tol.\n\nDev: Temp stable in weaning servo isolette. Alert and active\nwith cares. Irritable at times. Loves pacifier. Settles well\nin prone position. Cont to support developmental milestones.\n\n\nParenting: Mom called x1 for update. will be in this\nevening. Cont to support and update.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2159-11-26 00:00:00.000", "description": "Report", "row_id": 1699506, "text": "fellows exam note\ncomfortable, on NC\nheent: afof\nheart: soft HSM murmur at LSB\nlungs: cta(b)\nabd: soft\nneuro: non focal\n" }, { "category": "Nursing/other", "chartdate": "2159-11-26 00:00:00.000", "description": "Report", "row_id": 1699507, "text": "fellow exam note\ncomfortable\nheent: afof\nlungs: cta(b/l)\nherat: no murmur\nabd : soft , ND\nneuro: nonfocal\n" }, { "category": "Nursing/other", "chartdate": "2159-12-03 00:00:00.000", "description": "Report", "row_id": 1699545, "text": "fellows exm note\ncomfortable on CPAP 6\nheent: afof\nlungs: cclr with ocs crackles\nheart: soft intermittent sem, pulses nl\nabd: soft\nneuro: nonfocal\n" }, { "category": "Nursing/other", "chartdate": "2159-11-20 00:00:00.000", "description": "Report", "row_id": 1699472, "text": "NPN 7a-7p\n\n\nResp: Infant remains on nasal prong cpap 5cm. Fi02 21%. RR\n30-50's. Occasional drifts in sats. Recovers quickly on own.\nBrady x1 so far. QSR. IC/SC retractions. Ls clr/=. Conts on\ncaffiene. Cont to monitor.\n\nFEn: Infant conts on tf 140cc/kg. Enteral feeds of pe 20 at\n120cc/kg. Tol well gavaged over 30 mins. Increasing 10cc/kg\n at 12&24. IVF of D10 2:1 at 30cc/kg via picc line. Abd\nround soft. Ag 21.5cm. Sm spit x1 this am. No stool thus far\nvoiding with each diaper change. Will check dstick with next\ncare. Cont to advance feeds as tol.\n\nDev: Temp stable in servo isolette. Alert and irrtable with\ncares. Settles well between. Nested in sheepskin with\nboundries in place. Cont to support developmental\nmilestones.\n\nParenting: Mom called x1 for update. will be in this\nevening. Cont to support and update.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2159-11-21 00:00:00.000", "description": "Report", "row_id": 1699473, "text": "NPN\n\n\n#1 Resp- Remains on Prong CPAP of 5cms in 21% o2.BS clear.\nMild retractions.Sxn x2.RR= 30-60's.Continues to have some\nA's+ B's. See flowsheet. Remains on caffeine.A= Stable on\nCPAP. P= Monitor.\n#2 F/N - Abd soft+ full,+bs. Occ soft loops.AG\n21.5-22.Voiding+ stooling in adeq amts.Wt up 30 gms. Tf=\n150cc/kg/day.Tolerating advancing feeds of Pe 20 cals w/sm\nspit x1. Minimal asps.Feeds given on a over 1 hr.A=\nTolerating feeds well. P= Monitor wt gain+ feeding\ntolerance.\n#5 - No contact yet tonight.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2159-11-21 00:00:00.000", "description": "Report", "row_id": 1699474, "text": "Respiratory Care\nBaby continues on prong CPAP 5, 21%. BS clear. Sxn q8h for sm-mod yellow secretions. RR 30's-50's with mild IC/SCR. 3 QSR-mild stim bradys as per flowsheet. On caffeine. Will cont to follow closely.\n" }, { "category": "Nursing/other", "chartdate": "2159-11-21 00:00:00.000", "description": "Report", "row_id": 1699475, "text": "Neonatology\nDOing well. ON CPAP low fio2. On caffeine. Spells not a problem. Comfortable appearing. No murmur. WIll continue on CPAP for now.\n\nWt 1080 up 30. Abdomen benign. ALmost to full volume feeds. Tolerating gavage at 130 cc/k/d. Will move to full feeds today.\n\nCOntinue current nutritional and resp management.\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2159-11-28 00:00:00.000", "description": "Report", "row_id": 1699513, "text": "npn 1900-0700\n\n9 cardiac\n\n#1 resp\no: pt remains in nc 500cc with fio2 30-40%. lsc and equal.\nrr 20-50's. moderate sc/ic retractions noted. nasal\nbreakdown with bloody drainage noted. sux x1 for large\nbloody plugs. brady x6 thus far this shift, 13 for past 24\nhours. a: needing assistance of o2 via nc. brady's with\noccation stimulation needed for recovery. p: cotninue to\nmonitor and support.\n#2 fen\nO: tf 140cc/kg of pe20 gavaged q4hours. wt. 1.205kg (+15gms)\nabd full and round, no loops. ag stable 21cm. voiding qs.\nstools x1 green guiac +. spits after each feeding, one\nbright yellow in color. dstic 88. max aspirate of 2cc\npartially digested milk.\n#4 g&d\no: pt changed from air mode to servo controlled isolette for\ninability to stabilize temps. temps ranging from 97.5-100.0.\nalert but drowsy with cares. fontanelles soft and flat.\nmaew. eye drainage green in color noted to left eye.\n#5 parenting\no: no contact with thus far this shift.\n#9 cardiac\no: pt with + murmur soft. pale pink, mottles with cares.\nstrong extrem pulses. hr 130-160. bp 72/34 with mean 47. hct\n32.2. p continue to assess for changes and support.\n\nREVISIONS TO PATHWAY:\n\n 9 cardiac; added\n Start date: \n\n" }, { "category": "Nursing/other", "chartdate": "2159-12-03 00:00:00.000", "description": "Report", "row_id": 1699546, "text": "Respiratory Care\nBaby continues on cpap 6, fio2 21-28%, bs clear, rr 40-50's, sx mod white secretions, on caffeine, had one spell today so far. Will continue to follow.\n" }, { "category": "Nursing/other", "chartdate": "2159-12-04 00:00:00.000", "description": "Report", "row_id": 1699547, "text": "NPN 1900-0700\n\n\n1. RESP: O: Pt remains in NP PCAP 6, requiring 21-25%\nFiO2. Tube changed at 2100 by RRT. sounds are clear.\nRR 30-50's. Sxn for mod amounts of blood-tinged secretions.\n2 spells noted so far this shift. Pt is on caffeine. A:\nStable on CPAP. P: Monitor.\n\n2. F&N: O: TF remain at 140cc/k/dof PE30 with .\nFeeds gavaged in over 1.5 hours. Pt had 2 small spits so\nfar this shift. A/G stable. Abd full and soft. BS+. No\naspirates noted. Voiding and passing guiac negative green\nstool. Weight gain 25 grams. A: Tol feeds well. ?reflux.\nP: Monitor.\n\n4. DEV: O: Temp swaddled in air isolette.\nFontanels are soft and flat. Irritable with cares but\nsettles well between cares. Right wrist bump remains. A:\nAGA. P: Continue to support infant's needs.\n\n5. PAR: No contact from so far this shift.\n\n9. C/V: O: Murmur persists. HR 150-170's. Pt is pink\nand well-perfused. BP stable. A: Alt C/V. P: Monitor.\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2159-12-04 00:00:00.000", "description": "Report", "row_id": 1699548, "text": "Respiratory Care\nBaby continues on NPCPAP 6 with 02 req 21-25% thsi shift. BS clear. Sxn q4h for mod-lg sec as per flowsheet. NPT replaced. RR 30's-50 with IC/SCR. Two bradys recorded as of this writing. On caffeine. Will cont to follow/ support as indicated.\n" }, { "category": "Nursing/other", "chartdate": "2159-12-04 00:00:00.000", "description": "Report", "row_id": 1699549, "text": "Nursing Progress Note\n\n10 ALT IN SKIN INTEGRITY\n\n#1 RESP and #9. CV: Remains on NP CPAP of 6. FIO2 mostly 21\n% all day.Briefly up to 25% for desat associated with\ncares and feeding. Clear equal BS with good aeration.\nSuctioned thick cloudy secretions moderate amt from NP tube\nand whitish orally. One spell associated with feeding\nrequiring mild stim. P/ Cont caffeine as ordered. Cont to\nmonitor for increasing spells on CPAP.\n#2 FEN:Tolerating PE30 with PM for TF 140cc/k/d Gavaged over\n1 hour . No spit. Benign soft abdomen.No loops. Voiding\nQS. No BM.P/ Cont to monitor for feeding intolerance and\ndialy wt.\n#4 G/D: Temp stable on air isolette. alert and active with\ngood tone. Calms with bounderies and containment cares. P/\nCont to support G/D\n#5 Parenting: No contact with family thus far.\n#10: Skin integrity: Skin integrity intact. Pin point\nscabbed noted but no tenderness, redness or drainage on\nright wrist.Dr. aware of healed site. Will resolved\nskin integrity problem at present.\n\nREVISIONS TO PATHWAY:\n\n 10 ALT IN SKIN INTEGRITY; resolved\n\n" }, { "category": "Nursing/other", "chartdate": "2159-12-04 00:00:00.000", "description": "Report", "row_id": 1699550, "text": "fellows exam note\ncomfortable\nheent: afof\nlungs: clr\nheart: soft murmur\nabd: soft\n" }, { "category": "Nursing/other", "chartdate": "2159-12-04 00:00:00.000", "description": "Report", "row_id": 1699551, "text": "Respiratory Care\nPt recieved on NP-CPAP +6cm's with the fio2 21 to 25%. PT suctioned for a small amt of thick white secretions. Plan is to follow on CPAP.\n" }, { "category": "Nursing/other", "chartdate": "2159-11-28 00:00:00.000", "description": "Report", "row_id": 1699514, "text": "Neonatology\nDoing well. Remains in NCO2 at 500 cc with 35-40% Fio2. Slightlky increased freq of spells. Some nasal excoriation with WIll continue to monitor murmur. Consider need for reecho if persistent. CXR to be done.\n\nIn isollette.\n\nWt 1205 up 15. Tolerating feeds at 140 cc/k/d. Abdomen benign.\nWill do KUB\n\nHct 32.2. CBC unremarkable.\n\nContinue as at present.\n" }, { "category": "Nursing/other", "chartdate": "2159-11-28 00:00:00.000", "description": "Report", "row_id": 1699515, "text": "fellow exam note\ncomfortable\nafof\nlungs: clr\nheart: hsm at left sternal border\nabd: soft\nneuro: nonfocal\n\n" }, { "category": "Nursing/other", "chartdate": "2159-11-28 00:00:00.000", "description": "Report", "row_id": 1699516, "text": "NICU nursing note\n\n\n1. Resp=O/cont on NCO2 at 500cc/min flow 35-45%FIO2. LSCE.\nI/SC retr. noted with care. (4)spells so far this shift\n(please refer to flowsheet). Cont on caffeine. A/Alt in\nResp P/cont to monitor for resp distress.\n\n2. FEN=O/TF cont at 140cc/k of PE20. NG feeds run over\n1hour15min after sm spitx1. Abd benign. max resid=3cc.\nvoiding QS. Sm green guiac+ stool after rectal stim.\nDstick 84 at 1300. A/tolerating current regime. P/cont to\nmonitor for feeding intolerance.\n\n4. Dev=O/temp stable in servo isolette. Alert and active\nwith care. Sleeping well between feeds. A/Alt. in Devl.\nP/cont to monitor and support G&D.\n\n5. Parenting=O/ called for update x1 and both\nvisited late this afternoon. Interacting and participating\nin care. A/appropriate and actively involved. P/Cont to\nsupport and educate .\n\n6. Cardiac=O/Soft murmur cont to be heard. Team aware.\nEcho done (please refer to report). Mom and dad updated.\nHR140-160's, pale/pink, w/p. A/cardiac murmur. P/cont to\nmonitor cardiac status.\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2159-11-30 00:00:00.000", "description": "Report", "row_id": 1699524, "text": "Respiratory Care\nBaby remains on np cpap 6 21-23% 30% while kangarooing.Sx nptube for mod-lg thick yellow secs.Had several spells this shift.RR 30-40.On caffine and nasal drops.\n" }, { "category": "Nursing/other", "chartdate": "2159-11-30 00:00:00.000", "description": "Report", "row_id": 1699525, "text": "Neonatology\nMore comfortable and lower FIo2 now back on CPAP. To continue on CPAP for now. Caffeine dose optimized. Predforte being given to nose for swelling. Will dc Predforte after several days rx and consider again around time of dc of CPAP.\n\nWT 1225 down 10 grams. TF at 140 cc/k/d. Cals at 24. Will increase to 26 cal this am and monitor tolerance. Fe and Vitamin E to be started.\n\nCOntinue current resp management and nutritional care.\n\n" }, { "category": "Nursing/other", "chartdate": "2159-11-30 00:00:00.000", "description": "Report", "row_id": 1699526, "text": "fellows exam note\ncomfortable\nafof\nlungs: cta\nheart: soft SEM\nabd: soft\nneuro: nonfocal\next: small escar at rt wrist, no erythema, no tenderness.\n- continue to observe.\n" }, { "category": "Nursing/other", "chartdate": "2159-11-30 00:00:00.000", "description": "Report", "row_id": 1699527, "text": "NICU nursing progress note\n\n\nPlease refer to flowsheet for specific info.\nResp/ A and B's\nO: remains with Np cpap/ 6, RR 20-40's, sat's 94-99%.\nBSCE bilat. Sxn for thick yellow secretions. IC/Sc ret.\nCaffeine optimized today. 4 spells since 7am today. A:\nStable. Periodic breathing pattern. P: cont to provide opt.\noxygenation. D/C pred forte for excoriated nares.\nCV\nO: +murmur. HR 140-160's, pale pink, bp means in 40's.\nA:stable. P: cont to follow.\nF/N\nO: TF of 140cc/k/d of PE 26. Gavaged over 1'\" due to\nspits. To start Vit E, and Fe. Abd. soft, round, pink, no\nloops. Voiding/ stooling (+) (from exc. nares), examined by\nDr. . KUB previously done reported as benign. No\nchanges. Min. asp. Small spit. Girth 21cm. A: Stable. P:\ncont to provide opt. nut., follow.\nG/D, Skin integrity\nO: Temp stable in servo controlled isolette. Active and\nalert with cares. Font soft, flat. Escar on wrist healing\nwell. MAE. Calms with containment and pacifier. Boundaries\nin place. A: AGA P: cont to support dev. milestones.\nParenting\nO: Dad called and updated, verbalizing understanding. A:\nInvolved and loving . p: cont to update, support,\neducate.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2159-11-30 00:00:00.000", "description": "Report", "row_id": 1699528, "text": "Respiratory Care\nPt recieved on NP-CPAP +6cm's with the fio2 21 to 26%. NP tube replaced with new NP tube, tolerated well. PT suctioned for a large amt of thick yellow secretions. Plans is to follow on CPAP.\n" }, { "category": "Nursing/other", "chartdate": "2159-12-01 00:00:00.000", "description": "Report", "row_id": 1699529, "text": "NPN NOCS\n\n\n1. O: Remains on NP CPAP of 6. FiO2 21%. LS clear. Suctioned\nfor thick secretions. RR 28-30's. Episodes of periodic and\nshallow breathing noted. On caffein. Had had 4 spells thus\nfar this shift(see flowsheet for details). A: Stable on\nCPAP/A's and B's. P: Continue to monitor closely.\n\n2. Wt 1230, up 5gms. TF remain at 140cc/kg of PE26. Gavaged\nover 1hr 15min. Abd benign. Min residual. No spits. Voiding\nand stooling. A: Tol feeds. P: Continue to monitor.\n\n4. O: Irritable with cares. Settles well between cares.\nAFOF. Temp stable in servo isolette. Boundaries in place. A:\nAGA. P: Continue to support dev. needs.\n\n5. No contact from thus far this shift.\n\n9. Soft murmur continues. VSS.\n\n10. Continues with scabbed area to right wrist, no drainage.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2159-12-01 00:00:00.000", "description": "Report", "row_id": 1699530, "text": "Respiratory Care Note\nPt remains on NP CPAP +6 FIO2 21%. B.S.ess. clear with good air entry. Nares sx'ed for mod amt white secretions. 4 bradys with apnea noted this shift as of this note.\n" }, { "category": "Nursing/other", "chartdate": "2159-11-13 00:00:00.000", "description": "Report", "row_id": 1699424, "text": "NICU Nursing Note 1900-0700\n\n\n#1 RESP\nEarly in shift had increased WOB, dimished BS, spells,\napnea. Given additional 10cc/kg/day bolus of caffeine.\nChanged NP tube to 3.0, since remains on NP CPAP of 6, FiO2\n21%. RR 30-60's. Coarse bilaterally, dimished in the bases,\nbut improving from earlier in shift. 7 spells since changing\nNP tube, NNP aware.\n\n#2 FEN\nWeight tonight 1025gm (-65). TF 110 cc/kg/day, NPO. PICC\n(central) inserted by NNP. UAC d/c'd st 2200. PN D7.5\ninfusing via DUVC with IL piggybacked in. Abd is soft, flat,\npink, +BS, no loops, no spits, no aspirates. Remains NPO AM\nlabs today: 147/3.5/115/16. D/S 138. 24 hr u/o was 4.4\ncc/kg/hr, no stool.\n\n#3 Sepsis\nContinues on ampicillin and gentamycin for sepsis. Getn\nlevels tonight were 1.2/5.6. Continue to follow.\n\n#4 DEV\nMoved to isolette. Less irritable in isolette. Alert, active\nwith cares, settles with positioning. MAE. Irritable at\ntimes.\n\n#5 \nNo contact.\n\n#6 Bili\nAM bili was 4.9/0.3, remains under single phtx.\n\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2159-11-13 00:00:00.000", "description": "Report", "row_id": 1699425, "text": "Addendum to NPN\n24 hr urine output was 5.1 cc/kg/hr.\n" }, { "category": "Nursing/other", "chartdate": "2159-11-13 00:00:00.000", "description": "Report", "row_id": 1699426, "text": "Newborn Med Attending\n\nCont on CPAP6, RA-30% O2. Occ spells. AF flat, clear BS, no murmur, abd soft, MAE. Wt=1025 down 65, on 110 cc/kg/d Pn and IL. Bili=4.9.\nA/P: Infant with resolving RDS, As and Bs, presumed sepsis and hyperbili. Wean O2 as tolerated. Increase Tf and start trophic feeds. Cont phototherapy.\n" }, { "category": "Nursing/other", "chartdate": "2159-11-13 00:00:00.000", "description": "Report", "row_id": 1699427, "text": "Clinical Nutrition:\nO:\nFormer 27 weeker, BB now on dol #3\nMaternal history/delivery reviewed.\nBirth wt: 1135g (50-75th%ile)\nCurrent wt: 1025g (-65g)\nBirth LN: 35cm (25-50th%ile)\nBirth HC: 26cm (50-75th%ile)\nLabs: noted\nDsticks: 138 this am\nTF: ~140 cc/kg/day\nAccess: noncentral PICC\nNutrition: BM20 @ 10cc/kg to start this afternoon & PN/IL (D7.5 & 2g% AA w/ IL)\nProjected 24 hr nutrition: ~71 Kcals/kg & ~2.1 g/kg of AA\nGI: soft belly\n\nA/goals:\nStarted on PN on DoL #1 d/t VLBW & anticipated delay in starting enteral feeds. Plan is to start trophic feeds this afternoon. Advancing PN/IL Qday per NICU protocol. Lytes & dsticks have been stable, h/o hyperglycemia on dol#1. Total fluids increased to 140cc/kg/day, as Na was 147 this am, maximizing acetate in PN & providing add'l Ca/Phos as volume/osmolarity allows. Growth goals: 15-20 g/kg/day, ~0.5-1.0 cm/wk for HC & ~1.0 cm/wk for LN. Tg level to be checked w/next blood draw. Wil cont. to follow w/team & participating in nutrition plans.\n\n" }, { "category": "Nursing/other", "chartdate": "2159-11-13 00:00:00.000", "description": "Report", "row_id": 1699428, "text": "Social Work\n\n\nCovering for LICSW. Mother known to her from her admission on 6s, she will follow up with family when she returns on thursday.\nFamily meeting today with , neonatology fellow, RN and social work. Medical issue sof twins reviewed, what to anticipate over the next few weeks. appropriately anxious, are adjusting to preterm delivery. mother states that pregnancy complicated throughout, has been on antepartum service since weeks gestation. Mother to be discharged home tomorrow, couple live in . mother has begun pumping, will need much support and encouragement, with milk coming in slowly. Has for home.\n given parent packet.\n\n" }, { "category": "Nursing/other", "chartdate": "2159-11-17 00:00:00.000", "description": "Report", "row_id": 1699453, "text": "NPN 7a-7p\n\n3 Sepsis\n7 CV:\n\nResp: Received infant on np cpap 5cm. Dc'd to RA at 1200.\ntol well thus far. No spontaneous desats thus far. Ls clr/=.\nRR 40-50's. Ic/Sc retractions noted. Sxn x1 this am for mod\nwhite secretions via et tube and sm clr orally. Cont with\ncurrent plan.\n\nFen: Infant conts on tf 150cc/kg. IVF of d10w with lipids\ninfusing at 90cc/kg via picc line. Etneral feeds of pe 20 at\n60cc/kg increasing 10cc/kg at 08&20. Tol well gavaged\nover 30 mins. Abd round soft. Transient loops noted.\nAspirating lg amounts of air from ng tube. No stool thus\nfar. Voiding with each diaper change. Dstick 102. No spits.\nMinimal aspirates. Ag stable 21-21.5cm. Cont to advance\nfeeds as tol.\n\nSepsis: Infant completed 7day abx tx today. Abx dc'd.\n\nDev: Temp stable in servo isolette. Nested in sheepskin with\nboundries in place. Alert and active. Irritable at times.\nLoves pacifier. Cont to support developmental milestones.\n\nParenting: Dad called today for update. Mom and Dad unable\nto visit today, as they are both sick. Cont to support and\nupdate.\n\n: Phototx dc'd today. Level to be checked in AM.\n\nCV: Murmur heard for first time with 1200 care. Infant is\npink. Pulses normal. No pulses noted. Team aware. 4\nextremety bp's noted in carevue. Brady x6 so far this shift.\nrequiring mild stim. Hr drop no desat usually during feed.\nCont to monitor await plan per team.\n\nREVISIONS TO PATHWAY:\n\n 3 Sepsis; resolved\n 7 CV:; added\n Start date: \n\n" }, { "category": "Nursing/other", "chartdate": "2159-11-17 00:00:00.000", "description": "Report", "row_id": 1699454, "text": "Neonatology-NNP Physical Exam\n\nInfant currently in RA. Active, alert in an isolette, AFOF, sutures opposed, good tone. BBS clear and equal with good air entry. Gr murmur, pulses +2, pink, RRR. Abdomen soft, non-distended with active bowel sounds, no HSM. Please refer to attending progress note for detailed plan.\n" }, { "category": "Nursing/other", "chartdate": "2159-11-18 00:00:00.000", "description": "Report", "row_id": 1699455, "text": "Respiratory Care Note\nPt. restarted on CPAP this shift for increased spells. Pt. improved after CPAP applied. Pt. placed on 5cmH2O of nasal prong CPAP and 21% FIO2. Pt. is on caffeine. To follow.\n" }, { "category": "Nursing/other", "chartdate": "2159-11-23 00:00:00.000", "description": "Report", "row_id": 1699487, "text": "0700- NPN\n\n\nRESP: Pt cont on Prong CPAP of 5 with FiO2 at 21%. RR\n30's-50's, O2 sats 96-100%. LS clear/=, mild SC/IC\nretractions noted. Suctioned x 2 using TB syringe, small\namounts of secretions. A/B spells with apnea x 7 this\nshift, required mild stim. A: Pt cont with occasional A/B\nspells. P: Cont to monitor resp status. Cont on Caffeine\nas ordered.\n\nCV: HR 130's-150's, BP this morning 67/35 with mean 46.\nLoud murmur heard at each care. Pt without palmar pulses.\nPeripheral pulses normal, cap refill brisk. Pt is pink and\nwell perfused. ECHO being done at this time. A: Pt with\nloud murmur. P: Cont to monitor murmur.\n\nFEN: TF are currently at 130cc/kg/d. Pt is NPO, receiving\nIVF D10 with 2NaCl+1KCl. No aspirates, abd girths stable at\n21-22cm. Abdomen full, round, pink, BS+, transient soft\nloops noted. Pt voiding QS, sm brown stool x 1 (guiac-).\nA: Pt NPO at this time, receiving IVF. P: Cont NPO, start\nPN/IL this evening when bag arrives from Pharmacy.\n\nG&D: Temps stable in servo-controlled isolette. MAE, alert\nand active with cares. Sleeps between cares, sucks pacifier\nand brings hands to face for comfort. Dad kangarooed pt x 1\nhr, tolerated well. Fontanels soft and flat. A: AGA. P:\nCont to support growth and development.\n\nPARENTING: Mom called x 1, both in to visit x 2 hr.\n updated by this RN. A: loving and invested.\nP: Cont to support and educate .\n\nPARENTING:\n\n\n" }, { "category": "Nursing/other", "chartdate": "2159-11-23 00:00:00.000", "description": "Report", "row_id": 1699488, "text": "Respiratory Care\nBaby continues on cpap5, fio2 21%, Bs clear, rr 30-50's, baby on caffeine, had 5 spells this shift so far. Will continue to follow.\n" }, { "category": "Nursing/other", "chartdate": "2159-11-24 00:00:00.000", "description": "Report", "row_id": 1699489, "text": "NPN 1900-0700\n\n\n1 Resp\nRemains on prong CPAP 5 in RA. RR 30-60's. Lung sounds\nclear/=. Suctioned for mod thick yellow from nares x's 1.\nMild inter/subcostal retractions noted. Continues on\ncaffiene. See flow sheet for details.\n\n2 FEN\nCurrent weight 1.125 kg, up 5 grams. TF remain at\n130cc/kg/day. NPO. PN of D 10 with lipids infusing well\nvia piv. Dstick wnl. Abd soft, bs =. Girth stable.\nVoiding with each diaper change. No stool.\n\n4 DEV\nTemp stable in servo controlled isolette. Awake and active\nwith cares. Sleeps well between cares. Sucks\nintermittently on pacifier. State screen sent.\n\n5 Parenting\nMom called for update. Aware of echo results.\n\n8 CV\nRecieved first dose of 3 of indocin. Murmer noteable softer\nafter dose. HR 150-160s. Warm, pink and well perfused.\nPeripheral pulses wnl. See flow sheet for bp.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2159-11-24 00:00:00.000", "description": "Report", "row_id": 1699490, "text": "Respiratory Care\nBaby remains on cpap 5 21%.Has occ spells.Started on indo tonght.RR 40-60'sBS clear.\n" }, { "category": "Nursing/other", "chartdate": "2159-11-24 00:00:00.000", "description": "Report", "row_id": 1699491, "text": "Neonatology Attending\n\nDay 14\n\nRemains on CPAP with 21% oxygen. Has had 12 bradycardic events over last 24 hours. Appears better since indomethacin started. Continues on caffeine. Soft murmur heard most recently. Received 2nd dose of indomethacin this morning. BP mean 46. Weight 1125 gms (+5). NPO. TF at 130 cc/kg/d. On PN and lipids. CPAP belly with good bowel sounds. Stable temperature in incubator.\n\nPDA may be responding to medical therapy. Less breathing control immaturity evident this morning. Will continue to monitor cardio-respiratory status closely. Will keep NPO during PDA therapy. Family up to date.\n" }, { "category": "Nursing/other", "chartdate": "2159-11-12 00:00:00.000", "description": "Report", "row_id": 1699416, "text": "Nursing Progress Note\n\n6 Hyperbilirubinemia\n\n#1. O: Infant remains orally intubated on unchanged settings\nof 17/5 x16. FiO2 overnight has been 21-26%. ABG 7.26-51. NO\nchanges made. No spells. ETT suctioned for mod white. A:\nStable on current settings. P: Continue to monitor resp\nstatus.\n\n#2. O: Infant remains NPO on TF's of 100cc/k/d. 1/2NS with\nhep infusing well via UAC. D10PN and D5W infusing well via\nPIV. D/S 126-166. Voiding 4cc/k/hr x12hrs. No stools thus\nfar tonight. Abd soft and flat with hypoactive bowel sounds.\nWgt is down 45gms tonight to 1090gms. A: NPO. P: Continue to\nmonitor FEN status.\n\n#3. O: Infant remains on ampicillin and gentamicin for r/o\nsepsis. Rpt CBCD done. WBC 10.3, Hct39, Plt250, 61N, 4B.\nBlood cultures pending. A: Sepsis. P: Continue to follow.\n\n#4. O: Infant remains on radiant warmer with stable temp. He\nis alert and active with cares. MAEW. Sucking on ETT\nintermittently. A: AGA. P: Continue to assess and support\ndevelopmental needs. ?HUS Tuesday.\n\n#5. No contact from thus far.\n\n#6. O: Bili this a.m. 6.1-0.3. Infant started under single\nphototherapy. Eye shields in place. A: Hyperbili. P:\nContinue with treatment.\n\nREVISIONS TO PATHWAY:\n\n 6 Hyperbilirubinemia; added\n Start date: \n\n" }, { "category": "Nursing/other", "chartdate": "2159-11-12 00:00:00.000", "description": "Report", "row_id": 1699417, "text": "Newborn Med Attending\n\nCont on SIMV 17/5 x 16 21-28% O2. AF flat, clear BS, no murmur, abd soft, MAE. WT=1090 down 445. TF=100 cc/kg/d Pn and IL. Bili=6.1.\nA/P: Infant with RDS, neutropenia and hyperbili. Wean from vent as tolerated. Cont phototherapy. Increase total fluids, consider starting trophic feeds.\n" }, { "category": "Nursing/other", "chartdate": "2159-11-12 00:00:00.000", "description": "Report", "row_id": 1699418, "text": "Cont amp and gent for min of 7 days.\n" }, { "category": "Nursing/other", "chartdate": "2159-11-12 00:00:00.000", "description": "Report", "row_id": 1699419, "text": "Respiratory Care\nBaby extubated to cpap 6, fio2 32%, Bs clear, sx small white secretions, rr 50-60's, caffeine started. Post extubation abg 7.31/42/80/22/-4. Will continue to follow.\n" }, { "category": "Nursing/other", "chartdate": "2159-11-16 00:00:00.000", "description": "Report", "row_id": 1699447, "text": "Social Work\n known to this social worker from mo's previous adm to high risk. She is a 28 yo, ma, employed mo who lives w/ her husband in . Couple have known eachother x 5 yrs, but have been high school sweethearts for past x 14 yrs.\n\nMother has a hx of depression and eating disorder/anorexia, which have coincided w/ eachother. Her baseline re her affect is quite subdued and quiet. Her last bout of depression was x 2 yrs ago when her father passed away. Mo was hospitalized once for her e/d in at the age of 22 yrs. She has been in recovery ever since this time, but continues to struggle w/ issues related to eating particularly when she was pregnant. Mo has been on zoloft in the past, which she reports has helped her combat the sxs of her depression. She saw a therapist ijn around the time of her fa's death, but currently does not see anyone. I have requested that she consider reconnecting w/ her therapist, as she is at risk for post partum depression. She understands and is thinking about this as an option.\n\nMother and father appear to be supportive of one another. They know eachother very well, and husband can identify his wife's signs/sxs of depression and her needs. Sw will continue to follow for support during twins' NICU admission. I ahve given the SSI forms to fill out.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2159-11-16 00:00:00.000", "description": "Report", "row_id": 1699448, "text": "Social Work\nMet w/ at the bedside. Mo very stressed last night, according to husb's report. Mo tearful when discussing issues regarding inability to now breastfeed. She has dilligently been pumping every x 3 hrs for the past x 6 days and has had no milk. As this is another issue that has to do w/ how she sees herself and her body/body make-up, mo will need extra sensitivity and support around bottlefeeding. SW provided reassurance in attempting to alleviate some self-blaming re body and self-esteem issues. Husb extremely supportive and couple seem to have a close relationship.\n" }, { "category": "Nursing/other", "chartdate": "2159-11-16 00:00:00.000", "description": "Report", "row_id": 1699449, "text": "NPN 0700-1900\n\n\n1. Resp: Infant remains in NP CPAP 5 in 21% FiO2.\nRR=30-50's. Baseline mild SCR/ICR. LS clear. Suctioned NP\ntube x2 for mod amounts thick white secretions. 1 spell\nthis am--brady to 57. No desat. QSR. 5 spells in past\n24hrs. On caffeine.\n\n2. FEN: TF=150cc/k/day. Currently receiving PND10 and IL\nat 110cc/k/day = 4.7cc/hr and 0.5cc/hr respectively via\nPICC. Enteral feeds of PE20 currently at 40cc/k/day. Plan\nis to advance enteral feeds by 10cc/k/. Min asp/no\nspits. AG stable. Abd is full but soft. Transient loops\nthis am. Rec'd Glycerin sliver at 0830 with mod mec\nresults. U/O=3.6cc/k/hr. Lytes to be checked in am.\n\n3. Sepsis: Today is day # ampi and gent. LP done this\nafternoon. Results pnd. Bld cx neg.\n\n4. G&D: Infant is alert and active with cares. Sleeps\nwell between cares. Temps stable nested in sheepskin in\nservo controlled isolette. HUS done this am. AGA. AFSF.\n\n5. Parenting: in at 1300. Participated in cares.\nUpdated at bedside. Asking appropriate questions. Offer\nupdates and support.\n\n6. Hyperbili: remains under single phototx. Sl\njaundiced. to be checked in am.\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2159-11-21 00:00:00.000", "description": "Report", "row_id": 1699476, "text": "NPN 7a-7p\n\n\nResp: Infant conts on nasal prong cpap 5dm. Fio2 21%. Rr\n30-50's. Ls clr/=. Sxn x1 for sm white secretions. Brady x1\nso far this shift. Conts on caffiene. Cont to monitor.\n\nFen: Infant presently at 140cc/kg of pe 20. Reached full\nfeeds at 1200. To advance 10cc/kg at 12mn to reach 150cc/kg.\nIVf hl at 1200. Will check dstick with next care. Abd full\nsoft. Active bs AG 21-21.5cm. No stool thus far. Voiding\nwith each diaper change. Feeding time increased to 60 min\nfor spits. Lg spit x1 thus far. Cont with above feeding\nplan.\n\nDev: Temp stable in servo isolette. Alert and irritable with\ncares. Likes pacifier. Settles well in prone position.\nBrings hands to mouth. Cont to support developmental\nmilestones.\n\nParenting: Mom and Dad in this afternoon. Held sister. \nkangaroo with next care. Updated at bedside. cont to support\nand update.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2159-11-21 00:00:00.000", "description": "Report", "row_id": 1699477, "text": "Respiratory Care\nBaby continues on cpap 5, fio2 21%, Bs clear, sx small white, rr 30-50's, on caffeine, had one spell on this shift so far. Will continue to follow.\n" }, { "category": "Nursing/other", "chartdate": "2159-11-22 00:00:00.000", "description": "Report", "row_id": 1699478, "text": "NPN\n\n\n#1 Resp- Remains on Prong CPAP of 5cms in 21% o2.RR=\n30-50's. BS clear. mild retractions.Sxn x1 for lg\nyellow.Remains on Caffeine. Occ A's + B's. See flowsheet.A=\nStable on CPAP. P= Monitor.\n#2 F/N- Abd soft+ full,+bs no loops.Tolerating ng feeds of\nPe 20 cals w/sm spit x1.Minimal asps.Feeds given on a \nover 1 hr q 4 hrs.Voiding+ stooling in adeq amts.Wt down\n15gms.Tf= 150cc/kg/day.A= Tolerating feeds well w/some sm\nspits.P= monitor wt gain+ feeding tolerance.\n#5 - No contact yet tonight.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2159-11-22 00:00:00.000", "description": "Report", "row_id": 1699479, "text": "RESPIRATORY CARE NOTE\nBaby #1 remains on Prong CPAP 5 FiO2 21%. Suctioned nares for lg amt of yelow secretions. Breath sounds are clear. RR 30-50's stable on CPAP cont to follow.\n" }, { "category": "Nursing/other", "chartdate": "2159-11-22 00:00:00.000", "description": "Report", "row_id": 1699480, "text": "Neonatology\nRemains on CPAP at 5 low Fio2. Comfortablke appearing. WIll consider trial off CPAP early next week.\n\nWT 1065 down 15. Tf at 150 cc/k/d. Full feeds being tolerated by gavage. PICC to be dced. Abdomen bneign. Will advance to 22 cal.\n\nCOntinue current nutirional and resp management\n" }, { "category": "Nursing/other", "chartdate": "2159-11-22 00:00:00.000", "description": "Report", "row_id": 1699481, "text": "0700- NPN\n\n\nRESP: Cont on Prong CPAP of 5 with FiO2 21-28%. RR\n30's-50's, O2 sats 97-100%. LS clear/=, mild SC/IC\nretractions noted. Suctioned x 2. Nares suctioned via TB\nsyringe, mod thick yellow secretions. Small white\nsecretions from mouth. A/B spells x 5 so far this shift, HR\nto 50's-70's and requiring mild stim. See flow sheet for\ndetails on A/B spells. A: Pt with occasional A/B spells.\nP: Cont to monitor resp status. Cont on Caffeine.\n\nFEN: TF cont at 150cc/kg/d. PE increased to 22 cals/oz.\nNo spits, abd girth stable at 21cm. Bright green aspirate\nof 0.2cc x 1, MD aware. Abdomen soft, full, pink, BS+,\ntransient soft loops noted. Pt is voiding, no stool yet\nthis shift. A: Pt tolerating feeds at this time. P: Cont\nto monitor feeding tolerance.\n\nG&D: Temps stable in servo isolette. MAE, alert and active\nwith cares. Sleeps between cares, sucks pacifier and brings\nhands to face for comfort. Fontanels soft and flat. A:\nAGA. P: Cont to support growth and development.\n\nPARENTING: Mom called x 1, updated by this RN. She plans\nto visit this evening. A: loving and invested. P:\nCont to support and educate .\n\n\n" }, { "category": "Nursing/other", "chartdate": "2159-11-29 00:00:00.000", "description": "Report", "row_id": 1699517, "text": "1900-0700 NPN\n\n\n#1RESPIRATORY\nO:REMAINS ON NC 500CC 30-40%. BS CLEAR; UAC NOTED. RESP RATE\n40-64 WITH IC/SC RETRACTIONS. BRADYS X6 OVERNIGHT--11 IN\nPAST 24HR.\nA:NC WITH BRADYS\nP:CONTINUE TO MONITOR FREQUENCY/SEVERITY OF SPELLS CLOSELY,\nWEAN 02 AS TOLERATED\n\n#2F/E/N\nO:TF AT 140CC/KG PE20 28CC Q4HR GAVAGE OVER ONE HOUR 15\".\nABDOMEN SOFT, FULL WTIH GOOD B.S. AG 22CM. ASPIRATES 1.8-4CC\nOVERNIGHT. 4CC ASPIRATE HAD BLOODY FLECKS IN IT--DISCARDED\n NNP ORDER. VOIDING WELL; NO STOOLS. NO SPITS WITH TWO\nOVERNIGHT FEEDS THUS FAR. WT UP 30GM\nA:TOLERATING FULL FEEDS WELL THUS FAR\nP:CONTINUE TO MONITOR TOLERANCE TO FEEDS CLOSELY, ?INCREASE\nCALS TODAY, MONITOR WT GAIN\n\n#4G&D\nO:IN SERVO CONTROL ISOLETTE WITH STABLE TEMPERATURE.\nACTIVE/MAE WITH CARES; SLEEPING WELL BETWEEN. NESTED ON\nSHEEPSKIN W/BOOUNDARIES. FONTANEL SOFT AND FLAT; SUTURES\nSMOOTH\nA:AGA\nP:CONTINUE TO SUPPORT AND MONITOR\n\n#5PARENTING\nNO CONTACT OVERNIGHT\nA:UNABLE TO ASSESS\nP:CONTINUE TO SUPPORT, EDUCATE AND KEEP UP TO DATE\n\n#9CV\nO:COLOR PALE/PINK. HR 148-176. SOFT MURMUR HEARD WITH EACH\nSET OF CARES. GOOD PULSES.\nA:STABLE\nP:CONTINUE TO MONITOR FOR S/S OF COMPROMISE\n\nSKIN\nO:NOSE IRRITATED, BROKEN DOWN AND BLEEDING. EXAMINED BY\nNNP--ORDERED A&D AND NOSE DROPS. RIGHT WRIST HAS WHAT\nAPPEARS TO BE AN OLD IV SITE THAT IS SCABBED OVER BUT RED\nAROUND PERIMETER--NNP ALSO EXAMINED\nA:SENSITIVE SKIN\nP:MONITOR WRIST, AVOID IRRITABION TO NARES AND AVOID\nSUCTIONING AS ABLE\n\n\n" }, { "category": "Nursing/other", "chartdate": "2159-11-29 00:00:00.000", "description": "Report", "row_id": 1699518, "text": "BABY HAD ADDITIONAL 5 BRADYS SINCE ABOVE NOTE WRITTEN. SPOKE TO NNP X2 RE:INCREASED FREQUENCY. NC FLOW INCRESAED TO 600CC PER ORDER. BABY REMAINS ON FEEDS OVER 1HR 15\" WITH HOB ELEVATED AND WAS SUCTIONED X1 FOR SMALL AMT SECRETIONS.\n" }, { "category": "Nursing/other", "chartdate": "2159-11-29 00:00:00.000", "description": "Report", "row_id": 1699519, "text": "FELLOWS EXAM NOTE\nCOMFORTABLE, WITH INC. SPELLS\nHEENT: AFOF\nLUNGS: CTA (B) WITH SOME CRACKLES DIFFUSELY\nHEART: SOFT HSM, PULSES NL X4\nAB: SOFT, ND, +BS\nEXT: INTACT\nNEURO: NONFOCAL\n" }, { "category": "Nursing/other", "chartdate": "2159-11-29 00:00:00.000", "description": "Report", "row_id": 1699520, "text": "Neonatology\nPlaced on CPAP for increased spells. Soft murmur shown to small PDA with restrictive flow on echo Spells improved and Fio2 back done on increased CPAP to 6. WIll rx with a single dose of Lasix and monitor response.\n\n\n\nOn full feeds now S/P Indocin rx.\n\nHCt 32 on Tuesday.\n" }, { "category": "Nursing/other", "chartdate": "2159-11-29 00:00:00.000", "description": "Report", "row_id": 1699521, "text": "Social Work\nMet w/ very briefly yesterday. They appear to be doing quite well, continuing to be supportive of one another. I will try and touch base w/ them again today.\n" }, { "category": "Nursing/other", "chartdate": "2159-11-17 00:00:00.000", "description": "Report", "row_id": 1699450, "text": "1. Resp: O: Infant received on CPAP of 5cm, in RA. He has\nonly needed an increase in FiO2 once, due to a desat, w/ no\nbrady. He is on caffeine as ordered. RR 30-50s. Ls clear.\nColor pink. Sxned q 4 hours for a small-mod amt of thick,\nwhite secretions. A: Stable on CPAP in RA. P: Monitor. Sxn\nprn. Meds as ordered.\n\n2. F/N: O: Infant is on TF = 150cc/k/d, working up on feeds.\nHe is now at 50cc/k/d of q 4 hour gavage feeds of PE20. No\nasps, no spits, benign abd. His asp is largely air and he\nhas visibly transient loops. He has had a small mec stool.\nU/o was 2.9cc/k/hr for the last 8 hours. He gained 55g.\nLytes were sent, results are pnd. D/s was 118. A: Tol w/u on\nfeeds so far. P: Continue w/ plan. Check results of labs.\n\n3. Sepsis: O: Infant is on ampi and gent as ordered. He is\nstable in RA on CPAP, active w/ cares, sucking on a pacifier\nand tol feeds. A: No s/sx worsening sepsis. P: Continue w/\nantibx as ordered. Monitor.\n\n4. G/d: O: Infant is active and alert w/ cares, sometimes\nfussy. He settles well between cares and sucks on a\npacifier. A/P: Continue to support infant needs.\n\n5. : No contact so far this shift.\n\n6. : O: Infant is under single phototx w/ his eyes\ncovered. A was sent and results are pnd at this time.\nA: Hyperbilirubinemia. P: Phototx as ordered. Check results\nof labs.\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2159-11-17 00:00:00.000", "description": "Report", "row_id": 1699451, "text": "Respiratory CAre Note\nPt remains on NP CPAP +5 FIO2 21%. B.S. clear with good air entry. Nares sx'ed for mod white secretions. 1 brady noted this shift.\n" }, { "category": "Nursing/other", "chartdate": "2159-11-17 00:00:00.000", "description": "Report", "row_id": 1699452, "text": "Neonatology Attending\nDOL 7\n\nRemains on CPAP 5 cm H2O in 21% FIO2. On caffeine with one bradycardia overnight.\n\nNo murmur.\n\nBilirubin 1.9/0.4 under single phototherapy.\n\nWt 1020 (+55) on TFI 150 cc/kg/day, including enteral feeds 60 cc/kg/day PE20, tolerating well. D-stick 118. Abdomen benign. Small stool with glycerin. Urine output 2.9 cc/kg/hr. 139/4.3/106/19.\n\nNow day 7 of antibiotic coverage. LP last night showed WBC 22 (1 poly, 13 lymphocytes) RBC 1 glucose 94, prot 113.\n\nA&P\nPreterm infant with resolving surfactant deficiency, respiratory and feeding immaturity.\n\nWe will attempt to discontinue CPAP in the next 24 hours.\n\nContinue to advance enteral feeds by 10 cc/kg/day as tolerated.\n\nWe will discontinue antibiotics today given the preponderance of lympohcytes and normal glucose and protein levels in CSF.\n\nPhototherapy will be discontinued and bilirubin rechecked in 24 hours.\n" }, { "category": "Nursing/other", "chartdate": "2159-11-22 00:00:00.000", "description": "Report", "row_id": 1699482, "text": "Respiratory Care\npt cont on prong CPAP. FIO2.21, RR 40'S, BS clear. sx for sm. amt. On caffeine. 3 spells noted this shift. Plan to support as needed.\n" }, { "category": "Nursing/other", "chartdate": "2159-11-30 00:00:00.000", "description": "Report", "row_id": 1699523, "text": "NPN NOCS\n\n\n1. O: Remains on NP CPAP of 6. FiO2 moslty 21-23(increase\n30% when held tonight). RR 30-40's. LS clear. Suctioned for\nthick secretions. On caffeine. Infant has had 4 spells thus\nfar this shift(see flowsheet for details). A: Stable on\nCPAP/A's and B's. P: Continue to montior closely.\n\n2. O: Wt 1225, down 10gms. TF remains at 140cc/kg of PE24.\nGavaged over 1hr 15min. No spits. Abd benign. No residual.\nVoiding, no stool. A: Tol feeds. P: Continue with plan.\n\n4. O: Alert and active with cares. AFOF. Temp stable in\nservo isolette. Boundaries in place. A: AGA. P: Continue to\nsupport dev. needs.\n\n5. O: in for eve cares. Update given. Asking\nappropriate questions. Independent with cares. Kangarood for\n45min. A: Involved family. P: Continue to update daily and\noffer support.\n\n9. Soft murmur continues. VSS.\n\n10. Skin intact. Small scabbed area continues on Right\nwrist-no drainage.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2159-11-10 00:00:00.000", "description": "Report", "row_id": 1699408, "text": "NNP On-Call/Procedure Note\nUmbilical vessel catheterizations\n\nIndications: fluids, labs, BP monitoring\n\n#3.5 single lumen catheter inserted into umbilical artery to 16 cm, draws and flushes easily. X-ray shows tip high, pulled back to 13 cm . 2 attemtps at UVC placement unsuccessful with catheter coiled in liver. UVC removed. Infant tolerated all procedures well, no complications.\n" }, { "category": "Nursing/other", "chartdate": "2159-11-11 00:00:00.000", "description": "Report", "row_id": 1699409, "text": "RESPIRATORY CARE NOTE\nBaby boy #1 27 born via C/S. Apgars 5-7-8. Intubated in the DR a 2.5 ETT. Taped @ 7cm. Transport to the NICU being bagged with 100% O2. Placed on vent settings 30/5 Rate 30 FiO2 100%. CxR taken ETT in good position. Survanta 4.5cc given at hrs. Through the night vent settings weaned to 20/5 Rate 25 FIO2 28%. 2nd dose of survanta 4.5cc given at 1am. Abg PO2 67 CO2 43 PH 7.31. Rate weaned to 20. Current vent settings 20/5 Rate 20 FiO2 28%. Will cont to wean as tolerated. Cont to monitor closely.\n" }, { "category": "Nursing/other", "chartdate": "2159-11-12 00:00:00.000", "description": "Report", "row_id": 1699420, "text": "NPN 0700-1900\n\n\nRESP: Received infant intubated on settings of 17/5 X16.\nInfant received loading dose of caffeine and was extubated\nat 1200 to NP CPAP 6. ABG at 1330 7.31/42/80/22/-4, no\nchanges made. FiO2 24-35%. O2sat 96-99%. RR 40-60 with\nmild/mod IC/SC rtx. Infant has periods of shallow breathing\nand occ. sat drifts to 80%, at times requiring incr in O2.\nNo bradycardias. LS clear/coarse, slightly diminished\nbilaterally in bases.\n\nCV: No murmur heard on exam. HR 130-150's. Infant appears\nruddy, well-perfused with nl pulses. He has some miild\ngeneralized edema. Art means 34-41. BP cuff means\ncorrelating. Total blood out=4.6cc.\n\nFEN: bw=1135g. TF incr to 110cc/kg/d. Infant is NPO.\nCurrently receiving 1/2NS with 0.5U hep/cc via UAC, PND10 at\n50cc/kg and D5W at 40cc/kg via PIV. D-stick 105. Abdomen\nsoft and round. +BS. No loops, no stools this shift.\nUO=5.7cc/kg/hr X12hr. Plan to check lytes and bili in AM.\n\nSepsis: BC NGTD. On day of antibx. Receiving amp and\ngent. Plan to check gent levels tonight. Plan for LP\ntomorrow.\n\nG&D: AFSF. MAE. Temp stable, nested on sheepskin on open\nwarmer. Alert and active with cares. Irritable at times,\nsettles with containment. Plan for HUS on Fri.\n\n: in to visit this afternoon. Asking\nappropriate questions. Mom participating in cares, with some\nverbal cuing. Updated at bedside by this RN and Dr.\n. Grandparents in to visit this evening. Plan for a\nfamily meeting tomorrow at 1400.\n\nHyperbili: Continues on single phototherapy with eye shields\non. Plan to check bili in AM.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2159-11-13 00:00:00.000", "description": "Report", "row_id": 1699421, "text": "Neonatology NP NOte\nPlacement of percutaneous central venous catheter\nIndication need for prolonged Iv therapy\nParental consent in chart\nleft leg prepped and draped. introducer inserted into left saphenous vein, catheter inserted and threaded to 19 cm, no blood return, when catheter pulled back to 15 cm, good blood return and line flushes easily. line secured, xray shows tip of catheter in inguinal region in IVC. Infant tolerate procedure well. No complications.\n" }, { "category": "Nursing/other", "chartdate": "2159-11-13 00:00:00.000", "description": "Report", "row_id": 1699422, "text": "UAC removed. no oozing from cord, no complications.\n" }, { "category": "Nursing/other", "chartdate": "2159-11-13 00:00:00.000", "description": "Report", "row_id": 1699423, "text": "RESPIRATORY CARE NOTE\nBaby boy #1 received on NP CPAP 6 Fio2 31%. FiO2 cont to increase. NP tube changed at 10pm. new NP tube size 3.o was placed. Nares were suctioned for lg amt of yelllow secreetions. Breath sounds are coarse. After tube change FiO2 weaned to 21%. RR 30-60's will cont to monitor closely.\n" }, { "category": "Nursing/other", "chartdate": "2159-11-23 00:00:00.000", "description": "Report", "row_id": 1699483, "text": "NPN 1900-0700\n\n8 CV\n\n1 Resp\nContinues on prong CPAP 5 with FiO2 requirements 21-28%. RR\n40-60's. Lung sounds clear/=. Suctioned x's 1 for mod\ncloudy from nares. Inter/subcostal retractions noted.\nContinues on caffiene, see flow sheet for spells.\n\n2 FEN\nCurrent weight 1.120 kg, up 65 grams. TF decreased to\n130cc/kg/day. NPO. IVF of D 10 with lytes infusing well\nvia piv. Abd soft, bs +. Girth stable. Small spit x's 1.\n\n\n4 DEV\nTemp stable in servo controlled isolette. Awake and active\nwith cares. Sleeps well between cares. Sucks\nintermittently on pacifier.\n\n5 Parenting\nMom and Dad in for care. Both participated in weight\nand care.\n\n8 CV\nLoud murmer noted at 1200 am. HR 130-170's. Warm pink and\nwell perfused. See flowsheet for BP. No pulses\nnoted. Brisk cap refill. Echo to be done.\n\n\n\nREVISIONS TO PATHWAY:\n\n 8 CV; added\n Start date: \n\n" }, { "category": "Nursing/other", "chartdate": "2159-11-23 00:00:00.000", "description": "Report", "row_id": 1699484, "text": "Respiratory care note\nPt. continues on 5cmH2O of nasal prong CPAP and 21-28% FIO2. BS are clear. Pt. on caffeine, continues to have spells. To follow.\n" }, { "category": "Nursing/other", "chartdate": "2159-11-23 00:00:00.000", "description": "Report", "row_id": 1699485, "text": "Neonatology\nRemains on CPAP. RA. Few spells. Comfortable appearing. Loud murmur c/w PDA noted this am. CXR shows slightly enlarged glbular heart size.\n\nWT up 55. TF at 130 cc/k/d. NPO overnight due to murmru. ABdomen slightly distended. Few aspirates and spits overnight.\n\nTemp stable in isollette.\n\nContinue current resp rx. EVal need for indo rx.\n" }, { "category": "Nursing/other", "chartdate": "2159-11-23 00:00:00.000", "description": "Report", "row_id": 1699486, "text": "fellow exam note\ncomfortable\nheent: afof\nlungs: cta(b/l), with occ crackles\nheart: 2-3/6 hsm, pulses nl X 4. no pulse\nabd: soft, a bit distended, but benign and ND\next: x4\nneuro: nonfocal\n" }, { "category": "Nursing/other", "chartdate": "2159-11-29 00:00:00.000", "description": "Report", "row_id": 1699522, "text": "NPN 1320\n\n\n#1 Resp: was placed on NP CPAP at 0800 d/t numerous\nspells (17 in 24hrs). Baby started at 5cms then increased to\n6cms when spells continued. FIO2 25-30%. Weaned as\ntolerated. RR 30-50, lungs clear, = bilat. Mild IC/SC\nretractions. Continues on caffeine.\nA: Spells have diminished somewhat since increasing to 6cms\nCPAP.\nP: Assess for increasing spells.\n#2 F/N: Cals increased to 24/oz today. Remains on\n140cc/kg/d, 28cc X 1hr 15mins. Abd full, soft. AG stable.\nBowel snds present. No spits, no significant aspirates. One\nheme pos. stool, 2nd stool heme negative.\nA: Tolerating feeds thus far.\nP: Increase cals as ordered/tolerated.\n#4 Dev: remains in a heated isolette on servo control\nw/i a nested sheepskin. Position changed q 4 hrs. Irritable\nat times, possibly d/t skin breakdown around nares.\nTemps stable, moving all extremities.\nA: AGA 30+ corrected.\nP: Cont dev. supports.\n#5 : Mother phoned this AM. Informed that was\nput back on CPAP. Mom asking appropriate questions. Plans to\ncome in at 4pm to kangaroo the babies.\nA: Invested family.\nP: Cont to keep updated and involved.\n#9 CV: HR 150-170's today. Murmur audible. BP 68/46 M55.\nColor pale pink. Perfusion adequated.\nA: Stable w/ murmur.\nP: Cont to assess.\n#10 Skin: Right nares now with NP CPAP tube in place. Pred\nforte gtts applied as ordered to help reduce swelling. Small\namt of bldg. noted after tube placed, now improved.\nScab on right hand present, healing.\nA: Sore nares, otherwise skin intact.\nP: Cont to assess for skin breakdown.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2159-11-11 00:00:00.000", "description": "Report", "row_id": 1699410, "text": "NURSING PROGRESS NOTE\n\n1 Alt in resp status\n2 Alt in FEN\n3 Sepsis\n4 Alt in Development\n5 Alt in parenting\n\n1 - RESP - PT RECEIVED INTUBATED FROM DR - ABLE TO WEAN\nTHROUGH NIGHT TO CURRENT SETTINGS OF 18/5, X20 21%. BREATH\nSOUNDS SLIGHT CRSE TO CLEAR. SXN - THIN CLEAR SECRETIONS X1.\n HAS RECEIVED TWO DOSES OF SURVANTA. LAST ABG PRIOR TO THESE\nSETTINGS=7.34/38/61/21/-4. AT 0600.\nA/P; PT WEANING THROUGH NIGHT, CONT TO WEAN AS TOL\n\n2 - FEN - NPO.TF=100CC/K OF D10W W/ HEPARIN. PT \nIVF THROUGH UVC WITHOUT DIFFICULTY. DSTICK=81-166. ABD SOFT,\nFLAT. U.O FOR 12 HRS=3.3CC/K/HR, NO STOOLS YEST. BW-1.135.\n\n3 - SEPSIS - TEMP STABLE ON OPEN WARMER. PT DROWSY,\nRESPONDING TO CARES. RECEIVING AMP AND GENT. CBC SHIFTED,\nBLOOD CX PENDING\n\n4 - DEV - TEMP STABLE - WARM X1 - PROBE ADJUSTED. PT\n W/ CARES, NESTED ON OPEN WARMER. AFOF.\n\n5 - PARENT - MOM AND DAD UP TO VISIT, ABLE TO SEE BABIES,\nTAKE SOME PICTURES. APPEAR NERVOUS, NOT READY TO ASK\nQUESTIONS\n\nREVISIONS TO PATHWAY:\n\n 1 Alt in resp status; added\n Start date: \n 2 Alt in FEN; added\n Start date: \n 3 Sepsis; added\n Start date: \n 4 Alt in Development; added\n Start date: \n 5 Alt in parenting; added\n Start date: \n\n" }, { "category": "Nursing/other", "chartdate": "2159-11-11 00:00:00.000", "description": "Report", "row_id": 1699411, "text": "Neonatology Attending Note\nDay 1\n\nRESP: s/p surfactant x 2. SIMV now 18/5 x 20, RA. RR50-60s. Last gas 7.34/38/61, since weaned PIP.\n\nCV: HR 130-160s. Mean BP 30s. No murmur. Sl edema. Ruddy-pink.\n\nFEN: Wt 1135. NPO. TF 100 cc/k/day D10w. PIV heplocked. d/s 81, 56, 134, 166. Abd flat, soft. u/o 3.3. No stool yet.\n\nID: On amp/gent. Blood cx pending.\n\nImp: prematurity, RDS, r/o sepsis\nPlan:\n1. Wean vent as tolerated\n2. Monitor BP, for PDA\n3. Maintain 100 cc/k/day, begin PN. Follow lytes.\n4. Con't amp/gent pending lab results and clinical course. With initial neutropenia, bandemia probable 7 day course.\n5. Will need initial screening HUS soon.\n" }, { "category": "Nursing/other", "chartdate": "2159-11-14 00:00:00.000", "description": "Report", "row_id": 1699434, "text": "Respiratory Therapy\nContinues on NP CPAP of 6, 0.21-0.32. RR 40-60. On caffeine with no spells. Plan to continue with CPAP as tolerated.\n" }, { "category": "Nursing/other", "chartdate": "2159-11-14 00:00:00.000", "description": "Report", "row_id": 1699435, "text": "NPN 0700-1900\n\n\nRESP: Infant continues on NP CPAP 6. FiO2 21-32%. O2sat\n93-98%. RR 40-50's with mild IC/SC rtx. LS clear and equal.\nSxn'd X1 for mod amt of white secretions via NP tube, and lg\namt of white oral secretions. No A/B's this shift. Continues\non caffeine.\n\nFEN: bw=1135g. TF incr to 150cc/kg/d. Currently receiving\nPND7.5 and D5W with 2mEq of sodium acetate and 1mEq KCl via\ncentral PICC. IL stopped d/t triglycerides of 229. Infant\nstarted enteral feeds at 10cc/kg. Tolerating well. Abdomen\nsoft and round. +BS. No loops. Had 1.4cc dark green biliious\naspirate at 08, discarded. NNP aware. Began feeds as\nplanned. No stool this shift. UO=3.1cc/kg/hr X8hrs. Plan to\nresume IL this evening, check lytes and triglycerides in AM.\n\n\nSepsis: Continues on antibx, amp and gent. Day . VS\nstable. Plan for LP on Fri.\n\nDEV: AFSF. MAE. Temp stable, nested on sheepskin in\nservo-controlled isolette. Alert and active with cares.\nSleeps well between cares. Plan for HUS on Fri.\n\n: Mom and dad in to visit this morning. Updated at\nbedside. Providing cares with some verbal cuing. Mom\ndischarged today. Plan to call later today and to visit\ntomorrow.\n\nHyperbili: Continues on single phototherapy with eye shields\non.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2159-11-15 00:00:00.000", "description": "Report", "row_id": 1699436, "text": "NURSING PROGRESS NOTE\n\n\n1 - RESP - PT REMAINS ON NP 21-30%, INCREASED O2 W/\nCARES. BSC/=, MILD SC/IC RETRACTIONS NOTED. SXN -\nWHITE/CLOUDY SECRETIONS. NO A/BS NOTEDE. PT ON CAFFEINE\n\n2 - FEN - TF=150C/K. PT RECEIVING PND7.5 AND LIPIDS AT\n140CC/K. INFUSING VIA PICC WITHOUT DIFFICULTY PT RECEIVING\nENTERAL FEEDS AT 10CC/K OF BM/PE20. FIRST FEED HELD FOR FULL\nLOOPY BELLY AND ASPIRATE=2.2CC - LIGHT BROWN IN COLOR. NNP\nAWARE, ASPIRATE RECHECKED IN 1 HR - NO ASPIRATE. FEEDS\nCONTINUED AT NEXT CARE TIME. ABD SOFT, +BS, NO LOOPS. AG=21.\n U.O=4CC/KG/HR/YESTERDAY. NO STOOLS. WT=960(+14) LABS DUE\nIN AM.\n\n3 - SEPSIS - PT CONTINUING ON AMP AND GENT, Day . temp\nstable. pt active and alert w/ cares\n\n4 - DEV - TEMP STABLE, SERVO MODE ISOLETTE. NESTED. AFOF.\nALERT W. CARES - SETTLES WELL BETWEEN CARES.\n\n5 - PARENT - NO FAMILY CONTACT THUS FAR TONIGHT\n\n6 - - PT REMAINS UNDER SINGLE PHOTOTHERAPY, EYE SHIELDS\nON. PT VOIDING, NO STOOLS\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2159-11-15 00:00:00.000", "description": "Report", "row_id": 1699437, "text": "Respiratory Care Note\nPt. continues on 6cmH2O of NPCPAP and 21-24% FIO2. BS are clear. Pt.'s FIO2 is down maybe pt. could be decreased to 5 cmH2O of CPAP. To follow.\n" }, { "category": "Nursing/other", "chartdate": "2159-11-15 00:00:00.000", "description": "Report", "row_id": 1699438, "text": "Newborn Med Attending\n\nCont on CPAP6, RA-30% O2. No spells. AF flat, clear BS, no murmur, abd soft, MAE. WT=960 up 40, on 150 cc/kg/d Pn/IL and trophic feeds. On amp and gent.\nA/P: Infant with residual RDS. Cont to wean from CPAP as tolerated. Advance feeds as tolerated. Cont abx d . Cont phototherapy.\n" }, { "category": "Nursing/other", "chartdate": "2159-11-15 00:00:00.000", "description": "Report", "row_id": 1699439, "text": "Rehab/OT\n\n observed today during cares. Care plan to be posted in next 1-2 days. Met with at the bedside. Discussed the role of OT, infant stress signals, and ways to comfort during his NICU stay. Refer to care plan for recommendations.\n" }, { "category": "Nursing/other", "chartdate": "2159-11-19 00:00:00.000", "description": "Report", "row_id": 1699464, "text": "0700- NPN\n\n\nRESP: Pt cont on Prong CPAP of 5, mainly in RA with FiO2 at\n30% x 1 this shift. RR 30's-60's, O2 sats 96-100%. LS\nclear/=, mild SC/IC retractions noted. Brady spells x 3\nwith HR to 61-80 requiring mild stim and increase in O2.\nSuctioned x 2, sm yellow secretions nasally and sm-mod\ncloudy secretions orally. A: Resp status stable, A/B spells\ncontinue. P: Cont to monitor resp status and A/B spells.\n\nFEN: TF cont at 150cc/kg/d. EF are currently at 100cc/kg/d\nof BM20/PE20. IVF is at 50cc/kg/d of PN10 and IL, infusing\nwell through PICC line in left arm. D-stick was 105. No\nspits. Aspirates 0.4-1.4 nonbilious, nonbilious partially\ndigested formula. Abd girths stable at 20.5-21cm. Abdomen\nsoft, round, pink, BS+, no loops. Pt voided 3.6cc/kg/hr in\n8hrs, sm meconium stool x 1.\n\nG&D: Temps stable in servo isolette. MAE, alert and active\nwith cares. Sleeps between cares, brings hands to midline\nfor comfort. Fontanels soft and flat. A: AGA. P: Cont to\nsupport growth and development.\n\nPARENTING: Mom called x 1, updated by this RN. Mom plans\nto visit this evening. A: loving and invested. P:\nCont to support and educate .\n\n\n" }, { "category": "Nursing/other", "chartdate": "2159-11-19 00:00:00.000", "description": "Report", "row_id": 1699465, "text": "0700- NPN ADDENDUM\nFEN: A: FEN status stable. Pt tolerating feeds at this time. P: Cont to monitor feeding tolerance and increase EF by 10cc/kg/d as ordered.\n" }, { "category": "Nursing/other", "chartdate": "2159-11-19 00:00:00.000", "description": "Report", "row_id": 1699466, "text": "Respiratory Care\nPt cont on CPAP. fio2 .221, rr 40's, bs clear. On caffeine. 4 spells noted. Plan to support as needed. Will follow.\n" }, { "category": "Nursing/other", "chartdate": "2159-11-20 00:00:00.000", "description": "Report", "row_id": 1699467, "text": "NPN 1900-0700\n\n\n1. RESP: O: Pt remains on prong CPAP 5, requiring 21%\nFiO2. RR 30-50's. Mild S/C retractions noted. Lung sounds\nare clear. Sxn for large yellow secretions X 1 so far this\nshift. Pt is on caffeine. No spells noted so far this\nshift. A: Stable in CPAP. P: Monitor.\n\n2. F&N: O: TF remain at 150cc/k/d. Enteral feeds of PE20\nwere advanced to 110cc/k/d. Abd benign. BS+. IVF of D10\nwith lytes infusing well via PICC. A/G stable. No spits\nand minimal aspirates noted. U/O 3.4cc/k/h. No stool\nnoted. No weight change. A: Working up on feeds. P:\nMonitor.\n\n4. DEV: O: kangaroo-ed with Dad X 1 hour and tol\nwell. Temp stable in servo-controlled isolette. MAE.\nFontanels are soft and flat. A: AGA. P: Continue to\nsupport infant's needs.\n\n5. PAR: O: in at . Mom did cares and Dad\ngave kangaroo care. They asked appropriate questions and\nspoke lovingly to . A: Loving, vested family. P:\nContinue to support .\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2159-11-20 00:00:00.000", "description": "Report", "row_id": 1699468, "text": "RESPIRATORY CARE NOTE\nBaby #1 remains on Prong CPAP 5 FiO2 21%. Suctioned nares for mod-lg amt of yellow secretions. Breath sounds are clear. RR 30-50's stable on CPAP cont to follow.\n" }, { "category": "Nursing/other", "chartdate": "2159-11-20 00:00:00.000", "description": "Report", "row_id": 1699469, "text": "Newborn Med Attending\n\nCont on CPAP5, RA, no spells overnight. AF flat, clear BS, no murmur, abd soft, MAE. On 150 cc/kg/d IVF and Pe20.\nA/P; Inffant with resolving RDS. Monitor for spells. Cont to advance PG feeds.\n" }, { "category": "Nursing/other", "chartdate": "2159-11-27 00:00:00.000", "description": "Report", "row_id": 1699508, "text": "npn 1900-0700\n\n\n#1 resp\no: pt remains on nc 400ccflow with fio2 25-30%. lsc and\nequal. ic/sc retractions noted rr 50-60's. cleaned for large\namt dry blood at end of nares. spell x2 thus far this shift\nneeding mild stim for one. a: requiring assitance of o2 and\nspelling. p continue to monitor and support.\n#2 fen\no: tf 140cc/kg. enteral feeds of pe20 currently @ 40cc/kg\ngavaged q4hours. ivf of pnd10 via piv currently @ 100cc/kg.\nwt. 1.190kg (+20gms). abd soft and round with good bs. soft\nloops noted with one care. ag stable 20-21cm. no spits. max\naspirate 0.4cc. u.o. past 24hours 2.4cc/kg. a: tolerating\ninitiation of feedings well. p: continue to monitor for\nchanges and support. advance feedings by 40cc/kg .\n#4 g&d\no: pt in air controlled isolette swaddle with warm temps.\nisolette weaned several times. temps as high as 100.0. alert\nand awake with cares, occationally waking between cares.\nfontanelles soft and flat with slightly spread sutures.\nsucking on pacifier and hands. iv infiltrate at beginning of\nshift with blistered area over right wrist where cannula tip\nended. a: stable p: continue to monitor for changes and\nsupport.\n#5 paretning\no: no contact with thus far this shift.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2159-11-27 00:00:00.000", "description": "Report", "row_id": 1699509, "text": "nsg addend\naddition to fen. guiac + stool this evening.\n" }, { "category": "Nursing/other", "chartdate": "2159-12-14 00:00:00.000", "description": "Report", "row_id": 1699600, "text": "Neonatology\nQuick self resolving desats. Upper airway congestion noted.\nRemaisn in NCO2 STable flow and concentration.. CV stable\n\nPale. Transfused this week. WIll recheck Hct and consider need for further rx.\n\nOld IV site slightly swollen. Will examine and consider CBC.\n\nWt 1730 up 30. Abdomen bneign. Tolerating feeds at 140 cc/k/d.Abdomen benign. Tolerating gavage.\n\nContinue current nutritional regimen and resp monitoring.\n" }, { "category": "Nursing/other", "chartdate": "2159-12-14 00:00:00.000", "description": "Report", "row_id": 1699601, "text": "fellows exam note\ncomfortable on NC\nlungs clr\nheart: soft SE murmur\nwell perfused, wnl pulses\nabd: soft\nneuro: nonfocal\n" }, { "category": "Nursing/other", "chartdate": "2159-12-14 00:00:00.000", "description": "Report", "row_id": 1699602, "text": "#1Resp\n remains in nasal cannulaAT 300CC FLOW BETWEEN 45-55%,\nBUT MOSTLY ABOUT 48%. LUNGS SL COARSE. MILD TO MOD\nRETRACTIONS. RR 40-70'S. COLOR MOTTLED. OCCASIONAL DRIFTS TO\n80'S WHICH REQUIRE INCREASE IN O2 OR REPOSITIONING.\nA. STILL REQUIRING O2\nP. PLAN TO CHECK A CBC TODAY.\n#2FEN\nBABY CONT ON 140CC/KG OF PE 30 WITH OR 40CC OVER 90\nMINUTES. TINY DRIBBLE X1. ABD ROUND BUT SOFT, ACTIVE BOWEL\nSOUNDS. VOIDING, BUT NO STOOL. ONE ASP 6CC, PARTIALLY\nDIGESTED WITH SPECK OF OLD BLOOD.\nA. FEEDS\nP. CONT TO MONITOR TO FEEDS\n#4DEV\nTEMP STABLE IN AN OPEN CRIB. FFUSSY WHEN AWAKENS. SUCKS ON\nPACIFIER. SWADDLED.\nA. STABLE\nP. CONT TO PROMOTE GROWTH AND DEV.\n#5PARENT\nNO CONTACT SO FAR TODAY. PLAN TO VISIT AT 1630\nTODAY.\n#9CV\nSOFT MURMUR. BP WITH MEANS AT 34. COLORPINK WITH MOTTLY\nUNDERTONE. HR IN 170'S.\n#10A&B\nBABY CONT ON CAFFEINE. HE HAS HAD OCC DRIFT. TEAM INFORMED .\nONE BRADY SO FAR AS WELL AS ONE TRUE DESAT WHICH WAS SLOW TO\nRESOLVE.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2159-12-14 00:00:00.000", "description": "Report", "row_id": 1699603, "text": "#5PARENTS\nMOM AND DAD HERE AT 1600 AND MET WITH FELLOW AND DR. .\n\nADDENDUM\nCOLOR IMPROVED THIS AFTERNOON.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2159-12-18 00:00:00.000", "description": "Report", "row_id": 1699614, "text": "NPN Days\n\n\n1. O: Received pt in NC 400cc flow 40-50%. RR 60-80's. Ls\nclear. Mild-mod subcostal retractions. No spells. On\nCaffeine. A: Cont with increased O2 requirement. P: Cont to\nmonitor resp status.\n\n2. O: TF decreased to 130cc/kg of PE32+PM via ngt. Min asp.\n1 spit after Fellow exam. Voiding. A: feeds. P: Cont to\nmonitor wt, abd, and of feeds.\n\n4. O: Temp stable swaddled in open crib. and active\nwith cares. Int sucking on pacifier. A/P: Cont to cluster\ncare. Cont to monitor temp.\n\n5. O: Mom called X1. Asking appropriate questions. Rn\nupdated Mom. to be in at 1700 care. A/P: Cont to\neducate and support.\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2159-12-19 00:00:00.000", "description": "Report", "row_id": 1699615, "text": "NNP 7p-7a\n\n\nRESP: Pt on NC 400cc flow,48-50% O2. Mild subcostal\nretractions. RR:40-70's. No spells. Remains on caffeine. LS:\ncl/=. Continue to wean 02.\n\nCV: Soft PDA murmur heard during cares. HR:140-170's. Pt is\npale pink and well profused. BP 78/41, MAP of 56. Continue\nto monitor murmur.\n\nFEN: Current weight is 1915g(+20g). TF: 130cc/kg PE32 with\nPM. 41cc gavaged over an hour. Minimal asp. no spits.\nVoiding with each diaper chg. Med, green, quiac neg stool\nx1. Abdominal girth is 27cm. Continues on vit E and Fe.\nContinue to monitor total fluid intake.\n\nParenting: No contact from .\n\n\n\nDEV: Temp is stable, while swaddled in an open crib. Pt is\n and active during cares. Pt is content closely\nsharing a crib with his sister. Pt is able to hold pacifier\nto mouth on his own.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2159-12-13 00:00:00.000", "description": "Report", "row_id": 1699598, "text": "NPN DAYS\n\n\nALT IN RESP:REMAINS IN NASAL CANNULA 02, 300CC FLOW, 45% ALL\nDAY. LUNGS CLEAR, RR 40-60'S WITH MILD SUBCOASTAL\nRETRACTIONS. SX NARES ONCE FOR MOD AMT OF YELLOW SECRETIONS\nAND SLIGHTLY BLOOD TINGED AT END OF SX. NO EPISODES OF APNEA\nOR BRADYCARDIA THIS SHIFT. OCCASIONAL DRIFTS IN O2 SATS,\nTHAT SELF RESOLVE. REMAINS ON CAFFEINE. CONTINUE TO MONITOR\nRESP STATUS CLOSELY AND WEAN O2 AS .\n\nCV:CONTINUES TO HAVE SOFT MURMUR. HR 160'S. BP 55/30 40. NO\n PULSES. GOOD PINK COLOR, AND CAP REFILL. CONTINUE TO\nMONITOR CV STATUS FOR ANY CHANGES IN EXAM.\n\nALT IN NUTRITION R/ : FULL VOLUME FEEDS WELLON\n140CC/K/D OF PE 30 W/, 40CC Q4HRS VIA GAVAGE OVER 1HR\nAND 10MINS. ABD EXAM BENIGN, NO LOOPS, NO SPITS. GIRTH\n24-26. ASP. 1.2-1.8CC. VOIDING AND STOOLING WELL. STOOL\nGUIAC NEG. CONTINUE CURRENT FEEDING PLAN. DO NOT OFFER\nBOTTLE YET, TO ENSURE BABY STAYS OFF CPAP.\n\nALT IN GROWTH AND DEVELOPMENT D/ : AND ACTIVE WITH\nCARES. SLEEPS WELL BTW FEEDS. MAINTAINS TEMP IN OPEN CRIB.\nTEMP AND 1PM 100, REMOVED HEAVY BLANKET. MD AWARE. SWADDLED\nAND NESTED IN SHEEPSKIN. CO BEDDING WITH SISTER. CONTINUE\nDEVELOPMENTAL CARES. REPEAT EYE EXAM NEXT WEEK.\n\nALT IN PARENTING:MOM CALLED FOR UPDATE THIS MORNING. \nWILL BE IN TO VISIT AT 4:30PM. THEY WILL HOLD HIM FOR\n90MINS. CONTINUE TO SUPPORT AND UPDATE.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2159-12-17 00:00:00.000", "description": "Report", "row_id": 1699608, "text": "Neonatology\nDOing well. REmains in NCO2 at 400 cc. Still with intermittent increases in Rr and slightly increased WOB. No spells.\nMurmur as before. Will check CXR and consider need for echo in coming days. Has had two with tiny PDAs documented on previous films.\n\nWt 1865 up 40. Tolerating feeds at 140 cc/k/d of 30 cal via gavage. Took single bottle yesterday. Abdomen benign.\n\n" }, { "category": "Nursing/other", "chartdate": "2159-12-17 00:00:00.000", "description": "Report", "row_id": 1699609, "text": "NPN Days\n\n\n1. O: Received in NC 400cc flow 35-45%. RR 30-80's, mostly\n60-80's. Ls clear. Mild-mod subcostal retractions. No\nspells. CXR obtained. A/P: Cont to monitor resp status.\n\n2. O: TF 140cc/kg of PE30+PM via ngt. Min asp. No spits.\nVoiding and stooling G-. A: feeds. P: Cont to Monitor\nwt, abd, and of feeds.\n\n4. O: Temp stable swaddled in open crib. and active\nwith cares. A/P: Cont to monitor temp. Cont to cluster care.\n\n5. O: Dad called X1. Asking appropriate questions. A/P: Cont\nto educate and support.\n\n9. O: +soft murmur. HR 160-170's. PInk. Good perfusion. A/P:\nCont to monitor CV.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2159-12-19 00:00:00.000", "description": "Report", "row_id": 1699616, "text": "NPN\n\n\nADD: I have examined infant and agree with above co-workers\nnoted by .\n\n\n" }, { "category": "Nursing/other", "chartdate": "2159-12-19 00:00:00.000", "description": "Report", "row_id": 1699617, "text": "Neonatology\nRemains in 400_> 200 cc NCO2. Comfortable appearing but tachypneic.\nWIll follow resp need and consider need for diruetic rx in coming days.\n\nWt up 20. TF decreased to 103 cc/k/d of 32 cal. Abdomen bneign. Remains on gavage feeds. Occasional bottles.\n\nEye exam for today.\n\nWill consider possibility of tx for later this week.\n" }, { "category": "Nursing/other", "chartdate": "2159-12-19 00:00:00.000", "description": "Report", "row_id": 1699618, "text": "fellows exam note\ncomfortable\nneuro: active, currently sleeping, easily arousable\nlugns clr\nheart: no murmur\nabd soft\n\n" }, { "category": "Nursing/other", "chartdate": "2159-12-19 00:00:00.000", "description": "Report", "row_id": 1699619, "text": "Nursing Progress Note\n\n\n#1-O/A- Received infant on NCO2 300cc 50%. Infant remains\non NCO2 weaned to 200cc, 50%. No resp distress. No bradys.\nCont on Caffeine. P- Cont to assess for Resp needs.\n#2-O/A- TF=130cc/kg/d of PE32w/ via NGT. Abd exam\nbenign. Voiding and stooling. Cont on Vit e and iron. P-\nCont to assess for FEN needs.\n#4-O/A- cont to be awake and active with cluster cares\nq4hrs. Sleeps well between cares. Temp stable in open\ncrib. Sucks on pacifier. Eye exam done today, stg 1, zone\n f/u . P- Cont to assess for G&D needs.\n#5-O/ Mom called with updates given. Plans to transfer\ntwins to when resp status is stable. P-\nCont to enc parental calls and visits.\n#9-O/A- Cont with soft murmur, known sm PDA by echo. No cv\ndistress. P- Cont to assess for CV needs.\nSee flowsheet for further details.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2159-12-17 00:00:00.000", "description": "Report", "row_id": 1699610, "text": "Clinical Nutrition:\nO:\n32 CGA, BB now on DoL #38\nWt: 1865g (+40g)-(~50th%ile); gained an average of 27 g/kg/day over the last week.\nLN: 42.5cm (25-50th%ile)\nHC: 29.5cm (~25th%ile)\n: none recent\nMeds: Iron (~4.0 mg/kg/day from feeds & supplement) & vit E\nNutrition: PE30 w/ @ 140 cc/kg/day\nProjected 24hr intake: ~140 Kcals/kg & ~4.0 g/kg of protein\nGI: max asp=5cc, minimal spits noted\n\nA/goals:\nTolerating gavage feeds, bottled ~25% of bottle yesterday. Voiding & stooling. Wt gain slightly above goal range over the last week. Would hold on decreasing conc. of feeds until PO feeding improves. Nutrition checked last week, Phos=4.3; would re-check this week, may need supplementation. Continues on iron & vit E. Will cont. to follow w/team & participate in nutrition plans.\n" }, { "category": "Nursing/other", "chartdate": "2159-12-18 00:00:00.000", "description": "Report", "row_id": 1699611, "text": "NNP 7a-7p\n\n\nRESP: In NC 400cc flow with 35-40% O2. Mild-Moderate S/C\nretractions. Ls, cl/=. RR:40-70's. NO spells so far this\nshift. Pt remains on caffeine. Continue to monitor o2 sats\nand wean o2.\n\nFEN: Present weight 1.865kg. TF: 140cc/kg PE30PM. 44cc\ngavaged over an hour. Minimal asp. 1 spit. voiding with each\ndiaper change. Lg, green, Quiac neg stool x1. Abdominal\ngirth of 27. Pt remains on vit E and Fe. Continue to support\n and encourage bottle feeding.\n\nDEV: Temp is stable swaddled in an open crib. Active and\n with cares. Pt enjoys being snuggled close with his\nsister. Comforts with containment and pacifier. Continue to\nsupport developmental milestones.\n\n: No contact from so far this shift.\n\nCV: No murmur heard so far this shift. HR:150-180's. Pt is\nwell perfused and pale pink.\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2159-12-18 00:00:00.000", "description": "Report", "row_id": 1699612, "text": "Neonatology\nDOing well. REmains in NCO2. COmfortable apeparing. Received a dose of lasix yesterday with little effect. Will plan to start trial of diuril and if continued high need monitor response.\n\nWt 1895 up 30. TF at1 40 cc/k/d of 30 cal. Tolerating via gavage. Abdomen bneign.\n\nTemp stable co-bedding.\n\nEye exam for Wednesday.\n" }, { "category": "Nursing/other", "chartdate": "2159-12-18 00:00:00.000", "description": "Report", "row_id": 1699613, "text": "fellows exam note\ncomfortable\nheent:afof\nlungs corases slightly, good areation\nheart: soft intermittnet murmur\nabd: soft\nneuro: nonfocal\n\n...will . TF to 130 and inc. to 32 cal\n" }, { "category": "Nursing/other", "chartdate": "2159-12-21 00:00:00.000", "description": "Report", "row_id": 1699625, "text": "Neonatology\nRemains in NCO2 200 cc 40%. Comfortable. Stable O2 need.\n\nWt up 509. Abdomen . feeds. Poor .\n\nDC summary dicatde.\nNo hearing done.\nWIll need eye exam in two weeks\nDr .\n\n transfer to this afternoon with sib.\n" }, { "category": "Nursing/other", "chartdate": "2159-12-03 00:00:00.000", "description": "Report", "row_id": 1699543, "text": "Clinical Nutrition\nO:\n~31 wk CGA BB on DOL 23.\nWt: 1295 g (+60)(~25th to 50th %ile); birth wt: 1130 g. Average wt gain over past wk ~12 g/kg/d.\nHC: 27 cm (~10th to 25th %ile); last: 26 cm ()\nLN: 39 cm (~25th %ile) ;last: 39 cm\nMeds include Vit E and Fe.\n not due yet.\nNutrition: 140 cc/kg/d of PE 30 w/ (feeds just increased today.) Projected intake for next 24 hrs ~140 kcal/kg/d, and 4.1 g pro/kg/d.\nGI: Abdomen benign.\n\nA/Goals:\nTolerating feeds without GI problems. not due yet. Current feeds + supps meeting recommendations for kcals/pro/vits and mins. Growth is not meeting recommendations for wt gain of ~15 to 20 g/kg/d or for LN gain on average of ~1 cm/wk. HC gain is on average meeting recommendations. Expect growth to improve now that feeds have been increased. Will continue to follow w/ team and participate in nutrition plans.\n" }, { "category": "Nursing/other", "chartdate": "2159-12-03 00:00:00.000", "description": "Report", "row_id": 1699544, "text": "NPN 1400\n\n\n#1 Resp: remains on NP CPAP of 6cms 21-28% today. Lungs\nare clear, =. Infant requires suctioning for mod amts of\nthick white/yellow secretions down ETT and white orally. RR\n30-50. Continues to have occasional spells; 2 brady's this\nshift HR 73-66 during the 1pm feeding. Self resolved X1,\nstime X1. Remains on caffeine as ordered.\nA: Comfortable on CPAP. Occ. spells.\nP: Cont CPAP, monitor spells.\n#2 F/N: remains on 140cc/kg/d 30cc q 4hrs X1hr, cals\nnow increased to 30/oz. Abd soft and full, bowel snds\nactive. AG stable at 20.5-21cms. Voiding and stooling.\nA: Tol feeds well. No spits.\nP: cont to assess for feeding intolerance.\n#4 G/D: remains on servo heat control positioned prone\nw/i a nested sheepskin. Position changed q 4 hrs. Stresses\nwhen disturbed by flailing extremities and crying. Calms\ndown w/ positioning and offering a pacifier.\nA: AGA 30 wkr.\nP: cont dev. supports.\n#5 : Mom phoned this afternoon. Asking about babies.\nPlans to visit at 4pm today.\nA: Invested family.\nP: Cont to keep updated and informed. Kangaroo day\ntomorrow.\n#9 CV: HR 150-170 murmur loud. BP wnl taken during the noc.\nA: Stable CV status w/ murmur.\nP: Cont to assess.\n#10 Skin: No evidence of skin breakdown at this time.\nA: Skin intact.\nP: Cont to assess for areas of skin breakdown.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2159-12-21 00:00:00.000", "description": "Report", "row_id": 1699626, "text": "1. remains on nasal cannula 200cc 40%O2, color pink,\nBBS equal, clear, RR40-70, sc rets, on caffeine-no spells P:\ncontinue to monitor/document, wean/supply O2 to keep\nsats>93.\n2. TF restricted at 130cc/k/d of PE30 with PM, 44cc q4h pg\nover 1h, abd soft, umbi hernia soft, voiding, no stool yet\nthis shift, sm spit x1, max aspirate 4cc, A: tolerating\nfeedings P: continue present care, offer po when Mom visits\nor if very awake/.\n4. temps stable swaddled in open crib with sister, sucks\nwell on pacifier, Continue to support growth and\ndevelopment.\n5. Mom called this am, aware that transfer to \nwill not be today, probably tomorrow. planning to visit\nlater today P: continue to update and offer support.\n9. HR 140-160's, color pink, murmur audible, pulse nl,\ncontinue to assess/monitor.\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2159-12-22 00:00:00.000", "description": "Report", "row_id": 1699627, "text": "#1 PT REMAINS ON NC02 200CC 40%. RR 40-70. LS ARE CLEAR AND\nEQUAL. NO BRADY'S, SAT DRIFTS TO HIGH 80'S. CONT ON CAFF.\nINCREASED WOB WITH PO FEED.\n#2 TF 130CC/KG PE30C/PRO. FEEDS TOLERATED WELL. NO SPITS,\nMIN ASP, ABD BENIGN. VOIDING, NO STOOL AT THIS TIME IN\nSHIFT. PO FED X1. WEIGHT INCREASE 65GM.\n#4 TEMPS STABLE SWADDLED IN OPEN CRIB. AND ACTIVE.\nPLAN TO TRANSFER TO TODAY.\n#5 NO CONTACT FROM FAMILY AT THIS TIME IN SHIFT.\n#9 PINK. HR 140-60. MURMER NOTED.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2159-12-22 00:00:00.000", "description": "Report", "row_id": 1699628, "text": "NICU Attending Transfer Note\n\nPlease see typed discharge summary for details of pre/perinatal hx and hospital course by system, Newborn PEx form for details of discharge PEx. DOL # 42 for this former 27 week gestation male = 34 week CGA, current active issues are CLD, resolving A/B, growth and nutrition, ROP.\n\nCVR/RESP: Known PDA murmur (small by echo, no hemodynamic significance). Remains in NCO2 200 cc/min flow 40% FiO2, remains on caffeine no A/B. will continue to wean NCO@ as tolerated, d/c caffeine once stable post transport.\n\nFEN: Discharge weight 2085, up 65 gm copmared to yesterday, receiving 130 cc/kg/d PE 30 with PM. PO/PG. Also on Vit E/Fe. Will continue current diet, continue to encourage PO intake.\n\nENV'T: Stable temp co-bedding with twin sister.\n\nOPHTHO: Most recent eye exam showed OS stage 1 zone 2, OD stage 1, zone 3. F/u in 2 weeks.\n\nDISPO: Ready for transfer to today. Will accepting MD prior to transfer.\n" }, { "category": "Nursing/other", "chartdate": "2159-12-22 00:00:00.000", "description": "Report", "row_id": 1699629, "text": "NICU Attending Transfer Note\n\nI spoke with accepting MD Pu at to review hospital course and current condition.\n\nPMD will be Dr. (. I left message re: transfer of twins, and will fax copy of discharge summary to her office.\n" }, { "category": "Nursing/other", "chartdate": "2159-12-05 00:00:00.000", "description": "Report", "row_id": 1699558, "text": "NPN DAYS CONTINUED\nALT IN PARENTING: IN TO VISIT AT 4PM. MOM TOOK TEMP AND CHANGED DIAPER. DAD KANGAROOED FOR 90MINS. BABY WELL. UPDATED AT BEDSIDE. CONTINUE TO SUPPORT AND UPDATE.\n" }, { "category": "Nursing/other", "chartdate": "2159-12-06 00:00:00.000", "description": "Report", "row_id": 1699559, "text": "Respiratory care Note\nPt. continues on 5cmH2O of NPCPAP and 21-25%. BS are clear. Pt. on caffeine. One documented spell thus far. To follow.\n" }, { "category": "Nursing/other", "chartdate": "2159-12-06 00:00:00.000", "description": "Report", "row_id": 1699560, "text": "NPN NIghts\n\n\n1. O: REceived pt on NP CPAP of 5. FiO2 22-25%. 2spells thus\nfar this shift both QSR; 2 in 24 hrs. On caffeine. Mild\nSubcostal retractions. Sxn'd thick yellow.A: 2 spells. P:\nCont to monitor resp status.\n\n2. O: wt 1400 gms, up 45. TF 140cc/kg of PE 30+PM via ngt. 1\nspit. Min asp. Voiding an dstooling G-. AG 21-22cm. A: \nfeeds. P: Cont to monitor wt, abd, and of feeds.\n\n4. O: Air isolette weaned X2 for temp 99.2-99.5. Temp 98.8\nin 27.2 isolette swaddled. Alert and active with cares. A/P:\nCont to monitor temp. Cont to cluster cares.\n\n5. No conatct thus far this shift.\n\n9. O: + murmur. NL pulses. Hr 150-170's. Bp 71/33 48. A/P:\nCont to monitor CV status.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2159-12-06 00:00:00.000", "description": "Report", "row_id": 1699561, "text": "fellowsexam note\nsleeping, easily arousable, feeding\nheent:afof\nlungs clr\nheart: no murmur\nabd:soft\n\ntolerated CPAP5 yesterday and overnight, will try to wean to NC later this week\n" }, { "category": "Nursing/other", "chartdate": "2159-12-06 00:00:00.000", "description": "Report", "row_id": 1699562, "text": "Neonatology Attending\n\nNow day of life 26\n ON CPAP of 5 and in 21% FIO2\nOn caffeine.\n4 episodes of apnea and bradycardia in the\nHR 150-170s\nBP stable\n\nWt. up 45 to 1400gm on 140cc/kg of PE30 with \nFeedings well tolerated by gavage.\nOnly occasional spitting.\nNormal urine and stool output.\n\nAssessment/plan:\nSteady progress continues - tolerated wean of CPAP.\nWill continue with current management.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2159-12-06 00:00:00.000", "description": "Report", "row_id": 1699563, "text": "Respiratory Care Note\nReceived pt on NP CPAP 5. O2 21%-25%. 4 spells in a 24 hour period, one this am required stim. BS are clear. Sux for mod amt yellow secretions. Continues on caffine.\n" }, { "category": "Nursing/other", "chartdate": "2159-12-06 00:00:00.000", "description": "Report", "row_id": 1699564, "text": "NPN DAYS\n\n\nALT IN RESP:REMAINS ON NP CPAP 5, 21-28%. LUNGS CLEAR, RR\n40-70'S WITH SUBCOASTAL RETRACTIONS. SX Q4HRS FOR MOD AMT OF\nTHICK YELLOW SECRETIONS FROM NP TUBE AND NARES. 1 EPISODE OF\nBRADYCARDIA THIS SHIFT, NEEDING MOD STIM. REMAINS ON\nCAFFEINE. CONTINUE TO MONITOR RESP STATUS CLOSELY AND WEAN\nO2 AS . WILL TRIAL OFF CPAP AT THE END OF THIS WEEK OR\nBEGINNING OF NEXT WEEK.\n\nCV:CONTINUES TO HAVE A SOFT MURMUR. HR 160-170'S. BP THIS\nMORNING 66/33 44. NO EVIDENCE OF CARDIAC COMPROMISE.\nCONTINUE TO MONITOR FOR ANY CHANGES IN EXAM.\n\nALT IN NUTRITION R/ : FULL VOLUME FEEDS WLEL ON\n140CC/K/D OF PE30 W/, 33CC Q4HRS VIA GAVAGE OVER\n90MINS. ABD EXAM BENIGN, NO LOOPS, NO SPITS. GIRTH 22-23.\nVOIDING AND STOOLING WELL. STOOL GUAIC NEG. CONTINUE CURRENT\nFEEDING PLAN. MONITOR FOR ANY FEDDING INTOLERANCE.\n\nALT IN GROWTH AND DEVELOPMENT D/ :ALERT AND ACTIVE WITH\nCARES. SLEEPS WELL BTW FEEDS. MAINTAINS TMEP IN AIR\nCONTROLLED ISOLETTE. SWADDLED AND NESTED IN SHEEPSKIN.\nCONTINUE DEVELOPMENTAL CARES.\n\nALT IN PARENTING: IN TO VISIT AT 5PM. MOM TOOK TEMP\nAND CHANGED DIAPER ANDHELD BABY FOR 90MINS. UPDATED\nAT BEDSIDE. CONTINUE TO SUPPORT AND UPDATE.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2159-12-09 00:00:00.000", "description": "Report", "row_id": 1699576, "text": "RESPIRATORY CARE NOTE\nBaby #1 remains on Prong CPAP 5 FiO2 23-27%. Suctioned nares for mod amt of white secretions. Breath sounds are clear. Two brady's so far tonight requiring mild stim. Will cont to monitor closely.\n" }, { "category": "Nursing/other", "chartdate": "2159-12-09 00:00:00.000", "description": "Report", "row_id": 1699577, "text": "Neo attending\nDOL 29 for this infant who remains on CPAP of 5. Remains on caffeine.\nWeight\n\nRRR no m/r/g\nCLear BS\nSoft abdomen\n+ BS\n\nA/P:\nResp: continue CPAP for evidence of immature resp pattern\nCVR: Stable\nFEN: 140 cc/kg/d of enteral feeds.\n\nNo new medical changes.\n" }, { "category": "Nursing/other", "chartdate": "2159-11-25 00:00:00.000", "description": "Report", "row_id": 1699499, "text": "Nursing Progress Note\n\n8 CV\n\n#1 O: Remains on nasal prong cpap 5cms 21%, RR 40's-70's,\nbaseline IC/SC retractions. Lungs clear/equal, color pink.\nNares excoriated from prongs and remain problem/duoderm\ncushion placed. sx'd w/tb syringe very gentlyw/bloody thick\nsecretions. bradys x2 today, w/apnea and desat; cont on\ncaffeine as ordered w/dose maximized. A: still occ bradys\nr/t prematurity P: ? trial off cpap in several days\n#2 O: remains NPO w/ PIV TPN D10W/IL infusing well at\n130cc/k/d. abd benign, vdg and stooling guiac neg stools. A:\nadequate hydration P: start feeds 24h after last Indocin\ndose at 10cc/k/d to get digestion going.\n#4 O: alert w/cares, irritable w/nares excoriation but\nsettles w/pacifier and holding. KC w/mom for 3hours and tol\nwell.\n#5 O: in to hold, updated on present status. Worried\nabout bleeding from nares, felt better after seeing area and\nduoderm applied.\n#8 O: no murmur heard since yesterday A: successful tx of\nPDA P: resolve.\n\nREVISIONS TO PATHWAY:\n\n 8 CV; resolved\n\n" }, { "category": "Nursing/other", "chartdate": "2159-12-09 00:00:00.000", "description": "Report", "row_id": 1699578, "text": "NPN DAYS\n\n\nALT IN RESP:REMAINS ON NASAL PRONG CPAP OF 5, O2 REQUIREMENT\n27-41%. LUNGS CLEAR, NO NEED TO SX TODAY. RR 40-80'S WITH\nMILD SUBCOASTAL RETRACTIONS. BABY HAS FREQUENT PERIODS OF\nPERIODIC BREATHING, MOST SELF RESOLVED. 3 EPISODES OF APNEA\nWITH BRADYCARDIA THIS SHIFT NEEDING MILD TO MOD STIM.\nREMAINS ON CAFFEINE. CONTINUE TO MONITOR FOR SPELLS. \nNEED TO INCREASE TO CPAP 6 IF CONTINUES TO HAVE LOTS OF\nPERIODIC BREATHING.\n\nCV:CONTINUES TO HAVE A SOFT MURMUR.HR 150-160'S. GOOD COLOR\nAND CAP REFILL. NO EVIDENCE OF CARDIAC COMPROMISE. CONTINUE\nTO MONITOR FOR CHANGES IN EXAM.\n\nALT IN NUTRITION R/ : FULL VOLUME FEEDS EWLLON\n140CC/K/D OF PE 30W/, 35CC Q4HRS VIA GAVAGE OVER\n90MINS. ABD EXAM BENIGN, NO LOOPS,NO SPITS. GIRTH 23-24.ASP.\n0.4-3.2CC. VOIDING AND STOOLING WELL. STOOL GUIAC NEG.\nCONTINUE CURRENT FEEDING PLAN.\n\nALT IN GROWTH AND DEVELOPMENT D/ : ALERT AND ACTIVE\nWITH CARES. SLEEPS WELL BTW FEEDS. PLACED IN LARGE OPEN CRIB\nWITH SISTER THIS AFTERNOON. SWADDLED AND NESTED IN\nSHEEPSKIN. CONTINUE DEVELOPMENTAL CARES.\n\nALT IN PARENTING: IN TO VISIT AT 9AM. DAD HELD BABY\nFOR 90MINS. UPDATED AT BEDSIDE. HAD THEIR BABY\nSHOWER THIS AFTERNOON. CONTINUE TO SUPPORT AND UPDATE.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2159-12-09 00:00:00.000", "description": "Report", "row_id": 1699579, "text": "NPN DAYS ADDENDUM\nINCREASED CPAP TO 6 AT 5:30PM, TO SEE IF IT WILL HELP WITH HIS FREQUENT DRIFTS IN O2 SATS, AND PERIODIC BREATHING, AND HOPEFULLY DECREASE O2 REQUIREMENT.\n" }, { "category": "Nursing/other", "chartdate": "2159-12-09 00:00:00.000", "description": "Report", "row_id": 1699580, "text": "Respiratory Care\nPt remains on nasal prong CPAP +6cm's with the fio2 30 to 40%. Pt's fio2 requirement increased this shift, CPAP increased from 5 to 6cm's. Plan is to follow.\n" }, { "category": "Nursing/other", "chartdate": "2159-12-10 00:00:00.000", "description": "Report", "row_id": 1699581, "text": "NPNOte:\n\n\n#1. Placed on NP cPAP of 6cm Nasal prong cpap at 9pm,\nFio2 21%, BBS clear and equal, mild intercostal/ subcostal\nretractions present, no spells thus far this shift,\nOccassional sat drifts to low 80's noted QSR. Remains on\nCaffine.A; on Np CPAP. P; continue resp support as\nneeded.\n\n#2.Todays weight 1510 up 20gms, TF=140cc/kg/day, Pe30 with\n,Pg feeds given over 90mts, H/o spits, no spits thus\nfar this shift, BS+, no loops, voided and no stool. A; Feeds\ntolerated. P; Continue current feeding plan.\n\n#4. Alert and active with care, temp stable in a crib 99-\n99.2, co-bedding with sibling. repeat PKu sent. A; AGA P;\ncontinue dev support.\n\n#5.No contacts from thus far this shift.\n\n#9.Soft murmur present, pale pink well perfused.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2159-11-25 00:00:00.000", "description": "Report", "row_id": 1699500, "text": "Respiratory Care\nPt recieved on nasal prong CPAP +5cm's with the fio2 21%. PT suctioned for a mod amt of thickish white secretions. Plan is to trial off of CPAP first of the week.\n" }, { "category": "Nursing/other", "chartdate": "2159-11-26 00:00:00.000", "description": "Report", "row_id": 1699501, "text": "Respiratory Care\nBaby began shift on prong cpap5 21%.Nares appeared red and sore,and baby .Taken off cpap and applied A$D ointment to nares,placed on 400cc n/c.2spells so far this shift.Rr 40-60's.\n" }, { "category": "Nursing/other", "chartdate": "2159-11-26 00:00:00.000", "description": "Report", "row_id": 1699502, "text": "NURSING PROGRESS NOTE\n\n\n1. RESPIRATORY\nCPAP DC'D AT 2200, TOLERATING NASAL CANNULA O2 AT 400CC,\n30%. BBS CLEAR, RR 40-60'S WITH MODERATE IC/SC RETRACTIONS.\nX3 EPISODES OF APNEA/BRADYCARDIA SINCE OFF CPAP. SUCTIONED\nGENTLY BY RT AT 0500 FOR LARGE AMT THICK SECRETIONS.\n2. FN\nTONIGHT'S WEIGHT UP 25 GRAMS TO 1.17KG. APPEARS MILDLY\nEDEMATOUS. TROPHIC FEEDINGS STARTED AT , 1CC ASPIRATE\nX1. ABD FULL, SOFT. 130CC/KG OF PN AND IL INFUSING VIA PIV.\nOUTPUT FOR THIS SHIFT 2.3CC/KG/HOUR.\n4. G&D\nSERVO DECREASED OVERNIGHT. ALERT, IRRITABLE WITH CARE.\nVERY SORE NOSE !!!. LOVES PACIFIER.\n5. PARENTING\nDAD CALLED AND UPDATED.\nCV-NO MURMUR HEARD. HEART RATE 160-170. BP 77/30 M47.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2159-11-26 00:00:00.000", "description": "Report", "row_id": 1699503, "text": "Neonatology Attending\nDOL 16\n\n is in NC 400 cc/min of 25-40% FIO2 since last night. Four apnea/bradycardias, self-resolving, on caffeine.\n\nCompleted indomethacin course on the weekend. No murmur. BP normal.\n\nWt 1170 (+25) on TFI 140 cc/kg/day including enteral feeds PE20 at 20 cc/kg/day, tolerating well. Urine output 2.3 cc/kg/hr. Abdomen benign.\n\nA&P\nPreterm infant with resolving surfactant deficiency, s/p indomethacin for PDA, feeding immaturity.\n\nWe will continue to monitor cardiorespiratory status and wean supplemental oxygen as tolerated.\n\nFeeds will be advanced as tolerated to previous levels.\n" }, { "category": "Nursing/other", "chartdate": "2159-12-02 00:00:00.000", "description": "Report", "row_id": 1699537, "text": "Newborn Med Attending\n\nDOL#22. Cont on CPAP6, 23% O2. Several spells, on caffeine. AF flat, clear BS, soft murmur, abd soft, MAE. WT=1235 up 5, on 140 cc/kg/d PE26 with PM.\nA/P: Infant with CLD and As and Bs. Monitor for spells. Increase to PE28.\n" }, { "category": "Nursing/other", "chartdate": "2159-12-02 00:00:00.000", "description": "Report", "row_id": 1699538, "text": "Respiratory Care\nPt cont on CPAP. Fio2 .21-.25, bs clear, rr 40-60, sx for mod amt. On caffeine. Few spells noted. Plan to support as needed.\n" }, { "category": "Nursing/other", "chartdate": "2159-12-11 00:00:00.000", "description": "Report", "row_id": 1699593, "text": "Nursing Progress Note\n\n\n#1-O/A- Received infant on NP CPAP 6cm. Infant remains on\nNP CPAP 6cm. FIO2 has been mostly 21% this shift. Sxn\nq4hrs for mod white-yellow from ETT. No resp distress. No\nbradys so far this shift. P- Cont to assess for resp\nneeds.\n#2-O/A- TF=140cc/kg/d of PE30w/ via NGT. Abd exam\nbenign. Voiding and stooling. feeds. P- Cont to\nassess for FEN needs.\n#4-O/A- cont to be awake and active with cluster\ncares. Sleeps well between cares. Temp stable in open\ncrib. Cobedding with sister. P- Cont to assess for G&D\nneeds.\n#5-O/ Mom called with updates given. in to hold\nthis pm. P- Cont to enc parental calls and visits.\n#9-O/A- Cont with loud murmur. HR and BP stable. Good\npulses/perfusion. Infant pale at beginning of shift.\nReceived 30cc PRBC's this shift NNP's orders for HCT of\n22. Infant much pinker after transfusion. No CV distress.\nP- Cont to assess for CV needs.\nSee flowsheet for further details.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2159-12-11 00:00:00.000", "description": "Report", "row_id": 1699594, "text": "Respiratory Care\nPt recieved on NP-CPAP +5cm's with the fio2 21 to 25%. PT respiratory rates 30's to 50's with clear B/S. Plan is to trial off CPAP when tolerated.\n" }, { "category": "Nursing/other", "chartdate": "2159-12-11 00:00:00.000", "description": "Report", "row_id": 1699595, "text": "NICU nursing progress note\n\n\nPlease refer to flowsheet for specific info.\nResp/ A and b's\nO: currently with Nprong cpap/6, rr 40-60's, sat's\n92-98%, Sc retractions. Sxn q 4 for large thick yellow\nsecretions nares. orally cloudy. On caffeine. No brady's.\nA; Stable. P: cont to provide opt. oxygenation.\nCV\nO: + murmur appreciated, soft. HR 150-160's. Pink, well\nperfused with cap refill <2sec. A: Stable. P:cont to follow.\nF/N\nO: Weight 1660g ^65g. TF 140cc/k/d of PE 30 w/ .\nGavaged over 1'\" due to hx of spits. No spits. min asp.\nVoiding/ stooling heme (-), Abd. soft, pink, no loops,\nactive bs. A: Stable. Gaining weight. P: cont to follow,\nprovide opt. nut.\nG/D\nO: Temp stable in open crib co-bedding with twin sister.\nActive and with cares. Calms with containment and\npacifier, boundaries in place. MAE. Font soft, flat. A: AGA\nP: cont to support dev. milestones, follow.\nParenting\nNo contact with thus far tonight.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2159-12-16 00:00:00.000", "description": "Report", "row_id": 1699604, "text": "Neonatology Attending\n\nDOL 36 CGA 32 5/7 weeks\n\nIn NCO2 300-400 cc 45-50%. Gradually trending up in O2 requirement. Sats drift frequently. R 60s-80s. 1 A/B. On caffeine.\n\nMurmur secondary to small PDA. BP 73/48 mean 55.\n\nOn 140 cc/kg/d PE 30 with . Takes ~ feeds po. Occ spit. Voiding. Stooling. Wt 1825 grams (up 45).\n\nCobedding with sister.\n\n visiting and up to date. Desire WH transfer.\n\nA: Stable. Gradually increasing O2 requirement. If WOB increases or increased O2 requirement may need CPAP.\n\nP: Monitor\n Adjust O2 as needed\n Encourage pos as tolerated\n WH when ready for Level II care\n\n" }, { "category": "Nursing/other", "chartdate": "2159-12-16 00:00:00.000", "description": "Report", "row_id": 1699605, "text": "Neonatology Attending\nExam AF soft, flat, clear bs, + murmur, benign abd, active, sleeping, good perfusion, feed infusing\n" }, { "category": "Nursing/other", "chartdate": "2159-12-02 00:00:00.000", "description": "Report", "row_id": 1699539, "text": "NICU nursing progress note\n\n\nPlease refer to flowsheet for specific info.\nResp/ a and bs\nO: remains with NP cpap/6, RR 30-60's, fi02 21-23%.\nSat's 94-99%. BSCE bilat. IC/SC ret. SXN q 4 hrs for thick\nyellow secretions. Periodic breathing pattern. On caffeine.\n3 spells today, mod stim to qsr. A: Stable. P: cont to\nprovide opt. oxygenation. Follow.\nCV\nO: +murmur, hr 130-170's. pink and well perfused with cap\nrefill <2sec. A: Stable P: cont to follow.\nF/N\nO: TF of 140cc/kg/d of pe 28 with (increased today)\nGavaged over 1'\" for spits. No spits today. Max asp. of 5\ncc partially digested formula. Abd. soft, pink, no loops,\nactive bs. Voiding/ stooling heme (-). A: Stable. P: cont to\nprovide opt. nut., follow.\nG/d\nO: Temp stable in servo controlled isolette. Active and\nalert with cares. Irritable at times, calms with containment\nand pacifier. Boundaries in place. MAE. Font. soft, flat. A:\nAGA P: cont to support dev. milestones.\nParenting\nO: Mom and dad in and updated at bedside, verbalizing\nunderstanding. Kangaroo with dad and tolerated well. A:\nInvolved and loving . P: cont to update, support,\neducate.\nSkin integrity\nO: right wrist escar resolved, healed well.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2159-12-03 00:00:00.000", "description": "Report", "row_id": 1699540, "text": "NPN 1900-0700\n\n\n1. RESP: O: Pt remains on NP CPAP 6, requiring 21% FiO2.\nRR 30-50's. Baseline retractions noted. Lung sounds are\nclear. Sxn for large thick yellow/ NP and nasal\nsecretions and small white oral secretions. Pt is on\ncaffeine and has had 5 spells so far this shift. A: Stable\non CPAP. Continues to spell. P: Monitor.\n\n2. F&N: O: TF remain at 140cc/k/d of PE28 with .\nFeeds gavaged in over 1 hour 10 minutes. Abd benign. BS+.\nA/G stable. No spits and minimal aspirates noted. Voiding\nand passing green guiac negative stool. Weight gain 60\ngrams. A: Tol feeds well. Gaining weight. P: Monitor.\n\n4&10. DEV: O: Pt remains in servo-controlled isolette on\nsheepskin. Temp stable. MAE. Fontanels are soft and flat.\nSkin is intact. A: AGA. P: Continue to support infant's\nneeds.\n\n5. PAR: No contact from so far this shift.\n\n9. C/V: O: Murmur persists. HR 150-170's. Pt is pink\nand well-perfused. BP stable. A: Alt C/V. P: Monitor.\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2159-12-03 00:00:00.000", "description": "Report", "row_id": 1699541, "text": "Respiratory Care\nBaby continues on NPCAP 6, 21%. BS clear. Sxn q4h as per flowsheet. RR mostly 30's-40's with IC/SCR. 4 A's/B's/desats as per flowsheet. On caffeine. Plan cont CPAP, will follow closely.\n" }, { "category": "Nursing/other", "chartdate": "2159-12-03 00:00:00.000", "description": "Report", "row_id": 1699542, "text": "Neonatology\nRemains on CPAP. Comfortable appearing. Low Fio2.\nModerate number of spells. Murmur as before.\n\nWt 1295 up 60. Tolerating gavage feeds at 140 cc/k/d of 28 cal. Will increase to 30 cal and monitor tolerance.\nAbdomen bneign.\n\nTemp stable\n\nCOntinue current resp rx and nutrition. Plan to continue CPAP for at least few more days.\n" }, { "category": "Nursing/other", "chartdate": "2159-12-16 00:00:00.000", "description": "Report", "row_id": 1699606, "text": "NICU Nursing Progress Note\n\nRESP/APNEA AND BRADYCARDIA\nO: Remains in nasal cannula 400cc flow rate, requiring\n40-50% O2 to maintain O2 sats within parameters. Breath\nsounds, resp rate, and WOB are at baseline. Remains on\ncaffeine. 1 A&B noted so far this shift.\nA: 36 day old infant with moderate persistent O2 requirement\nand murmur. Occasional spells and hx of unsuccessful\ntransition to nasal cannula after 1 week trial.\nP: Discuss potential for follow-up ECHO of known small PDA.\n\nHEMODYNAMICS\nO: Murmur persists. Pulse pressure 27. Cap refill brisk. HR\n140-150 at rest.\nA: Persistent Murmur.\nP: As above.\n\nNUTRITION\nO: Total fluids 140cc/kg. Remains on PE 30 with PM and is\nbeginning to take po feeds. Abd exam benign. Voiding. Has\nnot passed stool today. Has hx spitting, but none noted so\nfar today. Able to take 43 and 24cc with volufeed and yellow\nnipple. Remains on Ferinsol and Vit E.\nA: Po ability improving. No evidence of intolerance to\nfeeds.\nP: Assess. Po feed as .\n\nDEVELOPMENT\nO: Temp stable co-bedding in open crib. Active and \nwith cares. Sleeps between. Sucking on pacifier and fingers.\nA: Appropriate behavior.\nP: Support development.\n\nPARENTING\nO: in for 1300 cares. Independent in temp taking and\ndiaper change. Updated regarding infant's status and plan of\ncare. Mom fed infant with bottle and handles infant well.\nA: Involved .\nP: Support and keep informed.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2159-12-17 00:00:00.000", "description": "Report", "row_id": 1699607, "text": "Nursing progress note\n\n\n#1 O: Remains in 400cc flow nasal cannula, 50-40% O2. Breath\nsounds equal 7 clear with mod SC retractions. Nares\nsuctioned with TB syringe for hard green plugs. Remains on\ncaffeine. No spells this shift. A: Unchanged. P: Cont to\nassess. Suction prn.\n#2 O: Wgt up 40 gms. Remains on 140cc/k/d PE30 w/PM. Feeds\ngiven PG, q4h, over 1 hr. Abd soft with active bowel & no\nloops. No spits. Max aspirate was 5.6cc. abd soft with\nactive bowel sounds & no loops.Small stool X's 1. Voiding.\nA: tolerating feeds & gaining wgt. P: Cont to assess.\n#4 O: Temp stable co-bedding with twin. with cares.\nSucks on pacifier. A: AGA. P: Cont to assess.\n#9 O: Soft murmur heard with each cares. Pink & well\nperfused. BP stable. A: Unchanged. P: Cont to assess.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2159-12-20 00:00:00.000", "description": "Report", "row_id": 1699620, "text": "#1Resp\n remains in nasal cannula with 200cc flow at 50%. Lungs\nclear with some mild stuffiness. RR 40-70's with subcostal\nretractions. is noted to have increase in work of\nbreath with bottling. He cont on caffeine. Less drifting\nthan last week.\nA. O2 requirement persists.\nP. Cont to monitor.\n#2FEN\nBaby cont on 130cc/kg of PE32 with . Abd round but\nsoft. Minimal asp. No spits so far. Void and stooling.\nBottled about half feed at 0100.\nA. feeds\nP. Cont to monitor to feeds as well as weight\n#4Dev\nSl warm. Outfit changed. Awake and with cares but\ntires. Eyelids and feet sl puffy.\n#5Parent\nNo contact\n#9CV\nSoft murmur heard. Color pale pink. BP within normal limits,\nGood perfusion\n\n\n" }, { "category": "Nursing/other", "chartdate": "2159-11-18 00:00:00.000", "description": "Report", "row_id": 1699456, "text": "NPN\n\n\n1.Resp: Infant received in 200cc NC in 21%, having \nspells an hour. Placed back on CPAP Nasal prongs at 22:00.\nSince that time apneic spells have decreased-3spells in\n9hrs. Remains in RA with a CPAP of 5. RR=30-60's with mild\nIC/SC retractions. BBS clear/equal. On caffeine, dose\nrewritten-now maximized.\nA/P: Significant decrease in apneic on CPAP-placed on prongs\ndue to increased nasal secretions on NPT. Cont. to monitor\nfrequency of spells closely and resp. changes in resp exam.\n\n2.FEN: Wt=1.030kg, up 10gr. TF at 150cc/kg/d, enteral feeds\nincreased at 1am after spells decreased to 70cc/kg/d, PN/IL\nnow at 80cc/kg/d via PICCL. Abd full/soft transient\nloops,Ag=19-21,stooled x1 mod mec, heme pos.,\nuop=2.6cc/kg/hr. Spit x1, min. aspirates, mod air removed\nwith aspirates.\nA/P: Tolerating feeds,advance as tolerated 10cc/kg .\n\n3.Dev: Quiet in between cares, opening eyes during wt.\nSucking on pacifier intermittently. Placed supine with\nprongs, quiet.\nA/P: Quiet premie, cont. to promote development, due\nto KC after they recover from stomach bug.\n5.Parenting: No contact this shift.\n\n6.Hyperbili: Rebound drawn this am-results pending-\nsingle phototx d/c'd Friday.\n\n7.CV: Intermittent murmur noted overnight. Well perfused,\npercordium quiet, pulses nl, infant is in RA despite spells.\nBP stable, but high pulse pressures-77/40 M=56. A/P: Cont.\nto closely monitor and assess for signs of PDA.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2159-12-20 00:00:00.000", "description": "Report", "row_id": 1699621, "text": "Neonatology\nRemains on NCO2. IN 300 cc at 30%. Comfortable appearing. Soft murmur.\nWill consider course of diuril and monitor response.\n\nWt up 55. TF at 130 cc/k/d of 32 cal. Good weight gain so will decrease to 30 cal monitor growth. ABdomen benign. feeds well. Required increased Fio2 with feeds. Will contact re possibility of transfer for tomorrow or in coming days.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2159-12-20 00:00:00.000", "description": "Report", "row_id": 1699622, "text": "fellows exam note\ncomfortable\nneuro: nonfocal\nlungs clr\nheart: very soft murmur, sem\nabd: soft\n\n" }, { "category": "Nursing/other", "chartdate": "2159-12-20 00:00:00.000", "description": "Report", "row_id": 1699623, "text": "NPN Days\n\n\n1) Resp: Remains on NC 200cc flow and 40-50% Fi02. BBS\n=clear with mild SC/IC retractions. No spells. Suctioned\nnares for green mucous. Plan: Titrate Fi02 as needed.\nMonitor for increase in WOB.\n2) FEN: Decreased calories to 30/oz, Tf 130/k/d of PE 30\nwith PM. Pg over 1 hour. Po once a shift. No spits or\naspirates. Abd full with active bowel sounds. Voiding, no\nstool. feedings well. Plan: Cont with current feeding\nregime. Monitor weight gain. PO 2x day. Cont to monitor\nfor feeding intolerance.\n4) G/D: Infant nested in open crib with sibling. Temp\nunstable secondary to room temp being high. Infant awake\nand before feedings due. Sucks on pacifier. Plan:\nCont with current developmental plan.\n5) Parenting: Mom called and was updated by RN. She will be\nin for 5pm feeding. Plan: Cont support and updates.\n9) Cardiac: Soft intermittant murmur noted. CV stable.\nPink and well perfused. Plan: Cont to monitor.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2159-12-21 00:00:00.000", "description": "Report", "row_id": 1699624, "text": "NPN 1900-0700\n\n\n1. Resp: Infant remains in NC 200cc flow and 30-45% FiO2.\nO2 sats maintained 94-99%. Mod SCR. LS clear/=. No spells\nin 5 days. Does, however, have periodic breathing\noccasionally with desats to mid 80's that are self resolved.\nOn caffeine. RR=40-70's.\n\n2. FEN: WT=2020gms (up 50gms). TF=130cc/k/day PE30 with\nPM. Gavaged 44cc over 1hr. No spits. Max asp=4.8cc.\nStooled x1. Abd is soft and round with active bs.\n\n3. Parenting: No contact yet this shift.\n\n4. G&D: wakes for most feeds. and active with\ncares. Sleeps well between cares and settles well with\npacifier. AFSF. Temps stable swaddled in open crib\ncobedding with sister. Brings hands to face. AGA.\n\n5. CV: HR=140-160's. Soft audible murmur. Mild edema of\nLE's. Pink, well perfused.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2159-11-18 00:00:00.000", "description": "Report", "row_id": 1699457, "text": "Neonatology Attending\nDOL 8\n\n is on CPAP 5 cm H2O in room air after transitioning from NC. Seven bradycardias since start of CPAP, on caffeine. No significant distress.\n\nNo murmur noted today. BP means 49-56.\n\nBilirubin 2.7/0.3 after phototherapy discontinued yesterday.\n\nWt 1030 (+10) on TFI 150 cc/kg/day, including enteral feeds PE20 70 cc/kg/day, tolerating well. Abdomen benign. Stooling small amounts. Urine output 2.8 cc/kg/hr in the past 24 hours.\n\n have gastroenteritis (not visiting until symptoms resolve).\n\nA&P\nPreterm infant with respiratory and feeding immaturity, resolving hyperbilirubinemia.\n\nWe will continue on CPAP for a few days given increase in apnea yesterday.\n\nContinue to advance enteral feeds by 10 cc/kg/day as tolerated. We will discontinue PN tomorrow.\n" }, { "category": "Nursing/other", "chartdate": "2159-11-18 00:00:00.000", "description": "Report", "row_id": 1699458, "text": "Neonatology-NNP Physical Exam\n\nInfant remains on CPAP. Active, alert in an isolette, AFOF, sutures opposed, good tone. BBS clear and equal with good air entry. No murmur, pulses +2, pink, RRR. Abdomen soft, round, no HSM, tolerating feeds. Please refer to attending progress note for detailed plan.\n" }, { "category": "Nursing/other", "chartdate": "2159-11-24 00:00:00.000", "description": "Report", "row_id": 1699492, "text": "Nursing Progress Note\n\n\n#1 O: remains in nasal prong cpap 5cms, 21%; nares very\nirritated and some breakdown noted. duoderm applied by RT\n() and baby seems more comfortable. Lg thick\nsecretions sx from nares, blood tinged-breathing more\ncomfortably after. RR 20's-40's, baseline SC/IC retractions,\nlungs clear/equal.P: monitor for further breakdown around\nprongs. ? ready to trial off cpap soon?\n#2 O: NPO while being tx for PDA w/indocin; IV PN D10/IL\ninfusing via PIV, DS stable. Abd soft, round, active bowel\nsounds. vdg ~5cc/diaper, stools guiac neg x2. P: npo until\nfinished w/indocin, retart feeds tomorrow?\n#4 O: alert, irritable w/cares but better w/duoderm to nose.\nPacifier to settle, containment helpful as well.\n#5 O: mom called and updated re: murmur, indocin, etc.\n will be in to visit later this shift.\n#8 O: received 2nd dose indocin this morning as ordered,\nmurmur soft prior to this and not heard since. cont on\ncaffeine as ordered, no apnea or bradycardias noted this\nshift.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2159-11-24 00:00:00.000", "description": "Report", "row_id": 1699493, "text": "Respiratory Care Note\nPt remains on Prong CPAP +5 FIO2 21%. B.S. clear with good air entry. Nares sx'ed for large amt thick yellow/bloody secretions. Without apnea or bradys noted this shift.\n" }, { "category": "Nursing/other", "chartdate": "2159-11-24 00:00:00.000", "description": "Report", "row_id": 1699494, "text": "Neonatology - NNP Progress Note\n\n is active with good tone. AFOF. He is pink, well perfused, no murmur auscultated. Pulses sl full. Will receive final dose of Indocin tonite @ . He is comfortable on CPaP prongs. Fio2 21%. Breath sounds clear and equal. Remains NPO. PN/IL infusing via PIV. Abd soft, active bowel sounds, no loops. UO down today. Dry diaper x 1. Stable temp in servo isolette. updated @ bedside. Please refer to neonatology attending note for detailed plan.\n" }, { "category": "Nursing/other", "chartdate": "2159-12-22 00:00:00.000", "description": "Report", "row_id": 1699630, "text": "TRansfer Note\n\n\n1. O: Received pt on NC 200cc 40%. RR 50-70's. Ls clear.\nMild I/S retractions. No spells. A/P: Cont to monitor resp\nstatus. Wean O2 as .\n\n2. O: TF 130cc/kg of PE30+PM via ngt. Min asp. No spits.\nVoiding. +bs. A: feeds. P: Cont to monitor wt, abd, and\npo intake.\n\n4. O: Temp stable swaddled in open crib. and active\nwith cares. A/P: Cont to cluster care. Cont to monitor temp.\n\n Report given to Rn at . Transfer sheet\ncompleted. signed consent. Ambulance for 10:30am.\nA/P: To transfer to .\n\n\n" }, { "category": "Nursing/other", "chartdate": "2159-11-25 00:00:00.000", "description": "Report", "row_id": 1699495, "text": "NPN\n\n\n#1 Resp- Remains in Prong CPAP of 5cms in RA.BS clear. Mild\nretractions.RR=30-50's.Sxn x1. Remains on Caffeine.See\nflowsheet for A's+Bs'.A= Stable on CPAP. P= Monitor.\n#2 F/N- Remains NPO. PIV patent infusing TPN+IL at\n130cc/kg/day.Wt up 20gms.Abd soft and full.AG=22cms.See\nflowsheet for UO.\n#5 -No contact yet tonight.\n#8 CV- Dose #3 of Indo given.No M.HR=130-160's.Pink. B/P\nWNL.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2159-11-25 00:00:00.000", "description": "Report", "row_id": 1699496, "text": "Respiratory Care\nBaby remains on cpap 5 21%.2 spells documented.RR 30-40's.BS = clear.On caffine.\n" }, { "category": "Nursing/other", "chartdate": "2159-11-25 00:00:00.000", "description": "Report", "row_id": 1699497, "text": "Neonatology Attending\nDOL 15\n\n is on CPAP 5 cm H2O in room air, with no distress. Two apneas/bradycardias overnight. Nasal excoriation secondary to CPAP prongs has been a problem.\n\nIndomethacin completed last night. No murmur since then. BP 60/31 (41).\n\nWt 1145 (+20) on TFI 130 cc/kg/day PN-D10W/IL. Remains NPO for indomethacin. Urine output 2 cc/kg/hr in the past 24 hours. Abdomen benign. Stooling normally (guiac negative).\n\nA&P\nPreterm infant with respiratory immaturity, s/p PDA treatment.\n\nWe will consider a trial off CPAP tomorrow.\n\nWe will restart feeds once 24 hours have elapsed since indomethacin.\n" }, { "category": "Nursing/other", "chartdate": "2159-11-25 00:00:00.000", "description": "Report", "row_id": 1699498, "text": "Neonatology Attending\nAddendum-Physical Examination\n\nHEENT AFSF; CPAP in place; nasal excoriation as above\nCHEST mild retractions; good bs bilat; no crackles\nCVS well-perfused; RRR: femoral pulses normal; S1S2 normal; no murmur\nABD soft, non-distended; bs active\nINTEG normal\nCNS active, resp to stim; tone AGA\n" }, { "category": "Nursing/other", "chartdate": "2159-12-01 00:00:00.000", "description": "Report", "row_id": 1699531, "text": "Neonatology Attending\n\nExam AF soft, flat, + periodic breathing, clear bs, no murmur appreciated, benign abd, active\n\n in. I updated them at bedside.\n\n" }, { "category": "Nursing/other", "chartdate": "2159-12-01 00:00:00.000", "description": "Report", "row_id": 1699532, "text": "Neonatology Attending\n\nDOL 21 CGA 30 4/7 weeks\n\nOn CPAP secondary to spells. On 21-30% CPAP 6. R 30s-40s. 11 A/B in 24 hours. On caffeine ~10 mg/kg.\n\nRestrictive PDA with persistent murmur. BP 68/39 mean 50.\n\nOn 140 cc/kg/d PE 26 pg over 75 min. Tolerating feeds. Voiding. Stooling. 142/5.3/110/24 Wt 1230 grams (up 5).\n\n visiting.\n\nA: Significant periodic breathing with desats. Caffeine dose just adjusted for wt. If he continues to have significant events he will need reintubation.\n\nP: Caffeine bolus\n Monitor\n If events remain significant, reintubation\n Add today and advance to 28 cal tomorrow\n\n" }, { "category": "Nursing/other", "chartdate": "2159-12-01 00:00:00.000", "description": "Report", "row_id": 1699533, "text": "Respiratory Care\nPt cont on NP CPAP. Fio2 .21-.26, bs clear, rr 30-50, sx for mod amt. Few cluster of spells noted this am. Rec'd bolus of caffeine. Will consider reintubation if spells increase. Plan to support as needed.\n" }, { "category": "Nursing/other", "chartdate": "2159-12-01 00:00:00.000", "description": "Report", "row_id": 1699534, "text": "NICU nursing progress note\n\n\nPlease refer to flowsheet for specific info.\nResp/ A and B's\nO: remains with NP cpap/6, fi02 21-24%, RR 20-50's,\nsat's 94-99%. Periodic breathing pattern. Sxn for thick\nyellow secretions in mod. amount. Caffeine optimized today\nwith one time bolus. 4 spells on dayshift. 8 spells since\nmidnight. A: Stable. need reintubation, due to spells.\nP: cont to provide opt. ventilation/ oxygenation.\nCV\nO: +Murmur, HR 130-160's. Pink and well perfused w/ cap\nrefill <2sec. A: Hemodynamically stable. P: cont to follow.\nF/N\nO: TF of 140cc/kg/day of PE 26/ BM 26 with added to\nfeedings this pm. Abd. soft, pink, no loops, active bs.\nVoiding. Stooling heme (-). No spits, min. asp. HOB\nelevated.A: stable. p: cont to provide opt. nut., follow.\nG/d\nO: Temp stable in servo controlled isolette. Active and\nalert with cares. Calms with containment and pacifier. MAE.\nFont soft, flat. A: AGA P: cont to support dev. milestones.\nParenting\no: Mom and dad in and updated at bedside, by RN and Dr.\n. Verbalizing understanding. P: cont to update,\nsupport, educate.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2159-12-02 00:00:00.000", "description": "Report", "row_id": 1699535, "text": "NPN NIghts\n\n\n1. O: Received pt in NP CPAP of 6. FiO2 21-22%. Ls clear. RR\n30-50's with periodic breathing. 3 spells thus far this\nshift requiring mild stim to recover. Sxn'd for small\nyellow. A: Cont with periodic breathing. P: Cont to monitor\nresp status.\n\n2. O: Wt 1235 gms, up 5. TF 140cc/kg of PE26+PM via ngt. Min\nasp. 1 small spit. Voiding an dstooling G-. Iron given as\nordered. A: Tol feeds. P: Cont to monitor wt, abd, and tol\nof feeds.\n\n4. O: Temp stable nested in air isolette. Alert and active\nwith cares. A/P: Cont to monitor temp. Cont to cluster\ncares.\n\n5. O: Mom called X1. Rn updated Mom. asking appropriate\nquestions re spells. A/P: Cont to educate and support.\n\n9. O: +Murmur. Nl pulses. BP 71/41 52. Hr 140-160's. A/P:\nCont to monitor CV status.\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2159-12-02 00:00:00.000", "description": "Report", "row_id": 1699536, "text": "Respiratory care Note\nPt. continues on 6cmH2O of NPCPAP and 21-23% FIO2. BS are clear. On caffeine. Pt. has had 3 spells so far tonight. To continue on CPAP.\n" }, { "category": "Nursing/other", "chartdate": "2159-12-05 00:00:00.000", "description": "Report", "row_id": 1699552, "text": "NPN 1900-\n\n\n1. RESP: O: Pt remains in NP CPAP 6, requiring 21% FiO2.\nRR 30-50's. Lung sounds are clear. Baseline retractions.\nSxn for large amounts of slightly blood-tinged secretions\nvia NP tube, large yellow via nare, and mod white via mouth.\nOne spell noted so far this shift. Pt is on caffeine. A:\nStable in CPAP. P: Monitor.\n\n2. F&N: O: TF remain at 140cc/k/d of PE30 with .\nFeeds gavaged in over 1.5 hours. Abd benign. BS+. No\nspits and minimal aspirates noted. Nutrition pending.\nVoiding well. No stool noted. Weight gain 35 grams. A:\nTol feeds well. Gaining weight. P: Monitor.\n\n4. DEV: O: is active and alert during cares. Temp\nstable swaddled in air isolette. Weaning air isolette. A:\nAGA. P: Continue to support infant's needs.\n\n5. PAR: No contact from so far this shift.\n\n9. C/V: O: Loud murmur persists. HR 150-170's. Pt is\npink and well-perfused. BP stable. A: Alt C/V. P:\nMonitor.\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2159-12-05 00:00:00.000", "description": "Report", "row_id": 1699553, "text": "Respiratory Care Note\nPt. continues on 6cmH2O of NPCPAP and 21%. BS are clear. Pt. is on caffeine. One spell so far. To follow.\n" }, { "category": "Nursing/other", "chartdate": "2159-12-05 00:00:00.000", "description": "Report", "row_id": 1699554, "text": "Neonatology\nDOing well. Remaisn in RA, on CPAP Will wean CPAP to 5 and consider timing of trial off at end of week.. Few spells. Comfortable apeparing\nCV stable\n\nWt 1355 up 35. Tolerateing feeds at 140 cc/k/d of 30 cal. Abdomen bneign. Tolerating gavage feeds well. Nutrition in good range.\n\nContinue current nutritional regimen and resp monitoring.\n" }, { "category": "Nursing/other", "chartdate": "2159-12-05 00:00:00.000", "description": "Report", "row_id": 1699555, "text": "NPN DAYS\n\n\nALT IN RESP:REMAINS IN NP CPAP. RECEIVED BABY ON 6CM,\nDECREASED TO CPAP 5 THIS MORNING. O2 REQUIREMENT TODAY\n21-25%. LUNGS CLEAR, WITH MILD INTERCOASTAL/SUBCOASTAL\nRETRACTIONS. RR 24-44. NO EPISODES OF APNEA OR BRADYCARDIA\nTHIS SHIFT. REMAINS ON CAFFEINE. SX Q4HRS FOR MOD AMT OF\nTHICK YELLOW SECRETIONS FROM NP TUBE, AND WHITE FROM MOUTH.\nCONTINUE TO MONITOR RESP STATUS CLOSELY AND WEAN O2 AS TOL.\n\nCV:CONTINUES TO HAVE A SOFT MURMUR. HR 160'S. BP THIS\nMORNING 74/39 51. GOOD COLOR. NO EVIDENCE OF CARDIAC\nCOMPROMISE. CONTINUE TO MONITOR FOR ANY CAHNGES IN EXAM.\n\nALT IN GROWTH AND DEVELOPMENT D/ :ALERT AND ACTIVE WITH\nCARES. SLEEPS WELL BTW FEEDS. MAINTAINS TEMP IN AIR\nCONTROLLED ISOLETTE. SWADDLED AND NESTED IN SHEEPSKIN.\nCONTINUE DEVELOPMENTAL CARES.\n\nALT IN NUTRITION R/ :TOL FULL VOLUME FEEDS WELL ON\n140CC/K/D OF PE 30 W/, 32CC Q4HRS VIA GAVAGE OVER\n90MINS. ABD EXAM BENIGN, NO LOOPS, NO SPITS. GIRTH 22, ASP.\n1CC. VOIDING AND STOOLING WELL. STOOL GUAIC NEG. CONTINUE\nCURRENT FEEDING PLAN. MONITOR FOR ANY FEEDING INTOLERANCE.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2159-12-05 00:00:00.000", "description": "Report", "row_id": 1699556, "text": "fellows exam note\ncomfortabl on cpap 6\nafof\nlungs clr\nheart: soft murmur\nabd: soft\nneuro: nonfocal, active\n" }, { "category": "Nursing/other", "chartdate": "2159-12-05 00:00:00.000", "description": "Report", "row_id": 1699557, "text": "Respiratory Care\nPt remains on NP-CPAP +5cm's with the fio2 21 to 30%. Pt suctioned for a small amt of thick yellow secretions. Respiratory rates 30's to 60's. Pt weaned down on CPAP from 6 to 5cm's, plan is to follow on CPAP.\n" }, { "category": "Nursing/other", "chartdate": "2159-12-08 00:00:00.000", "description": "Report", "row_id": 1699571, "text": "NPN\n\n\n#1 Resp=Placed on PRONG CPAP of 5cms in 21-30% from NC\nafter 7 A's+B'.No other A's+B's after being placed on\nCPAP.Remains on Caffeine.A= Improving on CPAP. P=Monitor.\n#2 F/N- Abd soft,+bs, no loops. Tolerating ng feeds of Pe 30\ncals w/o spits. minimal asps.Feeds given on a over\n90mins.Voiding+ stooling in adeq amts.Wt up 40gms.\n#5 - No contact tonight.\n#9 Cv-+M. HR= 160-170.B/P WNL.Pink.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2159-12-08 00:00:00.000", "description": "Report", "row_id": 1699572, "text": "NICU Nursing Progress Note\n\nRESP\nO: Remains in prong CPAP 5 cms requiring 25-30% O2 to\nmaintain O2 sats within parameters set. Breath sounds, resp\nrate, and WOB are at baseline. Nares suctioned for lgr white\nsecretions X1 so far. Duoderm in place over septum of\nnostrils. Old laceration observable but healing well.\nRemains on caffeine. No apnea, bradycardia, or spontaneous\ndesat noted so far this shift.\nA: Comfortable resps and no evidence of compromise on CPAP.\nP: Support adequate ventilation.\n\nHEMODYNAMICS\nO: Murmur audible over precordium. Cap refill brisk. BP\nstable. HR 160-170.\nA: No evidence of compromised perfusion.\nP: Monitor and assess.\n\nNUTRITION\nO: Remains on TF 140cc/Kg/day of PE30 with PM by gavage over\n90 mins due to hx spitting. No spits today so far. Abd exam\nbenign. Voiding.\nA: No evidence of intolerance.\nP: Assess.\n\nDEVELOPMENT\nO: Temp stable in off isolette. Active and laert with cares.\n\nA: Appropriate behavior.\nP: Support development.\n\nPARENTING\nO: in for cares. Independent in temp taking, diaper\nchange, and handling infant in isolette.\nHeld infant during feeding. Updated regarding need for CPAP\nand current status.\nA: Involved .\nP: Support and keep informed.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2159-12-07 00:00:00.000", "description": "Report", "row_id": 1699565, "text": "Respiratory Note\nPt. continues on 5cmH2O of nasal prong CPAP and 21-26% FIO2. BS are clear. To follow.\n" }, { "category": "Nursing/other", "chartdate": "2159-12-07 00:00:00.000", "description": "Report", "row_id": 1699566, "text": "NPN\n\n\n#1 Resp- Remains on CPAP of 5cms in 21-25% o2. BS clear, Sxn\nq 8 hrs.Mild retractions. RR= 40-60.Remains on\ncaffeine.Continues to have A's+ B's (x5 tonight.)\n#2F/N- Abd soft+ full,+bs, no loops. Tolerating feeds of Pe\n30cals w/ w/o spits. Minimal asps.Wt up 45gms.Voiding+\nstooling in adeq amts.Ng feeds given on a over 90mins q\n4hrs.A= Tolerating feeds w/occ spits. p=Monitor wt gain+\nfeeding tolerance.\n#5 -no contact tonight.\n#9 CV- Pink,+M=soft,B/P WNL.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2159-12-07 00:00:00.000", "description": "Report", "row_id": 1699567, "text": "Neonatology Attending Progress Note\n\nNow day of life 27 for this 27 week gestation infant.\n\nCurrently on nasal cannula as of 8 AM taking off CPAP - in 300cc of 35% O2.\nThus far appears to be well tolerated.\n\nRemains on caffeine.\nHR 160-170s\n\nWt. 1445gm up 45gm on 140cc/kg/d of PE30 with \nFeedings well tolerated by gavage.\n\nAssessment/plan:\nFollowing respiratory status closely.\nWill place back on CPAP if develops increased work of breathing or frequent apnea.\n\n" }, { "category": "Nursing/other", "chartdate": "2159-12-08 00:00:00.000", "description": "Report", "row_id": 1699573, "text": "NICU Attending Note\n\nDOL # 27 = 31 3/7 weeks CGA with A/B, evolving CLD, issues of growth and nutrition. No new concerns.\n\nFull PEx to follow\n\nCVR/RESP: Murmur with small PDA on echo, mild retractions, BS clear/=. Last noc placed back on NPCPAP, 5 cm H20, 21-26% FiO2 for increased A/B, also on caffeine, now with decreased severity of episodes. Will continue current management.\n\nFEN: Abd benign, weight today 1430, down 15 gm , on 140 PE 30 with PM, all PG. Will continue current diet.\n\nDISPO: Will transfer to when off CPAP.\n" }, { "category": "Nursing/other", "chartdate": "2159-12-08 00:00:00.000", "description": "Report", "row_id": 1699574, "text": "NICU Attending Note\nPEx: Well appearing, AFSOF, RRR wtih 1/6 systolic murmur, BS clear/=, minimal intercostal retractions, abd benign without HSM, skin pink and well perfused, alert and in NAD\n" }, { "category": "Nursing/other", "chartdate": "2159-12-09 00:00:00.000", "description": "Report", "row_id": 1699575, "text": "NPNOte;\n\n\n#1. Remains on nasal prong CPAp of 5cm, Fio2 23-27%, BBS\nclear and equal, mild intercostal/ subcostal retractions\npresent,whitish nasal and oral secretions suctioned.spellx1,\nrequired increase in o2 and stim. Remains on Caffine. A;\nstable on CPAP. P; continue resp support as needed.\n\n#2.Todays weight=1490 up 60gms, TF=140cc/kg/day,Pe30 with\n, Pg feeds given over 1hr30mts.H/O spits,no spits,BS+,\nno loops, voided and no stool. A; Feeds tolerated. P;\ncontinue current feeding plan.\n\n#4.alert and active with care, temp stable in a off\nisolette, swaddled, loves pacifier. A; AGA P; continue dev\nsupport.\n\n#5. No contacts from thus far this shift.\n\n#9.Soft murmur heard, pink, well perfused. Bo mean 45.\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2159-12-11 00:00:00.000", "description": "Report", "row_id": 1699587, "text": "1900-0730 NPN\n\n\nRESP: O/A: Pt cont on NP CPAP of 6, FiO2 21-25%. RR\n40's-60's, O2 sats 94-99%. LS clear/=, S/C retractions\nnoted. Suctioned Q4Hr with cares for sm-lg amt secretions\nvia ETT, sm-mod amt secretions via nares, sm amt secretions\norally. Bradycaric spells x 1 with HR to 56 and desat to\n72%, required mild stim and increase in O2. P: Cont to\nmonitor resp status. Cont on Caffeine as ordered.\n\nCV: O/A: Pt has soft murmur heard at each care. HR\n150's-160's. BP 73/24 with mean=42. Pt is pale-pink, well\nperfused. Peripheral pulses normal, cap refill brisk. P:\nCont to monitor CV status. Obtain Hct and retic count at\n0500 care. Pt to have cardiac ECHO in AM.\n\nFEN: O/A: Wgt tonight was 1595g, a gain of 85g. TF cont at\n140cc/kg/d of PE30 with PM. No spits, max aspirate was\n5.0cc, abd girths stable at 25-26cm. Abdomen soft, round,\npink, BS+, no loops noted. Pt is vdg, med stool x 1 (guiac\n-). P: Cont to monitor feeding tolerance and assess for\nreadiness to PO feed. Obtain nutrition at 0500 care.\n\nG&D: Temps stable in open crib, pt is dressed and swaddled.\nPt is cobedding with sibling, sheepskin present. MAE, alert\nand active with cares. Sleeps between cares. Sucks\npacifier and brings hands to face for comfort. Fontanels\nsoft/flat. P: Cont to support growth and development.\n\nPARENTING: No contact from as of yet this shift.\nP: Cont to support/educate .\n\n\n" }, { "category": "Nursing/other", "chartdate": "2159-12-11 00:00:00.000", "description": "Report", "row_id": 1699588, "text": "Respiratory Care\nBaby continues on NPCPAP 6 with 02 req 21-28% this shift. BS clear. NPT sxn for lg-sm amts tan sec and naris for sm-mod white. RR 40's-60's with SCR. Two mild-QSR stim A's & B's as of this writing. On caffeine. Will cont present management.\n" }, { "category": "Nursing/other", "chartdate": "2159-12-07 00:00:00.000", "description": "Report", "row_id": 1699568, "text": "fellows exam note\nactive\nheent: afof\nheart: soft sem, pulses equal, not bounding\nlungs: clr\nabd: soft\n\n" }, { "category": "Nursing/other", "chartdate": "2159-12-07 00:00:00.000", "description": "Report", "row_id": 1699569, "text": "NPN DAYS\n\n\nALT IN RESP:RECEIVED BABY ON NP CPAP OF 5. TUBE REMOVED AND\nPLACED ON NASAL CANNULA O2 AT 8AM. O2 REQUIREMENT TODAY\n300CC FLOW, 30-40%. HE HAS HAD 4 BRADYCARDIA EPISODES TODAY\nTHAT APPEAR TO BE WITH REFLUX. MOST DURING GAVAGE FEEDS, AND\n1 WITH A SPIT. ALL NEEDING MILD TO MOD STIM. RR 40-60'S WITH\nMILD SUBCOASTAL RETRACTIONS. REMAINS ON CAFFEINE. SX ONCE\nWHEN CPAP REMOVED. CONTINUE TO MONITOR FOR SPELLS, AND WOB.\nIF HAS INCREASING SPELLS THEN WILL PUT BACK ON NASAL PRONG\nCPAP.\n\nCV:CONTINUES TO HAVE SOFT MURMUR. HR 160'S. BP 63/29 42 THIS\nMORNING. GOOD PINK COLOR. NO EVIDENCE OF CARDIAC COMPROMISE.\nCONTINUE TO MONITOR FOR ANY CHANGES IN EXAM.\n\n TIN NUTRITION R/ : FULL VOLUME FEEDS WELL ON\n140CC/K/D OF PE 30 W/, 34CC Q4HRS VIA GAVAGE OVER\n90MINS. ABD EXAM BENIGN. NO LOOPS, 1 MOD SPIT TODAY. GIRTH\n22-23. ASP. 0.4-0.8CC. VOIDING WELL, NO STOOL TODAY.\nCONTINUE CURRENT FEEDING PLAN. BE ABLE TO START BOTTLIN\nGNEXT WEEK IF STAYS OFF CPAP.\n\nALT IN GROWTH AND DEVELOPMENT D/ :ALERT AND ACTIVE WITH\nCARES. SLEEPS WELL BTW FEESD. MAINTAINS TEMP IN OFF\nISOLETTE. SWADDLED AND NESTED IN SHEEPSKIN. SUCKS ON\nPACIFER INTERMIT. CONTINUE DEVELOPMENTAL CARES. BE ABLE\nTO GO INTO CRIB SOON.\n\nALT IN PARENTING: IN TO VISIT AT 5PM. MOM TOOK TEMP\nAND CHANGED DIAPER AND DAD HELD FOR 90MINS. UPDATED\nAT BEDSIDE. CONTINUE TO SUPPORT AND UPDATE. \nAGRREABLE TO TRANSFER TO WINCESTER NEXT WEEK IF HE STAYS OFF\nCPAP.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2159-12-08 00:00:00.000", "description": "Report", "row_id": 1699570, "text": "Respiratory Care\nBaby placed on prong cpap 5 21-30% after several spells.Sx nares x 2 for lg thick yellow secs.No spells documented since placed on cpap.RR 50-70'sBS clear.\n" }, { "category": "Nursing/other", "chartdate": "2159-12-10 00:00:00.000", "description": "Report", "row_id": 1699582, "text": "RESPIRATORY CARE NOTE\nBaby received on Prong CPAP 6 FiO2 30-35%. At 9pm baby was switched to NP CPAP to try to wean the FiO2. FiO2 weaned to 21%. Suctioned NP tube for mod amt of white secretions. Breath sounds are clear. Occasional drifts on the sat monitor. on NP CPAP cont to follow.\n" }, { "category": "Nursing/other", "chartdate": "2159-12-10 00:00:00.000", "description": "Report", "row_id": 1699583, "text": "Newonatology\nRemains on CPAP. Low fio2. Comfortable apeparing this am after req increased FIo2 last night. Changed top prong CPAP this am. No spells.\n\nWt 1510 up 20. Tolerating full volume feeds at 30 cal via gavage.\nAbdomen benign.\n\nCOntinue on CPAP through end of week.\n\nCOntinue as at present.\n" }, { "category": "Nursing/other", "chartdate": "2159-12-10 00:00:00.000", "description": "Report", "row_id": 1699584, "text": "Respiratory Care\nBaby continues on cpap 6, fio2 21-24%, bs clear, rr 40-60's, sx mod white secretions, on caffeine, had one spell thus far on this shift. Will continue to follow.\n" }, { "category": "Nursing/other", "chartdate": "2159-12-10 00:00:00.000", "description": "Report", "row_id": 1699585, "text": "fellows exam note\ncomfortable, cobedding with sibling\nheent: afof\nlungs: clr\nheart: HSM heard at left SB, radiating to lung fields., pulses normal\nabd: soft\nneuro: nonfocal\n" }, { "category": "Nursing/other", "chartdate": "2159-12-11 00:00:00.000", "description": "Report", "row_id": 1699589, "text": "1900-0730 NPN ADDENDUM\nHct drawn this AM came back at 22.8-NNP aware. Peripheral IV placed in left hand for transfusion of RBC's to be done on day shift. Consent for transfusion is signed. to be notified prior to start of transfusion.\n" }, { "category": "Nursing/other", "chartdate": "2159-12-11 00:00:00.000", "description": "Report", "row_id": 1699590, "text": "FELLOWS EXAM NOTE\nCOMFORTABLE\nHEENT: AFOF\nLUNGS: CLR\nHEART: SOFT HSM, PULSES WNL\nabd: soft\nneuro: nonfocal\na bit pale\n" }, { "category": "Nursing/other", "chartdate": "2159-12-11 00:00:00.000", "description": "Report", "row_id": 1699591, "text": "Clinical Nutrition\nO:\n~32 wk CGA BB on DOL 31.\nWt: 1595 g (+85)(~25th to 50th %ile); birth wt: 1130 g. Averate wt gain over past wk ~25 g/kg/d.\nHC: 28 cm (~10th to 25th %ile); last: 27 cm\nLN: 40 cm (~25th %ile); last: 39 cm\nMeds include Fe and Vit E\n noted.\nNutrition: 140 cc/kg/d PE 30 w/ , all pg over 90 min. feeds. Average of past 3 d intake ~141 cc/kg/d, providing ~141 kcal/kg/d, and ~4.1 g pro/kg/d.\nGI: Abdomen benign.\n\nA/Goals:\nTolerating feeds without GI problems. noted and within acceptable range. Current feeds meeting recommendations for kcals/pro/vits and mins. Growth is meeting recommendations for HC and LN gains. Wt gain is exceeding recommended ~15 to 20 g/kg/d; represents catchup growth. Will continue to follow w/ team and participate in nutrition plans.\n" }, { "category": "Nursing/other", "chartdate": "2159-12-11 00:00:00.000", "description": "Report", "row_id": 1699592, "text": "Neonatology\nRemains on CPAP. Comfortable apeparing. Low FIo2. Continued intermittent spells. Murmur louder this am. be related to anemia. Will reconsider echo in am if persistent. Caffeine dose to be titrated.\n\nWt 1595 up 85. TF at1 40 cc/k/d of 30 cal. Abdomen bneign. COntinue current feeds\n\nBeing transfused for Hct of 22.\n\nWills chedule 30 day HUS.\n" }, { "category": "Nursing/other", "chartdate": "2159-12-14 00:00:00.000", "description": "Report", "row_id": 1699599, "text": "NICU nursing progress note\n\n\nPlease refer to flowsheet for specific info.\nResp / A and B's\nO: remains with NC 300cc flow of 50% fi02. RR 40-80's,\ntachypneic at times. Sat's 92-98%. SC ret. Sxn x1 for thick\ncloudy/ bld tinge secretions via nares in mod. amt. On\ncaffeine. One brady tonight with feed req. mod. stim. A:\nStable. Breathing comfortably. P: cont to provide opt.\noxygenation. Follow.\nCV\nO: + soft murmur, HR 140-160's, BP 61/37 (41). Pink, and\nwell perfused, Cap refill <2sec., no pulses. A:\nStable. P: cont to follow.\nF/N\nO: Weight 1730g ^ 30g. TF of 140cc/kg/day of PE 30 w/.\nGavaged over 1'\". Max asp of 5.0cc partially digested\nfomula. HOB elev. Abd. girth 26.5-27cm. Abd. soft, pink, no\nloops, active bs.Voiding/stooling heme (-). A: Stable.\ngaining weight on current plan. P: cont to provide opt.\noxygenation.\nG/D\nO: Temp stable in open crib co-bedding with twin sister.\nActive and with cares. Sleeps well in between. Font\nsoft, flat. MAE. Bath given tonight and well tolerated.\nCalms with containment and pacifier. A: AGA P: cont to\nsupport dev. milestones.\nParenting\nNo contact with thus far tonight. Plan is for\ntransfer to Hosp. Possibly later next week.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2159-12-10 00:00:00.000", "description": "Report", "row_id": 1699586, "text": "NPN DAYS\n\n\nALT IN RESP:REMAINS IN NP CPAP 6, 21-30%, MOSTLY 21-24%.\nLUNGS CLEAR, RR 40'S WITH MILD SUBCOASTAL RETRACTIONS. 1\nEPISODE OF BRADYCARDIA NEEDING MILD STIM. REMAINS ON\nCAFFEINE. SX Q4HRS FOR MOD AMT OF WHITE SECRETIONS FROM NP\nTUBE, NARES, AND MOUTH. BABY DOING MUCH BETTER ON THE NP\nCPAP RATHER THAN NASAL PRONG CPAP. MUCH FEWER EPISODES OF\nPERIODIC BREATHING AND DESATS. CONTINUE TO MONITOR RESP\nSTATUS CLOSELY AND WEAN O2 AS . WILL POSSIBLE TRIAL OFF\nCPAP AGAIN AT THE END OF THE WEEK.\n\nCV:CONTINUES TO HAVE A MURMUR. HR 140-160'S. COLOR PALE\nPINK. STABLE BP LAST NIGHT. WILL CHECK HCT IN THE MORNING,\nAND CONSIDER ECHO TOMORROW TO CONFIRM THAT PDA IS VERY\nSMALL. CONTINUE OT MONITOR FOR ANY CHANGES IN EXAM.\n\nALT IN NUTRITION R/ : FULL VOLUME FEEDS WELL ON\n140CC/K/D OF PE 30 W/, 35CC Q4HRS VIA GAVAGE OVER\n90MINS. ABD EXAM BENIGN, NO LOOPS, NO SPITS. GIRTH 24. ASP.\n0.6-1.6CC. VOIDING AND STOOLING WELL, STOOL GUIAC NEG.\nCONTINUE CURRENT FEEDING PLAN.\n\nALT IN GROWTH AND DEVELOPMENT D/ :ALERT AND ACTIVE WITH\nCARES. SLEEPS WELL BTW FEEDS. MAINTAINS TEMP IN OPEN CRIB.\nCO BEDDING WITH SISTER. EYE EXAM WEDNESDAY. CONTINUE\nDEVELOPMENTAL CARES.\n\nALT IN PARENTING: IN TO VISIT AT 1PM. MOM TEMP\nAND CHANGED DIAPER AND HELD BABY FOR 90MINS. UPDATED\nAT BEDSIDE. CONTINUE TO SUPPORT AND UPDATE.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2159-12-13 00:00:00.000", "description": "Report", "row_id": 1699596, "text": "NICU nursing progress note\n\n\nPlease refer to flowsheet for specific info.\nResp\nO: remains with NC 300cc flow of fi02 48-55%. RR\n30-80's, sat's 90-97%. Sxn for thick cloudy secretions /\nnares in mod. amount x 1. BSCE bilat. Tachypneic at times.\nIC/SC ret. On caffeine, no spells. A: Stable. Breathing\ncomfortably. P: Cont to provide opt. oxygenation.\nCV\nO: + murmur appreciated. HR 150-160's, BP 50/38 (43). Pink,\nwell perfused, cap refill brisk <2sec. A: Stable. p: cont to\nfollow.\nF/N\nO: Weight 1700g ^40g. TF of 140cc/kg/d of PE 30 w/ .\nGAvaged over 1'\" . No spits tonight. Max. asp. of 4.2cc\npartially digested formula. Girth 26.5-27cm. Abd. soft,\npink, no loops, active bs. Voiding/ no stool tonight. A:\nstable. gaining wt. on current plan. P: cont to provide opt.\nnut., follow.\nG/d\nO: Temp stable in open crib co- bedding with twin sister.\nActive and with cares. Irritable at times. Calms with\ncontainment and pacifier. Boundaries in place. Font soft,\nflat. MAE. A: AGA p: cont to support dev. milestones.\nParenting\n No contact from overnight. Plan is to transfer to\n.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2159-12-13 00:00:00.000", "description": "Report", "row_id": 1699597, "text": "Neonatology\nDOing well. Remains in NCO2 300 cc flow. after dc of CPAP yesterday.Few spells. Generally comfortable appearing.\nMurmur as before.\n\nWt 1700 up 40. Tolerating feeds at 140 cc/k/d of 30 cal. Abdomen benign. Tolerating vagae.\n\nFU eye exam for next week.\n\nContinue current resp rx and nutitional management.\n" } ]

[ { "category": "Radiology", "chartdate": "2122-08-31 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1248161, "text": " 7:34 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change, pulmonary edema? pneumonia?\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 88 year old woman with COPD, diastolic heart failure, severe AS, admitted for\n SOB, diuresed with lasix.\n REASON FOR THIS EXAMINATION:\n interval change, pulmonary edema? pneumonia?\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: COPD and heart failure with diuresis.\n\n FINDINGS: In comparison with the study of , there is persistent evidence\n of congestive failure, possibly slightly improved following diuresis.\n Atelectatic changes are again seen at both bases. No definite pneumonia,\n though superimposed consolidation would have to be considered in the\n appropriate clinical setting.\n\n\n" }, { "category": "Radiology", "chartdate": "2122-08-30 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1248121, "text": " 3:25 PM\n CHEST (PORTABLE AP) Clip # \n Reason: chf?\n ______________________________________________________________________________\n MEDICAL CONDITION:\n History: 88F with sob, hx of chf\n REASON FOR THIS EXAMINATION:\n chf?\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 88-year-old woman with dyspnea and history of CHF. Evaluate for\n CHF.\n\n COMPARISON: No relevant comparisons available.\n\n FINDINGS: A frontal semi-upright view of the chest was obtained portably.\n Bilateral hazy opacities with indistinct pulmonary vasculature are noted with\n more nodular opacity at the right lung base. Blunting of the costophrenic\n sulci bilaterally may represent tiny pleural effusions. In the setting of\n cardiomegaly and mitral annular calcifications, the findings suggest mild\n congestive heart failure. No pneumothorax although the lung apices are\n partially obscured by the chin. Aortic knob calcifications are noted. There\n is no acute osseous abnormality. No free air under the diaphragm.\n\n IMPRESSION: Findings suggest mild congestive heart failure. Recommend\n followup after resolution to exclude underlying pneumonia given more nodular\n opacity at the right lung base.\n\n Findings discused with Dr. (cardiology) in person at 5:25pm .\n\n" }, { "category": "Radiology", "chartdate": "2122-09-02 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1248479, "text": " 12:40 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Question acute pneumonia, COPD exacerbation.\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 88 year old woman with known CHF secondary to aortic stenosis and COPD with\n chronic cough now newly productive of sputum.\n REASON FOR THIS EXAMINATION:\n Question acute pneumonia, COPD exacerbation.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 88-year-old woman with known CHF secondary to aortic stenosis and\n COPD with chronic cough, now presenting with new productive cough, ? acute\n pneumonia.\n\n COMPARISON: .\n\n TECHNIQUE: AP upright chest radiograph.\n\n FINDINGS: Heart is mildly enlarged and calcifications are seen in the aortic\n arch as before. Cardiomediastinal contours are stable. There is a small\n round patchy area of opacity projecting over the right base. In the\n appropriate clinical context, this could represent a developing pneumonia.\n Bibasilar atelectasis again noted. No significant pleural effusions and no\n pneumothorax.\n\n IMPRESSION:\n Small area of opacification within the right base could represent developing\n pneumonia in the appropriate clinical context.\n\n" }, { "category": "Echo", "chartdate": "2122-08-31 00:00:00.000", "description": "Report", "row_id": 104012, "text": "PATIENT/TEST INFORMATION:\nIndication: Aortic stenosis. Congestive heart failure. Valvular heart disease.\nHeight: (in) 62\nWeight (lb): 180\nBSA (m2): 1.83 m2\nBP (mm Hg): 122/97\nHR (bpm): 61\nStatus: Inpatient\nDate/Time: at 09:14\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Elongated LA.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. No ASD by 2D or color\nDoppler.\n\nLEFT VENTRICLE: Normal LV wall thickness, cavity size and regional/global\nsystolic function (LVEF >55%). [Intrinsic LV systolic function likely\ndepressed given the severity of valvular regurgitation.] No resting LVOT\ngradient.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Mildy dilated aortic root. Normal ascending aorta diameter. Normal\naortic arch diameter. No 2D or Doppler evidence of distal arch coarctation.\n\nAORTIC VALVE: Severely thickened/deformed aortic valve leaflets. Critical AS\n(area <0.8cm2). Mild (1+) AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Moderate mitral annular\ncalcification. Moderate (2+) MR. [Due to acoustic shadowing, the severity of\nMR may be significantly UNDERestimated.]\n\nTRICUSPID VALVE: Mild [1+] TR. Mild PA systolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.\n\nPERICARDIUM: Very small pericardial effusion. Effusion circumferential. No\nechocardiographic signs of tamponade.\n\nConclusions:\nThe left atrium is mildly elongated. No atrial septal defect is seen by 2D or\ncolor Doppler. Left ventricular wall thickness, cavity size and\nregional/global systolic function are normal (LVEF >55%). [Intrinsic left\nventricular systolic function is likely more depressed given the severity of\nmitral regurgitation.] Right ventricular chamber size and free wall motion are\nnormal. The aortic root is mildly dilated at the sinus level. The aortic valve\nleaflets are severely thickened/deformed. There is critical aortic valve\nstenosis (valve area <0.8cm2). Mild (1+) aortic regurgitation is seen. The\nmitral valve leaflets are mildly thickened. Moderate (2+) mitral regurgitation\nis seen. [Due to acoustic shadowing, the severity of mitral regurgitation may\nbe significantly UNDERestimated.] There is mild pulmonary artery systolic\nhypertension. There is a very small circumferential pericardial effusion\nwithout evidence of hemodynamic compromise.\n\nIMPRESSION: Critical aortic valve stenosis. Normal biventricular cavity sizes\nwith preserved global and regional biventricular systolic function. Moderate\nmitral regurgitation. Pulmonary artery hypertension. Mild aortic\nregurgitation.\n\nCLINICAL IMPLICATIONS:\nThe patient has severe aortic valve stenosis. Based on ACC/AHA Valvular\nHeart Disease Guidelines, if the patient is symptomatic (angina, syncope, CHF)\nand a surgical candidate, surgical intervention has been shown to improve\nsurvival.\n\n\n" }, { "category": "ECG", "chartdate": "2122-08-30 00:00:00.000", "description": "Report", "row_id": 306410, "text": "Normal sinus rhythm. Right bundle-branch block. Non-specific ST-T wave changes.\nNo previous tracing available for comparison.\n\n" } ]

[ { "category": "Radiology", "chartdate": "2105-02-27 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 859529, "text": " 12:30 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: assess for bleed or edema, mass\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 39 year old man with altered mental status, found down\n REASON FOR THIS EXAMINATION:\n assess for bleed or edema, mass\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: ACKe FRI 1:24 PM\n no bleed, no mass, no mass effect.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: A 39-year-old man with altered mental status, found down.\n\n COMPARISON: None.\n\n TECHNIQUE: CT of the head without IV contrast.\n\n FINDINGS: No hydrocephalus, shift of normally midline structures, intra or\n extra-axial hemorrhage, or vascular territorial infarct is identified. There\n is no intracranial mass lesion seen. The osseous and soft tissues structures\n are unremarkable.\n\n IMPRESSION: No acute intracranial pathology. These findings were relayed to\n the ED dashboard at 2:00 p.m. on .\n\n\n" }, { "category": "Radiology", "chartdate": "2105-02-27 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 859530, "text": " 12:32 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for ETT placement,pulm edema/infiltrate\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 39 year old man s/p intubation, resp distress\n REASON FOR THIS EXAMINATION:\n eval for ETT placement,pulm edema/infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 39-year-old man status post intubation.\n\n COMPARISON: No prior studies are available for comparison.\n\n SEMI-UPRIGHT AP CHEST: An endotracheal tube is in place, with the tip 5.4 cm\n from the carina. The tube cuff appears over-inflated. Cardiac and mediastinal\n contours are normal. There is a right upper lobe infiltrate. There is\n increased opacity of the entire left lung, most prominently in the left mid\n lung field. The right lung base is well aerated. The findings may represent\n infection vs. asymmetric pulmonary edema vs. aspiration. No pneumothorax is\n identified on this semi- upright radiograph. The osseous structures are\n unremarkable.\n\n IMPRESSION: 1) Satisfactorily positioned endotracheal tube. The\n endotracheal tube cuff appears that it may be overinflated, clinical\n correlation is requested.\n 2) Opacity of the right upper lobe and left lung that could reflect infection\n\n" }, { "category": "Radiology", "chartdate": "2105-02-27 00:00:00.000", "description": "CT C-SPINE W/O CONTRAST", "row_id": 859534, "text": " 12:39 PM\n CT C-SPINE W/O CONTRAST; CT RECONSTRUCTION Clip # \n Reason: assess for fracture or sublux\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 39 year old man with altered mental status\n REASON FOR THIS EXAMINATION:\n assess for fracture or sublux\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: ACKe FRI 1:19 PM\n no fracture\n vert body alignment ok\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 39-year-old man with altered mental status, found down. Assess\n for fracture.\n\n COMPARISON: None.\n\n TECHNIQUE: Noncontrast CT images through the cervical spine, reconfigured\n into bone windows, and reformatted into coronal and sagittal planes.\n\n FINDINGS: The vertebral body alignment is satisfactory. No fractures or\n subluxations are identified. The outline of the thecal sac is unremarkable.\n Although incompletely imaged, there is mild overdistension of the tracheal\n cuff.\n\n IMPRESSION: No fracture or subluxation seen.\n\n" }, { "category": "Radiology", "chartdate": "2105-02-28 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 859644, "text": " 10:40 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Please evaluate for change\n Admitting Diagnosis: RESPIRATORY FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 39 year old man found down, intubated, with bilateral infiltrates\n REASON FOR THIS EXAMINATION:\n Please evaluate for change\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Found down, intubated, with bilateral infiltrates.\n\n PORTABLE AP CHEST, ONE VIEW: Comparison . There is an ET tube 4 cm\n above the carina. Lucency around the distal aspect of the ET tube (likely\n balloon) appears unchanged. There has been interval placement of an NG tube\n which extends into the stomach, tip likely in the region of the distal antrum.\n\n The lung volumes are diminished. The apparent increase in cardiac size is\n likely due to lower lung volumes and differences in technique. Again, seen\n are multifocal airspace opacities, which allowing for changes in lung volume,\n are not significantly changed. Differential includes multifocal infection,\n aspiration, as well as asymmetric edema. There are no pleural effusions.\n\n\n" }, { "category": "Radiology", "chartdate": "2105-02-28 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 859697, "text": " 9:38 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: assess for infiltrates, ?asp pneumonia\n Admitting Diagnosis: RESPIRATORY FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 39 year old man with hx of narcotic OD and intubated for airway protection now\n s/p extubation and fever to 102\n REASON FOR THIS EXAMINATION:\n assess for infiltrates, ?asp pneumonia\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Narcotic overdose. Fever.\n\n COMPARISON: .\n\n AP SEMIUPRIGHT CHEST: Lungs volumes are improved over the most recent prior\n study. The patient has been extubated. Lungs showed some clearing since the\n initial film, though there is some persistent perihilar opacity bilaterally.\n The right upper lung zone abnormality is no longer evident. There is no\n effusion. The heart does not appear enlarged.\n\n IMPRESSION: Improving lung opacities with some persistent perihilar opacity,\n which may represent resolving edema. The areas of lung that have cleared\n entirely may have represented areas of aspiration. Continued followup is\n warranted.\n\n\n" }, { "category": "Radiology", "chartdate": "2105-03-01 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 859715, "text": " 6:19 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval eval of infiltrates\n Admitting Diagnosis: RESPIRATORY FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 39 year old man found down, intubated, with bilateral infiltrates; now s/p\n extubation\n REASON FOR THIS EXAMINATION:\n interval eval of infiltrates\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Found down, intubated, with bilateral infiltrates. Status post\n extubation. Assess for change.\n\n PORTABLE AP CHEST, ONE VIEW: Comparison is made to prior films of and\n . The cardiac silhouette appears mildly enlarged, although this could\n be due to AP technique. There are multifocal airspace opacities as well as\n perihilar haziness. Appearances have slightly progressed from , 21:55,\n although have improved from , 12:33. This waxing/ appearance\n suggests a component of fluid overload/edema superimposed on multifocal\n infection. There are no pleural effusions.\n\n" }, { "category": "ECG", "chartdate": "2105-02-28 00:00:00.000", "description": "Report", "row_id": 192586, "text": "Sinus tachycardia\nNormal ECG except for rate\nSince previous tracing, the rate is faster\n\n" }, { "category": "ECG", "chartdate": "2105-02-27 00:00:00.000", "description": "Report", "row_id": 192587, "text": "Sinus rhythm\nNormal ECG\n\n" }, { "category": "Nursing/other", "chartdate": "2105-02-27 00:00:00.000", "description": "Report", "row_id": 1422254, "text": "Nursing Progress Note 7PM-11PM:\nNeuro: Pt sedated on propofol at 75mcg/kg/min and requires small boluses to keep comfortable(2cc's at a time) with good effect. Able to open eyes to name called, follows simple commands. Squeezes my hands and moves legs to commands. Denies pain. Turned and positioned, skin intact.\n\nCV: BP 100-140/50-60 depending on level of sedation. HR sinus tach 106-120. Denies chest pain. K+ repletion added to maintenance IVF so pt has 1000cc's NS with 40meq kcl at 150cc/hr for the first liter to be followed by plain NS at 150cc/hr. Phos was low at 1.2 so pt to get 500cc's NS with 30MM kphos over next 6hrs. This was hung at 9PM. Pt also received 2gm mag IV. Pt also given 1000cc's NS bolus for fever/low UO.\n\nResp: Vent settings adjusted according to ABG's. Currently on AC 22, TV 550, FIO2 50% with 10cm peep with stable gas. Lungs coarse with good aeration throughout. Suctioned and sputum sent for culture.\n\nID: Spiked temp to 102.6 at 7:30PM and was fully cultured. Tylenol given via OGT. Pt on levoquin/flagyl WBC was low on admission. Pt denies abdominal pain. LFT's repeated as ordered.\n\nGI: NPO with OGT to LIS draining green/black bile after getting charcoal in EW. Faint hypoactive bowel sounds\n\nGU: Urine is very cloudy/pussy looking. Specimen sent for culture. UO is adequate but low.\n\nSkin: Intact.\n\nAccess: Three peripheral IV's in place.\n" }, { "category": "Nursing/other", "chartdate": "2105-02-28 00:00:00.000", "description": "Report", "row_id": 1422255, "text": "Neuro: Pt with increased restlessness and anxiety. Propofol increased to 100mcg/kg/min with minimal effect. Changed to Versed and Fentanyl at 0300 seems more comfortable. Requiring occasional boluses during care. MAE, follows commands and nods head to simple questions when sedation off. PERRL bilat. Cervical collar to remain in place until MD can perform subjective assessment when MS allows.\n\nResp: Current vent settings 22x550/40%/10. AM ABG 7.43/39/155/27. PO2 actually went up when vent weaned to 40% from 50. Lung sounds coarse throughout. Suctioned x3 for decreasing amts of blood tinged sputum. O2 sats 98-100.\n\nCardiac: HR 90-100's, B/P 110-125/60-70's, No ectopy noted, peripheral pulses easily palpable.\n\nGI: Abd distended with hypoactive bowel sounds. NPO. NGT to intermittent suction draining small amts of black bile. No BM this shift. Pancreatic enzymes trending down. IVF NS40K at 150cc/hr continues.\n\nGU: Voiding 40-100cc/hr of cloudy urine. Sample pending. BUN 13 Cr 0.7\n\nID: Tmax 101.2, Tcurrent 100.6. Diaphoretic at times. Tylenol 650mg given x1 with good effect. Continues on IV abx for presumed asp pna.\n\nDerm: Grossly intact, repositioned frequently, Aline site benign, PIV x3 patent sites benign.\n\nPlan: NPO with IVF, Follow pancreatic enzymes, Titrate sedation as needed, IV abx, follow cultures, wean vent as tolerated.\n" }, { "category": "Nursing/other", "chartdate": "2105-02-27 00:00:00.000", "description": "Report", "row_id": 1422252, "text": "Respiratory Care:\nPt received from ER on A/C settings; changes made to decrease volume & increase respiratory rate. Reported that patient has difficult airway. Pt suctioned for mod amounts of thick blood-tinged yellow secretions. Plan to continue ventilating as ordered.\n" }, { "category": "Nursing/other", "chartdate": "2105-02-27 00:00:00.000", "description": "Report", "row_id": 1422253, "text": "Nursing Admit/Progress Note 1500-1900\nThis 39yo man was found unconscious in bed, last seen awake/alert ~ 2hrs previously when he C/O chills, vomiting. Pt given Narcan 1mg, became combative, and was intubated @ scene(chipping 1 tooth) for airway protection. Pt had had suicidal ideations for the last several days per his wife. takes Percocet, Oxycontin for chronic back pain, and drinks ~12 beers several times/wk. He smokes ~1 pack/wk. Other PMH: HTN, anxiety/depression, L arm surgery with scarring (? metal plate or screws). Family is primarily Spainish speaking, but pt speaks/understands English as well.\n\nNeuro: Pt sedated on Propofol @ 75mcg/kg/min. Opens eyes to voice, squeezes hand on command. Occas lower extremety tremors. PEARL @ 3mm and sluggish bilat. MAE on bed, restrained with soft wrist restraints. Cervical collar in place. Head and C-spine CT scans neg.\n\nResp: Initially on AC settings 100%/25 X 550/+10-> ABG 7.46/35/367. FiO2 reduced to 60% and rate decreased to 22. ABG to follow. Lungs clear. Suctionned for mod amt thick, blood-tinged clear secretions X 1. CXR from admit showed opacities in RUL/LLL. Pt rec'ing Flagyl, Levo for probable aspiration PNA.\n\nCV: HR 95-99SR without ectopy. BP 116/89 periph, 148/86 per arterial line. Labs from 1730 include Hct 32.4, K+ 3.5, Mg 1.8, Phos 1.2, Lactate 2.1, Amylase 1231, CPK 1161. MD aware.\n\nGI: OGT to LIWS, draining mod amt charcoal colored fluid. Abd firm/distended with hypoactive bowel snds. No stool since admit.\n\nGU: Foley draining yellow/cloudy urine @ 40-60ml/hr. Pt rec'ing NS @ 150ml/hr X 2liters.\n\nSocial: Wife and various other relatives @ bedside, appropriate.\n\nPlan: Cont to ventilate pt overnight. Cont to hydrate for ? pancreatitis. Sitter/Psych consult when awake.\n" }, { "category": "Nursing/other", "chartdate": "2105-02-28 00:00:00.000", "description": "Report", "row_id": 1422256, "text": "Nursing Progress Note.\n\nRESP: Pt received on MV c the following settings; AC-22-40-550-10 c the following nl routine AM lab values; 7.43-39-155. Pt c nl sats, RR and resp effort this AM and therefore MV settings changed to CPAP/PS of c 40% FiO2 c good tol and no overt change in resp status/fxn. Minimal thick tannish sec per ETT today. LS found to be rhoncherous to clear c good cough reflex noted. AM RSBI value of 58 noted. CPAP/PS weaned down to 5/5 c again good tol of lowered setting. +Cuff leak reported by RT. Neck collar d/c'ed s/p HO eval @ 15:00 to facilitate extubation. Pt subsequently extubated to 40% CS face tent @ 15:30, currently on 2LNCO2 c nl sats, RR, and resp effort. Pt denies SOB/dyspnea since extubation. Pt able to speak in full sentences s dyspnea. Pt currently c/o sore throat and raspy voice, otherwise no resp distress. Of note/per chart, pt was a diff intubation in field.\n\nMS: Pt is times three s/p extubation. MAE, appears sleepy but o/w is in NAD. Pt received on IV Fentanyl @ 100mcg/hr & IV Verced @ 4mg/hr which are now infusing @ 10mcg/hr & 1mg/hr respectively. Pt started on Q8hr 10mg PO Valium 2nd risk of withdrawal, CIWA scale initiated c no evidence of withdrawal @ this time. Pt denies any neck pair or discomfort c full ROM noted in neck s/p collar removal. Soft wrist restraints d/c'ed s/p extubation.\n\nCV: Hemodynamically stable c low grade temp of 100.1 this AM. NSR c no ectopy. Pt to be restarted on daily anti-HTN PO 25mg Atenolol this evening. Three PIV's remain intact and patent. L radial a-line also in place c optimally dampened waveform noted. Unexplained anemia (AM HCT of 28.8), will guaic all stools per team request.\n\nGU: The pt is currently net input 2.6 liters input today and he is net input 4.6 liters input since admit.\n\nGI: Pt was NPO s/p extubation, will now adv diet slowly as tol s/p extubation. Abd is soft, NT, ND c +BS appreciated.\n\nSOC: Pt receiving multiple family members throughout shift including siblings, wife and mother -- all kept up-to-date c /pt status. The pt is a Full Code.\n\nOTHER: Please see CareVue for additional pt care data/comments. Univ isolation precautions in place.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2105-03-01 00:00:00.000", "description": "Report", "row_id": 1422257, "text": "NURSING PROGRESS NOTES 1900-0700\nREVIEW OF SYSTEMS:\n\nNEURO: PT A&O X3 MAE FOLLOWS COMMANDS. PT DID NOT SLEEP WELL LAST NIGHT, AWAKE ON AND OFF, EVENTHOUGH HE LOOKS VERY SLEEPY. TMAX 102.1-TYLENOL, BCX2,URINE C/S AND PCXR DONE.\nPT C/O BACK PAIN FROM HIS HERNIATED DISKS PERCOCET 2 TABS GIVEN AT 2130 AND 0400, W/ GOOD RELIEF. CIWA SCAL 0-1 THROUGHOUT NIGHT. VALIUM 10MG PO GIVEN TID AS ORDERED AND ATIVAN ORDERED IF CIWA SCALE >10. PT ORDERED HAVE SAFETY SITTER FOR SI REPORTED BY WIFE, THE BED FACILITATOR/SUPERVISOR MADE AWARE AT , HOWEVER NO SAFETY SITTERS AVAILABLE.\n\nRESP: PT O2 INCREASED TO 3L NC FOR SATS OF 91-92% ON 2LNC. PT ENCOURAGED TO AND TO DO IS FIRST ATTEMPT IS 500-750, 2ND ATTEMPT WA 1000-1250. LS EXP WHEEZES/RHONCHI ON RIGHT SIDE W/ RHOCHI AND DIMINISHED BASE ON LEFT. PT C/O MIDSTERNAL CP ONLY W/ DEEP BREATHES AND COUGHING DR AWARE. NEB. TX ORDERED AND GIVEN W/ SOME RELIEF. PERCOCET 2TABS GIVEN AT 0400 FOR PLEURITIC PAIN W/ GOOD RELIEF PAIN WAS #10 AND DROPPED TO 0 AFTER PAIN MED.\n\nCV: TELE ST 90-110S PT ATENOLOL 25MG PO GIVEN AS ORDERED AT BP DOWN TO 150S/80S. @ 0400 PT 180/100, ATENOLOL 25MG PO ORDERED AND GIVEN BP AT PRESENT 140/80S. HRT SOUNDS S1S2. PEDAL PULSES +3. PT HCT 26.6 THIS AM TX GOAL 22. NO ACTIVE BLEEDING NOTED. K+3.7, MG 1.9, PHOS 1.6. PT HAS NO IVF PER MICU TEAM ORDER.\n\nGI: PT IS CLEAR LIQUIDS W/ ADV AS TOLERATED DIET. PT HAS TAKEN SIPS OF WATER W/ MEDS TOLERATED WELL, BUT STATES HIS THROAT IS SORE SO HE ONLYL TAKES SIPS. ABD SOFT BS + NO STOOL THIS SHIFT. PLEASE GUIAC ALL STOOLS.\n\nGU: PT HAS FOLEY CATH DRAINING YELLOW URINE 60-120CC/HR.\n\nSKIN: INTACT\n\nID: PT HAD TEMP SPIKE AT 2100 102.1 ORALLY. BC X2, URINE C/S OBTAINED, PCXR DONE.\nBC X1 AND URINE C/S PENDING, SPUTUM C/S GRAM STAIN- POS FOR GRAM + COCCI IN PAIRS, CX PRELIM.- SPARSE GROWTH OROPHARANGEAL FLORA.\nPT ON FAMOTIDINE Q12HRS IV.\n\nENDO: PT HAS FINGERSTICKS QID, CAN BE CHANGED TO AC&HS ONCE HE STARTS EATING LAST BS @ 0000- 131 W/ NO COVERAGE.\n\nSOCIAL: WIFE: , MOTHER HAD SPENT THE NIGHT IN WAITING ROOM. PT HAS 4 DAUGHTERS.\n\nPSYCHOLOGICAL/EMOTIONAL: THIS RN ASKED PT WHAT HAD HAPPENED TO HIM AFTER HE DROPPED OFF HIS DAUGHTERS AT SCHOOL. HE STATES HE REMEMBERS GOING IN HIS HOUSE AND THAT'S IT. HE STATES HE HAS BEEN DEPRESSED SINCE BECOMING DISABLED AND OUT OF WORK BUT HE WOULD NEVER DO SOMETHING \"STUPID LIKE THAT\" REFERING TO SUICIDE. HE DENIES HAVING BEEN SUICIDAL FOR THE PAST FEW DAYS, AS WIFE REPORTS, HE STATES \"MY WIFE AND I DISCUSS THINGS I DON'T GO TO A COUNCILOR OR ANYONE LIKE THAT BECAUSE I DON'T LIKE SITTING DOWN AND TALKING TO PEOPLE LIKE THAT, SO I TALK TO MY WIFE.\" HE DENIES TAKING ANYMORE MEDICATION THAT MORNING THAN HE USUALLY TAKES FOR PAIN. PT DISCUSSED HIS FARTHER'S DEATH WHEN PT WAS AGE 8 AND HOW DEVISTATED HE WAS. EMOTIONAL SUPPORT GIVEN.\n\nCODE: FULL\n\nPLAN:\n1. ASSESS RESP STATUS AND CONT TO ENCOURAGE PT TO AND USE IS Q 1HR WA. GIVE NEBS AS NEEDED.\n2. MAINTAIN PT COMFORT LEVEL PT USING PE\n" }, { "category": "Nursing/other", "chartdate": "2105-03-01 00:00:00.000", "description": "Report", "row_id": 1422258, "text": "NURSING PROGRESS NOTES 1900-0700\n(Continued)\nRCOCET 1-2 TABS Q 4HRS FOR CHRONIC BACK PAIN AND PLEURITIC PAIN.\n3. MONITOR FEVER CURVE.\n4. ENCOURAGE PT TO TAKE PO FLUIDS D/T PT HAS NO IVF ORDERED.\n5. ASSESS AND GIVE PT EMOTIONAL SUPPORT D/T DEPRESSION AND ?SUICIDAL IDEATION (PER WIFE). PSYCHOLOGICAL EVAL NEEDED. 1:1 FOR SAFETY.\n6. PLEASE KEEP WIFE AND PT UPDATED W/ PLAN OF CARE.\n7. PLEASE ALLOW PT TO HAVE ADEQUATE REST PERIODS THROUGHOUT DAY W/ LESS VISITORS D/T POOR SLEEP LAST NIGHT.\n8. CONT TO MONITOR CIWA SCALE IF >10 GIVE ATIVAN 1-2MG PO\n" }, { "category": "Nursing/other", "chartdate": "2105-03-01 00:00:00.000", "description": "Report", "row_id": 1422259, "text": "Nursing Progress Note.\n\nRESP: Pt now on 3LNCO2 c nl sats, RR & resp effort. Incentive spirometry provided c encouragement/instruction on optimal technique c pt pulling 2 liter vols. Pt OOB to chair/ambulated on unit c no c/o SOB, dyspnea, dizzyness or lightheadedness. Will titrate off NC as tol. Pt thought to have a chemical pneumonitis s/p probable asp on and spiking temps (101.2 this AM) and subsequently started on PO Levofloxacin and Flagyl for cov.\n\nCV: Hemodynamically stable. NSR c no ectopy. R radial a-line d/c'ed today in prep for transfer to gen med floor when able. Foley cath also d/c'ed this AM c pt spontaneously voiding adeq amounts of clear yellow urine. The pt is currently net output 200ml today but is net input 4.3 liters since admit. SQ Heparin therapy for DVT prophylaxis d/c'd now that pt is OOB/ambulating. No c/o cp thus far today.\n\nMS: Sitter provided @ BS all shift to ensure pt safety s/p apparent narc overdose and question of pt suicidality. However, pt attempts to appear upbeat and cooperative. Pt is times three, MAE, following commands and mildly fatigued. CIWA scale values of zero obtained all shift. Pt c/o LBP and med c 2# Percocet tabs @ 10:00 c + results reported by pt. Psych consult performed @ BS today, will maintain 1:1 sitter and the pt will need to be seen again by Psych service prior to d/c from Hosp to ensure pt safety.\n\nGI: Pt diet adv to solids c pt able to tol soup & crackers. No BM output @ this time but will be sure to guaic stools to assess for GI blood loss.\n\nSOC: The pt has restricted family visitors to his wife, mother, and possibly one of his dtrs. The pt is a Full Code.\n\nOTHER: Please see CareVue for additional pt care data/comments. Univ isolation precautions in place. RN Transfer Note completed and placed in front of pt chart.\n" }, { "category": "Nursing/other", "chartdate": "2105-03-02 00:00:00.000", "description": "Report", "row_id": 1422260, "text": "NURSING PROGRESS NOTES 1900-0700\nREVIEW OF SYSTEMS:\n\nNEURO: A&O X3 MAE PT SLEPT WELL LAST NOC. C/O BACK PAIN AT 2200 PAIN LEVEL #3 PERCOCET 2 TABS GIVEN W/ GOOD RELIEF PAIN. CIWA SCALE 0 THROUGHOUT SHIFT. SAFTEY SITTER AT BEDSIDE THROUGHOUT SHIFT FOR SAFETY AND ? OF SUICIDAL IDEATION.\n\nRESP: O2 ON 3.5L NC SATS 97-98% RIGHT SIDE LS RHONCHI W/ DIMINISHED BASES LEFT SIDE CLEAR W/ DIMINISHED BASES. PT HAS CONGESTED COUGH NONPRODUCTIVE. INCENTIVE SPEROMETRY DONE W/ VOLUMES OF .\n\nCV: TELE SR 80S VSS, HRT SOUNDS S1S2. PEDAL PULSES +4 HCT AT 2200 27.5, THIS AM HCT 29. REST OF LABS PENDING.\n\nGI: ABD SOFT BS+ NO STOOL THIS SHIFT. PLEASE GUIAC ALL STOOLS\n\nGU: PT VOIDED IN URINAL X 1 THIS SHIFT.\n\nSKIN: INTACT\n\nCODE: FULL\n\nSOCIAL: WIFE CONTACT ALLOWED TO SEE PT: WIFE, MOTHER AND OLDEST DAUGHTER.\n\nPLAN:\n1. AWAITING REST OF LABS AND REPLACE AS NEEDED\n2. GIVE EMOTIONAL SUPPORT AS NEEDED\n3. AWAITING TX TO FLOOR AND CONT 1:1 SITTER\n4. BEFORE DC FROM HOSPITAL HAVE PSYCH SEE PT TO FOR SAFETY.\n5. CONT INCET. SPIROMETRY Q 1HR WHILE AWAKE\n6. CONT TO ASSESS FOR ETOH W/DRAWAL\n" }, { "category": "Nursing/other", "chartdate": "2105-03-02 00:00:00.000", "description": "Report", "row_id": 1422261, "text": "Nursing Progress Note.\n\nMS: Pt remains cooperative, MAE, times three, following commands and able to ambulate on unit s SOB/dyspnea. Pt c/o lower back pain and med c #2 Percocets @ 10:00 c good results reported. Affect is slightly flat. Pt denies being suicidal now or prior to admit. Pt reports not wanting to go to an inpatient psychiatric unit. Pts story does not mesh c the story reported by his wife who he lives with pt. Wife reports a story that @ times includes; pt being extremely depressed, not leaving the house/receiving visitors, extreme emotional lability, abusive behav, daily ETOH abuse and is uncertain how much prescription meds (Percocet, Oxycontin) he takes. Social Work & Psychiatry both met and spoke c wife this AM. Pt also seen by Psychiatric RN Case Worker. Pt will be seen by Emergency Team Clinician shortly to determine whether pt should be transferred to an in-pt psych facility ( 4) versus a general medical unit. Verbal and non-verbal support provided to pt, wife and pt visitors. &/or blunt instruments removed from room for pt safety. One to one sitter remains at BS to ensure pt safety. 10mg PO Valium Q8 hr dosing d/c'ed today c no evidence of ETOH/Benzo withdrawal evident (CIWA scale remains zero).\n\nRESP: Pt now on RA c sats in the low to high 90's c nl RR and resp effort. Pt utilizing incentive spirometer correctly and moving 2.5 liters c effort. LS are fairly clear, diminished @ bases. Pt has a dry, non-prod cough. Pt also ambulated on unit c 2LNCO2 c good tol earlier. PO antibiotics d/c'ed today.\n\nCV: Hemodynamically stable and afebrile. Pt voiding adequate amounts c urinal. NSR c no VEA. Lab AM values for potassium and magnesium were 3.6 and 1.9 respectively, repleted c 40MEQ KCL PO and 400mg MagOxide PO.\n\nGI: Pt c improved PO intake for lunch. Will guaic next stool to assist c anemia work-up.\n\nSOC: Wife and brother-in-law have visited today. Spoke c wife who subsequently met c and spoke to Psychiatry and Social Work. The pt is a Full Code.\n\nOTHER: Please see CareVue for additional pt care data/comments. Univ isolation precautions in place.\n" } ]

[ { "category": "Nursing/other", "chartdate": "2197-07-12 00:00:00.000", "description": "Report", "row_id": 1534462, "text": "Nursing admission notes 0330\nreview carevue for additonal data\n\n83 yo female with multiple medical problem (see adimission history/FHP) presented to ED, Patient with s/p total colectomy on for ulcerative colitis and prolonged hospitalization secondary to a fib and wound infection. She was discharged to rehab with MACU level with a wound VAC and two week course of vanco and zosyn.She was readmitted for accute renal failure with creat 1.8, fever and necrotic areas of her wound. She was discharged to rehab on stable condition. She presented today with c/o low urine output with BUN/Cr 42/4.3 and K 5.3 and treated in ED with kexalate. Also she was hypotensive responded to fluid bolus 2L and her INR was 8.2 and given vit K, tranfered to MICU for further management and care.\n\nNeuro: Alert, oriented x3, folowing commands, MAE,with given h/o spinal stenosis and lumbar scoliosis. Denies pain.\n\nResp: On nasal canula with O2 2L and O2 sats 96-99%, RR 12-20,unlaboured, Bilateral lung sounds clear.\n\nCv: On slow a fib, Hr 40-50's, SBP 100-110. Rt hand PICC line in place IV NS 200ml/hr onflow. Awaiting am labs.\n\nGu/GI: Renal heart healthy diet, abd soft, Bs present, ileostomy stoma looks pink and healthy, stoma care given. Uo 10-15ml/hr, MD aware. Awaiting Am labs.\n\nSkin: duaderm in place for decub over coccyx, abd wound dressing intact, dressing to be changed.\\\n\nSocial: Contact daughter over phone.\nId: Afebrile, no iv abx.\n\nPlan: Continue monitor UO and LAbs\n Monitor am labd for K and inr and treat accordingly\n Stoma and wound care\n Emotional support to patient.\n\n" }, { "category": "ECG", "chartdate": "2197-07-12 00:00:00.000", "description": "Report", "row_id": 285546, "text": "Atrial fibrillation, average ventricular response 61. No significant changes\nhave occurred.\nTRACING #3\n\n" }, { "category": "ECG", "chartdate": "2197-07-11 00:00:00.000", "description": "Report", "row_id": 285547, "text": "Atrial fibrillation, average ventricular response 52. Since previous tracing\nthe ventricular response rate has slowed somewhat. No other changes are seen.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2197-07-11 00:00:00.000", "description": "Report", "row_id": 285548, "text": "Atrial fibrillation, average ventricular response 60. Since tracing\nof the ventricular response rate has slowed. The Q-T interval is\nminimally prolonged. No other significant changes have occurred.\nTRACING #1\n\n" } ]

[ { "category": "Nursing/other", "chartdate": "2132-05-07 00:00:00.000", "description": "Report", "row_id": 1813494, "text": "1 1. CV/RESP\n2 2.FEN\n3 3. Rule Out Sepsis\n4 4.Social\n5 5. G&D\n\nREVISIONS TO PATHWAY:\n\n 1 1. CV/RESP; added\n Start date: \n 2 2.FEN; added\n Start date: \n 3 3. Rule Out Sepsis; added\n Start date: \n 4 4.Social; added\n Start date: \n 5 5. G&D; added\n Start date: \n\n" }, { "category": "Nursing/other", "chartdate": "2132-05-07 00:00:00.000", "description": "Report", "row_id": 1813495, "text": "1. CV/RESP O: Infant intubated in the LD with 2.5 ETT\ntaped 7cm at the lip without incident. No respiratory effort\nand minimal improvement in color despite handbagging per\nface mask prior to intubation. Poor air exchange noted, but\ninfant pinked up after intubation in LD with good HR.\nCurrently on HFOV sensormedics with parameters of AMP 40 MAP\n16 and 100% FIo2. Vibrations noted from clavicle to\numbilicus. Moderate pitch and intensity noted per\nauscultation. Fio2 requirement mostly 80-100% to maintain\nsats in hi 80s and 90s. Rec'd Survanta x2, tolerated well.\nCXR/babygram taken x2. Serial ABGs done, requiring NaHC03\nx1 for ABG 7.19/41/48/16/-11. HRR without audible murmur.\nPale/dusky with bruising noted on extremities and trunk.\nNSR. BP MAP 21-34. Infant requiring x2 NS bolus for\ndecrease MAPs with good response initially. Dopamine\nstarted at 5mcg/kg/min for MAPs 24-25 with minimal response.\nDopamine now at 17mcg/kg/min (0.85cc/hr) for maps 21-25 and\n17cc PRBCs given for persistent hypotension. Peripheral\npulses equal and palpable. HR 150-180s. Rt. radial art line\nplaced--fingers noted to bluish in color with poor cap\nrefill and therefore dc'd. Currently, rt. fingers pink with\ncap refill 3sec. A: Labile CV/RESP status despite\nincreasing vent support and max. vasopressors/volume\nexpandersP: Monitor and document. Serial CXR/ABGs\n2. FEN Remains NPO on TF=80cc/kg/day. Abdomen soft, girth\nstable at 19.5cm with hypoactive BS. D/S 70- 117. DL UVC\nin place and secure to abdomen per bridge tape. D10w with\nheparin infusing at 1.4cc/hr each line respectively.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2132-05-07 00:00:00.000", "description": "Report", "row_id": 1813496, "text": "RESPIRATORY CARE NOTE\nBaby #1 28 born via C/S apgars 2 & 6 received PPV in the DR. in the DR a 2.5 ETT taped at 7cm. Transported to the NICU being bagged with 100% O2. Survanta 4cc given at 2300 hrs. Place on HiFI Vent MAP 14 AMP 35 FiO2 100%. Two N/S bolus given for BP. Started on Dopamine. 17cc of PRBC given. Fentanyl given for sedation. Bicarb given for acidosis. Baby remains critically ill. Last abg drawn PO2 48 CO2 41 PH 7.19 16 -11. Second dose of survanta 4cc given at 0545 hrs. Current vent settings MAP 16 AMP 40 FiO2 100%. Cont to monitor very closely.\n" }, { "category": "Nursing/other", "chartdate": "2132-05-07 00:00:00.000", "description": "Report", "row_id": 1813497, "text": "Continuation\n2. FEN O: No void/stool thus far. PIV on lt. hand\nremains patent to flush without redness or edema. A:\nStable NPO. Normoglycemic. P: Maintain IVF at\n80cc/kg/day. D/S PRN. Labs as ordered.\n3. ROS O: Bld cx and CBC drawn. Recd Amp and\nCeftoxamine. A: Bld cx pending. P: Monitor lab result.\nAntibx as ordered. Monitor levels.\n4. SOCIAL O: Mom and dad able to see both infant prior to\n transfer from LD. No further contact . A:Concerned\nfamily P: Support and keep updated. Encourage to ask\nquestions.\n5. G&D O: Active with handling. Rec'd Fentanyl x1 with\ngood result for noted agitation as evidenced by crying and\nflailing of extremities accompanied by desats to lo 80s.\nInfant more calm and relax after med given. Temp wnl under\nradiant warmer. Lower extremities noted to have skeletal\ndeformities with legs bowed and feet turned inward.\nAnt/post fontanel soft, but full and boggy. Sutures very\nwidened. No seizure activity noted. A: Labile with cares.\n\nVisible physical abnormality. P; HUS this am. Monitor.\nComfort measures. Consider Fentanyl gtt if infant remains\nagitated.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2132-05-07 00:00:00.000", "description": "Report", "row_id": 1813498, "text": "Case Management Note\nChart reviewed to date. I will cont to follow & provide clinical updates as requested to insurance, HCVM. I will leave list w/names & phone #'s for EIP & VNA in baby's chart.\n" }, { "category": "Nursing/other", "chartdate": "2132-05-07 00:00:00.000", "description": "Report", "row_id": 1813499, "text": "Attending Update\n of life 1\nHIFI MAP 18 Amp 50 on 100%\nABG 7.06/101/36/\nno murmur MBP 26-30 on Dopa 21 mcg/kg/min\nnormals saline X3 this am\ngetting 10 cc/kg of blood\non amp/cefotax\n\ntotal fluids 80 cc/kg/day\nno void ever no stool\ndstick 109 this am\nbirhtweight 980\n\nK 6.3 Na 136 Cl 108\n\ntemp stable\ngot morphine twice this am\n\nImp-in critical condition requiring a lot of support\nwill continue to maintain blood pressure\nwill continue antibiotics\nwill check a chest x-ray\nwill repeat ABG\n" }, { "category": "Nursing/other", "chartdate": "2132-05-07 00:00:00.000", "description": "Report", "row_id": 1813492, "text": "Neonatology\nPatient is 998 gram product of 28 week twin gestation born to 38 yo G4P2 woman whose pregnancy was complicated by maternal hypertension marked oligo, and late diagnosis of pregnancy (several weeks ago). Mother with HCT up until 2 weeks ago for HTN. This drug relatively contraindicated in pregnancy. C Hanged to metoprolol when pregnancy diagnosed. When seen for prenatal visit today, marked oligo and non-reassuring FHM seen. These lead to transfer here with ultimate section. No prenatal BMZ given.\n\nO+, ab- HBsag-, RPRNR, RI. GBS?\n\nAT cestion emerged with decreased HR and tone. No resp effort. GIven BMV with rapid response in HR. Apgar 2,6. Intubated in DR. to NICU after visiting with parents.\n\nOn exam pink pale infant with decreased activity and tone. Skin with bruising about trunk, ext and face. PE c/w 28-29 weeks. HEENT notable for markedly enlarged posterior fontanelle and occipiotal suture. ? softened cranial bones. Lungs coarse BS bilaterally. Cor nl s1s2w/o murmurs. Abdomen benign. Genitalia nl preemie male, Both testes undescended. Hips normal. Ext notable for flattend feet, Left hand with only two diagnolly oriented creases. Limbs mobile through full rom. Neuro dcereased tone and activity throughout. Spine intact. Anus patent.\n\n\nRequire PIP as high as low 30s to move chest in NICU.Placed on HFOV. Given NS bolus x 2 for perfusion and BP. BS in good range.\n\nA- 28-29 week infant with res failuyre req HFOV. Most likely cause is HMD +/- component of pulmonary hypoplasia. Dysmorphisms may be due to deformation, but possibility of chromosomal abnormalities also exist.\n\nP Admit NICU\n Resp support with surfactant (at least severqal doses) and HFOV.\n Titration of above via clinical, lab and non-invasive monitoring.\n\nPROCEDURE NOTE\nUV lione placed with 3.5 double lumen catheter in usual fashion. CXR shows tip in good position. Unable to thread UA past 6 cm. Peripheral a-line placed in right radial in usual fashion. Distal perfusion intact after procedure. Taped with all fingers visible.\n\n NPO at present with IV hydration.\n Abx for 48 h r/o. Will use third generation cephalosporin rather tha gent given h/o maternal ACE inhibitor given possible effect on neonatal renal function.\n\n Usual attention to metabolic issues and bili.\n\n HUS for am.\n\n Spoke to mother and father in RR%. discussed sever nature of resp illness possibility of pulm hypoplasia and presence of dysmorphisms. DIcsussed plan for night and plan for chromosomes in am. They appear to understand.\n\n\n\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2132-05-07 00:00:00.000", "description": "Report", "row_id": 1813493, "text": "Neonatology-NNP Procedure Note\n\nProcedure: Endotracheal intubation\nIndication: Respiratory distress\n\nInfant in supine position in DR. direct larynoscopy, the vocal cords were visualized using a size 0 blade. A 2.5 Fr ETT was inserted through the vocal cords and secured at 7 cm. A CXR confirmed placement. The infant tolerated the procedure with out incident.\n\n\nProcedure: UVC placement\nIndication: Continuous IV nutrition\n\nInfant placed in supine position with cardio-respiratory monitor in place. Infant prepped and draped in sterile fashion. Using sterile technique a 3.5 Fr double lumen UVC was inserted into the umbilical vein and advanced to 8cm with positive blood return. The UVC was sutured at 8cm. An xray revealed plecment of the the tip above the diaphram. The catheter was withdrawn 0.5 cm and secured at 7.5 cm. The umbilical cord was oozing blood periodically during the procedure, estimated blood loss of ~2-3cc.\n\n\n" }, { "category": "Radiology", "chartdate": "2132-05-07 00:00:00.000", "description": "BABYGRAM (CHEST ONLY)", "row_id": 829833, "text": " 5:05 AM\n BABYGRAM (CHEST ONLY) Clip # \n Reason: evaluate lung fields\n Admitting Diagnosis: NEWBORN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Infant with prematurity, on HFOV, increased support\n REASON FOR THIS EXAMINATION:\n evaluate lung fields\n ______________________________________________________________________________\n FINAL REPORT\n CHEST:\n\n Comparison is made with an exam done earlier in the day. Since that time the\n lung volumes have decreased and the lungs become increasingly opaque. ETT and\n umbilical venous line are unchanged in position.\n\n" }, { "category": "Radiology", "chartdate": "2132-05-06 00:00:00.000", "description": "P BABYGRAM CHEST & ABD (TOGETHER ONE FILM) PORT", "row_id": 829829, "text": " 11:43 PM\n BABYGRAM CHEST & ABD (TOGETHER ONE FILM) PORT Clip # \n Reason: verify ETT placement, UVC placement\n Admitting Diagnosis: NEWBORN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Infant with prematurity at 28 weeks\n REASON FOR THIS EXAMINATION:\n verify ETT placement, UVC placement\n ______________________________________________________________________________\n FINAL REPORT\n CHEST.\n\n This is our initial film on this baby born at 20 week gestation. The patient\n is intubated with the endotracheal tube above the carina. An umbilical venous\n line has been introduced and is high in the right atrium. The lung volumes\n are low and the lungs quite hazy compatible with hyaline membrane disease.\n The bowel gas pattern is within normal limits.\n\n" }, { "category": "Nursing/other", "chartdate": "2132-05-07 00:00:00.000", "description": "Report", "row_id": 1813500, "text": "Family meeting note\nMet with mom, dad, to discuss the condition of the patient. They were updated to his current condition and the amount of support required to maintain him in this condition.\n\nI explained that we were nearing limit of what we could do for him. I explained what other things could be done. The family explained what they would like done. The summary is below:\n\nWe will maintain our current level of management.\n\nShould he have a decompensation, we will not do invasive procedure including reintubation, needle aspiration, and chest tube.\n\nWe will not provide chest compression, arrest medications, or bag-mask ventilation.\n\nWe will make him comfortable with medications if necessary.\n\nThis plan was discussed with the medical care team and an order was written in the medical record\n" }, { "category": "Nursing/other", "chartdate": "2132-05-07 00:00:00.000", "description": "Report", "row_id": 1813501, "text": "Respiratory Care Note\nReceived pt on HFOV on MAP 16, AMP 40, FiO2 100%. After ABG of 7.06/101/36/30/-6 increased to MAP 18, AMP to 50. Repeat VBG:7.15/59/35/22/-10. Weaned AMP to 48, which is current setting. Suctioned for scant secretions from ETT. Pt on Dopamine. Received PRBC's and fluid boluses t/o shift. Pt is currently DNR as per Dr. . Will folow on HFOV.\n" }, { "category": "Nursing/other", "chartdate": "2132-05-07 00:00:00.000", "description": "Report", "row_id": 1813502, "text": "SOCIAL WORK\nHave met with both and their 2 older children today. they present as quiet and private but supportive of each other. Father has been the most verbal of the family, while mother has been mostly withdrawn and quiet. They have sustained the loss of this twin's sister, , earlier today and now are aware of the critical condition of this infant, . Their older children, age 20 and , age 17 have been with their all day. Father expressed appreciation for all staff is doing to help their son, however stated \"we know it is in God's hands and we have alot of faith\". Extended family are apparently just becoming aware of circumstances and have begun to contact family. were given Family Healing packet and are contemplating their wishes regarding burial arrangements for their daughter. Assistance was offered to help with these decisions as well as other support as they go through this tragic loss. have my tel # and are aware that I will cont to follow through Friday with bereavement f/u next week.\n" }, { "category": "Nursing/other", "chartdate": "2132-05-07 00:00:00.000", "description": "Report", "row_id": 1813503, "text": "Nursing Note\nSee flow sheet for medications given, interventions, calculations, and VS.\n\nSocial: Pt made DNR per request. At 1855, pt's ETT removed per request, care redirected with MD. and siblings currently in holding pt. Attending MD's note for further details.\n\nPt cont to have persistent sats in 50-60%'s. BP means dropping to low 20's with Dopamine at 25mcg/kg. Pt cont to retain fluid, no void since birth despite TF restricted. Morphine given prior to extubation for comfort.\n" }, { "category": "Nursing/other", "chartdate": "2132-05-07 00:00:00.000", "description": "Report", "row_id": 1813504, "text": "Neonatology Progress Note\n died at 19:37. He was being held by his mother.\n" }, { "category": "Nursing/other", "chartdate": "2132-05-07 00:00:00.000", "description": "Report", "row_id": 1813505, "text": "Neonatology Progress Note\n in a state of critical condition this afternoon. He had refractory hypoxia and a mixed metabolic acidosis. He continued on HiFi ventilation with a MAP 18 and Amplitude of 50 100% FiO2. He was profoundly hypotensive despite dopamine support at 21-25 mcg/kg/min, several normal saline boluses, and another transfusion of PRBC's of 10 cc/kg. He was also given bicarbonate to improve his acid base balance. He was given morphine for pain and discomfort. During his life, he was anuric and generally edematous which was worrisome for lack of renal function. His chest xrays showed poor expanion of the chest c/w pulmonary hypoplasia.\n\n\nI met with the family several times during the afternoon to update them on progress. We discussed the grim prognsis given his unresponsiveness to medical intervention.\n\nThe family came to see . The family and all the members of the care team agreed that redirection of care to comfort measures were in his best interest.\n\nHe was extubated at 18:54. He was held by his mother and the other members of his family.\n" }, { "category": "Nursing/other", "chartdate": "2132-05-07 00:00:00.000", "description": "Report", "row_id": 1813506, "text": "NPN\n in to visit shortly after 1900, and MD discussed wishes regarding infant's critical state. Mother, father, and siblings present at bedside. extubated, wrapped in blanket, and placed in mother's arms to hold. Family is loving and very supportive of each other, expressing their wishes with staff. Photographs taken of family holding infant, then this RN allowed family private time with infant. Family given roll of film per their request. MD pronounced death of infant at 1937pm. Family allowed time with infant until they alerted this RN that they were ready to depart. Post-mortem care completed per hospital policy. Infant cleansed and dressed. Handprints, footprints, and whisp of hair placed in memory box along with baby blanket and additional mom from bedside. Infant wrapped according to policy and transported to morgue with assistance from ,RN.\n" }, { "category": "Radiology", "chartdate": "2132-05-07 00:00:00.000", "description": "P BABYGRAM (CHEST ONLY) PORT", "row_id": 829863, "text": " 12:39 PM\n BABYGRAM (CHEST ONLY) PORT Clip # \n Reason: infant on increased respiratory support\n Admitting Diagnosis: NEWBORN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Infant with prematurity\n REASON FOR THIS EXAMINATION:\n infant on increased respiratory support\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Prematurity with increased respiratory support.\n\n Since last examination dated earlier in the day, there has been no significant\n change in near-complete opacification and marked hypoinflation of both lungs\n with minimal sparing of the central portion of the right lung. Scattered air\n bronchograms are seen throughout the entire left lung. ET tube is present\n with its tip overlying the T2 vertebral body. Umbilical venous catheter is\n present with its tip overlying the T6 vertebral body. Limited exam due to\n marked rotation of the child to the left side.\n\n IMPRESSION: Marked hypoinflation of the lungs consistent with hyaline\n membrane disease, unchanged since last exam.\n\n\n" } ]

[ { "category": "Nursing/other", "chartdate": "2181-06-18 00:00:00.000", "description": "Report", "row_id": 1339359, "text": "1715 Update:\nBrother arrives to room with sister. Requesting 15min with pt and then verbalizing wishes to withdraw life support. 1:1 support for family provided. Appear to be coping effectively. Notified MD's wish to update family on pt status. Pt's original wish to go home to to see his mother discussed with family who confirm this, though report that they do not regret his coming to this facility and are very appreciative of this care. Continue to verbalize wishes to withdraw life support, and maintain comfort care. Team notified. To discuss plan with family.\n" }, { "category": "Nursing/other", "chartdate": "2181-06-19 00:00:00.000", "description": "Report", "row_id": 1339360, "text": "Resp Care Note, Pt remains on current vent settings. See vent flow sheet for details. Suctioned for scant amts bld tinged secretions. Paralyzed and sedated. Getting levophed,neosynephrine and pitressin.Will cont to monitor resp status.\n" }, { "category": "Nursing/other", "chartdate": "2181-06-19 00:00:00.000", "description": "Report", "row_id": 1339361, "text": "npn\nneuro: pt continues to be non-responsive, fent at 200mcg from 250 and versed remains at 5mg/hr, perrla at 3mm, no movement noted. nor is pt overbreathing vent\n\npain: pt on multlple sedation gtts\n\ncad hr 100 to 90's sr to st with no ectopy noted. abp range 92/52 to 103/55 with levophed titrated down to .17mcg. with maps remaining in the 60's. vasopressin cotn at 2.4.\n\nresp: vent settings unchanged ACx50%fio2x26x500xpeep5. am abg 7.47/32/82, ls coarse thru out, sats mid 90's\n\ngi: + ascites, bs+ , ngt cont at ilws with bilious drainage with approx. 200cc rectal tube patent drainage liquid brown stool with 275cc out.\n\ngu: uo 40 to 80cc/hr pt 1200 + at 12mn, am K+ 3.1 being repleted with iv kcl, mag 2.1, lactic acid 4.7,\n\nendo: bs > 150 needing ssi\n\nid afebrile, lactic 4.7, continues on antibiotic,\n\nsocial: family meeting with Dr. , pt made DNR.\n\nplan: continue current level of care, ? making pt if no improvement over next 24 hours. cont. to moniotr vs, labs, and replete lytes.\n" }, { "category": "Nursing/other", "chartdate": "2181-06-19 00:00:00.000", "description": "Report", "row_id": 1339362, "text": "Resp Care\nPt remains intubated on A/C. Dropped RR from 26 to 20. Family still undecided on whether to change Pt's code status. No other changes noted.\n" }, { "category": "Nursing/other", "chartdate": "2181-06-21 00:00:00.000", "description": "Report", "row_id": 1339369, "text": "NPN 0700-1900:\nNeuro: Pt is unresponsive to any stimuli, not moving any extremity, pupils dilated, reactive to light, gag and cough reflex impaired, OFF sedation.\n\nResp: Intubated on mechanical ventilator CPAP with PS 5 PEEP 5, suctioned with excessive loose tan secretions, LS coarse all through, RR 19-26, SPO2 99-100%.\n\nCV: ST HR 102-130, BP 95-138/64-92, with RIJ (Presep. cath dressing changed today), Rt radial A-line, and 2 periphgeral IV lines, peripheral pulses difficult to palpate, bilateral LE edema, on antibiotics (Vancomycin and Zosyn), OFF levophed, on Vasopressin at 2.4 units/hr, CVP 12-16.\n\nGI/GU: With Rt nare NG tube in place, TF Nepro was at goal 30 ml/hr, yet it's stopped due to possible extubation today, abdomen softly distended with ascites, receiving Lactulose for possible hepatic encephalopathy, with a mushroom catheter drained brownish liquid stool, with Foley cath draining icteric color sedimentary u/o 60-80 ml/hr, FS was 169 received 2 units of R insulin.\n\nInteg: With bilateral lower extremities edema, on universal precaution, skin warm and dry, T max 99.4.\n\nSocial: No contact from family today.\n\nPlan: Continue antibiotics and steroids, monitor BP and consider stopping vasopressin, monitor FS and give regular insulin as per sliding scale, consider extubation, pulmonary toilet, ? CT scan of brain in future. Attending Physician will talk to the family about the unresponsiveness and that nothing else could be offered for pt.\n" }, { "category": "Nursing/other", "chartdate": "2181-06-21 00:00:00.000", "description": "Report", "row_id": 1339370, "text": "Respiratory Care\n\n Pt continues on CPAP/PSV 5/5 in NARD. No changes today. Will continue to follow closely.\n" }, { "category": "Nursing/other", "chartdate": "2181-06-21 00:00:00.000", "description": "Report", "row_id": 1339371, "text": "Addendum to NPN:\nPt is gasping and tachypneac and tacycardiac, Doctors informed that he's not ready for extubation and he's still completely unresponsive, recommended to keep TF withheld until they talk to the family.\n" }, { "category": "Nursing/other", "chartdate": "2181-06-21 00:00:00.000", "description": "Report", "row_id": 1339372, "text": "NPN 1900-2305\nPt found to bldg profusely from CVL line and mouth at , pink pad at head and back soaked, MAP's in 40's, HO notified, family called by , RN continued to provide supportive care, labs drawn, Vasopressin started, given 7L NS flds IV total, 1unit PRBC's and 1 unit plasma. Pt continued to bld. from CVL line and mouth, at 2200 began to bld. from nares, site appeared to be pulsating, sx'd total of 1.4L of hemoptysis. At 2250 Attending notified family of pt.'s worsened condition, pt made . At 2300 Levophed, Vasopressin, and fld. boluses turned off, pt extubated, gasped 1 air of breath and no further respirations, ABP down to 40's at this time. At 2305 pt expired, verified by HO and Telemetry. Family notified by HO.\n" }, { "category": "Nursing/other", "chartdate": "2181-06-17 00:00:00.000", "description": "Report", "row_id": 1339352, "text": "Admission and NPN 01-0700:\nThis is a 54 yo male pt with a hx of HCV, hepatocellular CA, cirrhosis, etho, who has been living in a nursing home transitioning to hospice. Plan was for pt to go back to where he would likely die soon. Instructions were that he wanted to remain full code in hopes that he would be able to make it back to . Yesterday, pt was noted to have MS changes and was sent to ED. On arrival he was noted to be hypotensive SBP 60s, given NS boluses and started on Levophed drip. Lactate was 10.6, EKG showed peaked T wave and K was 6.8. An NG tube was placed and was given Kayexalate; coffee ground material was aspirated. Given IV vancomycin, Flagyl, Levofloxacin, Albumin, and Protonix. LFTs were c/w cholangitis and RUQ US showed no significant changes from prior exam. Surgery was consulted and felt that pt is not a surgical candidate given comorbidities and overall prognosis. This was communicated to pt's friends who accompanied him in the , but they felt uncomfortable changing his code status. His brother is flying to from and the wish was expressed that the pt be supported fully, including intubation if necessary, until his brother arrives today (). CXR showed pulmonary edema, a presept catheter was inserted in ED and started on sepsis protocol, transferred to to continue sepsis protocol and intubate if needed.\n\nROS:\nNeuro: Pt is lethargic, answers questions intermittently with an unclear speech, oriented to name and place (names ), R/O hepatic encephalitis started on Lactulose,\nc/o abdominal pain given Morphine sulfate 2 mg IV. RUQ US preliminary showed portal vein thrombosis, rt lobe liver lesions consistent with HC, minimal amount of ascites, gallbladder thickening with no evidence of acute cholecystitis.\n\nResp: Breathing regularly on NC 4 L/min, at times desats to 88% reminded to take deep breaths goes up to 94-95%, RR 20-26, LS coarse all through, CXR showed multifical pneumonia/asymmetric pulmonary edema.\n\nCV: ST HR 105-115, BP 97-114/43-56, with presep cath and 2 peripheral IV lines, on Levophed at 0.15 mcg/kg/min, with edema all over especially extremities and ascites, on Vancomycin, Flagyl and Zosyn, bld tests revealed Hct 35, WBC 9.6, Lactate 6.2, INR 2.1 given vit. K.\nEKG done in ICU, CVP 12-14, SVO2 80-84, sepsis protocol continued.\n\nGI/GU: With NGT in place, to be kept NPO (except for meds) for possible intubation. Abdomen softly distended with ascites, with Foley cath drained 100-140 ml/hr clear yellowish u/o.\n\nInteg: With jaundice, icteric eyes, edema all over, peripheral pulses weak.\n\nSocial:No contacts from family/friends during the night.\n\nPlan: Minitor BP and continue Levophed to maintain MAP above 60, monitor CVP and bolus with 500 ml NS if less than 12, monitor for worsening of pulmonary edema, repeat CXR, continue sepsis protocol, monitor lytes especially K and replete accordingly (or give Kayexalate if K is high), Keep NPO except for meds for possible intubation if needed.\n" }, { "category": "Nursing/other", "chartdate": "2181-06-17 00:00:00.000", "description": "Report", "row_id": 1339353, "text": "Respiratory Care Note\nPt intubated for impending respiratory failure with #7.5ETT and taped at 23 at lip. ETCO2 color change to yellow. BS coarse equal. Pt suctioned for moderate to copious amts thick, brown secretions. Sputum specimen sent to lab. Pt placed on AC as noted. FiO2 weaned according to ABG's. Pt desatted to 89% - pt suctioned for frothy, bloody secretions. PEEP and Fio2 increased accordingly with sats of 91-93%. Plan to continue on current settings - adjust settings according to ABG's.\n" }, { "category": "Nursing/other", "chartdate": "2181-06-17 00:00:00.000", "description": "Report", "row_id": 1339354, "text": " nsg note: 7:00-19:00\nthis is a 54 y.o. male pt from his nsg home to ed with change in mental status, with pmh hep c, ascites, hepatocelluar carcinoma. presented with increased jaundice, hypotension, abd pain, hyperkalemia. given morphine for pain, kayexalate, bicarb, calcium gluconate in er. initial lactate 10.6, presep cath was inserted and started on sepsis protocol. started on levoquin, vanco, and flagyl. initial temp 34.2. was on bair hugger. temp nl currently 98.8 ax and has been off bair hugger this shift. hypotension tx'd with levophed and pt had received 4.5 liters ivf in er.\n\nsig events this shift: pt remains full code until brother comes in to visit pt this eve or tomorrow. brother cell phone #: (. he is flying in from . and another contact person is a close friend who visited pt today. pt's pain increasing not responding to several doses of iv morphine given (see care vue), becoming more acidotic, requiring intubation at 12:55pm. sedated with fentanyl and versed but asynchronous with vent requiring increased fentanyl and versed doses. became hypotensive shortly after intubated and started on vasopressin and given total of 800cc d5w with 150meq na bicarb until cvp up to 18, desating to 88% on 50% fi02 and suctioned for lg amt thick frothy blood tinged sputum. fi02 increased to 70%, peep up to 12 and sedation increased sec. to desynchronous with vent. last abg: 7.25/42/86.\n\nneuro: sedated currently on 300mcg fentanyl and versed 5mg/hr but remains desynchronous with vent. not following commands. no spontaneous movement presently.\n\ncv: hr ranging 100s-130s st with no ectopy. bp ranging 80s-140s/40s-50s. levophed currently at .3mcg/kg/min. neo gtt started at .5mcg/kg/min. hr up to 130s. levophed titrated down to .25mcg/kg/min at 7pm and neo increased to 1 mcg/kg/min. cvp currently 18 but pt on 12 peep. + pedal edema. vasopressin also infusing at 2.4u/hr. lactate trending up to 7.2 (was 5.8). am troponin .05. ordered for pm troponin, ck, mb. pt received 2 units ffp for inr of 2.5. also received 5mg vitamin k po last noc. ionized ca .7. received 4gm calcium gluconate.\n\nresp: intubated currently on 100% fi02 since desating at 6:45pm with no sputum produced after suctioned. tidal volume 500. rr 18, 12 peep. suctioned earlier for lg amt thick blood tinged purulent secretions. sent for cx. sp02 currrently 94%.-98%.\n\ngi/gu: abd with + ascites, +bs, remains npo. was given 1 dose lactulose in am for sm amt and very lg amt light brown ob + stool. rectal tube inserted. ngt placed to suction after intubated draining small amt bilious material. foley patent draining 30+cc/hr.\n\nskin: warm, dry, intact.\n\nlines: r presep tlcl and rlp and llp #18g piv patent.\n\nplan: continue to titrate sedation to have pt more synchronous with vent. titrate levophed and neo to keep map 65 or >. monitor lactate q4hrs, 8pm cbc, chem10, cardiac enzymes, and pt. Awaiting brother's visit tonight or tomorrow to ? make cmo. pt rem\n" }, { "category": "Nursing/other", "chartdate": "2181-06-17 00:00:00.000", "description": "Report", "row_id": 1339355, "text": " nsg note: 7:00-19:00\n(Continued)\nains full code. continue ivabx. maintain npo.\n" }, { "category": "Nursing/other", "chartdate": "2181-06-18 00:00:00.000", "description": "Report", "row_id": 1339356, "text": "54 yr old male HX of HVC heptaocellluar CA cirrhois living in Nsg home transitioning to hospice pt wanted to return to to spend final days He was to remain full code so that he may hopefully return there. Pt was then admitted to ED with sepsis protocol Lactate was 10.6 hypotensive in 60's. Awaiting arrival of brother and continuing with full aggressive treatments until his arrival.\n\nNeuro came to ED with M/S current paralazed/ cisaturcurium @ 0.10 started at 0.06 with TOF of 4 twitches Pt has been unpresposive since start of shift Cisatracurium started at 2300. Fentanyl A2 300/mcg/kg and Versed @ 6mg/hr.\n\nCV pt has been hypotensive remains on on levo current @ 0.12 vasopressin 2.4mg neo 4.3 mcg/kg B/p is currently stable with map's above 60 but have to titrate levophed up and down at times. Hr was tachy but has remained stable low 100's. Pt is edematous throughout Has rec'd fluid bolus 1L 2 units FFP and 1000cc soduim bicarb this shift CVP varies from Lactate @ 7.8 has been rising TMax 99.8\n\nResp pt with Pulmonary edema very acidiotic with gases at 7.29/47/168/24 possible ARDS, PNA current vent setting 50 % fio2/500/28/10 peep pt had been on 100FIO2 before being paralazed and was over breathing vent. O2 sATS WERE DROPPING. CURENTLY 96% . Breath sounds are very coasrse throughout Sx for white frothy secretions with bright red blood Flagyl nd Zosyn q 8 hrs\n\nGI/GU ARF abd distended U/O adequate amber and clear Bun and creatinine both elevated Bun 73 Creat above 2 (see carevue) Pt with possible GI bleed previous coffee ground aspirate possible worsening of esophagitis and varices.\n\nsocial pt has sister who lives in no children nenver been married, brother should be arriving this AM\n\n\n" }, { "category": "Nursing/other", "chartdate": "2181-06-18 00:00:00.000", "description": "Report", "row_id": 1339357, "text": "Resp Care\nPt intubated, septic, on maximal vent. support. ABGs with met. acidosis. Suctioning pulm edema.Plan is to continue with support.\n" }, { "category": "Nursing/other", "chartdate": "2181-06-18 00:00:00.000", "description": "Report", "row_id": 1339358, "text": "Shift Note: 0700-1900\nNeuro: Received pt paralyzed on cisatracurium w/ TOF 4/4 L facial twitch and breathing over vent by 1-2 breaths. Cisatracurium titrated up, though has since been D/C'd. Continues on Fentanyl and Versed gtt currently with Fentanyl at 300mcg/hr and Versed at 7mg/hr. Pt remains unresponsive, no longer breathing over vent, and not currently withdrawing from nail bed pressure. Will titrated sedation. See careview. PERRLA. L pupil sluggish, R brisk.\n\nCV: Received on tripple pressors, Neo weaned off at 1400. Pt continues on Levo at 0.3mcg/kg/hr and Vassopressin at 2.4units/hr. BP 88/50 - low 100's/60's with MAP's >60. Presep cath in place. Svo2 78-80%. CVP 14-18. HR low 100's, NSR-ST.\n\nID: Low grade temp. Tmax 100.1. Pt continues on IV vanco, flagyl and zosyn as ordered. Lactate has been trending down though last result 4.9 up from 4.7. Will recheck lactate with next ABG.\n\nResp: Intubated and Vented currently AC 500/5 X26 FiO2 50%. Pox 95-98%. BBS CTA, bronchial t/o. Last ABG 7.49/32/84/25 at rate of 28. Will recheck ABG on current settings.\n\nFEN: Remains NPO, abd. Soft-distended. BS absent. NGT to intermittent low wall snx. 100ml thick brown fluid out. 250ml brown liquid stool out. Hct stable at 30.1. Gums oozing sm. amount brb, otherwise no s/s active bleeding. Fluid status +9.3L LOS. UOP 40-100ml/hr.\n\nSocial: Per report 54yr gentleman to MICU from nursing home, pt w/heptocellular ca. Was in the process of transitioning to hospice care prior to admit. Currently pt is full code as pt was hoping to go home to to see his mother one more time, and was not planning ot discuss his health status as per cultural tradition r/t elderly family member. brother has been at bedside t/o shift. Brother reports discussing pt status and prognosis with MD and seems to be leaning towards CMO direction. Discussing end of life issues with this RN. Currently awaiting sister from out of state who brother has gone to pick up at airport.\n\nPlan: Continue current care. Pt remains full code at this time. Team to discuss goals with family once sister present.\n" }, { "category": "Nursing/other", "chartdate": "2181-06-20 00:00:00.000", "description": "Report", "row_id": 1339365, "text": "RESPIRATORY CARE NOTE\n\nPt remains intubated and fully ventilated on AC settings. No vent changes made during the noc. No ABG drawn. Last ABG @ 1600 showed adequate ventilation and oxygenation. BLBS are coarse at times. Sxn for thick tan secretions.\n\n , RRT\n" }, { "category": "Nursing/other", "chartdate": "2181-06-20 00:00:00.000", "description": "Report", "row_id": 1339366, "text": "Micu/SICU NPN HD #5\nEvents: sedation turned off, pt changed to PSV\n\nS/O:\n\nNeuro: pt is unresponsive to all stimuli, fent/midaz stopped at 10A, no independent movement of extremities\n\nPulm: remains intubated on PSV 15+5/0.5, SRR 12-24, Vt 300's, LS rales on left, right side is coarse and dim at base, suctioned x2 for thick bloody sputum\n\nCV:Levophed and vasopressin, Levo weaned to maintain MAP > 60, SR 80's-90's, please see flowsheet for data\n\nGI/GU: palpable abdominal ascites, tolerating Nepro at goal rate of 30cc/h, brown liqud stool per mushroom cath, Foley draining sm amts icteric urine with visible sediment\n\nAccess: right IJ Presep cath da #5, right radial art line day #5\n\nA:\n\naltered breathing r/t volume overload\nhigh risk fo rinfection r/t invasive lines, indwelling cath\n\nP:\n\ncontineu to montor hemodynamic/respiratory status, continue to wean resp suppot as toleated, wean pressors as tolerated, family meeting to discuss plan of care and treatment goals\n" }, { "category": "Nursing/other", "chartdate": "2181-06-21 00:00:00.000", "description": "Report", "row_id": 1339367, "text": "54 yr old male heptacelluar CA cirrhois, admitted with sepsis,(see previous notes) current;y on pressure support pt is DNR\n\nNeuro pt unresponsive since beginning of shift (verbal or motor) does not withdraw extremities to nail bed stimulus etc. Pt has not been sedated since previous shift.\n\nCV continues on pressors. Levo @0.05 titrated down to 0.03 for several hr. Pt dropping B/P with map in high 50's Increased levo to 0.04 and pt map currently at 61. IV access pre- IJ Aline and peripheral IV in right forearm compression boots on lower ext. COntinues on vasopressin @2.4/ Pt has been made DNR but family did not wish to withdraw life support at this time.\n\n\n Resp Pt on pressure support at 12 FIO@ 50/ 18 bpm. Sx for thick bloody secretions. ALso liquid bloody secretions from oral cavity sx by yanker. Breath sounds are coarse bilaterally o2 sats remain stable at 95%\n\nGI/GU visible ascities in abdominal area. TF @ 30 with residuals in50-60's/ Voiding brown urine with sediment about 30cc /hr. Rectal bag draining brown/liquid stool.\n\nSkin remains intact. No calls or visits from family this shift\nContinue to wean vent setting and pressors as tolerated\n" }, { "category": "Nursing/other", "chartdate": "2181-06-21 00:00:00.000", "description": "Report", "row_id": 1339368, "text": "Resp. Care\nRemained intubated and ventilated on psv with no remarkable changes overnight. RSBI = 72. Weaned down to cpap/psv 5/5 50%/\n" }, { "category": "Nursing/other", "chartdate": "2181-06-19 00:00:00.000", "description": "Report", "row_id": 1339363, "text": "Shift Note: 0700-1900\nNeuro: Pt remains unresponsive. Received on Fentanyl 200mcg/hr and versed 5mg/hr, weaned to fentanyl 150mcg/hr and versed 3mg/hr. Pt appeared uncomfortable with ET position change today, coughing and RR 30. PERRLA. Does not withdraw from nail bed pressure to Bilat U/L extremities.\n\nCV: HR 90's, SR. Continues on Levo and vasopressin. Levo weaned to .135mcg/kg/min. BP 89/49 to low 100's/50's with MAP 62-70. CVP 15-16. UOP down today from yesterday, averaging ~25-40ml/hr. Currently receiving fluid bolus 250ml NS for UOP 15ml.\n\nResp: Remains intub. and on vent currently at AC 500/5 X20 FiO2 50%. ABG on these settings 7.45/38/71/27. ET noted to be at 20cm this am. Advanced by RT as ordered to 23cm during which pt appeared uncomfortable with coughing as above. RR to 30, otherwise pt has not been noted to breath over set rate this shift. No secretions with snx this am, though snx with lavage by RT with ET tube position change resulted in copius thick bloody secretions as pt was having yesterday. Now snx for sm. amount thick bloody secretions.\n\nFEN: Started on TF nepro at 1500 at 10ml/hr. to advance to goal 30ml/hr as ordered. Hct stabloe at 29.4. K 3.5 repleated with 40mEq KCL IV and 40mEq PO. Repeat KCL 4.7. Fluid status +10.3L LOS.\n\nSocial: Family present at bedside this am until noon time. Many visitors in today. S/P family meeting yesterday pt is DNR. Per report, another family meeting is planned to discuss goals/plan.\n\nPlan: Continue to wean pressors and sedation as able. Monitor MS closely. Monitor fluid status and UOP closely. Continue with present level of care.\n" }, { "category": "Nursing/other", "chartdate": "2181-06-20 00:00:00.000", "description": "Report", "row_id": 1339364, "text": "npn\npt remains unrespoive, fent decreased to 50 mcg and versed to 2mg.\n\nneuro: unresponsive, fent to 50 mcg and versed to 2mg /hr, perrla at 3mm no chage.\n\npain: remains sedated on gtts\n\ncad hr sr 90's no ectopy noted abp range 102/58 to 88/54 with maps in the 60's levophed gtt at .08 and vaspressin remains at 2.4.\n\nresp no vent changes made acx50% fio2 tv 500 rr 20 peep5, ls coarse thru out. suctioned for old blood tinged secretions, small amt of oral secretions , sat mid 90's overbreathing occasionally esp after turning.\n\ngi: ascites, bs+ tf advanced to 20cc/hrrectal tube patent for clearish brown stool,\n\ngu: uo 20cc/hr pt 10 l for los, am K+ 4.6, mag 2.3 hct stable at 28.6\n\nendo: bs<150 no coverage ssi needed.\n\nid: temp max 99, cont on antibiotics.\n\nsocial: multiple family members visiting on eves.\n\nplan: continue current poc, pcp to be by md's today for further discussion with over all prognosis, cont to wean levophed as tolerated, monitor fluid status, lytes prn\n\n\n" }, { "category": "ECG", "chartdate": "2181-06-18 00:00:00.000", "description": "Report", "row_id": 308101, "text": "Reversed L-R arm lead\nSinus tachycardia\nEarly precordial QRS transition\nConsider left ventricular hypertrophy\nModest nonspecific ST-T wave changes\nSince previous tracing of , L-R arm lkead reversed and ST-T wave\nabnormalities decreased\n\n" }, { "category": "ECG", "chartdate": "2181-06-17 00:00:00.000", "description": "Report", "row_id": 308102, "text": "Sinus tachycardia\nEarly precordial QRS transition\nConsider left ventricular hypertrophy\nDiffuse ST-T wave abnormalities with prolonged Q-Tc interval - clinical\ncorrelation is suggested for posasible in part ischemia and/or\ndrug/metabolic/electrolyte effect\nSince previous tracing of , ST-T wave changes appear less prominent\n\n" }, { "category": "ECG", "chartdate": "2181-06-16 00:00:00.000", "description": "Report", "row_id": 308103, "text": "Baseline artifact makes proper interpretation difficult. Probable sinus\ntachycardia. Early transition with anteroseptal ST segment depression -\nconsider ischemia. Since the previous tracing anterior ST segment depressions\nare new.\n\n" }, { "category": "Radiology", "chartdate": "2181-06-18 00:00:00.000", "description": "LP UNILAT LOWER EXT VEINS LEFT PORT", "row_id": 911940, "text": " 9:47 AM\n UNILAT LOWER EXT VEINS LEFT PORT Clip # \n Reason: LLE SWELLING\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 54 year old man with unilateral leg edema\n REASON FOR THIS EXAMINATION:\n ? DVT\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 54-year-old male with left leg edema.\n\n TECHNIQUE: Grayscale and color Doppler ultrasound of the left lower\n extremity.\n\n COMPARISON: Ultrasound dated .\n\n FINDINGS: Normal flow, compressibility, and augmentation are seen in left\n common femoral, superficial femoral, and popliteal veins. No evidence of DVT.\n\n IMPRESSION: No evidence of DVT.\n\n\n" }, { "category": "Radiology", "chartdate": "2181-06-17 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 911872, "text": " 1:05 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: ? ETT placement\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 54 year old man with sepsis, cirrhosis, and now s/p intubation.\n REASON FOR THIS EXAMINATION:\n ? ETT placement\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST ON AT 12:12\n\n INDICATION: Sepsis and ETT placement.\n\n COMPARISON: at 05:27.\n\n The tip of the ETT is appropriately located at 3.8 cm above the carina.\n Compared to the prior study there is some increased patchiness at the lower\n lungs zones bilaterally suggesting worsening in fluid status. Tip of the\n right CVL remains in place and there is no PTX.\n\n IMPRESSION: Appropriately located ETT; some worsening of airspace findings\n bilaterally in the lower lung zones - fluid overload likely - follow-up\n recommended to assess for further change.\n\n" }, { "category": "Radiology", "chartdate": "2181-06-19 00:00:00.000", "description": "US ABD LIMIT, SINGLE ORGAN", "row_id": 912076, "text": " 10:58 AM\n US ABD LIMIT, SINGLE ORGAN Clip # \n Reason: evaluate for worsening portal vein thrombosis. PLEASE ASSESS\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 54 year old man with hep C, intubated with worsening Tbili and INR,\n ?worsening portal vein thrombosis\n REASON FOR THIS EXAMINATION:\n evaluate for worsening portal vein thrombosis. PLEASE ASSESS WITH DOPPLERS.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 54-year-old male with worsening portal vein thrombosis.\n\n TECHNIQUE: Transabdominal ultrasound with portal vein Doppler.\n\n COMPARISON: Abdominal ultrasound dated .\n\n FINDINGS: Again note is made of thrombosis of main, right, and left portal\n vein, with echogenic material within the veins with arterial flow,\n representing tumor thrombus in this patient with hepatitis C and large tumor\n in the right lobe of the liver. Again note is made of heterogeneous\n echogenicity of the liver, with a large mass in the right lobe. The\n evaluation of abdominal organs is somewhat limited in this intubated patient.\n Note is made of flow in the splenic vein and SMV. Pancreatic head is\n unremarkable. Again note is made of gallbladder edema, measuring 8 mm,\n overall unchanged compared to the prior study. Again note is made of small\n amount of ascites.\n\n IMPRESSION:\n 1. Persistent extensive portal venous thrombosis involving main, right and\n left portal veins with tumor thrombus with arterial flow, extending from a\n large heterogeneous right hepatic mass. Underlying echogenic liver in this\n patient with hepatitis C.\n 2. Small amount of ascites.\n 3. Unchanged appearance of gallbladder edema.\n\n Please note the evaluation of abdominal organs was somewhat limited in this\n patient with intubation.\n\n" }, { "category": "Radiology", "chartdate": "2181-06-20 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 912295, "text": " 1:57 PM\n CHEST (PORTABLE AP) Clip # \n Reason: please assess for change in pulmonary infiltrate\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 54 year old man with sepsis, cirrhosis, and resp failure req intubation\n\n REASON FOR THIS EXAMINATION:\n please assess for change in pulmonary infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 54-year-old, septic, assess pulmonary infiltrates.\n\n Portable supine frontal radiograph compared to several studies dating back to\n , most recently .\n\n The endotracheal tube has been advanced and now terminates several centimeters\n above the carina in satisfactory position. There is minimal improvement in\n multifocal pulmonary opacities in the right lung. The left lung appears\n unchanged. Cardiac contours are somewhat difficult to assess but are\n unchanged. Right IJ central venous catheter and NG tube are stable.\n\n" }, { "category": "Radiology", "chartdate": "2181-06-16 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 911813, "text": " 7:57 PM\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \n Reason: confirm line placement\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 54 year old man with tachypnea (now on non-rebreather) and interval increase\n in ascites. Concern for fluid overload.\n\n REASON FOR THIS EXAMINATION:\n confirm line placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Tachypnea and a concern for fluid overload, confirm new line\n placement.\n\n COMPARISON: at 19:02 p.m.\n\n FINDINGS: In the one hour interval, a right internal jugular central venous\n catheter has been placed with the tip projecting over the cavoatrial junction.\n There is no evidence for pneumothorax. Opacification of both lungs appears to\n be worsening.\n\n IMPRESSION: Worsening bilateral opacification with new central venous line\n provjecting over cavoatrial junction.\n\n" }, { "category": "Radiology", "chartdate": "2181-06-16 00:00:00.000", "description": "P LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT", "row_id": 911811, "text": " 7:45 PM\n LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT Clip # \n Reason: eval for flow and possible tap site for eval of SBP\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 54 year old man with hep C, increasing abdominal pain and distention.\n\n REASON FOR THIS EXAMINATION:\n eval for flow and possible tap site for eval of SBP\n ______________________________________________________________________________\n WET READ: JWK SUN 1:36 AM\n 1. Portal vein thrombosis with apparent cavernous transformation. Unchanged\n compared to prior examination of .\n\n 2. Heterogeneous right liver lobe lesions consistent with HCC.\n\n 3. Minimal amount of ascites.\n\n 4. Gallbladder wall thickening with no evidence of acute cholecystitis.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 54-year-old man with hepatitis C and increasing abdominal pain\n and distention. Evaluate for flow and possible tap of ascites for SBP.\n\n COMPARISON: .\n\n RIGHT UPPER QUADRANT ULTRASOUND: The liver is nodular and cirrhotic. An\n echogenic region in the liver extending from the capsule and involving much of\n the right lobe of the liver is consistent with the patient's known history of\n hepatocellular carcinoma. There is thrombosis of the portal vein with\n apparent cavernous transformation, which was seen on the prior examination.\n There is gallbladder wall thickening measuring 7 mm. Scant amount of\n perihepatic as well as right lower quadrant ascites.\n\n IMPRESSION:\n 1. Portal vein thrombosis with findings suggestive of cavernous\n transformation. This is unchanged compared to the prior ultrasound of , .\n 2. Diffusely echogenic and nodular liver with extensive area of echogenicity\n in the right lobe consistent with the patient's history of hepatocellular\n carcinoma.\n 3. Gallbladder wall edema. The differential diagnosis includes inflammation,\n cirrhosis, hypoalbuminemia, and right-sided congestive heart failure.\n 4. Too small amount of ascites for tap.\n\n\n" }, { "category": "Radiology", "chartdate": "2181-06-16 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 911808, "text": " 6:49 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for infiltrate, effusion\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 54 year old man with tachypnea (now on non-rebreather) and interval increase\n in ascites. Concern for fluid overload.\n\n REASON FOR THIS EXAMINATION:\n eval for infiltrate, effusion\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Tachypnea and increase in ascites.\n\n COMPARISON: .\n\n FINDINGS: There are multiple new ill-defined patchy opacities throughout both\n lungs, perihilar haze, and an effaced right diaphragmatic border. This is\n secondary to multifocal pneumonia, asymmetric pulmonary edema, or combination.\n A small right pleural effusion is also present. The cardiac size continues to\n be normal, and the mediastinal contours are normal. An NG tube is located in\n the stomach.\n\n IMPRESSION: Multifocal pneumonia, asymmetric pulmonary edema, or combination.\n\n" }, { "category": "Radiology", "chartdate": "2181-06-19 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 912048, "text": " 5:53 AM\n CHEST (PORTABLE AP) Clip # \n Reason: volume status, ett placement\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 54 year old man with sepsis, cirrhosis, and resp failure req intubation\n REASON FOR THIS EXAMINATION:\n volume status, ett placement\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 5:38 A.M. ON .\n\n HISTORY: Sepsis, cirrhosis, respiratory failure.\n\n IMPRESSION: AP chest compared to and 14:\n\n Multifocal infection including nodules in the left lower lung _____ region of\n consolidation in the right upper lung and smaller regions at the bases has all\n progressed since . Distention of the stomach with air and fluid is\n improved. Right internal jugular line in standard placement. Tip of the\n endotracheal tube is more than 2 cm above the upper margin of the clavicles\n and nearly 7 cm from the carina, 3-4 cm too high. No pneumothorax. Heart\n normal size, midline.\n\n Dr. paged to report these findings.\n\n\n" }, { "category": "Radiology", "chartdate": "2181-06-17 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 911836, "text": " 6:04 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please eval for interval change\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 54 year old man with tachypnea (now on non-rebreather) and interval increase\n in ascites. Concern for fluid overload.\n\n REASON FOR THIS EXAMINATION:\n please eval for interval change\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST ON AT 05:27.\n\n INDICATION: Increased tachypnea and ascites. Check for fluid overload.\n\n COMPARISON: at 20:00.\n\n FINDINGS: Bilaterally there is better aeration of the lungs with less density\n in the right upper lung field and left upper and mid lung zones. The\n pulmonary vasculature still appears distended. Right CVL line and NGT remain\n in place. There is no PTX. There is likely right pleural fluid layering out\n which is more prominent than previous study.\n\n IMPRESSION:\n\n Improved aeration of the lungs with features of fluid overload and possible\n worsening right effusion.\n\n\n" } ]

[ { "category": "ECG", "chartdate": "2152-05-08 00:00:00.000", "description": "Report", "row_id": 170874, "text": "Atrial fibrillation with a rapid ventricular response. Prior anteroseptal\nmyocardial infarction. Non-specific ST-T wave abnormalities. Compared to the\nprevious tracing of the ventricular response has slowed. Otherwise, no\ndiagnostic interim change.\n\n" }, { "category": "ECG", "chartdate": "2152-05-08 00:00:00.000", "description": "Report", "row_id": 170875, "text": "Atrial fibrillation with a rapid ventricular response, average around 130 per\nminute. Minor right ventricular conduction delay. Prior anterior wall\nmyocardial infarction. Non-specific ST-T wave changes consistent with ischemia,\netc. Compared to the previous tracing of atrial fibrillation is now\nseen. Clinical correlation is suggested.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2152-05-07 00:00:00.000", "description": "Report", "row_id": 170876, "text": "Sinus rhythm. Probable left atrial abnormality. Possible prior anterior wall\nmyocardial infarction with biphasic T wave inversions in leads V4-V5 raising\nconsideration of evolving anterior ischemia. Compared to the previous tracing\nof the latter finding is new or more apparent. Clinical correlation is\nsuggested.\nTRACING #1\n\n" }, { "category": "Nursing/other", "chartdate": "2152-05-10 00:00:00.000", "description": "Report", "row_id": 1403329, "text": " 4 ICU nursing progress note:\n Sepsis: Afebrile..changed antibiotics to levofloxicin and dc' unyson.\nMRI not done d/t unavailability of enterpreteur. Now able to book enterpreteur for 10:30a tomorrow and do MRI. Grand-daughter aware.\n Cardiac: In/out af and nsr..rate as high as 120's..pt on/off bedpan. Increased lopressor. BP 120-140/60-70\n GI: No c/o pain or nausea..no pain meds required. Taking po liqs and tolerating well. Small amt liquid green stool. ??repeat ERCP on Friday.\n Endo: BS in good range. No insulin required.\n Respiratory: Room air..sats 97%\n Neuro: Difficult to communicated with d/t language barrier. Is alert and orientated. When shown..can follow visual commands. Wife in to visit.\n Socail: Spoke with grand-daughter ..updated on plan.\n Dispo: Pt awaiting bed on medical floor.\n" }, { "category": "Nursing/other", "chartdate": "2152-05-11 00:00:00.000", "description": "Report", "row_id": 1403330, "text": "NPN 1900-0300\n Alert, unable to determine orientation d/t language barrier, and no contact with family this shift, following visual commands. Awaiting MRI/MRCP today to eval liver mass and biliary blockage. ERCP on , specimen parasites at that time to determine speciation and then tx medically. Lungs CTA, RR 19-23, O2 sats 95-97% on RA, HR NSR-AFib 70-90's, BP's 138-147/50-60's, Tmax 98.6, cont. Levofloxacin IV, day#2 of 11 days for G- bcxs. FBS 117-157 tx with SSI, Urine with clots, foley cath remains intact. To floor today when bed available. Granddaughter to accompany pt to MRI/MRCP, she is the interpreter.\n" }, { "category": "Radiology", "chartdate": "2152-05-07 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 916468, "text": " 9:01 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Rule out parasitic lung involvement.\n Admitting Diagnosis: OBSTRUCTIVE JAUNDICE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old man with acute cholangitis, probable biliary parasitic infection, ?\n ascaaris.\n REASON FOR THIS EXAMINATION:\n Rule out parasitic lung involvement.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Acute cholangitis and probable biliary parasitic infection,\n evaluate for parasitic lung involvement.\n\n COMPARISON: .\n\n TECHNIQUE: Single AP portable upright chest.\n\n FINDINGS: The right chest wall is partially excluded from the radiograph.\n There is stable mild cardiomegaly. Since the examination of ,\n the left internal jugular venous access catheter has been removed and a small\n left pleural effusion and left lower lobe atelectasis appear improved.\n\n IMPRESSION:\n\n 1) Improved small left pleural effusion and left lower lobe atelectasis.\n\n 2) Portable chest x-ray is relatively insensitive for detection of\n ear;u changes of eosinophilic pneumonia or other manifestations of parasitic\n disease. If there is strong clinical suspicion for eosinophilic pneumonia,\n dedicated PA and lateral chest x-ray or CT of the chest is recommended.\n\n\n" }, { "category": "Radiology", "chartdate": "2152-05-13 00:00:00.000", "description": "ABDOMEN (SUPINE & ERECT)", "row_id": 917350, "text": " 1:39 PM\n ABDOMEN (SUPINE & ERECT) Clip # \n Reason: obstruction?\n Admitting Diagnosis: OBSTRUCTIVE JAUNDICE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old man with nausea vomiting, recent ERCP procedure with sphincterotomy\n REASON FOR THIS EXAMINATION:\n obstruction?\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Nausea and vomiting.\n\n Four portable radiographs of the abdomen are submitted.\n\n The small and large bowel are normal in caliber without evidence of\n obstruction. Air and stool are seen within the colon. Linear markings\n projecting over the right abdomen on the two supine projections likely\n represent processing artifact. No air fluid levels are evident on the left\n lateral decubitus view. No pneumoperitoneum is detected.\n\n Marked osseous deformity about the right hip joint is incompletely assessed.\n Marked degenerative change of the thoracal lumbar spine is also incompletely\n assessed.\n\n IMPRESSION:\n\n Nonobstructive bowel gas pattern. No pneumoperitoneum.\n\n\n" }, { "category": "Radiology", "chartdate": "2152-05-11 00:00:00.000", "description": "MRCP (MR ABD W&W/OC)", "row_id": 917050, "text": " 11:10 AM\n MRCP (MR ABD W&W/OC); MR CONTRAST GADOLIN Clip # \n MR 3D RENDERING W/POST PROCESSING ON INDEPENDENT WS\n Reason: Please eval liver for liver mass to r/o tumor, echinococcal\n Admitting Diagnosis: OBSTRUCTIVE JAUNDICE\n Contrast: MAGNEVIST Amt: 20\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old man with hx of previous CT abd with 4.8cm x3.2cm liver mass in L\n lobe in with U/S from OSH today that could not visualize mass. Pt now\n admitted with cholangitis and ? parasites in ERCP. Pt with CRF that precludes\n CT with contrast.\n REASON FOR THIS EXAMINATION:\n Please eval liver for liver mass to r/o tumor, echinococcal cyst, abscess\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: Previous abdominal CT with liver mass. Febrile with cholangitis\n and possible parasites in common bile duct on ERCP. Elevated creatinine.\n\n TECHNIQUE: Multiplanar T1- and T2-weighted imaging of the liver and biliary\n tree including thick slab SSFSE, 3D non-breath hold MRCP sequences, and pre-\n and dynamic post-gadolinium 3D T1 spoiled gradient echo sequences and\n subtraction sequences. Non-breath hold techniques were used.\n\n COMPARISON: Reference is made to an ERCP images from .\n\n MRI OF THE ABDOMEN WITHOUT AND WITH GADOLINIUM: There are multiple low signal\n intensity filling defects within the extrahepatic biliary ducts. Some may\n correspond to the filling defects seen on recent ERCP. Low signal intensity\n seen on T2-weighted images within the peripheral intrahepatic bile ducts could\n be due to air from prior ERCP. There are extensive, geographic areas of\n increased arterial enhancement throughout all liver lobes, with enhancement of\n the bile ducts. The majority of areas show focally dilated bile ducts in the\n vicinity. Several more nodular areas of arterial enhancement are also\n identified within the liver, most pronounced in the left lobe. These show\n corresponding areas of high T2 signal as well. The largest abnormal lesion is\n in the superior aspect of the left lobe of the liver (segment II) which\n measures approximately 1.5 cm. The lesion never demonstrates complete\n enhancement on delayed duct post- gadolinium sequences. Two large gallstones\n are present within the gallbladder. The pancreas is atrophic. The adrenal\n glands are unremarkable. The hepatic veins and portal vein are patent. There\n are small bilateral pleural effusions. Multiple bilateral renal cysts are\n present. One large cyst is present laterally within each kidney. These cysts\n demonstrate posteriorly layering T1 hyperintense and T2 hypointense material\n which could be blood products. The spleen is unremarkable.\n\n IMPRESSION:\n 1. Multiple filling defects within the extrahepatic biliary ducts. Findings\n could be due to air bubbles, blood clot, or parasites as described on recent\n ERCP.\n\n 2. Heterogeneous enhancement in liver consistent with cholangitis.\n (Over)\n\n 11:10 AM\n MRCP (MR ABD W&W/OC); MR CONTRAST GADOLIN Clip # \n MR 3D RENDERING W/POST PROCESSING ON INDEPENDENT WS\n Reason: Please eval liver for liver mass to r/o tumor, echinococcal\n Admitting Diagnosis: OBSTRUCTIVE JAUNDICE\n Contrast: MAGNEVIST Amt: 20\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n 3. 1.5-cm area of abnormal signal intensity in the superior aspect of left\n lobe of the liver (segment II). This could represent a biloma or a developing\n abscess. At this time, the collection is too small for percutaneous drainage.\n\n 4. Multiple rounded areas of T2 signal hyperintensity within the liver with\n corresponding arterial enhancement. Findings are difficult to assess given\n extensive perfusion anomalies associated with presumed cholangitis. Follow up\n after resolution of cholangitis is recommended to exclude arterial enhancing\n neoplasms such as hepatocellular carcinoma.\n\n 5. Multiple bilateral renal cysts, the largest of which bilaterally contain\n posteriorly layering components, likely hemorrhagic. Attention to these areas\n should be paid on future followup studies.\n\n 6. Two large gallstones within the gallbladder.\n\n Results were discussed with Dr. at 7:10 p.m. on .\n\n\n" }, { "category": "Radiology", "chartdate": "2152-05-07 00:00:00.000", "description": "ERCP BILIARY ONLY BY GI UNIT", "row_id": 916615, "text": " 4:39 PM\n ERCP BILIARY ONLY BY GI UNIT Clip # \n Reason: R/O CBD stones\n Admitting Diagnosis: OBSTRUCTIVE JAUNDICE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old man with elevated LFTs, fever and dilated CBD/cholelithiasis by abd\n u/s.\n ERCP performed \n REASON FOR THIS EXAMINATION:\n R/O CBD stones\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 78-year-old woman with elevated LFT, fever. Dilated CBD.\n\n ERCP: Fourteen ERCP images obtained by Dr. , and demonstrated mildly\n dilated biliary tree with mobile filling defects within extrahepatic ducts.\n Biliary stent placement was performed. Please also refer to the official\n report by endoscopist.\n\n" }, { "category": "Radiology", "chartdate": "2152-05-08 00:00:00.000", "description": "R KNEE( (SINGLE VIEW) RIGHT", "row_id": 916620, "text": " 5:04 PM\n KNEE( (SINGLE VIEW) RIGHT; FEMUR (AP & LAT) RIGHT Clip # \n TIB/FIB (AP & LAT) RIGHT PORT\n Reason: ?any metal in R leg\n Admitting Diagnosis: OBSTRUCTIVE JAUNDICE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old man with questionable hx of R leg surgery as child with possible\n metal rod placement\n REASON FOR THIS EXAMINATION:\n ?any metal in R leg\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Right leg surgery. Assess for metallic foreign body.\n\n Three radiographs of the right femur, knee, and leg are submitted. There is\n marked deformity of the proximal right femur. A retained metallic screw is\n seen in the region of the basicervical femoral neck. No discernable hip joint\n space is evident on the single view of the right hip. Calcified sutures and\n vascular calcifications are seen to project over the right thigh.\n\n Prominent degenerative change is seen to involve the medial and lateral\n compartments of the knee. There is evidence of an old lateral tibial plateau\n fracture.\n\n Limited assessment of the ankle joint is grossly unremarkable.\n\n\n" }, { "category": "Radiology", "chartdate": "2152-05-10 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 916898, "text": " 1:15 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Pna?\n Admitting Diagnosis: OBSTRUCTIVE JAUNDICE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old man with acute cholangitis, probable biliary parasitic infection,\n ? ascaaris.\n REASON FOR THIS EXAMINATION:\n Pna?\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Acute cholangitis, probable biliary parasitic infection, evaluate\n for pneumonia.\n\n COMPARISON: .\n\n TECHNIQUE: Single AP portable upright chest.\n\n FINDINGS: There is stable cardiomegaly and mild congestive heart failure.\n Left pleural effusion and atelectasis appear unchanged. No pneumothorax.\n\n IMPRESSION:\n 1. Cardiomegaly and mild CHF.\n 2. Left pleural effusion and atelectasis.\n\n\n" }, { "category": "Radiology", "chartdate": "2152-05-11 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 916985, "text": " 5:47 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Please assess for interval change\n Admitting Diagnosis: OBSTRUCTIVE JAUNDICE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old man with cough, ? LLL atelectasis versus pneumonia, effusion.\n REASON FOR THIS EXAMINATION:\n Please assess for interval change\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Cough, evaluation left lower lobe atelectasis.\n\n Portable AP chest radiograph compared to .\n\n The cardiomegaly is unchanged as well as mild congestive heart failure. Small\n left lower lobe consolidation could be due to atelectasis but infectious\n process cannot be excluded. A small left pleural effusion is stable.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2152-05-08 00:00:00.000", "description": "Report", "row_id": 1403322, "text": "NARRATIVE NOTE:\n\n78 YEAR OLD MALE WHO WAS ADM TO MICU AFTER ERCP. PLEASE SEE H&P. UNABLE TO OBTAIN INFORMATION FOR ADM H&P FROM PT AS HE IS SPEAKING ONLY AND NO FAMILY MEMBERS HAVE COME TO MICU WITH PT. INFORMATION OBTAINED WAS FROM CHART AND ERCP NURSE.\n\nCV: B/P HAS RANGED FROM 95/50-135/49. NSR WITH HR RANGING FROM 88-92,WITH NO ECTOPY OPTAINED. PT DID HAVE A SHORT EPISODE OF A-FIB, WITH HR 122-133. EKG WAS OBTAINED AND PT WAS GIVEN AM DOSE OF AMIODARONE EARLY AND WAS GIVEN LOPRESSOR 5MG IV WHICH WAS EFFECTIVE IN SLOWING THE RATE. PT CONVERTED BACK TO SR AFTER APPROX 1 HOUR. UNABLE TO DETERMINE IF PT HAD C/P. K+ AT 2100 WAS 3.6 AND WAS REPLEATED WITH 40MEQ PO, THIS AM K+ 3.9. MG+ THIS AM IS 1.6 AND WILL BE REPLEATED. HCT 34.\n\nNEURO: UNABLE TO DETERMINE ORIENTATION. PT HAS REMAINED ALERT AND EASILY AROUSABLE WITH VERBAL STIMULI. THE WORD FOR PAIN ?\"\". PT SMILED AND NODDED YES IN RESPONSE X2 AND WAS MED WITH MORPHINE 2 MG IV BOTH TIMES. PT WOULD RUB ABD BUT NOT IN ONE SPECIFIC LOCATION.\n\nRESP: PT HAS A LONG TERM HX OF SMOKING BUT QUIT 3 YEARS AGO. LUNGS CLEAR BUT DIM IN THE BASES. RR 19-25, NO DISTRESS NOTED. ABG'S DONE 7.42/35/86/23/0. SAO2 95-100% ON 2L N/C.\n\nGU: FOLEY CATH PATENT, PT DID PULL ON IT. URINE IN ADEQUATE AMTS AMBER IN COLOR BUT NOW WITH SOME CLOTS PRESENT. BASELINE CREAT IS 1.5, THIS AM HIS CREAT IS 1.8. IS GETTING NS AT 250/HR.\n\nGI: ABD IS SOFTLY DISTENDED WITH + BS. PT HAD A LG BM AFTER THE ERCP IN RECOVERY BUT ONLY PASSED A VERY SM AMT WHICH WAS SENT TO THE LAB FOR O+P. STILL NEED 2 MORE SPECIMENS. PT IS DRINKING WATER AND TAKING PO MEDS WITH NO DIFFICULTY.\n\nID: AT OSH PT RECIEVED UNASYN/CLINDA/GENT. PT NOW ON AMPICILLIN Q8HR IV. LACTIC ACID THIS AM IS 2 WHICH IS DOWN FROM 3.9.\n\nSOCIAL: PT IS AND HAD NO FAMILY PRESENT. HE IS MARRIED AND LIVES WITH HIS WIFE.\n\nPLAN: REPLETE LYTES. PT WILL PROBABLY BE CALLED OUT TO THE FLOOR TODAY\n" }, { "category": "Nursing/other", "chartdate": "2152-05-09 00:00:00.000", "description": "Report", "row_id": 1403325, "text": "MICU/SICU Nursing Progress Note (0700-1900)\n\nPlease see carevue for all objective data. Awaiting MRI, checklist has been sent. Will need interpreter while in MRI.\n\nCNS: Pt. is able to communicate with some translated phrases that family has prepared. He also seems to understand gestures, etc. According to grand-daughter, , pt.sometimes becomes confused, but is generally aware of what is going on re: diagnosis and plan of care.\n\nPAIN: Pt. did admit to abdominal pain this AM when questioned. Relieved with MSO4 2mg IVP x 1. He now denies pain per grand-daughter.\n\nCVS: In AFib with VR 110-120 for 60min this AM. B/P stable 120-140/syst. Lopressor 12.5mg po given and pt. later converted to NSR with rate in the 80's.\n\nRESP: Sats of 98% on 2lnc. Pt. did develop I and E wheezes with exertion today, treated with albuterol and atrovent nebs. Lungs now clear, decreased at the bases.\n" }, { "category": "Nursing/other", "chartdate": "2152-05-09 00:00:00.000", "description": "Report", "row_id": 1403326, "text": "NPN (cont'd)\n\nGI: Abdomen soft and distended with active bowel sounds. Tolerating clear liqs well...asking for food per grand-daughter. Pt. passing small amounts of liquid, brown, guiac+ stool x 2.\n\nID: T max of 99.7po. Remains on unasyn. Surveillance blood cultures x 2 done.\n\nF and E: Phosphate replaced. 560cc- fluid balance a this time...UOP approximately 100cc/hr.\n\nSOCIAL: Contact with grand-daughter x 2 today, updated on plan of care.\n\nPLAN: Awaiting MRI. ?repeat ERCP Friday.\n" }, { "category": "Nursing/other", "chartdate": "2152-05-09 00:00:00.000", "description": "Report", "row_id": 1403327, "text": "Resp Care\n\nPt followed by respiratory for bronchodilators Q6 PRN. BS slightly wheezy this morning with exertion which relieved with alb/atr nebs. BS essentially clear for the remainder of the shift. Pt tol tx well with stable HR t/o tx. Will cont to follow.\n" }, { "category": "Nursing/other", "chartdate": "2152-05-10 00:00:00.000", "description": "Report", "row_id": 1403328, "text": "NPN 1900-0300\n78 y/o male with hx of Cardiac stenting, MI, Afib, chronic L sided wknss., liver mass adm on with abd. pain and sepsis. ERCP revealed gallstones, and blockage of common bile duct with parasite also found. Also BC growing G- rods, tx'ing with unasyn. To have MRI/MRCP on to look at ?liver mass and biliary tree. To have repeat ERCP on Fri.\n\nNeuro: A&Ox3 according to granddaughte who is translator, responds adequately to gestures, no c/o pain this shift, SR up x 4.\n\nResp: Lungs CTA bilat., O2 at 2L NC, RR 18-22, SPO2 94-98%.\n\nCV: HR 88-108 NSR-AFIB, SR at start of shift, now back to stable Afib, BP's 123-146/50-70's, continues on Lopressor po, no c/o CP, no edema.\n\nID: Tmax 99.7, on Unasyn IV, to start praziquantel po in the am for parasites.\n\nEndo: FBS 123-125, no SSI required.\n\nGI: BS (+), abd softly distended, tolerating po flds, no bm this shift, to collect stool for O&P with next BM.\n\nGU: Foley cath intact draining pink/ urine with sediment in adequate amts.\n\nSkin: Light purple/dark purple hematoma to RU Arm.\n\nSocial: Granddaughter is translator.\n\nPlan: Continue to monitor VS, adm anti-helmintic when available this am, take pt to MRI/MRCP (MRI checklist already faxed to dept.), to ERCP on Fri.\n" }, { "category": "Nursing/other", "chartdate": "2152-05-08 00:00:00.000", "description": "Report", "row_id": 1403323, "text": "78 yr old pt with hx of CAD, liver mass NECROTIC, and renal insuf,\nadmitted to icu post ERCP. found paracites in bile duct and stent placed but parasites still in duct, pt is septic with gm neg rods in bc and has fever. will poss require to open bile dust spincter but needs to be off plavix and asa for 5-7 days pre .\n\nneuro: difficult to assess pt as speaks cantonesse and grand daughter interpreted most of day. no c/o pain. seems to answer all questions appropriatly. pt has sheets of common tems and questions written in and english for communication and is abble to read and answer. pt not very mobile since heart stent placed 4 yrs ago walks with walker or cane. rt leg has limited ROM d/ as teenager. xrayed rt leg to identify presecnce of metal for MRI.\n\ncard: stented 4yr ago. pt with inc WOB using abd muscles at end of expiration. hx afib and has had 2 episode first 1 lasting 1 hr and recerntly into afib with rate and tx with lasix, lopressor and stopped iv fluids but is still in and out of afib; ?? if started with temp spike as temp up to 101.4 with atart of af at 1315. no c/o pain or SOB with af but pt did have inc sob and wheezing wqith HOB down prior to lasix..800-1000cc off with lasix and ls cleared now\n\nresp: ra sat 92 and 98-99 with 2l nc ls as noted above\n\ngi: lg bm in ercp and smALL BM HERE SENT FOR O&P. TAKING LG AMTS CLEAR LIQUIDS\n\nGU: FOLEY IN PLACE AMBER URINE W/ LG AMT SLUDGE ?? BILIRUBIN, CULT SENT BALANCE POS 2000CC FROM MIDNIGHT\n\nLABS: INR ELEVATED AND PLATS DOWN, POSS DIC OR HIT. LABS SENT\n\nSKIN: SEVERAL ECHYMOTIC AREAS NOTED WITH BP CUFF AND IV SITES. LT BACK WITH LG BLACK RAISED LESOION. PT IS JAUNDICE NO BREAKDOWN\n\nTESTING: PT PLANNED FOR MRI WITH CONTRAST AND MRI EVAL SHEET INITIATED AND WILL VERIFY METAL IN RT PRIOR TO MRI\n\nSOCIAL: FAMILY INFORMED AND PHONES NEMBERS ON BOARD\n\nPLAN: PROB IN DAYS AND IV ANTIBX FOR SEPSIS, POSS\n\n\n\nREPLEATED MAG 0700\n" }, { "category": "Nursing/other", "chartdate": "2152-05-09 00:00:00.000", "description": "Report", "row_id": 1403324, "text": "Pt 78 y/o speaking male with a PMH of afib, cardiac stenting, MI, chronic L side weakness, liver mass. Admitted with abd pain. ERCP revealed gallstones and blockage of bile duct with what is probably a paracite. Stent was placed in duct but could not remive paracite. Pt will need surgery to rectify but had been on ASA and plavix at home and will need to be off these meds for 5 days prior to undergoing surgery.\n\nNeuro: Pt is alert, pleasant, and cooperative. Orientation difficult to assess language barrier, but pt seems fully aware of his surroundings. C/O pain 'tong' in abd tx with 2mg morphine sulfate with good relief. MAE, slept much of night.\n\nResp: Lung sounds clear in apices and coarse/crackle in bases. O2 sats high 90's on 2L O2 no c/o sob at all this shift.\n\nCardiac: SR with no episodes of afib this shift. No ectopy on monitor. B/P unremarkable with systolics largely 120's-130's.\n\nGI: tolerating clear liquids well. No bm this shift. Blood sugar unremarkable. Abd distended wit positive bowel sounds. C/O abd pain when asked but cannot quantify barrier. To get MRI of bile duct, liver today to assess mass.\n\nGU: Voiding yellow urine with sludge via foley. AM lytes pending. u/o approx 100cc/hr\n\nDerm: Slightly jaundiced, PIV x2 intact, peripheral pulses easily palpable. Large hematoma on R bicep unchanged from prior shift.\n\nID: Afebrile throughout shift. Continues on ivabx G- rods in blood from both bottles.\n\nHeme: HIT/DIC labs sent. Coags remain stable but elevated\n\nPlan: MRI of liver today, continue ivabx, hold asa and plavix, follow on DIC/HIT data, monitor for afib/rvr, to OR once coags wnl,\n" } ]

[ { "category": "Physician ", "chartdate": "2146-11-01 00:00:00.000", "description": "Physician Attending Admission Note - MICU", "row_id": 596343, "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 Patient admitted from: \n Allergies:\n Ciprofloxacin\n Rash; itching;\n Last dose of Antibiotics:\n Ampicillin/Sulbactam (Unasyn) - 08:49 PM\n Infusions:\n Other ICU medications:\n Hydromorphone (Dilaudid) - 08:25 PM\n Pantoprazole (Protonix) - 08:58 PM\n Metoprolol - 10:50 PM\n Other medications:\n Past medical history:\n Family history:\n Social History:\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other:\n Review of systems:\n Constitutional: No(t) Fever\n Cardiovascular: No(t) Chest pain\n Respiratory: No(t) Dyspnea\n Gastrointestinal: Abdominal pain\n Genitourinary: Foley\n Heme / Lymph: Anemia\n Psychiatric / Sleep: No(t) Agitated\n Pain: No pain / appears comfortable\n Flowsheet Data as of 11:56 PM\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\nC (98.6\n HR: 85 (85 - 111) bpm\n BP: 95/53(64) {95/53(64) - 157/75(97)} mmHg\n RR: 17 (15 - 21) insp/min\n SpO2: 94%\n Heart rhythm: AF (Atrial Fibrillation)\n Total In:\n 691 mL\n PO:\n TF:\n IVF:\n 691 mL\n Blood products:\n Total out:\n 0 mL\n 340 mL\n Urine:\n 340 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 351 mL\n Respiratory\n O2 Delivery Device: None\n SpO2: 94%\n ABG: ////\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 31.2 %\n [image002.jpg]\n 08:06 PM\n 08:54 PM\n Hct\n 31.2\n TropT\n <0.01\n Other labs: PT / PTT / INR:14.8/25.9/1.3, CK / CKMB /\n Troponin-T:51/3/<0.01\n Assessment and Plan\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines / Intubation:\n 20 Gauge - 11:18 PM\n Comments:\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: None)\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 32 minutes\n Patient is critically ill\n" }, { "category": "Physician ", "chartdate": "2146-11-02 00:00:00.000", "description": "Physician Attending Admission Note - MICU", "row_id": 596345, "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 76 yo woman transferred from OSH on for ERCP. Initially presented\n with abd pain and elevateed LFTs. CT showed gallstones. Underwent\n ERCP for suspected CBD stone --> unable to cannulate. At , had\n ERCP with sphincterotomy on , repeat on to extend\n sphincterotomy. Melena noted today\n went again to ERCP. Bleeding\n from sphincterotomy site cauterized, injected, and stented with control\n of bleeding transferred to for further management. Here, noted to\n have HR in 100-110 in afib. At that rate, had TWI and 1mm ST\n Patient admitted from: \n Allergies:\n Ciprofloxacin\n Rash; itching;\n Last dose of Antibiotics:\n Ampicillin/Sulbactam (Unasyn) - 08:49 PM\n Infusions:\n Other ICU medications:\n Hydromorphone (Dilaudid) - 08:25 PM\n Pantoprazole (Protonix) - 08:58 PM\n Metoprolol - 10:50 PM\n Other medications: per ICU resident note\n Past medical history:\n Family history:\n Social History:\n CHF\n Severe tricuspid regurgitation\n Atrial fib on coumadin\n Hypertension\n Aortic dissection s/p open heart surgery - patient states she had an\n aneursym which was repaired with plastic.\n Stroke (per OSH records)\n Per ICU resident note\n Occupation:\n Drugs:\n Tobacco: None\n Alcohol: None\n Other: per ICU resident note\n Review of systems:\n Constitutional: No(t) Fever\n Cardiovascular: No(t) Chest pain\n Respiratory: No(t) Dyspnea\n Gastrointestinal: Abdominal pain\n Genitourinary: Foley\n Heme / Lymph: Anemia\n Psychiatric / Sleep: No(t) Agitated\n Pain: No pain / appears comfortable\n Flowsheet Data as of 11:56 PM\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\nC (98.6\n HR: 85 (85 - 111) bpm\n BP: 95/53(64) {95/53(64) - 157/75(97)} mmHg\n RR: 17 (15 - 21) insp/min\n SpO2: 94%\n Heart rhythm: AF (Atrial Fibrillation)\n Total In:\n 691 mL\n PO:\n TF:\n IVF:\n 691 mL\n Blood products:\n Total out:\n 0 mL\n 340 mL\n Urine:\n 340 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 351 mL\n Respiratory\n O2 Delivery Device: None\n SpO2: 94%\n ABG: ////\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 31.2 %\n [image002.jpg]\n 08:06 PM\n 08:54 PM\n Hct\n 31.2\n TropT\n <0.01\n Other labs: PT / PTT / INR:14.8/25.9/1.3, CK / CKMB /\n Troponin-T:51/3/<0.01\n Assessment and Plan\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines / Intubation:\n 20 Gauge - 11:18 PM\n Comments:\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: None)\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 32 minutes\n Patient is critically ill\n" }, { "category": "Physician ", "chartdate": "2146-11-02 00:00:00.000", "description": "Physician Attending Admission Note - MICU", "row_id": 596352, "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 76 yo woman transferred from OSH on for ERCP. Initially presented\n with abd pain and elevateed LFTs. CT showed gallstones. Underwent\n ERCP for suspected CBD stone --> unable to cannulate. At , had\n ERCP with sphincterotomy on , repeat on to extend\n sphincterotomy. Melena noted today\n went again to ERCP. Bleeding\n from sphincterotomy site cauterized, injected, and stented with control\n of bleeding transferred to for further management. Here, noted to\n have HR in 100-110 in afib. At that rate, had TWI and 1mm ST\n depression in lateral precordial leads. After 5mg iv Lopressor, these\n returned to baseline. Pt herself denies any chest pain.\n Patient admitted from: \n Allergies:\n Ciprofloxacin\n Rash; itching;\n Last dose of Antibiotics:\n Ampicillin/Sulbactam (Unasyn) - 08:49 PM\n Infusions:\n Other ICU medications:\n Hydromorphone (Dilaudid) - 08:25 PM\n Pantoprazole (Protonix) - 08:58 PM\n Metoprolol - 10:50 PM\n Other medications: per ICU resident note\n Past medical history:\n Family history:\n Social History:\n CHF\n Severe tricuspid regurgitation\n Atrial fib on coumadin\n Hypertension\n Aortic dissection s/p open heart surgery - patient states she had an\n aneursym which was repaired with plastic.\n Stroke (per OSH records)\n Per ICU resident note\n Occupation:\n Drugs:\n Tobacco: None\n Alcohol: None\n Other: per ICU resident note\n Review of systems:\n Constitutional: No(t) Fever\n Cardiovascular: No(t) Chest pain\n Respiratory: No(t) Dyspnea\n Gastrointestinal: Abdominal pain\n Genitourinary: Foley\n Heme / Lymph: Anemia\n Psychiatric / Sleep: No(t) Agitated\n Pain: No pain / appears comfortable\n Flowsheet Data as of 11:56 PM\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\nC (98.6\n HR: 85 (85 - 111) bpm\n BP: 95/53(64) {95/53(64) - 157/75(97)} mmHg\n RR: 17 (15 - 21) insp/min\n SpO2: 94%\n Heart rhythm: AF (Atrial Fibrillation)\n Total In:\n 691 mL\n PO:\n TF:\n IVF:\n 691 mL\n Blood products:\n Total out:\n 0 mL\n 340 mL\n Urine:\n 340 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 351 mL\n Respiratory\n O2 Delivery Device: None\n SpO2: 94%\n ABG: ////\n Physical Examination\n Gen: Conversant. NAD\n CV: HSM throughout. RV heave. Irreg irreg.\n Res: CTA ant\n Abd: soft. NT. ND.\n Ext: no LE edema\n Labs / Radiology\n 31.2 %\n [image002.jpg]\n 08:06 PM\n 08:54 PM\n Hct\n 31.2\n TropT\n <0.01\n Other labs: PT / PTT / INR:14.8/25.9/1.3, CK / CKMB /\n Troponin-T:51/3/<0.01\n Assessment and Plan\n 76 yo woman with GI bleed, blood loss anemia, biliary obstruction, s/p\n ERCP today.\n 1. GI Bleed/Blood Loss Anemia: trend Hcts. Transfuse for Hct <\n 30 given EKG evidence of ischemia with tachycardia\n 2. CBD stone: Follow bilirubin. Hopefully sphincterotomy plus\n stent will resolve acute problem. ?need for cholecystectomy in the\n future\n 3. Cardiac ischemia: Trend cardiac enzymes. EKG changes appear\n to be in setting of demand and resolve with slowing of rate. B-blocker\n for rate control with close eye on blood pressure. Has known CHF as\n well -> records of OSH workup may be helpful.\n Remainder of issues per ICU team.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines / Intubation:\n 20 Gauge - 11:18 PM\n Comments:\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: None)\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 32 minutes\n Patient is critically ill\n" }, { "category": "Physician ", "chartdate": "2146-11-02 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 596420, "text": "Chief Complaint: GI Bleed\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n EKG - At 08:37 PM\n NASAL SWAB - At 08:37 PM\n EKG - At 10:51 PM\n EKG - At 11:15 PM\n EKG - At 02:01 AM\n History obtained from Medical records\n Allergies:\n Ciprofloxacin\n Rash; itching;\n Last dose of Antibiotics:\n Ampicillin/Sulbactam (Unasyn) - 02:02 AM\n Infusions:\n Other ICU medications:\n Hydromorphone (Dilaudid) - 08:25 PM\n Pantoprazole (Protonix) - 08:58 PM\n Metoprolol - 06:51 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 Flowsheet Data as of 10:02 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: 36.7\nC (98\n HR: 97 (85 - 111) bpm\n BP: 137/86(93) {91/46(58) - 157/86(97)} mmHg\n RR: 18 (15 - 24) insp/min\n SpO2: 95%\n Heart rhythm: AF (Atrial Fibrillation)\n Total In:\n 692 mL\n 1,019 mL\n PO:\n TF:\n IVF:\n 692 mL\n 669 mL\n Blood products:\n 350 mL\n Total out:\n 340 mL\n 210 mL\n Urine:\n 340 mL\n 210 mL\n NG:\n Stool:\n Drains:\n Balance:\n 352 mL\n 809 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 95%\n ABG: ///26/\n Physical Examination\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, Bowel sounds present\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 9.7 g/dL\n 80 K/uL\n 129 mg/dL\n 0.9 mg/dL\n 26 mEq/L\n 3.6 mEq/L\n 36 mg/dL\n 110 mEq/L\n 145 mEq/L\n 28.7 %\n 4.5 K/uL\n [image002.jpg]\n 08:06 PM\n 08:54 PM\n 01:56 AM\n 04:25 AM\n WBC\n 4.5\n Hct\n 31.2\n 29.1\n 28.7\n Plt\n 80\n Cr\n 0.9\n TropT\n <0.01\n <0.01\n Glucose\n 129\n Other labs: PT / PTT / INR:14.5/28.2/1.3, CK / CKMB /\n Troponin-T:39/3/<0.01, ALT / AST:139/185, Alk Phos / T Bili:400/2.3,\n Amylase / Lipase:/49, Albumin:3.5 g/dL, LDH:210 IU/L, Ca++:8.5 mg/dL,\n Mg++:2.0 mg/dL, PO4:3.2 mg/dL\n Assessment and Plan\n 76 yo female with CBD stone and procedure complicated by bleeding--now\n s/p intervention with cautery and reasonable expectation of control of\n bleeding. Hospital course now is complicated by myocardial ischemia in\n the setting of high \"demand\".\n GASTROINTESTINAL BLEED, LOWER (HEMATOCHEZIA, BRBPR, GI BLEED, GIB)-\n -PPI\n -Follow HCT\n -Maintain IV Access and will need volume replacement\n ATRIAL FIBRILLATION (AFIB)\n -rate control as needed\n -Will follow cardiac enzymes and ECG as enzyme changes did seem to be\n related to rapid heart rate\n Thrombocytopenia-\n -Follow PLT\n -Will obtain old records to evaluate trend\n Cholelithiasis-\n -Will continue to monitor enzymes and exam\n ICU Care\n Nutrition: NPO this morning\n Glycemic Control:\n Lines:\n 18 Gauge - 02:57 AM\n 20 Gauge - 06:52 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: 35 minutes\n" }, { "category": "Physician ", "chartdate": "2146-11-02 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 596421, "text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n EKG - At 08:37 PM\n NASAL SWAB - At 08:37 PM\n EKG - At 10:51 PM\n EKG - At 11:15 PM\n EKG - At 02:01 AM\n - 500cc NS boluses x2, 1u pRBC was given as well\n - continued to have melena\n - metoprolol IV 5mg x1, 2.5mg x1, 5mgx1\n - dynamic EKG changes\n - CE neg x1\n Allergies:\n Ciprofloxacin\n Rash; itching;\n Last dose of Antibiotics:\n Ampicillin/Sulbactam (Unasyn) - 02:02 AM\n Infusions:\n Other ICU medications:\n Hydromorphone (Dilaudid) - 08:25 PM\n Pantoprazole (Protonix) - 08:58 PM\n Metoprolol - 03:10 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:35 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: 36.7\nC (98\n HR: 97 (85 - 111) bpm\n BP: 137/86(93) {91/46(58) - 157/86(97)} mmHg\n RR: 18 (15 - 24) insp/min\n SpO2: 95%\n Heart rhythm: AF (Atrial Fibrillation)\n Total In:\n 692 mL\n 1,016 mL\n PO:\n TF:\n IVF:\n 692 mL\n 666 mL\n Blood products:\n 350 mL\n Total out:\n 340 mL\n 210 mL\n Urine:\n 340 mL\n 210 mL\n NG:\n Stool:\n Drains:\n Balance:\n 352 mL\n 806 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 95%\n ABG: ///26/\n Physical Examination\n General: AOx3, NAD\n HEENT: Sclera anicteric, MMM, oropharynx clear\n Neck: supple, JVP not elevated, no LAD. Bounding pulsation in the\n neck.\n Lungs: CTAB\n CV: Irregular with a holosystolic murmur present, heard best at the\n apex.\n Abdomen: No tenderness. No rebound or guarding present. No HSM\n Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema\n Labs / Radiology\n 80 K/uL\n 9.7 g/dL\n 129 mg/dL\n 0.9 mg/dL\n 26 mEq/L\n 3.6 mEq/L\n 36 mg/dL\n 110 mEq/L\n 145 mEq/L\n 28.7 %\n 4.5 K/uL\n [image002.jpg]\n 08:06 PM\n 08:54 PM\n 01:56 AM\n 04:25 AM\n WBC\n 4.5\n Hct\n 31.2\n 29.1\n 28.7\n Plt\n 80\n Cr\n 0.9\n TropT\n <0.01\n Glucose\n 129\n Other labs:\n PT / PTT / INR:14.5/28.2/1.3,\n CK / CKMB / Troponin-T:39/3/<0.01,\n ALT / AST:139/185, Alk Phos / T Bili:400/2.3, Amylase / Lipase:/49,\n Albumin:3.5 g/dL, LDH:210 IU/L,\n Ca++:8.5 mg/dL, Mg++:2.0 mg/dL, PO4:3.2 mg/dL\n Micro: MRSA screen pending\n Imaging:\n ERCP ()\n * Clotted blood and oozing was seen in the major papilla.\n * Epinephrine 1/ hemostasis with success.\n * -CAP Electrocautery was applied for hemostasis successfully.\n * Cannulation of the biliary duct was successful and deep with a\n sphincterotome using a free-hand technique. Contrast medium was\n injected resulting in complete.\n * A moderate dilation was seen at the CBD with the CBD measuring\n 12-13mm.\n * A 10FR by 5cm double pigtail biliary stent was placed successfully\n using a Microvasive 10FR stent introducer kit.\n TTE (from OSH): EF 55-60%, septal flattening of the\n interventricular septum consistent with right vent or pressure\n overload. Mildly dilated left atrium. Right vent severely dilated\n with moderately reduced right vent global systolic function. Right\n atrial cavity is severely dilated. Mild AR and AS. Mild MR. \n TR.\n Assessment and Plan\n 76 yo female with pmh of severe TR, Rt-sided CHF, and atrial fib on\n coumadin being transferred to the for monitoring after being noted\n to have GIB s/p ERCP, hemostasis at sphincterotomy site and stent\n placement.\n # Melena/GI bleed: Found to be secondary to sphincterotomy now s/p\n repeat ERCP with thermal therapy and CBD stent placement. Bleeding was\n seen to have decreased greatly after the repeat ERCP.\n - Per ERCP fellow, should expect continued melena for the next couple\n of days.\n - s/p DDAVP. INR now down to 1.3 so will hold off FFP.\n - Keep NPO\n - Trend Hct q6h. Check Hct at 8am today (after transfusion with 1u\n pRBC), will transfuse for Hct < 30\n - Maintaine active type and screen\n - Continue IV PPI\n # Ischemic EKG changes: Patient is without current or recent chest\n pain, however as her heart rate rises she is seen to have ST\n depressions and T-wave inversions in her lateral leads. Most likely\n demand ischemia in the setting of GIB.\n - IV metoprolol prn to keep her rate ideally < 90, as she cannot take\n PO currently\n - Atorvastatin 80 mg po daily started due to concern for ischemia but\n she cannot take PO currently\n - CE's were negativex 2. Will trend her CE (one more set)\n - Cannot give ASA, heparin, plavix as she is currently bleeding.\n - Serial EKGs\n - Transfuse for Hct < 30\n # Biliary obstruction: Now s/p stent placement.\n - Continue unasyn\n - Trend LFTs and lipase\n - F/u ERCP recs\n # Thrombocytopenia: The patient has had platlets ranging from 74 to 98\n during this hospitalization. They have remained stable. Unknown what\n her baseline is. Unlikely to be HIT given that she is currently\n bleeding.\n - Obtain OSH records for baseline.\n - Trend\n # Right-sided CHF: The patient had a TTE at the OSH which showed\n right-sided heart failure and a normal LVEF.\n - Continue aldactone and lasix per home regimen as her blood pressure\n tolerates.\n - Will closely monitor fluid status.\n # Atrial fibrillation: The patient is currently in atrial\n fibrillation. She is anticoagulated with warfarin as an outpatient.\n - Holding warfarin due to active bleeding.\n - Not on a rate-controlling as an outpatient (so far as we\n know). Will need to confirm home meds in the am.\n - As above will use IV metoprolol prn to control her rate.\n ICU Care\n Nutrition: NPO\n Glycemic Control: no ISS\n Lines:\n 20 Gauge - 08:25 PM\n 18 Gauge - 02:57 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: IV PPI\n VAP: not indicated\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU for now\n" }, { "category": "Physician ", "chartdate": "2146-11-02 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 596424, "text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n EKG - At 08:37 PM\n NASAL SWAB - At 08:37 PM\n EKG - At 10:51 PM\n EKG - At 11:15 PM\n EKG - At 02:01 AM\n - 500cc NS boluses x2, 1u pRBC was given as well\n - continued to have melena\n - metoprolol IV 5mg x1, 2.5mg x1, 5mgx1\n - dynamic EKG changes\n - CE neg x1\n Allergies:\n Ciprofloxacin\n Rash; itching;\n Last dose of Antibiotics:\n Ampicillin/Sulbactam (Unasyn) - 02:02 AM\n Infusions:\n Other ICU medications:\n Hydromorphone (Dilaudid) - 08:25 PM\n Pantoprazole (Protonix) - 08:58 PM\n Metoprolol - 03:10 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:35 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: 36.7\nC (98\n HR: 97 (85 - 111) bpm\n BP: 137/86(93) {91/46(58) - 157/86(97)} mmHg\n RR: 18 (15 - 24) insp/min\n SpO2: 95%\n Heart rhythm: AF (Atrial Fibrillation)\n Total In:\n 692 mL\n 1,016 mL\n PO:\n TF:\n IVF:\n 692 mL\n 666 mL\n Blood products:\n 350 mL\n Total out:\n 340 mL\n 210 mL\n Urine:\n 340 mL\n 210 mL\n NG:\n Stool:\n Drains:\n Balance:\n 352 mL\n 806 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 95%\n ABG: ///26/\n Physical Examination\n General: AOx3, NAD\n HEENT: Sclera anicteric, MMM, oropharynx clear\n Neck: supple, no LAD. Bounding pulsation in the neck.\n Lungs: CTAB\n CV: Irregular with a holosystolic murmur present, heard best at the\n apex.\n Abdomen: No tenderness. No rebound or guarding present. No HSM\n Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema\n Labs / Radiology\n 80 K/uL\n 9.7 g/dL\n 129 mg/dL\n 0.9 mg/dL\n 26 mEq/L\n 3.6 mEq/L\n 36 mg/dL\n 110 mEq/L\n 145 mEq/L\n 28.7 %\n 4.5 K/uL\n [image002.jpg]\n 08:06 PM\n 08:54 PM\n 01:56 AM\n 04:25 AM\n WBC\n 4.5\n Hct\n 31.2\n 29.1\n 28.7\n Plt\n 80\n Cr\n 0.9\n TropT\n <0.01\n Glucose\n 129\n Other labs:\n PT / PTT / INR:14.5/28.2/1.3,\n CK / CKMB / Troponin-T:39/3/<0.01,\n ALT / AST:139/185, Alk Phos / T Bili:400/2.3, Amylase / Lipase:/49,\n Albumin:3.5 g/dL, LDH:210 IU/L,\n Ca++:8.5 mg/dL, Mg++:2.0 mg/dL, PO4:3.2 mg/dL\n Micro: MRSA screen pending\n Imaging:\n ERCP ()\n * Clotted blood and oozing was seen in the major papilla.\n * Epinephrine 1/ hemostasis with success.\n * -CAP Electrocautery was applied for hemostasis successfully.\n * Cannulation of the biliary duct was successful and deep with a\n sphincterotome using a free-hand technique. Contrast medium was\n injected resulting in complete.\n * A moderate dilation was seen at the CBD with the CBD measuring\n 12-13mm.\n * A 10FR by 5cm double pigtail biliary stent was placed successfully\n using a Microvasive 10FR stent introducer kit.\n TTE (from OSH): EF 55-60%, septal flattening of the\n interventricular septum consistent with right vent or pressure\n overload. Mildly dilated left atrium. Right vent severely dilated\n with moderately reduced right vent global systolic function. Right\n atrial cavity is severely dilated. Mild AR and AS. Mild MR. \n TR.\n Assessment and Plan\n 76 yo female with pmh of severe TR, Rt-sided CHF, and atrial fib on\n coumadin being transferred to the for monitoring after being noted\n to have GIB s/p ERCP, hemostasis at sphincterotomy site and stent\n placement.\n # Melena/GI bleed: Found to be secondary to sphincterotomy now s/p\n repeat ERCP with thermal therapy and CBD stent placement. Bleeding was\n seen to have decreased greatly after the repeat ERCP.\n - Per ERCP fellow, should expect continued melena for the next couple\n of days.\n - s/p DDAVP per ERCP.\n - INR now down to 1.3 so will hold off FFP.\n - Keep NPO, f/u on ERCP recs on when to advance diet\n - 1L NS bolus for now as patient is orthostatic, and she is NPO\n - Trend Hct q6h. Check Hct at 8am today (after transfusion with 1u\n pRBC), will transfuse for Hct < 30\n - Maintain active type and screen\n - Continue IV PPI\n # Ischemic EKG changes: Patient had no chest pain but did have ST\n depressions and T-wave inversions in her lateral leads. Most likely\n demand ischemia in the setting of GIB.\n - IV metoprolol prn to keep her rate ideally < 90, as she cannot take\n PO currently, will transition to PO metoprolol when starting to take PO\n - Atorvastatin 80 mg po daily started due to concern for ischemia but\n she cannot take PO currently\n - CE's were negativex 2. Will trend her CE (one more set)\n - Cannot give ASA, heparin, plavix as she is currently bleeding.\n - Serial EKG if pt develops chest pain\n - Transfuse for Hct < 30\n # Biliary obstruction: Now s/p stent placement.\n - Continue unasyn\n - Trend LFTs and lipase\n - F/u ERCP recs\n # Thrombocytopenia: The patient has had platlets ranging from 74 to 98\n during this hospitalization. They have remained stable. Unknown what\n her baseline is.\n - Obtain OSH records for baseline.\n - obtain HIT antibody\n - Trend\n # Right-sided CHF: The patient had a TTE at the OSH which showed\n right-sided heart failure and a normal LVEF.\n - hold aldactone and lasix as her BP has been low normal\n - patient is pre-load dependent as she has right-sided heart failure,\n will need to give IVF boluses today, start with 1L this AM\n # Atrial fibrillation: The patient is currently in atrial\n fibrillation. She is anticoagulated with warfarin as an outpatient.\n - Holding warfarin due to active bleeding.\n - Not on a rate-controlling as an outpatient (so far as we\n know). Will need to confirm home meds in the am.\n - As above will use IV metoprolol prn to control her rate, will\n transition to PO metoprolol once taking PO\n ICU Care\n Nutrition: NPO for now, pending ERCP recs\n Glycemic Control: no ISS\n Lines:\n 20 Gauge - 08:25 PM\n 18 Gauge - 02:57 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: IV PPI\n VAP: not indicated\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU for now, can transfer to floor once Hct is stable,\n earliest this afternoon\n" }, { "category": "Nursing", "chartdate": "2146-11-02 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 596506, "text": "Ms is a 76 yo female with pmh of severe TR, Rt-sided CHF, and\n atrial fib being transferred to the for monitoring after\n undergoing a GI bleed today and ERCP with stent placement. She\n originally presented to Hospital with dyspnea and abdominal\n pain on . There she was found to have elevated LFTs and an ERCP\n was attempted on , however cannulation was unsuccessful. Her INR\n was 1.7 as she is on coumadin so she received 2 units of FFP prior to\n transfer.\n She was transferred to and repeat ERCP on again had\n unsuccessful cannulation, however a small pre-cut of the sphincter was\n attempted with slight oozing. Repeat ERCP on showed sludge and\n the sphincterotomy was extended. On she developed melena and her\n bilibrubin increased to 2; INR 1.4. Hct remained stable @ 34. Due to\n concern for hemobilia ERCP was repeated and bleeding was noted from the\n sphincterotomy site. Epinephrine was injected, a double pigtail CBD\n stent was placed, and Bicap thermal therapy was applied to the area.\n Bleeding decreased markedly in response to these interventions. Pt was\n transferred to MICU for further monitoring .\n Allergies:Cipro.\n Iv aceess:18+20.\n Precuations:Universal.\n ROS;Neuro;alert and oreinted x3,impulsive,restless,poor attention\n span.Resp:lung sound clear,on RA sats>95, CVS: Afib 100-140,sbp\n 120-150,GU: colured urine,poor urine output,Gi:abd soft,melanotic\n stool,last HCt 33.6,SKIN:intact.\n Gastrointestinal bleed, lower (Hematochezia, BRBPR, GI Bleed, GIB)\n Assessment:\n Pt with malenic stool s/p ERCP,had a smear of melanotic stool in this\n shift,denied abd pain/nausea or vomiting,\n Action:\n Contd IV Ppi,had 1 unit of PRBC in the previous shift,contd NPO status.\n Response:\n HCt rpt at 1830 hrs is 33.6,\n Plan:\n Will cont to monitor,cont Iv PPI,NPO,next HCt at 0200am,transfuse as\n needed.\n Atrial fibrillation (Afib)\n Assessment:\n Known c/o afib,not on any rate controling meds,HR 100-140, pt restless\n and impulsive ,tachy even up to 140\ns with exertion, no s/o chest pain\n /sob, urine output\n Action:\n Received 2L NS, bolus,also received lopressor 5mg IVP,trazadone 25 po\n x1 given for insomnia/restlessness\n Response:\n HR in low 100\ns post lopressor,no sig improovement with fluid\n bolus,satting >95%on RA,RR 20\ns,no s/s of fluid overload .UOP ~20cc/hr\n Plan:\n Continue to monitor hr and u/o.,metroprolol as needed.\n Demographics\n Attending MD:\n S.\n Admit diagnosis:\n POST ERCP\n Code status:\n Full code\n Height:\n Admission weight:\n 44.3 kg\n Daily weight:\n 43.6 kg\n Allergies/Reactions:\n Ciprofloxacin\n Rash; itching;\n Precautions:\n PMH:\n CV-PMH: CAD, CHF, CVA\n Additional history: afib, R sided weakness from previous stroke\n Surgery / Procedure and date: pt states she had open heart surgery in\n due to an aneurysm\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:138\n D:77\n Temperature:\n 96.3\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 23 insp/min\n Heart Rate:\n 107 bpm\n Heart rhythm:\n AF (Atrial Fibrillation)\n O2 delivery device:\n None\n O2 saturation:\n 97% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 24h total in:\n 5,409 mL\n 24h total out:\n 495 mL\n Pertinent Lab Results:\n Sodium:\n 145 mEq/L\n 04:25 AM\n Potassium:\n 3.6 mEq/L\n 04:25 AM\n Chloride:\n 110 mEq/L\n 04:25 AM\n CO2:\n 26 mEq/L\n 04:25 AM\n BUN:\n 36 mg/dL\n 04:25 AM\n Creatinine:\n 0.9 mg/dL\n 04:25 AM\n Glucose:\n 129 mg/dL\n 04:25 AM\n Hematocrit:\n 33.6 %\n 06:40 PM\n Valuables / Signature\n Patient valuables: Glasses\n Other valuables:\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry: none\n Transferred from: 403\n Transferred to: 11R 1166\n Date & time of Transfer: 12MN\n" }, { "category": "Physician ", "chartdate": "2146-11-02 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 596411, "text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n EKG - At 08:37 PM\n NASAL SWAB - At 08:37 PM\n EKG - At 10:51 PM\n EKG - At 11:15 PM\n EKG - At 02:01 AM\n - 500cc NS boluses x2, 1u pRBC was given as well\n - continued to have melena\n - metoprolol IV 5mg x1, 2.5mg x1, 5mgx1\n - dynamic EKG changes\n - CE neg x1\n Allergies:\n Ciprofloxacin\n Rash; itching;\n Last dose of Antibiotics:\n Ampicillin/Sulbactam (Unasyn) - 02:02 AM\n Infusions:\n Other ICU medications:\n Hydromorphone (Dilaudid) - 08:25 PM\n Pantoprazole (Protonix) - 08:58 PM\n Metoprolol - 03:10 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:35 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: 36.7\nC (98\n HR: 97 (85 - 111) bpm\n BP: 137/86(93) {91/46(58) - 157/86(97)} mmHg\n RR: 18 (15 - 24) insp/min\n SpO2: 95%\n Heart rhythm: AF (Atrial Fibrillation)\n Total In:\n 692 mL\n 1,016 mL\n PO:\n TF:\n IVF:\n 692 mL\n 666 mL\n Blood products:\n 350 mL\n Total out:\n 340 mL\n 210 mL\n Urine:\n 340 mL\n 210 mL\n NG:\n Stool:\n Drains:\n Balance:\n 352 mL\n 806 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 95%\n ABG: ///26/\n Physical Examination\n General: Elderly female lying in bed uncomfortably. Sleepy, oriented\n to person, (but didn't know what hospital she was in), and time.\n HEENT: Sclera anicteric, MMM, oropharynx clear\n Neck: supple, JVP not elevated, no LAD. Large pulsations of her neck\n veins likely from TR.\n Lungs: Patient is breathing comfortably. Left lung had focal wheezing\n which cleared after coughing. Otherwise CTAB.\n CV: Irregular with a holosystolic murmur present, heard best at the\n apex.\n Abdomen: Hypoactive bowel sounds, soft, tender to palpation throughout\n with the most tenderness in her epigastric region. No rebound or\n guarding present. No HSM\n GU: no foley\n Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema\n Labs / Radiology\n 80 K/uL\n 9.7 g/dL\n 129 mg/dL\n 0.9 mg/dL\n 26 mEq/L\n 3.6 mEq/L\n 36 mg/dL\n 110 mEq/L\n 145 mEq/L\n 28.7 %\n 4.5 K/uL\n [image002.jpg]\n 08:06 PM\n 08:54 PM\n 01:56 AM\n 04:25 AM\n WBC\n 4.5\n Hct\n 31.2\n 29.1\n 28.7\n Plt\n 80\n Cr\n 0.9\n TropT\n <0.01\n Glucose\n 129\n Other labs:\n PT / PTT / INR:14.5/28.2/1.3,\n CK / CKMB / Troponin-T:39/3/<0.01,\n ALT / AST:139/185, Alk Phos / T Bili:400/2.3, Amylase / Lipase:/49,\n Albumin:3.5 g/dL, LDH:210 IU/L,\n Ca++:8.5 mg/dL, Mg++:2.0 mg/dL, PO4:3.2 mg/dL\n Micro: MRSA screen pending\n Imaging:\n ERCP ()\n * Clotted blood and oozing was seen in the major papilla.\n * Epinephrine 1/ hemostasis with success.\n * -CAP Electrocautery was applied for hemostasis successfully.\n * Cannulation of the biliary duct was successful and deep with a\n sphincterotome using a free-hand technique. Contrast medium was\n injected resulting in complete.\n * A moderate dilation was seen at the CBD with the CBD measuring\n 12-13mm.\n * A 10FR by 5cm double pigtail biliary stent was placed successfully\n using a Microvasive 10FR stent introducer kit.\n TTE (from OSH): EF 55-60%, septal flattening of the\n interventricular septum consistent with right vent or pressure\n overload. Mildly dilated left atrium. Right vent severely dilated\n with moderately reduced right vent global systolic function. Right\n atrial cavity is severely dilated. Mild AR and AS. Mild MR. \n TR.\n Assessment and Plan\n 76 yo female with pmh of severe TR, Rt-sided CHF, and atrial fib on\n coumadin being transferred to the for monitoring after being noted\n to have GIB s/p ERCP, hemostasis at sphincterotomy site and stent\n placement.\n # Melena/GI bleed: Found to be secondary to sphincterotomy now s/p\n repeat ERCP with thermal therapy and CBD stent placement. Bleeding was\n seen to have decreased greatly after the repeat ERCP.\n - Per ERCP fellow, should expect continued melena for the next couple\n of days.\n - s/p DDAVP. INR now down to 1.3 so will hold off FFP.\n - Keep NPO\n - Trend Hct q6h. Check Hct at 8am today (after transfusion with 1u\n pRBC), will transfuse for Hct < 30\n - Maintaine active type and screen\n - Continue IV PPI\n # Ischemic EKG changes: Patient is without current or recent chest\n pain, however as her heart rate rises she is seen to have ST\n depressions and T-wave inversions in her lateral leads. Most likely\n demand ischemia in the setting of GIB.\n - IV metoprolol prn to keep her rate ideally < 90, as she cannot take\n PO currently\n - Atorvastatin 80 mg po daily started due to concern for ischemia but\n she cannot take PO currently\n - CE's were negativex 2. Will trend her CE (one more set)\n - Cannot give ASA, heparin, plavix as she is currently bleeding.\n - Serial EKGs\n - Transfuse for Hct < 30\n # Biliary obstruction: Now s/p stent placement.\n - Continue unasyn\n - Trend LFTs and lipase\n - F/u ERCP recs\n # Thrombocytopenia: The patient has had platlets ranging from 74 to 98\n during this hospitalization. They have remained stable. Unknown what\n her baseline is. Unlikely to be HIT given that she is currently\n bleeding.\n - Obtain OSH records for baseline.\n - Trend\n # Right-sided CHF: The patient had a TTE at the OSH which showed\n right-sided heart failure and a normal LVEF.\n - Continue aldactone and lasix per home regimen as her blood pressure\n tolerates.\n - Will closely monitor fluid status.\n # Atrial fibrillation: The patient is currently in atrial\n fibrillation. She is anticoagulated with warfarin as an outpatient.\n - Holding warfarin due to active bleeding.\n - Not on a rate-controlling as an outpatient (so far as we\n know). Will need to confirm home meds in the am.\n - As above will use IV metoprolol prn to control her rate.\n ICU Care\n Nutrition: NPO\n Glycemic Control: no ISS\n Lines:\n 20 Gauge - 08:25 PM\n 18 Gauge - 02:57 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: IV PPI\n VAP: not indicated\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU for now\n" }, { "category": "Nursing", "chartdate": "2146-11-02 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 596504, "text": "Ms is a 76 yo female with pmh of severe TR, Rt-sided CHF, and\n atrial fib being transferred to the for monitoring after\n undergoing a GI bleed today and ERCP with stent placement. She\n originally presented to Hospital with dyspnea and abdominal\n pain on . There she was found to have elevated LFTs and an ERCP\n was attempted on , however cannulation was unsuccessful. Her INR\n was 1.7 as she is on coumadin so she received 2 units of FFP prior to\n transfer.\n She was transferred to and repeat ERCP on again had\n unsuccessful cannulation, however a small pre-cut of the sphincter was\n attempted with slight oozing. Repeat ERCP on showed sludge and\n the sphincterotomy was extended. On she developed melena and her\n bilibrubin increased to 2; INR 1.4. Hct remained stable @ 34. Due to\n concern for hemobilia ERCP was repeated and bleeding was noted from the\n sphincterotomy site. Epinephrine was injected, a double pigtail CBD\n stent was placed, and Bicap thermal therapy was applied to the area.\n Bleeding decreased markedly in response to these interventions. Pt was\n transferred to MICU for further monitoring .\n Allergies:Cipro.\n Iv aceess:18+20.\n Precuations:Universal.\n ROS;Neuro;alert and oreinted x3,impulsive,restless,poor attention\n span.Resp:lung sound clear,on RA sats>95, CVS: Afib 100-140,sbp\n 120-150,GU: colured urine,poor urine output,Gi:abd soft,melanotic\n stool,last HCt 33.6,SKIN:intact.\n Gastrointestinal bleed, lower (Hematochezia, BRBPR, GI Bleed, GIB)\n Assessment:\n Pt with malenic stool s/p ERCP,had a smear of melanotic stool in this\n shift,denied abd pain/nausea or vomiting,\n Action:\n Contd IV Ppi,had 1 unit of PRBC in the previous shift,contd NPO status.\n Response:\n HCt rpt at 1830 hrs is 33.6,\n Plan:\n Will cont to monitor,cont Iv PPI,NPO,next HCt at 0200am,transfuse as\n needed.\n Atrial fibrillation (Afib)\n Assessment:\n Known c/o afib,not on any rate controling meds,HR 100-140, pt restless\n and impulsive ,tachy even up to 140\ns with exertion, no s/o chest pain\n /sob, urine output\n Action:\n Received 2L NS, bolus,also received lopressor 5mg IVP,trazadone 25 po\n x1 given for insomnia/restlessness\n Response:\n HR in low 100\ns post lopressor,no sig improovement with fluid\n bolus,satting >95%on RA,RR 20\ns,no s/s of fluid overload .\n Plan:\n Continue to monitor hr and u/o.,metroprolol as needed.\n" }, { "category": "Physician ", "chartdate": "2146-11-02 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 596398, "text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n EKG - At 08:37 PM\n NASAL SWAB - At 08:37 PM\n EKG - At 10:51 PM\n EKG - At 11:15 PM\n EKG - At 02:01 AM\n - 500cc NS boluses x2, 1u pRBC was given as well\n - continued to have melena\n - metoprolol IV 5mg x1, 2.5mg x1, 5mgx1\n - dynamic EKG changes\n - CE neg x1\n Allergies:\n Ciprofloxacin\n Rash; itching;\n Last dose of Antibiotics:\n Ampicillin/Sulbactam (Unasyn) - 02:02 AM\n Infusions:\n Other ICU medications:\n Hydromorphone (Dilaudid) - 08:25 PM\n Pantoprazole (Protonix) - 08:58 PM\n Metoprolol - 03:10 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:35 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: 36.7\nC (98\n HR: 97 (85 - 111) bpm\n BP: 137/86(93) {91/46(58) - 157/86(97)} mmHg\n RR: 18 (15 - 24) insp/min\n SpO2: 95%\n Heart rhythm: AF (Atrial Fibrillation)\n Total In:\n 692 mL\n 1,016 mL\n PO:\n TF:\n IVF:\n 692 mL\n 666 mL\n Blood products:\n 350 mL\n Total out:\n 340 mL\n 210 mL\n Urine:\n 340 mL\n 210 mL\n NG:\n Stool:\n Drains:\n Balance:\n 352 mL\n 806 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 95%\n ABG: ///26/\n Physical Examination\n General: Elderly female lying in bed uncomfortably. Sleepy, oriented\n to person, (but didn't know what hospital she was in), and time.\n HEENT: Sclera anicteric, MMM, oropharynx clear\n Neck: supple, JVP not elevated, no LAD. Large pulsations of her neck\n veins likely from TR.\n Lungs: Patient is breathing comfortably. Left lung had focal wheezing\n which cleared after coughing. Otherwise CTAB.\n CV: Irregular with a holosystolic murmur present, heard best at the\n apex.\n Abdomen: Hypoactive bowel sounds, soft, tender to palpation throughout\n with the most tenderness in her epigastric region. No rebound or\n guarding present. No HSM\n GU: no foley\n Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema\n Labs / Radiology\n 80 K/uL\n 9.7 g/dL\n 129 mg/dL\n 0.9 mg/dL\n 26 mEq/L\n 3.6 mEq/L\n 36 mg/dL\n 110 mEq/L\n 145 mEq/L\n 28.7 %\n 4.5 K/uL\n [image002.jpg]\n 08:06 PM\n 08:54 PM\n 01:56 AM\n 04:25 AM\n WBC\n 4.5\n Hct\n 31.2\n 29.1\n 28.7\n Plt\n 80\n Cr\n 0.9\n TropT\n <0.01\n Glucose\n 129\n Other labs:\n PT / PTT / INR:14.5/28.2/1.3,\n CK / CKMB / Troponin-T:39/3/<0.01,\n ALT / AST:139/185, Alk Phos / T Bili:400/2.3, Amylase / Lipase:/49,\n Albumin:3.5 g/dL, LDH:210 IU/L,\n Ca++:8.5 mg/dL, Mg++:2.0 mg/dL, PO4:3.2 mg/dL\n Micro: MRSA screen pending\n Imaging:\n ERCP ()\n * Clotted blood and oozing was seen in the major papilla.\n * Epinephrine 1/ hemostasis with success.\n * -CAP Electrocautery was applied for hemostasis successfully.\n * Cannulation of the biliary duct was successful and deep with a\n sphincterotome using a free-hand technique. Contrast medium was\n injected resulting in complete.\n * A moderate dilation was seen at the CBD with the CBD measuring\n 12-13mm.\n * A 10FR by 5cm double pigtail biliary stent was placed successfully\n using a Microvasive 10FR stent introducer kit.\n TTE (from OSH): EF 55-60%, septal flattening of the\n interventricular septum consistent with right vent or pressure\n overload. Mildly dilated left atrium. Right vent severely dilated\n with moderately reduced right vent global systolic function. Right\n atrial cavity is severely dilated. Mild AR and AS. Mild MR. \n TR.\n Assessment and Plan\n 76 yo female with pmh of severe TR, Rt-sided CHF, and atrial fib on\n coumadin being transferred to the for monitoring after being noted\n to have GIB s/p ERCP, hemostasis at sphincterotomy site and stent\n placement.\n # Melena/GI bleed: Found to be secondary to sphincterotomy now s/p\n repeat ERCP with thermal therapy and CBD stent placement. Bleeding was\n seen to have decreased greatly after the repeat ERCP.\n - Per ERCP fellow, should expect continued melena for the next couple\n of days.\n - s/p DDAVP. INR now down to 1.3 so will hold off FFP.\n - Keep NPO\n - Trend Hct q6h. Check Hct at 8am today (after transfusion with 1u\n pRBC), will transfuse for Hct < 30\n - Maintaine active type and screen\n - Continue IV PPI\n # Ischemic EKG changes: Patient is without current or recent chest\n pain, however as her heart rate rises she is seen to have ST\n depressions and T-wave inversions in her lateral leads. Most likely\n demand ischemia in the setting of GIB.\n - IV metoprolol prn to keep her rate ideally < 90, as she cannot take\n PO currently\n - Atorvastatin 80 mg po daily started due to concern for ischemia but\n she cannot take PO currently\n - CE's were negativex 2. Will trend her CE (one more set)\n - Cannot give ASA, heparin, plavix as she is currently bleeding.\n - Serial EKGs\n - Transfuse for Hct < 30\n # Biliary obstruction: Now s/p stent placement.\n - Continue unasyn\n - Trend LFTs and lipase\n - F/u ERCP recs\n # Thrombocytopenia: The patient has had platlets ranging from 74 to 98\n during this hospitalization. They have remained stable. Unknown what\n her baseline is. Unlikely to be HIT given that she is currently\n bleeding.\n - Obtain OSH records for baseline.\n - Trend\n # Right-sided CHF: The patient had a TTE at the OSH which showed\n right-sided heart failure and a normal LVEF.\n - Continue aldactone and lasix per home regimen as her blood pressure\n tolerates.\n - Will closely monitor fluid status.\n # Atrial fibrillation: The patient is currently in atrial\n fibrillation. She is anticoagulated with warfarin as an outpatient.\n - Holding warfarin due to active bleeding.\n - Not on a rate-controlling as an outpatient (so far as we\n know). Will need to confirm home meds in the am.\n - As above will use IV metoprolol prn to control her rate.\n ICU Care\n Nutrition: NPO\n Glycemic Control: no ISS\n Lines:\n 20 Gauge - 08:25 PM\n 18 Gauge - 02:57 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: IV PPI\n VAP: not indicated\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n" }, { "category": "Nursing", "chartdate": "2146-11-02 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 596480, "text": "Ms is a 76 yo female with pmh of severe TR, Rt-sided CHF, and\n atrial fib being transferred to the for monitoring after\n undergoing a GI bleed today and ERCP with stent placement. She\n originally presented to Hospital with dyspnea and abdominal\n pain on . There she was found to have elevated LFTs and an ERCP\n was attempted on , however cannulation was unsuccessful. Her INR\n was 1.7 as she is on coumadin so she received 2 units of FFP prior to\n transfer.\n She was transferred to and repeat ERCP on again had\n unsuccessful cannulation, however a small pre-cut of the sphincter was\n attempted with slight oozing. Repeat ERCP on showed sludge and\n the sphincterotomy was extended. On she developed melena and her\n bilibrubin increased to 2; INR 1.4. Hct remained stable @ 34. Due to\n concern for hemobilia ERCP was repeated and bleeding was noted from the\n sphincterotomy site. Epinephrine was injected, a double pigtail CBD\n stent was placed, and Bicap thermal therapy was applied to the area.\n Bleeding decreased markedly in response to these interventions. Pt was\n transferred to MICU for further monitoring\n Gastrointestinal bleed, lower (Hematochezia, BRBPR, GI Bleed, GIB)\n Assessment:\n Pt remains NPO, though asking for soup.\n Passed large liquid brown stool this am.\n No c/o pain/nausea. Stated she was hungry.\n Action:\n Hct drawn at 12n Had received 1u RPC early am\n Response:\n Hct at 30. No further stools this shift.\n Plan:\n Repeat Hct this eve\nif stable pt is to be called out to medical floor\n with telemetry.\n Atrial fibrillation (Afib)\n Assessment:\n Continues in af..rate 90-120 depending on level of activity.\n Orthostatic by hr when sitting up.\n u/o poor.\n BP 130-150/70-80\n Action:\n Pt given 1000cc fluid bolus..??dry\n Response:\n No real change in hr after fluid bolus. u/o slightly increased.\n Plan:\n Continue to monitor hr and u/o. ??may need more fluid.\n" }, { "category": "Nursing", "chartdate": "2146-11-02 00:00:00.000", "description": "Nursing Progress Note", "row_id": 596376, "text": "Ms is a 76 yo female with pmh of severe TR, Rt-sided CHF, and\n atrial fib being transferred to the for monitoring after\n undergoing a GI bleed today and ERCP with stent placement. She\n originally presented to Hospital with dyspnea and abdominal\n pain on . There she was found to have elevated LFTs and an ERCP\n was attempted on , however cannulation was unsuccessful. Her INR\n was 1.7 as she is on coumadin so she received 2 units of FFP prior to\n transfer.\n She was transferred to and repeat ERCP on again had\n unsuccessful cannulation, however a small pre-cut of the sphincter was\n attempted with slight oozing. Repeat ERCP on showed sludge and\n the sphincterotomy was extended. On she developed melena and her\n bilibrubin increased to 2; INR 1.4. Hct remained stable @ 34. Due to\n concern for hemobilia ERCP was repeated and bleeding was noted from the\n sphincterotomy site. Epinephrine was injected, a double pigtail CBD\n stent was placed, and Bicap thermal therapy was applied to the area.\n Bleeding decreased markedly in response to these interventions. Pt was\n transferred to MICU for further monitoring\n Gastrointestinal bleed, lower (Hematochezia, BRBPR, GI Bleed, GIB)\n Assessment:\n Received pt with continued melanotic loose stools, repeat Hct 31.2.\n Denying any nausea or vomiting. C/o epigastric pain. BP\n 130-150/60\ns, AF low 100\ns. Skin warm with good pedal pulses. Foley\n placed with good output. Lungs clear throughout. Sp02 96% RA.\n Afebrile.\n Action:\n Serial Hcts\n0200 Hct 29 and pt receiving 1 unit PRBC over 3 hours.\n Total of 1 L NS given over 2 hours. IV unasyn for s/p ERCP. PRN\n dialudid for pain\n Response:\n Repeat Hct pending. Pt had 2 small-medium episodes of melanotic liquid\n stool. BP 100/60; UO greater than 30 cc/hr. Pt up for most of night but\n denying pain after dialudid\n Plan:\n Continue with serial Hcts. Transfuse for Hct <30, IVF for UO <30 cc/hr.\n PRN dialudid for pain\n Atrial fibrillation (Afib)\n Assessment:\n Received pt in AF in the low 100\ns with obvious ST depressions on tele.\n Denying and CP or SOB\n Action:\n Serial EKG\ns showing ST depression and T wave inversion, CE\ns sent and\n negative---gave total of 7.5 mg IV lopressor with 1 L NS.\n Response:\n AF 80\ns-90, denying any CP or SOB\n Plan:\n Lopressor for HR >90; follow CE\n" }, { "category": "Physician ", "chartdate": "2146-11-02 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 596358, "text": "TITLE:\n Chief Complaint: Monitoring s/p sphincterotomy bleed and re-ERCP\n HPI:\n Ms is a 76 yo female with pmh of severe TR, Rt-sided CHF, and\n atrial fib being transferred to the for monitoring after\n undergoing a GI bleed today and ERCP with stent placement. She\n originally presented to Hospital with dyspnea and abdominal\n pain on . There she was found to have elevated LFTs and an ERCP\n was attempted on , however cannulation was unsuccessful. Her INR\n was 1.7 so she received 2 units of FFP prior to transfer.\n She was transferred to and repeat ERCP on again had\n unsuccessful cannulation, however a small pre-cut of the sphincter was\n attempted with slight oozing. Repeat ERCP on showed sludge and\n the sphincterotomy was extended. Today she developed melena and her\n bilibrubin increased to 2; INR 1.4. Hct remained stable. Due to\n concern for hemobilia ERCP was repeated and bleeding was noted from the\n sphincterotomy site. Epinephrine was injected, a double pigtail CBD\n stent was placed, and Bicap thermal therapy was applied to the area.\n Bleeding decreased markedly in response to these interventions.\n On arrival to the she states she continues to have epigastric\n abdominal pain which she describes as severe. Admitted to vomiting\n last night, but currently denies nausea. Denies dizziniess. She\n continues to have melena.\n Patient admitted from: OR / PACU\n History obtained from Medical records\n Allergies:\n Ciprofloxacin\n Rash; itching;\n Last dose of Antibiotics:\n Ampicillin/Sulbactam (Unasyn) - 02:02 AM\n Infusions:\n Other ICU medications:\n Hydromorphone (Dilaudid) - 08:25 PM\n Pantoprazole (Protonix) - 08:58 PM\n Metoprolol - 03:10 AM\n Other medications:\n Aldactone 25 mg po daily\n Furosemide 40 mg po daily\n Captopril ?\n Coumadin 6 mg po daily\n .\n Medications on transfer:\n Pantoprazole 40 mg IV Q24H\n Phytonadione 10 mg IV ONCE\n Ampicillin-Sulbactam 3 g IV Q6H Day 1 - \n HYDROmorphone (Dilaudid) 0.125 mg IV Q6H:PRN pain\n Prochlorperazine 10 mg IV Q6H:PRN nausea\n Ondansetron 4 mg IV Q8H:PRN nausea\n Acetaminophen 325-650 mg PO Q6H:PRN pain, fever\n Spironolactone 25 mg PO DAILY\n Furosemide 40 mg PO DAILY\n Past medical history:\n Family history:\n Social History:\n Severe tricuspid regurgitation\n Rt-sided CHF\n Atrial fib on coumadin\n Hypertension\n Aortic dissection s/p open heart surgery - patient states she had an\n aneursym which was repaired with plastic.\n Stroke (per OSH records)\n NC\n Occupation: Accountant\n Drugs: Denies\n Tobacco: Denies\n Alcohol: Denies\n Other: Lives with her daughter\n Review of systems:\n Constitutional: (+) Per HPI. Occasionally has HA. Also states she has\n edema sometimes, but not currently.(-) Denies fever, chills,gain,\n rhinorrhea, congestion, cough, shortness of breath. Denied chest pain\n or tightness, orthopnea, PND, palpitations.\n Flowsheet Data as of 03:15 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: 36.9\nC (98.4\n HR: 98 (85 - 111) bpm\n BP: 104/57(82) {91/46(58) - 157/75(97)} mmHg\n RR: 24 (15 - 24) insp/min\n SpO2: 95%\n Heart rhythm: AF (Atrial Fibrillation)\n Total In:\n 692 mL\n 632 mL\n PO:\n TF:\n IVF:\n 692 mL\n 632 mL\n Blood products:\n Total out:\n 340 mL\n 130 mL\n Urine:\n 340 mL\n 130 mL\n NG:\n Stool:\n Drains:\n Balance:\n 352 mL\n 502 mL\n Respiratory\n O2 Delivery Device: None\n SpO2: 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 29.1 %\n [image002.jpg]\n \n 2:33 A9/22/ 08:06 PM\n \n 10:20 P9/22/ 08:54 PM\n \n 1:20 P9/23/ 01:56 AM\n \n 11:50 P\n \n 1:20 A\n \n 7:20 P\n 1//11/006\n 1:23 P\n \n 1:20 P\n \n 11:20 P\n \n 4:20 P\n Hct\n 31.2\n 29.1\n TropT\n <0.01\n Other labs: PT / PTT / INR:14.8/25.9/1.3, CK / CKMB /\n Troponin-T:51/3/<0.01\n Assessment and Plan\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 08:25 PM\n 18 Gauge - 02:57 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n" }, { "category": "Physician ", "chartdate": "2146-11-02 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 596360, "text": "TITLE:\n Chief Complaint: Monitoring s/p sphincterotomy bleed and re-ERCP\n HPI:\n Ms is a 76 yo female with pmh of severe TR, Rt-sided CHF, and\n atrial fib being transferred to the for monitoring after\n undergoing a GI bleed today and ERCP with stent placement. She\n originally presented to Hospital with dyspnea and abdominal\n pain on . There she was found to have elevated LFTs and an ERCP\n was attempted on , however cannulation was unsuccessful. Her INR\n was 1.7 so she received 2 units of FFP prior to transfer.\n She was transferred to and repeat ERCP on again had\n unsuccessful cannulation, however a small pre-cut of the sphincter was\n attempted with slight oozing. Repeat ERCP on showed sludge and\n the sphincterotomy was extended. Today she developed melena and her\n bilibrubin increased to 2; INR 1.4. Hct remained stable. Due to\n concern for hemobilia ERCP was repeated and bleeding was noted from the\n sphincterotomy site. Epinephrine was injected, a double pigtail CBD\n stent was placed, and Bicap thermal therapy was applied to the area.\n Bleeding decreased markedly in response to these interventions.\n On arrival to the she states she continues to have epigastric\n abdominal pain which she describes as severe. Admitted to vomiting\n last night, but currently denies nausea. Denies dizziniess. She\n continues to have melena.\n Patient admitted from: OR / PACU\n History obtained from Medical records\n Allergies:\n Ciprofloxacin\n Rash; itching;\n Last dose of Antibiotics:\n Ampicillin/Sulbactam (Unasyn) - 02:02 AM\n Infusions:\n Other ICU medications:\n Hydromorphone (Dilaudid) - 08:25 PM\n Pantoprazole (Protonix) - 08:58 PM\n Metoprolol - 03:10 AM\n Other medications:\n Aldactone 25 mg po daily\n Furosemide 40 mg po daily\n Captopril ?\n Coumadin 6 mg po daily\n .\n Medications on transfer:\n Pantoprazole 40 mg IV Q24H\n Phytonadione 10 mg IV ONCE\n Ampicillin-Sulbactam 3 g IV Q6H Day 1 - \n HYDROmorphone (Dilaudid) 0.125 mg IV Q6H:PRN pain\n Prochlorperazine 10 mg IV Q6H:PRN nausea\n Ondansetron 4 mg IV Q8H:PRN nausea\n Acetaminophen 325-650 mg PO Q6H:PRN pain, fever\n Spironolactone 25 mg PO DAILY\n Furosemide 40 mg PO DAILY\n Past medical history:\n Family history:\n Social History:\n Severe tricuspid regurgitation\n Rt-sided CHF\n Atrial fib on coumadin\n Hypertension\n Aortic dissection s/p open heart surgery - patient states she had an\n aneursym which was repaired with plastic.\n Stroke (per OSH records)\n NC\n Occupation: Accountant\n Drugs: Denies\n Tobacco: Denies\n Alcohol: Denies\n Other: Lives with her daughter\n Review of systems:\n Constitutional: (+) Per HPI. Occasionally has HA. Also states she has\n edema sometimes, but not currently.(-) Denies fever, chills,gain,\n rhinorrhea, congestion, cough, shortness of breath. Denied chest pain\n or tightness, orthopnea, PND, palpitations.\n Flowsheet Data as of 03:15 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: 36.9\nC (98.4\n HR: 98 (85 - 111) bpm\n BP: 104/57(82) {91/46(58) - 157/75(97)} mmHg\n RR: 24 (15 - 24) insp/min\n SpO2: 95%\n Heart rhythm: AF (Atrial Fibrillation)\n Total In:\n 692 mL\n 632 mL\n PO:\n TF:\n IVF:\n 692 mL\n 632 mL\n Blood products:\n Total out:\n 340 mL\n 130 mL\n Urine:\n 340 mL\n 130 mL\n NG:\n Stool:\n Drains:\n Balance:\n 352 mL\n 502 mL\n Respiratory\n O2 Delivery Device: None\n SpO2: 95%\n Physical Examination\n General: Elderly female lying in bed uncomfortably. Sleepy, oriented\n to person, (but didn't know what hospital she was in), and time.\n HEENT: Sclera anicteric, MMM, oropharynx clear\n Neck: supple, JVP not elevated, no LAD. Large pulsations of her neck\n veins likely from TR.\n Lungs: Patient is breathing comfortably. Left lung had focal wheezing\n which cleared after coughing. Otherwise CTAB.\n CV: Irregular with a holosystolic murmur present, heard best at the\n apex.\n Abdomen: Hypoactive bowel sounds, soft, tender to palpation throughout\n with the most tenderness in her epigastric region. No rebound or\n guarding present. No HSM\n GU: no foley\n Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema\n Labs / Radiology\n 29.1 %\n [image002.jpg]\n \n 2:33 A9/22/ 08:06 PM\n \n 10:20 P9/22/ 08:54 PM\n \n 1:20 P9/23/ 01:56 AM\n \n 11:50 P\n \n 1:20 A\n \n 7:20 P\n 1//11/006\n 1:23 P\n \n 1:20 P\n \n 11:20 P\n \n 4:20 P\n Hct\n 31.2\n 29.1\n TropT\n <0.01\n Other labs: PT / PTT / INR:14.8/25.9/1.3, CK / CKMB /\n Troponin-T:51/3/<0.01\n Hct 36.5 --> 38.8 --> 35.1 --> 34.6\n .\n Micro: No micro data\n .\n Images:\n .\n EKG: Atrial fibrillation, nl axis, nl intervals. TWI in V1-V6 with STD\n in V4-V6 depending on the rate. Change from previous EKG yesterday.\n .\n CT abdomen/pelvis from OSH: Contracted gallbladder with gallstones.\n .\n CT chest (from OSH): 1.3 cm calcified RUL nodule likely a\n granuloma. Parenchymal scarring in both lung apices.\n .\n TTE (from OSH): EF 55-60%, septal flattening of the\n interventricular septum consistent with right vent or pressure\n overload. Mildly dilated left atrium. Right vent severely dilated\n with moderately reduced right vent global systolic function. Right\n atrial cavity is severely dilated. Mild AR and AS. Mild MR. \n TR.\n Assessment and Plan\n 76 yo female with pmh of severe TR, Rt-sided CHF, and atrial fib being\n transferred to the for monitoring after undergoing a bleeding\n today from the sphincterotomy site and ERCP with stent placement.\n # Melena/GI bleed: Found to be secondary to sphincterotomy now s/p\n repeat ERCP with thermal therapy and CBD stent placement. Bleeding was\n seen to have decreased greatly after the repeat ERCP. Per ERCP fellow,\n should expect continued melena for the next couple of days.\n - Gave DDAVP per ERCP recs. Rechecked INR, now down to 1.3 so will\n hold off FFP.\n - Keep NPO\n - Trend Hct q6h, will transfuse for Hct < 30 if she continues to have\n active bleeding.\n - Active type and screen\n - Continue IV PPI\n # Ischemic EKG changes: Patient is without current or recent chest\n pain, however as her heart rate rises she is seen to have ST\n depressions and T-wave inversions in her lateral leads. This is\n concerning for demand ischemia. Her first set of CE's were negative.\n - IV metoprolol prn to keep her rate ideally < 90.\n - Cannot give ASA as she is currently bleeding.\n - Will trend her CE's\n - Atorvastatin 80 mg po daily started due to concern for ischemia.\n - Serial EKGs\n - Transfuse for Hct < 30\n # Biliary obstruction: Now s/p stent placement.\n - Continue unasyn\n - Trend LFTs and lipase\n - F/u ERCP recs\n # Right-sided CHF: The patient had a TTE at the OSH which showed\n right-sided heart failure and a normal LVEF.\n - Continue aldactone and lasix per home regimen as her blood pressure\n tolerates.\n - Will closely monitor fluid status.\n # Atrial fibrillation: The patient is currently in atrial\n fibrillation. She is anticoagulated with warfarin as an outpatient.\n - Holding warfarin due to active bleeding.\n - Not on a rate-controlling as an outpatient (so far as we\n know). Will need to confirm home meds in the am. As above will use IV\n metoprolol prn to control her rate.\n # Thrombocytopenia: The patient has had platlets ranging from 74 to 98\n during this hospitalization. They have remained stable. Unknown what\n her baseline is. Unlikely to be HIT given that she is currently\n bleeding.\n - Obtain OSH records for baseline.\n - Trend\n ICU Care\n Nutrition: NPO, IVF prn\n Glycemic Control:\n Lines:\n 20 Gauge - 08:25 PM\n 18 Gauge - 02:57 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n" }, { "category": "Nursing", "chartdate": "2146-11-02 00:00:00.000", "description": "Nursing Progress Note", "row_id": 596362, "text": "Gastrointestinal bleed, lower (Hematochezia, BRBPR, GI Bleed, GIB)\n Assessment:\n Action:\n Response:\n Plan:\n Atrial fibrillation (Afib)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2146-11-02 00:00:00.000", "description": "Nursing Progress Note", "row_id": 596363, "text": "Ms is a 76 yo female with pmh of severe TR, Rt-sided CHF, and\n atrial fib being transferred to the for monitoring after\n undergoing a GI bleed today and ERCP with stent placement. She\n originally presented to Hospital with dyspnea and abdominal\n pain on . There she was found to have elevated LFTs and an ERCP\n was attempted on , however cannulation was unsuccessful. Her INR\n was 1.7 as she is on coumadin so she received 2 units of FFP prior to\n transfer.\n She was transferred to and repeat ERCP on again had\n unsuccessful cannulation, however a small pre-cut of the sphincter was\n attempted with slight oozing. Repeat ERCP on showed sludge and\n the sphincterotomy was extended. On she developed melena and her\n bilibrubin increased to 2; INR 1.4. Hct remained stable @ 34. Due to\n concern for hemobilia ERCP was repeated and bleeding was noted from the\n sphincterotomy site. Epinephrine was injected, a double pigtail CBD\n stent was placed, and Bicap thermal therapy was applied to the area.\n Bleeding decreased markedly in response to these interventions. Pt was\n transferred to MICU for further monitoring\n Gastrointestinal bleed, lower (Hematochezia, BRBPR, GI Bleed, GIB)\n Assessment:\n Received pt with continued melanotic loose stools, repeat Hct 31.2.\n Denying any nausea or vomiting. C/o epigastric pain. BP\n 130-150/60\ns, AF low 100\ns. Skin warm with good pedal pulses. Foley\n placed with good output. Lungs clear throughout. Sp02 96% RA.\n Afebrile.\n Action:\n Serial Hcts\n0200 Hct 29 and pt receiving 1 unit PRBC. Total of 1 L NS\n given over 2 hours. IV unasyn for s/p ERCP. PRN dialudid for pain\n Response:\n Repeat Hct pending. Pt had 2 small-medium episodes of melanotic liquid\n stool. BP 100/60; UO greater than 30 cc/hr. Pt up for most of night but\n denying pain after dialudid\n Plan:\n Continue with serial Hcts. Transfuse for Hct <30, IVF for UO <30 cc/hr.\n PRN dialudid for pain\n Atrial fibrillation (Afib)\n Assessment:\n Received pt in AF in the low 100\ns with obvious ST depressions on tele\n Action:\n Serial EKG\ns showing ST depression and T wave inversion, CE\ns sent and\n negative---gave total of 7.5 mg IV lopressor with 1 L NS.\n Response:\n AF 80\ns-90.\n Plan:\n Lopressor for HR >90; follow CE\n" }, { "category": "ECG", "chartdate": "2146-11-01 00:00:00.000", "description": "Report", "row_id": 234979, "text": "Atrial fibrillation with borderline rapid ventricular response. Left\nventricular hypertrophy. ST-T wave abnormalities. Since the previous tracing\nof QRS voltage is more prominent and ST-T wave abnormalities are more\nprominent.\n\n" }, { "category": "ECG", "chartdate": "2146-10-31 00:00:00.000", "description": "Report", "row_id": 234980, "text": "Atrial fibrillation. Diffuse non-specific T wave changes with T wave inversion\nin leads V1-V4 and flat T waves throughout the rest of the tracing. These\nchanges are non-specific. No previous tracing available for comparison.\n\n" }, { "category": "Radiology", "chartdate": "2146-11-09 00:00:00.000", "description": "UNILAT LOWER EXT VEINS", "row_id": 1100427, "text": " 10:29 AM\n UNILAT LOWER EXT VEINS Clip # \n Reason: assess for DVT in Right leg.\n Admitting Diagnosis: POST ERCP\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old woman with diastolic heart failure, recent GI bleed, s/p ercp for\n choledocolithiais.\n REASON FOR THIS EXAMINATION:\n assess for DVT in Right leg.\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): EAGg WED 1:33 PM\n Nonvisualization of one posterior tibial vein, otherwise, unremarkable right\n lower extremity ultrasound without evidence of DVT.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 76-year-old female with diastolic heart failure, recent GI bleed\n and status post ERCP for choledocholithiasis. Assess for DVT in the right\n leg.\n\n COMPARISON: No prior study available for comparison.\n\n RIGHT LOWER EXTREMITY ULTRASOUND: Grayscale and Doppler son of the right\n common femoral, superficial femoral, popliteal, and calf veins was performed.\n There is normal flow, compressibility, and augmentation of the veins. Please\n note that only posterior tibial vein was visualized.\n\n IMPRESSION: Nonvisualization of one posterior tibial vein, otherwise,\n unremarkable right lower extremity ultrasound without evidence of DVT.\n\n" }, { "category": "Radiology", "chartdate": "2146-11-09 00:00:00.000", "description": "UNILAT LOWER EXT VEINS", "row_id": 1100428, "text": ", C. MED 11R 10:29 AM\n UNILAT LOWER EXT VEINS Clip # \n Reason: assess for DVT in Right leg.\n Admitting Diagnosis: POST ERCP\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old woman with diastolic heart failure, recent GI bleed, s/p ercp for\n choledocolithiais.\n REASON FOR THIS EXAMINATION:\n assess for DVT in Right leg.\n ______________________________________________________________________________\n PFI REPORT\n Nonvisualization of one posterior tibial vein, otherwise, unremarkable right\n lower extremity ultrasound without evidence of DVT.\n\n" }, { "category": "Radiology", "chartdate": "2146-11-09 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1100426, "text": " 10:29 AM\n CHEST (PA & LAT) Clip # \n Reason: assess for CHF\n Admitting Diagnosis: POST ERCP\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old woman with dCHF, decreased BS on L\n REASON FOR THIS EXAMINATION:\n assess for CHF\n ______________________________________________________________________________\n FINAL REPORT\n PA AND LATERAL VIEWS OF THE CHEST\n\n REASON FOR EXAM: Decreased breath sounds on left, assess for CHF.\n\n No prior studies are available for comparison.\n\n There is moderate cardiomegaly. There is deformity of the chest wall in the\n left apex associated with pleural thickening at the apex, please correlate\n with surgical history. There is evidence of volume loss in the apex\n bilaterally with pleuroparenchymal scarring. Ovoid opacity in the right apex\n overlying the right clavicle measures 14 x 7 mm.\n Sternal wires are aligned. Bilateral pleural effusions are small.\n\n IMPRESSION: No evidence of overt CHF or pneumonia.\n\n Small bilateral pleural effusions.\n\n Findings in the upper lobes are of unknown chronicity and etiology.\n Correlation with prior studies is recommended to assess evolution. If not\n available, CT would be helpful to better assesment including the nodular\n opacity in the right side.\n\n\n" }, { "category": "Radiology", "chartdate": "2146-10-31 00:00:00.000", "description": "ERCP BILIARY&PANCREAS BY GI UNIT", "row_id": 1099106, "text": " 10:28 PM\n ERCP BILIARY&PANCREAS BY GI UNIT Clip # \n Reason: ERCP films from \n Admitting Diagnosis: POST ERCP\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old woman with dilated CBD and CBD sludge\n REASON FOR THIS EXAMINATION:\n ERCP films from \n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: CBD sludge.\n\n ERCP: Scout images demonstrate vascular calcifications of the right upper\n quadrant, likely within the common hepatic artery distribution. Subsequent\n images demonstrate cannulation of the common bile duct with scattered distal\n CBD filling defects, consistent with sludge. Moderate dilation of the CBD and\n intrahepatic bile ducts is present. The cystic duct and gallbladder appear\n unremarkable. A balloon sweep was performed. Please refer to the operative\n note for further details.\n\n IMPRESSION: Distal CBD sludge and diffuse biliary dilatation.\n\n" }, { "category": "Radiology", "chartdate": "2146-10-28 00:00:00.000", "description": "ERCP BILIARY&PANCREAS BY GI UNIT", "row_id": 1099025, "text": " 1:07 PM\n ERCP BILIARY&PANCREAS BY GI UNIT Clip # \n Reason: Scout film only\n Admitting Diagnosis: POST ERCP\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Scout film only\n REASON FOR THIS EXAMINATION:\n Scout film only\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Biliary disease.\n\n Two scout images were submitted from the operating room. These demonstrate\n vascular calcifications in the right upper quadrant, likely within the common\n hepatic artery circulation. Please refer to the operative note for further\n details.\n\n" }, { "category": "Radiology", "chartdate": "2146-11-04 00:00:00.000", "description": "RENAL U.S.", "row_id": 1099799, "text": " 2:08 PM\n RENAL U.S. Clip # \n Reason: HEMATURIA YESTERDAY. ACUTE RENAL FAILURE. ASSES FOR STRUCTURAL ETIOLOGY\n Admitting Diagnosis: POST ERCP\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old woman with amdission for choledocolithiasis, complicated by acute\n renal failure, hematuria yesterday\n REASON FOR THIS EXAMINATION:\n assess for structural etiology\n ______________________________________________________________________________\n FINAL REPORT\n RENAL ULTRASOUND\n\n INDICATION: 76-year-old woman with recent admission for choledocholithiasis\n complicated by acute renal failure and hematuria.\n\n FINDINGS: Right kidney measures 8.3 cm in length. Left kidney measuring 9.1\n cm in length. There is normal bilateral parenchymal width and echogenicity.\n No stones or hydronephrosis is identified. Small amount of perihepatic fluid\n is seen. The urinary bladder is catheterized and not distended.\n\n IMPRESSION: Normal renal ultrasound. Small amount of abdominal fluid.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2146-11-01 00:00:00.000", "description": "ERCP BILIARY&PANCREAS BY GI UNIT", "row_id": 1099319, "text": " 7:57 PM\n ERCP BILIARY&PANCREAS BY GI UNIT Clip # \n Reason: please review ERCP films from \n Admitting Diagnosis: POST ERCP\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old woman with CBD stent placement- sphincterotomy bleeding.\n REASON FOR THIS EXAMINATION:\n please review ERCP films from \n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 76-year-old female with CBD stent, bleeding from sphincterotomy.\n\n ERCP: Scout image demonstrates vascular calcifications in the right upper\n quadrant, likely in the common hepatic artery distribution. Subsequent images\n demonstrate cannulation of the common bile duct with moderate CBD and\n intrahepatic ductal dilatation. No definite filling defects were identified.\n A double pigtail biliary stent was placed. Please refer to the operative note\n for further details.\n\n IMPRESSION: Diffuse biliary dilatation, likely due to clotting at ampulla.\n\n" } ]

[ { "category": "Radiology", "chartdate": "2165-03-07 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 999001, "text": " 12:30 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: ptx\n Admitting Diagnosis: MITRAL REGURGITATION\\CARDIAC CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old man with s/p MV Repair on IABP\n REASON FOR THIS EXAMINATION:\n ptx\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: MVR, on IABP.\n\n CHEST, ONE VIEW: Comparison with . Intra-aortic balloon pump\n is approximately 10 cm below the superior aspect of the aortic arch and should\n be advanced. Please note that this was performed on a subsequent chest x-ray\n dated , 14:19 p.m. The inferior approach Swan-Ganz catheter\n has been replaced by a right internal jugular vein approach Swan-Ganz catheter\n which terminates in the region of the pulmonary artery trunk. The\n endotracheal tube is approximately 2.4 cm above the carina. Nasogastric tube\n courses below the diaphragm. Two mediastinal tubes, a left chest tube, and a\n right chest tube are new. The right pleural effusion has decreased in size;\n however, the left pleural effusion has probably increased slightly. There is\n also a mild amount of perihilar pulmonary edema, probably slightly worse than\n the last exam. No pneumothorax identified on this supine view. Osseous\n structures are notable for new sternotomy wires.\n\n IMPRESSION:\n 1. IABP pump 10 cm below the superior aspect of the aortic arch; please note\n that this was advanced as shown on the subsequent examination.\n 2. Decreased right pleural effusion, slightly increased small left pleural\n effusion. Left retrocardiac atelectasis unchanged.\n\n" }, { "category": "Radiology", "chartdate": "2165-03-04 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 998525, "text": " 5:47 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: eval for line placment\n Admitting Diagnosis: MITRAL REGURGITATION\\CARDIAC CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old man with severe MR now s/p PA catheter and IABP\n REASON FOR THIS EXAMINATION:\n eval for line placment\n ______________________________________________________________________________\n WET READ: AKSb MON 8:06 PM\n Cardiomegaly, b/l effusions, moderate interstitial edema. IABP in aorta,\n below arch, and PA catheter is presumably in main PA, can be advanced.\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 6:07 P.M. \n\n HISTORY: Severe mitral regurgitation. Pulmonary artery catheter and IABP.\n\n IMPRESSION: AP chest reviewed in the absence of prior chest radiographs:\n\n Tip of the intraaortic balloon pump projects just superior to the left main\n bronchus approximately 3 cm below the apex of the aortic knob. Heart is\n mildly enlarged. Pulmonary edema is mild. Small bilateral pleural effusions\n are presumed. Tip of the ascending Swan-Ganz catheter projects over the main\n pulmonary artery. No pneumothorax. Leftward displacement of the trachea at\n the thoracic inlet could be due to a goiter in the right lobe of the thyroid\n gland or tortuous and/or dilated head and neck vessels.\n\n\n" }, { "category": "Radiology", "chartdate": "2165-03-07 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 999013, "text": " 1:53 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: evaluation of lines - IABP advanced and ETT adjusted\n Admitting Diagnosis: MITRAL REGURGITATION\\CARDIAC CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old man with s/p mvr\n REASON FOR THIS EXAMINATION:\n evaluation of lines - IABP advanced and ETT adjusted\n ______________________________________________________________________________\n FINAL REPORT\n TYPE OF EXAMINATION: Chest AP portable single view.\n\n INDICATION: Evaluate lines, intra-aortic balloon pump device advanced an ETT\n adjusted.\n\n FINDINGS: AP single view of the chest obtained with patient in supine\n position is analyzed in direct comparison with a preceding similar examination\n obtained one-and-a-half hour earlier during the same day. The ETT terminates\n now in the trachea some 4 cm above the level of the carina. The Swan-Ganz\n catheter has been advanced by a few centimeters and terminates now in the\n central portion of the common right middle and lower lobe artery. Also the\n intra-aortic balloon pump has been adjusted and its tip is now projecting over\n the central portion of the aortic arch, thus in appropriate position.\n Appearance of bilateral chest tubes advance from below but metallic component\n of mitral valve annuloplasty unaltered. No new pulmonary parenchymal\n densities or significantly increased congestive pattern.\n\n IMPRESSION: Appropriate adjustments of indwelling devices.\n\n\n" }, { "category": "Radiology", "chartdate": "2165-03-05 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 998578, "text": " 7:51 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval placement of IABP\n Admitting Diagnosis: MITRAL REGURGITATION\\CARDIAC CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old man with new severe MR shock\n REASON FOR THIS EXAMINATION:\n eval placement of IABP\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: shock.\n\n CHEST, ONE VIEW: Comparison with , 21:31 and 18:07.\n Endotracheal tube, nasogastric tube, Swan-Ganz catheter, and IABP remain in\n position. Bilateral pleural effusions are layering, and are probably slightly\n worse than the last exam. Pulmonary edema is not discernibly improved\n compared to the 21:31 examination. Osseous structures remain unchanged.\n\n IMPRESSION: Probably worsening bilateral pleural effusions, without\n appreciable improvement in pulmonary edema since :31 . Findings\n discussed with Dr. by telephone at 10:30 a.m., .\n\n" }, { "category": "Radiology", "chartdate": "2165-03-04 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 998534, "text": " 9:13 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: assess line placements\n Admitting Diagnosis: MITRAL REGURGITATION\\CARDIAC CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old man with severe MR s/p PA catheter and IABP, now also s/p ETT and\n OGT placement\n REASON FOR THIS EXAMINATION:\n assess line placements\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Severe mitral regurgitation, intubated.\n\n CHEST, ONE VIEW: Comparison with , 18:07. A new endotracheal tube\n terminates approximately 3.0 cm above the carina. A new nasogastric tube\n courses below the end of the film in the stomach. An IABD terminates just\n below the aortic arch. A Swan-Ganz catheter from the femoral region\n terminates at the level of the main pulmonary artery. Cardiac, mediastinal,\n and hilar contours are similar, though mild pulmonary edema has slightly\n improved since three hours prior. Bilateral pleural effusions are probably\n similar to the last exam. Osseous structures are unchanged.\n\n IMPRESSION: Successful intubation and nasogastric tube placement. Mild\n pulmonary edema, slightly improved since three hours prior. Probably similar\n bilateral pleural effusions.\n\n\n" }, { "category": "Radiology", "chartdate": "2165-03-05 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 998623, "text": " 11:21 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: eval for ICH\n Admitting Diagnosis: MITRAL REGURGITATION\\CARDIAC CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old man with htn, hyperlipidemia w/ new 4+ MR shock s/p\n IABP w/ MS changes and recent fall.\n REASON FOR THIS EXAMINATION:\n eval for ICH\n CONTRAINDICATIONS for IV CONTRAST:\n recent cath\n ______________________________________________________________________________\n FINAL REPORT\n ROUTINE UNENHANCED HEAD CT.\n\n HISTORY: Hypertension, hyperlipidemia, shock status post intra-\n arterial balloon pump with mental status change and recent fall.\n\n There are no comparison studies.\n\n FINDINGS:\n\n No acute intracranial hemorrhage or acute transcortical infarction is seen.\n There are mild small vessel ischemic sequela in the subcortical and\n periventricular white matter. There is extensive bilateral cavernous carotid\n artery calcification.\n\n A tiny hyperdense focus is seen in the anterior third ventricle which could\n represent an incidental colloid cyst. This does not result in hydrocephalus\n and measures approximately 3 mm in greatest dimension.\n\n There is pooling of secretions in the nasopharyngeal lumen.\n\n This is likely related to endotracheal intubation. Scattered bilateral\n ethmoid opacification is seen.\n\n There is a focal hyperdense lesion in the right superior orbit which appears\n to be extraconal. This does not follow the hounsfield unit for bone and could\n represent a foriegn body_ or sequela of prior surgery. Please correlate with\n prior surgical history and a CT of the orbit with and without contrast can be\n performed for further evaluation if clinically indicated.\n\n IMPRESSION:\n\n No acute abnormality.\n\n Hyperdense lesion in the right superior orbit, please see above.\n (Over)\n\n 11:21 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: eval for ICH\n Admitting Diagnosis: MITRAL REGURGITATION\\CARDIAC CATH\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2165-03-06 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 998811, "text": " 12:33 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Please evaluate for infiltrate/consolidation / device placem\n Admitting Diagnosis: MITRAL REGURGITATION\\CARDIAC CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old man with cardiogenic shock, with IABP and intubated\n REASON FOR THIS EXAMINATION:\n Please evaluate for infiltrate/consolidation / device placement.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Followup.\n\n COMPARISON: .\n\n FINDINGS: In comparison with a previous examination, there are no major\n changes. Slight cardiomegaly, unchanged pleural effusions. No newly appeared\n opacities. The tubes and lines are also in unchanged position.\n\n IMPRESSION: Unchanged radiographic appearance as compared to previous\n examination.\n\n\n DR. \n" }, { "category": "Radiology", "chartdate": "2165-03-13 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 999974, "text": " 4:15 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for pleural effusions\n Admitting Diagnosis: MITRAL REGURGITATION\\CARDIAC CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old man s/p MV repair\n REASON FOR THIS EXAMINATION:\n eval for pleural effusions\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Evaluation for pleural effusions.\n\n COMPARISON: . In the interval, the monitoring and support\n devices has been removed.\n\n FINDINGS: There is subtle blunting of the costophrenic angles, consistent\n with mild bilateral pleural effusion. The extent of the effusion is not\n extensive. The size of the heart is slightly over the normal limits.\n\n IMPRESSION: No signs of pneumonia, no overhydration.\n\n\n DR. \n" }, { "category": "Radiology", "chartdate": "2165-03-10 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 999438, "text": " 11:20 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate post chest tube removal\n Admitting Diagnosis: MITRAL REGURGITATION\\CARDIAC CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old man with recent mitral valve surgery -\n REASON FOR THIS EXAMINATION:\n evaluate post chest tube removal\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE AP PORTABLE VIEW OF THE CHEST.\n\n REASON FOR EXAM: S/P recent mitral valve surgery post chest tube removal.\n\n Comparison is made with prior study .\n\n Right chest tube has been removed. There is no pneumothorax but note is made\n that the right CP angle was not included on the film. ET tube tip is 4.3 cm\n above the carina. Right Swan-Ganz catheter tip is in the main pulmonary\n artery. The inferior aspect of the left hemithorax was also not included in\n the film. Cardiomegaly is stable. Mild interstitial pulmonary edema has\n improved. NG tube tip is not visualized. Small right and moderate left\n pleural effusions are stable.\n\n\n DR. \n" }, { "category": "Radiology", "chartdate": "2165-03-14 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1000061, "text": " 8:26 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for pleural effusions\n Admitting Diagnosis: MITRAL REGURGITATION\\CARDIAC CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old man s/p MR repair\n REASON FOR THIS EXAMINATION:\n eval for pleural effusions\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST, .\n\n COMPARISON: .\n\n INDICATION: Pleural effusion assessment.\n\n Small left pleural effusion has slightly increased in size with adjacent\n worsening atelectasis at the left lung base. Small right pleural effusion is\n unchanged. The remainder of the exam is also without change.\n\n\n" }, { "category": "Echo", "chartdate": "2165-03-07 00:00:00.000", "description": "Report", "row_id": 85973, "text": "PATIENT/TEST INFORMATION:\nIndication: Aortic valve disease. Congestive heart failure. Left ventricular function. Mitral valve disease. Mitral valve prolapse. Right ventricular function. Valvular heart disease.\nStatus: Inpatient\nDate/Time: at 09:52\nTest: TEE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Marked LA enlargement. No spontaneous echo contrast in the body\nof the LAA. All four pulmonary veins identified and enter the left\natrium.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. A catheter or pacing wire is\nseen in the RA. No ASD by 2D or color Doppler.\n\nLEFT VENTRICLE: Normal LV wall thickness. Top normal/borderline dilated LV\ncavity size. Moderately depressed LVEF.\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: basal anterior\n- hypo; mid anterior - hypo; basal anteroseptal - hypo; mid anteroseptal -\nhypo; basal inferoseptal - hypo; mid inferoseptal - hypo; basal inferior -\nhypo; mid inferior - hypo; basal inferolateral - hypo; mid inferolateral -\nhypo; basal anterolateral - hypo; mid anterolateral - hypo; anterior apex -\nhypo; septal apex - hypo; inferior apex - hypo; lateral apex - hypo; apex -\nhypo;\n\nRIGHT VENTRICLE: Mildly dilated RV cavity. Moderate global RV free wall\nhypokinesis.\n\nAORTA: Normal aortic diameter at the sinus level. Normal ascending aorta\ndiameter. Simple atheroma in descending aorta.\n\nAORTIC VALVE: Three aortic valve leaflets. Mildly thickened aortic valve\nleaflets. No AS. Mild to moderate (+) AR.\n\nMITRAL VALVE: Moderately thickened mitral valve leaflets. Elongated mitral\nvalve leaflets. Moderate/severe MVP. Partial mitral leaflet flail. Eccentric\nMR jet. Severe (4+) MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial 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. The TEE probe was passed\nwith assistance from the anesthesioology staff using a laryngoscope. No TEE\nrelated complications.\n\nConclusions:\nThe left atrium is markedly dilated. No spontaneous echo contrast is seen in\nthe body of the left atrium or left atrial appendage. No atrial septal defect\nis seen by 2D or color Doppler. Left ventricular wall thicknesses are normal.\nThe left ventricular cavity size is top normal/borderline dilated. Overall\nleft ventricular systolic function is moderately depressed (LVEF= 30-40%). The\nright ventricular cavity is mildly dilated with moderate global free wall\nhypokinesis. There are simple atheroma in the descending thoracic aorta. There\nare three aortic valve leaflets. The aortic valve leaflets are mildly\nthickened. There is no aortic valve stenosis. Mild to moderate (+) aortic\nregurgitation is seen. The mitral valve leaflets are moderately thickened. The\nmitral valve leaflets are elongated. There is moderate/severe mitral valve\nprolapse. There is partial mitral leaflet flail. An eccentric, XXX directed\njet of Severe (4+) mitral regurgitation is seen.\n\nPOST CPB:\n\n1. Posterior annuloplasty ring in mitral position. Well seated and stable.\n\n2. No evidence of dynamoc LVOT obstruction.\n\n3. MVA by PHT = 2.5 cm2.\n\n5. Mean Gradient acorss mitral vlave = 2 mm Hg\n\n6. Improved RV systolic function with inotropic support.\n\n7. Improved LV systolic function\n\n\n" }, { "category": "Echo", "chartdate": "2165-03-04 00:00:00.000", "description": "Report", "row_id": 85974, "text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. Myocardial infarction. Preoperative assessment.\nWeight (lb): 205\nBP (mm Hg): 97/44\nHR (bpm): 105\nStatus: Inpatient\nDate/Time: at 17:00\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Dilated LA.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in the RA\nand extending into the RV.\n\nLEFT VENTRICLE: Mild symmetric LVH with normal cavity size. Normal regional LV\nsystolic function. [Intrinsic LV systolic function likely depressed given the\nseverity of valvular regurgitation.] No VSD.\n\nRIGHT VENTRICLE: Markedly dilated RV cavity. Moderate global RV free wall\nhypokinesis. Abnormal septal motion/position consistent with RV\npressure/volume overload.\n\nAORTA: Mildly dilated aortic sinus. Normal ascending aorta diameter.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. No valvular AS. The\nincreased transaortic velocity is related to high cardiac output.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Partial mitral leaflet\nflail. Severe (4+) MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Moderate [2+] TR. Moderate\nPA systolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with\nphysiologic PR.\n\nPERICARDIUM: No pericardial effusion.\n\nConclusions:\nThe left atrium is dilated. There is mild symmetric left ventricular\nhypertrophy with normal cavity size. Regional left ventricular wall motion is\nnormal. [Intrinsic left ventricular systolic function is likely more depressed\ngiven the severity of valvular regurgitation.] There is no ventricular septal\ndefect. The right ventricular cavity is markedly dilated with moderate global\nfree wall hypokinesis. There is abnormal septal motion/position consistent\nwith right ventricular pressure/volume overload. The aortic root is mildly\ndilated at the sinus level. The aortic valve leaflets (3) appear structurally\nnormal with good leaflet excursion and no aortic stenosis. There is no\nvalvular aortic stenosis. The increased transaortic velocity is likely related\nto high cardiac output. The mitral valve leaflets are mildly thickened. There\nis partial mitral leaflet flail of the posterior mitral valve leaflet. The\npapillary muscles appear intact. Severe (4+) mitral regurgitation is seen.\nModerate [2+] tricuspid regurgitation is seen. There is moderate pulmonary\nartery systolic hypertension. There is no pericardial effusion.\n\nIMPRESSION: Severe acute mitral regurgitation likely due to chordal rupture\nand partial leaflet flail rather than papillary muscle dysfunction or rupture.\nMarkedly dilated right ventricle with moderate to severe RV hypokinesis and\nevidence of RV pressure/volume overload. Left ventricular function appears\nintact without regional dysfunction. Moderate pulmonary artery systolic\nhypertension.\n\nDrs. and were present in the emergency room during this\npatient's study.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2165-03-04 00:00:00.000", "description": "Report", "row_id": 1671490, "text": "CCU Nursing Progress Note\n79yom with h/o 2+MR 2 years ago, HTN, hyperlipidemia, diverticulitis and ETOH, went to OSH for severe SOB. Was found to be CHF, ROMI but Echo revealed 4+MR posterior leaflet, 3+TR with severe pulmonary HTN peak systolic 100mmhg and good LVEF 65%. Transferred to cath lab on 4l np but had started to DT PTA. Cath lab revealed elevated filling pressures PAP PWP 25 MVO2 42 CI 1.6 IABP placed right fem with PA catheter, received lasix 40mg IVB 1600.\n\nROS: Neuro arrived from cath lab obtunded in 4 point restraints. Never opened eyes but could hear and repeat what was said to him. After trying to turn pt he became aggitiated pulling at invasive lines. Intern/resident into examine and pt recevied valium 5mg IVB 1700 and repeated 5mg, 1 hr later at 1800. Presently pt to be intubated.\nCV-VSS IABP 1:1 right groin with good aumentation and systolic unloading MAP 80's. Hemodynamics revealed PAP 74/40 CVP 20 CO/CI/SVR 5.3/2.5/543 with MvO2 64%. Heparin started 1000 units/hr at 1730. Poor response to lasix 40mg and repeated with 80mg IVB 1740.\nResp-Somulent with poor inspiratory effort, using abd accessory muscles on 100% NRB 6l np O2 sats 95%. ABG 7.28/64/196. Anesthesia called for non emergent intubation pre-op.\nID WBC 13.4 afebrile on levoquin for \"cough\" at OSH.\nGU-BUN/Cr 41/1.5 s/p 45cc contrast. Foley with amber urine, poor response to lasix 40mg-repeat with 80mg with poor response.\nGI-obese abd with hypoactive BS through out. NPO Elevated\nSkin-right fem groin small amount to bleeding at site no hematoma. Pedal pulses are weak palpable/warm.\nAccess-right fem IABP, with art blood access side arm, right fem PA catheter, 1 PIV.\nSocial-married with for 2 years, he has a son and daughter. also +ETOH having fights with step mother and his sister... Found in the pt room crying after his son yelled at her for not telling him he was in the hospital. The patient did not want him to know. Social service consult.\nA/P-79yom with 4+MR leaflet now on IABP waiting for MVR in am. Aggressive diuresis overnight possible lasix gtt. Intubate and continue valium/versed prn bolus. Keep family aware of POC as discussed in mulitdisciplinary rounds.\n\n" }, { "category": "Nursing/other", "chartdate": "2165-03-04 00:00:00.000", "description": "Report", "row_id": 1671491, "text": "RESPIRATORY CARE: PT INTUBATED FOR IMPENDING RESPIRATORY\nFAILURE W/ 7.5 ORAL ETT AND PLACED ON VENTILATORY\nSUPPORT/ SEDATED BY RN AS PER CV. TO OR IN AM.\n" }, { "category": "Nursing/other", "chartdate": "2165-03-05 00:00:00.000", "description": "Report", "row_id": 1671492, "text": "ccu nsg progress note.\n79 yo male w 2yr hx mvp x 2+mr-refused surgical intervention in the past.\n admitted to osh w acute onset of sever sob.\n echo-new 4+mr & leaflet. new 3+tr. sever pulm htn. preserved lvef. & non- dilated lv. r/o mi. neg cspine (fall prior to admission). neg cta chest-r/o pe. cultured-all neg (bc, urine, & influenza a/b). increased confusion (baseline- confused)-?etoh wdrawl ( mixed drinks/night).\n transfered to for further management. cardiac cath- rhc-elevated r/l filling pressures. lhc-non-obstructive cad, iabp placed. tee-sever mr ? due to chordal rupture & partial leaflet . markedly dilated rv w mod/sever rv hypokensis & evidence of rv pressure/volume overload. lv intact. moderate pulm htn. admiited to ccu for further management & surical evaluation.\n\no:sedated w fent/versed gtts. responds to noxious stim w wdrawl. does not follow simple commands. becomes restless/agitated w minimal stimuli. soft restraints to upper extrem. leg immobilizers x2 r/l. intubated/vented-settings adjusted to o2 sats & abgs. requiring increased peep-8 to improve oxygenation & allow decrease in fio2. breath sounds= course throughout. sx-thick tan/blood tinged secretions. sr to st w freq/occasional pacs. iabp 1:1 w gd systolic/diastolic unloading & gd augmentation. dopa added to maintain iabp maps >60. pads upper 20 to low 30's. ci>2. heparin gtt w theraputic ptt. pulses >=1+bilaterally. npo. ogt lis-bilious. lasix gtt started- diuresing well. afebrile-bc & urine sent. intact skin. am labs sent. access-vip swan & peripheral iv x1. son called & up-dated on dad's condition.\n\na:gd sedation w fent/versed gtts. improved oxygenation w increased peep & diuresis. requiring dopa to maint iabp maps >60.\n\np:contin present management. needs ?head ct &/or mri. ?surgical date. support pt/family as indicated.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2165-03-08 00:00:00.000", "description": "Report", "row_id": 1671508, "text": "Resp. care note - Pt. remaines intubated and vented, weaned to PSV tol ok at this time.\n" }, { "category": "Nursing/other", "chartdate": "2165-03-11 00:00:00.000", "description": "Report", "row_id": 1671522, "text": "Respiratory Care Note\nPt received on PSV 5/5. Pt placed on SBT 5/0 as noted. Pt tolerated well with a RSBI of 76 with a VT 342 and RR 26 and good follow up ABG. Subglottic suctioning done prior to extubation. Pt had a positive cuff leak test. Pt extubated to cool aerosol. Post-extubation ABG with a PaO2 63. Pt has upper airway congestion which clears with NT suctioning. Sats in low 90's - face tent replaced with aerosol mask. Sats increased to mid to high 90's. Pt up in chair and doing much better.\n" }, { "category": "Nursing/other", "chartdate": "2165-03-08 00:00:00.000", "description": "Report", "row_id": 1671509, "text": "0700-1900:\nneuro: sedation turned off and pt followed commands, was able to wiggle toes and opened eyes to command. pt then resedated on propofol gtt. perrl. grimaces to painful stimuli, + cough reflex. t max 99.7. morphine given prn pain with good effect.\n\ncv: a paced at times for hemodynamic support, nsr 60's, pvcs noted. electrolytes repleted as needed. iabp to right groin with good augmentation and unloading, d/c'd by pa at 1245. site wnl, no hematoma and pp bilaterally. right foot slightly cool with good capillary refill. ci remains > 2 throughout day with mixed venous > 65. pt does drop svo2 with activity but resolves quickly once resedated. filling pressures 40-50's/20's. cvp 10-13.\n\nresp: lungs rhoncherous at times, clear with suctioning. suctioned for thick bloody secretions. remains orally intubated on cpap with good abg. attempted to wean pressure support with high rr and low tidal volume. ct to 20 cm sxn, no airleak. serosanguinous drainage, decreased amounts. o2 sat pleth difficult to obtaib at times, but 99% on abg.\n\ngi/gu: abd soft, nd. bs positive. ogt to lws with bilious drainage. foley to gravity, good huo. cr wnl.\n\nendo: fs qid, cover per riss.\n\nplan: monitor hemodynamics, keep sedated overnight and attempt to wean vent in am.\n" }, { "category": "Nursing/other", "chartdate": "2165-03-08 00:00:00.000", "description": "Report", "row_id": 1671510, "text": "nursing note 7p to 11p:\nallergies: NKDA\n\nneuro: difficult to access d/t intubation, has hx of alcohol withdrawl was intubated for a/w protection prior to surgery), no response to painful stimuli, + aggitation with repositioning (coughing & gagging w/decreased sats), PERRL, remains on propofol gtt for sedation and receiving morphine iv for pain\n\nresp: vented (50%/rate 24/PEEP 5/PS 14) sats 100%, suctioned for small amounts of bloody tinged thick secretions, lungs clear in all lobes, ct w/straw drainage, attempted to wean PS to 10 at beginning of shift abg good but tv decreased to 200's and rr ^ to 30's ^ PS to 14, pat. appears comfortable, no plan on weaning again tonight md\n\ncardio: hr 60's nsr w/occas. pvc's, a-line pressure >100 systolically w/mean in the mid 80's, neosynephrine decreased to 0.3 mcg @ 2130, pad's low 20's (hx of severe pulm htn), cvp 9-11, ci > 3.o w/ co > 6L/min, pacing wires w/back up rate of 40 & MV @ 7, a-wires checked not capturing, doppler pulses, rt. fem iabp site intact w/no drainage, upper extremities w/slight edema\n\ngu/gi: foley w/good uo, obese, +bs w/no bm, abdomen soft\n\nid: receiving cipro & vanco\n\nendo: covered w/cvicu sliding scale\n\nplan/goal: con't to wean neosynephrine if tolerated, attempt to wean vent in the a.m., con't monitoring hemodynamics, con't w/nursing care plan\n" }, { "category": "Nursing/other", "chartdate": "2165-03-09 00:00:00.000", "description": "Report", "row_id": 1671511, "text": "Resp Care: Pt recieved on PSV 10/5 50%. Pt tachypnic with RR in 30's and VT of 200-> PS increased to 14 with good results. LS clear/diminished bilaterally. Pt suctioned for scant to small amounts of blood-tinged secretions. Most recent ABG: 7.43/43/117/29/4. PLAN: wean PS as tolerated.\n\n" }, { "category": "Nursing/other", "chartdate": "2165-03-12 00:00:00.000", "description": "Report", "row_id": 1671523, "text": "Neuro: Pt alert, acutely confused, can only tell his own name, saying it's \"8008\" for year, \"I need to go to work & catch the train\", yelling out names and talking to self which was not understandable; following commands inconsistently, MAE's, PERRL 3mm brisk; getting more agitated towards AM, did not sleep at all, talking to self all night\n\nCV: Afebrile; SR 80's-90's with freq PVC's, 9 beats run VT x2, Mg, K, Ca repleted, SBP by a line 130's-170's, NIBP consistently 120's, PA awared of discrepency; on NTG gtt @ 4mcg/kg/min, 10 mg IV lopressor q4h, 0.625 vasotec IV q6h with minimal effect; 2A 2V wires, A wires do not work, V wires sense & capture, pacer turned off; palp pulses x4\n\nResp: Lung sound clear, dim @ bases, expectorated secretion, pt swallow back; on closed face mask with 40% FiO2, sat 97-99%; not follwoing commands appropriately, not able to given MDI\n\nGI: Abd soft, hypo bowel sound; strict NPO, speech & swallow eval today; no BM\n\nGU: Foley draining clear yellow urine, brisk diuresis with IV lasix\n\nInteg: Intact, slight redness on coccyx, no breakdown\n\nEndo: Cover per protocol\n\nID: WBC WNL\n\nSocial: No calls overnight\n\nPlan: monitor hemodynamics, resp status, labs; monitor mental status; safety; speech & swallo today; wean NTG as tol, ?change antihypertensive regimen if NTG is not effective\n" }, { "category": "Nursing/other", "chartdate": "2165-03-07 00:00:00.000", "description": "Report", "row_id": 1671502, "text": "resp care - Pt recieved from OR intubated w/ #7.5ETT, 23@lip. ETT moved to 22@lip per PA and CXR. Pt is on full vent support with settings changed per ABGs. BLBS are clear. Plan is to keep pt. intubated overNOC. See carevue for details.\n" }, { "category": "Nursing/other", "chartdate": "2165-03-07 00:00:00.000", "description": "Report", "row_id": 1671503, "text": "iabp repositioned with improved trace. central lumen transduced for alarm purposes.\n" }, { "category": "Nursing/other", "chartdate": "2165-03-07 00:00:00.000", "description": "Report", "row_id": 1671504, "text": "extremely labile bp with low filling pressures, marginal svo2 & ci, brisk huo & frequent pvc's with occasional couplets. volume given,low dose epi resumed(had been turned off on arrival for sbp > 170) with improvement but continues with lability & high volume needs,see flow sheet.lytes repleted & a paced for ventricular ectopy supression with significant improvement. v wires not tested as yet d/t above & hypokalemia.iabp with generally good augmentation & unloading. feet warm bilat. with dopplerable pulses x 4.hypotension with rigid extremities,coughing after turning with rise in cvp & pap although pupils remain pinpoint bilat. propofol increased & morphine given with improvement.family in,son & wife will share spokesperson role at family request.\n" }, { "category": "Nursing/other", "chartdate": "2165-03-07 00:00:00.000", "description": "Report", "row_id": 1671505, "text": "hemodynamics & bp finally settled out after prbc's given. remains on low dose epi & neo w ci > 2 by FICK,svo2 > 65%,warm extremities & adequate huo.plan to wean iabp tomorrow & dc if possible(cardiology to remove) then wake & wean vent as tolerated.cipro started x 5 days for + ua. duoderm intact on coccyx from ccu,not removed for inspection.\n" }, { "category": "Nursing/other", "chartdate": "2165-03-08 00:00:00.000", "description": "Report", "row_id": 1671506, "text": "pt remained on full vent support through shift as planned due to balloon pump remaining. sx'd for minimal secretions. plan to be revakuated for possibility of weaning on AM rounds.\n" }, { "category": "Nursing/other", "chartdate": "2165-03-08 00:00:00.000", "description": "Report", "row_id": 1671507, "text": "CVICU NPN\nO: ROS\n\nNeuro: Maintained sedated on propofol and given morphine for turning x1. PEARL 2mm bilat. Impaired gag, cough. Minimal movement while sedated. Pt turned x2 w/ poor toleration d/t hemodynamic compromise. Sv02 and BP dipped w/ slow recovery.\n\nCV: Apaced for inc vea and hypotension. This am in nsr 60's w/ freq apc's. VEA resolved w/ electrolyte repletion. Placed on vvi pacer at 50. Cont on neo and epi w/ Map >60 and stable CO/CI. Cont on IABP 1:1 w/ consistent systolic and diastolic unloading and gd augmentation. Pedal pulses dopplerable w/ gd csm. FP stable, received 1 liter fluid for low cvp and hypotension w/ gd effect.\n\nResp: Remains fully vented w/ no attempts to wean. Stable abg on imv. 02sats 97-100% on 50% and 5peep. LS coarse, sxned for mod amt thick bld tinged secretions.\n\nRenal: Adequate u/o . Body balance even this am. Lytes repleted and wnl.\n\nGi: Abd soft/distended, no bs. OGT to lcs w/ bilious dnge. Carafate and zantac.\n\nEndo: Insulin gtt weaned off w/ stable BS 105.\n\nHeme: Hct 27.6, inr 1.2 Moderate amt serosang dnge via ct, total since mn 330cc.\n\nID: Tmax 37.2, wbc 7.6. Remains on cipro, vanco.\n\nSkin: Sternal and mediastinal dsgs D&I. Feet warm w/ gd csm. Duoderm to coccyx area intact.\n\nSH: No family contact .\n\nA: Hemodynamically stable on Epi, neo and IABP 1:1.\n\nP: Cont to monitor and support hemodynamics. Wean pressors, then IABP. Cont pulm toilet. Propofol is off at present. Cont to monitor NVS. Monitor for DT's. Once IABP is d/ced, wake, wean and extubate.\nMonito fluid balance, replete lytes.\n" }, { "category": "Nursing/other", "chartdate": "2165-03-11 00:00:00.000", "description": "Report", "row_id": 1671520, "text": "S/P MVR .\n\nNEURO: OPENS EYES TO VOICE, TRACKS. MOVING TOES ON BOTH FEET TO COMMAND, SQUEEZING WITH R HAND ON COMMAND, NO MOVEMENT L HAND ON COMMAND. PEARL AT 3MM/BRISK. PROPOFOL GTT WEANED FROM 30MCG/KG TO 20 MCG/KG. MORPHINE 2MG IV X 2 PRIOR TO REPOSITIONING.\n\nPULM: CPAP MODE, PS 10 ALL SHIFT, ABG GOOD. PS DECREASED TO 5 AT 0650. LESS UNCONTROLLED COUGHING SPELLS SINCE CHEST TUBES DC'D. LUNGS CLEAR AFTER SX. SECRETIONS THIN CLEAR FROM MOUTH AND ETT.\n\nCV: NSR WITH FREQUENT ECTOPY, PAC'S AND PVC'S DESPITE AGGRESSIVE ELECTROLYTE REPLETION. OFF NEO GTT, MAP > 60. CCO SWAN VIA RIJ, SVO2 70'S-80'S, FICK CO/CI GOOD. CCO RECALED AT 0200 TO MV02 75/HGB 9.7. PAS UP TO 80'S WITH COUGHING, 50'S WHEN QUIET. CVP ~ 5. HCT 27.3PEDAL PULSES DOPPLED, EXTREMITIES W&D. L RADIAL ALINE SITE WNL, POSITIONAL. STERNAL INCISISON CLEAN AND DRY, DSG CHANGED.\n\nENDO: QID SSRI COVERAGE. 6 UNITS REGULAR INSULIN SC AT 0620 FOR FSBS 168.\n\nGI: ABDOMEN SOFT, + BS. OGT TO LCS DRAINED 200CC BILIOUS FLUID, PLACEMENT VERIFIED Q4H.\n\nRENAL: 1400 CC RESPONSE TO IV LASIX. NEGATIVE 2.1 LITERS AT 2300. CREATININE 0.7/BUN 13.\n\nSOCIAL: WIFE CALLED IN FOR UPDATE ~ 2100.\n\nPLAN: DC PROPOFOL, WEAN TO EXTUBATE IF ABLE. CONTINUE DIURESIS. DC CCO THIS AM. ? REWIRE CORDIS FOR TRIPLE LUMEN ACCESS. EVALUATE FOR NUTRITION, ? IVHA IF NOT ABLE TO EXTUBATE TODAY.\n" }, { "category": "Nursing/other", "chartdate": "2165-03-11 00:00:00.000", "description": "Report", "row_id": 1671521, "text": "7a-7p\nNeuro: Pt alert, following commands, mae's. Pt c/o pain this am with turning, iv push morphine given for repos with good relief. When pt extubated alert/ oriented to self/ year not to place.\n\nCV: Tele sr with frequent pvc's. Lytes repleted, palpable pulses. Goal sbp 130's, nitro drip titrated for sbp <130's. 5mg iv push lopressorx2 doses given np for heart rate in the 100's with ventricular bigeminy. Pa pressures 50's/20's, team aware. Svo2 70's-80's, cvp 2-3, swan d/c'd without incident per team.\n\nResp: Pt received on cpap 50% 5/5, weaned to 5/0, ok to extubate np . Pt placed on open face tent, sats 90%, cough/ deep breathe/ is. Turned/ chest pt done, sats still 92%. Placed on high closed face mask. Sats increased to 96%. Pt has lots of secretions, Sx mouth for thin white secretions. rr20's, aggressive pulmonary toilet.\n\nGI/GU: abd soft, hypoactive, ? aspiration precautions, pt has a gag/ weak cough. Attempted ice chips coughed after 1 ice chip. Np aware. NPO until further swallow eval. foley to gravity draining adequate amounts of urine.\n\nEndo: regular insulin sliding scale per cvicu protocol\n\nSkin: see flowsheet\n\nSocial: Wife in to visit updated on , also called updated on per wife.\n\nPlan: Continue aggressive pulmonary toilet, sx prn for secretions. Pain mgmt, ? speech/swallow, wean nitro drip as pt tolerates.\n" }, { "category": "Nursing/other", "chartdate": "2165-03-10 00:00:00.000", "description": "Report", "row_id": 1671516, "text": "S/P MVR.\n\nNEURO: ORALLY INTUBATED, SEDATED ON PROPOFOL GTT AT 30MCG/KG. ATTEMPTS TO OPEN EYES WHEN NAME IS CALLED, DOES NOT FOLLOW COMMAND. NO MOVEMENT OF EXTREMITIES, FLACCID WITH TURNING. PEARL AT 3MM.\n\nPULM: CPAP MODE, PS 14. NO VENT WEANING. COUGH WITH COPIOUS AMTS THIN ORAL AND ETT SECRETIONS WITH ANY MOVING, DROP IN SAT(84) AND SVO2(48) WITH REPOSITIONING/COUGHING. LUNGS CLEAR AFTER SUCTIONING.\n\nCV: NSR WITH OCCASIONAL PVC, PAC, V PACED BEATS WHEN HR DROPS BELOW 60. MAG, CA, K REPLETED PER LABS. NEO GTT ON MOST OF SHIFT TO KEEP MAP > 60. CCO RIJ, SVO2 70'S MOST OF SHIFT, DROPS TO 48 WITH REPOSTIONING. PEDAL PULSES DOPPLED.\n\nENDO: QID SSRI COVERAGE OF BLD SUGARS.\n\nGI: ABDOMEN SOFT, + BS, OGT TO LCS, MINIMAL BILIOUS DRAINAGE.\n\nRENAL: GREAT DIRUESIS FROM LASIX. 2300 OUTPUT 1.4 LITERS NEGATIVE. WEIGHT DOWN.\n\nPLAN: ATTEMPT TO WEAN OFF PROPOFOL AGAIN THIS AM, ? WEAN DOWN PS. NEO GTT TO KEEP MAP > 60. SX PRN.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2165-03-10 00:00:00.000", "description": "Report", "row_id": 1671517, "text": "Resp. care note - Pt. remaines intubated and vented, PS weaned to 12cmH2O tol ok at this time.\n" }, { "category": "Nursing/other", "chartdate": "2165-03-10 00:00:00.000", "description": "Report", "row_id": 1671518, "text": "POD #3 MV ring\nNsr with up to 11 pvc/min. 1 episode of ventricular bigeminy. Neosynephrine weaned off. Distal extremities warm. General edema noted - distal extremities and genitals.\n\nBreathsounds coarse at times. ETT suctioned several times per hour by several staff members for thin, clear secretions. Copious thin, clear oral secretions noted. Wife and daughter (a dental hygenist) commented that Mr. has been drooling for 5-10years (soaking his pillow). Difficult to contain secretions. Constant oral suctioning required. Mediastinal and L pleural CT removed. CXR done. CPAP w/14PS weaned to 10. Plan to aim for extubation over the next couple of days.\n\nNo nutrition. Post pyloric feeding tube desired by Dr. in 1-2days if extubation doesn't take place. No parenteral and enteral feeding at this time. Caution to be used due to aspiration rist. Bowel sounds present. No stool.\n\nContinues on Cipro for bronchitis. No fever today.\n\nContinue to appear drowsy. Did open eyes for Dr. when his name was called. Did open his eyes when his wife called his name at the bedside. No spontaneous movement of extremities noted.\n\nNo evidence of pain. No morphine given this shift. Would like to have propofol off but continuous coughing a problem when propofol dose lowered. Need to use caution with so much coughing for sternal wound healing (as discussed by Dr. \n\nSkin intact.\n\nPlan to continue to suction oral secretions and keep ett clear. Plan to continue to wean pressure support. Plan to wean propofol. Plan to monitor nutritional needs.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2165-03-11 00:00:00.000", "description": "Report", "row_id": 1671519, "text": "Resp Care: Pt continue on mechanical ventilation: PSV 10/5 50%. No changes overnight. VE 9-10LPM. LS essentially clear; coarse at times but clear with suction. Pt sxn'd for small to moderate amounts of thick tan secretions. RSBI this am: 109. Most recent ABG: 7.44/52/109/36/9/98. PLAN: continue to wean as tolerated.\n" }, { "category": "Nursing/other", "chartdate": "2165-03-05 00:00:00.000", "description": "Report", "row_id": 1671495, "text": "RESPIRATORY CARE: PT W/ A 7.5 ORAL ETT IN PLACE.\nPT IS SEDATED BUT FAIRLY AROUSABLE TO VOICE.\nREMAINS ON THE AC MODE AS PER CV. ABG STABLE. NO\nCHANGES. IABP 1:1 REMAINS. SURGERY PLANNED FOR\nLATER IN WEEK. SX FOR BLOOD-TINGED SPUTUM.\nWILL C/W AC MODE AS TOLERATED.\n" }, { "category": "Nursing/other", "chartdate": "2165-03-06 00:00:00.000", "description": "Report", "row_id": 1671496, "text": "Resp Care: Pt continues intubated #7.5 oett secured @ 23 @ lip and on ventilatory support with a/c, fi02 down with improved oxygenation; bs clear to coarse, sxn thick bloody secretions, rsbi held d/t hemodynamic status, will cont full support while awaiting OR.\n" }, { "category": "Nursing/other", "chartdate": "2165-03-06 00:00:00.000", "description": "Report", "row_id": 1671497, "text": "ccu nsg progress note.\no:sedated w fent/versed gtts w effect. arousable to stimuli-not following commands. wo agitation when stimulated. moving all extrem on bed. remains intubated/vented w present setting-ac/600x14,50%,+5 w am abg-7.49/42/101/33/8 & sats upper 90's. breath sounds=course through- out. sx-thick tannish bl tinged secretions. hemody stable. nsr w occassional pvc's. iabp 1:1 w maps 60's on dopamine 6mcg/kg/min, adequate systolic/diastolic unloading, & gd augmentation. 0500 co/ci-7.3/3.44. heparin gtt adjusted to ptt-increased from 1440u to 1600u @ 0500 for ptt-58.3. npo. ogt lis-bilious. wo stool. lasix gtt contin @ 5mg/hr. neg 1l @ 2300 & approx 400ml @ 0500. k replaced @ 2200 & 0500 & calcium @ 2200. low grade t-99.5 on abx.\n\na:stable @ present. awaiting cardiac -?date.\n\np:contin present management. support pt/family as indicated.\n" }, { "category": "Nursing/other", "chartdate": "2165-03-06 00:00:00.000", "description": "Report", "row_id": 1671498, "text": "Respiratory care\nPt remains intubated , no vent changes this shift, Plan to go to or tommorrow.\n" }, { "category": "Nursing/other", "chartdate": "2165-03-06 00:00:00.000", "description": "Report", "row_id": 1671499, "text": "Nursing Progress Note\n\nO: Please see flow sheet for objective data. Tele sinus rhythm with occ-frequent PVC's. IABP remains on 1:1 with good augmentation. Augmented MAP's >60. Dopamine conts at 6mcgs/kg/min. IV Heparin at 1600units/hr. Lasix drip at 5mg/hr. R groin conts with sm ooze, no hematoma, LE are warm with trace pulses. Seen by CT surgery this pm with plan for MVR in am.\n\nResp: Pt remains intubated. A/C 50% 600 x's 14 8. No changes made during this shift. O2 sats 96-99%. Lungs rales in bases. suctioned for mod amts of thick bldy sputum as well as copious amts of oral secretions.\n\nNeuro: Pt received on Versed 7mg/hr and Fentanyl at 100mcgs/hr. Versed off for short period of time this am. Pt able to follow commands and respond to his name, MAE. Versed restarted at 2mg/hr with good control of any agitation. Bilateral soft limb restraints in place for protection of lines and ETT.\n\nGI/GU: Pt remains NPO. Abd is soft with bowel sounds present. No BM. Foley draining CYU. Creat 1.1 HUO>80cc's. U/A C&S sent.\n\nID: Temp 99-99.8. Urine sent. WBC wnl.\n\nSocial: Wife and daughter in to visit. Spoke with cardiology team. Daughter remains concerned about stress between pt and his son.\n\nA&P: 79 yo man with mitral valve , for MV repair vs MVR in am. Cont with diuresis overnite. check lytes. Cont with POC.\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2165-03-07 00:00:00.000", "description": "Report", "row_id": 1671500, "text": "CCU NPN 7P-7A\n79 yr old presented to OSH with severe SOB, CHF found to have 4+MR posterior leaflet, also 3+TR, EF 65%, ruled out for transferred to -cath lab for IABP, intubated for CHF, evaluated by surgery. Diuresing on IV lasix. To have MV repair vs. replacement 1st case this AM. AB's for 2wk h/o nonproductive cough prior to adm.\n\nCV: HR 80's NSR, rare-frq PVC's with short runs VT(6 bt), K+ 3.5 repleated with 60 mEq last eve. Cont on IABP 1:1, with good augmentation, sys/dia unloading. Maps 60's on 6 mcg/kg/min dopamine, dropped to 50's requiring increase in Dopa to 7mcg/kg/min to maintain MAP>60. Was neg 1500cc at MN, lasix stopped for couple hours when became hypotensive, now resumed at 5mg/hr. UO has been >100cc/hr.\nCO 5.0, CI 2.36, SVR 368 MV sat 58%. Swan slipped out to RV when turning pt, pulled all the way to CVP.\nPulses initially difficult to palp, later dopplerable. Feet and hands are cool. R groin with old ooz, no active bleeding.\nHep gtt at 1600 units/hr, PT 71 last eve. AM labs pnd.\n\nResp: vented, AC 50% 600x14 5 peep. Suctioning for thin bloody secretions initially, now thicker. Vap proticol followed.\nLS clear, bronchial at R base, crackles initially, clearer later.\n\nID: T 99 core, WBC 9.0. on levoflox iv q 48 hrs, dosed at MN.\n\nT&C 2 units PRc's. HCT 33.5\n\nNeuro: tries to open eyes to voice, squeezes hand to command, nodded to simple questions at onset of shift, sedation increased for excessive cough reflex with ETT. Has appeared comfortable. PERL. MAE.\n\nSoc: no calls overnight, wife here , (from 1st marriage) and daughter also here. Wife, , to be called first:\nSon ; cell: \n\nA/P; 79 yr old to have repair/replacement of MV this AM, supported on IV dopamine, IABP, lasix gtt. cont close monitoring until surgery this AM. Cont to support and inform pt family.\n\n\n\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2165-03-07 00:00:00.000", "description": "Report", "row_id": 1671501, "text": "Resp Care\nRemains intubated and ventilated on a/c with no remarkable changes overnight. O2 sat 100%, no abgs. Pt waiting to go to o.r. later this morning.\n" }, { "category": "Nursing/other", "chartdate": "2165-03-09 00:00:00.000", "description": "Report", "row_id": 1671512, "text": "S/P MV REPAIR ON . IABP DC'D .\n\nNEURO: ORALLY INTUBATED. SEDATED ON PROPOFOL GTT, WEANING OFF SLOWLY FOR ATTEMPT TO EXTUBATE THIS AM. PEARL AT 3MM/BRISK. OPENS EYES WITH REPOSITIONING BUT NOT TO COMMAND. NO MOVEMENT OF EXTREMITIES NOTED WITH REPOSITIONING.\n\nPULM: CPAP MODE, 14 PS. 33 20-35. ABG WNL. LUNGS COARSE, SX'D FREQUENTLY FOR SMALL AMTS THICK BLD TINGED SECRETIONS. CT DRAINING SMALL AMTS STRAW COLORED FLUID. NO AIR LEAK. RSBI 152 PER RESPIRATORY THERAPIST.\n\nCV: NSR 60'S-70'S, RARE PVC. MAG, CA+ REPLETED. NEO GTT ON TO MAINTAIN MAP > 60. CCO VIA RIJ, SVO2'S 60'S, FICK CO/CI WNL. CVP ~ 10. PEDAL PULSES DOPPLED. HCT 26.0, PLT 145K. R IABP SITE WNL, DSG CHANGED.\n\nENDO: QID SSRI COVERAGE, 4 UNITS SC AT 2400 AND 0600 FOR BS 140'S.\n\nGI: ABDOMEN SOFT, HYPOACTIVE BS. OGT TO LCS, DRAINING BILIOUS FLUID. PLACEMENT CHECKED Q4H.\n\nGU: FOLEY TO CD DRAINING QS AMTS CLEAR YELLOW URINE.\n\nSOCIAL: NO VISITORS OR PHONE INQUIRIES.\n\nPLAN: WEAN OFF PROPOFOL, ASSESS NEURO STATUS. WEAN FROM VENT, EXTUBATE AS TOLERATED. ? USE PRECEDEX INSTEAD OF PROPOFOL PRN FOR ANXIETY DURING WEANING. DC CCO SWAN LINE AFTER EXTUBATION. WEAN NEO AS TOLERATED.\n\n" }, { "category": "Nursing/other", "chartdate": "2165-03-09 00:00:00.000", "description": "Report", "row_id": 1671513, "text": "Resp. care note - Pt. remaines intubated and vented, no vent changes made at this time.\n" }, { "category": "Nursing/other", "chartdate": "2165-03-09 00:00:00.000", "description": "Report", "row_id": 1671514, "text": "POD 2 MV repair\nNeuro: sedated w/ propofol gtt, off x1hr pt did not follow commands as instructed, +coughing, no gag reflex, no spontaneous limb mov't noted. R pupil slightly larger and sluggish. waffle boots on for heel protection and minimize risk to foot drop. morphine given as noted prior to turns, hypertensive and prolonged gagging w/ turns.\n\nCV: NSR w/ rare PVC's (up to 11/min noted). serum K repleted x1. lowest CI 2.36 by FICK. V sensing throughout day, Awires remain non-functional. distal LE pulses present via doppler. weaned off neo today.\n\nResp: ETT #7.5, 22@lip moved from L to R. CPAP 50%O2 f , periods of pt rate up to 33 w/ mov't, Vt 550-700, PS 14, unable to wean today. coarse LS throughout. sx'd frequently, esp when turning, thick white blood-tinged sputum. mediastinal/L pleural CT draining straw colored drainage.\n\nGI: OGT to LCS, mod amt of bilious drainage. abd soft/non-distended.\npt remains w/out any parenteral/enteral feedings. hypoactive bowel sounds, has not had BM.\n\nGU: started Lasix 20mg today, diuresed about 600cc earlier. plan to cont diuresis.\n\nID: last dose of vanco given. temp to 100.4 today, plan to monitor, no cultures sent.\n\nSkin: intact. no dsg noted at coccyx (pink). lower extremity edema including genitals.\n\nSocial: no visitors. spoke to wife via phone x2.\n\nPlan: wean off propofol, needs neuro assessment when more awake. wean off vent. cont diuresing maintaining K >4.4. start nutrition soon.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2165-03-10 00:00:00.000", "description": "Report", "row_id": 1671515, "text": "Resp Care: Pt continues on mechanical ventilation: PSV 14/5 50% No changes. LS clear bilaterally. PT suctioned for small amounts of thick white/tan secretions. MDI's given as ordered. RSBI this am 127. PLAN: continue current support, Wean PS as tolerated.\n" }, { "category": "Nursing/other", "chartdate": "2165-03-05 00:00:00.000", "description": "Report", "row_id": 1671493, "text": "Resp Care: Pt intubated for hypercarbic resp failure, #7.5 oett secured @ 23 @ lip, placed on ventilatory support with a/c, settings titrated to abg, peep increased to improve oxygenation; bs coarse, sxn thick blood tinged secretions, rsbi held d/t impending OR, will cont full support.\n" }, { "category": "Nursing/other", "chartdate": "2165-03-05 00:00:00.000", "description": "Report", "row_id": 1671494, "text": "Nursing Progress Note\n\nO: Please see flow sheet for objective data. Tele sinus with bursts of ST and PVC's. given dose of lopressor 12.5mg at 1600. Pt received on IABP 1:1 with fair augmentation. augmented MAP's > 60. Remains on dopamine at 5mcgs/kg/min. IV Heaprin ^'d to 1200units/hr for PTT of 47. Pt received on lasix drip at 2.5mg/hr. ^'d back to 5mg/hr after CT with lower urine output.\n\nResp: Pt received intubated A/C 60% 600 14 8. Please see flow sheet for abgs'. Suctioned for sm amts of tan sputum. Lungs diminished with crackles in bases. Conts on Levofloxacin for ? cough.\n\nNeuro: Pt received on Versed at 3mg/hr and Fentanyl at 75mcgs/hr. Pt responding to his name able to open his eyes and shake his head. following commands intermittently. pt becomming ^'ingly agitated when stimulated over the coarse of the shift. Very diaphoretic, without temp, ? withdrawal. Versed titrated up to 7mg/hr during the shift. Pt conts to respond to tactile stimulation, grimacing with mouth care and repositioning.\n\nGI/GU: Pt is NPO x meds via OG tube. Abd is soft with bowel sounds present. Foley draining CYU. Creat 1.4 this am. HUO> 50cc/hr. Conts on Lasix drip.\n\nID: TM 99.4. Cultures to date are pending. WBC wnl.\n\nSocial: Both wife and son called regarding pt condition. Updated by RN. Aware that surgery will happen this week.\n\nA&P: 79 yo man with mitral leaflet requiring IABP insertion for cardiogenic shock and intubation for ^'d agitation and confusion related to ETOH withdrawal. Hemodynamics stable. conts on lasix drip for aggressive diuresis. Check lytes. Sedate as needed for h/o ETOH abuse. Awaiting time for MVR from CT surgery. Keep family updated as to OR.\n\n" }, { "category": "ECG", "chartdate": "2165-03-07 00:00:00.000", "description": "Report", "row_id": 214501, "text": "Sinus rhythm. Rightward axis. Right bundle-branch block. Low voltage. Findings\nare compatible with right ventricular volume and/or pressure overload.\nConsider lung disease. No previous tracing available for comparison.\n\n" } ]

[ { "category": "Nursing/other", "chartdate": "2120-12-05 00:00:00.000", "description": "Report", "row_id": 1594452, "text": "CCU NPN: \n\nS: \"You just can't do anything when you're in bed ...\"\n\nO: See CareVue flowsheet for complete assessment details\n\nCV: HR 100, AV-paced. BP stable - started on 12.5mg Metoprolol PO BID which pt. has tolerated well thus far. Pericardial drain site and right femoral groin site D/I (post-drain and sheath removal). Transfusion of 1U PRBCs completed w/o incident - continue to follow Hct. ECHO results : small pericardial effusion, no signs of tamponade. Coumadin restarted this PM as ordered.\n\nRESP: Lungs CTA. Remains on 4L NC w/ O2 sat > 95%.\n\nGI/GU: Abd. soft, non-tender, non-distended. BS active x4 quadrants. Tolerating PO intake w/o difficulty. Large BM earlier in day - Colace held this PM. Received Lasix 40mg post-transfusion w/ adequate results.\n\nSKIN: Impaired skin integrity. Excoriation noted under breasts - to which triple antibiotic ointment applied. Reddened lower extremities (appear cellulitis-like) pt.'s baseline. +2 edema noted throughout.\n\nNEURO/SOCIAL: Alert and oriented x3. MAE, +CSM. Asking appropriate questions re: plan of care. Family visiting in evening - aware of transfer.\n\nA/P: S/P attempted VT ablation c/b pericardiocentesis and pericardial drain placement. Pericardial drain and PA-line discontinued which pt. tolerated w/o difficulty - no sx's of tamponade w/ small, residual effusion. Plan for poss. rate decrease of PCM device 1/6 per EP. Continue to follow Hct. Metoprolol and Coumadin added to med regimen this PM. transfer to floor when bed available.\n\n" }, { "category": "Nursing/other", "chartdate": "2120-12-04 00:00:00.000", "description": "Report", "row_id": 1594449, "text": "CCU NPN 0700-1900\n\n88 y/o female w/ stable Vtach w/ rate of 90 at home for the past 2-3 weeks. Pt has ICD and known large apical aneurysm. Also has hx of PAF on coumadim hels for todays procedure. Class HF, 4+, AI, nonischemic DCM, EF 30%.\nBriefly, Pt had elective VT ablation today, developed pericardial effusion w/ decrease in CI, requiring pericardial Tap/drain w/ good results.\n\nS/O: \"my chest hurts\"\nsee carevue for complete objective data.\n\nNeuro: ALERT AND ORIENTED X3, MAE, FOLLOWS COMMANDS.\nCV: PER EP ATTENDING, PT IS AV PACED W/ AV SYNCHRONY AT AT RATE OF 100. PT'S INTRINSIC VT RATE STARTS AT 90BPM. PM/ICD PROGRAMMED FOR DDD.\nBP 100/50, PA LINE PULLED BACK TO RA, CVP = 6.\nHCT 24, CURRENTLY BEING TRANSFUSED W/ 1UNIT PRBC. PERICARDIAL DRAIN INTACT, ASPIRATED FOR 20CC AT 1630, AND ANOTHER 5CC AT 1800 W/O DIFFICULTY. PT C/O PAIN IN CHEST AT DRAIN SITE. MEDICATED W/ 1MG IV MSO4 W/ FAIR EFFECT, 650MG OF TYLENOL GIVEN W/ GOOD EFFECT.\nINR 1.0. PT PO 150OF MEXILETINE A/O'D FOR VT.\nEKG DONE, ECHO ORDERED FOR AM.\n\nRESP: LS CTA ON ARRIVAL O2 SAT MONITOR ON PT'S NOSE D/T COOL EXTREMITIES. NO SOB.\n\nGI: ABD SOFT,NT,+BS, NO STOOL.\nGU: KNOWN CRI BUN 87 CREAT 2.7\nREC'D 60MG OF IV LASIX IN EP LAB, FOLEY DRAINING ADEQUATE U/O.\n\nSKIN: SKIN UNDER RIGHT BREAST IMPAIRED, CLEANSED, OPEN TO AIR.\nOTHERWISE SKIN INTACT\nLOWER FRONT SHINS W/ RASH AND EDEMA, NOT NEW.\nACCESS; PT DIFFICULT STICK, HAS R FEM ACCESS - SIDE PORT OF SWAN.\nSOCIAL: PT WITH LARGE INVOLVED FAMILY, RELATIVE WORKS IN AS RN.\n\nA/P:\nPT ANEMIC, STABLE AFTER VT ABLATION C/B PERICARDIAL EFFUSION. PERICARDIAL DRAIN INTACT, ASPIRATION W/O DIFFICULTY.\nCOMPLETE TRANSFUSION OF 1UNIT PRBC, MONITOR FOR CHF, U/O, FOLLOW UP W/ POST TRANSFUSION HCT.\nPERICARDIAL DRAIN CARE PER PROTOCOL.\nIV TEAM AWARE OF NEED FOR ADDITIONAL ACCESS/PLANS TO D/C FEM LINE.\nCONT MEXILETINE FOR VT A/O'D.\nPAIN CONTROL.\n\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2120-12-05 00:00:00.000", "description": "Report", "row_id": 1594450, "text": "CCU NPN: 1900-0700\n\nS: \"If I had known they were going to put this thing in my chest, I wouldn't have done the procedure ...\"\n\nO: See CareVue flowsheet for complete assessment details\n\nCV: HR 100, AV-paced (overdrive pacing at rate of 100 w/ AV synchrony - PCM/ICD set in DDD mode w/ intrinsic rhythm at rate of 90). Mexilitine PO adm. as ordered. BP marginal w/ SBP 90-110, MAP > 55 - CCU team aware. PA-line D/I via right femoral vein - retracted to RA w/ CVP 3-8. 250cc NS bolus adm. x1 as UOP decreased and CVP decreased to 3 w/ positive response. Transfused 1U PRBCs for Hct 26.4 - post-transfusion Hct: 28.5 - awaiting plans from team re: poss. add. transfusion. Pericardial drain site D/I - draining to gravity w/ serosanguinous drainage. Flushed w/ Heparin per protocol - drainage decreased throughout shift (from 5 -> 0cc). Pericardial fluid cultures pending.\n\nRESP: Lungs CTA bilaterally. RR 20s, denies SOB, DOE. O2 sat > 95% on 4L NC (uses 2L O2 at home).\n\nGI/GU: Abd. soft, non-tender, non-distended. BS active x4 quadrants. Tolerating clear liquids at HS - offered snack which pt. declined. No stool. Foley patent of clear, light yellow urine - urine culture/ U/A specimen pending. UOP 24-90cc/hr - adm. 20mg Lasix IVP at 2215 w/ transient improvement in UOP - noted to have decreased CVP and UOP later in shift which improved w/ 250cc NS bolus x1. I/O: +814cc , +70cc thus far. Elevated BUN/Creat - 81/2.8 (87/2.7 ).\n\nSKIN: Skin impaired in lower extremities, coccyx and under bilateral breasts. Noted to have reddened rash on bilateral calves - pt. reports this is \"at least 4 years old - I've had it looked at several times\" - appearance similar to that of cellulitis - W/D/I, cleansed w/ soap and H2O. +2 pedal edema (pt. reports also baseline). Slight redness in coccyx (peri-anal area) to which Aloe Vesta moisture barrier cream applied and pt. encouraged to reposition off back (although reluctant to do so). Skin breakdown (friction tears) noted under bilateral breasts - cleansed and triple antibiotic ointment covered w/ sterile gauze applied.\n\nNEURO: Alert and oriented x3. Pleasant and cooperative. Restless at times during night despite receiving dose of Xanax per pt. request at HS. MAE, +CSM. Demonstrated understanding of activity restrictions post-procedure. Asking appropriate questions re: plan of care. Family visiting in evening.\n\nA/P: Admitted for respiratory distress although elective VT ablation was planned for this week. S/P attempted VT ablation c/b perforation and resulting pericardial effusion prompting pericardiocentesis and drain placement. Altered hemodynamics peri-procedure which improved after drain placement. BP continues to be marginal - continue to hold beta-blocker until further notice from team. ICD/device interrogation 1/5 per EP? - continue Mexilitine, Amiodarone as ordered. Continue to flush pericardial drain per protocol - discontinuation of drain and PA-line ? Repeat ECHO\n" }, { "category": "Nursing/other", "chartdate": "2120-12-05 00:00:00.000", "description": "Report", "row_id": 1594451, "text": "(Continued)\n. H/o chronic anemia - add. PRBC transfusion? I/O. Follow pain and response to current pain management. Additional IV access once PA-line/venous sheath removed? Emotional support and comfort. Awaiting further plans from team.\n\n\n\n\n" }, { "category": "Echo", "chartdate": "2120-12-05 00:00:00.000", "description": "Report", "row_id": 80302, "text": "PATIENT/TEST INFORMATION:\nIndication: Pericardial effusion. Follow-up tap.\nHeight: (in) 60\nWeight (lb): 158\nBSA (m2): 1.69 m2\nBP (mm Hg): 108/38\nHR (bpm): 100\nStatus: Inpatient\nDate/Time: at 11:01\nTest: Portable TTE (Focused views)\nDoppler: Limited Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in the RA.\n\nLEFT VENTRICLE: Depressed LVEF.\n\nRIGHT VENTRICLE: Normal RV chamber size.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Moderate mitral annular\ncalcification.\n\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets.\n\nPERICARDIUM: Small pericardial effusion. No echocardiographic signs of\ntamponade.\n\nGENERAL COMMENTS: Left pleural effusion.\n\nConclusions:\nThere is a large left ventricular apical aneurysm. There may be thrombus in\nthe aneurysm. Right ventricular chamber size is small. The aortic valve\nleaflets (3) are mildly thickened but aortic stenosis is not present. The\nmitral valve leaflets are mildly thickened. The tricuspid valve leaflets are\nmildly thickened. There is a small pericardial effusion. There is a somewhat\nechodense pericardial region, particularly posteriorly which may present\nresidual organized effusion and/or thickening. There are no echocardiographic\nsigns of tamponade.\n\n\n" }, { "category": "Echo", "chartdate": "2120-12-04 00:00:00.000", "description": "Report", "row_id": 80332, "text": "PATIENT/TEST INFORMATION:\nIndication: Pericardial effusion s/p tap pf 370 cc..\nHeight: (in) 60\nWeight (lb): 158\nBSA (m2): 1.69 m2\nBP (mm Hg): 180/70\nHR (bpm): 90\nStatus: Inpatient\nDate/Time: at 12:45\nTest: Portable TTE (Focused views)\nDoppler: No Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nPERICARDIUM: Trivial/physiologic pericardial effusion.\n\nConclusions:\nThere is a trivial/physiologic pericardial effusion.\n\nCompared with the prior study (tape reviewed) of , the pericardial\neffusion has resolved and the right ventricular cavity is expanded.\n\n\n" }, { "category": "Echo", "chartdate": "2120-12-04 00:00:00.000", "description": "Report", "row_id": 80333, "text": "PATIENT/TEST INFORMATION:\nIndication: Pericardial effusion s/p EP procedure. Evaluate current effusion pre tap.\nHeight: (in) 60\nWeight (lb): 158\nBSA (m2): 1.69 m2\nBP (mm Hg): 80/30\nHR (bpm): 102\nStatus: Inpatient\nDate/Time: at 12:40\nTest: Portable TTE (Focused views)\nDoppler: No Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT VENTRICLE: Apical LV aneurysm.\n\nPERICARDIUM: Moderate to large pericardial effusion. Effusion circumferential.\nRV diastolic collapse, c/w impaired fillling/tamponade physiology.\n\nConclusions:\nThere is a large (6cm) apical left ventricular aneurysm. There is a moderate\nto large sized (2.5cm anterior to the right ventricle) circumferential\npericardial effusion with evidence of right ventricular diastolic collapse,\nconsistent with impaired fillling/tamponade physiology.\nCompared with the prior study (images reviewed) of earlier in the day), the\nfindings are similar.\n\n\n" }, { "category": "Echo", "chartdate": "2120-12-04 00:00:00.000", "description": "Report", "row_id": 80334, "text": "PATIENT/TEST INFORMATION:\nIndication: Pericardial effusion . Evaluate during EP procedure\nHeight: (in) 60\nWeight (lb): 159\nBSA (m2): 1.69 m2\nBP (mm Hg): 85/31\nHR (bpm): 90\nStatus: Inpatient\nDate/Time: at 11:18\nTest: Portable TTE (Focused views)\nDoppler: No Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in the RA.\n\nPERICARDIUM: Moderate pericardial effusion. RV diastolic collapse, c/w\nimpaired fillling/tamponade physiology.\n\nGENERAL COMMENTS: Right pleural effusion.\n\nConclusions:\nThere is a moderate sized circumferential pericardial effusion that measures\n2cm anterior to the right ventricle and slightly increases in size during the\ncourse of the study with corresponding decrease in right ventricular cavity\nsize/compression/tamponade physiology. A large left ventricular apical\naneurysm is identified.\n\n\n" }, { "category": "Radiology", "chartdate": "2120-12-06 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 895964, "text": " 10:31 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evidence of CHF?\n Admitting Diagnosis: VENTRICULAR TACHYCARDIA\\VENTRICULAR TACHYCARDIA ABLATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 88F with CHF, ICD for VT.\n REASON FOR THIS EXAMINATION:\n evidence of CHF?\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 88-year-old woman with CHF. ICD for VT.\n\n COMPARISON: .\n\n UPRIGHT AP PORTABLE CHEST: The ICD remains in similar position.\n Moderate-to-severe cardiomegaly is unchanged. Atherosclerotic calcifications\n are again noted in the tortuous aorta. The pulmonary vascularity is within\n normal limits. Small bilateral pleural effusions are unchanged. No\n pneumothorax is seen.\n\n IMPRESSION: Unchanged cardiomegaly without failure. Small bilateral pleural\n effusions unchanged.\n\n\n" }, { "category": "Radiology", "chartdate": "2120-12-05 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 895753, "text": " 7:34 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please eval for infiltrate, consolidation, pleural effusion\n Admitting Diagnosis: VENTRICULAR TACHYCARDIA\\VENTRICULAR TACHYCARDIA ABLATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 88 year old woman s/p VT ablation and pericardial effusion.\n REASON FOR THIS EXAMINATION:\n please eval for infiltrate, consolidation, pleural effusion\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 88-year-old woman status post VT ablation and pericardial\n effusion. Please evaluate for infiltrate, consolidation, or pleural effusion.\n\n AP chest radiograph dated , is reviewed. No prior studies are\n available for comparison.\n\n An ICD device is seen overlying the left chest with leads terminating in the\n right atrium and ventricle. There is no evidence of pneumothorax. Two drains\n are seen overlying pericardium..\n\n A tortuous aorta is seen with calcification noted in the arch. The cardiac\n silhouette appears _enlarged and moderate bilateral pleural effusions are also\n seen.\n\n IMPRESSION: ICD device seen in place without evidence of pneumothorax.\n Enlarged cardiac silhouette with pericardial drains seen overlying the heart.\n Bilateral pleural effusions are seen, without evidence of focal\n consolidations.\n\n" }, { "category": "ECG", "chartdate": "2120-12-06 00:00:00.000", "description": "Report", "row_id": 202327, "text": "A-V sequentially paced rhythm with capture. Compared to the previous tracing\nof no diagnostic interim change.\n\n" }, { "category": "ECG", "chartdate": "2120-12-05 00:00:00.000", "description": "Report", "row_id": 202328, "text": "Dual chamber pacemaker\nPacemaker rhythm - no further analysis\nSince previous tracing of , no significant change\n\n" }, { "category": "ECG", "chartdate": "2120-12-04 00:00:00.000", "description": "Report", "row_id": 202329, "text": "Dual chamber pacemaker.\nPacemaker rhythm - no further analysis\nSince previous tracing of , paced rhythm seen\n\n" }, { "category": "ECG", "chartdate": "2120-12-04 00:00:00.000", "description": "Report", "row_id": 202330, "text": "Sinus bradycardia with 1st degree A-V block.\nProlonged QT interval\nQRS changes V3/V4 may be due to LVH but cannot rule out anterior infarct\nLVH with secondary repolarization abnormality\nInferior/lateral ST-T changes are probably due to ventricular hypertrophy\nSince previous tracing of , no significant change\n\n" }, { "category": "ECG", "chartdate": "2120-12-04 00:00:00.000", "description": "Report", "row_id": 202331, "text": "Sinus bradycardia\nBorderline first degree A-V block\nLong QTc interval\nQRS changes V3/V4 - may be due to anterior infarct, ischemia or metabolic\nchanges\nLVH with secondary ST-T changes\nClinical correlation is suggested\nSince previous tracing of , no significant change\n\n" }, { "category": "ECG", "chartdate": "2120-12-04 00:00:00.000", "description": "Report", "row_id": 202332, "text": "Sinus bradycardia\nFirst degree A-V block\nQRS changes V3/V4 - may be due to anterior infarct, ischemia or metabolic\nabnormality\nLVH with secondary ST-T changes\nProlonged Q-Tc interval\nClinical correlation is suggested\nNo previous tracing available for comparison\n\n" }, { "category": "Radiology", "chartdate": "2120-12-08 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 896201, "text": " 2:02 PM\n CHEST (PA & LAT) Clip # \n Reason: r/o chf\n Admitting Diagnosis: VENTRICULAR TACHYCARDIA\\VENTRICULAR TACHYCARDIA ABLATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 88 year old woman s/p tamponade following attempted VT ablation\n REASON FOR THIS EXAMINATION:\n r/o chf\n ______________________________________________________________________________\n FINAL REPORT\n EXAM ORDER: Chest.\n\n HISTORY: Status post tamponade following VT ablation.\n\n Chest: PA and lateral views are compared to previous examination of . The pleural effusions have increased, associated with bibasilar\n atelectasis. The lungs are clear without evidence of pulmonary edema. There\n is dual-chamber pacemaker with the leads overlying right atrium and ventricle.\n\n" } ]

[ { "category": "Echo", "chartdate": "2116-08-24 00:00:00.000", "description": "Report", "row_id": 75756, "text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function.\nHeight: (in) 72\nWeight (lb): 235\nBSA (m2): 2.28 m2\nBP (mm Hg): 134/82\nHR (bpm): 71\nStatus: Inpatient\nDate/Time: at 11:31\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Moderate LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA.\n\nLEFT VENTRICLE: Mild symmetric LVH. Normal LV cavity size. Overall normal LVEF\n(>55%). No resting LVOT gradient.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic root diameter. Mildly dilated ascending aorta.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). Mild (1+) AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Moderate mitral annular\ncalcification. Mild (1+) MR. [Due to acoustic shadowing, the severity of MR\nmay be significantly UNDERestimated.]\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with\nphysiologic PR.\n\nPERICARDIUM: No pericardial effusion.\n\nConclusions:\nThe left atrium is moderately dilated. There is mild symmetric left\nventricular hypertrophy. The left ventricular cavity size is normal. Overall\nleft ventricular systolic function is normal (LVEF>55%). Right ventricular\nchamber size and free wall motion are normal. The ascending aorta is mildly\ndilated. The aortic valve leaflets (3) are mildly thickened. Mild (1+) aortic\nregurgitation is seen. The mitral valve leaflets are mildly thickened. Mild\n(1+) mitral regurgitation is seen. [Due to acoustic shadowing, the severity of\nmitral regurgitation may be significantly UNDERestimated.] There is no\npericardial effusion.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2116-08-25 00:00:00.000", "description": "Report", "row_id": 1388274, "text": "CCU NPN 7P-7A\naddendum: ?NSTEMI vs demand ischemia(^troponin in setting of\nCHF and pneumaonia)\n" }, { "category": "Nursing/other", "chartdate": "2116-08-25 00:00:00.000", "description": "Report", "row_id": 1388275, "text": "resp care - Pt continues to have coarse rhonchi and E wheezes t/o. Neb tx and MDIs given. MDs reluctant to order BIPAP due to possible nasopharyngeal bleeding.Continued resp support planned.\n" }, { "category": "Nursing/other", "chartdate": "2116-08-25 00:00:00.000", "description": "Report", "row_id": 1388276, "text": "CCU progress note 7a-7p\n\nEVENTS: Pulmonary Edema flash 15min after Nitro was turned off this morning -> became Tachy 110s, BP 160s diaphoretic w/ L chest/flank chest pain - NTG restarted, given 2mg Morphine IVP, lasix 20mg ivp and increased Fio2. CP resolved after morphine - EKG done w/ ischemic changes noted. High flow mask increased to 95% and weaned back to 60% after a few hours, once pt had recovered.\n\n\nID: tmax 99.1. on zosyn for klebsiela pneumonia bacteremia.\n\nNEURO: A+Ox3. anxious about going home - seeing wife \"I want to get back to hospital so my wife can visit me!!!\" Social work consulted, wife called - wife to visit in am.\n\nRESP: LS coarse, wheezy, rhonchorous - RR high 20s - 40s when he flashed at 1115am. Fio2 60% on high flow face mask - which was increased to 95% during pulmonary edema flash. Sats were 84-88% at that time - now 93-96% on 60% high flow. Productive thin/thick bloody secretions all morning. after heparin gtt turned off at 11am - no further hemoptysis this afternoon/evening. CPT done + deep breathing and coughing encouraged.\n\nCARDIAC: SR/ST 90s-114. rare PVC. repleated K this morning. pm lytes pnd. BP 100s-160s today. ST/^BP w/ pulmonary edema flash. resolved w/ morphine 2mg, lasix 20mg + ntg turned back on. NITRO @ 0.56mcg/k/min. Heparin gtt off since 11am. Started on lisinopril. for increased dose in am. lwr extremity edema. HCT 27. repeat pnd this evening.\n\nENDO: titrating insulin gtt. Q1H fingersticks. on steroids. \"i've never been a diabetic before!\"\n\nGI/GU: foley patent. pink tinged urine. lasix 20mg IVP given this morning during flash w/ small results, lasix 40mg IVP given this afternoon with good results of clear yellow urine. abd distended obese. +BS. mod BM today, soft brown.\n\nPLAN: FS q1h w/ insulin gtt. repleat lytes as needed. con't ntg gtt. monitor resp status - pulmonary toliet. emotional support. cont' abx.\n" }, { "category": "Nursing/other", "chartdate": "2116-08-26 00:00:00.000", "description": "Report", "row_id": 1388277, "text": "Nursing Note 7p-7a\nS:\" I can't catch my breath\".\nO: See careview for complete objective data.\nNeuro- A+Ox3, cooperative w/care but anxious. MAE in bed.\nCV/Resp- Tele in ST w/ HR 95-104. @ Approx MN pt had episode of flash pulmonary edema, RR 35-40 and sats 86-89% on 60% HiFlow. EKG done showed rapid AF 140s-150s. HO notified, pt given 2mg Ms04 x3, 5mg iv lopressor x3, 1 atrovent neb, 20 iv lasix and increased his Nitro gtt to 0.58mcg/kg/min. Placed on a 100% NRB. After approx 30 mins his breathing/sats improved but remained in AF w/ HR 112-130. Restarted on Heparin gtt @ 950 U/hr, AM PTT 31.0 Nitro gtt weaned to 0.47mcg/kg/min maintaining NBPs 100-110/50s-60s. K+ 4.2 (heme) repleated, repeat 3.6\nGI/GU- Abd very distended, KUB ordered. +bs, had OB+ dark black/green liquid stool, x1 HO aware. Voided approx 1L to maintenence lasix dose plus additional 40mg/20mgs iv. 2100, Cre 1.6\nID- Afeb, wbc 27.9 conts on abx for Klebsiella PNA.\nA/P: 79yo s/p NSTEMI, no cath done. Cont plan of care.\n" }, { "category": "Nursing/other", "chartdate": "2116-08-24 00:00:00.000", "description": "Report", "row_id": 1388272, "text": "CCU Nursing Progress Note 7am-7pm\nS: I'll do that proceedure, but I'm having some internal bleeding.\n\nO: Pt spoke with physicians, and wishes to proceed with cath. Misunderstanding md's and thinks he is having internal bleeding. See further assessment to follow. Pt given further clarification.\n\nResp - ls are coarse and wheezy and pt cont on 60% hiflow neb throughout day. Pt with productive cough, lg amts bloody sputum. Pt given nebs and inhalers as ordered, and needs prn inhalers q4-6hrs as ordered. CPT by resp tx.\nDespite hemoptysis, HCT remains stable at 30.2 (30.7 on admit)\n\nCV - HR 70-90's nsr with rare pvc and rare apc. K+3.7 rx with 40meq KCl. Bp 120-160's/60's. Cont on Hydralazine 10mg IV q6hrs as well as IVNTG which was increased from 0.2mcgs/kg/min to 0.52mgcg/kg/min.\n\nGU - u/o via foley is cloudy pink tinged, which was less pink throughout shift. u/o dropped +>- rx with 20mg ivp lasix>> diuresed 670cc.\n\nGI - Appetite good for nas/low chol diabetic diet. Abd is lg with +bs. Passing small amts OB+liquid stool.\n\nEndo - pt NPO for cath which was reversed prior to breakfast. Insulin gtt started at 9am and titrated up from 2units/hr to 8.5units/hr. See careview for exact sugars and insulin titration. Of note, pt currently on steriods\n\nID - afebrile, although WBC 19.8 on admit. Pt currently on steriods.\n\nActivity - Able to dangle and pivot to commode with 1 nurse assist. No orthostatic changes. Tolerated well\n\nSocial - Wife unable to visit pt today, but has spoken with her husband and this nurse and is aware of poc.\n\nA: Cont to require diuresis, inhalers. Hct stable despite hemoptysis, requiring insulin gtt for bs control.\n\nP: cont aggressive pul. toileting including cpt and inhalers, monitor hcts q12hrs, lasix prn, cont insulin gtt till stable, increase activity as tolerated, plan for cath once pneumonia and CHF are stabilized, keep pt and wife informed of poc per multidisiciplinary rounds.\n" }, { "category": "Nursing/other", "chartdate": "2116-08-25 00:00:00.000", "description": "Report", "row_id": 1388273, "text": "CCU NPN 7P-7A\nCV: HR 68-80's NSR, occ PVC, BP 117-140/60, cont on IV Nitro at .52mcg/kg/min. IV hydral. Denies CP. Edema of lower ext L ankle >R. Pulses weak palp. Lasix given earlier in eve with good response. Neg 1300 at MN. Hep gtt cont at 1150 units/hr. Leg cramps prior to adm, leni's neg at OSH.\n\nResp: RR 20-28, sating 95-99% on .60 high flow neb. LS coarse throughout with exp wheezing. Cont on inhalers and atr/alb nebs as ordered. Cont to cough up bright bloody sputum. CPT x1 and enc to DB/cough. On steroid taper for COPD exacerbtion.\n\nID: Cont on Zosyn for pna, klebsiela bacteremia. Afebrile.\n\nNeuro: A&Ox3, no tremor or agitation. Slept well.\n\nEndo: cont on reg ins gtt, FS BS q 1 hr, 87-150's, titrating gtt accordingly.\n\nGU: urine hematuric(pink), >100cc/hr.\n\nSkin: intact, reddish rash on upper back.\n\nSoc: MD spoke to wife on phone earlier to update.\n\nStatus: DNR/DNI, did agree to cath.\n\nA/P: 79 yr old transferred from OSH for cath after ruling in for NSTEMI, on NTG/hep, unable to have cath until resp status improves, being treated for pna and klebsiela bacteremia with Zosyn/steroids, source of hemoptasis yet unknown. If not resolved will need pul consult. Hemodynamically stable. Prob transition back to po meds today. Cr 1.4 on adm to OSH, bump to 1.7, now trending down. Cont to support pt/family.\n" }, { "category": "Nursing/other", "chartdate": "2116-08-27 00:00:00.000", "description": "Report", "row_id": 1388280, "text": "CCU Nursing Progress Note 0700-1900\nS: \"my coughing is so much better since they shocked me, I'm not hacking anymore.\"\n\nO: see CCU flow sheet for complete objective data\n\nCV: pt in AF this am rate 112-124, on amiodarone 0.5mg/min. Underwent d/c cardioversion @ 200J--> NSR. Dr. and anesthesia present. Given 60mg IV propofol by anesthesiologist for sedation. Amiodarone load finished at 1100 and started on po dose. Remains on DTZ. Remains in sinus rhythm, although p wave morphology shifts periodically (see strip). BP 115-160/48-77, on lisinopril, isordil added. Heparin @ 1350 units/hour, PTT 74.5. (goal 60-100).\n\nResp: lungs with rhonchi throughout, bibasilar crackles. On cool neb 60% with sats 93-96%. O2 sat drops to 86-87% when he takes his mask off. Tried on 6L NP for meals, but sat dropped to 89%. Cough less productive over course of shift.\n\nGI: large OB + black/green loose stool X2. Sample sent for c diff. Abdomen softly distended, +BS.\n\nGU: foley in, 110-400cc/hour, I/O (-) 1600 cc so far. Given 40 meq Kcl this am for K 3.6, given 1 gm magnesium for Mg 1.8. Repeat PND. To have repeat lytes this evening.\n\nEndo: given 1/2 dose of ss regular insulin this am d/t NPO for cardioversion. Now eating. To start glargine this pm.\n\nSkin: small stage II decube over coccyx (1/2 cm long X 1mm wide), no drainage. Cleansed with wound spray, dried. Duoderm with hy-tape picture frame. Pt. reports past history of R heel necrotic area 2 years ago with hospitalization. Waffle boots placed, heels lubricated with aloe vesta. Right heel soft, no redness. Skin care nurse in to evaluate bruising over glutes. Does not feel it's a deep tissue injury. To apply aloe vesta to bruised sites , will need overlay bed when transferred to floor. Turned s to s and instructed to stay off of back. Have consulted PT to mobilize.\n\nID: afebrile, WBC 23.3, continues on zosyn (day 8 of 10).\n\nNeuro: alert and oriented X3, cooperative with care.\n\nAccess: 2 new PIV placed, previous IV's removed.\n\nSocial: wife called, updated on multidisciplinary POC. To visit tomorrow.\n\nA: stable in sinus rhythm post d/c cardioversion with alternating p wave morphology. Therapeutic PTT. Cough improved, still with ^ O2 requirement. Diuresing well. Skin breakdown over coccyx, potential for skin breakdown over heels.\n\nP: continue to turn q 2 hours, keep off of back, change duoderm q 3 days as needed, waffle boots, overlay for bed upon transfer from CCU. Aloe vesta to heels and bruised areas over glutes. Monitor I/O, follow lytes--recheck this evening. Awaiting PT consult. Continue c&db.\n" }, { "category": "Nursing/other", "chartdate": "2116-08-28 00:00:00.000", "description": "Report", "row_id": 1388281, "text": "Nursing Note 7p-7a\nS:\"I felt better right away\".\nO: See careview for complete objective data.\nNeuro- A+Ox3, pleasant/cooperative.\n Pt remains in SR post cardioversion. Rare PVCs, HR 65-80. Conts on po Amio, Dilt & lisinopril. NBPs 115-140/50s. Heparin gtt conts @ 1350 U/hr, PTT 80.2 (therapeutic). AM Hct 25.2 (27.7). K+ 3.6, Mg+ 2.0\nResp- Remains on a 60% Hi-Flow mask w/sats 93-99%. Desats into high 80s on exertion. LS +rhonchi heard throughout. Productive coughing thick tan (occ blood tinged) sputum. Given PRN albut/atrov x1 and using an Acapella device to help loosen conjestion. On a prednisone taper for COPD.\nGI/ Pt had med amts of loose black/green OB+ stools x3. C-diff neg. Conts diuresing well on lasix, balance -4700. Has 1200cc FR in effect.\nID- Afeb, wbc 25.7 (23.3) conts on zosyn for Klebsiella PNA.\nEndo- Monitoring sugars on prednisone w/RISS & qhs Glargine.\nSkin- Duoderm to coccyx intact, bruises on buttocks unchanged. Waffle boots off @ 6am. Has a PT consult for today.\nA/P: Remains in SR post cardioversion, conts on po Amio/Dilt and Heparin gtt. Still having loose black OB+ stools w/HCT drops ? tnsf prbc. Cont pulmonary toilet, needs CXR. Cont abx, monitor Hct, lytes, coags.\n" }, { "category": "Nursing/other", "chartdate": "2116-08-28 00:00:00.000", "description": "Report", "row_id": 1388282, "text": "Respiratory therapy\nPt presents on .6 hi flow full FM for sats btwn 88-93%. When pt on BP desats to 86-88% slow to recover. BS diffuse coarse rhonchi all fields. Clear slightly after productive cough. advair admin @ 20:00, Alb/Atro neb given @ MN W no noticible improvement in sats or BS. pt instructed on use of acapella to facilitate expectoration of secretions and demonstrated good technique. Pt expectorated sml amt bright red blood. RN informed. Not unusual for this pt. Plan: encourage CDB exercises. Suggest increasing FiO2 to 95% during position changes or when pt needs bed pan.\n" }, { "category": "Nursing/other", "chartdate": "2116-08-26 00:00:00.000", "description": "Report", "row_id": 1388278, "text": "CCU progress note 7a-7p\n\nNEURO: A+Ox3. MAE. assists with turns. no c/o pain. wife in to visit this afternoon - updated by CCU team.\n\nID: afebrile. Tmax 98.6. on zosyn q8h for kelciella pna bacteremia.\n\nCARDIAC: AFIB 130s this morning - BP 130s. Weaned NITROGLYCERINE gtt slowly to 0.25mcg/k/min. Started on AMIODARONE - given 150mg bolus then started on 1mg/min for 6hrs - to decrease to 0.5mg/min at 5pm. Started on lopressor 25mg but d/c'd this afternoon and started on Diltiazem 30mg QID. On lisinopril 40mg , , lipitor. Now AFIB 80s-110s. HEPARIN ^1150u/hr - PTT pnd from 5pm. HCT 25 this morning - given 1u PRBCs today. post transfusion HCT pnd. 4 peripheral IVs.\n\nRESP: LS coarse. switched to Highflow face mask and titrated down to 60% FIO2 w/ sats 93-96%. Productive thick bloody sputum. strong cough. pulmonary toliet - nebs.\n\nGI/GU: foley patent. Lasix 80mg IVP + 40mg PO given at 12pm. Good diuresis all day. clear yellow urine. abd obese +BS. loose BM black guiac POS stool x 1. Eating meals well. NPO after midnight for ?cardioversion in am.\n\nENDO: FS QID w/ sliding scale coverage. FS <200 w/ coverage. was on tapered steroid dose.\n\nPLAN: PTT, HCT and Lytes pnd from 5pm. repleat lytes + adjust Hep gtt + ?another unit PRBCs. Con't cardiac meds. If pt unable to convert by am - will be cardioverted - NPO after midnite. GOAL 1-1.5L negative - aggressive diuresis. pulmonary toliet.\n" }, { "category": "Nursing/other", "chartdate": "2116-08-27 00:00:00.000", "description": "Report", "row_id": 1388279, "text": "Nursing Note 7p-7a\nS:\"I'm getting a lot of junk up\".\nO: See careview for complete objective data.\nNeuro- A+Ox3, cooperative less anxious. MAE in bed, slept fair.\nCV- Remains in AF w/ HR 85-120. Conts on Amiodarone gtt @ 0.5mcg/min for 18hrs (until 11am). Conts on po Dilt 60mg qid and lisinopril. NBPs 112-134/54-75. Nitro gtt successfully weaned off @ 2100. Heparin gtt ^ 1350 u/hr (PTT <60), AM PTT 73.4. HCT 27.7 (29.7) K+3.3 was repleated.\nResp- Remains on 60% fi02 Hi-Flow mask w/sats 93-99%. Has strong cough expectorating lg amts of thick tan blood tinged sputum. Hemeoptisis etiology unknown. LS coarse throughout w/ occ exp wheeze. Gave PRN Atrovent neb x1. Conts on prednisone taper for COPD exacerbation.\nID- Afeb, wbc 23.3 (21.5). Conts on Zosyn for Klebsiella PNA/ bacteremia.\nEndo- Sugars monitored d/t steroids, 273 @ MN covered per RISS.\nGI/GU- NPO p MN. Obese, +bs, lg liq black/green stool x1 OB+. Conts diuresing well to 80 iv lasix. Balance -3600, Cre 1.5 Pt placed on a 1200cc FR.\nSkin- Several sm bruises on buttocks from bed pan use.\nA/P: 79yo male tnsf from OSH w/ NSTEMI for cath. Not candidate for cath d/t COPD, tx medically. On steroids/zosyn for Klebsiella PNA/ bacteremia. CHF exacerbation w/ flash pulmonary edema x2. Diuresing well on lasix. Rapid AF, tx w/ Amio/Heparin gtts po Dilt. Unable to convert to SR overnight. NPO for cardioversion this AM. Cont plan of care, monitor sugars/lytes/HCT/coags.\n" }, { "category": "ECG", "chartdate": "2116-09-05 00:00:00.000", "description": "Report", "row_id": 194446, "text": "Sinus bradycardia\nLeft atrial abnormality\nRight bundle branch block\nInferior/lateral ST-T changes may be due to myocardial ischemia\nNo change from previous\n\n" }, { "category": "ECG", "chartdate": "2116-09-03 00:00:00.000", "description": "Report", "row_id": 194447, "text": "Sinus rhythm. Left atrial abnormality. Right bundle-branch block. Left\nventricular hypertrophy. Diffuse ST-T wave abnormalities could be due in part\nto left ventricular hypertrophy and/or possible ischemia. Clinical correlation\nis suggested. Since the previous tracing of probably no significant\nchange.\n\n" }, { "category": "ECG", "chartdate": "2116-09-01 00:00:00.000", "description": "Report", "row_id": 194448, "text": "Sinus rhythm. Compared to tracing #1 there is more prominent ST segment\ndepression in the anterolateral leads suggestive of myocardial ischemia.\nClinical correlation is suggested.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2116-08-31 00:00:00.000", "description": "Report", "row_id": 194449, "text": "Baseline artifact. Sinus rhythm. Left axis deviation with left anterior\nfascicular block. Right bundle-branch block. Non-diagnostic Q waves in\nleads I and aVL. Left ventricular hypertrophy. ST-T wave abnormalities most\nlikely related to left ventricular hypertrophy. Compared to the previous\ntracing of no significant change.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2116-08-31 00:00:00.000", "description": "Report", "row_id": 194691, "text": "Sinus rhythm. Compared to the previous tracing of no significant\ndiagnostic change.\nTRACING #4\n\n" }, { "category": "ECG", "chartdate": "2116-08-31 00:00:00.000", "description": "Report", "row_id": 194692, "text": "Sinus rhythm. Compared to the previous tracing of no significant\ndiagnostic change.\nTRACING #3\n\n" }, { "category": "ECG", "chartdate": "2116-08-30 00:00:00.000", "description": "Report", "row_id": 194693, "text": "Sinus rhythm. Compared to the previous tracing of no significant\ndiagnostic change.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2116-08-29 00:00:00.000", "description": "Report", "row_id": 194694, "text": "Sinus rhythm. Right bundle-branch block. Non-diagnostic Q waves in\nleads I and aVL. Borderline voltage criteria for left ventricular hypertrophy.\nNon-specific ST-T wave abnormalities. Compared to the previous tracing\nof no significant diagnostic change.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2116-08-27 00:00:00.000", "description": "Report", "row_id": 194695, "text": "Sinus rhythm\nShort PR interval\nRight bundle branch block\nOld lateral myocardial infarct\nNonspecific ST-T wave changes\nSince previous tracing, no significant change\n\n" }, { "category": "ECG", "chartdate": "2116-08-25 00:00:00.000", "description": "Report", "row_id": 194696, "text": "Sinus tachycardia. Right bundle-branch block. Compared to the previous tracing\nof the rate has increased. There is now left axis deviation and more\nprominent ST segment depression. Otherwise, no diagnostic interim change.\nClinical correlation is suggested.\n\n" }, { "category": "ECG", "chartdate": "2116-08-24 00:00:00.000", "description": "Report", "row_id": 194697, "text": "Sinus rhythm\nRight bundle branch block\nInferolateral ST-T wave changes\nSince previous tracing, no significant change\n\n" }, { "category": "ECG", "chartdate": "2116-08-24 00:00:00.000", "description": "Report", "row_id": 194698, "text": "Sinus rhythm\nRight bundle branch block\nInferior/lateral ST-T changes\nSince previous tracing, no significant change\n\n" }, { "category": "Nursing/other", "chartdate": "2116-08-24 00:00:00.000", "description": "Report", "row_id": 1388267, "text": "CCU NPN\n\n79 YR OLD INITIALLY ADM TO HOSP ON W SOB, FEVER R/I NSTEMI. PEAK CK 314, MB 26.5, TROPONIN 3.6. C/B PNA AND GM NEG BACTEREMIA, EXACERBATION COPD. STARTED ON SOLUMEDROL, ANTICOAGULATED AND RECEIVED ABX. PT DID WELL, OFF HEPARIN AND WAS TRANSFERED TO TELE UNIT W PLANS FOR STRESS TEST. ON PT DEVELOPED SOB DROPPING SATS TO 80% ON 4L NP( OFF HEPARIN) HE WAS TRANSFERED BACK TO ICU. STARTED ON HEPARIN, IV NTG, GIVEN MS04 AND LASIX. CXR PULM EDEMA. EKG SHOWED STD V4-V6. HE WAS TRANSFERED TO CCU FOR MANAGMENT CHF AND POSSIBLE CATH . PT WAS TX ON NASAL BIPAP IN ROUTE AND ARRIVED IN NO APPARENT DISTRESS. PT WAS DNR/DNI AT . DR SPOKE W PT ON ADMISSION AND HE WISHES TO BE DNR/DNI HERE AS WELL.\nPMH: RENAL ARTERY STENOSIS W RA STENT ON \n CAD S/P MI S/P STENTS MID LCX AND RAMUS \n GIB, PUD\n HTN\n L KNEE REPLACMENT, GOUT\n + ETOH REPORTS 2 DRINKS BRANDY/DAY. NO WITHDRAWAL THUS FAR.\n CVA\n\nCV: REMAINS IN NSR WITH HR 60-80 RARE PAC'S NOTED. CK ON ADM 62 TROPONIN 1.4 SBP 150-160. STARTED ON HYDRALAZINE 10 MG IV Q/6/HR. SBP IMPROVING AFTER DOSE 115-130. CON'T ON HEPARIN GTT @ 1150U/HR W PTT 50.9 CON'T ON NTG GTT @ 0.2 MCG/KG. DENIES SOB/CP. ADM EKG COMPLETED. NOTED PT'S R LOWER LEG AND FT LARGE AND SWOLLEN. DENIES CALF PAIN NEG SIGN. DR OF FINDINGS. PT ALSO REPORTS HE HAD CRAMPING OF HIS R LEG BEFORE BECOMING SOB. REMAINS ON HEPARIN. PT WILL HAVE LOWER EXT. NON INVASIVE SCHEDULED FOR TODAY . DP/PT + BILAT BY DOPPLER.\n\nRESP; TRANSFERED ON A NASAL BIPAP 12/6 @ 100%. PLACED ON HIGH FLOW 60% FM SATS 95-96%. RR-18-21 REG. BS COURSE.CRACKLES 1/4 UP BIALT. SOME AUDIBLE EXP WHEEXES NOTED ESP W ACTIVITY. RECEIVED ALB/ATRV NEBS. AFTER TREATMENT PT COUGHING UP THICK BLOODY SECRETIONS. SENT FOR CULTURE. CXR COMPLETED. DR AWARE OF SECRETIONS. HAS DAILY INHALERS AND PREDNISONE ORDERED. ADDITIONAL LASIX 20 MG GIVEN W ADEQUATE DIURESIS. SATS NOW STABLE AT 96-97%. NO CHANGE IN SATS W REPOSITIONING-TURNING.\n\nGI: REMAINS NPO FOR POSSIBLE CATH. TOL SIPS OF CL'S W MEDS. ABD DISTENDED, SOFT NON TENDER. PT REPORTS 2 DAYS DIARRHEA / ABX RELATED. HAD 1 LOOSE STOOL BROWN GUIAC +. WILL ASK AND USE BP.\n\nGU: FOLEY DRAINING PINK TO BLOODY URINE. IS SLOWLY CLEARING ? TRAUMA RELATED IN TRANSPORT. URINE SENT FOR A AND C/S BUN 43 CREAT 1.6 CON'T TO DIURESE AGGRESSIVLY FROMLASIX.\n\nSKIN; INTACT SOME BRUISING ON ARMS FROM BLOOD DRAWS, IV SITES.\n\nID: AFEBRILE WBC 19.8 WILL CON'T ON ZOYSN. S/P KLEIBS. BACTEREMIA. BLD CULT SENT.\n\nNEURO: A/O X3. MAE, FOLLOWS ALL COMMNADS. REPORTS ETOH USE. BRANDY X2/DAILY. NO WITHDRAWAL HX THIS ADMISSION. PT STARTED ON CIWA SCALE. HAS VALIUM IF NEEDED IF CIWA > 12. BED ALARM ACTIVATED, ALTHOUGH PT HAS MADE NO ATTEMPTS TO GET OOB. HE HAS BEEN QUIET AND COOPERATIVE. POST CVA WITH LITTLE RESIDUAL NOTED. HAS BILAT HA WHCIH ARE IN. HAS MACULAR DEGENERATION. ORIENTED TO UNIT AND CALL SYSTEM.\n\nACCESS; ADDITIONAL IV #20 PLACED IN R ANT UA. HAS PIV'S X4\n\nLABS: K+ 3.8 RECEIVE\n" }, { "category": "Nursing/other", "chartdate": "2116-08-24 00:00:00.000", "description": "Report", "row_id": 1388268, "text": "(Continued)\nD 20 MEQ KCL\n CREAT 1.6\n HCT 30.7\n MG 2.1\n BS 262 RECEIVED 4 UNITS REG ( 1/2 DOSE OF AS PT IS NPO FOR CATH LAB)\n\nSOCIAL: PT STATES WIFE IS AWARE OF HIS TRANSFER HERE, BUT NO INQUIERES OVERNOC. PT STATES WIFE IS HCP.\n\nA/P: NPO FOR CATH\n NON INVASIVES FOR TODAY. FOLLOW RESP STATUS. CON'T PER NSG JUDGEMENT AND ORDERS. UPDATE PT W POC.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2116-08-24 00:00:00.000", "description": "Report", "row_id": 1388269, "text": "Resp Care\nPt. received from /via EMS on nasal CPAP thru ventilator?. Placed on high flow neb @ 95%. No resp. distress noted 20-25bpm with SPo2 95-8%. Weaned down to 50%. Neb tx given x1. Bs: coarse/congested bilat. with a few diffuse exp. wheezes. Will follow, NIPPV not indicated at this time.\n" }, { "category": "Nursing/other", "chartdate": "2116-08-24 00:00:00.000", "description": "Report", "row_id": 1388270, "text": "ADDENDUM: 0600 PT AWOKE COUGHING RAISING THICK BLOODY SPUTUM. C/O DIFFICULTY BREATHING. BS COURSE AUDIBLE EXP WHEEZES,. O2 SATS 94%. HR 94 PT ANXIOUS. RR-24. ALB/ATR TX GIVEN. AM PREDINSONE PO GIVEN 60MG. ADDITIONAL MS04 2MG GIVEN. PT FEELING BETTER. IMPROVING HR 76, SATS 96%. PT MORE CALM. IMPROVING RESP STATUS.\n" }, { "category": "Nursing/other", "chartdate": "2116-08-24 00:00:00.000", "description": "Report", "row_id": 1388271, "text": "resp care - Pt exhibited frank hemoptysis t/o the day with coarse BS t/o. Albuterol/atrovent nebs given Q4H followed by CPT aided pt cough and cleared BS. Continued tx recommended.\n" }, { "category": "Radiology", "chartdate": "2116-08-28 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 930521, "text": " 7:13 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval pulm edema\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79yoM with hypoxia, CHF, NSTEMI, pneumonia, klebsiella bacteremia.\n\n REASON FOR THIS EXAMINATION:\n eval pulm edema\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 7:55 a.m., \n\n HISTORY: Hypoxia, CHF, MI and klebsiella pneumonia.\n\n IMPRESSION: AP chest compared to through 4.\n\n Lung volumes are lower than on , which may account in part for\n intensification of perihilar edema and more pronounced left lower lobe\n consolidation. Pneumonia cannot be excluded. The heart is top normal in\n size, unchanged. Small left pleural effusion persists. No pneumothorax.\n\n\n" }, { "category": "Radiology", "chartdate": "2116-08-30 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 930753, "text": " 9:54 AM\n CHEST (PA & LAT) Clip # \n Reason: eval for new pneumonia\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old man with fever, sob, eval for new pneumonia\n REASON FOR THIS EXAMINATION:\n eval for new pneumonia\n ______________________________________________________________________________\n FINAL REPORT\n PA AND LATERAL CHEST ON .\n\n INDICATION: Fever, dyspnea.\n\n COMPARISON: at 07:55.\n\n FINDINGS:\n\n Compared to the prior film, there is improved aeration and less density in the\n paracentral regions suggesting some diminution in pulmonary edema. However,\n there is residual airspace density and no evidence for pleural effusion. No\n new focal consolidation is seen. An area of atelectasis is noted in the\n frontal view adjacent to the left heart border which is subsegmental in\n nature.\n\n IMPRESSION: Improving appearance of the chest with no new consolidations.\n\n\n" }, { "category": "Radiology", "chartdate": "2116-08-26 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 930230, "text": " 6:59 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval interval changes\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79yoM with hypoxia, CHF, NSTEMI, pneumonia, klebsiella bacteremia.\n\n REASON FOR THIS EXAMINATION:\n eval interval changes\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 7:39 A.M., \n\n HISTORY: Hypoxia, CHF. MI. Klebsiella pneumonia.\n\n IMPRESSION: AP chest compared to and 3:\n\n Moderately severe pulmonary edema has worsened. This could obscure coexistent\n pneumonia, but I see no region of particularly dense consolidation to suggest\n it. Small left pleural effusion may be present, but left costal pleural\n thickening is probably chronic. Heart size is top normal. No pneumothorax.\n\n\n" }, { "category": "Radiology", "chartdate": "2116-08-24 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 929920, "text": " 1:23 AM\n CHEST (PORTABLE AP) Clip # \n Reason: pt with recent NSTEMI, pls eval for CHF\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old man with SOB\n REASON FOR THIS EXAMINATION:\n pt with recent NSTEMI, pls eval for CHF\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 1:47 A.M.\n\n HISTORY: Shortness of breath. Recent MI.\n\n IMPRESSION: AP chest compared to , the most recent prior\n chest radiograph available:\n\n Mild pulmonary edema is new. Mild cardiomegaly unchanged. Left pleural\n thickening is stable. No pneumothorax. Widening of the superior mediastinum\n is comparable probably due to combination of mediastinal fat and thyroid\n enlargement.\n\n" }, { "category": "Radiology", "chartdate": "2116-08-25 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 930065, "text": " 8:04 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval interval changes, pneumonia, effusion, CHF\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79yoM with hypoxia, CHF, NSTEMI, pneumonia, klebsiella bacteremia.\n\n REASON FOR THIS EXAMINATION:\n eval interval changes, pneumonia, effusion, CHF\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 79-year-old male with hypoxia. Evaluate for interval changes.\n\n COMPARISONS: Comparison is made to .\n\n TECHNIQUE: AP portable upright single view of the chest.\n\n FINDINGS: There is again noted cardiomegaly. The cardiac silhouette and\n mediastinal contours are unchanged when compared to prior study. The aorta is\n tortuous and calcified.\n\n There is again noted a perihilar haziness and prominence of the pulmonary\n vascularity, representing pulmonary edema. However, the pulmonary edema is\n slightly improved since the prior study. There is a left retrocardiac\n consolidation which could be secondary to asymmetric pulmonary edema, but\n superimposed pneumonia cannot be excluded. It appears slightly improved when\n compared to prior study.\n\n IMPRESSION: Interval improvement in pulmonary edema and in left retrocardiac\n opacity.\n\n" } ]

[ { "category": "Radiology", "chartdate": "2200-02-27 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1224474, "text": " 10:33 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Please evaluate for causes of shortness of breath. Please \n Admitting Diagnosis: PANCREATIC CANCER;BILE DUCT OBSTRUCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old man with DVT, pancreatic cancer and shortness of breath\n REASON FOR THIS EXAMINATION:\n Please evaluate for causes of shortness of breath. Please also evaluate PICCL\n position.\n ______________________________________________________________________________\n WET READ: 11:00 PM\n Right PICC line going into the right IJ vein. Right upper quadrant pigtail\n catheter noted. Clear lungs. d/w Dr. at 11 pm on .\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: History of DVT, pancreatic cancer, and shortness of breath.\n Evaluate PICC.\n\n COMPARISONS: None.\n\n FINDINGS: A right PICC ends in the right internal jugular vein. Coarse\n interstitial lung markings likely reflect underlying chronic lung disease.\n There is no consolidation, edema, pleural effusion, or pneumothorax. The\n cardiomediastinal silhouette is normal. A pigtail catheter and stent are seen\n in the right upper quadrant.\n\n IMPRESSION: PICC ends in the right internal jugular vein.\n\n" }, { "category": "Radiology", "chartdate": "2200-02-28 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1224477, "text": " 12:35 AM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: Please confirm PICCL position.\n Admitting Diagnosis: PANCREATIC CANCER;BILE DUCT OBSTRUCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old man with PICC originally in IJ now repositioned.\n REASON FOR THIS EXAMINATION:\n Please confirm PICCL position.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Repositioned PICC. Evaluate placement.\n\n COMPARISON: Chest radiograph of .\n\n FINDINGS: A right PICC ends in the mid subclavian vein. Coarse interstitial\n markings in the lungs are unchanged and reflect underlying chronic lung\n disease. There is no consolidation, edema, pleural effusion, or pneumothorax.\n The cardiomediastinal silhouette is normal.\n\n IMPRESSION:\n 1. PICC ends in the mid right subclavian vein.\n 2. Mild chronic lung disease.\n\n" }, { "category": "Echo", "chartdate": "2200-02-28 00:00:00.000", "description": "Report", "row_id": 85425, "text": "PATIENT/TEST INFORMATION:\nIndication: RV Strain\nHeight: (in) 62\nWeight (lb): 145\nBSA (m2): 1.67 m2\nBP (mm Hg): 98/60\nHR (bpm): 104\nStatus: Outpatient\nDate/Time: at 11:28\nTest: TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT VENTRICLE: Normal LV wall thickness, cavity size, and global systolic\nfunction (LVEF>55%). Suboptimal technical quality, a focal LV wall motion\nabnormality cannot be fully excluded.\n\nRIGHT VENTRICLE: Normal RV chamber size. Normal RV systolic function. Nl\ninterventricular septal motion.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows. Suboptimal\nimage quality - bandages, defibrillator pads or electrodes. Suboptimal image\nquality as the patient was difficult to position.\n\nConclusions:\nPoor image quality. Left ventricular wall thickness, cavity size, and global\nsystolic function are normal (LVEF>55%). Due to suboptimal technical quality,\na focal wall motion abnormality cannot be fully excluded. Right ventricular\nchamber size is normal with normal free wall contractility. Interventricular\nseptal motion is normal. There is no pericardial effusion.\n\nIMPRESSION: No clear evidence of RV strain.\n\n\n" }, { "category": "Radiology", "chartdate": "2200-02-28 00:00:00.000", "description": "CTA CHEST W&W/O C&RECONS, NON-CORONARY", "row_id": 1224495, "text": " 6:33 AM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY; CTA AORTA/BIFEM/ILIAC RUNOFF W/W&WO C AND RECONSClip # \n Reason: rule out pulmonary emoblism\n Admitting Diagnosis: PANCREATIC CANCER;BILE DUCT OBSTRUCTION\n Contrast: OMNIPAQUE Amt:\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old man with LLE DVT and new shortness of breath\n REASON FOR THIS EXAMINATION:\n rule out pulmonary emoblism\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: KKgc 10:29 AM\n 1. Extensive pulmonary embolism involving the right main and segmental\n pulmonary arteries of the right lower and segmental arteries of the left\n lower . No right heart strain.\n 2. Multifocal consolidation in both lungs, predominantly involving both upper\n lobes and the right middle , concerning for multifocal pneumonia.\n 3. Bilateral small pleural effusions.\n 4. Known pancreatic malignancy, is not well assessed in this study. Bulky\n pancreatic head may represent the known mass. Metastatic disease in the\n abdomen including multifocal liver metastasis, enlarged gastrohepatic and\n retroperitoneal adenopathy, and thickened left adrenal gland.\n 5. Diffuse thickening of the gastric and colonic walls could be reactive\n changes versus third spacing.\n 6. Moderate amount of abdominal ascites.\n 7. Percutaneous cholecystostomy tube and duodenal stent are in place.\n 8. Extensive atherosclerotic disease of the iliac arteries.\n\n RIGHT: There is a long segment occlusion of the right external iliac and the\n common femoral artery, with reconstitution at the level of distal CFA.\n Multifocal stenosis of the right SFA, popliteal arteries, with absent flow in\n the right anterior tibial and peroneal at the distal third of the leg.\n\n LEFT: Multiple areas of high-grade stenosis with short segment near-complete\n occlusion of the left external iliac artery, with multiple areas of high-grade\n stenosis in the femoral, popliteal arteries of the left lower extremity.\n Absent flow in the anterior tibial and peroneal distal to the ankle.\n\n Patent posterior tibials bilaterally.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: A 58-year-old man with left lower extremity DVT and new shortness\n of breath, to rule out pulmonary embolism.\n\n COMPARISON: None available.\n\n TECHNIQUE: MDCT helical images were acquired through the chest, abdomen, and\n pelvis after the administration of 130 mL of Omnipaque intravenous contrast\n using the CTA protocol. Sagittal and coronal reformats and multiplanar\n reconstructions were generated and reviewed.\n\n FINDINGS:\n (Over)\n\n 6:33 AM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY; CTA AORTA/BIFEM/ILIAC RUNOFF W/W&WO C AND RECONSClip # \n Reason: rule out pulmonary emoblism\n Admitting Diagnosis: PANCREATIC CANCER;BILE DUCT OBSTRUCTION\n Contrast: OMNIPAQUE Amt:\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n CT CHEST: A right upper extremity PICC ends in the right subclavian vein. The\n major airways are patent to subsegmental levels bilaterally. Perihilar\n consolidations are seen in both upper lobes, right middle , lingula, and\n minimally within the left lower , are highly concerning for an acute\n infection. Subpleural consolidation seen in the left lower , \n represent an infarct. Bilateral small simple pleural effusions are present.\n The thoracic aorta has mild atherosclerotic calcification without aneurysmal\n dilation. Aortic annular calcification is seen. Minimal coronary arterial\n calcification is noted. Acute pulmonary emboli are seen within the right main\n pulmonary artery, extending into the lobar branches of the right middle, lower\n and multiple segmental and subsegmental branches of the right lower\n . On the left, pulmonary emboli are seen within the segmental branches of\n the left lower supplying the posterior basal. No acute thoracic aortic\n pathology is seen. A right paratracheal lymph node measures 11.4 mm in\n maximum dimension. Few additional subcentimeter mediastinal lymph nodes are\n also seen.\n\n CT OF THE ABDOMEN: Multiple hypoenhancing liver lesions are consistent with\n known metastatic disease. The largest in segment V of the liver measures 3.8\n x 3.1 cm. The largest in segment II of the liver measures 4.6 x 4.3 cm\n (8a:60). Bulky appearance of the pancreatic head, likely represents the known\n pancreatic mass. Accurate delineation of the mass is difficult in this single\n phase study. Multiple enlarged lymph nodes are seen in the gastrohepatic\n ligament, the largest measuring 3.6 x 2.2 cm. Multiple hypoenhancing\n retroperitoneal adenopathy is also seen, with the largest left paraaortic node\n measuring 1.5 x 1.9 cm (3aa:118). The right adrenal gland is normal. There\n is nodular thickening of the left adrenal gland. Both kidneys enhance and\n excrete contrast symmetrically. A 2.1 cm exophytic hypodense lesion in the\n lower pole of the left kidney likely represents a simple renal cortical cyst.\n An additional subcentimeter hypodensity in the lower pole of the left kidney\n measuring 8 mm (3a:137) is not characterized. There is diffuse edema seen\n throughout the entire colon and the stomach, which could be reactive changes\n or third spacing. There is no intraabdominal free air. A small amount of\n free fluid is seen in the abdomen, predominantly in the perihepatic region and\n pelvis. There is no free air. A metallic duodenal stent is in place. A\n percutaneous cholecystostomy drainage catheter is seen within the gallbladder.\n An additional metallic wire extending from the gallbladder to the duodenum is\n noted.\n\n CTA RUNOFF:\n\n THORAX: The thoracic aorta is normal in course and caliber. Minimal\n atherosclerotic calcification is seen, without aneurysmal dilation.\n\n (Over)\n\n 6:33 AM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY; CTA AORTA/BIFEM/ILIAC RUNOFF W/W&WO C AND RECONSClip # \n Reason: rule out pulmonary emoblism\n Admitting Diagnosis: PANCREATIC CANCER;BILE DUCT OBSTRUCTION\n Contrast: OMNIPAQUE Amt:\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n ABDOMEN/PELVIS: The abdominal aorta has mild atherosclerotic calcification,\n without aneurysmal dilation. Minimal calcification is seen at the origin of\n the superior mesenteric artery, which opacifies normally in the distal\n portion. There is a separate origin of the hepatic and splenic arteries from\n the aorta. An accessory left hepatic artery is present. Calcifications are\n seen in the ostia of the left renal artery, with normal opacification\n distally. Accessory right renal artery is noted. Extensive atherosclerotic\n calcification is seen in both common iliac arteries, with normal\n opacification.\n\n RIGHT LOWER EXTREMITY: There is near-complete occlusion with right external\n iliac artery just distal to its origin, with no appreciable flow seen upto the\n level of the distal right common femoral artery (3ac:212). There is\n reconstitution of flow in the distal right CFA, with high-grade stenosis at\n this level. Flow is seen within stenotic superficial femoral and deep femoral\n arteries. Multifocal high-grade stenosis of the right SFA is noted. There\n is a normal trifurcation with patent anterior tibial, posterior tibial, and\n peroneal arteries in the proximal leg. There is occlusion of the anterior\n tibial and peroneal arteries at the distal third of the leg (3ac:461), with\n flow seen only in the posterior tibial artery beyond this level.\n\n LEFT LOWER EXTREMITY: Normal flow is seen within a heavily calcified left\n common iliac artery. A few short segment high-grade stenosis is seen within\n the left external iliac artery (3ac:197 and 182) without complete occlusion.\n Areas of high-grade stenosis are seen in the patent left superficial femoral\n and deep femoral vessels.The left popliteal artery has high-grade stenosis at\n multiple levels with minimal flow. There is a normal trifurcation with flow\n seen within the anterior tibial, posterior tibial, and peroneal arteries. At\n the level of the left ankle, there is occlusion of the anterior tibial and\n peroneal arteries with flow seen only in the posterior tibial artery. There\n is significant enlargement and subcutaneous edema in the left lower extremity,\n secondary to the patient's known DVT. The left femoral vein is enlarged in a\n few regions, but a DVT is not demonstrated in this arterial phase study.\n\n BONES AND SOFT TISSUES: No bone lesions suspicious for infection or\n malignancy are detected.\n\n IMPRESSION:\n 1. Extensive pulmonary embolism involving the right main, lobar and segmental\n arteries of the right lower and segmental arteries of the left lower\n . No right heart strain.\n 2. Multifocal consolidation in both lungs, predominantly involving both upper\n lobes and the right middle , concerning for multifocal pneumonia.\n Bilateral small pleural effusions.\n 3. Known pancreatic malignancy, is not well assessed in this study. Bulky\n (Over)\n\n 6:33 AM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY; CTA AORTA/BIFEM/ILIAC RUNOFF W/W&WO C AND RECONSClip # \n Reason: rule out pulmonary emoblism\n Admitting Diagnosis: PANCREATIC CANCER;BILE DUCT OBSTRUCTION\n Contrast: OMNIPAQUE Amt:\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n pancreatic head may represent the known mass. Metastatic disease in the\n abdomen including multifocal liver metastasis, enlarged\n gastrohepatic/retroperitoneal adenopathy, and thickened left adrenal gland.\n 4. Diffuse thickening of the gastric and colonic walls could be reactive\n changes versus third spacing. Moderate amount of abdominal ascites.\n 5. Percutaneous cholecystostomy tube and duodenal stent are in place.\n 6. Extensive atherosclerotic disease of the iliac arteries.\n RIGHT: Long segment occlusion of the right external iliac and the common\n femoral artery, with reconstitution at the level of distal CFA. Multifocal\n stenosis of the right SFA and popliteal arteries, with absent flow in the\n right anterior tibial and peroneal at the distal third of the leg.\n LEFT: Multiple areas of high-grade stenosis and short segment near-complete\n occlusion of the left external iliac artery, with multiple areas of high-grade\n stenosis in the femoral, popliteal arteries of the left lower extremity.\n Absent flow in the anterior tibial and peroneal distal to the ankle.\n Patent posterior tibials bilaterally.\n\n The above findings were discussed via telephone with Dr. at 8:30 A.M on\n .\n\n\n\n" }, { "category": "ECG", "chartdate": "2200-02-27 00:00:00.000", "description": "Report", "row_id": 215492, "text": "Sinus rhythm. Diffuse T wave changes which are non-specific. Low QRS voltages\nin the limb leads. No previous tracing available for comparison.\n\n" } ]

[ { "category": "ECG", "chartdate": "2150-01-28 00:00:00.000", "description": "Report", "row_id": 189670, "text": "Sinus tachycardia, rate 101, with occasional atrial premature beats. Borderline\nfirst degree A-V block. Minor non-specific repolarization abnormalities. No\nprevious tracing available for comparison.\n\n" }, { "category": "Nursing/other", "chartdate": "2150-01-29 00:00:00.000", "description": "Report", "row_id": 1438202, "text": "condition update\nD: pt arrived from er, unresponsive, pupils fixed and non reactive. upper extremities posturing and withdraws lower extremities to painful stimuli. left pupil slightly larger than rt approximately .5mm noted. head ct done and reviewed by Dr. . Dr. in to evaluate pt.\ncardiac: pt arrived on dopa and titrated up to 9mcg/kg/min for sbp 140-160. Dr in to eval pt and goal of sbp 130-140 set. dopa currently at 9mcgs/kg/min. vasopressin at .04units/min. sbp 130's. hr nsr rate in the 90's.\ngu: urine output remains adequate. iv fluid ns at 50cc/hr infusing.\ngi: pt remains npo and ngt patent and draining brown drainage. pt remains on protonix.\nfamily support; neurology resident spoke to family about pt's condition. pt made dnr by daughter. family would like pressors used tonight. they will be in in the am and talk to team about possiblely withdrawing care and making comfort measure.\na: continue to offer family support. titrate pressor for sbp 130-140 per Dr. . continue with neuro exam.\nr: no change in neuro status. sbp within paremeters on dopa and vasopressin. await family meeting in am.\n\n" }, { "category": "Nursing/other", "chartdate": "2150-01-29 00:00:00.000", "description": "Report", "row_id": 1438203, "text": "Respiratory Care:\nPt. remains on full ventilatory support. No adjustments to minute ventilation. Weaned FIO2 via SPO2 to 40%. Pt. taken for repeat head CT. Report to follow. Attempted RSBI in a.m., but no spontaneous respiratory efforts noted for 60 seconds (there were no changes in vital signs or decrease in SPO2). B/S with scattered rhonchi>>ETS small to moderate pale yellow to tan. SPO2 100% on 40% FIO2. Family meeting in a.m.\n" }, { "category": "Nursing/other", "chartdate": "2150-01-29 00:00:00.000", "description": "Report", "row_id": 1438204, "text": "Focus-Condition Update\nData-This am, pt remains unresponsive, pupils nonreactive 5mm, gag reflex present. Pt has own spon breaths. Pt on Dopamine at 9mcg/kg/min and Vasopressin at .04 to maintain SBP 130-140/.\nfamily in to visit at 11:00.\nAction-Family meeting with Mr. (husband0 and daughter .\nand Dr. and Dr. from neuromed. Dr. updated family on pts grave conbdition. Family requested that pt be made CMO.\nDopamine and Vasopressin dc'd. Pt placed on CPAP/ FIo2 21%.\nPt started on Morphine gtt.\nResponse-Ptr has spon breaths /min. SBP in the 70's. Family visited and then went home.\nPt comfortable on Morphine gtt at 10mg/hr.\n" }, { "category": "Nursing/other", "chartdate": "2150-01-29 00:00:00.000", "description": "Report", "row_id": 1438205, "text": "Resp Care\nPt put on minmal vent settings. Pt removed from vent @1824\n" }, { "category": "Nursing/other", "chartdate": "2150-01-29 00:00:00.000", "description": "Report", "row_id": 1438206, "text": "Focus-Condition Update\nData-18:00 Pt asystolic, no BP. Dr. in to see pt. Pt pronounced at 18:00.\n" }, { "category": "Nursing/other", "chartdate": "2150-01-29 00:00:00.000", "description": "Report", "row_id": 1438207, "text": "Pt transported to morgue. wedding rings x2 on patient left ring finger.\n\n" } ]

[ { "category": "Radiology", "chartdate": "2144-01-26 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1179997, "text": " 2:03 PM\n CHEST (PA & LAT) Clip # \n Reason: eval for pna\n Admitting Diagnosis: SEIZURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old man with hypoxia\n REASON FOR THIS EXAMINATION:\n eval for pna\n ______________________________________________________________________________\n FINAL REPORT\n PA AND LATERAL CHEST, \n\n HISTORY: Hypoxia, suspect pneumonia.\n\n IMPRESSION: PA and lateral chest reviewed in the absence of prior chest\n radiographs:\n\n The lateral view shows a wedge-shaped area of opacity in one of the lower\n lungs, could be a composite shadow of anterior spinal osteophytes and large\n lower lung vessels. Two other regions of abnormality are the suggestion of\n 11-mm wide right upper lobe nodule at the level of the first anterior\n interspace and fullness in the right lower paratracheal mediastinum, which\n could be adenopathy or fat. All these issues would be resolved with routine\n chest CT.\n\n Heart is top normal size, there is no pulmonary edema or pleural effusion.\n\n\n" }, { "category": "Radiology", "chartdate": "2144-01-24 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1179733, "text": " 12:50 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval placement\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old man with intuabtion\n REASON FOR THIS EXAMINATION:\n eval placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Patient with respiratory failure and intubation. Assess for ET\n tube placement.\n\n COMPARISONS: Chest radiograph of .\n\n FINDINGS:\n\n ET tube is terminating 5 cm from the carina. NG tube terminates within the\n stomach.\n\n Lung volumes are low. Left costophrenic angle is obscured, suggestive of\n small pleural effusion. There is no focal consolidation. There is no right\n pleural effusion or pneumothorax. The hilar and mediastinal silhouette\n appears prominent. The heart size is normal. The pulmonary vasculature\n appears prominent. Linear bilateral opacities likely represent atelectasis.\n Retrocardiac opacity may represent atelectasis, aspiration and superimposed\n infection cannot be entirely excluded.\n\n IMPRESSION:\n\n 1. ET tube terminates 5 cm from the carina without evidence of pneumothorax.\n\n 2. There is prominence of hilar and mediastinal silhouette and pulmonary\n vasculature, which may be reflective of increased pulmonary vascular pressure.\n\n 3. Retrocardiac opacity, likely atelectasis or aspiration; however,\n superimposed infection cannot be entirely excluded.\n\n\n\n" } ]

[ { "category": "ECG", "chartdate": "2193-12-29 00:00:00.000", "description": "Report", "row_id": 182607, "text": "Artifact is present. Atrial fibrillation with a rapid ventricular response.\nLeft axis deviation. Non-specific ST-T wave changes. Compared to the previous\ntracing atrial fibrillation is new.\n\n" }, { "category": "ECG", "chartdate": "2193-12-28 00:00:00.000", "description": "Report", "row_id": 182608, "text": "Baseline artifact. Sinus rhythm. Modest inferior ST-T wave changes which\nare non-specific. Compared to the previous tracing of atrial\nfibrilltaion has now converted to sinus rhythm.\n\n" }, { "category": "Nursing", "chartdate": "2194-01-01 00:00:00.000", "description": "Nursing Progress Note", "row_id": 398490, "text": "CVA (Stroke, Cerebral infarction), Hemorrhagic\n Assessment:\n Action:\n Response:\n Plan:\n Atrial fibrillation (Afib)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2194-01-01 00:00:00.000", "description": "Nursing Progress Note", "row_id": 398492, "text": "CVA (Stroke, Cerebral infarction), Hemorrhagic\n Assessment:\n Action:\n Response:\n Plan:\n Atrial fibrillation (Afib)\n Assessment:\n Action:\n Response:\n Plan:\n CVA (Stroke, Cerebral infarction), Hemorrhagic\n Assessment:\n Neuro bedside for assessment- no change in pt condition since MRI, pt\n not interactive, grimacing with oral care and will withdraw bilat feet\n to pain\n Action:\n ? pt in pain and given 1xdose 2mg IV Morphine, 650 mg acetaminophen,\n minimizing ? painful/ irritatinginterventions\n Response:\n Pt temp down to 96, RR and HR decreasing, BP labile with nursing\n care/interventions- BP as high as 180\ns while attempting to suction and\n down to 80/ post IV morphine (confirmed by BP cuff)\n Plan:\n Cont current level of care at this time\n" }, { "category": "Nursing", "chartdate": "2194-01-01 00:00:00.000", "description": "Nursing Progress Note", "row_id": 398578, "text": "Events: Multiple family at bedside- meeting with family and attending-\n at 12 PM made CMO and terminal extubation and placed on morphine gtt.\n CVA (Stroke, Cerebral infarction), Hemorrhagic\n Assessment:\n No acute change in MS, once extubated would intermittently groan\n Action:\n CMO\n Response:\n Remains comfortable on Morphine gtt\n Plan:\n Cont Morphine gtt for pain/resp status, comfort measures\n" }, { "category": "Physician ", "chartdate": "2194-01-02 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 398643, "text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n - Extubated\n - Made CMO\n - Morphine drip; scopolamine patch\n - Became tachycardic again to 130s in the evening.\n - RVR later yesterday, but with good pressures.\n Allergies:\n Coumadin (Oral) (Warfarin Sodium)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Morphine Sulfate - 8 mg/hour\n Other ICU medications:\n Morphine Sulfate - 06:42 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 06:51 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 38\nC (100.4\n Tcurrent: 35.9\nC (96.7\n HR: 160 (90 - 160) bpm\n BP: 107/63(77) {98/55(67) - 171/101(128)} mmHg\n RR: 7 (7 - 21) insp/min\n SpO2: 65%\n Heart rhythm: AF (Atrial Fibrillation)\n Total In:\n 1,417 mL\n 55 mL\n PO:\n TF:\n IVF:\n 1,357 mL\n 55 mL\n Blood products:\n Total out:\n 515 mL\n 60 mL\n Urine:\n 515 mL\n 60 mL\n NG:\n Stool:\n Drains:\n Balance:\n 902 mL\n -5 mL\n Respiratory support\n O2 Delivery Device: None\n Ventilator mode: [: CPAP/PSV :]\n Vt (Spontaneous): 413 (413 - 413) mL\n PS : 5 cmH2O\n RR (Spontaneous): 14\n PEEP: 5 cmH2O\n FiO2: 40%\n PIP: 10 cmH2O\n SpO2: 65%\n ABG: ////\n Ve: 6.4 L/min\n Physical Examination\n General: Sedated, appears comfortable. Pale and clearly hemiparetic\n elderly man.\n HEENT: Sclera anicteric, PERRL, MMM\n Lungs: Clear to auscultation bilaterally on anterior exam, no wheezes,\n rales, ronchi\n CV: Irregularly irregular. Tachycardic.\n Abdomen: Soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness or guarding\n Ext: warm, well perfused, 1+ pulses, no clubbing, cyanosis or edema\n Neuro: Non-responsive.\n Labs / Radiology\n 265 K/uL\n 9.8 g/dL\n 102 mg/dL\n 1.4 mg/dL\n 20 mEq/L\n 3.9 mEq/L\n 15 mg/dL\n 111 mEq/L\n 139 mEq/L\n 30.5 %\n 9.3 K/uL\n [image002.jpg]\n 02:52 AM\n 02:58 AM\n 07:50 AM\n 08:52 AM\n 11:23 AM\n 02:00 PM\n 08:52 PM\n 03:30 AM\n 04:01 AM\n 03:43 AM\n WBC\n 11.4\n 11.3\n 10.7\n 8.8\n 9.3\n Hct\n 35.3\n 32.5\n 32.5\n 30.4\n 30.5\n Plt\n 285\n 278\n 293\n 261\n 265\n Cr\n 1.6\n 1.6\n 1.5\n 1.5\n 1.4\n TropT\n 0.11\n 0.11\n TCO2\n 24\n Glucose\n 128\n 125\n 155\n 143\n 140\n 127\n 102\n Other labs: PT / PTT / INR:11.9/27.5/1.0, CK / CKMB /\n Troponin-T:1057/9/0.11, Lactic Acid:1.3 mmol/L, Ca++:7.4 mg/dL,\n Mg++:1.9 mg/dL, PO4:2.1 mg/dL\n CXR\n Final; no interval change\n Assessment and Plan\n 73 yo M with a history of a. fib, L MCA stroke, recurrent seizures who\n initially presented after witnessed seizure, now transferred to the\n MICU with tachycardia and hypotension and found to have full right MCA\n territory stroke with only viable cortex supplied by anterior cerebral\n and posterior cerebral on right. No meaningful recovery expected and\n patient has been made CMO.\n # Right MCA stroke. Likely etiology of patient\ns seizure presentation\n and AMS secondary to very large cortical infarction now with greater\n loss of cortical function.\n - Continue comfort measures only\n - Continue morphine drip\n - Continue seizure prophylaxis with tegretol\n - Appreciate neurology, stroke, palliative care recommendations\n # Autonomic lability. Likely secondary to continued autoregulation.\n - Continue rate control prn\n - Continue fluid boluses prn\n - Continue to hold anticoagulation given small hemorrhagic conversion\n # A fib. Episode last night of a. fib with RVR.\n - Continue rate control prn\n # Acute renal failure. Stable/improving.\n - Continue maintenance fluids\n - Continue to renally dose medications; avoid nephrotoxins\n # Seizures. Likely secondary to new R MCA stroke.\n - Continue seizure prophylaxis with tegretol\n # FEN: Supportive maintenance fluids, replete electrolytes prn, NPO\n # Prophylaxis: Comfort measures only\n # Access: PIV\n # Communication: Patient and daughter\n # Code: CMO (discussed with daughter, family)\n # Disposition: ICU at this time\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Arterial Line - 05:00 PM\n 20 Gauge - 11:23 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2194-01-02 00:00:00.000", "description": "Physician Resident/Attending Progress Note - MICU", "row_id": 398647, "text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n - Extubated\n - Made CMO\n - Morphine drip; scopolamine patch\n - Became tachycardic again to 130s in the evening.\n - RVR later yesterday, but with good pressures.\n Allergies:\n Coumadin (Oral) (Warfarin Sodium)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Morphine Sulfate - 8 mg/hour\n Other ICU medications:\n Morphine Sulfate - 06:42 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 06:51 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 38\nC (100.4\n Tcurrent: 35.9\nC (96.7\n HR: 160 (90 - 160) bpm\n BP: 107/63(77) {98/55(67) - 171/101(128)} mmHg\n RR: 7 (7 - 21) insp/min\n SpO2: 65%\n Heart rhythm: AF (Atrial Fibrillation)\n Total In:\n 1,417 mL\n 55 mL\n PO:\n TF:\n IVF:\n 1,357 mL\n 55 mL\n Blood products:\n Total out:\n 515 mL\n 60 mL\n Urine:\n 515 mL\n 60 mL\n NG:\n Stool:\n Drains:\n Balance:\n 902 mL\n -5 mL\n Respiratory support\n O2 Delivery Device: None\n Ventilator mode: [: CPAP/PSV :]\n Vt (Spontaneous): 413 (413 - 413) mL\n PS : 5 cmH2O\n RR (Spontaneous): 14\n PEEP: 5 cmH2O\n FiO2: 40%\n PIP: 10 cmH2O\n SpO2: 65%\n ABG: ////\n Ve: 6.4 L/min\n Physical Examination\n General: Sedated, appears comfortable. Pale and clearly hemiparetic\n elderly man.\n HEENT: Sclera anicteric, PERRL, MMM\n Lungs: Clear to auscultation bilaterally on anterior exam, no wheezes,\n rales, ronchi\n CV: Irregularly irregular. Tachycardic.\n Abdomen: Soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness or guarding\n Ext: warm, well perfused, 1+ pulses, no clubbing, cyanosis or edema\n Neuro: Non-responsive.\n Labs / Radiology\n 265 K/uL\n 9.8 g/dL\n 102 mg/dL\n 1.4 mg/dL\n 20 mEq/L\n 3.9 mEq/L\n 15 mg/dL\n 111 mEq/L\n 139 mEq/L\n 30.5 %\n 9.3 K/uL\n [image002.jpg]\n 02:52 AM\n 02:58 AM\n 07:50 AM\n 08:52 AM\n 11:23 AM\n 02:00 PM\n 08:52 PM\n 03:30 AM\n 04:01 AM\n 03:43 AM\n WBC\n 11.4\n 11.3\n 10.7\n 8.8\n 9.3\n Hct\n 35.3\n 32.5\n 32.5\n 30.4\n 30.5\n Plt\n 285\n 278\n 293\n 261\n 265\n Cr\n 1.6\n 1.6\n 1.5\n 1.5\n 1.4\n TropT\n 0.11\n 0.11\n TCO2\n 24\n Glucose\n 128\n 125\n 155\n 143\n 140\n 127\n 102\n Other labs: PT / PTT / INR:11.9/27.5/1.0, CK / CKMB /\n Troponin-T:1057/9/0.11, Lactic Acid:1.3 mmol/L, Ca++:7.4 mg/dL,\n Mg++:1.9 mg/dL, PO4:2.1 mg/dL\n CXR\n Final; no interval change\n Assessment and Plan\n 73 yo M with a history of a. fib, L MCA stroke, recurrent seizures who\n initially presented after witnessed seizure, now transferred to the\n MICU with tachycardia and hypotension and found to have full right MCA\n territory stroke with only viable cortex supplied by anterior cerebral\n and posterior cerebral on right. No meaningful recovery expected and\n patient has been made CMO.\n # Right MCA stroke. Likely etiology of patient\ns seizure presentation\n and AMS secondary to very large cortical infarction now with greater\n loss of cortical function.\n - Continue comfort measures only\n - Continue morphine drip\n - Continue seizure prophylaxis with tegretol\n - Appreciate neurology, stroke, palliative care recommendations\n # Autonomic lability. Likely secondary to continued autoregulation.\n - Continue rate control prn\n - Continue fluid boluses prn\n - Continue to hold anticoagulation given small hemorrhagic conversion\n # A fib. Episode last night of a. fib with RVR.\n - Continue rate control prn\n # Acute renal failure. Stable/improving.\n - Continue maintenance fluids\n - Continue to renally dose medications; avoid nephrotoxins\n # Seizures. Likely secondary to new R MCA stroke.\n - Continue seizure prophylaxis with tegretol\n # FEN: Supportive maintenance fluids, replete electrolytes prn, NPO\n # Prophylaxis: Comfort measures only\n # Access: PIV\n # Communication: Patient and daughter\n # Code: CMO (discussed with daughter, family)\n # Disposition: ICU at this time\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Arterial Line - 05:00 PM\n 20 Gauge - 11:23 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n ------ Protected Section ------\n MICU ATTENDING ADDENDUM\n I saw and examined the patient, and was physically present with the ICU\n team for the key portions of the services provided. I agree with the\n note above, including the assessment and plan. I would emphasize and\n add the following points: 73M s/p prior CVA c/b hemiparesis initially\n admitted with seizures, AF c RVR, massive RCA CVA. Agree with plan to\n manage large R CVA with ongoing comfort-centered care. Remainder of\n plan as outlined above.\n Total time: 15 min\n ------ Protected Section Addendum Entered By: , MD\n on: 01:06 PM ------\n" }, { "category": "Physician ", "chartdate": "2194-01-01 00:00:00.000", "description": "Physician Resident/Attending Progress Note - MICU", "row_id": 398568, "text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n - Family Meeting: Awaiting family from out of town. Would like to plan\n for extubation in the morning .\n - Neuro recs: Comfort measures.\n - Palliative care recs: Nothing new.\n - Patient hypotensive during the afternoon, bolused 500cc with good\n response. However continued to have lability of blood pressure during\n the afternoon/evening\n - Went into A. fib with RVR (150s). Gave 5mg Lopressor with rate to\n 100s, blood pressure 80s/40s during so bolused 500cc. Pressures/rate\n stabilized.\n Allergies:\n Coumadin (Oral) (Warfarin Sodium)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Morphine Sulfate - 11:15 PM\n Metoprolol - 11:30 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:12 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.9\nC (100.3\n Tcurrent: 37.9\nC (100.3\n HR: 104 (75 - 173) bpm\n BP: 116/75(88) {82/59(71) - 167/118(137)} mmHg\n RR: 15 (12 - 41) insp/min\n SpO2: 100%\n Heart rhythm: AF (Atrial Fibrillation)\n Total In:\n 2,583 mL\n 935 mL\n PO:\n TF:\n IVF:\n 2,583 mL\n 935 mL\n Blood products:\n Total out:\n 730 mL\n 245 mL\n Urine:\n 730 mL\n 245 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,853 mL\n 691 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 492 (418 - 711) mL\n PS : 5 cmH2O\n RR (Spontaneous): 17\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI Deferred: CMO\n PIP: 11 cmH2O\n SpO2: 100%\n ABG: ///20/\n Ve: 7.9 L/min\n Physical Examination\n General: Intubated and sedated. Pale and clearly hemiparetic elderly\n man.\n HEENT: Sclera anicteric, PERRL, MMM\n Neck: supple, JVP not elevated, no LAD\n Lungs: Clear to auscultation bilaterally on anterior exam, no wheezes,\n rales, ronchi\n CV: Irregularly irregular. Tachycardic.\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness or guarding, no organomegaly\n Ext: warm, well perfused, 1+ pulses, no clubbing, cyanosis or edema\n Neuro: Non-responsive. Only eye opening without fixation or movements\n on physical stimulation. No response to voice. Completely non-verbal.\n Only reflexive bodily movements when being moved around. Rigid and\n wasted right leg, left more flaccid. Upper limbs rigid R > L. R flexor\n and L extensor.\n Labs / Radiology\n 265 K/uL\n 9.8 g/dL\n 102 mg/dL\n 1.4 mg/dL\n 20 mEq/L\n 3.9 mEq/L\n 15 mg/dL\n 111 mEq/L\n 139 mEq/L\n 30.5 %\n 9.3 K/uL\n [image002.jpg]\n 02:52 AM\n 02:58 AM\n 07:50 AM\n 08:52 AM\n 11:23 AM\n 02:00 PM\n 08:52 PM\n 03:30 AM\n 04:01 AM\n 03:43 AM\n WBC\n 11.4\n 11.3\n 10.7\n 8.8\n 9.3\n Hct\n 35.3\n 32.5\n 32.5\n 30.4\n 30.5\n Plt\n 285\n 278\n 293\n 261\n 265\n Cr\n 1.6\n 1.6\n 1.5\n 1.5\n 1.4\n TropT\n 0.11\n 0.11\n TCO2\n 24\n Glucose\n 128\n 125\n 155\n 143\n 140\n 127\n 102\n Other labs: PT / PTT / INR:11.9/27.5/1.0, CK / CKMB /\n Troponin-T:1057/9/0.11, Lactic Acid:1.3 mmol/L, Ca++:7.4 mg/dL,\n Mg++:1.9 mg/dL, PO4:2.1 mg/dL\n CXR\n There is no interval pneumothorax, pleural effusion or focal\n consolidation.\n Urine\n negative; final\n MRSA screen\n negative; final\n CSF\n negative; final\n Blood cultures\n negative; pending\n Assessment and Plan\n 73 yo M with a history of afib, L MCA stroke, recurrent seizures who\n initially presented after witnessed seizure, now transferred to the\n MICU with tachycardia and hypotension and found to have full right MCA\n territory stroke with only viable cortex supplied by anterior cerebral\n and posterior cerebral on right. No meaningful recovery expected and\n family is in agreement with plans to transition to CMO. He is presently\n DNR/do not re-intubate.\n # Left MCA stroke. Likely etiology of patient\ns seizure presentation\n and AMS secondary to very large cortical infarction now with greater\n loss of cortical function.\n - Plan to make CMO after formal discussion with family\n - Comfort measure only; start morphine drip\n - Continue supportive care for comfort\n - Continue seizure prophylaxis with tegretol\n - Appreciate neurology, stroke, palliative care recommendations\n # Autonomic lability. Likely etiology of patient\ns labile BP secondary\n to continued autoregulation.\n - Continue rate control prn\n - Continue fluid boluses prn\n - Continue to hold anticoagulation given small hemorrhagic conversion\n # A fib. Episode last night of a. fib with RVR that responded well to\n lopressor.\n - Continue rate control prn\n # Acute renal failure. Improving. Consider prerenal with increased\n viscosity and dislodging of clot or increased clotting in small vessel.\n - Continue maintenance fluids\n - Continue to renally dose medications; avoid nephrotoxins\n # Seizures. Likely secondary to new L MCA stroke.\n - Continue seizure prophylaxis with tegretol\n # Concern for hypoperfused RLE.\n - Continue to monitor\n # FEN: Supportive maintenance fluids, replete electrolytes prn, NPO\n # Prophylaxis: Boots only, famotidine\n # Access: PIV x3\n # Communication: Patient and daughter\n # Code: DNR/DNI (discussed with daughter, family); will be made CMO\n today\n # Disposition: ICU pending determination of care\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Arterial Line - 05:00 PM\n 20 Gauge - 11:23 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n ------ Protected Section ------\n MICU ATTENDING ADDENDUM\n I saw and examined the patient, and was physically present with the ICU\n team for the key portions of the services provided. I agree with the\n note above, including the assessment and plan. I would emphasize and\n add the following points: 73M s/p prior CVA c/b hemiparesis initially\n admitted with seizures, AF c RVR, massive RCA CVA. Lopressor o/n for AF\n c RVR.\n Exam notable for Tm 100.3 BP 116/60 HR 100-150AF RR 16 with sat 99 on\n PSV 5/5 0.4. Unresponse, occasional eye opening but not to threat or\n voice. Dense R paresis. PERRL. CTA B. Irreg s1s2 2/6Sm. Soft +BS. Cool\n B, trace edema. Labs notable for WBC 8K, HCT 30, K+ 3.7, Cr 1.5.\n Agree with plan to manage large R CVA with transition to CMO and\n extubation today, family at bedside and are in agreement with this\n transition in goal of care. Remainder of plan as outlined above.\n Patient is critically ill\n Total time: 30 min\n ------ Protected Section Addendum Entered By: , MD\n on: 04:45 PM ------\n" }, { "category": "Nursing", "chartdate": "2194-01-02 00:00:00.000", "description": "Nursing Progress Note", "row_id": 398621, "text": "Comfort care (CMO, Comfort Measures)\n Assessment:\n Patient comfort care only. Family at bedside throughout night.\n Unresponsive.\n Action:\n Continued on morphine gtt @ 8mg/hr. Emotional support provided to\n family. Pain assessed/treated.\n Response:\n Continues to have - resp. Appears to be comfortable.\n Plan:\n CMO. Titrate morphine gtt as needed for comfort. Provide emotional\n support for family.\n" }, { "category": "Physician ", "chartdate": "2194-01-02 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 398625, "text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n - Extubated\n - Made CMO\n - Morphine drip; scopolamine patch\n - Became tachycardic again to 130s in the evening.\n - RVR later yesterday, but with good pressures.\n Allergies:\n Coumadin (Oral) (Warfarin Sodium)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Morphine Sulfate - 8 mg/hour\n Other ICU medications:\n Morphine Sulfate - 06:42 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 06:51 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 38\nC (100.4\n Tcurrent: 35.9\nC (96.7\n HR: 160 (90 - 160) bpm\n BP: 107/63(77) {98/55(67) - 171/101(128)} mmHg\n RR: 7 (7 - 21) insp/min\n SpO2: 65%\n Heart rhythm: AF (Atrial Fibrillation)\n Total In:\n 1,417 mL\n 55 mL\n PO:\n TF:\n IVF:\n 1,357 mL\n 55 mL\n Blood products:\n Total out:\n 515 mL\n 60 mL\n Urine:\n 515 mL\n 60 mL\n NG:\n Stool:\n Drains:\n Balance:\n 902 mL\n -5 mL\n Respiratory support\n O2 Delivery Device: None\n Ventilator mode: [: CPAP/PSV :]\n Vt (Spontaneous): 413 (413 - 413) mL\n PS : 5 cmH2O\n RR (Spontaneous): 14\n PEEP: 5 cmH2O\n FiO2: 40%\n PIP: 10 cmH2O\n SpO2: 65%\n ABG: ////\n Ve: 6.4 L/min\n Physical Examination\n General: Sedated, appears comfortable. Pale and clearly hemiparetic\n elderly man.\n HEENT: Sclera anicteric, PERRL, MMM\n Lungs: Clear to auscultation bilaterally on anterior exam, no wheezes,\n rales, ronchi\n CV: Irregularly irregular. Tachycardic.\n Abdomen: Soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness or guarding\n Ext: warm, well perfused, 1+ pulses, no clubbing, cyanosis or edema\n Neuro: Nonresponsive. Only eye opening without fixation or movements on\n physical stimulation. No response to voice. Completely non-verbal. Only\n reflexive bodily movements when being moved around. Rigid and wasted\n right leg, left more flaccid. Upper limbs rigid R > L. R flexor and L\n extensor.\n Labs / Radiology\n 265 K/uL\n 9.8 g/dL\n 102 mg/dL\n 1.4 mg/dL\n 20 mEq/L\n 3.9 mEq/L\n 15 mg/dL\n 111 mEq/L\n 139 mEq/L\n 30.5 %\n 9.3 K/uL\n [image002.jpg]\n 02:52 AM\n 02:58 AM\n 07:50 AM\n 08:52 AM\n 11:23 AM\n 02:00 PM\n 08:52 PM\n 03:30 AM\n 04:01 AM\n 03:43 AM\n WBC\n 11.4\n 11.3\n 10.7\n 8.8\n 9.3\n Hct\n 35.3\n 32.5\n 32.5\n 30.4\n 30.5\n Plt\n 285\n 278\n 293\n 261\n 265\n Cr\n 1.6\n 1.6\n 1.5\n 1.5\n 1.4\n TropT\n 0.11\n 0.11\n TCO2\n 24\n Glucose\n 128\n 125\n 155\n 143\n 140\n 127\n 102\n Other labs: PT / PTT / INR:11.9/27.5/1.0, CK / CKMB /\n Troponin-T:1057/9/0.11, Lactic Acid:1.3 mmol/L, Ca++:7.4 mg/dL,\n Mg++:1.9 mg/dL, PO4:2.1 mg/dL\n CXR\n Final; no interval change\n Assessment and Plan\n 73 yo M with a history of a. fib, L MCA stroke, recurrent seizures who\n initially presented after witnessed seizure, now transferred to the\n MICU with tachycardia and hypotension and found to have full right MCA\n territory stroke with only viable cortex supplied by anterior cerebral\n and posterior cerebral on right. No meaningful recovery expected and\n patient has been made CMO.\n # Right MCA stroke. Likely etiology of patient\ns seizure presentation\n and AMS secondary to very large cortical infarction now with greater\n loss of cortical function.\n - Continue comfort measures only\n - Continue morphine drip\n - Continue seizure prophylaxis with tegretol\n - Appreciate neurology, stroke, palliative care recommendations\n # Autonomic lability. Likely secondary to continued autoregulation.\n - Continue rate control prn\n - Continue fluid boluses prn\n - Continue to hold anticoagulation given small hemorrhagic conversion\n # A fib. Episode last night of a. fib with RVR.\n - Continue rate control prn\n # Acute renal failure. Stable/improving.\n - Continue maintenance fluids\n - Continue to renally dose medications; avoid nephrotoxins\n # Seizures. Likely secondary to new R MCA stroke.\n - Continue seizure prophylaxis with tegretol\n # FEN: Supportive maintenance fluids, replete electrolytes prn, NPO\n # Prophylaxis: Comfort measures only\n # Access: PIV\n # Communication: Patient and daughter\n # Code: CMO (discussed with daughter, family)\n # Disposition: ICU at this time\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Arterial Line - 05:00 PM\n 20 Gauge - 11:23 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2193-12-30 00:00:00.000", "description": "Nursing Progress Note", "row_id": 398392, "text": "73 yo M with a history of afib, L MCA stroke, recurrent seizures who\n initally presented after witnessed seizure, now transferred to the MICU\n with tachycardia and hypotension. Likely neurologic given primary\n presenting complaint AMS. Will obtain MR stable.\n Atrial fibrillation (Afib)\n Assessment:\n Action:\n Response:\n Plan:\n Seizure, without status epilepticus\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2193-12-31 00:00:00.000", "description": "Nursing Progress Note", "row_id": 398401, "text": "Pt is a 73 yo Cantonese speaking man with a h/o of a left LMCA stroke\n in with residual right sided hemiplegia and recurrent seizure\n disorder. Pt was found during a seizure by his wife. The pt had been\n seizing for an undetermined amount of time. EMS called and administered\n valium 5mg ivp with resolution of seizure activity. He was intubated in\n the ed on his arrival for airway protection. Continuous eeg monitoring\n w/o evidence of further seizure activity. He was transferred to the\n TSICU as a MICU border. His brief hospital course has been complicated\n by new onset afib with hemodynamic instability and poor perfusion to\n his rle which is suspicious for a new embolic stroke\n" }, { "category": "Physician ", "chartdate": "2193-12-29 00:00:00.000", "description": "Intensivist Note", "row_id": 398288, "text": "TSICU\n HPI:\n 73yo Cantonese speaking M with pAfib on Plavix and h/o large L MCA\n stroke with baseline R hemiparesis and seizures who was found to have\n increased tone and upward gaze deviation per family this morning around\n 9am. He was seen normal around 90 minutes prior hence\n unclear how long he was seizing. Patient was still seizing upon\n EMS arrival and improved with Valium 5mg IV per report but\n patient remains nonverbal and not following commands with\n intermittently increased tone on L. EEG performed in the ED\n showed that he was not continuing to seize but patient spiked to\n 100.8 while in the ED hence underwent LP. Transferred to TICU\n intubated, sedated.\n Chief complaint:\n SZ\n PMHx:\n PMH: CAD, Afib, L MCA CVA ', HTN, Seizure d/o.\n PSH: none\n Current medications:\n Acetaminophen 5. Amiodarone 6. Amiodarone 7. Amiodarone 8.\n Carbamazepine\n 9. Calcium Gluconate 10. Clopidogrel 11. Dextrose 50% 12. Famotidine\n 13. Glucagon 14. Heparin 15. HydrALAzine\n 16. HydrALAzine 17. Insulin 18. Labetalol 19. Lorazepam 20. Lorazepam\n 21. Magnesium Sulfate 22. Metoprolol Tartrate\n 23. Metoprolol Tartrate 24. Pneumococcal Vac Polyvalent 25. Potassium\n Chloride 26. Pravastatin 27. Propofol\n 24 Hour Events:\n INVASIVE VENTILATION - START 04:20 PM\n ARTERIAL LINE - START 05:00 PM\n EKG - At 04:20 AM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Propofol - 20 mcg/Kg/min\n Amiodarone - 1 mg/min\n Other ICU medications:\n Hydralazine - 05:10 PM\n Labetalol - 03:31 AM\n Metoprolol - 03:45 AM\n Amiodarone - 04:17 AM\n Other medications:\n Flowsheet Data as of 05:13 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.6\nC (99.6\n T current: 37.6\nC (99.6\n HR: 112 (85 - 155) bpm\n BP: 99/57(71) {99/55(71) - 194/96(132)} mmHg\n RR: 24 (21 - 42) insp/min\n SPO2: 99%\n Heart rhythm: AF (Atrial Fibrillation)\n Total In:\n 3,082 mL\n 379 mL\n PO:\n Tube feeding:\n IV Fluid:\n 1,782 mL\n 379 mL\n Blood products:\n Total out:\n 450 mL\n 490 mL\n Urine:\n 450 mL\n 490 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,632 mL\n -111 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 486 (486 - 687) mL\n PS : 5 cmH2O\n RR (Set): 14\n RR (Spontaneous): 25\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 67\n PIP: 11 cmH2O\n Plateau: 17 cmH2O\n SPO2: 99%\n ABG: 7.38/39/160/22/-1\n Ve: 11.3 L/min\n PaO2 / FiO2: 400\n Physical Examination\n HEENT: PERRL\n Cardiovascular: (Rhythm: Irregular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Diminished: RLL), (Sternum: Stable )\n Abdominal: Soft, Non-distended, Non-tender\n Left Extremities: (Edema: Absent)\n Right Extremities: (Edema: Absent)\n Neurologic: Sedated\n Labs / Radiology\n 285 K/uL\n 11.3 g/dL\n 125 mg/dL\n 1.6 mg/dL\n 22 mEq/L\n 4.2 mEq/L\n 23 mg/dL\n 113 mEq/L\n 142 mEq/L\n 35.3 %\n 11.4 K/uL\n [image002.jpg]\n 05:30 PM\n 05:48 PM\n 10:40 PM\n 02:52 AM\n 02:58 AM\n WBC\n 15.9\n 11.4\n Hct\n 41.6\n 35.3\n Plt\n 378\n 285\n Creatinine\n 1.9\n 1.6\n TCO2\n 19\n 19\n 24\n Glucose\n 180\n 128\n 125\n Other labs: PT / PTT / INR:13.1/29.9/1.1, Lactic Acid:1.3 mmol/L,\n Ca:8.3 mg/dL, Mg:1.8 mg/dL, PO4:3.1 mg/dL\n Assessment and Plan\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF), SEIZURE, WITHOUT\n STATUS EPILEPTICUS, HYPERTENSION, BENIGN\n Assessment and Plan: 73 M w/ pAfib on Plavix, SZ d/o p/w with SZ,\n intubated for airway protection\n NEURO: Intubated, Tegretol to 300mg ,started Ativan 1mg IV TID for\n bridge, EEG o/n\n Neuro checks Q: 1\n Pain: APAP prn\n CVS: Afib, on amio gtt, Hypertensive, SBP<160, Hydral labetolol prn, on\n metoprolol 32'', pravastatin 20'\n PULM: no issues\n GI: NPO\n RENAL: ARF, Cr 2.0, boluses, follow UO\n HEME: ? heparin gtt, plavix 75'\n ENDO: RISS\n ID: f/u LP, WC 15.9, Afeb\n TLD: PIV, ETT, foley, Left Aline\n IVF: NS @100\n CONSULTS:\n BILLING DIAGNOSIS:\n ICU CARE:\n GLYCEMIC CONTROL: RISS\n PROPHYLAXIS:\n DVT - SCDs\n STRESS ULCER - H2B\n VAP BUNDLE -\n COMMUNICATIONS:\n ICU Consent: daughter\n CODE STATUS: FULL\n DISPOSITION: TICU\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 04:30 PM\n Arterial Line - 05:00 PM\n 20 Gauge - 04:19 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent:\n Patient is critically ill\n" }, { "category": "Physician ", "chartdate": "2193-12-29 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 398290, "text": "Chief Complaint: Seizures\n Reason for transfer: hypotension and tachycardia\n HPI:\n 73 yo Cantonese speaking male with a history of L MCA stroke in ,\n with recurrent seizure disorder, who presented to the ED after a\n prolonged seizure witnessed at home. Per family, he was found\n unresponsive, with increased stiffness, and eyes deviated upwards on\n the morning of admission. Two hours prior to seizure he was observed by\n his wife, and was thought to be in his usual state of health. EMS\n administered Valium 5mg IV x1, and seizure abated.\n At baseline he is aphasic but able to ambulate with a cane and leg\n brace.\n .\n In the ED, initial vs were: T98.8 P80 BP193/112 R21 O2 sat 100% on NRB.\n Patient was given Metoprolol 5mg IV x1 for HTN. He was thought to have\n intermittent increased tone on L without returning to baseline mental\n status hence underwent emergent EEG monitoring while in ED which did\n not show seizure activity.\n While in the ED, Tmax was 100.8. He became diaphoretic hence underwent\n LP. Thereafter he was given Vancomyin 1g and Ceftriaxone 2g.\n While in the ED, patient became acutely tachypneic. ABG was\n 7.39/30/116. He was subsequently intubated.\n Patient was also noted to have poor circulation and hyperemic RLE.\n Vascular surgery was consulted who recommended a heparin gtt and LENI\n to evaluate for DVT. He was admitted to neuro ICU.\n Overnight, changes of RLE seemed to self-resolve. Heparin was never\n started. LENI was negative.\n This morning at 4am, patient was found to be tachycardic to 140s, and\n hypotensive to 80s/50s. He was given an amiodarone bolus and started on\n an amiodarone gtt. Patient was also given a 500cc bolus of IV fluids.\n Given concerns for PE, a heparin gtt was started. On MICU evaluation\n the HR was in 120s, BPs 110/80s. He was transferred to the MICU for\n medical evaluation of hypotension and tachycardia.\n .\n .\n Review of systems:\n (+) Per HPI\n (-) Unable to complete\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Propofol - 10 mcg/Kg/min\n Amiodarone - 1 mg/min\n Heparin Sodium - 1,050 units/hour\n Other ICU medications:\n Hydralazine - 05:10 PM\n Labetalol - 03:31 AM\n Metoprolol - 03:45 AM\n Amiodarone - 04:17 AM\n Heparin Sodium - 09:00 AM\n Other medications:\n Home Medications (per OMR):\n 1. Metoprolol 32ml\n 2. Tegretol 200mg \n 3. Plavix 75mg daily\n 4. Pravastatin 20mg\n .\n MEDICATIONS ON TRANSFER:\n Acetaminophen 650 mg PO/NG Q6H:PRN T>100.4 or pain\n Lorazepam 0.5-2 mg IV Q4H:PRN seizures > 5 minutes\n Carbamazepine 300 mg PO/NG \n Pravastatin 20 mg PO DAILY\n Clopidogrel 75 mg PO/NG DAILY\n Metoprolol Tartrate 37.5 mg PO/NG \n Famotidine 20 mg PO/NG Q24H\n Insulin SC (per Insulin Flowsheet) Sliding Scale\n Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol\n Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol\n Lorazepam 1 mg IV BID\n Propofol 20-100 mcg/kg/min IV DRIP INFUSION\n Potassium Chloride IV Sliding Scale\n Calcium Gluconate IV Sliding Scale\n Magnesium Sulfate IV Sliding Scale\n Amiodarone 1 mg/min IV DRIP INFUSION Duration: 6 Hours Start: After\n completion of bolus dose\n Amiodarone 0.5 mg/min IV DRIP INFUSION Duration: 18 Hours Start: After\n completion of 1 mg/min infused dose.\n Heparin IV per Weight-Based Dosing Guidelines\n Past medical history:\n Family history:\n Social History:\n (per OMR notes):\n 1. hx of Afib\n 2. hx of stroke - large L MCA stroke in thought to be\n cardioembolic in origin.\n 3. Hypercholesterolemia\n 4. Seizures\n Non contributory\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: Lives at home with wife. Emigrated from > 30 yrs ago.\n Smoked heavily over 30 yrs but quit since stroke in . No\n drug or EtOH hx.\n Review of systems:\n Flowsheet Data as of 10:17 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: 37.4\nC (99.3\n HR: 122 (85 - 155) bpm\n BP: 101/58(73) {87/53(64) - 194/96(132)} mmHg\n RR: 23 (21 - 42) insp/min\n SpO2: 98%\n Heart rhythm: AF (Atrial Fibrillation)\n Total In:\n 3,082 mL\n 1,997 mL\n PO:\n TF:\n IVF:\n 1,782 mL\n 1,997 mL\n Blood products:\n Total out:\n 450 mL\n 845 mL\n Urine:\n 450 mL\n 845 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,632 mL\n 1,152 mL\n Respiratory\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 430 (430 - 687) mL\n PS : 5 cmH2O\n RR (Set): 14\n RR (Spontaneous): 22\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 67\n PIP: 10 cmH2O\n Plateau: 17 cmH2O\n SpO2: 98%\n ABG: 7.38/39/160/21/-1\n Ve: 8.8 L/min\n PaO2 / FiO2: 400\n Physical Examination\n Vitals: Tmax overnight:99.6 BP:101/58 P:122 R: 21 O2: 98% on PS 5/5\n FiO2 40%\n General: Intubated and sedated\n HEENT: Sclera anicteric, PERRL, MMM\n Neck: supple, JVP not elevated, no LAD\n Lungs: Clear to auscultation bilaterally on anterior exam, no wheezes,\n rales, ronchi\n CV: Irregularly irregular. Tachycardic.\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness or guarding, no organomegaly\n Ext: warm, well perfused, 1+ pulses, no clubbing, cyanosis or edema\n Labs / Radiology\n 278 K/uL\n 10.4 g/dL\n 155 mg/dL\n 1.6 mg/dL\n 20 mg/dL\n 21 mEq/L\n 111 mEq/L\n 4.1 mEq/L\n 140 mEq/L\n 32.5 %\n 11.3 K/uL\n [image002.jpg]\n \n 2:33 A1/9/ 05:30 PM\n \n 10:20 P1/9/ 05:48 PM\n \n 1:20 P1/9/ 10:40 PM\n \n 11:50 P1/10/ 02:52 AM\n \n 1:20 A1/10/ 02:58 AM\n \n 7:20 P1/10/ 07:50 AM\n 1//11/006\n 1:23 P1/10/ 08:52 AM\n \n 1:20 P\n \n 11:20 P\n \n 4:20 P\n WBC\n 15.9\n 11.4\n 11.3\n Hct\n 41.6\n 35.3\n 32.5\n Plt\n 378\n 285\n 278\n Cr\n 1.9\n 1.6\n 1.6\n TC02\n 19\n 19\n 24\n Glucose\n 180\n 128\n 125\n 155\n Other labs: PT / PTT / INR:13.5/30.9/1.2, Lactic Acid:1.3 mmol/L,\n Ca++:7.7 mg/dL, Mg++:2.3 mg/dL, PO4:3.0 mg/dL\n Imaging: CT Head: . No acute intracranial hemorrhage or mass\n effect. Old left cerebral hemisphere infarction.\n .\n CXR: The ET tube tip is 4.6 cm above the carina. The NG tube tip is\n in the stomach. The lungs are clear without infiltrate or effusion.\n Again seen are multiple small pulmonary nodules very dense for their\n size, likely representing old granulomatous disease. The largest of\n these is in the right lower lung, measuring 6 mm. No focal infiltrate.\n .\n CXR (my read): ET tube 3.2cm above carina. Lungs clear without\n infiltrate or effusion.\n .\n R LENI\n IMPRESSION: No evidence of deep venous thrombosis, however, the right\n peroneal veins were not visualized.\n Microbiology: Blood cultures x2 pending\n CSF culture pending\n ECG: EKG on admission: NSR @ 95bpm. LAD. No ST segment changes or TWI.\n EKG 4am: Atrial fibrillation @ 148bpm. LAD. No ST segment changes.\n Assessment and Plan\n ATRIAL FIBRILLATION (AFIB)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n SEIZURE, WITHOUT STATUS EPILEPTICUS\n HYPERTENSION, BENIGN\n 73 yo M with a history of afib, L MCA stroke, recurrent seizures who\n initally presented after witnessed seizure, now transferred to the MICU\n with tachycardia and hypotension.\n .\n 1. Tachycardia and hypotension: Patient initally hypertensive in the\n ED, and has been getting metoprolol and Hydralazine for hypertension.\n Now intubated, on sedatives, and hypotensives. Differential includes\n hypovolemia, medication effect, hypotension secondary to Afib with RVR,\n PE, MI, sepsis. Given that inital hypotensive episode was this morning\n in the context of a rapid heart rate in the 150s, Afib is likely\n etiology. However, given concern for LE thrombus yesterday which seems\n to have resolved, tachypnea requiring intubation, PE is on the\n differential. CTA was defered given Acute renal failure, which is\n resolving. Sepsis is possible since patient had a fever of 100.8 in the\n ED. However since admission patient has remained afebrile. It is\n reassuring that CSF results do not support infection.\n -continue heparin gtt empirically for PE\n -consider CTA this evening or tomorrow as renal function improves\n -control atrial fibrillation with amiodarone gtt\n -start low dose po metoprolol for rate control. Wean up as BP\n tolerates.\n -rule out MI\n -rule out infection: obtain urine culture, follow up blood cultures,\n follow up CSF cultures\n -culture if spikes; consider antibiotic coverage. Would hold off for\n now given no localizing sources of infection.\n .\n 2. Respiratory failure: Patient was intubated for tachypnea in the ER.\n Currently with good O2 saturations on PS 5/5. Would favor extubation to\n avoid sedating medications that may be contributing to hypotension.\n -consider extubation today\n .\n # Acute renal failure: Baseline Cr 0.9. Cr on admission was 2.0, down\n to 1.6 today. Would consider CTA tomorrow assuming renal function woudl\n improve further. However if becomes tachycardic or hypoxic, could\n consider CTA earlier.\n -obtain urine lytes\n -avoid nephrotoxins; renally dose medications\n .\n #. Seizures: Patient with recurrent seizure disorder. EEG performed\n shows no seizure activity since admission.\n -Continue Tegretol 300mg \n -Continue Ativan 1mg IV BID\n -f/u neurology recs\n .\n # h/o MCA stroke:\n -continue plavix, pravastatin per outpatient regimen\n .\n # Concern for hyperemic RLE: RLE hyperemic in the ED. R LENI negative.\n Vascular evaluated the patient and has signed off. Currently both LEs\n have good circulation and pulses.\n -continue to monitor\n .\n .\n # FEN: No IVF, replete electrolytes, NPO for now\n # Prophylaxis: Heparin gtt, Famotidine\n # Access: PIV x3\n # Communication: Patient and daughter\n # Code: Full (discussed with daughter)\n # Disposition: ICU pending clinical improvement\n .\n .\n \n \n PGY-2\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 04:30 PM\n Arterial Line - 05:00 PM\n 20 Gauge - 04:19 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2193-12-29 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 398296, "text": "Chief Complaint: Seizures\n Reason for transfer: hypotension and tachycardia\n HPI:\n 73 yo Cantonese speaking male with a history of L MCA stroke in ,\n with recurrent seizure disorder, who presented to the ED after a\n prolonged seizure witnessed at home. Per family, he was found\n unresponsive, with increased stiffness, and eyes deviated upwards on\n the morning of admission. Two hours prior to seizure he was observed by\n his wife, and was thought to be in his usual state of health. EMS\n administered Valium 5mg IV x1, and seizure abated.\n At baseline he is aphasic but able to ambulate with a cane and leg\n brace.\n .\n In the ED, initial vs were: T98.8 P80 BP193/112 R21 O2 sat 100% on NRB.\n Patient was given Metoprolol 5mg IV x1 for HTN. He was thought to have\n intermittent increased tone on L without returning to baseline mental\n status hence underwent emergent EEG monitoring while in ED which did\n not show seizure activity.\n While in the ED, Tmax was 100.8. He became diaphoretic hence underwent\n LP. Thereafter he was given Vancomyin 1g and Ceftriaxone 2g.\n While in the ED, patient became acutely tachypneic. ABG was\n 7.39/30/116. He was subsequently intubated.\n Patient was also noted to have poor circulation and hyperemic RLE.\n Vascular surgery was consulted who recommended a heparin gtt and LENI\n to evaluate for DVT. He was admitted to neuro ICU.\n Overnight, changes of RLE seemed to self-resolve. Heparin was never\n started. LENI was negative.\n This morning at 4am, patient was found to be tachycardic to 140s, and\n hypotensive to 80s/50s. He was given an amiodarone bolus and started on\n an amiodarone gtt. Patient was also given a 500cc bolus of IV fluids.\n Given concerns for PE, a heparin gtt was started. On MICU evaluation\n the HR was in 120s, BPs 110/80s. He was transferred to the MICU for\n medical evaluation of hypotension and tachycardia.\n .\n .\n Review of systems:\n (+) Per HPI\n (-) Unable to complete\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Propofol - 10 mcg/Kg/min\n Amiodarone - 1 mg/min\n Heparin Sodium - 1,050 units/hour\n Other ICU medications:\n Hydralazine - 05:10 PM\n Labetalol - 03:31 AM\n Metoprolol - 03:45 AM\n Amiodarone - 04:17 AM\n Heparin Sodium - 09:00 AM\n Other medications:\n Home Medications (per OMR):\n 1. Metoprolol 32ml\n 2. Tegretol 200mg \n 3. Plavix 75mg daily\n 4. Pravastatin 20mg\n .\n MEDICATIONS ON TRANSFER:\n Acetaminophen 650 mg PO/NG Q6H:PRN T>100.4 or pain\n Lorazepam 0.5-2 mg IV Q4H:PRN seizures > 5 minutes\n Carbamazepine 300 mg PO/NG \n Pravastatin 20 mg PO DAILY\n Clopidogrel 75 mg PO/NG DAILY\n Metoprolol Tartrate 37.5 mg PO/NG \n Famotidine 20 mg PO/NG Q24H\n Insulin SC (per Insulin Flowsheet) Sliding Scale\n Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol\n Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol\n Lorazepam 1 mg IV BID\n Propofol 20-100 mcg/kg/min IV DRIP INFUSION\n Potassium Chloride IV Sliding Scale\n Calcium Gluconate IV Sliding Scale\n Magnesium Sulfate IV Sliding Scale\n Amiodarone 1 mg/min IV DRIP INFUSION Duration: 6 Hours Start: After\n completion of bolus dose\n Amiodarone 0.5 mg/min IV DRIP INFUSION Duration: 18 Hours Start: After\n completion of 1 mg/min infused dose.\n Heparin IV per Weight-Based Dosing Guidelines\n Past medical history:\n Family history:\n Social History:\n (per OMR notes):\n 1. hx of Afib\n 2. hx of stroke - large L MCA stroke in thought to be\n cardioembolic in origin.\n 3. Hypercholesterolemia\n 4. Seizures\n Non contributory\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: Lives at home with wife. Emigrated from > 30 yrs ago.\n Smoked heavily over 30 yrs but quit since stroke in . No\n drug or EtOH hx.\n Review of systems:\n Flowsheet Data as of 10:17 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: 37.4\nC (99.3\n HR: 122 (85 - 155) bpm\n BP: 101/58(73) {87/53(64) - 194/96(132)} mmHg\n RR: 23 (21 - 42) insp/min\n SpO2: 98%\n Heart rhythm: AF (Atrial Fibrillation)\n Total In:\n 3,082 mL\n 1,997 mL\n PO:\n TF:\n IVF:\n 1,782 mL\n 1,997 mL\n Blood products:\n Total out:\n 450 mL\n 845 mL\n Urine:\n 450 mL\n 845 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,632 mL\n 1,152 mL\n Respiratory\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 430 (430 - 687) mL\n PS : 5 cmH2O\n RR (Set): 14\n RR (Spontaneous): 22\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 67\n PIP: 10 cmH2O\n Plateau: 17 cmH2O\n SpO2: 98%\n ABG: 7.38/39/160/21/-1\n Ve: 8.8 L/min\n PaO2 / FiO2: 400\n Physical Examination\n Vitals: Tmax overnight:99.6 BP:101/58 P:122 R: 21 O2: 98% on PS 5/5\n FiO2 40%\n General: Intubated and sedated\n HEENT: Sclera anicteric, PERRL, MMM\n Neck: supple, JVP not elevated, no LAD\n Lungs: Clear to auscultation bilaterally on anterior exam, no wheezes,\n rales, ronchi\n CV: Irregularly irregular. Tachycardic.\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness or guarding, no organomegaly\n Ext: warm, well perfused, 1+ pulses, no clubbing, cyanosis or edema\n Labs / Radiology\n 278 K/uL\n 10.4 g/dL\n 155 mg/dL\n 1.6 mg/dL\n 20 mg/dL\n 21 mEq/L\n 111 mEq/L\n 4.1 mEq/L\n 140 mEq/L\n 32.5 %\n 11.3 K/uL\n [image002.jpg]\n \n 2:33 A1/9/ 05:30 PM\n \n 10:20 P1/9/ 05:48 PM\n \n 1:20 P1/9/ 10:40 PM\n \n 11:50 P1/10/ 02:52 AM\n \n 1:20 A1/10/ 02:58 AM\n \n 7:20 P1/10/ 07:50 AM\n 1//11/006\n 1:23 P1/10/ 08:52 AM\n \n 1:20 P\n \n 11:20 P\n \n 4:20 P\n WBC\n 15.9\n 11.4\n 11.3\n Hct\n 41.6\n 35.3\n 32.5\n Plt\n 378\n 285\n 278\n Cr\n 1.9\n 1.6\n 1.6\n TC02\n 19\n 19\n 24\n Glucose\n 180\n 128\n 125\n 155\n Other labs: PT / PTT / INR:13.5/30.9/1.2, Lactic Acid:1.3 mmol/L,\n Ca++:7.7 mg/dL, Mg++:2.3 mg/dL, PO4:3.0 mg/dL\n Imaging: CT Head: . No acute intracranial hemorrhage or mass\n effect. Old left cerebral hemisphere infarction.\n .\n CXR: The ET tube tip is 4.6 cm above the carina. The NG tube tip is\n in the stomach. The lungs are clear without infiltrate or effusion.\n Again seen are multiple small pulmonary nodules very dense for their\n size, likely representing old granulomatous disease. The largest of\n these is in the right lower lung, measuring 6 mm. No focal infiltrate.\n .\n CXR (my read): ET tube 3.2cm above carina. Lungs clear without\n infiltrate or effusion.\n .\n R LENI\n IMPRESSION: No evidence of deep venous thrombosis, however, the right\n peroneal veins were not visualized.\n Microbiology: Blood cultures x2 pending\n CSF culture pending\n ECG: EKG on admission: NSR @ 95bpm. LAD. No ST segment changes or TWI.\n EKG 4am: Atrial fibrillation @ 148bpm. LAD. No ST segment changes.\n Assessment and Plan\n ATRIAL FIBRILLATION (AFIB)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n SEIZURE, WITHOUT STATUS EPILEPTICUS\n HYPERTENSION, BENIGN\n 73 yo M with a history of afib, L MCA stroke, recurrent seizures who\n initally presented after witnessed seizure, now transferred to the MICU\n with tachycardia and hypotension.\n .\n 1. Tachycardia and hypotension: Patient initally hypertensive in the\n ED, and has been getting metoprolol and Hydralazine for hypertension.\n Now intubated, on sedatives, and hypotensives. Differential includes\n hypovolemia, medication effect, hypotension secondary to Afib with RVR,\n PE, MI, sepsis. Given that inital hypotensive episode was this morning\n in the context of a rapid heart rate in the 150s, Afib is likely\n etiology. However, given concern for LE thrombus yesterday which seems\n to have resolved, tachypnea requiring intubation, PE is on the\n differential. CTA was defered given Acute renal failure, which is\n resolving. Sepsis is possible since patient had a fever of 100.8 in the\n ED. However since admission patient has remained afebrile. It is\n reassuring that CSF results do not support infection.\n -continue heparin gtt empirically for PE\n -consider CTA this evening or tomorrow as renal function improves\n -obtain LENI of LLE (R negative)\n -consider echo\n -control atrial fibrillation with amiodarone gtt\n -start low dose po metoprolol for rate control. Wean up as BP\n tolerates.\n -rule out MI\n -rule out infection: obtain urine culture, follow up blood cultures,\n follow up CSF cultures\n -culture if spikes; consider antibiotic coverage. Would hold off for\n now given no localizing sources of infection.\n .\n 2. Respiratory failure: Patient was intubated for tachypnea in the ER.\n Currently with good O2 saturations on PS 5/5. Would favor extubation to\n avoid sedating medications that may be contributing to hypotension.\n -d/c Propofol\n -optimize for extubation\n .\n # Acute renal failure: Baseline Cr 0.9. Cr on admission was 2.0, down\n to 1.6 today. Would consider CTA tomorrow assuming renal function woudl\n improve further. However if becomes tachycardic or hypoxic, could\n consider CTA earlier.\n -obtain urine lytes\n -avoid nephrotoxins; renally dose medications\n .\n #. Seizures: Patient with recurrent seizure disorder. EEG performed\n shows no seizure activity since admission.\n -Continue Tegretol 300mg \n -Disontinue Ativan 1mg IV BID\n -f/u neurology recs\n .\n # h/o MCA stroke:\n -continue plavix, pravastatin per outpatient regimen\n .\n # Concern for hyperemic RLE: RLE hyperemic in the ED. R LENI negative.\n Vascular evaluated the patient and has signed off. Currently both LEs\n have good circulation and pulses.\n -continue to monitor\n .\n .\n # FEN: No IVF, replete electrolytes, NPO for now\n # Prophylaxis: Heparin gtt, Famotidine\n # Access: PIV x3\n # Communication: Patient and daughter\n # Code: Full (discussed with daughter)\n # Disposition: ICU pending clinical improvement\n .\n .\n \n \n PGY-2\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 04:30 PM\n Arterial Line - 05:00 PM\n 20 Gauge - 04:19 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2193-12-29 00:00:00.000", "description": "Weekend Intensivist", "row_id": 398297, "text": "TITLE: WEEKEND INTENSIVIST ADDENDUM\n I saw and examined the patient, and was physically present with the ICU\n team for the key portions of the services provided. I agree with the\n note above, including the assessment and plan. I would emphasize and\n add the following points:\n 73 y/o with seizure to neuro ICU now transferred to the MICU for resp\n failure, tachycardia, hypotension.\n Initially admitted yesterday in setting of seizures, here CT LP neg,\n concern for subclinical seizures, EEG x24 hours negative. Intubated\n initially in the ED for tachypnea 7.39/30/116 ?on NRB but subsequently\n PaO2s in 200s on FiO2 40%.\n Course also notable for decreased pulses in RLE now improved.\n This AM tachy to 140\ns and hypotensive to . Given 500cc bolus and\n started on amio gtt. Heparin gtt started for concern re: PE.\n PMHx notable for stroke, Afib.\n Allergies notable for coumadin. Meds notable for tegretol.\n Tm 99.6 BP 120/60 P100-110s PSV 5/5/40% TV ~300s. RR\n On exam pupils pinpoint, plegic on R with increased tone, on L\n WBC 11.3 / 32.5 / 278\n Cr 2.0\n 1.6 Bicarb 21\n CXR with no new infiltrates\n Hypotension: in setting of propofol, metoprolol, afib with RVR, now\n improved after IVF and amiodarone; however hemodynamic behavior and ?of\n new sz, RLE thrombus, also raising concern for new PE. Will\n heparinize, check LENIs +; if hypotension recurs / worsens consider\n echo. CTA ?tomorrow if Cr improves.\n Resp failure seems primary d/t mental status, currently on , SBT on\n minimal O2. Mental status currently suspected to be encephalopathy\n post seizure, appreciate neuro input.\n Renal failure\n ?etiology, seems better with hydration, check urine\n lytes, sediment.\n Remainder of plan as above.\n Pt is critically ill.\n CC time 45 minutes.\n" }, { "category": "Physician ", "chartdate": "2193-12-29 00:00:00.000", "description": "Weekend Intensivist", "row_id": 398298, "text": "TITLE: WEEKEND INTENSIVIST ADDENDUM\n I saw and examined the patient, and was physically present with the ICU\n team for the key portions of the services provided. I agree with the\n note above, including the assessment and plan. I would emphasize and\n add the following points:\n 73 y/o with seizure to neuro ICU now transferred to the MICU for resp\n failure, tachycardia, hypotension.\n Initially admitted yesterday in setting of seizures, here CT LP neg,\n concern for subclinical seizures, EEG x24 hours negative. Intubated\n initially in the ED for tachypnea 7.39/30/116 ?on NRB but subsequently\n PaO2s in 200s on FiO2 40%.\n Course also notable for decreased pulses in RLE now improved.\n This AM tachy to 140\ns and hypotensive to SBP 80s. Given 500cc bolus\n and started on amio gtt. Heparin gtt started for concern re: PE.\n PMHx notable for stroke, Afib.\n Allergies notable for coumadin. Meds notable for tegretol.\n Tm 99.6 BP 120/60 P100-110s PSV 5/5/40% TV ~300s. RR\n On exam pupils pinpoint, plegic on R with increased tone, on L\n WBC 11.3 / 32.5 / 278\n Cr 2.0\n 1.6 Bicarb 21\n CXR with no new infiltrates\n Hypotension: in setting of propofol, metoprolol, afib with RVR, now\n improved after IVF and amiodarone; however hemodynamic behavior and ?of\n new sz, RLE thrombus, also raising concern for new PE. Will\n heparinize, check LENIs +; if hypotension recurs / worsens consider\n echo. CTA ?tomorrow if Cr improves.\n Resp failure seems primary d/t mental status, currently on , SBT on\n minimal O2. Mental status currently suspected to be encephalopathy\n post seizure, appreciate neuro input.\n Renal failure\n ?etiology, seems better with hydration, check urine\n lytes, sediment.\n Remainder of plan as above.\n Pt is critically ill.\n CC time 45 minutes.\n" }, { "category": "Nursing", "chartdate": "2193-12-30 00:00:00.000", "description": "Nursing Progress Note", "row_id": 398390, "text": "73 yo M with a history of afib, L MCA stroke, recurrent seizures who\n initally presented after witnessed seizure, now transferred to the MICU\n with tachycardia and hypotension. Likely neurologic given primary\n presenting complaint AMS. Will obtain MR stable.\n Atrial fibrillation (Afib)\n Assessment:\n Action:\n Response:\n Plan:\n Seizure, without status epilepticus\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2193-12-30 00:00:00.000", "description": "Nursing Progress Note", "row_id": 398394, "text": "73 yo M with a history of afib, L MCA stroke, recurrent seizures who\n initally presented after witnessed seizure, now transferred to the MICU\n with tachycardia and hypotension. Likely neurologic given primary\n presenting complaint AMS. Will obtain MR stable.\n Atrial fibrillation (Afib)\n Assessment:\n HR continues in AF, rate 90\ns-120\ns with occasional short runs of\n RAF(140\ns-150\ns), no ectopy noted, sbp stable with rapid rates, on\n heparin gtt & po plavix\n Action:\n Po diltiazem dose increased today, heparin gtt & po plavix dc\nd today\n after MRI of head today noted sm L sided bleed\n Response:\n Continues on AF, rate controlled most of day\n Plan:\n Continue to assess, po diltiazem as ordered\n Seizure, without status epilepticus\n Assessment:\n No sz activity noted, PERL, pt unresponvsive, withdraws to pain,\n impaired cough/gag, does have spont RR\n Action:\n MRI of head today, po tegretol as ordered\n Response:\n Lg R MCA stroke noted & sm L side bleed noted on MRI so heparin gtt &\n po plavix dc\nd, pt with poor prognosis, Dr. in to talk with\n family\n Plan:\n DNR/DNI, palliative care consult, possible CMO tomorrow once all family\n members present\n" }, { "category": "Nursing", "chartdate": "2193-12-29 00:00:00.000", "description": "Nursing Progress Note", "row_id": 398291, "text": "Seizure, without status epilepticus\n Assessment:\n PEARL 3mm bilat and brisk, impaired corneals, impaired gag, cough\n intact. Pt MAE but does not focus and is not purposeful. No\n spontaneous movement noted. Withdraws to painful stimuli. Posturing\n noted w/ LUE. Twitching also noted intermittently but no seizure\n activity seen. Cont EEG continues.\n Action:\n Q1hr neuro checks. Sedated on low dose Propofol and lightened q4hrs\n for exam. Sz precautions maintained. Continuous EEG . Heparin gtt\n initiated ?PE picture. Unable to obtain CT c contrast ARF.\n Response:\n Neuro exam remains unchanged. Hyperdynamic w/ resp compromise off\n Propofol. EEG running. No obvious seizure activity noted.\n Plan:\n Cont to monitor neuro signs. Maintain on Propofol w/ ativan as\n ordered. EEG evaluation. Lopressor/Labetalol for htn control. PTT\n at 1500.\n Atrial fibrillation (Afib)\n Assessment:\n Pt continues in afib HR 90-120\ns. SBP dropping to 80\n Action:\n Amiodarone gtt continues, rate changed to 0.5mg at 1100 and\n is to run until 0500\n Fluid bolused x 3 to maintain MAP >65\n Response:\n Persistent afib w/ rate 90-120\ns. BP stable p fluid boluses.\n Amiodarone gtt continues. HR remains afib w/ rate <120.\n Plan:\n Cont to monitor hemodynamics. Replete lytes as needed. Cont amio and\n transition to po amio.\n" }, { "category": "Nursing", "chartdate": "2193-12-29 00:00:00.000", "description": "Nursing Progress Note", "row_id": 398292, "text": "73 yo Cantonese speaking male with a history of L MCA stroke in ,\n with recurrent seizure disorder, who presented to the ED after a\n prolonged seizure witnessed at home. Per family, he was found\n unresponsive, with increased stiffness, and eyes deviated upwards on\n the morning of admission. Two hours prior to seizure he was observed by\n his wife, and was thought to be in his usual state of health. EMS\n administered Valium 5mg IV x1, and seizure abated.\n At baseline he is aphasic but able to ambulate with a cane and leg\n brace.\n Seizure, without status epilepticus\n Assessment:\n PEARL 3mm bilat and brisk, impaired corneals, impaired gag, cough\n intact. Pt MAE but does not focus and is not purposeful. No\n spontaneous movement noted. Withdraws to painful stimuli. Posturing\n noted w/ LUE. Twitching also noted intermittently but no seizure\n activity seen. Cont EEG continues.\n Action:\n Q1hr neuro checks. Sedated on low dose Propofol and lightened q4hrs\n for exam. Sz precautions maintained. Continuous EEG . Heparin gtt\n initiated ?PE picture. Unable to obtain CT c contrast ARF.\n Response:\n Neuro exam remains unchanged. Hyperdynamic w/ resp compromise off\n Propofol. EEG running. No obvious seizure activity noted.\n Plan:\n Cont to monitor neuro signs. Maintain on Propofol w/ ativan as\n ordered. EEG evaluation. Lopressor/Labetalol for htn control. PTT\n at 1500.\n Atrial fibrillation (Afib)\n Assessment:\n Pt continues in afib HR 90-120\ns. SBP dropping to 80\n Action:\n Amiodarone gtt continues, rate changed to 0.5mg at 1100 and\n is to run until 0500\n Fluid bolused x 3 to maintain MAP >65\n Response:\n Persistent afib w/ rate 90-120\ns. BP stable p fluid boluses.\n Amiodarone gtt continues. HR remains afib w/ rate <120.\n Plan:\n Cont to monitor hemodynamics. Replete lytes as needed. Cont amio and\n transition to po amio.\n" }, { "category": "Respiratory ", "chartdate": "2193-12-30 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 398387, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 3\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type: Standard\n Size: 7.5mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Clear\n Comments:\n Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount: Suctioned / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Plan\n Next 24-48 hours: Comfort measures only\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n MRI\n 11:00\n" }, { "category": "Nursing", "chartdate": "2193-12-31 00:00:00.000", "description": "Nursing Progress Note", "row_id": 398457, "text": "MRI with acute infarct involving the entire right MCA territory with\n small amount of hemorrhage in the right temporal lobe, mass effect on\n right lateral ventricle and 4mm right to left midline shift with near\n complete occlusion of the right ICA.\n - Heparin, plavix discontinued based on MRI findings\n Events: Neuro following-no new recommendations-cont tegritol. T max\n 100.1 ax + diaphoretic, RR 30\ns, flushed face, hypertensive to 180\n and RAF 130-140\ns- treating with 650mg Tylenol and 2 mg pt\n fever breaking, RR 20\ns, HR trending to 80 to low 100\ns, but BP falling\n 80/40 via A line and correlates with NBP- given 500cc IVF bolus x 2.\n Dr. bedside and speaking to family about prognosis with further\n care- plan to maintain current level of care- DNR/DNI and CMO when more\n family present.\n CVA (Stroke, Cerebral infarction), Hemorrhagic\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2194-01-01 00:00:00.000", "description": "Nursing Progress Note", "row_id": 398500, "text": "CVA (Stroke, Cerebral infarction), Hemorrhagic\n Assessment:\n Full right MCA territory stroke now, on top of previous left MCA.\n Action:\n Response:\n Plan:\n Atrial fibrillation (Afib)\n Assessment:\n Action:\n Response:\n Plan:\n CVA (Stroke, Cerebral infarction), Hemorrhagic\n Assessment:\n Neuro bedside for assessment- no change in pt condition since MRI, pt\n not interactive, grimacing with oral care and will withdraw bilat feet\n to pain\n Action:\n ? pt in pain and given 1xdose 2mg IV Morphine, 650 mg acetaminophen,\n minimizing ? painful/ irritatinginterventions\n Response:\n Pt temp down to 96, RR and HR decreasing, BP labile with nursing\n care/interventions- BP as high as 180\ns while attempting to suction and\n down to 80/ post IV morphine (confirmed by BP cuff)\n Plan:\n Cont current level of care at this time\n" }, { "category": "Nursing", "chartdate": "2194-01-01 00:00:00.000", "description": "Nursing Progress Note", "row_id": 398504, "text": "CVA (Stroke, Cerebral infarction), Hemorrhagic\n Assessment:\n Full right MCA territory stroke now, on top of previous left MCA.\n Patient unresponsive, occasionally opening eyes, very minimal response,\n flex-withdraws to stimulation. Intubated for airway protection\n Action:\n Continue monitor neuro checks, continue tegretol\n Response:\n Neuro unchanged, low grade temp, poor prognosis\n Plan:\n Possible CMO in AM, nuero/stoke team following\n Atrial fibrillation (Afib)\n Assessment:\n HR 80-120, a fib without pvc\n Action:\n Continued po dilt, HR up to 140-170\ns, iv metoprolol 5mg and morphine\n 2mg iv push and 500ml fluid bolus\n Response:\n HR 10-120\ns a fib\n Plan:\n Continue po dilt, monitor labs, possible transition to CMO today\n" }, { "category": "Physician ", "chartdate": "2193-12-31 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 398436, "text": "Chief Complaint: Seizure and persistently altered mental status\n afterward.\n 24 Hour Events:\n MAGNETIC RESONANCE IMAGING - At 10:30 AM\n - MRI with acute infarct involving the entire right MCA territory with\n small amount of hemorrhage in the right temporal lobe, mass effect on\n right lateral ventricle and 4mm right to left midline shift with near\n complete occlusion of the right ICA.\n - Heparin, plavix discontinued based on MRI findings\n - Palliative care consulted and noted that they briefly met with\n family, that the is family overwhelmed with rapid turn of events, and\n that they are available tomorrow to assit with care\n - Stroke team consulted and recommending allowing BP to autoregulate\n (can treat SBP > 200 with hydralazine 10mg IV), continue tegretol as\n seizure ppx\n - Patient will likely be made CMO in the morning\n Allergies:\n Coumadin (Oral) (Warfarin Sodium)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:06 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.7\nC (99.9\n Tcurrent: 37\nC (98.6\n HR: 101 (89 - 128) bpm\n BP: 106/62(77) {82/53(64) - 151/88(107)} mmHg\n RR: 17 (15 - 23) insp/min\n SpO2: 100%\n Heart rhythm: AF (Atrial Fibrillation)\n Total In:\n 850 mL\n 518 mL\n PO:\n TF:\n IVF:\n 790 mL\n 518 mL\n Blood products:\n Total out:\n 780 mL\n 260 mL\n Urine:\n 780 mL\n 260 mL\n NG:\n Stool:\n Drains:\n Balance:\n 70 mL\n 258 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 582 (487 - 712) mL\n PS : 5 cmH2O\n RR (Spontaneous): 22\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI Deferred: CMO\n PIP: 11 cmH2O\n SpO2: 100%\n ABG: ///20/\n Ve: 8.6 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 261 K/uL\n 9.8 g/dL\n 127 mg/dL\n 1.5 mg/dL\n 20 mEq/L\n 3.7 mEq/L\n 17 mg/dL\n 110 mEq/L\n 137 mEq/L\n 30.4 %\n 8.8 K/uL\n [image002.jpg]\n 10:40 PM\n 02:52 AM\n 02:58 AM\n 07:50 AM\n 08:52 AM\n 11:23 AM\n 02:00 PM\n 08:52 PM\n 03:30 AM\n 04:01 AM\n WBC\n 11.4\n 11.3\n 10.7\n 8.8\n Hct\n 35.3\n 32.5\n 32.5\n 30.4\n Plt\n 285\n 278\n 293\n 261\n Cr\n 1.6\n 1.6\n 1.5\n 1.5\n TropT\n 0.11\n 0.11\n TCO2\n 19\n 24\n Glucose\n 128\n 125\n 155\n 143\n 140\n 127\n Other labs: PT / PTT / INR:11.9/27.5/1.0, CK / CKMB /\n Troponin-T:1057/9/0.11, Lactic Acid:1.3 mmol/L, Ca++:7.3 mg/dL,\n Mg++:2.0 mg/dL, PO4:1.9 mg/dL\n Imaging: MRI shows new stroke of right MCA territory with very small\n preserved cortex at midline.\n Assessment and Plan\n CVA (STROKE, CEREBRAL INFARCTION), HEMORRHAGIC\n ATRIAL FIBRILLATION (AFIB)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n SEIZURE, WITHOUT STATUS EPILEPTICUS\n HYPERTENSION, BENIGN\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Arterial Line - 05:00 PM\n 20 Gauge - 11:23 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2193-12-31 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 398438, "text": "Chief Complaint: Seizure and persistently altered mental status\n afterward.\n 24 Hour Events:\n MAGNETIC RESONANCE IMAGING - At 10:30 AM\n - MRI with acute infarct involving the entire right MCA territory with\n small amount of hemorrhage in the right temporal lobe, mass effect on\n right lateral ventricle and 4mm right to left midline shift with near\n complete occlusion of the right ICA.\n - Heparin, plavix discontinued based on MRI findings\n - Palliative care consulted and noted that they briefly met with\n family, that the is family overwhelmed with rapid turn of events, and\n that they are available tomorrow to assist with care\n - Stroke team consulted and recommending allowing BP to autoregulate\n (can treat SBP > 200 with hydralazine 10mg IV), continue tegretol as\n seizure ppx\n - Patient will likely be made CMO in the morning\n Allergies:\n Coumadin (Oral) (Warfarin Sodium)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:06 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.7\nC (99.9\n Tcurrent: 37\nC (98.6\n HR: 101 (89 - 128) bpm\n BP: 106/62(77) {82/53(64) - 151/88(107)} mmHg\n RR: 17 (15 - 23) insp/min\n SpO2: 100%\n Heart rhythm: AF (Atrial Fibrillation)\n Total In:\n 850 mL\n 518 mL\n PO:\n TF:\n IVF:\n 790 mL\n 518 mL\n Blood products:\n Total out:\n 780 mL\n 260 mL\n Urine:\n 780 mL\n 260 mL\n NG:\n Stool:\n Drains:\n Balance:\n 70 mL\n 258 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 582 (487 - 712) mL\n PS : 5 cmH2O\n RR (Spontaneous): 22\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI Deferred: CMO\n PIP: 11 cmH2O\n SpO2: 100%\n ABG: ///20/\n Ve: 8.6 L/min\n Physical Examination\n General: Intubated and sedated. Pale and clearly hemiparetic elderly\n man.\n HEENT: Sclera anicteric, PERRL, MMM\n Neck: supple, JVP not elevated, no LAD\n Lungs: Clear to auscultation bilaterally on anterior exam, no wheezes,\n rales, ronchi\n CV: Irregularly irregular. Tachycardic.\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness or guarding, no organomegaly\n Ext: warm, well perfused, 1+ pulses, no clubbing, cyanosis or edema\n Neuro: Non-responsive. Only eye opening without fixation or movements\n on physical stimulation. No response to voice. Completely non-verbal.\n Only reflexive bodily movements when being moved around. Rigid and\n wasted right leg, left more flaccid. Upper limbs rigid R > L. R flexor\n and L extensor.\n Labs / Radiology\n 261 K/uL\n 9.8 g/dL\n 127 mg/dL\n 1.5 mg/dL\n 20 mEq/L\n 3.7 mEq/L\n 17 mg/dL\n 110 mEq/L\n 137 mEq/L\n 30.4 %\n 8.8 K/uL\n [image002.jpg]\n 10:40 PM\n 02:52 AM\n 02:58 AM\n 07:50 AM\n 08:52 AM\n 11:23 AM\n 02:00 PM\n 08:52 PM\n 03:30 AM\n 04:01 AM\n WBC\n 11.4\n 11.3\n 10.7\n 8.8\n Hct\n 35.3\n 32.5\n 32.5\n 30.4\n Plt\n 285\n 278\n 293\n 261\n Cr\n 1.6\n 1.6\n 1.5\n 1.5\n TropT\n 0.11\n 0.11\n TCO2\n 19\n 24\n Glucose\n 128\n 125\n 155\n 143\n 140\n 127\n Other labs: PT / PTT / INR:11.9/27.5/1.0, CK / CKMB /\n Troponin-T:1057/9/0.11, Lactic Acid:1.3 mmol/L, Ca++:7.3 mg/dL,\n Mg++:2.0 mg/dL, PO4:1.9 mg/dL\n Imaging: MRI shows new stroke of right MCA territory with very small\n preserved cortex at midline.\n Assessment and Plan\n 73 yo M with a history of afib, L MCA stroke, recurrent seizures who\n initally presented after witnessed seizure, now transferred to the MICU\n with tachycardia and hypotension.\n Full right MCA territory stroke now, on top of previous left MCA. Only\n viable cortex supplied by anterior cerebral and posterior cerebral on\n right. No meaningful recovery expected, therefore need to discuss\n further with family, who wanted time to think about transition to CMO.\n He is presentely DNR/do not re-intubate.\n #. Discussion with family\n - Plan to meet with them again to determine whether to continue\n treatment or transition to CMO\n #. Tachycardia and hypotension\n Stroke team want BP to autoregulate at present.\n - If BP > 200 mmHg then hydralazine.\n - Keep rate controlled enough to prevent myocardial ischemia.\n - Stop anticoagulants given small hemorrhagic conversion\n #. AMS\n Secondary to very large cortical infarction now with great some of\n fractional loss of cortical function.\n - Continue to hold sedating medications\n - Continue anticonvulsants\n - Appreciate Neuro recs\n - Discuss further with family\n # Acute renal failure\n Continues to improve. Versus prerenal with increased viscosity and\n dislodging of clot or increased clotting in small vessel. Possible\n component of etiology.\n - Continue maintenance fluids only for now\n - Avoid nephrotoxins; renally dose medications\n #. Seizures\n Patient with recurrent seizure disorder. EEG performed shows no seizure\n activity since admission. Continue Mx as above\n -Continue Tegretol 300mg \n -Disontinue Ativan 1mg IV BID\n -f/u neurology recs\n # Concern for hypoperfused RLE\n Improved perfusion in context of heparin gtt.\n - Continue to monitor\n # FEN: Supportive maintenance fluids, replete electrolytes, NPO for now\n # Prophylaxis: Boots only, Famotidine\n # Access: PIV x3\n # Communication: Patient and daughter\n # Code: Full (discussed with daughter)\n # Disposition: ICU pending clinical improvement\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Arterial Line - 05:00 PM\n 20 Gauge - 11:23 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Respiratory ", "chartdate": "2194-01-01 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 398496, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 5\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Tube Type\n ETT:\n Position: 22 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 28 cmH2O\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Moderate\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Plan\n Next 24-48 hours: Comfort measures only\n Reason for continuing current ventilatory support: Cannot protect\n airway, Underlying illness not resolved\n" }, { "category": "Physician ", "chartdate": "2193-12-29 00:00:00.000", "description": "Intensivist Note", "row_id": 398268, "text": "TSICU\n HPI:\n 73yo Cantonese speaking M with pAfib on Plavix and h/o large L MCA\n stroke with baseline R hemiparesis and seizures who was found to have\n increased tone and upward gaze deviation per family this morning around\n 9am. He was seen normal around 90 minutes prior hence\n unclear how long he was seizing. Patient was still seizing upon\n EMS arrival and improved with Valium 5mg IV per report but\n patient remains nonverbal and not following commands with\n intermittently increased tone on L. EEG performed in the ED\n showed that he was not continuing to seize but patient spiked to\n 100.8 while in the ED hence underwent LP. Transferred to TICU\n intubated, sedated.\n Chief complaint:\n SZ\n PMHx:\n PMH: CAD, Afib, L MCA CVA ', HTN, Seizure d/o.\n PSH: none\n Current medications:\n Acetaminophen 5. Amiodarone 6. Amiodarone 7. Amiodarone 8.\n Carbamazepine\n 9. Calcium Gluconate 10. Clopidogrel 11. Dextrose 50% 12. Famotidine\n 13. Glucagon 14. Heparin 15. HydrALAzine\n 16. HydrALAzine 17. Insulin 18. Labetalol 19. Lorazepam 20. Lorazepam\n 21. Magnesium Sulfate 22. Metoprolol Tartrate\n 23. Metoprolol Tartrate 24. Pneumococcal Vac Polyvalent 25. Potassium\n Chloride 26. Pravastatin 27. Propofol\n 24 Hour Events:\n INVASIVE VENTILATION - START 04:20 PM\n ARTERIAL LINE - START 05:00 PM\n EKG - At 04:20 AM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Propofol - 20 mcg/Kg/min\n Amiodarone - 1 mg/min\n Other ICU medications:\n Hydralazine - 05:10 PM\n Labetalol - 03:31 AM\n Metoprolol - 03:45 AM\n Amiodarone - 04:17 AM\n Other medications:\n Flowsheet Data as of 05:13 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.6\nC (99.6\n T current: 37.6\nC (99.6\n HR: 112 (85 - 155) bpm\n BP: 99/57(71) {99/55(71) - 194/96(132)} mmHg\n RR: 24 (21 - 42) insp/min\n SPO2: 99%\n Heart rhythm: AF (Atrial Fibrillation)\n Total In:\n 3,082 mL\n 379 mL\n PO:\n Tube feeding:\n IV Fluid:\n 1,782 mL\n 379 mL\n Blood products:\n Total out:\n 450 mL\n 490 mL\n Urine:\n 450 mL\n 490 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,632 mL\n -111 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 486 (486 - 687) mL\n PS : 5 cmH2O\n RR (Set): 14\n RR (Spontaneous): 25\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 67\n PIP: 11 cmH2O\n Plateau: 17 cmH2O\n SPO2: 99%\n ABG: 7.38/39/160/22/-1\n Ve: 11.3 L/min\n PaO2 / FiO2: 400\n Physical Examination\n HEENT: PERRL\n Cardiovascular: (Rhythm: Irregular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Diminished: RLL), (Sternum: Stable )\n Abdominal: Soft, Non-distended, Non-tender\n Left Extremities: (Edema: Absent)\n Right Extremities: (Edema: Absent)\n Neurologic: Sedated\n Labs / Radiology\n 285 K/uL\n 11.3 g/dL\n 125 mg/dL\n 1.6 mg/dL\n 22 mEq/L\n 4.2 mEq/L\n 23 mg/dL\n 113 mEq/L\n 142 mEq/L\n 35.3 %\n 11.4 K/uL\n [image002.jpg]\n 05:30 PM\n 05:48 PM\n 10:40 PM\n 02:52 AM\n 02:58 AM\n WBC\n 15.9\n 11.4\n Hct\n 41.6\n 35.3\n Plt\n 378\n 285\n Creatinine\n 1.9\n 1.6\n TCO2\n 19\n 19\n 24\n Glucose\n 180\n 128\n 125\n Other labs: PT / PTT / INR:13.1/29.9/1.1, Lactic Acid:1.3 mmol/L,\n Ca:8.3 mg/dL, Mg:1.8 mg/dL, PO4:3.1 mg/dL\n Assessment and Plan\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF), SEIZURE, WITHOUT\n STATUS EPILEPTICUS, HYPERTENSION, BENIGN\n Assessment and Plan: 73 M w/ pAfib on Plavix, SZ d/o p/w with SZ,\n intubated for airway protection\n NEURO: Intubated, Tegretol to 300mg ,started Ativan 1mg IV TID for\n bridge, EEG o/n\n Neuro checks Q: 1\n Pain: APAP prn\n CVS: Afib, on amio gtt, Hypertensive, SBP<160, Hydral labetolol prn, on\n metoprolol 32'', pravastatin 20'\n PULM: no issues\n GI: NPO\n RENAL: ARF, Cr 2.0, boluses, follow UO\n HEME: ? heparin gtt, plavix 75'\n ENDO: RISS\n ID: f/u LP, WC 15.9, Afeb\n TLD: PIV, ETT, foley, Left Aline\n IVF: NS @100\n CONSULTS:\n BILLING DIAGNOSIS:\n ICU CARE:\n GLYCEMIC CONTROL: RISS\n PROPHYLAXIS:\n DVT - SCDs\n STRESS ULCER - H2B\n VAP BUNDLE -\n COMMUNICATIONS:\n ICU Consent: daughter\n CODE STATUS: FULL\n DISPOSITION: TICU\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 04:30 PM\n Arterial Line - 05:00 PM\n 20 Gauge - 04:19 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent:\n Patient is critically ill\n" }, { "category": "Nursing", "chartdate": "2193-12-29 00:00:00.000", "description": "Nursing Progress Note", "row_id": 398270, "text": "Seizure, without status epilepticus\n Assessment:\n PEARL 3mm bilat and brisk, impaired corneals, impaired gag, cough\n intact. Pt did open eyes sl to pain x1 off Propofol. Pt MAE but does\n not focus and is not purposeful. No spontaneous movement noted.\n Withdraws to painful stimuli. Posturing noted w/ LUE. Twitching also\n noted intermittently but no seizure activity seen.\n Action:\n Q1hr neuro checks. Sedated on Propofol and lightened q4hrs for exam.\n Sz precautions. Continuous eeg . Ativan is due at 0600. No other\n ativan given.\n Response:\n Corneals and gag returned but no other improvement in neuro exam.\n Hyperdynamic w/ resp compromise off Propofol. EEG running. No obvious\n seizure activity noted.\n Plan:\n Cont to monitor neuro signs. Maintain on Propofol w/ ativan as\n ordered. EEG evaluation. Lopressor/Labetalol for htn control.\n ?Repeat head ct.\n Atrial fibrillation (Afib)\n Assessment:\n Pt went into rapid afib this am about 0330. Rate as high as 150-160.\n Stable bp with this rhythm.\n Action:\n Mg and ca gluconate given. Labetalol and Lopressor given.\n Response:\n Persistent afib w/ rate 130-150. BP remained stable. Amio bolus\n given and pt started on amio gtt. HR remains afib w/ rate <120.\n Stable bp on amio.\n Plan:\n Cont to monitor hemodynamics. Replete lytes as needed. Cont amio and\n transition to po amio.\n" }, { "category": "Nursing", "chartdate": "2193-12-31 00:00:00.000", "description": "Nursing Progress Note", "row_id": 398431, "text": "Pt is a 73 yo Cantonese speaking man with a h/o of a left LMCA stroke\n in with residual right sided hemiplegia and recurrent seizure\n disorder. Pt was found during a seizure by his wife. The pt had been\n seizing for an undetermined amount of time. EMS called and administered\n valium 5mg ivp with resolution of seizure activity. He was intubated in\n the ed on his arrival for airway protection. Continuous eeg monitoring\n w/o evidence of further seizure activity. He was transferred to the\n TSICU as a MICU border. His brief hospital course has been complicated\n by new onset afib with hemodynamic instability and poor perfusion to\n his rle which is suspicious for a new embolic stroke\n Atrial fibrillation (Afib)\n Assessment:\n HR 90-120\ns, in AF, no ectopy noted, SBP stable with rapid rates.\n Action:\n Continued Po diltiazem\n Response:\n Continues on AF, rate controlled\n Plan:\n Continue to assess, po diltiazem as ordered\n CVA (Stroke, Cerebral infarction), Hemorrhagic\n Assessment:\n Lg R MCA stroke noted & sm L side bleed noted on MRI this pm, patient\n unresponsive, withdraws to stimulation, not following commands or\n opening eyes, body is stiff and pupils 2mm and sluggishly reacting to\n light. Cough and gag impaired.\n Action:\n Continue po tegretol. Continue q 4hrs neuro checks\n Response:\n No seizure activity noted, uMS unchanged\n Plan:\n DNR/DNI, palliative care consult, possible CMO tomorrow once all family\n members presen\n" }, { "category": "Physician ", "chartdate": "2193-12-30 00:00:00.000", "description": "Physician Resident/Attending Progress Note - MICU", "row_id": 398375, "text": "Chief Complaint: Seizure and altered mental status\n 24 Hour Events:\n ULTRASOUND - At 02:00 PM\n LE's\n - Patient brought to floor\n - Given 5 mg lopressor in TSICU then another 10 mg on floor - helped to\n rate control from ~ 140 to 100s.\n - Started diltiazem 30 mg QID\n - Sedation (propofol and lorazepam) stopped at about 11:30 a.m. and\n patient still not to baseline by evening.\n - Per family, patient can follow commands (such as squeeze hand) and\n will look around meaningfully at baseline, but can neither speak nor\n move.\n - EEG electrodes removed this a.m. for MRI\n - Neurology suggested MRI as soon as stable (we should\n get this in a.m.\n - Let SBP run 120s-150s if possible given possible stroke\n - EEG electrodes can be replaced after MRI if Neuro/we like.\n - BP quite labile, particularly when patient being passively moved\n around\n Allergies:\n Coumadin (Oral) (Warfarin Sodium)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Heparin Sodium - 550 units/hour\n Other ICU medications:\n Heparin Sodium - 09:00 AM\n Metoprolol - 05:44 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:46 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.8\nC (100\n Tcurrent: 36.6\nC (97.9\n HR: 107 (82 - 129) bpm\n BP: 107/59(75) {87/53(64) - 180/99(129)} mmHg\n RR: 20 (16 - 27) insp/min\n SpO2: 99%\n Heart rhythm: AF (Atrial Fibrillation)\n Total In:\n 4,779 mL\n 290 mL\n PO:\n TF:\n IVF:\n 4,679 mL\n 230 mL\n Blood products:\n Total out:\n 1,645 mL\n 265 mL\n Urine:\n 1,395 mL\n 265 mL\n NG:\n 250 mL\n Stool:\n Drains:\n Balance:\n 3,134 mL\n 25 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 616 (406 - 677) mL\n PS : 5 cmH2O\n RR (Spontaneous): 23\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 37\n PIP: 7 cmH2O\n SpO2: 99%\n ABG: ///20/\n Ve: 9.5 L/min\n Physical Examination\n General: Intubated and sedated. Pale and clearly hemiparetic elderly\n man.\n HEENT: Sclera anicteric, PERRL, MMM\n Neck: supple, JVP not elevated, no LAD\n Lungs: Clear to auscultation bilaterally on anterior exam, no wheezes,\n rales, ronchi\n CV: Irregularly irregular. Tachycardic.\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness or guarding, no organomegaly\n Ext: warm, well perfused, 1+ pulses, no clubbing, cyanosis or edema\n Neuro: Non-responsive. Only eye opening without fixation or movements\n on physical stimulation. No response to voice. Completely non-verbal.\n Only reflexive bodily movements when being moved around. Rigid and\n wasted right leg, left more flaccid. Upper limbs rigid R > L. R flexor\n and L extensor.\n Labs / Radiology\n 293 K/uL\n 10.4 g/dL\n 140 mg/dL\n 1.5 mg/dL\n 20 mEq/L\n 4.0 mEq/L\n 17 mg/dL\n 110 mEq/L\n 137 mEq/L\n 32.5 %\n 10.7 K/uL\n [image002.jpg]\n 05:48 PM\n 10:40 PM\n 02:52 AM\n 02:58 AM\n 07:50 AM\n 08:52 AM\n 11:23 AM\n 02:00 PM\n 08:52 PM\n 03:30 AM\n WBC\n 11.4\n 11.3\n 10.7\n Hct\n 35.3\n 32.5\n 32.5\n Plt\n 285\n 278\n 293\n Cr\n 1.6\n 1.6\n 1.5\n TropT\n 0.11\n 0.11\n TCO2\n 19\n 19\n 24\n Glucose\n 128\n 125\n 155\n 143\n 140\n Other labs: PT / PTT / INR:13.2/64.1/1.1, CK / CKMB /\n Troponin-T:1057/9/0.11, Lactic Acid:1.3 mmol/L, Ca++:7.1 mg/dL,\n Mg++:2.0 mg/dL, PO4:2.8 mg/dL\n Assessment and Plan\n 73 yo M with a history of afib, L MCA stroke, recurrent seizures who\n initally presented after witnessed seizure, now transferred to the MICU\n with tachycardia and hypotension. Likely neurologic given primary\n presenting complaint AMS. Will obtain MR stable.\n #. Tachycardia and hypotension\n Still in AF with some rate control of otherwise with diltiazem PO.\n Pressures now better. LENIs negative and no little suspicion for PE\n would not explain seizure and AMS, and hemodynamic fluctuations not\n consistent with.\n -continue heparin gtt empirically for PE\n - Increase diltaizem to 45 mg QID (from 30 mg)\n #. AMS\n Likely brainstem stroke given possible emboli to left leg,\n hypertension, seizure, posturing of limbs. Not evident on CT but this\n was early and posturing of left arm more consistent with subcortical\n infarction. Therefore MRI with stroke protocol as above. Not likely\n that seizures are contributing given that these were not seen before\n and are typically motor.\n - Continue to hold sedating medications\n - NR as above when stable\n - Continue anticonvulsants\n - Restart EEG monitoring after MRI\n - Appreciate Neuro recs\n # Acute renal failure\n Improving. Possible embolic now on heparin and improving. Versus\n prerenal with increased viscosity and dislodging of clot or increased\n clotting in small vessel. Possible component of etiology.\n - Calculate FeUrea\n -avoid nephrotoxins; renally dose medications\n #. Seizures\n Patient with recurrent seizure disorder. EEG performed shows no seizure\n activity since admission. Continue Mx as above\n -Continue Tegretol 300mg \n -Disontinue Ativan 1mg IV BID\n -f/u neurology recs\n # h/o MCA stroke:\n -continue plavix, pravastatin per outpatient regimen\n - Determine full risk of using coumadin\n # Concern for hypoperfused RLE: R LENI negative. Vascular evaluated the\n patient and has signed off. Currently both LEs have good circulation\n and pulses.\n -continue to monitor\n # FEN: No IVF, replete electrolytes, NPO for now\n # Prophylaxis: Heparin gtt, Famotidine\n # Access: PIV x3\n # Communication: Patient and daughter\n # Code: Full (discussed with daughter)\n # Disposition: ICU pending clinical improvement\n .\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Arterial Line - 05:00 PM\n 20 Gauge - 11:23 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n ------ Protected Section ------\n MICU ATTENDING ADDENDUM\n I saw and examined the patient, and was physically present with the ICU\n team for the key portions of the services provided. I agree with the\n note above, including the assessment and plan. I would emphasize and\n add the following points: 73M s/p prior CVA c/b hemiparesis initially\n admitted with seizures, intubated in ED. Admit to NSICU, head CT stable\n - developed AF c c/b hypotension. Now off sedation but not at\n baseline per family, awaitng MRI, remains in AF.\n Exam notable for Tm 100.0 BP 120/60 HR 100-115AF RR 16 with sat 99 on\n PSV 5/5 0.4 7.38/39/160. Minimally response, occasional eye opening but\n not to threat or voice. Dense R paresis. PERRL. CTA B. Irreg s1s2\n 2/6Sm. Soft +BS. Cool B, trace edema. Labs notable for WBC 10K, HCT\n 32, K+ 4.0, Cr 1.5. CXR with , EKG .\n Agree with plan to manage new onset seizures +/- CVA in the setting of\n AF with tegretol, plavix and urgent MRI while intubated. Will continue\n to hold sedation given encephalopathy in the setting possible CVA. For\n AF , increase dilt to 45 QID, check echo, hold amio and\n continue heparin. For respiratory failure, will place NGT, wean vent,\n hold on CTA (LENIs negative, on heparin). RLE stable / improving on\n heparin. Above d/w family at bedside. Remainder of plan as outlined\n above.\n FAMILY MEETING\n MRI with new large R CVA, findings d/w neuro, will\n hold further anticoagulation given risk of bleeding. Findings also\n discussed with wife and daughter in detail. Family will gather this\n evening, while we continue supportive care including mechanical\n ventilation. Family leaning toward transition to CMO, but want time to\n discuss. For now, patient is DNR, will notify NEOB and palliavtive care\n teams as withdrawal is likely in the next 24 hours given very poor\n prognosis for recovery beyond current state.\n Patient is critically ill\n Total time: 100 min\n ------ Protected Section Addendum Entered By: , MD\n on: 04:46 PM ------\n" }, { "category": "Respiratory ", "chartdate": "2193-12-28 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 398246, "text": "Demographics\n Day of mechanical ventilation: 1\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 Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Clear\n Secretions\n Sputum color / consistency: /\n Sputum source/amount: /\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 placed on PSV settings as charted; awaiting ABG results at\n this time.\n Assessment of breathing comfort: No response (sleeping / sedated)\n Plan\n Next 24-48 hours: Continue ventilating as ordered.\n" }, { "category": "Nursing", "chartdate": "2193-12-31 00:00:00.000", "description": "Nursing Progress Note", "row_id": 398483, "text": "MRI with acute infarct involving the entire right MCA territory with\n small amount of hemorrhage in the right temporal lobe, mass effect on\n right lateral ventricle and 4mm right to left midline shift with near\n complete occlusion of the right ICA.\n - Heparin, plavix discontinued based on MRI findings\n Events: Neuro following-no new recommendations-cont tegritol. T max\n 100.1 ax + diaphoretic, RR 30\ns, flushed face, hypertensive to 180\n and RAF 130-140\ns- treating with 650mg Tylenol and 2 mg pt\n fever breaking, RR 20\ns, HR trending to 80 to low 100\ns, but BP falling\n 80/40 via A line and correlates with NBP- given 500cc IVF bolus x 2.\n Dr. bedside and speaking to family about prognosis with further\n care- plan to maintain current level of care- DNR/DNI and CMO when more\n family present.\n CVA (Stroke, Cerebral infarction), Hemorrhagic\n Assessment:\n Neuro bedside for assessment- no change in pt condition since MRI, pt\n not interactive, grimacing with oral care and will withdraw bilat feet\n to pain\n Action:\n ? pt in pain and given 1xdose 2mg IV Morphine, 650 mg acetaminophen,\n minimizing ? painful/ irritatinginterventions\n Response:\n Pt temp down to 96, RR and HR decreasing, BP labile with nursing\n care/interventions- BP as high as 180\ns while attempting to suction and\n down to 80/ post IV morphine (confirmed by BP cuff)\n Plan:\n Cont current level of care at this time\n" }, { "category": "Nursing", "chartdate": "2193-12-28 00:00:00.000", "description": "Nursing Progress Note", "row_id": 398252, "text": "73 yo Cantonese speaking male s/p 30 minute witnessed seizure relieved\n by 5mg valium by EMS in the field. Taken to , head CT negative, EEG\n negative for seizure activity, intubated in ED for airway protection\n unresponsiveness and transferred to T/SICU for further monitoring.\n RLE dusky, DP pulses absent on both LE\ns, PT pulses dopplerable. RLE\n color resolving without intervention. Vascular surgery involved,\n decided to hold off on heparin gtt at this time.\n Seizure, without status epilepticus\n Assessment:\n Pt unresponsive to voice, MAE\ns on bed, right sided hemiparesis at\n baseline. Impaired cough and gag. Absent corneals. Pupils 2-3mm\n sluggish to light. Withdraws to nailbed pressure at times.\n Action:\n Continuous EEG set-up\n Home dose tegretol administered\n Ativan 1mg TID and PRN for seizure activity\n Seizure precautions\n Response:\n No seizure activity noted\n Plan:\n Continue EEG, continue home meds, ativan IVP for seizure activity\n Hypertension, benign\n Assessment:\n Pt arrived from with BP 180/100 with HR 100\ns. Has hx htn.\n Action:\n 5mg Lopressor x 2\n 5mg Hydralazine x 3\n Response:\n BP 120\ns, HR 80\n Plan:\n Goal SBP <160\n" }, { "category": "Nursing", "chartdate": "2193-12-28 00:00:00.000", "description": "Nursing Progress Note", "row_id": 398253, "text": "73 yo Cantonese speaking male s/p 30 minute witnessed seizure relieved\n by 5mg valium by EMS in the field. Taken to , head CT negative, EEG\n negative for seizure activity, intubated in ED for airway protection\n unresponsiveness and transferred to T/SICU for further monitoring.\n RLE dusky, DP pulses absent on both LE\ns, PT pulses dopplerable. RLE\n color resolving without intervention. Vascular surgery involved,\n decided to hold off on heparin gtt at this time.\n Seizure, without status epilepticus\n Assessment:\n Pt unresponsive to voice, MAE\ns on bed, right sided hemiparesis at\n baseline. Impaired cough and gag. Absent corneals. Pupils 2-3mm\n sluggish to light. Withdraws to nailbed pressure at times.\n Action:\n Continuous EEG set-up\n Home dose tegretol administered\n Ativan 1mg TID and PRN for seizure activity\n Seizure precautions\n Response:\n No seizure activity noted\n Plan:\n Continue EEG, continue home meds, ativan IVP for seizure activity\n Hypertension, benign\n Assessment:\n Pt arrived from with BP 180/100 with HR 100\ns. Has hx htn.\n Action:\n 5mg Lopressor x 2\n 5mg Hydralazine x 3\n Response:\n BP 120\ns, HR 80\n Plan:\n Goal SBP <160\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Bun 27, creat 1.9, urine output low.\n Action:\n 1L LR fluid bolus administered\n Response:\n Awaiting results of bolus.\n Plan:\n Continue to assess renal status.\n" }, { "category": "Physician ", "chartdate": "2193-12-30 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 398355, "text": "Chief Complaint: Seizure and altered mental status\n 24 Hour Events:\n ULTRASOUND - At 02:00 PM\n LE's\n - Patient brought to floor\n - Given 5 mg lopressor in TSICU then another 10 mg on floor - helped to\n rate control from ~ 140 to 100s.\n - Started diltiazem 30 mg QID\n - Sedation (propofol and lorazepam) stopped at about 11:30 a.m. and\n patient still not to baseline by evening.\n - Per family, patient can follow commands (such as squeeze hand) and\n will look around meaningfully at baseline, but can neither speak nor\n move.\n - EEG electrodes removed this a.m. for MRI\n - Neurology suggested MRI as soon as hemodynamically stable (we should\n get this in a.m.\n - Let SBP run 120s-150s if possible given possible stroke\n - EEG electrodes can be replaced after MRI if Neuro/we like.\n - BP quite labile, particularly when patient being passively moved\n around\n Allergies:\n Coumadin (Oral) (Warfarin Sodium)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Heparin Sodium - 550 units/hour\n Other ICU medications:\n Heparin Sodium - 09:00 AM\n Metoprolol - 05:44 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:46 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.8\nC (100\n Tcurrent: 36.6\nC (97.9\n HR: 107 (82 - 129) bpm\n BP: 107/59(75) {87/53(64) - 180/99(129)} mmHg\n RR: 20 (16 - 27) insp/min\n SpO2: 99%\n Heart rhythm: AF (Atrial Fibrillation)\n Total In:\n 4,779 mL\n 290 mL\n PO:\n TF:\n IVF:\n 4,679 mL\n 230 mL\n Blood products:\n Total out:\n 1,645 mL\n 265 mL\n Urine:\n 1,395 mL\n 265 mL\n NG:\n 250 mL\n Stool:\n Drains:\n Balance:\n 3,134 mL\n 25 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 616 (406 - 677) mL\n PS : 5 cmH2O\n RR (Spontaneous): 23\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 37\n PIP: 7 cmH2O\n SpO2: 99%\n ABG: ///20/\n Ve: 9.5 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 293 K/uL\n 10.4 g/dL\n 140 mg/dL\n 1.5 mg/dL\n 20 mEq/L\n 4.0 mEq/L\n 17 mg/dL\n 110 mEq/L\n 137 mEq/L\n 32.5 %\n 10.7 K/uL\n [image002.jpg]\n 05:48 PM\n 10:40 PM\n 02:52 AM\n 02:58 AM\n 07:50 AM\n 08:52 AM\n 11:23 AM\n 02:00 PM\n 08:52 PM\n 03:30 AM\n WBC\n 11.4\n 11.3\n 10.7\n Hct\n 35.3\n 32.5\n 32.5\n Plt\n 285\n 278\n 293\n Cr\n 1.6\n 1.6\n 1.5\n TropT\n 0.11\n 0.11\n TCO2\n 19\n 19\n 24\n Glucose\n 128\n 125\n 155\n 143\n 140\n Other labs: PT / PTT / INR:13.2/64.1/1.1, CK / CKMB /\n Troponin-T:1057/9/0.11, Lactic Acid:1.3 mmol/L, Ca++:7.1 mg/dL,\n Mg++:2.0 mg/dL, PO4:2.8 mg/dL\n Assessment and Plan\n ATRIAL FIBRILLATION (AFIB)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n SEIZURE, WITHOUT STATUS EPILEPTICUS\n HYPERTENSION, BENIGN\n 73 yo M with a history of afib, L MCA stroke, recurrent seizures who\n initally presented after witnessed seizure, now transferred to the MICU\n with tachycardia and hypotension.\n .\n 1. Tachycardia and hypotension: Patient initally hypertensive in the\n ED, and has been getting metoprolol and Hydralazine for hypertension.\n Now intubated, on sedatives, and hypotensives. Differential includes\n hypovolemia, medication effect, hypotension secondary to Afib with RVR,\n PE, MI, sepsis. Given that inital hypotensive episode was this morning\n in the context of a rapid heart rate in the 150s, Afib is likely\n etiology. However, given concern for LE thrombus yesterday which seems\n to have resolved, tachypnea requiring intubation, PE is on the\n differential. CTA was defered given Acute renal failure, which is\n resolving. Sepsis is possible since patient had a fever of 100.8 in the\n ED. However since admission patient has remained afebrile. It is\n reassuring that CSF results do not support infection.\n -continue heparin gtt empirically for PE\n -consider CTA this evening or tomorrow as renal function improves\n -obtain LENI of LLE (R negative)\n -consider echo\n -control atrial fibrillation with amiodarone gtt\n -start low dose po metoprolol for rate control. Wean up as BP\n tolerates.\n -rule out MI\n -rule out infection: obtain urine culture, follow up blood cultures,\n follow up CSF cultures\n -culture if spikes; consider antibiotic coverage. Would hold off for\n now given no localizing sources of infection.\n .\n 2. Respiratory failure: Patient was intubated for tachypnea in the ER.\n Currently with good O2 saturations on PS 5/5. Would favor extubation to\n avoid sedating medications that may be contributing to hypotension.\n -d/c Propofol\n -optimize for extubation\n .\n # Acute renal failure: Baseline Cr 0.9. Cr on admission was 2.0, down\n to 1.6 today. Would consider CTA tomorrow assuming renal function woudl\n improve further. However if becomes tachycardic or hypoxic, could\n consider CTA earlier.\n -obtain urine lytes\n -avoid nephrotoxins; renally dose medications\n .\n #. Seizures: Patient with recurrent seizure disorder. EEG performed\n shows no seizure activity since admission.\n -Continue Tegretol 300mg \n -Disontinue Ativan 1mg IV BID\n -f/u neurology recs\n .\n # h/o MCA stroke:\n -continue plavix, pravastatin per outpatient regimen\n .\n # Concern for hyperemic RLE: RLE hyperemic in the ED. R LENI negative.\n Vascular evaluated the patient and has signed off. Currently both LEs\n have good circulation and pulses.\n -continue to monitor\n .\n .\n # FEN: No IVF, replete electrolytes, NPO for now\n # Prophylaxis: Heparin gtt, Famotidine\n # Access: PIV x3\n # Communication: Patient and daughter\n # Code: Full (discussed with daughter)\n # Disposition: ICU pending clinical improvement\n .\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Arterial Line - 05:00 PM\n 20 Gauge - 11:23 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2193-12-30 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 398363, "text": "Chief Complaint: Seizure and altered mental status\n 24 Hour Events:\n ULTRASOUND - At 02:00 PM\n LE's\n - Patient brought to floor\n - Given 5 mg lopressor in TSICU then another 10 mg on floor - helped to\n rate control from ~ 140 to 100s.\n - Started diltiazem 30 mg QID\n - Sedation (propofol and lorazepam) stopped at about 11:30 a.m. and\n patient still not to baseline by evening.\n - Per family, patient can follow commands (such as squeeze hand) and\n will look around meaningfully at baseline, but can neither speak nor\n move.\n - EEG electrodes removed this a.m. for MRI\n - Neurology suggested MRI as soon as stable (we should\n get this in a.m.\n - Let SBP run 120s-150s if possible given possible stroke\n - EEG electrodes can be replaced after MRI if Neuro/we like.\n - BP quite labile, particularly when patient being passively moved\n around\n Allergies:\n Coumadin (Oral) (Warfarin Sodium)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Heparin Sodium - 550 units/hour\n Other ICU medications:\n Heparin Sodium - 09:00 AM\n Metoprolol - 05:44 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:46 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.8\nC (100\n Tcurrent: 36.6\nC (97.9\n HR: 107 (82 - 129) bpm\n BP: 107/59(75) {87/53(64) - 180/99(129)} mmHg\n RR: 20 (16 - 27) insp/min\n SpO2: 99%\n Heart rhythm: AF (Atrial Fibrillation)\n Total In:\n 4,779 mL\n 290 mL\n PO:\n TF:\n IVF:\n 4,679 mL\n 230 mL\n Blood products:\n Total out:\n 1,645 mL\n 265 mL\n Urine:\n 1,395 mL\n 265 mL\n NG:\n 250 mL\n Stool:\n Drains:\n Balance:\n 3,134 mL\n 25 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 616 (406 - 677) mL\n PS : 5 cmH2O\n RR (Spontaneous): 23\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 37\n PIP: 7 cmH2O\n SpO2: 99%\n ABG: ///20/\n Ve: 9.5 L/min\n Physical Examination\n General: Intubated and sedated. Pale and clearly hemiparetic elderly\n man.\n HEENT: Sclera anicteric, PERRL, MMM\n Neck: supple, JVP not elevated, no LAD\n Lungs: Clear to auscultation bilaterally on anterior exam, no wheezes,\n rales, ronchi\n CV: Irregularly irregular. Tachycardic.\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness or guarding, no organomegaly\n Ext: warm, well perfused, 1+ pulses, no clubbing, cyanosis or edema\n Neuro: Non-responsive. Only eye opening without fixation or movements\n on physical stimulation. No response to voice. Completely non-verbal.\n Only reflexive bodily movements when being moved around. Rigid and\n wasted right leg, left more flaccid. Upper limbs rigid R > L. R flexor\n and L extensor.\n Labs / Radiology\n 293 K/uL\n 10.4 g/dL\n 140 mg/dL\n 1.5 mg/dL\n 20 mEq/L\n 4.0 mEq/L\n 17 mg/dL\n 110 mEq/L\n 137 mEq/L\n 32.5 %\n 10.7 K/uL\n [image002.jpg]\n 05:48 PM\n 10:40 PM\n 02:52 AM\n 02:58 AM\n 07:50 AM\n 08:52 AM\n 11:23 AM\n 02:00 PM\n 08:52 PM\n 03:30 AM\n WBC\n 11.4\n 11.3\n 10.7\n Hct\n 35.3\n 32.5\n 32.5\n Plt\n 285\n 278\n 293\n Cr\n 1.6\n 1.6\n 1.5\n TropT\n 0.11\n 0.11\n TCO2\n 19\n 19\n 24\n Glucose\n 128\n 125\n 155\n 143\n 140\n Other labs: PT / PTT / INR:13.2/64.1/1.1, CK / CKMB /\n Troponin-T:1057/9/0.11, Lactic Acid:1.3 mmol/L, Ca++:7.1 mg/dL,\n Mg++:2.0 mg/dL, PO4:2.8 mg/dL\n Assessment and Plan\n 73 yo M with a history of afib, L MCA stroke, recurrent seizures who\n initally presented after witnessed seizure, now transferred to the MICU\n with tachycardia and hypotension. Likely neurologic given primary\n presenting complaint AMS. Will obtain MR stable.\n #. Tachycardia and hypotension\n Still in AF with some rate control of otherwise RVR with diltiazem PO.\n Pressures now better. LENIs negative and no little suspicion for PE\n would not explain seizure and AMS, and hemodynamic fluctuations not\n consistent with.\n -continue heparin gtt empirically for PE\n - Increase diltaizem to 45 mg QID (from 30 mg)\n #. AMS\n Likely brainstem stroke given possible emboli to left leg,\n hypertension, seizure, posturing of limbs. Not evident on CT but this\n was early and posturing of left arm more consistent with subcortical\n infarction. Therefore MRI with stroke protocol as above. Not likely\n that seizures are contributing given that these were not seen before\n and are typically motor.\n - Continue to hold sedating medications\n - NR as above when stable\n - Continue anticonvulsants\n - Restart EEG monitoring after MRI\n - Appreciate Neuro recs\n # Acute renal failure\n Improving. Possible embolic now on heparin and improving. Versus\n prerenal with increased viscosity and dislodging of clot or increased\n clotting in small vessel. Possible component of etiology.\n - Calculate FeUrea\n -avoid nephrotoxins; renally dose medications\n #. Seizures\n Patient with recurrent seizure disorder. EEG performed shows no seizure\n activity since admission. Continue Mx as above\n -Continue Tegretol 300mg \n -Disontinue Ativan 1mg IV BID\n -f/u neurology recs\n # h/o MCA stroke:\n -continue plavix, pravastatin per outpatient regimen\n - Determine full risk of using coumadin\n # Concern for hypoperfused RLE: R LENI negative. Vascular evaluated the\n patient and has signed off. Currently both LEs have good circulation\n and pulses.\n -continue to monitor\n # FEN: No IVF, replete electrolytes, NPO for now\n # Prophylaxis: Heparin gtt, Famotidine\n # Access: PIV x3\n # Communication: Patient and daughter\n # Code: Full (discussed with daughter)\n # Disposition: ICU pending clinical improvement\n .\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Arterial Line - 05:00 PM\n 20 Gauge - 11:23 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2194-01-01 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 398554, "text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n - Family Meeting: Awaiting family from out of town. Would like to plan\n for extubation in the morning .\n - Neuro recs: Comfort measures.\n - Palliative care recs: Nothing new.\n - Patient hypotensive during the afternoon, bolused 500cc with good\n response. However continued to have lability of blood pressure during\n the afternoon/evening\n - Went into A. fib with RVR (150s). Gave 5mg Lopressor with rate to\n 100s, blood pressure 80s/40s during so bolused 500cc. Pressures/rate\n stabilized.\n Allergies:\n Coumadin (Oral) (Warfarin Sodium)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Morphine Sulfate - 11:15 PM\n Metoprolol - 11:30 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:12 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.9\nC (100.3\n Tcurrent: 37.9\nC (100.3\n HR: 104 (75 - 173) bpm\n BP: 116/75(88) {82/59(71) - 167/118(137)} mmHg\n RR: 15 (12 - 41) insp/min\n SpO2: 100%\n Heart rhythm: AF (Atrial Fibrillation)\n Total In:\n 2,583 mL\n 935 mL\n PO:\n TF:\n IVF:\n 2,583 mL\n 935 mL\n Blood products:\n Total out:\n 730 mL\n 245 mL\n Urine:\n 730 mL\n 245 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,853 mL\n 691 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 492 (418 - 711) mL\n PS : 5 cmH2O\n RR (Spontaneous): 17\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI Deferred: CMO\n PIP: 11 cmH2O\n SpO2: 100%\n ABG: ///20/\n Ve: 7.9 L/min\n Physical Examination\n General: Intubated and sedated. Pale and clearly hemiparetic elderly\n man.\n HEENT: Sclera anicteric, PERRL, MMM\n Neck: supple, JVP not elevated, no LAD\n Lungs: Clear to auscultation bilaterally on anterior exam, no wheezes,\n rales, ronchi\n CV: Irregularly irregular. Tachycardic.\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness or guarding, no organomegaly\n Ext: warm, well perfused, 1+ pulses, no clubbing, cyanosis or edema\n Neuro: Non-responsive. Only eye opening without fixation or movements\n on physical stimulation. No response to voice. Completely non-verbal.\n Only reflexive bodily movements when being moved around. Rigid and\n wasted right leg, left more flaccid. Upper limbs rigid R > L. R flexor\n and L extensor.\n Labs / Radiology\n 265 K/uL\n 9.8 g/dL\n 102 mg/dL\n 1.4 mg/dL\n 20 mEq/L\n 3.9 mEq/L\n 15 mg/dL\n 111 mEq/L\n 139 mEq/L\n 30.5 %\n 9.3 K/uL\n [image002.jpg]\n 02:52 AM\n 02:58 AM\n 07:50 AM\n 08:52 AM\n 11:23 AM\n 02:00 PM\n 08:52 PM\n 03:30 AM\n 04:01 AM\n 03:43 AM\n WBC\n 11.4\n 11.3\n 10.7\n 8.8\n 9.3\n Hct\n 35.3\n 32.5\n 32.5\n 30.4\n 30.5\n Plt\n 285\n 278\n 293\n 261\n 265\n Cr\n 1.6\n 1.6\n 1.5\n 1.5\n 1.4\n TropT\n 0.11\n 0.11\n TCO2\n 24\n Glucose\n 128\n 125\n 155\n 143\n 140\n 127\n 102\n Other labs: PT / PTT / INR:11.9/27.5/1.0, CK / CKMB /\n Troponin-T:1057/9/0.11, Lactic Acid:1.3 mmol/L, Ca++:7.4 mg/dL,\n Mg++:1.9 mg/dL, PO4:2.1 mg/dL\n CXR\n There is no interval pneumothorax, pleural effusion or focal\n consolidation.\n Urine\n negative; final\n MRSA screen\n negative; final\n CSF\n negative; final\n Blood cultures\n negative; pending\n Assessment and Plan\n 73 yo M with a history of afib, L MCA stroke, recurrent seizures who\n initially presented after witnessed seizure, now transferred to the\n MICU with tachycardia and hypotension and found to have full right MCA\n territory stroke with only viable cortex supplied by anterior cerebral\n and posterior cerebral on right. No meaningful recovery expected and\n family is in agreement with plans to transition to CMO. He is presently\n DNR/do not re-intubate.\n # Left MCA stroke. Likely etiology of patient\ns seizure presentation\n and AMS secondary to very large cortical infarction now with greater\n loss of cortical function.\n - Plan to make CMO after formal discussion with family\n - Comfort measure only; start morphine drip\n - Continue supportive care for comfort\n - Continue seizure prophylaxis with tegretol\n - Appreciate neurology, stroke, palliative care recommendations\n # Autonomic lability. Likely etiology of patient\ns labile BP secondary\n to continued autoregulation.\n - Continue rate control prn\n - Continue fluid boluses prn\n - Continue to hold anticoagulation given small hemorrhagic conversion\n # A fib. Episode last night of a. fib with RVR that responded well to\n lopressor.\n - Continue rate control prn\n # Acute renal failure. Improving. Consider prerenal with increased\n viscosity and dislodging of clot or increased clotting in small vessel.\n - Continue maintenance fluids\n - Continue to renally dose medications; avoid nephrotoxins\n # Seizures. Likely secondary to new L MCA stroke.\n - Continue seizure prophylaxis with tegretol\n # Concern for hypoperfused RLE.\n - Continue to monitor\n # FEN: Supportive maintenance fluids, replete electrolytes prn, NPO\n # Prophylaxis: Boots only, famotidine\n # Access: PIV x3\n # Communication: Patient and daughter\n # Code: DNR/DNI (discussed with daughter, family); will be made CMO\n today\n # Disposition: ICU pending determination of care\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Arterial Line - 05:00 PM\n 20 Gauge - 11:23 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Respiratory ", "chartdate": "2193-12-30 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 398338, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 3\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Tube Type\n ETT:\n Position: 22 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 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: Continue with daily RSBI tests & SBT's as tolerated;\n Comments: RSBI-37\n Reason for continuing current ventilatory support: Cannot protect\n airway, Underlying illness not resolved; Comments: pt still has poor\n mental status\n" }, { "category": "Nursing", "chartdate": "2193-12-30 00:00:00.000", "description": "Nursing Progress Note", "row_id": 398343, "text": "Pt is a 73 yo Cantonese speaking man with a h/o of a left LMCA stroke\n in with residual right sided hemiplegia and recurrent seizure\n disorder. Pt was found during a seizure by his wife. The pt had been\n seizing for an undetermined amount of time. EMS called and administered\n valium 5mg ivp with resolution of seizure activity. He was intubated in\n the ed on his arrival for airway protection. Continuous eeg monitoring\n w/o evidence of further seizure activity. He was transferred to the\n TSICU as a MICU border. His brief hospital course has been complicated\n by new onset afib with hemodynamic instability and poor perfusion to\n his rle which is suspicious for a new embolic stroke or possibly a pe.\n The family has been apprised of the pt\ns current condition and he\n remains a full code.\n Atrial fibrillation (Afib)\n Assessment:\n New onset of a-fib this admit.\n Action:\n Bolused with amio and amio gtt started;\n Response:\n Remains tachycardic to 120-130\ns most of shift despite amio; begun on\n po diltiazem every 6hrs. Amiodarone gtt completed at 12MN.\n Hypertensive to 130\ns at rest; increasing to 170-180\ns with mod\n stimulation. Bp labile via aline to left radial\n Plan:\n Continue to monitor; may need additional agents. Await po amiodarone\n Seizure, without status epilepticus\n Assessment:\n Presenting seizure resolved with 5mg valium. Hx of seizures since CVA\n in . No seizure acitivity noted on EEG in EW. Some vascular issues\n noted to RLE, lenies bilaterally negative.\n Action:\n Neuro checks every 2hrs. seizure pads. Carbamazepine level drawn;\n maintained on heparin gtt\n Response:\n No seizure activity noted. Some eye\ntwitching\n noted early in shift,\n resident and in to eval; similar eye movements noted\n in EW on admit and found to be inconsistent with seizures per resident.\n Supratherapeutic PTT, heparin gtt temporarily held and adjusted per\n sliding scale. Dopplerable DP bil legs; PT weak, palpable. Both legs\n mildly warm,equal.\n Plan:\n Heparin gtt, next PTT due 6am. Cont to monitor. Vascular and neurology\n following\n" }, { "category": "Nursing", "chartdate": "2193-12-31 00:00:00.000", "description": "Nursing Progress Note", "row_id": 398420, "text": "Pt is a 73 yo Cantonese speaking man with a h/o of a left LMCA stroke\n in with residual right sided hemiplegia and recurrent seizure\n disorder. Pt was found during a seizure by his wife. The pt had been\n seizing for an undetermined amount of time. EMS called and administered\n valium 5mg ivp with resolution of seizure activity. He was intubated in\n the ed on his arrival for airway protection. Continuous eeg monitoring\n w/o evidence of further seizure activity. He was transferred to the\n TSICU as a MICU border. His brief hospital course has been complicated\n by new onset afib with hemodynamic instability and poor perfusion to\n his rle which is suspicious for a new embolic stroke\n Atrial fibrillation (Afib)\n Assessment:\n HR 90-120\ns, in AF, no ectopy noted, SBP stable with rapid rates.\n Action:\n Continued Po diltiazem\n Response:\n Continues on AF, rate controlled\n Plan:\n Continue to assess, po diltiazem as ordered\n CVA (Stroke, Cerebral infarction), Hemorrhagic\n Assessment:\n Lg R MCA stroke noted & sm L side bleed noted on MRI this pm, patient\n unresponsive, withdraws to stimulation, not following commands or\n opening eyes, body is stiff and pupils 2mm and sluggishly reacting to\n light. Cough and gag impaired.\n Action:\n Continue po tegretol. Continue q 4hrs neuro checks\n Response:\n No seizure activity noted, uMS unchanged\n Plan:\n DNR/DNI, palliative care consult, possible CMO tomorrow once all family\n members presen\n" }, { "category": "Respiratory ", "chartdate": "2193-12-31 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 398426, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 4\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Tube Type\n ETT:\n Position: 22 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 28 cmH2O\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Diminished\n 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: Comfort measures only\n" }, { "category": "General", "chartdate": "2194-01-01 00:00:00.000", "description": "Generic Note", "row_id": 398546, "text": "TITLE:\n Nutrition Screen:\n 73 yo Male who initially presented after witnessed seizure, now\n transferred to the MICU with tachycardia and hypotension and found to\n have full right MCA territory. No meaningful recovery expected and\n family is in agreement with plans to transition to CMO. He is presently\n DNR/do not re-intubate. No plans for tube feed at this time. Will\n sign off for now. Please consult nutrition if plans change.\n #\n" }, { "category": "Nursing", "chartdate": "2194-01-02 00:00:00.000", "description": "Nursing Progress Note", "row_id": 398616, "text": "Comfort care (CMO, Comfort Measures)\n Assessment:\n Patient comfort care only. Family at bedside throughout night.\n Unresponsive.\n Action:\n Continued on morphine gtt @ 8mg/hr. Emotional support provided to\n family. Pain assessed/treated.\n Response:\n Continues to have - resp. Appears to be comfortable.\n Plan:\n CMO. Titrate morphine gtt as needed for comfort. Provide emotional\n support for family.\n" }, { "category": "Nursing", "chartdate": "2193-12-29 00:00:00.000", "description": "Nursing Progress Note", "row_id": 398324, "text": "Pt is a 73 yo Cantonese speaking man with a h/o of a left LMCA stroke\n in with residual right sided hemiplegia and recurrent seizure\n disorder. Pt was found during a seizure by his wife. The pt had been\n seizing for an undetermined amount of time. EMS called and administered\n valium 5mg ivp with resolution of seizure activity. He was intubated in\n the ed on his arrival for airway protection. Continuous eeg monitoring\n w/o evidence of further seizure activity. He was transferred to the\n TSICU as a MICU border. His brief hospital course has been complicated\n by new onset afib with hemodynamic instability and poor perfusion to\n his rle which is suspicious for a new embolic stroke or possibly a pe.\n The family has been apprised of the pt\ns current condition and he\n remains a full code.\n Seizure, without status epilepticus\n Assessment:\n Received pt from the TSICU intubated and orally vented on psv5/peep5\n Action:\n Response:\n Plan:\n Atrial fibrillation (Afib)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2193-12-29 00:00:00.000", "description": "Nursing Progress Note", "row_id": 398327, "text": "Pt is a 73 yo Cantonese speaking man with a h/o of a left LMCA stroke\n in with residual right sided hemiplegia and recurrent seizure\n disorder. Pt was found during a seizure by his wife. The pt had been\n seizing for an undetermined amount of time. EMS called and administered\n valium 5mg ivp with resolution of seizure activity. He was intubated in\n the ed on his arrival for airway protection. Continuous eeg monitoring\n w/o evidence of further seizure activity. He was transferred to the\n TSICU as a MICU border. His brief hospital course has been complicated\n by new onset afib with hemodynamic instability and poor perfusion to\n his rle which is suspicious for a new embolic stroke or possibly a pe.\n The family has been apprised of the pt\ns current condition and he\n remains a full code.\n Seizure, without status epilepticus\n Assessment:\n Received pt from the TSICU intubated and orally vented on psv5/peep5\n and o2 40%. SRR 20\ns with TV ~400cc. Neuro exam is essentially\n unchanged: perrl briskly reactive; all extremities withdrawing from\n pain. No visual evidence of seizure activity.\n Action:\n Per micu team, will keep intubated for airway protection. No change in\n neuro exam.\n Response:\n None; no evidence of seizure activity.\n Plan:\n Monitor closely for seizure activity. Per micu team, pt will need\n mri/mra to determine whether he has had another stroke.\n Atrial fibrillation (Afib)\n Assessment:\n Received pt from the TSICU in afib with rates 130-140\ns. No ventricular\n ectopy noted. Pt continues on an amiodarone drip. SBP\ns 130-150\n Lower extremity pedal pulses (dorsal and tibial) are all weakly\n palpable. RLE is warm with normal coloration.\n Action:\n Pt received a total of 10mg ivp lopressor on arrival to the micu. HR\n currently 100-110\ns, afib.\n Response:\n Improved rate control s/p lopressor although pt remains in afib. He is\n hemodynamically stable.\n Plan:\n Monitor hemodynamic status closely. Amiodarone drip to continue through\n 0500 tomorrow.\n" }, { "category": "Nursing", "chartdate": "2193-12-31 00:00:00.000", "description": "Nursing Progress Note", "row_id": 398474, "text": "MRI with acute infarct involving the entire right MCA territory with\n small amount of hemorrhage in the right temporal lobe, mass effect on\n right lateral ventricle and 4mm right to left midline shift with near\n complete occlusion of the right ICA.\n - Heparin, plavix discontinued based on MRI findings\n Events: Neuro following-no new recommendations-cont tegritol. T max\n 100.1 ax + diaphoretic, RR 30\ns, flushed face, hypertensive to 180\n and RAF 130-140\ns- treating with 650mg Tylenol and 2 mg pt\n fever breaking, RR 20\ns, HR trending to 80 to low 100\ns, but BP falling\n 80/40 via A line and correlates with NBP- given 500cc IVF bolus x 2.\n Dr. bedside and speaking to family about prognosis with further\n care- plan to maintain current level of care- DNR/DNI and CMO when more\n family present.\n CVA (Stroke, Cerebral infarction), Hemorrhagic\n Assessment:\n Neuro bedside for assessment- no change in pt condition since MRI, pt\n not interactive, grimacing with oral care and will withdraw bilat feet\n to pain\n Action:\n ? pt in pain and given 1xdose 2mg IV Morphine, 650 mg acetaminophen,\n minimizing ? painful/ irritatinginterventions\n Response:\n Pt temp down to 96, RR and HR decreasing, BP labile with nursing\n care/interventions- BP as high as 180\ns while attempting to suction and\n down to 80/ post IV morphine (confirmed by BP cuff)\n Plan:\n Cont current level of care at this time\n" }, { "category": "Nursing", "chartdate": "2194-01-01 00:00:00.000", "description": "Nursing Progress Note", "row_id": 398521, "text": "CVA (Stroke, Cerebral infarction), Hemorrhagic\n Assessment:\n Full right MCA territory stroke now, on top of previous left MCA.\n Patient unresponsive, occasionally opening eyes, very minimal response,\n flex-withdraws to stimulation. Intubated for airway protection\n Action:\n Continue monitor neuro checks, continue tegretol\n Response:\n Neuro unchanged, low grade temp, poor prognosis\n Plan:\n Possible CMO in AM, nuero/stoke team following\n Atrial fibrillation (Afib)\n Assessment:\n HR 80-120, a fib without pvc\n Action:\n Continued po dilt, HR up to 140-170\ns, iv metoprolol 5mg and morphine\n 2mg iv push and 500ml fluid bolus\n Response:\n HR 10-120\ns a fib\n Plan:\n Continue po dilt, monitor labs, possible transition to CMO today\n" }, { "category": "Physician ", "chartdate": "2194-01-01 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 398531, "text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n - Family Meeting: Awaiting family from out of town. Would like to plan\n for extubation in the morning .\n - Neuro recs: Comfort measures.\n - Palliative care recs: Nothing new.\n - Patient hypotensive during the afternoon, bolused 500cc with good\n response. However continued to have lability of blood pressure during\n the afternoon/evening\n - Went into A. fib with RVR (150s). Gave 5mg Lopressor with rate to\n 100s, blood pressure 80s/40s during so bolused 500cc. Pressures/rate\n stabilized.\n Allergies:\n Coumadin (Oral) (Warfarin Sodium)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Morphine Sulfate - 11:15 PM\n Metoprolol - 11:30 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:12 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.9\nC (100.3\n Tcurrent: 37.9\nC (100.3\n HR: 104 (75 - 173) bpm\n BP: 116/75(88) {82/59(71) - 167/118(137)} mmHg\n RR: 15 (12 - 41) insp/min\n SpO2: 100%\n Heart rhythm: AF (Atrial Fibrillation)\n Total In:\n 2,583 mL\n 935 mL\n PO:\n TF:\n IVF:\n 2,583 mL\n 935 mL\n Blood products:\n Total out:\n 730 mL\n 245 mL\n Urine:\n 730 mL\n 245 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,853 mL\n 691 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 492 (418 - 711) mL\n PS : 5 cmH2O\n RR (Spontaneous): 17\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI Deferred: CMO\n PIP: 11 cmH2O\n SpO2: 100%\n ABG: ///20/\n Ve: 7.9 L/min\n Physical Examination\n General: Intubated and sedated. Pale and clearly hemiparetic elderly\n man.\n HEENT: Sclera anicteric, PERRL, MMM\n Neck: supple, JVP not elevated, no LAD\n Lungs: Clear to auscultation bilaterally on anterior exam, no wheezes,\n rales, ronchi\n CV: Irregularly irregular. Tachycardic.\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness or guarding, no organomegaly\n Ext: warm, well perfused, 1+ pulses, no clubbing, cyanosis or edema\n Neuro: Non-responsive. Only eye opening without fixation or movements\n on physical stimulation. No response to voice. Completely non-verbal.\n Only reflexive bodily movements when being moved around. Rigid and\n wasted right leg, left more flaccid. Upper limbs rigid R > L. R flexor\n and L extensor.\n Labs / Radiology\n 265 K/uL\n 9.8 g/dL\n 102 mg/dL\n 1.4 mg/dL\n 20 mEq/L\n 3.9 mEq/L\n 15 mg/dL\n 111 mEq/L\n 139 mEq/L\n 30.5 %\n 9.3 K/uL\n [image002.jpg]\n 02:52 AM\n 02:58 AM\n 07:50 AM\n 08:52 AM\n 11:23 AM\n 02:00 PM\n 08:52 PM\n 03:30 AM\n 04:01 AM\n 03:43 AM\n WBC\n 11.4\n 11.3\n 10.7\n 8.8\n 9.3\n Hct\n 35.3\n 32.5\n 32.5\n 30.4\n 30.5\n Plt\n 285\n 278\n 293\n 261\n 265\n Cr\n 1.6\n 1.6\n 1.5\n 1.5\n 1.4\n TropT\n 0.11\n 0.11\n TCO2\n 24\n Glucose\n 128\n 125\n 155\n 143\n 140\n 127\n 102\n Other labs: PT / PTT / INR:11.9/27.5/1.0, CK / CKMB /\n Troponin-T:1057/9/0.11, Lactic Acid:1.3 mmol/L, Ca++:7.4 mg/dL,\n Mg++:1.9 mg/dL, PO4:2.1 mg/dL\n CXR\n There is no interval pneumothorax, pleural effusion or focal\n consolidation.\n Urine\n negative; final\n MRSA screen\n negative; final\n CSF\n negative; final\n Blood cultures\n negative; pending\n Assessment and Plan\n 73 yo M with a history of afib, L MCA stroke, recurrent seizures who\n initially presented after witnessed seizure, now transferred to the\n MICU with tachycardia and hypotension and found to have full right MCA\n territory stroke with only viable cortex supplied by anterior cerebral\n and posterior cerebral on right. No meaningful recovery expected and\n family is in agreement with plans to transition to CMO. He is presently\n DNR/do not re-intubate.\n # Left MCA stroke. Likely etiology of patient\ns seizure presentation\n and AMS secondary to very large cortical infarction now with greater\n loss of cortical function.\n - Discuss with family again this AM regarding plans for continued\n treatment vs transition to CMO\n - Continue supportive care\n - Continue seizure prophylaxis with tegretol\n - Continue to hold sedating medications (hold ativan)\n - Appreciate neurology, stroke, palliative care recs; will continue to\n follow\n # Autonomic lability. Likely etiology of patient\ns labile BP secondary\n to continued autoregulation.\n - Consider hydralazine for SBP > 200\n - Continue rate control prn\n - Continue fluid boluses prn\n - Continue to hold anticoagulation given small hemorrhagic conversion\n # A fib. Episode last night of a. fib with RVR that responded well to\n lopressor.\n - Continue rate control prn\n # Acute renal failure. Improving. Consider prerenal with increased\n viscosity and dislodging of clot or increased clotting in small vessel.\n - Continue maintenance fluids\n - Continue to renally dose medications; avoid nephrotoxins\n # Seizures. Likely secondary to new L MCA stroke.\n - Continue seizure prophylaxis with tegretol\n # Concern for hypoperfused RLE.\n - Continue to monitor\n # FEN: Supportive maintenance fluids, replete electrolytes, NPO for now\n # Prophylaxis: Boots only, famotidine\n # Access: PIV x3\n # Communication: Patient and daughter\n # Code: DNR/DNI (discussed with daughter, family)\n # Disposition: ICU pending determination of care\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Arterial Line - 05:00 PM\n 20 Gauge - 11:23 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2193-12-29 00:00:00.000", "description": "Nursing Progress Note", "row_id": 398319, "text": "73 yo Cantonese speaking male with a history of L MCA stroke in ,\n with recurrent seizure disorder, who presented to the ED after a\n prolonged seizure witnessed at home. Per family, he was found\n unresponsive, with increased stiffness, and eyes deviated upwards on\n the morning of admission. Two hours prior to seizure he was observed by\n his wife, and was thought to be in his usual state of health. EMS\n administered Valium 5mg IV x1, and seizure abated.\n At baseline he is aphasic but able to ambulate with a cane and leg\n brace.\n Seizure, without status epilepticus\n Assessment:\n PEARL 3mm bilat and brisk, impaired corneals, impaired gag, cough\n intact. Pt MAE but does not focus and is not purposeful. No\n spontaneous movement noted. Withdraws to painful stimuli. Posturing\n noted w/ LUE. Twitching also noted intermittently but no seizure\n activity seen. Cont EEG continues.\n Action:\n Q1hr neuro checks. Sedated on low dose Propofol d/c\nd. Seizure\n precautions maintained. Continuous EEG d/c\nd . Heparin gtt initiated\n ?PE picture. Unable to obtain CT c contrast ARF.\n Response:\n Neuro exam remains unchanged. . No obvious seizure activity noted.\n Plan:\n Cont to monitor neuro signs. Maintain on Propofol w/ ativan as\n ordered. EEG evaluation. Lopressor/Labetalol for htn control. PTT\n at 1500 >150, heparin on hold, redraw PTT in 1 hour.\n Atrial fibrillation (Afib)\n Assessment:\n Pt continues in afib HR 90-130\ns. SBP dropping to 80\n Action:\n Amiodarone gtt continues, rate changed to 0.5mg at 1100 and\n is to run until 0500 \n Fluid bolused x 3 to maintain MAP >65\n Lopressor 5mg for afib with rate 130\n Response:\n Persistent afib w/ rate 90-120\ns. BP stable p fluid boluses.\n Amiodarone gtt continues. HR remains afib w/ rate <120.\n Plan:\n Cont to monitor hemodynamics. Replete lytes as needed. Continue amio\n and transition to po amio.\n" }, { "category": "Nursing", "chartdate": "2193-12-29 00:00:00.000", "description": "Nursing Progress Note", "row_id": 398316, "text": "73 yo Cantonese speaking male with a history of L MCA stroke in ,\n with recurrent seizure disorder, who presented to the ED after a\n prolonged seizure witnessed at home. Per family, he was found\n unresponsive, with increased stiffness, and eyes deviated upwards on\n the morning of admission. Two hours prior to seizure he was observed by\n his wife, and was thought to be in his usual state of health. EMS\n administered Valium 5mg IV x1, and seizure abated.\n At baseline he is aphasic but able to ambulate with a cane and leg\n brace.\n Seizure, without status epilepticus\n Assessment:\n PEARL 3mm bilat and brisk, impaired corneals, impaired gag, cough\n intact. Pt MAE but does not focus and is not purposeful. No\n spontaneous movement noted. Withdraws to painful stimuli. Posturing\n noted w/ LUE. Twitching also noted intermittently but no seizure\n activity seen. Cont EEG continues.\n Action:\n Q1hr neuro checks. Sedated on low dose Propofol and lightened q4hrs\n for exam. Seizure precautions maintained. Continuous EEG . Heparin\n gtt initiated ?PE picture. Unable to obtain CT c contrast ARF.\n Response:\n Neuro exam remains unchanged. Hyperdynamic w/ resp compromise off\n Propofol. No obvious seizure activity noted.\n Plan:\n Cont to monitor neuro signs. Maintain on Propofol w/ ativan as\n ordered. EEG evaluation. Lopressor/Labetalol for htn control. PTT\n at 1500 pending.\n Atrial fibrillation (Afib)\n Assessment:\n Pt continues in afib HR 90-130\ns. SBP dropping to 80\n Action:\n Amiodarone gtt continues, rate changed to 0.5mg at 1100 and\n is to run until 0500\n Fluid bolused x 3 to maintain MAP >65\n Lopressor 5mg for afib with rate 130\n Response:\n Persistent afib w/ rate 90-120\ns. BP stable p fluid boluses.\n Amiodarone gtt continues. HR remains afib w/ rate <120.\n Plan:\n Cont to monitor hemodynamics. Replete lytes as needed. Continue amio\n and transition to po amio.\n" }, { "category": "Respiratory ", "chartdate": "2193-12-29 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 398317, "text": "Demographics\n Day of mechanical ventilation: 2\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: 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 / Copious\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Invasive ventilation assessment:\n Trigger work assessment:\n Comments: Pt continues on PSV as charted.\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Underlying illness\n not resolved\n" }, { "category": "Physician ", "chartdate": "2193-12-31 00:00:00.000", "description": "Physician Resident/Attending Progress Note - MICU", "row_id": 398468, "text": "Chief Complaint: Seizure and persistently altered mental status\n afterward.\n 24 Hour Events:\n MAGNETIC RESONANCE IMAGING - At 10:30 AM\n - MRI with acute infarct involving the entire right MCA territory with\n small amount of hemorrhage in the right temporal lobe, mass effect on\n right lateral ventricle and 4mm right to left midline shift with near\n complete occlusion of the right ICA.\n - Heparin, plavix discontinued based on MRI findings\n - Palliative care consulted and noted that they briefly met with\n family, that the is family overwhelmed with rapid turn of events, and\n that they are available tomorrow to assist with care\n - Stroke team consulted and recommending allowing BP to autoregulate\n (can treat SBP > 200 with hydralazine 10mg IV), continue tegretol as\n seizure ppx\n - Patient will likely be made CMO in the morning\n Allergies:\n Coumadin (Oral) (Warfarin Sodium)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:06 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.7\nC (99.9\n Tcurrent: 37\nC (98.6\n HR: 101 (89 - 128) bpm\n BP: 106/62(77) {82/53(64) - 151/88(107)} mmHg\n RR: 17 (15 - 23) insp/min\n SpO2: 100%\n Heart rhythm: AF (Atrial Fibrillation)\n Total In:\n 850 mL\n 518 mL\n PO:\n TF:\n IVF:\n 790 mL\n 518 mL\n Blood products:\n Total out:\n 780 mL\n 260 mL\n Urine:\n 780 mL\n 260 mL\n NG:\n Stool:\n Drains:\n Balance:\n 70 mL\n 258 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 582 (487 - 712) mL\n PS : 5 cmH2O\n RR (Spontaneous): 22\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI Deferred: CMO\n PIP: 11 cmH2O\n SpO2: 100%\n ABG: ///20/\n Ve: 8.6 L/min\n Physical Examination\n General: Intubated and sedated. Pale and clearly hemiparetic elderly\n man.\n HEENT: Sclera anicteric, PERRL, MMM\n Neck: supple, JVP not elevated, no LAD\n Lungs: Clear to auscultation bilaterally on anterior exam, no wheezes,\n rales, ronchi\n CV: Irregularly irregular. Tachycardic.\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness or guarding, no organomegaly\n Ext: warm, well perfused, 1+ pulses, no clubbing, cyanosis or edema\n Neuro: Non-responsive. Only eye opening without fixation or movements\n on physical stimulation. No response to voice. Completely non-verbal.\n Only reflexive bodily movements when being moved around. Rigid and\n wasted right leg, left more flaccid. Upper limbs rigid R > L. R flexor\n and L extensor.\n Labs / Radiology\n 261 K/uL\n 9.8 g/dL\n 127 mg/dL\n 1.5 mg/dL\n 20 mEq/L\n 3.7 mEq/L\n 17 mg/dL\n 110 mEq/L\n 137 mEq/L\n 30.4 %\n 8.8 K/uL\n [image002.jpg]\n 10:40 PM\n 02:52 AM\n 02:58 AM\n 07:50 AM\n 08:52 AM\n 11:23 AM\n 02:00 PM\n 08:52 PM\n 03:30 AM\n 04:01 AM\n WBC\n 11.4\n 11.3\n 10.7\n 8.8\n Hct\n 35.3\n 32.5\n 32.5\n 30.4\n Plt\n 285\n 278\n 293\n 261\n Cr\n 1.6\n 1.6\n 1.5\n 1.5\n TropT\n 0.11\n 0.11\n TCO2\n 19\n 24\n Glucose\n 128\n 125\n 155\n 143\n 140\n 127\n Other labs: PT / PTT / INR:11.9/27.5/1.0, CK / CKMB /\n Troponin-T:1057/9/0.11, Lactic Acid:1.3 mmol/L, Ca++:7.3 mg/dL,\n Mg++:2.0 mg/dL, PO4:1.9 mg/dL\n Imaging: MRI shows new stroke of right MCA territory with very small\n preserved cortex at midline.\n Assessment and Plan\n 73 yo M with a history of afib, L MCA stroke, recurrent seizures who\n initally presented after witnessed seizure, now transferred to the MICU\n with tachycardia and hypotension.\n Full right MCA territory stroke now, on top of previous left MCA. Only\n viable cortex supplied by anterior cerebral and posterior cerebral on\n right. No meaningful recovery expected, therefore need to discuss\n further with family, who wanted time to think about transition to CMO.\n He is presentely DNR/do not re-intubate.\n #. Discussion with family\n - Plan to meet with them again to determine whether to continue\n treatment or transition to CMO\n #. Tachycardia and hypotension\n Stroke team want BP to autoregulate at present.\n - If BP > 200 mmHg then hydralazine.\n - Keep rate controlled enough to prevent myocardial ischemia.\n - Stop anticoagulants given small hemorrhagic conversion\n #. AMS\n Secondary to very large cortical infarction now with great some of\n fractional loss of cortical function.\n - Continue to hold sedating medications\n - Continue anticonvulsants\n - Appreciate Neuro recs\n - Discuss further with family\n # Acute renal failure\n Continues to improve. Versus prerenal with increased viscosity and\n dislodging of clot or increased clotting in small vessel. Possible\n component of etiology.\n - Continue maintenance fluids only for now\n - Avoid nephrotoxins; renally dose medications\n #. Seizures\n Patient with recurrent seizure disorder. EEG performed shows no seizure\n activity since admission. Continue Mx as above\n -Continue Tegretol 300mg \n -Disontinue Ativan 1mg IV BID\n -f/u neurology recs\n # Concern for hypoperfused RLE\n Improved perfusion in context of heparin gtt.\n - Continue to monitor\n # FEN: Supportive maintenance fluids, replete electrolytes, NPO for now\n # Prophylaxis: Boots only, Famotidine\n # Access: PIV x3\n # Communication: Patient and daughter\n # Code: Full (discussed with daughter)\n # Disposition: ICU pending clinical improvement\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Arterial Line - 05:00 PM\n 20 Gauge - 11:23 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n ------ Protected Section ------\n MICU ATTENDING ADDENDUM\n I saw and examined the patient, and was physically present with the ICU\n team for the key portions of the services provided. I agree with the\n note above, including the assessment and plan. I would emphasize and\n add the following points: 73M s/p prior CVA c/b hemiparesis initially\n admitted with seizures, intubated in ED. Admit to NSICU, head CT stable\n - developed AF c c/b hypotension. Ongoing AF c , massive RCA CVA\n on MRI.\n Exam notable for Tm 100.0 BP 120/60 HR 100-115AF RR 16 with sat 99 on\n PSV 5/5 0.4 7.38/39/160. Minimally response, occasional eye opening but\n not to threat or voice. Dense R paresis. PERRL. CTA B. Irreg s1s2\n 2/6Sm. Soft +BS. Cool B, trace edema. Labs notable for WBC 8K, HCT 30,\n K+ 3.7, Cr 1.5.\n Agree with plan to manage large R CVA with vent support and tegretol\n for seizures. For AF , increase dilt to 45 QID. Will meet\n with family - likely transition to CMO with extubation in the next few\n days, palliative care team following. Remainder of plan as outlined\n above.\n Patient is critically ill\n Total time: 30 min\n ------ Protected Section Addendum Entered By: , MD\n on: 05:37 PM ------\n" }, { "category": "Nursing", "chartdate": "2194-01-02 00:00:00.000", "description": "Nursing Progress Note", "row_id": 398673, "text": "NPN 0700-1530:\n Pt expired at 1523,appeared comfortable was on Morphine gtt at\n 10mg/hr.Family at bedside,doing o.K. House staff evaluated and declared\n death around 15 23. Pt family refused Autopsy.\n" }, { "category": "Nursing", "chartdate": "2193-12-31 00:00:00.000", "description": "Nursing Progress Note", "row_id": 398402, "text": "Pt is a 73 yo Cantonese speaking man with a h/o of a left LMCA stroke\n in with residual right sided hemiplegia and recurrent seizure\n disorder. Pt was found during a seizure by his wife. The pt had been\n seizing for an undetermined amount of time. EMS called and administered\n valium 5mg ivp with resolution of seizure activity. He was intubated in\n the ed on his arrival for airway protection. Continuous eeg monitoring\n w/o evidence of further seizure activity. He was transferred to the\n TSICU as a MICU border. His brief hospital course has been complicated\n by new onset afib with hemodynamic instability and poor perfusion to\n his rle which is suspicious for a new embolic stroke\n Atrial fibrillation (Afib)\n Assessment:\n HR continues in AF, rate 90\ns-120\ns with occasional short runs of\n RAF(140\ns-150\ns), no ectopy noted, sbp stable with rapid rates, on\n heparin gtt & po plavix\n Action:\n Po diltiazem dose increased today, heparin gtt & po plavix dc\nd today\n after MRI of head today noted sm L sided bleed\n Response:\n Continues on AF, rate controlled most of day\n Plan:\n Continue to assess, po diltiazem as ordered\n" }, { "category": "Respiratory ", "chartdate": "2193-12-31 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 398463, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 4\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: 22 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n :\n Cuff Management:\n Vol/Press:\n Cuff pressure: 28 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n 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 Plan\n Next 24-48 hours: Pt to soon be made CMO\n" }, { "category": "Nursing", "chartdate": "2193-12-31 00:00:00.000", "description": "Nursing Progress Note", "row_id": 398403, "text": "Pt is a 73 yo Cantonese speaking man with a h/o of a left LMCA stroke\n in with residual right sided hemiplegia and recurrent seizure\n disorder. Pt was found during a seizure by his wife. The pt had been\n seizing for an undetermined amount of time. EMS called and administered\n valium 5mg ivp with resolution of seizure activity. He was intubated in\n the ed on his arrival for airway protection. Continuous eeg monitoring\n w/o evidence of further seizure activity. He was transferred to the\n TSICU as a MICU border. His brief hospital course has been complicated\n by new onset afib with hemodynamic instability and poor perfusion to\n his rle which is suspicious for a new embolic stroke\n Atrial fibrillation (Afib)\n Assessment:\n HR continues in AF, rate 90\ns-120\ns with occasional short runs of\n RAF(140\ns-150\ns), no ectopy noted, sbp stable with rapid rates, on\n heparin gtt & po plavix\n Action:\n Po diltiazem dose increased today, heparin gtt & po plavix dc\nd today\n after MRI of head today noted sm L sided bleed\n Response:\n Continues on AF, rate controlled most of day\n Plan:\n Continue to assess, po diltiazem as ordered\n CVA (Stroke, Cerebral infarction), Hemorrhagic\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2194-01-01 00:00:00.000", "description": "Nursing Progress Note", "row_id": 398591, "text": "Events: Multiple family at bedside- meeting with family and attending-\n at 12 PM made CMO and terminal extubation and placed on morphine gtt.\n Morphine currently 8mg/hr and - breathing.\n CVA (Stroke, Cerebral infarction), Hemorrhagic\n Assessment:\n No acute change in MS, once extubated would intermittently groan\n Action:\n CMO\n Response:\n Remains comfortable on Morphine gtt\n Plan:\n Cont Morphine gtt for pain/resp status, comfort measures\n" }, { "category": "Nursing", "chartdate": "2194-01-01 00:00:00.000", "description": "Nursing Progress Note", "row_id": 398588, "text": "Events: Multiple family at bedside- meeting with family and attending-\n at 12 PM made CMO and terminal extubation and placed on morphine gtt.\n Morphine currently 8mg/hr and - breathing.\n CVA (Stroke, Cerebral infarction), Hemorrhagic\n Assessment:\n No acute change in MS, once extubated would intermittently groan\n Action:\n CMO\n Response:\n Remains comfortable on Morphine gtt\n Plan:\n Cont Morphine gtt for pain/resp status, comfort measures\n" }, { "category": "Nursing", "chartdate": "2194-01-02 00:00:00.000", "description": "Nursing Progress Note", "row_id": 398660, "text": "Pt expired at 1523,appeared comfortable was on Morphine gtt at\n 10mg/hr.Family at bedside,doing ok.MD evaluated and declared death at\n 15 23.\n" }, { "category": "General", "chartdate": "2194-01-02 00:00:00.000", "description": "ICU Event Note", "row_id": 398661, "text": "TITLE:\n Clinician: Resident\n Called to evaluate patient. He was without heart rate, without breath\n sounds, without spontaneous movement and without corneal reflexes.\n Patient time of death declared at 15:23. Family aware and by patient's\n bedside.\n" }, { "category": "Respiratory ", "chartdate": "2193-12-29 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 398277, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 2\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Reason: seizures\n Tube Type\n ETT:\n Position: 21 cm at teeth\n Route:\n Type: Standard\n Size: 7.5mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 26 cmH2O\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: Tan / Thick\n Sputum source/amount: Suctioned / Scant\n Comments/Plan\n Pt remains unchanged overnight, on minimal vent support- PSV 5/5 40%.\n RSBI=67. See flowsheet for further pt data. Will follow.\n 06:04\n" }, { "category": "Radiology", "chartdate": "2193-12-29 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1115827, "text": " 5:32 AM\n CHEST (PORTABLE AP) Clip # \n Reason: int changes, ? aspiration\n Admitting Diagnosis: SEIZURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with SZ d/o\n REASON FOR THIS EXAMINATION:\n int changes, ? aspiration\n ______________________________________________________________________________\n FINAL REPORT\n CHEST\n\n HISTORY: Intubation. Possible aspiration.\n\n Small bilateral calcified granulomas are again demonstrated. There is\n ill-defined increased streaky density at the left base. The heart and\n mediastinal structures are unchanged. An endotracheal tube and nasogastric\n tube remain in place.\n\n IMPRESSION: Increased streaky density at the left base that may represent a\n developing parenchymal infiltrate.\n\n\n" }, { "category": "Radiology", "chartdate": "2193-12-28 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1115738, "text": " 11:12 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: SEIZURE, ? ICH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with 30 min sz, known sz hx\n REASON FOR THIS EXAMINATION:\n ICH\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: SHfd SAT 12:05 PM\n No ICH\n Old L cerebral hemesphere infarct. IF concern for acute infarct MRI can be\n obtained. `\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAM: 73-year-old man with seizure.\n\n COMPARISON: Head CT from .\n\n NON-CONTRAST HEAD CT: Large area of hypodensity-CSF density in the left\n cerebral hemisphere with dilatation of the left lateral ventricle is\n compatible with patient's known old infarct. This infarct involves the left\n frontal, parietal, occipital and temporal lobes. There is no intracranial\n hemorrhage or mass effect. Imaged mastoid air cells and paranasal sinuses are\n unremarkable. There is no lytic or blastic osseous lesion to suggest\n malignancy.\n\n IMPRESSION:\n\n 1. No acute intracranial hemorrhage or mass effect . In case of clinical\n concern for acute infarction, an MRI can be obtained. Old left cerebral\n hemisphere infarction.\n\n" }, { "category": "Radiology", "chartdate": "2193-12-31 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1116126, "text": " 3:17 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for interval change\n Admitting Diagnosis: SEIZURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with respiratory failure\n REASON FOR THIS EXAMINATION:\n eval for interval change\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Respiratory failure.\n\n COMPARISON: One day prior.\n\n A frontal radiograph of the chest shows an endotracheal tube which ends 4.6 cm\n above the carina. A nasogastric tube is coiled within the stomach and\n unchanged from the previous study. Cardiac, mediastinal and hilar contours\n are also unchanged. There is no interval pneumothorax, pleural effusion or\n focal consolidation.\n\n\n" }, { "category": "Radiology", "chartdate": "2193-12-28 00:00:00.000", "description": "R UNILAT LOWER EXT VEINS RIGHT", "row_id": 1115762, "text": " 3:33 PM\n UNILAT LOWER EXT VEINS RIGHT Clip # \n Reason: DVT\n Admitting Diagnosis: SEIZURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with RLE discoloration\n REASON FOR THIS EXAMINATION:\n DVT\n ______________________________________________________________________________\n WET READ: SHfd SAT 4:02 PM\n No evidence of Right LE DVT. R peroneal vein not imaged.\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAM: Right lower extremity discoloration. Clinical concern for\n deep venous thrombosis.\n\n TECHNIQUE: Grayscale and Doppler ultrasound images of the right lower\n extremity veins were submitted for interpretation.\n\n FINDINGS: Right common femoral, superficial femoral, and popliteal veins\n demonstrate normal compressibility, flow, and augmentation. The right\n posterior tibial veins are patent. The right peroneal veins are not\n visualized. The left common femoral vein demonstrates symmetric waveforms and\n augmentation.\n\n IMPRESSION: No evidence of deep venous thrombosis, however, the right peroneal\n veins were not visualized.\n\n" }, { "category": "Radiology", "chartdate": "2193-12-30 00:00:00.000", "description": "MRA BRAIN W/O CONTRAST", "row_id": 1115983, "text": " 10:18 AM\n MR HEAD W/O CONTRAST; MRA BRAIN W/O CONTRAST Clip # \n Reason: Thromboembolic stroke.\n Admitting Diagnosis: SEIZURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with history of atrial fib, previous stroke, now presents with\n motor seizure and reduced level of consciousness, in context of thomboemboli to\n lower extremities.\n REASON FOR THIS EXAMINATION:\n Thromboembolic stroke.\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: MBue MON 1:41 PM\n findings consitent with acute infarct involving the entire right MCA\n territory with small amount of hemorrhage in the rt temporal lobe, mass effect\n on rt lateral ventricle and 4mm rt to left midline shift. near complete\n occlusion of the rt ICA with trace signal noted in the cavernous portion of\n the right ICA.\n\n Old left MCA infart with hemorrhagic blood products noted in the left temporal\n region and left cerebellum. Trace flow noted in the left supraclinoid ICA and\n left MCA likely secondary to filling via collaterals.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 73-year-old male with history of atrial fibrillation, previous left-\n sided MCA stroke, now with motor seizure and reduce level of consciousness.\n Question thromboembolic stroke.\n\n COMPARISON: CT head dated .\n\n TECHNIQUE: Multiplanar T1- and T2-weighted images were obtained through the\n brain. MR angiography of the circle of was also obtained utilizing\n time-of-flight technique.\n\n FINDINGS: There is extensive area of restricted diffusion involving the\n entire right MCA territory which is consistent with an acute right MCA\n infarct. There is a linear focus of low signal noted on the gradient echo\n images (13:15), which is located in the right temporal region and may\n represent a small amount of associated hemorrhage. There is minimal right to\n left midline shift of approximately 4 mm. Also noted is mass effect on the\n right lateral ventricle.\n\n Within the left MCA territory involving the left frontotemporal and parietal\n regions is low signal on T1-weighted and FLAIR images consistent with\n encephalomalacia in this region of prior infarct. Also noted is an area of\n encephalomalacia within the left occipital region. Linear serpiginous foci of\n low signal intensity is noted on gradient echo images, likely corresponding to\n areas of laminar necrosis within the left MCA territory. Also noted is a more\n focal area of low signal intensity on gradient echo images measuring 1.3 x 2.4\n cm in the left temporal region and an additional area within the left\n cerebellar hemisphere measuring 1.4 x 1.2 cm, likely representing regions of\n hemorrhage associated with this infarcted brain parenchyma. The left cerebral\n (Over)\n\n 10:18 AM\n MR HEAD W/O CONTRAST; MRA BRAIN W/O CONTRAST Clip # \n Reason: Thromboembolic stroke.\n Admitting Diagnosis: SEIZURE\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n peduncle has atrophied consistent with wallerian degeneration secondary to the\n known left-sided MCA infarct. There is ex-vacuo dilatation of the left\n lateral ventricle. The basilar cisterns are patent.\n\n MR ANGIOGRAPHY OF THE CIRCLE OF : High signal is noted within the\n distal cervical internal carotid artery on the right, which tapers more\n distally, suggestive of occlusion. Minimal signal is noted within the\n cavernous portion of the right internal carotid artery and minimal-to-no\n signal is noted in the right A1 segment of the anterior cerebral artery. The\n A2 segment on the right is patent secondary to left-sided collateral\n circulation and retrograde filling.\n\n No flow is noted proximally within the left ICA with collateral filling and\n retrograde flow, likely secondary to the left ophthalmic artery, supplying the\n supraclinoid left internal carotid artery. The left MCA demonstrates some\n flow but is severely attenuated. The left A1 and A2 segments of the anterior\n cerebral artery are patent. The posterior cerebral arteries, basilar, and\n vertebral arteries are patent with mild narrowing of the left posterior\n cerebral artery without focal stenosis. No aneurysms are identified.\n\n IMPRESSION:\n 1. 4 mm of right to left midline shift and mass effect on the right lateral\n ventricle.\n 2. Acute infarct involving the entire right MCA territory with near complete\n occlusion of the right internal carotid and complete occlusion of the right\n MCA. Small amount of hemorrhage noted in the right temporal region.\n 3. Encephalomalacia within the left MCA territory consistent with known prior\n infarct. Small amount of associated hemorrhagic products located within the\n left temporal and left cerebellar hemisphere.\n 4. Mild narrowing of the left posterior cerebral artery without focal\n stenosis, thrombosis or aneurysm formation.\n\n These findings were communicated to Dr. on at 1:30 p.m.\n\n" }, { "category": "Radiology", "chartdate": "2193-12-28 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1115737, "text": " 11:09 AM\n CHEST (PORTABLE AP) Clip # \n Reason: infiltrate\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with s/p sz\n REASON FOR THIS EXAMINATION:\n infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 73-year-old man status post seizure.\n\n COMPARISON: .\n\n SINGLE AP UPRIGHT VIEW OF THE CHEST AT 11:15 A.M.: Lung volumes are low, but\n there is no consolidation or pleural effusion. The right hemidiaphragm\n remains slightly elevated, but this is unchanged. There is no pneumothorax.\n The aorta remains tortuous. The heart size is normal. There is no hilar or\n mediastinal enlargement. Pulmonary vascularity is normal. Minimal prominence\n of interstitial markings in the right lung is similar to prior studies.\n\n IMPRESSION: No acute cardiopulmonary abnormality.\n DFDdp\n\n" }, { "category": "Radiology", "chartdate": "2193-12-28 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1115761, "text": " 2:59 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: eval tube position\n Admitting Diagnosis: SEIZURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with s/p intubation\n REASON FOR THIS EXAMINATION:\n eval tube position\n ______________________________________________________________________________\n FINAL REPORT\n CHEST SINGLE VIEW ON .\n\n HISTORY: Intubation.\n\n FINDINGS: The ET tube tip is 4.6 cm above the carina. The NG tube tip is in\n the stomach. The lungs are clear without infiltrate or effusion. Again seen\n are multiple small pulmonary nodules very dense for their size, likely\n representing old granulomatous disease. The largest of these is in the right\n lower lung, measuring 6 mm. No focal infiltrate.\n\n\n" }, { "category": "Radiology", "chartdate": "2193-12-29 00:00:00.000", "description": "LP UNILAT LOWER EXT VEINS LEFT PORT", "row_id": 1115862, "text": " 12:37 PM\n UNILAT LOWER EXT VEINS LEFT PORT Clip # \n Reason: SOB EVAL FOR DVT\n Admitting Diagnosis: SEIZURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with AF and possible PE\n REASON FOR THIS EXAMINATION:\n DVT.\n ______________________________________________________________________________\n WET READ: SPfc 1:20 PM\n Non-visualization of the peroneal and posterior tibial calf veins and\n otherwise No deep venous thrombosis in the left lower extremity.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Question of deep venous thrombosis.\n\n COMPARISON: Images from the contralateral leg done one day prior.\n\n FINDINGS: Waveforms at the common femoral veins are symmetric bilaterally\n with appropriate response to Valsalva maneuvers. In the left lower extremity,\n the common femoral, proximal greater saphenous, superficial femoral, and\n popliteal veins are normal with appropriate compressibility, wall-to-wall flow\n on color analysis and response to waveform, augmentation. The posterior\n tibial and peroneal veins in the calf were not visualized.\n\n IMPRESSION: No evidence of deep venous thrombosis in the left lower extremity\n to the level of the knee. Non-visualization of the posterior tibial and\n peroneal veins in the calf.\n\n" }, { "category": "Radiology", "chartdate": "2193-12-30 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1115931, "text": " 3:37 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Infection, evidence of thromboembolism.\n Admitting Diagnosis: SEIZURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with h/o AF stroke, p/w AMS.\n REASON FOR THIS EXAMINATION:\n Infection, evidence of thromboembolism.\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 4:27 A.M., \n\n HISTORY: Stroke, question infection or thromboembolism.\n\n IMPRESSION: AP chest compared to 6:38 a.m. on :\n\n Mild basal edema has changed in distribution but not in overall severity.\n There is no consolidation to suggest pneumonia. No pleural effusion or\n indication of central adenopathy. Heart size is normal. ET tube in standard\n placement, NG tube coiled in the stomach. No pneumothorax.\n\n\n" } ]

[ { "category": "Radiology", "chartdate": "2145-03-11 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 950895, "text": " 7:01 AM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: ? NGT placement\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old man with ESRD on HD transferred in shock s/p cath with PTCA to his\n mid circ, advanced his NGT\n REASON FOR THIS EXAMINATION:\n ? NGT placement\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAM: NG tube placement, patient with ESRD in shock, post cath.\n\n SINGLE AP PORTABLE VIEW OF THE CHEST:\n Comparison to prior study performed seven hours before, NG tube tip is in the\n stomach. Swan- Ganz catheter tip is in the right outflow tract. Otherwise no\n short- interval changes.\n\n" }, { "category": "Radiology", "chartdate": "2145-03-11 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 950872, "text": " 12:36 AM\n CHEST (PORTABLE AP) Clip # \n Reason: NGT placement, ETT placement, ? pulmonary infiltrates\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old man with ESRD on HD transferred in shock now s/p cath with PTCA to\n his mid circ\n REASON FOR THIS EXAMINATION:\n NGT placement, ETT placement, ? pulmonary infiltrates\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAM: Assess tubes and lines. Patient with ESRD, transferred in\n shock. Assess for pulmonary abnormalities.\n\n SINGLE AP PORTABLE VIEW OF THE CHEST.\n\n There is mild cardiomegaly. Left transvenous pacemaker leads are in standard\n positions in the right atrium and right ventricle. ET tube tip projects 4 cm\n above the carina. NG tube tip is near the EG junction. Right subclavian\n catheter tip is in the SVC. There is no pneumothorax. Illdefined opacity in\n the left lower lobe retrocardiac area is likely atelectasis, otherwise the\n lungs are clear. There is no sizable pleural effusion.\n\n\n" }, { "category": "Radiology", "chartdate": "2145-03-12 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 951087, "text": " 7:20 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Assess for interval change.\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old man with ESRD on HD transferred in shock s/p cath with PTCA to his\n mid circ.\n REASON FOR THIS EXAMINATION:\n Assess for interval change.\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 8:44 A.M., \n\n HISTORY: End-stage renal disease on hemodialysis. In shock.\n\n IMPRESSION: AP chest compared to :\n\n Lung volumes are low. Left lower lobe consolidation unchanged since \n could be pneumonia or atelectasis. Small accompanying left pleural effusion\n is clinically insignificant. Heart size is top normal. Right lung is grossly\n clear. Nasogastric tube ends in the distal stomach. No endotracheal tube is\n present. Left-sided transsubclavian right ventricular defibrillator and right\n atrial pacer leads are unchanged in standard positions. The tip of an\n ascending Swan-Ganz catheter projects over the proximal right pulmonary\n artery. Tip of a right subclavian dual channel dialysis catheter projects\n over the SVC. No pneumothorax.\n\n" }, { "category": "Radiology", "chartdate": "2145-03-12 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 951178, "text": " 3:31 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: ETT tube placement\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old man with ESRD on HD s/p intubation\n REASON FOR THIS EXAMINATION:\n ETT tube placement\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: End-stage renal disease on hemodialysis, status post\n intubation, check position.\n\n FINDINGS: The endotracheal tube is at the carina angle.\n\n The position of the various other lines and tubes is unchanged since the prior\n chest x-ray of 7 hours earlier. The lung fields remain clear. The heart is\n somewhat enlarged.\n\n IMPRESSION: Endotracheal tube at level of carina. Dr. informed.\n\n\n" }, { "category": "Radiology", "chartdate": "2145-03-11 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 951015, "text": " 4:55 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: Rule out infarct.\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old man with history of seizure, shock, proximal weakness, question\n watershed infarct.\n REASON FOR THIS EXAMINATION:\n Rule out infarct.\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 81-year-old male with history of seizure, shock and proximal\n weakness. Evaluate for infarct.\n\n COMPARISONS: None.\n\n TECHNIQUE: Non-contrast head CT.\n\n FINDINGS: Assessment for subarachnoid hemorrhage is limited secondary to\n contrast from outside imaging study. Allowing for this factor, there is no\n evidence of hemorrhage, shift of normally midline structures, mass effect or\n hydrocephalus. Periventricular white matter hypodensity is consistent with\n chronic microvascular ischemia. An old lacune infarct is present in the right\n putamen. Prominence of the ventricles and sulci is consistent with age-\n appropriate atrophy. The basal cisterns are not effaced. There is mild\n mucosal thickening within the sphenoid and maxillary sinuses. The visualized\n mastoid air cells are well aerated.\n\n IMPRESSION:\n 1. Assessment for subtle subarachnoid hemorrhage limited due to contrast from\n outside imaging study. No evidence of hemorrhage, infarct or mass effect.\n 2. Mucosal thickening in the sphenoid and maxillary sinuses, likely\n inflammatory in etiology.\n\n Findings were discussed with Dr. at 1:30 p.m. on .\n\n" }, { "category": "Echo", "chartdate": "2145-03-12 00:00:00.000", "description": "Report", "row_id": 75601, "text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. Right ventricular function. Pulsus. ?evidence of tamponade\nHeight: (in) 68\nWeight (lb): 185\nBSA (m2): 1.98 m2\nBP (mm Hg): 73/34\nHR (bpm): 110\nStatus: Inpatient\nDate/Time: at 13:00\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT ATRIUM: Mild LA enlargement.\n\nLEFT VENTRICLE: Severely depressed LVEF.\n\nRIGHT VENTRICLE: Dilated RV cavity. RV function depressed.\n\nAORTA: Mildly dilated aortic sinus.\n\nAORTIC VALVE: Moderately thickened aortic valve leaflets.\n\nTRICUSPID VALVE: Severe [4+] TR. Indeterminate PA systolic pressure.\n\nPERICARDIUM: No pericardial effusion.\n\nConclusions:\nThe left atrium is mildly dilated. Overall left ventricular systolic function\nis severely depressed. The right ventricular cavity is dilated. Right\nventricular systolic function appears depressed. The aortic root is mildly\ndilated at the sinus level. The aortic valve leaflets are moderately\nthickened. Severe [4+] tricuspid regurgitation is seen. The pulmonary artery\nsystolic pressure could not be determined. There is no pericardial effusion.\n\nCompared with the prior study (images reviewed) of , biventriuclar\nsystolic funciton is worse. The degree of tricuspid regurgitation has\nincreased.\n\n\n" }, { "category": "ECG", "chartdate": "2145-03-12 00:00:00.000", "description": "Report", "row_id": 196978, "text": "Ventricular paced rhythm\nSince previous tracing of the same date, narrower QRS interval noted\n\n" }, { "category": "ECG", "chartdate": "2145-03-12 00:00:00.000", "description": "Report", "row_id": 196979, "text": "The rhythm may be atrial sensed and ventricular paced. There is now a widened\nQRS interval. There may be metabolic abnormality. Followup and clinical\ncorrelation are suggested.\n\n" }, { "category": "ECG", "chartdate": "2145-03-11 00:00:00.000", "description": "Report", "row_id": 196980, "text": "Sinus rhythm. A-V conduction delay. The P-R interval 0.22. Left atrial\nabnormality. Occasional atrial ectopy. Right bundle-branch block. Left anterior\nfascicular block. Compared to the previous tracing of the anterolateral\nST-T wave abnormalities have improved and atrial ectopy has appeaed.\nOtherwise, no diagnostic interim change.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2145-03-10 00:00:00.000", "description": "Report", "row_id": 196981, "text": "Sinus rhythm. A-V conduction delay. P_R interval 0.22. Left atrial abnormality.\nRight bundle-branch block. Left anterior fascicular block. Compared to the\nprevious tracing of the ST-T wave abnormalities recorded in the\nprecordial leads are superimposed on the changes of right bundle-branch block\nand suggest anterolateral ischemia as compared to the previous tracing\nof . Followup and clinical correlation are suggested.\nTRACING #1\n\n" }, { "category": "Nursing/other", "chartdate": "2145-03-12 00:00:00.000", "description": "Report", "row_id": 1464055, "text": "resp care\npt intubated s/p arrest. presently on ac mode, status changed to CMO. does not appear uncomfortable at present time on rate 10, fio2 40%,+spont efforts. refer to flow sheet for further data.\n" }, { "category": "Nursing/other", "chartdate": "2145-03-12 00:00:00.000", "description": "Report", "row_id": 1464056, "text": "CCU NPN: please see flowsheet for objective data\n\nCardiac: HR 30-120Vpaced. BP 60-110/ PA 29-42/13-25 wedge 18-32 around 11am eyes rolled back,unresponsive,woke up then happened again and this time HR dropped to 30's not pacing,given ).5 mg atropine x4.HR did respond rate increased to 100's then would drop again.agonal respirations,BP dropped levo at .25. EP called,changed voltage to max no AV conduction,now totally pacer dependent. Aline placed to better monitor BP and ABG's.neurologically remained just responsive to stimuli with groans. levo needs increasing to 0.45. echo done STAT left atrium dilated,RV dilated TR 4+,biventricular failure worse. 2:30 became asystolic,code called.CPR,intubated. recieved mult doses epi,wide open fluids,bicarb x2 cacl x1,K 6.9 received 10 units reg insulin and amp D50. epi wide open at one time,also was receivng blood at that time. HR recovered to 100's vapced,epi at 0.01 levo off. family called. Dr ,Dr and Dr talked with family and now comfort measures only. off epi,HR maintaining at 100-110,bp 60-70's/ vented 40% rate 10 TV 550.\n\nSocial: wife and two sons and daughter-in-laws in by bedside,priest came to give sacrements of the sick.\n\nSkin: both heels purple,wearing waffle boots,no breakdown on back\n\nNeuro: on no sedation,moves arms occasionally,not responsive.\n\nA/P: comfort measures,emotional support family.\n" }, { "category": "Nursing/other", "chartdate": "2145-03-12 00:00:00.000", "description": "Report", "row_id": 1464057, "text": "ccu npn\n\nFamily @ bedside. pt cmo status/appears comfortable. 2045 noted pt hr down to 60 idiovent rhythm w sbp drop to 50/ 2100 noted pea/asystole no bp noted. md . family and md pt. support given to family by nursing and medical staff. all personal belongings home w family. pt prepared for transport to morgue.\n" }, { "category": "Nursing/other", "chartdate": "2145-03-12 00:00:00.000", "description": "Report", "row_id": 1464053, "text": "CCU Nursing note\nLevo initally increased to obtain SBP>110, However thereafter increases required just to keep MAP >60. Increased from .05 to 2.5 over coarse of am. Hr now up to 120 c increase in Levo. Intern and resident aware. Currently giving 500cc Fluid bolus. Checking random vanc level. If less than parameters set forth in order dose vanc. continues to be afebrile. WBC 15.2\n" }, { "category": "Nursing/other", "chartdate": "2145-03-12 00:00:00.000", "description": "Report", "row_id": 1464054, "text": "CCU Nursing note\nS-\"My throat just hurts.\"\nO-see flowsheet for additional details.\n\nN-a/ox3, complaints of pain in throat and back relieved by IV morphine as ordered. Throat spray prn (in room) for throat discomfort s/p extubation. MAE. Neuro consulted c note in chart. Suspected hypoxic and metabolic encephalopathy to account for mental status changes. Reccomended to Keep SBP>110 to prevent further ischemic injury and obtain EEG.\n\nCV-NSR 90s, SBP 92-108 while weaning Levo, however came upon Neuro recs in chart and increased Levo to obtain SBP>110 until further notice. CVP 12-15, PADs 17-24, CO 6.3-6.7, CI 3.1-3.3, SVR 561-660. PA line left groin-dsg intact. Pulses dopplerable, Extremities cool to touch. CKs trending down. PICC to be placed today. Hct stable.\n\nResp-LSCTA. O2 via NC. Productive, strong, cough, blood tinged sputum.\n\nGI-Tolerating clear liquids. Positive BS. NGT-guic positive aspirate.\n\nGU-oliguric. HD dependent. HD today? Fistula right brachial repaired 1 week ago-f/u c renal if ready to use or not. If not pt has right subclavian catheter.\n\nEndo-SSI.\n\nID-afebrile. Dosed Zoysn as ordered.\n\nSkin-waffle boots for reddened heels. Other pressure areas intact.\nRight femoral wnl s/p TLC removal.\n\nsocial/dispo-married c children. No calls from family this shift. Full code. Son HCP.\n\na/p-81y.o M c on HD, CAD s/p CABG, HTN, IDDM, presented with hypotension now s/p PTCA to circ. Continue c as outlined in multidisplanary rounds. f/u am labs. PICC placement/HD today? Patient updated on by RN.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2145-03-11 00:00:00.000", "description": "Report", "row_id": 1464049, "text": "Resp Care\nPt received on intubated on vent; with #8 ett @ 22 lip, patent and secure. (see carevue for settings). Suctioned for mod amt of blood-tinged secretions. Weaned fio2 based abgs. rsbi 40. Currently on sbt. Awaiting abg. Plan to wean to extubate. Will continue to monitor.\n" }, { "category": "Nursing/other", "chartdate": "2145-03-11 00:00:00.000", "description": "Report", "row_id": 1464050, "text": "CCU Nursing note\nS-intubated, sedated.\no-see flowsheet and admission note for additional details.\n\n pt on Propofol-switched to Fent and versed currently @ 12.5mcg/hr and 1.5mg/hr respectively. Opening eyes spontaneously, MAE, following commands inconsistently. Right pupil irregular in shape 2-3mm/reactive, left pupil 3mm/reactive. Impaired gag and cough.\n\nCV-See cath report for details. Unsuccessful agioplasty to 100% LCx requiring rotoblater c desired results. Arrived to CCU c PA line, arterial and venous sheath in left groin. TLC right groin from OSH. 1 20g PIV right AC. S/P repaired AV fistula (1 wk ago) right brachial. cath right subclavian. All line dsgs intact. Levo now @ 0.156mcg/kg, tele 80s NSR, ABP 80s-140s, CVP 15-16, PADs 23-24, CO 6.2, CI 3, SVR 800. S/p prbc x1 c f/u Hct 36. Trop @ OSH 13, now 6.44, CK . PTT elevated upon admit and bleeding from mouth/nose-Heprin products d/c'd. Bilateral pedal pulses dopplerable, all extremities cool.\n\n pt on AC/ 100%. FiO2 weaned overnight. Currently on SBT. Please see carevue for ABG and changes in vent settings. LSCTA. ETT retaped.\n\nGI-Will advance OGT per CXRAY results. hypoactive BS. gastrocult +. NPO. Last BM unknown.\n\nGU-anuric MD. dependent. Last done . +1650 LOS. Last K 5.5. Next HD due today per prior schedule-renal will be consulted.\n\nID-blood cultures drawn and sent. Afebrile. Vanc and zosyn dosed x1.\n\nSkin-pressure areas intact. Bilateral wrist restraints for integrity.\nendo-SSI.\nSocial/dispo-per chart married c two adult sons. contact with family this shift. Full code\n\nA/P-81y.o Male c extensive cardiac hx, RF, CVA, s/p PCTA to LCX c hypotension requiring pressor. Considering septic shock as PA #'s do not look cardiogenic. ?possible HD catheter infx? Cultures pending. COvered c broad spectrum abxs for now. Troponin bump Likely demand ischemia in setting of afib @ OSH c RVR and hypotension. Trend Cardiac enzymes. Echo 15%. Coffee ground emesis @ OSH-? possible tear or bleeding ulcer. IV PPI-transfuse for Hct <30. Right Fem TLC from OSH will need to be replaced.\n" }, { "category": "Nursing/other", "chartdate": "2145-03-11 00:00:00.000", "description": "Report", "row_id": 1464051, "text": "Resp Care\n\nPt extubated this morning to 50% cool aerosol tol well with spo2 99-100% RR 18-20. Cuff leak present prior to extubation with good cough noted. Pt expectorating small to mod amts of bloody secretions. Will cont to monitor for s/s fatigue.\n" }, { "category": "Nursing/other", "chartdate": "2145-03-11 00:00:00.000", "description": "Report", "row_id": 1464052, "text": "CCU NPN:please see flowsheet for objective data\n\nS:\"I am really sick\"\nCardiac: HR 90's NSR BP 73-110/42-53 titrating levophed 0.035 to 0.070 mcg/kg/min feet and hands remain cool to cold,dopplerable pulses\n\nResp: extubated this am. initially having large amounts of thick bloody secretions from back of throat,able to cough it into his mouth and then suctioning. large clots also. now thick clear blood tinged much less. lungs clear,coarse at bases. sats 96-100.\n\nID: afebrile,on zosyn\n\nEndocrine: FS 96-142 no insulin required\n\nSkin: both heels red the left more than right,waflle boots applied.has two incision sites from thrombectomy on left side,both have steri strips in place,upper one covered with 4X4 and tegaderm. triple lumen from OH d/ced and PIV(bleeding) femoral aline also d/ced.turning q2-3\n\nHeme: HCT at 1800 32.1 (35.4) NGT aspirates trace positive\n\nGU: to have tomorrow. ? patency of fistula, MD from OH said the fistula could be used now.\n\nGI: hypoactive BS,tolerating ice chips,have requested sugar free popsicles.\n\nNeuro: as day progressed became more alert. oriented x2 and sometimes confused,knows he is in hospital and knows Dr . had CT scan this evening as neuro concerned may have had embolic stroke due to hypotension. moves all extremities thought weakly. son reports that father is very weak and needs person assist getting OOB etc. walks with walker and someone behind him to help.\n\nPain: has c/o throat pain several times,treated with morphine 1mg x2 with good effect,\n\nA:81 yo ext cardiac and med hx s/p unsuccessful PTCA of LCX had rotoblater minimal success,now extubated\n\nP: cont to follow BP and titrate levo\n follow FS and cover SSI\n cont to assist in clearing of secretions\n abx as ordered\n emotional support\n assess throat pain and treat\n\n\n\n" } ]

[ { "category": "Physician ", "chartdate": "2131-06-25 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 682912, "text": "Chief Complaint: pancreatitis, resp failure\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n FEVER - 101.5\nF - 04:00 PM\n Tachypnea and put back on AC vent\n before spiking fevers\n Allergies:\n Meropenem\n skin blisters a\n Last dose of Antibiotics:\n Metronidazole - 12:00 AM\n Linezolid - 11:51 AM\n Micafungin - 10:04 PM\n Aztreonam - 01:48 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 12:21 PM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: Fever\n Flowsheet Data as of 11:02 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.6\nC (101.5\n Tcurrent: 37.9\nC (100.2\n HR: 113 (108 - 117) bpm\n BP: 109/59(74) {79/43(31) - 136/75(90)} mmHg\n RR: 25 (23 - 40) insp/min\n SpO2: 100%\n Heart rhythm: SB (Sinus Bradycardia)\n Wgt (current): 104 kg (admission): 113.5 kg\n Height: 67 Inch\n Total In:\n 2,202 mL\n 1,169 mL\n PO:\n TF:\n 1,204 mL\n 550 mL\n IVF:\n 998 mL\n 559 mL\n Blood products:\n Total out:\n 256 mL\n 135 mL\n Urine:\n 256 mL\n 135 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,946 mL\n 1,034 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 18\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 40%\n PIP: 24 cmH2O\n Plateau: 21 cmH2O\n SpO2: 100%\n ABG: 7.42/27/67/22/-4\n Ve: 13.8 L/min\n PaO2 / FiO2: 168\n Physical Examination\n Labs / Radiology\n 6.7 g/dL\n 230 K/uL\n 121 mg/dL\n 2.7 mg/dL\n 22 mEq/L\n 3.7 mEq/L\n 61 mg/dL\n 102 mEq/L\n 137 mEq/L\n 22.2 %\n 18.9 K/uL\n [image002.jpg]\n 05:57 PM\n 09:02 PM\n 01:42 AM\n 01:50 AM\n 03:18 AM\n 03:44 PM\n 01:38 AM\n 06:00 AM\n 01:12 AM\n 06:06 AM\n WBC\n 34.0\n 35.7\n 30.9\n 27.6\n 18.9\n Hct\n 21.6\n 23.1\n 22.2\n 24.0\n 22.2\n Plt\n 291\n 305\n 264\n 268\n 230\n Cr\n 1.2\n 1.8\n 2.8\n 1.6\n 2.7\n TCO2\n 27\n 22\n 26\n 18\n Glucose\n 126\n 136\n 170\n 95\n 170\n 121\n Other labs: PT / PTT / INR:15.3/34.3/1.3, CK / CKMB /\n Troponin-T:214/3/0.07, ALT / AST:81/79, Alk Phos / T Bili:422/8.5,\n Amylase / Lipase:77/88, Differential-Neuts:86.0 %, Band:2.0 %,\n Lymph:3.0 %, Mono:4.0 %, Eos:2.0 %, D-dimer:6389 ng/mL, Fibrinogen:541\n mg/dL, Lactic Acid:2.6 mmol/L, Albumin:2.3 g/dL, LDH:529 IU/L, Ca++:8.4\n mg/dL, Mg++:2.0 mg/dL, PO4:2.3 mg/dL\n Assessment and Plan\n FEVER, UNKNOWN ORIGIN (FUO, HYPERTHERMIA, PYREXIA)\n AROUSAL, ATTENTION, AND COGNITION, IMPAIRED\n BALANCE, IMPAIRED\n MOTOR FUNCTION, IMPAIRED\n MUSCLE PERFORMACE, IMPAIRED\n RESPIRATION / GAS EXCHANGE, IMPAIRED\n SEIZURE, WITHOUT STATUS EPILEPTICU\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n IMPAIRED SKIN INTEGRITY\n HEPATITIS, ACUTE TOXIC (INCLUDING ALCOHOLIC, ACETAMINOPHEN, ETC.)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n 1. Cyclical feversduring which he requires vasopressor support:\n DDx SIRS, line infections, panc necrrosis with infection, PNA, drug\n fever, serotonin syndrome. At this point he has been\n pan cultured\n nothing new. conjunction with ID consultants we have been weaning\n off ABX since nothing has grown\n will continue aztreonam / micafungin\n for while monitoring culture data. Possible repeat imaging in a week of\n pancreas but we are loathe to initiate empiric panc drainage if there\n is another possible source as this can can lead to long term\n complications. However, if fevers persist and no other source can be\n found we may be forced.\n 2. Resp Failure: Agree with plan to manage respiratory failure\n with ongoing TM trials and sedation wean - will get OOB to chair today,\n and wean methadone\n 3. Given possibility of sz activity, will continue keppra and\n valium at current doses.\n 4. For ARF, HD yesterday\n 5. For pancreatitis, will continue post-pyloric TFs, and will\n continue to hold off on any drainage of new peripancreatic fluid\n collection.\n ICU Care\n Nutrition:\n Nutren 2.0 () - 01:41 PM 50 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 08:15 PM\n PICC Line - 08:37 AM\n Dialysis Catheter - 08:55 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 40 minutes\n Patient is critically ill\n" }, { "category": "Physician ", "chartdate": "2131-06-03 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 678571, "text": "Chief Complaint: respiratory failure, shock\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI: seen by heme\n this morning\n tachypnea, tachycardia, hypotensionm hypoxemia\n 24 Hour Events:\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Daptomycin - 09:30 PM\n Metronidazole - 04:00 AM\n Infusions:\n Norepinephrine - 0.04 mcg/Kg/min\n Midazolam (Versed) - 12 mg/hour\n Other ICU medications:\n Pantoprazole (Protonix) - 08:00 PM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:58 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: 35.9\nC (96.7\n HR: 101 (100 - 117) bpm\n BP: 92/52(67) {87/46(60) - 113/65(92)} mmHg\n RR: 30 (24 - 38) insp/min\n SpO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 128 kg (admission): 113.5 kg\n Height: 67 Inch\n CVP: 10 (5 - 17)mmHg\n Total In:\n 9,439 mL\n 2,782 mL\n PO:\n TF:\n IVF:\n 7,678 mL\n 2,199 mL\n Blood products:\n Total out:\n 12,968 mL\n 4,060 mL\n Urine:\n 145 mL\n 183 mL\n NG:\n 350 mL\n 250 mL\n Stool:\n Drains:\n Balance:\n -3,529 mL\n -1,276 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n Vt (Spontaneous): 535 (535 - 535) mL\n RR (Set): 30\n RR (Spontaneous): 0\n PEEP: 12 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10\n PIP: 22 cmH2O\n Plateau: 24 cmH2O\n SpO2: 100%\n ABG: 7.39/42/85./26/0\n Ve: 11.3 L/min\n PaO2 / FiO2: 170\n Physical Examination\n intubated, sedated, unresponsive\n Labs / Radiology\n 8.2 g/dL\n 77 K/uL\n 139 mg/dL\n 1.8 mg/dL\n 26 mEq/L\n 4.9 mEq/L\n 25 mg/dL\n 104 mEq/L\n 138 mEq/L\n 24.4 %\n 37.2 K/uL\n [image002.jpg]\n 07:19 PM\n 10:09 PM\n 03:05 AM\n 03:53 AM\n 10:55 AM\n 01:58 PM\n 04:00 PM\n 10:34 PM\n 02:38 AM\n 04:01 AM\n WBC\n 28.9\n 37.2\n Hct\n 24.5\n 24.6\n 24.4\n Plt\n 54\n 64\n 77\n Cr\n 1.6\n 1.8\n TCO2\n 26\n 27\n 26\n 25\n 28\n 27\n 26\n Glucose\n 159\n 177\n 160\n 119\n 130\n 123\n 139\n Other labs: PT / PTT / INR:15.8/39.1/1.4, ALT / AST:29/257, Alk Phos /\n T Bili:132/14.0, Amylase / Lipase:19/35, Differential-Neuts:37.0 %,\n Band:18.0 %, Lymph:7.0 %, Mono:2.0 %, Eos:15.0 %, D-dimer:6389 ng/mL,\n Fibrinogen:293 mg/dL, Lactic Acid:1.3 mmol/L, Albumin:1.6 g/dL, LDH:607\n IU/L, Ca++:9.4 mg/dL, Mg++:1.9 mg/dL, PO4:4.8 mg/dL\n Assessment and Plan\n shock - another relatively acute episode of hypotension accompanied\n by tachycardia, tachypnea, hypoxemia\n concerning for PE, repeat lower\n and upper ultrasounds\n if neg do CT-A\n Eosinophilia, leukocytosis\n stop flagyl today, follow\n HEPATITIS, ACUTE TOXIC (INCLUDING ALCOHOLIC, ACETAMINOPHEN, ETC.)\n continue supportive care\n RESPIRATORY FAILURE due to ARDS\n on maximal vent support currently,\n wean as tolerated\n PANCREATITIS, ACUTE\n enzymes normal now for nearly 2 weeks, start\n TF\n cerebral edema, seizure\n cont kepra\n ARF\n continue CVVH, hold off on volume removal until BP stabilizes\n ICU Care\n Nutrition:\n TPN w/ Lipids - 02:30 PM 73. mL/hour\n Glycemic Control:\n Lines:\n Multi Lumen - 02:02 PM\n Dialysis Catheter - 04:56 PM\n Arterial Line - 01:30 PM\n Prophylaxis:\n DVT: boots\n Stress ulcer: ppi\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition : icu\n Total time spent: 40\n" }, { "category": "Physician ", "chartdate": "2131-06-02 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 678367, "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 ULTRASOUND - At 09:00 PM\n bil lower extremities r/o dvt\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Daptomycin - 09:30 PM\n Metronidazole - 04:00 AM\n Infusions:\n Norepinephrine - 0.03 mcg/Kg/min\n Calcium Gluconate (CRRT) - 1.2 grams/hour\n KCl (CRRT) - 1 mEq./hour\n Midazolam (Versed) - 17 mg/hour\n Other ICU medications:\n Pantoprazole (Protonix) - 08:00 PM\n Diazepam (Valium) - 11:56 PM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:18 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.7\nC (99.8\n Tcurrent: 36.8\nC (98.3\n HR: 104 (97 - 124) bpm\n BP: 100/53(69) {94/48(64) - 132/75(95)} mmHg\n RR: 38 (35 - 50) insp/min\n SpO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 128 kg (admission): 113.5 kg\n Height: 67 Inch\n CVP: 13 (5 - 13)mmHg\n Total In:\n 8,974 mL\n 3,038 mL\n PO:\n TF:\n IVF:\n 6,847 mL\n 2,433 mL\n Blood products:\n 375 mL\n Total out:\n 9,202 mL\n 4,447 mL\n Urine:\n 162 mL\n 75 mL\n NG:\n 100 mL\n 50 mL\n Stool:\n Drains:\n Balance:\n -228 mL\n -1,409 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 30\n RR (Spontaneous): 0\n PEEP: 12 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10, RR >35\n PIP: 29 cmH2O\n SpO2: 100%\n ABG: 7.45/36/80./23/1\n Ve: 15.2 L/min\n PaO2 / FiO2: 160\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 8.2 g/dL\n 54 K/uL\n 160 mg/dL\n 1.6 mg/dL\n 23 mEq/L\n 4.6 mEq/L\n 26 mg/dL\n 102 mEq/L\n 136 mEq/L\n 24.5 %\n 28.9 K/uL\n [image002.jpg]\n 09:27 AM\n 02:33 PM\n 03:16 PM\n 03:36 PM\n 05:18 PM\n 07:13 PM\n 07:19 PM\n 10:09 PM\n 03:05 AM\n 03:53 AM\n WBC\n 28.9\n Hct\n 22.6\n 26.5\n 24.5\n Plt\n 63\n 54\n Cr\n 1.6\n TCO2\n 28\n 26\n 30\n 25\n 26\n 27\n 26\n Glucose\n 159\n 177\n 160\n Other labs: PT / PTT / INR:15.8/40.5/1.4, ALT / AST:29/257, Alk Phos /\n T Bili:132/14.0, Amylase / Lipase:19/35, Differential-Neuts:37.0 %,\n Band:18.0 %, Lymph:7.0 %, Mono:2.0 %, Eos:15.0 %, D-dimer:6389 ng/mL,\n Fibrinogen:293 mg/dL, Lactic Acid:1.5 mmol/L, Albumin:1.6 g/dL, LDH:607\n IU/L, Ca++:9.1 mg/dL, Mg++:2.0 mg/dL, PO4:4.3 mg/dL\n Assessment and Plan\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n IMPAIRED HEALTH MAINTENANCE\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n IMPAIRED SKIN INTEGRITY\n HYPOTENSION (NOT SHOCK)\n HEPATITIS, ACUTE TOXIC (INCLUDING ALCOHOLIC, ACETAMINOPHEN, ETC.)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n PANCREATITIS, ACUTE\n ICU Care\n Nutrition:\n TPN w/ Lipids - 03:22 PM 73 mL/hour\n Glycemic Control:\n Lines:\n Multi Lumen - 02:02 PM\n Dialysis Catheter - 04:56 PM\n Arterial Line - 01:30 PM\n 20 Gauge - 11:15 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": "2131-05-28 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 677369, "text": "TITLE:\n Chief Complaint: cerebral edema, pancreatitis\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 -hypertonic saline changed to q3hrs\n -neo weaned off\n -progress weaning levo\n -cont to wean versed drip\n History obtained from Medical records\n Patient unable to provide history: Sedated, Unresponsive\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Metronidazole - 02:00 AM\n Meropenem - 03:00 AM\n Vancomycin - 08:08 AM\n Infusions:\n Norepinephrine - 0.05 mcg/Kg/min\n Fentanyl (Concentrate) - 100 mcg/hour\n Calcium Gluconate (CRRT) - 2 grams/hour\n Midazolam (Versed) - 16 mg/hour\n KCl (CRRT) - 2 mEq./hour\n Other ICU medications:\n Pantoprazole (Protonix) - 08:08 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 08:51 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37\nC (98.6\n Tcurrent: 36.6\nC (97.9\n HR: 103 (93 - 111) bpm\n BP: 103/57(70) {79/42(55) - 104/59(74)} mmHg\n RR: 30 (29 - 32) insp/min\n SpO2: 97%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 132 kg (admission): 113.5 kg\n Height: 67 Inch\n CVP: 22 (10 - 22)mmHg\n Total In:\n 10,221 mL\n 3,539 mL\n PO:\n TF:\n IVF:\n 9,667 mL\n 3,539 mL\n Blood products:\n Total out:\n 17,969 mL\n 5,727 mL\n Urine:\n 156 mL\n 25 mL\n NG:\n 150 mL\n 100 mL\n Stool:\n Drains:\n Balance:\n -7,748 mL\n -2,188 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 30\n RR (Spontaneous): 0\n PEEP: 12 cmH2O\n FiO2: 40%\n RSBI Deferred: PEEP > 10\n PIP: 29 cmH2O\n Plateau: 25 cmH2O\n Compliance: 33.3 cmH2O/mL\n SpO2: 97%\n ABG: 7.41/45/84./26/2\n Ve: 12.9 L/min\n PaO2 / FiO2: 210\n Physical Examination\n General Appearance: Well nourished, total body fluid overload\n Eyes / Conjunctiva: PERRL, pupils 2mm->1mm\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: (Expansion: Symmetric), (Breath Sounds:\n Rhonchorous: )\n Abdominal: Soft, Distended\n Extremities: Right: 4+, Left: 4+\n Skin: Warm\n Neurologic: No(t) Attentive, No(t) Follows simple commands, Responds\n to: Not assessed, No(t) Oriented (to): , Movement: Not assessed,\n Sedated, Tone: Not assessed\n Labs / Radiology\n 9.9 g/dL\n 59 K/uL\n 199 mg/dL\n 1.8 mg/dL\n 26 mEq/L\n 4.0 mEq/L\n 21 mg/dL\n 108 mEq/L\n 145 mEq/L\n 29.0 %\n 38.2 K/uL\n [image002.jpg]\n 04:23 PM\n 09:57 PM\n 10:11 PM\n 04:39 AM\n 04:49 AM\n 11:06 AM\n 05:22 PM\n 11:09 PM\n 04:10 AM\n 04:20 AM\n WBC\n 45.9\n 44.7\n 38.2\n Hct\n 29.2\n 30.4\n 29.0\n Plt\n 67\n 68\n 59\n Cr\n 2.6\n 2.4\n 2.2\n 1.8\n TCO2\n 25\n 28\n 28\n 28\n 30\n 30\n Glucose\n 174\n 188\n 176\n 187\n 175\n 188\n 166\n 199\n Other labs: PT / PTT / INR:19.5/53.6/1.8, ALT / AST:20/210, Alk Phos /\n T Bili:236/20.6, Amylase / Lipase:16/34, Differential-Neuts:71.0 %,\n Band:8.0 %, Lymph:6.0 %, Mono:4.0 %, Eos:2.0 %, D-dimer: ng/mL,\n Fibrinogen:402 mg/dL, Lactic Acid:1.7 mmol/L, Albumin:1.7 g/dL, LDH:742\n IU/L, Ca++:8.5 mg/dL, Mg++:1.8 mg/dL, PO4:2.6 mg/dL\n Assessment and Plan\n 28M h/o EtOH abuse, weakness, fatigue, UGIB c/b hematemesis / melena.\n Has developed massive fluid requirement, hypotension, ARDS in the\n setting of severe pancreatitis, alcoholic hepatitis and borderline\n renal function. Head CT with edema, on 23% NS for induced osmorx.\nCEREBRAL EDEMA\n - hypertonic (23%) saline q3h with frequent monitoring of Sosm and\n sodium for cerebral edema.\n -Managing in setting of CVVH - renal aware and managing with knowledge\n of hypertonic saline tx\n -Pupils now more appropriately constricted given narcotics on board --\n suggestive of improvement in IC pressure.\n -Repeat imaging would be optimal but not yet realistic given pt\n acuity and accompanying risks of transferring for imaging\n -On keppra prophylactically\n -EEG initial read s evidence of sz activity- final read pending.\nARDS\n - low volume ventilation (400x30)\n - will continue to wean PEEP as tolerated\n - starting sedation wean though long road given large volume of\n distribution.\nSHOCK\n -off of one pressor, progress weaning second\n -Continuing broad spectrum abx pend cx data for guidance.\n -remains afebrile\n\n -CVVHD\n -Progress removing fluid - visibably less edema over weekend\n -weaning PEEP, FiO2 as tol\n -follow espophageal pressures as needed.\nPANCREATITIS\n -presumed due to EtOH\n -c/b ARDS\n -NPO\n - following\n -continue TPN with heparin\n\nEtOH HEPATITIS\n\nUGIB\n -Dieulafois lesion at GEJ\n -monitor serial HCT\n\n IMPAIRED SKIN INTEGRITY\n -cont large amount of oozing form skin breakdown in lower extremities\n Remainder of plan as outlined in resident note.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Arterial Line - 01:35 PM\n Multi Lumen - 02:02 PM\n Dialysis Catheter - 04:56 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: 45 minutes\n Patient is critically ill\n" }, { "category": "Physician ", "chartdate": "2131-07-05 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 685172, "text": "Chief Complaint: pancreatitis, resp failure,\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n Long family meeting with Dr Neuro\n prognosis- confirms severe anxia but extent of recovery remains to be\n seen. He is LTAC candidate.\n Allergies:\n Meropenem\n skin blisters a\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 12:02 PM\n Famotidine (Pepcid) - 12:03 PM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 11:11 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.7\nC (99.9\n Tcurrent: 37.7\nC (99.9\n HR: 123 (110 - 125) bpm\n BP: 130/85(91) {99/58(77) - 144/100(106)} mmHg\n RR: 28 (28 - 46) insp/min\n SpO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 98.6 kg (admission): 113.5 kg\n Height: 67 Inch\n Total In:\n 2,401 mL\n 888 mL\n PO:\n TF:\n 1,200 mL\n 558 mL\n IVF:\n 151 mL\n Blood products:\n Total out:\n 2,670 mL\n 950 mL\n Urine:\n 2,670 mL\n 950 mL\n NG:\n Stool:\n Drains:\n Balance:\n -269 mL\n -62 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n SpO2: 100%\n ABG: ///17/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 6.9 g/dL\n 367 K/uL\n 115 mg/dL\n 0.8 mg/dL\n 17 mEq/L\n 4.2 mEq/L\n 38 mg/dL\n 116 mEq/L\n 142 mEq/L\n 22.4 %\n 10.3 K/uL\n [image002.jpg]\n 02:32 AM\n 04:25 AM\n 03:56 PM\n 02:32 AM\n 08:00 PM\n 12:35 AM\n 03:21 AM\n 04:44 PM\n 02:42 AM\n 04:46 AM\n WBC\n 10.9\n 11.0\n 10.5\n 11.1\n 11.6\n 10.3\n Hct\n 22.2\n 22.5\n 22.3\n 22.1\n 23.6\n 22.4\n Plt\n 290\n 310\n 327\n \n Cr\n 1.9\n 1.6\n 1.3\n 1.2\n 1.2\n 1.1\n 1.0\n 1.0\n 0.8\n TCO2\n 20\n Glucose\n 116\n 161\n 97\n 93\n 147\n 187\n 111\n 115\n Other labs: PT / PTT / INR:13.6/28.0/1.2, CK / CKMB /\n Troponin-T:214/3/0.07, ALT / AST:60/85, Alk Phos / T Bili:247/2.8,\n Amylase / Lipase:78/91, Differential-Neuts:57.0 %, Band:4.0 %,\n Lymph:23.0 %, Mono:4.0 %, Eos:3.0 %, D-dimer:6389 ng/mL, Fibrinogen:541\n mg/dL, Lactic Acid:2.6 mmol/L, Albumin:2.4 g/dL, LDH:437 IU/L, Ca++:9.2\n mg/dL, Mg++:1.8 mg/dL, PO4:4.2 mg/dL\n Assessment and Plan\n FEVER, UNKNOWN ORIGIN (FUO, HYPERTHERMIA, PYREXIA)\n AROUSAL, ATTENTION, AND COGNITION, IMPAIRED\n BALANCE, IMPAIRED\n MOTOR FUNCTION, IMPAIRED\n MUSCLE PERFORMACE, IMPAIRED\n RESPIRATION / GAS EXCHANGE, IMPAIRED\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n IMPAIRED SKIN INTEGRITY\n HEPATITIS, ACUTE TOXIC (INCLUDING ALCOHOLIC, ACETAMINOPHEN, ETC.)\n 1. Cyclical fevers: Temp to 101.9 again last PM but stable\n WBC and CXR, pan cx. stable off all ABX, CXR is improved and no focal\n sources. Overall stable WBC and this could be central. We will follow\n cx, follow up CMV viral load, LFTS, we can consider abd imaging but my\n sense is that in the absence of exam change IR or surgery would be\n loathe to intervent on pancreas unless systemically ill and thus\n imaging alone is not helpful at this point. Should fevers persist or he\n deteriorate we can re evaluate.\n 2. Resp Failure: yesterday with increased frothy pink sputum, ?\n volume overload. But CXR without infiltrate and echo WNL. He is\n positive everyday so may just be secrtions\n we will start lasix to\n keep closer to even and reduce obligate ins.\n 3. Altered Mental status: MRI with concerning anoxic features and\n prognosis from Dr was he could improve slightly but unlikely to\n recover dramatically. Family would like 2nd opinion and we will contact\n Dr who will see him today.\n 4. ARF: resolved, off HD, start po lasix to match I and O\n more closely\n 5. Transaminitis: follow LFTS and CMV viral load\n 6. CMV: need toclarify with ID what pregnant healthcare\n workers need to do as precautions\n Remaining issues as per Housestaff\n ICU Care\n Nutrition:\n Nutren 2.0 () - 12:21 PM 50 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 08:37 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent:\n" }, { "category": "Physician ", "chartdate": "2131-06-23 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 682485, "text": "Chief Complaint:\n 24 Hour Events:\n BRONCHOSCOPY - At 02:45 PM\n BLOOD CULTURED - At 09:40 PM\n FEVER - 102.0\nF - 08:00 PM\n \n - Febrile again to 102, requireing levophed.\n - ID recommended asking IR if tap of fluid collections is even\n possible. If not, would re-image in a few days to see if fluid\n collections are evolving.\n - CMV VL 7,210 copies/ml - ID said likely shedding post-infection -\n re-check in 1 week and re-eval at that time.\n - Bronch showed thin secretions possibly to volume overload. Also\n small lesion at take-off of RML, but not concerning for source of\n bleeding. He was put on dry trach mask in attempt to dry some\n secretions.\n Allergies:\n Meropenem\n skin blisters a\n Last dose of Antibiotics:\n Vancomycin - 02:18 PM\n Ciprofloxacin - 08:00 PM\n Micafungin - 10:08 PM\n Linezolid - 12:25 AM\n Aztreonam - 02:02 AM\n Metronidazole - 04:22 AM\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 08:07 PM\n Heparin Sodium (Prophylaxis) - 04:23 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 12 AM\n Tmax: 38.9\nC (102\n Tcurrent: 37.7\nC (99.8\n HR: 108 (101 - 120) bpm\n BP: 114/59(76) {70/46(45) - 129/72(88)} mmHg\n RR: 34 (26 - 40) insp/min\n SpO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 103.9 kg (admission): 113.5 kg\n Height: 67 Inch\n Total In:\n 2,903 mL\n 990 mL\n PO:\n TF:\n 975 mL\n 358 mL\n IVF:\n 1,598 mL\n 572 mL\n Blood products:\n Total out:\n 253 mL\n 170 mL\n Urine:\n 253 mL\n 170 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,650 mL\n 821 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n SpO2: 100%\n ABG: ///22/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 264 K/uL\n 6.6 g/dL\n 170 mg/dL\n 2.8 mg/dL\n 22 mEq/L\n 3.3 mEq/L\n 64 mg/dL\n 98 mEq/L\n 132 mEq/L\n 22.2 %\n 30.9 K/uL\n [image002.jpg]\n 04:57 PM\n 02:28 AM\n 02:50 AM\n 05:09 PM\n 05:55 PM\n 05:57 PM\n 09:02 PM\n 01:42 AM\n 01:50 AM\n 03:18 AM\n WBC\n 38.5\n 38.6\n 34.0\n 35.7\n 30.9\n Hct\n 22.7\n 22.6\n 21.6\n 23.1\n 22.2\n Plt\n 282\n 277\n 291\n 305\n 264\n Cr\n 2.4\n 1.2\n 1.8\n 2.8\n TCO2\n 20\n 22\n 21\n 27\n Glucose\n 132\n 126\n 136\n 170\n Other labs: PT / PTT / INR:15.8/39.1/1.4, CK / CKMB /\n Troponin-T:214/3/0.07, ALT / AST:121/118, Alk Phos / T Bili:379/10.8,\n Amylase / Lipase:77/88, Differential-Neuts:80.0 %, Band:6.0 %,\n Lymph:3.0 %, Mono:1.0 %, Eos:1.0 %, D-dimer:6389 ng/mL, Fibrinogen:541\n mg/dL, Lactic Acid:2.4 mmol/L, Albumin:2.3 g/dL, LDH:529 IU/L, Ca++:8.3\n mg/dL, Mg++:2.2 mg/dL, PO4:2.9 mg/dL\n Assessment and Plan\n AROUSAL, ATTENTION, AND COGNITION, IMPAIRED\n BALANCE, IMPAIRED\n MOTOR FUNCTION, IMPAIRED\n MUSCLE PERFORMACE, IMPAIRED\n RESPIRATION / GAS EXCHANGE, IMPAIRED\n SEIZURE, WITHOUT STATUS EPILEPTICUS\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n IMPAIRED SKIN INTEGRITY\n HEPATITIS, ACUTE TOXIC (INCLUDING ALCOHOLIC, ACETAMINOPHEN, ETC.)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ICU Care\n Nutrition:\n Nutren 2.0 () - 02:00 PM 50 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 08:15 PM\n PICC Line - 08:37 AM\n Dialysis Catheter - 08:55 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP: HOB elevation\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:ICU\n" }, { "category": "Physician ", "chartdate": "2131-06-23 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 682486, "text": "Chief Complaint:\n 24 Hour Events:\n BRONCHOSCOPY - At 02:45 PM\n BLOOD CULTURED - At 09:40 PM\n FEVER - 102.0\nF - 08:00 PM\n \n - Febrile again to 102, requireing levophed.\n - ID recommended asking IR if tap of fluid collections is even\n possible. If not, would re-image in a few days to see if fluid\n collections are evolving.\n - CMV VL 7,210 copies/ml - ID said likely shedding post-infection -\n re-check in 1 week and re-eval at that time.\n - Bronch showed thin secretions possibly to volume overload. Also\n small lesion at take-off of RML, but not concerning for source of\n bleeding. He was put on dry trach mask in attempt to dry some\n secretions.\n Allergies:\n Meropenem\n skin blisters a\n Last dose of Antibiotics:\n Vancomycin - 02:18 PM\n Ciprofloxacin - 08:00 PM\n Micafungin - 10:08 PM\n Linezolid - 12:25 AM\n Aztreonam - 02:02 AM\n Metronidazole - 04:22 AM\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 08:07 PM\n Heparin Sodium (Prophylaxis) - 04:23 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 12 AM\n Tmax: 38.9\nC (102\n Tcurrent: 37.7\nC (99.8\n HR: 108 (101 - 120) bpm\n BP: 114/59(76) {70/46(45) - 129/72(88)} mmHg\n RR: 34 (26 - 40) insp/min\n SpO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 103.9 kg (admission): 113.5 kg\n Height: 67 Inch\n Total In:\n 2,903 mL\n 990 mL\n PO:\n TF:\n 975 mL\n 358 mL\n IVF:\n 1,598 mL\n 572 mL\n Blood products:\n Total out:\n 253 mL\n 170 mL\n Urine:\n 253 mL\n 170 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,650 mL\n 821 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n SpO2: 100%\n ABG: ///22/\n Physical Examination\n GEN: Trached.\n HEENT: Icteric sclera. MMM.\n NECK: Trach site with no oozing.\n LUNGS: Anterior auscultation with upper airway noise; good airway\n movement.\n HEART: RRR, normal S1, S2.\n ABD: Distended. Firm, but unchanged.\n EXTREM: 2+ edema, ulcers/lesions on legs with bandages C/D/I.\n SKIN: Jaundiced.\n NEURO: Twitching mouth and arms. ? clonus. Opens eyes, squeezes hand to\n command.\n Labs / Radiology\n 264 K/uL\n 6.6 g/dL\n 170 mg/dL\n 2.8 mg/dL\n 22 mEq/L\n 3.3 mEq/L\n 64 mg/dL\n 98 mEq/L\n 132 mEq/L\n 22.2 %\n 30.9 K/uL\n [image002.jpg]\n 04:57 PM\n 02:28 AM\n 02:50 AM\n 05:09 PM\n 05:55 PM\n 05:57 PM\n 09:02 PM\n 01:42 AM\n 01:50 AM\n 03:18 AM\n WBC\n 38.5\n 38.6\n 34.0\n 35.7\n 30.9\n Hct\n 22.7\n 22.6\n 21.6\n 23.1\n 22.2\n Plt\n 282\n 277\n 291\n 305\n 264\n Cr\n 2.4\n 1.2\n 1.8\n 2.8\n TCO2\n 20\n 22\n 21\n 27\n Glucose\n 132\n 126\n 136\n 170\n Other labs: PT / PTT / INR:15.8/39.1/1.4, CK / CKMB /\n Troponin-T:214/3/0.07, ALT / AST:121/118, Alk Phos / T Bili:379/10.8,\n Amylase / Lipase:77/88, Differential-Neuts:80.0 %, Band:6.0 %,\n Lymph:3.0 %, Mono:1.0 %, Eos:1.0 %, D-dimer:6389 ng/mL, Fibrinogen:541\n mg/dL, Lactic Acid:2.4 mmol/L, Albumin:2.3 g/dL, LDH:529 IU/L, Ca++:8.3\n mg/dL, Mg++:2.2 mg/dL, PO4:2.9 mg/dL\n Assessment and Plan\n AROUSAL, ATTENTION, AND COGNITION, IMPAIRED\n BALANCE, IMPAIRED\n MOTOR FUNCTION, IMPAIRED\n MUSCLE PERFORMACE, IMPAIRED\n RESPIRATION / GAS EXCHANGE, IMPAIRED\n SEIZURE, WITHOUT STATUS EPILEPTICUS\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n IMPAIRED SKIN INTEGRITY\n HEPATITIS, ACUTE TOXIC (INCLUDING ALCOHOLIC, ACETAMINOPHEN, ETC.)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ICU Care\n Nutrition:\n Nutren 2.0 () - 02:00 PM 50 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 08:15 PM\n PICC Line - 08:37 AM\n Dialysis Catheter - 08:55 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP: HOB elevation\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:ICU\n" }, { "category": "Physician ", "chartdate": "2131-06-23 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 682488, "text": "Chief Complaint:\n 24 Hour Events:\n BRONCHOSCOPY - At 02:45 PM\n BLOOD CULTURED - At 09:40 PM\n FEVER - 102.0\nF - 08:00 PM\n \n - Febrile again to 102, requireing levophed.\n - ID recommended asking IR if tap of fluid collections is even\n possible. If not, would re-image in a few days to see if fluid\n collections are evolving.\n - CMV VL 7,210 copies/ml - ID said likely shedding post-infection -\n re-check in 1 week and re-eval at that time.\n - Bronch showed thin secretions possibly to volume overload. Also\n small lesion at take-off of RML, but not concerning for source of\n bleeding. He was put on dry trach mask in attempt to dry some\n secretions.\n Allergies:\n Meropenem\n skin blisters a\n Last dose of Antibiotics:\n Vancomycin - 02:18 PM\n Ciprofloxacin - 08:00 PM\n Micafungin - 10:08 PM\n Linezolid - 12:25 AM\n Aztreonam - 02:02 AM\n Metronidazole - 04:22 AM\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 08:07 PM\n Heparin Sodium (Prophylaxis) - 04:23 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 12 AM\n Tmax: 38.9\nC (102\n Tcurrent: 37.7\nC (99.8\n HR: 108 (101 - 120) bpm\n BP: 114/59(76) {70/46(45) - 129/72(88)} mmHg\n RR: 34 (26 - 40) insp/min\n SpO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 103.9 kg (admission): 113.5 kg\n Height: 67 Inch\n Total In:\n 2,903 mL\n 990 mL\n PO:\n TF:\n 975 mL\n 358 mL\n IVF:\n 1,598 mL\n 572 mL\n Blood products:\n Total out:\n 253 mL\n 170 mL\n Urine:\n 253 mL\n 170 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,650 mL\n 821 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n SpO2: 100%\n ABG: ///22/\n Physical Examination\n GEN: Trached.\n HEENT: Icteric sclera. MMM.\n NECK: Trach site with no oozing.\n LUNGS: Anterior auscultation with upper airway noise; good airway\n movement.\n HEART: RRR, normal S1, S2.\n ABD: Distended. Firm, but unchanged.\n EXTREM: 2+ edema, ulcers/lesions on legs with bandages C/D/I.\n SKIN: Jaundiced.\n NEURO: Twitching mouth and arms. ? clonus. Opens eyes, squeezes hand to\n command.\n Labs / Radiology\n 264 K/uL\n 6.6 g/dL\n 170 mg/dL\n 2.8 mg/dL\n 22 mEq/L\n 3.3 mEq/L\n 64 mg/dL\n 98 mEq/L\n 132 mEq/L\n 22.2 %\n 30.9 K/uL\n [image002.jpg]\n 04:57 PM\n 02:28 AM\n 02:50 AM\n 05:09 PM\n 05:55 PM\n 05:57 PM\n 09:02 PM\n 01:42 AM\n 01:50 AM\n 03:18 AM\n WBC\n 38.5\n 38.6\n 34.0\n 35.7\n 30.9\n Hct\n 22.7\n 22.6\n 21.6\n 23.1\n 22.2\n Plt\n 282\n 277\n 291\n 305\n 264\n Cr\n 2.4\n 1.2\n 1.8\n 2.8\n TCO2\n 20\n 22\n 21\n 27\n Glucose\n 132\n 126\n 136\n 170\n Other labs: PT / PTT / INR:15.8/39.1/1.4, CK / CKMB /\n Troponin-T:214/3/0.07, ALT / AST:121/118, Alk Phos / T Bili:379/10.8,\n Amylase / Lipase:77/88, Differential-Neuts:80.0 %, Band:6.0 %,\n Lymph:3.0 %, Mono:1.0 %, Eos:1.0 %, D-dimer:6389 ng/mL, Fibrinogen:541\n mg/dL, Lactic Acid:2.4 mmol/L, Albumin:2.3 g/dL, LDH:529 IU/L, Ca++:8.3\n mg/dL, Mg++:2.2 mg/dL, PO4:2.9 mg/dL\n Assessment and Plan\n 28M with alcoholic hepatitis and necrotizing pancreatitis complicated\n by ARDS, SIRS, ARF, UGIB, fevers.\n #. ID: Persistent leukocytosis and fevers now that off CVVH. Possible\n that continued fevers necrotizing pancreatitis. Also with\n persistent yeast in ucx, persistent colonic inflammation on CT. On\n aztreonam, linezolid (since ) and flagyl (since ). Started\n micafungin and po vanc . In setting of fevers and hypotension,\n Cipro was started .\n - New fluid collection peri-pancreas but would hold off on fluid\n drainage\n - Check CXR\n - Bronch today\n - Cont broad coverage with linezolid (-), aztreo (-), flagyl\n (-), mica (-). D/c vanc po (-), Cipro IV ( -).\n - F/u c diff (neg x2), if neg x3 can d/c po vanc\n - Follow WBC count, temp curve, and culture data\n - F/u ID recs\n # Shock: Pressures dropped to 70/40 again in setting of fever. Likely\n septic shock. Will treat for infection as above. If requires pressors\n without fever consider other etiologies of hypotension including\n cardiogenic.\n - Cont weaning steroids; change to PO prednisone 5 mg today\n - Keep a-line until off pressors x 24 h\n - Infectious w/u as above\n # Elevated LFTs: A/w alcoholic hepatitis. RUQ u/s showed sludge\n concerning for cholestasis but also seen on u/s. HIDA neg.\n TPN stopped . T Bili and transaminases improving today.\n - weaning off benzos - 5 mg valium today\n - continue to trend\n #. Respiratory Failure: ARDS secondary to necrotizing pancreatitis. S/p\n trach placement on . Continues to have blood/clots suctioned from\n trach\n - DDAVP if acute bleeding (max few doses). Had required amicar shortly\n after trach for continued bleeding but complicated by seizure shortly\n after starting this.\n - Cte fentanyl boluses\n - Wean methadone and valium as tolerated\n - Cte OOB to chair daily\n - Trach\n #. Acute renal Failure: Multifactorial inc. ATN from hypotension\n - Was supposed to transition to HD today but pressures not able to\n tolerate. No need for filtration so will reassess tmrw.\n - Aztreonam 2000mg q12h while on CVVH.\n - continue Keppra at 1000mg Q24 with 500 mg after HD\n #. Adrenal Insufficiency: Unclear with stim if clear adrenal\n insufficiency but hypotension improving with steroids (lower pressor\n requirement) and eosinophilia resolved.\n - transition to PO prednisone 5 mg daily today\n # Seizures: CT head without intracranial process. EEG showed occipital\n seizures which does not correlate with clinical symptoms, but repeat\n EEG on higher dose Keppra showed no seizures. As patient now with\n purposeful movements, this may actually be patient waking up, not\n seizures.\n - Continue keppra at HD dosing\n # Altered Mental Status:\n - Titrate down sedating meds; decrease methadone to today and qd\n tomorrow\n ICU Care\n Nutrition:\n Nutren 2.0 () - 02:00 PM 50 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 08:15 PM\n PICC Line - 08:37 AM\n Dialysis Catheter - 08:55 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP: HOB elevation\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:ICU\n" }, { "category": "Physician ", "chartdate": "2131-06-23 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 682491, "text": "Chief Complaint:\n 24 Hour Events:\n BRONCHOSCOPY - At 02:45 PM\n BLOOD CULTURED - At 09:40 PM\n FEVER - 102.0\nF - 08:00 PM\n \n - Febrile again to 102, requireing levophed.\n - ID recommended asking IR if tap of fluid collections is even\n possible. If not, would re-image in a few days to see if fluid\n collections are evolving.\n - CMV VL - ID said likely shedding post-infection - re-check in 1 week\n and re-eval at that time.\n - Bronch showed thin secretions possibly to volume overload. Also\n small lesion at take-off of RML, but not concerning for source of\n bleeding. He was put on dry trach mask in attempt to dry some\n secretions.\n Allergies:\n Meropenem\n skin blisters a\n Last dose of Antibiotics:\n Vancomycin - 02:18 PM\n Ciprofloxacin - 08:00 PM\n Micafungin - 10:08 PM\n Linezolid - 12:25 AM\n Aztreonam - 02:02 AM\n Metronidazole - 04:22 AM\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 08:07 PM\n Heparin Sodium (Prophylaxis) - 04:23 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 12 AM\n Tmax: 38.9\nC (102\n Tcurrent: 37.7\nC (99.8\n HR: 108 (101 - 120) bpm\n BP: 114/59(76) {70/46(45) - 129/72(88)} mmHg\n RR: 34 (26 - 40) insp/min\n SpO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 103.9 kg (admission): 113.5 kg\n Height: 67 Inch\n Total In:\n 2,903 mL\n 990 mL\n PO:\n TF:\n 975 mL\n 358 mL\n IVF:\n 1,598 mL\n 572 mL\n Blood products:\n Total out:\n 253 mL\n 170 mL\n Urine:\n 253 mL\n 170 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,650 mL\n 821 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n SpO2: 100%\n ABG: ///22/\n Physical Examination\n GEN: Trached.\n HEENT: Icteric sclera. MMM.\n NECK: Trach site with no oozing.\n LUNGS: Anterior auscultation with upper airway noise; good airway\n movement.\n HEART: RRR, normal S1, S2.\n ABD: Distended. Firm, but unchanged.\n EXTREM: 2+ edema, ulcers/lesions on legs with bandages C/D/I.\n SKIN: Jaundiced.\n NEURO: Twitching mouth and arms. ? clonus. Opens eyes, squeezes hand to\n command.\n Labs / Radiology\n 264 K/uL\n 6.6 g/dL\n 170 mg/dL\n 2.8 mg/dL\n 22 mEq/L\n 3.3 mEq/L\n 64 mg/dL\n 98 mEq/L\n 132 mEq/L\n 22.2 %\n 30.9 K/uL\n [image002.jpg]\n 04:57 PM\n 02:28 AM\n 02:50 AM\n 05:09 PM\n 05:55 PM\n 05:57 PM\n 09:02 PM\n 01:42 AM\n 01:50 AM\n 03:18 AM\n WBC\n 38.5\n 38.6\n 34.0\n 35.7\n 30.9\n Hct\n 22.7\n 22.6\n 21.6\n 23.1\n 22.2\n Plt\n 282\n 277\n 291\n 305\n 264\n Cr\n 2.4\n 1.2\n 1.8\n 2.8\n TCO2\n 20\n 22\n 21\n 27\n Glucose\n 132\n 126\n 136\n 170\n Other labs: PT / PTT / INR:15.8/39.1/1.4, CK / CKMB /\n Troponin-T:214/3/0.07, ALT / AST:121/118, Alk Phos / T Bili:379/10.8,\n Amylase / Lipase:77/88, Differential-Neuts:80.0 %, Band:6.0 %,\n Lymph:3.0 %, Mono:1.0 %, Eos:1.0 %, D-dimer:6389 ng/mL, Fibrinogen:541\n mg/dL, Lactic Acid:2.4 mmol/L, Albumin:2.3 g/dL, LDH:529 IU/L, Ca++:8.3\n mg/dL, Mg++:2.2 mg/dL, PO4:2.9 mg/dL\n Ca: 8.3 Mg: 2.2 P: 2.9\n ALT: 121\n AP: 379\n Tbili: 10.8\n Alb:\n AST: 118\n LDH:\n Dbili:\n TProt:\n :\n Lip:\n CMV VL - 7,210 copies/ml\n Assessment and Plan\n 28M with alcoholic hepatitis and necrotizing pancreatitis complicated\n by ARDS, SIRS, ARF, UGIB, fevers.\n #. ID: Persistent leukocytosis and fevers now that off CVVH. Possible\n that continued fevers necrotizing pancreatitis. Also with\n persistent yeast in ucx, persistent colonic inflammation on CT, and\n pancreatic fluid collections. On aztreonam, linezolid (since ) and\n flagyl (since ). Started micafungin and po vanc . In setting\n of fevers and hypotension, Cipro was started , but d/c\ned. Surgery\n was consulted for new fluid collection peri-pancreas but they feel they\n are not infected (no gas on CT) and would hold off on fluid drainage.\n - Cont broad coverage with linezolid (-), aztreo (-), flagyl\n (-), mica (-). D/c vanc po (-), Cipro IV ( -).\n - F/u c diff (neg x2), if neg x3 can d/c po vanc\n - Follow WBC count, temp curve, and culture data\n - F/u ID recs\n # Shock: Pressures dropped to 70/40 again in setting of fever. Likely\n septic shock. Will treat for infection as above. If requires pressors\n without fever consider other etiologies of hypotension including\n cardiogenic.\n - Cont weaning steroids; change to PO prednisone 5 mg today\n - Keep a-line until off pressors x 24 h\n - Infectious w/u as above\n # Elevated LFTs: A/w alcoholic hepatitis. RUQ u/s showed sludge\n concerning for cholestasis but also seen on u/s. HIDA neg.\n TPN stopped . T Bili and transaminases improving today.\n - weaning off benzos - 5 mg valium today\n - continue to trend\n #. Respiratory Failure: ARDS secondary to necrotizing pancreatitis. S/p\n trach placement on . Bronch without obvious source of bleeding\n and with only thin secretions throughout.\n - DDAVP if acute bleeding (max few doses). Had required amicar shortly\n after trach for continued bleeding but complicated by seizure shortly\n after starting this.\n - Cte fentanyl boluses\n - Wean methadone and valium as tolerated\n - Cte OOB to chair daily\n - Trach care\n #. Acute renal Failure: Multifactorial inc. ATN from hypotension\n - Was supposed to transition to HD today but pressures not able to\n tolerate. No need for filtration so will reassess tmrw.\n - Aztreonam 2000mg q12h while on CVVH.\n - continue Keppra at 1000mg Q24 with 500 mg after HD\n #. Adrenal Insufficiency: Unclear with stim if clear adrenal\n insufficiency but hypotension improving with steroids (lower pressor\n requirement) and eosinophilia resolved.\n - transition to PO prednisone 5 mg daily today\n # Seizures: CT head without intracranial process. EEG showed occipital\n seizures which does not correlate with clinical symptoms, but repeat\n EEG on higher dose Keppra showed no seizures. As patient now with\n purposeful movements, this may actually be patient waking up, not\n seizures.\n - Continue keppra at HD dosing\n # Altered Mental Status:\n - Titrate down sedating meds; decrease methadone to today and qd\n tomorrow\n ICU Care\n Nutrition:\n Nutren 2.0 () - 02:00 PM 50 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 08:15 PM\n PICC Line - 08:37 AM\n Dialysis Catheter - 08:55 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP: HOB elevation\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:ICU\n" }, { "category": "Physician ", "chartdate": "2131-05-18 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 674930, "text": "Chief Complaint:\n 24 Hour Events:\n CORDIS/INTRODUCER - START 02:05 PM\n INVASIVE VENTILATION - START 02:45 PM\n ENDOSCOPY - At 05:00 PM\n INVASIVE VENTILATION - STOP 05:36 PM\n ULTRASOUND - At 08:30 PM\n liver.\n INVASIVE VENTILATION - START 02:50 AM\n INVASIVE VENTILATION - STOP 05:41 AM\n - Intubated for EGD, shows diulefoy lesion, extubated\n - Required multiple liters of fluid to maintain BPs, 12 + liters\n positive Reintubated early am for tiring, increasing CO2\n - Started on pressors\n - c/s as CT shows 30% of necrotic pancreas\n - Started on phenylephrine this am\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Fentanyl (Concentrate) - 200 mcg/hour\n Midazolam (Versed) - 10 mg/hour\n Pantoprazole (Protonix) - 8 mg/hour\n Propofol - 100 mcg/Kg/min\n Phenylephrine - 1.2 mcg/Kg/min\n Other ICU medications:\n Lorazepam (Ativan) - 02:45 PM\n Pantoprazole (Protonix) - 03:05 PM\n Midazolam (Versed) - 04:55 PM\n Propofol - 05:00 PM\n Fentanyl - 05:05 PM\n Hydromorphone (Dilaudid) - 06:57 PM\n Diazepam (Valium) - 02:00 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 05:49 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.7\nC (99.9\n Tcurrent: 37\nC (98.6\n HR: 105 (105 - 149) bpm\n BP: 101/47(61) {74/34(42) - 131/98(104)} mmHg\n RR: 24 (24 - 48) insp/min\n SpO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 9,057 mL\n 4,457 mL\n PO:\n TF:\n IVF:\n 5,557 mL\n 4,457 mL\n Blood products:\n Total out:\n 544 mL\n 170 mL\n Urine:\n 544 mL\n 170 mL\n NG:\n Stool:\n Drains:\n Balance:\n 8,513 mL\n 4,287 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 16\n RR (Spontaneous): 2\n PEEP: 10 cmH2O\n FiO2: 100%\n PIP: 39 cmH2O\n Plateau: 28 cmH2O\n SpO2: 100%\n ABG: 7.34/41/47/20/-3\n Ve: 15.6 L/min\n PaO2 / FiO2: 47\n Physical Examination\n General: Sedated\n HEENT: ETT tube in place\n Neck: supple\n Lungs: decreased breath sounds\n CV: tachycardic with normal rhytyhm, normal S1 + S2, no murmurs, rubs,\n gallops\n Abdomen: soft, non tender\n Ext: Warm, well perfused\n Neuro: sedated\n Labs / Radiology\n 124 K/uL\n 10.0 g/dL\n 170 mg/dL\n 1.4 mg/dL\n 20 mEq/L\n 3.6 mEq/L\n 15 mg/dL\n 92 mEq/L\n 127 mEq/L\n 29.6 %\n 14.9 K/uL\n [image002.jpg]\n 04:43 PM\n 06:24 PM\n 09:48 PM\n 01:22 AM\n 03:35 AM\n 04:58 AM\n WBC\n 19.0\n 18.7\n 14.9\n Hct\n 31.4\n 30.4\n 29.6\n Plt\n 173\n 147\n 124\n Cr\n 0.8\n 1.2\n 1.4\n TCO2\n 15\n 21\n 23\n Glucose\n 66\n 142\n 170\n Other labs: PT / PTT / INR:19.5/71.6/1.8, ALT / AST:191/898, Alk Phos /\n T Bili:231/15.5, Amylase / Lipase:/516, Lactic Acid:4.0 mmol/L,\n Albumin:2.7 g/dL, Ca++:5.7 mg/dL, Mg++:2.1 mg/dL, PO4:3.2 mg/dL\n RUQ Ultrasound: Limited study demonstrating marked liver echogenicity,\n consistent with fatty infiltration, although more severe liver disease\n including significant hepatic fibrosis and cirrhosis cannot be excluded\n on this study. There is no intrahepatic biliary dilatation, and the\n common bile duct measures 4 mm. There is normal flow in the portal\n vein.\n Assessment and Plan\n 28 year old male with a history of alcoholism presenting with acute\n hepatitis, pancreatitis, and UGIB.\n .\n # Respiratory Failure. Unclear etiology of hypoxia: Patient electively\n intubated for EGD then extubated. Required NRB to maintain sats in 90s.\n Continue tachypnea to the 40s, tired, CO2 increased, then reintubated.\n Initial CXR unremarkable. Concern for progression to ARDS secondary to\n pancreatitis.\n .\n # Hypotension. Differential includes pancreatitis vs infection.\n Required large volume fluid to maintain pressures overnight. Now on\n phenylephrine.\n - Continue pressors for MAPs > 65\n - IVF bolus as needed\n - F/u cultures\n - Consider antibiotics\n .\n # Pancreatitis: Most likely alcoholic in etiology, with elevated\n lipase to 1600. CT shows ? 30 % necrosis. Per surgery no antibiotics\n currently.\n - continue aggessive hydration\n - trend lipase\n - f/u am lipid panel\n - f/u surgery recs\n .\n # Acute Hepatitis: Likely alcoholic hepatitis. CT scan shows fatty\n infiltration, and no evidence of distal obstruction. RUQ u/s shows\n marked liver echogenicity.\n - f/u viral hepatitis panel\n - c/s GI\n - trend LFTs\n .\n # Leukocytosis: Marked leukocytosis with low grade temperature, lactate\n 3.6.. UA with + wbcs in ED, but repeat negative. be secondary to\n pancreatitis, however cannot rule out infection. Treated in ED with\n ciprofloxacin and flagyl. Urine and blood cultures pending.\n - f/u blood cultures and urine culture\n - sputum fx\n - f/u final CT read\n .\n # Hematemesis: EGD showed diuelafoy's lesion. Crit stable.\n -f/u GI recs\n -continue PPI\n -maintain active type and screen\n .\n # Hyponatremia: Most likely due to volume depletion in the setting of\n inability to tolerate POs. Patient markedly dry on exam. also\n reflect a more chronic long-term liver disease. Improving 127 from 118.\n - consider sending urine lytes this am\n # Alcoholism: Patient describes history of withdrawl symptoms, but not\n prior seizure. Last drink was night prior to presenation.\n Tachycardia, weakness, and elevated lactate could be consistent with\n thiamine deficiency.\n - thiamine, vb12, folate\n - valium with CIWA > 10\n - social work consult when medically stable\n .\n # FEN: IVF, replete electrolytes, NPO\n .\n # Prophylaxis: scds, PPI gtt\n .\n # Access: peripherals and femoral cortis\n .\n # Code: Full Code\n .\n # Disposition: ICU\n ICU Care\n Nutrition: NPO\n Glycemic Control:\n Lines:\n 18 Gauge - 01:49 PM\n 16 Gauge - 01:50 PM\n Cordis/Introducer - 02:05 PM\n 20 Gauge - 03:33 AM\n Prophylaxis:\n DVT: SCDs\n Stress ulcer: PPIs\n VAP:\n Comments:\n Communication: Comments:\n Code status: full\n Disposition:ICU\n" }, { "category": "Respiratory ", "chartdate": "2131-05-19 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 675408, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 0\n Ideal body weight: 67.1 None\n Ideal tidal volume: 268.4 / 402.6 / 536.8 mL/kg\n Airway\n 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: 7mm\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Clear\n Comments:\n Secretions\n Sputum color / consistency: Yellow / Thin\n Sputum source/amount: Suctioned / Small\n Comments:\n Ventilation Assessment\n Trigger work assessment: Not triggering\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Utilize ARDSnet protocol, Maintain PEEP at current\n level and reduce FiO2 as tolerated\n Reason for continuing current ventilatory support: Sedated / Paralyzed,\n Intolerant of weaning attempts, Hemodynimic instability, Underlying\n illness not resolved\n Respiratory Care Shift Procedures\n Placement of Esophageal balloon catheter.\n Bedside Procedures:\n Comments:\n Patient remains intubated and on mechanical ventilation, breath sounds\n bilaterally clear suctioned intermittently for small bile-like\n secretion (yellow), secretion specimen sent to lab for CX and Gram\n Stain, balloon measurement showed that patient was underpeep for\n 4CmH2O, P\n" }, { "category": "Respiratory ", "chartdate": "2131-05-19 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 675410, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 0\n Ideal body weight: 67.1 None\n Ideal tidal volume: 268.4 / 402.6 / 536.8 mL/kg\n Airway\n 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: 7mm\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Clear\n Comments:\n Secretions\n Sputum color / consistency: Yellow / Thin\n Sputum source/amount: Suctioned / Small\n Comments:\n Ventilation Assessment\n Trigger work assessment: Not triggering\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Utilize ARDSnet protocol, Maintain PEEP at current\n level and reduce FiO2 as tolerated\n Reason for continuing current ventilatory support: Sedated / Paralyzed,\n Intolerant of weaning attempts, Hemodynimic instability, Underlying\n illness not resolved\n Respiratory Care Shift Procedures\n Placement of Esophageal balloon catheter.\n Bedside Procedures:\n Comments:\n Patient remains intubated and on mechanical ventilation, breath sounds\n bilaterally clear suctioned intermittently for small bile-like\n secretion (yellow), secretion specimen sent to lab for CX and Gram\n Stain, balloon measurement showed that patient was underpeep for\n 4CmH2O, PEEP increased from 20 to 24, frequency from 24 to 30, to cope\n with acid-base balance and severe hypoxemia. FiO2 weaned from 100% to\n 80%, will continues to be closely followed.\n" }, { "category": "Physician ", "chartdate": "2131-05-17 00:00:00.000", "description": "MICU Attending Admission Note", "row_id": 674780, "text": "TITLE: MICU ATTENDING ADMISSION NOTE\n I saw and examined the patient, and was physically present with the ICU\n team for the key portions of the services provided. I would emphasize\n the following points: 28M EtOH abuse, weakness, fatigue, UGIB c/b\n hematemesis / melena. Last drank 18h PTA. In ED, SBP 50/p c HR 150s, rx\n IVF x5L, 1 unit PRBC, cipro / flagyl. Imaging notable for pancreatitis\n and fatty liver changes. Admitted to MICU, intubated, EGD with\n dieulafois lesion. Access includes cordis and 14g, 16g PIVs.\n Exam notable for Tm 100.1 BP 100/50 HR 130 RR 35 with sat 100 on VAC\n 500x12 1.0 5. JVP flat. Tachy / hyperdynamic. CTA B. Distended, +BS,\n mild diffuse tenderness, no rebound. Labs notable for WBC 23K, HCT 37,\n Na 118, K+ 3.7, Cr 1.4, AG 33, lactate 8.1, TB 20, Lip 1500, INR 1.6.\n CT c pancreatitis and fatty liver changes.\n Agree with plan to manage UGIB with intubation and EGD now - initial\n findings c/w dieulafois lesion at GEJ. Will treat with IV PPI and will\n extubate post procedure. Will continue to use volume and RBCs to keep\n HCT >30. Will check HCT q4h and recheck coags this PM, but will hold on\n FFP for now. Pancreatitis likely due to EtOH, will check RUQ usg now\n and follow labs while patient remains NPO. Will need aggressive IVF\n overnight, will give NaHCO3 x 3amps in 1L D5 x2L now and then check f/u\n labs. His lactic acidosis and AG are out of proportion for his degree\n of hypotension - will give thiamine 200mg IV now and follow. For fatty\n liver will check hep serologies but suspect alcoholic hepatitis is the\n major issue\n will provide supportive care and follow labs while\n holding off on steroids given ongoing GIB. Will manage incipient EtOH\n withdrawal with PO valium 20mg per CIWA. For elevated WBCs and positive\n UA, will continue cipro / flagyl and check prostate exam while awaiting\n cultures. Suspect hyponatremia is a function of profound volume\n depletion. Remainder of plan as outlined in resident admission.\n Patient is critically ill\n Total time: 50 min\n" }, { "category": "Physician ", "chartdate": "2131-05-18 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 674991, "text": "Chief Complaint:\n 24 Hour Events:\n CORDIS/INTRODUCER - START 02:05 PM\n INVASIVE VENTILATION - START 02:45 PM\n ENDOSCOPY - At 05:00 PM\n INVASIVE VENTILATION - STOP 05:36 PM\n ULTRASOUND - At 08:30 PM\n liver.\n INVASIVE VENTILATION - START 02:50 AM\n INVASIVE VENTILATION - STOP 05:41 AM\n - Intubated for EGD, shows diulefoy lesion, extubated\n - Required multiple liters of fluid to maintain BPs, 12 + liters\n positive c/s as CT shows 30% of necrotic pancreas\n - Started on phenylephrine this am\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Fentanyl (Concentrate) - 200 mcg/hour\n Midazolam (Versed) - 10 mg/hour\n Pantoprazole (Protonix) - 8 mg/hour\n Propofol - 100 mcg/Kg/min\n Phenylephrine - 1.2 mcg/Kg/min\n Other ICU medications:\n Lorazepam (Ativan) - 02:45 PM\n Pantoprazole (Protonix) - 03:05 PM\n Midazolam (Versed) - 04:55 PM\n Propofol - 05:00 PM\n Fentanyl - 05:05 PM\n Hydromorphone (Dilaudid) - 06:57 PM\n Diazepam (Valium) - 02:00 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 05:49 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.7\nC (99.9\n Tcurrent: 37\nC (98.6\n HR: 105 (105 - 149) bpm\n BP: 101/47(61) {74/34(42) - 131/98(104)} mmHg\n RR: 24 (24 - 48) insp/min\n SpO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 9,057 mL\n 4,457 mL\n PO:\n TF:\n IVF:\n 5,557 mL\n 4,457 mL\n Blood products:\n Total out:\n 544 mL\n 170 mL\n Urine:\n 544 mL\n 170 mL\n NG:\n Stool:\n Drains:\n Balance:\n 8,513 mL\n 4,287 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 16\n RR (Spontaneous): 2\n PEEP: 10 cmH2O\n FiO2: 100%\n PIP: 39 cmH2O\n Plateau: 28 cmH2O\n SpO2: 100%\n ABG: 7.34/41/47/20/-3\n Ve: 15.6 L/min\n PaO2 / FiO2: 47\n Physical Examination\n General: Sedated\n HEENT: ETT tube in place\n Neck: supple\n Lungs: decreased breath sounds\n CV: tachycardic, no mumurs\n Abdomen: soft, obese, decreased BS\n Ext: Warm, well perfused\n Neuro: sedated\n Labs / Radiology\n 124 K/uL\n 10.0 g/dL\n 170 mg/dL\n 1.4 mg/dL\n 20 mEq/L\n 3.6 mEq/L\n 15 mg/dL\n 92 mEq/L\n 127 mEq/L\n 29.6 %\n 14.9 K/uL\n [image002.jpg]\n 04:43 PM\n 06:24 PM\n 09:48 PM\n 01:22 AM\n 03:35 AM\n 04:58 AM\n WBC\n 19.0\n 18.7\n 14.9\n Hct\n 31.4\n 30.4\n 29.6\n Plt\n 173\n 147\n 124\n Cr\n 0.8\n 1.2\n 1.4\n TCO2\n 15\n 21\n 23\n Glucose\n 66\n 142\n 170\n Other labs: PT / PTT / INR:19.5/71.6/1.8, ALT / AST:191/898, Alk Phos /\n T Bili:231/15.5, Amylase / Lipase:/516, Lactic Acid:4.0 mmol/L,\n Albumin:2.7 g/dL, Ca++:5.7 mg/dL, Mg++:2.1 mg/dL, PO4:3.2 mg/dL\n RUQ Ultrasound: Limited study demonstrating marked liver echogenicity,\n consistent with fatty infiltration, although more severe liver disease\n including significant hepatic fibrosis and cirrhosis cannot be excluded\n on this study. There is no intrahepatic biliary dilatation, and the\n common bile duct measures 4 mm. There is normal flow in the portal\n vein.\n Assessment and Plan\n 28 year old male with a history of alcoholism presenting with acute\n hepatitis, pancreatitis, and UGIB.\n .\n # Respiratory Failure. Unclear etiology of hypoxia: Patient electively\n intubated for EGD then extubated. Required NRB to maintain sats in 90s.\n Continue tachypnea to the 40s, tired, CO2 increased, then reintubated.\n Initial CXR unremarkable. Concern for progression to /ARDS secondary\n to pancreatitis.\n - ARDSnet ventilator settings\n - monitor abdominal pressures\n - fentanyl and versed for sedation\n - wean settings as tolerated\n - repeat ABG this afternoon\n .\n # Pancreatitis: Most likely alcoholic in etiology, lipase peaked at\n 1600. CT scan shows probable 30% necrosis. Complicated by SIRS\n physiology. Significant hypotension, required large volume fluid to\n maintain pressures overnight. Now on phenylephrine. Also with\n leukocytosis likely related to pancreatitis but low threshold to treat\n for infection. Per surgery currently not treating with antibiotics.\n - aggressive IV hydration\n - attempt to wean neo\n - place arterial line for BP monitoring\n - wean propofol\n - strict NPO (no PO meds)\n - f/u cultures\n - f/u final CT read\n - trend lipase\n - f/u am lipid panel\n - f/u surgery recs\n .\n # Acute Hepatitis: Likely alcoholic hepatitis. CT scan shows fatty\n infiltration, and no evidence of distal obstruction. RUQ u/s shows\n marked liver echogenicity.\n - f/u viral hepatitis panel\n - trend LFTs\n - f/u GI recs\n .\n # Hematemesis: EGD showed diuelafoy's lesion. Crit stable.\n -f/u GI recs\n -continue PPI\n -maintain active type and screen\n .\n # Hyponatremia: Most likely due to volume depletion. Patient markedly\n dry on initial exam. also reflect a more chronic long-term liver\n disease. Improving 127 from 118.\n - continue to follow\n # Alcoholism: Patient describes history of withdrawl symptoms, but not\n prior seizure. Last drink was night prior to presenation.\n Tachycardia, weakness, and elevated lactate could be consistent with\n thiamine deficiency.\n - thiamine level pending\n - thiamine, vb12, folate\n - valium with CIWA > 10\n - social work consult when medically stable\n .\n # FEN: IVF, replete electrolytes, NPO\n .\n # Prophylaxis: scds, PPI\n .\n # Access: pIV, plan to d/c cordis and place IJ to monitor CVPs\n .\n # Code: Full Code\n .\n # Disposition: ICU\n ICU Care\n Nutrition: NPO\n Glycemic Control:\n Lines:\n 18 Gauge - 01:49 PM\n 16 Gauge - 01:50 PM\n Cordis/Introducer - 02:05 PM\n 20 Gauge - 03:33 AM\n Prophylaxis:\n DVT: SCDs\n Stress ulcer: PPIs\n VAP:\n Comments:\n Communication: Comments: will attempt to locate next of \n Code status: full\n Disposition:ICU\n" }, { "category": "Physician ", "chartdate": "2131-05-18 00:00:00.000", "description": "Physician Resident/Attending Progress Note - MICU", "row_id": 675104, "text": "Chief Complaint:\n 24 Hour Events:\n CORDIS/INTRODUCER - START 02:05 PM\n INVASIVE VENTILATION - START 02:45 PM\n ENDOSCOPY - At 05:00 PM\n INVASIVE VENTILATION - STOP 05:36 PM\n ULTRASOUND - At 08:30 PM\n liver.\n INVASIVE VENTILATION - START 02:50 AM\n INVASIVE VENTILATION - STOP 05:41 AM\n - Intubated for EGD, shows diulefoy lesion, extubated\n - Required multiple liters of fluid to maintain BPs, 12 + liters\n positive c/s as CT shows 30% of necrotic pancreas\n - Started on phenylephrine this am\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Fentanyl (Concentrate) - 200 mcg/hour\n Midazolam (Versed) - 10 mg/hour\n Pantoprazole (Protonix) - 8 mg/hour\n Propofol - 100 mcg/Kg/min\n Phenylephrine - 1.2 mcg/Kg/min\n Other ICU medications:\n Lorazepam (Ativan) - 02:45 PM\n Pantoprazole (Protonix) - 03:05 PM\n Midazolam (Versed) - 04:55 PM\n Propofol - 05:00 PM\n Fentanyl - 05:05 PM\n Hydromorphone (Dilaudid) - 06:57 PM\n Diazepam (Valium) - 02:00 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 05:49 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.7\nC (99.9\n Tcurrent: 37\nC (98.6\n HR: 105 (105 - 149) bpm\n BP: 101/47(61) {74/34(42) - 131/98(104)} mmHg\n RR: 24 (24 - 48) insp/min\n SpO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 9,057 mL\n 4,457 mL\n PO:\n TF:\n IVF:\n 5,557 mL\n 4,457 mL\n Blood products:\n Total out:\n 544 mL\n 170 mL\n Urine:\n 544 mL\n 170 mL\n NG:\n Stool:\n Drains:\n Balance:\n 8,513 mL\n 4,287 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 16\n RR (Spontaneous): 2\n PEEP: 10 cmH2O\n FiO2: 100%\n PIP: 39 cmH2O\n Plateau: 28 cmH2O\n SpO2: 100%\n ABG: 7.34/41/47/20/-3\n Ve: 15.6 L/min\n PaO2 / FiO2: 47\n Physical Examination\n General: Sedated\n HEENT: ETT tube in place\n Neck: supple\n Lungs: decreased breath sounds\n CV: tachycardic, no mumurs\n Abdomen: soft, obese, decreased BS\n Ext: Warm, well perfused\n Neuro: sedated\n Labs / Radiology\n 124 K/uL\n 10.0 g/dL\n 170 mg/dL\n 1.4 mg/dL\n 20 mEq/L\n 3.6 mEq/L\n 15 mg/dL\n 92 mEq/L\n 127 mEq/L\n 29.6 %\n 14.9 K/uL\n [image002.jpg]\n 04:43 PM\n 06:24 PM\n 09:48 PM\n 01:22 AM\n 03:35 AM\n 04:58 AM\n WBC\n 19.0\n 18.7\n 14.9\n Hct\n 31.4\n 30.4\n 29.6\n Plt\n 173\n 147\n 124\n Cr\n 0.8\n 1.2\n 1.4\n TCO2\n 15\n 21\n 23\n Glucose\n 66\n 142\n 170\n Other labs: PT / PTT / INR:19.5/71.6/1.8, ALT / AST:191/898, Alk Phos /\n T Bili:231/15.5, Amylase / Lipase:/516, Lactic Acid:4.0 mmol/L,\n Albumin:2.7 g/dL, Ca++:5.7 mg/dL, Mg++:2.1 mg/dL, PO4:3.2 mg/dL\n RUQ Ultrasound: Limited study demonstrating marked liver echogenicity,\n consistent with fatty infiltration, although more severe liver disease\n including significant hepatic fibrosis and cirrhosis cannot be excluded\n on this study. There is no intrahepatic biliary dilatation, and the\n common bile duct measures 4 mm. There is normal flow in the portal\n vein.\n Assessment and Plan\n 28 year old male with a history of alcoholism presenting with acute\n hepatitis, pancreatitis, and UGIB.\n .\n # Respiratory Failure. Unclear etiology of hypoxia: Patient electively\n intubated for EGD then extubated. Required NRB to maintain sats in 90s.\n Continue tachypnea to the 40s, tired, CO2 increased, then reintubated.\n Initial CXR unremarkable. Concern for progression to /ARDS secondary\n to pancreatitis.\n - ARDSnet ventilator settings\n - monitor abdominal pressures\n - fentanyl and versed for sedation\n - wean settings as tolerated\n - repeat ABG this afternoon\n .\n # Pancreatitis: Most likely alcoholic in etiology, lipase peaked at\n 1600. CT scan shows probable 30% necrosis. Complicated by SIRS\n physiology. Significant hypotension, required large volume fluid to\n maintain pressures overnight. Now on phenylephrine. Also with\n leukocytosis likely related to pancreatitis but low threshold to treat\n for infection. Per surgery currently not treating with antibiotics.\n - aggressive IV hydration\n - attempt to wean neo\n - place arterial line for BP monitoring\n - wean propofol\n - strict NPO (no PO meds)\n - f/u cultures\n - f/u final CT read\n - trend lipase\n - f/u am lipid panel\n - f/u surgery recs\n .\n # Acute Hepatitis: Likely alcoholic hepatitis. CT scan shows fatty\n infiltration, and no evidence of distal obstruction. RUQ u/s shows\n marked liver echogenicity.\n - f/u viral hepatitis panel\n - trend LFTs\n - f/u GI recs\n .\n # Hematemesis: EGD showed diuelafoy's lesion. Crit stable.\n -f/u GI recs\n -continue PPI\n -maintain active type and screen\n .\n # Hyponatremia: Most likely due to volume depletion. Patient markedly\n dry on initial exam. also reflect a more chronic long-term liver\n disease. Improving 127 from 118.\n - continue to follow\n # Alcoholism: Patient describes history of withdrawl symptoms, but not\n prior seizure. Last drink was night prior to presenation.\n Tachycardia, weakness, and elevated lactate could be consistent with\n thiamine deficiency.\n - thiamine level pending\n - thiamine, vb12, folate\n - valium with CIWA > 10\n - social work consult when medically stable\n .\n # FEN: IVF, replete electrolytes, NPO\n .\n # Prophylaxis: scds, PPI\n .\n # Access: pIV, plan to d/c cordis and place IJ to monitor CVPs\n .\n # Code: Full Code\n .\n # Disposition: ICU\n ICU Care\n Nutrition: NPO\n Glycemic Control:\n Lines:\n 18 Gauge - 01:49 PM\n 16 Gauge - 01:50 PM\n Cordis/Introducer - 02:05 PM\n 20 Gauge - 03:33 AM\n Prophylaxis:\n DVT: SCDs\n Stress ulcer: PPIs\n VAP:\n Comments:\n Communication: Comments: will attempt to locate next of \n Code status: full\n Disposition:ICU\n ------ Protected Section ------\n MICU ATTENDING ADDENDUM\n I saw and examined the patient, and was physically present with the ICU\n team for the key portions of the services provided. I agree with the\n note above, including the assessment and plan. I would emphasize and\n add the following points: 28M EtOH abuse, weakness, fatigue, UGIB c/b\n hematemesis / melena. Last drank 18h PTA. In ED, SBP 50/p c HR 150s, rx\n IVF x5L, 1 unit PRBC, cipro / flagyl. Imaging notable for pancreatitis\n and fatty liver changes. 16L IVF o/n, reintubated on high dose sedation\n and low dose neo. Lactate down from 8 to 3.\n Exam notable for Tm 99.9 BP 95/50 HR 105 RR 35 with sat 100 on VAC\n 500x12 1.0 5. +TBB. Sedated, min responsive. Hyperdynamic. Bronchial BS\n B. RRR s1s2. Distended, minimal bowel sounds. 2+ edema. Labs notable\n for WBC 15K, HCT 30, K+ 3.6, Cr 1.4, AG 15, lactate 3.6, TB 15, Lip\n 516, INR 1.8. CXR with elevated ETT, evolving ARDS.\n Agree with plan to manage resp failure with low volume ventilation for\n evolving /ARDS (380x24); will follow IAP and would place balloon if\n compliance or oxygenation worsens but suspect a large component of his\n poor compliance is due to extrinsic restriction. Need to get him off\n propofol given ongoing issues with pancreatitis and long expected ICU\n course. Continue volume resuscitation, goal UOP >30cc/h, CVP >15 and\n minimal PPV on arterial line tracing. UGIB from Dieulafois lesion at\n GEJ appears stable, will monitor serial HCT and continue PPI IV. Will\n check HCT q6h and recheck coags this PM, but will hold on FFP for now.\n Will continue to use volume and RBCs to keep HCT >30 and CVP >12 -\n needs art line and CVL with d/c groin cordis. Pancreatitis likely due\n to EtOH, NPO, following, hold ABX but pancx and check bedside USG\n for possible ascites / peritonitis especially if IAP elevated; low\n threshold to add meropenem if he deteriorates. AG acidosis is\n improving, as are other metabolic parameters. For fatty liver will\n check hep serologies but suspect alcoholic hepatitis is the major issue\n will provide supportive care and follow labs while holding off on\n steroids given ongoing GIB. Needs SW consult to reach out to family.\n Remainder of plan as outlined above.\n Patient is critically ill\n Total time: 50 min\n ------ Protected Section Addendum Entered By: , MD\n on: 04:29 PM ------\n" }, { "category": "Nursing", "chartdate": "2131-05-18 00:00:00.000", "description": "Nursing Progress Note", "row_id": 674829, "text": "TITLE:\n Pancreatitis, acute\n Assessment:\n Pt with h/o ETOH abuse. Pancreateic enzymes and LFTs elevated. CT\n revealing 30% necrosis of pancreas. Lactate 4.1. + BS. Abdomen\n obese/distended. NPO.\n Urine output marginal 15-40cc clear amber urine hourly. SBP 85-115 with\n MAPs ranging 52-65.\n LCTAB. Remains on NRB with saturations >94%. Weak productive cough.\n Action:\n US of liver obtained.\n Pt receiving 500cc NS boluses with maintenance fluid infusing at\n 200cc/hr.\n Pt continues on Protonix drip.\n Response:\n US revealing dense cirrhosis per Dr .\n Lactate this AM\n Urine output remains marginal. Blood pressure responding well to fluid\n boluses however continues to require aggressive fluid resuscitation.\n Plan:\n Remain NPO.\n Continue Protonix until GI re-evaluates pt today.\n Continue aggressive fluid resusitiation as needs to maintain SBP >80\n and MAP >60.\n Monitor labs.\n Gastrointestinal bleed, upper (Melena, GI Bleed, GIB)\n Assessment:\n Pt presented with L NGT not putting out any drainage; no melena/no\n emesis.\n Action:\n Intubated for endoscopy\n patient was extremely difficult/impossible to\n sedate properly for procedure, necessitating large doses of sedatives\n (see metavision and ); endoscopy; resent crit. On\n Octreotide/protonix gtts.\n Response:\n Pt became barely sedated after multiple gtts initiated; able to\n tolerate endoscopy. Repeat crit stable, slightly decreased but in\n setting of multiple fluid boluses. Endoscopy showed multiple gastric\n erosion sites. No active bleeding site indentified. NGT D/Ced. No\n evidence of varices so Octreotide gtt D/Ced.\n Plan:\n NPO; monitor crit closely; continue protonix gtt until at least\n tomorrow per GI.\n Alcohol withdrawal (including delirium tremens, DTs, seizures)\n Assessment:\n Pt drinks daily in large quantities, hard liquor. Reports at times,\n feeling tremulous at home if he has not had a drink in a while. Pt last\n drank night of . Patient appears anxious, tachycardic, tremulous,\n slightly diaphoretic and confused as to date.\n Action:\n Followed CIWA scale. Patient\ns CIWA scale 11. Ativan administered,\n later diazepam when Ativan discontinued.\n Response:\n Patient slightly less tremulous; remembers date and recalls location\n (; ICU) better than he did when first presenting to SICU.\n Plan:\n Continue to follow CIWA scale and treat with diazepam when CIWA scale\n above 10. Monitor closely.\n" }, { "category": "Nursing", "chartdate": "2131-05-18 00:00:00.000", "description": "Nursing Progress Note", "row_id": 674832, "text": "TITLE:\n Pancreatitis, acute\n Assessment:\n Pt with h/o ETOH abuse. Pancreateic enzymes and LFTs elevated. CT\n revealing 30% necrosis of pancreas. Lactate 4.1. + BS. Abdomen\n obese/distended. NPO.\n Urine output marginal 15-40cc clear amber urine hourly. SBP 85-125 with\n MAPs ranging 52-100.\n LCTAB. Remains on NRB with saturations >94%. Weak productive cough.\n Tachypneic w/RR 28-50.\n Action:\n US of liver obtained.\n Pt receiving 500cc NS boluses with maintenance fluid infusing at\n 300cc/hr.\n Pt continues on Protonix drip.\n ABG obtained. Monitoring labs.\n Response:\n US revealing dense cirrhosis per Dr .\n Lactate this AM\n Urine output remains marginal. Blood pressure responding well to fluid\n boluses however continues to require aggressive fluid resuscitation.\n Remains tachypneic appearing to tire out.\n Plan:\n Remain NPO.\n Continue Protonix until GI re-evaluates pt today.\n Continue aggressive fluid resuscitation as needs to maintain SBP >80\n and MAP >60.\n Monitor labs treating as needed.\n Alcohol withdrawal (including delirium tremens, DTs, seizures)\n Assessment:\n Pt drinks hard liquor daily in large quantities. Last drink night of\n .\n Pt appearing anxious in bed. Tachycardic with HR 130-140s with feelings\n of tremors. Diaphoretic. Oriented x3.\n Action:\n Following CIWA scale and administering Diazepam for score >10.\n Response:\n Pt appearing more comfortable and less anxious and restless. No tremors\n noted.\n Palms remain clammy.\n Plan:\n Continue to monitor closely and follow CIWA scale and treat with\n Diazepam when CIWA score >10.\n" }, { "category": "Nursing", "chartdate": "2131-05-18 00:00:00.000", "description": "Nursing Progress Note", "row_id": 674889, "text": "TITLE:\n Pancreatitis, acute\n Assessment:\n Pt with h/o ETOH abuse. Pancreateic enzymes and LFTs\n elevated. CT revealing 30% necrosis of pancreas.\n Afebrile. Lactate 4.1. + BS. Abdomen obese/distended. NPO.\n Urine output marginal 15-40cc clear amber urine hourly. SBP\n 85-125 with MAPs ranging 52-100. +PP.\n LCTAB. Remains on NRB with saturations >94%. Weak productive\n cough. Tachypneic w/RR 28-50.\n Pt appearing anxious in bed. Tachycardic with HR 130-140\n with feelings of tremors. Diaphoretic. Oriented x3. Following CIWA\n scale and treating for score >10 with Diazepam. Progressively overnight\n pt remained tachypneic appearing increasingly tired and lethargic with\n oxygen saturation falling to 89-92% while on NRB. Dr into speak\n with pt regarding need for intubation.\n Action:\n US of liver obtained. General surgery into evaluate pt.\n Pt receiving 500cc NS boluses with maintenance fluid\n infusing at 300cc/hr and Sodium Bicarb at 250cc/hr.\n Pt continues on Protonix drip.\n Monitoring labs.\n Pt intubated at approx 0240 for impending respiratory\n failure. Placed on CMV Rate 24 100% FiO2. OG tube placed. Pt sedated\n on Propofol/Fentanyl/Versed.\n Response:\n US revealing dense cirrhosis per Dr .\n Lactate this AM 3.7\n Urine output remains marginal (Dr notified). Blood\n pressure responds fairly to fluid boluses however continues to require\n aggressive fluid resuscitation. Pt started on Neo for additional blood\n pressure support while sedated. Tachycardia improved with HR 105-110.\n Lungs clear to rhonchorous. Scant to no secretions.\n Plan:\n Remain NPO. Obtain x-ray to confirm OG placement.\n Continue Protonix until GI re-evaluates pt today.\n Continue aggressive fluid resuscitation and titrating Neo as\n needs to maintain SBP >80 and MAP >60. Continue\n Propofol/Fentanyl/Versed drips.\n Monitor labs treating as needed.\n ? Placement of arterial line and/or central line.\n" }, { "category": "Physician ", "chartdate": "2131-05-18 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 674900, "text": "Chief Complaint:\n 24 Hour Events:\n CORDIS/INTRODUCER - START 02:05 PM\n INVASIVE VENTILATION - START 02:45 PM\n ENDOSCOPY - At 05:00 PM\n INVASIVE VENTILATION - STOP 05:36 PM\n ULTRASOUND - At 08:30 PM\n liver.\n INVASIVE VENTILATION - START 02:50 AM\n INVASIVE VENTILATION - STOP 05:41 AM\n - Intubated for EGD, shows diulefoy lesion, extubated\n - Required multiple liters of fluid to maintain BPs, 12 + liters\n positive Reintubated early am for tiring, increasing CO2\n - Started on pressors\n - c/s as CT shows 30% of necrotic pancreas\n - Started on phenylephrine this am\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Fentanyl (Concentrate) - 200 mcg/hour\n Midazolam (Versed) - 10 mg/hour\n Pantoprazole (Protonix) - 8 mg/hour\n Propofol - 100 mcg/Kg/min\n Phenylephrine - 1.2 mcg/Kg/min\n Other ICU medications:\n Lorazepam (Ativan) - 02:45 PM\n Pantoprazole (Protonix) - 03:05 PM\n Midazolam (Versed) - 04:55 PM\n Propofol - 05:00 PM\n Fentanyl - 05:05 PM\n Hydromorphone (Dilaudid) - 06:57 PM\n Diazepam (Valium) - 02:00 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 05:49 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.7\nC (99.9\n Tcurrent: 37\nC (98.6\n HR: 105 (105 - 149) bpm\n BP: 101/47(61) {74/34(42) - 131/98(104)} mmHg\n RR: 24 (24 - 48) insp/min\n SpO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 9,057 mL\n 4,457 mL\n PO:\n TF:\n IVF:\n 5,557 mL\n 4,457 mL\n Blood products:\n Total out:\n 544 mL\n 170 mL\n Urine:\n 544 mL\n 170 mL\n NG:\n Stool:\n Drains:\n Balance:\n 8,513 mL\n 4,287 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 16\n RR (Spontaneous): 2\n PEEP: 10 cmH2O\n FiO2: 100%\n PIP: 39 cmH2O\n Plateau: 28 cmH2O\n SpO2: 100%\n ABG: 7.34/41/47/20/-3\n Ve: 15.6 L/min\n PaO2 / FiO2: 47\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 124 K/uL\n 10.0 g/dL\n 170 mg/dL\n 1.4 mg/dL\n 20 mEq/L\n 3.6 mEq/L\n 15 mg/dL\n 92 mEq/L\n 127 mEq/L\n 29.6 %\n 14.9 K/uL\n [image002.jpg]\n 04:43 PM\n 06:24 PM\n 09:48 PM\n 01:22 AM\n 03:35 AM\n 04:58 AM\n WBC\n 19.0\n 18.7\n 14.9\n Hct\n 31.4\n 30.4\n 29.6\n Plt\n 173\n 147\n 124\n Cr\n 0.8\n 1.2\n 1.4\n TCO2\n 15\n 21\n 23\n Glucose\n 66\n 142\n 170\n Other labs: PT / PTT / INR:19.5/71.6/1.8, ALT / AST:191/898, Alk Phos /\n T Bili:231/15.5, Amylase / Lipase:/516, Lactic Acid:4.0 mmol/L,\n Albumin:2.7 g/dL, Ca++:5.7 mg/dL, Mg++:2.1 mg/dL, PO4:3.2 mg/dL\n Assessment and Plan\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ALCOHOL WITHDRAWAL (INCLUDING DELIRIUM TREMENS, DTS, SEIZURES)\n ALCOHOL ABUSE\n PANCREATITIS, ACUTE\n GASTROINTESTINAL BLEED, UPPER (MELENA, GI BLEED, GIB)\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 01:49 PM\n 16 Gauge - 01:50 PM\n Cordis/Introducer - 02:05 PM\n 20 Gauge - 03:33 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: full\n Disposition:ICU\n" }, { "category": "Physician ", "chartdate": "2131-05-18 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 674906, "text": "Chief Complaint:\n 24 Hour Events:\n CORDIS/INTRODUCER - START 02:05 PM\n INVASIVE VENTILATION - START 02:45 PM\n ENDOSCOPY - At 05:00 PM\n INVASIVE VENTILATION - STOP 05:36 PM\n ULTRASOUND - At 08:30 PM\n liver.\n INVASIVE VENTILATION - START 02:50 AM\n INVASIVE VENTILATION - STOP 05:41 AM\n - Intubated for EGD, shows diulefoy lesion, extubated\n - Required multiple liters of fluid to maintain BPs, 12 + liters\n positive Reintubated early am for tiring, increasing CO2\n - Started on pressors\n - c/s as CT shows 30% of necrotic pancreas\n - Started on phenylephrine this am\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Fentanyl (Concentrate) - 200 mcg/hour\n Midazolam (Versed) - 10 mg/hour\n Pantoprazole (Protonix) - 8 mg/hour\n Propofol - 100 mcg/Kg/min\n Phenylephrine - 1.2 mcg/Kg/min\n Other ICU medications:\n Lorazepam (Ativan) - 02:45 PM\n Pantoprazole (Protonix) - 03:05 PM\n Midazolam (Versed) - 04:55 PM\n Propofol - 05:00 PM\n Fentanyl - 05:05 PM\n Hydromorphone (Dilaudid) - 06:57 PM\n Diazepam (Valium) - 02:00 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 05:49 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.7\nC (99.9\n Tcurrent: 37\nC (98.6\n HR: 105 (105 - 149) bpm\n BP: 101/47(61) {74/34(42) - 131/98(104)} mmHg\n RR: 24 (24 - 48) insp/min\n SpO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 9,057 mL\n 4,457 mL\n PO:\n TF:\n IVF:\n 5,557 mL\n 4,457 mL\n Blood products:\n Total out:\n 544 mL\n 170 mL\n Urine:\n 544 mL\n 170 mL\n NG:\n Stool:\n Drains:\n Balance:\n 8,513 mL\n 4,287 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 16\n RR (Spontaneous): 2\n PEEP: 10 cmH2O\n FiO2: 100%\n PIP: 39 cmH2O\n Plateau: 28 cmH2O\n SpO2: 100%\n ABG: 7.34/41/47/20/-3\n Ve: 15.6 L/min\n PaO2 / FiO2: 47\n Physical Examination\n General: Sedated\n HEENT: ETT tube in place\n Neck: supple\n Lungs: decreased breath sounds\n CV: tachycardic with normal rhytyhm, normal S1 + S2, no murmurs, rubs,\n gallops\n Abdomen: soft, non tender\n Ext: Warm, well perfused\n Neuro: sedated\n Labs / Radiology\n 124 K/uL\n 10.0 g/dL\n 170 mg/dL\n 1.4 mg/dL\n 20 mEq/L\n 3.6 mEq/L\n 15 mg/dL\n 92 mEq/L\n 127 mEq/L\n 29.6 %\n 14.9 K/uL\n [image002.jpg]\n 04:43 PM\n 06:24 PM\n 09:48 PM\n 01:22 AM\n 03:35 AM\n 04:58 AM\n WBC\n 19.0\n 18.7\n 14.9\n Hct\n 31.4\n 30.4\n 29.6\n Plt\n 173\n 147\n 124\n Cr\n 0.8\n 1.2\n 1.4\n TCO2\n 15\n 21\n 23\n Glucose\n 66\n 142\n 170\n Other labs: PT / PTT / INR:19.5/71.6/1.8, ALT / AST:191/898, Alk Phos /\n T Bili:231/15.5, Amylase / Lipase:/516, Lactic Acid:4.0 mmol/L,\n Albumin:2.7 g/dL, Ca++:5.7 mg/dL, Mg++:2.1 mg/dL, PO4:3.2 mg/dL\n RUQ Ultrasound: Limited study demonstrating marked liver echogenicity,\n consistent with fatty infiltration, although more severe liver disease\n including significant hepatic fibrosis and cirrhosis cannot be excluded\n on this study. There is no intrahepatic biliary dilatation, and the\n common bile duct measures 4 mm. There is normal flow in the portal\n vein.\n Assessment and Plan\n 28 year old male with a history of alcoholism presenting with acute\n hepatitis, pancreatitis, and UGIB.\n .\n # Hematemesis: EGD showed diuelafoy's lesion.\n -f/u GI recs\n -continue PPI\n .\n # Hypoxia: Patient electively intubated for EGD then extubated. Has\n required NRB to maintain sats in 90s. Initial CXR unremarkable. Concern\n for ARDS secondary to pancreatitis.\n .\n # Pancreatitis: Most likely alcoholic in etiology, with elevated\n lipase to 1600. CT shows ? 30 % necrosis.\n - continue aggessive hydration\n - serial abdominal exams\n - trend lipase\n - f/u am lipid panel\n - f/u surgery recs\n .\n # Acute Hepatitis: Likely alcoholic hepatitis. CT scan shows fatty\n infiltration, and no evidence of distal obstruction.\n - f/u viral hepatitis panel\n - hepatology following\n - avoid hepatically cleared meds\n - trend LFTs\n .\n # Leukocytosis: Marked leukocytosis with low grade temperature, lactate\n trending down. UA with + wbcs in ED, but repeat negative. be\n secondary to pancreatitis, however cannot rule out infection. Urine and\n blood cultures pending.\n - f/u blood cultures and urine culture\n - f/u final CT read\n .\n # Hyponatremia: Most likely due to volume depletion in the setting of\n inability to tolerate POs. Patient markedly dry on exam. also\n reflect a more chronic long-term liver disease.\n - fluid repletion as given above\n - consider sending urine lytes this am\n # Alcoholism: Patient describes history of withdrawl symptoms, but not\n prior seizure. Last drink was night prior to presenation.\n Tachycardia, weakness, and elevated lactate could be consistent with\n thiamine deficiency.\n - thiamine, vb12, folate\n - valium with CIWA > 10\n - social work consult when medically stable\n .\n # FEN: IVF, replete electrolytes, NPO\n .\n # Prophylaxis: scds, PPI gtt\n .\n # Access: peripherals and femoral cortis\n .\n # Code: Full Code\n .\n # Disposition: ICU\n ICU Care\n Nutrition: NPO\n Glycemic Control:\n Lines:\n 18 Gauge - 01:49 PM\n 16 Gauge - 01:50 PM\n Cordis/Introducer - 02:05 PM\n 20 Gauge - 03:33 AM\n Prophylaxis:\n DVT: SCDs\n Stress ulcer: PPIs\n VAP:\n Comments:\n Communication: Comments:\n Code status: full\n Disposition:ICU\n" }, { "category": "Nutrition", "chartdate": "2131-05-18 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 675101, "text": "Subjective: Patient intubated and sedated.\n Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 170 cm\n 113.5 kg\n 111.3 kg ( 07:00 AM)\n 39.1\n Ideal body weight\n % Ideal body weight\n Adjusted weight\n Usual body weight\n % Usual body weight\n 67.1 kg\n 169%\n 79kg\n Diagnosis: Pancreatitis\n PMH : Heavy ETOH (6 large hard alcohol drinks per day)\n Food allergies and intolerances: no known food allergies.\n Pertinent medications: RISS, Thaimine, cyanocobalamin, Mvit, Fentanyl,\n Versed, Phenylephrine, others noted\n Labs:\n Value\n Date\n Glucose\n 131 mg/dL\n 02:33 PM\n Glucose Finger Stick\n 159\n 04:00 PM\n BUN\n 15 mg/dL\n 02:33 PM\n Creatinine\n 1.4 mg/dL\n 03:35 AM\n Sodium\n 127 mEq/L\n 03:35 AM\n Potassium\n 3.6 mEq/L\n 03:35 AM\n Chloride\n 92 mEq/L\n 03:35 AM\n TCO2\n 20 mEq/L\n 03:35 AM\n PO2 (arterial)\n 95. mm Hg\n 02:51 PM\n PCO2 (arterial)\n 35 mm Hg\n 02:51 PM\n pH (arterial)\n 7.38 units\n 02:51 PM\n pH (urine)\n 6.5 units\n 08:00 PM\n CO2 (Calc) arterial\n 22 mEq/L\n 02:51 PM\n Albumin\n 2.7 g/dL\n 09:48 PM\n Calcium non-ionized\n 5.9 mg/dL\n 02:33 PM\n Phosphorus\n 2.1 mg/dL\n 02:33 PM\n Ionized Calcium\n 0.84 mmol/L\n 02:51 PM\n Magnesium\n 1.9 mg/dL\n 02:33 PM\n ALT\n 180 IU/L\n 02:33 PM\n Alkaline Phosphate\n 228 IU/L\n 02:33 PM\n AST\n 838 IU/L\n 02:33 PM\n Amylase\n 112 IU/L\n 02:33 PM\n Total Bilirubin\n 15.5 mg/dL\n 02:33 PM\n WBC\n 16.4 K/uL\n 02:33 PM\n Hgb\n 10.3 g/dL\n 02:33 PM\n Hematocrit\n 28.4 %\n 02:33 PM\n Current diet order / nutrition support: Diet: NPO\n GI: abd firm, distended, absent bowel sounds\n Assessment of Nutritional Status\n Obese, At risk for malnutrition\n Pt at risk due to: chronic ETOH, possible prolonged intubation\n Estimated Nutritional Needs (based on adjusted wt)\n Calories: 1580- (BEE x or / 20-25 cal/kg)\n Protein: 94-119 (1.2-1.5 g/kg)\n Fluid: per team\n Estimation of previous intake: Excessive\n Estimation of current intake: Inadequate\n Specifics:\n 28 year old male with a h/o ETOH presenting with acute hepatitis,\n pancreatitis, and UGIB. Patient was found to have a lesion at GEJ on\n his EGD, and is still putting out small amount of blood from OGT, but\n HCT is stable RN. Pancreas scan showed 30% necrosis of pancreas.\n Patient is currently very unstable: intubated, sedated, on pressor\n support, and with a Na of 127. Would recommend holding off on feeding\n patient until patient is more stable. Would recommend enteral feeding\n via an NJT (with tip of tube past ligament of trietz to avoid\n stimulating the pancreas) over TPN as eventual feeding goal. Will\n provide recommendations below for both TPN and tube feeds.\n Medical Nutrition Therapy Plan - Recommend the Following\n 1) For enteral feeds, recommend placing a feeding tube past the\n ligament of trietz, with tube feed goal of Replete with Fiber @ 70cc/hr\n (1680kcals, 104g protein) to meet 100% estimated needs.\n 2) If TPN is started, recommend goal of 70kg 3-in-1.\n 3) Will follow plan/progress.\n Please page with any questions. #\n" }, { "category": "Social Work", "chartdate": "2131-05-18 00:00:00.000", "description": "Social Work Progress Note", "row_id": 675153, "text": "28 yr old gentleman presented to ED yesterday accompanied by his\n friend/roommate . Per nursing pt was refusing to allow\n staff to contact his , pt has no health care proxy, spouse or\n children. Today pt is intubated and in critical condition. Met with\n MICU Attending who is in agreement that pt is to sick and that it is\n necessary to reach out to his .\n , and are both physicians, found the phone #\n to their practice on line (. Referred to the\n Attending, they will arrive here shortly .\n" }, { "category": "Physician ", "chartdate": "2131-05-19 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 675366, "text": "Chief Complaint:\n 24 Hour Events:\n ARTERIAL LINE - START 01:35 PM\n MULTI LUMEN - START 02:02 PM\n -large volume fluid recussitation, 1 lt/hr + max neo, +levo\n -2uPRBC\n -overbreathing vent, increased midaz/fent\n -hypoxic, increased peep and fio2\n -elevated bladder pressures to 25 then 31; surgery wants to wait\n -surgery declined need for abx\n -family updated\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Norepinephrine - 0.03 mcg/Kg/min\n Phenylephrine - 5 mcg/Kg/min\n Midazolam (Versed) - 20 mg/hour\n Fentanyl (Concentrate) - 500 mcg/hour\n Other ICU medications:\n Pantoprazole (Protonix) - 09:30 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:12 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: 36.9\nC (98.4\n HR: 114 (103 - 118) bpm\n BP: 75/56(64) {74/43(59) - 95/62(72)} mmHg\n RR: 31 (20 - 36) insp/min\n SpO2: 98%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 111.3 kg (admission): 113.5 kg\n Height: 67 Inch\n CVP: 28 (18 - 33)mmHg\n Bladder pressure: 26 (15 - 31) mmHg\n Total In:\n 24,249 mL\n 3,827 mL\n PO:\n TF:\n IVF:\n 23,549 mL\n 3,827 mL\n Blood products:\n 700 mL\n Total out:\n 377 mL\n 143 mL\n Urine:\n 377 mL\n 143 mL\n NG:\n Stool:\n Drains:\n Balance:\n 23,872 mL\n 3,684 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 500) mL\n RR (Set): 24\n RR (Spontaneous): 6\n PEEP: 20 cmH2O\n FiO2: 100%\n RSBI Deferred: PEEP > 10\n PIP: 40 cmH2O\n Plateau: 37 cmH2O\n Compliance: 26.7 cmH2O/mL\n SpO2: 98%\n ABG: 7.30/35/87./15/-7\n Ve: 13.6 L/min\n PaO2 / FiO2: 88\n Physical Examination\n General: Sedated\n HEENT: ETT tube in place\n Neck: supple\n Lungs: decreased breath sounds\n CV: tachycardic, no mumurs\n Abdomen: soft, obese, decreased BS\n Ext: Warm, well perfused\n Neuro: sedated\n Labs / Radiology\n 133 K/uL\n 12.2 g/dL\n 109 mg/dL\n 1.4 mg/dL\n 15 mEq/L\n 3.7 mEq/L\n 13 mg/dL\n 97 mEq/L\n 128 mEq/L\n 35.8 %\n 19.5 K/uL\n [image002.jpg]\n 02:33 PM\n 02:51 PM\n 07:56 PM\n 08:11 PM\n 09:50 PM\n 12:22 AM\n 02:14 AM\n 02:34 AM\n 04:33 AM\n 06:10 AM\n WBC\n 16.4\n 16.1\n 19.5\n Hct\n 28.4\n 27.4\n 35.8\n Plt\n 132\n 135\n 133\n Cr\n 1.6\n 1.7\n 1.4\n TCO2\n 22\n 18\n 17\n 17\n 19\n 18\n 18\n Glucose\n 131\n 105\n 109\n Other labs: PT / PTT / INR:21.1/72.2/2.0, ALT / AST:153/640, Alk Phos /\n T Bili:229/15.5, Amylase / Lipase:78/268, Lactic Acid:3.1 mmol/L,\n Albumin:2.3 g/dL, LDH:616 IU/L, Ca++:7.9 mg/dL, Mg++:2.5 mg/dL, PO4:2.5\n mg/dL\n Assessment and Plan\n 28 year old male with a history of alcoholism presenting with\n necrotizing pancreatitis, ARDS, elevated IAP and UGIB.\n # Respiratory Failure. ARDS related to necrotizing pancreatis\n compounded by hypoxia, tachypnea in setting of anion gap metabolic\n acidosis, increased abdominal pressure, and etoh withdrawl.\n - ARDSnet ventilator settings with stable Vt and p02 in 70s\n - Permissible tachypnea is tolerated in setting of AGMA; monitor for\n stacked breaths and if so then paralysis.\n monitor abdominal pressures\n - PEEP of 20 to overcome IAP; elevated peak aw pressures so will check\n ballon pressure to address if this elevated IAP or thoracic\n pressures.\n -maxed out on fentanyl and versed for sedation\n # Shock/Necrotizing pancreatitis: EtOH induced. Requiring large volume\n fluid resuscitation as well as maxed neo and low dose levo.\n - continue fluids; if appropriate will use vigileo to determine\n resuscitative capacity. No surgical benefit at this time.\n - wean levo and monitor UOP\n - add meropenem for ppx\n - monitor lactate lipase and AGMA\n # IAP elevation: secondary to third spacing and edema. Bladder\n pressures as high as 31. Will use groin cordis to better measure\n pressure. Surgery recommends no intervention currently. If ventilation\n is impeded by increased IAP, if decrease in UOP, if worsened\n AGMA/lactate will consider surgical release of pressures if surgery\n deems appropriate.\n # Acute hepatitis: Likely alcoholic hepatiis with fatty infiltration,\n and no evidence of distal obstruction. RUQ u/s shows marked liver\n echogenicity but no ascites.\n - f/u viral hepatitis panel, LFTs\n # Hematemesis: EGD showed diuelafoy's lesion. HCT over 30 s/p 2xpRBC\n on . HCT>30\n # Hyponatremia, hypervolemic: secondary to aggressive resuscitation.\n Improved.\n # Alcoholism: Patient describes history of withdrawl symptoms, but not\n prior seizure. Last drink was night prior to presenation.\n Tachycardia, weakness, and elevated lactate could be consistent with\n thiamine deficiency.\n - thiamine, vb12, folate\n - valium with CIWA > 10\n # FEN: IVF, replete electrolytes, NPO\n # Prophylaxis: scds, PPI\n # Access: pIV, plan to d/c cordis and place IJ to monitor CVPs\n # Code: Full Code\n # Disposition: ICU\n # Family updated\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 01:49 PM\n 16 Gauge - 01:50 PM\n Cordis/Introducer - 02:05 PM\n 20 Gauge - 03:33 AM\n Arterial Line - 01:35 PM\n Multi Lumen - 02:02 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": "2131-05-17 00:00:00.000", "description": "Nursing Progress Note", "row_id": 674815, "text": "Pancreatitis, acute\n Assessment:\n Pt with h/o etoh abuse (6\nlarge\n hard liquor drinks per day). Panc\n enymes/LFTs elevated. CT remarkable for pancreatitis and fatty liver\n changes. Lactate 8.1 in ED. + Bowel sounds in all 4 quads; abdomen\n obese/distended.\n Action:\n NPO; 2L NS boluses; NS maintenance fluid for several hours now\n maintenance fluid of D5W with 3 amps of Bicarb\n Response:\n Patient\ns urine output has decreased and continues to require\n aggressive fluid resuscitation.\n Plan:\n Remain NPO; fluid resuscitation; continue to monitor labs; surgery\n consult now since second of CT shows 30% of pancreas necrotic.\n Gastrointestinal bleed, upper (Melena, GI Bleed, GIB)\n Assessment:\n Pt presented with L NGT not putting out any drainage; no melena/no\n emesis.\n Action:\n Intubated for endoscopy\n patient was extremely difficult/impossible to\n sedate properly for procedure, necessitating large doses of sedatives\n (see metavision and ); endoscopy; resent crit. On\n Octreotide/protonix gtts.\n Response:\n Pt became barely sedated after multiple gtts initiated; able to\n tolerate endoscopy. Repeat crit stable, slightly decreased but in\n setting of multiple fluid boluses. Endoscopy showed multiple gastric\n erosion sites. No active bleeding site indentified. NGT D/Ced. No\n evidence of varices so Octreotide gtt D/Ced.\n Plan:\n NPO; monitor crit closely; continue protonix gtt until at least\n tomorrow per GI.\n" }, { "category": "Nursing", "chartdate": "2131-05-17 00:00:00.000", "description": "Nursing Progress Note", "row_id": 674816, "text": "Pancreatitis, acute\n Assessment:\n Pt with h/o etoh abuse (6\nlarge\n hard liquor drinks per day). Panc\n enymes/LFTs elevated. CT remarkable for pancreatitis and fatty liver\n changes. Lactate 8.1 in ED. + Bowel sounds in all 4 quads; abdomen\n obese/distended.\n Action:\n NPO; 2L NS boluses; NS maintenance fluid for several hours now\n maintenance fluid of D5W with 3 amps of Bicarb\n Response:\n Patient\ns urine output has decreased and continues to require\n aggressive fluid resuscitation.\n Plan:\n Remain NPO; fluid resuscitation; continue to monitor labs; surgery\n consult now since second of CT shows 30% of pancreas necrotic.\n Gastrointestinal bleed, upper (Melena, GI Bleed, GIB)\n Assessment:\n Pt presented with L NGT not putting out any drainage; no melena/no\n emesis.\n Action:\n Intubated for endoscopy\n patient was extremely difficult/impossible to\n sedate properly for procedure, necessitating large doses of sedatives\n (see metavision and ); endoscopy; resent crit. On\n Octreotide/protonix gtts.\n Response:\n Pt became barely sedated after multiple gtts initiated; able to\n tolerate endoscopy. Repeat crit stable, slightly decreased but in\n setting of multiple fluid boluses. Endoscopy showed multiple gastric\n erosion sites. No active bleeding site indentified. NGT D/Ced. No\n evidence of varices so Octreotide gtt D/Ced.\n Plan:\n NPO; monitor crit closely; continue protonix gtt until at least\n tomorrow per GI.\n Alcohol withdrawal (including delirium tremens, DTs, seizures)\n Assessment:\n Pt drinks daily in large quantities, hard liquor. Reports at times,\n feeling tremulous at home if he has not had a drink in a while. Pt last\n drank night of . Patient appears anxious, tachycardic, tremulous,\n slightly diaphoretic and confused as to date.\n Action:\n Followed CIWA scale. Patient\ns CIWA scale 11. Ativan administered,\n later diazepam when Ativan discontinued.\n Response:\n Patient slightly less tremulous; remembers date and recalls location\n (; ICU) better than he did when first presenting to SICU.\n Plan:\n Continue to follow CIWA scale and treat with diazepam when CIWA scale\n above 10. Monitor closely.\n" }, { "category": "Respiratory ", "chartdate": "2131-05-19 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 675243, "text": "Demographics\n Day of intubation: 2\n Day of mechanical ventilation: 2\n Ideal body weight: 67.1 None\n Ideal tidal volume: 268.4 / 402.6 / 536.8 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location: ICU\n Reason: Re-intubation\n Tube Type\n ETT:\n Position: 23 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Cuff volume: 6 mL / Air\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Small\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Nasal flaring, Accessory muscle\n use, Frequent desaturation episodes, Tachypneic (RR> 35 b/min), High\n flow demand\n Assessment of breathing comfort: No response (sleeping / sedated)\n Invasive ventilation assessment:\n Trigger work assessment: Abnormal trigger efforts (efforts during\n inspiratory)\n Dysynchrony assessment: Vigorous inspiratory efforts, Erratic exhaled\n Tidal Volumes, Frequent alarms (High pressure, High rate)\n Comments: Patient remains dysynchronous despite high amounts of\n sedation.\n Plan\n Next 24-48 hours: Maintain PEEP at current level and reduce FiO2 as\n tolerated\n Reason for continuing current ventilatory support: Cannot protect\n airway, Hemodynimic instability, Underlying illness not resolved\n" }, { "category": "Respiratory ", "chartdate": "2131-05-18 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 674880, "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: 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: 7mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Cuff volume: 6 mL / Air\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: Blood Tinged / Thick\n Sputum source/amount: Suctioned / Small\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Dysynchrony assessment: Vigorous inspiratory efforts, Erratic exhaled\n Tidal Volumes\n Comments: Patient dysynchronous when awake.\n Plan\n Next 24-48 hours: Maintain PEEP at current level and reduce FiO2 as\n tolerated\n Reason for continuing current ventilatory support: Cannot protect\n airway, Underlying illness not resolved\n Respiratory Care Shift Procedures\n Bedside Procedures:\n ABG puncture (0500)\n Comments:\n" }, { "category": "Nursing", "chartdate": "2131-05-19 00:00:00.000", "description": "Nursing Progress Note", "row_id": 675329, "text": "Hypotension (not Shock)\n Assessment:\n Increasingly hypotensive this evening\n CO decreasing from 9 to 5 overnight\n SVV 18-23\n CVP 28-30\n Action:\n Neo increased to max dose at 5mcg/kg/min\n 4 liters LR bolus given\n 2 units PRBC given\n Calcium aggressively repleated\n Levophed started at low dose\n MICU intern and resident aware of all hemodynamics\n Response:\n Maintaining Map >60\n Plan:\n Wean vasopressors as tolerated\n Evaluate need for vasopressors vs additional fluid recessitaiton.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Remains ventilated on AC\n Continues to breath over ventilator RR mid to high 30\n Sats 92-96%\n Remains in metabolic acidosis\n Action:\n ABG followed closely\n Response:\n Worsening oxygenation overnight, both FiO2 and PEEP increased\n overnight. Currently on 100% fiO2 20 Peep paO2 88. Large amounts of\n sedation although continues to overbreath and is dysicronise with vent.\n Plan:\n Cont to monitor abg closely follow up with team regarding use of\n paralytic to increase oxygenation and improve vent compliance.\n Pancreatitis, acute\n Assessment:\n Abdomen firmly distended.\n Bladder pressure 25 this evening.\n WBC increasing.\n Action:\n Micu team aware of all bladder pressures and lab values. Surgery\n resident also notified of elevated bladder pressures.\n Response:\n Fluid recisstation decreased and levophed started.\n Plan:\n Continue to monitor and follow up with surgical team.\n" }, { "category": "Physician ", "chartdate": "2131-05-19 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 675308, "text": "Chief Complaint:\n 24 Hour Events:\n ARTERIAL LINE - START 01:35 PM\n MULTI LUMEN - START 02:02 PM\n -large volume fluid recussitation, 1 lt/hr + max neo, +levo\n -2uPRBC\n -overbreathing vent, increased midaz/fent\n -hypoxic, increased peep and fio2\n -elevated bladder pressures to 25 then 31; surgery wants to wait\n -surgery declined need for abx\n -family updated\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Norepinephrine - 0.03 mcg/Kg/min\n Phenylephrine - 5 mcg/Kg/min\n Midazolam (Versed) - 20 mg/hour\n Fentanyl (Concentrate) - 500 mcg/hour\n Other ICU medications:\n Pantoprazole (Protonix) - 09:30 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:12 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: 36.9\nC (98.4\n HR: 114 (103 - 118) bpm\n BP: 75/56(64) {74/43(59) - 95/62(72)} mmHg\n RR: 31 (20 - 36) insp/min\n SpO2: 98%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 111.3 kg (admission): 113.5 kg\n Height: 67 Inch\n CVP: 28 (18 - 33)mmHg\n Bladder pressure: 26 (15 - 31) mmHg\n Total In:\n 24,249 mL\n 3,827 mL\n PO:\n TF:\n IVF:\n 23,549 mL\n 3,827 mL\n Blood products:\n 700 mL\n Total out:\n 377 mL\n 143 mL\n Urine:\n 377 mL\n 143 mL\n NG:\n Stool:\n Drains:\n Balance:\n 23,872 mL\n 3,684 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 500) mL\n RR (Set): 24\n RR (Spontaneous): 6\n PEEP: 20 cmH2O\n FiO2: 100%\n RSBI Deferred: PEEP > 10\n PIP: 40 cmH2O\n Plateau: 37 cmH2O\n Compliance: 26.7 cmH2O/mL\n SpO2: 98%\n ABG: 7.30/35/87./15/-7\n Ve: 13.6 L/min\n PaO2 / FiO2: 88\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 133 K/uL\n 12.2 g/dL\n 109 mg/dL\n 1.4 mg/dL\n 15 mEq/L\n 3.7 mEq/L\n 13 mg/dL\n 97 mEq/L\n 128 mEq/L\n 35.8 %\n 19.5 K/uL\n [image002.jpg]\n 02:33 PM\n 02:51 PM\n 07:56 PM\n 08:11 PM\n 09:50 PM\n 12:22 AM\n 02:14 AM\n 02:34 AM\n 04:33 AM\n 06:10 AM\n WBC\n 16.4\n 16.1\n 19.5\n Hct\n 28.4\n 27.4\n 35.8\n Plt\n 132\n 135\n 133\n Cr\n 1.6\n 1.7\n 1.4\n TCO2\n 22\n 18\n 17\n 17\n 19\n 18\n 18\n Glucose\n 131\n 105\n 109\n Other labs: PT / PTT / INR:21.1/72.2/2.0, ALT / AST:153/640, Alk Phos /\n T Bili:229/15.5, Amylase / Lipase:78/268, Lactic Acid:3.1 mmol/L,\n Albumin:2.3 g/dL, LDH:616 IU/L, Ca++:7.9 mg/dL, Mg++:2.5 mg/dL, PO4:2.5\n mg/dL\n Assessment and Plan\n HYPOTENSION (NOT SHOCK)\n HEPATITIS, ACUTE TOXIC (INCLUDING ALCOHOLIC, ACETAMINOPHEN, ETC.)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ALCOHOL WITHDRAWAL (INCLUDING DELIRIUM TREMENS, DTS, SEIZURES)\n ALCOHOL ABUSE\n PANCREATITIS, ACUTE\n GASTROINTESTINAL BLEED, UPPER (MELENA, GI BLEED, GIB)\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 01:49 PM\n 16 Gauge - 01:50 PM\n Cordis/Introducer - 02:05 PM\n 20 Gauge - 03:33 AM\n Arterial Line - 01:35 PM\n Multi Lumen - 02:02 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": "2131-05-19 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 675309, "text": "Chief Complaint:\n 24 Hour Events:\n ARTERIAL LINE - START 01:35 PM\n MULTI LUMEN - START 02:02 PM\n -large volume fluid recussitation, 1 lt/hr + max neo, +levo\n -2uPRBC\n -overbreathing vent, increased midaz/fent\n -hypoxic, increased peep and fio2\n -elevated bladder pressures to 25 then 31; surgery wants to wait\n -surgery declined need for abx\n -family updated\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Norepinephrine - 0.03 mcg/Kg/min\n Phenylephrine - 5 mcg/Kg/min\n Midazolam (Versed) - 20 mg/hour\n Fentanyl (Concentrate) - 500 mcg/hour\n Other ICU medications:\n Pantoprazole (Protonix) - 09:30 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:12 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: 36.9\nC (98.4\n HR: 114 (103 - 118) bpm\n BP: 75/56(64) {74/43(59) - 95/62(72)} mmHg\n RR: 31 (20 - 36) insp/min\n SpO2: 98%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 111.3 kg (admission): 113.5 kg\n Height: 67 Inch\n CVP: 28 (18 - 33)mmHg\n Bladder pressure: 26 (15 - 31) mmHg\n Total In:\n 24,249 mL\n 3,827 mL\n PO:\n TF:\n IVF:\n 23,549 mL\n 3,827 mL\n Blood products:\n 700 mL\n Total out:\n 377 mL\n 143 mL\n Urine:\n 377 mL\n 143 mL\n NG:\n Stool:\n Drains:\n Balance:\n 23,872 mL\n 3,684 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 500) mL\n RR (Set): 24\n RR (Spontaneous): 6\n PEEP: 20 cmH2O\n FiO2: 100%\n RSBI Deferred: PEEP > 10\n PIP: 40 cmH2O\n Plateau: 37 cmH2O\n Compliance: 26.7 cmH2O/mL\n SpO2: 98%\n ABG: 7.30/35/87./15/-7\n Ve: 13.6 L/min\n PaO2 / FiO2: 88\n Physical Examination\n General: Sedated\n HEENT: ETT tube in place\n Neck: supple\n Lungs: decreased breath sounds\n CV: tachycardic, no mumurs\n Abdomen: soft, obese, decreased BS\n Ext: Warm, well perfused\n Neuro: sedated\n Labs / Radiology\n 133 K/uL\n 12.2 g/dL\n 109 mg/dL\n 1.4 mg/dL\n 15 mEq/L\n 3.7 mEq/L\n 13 mg/dL\n 97 mEq/L\n 128 mEq/L\n 35.8 %\n 19.5 K/uL\n [image002.jpg]\n 02:33 PM\n 02:51 PM\n 07:56 PM\n 08:11 PM\n 09:50 PM\n 12:22 AM\n 02:14 AM\n 02:34 AM\n 04:33 AM\n 06:10 AM\n WBC\n 16.4\n 16.1\n 19.5\n Hct\n 28.4\n 27.4\n 35.8\n Plt\n 132\n 135\n 133\n Cr\n 1.6\n 1.7\n 1.4\n TCO2\n 22\n 18\n 17\n 17\n 19\n 18\n 18\n Glucose\n 131\n 105\n 109\n Other labs: PT / PTT / INR:21.1/72.2/2.0, ALT / AST:153/640, Alk Phos /\n T Bili:229/15.5, Amylase / Lipase:78/268, Lactic Acid:3.1 mmol/L,\n Albumin:2.3 g/dL, LDH:616 IU/L, Ca++:7.9 mg/dL, Mg++:2.5 mg/dL, PO4:2.5\n mg/dL\n Assessment and Plan\n HYPOTENSION (NOT SHOCK)\n HEPATITIS, ACUTE TOXIC (INCLUDING ALCOHOLIC, ACETAMINOPHEN, ETC.)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ALCOHOL WITHDRAWAL (INCLUDING DELIRIUM TREMENS, DTS, SEIZURES)\n ALCOHOL ABUSE\n PANCREATITIS, ACUTE\n GASTROINTESTINAL BLEED, UPPER (MELENA, GI BLEED, GIB)\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 01:49 PM\n 16 Gauge - 01:50 PM\n Cordis/Introducer - 02:05 PM\n 20 Gauge - 03:33 AM\n Arterial Line - 01:35 PM\n Multi Lumen - 02:02 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": "2131-05-19 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 675310, "text": "Chief Complaint:\n 24 Hour Events:\n ARTERIAL LINE - START 01:35 PM\n MULTI LUMEN - START 02:02 PM\n -large volume fluid recussitation, 1 lt/hr + max neo, +levo\n -2uPRBC\n -overbreathing vent, increased midaz/fent\n -hypoxic, increased peep and fio2\n -elevated bladder pressures to 25 then 31; surgery wants to wait\n -surgery declined need for abx\n -family updated\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Norepinephrine - 0.03 mcg/Kg/min\n Phenylephrine - 5 mcg/Kg/min\n Midazolam (Versed) - 20 mg/hour\n Fentanyl (Concentrate) - 500 mcg/hour\n Other ICU medications:\n Pantoprazole (Protonix) - 09:30 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:12 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: 36.9\nC (98.4\n HR: 114 (103 - 118) bpm\n BP: 75/56(64) {74/43(59) - 95/62(72)} mmHg\n RR: 31 (20 - 36) insp/min\n SpO2: 98%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 111.3 kg (admission): 113.5 kg\n Height: 67 Inch\n CVP: 28 (18 - 33)mmHg\n Bladder pressure: 26 (15 - 31) mmHg\n Total In:\n 24,249 mL\n 3,827 mL\n PO:\n TF:\n IVF:\n 23,549 mL\n 3,827 mL\n Blood products:\n 700 mL\n Total out:\n 377 mL\n 143 mL\n Urine:\n 377 mL\n 143 mL\n NG:\n Stool:\n Drains:\n Balance:\n 23,872 mL\n 3,684 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 500) mL\n RR (Set): 24\n RR (Spontaneous): 6\n PEEP: 20 cmH2O\n FiO2: 100%\n RSBI Deferred: PEEP > 10\n PIP: 40 cmH2O\n Plateau: 37 cmH2O\n Compliance: 26.7 cmH2O/mL\n SpO2: 98%\n ABG: 7.30/35/87./15/-7\n Ve: 13.6 L/min\n PaO2 / FiO2: 88\n Physical Examination\n General: Sedated\n HEENT: ETT tube in place\n Neck: supple\n Lungs: decreased breath sounds\n CV: tachycardic, no mumurs\n Abdomen: soft, obese, decreased BS\n Ext: Warm, well perfused\n Neuro: sedated\n Labs / Radiology\n 133 K/uL\n 12.2 g/dL\n 109 mg/dL\n 1.4 mg/dL\n 15 mEq/L\n 3.7 mEq/L\n 13 mg/dL\n 97 mEq/L\n 128 mEq/L\n 35.8 %\n 19.5 K/uL\n [image002.jpg]\n 02:33 PM\n 02:51 PM\n 07:56 PM\n 08:11 PM\n 09:50 PM\n 12:22 AM\n 02:14 AM\n 02:34 AM\n 04:33 AM\n 06:10 AM\n WBC\n 16.4\n 16.1\n 19.5\n Hct\n 28.4\n 27.4\n 35.8\n Plt\n 132\n 135\n 133\n Cr\n 1.6\n 1.7\n 1.4\n TCO2\n 22\n 18\n 17\n 17\n 19\n 18\n 18\n Glucose\n 131\n 105\n 109\n Other labs: PT / PTT / INR:21.1/72.2/2.0, ALT / AST:153/640, Alk Phos /\n T Bili:229/15.5, Amylase / Lipase:78/268, Lactic Acid:3.1 mmol/L,\n Albumin:2.3 g/dL, LDH:616 IU/L, Ca++:7.9 mg/dL, Mg++:2.5 mg/dL, PO4:2.5\n mg/dL\n Assessment and Plan\n 28 year old male with a history of alcoholism presenting with acute\n hepatitis, pancreatitis, and UGIB.\n .\n # Respiratory Failure. Unclear etiology of hypoxia: Patient electively\n intubated for EGD then extubated. Required NRB to maintain sats in 90s.\n Continue tachypnea to the 40s, tired, CO2 increased, then reintubated.\n Initial CXR unremarkable. Concern for progression to /ARDS secondary\n to pancreatitis.\n - ARDSnet ventilator settings\n - monitor abdominal pressures\n - fentanyl and versed for sedation\n - wean settings as tolerated\n - repeat ABG this afternoon\n .\n # Pancreatitis: Most likely alcoholic in etiology, lipase peaked at\n 1600. CT scan shows probable 30% necrosis. Complicated by SIRS\n physiology. Significant hypotension, required large volume fluid to\n maintain pressures overnight. Now on phenylephrine. Also with\n leukocytosis likely related to pancreatitis but low threshold to treat\n for infection. Per surgery currently not treating with antibiotics.\n - aggressive IV hydration\n - attempt to wean neo\n - place arterial line for BP monitoring\n - wean propofol\n - strict NPO (no PO meds)\n - f/u cultures\n - f/u final CT read\n - trend lipase\n - f/u am lipid panel\n - f/u surgery recs\n .\n # Acute Hepatitis: Likely alcoholic hepatitis. CT scan shows fatty\n infiltration, and no evidence of distal obstruction. RUQ u/s shows\n marked liver echogenicity.\n - f/u viral hepatitis panel\n - trend LFTs\n - f/u GI recs\n .\n # Hematemesis: EGD showed diuelafoy's lesion. Crit stable.\n -f/u GI recs\n -continue PPI\n -maintain active type and screen\n .\n # Hyponatremia: Most likely due to volume depletion. Patient markedly\n dry on initial exam. also reflect a more chronic long-term liver\n disease. Improving 127 from 118.\n - continue to follow\n # Alcoholism: Patient describes history of withdrawl symptoms, but not\n prior seizure. Last drink was night prior to presenation.\n Tachycardia, weakness, and elevated lactate could be consistent with\n thiamine deficiency.\n - thiamine level pending\n - thiamine, vb12, folate\n - valium with CIWA > 10\n - social work consult when medically stable\n .\n # FEN: IVF, replete electrolytes, NPO\n .\n # Prophylaxis: scds, PPI\n .\n # Access: pIV, plan to d/c cordis and place IJ to monitor CVPs\n .\n # Code: Full Code\n .\n # Disposition: ICU\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 01:49 PM\n 16 Gauge - 01:50 PM\n Cordis/Introducer - 02:05 PM\n 20 Gauge - 03:33 AM\n Arterial Line - 01:35 PM\n Multi Lumen - 02:02 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": "2131-05-19 00:00:00.000", "description": "Physician Resident/Attending Progress Note - MICU", "row_id": 675418, "text": "Chief Complaint:\n 24 Hour Events:\n ARTERIAL LINE - START 01:35 PM\n MULTI LUMEN - START 02:02 PM\n -large volume fluid recussitation, 1 lt/hr + max neo, +levo\n -2uPRBC\n -overbreathing vent, increased midaz/fent\n -hypoxic, increased peep and fio2\n -elevated bladder pressures to 25 then 31; surgery wants to wait\n -surgery declined need for abx\n -family updated\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Norepinephrine - 0.03 mcg/Kg/min\n Phenylephrine - 5 mcg/Kg/min\n Midazolam (Versed) - 20 mg/hour\n Fentanyl (Concentrate) - 500 mcg/hour\n Other ICU medications:\n Pantoprazole (Protonix) - 09:30 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:12 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: 36.9\nC (98.4\n HR: 114 (103 - 118) bpm\n BP: 75/56(64) {74/43(59) - 95/62(72)} mmHg\n RR: 31 (20 - 36) insp/min\n SpO2: 98%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 111.3 kg (admission): 113.5 kg\n Height: 67 Inch\n CVP: 28 (18 - 33)mmHg\n Bladder pressure: 26 (15 - 31) mmHg\n Total In:\n 24,249 mL\n 3,827 mL\n PO:\n TF:\n IVF:\n 23,549 mL\n 3,827 mL\n Blood products:\n 700 mL\n Total out:\n 377 mL\n 143 mL\n Urine:\n 377 mL\n 143 mL\n NG:\n Stool:\n Drains:\n Balance:\n 23,872 mL\n 3,684 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 500) mL\n RR (Set): 24\n RR (Spontaneous): 6\n PEEP: 20 cmH2O\n FiO2: 100%\n RSBI Deferred: PEEP > 10\n PIP: 40 cmH2O\n Plateau: 37 cmH2O\n Compliance: 26.7 cmH2O/mL\n SpO2: 98%\n ABG: 7.30/35/87./15/-7\n Ve: 13.6 L/min\n PaO2 / FiO2: 88\n Physical Examination\n General: Sedated\n HEENT: ETT tube in place\n Neck: supple\n Lungs: decreased breath sounds\n CV: tachycardic, no mumurs\n Abdomen: soft, obese, decreased BS\n Ext: Warm, well perfused\n Neuro: sedated\n Labs / Radiology\n 133 K/uL\n 12.2 g/dL\n 109 mg/dL\n 1.4 mg/dL\n 15 mEq/L\n 3.7 mEq/L\n 13 mg/dL\n 97 mEq/L\n 128 mEq/L\n 35.8 %\n 19.5 K/uL\n [image002.jpg]\n 02:33 PM\n 02:51 PM\n 07:56 PM\n 08:11 PM\n 09:50 PM\n 12:22 AM\n 02:14 AM\n 02:34 AM\n 04:33 AM\n 06:10 AM\n WBC\n 16.4\n 16.1\n 19.5\n Hct\n 28.4\n 27.4\n 35.8\n Plt\n 132\n 135\n 133\n Cr\n 1.6\n 1.7\n 1.4\n TCO2\n 22\n 18\n 17\n 17\n 19\n 18\n 18\n Glucose\n 131\n 105\n 109\n Other labs: PT / PTT / INR:21.1/72.2/2.0, ALT / AST:153/640, Alk Phos /\n T Bili:229/15.5, Amylase / Lipase:78/268, Lactic Acid:3.1 mmol/L,\n Albumin:2.3 g/dL, LDH:616 IU/L, Ca++:7.9 mg/dL, Mg++:2.5 mg/dL, PO4:2.5\n mg/dL\n Assessment and Plan\n 28 year old male with a history of alcoholism presenting with\n necrotizing pancreatitis, ARDS, elevated IAP and UGIB.\n # Respiratory Failure. ARDS related to necrotizing pancreatis\n compounded by hypoxia, tachypnea in setting of anion gap metabolic\n acidosis, increased abdominal pressure, and etoh withdrawl.\n - ARDSnet ventilator settings with stable Vt and p02 in 70s\n - Permissible tachypnea is tolerated in setting of AGMA; monitor for\n stacked breaths and if so then paralysis.\n monitor abdominal pressures\n - PEEP of 20 to overcome IAP; elevated peak aw pressures so will check\n ballon pressure to address if this elevated IAP or thoracic\n pressures.\n -maxed out on fentanyl and versed for sedation\n # Shock/Necrotizing pancreatitis: EtOH induced. Requiring large volume\n fluid resuscitation as well as maxed neo and low dose levo.\n - continue fluids; if appropriate will use vigileo to determine\n resuscitative capacity. No surgical benefit at this time.\n - wean levo and monitor UOP\n - add meropenem for ppx\n - monitor lactate lipase and AGMA\n # IAP elevation: secondary to third spacing and edema. Bladder\n pressures as high as 31. Will use groin cordis to better measure\n pressure. Surgery recommends no intervention currently. If ventilation\n is impeded by increased IAP, if decrease in UOP, if worsened\n AGMA/lactate will consider surgical release of pressures if surgery\n deems appropriate.\n # Acute hepatitis: Likely alcoholic hepatiis with fatty infiltration,\n and no evidence of distal obstruction. RUQ u/s shows marked liver\n echogenicity but no ascites.\n - f/u viral hepatitis panel, LFTs\n # Hematemesis: EGD showed diuelafoy's lesion. HCT over 30 s/p 2xpRBC\n on . HCT>30\n # Hyponatremia, hypervolemic: secondary to aggressive resuscitation.\n Improved.\n # Alcoholism: Patient describes history of withdrawl symptoms, but not\n prior seizure. Last drink was night prior to presenation.\n Tachycardia, weakness, and elevated lactate could be consistent with\n thiamine deficiency.\n - thiamine, vb12, folate\n - valium with CIWA > 10\n # FEN: IVF, replete electrolytes, NPO\n # Prophylaxis: scds, PPI\n # Access: pIV, plan to d/c cordis and place IJ to monitor CVPs\n # Code: Full Code\n # Disposition: ICU\n # Family updated\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 01:49 PM\n 16 Gauge - 01:50 PM\n Cordis/Introducer - 02:05 PM\n 20 Gauge - 03:33 AM\n Arterial Line - 01:35 PM\n Multi Lumen - 02:02 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n ------ Protected Section ------\n MICU ATTENDING ADDENDUM\n I saw and examined the patient, and was physically present with the ICU\n team for the key portions of the services provided. I agree with the\n note above, including the assessment and plan. I would emphasize and\n add the following points: 28M EtOH abuse, weakness, fatigue, UGIB c/b\n hematemesis / melena. Has developed massive fluid requirement,\n hypotension, ARDS in the setting of severe pancreatitis, alcoholic\n hepatitis and borderline renal function. IAP and vent requirements are\n rising. Transfused 2 units PRBC.\n Exam notable for Tm 99.9 BP 95/50 HR 115 RR 35 with sat 100 on VAC\n 400x32/24 1.0 20 7.30/35/87 CVP 18 IAP 31. +TBB 40L UOP 1.4 - stable.\n Sedated, min responsive. Hyperdynamic. Bronchial BS B. RRR s1s2.\n Distended, minimal bowel sounds. Massive edema. Labs notable for WBC\n 19K, HCT 35, K+ 3.7, Cr 1.4, AG 15, lactate 3.1, INR 2.0. CXR with\n ARDS.\n Agree with plan to manage respiratory failure with low volume\n ventilation for evolving /ARDS (380x36); will follow IAP and place\n balloon to titrate PEEP as we wean oxygen. Would like to hold off on\n paralysis unless asynchrony is a limiting factor; can increase RR to 30\n and monitor for autopeep. He has received 40L IVF over the course of\n the last 2 days but is still on pressors. A-line is dampened - follow\n cuff pressures for now and wean neo / levo as able. Continue volume\n resuscitation, goal UOP >30cc/h, CVP >20. UGIB from Dieulafois lesion\n at GEJ appears stable, will monitor serial HCT and continue PPI IV.\n Will check HCT q6h and recheck coags this PM, but will hold on FFP for\n now. Pancreatitis likely due to EtOH, NPO, following; will add\n meropenem given deterioration. Can't use gut for now; may need TPN in\n the next few days. Alcoholic hepatitis is improving by numbers\n will\n provide supportive care and follow labs while holding off on steroids\n given ongoing GIB. Can d/c cordis. Above d/w family at bedside.\n Remainder of plan as outlined above.\n Patient is critically ill\n Total time: 60 min\n ------ Protected Section Addendum Entered By: , MD\n on: 04:43 PM ------\n" }, { "category": "Nursing", "chartdate": "2131-05-19 00:00:00.000", "description": "Nursing Progress Note", "row_id": 675442, "text": "Hypotension (not Shock)\n Assessment:\n Pt is pressor dependant to maintain MAP 65-70\n Received on max Neo and low dose levo\n Dampended aline ? accuracy of vigelence monitor\n MD to follow NBP\n Remains in ST\n Action:\n IVF rate decreased from 350-250cc/hr.\n Levo titrated to as low as 0.01\n Urine output <20 Fluid bolus given\n Response:\n Initially tolerated wean of Levo but then required more \n to low MAP\n Levo up to high.05mcg/kg/min MICU aware\n + response in urine output post bolus\n Aline still dampened at times but MAP\ns between Aline and\n NBP correlating. MD aware. RN ? if should be following aline\n vs NBP and expressing need to resite /aline since on multiple pressors\n per MICU will rewire/resite if pressor requirement increases.\n Plan:\n Cont to closely monitor Hemodynamics\n Titrate pressors as tolerated.\n Rewire aline\n Maintain MAP >65 and u/o >20\n ? Albumin if u/o drops again\n Pancreatitis, acute\n Assessment:\n Abd remains firm and distended\n No BS\n IABP 25-27 MICU and surgergy aware\n Surgery into eval this am. No surgical intervention at this\n time\n WBC\ns elevated to 19.8\n Action:\n MICU started pt on ABX for ppx\n IABP continuously monitored\n OGT remains to LCS\n Response:\n IABP remains stable\n Lipase trending down\n Plan:\n Cont to follow amylase and lipase\n Monitor IABP\n Follow WBC\n ? need to re-ultrasound or rescan if pt stable\n Respiratory failure, acute (ARDS/)\n Assessment:\n Pt received on CMV mode TV 400X24 peep 20\n Pt visible tachypnic and overbreathing vent by breathes\n per minute despite max sedation\n PIP\ns 38-42\n Sats 97% Pa02 in 80\n Action:\n RR increased on 28 to match pt\ns efforts\n ? by this RN for need to start paralytics if pt remains\n dysychronous with vent\n Esophageal ballon study done at bedside\n Pt under peep by approx \n Fi02 decreased to .80%\n ABG\ns + AG metabolic acidosis\n Response:\n Tolerated decrease in Fi02 initially\n MICU will tolerate Pa02 >65\n ABG\n in PM showing 7.25/49/60 MICU made aware\n Increased RR to 30 and PEEP to 24 with slight improvement\n Lung sounds unchanged\n Low threshold to start paralytics if Oxygenation worsens\n Plan:\n Frequent monitor of ABG\n Cont on protective settings\n Paralytics if oxygenation worsens\n" }, { "category": "Nursing", "chartdate": "2131-05-18 00:00:00.000", "description": "Nursing Progress Note", "row_id": 674875, "text": "TITLE:\n Pancreatitis, acute\n Assessment:\n Pt with h/o ETOH abuse. Pancreateic enzymes and LFTs\n elevated. CT revealing 30% necrosis of pancreas.\n Afebrile. Lactate 4.1. + BS. Abdomen obese/distended. NPO.\n Urine output marginal 15-40cc clear amber urine hourly. SBP\n 85-125 with MAPs ranging 52-100.\n LCTAB. Remains on NRB with saturations >94%. Weak productive\n cough. Tachypneic w/RR 28-50.\n Pt appearing anxious in bed. Tachycardic with HR 130-140\n with feelings of tremors. Diaphoretic. Oriented x3. Following CIWA\n scale and treating for score >10 with Diazepam. Progressively overnight\n pt appearing more lethargic and remained tachypneic appearing\n increasingly tired with oxygen saturation falling to 89-92% while on\n NRB.\n Action:\n US of liver obtained.\n Pt receiving 500cc NS boluses with maintenance fluid\n infusing at 300cc/hr and Sodium Bicarb at 250cc/hr.\n Pt continues on Protonix drip.\n Monitoring labs.\n Pt intubated at approx 0240 for impending respiratory\n failure. Placed on CMV Rate 24 100% FiO2. OG tube placed. Pt sedated\n on Propofol/Fentanyl/Versed.\n Response:\n US revealing dense cirrhosis per Dr .\n Lactate this AM\n Urine output remains marginal. Blood pressure responds\n fairly to fluid boluses however continues to require aggressive fluid\n resuscitation. Pt started on Neo for additional blood pressure support\n while sedated. Tachycardia improved with HR 105-110.\n Lungs clear to rhonchorous. Scant to no secretions.\n Plan:\n Remain NPO. Obtain x-ray to confirm OG placement.\n Continue Protonix until GI re-evaluates pt today.\n Continue aggressive fluid resuscitation and titrating Neo as\n needs to maintain SBP >80 and MAP >60. Continue\n Propofol/Fentanyl/Versed drips.\n Monitor labs treating as needed.\n ? Placement of arterial line and/or central line.\n" }, { "category": "Respiratory ", "chartdate": "2131-05-18 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 675133, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 0\n Ideal body weight: 67.1 None\n Ideal tidal volume: 268.4 / 402.6 / 536.8 mL/kg\n Airway\n 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: 7mm\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Clear\n Comments:\n Secretions\n Sputum color / consistency: White / Thin\n Sputum source/amount: Suctioned / Small\n Comments:\n Plan\n Next 24-48 hours:\n Reason for continuing current ventilatory support: Underlying illness\n not resolved\n Bedside Procedures:\n Comments:\n Patient remains intubated and on mechanical ventilation, breath sounds\n essentially clear, suctioned intermittently for small amount of thin\n clear secretion, SPO2 remained upper 90%, FiO2 weaned from 70 to 60\n then to 50%, ETT advanced 2cm , from 21 to 23 at the teeth per team\n verbal order, no distress occurred, will continues to be followed.\n" }, { "category": "Nursing", "chartdate": "2131-05-22 00:00:00.000", "description": "Nursing Progress Note", "row_id": 676116, "text": "TITLE:\n Hypotension (not Shock)\n Assessment:\n mean bp fluctuating between 60-70. Neosynephrine at 5mcg/kg/m and\n levophed 0.02. Uop marginal at 15-20cc/hr, with 1 hr episode no urine\n output (foley patent & irrigated freely)\n Action:\n levophed titrated to 0.04 mcg to achieve goal mbp >70, uop still\n remained low, albumin 25gm iv x1\n Response:\n decreased levo to 0.03 mcg\nmbp still >70.\n Plan:\n wean levophed before neo for goal mbp >70\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Remains sedated on fentanyl 225mcg and versed 20 mg/hr/PaO2 86 on fio2\n 60% peep24.O2sats 94-96% bbs coarse to clear upper lobes diminish lower\n lobes bilat. Triadyne w rotation/percussion continues with\n readjustments made to Lt side > rt side rotation\n Action:\n HO made aware abg results->fio2 decr to 50%, per Dr , follow O2\n sats no need to repeat abg if sat > 94%. Suctioning for sm amts of\n bilious. Vap bundle, suct orally for sm amts frothy blood tinge\n secretions.\n Response:\n Breath sounds clearer after suctioning (tolerated well w/o desats).\n Tolerating change in rotation. Sats > 94% on 50%\n Plan:\n Cont to wean fio2 as tol.Wean fentanyl as tolerated allowing 1-2breaths\n over set rate max.. Vap bundle.\n Pancreatitis, acute\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Physician ", "chartdate": "2131-05-22 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 676299, "text": "Chief Complaint:\n 24 Hour Events:\n - Restarted levophed.\n - weaned levo to 0.02\n - elevated ddimer, high fdps, high fibrinogen\n - wbc to 24, blood, urine, cdiff\n - albumin given\n - abx continued\n - bladder pressure at 20\n - FIO2 decreased from 60 to 50% at 9pm\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Meropenem - 05:54 AM\n Infusions:\n Norepinephrine - 0.02 mcg/Kg/min\n Phenylephrine - 5 mcg/Kg/min\n Fentanyl (Concentrate) - 300 mcg/hour\n Midazolam (Versed) - 20 mg/hour\n Other ICU medications:\n Pantoprazole (Protonix) - 08:22 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:06 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.4\nC (99.4\n Tcurrent: 37.2\nC (98.9\n HR: 101 (101 - 108) bpm\n BP: 105/62(77) {92/59(71) - 117/81(94)} mmHg\n RR: 15 (0 - 30) insp/min\n SpO2: 94%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 156 kg (admission): 113.5 kg\n Height: 67 Inch\n CVP: 23 (14 - 27)mmHg\n Bladder pressure: 20 (19 - 24) mmHg\n Total In:\n 2,817 mL\n 835 mL\n PO:\n TF:\n IVF:\n 2,817 mL\n 735 mL\n Blood products:\n 100 mL\n Total out:\n 830 mL\n 508 mL\n Urine:\n 530 mL\n 208 mL\n NG:\n 300 mL\n 100 mL\n Stool:\n Drains:\n 200 mL\n Balance:\n 1,987 mL\n 327 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 30\n RR (Spontaneous): 5\n PEEP: 24 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10\n PIP: 44 cmH2O\n Plateau: 40 cmH2O\n Compliance: 33.3 cmH2O/mL\n SpO2: 94%\n ABG: 7.29/38/86/18/-7\n Ve: 12.4 L/min\n PaO2 / FiO2: 172\n Physical Examination\n Gen: sedated\n HEENT: intubated\n Chest: coarse BS bl\n CV: distant heart sounds, RRR, S1S2\n Abd: distended, abdominal wall edema\n Ext: anasarca throughout\n Labs / Radiology\n 61 K/uL\n 10.6 g/dL\n 94 mg/dL\n 3.0 mg/dL\n 18 mEq/L\n 4.3 mEq/L\n 18 mg/dL\n 102 mEq/L\n 133 mEq/L\n 32.9 %\n 24.4 K/uL\n [image002.jpg]\n 12:04 PM\n 02:30 PM\n 06:50 PM\n 09:15 PM\n 10:34 PM\n 02:42 AM\n 03:01 AM\n 02:11 PM\n 08:20 PM\n 02:39 AM\n WBC\n 16.5\n 18.5\n 24.4\n Hct\n 31.5\n 31.4\n 32.0\n 34.0\n 32.9\n Plt\n 69\n 51\n 61\n 61\n Cr\n 2.2\n 1.8\n 2.1\n 3.0\n TCO2\n 21\n 21\n 20\n 20\n 19\n Glucose\n 107\n 97\n 100\n 103\n 94\n Other labs: PT / PTT / INR:20.9/47.6/2.0, ALT / AST:69/194, Alk Phos /\n T Bili:218/16.7, Amylase / Lipase:17/28, Differential-Neuts:64.0 %,\n Band:2.0 %, Lymph:11.0 %, Mono:8.0 %, Eos:3.0 %, D-dimer: ng/mL,\n Fibrinogen:402 mg/dL, Lactic Acid:2.1 mmol/L, Albumin:2.3 g/dL, LDH:494\n IU/L, Ca++:7.9 mg/dL, Mg++:2.2 mg/dL, PO4:2.7 mg/dL\n 8:20p\n _______________________________________________________________________\n pH\n 7.29\n pCO2\n 38\n pO2\n 86\n HCO3\n 19\n BaseXS\n -7\n HEPARIN DEPENDENT ANTIBODIES\n Results Pending\n Assessment and Plan\n Mr. is a 28 year old gentleman with alcoholic hepatitis and\n necrotizing pancreatitis complicated by ARDS, SIRS, and UGIB.\n # Respiratory Failure: ARDS secondary to necrotizing pancreatitis\n compounded by hypoxia, tachypnea in setting of anion gap metabolic\n acidosis, increased abdominal pressure, and EtOH withdrawl. Rising WBC\n could also suggest secondary VAP. Patient w/ some dysychrony w/\n reduction of sedation.\n - Continue current vent settings for now, recheck ABG\n - intra-abdominal pressures improved\n - Begin to wean sedation as tolerated. Would prefer to wean down\n fentanyl and then midaxolam.\n - send sputum Cx\n # Necrotizing pancreatitis/SIRS: Likely secondary to alcohol\n complicated by SIRS. Patient continues to have pressor requirement,\n with neo +/- levo. Volume resucsitation with >54L.\n - Continue empiric meropenem for now.\n - Wean pressors as able, starting with levophed\n - no improvement with albumin trial yesterday\n - Monitor chemistries.\n - Continue to hold MIVF, boluses PRN\n - Follow-up with recs if any\n # Acute renal failure: Creatinine continues to trend up with oliguria,\n likely secondary to SIRS/hypotension and IABP leading to ATN. Cr now\n up to 3.0\n - Urine lytes, eos, osm sent yesterday\n - renal c/s, w/ likely need for CVVH in the near future\n - Trend UOP, bolus IVF to maintain goal >20 cc/hr.\n # Leukocytosis: Rise of WBC to 24 from 16 two days prior. Patient has\n been afebrile, but have concern for a potential blossoming infection\n already on meropeneum. Will resend cultures and have low threshold to\n started coverage for potential line infection.\n #Thrombocytopenia: platelets trending down, but pleatued today. No\n clear etiology at this time. DIC panel negative, and HIT antibody\n pending.\n # IAP elevation: Secondary to third spacing and edema. Per surgery, not\n a good surgical candidate at this time.\n # Acute hepatitis: Likely alcoholic hepatitis with fatty infiltration,\n and no evidence of distal obstruction. RUQ u/s shows marked liver\n echogenicity but no ascites.\n - Trend LFTs\n # Hematemesis: EGD showed diuelafoy's lesion. HCT stable since 2 units\n PRBC on .\n - Trend hct, transfuse for hct<21\n # Hyponatremia: In setting of decreased effective circulating volume in\n setting of SIRS and IABP.\n - Trend chemistries.\n # Alcoholism: Patient describes history of withdrawal symptoms, but\n not prior seizure. Last drink was night prior to presentation.\n Tachycardia, weakness, and elevated lactate could be consistent with\n thiamine deficiency.\n - Thiamine, vb12, folate\n - Valium with CIWA > 10\n FEN: IVF, replete electrolytes, NPO. Would consider starting TPN after\n 5-7 days. If patient has no significant change over the next 1-2 days,\n may begin TPN on approximately . Getting nutrition recs, and will\n setting if want to do TPN vs. post-jejunum NG. Feel pt likely too\n unstable to have NG placed in IR.\n PPx: SCDs, PPI\n Access: RIJ, right radial art line.\n Code: Full Code\n Dispo: ICU level of care.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Arterial Line - 01:35 PM\n Multi Lumen - 02:02 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Respiratory ", "chartdate": "2131-05-22 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 676376, "text": "TITLE:\n Demographics\n Day of intubation:\n Day of mechanical ventilation: 0\n Ideal body weight: 67.1 None\n Ideal tidal volume: 268.4 / 402.6 / 536.8 mL/kg\n Airway\n 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: 7mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Scant\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 claim of dyspnea)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment: Not triggering\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: plan is to keep pt on full support and revaluate in\n AM roubds\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n" }, { "category": "Respiratory ", "chartdate": "2131-05-23 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 676433, "text": "Demographics\n Day of mechanical ventilation: 0\n Ideal body weight: 67.1 None\n Ideal tidal volume: 268.4 / 402.6 / 536.8 mL/kg\n Airway\n Tube Type\n ETT:\n Position: 25 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 Secretions\n Sputum color / consistency: Yellow / Thin\n Sputum source/amount: Suctioned / Small\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Pt out of sync with set rate of\n 30 at times.\n Assessment of breathing comfort: No response (sleeping / sedated)\n Trigger work assessment: Frequent failed trigger efforts, Abnormal\n trigger efforts (efforts during inspiratory)\n Plan\n Next 24-48 hours: Utilize ARDSnet protocol; Comments: Obtain newTPP\n with esophageal balloon.\n" }, { "category": "Nutrition", "chartdate": "2131-05-22 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 676293, "text": "Subjective Pt intubated/sedated.\n Objective\n Current Wt: 156 kg\n Admit Wt: 113.5 kg\n Wt Change : increase of 42.5 kg (fluid)\n Patient has RIJ line\n Pertinent medications: fentanyl, midazolam, protonix, Abx,\n norephinephrine, phenylephrine, RISS, cyanocobalamin, MVI, others noted\n Labs:\n Value\n Date\n Glucose\n 94 mg/dL\n 02:39 AM\n Glucose Finger Stick\n 122\n 10:00 AM\n BUN\n 18 mg/dL\n 02:39 AM\n Creatinine\n 3.0 mg/dL\n 02:39 AM\n Sodium\n 133 mEq/L\n 02:39 AM\n Potassium\n 4.3 mEq/L\n 02:39 AM\n Chloride\n 102 mEq/L\n 02:39 AM\n TCO2\n 18 mEq/L\n 02:39 AM\n PO2 (arterial)\n 122 mm Hg\n 10:29 AM\n PCO2 (arterial)\n 39 mm Hg\n 10:29 AM\n pH (arterial)\n 7.27 units\n 10:29 AM\n pH (venous)\n 7.25 units\n 10:31 AM\n pH (urine)\n 6.5 units\n 02:58 PM\n CO2 (Calc) arterial\n 19 mEq/L\n 10:29 AM\n Albumin\n 2.3 g/dL\n 02:39 AM\n Calcium non-ionized\n 7.9 mg/dL\n 02:39 AM\n Phosphorus\n 2.7 mg/dL\n 02:39 AM\n Ionized Calcium\n 1.08 mmol/L\n 10:29 AM\n Magnesium\n 2.2 mg/dL\n 02:39 AM\n ALT\n 69 IU/L\n 02:39 AM\n Alkaline Phosphate\n 218 IU/L\n 02:39 AM\n AST\n 194 IU/L\n 02:39 AM\n Amylase\n 17 IU/L\n 02:39 AM\n Total Bilirubin\n 16.7 mg/dL\n 02:39 AM\n WBC\n 24.4 K/uL\n 02:39 AM\n Hgb\n 10.6 g/dL\n 02:39 AM\n Hematocrit\n 32.9 %\n 02:39 AM\n Current diet order / nutrition support: NPO\n GI: abd firm, distended, bowel sounds absent\n Assessment of Nutritional Status\n Consult received for TPN recs for this 28 year old male with h/o ETOH\n abuse p/w acute hepatitis, pancreatitis, UGIB, hyponatremia. Patient\n remains intubated/sedated, and on pressors. If possible, recommend tube\n feeds via NJ tube (past the ligament of trietz to avoid pancreas\n stimulation) over TPN initiation. Will provide recs below.\n Medical Nutrition Therapy Plan - Recommend the Following\n 1. For enteral feeds, recommend placing a feeding tube past the\n ligament of trietz, with tube feed goal: Replete with Fiber @ 70 ml/hr\n (1680 kcals/104g protein).\n 2. If TPN is initiated, recommend start Day 1 standard with lytes\n based on am labs. Will advance TPN based on am labs/FSBG/triglyceride\n levels. Recommend TPN goal 70kg 3-in-1.\n 3. CHEM 10 labs daily. Monitor and replete lytes PRN\n 4. FSBG q6h. Correct with RISS\n 5. Check triglyercides. If <400, ok to add lipid to TPN\n 6. Will follow\n" }, { "category": "Nutrition", "chartdate": "2131-05-22 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 676296, "text": "Subjective Pt intubated/sedated. RN, likely to start TPN tomorrow\n at this point in time, patient is too unstable to place a\n post-pyloric feeding tube. HCT remains stable.\n Objective\n Current Wt: 156 kg\n Admit Wt: 113.5 kg\n Wt Change : increase of 42.5 kg (fluid)\n Patient has RIJ line\n Pertinent medications: fentanyl, midazolam, protonix, Abx,\n norephinephrine, phenylephrine, RISS, cyanocobalamin, MVI, others noted\n Labs:\n Value\n Date\n Glucose\n 94 mg/dL\n 02:39 AM\n Glucose Finger Stick\n 122\n 10:00 AM\n BUN\n 18 mg/dL\n 02:39 AM\n Creatinine\n 3.0 mg/dL\n 02:39 AM\n Sodium\n 133 mEq/L\n 02:39 AM\n Potassium\n 4.3 mEq/L\n 02:39 AM\n Chloride\n 102 mEq/L\n 02:39 AM\n TCO2\n 18 mEq/L\n 02:39 AM\n PO2 (arterial)\n 122 mm Hg\n 10:29 AM\n PCO2 (arterial)\n 39 mm Hg\n 10:29 AM\n pH (arterial)\n 7.27 units\n 10:29 AM\n pH (venous)\n 7.25 units\n 10:31 AM\n pH (urine)\n 6.5 units\n 02:58 PM\n CO2 (Calc) arterial\n 19 mEq/L\n 10:29 AM\n Albumin\n 2.3 g/dL\n 02:39 AM\n Calcium non-ionized\n 7.9 mg/dL\n 02:39 AM\n Phosphorus\n 2.7 mg/dL\n 02:39 AM\n Ionized Calcium\n 1.08 mmol/L\n 10:29 AM\n Magnesium\n 2.2 mg/dL\n 02:39 AM\n ALT\n 69 IU/L\n 02:39 AM\n Alkaline Phosphate\n 218 IU/L\n 02:39 AM\n AST\n 194 IU/L\n 02:39 AM\n Amylase\n 17 IU/L\n 02:39 AM\n Total Bilirubin\n 16.7 mg/dL\n 02:39 AM\n WBC\n 24.4 K/uL\n 02:39 AM\n Hgb\n 10.6 g/dL\n 02:39 AM\n Hematocrit\n 32.9 %\n 02:39 AM\n Current diet order / nutrition support: NPO\n GI: abd firm, distended, bowel sounds absent\n Assessment of Nutritional Status\n Consult received for TPN recs for this 28 year old male with h/o ETOH\n abuse p/w acute hepatitis, pancreatitis, and hyponatremia. Patient\n remains intubated/sedated, and on pressors. Currently, patient is not\n stable enough to place a post-pyloric feeding tube therefore TPN\n required for nutrition support. When placement is possible, recommend\n tube feeds via NJ tube (with tip placed past the ligament of trietz to\n avoid pancreas stimulation) over TPN. Will provide recs below.\n Medical Nutrition Therapy Plan - Recommend the Following\n 1. When TPN is initiated, recommend start Day 1 standard with\n lytes based on am labs. Will advance TPN based on am\n labs/FSBG/triglyceride levels. Recommend TPN goal: 70kg 3-in-1.\n 2. When NJ tube placement is possible, recommend placing NJ tube\n (with tip past the ligament of trietz), with goal: Replete with Fiber @\n 70 ml/hr (1680 kcals/104g protein). Recommend discontinuing TPN once\n tolerance at goal is established.\n 3. CHEM 10 labs daily. Monitor and replete lytes PRN\n 4. FSBG q6h. Correct with RISS\n 5. Check triglyercides. If <400, ok to add lipid to TPN\n 6. Will follow\n" }, { "category": "Nursing", "chartdate": "2131-05-24 00:00:00.000", "description": "Nursing Progress Note", "row_id": 676703, "text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Patient vented on large amounts of PEEP/Fio2 @50%\n Action:\n Fio2 to .4, and slowly weaning PEEP in increments\n Possibly starting CVVHD today for gentle fluid removal\n Response:\n Tolerating decreased Fio2 and decreased PEEP well so far.\n Need to place access for dialysis cath later this shift\n Plan:\n Wean vent as tolerated\n CVVHD if adequate access\n Frequent abgs as needed\n Hypotension (not Shock)\n Assessment:\n Action:\n Response:\n Plan:\n Problem - Description In Comments\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Physician ", "chartdate": "2131-05-22 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 676284, "text": "Chief Complaint:\n 24 Hour Events:\n - Restarted levophed.\n - weaned levo to 0.02\n - elevated ddimer, high fdps, high fibrinogen\n - wbc to 24, blood, urine, cdiff\n - albumin given\n - abx continued\n - bladder pressure at 20\n - FIO2 decreased from 60 to 50% at 9pm\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Meropenem - 05:54 AM\n Infusions:\n Norepinephrine - 0.02 mcg/Kg/min\n Phenylephrine - 5 mcg/Kg/min\n Fentanyl (Concentrate) - 300 mcg/hour\n Midazolam (Versed) - 20 mg/hour\n Other ICU medications:\n Pantoprazole (Protonix) - 08:22 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:06 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.4\nC (99.4\n Tcurrent: 37.2\nC (98.9\n HR: 101 (101 - 108) bpm\n BP: 105/62(77) {92/59(71) - 117/81(94)} mmHg\n RR: 15 (0 - 30) insp/min\n SpO2: 94%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 156 kg (admission): 113.5 kg\n Height: 67 Inch\n CVP: 23 (14 - 27)mmHg\n Bladder pressure: 20 (19 - 24) mmHg\n Total In:\n 2,817 mL\n 835 mL\n PO:\n TF:\n IVF:\n 2,817 mL\n 735 mL\n Blood products:\n 100 mL\n Total out:\n 830 mL\n 508 mL\n Urine:\n 530 mL\n 208 mL\n NG:\n 300 mL\n 100 mL\n Stool:\n Drains:\n 200 mL\n Balance:\n 1,987 mL\n 327 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 30\n RR (Spontaneous): 5\n PEEP: 24 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10\n PIP: 44 cmH2O\n Plateau: 40 cmH2O\n Compliance: 33.3 cmH2O/mL\n SpO2: 94%\n ABG: 7.29/38/86/18/-7\n Ve: 12.4 L/min\n PaO2 / FiO2: 172\n Physical Examination\n Gen: sedated\n HEENT: intubated\n Chest: coarse BS bl\n CV: distant heart sounds, RRR, S1S2\n Abd: distended, abdominal wall edema\n Ext: anasarca throughout\n Labs / Radiology\n 61 K/uL\n 10.6 g/dL\n 94 mg/dL\n 3.0 mg/dL\n 18 mEq/L\n 4.3 mEq/L\n 18 mg/dL\n 102 mEq/L\n 133 mEq/L\n 32.9 %\n 24.4 K/uL\n [image002.jpg]\n 12:04 PM\n 02:30 PM\n 06:50 PM\n 09:15 PM\n 10:34 PM\n 02:42 AM\n 03:01 AM\n 02:11 PM\n 08:20 PM\n 02:39 AM\n WBC\n 16.5\n 18.5\n 24.4\n Hct\n 31.5\n 31.4\n 32.0\n 34.0\n 32.9\n Plt\n 69\n 51\n 61\n 61\n Cr\n 2.2\n 1.8\n 2.1\n 3.0\n TCO2\n 21\n 21\n 20\n 20\n 19\n Glucose\n 107\n 97\n 100\n 103\n 94\n Other labs: PT / PTT / INR:20.9/47.6/2.0, ALT / AST:69/194, Alk Phos /\n T Bili:218/16.7, Amylase / Lipase:17/28, Differential-Neuts:64.0 %,\n Band:2.0 %, Lymph:11.0 %, Mono:8.0 %, Eos:3.0 %, D-dimer: ng/mL,\n Fibrinogen:402 mg/dL, Lactic Acid:2.1 mmol/L, Albumin:2.3 g/dL, LDH:494\n IU/L, Ca++:7.9 mg/dL, Mg++:2.2 mg/dL, PO4:2.7 mg/dL\n 8:20p\n _______________________________________________________________________\n pH\n 7.29\n pCO2\n 38\n pO2\n 86\n HCO3\n 19\n BaseXS\n -7\n HEPARIN DEPENDENT ANTIBODIES\n Results Pending\n Assessment and Plan\n Mr. is a 28 year old gentleman with alcoholic hepatitis and\n necrotizing pancreatitis complicated by ARDS, SIRS, and UGIB.\n # Respiratory Failure: ARDS secondary to necrotizing pancreatitis\n compounded by hypoxia, tachypnea in setting of anion gap metabolic\n acidosis, increased abdominal pressure, and EtOH withdrawl.\n - Continue current vent settings for now\n - intra-abdominal pressures improved\n - consider changing bed rotation parameters so only supine and\n left-sided to minimize pressure on IVC.\n - Begin to wean sedation as tolerated. Would prefer to wean down\n fentanyl and then midaxolam.\n # Necrotizing pancreatitis/SIRS: Likely secondary to alcohol\n complicated by SIRS. Patient continues to have pressor requirement and\n volume resucsitation with >54L.\n - Continue empiric meropenem for now. Will discuss with surgical team.\n - Wean pressors as able, starting with levophed\n - If hypotensive, consider using albumin 25-50 grams in preference to\n additional IVF boluses to maintain MAP>60 and UOP>20 cc/hr.\n - Monitor chemistries.\n - Continue to hold MIVF\n - Follow-up with recs if any\n # Acute renal failure: Creatinine continues to trend up with oliguria,\n likely secondary to SIRS/hypotension and IABP leading to ATN.\n - Urine lytes, eos, osm\n - Trend UOP, bolus IVF to maintain goal >20 cc/hr.\n #Thrombocytopenia: platelets trending down. No clear etiology at this\n time. Recommend checking DIC panel and HIT antibody.\n # IAP elevation: Secondary to third spacing and edema. Per surgery, not\n a good surgical candidate at this time.\n # Acute hepatitis: Likely alcoholic hepatitis with fatty infiltration,\n and no evidence of distal obstruction. RUQ u/s shows marked liver\n echogenicity but no ascites.\n - Trend LFTs\n # Hematemesis: EGD showed diuelafoy's lesion. HCT stable since 2 units\n PRBC on .\n - Trend hct, transfuse for hct<21\n # Hyponatremia: In setting of decreased effective circulating volume in\n setting of SIRS and IABP.\n - Trend chemistries.\n # Alcoholism: Patient describes history of withdrawal symptoms, but\n not prior seizure. Last drink was night prior to presentation.\n Tachycardia, weakness, and elevated lactate could be consistent with\n thiamine deficiency.\n - Thiamine, vb12, folate\n - Valium with CIWA > 10\n FEN: IVF, replete electrolytes, NPO. Would consider starting TPN after\n 5-7 days. If patient has no significant change over the next 1-2 days,\n may begin TPN on approximately .\n PPx: SCDs, PPI\n Access: RIJ, right radial art line.\n Code: Full Code\n Dispo: ICU level of care.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Arterial Line - 01:35 PM\n Multi Lumen - 02:02 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": "2131-05-23 00:00:00.000", "description": "Nursing Progress Note", "row_id": 676551, "text": " Problem\n altered neurological function\n Assessment:\n Without corneal/gag and cough reflexed.\n Pupiles , reactive (left brisk, right sluggish)\n Concern for cerebral edema\n Seizure activity with twitching of eyes/forehead and right arm\n Action:\n Head CT done\n Neuro consulted\n Versed 6 mg/ Ativan 4 mg given\n Response:\n Neuro at bedside at this \n further seizure activity since loraz. given\n Awaiting recommendations.\n Plan:\n Follow neuro recommendations.\n Impaired Skin Integrity\n Assessment:\n Multiple areas of open/broken blisters on arms/legs\n Action:\n Areas left open to drain\n Covered with pads to absorb drainage\n Response:\n Tolerating well\n No areas of infection noted\n Plan:\n Nystatin order for groin.\n Continue to allow skin to drian.\n Hypotension (not Shock)\n Assessment:\n On neo and levo .04\n Maintaining sbp>100\n Action:\n Keeping pressors at current does\n Only wean if significant increase in blood pressure.\n Response:\n Stable\n Plan:\n Pressors as needed\n Call MICU team with any hypotension\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Vented on CMV ./+24\n Action:\n No changes in vent\n Response:\n Gases stable\n Plan:\n Keep on current settings.\n" }, { "category": "Physician ", "chartdate": "2131-05-23 00:00:00.000", "description": "Physician Resident/Attending Progress Note - MICU", "row_id": 676533, "text": "Chief Complaint:\n 24 Hour Events:\n - Started vanco to cover for line infection given leukocytosis\n - Renal consulted, prelim ATN on sediment\n - Pan-cultured inc sputum\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 10:00 PM\n Meropenem - 06:05 AM\n Infusions:\n Fentanyl (Concentrate) - 400 mcg/hour\n Phenylephrine - 4.8 mcg/Kg/min\n Midazolam (Versed) - 30 mg/hour\n Other ICU medications:\n Pantoprazole (Protonix) - 08:15 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:52 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: 36.7\nC (98.1\n HR: 106 (94 - 109) bpm\n BP: 97/67(79) {88/51(64) - 116/73(88)} mmHg\n RR: 15 (10 - 45) insp/min\n SpO2: 98%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 156 kg (admission): 113.5 kg\n Height: 67 Inch\n CVP: 25 (0 - 30)mmHg\n Bladder pressure: 20 (20 - 20) mmHg\n Total In:\n 2,301 mL\n 611 mL\n PO:\n TF:\n IVF:\n 2,201 mL\n 611 mL\n Blood products:\n 100 mL\n Total out:\n 1,236 mL\n 105 mL\n Urine:\n 561 mL\n 105 mL\n NG:\n 350 mL\n Stool:\n Drains:\n 325 mL\n Balance:\n 1,065 mL\n 506 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 30\n RR (Spontaneous): 0\n PEEP: 24 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10\n PIP: 46 cmH2O\n Plateau: 39 cmH2O\n Compliance: 28.6 cmH2O/mL\n SpO2: 98%\n ABG: 7.28/40/101/17/-7\n Ve: 12.1 L/min\n PaO2 / FiO2: 202\n Physical Examination\n Gen: sedated\n HEENT: intubated. Scleral edema\n Chest: coarse BS bl\n CV: distant heart sounds, RRR, S1S2\n Abd: distended, abdominal wall edema\n Ext: Anasarca\n Neuro: Sedated. Pupils 6 mm, reactive.\n Labs / Radiology\n 64 K/uL\n 10.4 g/dL\n 100 mg/dL\n 3.2 mg/dL\n 17 mEq/L\n 4.1 mEq/L\n 21 mg/dL\n 101 mEq/L\n 130 mEq/L\n 31.7 %\n 29.3 K/uL\n [image002.jpg]\n 03:01 AM\n 02:11 PM\n 08:20 PM\n 02:39 AM\n 10:29 AM\n 05:04 PM\n 05:54 PM\n 10:25 PM\n 03:01 AM\n 03:09 AM\n WBC\n 24.4\n 30.5\n 29.3\n Hct\n 34.0\n 32.9\n 32.2\n 31.7\n Plt\n 61\n 61\n 66\n 64\n Cr\n 2.1\n 3.0\n 3.2\n 3.2\n TCO2\n 20\n 19\n 19\n 18\n 19\n 20\n Glucose\n 103\n 94\n 106\n 93\n 100\n Other labs: PT / PTT / INR:19.0/42.6/1.8, ALT / AST:55/228, Alk Phos /\n T Bili:218/19.2, Amylase / Lipase:16/37, Differential-Neuts:64.0 %,\n Band:2.0 %, Lymph:11.0 %, Mono:8.0 %, Eos:3.0 %, D-dimer: ng/mL,\n Fibrinogen:402 mg/dL, Lactic Acid:2.1 mmol/L, Albumin:2.1 g/dL, LDH:576\n IU/L, Ca++:7.9 mg/dL, Mg++:2.3 mg/dL, PO4:3.1 mg/dL\n Assessment and Plan\n Mr. is a 28 year old gentleman with alcoholic hepatitis and\n necrotizing pancreatitis complicated by ARDS, SIRS, and UGIB.\n # Neuro: Patient with dilated pupils on high dose fentaynl gtt.\n Concerning for cerebral edema or other acute process.\n - Non-contrast CTH\n # Respiratory Failure: ARDS secondary to necrotizing pancreatitis\n compounded by hypoxia, tachypnea in setting of anion gap metabolic\n acidosis, increased abdominal pressure, and EtOH withdrawl. Rising WBC\n could also be secondary to VAP.\n - Continue current vent settings for now, recheck ABG\n - Continue to monitor IAP\n - Begin to wean sedation as tolerated. Would prefer to wean down\n fentanyl and then midaz.\n - send sputum Cx\n - Continue vanco and meropenem.\n # Leukocytosis: WBC up to 29 today. Patient continues to be afebrile.\n Concern for CVL infection, VAP, loculated effusion, or necrotizing\n pancreatitis complication including abscess formation.\n - Continue empiric vancomycin and meropenem, AM vanco level.\n - CT torso with PO contrast to assess for complication of pancreatitis\n including abscess or organization of right-sided pleural effusion.\n - Follow-up culture data\n # Necrotizing pancreatitis/SIRS: Likely secondary to alcohol\n complicated by SIRS and ARDS. Patient continues to have pressor\n requirement, with neo +/- levo. Aggressive volume resucsitation with\n >56. Patient without improvement with albumin trial, likely\n secondary to SIRS and increased vascular permeability.\n - Continue empiric meropenem for now.\n - Wean pressors as able, starting with levophed\n - Monitor chemistries.\n - Continue to hold MIVF, boluses PRN to maintain UOP>20 cc/hr although\n increase pressors first.\n - Follow-up with recs if any\n - CT torso as above.\n # Acute renal failure: Creatinine continues to trend up to 3.2 with\n oliguria, likely secondary to SIRS/hypotension and IABP leading to\n ATN. Appreciate renal recs - urine sediment consistent with ATN.\n - Follow-up renal recs, patient likely candidate for CVVH as\n creatinine, lytes, and BUN continue to rise.\n - Trend UOP, bolus IVF to maintain goal >20 cc/hr.\n #Thrombocytopenia: Platelets trending down over hospital course but\n stable today. No clear etiology at this time. DIC panel and HIT PF4\n antibody negative.\n - Trend plt\n # IAP elevation: Secondary to third spacing and edema. Per surgery, not\n a good surgical candidate at this time.\n # Acute hepatitis: Likely alcoholic hepatitis with fatty infiltration,\n and no evidence of distal obstruction. RUQ u/s shows marked liver\n echogenicity but no ascites.\n - Trend LFTs\n # Hematemesis: EGD showed diuelafoy's lesion. HCT stable since 2 units\n PRBC on .\n - Trend hct, transfuse for hct<21\n # Hyponatremia: In setting of decreased effective circulating volume in\n setting of SIRS and IABP.\n - Trend chemistries.\n # Alcoholism: Patient describes history of withdrawal symptoms, but\n not prior seizure. Last drink was night prior to presentation.\n Tachycardia, weakness, and elevated lactate could be consistent with\n thiamine deficiency.\n - Thiamine, vb12, folate\n - Valium with CIWA > 10\n FEN: NPO. TPN to start in AM.\n PPx: SCDs, PPI\n Access: RIJ, right radial a-line\n Dispo: ICU level of care\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Arterial Line - 01:35 PM\n Multi Lumen - 02:02 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n ------ Protected Section ------\n MICU ATTENDING ADDENDUM\n I saw and examined the patient, and was physically present with the ICU\n team for the key portions of the services provided. I agree with the\n note above, including the assessment and plan. I would emphasize and\n add the following points: 28M EtOH abuse, weakness, fatigue, UGIB c/b\n hematemesis / melena. Has developed massive fluid requirement,\n hypotension, ARDS in the setting of severe pancreatitis, alcoholic\n hepatitis and borderline renal function. Creatinine up o/n, as is WBC.\n Pan cx, started on vanco. Pupils dilated but reactive on exam.\n Exam notable for Tm 98.9 BP 103/60 HR 110 RR 35 with sat 98 on VAC\n 400x30/30 0.5 24 7.28/40/101 CVP 25 IAP 25. +TBB 57L. Sedated, min\n responsive, pupils 6 to 4B. Hyperdynamic. Bronchial BS B. RRR s1s2.\n Distended, minimal bowel sounds. Massive edema. Labs notable for WBC\n 29K, HCT 31, K+ 4.1, Cr 3.2, lactate 2.1, INR 1.8. CXR with worsening\n ARDS R>L.\n Agree with plan to obtain I- head CT today given change in pupillary\n exam. Will also obtain torso CT with oral contrast to assess lungs and\n pancreas while covering possible evolving sepsis with vanco / .\n Will manage ARDS with low volume ventilation (400x30); will attempt to\n wean PEEP if we can keep FiO2 <0.5. For , hold on further\n fluids and increase pressors if UOP <20cc/h. ARF is progressive though\n UOP is stable, renal following, may need to consider CVVH. Will dose\n vanco to level. Pancreatitis likely due to EtOH, NPO, following.\n Can't use gut for now; will try to pass doboff and allow this to drift\n into post pyloric position, but will also need to start TPN tomorrow.\n Alcoholic hepatitis is stable. UGIB from Dieulafois lesion at GEJ\n appears stable, will monitor serial HCT and continue PPI IV.\n Thrombocytopenia is stable, await HIT. Above d/w family in family mtg.\n Remainder of plan as outlined above.\n Patient is critically ill\n Total time: 60 min\n ------ Protected Section Addendum Entered By: , MD\n on: 03:44 PM ------\n" }, { "category": "Nursing", "chartdate": "2131-05-25 00:00:00.000", "description": "Nursing Progress Note", "row_id": 676777, "text": "Hypotension (not Shock)\n Assessment:\n SBP initially labile with recent initiation of CRRT. Pt very sensitive\n to any activity/movement and drops SBP.\n Action:\n Neo and Levophed drips titrated as needed to maintain MAP >65. Per\n renal recs\n fluid removed @ 100cc/hr.\n Response:\n Pt. remains maxed on Neo and on very low dose Levophed in order to take\n off 100cc/hr fluid via CRRT.\n Plan:\n Cont. to monitor hemodynamics closely, titrate pressors as needed.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n Problem\n Cerebral edema\n Assessment:\n Pupils remain 6mm and sluggish bilaterally. No response to pain,\n sedated on Fentanyl and Versed drips.\n Action:\n Response:\n Plan:\n" }, { "category": "Physician ", "chartdate": "2131-05-25 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 676840, "text": "Chief Complaint: Acute pancreatitis\n 24 Hour Events:\n - Changed hypertonic saline to continous 3%\n - Neuro/nsurg wanted repeat ct head\n - Decreased peep/fio2\n - HD line placed and CVVH started\n - EEG underway\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 12:00 PM\n Metronidazole - 02:36 AM\n Meropenem - 05:47 AM\n Infusions:\n Fentanyl (Concentrate) - 400 mcg/hour\n Midazolam (Versed) - 30 mg/hour\n Phenylephrine - 5 mcg/Kg/min\n Other ICU medications:\n Pantoprazole (Protonix) - 08:21 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 06:55 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.6\nC (99.6\n Tcurrent: 37.1\nC (98.7\n HR: 94 (93 - 106) bpm\n BP: 107/56(73) {82/43(56) - 130/69(90)} mmHg\n RR: 30 (0 - 31) insp/min\n SpO2: 98%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 156 kg (admission): 113.5 kg\n Height: 67 Inch\n CVP: 16 (15 - 25)mmHg\n Total In:\n 14,293 mL\n 2,159 mL\n PO:\n TF:\n IVF:\n 13,230 mL\n 1,835 mL\n Blood products:\n Total out:\n 1,413 mL\n 1,881 mL\n Urine:\n 164 mL\n 30 mL\n NG:\n 200 mL\n Stool:\n Drains:\n Balance:\n 12,880 mL\n 278 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 30\n RR (Spontaneous): 0\n PEEP: 20 cmH2O\n FiO2: 40%\n RSBI Deferred: PEEP > 10\n PIP: 42 cmH2O\n Plateau: 33 cmH2O\n Compliance: 30.8 cmH2O/mL\n SpO2: 98%\n ABG: 7.28/48/89./18/-4\n Ve: 11.8 L/min\n PaO2 / FiO2: 223\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 70 K/uL\n 10.3 g/dL\n 175 mg/dL\n 3.9 mg/dL\n 18 mEq/L\n 3.9 mEq/L\n 30 mg/dL\n 106 mEq/L\n 135 mEq/L\n 30.7 %\n 44.1 K/uL\n [image002.jpg]\n 06:30 PM\n 01:22 AM\n 01:32 AM\n 09:55 AM\n 04:11 PM\n 09:39 PM\n 10:00 PM\n 02:26 AM\n 04:29 AM\n 04:48 AM\n WBC\n 38.9\n 44.1\n Hct\n 31.0\n 30.4\n 30.7\n Plt\n 99\n 70\n Cr\n 3.8\n 4.0\n 3.9\n TCO2\n 21\n 17\n 17\n 21\n 20\n 24\n Glucose\n 105\n 142\n 131\n 173\n 175\n Other labs: PT / PTT / INR:18.7/58.3/1.7, ALT / AST:37/219, Alk Phos /\n T Bili:218/20.6, Amylase / Lipase:16/37, Differential-Neuts:75.0 %,\n Band:0.0 %, Lymph:4.0 %, Mono:12.0 %, Eos:6.0 %, D-dimer: ng/mL,\n Fibrinogen:402 mg/dL, Lactic Acid:1.7 mmol/L, Albumin:2.1 g/dL, LDH:624\n IU/L, Ca++:8.1 mg/dL, Mg++:2.4 mg/dL, PO4:3.2 mg/dL\n Assessment and Plan\n Mr. is a 28 year old gentleman with alcoholic hepatitis and\n necrotizing pancreatitis complicated by ARDS, SIRS, and UGIB.\n # Neuro: Patient with dilated pupils on high dose fentaynl gtt. CTH\n demonstrated loss of grey white differentiation with questionable\n effacement and possible seizure activity. Neuro and neurosurg consulted\n and patietn received ativan, keppra load, and hypertonic saline of\n hyponatremia. Patient converted to 3% IVF infusion.\n - Per neuro, keppra IV maintenance dose\n - Convert back to 23% hypertonic saline boluses Q3H with regular serum\n sodium checks.\n - EEG to be completed today\n - Per neurosurg, repeat CTH today\n - Follow-up with neurosurg and neuro recs if any.\n # Respiratory Failure: ARDS secondary to necrotizing pancreatitis\n compounded by hypoxia, tachypnea in setting of anion gap metabolic\n acidosis, increased abdominal pressure, and EtOH withdrawl. PEEP\n decreased to 20 and FiO2 to 40%.\n - Wean FiO2 and PEEP, goal PaO2>60-65%\n - Continue to monitor IAP\n # Leukocytosis: WBC up to 44.9 today. Concern for CVL infection, VAP,\n loculated effusion, sinusitis, or pancreatitis complication including\n abscess formation. CT chest with multifocal infiltrates that could\n represent VAP vs ARDS. CTAP did not demonstrate any new pancreatic\n fluid collections. On last differential, past had a predominantly left\n shift, although also with 6% eos.\n - Continue empiric vancomycin, meropenem, and flagyl. AM vanco level\n today\n - Recheck differential, if elevated would consider drug reaction as\n potential etiology to leukocytosis and likely switch meropenem.\n - Follow-up culture data\n - Afrin and nasal saline spray\n # Necrotizing pancreatitis/SIRS: Secondary to alcohol complicated by\n SIRS and ARDS. Patient continues to have pressor requirement, with neo\n +/- levo. Aggressive volume resuscitation with >58L. Patient\n without improvement with albumin trial, likely secondary to SIRS and\n increased vascular permeability.\n - Continue empiric antimicrobials.\n - Wean pressors as able, starting with levophed\n - Hypertonic saline as above in order to increase intravascular volume.\n - Monitor chemistries.\n - Follow-up with recs if any\n # Hyponatremia: In setting of decreased effective circulating volume in\n setting of SIRS and IABP. Patient received hypertonic saline overnight\n per neurosurgery. Serum sodium stable this morning.\n - Hypertonic saline as above.\n - Trend chemistries.\n - Follow-up with neurosurgery recs if any.\n # Acute renal failure: Patient had HD line placed and CVVH was\n initiated yesterday.\n - CVVH per renal.\n - Trend chemistries\n #Thrombocytopenia: Platelets stable. No clear etiology at this time.\n DIC panel and HIT PF4 antibody negative.\n - Trend plt, transfuse for plt<10 or <50 if signs of hemorrhage.\n # IAP elevation: Secondary to third spacing and edema. Per surgery, not\n a good surgical candidate at this time.\n # Acute hepatitis: Likely alcoholic hepatitis with fatty infiltration,\n and no evidence of distal obstruction. RUQ u/s shows marked liver\n echogenicity but no ascites.\n - Trend LFTs\n # Hematemesis: EGD showed diuelafoy's lesion. HCT stable since 2 units\n PRBC on .\n - Trend hct, transfuse for hct<21\n # Alcoholism: Patient describes history of withdrawal symptoms, but\n not prior seizure. Last drink was night prior to presentation.\n Tachycardia, weakness, and elevated lactate could be consistent with\n thiamine deficiency.\n - Thiamine, vb12, folate\n - Valium with CIWA > 10\n FEN: TPN, replete as necessary. Consider dobhoff placement today.\n PPx: Heparin in TPN, PPI\n Access: RIJ (quad), LIJ (HD) right radial a-line\n Dispo: ICU level of care\n ICU Care\n Nutrition:\n TPN without Lipids - 04:08 PM 47 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 01:35 PM\n Multi Lumen - 02:02 PM\n Dialysis Catheter - 04:56 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": "2131-05-25 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 676842, "text": "Chief Complaint: Acute pancreatitis\n 24 Hour Events:\n - Changed hypertonic saline to continous 3%\n - Neuro/nsurg wanted repeat ct head\n - Decreased peep/fio2\n - HD line placed and CVVH started\n - EEG underway\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 12:00 PM\n Metronidazole - 02:36 AM\n Meropenem - 05:47 AM\n Infusions:\n Fentanyl (Concentrate) - 400 mcg/hour\n Midazolam (Versed) - 30 mg/hour\n Phenylephrine - 5 mcg/Kg/min\n Other ICU medications:\n Pantoprazole (Protonix) - 08:21 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 06:55 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.6\nC (99.6\n Tcurrent: 37.1\nC (98.7\n HR: 94 (93 - 106) bpm\n BP: 107/56(73) {82/43(56) - 130/69(90)} mmHg\n RR: 30 (0 - 31) insp/min\n SpO2: 98%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 156 kg (admission): 113.5 kg\n Height: 67 Inch\n CVP: 16 (15 - 25)mmHg\n Total In:\n 14,293 mL\n 2,159 mL\n PO:\n TF:\n IVF:\n 13,230 mL\n 1,835 mL\n Blood products:\n Total out:\n 1,413 mL\n 1,881 mL\n Urine:\n 164 mL\n 30 mL\n NG:\n 200 mL\n Stool:\n Drains:\n Balance:\n 12,880 mL\n 278 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 30\n RR (Spontaneous): 0\n PEEP: 20 cmH2O\n FiO2: 40%\n RSBI Deferred: PEEP > 10\n PIP: 42 cmH2O\n Plateau: 33 cmH2O\n Compliance: 30.8 cmH2O/mL\n SpO2: 98%\n ABG: 7.28/48/89./18/-4\n Ve: 11.8 L/min\n PaO2 / FiO2: 223\n Physical Examination\n Gen: Sedated\n HEENT: ETT in place.. Scleral edema\n Chest: coarse BS bl, rhonchorous throughout\n CV: distant heart sounds, RRR, S1S2\n Abd: distended, abdominal wall edema\n Ext: Anasarca\n Neuro: Sedated. Pupils 6 mm, reactive.\n Labs / Radiology\n 70 K/uL\n 10.3 g/dL\n 175 mg/dL\n 3.9 mg/dL\n 18 mEq/L\n 3.9 mEq/L\n 30 mg/dL\n 106 mEq/L\n 135 mEq/L\n 30.7 %\n 44.1 K/uL\n 06:30 PM\n 01:22 AM\n 01:32 AM\n 09:55 AM\n 04:11 PM\n 09:39 PM\n 10:00 PM\n 02:26 AM\n 04:29 AM\n 04:48 AM\n WBC\n 38.9\n 44.1\n Hct\n 31.0\n 30.4\n 30.7\n Plt\n 99\n 70\n Cr\n 3.8\n 4.0\n 3.9\n TCO2\n 21\n 17\n 17\n 21\n 20\n 24\n Glucose\n 105\n 142\n 131\n 173\n 175\n Other labs: PT / PTT / INR:18.7/58.3/1.7, ALT / AST:37/219, Alk Phos /\n T Bili:218/20.6, Amylase / Lipase:16/37, Differential-Neuts:75.0 %,\n Band:0.0 %, Lymph:4.0 %, Mono:12.0 %, Eos:6.0 %, D-dimer: ng/mL,\n Fibrinogen:402 mg/dL, Lactic Acid:1.7 mmol/L, Albumin:2.1 g/dL, LDH:624\n IU/L, Ca++:8.1 mg/dL, Mg++:2.4 mg/dL, PO4:3.2 mg/dL\n Assessment and Plan\n Mr. is a 28 year old gentleman with alcoholic hepatitis and\n necrotizing pancreatitis complicated by ARDS, SIRS, and UGIB.\n # Neuro: Patient with dilated pupils on high dose fentaynl gtt. CTH\n demonstrated loss of grey white differentiation with questionable\n effacement and possible seizure activity. Neuro and neurosurg consulted\n and patietn received ativan, keppra load, and hypertonic saline of\n hyponatremia. Patient converted to 3% IVF infusion.\n - Per neuro, keppra IV maintenance dose\n - Convert back to 23% hypertonic saline boluses Q3H with regular serum\n sodium checks.\n - EEG to be completed today\n - Per neurosurg, repeat CTH today\n - Follow-up with neurosurg and neuro recs if any.\n # Respiratory Failure: ARDS secondary to necrotizing pancreatitis\n compounded by hypoxia, tachypnea in setting of anion gap metabolic\n acidosis, increased abdominal pressure, and EtOH withdrawl. PEEP\n decreased to 20 and FiO2 to 40%.\n - Wean FiO2 and PEEP, goal PaO2>60-65%\n - Continue to monitor IAP\n # Leukocytosis: WBC up to 44.9 today. Concern for CVL infection, VAP,\n loculated effusion, sinusitis, or pancreatitis complication including\n abscess formation. CT chest with multifocal infiltrates that could\n represent VAP vs ARDS. CTAP did not demonstrate any new pancreatic\n fluid collections. On last differential, past had a predominantly left\n shift, although also with 6% eos.\n - Continue empiric vancomycin, meropenem, and flagyl. AM vanco level\n today\n - Recheck differential, if elevated would consider drug reaction as\n potential etiology to leukocytosis and likely switch meropenem.\n - Follow-up culture data\n - Afrin and nasal saline spray\n # Necrotizing pancreatitis/SIRS: Secondary to alcohol complicated by\n SIRS and ARDS. Patient continues to have pressor requirement, with neo\n +/- levo. Aggressive volume resuscitation with >58L. Patient\n without improvement with albumin trial, likely secondary to SIRS and\n increased vascular permeability.\n - Continue empiric antimicrobials.\n - Wean pressors as able, starting with levophed\n - Hypertonic saline as above in order to increase intravascular volume.\n - Monitor chemistries.\n - Follow-up with recs if any\n # Hyponatremia: In setting of decreased effective circulating volume in\n setting of SIRS and IABP. Patient received hypertonic saline overnight\n per neurosurgery. Serum sodium stable this morning.\n - Hypertonic saline as above.\n - Trend chemistries.\n - Follow-up with neurosurgery recs if any.\n # Acute renal failure: Patient had HD line placed and CVVH was\n initiated yesterday.\n - CVVH per renal.\n - Trend chemistries\n #Thrombocytopenia: Platelets stable. No clear etiology at this time.\n DIC panel and HIT PF4 antibody negative.\n - Trend plt, transfuse for plt<10 or <50 if signs of hemorrhage.\n # IAP elevation: Secondary to third spacing and edema. Per surgery, not\n a good surgical candidate at this time.\n # Acute hepatitis: Likely alcoholic hepatitis with fatty infiltration,\n and no evidence of distal obstruction. RUQ u/s shows marked liver\n echogenicity but no ascites.\n - Trend LFTs\n # Hematemesis: EGD showed diuelafoy's lesion. HCT stable since 2 units\n PRBC on .\n - Trend hct, transfuse for hct<21\n # Alcoholism: Patient describes history of withdrawal symptoms, but\n not prior seizure. Last drink was night prior to presentation.\n Tachycardia, weakness, and elevated lactate could be consistent with\n thiamine deficiency.\n - Thiamine, vb12, folate\n - Valium with CIWA > 10\n FEN: TPN, replete as necessary. Consider dobhoff placement today.\n PPx: Heparin in TPN, PPI\n Access: RIJ (quad), LIJ (HD) right radial a-line\n Dispo: ICU level of care\n ICU Care\n Nutrition:\n TPN without Lipids - 04:08 PM 47 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 01:35 PM\n Multi Lumen - 02:02 PM\n Dialysis Catheter - 04:56 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": "2131-05-25 00:00:00.000", "description": "Nursing Progress Note", "row_id": 676822, "text": "Hypotension (not Shock)\n Assessment:\n SBP initially labile with recent initiation of CRRT. Pt very sensitive\n to any activity/movement and drops SBP/MAP.\n Action:\n Neo and Levophed drips titrated as needed to maintain MAP >65. Per\n renal recs\n fluid removed @ 100cc/hr via CRRT. MICU and renal in\n agreement that they would like pt negative even if pressor requirement\n goes up.\n Response:\n Pt. remains maxed on Neo and on very low dose Levophed in order to take\n off 100cc/hr fluid via CRRT.\n Plan:\n Cont. to monitor hemodynamics closely, titrate pressors as needed,\n follow labs closely.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n ABGs stable, oxygenation slightly lower in mid 80s but acceptable per\n team. Lung sounds dim to bases. Sats 92-96%. Tolerating today\ns PEEP\n drop to 20.\n Action:\n None taken.\n Response:\n No vent changes overnight.\n Plan:\n Cont. to monitor.\n Problem\n Cerebral edema\n Assessment:\n Pupils remain 6mm and sluggish bilaterally. No response to pain, no\n deep reflexes. limited neuro exam, sedated on Fentanyl and Versed\n drips. No seizure activity.\n Action:\n Neuro status closely monitored, begun on 3% NaCl drip, sodium and\n lytes monitored frequently. Cont. EEG in place.\n Response:\n No change in neuro status overnight.\n Plan:\n Cont. per above measures, to have head CT today to further assess\n cerebral edema.\n" }, { "category": "Nursing", "chartdate": "2131-05-25 00:00:00.000", "description": "Nursing Progress Note", "row_id": 676823, "text": "Impaired Skin Integrity\n Assessment:\n Pt. up 60+L fluid, grossly edematous, weeping continuously from mult.\n Blistered areas all over body. Scleral edema increased , difficult to\n open eyes to examine pupils. Skin taut to abdomen, bladder pressure 19.\n Action:\n All attempts made to keep pt\ns skin as dry as possible, frequent pad\n changes done.\n Response:\n Cont. with anasarca and massive insensible fluid losses.\n Plan:\n Cont. skin care as able, pt\ns on Bari max bed.\n Problem\n Renal failure.\n Assessment:\n Minimal HUO, icteric urine with sediment. CRRT running overnight to\n keep pt 100cc/hr negative.\n Action:\n CRRT per above parameters.\n Response:\n Pt. tolerating fluid off in small amounts, remains on Neo and low dose\n Levophed.\n Plan:\n Cont. per above.\n" }, { "category": "Physician ", "chartdate": "2131-05-21 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 675962, "text": "Chief Complaint:\n 24 Hour Events:\n D/c'd R femoral line\n D/c'd maintenence fluids, bolused prn hypotension. Levophed restarted\n am of .\n ESOPHOGEAL BALLOON - At 08:45 AM\n CORDIS/INTRODUCER - STOP 02:05 PM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Meropenem - 12:15 AM\n Infusions:\n Fentanyl (Concentrate) - 300 mcg/hour\n Midazolam (Versed) - 20 mg/hour\n Phenylephrine - 5 mcg/Kg/min\n Other ICU medications:\n Pantoprazole (Protonix) - 08:41 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 05:19 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: 36.8\nC (98.3\n HR: 100 (94 - 106) bpm\n BP: 89/67(77) {72/47(56) - 104/68(79)} mmHg\n RR: 30 (0 - 30) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 111.3 kg (admission): 113.5 kg\n Height: 67 Inch\n CVP: 28 (19 - 35)mmHg\n Total In:\n 6,683 mL\n 1,180 mL\n PO:\n TF:\n IVF:\n 6,638 mL\n 1,180 mL\n Blood products:\n Total out:\n 416 mL\n 94 mL\n Urine:\n 416 mL\n 94 mL\n NG:\n Stool:\n Drains:\n Balance:\n 6,267 mL\n 1,086 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 30\n RR (Spontaneous): 0\n PEEP: 24 cmH2O\n FiO2: 70%\n RSBI Deferred: PEEP > 10, FiO2 > 60%, Hemodynamic Instability\n PIP: 46 cmH2O\n Plateau: 42 cmH2O\n Compliance: 23.5 cmH2O/mL\n SpO2: 97%\n ABG: 7.30/40/82./18/-5\n Ve: 11.7 L/min\n PaO2 / FiO2: 119\n Physical Examination\n Gen: sedated\n HEENT: intubated\n Chest: coarse BS bl\n CV: distant heart sounds, RRR, S1S2\n Abd: distended, abdominal wall edema\n Ext: anasarca throughout\n Labs / Radiology\n 51 K/uL\n 11.0 g/dL\n 100 mg/dL\n 1.8 mg/dL\n 18 mEq/L\n 3.9 mEq/L\n 15 mg/dL\n 100 mEq/L\n 129 mEq/L\n 32.0 %\n 18.5 K/uL\n [image002.jpg]\n 04:55 AM\n 08:07 AM\n 10:04 AM\n 12:04 PM\n 02:30 PM\n 06:50 PM\n 09:15 PM\n 10:34 PM\n 02:42 AM\n 03:01 AM\n WBC\n 16.5\n 18.5\n Hct\n 31.5\n 31.4\n 32.0\n Plt\n 69\n 51\n Cr\n 2.2\n 1.8\n TCO2\n 22\n 21\n 22\n 21\n 21\n 20\n 20\n Glucose\n 108\n 107\n 97\n 100\n Other labs: PT / PTT / INR:20.9/47.6/2.0, ALT / AST:94/271, Alk Phos /\n T Bili:200/14.0, Amylase / Lipase:45/268, Lactic Acid:2.4 mmol/L,\n Albumin:2.2 g/dL, LDH:616 IU/L, Ca++:7.7 mg/dL, Mg++:1.9 mg/dL, PO4:2.4\n mg/dL\n Assessment and Plan\n Mr. is a 28 year old gentleman with alcoholic hepatitis and\n necrotizing pancreatitis complicated by ARDS, SIRS, and UGIB.\n # Respiratory Failure: ARDS secondary to necrotizing pancreatitis\n compounded by hypoxia, tachypnea in setting of anion gap metabolic\n acidosis, increased abdominal pressure, and EtOH withdrawl.\n - Continue current vent settings for now\n - check intraabdominal pressure\n - consider changing bed rotation parameters so only supine and\n left-sided to minimize pressure on IVC.\n - Begin to wean sedation as tolerated. Would prefer to wean down\n fentanyl and then midaxolam.\n # Necrotizing pancreatitis/SIRS: Likely secondary to alcohol\n complicated by SIRS. Patient continues to have pressor requirement and\n volume resucsitation with >54L.\n - Continue empiric meropenem for now. Will discuss with surgical team.\n - Wean pressors as able, starting with levophed\n - If hypotensive, consider using albumin 25-50 grams in preference to\n additional IVF boluses to maintain MAP>60 and UOP>20 cc/hr.\n - Monitor chemistries.\n - Continue to hold MIVF\n - Follow-up with recs if any\n # Acute renal failure: Creatinine continues to trend up with oliguria,\n likely secondary to SIRS/hypotension and IABP leading to ATN.\n - Urine lytes, eos, osm\n - Trend UOP, bolus IVF to maintain goal >20 cc/hr.\n #Thrombocytopenia: platelets trending down. No clear etiology at this\n time. Recommend checking DIC panel and HIT antibody.\n # IAP elevation: Secondary to third spacing and edema. Per surgery, not\n a good surgical candidate at this time.\n # Acute hepatitis: Likely alcoholic hepatitis with fatty infiltration,\n and no evidence of distal obstruction. RUQ u/s shows marked liver\n echogenicity but no ascites.\n - Trend LFTs\n # Hematemesis: EGD showed diuelafoy's lesion. HCT stable since 2 units\n PRBC on .\n - Trend hct, transfuse for hct<21\n # Hyponatremia: In setting of decreased effective circulating volume in\n setting of SIRS and IABP.\n - Trend chemistries.\n # Alcoholism: Patient describes history of withdrawal symptoms, but\n not prior seizure. Last drink was night prior to presentation.\n Tachycardia, weakness, and elevated lactate could be consistent with\n thiamine deficiency.\n - Thiamine, vb12, folate\n - Valium with CIWA > 10\n FEN: IVF, replete electrolytes, NPO. Would consider starting TPN after\n 5-7 days. If patient has no significant change over the next 1-2 days,\n may begin TPN on approximately .\n PPx: SCDs, PPI\n Access: RIJ, right radial art line.\n Code: Full Code\n Dispo: ICU level of care.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Arterial Line - 01:35 PM\n Multi Lumen - 02:02 PM\n Prophylaxis:\n DVT: SCD\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Respiratory ", "chartdate": "2131-05-25 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 676821, "text": "Demographics\n Ideal body weight: 67.1 None\n Ideal tidal volume: 268.4 / 402.6 / 536.8 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Tube Type\n ETT:\n Position: 24 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7mm\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: Tan / Thick\n Sputum source/amount: Suctioned / Scant\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort:\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Utilize ARDSnet protocol\n Reason for continuing current ventilatory support: Sedated / Paralyzed,\n Cannot protect airway, Cannot manage secretions\n Bedside Procedures:\n Comments: Pt remains intubated, high peep. For any vent changes.\n Consult Micu team\n" }, { "category": "Nursing", "chartdate": "2131-05-21 00:00:00.000", "description": "Nursing Progress Note", "row_id": 675826, "text": "TITLE:\n Hypotension (not Shock)\n Assessment:\n Periods of hypotension with Mean bp < 60 on neosynephrine Very sedate\n (high dose fentanyl &versed gtts) pupils 2-4mm sluggish reactive, no\n gag, impaired cough, does not withdraw to pain\n Sr- no ectopics. Vigeleo co 4.7-7 range w svv cvp 23-30\n Anasarca with Uop 13-18cc/hr icteric urine\n Action:\n Notified Dr\n and Dr re: low bp\ns.Fluid bloused x 4 = total\n 1500 cc fld , Neo titrated from 4.4 to 5mcg/kg/min. fentanyl weaned to\n 300mcg/hr, versed remains at 20mg/hr.\n Response:\n Transient bp improvements with fluid boluses. Creat 1.8 this am.\n Plan:\n If persistent mbp < 60 may restart levophed ,please Call HO if\n requires levophed. Wean pressors once bp more stable. ? crrt later this\n week if low uop persists and creat continues to rise.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Intubated on fio2 70% peep 24 tv 400 rr 30 sedated on fentanyl and\n versed, not overbreathing ventilator. Bbs clear upper lobes and\n diminished bibasilarly.Orally suct for bloody secretions, sm amts of\n blood via lt nares. Triadyne bed with maximal side to side rotation.\n Action:\n Maximal rotation throughout the night, when supine bp drops and sats\n down to low 90\ns.Suctioned for no secretions. Lactates stable at\n 2.6-2.4, Dr aware. Brief desat to 90 with turning side to side for\n am care recovered within 5 mins.loose packing to bilat nares. Ffreq\n oral care. Am labs done\n Response:\n Abg adequate with fio2 decrease to 70%.Poorly tolerates supine\n position, bp and sats improved w maximal rotation side to side.Plt\n count down to 51k this am-Dr made aware.(receiving NO heparin\n products)\n Plan:\n Wean fio2 if tolerates. Pulm toilet, Vap bundlecontinuing rotation with\n triadyne bed. Maintain fentanyl and versed sedation until ventilator\n requirements diminished.Continue to monitor labs.\n" }, { "category": "Respiratory ", "chartdate": "2131-05-20 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 675706, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 0\n Ideal body weight: 67.1 None\n Ideal tidal volume: 268.4 / 402.6 / 536.8 mL/kg\n Airway\n 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: 7mm\n Tracheostomy tube:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Diminished\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 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 Hemodynimic instability, Underlying illness not resolved\n Respiratory Care Shift Procedures\n Bedside Procedures:\n Pleural pressure measurement (0900 am)\n Comments: Patient underpeep only by 1cmH2O, is within correct gap.\n Patient remains intubated and on mechanical ventilation, breath sounds\n bilaterally clear at the upper lungs, diminished at the bases,\n suctioned intermittently for moderate to small amounts of bright\n yellow, bile-like secretions, has been back on 100% due to aggravation\n of hypoxemia, now so far FiO2 weaned down to 80%, will continues to be\n followed.\n" }, { "category": "Nursing", "chartdate": "2131-05-22 00:00:00.000", "description": "Nursing Progress Note", "row_id": 676188, "text": "TITLE:\n Hypotension (not Shock)\n Assessment:\n mean bp fluctuating between 60-70. Neosynephrine at 5mcg/kg/m and\n levophed 0.02. Uop marginal at 15-20cc/hr, with 1 hr episode no urine\n output (foley patent & irrigated freely)\n Action:\n levophed titrated to 0.04 mcg to achieve goal mbp >70, uop still\n remained low, albumin 25gm iv x1\n Response:\n decreased levo to 0.03 mcg\nmbp still >70. little urinary output\n response to albumin. Creat rising 3.0 today.Wt increased 8kg in 24hrs\n Plan:\n Needs evaluation for crrt. Wean levophed before neo for goal mbp >70 .\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Remains sedated on fentanyl 225mcg and versed 20 mg/hr/PaO2 86 on fio2\n 60% peep24.O2sats 94-96% bbs coarse to clear upper lobes diminish lower\n lobes bilat. Triadyne w rotation/percussion continues with\n readjustments made to Lt side > rt side rotation\n Action:\n HO made aware abg results->fio2 decr to 50%, per Dr , follow O2\n sats no need to repeat abg if sat > 94%. Suctioning for sm amts of\n bilious. Vap bundle, suct orally for sm amts frothy blood tinge\n secretions.\n Response:\n Breath sounds clearer after suctioning (tolerated well w/o desats).\n Tolerating change in rotation. Sats > 94% on 50%\n Plan:\n Cont to wean fio2 as tol..Wean fentanyl as tolerated allowing\n 1-2breaths over set rate max.. Vap bundle.\n Pancreatitis, acute\n Assessment:\n Abd firm distended, bladder pressure 19 overnight.\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2131-05-21 00:00:00.000", "description": "Nursing Progress Note", "row_id": 675820, "text": "TITLE:\n Hypotension (not Shock)\n Assessment:\n Periods of hypotension with Mean bp < 60 on neosynephrine Very sedate\n (high dose fentanyl &versed gtts) pupils 2-4mm sluggish reactive, no\n gag, impaired cough, does not withdraw to pain\n Sr- no ectopics. Vigeleo co 4.7-7 range w svv cvp 23-30\n Anasarca with Uop 13-18cc/hr icteric urine\n Action:\n Notified Dr\n and Dr re: low bp\ns.Fluid bloused x 4 = total\n 1500 cc fld , Neo titrated from 4.4 to 5mcg/kg/min. fentanyl weaned to\n 300mcg/hr, versed remains at 20mg/hr.\n Response:\n Transient bp improvements with fluid boluses. Creat 1.8 this am.\n Plan:\n If persistent mbp < 60 may restart levophed ,please Call HO if\n requires levophed. Wean pressors once bp more stable. ? crrt later this\n week if low uop persists and creat continues to rise.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Intubated on fio2 70% peep 24 tv 400 rr 30 sedated on fentanyl and\n versed, not overbreathing ventilator. Bbs clear upper lobes and\n diminished bibasilarly. Triadyne bed with maximal side to side\n rotation.\n Action:\n Maximal rotation throughout the night, when supine bp drops and sats\n down to low 90\ns.Suctioned for no secretions. Lactates stable at\n 2.6-2.4, Dr aware. Brief desat to 90 with turning side to side for\n am care recovered within 5 mins.\n Response:\n Abg adequate with fio2 decrease to 70%.Poorly tolerates supine\n position, bp and sats improved w maximal rotation side to side.\n Plan:\n Wean fio2 if tolerates. Pulm toilet, continuing rotation with triadyne\n bed. Maintain fentanyl and versed sedation until ventilator\n requirements diminished.\n" }, { "category": "Nursing", "chartdate": "2131-05-22 00:00:00.000", "description": "Nursing Progress Note", "row_id": 676377, "text": "Impaired Skin Integrity\n Assessment:\n - Pt has generalized anasarca with a tbb of +55 L. Patient\n posterior side is intact, but patient\ns lower extremities are extremely\n fluid overloaded and patient has diffuse blistering throughout lower\n extremities, oozing serous fluid.\n - Patient has two old puncture sites, one in R antecubital\n (former peripheral IV site) and one in R groin (former cordis site)\n draining serous fluid.\n Action:\n - Lower extremities cleansed with normal saline; gently patted\n dry; adaptic/Vaseline gauze and softsorb applied and covered with net\n mesh to keep softsorbs intact.\n - Both puncture sites covered with drainage bags to catch\n serous output.\n Response:\n - Patient\ns blistering/oozing of serous fluid remains.\n - Drainage bags on puncture sites intact/surrounding skin\n appears intact.\n Plan:\n - Continue cleanse/treatment, relieve areas of pressure, ?\n consult wound care nurse for further treatment.\n - Continue to monitor skin integrity.\n Hypotension (not Shock)\n Assessment:\n - Pt on max neo and low dose levo to achieve MAP >70\n - Urine output average 25 cc/hour\n Action:\n - Levophed weaned to off this morning\n Response:\n - After several hours off levo, patient\ns MAP dropped to\n 60-65 and correspondingly, urine output\n Decreased to 10-11 cc/hour, so levo turned back on to\n 0.02\n Plan:\n - Continue to keep MAP >70, monitor perfusion, urine output\n Respiratory failure, acute (not ARDS/)\n Assessment:\n - This morning, patient dysynchronous and overbreathing\n ventilator by 5-7 breaths per minute.\n - Lung sounds rhonchorous, diminished in bases\n Action:\n - Increased patient\ns fentanyl gtt to 300 from 225 to improve\n synchrony with vent\n - Adjusted patient\ns position into modified swimmer\n position, left side down, to help aerate R lung and improve perfusion\n with L lung\n - Moved patient onto a larger bed to provide more efficient\n rotating\n - Sent sputum culture\n Response:\n - ABG improved to 122 from 86\n - Patient more synchronous with vent\n - Tolerating rotating\n Plan:\n - No vent changes for today\n - Follow up sputum culture.\n Pancreatitis, acute\n Assessment:\n - Abd firm distended no active bowel sounds present. Ngt to lws w\n bilious to brown drainage, lightening up slightly as shift continues.\n Action:\n - Bladder pressure 20 this shift. Repeated CBC/lytes\n pending.\n Nutrition consulted.\n Response:\n - Team expects patient\ns bilirubin to remain elevated for a long time\n (up to weeks) r/t pancreatitis.\n Plan:\n - Continue to follow bladder pressures. Monitor labs. Monitor for signs\n of bleeding. ? TPN versus jejunum feeding\n per MICU attending will\n decide on this matter tomorrow. Surgery still consulting.\n" }, { "category": "Nursing", "chartdate": "2131-05-18 00:00:00.000", "description": "Nursing Progress Note", "row_id": 675192, "text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Patient remains intubated and sedated on CMV. Sxn\ning seldomly for\n small amounts of white/tan secretions. LS clear with diminished at the\n bases.\n Action:\n Turn and reposition patient frequently; wean Fi02 throughout day.\n Response:\n Patient\ns O2 sats 94-98%, ABG checked this afternoon within normal\n limits.\n Plan:\n Continue intubation and sedation; monitor for progression into ARDS\n secondary to pancreatitis.\n Gastrointestinal bleed, upper (Melena, GI Bleed, GIB)\n Assessment:\n Pt with OGT to cont LWS, small amount of dark blood/mucous from OGT\n minimal amounts.\n Action:\n Placement of OG confirmed via Xray and auscultation; rechecked\n Hematocrit. Shut off protonix gtt\n Response:\n Hematocrit level stable. No s/s bleeding.\n Plan:\n Continue crit checks; type and screen active\n due to be resent on\n ; protonix \n Pancreatitis, acute\n Assessment:\n Pt with hypo bowel sounds on left sides; absent on right. Abd\n firm/distended. Patient hypotensive and oliguric.\n Action:\n Strict NPO; OGT to cont LWS putting out dark red blood in small\n amounts; received multiple boluses and increased maintenance fluids to\n 250 an hour.\n Response:\n Continues to require aggressive fluid resuscitation and remains on neo\n Plan:\n Remain strict NPO; fluid resuscitation; try to wean neo as tolerated.\n Surgery will continue to closely consult.\n" }, { "category": "Nursing", "chartdate": "2131-05-18 00:00:00.000", "description": "Nursing Progress Note", "row_id": 675195, "text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Patient remains intubated and sedated on CMV. Sxn\ning seldomly for\n small amounts of white/tan secretions. LS clear with diminished at the\n bases.\n Action:\n Turn and reposition patient frequently; wean Fi02 throughout day.\n Response:\n Patient\ns O2 sats 94-98%, ABG checked this afternoon within normal\n limits.\n Plan:\n Continue intubation and sedation; monitor for progression into ARDS\n secondary to pancreatitis.\n Gastrointestinal bleed, upper (Melena, GI Bleed, GIB)\n Assessment:\n Pt with OGT to cont LWS, small amount of dark blood/mucous from OGT\n minimal amounts.\n Action:\n Placement of OG confirmed via Xray and auscultation; rechecked\n Hematocrit. Shut off protonix gtt\n Response:\n Hematocrit level stable. No s/s bleeding.\n Plan:\n Continue crit checks; type and screen active\n due to be resent on\n ; protonix \n Pancreatitis, acute\n Assessment:\n Pt with hypo bowel sounds on left sides; absent on right. Abd\n firm/distended. Patient hypotensive and oliguric.\n Action:\n Strict NPO; OGT to cont LWS putting out dark red blood in small\n amounts; received multiple boluses and increased maintenance fluids to\n 250 an hour.\n Response:\n Continues to require aggressive fluid resuscitation and remains on neo\n Plan:\n Remain strict NPO; fluid resuscitation; try to wean neo as tolerated.\n Surgery will continue to closely consult.\n Hypotension (not Shock)\n Assessment:\n Patient remains on neo, requiring aggressive fluid bolusing. MAP 59-62.\n Urine output 0-13 cc/hour. CVP 17-19\n Action:\n Continued fluid blousing; applied vigileo showing CO and SVV 18-22\n Response:\n Patient remains hypotensive despite fluid resuscitation and SVV remains\n elevated at 16-17, CVP up 20-22. Remains oliguric and neo requirements\n have continued to increase.\n Plan:\n Continue fluid/pressor as needed.\n" }, { "category": "Nursing", "chartdate": "2131-05-18 00:00:00.000", "description": "Nursing Progress Note", "row_id": 675047, "text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n Hepatitis, acute toxic (including alcoholic, acetaminophen, etc.)\n Assessment:\n Action:\n Response:\n Plan:\n Gastrointestinal bleed, upper (Melena, GI Bleed, GIB)\n Assessment:\n Action:\n Response:\n Plan:\n Pancreatitis, acute\n Assessment:\n Pt with hypo bowel sounds on left sides; absent on right. Abd\n firm/distended. Hypotensive despite fluid resuscitation.\n Action:\n Strict NPO; OGT to cont LWS putting out dark red blood in small\n amounts; received __ L of fluid boluses and on maintenance fluids on\n 200 cc/hour. Surgery consulting.\n Response:\n Plan:\n Remain strict NPO; fluid resuscitation; try to wean neo as tolerated.\n be transferred to \ns service.\n" }, { "category": "Nursing", "chartdate": "2131-05-18 00:00:00.000", "description": "Nursing Progress Note", "row_id": 675190, "text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Patient remains intubated and sedated on CMV. Sxn\ning seldomly for\n small amounts of white/tan secretions. LS clear with diminished at the\n bases.\n Action:\n Turn and reposition patient frequently; wean Fi02 throughout day.\n Response:\n Patient\ns O2 sats 94-98%, ABG checked this afternoon within normal\n limits.\n Plan:\n Continue intubation and sedation.\n Hepatitis, acute toxic (including alcoholic, acetaminophen, etc.)\n Assessment:\n Action:\n Response:\n Plan:\n Gastrointestinal bleed, upper (Melena, GI Bleed, GIB)\n Assessment:\n Pt with OGT to cont LWS, small amount of dark blood/mucous from OGT\n minimal amounts.\n Action:\n Placement of OG confirmed via Xray and auscultation; rechecked\n Hematocrit.\n Response:\n Hematocrit level stable. No s/s bleeding.\n Plan:\n Pancreatitis, acute\n Assessment:\n Pt with hypo bowel sounds on left sides; absent on right. Abd\n firm/distended. Patient hypotensive and oliguric.\n Action:\n Strict NPO; OGT to cont LWS putting out dark red blood in small\n amounts; received multiple boluses and increased maintenance fluids to\n 250 an hour.\n Response:\n Continues to require aggressive fluid resuscitation and remains on neo\n Plan:\n Remain strict NPO; fluid resuscitation; try to wean neo as tolerated.\n Surgery will continue to closely consult.\n" }, { "category": "Physician ", "chartdate": "2131-06-02 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 678360, "text": "TITLE:\n Chief Complaint: Mr. is a 28 year old gentleman with alcoholic\n hepatitis and necrotizing pancreatitis complicated by ARDS, SIRS, and\n UGIB.\n 24 Hour Events:\n ULTRASOUND - At 09:00 PM\n bil lower extremities r/o dvt\n - Hct 24 -> 22.6 -> transfused 1 u PRBC, DDAVP -> 26. Heme-onc to see\n pt on re: ?DIC.\n - hypotensive to SBP in 60s while getting CVVH, went up on pressors and\n stabilized\n - got tachypneic to 50s and we went up on fent/midaz significantly, but\n responded only marginally. got cxr (unchanged), ekg (unchanged).\n despite high RR did not drop PCO2 significantly so got LENIs to r/o DVT\n b/c of concern for PE, neg study. ?naloxone reaction.\n - started daptomycin and flagyl to cover for cellulitis and c. diff.\n didn't do vancomycin b/c of ?allergy in setting of eosinophilia.\n - called IP re: trach; will plan to do procedure on monday and family\n preferred not to do it today\n - surgery agrees w/ post-pyloric TFs. advanced OGT and gave reglan for\n motility.\n - small BM, sent c diff\n - surgery signed off, will come on a prn basis\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Daptomycin - 09:30 PM\n Metronidazole - 04:00 AM\n Infusions:\n Norepinephrine - 0.03 mcg/Kg/min\n Calcium Gluconate (CRRT) - 1.2 grams/hour\n KCl (CRRT) - 1 mEq./hour\n Fentanyl (Concentrate) - 350 mcg/hour\n Midazolam (Versed) - 17 mg/hour\n Other ICU medications:\n Pantoprazole (Protonix) - 08:00 PM\n Diazepam (Valium) - 11:56 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 07:52 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.7\nC (99.8\n Tcurrent: 36.8\nC (98.3\n HR: 104 (97 - 124) bpm\n BP: 100/53(69) {94/48(64) - 132/75(95)} mmHg\n RR: 38 (35 - 50) insp/min\n SpO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 128 kg (admission): 113.5 kg\n Height: 67 Inch\n CVP: 13 (5 - 13)mmHg\n Total In:\n 8,974 mL\n 2,969 mL\n PO:\n TF:\n IVF:\n 6,847 mL\n 2,400 mL\n Blood products:\n 375 mL\n Total out:\n 9,202 mL\n 3,954 mL\n Urine:\n 162 mL\n 75 mL\n NG:\n 100 mL\n 50 mL\n Stool:\n Drains:\n Balance:\n -228 mL\n -985 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 30\n RR (Spontaneous): 0\n PEEP: 12 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10, RR >35\n PIP: 29 cmH2O\n Plateau: 13 cmH2O\n SpO2: 100%\n ABG: 7.45/36/80./23/1\n Ve: 15.2 L/min\n PaO2 / FiO2: 160\n Physical Examination\n General Appearance: Well nourished, Overweight / Obese, anasarca\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: Rhonchorous: )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: 2+, Left: 2+\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 54 K/uL\n 8.2 g/dL\n 160 mg/dL\n 1.6 mg/dL\n 23 mEq/L\n 4.6 mEq/L\n 26 mg/dL\n 102 mEq/L\n 136 mEq/L\n 24.5 %\n 28.9 K/uL\n [image002.jpg]\n 09:27 AM\n 02:33 PM\n 03:16 PM\n 03:36 PM\n 05:18 PM\n 07:13 PM\n 07:19 PM\n 10:09 PM\n 03:05 AM\n 03:53 AM\n WBC\n 28.9\n Hct\n 22.6\n 26.5\n 24.5\n Plt\n 63\n 54\n Cr\n 1.6\n TCO2\n 28\n 26\n 30\n 25\n 26\n 27\n 26\n Glucose\n 159\n 177\n 160\n Other labs: PT / PTT / INR:15.8/40.5/1.4, ALT / AST:29/257, Alk Phos /\n T Bili:132/14.0, Amylase / Lipase:19/35, Differential-Neuts:37.0 %,\n Band:18.0 %, Lymph:7.0 %, Mono:2.0 %, Eos:15.0 %, D-dimer:6389 ng/mL,\n Fibrinogen:293 mg/dL, Lactic Acid:1.5 mmol/L, Albumin:1.6 g/dL, LDH:607\n IU/L, Ca++:9.1 mg/dL, Mg++:2.0 mg/dL, PO4:4.3 mg/dL\n Assessment and Plan\n Mr. is a 28 year old gentleman with alcoholic hepatitis and\n necrotizing pancreatitis complicated by ARDS, SIRS, and UGIB.\n # Anemia: Initially p/w hematemesis and EGD showed diuelafoy's lesion.\n Hct continues to trend down (30->25->24), now s/p 3 units since .\n CTAP with new pancreatic pseudocyst but per d/w radiology no definitive\n explanation for hct drop. NG lavage negative. GI also doubts\n possibility of significant GI bleed, will not scope for now. Also on\n differential is DIC given occasional schistocytes seen on smear.\n - Trend CBC Q8H, transfuse for hct<21 or plt<50\n - GI reccs\n - consider heme-onc consult\n - CVVH at even to slightly negative balance for now\n - Hemolysis labs\n - consider heme-onc consult\n # Respiratory Failure: ARDS secondary to necrotizing pancreatitis\n compounded by hypoxia, tachypnea in setting of anion gap metabolic\n acidosis, increased abdominal pressure, and EtOH withdrawal. PEEP\n decreased to 12 from 20 and FiO2 to 50%.\n - Wean FiO2 and PEEP, goal PaO2>60-65%\n - wean sedation as tolerated\n # Leukocytosis: WBC count trending down but again with eosinophilia on\n and spiked fever in early a.m. Has been off meropenem/vanc since\n and flagyl since . CT abdomen shows bowel thickening thought\n to likely represent colitis and not bowel wall edema. Paranasal\n sinuses also opacified.\n - touch base with ID regarding restarting antibiotics\n - HD and CVL line culture\n - f/u culture data\n # Neuro: Initially dilated pupils with CT showing cerebral edema. Neuro\n exam now stable. Repeat CTH demonstrates interval improvement.\n - Continue leviteracetam\n - Wean sedation as possible\n - Neuro recs if any\n # Necrotizing pancreatitis/SIRS: Secondary to alcohol complicated by\n SIRS and ARDS. Patient continues to have pressor requirement, with neo\n +/- levo. Aggressive volume resuscitation with >50L but\n diuresing well. Also with new pseudocyst (3 cm x 3 cm) on abdominal CT\n on .\n - Wean pressors with goal MAP >65\n - advance OGT and assess for post-pyloric positioning\n - trophic tube feeds once OGT post-pyloric\n - naloxone po to promote bowel motility\n # Hyponatremia: In setting of decreased effective circulating volume\n in setting of SIRS and IABP. Patient has received hypertonic saline\n boluses with improvement in serum sodium and osm.\n - Given improvement in neuro exam, continue to hold hypertonic saline.\n # Acute renal failure: Patient had HD line placed and on CVVH. CVVH\n with even TBB pending assessment of hemorrhage.\n - CVVH per renal.\n - Trend chemistries\n #Thrombocytopenia: Platelets stable but have trended down from a\n normal count on admission. No clear etiology at this time. DIC panel\n with elevated FDP but normal fibrinogen. HIT PF4 antibody negative.\n - Trend plt, transfuse for plt<10 or <50 if signs of hemorrhage.\n # Wound care: Per wound care recs.\n # Acute hepatitis: Likely alcoholic hepatitis with fatty infiltration,\n and no evidence of distal obstruction. RUQ u/s shows marked liver\n echogenicity but no ascites.\n - Trend LFTs\n # Alcoholism: Patient describes history of withdrawal symptoms, but\n not prior seizure. Last drink was night prior to presentation.\n Tachycardia, weakness, and elevated lactate could be consistent with\n thiamine deficiency.\n - Thiamine, vb12, folate\n - Valium with CIWA > 10\n FEN: TPN without heparin, replete as necessary.\n ICU Care\n Nutrition:\n TPN w/ Lipids - 03:22 PM 73 mL/hour\n Glycemic Control:\n Lines:\n Multi Lumen - 02:02 PM\n Dialysis Catheter - 04:56 PM\n Arterial Line - 01:30 PM\n 20 Gauge - 11:15 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2131-06-07 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 679309, "text": "Chief Complaint:\n 24 Hour Events:\n BRONCHOSCOPY - At 05:32 PM\n EKG - At 08:00 PM\n EKG - At 09:04 PM\n DIALYSIS CATHETER - START 11:35 PM\n EKG - At 04:15 AM\n FEVER - 103.0\nF - 12:00 PM\n :\n - Bronched. Secretions not seen. BAL from RLL and trach wash sent for\n bacterial and fungal cx, cell count, cytology.\n - ID recommended adding flagyl IV.\n - peripheral bcx growing GPC. D/c'd dapto and started linezolid\n given possibility of enterococcus.\n - Pt alarming for ST elevations on tele. EKG with ?STE in V2. Repeat\n EKG with ?STE in V1-V3 with scooped T segments. Cardiac enyzmes mildly\n elevated with CK 220 but MB 2 and Trop 0.07. EKGs faxed to Cards who\n thought more c/w metabolic changes given acidemia and increasing K.\n Given kayexalate pr, then calcium chloride, dextrose, insulin. Placed\n RIJ for CVVH with DDAVP given beforehand. Repeat EKG improved.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Daptomycin - 06:42 PM\n Aztreonam - 08:00 PM\n Linezolid - 10:05 PM\n Metronidazole - 02:00 AM\n Infusions:\n Norepinephrine - 0.14 mcg/Kg/min\n Fentanyl (Concentrate) - 350 mcg/hour\n Calcium Gluconate (CRRT) - 1.4 grams/hour\n Midazolam (Versed) - 15 mg/hour\n Other ICU medications:\n Dextrose 50% - 10:25 PM\n Heparin Sodium (Prophylaxis) - 04:30 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 07:28 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 39.4\nC (103\n Tcurrent: 37\nC (98.6\n HR: 99 (99 - 125) bpm\n BP: 107/61(77) {93/51(65) - 132/85(97)} mmHg\n RR: 14 (14 - 39) insp/min\n SpO2: 99%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 134 kg (admission): 113.5 kg\n Height: 67 Inch\n CVP: 291 (0 - 291)mmHg\n Total In:\n 3,728 mL\n 1,957 mL\n PO:\n TF:\n IVF:\n 1,920 mL\n 1,412 mL\n Blood products:\n Total out:\n 595 mL\n 2,839 mL\n Urine:\n 395 mL\n 60 mL\n NG:\n 200 mL\n 200 mL\n Stool:\n Drains:\n Balance:\n 3,133 mL\n -882 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 30\n RR (Spontaneous): 0\n PEEP: 15 cmH2O\n FiO2: 80%\n RSBI Deferred: PEEP > 10\n PIP: 29 cmH2O\n Plateau: 23 cmH2O\n SpO2: 99%\n ABG: 7.25/50/106/19/-5\n Ve: 10.9 L/min\n PaO2 / FiO2: 133\n Physical Examination\n GEN: Intubated, sedated\n HEENT: icteric sclera. MMM\n NECK: Sites clean/dry/no oozing\n LUNGS: Crackles bilaterally anteriorly.\n HEART: RRR\n ABD: Distended. NT.\n EXTREM: 2+ edema with weeping wounds without surrounding erythema\n SKIN: Jaundice\n Labs / Radiology\n 77 K/uL\n 7.3 g/dL\n 233 mg/dL\n 3.0 mg/dL\n 19 mEq/L\n 6.1 mEq/L\n 40 mg/dL\n 102 mEq/L\n 131 mEq/L\n 26.0 %\n 69.0 K/uL\n [image002.jpg]\n 12:47 PM\n 02:12 PM\n 03:38 PM\n 06:35 PM\n 08:42 PM\n 08:53 PM\n 02:05 AM\n 02:12 AM\n 06:02 AM\n 06:11 AM\n WBC\n 69.0\n Hct\n 26.0\n Plt\n 77\n Cr\n 2.4\n 2.7\n 3.3\n 3.0\n TropT\n 0.07\n 0.06\n 0.07\n TCO2\n 21\n 19\n 20\n 23\n 19\n 23\n Glucose\n 145\n 200\n 191\n 233\n Other labs: PT / PTT / INR:19.8/63.8/1.8, CK / CKMB /\n Troponin-T:214/3/0.07, ALT / AST:43/205, Alk Phos / T Bili:145/23.0,\n Amylase / Lipase:19/35, Differential-Neuts:49.0 %, Band:0.0 %,\n Lymph:9.0 %, Mono:7.0 %, Eos:21.0 %, D-dimer:6389 ng/mL, Fibrinogen:419\n mg/dL, Lactic Acid:2.2 mmol/L, Albumin:1.7 g/dL, LDH:821 IU/L, Ca++:8.3\n mg/dL, Mg++:2.2 mg/dL, PO4:7.2 mg/dL\n Assessment and Plan\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n IMPAIRED SKIN INTEGRITY\n HEPATITIS, ACUTE TOXIC (INCLUDING ALCOHOLIC, ACETAMINOPHEN, ETC.)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ICU Care\n Nutrition:\n TPN w/ Lipids - 04:05 PM 73. mL/hour\n Glycemic Control:\n Lines:\n 20 Gauge - 03:56 PM\n Arterial Line - 08:15 PM\n Multi Lumen - 10:00 PM\n Dialysis Catheter - 11:35 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:ICU\n" }, { "category": "Physician ", "chartdate": "2131-06-11 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 680118, "text": "Chief Complaint:\n 24 Hour Events:\n - Tolerated CVVH with good diuresis\n - ID rec 1) continue Flagyl/Linezolid/Aztreonam/Micafungin, 2) consider\n heme re-consult for persistantly altered differential despite long\n course of ABX and ? hemophagocytic syndrome, 3) would add Cipro if\n clinical deterioration, and 4) consider change linezolid to dapto if\n TCP worsens.\n - Renal rec continue CVVH with UF 100 cc/hr as she tolerates.\n - PM Hct stable.\n - Pt became bronchospastic in evening with some oozing at trach site.\n CXR appeared improved if anything. Given bronchodilators with good\n effect\n Allergies:\n Meropenem\n skin blisters a\n Last dose of Antibiotics:\n Metronidazole - 10:00 AM\n Vancomycin - 04:39 PM\n Aztreonam - 09:30 PM\n Linezolid - 10:28 PM\n Micafungin - 12:04 AM\n Infusions:\n Norepinephrine - 0.03 mcg/Kg/min\n Fentanyl (Concentrate) - 100 mcg/hour\n Midazolam (Versed) - 10 mg/hour\n Calcium Gluconate (CRRT) - 1.6 grams/hour\n Other ICU medications:\n Fentanyl - 04:34 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:59 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.1\nC (98.8\n Tcurrent: 35.7\nC (96.3\n HR: 104 (84 - 107) bpm\n BP: 92/49(63) {91/48(62) - 129/74(93)} mmHg\n RR: 14 (9 - 28) insp/min\n SpO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 134 kg (admission): 113.5 kg\n Height: 67 Inch\n CVP: 20 (11 - 21)mmHg\n Total In:\n 10,596 mL\n 2,852 mL\n PO:\n TF:\n 480 mL\n 92 mL\n IVF:\n 8,289 mL\n 2,230 mL\n Blood products:\n Total out:\n 14,018 mL\n 4,260 mL\n Urine:\n 78 mL\n NG:\n Stool:\n Drains:\n Balance:\n -3,422 mL\n -1,408 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 24\n RR (Spontaneous): 0\n PEEP: 8 cmH2O\n FiO2: 40%\n RSBI Deferred: Unstable Airway\n PIP: 18 cmH2O\n SpO2: 100%\n ABG: 7.33/52/131/24/0\n Ve: 10.6 L/min\n PaO2 / FiO2: 328\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 82 K/uL\n 8.1 g/dL\n 155 mg/dL\n 0.9 mg/dL\n 24 mEq/L\n 4.5 mEq/L\n 35 mg/dL\n 98 mEq/L\n 132 mEq/L\n 24.5 %\n 28.3 K/uL\n [image002.jpg]\n 08:15 AM\n 08:34 AM\n 02:08 PM\n 02:31 PM\n 05:15 PM\n 08:27 PM\n 08:36 PM\n 11:00 PM\n 02:20 AM\n 02:35 AM\n WBC\n 29.6\n 28.3\n Hct\n 23.9\n 24.5\n Plt\n 69\n 82\n Cr\n 0.9\n 0.9\n TCO2\n 26\n 25\n 25\n 27\n 27\n 29\n Glucose\n 166\n 177\n 131\n 155\n Other labs: PT / PTT / INR:16.1/37.7/1.4, CK / CKMB /\n Troponin-T:214/3/0.07, ALT / AST:74/206, Alk Phos / T Bili:172/28.5,\n Amylase / Lipase:19/35, Differential-Neuts:68.0 %, Band:5.0 %,\n Lymph:7.0 %, Mono:4.0 %, Eos:0.0 %, D-dimer:6389 ng/mL, Fibrinogen:502\n mg/dL, Lactic Acid:1.6 mmol/L, Albumin:2.0 g/dL, LDH:775 IU/L, Ca++:8.7\n mg/dL, Mg++:2.1 mg/dL, PO4:3.3 mg/dL\n Assessment and Plan\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n IMPAIRED SKIN INTEGRITY\n HEPATITIS, ACUTE TOXIC (INCLUDING ALCOHOLIC, ACETAMINOPHEN, ETC.)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ICU Care\n Nutrition:\n TPN w/ Lipids - 03:48 PM 76 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 08:15 PM\n Multi Lumen - 10:00 PM\n Dialysis Catheter - 11:35 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": "2131-05-28 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 677358, "text": "Chief Complaint:\n 24 Hour Events:\n 23% saline changed to q3hrs\n decreased fi02 and peep\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:00 AM\n Metronidazole - 02:00 AM\n Meropenem - 03:00 AM\n Infusions:\n Norepinephrine - 0.05 mcg/Kg/min\n Fentanyl (Concentrate) - 100 mcg/hour\n Calcium Gluconate (CRRT) - 2 grams/hour\n Midazolam (Versed) - 16 mg/hour\n KCl (CRRT) - 2 mEq./hour\n Other ICU medications:\n Pantoprazole (Protonix) - 07:52 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 07:17 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37\nC (98.6\n Tcurrent: 35.9\nC (96.7\n HR: 104 (93 - 111) bpm\n BP: 96/55(68) {79/42(55) - 104/59(74)} mmHg\n RR: 31 (29 - 32) insp/min\n SpO2: 98%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 132 kg (admission): 113.5 kg\n Height: 67 Inch\n CVP: 13 (10 - 18)mmHg\n Total In:\n 10,221 mL\n 2,726 mL\n PO:\n TF:\n IVF:\n 9,667 mL\n 2,726 mL\n Blood products:\n Total out:\n 17,969 mL\n 5,055 mL\n Urine:\n 156 mL\n 25 mL\n NG:\n 150 mL\n 100 mL\n Stool:\n Drains:\n Balance:\n -7,748 mL\n -2,329 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 30\n RR (Spontaneous): 0\n PEEP: 12 cmH2O\n FiO2: 40%\n RSBI Deferred: PEEP > 10\n PIP: 29 cmH2O\n Plateau: 25 cmH2O\n Compliance: 33.3 cmH2O/mL\n SpO2: 98%\n ABG: 7.41/45/84./26/2\n Ve: 12.9 L/min\n PaO2 / FiO2: 210\n Physical Examination\n General Appearance: Well nourished, total body fluid overload\n Eyes / Conjunctiva: PERRL, pupil 3mm b/l - smaller than prev\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Clear : anteriorly)\n Abdominal: Soft, No(t) Bowel sounds present, Distended\n Extremities: Right: 4+, Left: 4+, No(t) Cyanosis\n Skin: Not assessed\n Neurologic: No(t) Attentive, No(t) Follows simple commands, Responds\n to: Not assessed, No(t) Oriented (to): , Movement: Not assessed,\n Sedated, Tone: Not assessed\n Labs / Radiology\n 59 K/uL\n 9.9 g/dL\n 199 mg/dL\n 1.8 mg/dL\n 26 mEq/L\n 4.0 mEq/L\n 21 mg/dL\n 108 mEq/L\n 145 mEq/L\n 29.0 %\n 38.2 K/uL\n [image002.jpg]\n 04:23 PM\n 09:57 PM\n 10:11 PM\n 04:39 AM\n 04:49 AM\n 11:06 AM\n 05:22 PM\n 11:09 PM\n 04:10 AM\n 04:20 AM\n WBC\n 45.9\n 44.7\n 38.2\n Hct\n 29.2\n 30.4\n 29.0\n Plt\n 67\n 68\n 59\n Cr\n 2.6\n 2.4\n 2.2\n 1.8\n TCO2\n 25\n 28\n 28\n 28\n 30\n 30\n Glucose\n 174\n 188\n 176\n 187\n 175\n 188\n 166\n 199\n Other labs: PT / PTT / INR:19.5/53.6/1.8, ALT / AST:20/210, Alk Phos /\n T Bili:236/20.6, Amylase / Lipase:16/34, Differential-Neuts:71.0 %,\n Band:8.0 %, Lymph:6.0 %, Mono:4.0 %, Eos:2.0 %, D-dimer: ng/mL,\n Fibrinogen:402 mg/dL, Lactic Acid:1.7 mmol/L, Albumin:1.7 g/dL, LDH:742\n IU/L, Ca++:8.5 mg/dL, Mg++:1.8 mg/dL, PO4:2.6 mg/dL\n Assessment and Plan\n Mr. is a 28 year old gentleman with alcoholic hepatitis and\n necrotizing pancreatitis complicated by ARDS, SIRS, and UGIB.\n # Neuro: Initially dilated pupils with CT showing cerebral edema.\n Pupils less dilated and more reactive.\n - continuing keppra and 23% hypertonic saline boluses Q3H with regular\n serum sodium checks. Goal Na 145-150, Osm 310-315\n - Consider mannitol if serum sodium does not improve\n - Wean sedation (starting with fentanyl) as possible\n # Respiratory Failure: ARDS secondary to necrotizing pancreatitis\n compounded by hypoxia, tachypnea in setting of anion gap metabolic\n acidosis, increased abdominal pressure, and EtOH withdrawl. PEEP\n decreased to 12 from 20 and FiO2 to 40%.\n - Wean FiO2 and PEEP, goal PaO2>60-65%\n # Leukocytosis: Stable. Initial concern for infection but normal cx\n suggests that this may be inflammatory reaction. No eos on diff and CT\n without abscesses\n - Continue empiric vancomycin, meropenem, and flagyl. AM vanco level\n today\n - Follow-up culture data\n - f/u ID reccs\n # Necrotizing pancreatitis/SIRS: Secondary to alcohol complicated by\n SIRS and ARDS. Patient continues to have pressor requirement, with neo\n +/- levo. Aggressive volume resuscitation with >53L.\n - Continue empiric antimicrobials.\n - weaning pressors neo at 0.1 and levo at 0.05.\n - Hypertonic saline as above in order to increase intravascular volume.\n # Hyponatremia: In setting of decreased effective circulating volume\n in setting of SIRS and IABP. Patient receiving hypertonic saline\n boluses with improvement in serum sodium.\n - Hypertonic saline as above.\n # Acute renal failure: Patient had HD line placed and CVVH was\n initiated yesterday.\n - CVVH per renal. UF with net neg 300cc/hr\n - Trend chemistries\n #Thrombocytopenia: Platelets stable. No clear etiology at this time.\n DIC panel and HIT PF4 antibody negative.\n - Trend plt, transfuse for plt<10 or <50 if signs of hemorrhage.\n # IAP elevation: Secondary to third spacing and edema. Per surgery, not\n a good surgical candidate at this time.\n # Acute hepatitis: Likely alcoholic hepatitis with fatty infiltration,\n and no evidence of distal obstruction. RUQ u/s shows marked liver\n echogenicity but no ascites.\n - Trend LFTs\n # Hematemesis: EGD showed diuelafoy's lesion. HCT stable since 2 units\n PRBC on .\n - Trend hct, transfuse for hct<21\n # Alcoholism: Patient describes history of withdrawal symptoms, but\n not prior seizure. Last drink was night prior to presentation.\n Tachycardia, weakness, and elevated lactate could be consistent with\n thiamine deficiency.\n - Thiamine, vb12, folate\n - Valium with CIWA > 10\n FEN: TPN, replete as necessary.\n PPx: Heparin and H2B in TPN\n Access: RIJ (quad), LIJ (HD), right radial a-line\n Dispo: ICU level of care\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Arterial Line - 01:35 PM\n Multi Lumen - 02:02 PM\n Dialysis Catheter - 04:56 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Respiratory ", "chartdate": "2131-05-30 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 677811, "text": "Demographics\n Day of mechanical ventilation: 13\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Tube Type\n ETT:\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 Secretions\n Sputum color / consistency: White / Thin\n Sputum source/amount: Suctioned / Scant\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Sedated / Paralyzed,\n Underlying illness not resolved.\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n CT\n 1215\n none\n" }, { "category": "General", "chartdate": "2131-06-11 00:00:00.000", "description": "Generic Note", "row_id": 680261, "text": "TITLE: Event Note\n Team called to bedside at ~7pm by RT for high inspiratory pressures.\n Patient had received brochodilators but was persistently wheezing, has\n had persistent oozing from trach site and has been receiving DDAVP.\n Team transiently called away for code blue on another patient, returned\n <10 minutes later to find patient in respiratory distress. RT removed\n large blood and mucus clot, patient transiently without a palpable\n pulse prior to clot removal. Pulses were again palpable after <30\n sec. ABG revealed 7.13/65/201. Patient was also noted to have\n markedly increased swelling of the lower-face and neck. Portable CXR\n obtained. Bedside bronch performed by surgery resident, revealed\n extensive clot in upper-extremity. Vent settings at 100% FiO2, Vt 400,\n RR 24, PEEP 8. CT called to re-evaluate patient.\n" }, { "category": "Physician ", "chartdate": "2131-06-11 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 680198, "text": "Chief Complaint:\n 24 Hour Events:\n - Tolerated CVVH with good diuresis\n - ID rec 1) continue Flagyl/Linezolid/Aztreonam/Micafungin, 2) consider\n heme re-consult for persistantly altered differential despite long\n course of ABX and ? hemophagocytic syndrome, 3) would add Cipro if\n clinical deterioration, and 4) consider change linezolid to dapto if\n thrombocytopenia worsens\n - Renal rec continue CVVH with UF 100 cc/hr as she tolerates.\n - PM Hct stable.\n - Pt became bronchospastic in evening with some oozing at trach site.\n CXR appeared improved if anything. Given bronchodilators with good\n effect\n Allergies:\n Meropenem\n skin blisters a\n Last dose of Antibiotics:\n Metronidazole - 10:00 AM\n Vancomycin - 04:39 PM\n Aztreonam - 09:30 PM\n Linezolid - 10:28 PM\n Micafungin - 12:04 AM\n Infusions:\n Norepinephrine - 0.03 mcg/Kg/min\n Fentanyl (Concentrate) - 100 mcg/hour\n Midazolam (Versed) - 10 mg/hour\n Calcium Gluconate (CRRT) - 1.6 grams/hour\n Other ICU medications:\n Fentanyl - 04:34 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:59 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.1\nC (98.8\n Tcurrent: 35.7\nC (96.3\n HR: 104 (84 - 107) bpm\n BP: 92/49(63) {91/48(62) - 129/74(93)} mmHg\n RR: 14 (9 - 28) insp/min\n SpO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 134 kg (admission): 113.5 kg\n Height: 67 Inch\n CVP: 20 (11 - 21)mmHg\n Total In:\n 10,596 mL\n 2,852 mL\n PO:\n TF:\n 480 mL\n 92 mL\n IVF:\n 8,289 mL\n 2,230 mL\n Blood products:\n Total out:\n 14,018 mL\n 4,260 mL\n Urine:\n 78 mL\n NG:\n Stool:\n Drains:\n Balance:\n -3,422 mL\n -1,408 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 24\n RR (Spontaneous): 0\n PEEP: 8 cmH2O\n FiO2: 40%\n RSBI Deferred: Unstable Airway\n PIP: 18 cmH2O\n SpO2: 100%\n ABG: 7.33/52/131/24/0\n Ve: 10.6 L/min\n PaO2 / FiO2: 328\n Physical Examination\n GEN: Intubated, sedated\n HEENT: icteric sclera. MMM\n NECK: Trach site with minimal oozing\n LUNGS: Anterior auscultation with upper airway noise; good airway\n movement\n HEART: , ; S1, S2\n ABD: Distended. NT.\n EXTREM: 2+ edema, ulcers/lesions on legs with bandages C/D/I\n SKIN: Jaundice\n Labs / Radiology\n 82 K/uL\n 8.1 g/dL\n 155 mg/dL\n 0.9 mg/dL\n 24 mEq/L\n 4.5 mEq/L\n 35 mg/dL\n 98 mEq/L\n 132 mEq/L\n 24.5 %\n 28.3 K/uL\n [image002.jpg]\n N:68 Band:5 L:7 M:4 E:0 Bas:0 Metas: 10 Myelos: 3 Promyel: 3 Nrbc: 15\n Ca: 8.7 Mg: 2.1 P: 3.3\n ALT: 74\n AP: 172\n Tbili: 28.5\n Alb:\n AST: 206\n LDH: 775\n Dbili:\n TProt:\n :\n Lip:\n PT: 16.1\n PTT: 37.7\n INR: 1.4\n 08:15 AM\n 08:34 AM\n 02:08 PM\n 02:31 PM\n 05:15 PM\n 08:27 PM\n 08:36 PM\n 11:00 PM\n 02:20 AM\n 02:35 AM\n WBC\n 29.6\n 28.3\n Hct\n 23.9\n 24.5\n Plt\n 69\n 82\n Cr\n 0.9\n 0.9\n TCO2\n 26\n 25\n 25\n 27\n 27\n 29\n Glucose\n 166\n 177\n 131\n 155\n Other labs: PT / PTT / INR:16.1/37.7/1.4, CK / CKMB /\n Troponin-T:214/3/0.07, ALT / AST:74/206, Alk Phos / T Bili:172/28.5,\n Amylase / Lipase:19/35, Differential-Neuts:68.0 %, Band:5.0 %,\n Lymph:7.0 %, Mono:4.0 %, Eos:0.0 %, D-dimer:6389 ng/mL, Fibrinogen:502\n mg/dL, Lactic Acid:1.6 mmol/L, Albumin:2.0 g/dL, LDH:775 IU/L, Ca++:8.7\n mg/dL, Mg++:2.1 mg/dL, PO4:3.3 mg/dL\n No new culture data\n Assessment and Plan\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n IMPAIRED SKIN INTEGRITY\n HEPATITIS, ACUTE TOXIC (INCLUDING ALCOHOLIC, ACETAMINOPHEN, ETC.)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n 28M with alcoholic hepatitis and necrotizing pancreatitis complicated\n by ARDS, SIRS, ARF, UGIB, fevers and eosinophilia\n #. Fever: Afebrile x>3days - source unclear. Question of fever \n adrenal insufficiency; now on steroids. Concern for infection with\n increased bandemia today although leukocytosis improved.\n Blood/tissue/BAL cx NGTD, CT abd with persistent inflammation\n concerning for infection. CT sinuses w/ opacification of unclear time\n course.\n - Cte broad spectrum antibiotic coverage with aztreonam for extended GN\n coverage, linezolid for MRSA and VRE for bacteremia, flagyl IV, vanc PO\n empirically per ID recs given increasing leukocytosis and colon\n inflammation on CT, micafungin for antifungal coverage\n - Per ID, add ciprofloxacin if decompensates. Also restart vancomycin\n PR\n - F/u WBC and temp curve\n - F/u derm biopsy results to see if skin infection; already on broad\n spectrum antibiotic coverage inc. skin flora coverage\n - F/u cultures\n - F/u ID recs; question: how to down abx over next few days\n #. Respiratory Failure: ARDS secondary to necrotizing pancreatitis. S/p\n trach placement on . Sutures out on \n - Decrease sedation (both fentanyl and versed) with goal of trying\n pressure support. Given that patient may have withdrawal from\n benzodiazepenes with weaning of midazolam, start valium standing\n (5-10mg q8 hours)\n - Cont to wean as tolerated\n #. Adrenal Insufficiency: Unclear with stim if clear adrenal\n insufficiency but hypotension improving with steroids (lower pressor\n requirement) and improving eosinophilia\n - Will continue steroids IV X 5 days (day 5) then change to prednisone\n to taper\n #. Hyperbilirubinemia: Likely related to underlying shock liver and\n ?obstructive etiology from necrotizing pancreatitis. Continue to trend.\n #. Eosinophilia: Resolved. Adrenal insufficiency v. drug reaction\n (?PPI; vanc & dapto less likely d/t time course). Fungal and parasitic\n infection also possible etiologies.\n - stim positive for adrenal insufficiency. Cte steroids.\n - Off PPI, vanc, dapto\n - Cte fungal coverage as above\n #. Anemia: Hct stable since 1 unit pRBC and 1 dose DDAVP s/p trach with\n some oozing at site.\n - recheck hemolysis labs\n - trend hcts Q6H, 1unit pRBCs now, guaiac stools and NGT aspirate\n - If not appropriate bump with blood consider scope to ensure doboff\n did not cause significant bleed\n - holding ppx with PPI or sucralfate given issues of eosinophilia and\n ARF\n #. Thrombocytopenia: Appreciate heme recs. Do not feel this is DIC.\n - Monitor platelets daily and transfuse for plt <10 or <50 if signs of\n bleed\n - monitor daily\n #. Acute renal Failure: Appreciate renal recs. Cr improved on CVVH. Off\n sucralfate due to concern for electrolyte abnormalities.\n - Cte volume depletion with CVVH as long as pressor requirement does\n not increase\n #. Wounds: Derm biopsy pending - inflammatory, infectious, or reactive.\n F/u recs.\n #. Agitation: Cont methadone given decreased sensitivity to fentanyl;\n titrate prn\n #. Glucose intolerance: In setting of steroids; adjust ISS prn. As\n blood glucose continues to run high, will increase insulin included in\n TPN.\n ICU Care\n Nutrition:\n TPN w/ Lipids - 03:48 PM 76 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 08:15 PM\n Multi Lumen - 10:00 PM\n Dialysis Catheter - 11:35 PM\n Prophylaxis:\n DVT: Pneumoboots\n Stress ulcer: Not currently on PPI\n VAP: Mouth care\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Respiratory ", "chartdate": "2131-06-11 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 680206, "text": "Airway\n Tracheostomy tube:\n Type: Standard\n Manufacturer: Portex\n Size: 8.0mm\n Lung sounds\n RLL Lung Sounds: Rhonchi\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Rhonchi\n Secretions\n Sputum color / consistency: Bloody / Thick\n Sputum source/amount: Suctioned / Small\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Active exhalations; Comments:\n pt remains on A/C ventilation, no changes made this shift. Pt\n dysynchronous w/ vent, has erratic Vt.\n Assessment of breathing comfort: No claim of dyspnea\n Dysynchrony assessment: Erratic exhaled Tidal Volumes\n" }, { "category": "Physician ", "chartdate": "2131-06-11 00:00:00.000", "description": "Physician Resident/Attending Progress Note - MICU", "row_id": 680213, "text": "Chief Complaint:\n 24 Hour Events:\n - Tolerated CVVH with good diuresis\n - ID rec 1) continue Flagyl/Linezolid/Aztreonam/Micafungin, 2) consider\n heme re-consult for persistantly altered differential despite long\n course of ABX and ? hemophagocytic syndrome, 3) would add Cipro if\n clinical deterioration, and 4) consider change linezolid to dapto if\n thrombocytopenia worsens\n - Renal rec continue CVVH with UF 100 cc/hr as she tolerates.\n - PM Hct stable.\n - Pt became bronchospastic in evening with some oozing at trach site.\n CXR appeared improved if anything. Given bronchodilators with good\n effect\n Allergies:\n Meropenem\n skin blisters a\n Last dose of Antibiotics:\n Metronidazole - 10:00 AM\n Vancomycin - 04:39 PM\n Aztreonam - 09:30 PM\n Linezolid - 10:28 PM\n Micafungin - 12:04 AM\n Infusions:\n Norepinephrine - 0.03 mcg/Kg/min\n Fentanyl (Concentrate) - 100 mcg/hour\n Midazolam (Versed) - 10 mg/hour\n Calcium Gluconate (CRRT) - 1.6 grams/hour\n Other ICU medications:\n Fentanyl - 04:34 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:59 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.1\nC (98.8\n Tcurrent: 35.7\nC (96.3\n HR: 104 (84 - 107) bpm\n BP: 92/49(63) {91/48(62) - 129/74(93)} mmHg\n RR: 14 (9 - 28) insp/min\n SpO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 134 kg (admission): 113.5 kg\n Height: 67 Inch\n CVP: 20 (11 - 21)mmHg\n Total In:\n 10,596 mL\n 2,852 mL\n PO:\n TF:\n 480 mL\n 92 mL\n IVF:\n 8,289 mL\n 2,230 mL\n Blood products:\n Total out:\n 14,018 mL\n 4,260 mL\n Urine:\n 78 mL\n NG:\n Stool:\n Drains:\n Balance:\n -3,422 mL\n -1,408 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 24\n RR (Spontaneous): 0\n PEEP: 8 cmH2O\n FiO2: 40%\n RSBI Deferred: Unstable Airway\n PIP: 18 cmH2O\n SpO2: 100%\n ABG: 7.33/52/131/24/0\n Ve: 10.6 L/min\n PaO2 / FiO2: 328\n Physical Examination\n GEN: Intubated, sedated\n HEENT: icteric sclera. MMM\n NECK: Trach site with minimal oozing\n LUNGS: Anterior auscultation with upper airway noise; good airway\n movement\n HEART: , ; S1, S2\n ABD: Distended. NT.\n EXTREM: 2+ edema, ulcers/lesions on legs with bandages C/D/I\n SKIN: Jaundice\n Labs / Radiology\n 82 K/uL\n 8.1 g/dL\n 155 mg/dL\n 0.9 mg/dL\n 24 mEq/L\n 4.5 mEq/L\n 35 mg/dL\n 98 mEq/L\n 132 mEq/L\n 24.5 %\n 28.3 K/uL\n [image002.jpg]\n N:68 Band:5 L:7 M:4 E:0 Bas:0 Metas: 10 Myelos: 3 Promyel: 3 Nrbc: 15\n Ca: 8.7 Mg: 2.1 P: 3.3\n ALT: 74\n AP: 172\n Tbili: 28.5\n Alb:\n AST: 206\n LDH: 775\n Dbili:\n TProt:\n :\n Lip:\n PT: 16.1\n PTT: 37.7\n INR: 1.4\n 08:15 AM\n 08:34 AM\n 02:08 PM\n 02:31 PM\n 05:15 PM\n 08:27 PM\n 08:36 PM\n 11:00 PM\n 02:20 AM\n 02:35 AM\n WBC\n 29.6\n 28.3\n Hct\n 23.9\n 24.5\n Plt\n 69\n 82\n Cr\n 0.9\n 0.9\n TCO2\n 26\n 25\n 25\n 27\n 27\n 29\n Glucose\n 166\n 177\n 131\n 155\n Other labs: PT / PTT / INR:16.1/37.7/1.4, CK / CKMB /\n Troponin-T:214/3/0.07, ALT / AST:74/206, Alk Phos / T Bili:172/28.5,\n Amylase / Lipase:19/35, Differential-Neuts:68.0 %, Band:5.0 %,\n Lymph:7.0 %, Mono:4.0 %, Eos:0.0 %, D-dimer:6389 ng/mL, Fibrinogen:502\n mg/dL, Lactic Acid:1.6 mmol/L, Albumin:2.0 g/dL, LDH:775 IU/L, Ca++:8.7\n mg/dL, Mg++:2.1 mg/dL, PO4:3.3 mg/dL\n No new culture data\n Assessment and Plan\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n IMPAIRED SKIN INTEGRITY\n HEPATITIS, ACUTE TOXIC (INCLUDING ALCOHOLIC, ACETAMINOPHEN, ETC.)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n 28M with alcoholic hepatitis and necrotizing pancreatitis complicated\n by ARDS, SIRS, ARF, UGIB, fevers and eosinophilia\n #. Fever: Afebrile x>3days - source unclear. Question of fever \n adrenal insufficiency; now on steroids. Concern for infection with\n increased bandemia today although leukocytosis improved.\n Blood/tissue/BAL cx NGTD, CT abd with persistent inflammation\n concerning for infection. CT sinuses w/ opacification of unclear time\n course.\n - Cte broad spectrum antibiotic coverage with aztreonam for extended GN\n coverage, linezolid for MRSA and VRE for bacteremia, flagyl IV, vanc PO\n empirically per ID recs given increasing leukocytosis and colon\n inflammation on CT, micafungin for antifungal coverage\n - Per ID, add ciprofloxacin if decompensates. Also restart vancomycin\n PR\n - F/u WBC and temp curve\n - F/u derm biopsy results to see if skin infection; already on broad\n spectrum antibiotic coverage inc. skin flora coverage\n - F/u cultures\n - F/u ID recs; question: how to down abx over next few days\n #. Respiratory Failure: ARDS secondary to necrotizing pancreatitis. S/p\n trach placement on . Sutures out on \n - Decrease sedation (both fentanyl and versed) with goal of trying\n pressure support. Given that patient may have withdrawal from\n benzodiazepenes with weaning of midazolam, start valium standing\n (5-10mg q8 hours)\n - Cont to wean as tolerated\n #. Adrenal Insufficiency: Unclear with stim if clear adrenal\n insufficiency but hypotension improving with steroids (lower pressor\n requirement) and improving eosinophilia\n - Will continue steroids IV X 5 days (day 5) then change to prednisone\n to taper\n #. Hyperbilirubinemia: Likely related to underlying shock liver and\n ?obstructive etiology from necrotizing pancreatitis. Continue to trend.\n #. Eosinophilia: Resolved. Adrenal insufficiency v. drug reaction\n (?PPI; vanc & dapto less likely d/t time course). Fungal and parasitic\n infection also possible etiologies.\n - stim positive for adrenal insufficiency. Cte steroids.\n - Off PPI, vanc, dapto\n - Cte fungal coverage as above\n #. Anemia: Hct stable since 1 unit pRBC and 1 dose DDAVP s/p trach with\n some oozing at site.\n - recheck hemolysis labs\n - trend hcts Q6H, 1unit pRBCs now, guaiac stools and NGT aspirate\n - If not appropriate bump with blood consider scope to ensure doboff\n did not cause significant bleed\n - holding ppx with PPI or sucralfate given issues of eosinophilia and\n ARF\n #. Thrombocytopenia: Appreciate heme recs. Do not feel this is DIC.\n - Monitor platelets daily and transfuse for plt <10 or <50 if signs of\n bleed\n - monitor daily\n #. Acute renal Failure: Appreciate renal recs. Cr improved on CVVH. Off\n sucralfate due to concern for electrolyte abnormalities.\n - Cte volume depletion with CVVH as long as pressor requirement does\n not increase\n #. Wounds: Derm biopsy pending - inflammatory, infectious, or reactive.\n F/u recs.\n #. Agitation: Cont methadone given decreased sensitivity to fentanyl;\n titrate prn\n #. Glucose intolerance: In setting of steroids; adjust ISS prn. As\n blood glucose continues to run high, will increase insulin included in\n TPN.\n ICU Care\n Nutrition:\n TPN w/ Lipids - 03:48 PM 76 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 08:15 PM\n Multi Lumen - 10:00 PM\n Dialysis Catheter - 11:35 PM\n Prophylaxis:\n DVT: Pneumoboots\n Stress ulcer: Not currently on PPI\n VAP: Mouth care\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: 28M alcoholic hepatitis, pancreatitis,\n refractory shock, ARDS - now tolerating aggressive fluid removal on low\n dose pressors. WBC and sedation down, tolerating CVVH with fluid\n removal.\n Exam notable for Tm 98.8 BP 110/50 HR 85-110 CVP 20 RR 30 with sat 100\n on VAC 400x24 0.4 8 7.33/52/131. WD man, anasarca, chemosis. Partial\n eye opening to command. Coarse BS B. Distant s1s2. Obese, no BS. 3+\n edema. Labs notable for WBC 28K, HCT 25, lactate 3.2. CXR with low\n volumes.\n Agree with plan to manage respiratory failure with slow wean of\n sedation and transition to PSV as mental status allows. Will initiate\n PGT valium and attempt to d/c drip sedation over next 24 hours. Will\n use ddvap and amicar for trach ooze; thoracic team to reevaluate later\n today. For ongoing fevers and leukocytosis with pressor requirement,\n will continue steroids and broad antibiotic coverage. Will check\n ferritin and d/w heme re HLH / BMBx, but suspect ongoing supportive\n care is the best way forward. For ARF, continue CVVH with goal\n -250cc/h. For pancreatitis, continue trophic post-pyloric TFs; he is\n now , check f/u lipase this PM. Will increase insulin in\n TPN for persistent hyperglycemia. Remainder of plan as outlined above.\n Plan d/w family at bedside.\n Patient is critically ill\n Total time: 50 min\n ------ Protected Section Addendum Entered By: , MD\n on: 04:28 PM ------\n" }, { "category": "Respiratory ", "chartdate": "2131-05-31 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 678043, "text": "Demographics\n Day of mechanical ventilation: 14\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Tube Type\n ETT:\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 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: Triggering synchronously\n Plan\n Next 24-48 hours: Maintain PEEP at current level and reduce FiO2 as\n tolerated\n Reason for continuing current ventilatory support: Underlying illness\n not resolved\n" }, { "category": "Respiratory ", "chartdate": "2131-06-10 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 679977, "text": "Demographics\n Day of mechanical ventilation: 24\n Ideal body weight: 67.1 None\n Ideal tidal volume: 268.4 / 402.6 / 536.8 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Tube Type\n Tracheostomy tube:\n Type: Standard\n Manufacturer: Portex\n Size: 8.0mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 29 cmH2O\n Cuff volume: mL /\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Rhonchi\n Secretions\n Sputum color / consistency: Bloody / Thick\n Sputum source/amount: Suctioned / Small\n Comments: lungs more coarse today. Sx'ing BRB. RN aware.\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing;\n Comments: FiO2 weaned today. Tol well. Conts. to have few periods of\n dissynchrony. ABG WNL.\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, Adjust Min. ventilation to control pH\n Reason for continuing current ventilatory support: Underlying illness\n not resolved\n Respiratory Care Shift Procedures\n 15:29\n" }, { "category": "Physician ", "chartdate": "2131-06-12 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 680336, "text": "Chief Complaint:\n 24 Hour Events:\n STOOL CULTURE - At 01:21 PM\n for cdiff\n RESPIRATORY ARREST - At 07:28 PM\n team at bedside.\n BRONCHOSCOPY - At 08:14 PM\n Dr , time out done prior to proced\n BRONCHOSCOPY - At 08:48 PM\n Dr .\n - Concern for hemophagocytic syndrome - Checking ferritin (>);\n heme-onc consulted, feel hemophagocytic syndrome is unlikely.\n - Plan to increase insulin in TPN, but TPN recs not available in time\n - In anticipation of bzd withdrawal with weaning of midazolam, started\n valium 10mg PO TID. Plan to wean fentanyl, versed as tolerated in hopes\n of trying pressure support.\n - Per ID, restarted vanc PR; will restart ciprofloxacin if\n decompensates\n - Amylase 47, lipase 47\n - 6pm I/O -2L\n - 6pm Doing well on pressure support, versed weaned off. After incident\n below, restarted on assist control.\n - 7:30pm Respiratory distress - Initially with bronchospasm, then\n apneic and briefly without pulse (?minutes). Improved with deep suction\n - large clot removed with return of pulse, BP and improved ventilation.\n Thoracics performed bedside bronchoscopy - determined that trach is too\n short; on further reevaluation by attending, appropriate size and not\n needing replacement; clots removed with repeat bronchoscopy. Heme/onc\n aware, recommended Amicar for bleeding at trach site - started.\n Allergies:\n Meropenem\n skin blisters a\n Last dose of Antibiotics:\n Vancomycin - 04:00 PM\n Aztreonam - 09:24 PM\n Linezolid - 11:00 PM\n Micafungin - 12:33 AM\n Metronidazole - 02:01 AM\n Infusions:\n Fentanyl (Concentrate) - 100 mcg/hour\n Norepinephrine - 0.03 mcg/Kg/min\n Midazolam (Versed) - 5 mg/hour\n Calcium Gluconate (CRRT) - 1.6 grams/hour\n KCl (CRRT) - 2 mEq./hour\n Other ICU medications:\n Atropine - 07:30 PM\n Midazolam (Versed) - 09:03 PM\n Other medications:\n Changes to medical and family history:\n None\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Intubated, sedated.\n Flowsheet Data as of 06:08 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37\nC (98.6\n Tcurrent: 35.4\nC (95.8\n HR: 80 (30 - 126) bpm\n BP: 118/68(87) {59/41(47) - 168/94(124)} mmHg\n RR: 26 (10 - 31) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 123.3 kg (admission): 113.5 kg\n Height: 67 Inch\n CVP: 16 (14 - 49)mmHg\n Total In:\n 11,516 mL\n 2,538 mL\n PO:\n TF:\n 481 mL\n 91 mL\n IVF:\n 9,455 mL\n 2,234 mL\n Blood products:\n Total out:\n 13,098 mL\n 3,404 mL\n Urine:\n 65 mL\n 37 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,582 mL\n -866 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n Vt (Spontaneous): 725 (725 - 725) mL\n PS : 10 cmH2O\n RR (Set): 26\n RR (Spontaneous): 0\n PEEP: 8 cmH2O\n FiO2: 50%\n RSBI Deferred: Hemodynamic Instability\n PIP: 20 cmH2O\n SpO2: 100%\n ABG: 7.33/50/143/25/0\n Ve: 11.9 L/min\n PaO2 / FiO2: 286\n Physical Examination\n Labs / Radiology\n 93 K/uL\n 7.8 g/dL\n 208 mg/dL\n 0.6 mg/dL\n 25 mEq/L\n 4.7 mEq/L\n 36 mg/dL\n 95 mEq/L\n 130 mEq/L\n 23.5 %\n 28.2 K/uL\n [image002.jpg]\n ALT: 97\n AP: 198\n Tbili: 28.7\n Alb:\n AST: 234\n LDH: 706\n Dbili:\n TProt:\n : 51\n Lip: 41\n PT: 15.8\n PTT: 33.2\n INR: 1.4\n 08:29 AM\n 08:42 AM\n 02:06 PM\n 02:20 PM\n 07:32 PM\n 07:44 PM\n 08:51 PM\n 01:27 AM\n 01:36 AM\n 05:36 AM\n WBC\n 28.2\n Hct\n 23.5\n Plt\n 93\n Cr\n 0.9\n 0.9\n 0.9\n 0.6\n TCO2\n 28\n 28\n 23\n 25\n 28\n 28\n Glucose\n 30\n 106\n 208\n Other labs: PT / PTT / INR:15.8/33.2/1.4, CK / CKMB /\n Troponin-T:214/3/0.07, ALT / AST:97/234, Alk Phos / T Bili:198/28.7,\n Amylase / Lipase:51/41, Differential-Neuts:68.0 %, Band:5.0 %,\n Lymph:7.0 %, Mono:4.0 %, Eos:0.0 %, D-dimer:6389 ng/mL, Fibrinogen:502\n mg/dL, Lactic Acid:1.5 mmol/L, Albumin:2.0 g/dL, LDH:706 IU/L, Ca++:8.8\n mg/dL, Mg++:2.0 mg/dL, PO4:3.5 mg/dL\n 4:11 pm TISSUE Source: Skin biopsy r/o HSV 1 and HSV2.\n GRAM STAIN (Final ):\n NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.\n NO MICROORGANISMS SEEN.\n TISSUE (Preliminary):\n REPORTED BY PHONE TO 11:30AM.\n Due to mixed bacterial types (>=3) an abbreviated workup is\n performed; P.aeruginosa, S.aureus and beta strep. are reported if\n present. Susceptibility will be performed on P.aeruginosa and\n S.aureus if sparse growth or greater..\n STAPHYLOCOCCUS, COAGULASE NEGATIVE. RARE GROWTH.\n ENTEROCOCCUS SP..\n Isolated from broth media only, INDICATING VERY LOW NUMBERS OF\n ORGANISMS.\n STAPHYLOCOCCUS, COAGULASE NEGATIVE.\n 2ND STRAIN Isolated from broth media only, INDICATING VERY LOW\n NUMBERS OF ORGANISMS.\n ANAEROBIC CULTURE (Preliminary): NO ANAEROBES ISOLATED.\n FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.\n ACID FAST SMEAR (Final ):\n NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.\n ACID FAST CULTURE (Preliminary):\n VIRAL CULTURE (Preliminary): No Virus isolated so far.\n Assessment and Plan\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n IMPAIRED SKIN INTEGRITY\n HEPATITIS, ACUTE TOXIC (INCLUDING ALCOHOLIC, ACETAMINOPHEN, ETC.)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ICU Care\n Nutrition:\n TPN w/ Lipids - 02:10 PM 35 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 08:15 PM\n Multi Lumen - 10:00 PM\n Dialysis Catheter - 11:35 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "General", "chartdate": "2131-05-29 00:00:00.000", "description": "Physician note", "row_id": 677539, "text": "Chief Complaint:\n 24 Hour Events:\n ARTERIAL LINE - STOP 01:30 PM\n ARTERIAL LINE - START 01:30 PM\n - Arterial line re-sited to left radial\n - Weaned sedation down (fetaynl preferentially), patient started moving\n and so went back up a bit.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Metronidazole - 02:00 AM\n Vancomycin - 08:08 AM\n Meropenem - 02:25 PM\n Infusions:\n Norepinephrine - 0.06 mcg/Kg/min\n Fentanyl (Concentrate) - 50 mcg/hour\n Calcium Gluconate (CRRT) - 1.4 grams/hour\n Midazolam (Versed) - 12 mg/hour\n KCl (CRRT) - 3 mEq./hour\n Other ICU medications:\n Pantoprazole (Protonix) - 07:32 PM\n Diazepam (Valium) - 04:51 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 07:07 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37\nC (98.6\n Tcurrent: 36.1\nC (97\n HR: 99 (96 - 112) bpm\n BP: 101/52(68) {77/37(50) - 135/78(98)} mmHg\n RR: 30 (23 - 31) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 128 kg (admission): 113.5 kg\n Height: 67 Inch\n CVP: 14 (13 - 22)mmHg\n Total In:\n 10,808 mL\n 2,161 mL\n PO:\n TF:\n IVF:\n 9,032 mL\n 1,648 mL\n Blood products:\n Total out:\n 14,321 mL\n 1,662 mL\n Urine:\n 50 mL\n NG:\n 140 mL\n 100 mL\n Stool:\n Drains:\n Balance:\n -3,513 mL\n 499 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 30\n RR (Spontaneous): 2\n PEEP: 12 cmH2O\n FiO2: 60%\n RSBI Deferred: PEEP > 10\n PIP: 28 cmH2O\n Plateau: 24 cmH2O\n Compliance: 38.5 cmH2O/mL\n SpO2: 98%\n ABG: 7.42/48/81./29/5\n Ve: 11.4 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 44 K/uL\n 7.9 g/dL\n 170 mg/dL\n 2.0 mg/dL\n 29 mEq/L\n 3.5 mEq/L\n 23 mg/dL\n 109 mEq/L\n 148 mEq/L\n 24.2 %\n 29.1 K/uL\n [image002.jpg]\n 11:09 PM\n 04:10 AM\n 04:20 AM\n 10:00 AM\n 10:10 AM\n 04:08 PM\n 04:20 PM\n 10:12 PM\n 04:02 AM\n 04:17 AM\n WBC\n 38.2\n 29.1\n Hct\n 29.0\n 24.2\n Plt\n 59\n 44\n Cr\n 1.8\n 2.0\n 2.2\n 2.0\n TCO2\n 30\n 30\n 31\n 32\n 32\n 32\n Glucose\n 199\n 205\n 196\n 196\n 178\n 170\n Other labs: PT / PTT / INR:17.5/59.4/1.6, ALT / AST:11/162, Alk Phos /\n T Bili:155/14.5, Amylase / Lipase:16/34, Differential-Neuts:71.0 %,\n Band:8.0 %, Lymph:6.0 %, Mono:4.0 %, Eos:2.0 %, D-dimer: ng/mL,\n Fibrinogen:402 mg/dL, Lactic Acid:1.6 mmol/L, Albumin:1.6 g/dL, LDH:742\n IU/L, Ca++:9.1 mg/dL, Mg++:1.7 mg/dL, PO4:3.3 mg/dL\n Assessment and Plan\n IMPAIRED HEALTH MAINTENANCE\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n IMPAIRED SKIN INTEGRITY\n HYPOTENSION (NOT SHOCK)\n HEPATITIS, ACUTE TOXIC (INCLUDING ALCOHOLIC, ACETAMINOPHEN, ETC.)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n PANCREATITIS, ACUTE\n ICU Care\n Nutrition:\n TPN w/ Lipids - 09:10 PM 73 mL/hour\n Glycemic Control:\n Lines:\n Multi Lumen - 02:02 PM\n Dialysis Catheter - 04:56 PM\n Arterial Line - 01:30 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "General", "chartdate": "2131-05-29 00:00:00.000", "description": "Physician note", "row_id": 677540, "text": "Chief Complaint:\n 24 Hour Events:\n ARTERIAL LINE - STOP 01:30 PM\n ARTERIAL LINE - START 01:30 PM\n - Arterial line re-sited to left radial\n - Weaned sedation down (fetaynl preferentially), patient started moving\n and so went back up a bit.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Metronidazole - 02:00 AM\n Vancomycin - 08:08 AM\n Meropenem - 02:25 PM\n Infusions:\n Norepinephrine - 0.06 mcg/Kg/min\n Fentanyl (Concentrate) - 50 mcg/hour\n Calcium Gluconate (CRRT) - 1.4 grams/hour\n Midazolam (Versed) - 12 mg/hour\n KCl (CRRT) - 3 mEq./hour\n Other ICU medications:\n Pantoprazole (Protonix) - 07:32 PM\n Diazepam (Valium) - 04:51 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 07:07 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37\nC (98.6\n Tcurrent: 36.1\nC (97\n HR: 99 (96 - 112) bpm\n BP: 101/52(68) {77/37(50) - 135/78(98)} mmHg\n RR: 30 (23 - 31) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 128 kg (admission): 113.5 kg\n Height: 67 Inch\n CVP: 14 (13 - 22)mmHg\n Total In:\n 10,808 mL\n 2,161 mL\n PO:\n TF:\n IVF:\n 9,032 mL\n 1,648 mL\n Blood products:\n Total out:\n 14,321 mL\n 1,662 mL\n Urine:\n 50 mL\n NG:\n 140 mL\n 100 mL\n Stool:\n Drains:\n Balance:\n -3,513 mL\n 499 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 30\n RR (Spontaneous): 2\n PEEP: 12 cmH2O\n FiO2: 60%\n RSBI Deferred: PEEP > 10\n PIP: 28 cmH2O\n Plateau: 24 cmH2O\n Compliance: 38.5 cmH2O/mL\n SpO2: 98%\n ABG: 7.42/48/81./29/5\n Ve: 11.4 L/min\n PaO2 / FiO2: 137\n Physical Examination\n General Appearance: Well nourished, total body fluid overload\n Eyes / Conjunctiva: PERRL, pupils 2mm->1mm\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: (Expansion: Symmetric), (Breath Sounds:\n Rhonchorous: )\n Abdominal: Soft, Distended\n Extremities: Right: 4+, Left: 4+\n Skin: Warm\n Neurologic: No(t) Attentive, No(t) Follows simple commands, Responds\n to: Not assessed, No(t) Oriented (to): , Movement: Not assessed,\n Sedated, Tone: Not assessed\n Labs / Radiology\n 44 K/uL\n 7.9 g/dL\n 170 mg/dL\n 2.0 mg/dL\n 29 mEq/L\n 3.5 mEq/L\n 23 mg/dL\n 109 mEq/L\n 148 mEq/L\n 24.2 %\n 29.1 K/uL\n [image002.jpg]\n 11:09 PM\n 04:10 AM\n 04:20 AM\n 10:00 AM\n 10:10 AM\n 04:08 PM\n 04:20 PM\n 10:12 PM\n 04:02 AM\n 04:17 AM\n WBC\n 38.2\n 29.1\n Hct\n 29.0\n 24.2\n Plt\n 59\n 44\n Cr\n 1.8\n 2.0\n 2.2\n 2.0\n TCO2\n 30\n 30\n 31\n 32\n 32\n 32\n Glucose\n 199\n 205\n 196\n 196\n 178\n 170\n Other labs: PT / PTT / INR:17.5/59.4/1.6, ALT / AST:11/162, Alk Phos /\n T Bili:155/14.5, Amylase / Lipase:16/34, Differential-Neuts:71.0 %,\n Band:8.0 %, Lymph:6.0 %, Mono:4.0 %, Eos:2.0 %, D-dimer: ng/mL,\n Fibrinogen:402 mg/dL, Lactic Acid:1.6 mmol/L, Albumin:1.6 g/dL, LDH:742\n IU/L, Ca++:9.1 mg/dL, Mg++:1.7 mg/dL, PO4:3.3 mg/dL\n Assessment and Plan\n IMPAIRED HEALTH MAINTENANCE\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n IMPAIRED SKIN INTEGRITY\n HYPOTENSION (NOT SHOCK)\n HEPATITIS, ACUTE TOXIC (INCLUDING ALCOHOLIC, ACETAMINOPHEN, ETC.)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n PANCREATITIS, ACUTE\n ICU Care\n Nutrition:\n TPN w/ Lipids - 09:10 PM 73 mL/hour\n Glycemic Control:\n Lines:\n Multi Lumen - 02:02 PM\n Dialysis Catheter - 04:56 PM\n Arterial Line - 01:30 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "General", "chartdate": "2131-05-29 00:00:00.000", "description": "Physician note", "row_id": 677541, "text": "Chief Complaint:\n 24 Hour Events:\n ARTERIAL LINE - STOP 01:30 PM\n ARTERIAL LINE - START 01:30 PM\n - Arterial line re-sited to left radial\n - Weaned sedation down (fetaynl preferentially), patient started moving\n and so went back up a bit.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Metronidazole - 02:00 AM\n Vancomycin - 08:08 AM\n Meropenem - 02:25 PM\n Infusions:\n Norepinephrine - 0.06 mcg/Kg/min\n Fentanyl (Concentrate) - 50 mcg/hour\n Calcium Gluconate (CRRT) - 1.4 grams/hour\n Midazolam (Versed) - 12 mg/hour\n KCl (CRRT) - 3 mEq./hour\n Other ICU medications:\n Pantoprazole (Protonix) - 07:32 PM\n Diazepam (Valium) - 04:51 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 07:07 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37\nC (98.6\n Tcurrent: 36.1\nC (97\n HR: 99 (96 - 112) bpm\n BP: 101/52(68) {77/37(50) - 135/78(98)} mmHg\n RR: 30 (23 - 31) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 128 kg (admission): 113.5 kg\n Height: 67 Inch\n CVP: 14 (13 - 22)mmHg\n Total In:\n 10,808 mL\n 2,161 mL\n PO:\n TF:\n IVF:\n 9,032 mL\n 1,648 mL\n Blood products:\n Total out:\n 14,321 mL\n 1,662 mL\n Urine:\n 50 mL\n NG:\n 140 mL\n 100 mL\n Stool:\n Drains:\n Balance:\n -3,513 mL\n 499 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 30\n RR (Spontaneous): 2\n PEEP: 12 cmH2O\n FiO2: 60%\n RSBI Deferred: PEEP > 10\n PIP: 28 cmH2O\n Plateau: 24 cmH2O\n Compliance: 38.5 cmH2O/mL\n SpO2: 98%\n ABG: 7.42/48/81./29/5\n Ve: 11.4 L/min\n PaO2 / FiO2: 137\n Physical Examination\n General Appearance: Well nourished, total body fluid overload\n Eyes / Conjunctiva: PERRL, pupils 2mm->1mm\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: (Expansion: Symmetric), (Breath Sounds:\n Rhonchorous: )\n Abdominal: Soft, Distended\n Extremities: Right: 4+, Left: 4+\n Skin: Warm\n Neurologic: No(t) Attentive, No(t) Follows simple commands, Responds\n to: Not assessed, No(t) Oriented (to): , Movement: Not assessed,\n Sedated, Tone: Not assessed\n Labs / Radiology\n 44 K/uL\n 7.9 g/dL\n 170 mg/dL\n 2.0 mg/dL\n 29 mEq/L\n 3.5 mEq/L\n 23 mg/dL\n 109 mEq/L\n 148 mEq/L\n 24.2 %\n 29.1 K/uL\n [image002.jpg]\n 11:09 PM\n 04:10 AM\n 04:20 AM\n 10:00 AM\n 10:10 AM\n 04:08 PM\n 04:20 PM\n 10:12 PM\n 04:02 AM\n 04:17 AM\n WBC\n 38.2\n 29.1\n Hct\n 29.0\n 24.2\n Plt\n 59\n 44\n Cr\n 1.8\n 2.0\n 2.2\n 2.0\n TCO2\n 30\n 30\n 31\n 32\n 32\n 32\n Glucose\n 199\n 205\n 196\n 196\n 178\n 170\n Other labs: PT / PTT / INR:17.5/59.4/1.6, ALT / AST:11/162, Alk Phos /\n T Bili:155/14.5, Amylase / Lipase:16/34, Differential-Neuts:71.0 %,\n Band:8.0 %, Lymph:6.0 %, Mono:4.0 %, Eos:2.0 %, D-dimer: ng/mL,\n Fibrinogen:402 mg/dL, Lactic Acid:1.6 mmol/L, Albumin:1.6 g/dL, LDH:742\n IU/L, Ca++:9.1 mg/dL, Mg++:1.7 mg/dL, PO4:3.3 mg/dL\n Assessment and Plan\n Mr. is a 28 year old gentleman with alcoholic hepatitis and\n necrotizing pancreatitis complicated by ARDS, SIRS, and UGIB.\n # Neuro: Initially dilated pupils with CT showing cerebral edema.\n Pupils less dilated and more reactive.\n - continuing keppra and 23% hypertonic saline boluses Q3H with regular\n serum sodium checks. Goal Na 145-150, Osm 310-315\n - Consider mannitol if serum sodium does not improve\n - Wean sedation (starting with fentanyl) as possible\n # Respiratory Failure: ARDS secondary to necrotizing pancreatitis\n compounded by hypoxia, tachypnea in setting of anion gap metabolic\n acidosis, increased abdominal pressure, and EtOH withdrawl. PEEP\n decreased to 12 from 20 and FiO2 to 40%.\n - Wean FiO2 and PEEP, goal PaO2>60-65%\n # Leukocytosis: Stable. Initial concern for infection but normal cx\n suggests that this may be inflammatory reaction. No eos on diff and CT\n without abscesses\n - dc vancomycin, meropenem, and flagyl since no infection source.\n Monitor closely\n - Follow-up culture data\n - f/u ID reccs\n # Necrotizing pancreatitis/SIRS: Secondary to alcohol complicated by\n SIRS and ARDS. Patient continues to have pressor requirement, with neo\n +/- levo. Aggressive volume resuscitation with >53L.\n - Continue empiric antimicrobials.\n - weaning pressors: neo is off and levo at 0.05.\n - Hypertonic saline as above in order to increase intravascular volume.\n # Hyponatremia: In setting of decreased effective circulating volume\n in setting of SIRS and IABP. Patient receiving hypertonic saline\n boluses with improvement in serum sodium.\n - Hypertonic saline as above.\n # Acute renal failure: Patient had HD line placed and CVVH was\n initiated yesterday.\n - CVVH per renal. UF with net neg 300cc/hr\n - Trend chemistries\n #Thrombocytopenia: Platelets stable. No clear etiology at this time.\n DIC panel and HIT PF4 antibody negative.\n - Trend plt, transfuse for plt<10 or <50 if signs of hemorrhage.\n # IAP elevation: Secondary to third spacing and edema. Per surgery, not\n a good surgical candidate at this time.\n # Acute hepatitis: Likely alcoholic hepatitis with fatty infiltration,\n and no evidence of distal obstruction. RUQ u/s shows marked liver\n echogenicity but no ascites.\n - Trend LFTs\n # Hematemesis: EGD showed diuelafoy's lesion. HCT stable since 2 units\n PRBC on .\n - Trend hct, transfuse for hct<21\n # Alcoholism: Patient describes history of withdrawal symptoms, but\n not prior seizure. Last drink was night prior to presentation.\n Tachycardia, weakness, and elevated lactate could be consistent with\n thiamine deficiency.\n - Thiamine, vb12, folate\n - Valium with CIWA > 10\n FEN: TPN, replete as necessary.\n PPx: Heparin and H2B in TPN\n Access: RIJ (quad), LIJ (HD), right radial a-line\n Dispo: ICU level of care\n ICU Care\n Nutrition:\n TPN w/ Lipids - 09:10 PM 73 mL/hour\n Glycemic Control:\n Lines:\n Multi Lumen - 02:02 PM\n Dialysis Catheter - 04:56 PM\n Arterial Line - 01:30 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2131-05-31 00:00:00.000", "description": "Nursing Progress Note", "row_id": 677903, "text": " Problem\n Cerebral Edema\n Assessment:\n Pupils 2mm, sluggish to briskly reactive\n No movement of extremities\n No gag, however pt clearly reacts to mouth care, bites on\n bite block\n Spontaneous cough x3 episodes this shift, can not recreate\n cough with suctioning\n CT scan from showed less cerebral edema than\n previous scan\n No S+S of seizure activity\n Action:\n Q 2 hour neuro checks\n Maintain map > 60 to maintain CPP > 60 (no way to measure\n ICP at this time)\n Keppra as ordered\n CRRT to assist with fluid removal\n Response:\n Small improvements noted in neuro exam\n Improvement in cerebral edema noted on CT scan\n Plan:\n Continue current monitoring and management\n Continue keppra\n Continue CRRT\n Patient and family support\n Impaired Skin Integrity\n Assessment:\n Open blisters on legs continue to weep serous to sero-sang\n fluid\n Red rash present\n Back and buttocks continue to be intact, no skin breakdown\n Bilat heels with ? deep tissue injury\n Action:\n Leg wounds cleansed with wound cleanser\n Aquacel to all open blisters\n Aloe-vesta to all intact skin\n Covered with softsorb and mesh stockings\n Turned q20 minutes on rotating bed, and total turn for linen\n changes q 4\n CRRT to assist with fluid removal\n Response:\n No progression of skin breakdown\n Improvements noted on legs since Monday \n Plan:\n Continue recommendations by skin nurse on treatment\n Continue q 20 minutes rotation\n Patient and family support;\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt remains on AC, 50%, 12 Peep, RR 30 X 400 with last ABG:\n 7.43, 48, 76, 6, 33.\n Lung sounds clear, diminished bases\n Suctioned for scant amount thick clear yellow tinged sputum\n Patient biting/clenching down on bite block with mouth care\n No cough initiated with ETT suctioning\n Action:\n Bed on constant rotation\n VAP protocol\n CRRT for fluid removal\n Chest x-ray\n Response:\n Remains in a mild metabolic alkalosis with concerning ARDS\n picture\n Plan:\n Continue rotation\n Continue VAP protocol\n Wean ventilator as tolerated\n Pancreatitis, acute\n Assessment:\n Afebrile\n MAP > 60 met with levophed gtt\n HCT 23.8\n Abdomen softly distended with + hypoactive bs\n Remains many liters fluid positive\n Action:\n Transfused one unit of PRBC\n CRRT for goal to keep patient even\n ABX discontinued yesterday \n Levophed gtt weaned slightly to 0.1 mcg/kg/min\n Response:\n WBC 31 from 36\n Platelets 60 from 48\n HCT now 25.7 from 23.8, no S+S of active bleeding\n Fluid balance for +177 cc\n Fluid balance MN\n 0600 :\n Plan:\n Continue CRRT for goal even fluid balance\n Patient and family support\n Continue to monitor labs, HCT\ns, S+S of bleeding\n" }, { "category": "Physician ", "chartdate": "2131-05-26 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 677088, "text": "TITLE:\n Chief Complaint:\n Mr. is a 28 year old gentleman with alcoholic hepatitis and\n necrotizing pancreatitis complicated by ARDS, SIRS, and UGIB.\n 24 Hour Events:\n \n changed hypertonic saline to continous\n neuro/nsurg wanted repeat ct head\n decreased peep/fio2\n hd line pplaced and cvvh started\n \n - Switched back to 23% saline. Afternoon Na 139, PM Na 142. Written for\n additional 2 doses of 23%.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:55 AM\n Metronidazole - 01:41 AM\n Meropenem - 02:47 AM\n Infusions:\n Norepinephrine - 0.03 mcg/Kg/min\n Calcium Gluconate (CRRT) - 1.4 grams/hour\n Phenylephrine - 5 mcg/Kg/min\n Fentanyl (Concentrate) - 350 mcg/hour\n Midazolam (Versed) - 30 mg/hour\n Other ICU medications:\n Pantoprazole (Protonix) - 08:03 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 07:03 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.6\nC (99.6\n Tcurrent: 37.1\nC (98.8\n HR: 99 (90 - 106) bpm\n BP: 104/50(67) {95/47(63) - 114/57(76)} mmHg\n RR: 32 (30 - 41) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 156 kg (admission): 113.5 kg\n Height: 67 Inch\n CVP: 12 (11 - 22)mmHg\n Total In:\n 9,927 mL\n 3,355 mL\n PO:\n TF:\n IVF:\n 8,691 mL\n 2,828 mL\n Blood products:\n Total out:\n 11,304 mL\n 4,118 mL\n Urine:\n 270 mL\n 105 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,377 mL\n -763 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 30\n RR (Spontaneous): 4\n PEEP: 16 cmH2O\n FiO2: 40%\n RSBI Deferred: PEEP > 10\n PIP: 37 cmH2O\n Plateau: 29 cmH2O\n Compliance: 95.2 cmH2O/mL\n SpO2: 95%\n ABG: 7.36/42/70/20/-1\n Ve: 12.4 L/min\n PaO2 / FiO2: 175\n Physical Examination\n General Appearance: Overweight / Obese\n Head, Ears, Nose, Throat: 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: (Expansion: Symmetric), (Breath Sounds: Crackles :\n )\n Abdominal: Soft, Obese\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 85 K/uL\n 10.1 g/dL\n 170 mg/dL\n 2.9 mg/dL\n 20 mEq/L\n 3.5 mEq/L\n 26 mg/dL\n 109 mEq/L\n 141 mEq/L\n 29.9 %\n 35.1 K/uL\n [image002.jpg]\n 09:39 PM\n 10:00 PM\n 02:26 AM\n 04:29 AM\n 04:48 AM\n 09:51 AM\n 04:18 PM\n 08:52 PM\n 02:08 AM\n 02:28 AM\n WBC\n 44.1\n 35.1\n Hct\n 30.7\n 29.9\n Plt\n 70\n 85\n Cr\n 4.0\n 3.9\n 2.9\n TCO2\n 21\n 20\n 24\n 21\n 21\n 25\n 25\n Glucose\n 173\n 175\n 147\n 182\n 182\n 170\n Other labs: PT / PTT / INR:19.5/53.6/1.8, ALT / AST:20/209, Alk Phos /\n T Bili:239/19.5, Amylase / Lipase:16/36, Differential-Neuts:71.0 %,\n Band:8.0 %, Lymph:6.0 %, Mono:4.0 %, Eos:2.0 %, D-dimer: ng/mL,\n Fibrinogen:402 mg/dL, Lactic Acid:2.1 mmol/L, Albumin:2.1 g/dL, LDH:742\n IU/L, Ca++:8.0 mg/dL, Mg++:1.9 mg/dL, PO4:2.3 mg/dL\n Assessment and Plan\n Mr. is a 28 year old gentleman with alcoholic hepatitis and\n necrotizing pancreatitis complicated by ARDS, SIRS, and UGIB.\n # Neuro: Patient with dilated pupils on high dose fentaynl gtt. CTH\n demonstrated loss of grey white differentiation with questionable\n effacement and possible seizure activity. Neuro and neurosurg consulted\n and patient received ativan, keppra load, and hypertonic saline of\n hyponatremia. Patient converted to 23% saline boluses with improvement\n in serum sodium and osmolility.\n - Per neuro, keppra IV maintenance dose\n - Continue 23% hypertonic saline boluses Q3H with regular serum sodium\n checks.\n - f/u EEG read\n - follow-up with neurology and neurosurg regarding frequency of saline\n boluses, need for repeat head CT given improving osmolality\n - Consider mannitol if serum sodium does not improve.\n - Wean sedation (starting with fentanyl) as possible.\n # Respiratory Failure: ARDS secondary to necrotizing pancreatitis\n compounded by hypoxia, tachypnea in setting of anion gap metabolic\n acidosis, increased abdominal pressure, and EtOH withdrawl. PEEP\n decreased to 16 from 20 and FiO2 to 40%.\n - Wean FiO2 and PEEP, goal PaO2>60-65%\n # Leukocytosis: WBC up to 44.9 on but now trending down.\n Concern for CVL infection, VAP, loculated effusion, sinusitis, or\n pancreatitis complication including abscess formation. CT chest with\n multifocal infiltrates that could represent VAP vs ARDS. CTAP did not\n demonstrate any new pancreatic fluid collections. On prior\n differential, had a neutrophilic predominance with 6% eosinophils but\n now with falling white count and normal eosinophil differential. Spoke\n to nurse and confirmed that patient has not been getting saline\n flushes/afrin, suggesting improvement in leukocytosis supports\n diagnosis of c. diff with improvement on flagyl.\n - Continue empiric vancomycin, meropenem, and flagyl. AM vanco level\n today\n - continue to follow CBC differential, if elevated would consider drug\n reaction as potential etiology to leukocytosis and likely switch\n Meropenem to zosyn.\n - Follow-up culture data\n - f/u ID reccs\n # Necrotizing pancreatitis/SIRS: Secondary to alcohol complicated by\n SIRS and ARDS. Patient continues to have pressor requirement, with neo\n +/- levo. Aggressive volume resuscitation with >58L. Patient\n without improvement with albumin trial, likely secondary to SIRS and\n increased vascular permeability.\n - Continue empiric antimicrobials.\n - Wean pressors as able, starting with levophed\n - Hypertonic saline as above in order to increase intravascular volume.\n - Monitor chemistries.\n - Follow-up with recs if any\n # Hyponatremia: In setting of decreased effective circulating volume\n in setting of SIRS and IABP. Patient receiving hypertonic saline\n boluses with improvement in serum sodium.\n - Hypertonic saline as above.\n - Trend chemistries.\n - Follow-up with neurosurgery recs if any.\n # Acute renal failure: Patient had HD line placed and CVVH was\n initiated yesterday.\n - CVVH per renal.\n - Trend chemistries\n #Thrombocytopenia: Platelets stable. No clear etiology at this time.\n DIC panel and HIT PF4 antibody negative.\n - Trend plt, transfuse for plt<10 or <50 if signs of hemorrhage.\n # IAP elevation: Secondary to third spacing and edema. Per surgery, not\n a good surgical candidate at this time.\n # Acute hepatitis: Likely alcoholic hepatitis with fatty infiltration,\n and no evidence of distal obstruction. RUQ u/s shows marked liver\n echogenicity but no ascites.\n - Trend LFTs\n # Hematemesis: EGD showed diuelafoy's lesion. HCT stable since 2 units\n PRBC on .\n - Trend hct, transfuse for hct<21\n # Alcoholism: Patient describes history of withdrawal symptoms, but\n not prior seizure. Last drink was night prior to presentation.\n Tachycardia, weakness, and elevated lactate could be consistent with\n thiamine deficiency.\n - Thiamine, vb12, folate\n - Valium with CIWA > 10\n FEN: TPN, replete as necessary.\n PPx: Heparin and H2B in TPN\n Access: RIJ (quad), LIJ (HD), right radial a-line\n Dispo: ICU level of care\n ICU Care\n Nutrition:\n TPN w/ Lipids - 06:00 PM 75 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 01:35 PM\n Multi Lumen - 02:02 PM\n Dialysis Catheter - 04:56 PM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Heparin in TPN)\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n ------ Protected Section ------\n I saw and examined the patient, and was physically present with the ICU\n team for the key portions of the services provided. I agree with the\n note above, including the assessment and plan. I would emphasize and\n add the following points:\n 28M h/o EtOH abuse, weakness, fatigue, UGIB c/b hematemesis / melena.\n Has developed massive fluid requirement, hypotension, ARDS in the\n setting of severe pancreatitis, alcoholic hepatitis and borderline\n renal function. Head CT with edema, on 23% NS for induced osmorx. Fever\n curve down on / vanco / flagyl\nafebrile x last 24hrs. Ongoing\n CVVH. EEG completed\n preliminary read is no active seizure activity.\n Tmax: 37.6\nC (99.6\n Tcurrent: 37.1\nC (98.8\n HR: 99 (90 - 106) bpm\n BP: 104/50(67) {95/47(63) - 114/57(76)} mmHg\n RR: 32 (30 - 41) insp/min\n SpO2: 95%\n Sedated, min responsive\n Pupils 6 to 4 b/l.\n Hyperdynamic, RR\n Bronchial BS b/l\n Distended, minimal bowel sounds.\n Massive edema.\n Tighten glycemic control\n insulin\n stop sc insulin - not absorbing\n CEREBRAL EDEMA\n - hypertonic (23%) saline q6h with frequent monitoring of osm and\n sodium for cerebral edema. Sosm moving into desired range. Pupils\n remain dilated though reactive. Repeat imaging would be optimal but\n perhaps not realistic given pt\ns acuity and accompanying risks of\n transferring for imaging. D/W nuero/NS. On keppra proph. EEG initial\n read s evidence of sz activity.\n ARDS\n - low volume ventilation (400x30); will continue to wean PEEP as\n tolerated. 20->16. Once requirements down, able to start weaning\n sedation though long road given large volume of distribution.\n SHOCK\n -cont require pressors, avoid fluid boluses as able given huge total\n body fluid overload. Continuing broad spectrum abx pend cx data for\n guidance. Afebrile last 24hrs which is positive.\n ARF\n -CVVHD\n PANCREATITIS\n -presumed due to EtOH\n -c/b ARDS\n -NPO\n - following\n -continue TPN with heparin\n EtOH HEPATITIS\n UGIB\n -Dieulafois lesion at GEJ\n -monitor serial HCT\n Remainder of plan as outlined in resident note.\n Patient is critically ill\n Total time: 60 min\n ------ Protected Section Addendum Entered By: , MD\n on: 14:48 ------\n" }, { "category": "Nursing", "chartdate": "2131-05-26 00:00:00.000", "description": "Nursing Progress Note", "row_id": 677137, "text": "Impaired Skin Integrity\n Assessment:\n Anasarca continues with 3^rd spaced fluid blistering on legs\n All puncture sites weeping fluid\n Large insensible losses, unable to quantify\n Action:\n Pads under legs and arms changed q 1-2 hours\n Bed rotation on at all times rotating side to side every 20\n minutes\n CRRT for goal fluid removal as much as patient will tolerate\n without increasing vasopressors\n Response:\n No progression of skin breakdown noted\n Patient\ns weight is down 12 Kg\n Plan:\n Continue CRRT\n Continue vigilant skin care, turning and linen changes\n Skin nurse consult ordered per MICU\n Pancreatitis, acute\n Assessment:\n Afebrile\n Anasarca continues\n WBC remains elevated\n Goal MAP > 65 met with vasopressors\n Action:\n CRRT\n Weaning vasopressors\n Antibiotics ATC\n Slow wean of sedation\n Sputum culture sent\n Response:\n Small improvements noted in fluid removal, no temps\n LFT\ns appear to have peaked\n Plan:\n Continue CRRT\n Continue ABX\n Continue to monitor labs\n Follow up on culture results\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Continues to have respiratory failure\n LS diminished\n High peep requirements with low tidal volumes\n Action:\n Peep wean in progress, currently @ 16 from 24 in past\n Frequent repositioning\n VAP protocol\n Sputum culture sent\n Fio2 @ 40%\n Response:\n Improved blood gas (7.36, 42, 82, -1, 25.)\n Plan:\n Continue slow vent wean as patient tolerates\n Problem - Description In Comments: Cerebral Edema\n Assessment:\n Pupils 7mm, sluggishly reactive\n No cough\n No gag\n No corneal reflex\n Does not move extremities to painful stimuli\n Does slightly over breath ventilator\n No S+S of seizure activity\n Action:\n Neurology continues to follow\n Hypertonic saline to increase sodium and osmolarity\n CRRT for fluid removal\n HOB elevated as tolerated\n Keppra\n Response:\n No Seizure activity noted\n Neurologic exam remains very concerning\n Plan:\n Continue q 2 hour neuro evaluations\n Continue anti-epileptics\n Continue sedation, wean slowly\n Continue hypertonic saline\n Continue to monitor q 6 hour sodium and osmolarity levels\n No bolt at this time\n Continued support offered to family. MICU team in very frequent\n contact with patient\ns brother and father, updating them on the plan of\n care and allowing time to answer many questions.\n" }, { "category": "Nursing", "chartdate": "2131-06-12 00:00:00.000", "description": "Nursing Progress Note", "row_id": 680447, "text": "Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Action:\n Response:\n Plan:\n Problem\n bleeding from trach\n Assessment:\n No bleeding noted from trach site this shift\n Some oral bleeding from lip and gums\n Difficult to suction out mouth due to patient\ns constant biting on\n suction\n No blood suctioned from trach\n Action:\n Amicar gtt resumed @1 mg/hr for 16 hrs. more\n Oral care as able\n Response:\n Stable\n Plan:\n Continue with amicar\n Notify MICU team if any increased bleeding from trach noted.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Switched from CMV to CPAP with 12 pressure support\n Versed off, on bolus doses if needed\n Action:\n Tolerating CPAP mode well with good blood gases\n Response:\n Will keep on current settings\n Plan:\n Continue to remove fluid with CRRT as tolerated\n CPAP mode as tolerates\n" }, { "category": "Physician ", "chartdate": "2131-06-12 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 680342, "text": "Chief Complaint:\n 24 Hour Events:\n STOOL CULTURE - At 01:21 PM\n for cdiff\n RESPIRATORY ARREST - At 07:28 PM\n team at bedside.\n BRONCHOSCOPY - At 08:14 PM\n Dr , time out done prior to proced\n BRONCHOSCOPY - At 08:48 PM\n Dr .\n - Concern for hemophagocytic syndrome - Checking ferritin (>);\n heme-onc consulted, feel hemophagocytic syndrome is unlikely.\n - Plan to increase insulin in TPN, but TPN recs not available in time\n - In anticipation of bzd withdrawal with weaning of midazolam, started\n valium 10mg PO TID. Plan to wean fentanyl, versed as tolerated in hopes\n of trying pressure support.\n - Per ID, restarted vanc PR; will restart ciprofloxacin if\n decompensates\n - Amylase 47, lipase 47\n - 6pm I/O -2L\n - 6pm Doing well on pressure support, versed weaned off. After incident\n below, restarted on assist control.\n - 7:30pm Respiratory distress - Initially with bronchospasm, then\n apneic and briefly without pulse (?minutes). Improved with deep suction\n - large clot removed with return of pulse, BP and improved ventilation.\n Thoracics performed bedside bronchoscopy - determined that trach is too\n short; on further reevaluation by attending, appropriate size and not\n needing replacement; clots removed with repeat bronchoscopy. Heme/onc\n aware, recommended Amicar for bleeding at trach site - started.\n Allergies:\n Meropenem\n skin blisters a\n Last dose of Antibiotics:\n Vancomycin - 04:00 PM\n Aztreonam - 09:24 PM\n Linezolid - 11:00 PM\n Micafungin - 12:33 AM\n Metronidazole - 02:01 AM\n Infusions:\n Fentanyl (Concentrate) - 100 mcg/hour\n Norepinephrine - 0.03 mcg/Kg/min\n Midazolam (Versed) - 5 mg/hour\n Calcium Gluconate (CRRT) - 1.6 grams/hour\n KCl (CRRT) - 2 mEq./hour\n Other ICU medications:\n Atropine - 07:30 PM\n Midazolam (Versed) - 09:03 PM\n Other medications:\n Changes to medical and family history:\n None\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Intubated, sedated.\n Flowsheet Data as of 06:08 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37\nC (98.6\n Tcurrent: 35.4\nC (95.8\n HR: 80 (30 - 126) bpm\n BP: 118/68(87) {59/41(47) - 168/94(124)} mmHg\n RR: 26 (10 - 31) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 123.3 kg (admission): 113.5 kg\n Height: 67 Inch\n CVP: 16 (14 - 49)mmHg\n Total In:\n 11,516 mL\n 2,538 mL\n PO:\n TF:\n 481 mL\n 91 mL\n IVF:\n 9,455 mL\n 2,234 mL\n Blood products:\n Total out:\n 13,098 mL\n 3,404 mL\n Urine:\n 65 mL\n 37 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,582 mL\n -866 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n Vt (Spontaneous): 725 (725 - 725) mL\n PS : 10 cmH2O\n RR (Set): 26\n RR (Spontaneous): 0\n PEEP: 8 cmH2O\n FiO2: 50%\n RSBI Deferred: Hemodynamic Instability\n PIP: 20 cmH2O\n SpO2: 100%\n ABG: 7.33/50/143/25/0\n Ve: 11.9 L/min\n PaO2 / FiO2: 286\n Physical Examination\n GEN: Intubated, sedated\n HEENT: icteric sclera. MMM\n NECK: Trach site with minimal oozing\n LUNGS: Anterior auscultation with upper airway noise; good airway\n movement\n HEART: , ; S1, S2\n ABD: Distended. NT.\n EXTREM: 2+ edema, ulcers/lesions on legs with bandages C/D/I\n SKIN: Jaundice\n Labs / Radiology\n 93 K/uL\n 7.8 g/dL\n 208 mg/dL\n 0.6 mg/dL\n 25 mEq/L\n 4.7 mEq/L\n 36 mg/dL\n 95 mEq/L\n 130 mEq/L\n 23.5 %\n 28.2 K/uL\n [image002.jpg]\n ALT: 97\n AP: 198\n Tbili: 28.7\n Alb:\n AST: 234\n LDH: 706\n Dbili:\n TProt:\n : 51\n Lip: 41\n PT: 15.8\n PTT: 33.2\n INR: 1.4\n 08:29 AM\n 08:42 AM\n 02:06 PM\n 02:20 PM\n 07:32 PM\n 07:44 PM\n 08:51 PM\n 01:27 AM\n 01:36 AM\n 05:36 AM\n WBC\n 28.2\n Hct\n 23.5\n Plt\n 93\n Cr\n 0.9\n 0.9\n 0.9\n 0.6\n TCO2\n 28\n 28\n 23\n 25\n 28\n 28\n Glucose\n 30\n 106\n 208\n Other labs: PT / PTT / INR:15.8/33.2/1.4, CK / CKMB /\n Troponin-T:214/3/0.07, ALT / AST:97/234, Alk Phos / T Bili:198/28.7,\n Amylase / Lipase:51/41, Differential-Neuts:68.0 %, Band:5.0 %,\n Lymph:7.0 %, Mono:4.0 %, Eos:0.0 %, D-dimer:6389 ng/mL, Fibrinogen:502\n mg/dL, Lactic Acid:1.5 mmol/L, Albumin:2.0 g/dL, LDH:706 IU/L, Ca++:8.8\n mg/dL, Mg++:2.0 mg/dL, PO4:3.5 mg/dL\n 4:11 pm TISSUE Source: Skin biopsy r/o HSV 1 and HSV2.\n GRAM STAIN (Final ):\n NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.\n NO MICROORGANISMS SEEN.\n TISSUE (Preliminary):\n REPORTED BY PHONE TO 11:30AM.\n Due to mixed bacterial types (>=3) an abbreviated workup is\n performed; P.aeruginosa, S.aureus and beta strep. are reported if\n present. Susceptibility will be performed on P.aeruginosa and\n S.aureus if sparse growth or greater..\n STAPHYLOCOCCUS, COAGULASE NEGATIVE. RARE GROWTH.\n ENTEROCOCCUS SP..\n Isolated from broth media only, INDICATING VERY LOW NUMBERS OF\n ORGANISMS.\n STAPHYLOCOCCUS, COAGULASE NEGATIVE.\n 2ND STRAIN Isolated from broth media only, INDICATING VERY LOW\n NUMBERS OF ORGANISMS.\n ANAEROBIC CULTURE (Preliminary): NO ANAEROBES ISOLATED.\n FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.\n ACID FAST SMEAR (Final ):\n NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.\n ACID FAST CULTURE (Preliminary):\n VIRAL CULTURE (Preliminary): No Virus isolated so far.\n Assessment and Plan\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n IMPAIRED SKIN INTEGRITY\n HEPATITIS, ACUTE TOXIC (INCLUDING ALCOHOLIC, ACETAMINOPHEN, ETC.)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ICU Care\n Nutrition:\n TPN w/ Lipids - 02:10 PM 35 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 08:15 PM\n Multi Lumen - 10:00 PM\n Dialysis Catheter - 11:35 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": "2131-06-12 00:00:00.000", "description": "Nursing Progress Note", "row_id": 680323, "text": "TITLE:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n At begin of shift, diffuse wheezes noted bilat, discoordinate breathing\n pattern, elevated pip\ns 40\ns, O2 sats >95%.Bp and HR stable at this\n time on low dose levophed, fentanyl 100mcg and versed (off). RT paged\n and here to eval, mdi\ns given and lavage and suct for small amts bloody\n secretions.\n Action:\n Wheezing persisted, ambued 100% initially hemodynamically stable &\n progressive unstable as unable to adeq ventilate,large subq air noted w\n bagging sats drop 86% and hr 30 sbp 59. Code called and prepared to\n initiate cpr when lg bldy plug removed from trach. Hemodynamic\n stability reestablished.\n Bronched by Dr after obstructed airway event-> ? anatomical\n obstruction occurring with trach/tissue obstruction. Sats stable\n throughout bronch. Dr paged and here to eval. Rebronched\n for tough fibrinous clot in airways(*requiring extensive irrigation to\n free up) and large amts of nasal and epiglottal region clot extracted\n also. No active fresh bleeding noted in trachea. O2 sats stable\n throughout the procedure and weaned fio2 gradually overnight to 50%.\n Lavage and suct q2h overnight for small amts of thin bloody\n secretions.MDI\ns given overnight as ordered. Continues to receive\n steroids(adrenal insufficiency)\n Response:\n No further airway obstruction or desats overnight, no fresh clots noted\n with suctioning, pip\ns stable. Bbs clear diminish bilat no further\n wheezing.\n Plan:\n Cont aggressive pulm toilet, Vap bundle. If recurrence of airway\n obstruction, Dr d/w family ? intubate orally and re-explore\n trach site.Consents obtained for same in event that reexplor of trach\n necessary.\n Problem\n Tracheostomy site bleeding\n Assessment:\n Surgicel in place around trach site and Large amts of old clot around\n trach site noted. Also as above clots in oropharyngeal and epiglottal\n region as well. Micu team evaluated w consult recommendations from\n hematology\n Action:\n Amicar 1gm/hr x 8hrs. Meticulous trach care done with removal of old\n surgicel around trach and old clots. Sinus arrhythmia to sinus brady\n after amicar gtt started,? r/t amicar drip. 12 lead ekg done no\n changes.\n Response:\n Scant to no bleeding around trach site. Amicar gtt completed by 0600..\n Sinus arrhythmia resolved.\n Plan:\n Meticulous Trach care and pulm toilet, notify team if bldg around trach\n or increase in blood suctioned from trach.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Tolerating crrt running net negative 100-400cc/hrly until acute airway\n obstruction @. Ca gluc and K+ per crrt protocol and citrate\n infusing as ordered\n Action:\n Labs q6h, repleting Ca+ and K+ per protocol. Crrt recirculating while\n bronch being performed and during resuscitation efforts. Resumed crrt\n once recovered from resuscitation and bronch completed.\n Response:\n Tolerating fld removal Net 1.6liter negative at midnight Creat 0.6 Bun\n Plan:\n" }, { "category": "Nursing", "chartdate": "2131-06-12 00:00:00.000", "description": "Nursing Progress Note", "row_id": 680325, "text": "TITLE:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n At begin of shift, diffuse wheezes noted bilat, discoordinate breathing\n pattern, elevated pip\ns 40\ns, O2 sats >95%.Bp and HR stable at this\n time on low dose levophed, fentanyl 100mcg and versed (off). RT paged\n and here to eval, mdi\ns given and lavage and suct for small amts bloody\n secretions.\n Action:\n Wheezing persisted, ambued 100% initially hemodynamically stable &\n progressive unstable as unable to adeq ventilate,large subq air noted w\n bagging sats drop 86% and hr 30 sbp 59. Code called and prepared to\n initiate cpr when lg bldy plug removed from trach. Hemodynamic\n stability reestablished.\n Bronched by Dr after obstructed airway event-> ? anatomical\n obstruction occurring with trach/tissue obstruction. Sats stable\n throughout bronch. Dr paged and here to eval. Rebronched\n for tough fibrinous clot in airways(*requiring extensive irrigation to\n free up) and large amts of nasal and epiglottal region clot extracted\n also. No active fresh bleeding noted in trachea. O2 sats stable\n throughout the procedure and weaned fio2 gradually overnight to 50%.\n Lavage and suct q2h overnight for small amts of thin bloody\n secretions.MDI\ns given overnight as ordered. Continues to receive\n steroids(adrenal insufficiency)\n Response:\n No further airway obstruction or desats overnight, no fresh clots noted\n with suctioning, pip\ns stable. Bbs clear diminish bilat no further\n wheezing.\n Plan:\n Cont aggressive pulm toilet, Vap bundle. If recurrence of airway\n obstruction, Dr d/w family ? intubate orally and re-explore\n trach site.Consents obtained for same in event that reexplor of trach\n necessary.\n Problem\n Tracheostomy site bleeding\n Assessment:\n Surgicel in place around trach site and Large amts of old clot around\n trach site noted. Also as above clots in oropharyngeal and epiglottal\n region as well. Micu team evaluated w consult recommendations from\n hematology\n Action:\n Amicar 1gm/hr x 8hrs. Meticulous trach care done with removal of old\n surgicel around trach and old clots. Sinus arrhythmia to sinus brady\n after amicar gtt started,? r/t amicar drip. 12 lead ekg done no\n changes.\n Response:\n Scant to no bleeding around trach site. Amicar gtt completed by 0600..\n Sinus arrhythmia resolved.\n Plan:\n Meticulous Trach care and pulm toilet, notify team if bldg around trach\n or increase in blood suctioned from trach.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Tolerating crrt running net negative 100-400cc/hrly until acute airway\n obstruction @. Ca gluc and K+ per crrt protocol and citrate\n infusing as ordered\n Action:\n Labs q6h, repleting Ca+ and K+ per protocol. Crrt recirculating while\n bronch being performed and during resuscitation efforts. Resumed crrt\n once recovered from resuscitation and bronch completed.\n Response:\n Tolerating fld removal Net 1.6liter negative at midnight Creat 0.6\n Bun36.\n Plan:\n Labs q6h while on crrt. Titrate Ca+ and K+ per protocol .Crrt filter to\n be changed today at 1800.\n" }, { "category": "Nursing", "chartdate": "2131-06-12 00:00:00.000", "description": "Nursing Progress Note", "row_id": 680327, "text": "TITLE:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n At begin of shift, diffuse wheezes noted bilat, discoordinate breathing\n pattern, elevated pip\ns 40\ns, O2 sats >95%.Bp and HR stable at this\n time on low dose levophed, fentanyl 100mcg and versed (off). RT paged\n and here to eval, mdi\ns given and lavage and suct for small amts bloody\n secretions.\n Action:\n Wheezing persisted, ambued 100% initially hemodynamically stable &\n progressive unstable as unable to adeq ventilate,large subq air noted w\n bagging sats drop 86% and hr 30 sbp 59. Code called and prepared to\n initiate cpr when lg bldy plug removed from trach. Hemodynamic\n stability reestablished.\n Bronched by Dr after obstructed airway event-> ? anatomical\n obstruction occurring with trach/tissue obstruction. Sats stable\n throughout bronch. Dr paged and here to eval. Rebronched\n for tough fibrinous clot in airways(*requiring extensive irrigation to\n free up) and large amts of nasal and epiglottal region clot extracted\n also. No active fresh bleeding noted in trachea. O2 sats stable\n throughout the procedure and weaned fio2 gradually overnight to 50%.\n Lavage and suct q2h overnight for small amts of thin bloody\n secretions.MDI\ns given overnight as ordered. Continues to receive\n steroids(adrenal insufficiency)\n Response:\n No further airway obstruction or desats overnight, no fresh clots noted\n with suctioning, pip\ns stable. Bbs clear diminish bilat no further\n wheezing.\n Plan:\n Cont aggressive pulm toilet, Vap bundle. If recurrence of airway\n obstruction, Dr d/w family ? intubate orally and re-explore\n trach site.Consents obtained for same in event that reexplor of trach\n necessary.\n Problem\n Tracheostomy site bleeding\n Assessment:\n Surgicel in place around trach site and Large amts of old clot around\n trach site noted. Also as above clots in oropharyngeal and epiglottal\n region as well. Micu team evaluated w consult recommendations from\n hematology\n Action:\n Amicar 1gm/hr x 8hrs. Meticulous trach care done with removal of old\n surgicel around trach and old clots. Sinus arrhythmia to sinus brady\n after amicar gtt started,? r/t amicar drip. 12 lead ekg done no\n changes.\n Response:\n Scant to no bleeding around trach site. Amicar gtt completed by 0600..\n Sinus arrhythmia resolved.\n Plan:\n Meticulous Trach care and pulm toilet, notify team if bldg around trach\n or increase in blood suctioned from trach.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Tolerating crrt running net negative 100-400cc/hrly until acute airway\n obstruction @. Ca gluc and K+ per crrt protocol and citrate\n infusing as ordered\n Action:\n Labs q6h, repleting Ca+ and K+ per protocol. Crrt recirculating while\n bronch being performed and during resuscitation efforts. Resumed crrt\n once recovered from resuscitation and bronch completed.\n Response:\n Tolerating fld removal Net 1.6liter negative at midnight Creat 0.6\n Bun36. Hyponatremic Na+ 130 this am.\n Plan:\n Labs q6h while on crrt. Titrate Ca+ and K+ per protocol .Crrt filter to\n be changed today at 1800.Check with renal re: possible change in\n dialysate. Check with micu team re: possible change in tpn mix.\n" }, { "category": "Physician ", "chartdate": "2131-06-12 00:00:00.000", "description": "Physician Resident/Attending Progress Note - MICU", "row_id": 680437, "text": "Chief Complaint:\n 24 Hour Events:\n STOOL CULTURE - At 01:21 PM\n for cdiff\n RESPIRATORY ARREST - At 07:28 PM\n team at bedside.\n BRONCHOSCOPY - At 08:14 PM\n Dr , time out done prior to proced\n BRONCHOSCOPY - At 08:48 PM\n Dr .\n - Concern for hemophagocytic syndrome - Checking ferritin (>);\n heme-onc consulted, feel hemophagocytic syndrome is unlikely.\n - Plan to increase insulin in TPN, but TPN recs not available in time\n - In anticipation of bzd withdrawal with weaning of midazolam, started\n valium 10mg PO TID. Plan to wean fentanyl, versed as tolerated in hopes\n of trying pressure support.\n - Per ID, restarted vanc PR; will restart ciprofloxacin if\n decompensates\n - Amylase 47, lipase 47\n - 6pm I/O -2L\n - 6pm Doing well on pressure support, versed weaned off. After incident\n below, restarted on assist control.\n - 7:30pm Respiratory distress - Initially with bronchospasm, then\n apneic and briefly without pulse (?minutes). Improved with deep suction\n - large clot removed with return of pulse, BP and improved ventilation.\n Thoracics performed bedside bronchoscopy - determined that trach is too\n short; on further reevaluation by attending, appropriate size and not\n needing replacement; clots removed with repeat bronchoscopy. Heme/onc\n aware, recommended Amicar for bleeding at trach site - started.\n Allergies:\n Meropenem\n skin blisters a\n Last dose of Antibiotics:\n Vancomycin - 04:00 PM\n Aztreonam - 09:24 PM\n Linezolid - 11:00 PM\n Micafungin - 12:33 AM\n Metronidazole - 02:01 AM\n Infusions:\n Fentanyl (Concentrate) - 100 mcg/hour\n Norepinephrine - 0.03 mcg/Kg/min\n Midazolam (Versed) - 5 mg/hour\n Calcium Gluconate (CRRT) - 1.6 grams/hour\n KCl (CRRT) - 2 mEq./hour\n Other ICU medications:\n Atropine - 07:30 PM\n Midazolam (Versed) - 09:03 PM\n Other medications:\n Changes to medical and family history:\n None\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Intubated, sedated.\n Flowsheet Data as of 06:08 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37\nC (98.6\n Tcurrent: 35.4\nC (95.8\n HR: 80 (30 - 126) bpm\n BP: 118/68(87) {59/41(47) - 168/94(124)} mmHg\n RR: 26 (10 - 31) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 123.3 kg (admission): 113.5 kg\n Height: 67 Inch\n CVP: 16 (14 - 49)mmHg\n Total In:\n 11,516 mL\n 2,538 mL\n PO:\n TF:\n 481 mL\n 91 mL\n IVF:\n 9,455 mL\n 2,234 mL\n Blood products:\n Total out:\n 13,098 mL\n 3,404 mL\n Urine:\n 65 mL\n 37 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,582 mL\n -866 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n Vt (Spontaneous): 725 (725 - 725) mL\n PS : 10 cmH2O\n RR (Set): 26\n RR (Spontaneous): 0\n PEEP: 8 cmH2O\n FiO2: 50%\n RSBI Deferred: Hemodynamic Instability\n PIP: 20 cmH2O\n SpO2: 100%\n ABG: 7.33/50/143/25/0\n Ve: 11.9 L/min\n PaO2 / FiO2: 286\n Physical Examination\n GEN: Intubated, sedated\n HEENT: icteric sclera. MMM\n NECK: Trach site with minimal oozing\n LUNGS: Anterior auscultation with upper airway noise; good airway\n movement\n HEART: , ; S1, S2\n ABD: Distended. NT.\n EXTREM: 2+ edema, ulcers/lesions on legs with bandages C/D/I\n SKIN: Jaundice\n Labs / Radiology\n 93 K/uL\n 7.8 g/dL\n 208 mg/dL\n 0.6 mg/dL\n 25 mEq/L\n 4.7 mEq/L\n 36 mg/dL\n 95 mEq/L\n 130 mEq/L\n 23.5 %\n 28.2 K/uL\n [image002.jpg]\n ALT: 97\n AP: 198\n Tbili: 28.7\n Alb:\n AST: 234\n LDH: 706\n Dbili:\n TProt:\n : 51\n Lip: 41\n PT: 15.8\n PTT: 33.2\n INR: 1.4\n 08:29 AM\n 08:42 AM\n 02:06 PM\n 02:20 PM\n 07:32 PM\n 07:44 PM\n 08:51 PM\n 01:27 AM\n 01:36 AM\n 05:36 AM\n WBC\n 28.2\n Hct\n 23.5\n Plt\n 93\n Cr\n 0.9\n 0.9\n 0.9\n 0.6\n TCO2\n 28\n 28\n 23\n 25\n 28\n 28\n Glucose\n 30\n 106\n 208\n Other labs: PT / PTT / INR:15.8/33.2/1.4, CK / CKMB /\n Troponin-T:214/3/0.07, ALT / AST:97/234, Alk Phos / T Bili:198/28.7,\n Amylase / Lipase:51/41, Differential-Neuts:68.0 %, Band:5.0 %,\n Lymph:7.0 %, Mono:4.0 %, Eos:0.0 %, D-dimer:6389 ng/mL, Fibrinogen:502\n mg/dL, Lactic Acid:1.5 mmol/L, Albumin:2.0 g/dL, LDH:706 IU/L, Ca++:8.8\n mg/dL, Mg++:2.0 mg/dL, PO4:3.5 mg/dL\n 4:11 pm TISSUE Source: Skin biopsy r/o HSV 1 and HSV2.\n GRAM STAIN (Final ):\n NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.\n NO MICROORGANISMS SEEN.\n TISSUE (Preliminary):\n REPORTED BY PHONE TO 11:30AM.\n Due to mixed bacterial types (>=3) an abbreviated workup is\n performed; P.aeruginosa, S.aureus and beta strep. are reported if\n present. Susceptibility will be performed on P.aeruginosa and\n S.aureus if sparse growth or greater..\n STAPHYLOCOCCUS, COAGULASE NEGATIVE. RARE GROWTH.\n ENTEROCOCCUS SP..\n Isolated from broth media only, INDICATING VERY LOW NUMBERS OF\n ORGANISMS.\n STAPHYLOCOCCUS, COAGULASE NEGATIVE.\n 2ND STRAIN Isolated from broth media only, INDICATING VERY LOW\n NUMBERS OF ORGANISMS.\n ANAEROBIC CULTURE (Preliminary): NO ANAEROBES ISOLATED.\n FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.\n ACID FAST SMEAR (Final ):\n NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.\n ACID FAST CULTURE (Preliminary):\n VIRAL CULTURE (Preliminary): No Virus isolated so far.\n Assessment and Plan\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n IMPAIRED SKIN INTEGRITY\n HEPATITIS, ACUTE TOXIC (INCLUDING ALCOHOLIC, ACETAMINOPHEN, ETC.)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n 28M with alcoholic hepatitis and necrotizing pancreatitis complicated\n by ARDS, SIRS, ARF, UGIB, fevers and eosinophilia\n #. Respiratory Failure: ARDS secondary to necrotizing pancreatitis. S/p\n trach placement on . Sutures out on \n - Decrease sedation (both fentanyl and versed) with goal of trying\n pressure support again today\n - Continue valium standing (5-10mg q8 hours) to avoid benzo withdrawal\n - Cont to wean as tolerated\n # Bleeding around trach site: Was given amicar yesterday\n - f/u Heme/Onc recs\n - complete 24hr cycle of amicar\n #. ID: Afebrile x>3days - source unclear. Question of fever adrenal\n insufficiency; now on steroids. Concern for infection with increased\n bandemia today although leukocytosis improved. Blood/tissue/BAL cx\n NGTD, CT abd with persistent inflammation concerning for infection. CT\n sinuses w/ opacification of unclear time course.\n - Cte broad spectrum antibiotic coverage with aztreonam for extended GN\n coverage, linezolid for MRSA and VRE for bacteremia, flagyl IV, vanc PO\n empirically per ID recs given increasing leukocytosis and colon\n inflammation on CT, micafungin for antifungal coverage\n - Per ID, add ciprofloxacin if decompensates. Also restart vancomycin\n PR\n - Send c diff, 2^nd sample\n - F/u WBC count, temp curve, and culture data\n - F/u ID recs; question: how to down abx over next few days\n #. Adrenal Insufficiency: Unclear with stim if clear adrenal\n insufficiency but hypotension improving with steroids (lower pressor\n requirement) and improving eosinophilia\n - wean to 75mg IV Q8hr\n #. Hyperbilirubinemia: Likely related to underlying shock liver and\n ?obstructive etiology from necrotizing pancreatitis. Continue to trend.\n #. Eosinophilia: Resolved. Adrenal insufficiency v. drug reaction\n (?PPI; vanc & dapto less likely d/t time course). Fungal and parasitic\n infection also possible etiologies.\n - stim positive for adrenal insufficiency. Cte steroids.\n - Off PPI, vanc, dapto\n - Cte fungal coverage as above\n #. Anemia: Hct slowly trending downwards, likely related to slow ooze\n from trach site\n - Hct , guaiac stools and NGT aspirate\n #. Thrombocytopenia: Appreciate heme recs. Do not feel this is DIC.\n - Monitor platelets daily and transfuse for plt <10 or <50 if signs of\n bleed\n - monitor daily\n #. Acute renal Failure: Appreciate renal recs. Cr improved on CVVH. Off\n sucralfate due to concern for electrolyte abnormalities.\n - Cte volume depletion with CVVH as long as pressor requirement does\n not increase\n - Begin thinking about placing tunneled dialysis catheter\n #. Agitation: Cont methadone, valium\n #. Glucose intolerance: In setting of steroids; adjust ISS prn. As\n blood glucose continues to run high, will increase insulin included in\n TPN.\n ICU Care\n Nutrition:\n TPN w/ Lipids - 02:10 PM 35 mL/hour\n Tubefeeds\n Now that he\ns having bowel movements, increase to goal\n Glycemic Control:\n Lines:\n Arterial Line - 08:15 PM\n Multi Lumen - 10:00 PM\n Dialysis Catheter - 11:35 PM\n Prophylaxis:\n DVT: Heparin SQ\n Stress ulcer: H2 Blocker\n VAP: Trach care\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n ------ Protected Section ------\n MICU ATTENDING ADDENDUM\n I saw and examined the patient, and was physically present with the ICU\n 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: 28M alcoholic hepatitis, pancreatitis,\n refractory shock, ARDS - now tolerating aggressive fluid removal on low\n dose pressors. WBC and sedation down, tolerating CVVH with fluid\n removal. Trach bleeding c/b airway occlusion o/n, improved with bronch\n and amicar.\n Exam notable for Tm 98.6 BP 100/50 HR 90-110 CVP 20 RR 30 with sat 100\n on VAC 400x24/26 0.5 8 7.33/50/143. WD man, anasarca, chemosis. Partial\n eye opening to command. Coarse BS B. Distant s1s2. Obese, no BS. 3+\n edema. Labs notable for WBC 28K, HCT 23, Na 129, lactate 1.5. CXR with\n low volumes.\n Agree with plan to manage respiratory failure with slow wean of\n sedation and transition to PSV as mental status allows. Will continue\n IV valium and attempt to d/c drip sedation over next 24 hours. Will use\n amicar for trach ooze x24h; thoracic team assistance overnight\n appreciated. For ongoing fevers and leukocytosis with pressor\n requirement, will continue steroids ( to 75 q8h) and broad\n antibiotic coverage. Will d/w ID re stepwise reduction in abx coverage\n as cultures to date have been unrevealing. Will quantify ferritin\n (>)and d/w heme re HLH / BMBx, but suspect continuing supportive\n care is the best way forward; will continue IV steroids. For ARF,\n continue CVVH with goal -250cc/h; will need tunnelled line this week\n IR consult today. For pancreatitis, will increase post-pyloric TFs; he\n is now , be able to stop TPN soon. Will increase insulin in\n TPN for persistent hyperglycemia. Remainder of plan as outlined above.\n Plan d/w family at bedside.\n Patient is critically ill\n Total time: 50 min\n ------ Protected Section Addendum Entered By: , MD\n on: 02:16 PM ------\n" }, { "category": "Physician ", "chartdate": "2131-05-26 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 677085, "text": "TITLE:\n Chief Complaint:\n Mr. is a 28 year old gentleman with alcoholic hepatitis and\n necrotizing pancreatitis complicated by ARDS, SIRS, and UGIB.\n 24 Hour Events:\n \n changed hypertonic saline to continous\n neuro/nsurg wanted repeat ct head\n decreased peep/fio2\n hd line pplaced and cvvh started\n \n - Switched back to 23% saline. Afternoon Na 139, PM Na 142. Written for\n additional 2 doses of 23%.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:55 AM\n Metronidazole - 01:41 AM\n Meropenem - 02:47 AM\n Infusions:\n Norepinephrine - 0.03 mcg/Kg/min\n Calcium Gluconate (CRRT) - 1.4 grams/hour\n Phenylephrine - 5 mcg/Kg/min\n Fentanyl (Concentrate) - 350 mcg/hour\n Midazolam (Versed) - 30 mg/hour\n Other ICU medications:\n Pantoprazole (Protonix) - 08:03 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 07:03 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.6\nC (99.6\n Tcurrent: 37.1\nC (98.8\n HR: 99 (90 - 106) bpm\n BP: 104/50(67) {95/47(63) - 114/57(76)} mmHg\n RR: 32 (30 - 41) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 156 kg (admission): 113.5 kg\n Height: 67 Inch\n CVP: 12 (11 - 22)mmHg\n Total In:\n 9,927 mL\n 3,355 mL\n PO:\n TF:\n IVF:\n 8,691 mL\n 2,828 mL\n Blood products:\n Total out:\n 11,304 mL\n 4,118 mL\n Urine:\n 270 mL\n 105 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,377 mL\n -763 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 30\n RR (Spontaneous): 4\n PEEP: 16 cmH2O\n FiO2: 40%\n RSBI Deferred: PEEP > 10\n PIP: 37 cmH2O\n Plateau: 29 cmH2O\n Compliance: 95.2 cmH2O/mL\n SpO2: 95%\n ABG: 7.36/42/70/20/-1\n Ve: 12.4 L/min\n PaO2 / FiO2: 175\n Physical Examination\n General Appearance: Overweight / Obese\n Head, Ears, Nose, Throat: 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: (Expansion: Symmetric), (Breath Sounds: Crackles :\n )\n Abdominal: Soft, Obese\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 85 K/uL\n 10.1 g/dL\n 170 mg/dL\n 2.9 mg/dL\n 20 mEq/L\n 3.5 mEq/L\n 26 mg/dL\n 109 mEq/L\n 141 mEq/L\n 29.9 %\n 35.1 K/uL\n [image002.jpg]\n 09:39 PM\n 10:00 PM\n 02:26 AM\n 04:29 AM\n 04:48 AM\n 09:51 AM\n 04:18 PM\n 08:52 PM\n 02:08 AM\n 02:28 AM\n WBC\n 44.1\n 35.1\n Hct\n 30.7\n 29.9\n Plt\n 70\n 85\n Cr\n 4.0\n 3.9\n 2.9\n TCO2\n 21\n 20\n 24\n 21\n 21\n 25\n 25\n Glucose\n 173\n 175\n 147\n 182\n 182\n 170\n Other labs: PT / PTT / INR:19.5/53.6/1.8, ALT / AST:20/209, Alk Phos /\n T Bili:239/19.5, Amylase / Lipase:16/36, Differential-Neuts:71.0 %,\n Band:8.0 %, Lymph:6.0 %, Mono:4.0 %, Eos:2.0 %, D-dimer: ng/mL,\n Fibrinogen:402 mg/dL, Lactic Acid:2.1 mmol/L, Albumin:2.1 g/dL, LDH:742\n IU/L, Ca++:8.0 mg/dL, Mg++:1.9 mg/dL, PO4:2.3 mg/dL\n Assessment and Plan\n Mr. is a 28 year old gentleman with alcoholic hepatitis and\n necrotizing pancreatitis complicated by ARDS, SIRS, and UGIB.\n # Neuro: Patient with dilated pupils on high dose fentaynl gtt. CTH\n demonstrated loss of grey white differentiation with questionable\n effacement and possible seizure activity. Neuro and neurosurg consulted\n and patient received ativan, keppra load, and hypertonic saline of\n hyponatremia. Patient converted to 23% saline boluses with improvement\n in serum sodium and osmolility.\n - Per neuro, keppra IV maintenance dose\n - Continue 23% hypertonic saline boluses Q3H with regular serum sodium\n checks.\n - f/u EEG read\n - follow-up with neurology and neurosurg regarding frequency of saline\n boluses, need for repeat head CT given improving osmolality\n - Consider mannitol if serum sodium does not improve.\n - Wean sedation (starting with fentanyl) as possible.\n # Respiratory Failure: ARDS secondary to necrotizing pancreatitis\n compounded by hypoxia, tachypnea in setting of anion gap metabolic\n acidosis, increased abdominal pressure, and EtOH withdrawl. PEEP\n decreased to 16 from 20 and FiO2 to 40%.\n - Wean FiO2 and PEEP, goal PaO2>60-65%\n # Leukocytosis: WBC up to 44.9 on but now trending down.\n Concern for CVL infection, VAP, loculated effusion, sinusitis, or\n pancreatitis complication including abscess formation. CT chest with\n multifocal infiltrates that could represent VAP vs ARDS. CTAP did not\n demonstrate any new pancreatic fluid collections. On prior\n differential, had a neutrophilic predominance with 6% eosinophils but\n now with falling white count and normal eosinophil differential. Spoke\n to nurse and confirmed that patient has not been getting saline\n flushes/afrin, suggesting improvement in leukocytosis supports\n diagnosis of c. diff with improvement on flagyl.\n - Continue empiric vancomycin, meropenem, and flagyl. AM vanco level\n today\n - continue to follow CBC differential, if elevated would consider drug\n reaction as potential etiology to leukocytosis and likely switch\n Meropenem to zosyn.\n - Follow-up culture data\n - f/u ID reccs\n # Necrotizing pancreatitis/SIRS: Secondary to alcohol complicated by\n SIRS and ARDS. Patient continues to have pressor requirement, with neo\n +/- levo. Aggressive volume resuscitation with >58L. Patient\n without improvement with albumin trial, likely secondary to SIRS and\n increased vascular permeability.\n - Continue empiric antimicrobials.\n - Wean pressors as able, starting with levophed\n - Hypertonic saline as above in order to increase intravascular volume.\n - Monitor chemistries.\n - Follow-up with recs if any\n # Hyponatremia: In setting of decreased effective circulating volume\n in setting of SIRS and IABP. Patient receiving hypertonic saline\n boluses with improvement in serum sodium.\n - Hypertonic saline as above.\n - Trend chemistries.\n - Follow-up with neurosurgery recs if any.\n # Acute renal failure: Patient had HD line placed and CVVH was\n initiated yesterday.\n - CVVH per renal.\n - Trend chemistries\n #Thrombocytopenia: Platelets stable. No clear etiology at this time.\n DIC panel and HIT PF4 antibody negative.\n - Trend plt, transfuse for plt<10 or <50 if signs of hemorrhage.\n # IAP elevation: Secondary to third spacing and edema. Per surgery, not\n a good surgical candidate at this time.\n # Acute hepatitis: Likely alcoholic hepatitis with fatty infiltration,\n and no evidence of distal obstruction. RUQ u/s shows marked liver\n echogenicity but no ascites.\n - Trend LFTs\n # Hematemesis: EGD showed diuelafoy's lesion. HCT stable since 2 units\n PRBC on .\n - Trend hct, transfuse for hct<21\n # Alcoholism: Patient describes history of withdrawal symptoms, but\n not prior seizure. Last drink was night prior to presentation.\n Tachycardia, weakness, and elevated lactate could be consistent with\n thiamine deficiency.\n - Thiamine, vb12, folate\n - Valium with CIWA > 10\n FEN: TPN, replete as necessary.\n PPx: Heparin and H2B in TPN\n Access: RIJ (quad), LIJ (HD), right radial a-line\n Dispo: ICU level of care\n ICU Care\n Nutrition:\n TPN w/ Lipids - 06:00 PM 75 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 01:35 PM\n Multi Lumen - 02:02 PM\n Dialysis Catheter - 04:56 PM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Heparin in TPN)\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2131-06-12 00:00:00.000", "description": "Nursing Progress Note", "row_id": 680313, "text": "TITLE:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n Problem - Description In Comments\n Assessment:\n Action:\n Response:\n Plan:\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Physician ", "chartdate": "2131-06-13 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 680589, "text": "Chief Complaint:\n 24 Hour Events:\n \n - Amicar continued for 24 h (course up to 10d per Heme)\n - Tube feed goals increased to 50 cc/h\n - Midaz gtt d/c'd -> bolus with goal improved PS\n - ID: Cont current meds; consider cipro if decomp\n - Noted to have some bleeding from near back of mouth; likely from\n ulcer. Cont amicar and reassess in AM.\n - Had orofacial and bilat upper extrem twitching at 5am. Received\n ativan 2mg IV x 2 with persistence of mvts but gradually becoming more\n intermittent over 1/2 hour. Seen by Neuro who agreed w/ plan for CT\n head. Also recommended early keppra dose. Ativan prn for recurrent\n episode; if not responsive to 2 doses, restart versed gtt. Neuro to see\n this AM.\n Allergies:\n Meropenem\n skin blisters a\n Last dose of Antibiotics:\n Vancomycin - 04:00 PM\n Micafungin - 12:33 AM\n Aztreonam - 08:10 AM\n Linezolid - 10:15 PM\n Metronidazole - 02:12 AM\n Infusions:\n Norepinephrine - 0.03 mcg/Kg/min\n Fentanyl (Concentrate) - 100 mcg/hour\n Calcium Gluconate (CRRT) - 1.6 grams/hour\n KCl (CRRT) - 2 mEq./hour\n Other ICU medications:\n Famotidine (Pepcid) - 12:35 PM\n Heparin Sodium (Prophylaxis) - 12:35 PM\n Diazepam (Valium) - 10:23 PM\n Lorazepam (Ativan) - 04:45 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:57 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 HR: 85 (73 - 94) bpm\n BP: 136/76(98) {98/45(62) - 136/76(98)} mmHg\n RR: 19 (11 - 23) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 118.9 kg (admission): 113.5 kg\n Height: 67 Inch\n CVP: 6 (6 - 19)mmHg\n Total In:\n 10,200 mL\n 2,681 mL\n PO:\n TF:\n 481 mL\n IVF:\n 9,222 mL\n 2,191 mL\n Blood products:\n Total out:\n 15,987 mL\n 3,635 mL\n Urine:\n 162 mL\n NG:\n Stool:\n Drains:\n Balance:\n -5,787 mL\n -954 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 400 (400 - 400) mL\n Vt (Spontaneous): 709 (333 - 797) mL\n PS : 12 cmH2O\n RR (Set): 26\n RR (Spontaneous): 14\n PEEP: 8 cmH2O\n FiO2: 50%\n RSBI Deferred: Agitated\n PIP: 22 cmH2O\n SpO2: 100%\n ABG: 7.34/47/144/22/0\n Ve: 10.4 L/min\n PaO2 / FiO2: 288\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 118 K/uL\n 8.0 g/dL\n 136 mg/dL\n 1.0 mg/dL\n 22 mEq/L\n 3.9 mEq/L\n 35 mg/dL\n 96 mEq/L\n 132 mEq/L\n 23.9 %\n 21.8 K/uL\n [image002.jpg]\n 01:27 AM\n 01:36 AM\n 05:21 AM\n 05:36 AM\n 10:31 AM\n 04:07 PM\n 09:44 PM\n 09:51 PM\n 02:58 AM\n 03:09 AM\n WBC\n 28.2\n 21.8\n Hct\n 23.5\n 23.9\n Plt\n 93\n 118\n Cr\n 0.6\n 0.9\n 1.0\n 1.0\n TCO2\n 28\n 28\n 24\n 27\n 25\n 26\n Glucose\n 45\n 136\n Other labs: PT / PTT / INR:16.1/35.0/1.4, CK / CKMB /\n Troponin-T:214/3/0.07, ALT / AST:97/234, Alk Phos / T Bili:198/28.7,\n Amylase / Lipase:51/41, Differential-Neuts:68.0 %, Band:5.0 %,\n Lymph:7.0 %, Mono:4.0 %, Eos:0.0 %, D-dimer:6389 ng/mL, Fibrinogen:502\n mg/dL, Lactic Acid:1.2 mmol/L, Albumin:2.0 g/dL, LDH:706 IU/L, Ca++:8.8\n mg/dL, Mg++:1.9 mg/dL, PO4:3.4 mg/dL\n Assessment and Plan\n SEIZURE, WITHOUT STATUS EPILEPTICUS\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n IMPAIRED SKIN INTEGRITY\n HEPATITIS, ACUTE TOXIC (INCLUDING ALCOHOLIC, ACETAMINOPHEN, ETC.)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ICU Care\n Nutrition:\n TPN w/ Lipids - 05:00 PM 71 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 08:15 PM\n Multi Lumen - 10:00 PM\n Dialysis Catheter - 11:35 PM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Other, Heparin in TPN)\n Stress ulcer: H2 blocker\n VAP: HOB elevation, Mouth care\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:ICU\n" }, { "category": "Physician ", "chartdate": "2131-06-13 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 680590, "text": "Chief Complaint:\n 24 Hour Events:\n \n - Amicar continued for 24 h (course up to 10d per Heme)\n - Tube feed goals increased to 50 cc/h\n - Midaz gtt d/c'd -> bolus with goal improved PS\n - ID: Cont current meds; consider cipro if decomp\n - Noted to have some bleeding from near back of mouth; likely from\n ulcer. Cont amicar and reassess in AM.\n - Had orofacial and bilat upper extrem twitching at 5am. Received\n ativan 2mg IV x 2 with persistence of mvts but gradually becoming more\n intermittent over 1/2 hour. Seen by Neuro who agreed w/ plan for CT\n head. Also recommended early keppra dose. Ativan prn for recurrent\n episode; if not responsive to 2 doses, restart versed gtt. Neuro to see\n this AM.\n Allergies:\n Meropenem\n skin blisters a\n Last dose of Antibiotics:\n Vancomycin - 04:00 PM\n Micafungin - 12:33 AM\n Aztreonam - 08:10 AM\n Linezolid - 10:15 PM\n Metronidazole - 02:12 AM\n Infusions:\n Norepinephrine - 0.03 mcg/Kg/min\n Fentanyl (Concentrate) - 100 mcg/hour\n Calcium Gluconate (CRRT) - 1.6 grams/hour\n KCl (CRRT) - 2 mEq./hour\n Other ICU medications:\n Famotidine (Pepcid) - 12:35 PM\n Heparin Sodium (Prophylaxis) - 12:35 PM\n Diazepam (Valium) - 10:23 PM\n Lorazepam (Ativan) - 04:45 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:57 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 HR: 85 (73 - 94) bpm\n BP: 136/76(98) {98/45(62) - 136/76(98)} mmHg\n RR: 19 (11 - 23) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 118.9 kg (admission): 113.5 kg\n Height: 67 Inch\n CVP: 6 (6 - 19)mmHg\n Total In:\n 10,200 mL\n 2,681 mL\n PO:\n TF:\n 481 mL\n IVF:\n 9,222 mL\n 2,191 mL\n Blood products:\n Total out:\n 15,987 mL\n 3,635 mL\n Urine:\n 162 mL\n NG:\n Stool:\n Drains:\n Balance:\n -5,787 mL\n -954 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 400 (400 - 400) mL\n Vt (Spontaneous): 709 (333 - 797) mL\n PS : 12 cmH2O\n RR (Set): 26\n RR (Spontaneous): 14\n PEEP: 8 cmH2O\n FiO2: 50%\n RSBI Deferred: Agitated\n PIP: 22 cmH2O\n SpO2: 100%\n ABG: 7.34/47/144/22/0\n Ve: 10.4 L/min\n PaO2 / FiO2: 288\n Physical Examination\n GEN: Intubated, sedated\n HEENT: icteric sclera. MMM\n NECK: Trach site with minimal oozing\n LUNGS: Anterior auscultation with upper airway noise; good airway\n movement\n HEART: , ; S1, S2\n ABD: Distended. NT.\n EXTREM: 2+ edema, ulcers/lesions on legs with bandages C/D/I\n SKIN: Jaundice\n Labs / Radiology\n 118 K/uL\n 8.0 g/dL\n 136 mg/dL\n 1.0 mg/dL\n 22 mEq/L\n 3.9 mEq/L\n 35 mg/dL\n 96 mEq/L\n 132 mEq/L\n 23.9 %\n 21.8 K/uL\n [image002.jpg]\n 01:27 AM\n 01:36 AM\n 05:21 AM\n 05:36 AM\n 10:31 AM\n 04:07 PM\n 09:44 PM\n 09:51 PM\n 02:58 AM\n 03:09 AM\n WBC\n 28.2\n 21.8\n Hct\n 23.5\n 23.9\n Plt\n 93\n 118\n Cr\n 0.6\n 0.9\n 1.0\n 1.0\n TCO2\n 28\n 28\n 24\n 27\n 25\n 26\n Glucose\n 45\n 136\n Other labs: PT / PTT / INR:16.1/35.0/1.4, CK / CKMB /\n Troponin-T:214/3/0.07, ALT / AST:97/234, Alk Phos / T Bili:198/28.7,\n Amylase / Lipase:51/41, Differential-Neuts:68.0 %, Band:5.0 %,\n Lymph:7.0 %, Mono:4.0 %, Eos:0.0 %, D-dimer:6389 ng/mL, Fibrinogen:502\n mg/dL, Lactic Acid:1.2 mmol/L, Albumin:2.0 g/dL, LDH:706 IU/L, Ca++:8.8\n mg/dL, Mg++:1.9 mg/dL, PO4:3.4 mg/dL\n Assessment and Plan\n SEIZURE, WITHOUT STATUS EPILEPTICUS\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n IMPAIRED SKIN INTEGRITY\n HEPATITIS, ACUTE TOXIC (INCLUDING ALCOHOLIC, ACETAMINOPHEN, ETC.)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ICU Care\n Nutrition:\n TPN w/ Lipids - 05:00 PM 71 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 08:15 PM\n Multi Lumen - 10:00 PM\n Dialysis Catheter - 11:35 PM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Other, Heparin in TPN)\n Stress ulcer: H2 blocker\n VAP: HOB elevation, Mouth care\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:ICU\n" }, { "category": "Physician ", "chartdate": "2131-06-13 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 680594, "text": "Chief Complaint:\n 24 Hour Events:\n \n - Amicar continued for 24 h (course up to 10d per Heme)\n - Tube feed goals increased to 50 cc/h\n - Midaz gtt d/c'd -> bolus with goal improved PS\n - ID: Cont current meds; consider cipro if decomp\n - Noted to have some bleeding from near back of mouth; likely from\n ulcer. Cont amicar and reassess in AM.\n - Had orofacial and bilat upper extrem twitching at 5am. Received\n ativan 2mg IV x 2 with persistence of mvts but gradually becoming more\n intermittent over 1/2 hour. Seen by Neuro who agreed w/ plan for CT\n head. Also recommended early keppra dose. Ativan prn for recurrent\n episode; if not responsive to 2 doses, restart versed gtt. Neuro to see\n this AM.\n Allergies:\n Meropenem\n skin blisters a\n Last dose of Antibiotics:\n Vancomycin - 04:00 PM\n Micafungin - 12:33 AM\n Aztreonam - 08:10 AM\n Linezolid - 10:15 PM\n Metronidazole - 02:12 AM\n Infusions:\n Norepinephrine - 0.03 mcg/Kg/min\n Fentanyl (Concentrate) - 100 mcg/hour\n Calcium Gluconate (CRRT) - 1.6 grams/hour\n KCl (CRRT) - 2 mEq./hour\n Other ICU medications:\n Famotidine (Pepcid) - 12:35 PM\n Heparin Sodium (Prophylaxis) - 12:35 PM\n Diazepam (Valium) - 10:23 PM\n Lorazepam (Ativan) - 04:45 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:57 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 HR: 85 (73 - 94) bpm\n BP: 136/76(98) {98/45(62) - 136/76(98)} mmHg\n RR: 19 (11 - 23) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 118.9 kg (admission): 113.5 kg\n Height: 67 Inch\n CVP: 6 (6 - 19)mmHg\n Total In:\n 10,200 mL\n 2,681 mL\n PO:\n TF:\n 481 mL\n IVF:\n 9,222 mL\n 2,191 mL\n Blood products:\n Total out:\n 15,987 mL\n 3,635 mL\n Urine:\n 162 mL\n NG:\n Stool:\n Drains:\n Balance:\n -5,787 mL\n -954 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 400 (400 - 400) mL\n Vt (Spontaneous): 709 (333 - 797) mL\n PS : 12 cmH2O\n RR (Set): 26\n RR (Spontaneous): 14\n PEEP: 8 cmH2O\n FiO2: 50%\n RSBI Deferred: Agitated\n PIP: 22 cmH2O\n SpO2: 100%\n ABG: 7.34/47/144/22/0\n Ve: 10.4 L/min\n PaO2 / FiO2: 288\n Physical Examination\n GEN: Intubated, sedated\n HEENT: icteric sclera. MMM\n NECK: Trach site with minimal oozing\n LUNGS: Anterior auscultation with upper airway noise; good airway\n movement\n HEART: , ; S1, S2\n ABD: Distended. NT.\n EXTREM: 2+ edema, ulcers/lesions on legs with bandages C/D/I\n SKIN: Jaundice\n Labs / Radiology\n 118 K/uL\n 8.0 g/dL\n 136 mg/dL\n 1.0 mg/dL\n 22 mEq/L\n 3.9 mEq/L\n 35 mg/dL\n 96 mEq/L\n 132 mEq/L\n 23.9 %\n 21.8 K/uL\n [image002.jpg]\n 01:27 AM\n 01:36 AM\n 05:21 AM\n 05:36 AM\n 10:31 AM\n 04:07 PM\n 09:44 PM\n 09:51 PM\n 02:58 AM\n 03:09 AM\n WBC\n 28.2\n 21.8\n Hct\n 23.5\n 23.9\n Plt\n 93\n 118\n Cr\n 0.6\n 0.9\n 1.0\n 1.0\n TCO2\n 28\n 28\n 24\n 27\n 25\n 26\n Glucose\n 45\n 136\n Other labs: PT / PTT / INR:16.1/35.0/1.4, CK / CKMB /\n Troponin-T:214/3/0.07, ALT / AST:97/234, Alk Phos / T Bili:198/28.7,\n Amylase / Lipase:51/41, Differential-Neuts:68.0 %, Band:5.0 %,\n Lymph:7.0 %, Mono:4.0 %, Eos:0.0 %, D-dimer:6389 ng/mL, Fibrinogen:502\n mg/dL, Lactic Acid:1.2 mmol/L, Albumin:2.0 g/dL, LDH:706 IU/L, Ca++:8.8\n mg/dL, Mg++:1.9 mg/dL, PO4:3.4 mg/dL\n CT Head: ***Prelim read*** No hemorrhage or other acute intracranial\n process.\n Assessment and Plan\n SEIZURE, WITHOUT STATUS EPILEPTICUS\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n IMPAIRED SKIN INTEGRITY\n HEPATITIS, ACUTE TOXIC (INCLUDING ALCOHOLIC, ACETAMINOPHEN, ETC.)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n 28M with alcoholic hepatitis and necrotizing pancreatitis complicated\n by ARDS, SIRS, ARF, UGIB, fevers and eosinophilia\n #. Respiratory Failure: ARDS secondary to necrotizing pancreatitis. S/p\n trach placement on . Sutures out on \n - Decrease PEEP today as tolerated\n - Continue valium standing (5-10mg q8 hours) to avoid benzo withdrawal\n - Cont to wean as tolerated\n - continue methadone to decrease fentanyl requirement\n # Seizures: Had increased twitching of head and arms yesterday with\n deviation of eyes to R. Was given Ativan x 2, Keppra dose early, and\n Neuro saw him and agreed that these are likely seizures. CT head\n without intracranial process.\n - Ativan 2mg MR1 if repeat seizure\n - EEG today to define if new focus of seizures\n # Bleeding around trach site: Amicar was continued for another 24 hrs\n with better hemostasis around trach\n - f/u Heme/Onc recs\n - complete >24hr cycle of amicar\n #. ID: Afebrile x>3days - source unclear. Question of fever adrenal\n insufficiency; now on steroids. Concern for infection with increased\n bandemia today although leukocytosis improved. Blood/tissue/BAL cx\n NGTD, CT abd with persistent inflammation concerning for infection. CT\n sinuses w/ opacification of unclear time course.\n - Cte broad spectrum antibiotic coverage with aztreonam for extended GN\n coverage, linezolid for MRSA and VRE for bacteremia, flagyl IV, vanc PO\n empirically per ID recs given increasing leukocytosis and colon\n inflammation on CT.\n - Per ID, add ciprofloxacin if decompensates. Also restart vancomycin\n PR\n - C diff negative, Send c diff, 2^nd sample\n - F/u WBC count, temp curve, and culture data\n - F/u ID recs; question: how to down abx over next few days\n #. Adrenal Insufficiency: Unclear with stim if clear adrenal\n insufficiency but hypotension improving with steroids (lower pressor\n requirement) and improving eosinophilia\n - weaned on to 75mg IV Q8hr\n #. Hyperbilirubinemia: Likely related to underlying shock liver and\n ?obstructive etiology from necrotizing pancreatitis. Continue to trend.\n #. Eosinophilia: Resolved. Adrenal insufficiency v. drug reaction\n (?PPI; vanc & dapto less likely d/t time course). Fungal and parasitic\n infection also possible etiologies.\n - stim suggestive of adrenal insufficiency. Cte steroid taper.\n - Off PPI, vanc, dapto\n #. Anemia: Hct slowly trending downwards, likely related to slow ooze\n from trach site\n - Hct , guaiac stools and NGT aspirate\n #. Thrombocytopenia: Appreciate heme recs. Do not feel this is DIC.\n - Monitor platelets daily and transfuse for plt <10 or <50 if signs of\n bleed\n - monitor daily\n #. Acute renal Failure: Appreciate renal recs. Cr improved on CVVH. Off\n sucralfate due to concern for electrolyte abnormalities.\n - Cte volume depletion with CVVH as long as pressor requirement does\n not increase\n - Begin thinking about placing tunneled dialysis catheter\n #. Agitation: Cont methadone, valium\n #. Glucose intolerance: In setting of steroids; adjust ISS prn. As\n blood glucose continues to run high, will increase insulin included in\n TPN.\n ICU Care\n Nutrition:\n TPN w/ Lipids - 05:00 PM 71 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 08:15 PM\n Multi Lumen - 10:00 PM\n Dialysis Catheter - 11:35 PM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Other, Heparin in TPN)\n Stress ulcer: H2 blocker\n VAP: HOB elevation, Mouth care\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:ICU\n" }, { "category": "Nursing", "chartdate": "2131-05-26 00:00:00.000", "description": "Nursing Progress Note", "row_id": 677045, "text": "TITLE:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n FiO2 40% tv 400 rr 30 peep @ 16cm. bbs clear upper lobes diminish\n bibasilarly. Rotating bed for pulm toilet, at 20 degree rotation d/t\n crrt\n Action:\n Abg pao2 80\ns on above settings Holding for now on any further wean of\n peep given earlier adjustments in vent settings today per team.Vap\n bundle. Lavage and suctioned (** needs sputum sent d/t persistent elev\n wbc). Turned side to side , lt side down .Pcxr done this am. Breathing\n over vent to mid 40\ns with fentanyl decr to 300mcg\n Response:\n Unable to obtain sputum despite lavage w ns. O2 sats down from 98-95% w\n left side down.. increased fentanyl back to 350 mcg/hr( excess\n autopeep)\n Plan:\n Reattempt rotation. VAP bundle. Attempt obtain sputum for c&s.reattempt\n wean fentanyl\n Problem\n Cerebral Edema\n Assessment:\n No cough no gag, no corneals. Pupils 6-7mm minimally sluggish react\n Action:\n Serum osm and Serum Na+ checks q4h -6h overnight.Hypertonic NS 23.4 %\n reordered x 2 more doses overnight. Via central line\n Response:\n No change in neuro exam overnight.Serum Na+ 142 serum osm 306\n overnight (goal >320). Repeat serum osm and Na pending.\n Plan:\n ? repeat CT scan today. Check w team re: repeat Hypertonic NS orders.\n Impaired Skin Integrity\n Assessment:\n Anasarca with tbb > 60 liters since adm. Extensive blisters bilat\n lower extrems &abdomen/chest and generalized weeping from all body\n surface areas(except back & buttocks dry). ? drug reaction vs total\n body fluid volume excess.\n Action:\n Bathed and changed bed linens at least every 2hrs, double guard to\n back. Bari Max bed w rotation on and off dependent upon pt tolerance w\n crrt.\n Response:\n Skin integrity very poor ble and abd, back and buttocks no skin\n breakdown.blistered areas bilat lower extrems open to air.\n Plan:\n Continue w bari max bed, frequent absorbent pad changes to keep pt\n skin dry. ? order new bed\n bed scale still not functioning properly.\n ? skin care consult.\n Pancreatitis, acute\n Assessment:\n Liver enzymes and t bili remain elevated, acute pancreatitis c/b\n multiorgan failure. Crrt for fluid removal ,no dialysate.\n Action:\n Crrt w goal to remove as much fluid as bp tolerates per renal.\n Tolerating pfr 700cc/hr with net negative 200-300cc/hr .. Labs q6h,\n repleting Ca+ and K+ per renal titrated scale. Glucoses 170-180 range.\n Tpn w insulin 15units in bag, glucoses rx\nd w 2 units regular x 2\n overnight.\n Response:\n Net negative 1.3liter at mn w no appreciable change in pressor\n requirements. Cvp 14-11\n Plan:\n Continue crrt w goal to remove as much fld as tolerates without signif\n increase in pressor requirement.\n" }, { "category": "Nursing", "chartdate": "2131-05-26 00:00:00.000", "description": "Nursing Progress Note", "row_id": 677046, "text": "TITLE:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n FiO2 40% tv 400 rr 30 peep @ 16cm. bbs clear upper lobes diminish\n bibasilarly. Rotating bed for pulm toilet, at 20 degree rotation d/t\n crrt\n Action:\n Abg pao2 80\ns on above settings Holding for now on any further wean of\n peep given earlier adjustments in vent settings today per team.Vap\n bundle. Lavage and suctioned (** needs sputum sent d/t persistent elev\n wbc). Turned side to side , lt side down .Pcxr done this am. Breathing\n over vent to mid 40\ns with fentanyl decr to 300mcg\n Response:\n Unable to obtain sputum despite lavage w ns. O2 sats down from 98-95% w\n left side down.. increased fentanyl back to 350 mcg/hr( excess\n autopeep)\n Plan:\n Reattempt rotation. VAP bundle. Attempt obtain sputum for c&s.reattempt\n wean fentanyl\n Problem\n Cerebral Edema\n Assessment:\n No cough no gag, no corneals. Pupils 6-7mm minimally sluggish react\n Action:\n Serum osm and Serum Na+ checks q4h -6h overnight.Hypertonic NS 23.4 %\n reordered x 2 more doses overnight. Via central line\n Response:\n No change in neuro exam overnight.Serum Na+ 142 serum osm 306\n overnight (goal >320). Repeat serum osm and Na pending.\n Plan:\n ? repeat CT scan today. Check w team re: repeat Hypertonic NS orders.\n Impaired Skin Integrity\n Assessment:\n Anasarca with tbb + > 70 liters since adm. Extensive blisters bilat\n lower extrems &abdomen/chest and generalized weeping from all body\n surface areas(except back & buttocks dry). ? drug reaction vs total\n body fluid volume excess.\n Action:\n Bathed and changed bed linens at least every 2hrs, double guard to\n back. Bari Max bed w rotation on and off dependent upon pt tolerance w\n crrt.\n Response:\n Skin integrity very poor ble and abd, back and buttocks no skin\n breakdown.blistered areas bilat lower extrems open to air.\n Plan:\n Continue w bari max bed, frequent absorbent pad changes to keep pt\n skin dry. ? order new bed\n bed scale still not functioning properly.\n ? skin care consult.\n Pancreatitis, acute\n Assessment:\n Liver enzymes and t bili remain elevated, acute pancreatitis c/b\n multiorgan failure. Crrt for fluid removal ,no dialysate.\n Action:\n Crrt w goal to remove as much fluid as bp tolerates per renal.\n Tolerating pfr 700cc/hr with net negative 200-300cc/hr .. Labs q6h,\n repleting Ca+ and K+ per renal titrated scale. Glucoses 170-180 range.\n Tpn w insulin 15units in bag, glucoses rx\nd w 2 units regular x 2\n overnight.\n Response:\n Net negative 1.3liter at mn w no appreciable change in pressor\n requirements. Cvp 14-11\n Plan:\n Continue crrt w goal to remove as much fld as tolerates without signif\n increase in pressor requirement.\n" }, { "category": "Physician ", "chartdate": "2131-05-26 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 677048, "text": "TITLE:\n Chief Complaint:\n Mr. is a 28 year old gentleman with alcoholic hepatitis and\n necrotizing pancreatitis complicated by ARDS, SIRS, and UGIB.\n 24 Hour Events:\n \n changed hypertonic saline to continous\n neuro/nsurg wanted repeat ct head\n decreased peep/fio2\n hd line pplaced and cvvh started\n \n - Switched back to 23% saline. Afternoon Na 139, PM Na 142. Written for\n additional 2 doses of 23%.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:55 AM\n Metronidazole - 01:41 AM\n Meropenem - 02:47 AM\n Infusions:\n Norepinephrine - 0.03 mcg/Kg/min\n Calcium Gluconate (CRRT) - 1.4 grams/hour\n Phenylephrine - 5 mcg/Kg/min\n Fentanyl (Concentrate) - 350 mcg/hour\n Midazolam (Versed) - 30 mg/hour\n Other ICU medications:\n Pantoprazole (Protonix) - 08:03 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 07:03 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.6\nC (99.6\n Tcurrent: 37.1\nC (98.8\n HR: 99 (90 - 106) bpm\n BP: 104/50(67) {95/47(63) - 114/57(76)} mmHg\n RR: 32 (30 - 41) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 156 kg (admission): 113.5 kg\n Height: 67 Inch\n CVP: 12 (11 - 22)mmHg\n Total In:\n 9,927 mL\n 3,355 mL\n PO:\n TF:\n IVF:\n 8,691 mL\n 2,828 mL\n Blood products:\n Total out:\n 11,304 mL\n 4,118 mL\n Urine:\n 270 mL\n 105 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,377 mL\n -763 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 30\n RR (Spontaneous): 4\n PEEP: 16 cmH2O\n FiO2: 40%\n RSBI Deferred: PEEP > 10\n PIP: 37 cmH2O\n Plateau: 29 cmH2O\n Compliance: 95.2 cmH2O/mL\n SpO2: 95%\n ABG: 7.36/42/70/20/-1\n Ve: 12.4 L/min\n PaO2 / FiO2: 175\n Physical Examination\n General Appearance: Overweight / Obese\n Head, Ears, Nose, Throat: 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: (Expansion: Symmetric), (Breath Sounds: Crackles :\n )\n Abdominal: Soft, Obese\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 85 K/uL\n 10.1 g/dL\n 170 mg/dL\n 2.9 mg/dL\n 20 mEq/L\n 3.5 mEq/L\n 26 mg/dL\n 109 mEq/L\n 141 mEq/L\n 29.9 %\n 35.1 K/uL\n [image002.jpg]\n 09:39 PM\n 10:00 PM\n 02:26 AM\n 04:29 AM\n 04:48 AM\n 09:51 AM\n 04:18 PM\n 08:52 PM\n 02:08 AM\n 02:28 AM\n WBC\n 44.1\n 35.1\n Hct\n 30.7\n 29.9\n Plt\n 70\n 85\n Cr\n 4.0\n 3.9\n 2.9\n TCO2\n 21\n 20\n 24\n 21\n 21\n 25\n 25\n Glucose\n 173\n 175\n 147\n 182\n 182\n 170\n Other labs: PT / PTT / INR:19.5/53.6/1.8, ALT / AST:20/209, Alk Phos /\n T Bili:239/19.5, Amylase / Lipase:16/36, Differential-Neuts:71.0 %,\n Band:8.0 %, Lymph:6.0 %, Mono:4.0 %, Eos:2.0 %, D-dimer: ng/mL,\n Fibrinogen:402 mg/dL, Lactic Acid:2.1 mmol/L, Albumin:2.1 g/dL, LDH:742\n IU/L, Ca++:8.0 mg/dL, Mg++:1.9 mg/dL, PO4:2.3 mg/dL\n Assessment and Plan\n Mr. is a 28 year old gentleman with alcoholic hepatitis and\n necrotizing pancreatitis complicated by ARDS, SIRS, and UGIB.\n # Neuro: Patient with dilated pupils on high dose fentaynl gtt. CTH\n demonstrated loss of grey white differentiation with questionable\n effacement and possible seizure activity. Neuro and neurosurg consulted\n and patietn received ativan, keppra load, and hypertonic saline of\n hyponatremia. Patient converted to 3% IVF infusion.\n - Per neuro, keppra IV maintenance dose\n - Convert back to 23% hypertonic saline boluses Q3H with regular serum\n sodium checks.\n - EEG to be completed today\n - Per neurosurg, repeat CTH today if stable\n - Follow-up with neurosurg and neuro recs if any.\n - Consider mannitol if serum sodium does not improve.\n - Wean sedation (starting with fentanyl) as possible.\n # Respiratory Failure: ARDS secondary to necrotizing pancreatitis\n compounded by hypoxia, tachypnea in setting of anion gap metabolic\n acidosis, increased abdominal pressure, and EtOH withdrawl. PEEP\n decreased to 20 and FiO2 to 40%.\n - Wean FiO2 and PEEP, goal PaO2>60-65%\n # Leukocytosis: WBC up to 44.9 today. Concern for CVL infection, VAP,\n loculated effusion, sinusitis, or pancreatitis complication including\n abscess formation. CT chest with multifocal infiltrates that could\n represent VAP vs ARDS. CTAP did not demonstrate any new pancreatic\n fluid collections. On last differential, past had a predominantly left\n shift, although also with 6% eos suggesting possible drug reaction\n (?meropenem).\n - Continue empiric vancomycin, meropenem, and flagyl. AM vanco level\n today\n - Recheck differential, if elevated would consider drug reaction as\n potential etiology to leukocytosis and likely switch Meropenem.\n - Follow-up culture data\n - Afrin and nasal saline spray\n - ID consult\n # Necrotizing pancreatitis/SIRS: Secondary to alcohol complicated by\n SIRS and ARDS. Patient continues to have pressor requirement, with neo\n +/- levo. Aggressive volume resuscitation with >58L. Patient\n without improvement with albumin trial, likely secondary to SIRS and\n increased vascular permeability.\n - Continue empiric antimicrobials.\n - Wean pressors as able, starting with levophed\n - Hypertonic saline as above in order to increase intravascular volume.\n - Monitor chemistries.\n - Follow-up with recs if any\n # Hyponatremia: In setting of decreased effective circulating volume\n in setting of SIRS and IABP. Patient received hypertonic saline\n overnight per neurosurgery. Serum sodium stable this morning.\n - Hypertonic saline as above.\n - Trend chemistries.\n - Follow-up with neurosurgery recs if any.\n # Acute renal failure: Patient had HD line placed and CVVH was\n initiated yesterday.\n - CVVH per renal.\n - Trend chemistries\n #Thrombocytopenia: Platelets stable. No clear etiology at this time.\n DIC panel and HIT PF4 antibody negative.\n - Trend plt, transfuse for plt<10 or <50 if signs of hemorrhage.\n # IAP elevation: Secondary to third spacing and edema. Per surgery, not\n a good surgical candidate at this time.\n # Acute hepatitis: Likely alcoholic hepatitis with fatty infiltration,\n and no evidence of distal obstruction. RUQ u/s shows marked liver\n echogenicity but no ascites.\n - Trend LFTs\n # Hematemesis: EGD showed diuelafoy's lesion. HCT stable since 2 units\n PRBC on .\n - Trend hct, transfuse for hct<21\n # Alcoholism: Patient describes history of withdrawal symptoms, but\n not prior seizure. Last drink was night prior to presentation.\n Tachycardia, weakness, and elevated lactate could be consistent with\n thiamine deficiency.\n - Thiamine, vb12, folate\n - Valium with CIWA > 10\n FEN: TPN, replete as necessary.\n PPx: Heparin and H2B in TPN\n Access: RIJ (quad), LIJ (HD), right radial a-line\n Dispo: ICU level of care\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: 28M EtOH abuse, weakness, fatigue, UGIB c/b\n hematemesis / melena. Has developed massive fluid requirement,\n hypotension, ARDS in the setting of severe pancreatitis, alcoholic\n hepatitis and borderline renal function. Creatinine up o/n, as is WBC.\n Pan cx, started on vanco. Head CT with edema, on 23% NS for induced\n osmorx. Now febrile on / vanco / flagyl. TPN started. Ongoing CVVH\n / EEG.\n Exam notable for Tm 99.6 BP 90/50 HR 98 RR 30 with sat 98 on VAC\n 400x32/30 0.4 20 7.28/48/89 CVP 25 IAP 25. +TBB 57L. Sedated, min\n responsive, pupils 6 to 4B. Hyperdynamic. Bronchial BS B. RRR s1s2.\n Distended, minimal bowel sounds. Massive edema. Labs notable for WBC\n 44K, HCT 29, K+ 4.2, Cr 3.9, lactate 1.6, INR 1.6. CXR with worsening\n ARDS R>L.\n Agree with plan to continue hypertonic (23%) saline q6h with frequent\n monitoring of osm and sodium for early edema - appreciate nsurg and\n neuro input; will attempt CT if CVVH goes down. Goal osm is 320-330,\n will add mannitol if he fails to have osm >320 by this PM. Will also\n continue fluid removal and keppra, early read of EEG without seizures.\n Will manage ARDS with low volume ventilation (400x30); will continue to\n wean PEEP as long as FiO2 <0.5 and PaO2>60. Given falling vent\n requirement, will work hard to get sedation down over the next day\n his volume of distribution is huge and he will autotaper on both benzos\n and narcotics. For , hold on further fluids and run -200cc/h\n as long as pressor requirement is stable. have evolving sepsis\n based upon WBC and fever - continue triple abx and max supportive care\n while following cultures and consulting ID. Will treat sinusitis and\n follow eos - will transition to zosyn for possible drug reaction\n if they remain elevated. ARF is progressive and UOP down, continue\n CVVH; will dose vanco to level. Pancreatitis likely due to EtOH, NPO,\n following. Can't use gut for now; continue TPN with heparin, PPI,\n insulin as needed. Alcoholic hepatitis is stable, though bili is up\n somewhat. UGIB from Dieulafois lesion at GEJ appears stable, will\n monitor serial HCT and continue PPI IV. Above d/w family in detail at\n family mtg. Remainder of plan as outlined above.\n ICU Care\n Nutrition:\n TPN w/ Lipids - 06:00 PM 75 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 01:35 PM\n Multi Lumen - 02:02 PM\n Dialysis Catheter - 04:56 PM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Heparin in TPN)\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2131-06-11 00:00:00.000", "description": "Nursing Progress Note", "row_id": 680239, "text": "Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n CRRT continues with BUN: 36 Creatinine: .9\n Off CRRT for ~ 45 minutes Creatinine increased to 2.7\n Remains several kilograms positive\n Slight respiratory acidosis, metabolically stable\n Action:\n CRRT to remove as much fluid as possible without increasing\n vasopressors\n Q 6 hour lab monitoring\n Response:\n MN\n 1700 fluid balance negative 2600 cc\n No increase in vasopressor requirements\n Electrolytes acceptable\n Plan:\n Continue with CRRT to remove as much fluid as possible\n without having to increase vasopressors\n Continue q 6 hour monitoring of electrolytes, renal\n function, acid base balance\n Problem\n bleeding from Tracheostomy site\n Assessment:\n Constant oozing / bleeding from tracheostomy site continues\n INR 1.4\n HCT stable @ 24.9\n Platelets 82 from 69\n Action:\n Surgicell dressings were not removed in hopes of not\n dislodging any formed clot\n Area reinforced with more surgicell\n DSD\ns changed ~ q 5 hours to contain drainage\n MICU team to consult with Hematology\n Thoracic team has evaluated x2 this shift, no surgical\n intervention at this time\n HOB > 30 degrees\n Response:\n Continues to ooze / bleed, uncertain if slowing down or not\n No HCT drop from to \n Plan:\n Continue to monitor HCT daily\n Continue to reinforce dressing\n Continue to elevate HOB as tolerated with bed rotation and\n CRRT.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n In AM pt on AC, 40%, 8 peep, 24 x 400\n Appeared comfortably breathing, not using accessory muscles,\n not flaring nostrils as he has done in the past.\n Suctioned for thick bloody sputum\n Slight respiratory acidosis with PH 7.33, PaCo2 51, PaO2\n 125, BE 0, 28.\n Not breathing over ventilator.\n Action:\n Midazolam drip weaned to 5mg/hr, then stopped @ 1800.\n Valium ordered ATC\n Vent setting changed to CPAP + PS, 40%, 8 peep, 10 PS\n VAP protocol\n Rotating bed\n Response:\n RR ~ , MV ~ 10, appears comfortable\n O2 Sats ~ 100%\n Plan:\n Continue to monitor respiratory status\nvs.\n sedation\n Recheck ABG and electrolytes @ \n VAP protocol\n Rotation on bed , pt in constant rotation\n Impaired Skin Integrity\n Assessment:\n Popped blisters and open areas on legs improving\n Much less weeping / drainage\n Heels remain intact with purple area unchanged\n Action:\n Cleansed with wound cleanser\n Aloe vesta applied to intact skin\n Minimal adaptic used on a few areas\n Covered with Softsorb\n Heels elevated off bed at all times with waffle boots\n Response:\n Legs improving\n Heels unchanged, not worsening\n No evidence of any new skin breakdown\n Plan:\n Continue rotating bed\n Continue excellent skin care,\n Continue q 12 hour dressing changes\n Continue keeping heels elevated off bed\n Sepsis, Severe (with organ dysfunction)\n Assessment:\n Afebrile\n WBC 28 from 29\n Levophed @ .03 mcg/kg/min and not increased in setting of\n fluid removal with CRRT\n Respiratory status improving\n Action:\n ABX ATC\n Stool sent for culture\n Response:\n Resolving sepsis\n Plan:\n Continue current treatment\n Follow up on culture results\n Continue to discuss with ID.\n Patient and family support.\n" }, { "category": "Respiratory ", "chartdate": "2131-06-12 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 680310, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 26\n Ideal body weight: 67.1 None\n Ideal tidal volume: 268.4 / 402.6 / 536.8 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Tube Type\n Tracheostomy tube:\n Type: Cuffed, Perc Trach\n Manufacturer: Portex\n Size: 8.0mm\n PMV: No\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Cuff volume: mL / \n Airway problems: bronch done, copious bloody mucous\n plug & clots found in oropharynx & laryngopharynx, multiple\n washout\\; fibrous clot @ stoma, minimal distal secretions. No fresh\n bleeding in airway.\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: Bloody / Thin\n Sputum source/amount: Suctioned / Scant\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing,\n Accessory muscle use; Comments: Switch from PSV to vent support; mucous\n plugging caused brady & hypotensive.\n Assessment of breathing comfort: No response (sleeping / sedated)\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously, Frequent failed\n trigger efforts\n Dysynchrony assessment:\n Comments: asynchronous when sedation not set appropriately.\n Plan\n Next 24-48 hours: Adjust Min. ventilation to control pH; Comments: No\n RSBI as VS has been unstable.\n Reason for continuing current ventilatory support: Sedated / Paralyzed,\n Cannot manage secretions, Underlying illness not resolved\n" }, { "category": "Physician ", "chartdate": "2131-06-13 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 680608, "text": "Chief Complaint:\n 24 Hour Events:\n \n - Amicar continued for 24 h (course up to 10d per Heme)\n - Tube feed goals increased to 50 cc/h\n - Midaz gtt d/c'd -> bolus with goal improved PS\n - ID: Cont current meds; consider cipro if decomp\n - Noted to have some bleeding from near back of mouth; likely from\n ulcer. Cont amicar and reassess in AM.\n - Had orofacial and bilat upper extrem twitching at 5am. Received\n ativan 2mg IV x 2 with persistence of mvts but gradually becoming more\n intermittent over 1/2 hour. Seen by Neuro who agreed w/ plan for CT\n head. Also recommended early keppra dose. Ativan prn for recurrent\n episode; if not responsive to 2 doses, restart versed gtt. Neuro to see\n this AM.\n Allergies:\n Meropenem\n skin blisters a\n Last dose of Antibiotics:\n Vancomycin - 04:00 PM\n Micafungin - 12:33 AM\n Aztreonam - 08:10 AM\n Linezolid - 10:15 PM\n Metronidazole - 02:12 AM\n Infusions:\n Norepinephrine - 0.03 mcg/Kg/min\n Fentanyl (Concentrate) - 100 mcg/hour\n Calcium Gluconate (CRRT) - 1.6 grams/hour\n KCl (CRRT) - 2 mEq./hour\n Other ICU medications:\n Famotidine (Pepcid) - 12:35 PM\n Heparin Sodium (Prophylaxis) - 12:35 PM\n Diazepam (Valium) - 10:23 PM\n Lorazepam (Ativan) - 04:45 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:57 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 HR: 85 (73 - 94) bpm\n BP: 136/76(98) {98/45(62) - 136/76(98)} mmHg\n RR: 19 (11 - 23) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 118.9 kg (admission): 113.5 kg\n Height: 67 Inch\n CVP: 6 (6 - 19)mmHg\n Total In:\n 10,200 mL\n 2,681 mL\n PO:\n TF:\n 481 mL\n IVF:\n 9,222 mL\n 2,191 mL\n Blood products:\n Total out:\n 15,987 mL\n 3,635 mL\n Urine:\n 162 mL\n NG:\n Stool:\n Drains:\n Balance:\n -5,787 mL\n -954 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 400 (400 - 400) mL\n Vt (Spontaneous): 709 (333 - 797) mL\n PS : 12 cmH2O\n RR (Set): 26\n RR (Spontaneous): 14\n PEEP: 8 cmH2O\n FiO2: 50%\n RSBI Deferred: Agitated\n PIP: 22 cmH2O\n SpO2: 100%\n ABG: 7.34/47/144/22/0\n Ve: 10.4 L/min\n PaO2 / FiO2: 288\n Physical Examination\n GEN: Intubated, sedated\n HEENT: icteric sclera. MMM\n NECK: Trach site with minimal oozing\n LUNGS: Anterior auscultation with upper airway noise; good airway\n movement\n HEART: , ; S1, S2\n ABD: Distended. NT.\n EXTREM: 2+ edema, ulcers/lesions on legs with bandages C/D/I\n SKIN: Jaundice\n NEURO: Mouth twitching. Arms jerking bilaterally.\n Labs / Radiology\n 118 K/uL\n 8.0 g/dL\n 136 mg/dL\n 1.0 mg/dL\n 22 mEq/L\n 3.9 mEq/L\n 35 mg/dL\n 96 mEq/L\n 132 mEq/L\n 23.9 %\n 21.8 K/uL\n [image002.jpg]\n 01:27 AM\n 01:36 AM\n 05:21 AM\n 05:36 AM\n 10:31 AM\n 04:07 PM\n 09:44 PM\n 09:51 PM\n 02:58 AM\n 03:09 AM\n WBC\n 28.2\n 21.8\n Hct\n 23.5\n 23.9\n Plt\n 93\n 118\n Cr\n 0.6\n 0.9\n 1.0\n 1.0\n TCO2\n 28\n 28\n 24\n 27\n 25\n 26\n Glucose\n 45\n 136\n Other labs: PT / PTT / INR:16.1/35.0/1.4, CK / CKMB /\n Troponin-T:214/3/0.07, ALT / AST:97/234, Alk Phos / T Bili:198/28.7,\n Amylase / Lipase:51/41, Differential-Neuts:68.0 %, Band:5.0 %,\n Lymph:7.0 %, Mono:4.0 %, Eos:0.0 %, D-dimer:6389 ng/mL, Fibrinogen:502\n mg/dL, Lactic Acid:1.2 mmol/L, Albumin:2.0 g/dL, LDH:706 IU/L, Ca++:8.8\n mg/dL, Mg++:1.9 mg/dL, PO4:3.4 mg/dL\n CT Head: ***Prelim read*** No hemorrhage or other acute intracranial\n process.\n Assessment and Plan\n 28M with alcoholic hepatitis and necrotizing pancreatitis complicated\n by ARDS, SIRS, ARF, UGIB, fevers and eosinophilia\n #. Respiratory Failure: ARDS secondary to necrotizing pancreatitis. S/p\n trach placement on . Sutures out on \n - Decrease PEEP today as tolerated\n - Cont to wean as tolerated\n - continue methadone to decrease fentanyl requirement\n # Seizures: Had increased twitching of head and arms yesterday with\n deviation of eyes to R. Was given Ativan x 2, Keppra dose early, and\n Neuro saw him and agreed that these are likely seizures. CT head\n without intracranial process.\n - Restart midazolam gtt as may be benzo withdrawal\n - EEG today to define if new focus of seizures\n - Consider d/c flagyl or other drugs that may lower seizure threshold\n - Consider load phosphenytoin\n # Bleeding around trach site: Amicar was continued for another 24 hrs\n with better hemostasis around trach\n - f/u Heme/Onc recs\n - completed amicar course\n #. ID: Afebrile.. Question of fever adrenal insufficiency; now on\n steroids. leukocytosis improved. Blood/tissue/BAL cx NGTD,\n - Cte broad spectrum antibiotic coverage with aztreonam for extended GN\n coverage, linezolid for MRSA and VRE for bacteremia, flagyl IV, vanc PO\n empirically per ID recs given increasing leukocytosis and colon\n inflammation on CT.\n - Per ID, add ciprofloxacin if decompensates. Also restart vancomycin\n PR\n - C diff negative, Send c diff, 2^nd sample. If negative d/c vanc po\n and flagyl\n - F/u WBC count, temp curve, and culture data\n - F/u ID recs; question: how to down abx over next few days\n #. Adrenal Insufficiency: Unclear with stim if clear adrenal\n insufficiency but hypotension improving with steroids (lower pressor\n requirement) and improving eosinophilia\n - weaned on to 75mg IV Q8hr continue this dose X 1 more day then\n down to 50mg \n #. Hyperbilirubinemia: Likely related to underlying shock liver, TPN,\n and ?obstructive etiology from necrotizing pancreatitis. Continue to\n trend.\n #. Anemia: stable\n - Hct QD, guaiac stools and NGT aspirate\n #. Thrombocytopenia: almost resolved\n - Monitor platelets daily and transfuse for plt <10 or <50 if signs of\n bleed\n - monitor daily\n #. Acute renal Failure: Appreciate renal recs. Cr improved on CVVH. Off\n sucralfate due to concern for electrolyte abnormalities.\n - Cte volume depletion with CVVH as long as pressor requirement does\n not increase\n - Begin thinking about placing tunneled dialysis catheter\n ICU Care\n Nutrition:\n TPN w/ Lipids - 05:00 PM 71 mL/hour\n TFs on hold for IR today\n Glycemic Control:\n Lines:\n Arterial Line - 08:15 PM\n Multi Lumen - 10:00 PM\n Dialysis Catheter - 11:35 PM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Other, Heparin in TPN)\n Stress ulcer: H2 blocker\n VAP: HOB elevation, Mouth care\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:ICU\n" }, { "category": "Nutrition", "chartdate": "2131-06-13 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 680620, "text": "Subjective: patient intubated and sedated.\n Objective\n Current Wt: 118.9kg\n Pertinent medications: Fentanyl, Levophed, RISS, ABx, others noted\n Labs:\n Value\n Date\n Glucose\n 114 mg/dL\n 09:56 AM\n Glucose Finger Stick\n 165\n 10:00 AM\n BUN\n 35 mg/dL\n 02:58 AM\n Creatinine\n 1.0 mg/dL\n 02:58 AM\n Sodium\n 132 mEq/L\n 02:58 AM\n Potassium\n 3.2 mEq/L\n 09:56 AM\n Chloride\n 96 mEq/L\n 02:58 AM\n TCO2\n 22 mEq/L\n 02:58 AM\n PO2 (arterial)\n 144 mm Hg\n 09:56 AM\n PCO2 (arterial)\n 36 mm Hg\n 09:56 AM\n pH (arterial)\n 7.36 units\n 09:56 AM\n pH (venous)\n 7.25 units\n 10:31 AM\n pH (urine)\n 7.0 units\n 10:07 PM\n CO2 (Calc) arterial\n 21 mEq/L\n 09:56 AM\n Albumin\n 2.0 g/dL\n 04:16 PM\n Calcium non-ionized\n 8.8 mg/dL\n 02:58 AM\n Phosphorus\n 3.4 mg/dL\n 02:58 AM\n Ionized Calcium\n 1.10 mmol/L\n 03:09 AM\n Magnesium\n 1.9 mg/dL\n 02:58 AM\n ALT\n 97 IU/L\n 01:27 AM\n Alkaline Phosphate\n 198 IU/L\n 01:27 AM\n AST\n 234 IU/L\n 01:27 AM\n Amylase\n 51 IU/L\n 01:27 AM\n Total Bilirubin\n 28.7 mg/dL\n 01:27 AM\n Triglyceride\n 154 mg/dL\n 02:10 AM\n WBC\n 21.8 K/uL\n 02:58 AM\n Hgb\n 8.0 g/dL\n 02:58 AM\n Hematocrit\n 23.9 %\n 02:58 AM\n Current diet order / nutrition support: Tube Feed: not running\n TPN: 70kg 3-in-1: 1750mL (298dextrose/ 105amino acid/ 35fat) =\n 1783kcals\n GI: hypoactive bowel sounds, abd softly distended\n Assessment of Nutritional Status\n Patient continues to receive TPN at goal, which meets 100% of estimated\n calorie and protein needs. Tube feeds were also started after a\n post pyloric feeding tube was placed. Fibersource @ 20cc/hr was running\n and patient was tolerating. Tube feeds are now off for OR today (for\n tunneled dialysis line placement). Now that tube feeds are to be\n advanced past a trophic rate, recommend using a concentrated formula to\n help minimize volume needed to meet 100% of estimated needs. Will need\n to dilute Nutren 2.0 to\n strength in order to fit the needed amount\n protein modular.\n Medical Nutrition Therapy Plan - Recommend the Following\n 1) Recommend eventual tube feed goal of\n strength Nutren 2.0 @\n 50cc/hr + 40g Beneprotein (1943kcals, 106g protein). Start at 10cc/hr\n and advance rate very slowly to monitor tolerance.\n 2) Monitor tolerance with abd exam; no residual checks with\n post-pyloric tube.\n 3) Once tube feed is advancing toward goal, will provide\n recommendations for the start of TPN wean.\n 4) Following, please page with any questions. #\n" }, { "category": "Respiratory ", "chartdate": "2131-05-25 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 676960, "text": "Demographics\n Day of intubation: \n Day of mechanical ventilation: 0\n Ideal body weight: 67.1 None\n Ideal tidal volume: 268.4 / 402.6 / 536.8 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type:\n Size:\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Diminished\n LUL Lung Sounds: Diminished\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Clear / Thick\n Sputum source/amount: Suctioned / Scant\n Comments:\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours:\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: 28 yr old male with necrotizing pancratitis. On full\n mechanical ventilation with metabolic acidosis. MDs want Paco2 to be in\n the range of 60-70 mmHg. On CVVHD , esophageal catheter in place but\n tranpulmonary pressure not measured. Patient suctioned for scant to\n none secretion but has some nasal discharge from time to time. ETT\n rotated and advanced to 24 cm @ lips.. CXR LLL atelectasis ,\n moderate pleural effusion , BS diminished , Skin integrity poor\n oozing.\n" }, { "category": "Nursing", "chartdate": "2131-05-26 00:00:00.000", "description": "Nursing Progress Note", "row_id": 677055, "text": "TITLE:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n FiO2 40% tv 400 rr 30 peep @ 16cm. bbs clear upper lobes diminish\n bibasilarly. Rotating bed for pulm toilet, at 20 degree rotation d/t\n crrt\n Action:\n Abg pao2 80\ns on above settings Holding for now on any further wean of\n peep given earlier adjustments in vent settings today per team.Vap\n bundle. Lavage and suctioned (** needs sputum sent d/t persistent elev\n wbc). Turned side to side , lt side down .Pcxr done this am. Breathing\n over vent to mid 40\ns with fentanyl decr to 300mcg\n Response:\n Unable to obtain sputum despite lavage w ns. O2 sats down from 98-95% w\n left side down.. increased fentanyl back to 350 mcg/hr( excess\n autopeep)\n Plan:\n Reattempt rotation. VAP bundle. Attempt obtain sputum for c&s.reattempt\n wean fentanyl\n Problem\n Cerebral Edema\n Assessment:\n No cough no gag, no corneals. Pupils 6-7mm minimally sluggish react\n Action:\n Serum osm and Serum Na+ checks q4h -6h overnight.Hypertonic NS 23.4 %\n reordered x 2 more doses overnight. Via central line\n Response:\n No change in neuro exam overnight.Serum Na+ 142 serum osm 306\n overnight (goal >320). Repeat serum osm and Na pending.\n Plan:\n ? repeat CT scan today. Check w team re: repeat Hypertonic NS orders.\n Impaired Skin Integrity\n Assessment:\n Anasarca with tbb + > 70 liters since adm. Extensive blisters bilat\n lower extrems &abdomen/chest and generalized weeping from all body\n surface areas(except back & buttocks dry). ? drug reaction vs total\n body fluid volume excess.\n Action:\n Bathed and changed bed linens at least every 2hrs, double guard to\n back. Bari Max bed w rotation on and off dependent upon pt tolerance w\n crrt.\n Response:\n Skin integrity very poor ble and abd, back and buttocks no skin\n breakdown.blistered areas bilat lower extrems open to air.\n Plan:\n Continue w bari max bed, frequent absorbent pad changes to keep pt\n skin dry. ? order new bed\n bed scale still not functioning properly.\n ? skin care consult.\n Pancreatitis, acute\n Assessment:\n Liver enzymes and t bili remain elevated, acute pancreatitis c/b\n multiorgan failure. Crrt for fluid removal ,no dialysate.\n Action:\n Crrt w goal to remove as much fluid as bp tolerates per renal.\n Tolerating pfr 700cc/hr with net negative 200-300cc/hr .. Labs q6h,\n repleting Ca+ and K+ per renal titrated scale. Glucoses 170-180 range.\n Tpn w insulin 15units in bag, glucoses rx\nd w 2 units regular x 2\n overnight.\n Response:\n Net negative 1.3liter at mn w no appreciable change in pressor\n requirements. Cvp 14-11\n Plan:\n Continue crrt w goal to remove as much fld as tolerates without signif\n increase in pressor requirement.\n" }, { "category": "Physician ", "chartdate": "2131-05-27 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 677201, "text": "Chief Complaint:\n 24 Hour Events:\n \n - Switched back to 23% saline. Afternoon Na 139, PM Na 142. Written for\n additional 2 doses of 23%.\n \n - continued 23% saline q6h\n - wbc trending down; d/c'd afrin b/c hadn't gotten it at all\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:33 AM\n Meropenem - 02:04 AM\n Metronidazole - 02:30 AM\n Infusions:\n Calcium Gluconate (CRRT) - 2 grams/hour\n Norepinephrine - 0.03 mcg/Kg/min\n Phenylephrine - 1.8 mcg/Kg/min\n Fentanyl (Concentrate) - 250 mcg/hour\n KCl (CRRT) - 4 mEq./hour\n Midazolam (Versed) - 25 mg/hour\n Other ICU medications:\n Pantoprazole (Protonix) - 08:10 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:58 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: 35.8\nC (96.5\n HR: 90 (90 - 100) bpm\n BP: 108/57(74) {92/50(64) - 113/71(85)} mmHg\n RR: 20 (3 - 33) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 140 kg (admission): 113.5 kg\n Height: 67 Inch\n CVP: 20 (14 - 21)mmHg\n Total In:\n 12,114 mL\n 3,376 mL\n PO:\n TF:\n IVF:\n 10,318 mL\n 2,861 mL\n Blood products:\n Total out:\n 18,126 mL\n 5,213 mL\n Urine:\n 238 mL\n 58 mL\n NG:\n 400 mL\n 150 mL\n Stool:\n Drains:\n Balance:\n -6,012 mL\n -1,837 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 30\n RR (Spontaneous): 0\n PEEP: 16 cmH2O\n FiO2: 40%\n RSBI Deferred: PEEP > 10\n PIP: 34 cmH2O\n Plateau: 28 cmH2O\n Compliance: 38.8 cmH2O/mL\n SpO2: 97%\n ABG: 7.37/47/81./23/0\n Ve: 14.3 L/min\n PaO2 / FiO2: 205\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 67 K/uL\n 10.0 g/dL\n 175 mg/dL\n 2.4 mg/dL\n 23 mEq/L\n 3.7 mEq/L\n 22 mg/dL\n 107 mEq/L\n 143 mEq/L\n 29.2 %\n 45.9 K/uL\n [image002.jpg]\n 02:08 AM\n 02:28 AM\n 10:00 AM\n 10:17 AM\n 04:06 PM\n 04:23 PM\n 09:57 PM\n 10:11 PM\n 04:39 AM\n 04:49 AM\n WBC\n 35.1\n 45.9\n Hct\n 29.9\n 29.2\n Plt\n 85\n 67\n Cr\n 2.9\n 2.9\n 2.8\n 2.6\n 2.4\n TCO2\n 25\n 26\n 25\n 28\n 28\n Glucose\n 182\n 170\n 187\n 174\n 192\n 174\n 188\n 176\n 187\n 175\n Other labs: PT / PTT / INR:19.5/53.6/1.8, ALT / AST:20/210, Alk Phos /\n T Bili:236/20.6, Amylase / Lipase:16/34, Differential-Neuts:71.0 %,\n Band:8.0 %, Lymph:6.0 %, Mono:4.0 %, Eos:2.0 %, D-dimer: ng/mL,\n Fibrinogen:402 mg/dL, Lactic Acid:1.8 mmol/L, Albumin:1.7 g/dL, LDH:742\n IU/L, Ca++:9.1 mg/dL, Mg++:1.7 mg/dL, PO4:2.6 mg/dL\n Assessment and Plan\n IMPAIRED HEALTH MAINTENANCE\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n IMPAIRED SKIN INTEGRITY\n HYPOTENSION (NOT SHOCK)\n HEPATITIS, ACUTE TOXIC (INCLUDING ALCOHOLIC, ACETAMINOPHEN, ETC.)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n PANCREATITIS, ACUTE\n ICU Care\n Nutrition:\n TPN w/ Lipids - 12:38 PM 74 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 01:35 PM\n Multi Lumen - 02:02 PM\n Dialysis Catheter - 04:56 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": "2131-05-27 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 677202, "text": "Chief Complaint:\n 24 Hour Events:\n \n - Switched back to 23% saline. Afternoon Na 139, PM Na 142. Written for\n additional 2 doses of 23%.\n \n - continued 23% saline q6h\n - wbc trending down; d/c'd afrin b/c hadn't gotten it at all\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:33 AM\n Meropenem - 02:04 AM\n Metronidazole - 02:30 AM\n Infusions:\n Calcium Gluconate (CRRT) - 2 grams/hour\n Norepinephrine - 0.03 mcg/Kg/min\n Phenylephrine - 1.8 mcg/Kg/min\n Fentanyl (Concentrate) - 250 mcg/hour\n KCl (CRRT) - 4 mEq./hour\n Midazolam (Versed) - 25 mg/hour\n Other ICU medications:\n Pantoprazole (Protonix) - 08:10 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:58 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: 35.8\nC (96.5\n HR: 90 (90 - 100) bpm\n BP: 108/57(74) {92/50(64) - 113/71(85)} mmHg\n RR: 20 (3 - 33) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 140 kg (admission): 113.5 kg\n Height: 67 Inch\n CVP: 20 (14 - 21)mmHg\n Total In:\n 12,114 mL\n 3,376 mL\n PO:\n TF:\n IVF:\n 10,318 mL\n 2,861 mL\n Blood products:\n Total out:\n 18,126 mL\n 5,213 mL\n Urine:\n 238 mL\n 58 mL\n NG:\n 400 mL\n 150 mL\n Stool:\n Drains:\n Balance:\n -6,012 mL\n -1,837 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 30\n RR (Spontaneous): 0\n PEEP: 16 cmH2O\n FiO2: 40%\n RSBI Deferred: PEEP > 10\n PIP: 34 cmH2O\n Plateau: 28 cmH2O\n Compliance: 38.8 cmH2O/mL\n SpO2: 97%\n ABG: 7.37/47/81./23/0\n Ve: 14.3 L/min\n PaO2 / FiO2: 205\n Physical Examination\n General Appearance: Overweight / Obese\n Head, Ears, Nose, Throat: 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: (Expansion: Symmetric), (Breath Sounds: Crackles :\n )\n Abdominal: Soft, Obese\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 67 K/uL\n 10.0 g/dL\n 175 mg/dL\n 2.4 mg/dL\n 23 mEq/L\n 3.7 mEq/L\n 22 mg/dL\n 107 mEq/L\n 143 mEq/L\n 29.2 %\n 45.9 K/uL\n [image002.jpg]\n 02:08 AM\n 02:28 AM\n 10:00 AM\n 10:17 AM\n 04:06 PM\n 04:23 PM\n 09:57 PM\n 10:11 PM\n 04:39 AM\n 04:49 AM\n WBC\n 35.1\n 45.9\n Hct\n 29.9\n 29.2\n Plt\n 85\n 67\n Cr\n 2.9\n 2.9\n 2.8\n 2.6\n 2.4\n TCO2\n 25\n 26\n 25\n 28\n 28\n Glucose\n 182\n 170\n 187\n 174\n 192\n 174\n 188\n 176\n 187\n 175\n Other labs: PT / PTT / INR:19.5/53.6/1.8, ALT / AST:20/210, Alk Phos /\n T Bili:236/20.6, Amylase / Lipase:16/34, Differential-Neuts:71.0 %,\n Band:8.0 %, Lymph:6.0 %, Mono:4.0 %, Eos:2.0 %, D-dimer: ng/mL,\n Fibrinogen:402 mg/dL, Lactic Acid:1.8 mmol/L, Albumin:1.7 g/dL, LDH:742\n IU/L, Ca++:9.1 mg/dL, Mg++:1.7 mg/dL, PO4:2.6 mg/dL\n Assessment and Plan\n IMPAIRED HEALTH MAINTENANCE\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n IMPAIRED SKIN INTEGRITY\n HYPOTENSION (NOT SHOCK)\n HEPATITIS, ACUTE TOXIC (INCLUDING ALCOHOLIC, ACETAMINOPHEN, ETC.)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n PANCREATITIS, ACUTE\n ICU Care\n Nutrition:\n TPN w/ Lipids - 12:38 PM 74 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 01:35 PM\n Multi Lumen - 02:02 PM\n Dialysis Catheter - 04:56 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": "2131-05-27 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 677205, "text": "Chief Complaint:\n 24 Hour Events:\n \n - Switched back to 23% saline. Afternoon Na 139, PM Na 142. Written for\n additional 2 doses of 23%.\n \n - continued 23% saline q6h\n - wbc trending down; d/c'd afrin b/c hadn't gotten it at all\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:33 AM\n Meropenem - 02:04 AM\n Metronidazole - 02:30 AM\n Infusions:\n Calcium Gluconate (CRRT) - 2 grams/hour\n Norepinephrine - 0.03 mcg/Kg/min\n Phenylephrine - 1.8 mcg/Kg/min\n Fentanyl (Concentrate) - 250 mcg/hour\n KCl (CRRT) - 4 mEq./hour\n Midazolam (Versed) - 25 mg/hour\n Other ICU medications:\n Pantoprazole (Protonix) - 08:10 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:58 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: 35.8\nC (96.5\n HR: 90 (90 - 100) bpm\n BP: 108/57(74) {92/50(64) - 113/71(85)} mmHg\n RR: 20 (3 - 33) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 140 kg (admission): 113.5 kg\n Height: 67 Inch\n CVP: 20 (14 - 21)mmHg\n Total In:\n 12,114 mL\n 3,376 mL\n PO:\n TF:\n IVF:\n 10,318 mL\n 2,861 mL\n Blood products:\n Total out:\n 18,126 mL\n 5,213 mL\n Urine:\n 238 mL\n 58 mL\n NG:\n 400 mL\n 150 mL\n Stool:\n Drains:\n Balance:\n -6,012 mL\n -1,837 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 30\n RR (Spontaneous): 0\n PEEP: 16 cmH2O\n FiO2: 40%\n RSBI Deferred: PEEP > 10\n PIP: 34 cmH2O\n Plateau: 28 cmH2O\n Compliance: 38.8 cmH2O/mL\n SpO2: 97%\n ABG: 7.37/47/81./23/0\n Ve: 14.3 L/min\n PaO2 / FiO2: 205\n Physical Examination\n General Appearance: Overweight / Obese\n Head, Ears, Nose, Throat: 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: (Expansion: Symmetric), (Breath Sounds: Crackles :\n )\n Abdominal: Soft, Obese\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 67 K/uL\n 10.0 g/dL\n 175 mg/dL\n 2.4 mg/dL\n 23 mEq/L\n 3.7 mEq/L\n 22 mg/dL\n 107 mEq/L\n 143 mEq/L\n 29.2 %\n 45.9 K/uL\n [image002.jpg]\n 02:08 AM\n 02:28 AM\n 10:00 AM\n 10:17 AM\n 04:06 PM\n 04:23 PM\n 09:57 PM\n 10:11 PM\n 04:39 AM\n 04:49 AM\n WBC\n 35.1\n 45.9\n Hct\n 29.9\n 29.2\n Plt\n 85\n 67\n Cr\n 2.9\n 2.9\n 2.8\n 2.6\n 2.4\n TCO2\n 25\n 26\n 25\n 28\n 28\n Glucose\n 182\n 170\n 187\n 174\n 192\n 174\n 188\n 176\n 187\n 175\n Other labs: PT / PTT / INR:19.5/53.6/1.8, ALT / AST:20/210, Alk Phos /\n T Bili:236/20.6, Amylase / Lipase:16/34, Differential-Neuts:71.0 %,\n Band:8.0 %, Lymph:6.0 %, Mono:4.0 %, Eos:2.0 %, D-dimer: ng/mL,\n Fibrinogen:402 mg/dL, Lactic Acid:1.8 mmol/L, Albumin:1.7 g/dL, LDH:742\n IU/L, Ca++:9.1 mg/dL, Mg++:1.7 mg/dL, PO4:2.6 mg/dL\n Assessment and Plan\n Mr. is a 28 year old gentleman with alcoholic hepatitis and\n necrotizing pancreatitis complicated by ARDS, SIRS, and UGIB.\n # Neuro: Patient with dilated pupils on high dose fentaynl gtt. CTH\n demonstrated loss of grey white differentiation with questionable\n effacement and possible seizure activity. Neuro and neurosurg consulted\n and patient received ativan, keppra load, and hypertonic saline of\n hyponatremia. Patient converted to 23% saline boluses with improvement\n in serum sodium and osmolility.\n - Per neuro, keppra IV maintenance dose\n - Continue 23% hypertonic saline boluses Q3H with regular serum sodium\n checks.\n - f/u EEG read\n - follow-up with neurology and neurosurg regarding frequency of saline\n boluses, need for repeat head CT given improving osmolality\n - Consider mannitol if serum sodium does not improve.\n - Wean sedation (starting with fentanyl) as possible.\n # Respiratory Failure: ARDS secondary to necrotizing pancreatitis\n compounded by hypoxia, tachypnea in setting of anion gap metabolic\n acidosis, increased abdominal pressure, and EtOH withdrawl. PEEP\n decreased to 16 from 20 and FiO2 to 40%.\n - Wean FiO2 and PEEP, goal PaO2>60-65%\n # Leukocytosis: WBC up to 44.9 on but now trending down.\n Concern for CVL infection, VAP, loculated effusion, sinusitis, or\n pancreatitis complication including abscess formation. CT chest with\n multifocal infiltrates that could represent VAP vs ARDS. CTAP did not\n demonstrate any new pancreatic fluid collections. On prior\n differential, had a neutrophilic predominance with 6% eosinophils but\n now with falling white count and normal eosinophil differential. Spoke\n to nurse and confirmed that patient has not been getting saline\n flushes/afrin, suggesting improvement in leukocytosis supports\n diagnosis of c. diff with improvement on flagyl.\n - Continue empiric vancomycin, meropenem, and flagyl. AM vanco level\n today\n - continue to follow CBC differential, if elevated would consider drug\n reaction as potential etiology to leukocytosis and likely switch\n Meropenem to zosyn.\n - Follow-up culture data\n - f/u ID reccs\n # Necrotizing pancreatitis/SIRS: Secondary to alcohol complicated by\n SIRS and ARDS. Patient continues to have pressor requirement, with neo\n +/- levo. Aggressive volume resuscitation with >58L. Patient\n without improvement with albumin trial, likely secondary to SIRS and\n increased vascular permeability.\n - Continue empiric antimicrobials.\n - Wean pressors as able, starting with levophed\n - Hypertonic saline as above in order to increase intravascular volume.\n - Monitor chemistries.\n - Follow-up with recs if any\n # Hyponatremia: In setting of decreased effective circulating volume\n in setting of SIRS and IABP. Patient receiving hypertonic saline\n boluses with improvement in serum sodium.\n - Hypertonic saline as above.\n - Trend chemistries.\n - Follow-up with neurosurgery recs if any.\n # Acute renal failure: Patient had HD line placed and CVVH was\n initiated yesterday.\n - CVVH per renal.\n - Trend chemistries\n #Thrombocytopenia: Platelets stable. No clear etiology at this time.\n DIC panel and HIT PF4 antibody negative.\n - Trend plt, transfuse for plt<10 or <50 if signs of hemorrhage.\n # IAP elevation: Secondary to third spacing and edema. Per surgery, not\n a good surgical candidate at this time.\n # Acute hepatitis: Likely alcoholic hepatitis with fatty infiltration,\n and no evidence of distal obstruction. RUQ u/s shows marked liver\n echogenicity but no ascites.\n - Trend LFTs\n # Hematemesis: EGD showed diuelafoy's lesion. HCT stable since 2 units\n PRBC on .\n - Trend hct, transfuse for hct<21\n # Alcoholism: Patient describes history of withdrawal symptoms, but\n not prior seizure. Last drink was night prior to presentation.\n Tachycardia, weakness, and elevated lactate could be consistent with\n thiamine deficiency.\n - Thiamine, vb12, folate\n - Valium with CIWA > 10\n FEN: TPN, replete as necessary.\n PPx: Heparin and H2B in TPN\n Access: RIJ (quad), LIJ (HD), right radial a-line\n Dispo: ICU level of care\n ICU Care\n Nutrition:\n TPN w/ Lipids - 12:38 PM 74 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 01:35 PM\n Multi Lumen - 02:02 PM\n Dialysis Catheter - 04:56 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": "2131-06-14 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 680776, "text": "Chief Complaint:\n 24 Hour Events:\n EEG - At 04:53 PM\n \n - Midaz was started for likely seizures. Attempted to wean in PM, but\n increased twitching at 9:15 with upward gaze. Given 2 mg ativan and\n went up on midaz gtt to 3 with good effect. Later in morning, nurse\n noted pt twiches more when stimulated, so may be waking up.\n - EEG showed 2 occipital seizures, but neuro stated unclear if this\n clinically correlates. Keppra was increased to 1000 mg .\n - ID has signed off\n - Renal stated to continue CVVH today and plan for transition to HD\n tomorrow.\n - Derm called about bx which showed extensive edema, neutrophils,\n eosinophils, histiocytes. Possibly related to hypersensitivity rxn,\n but also may be leaky vessels with high white count.\n - TF shut off at MN for IR guided tunneled line.\n Allergies:\n Meropenem\n skin blisters a\n Last dose of Antibiotics:\n Vancomycin - 04:00 PM\n Micafungin - 12:33 AM\n Aztreonam - 08:00 PM\n Linezolid - 10:00 PM\n Metronidazole - 02:00 AM\n Infusions:\n Fentanyl (Concentrate) - 100 mcg/hour\n Midazolam (Versed) - 3 mg/hour\n Calcium Gluconate (CRRT) - 1.6 grams/hour\n KCl (CRRT) - 4 mEq./hour\n Other ICU medications:\n Diazepam (Valium) - 08:02 AM\n Lorazepam (Ativan) - 01:20 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 06:19 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.1\nC (98.7\n Tcurrent: 36.2\nC (97.1\n HR: 87 (81 - 102) bpm\n BP: 110/62(80) {96/46(63) - 136/76(98)} mmHg\n RR: 21 (12 - 24) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 118.9 kg (admission): 113.5 kg\n Height: 67 Inch\n CVP: 11 (6 - 16)mmHg\n Total In:\n 11,138 mL\n 3,217 mL\n PO:\n TF:\n 602 mL\n 1 mL\n IVF:\n 8,793 mL\n 2,729 mL\n Blood products:\n Total out:\n 15,874 mL\n 3,969 mL\n Urine:\n 135 mL\n 23 mL\n NG:\n Stool:\n Drains:\n Balance:\n -4,736 mL\n -752 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 585 (545 - 796) mL\n PS : 8 cmH2O\n RR (Spontaneous): 18\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 46\n PIP: 17 cmH2O\n SpO2: 100%\n ABG: 7.35/47/174/21/0\n Ve: 10.8 L/min\n PaO2 / FiO2: 348\n Physical Examination\n GEN: Intubated, sedated\n HEENT: icteric sclera. MMM\n NECK: Trach site with minimal oozing\n LUNGS: Anterior auscultation with upper airway noise; good airway\n movement\n HEART: RRR, normal; S1, S2\n ABD: Distended. NT.\n EXTREM: 2+ edema, ulcers/lesions on legs with bandages C/D/I\n SKIN: Jaundice\n NEURO: Mouth twitching. Arms jerking bilaterally.\n Labs / Radiology\n 142 K/uL\n 8.6 g/dL\n 78 mg/dL\n 1.0 mg/dL\n 21 mEq/L\n 3.8 mEq/L\n 34 mg/dL\n 99 mEq/L\n 134 mEq/L\n 26.9 %\n 22.3 K/uL\n [image002.jpg]\n 09:51 PM\n 02:58 AM\n 03:09 AM\n 09:56 AM\n 02:43 PM\n 04:16 PM\n 09:28 PM\n 12:01 AM\n 03:25 AM\n 03:39 AM\n WBC\n 21.8\n 21.5\n 22.3\n Hct\n 23.9\n 24.6\n 25.4\n 26.9\n Plt\n 118\n 115\n 142\n Cr\n 1.0\n 1.0\n TCO2\n 25\n 26\n 21\n 26\n 26\n 27\n Glucose\n 136\n 114\n 144\n 78\n 78\n Other labs: PT / PTT / INR:15.4/31.9/1.4, CK / CKMB /\n Troponin-T:214/3/0.07, ALT / AST:150/246, Alk Phos / T Bili:299/30.5,\n Amylase / Lipase:51/41, Differential-Neuts:68.0 %, Band:5.0 %,\n Lymph:7.0 %, Mono:4.0 %, Eos:0.0 %, D-dimer:6389 ng/mL, Fibrinogen:502\n mg/dL, Lactic Acid:1.3 mmol/L, Albumin:2.0 g/dL, LDH:706 IU/L, Ca++:8.9\n mg/dL, Mg++:1.8 mg/dL, PO4:2.3 mg/dL\n Assessment and Plan\n 28M with alcoholic hepatitis and necrotizing pancreatitis complicated\n by ARDS, SIRS, ARF, UGIB, fevers and eosinophilia\n #. Respiratory Failure: ARDS secondary to necrotizing pancreatitis. S/p\n trach placement on . Sutures out on \n - Cont to wean vent with trach mask trial as tolerated\n - Decrease fentanyl, continue methadone\n # Seizures: Had increased twitching of head and arms yesterday with\n deviation of eyes to R. Was given Ativan x 2, Keppra dose increased.\n CT head without intracranial process. EEG showed occipital seizures\n which does not correlate with clinical symptoms. actually be\n patient waking up, not seizures.\n - F/u neuro recs\n - Wean off midazolam as tolerated with low dose valium to prevent\n withdrawal; monitor vitals\n - Consider d/c drugs that may lower seizure threshold\n # Hyperbilirubinemia: Patient has had continuously increasing T Bili\n and alkaline phosphatase. Has alcoholic hepatitis but also on TPN.\n Concerning for cholestasis.\n - Fractionate bilirubin\n - Stop TPN as tube feeds at goal\n - Weaning off benzos\n - Consider RUQ U/S if hyperbilirubinemia persist\n #. Acute renal Failure: Appreciate renal recs. Cr improved on CVVH. Off\n sucralfate due to concern for electrolyte abnormalities.\n - Cte volume depletion with CVVH as long as pressor requirement does\n not increase\n - Plan for tunneled dialysis catheter today to transition to HD\n tomorrow; f/u Renal recs\n #. ID: Afebrile. Question of fever adrenal insufficiency; now on\n steroids. leukocytosis improved. Blood/tissue/BAL cx NGTD,\n - Cte broad spectrum antibiotic coverage with aztreonam for extended GN\n coverage, linezolid for MRSA and VRE for bacteremia with plan to stop\n aztreonam first (Day 1=. Day #9 today)\n - C diff negative X 2. D/C Flagyl and Vanc PO today.\n - F/u WBC count, temp curve, and culture data\n #. Adrenal Insufficiency: Unclear with stim if clear adrenal\n insufficiency but hypotension improving with steroids (lower pressor\n requirement) and improving eosinophilia\n - Wean to 50mg Q8H today\n #. Thrombocytopenia: almost resolved\n - Monitor platelets daily and transfuse for plt <10 or <50 if signs of\n bleed\n - monitor daily\n # ?HLH: Elevated ferritin. Check quantitated ferritin to r/o HLH.\n ICU Care\n Nutrition:\n TPN w/ Lipids - 01:58 PM 77 mL/hour - d/c today\n TFs - held currently for IR guided catheter placement but at goal\n Glycemic Control: ISS\n Lines:\n Arterial Line - 08:15 PM\n Multi Lumen - 10:00 PM\n Dialysis Catheter - 11:35 PM\n Plan for IR-guided HD tunneled cath and L PICC today\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 pending above\n" }, { "category": "Nursing", "chartdate": "2131-06-14 00:00:00.000", "description": "Nursing Progress Note", "row_id": 680705, "text": "Seizure, without status epilepticus\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 Impaired Skin Integrity\n Assessment:\n Action:\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Respiratory ", "chartdate": "2131-05-26 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 677129, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 0\n Ideal body weight: 67.1 None\n Ideal tidal volume: 268.4 / 402.6 / 536.8 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type: Standard\n Size: 7mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / None\n Comments:\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours:\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: patient remains on mechanical ventilation with improved ABG &\n BS. Suctioned for minimal amount of thick yellow secretion requires\n lavages. Still on CVVHD poor skin integrity oozing; esophageal balloon\n in place , but transpul monary pressure not measured.\n" }, { "category": "Respiratory ", "chartdate": "2131-05-27 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 677286, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 10\n Ideal body weight: 67.1 None\n Ideal tidal volume: 268.4 / 402.6 / 536.8 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type: Standard\n Size: 7mm\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: Clear / Thick\n Sputum source/amount: Suctioned / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern:\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours:\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: Patient remains on mechanical ventilation with better\n compliance and ABG. On CVVHD BS improved suctioned for minimal amount\n of secretion.\n" }, { "category": "Nursing", "chartdate": "2131-06-12 00:00:00.000", "description": "Nursing Progress Note", "row_id": 680491, "text": "Addendum\nmucosal bleeding\n When performing deep epiglottal suctioning, clot noticed coming from\n right side of mouth.\n No blood noticed from trach.\n No blood suctioned from trach.\n MICU team over w/Dr. . Mouth examined with visualization of\n cheeks. ?biting of lower right cheek causing bleeding.\n Will keep on amicar and continue with frequent deep epiglottal\n suctioning.\n Keep monitoring for increasing of any oral bleeding.\n Call MICU team with any changes.\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Respiratory ", "chartdate": "2131-06-13 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 680683, "text": "Tracheostomy tube:\n Type: Standard\n Manufacturer: Portex\n Size: 8.0mm\n Lung sounds\n RLL Lung Sounds: Rhonchi\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: pt remains trached w/ #8.0\n portex on PSV. No vent changes made this shift. Continues on\n +12PSV/+8PEEP w/ Vt ~600s RR mid teens maintaining Ve ~8L/M.\n Assessment of breathing comfort: No claim of dyspnea\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: maintain support\n Reason for continuing current ventilatory support: Underlying illness\n not resolved\n" }, { "category": "Physician ", "chartdate": "2131-06-08 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 679501, "text": "Chief Complaint:\n 24 Hour Events:\n - Hyperkalemia and ECG improved with CVVH - renal recommended to\n continue CVVH.\n - Post-pyloric NG tube placed with OG tube d/c'd\n - Methadone 5mg TID started\n - Carafate started and Pantoprazole d/c'd for ? PPI induced\n eosinophilia.\n - ID recommended starting micofungin and flagyl.\n - ID also recommended HIV test which may be done via the health care\n proxy, but I left a message and did not get a call back.\n - Derm came by and biopsied leg - their suspicion was ulcers due to\n edema but will rule out other pathology.\n - This AM Hct of 20, transfusing 1 U. Consider desmopressin or plt\n transfusion.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Micafungin - 08:00 PM\n Aztreonam - 09:00 PM\n Linezolid - 10:00 PM\n Metronidazole - 02:00 AM\n Vancomycin - 04:00 AM\n Infusions:\n Norepinephrine - 0.05 mcg/Kg/min\n Fentanyl (Concentrate) - 350 mcg/hour\n Midazolam (Versed) - 15 mg/hour\n KCl (CRRT) - 30 mEq./hour\n Calcium Gluconate (CRRT) - 1.4 grams/hour\n Other ICU medications:\n Carafate (Sucralfate) - 04:00 AM\n Heparin Sodium (Prophylaxis) - 04:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:49 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.9\nC (98.4\n Tcurrent: 36.8\nC (98.3\n HR: 96 (83 - 101) bpm\n BP: 98/52(65) {88/46(60) - 122/67(83)} mmHg\n RR: 30 (8 - 30) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 134 kg (admission): 113.5 kg\n Height: 67 Inch\n CVP: 12 (12 - 291)mmHg\n Total In:\n 9,121 mL\n 2,718 mL\n PO:\n TF:\n IVF:\n 7,364 mL\n 2,290 mL\n Blood products:\n 6 mL\n Total out:\n 11,625 mL\n 3,415 mL\n Urine:\n 122 mL\n 24 mL\n NG:\n 500 mL\n Stool:\n Drains:\n Balance:\n -2,504 mL\n -697 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 30\n RR (Spontaneous): 0\n PEEP: 10 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10\n PIP: 30 cmH2O\n Plateau: 24 cmH2O\n Compliance: 28.6 cmH2O/mL\n SpO2: 100%\n ABG: 7.35/51/86/24/0\n Ve: 11.9 L/min\n PaO2 / FiO2: 172\n Physical Examination\n GEN: Intubated, sedated\n HEENT: icteric sclera. MMM\n NECK: Sites clean/dry/no oozing\n LUNGS: Crackles bilaterally anteriorly.\n HEART: RRR\n ABD: Distended. NT.\n EXTREM: 2+ edema with weeping wounds without surrounding erythema,\n ulcers/lesions on legs with bandages C/D/I\n SKIN: Jaundice\n Labs / Radiology\n 58 K/uL\n 6.8 g/dL\n 231 mg/dL\n 1.5 mg/dL\n 24 mEq/L\n 3.8 mEq/L\n 36 mg/dL\n 96 mEq/L\n 131 mEq/L\n 20.7 %\n 56.6 K/uL\n [image002.jpg]\n 06:11 AM\n 09:52 AM\n 10:05 AM\n 03:52 PM\n 03:58 PM\n 09:57 PM\n 12:02 AM\n 03:36 AM\n 03:53 AM\n 04:48 AM\n WBC\n 48.4\n 56.6\n Hct\n 20.4\n 20.7\n Plt\n 45\n 58\n Cr\n 1.5\n TCO2\n 23\n 23\n 27\n 29\n 26\n 29\n Glucose\n 255\n 249\n 290\n \n 231\n Other labs: PT / PTT / INR:19.1/46.0/1.8, CK / CKMB /\n Troponin-T:214/3/0.07, ALT / AST:42/182, Alk Phos / T Bili:129/23.3,\n Amylase / Lipase:19/35, Differential-Neuts:58.0 %, Band:4.0 %,\n Lymph:4.0 %, Mono:11.0 %, Eos:9.0 %, D-dimer:6389 ng/mL, Fibrinogen:419\n mg/dL, Lactic Acid:2.0 mmol/L, Albumin:1.7 g/dL, LDH:821 IU/L, Ca++:7.9\n mg/dL, Mg++:1.7 mg/dL, PO4:4.1 mg/dL\n Assessment and Plan\n 28yo M with alcoholic hepatitis and necrotizing pancreatitis\n complicated by ARDS, SIRS, ARF, UGIB, fevers and eosinophilia.\n #. Fever: GPCs growing in peripheral blood are coag negative staph.\n Consider d/c linezolid today.\n - Cte aztreonam for extended GN coverage. CT abd with no change but\n continued colonic thickening consistent with infection.\n - F/U derm biopsy results to see if skin infection already on broad\n spectrum antibiotic coverage inc. skin flora coverage\n - Cte broad spectrum antibiotic coverage with aztreonam and linezolid\n for MRSA and VRE for bacteremia\n - F/U cultures\n - Consider TEE to r/o vegetations as TTE was not a definitive study.\n - appreciate ID recs. Added Vanc PO/PR empirically per ID recs given\n increasing leukocytosis and colon inflammation on CT.\n - Cte anti-fungal as potential bowel compromise\n #. Respiratory Failure: ARDS secondary to necrotizing pancreatitis.\n - Oxygenating well on 10 of PEEP. Goal is to wean down peep so can get\n trach placement as has been intubated many days.\n #. Adrenal Insufficiency: Unclear with stim if clear adrenal\n insufficiency but hypotension improving with steroids (lower pressor\n requirement) and improving eosinophilia\n - Will continue steroids Iv X 5 days (day 3) then change to prednisone\n to taper\n #. Anemia: Hct lower this am. No clear source of bleeding except from\n NGT where had old blood suctioned up last pm. ?small bleed from doboff\n placement\n - trend hcts Q6H\n - 1unit pRBCs now\n - guaiac stools and NGT aspirate\n - Check hemolysis labs\n - If not appropriate bump with blood consider scope to ensure doboff\n did not cause significant bleed\n #. Eosinophilia: Likely drug reaction (to vanc, ppi or dapto?) with\n parasitic or fungal infection also possible etiologies.\n - stim positive for adrenal insufficiency. Cte steroids.\n - Cte fungal coverage as above\n - Stopped ppi and started sucralfate instead since has doboff now and\n PPIs can cause eosinophilia\n #. Thrombocytopenia: Appreciate heme recs. Do not feel this is DIC.\n - Monitor platelets daily and transfuse for plt <10 or <50 if signs of\n bleed\n #. Acute renal Failure: Appreciate renal recs. Will continue CVVH\n #. Wounds: Derm biopsy pending but likely edema caused wounds\n ICU Care\n Nutrition:\n F/U nutrition recs re:TFs this am\n Glycemic Control: ISS\n Lines:\n Arterial Line - 08:15 PM\n Multi Lumen - 10:00 PM\n Dialysis Catheter - 11:35 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: Sucralafate\n VAP: HOB elevation, Mouth care\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:ICU\n" }, { "category": "Physician ", "chartdate": "2131-06-14 00:00:00.000", "description": "Physician Resident/Attending Progress Note - MICU", "row_id": 680809, "text": "Chief Complaint:\n 24 Hour Events:\n EEG - At 04:53 PM\n \n - Midaz was started for likely seizures. Attempted to wean in PM, but\n increased twitching at 9:15 with upward gaze. Given 2 mg ativan and\n went up on midaz gtt to 3 with good effect. Later in morning, nurse\n noted pt twiches more when stimulated, so may be waking up.\n - EEG showed 2 occipital seizures, but neuro stated unclear if this\n clinically correlates. Keppra was increased to 1000 mg .\n - ID has signed off\n - Renal stated to continue CVVH today and plan for transition to HD\n tomorrow.\n - Derm called about bx which showed extensive edema, neutrophils,\n eosinophils, histiocytes. Possibly related to hypersensitivity rxn,\n but also may be leaky vessels with high white count.\n - TF shut off at MN for IR guided tunneled line.\n Allergies:\n Meropenem\n skin blisters a\n Last dose of Antibiotics:\n Vancomycin - 04:00 PM\n Micafungin - 12:33 AM\n Aztreonam - 08:00 PM\n Linezolid - 10:00 PM\n Metronidazole - 02:00 AM\n Infusions:\n Fentanyl (Concentrate) - 100 mcg/hour\n Midazolam (Versed) - 3 mg/hour\n Calcium Gluconate (CRRT) - 1.6 grams/hour\n KCl (CRRT) - 4 mEq./hour\n Other ICU medications:\n Diazepam (Valium) - 08:02 AM\n Lorazepam (Ativan) - 01:20 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 06:19 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.1\nC (98.7\n Tcurrent: 36.2\nC (97.1\n HR: 87 (81 - 102) bpm\n BP: 110/62(80) {96/46(63) - 136/76(98)} mmHg\n RR: 21 (12 - 24) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 118.9 kg (admission): 113.5 kg\n Height: 67 Inch\n CVP: 11 (6 - 16)mmHg\n Total In:\n 11,138 mL\n 3,217 mL\n PO:\n TF:\n 602 mL\n 1 mL\n IVF:\n 8,793 mL\n 2,729 mL\n Blood products:\n Total out:\n 15,874 mL\n 3,969 mL\n Urine:\n 135 mL\n 23 mL\n NG:\n Stool:\n Drains:\n Balance:\n -4,736 mL\n -752 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 585 (545 - 796) mL\n PS : 8 cmH2O\n RR (Spontaneous): 18\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 46\n PIP: 17 cmH2O\n SpO2: 100%\n ABG: 7.35/47/174/21/0\n Ve: 10.8 L/min\n PaO2 / FiO2: 348\n Physical Examination\n GEN: Intubated, sedated\n HEENT: icteric sclera. MMM\n NECK: Trach site with minimal oozing\n LUNGS: Anterior auscultation with upper airway noise; good airway\n movement\n HEART: RRR, normal; S1, S2\n ABD: Distended. NT.\n EXTREM: 2+ edema, ulcers/lesions on legs with bandages C/D/I\n SKIN: Jaundice\n NEURO: Mouth twitching. Arms jerking bilaterally.\n Labs / Radiology\n 142 K/uL\n 8.6 g/dL\n 78 mg/dL\n 1.0 mg/dL\n 21 mEq/L\n 3.8 mEq/L\n 34 mg/dL\n 99 mEq/L\n 134 mEq/L\n 26.9 %\n 22.3 K/uL\n [image002.jpg]\n 09:51 PM\n 02:58 AM\n 03:09 AM\n 09:56 AM\n 02:43 PM\n 04:16 PM\n 09:28 PM\n 12:01 AM\n 03:25 AM\n 03:39 AM\n WBC\n 21.8\n 21.5\n 22.3\n Hct\n 23.9\n 24.6\n 25.4\n 26.9\n Plt\n 118\n 115\n 142\n Cr\n 1.0\n 1.0\n TCO2\n 25\n 26\n 21\n 26\n 26\n 27\n Glucose\n 136\n 114\n 144\n 78\n 78\n Other labs: PT / PTT / INR:15.4/31.9/1.4, CK / CKMB /\n Troponin-T:214/3/0.07, ALT / AST:150/246, Alk Phos / T Bili:299/30.5,\n Amylase / Lipase:51/41, Differential-Neuts:68.0 %, Band:5.0 %,\n Lymph:7.0 %, Mono:4.0 %, Eos:0.0 %, D-dimer:6389 ng/mL, Fibrinogen:502\n mg/dL, Lactic Acid:1.3 mmol/L, Albumin:2.0 g/dL, LDH:706 IU/L, Ca++:8.9\n mg/dL, Mg++:1.8 mg/dL, PO4:2.3 mg/dL\n Assessment and Plan\n 28M with alcoholic hepatitis and necrotizing pancreatitis complicated\n by ARDS, SIRS, ARF, UGIB, fevers and eosinophilia\n #. Respiratory Failure: ARDS secondary to necrotizing pancreatitis. S/p\n trach placement on . Sutures out on \n - Cont to wean vent with trach mask trial as tolerated\n - Decrease fentanyl, continue methadone\n # Seizures: Had increased twitching of head and arms yesterday with\n deviation of eyes to R. Was given Ativan x 2, Keppra dose increased.\n CT head without intracranial process. EEG showed occipital seizures\n which does not correlate with clinical symptoms. actually be\n patient waking up, not seizures.\n - F/u neuro recs\n - Wean off midazolam as tolerated with low dose valium to prevent\n withdrawal; monitor vitals\n - Consider d/c drugs that may lower seizure threshold\n # Hyperbilirubinemia: Patient has had continuously increasing T Bili\n and alkaline phosphatase. Has alcoholic hepatitis but also on TPN.\n Concerning for cholestasis.\n - Fractionate bilirubin\n - Stop TPN as tube feeds at goal\n - Weaning off benzos\n - Consider RUQ U/S if hyperbilirubinemia persist\n #. Acute renal Failure: Appreciate renal recs. Cr improved on CVVH. Off\n sucralfate due to concern for electrolyte abnormalities.\n - Cte volume depletion with CVVH as long as pressor requirement does\n not increase\n - Plan for tunneled dialysis catheter today to transition to HD\n tomorrow; f/u Renal recs\n #. ID: Afebrile. Question of fever adrenal insufficiency; now on\n steroids. leukocytosis improved. Blood/tissue/BAL cx NGTD,\n - Cte broad spectrum antibiotic coverage with aztreonam for extended GN\n coverage, linezolid for MRSA and VRE for bacteremia with plan to stop\n aztreonam first (Day 1=. Day #9 today)\n - C diff negative X 2. D/C Flagyl and Vanc PO today.\n - F/u WBC count, temp curve, and culture data\n #. Adrenal Insufficiency: Unclear with stim if clear adrenal\n insufficiency but hypotension improving with steroids (lower pressor\n requirement) and improving eosinophilia\n - Wean to 50mg Q8H today\n #. Thrombocytopenia: almost resolved\n - Monitor platelets daily and transfuse for plt <10 or <50 if signs of\n bleed\n - monitor daily\n # ?HLH: Elevated ferritin. Check quantitated ferritin to r/o HLH.\n ICU Care\n Nutrition:\n TPN w/ Lipids - 01:58 PM 77 mL/hour - d/c today\n TFs - held currently for IR guided catheter placement but at goal\n Glycemic Control: ISS\n Lines:\n Arterial Line - 08:15 PM\n Multi Lumen - 10:00 PM\n Dialysis Catheter - 11:35 PM\n Plan for IR-guided HD tunneled cath and L PICC today\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 pending above\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: 28M alcoholic hepatitis, pancreatitis,\n refractory shock, ARDS - now tolerating aggressive fluid removal and\n off pressors. WBC and sedation down. Ongoing ? seizures when off benzo\n gtt.\n Exam notable for Tm 98.7 BP 115/50 HR 85 CVP 9 RR 30 with sat 100 on\n PSV 8/5 7.35/47/174 TBB -4L/24h. WD man, anasarca, chemosis. Partial\n eye opening to command. Coarse BS B. Distant s1s2. Obese, + BS. 3+\n edema. Labs notable for WBC 22K, HCT 26, Na 132, TB 30.5. No new\n imaging.\n Agree with plan to manage respiratory failure with slow wean of\n sedation and wean of PSV to TM trials as mental status allows. Given\n question of sz activity, will resume low dose valium PO now, and\n continue keppra at higher dose while we actively wean down drip\n sedation. For shock (resolved), will wean steroids (HC 50 q8h) and will\n narrow abx to aztreonam and linezolid. Will quantify ferritin (>)\n and d/w heme re HLH / BMBx, but suspect continuing supportive care is\n the best way forward. For ARF, change CVVH to HD; will need tunnelled\n line and PICC today in IR. For pancreatitis, will increase post-pyloric\n TFs; he is now stooling with good bowel sounds, will stop TPN\n especially given ongoing elevation in LFTs. Remainder of plan as\n outlined above. Plan d/w family at bedside.\n Patient is critically ill\n Total time: 50 min\n ------ Protected Section Addendum Entered By: , MD\n on: 01:33 PM ------\n" }, { "category": "Nursing", "chartdate": "2131-06-13 00:00:00.000", "description": "Nursing Progress Note", "row_id": 680557, "text": "TITLE:\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Crrt running net negative 300cc/hr. Net loss 5.7 liters @mn. Levophed\n at 0.03mcg/kg/m. Goal to remove as much fld as possible w/o increase\n pressor req.\n Action:\n Cont to run crrt net negative ~ 300cc/hr. High tmp and filter clotted\n at . Filter changed and crrt resumed at 2130. Pt hemodynamically\n stable on and off crrt. Labs q6h and crrt Ca+ and K+ titrated.\n Response:\n Tolerating crrt w net removal 300cc/hrly. Remains on same dose\n levophed.\n Plan:\n Npo for tunneled dialysis cath in IR today.\n Problem\n bleeding from trach and oral cavity\n Assessment:\n No bleeding noted at or around trach site.Oral cavity w blood and clots\n in small amts. Amicar gtt continuous at 1gm/hr. O2 sats stable without\n desaturation .\n Action:\n Trach care done, no oozing noted around trach site, tracheal suctioned\n for rust color sputum and no clots. Subglottal and oropharynx suct for\n small amts of clot and old blood q4h.\n Response:\n Bleeding resolved around trach site. Some bleeding continues orally.\n Hct stable.\n Plan:\n Cont Vap bundle, freq subglottal and oral/nasopharyngeal suct to remove\n old blood and clot in subglottal region. Cont amicar gtt. Cont to trend\n hcts\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Cpap mode 50% ps 12 peep 8 Stv500-700 w rr 12-18. Bbs clear but\n diminish bibasilarly. Sats stable > 95% throughout noc. Chest\n excursion gd.\n Action:\n Abg\ns q6h Vap bundle. Suct q4h and lavage for sm amts of rusty color\n sputum via trach. Oral suct for bld and clots in small amts.\n Response:\n Abg wnl. Tolerating cpap mode\n Plan:\n Cont to monitor abg, pt tolerance to cpap.Vap bundle. Freq oral and\n subglottal suction\n ------ Protected Section ------\n Seizure without status epilepticus\n Assessment: Rhythmic Facial twitching noted. Pupils equal brisk at\n 3mm, neuro exam otherwise unchanged with impaired gag and cough ,+\n corneals, does not withdraw to pain. Sbp stable , hr 58-80\ns nsr .O2\n sats and stv unchanged.\n Action: Dr paged and ativan 2mg iv given with repeat dose in\n 3mins for persistant facial twitching.\n Response: twitching subsided. Neuro in to eval and consult Dr \n here, Keppra dose given MD.\n Plan: Off crrt ,CT scan.See neuro recs and ? restart versed.\n ------ Protected Section Addendum Entered By: , RN\n on: 05:42 ------\n" }, { "category": "Nursing", "chartdate": "2131-06-14 00:00:00.000", "description": "Nursing Progress Note", "row_id": 680755, "text": "Seizure, without status epilepticus\n Assessment:\n Intermitant twitching noted during day shift\n EEG + occipital seizure activity\n No findings on EEG to indicate facial twitching SZ per NMED\n At 2100 increase in twitching to face, bil shoulders, bil arms and eyes\n noted to be deviated up bilaterally\n Action:\n Dr contact and to bedside to assess\n 2 mg ativan given with immediate effect\n twitching resolved\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received on CPAP 50% PS 12 Peep 8\n Lungs with occasional rhonchi to bil upper lobes\n Suctioned for white to clear secretions this evening\n Suctioned for bloody secretions x 1 @ 2300 ( some clots and some frank\n blood)\n RR 18-22 when calm and at times up to 30\ns with stimulation\n Action:\n Pressure support weaned to 8 over shift\n Peep weaned to 5\n Albuterol MDI\ns Q4\n MICU intern notified of episode of bloody secretions\n HCT\n and Coags drawn\n Response:\n Adequate oxygenation and ventilation on current vent settings\n Sats remain 100 %\n No further episodes of bloody or blood tinged secretions\n HCT, PLT, and coags stable\n Plan:\n Continue to monitor respiratory status, monitor for sings of bleeding\n in airway, monitor labs. Wean as tolerated.\n Impaired Skin Integrity\n Assessment:\n Trach site with no active bleeding noted\n BLE with improving wounds\n please see metavision for details\n Action:\n Trach care as needed\n BLE cleansed with wound cleanser, aloevest to intact skin and soft sorb\n covering open weeping areas\n Legs wrapped in kerlix\n Heels elevated in waffle boots\n Response:\n Skin integrity improved\n Plan:\n Continue to monitor trach site, trach care prn, heels elevated, dsg\n changes to ble.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Remains on CRRT\n Tolerating aggressive fluid removal\n CVP 10-12\n No peripheral edema noted\n Weight down to 113 kg this am (admission weight)\n Action:\n Ran 300 cc neg/hr yesterday\n Total 5 liters negative at midnight\n Dr contact regarding continuing aggressive fluid removal\n despite pt not appearing clinically fluid overloaded\n Response:\n Fluid removal decreased to 200 cc/ hr until am rounds\n Plan:\n To IR today for tunneled HD cath, possible transition to HD tomorrow.\n" }, { "category": "Nursing", "chartdate": "2131-06-14 00:00:00.000", "description": "Nursing Progress Note", "row_id": 680757, "text": "Seizure, without status epilepticus\n Assessment:\n Intermitant twitching noted during day shift\n EEG + occipital seizure activity\n No findings on EEG to indicate facial twitching SZ per NMED\n At 2100 increase in twitching to face, bil shoulders, bil arms and eyes\n noted to be deviated up bilaterally\n Action:\n Dr contact and to bedside to assess\n 2 mg ativan given with immediate effect\n twitching resolved\n Similar episode at 0100, additional 2 mg ativan given and versed turned\n back up to 3 mg/hr per DR \n Increased dose keppra given as ordered\n Response:\n Pt noted to have increased twitching with stimulation at times\n overnight but remained responsive to name and would resolve with rest/\n decreased stimulation. Dr aware. No further ativan bolus given.\n Plan:\n Continue to monitor for seizure activity and follow up on neurology\n recommendations. MRI ordered but postponed at this time per MICU.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received on CPAP 50% PS 12 Peep 8\n Lungs with occasional rhonchi to bil upper lobes\n Suctioned for white to clear secretions this evening\n Suctioned for bloody secretions x 1 @ 2300 ( some clots and some frank\n blood)\n RR 18-22 when calm and at times up to 30\ns with stimulation\n Action:\n Pressure support weaned to 8 over shift\n Peep weaned to 5\n Albuterol MDI\ns Q4\n MICU intern notified of episode of bloody secretions\n HCT\n and Coags drawn\n Response:\n Adequate oxygenation and ventilation on current vent settings\n Sats remain 100 %\n No further episodes of bloody or blood tinged secretions\n HCT, PLT, and coags stable\n Plan:\n Continue to monitor respiratory status, monitor for sings of bleeding\n in airway, monitor labs. Wean as tolerated.\n Impaired Skin Integrity\n Assessment:\n Trach site with no active bleeding noted\n BLE with improving wounds\n please see metavision for details\n Action:\n Trach care as needed\n BLE cleansed with wound cleanser, aloevest to intact skin and soft sorb\n covering open weeping areas\n Legs wrapped in kerlix\n Heels elevated in waffle boots\n Response:\n Skin integrity improved\n Plan:\n Continue to monitor trach site, trach care prn, heels elevated, dsg\n changes to ble.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Remains on CRRT\n Tolerating aggressive fluid removal\n CVP 10-12\n No peripheral edema noted\n Weight down to 113 kg this am (admission weight)\n Action:\n Ran 300 cc neg/hr yesterday\n Total 5 liters negative at midnight\n Dr contact regarding continuing aggressive fluid removal\n despite pt not appearing clinically fluid overloaded\n Response:\n Fluid removal decreased to 200 cc/ hr until am rounds\n Plan:\n To IR today for tunneled HD cath, possible transition to HD tomorrow.\n" }, { "category": "Physician ", "chartdate": "2131-06-14 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 680762, "text": "Chief Complaint:\n 24 Hour Events:\n EEG - At 04:53 PM\n \n - Midaz was started for likely seizures. Attempted to wean in PM, but\n increased twitching at 9:15 with upward gaze. Given 2 mg ativan and\n went up on midaz gtt to 3 with good effect. Later in morning, nurse\n noted pt twiches more when stimulated, so may be waking up.\n - EEG showed 2 occipital seizures, but neuro stated unclear if this\n clinically correlates. Keppra was increased to 1000 mg .\n - ID has signed off\n - Renal stated to continue CVVH today and plan for transition to HD\n tomorrow.\n - Derm called about bx which showed extensive edema, neutrophils,\n eosinophils, histiocytes. Possibly related to hypersensitivity rxn,\n but also may be leaky vessels with high white count.\n - TF shut off at MN for IR guided tunneled line.\n Allergies:\n Meropenem\n skin blisters a\n Last dose of Antibiotics:\n Vancomycin - 04:00 PM\n Micafungin - 12:33 AM\n Aztreonam - 08:00 PM\n Linezolid - 10:00 PM\n Metronidazole - 02:00 AM\n Infusions:\n Fentanyl (Concentrate) - 100 mcg/hour\n Midazolam (Versed) - 3 mg/hour\n Calcium Gluconate (CRRT) - 1.6 grams/hour\n KCl (CRRT) - 4 mEq./hour\n Other ICU medications:\n Diazepam (Valium) - 08:02 AM\n Lorazepam (Ativan) - 01:20 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 06:19 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.1\nC (98.7\n Tcurrent: 36.2\nC (97.1\n HR: 87 (81 - 102) bpm\n BP: 110/62(80) {96/46(63) - 136/76(98)} mmHg\n RR: 21 (12 - 24) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 118.9 kg (admission): 113.5 kg\n Height: 67 Inch\n CVP: 11 (6 - 16)mmHg\n Total In:\n 11,138 mL\n 3,217 mL\n PO:\n TF:\n 602 mL\n 1 mL\n IVF:\n 8,793 mL\n 2,729 mL\n Blood products:\n Total out:\n 15,874 mL\n 3,969 mL\n Urine:\n 135 mL\n 23 mL\n NG:\n Stool:\n Drains:\n Balance:\n -4,736 mL\n -752 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 585 (545 - 796) mL\n PS : 8 cmH2O\n RR (Spontaneous): 18\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 46\n PIP: 17 cmH2O\n SpO2: 100%\n ABG: 7.35/47/174/21/0\n Ve: 10.8 L/min\n PaO2 / FiO2: 348\n Physical Examination\n GEN: Intubated, sedated\n HEENT: icteric sclera. MMM\n NECK: Trach site with minimal oozing\n LUNGS: Anterior auscultation with upper airway noise; good airway\n movement\n HEART: RRR, normal; S1, S2\n ABD: Distended. NT.\n EXTREM: 2+ edema, ulcers/lesions on legs with bandages C/D/I\n SKIN: Jaundice\n NEURO: Mouth twitching. Arms jerking bilaterally.\n Labs / Radiology\n 142 K/uL\n 8.6 g/dL\n 78 mg/dL\n 1.0 mg/dL\n 21 mEq/L\n 3.8 mEq/L\n 34 mg/dL\n 99 mEq/L\n 134 mEq/L\n 26.9 %\n 22.3 K/uL\n [image002.jpg]\n 09:51 PM\n 02:58 AM\n 03:09 AM\n 09:56 AM\n 02:43 PM\n 04:16 PM\n 09:28 PM\n 12:01 AM\n 03:25 AM\n 03:39 AM\n WBC\n 21.8\n 21.5\n 22.3\n Hct\n 23.9\n 24.6\n 25.4\n 26.9\n Plt\n 118\n 115\n 142\n Cr\n 1.0\n 1.0\n TCO2\n 25\n 26\n 21\n 26\n 26\n 27\n Glucose\n 136\n 114\n 144\n 78\n 78\n Other labs: PT / PTT / INR:15.4/31.9/1.4, CK / CKMB /\n Troponin-T:214/3/0.07, ALT / AST:150/246, Alk Phos / T Bili:299/30.5,\n Amylase / Lipase:51/41, Differential-Neuts:68.0 %, Band:5.0 %,\n Lymph:7.0 %, Mono:4.0 %, Eos:0.0 %, D-dimer:6389 ng/mL, Fibrinogen:502\n mg/dL, Lactic Acid:1.3 mmol/L, Albumin:2.0 g/dL, LDH:706 IU/L, Ca++:8.9\n mg/dL, Mg++:1.8 mg/dL, PO4:2.3 mg/dL\n Assessment and Plan\n 28M with alcoholic hepatitis and necrotizing pancreatitis complicated\n by ARDS, SIRS, ARF, UGIB, fevers and eosinophilia\n #. Respiratory Failure: ARDS secondary to necrotizing pancreatitis. S/p\n trach placement on . Sutures out on \n - Cont to wean PEEP as tolerated\n - continue methadone to decrease fentanyl requirement\n # Seizures: Had increased twitching of head and arms yesterday with\n deviation of eyes to R. Was given Ativan x 2, Keppra dose increased.\n CT head without intracranial process. EEG showed occipital seizures\n which does not correlate with clinical symptoms. actually be\n patient waking up not seizures.\n - F/U neuron recs\n - Cte wean midazolam\n - Consider d/c drugs that may lower seizure threshold\n # Hyperbilirubinemia: Patient has had continuously increasing T Bili\n and alkaline phosphatase. Has alcoholic hepatitis but also on TPN.\n Concerning for cholestasis.\n - Fractionate bilirubin\n - Consider RUQ US\n #. Acute renal Failure: Appreciate renal recs. Cr improved on CVVH. Off\n sucralfate due to concern for electrolyte abnormalities.\n - Cte volume depletion with CVVH as long as pressor requirement does\n not increase\n - Plan for tunneled dialysis catheter today\n #. ID: Afebrile. Question of fever adrenal insufficiency; now on\n steroids. leukocytosis improved. Blood/tissue/BAL cx NGTD,\n - Cte broad spectrum antibiotic coverage with aztreonam for extended GN\n coverage, linezolid for MRSA and VRE for bacteremia. (Day 1=. Day #9\n today)\n - C diff negative X 2. D/C Flagyl and Vanc PO today.\n - F/u WBC count, temp curve, and culture data\n #. Adrenal Insufficiency: Unclear with stim if clear adrenal\n insufficiency but hypotension improving with steroids (lower pressor\n requirement) and improving eosinophilia\n - Wean to 50mg Q8H today\n #. Thrombocytopenia: almost resolved\n - Monitor platelets daily and transfuse for plt <10 or <50 if signs of\n bleed\n - monitor daily\n ICU Care\n Nutrition:\n TPN w/ Lipids - 01:58 PM 77 mL/hour and TFs (held currently\n for IR guided catheter placement)\n Glycemic Control: ISS\n Lines:\n Arterial Line - 08:15 PM\n Multi Lumen - 10:00 PM\n Dialysis Catheter - 11:35 PM\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 pending above\n" }, { "category": "Nursing", "chartdate": "2131-05-27 00:00:00.000", "description": "Nursing Progress Note", "row_id": 677279, "text": "Impaired Skin Integrity\n Assessment:\n Multiple blisters on legs, buttocks and arms, with generalized edema\n Action:\n pt on CVVH therapy to remove intravascular fluid, pads placed on bed to\n absorbe large amts serous oozing, consult placed with wound care, skin\n evaluated by Micu team\n Response:\n pt continues to ooze large amts serous fluid, several darkened\n blisters on legs, along with large serous filled fluid blisters on\n thighs\n Plan:\n consult with wound care, keep extremities clean and as dry as possible\n to avoid infection\n Hypotension (not Shock)\n Assessment:\n Hypotensive throughout shift, with sys 80\ns occas\n Action:\n Neo and levo gtts titrated to keep Map > 60, fluid given via rescue\n line,\n Response:\n BP remains labile with adjusting of sedation, pressors and PFR to keep\n pt normotensive\n Plan:\n continue to titrate gtts, keep map > 60 per Micu team\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt on CMV mode ventilation\n Action:\n Pt suctioned for small amts light yellow secretions, repositioned on\n rotating bed , frequent oral care\n Response:\n 02 sats stable, abg stable, pt overbreathes vent occas by 3-5 breaths\n Plan:\n continue to monitor abg\ns, medicate to keep in synch with vent,\n Problem - Description In Comments\n Assessment:\n acute renal failure with minimal icteric u/o\n Action:\n pt on cvvh to remove large amts intravascular fluid\n Response:\n pt continues to make marginal u/o\n Plan:\n run cvvh to keep pt -300cc/hr per renal and Micu\n" }, { "category": "Respiratory ", "chartdate": "2131-05-28 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 677457, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 11\n Ideal body weight: 67.1 None\n Ideal tidal volume: 268.4 / 402.6 / 536.8 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type: Standard\n Size: 7mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Crackles\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: /\n Sputum source/amount: Suctioned / None\n Comments:\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern:\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours:\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments: Patient remains on mechanical ventilation with good\n improvement.. On CVVHD bs diminished. CXR bibasilar atelectasis and\n small bilateral effusion.\n" }, { "category": "Respiratory ", "chartdate": "2131-06-13 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 680553, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 27\n Ideal body weight: 67.1 None\n Ideal tidal volume: 268.4 / 402.6 / 536.8 mL/kg\n Airway\n Tracheostomy tube:\n Type: Standard, Cuffed, Inner Cannula\n Manufacturer: Portex\n Size: 8.0mm\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 24 cmH2O\n Cuff volume: 8 mL /\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: Blood Tinged / Thick\n Sputum source/amount: Suctioned / Small\n Comments/Plan\n Pt remains trached, vent supported. No changes made overnight. See\n flowsheet for further pt data. Will follow.\n 05:19\n" }, { "category": "Physician ", "chartdate": "2131-06-14 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 680748, "text": "Chief Complaint:\n 24 Hour Events:\n EEG - At 04:53 PM\n \n - Midaz was started for likely seizures, but attempted to wean in PM,\n but increased twitching at 9:15 with upward gaze. Given 2 mg ativan\n and went up on midaz gtt to 3 with good effect. Later in morning,\n nurse noted pt twiches more when stimulated, so may be waking up.\n - EEG showed 2 occipital seizures, but neuro stated unclear if this\n clinically correlates. Keppra was increased to 1000 mg .\n - ID has signed off\n - Renal stated to continue CVVH today and plan for transition to HD\n tomorrow.\n - Derm called about bx which showed extensive edema, neutrophils,\n eosinophils, histiocytes. Possibly related to hypersensitivity rxn,\n but also may be leaky vessels with high white count.\n - TF shut off at MN for IR guided tunneled line.\n Allergies:\n Meropenem\n skin blisters a\n Last dose of Antibiotics:\n Vancomycin - 04:00 PM\n Micafungin - 12:33 AM\n Aztreonam - 08:00 PM\n Linezolid - 10:00 PM\n Metronidazole - 02:00 AM\n Infusions:\n Fentanyl (Concentrate) - 100 mcg/hour\n Midazolam (Versed) - 3 mg/hour\n Calcium Gluconate (CRRT) - 1.6 grams/hour\n KCl (CRRT) - 4 mEq./hour\n Other ICU medications:\n Diazepam (Valium) - 08:02 AM\n Lorazepam (Ativan) - 01:20 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 06:19 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.1\nC (98.7\n Tcurrent: 36.2\nC (97.1\n HR: 87 (81 - 102) bpm\n BP: 110/62(80) {96/46(63) - 136/76(98)} mmHg\n RR: 21 (12 - 24) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 118.9 kg (admission): 113.5 kg\n Height: 67 Inch\n CVP: 11 (6 - 16)mmHg\n Total In:\n 11,138 mL\n 3,217 mL\n PO:\n TF:\n 602 mL\n 1 mL\n IVF:\n 8,793 mL\n 2,729 mL\n Blood products:\n Total out:\n 15,874 mL\n 3,969 mL\n Urine:\n 135 mL\n 23 mL\n NG:\n Stool:\n Drains:\n Balance:\n -4,736 mL\n -752 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 585 (545 - 796) mL\n PS : 8 cmH2O\n RR (Spontaneous): 18\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 46\n PIP: 17 cmH2O\n SpO2: 100%\n ABG: 7.35/47/174/21/0\n Ve: 10.8 L/min\n PaO2 / FiO2: 348\n Physical Examination\n GEN: Intubated, sedated\n HEENT: icteric sclera. MMM\n NECK: Trach site with minimal oozing\n LUNGS: Anterior auscultation with upper airway noise; good airway\n movement\n HEART: RRR, normal; S1, S2\n ABD: Distended. NT.\n EXTREM: 2+ edema, ulcers/lesions on legs with bandages C/D/I\n SKIN: Jaundice\n NEURO: Mouth twitching. Arms jerking bilaterally.\n Labs / Radiology\n 142 K/uL\n 8.6 g/dL\n 78 mg/dL\n 1.0 mg/dL\n 21 mEq/L\n 3.8 mEq/L\n 34 mg/dL\n 99 mEq/L\n 134 mEq/L\n 26.9 %\n 22.3 K/uL\n [image002.jpg]\n 09:51 PM\n 02:58 AM\n 03:09 AM\n 09:56 AM\n 02:43 PM\n 04:16 PM\n 09:28 PM\n 12:01 AM\n 03:25 AM\n 03:39 AM\n WBC\n 21.8\n 21.5\n 22.3\n Hct\n 23.9\n 24.6\n 25.4\n 26.9\n Plt\n 118\n 115\n 142\n Cr\n 1.0\n 1.0\n TCO2\n 25\n 26\n 21\n 26\n 26\n 27\n Glucose\n 136\n 114\n 144\n 78\n 78\n Other labs: PT / PTT / INR:15.4/31.9/1.4, CK / CKMB /\n Troponin-T:214/3/0.07, ALT / AST:150/246, Alk Phos / T Bili:299/30.5,\n Amylase / Lipase:51/41, Differential-Neuts:68.0 %, Band:5.0 %,\n Lymph:7.0 %, Mono:4.0 %, Eos:0.0 %, D-dimer:6389 ng/mL, Fibrinogen:502\n mg/dL, Lactic Acid:1.3 mmol/L, Albumin:2.0 g/dL, LDH:706 IU/L, Ca++:8.9\n mg/dL, Mg++:1.8 mg/dL, PO4:2.3 mg/dL\n Assessment and Plan\n SEIZURE, WITHOUT STATUS EPILEPTICUS\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n IMPAIRED SKIN INTEGRITY\n HEPATITIS, ACUTE TOXIC (INCLUDING ALCOHOLIC, ACETAMINOPHEN, ETC.)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n 28M with alcoholic hepatitis and necrotizing pancreatitis complicated\n by ARDS, SIRS, ARF, UGIB, fevers and eosinophilia\n #. Respiratory Failure: ARDS secondary to necrotizing pancreatitis. S/p\n trach placement on . Sutures out on \n - Decrease PEEP today as tolerated\n - Cont to wean as tolerated\n - continue methadone to decrease fentanyl requirement\n # Seizures: Had increased twitching of head and arms yesterday with\n deviation of eyes to R. Was given Ativan x 2, Keppra dose early, and\n Neuro saw him and agreed that these are likely seizures. CT head\n without intracranial process.\n - Restart midazolam gtt as may be benzo withdrawal\n - EEG today to define if new focus of seizures\n - Consider d/c flagyl or other drugs that may lower seizure threshold\n - Consider load phosphenytoin\n # Bleeding around trach site: Amicar was continued for another 24 hrs\n with better hemostasis around trach\n - f/u Heme/Onc recs\n - completed amicar course\n #. ID: Afebrile.. Question of fever adrenal insufficiency; now on\n steroids. leukocytosis improved. Blood/tissue/BAL cx NGTD,\n - Cte broad spectrum antibiotic coverage with aztreonam for extended GN\n coverage, linezolid for MRSA and VRE for bacteremia, flagyl IV, vanc PO\n empirically per ID recs given increasing leukocytosis and colon\n inflammation on CT.\n - Per ID, add ciprofloxacin if decompensates. Also restart vancomycin\n PR\n - C diff negative, Send c diff, 2^nd sample. If negative d/c vanc po\n and flagyl\n - F/u WBC count, temp curve, and culture data\n - F/u ID recs; question: how to down abx over next few days\n #. Adrenal Insufficiency: Unclear with stim if clear adrenal\n insufficiency but hypotension improving with steroids (lower pressor\n requirement) and improving eosinophilia\n - weaned on to 75mg IV Q8hr continue this dose X 1 more day then\n down to 50mg \n #. Hyperbilirubinemia: Likely related to underlying shock liver, TPN,\n and ?obstructive etiology from necrotizing pancreatitis. Continue to\n trend.\n #. Anemia: stable\n - Hct QD, guaiac stools and NGT aspirate\n #. Thrombocytopenia: almost resolved\n - Monitor platelets daily and transfuse for plt <10 or <50 if signs of\n bleed\n - monitor daily\n #. Acute renal Failure: Appreciate renal recs. Cr improved on CVVH. Off\n sucralfate due to concern for electrolyte abnormalities.\n - Cte volume depletion with CVVH as long as pressor requirement does\n not increase\n - Plan for tunneled dialysis catheter\n ICU Care\n Nutrition:\n TPN w/ Lipids - 01:58 PM 77 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 08:15 PM\n Multi Lumen - 10:00 PM\n Dialysis Catheter - 11:35 PM\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" }, { "category": "Nursing", "chartdate": "2131-06-08 00:00:00.000", "description": "Nursing Progress Note", "row_id": 679481, "text": "Sepsis, Severe (with organ dysfunction)\n Assessment:\n Hypotensive this evening MAP 58-60 SBP 86-90\n Received on CRRT\n negative 2.5 liters\n Low dose levophed gtt\n Minimally responsive to pain on large doses of fentanyl and versed\n Flexiseal in place for vanco enema for CDIFF\n minimal stool output\n HCT 20 (from 26 ) this am\n PLT 45\n Action:\n Levophed gtt titrated up slightly and pt ran even for remainder of\n evening\n Once able to come back down on levophed begain taking fluid off at rate\n 100-150 cc/hr\n Started on methadone\n Fentanyl titrated down slightly\n PO and PR vanco per order\n 1 unit PRBC transfusing\n Response:\n BP stable\n Remains adequately sedated\n Plan:\n Check repeat HCT this am, wean sedation as tolerated, continue to take\n of fluid as tolerated.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received on AC 50% 400 x 30 Peep 15\n Breathing over only when in discomfort\n Sats 100 %\n Action:\n Peep weaned down to 10 over night\n Response:\n Tolerated well, Sats 98-100 % and ABG continue to show adequate\n oxygenation and ventilation.\n Plan:\n Continue to wean as tolerated. Long term plan for tracheostomy, goal\n Peep 5 prior to procedure.\n Impaired Skin Integrity\n Assessment:\n Multiple blisters and to BLE\n Improving\n Action:\n Dressed per skin care recommendations\n Adaptic used on areas with little or no drainage to prevent pulling at\n healing tissue\n Aquacel used in areas with moderate to large amounts of drainage.\n On rotating bed with constant rotation and Q6 manual turn\n Response:\n Improving\n Plan:\n Continue to dress per skin care recommendations and frequent\n repositioning.\n" }, { "category": "Respiratory ", "chartdate": "2131-06-08 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 679617, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 22\n Ideal body weight: 67.1 None\n Ideal tidal volume: 268.4 / 402.6 / 536.8 mL/kg\n Airway\n Tracheostomy tube: portex\n Type: cuffed\n Manufacturer:\n Size: 8.0\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: Rhonchi\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Scant\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Sedated / Paralyzed,\n Cannot protect airway\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n OR\n 1600\n trach\n Bedside Procedures:\n Comments:\n" }, { "category": "Nursing", "chartdate": "2131-05-25 00:00:00.000", "description": "Nursing Progress Note", "row_id": 676947, "text": " Problem\n Pancreatitis/Multisystem Organ Failure\n Assessment:\n Patient w/ETOH induced hepatic failure/pancreatitis, resulting in\n severe sepsis, multisystem organ failure\n Action:\n Vented, .4/x30/+20 beginning of shift\npeep to 16 at end of shift\n CRRT w/ citrate to take off fluid\n Hypertonic saline boluses to decrease cerebral edema\n Continue w/q 1 hr. neuro checks\ndid cough once with suctioning\n Sedation as needed for adequate ventilation\n Response:\n Tolerated vent wean per abgs\n Taking off 200-300cc/hr via CRRT, tolerating well.\n Remains on neo 5 and VERY small amount of levo, okay w/team to\n tolerate fluid removal\n Fentanyl to 350, tolerating well.\n Plan:\n No further vent changes.\n Continue to remove fluid as tolerated.\n Hypertonic saline for four doses, recheck Na and serum osmo, check with\n MICU re: additional doses\n Continue with frequent neuro checks\n Provide support to family , encourage brother to go home tonight.\n Update MICU as necessary, call with any changes.\n" }, { "category": "Physician ", "chartdate": "2131-05-25 00:00:00.000", "description": "Physician Resident/Attending Progress Note - MICU", "row_id": 676949, "text": "Chief Complaint: Acute pancreatitis\n 24 Hour Events:\n - Changed hypertonic saline to continous 3%\n - Neuro/nsurg wanted repeat ct head\n - Decreased peep/fio2\n - HD line placed and CVVH started\n - EEG underway\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 12:00 PM\n Metronidazole - 02:36 AM\n Meropenem - 05:47 AM\n Infusions:\n Fentanyl (Concentrate) - 400 mcg/hour\n Midazolam (Versed) - 30 mg/hour\n Phenylephrine - 5 mcg/Kg/min\n Other ICU medications:\n Pantoprazole (Protonix) - 08:21 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 06:55 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.6\nC (99.6\n Tcurrent: 37.1\nC (98.7\n HR: 94 (93 - 106) bpm\n BP: 107/56(73) {82/43(56) - 130/69(90)} mmHg\n RR: 30 (0 - 31) insp/min\n SpO2: 98%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 156 kg (admission): 113.5 kg\n Height: 67 Inch\n CVP: 16 (15 - 25)mmHg\n Total In:\n 14,293 mL\n 2,159 mL\n PO:\n TF:\n IVF:\n 13,230 mL\n 1,835 mL\n Blood products:\n Total out:\n 1,413 mL\n 1,881 mL\n Urine:\n 164 mL\n 30 mL\n NG:\n 200 mL\n Stool:\n Drains:\n Balance:\n 12,880 mL\n 278 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 30\n RR (Spontaneous): 0\n PEEP: 20 cmH2O\n FiO2: 40%\n RSBI Deferred: PEEP > 10\n PIP: 42 cmH2O\n Plateau: 33 cmH2O\n Compliance: 30.8 cmH2O/mL\n SpO2: 98%\n ABG: 7.28/48/89./18/-4\n Ve: 11.8 L/min\n PaO2 / FiO2: 223\n Physical Examination\n Gen: Sedated\n HEENT: ETT in place.. Scleral edema. Pupils 7mm and minimally reactive\n worsened from yesterday.\n Chest: coarse BS bl, rhonchorous throughout\n CV: distant heart sounds, RRR, S1S2\n Abd: distended although improved from yesterday. -BS\n Ext: Anasarca\n Neuro: Sedated. Pupils 6 mm, reactive.\n Labs / Radiology\n 70 K/uL\n 10.3 g/dL\n 175 mg/dL\n 3.9 mg/dL\n 18 mEq/L\n 3.9 mEq/L\n 30 mg/dL\n 106 mEq/L\n 135 mEq/L\n 30.7 %\n 44.1 K/uL\n 06:30 PM\n 01:22 AM\n 01:32 AM\n 09:55 AM\n 04:11 PM\n 09:39 PM\n 10:00 PM\n 02:26 AM\n 04:29 AM\n 04:48 AM\n WBC\n 38.9\n 44.1\n Hct\n 31.0\n 30.4\n 30.7\n Plt\n 99\n 70\n Cr\n 3.8\n 4.0\n 3.9\n TCO2\n 21\n 17\n 17\n 21\n 20\n 24\n Glucose\n 105\n 142\n 131\n 173\n 175\n Other labs: PT / PTT / INR:18.7/58.3/1.7, ALT / AST:37/219, Alk Phos /\n T Bili:218/20.6, Amylase / Lipase:16/37, Differential-Neuts:75.0 %,\n Band:0.0 %, Lymph:4.0 %, Mono:12.0 %, Eos:6.0 %, D-dimer: ng/mL,\n Fibrinogen:402 mg/dL, Lactic Acid:1.7 mmol/L, Albumin:2.1 g/dL, LDH:624\n IU/L, Ca++:8.1 mg/dL, Mg++:2.4 mg/dL, PO4:3.2 mg/dL\n Assessment and Plan\n Mr. is a 28 year old gentleman with alcoholic hepatitis and\n necrotizing pancreatitis complicated by ARDS, SIRS, and UGIB.\n # Neuro: Patient with dilated pupils on high dose fentaynl gtt. CTH\n demonstrated loss of grey white differentiation with questionable\n effacement and possible seizure activity. Neuro and neurosurg consulted\n and patietn received ativan, keppra load, and hypertonic saline of\n hyponatremia. Patient converted to 3% IVF infusion.\n - Per neuro, keppra IV maintenance dose\n - Convert back to 23% hypertonic saline boluses Q3H with regular serum\n sodium checks.\n - EEG to be completed today\n - Per neurosurg, repeat CTH today if stable\n - Follow-up with neurosurg and neuro recs if any.\n - Consider mannitol if serum sodium does not improve.\n - Wean sedation (starting with fentanyl) as possible.\n # Respiratory Failure: ARDS secondary to necrotizing pancreatitis\n compounded by hypoxia, tachypnea in setting of anion gap metabolic\n acidosis, increased abdominal pressure, and EtOH withdrawl. PEEP\n decreased to 20 and FiO2 to 40%.\n - Wean FiO2 and PEEP, goal PaO2>60-65%\n # Leukocytosis: WBC up to 44.9 today. Concern for CVL infection, VAP,\n loculated effusion, sinusitis, or pancreatitis complication including\n abscess formation. CT chest with multifocal infiltrates that could\n represent VAP vs ARDS. CTAP did not demonstrate any new pancreatic\n fluid collections. On last differential, past had a predominantly left\n shift, although also with 6% eos suggesting possible drug reaction\n (?meropenem).\n - Continue empiric vancomycin, meropenem, and flagyl. AM vanco level\n today\n - Recheck differential, if elevated would consider drug reaction as\n potential etiology to leukocytosis and likely switch meropenem.\n - Follow-up culture data\n - Afrin and nasal saline spray\n - ID consult\n # Necrotizing pancreatitis/SIRS: Secondary to alcohol complicated by\n SIRS and ARDS. Patient continues to have pressor requirement, with neo\n +/- levo. Aggressive volume resuscitation with >58L. Patient\n without improvement with albumin trial, likely secondary to SIRS and\n increased vascular permeability.\n - Continue empiric antimicrobials.\n - Wean pressors as able, starting with levophed\n - Hypertonic saline as above in order to increase intravascular volume.\n - Monitor chemistries.\n - Follow-up with recs if any\n # Hyponatremia: In setting of decreased effective circulating volume in\n setting of SIRS and IABP. Patient received hypertonic saline overnight\n per neurosurgery. Serum sodium stable this morning.\n - Hypertonic saline as above.\n - Trend chemistries.\n - Follow-up with neurosurgery recs if any.\n # Acute renal failure: Patient had HD line placed and CVVH was\n initiated yesterday.\n - CVVH per renal.\n - Trend chemistries\n #Thrombocytopenia: Platelets stable. No clear etiology at this time.\n DIC panel and HIT PF4 antibody negative.\n - Trend plt, transfuse for plt<10 or <50 if signs of hemorrhage.\n # IAP elevation: Secondary to third spacing and edema. Per surgery, not\n a good surgical candidate at this time.\n # Acute hepatitis: Likely alcoholic hepatitis with fatty infiltration,\n and no evidence of distal obstruction. RUQ u/s shows marked liver\n echogenicity but no ascites.\n - Trend LFTs\n # Hematemesis: EGD showed diuelafoy's lesion. HCT stable since 2 units\n PRBC on .\n - Trend hct, transfuse for hct<21\n # Alcoholism: Patient describes history of withdrawal symptoms, but\n not prior seizure. Last drink was night prior to presentation.\n Tachycardia, weakness, and elevated lactate could be consistent with\n thiamine deficiency.\n - Thiamine, vb12, folate\n - Valium with CIWA > 10\n FEN: TPN, replete as necessary.\n PPx: Heparin and H2B in TPN\n Access: RIJ (quad), LIJ (HD), right radial a-line\n Dispo: ICU level of care\n ICU Care\n Nutrition:\n TPN without Lipids - 04:08 PM 47 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 01:35 PM\n Multi Lumen - 02:02 PM\n Dialysis Catheter - 04:56 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n ------ Protected Section ------\n MICU ATTENDING ADDENDUM\n I saw and examined the patient, and was physically present with the ICU\n team for the key portions of the services provided. I agree with the\n note above, including the assessment and plan. I would emphasize and\n add the following points: 28M EtOH abuse, weakness, fatigue, UGIB c/b\n hematemesis / melena. Has developed massive fluid requirement,\n hypotension, ARDS in the setting of severe pancreatitis, alcoholic\n hepatitis and borderline renal function. Creatinine up o/n, as is WBC.\n Pan cx, started on vanco. Head CT with edema, on 23% NS for induced\n osmorx. Now febrile on / vanco / flagyl. TPN started. Ongoing CVVH\n / EEG.\n Exam notable for Tm 99.6 BP 90/50 HR 98 RR 30 with sat 98 on VAC\n 400x32/30 0.4 20 7.28/48/89 CVP 25 IAP 25. +TBB 57L. Sedated, min\n responsive, pupils 6 to 4B. Hyperdynamic. Bronchial BS B. RRR s1s2.\n Distended, minimal bowel sounds. Massive edema. Labs notable for WBC\n 44K, HCT 29, K+ 4.2, Cr 3.9, lactate 1.6, INR 1.6. CXR with worsening\n ARDS R>L.\n Agree with plan to continue hypertonic (23%) saline q6h with frequent\n monitoring of osm and sodium for early edema - appreciate nsurg and\n neuro input; will attempt CT if CVVH goes down. Goal osm is 320-330,\n will add mannitol if he fails to have osm >320 by this PM. Will also\n continue fluid removal and keppra, early read of EEG without seizures.\n Will manage ARDS with low volume ventilation (400x30); will continue to\n wean PEEP as long as FiO2 <0.5 and PaO2>60. Given falling vent\n requirement, will work hard to get sedation down over the next day\n his volume of distribution is huge and he will autotaper on both benzos\n and narcotics. For , hold on further fluids and run -200cc/h\n as long as pressor requirement is stable. have evolving sepsis\n based upon WBC and fever - continue triple abx and max supportive care\n while following cultures and consulting ID. Will treat sinusitis and\n follow eos - will transition to zosyn for possible drug reaction\n if they remain elevated. ARF is progressive and UOP down, continue\n CVVH; will dose vanco to level. Pancreatitis likely due to EtOH, NPO,\n following. Can't use gut for now; continue TPN with heparin, PPI,\n insulin as needed. Alcoholic hepatitis is stable, though bili is up\n somewhat. UGIB from Dieulafois lesion at GEJ appears stable, will\n monitor serial HCT and continue PPI IV. Above d/w family in detail at\n family mtg. Remainder of plan as outlined above.\n Patient is critically ill\n Total time: 100 min\n ------ Protected Section Addendum Entered By: , MD\n on: 05:46 PM ------\n" }, { "category": "Nursing", "chartdate": "2131-05-27 00:00:00.000", "description": "Nursing Progress Note", "row_id": 677190, "text": "Hypotension (not Shock)\n Assessment:\n MAP remains stable and > 60\n Pt is on Neo and Levo\n CRRT continuously to remove fluid\n Action:\n Neo weaning down, presently at 1.5 mcg/kg/min\n Removal of 300-500cc fluid q hr\n Fentanyl weaned to 250 mcg/hr, versed weaned to 25 mg/hr\n Response:\n Bp remains stable\n Pt was -6 L by midnight\n Plan:\n Wean neo as tolerated, to off if possible\n Wean fentanyl and versed as ordered\n Continue removing fluid as tolerated with CRRT.\n Impaired Skin Integrity\n Assessment:\n Blisters on legs oozing very large amounts serous fluid\n Action:\n Pads changed under legs prn\n Response:\n Legs continue to ooze\n Plan:\n Skin care consult.\n" }, { "category": "Physician ", "chartdate": "2131-06-09 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 679751, "text": "Chief Complaint:\n 24 Hour Events:\n - Trach placed; PEEP decreased to 8\n - Methadone started and able to wean fentanyl down 350 -> 250\n - Levophed weaned down to 0.03 throughout day\n - Received 1 unit pRBC post trach with increase in Hct 21 -> 24\n - Received DDAVP x 1 dose for oozing around trach site\n - Increased ISS for hyperglycemia in setting of steroids\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 04:00 AM\n Aztreonam - 08:00 PM\n Micafungin - 09:00 PM\n Linezolid - 10:00 PM\n Metronidazole - 02:00 AM\n Infusions:\n Norepinephrine - 0.02 mcg/Kg/min\n Midazolam (Versed) - 15 mg/hour\n Calcium Gluconate (CRRT) - 2 grams/hour\n KCl (CRRT) - 4 mEq./hour\n Fentanyl (Concentrate) - 200 mcg/hour\n Other ICU medications:\n Carafate (Sucralfate) - 04:00 AM\n Heparin Sodium (Prophylaxis) - 04:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:11 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.1\nC (98.8\n Tcurrent: 36.2\nC (97.1\n HR: 82 (72 - 95) bpm\n BP: 102/59(71) {84/44(56) - 126/66(85)} mmHg\n RR: 21 (21 - 30) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 134 kg (admission): 113.5 kg\n Height: 67 Inch\n CVP: 13 (11 - 20)mmHg\n Total In:\n 11,098 mL\n 2,908 mL\n PO:\n TF:\n IVF:\n 8,814 mL\n 2,445 mL\n Blood products:\n 798 mL\n Total out:\n 12,489 mL\n 2,758 mL\n Urine:\n 24 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,391 mL\n 150 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 30\n RR (Spontaneous): 0\n PEEP: 8 cmH2O\n FiO2: 50%\n PIP: 24 cmH2O\n Plateau: 21 cmH2O\n Compliance: 30.8 cmH2O/mL\n SpO2: 98%\n ABG: 7.42/40/111/24/1\n Ve: 11.9 L/min\n PaO2 / FiO2: 222\n Physical Examination\n GEN: Intubated, sedated\n HEENT: icteric sclera. MMM\n NECK: Sites clean/dry/no oozing\n LUNGS: Crackles bilaterally anteriorly.\n HEART: RRR\n ABD: Distended. NT.\n EXTREM: 2+ edema with weeping wounds without surrounding erythema,\n ulcers/lesions on legs with bandages C/D/I\n SKIN: Jaundice\n Labs / Radiology\n 43 K/uL\n 8.3 g/dL\n 157 mg/dL\n 1.2 mg/dL\n 24 mEq/L\n 3.4 mEq/L\n 36 mg/dL\n 98 mEq/L\n 131 mEq/L\n 24.9 %\n 40.7 K/uL\n [image002.jpg]\n 10:28 AM\n 12:54 PM\n 06:02 PM\n 06:08 PM\n 09:18 PM\n 09:33 PM\n 12:23 AM\n 01:12 AM\n 01:57 AM\n 04:24 AM\n WBC\n 40.7\n Hct\n 22.3\n 21.7\n 24.6\n 24.9\n Plt\n 47\n 43\n Cr\n 1.2\n TCO2\n 30\n 29\n 29\n 27\n 26\n 27\n Glucose\n 187\n 194\n 186\n 181\n 157\n Other labs: PT / PTT / INR:17.5/38.7/1.6, CK / CKMB /\n Troponin-T:214/3/0.07, ALT / AST:49/186, Alk Phos / T Bili:133/26.8,\n Amylase / Lipase:19/35, Differential-Neuts:56.0 %, Band:14.0 %,\n Lymph:4.0 %, Mono:6.0 %, Eos:1.0 %, D-dimer:6389 ng/mL, Fibrinogen:502\n mg/dL, Lactic Acid:2.0 mmol/L, Albumin:1.7 g/dL, LDH:920 IU/L, Ca++:7.6\n mg/dL, Mg++:2.0 mg/dL, PO4:2.2 mg/dL\n tissue cx pending. BAL/asp: bact cx neg, fungal pending. \n coag neg staph x 1 bottle.\n Derm biopsy: mixed cells c/w either inflammatory, infectious, or\n reactive\n Assessment and Plan\n 28yo M with alcoholic hepatitis and necrotizing pancreatitis\n complicated by ARDS, SIRS, ARF, UGIB, fevers and eosinophilia.\n #. Fever: Afebrile x >2d; source unclear. Question of fever adrenal\n insufficiency; now on steroids. Concern for infection with increased\n bandemia today although leukocytosis improved. Blood/tissue/BAL cx\n NGTD, CT abd with persistent inflammation concerning for infection. CT\n sinuses w/ opacification of unclear time course.\n - Cte broad spectrum antibiotic coverage with aztreonam for extended GN\n coverage, linezolid for MRSA and VRE for bacteremia, flagyl IV, vanc\n PO/PR empirically per ID recs given increasing leukocytosis and colon\n inflammation on CT, micafungin for antifungal coverage\n - F/u WBC and temp curve\n - F/u derm biopsy results to see if skin infection; already on broad\n spectrum antibiotic coverage inc. skin flora coverage\n - F/u cultures\n - Consider TEE to r/o vegetations as TTE was not a definitive study\n - F/u ID recs; question tx of sinuses but already on broad coverage\n #. Respiratory Failure: ARDS secondary to necrotizing pancreatitis. S/p\n trach placement yesterday on PEEP 8\n - Sutures out on \n - Cont to wean as tolerated\n #. Adrenal Insufficiency: Unclear with stim if clear adrenal\n insufficiency but hypotension improving with steroids (lower pressor\n requirement) and improving eosinophilia\n - Will continue steroids IV X 5 days (day 3) then change to prednisone\n to taper\n #. Eosinophilia: Adrenal insufficiency v. drug reaction (?PPI; vanc &\n dapto less likely d/t time course). Fungal and parasitic infection also\n possible etiologies.\n - stim positive for adrenal insufficiency. Cte steroids.\n - Off PPI, vanc, dapto\n - Cte fungal coverage as above\n #. Anemia: Hct stable since 1 unit pRBC and 1 dose DDAVP s/p trach with\n some oozing at site.\n - recheck hemolysis labs\n - trend hcts Q6H, 1unit pRBCs now, guaiac stools and NGT aspirate\n - If not appropriate bump with blood consider scope to ensure doboff\n did not cause significant bleed\n - holding ppx with PPI or sucralfate given issues of eosinophilia and\n ARF\n #. Thrombocytopenia: Appreciate heme recs. Do not feel this is DIC.\n Recent decrease may be in setting of linezolid.\n - Monitor platelets daily and transfuse for plt <10 or <50 if signs of\n bleed\n - Would linezolid when/if able\n #. Acute renal Failure: Appreciate renal recs. Cr improved on CVVH. Off\n sucralfate due to concern for electrolyte abnormalities.\n #. Wounds: Derm biopsy pending - inflammatory, infectious, or reactive.\n F/u recs.\n #. Agitation: Cont methadone given decreased sensitivity to fentanyl;\n titrate prn\n #. Glucose intolerance: In setting of steroids; adjust ISS prn\n ICU Care\n Nutrition:\n TPN w/ Lipids - 07:00 PM 75 mL/hour\n Glycemic Control: ISS\n Lines:\n Arterial Line - 08:15 PM\n Multi Lumen - 10:00 PM\n Dialysis Catheter - 11:35 PM\n Prophylaxis:\n DVT: Pneumoboots\n Stress ulcer: Holding PPI and sucralfate for now\n VAP: HOB elevation, Mouth care\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n" }, { "category": "Nursing", "chartdate": "2131-06-09 00:00:00.000", "description": "Nursing Progress Note", "row_id": 679766, "text": "Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Continues on CRRT\n Tolerating fluid removal for most of evening on low doses of levophed\n BP slightly labile with repositioning but stabilizes without\n intervention\n Hypokalemic and hypocalcemic overnight despite KCL and Calcium\n Gluconate gtts\n Action:\n Fluid removed over evening\n Required small fluid bolus for hypotension and running even for several\n hours\n Renal fellow contact regarding lab values\n Response:\n 1.4 liters negative at midnight\n Currently able to take fluid off and tolerating with stable BP\n Per renal fellow no changes in post filter replacement fluid or\n dialysiate dispite low potassium and stable bicarb\n Calcium slidding scale tightened although per Dr , no\n additional calcium gluconate even though Ica 1.0. Per renal this is an\n acceptable level. MICU intern DRLEONG, also aware of low\n ionized calcium.\n Per renal fellow 40 meq kcl given to supplement gtt.\n Ica up to 1.05 and K up to 3.9\n Plan:\n Continue to take of fluid as tolerated, monitor labs, follow up with\n renal regarding changing solution for post filter replacement fluid or\n dialysate to assist with hypokalemia. Follow up regarding adding\n additional calcium for low levels. Monitor telemetry.\n Impaired Skin Integrity\n Assessment:\n Trach site oozing blood from site.\n Multiple areas of open blisters and to BLE\n Action:\n Surgiseal around trach site and drain sponge\n Thoracic surgery and MICU aware\n Given one dose DDACP\n Response:\n Legs improving\n Less bleeding from trach site\n Plan:\n Cont to monitor, skin care as recomonded. Skin rn and derm following.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received on AC 50 % 400 x 30 peep 10\n Minimal resp over vent noted\n Lungs clear but diminished at bases\n Action:\n CXR post trach placement\n Peep decreased to 8\n Response:\n Tolerating with adequate oxygenation and ventilation.\n Plan:\n Monitor closely and wean vent as tolerated.\n" }, { "category": "Nursing", "chartdate": "2131-05-28 00:00:00.000", "description": "Nursing Progress Note", "row_id": 677445, "text": " Problem\n Cerebral edema\n Assessment:\n Pupils 3mm sluggish to briskly reactive\n Cough x1 only this shift when turning\n No gag\n No movement of extremities\n No seizure activity\n Action:\n Antiepileptics\n Hypertonic saline q 3 hours\n CRRT for fluid removal\n Maintain MAP >60/65 to hopefully maintain CPP > 60 (no way\n to monitor ICP)\n Response:\n No s+s of seizure activity\n Improvement in pupils from (where 7mm sluggish)\n No signs of worsening ICP / herniation\n Plan:\n Continue q 3 hour hypertonic saline\n Continue antiepileptics\n Continue q 2 hour neuro evaluations\n Continue to maintain MAP > 60/65\n Continue to monitor serum sodium and osmolarity levels (goal\n na+ 145-150, osmo 320)\n Impaired Skin Integrity\n Assessment:\n Multiple blistered areas of skin on legs and one of right\n side of abdomen\n Amount of drainage from legs has decreased significantly\n Weeping areas on arms / any puncture site\n has slowed down\n Back, buttocks, heels all remain intact\n Action:\n Q 15 minute rotation function of bed on\n Pads under legs and arms changed frequently\n Full linen change and full body turn q 4 hours\n CRRT for fluid removal\n Response:\n No progression of skin breakdown\n Overall drainage amounts are decreasing\n Still unable to quantify insensible losses from 3^rd spaced\n fluid\n Plan:\n Continue aggressive skin care\n Continue changing linens frequently\n Awaiting skin nurse consult.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n LS clear upper, diminished bases\n FiO2 50%, 12 peep, rr 30 x 400 on AC\n No cough when suctioned for minimal secreations\n Action:\n Constant rotation\n VAP protocol\n CRRT\n Response:\n PAO2 in 70\ns this afternoon, FIO2 increased to 50%\n LS clear even to right base, remain decreased left base\n Plan:\n Continue to wean ventilator as tolerated\n Continue VAP protocol\n Continue rotation\n Pancreatitis, acute\n Assessment:\n WBC 38 (44)\n Remains sedated on midazolam and fentanyl drips\n Remains on levophed for goal MAP > 60-65\n Remains ~20 Kg positive from admission weight\n Renal failure continues (creat\n Goal fluid removal is for as much as patient will tolerate\n without having to increase Levophed\n Elevated blood glucose levels\n Action:\n Vancomycin and Meropenum continue\n Flagyl discontinued\n Midazolam weaned to 12 mg/hr from 16\n Insulin increased in TPN\n CRRT for current fluid balance MN\n 1700:\n Response:\n Unable to keep aggressive net -300 cc goal as pt became\n hypotensive and more tachycardic\n CVP now ~16\n Tolerating slow sedation wean\n Awaiting response from increase in insulin in TPN\n Plan:\n Continue supportive measures\n Wean ventilator as toleratee\n Wean sedation as tolerated\n Wean vasopressors as tolerated\n CRRT to remove as much fluid as pt will tolerate without\n increasing vasopressors\n Patient and family support.\n" }, { "category": "Nursing", "chartdate": "2131-05-28 00:00:00.000", "description": "Nursing Progress Note", "row_id": 677448, "text": " Problem\n Cerebral edema\n Assessment:\n Pupils 3mm sluggish to briskly reactive\n Cough x1 only this shift when turning\n No gag\n No movement of extremities\n No seizure activity\n Action:\n Antiepileptics\n Hypertonic saline q 3 hours\n CRRT for fluid removal\n Maintain MAP >60/65 to hopefully maintain CPP > 60 (no way\n to monitor ICP)\n Response:\n No s+s of seizure activity\n Improvement in pupils from (where 7mm sluggish)\n No signs of worsening ICP / herniation\n Sodium 149\n Osmolarity 312\n Plan:\n Continue q 3 hour hypertonic saline\n Continue antiepileptics\n Continue q 2 hour neuro evaluations\n Continue to maintain MAP > 60/65\n Continue to monitor serum sodium and osmolarity levels (goal\n na+ 145-150, osmo 320)\n ? change hypertonic saline to q 6 hours, will discuss with\n Dr. \n Impaired Skin Integrity\n Assessment:\n Multiple blistered areas of skin on legs and one of right\n side of abdomen\n Amount of drainage from legs has decreased significantly\n Weeping areas on arms / any puncture site\n has slowed down\n Back, buttocks, heels all remain intact\n Action:\n Q 15 minute rotation function of bed on\n Pads under legs and arms changed frequently\n Full linen change and full body turn q 4 hours\n CRRT for fluid removal\n Response:\n No progression of skin breakdown\n Overall drainage amounts are decreasing\n Still unable to quantify insensible losses from 3^rd spaced\n fluid\n Plan:\n Continue aggressive skin care\n Continue changing linens frequently\n Awaiting skin nurse consult.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n LS clear upper, diminished bases\n FiO2 50%, 12 peep, rr 30 x 400 on AC\n No cough when suctioned for minimal secretions\n Action:\n Constant rotation\n VAP protocol\n CRRT\n Response:\n PAO2 in 70\ns this afternoon, FIO2 increased to 50%\n LS clear even to right base, remain decreased left base\n Plan:\n Continue to wean ventilator as tolerated\n Continue VAP protocol\n Continue rotation\n Pancreatitis, acute\n Assessment:\n WBC 38 (44)\n Remains sedated on midazolam and fentanyl drips\n Remains on levophed for goal MAP > 60-65\n Remains ~20 Kg positive from admission weight\n Renal failure continues (creat\n Goal fluid removal is for as much as patient will tolerate\n without having to increase Levophed\n Elevated blood glucose levels\n Action:\n Vancomycin and Meropenum continue\n Flagyl discontinued\n Midazolam weaned to 12 mg/hr from 16\n Insulin increased in TPN\n CRRT for current fluid balance MN\n 1700: net - 2600 cc\ns (-\n 6500 cc\ns for )\n Response:\n Unable to keep aggressive net -300 cc goal as pt became\n hypotensive and more tachycardic\n CVP now ~16\n Tolerating slow sedation wean\n Awaiting response from increase in insulin in TPN\n Plan:\n Continue supportive measures\n Wean ventilator as tolerated\n Wean sedation as tolerated\n Wean vasopressors as tolerated\n CRRT to remove as much fluid as pt will tolerate without\n increasing vasopressors\n Patient and family support.\n" }, { "category": "General", "chartdate": "2131-05-29 00:00:00.000", "description": "Physician note", "row_id": 677580, "text": "Chief Complaint:\n 24 Hour Events:\n ARTERIAL LINE - STOP 01:30 PM\n ARTERIAL LINE - START 01:30 PM\n - Arterial line re-sited to left radial\n - Weaned sedation down (fetaynl preferentially), patient started moving\n and so went back up a bit.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Metronidazole - 02:00 AM\n Vancomycin - 08:08 AM\n Meropenem - 02:25 PM\n Infusions:\n Norepinephrine - 0.06 mcg/Kg/min\n Fentanyl (Concentrate) - 50 mcg/hour\n Calcium Gluconate (CRRT) - 1.4 grams/hour\n Midazolam (Versed) - 12 mg/hour\n KCl (CRRT) - 3 mEq./hour\n Other ICU medications:\n Pantoprazole (Protonix) - 07:32 PM\n Diazepam (Valium) - 04:51 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 07:07 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37\nC (98.6\n Tcurrent: 36.1\nC (97\n HR: 99 (96 - 112) bpm\n BP: 101/52(68) {77/37(50) - 135/78(98)} mmHg\n RR: 30 (23 - 31) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 128 kg (admission): 113.5 kg\n Height: 67 Inch\n CVP: 14 (13 - 22)mmHg\n Total In:\n 10,808 mL\n 2,161 mL\n PO:\n TF:\n IVF:\n 9,032 mL\n 1,648 mL\n Blood products:\n Total out:\n 14,321 mL\n 1,662 mL\n Urine:\n 50 mL\n NG:\n 140 mL\n 100 mL\n Stool:\n Drains:\n Balance:\n -3,513 mL\n 499 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 30\n RR (Spontaneous): 2\n PEEP: 12 cmH2O\n FiO2: 60%\n RSBI Deferred: PEEP > 10\n PIP: 28 cmH2O\n Plateau: 24 cmH2O\n Compliance: 38.5 cmH2O/mL\n SpO2: 98%\n ABG: 7.42/48/81./29/5\n Ve: 11.4 L/min\n PaO2 / FiO2: 137\n Physical Examination\n General Appearance: Well nourished, total body fluid overload\n Eyes / Conjunctiva: PERRL, pupils 2mm->1mm\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: (Expansion: Symmetric), (Breath Sounds:\n Rhonchorous: )\n Abdominal: Soft, Distended\n Extremities: Right: 4+, Left: 4+\n Skin: Warm\n Neurologic: No(t) Attentive, No(t) Follows simple commands, Responds\n to: Not assessed, No(t) Oriented (to): , Movement: Not assessed,\n Sedated, Tone: Not assessed\n Labs / Radiology\n 44 K/uL\n 7.9 g/dL\n 170 mg/dL\n 2.0 mg/dL\n 29 mEq/L\n 3.5 mEq/L\n 23 mg/dL\n 109 mEq/L\n 148 mEq/L\n 24.2 %\n 29.1 K/uL\n [image002.jpg]\n 11:09 PM\n 04:10 AM\n 04:20 AM\n 10:00 AM\n 10:10 AM\n 04:08 PM\n 04:20 PM\n 10:12 PM\n 04:02 AM\n 04:17 AM\n WBC\n 38.2\n 29.1\n Hct\n 29.0\n 24.2\n Plt\n 59\n 44\n Cr\n 1.8\n 2.0\n 2.2\n 2.0\n TCO2\n 30\n 30\n 31\n 32\n 32\n 32\n Glucose\n 199\n 205\n 196\n 196\n 178\n 170\n Other labs: PT / PTT / INR:17.5/59.4/1.6, ALT / AST:11/162, Alk Phos /\n T Bili:155/14.5, Amylase / Lipase:16/34, Differential-Neuts:71.0 %,\n Band:8.0 %, Lymph:6.0 %, Mono:4.0 %, Eos:2.0 %, D-dimer: ng/mL,\n Fibrinogen:402 mg/dL, Lactic Acid:1.6 mmol/L, Albumin:1.6 g/dL, LDH:742\n IU/L, Ca++:9.1 mg/dL, Mg++:1.7 mg/dL, PO4:3.3 mg/dL\n Assessment and Plan\n Mr. is a 28 year old gentleman with alcoholic hepatitis and\n necrotizing pancreatitis complicated by ARDS, SIRS, and UGIB.\n # Neuro: Initially dilated pupils with CT showing cerebral edema.\n Pupils less dilated and more reactive.\n - continuing keppra\n - 23% hypertonic saline boluses Q12H. Goal Na 145-150, Osm 310-315.\n - Wean sedation as possible\n - consider repeat CT\n # Respiratory Failure: ARDS secondary to necrotizing pancreatitis\n compounded by hypoxia, tachypnea in setting of anion gap metabolic\n acidosis, increased abdominal pressure, and EtOH withdrawl. PEEP\n decreased to 12 from 20 and FiO2 to 40%.\n - Wean FiO2 and PEEP, goal PaO2>60-65%\n # Leukocytosis: Stable. Initial concern for infection but normal cx\n suggests that this may be inflammatory reaction. No eos on diff and CT\n without abscesses\n - step wise dc abx: flagyl, then meropenem and vancomycin if no skin\n infection. Monitor closely\n - Follow-up culture data\n # Anemia: Initially pw hematemesis and EGD showed diuelafoy's lesion.\n Last PRBC on . HCT now at 24 from 30.\n - repeat HCT, if value correct then HCT/PLT and hemolyisis labs.\n - Trend hct, transfuse for hct<24\n # Necrotizing pancreatitis/SIRS: Secondary to alcohol complicated by\n SIRS and ARDS. Patient continues to have pressor requirement, with neo\n +/- levo. Aggressive volume resuscitation with >53L.\n - Continue empiric antimicrobials.\n - weaning pressors: levo at 0.05.\n - Hypertonic saline as above in order to increase intravascular volume.\n # Hyponatremia: In setting of decreased effective circulating volume\n in setting of SIRS and IABP. Patient receiving hypertonic saline\n boluses with improvement in serum sodium.\n - Hypertonic saline as above.\n # Acute renal failure: Patient had HD line placed and CVVH was\n initiated yesterday.\n - CVVH per renal. UF with net neg 200 cc/hr\n - Trend chemistries\n #Thrombocytopenia: Platelets stable. No clear etiology at this time.\n DIC panel and HIT PF4 antibody negative.\n - Trend plt, transfuse for plt<10 or <50 if signs of hemorrhage.\n # IAP elevation: Secondary to third spacing and edema. Per surgery, not\n a good surgical candidate at this time.\n # Acute hepatitis: Likely alcoholic hepatitis with fatty infiltration,\n and no evidence of distal obstruction. RUQ u/s shows marked liver\n echogenicity but no ascites.\n - Trend LFTs\n # Alcoholism: Patient describes history of withdrawal symptoms, but\n not prior seizure. Last drink was night prior to presentation.\n Tachycardia, weakness, and elevated lactate could be consistent with\n thiamine deficiency.\n - Thiamine, vb12, folate\n - Valium with CIWA > 10\n FEN: TPN, replete as necessary.\n PPx: Heparin and H2B in TPN\n Access: RIJ (quad), LIJ (HD), right radial a-line\n Dispo: ICU level of care\n ICU Care\n Nutrition:\n TPN w/ Lipids - 09:10 PM 73 mL/hour\n Glycemic Control:\n Lines:\n Multi Lumen - 02:02 PM\n Dialysis Catheter - 04:56 PM\n Arterial Line - 01:30 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2131-06-14 00:00:00.000", "description": "Nursing Progress Note", "row_id": 680743, "text": "Seizure, without status epilepticus\n Assessment:\n Action:\n Response:\n Plan:\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Received on CPAP 50% PS 12 Peep 8\n Lungs with occasional rhonchi to bil upper lobes\n Suctioned for white to clear secretions this evening\n Suctioned for bloody secretions x 1 @ 2300 ( some clots and some frank\n blood)\n RR 18-22 when calm and at times up to 30\ns with stimulation\n Action:\n Pressure support weaned to 8 over shift\n Peep weaned to 5\n Albuterol MDI\ns Q4\n MICU intern notified of episode of bloody secretions\n HCT\n and Coags drawn\n Response:\n Adequate oxygenation and ventilation on current vent settings\n No further episodes of bloody or blood tinged secretions\n HCT, PLT, and coags stable\n Plan:\n Continue to monitor respiratory status, monitor for sings of bleeding\n in airway, monitor labs. Wean as tolerated.\n Impaired Skin Integrity\n Assessment:\n Action:\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Physician ", "chartdate": "2131-06-14 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 680745, "text": "Chief Complaint:\n 24 Hour Events:\n EEG - At 04:53 PM\n \n - Midaz was started for likely seizures, but attempted to wean in PM,\n but increased twitching at 9:15 with upward gaze. Given 2 mg ativan\n and went up on midaz gtt to 3 with good effect. Later in morning,\n nurse noted pt twiches more when stimulated, so may be waking up.\n - EEG showed 2 occipital seizures, but neuro stated unclear if this\n clinically correlates. Keppra was increased to 1000 mg .\n - ID has signed off\n - Renal stated to continue CVVH today and plan for transition to HD\n tomorrow.\n - Derm called about bx which showed extensive edema, neutrophils,\n eosinophils, histiocytes. Possibly related to hypersensitivity rxn,\n but also may be leaky vessels with high white count.\n - TF shut off at MN for IR guided tunneled line.\n Allergies:\n Meropenem\n skin blisters a\n Last dose of Antibiotics:\n Vancomycin - 04:00 PM\n Micafungin - 12:33 AM\n Aztreonam - 08:00 PM\n Linezolid - 10:00 PM\n Metronidazole - 02:00 AM\n Infusions:\n Fentanyl (Concentrate) - 100 mcg/hour\n Midazolam (Versed) - 3 mg/hour\n Calcium Gluconate (CRRT) - 1.6 grams/hour\n KCl (CRRT) - 4 mEq./hour\n Other ICU medications:\n Diazepam (Valium) - 08:02 AM\n Lorazepam (Ativan) - 01:20 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 06:19 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.1\nC (98.7\n Tcurrent: 36.2\nC (97.1\n HR: 87 (81 - 102) bpm\n BP: 110/62(80) {96/46(63) - 136/76(98)} mmHg\n RR: 21 (12 - 24) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 118.9 kg (admission): 113.5 kg\n Height: 67 Inch\n CVP: 11 (6 - 16)mmHg\n Total In:\n 11,138 mL\n 3,217 mL\n PO:\n TF:\n 602 mL\n 1 mL\n IVF:\n 8,793 mL\n 2,729 mL\n Blood products:\n Total out:\n 15,874 mL\n 3,969 mL\n Urine:\n 135 mL\n 23 mL\n NG:\n Stool:\n Drains:\n Balance:\n -4,736 mL\n -752 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 585 (545 - 796) mL\n PS : 8 cmH2O\n RR (Spontaneous): 18\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 46\n PIP: 17 cmH2O\n SpO2: 100%\n ABG: 7.35/47/174/21/0\n Ve: 10.8 L/min\n PaO2 / FiO2: 348\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 142 K/uL\n 8.6 g/dL\n 78 mg/dL\n 1.0 mg/dL\n 21 mEq/L\n 3.8 mEq/L\n 34 mg/dL\n 99 mEq/L\n 134 mEq/L\n 26.9 %\n 22.3 K/uL\n [image002.jpg]\n 09:51 PM\n 02:58 AM\n 03:09 AM\n 09:56 AM\n 02:43 PM\n 04:16 PM\n 09:28 PM\n 12:01 AM\n 03:25 AM\n 03:39 AM\n WBC\n 21.8\n 21.5\n 22.3\n Hct\n 23.9\n 24.6\n 25.4\n 26.9\n Plt\n 118\n 115\n 142\n Cr\n 1.0\n 1.0\n TCO2\n 25\n 26\n 21\n 26\n 26\n 27\n Glucose\n 136\n 114\n 144\n 78\n 78\n Other labs: PT / PTT / INR:15.4/31.9/1.4, CK / CKMB /\n Troponin-T:214/3/0.07, ALT / AST:150/246, Alk Phos / T Bili:299/30.5,\n Amylase / Lipase:51/41, Differential-Neuts:68.0 %, Band:5.0 %,\n Lymph:7.0 %, Mono:4.0 %, Eos:0.0 %, D-dimer:6389 ng/mL, Fibrinogen:502\n mg/dL, Lactic Acid:1.3 mmol/L, Albumin:2.0 g/dL, LDH:706 IU/L, Ca++:8.9\n mg/dL, Mg++:1.8 mg/dL, PO4:2.3 mg/dL\n Assessment and Plan\n SEIZURE, WITHOUT STATUS EPILEPTICUS\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n IMPAIRED SKIN INTEGRITY\n HEPATITIS, ACUTE TOXIC (INCLUDING ALCOHOLIC, ACETAMINOPHEN, ETC.)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ICU Care\n Nutrition:\n TPN w/ Lipids - 01:58 PM 77 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 08:15 PM\n Multi Lumen - 10:00 PM\n Dialysis Catheter - 11:35 PM\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" }, { "category": "Physician ", "chartdate": "2131-06-14 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 680746, "text": "Chief Complaint:\n 24 Hour Events:\n EEG - At 04:53 PM\n \n - Midaz was started for likely seizures, but attempted to wean in PM,\n but increased twitching at 9:15 with upward gaze. Given 2 mg ativan\n and went up on midaz gtt to 3 with good effect. Later in morning,\n nurse noted pt twiches more when stimulated, so may be waking up.\n - EEG showed 2 occipital seizures, but neuro stated unclear if this\n clinically correlates. Keppra was increased to 1000 mg .\n - ID has signed off\n - Renal stated to continue CVVH today and plan for transition to HD\n tomorrow.\n - Derm called about bx which showed extensive edema, neutrophils,\n eosinophils, histiocytes. Possibly related to hypersensitivity rxn,\n but also may be leaky vessels with high white count.\n - TF shut off at MN for IR guided tunneled line.\n Allergies:\n Meropenem\n skin blisters a\n Last dose of Antibiotics:\n Vancomycin - 04:00 PM\n Micafungin - 12:33 AM\n Aztreonam - 08:00 PM\n Linezolid - 10:00 PM\n Metronidazole - 02:00 AM\n Infusions:\n Fentanyl (Concentrate) - 100 mcg/hour\n Midazolam (Versed) - 3 mg/hour\n Calcium Gluconate (CRRT) - 1.6 grams/hour\n KCl (CRRT) - 4 mEq./hour\n Other ICU medications:\n Diazepam (Valium) - 08:02 AM\n Lorazepam (Ativan) - 01:20 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 06:19 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.1\nC (98.7\n Tcurrent: 36.2\nC (97.1\n HR: 87 (81 - 102) bpm\n BP: 110/62(80) {96/46(63) - 136/76(98)} mmHg\n RR: 21 (12 - 24) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 118.9 kg (admission): 113.5 kg\n Height: 67 Inch\n CVP: 11 (6 - 16)mmHg\n Total In:\n 11,138 mL\n 3,217 mL\n PO:\n TF:\n 602 mL\n 1 mL\n IVF:\n 8,793 mL\n 2,729 mL\n Blood products:\n Total out:\n 15,874 mL\n 3,969 mL\n Urine:\n 135 mL\n 23 mL\n NG:\n Stool:\n Drains:\n Balance:\n -4,736 mL\n -752 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 585 (545 - 796) mL\n PS : 8 cmH2O\n RR (Spontaneous): 18\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 46\n PIP: 17 cmH2O\n SpO2: 100%\n ABG: 7.35/47/174/21/0\n Ve: 10.8 L/min\n PaO2 / FiO2: 348\n Physical Examination\n GEN: Intubated, sedated\n HEENT: icteric sclera. MMM\n NECK: Trach site with minimal oozing\n LUNGS: Anterior auscultation with upper airway noise; good airway\n movement\n HEART: RRR, normal; S1, S2\n ABD: Distended. NT.\n EXTREM: 2+ edema, ulcers/lesions on legs with bandages C/D/I\n SKIN: Jaundice\n NEURO: Mouth twitching. Arms jerking bilaterally.\n Labs / Radiology\n 142 K/uL\n 8.6 g/dL\n 78 mg/dL\n 1.0 mg/dL\n 21 mEq/L\n 3.8 mEq/L\n 34 mg/dL\n 99 mEq/L\n 134 mEq/L\n 26.9 %\n 22.3 K/uL\n [image002.jpg]\n 09:51 PM\n 02:58 AM\n 03:09 AM\n 09:56 AM\n 02:43 PM\n 04:16 PM\n 09:28 PM\n 12:01 AM\n 03:25 AM\n 03:39 AM\n WBC\n 21.8\n 21.5\n 22.3\n Hct\n 23.9\n 24.6\n 25.4\n 26.9\n Plt\n 118\n 115\n 142\n Cr\n 1.0\n 1.0\n TCO2\n 25\n 26\n 21\n 26\n 26\n 27\n Glucose\n 136\n 114\n 144\n 78\n 78\n Other labs: PT / PTT / INR:15.4/31.9/1.4, CK / CKMB /\n Troponin-T:214/3/0.07, ALT / AST:150/246, Alk Phos / T Bili:299/30.5,\n Amylase / Lipase:51/41, Differential-Neuts:68.0 %, Band:5.0 %,\n Lymph:7.0 %, Mono:4.0 %, Eos:0.0 %, D-dimer:6389 ng/mL, Fibrinogen:502\n mg/dL, Lactic Acid:1.3 mmol/L, Albumin:2.0 g/dL, LDH:706 IU/L, Ca++:8.9\n mg/dL, Mg++:1.8 mg/dL, PO4:2.3 mg/dL\n Assessment and Plan\n SEIZURE, WITHOUT STATUS EPILEPTICUS\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n IMPAIRED SKIN INTEGRITY\n HEPATITIS, ACUTE TOXIC (INCLUDING ALCOHOLIC, ACETAMINOPHEN, ETC.)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ICU Care\n Nutrition:\n TPN w/ Lipids - 01:58 PM 77 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 08:15 PM\n Multi Lumen - 10:00 PM\n Dialysis Catheter - 11:35 PM\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" }, { "category": "Nursing", "chartdate": "2131-06-09 00:00:00.000", "description": "Nursing Progress Note", "row_id": 679852, "text": "Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Oliguric with hourly output of 0-5cc of icteric urine with sludge.\n BUN/CR 42 and 1.5 respectively.\n Action:\n CRRT adjusted to achieve negative hourly fluid balance of 200-250cc/hr\n (see renal MD notes)\n Response:\n Tolerating fluid removal well with minimal adjustment in pressor\n support.\n Plan:\n Follow UO, bun/cr and continue CRRT as ordered.\n Sepsis, Severe (with organ dysfunction)\n Assessment:\n Tmax 99.9, wbc 40. ETT secretions thick and rust colored in small to\n moderate amount.\n Action:\n Continued on ABx coverage empirically for C.diff and skin infection\n and possible pneumonia.\n Response:\n Remains afebrile and hemodynamically stable.\n Plan:\n Folllow culture data, wbc and hemodyanmics, continue antibiotics and\n notify team of any change.\n Impaired Skin Integrity\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": "2131-06-09 00:00:00.000", "description": "Nursing Progress Note", "row_id": 679853, "text": "Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Oliguric with hourly output of 0-5cc of icteric urine with sludge.\n BUN/CR 42 and 1.5 respectively.\n Action:\n CRRT adjusted to achieve negative hourly fluid balance of 200-250cc/hr\n (see renal MD notes)\n Response:\n Tolerating fluid removal well with minimal adjustment in pressor\n support.\n Plan:\n Follow UO, bun/cr and continue CRRT as ordered.\n Sepsis, Severe (with organ dysfunction)\n Assessment:\n Tmax 99.9, wbc 40. ETT secretions thick and rust colored in small to\n moderate amount.\n Action:\n Continued on ABx coverage empirically for C.diff and skin infection\n and possible pneumonia.\n Response:\n Remains afebrile and hemodynamically stable.\n Plan:\n Follow culture data, wbc and hemodyanmics, continue antibiotics and\n notify team of any change.\n Impaired Skin Integrity\n Assessment:\n Skin is warm and dry with general edema and peripheral pulses are\n palpable. Multiple lower extremity blisters are healing with less\n weeping noted from sites and errythema is also resolving.\n Action:\n Rotating side to side, waffle boots in place and barrier cream applied\n to elbows and heels.\n Response:\n Skin surfaces unchanged.\n Plan:\n Continue meticulous skin care, monitor for further areas of skin\n impairment. Enteral and parenteral nutrition as tolerated.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Lungs clear to auscultation and secretions in small quantity. 02 Sat\n consistently >95% and pt tolerates repositioning and care with no\n desaturation observed.\n Action:\n Set rate decreased from 30 to 26\n Response:\n Respiratory rate <20 and 02 sat 96% with no increased work of breathing\n observed.\n Plan:\n Continue vent changes as tolerated and follow respiratory effort and 02\n sats. ABG\ns and CXR\ns as indicated.\n" }, { "category": "Physician ", "chartdate": "2131-05-28 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 677354, "text": "Chief Complaint:\n 24 Hour Events:\n 23% saline changed to q3hrs\n decreased fi02 and peep\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:00 AM\n Metronidazole - 02:00 AM\n Meropenem - 03:00 AM\n Infusions:\n Norepinephrine - 0.05 mcg/Kg/min\n Fentanyl (Concentrate) - 100 mcg/hour\n Calcium Gluconate (CRRT) - 2 grams/hour\n Midazolam (Versed) - 16 mg/hour\n KCl (CRRT) - 2 mEq./hour\n Other ICU medications:\n Pantoprazole (Protonix) - 07:52 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 07:17 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37\nC (98.6\n Tcurrent: 35.9\nC (96.7\n HR: 104 (93 - 111) bpm\n BP: 96/55(68) {79/42(55) - 104/59(74)} mmHg\n RR: 31 (29 - 32) insp/min\n SpO2: 98%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 132 kg (admission): 113.5 kg\n Height: 67 Inch\n CVP: 13 (10 - 18)mmHg\n Total In:\n 10,221 mL\n 2,726 mL\n PO:\n TF:\n IVF:\n 9,667 mL\n 2,726 mL\n Blood products:\n Total out:\n 17,969 mL\n 5,055 mL\n Urine:\n 156 mL\n 25 mL\n NG:\n 150 mL\n 100 mL\n Stool:\n Drains:\n Balance:\n -7,748 mL\n -2,329 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 30\n RR (Spontaneous): 0\n PEEP: 12 cmH2O\n FiO2: 40%\n RSBI Deferred: PEEP > 10\n PIP: 29 cmH2O\n Plateau: 25 cmH2O\n Compliance: 33.3 cmH2O/mL\n SpO2: 98%\n ABG: 7.41/45/84./26/2\n Ve: 12.9 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 59 K/uL\n 9.9 g/dL\n 199 mg/dL\n 1.8 mg/dL\n 26 mEq/L\n 4.0 mEq/L\n 21 mg/dL\n 108 mEq/L\n 145 mEq/L\n 29.0 %\n 38.2 K/uL\n [image002.jpg]\n 04:23 PM\n 09:57 PM\n 10:11 PM\n 04:39 AM\n 04:49 AM\n 11:06 AM\n 05:22 PM\n 11:09 PM\n 04:10 AM\n 04:20 AM\n WBC\n 45.9\n 44.7\n 38.2\n Hct\n 29.2\n 30.4\n 29.0\n Plt\n 67\n 68\n 59\n Cr\n 2.6\n 2.4\n 2.2\n 1.8\n TCO2\n 25\n 28\n 28\n 28\n 30\n 30\n Glucose\n 174\n 188\n 176\n 187\n 175\n 188\n 166\n 199\n Other labs: PT / PTT / INR:19.5/53.6/1.8, ALT / AST:20/210, Alk Phos /\n T Bili:236/20.6, Amylase / Lipase:16/34, Differential-Neuts:71.0 %,\n Band:8.0 %, Lymph:6.0 %, Mono:4.0 %, Eos:2.0 %, D-dimer: ng/mL,\n Fibrinogen:402 mg/dL, Lactic Acid:1.7 mmol/L, Albumin:1.7 g/dL, LDH:742\n IU/L, Ca++:8.5 mg/dL, Mg++:1.8 mg/dL, PO4:2.6 mg/dL\n Assessment and Plan\n IMPAIRED HEALTH MAINTENANCE\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n IMPAIRED SKIN INTEGRITY\n HYPOTENSION (NOT SHOCK)\n HEPATITIS, ACUTE TOXIC (INCLUDING ALCOHOLIC, ACETAMINOPHEN, ETC.)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n PANCREATITIS, ACUTE\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Arterial Line - 01:35 PM\n Multi Lumen - 02:02 PM\n Dialysis Catheter - 04:56 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": "2131-05-28 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 677355, "text": "Chief Complaint:\n 24 Hour Events:\n 23% saline changed to q3hrs\n decreased fi02 and peep\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:00 AM\n Metronidazole - 02:00 AM\n Meropenem - 03:00 AM\n Infusions:\n Norepinephrine - 0.05 mcg/Kg/min\n Fentanyl (Concentrate) - 100 mcg/hour\n Calcium Gluconate (CRRT) - 2 grams/hour\n Midazolam (Versed) - 16 mg/hour\n KCl (CRRT) - 2 mEq./hour\n Other ICU medications:\n Pantoprazole (Protonix) - 07:52 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 07:17 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37\nC (98.6\n Tcurrent: 35.9\nC (96.7\n HR: 104 (93 - 111) bpm\n BP: 96/55(68) {79/42(55) - 104/59(74)} mmHg\n RR: 31 (29 - 32) insp/min\n SpO2: 98%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 132 kg (admission): 113.5 kg\n Height: 67 Inch\n CVP: 13 (10 - 18)mmHg\n Total In:\n 10,221 mL\n 2,726 mL\n PO:\n TF:\n IVF:\n 9,667 mL\n 2,726 mL\n Blood products:\n Total out:\n 17,969 mL\n 5,055 mL\n Urine:\n 156 mL\n 25 mL\n NG:\n 150 mL\n 100 mL\n Stool:\n Drains:\n Balance:\n -7,748 mL\n -2,329 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 30\n RR (Spontaneous): 0\n PEEP: 12 cmH2O\n FiO2: 40%\n RSBI Deferred: PEEP > 10\n PIP: 29 cmH2O\n Plateau: 25 cmH2O\n Compliance: 33.3 cmH2O/mL\n SpO2: 98%\n ABG: 7.41/45/84./26/2\n Ve: 12.9 L/min\n PaO2 / FiO2: 210\n Physical Examination\n General Appearance: Well nourished, total body fluid overload\n Eyes / Conjunctiva: PERRL, pupil 3mm b/l - smaller than prev\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Clear : anteriorly)\n Abdominal: Soft, No(t) Bowel sounds present, Distended\n Extremities: Right: 4+, Left: 4+, No(t) Cyanosis\n Skin: Not assessed\n Neurologic: No(t) Attentive, No(t) Follows simple commands, Responds\n to: Not assessed, No(t) Oriented (to): , Movement: Not assessed,\n Sedated, Tone: Not assessed\n Labs / Radiology\n 59 K/uL\n 9.9 g/dL\n 199 mg/dL\n 1.8 mg/dL\n 26 mEq/L\n 4.0 mEq/L\n 21 mg/dL\n 108 mEq/L\n 145 mEq/L\n 29.0 %\n 38.2 K/uL\n [image002.jpg]\n 04:23 PM\n 09:57 PM\n 10:11 PM\n 04:39 AM\n 04:49 AM\n 11:06 AM\n 05:22 PM\n 11:09 PM\n 04:10 AM\n 04:20 AM\n WBC\n 45.9\n 44.7\n 38.2\n Hct\n 29.2\n 30.4\n 29.0\n Plt\n 67\n 68\n 59\n Cr\n 2.6\n 2.4\n 2.2\n 1.8\n TCO2\n 25\n 28\n 28\n 28\n 30\n 30\n Glucose\n 174\n 188\n 176\n 187\n 175\n 188\n 166\n 199\n Other labs: PT / PTT / INR:19.5/53.6/1.8, ALT / AST:20/210, Alk Phos /\n T Bili:236/20.6, Amylase / Lipase:16/34, Differential-Neuts:71.0 %,\n Band:8.0 %, Lymph:6.0 %, Mono:4.0 %, Eos:2.0 %, D-dimer: ng/mL,\n Fibrinogen:402 mg/dL, Lactic Acid:1.7 mmol/L, Albumin:1.7 g/dL, LDH:742\n IU/L, Ca++:8.5 mg/dL, Mg++:1.8 mg/dL, PO4:2.6 mg/dL\n Assessment and Plan\n IMPAIRED HEALTH MAINTENANCE\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n IMPAIRED SKIN INTEGRITY\n HYPOTENSION (NOT SHOCK)\n HEPATITIS, ACUTE TOXIC (INCLUDING ALCOHOLIC, ACETAMINOPHEN, ETC.)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n PANCREATITIS, ACUTE\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Arterial Line - 01:35 PM\n Multi Lumen - 02:02 PM\n Dialysis Catheter - 04:56 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": "2131-05-28 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 677359, "text": "Chief Complaint:\n 24 Hour Events:\n 23% saline changed to q3hrs\n decreased fi02 and peep\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:00 AM\n Metronidazole - 02:00 AM\n Meropenem - 03:00 AM\n Infusions:\n Norepinephrine - 0.05 mcg/Kg/min\n Fentanyl (Concentrate) - 100 mcg/hour\n Calcium Gluconate (CRRT) - 2 grams/hour\n Midazolam (Versed) - 16 mg/hour\n KCl (CRRT) - 2 mEq./hour\n Other ICU medications:\n Pantoprazole (Protonix) - 07:52 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 07:17 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37\nC (98.6\n Tcurrent: 35.9\nC (96.7\n HR: 104 (93 - 111) bpm\n BP: 96/55(68) {79/42(55) - 104/59(74)} mmHg\n RR: 31 (29 - 32) insp/min\n SpO2: 98%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 132 kg (admission): 113.5 kg\n Height: 67 Inch\n CVP: 13 (10 - 18)mmHg\n Total In:\n 10,221 mL\n 2,726 mL\n PO:\n TF:\n IVF:\n 9,667 mL\n 2,726 mL\n Blood products:\n Total out:\n 17,969 mL\n 5,055 mL\n Urine:\n 156 mL\n 25 mL\n NG:\n 150 mL\n 100 mL\n Stool:\n Drains:\n Balance:\n -7,748 mL\n -2,329 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 30\n RR (Spontaneous): 0\n PEEP: 12 cmH2O\n FiO2: 40%\n RSBI Deferred: PEEP > 10\n PIP: 29 cmH2O\n Plateau: 25 cmH2O\n Compliance: 33.3 cmH2O/mL\n SpO2: 98%\n ABG: 7.41/45/84./26/2\n Ve: 12.9 L/min\n PaO2 / FiO2: 210\n Physical Examination\n General Appearance: Well nourished, total body fluid overload\n Eyes / Conjunctiva: PERRL, pupil 3mm b/l - smaller than prev\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Clear : anteriorly)\n Abdominal: Soft, No(t) Bowel sounds present, Distended\n Extremities: Right: 4+, Left: 4+, No(t) Cyanosis\n Skin: Not assessed\n Neurologic: No(t) Attentive, No(t) Follows simple commands, Responds\n to: Not assessed, No(t) Oriented (to): , Movement: Not assessed,\n Sedated, Tone: Not assessed\n Labs / Radiology\n 59 K/uL\n 9.9 g/dL\n 199 mg/dL\n 1.8 mg/dL\n 26 mEq/L\n 4.0 mEq/L\n 21 mg/dL\n 108 mEq/L\n 145 mEq/L\n 29.0 %\n 38.2 K/uL\n [image002.jpg]\n 04:23 PM\n 09:57 PM\n 10:11 PM\n 04:39 AM\n 04:49 AM\n 11:06 AM\n 05:22 PM\n 11:09 PM\n 04:10 AM\n 04:20 AM\n WBC\n 45.9\n 44.7\n 38.2\n Hct\n 29.2\n 30.4\n 29.0\n Plt\n 67\n 68\n 59\n Cr\n 2.6\n 2.4\n 2.2\n 1.8\n TCO2\n 25\n 28\n 28\n 28\n 30\n 30\n Glucose\n 174\n 188\n 176\n 187\n 175\n 188\n 166\n 199\n Other labs: PT / PTT / INR:19.5/53.6/1.8, ALT / AST:20/210, Alk Phos /\n T Bili:236/20.6, Amylase / Lipase:16/34, Differential-Neuts:71.0 %,\n Band:8.0 %, Lymph:6.0 %, Mono:4.0 %, Eos:2.0 %, D-dimer: ng/mL,\n Fibrinogen:402 mg/dL, Lactic Acid:1.7 mmol/L, Albumin:1.7 g/dL, LDH:742\n IU/L, Ca++:8.5 mg/dL, Mg++:1.8 mg/dL, PO4:2.6 mg/dL\n Assessment and Plan\n Mr. is a 28 year old gentleman with alcoholic hepatitis and\n necrotizing pancreatitis complicated by ARDS, SIRS, and UGIB.\n # Neuro: Initially dilated pupils with CT showing cerebral edema.\n Pupils less dilated and more reactive.\n - continuing keppra and 23% hypertonic saline boluses Q3H with regular\n serum sodium checks. Goal Na 145-150, Osm 310-315\n - Consider mannitol if serum sodium does not improve\n - Wean sedation (starting with fentanyl) as possible\n # Respiratory Failure: ARDS secondary to necrotizing pancreatitis\n compounded by hypoxia, tachypnea in setting of anion gap metabolic\n acidosis, increased abdominal pressure, and EtOH withdrawl. PEEP\n decreased to 12 from 20 and FiO2 to 40%.\n - Wean FiO2 and PEEP, goal PaO2>60-65%\n # Leukocytosis: Stable. Initial concern for infection but normal cx\n suggests that this may be inflammatory reaction. No eos on diff and CT\n without abscesses\n - Continue empiric vancomycin, meropenem, and flagyl. AM vanco level\n today\n - Follow-up culture data\n - f/u ID reccs\n # Necrotizing pancreatitis/SIRS: Secondary to alcohol complicated by\n SIRS and ARDS. Patient continues to have pressor requirement, with neo\n +/- levo. Aggressive volume resuscitation with >53L.\n - Continue empiric antimicrobials.\n - weaning pressors: neo is off and levo at 0.05.\n - Hypertonic saline as above in order to increase intravascular volume.\n # Hyponatremia: In setting of decreased effective circulating volume\n in setting of SIRS and IABP. Patient receiving hypertonic saline\n boluses with improvement in serum sodium.\n - Hypertonic saline as above.\n # Acute renal failure: Patient had HD line placed and CVVH was\n initiated yesterday.\n - CVVH per renal. UF with net neg 300cc/hr\n - Trend chemistries\n #Thrombocytopenia: Platelets stable. No clear etiology at this time.\n DIC panel and HIT PF4 antibody negative.\n - Trend plt, transfuse for plt<10 or <50 if signs of hemorrhage.\n # IAP elevation: Secondary to third spacing and edema. Per surgery, not\n a good surgical candidate at this time.\n # Acute hepatitis: Likely alcoholic hepatitis with fatty infiltration,\n and no evidence of distal obstruction. RUQ u/s shows marked liver\n echogenicity but no ascites.\n - Trend LFTs\n # Hematemesis: EGD showed diuelafoy's lesion. HCT stable since 2 units\n PRBC on .\n - Trend hct, transfuse for hct<21\n # Alcoholism: Patient describes history of withdrawal symptoms, but\n not prior seizure. Last drink was night prior to presentation.\n Tachycardia, weakness, and elevated lactate could be consistent with\n thiamine deficiency.\n - Thiamine, vb12, folate\n - Valium with CIWA > 10\n FEN: TPN, replete as necessary.\n PPx: Heparin and H2B in TPN\n Access: RIJ (quad), LIJ (HD), right radial a-line\n Dispo: ICU level of care\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Arterial Line - 01:35 PM\n Multi Lumen - 02:02 PM\n Dialysis Catheter - 04:56 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": "2131-05-28 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 677373, "text": "Chief Complaint:\n 24 Hour Events:\n 23% saline changed to q3hrs\n decreased fi02 and peep\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:00 AM\n Metronidazole - 02:00 AM\n Meropenem - 03:00 AM\n Infusions:\n Norepinephrine - 0.05 mcg/Kg/min\n Fentanyl (Concentrate) - 100 mcg/hour\n Calcium Gluconate (CRRT) - 2 grams/hour\n Midazolam (Versed) - 16 mg/hour\n KCl (CRRT) - 2 mEq./hour\n Other ICU medications:\n Pantoprazole (Protonix) - 07:52 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 07:17 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37\nC (98.6\n Tcurrent: 35.9\nC (96.7\n HR: 104 (93 - 111) bpm\n BP: 96/55(68) {79/42(55) - 104/59(74)} mmHg\n RR: 31 (29 - 32) insp/min\n SpO2: 98%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 132 kg (admission): 113.5 kg\n Height: 67 Inch\n CVP: 13 (10 - 18)mmHg\n Total In:\n 10,221 mL\n 2,726 mL\n PO:\n TF:\n IVF:\n 9,667 mL\n 2,726 mL\n Blood products:\n Total out:\n 17,969 mL\n 5,055 mL\n Urine:\n 156 mL\n 25 mL\n NG:\n 150 mL\n 100 mL\n Stool:\n Drains:\n Balance:\n -7,748 mL\n -2,329 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 30\n RR (Spontaneous): 0\n PEEP: 12 cmH2O\n FiO2: 40%\n RSBI Deferred: PEEP > 10\n PIP: 29 cmH2O\n Plateau: 25 cmH2O\n Compliance: 33.3 cmH2O/mL\n SpO2: 98%\n ABG: 7.41/45/84./26/2\n Ve: 12.9 L/min\n PaO2 / FiO2: 210\n Physical Examination\n General Appearance: Well nourished, total body fluid overload\n Eyes / Conjunctiva: PERRL, pupil 3mm b/l - smaller than prev\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Clear : anteriorly)\n Abdominal: Soft, No(t) Bowel sounds present, Distended\n Extremities: Right: 4+, Left: 4+, No(t) Cyanosis\n Skin: Not assessed\n Neurologic: No(t) Attentive, No(t) Follows simple commands, Responds\n to: Not assessed, No(t) Oriented (to): , Movement: Not assessed,\n Sedated, Tone: Not assessed\n Labs / Radiology\n 59 K/uL\n 9.9 g/dL\n 199 mg/dL\n 1.8 mg/dL\n 26 mEq/L\n 4.0 mEq/L\n 21 mg/dL\n 108 mEq/L\n 145 mEq/L\n 29.0 %\n 38.2 K/uL\n [image002.jpg]\n 04:23 PM\n 09:57 PM\n 10:11 PM\n 04:39 AM\n 04:49 AM\n 11:06 AM\n 05:22 PM\n 11:09 PM\n 04:10 AM\n 04:20 AM\n WBC\n 45.9\n 44.7\n 38.2\n Hct\n 29.2\n 30.4\n 29.0\n Plt\n 67\n 68\n 59\n Cr\n 2.6\n 2.4\n 2.2\n 1.8\n TCO2\n 25\n 28\n 28\n 28\n 30\n 30\n Glucose\n 174\n 188\n 176\n 187\n 175\n 188\n 166\n 199\n Other labs: PT / PTT / INR:19.5/53.6/1.8, ALT / AST:20/210, Alk Phos /\n T Bili:236/20.6, Amylase / Lipase:16/34, Differential-Neuts:71.0 %,\n Band:8.0 %, Lymph:6.0 %, Mono:4.0 %, Eos:2.0 %, D-dimer: ng/mL,\n Fibrinogen:402 mg/dL, Lactic Acid:1.7 mmol/L, Albumin:1.7 g/dL, LDH:742\n IU/L, Ca++:8.5 mg/dL, Mg++:1.8 mg/dL, PO4:2.6 mg/dL\n Assessment and Plan\n Mr. is a 28 year old gentleman with alcoholic hepatitis and\n necrotizing pancreatitis complicated by ARDS, SIRS, and UGIB.\n # Neuro: Initially dilated pupils with CT showing cerebral edema.\n Pupils less dilated and more reactive.\n - continuing keppra and 23% hypertonic saline boluses Q3H with regular\n serum sodium checks. Goal Na 145-150, Osm 310-315\n - Consider mannitol if serum sodium does not improve\n - Wean sedation (starting with fentanyl) as possible\n # Respiratory Failure: ARDS secondary to necrotizing pancreatitis\n compounded by hypoxia, tachypnea in setting of anion gap metabolic\n acidosis, increased abdominal pressure, and EtOH withdrawl. PEEP\n decreased to 12 from 20 and FiO2 to 40%.\n - Wean FiO2 and PEEP, goal PaO2>60-65%\n # Leukocytosis: Stable. Initial concern for infection but normal cx\n suggests that this may be inflammatory reaction. No eos on diff and CT\n without abscesses\n - dc vancomycin, meropenem, and flagyl since no infection source.\n Monitor closely\n - Follow-up culture data\n - f/u ID reccs\n # Necrotizing pancreatitis/SIRS: Secondary to alcohol complicated by\n SIRS and ARDS. Patient continues to have pressor requirement, with neo\n +/- levo. Aggressive volume resuscitation with >53L.\n - Continue empiric antimicrobials.\n - weaning pressors: neo is off and levo at 0.05.\n - Hypertonic saline as above in order to increase intravascular volume.\n # Hyponatremia: In setting of decreased effective circulating volume\n in setting of SIRS and IABP. Patient receiving hypertonic saline\n boluses with improvement in serum sodium.\n - Hypertonic saline as above.\n # Acute renal failure: Patient had HD line placed and CVVH was\n initiated yesterday.\n - CVVH per renal. UF with net neg 300cc/hr\n - Trend chemistries\n #Thrombocytopenia: Platelets stable. No clear etiology at this time.\n DIC panel and HIT PF4 antibody negative.\n - Trend plt, transfuse for plt<10 or <50 if signs of hemorrhage.\n # IAP elevation: Secondary to third spacing and edema. Per surgery, not\n a good surgical candidate at this time.\n # Acute hepatitis: Likely alcoholic hepatitis with fatty infiltration,\n and no evidence of distal obstruction. RUQ u/s shows marked liver\n echogenicity but no ascites.\n - Trend LFTs\n # Hematemesis: EGD showed diuelafoy's lesion. HCT stable since 2 units\n PRBC on .\n - Trend hct, transfuse for hct<21\n # Alcoholism: Patient describes history of withdrawal symptoms, but\n not prior seizure. Last drink was night prior to presentation.\n Tachycardia, weakness, and elevated lactate could be consistent with\n thiamine deficiency.\n - Thiamine, vb12, folate\n - Valium with CIWA > 10\n FEN: TPN, replete as necessary.\n PPx: Heparin and H2B in TPN\n Access: RIJ (quad), LIJ (HD), right radial a-line\n Dispo: ICU level of care\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Arterial Line - 01:35 PM\n Multi Lumen - 02:02 PM\n Dialysis Catheter - 04:56 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": "2131-05-28 00:00:00.000", "description": "Nursing Progress Note", "row_id": 677442, "text": " Problem\n Cerebral edema\n Assessment:\n Pupils 3mm sluggish to briskly reactive\n Cough x1 only this shift when turning\n No gag\n No movement of extremities\n No seizure activity\n Action:\n Antiepileptics\n Hypertonic saline q 3 hours\n CRRT for fluid removal\n Maintain MAP >60/65 to hopefully maintain CPP > 60 (no way\n to monitor ICP)\n Response:\n No s+s of seizure activity\n Improvement in pupils from (where 7mm sluggish)\n No signs of worsening ICP / herniation\n Plan:\n Continue q 3 hour hypertonic saline\n Continue antiepileptics\n Continue q 2 hour neuro evaluations\n Continue to maintain MAP > 60/65\n Continue to monitor serum sodium and osmolarity levels (goal\n na+ 145-150, osmo 320)\n Impaired Skin Integrity\n Assessment:\n Multiple blistered areas of skin on legs and one of right\n side of abdomen\n Amount of drainage from legs has decreased significantly\n Weeping areas on arms / any puncture site\n has slowed down\n Back, buttocks, heels all remain intact\n Action:\n Q 15 minute rotation function of bed on\n Pads under legs and arms changed frequently\n Full linen change and full body turn q 4 hours\n CRRT for fluid removal\n Response:\n No progression of skin breakdown\n Overall drainage amounts are decreasing\n Still unable to quantify insensible losses from 3^rd spaced\n fluid\n Plan:\n Continue aggressive skin care\n Continue changing linens frequently\n Awaiting skin nurse consult.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n LS clear upper, diminished bases\n FiO2 50%, 12 peep, rr 30 x 400 on AC\n No cough when suctioned for minimal secreations\n Action:\n Constant rotation\n VAP protocol\n CRRT\n Response:\n PAO2 in 70\ns this afternoon, FIO2 increased to 50%\n LS clear even to right base, remain decreased left base\n Plan:\n Continue to wean ventilator as tolerated\n Continue VAP protocol\n Continue rotation\n Pancreatitis, acute\n Assessment:\n WBC 38\n Remains sedated on midazolam and fentanyl drips\n Remains on levophed for goal MAP > 60-65\n Remains ~20 Kg positive from admission weight\n Renal failure continues\n Goal fluid removal is for as much as patient will tolerate\n without having to increase Levophed\n Elevated blood glucose levels\n Action:\n Vancomycin and Meropenum continue\n Flagyl discontinued\n Midazolam weaned to 12 mg/hr from 16\n Insulin increased in TPN\n CRRT for current fluid balance MN\n 1700:\n Response:\n Unable to keep aggressive net -300 cc goal as pt became\n hypotensive and more tachycardic\n CVP now ~16\n Tolerating slow sedation wean\n Awaiting response from increase in insulin in TPN\n Plan:\n Continue supportive measures\n Wean ventilator as toleratee\n Wean sedation as tolerated\n Wean vasopressors as tolerated\n CRRT to remove as much fluid as pt will tolerate without\n increasing vasopressors\n Patient and family support.\n" }, { "category": "Physician ", "chartdate": "2131-06-09 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 679733, "text": "Chief Complaint:\n 24 Hour Events:\n - Got trach-> sutures out in 1 week\n - Came down to 8 of PEEP\n - Started methadone and weaned fentanyl down to 250 (from 350)\n - Hct post-trach 21->1unit ordered->hct 24\n - levophed down to 0.03 throughout day\n - Derm biopsy showed mixed cells c/w either inflammatory, infectious,\n or reactive (ie allergic)\n - Talked to family but forgot to get them to sign HIV consent! (shoot)\n - Wrote for DDAVP X 1 dose for oozing around trach site\n - Increased ISS because sugars out of control in pm and ever since\n steroids started\n - Calcium low. Renal was called and did not want to replete. Will need\n to confirm today.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 04:00 AM\n Aztreonam - 08:00 PM\n Micafungin - 09:00 PM\n Linezolid - 10:00 PM\n Metronidazole - 02:00 AM\n Infusions:\n Norepinephrine - 0.02 mcg/Kg/min\n Midazolam (Versed) - 15 mg/hour\n Calcium Gluconate (CRRT) - 2 grams/hour\n KCl (CRRT) - 4 mEq./hour\n Fentanyl (Concentrate) - 200 mcg/hour\n Other ICU medications:\n Carafate (Sucralfate) - 04:00 AM\n Heparin Sodium (Prophylaxis) - 04:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:11 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.1\nC (98.8\n Tcurrent: 36.2\nC (97.1\n HR: 82 (72 - 95) bpm\n BP: 102/59(71) {84/44(56) - 126/66(85)} mmHg\n RR: 21 (21 - 30) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 134 kg (admission): 113.5 kg\n Height: 67 Inch\n CVP: 13 (11 - 20)mmHg\n Total In:\n 11,098 mL\n 2,908 mL\n PO:\n TF:\n IVF:\n 8,814 mL\n 2,445 mL\n Blood products:\n 798 mL\n Total out:\n 12,489 mL\n 2,758 mL\n Urine:\n 24 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,391 mL\n 150 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 30\n RR (Spontaneous): 0\n PEEP: 8 cmH2O\n FiO2: 50%\n PIP: 24 cmH2O\n Plateau: 21 cmH2O\n Compliance: 30.8 cmH2O/mL\n SpO2: 98%\n ABG: 7.42/40/111/24/1\n Ve: 11.9 L/min\n PaO2 / FiO2: 222\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 43 K/uL\n 8.3 g/dL\n 157 mg/dL\n 1.2 mg/dL\n 24 mEq/L\n 3.4 mEq/L\n 36 mg/dL\n 98 mEq/L\n 131 mEq/L\n 24.9 %\n 40.7 K/uL\n [image002.jpg]\n 10:28 AM\n 12:54 PM\n 06:02 PM\n 06:08 PM\n 09:18 PM\n 09:33 PM\n 12:23 AM\n 01:12 AM\n 01:57 AM\n 04:24 AM\n WBC\n 40.7\n Hct\n 22.3\n 21.7\n 24.6\n 24.9\n Plt\n 47\n 43\n Cr\n 1.2\n TCO2\n 30\n 29\n 29\n 27\n 26\n 27\n Glucose\n 187\n 194\n 186\n 181\n 157\n Other labs: PT / PTT / INR:17.5/38.7/1.6, CK / CKMB /\n Troponin-T:214/3/0.07, ALT / AST:49/186, Alk Phos / T Bili:133/26.8,\n Amylase / Lipase:19/35, Differential-Neuts:56.0 %, Band:14.0 %,\n Lymph:4.0 %, Mono:6.0 %, Eos:1.0 %, D-dimer:6389 ng/mL, Fibrinogen:502\n mg/dL, Lactic Acid:2.0 mmol/L, Albumin:1.7 g/dL, LDH:920 IU/L, Ca++:7.6\n mg/dL, Mg++:2.0 mg/dL, PO4:2.2 mg/dL\n Assessment and Plan\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n IMPAIRED SKIN INTEGRITY\n HEPATITIS, ACUTE TOXIC (INCLUDING ALCOHOLIC, ACETAMINOPHEN, ETC.)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ICU Care\n Nutrition:\n TPN w/ Lipids - 07:00 PM 75 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 08:15 PM\n Multi Lumen - 10:00 PM\n Dialysis Catheter - 11:35 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": "2131-06-09 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 679734, "text": "Chief Complaint:\n 24 Hour Events:\n - Got trach-> sutures out in 1 week\n - Came down to 8 of PEEP\n - Started methadone and weaned fentanyl down to 250 (from 350)\n - Hct post-trach 21->1unit ordered->hct 24\n - levophed down to 0.03 throughout day\n - Derm biopsy showed mixed cells c/w either inflammatory, infectious,\n or reactive (ie allergic)\n - Talked to family but forgot to get them to sign HIV consent! (shoot)\n - Wrote for DDAVP X 1 dose for oozing around trach site\n - Increased ISS because sugars out of control in pm and ever since\n steroids started\n - Calcium low. Renal was called and did not want to replete. Will need\n to confirm today.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 04:00 AM\n Aztreonam - 08:00 PM\n Micafungin - 09:00 PM\n Linezolid - 10:00 PM\n Metronidazole - 02:00 AM\n Infusions:\n Norepinephrine - 0.02 mcg/Kg/min\n Midazolam (Versed) - 15 mg/hour\n Calcium Gluconate (CRRT) - 2 grams/hour\n KCl (CRRT) - 4 mEq./hour\n Fentanyl (Concentrate) - 200 mcg/hour\n Other ICU medications:\n Carafate (Sucralfate) - 04:00 AM\n Heparin Sodium (Prophylaxis) - 04:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:11 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.1\nC (98.8\n Tcurrent: 36.2\nC (97.1\n HR: 82 (72 - 95) bpm\n BP: 102/59(71) {84/44(56) - 126/66(85)} mmHg\n RR: 21 (21 - 30) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 134 kg (admission): 113.5 kg\n Height: 67 Inch\n CVP: 13 (11 - 20)mmHg\n Total In:\n 11,098 mL\n 2,908 mL\n PO:\n TF:\n IVF:\n 8,814 mL\n 2,445 mL\n Blood products:\n 798 mL\n Total out:\n 12,489 mL\n 2,758 mL\n Urine:\n 24 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,391 mL\n 150 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 30\n RR (Spontaneous): 0\n PEEP: 8 cmH2O\n FiO2: 50%\n PIP: 24 cmH2O\n Plateau: 21 cmH2O\n Compliance: 30.8 cmH2O/mL\n SpO2: 98%\n ABG: 7.42/40/111/24/1\n Ve: 11.9 L/min\n PaO2 / FiO2: 222\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 43 K/uL\n 8.3 g/dL\n 157 mg/dL\n 1.2 mg/dL\n 24 mEq/L\n 3.4 mEq/L\n 36 mg/dL\n 98 mEq/L\n 131 mEq/L\n 24.9 %\n 40.7 K/uL\n [image002.jpg]\n 10:28 AM\n 12:54 PM\n 06:02 PM\n 06:08 PM\n 09:18 PM\n 09:33 PM\n 12:23 AM\n 01:12 AM\n 01:57 AM\n 04:24 AM\n WBC\n 40.7\n Hct\n 22.3\n 21.7\n 24.6\n 24.9\n Plt\n 47\n 43\n Cr\n 1.2\n TCO2\n 30\n 29\n 29\n 27\n 26\n 27\n Glucose\n 187\n 194\n 186\n 181\n 157\n Other labs: PT / PTT / INR:17.5/38.7/1.6, CK / CKMB /\n Troponin-T:214/3/0.07, ALT / AST:49/186, Alk Phos / T Bili:133/26.8,\n Amylase / Lipase:19/35, Differential-Neuts:56.0 %, Band:14.0 %,\n Lymph:4.0 %, Mono:6.0 %, Eos:1.0 %, D-dimer:6389 ng/mL, Fibrinogen:502\n mg/dL, Lactic Acid:2.0 mmol/L, Albumin:1.7 g/dL, LDH:920 IU/L, Ca++:7.6\n mg/dL, Mg++:2.0 mg/dL, PO4:2.2 mg/dL\n Assessment and Plan\n 28yo M with alcoholic hepatitis and necrotizing pancreatitis\n complicated by ARDS, SIRS, ARF, UGIB, fevers and eosinophilia.\n #. Fever: Afebrile x 35 h but source unclear. GPCs growing in\n peripheral blood are coag negative staph. Question of fever adrenal\n insufficiency; now on steroids.\n - CT abd with no change but continued colonic thickening consistent\n with infection.\n - F/u derm biopsy results to see if skin infection already on broad\n spectrum antibiotic coverage inc. skin flora coverage\n - Cte broad spectrum antibiotic coverage with aztreonam for extended GN\n coverage, linezolid for MRSA and VRE for bacteremia, flagyl IV, vanc\n PO/PR empirically per ID recs given increasing leukocytosis and colon\n inflammation on CT, micafungin for antifungal coverage\n - F/u cultures\n - Consider TEE to r/o vegetations as TTE was not a definitive study\n - Consent HIV\n - F/u ID recs; appreciate input\n #. Respiratory Failure: ARDS secondary to necrotizing pancreatitis.\n - Oxygenating well on 10 of PEEP. Goal is to wean down peep so can get\n trach placement as has been intubated many days.\n #. Adrenal Insufficiency: Unclear with stim if clear adrenal\n insufficiency but hypotension improving with steroids (lower pressor\n requirement) and improving eosinophilia\n - Will continue steroids IV X 5 days (day 3) then change to prednisone\n to taper\n #. Anemia: Hct lower this am. No clear source of bleeding except from\n NGT where had old blood suctioned up last pm. ?small bleed from Doboff\n placement.\n - recheck hemolysis labs\n - trend hcts Q6H, 1unit pRBCs now, guaiac stools and NGT aspirate\n - If not appropriate bump with blood consider scope to ensure doboff\n did not cause significant bleed\n - holding ppx with PPI or sucralfate given issues of eosinophilia and\n ARF\n #. Eosinophilia: Likely drug reaction (to vanc, ppi or dapto?) with\n parasitic or fungal infection also possible etiologies.\n - stim positive for adrenal insufficiency. Cte steroids.\n - Cte fungal coverage as above\n - Stopped PPI as can cause eosinophilia; will reassess tmrw\n #. Thrombocytopenia: Appreciate heme recs. Do not feel this is DIC.\n Recent decrease may be in setting of linezolid.\n - Monitor platelets daily and transfuse for plt <10 or <50 if signs of\n bleed\n - Would linezolid when/if able\n #. Acute renal Failure: Appreciate renal recs. Will continue CVVH. Stop\n sucralfate due to risk of electrolyte abnormalities.\n #. Wounds: Derm biopsy pending but likely edema caused wounds\n #. Agitation: Added methadone to given decreased sensitivity to\n fentanyl; titrate prn\n ICU Care\n Nutrition:\n TPN w/ Lipids - 07:00 PM 75 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 08:15 PM\n Multi Lumen - 10:00 PM\n Dialysis Catheter - 11:35 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": "2131-06-09 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 679749, "text": "Chief Complaint:\n 24 Hour Events:\n - Trach placed; PEEP decreased to 8\n - Methadone started and able to wean fentanyl down 350 -> 250\n - Levophed weaned down to 0.03 throughout day\n - Received 1 unit pRBC post trach with increase in Hct 21 -> 24\n - Received DDAVP x 1 dose for oozing around trach site\n - Increased ISS for hyperglycemia in setting of steroids\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 04:00 AM\n Aztreonam - 08:00 PM\n Micafungin - 09:00 PM\n Linezolid - 10:00 PM\n Metronidazole - 02:00 AM\n Infusions:\n Norepinephrine - 0.02 mcg/Kg/min\n Midazolam (Versed) - 15 mg/hour\n Calcium Gluconate (CRRT) - 2 grams/hour\n KCl (CRRT) - 4 mEq./hour\n Fentanyl (Concentrate) - 200 mcg/hour\n Other ICU medications:\n Carafate (Sucralfate) - 04:00 AM\n Heparin Sodium (Prophylaxis) - 04:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:11 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.1\nC (98.8\n Tcurrent: 36.2\nC (97.1\n HR: 82 (72 - 95) bpm\n BP: 102/59(71) {84/44(56) - 126/66(85)} mmHg\n RR: 21 (21 - 30) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 134 kg (admission): 113.5 kg\n Height: 67 Inch\n CVP: 13 (11 - 20)mmHg\n Total In:\n 11,098 mL\n 2,908 mL\n PO:\n TF:\n IVF:\n 8,814 mL\n 2,445 mL\n Blood products:\n 798 mL\n Total out:\n 12,489 mL\n 2,758 mL\n Urine:\n 24 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,391 mL\n 150 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 30\n RR (Spontaneous): 0\n PEEP: 8 cmH2O\n FiO2: 50%\n PIP: 24 cmH2O\n Plateau: 21 cmH2O\n Compliance: 30.8 cmH2O/mL\n SpO2: 98%\n ABG: 7.42/40/111/24/1\n Ve: 11.9 L/min\n PaO2 / FiO2: 222\n Physical Examination\n GEN: Intubated, sedated\n HEENT: icteric sclera. MMM\n NECK: Sites clean/dry/no oozing\n LUNGS: Crackles bilaterally anteriorly.\n HEART: RRR\n ABD: Distended. NT.\n EXTREM: 2+ edema with weeping wounds without surrounding erythema,\n ulcers/lesions on legs with bandages C/D/I\n SKIN: Jaundice\n Labs / Radiology\n 43 K/uL\n 8.3 g/dL\n 157 mg/dL\n 1.2 mg/dL\n 24 mEq/L\n 3.4 mEq/L\n 36 mg/dL\n 98 mEq/L\n 131 mEq/L\n 24.9 %\n 40.7 K/uL\n [image002.jpg]\n 10:28 AM\n 12:54 PM\n 06:02 PM\n 06:08 PM\n 09:18 PM\n 09:33 PM\n 12:23 AM\n 01:12 AM\n 01:57 AM\n 04:24 AM\n WBC\n 40.7\n Hct\n 22.3\n 21.7\n 24.6\n 24.9\n Plt\n 47\n 43\n Cr\n 1.2\n TCO2\n 30\n 29\n 29\n 27\n 26\n 27\n Glucose\n 187\n 194\n 186\n 181\n 157\n Other labs: PT / PTT / INR:17.5/38.7/1.6, CK / CKMB /\n Troponin-T:214/3/0.07, ALT / AST:49/186, Alk Phos / T Bili:133/26.8,\n Amylase / Lipase:19/35, Differential-Neuts:56.0 %, Band:14.0 %,\n Lymph:4.0 %, Mono:6.0 %, Eos:1.0 %, D-dimer:6389 ng/mL, Fibrinogen:502\n mg/dL, Lactic Acid:2.0 mmol/L, Albumin:1.7 g/dL, LDH:920 IU/L, Ca++:7.6\n mg/dL, Mg++:2.0 mg/dL, PO4:2.2 mg/dL\n tissue cx pending. BAL/asp: bact cx neg, fungal pending. \n coag neg staph x 1 bottle.\n Derm biopsy: mixed cells c/w either inflammatory, infectious, or\n reactive\n Assessment and Plan\n 28yo M with alcoholic hepatitis and necrotizing pancreatitis\n complicated by ARDS, SIRS, ARF, UGIB, fevers and eosinophilia.\n #. Fever: Afebrile x >2d; source unclear. Question of fever \n adrenal insufficiency; now on steroids Concern for infection given\n stably elevated WBC with increased bandemia today. Blood/tissue/BAL cx\n NGTD, CT abd with persistent inflammation concerning for infection. CT\n sinuses w/ opacification of unclear time course.\n - Cte broad spectrum antibiotic coverage with aztreonam for extended GN\n coverage, linezolid for MRSA and VRE for bacteremia, flagyl IV, vanc\n PO/PR empirically per ID recs given increasing leukocytosis and colon\n inflammation on CT, micafungin for antifungal coverage\n - F/u derm biopsy results to see if skin infection; already on broad\n spectrum antibiotic coverage inc. skin flora coverage\n - F/u cultures\n - Consider TEE to r/o vegetations as TTE was not a definitive study\n - F/u ID recs; question tx of sinuses but already on broad coverage\n #. Respiratory Failure: ARDS secondary to necrotizing pancreatitis. S/p\n trach placement yesterday on PEEP 8\n - Sutures out on \n - Cont to wean as tolerated\n #. Adrenal Insufficiency: Unclear with stim if clear adrenal\n insufficiency but hypotension improving with steroids (lower pressor\n requirement) and improving eosinophilia\n - Will continue steroids IV X 5 days (day 3) then change to prednisone\n to taper\n #. Eosinophilia: Adrenal insufficiency v. drug reaction (?PPI; vanc &\n dapto less likely d/t time course). Fungal and parasitic infection also\n possible etiologies.\n - stim positive for adrenal insufficiency. Cte steroids.\n - Off PPI, vanc, dapto\n - Cte fungal coverage as above\n #. Anemia: Hct stable since 1 unit pRBC and 1 dose DDAVP s/p trach with\n some oozing at site.\n - recheck hemolysis labs\n - trend hcts Q6H, 1unit pRBCs now, guaiac stools and NGT aspirate\n - If not appropriate bump with blood consider scope to ensure doboff\n did not cause significant bleed\n - holding ppx with PPI or sucralfate given issues of eosinophilia and\n ARF\n #. Thrombocytopenia: Appreciate heme recs. Do not feel this is DIC.\n Recent decrease may be in setting of linezolid.\n - Monitor platelets daily and transfuse for plt <10 or <50 if signs of\n bleed\n - Would linezolid when/if able\n #. Acute renal Failure: Appreciate renal recs. Cr improved on CVVH. Off\n sucralfate due to concern for electrolyte abnormalities.\n #. Wounds: Derm biopsy pending - inflammatory, infectious, or reactive.\n F/u recs.\n #. Agitation: Cont methadone given decreased sensitivity to fentanyl;\n titrate prn\n #. Glucose intolerance: In setting of steroids; adjust ISS prn\n ICU Care\n Nutrition:\n TPN w/ Lipids - 07:00 PM 75 mL/hour\n Glycemic Control: ISS\n Lines:\n Arterial Line - 08:15 PM\n Multi Lumen - 10:00 PM\n Dialysis Catheter - 11:35 PM\n Prophylaxis:\n DVT: Pneumoboots\n Stress ulcer: Holding PPI and sucralfate for now\n VAP: HOB elevation, Mouth care\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n" }, { "category": "Physician ", "chartdate": "2131-06-10 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 680001, "text": "Chief Complaint:\n 24 Hour Events:\n \n - Added heparin and famotidine to TPN\n - ID: Keep broad coverage for now. Cld change linezolid to dapto if\n concerned re: plts. Eosinophilia likely vanc or meropenem. Consider\n reinvolving Heme for left shift.\n - Requiring levophed on and off all night.\n - Hct stable in PM\n - CVVH pulling off 200 cc/h\n - Blood oozing from trach site -> DDAVP x 1 dose. Hct stable.\n Allergies:\n Meropenem\n skin blisters a\n Last dose of Antibiotics:\n Vancomycin - 04:00 AM\n Aztreonam - 08:05 PM\n Linezolid - 10:00 PM\n Micafungin - 11:00 PM\n Metronidazole - 02:00 AM\n Infusions:\n Fentanyl (Concentrate) - 150 mcg/hour\n KCl (CRRT) - 3 mEq./hour\n Midazolam (Versed) - 12 mg/hour\n Calcium Gluconate (CRRT) - 2 grams/hour\n Other ICU medications:\n Carafate (Sucralfate) - 10:20 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 07:06 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.7\nC (99.8\n Tcurrent: 36.2\nC (97.1\n HR: 89 (80 - 104) bpm\n BP: 91/50(62) {84/42(54) - 128/75(93)} mmHg\n RR: 15 (0 - 31) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 134 kg (admission): 113.5 kg\n Height: 67 Inch\n CVP: 8 (8 - 19)mmHg\n Total In:\n 9,393 mL\n 3,162 mL\n PO:\n TF:\n 148 mL\n 142 mL\n IVF:\n 7,336 mL\n 2,482 mL\n Blood products:\n Total out:\n 10,064 mL\n 3,775 mL\n Urine:\n 23 mL\n 18 mL\n NG:\n Stool:\n Drains:\n Balance:\n -671 mL\n -613 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 26\n RR (Spontaneous): 0\n PEEP: 8 cmH2O\n FiO2: 50%\n RSBI: 45\n PIP: 24 cmH2O\n Plateau: 20 cmH2O\n SpO2: 100%\n ABG: 7.36/36/77./21/-4\n Ve: 10.7 L/min\n PaO2 / FiO2: 156\n Physical Examination\n GEN: Intubated, sedated\n HEENT: icteric sclera. MMM\n NECK: Trach sites minimal oozing\n LUNGS: Crackles bilaterally anteriorly.\n HEART: RRR\n ABD: Distended. NT.\n EXTREM: 2+ edema, ulcers/lesions on legs with bandages C/D/I, Oozing\n from R groin ulcer\n SKIN: Jaundice\n Labs / Radiology\n 61 K/uL\n 7.7 g/dL\n 184 mg/dL\n 0.9 mg/dL\n 21 mEq/L\n 3.9 mEq/L\n 40 mg/dL\n 100 mEq/L\n 132 mEq/L\n 23.4 %\n 29.1 K/uL\n [image002.jpg]\n 04:24 AM\n 06:50 AM\n 08:11 AM\n 12:31 PM\n 04:16 PM\n 06:28 PM\n 08:15 PM\n 02:23 AM\n 02:43 AM\n 05:01 AM\n WBC\n 29.1\n Hct\n 23.3\n 23.6\n 23.4\n Plt\n 66\n 61\n Cr\n 1.5\n 0.9\n TCO2\n 27\n 26\n 25\n 24\n 27\n 25\n 21\n Glucose\n 157\n 149\n 184\n Other labs: PT / PTT / INR:16.1/43.4/1.4, CK / CKMB /\n Troponin-T:214/3/0.07, ALT / AST:55/193, Alk Phos / T Bili:138/25.0,\n Amylase / Lipase:19/35, Differential-Neuts:65.0 %, Band:12.0 %,\n Lymph:3.0 %, Mono:7.0 %, Eos:2.0 %, D-dimer:6389 ng/mL, Fibrinogen:502\n mg/dL, Lactic Acid:1.4 mmol/L, Albumin:2.0 g/dL, LDH:789 IU/L, Ca++:7.8\n mg/dL, Mg++:2.0 mg/dL, PO4:2.7 mg/dL\n Assessment and Plan\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n IMPAIRED SKIN INTEGRITY\n HEPATITIS, ACUTE TOXIC (INCLUDING ALCOHOLIC, ACETAMINOPHEN, ETC.)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n 28yo M with alcoholic hepatitis and necrotizing pancreatitis\n complicated by ARDS, SIRS, ARF, UGIB, fevers and eosinophilia.\n #. Fever: Afebrile x>3days - source unclear. Question of fever \n adrenal insufficiency; now on steroids. Concern for infection with\n increased bandemia today although leukocytosis improved.\n Blood/tissue/BAL cx NGTD, CT abd with persistent inflammation\n concerning for infection. CT sinuses w/ opacification of unclear time\n course.\n - Cte broad spectrum antibiotic coverage with aztreonam for extended GN\n coverage, linezolid for MRSA and VRE for bacteremia, flagyl IV, vanc PO\n empirically per ID recs given increasing leukocytosis and colon\n inflammation on CT, micafungin for antifungal coverage\n - F/u WBC and temp curve\n - F/u derm biopsy results to see if skin infection; already on broad\n spectrum antibiotic coverage inc. skin flora coverage\n - F/u cultures\n - F/u ID recs; question: how to down abx over next few days\n #. Respiratory Failure: ARDS secondary to necrotizing pancreatitis. S/p\n trach placement on \n - Sutures out on \n - Cont to wean as tolerated.\n - Cte to wean fentanyl\n #. Adrenal Insufficiency: Unclear with stim if clear adrenal\n insufficiency but hypotension improving with steroids (lower pressor\n requirement) and improving eosinophilia\n - Will continue steroids IV X 5 days (day 5) then change to prednisone\n to taper\n #. Eosinophilia: Adrenal insufficiency v. drug reaction (?PPI; vanc &\n dapto less likely d/t time course). Fungal and parasitic infection also\n possible etiologies.\n - stim positive for adrenal insufficiency. Cte steroids.\n - Off PPI, vanc, dapto\n - Cte fungal coverage as above\n #. Anemia: Hct stable since 1 unit pRBC and 1 dose DDAVP s/p trach with\n some oozing at site.\n - recheck hemolysis labs\n - trend hcts Q6H, 1unit pRBCs now, guaiac stools and NGT aspirate\n - If not appropriate bump with blood consider scope to ensure doboff\n did not cause significant bleed\n - holding ppx with PPI or sucralfate given issues of eosinophilia and\n ARF\n #. Thrombocytopenia: Appreciate heme recs. Do not feel this is DIC.\n - Monitor platelets daily and transfuse for plt <10 or <50 if signs of\n bleed\n - monitor daily\n #. Acute renal Failure: Appreciate renal recs. Cr improved on CVVH. Off\n sucralfate due to concern for electrolyte abnormalities.\n - Cte volume depletion with CVVH as long as pressor requirement does\n not increase\n #. Wounds: Derm biopsy pending - inflammatory, infectious, or reactive.\n F/u recs.\n #. Agitation: Cont methadone given decreased sensitivity to fentanyl;\n titrate prn\n #. Glucose intolerance: In setting of steroids; adjust ISS prn\n ICU Care\n Nutrition:\n TPN w/ Lipids - 05:28 PM 76 mL/hour\n Fibersource HN (Full) - 04:35 AM 20 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 08:15 PM\n Multi Lumen - 10:00 PM\n Dialysis Catheter - 11:35 PM\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: Heparin gtt)\n Stress ulcer: H2 blocker\n VAP: HOB elevation, Mouth care\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n" }, { "category": "Nursing", "chartdate": "2131-06-10 00:00:00.000", "description": "Nursing Progress Note", "row_id": 680003, "text": "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 Impaired Skin Integrity\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Physician ", "chartdate": "2131-06-10 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 679916, "text": "Chief Complaint:\n 24 Hour Events:\n \n - Added heparin and famotidine to TPN\n - ID: Keep broad coverage for now. Cld change linezolid to dapto if\n concerned re: plts. Eosinophilia likely vanc or meropenem. Consider\n reinvolving Heme for left shift.\n - Hct stable in PM\n - CVVH pulling off 200 cc/h\n - Blood oozing from trach site -> DDAVP x 1 dose. Hct stable.\n Allergies:\n Meropenem\n skin blisters a\n Last dose of Antibiotics:\n Vancomycin - 04:00 AM\n Aztreonam - 08:05 PM\n Linezolid - 10:00 PM\n Micafungin - 11:00 PM\n Metronidazole - 02:00 AM\n Infusions:\n Fentanyl (Concentrate) - 150 mcg/hour\n KCl (CRRT) - 3 mEq./hour\n Midazolam (Versed) - 12 mg/hour\n Calcium Gluconate (CRRT) - 2 grams/hour\n Other ICU medications:\n Carafate (Sucralfate) - 10:20 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 07:06 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.7\nC (99.8\n Tcurrent: 36.2\nC (97.1\n HR: 89 (80 - 104) bpm\n BP: 91/50(62) {84/42(54) - 128/75(93)} mmHg\n RR: 15 (0 - 31) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 134 kg (admission): 113.5 kg\n Height: 67 Inch\n CVP: 8 (8 - 19)mmHg\n Total In:\n 9,393 mL\n 3,162 mL\n PO:\n TF:\n 148 mL\n 142 mL\n IVF:\n 7,336 mL\n 2,482 mL\n Blood products:\n Total out:\n 10,064 mL\n 3,775 mL\n Urine:\n 23 mL\n 18 mL\n NG:\n Stool:\n Drains:\n Balance:\n -671 mL\n -613 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 26\n RR (Spontaneous): 0\n PEEP: 8 cmH2O\n FiO2: 50%\n RSBI: 45\n PIP: 24 cmH2O\n Plateau: 20 cmH2O\n SpO2: 100%\n ABG: 7.36/36/77./21/-4\n Ve: 10.7 L/min\n PaO2 / FiO2: 156\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 61 K/uL\n 7.7 g/dL\n 184 mg/dL\n 0.9 mg/dL\n 21 mEq/L\n 3.9 mEq/L\n 40 mg/dL\n 100 mEq/L\n 132 mEq/L\n 23.4 %\n 29.1 K/uL\n [image002.jpg]\n 04:24 AM\n 06:50 AM\n 08:11 AM\n 12:31 PM\n 04:16 PM\n 06:28 PM\n 08:15 PM\n 02:23 AM\n 02:43 AM\n 05:01 AM\n WBC\n 29.1\n Hct\n 23.3\n 23.6\n 23.4\n Plt\n 66\n 61\n Cr\n 1.5\n 0.9\n TCO2\n 27\n 26\n 25\n 24\n 27\n 25\n 21\n Glucose\n 157\n 149\n 184\n Other labs: PT / PTT / INR:16.1/43.4/1.4, CK / CKMB /\n Troponin-T:214/3/0.07, ALT / AST:55/193, Alk Phos / T Bili:138/25.0,\n Amylase / Lipase:19/35, Differential-Neuts:65.0 %, Band:12.0 %,\n Lymph:3.0 %, Mono:7.0 %, Eos:2.0 %, D-dimer:6389 ng/mL, Fibrinogen:502\n mg/dL, Lactic Acid:1.4 mmol/L, Albumin:2.0 g/dL, LDH:789 IU/L, Ca++:7.8\n mg/dL, Mg++:2.0 mg/dL, PO4:2.7 mg/dL\n Assessment and Plan\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n IMPAIRED SKIN INTEGRITY\n HEPATITIS, ACUTE TOXIC (INCLUDING ALCOHOLIC, ACETAMINOPHEN, ETC.)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ICU Care\n Nutrition:\n TPN w/ Lipids - 05:28 PM 76 mL/hour\n Fibersource HN (Full) - 04:35 AM 20 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 08:15 PM\n Multi Lumen - 10:00 PM\n Dialysis Catheter - 11:35 PM\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: Heparin gtt)\n Stress ulcer: H2 blocker\n VAP: HOB elevation, Mouth care\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:ICU\n" }, { "category": "Physician ", "chartdate": "2131-06-10 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 679917, "text": "Chief Complaint:\n 24 Hour Events:\n \n - Added heparin and famotidine to TPN\n - ID: Keep broad coverage for now. Cld change linezolid to dapto if\n concerned re: plts. Eosinophilia likely vanc or meropenem. Consider\n reinvolving Heme for left shift.\n - Hct stable in PM\n - CVVH pulling off 200 cc/h\n - Blood oozing from trach site -> DDAVP x 1 dose. Hct stable.\n Allergies:\n Meropenem\n skin blisters a\n Last dose of Antibiotics:\n Vancomycin - 04:00 AM\n Aztreonam - 08:05 PM\n Linezolid - 10:00 PM\n Micafungin - 11:00 PM\n Metronidazole - 02:00 AM\n Infusions:\n Fentanyl (Concentrate) - 150 mcg/hour\n KCl (CRRT) - 3 mEq./hour\n Midazolam (Versed) - 12 mg/hour\n Calcium Gluconate (CRRT) - 2 grams/hour\n Other ICU medications:\n Carafate (Sucralfate) - 10:20 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 07:06 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.7\nC (99.8\n Tcurrent: 36.2\nC (97.1\n HR: 89 (80 - 104) bpm\n BP: 91/50(62) {84/42(54) - 128/75(93)} mmHg\n RR: 15 (0 - 31) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 134 kg (admission): 113.5 kg\n Height: 67 Inch\n CVP: 8 (8 - 19)mmHg\n Total In:\n 9,393 mL\n 3,162 mL\n PO:\n TF:\n 148 mL\n 142 mL\n IVF:\n 7,336 mL\n 2,482 mL\n Blood products:\n Total out:\n 10,064 mL\n 3,775 mL\n Urine:\n 23 mL\n 18 mL\n NG:\n Stool:\n Drains:\n Balance:\n -671 mL\n -613 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 26\n RR (Spontaneous): 0\n PEEP: 8 cmH2O\n FiO2: 50%\n RSBI: 45\n PIP: 24 cmH2O\n Plateau: 20 cmH2O\n SpO2: 100%\n ABG: 7.36/36/77./21/-4\n Ve: 10.7 L/min\n PaO2 / FiO2: 156\n Physical Examination\n GEN: Intubated, sedated\n HEENT: icteric sclera. MMM\n NECK: Sites clean/dry/no oozing\n LUNGS: Crackles bilaterally anteriorly.\n HEART: RRR\n ABD: Distended. NT.\n EXTREM: 2+ edema with weeping wounds without surrounding erythema,\n ulcers/lesions on legs with bandages C/D/I\n SKIN: Jaundice\n Labs / Radiology\n 61 K/uL\n 7.7 g/dL\n 184 mg/dL\n 0.9 mg/dL\n 21 mEq/L\n 3.9 mEq/L\n 40 mg/dL\n 100 mEq/L\n 132 mEq/L\n 23.4 %\n 29.1 K/uL\n [image002.jpg]\n 04:24 AM\n 06:50 AM\n 08:11 AM\n 12:31 PM\n 04:16 PM\n 06:28 PM\n 08:15 PM\n 02:23 AM\n 02:43 AM\n 05:01 AM\n WBC\n 29.1\n Hct\n 23.3\n 23.6\n 23.4\n Plt\n 66\n 61\n Cr\n 1.5\n 0.9\n TCO2\n 27\n 26\n 25\n 24\n 27\n 25\n 21\n Glucose\n 157\n 149\n 184\n Other labs: PT / PTT / INR:16.1/43.4/1.4, CK / CKMB /\n Troponin-T:214/3/0.07, ALT / AST:55/193, Alk Phos / T Bili:138/25.0,\n Amylase / Lipase:19/35, Differential-Neuts:65.0 %, Band:12.0 %,\n Lymph:3.0 %, Mono:7.0 %, Eos:2.0 %, D-dimer:6389 ng/mL, Fibrinogen:502\n mg/dL, Lactic Acid:1.4 mmol/L, Albumin:2.0 g/dL, LDH:789 IU/L, Ca++:7.8\n mg/dL, Mg++:2.0 mg/dL, PO4:2.7 mg/dL\n Assessment and Plan\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n IMPAIRED SKIN INTEGRITY\n HEPATITIS, ACUTE TOXIC (INCLUDING ALCOHOLIC, ACETAMINOPHEN, ETC.)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ICU Care\n Nutrition:\n TPN w/ Lipids - 05:28 PM 76 mL/hour\n Fibersource HN (Full) - 04:35 AM 20 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 08:15 PM\n Multi Lumen - 10:00 PM\n Dialysis Catheter - 11:35 PM\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: Heparin gtt)\n Stress ulcer: H2 blocker\n VAP: HOB elevation, Mouth care\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:ICU\n" }, { "category": "Physician ", "chartdate": "2131-06-10 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 679920, "text": "Chief Complaint:\n 24 Hour Events:\n \n - Added heparin and famotidine to TPN\n - ID: Keep broad coverage for now. Cld change linezolid to dapto if\n concerned re: plts. Eosinophilia likely vanc or meropenem. Consider\n reinvolving Heme for left shift.\n - Hct stable in PM\n - CVVH pulling off 200 cc/h\n - Blood oozing from trach site -> DDAVP x 1 dose. Hct stable.\n Allergies:\n Meropenem\n skin blisters a\n Last dose of Antibiotics:\n Vancomycin - 04:00 AM\n Aztreonam - 08:05 PM\n Linezolid - 10:00 PM\n Micafungin - 11:00 PM\n Metronidazole - 02:00 AM\n Infusions:\n Fentanyl (Concentrate) - 150 mcg/hour\n KCl (CRRT) - 3 mEq./hour\n Midazolam (Versed) - 12 mg/hour\n Calcium Gluconate (CRRT) - 2 grams/hour\n Other ICU medications:\n Carafate (Sucralfate) - 10:20 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 07:06 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.7\nC (99.8\n Tcurrent: 36.2\nC (97.1\n HR: 89 (80 - 104) bpm\n BP: 91/50(62) {84/42(54) - 128/75(93)} mmHg\n RR: 15 (0 - 31) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 134 kg (admission): 113.5 kg\n Height: 67 Inch\n CVP: 8 (8 - 19)mmHg\n Total In:\n 9,393 mL\n 3,162 mL\n PO:\n TF:\n 148 mL\n 142 mL\n IVF:\n 7,336 mL\n 2,482 mL\n Blood products:\n Total out:\n 10,064 mL\n 3,775 mL\n Urine:\n 23 mL\n 18 mL\n NG:\n Stool:\n Drains:\n Balance:\n -671 mL\n -613 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 26\n RR (Spontaneous): 0\n PEEP: 8 cmH2O\n FiO2: 50%\n RSBI: 45\n PIP: 24 cmH2O\n Plateau: 20 cmH2O\n SpO2: 100%\n ABG: 7.36/36/77./21/-4\n Ve: 10.7 L/min\n PaO2 / FiO2: 156\n Physical Examination\n GEN: Intubated, sedated\n HEENT: icteric sclera. MMM\n NECK: Sites clean/dry/no oozing\n LUNGS: Crackles bilaterally anteriorly.\n HEART: RRR\n ABD: Distended. NT.\n EXTREM: 2+ edema with weeping wounds without surrounding erythema,\n ulcers/lesions on legs with bandages C/D/I\n SKIN: Jaundice\n Labs / Radiology\n 61 K/uL\n 7.7 g/dL\n 184 mg/dL\n 0.9 mg/dL\n 21 mEq/L\n 3.9 mEq/L\n 40 mg/dL\n 100 mEq/L\n 132 mEq/L\n 23.4 %\n 29.1 K/uL\n [image002.jpg]\n 04:24 AM\n 06:50 AM\n 08:11 AM\n 12:31 PM\n 04:16 PM\n 06:28 PM\n 08:15 PM\n 02:23 AM\n 02:43 AM\n 05:01 AM\n WBC\n 29.1\n Hct\n 23.3\n 23.6\n 23.4\n Plt\n 66\n 61\n Cr\n 1.5\n 0.9\n TCO2\n 27\n 26\n 25\n 24\n 27\n 25\n 21\n Glucose\n 157\n 149\n 184\n Other labs: PT / PTT / INR:16.1/43.4/1.4, CK / CKMB /\n Troponin-T:214/3/0.07, ALT / AST:55/193, Alk Phos / T Bili:138/25.0,\n Amylase / Lipase:19/35, Differential-Neuts:65.0 %, Band:12.0 %,\n Lymph:3.0 %, Mono:7.0 %, Eos:2.0 %, D-dimer:6389 ng/mL, Fibrinogen:502\n mg/dL, Lactic Acid:1.4 mmol/L, Albumin:2.0 g/dL, LDH:789 IU/L, Ca++:7.8\n mg/dL, Mg++:2.0 mg/dL, PO4:2.7 mg/dL\n Assessment and Plan\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n IMPAIRED SKIN INTEGRITY\n HEPATITIS, ACUTE TOXIC (INCLUDING ALCOHOLIC, ACETAMINOPHEN, ETC.)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n 28yo M with alcoholic hepatitis and necrotizing pancreatitis\n complicated by ARDS, SIRS, ARF, UGIB, fevers and eosinophilia.\n #. Fever: Afebrile x >2d; source unclear. Question of fever adrenal\n insufficiency; now on steroids. Concern for infection with increased\n bandemia today although leukocytosis improved. Blood/tissue/BAL cx\n NGTD, CT abd with persistent inflammation concerning for infection. CT\n sinuses w/ opacification of unclear time course.\n - Cte broad spectrum antibiotic coverage with aztreonam for extended GN\n coverage, linezolid for MRSA and VRE for bacteremia, flagyl IV, vanc PO\n empirically per ID recs given increasing leukocytosis and colon\n inflammation on CT, micafungin for antifungal coverage\n - F/u WBC and temp curve\n - F/u derm biopsy results to see if skin infection; already on broad\n spectrum antibiotic coverage inc. skin flora coverage\n - F/u cultures\n - F/u ID recs; question: how to down abx over next few days\n #. Respiratory Failure: ARDS secondary to necrotizing pancreatitis. S/p\n trach placement yesterday on PEEP 8\n - Sutures out on \n - Cont to wean as tolerated. Try pressure support today.\n - Cte to wean fentanyl\n #. Adrenal Insufficiency: Unclear with stim if clear adrenal\n insufficiency but hypotension improving with steroids (lower pressor\n requirement) and improving eosinophilia\n - Will continue steroids IV X 5 days (day 4) then change to prednisone\n to taper\n #. Eosinophilia: Adrenal insufficiency v. drug reaction (?PPI; vanc &\n dapto less likely d/t time course). Fungal and parasitic infection also\n possible etiologies.\n - stim positive for adrenal insufficiency. Cte steroids.\n - Off PPI, vanc, dapto\n - Cte fungal coverage as above\n #. Anemia: Hct stable since 1 unit pRBC and 1 dose DDAVP s/p trach with\n some oozing at site.\n - recheck hemolysis labs\n - trend hcts Q6H, 1unit pRBCs now, guaiac stools and NGT aspirate\n - If not appropriate bump with blood consider scope to ensure doboff\n did not cause significant bleed\n - holding ppx with PPI or sucralfate given issues of eosinophilia and\n ARF\n #. Thrombocytopenia: Appreciate heme recs. Do not feel this is DIC.\n Recent decrease may be in setting of linezolid.\n - Monitor platelets daily and transfuse for plt <10 or <50 if signs of\n bleed\n - Would d/c linezolid when/if able\n #. Acute renal Failure: Appreciate renal recs. Cr improved on CVVH. Off\n sucralfate due to concern for electrolyte abnormalities.\n - Cte volume depletion with CVVH as long as pressor requirement does\n not increase\n #. Wounds: Derm biopsy pending - inflammatory, infectious, or reactive.\n F/u recs.\n #. Agitation: Cont methadone given decreased sensitivity to fentanyl;\n titrate prn\n #. Glucose intolerance: In setting of steroids; adjust ISS prn\n ICU Care\n Nutrition:\n TPN w/ Lipids - 05:28 PM 76 mL/hour\n Fibersource HN (Full) - 04:35 AM 20 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 08:15 PM\n Multi Lumen - 10:00 PM\n Dialysis Catheter - 11:35 PM\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: Heparin gtt)\n Stress ulcer: H2 blocker\n VAP: HOB elevation, Mouth care\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:ICU\n" }, { "category": "Physician ", "chartdate": "2131-06-10 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 679933, "text": "Chief Complaint:\n 24 Hour Events:\n \n - Added heparin and famotidine to TPN\n - ID: Keep broad coverage for now. Cld change linezolid to dapto if\n concerned re: plts. Eosinophilia likely vanc or meropenem. Consider\n reinvolving Heme for left shift.\n - Requiring levophed on and off all night.\n - Hct stable in PM\n - CVVH pulling off 200 cc/h\n - Blood oozing from trach site -> DDAVP x 1 dose. Hct stable.\n Allergies:\n Meropenem\n skin blisters a\n Last dose of Antibiotics:\n Vancomycin - 04:00 AM\n Aztreonam - 08:05 PM\n Linezolid - 10:00 PM\n Micafungin - 11:00 PM\n Metronidazole - 02:00 AM\n Infusions:\n Fentanyl (Concentrate) - 150 mcg/hour\n KCl (CRRT) - 3 mEq./hour\n Midazolam (Versed) - 12 mg/hour\n Calcium Gluconate (CRRT) - 2 grams/hour\n Other ICU medications:\n Carafate (Sucralfate) - 10:20 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 07:06 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.7\nC (99.8\n Tcurrent: 36.2\nC (97.1\n HR: 89 (80 - 104) bpm\n BP: 91/50(62) {84/42(54) - 128/75(93)} mmHg\n RR: 15 (0 - 31) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 134 kg (admission): 113.5 kg\n Height: 67 Inch\n CVP: 8 (8 - 19)mmHg\n Total In:\n 9,393 mL\n 3,162 mL\n PO:\n TF:\n 148 mL\n 142 mL\n IVF:\n 7,336 mL\n 2,482 mL\n Blood products:\n Total out:\n 10,064 mL\n 3,775 mL\n Urine:\n 23 mL\n 18 mL\n NG:\n Stool:\n Drains:\n Balance:\n -671 mL\n -613 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 26\n RR (Spontaneous): 0\n PEEP: 8 cmH2O\n FiO2: 50%\n RSBI: 45\n PIP: 24 cmH2O\n Plateau: 20 cmH2O\n SpO2: 100%\n ABG: 7.36/36/77./21/-4\n Ve: 10.7 L/min\n PaO2 / FiO2: 156\n Physical Examination\n GEN: Intubated, sedated\n HEENT: icteric sclera. MMM\n NECK: Sites clean/dry/no oozing\n LUNGS: Crackles bilaterally anteriorly.\n HEART: RRR\n ABD: Distended. NT.\n EXTREM: 2+ edema with weeping wounds without surrounding erythema,\n ulcers/lesions on legs with bandages C/D/I\n SKIN: Jaundice\n Labs / Radiology\n 61 K/uL\n 7.7 g/dL\n 184 mg/dL\n 0.9 mg/dL\n 21 mEq/L\n 3.9 mEq/L\n 40 mg/dL\n 100 mEq/L\n 132 mEq/L\n 23.4 %\n 29.1 K/uL\n [image002.jpg]\n 04:24 AM\n 06:50 AM\n 08:11 AM\n 12:31 PM\n 04:16 PM\n 06:28 PM\n 08:15 PM\n 02:23 AM\n 02:43 AM\n 05:01 AM\n WBC\n 29.1\n Hct\n 23.3\n 23.6\n 23.4\n Plt\n 66\n 61\n Cr\n 1.5\n 0.9\n TCO2\n 27\n 26\n 25\n 24\n 27\n 25\n 21\n Glucose\n 157\n 149\n 184\n Other labs: PT / PTT / INR:16.1/43.4/1.4, CK / CKMB /\n Troponin-T:214/3/0.07, ALT / AST:55/193, Alk Phos / T Bili:138/25.0,\n Amylase / Lipase:19/35, Differential-Neuts:65.0 %, Band:12.0 %,\n Lymph:3.0 %, Mono:7.0 %, Eos:2.0 %, D-dimer:6389 ng/mL, Fibrinogen:502\n mg/dL, Lactic Acid:1.4 mmol/L, Albumin:2.0 g/dL, LDH:789 IU/L, Ca++:7.8\n mg/dL, Mg++:2.0 mg/dL, PO4:2.7 mg/dL\n Assessment and Plan\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n IMPAIRED SKIN INTEGRITY\n HEPATITIS, ACUTE TOXIC (INCLUDING ALCOHOLIC, ACETAMINOPHEN, ETC.)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n 28yo M with alcoholic hepatitis and necrotizing pancreatitis\n complicated by ARDS, SIRS, ARF, UGIB, fevers and eosinophilia.\n #. Fever: Afebrile x>3days - source unclear. Question of fever \n adrenal insufficiency; now on steroids. Concern for infection with\n increased bandemia today although leukocytosis improved.\n Blood/tissue/BAL cx NGTD, CT abd with persistent inflammation\n concerning for infection. CT sinuses w/ opacification of unclear time\n course.\n - Cte broad spectrum antibiotic coverage with aztreonam for extended GN\n coverage, linezolid for MRSA and VRE for bacteremia, flagyl IV, vanc PO\n empirically per ID recs given increasing leukocytosis and colon\n inflammation on CT, micafungin for antifungal coverage\n - F/u WBC and temp curve\n - F/u derm biopsy results to see if skin infection; already on broad\n spectrum antibiotic coverage inc. skin flora coverage\n - F/u cultures\n - F/u ID recs; question: how to down abx over next few days\n #. Respiratory Failure: ARDS secondary to necrotizing pancreatitis. S/p\n trach placement on PEEP 8\n - Sutures out on \n - Cont to wean as tolerated. Try pressure support today.\n - Cte to wean fentanyl\n #. Adrenal Insufficiency: Unclear with stim if clear adrenal\n insufficiency but hypotension improving with steroids (lower pressor\n requirement) and improving eosinophilia\n - Will continue steroids IV X 5 days (day 4) then change to prednisone\n to taper\n #. Eosinophilia: Adrenal insufficiency v. drug reaction (?PPI; vanc &\n dapto less likely d/t time course). Fungal and parasitic infection also\n possible etiologies.\n - stim positive for adrenal insufficiency. Cte steroids.\n - Off PPI, vanc, dapto\n - Cte fungal coverage as above\n #. Anemia: Hct stable since 1 unit pRBC and 1 dose DDAVP s/p trach with\n some oozing at site.\n - recheck hemolysis labs\n - trend hcts Q6H, 1unit pRBCs now, guaiac stools and NGT aspirate\n - If not appropriate bump with blood consider scope to ensure doboff\n did not cause significant bleed\n - holding ppx with PPI or sucralfate given issues of eosinophilia and\n ARF\n #. Thrombocytopenia: Appreciate heme recs. Do not feel this is DIC.\n Recent decrease may be in setting of linezolid.\n - Monitor platelets daily and transfuse for plt <10 or <50 if signs of\n bleed\n - Would d/c linezolid when/if able\n #. Acute renal Failure: Appreciate renal recs. Cr improved on CVVH. Off\n sucralfate due to concern for electrolyte abnormalities.\n - Cte volume depletion with CVVH as long as pressor requirement does\n not increase\n #. Wounds: Derm biopsy pending - inflammatory, infectious, or reactive.\n F/u recs.\n #. Agitation: Cont methadone given decreased sensitivity to fentanyl;\n titrate prn\n #. Glucose intolerance: In setting of steroids; adjust ISS prn\n ICU Care\n Nutrition:\n TPN w/ Lipids - 05:28 PM 76 mL/hour\n Fibersource HN (Full) - 04:35 AM 20 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 08:15 PM\n Multi Lumen - 10:00 PM\n Dialysis Catheter - 11:35 PM\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: Heparin gtt)\n Stress ulcer: H2 blocker\n VAP: HOB elevation, Mouth care\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:ICU\n" }, { "category": "Nursing", "chartdate": "2131-06-10 00:00:00.000", "description": "Nursing Progress Note", "row_id": 680012, "text": "28yo M with alcoholic hepatitis and necrotizing pancreatitis\n complicated by ARDS, SIRS, ARF, UGIB, fevers. On CRRT.\n trache\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Receive pt on CVVHD and pressors Levophed 0.02mcg/kg/min. Anuric\n foley u/o 0-10cc/hr icteric with sediment. Tol fluid removal\n -100-200/hr. levophed wean to off briefly became hypotensive SPB to\n 90\ns resumed levophed 0.03mcg/kg/min. LIJ TLC CVP 14-18. Skin warm\n dry anasarca +.\n Action:\n Tol Fluid removal with pressors SBP>100 MAPS>60. Electrolyte repletion\n per CRRT parameters. Hypothermic on bear hugger.\n Response:\n Pressor dependent for fluid removal. Fluid bal -1800 ( >25L)\n Plan:\n Cont fluid removal as tol Goal -100-200/hr.\n Monitor labs q6hrs per CRRT protocol.\n Electrolyte repletion per sliding scale.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received pt w/ trach #8 portex. Sedated Fent and Versed, On vent mode\n CMV % 8 peep , occas OBV 2-5bpm TV>350. sats 90-100%. Lungs\n rhonchi dim based episode I/E wheezes improved w/ MDI per RT. Wean\n F102 to 40%, seriel ABG followed current 7.36- 42-99-28 no further vent\n changes. Suctioned via trach q2hrs for sm\nmod bloody secretions. Cont\n to Ooz frank blood around trach site. Tryadyne bed autorotation most\n of shift. CXR bil infiltrated unchanged. T-max 98.4\n Action:\n Wean FIO2 40%. Cont hemopysis and bleeding around trach site.\n Started albuterol MDI, received Hydrocortisone q8hrs. Abx x4\n Response:\n Improved resp status w MDI. Bloody secretions now less.\n Plan:\n Monitor resp status.\n Seriel ABG\n Daily CXR\n Follow culture data\n Hepatitis, acute toxic (ETOH) necrotizing pancreatitis.\n Assessment:\n Received pt sedated Fentanyl 150mcg/hr and Versed 12mg/hr. wean fent\n and versed per methadone taper. Eyes closed most of time will open to\n noxious stimulation and occassionally opens spont . not tracking\n surrounding, gaze does not blink spont. Noted eyes deviate pupils 2-3mm\n PEARL. Brisk. Minimal response to painful stimulation. withdraws\n nailbed pressure all extreme. UE flaccid. No tremors siezures .\n received Keppra per routine.\n Action:\n Wean fentanyl by and verded by 2mg. received methadone. Level of\n responsiveness lighter.\n Response:\n Positive response to sedation taper. No seizure activity.\n Plan:\n Monitor NVS signs of seizures.\n Methadone\n Wean sedation per plan\n Monitor Keppra levels.\n Impaired Skin Integrity\n Assessment:\n Jaundice warm dry. Anasarca skin now dry no weeping. Skin lesions dry\n few noted exudate adaptic dsg DSD applied.\n Action:\n Dsg to LE lesions cleansed and dsg applied.\n Response:\n Lesions generally crusted/ healing.\n Plan:\n Follow wound/ derm recommendations. Dsg changes q12hrs.\n Bed rotation mode for freq turning.\n" }, { "category": "Nursing", "chartdate": "2131-06-08 00:00:00.000", "description": "Nursing Progress Note", "row_id": 679652, "text": "Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Cont CRRT to achieve goal neg as tolerated without\n increasing pressures\n K down to 3.6 Renal fellow notified\n Action:\n Pt becoming hypotensive at times and during that time pt was\n run even to avoid increased pressure requirement\n PBP fluid changed to K4 and Post filter rate increased to\n 1000 per renal fellow\n Response:\n Pt BP waxes/wanes with CVVH but did tolerate fluid\n removal. Currently about 1 liter neg without increasing pressors.\n Cont to monitor K and increase per sliding scale\n Plan:\n Cont with CRRT and fluid removal as tolerated\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received on A/C TV 400C30 Peep 10\n Lungs clear to diminished at bases\n Minimal secretions\n Action:\n Peep weaned to 8\n Lung sounds unchanged\n Bloody oral secretion\n Response:\n Tolerated peep wean\n Thoracic happy with peep of 8 OR an 1550 for trach\n Tolerated OR well received 1u FFP\n Peep increased to 10 after post OR Pa02 64\n Sxn for copious oral bloody secretions\n Plan:\n Wean Peep as tolerated\n Methadone increased to wean fent\n Fent decreased to 250mcg\n Sepsis, Severe (with organ dysfunction)\n Assessment:\n Remains afebrile\n Post transfusion crit 22.4\n Cont on low dose levo\n WBC\ns trending down\n Action:\n Cont with low dose levo .03-.05 depending on amout of fluid\n removal\n Cont ABx and steroids\n Post trach crit 21 awaiting another unit of blood\n Response:\n Levo holding at .03-.05 range\n Cont steroids\n Remains afebrile\n WBC\ns trending down\n Fungal culture still pending\n 1 PIV BC bottle grew out Coag\nstaph\n BAL neg\n Plan:\n Cont to monitor hemodynamics closely\n Wean levo as tolerated\n Cont with current plan of care\n" }, { "category": "Respiratory ", "chartdate": "2131-06-09 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 679841, "text": "Demographics\n :\n Day of mechanical ventilation: 23\n Ideal body weight: 67.1 None\n Ideal tidal volume: 268.4 / 402.6 / 536.8 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Tube Type\n Tracheostomy tube:\n Type: Standard\n Manufacturer: Portex\n Size: 8.0mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 29 cmH2O\n Cuff volume: mL /\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Clear\n Secretions\n Sputum color / consistency: Brown / Thick\n Sputum source/amount: Suctioned / Scant\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Active exhalations; Comments:\n slow sedation and vent weans\n Assessment of breathing comfort: No response (sleeping / sedated)\n Invasive ventilation assessment:\n Trigger work assessment: Abnormal trigger efforts (efforts during\n inspiratory)\n Dysynchrony assessment: Vigorous inspiratory efforts\n Comments: some periods of dissynchrony w/ sedation wean. RN aware.\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 Respiratory Care Shift Procedures\n 18:30\n" }, { "category": "Nursing", "chartdate": "2131-06-10 00:00:00.000", "description": "Nursing Progress Note", "row_id": 680008, "text": "28yo M with alcoholic hepatitis and necrotizing pancreatitis\n complicated by ARDS, SIRS, ARF, UGIB, fevers. On CRRT.\n trache\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Receive pt on CVVHD and pressors Levophed 0.02mcg/kg/min. Anuric\n foley u/o 0-10cc/hr icteric with sediment. Tol fluid removal\n -100-200/hr. levophed wean to off briefly became hypotensive SPB to\n 90\ns resumed levophed 0.03mcg/kg/min. LIJ TLC CVP 14-18. Skin warm\n dry anasarca +.\n Action:\n Tol Fluid removal with pressors SBP>100 MAPS>60. Electrolyte repletion\n per CRRT parameters.\n Response:\n Pressor dependent for fluid removal. Fluid bal -1800 ( >25L)\n Plan:\n Cont fluid removal as tol Goal -100-200/hr.\n Monitor labs q6hrs per CRRT protocol.\n Electrolyte repletion per sliding scale.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received pt w/ trach #8 portex. On vent mode CMV % 8 peep ,\n occas OBV 2-5bpm TV>350. sats 90-100%. Lungs rhonchi dim based\n episode I/E wheezes improved w/ MDI per RT. Wean F102 to 40%, seriel\n ABG followed current 7.36- 42-99-28 no further vent changes. Suctioned\n via trach q2hrs for sm\nmod bloody secretions. Cont to Ooz frank blood\n around trach site. Tryadyne bed autorotation most of shift. CXR bil\n infiltrated unchanged.\n Action:\n Wean FIO2 40%. Cont hemopysis and bleeding around trach site.\n Started albuterol MDI\n Response:\n Improved resp status w MDI. Bloody secretions now less.\n Plan:\n Monitor resp status.\n Seriel ABG\n Daily CXR\n Impaired Skin Integrity\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2131-05-28 00:00:00.000", "description": "Nursing Progress Note", "row_id": 677340, "text": "TITLE:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Bbs clear but diminished at bases. O2 sats >95% vent settings cmv tv\n 400 rr 30 fio2 40% peep 16\n Action:\n Peep weaned to 12cm. Vap bundle. Lavage and suct for thick clear.Bari\n Max bed w rotation.every 10 mins throughout noc.\n Response:\n O2 sats and abg adeq on 12cm peep. Bbs increasingly audible to bases\n and clear.\n Plan:\n Cont vap bundle, pulm toilet ,rotating bed\n Hypotension (not Shock)\n Assessment:\n Levophed(0.035mcg/kg/m) and neo (@ 2.75 mcg/kg /min) to achieve goal\n mbp > 60. MICU team goal to minimize pressor overnight if\n possible.Crrt continues w goal net negative -300cc/hr\n Action:\n Levo titrated up for mbp < 60 while weaning neo to off\n Response:\n Mbp > 60 with levophed currently at 0.05mcg/kg/min\n Plan:\n Cont to wean levophed as tolerated, while continue achieve net negative\n -300cc with crrt\n Impaired Skin Integrity\n Assessment:\n Large insensible loss from weeping of bilat lower extremeties blisters\n and rt and lt flank area. Decreased weepage from bilat upper\n extremeties\n Action:\n Linens and absorbent bed pads changed at least q2-3hr overnight. Bilat\n lower extrems wrapped in cloth sterile towel to decrease risk of\n cutaneous infection\n Response:\n Bilat lower extremeties continue w erythematous, edematous weeping\n blisters, frequency of absorbent pad changes decreased overnight with\n pt tolerating crrt fluid removal in excess of 7liters in past 24hrs.\n Plan:\n Cont. meticulous skin care and freq absorbent bed pad & sterile towel\n changes as frequently as necessary. Wound and skin consult. ?\n dermatology or plastics consult for further recommendations. Wbc\n remains elevated at 38 today.\n Problem Cerebral edema\n Assessment:\n No gag, no corneals, no cough at begin of shift. Pupils 2-3mm\n sluggishly reactive, no spontaneous movement or to noxious stimuli.\n Fentanyl(275 mcg/hr)and versed(22mg/hr) gtts continue. Per Micu attempt\n to wean sedation starting with fentanyl. No seizure activity.\n Action:\n Upon lavage and suction, weak cough and nasal flaring noted , otherwise\n exam unchanged. Fentanyl to 100mcg/hr. Versed to 16mg/hr. hypertonic\n saline 23.4% q3hrs overnight. Serum Osm and Na+ q6h overnight.\n Response:\n Neuro exam unchanged with exception of weak cough.Serum Osm 310 Serum\n Na+ 145\n Plan:\n Check with team re: any further narcotic/sedative wean.? Transition at\n some point to methadone. Hypertonic saline to continue through 12pm\n today, check with team re: further recommendations to follow serum osm\n and Na+s.\n" }, { "category": "Physician ", "chartdate": "2131-06-11 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 680192, "text": "Chief Complaint:\n 24 Hour Events:\n - Tolerated CVVH with good diuresis\n - ID rec 1) continue Flagyl/Linezolid/Aztreonam/Micafungin, 2) consider\n heme re-consult for persistantly altered differential despite long\n course of ABX and ? hemophagocytic syndrome, 3) would add Cipro if\n clinical deterioration, and 4) consider change linezolid to dapto if\n thrombocytopenia worsens\n - Renal rec continue CVVH with UF 100 cc/hr as she tolerates.\n - PM Hct stable.\n - Pt became bronchospastic in evening with some oozing at trach site.\n CXR appeared improved if anything. Given bronchodilators with good\n effect\n Allergies:\n Meropenem\n skin blisters a\n Last dose of Antibiotics:\n Metronidazole - 10:00 AM\n Vancomycin - 04:39 PM\n Aztreonam - 09:30 PM\n Linezolid - 10:28 PM\n Micafungin - 12:04 AM\n Infusions:\n Norepinephrine - 0.03 mcg/Kg/min\n Fentanyl (Concentrate) - 100 mcg/hour\n Midazolam (Versed) - 10 mg/hour\n Calcium Gluconate (CRRT) - 1.6 grams/hour\n Other ICU medications:\n Fentanyl - 04:34 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:59 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.1\nC (98.8\n Tcurrent: 35.7\nC (96.3\n HR: 104 (84 - 107) bpm\n BP: 92/49(63) {91/48(62) - 129/74(93)} mmHg\n RR: 14 (9 - 28) insp/min\n SpO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 134 kg (admission): 113.5 kg\n Height: 67 Inch\n CVP: 20 (11 - 21)mmHg\n Total In:\n 10,596 mL\n 2,852 mL\n PO:\n TF:\n 480 mL\n 92 mL\n IVF:\n 8,289 mL\n 2,230 mL\n Blood products:\n Total out:\n 14,018 mL\n 4,260 mL\n Urine:\n 78 mL\n NG:\n Stool:\n Drains:\n Balance:\n -3,422 mL\n -1,408 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 24\n RR (Spontaneous): 0\n PEEP: 8 cmH2O\n FiO2: 40%\n RSBI Deferred: Unstable Airway\n PIP: 18 cmH2O\n SpO2: 100%\n ABG: 7.33/52/131/24/0\n Ve: 10.6 L/min\n PaO2 / FiO2: 328\n Physical Examination\n GEN: Intubated, sedated\n HEENT: icteric sclera. MMM\n NECK: Trach site with minimal oozing\n LUNGS: Anterior auscultation with upper airway noise; good airway\n movement\n HEART: , ; S1, S2\n ABD: Distended. NT.\n EXTREM: 2+ edema, ulcers/lesions on legs with bandages C/D/I\n SKIN: Jaundice\n Labs / Radiology\n 82 K/uL\n 8.1 g/dL\n 155 mg/dL\n 0.9 mg/dL\n 24 mEq/L\n 4.5 mEq/L\n 35 mg/dL\n 98 mEq/L\n 132 mEq/L\n 24.5 %\n 28.3 K/uL\n [image002.jpg]\n N:68 Band:5 L:7 M:4 E:0 Bas:0 Metas: 10 Myelos: 3 Promyel: 3 Nrbc: 15\n Ca: 8.7 Mg: 2.1 P: 3.3\n ALT: 74\n AP: 172\n Tbili: 28.5\n Alb:\n AST: 206\n LDH: 775\n Dbili:\n TProt:\n :\n Lip:\n PT: 16.1\n PTT: 37.7\n INR: 1.4\n 08:15 AM\n 08:34 AM\n 02:08 PM\n 02:31 PM\n 05:15 PM\n 08:27 PM\n 08:36 PM\n 11:00 PM\n 02:20 AM\n 02:35 AM\n WBC\n 29.6\n 28.3\n Hct\n 23.9\n 24.5\n Plt\n 69\n 82\n Cr\n 0.9\n 0.9\n TCO2\n 26\n 25\n 25\n 27\n 27\n 29\n Glucose\n 166\n 177\n 131\n 155\n Other labs: PT / PTT / INR:16.1/37.7/1.4, CK / CKMB /\n Troponin-T:214/3/0.07, ALT / AST:74/206, Alk Phos / T Bili:172/28.5,\n Amylase / Lipase:19/35, Differential-Neuts:68.0 %, Band:5.0 %,\n Lymph:7.0 %, Mono:4.0 %, Eos:0.0 %, D-dimer:6389 ng/mL, Fibrinogen:502\n mg/dL, Lactic Acid:1.6 mmol/L, Albumin:2.0 g/dL, LDH:775 IU/L, Ca++:8.7\n mg/dL, Mg++:2.1 mg/dL, PO4:3.3 mg/dL\n No new culture data\n Assessment and Plan\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n IMPAIRED SKIN INTEGRITY\n HEPATITIS, ACUTE TOXIC (INCLUDING ALCOHOLIC, ACETAMINOPHEN, ETC.)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n 28M with alcoholic hepatitis and necrotizing pancreatitis complicated\n by ARDS, SIRS, ARF, UGIB, fevers and eosinophilia\n #. Fever: Afebrile x>3days - source unclear. Question of fever \n adrenal insufficiency; now on steroids. Concern for infection with\n increased bandemia today although leukocytosis improved.\n Blood/tissue/BAL cx NGTD, CT abd with persistent inflammation\n concerning for infection. CT sinuses w/ opacification of unclear time\n course.\n - Cte broad spectrum antibiotic coverage with aztreonam for extended GN\n coverage, linezolid for MRSA and VRE for bacteremia, flagyl IV, vanc PO\n empirically per ID recs given increasing leukocytosis and colon\n inflammation on CT, micafungin for antifungal coverage\n - F/u WBC and temp curve\n - F/u derm biopsy results to see if skin infection; already on broad\n spectrum antibiotic coverage inc. skin flora coverage\n - F/u cultures\n - F/u ID recs; question: how to down abx over next few days\n #. Respiratory Failure: ARDS secondary to necrotizing pancreatitis. S/p\n trach placement on \n - Sutures out on \n - Cont to wean as tolerated.\n - Cte to wean fentanyl\n #. Adrenal Insufficiency: Unclear with stim if clear adrenal\n insufficiency but hypotension improving with steroids (lower pressor\n requirement) and improving eosinophilia\n - Will continue steroids IV X 5 days (day 5) then change to prednisone\n to taper\n #. Eosinophilia: Adrenal insufficiency v. drug reaction (?PPI; vanc &\n dapto less likely d/t time course). Fungal and parasitic infection also\n possible etiologies.\n - stim positive for adrenal insufficiency. Cte steroids.\n - Off PPI, vanc, dapto\n - Cte fungal coverage as above\n #. Anemia: Hct stable since 1 unit pRBC and 1 dose DDAVP s/p trach with\n some oozing at site.\n - recheck hemolysis labs\n - trend hcts Q6H, 1unit pRBCs now, guaiac stools and NGT aspirate\n - If not appropriate bump with blood consider scope to ensure doboff\n did not cause significant bleed\n - holding ppx with PPI or sucralfate given issues of eosinophilia and\n ARF\n #. Thrombocytopenia: Appreciate heme recs. Do not feel this is DIC.\n - Monitor platelets daily and transfuse for plt <10 or <50 if signs of\n bleed\n - monitor daily\n #. Acute renal Failure: Appreciate renal recs. Cr improved on CVVH. Off\n sucralfate due to concern for electrolyte abnormalities.\n - Cte volume depletion with CVVH as long as pressor requirement does\n not increase\n #. Wounds: Derm biopsy pending - inflammatory, infectious, or reactive.\n F/u recs.\n #. Agitation: Cont methadone given decreased sensitivity to fentanyl;\n titrate prn\n #. Glucose intolerance: In setting of steroids; adjust ISS prn\n ICU Care\n Nutrition:\n TPN w/ Lipids - 03:48 PM 76 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 08:15 PM\n Multi Lumen - 10:00 PM\n Dialysis Catheter - 11:35 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Respiratory ", "chartdate": "2131-05-29 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 677642, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 12\n Ideal body weight: 67.1 None\n Ideal tidal volume: 268.4 / 402.6 / 536.8 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type: Standard\n Size: 7mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Diminished\n LUL Lung Sounds: Diminished\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount: Suctioned / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern:\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours:\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments: Patient remains on mechanical ventilation with high RR.\n Compliance apparently improved with PIP 25 cmH2o. ABG acceptable ,\n suctioned for scant to minimal amount of secretion. BS diminished on\n both sides , but better than days ago. CVVHD arount time clock.\n" }, { "category": "Respiratory ", "chartdate": "2131-05-31 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 677910, "text": "Demographics\n Day of intubation: \n Day of mechanical ventilation: 14\n Ideal body weight: 67.1 None\n Ideal tidal volume: 268.4 / 402.6 / 536.8 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Tube Type\n ETT:\n Position: 23 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Clear\n Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount: Suctioned / Scant\n Comments: Pt did have a slight improvement in cough and secretion\n mobility.\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Underlying illness\n not resolved\n" }, { "category": "Nursing", "chartdate": "2131-05-31 00:00:00.000", "description": "Nursing Progress Note", "row_id": 677919, "text": " Problem\n Cerebral Edema\n Assessment:\n Pupils 2mm, sluggish to briskly reactive\n No movement of extremities\n No gag, however pt clearly reacts to mouth care, bites on\n bite block\n Spontaneous cough x3 episodes this shift, can not recreate\n cough with suctioning\n CT scan from showed less cerebral edema than\n previous scan\n No S+S of seizure activity\n Action:\n Q 2 hour neuro checks\n Maintain map > 60 to maintain CPP > 60 (no way to measure\n ICP at this time)\n Keppra as ordered\n CRRT to assist with fluid removal\n Response:\n Small improvements noted in neuro exam\n Improvement in cerebral edema noted on CT scan\n Plan:\n Continue current monitoring and management\n Continue keppra\n Continue CRRT\n Patient and family support\n Impaired Skin Integrity\n Assessment:\n Open blisters on legs continue to weep serous to sero-sang\n fluid\n Red rash present\n Back and buttocks continue to be intact, no skin breakdown\n Bilat heels with ? deep tissue injury\n Action:\n Leg wounds cleansed with wound cleanser\n Aquacel to all open blisters\n Aloe-vesta to all intact skin\n Covered with softsorb and mesh stockings\n Turned q20 minutes on rotating bed, and total turn for linen\n changes q 4\n CRRT to assist with fluid removal\n Response:\n No progression of skin breakdown\n Improvements noted on legs since Monday \n Plan:\n Continue recommendations by skin nurse on treatment\n Continue q 20 minutes rotation\n Patient and family support;\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt remains on AC, 50%, 12 Peep, RR 30 X 400 with last ABG:\n 7.43, 48, 76, 6, 33.\n Lung sounds clear, diminished bases\n Suctioned for scant amount thick clear yellow tinged sputum\n Patient biting/clenching down on bite block with mouth care\n No cough initiated with ETT suctioning\n Action:\n Bed on constant rotation\n VAP protocol\n CRRT for fluid removal\n Chest x-ray\n Response:\n Remains in a mild metabolic alkalosis with concerning ARDS\n picture\n Plan:\n Continue rotation\n Continue VAP protocol\n Wean ventilator as tolerated\n Pancreatitis, acute\n Assessment:\n Afebrile\n MAP > 60 met with levophed gtt\n HCT 23.8\n Abdomen softly distended with + hypoactive bs\n Remains many liters fluid positive\n Action:\n Transfused one unit of PRBC\n CRRT for goal to keep patient even\n ABX discontinued yesterday \n Levophed gtt weaned slightly to 0.1 mcg/kg/min\n Response:\n WBC 31 from 36\n Platelets 60 from 48\n HCT now 25.7 from 23.8, no S+S of active bleeding\n Fluid balance for +177 cc\n Fluid balance MN\n 0600 : - 600 cc\n Plan:\n Continue CRRT for goal even fluid balance\n Patient and family support\n Continue to monitor labs, HCT\ns, S+S of bleeding\n" }, { "category": "Respiratory ", "chartdate": "2131-06-11 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 680064, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 25\n Ideal body weight: 67.1 None\n Ideal tidal volume: 268.4 / 402.6 / 536.8 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location:\n Reason:\n Tube Type\n Tracheostomy tube:\n Type: Standard\n Manufacturer: Portex\n Size: 8.0mm\n PMV: No\n Cuff Management:\n Vol/Press:\n Cuff pressure: 29 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Diminished\n LUL Lung Sounds: Diminished\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Bloody / 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:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Dysynchrony assessment: Frequent alarms (High pressure)\n Comments: When pt is not fully sedated, agitated, or becomes\n wheezey/bronchospastic, Pt alarms with \"High Pressure\" and \"Vol not\n Constant\"\n Plan\n Next 24-48 hours: Adjust Min. ventilation to control pH, Increase\n ventilatory support at night\n Reason for continuing current ventilatory support: Sedated / Paralyzed,\n Intolerant of weaning attempts, Cannot protect airway, Cannot manage\n secretions, Underlying illness not resolved; Comments: At , Pt had\n acute episode of bronchospasm, with prolonged expiratory cycle. Pt was\n suctioned, given many Albuterol MDI puffs, and settings changed in to\n order to help this acute episode. Pt had very bloody trach site, with\n much blood being suctioned from airway. After 1 hour of sucitoning,\n MDI treatments and boluses of sedation given by RN, pt only decreased\n wheezes slightly. As shift progressed, bronchospasm decreased but\n prolong expiratory phase remained. Pt had \"high pressure\" alarm\n ringing all night, be resloved with suctioning, changing position and\n MDI treatments. Pt not given RSBI due to bloody trach site, and danger\n of acute bronchospastic episode. Pt to continue current support and to\n be assessed by MD team. Pt recommended for Pulmonary consult.\n" }, { "category": "Respiratory ", "chartdate": "2131-06-19 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 681632, "text": "Airway\n Tube Type\n Tracheostomy tube:\n Type: Standard\n Manufacturer: Portex\n Size: 8.0mm\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: Blood Tinged / Thick\n Sputum source/amount: Suctioned / Moderate\n Ventilation Assessment\n Level of breathing assistance: Unassisted spontaneous breathing\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n" }, { "category": "Social Work", "chartdate": "2131-06-15 00:00:00.000", "description": "Social Work Progress Note", "row_id": 680972, "text": "Pt is making slow progress medically; brother continues to be at the\n bedside daily. Family has requested that brother be the spokesperson\n and the one to sign consents as he is more readily available. Pt\n parents have resumed their practice, both are MD\n Brother asking for counseling sessions for his family so that they can\n begin to work out a plan for being reunited with pt when pt regains his\n ability to communicate. Brother is concerned that family is not\n prepared to discuss issues of addiction.\n Will arrange for ongoing family counseling re: coping.\n" }, { "category": "Nursing", "chartdate": "2131-05-29 00:00:00.000", "description": "Nursing Progress Note", "row_id": 677638, "text": "Hypotension (not Shock)\n Assessment:\n Increasing pressor requirement through day, CRRT run as even as pt.\n unable to tolerate fluid removal. Hct 24, repeat of 22.6, reflecting 8\n point drop over 24 hours. No obvious source of bleeding.\n Action:\n Serial hcts, coags and degradation products sent. Tx\nd 1 unit PRBCs.\n Pressors titrated to maintain MAP 60-65. CRRT as tolerated, pt.\n running even through afternoon. Surgery following.\n Response:\n Able to come down off Levophed slightly after PRBCs given, pt. becoming\n more fluid positive.\n Plan:\n Serial hcts, ? abd. CT if inadequate hct bump. Levophed to maintain MAP\n >60-65, cont. to monitor I/Os, CRRT as tolerated.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Lung sounds dim to bases, no cough/gag noted. No secretions via\n suction. Tolerating vent settings, Fi02 to 50%.\n Action:\n Suctioned PRN, CPT, frequent bed rotation for lungs.\n Response:\n Stable , ABGs acceptable.\n Plan:\n Cont. to monitor, ? wean FI02 to 40%.\n Impaired Skin Integrity\n Assessment:\n Mult open weeping areas to extremities, blisters and popped blisters.\n Action:\n Frequent pad changes, rotation on bed, skin care.\n Response:\n Pt. less weepy and edematous over last few days, open areas clean\n appearing.\n Plan:\n Vigilant skin care, Bari max bed with rotation, wound care RN to see\n pt.\n" }, { "category": "Physician ", "chartdate": "2131-06-18 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 681483, "text": "Chief Complaint:\n 24 Hour Events:\n - Fentanyl and midazolam decreased with slight increase in HR to 110s.\n Increased valium to 10mg TID\n - Tolerated trach mask throughout day\n Allergies:\n Meropenem\n skin blisters a\n Last dose of Antibiotics:\n Ciprofloxacin - 12:34 PM\n Linezolid - 10:09 PM\n Aztreonam - 07:45 AM\n Metronidazole - 08:30 AM\n Infusions:\n Fentanyl (Concentrate) - 25 mcg/hour\n KCl (CRRT) - 3 mEq./hour\n Calcium Gluconate (CRRT) - 2.4 grams/hour\n Other ICU medications:\n Famotidine (Pepcid) - 12:06 AM\n Heparin Sodium (Prophylaxis) - 04:02 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:23 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.3\nC (99.2\n Tcurrent: 36.2\nC (97.1\n HR: 101 (94 - 113) bpm\n BP: 113/59(78) {87/48(64) - 129/70(90)} mmHg\n RR: 23 (19 - 33) insp/min\n SpO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 99.7 kg (admission): 113.5 kg\n Height: 67 Inch\n Total In:\n 9,973 mL\n 2,424 mL\n PO:\n TF:\n 1,200 mL\n 319 mL\n IVF:\n 8,753 mL\n 2,085 mL\n Blood products:\n Total out:\n 11,007 mL\n 2,337 mL\n Urine:\n 77 mL\n 20 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,034 mL\n 87 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n Ventilator mode: Standby\n Vt (Spontaneous): 567 (567 - 567) mL\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 0 cmH2O\n SpO2: 100%\n ABG: 7.45/37/105/24/1\n PaO2 / FiO2: 210\n Physical Examination\n GEN: Trached, sedated.\n HEENT: Icteric sclera. MMM.\n NECK: Trach site with no oozing.\n LUNGS: Anterior auscultation with upper airway noise; good airway\n movement.\n HEART: RRR, normal S1, S2.\n ABD: Distended. Grimacing with palpation.\n EXTREM: 2+ edema, ulcers/lesions on legs with bandages C/D/I.\n SKIN: Jaundiced.\n NEURO: Opening eyes to command. Purposeful movements of arms.\n Labs / Radiology\n 321 K/uL\n 8.0 g/dL\n 165 mg/dL\n 0.6 mg/dL\n 24 mEq/L\n 4.0 mEq/L\n 33 mg/dL\n 99 mEq/L\n 134 mEq/L\n 24.8 %\n 30.5 K/uL\n [image002.jpg]\n 06:23 PM\n 10:13 PM\n 04:13 AM\n 04:24 AM\n 11:20 AM\n 04:55 PM\n 10:00 PM\n 10:30 PM\n 03:49 AM\n 03:56 AM\n WBC\n 24.9\n 30.5\n Hct\n 23.9\n 24.8\n Plt\n 255\n 321\n Cr\n 0.8\n 1.2\n 0.6\n TCO2\n 19\n 19\n 18\n 19\n 24\n 26\n 27\n Glucose\n 172\n 199\n 167\n 110\n 186\n 185\n 160\n 165\n Other labs: PT / PTT / INR:15.6/33.4/1.4, ALT / AST:211/223, Alk Phos /\n T Bili:588/27.9, LDH:517 IU/L, Ca++:8.3 mg/dL, Mg++:1.8 mg/dL, PO4:1.3\n mg/dL\n ucx: Pending. sputum cx: Pending. , , bcx:\n Pending.\n Assessment and Plan\n 28M with alcoholic hepatitis and necrotizing pancreatitis complicated\n by ARDS, SIRS, ARF, UGIB, fevers.\n #. ID: Necrotizing pancreatitis. All abx (linezolid/aztreo D1 and\n flagyl D1 ) discontinued yesterday as afebrile since restarting\n CVVH and appeared clinically approved. Remains afebrile but worsened\n leukocytosis today. RUQ u/s concerning for sludge since .\n - Restart abx coverage with aztreo given necrotizing pancreatitis.\n - Consider HIDA scan of GI c/s for poss ERCP if bilirubin does not\n improve or hemodynamic instability over next few days as may need\n percutaneous drain\n - F/u WBC count, temp curve, and culture data\n - Cont steroid taper for possible adrenal insufficiency\n - Yeast in the urine- changed foley and re-cultured. If still with\n yeast will treat with anti-fungal.\n # Elevated LFTs: A/w alcoholic hepatitis but recent increase may be \n TPN, now discontinued. RUQ u/s showed sludge concerning for\n cholestasis but also seen on u/s. T Bili and transaminases\n stable today.\n - Favoring conservative management for now given hemodynamic stability\n but consider asking GI input for HIDA scan v. ERCP if clinical\n situation changes\n - TPN stopped \n - Weaning off benzos\n #. Respiratory Failure: ARDS secondary to necrotizing pancreatitis. S/p\n trach placement on . Sutures out on . Currently on trach mask\n with good ABG.\n - Start fentanyl patch while decreasing gtt, continue methadone\n - Cont to chair daily\n - Consider down-size trach\n # Seizures: CT head without intracranial process. EEG showed occipital\n seizures which does not correlate with clinical symptoms, but repeat\n EEG on higher dose Keppra showed no seizures. As patient now with\n purposeful movements, this may actually be patient waking up, not\n seizures.\n - Continue on higher dose keppra\n - F/u neuro recs\n - Wean off midazolam as tolerated with low dose valium to prevent\n withdrawal; monitor vitals\n #. Acute renal Failure: Appreciate renal recs.\n - Would dialyze for acidosis but likely does not need volume depletion\n as pressures borderline.\n - Cont CVVH while pressures low but would favor HD trial today\n - Aztreonam 2000mg q12h while on CVVH\n - Will change Keppra to 1000mg Q24 with 500 mg after HD if he\n transitions to HD\n #. Adrenal Insufficiency: Unclear with stim if clear adrenal\n insufficiency but hypotension improving with steroids (lower pressor\n requirement) and improving eosinophilia\n - Cont weaning hydrocort; D2/3 of 25mg Q8H today.\n ICU Care\n Nutrition:\n Nutren 2.0 () - 01:34 PM 50 mL/hour\n Glycemic Control: Glargine and RISS\n Lines:\n Arterial Line - 08:15 PM\n PICC Line - 08:37 AM\n Dialysis Catheter - 08:55 AM\n Prophylaxis:\n DVT: SQ Heparin\n Stress ulcer: H2 blocker\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU, screening for rehab\n" }, { "category": "Nursing", "chartdate": "2131-06-19 00:00:00.000", "description": "Nursing Progress Note", "row_id": 681633, "text": "TITLE:\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Negligeble icteric urine.Continues on crrt run even to -100cc/hr.\n Action:\n Pfr 450-500/hr w net negative fld balance .Labs q6h. Ca+ and K+\n titrated per crrt scale. Rescue flush q4h overnight.\n Response:\n Tolerating crrt w stable hemodynamics on no pressors, running slight\n negative hourly\n Plan:\n Transition to HD when available.Cont labs q6h while on crrt.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Bdline paO2 at 1800 abg. Trach collar at 70% upon assessment at 1900.\n Bbs clear diminished lt base > rt base. Abg O2 sat and Pulse O2 sat not\n correlating earlier.\n Action:\n Lavage and suct for small bldy clot and bldy secretions at begin of\n shift. Sat probe changed and repeat abg on 70% reflected paO2 180 and\n finger saturation more closely correlating with abg O2 sats. Weaned\n fio2 to 50% w paO2 dwn to 80\ns. Pcxr done reflected low lung volumes\n and ? fld per Dr . Increased fio2 back to 70% given pt\ns low lung\n volumes and secretions. Pt becomes tachypneic with turning,stimulation\n and reposition, resolved without medicating . Lavage and suct q4h\n overnight. Vap bundle. Trach care done, no bldg noted around trach\n site.\n Response:\n Adeq abg, less frequent episodes tachypnea overall, secretions less\n bloody, thick clear /bl tinged. Bbs clear but remain diminish\n bibasilar.\n Plan:\n Cont freq aggressive pulm toilet ,vap bundle.? Cpap given low lung\n volumes. Start rehab screening.\n Impaired Skin Integrity\n Assessment:\n Sloughing dry scaly skin to bilat lower extremeties, small amt of bld\n noted on old dressings. Bilat heel pressure sites unchanged.\n Action:\n Cleansed bilat lower legs with wound cleanser and adaptic to areas\n bilat posterior calf. Kling dsd applied.\n Response:\n Bilat lower legs healing. Heal pressure sores stable(waffle boots on)\n Plan:\n leg dressing changes per wound care recommendations.\n" }, { "category": "Physician ", "chartdate": "2131-06-20 00:00:00.000", "description": "Physician Resident/Attending Progress Note - MICU", "row_id": 681925, "text": "Chief Complaint:\n 24 Hour Events:\n NUCLEAR MEDICINE - At 09:57 AM\n INVASIVE VENTILATION - START 01:35 PM\n FEVER - 101.4\nF - 06:00 PM\n - Methadone dose decreased.\n - Spiked fever to 101.4 and became hypotensive to 70/40 requiring\n pressors, but weaned off once he defervesced. He was put back on the\n vent for tachypnea and hypoxia with ABG 7.49/29/53. CT abd/pelvis done\n to evaluate pancreas.\n - Unable to switch to HD due to continued low pressures yesterday.\n Allergies:\n Meropenem\n skin blisters a\n Last dose of Antibiotics:\n Linezolid - 12:15 AM\n Aztreonam - 02:34 AM\n Metronidazole - 04:00 AM\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 12:14 AM\n Heparin Sodium (Prophylaxis) - 04:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:54 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.6\nC (101.4\n Tcurrent: 36.9\nC (98.5\n HR: 89 (89 - 119) bpm\n BP: 123/59(78) {78/43(56) - 128/73(94)} mmHg\n RR: 22 (20 - 35) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 100.4 kg (admission): 113.5 kg\n Height: 67 Inch\n Total In:\n 5,341 mL\n 828 mL\n PO:\n TF:\n 883 mL\n 195 mL\n IVF:\n 4,457 mL\n 633 mL\n Blood products:\n Total out:\n 3,487 mL\n 0 mL\n Urine:\n 135 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,854 mL\n 828 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 510 (428 - 6,000) mL\n PS : 5 cmH2O\n RR (Set): 16\n RR (Spontaneous): 21\n PEEP: 5 cmH2O\n FiO2: 60%\n RSBI: 57\n PIP: 16 cmH2O\n SpO2: 100%\n ABG: 7.41/35/146/22/-1\n Ve: 10.6 L/min\n PaO2 / FiO2: 243\n Physical Examination\n GEN: Trached.\n HEENT: Icteric sclera. MMM.\n NECK: Trach site with no oozing.\n LUNGS: Anterior auscultation with upper airway noise; good airway\n movement.\n HEART: RRR, normal S1, S2.\n ABD: Distended. Firm, but unchanged.\n EXTREM: 2+ edema, ulcers/lesions on legs with bandages C/D/I.\n SKIN: Jaundiced.\n NEURO: Twitching mouth. Opens eyes, squeezes hand to command.\n Labs / Radiology\n 282 K/uL\n 7.3 g/dL\n 141 mg/dL\n 1.8 mg/dL\n 22 mEq/L\n 4.4 mEq/L\n 56 mg/dL\n 97 mEq/L\n 131 mEq/L\n 22.7 %\n 38.5 K/uL\n [image002.jpg]\n 10:56 PM\n 02:58 AM\n 03:10 AM\n 10:53 AM\n 12:57 PM\n 03:00 PM\n 10:13 PM\n 10:23 PM\n 03:00 AM\n 03:15 AM\n WBC\n 34.9\n 38.5\n Hct\n 24.6\n 22.7\n Plt\n 334\n 282\n Cr\n 0.6\n 1.2\n 1.8\n TCO2\n 26\n 27\n 23\n 22\n 18\n 25\n 23\n Glucose\n 151\n 114\n 121\n 140\n 135\n 141\n Other labs: PT / PTT / INR:15.0/33.3/1.3, CK / CKMB /\n Troponin-T:214/3/0.07, ALT / AST:204/226, Alk Phos / T Bili:446/20.1,\n Amylase / Lipase:77/68, Differential-Neuts:90.0 %, Band:0.0 %,\n Lymph:3.0 %, Mono:5.0 %, Eos:1.0 %, D-dimer:6389 ng/mL, Fibrinogen:502\n mg/dL, Lactic Acid:1.1 mmol/L, Albumin:2.0 g/dL, LDH:529 IU/L, Ca++:8.9\n mg/dL, Mg++:2.4 mg/dL, PO4:2.8 mg/dL\n CT ABD/PELVIS wet read:\n 1. large bore central catheter in RA. post-pyloric feeding tube at\n ligament of Treitz\n 2. compared to CT , bibasilar consolidation little changed,\n likely atelectasis. round glass density of lungs slightly improved.\n 3. fatty liver w/focal sparing along GB fossa. high density in GB ?IV\n contrast or sludge.\n 4. continued evolution of areas of necrosis within the pancreas. new\n fluid collection anterior to superior segment of duodenum 5.6 x 2.9 cm\n (2:36), and along pancreatic uncinate 2.2 x 1.9 cm (2:44). Persistent\n attenuation of splenic vein; SMA, SMV, PV remain patent; no\n pseudoaneurysm seen. 5. Unchanged diffuse colonic bowel wall thickening\n for which an infectious etiology is not excluded.\n Assessment and Plan\n 28M with alcoholic hepatitis and necrotizing pancreatitis complicated\n by ARDS, SIRS, ARF, UGIB, fevers.\n #. ID: Persistent leukocytosis and fevers now that off CVVH. On\n aztreonam, linezolid (since ) and flagyl (since ). Likely to\n have continued fevers necrotizing pancreatitis.\n - Abd CT with ?new abscess near pancreas. F/u final read but reviewed\n by Surgery with no role for surgical intervention\n - Given necrotizing pancreatitis and UA with mod yeast persistent after\n multiple foley changes, will restart anti-fungal but given liver\n function will likely need very low dose\n - Continue abx coverage with aztreo, flagyl, and linezolid given\n necrotizing pancreatitis.\n - Consider add po vanc for cdiff colitis given persistent colonic\n inflammation on CT and high wbcs\n - F/u WBC count, temp curve, and culture data\n - Diff with neutrophilia but no bands and no eos yesterday\n .\n # Shock: Patient had transient pressor requirement last pm in setting\n of fever. When fever resolved pressor requirement did as well. Likely\n septic shock. Will treat for infection as above. If requires pressors\n without fever consider other etiologies of hypotension including\n cardiogenic.\n - Cont weaning steroids\n .\n # Elevated LFTs: A/w alcoholic hepatitis. RUQ u/s showed sludge\n concerning for cholestasis but also seen on u/s. T Bili and\n transaminases improving today.\n - HIDA neg\n - TPN stopped \n - weaning off benzos\n #. Respiratory Failure: ARDS secondary to necrotizing pancreatitis. S/p\n trach placement on .\n - Cte fentanyl boluses and alternatingly wean methadone and valium as\n tolerate.\n - Cte OOB to chair daily\n #. Acute renal Failure: Multifactorial inc. ATN from hypotension\n - Was supposed to transition to HD today but pressures not able to\n tolerate. No need for filtration so will reassess tmrw.\n - Aztreonam 2000mg q12h while on CVVH. Change after aztreonam.\n - Will change Keppra to 1000mg Q24 with 500 mg after HD when able to\n tolerate HD\n #. Adrenal Insufficiency: Unclear with stim if clear adrenal\n insufficiency but hypotension improving with steroids (lower pressor\n requirement) and eosinophilia resolved.\n - Cont weaning hydrocort to q12h today\n # Seizures: CT head without intracranial process. EEG showed occipital\n seizures which does not correlate with clinical symptoms, but repeat\n EEG on higher dose Keppra showed no seizures. As patient now with\n purposeful movements, this may actually be patient waking up, not\n seizures.\n - Continue keppra (change dosing if changes to HD)\n - Wean valium today\n ICU Care\n Nutrition:\n Nutren 2.0 () - 02:00 AM 50 mL/hour\n Glycemic Control: ISS\n Lines:\n Arterial Line - 08:15 PM\n PICC Line - 08:37 AM\n Dialysis Catheter - 08:55 AM\n Prophylaxis:\n DVT: hep sc\n Stress ulcer: famotidine\n VAP:\n Comments:\n Communication: Comments: with brother\n status: Full code\n Disposition: ICU pending HD trial ; in screening process.\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: 28M alcoholic hepatitis, pancreatitis,\n refractory shock, ARDS. Febrile with transient pressor requirement\n yesterday, resolved; also on vent o/n for hypoxemia. CT o/n with ? new\n collection.\n Exam notable for Tm 101.4 BP 110/60 HR 100-110 RR 18 with sat 100\n on PSV 5/5 0.6 7.41/35/146. WD man, chemosis. Follows some commands.\n Coarse BS B. Distant s1s2. Obese, + BS. 3+ edema. Labs notable for WBC\n 38K, HCT 4.4, TB 20. CT c fatty liver, new fluid collection 3x6cm.\n Agree with plan to manage respiratory failure with ongoing TM trials\n and sedation wean - will get OOB to chair today, and will decrease\n valium to 5mg q8h. Given question of sz activity, will continue keppra.\n For shock (resolved), will continue to wean steroids (HC 12.5 q8h) and\n will continue linezolid / aztreonam / flagyl while monitoring LFTs,\n which are improving off TPN. Will d/w ID re antifungal coverage. For\n ARF, change CVVH to HD (first run tomorrow); will try to run even. For\n pancreatitis, will continue post-pyloric TFs; he is stooling with good\n bowel sounds. Will hold off on any drainage of new peripancreatic fluid\n collection. Needs PT eval and rehab screening. Will ask for PMV\n placement today. Plan d/w family at bedside. Remainder of plan as\n outlined above.\n Total time: 35 min\n ------ Protected Section Addendum Entered By: , MD\n on: 02:49 PM ------\n" }, { "category": "Respiratory ", "chartdate": "2131-06-21 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 682035, "text": "Airway\n Airway Placement Data\n Known difficult intubation: No\n Tube Type\n Tracheostomy tube:\n Type: Standard\n Manufacturer: Portex\n Size: 8.0mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 24 cmH2O\n Cuff volume: 8 mL /\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Clear\n Secretions\n Sputum color / consistency: Blood Tinged / Thick\n Sputum source/amount: Suctioned / Small\n" }, { "category": "Respiratory ", "chartdate": "2131-05-30 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 677686, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 13\n Ideal body weight: 67.1 None\n Ideal tidal volume: 268.4 / 402.6 / 536.8 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: 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: 7mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: cmH2O\n Cuff volume: mL /\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: 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 Comments: No vent changes during shift.\n Assessment of breathing comfort: No response (sleeping / sedated)\n Invasive ventilation assessment:\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": "Nursing", "chartdate": "2131-06-18 00:00:00.000", "description": "Nursing Progress Note", "row_id": 681570, "text": "Sepsis\nongoing w/pancreatitis\n Assessment:\n WBC bumpbed to 30 today, afater antibiotics dc/d\n Action:\n Linezolid and axtrenoman reordered\n HIDA scan for this afternoon\n Response:\n Off pressors still, hemodynamically stable\n Plan:\n Awaiting results of scan\n Impaired Skin Integrity\n Assessment:\n Right and left legs much improved with good healing occurring\n Action:\n Wash legs with wound cleanser, scrub to removed old dead skin\n Xerofoam and/or adaptic over areas with bleeding\n Moisture barrier cream on legs\n Cover with dsd\n Response:\n Ongoing healing\n Plan:\n Continue with above plan\n Wound care signed off\n Reconsult if needed\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n On CRRT, basically to keep even\n Action:\n Will recirc for hida scan\n Response:\n Tolerating very well.\n Plan:\n Keep on CRRT until filter clots or is due to be changed.\n Change to hemodialysis at that point.\n Respiration / Gas Exchange, Impaired\n Assessment:\n Off vent for >24 hrs.\n Action:\n Suction as needed\n Gentle chest pt as patient does have thick rust secretions\n Response:\n Toelrated well\n Plan:\n Begin rehab screen process as is off vent, and due to transition to\n hemdialysis.\n Family aware, supportive.\n" }, { "category": "Physician ", "chartdate": "2131-06-15 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 680932, "text": "Chief Complaint:\n 24 Hour Events:\n - LFTs rising including TB/DB. D/c TPN. Weaning off midazolam, placed\n on standing valium.\n - bronch washings: Pulmonary macrophages, bronchial epithelial\n cells, and inflammatory cells, including eosinophils. Neg for malignant\n cells.\n - R-sided PICC and HD tunneled cath placed by IR.\n - PT consult ordered.\n - Aztreonam changed to HD dosing per pharmacy but then since didnt get\n HD and will likely get CVVH tomorrow for borderline pressures changed\n back to 2gm Q12H\n - Fever to 102 at 8pm with tachycardia to 120s and BPs to 90s/50s.\n Blood, urine, sputum cultures sent. 500mL NS X 2 given with better BPs.\n Midazolam 1X dose given as well with better HRs. CXR looked better than\n prior with no edema nad no pna. RUQ U/S:Gallbladder nondistended, but\n lumen entirely replaced by echogenic material.\n Favor sludge, but could also reflect marked wall thickening related to\n third spacing. Started Cipro. Ordered HIDA for am.\n - On ABG 7.4/34/98 but then in setting of fever was tachypnic so\n went back up on PS 8/5 with RR 20. Weaned back to overnight with\n ABG 7.25/37/122.\n - Changed glargine to QD\n Allergies:\n Meropenem\n skin blisters a\n Last dose of Antibiotics:\n Metronidazole - 02:00 AM\n Aztreonam - 08:30 PM\n Linezolid - 10:00 PM\n Ciprofloxacin - 12:00 AM\n Infusions:\n Midazolam (Versed) - 3 mg/hour\n Fentanyl (Concentrate) - 100 mcg/hour\n Other ICU medications:\n Fentanyl - 12:23 PM\n Midazolam (Versed) - 05:45 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:14 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 39.1\nC (102.3\n Tcurrent: 36.6\nC (97.8\n HR: 101 (82 - 123) bpm\n BP: 100/53(69) {76/41(55) - 125/85(87)} mmHg\n RR: 27 (14 - 32) insp/min\n SpO2: 99%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 113 kg (admission): 113.5 kg\n Height: 67 Inch\n CVP: 9 (4 - 12)mmHg\n Total In:\n 7,376 mL\n 542 mL\n PO:\n TF:\n 501 mL\n 311 mL\n IVF:\n 5,412 mL\n 231 mL\n Blood products:\n Total out:\n 5,958 mL\n 0 mL\n Urine:\n 128 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,418 mL\n 542 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 400 (400 - 400) mL\n Vt (Spontaneous): 405 (405 - 640) mL\n PS : 5 cmH2O\n RR (Set): 22\n RR (Spontaneous): 29\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI Deferred: RR >35\n PIP: 11 cmH2O\n SpO2: 99%\n ABG: 7.35/37/122/16/-4\n Ve: 13.1 L/min\n PaO2 / FiO2: 244\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 194 K/uL\n 8.2 g/dL\n 178 mg/dL\n 1.5 mg/dL\n 16 mEq/L\n 4.4 mEq/L\n 72 mg/dL\n 99 mEq/L\n 132 mEq/L\n 25.8 %\n 21.7 K/uL\n [image002.jpg]\n 12:01 AM\n 03:25 AM\n 03:39 AM\n 06:10 PM\n 06:18 PM\n 07:58 PM\n 08:00 PM\n 01:31 AM\n 01:37 AM\n 04:30 AM\n WBC\n 22.3\n 24.4\n 21.7\n Hct\n 25.4\n 26.9\n 25.3\n 25.8\n Plt\n 142\n 193\n 194\n Cr\n 1.0\n 1.6\n 1.5\n TCO2\n 27\n 22\n 23\n 21\n 21\n Glucose\n 78\n 78\n 121\n 178\n Other labs: PT / PTT / INR:15.2/34.4/1.3, CK / CKMB /\n Troponin-T:214/3/0.07, ALT / AST:158/238, Alk Phos / T Bili:421/28.0,\n Amylase / Lipase:51/41, Differential-Neuts:68.0 %, Band:5.0 %,\n Lymph:7.0 %, Mono:4.0 %, Eos:0.0 %, D-dimer:6389 ng/mL, Fibrinogen:502\n mg/dL, Lactic Acid:1.1 mmol/L, Albumin:2.0 g/dL, LDH:706 IU/L, Ca++:8.3\n mg/dL, Mg++:2.4 mg/dL, PO4:3.5 mg/dL\n Assessment and Plan\n SEIZURE, WITHOUT STATUS EPILEPTICUS\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n IMPAIRED SKIN INTEGRITY\n HEPATITIS, ACUTE TOXIC (INCLUDING ALCOHOLIC, ACETAMINOPHEN, ETC.)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ICU Care\n Nutrition:\n Nutren 2.0 () - 02:00 PM 50 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 08:15 PM\n Multi Lumen - 10:00 PM\n Dialysis Catheter - 11:35 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": "2131-06-15 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 680933, "text": "Chief Complaint:\n 24 Hour Events:\n - LFTs rising including TB/DB. D/c TPN. Weaning off midazolam, placed\n on standing valium.\n - bronch washings: Pulmonary macrophages, bronchial epithelial\n cells, and inflammatory cells, including eosinophils. Neg for malignant\n cells.\n - R-sided PICC and HD tunneled cath placed by IR.\n - PT consult ordered.\n - Aztreonam changed to HD dosing per pharmacy but then since didnt get\n HD and will likely get CVVH tomorrow for borderline pressures changed\n back to 2gm Q12H\n - Fever to 102 at 8pm with tachycardia to 120s and BPs to 90s/50s.\n Blood, urine, sputum cultures sent. 500mL NS X 2 given with better BPs.\n Midazolam 1X dose given as well with better HRs. CXR looked better than\n prior with no edema nad no pna. RUQ U/S:Gallbladder nondistended, but\n lumen entirely replaced by echogenic material.\n Favor sludge, but could also reflect marked wall thickening related to\n third spacing. Started Cipro. Ordered HIDA for am.\n - On ABG 7.4/34/98 but then in setting of fever was tachypnic so\n went back up on PS 8/5 with RR 20. Weaned back to overnight with\n ABG 7.25/37/122.\n - Changed glargine to QD\n Allergies:\n Meropenem\n skin blisters a\n Last dose of Antibiotics:\n Metronidazole - 02:00 AM\n Aztreonam - 08:30 PM\n Linezolid - 10:00 PM\n Ciprofloxacin - 12:00 AM\n Infusions:\n Midazolam (Versed) - 3 mg/hour\n Fentanyl (Concentrate) - 100 mcg/hour\n Other ICU medications:\n Fentanyl - 12:23 PM\n Midazolam (Versed) - 05:45 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:14 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 39.1\nC (102.3\n Tcurrent: 36.6\nC (97.8\n HR: 101 (82 - 123) bpm\n BP: 100/53(69) {76/41(55) - 125/85(87)} mmHg\n RR: 27 (14 - 32) insp/min\n SpO2: 99%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 113 kg (admission): 113.5 kg\n Height: 67 Inch\n CVP: 9 (4 - 12)mmHg\n Total In:\n 7,376 mL\n 542 mL\n PO:\n TF:\n 501 mL\n 311 mL\n IVF:\n 5,412 mL\n 231 mL\n Blood products:\n Total out:\n 5,958 mL\n 0 mL\n Urine:\n 128 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,418 mL\n 542 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 400 (400 - 400) mL\n Vt (Spontaneous): 405 (405 - 640) mL\n PS : 5 cmH2O\n RR (Set): 22\n RR (Spontaneous): 29\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI Deferred: RR >35\n PIP: 11 cmH2O\n SpO2: 99%\n ABG: 7.35/37/122/16/-4\n Ve: 13.1 L/min\n PaO2 / FiO2: 244\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 194 K/uL\n 8.2 g/dL\n 178 mg/dL\n 1.5 mg/dL\n 16 mEq/L\n 4.4 mEq/L\n 72 mg/dL\n 99 mEq/L\n 132 mEq/L\n 25.8 %\n 21.7 K/uL\n [image002.jpg]\n 12:01 AM\n 03:25 AM\n 03:39 AM\n 06:10 PM\n 06:18 PM\n 07:58 PM\n 08:00 PM\n 01:31 AM\n 01:37 AM\n 04:30 AM\n WBC\n 22.3\n 24.4\n 21.7\n Hct\n 25.4\n 26.9\n 25.3\n 25.8\n Plt\n 142\n 193\n 194\n Cr\n 1.0\n 1.6\n 1.5\n TCO2\n 27\n 22\n 23\n 21\n 21\n Glucose\n 78\n 78\n 121\n 178\n Other labs: PT / PTT / INR:15.2/34.4/1.3, CK / CKMB /\n Troponin-T:214/3/0.07, ALT / AST:158/238, Alk Phos / T Bili:421/28.0,\n Amylase / Lipase:51/41, Differential-Neuts:68.0 %, Band:5.0 %,\n Lymph:7.0 %, Mono:4.0 %, Eos:0.0 %, D-dimer:6389 ng/mL, Fibrinogen:502\n mg/dL, Lactic Acid:1.1 mmol/L, Albumin:2.0 g/dL, LDH:706 IU/L, Ca++:8.3\n mg/dL, Mg++:2.4 mg/dL, PO4:3.5 mg/dL\n Assessment and Plan\n 28M with alcoholic hepatitis and necrotizing pancreatitis complicated\n by ARDS, SIRS, ARF, UGIB, fevers and eosinophilia\n #. Respiratory Failure: ARDS secondary to necrotizing pancreatitis. S/p\n trach placement on . Sutures out on \n - Cont to wean vent with trach mask trial as tolerated\n - Decrease fentanyl, continue methadone\n # Seizures: Had increased twitching of head and arms yesterday with\n deviation of eyes to R. Was given Ativan x 2, Keppra dose increased.\n CT head without intracranial process. EEG showed occipital seizures\n which does not correlate with clinical symptoms. actually be\n patient waking up, not seizures.\n - F/u neuro recs\n - Wean off midazolam as tolerated with low dose valium to prevent\n withdrawal; monitor vitals\n - Consider d/c drugs that may lower seizure threshold\n # Hyperbilirubinemia: Patient has had continuously increasing T Bili\n and alkaline phosphatase. Has alcoholic hepatitis but also on TPN.\n Concerning for cholestasis.\n - Fractionate bilirubin\n - Stop TPN as tube feeds at goal\n - Weaning off benzos\n - Consider RUQ U/S if hyperbilirubinemia persist\n #. Acute renal Failure: Appreciate renal recs. Cr improved on CVVH. Off\n sucralfate due to concern for electrolyte abnormalities.\n - Cte volume depletion with CVVH as long as pressor requirement does\n not increase\n - Plan for tunneled dialysis catheter today to transition to HD\n tomorrow; f/u Renal recs\n #. ID: Afebrile. Question of fever adrenal insufficiency; now on\n steroids. leukocytosis improved. Blood/tissue/BAL cx NGTD,\n - Cte broad spectrum antibiotic coverage with aztreonam for extended GN\n coverage, linezolid for MRSA and VRE for bacteremia with plan to stop\n aztreonam first (Day 1=. Day #9 today)\n - C diff negative X 2. D/C Flagyl and Vanc PO today.\n - F/u WBC count, temp curve, and culture data\n #. Adrenal Insufficiency: Unclear with stim if clear adrenal\n insufficiency but hypotension improving with steroids (lower pressor\n requirement) and improving eosinophilia\n - Wean to 50mg Q8H today\n #. Thrombocytopenia: almost resolved\n - Monitor platelets daily and transfuse for plt <10 or <50 if signs of\n bleed\n - monitor daily\n # ?HLH: Elevated ferritin. Check quantitated ferritin to r/o HLH.\n ICU Care\n Nutrition:\n Nutren 2.0 () - 02:00 PM 50 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 08:15 PM\n Multi Lumen - 10:00 PM\n Dialysis Catheter - 11:35 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": "2131-05-28 00:00:00.000", "description": "Nursing Progress Note", "row_id": 677313, "text": "TITLE:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Bbs clear but diminished at bases. O2 sats >95% vent settings cmv tv\n 400 rr 30 fio2 40% peep 16\n Action:\n Peep weaned to 12cm. Vap bundle. Lavage and suct for thick clear.Bari\n Max bed w rotation.every 10 mins throughout noc.\n Response:\n O2 sats and abg adeq on 12cm peep. Bbs increasingly audible to bases\n and clear.\n Plan:\n Cont vap bundle, pulm toilet ,rotating bed\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 Problem - Description In Comments\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Respiratory ", "chartdate": "2131-05-28 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 677317, "text": "Demographics\n Day of mechanical ventilation: 11\n Ideal body weight: 67.1 None\n Ideal tidal volume: 268.4 / 402.6 / 536.8 mL/kg\n Airway\n Tube Type\n ETT:\n Position: 23 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7mm\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Clear\n Comments:\n Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount: Suctioned / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Utilize ARDSnet protocol, Reduce PEEP as tolerated,\n Adjust Min. ventilation to control pH; Comments: PEEP slowly weaned. No\n balloon measurements this shift.\n Reason for continuing current ventilatory support: Underlying illness\n not resolved\n" }, { "category": "Nutrition", "chartdate": "2131-05-30 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 677790, "text": "Objective\n Current Wt: 130.5kg\n Adm wt: 113.5kg\n Pertinent medications: fentanyl, versed, norepinephrine, protonix,\n HISS, others noted\n Labs:\n Value\n Date\n Glucose\n 97 mg/dL\n 01:51 PM\n Glucose Finger Stick\n 129\n 10:00 AM\n BUN\n 22 mg/dL\n 10:44 AM\n Creatinine\n 1.8 mg/dL\n 10:44 AM\n Sodium\n 139 mEq/L\n 10:50 AM\n Potassium\n 3.6 mEq/L\n 01:51 PM\n Chloride\n 103 mEq/L\n 10:44 AM\n TCO2\n 29 mEq/L\n 10:44 AM\n PO2 (arterial)\n 66 mm Hg\n 01:51 PM\n PCO2 (arterial)\n 41 mm Hg\n 01:51 PM\n pH (arterial)\n 7.48 units\n 01:51 PM\n pH (venous)\n 7.25 units\n 10:31 AM\n pH (urine)\n 6.5 units\n 01:09 PM\n CO2 (Calc) arterial\n 31 mEq/L\n 01:51 PM\n Albumin\n 1.4 g/dL\n 09:30 AM\n Calcium non-ionized\n 9.0 mg/dL\n 10:44 AM\n Phosphorus\n 3.7 mg/dL\n 10:44 AM\n Ionized Calcium\n 1.07 mmol/L\n 01:51 PM\n Magnesium\n 2.1 mg/dL\n 10:44 AM\n ALT\n 19 IU/L\n 01:42 AM\n Alkaline Phosphate\n 141 IU/L\n 01:42 AM\n AST\n 227 IU/L\n 01:42 AM\n Amylase\n 16 IU/L\n 03:01 AM\n Total Bilirubin\n 14.5 mg/dL\n 01:42 AM\n WBC\n 36.3 K/uL\n 10:44 AM\n Hgb\n 8.5 g/dL\n 10:44 AM\n Hematocrit\n 25.7 %\n 10:44 AM\n Current diet order / nutrition support: TPN: 1750mL (298dextrose/ 105\n amino acid/ 35fat) = 1750kcals\n GI: abd obese, absent bowel sounds\n Assessment of Nutritional Status\n 28 y. o. M with alcoholic hepatitis and necrotizing pancreatitis\n complicated by ARDS, SIRS, and renal failure requiring CRRT, now with\n dropping HCT and possible ruptured pancreatic cyst. Patient is on TPN\n for full nutrition support; TPN is at goal and meeting 100% of\n estimated needs at 23kcals/kg adjusted wt and 1.3g protein/kg adjusted\n wt. Noted that today\ns TPN had to be stopped thrombocytopenia due\n to the large amount of heparin in bag. Tonight\ns TPN does not have\n heparin in bag. Patient needs to have triglycerides checked to ensure\n that patient can tolerate lipid in TPN.\n Medical Nutrition Therapy Plan - Recommend the Following\n 1) Continue with TPN at goal.\n 2) Please check Triglycerides.\n 3) Monitor lytes and BG.\n Following, please page with questions. #\n" }, { "category": "Physician ", "chartdate": "2131-05-30 00:00:00.000", "description": "ICU Attending Note", "row_id": 677794, "text": "Clinician: Attending\n MICU ATTENDING NOTE\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, including assessment and plan.\n 28yo man with necrotizing pancreatitis (30-40% necrosis via CT), ARDS,\n septic shock, renal failure. Head CT revealed edema, treated with 23%\n NS for induced osmorx.\n Events:\n Hct drop 30\n 24 yest morning: received ddAVP, 2U PRBC with insufficient\n response (23\n 25%)\n Haptoglobin 30 but FDP persistently high, no schistocytes. Bili\n predominantly direct.\n Improvement in oxygenation. FiO2 down to 0.5.\n Slight increase in pressor requirement.\n 9L/8L 24 h balance\n 1. Shock, remains levophed dependent.\n 2. Thrombocytopenia present since . Stable for the past few days.\n Heparin in TPN (prophylaxis)- hold as we w/u hct drop and\n thrombocytopenia. hct drop not c/w hemolysis. No clear source of\n bleed. NG lavage neg. No stool. No blood from ETT. Pan-CT. If no\n explanation for blood loss on CT, discuss with GI.\n 3. Neuro: pupil exam stable. D/C hypertonic saline.\n 4. ARDS: continue weaning FiO2 followed by PEEP. PEEP was as high as\n 24, now 12. Not a candidate for trach at this time.\n 5. Weaning sedation. Off versed. Fent 50mcg.\n 6. Meropenem (d10)/vanc (d7). Abx to stop today. Remains afebrile.\n 7. Skin breakdown- wound service recs.\n 8. Renal failure, on CVVHD. Much less anasarca.\n Critically ill, 50 minutes\n" }, { "category": "Nursing", "chartdate": "2131-06-16 00:00:00.000", "description": "Nursing Progress Note", "row_id": 681122, "text": "Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Pt remains off CRRT.\n Action:\n Serial labs. Strict i/o\n Response:\n K stable at 4.7. Bun and Creatinine on the rise. Minimal urine output\n via foley.\n Plan:\n Plan for CRRT versus hemodialysis this a.m.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt remains on CMV. O2 sat high 90\ns to 100%.\n Action:\n No vent changes. ABG sent.\n Response:\n Pt consistently over breathing vent. ABG acceptable. Pt frequently\n suctioned for thick, blood tinged sputum.\n Plan:\n Wean from vent as tolerates. Attempt trach collar. Aggressive\n pulmonary toilet.\n" }, { "category": "Nursing", "chartdate": "2131-06-17 00:00:00.000", "description": "Nursing Progress Note", "row_id": 681369, "text": "Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Continues of CRRT\n Bicarb this am 19\n Calcium gtt ^ 60ml/hr\n Fluid removal as tolerated\n U/O minimal Remain Icteric and cloudy\n Action:\n Discussed with Renal this am about Bicarb and Calcium\n Replacement fluid changed to B32 K2 Calcium Scale revised\n Goal -100cc/hr or more as tolerated\n Response:\n Bicarb up to 24 Calcium gtt decreased\n Foley cath changed per MICU\n Tolerating fluid removal well\n Tachycardic this pm ? if due to fluid removal\n 200cc bolus given with no change in HR per MICU\n Possible ^ HR r/t decrease in sedative medications and pt\n becoming more awake\n Plan:\n Cont CRRT until filter needs to be changed\n ABG/Potassium/Ionized Ca q6hrs or as needed\n Needs to have U/A sent now that foley has been changed\n" }, { "category": "Physician ", "chartdate": "2131-05-27 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 677224, "text": "TITLE:\n 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 - cont hypertonic saline tx cont\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Meropenem - 02:04 AM\n Metronidazole - 02:30 AM\n Vancomycin - 08:00 AM\n Infusions:\n Norepinephrine - 0.03 mcg/Kg/min\n Phenylephrine - 1.7 mcg/Kg/min\n Fentanyl (Concentrate) - 250 mcg/hour\n KCl (CRRT) - 4 mEq./hour\n Midazolam (Versed) - 25 mg/hour\n Calcium Gluconate (CRRT) - 2 grams/hour\n Other ICU medications:\n Pantoprazole (Protonix) - 08:10 PM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 09:23 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: 35.9\nC (96.6\n HR: 95 (90 - 100) bpm\n BP: 97/52(66) {92/50(64) - 113/71(85)} mmHg\n RR: 30 (28 - 33) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 140 kg (admission): 113.5 kg\n Height: 67 Inch\n CVP: 18 (17 - 21)mmHg\n Total In:\n 12,114 mL\n 4,497 mL\n PO:\n TF:\n IVF:\n 10,318 mL\n 3,944 mL\n Blood products:\n Total out:\n 18,126 mL\n 7,377 mL\n Urine:\n 238 mL\n 73 mL\n NG:\n 400 mL\n 150 mL\n Stool:\n Drains:\n Balance:\n -6,012 mL\n -2,880 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 30\n RR (Spontaneous): 0\n PEEP: 16 cmH2O\n FiO2: 40%\n RSBI Deferred: PEEP > 10\n PIP: 32 cmH2O\n Plateau: 28 cmH2O\n Compliance: 38.8 cmH2O/mL\n SpO2: 97%\n ABG: 7.37/47/81./23/0\n Ve: 12.1 L/min\n PaO2 / FiO2: 205\n Physical Examination\n General Appearance: Well nourished, total body fluid overload\n Eyes / Conjunctiva: PERRL, pupil 3mm b/l - smaller than prev\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Clear : anteriorly)\n Abdominal: Soft, No(t) Bowel sounds present, Distended\n Extremities: Right: 4+, Left: 4+, No(t) Cyanosis\n Skin: Not assessed\n Neurologic: No(t) Attentive, No(t) Follows simple commands, Responds\n to: Not assessed, No(t) Oriented (to): , Movement: Not assessed,\n Sedated, Tone: Not assessed\n Labs / Radiology\n 10.0 g/dL\n 67 K/uL\n 175 mg/dL\n 2.4 mg/dL\n 23 mEq/L\n 3.7 mEq/L\n 22 mg/dL\n 107 mEq/L\n 143 mEq/L\n 29.2 %\n 45.9 K/uL\n [image002.jpg]\n 02:08 AM\n 02:28 AM\n 10:00 AM\n 10:17 AM\n 04:06 PM\n 04:23 PM\n 09:57 PM\n 10:11 PM\n 04:39 AM\n 04:49 AM\n WBC\n 35.1\n 45.9\n Hct\n 29.9\n 29.2\n Plt\n 85\n 67\n Cr\n 2.9\n 2.9\n 2.8\n 2.6\n 2.4\n TCO2\n 25\n 26\n 25\n 28\n 28\n Glucose\n 182\n 170\n 187\n 174\n 192\n 174\n 188\n 176\n 187\n 175\n Other labs: PT / PTT / INR:19.5/53.6/1.8, ALT / AST:20/210, Alk Phos /\n T Bili:236/20.6, Amylase / Lipase:16/34, Differential-Neuts:71.0 %,\n Band:8.0 %, Lymph:6.0 %, Mono:4.0 %, Eos:2.0 %, D-dimer: ng/mL,\n Fibrinogen:402 mg/dL, Lactic Acid:1.8 mmol/L, Albumin:1.7 g/dL, LDH:742\n IU/L, Ca++:9.1 mg/dL, Mg++:1.7 mg/dL, PO4:2.6 mg/dL\n Assessment and Plan\n 28M h/o EtOH abuse, weakness, fatigue, UGIB c/b hematemesis / melena.\n Has developed massive fluid requirement, hypotension, ARDS in the\n setting of severe pancreatitis, alcoholic hepatitis and borderline\n renal function. Head CT with edema, on 23% NS for induced osmorx. Fever\n curve down on / vanco / flagyl\nafebrile x last 24hrs. Ongoing\n CVVH. EEG completed\n preliminary read is no active seizure activity.\nCEREBRAL EDEMA\n - hypertonic (23%) saline q6h with frequent monitoring of osm and\n sodium for cerebral edema. Challenging in setting of CVVH - renal\n managing with knowledge of hypertonic saline tx\n -Pupils now more appropriately constricted given narcotics on board --\n suggestive of improvement in IC pressure.\n -Repeat imaging would be optimal but not yet realistic given pt\n acuity and accompanying risks of transferring for imaging\n -On keppra proph\n -EEG initial read s evidence of sz activity- final read pending.\nARDS\n - low volume ventilation (400x30); will continue to wean PEEP as\n tolerated. 20->16. Once requirements down, able to start weaning\n sedation though long road given large volume of distribution.\nSHOCK\n -cont require two pressors - some progress weaning\n -able to take 7 liters off\n -Continuing broad spectrum abx pend cx data for guidance.\n -Afebrile last 48hrs\n -CVVHD\n -Progress removing fluid - 7Liters off in last 24hr\n -weaning PEEP, FiO2 as tol\n -follow espophageal pressures as needed.\nPANCREATITIS\n -presumed due to EtOH\n -c/b ARDS\n -NPO\n - following\n -continue TPN with heparin\nEtOH HEPATITIS\nUGIB\n -Dieulafois lesion at GEJ\n -monitor serial HCT\n IMPAIRED SKIN INTEGRITY\n -cont large amount of oozing form skin breakdown in lower extremities\n Remainder of plan as outlined in resident note.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Arterial Line - 01:35 PM\n Multi Lumen - 02:02 PM\n Dialysis Catheter - 04:56 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: 55 minutes\n Patient is critically ill\n" }, { "category": "Physician ", "chartdate": "2131-05-27 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 677242, "text": "Chief Complaint:\n 24 Hour Events:\n \n - Switched back to 23% saline. Afternoon Na 139, PM Na 142. Written for\n additional 2 doses of 23%.\n \n - continued 23% saline q6h\n - wbc trending down; d/c'd afrin b/c hadn't gotten it at all\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:33 AM\n Meropenem - 02:04 AM\n Metronidazole - 02:30 AM\n Infusions:\n Calcium Gluconate (CRRT) - 2 grams/hour\n Norepinephrine - 0.03 mcg/Kg/min\n Phenylephrine - 1.8 mcg/Kg/min\n Fentanyl (Concentrate) - 250 mcg/hour\n KCl (CRRT) - 4 mEq./hour\n Midazolam (Versed) - 25 mg/hour\n Other ICU medications:\n Pantoprazole (Protonix) - 08:10 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:58 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: 35.8\nC (96.5\n HR: 90 (90 - 100) bpm\n BP: 108/57(74) {92/50(64) - 113/71(85)} mmHg\n RR: 20 (3 - 33) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 140 kg (admission): 113.5 kg\n Height: 67 Inch\n CVP: 20 (14 - 21)mmHg\n Total In:\n 12,114 mL\n 3,376 mL\n PO:\n TF:\n IVF:\n 10,318 mL\n 2,861 mL\n Blood products:\n Total out:\n 18,126 mL\n 5,213 mL\n Urine:\n 238 mL\n 58 mL\n NG:\n 400 mL\n 150 mL\n Stool:\n Drains:\n Balance:\n -6,012 mL\n -1,837 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 30\n RR (Spontaneous): 0\n PEEP: 16 cmH2O\n FiO2: 40%\n RSBI Deferred: PEEP > 10\n PIP: 34 cmH2O\n Plateau: 28 cmH2O\n Compliance: 38.8 cmH2O/mL\n SpO2: 97%\n ABG: 7.37/47/81./23/0\n Ve: 14.3 L/min\n PaO2 / FiO2: 205\n Physical Examination\n General Appearance: Overweight / Obese\n Head, Ears, Nose, Throat: 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: (Expansion: Symmetric), (Breath Sounds: Crackles :\n )\n Abdominal: Soft, Obese\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 67 K/uL\n 10.0 g/dL\n 175 mg/dL\n 2.4 mg/dL\n 23 mEq/L\n 3.7 mEq/L\n 22 mg/dL\n 107 mEq/L\n 143 mEq/L\n 29.2 %\n 45.9 K/uL\n [image002.jpg]\n 02:08 AM\n 02:28 AM\n 10:00 AM\n 10:17 AM\n 04:06 PM\n 04:23 PM\n 09:57 PM\n 10:11 PM\n 04:39 AM\n 04:49 AM\n WBC\n 35.1\n 45.9\n Hct\n 29.9\n 29.2\n Plt\n 85\n 67\n Cr\n 2.9\n 2.9\n 2.8\n 2.6\n 2.4\n TCO2\n 25\n 26\n 25\n 28\n 28\n Glucose\n 182\n 170\n 187\n 174\n 192\n 174\n 188\n 176\n 187\n 175\n Other labs: PT / PTT / INR:19.5/53.6/1.8, ALT / AST:20/210, Alk Phos /\n T Bili:236/20.6, Amylase / Lipase:16/34, Differential-Neuts:71.0 %,\n Band:8.0 %, Lymph:6.0 %, Mono:4.0 %, Eos:2.0 %, D-dimer: ng/mL,\n Fibrinogen:402 mg/dL, Lactic Acid:1.8 mmol/L, Albumin:1.7 g/dL, LDH:742\n IU/L, Ca++:9.1 mg/dL, Mg++:1.7 mg/dL, PO4:2.6 mg/dL\n Assessment and Plan\n Mr. is a 28 year old gentleman with alcoholic hepatitis and\n necrotizing pancreatitis complicated by ARDS, SIRS, and UGIB.\n # Neuro: CTH demonstrated loss of grey white differentiation with\n questionable effacement and possible seizure activity. Neuro and\n neurosurg consulted and patient received ativan, keppra load, and\n hypertonic saline of hyponatremia. Patient converted to 23% saline\n boluses with improvement in serum sodium and osmolility. Neuro exam\n improved this am.\n - Per neuro, keppra IV maintenance dose\n - Continue 23% hypertonic saline boluses Q6H with regular serum sodium\n checks. Goal Na 145-150, Osm 310-315\n - f/u EEG read\n - Consider mannitol if serum sodium does not improve.\n - Wean sedation (starting with fentanyl) as possible.\n # Respiratory Failure: ARDS secondary to necrotizing pancreatitis\n compounded by hypoxia, tachypnea in setting of anion gap metabolic\n acidosis, increased abdominal pressure, and EtOH withdrawl. PEEP\n decreased to 16 from 20 and FiO2 to 40%.\n - Wean FiO2 and PEEP, goal PaO2>60-65%\n # Leukocytosis: Stable. Initial concern for infection (new or\n complication of pancreatitis) but normal cx suggest that this may be\n inflammatory reaction. No eos on diff and CT without abscesses\n - Continue empiric vancomycin, meropenem, and flagyl. AM vanco level\n today\n - Follow-up culture data\n - f/u ID reccs\n # Necrotizing pancreatitis/SIRS: Secondary to alcohol complicated by\n SIRS and ARDS. Patient continues to have pressor requirement, with neo\n +/- levo. Aggressive volume resuscitation with >58L. Patient\n without improvement with albumin trial, likely secondary to SIRS and\n increased vascular permeability.\n - Continue empiric antimicrobials.\n - less pressor requirement overnight, neo at 1.7 and levo at 0.02.\n - Hypertonic saline as above in order to increase intravascular volume.\n - Monitor chemistries.\n - Follow-up with recs if any\n # Hyponatremia: In setting of decreased effective circulating volume\n in setting of SIRS and IABP. Patient receiving hypertonic saline\n boluses with improvement in serum sodium.\n - Hypertonic saline as above.\n - Trend chemistries.\n - Follow-up with neurosurgery recs if any.\n # Acute renal failure: Patient had HD line placed and CVVH was\n initiated yesterday.\n - CVVH per renal.\n - Trend chemistries\n #Thrombocytopenia: Platelets stable. No clear etiology at this time.\n DIC panel and HIT PF4 antibody negative.\n - Trend plt, transfuse for plt<10 or <50 if signs of hemorrhage.\n # IAP elevation: Secondary to third spacing and edema. Per surgery, not\n a good surgical candidate at this time.\n # Acute hepatitis: Likely alcoholic hepatitis with fatty infiltration,\n and no evidence of distal obstruction. RUQ u/s shows marked liver\n echogenicity but no ascites.\n - Trend LFTs\n # Hematemesis: EGD showed diuelafoy's lesion. HCT stable since 2 units\n PRBC on .\n - Trend hct, transfuse for hct<21\n # Alcoholism: Patient describes history of withdrawal symptoms, but\n not prior seizure. Last drink was night prior to presentation.\n Tachycardia, weakness, and elevated lactate could be consistent with\n thiamine deficiency.\n - Thiamine, vb12, folate\n - Valium with CIWA > 10\n FEN: TPN, replete as necessary.\n PPx: Heparin and H2B in TPN\n Access: RIJ (quad), LIJ (HD), right radial a-line\n Dispo: ICU level of care\n ICU Care\n Nutrition:\n TPN w/ Lipids - 12:38 PM 74 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 01:35 PM\n Multi Lumen - 02:02 PM\n Dialysis Catheter - 04:56 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": "2131-05-29 00:00:00.000", "description": "Attending progress note", "row_id": 677632, "text": "Chief Complaint:\n 24 Hour Events:\n ARTERIAL LINE - STOP 01:30 PM\n ARTERIAL LINE - START 01:30 PM\n - Arterial line re-sited to left radial\n - Weaned sedation down (fetaynl preferentially), patient started moving\n and so went back up a bit.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Metronidazole - 02:00 AM\n Vancomycin - 08:08 AM\n Meropenem - 02:25 PM\n Infusions:\n Norepinephrine - 0.06 mcg/Kg/min\n Fentanyl (Concentrate) - 50 mcg/hour\n Calcium Gluconate (CRRT) - 1.4 grams/hour\n Midazolam (Versed) - 12 mg/hour\n KCl (CRRT) - 3 mEq./hour\n Other ICU medications:\n Pantoprazole (Protonix) - 07:32 PM\n Diazepam (Valium) - 04:51 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 07:07 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37\nC (98.6\n Tcurrent: 36.1\nC (97\n HR: 99 (96 - 112) bpm\n BP: 101/52(68) {77/37(50) - 135/78(98)} mmHg\n RR: 30 (23 - 31) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 128 kg (admission): 113.5 kg\n Height: 67 Inch\n CVP: 14 (13 - 22)mmHg\n Total In:\n 10,808 mL\n 2,161 mL\n PO:\n TF:\n IVF:\n 9,032 mL\n 1,648 mL\n Blood products:\n Total out:\n 14,321 mL\n 1,662 mL\n Urine:\n 50 mL\n NG:\n 140 mL\n 100 mL\n Stool:\n Drains:\n Balance:\n -3,513 mL\n 499 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 30\n RR (Spontaneous): 2\n PEEP: 12 cmH2O\n FiO2: 60%\n RSBI Deferred: PEEP > 10\n PIP: 28 cmH2O\n Plateau: 24 cmH2O\n Compliance: 38.5 cmH2O/mL\n SpO2: 98%\n ABG: 7.42/48/81./29/5\n Ve: 11.4 L/min\n PaO2 / FiO2: 137\n Physical Examination\n General Appearance: Well nourished, total body fluid overload\n Eyes / Conjunctiva: PERRL, pupils 2mm->1mm\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: (Expansion: Symmetric), (Breath Sounds:\n Rhonchorous: )\n Abdominal: Soft, Distended\n Extremities: Right: 4+, Left: 4+\n Skin: Warm\n Neurologic: No(t) Attentive, No(t) Follows simple commands, Responds\n to: Not assessed, No(t) Oriented (to): , Movement: Not assessed,\n Sedated, Tone: Not assessed\n Labs / Radiology\n 44 K/uL\n 7.9 g/dL\n 170 mg/dL\n 2.0 mg/dL\n 29 mEq/L\n 3.5 mEq/L\n 23 mg/dL\n 109 mEq/L\n 148 mEq/L\n 24.2 %\n 29.1 K/uL\n [image002.jpg]\n 11:09 PM\n 04:10 AM\n 04:20 AM\n 10:00 AM\n 10:10 AM\n 04:08 PM\n 04:20 PM\n 10:12 PM\n 04:02 AM\n 04:17 AM\n WBC\n 38.2\n 29.1\n Hct\n 29.0\n 24.2\n Plt\n 59\n 44\n Cr\n 1.8\n 2.0\n 2.2\n 2.0\n TCO2\n 30\n 30\n 31\n 32\n 32\n 32\n Glucose\n 199\n 205\n 196\n 196\n 178\n 170\n Other labs: PT / PTT / INR:17.5/59.4/1.6, ALT / AST:11/162, Alk Phos /\n T Bili:155/14.5, Amylase / Lipase:16/34, Differential-Neuts:71.0 %,\n Band:8.0 %, Lymph:6.0 %, Mono:4.0 %, Eos:2.0 %, D-dimer: ng/mL,\n Fibrinogen:402 mg/dL, Lactic Acid:1.6 mmol/L, Albumin:1.6 g/dL, LDH:742\n IU/L, Ca++:9.1 mg/dL, Mg++:1.7 mg/dL, PO4:3.3 mg/dL\n Assessment and Plan\n Mr. is a 28 year old gentleman with alcoholic hepatitis and\n necrotizing pancreatitis complicated by ARDS, SIRS, and UGIB.\n # Neuro: Initially dilated pupils with CT showing cerebral edema.\n Pupils less dilated and more reactive.\n - continuing keppra\n - 23% hypertonic saline boluses Q12H. Goal Na 145-150, Osm 310-315.\n - Wean sedation as possible\n - consider repeat CT\n # Respiratory Failure: ARDS secondary to necrotizing pancreatitis\n compounded by hypoxia, tachypnea in setting of anion gap metabolic\n acidosis, increased abdominal pressure, and EtOH withdrawl. PEEP\n decreased to 12 from 20 and FiO2 to 40%.\n - Wean FiO2 and PEEP, goal PaO2>60-65%\n # Leukocytosis: Stable. Initial concern for infection but normal cx\n suggests that this may be inflammatory reaction. No eos on diff and CT\n without abscesses\n - step wise dc abx: flagyl, then meropenem and vancomycin if no skin\n infection. Monitor closely\n - Follow-up culture data\n # Anemia: Initially pw hematemesis and EGD showed diuelafoy's lesion.\n Last PRBC on . HCT now at 24 from 30.\n - repeat HCT, if value correct then HCT/PLT and hemolyisis labs.\n - Trend hct, transfuse for hct<24\n # Necrotizing pancreatitis/SIRS: Secondary to alcohol complicated by\n SIRS and ARDS. Patient continues to have pressor requirement, with neo\n +/- levo. Aggressive volume resuscitation with >53L.\n - Continue empiric antimicrobials.\n - weaning pressors: levo at 0.05.\n - Hypertonic saline as above in order to increase intravascular volume.\n # Hyponatremia: In setting of decreased effective circulating volume\n in setting of SIRS and IABP. Patient receiving hypertonic saline\n boluses with improvement in serum sodium.\n - Hypertonic saline as above.\n # Acute renal failure: Patient had HD line placed and CVVH was\n initiated yesterday.\n - CVVH per renal. UF with net neg 200 cc/hr\n - Trend chemistries\n #Thrombocytopenia: Platelets stable. No clear etiology at this time.\n DIC panel and HIT PF4 antibody negative.\n - Trend plt, transfuse for plt<10 or <50 if signs of hemorrhage.\n # IAP elevation: Secondary to third spacing and edema. Per surgery, not\n a good surgical candidate at this time.\n # Acute hepatitis: Likely alcoholic hepatitis with fatty infiltration,\n and no evidence of distal obstruction. RUQ u/s shows marked liver\n echogenicity but no ascites.\n - Trend LFTs\n # Alcoholism: Patient describes history of withdrawal symptoms, but\n not prior seizure. Last drink was night prior to presentation.\n Tachycardia, weakness, and elevated lactate could be consistent with\n thiamine deficiency.\n - Thiamine, vb12, folate\n - Valium with CIWA > 10\n FEN: TPN, replete as necessary.\n PPx: Heparin and H2B in TPN\n Access: RIJ (quad), LIJ (HD), right radial a-line\n Dispo: ICU level of care\n ICU Care\n Nutrition:\n TPN w/ Lipids - 09:10 PM 73 mL/hour\n Glycemic Control:\n Lines:\n Multi Lumen - 02:02 PM\n Dialysis Catheter - 04:56 PM\n Arterial Line - 01:30 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n ------ Protected Section ------\n MICU ATTENDING ADDENDUM\n I saw and examined the patient, and was physically present with the ICU\n resident for key portions of the services provided. I agree with his\n note above, including assessment and plan.\n 28yo man with necrotizing pancreatitis (30-40% necrosis via CT), ARDS,\n septic shock, renal failure. Head CT with edema, on 23% NS for induced\n osmorx.\n 1. Shock, improved to reduced pressor requirement, though now remains\n levophed dependent while withdrawing fluid via CVVH. Reduce rate of\n fluid withdrawal.\n 2. Drop in cell lines--> repeat CBC. If hct drop is real, ddAVP for\n uremic platelets.\n 3. Neuro: pupil exam improved. stop hypertonic saline. hold off on CT.\n 4. ARDS continue weaning FiO2 followed by PEEP. PEEP was as high as\n 24, now 12. Not a candidate for trach at this time.\n 5. Weaning sedation.\n 6. Meropenem (d9)/vanc (d6) with plan to d/c meropenem tomorrow.\n Remains afebrile.\n 7. Heparin in TPN (prohpylaxis).\n 8. Skin breakdown- wound service recs.\n 9. Renal failure, on CVVHD. Much less anasarca.\n Critically ill, 45 minutes\n ------ Protected Section Addendum Entered By: , MD\n on: 18:17 ------\n" }, { "category": "Rehab Services", "chartdate": "2131-06-20 00:00:00.000", "description": "Physical Therapy Progress Note", "row_id": 681910, "text": "Subjective:\n Objective:\n Follow up PT visit to address goals of: . Patient seen today\n for balance training, patient education\n Updated medical status: on trach mask\n Activity\n Clarification\n I\n S\n CG\n Min\n Mod\n Max\n Rolling:\n\n\n\n\n T\n total A x 2\n Supine/\n Sidelying to Sit:\n\n\n\n\n T\n Total A x3\n Transfer:\n NT\n\n\n\n\n\n\n Sit to Stand:\n NT\n\n\n\n\n\n\n Ambulation:\n\n\n\n\n\n Stairs:\n\n\n\n\n\n Aerobic Activity Response:\n Position\n HR\n BP\n RR\n O[2] sat\n RPE\n Rest\n Supine\n 98\n 121/59\n 28\n 100 on 60% TM\n Activity\n Sit\n 100\n 123/62\n 34-40\n 100\n Recovery\n Supine\n 101\n 124/63\n 30\n 100\n Total distance walked:\n Minutes:\n Gait: NT\n Balance: mod to max A to maintain sitting EOB. Postural reactions noted\n when balance challenged\n Education / Communication: Pt. edu re: Role of PT, , d/c plan to\n rehab, RN comm re: pt. staus\n Other: Visual tracking noted across midline. Nods head yes to pain,\n otherwise did not respond to commands.\n PROM performed to bilat. UEs/\n : Pt. is 28 y.o. male with acute pancreatitis c/b PEA,\n prolonged intubation requiring trach, renal failure on CVVH, that p/w\n improved arousal and alertness since intial eval. Pt. continues to be\n functioning below baseline and recommend rehab placement upon d/c.\n Anticipated Discharge: Rehab\n Plan: Bed mobility, balance re-edu, therex\n Nsg recs: Lateral transfer bed to stretcher chair\n Face time: 12:20-12:44\n" }, { "category": "Rehab Services", "chartdate": "2131-06-20 00:00:00.000", "description": "PMV Evaluation/Dispense", "row_id": 681911, "text": "TITLE: PASSY-MUIR VALVE EVALUATION / DISPENSE\nHISTORY:\nThank you for consulting on this 28-year-old male who presented\nto ED on complaints of weakness, fatigue and\nconfusion for ~1 week, 2 days of melena and hematemesis. Patient\nwas found with grade 3 esophagitis in the lower\nand middle third of the esophagus; friability, erythema,\ncongestion and erosion in the whole stomach compatible with\nmoderately severe gastritis via EGD. CT scan revealed acute\npancreatitis with peripancreatic stranding and 30% necrosis.\nHospital course c/b continuous pressor requirement, alcoholic\nhepatitis, necrotizing pancreatitis, acute renal failure\nrequiring CVVHD, cerebral edema, ARDS, coagulopathy and\nthrombocytopenia thought to be due to liver failure (vs DIC) and\npossibly adrenal insufficiency. Patient was unable to wean from\nvent and underwent tracheostomy on and s/p bronchoscopy on\n clot resulting in brief PEA arrest. CVVH was\ndiscontinued on and patient to begin HD. Patient has been\ntolerating trach mask since and we were consulted to\nevaluate patient's ability to tolerate a Passy-Muir Speaking\nValve (PMV).\nPMH:\nalcohol dependency\ndepression\nTRACH TYPE:\n#8 Portex, cuffed, inner cannula\nSECRETIONS / ABILITY TO HANDLE CUFF DEFLATION:\nRN reported patient with intermittent moderate secretions.\nPatient was tracheal suctioned just prior to evaluation. O2 sats\nwere 98% and RR 28 prior to and following cuff deflation.\nSecretions were unremarkable following cuff deflation.\nPMV TOLERANCE / VOCAL QUALITY / O2 SATS:\nPMV was placed on patient's trach and patient was noted with\nimmediate coughing and audible secretions. Secretions had to be\nsuctioned via yankauer with cues for patient to open his mouth.\nModerate secretions were retrieved during each coughing episode.\nTracheal pressures remained within the normal range of +/- 10\ncm/H2O. Patient was unable to produce volitional voicing, however\nvoicing was heard with involuntary grunting and coughing. Vital\nsigns remained stable for sometime. Patient was noted with\neventual desaturation to low 80s, however RN felt was\nunreliable. Large rush of air was noted upon removal of PMV\nindicating breath stacking. O2 monitor was moved and PMV was\nreplaced for ~6 minutes with his father present in the room. PMV\nwas again removed with large rush of air and patient did appear\nto breathe easier. Cuff was reinflated and patient appeared\ncomfortable.\nSUMMARY:\nMr. cuff deflation without difficulty. He was\nnoted with productive coughing for moderate secretions with PMV\nin place, which he could not effectively managed and were\nsuctioned via Yankauer. Patient appeared to attempt to voice,\nhowever was unable to produce purposeful voicing MS. was\nnoted with functinal vocal quality with minimal vocalizations\nfrom involuntary grunting and coughing. Patient the PMV\nin brief trials, however was noted with desaturation x1 and\nlarge/heavy rush of air upon removal of PMV x2 indicating breath\nstacking. Patient is not quite appropriate for PMV placement at\nthis time as likely heavy breathstacking and patient's inability\nto communicate discomfort are concerning. We will continue to\nfollow and re-attempt PMV placement as patient continues to\nimprove.\nRECOMMENDATIONS:\n1. Patient is not appropriate for PMV placement at this time.\n2. We will continue to follow and re-attempt PMV placement as\npatient continues to improve.\n3. Continue NPO status and Q4 oral care.\nThese recommendations were shared with the patient, nurse and\nmedical team.\n_______________________________________\n , M.S., CCC-SLP\nPager #\nFace time: 1150-1205\nTotal time: 50 minutes\n" }, { "category": "Nursing", "chartdate": "2131-06-15 00:00:00.000", "description": "Nursing Progress Note", "row_id": 680924, "text": "Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Minimal urine output\n K stable ~ 4\n BUN up to 72, Creat stable at 1.6\n Action:\n Off CRRT overnight\n Response:\n Lytes remain stable\n Plan:\n HD vs CRRT this am.\n Fever\n Assessment:\n Temp 102.3 at 120\n RR high 30\n Appeared restless + twitching, moving bil upper extremities off bed\n Action:\n MICU paged and into assess patient\n Pan CX\n Cooling blanket and tyelnol\n CBC sent\n Liver US done at bedside to evaluate for cholecystitis\n Response:\n Temp down over several hours and Afebrile rest of night\n HR down to 90-100 , RR 18-26 although continues to have bursts up to\n 40\ns with agitation\n BP stable SBP > 90 MAP > 60\n WBC and HCT stable\n Per report US showed some sludge\n CIPRO started\n Plan:\n Plan for gallbladder study today, f/u on cultures, continue on IV abx.\n Seizure, without status epilepticus\n Assessment:\n On continuous EEG monitoring\n Continues to have twitching of face and BUE but not felt by team to be\n related to seizure activity\n Action:\n Monitor s/s seizure activity\n Keppra \n Response:\n No obvious s/s seizure activity\n Plan:\n Neurology to review EEG data this am.\n" }, { "category": "Nursing", "chartdate": "2131-06-16 00:00:00.000", "description": "Nursing Progress Note", "row_id": 681205, "text": "Respiration / Gas Exchange, Impaired\n Assessment:\n Received on CMV mode this am\n Lungs Rhonchorus in Bilateral upper lobes and diminished in\n lower lobes\n Moderate amts of oral bloody secretions\n Sxn thin white sputum from trach\n Action:\n Pt placed on CPAP this am\n Micu team aware of continued bloody oral secretions\n Lung sounds unchanged\n Response:\n Tolerating CPAP well placed on trach mask\n Tolerating trach mask since noon\n Secretions from trach minimal\n Oral secretions still remain bloody sxn 2 quarter size clots\n from mouth\n Plan:\n Trach mask as tolerated\n Frequent sxn of oral secretions\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n CRRT off this am ? HD\n Per renal SBP to hypotensive restarted Crrt\n Action:\n CRRT started per renal\n Response:\n Tolerating crrt well goal -50 to -100cc/hr increase as\n tolerated\n Plan:\n Cont CRRT for the rest of the weekend ? HD Monday\n ** Temp this am 101.2 Micu team aware\n Pt plan cultured this am for temp\n Remains with low grade temp since CRRT started\n F/U BC cont abx therapy\n" }, { "category": "Respiratory ", "chartdate": "2131-06-15 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 681052, "text": "Demographics\n Day of intubation: 29\n Day of mechanical ventilation: 29\n Ideal body weight: 67.1 None\n Ideal tidal volume: 268.4 / 402.6 / 536.8 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type:\n Size:\n Tracheostomy tube:\n Type:\n Manufacturer: Portex\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 24 cmH2O\n Cuff volume: 8 mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Tan / Thick\n Sputum source/amount: Suctioned / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern:\n Assessment of breathing comfort: No response (sleeping / sedated)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Sedated / Paralyzed,\n Underlying illness not resolved\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n Pt on trach collar for about three hours today. Back on vent RR has\n been increasing.\n, RRT 17:14\n" }, { "category": "Nursing", "chartdate": "2131-06-16 00:00:00.000", "description": "Nursing Progress Note", "row_id": 681203, "text": "Respiration / Gas Exchange, Impaired\n Assessment:\n Received on CMV mode this am\n Lungs Rhonchorus in Bilateral upper lobes and diminished in\n lower lobes\n Moderate amts of oral bloody secretions\n Sxn thin white sputum from trach\n Action:\n Pt placed on CPAP this am\n Micu team aware of continued bloody oral secretions\n Lung sounds unchanged\n Response:\n Tolerating CPAP well placed on trach mask\n Tolerating trach mask since noon\n Secretions from trach minimal\n Oral secretions still remain bloody sxn 2 quarter size clots\n from mouth\n Plan:\n Trach mask as tolerated\n Frequent sxn of oral secretions\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n CRRT off this am ? HD\n Per renal SBP to hypotensive restarted Crrt\n Action:\n CRRT started per renal\n Response:\n Tolerating crrt well goal -50 to -100cc/hr increase as\n tolerated\n Plan:\n Cont CRRT for the rest of the weekend ? HD Monday\n" }, { "category": "Physician ", "chartdate": "2131-05-30 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 677776, "text": "Chief Complaint: Nectrotizing pancreatitis c/b ARDS\n 24 Hour Events:\n - Weaned pressors earlier in the day but had to go back up overnight in\n setting of hct drop\n - Transfused 2 units PRBC, DDAVP.OGL negative, still no BM. Surgery\n suspects ruptured pancreatic cyst, no surgical intervention. Would be\n IR procedure if intervention required. Haptoglobin <20 but mostly\n direct bili. Smear without schistocytes.\n - Came down on FiO2 to 0.5\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Metronidazole - 02:00 AM\n Vancomycin - 07:50 AM\n Meropenem - 02:45 AM\n Infusions:\n Midazolam (Versed) - 3 mg/hour\n Norepinephrine - 0.07 mcg/Kg/min\n Fentanyl (Concentrate) - 50 mcg/hour\n Calcium Gluconate (CRRT) - 1.4 grams/hour\n KCl (CRRT) - 3 mEq./hour\n Other ICU medications:\n Pantoprazole (Protonix) - 07:49 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 12 AM\n Tmax: 37.1\nC (98.7\n Tcurrent: 36.6\nC (97.9\n HR: 105 (94 - 111) bpm\n BP: 96/50(64) {85/46(59) - 108/61(77)} mmHg\n RR: 29 (15 - 33) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 128 kg (admission): 113.5 kg\n Height: 67 Inch\n CVP: 15 (12 - 17)mmHg\n Total In:\n 9,518 mL\n 3,227 mL\n PO:\n TF:\n IVF:\n 7,417 mL\n 2,332 mL\n Blood products:\n 350 mL\n 277 mL\n Total out:\n 8,289 mL\n 2,829 mL\n Urine:\n 75 mL\n 22 mL\n NG:\n 100 mL\n 300 mL\n Stool:\n Drains:\n Balance:\n 1,229 mL\n 398 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 30\n RR (Spontaneous): 0\n PEEP: 12 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10\n PIP: 26 cmH2O\n Plateau: 22 cmH2O\n Compliance: 44.4 cmH2O/mL\n SpO2: 100%\n ABG: 7.44/50/71/28/7\n Ve: 12.5 L/min\n PaO2 / FiO2: 142\n Physical Examination\n General Appearance: Well nourished, total body fluid overload\n Eyes / Conjunctiva: PERRL, pupils 2mm->1mm\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: (Expansion: Symmetric), (Breath Sounds:\n Rhonchorous: )\n Abdominal: Soft, Distended\n Extremities: Right: 4+, Left: 4+\n Skin: Warm. Weeping blisters over LE b/l.\n Neurologic: No(t) Attentive, No(t) Follows simple commands, Responds\n to: Not assessed, No(t) Oriented (to): , Movement: Not assessed,\n Sedated, Tone: Not assessed\n Labs / Radiology\n 42 K/uL\n 8.9 g/dL\n 150 mg/dL\n 1.8 mg/dL\n 28 mEq/L\n 3.7 mEq/L\n 23 mg/dL\n 106 mEq/L\n 145 mEq/L\n 26.2 %\n 25.7 K/uL\n [image002.jpg]\n 09:43 AM\n 12:26 PM\n 02:00 PM\n 05:22 PM\n 06:38 PM\n 08:15 PM\n 08:30 PM\n 10:47 PM\n 01:42 AM\n 02:13 AM\n WBC\n 27.9\n 30.7\n 29.5\n 25.7\n Hct\n 22.6\n 25.0\n 24.3\n 26.2\n Plt\n 44\n 49\n 38\n 42\n Cr\n 2.0\n 1.8\n 1.8\n TCO2\n 32\n 36\n 34\n 35\n Glucose\n 166\n 179\n 150\n Other labs: PT / PTT / INR:16.2/60.4/1.5, ALT / AST:19/227, Alk Phos /\n T Bili:141/14.5, Amylase / Lipase:16/34, Differential-Neuts:55.0 %,\n Band:1.0 %, Lymph:16.0 %, Mono:7.0 %, Eos:6.0 %, D-dimer:6389 ng/mL,\n Fibrinogen:293 mg/dL, Lactic Acid:1.9 mmol/L, Albumin:1.4 g/dL, LDH:538\n IU/L, Ca++:8.6 mg/dL, Mg++:1.8 mg/dL, PO4:3.8 mg/dL\n Assessment and Plan\n Mr. is a 28 year old gentleman with alcoholic hepatitis and\n necrotizing pancreatitis complicated by ARDS, SIRS, and UGIB.\n # Anemia: Initially p/w hematemesis and EGD showed diuelafoy's lesion.\n Hct drop yesterday now s/p 2 units PRBC transfusion and DDAVP with\n inappropriate bump. INR 1.5, platelets <50. Elevated d-dimer and low\n haptoglobin concerning for hemolysis, although less likely given\n persistently elevated split products in setting of liver failure and\n smear negative for schistocytes. Concerning for ruptured cyst, less\n likely hemorrhagic pancreatitis as hemodynamics would have been\n expected to be significantly worse.\n - Recheck CBC Q6H, transfuse for hct<21, plt <50.\n - Discuss with surgery, radiology, and renal, but CTAP with PO and IV\n contrast indicated at this time to eval for hemorrhagic pancreatitis or\n ruptured hemorrhagic cyst. Will also discuss with GI regarding need for\n upper endoscopy if CT unremarkable. Will have family discussion prior\n to CT regarding renal prognosis from contrast.\n - NAC pre and post treatment.\n - Hold heparin in TPN.\n # Neuro: Initially dilated pupils with CT showing cerebral edema.\n Pupils less dilated and more reactive. Overall mental status and\n neuron exam improving. - Continue keppra\n - Wean sedation as possible\n - Consider repeat CTH\n - Neuro recs if any\n - Continue keppra.\n - Hold hypertonic saline.\n # Respiratory Failure: ARDS secondary to necrotizing pancreatitis\n compounded by hypoxia, tachypnea in setting of anion gap metabolic\n acidosis, increased abdominal pressure, and EtOH withdrawl. PEEP\n decreased to 12 from 20 and FiO2 to 50%.\n - Wean FiO2 and PEEP, goal PaO2>60-65%\n # Leukocytosis: Stable. Initial concern for infection but normal cx\n suggests that this may be inflammatory reaction. No eos on diff and CT\n without new fluid collection. Appreciate ID input, no antibiotic\n indication at this time. Flagyl discontinued.\n - Hold meropenem and vancomycin today.\n - Follow-up culture data\n # Necrotizing pancreatitis/SIRS: Secondary to alcohol complicated by\n SIRS and ARDS. Patient continues to have pressor requirement, with neo\n +/- levo. Aggressive volume resuscitation with >50L.\n - Wean pressors with goal MAP >65\n # Hyponatremia: In setting of decreased effective circulating volume\n in setting of SIRS and IABP. Patient has received hypertonic saline\n boluses with improvement in serum sodium and osm.\n - Given improvement in neuro exam, hold hypertonic saline.\n # Acute renal failure: Patient had HD line placed and on CVVH. CVVH\n with even TBB pending assessment of hemorrhage.\n - CVVH per renal.\n - Trend chemistries\n #Thrombocytopenia: Platelets stable. No clear etiology at this time.\n DIC panel and HIT PF4 antibody negative.\n - Trend plt, transfuse for plt<10 or <50 if signs of hemorrhage.\n # Wound care: Per wound care recs.\n # Acute hepatitis: Likely alcoholic hepatitis with fatty infiltration,\n and no evidence of distal obstruction. RUQ u/s shows marked liver\n echogenicity but no ascites.\n - Trend LFTs\n # Alcoholism: Patient describes history of withdrawal symptoms, but\n not prior seizure. Last drink was night prior to presentation.\n Tachycardia, weakness, and elevated lactate could be consistent with\n thiamine deficiency.\n - Thiamine, vb12, folate\n - Valium with CIWA > 10\n FEN: Hold TPN given heparin, replete as necessary.\n PPx: IV PPI. Hold heparin in TPN.\n Access: RIJ (quad), LIJ (HD), left radial a-line\n Dispo: ICU level of care\n ICU Care\n Nutrition:\n TPN w/ Lipids - 04:23 PM 73 mL/hour\n Glycemic Control:\n Lines:\n Multi Lumen - 02:02 PM\n Dialysis Catheter - 04:56 PM\n Arterial Line - 01:30 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2131-06-21 00:00:00.000", "description": "Nursing Progress Note", "row_id": 682021, "text": "Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Off CRRT for ~ 40 hours\n BUN 82, Creatinine 2.4 (1.8)\n Urine output MN\n 0500:\n Fluid balance MN\n 0500:\n Action:\n Limited fluid intake\n Tube feeds at goal\n Response:\n Unchanged\n Plan:\n HD today\n Arousal, Attention, and Cognition, Impaired\n Assessment:\n Wakes to voice if not already alert\n Turns head toward voice\n Lifting right arm\n Remains tremulous with movements\n MAE\n Does not follow commands\n Attempting to smile\n Action:\n Frequent verbal encouragement\n Orienting patient\n ROM, frequent repositioning\n Response:\n Neurologically improving\n Plan:\n Continue to monitor neuro status\n Continue to increase activity\n Patient and family support\n Impaired Skin Integrity\n Assessment:\n Skin peeling from resolved severe anasarca\n Open blisters healing well on legs\n Heels also improving\n Action:\n Cleansed, aloe vesta applied, soft sorb on right leg\n Waffle boots\n Frequent repositioning\n Response:\n Improving skin\n Plan:\n Continue diligent care\n" }, { "category": "Nursing", "chartdate": "2131-06-16 00:00:00.000", "description": "Nursing Progress Note", "row_id": 681113, "text": "Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Pt remains off CRRT.\n Action:\n Serial labs. Strict i/o\n Response:\n K stable at 4.7. Bun and Creatinine on the rise. Minimal urine output\n via foley.\n Plan:\n Plan for CRRT versus hemodialysis this a.m.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt remains on CMV. O2 sat high 90\ns to 100%.\n Action:\n No vent changes. ABG sent.\n Response:\n Pt consistently over breathing vent. ABG acceptable. Pt frequently\n suctioned for thick, blood tinged sputum.\n Plan:\n Wean from vent as tolerates. Attempt trach collar. Aggressive\n pulmonary toilet.\n" }, { "category": "Nutrition", "chartdate": "2131-06-18 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 681544, "text": "Objective\n Daily Wt: 99.7kg\n Pertinent medications: Fentanyl, RISS, Pepcid, Heparin, others noted\n Labs:\n Value\n Date\n Glucose\n 156 mg/dL\n 10:08 AM\n Glucose Finger Stick\n 151\n 04:00 PM\n BUN\n 33 mg/dL\n 03:49 AM\n Creatinine\n 0.6 mg/dL\n 03:49 AM\n Sodium\n 134 mEq/L\n 03:49 AM\n Potassium\n 3.5 mEq/L\n 10:08 AM\n Chloride\n 99 mEq/L\n 03:49 AM\n TCO2\n 24 mEq/L\n 03:49 AM\n PO2 (arterial)\n 115 mm Hg\n 10:08 AM\n PCO2 (arterial)\n 33 mm Hg\n 10:08 AM\n pH (arterial)\n 7.45 units\n 10:08 AM\n pH (venous)\n 7.25 units\n 10:31 AM\n pH (urine)\n 5.5 units\n 04:08 PM\n CO2 (Calc) arterial\n 24 mEq/L\n 10:08 AM\n Albumin\n 2.0 g/dL\n 04:16 PM\n Calcium non-ionized\n 8.3 mg/dL\n 03:49 AM\n Phosphorus\n 1.3 mg/dL\n 03:49 AM\n Ionized Calcium\n 1.06 mmol/L\n 10:08 AM\n Magnesium\n 1.8 mg/dL\n 03:49 AM\n ALT\n 211 IU/L\n 03:49 AM\n Alkaline Phosphate\n 588 IU/L\n 03:49 AM\n AST\n 223 IU/L\n 03:49 AM\n Amylase\n 77 IU/L\n 03:49 AM\n Total Bilirubin\n 27.9 mg/dL\n 03:49 AM\n Triglyceride\n 154 mg/dL\n 02:10 AM\n WBC\n 30.5 K/uL\n 03:49 AM\n Hgb\n 8.0 g/dL\n 03:49 AM\n Hematocrit\n 24.8 %\n 03:49 AM\n Current diet order / nutrition support: Tube Feeds: 3/4 strength Nutren\n 2.0 @ 50cc/hr + 40g Beneprotein (1943kcals, 106g protein)\n GI: hypoactive Bowel sounds, abd soft/distended, + semi-formed stool\n Assessment of Nutritional Status\n TPN has been off since , and tube feeds are at goal, which meet\n ~100% of estimated calorie and protein needs. However as renal\n function and labs improve, and patient is now off vent support,\n patient\ns protein and calorie needs will likely increase. Recommend\n increasing amount of protein modular in tube feeds. Will continue to\n monitor wt, tube feed tolerance, labs and renal function and adjust\n tube feeding regimen as needed.\n Medical Nutrition Therapy Plan - Recommend the Following\n 1) Recommend changing tube feed goal to\n strength Nutren 2.0 @\n 50cc/hr + 50g Beneprotein (1962kcals, 115g protein). This will provide\n 1.45g protein/kg adjusted wt and 25kcals/kg adjusted wt.\n 2) Will follow, increasing tube feeds and changing formula as\n needed.\n 3) Continue to monitor tube feed tolerance with abd exam.\n Following, please page with any questions. #\n" }, { "category": "Nursing", "chartdate": "2131-06-21 00:00:00.000", "description": "Nursing Progress Note", "row_id": 682022, "text": "Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Off CRRT for ~ 40 hours\n BUN 82, Creatinine 2.4 (1.8)\n Urine output this shift: 210 cc\n Fluid balance MN\n 0500: +840 cc\n Fluid balance : + 2400 cc\n Electrolytes acceptable\n Action:\n Limited fluid intake\n Tube feeds at goal\n Response:\n Unchanged\n Plan:\n HD today\n Arousal, Attention, and Cognition, Impaired\n Assessment:\n Wakes to voice if not already alert\n Turns head toward voice\n Lifting right arm\n Remains tremulous with movements\n MAE\n Does not follow commands\n Attempting to smile\n Action:\n Frequent verbal encouragement\n Orienting patient\n ROM, frequent repositioning\n Response:\n Neurologically improving\n Plan:\n Continue to monitor neuro status\n Continue to increase activity\n Patient and family support\n Impaired Skin Integrity\n Assessment:\n Skin peeling from resolved severe anasarca\n Open blisters healing well on legs\n Heels also improving\n Action:\n Cleansed, aloe vesta applied, soft sorb on right leg\n Waffle boots\n Frequent repositioning\n Aloe vesta applied to all skin\n Response:\n Improving skin\n Plan:\n Continue diligent care\n" }, { "category": "Nursing", "chartdate": "2131-06-17 00:00:00.000", "description": "Nursing Progress Note", "row_id": 681258, "text": "Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n On CRRT. Goal negative.\n Hemodynamically stable. Sedated on Fent/Versed.\n Hypotensive to high 80s x1 this shift.\n u/o marginal- approx ccs/hr. icteric & clear.\n Hypothermic at beginning of shift (95).\n Action:\n approx -30 ccs at midnight tonight.\n Flushed CRRT and gave pt small 200 cc bolus for transient hypotension.\n Treated with 2 grams calcium gluconate for hypocalcemia in addition to\n continuous replacement of CRRT.\n Bair hugger in place.\n Response:\n Responded well to fluid bolus.\n Tolerating CRRT well.\n u/o remains marginal.\n a.m labs pending.\n Temp 96-97 rest of the shift.\n Plan:\n D/w renal and MICU CRRT goals.\n Discuss ? HD in the coming days vs. CRRT.\n ? attempt to wean sedation further to assist with blood pressure\n management.\n Closely monitor temp & white count in light of recent temp spikes and\n CRRT use.\n Respiration / Gas Exchange, Impaired\n Assessment:\n Min oral secretions though pt at times biting down and preventing oral\n care.\n On TM 50% since this afternoon.\n ABGs wnl. RR 20s.\n When agitated or with stimulation. RR up to 30s though self resolves.\n LS clear, at times rhonchorous and wheezy.\n Action:\n Trach mask continued.\n Inhalers prn.\n Suctioned for scant amount of secretions.\n T&P frequently.\n Serial ABGs.\n Response:\n Continues to tolerate trach mask well. Not tachypneic, sats 98-100.\n Plan:\n Continue to closely monitor respiratory status. Frequent suctioning to\n check for clots/secretions.\n Serial gases. Provide orientation and redirection as needed. Provide\n comfort and support. Place back on vent if respiratory status changes.\n Impaired Skin Integrity\n Assessment:\n Multiple open, blisters to bilateral lower extremities and abdomen.\n Skin dry & peeling.\n Deep tissue injury to bilateral heels.\n +1 generalized edema.\n TF at goal rate. Loose green liquid/mucoid stool x2 this shift.\n FS elevated 170-270.\n Action:\n Aloe Vesta cream applied to all areas after cleaning site.\n Dressing applied on both knee/calf areas.\n Waffle boots in place, elevating heels.\n TF continues. Aloevesta to sacrum/coccyx as well.\n SQ Insulin sliding scale.\n Response:\n Skin remains unchanged though no new areas are noted.\n Tolerating TF well.\n Plan:\n Continue with good skin care- frequent turning, elevation of heels.\n Ensure adequate glucose control. Continually re-apply aloe vesta and\n keep skin moist.\n Provide comfort and support.\n" }, { "category": "Physician ", "chartdate": "2131-06-19 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 681704, "text": "Chief Complaint:\n 24 Hour Events:\n NUCLEAR MEDICINE - At 05:40 PM\n \n - Restarted on linezolid, aztreonam, and flagyl given increased\n leukocytosis/left shift\n - Pt to continue CVVH until filter clogs per Renal\n - Fentanyl gtt changed to prn boluses\n - PT/OT consulted; case manager starting Rehab screening\n - HIDA scan done. On return, more tachypneic with RR in 30s. ABG c/w\n resp alkalosis: 7.45/33/115 10am -> 7.50/30/55/24 6pm -> 7.49/25/66/20\n 6:30pm. Trach suctioned with no output. Given fentanyl bolus as\n appeared more uncomfortable. I/O net positive 670 cc -> CVVH rate\n increased as SBP 120s. Had clot when resuctioned. CXR showed mild fluid\n at bases with more plump pulm vasculature; smaller volumes likely c/w\n expiration - no collapse. Repeat ABG 7.46/37/180/27.\n Allergies:\n Meropenem\n skin blisters a\n Last dose of Antibiotics:\n Linezolid - 12:42 PM\n Aztreonam - 02:57 AM\n Metronidazole - 04:00 AM\n Infusions:\n Calcium Gluconate (CRRT) - 1.6 grams/hour\n Other ICU medications:\n Fentanyl - 07:09 PM\n Famotidine (Pepcid) - 12:08 AM\n Heparin Sodium (Prophylaxis) - 04:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:26 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37\nC (98.6\n Tcurrent: 35.9\nC (96.7\n HR: 95 (90 - 118) bpm\n BP: 126/70(91) {107/56(72) - 133/78(99)} mmHg\n RR: 30 (21 - 36) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 100.4 kg (admission): 113.5 kg\n Height: 67 Inch\n Total In:\n 8,831 mL\n 2,834 mL\n PO:\n TF:\n 995 mL\n 371 mL\n IVF:\n 7,796 mL\n 2,463 mL\n Blood products:\n Total out:\n 8,370 mL\n 2,381 mL\n Urine:\n 85 mL\n 35 mL\n NG:\n Stool:\n Drains:\n Balance:\n 461 mL\n 453 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n SpO2: 99%\n ABG: 7.44/39/125/25/2\n PaO2 / FiO2: 179\n Physical Examination\n GEN: Trached, sedated.\n HEENT: Icteric sclera. MMM.\n NECK: Trach site with no oozing.\n LUNGS: Anterior auscultation with upper airway noise; good airway\n movement.\n HEART: RRR, normal S1, S2.\n ABD: Distended. Firm, but unchanged.\n EXTREM: 2+ edema, ulcers/lesions on legs with bandages C/D/I.\n SKIN: Jaundiced.\n NEURO: Twitching mouth. No purposeful movements today.\n Labs / Radiology\n 334 K/uL\n 8.0 g/dL\n 151 mg/dL\n 0.6 mg/dL\n 25 mEq/L\n 3.9 mEq/L\n 29 mg/dL\n 98 mEq/L\n 132 mEq/L\n 24.6 %\n 34.9 K/uL\n [image002.jpg]\n Ca: 8.8 Mg: 1.8 P: 1.7\n ALT: 214\n AP: 519\n Tbili: 24.8\n Alb:\n AST: 227\n LDH: 529\n Dbili:\n TProt:\n :\n Lip:\n 10:30 PM\n 03:49 AM\n 03:56 AM\n 10:08 AM\n 06:00 PM\n 06:25 PM\n 08:18 PM\n 10:56 PM\n 02:58 AM\n 03:10 AM\n WBC\n 30.5\n 34.9\n Hct\n 24.8\n 24.6\n Plt\n 321\n 334\n Cr\n 0.6\n 0.6\n TCO2\n 26\n 27\n 24\n 24\n 20\n 27\n 26\n 27\n Glucose\n 185\n 160\n 165\n 156\n 116\n 112\n 151\n Other labs: PT / PTT / INR:15.0/33.3/1.3, CK / CKMB /\n Troponin-T:214/3/0.07, ALT / AST:214/227, Alk Phos / T Bili:519/24.8,\n Amylase / Lipase:77/68, Differential-Neuts:78.0 %, Band:9.0 %,\n Lymph:2.0 %, Mono:3.0 %, Eos:0.0 %, D-dimer:6389 ng/mL, Fibrinogen:502\n mg/dL, Lactic Acid:1.0 mmol/L, Albumin:2.0 g/dL, LDH:529 IU/L, Ca++:8.8\n mg/dL, Mg++:1.8 mg/dL, PO4:1.7 mg/dL\n U Cx with yeast persistently after foley changed and Blood Cx pending\n HIDA scan: Non-visualization of GB. Contrast in bowel consistent with\n patent common BD\n Assessment and Plan\n 28M with alcoholic hepatitis and necrotizing pancreatitis complicated\n by ARDS, SIRS, ARF, UGIB, fevers.\n #. ID: Persistent leukocytosis. Necrotizing pancreatitis. All abx\n (linezolid/aztreo D1 and flagyl D1 ) discontinued as\n appeared clinically improved, but WBC trended back up. Remains afebrile\n (but on CVVH) but worsened leukocytosis today. HIDA neg.\n - F/U fever curve after cvvh d/c\nd. If spikes or HD instability abd ct.\n - Continue abx coverage with aztreo, flagyl, and linezolid given\n necrotizing pancreatitis.\n - F/u WBC count, temp curve, and culture data\n - taper steroids to 12.5 mg today\n - added on diff to CBC from this am as may have increasing eosinophilia\n as cause of leukocytosis\n - Yeast in the urine- changed foley and re-cultured with persistent\n yeast but oliguric so unclear if true infection.\n # Elevated LFTs: A/w alcoholic hepatitis but recent increase may be \n TPN, now discontinued. RUQ u/s showed sludge concerning for\n cholestasis but also seen on u/s. T Bili and transaminases\n stable today.\n - HIDA neg\n - TPN stopped \n - Plan for weaning off benzos\n #. Respiratory Failure: ARDS secondary to necrotizing pancreatitis. S/p\n trach placement on . Sutures out on .\n - worse after HIDA likely from laying flat. Will repeat CXR to ensure\n trach in place.\n - Change gtt to PRN fentanyl boluses, continue methadone with wean\n tomorrow\n - goal to chair daily\n # Seizures: CT head without intracranial process. EEG showed occipital\n seizures which does not correlate with clinical symptoms, but repeat\n EEG on higher dose Keppra showed no seizures. As patient now with\n purposeful movements, this may actually be patient waking up, not\n seizures.\n - Continue keppra\n - Continue low dose valium to prevent withdrawal; Plan to wean valium\n today\n #. Acute renal Failure: Appreciate renal recs.\n - Transition to HD tomorrow\n - Would dialyze for acidosis but likely does not need volume depletion\n as pressures borderline.\n - Aztreonam 2000mg q12h while on CVVH\n - Will change Keppra to 1000mg Q24 with 500 mg after HD if he\n transitions to HD\n #. Adrenal Insufficiency: Unclear with stim if clear adrenal\n insufficiency but hypotension improving with steroids (lower pressor\n requirement) and improving eosinophilia\n - Cont weaning hydrocort; D3/3 of 25mg Q8H today. Change to 12.5 today\n # PT and OT eval for placement\n ICU Care\n Nutrition:\n Nutren 2.0 () - 05:40 PM 50 mL/hour\n Glycemic Control: ISS\n Lines:\n Arterial Line - 08:15 PM\n PICC Line - 08:37 AM\n Dialysis Catheter - 08:55 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP: HOB elevation\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:ICU pending placement\n" }, { "category": "Nursing", "chartdate": "2131-05-30 00:00:00.000", "description": "Nursing Progress Note", "row_id": 677844, "text": "Pt had a significant Hct drop yesterday and Hct remained low this\n morning. Levo/Fent gtts continue. CRRT even. Pt went to CTA of\n abdomen/pancreas to eval for bleeding and CT of head done today to\n assess cerebral edema. Family updated by MICU, radiology and renal post\n CT. Details following.\n Impaired Skin Integrity\n Assessment:\n Bilateral lower extremities wounds/blisters open with mod\n amounts of serosang drainage.\n Bilateral heel skin impairments as well.\n On Bigturn pressure reducing mattress, rotating.\n ? areas of petechiai, PLTs approx 40s all day.\n Coags slightly elevated. TPN with heparin in it this a.m.\n Unable to place compression sleeves on bilat lower\n extremities.\n ? drug rash on abdomen and feet.\n Action:\n Aquacel Ag and Aquacel applied to open, oozing areas.\n Attempted to not use pink pads to collect drainage, unsuccessfully.\n Wound care in to consult this morning and recommended use of\n Aquacel, sofsorb and net stockings as well as elevating bilat lower\n extremities off bed. Waffle boots recommended as well.\n Labs drawn frequently.\n TPN discontinued this morning. Tonights TPN ordered and hung\n without heparin.\n Pneumoboots to arms- awaiting arrival of compression sleeves &\n waffle boots from distribution.\n Abdomen and feet rash assessed by MICU team. IV ABX\n discontinued today.\n Response:\n INR & PTT decreased slightly after d/c of TPN.\n See wound care recs above and more explicit instructions in their note.\n Tolerating rotation well. Turned and pads changed underneath patient 3x\n this shift. (tol well).\n White count relatively stable.\n Plan:\n Continue to monitor and trend labs.\n Pneumoboots to arms and waffle boots to BLE.\n Closely monitor skin impairment and follow up with wound care as\n indicated.\n Per MICU team, if PLTs fall, (? Less than 40) would consider giving\n PLTs.\n Family updated re: poc and wound care consult recs. Provide comfort and\n support.\n Hypotension (not Shock)\n Assessment:\n Received on 0.07 mcg/kg/hr of Levophed\n Goal MAP >60.\n Hct stable at 24-25 all day.\n No obvious signs of bleeding- OGT output pink tinged but\n most likely d/t oozing mucosa.\n Coags slightly elevated.\n Oliguric, CRRT running even.\n Action:\n Levo titrated accordingly for MAP>60. Currently on 0.15\n mcg/kg/hour. Team aware.\n Hct checked q6.\n OGT lavage negative for coffee grounds and/or bright red\n blood.\n Team aware of increasing pressor requirements.\n Midaz turned off this morning and Fent decreased this p.m- no\n signs of pain noted.\n CRRT goal of running even.\n Response:\n MAP remains around 60 on current dose of levophed.\n CRRT approximately even (200 positive- most recent hour).\n Hct continues to be stable at 24.\n Plan:\n Per team, if Hct drops below 24, will most likely transfuse.\n Per team, will attempt to place pt more on left side to increase venous\n return & preload and potentially ameliorate blood pressure and decrease\n pressor requirements.\n CRRT even.\n Monitor neuro status and provide comfort and support.\n Gastrointestinal bleed, upper (Melena, GI Bleed, GIB)\n Assessment:\n Hct drop yesterday of 8 points, received 2 units yesterday with minimal\n bump in Hct.\n Hct 24 this a.m.\n No obvious signs of acute bleeding.\n Coags elevated.\n PLTs down. HIT negative. D-dimer, fibrinogen and hemolysis panel sent\n and inconclusive.\n Action:\n CT abd & pancreas as well CT head done.\n Q6 hcts.\n Response:\n Hct remains stable.\n Plan:\n Continue with q6 hcts. Per MICU will treat hct if <24.\n Monitor for any signs/source of bleeding.\n Provide comfort and support.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n CMV 40%/500/30.\n Not overbreathing vent.\n paO2s wnl this afternoon.\n Minimal secretions. No cough and impaired gag.\n Bicarb slightly elevated, causing alkalosis.\n Action:\n No vent adjustments made.\n paO2 of 66 this afternoon was post CT and most likely d/t transport off\n floor.\n CRRT replacement bath changed to K4/bicarb 22.\n Midaz gtt stopped this morning d/t significant half life. Fent\n decreased to 25 mcg/hour/\n Response:\n Pt recovered after transport well. paO2 91.\n Bicarb remains in low 30s.\n Pt is still not overbreathing vent, even with sedation weaned.\n Does now have corneal reflexes and pupils 2 mm sluggishly reactive.\n Plan:\n Closely monitor ABGs.\n Monitor for pain and ? need for bolus sedation.\n Monitor overbreathign of vent if present.\n Follow lytes and treat according to sliding scales. Provide comfort and\n support.\n" }, { "category": "Physician ", "chartdate": "2131-05-31 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 677997, "text": "Chief Complaint: Necrotizing pancreatitis c/b SIRS, ARDS, cerebral\n edema, ARF\n 24 Hour Events:\n - CT abd pancreatic cyst, Gi will re-eval in AM\n - CTH shows improvement\n - Pressor requirement increasing\n - Transfused 1 unit PRBC overnight for hct 23\n - dc abx\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 07:50 AM\n Meropenem - 02:45 AM\n Infusions:\n Fentanyl (Concentrate) - 25 mcg/hour\n Calcium Gluconate (CRRT) - 1.6 grams/hour\n KCl (CRRT) - 3 mEq./hour\n Norepinephrine - 0.09 mcg/Kg/min\n Other ICU medications:\n Pantoprazole (Protonix) - 08:34 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:17 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.1\nC (98.8\n Tcurrent: 36.7\nC (98\n HR: 107 (99 - 110) bpm\n BP: 108/58(74) {82/38(56) - 115/62(79)} mmHg\n RR: 30 (14 - 33) insp/min\n SpO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 128 kg (admission): 113.5 kg\n Height: 67 Inch\n CVP: 15 (9 - 21)mmHg\n Total In:\n 8,648 mL\n 3,225 mL\n PO:\n TF:\n IVF:\n 7,125 mL\n 2,419 mL\n Blood products:\n 277 mL\n 282 mL\n Total out:\n 8,471 mL\n 3,487 mL\n Urine:\n 71 mL\n NG:\n 450 mL\n Stool:\n Drains:\n Balance:\n 177 mL\n -262 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 30\n RR (Spontaneous): 0\n PEEP: 12 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10\n PIP: 23 cmH2O\n Plateau: 19 cmH2O\n SpO2: 100%\n ABG: 7.43/48/76./27/6\n Ve: 12.5 L/min\n PaO2 / FiO2: 152\n Physical Examination\n Gen: Anasarca improved. Intubated.\n HEENT: ETT in place, scleral edema. Pupils 3->2 mm b/l.\n CV: Nl S1+S2\n Pulm: Rhonchorous throughout\n Abd: Distended, soft, minimal BS\n Ext: 3+ edema.\n Skin: Weeping blisters of LE b/l\n Neuro: Sedated\n Labs / Radiology\n 60 K/uL\n 8.6 g/dL\n 150 mg/dL\n 2.0 mg/dL\n 27 mEq/L\n 4.3 mEq/L\n 24 mg/dL\n 102 mEq/L\n 140 mEq/L\n 25.7 %\n 31.2 K/uL\n [image002.jpg]\n 07:59 AM\n 10:44 AM\n 10:50 AM\n 01:51 PM\n 04:00 PM\n 04:02 PM\n 10:23 PM\n 10:37 PM\n 04:00 AM\n 04:07 AM\n WBC\n 36.3\n 32.8\n 31.2\n Hct\n 25.7\n 24.4\n 23.8\n 25.7\n Plt\n 48\n 54\n 60\n Cr\n 1.8\n 2.2\n 1.8\n 2.0\n TCO2\n 39\n 34\n 31\n 34\n 34\n 33\n Glucose\n 114\n 108\n 97\n 133\n 120\n 165\n 161\n 150\n Other labs: PT / PTT / INR:15.7/43.4/1.4, ALT / AST:23/269, Alk Phos /\n T Bili:138/14.8, Amylase / Lipase:19/35, Differential-Neuts:55.0 %,\n Band:1.0 %, Lymph:16.0 %, Mono:7.0 %, Eos:6.0 %, D-dimer:6389 ng/mL,\n Fibrinogen:293 mg/dL, Lactic Acid:1.5 mmol/L, Albumin:1.6 g/dL, LDH:607\n IU/L, Ca++:9.5 mg/dL, Mg++:2.0 mg/dL, PO4:4.1 mg/dL\n Imaging: CTH: 1. No acute intracranial hemorrhage, shift of normally\n midline structures or territorial infarction.\n 2. Interval improvement in the -white matter differentiation,\n particularly in the deep -white matter interface as well as at the\n vertex.\n CTAP: Gastric pseudocyst, stable peripancreatic fluid collections.\n Assessment and Plan\n Mr. is a 28 year old gentleman with alcoholic hepatitis and\n necrotizing pancreatitis complicated by ARDS, SIRS, and UGIB.\n # Anemia: Initially p/w hematemesis and EGD showed diuelafoy's lesion.\n Hct continues to trend down (25->24->23), now s/p 1 unit PRBC\n overnight. CTAP with gastric pseudocyst but per d/w radiology now\n definitive explanation for hct drop. GI to re-eval this morning.\n - Trend CBC Q8H, transfuse for hct<21 or plt<50\n - Follow-up with GI regarding further diagnostic and therapeutic\n interventions\n - CVVH at even to slightly negative balance for now\n - Hemolysis labs\n # Neuro: Initially dilated pupils with CT showing cerebral edema. Neuro\n exam now stable. Repeat CTH demonstrates interval improvement.\n - Continue leviteracetam\n - Wean sedation as possible\n - Neuro recs if any\n # Respiratory Failure: ARDS secondary to necrotizing pancreatitis\n compounded by hypoxia, tachypnea in setting of anion gap metabolic\n acidosis, increased abdominal pressure, and EtOH withdrawl. PEEP\n decreased to 12 from 20 and FiO2 to 50%.\n - Wean FiO2 and PEEP, goal PaO2>60-65%\n # Leukocytosis: Trendingd own. Initial concern for infection but normal\n cx suggests that this may be inflammatory reaction. No eos on diff.\n Appreciate ID input, no antibiotic indication at this time.\n Antibiotics now discontinued.\n - Trend fever curve and WBC.\n - Follow-up culture data\n # Necrotizing pancreatitis/SIRS: Secondary to alcohol complicated by\n SIRS and ARDS. Patient continues to have pressor requirement, with neo\n +/- levo. Aggressive volume resuscitation with >50L.\n - Wean pressors with goal MAP >65\n # Hyponatremia: In setting of decreased effective circulating volume\n in setting of SIRS and IABP. Patient has received hypertonic saline\n boluses with improvement in serum sodium and osm.\n - Given improvement in neuro exam, hold hypertonic saline.\n # Acute renal failure: Patient had HD line placed and on CVVH. CVVH\n with even TBB pending assessment of hemorrhage.\n - CVVH per renal.\n - Trend chemistries\n #Thrombocytopenia: Platelets stable. No clear etiology at this time.\n DIC panel and HIT PF4 antibody negative.\n - Trend plt, transfuse for plt<10 or <50 if signs of hemorrhage.\n # Wound care: Per wound care recs.\n # Acute hepatitis: Likely alcoholic hepatitis with fatty infiltration,\n and no evidence of distal obstruction. RUQ u/s shows marked liver\n echogenicity but no ascites.\n - Trend LFTs\n # Alcoholism: Patient describes history of withdrawal symptoms, but\n not prior seizure. Last drink was night prior to presentation.\n Tachycardia, weakness, and elevated lactate could be consistent with\n thiamine deficiency.\n - Thiamine, vb12, folate\n - Valium with CIWA > 10\n FEN: TPN without heparin, replete as necessary.\n PPx: IV PPI. SCD on arm, hold heparin.\n Access: RIJ (quad), LIJ (HD), left radial a-line\n Dispo: ICU level of care\n ICU Care\n Nutrition:\n TPN w/ Lipids - 05:03 PM 73 mL/hour\n Glycemic Control:\n Lines:\n Multi Lumen - 02:02 PM\n Dialysis Catheter - 04:56 PM\n Arterial Line - 01:30 PM\n 20 Gauge - 11:15 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Respiratory ", "chartdate": "2131-06-15 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 680912, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 29\n Ideal body weight: 67.1 None\n Ideal tidal volume: 268.4 / 402.6 / 536.8 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location:\n Reason:\n Tube Type\n Tracheostomy tube:\n Type: Standard\n Manufacturer: Portex\n Size: 8.0mm\n PMV: No\n Cuff Management:\n Vol/Press:\n Cuff pressure: 24 cmH2O\n Cuff volume: 8 mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Moderate\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated,\n Adjust Min. ventilation to control pH\n Reason for continuing current ventilatory support: Sedated / Paralyzed,\n Intolerant of weaning attempts, Cannot protect airway, Cannot manage\n secretions, Underlying illness not resolved; Comments: Pt had frequent\n tachypneic episodes that diminish with sedation and time without\n stimulation. Pt is suctioned in order to improve lung sounds. Pt has\n spontaneous expiratory tidal volumes with the 400-600ml. Pt is still\n unresponsive with occasional twitching/?seizure? activity. RSBI trial\n was stopped due to Resp rate reaching 35 bpm. Pt to continue current\n support\n" }, { "category": "Physician ", "chartdate": "2131-06-15 00:00:00.000", "description": "Physician Resident/Attending Progress Note - MICU", "row_id": 681040, "text": "Chief Complaint:\n 24 Hour Events:\n - LFTs rising including TB/DB. D/c TPN. Weaning off midazolam, placed\n on standing valium.\n - bronch washings: Pulmonary macrophages, bronchial epithelial\n cells, and inflammatory cells, including eosinophils. Neg for malignant\n cells.\n - R-sided PICC and HD tunneled cath placed by IR.\n - PT consult ordered.\n - Aztreonam changed to HD dosing per pharmacy but then since didnt get\n HD and will likely get CVVH tomorrow for borderline pressures changed\n back to 2gm Q12H\n - Fever to 102 at 8pm with tachycardia to 120s and BPs to 90s/50s.\n Blood, urine, sputum cultures sent. 500mL NS X 2 given with better BPs.\n Midazolam 1X dose given as well with better HRs. CXR looked better than\n prior with no edema nad no pna. RUQ U/S:Gallbladder nondistended, but\n lumen entirely replaced by echogenic material. Favor sludge, but could\n also reflect marked wall thickening related to third spacing. Started\n Cipro. Ordered HIDA for am.\n - On ABG 7.4/34/98 but then in setting of fever was tachypnic so\n went back up on PS 8/5 with RR 20. Weaned back to overnight with\n ABG 7.25/37/122.\n - Changed glargine to QD\n Allergies:\n Meropenem\n skin blisters a\n Last dose of Antibiotics:\n Metronidazole - 02:00 AM\n Aztreonam - 08:30 PM\n Linezolid - 10:00 PM\n Ciprofloxacin - 12:00 AM\n Infusions:\n Midazolam (Versed) - 3 mg/hour\n Fentanyl (Concentrate) - 100 mcg/hour\n Other ICU medications:\n Fentanyl - 12:23 PM\n Midazolam (Versed) - 05:45 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:14 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 39.1\nC (102.3\n Tcurrent: 36.6\nC (97.8\n HR: 101 (82 - 123) bpm\n BP: 100/53(69) {76/41(55) - 125/85(87)} mmHg\n RR: 27 (14 - 32) insp/min\n SpO2: 99%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 113 kg (admission): 113.5 kg\n Height: 67 Inch\n CVP: 9 (4 - 12)mmHg\n Total In:\n 7,376 mL\n 542 mL\n PO:\n TF:\n 501 mL\n 311 mL\n IVF:\n 5,412 mL\n 231 mL\n Blood products:\n Total out:\n 5,958 mL\n 0 mL\n Urine:\n 128 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,418 mL\n 542 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 400 (400 - 400) mL\n Vt (Spontaneous): 405 (405 - 640) mL\n PS : 5 cmH2O\n RR (Set): 22\n RR (Spontaneous): 29\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI Deferred: RR >35\n PIP: 11 cmH2O\n SpO2: 99%\n ABG: 7.35/37/122/16/-4\n Ve: 13.1 L/min\n PaO2 / FiO2: 244\n Physical Examination\n GEN: Intubated, sedated\n HEENT: icteric sclera. MMM\n NECK: Trach site with no oozing.\n LUNGS: Anterior auscultation with upper airway noise; good airway\n movement\n HEART: RRR, normal; S1, S2\n ABD: Distended. NT.\n EXTREM: 2+ edema, ulcers/lesions on legs with bandages C/D/I\n SKIN: Jaundice\n NEURO: Mouth twitching. Arms jerking bilaterally. Did not open eyes to\n command.\n Labs / Radiology\n 194 K/uL\n 8.2 g/dL\n 178 mg/dL\n 1.5 mg/dL\n 16 mEq/L\n 4.4 mEq/L\n 72 mg/dL\n 99 mEq/L\n 132 mEq/L\n 25.8 %\n 21.7 K/uL\n [image002.jpg]\n 12:01 AM\n 03:25 AM\n 03:39 AM\n 06:10 PM\n 06:18 PM\n 07:58 PM\n 08:00 PM\n 01:31 AM\n 01:37 AM\n 04:30 AM\n WBC\n 22.3\n 24.4\n 21.7\n Hct\n 25.4\n 26.9\n 25.3\n 25.8\n Plt\n 142\n 193\n 194\n Cr\n 1.0\n 1.6\n 1.5\n TCO2\n 27\n 22\n 23\n 21\n 21\n Glucose\n 78\n 78\n 121\n 178\n Other labs: PT / PTT / INR:15.2/34.4/1.3, CK / CKMB /\n Troponin-T:214/3/0.07, ALT / AST:158/238, Alk Phos / T Bili:421/28.0,\n Amylase / Lipase:51/41, Differential-Neuts:68.0 %, Band:5.0 %,\n Lymph:7.0 %, Mono:4.0 %, Eos:0.0 %, D-dimer:6389 ng/mL, Fibrinogen:502\n mg/dL, Lactic Acid:1.1 mmol/L, Albumin:2.0 g/dL, LDH:706 IU/L, Ca++:8.3\n mg/dL, Mg++:2.4 mg/dL, PO4:3.5 mg/dL\n Assessment and Plan\n 28M with alcoholic hepatitis and necrotizing pancreatitis complicated\n by ARDS, SIRS, ARF, UGIB, fevers and eosinophilia\n #. ID: Had been afebrile on broad coverage for severe necrotizing\n pancreatitis but spiked fever overnight with decreased BP. RUQ u/s\n concerning for sludge and pt started on cipro. Of note, had stopped\n flagyl and vanc po yesterday as C. diff neg x 2. Blood/tissue/BAL cx\n NGTD. It is possible that previous fevers had been masked by CVVH,\n which pt did not undergo yesterday\n - Cte broad spectrum antibiotic coverage with linezolid and aztreonam\n (D1 ) and cipro (D1 )->consider d/c cipro today\n - Consider adding back flagyl for anaerobic coverage.\n - D/C CVL today if he has enough access\n - HIDA scan if bilirubin does not improve or hemodynamic instability\n over next few days\n - F/u WBC count, temp curve, and culture data\n - F/u ID recs\n - Cont steroid taper for possible adrenal insufficiency\n # Hyperbilirubinemia: Patient has had continuously increasing T Bili\n and alkaline phosphatase. Has alcoholic hepatitis but also on TPN. Bili\n stable today but increased alk phos and RUQ u/s with sludge concerning\n for cholestasis.\n - Check HIDA scan if bilirubin does not improve or hemodynamically\n unstable\n - TPN stopped yesterday\n - Weaning off benzos\n #. Respiratory Failure: ARDS secondary to necrotizing pancreatitis. S/p\n trach placement on . Sutures out on . ABG good on PS but\n transition to trach mask limited by respiratory rate.\n - Cont to wean vent with trach mask trial as tolerated\n - Increasing fentanyl patch while decreasing gtt, continue methadone\n - Attempt OOB to chair today to improve respiratory mechanics\n # Seizures: CT head without intracranial process. EEG showed occipital\n seizures which does not correlate with clinical symptoms. actually\n be patient waking up, not seizures.\n - Repeat EEG today on higher dose keppra\n - F/u neuro recs\n - Wean off midazolam as tolerated with low dose valium to prevent\n withdrawal; monitor vitals\n #. Acute renal Failure: Appreciate renal recs.\n - Currently euvolemic so would favor running him even today. Would\n dialyze for acidosis but likely does not need volume depletion today.\n - Plan for tunneled dialysis catheter today to transition to HD\n tomorrow; f/u Renal recs\n #. Adrenal Insufficiency: Unclear with stim if clear adrenal\n insufficiency but hypotension improving with steroids (lower pressor\n requirement) and improving eosinophilia\n - Cont hydrocortisone 50mg Q8H D ->consider wean down to 25mg\n \n # ?HLH: Elevated ferritin. Awaiting quantitated ferritin to r/o HLH.\n ICU Care\n Nutrition:\n Nutren 2.0 () - 02:00 PM 50 mL/hour. Will likely be d/c\n with doboff given severe pancreatitis/hepatitis and PEG higher risk.\n Glycemic Control: ISS\n Lines:\n Arterial Line - 08:15 PM\n Multi Lumen - 10:00 PM\n Dialysis Catheter - 11:35 PM\n Prophylaxis:\n DVT: SQ heparin\n Stress ulcer: H2B\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n ------ Protected Section ------\n MICU ATTENDING ADDENDUM\n I saw and examined the patient, and was physically present with the ICU\n 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: 28M alcoholic hepatitis, pancreatitis,\n refractory shock, ARDS - now tolerating aggressive fluid removal and\n off pressors. WBC and sedation down. Ongoing ? seizures when off benzo\n gtt. Febrile with borderline BP overnight. Back on midazolam gtt as\n well as valium PGT. USG c likely GB sludge.\n Exam notable for Tm 102.0 BP 115/50 HR 85 CVP 9 RR 20-30 with sat 100\n on PSV 5/5 0.5 7.40/34/98 o/n, now 7.35/37/122. WD man, anasarca,\n chemosis. Partial eye opening to command. Coarse BS B. Distant s1s2.\n Obese, + BS. 3+ edema. Labs notable for WBC 22K, HCT 26, Na 132, TB\n 30.5. CXR clearer.\n Agree with plan to manage respiratory failure with slow wean of\n sedation and wean of PSV to TM trials as mental status allows - will\n try to get OOB to chair today. Given question of sz activity, will\n continue low dose valium PGT and keppra at higher dose while we recheck\n EEG and try to wean down drip sedation. For shock (resolved), will wean\n steroids (HC 25 q8h) and will continue abx while monitoring LFTs and\n RUQ exam. For ARF, change CVVH to HD; will try to run even. For\n pancreatitis, will increase post-pyloric TFs to goal; he is now\n stooling with good bowel sounds. Remainder of plan as outlined above.\n Plan d/w family at bedside.\n Patient is critically ill\n Total time: 40 min\n ------ Protected Section Addendum Entered By: , MD\n on: 04:36 PM ------\n" }, { "category": "Nursing", "chartdate": "2131-06-18 00:00:00.000", "description": "Nursing Progress Note", "row_id": 681534, "text": "Sepsis\nongoing w/pancreatitis\n Assessment:\n WBC bumpbed to 30 today, afater antibiotics dc/d\n Action:\n Linezolid and axtrenoman reordered\n HIDA scan for this afternoon\n Response:\n Off pressors still, hemodynamically stable\n Plan:\n Awaiting results of scan\n Impaired Skin Integrity\n Assessment:\n Right and left legs much improved with good healing occurring\n Action:\n Wash legs with wound cleanser, scrub to removed old dead skin\n Xerofoam and/or adaptic over areas with bleeding\n Moisture barrier cream on legs\n Cover with dsd\n Response:\n Ongoing healing\n Plan:\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n On CRRT, basically to keep even\n Action:\n Will recirc for hida scan\n Response:\n Tolerating very well.\n Plan:\n Keep on CRRT until filter clots or is due to be changed.\n Change to hemodialysis at that point.\n Respiration / Gas Exchange, Impaired\n Assessment:\n Off vent for >24 hrs.\n Action:\n Suction as needed\n Gentle chest pt as patient does have thick rust secretions\n Response:\n Toelrated well\n Plan:\n Begin rehab screen process as is off vent, and due to transition to\n hemdialysis.\n Family aware, supportive.\n" }, { "category": "Physician ", "chartdate": "2131-05-30 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 677744, "text": "Chief Complaint: Nectrotizing pancreatitis c/b ARDS\n 24 Hour Events:\n - Weaned pressors earlier in the day but had to go back up overnight in\n setting of hct drop\n - Transfused 2 units PRBC, DDAVP.OGL negative, still no BM. Surgery\n suspects ruptured pancreatic cyst, no surgical intervention. Would be\n IR procedure if intervention required. Haptoglobin <20 but mostly\n direct bili. Smear without schistocytes.\n - Came down on FiO2 to 0.5\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Metronidazole - 02:00 AM\n Vancomycin - 07:50 AM\n Meropenem - 02:45 AM\n Infusions:\n Midazolam (Versed) - 3 mg/hour\n Norepinephrine - 0.07 mcg/Kg/min\n Fentanyl (Concentrate) - 50 mcg/hour\n Calcium Gluconate (CRRT) - 1.4 grams/hour\n KCl (CRRT) - 3 mEq./hour\n Other ICU medications:\n Pantoprazole (Protonix) - 07:49 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 12 AM\n Tmax: 37.1\nC (98.7\n Tcurrent: 36.6\nC (97.9\n HR: 105 (94 - 111) bpm\n BP: 96/50(64) {85/46(59) - 108/61(77)} mmHg\n RR: 29 (15 - 33) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 128 kg (admission): 113.5 kg\n Height: 67 Inch\n CVP: 15 (12 - 17)mmHg\n Total In:\n 9,518 mL\n 3,227 mL\n PO:\n TF:\n IVF:\n 7,417 mL\n 2,332 mL\n Blood products:\n 350 mL\n 277 mL\n Total out:\n 8,289 mL\n 2,829 mL\n Urine:\n 75 mL\n 22 mL\n NG:\n 100 mL\n 300 mL\n Stool:\n Drains:\n Balance:\n 1,229 mL\n 398 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 30\n RR (Spontaneous): 0\n PEEP: 12 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10\n PIP: 26 cmH2O\n Plateau: 22 cmH2O\n Compliance: 44.4 cmH2O/mL\n SpO2: 100%\n ABG: 7.44/50/71/28/7\n Ve: 12.5 L/min\n PaO2 / FiO2: 142\n Physical Examination\n General Appearance: Well nourished, total body fluid overload\n Eyes / Conjunctiva: PERRL, pupils 2mm->1mm\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: (Expansion: Symmetric), (Breath Sounds:\n Rhonchorous: )\n Abdominal: Soft, Distended\n Extremities: Right: 4+, Left: 4+\n Skin: Warm\n Neurologic: No(t) Attentive, No(t) Follows simple commands, Responds\n to: Not assessed, No(t) Oriented (to): , Movement: Not assessed,\n Sedated, Tone: Not assessed\n Labs / Radiology\n 42 K/uL\n 8.9 g/dL\n 150 mg/dL\n 1.8 mg/dL\n 28 mEq/L\n 3.7 mEq/L\n 23 mg/dL\n 106 mEq/L\n 145 mEq/L\n 26.2 %\n 25.7 K/uL\n [image002.jpg]\n 09:43 AM\n 12:26 PM\n 02:00 PM\n 05:22 PM\n 06:38 PM\n 08:15 PM\n 08:30 PM\n 10:47 PM\n 01:42 AM\n 02:13 AM\n WBC\n 27.9\n 30.7\n 29.5\n 25.7\n Hct\n 22.6\n 25.0\n 24.3\n 26.2\n Plt\n 44\n 49\n 38\n 42\n Cr\n 2.0\n 1.8\n 1.8\n TCO2\n 32\n 36\n 34\n 35\n Glucose\n 166\n 179\n 150\n Other labs: PT / PTT / INR:16.2/60.4/1.5, ALT / AST:19/227, Alk Phos /\n T Bili:141/14.5, Amylase / Lipase:16/34, Differential-Neuts:55.0 %,\n Band:1.0 %, Lymph:16.0 %, Mono:7.0 %, Eos:6.0 %, D-dimer:6389 ng/mL,\n Fibrinogen:293 mg/dL, Lactic Acid:1.9 mmol/L, Albumin:1.4 g/dL, LDH:538\n IU/L, Ca++:8.6 mg/dL, Mg++:1.8 mg/dL, PO4:3.8 mg/dL\n Assessment and Plan\n Mr. is a 28 year old gentleman with alcoholic hepatitis and\n necrotizing pancreatitis complicated by ARDS, SIRS, and UGIB.\n # Anemia: Initially p/w hematemesis and EGD showed diuelafoy's lesion.\n Hct drop yesterday now s/p 2 units PRBC transfusion and DDAVP with\n inappropriate bump. INR 1.5, platelets <50. Elevated d-dimer and low\n haptoglobin concerning for hemolysis, although less likely given\n persistently elevated split products in setting of liver failure and\n smear negative for schistocytes.\n - Recheck CBC Q6H, transfuse for hct<21, plt <50.\n - Discuss with surgery, radiology, and renal, but CTAP with PO and IV\n contrast indicated at this time to eval for hemorrhagic pancreatitis or\n ruptured hemorrhagic cyst. Will also discuss with GI regarding need for\n upper endoscopy if CT unremarkable. Will have family discussion prior\n to CT.\n - NAC pretreatment.\n - Hold heparin in TPN.\n # Neuro: Initially dilated pupils with CT showing cerebral edema.\n Pupils less dilated and more reactive. Overall mental status and\n neuron exam improving. - Continue keppra\n - Wean sedation as possible\n - Consider repeat CTH\n - Neuro recs if any\n - Continue keppra.\n - Hold hypertonic saline.\n # Respiratory Failure: ARDS secondary to necrotizing pancreatitis\n compounded by hypoxia, tachypnea in setting of anion gap metabolic\n acidosis, increased abdominal pressure, and EtOH withdrawl. PEEP\n decreased to 12 from 20 and FiO2 to 50%.\n - Wean FiO2 and PEEP, goal PaO2>60-65%\n # Leukocytosis: Stable. Initial concern for infection but normal cx\n suggests that this may be inflammatory reaction. No eos on diff and CT\n without new fluid collection. Appreciate ID input, no antibiotic\n indication at this time. Flagyl discontinued.\n - Hold meropenem and vancomycin.\n - Follow-up culture data\n # Necrotizing pancreatitis/SIRS: Secondary to alcohol complicated by\n SIRS and ARDS. Patient continues to have pressor requirement, with neo\n +/- levo. Aggressive volume resuscitation with >50L.\n - Wean pressors with goal MAP >65\n # Hyponatremia: In setting of decreased effective circulating volume\n in setting of SIRS and IABP. Patient has received hypertonic saline\n boluses with improvement in serum sodium and osm.\n - Given improvement in neuro exam, hold hypertonic saline.\n # Acute renal failure: Patient had HD line placed and on CVVH. CVVH\n with even TBB pending assessment of hemorrhage.\n - CVVH per renal.\n - Trend chemistries\n #Thrombocytopenia: Platelets stable. No clear etiology at this time.\n DIC panel and HIT PF4 antibody negative.\n - Trend plt, transfuse for plt<10 or <50 if signs of hemorrhage.\n # Wound care: Per wound care recs.\n # Acute hepatitis: Likely alcoholic hepatitis with fatty infiltration,\n and no evidence of distal obstruction. RUQ u/s shows marked liver\n echogenicity but no ascites.\n - Trend LFTs\n # Alcoholism: Patient describes history of withdrawal symptoms, but\n not prior seizure. Last drink was night prior to presentation.\n Tachycardia, weakness, and elevated lactate could be consistent with\n thiamine deficiency.\n - Thiamine, vb12, folate\n - Valium with CIWA > 10\n FEN: Hold TPN given heparin, replete as necessary.\n PPx: IV PPI. Hold heparin in TPN.\n Access: RIJ (quad), LIJ (HD), left radial a-line\n Dispo: ICU level of care\n ICU Care\n Nutrition:\n TPN w/ Lipids - 04:23 PM 73 mL/hour\n Glycemic Control:\n Lines:\n Multi Lumen - 02:02 PM\n Dialysis Catheter - 04:56 PM\n Arterial Line - 01:30 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2131-05-30 00:00:00.000", "description": "Nursing Progress Note", "row_id": 677835, "text": "Impaired Skin Integrity\n Assessment:\n Bilateral lower extremities wounds/blisters open with mod\n amounts of serosang drainage.\n Bilateral heel skin impairments as well.\n On Bigturn pressure reducing mattress, rotating.\n ? areas of petechiai, PLTs approx 40s all day.\n Coags slightly elevated. TPN with heparin in it this a.m.\n Unable to place compression sleeves on bilat lower\n extremities.\n Action:\n Aquacel Ag and Aquacel applied to open, oozing areas.\n Attempted to not use pink pads to collect drainage, unsuccessfully.\n Wound care in to consult this morning and recommended use of\n Aquacel, sofsorb and net stockings as well as elevating bilat lower\n extremities off bed. Waffle boots recommended as well.\n Labs drawn frequently.\n TPN discontinued this morning. Tonights TPN ordered and hung\n without heparin.\n Pneumoboots to arms- awaiting arrival of compression sleeves &\n waffle boots from distribution.\n Response:\n INR & PTT decreased slightly after d/c of TPN.\n See wound care recs above and more explicit instructions in their note.\n Tolerating rotation well. Turned and pads changed underneath patient 3x\n this shift. (tol well).\n Plan:\n Continue to monitor and trend labs.\n Pneumoboots to arms and waffle boots to BLE.\n Hypotension (not Shock)\n Assessment:\n Action:\n Response:\n Plan:\n Gastrointestinal bleed, upper (Melena, GI Bleed, GIB)\n Assessment:\n Action:\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2131-05-31 00:00:00.000", "description": "Nursing Progress Note", "row_id": 678060, "text": "28M with necrotizing pancreatitis (30-40% necrosis via CT), ARDS,\n septic shock, renal failure. Head CT revealed edema, treated with 23%\n NS for induced osmorx, stopped .\n Events:\n Hct drop 25.7\n 24.4\n 23.8 then given 1U PRBC, 25.7 this morning. (3U\n PRBC over past 3 days with hct 22.6\n 25.7) Discussed with GI, do not\n feel scope is warranted now.\n Abd CT final read pending, showed gastric pseudocyst, peripancreatic\n cysts roughly stable. No explanation for blood loss. Head CT improved\n cerebral edema.\n Impaired Skin Integrity\n Assessment:\n Patient with multiple areas of blistering and oozing from right and\n left legs.\n Right and left heals with deep tissue injurie\n Also noted, left thumb with bruising around it. +Pulses, warm and fair\n CSM\n Action:\n Dressings to legs changed per wound care recs-wound cleanser/moister\n barrier cream/aqualcel/ light\n Soft sorb dressings and stockingnet covers\n H\n Response:\n Remains draining, but less so than yesterday\n Plan:\n Follow wound care recommendationsl.\n Heals off bed, waffle boots.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Intubated, ARDS picture.\n Improved cxray from today\n Action:\n PEEP to 10\n Response:\n Adequate abg\n Plan:\n No further vent changes.\n Consider decreasing fio2 for next change.\n Problem\n Acute Renal Failure/CRRT\n Assessment:\n ARF from sepsis due to pancreatitis.\n Action:\n CRRT running\n Goal to take off about 1-1.5 liters today as long as no increase in\n pressor requirement\n Response:\n Toelrating removing around 50-100cc hr\n Occasionally requiring some fluid back, but overall negative for the\n day.\n Plan:\n Continue to remove fluid as tolerated.\n" }, { "category": "Nutrition", "chartdate": "2131-05-25 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 676933, "text": "Subjective: Intubated and sedated.\n Objective\n Pertinent medications: Fentanyl, Versed, Phenylephrine, Norepinephrine,\n RISS, ABx, others noted\n Labs:\n Value\n Date\n Glucose\n 147 mg/dL\n 04:18 PM\n Glucose Finger Stick\n 220\n 10:00 AM\n BUN\n 30 mg/dL\n 04:29 AM\n Creatinine\n 3.9 mg/dL\n 04:29 AM\n Sodium\n 138 mEq/L\n 02:30 PM\n Potassium\n 3.3 mEq/L\n 04:18 PM\n Chloride\n 106 mEq/L\n 04:29 AM\n TCO2\n 18 mEq/L\n 04:29 AM\n PO2 (arterial)\n 77 mm Hg\n 04:18 PM\n PCO2 (arterial)\n 39 mm Hg\n 04:18 PM\n pH (arterial)\n 7.31 units\n 04:18 PM\n pH (venous)\n 7.25 units\n 10:31 AM\n pH (urine)\n 6.5 units\n 01:09 PM\n CO2 (Calc) arterial\n 21 mEq/L\n 04:18 PM\n Albumin\n 2.1 g/dL\n 01:22 AM\n Calcium non-ionized\n 8.1 mg/dL\n 04:29 AM\n Phosphorus\n 3.2 mg/dL\n 04:29 AM\n Ionized Calcium\n 0.95 mmol/L\n 04:18 PM\n Magnesium\n 2.4 mg/dL\n 04:29 AM\n ALT\n 27 IU/L\n 04:29 AM\n Alkaline Phosphate\n 252 IU/L\n 04:29 AM\n AST\n 209 IU/L\n 04:29 AM\n Amylase\n 16 IU/L\n 03:01 AM\n Total Bilirubin\n 19.5 mg/dL\n 04:29 AM\n WBC\n 44.1 K/uL\n 04:29 AM\n Hgb\n 10.3 g/dL\n 04:29 AM\n Hematocrit\n 30.7 %\n 04:29 AM\n Current diet order / nutrition support: Diet: NPO\n TPN: 1750mL (298dextrose/ 105amino acid/ 35fat) = 1750kcals\n GI: abd firm distended, absent bowel sounds\n Assessment of Nutritional Status\n 28 y. o. M with alcoholic hepatitis and necrotizing pancreatitis\n complicated by ARDS, SIRS, and UGIB. Patient remains intubated,\n sedated, on pressor support and now started on CVVH for fluid removal\n and correction of acidosis. TPN was started , and will advance to\n goal tonight. Goal TPN will provide 1.3g protein/kg adjusted wt. and\n will meet 100% of estimated kcals and protein needs. Triglycerides\n need to be checked to ensure that lipids can be given in TPN safely.\n Medical Nutrition Therapy Plan - Recommend the Following\n 1) Continue on goal TPN. Adjust lytes, insulin based on chem. 10\n and FSBG.\n 2) Please check triglycerides.\n 3) Following, please page with any questions. #\n" }, { "category": "Physician ", "chartdate": "2131-06-18 00:00:00.000", "description": "Physician Resident/Attending Progress Note - MICU", "row_id": 681530, "text": "Chief Complaint:\n 24 Hour Events:\n - All Abx stopped yesterday.\n - HD not started due to fluid contamination of HD machines.\n - Fentanyl and midazolam decreased with slight increase in HR to 110s.\n Increased valium to 10mg TID\n - Tolerated trach mask throughout day\n Allergies:\n Meropenem\n skin blisters a\n Last dose of Antibiotics:\n Ciprofloxacin - 12:34 PM\n Linezolid - 10:09 PM\n Aztreonam - 07:45 AM\n Metronidazole - 08:30 AM\n Infusions:\n Fentanyl (Concentrate) - 25 mcg/hour\n KCl (CRRT) - 3 mEq./hour\n Calcium Gluconate (CRRT) - 2.4 grams/hour\n Other ICU medications:\n Famotidine (Pepcid) - 12:06 AM\n Heparin Sodium (Prophylaxis) - 04:02 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:23 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.3\nC (99.2\n Tcurrent: 36.2\nC (97.1\n HR: 101 (94 - 113) bpm\n BP: 113/59(78) {87/48(64) - 129/70(90)} mmHg\n RR: 23 (19 - 33) insp/min\n SpO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 99.7 kg (admission): 113.5 kg\n Height: 67 Inch\n Total In:\n 9,973 mL\n 2,424 mL\n PO:\n TF:\n 1,200 mL\n 319 mL\n IVF:\n 8,753 mL\n 2,085 mL\n Blood products:\n Total out:\n 11,007 mL\n 2,337 mL\n Urine:\n 77 mL\n 20 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,034 mL\n 87 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n Ventilator mode: Standby\n Vt (Spontaneous): 567 (567 - 567) mL\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 0 cmH2O\n SpO2: 100%\n ABG: 7.45/37/105/24/1\n PaO2 / FiO2: 210\n Physical Examination\n GEN: Trached, sedated.\n HEENT: Icteric sclera. MMM.\n NECK: Trach site with no oozing.\n LUNGS: Anterior auscultation with upper airway noise; good airway\n movement.\n HEART: RRR, normal S1, S2.\n ABD: Distended. Grimacing with palpation.\n EXTREM: 2+ edema, ulcers/lesions on legs with bandages C/D/I.\n SKIN: Jaundiced.\n NEURO: Opening eyes to command. Purposeful movements of arms.\n Labs / Radiology\n 321 K/uL\n 8.0 g/dL\n 165 mg/dL\n 0.6 mg/dL\n 24 mEq/L\n 4.0 mEq/L\n 33 mg/dL\n 99 mEq/L\n 134 mEq/L\n 24.8 %\n 30.5 K/uL\n [image002.jpg]\n 06:23 PM\n 10:13 PM\n 04:13 AM\n 04:24 AM\n 11:20 AM\n 04:55 PM\n 10:00 PM\n 10:30 PM\n 03:49 AM\n 03:56 AM\n WBC\n 24.9\n 30.5\n Hct\n 23.9\n 24.8\n Plt\n 255\n 321\n Cr\n 0.8\n 1.2\n 0.6\n TCO2\n 19\n 19\n 18\n 19\n 24\n 26\n 27\n Glucose\n 172\n 199\n 167\n 110\n 186\n 185\n 160\n 165\n Other labs: PT / PTT / INR:15.6/33.4/1.4, ALT / AST:211/223, Alk Phos /\n T Bili:588/27.9, LDH:517 IU/L, Ca++:8.3 mg/dL, Mg++:1.8 mg/dL, PO4:1.3\n mg/dL\n ucx: Pending. sputum cx: Pending. , , bcx:\n Pending.\n Assessment and Plan\n 28M with alcoholic hepatitis and necrotizing pancreatitis complicated\n by ARDS, SIRS, ARF, UGIB, fevers.\n #. ID: Necrotizing pancreatitis. All abx (linezolid/aztreo D1 and\n flagyl D1 ) discontinued yesterday as afebrile since restarting\n CVVH and appeared clinically improved. Remains afebrile but worsened\n leukocytosis today. RUQ u/s concerning for sludge since .\n - Restart abx coverage with aztreo and linezolid given necrotizing\n pancreatitis.\n - HIDA scan today for poss cholecystitis; if hemodynamic instability\n over next few days may need percutaneous drain\n - F/u WBC count, temp curve, and culture data\n - Cont steroid taper for possible adrenal insufficiency\n - Yeast in the urine- changed foley and re-cultured. If still with\n yeast will treat with anti-fungal.\n # Elevated LFTs: A/w alcoholic hepatitis but recent increase may be \n TPN, now discontinued. RUQ u/s showed sludge concerning for\n cholestasis but also seen on u/s. T Bili and transaminases\n stable today.\n - HIDA scan today\n - TPN stopped \n - Plan for Weaning off benzos\n #. Respiratory Failure: ARDS secondary to necrotizing pancreatitis. S/p\n trach placement on . Sutures out on . Currently on trach mask\n with good ABG.\n - Change gtt to PRN fentanyl boluses, continue methadone with wean\n tomorrow\n - goal to chair daily\n # Seizures: CT head without intracranial process. EEG showed occipital\n seizures which does not correlate with clinical symptoms, but repeat\n EEG on higher dose Keppra showed no seizures. As patient now with\n purposeful movements, this may actually be patient waking up, not\n seizures.\n - Continue keppra\n - Continue low dose valium to prevent withdrawal; Plan to wean valium\n in next few days.\n #. Acute renal Failure: Appreciate renal recs.\n - Touch base with renal about transition to HD\n - Would dialyze for acidosis but likely does not need volume depletion\n as pressures borderline.\n - Cont CVVH while pressures low but would favor HD trial today if\n available\n - Aztreonam 2000mg q12h while on CVVH\n - Will change Keppra to 1000mg Q24 with 500 mg after HD if he\n transitions to HD\n #. Adrenal Insufficiency: Unclear with stim if clear adrenal\n insufficiency but hypotension improving with steroids (lower pressor\n requirement) and improving eosinophilia\n - Cont weaning hydrocort; D2/3 of 25mg Q8H today.\n # PT and OT eval for placement\n ICU Care\n Nutrition:\n Nutren 2.0 () - 01:34 PM 50 mL/hour\n Glycemic Control: Glargine and RISS\n Lines:\n Arterial Line - 08:15 PM\n PICC Line - 08:37 AM\n Dialysis Catheter - 08:55 AM\n Prophylaxis:\n DVT: SQ Heparin\n Stress ulcer: H2 blocker\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU, screening for rehab\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: 28M alcoholic hepatitis, pancreatitis,\n refractory shock, ARDS. USG c likely GB sludge, now off abx but WBC/\n bands are trending up. Mental status slowly resolving as we wean\n sedation. Now on TM x >24h.\n Exam notable for Tm 99.2 BP 120/60 HR 100-110 CVP 9 RR 23 with sat 100\n on 0.5TM 7.45/33/115. WD man, chemosis. Follows some commands. Coarse\n BS B. Distant s1s2. Obese, + BS. 3+ edema. Labs notable for WBC 30K,\n HCT 24, Na 137, TB 27. CXR clearer.\n Agree with plan to manage respiratory failure with ongoing TM trials\n and sedation wean - will try to get OOB to chair today, and will stop\n fentanyl gtt / decrease methadone tomorrow. Given question of sz\n activity, will continue valium PGT and keppra. For shock (resolved),\n will continue to wean steroids (HC 25 q8h) and will restart linezolid /\n aztreonam / flagyl while monitoring LFTs and checking HIDA today. If\n this is unrevealing, will need to recheck abd CT re collection. For\n ARF, change CVVH to HD; will try to run even. For pancreatitis, will\n continue post-pyloric TFs; he is stooling with good bowel sounds. Needs\n PT eval and rehab screening, though I suspect he is still febrile\n will see what happens off CVVH. Plan d/w family at bedside. Remainder\n of plan as outlined above.\n Patient is critically ill\n Total time: 50 min\n ------ Protected Section Addendum Entered By: , MD\n on: 01:48 PM ------\n" }, { "category": "Physician ", "chartdate": "2131-06-20 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 681822, "text": "Chief Complaint:\n 24 Hour Events:\n NUCLEAR MEDICINE - At 09:57 AM\n INVASIVE VENTILATION - START 01:35 PM\n FEVER - 101.4\nF - 06:00 PM\n \n - Spiked fever to 101.4 and became hypotensive to 70/40 requiring\n pressors, but weaned off once he defervesced. He was put back on the\n vent for tachypnea and hypoxia 7.49/29/53.\n - CT abd/pelv ordered to visualize pancrease.\n - hopefully switch to HD, but pressures still low so unlikely\n - Methadone dose decreased\n Allergies:\n Meropenem\n skin blisters a\n Last dose of Antibiotics:\n Linezolid - 12:15 AM\n Aztreonam - 02:34 AM\n Metronidazole - 04:00 AM\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 12:14 AM\n Heparin Sodium (Prophylaxis) - 04:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:54 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.6\nC (101.4\n Tcurrent: 36.9\nC (98.5\n HR: 89 (89 - 119) bpm\n BP: 123/59(78) {78/43(56) - 128/73(94)} mmHg\n RR: 22 (20 - 35) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 100.4 kg (admission): 113.5 kg\n Height: 67 Inch\n Total In:\n 5,341 mL\n 828 mL\n PO:\n TF:\n 883 mL\n 195 mL\n IVF:\n 4,457 mL\n 633 mL\n Blood products:\n Total out:\n 3,487 mL\n 0 mL\n Urine:\n 135 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,854 mL\n 828 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 510 (428 - 6,000) mL\n PS : 5 cmH2O\n RR (Set): 16\n RR (Spontaneous): 21\n PEEP: 5 cmH2O\n FiO2: 60%\n RSBI: 57\n PIP: 16 cmH2O\n SpO2: 100%\n ABG: 7.41/35/146/22/-1\n Ve: 10.6 L/min\n PaO2 / FiO2: 243\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 282 K/uL\n 7.3 g/dL\n 141 mg/dL\n 1.8 mg/dL\n 22 mEq/L\n 4.4 mEq/L\n 56 mg/dL\n 97 mEq/L\n 131 mEq/L\n 22.7 %\n 38.5 K/uL\n [image002.jpg]\n 10:56 PM\n 02:58 AM\n 03:10 AM\n 10:53 AM\n 12:57 PM\n 03:00 PM\n 10:13 PM\n 10:23 PM\n 03:00 AM\n 03:15 AM\n WBC\n 34.9\n 38.5\n Hct\n 24.6\n 22.7\n Plt\n 334\n 282\n Cr\n 0.6\n 1.2\n 1.8\n TCO2\n 26\n 27\n 23\n 22\n 18\n 25\n 23\n Glucose\n 151\n 114\n 121\n 140\n 135\n 141\n Other labs: PT / PTT / INR:15.0/33.3/1.3, CK / CKMB /\n Troponin-T:214/3/0.07, ALT / AST:204/226, Alk Phos / T Bili:446/20.1,\n Amylase / Lipase:77/68, Differential-Neuts:90.0 %, Band:0.0 %,\n Lymph:3.0 %, Mono:5.0 %, Eos:1.0 %, D-dimer:6389 ng/mL, Fibrinogen:502\n mg/dL, Lactic Acid:1.1 mmol/L, Albumin:2.0 g/dL, LDH:529 IU/L, Ca++:8.9\n mg/dL, Mg++:2.4 mg/dL, PO4:2.8 mg/dL\n Assessment and Plan\n AROUSAL, ATTENTION, AND COGNITION, IMPAIRED\n BALANCE, IMPAIRED\n MOTOR FUNCTION, IMPAIRED\n MUSCLE PERFORMACE, IMPAIRED\n RESPIRATION / GAS EXCHANGE, IMPAIRED\n SEIZURE, WITHOUT STATUS EPILEPTICUS\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n IMPAIRED SKIN INTEGRITY\n HEPATITIS, ACUTE TOXIC (INCLUDING ALCOHOLIC, ACETAMINOPHEN, ETC.)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ICU Care\n Nutrition:\n Nutren 2.0 () - 02:00 AM 50 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 08:15 PM\n PICC Line - 08:37 AM\n Dialysis Catheter - 08:55 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": "2131-06-20 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 681945, "text": "Airway\n Airway Placement Data\n Known difficult intubation: No\n Tube Type\n Tracheostomy tube:\n Type: Standard, Cuffed, Inner Cannula\n Manufacturer: Portex\n Size: 8.0mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 24 cmH2O\n Cuff volume: 8 mL /\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount: Suctioned / Scant\n Ventilation Assessment\n Level of breathing assistance: Pt came off ventilator at 8:30am, pt\n doing well and tolerating trach collar well, no increased WOB noted,\n Spo2 100% on 50% Fio2.\n Comments: per MICU Team pt to stay off ventilator as tolerated, may go\n back on vent if needed.\n Plan\n Next 24-48 hours:\n Reason for continuing current ventilatory support: only if pt in acute\n respiratory distress.\n" }, { "category": "Nursing", "chartdate": "2131-05-30 00:00:00.000", "description": "Nursing Progress Note", "row_id": 677728, "text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Received on CMV 50% 400 x 30 Peep 12\n ABG shows paO2 65-77 overnight\n Oxygen saturation 98-100%\n No secretions when suctioned\n lungs clear but diminished at bases right > left\n Action:\n Micu intern and resident aware of all ABG results\n Per Micu ok with current paO2 levels\n No vent changes made\n cxr this am\n Response:\n paO2 stable\n Plan:\n follow up with cxr results and consult renal regarding change in\n replacement fluid as ph slightly alkalodic.\n Hypotension (not Shock)\n Assessment:\n Remains on CRRT\n Unable to take of fluid d/t increasing pressor requirements\n Required fluid bolus 200 cc via rescue line x 2 for sbp 80 map 56-58\n Repeat HCT 24.3\n No active signs bleeding\n Plt 38-42\n Action:\n Micu resident and intern aware of increasing pressor requirement\n 1 unit PRBC given due to increased pressor requirement\n Able to titrate down pressor after unit blood given\n Per micu no platelets at this time\n Response:\n Hemodynamicly stable overnight after unit blood\n Repeat HCT 26.3\n Plan:\n Follow up with team regarding CT today. Goal to continue with fluid\n removal when pt able to tolerate.\n" }, { "category": "Physician ", "chartdate": "2131-05-30 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 677729, "text": "Chief Complaint: Nectrotizing pancreatitis c/b ARDS\n 24 Hour Events:\n - Weaned pressors earlier in the day but had to go back up overnight in\n setting of hct drop\n - Transfused 2 units PRBC, DDAVP. NGL negative, still no BM. Surgery\n believes that he ruptured pancreatic, no surgical intervention. Would\n be IR procedure if required. Haptoglobin <20 but mostly direct bili.\n Smear without schistocytes.\n - Came down on FiO2 to 0.5\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Metronidazole - 02:00 AM\n Vancomycin - 07:50 AM\n Meropenem - 02:45 AM\n Infusions:\n Midazolam (Versed) - 3 mg/hour\n Norepinephrine - 0.07 mcg/Kg/min\n Fentanyl (Concentrate) - 50 mcg/hour\n Calcium Gluconate (CRRT) - 1.4 grams/hour\n KCl (CRRT) - 3 mEq./hour\n Other ICU medications:\n Pantoprazole (Protonix) - 07:49 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 12 AM\n Tmax: 37.1\nC (98.7\n Tcurrent: 36.6\nC (97.9\n HR: 105 (94 - 111) bpm\n BP: 96/50(64) {85/46(59) - 108/61(77)} mmHg\n RR: 29 (15 - 33) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 128 kg (admission): 113.5 kg\n Height: 67 Inch\n CVP: 15 (12 - 17)mmHg\n Total In:\n 9,518 mL\n 3,227 mL\n PO:\n TF:\n IVF:\n 7,417 mL\n 2,332 mL\n Blood products:\n 350 mL\n 277 mL\n Total out:\n 8,289 mL\n 2,829 mL\n Urine:\n 75 mL\n 22 mL\n NG:\n 100 mL\n 300 mL\n Stool:\n Drains:\n Balance:\n 1,229 mL\n 398 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 30\n RR (Spontaneous): 0\n PEEP: 12 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10\n PIP: 26 cmH2O\n Plateau: 22 cmH2O\n Compliance: 44.4 cmH2O/mL\n SpO2: 100%\n ABG: 7.44/50/71/28/7\n Ve: 12.5 L/min\n PaO2 / FiO2: 142\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 42 K/uL\n 8.9 g/dL\n 150 mg/dL\n 1.8 mg/dL\n 28 mEq/L\n 3.7 mEq/L\n 23 mg/dL\n 106 mEq/L\n 145 mEq/L\n 26.2 %\n 25.7 K/uL\n [image002.jpg]\n 09:43 AM\n 12:26 PM\n 02:00 PM\n 05:22 PM\n 06:38 PM\n 08:15 PM\n 08:30 PM\n 10:47 PM\n 01:42 AM\n 02:13 AM\n WBC\n 27.9\n 30.7\n 29.5\n 25.7\n Hct\n 22.6\n 25.0\n 24.3\n 26.2\n Plt\n 44\n 49\n 38\n 42\n Cr\n 2.0\n 1.8\n 1.8\n TCO2\n 32\n 36\n 34\n 35\n Glucose\n 166\n 179\n 150\n Other labs: PT / PTT / INR:16.2/60.4/1.5, ALT / AST:19/227, Alk Phos /\n T Bili:141/14.5, Amylase / Lipase:16/34, Differential-Neuts:55.0 %,\n Band:1.0 %, Lymph:16.0 %, Mono:7.0 %, Eos:6.0 %, D-dimer:6389 ng/mL,\n Fibrinogen:293 mg/dL, Lactic Acid:1.9 mmol/L, Albumin:1.4 g/dL, LDH:538\n IU/L, Ca++:8.6 mg/dL, Mg++:1.8 mg/dL, PO4:3.8 mg/dL\n Assessment and Plan\n ICU Care\n Nutrition:\n TPN w/ Lipids - 04:23 PM 73 mL/hour\n Glycemic Control:\n Lines:\n Multi Lumen - 02:02 PM\n Dialysis Catheter - 04:56 PM\n Arterial Line - 01:30 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2131-05-30 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 677733, "text": "Chief Complaint: Nectrotizing pancreatitis c/b ARDS\n 24 Hour Events:\n - Weaned pressors earlier in the day but had to go back up overnight in\n setting of hct drop\n - Transfused 2 units PRBC, DDAVP. NGL negative, still no BM. Surgery\n believes that he ruptured pancreatic cyst, no surgical intervention.\n Would be IR procedure if required. Haptoglobin <20 but mostly direct\n bili. Smear without schistocytes.\n - Came down on FiO2 to 0.5\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Metronidazole - 02:00 AM\n Vancomycin - 07:50 AM\n Meropenem - 02:45 AM\n Infusions:\n Midazolam (Versed) - 3 mg/hour\n Norepinephrine - 0.07 mcg/Kg/min\n Fentanyl (Concentrate) - 50 mcg/hour\n Calcium Gluconate (CRRT) - 1.4 grams/hour\n KCl (CRRT) - 3 mEq./hour\n Other ICU medications:\n Pantoprazole (Protonix) - 07:49 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 12 AM\n Tmax: 37.1\nC (98.7\n Tcurrent: 36.6\nC (97.9\n HR: 105 (94 - 111) bpm\n BP: 96/50(64) {85/46(59) - 108/61(77)} mmHg\n RR: 29 (15 - 33) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 128 kg (admission): 113.5 kg\n Height: 67 Inch\n CVP: 15 (12 - 17)mmHg\n Total In:\n 9,518 mL\n 3,227 mL\n PO:\n TF:\n IVF:\n 7,417 mL\n 2,332 mL\n Blood products:\n 350 mL\n 277 mL\n Total out:\n 8,289 mL\n 2,829 mL\n Urine:\n 75 mL\n 22 mL\n NG:\n 100 mL\n 300 mL\n Stool:\n Drains:\n Balance:\n 1,229 mL\n 398 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 30\n RR (Spontaneous): 0\n PEEP: 12 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10\n PIP: 26 cmH2O\n Plateau: 22 cmH2O\n Compliance: 44.4 cmH2O/mL\n SpO2: 100%\n ABG: 7.44/50/71/28/7\n Ve: 12.5 L/min\n PaO2 / FiO2: 142\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 42 K/uL\n 8.9 g/dL\n 150 mg/dL\n 1.8 mg/dL\n 28 mEq/L\n 3.7 mEq/L\n 23 mg/dL\n 106 mEq/L\n 145 mEq/L\n 26.2 %\n 25.7 K/uL\n [image002.jpg]\n 09:43 AM\n 12:26 PM\n 02:00 PM\n 05:22 PM\n 06:38 PM\n 08:15 PM\n 08:30 PM\n 10:47 PM\n 01:42 AM\n 02:13 AM\n WBC\n 27.9\n 30.7\n 29.5\n 25.7\n Hct\n 22.6\n 25.0\n 24.3\n 26.2\n Plt\n 44\n 49\n 38\n 42\n Cr\n 2.0\n 1.8\n 1.8\n TCO2\n 32\n 36\n 34\n 35\n Glucose\n 166\n 179\n 150\n Other labs: PT / PTT / INR:16.2/60.4/1.5, ALT / AST:19/227, Alk Phos /\n T Bili:141/14.5, Amylase / Lipase:16/34, Differential-Neuts:55.0 %,\n Band:1.0 %, Lymph:16.0 %, Mono:7.0 %, Eos:6.0 %, D-dimer:6389 ng/mL,\n Fibrinogen:293 mg/dL, Lactic Acid:1.9 mmol/L, Albumin:1.4 g/dL, LDH:538\n IU/L, Ca++:8.6 mg/dL, Mg++:1.8 mg/dL, PO4:3.8 mg/dL\n Assessment and Plan\n Mr. is a 28 year old gentleman with alcoholic hepatitis and\n necrotizing pancreatitis complicated by ARDS, SIRS, and UGIB.\n # Neuro: Initially dilated pupils with CT showing cerebral edema.\n Pupils less dilated and more reactive. Overall mental status and\n neuron exam improving. Holding on hypertonic saline at this point.\n - Continue keppra\n - Wean sedation as possible\n - Consider repeat CT\n - Neuro recs if any\n # Respiratory Failure: ARDS secondary to necrotizing pancreatitis\n compounded by hypoxia, tachypnea in setting of anion gap metabolic\n acidosis, increased abdominal pressure, and EtOH withdrawl. PEEP\n decreased to 12 from 20 and FiO2 to 50%.\n - Wean FiO2 and PEEP, goal PaO2>60-65%\n # Leukocytosis: Stable. Initial concern for infection but normal cx\n suggests that this may be inflammatory reaction. No eos on diff and CT\n without new fluid collection. Appreciate ID input, no antibiotic\n indication at this time. Flagyl discontinued.\n - Hold meropenem today. Plan to d/c vancomycin tomorrow.\n - Follow-up culture data\n # Anemia: Initially p/w hematemesis and EGD showed diuelafoy's lesion.\n Hct drop yesterday now s/p 2 units PRBC transfusion and DDAVP. INR 1.5\n suggesting that synthetic function slowly improving. Platelets <50.\n Elevated d-dimer and low haptoglobin concerning for hemolysis, although\n less likely given persistently elevated split products in setting of\n liver failure. Smear negative for schistocytes.\n - Recheck CBCthis AM, transfuse for hct<21, plt <50.\n - hct check\n - NGL given GIB on presentation\n # Necrotizing pancreatitis/SIRS: Secondary to alcohol complicated by\n SIRS and ARDS. Patient continues to have pressor requirement, with neo\n +/- levo. Aggressive volume resuscitation with >50L.\n - Continue empiric antimicrobials.\n - Wean pressors with goal MAP >65\n # Hyponatremia: In setting of decreased effective circulating volume\n in setting of SIRS and IABP. Patient receiving hypertonic saline\n boluses with improvement in serum sodium.\n - Hypertonic saline as above.\n # Acute renal failure: Patient had HD line placed and CVVH was\n initiated yesterday.\n - CVVH per renal. UF with net neg 200 cc/hr\n - Trend chemistries\n #Thrombocytopenia: Platelets stable. No clear etiology at this time.\n DIC panel and HIT PF4 antibody negative.\n - Trend plt, transfuse for plt<10 or <50 if signs of hemorrhage.\n # IAP elevation: Secondary to third spacing and edema. Per surgery, not\n a good surgical candidate at this time.\n # Acute hepatitis: Likely alcoholic hepatitis with fatty infiltration,\n and no evidence of distal obstruction. RUQ u/s shows marked liver\n echogenicity but no ascites.\n - Trend LFTs\n # Alcoholism: Patient describes history of withdrawal symptoms, but\n not prior seizure. Last drink was night prior to presentation.\n Tachycardia, weakness, and elevated lactate could be consistent with\n thiamine deficiency.\n - Thiamine, vb12, folate\n - Valium with CIWA > 10\n FEN: TPN, replete as necessary.\n PPx: Heparin and H2B in TPN\n Access: RIJ (quad), LIJ (HD), right radial a-line\n Dispo: ICU level of care\n ICU Care\n Nutrition:\n TPN w/ Lipids - 04:23 PM 73 mL/hour\n Glycemic Control:\n Lines:\n Multi Lumen - 02:02 PM\n Dialysis Catheter - 04:56 PM\n Arterial Line - 01:30 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2131-05-30 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 677734, "text": "Chief Complaint: Nectrotizing pancreatitis c/b ARDS\n 24 Hour Events:\n - Weaned pressors earlier in the day but had to go back up overnight in\n setting of hct drop\n - Transfused 2 units PRBC, DDAVP. NGL negative, still no BM. Surgery\n believes that he ruptured pancreatic cyst, no surgical intervention.\n Would be IR procedure if required. Haptoglobin <20 but mostly direct\n bili. Smear without schistocytes.\n - Came down on FiO2 to 0.5\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Metronidazole - 02:00 AM\n Vancomycin - 07:50 AM\n Meropenem - 02:45 AM\n Infusions:\n Midazolam (Versed) - 3 mg/hour\n Norepinephrine - 0.07 mcg/Kg/min\n Fentanyl (Concentrate) - 50 mcg/hour\n Calcium Gluconate (CRRT) - 1.4 grams/hour\n KCl (CRRT) - 3 mEq./hour\n Other ICU medications:\n Pantoprazole (Protonix) - 07:49 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 12 AM\n Tmax: 37.1\nC (98.7\n Tcurrent: 36.6\nC (97.9\n HR: 105 (94 - 111) bpm\n BP: 96/50(64) {85/46(59) - 108/61(77)} mmHg\n RR: 29 (15 - 33) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 128 kg (admission): 113.5 kg\n Height: 67 Inch\n CVP: 15 (12 - 17)mmHg\n Total In:\n 9,518 mL\n 3,227 mL\n PO:\n TF:\n IVF:\n 7,417 mL\n 2,332 mL\n Blood products:\n 350 mL\n 277 mL\n Total out:\n 8,289 mL\n 2,829 mL\n Urine:\n 75 mL\n 22 mL\n NG:\n 100 mL\n 300 mL\n Stool:\n Drains:\n Balance:\n 1,229 mL\n 398 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 30\n RR (Spontaneous): 0\n PEEP: 12 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10\n PIP: 26 cmH2O\n Plateau: 22 cmH2O\n Compliance: 44.4 cmH2O/mL\n SpO2: 100%\n ABG: 7.44/50/71/28/7\n Ve: 12.5 L/min\n PaO2 / FiO2: 142\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 42 K/uL\n 8.9 g/dL\n 150 mg/dL\n 1.8 mg/dL\n 28 mEq/L\n 3.7 mEq/L\n 23 mg/dL\n 106 mEq/L\n 145 mEq/L\n 26.2 %\n 25.7 K/uL\n [image002.jpg]\n 09:43 AM\n 12:26 PM\n 02:00 PM\n 05:22 PM\n 06:38 PM\n 08:15 PM\n 08:30 PM\n 10:47 PM\n 01:42 AM\n 02:13 AM\n WBC\n 27.9\n 30.7\n 29.5\n 25.7\n Hct\n 22.6\n 25.0\n 24.3\n 26.2\n Plt\n 44\n 49\n 38\n 42\n Cr\n 2.0\n 1.8\n 1.8\n TCO2\n 32\n 36\n 34\n 35\n Glucose\n 166\n 179\n 150\n Other labs: PT / PTT / INR:16.2/60.4/1.5, ALT / AST:19/227, Alk Phos /\n T Bili:141/14.5, Amylase / Lipase:16/34, Differential-Neuts:55.0 %,\n Band:1.0 %, Lymph:16.0 %, Mono:7.0 %, Eos:6.0 %, D-dimer:6389 ng/mL,\n Fibrinogen:293 mg/dL, Lactic Acid:1.9 mmol/L, Albumin:1.4 g/dL, LDH:538\n IU/L, Ca++:8.6 mg/dL, Mg++:1.8 mg/dL, PO4:3.8 mg/dL\n Assessment and Plan\n Mr. is a 28 year old gentleman with alcoholic hepatitis and\n necrotizing pancreatitis complicated by ARDS, SIRS, and UGIB.\n # Neuro: Initially dilated pupils with CT showing cerebral edema.\n Pupils less dilated and more reactive. Overall mental status and\n neuron exam improving. Holding on hypertonic saline at this point.\n - Continue keppra\n - Wean sedation as possible\n - Consider repeat CT\n - Neuro recs if any\n # Respiratory Failure: ARDS secondary to necrotizing pancreatitis\n compounded by hypoxia, tachypnea in setting of anion gap metabolic\n acidosis, increased abdominal pressure, and EtOH withdrawl. PEEP\n decreased to 12 from 20 and FiO2 to 50%.\n - Wean FiO2 and PEEP, goal PaO2>60-65%\n # Leukocytosis: Stable. Initial concern for infection but normal cx\n suggests that this may be inflammatory reaction. No eos on diff and CT\n without new fluid collection. Appreciate ID input, no antibiotic\n indication at this time. Flagyl discontinued.\n - Hold meropenem today. Plan to d/c vancomycin tomorrow.\n - Follow-up culture data\n # Anemia: Initially p/w hematemesis and EGD showed diuelafoy's lesion.\n Hct drop yesterday now s/p 2 units PRBC transfusion and DDAVP. INR 1.5\n suggesting that synthetic function slowly improving. Platelets <50.\n Elevated d-dimer and low haptoglobin concerning for hemolysis, although\n less likely given persistently elevated split products in setting of\n liver failure. Smear negative for schistocytes.\n - Recheck CBCthis AM, transfuse for hct<21, plt <50.\n - hct check\n - NGL given GIB on presentation\n # Necrotizing pancreatitis/SIRS: Secondary to alcohol complicated by\n SIRS and ARDS. Patient continues to have pressor requirement, with neo\n +/- levo. Aggressive volume resuscitation with >50L.\n - Continue empiric antimicrobials.\n - Wean pressors with goal MAP >65\n # Hyponatremia: In setting of decreased effective circulating volume\n in setting of SIRS and IABP. Patient receiving hypertonic saline\n boluses with improvement in serum sodium.\n - Hypertonic saline as above.\n # Acute renal failure: Patient had HD line placed and on CVVH.\n - CVVH per renal. UF with net neg 200 cc/hr\n - Trend chemistries\n #Thrombocytopenia: Platelets stable. No clear etiology at this time.\n DIC panel and HIT PF4 antibody negative.\n - Trend plt, transfuse for plt<10 or <50 if signs of hemorrhage.\n # Wound care: Per wound care recs.\n # Acute hepatitis: Likely alcoholic hepatitis with fatty infiltration,\n and no evidence of distal obstruction. RUQ u/s shows marked liver\n echogenicity but no ascites.\n - Trend LFTs\n # Alcoholism: Patient describes history of withdrawal symptoms, but\n not prior seizure. Last drink was night prior to presentation.\n Tachycardia, weakness, and elevated lactate could be consistent with\n thiamine deficiency.\n - Thiamine, vb12, folate\n - Valium with CIWA > 10\n FEN: TPN, replete as necessary.\n PPx: Heparin and H2B in TPN\n Access: RIJ (quad), LIJ (HD), left radial a-line\n Dispo: ICU level of care\n ICU Care\n Nutrition:\n TPN w/ Lipids - 04:23 PM 73 mL/hour\n Glycemic Control:\n Lines:\n Multi Lumen - 02:02 PM\n Dialysis Catheter - 04:56 PM\n Arterial Line - 01:30 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2131-05-30 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 677735, "text": "Chief Complaint: Nectrotizing pancreatitis c/b ARDS\n 24 Hour Events:\n - Weaned pressors earlier in the day but had to go back up overnight in\n setting of hct drop\n - Transfused 2 units PRBC, DDAVP. NGL negative, still no BM. Surgery\n believes that he ruptured pancreatic cyst, no surgical intervention.\n Would be IR procedure if required. Haptoglobin <20 but mostly direct\n bili. Smear without schistocytes.\n - Came down on FiO2 to 0.5\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Metronidazole - 02:00 AM\n Vancomycin - 07:50 AM\n Meropenem - 02:45 AM\n Infusions:\n Midazolam (Versed) - 3 mg/hour\n Norepinephrine - 0.07 mcg/Kg/min\n Fentanyl (Concentrate) - 50 mcg/hour\n Calcium Gluconate (CRRT) - 1.4 grams/hour\n KCl (CRRT) - 3 mEq./hour\n Other ICU medications:\n Pantoprazole (Protonix) - 07:49 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 12 AM\n Tmax: 37.1\nC (98.7\n Tcurrent: 36.6\nC (97.9\n HR: 105 (94 - 111) bpm\n BP: 96/50(64) {85/46(59) - 108/61(77)} mmHg\n RR: 29 (15 - 33) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 128 kg (admission): 113.5 kg\n Height: 67 Inch\n CVP: 15 (12 - 17)mmHg\n Total In:\n 9,518 mL\n 3,227 mL\n PO:\n TF:\n IVF:\n 7,417 mL\n 2,332 mL\n Blood products:\n 350 mL\n 277 mL\n Total out:\n 8,289 mL\n 2,829 mL\n Urine:\n 75 mL\n 22 mL\n NG:\n 100 mL\n 300 mL\n Stool:\n Drains:\n Balance:\n 1,229 mL\n 398 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 30\n RR (Spontaneous): 0\n PEEP: 12 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10\n PIP: 26 cmH2O\n Plateau: 22 cmH2O\n Compliance: 44.4 cmH2O/mL\n SpO2: 100%\n ABG: 7.44/50/71/28/7\n Ve: 12.5 L/min\n PaO2 / FiO2: 142\n Physical Examination\n General Appearance: Well nourished, total body fluid overload\n Eyes / Conjunctiva: PERRL, pupils 2mm->1mm\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: (Expansion: Symmetric), (Breath Sounds:\n Rhonchorous: )\n Abdominal: Soft, Distended\n Extremities: Right: 4+, Left: 4+\n Skin: Warm\n Neurologic: No(t) Attentive, No(t) Follows simple commands, Responds\n to: Not assessed, No(t) Oriented (to): , Movement: Not assessed,\n Sedated, Tone: Not assessed\n Labs / Radiology\n 42 K/uL\n 8.9 g/dL\n 150 mg/dL\n 1.8 mg/dL\n 28 mEq/L\n 3.7 mEq/L\n 23 mg/dL\n 106 mEq/L\n 145 mEq/L\n 26.2 %\n 25.7 K/uL\n [image002.jpg]\n 09:43 AM\n 12:26 PM\n 02:00 PM\n 05:22 PM\n 06:38 PM\n 08:15 PM\n 08:30 PM\n 10:47 PM\n 01:42 AM\n 02:13 AM\n WBC\n 27.9\n 30.7\n 29.5\n 25.7\n Hct\n 22.6\n 25.0\n 24.3\n 26.2\n Plt\n 44\n 49\n 38\n 42\n Cr\n 2.0\n 1.8\n 1.8\n TCO2\n 32\n 36\n 34\n 35\n Glucose\n 166\n 179\n 150\n Other labs: PT / PTT / INR:16.2/60.4/1.5, ALT / AST:19/227, Alk Phos /\n T Bili:141/14.5, Amylase / Lipase:16/34, Differential-Neuts:55.0 %,\n Band:1.0 %, Lymph:16.0 %, Mono:7.0 %, Eos:6.0 %, D-dimer:6389 ng/mL,\n Fibrinogen:293 mg/dL, Lactic Acid:1.9 mmol/L, Albumin:1.4 g/dL, LDH:538\n IU/L, Ca++:8.6 mg/dL, Mg++:1.8 mg/dL, PO4:3.8 mg/dL\n Assessment and Plan\n Mr. is a 28 year old gentleman with alcoholic hepatitis and\n necrotizing pancreatitis complicated by ARDS, SIRS, and UGIB.\n # Neuro: Initially dilated pupils with CT showing cerebral edema.\n Pupils less dilated and more reactive. Overall mental status and\n neuron exam improving. Holding on hypertonic saline at this point.\n - Continue keppra\n - Wean sedation as possible\n - Consider repeat CT\n - Neuro recs if any\n # Respiratory Failure: ARDS secondary to necrotizing pancreatitis\n compounded by hypoxia, tachypnea in setting of anion gap metabolic\n acidosis, increased abdominal pressure, and EtOH withdrawl. PEEP\n decreased to 12 from 20 and FiO2 to 50%.\n - Wean FiO2 and PEEP, goal PaO2>60-65%\n # Leukocytosis: Stable. Initial concern for infection but normal cx\n suggests that this may be inflammatory reaction. No eos on diff and CT\n without new fluid collection. Appreciate ID input, no antibiotic\n indication at this time. Flagyl discontinued.\n - Hold meropenem today. Plan to d/c vancomycin tomorrow.\n - Follow-up culture data\n # Anemia: Initially p/w hematemesis and EGD showed diuelafoy's lesion.\n Hct drop yesterday now s/p 2 units PRBC transfusion and DDAVP. INR 1.5\n suggesting that synthetic function slowly improving. Platelets <50.\n Elevated d-dimer and low haptoglobin concerning for hemolysis, although\n less likely given persistently elevated split products in setting of\n liver failure. Smear negative for schistocytes.\n - Recheck CBCthis AM, transfuse for hct<21, plt <50.\n - hct check\n - NGL given GIB on presentation\n # Necrotizing pancreatitis/SIRS: Secondary to alcohol complicated by\n SIRS and ARDS. Patient continues to have pressor requirement, with neo\n +/- levo. Aggressive volume resuscitation with >50L.\n - Continue empiric antimicrobials.\n - Wean pressors with goal MAP >65\n # Hyponatremia: In setting of decreased effective circulating volume\n in setting of SIRS and IABP. Patient receiving hypertonic saline\n boluses with improvement in serum sodium.\n - Hypertonic saline as above.\n # Acute renal failure: Patient had HD line placed and on CVVH.\n - CVVH per renal. UF with net neg 200 cc/hr\n - Trend chemistries\n #Thrombocytopenia: Platelets stable. No clear etiology at this time.\n DIC panel and HIT PF4 antibody negative.\n - Trend plt, transfuse for plt<10 or <50 if signs of hemorrhage.\n # Wound care: Per wound care recs.\n # Acute hepatitis: Likely alcoholic hepatitis with fatty infiltration,\n and no evidence of distal obstruction. RUQ u/s shows marked liver\n echogenicity but no ascites.\n - Trend LFTs\n # Alcoholism: Patient describes history of withdrawal symptoms, but\n not prior seizure. Last drink was night prior to presentation.\n Tachycardia, weakness, and elevated lactate could be consistent with\n thiamine deficiency.\n - Thiamine, vb12, folate\n - Valium with CIWA > 10\n FEN: TPN, replete as necessary.\n PPx: Heparin and H2B in TPN\n Access: RIJ (quad), LIJ (HD), left radial a-line\n Dispo: ICU level of care\n ICU Care\n Nutrition:\n TPN w/ Lipids - 04:23 PM 73 mL/hour\n Glycemic Control:\n Lines:\n Multi Lumen - 02:02 PM\n Dialysis Catheter - 04:56 PM\n Arterial Line - 01:30 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2131-05-30 00:00:00.000", "description": "ICU Attending Note", "row_id": 677739, "text": "Clinician: Attending\n MICU ATTENDING NOTE\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, including assessment and plan.\n 28yo man with necrotizing pancreatitis (30-40% necrosis via CT), ARDS,\n septic shock, renal failure. Head CT with edema, on 23% NS for induced\n osmorx.\n Events:\n Hct drop 30\n 24 yest morning: received ddAVP, 2U PRBC with insufficient\n response (23\n 25%)\n Haptoglobin 30, FDP persistently high, no schistocytes. Bili\n predominantly direct.\n PPI.\n Improvement in oxygenation. FiO2 down to 0.5.\n Slight increase in pressor requirement.\n 9L/8L 24 h bal\n 1. Shock, remains levophed dependent.\n 2. Thrombocytopenia present since . Stable for the past few days.\n Heparin in TPN (prophylaxis)- hold as we w/u hct drop and\n thrombocytopenia. hct drop not c/w hemolysis. No clear source of\n bleed. NG lavage neg. No stool. No blood from ETT. Pan-CT, consider\n bronch. Discuss with GI.\n 3. Neuro: exam stable. Stop hypertonic saline.\n 4. ARDS continue weaning FiO2 followed by PEEP. PEEP was as high as\n 24, now 12. Not a candidate for trach at this time.\n 5. Weaning sedation. Off versed. Fent 50mcg.\n 6. Meropenem (d10)/vanc (d7). Abx to stop today. Remains afebrile.\n 7. Skin breakdown- wound service recs.\n 8. Renal failure, on CVVHD. Much less anasarca.\n Critically ill, 45 minutes\n" }, { "category": "Physician ", "chartdate": "2131-05-31 00:00:00.000", "description": "ICU Attending Note", "row_id": 677971, "text": "MICU ATTENDING NOTE\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, including assessment and plan.\n 28M with necrotizing pancreatitis (30-40% necrosis via CT), ARDS,\n septic shock, renal failure. Head CT revealed edema, treated with 23%\n NS for induced osmorx, stopped .\n Events:\n Hct drop 25.7\n 24.4\n 23.8 then given 1U PRBC, 25.7 this morning. (3U\n PRBC over past 3 days with hct 22.6\n 25.7) Discussed with GI, do not\n feel scope is warranted now.\n Abd CT final read pending, showed gastric pseudocyst, peripancreatic\n cysts roughly stable. No explanation for blood loss. Head CT improved\n cerebral edema.\n 0.5/400/30/12\n 8.6/8.4 24 h balance\n Norepi .09\n WBC 36\n 31, plts increased at 60.\n 1. Shock, remains levophed dependent.\n 2. Thrombocytopenia present since . Improved since yesterday off\n heparin in TPN (prophylaxis).\n 3. Nutrition: TPN without heparin.\n 4. No clear source of bleed. NG lavage neg. Brown, g+ stool. No blood\n from ETT. Repeat DIC labs. be due to oozing from known\n gastritis.\n 5. Neuro: pupil exam stable. D/C hypertonic saline.\n 6. ARDS: continue weaning FiO2 followed by PEEP. PEEP was as high as\n 24, now 12. Not a candidate for trach at this time.\n 7. Weaning sedation. Off versed. Fent 50mcg.\n 8. Off antibiotics. Vanc/ stopped yesterday, flagyl stopped .\n Remains afebrile.\n 9. Skin breakdown- wound service recs.\n 10. Renal failure, on CVVHD. Much less anasarca.\n Critically ill, 50 minutes\n" }, { "category": "Physician ", "chartdate": "2131-06-19 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 681649, "text": "Chief Complaint:\n 24 Hour Events:\n NUCLEAR MEDICINE - At 05:40 PM\n \n - Restarted on linezolid, aztreonam, and flagyl given increased\n leukocytosis/left shift\n - Pt to continue CVVH until filter clogs per Renal\n - Fentanyl gtt changed to prn boluses\n - PT/OT consulted; case manager starting Rehab screening\n - HIDA scan done. On return, more tachypneic with RR in 30s. ABG c/w\n resp alkalosis: 7.45/33/115 10am -> 7.50/30/55/24 6pm -> 7.49/25/66/20\n 6:30pm. Trach suctioned with no output. Given fentanyl bolus as\n appeared more uncomfortable. I/O net positive 670 cc -> CVVH rate\n increased as SBP 120s. Had clot when resuctioned. CXR showed mild fluid\n at bases with more plump pulm vasculature; smaller volumes likely c/w\n expiration - no collapse. Repeat ABG 7.46/37/180/27.\n Allergies:\n Meropenem\n skin blisters a\n Last dose of Antibiotics:\n Linezolid - 12:42 PM\n Aztreonam - 02:57 AM\n Metronidazole - 04:00 AM\n Infusions:\n Calcium Gluconate (CRRT) - 1.6 grams/hour\n Other ICU medications:\n Fentanyl - 07:09 PM\n Famotidine (Pepcid) - 12:08 AM\n Heparin Sodium (Prophylaxis) - 04:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:26 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37\nC (98.6\n Tcurrent: 35.9\nC (96.7\n HR: 95 (90 - 118) bpm\n BP: 126/70(91) {107/56(72) - 133/78(99)} mmHg\n RR: 30 (21 - 36) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 100.4 kg (admission): 113.5 kg\n Height: 67 Inch\n Total In:\n 8,831 mL\n 2,834 mL\n PO:\n TF:\n 995 mL\n 371 mL\n IVF:\n 7,796 mL\n 2,463 mL\n Blood products:\n Total out:\n 8,370 mL\n 2,381 mL\n Urine:\n 85 mL\n 35 mL\n NG:\n Stool:\n Drains:\n Balance:\n 461 mL\n 453 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n SpO2: 99%\n ABG: 7.44/39/125/25/2\n PaO2 / FiO2: 179\n Physical Examination\n GEN: Trached, sedated.\n HEENT: Icteric sclera. MMM.\n NECK: Trach site with no oozing.\n LUNGS: Anterior auscultation with upper airway noise; good airway\n movement.\n HEART: RRR, normal S1, S2.\n ABD: Distended. Firm, but unchanged.\n EXTREM: 2+ edema, ulcers/lesions on legs with bandages C/D/I.\n SKIN: Jaundiced.\n NEURO:\n Labs / Radiology\n 334 K/uL\n 8.0 g/dL\n 151 mg/dL\n 0.6 mg/dL\n 25 mEq/L\n 3.9 mEq/L\n 29 mg/dL\n 98 mEq/L\n 132 mEq/L\n 24.6 %\n 34.9 K/uL\n [image002.jpg]\n 10:30 PM\n 03:49 AM\n 03:56 AM\n 10:08 AM\n 06:00 PM\n 06:25 PM\n 08:18 PM\n 10:56 PM\n 02:58 AM\n 03:10 AM\n WBC\n 30.5\n 34.9\n Hct\n 24.8\n 24.6\n Plt\n 321\n 334\n Cr\n 0.6\n 0.6\n TCO2\n 26\n 27\n 24\n 24\n 20\n 27\n 26\n 27\n Glucose\n 185\n 160\n 165\n 156\n 116\n 112\n 151\n Other labs: PT / PTT / INR:15.0/33.3/1.3, CK / CKMB /\n Troponin-T:214/3/0.07, ALT / AST:214/227, Alk Phos / T Bili:519/24.8,\n Amylase / Lipase:77/68, Differential-Neuts:78.0 %, Band:9.0 %,\n Lymph:2.0 %, Mono:3.0 %, Eos:0.0 %, D-dimer:6389 ng/mL, Fibrinogen:502\n mg/dL, Lactic Acid:1.0 mmol/L, Albumin:2.0 g/dL, LDH:529 IU/L, Ca++:8.8\n mg/dL, Mg++:1.8 mg/dL, PO4:1.7 mg/dL\n Assessment and Plan\n ICU Care\n Nutrition:\n Nutren 2.0 () - 05:40 PM 50 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 08:15 PM\n PICC Line - 08:37 AM\n Dialysis Catheter - 08:55 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP: HOB elevation\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:ICU\n" }, { "category": "Physician ", "chartdate": "2131-06-19 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 681650, "text": "Chief Complaint:\n 24 Hour Events:\n NUCLEAR MEDICINE - At 05:40 PM\n \n - Restarted on linezolid, aztreonam, and flagyl given increased\n leukocytosis/left shift\n - Pt to continue CVVH until filter clogs per Renal\n - Fentanyl gtt changed to prn boluses\n - PT/OT consulted; case manager starting Rehab screening\n - HIDA scan done. On return, more tachypneic with RR in 30s. ABG c/w\n resp alkalosis: 7.45/33/115 10am -> 7.50/30/55/24 6pm -> 7.49/25/66/20\n 6:30pm. Trach suctioned with no output. Given fentanyl bolus as\n appeared more uncomfortable. I/O net positive 670 cc -> CVVH rate\n increased as SBP 120s. Had clot when resuctioned. CXR showed mild fluid\n at bases with more plump pulm vasculature; smaller volumes likely c/w\n expiration - no collapse. Repeat ABG 7.46/37/180/27.\n Allergies:\n Meropenem\n skin blisters a\n Last dose of Antibiotics:\n Linezolid - 12:42 PM\n Aztreonam - 02:57 AM\n Metronidazole - 04:00 AM\n Infusions:\n Calcium Gluconate (CRRT) - 1.6 grams/hour\n Other ICU medications:\n Fentanyl - 07:09 PM\n Famotidine (Pepcid) - 12:08 AM\n Heparin Sodium (Prophylaxis) - 04:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:26 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37\nC (98.6\n Tcurrent: 35.9\nC (96.7\n HR: 95 (90 - 118) bpm\n BP: 126/70(91) {107/56(72) - 133/78(99)} mmHg\n RR: 30 (21 - 36) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 100.4 kg (admission): 113.5 kg\n Height: 67 Inch\n Total In:\n 8,831 mL\n 2,834 mL\n PO:\n TF:\n 995 mL\n 371 mL\n IVF:\n 7,796 mL\n 2,463 mL\n Blood products:\n Total out:\n 8,370 mL\n 2,381 mL\n Urine:\n 85 mL\n 35 mL\n NG:\n Stool:\n Drains:\n Balance:\n 461 mL\n 453 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n SpO2: 99%\n ABG: 7.44/39/125/25/2\n PaO2 / FiO2: 179\n Physical Examination\n GEN: Trached, sedated.\n HEENT: Icteric sclera. MMM.\n NECK: Trach site with no oozing.\n LUNGS: Anterior auscultation with upper airway noise; good airway\n movement.\n HEART: RRR, normal S1, S2.\n ABD: Distended. Firm, but unchanged.\n EXTREM: 2+ edema, ulcers/lesions on legs with bandages C/D/I.\n SKIN: Jaundiced.\n NEURO:\n Labs / Radiology\n 334 K/uL\n 8.0 g/dL\n 151 mg/dL\n 0.6 mg/dL\n 25 mEq/L\n 3.9 mEq/L\n 29 mg/dL\n 98 mEq/L\n 132 mEq/L\n 24.6 %\n 34.9 K/uL\n [image002.jpg]\n Ca: 8.8 Mg: 1.8 P: 1.7\n ALT: 214\n AP: 519\n Tbili: 24.8\n Alb:\n AST: 227\n LDH: 529\n Dbili:\n TProt:\n :\n Lip:\n 10:30 PM\n 03:49 AM\n 03:56 AM\n 10:08 AM\n 06:00 PM\n 06:25 PM\n 08:18 PM\n 10:56 PM\n 02:58 AM\n 03:10 AM\n WBC\n 30.5\n 34.9\n Hct\n 24.8\n 24.6\n Plt\n 321\n 334\n Cr\n 0.6\n 0.6\n TCO2\n 26\n 27\n 24\n 24\n 20\n 27\n 26\n 27\n Glucose\n 185\n 160\n 165\n 156\n 116\n 112\n 151\n Other labs: PT / PTT / INR:15.0/33.3/1.3, CK / CKMB /\n Troponin-T:214/3/0.07, ALT / AST:214/227, Alk Phos / T Bili:519/24.8,\n Amylase / Lipase:77/68, Differential-Neuts:78.0 %, Band:9.0 %,\n Lymph:2.0 %, Mono:3.0 %, Eos:0.0 %, D-dimer:6389 ng/mL, Fibrinogen:502\n mg/dL, Lactic Acid:1.0 mmol/L, Albumin:2.0 g/dL, LDH:529 IU/L, Ca++:8.8\n mg/dL, Mg++:1.8 mg/dL, PO4:1.7 mg/dL\n Assessment and Plan\n 28M with alcoholic hepatitis and necrotizing pancreatitis complicated\n by ARDS, SIRS, ARF, UGIB, fevers.\n #. ID: Necrotizing pancreatitis. All abx (linezolid/aztreo D1 and\n flagyl D1 ) discontinued as appeared clinically improved, but\n WBC trended back up. Remains afebrile but worsened leukocytosis today.\n RUQ u/s concerning for sludge since . HIDA Scan done.\n - Restart abx coverage with aztreo and linezolid given necrotizing\n pancreatitis.\n - F/u WBC count, temp curve, and culture data\n - Cont steroid taper for possible adrenal insufficiency\n - Yeast in the urine- changed foley and re-cultured. If still with\n yeast will treat with anti-fungal.\n # Elevated LFTs: A/w alcoholic hepatitis but recent increase may be \n TPN, now discontinued. RUQ u/s showed sludge concerning for\n cholestasis but also seen on u/s. T Bili and transaminases\n stable today.\n - if hemodynamic instability over next few days may need percutaneous\n gall bladder drain\n - TPN stopped \n - Plan for Weaning off benzos\n #. Respiratory Failure: ARDS secondary to necrotizing pancreatitis. S/p\n trach placement on . Sutures out on . Currently on trach mask\n with good ABG.\n - Change gtt to PRN fentanyl boluses, continue methadone with wean\n tomorrow\n - goal to chair daily\n # Seizures: CT head without intracranial process. EEG showed occipital\n seizures which does not correlate with clinical symptoms, but repeat\n EEG on higher dose Keppra showed no seizures. As patient now with\n purposeful movements, this may actually be patient waking up, not\n seizures.\n - Continue keppra\n - Continue low dose valium to prevent withdrawal; Plan to wean valium\n in next few days.\n #. Acute renal Failure: Appreciate renal recs.\n - Touch base with renal about transition to HD\n - Would dialyze for acidosis but likely does not need volume depletion\n as pressures borderline.\n - Cont CVVH while pressures low but would favor HD trial today if\n available\n - Aztreonam 2000mg q12h while on CVVH\n - Will change Keppra to 1000mg Q24 with 500 mg after HD if he\n transitions to HD\n #. Adrenal Insufficiency: Unclear with stim if clear adrenal\n insufficiency but hypotension improving with steroids (lower pressor\n requirement) and improving eosinophilia\n - Cont weaning hydrocort; D2/3 of 25mg Q8H today.\n # PT and OT eval for placement\n ICU Care\n Nutrition:\n Nutren 2.0 () - 05:40 PM 50 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 08:15 PM\n PICC Line - 08:37 AM\n Dialysis Catheter - 08:55 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP: HOB elevation\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:ICU\n" }, { "category": "Physician ", "chartdate": "2131-06-19 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 681654, "text": "Chief Complaint:\n 24 Hour Events:\n NUCLEAR MEDICINE - At 05:40 PM\n \n - Restarted on linezolid, aztreonam, and flagyl given increased\n leukocytosis/left shift\n - Pt to continue CVVH until filter clogs per Renal\n - Fentanyl gtt changed to prn boluses\n - PT/OT consulted; case manager starting Rehab screening\n - HIDA scan done. On return, more tachypneic with RR in 30s. ABG c/w\n resp alkalosis: 7.45/33/115 10am -> 7.50/30/55/24 6pm -> 7.49/25/66/20\n 6:30pm. Trach suctioned with no output. Given fentanyl bolus as\n appeared more uncomfortable. I/O net positive 670 cc -> CVVH rate\n increased as SBP 120s. Had clot when resuctioned. CXR showed mild fluid\n at bases with more plump pulm vasculature; smaller volumes likely c/w\n expiration - no collapse. Repeat ABG 7.46/37/180/27.\n Allergies:\n Meropenem\n skin blisters a\n Last dose of Antibiotics:\n Linezolid - 12:42 PM\n Aztreonam - 02:57 AM\n Metronidazole - 04:00 AM\n Infusions:\n Calcium Gluconate (CRRT) - 1.6 grams/hour\n Other ICU medications:\n Fentanyl - 07:09 PM\n Famotidine (Pepcid) - 12:08 AM\n Heparin Sodium (Prophylaxis) - 04:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:26 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37\nC (98.6\n Tcurrent: 35.9\nC (96.7\n HR: 95 (90 - 118) bpm\n BP: 126/70(91) {107/56(72) - 133/78(99)} mmHg\n RR: 30 (21 - 36) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 100.4 kg (admission): 113.5 kg\n Height: 67 Inch\n Total In:\n 8,831 mL\n 2,834 mL\n PO:\n TF:\n 995 mL\n 371 mL\n IVF:\n 7,796 mL\n 2,463 mL\n Blood products:\n Total out:\n 8,370 mL\n 2,381 mL\n Urine:\n 85 mL\n 35 mL\n NG:\n Stool:\n Drains:\n Balance:\n 461 mL\n 453 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n SpO2: 99%\n ABG: 7.44/39/125/25/2\n PaO2 / FiO2: 179\n Physical Examination\n GEN: Trached, sedated.\n HEENT: Icteric sclera. MMM.\n NECK: Trach site with no oozing.\n LUNGS: Anterior auscultation with upper airway noise; good airway\n movement.\n HEART: RRR, normal S1, S2.\n ABD: Distended. Firm, but unchanged.\n EXTREM: 2+ edema, ulcers/lesions on legs with bandages C/D/I.\n SKIN: Jaundiced.\n NEURO:\n Labs / Radiology\n 334 K/uL\n 8.0 g/dL\n 151 mg/dL\n 0.6 mg/dL\n 25 mEq/L\n 3.9 mEq/L\n 29 mg/dL\n 98 mEq/L\n 132 mEq/L\n 24.6 %\n 34.9 K/uL\n [image002.jpg]\n Ca: 8.8 Mg: 1.8 P: 1.7\n ALT: 214\n AP: 519\n Tbili: 24.8\n Alb:\n AST: 227\n LDH: 529\n Dbili:\n TProt:\n :\n Lip:\n 10:30 PM\n 03:49 AM\n 03:56 AM\n 10:08 AM\n 06:00 PM\n 06:25 PM\n 08:18 PM\n 10:56 PM\n 02:58 AM\n 03:10 AM\n WBC\n 30.5\n 34.9\n Hct\n 24.8\n 24.6\n Plt\n 321\n 334\n Cr\n 0.6\n 0.6\n TCO2\n 26\n 27\n 24\n 24\n 20\n 27\n 26\n 27\n Glucose\n 185\n 160\n 165\n 156\n 116\n 112\n 151\n Other labs: PT / PTT / INR:15.0/33.3/1.3, CK / CKMB /\n Troponin-T:214/3/0.07, ALT / AST:214/227, Alk Phos / T Bili:519/24.8,\n Amylase / Lipase:77/68, Differential-Neuts:78.0 %, Band:9.0 %,\n Lymph:2.0 %, Mono:3.0 %, Eos:0.0 %, D-dimer:6389 ng/mL, Fibrinogen:502\n mg/dL, Lactic Acid:1.0 mmol/L, Albumin:2.0 g/dL, LDH:529 IU/L, Ca++:8.8\n mg/dL, Mg++:1.8 mg/dL, PO4:1.7 mg/dL\n U Cx and Blood Cx pending\n HIDA scan: Pending read\n Assessment and Plan\n 28M with alcoholic hepatitis and necrotizing pancreatitis complicated\n by ARDS, SIRS, ARF, UGIB, fevers.\n #. ID: Necrotizing pancreatitis. All abx (linezolid/aztreo D1 and\n flagyl D1 ) discontinued as appeared clinically improved, but\n WBC trended back up. Remains afebrile but worsened leukocytosis today.\n RUQ u/s concerning for sludge since . HIDA Scan done.\n - Continue abx coverage with aztreo, flagyl, and linezolid given\n necrotizing pancreatitis.\n - F/u WBC count, temp curve, and culture data\n - Cont steroid taper for possible adrenal insufficiency\n - Yeast in the urine- changed foley and re-cultured. If still with\n yeast will treat with anti-fungal.\n # Elevated LFTs: A/w alcoholic hepatitis but recent increase may be \n TPN, now discontinued. RUQ u/s showed sludge concerning for\n cholestasis but also seen on u/s. T Bili and transaminases\n stable today.\n - if hemodynamic instability over next few days may need percutaneous\n gall bladder drain\n - TPN stopped \n - Plan for Weaning off benzos\n #. Respiratory Failure: ARDS secondary to necrotizing pancreatitis. S/p\n trach placement on . Sutures out on . Currently on trach mask\n with good ABG.\n - Change gtt to PRN fentanyl boluses, continue methadone with wean\n tomorrow\n - goal to chair daily\n # Seizures: CT head without intracranial process. EEG showed occipital\n seizures which does not correlate with clinical symptoms, but repeat\n EEG on higher dose Keppra showed no seizures. As patient now with\n purposeful movements, this may actually be patient waking up, not\n seizures.\n - Continue keppra\n - Continue low dose valium to prevent withdrawal; Plan to wean valium\n in next few days.\n #. Acute renal Failure: Appreciate renal recs.\n - Touch base with renal about transition to HD\n - Would dialyze for acidosis but likely does not need volume depletion\n as pressures borderline.\n - Cont CVVH while pressures low but would favor HD trial today if\n available\n - Aztreonam 2000mg q12h while on CVVH\n - Will change Keppra to 1000mg Q24 with 500 mg after HD if he\n transitions to HD\n #. Adrenal Insufficiency: Unclear with stim if clear adrenal\n insufficiency but hypotension improving with steroids (lower pressor\n requirement) and improving eosinophilia\n - Cont weaning hydrocort; D2/3 of 25mg Q8H today.\n # PT and OT eval for placement\n ICU Care\n Nutrition:\n Nutren 2.0 () - 05:40 PM 50 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 08:15 PM\n PICC Line - 08:37 AM\n Dialysis Catheter - 08:55 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP: HOB elevation\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:ICU\n" }, { "category": "Physician ", "chartdate": "2131-06-20 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 681824, "text": "Chief Complaint:\n 24 Hour Events:\n NUCLEAR MEDICINE - At 09:57 AM\n INVASIVE VENTILATION - START 01:35 PM\n FEVER - 101.4\nF - 06:00 PM\n \n - Spiked fever to 101.4 and became hypotensive to 70/40 requiring\n pressors, but weaned off once he defervesced. He was put back on the\n vent for tachypnea and hypoxia 7.49/29/53.\n - CT abd/pelv ordered to visualize pancrease.\n - hopefully switch to HD, but pressures still low so unlikely\n - Methadone dose decreased\n Allergies:\n Meropenem\n skin blisters a\n Last dose of Antibiotics:\n Linezolid - 12:15 AM\n Aztreonam - 02:34 AM\n Metronidazole - 04:00 AM\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 12:14 AM\n Heparin Sodium (Prophylaxis) - 04:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:54 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.6\nC (101.4\n Tcurrent: 36.9\nC (98.5\n HR: 89 (89 - 119) bpm\n BP: 123/59(78) {78/43(56) - 128/73(94)} mmHg\n RR: 22 (20 - 35) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 100.4 kg (admission): 113.5 kg\n Height: 67 Inch\n Total In:\n 5,341 mL\n 828 mL\n PO:\n TF:\n 883 mL\n 195 mL\n IVF:\n 4,457 mL\n 633 mL\n Blood products:\n Total out:\n 3,487 mL\n 0 mL\n Urine:\n 135 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,854 mL\n 828 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 510 (428 - 6,000) mL\n PS : 5 cmH2O\n RR (Set): 16\n RR (Spontaneous): 21\n PEEP: 5 cmH2O\n FiO2: 60%\n RSBI: 57\n PIP: 16 cmH2O\n SpO2: 100%\n ABG: 7.41/35/146/22/-1\n Ve: 10.6 L/min\n PaO2 / FiO2: 243\n Physical Examination\n GEN: Trached, sedated.\n HEENT: Icteric sclera. MMM.\n NECK: Trach site with no oozing.\n LUNGS: Anterior auscultation with upper airway noise; good airway\n movement.\n HEART: RRR, normal S1, S2.\n ABD: Distended. Firm, but unchanged.\n EXTREM: 2+ edema, ulcers/lesions on legs with bandages C/D/I.\n SKIN: Jaundiced.\n NEURO: Twitching mouth. No purposeful movements today.\n Labs / Radiology\n 282 K/uL\n 7.3 g/dL\n 141 mg/dL\n 1.8 mg/dL\n 22 mEq/L\n 4.4 mEq/L\n 56 mg/dL\n 97 mEq/L\n 131 mEq/L\n 22.7 %\n 38.5 K/uL\n [image002.jpg]\n 10:56 PM\n 02:58 AM\n 03:10 AM\n 10:53 AM\n 12:57 PM\n 03:00 PM\n 10:13 PM\n 10:23 PM\n 03:00 AM\n 03:15 AM\n WBC\n 34.9\n 38.5\n Hct\n 24.6\n 22.7\n Plt\n 334\n 282\n Cr\n 0.6\n 1.2\n 1.8\n TCO2\n 26\n 27\n 23\n 22\n 18\n 25\n 23\n Glucose\n 151\n 114\n 121\n 140\n 135\n 141\n Other labs: PT / PTT / INR:15.0/33.3/1.3, CK / CKMB /\n Troponin-T:214/3/0.07, ALT / AST:204/226, Alk Phos / T Bili:446/20.1,\n Amylase / Lipase:77/68, Differential-Neuts:90.0 %, Band:0.0 %,\n Lymph:3.0 %, Mono:5.0 %, Eos:1.0 %, D-dimer:6389 ng/mL, Fibrinogen:502\n mg/dL, Lactic Acid:1.1 mmol/L, Albumin:2.0 g/dL, LDH:529 IU/L, Ca++:8.9\n mg/dL, Mg++:2.4 mg/dL, PO4:2.8 mg/dL\n Assessment and Plan\n AROUSAL, ATTENTION, AND COGNITION, IMPAIRED\n BALANCE, IMPAIRED\n MOTOR FUNCTION, IMPAIRED\n MUSCLE PERFORMACE, IMPAIRED\n RESPIRATION / GAS EXCHANGE, IMPAIRED\n SEIZURE, WITHOUT STATUS EPILEPTICUS\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n IMPAIRED SKIN INTEGRITY\n HEPATITIS, ACUTE TOXIC (INCLUDING ALCOHOLIC, ACETAMINOPHEN, ETC.)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ICU Care\n Nutrition:\n Nutren 2.0 () - 02:00 AM 50 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 08:15 PM\n PICC Line - 08:37 AM\n Dialysis Catheter - 08:55 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": "2131-06-20 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 681826, "text": "Chief Complaint:\n 24 Hour Events:\n NUCLEAR MEDICINE - At 09:57 AM\n INVASIVE VENTILATION - START 01:35 PM\n FEVER - 101.4\nF - 06:00 PM\n \n - Spiked fever to 101.4 and became hypotensive to 70/40 requiring\n pressors, but weaned off once he defervesced. He was put back on the\n vent for tachypnea and hypoxia 7.49/29/53.\n - CT abd/pelv ordered to visualize pancrease.\n - hopefully switch to HD, but pressures still low so unlikely\n - Methadone dose decreased\n Allergies:\n Meropenem\n skin blisters a\n Last dose of Antibiotics:\n Linezolid - 12:15 AM\n Aztreonam - 02:34 AM\n Metronidazole - 04:00 AM\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 12:14 AM\n Heparin Sodium (Prophylaxis) - 04:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:54 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.6\nC (101.4\n Tcurrent: 36.9\nC (98.5\n HR: 89 (89 - 119) bpm\n BP: 123/59(78) {78/43(56) - 128/73(94)} mmHg\n RR: 22 (20 - 35) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 100.4 kg (admission): 113.5 kg\n Height: 67 Inch\n Total In:\n 5,341 mL\n 828 mL\n PO:\n TF:\n 883 mL\n 195 mL\n IVF:\n 4,457 mL\n 633 mL\n Blood products:\n Total out:\n 3,487 mL\n 0 mL\n Urine:\n 135 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,854 mL\n 828 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 510 (428 - 6,000) mL\n PS : 5 cmH2O\n RR (Set): 16\n RR (Spontaneous): 21\n PEEP: 5 cmH2O\n FiO2: 60%\n RSBI: 57\n PIP: 16 cmH2O\n SpO2: 100%\n ABG: 7.41/35/146/22/-1\n Ve: 10.6 L/min\n PaO2 / FiO2: 243\n Physical Examination\n GEN: Trached, sedated.\n HEENT: Icteric sclera. MMM.\n NECK: Trach site with no oozing.\n LUNGS: Anterior auscultation with upper airway noise; good airway\n movement.\n HEART: RRR, normal S1, S2.\n ABD: Distended. Firm, but unchanged.\n EXTREM: 2+ edema, ulcers/lesions on legs with bandages C/D/I.\n SKIN: Jaundiced.\n NEURO: Twitching mouth. No purposeful movements today.\n Labs / Radiology\n 282 K/uL\n 7.3 g/dL\n 141 mg/dL\n 1.8 mg/dL\n 22 mEq/L\n 4.4 mEq/L\n 56 mg/dL\n 97 mEq/L\n 131 mEq/L\n 22.7 %\n 38.5 K/uL\n [image002.jpg]\n 10:56 PM\n 02:58 AM\n 03:10 AM\n 10:53 AM\n 12:57 PM\n 03:00 PM\n 10:13 PM\n 10:23 PM\n 03:00 AM\n 03:15 AM\n WBC\n 34.9\n 38.5\n Hct\n 24.6\n 22.7\n Plt\n 334\n 282\n Cr\n 0.6\n 1.2\n 1.8\n TCO2\n 26\n 27\n 23\n 22\n 18\n 25\n 23\n Glucose\n 151\n 114\n 121\n 140\n 135\n 141\n Other labs: PT / PTT / INR:15.0/33.3/1.3, CK / CKMB /\n Troponin-T:214/3/0.07, ALT / AST:204/226, Alk Phos / T Bili:446/20.1,\n Amylase / Lipase:77/68, Differential-Neuts:90.0 %, Band:0.0 %,\n Lymph:3.0 %, Mono:5.0 %, Eos:1.0 %, D-dimer:6389 ng/mL, Fibrinogen:502\n mg/dL, Lactic Acid:1.1 mmol/L, Albumin:2.0 g/dL, LDH:529 IU/L, Ca++:8.9\n mg/dL, Mg++:2.4 mg/dL, PO4:2.8 mg/dL\n Assessment and Plan\n 28M with alcoholic hepatitis and necrotizing pancreatitis complicated\n by ARDS, SIRS, ARF, UGIB, fevers.\n #. ID: Persistent leukocytosis. Necrotizing pancreatitis. All abx\n (linezolid/aztreo D1 and flagyl D1 ) discontinued as\n appeared clinically improved, but WBC trended back up. Remains afebrile\n (but on CVVH) but worsened leukocytosis today. HIDA neg.\n - F/U fever curve after cvvh d/c\nd. If spikes or HD instability abd ct.\n - Continue abx coverage with aztreo, flagyl, and linezolid given\n necrotizing pancreatitis.\n - F/u WBC count, temp curve, and culture data\n - taper steroids to 12.5 mg today\n - added on diff to CBC from this am as may have increasing eosinophilia\n as cause of leukocytosis\n - Yeast in the urine- changed foley and re-cultured with persistent\n yeast but oliguric so unclear if true infection.\n # Elevated LFTs: A/w alcoholic hepatitis but recent increase may be \n TPN, now discontinued. RUQ u/s showed sludge concerning for\n cholestasis but also seen on u/s. T Bili and transaminases\n stable today.\n - HIDA neg\n - TPN stopped \n - Plan for weaning off benzos\n #. Respiratory Failure: ARDS secondary to necrotizing pancreatitis. S/p\n trach placement on . Sutures out on .\n - worse after HIDA likely from laying flat. Will repeat CXR to ensure\n trach in place.\n - Change gtt to PRN fentanyl boluses, continue methadone with wean\n tomorrow\n - goal to chair daily\n # Seizures: CT head without intracranial process. EEG showed occipital\n seizures which does not correlate with clinical symptoms, but repeat\n EEG on higher dose Keppra showed no seizures. As patient now with\n purposeful movements, this may actually be patient waking up, not\n seizures.\n - Continue keppra\n - Continue low dose valium to prevent withdrawal; Plan to wean valium\n today\n #. Acute renal Failure: Appreciate renal recs.\n - Transition to HD tomorrow\n - Would dialyze for acidosis but likely does not need volume depletion\n as pressures borderline.\n - Aztreonam 2000mg q12h while on CVVH\n - Will change Keppra to 1000mg Q24 with 500 mg after HD if he\n transitions to HD\n #. Adrenal Insufficiency: Unclear with stim if clear adrenal\n insufficiency but hypotension improving with steroids (lower pressor\n requirement) and improving eosinophilia\n - Cont weaning hydrocort; D3/3 of 25mg Q8H today. Change to 12.5 today\n # PT and OT eval for placement\n ICU Care\n Nutrition:\n Nutren 2.0 () - 02:00 AM 50 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 08:15 PM\n PICC Line - 08:37 AM\n Dialysis Catheter - 08:55 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": "2131-05-28 00:00:00.000", "description": "Nursing Progress Note", "row_id": 677337, "text": "TITLE:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Bbs clear but diminished at bases. O2 sats >95% vent settings cmv tv\n 400 rr 30 fio2 40% peep 16\n Action:\n Peep weaned to 12cm. Vap bundle. Lavage and suct for thick clear.Bari\n Max bed w rotation.every 10 mins throughout noc.\n Response:\n O2 sats and abg adeq on 12cm peep. Bbs increasingly audible to bases\n and clear.\n Plan:\n Cont vap bundle, pulm toilet ,rotating bed\n Hypotension (not Shock)\n Assessment:\n Levophed(0.035mcg/kg/m) and neo (@ 2.75 mcg/kg /min) to achieve goal\n mbp > 60. MICU team goal to minimize pressor overnight if\n possible.Crrt continues w goal net negative -300cc/hr\n Action:\n Levo titrated up for mbp < 60 while weaning neo to off\n Response:\n Mbp > 60 with levophed currently at 0.05mcg/kg/min\n Plan:\n Cont to wean levophed as tolerated, while continue achieve net negative\n -300cc with crrt\n Impaired Skin Integrity\n Assessment:\n Large insensible loss from weeping of bilat lower extremeties blisters\n and rt and lt flank area. Decreased weepage from bilat upper\n extremeties\n Action:\n Linens and absorbent bed pads changed at least q2-3hr overnight. Bilat\n lower extrems wrapped in cloth sterile towel to decrease risk of\n cutaneous infection\n Response:\n Bilat lower extremeties continue w erythematous, edematous weeping\n blisters, frequency of absorbent pad changes decreased overnight with\n pt tolerating crrt fluid removal in excess of 7liters in past 24hrs.\n Plan:\n Cont. meticulous skin care and freq absorbent bed pad & sterile towel\n changes as frequently as necessary. Wound and skin consult. ?\n dermatology or plastics consult for further recommendations. Wbc\n remains elevated at 38 today.\n Problem Cerebral edema\n Assessment:\n No gag, no corneals, no cough at begin of shift. Pupils 2-3mm\n sluggishly reactive, no spontaneous movement or to noxious stimuli.\n Fentanyl(275 mcg/hr)and versed(22mg/hr) gtts continue. Per Micu attempt\n to wean sedation starting with fentanyl. No seizure activity.\n Action:\n Upon lavage and suction, weak cough and nasal flaring noted , otherwise\n exam unchanged. Fentanyl to 100mcg/hr. Versed to 16mg/hr. hypertonic\n saline 23.4% q3hrs overnight. Serum Osm and Na+ q6h overnight.\n Response:\n Neuro exam unchanged with exception of weak cough.\n Plan:\n Check with team re: any further narcotic/sedative wean.? Transition at\n some point to methadone.\n" }, { "category": "Nursing", "chartdate": "2131-06-20 00:00:00.000", "description": "Nursing Progress Note", "row_id": 681819, "text": "Respiration / Gas Exchange, Impaired\n Assessment:\n Afternoon ABG: 7.51, 27, 54, 0, 22 on trach mask\n Tachycardic, tachypnic, febrile\n Action:\n Place on CPAP + PS, 5 peep, 10 ps\n VAP protocol\n Repositioned frequently\n Response:\n 7.41, 35, 146, -1, 23\n HR in 90\ns NSR\n RR ~ 22\n Patient appears comfortable\n Plan:\n Pressure support decreased to 5\n Will recheck ABG\n Place back on trach mask when appropriate\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n ~ 80 cc\ns for urine output for 12 hours\n Icteric urine with sediment\n /Action:\n CRRT was stopped \n Response:\n Creatinine 1.8 (1.2).\n Fluid balance + ~ 1000 cc\ns MN\n 0600\n Plan:\n Attempt hemodialysis if possible\n Patient currently off vasopressors\n Arousal, Attention, and Cognition, Impaired\n Assessment:\n dx\n Action:\n Q 4 hour neuro exam\n Patient and family support\n Response:\n Unchanged from beginning of shift\n Plan:\n Continue neuro checks\n Continue to encourage patient to communicate, move extremities\n Hypotension (not Shock)\n Assessment:\n Start of shift patient requiring levophed to support blood pressure\n Action:\n Levophed weaned off\n CT scan of abdomen and pelvis done\n Response:\n CT results pending\\\n Remains off vasopressors\n No fever\n Plan:\n Continue to wean vent to collar\n" }, { "category": "Nursing", "chartdate": "2131-05-31 00:00:00.000", "description": "Nursing Progress Note", "row_id": 678058, "text": "Impaired Skin Integrity\n Assessment:\n Action:\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n Problem - Description In Comments\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Respiratory ", "chartdate": "2131-05-26 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 677016, "text": "Demographics\n Day of mechanical ventilation: 0\n Ideal body weight: 67.1 None\n Ideal tidal volume: 268.4 / 402.6 / 536.8 mL/kg\n Airway\n Tube Type\n ETT:\n Position: 24 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7mm\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: Suctioned / None\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 Trigger work assessment: Abnormal trigger efforts (efforts during\n inspiratory)\n Dysynchrony assessment: Possible air trapping\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 Underlying illness not resolved\n No balloon measurements this shift.. Last Pa02-70.\n" }, { "category": "Respiratory ", "chartdate": "2131-05-27 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 677172, "text": "Demographics\n Ideal body weight: 67.1 None\n Ideal tidal volume: 268.4 / 402.6 / 536.8 mL/kg\n Airway\n Tube Type\n ETT:\n Position: 24 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7mm\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Clear\n Comments:\n Secretions\n Sputum color / consistency: White / Thin\n Sputum source/amount: Suctioned / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Utilize ARDSnet protocol\n Reason for continuing current ventilatory support: Sedated / Paralyzed,\n Underlying illness not resolved\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Pleural pressure measurement (0200)\n Comments: TPP insp 6.8 TPP exp -3\n" }, { "category": "Nursing", "chartdate": "2131-06-17 00:00:00.000", "description": "Nursing Progress Note", "row_id": 681250, "text": "Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n On CRRT. Goal negative.\n Hemodynamically stable. Sedated on Fent/Versed.\n Hypotensive to high 80s x1 this shift.\n u/o marginal- approx ccs/hr. icteric & clear.\n Action:\n approx -30 ccs at midnight tonight.\n Flushed CRRT and gave pt small 200 cc bolus for transient hypotension.\n Response:\n Responded well to fluid bolus.\n Plan:\n Respiration / Gas Exchange, Impaired\n Assessment:\n Mod oral secretions though pt continually biting down and preventing\n oral care.\n On TM 50% since this afternoon.\n ABGs wnl. RR 20s.\n When agitated or with stimulation. RR up to 30s though self resolves.\n LS clear, at times rhonchorous and wheezy.\n Action:\n Trach mask continued.\n Inhalers prn.\n Response:\n Plan:\n Impaired Skin Integrity\n Assessment:\n Multiple open, blisters to bilateral lower extremities and abdomen.\n Skin dry & peeling.\n Deep tissue injury to bilateral heels.\n +1 generalized edema.\n TF at goal rate. Loose green liquid/mucoid stool x2 this shift.\n FS elevated 170-270.\n Action:\n Aloe Vesta cream applied to all areas after cleaning site.\n Dressing applied on both knee/calf areas.\n Waffle boots in place, elevating heels.\n TF continues. Aloevesta to sacrum/coccyx as well.\n SQ Insulin sliding scale.\n Response:\n Plan:\n" }, { "category": "Physician ", "chartdate": "2131-06-17 00:00:00.000", "description": "Physician Resident/Attending Progress Note - MICU", "row_id": 681337, "text": "Chief Complaint:\n 24 Hour Events:\n BLOOD CULTURED - At 11:30 AM\n PIV X2\n SPUTUM CULTURE - At 12:33 PM\n URINE CULTURE - At 12:33 PM\n FEVER - 101.2\nF - 08:00 AM\n \n - Renal recs: CVVH was started as he likely wouldn't tolerate HD due to\n low pressures.\n - Patient was continued on linezolid, aztreonam, and flagyl.\n - More tenderness in abd with concern for accalculus cholecystitis, but\n did not get HIDA scan as we would continue medical management. Will\n observe for now but if he decompensates, he may need a perc drain per\n IR.\n Allergies:\n Meropenem\n skin blisters a\n Last dose of Antibiotics:\n Ciprofloxacin - 12:34 PM\n Aztreonam - 08:05 PM\n Linezolid - 10:09 PM\n Metronidazole - 12:00 AM\n Infusions:\n Midazolam (Versed) - 1 mg/hour\n Fentanyl (Concentrate) - 50 mcg/hour\n Calcium Gluconate (CRRT) - 2.4 grams/hour\n Other ICU medications:\n Famotidine (Pepcid) - 01:30 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:34 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: 36.3\nC (97.3\n HR: 93 (85 - 108) bpm\n BP: 98/54(69) {81/38(52) - 124/70(91)} mmHg\n RR: 20 (19 - 32) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 103.1 kg (admission): 113.5 kg\n Height: 67 Inch\n Total In:\n 6,584 mL\n 2,432 mL\n PO:\n TF:\n 1,200 mL\n 278 mL\n IVF:\n 5,384 mL\n 2,154 mL\n Blood products:\n Total out:\n 6,966 mL\n 2,361 mL\n Urine:\n 487 mL\n 35 mL\n NG:\n Stool:\n Drains:\n Balance:\n -382 mL\n 71 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n Ventilator mode: Standby\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 0 (0 - 557) mL\n PS : 5 cmH2O\n RR (Set): 22\n RR (Spontaneous): 30\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 0 cmH2O\n SpO2: 100%\n ABG: 7.36/31/122/19/-6\n Ve: 13.5 L/min\n PaO2 / FiO2: 244\n Physical Examination\n GEN: Trached, sedated\n HEENT: icteric sclera. MMM\n NECK: Trach site with no oozing.\n LUNGS: Anterior auscultation with upper airway noise; good airway\n movement\n HEART: RRR, normal; S1, S2\n ABD: Distended. Grimmacing with palpation.\n EXTREM: 2+ edema, ulcers/lesions on legs with bandages C/D/I\n SKIN: Jaundice\n NEURO: Opening eyes to command. Purposeful movements of arms.\n Labs / Radiology\n 255 K/uL\n 7.7 g/dL\n 167 mg/dL\n 2.2 mg/dL\n 19 mEq/L\n 3.5 mEq/L\n 60 mg/dL\n 100 mEq/L\n 133 mEq/L\n 23.9 %\n 26.4 K/uL\n [image002.jpg]\n 06:31 PM\n 01:32 AM\n 03:05 AM\n 12:10 PM\n 01:36 PM\n 06:06 PM\n 06:23 PM\n 10:13 PM\n 04:13 AM\n 04:24 AM\n WBC\n 26.4\n Hct\n 23.2\n 23.9\n Plt\n 243\n 255\n Cr\n 2.0\n 2.4\n 2.2\n TCO2\n 17\n 16\n 18\n 19\n 19\n 18\n Glucose\n 166\n 154\n 162\n 220\n 67\n Other labs: PT / PTT / INR:16.1/32.9/1.4, CK / CKMB /\n Troponin-T:214/3/0.07, ALT / AST:211/247, Alk Phos / T Bili:564/29.7,\n Amylase / Lipase:51/41, Differential-Neuts:78.0 %, Band:3.0 %,\n Lymph:1.0 %, Mono:7.0 %, Eos:0.0 %, D-dimer:6389 ng/mL, Fibrinogen:502\n mg/dL, Lactic Acid:1.0 mmol/L, Albumin:2.0 g/dL, LDH:561 IU/L, Ca++:9.1\n mg/dL, Mg++:2.1 mg/dL, PO4:2.8 mg/dL\n Assessment and Plan\n 28M with alcoholic hepatitis and necrotizing pancreatitis complicated\n by ARDS, SIRS, ARF, UGIB, fevers.\n #. ID: No fevers since starting CVVH. RUQ u/s concerning for sludge and\n pt started flagyl.\n - Cte broad spectrum antibiotic coverage with linezolid and aztreonam\n (D1 ) and flagyl (added back )\n - Consider HIDA scan if bilirubin does not improve or hemodynamic\n instability over next few days as may need perc. drain\n - F/u WBC count, temp curve, and culture data\n - Cont steroid taper for possible adrenal insufficiency\n - Yeast in the urine- changed foley and re-cultured. If still with\n yeast will treat with anti-fungal.\n # Hyperbilirubinemia: T Bili stable. Has alcoholic hepatitis but was\n also on TPN. Bili. RUQ u/s with sludge concerning for cholestasis. Note\n that U/S also showed sludge.\n - Consider asking GI input for HIDA scan v. ERCP if hemodynamic\n instability\n - TPN stopped \n - Weaning off benzos\n #. Respiratory Failure: ARDS secondary to necrotizing pancreatitis. S/p\n trach placement on . Sutures out on . Currently on trach mask\n with good abg\n - Increasing fentanyl patch while decreasing gtt, continue methadone\n - Cte oob to chair daily\n - Consider down-size trach\n # Seizures: CT head without intracranial process. EEG showed occipital\n seizures which does not correlate with clinical symptoms, but repeat\n EEG on higher dose Keppra showed no seizures. As patient now with\n purposeful movements it may actually be patient waking up, not\n seizures.\n - Continue on higher dose keppra\n - F/u neuro recs\n - Wean off midazolam as tolerated with low dose valium to prevent\n withdrawal; monitor vitals\n #. Acute renal Failure: Appreciate renal recs.\n - Would dialyze for acidosis but likely does not need volume depletion\n as pressures borderline.\n - Cte CVVH while pressures low but consider HD when more stable\n tomorrow.\n - Aztreonam increased back to 2000mg q12h as back on CVVH\n - Will change Keppra to 1000mg Q24 with 500 mg after HD if he\n transitions to HD\n #. Adrenal Insufficiency: Unclear with stim if clear adrenal\n insufficiency but hypotension improving with steroids (lower pressor\n requirement) and improving eosinophilia\n - Weaned Hydrocort to 25mg Q8H (Day )\n ICU Care\n Nutrition:\n Nutren 2.0 () - 01:46 PM 50 mL/hour\n Glycemic Control: ISS\n Lines:\n Arterial Line - 08:15 PM\n PICC Line - 08:37 AM\n Dialysis Catheter - 08:55 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:ICU->screen for rehab tomorrow\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: 28M alcoholic hepatitis, pancreatitis,\n refractory shock, ARDS\n Events:\n * trach mask since 12pm yesterday!\n * tolerating more volume off\n * weaning fent/versed now at 50/1, methadone 10 q8, valium 5 q8\n Exam:\n Temp spike 101.2 off CVVH yest morning, afebrile on CVVH.\n Tolerating TF at goal.\n RN reported pt was much more interactive, best mental status to\n date-- shook his head when she asked if he had pain, very weak hand\n squeeze\n Anasarca (though much improved since I last saw him 1 week ago),\n chemosis. Unresponsive on my exam. Coarse BS B but decent air movement.\n Distant s1s2. Obese, + BS. 3+ edema. Labs notable for WBC 26K, bicarb\n 19\n Plan\n 1. Abx: Aztreonam/flagyl/linezolid-- d/c all abx\n 2. shock (resolved), continue to wean steroids (HC 25 q8h) - unclear\n if he has/had adrenal insufficiency but starting hydrocortisone\n coincided with improvement in shock\n 3. resp failure: tolerating TM.\n 4. OOB to chair.\n 5. LFTs and RUQ exam. Gall bladder sludge was present on USG but\n concern for cholecystitis with worse leukocytosis, fevers,\n hypotension, abd with stable TTP (grimaces to palpation, though\n difficult to interpret). Transaminitis significant but stable.\n Monitor, will consider HIDA or eval by GI for possible ERCP but I\n strongly favor conservative management given that these procedures\n might make him worse and he is unlikely to have obstruction.\n 6. ARF, CVVH with plan to stop after this 72h course and switch to HD.\n 7. Ileus: he is now stooling with good bowel sounds.\n 8. Sedation: taper fentanyl and versed to off. Continue methadone,\n valium.\n 9. Start screening for rehab.\n Pt is critically ill.\n Total time: 40 min\n ------ Protected Section Addendum Entered By: , MD\n on: 11:47 ------\n" }, { "category": "Physician ", "chartdate": "2131-06-19 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 681648, "text": "Chief Complaint:\n 24 Hour Events:\n NUCLEAR MEDICINE - At 05:40 PM\n \n - Restarted on linezolid, aztreonam, and flagyl given increased\n leukocytosis/left shift\n - Pt to continue CVVH until filter clogs per Renal\n - Fentanyl gtt changed to prn boluses\n - PT/OT consulted; case manager starting Rehab screening\n - HIDA scan done. On return, more tachypneic with RR in 30s. ABG c/w\n resp alkalosis: 7.45/33/115 10am -> 7.50/30/55/24 6pm -> 7.49/25/66/20\n 6:30pm. Trach suctioned with no output. Given fentanyl bolus as\n appeared more uncomfortable. I/O net positive 670 cc -> CVVH rate\n increased as SBP 120s. Had clot when resuctioned. CXR showed mild fluid\n at bases with more plump pulm vasculature; smaller volumes likely c/w\n expiration - no collapse. Repeat ABG 7.46/37/180/27.\n Allergies:\n Meropenem\n skin blisters a\n Last dose of Antibiotics:\n Linezolid - 12:42 PM\n Aztreonam - 02:57 AM\n Metronidazole - 04:00 AM\n Infusions:\n Calcium Gluconate (CRRT) - 1.6 grams/hour\n Other ICU medications:\n Fentanyl - 07:09 PM\n Famotidine (Pepcid) - 12:08 AM\n Heparin Sodium (Prophylaxis) - 04:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:26 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37\nC (98.6\n Tcurrent: 35.9\nC (96.7\n HR: 95 (90 - 118) bpm\n BP: 126/70(91) {107/56(72) - 133/78(99)} mmHg\n RR: 30 (21 - 36) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 100.4 kg (admission): 113.5 kg\n Height: 67 Inch\n Total In:\n 8,831 mL\n 2,834 mL\n PO:\n TF:\n 995 mL\n 371 mL\n IVF:\n 7,796 mL\n 2,463 mL\n Blood products:\n Total out:\n 8,370 mL\n 2,381 mL\n Urine:\n 85 mL\n 35 mL\n NG:\n Stool:\n Drains:\n Balance:\n 461 mL\n 453 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n SpO2: 99%\n ABG: 7.44/39/125/25/2\n PaO2 / FiO2: 179\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 334 K/uL\n 8.0 g/dL\n 151 mg/dL\n 0.6 mg/dL\n 25 mEq/L\n 3.9 mEq/L\n 29 mg/dL\n 98 mEq/L\n 132 mEq/L\n 24.6 %\n 34.9 K/uL\n [image002.jpg]\n 10:30 PM\n 03:49 AM\n 03:56 AM\n 10:08 AM\n 06:00 PM\n 06:25 PM\n 08:18 PM\n 10:56 PM\n 02:58 AM\n 03:10 AM\n WBC\n 30.5\n 34.9\n Hct\n 24.8\n 24.6\n Plt\n 321\n 334\n Cr\n 0.6\n 0.6\n TCO2\n 26\n 27\n 24\n 24\n 20\n 27\n 26\n 27\n Glucose\n 185\n 160\n 165\n 156\n 116\n 112\n 151\n Other labs: PT / PTT / INR:15.0/33.3/1.3, CK / CKMB /\n Troponin-T:214/3/0.07, ALT / AST:214/227, Alk Phos / T Bili:519/24.8,\n Amylase / Lipase:77/68, Differential-Neuts:78.0 %, Band:9.0 %,\n Lymph:2.0 %, Mono:3.0 %, Eos:0.0 %, D-dimer:6389 ng/mL, Fibrinogen:502\n mg/dL, Lactic Acid:1.0 mmol/L, Albumin:2.0 g/dL, LDH:529 IU/L, Ca++:8.8\n mg/dL, Mg++:1.8 mg/dL, PO4:1.7 mg/dL\n Assessment and Plan\n AROUSAL, ATTENTION, AND COGNITION, IMPAIRED\n BALANCE, IMPAIRED\n MOTOR FUNCTION, IMPAIRED\n MUSCLE PERFORMACE, IMPAIRED\n RESPIRATION / GAS EXCHANGE, IMPAIRED\n SEIZURE, WITHOUT STATUS EPILEPTICUS\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n IMPAIRED SKIN INTEGRITY\n HEPATITIS, ACUTE TOXIC (INCLUDING ALCOHOLIC, ACETAMINOPHEN, ETC.)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ICU Care\n Nutrition:\n Nutren 2.0 () - 05:40 PM 50 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 08:15 PM\n PICC Line - 08:37 AM\n Dialysis Catheter - 08:55 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP: HOB elevation\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:ICU\n" }, { "category": "Physician ", "chartdate": "2131-05-31 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 677935, "text": "Chief Complaint: Necrotizing pancreatitis c/b SIRS, ARDS, cerebral\n edema, ARF\n 24 Hour Events:\n - CT abd pancreatic cyst, Gi will re-eval in AM\n - CTH shows improvement\n - Pressor requirement increasing\n - hct/plt stable\n - dc abx\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 07:50 AM\n Meropenem - 02:45 AM\n Infusions:\n Fentanyl (Concentrate) - 25 mcg/hour\n Calcium Gluconate (CRRT) - 1.6 grams/hour\n KCl (CRRT) - 3 mEq./hour\n Norepinephrine - 0.09 mcg/Kg/min\n Other ICU medications:\n Pantoprazole (Protonix) - 08:34 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:17 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.1\nC (98.8\n Tcurrent: 36.7\nC (98\n HR: 107 (99 - 110) bpm\n BP: 108/58(74) {82/38(56) - 115/62(79)} mmHg\n RR: 30 (14 - 33) insp/min\n SpO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 128 kg (admission): 113.5 kg\n Height: 67 Inch\n CVP: 15 (9 - 21)mmHg\n Total In:\n 8,648 mL\n 3,225 mL\n PO:\n TF:\n IVF:\n 7,125 mL\n 2,419 mL\n Blood products:\n 277 mL\n 282 mL\n Total out:\n 8,471 mL\n 3,487 mL\n Urine:\n 71 mL\n NG:\n 450 mL\n Stool:\n Drains:\n Balance:\n 177 mL\n -262 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 30\n RR (Spontaneous): 0\n PEEP: 12 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10\n PIP: 23 cmH2O\n Plateau: 19 cmH2O\n SpO2: 100%\n ABG: 7.43/48/76./27/6\n Ve: 12.5 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 60 K/uL\n 8.6 g/dL\n 150 mg/dL\n 2.0 mg/dL\n 27 mEq/L\n 4.3 mEq/L\n 24 mg/dL\n 102 mEq/L\n 140 mEq/L\n 25.7 %\n 31.2 K/uL\n [image002.jpg]\n 07:59 AM\n 10:44 AM\n 10:50 AM\n 01:51 PM\n 04:00 PM\n 04:02 PM\n 10:23 PM\n 10:37 PM\n 04:00 AM\n 04:07 AM\n WBC\n 36.3\n 32.8\n 31.2\n Hct\n 25.7\n 24.4\n 23.8\n 25.7\n Plt\n 48\n 54\n 60\n Cr\n 1.8\n 2.2\n 1.8\n 2.0\n TCO2\n 39\n 34\n 31\n 34\n 34\n 33\n Glucose\n 114\n 108\n 97\n 133\n 120\n 165\n 161\n 150\n Other labs: PT / PTT / INR:15.7/43.4/1.4, ALT / AST:23/269, Alk Phos /\n T Bili:138/14.8, Amylase / Lipase:19/35, Differential-Neuts:55.0 %,\n Band:1.0 %, Lymph:16.0 %, Mono:7.0 %, Eos:6.0 %, D-dimer:6389 ng/mL,\n Fibrinogen:293 mg/dL, Lactic Acid:1.5 mmol/L, Albumin:1.6 g/dL, LDH:607\n IU/L, Ca++:9.5 mg/dL, Mg++:2.0 mg/dL, PO4:4.1 mg/dL\n Imaging: CTH: 1. No acute intracranial hemorrhage, shift of normally\n midline structures or territorial infarction.\n 2. Interval improvement in the -white matter differentiation,\n particularly in the deep -white matter interface as well as at the\n vertex.\n CTAP: Gastric pseudocyst, stable peripancreatic fluid collections.\n Assessment and Plan\n IMPAIRED HEALTH MAINTENANCE\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n IMPAIRED SKIN INTEGRITY\n HYPOTENSION (NOT SHOCK)\n HEPATITIS, ACUTE TOXIC (INCLUDING ALCOHOLIC, ACETAMINOPHEN, ETC.)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n PANCREATITIS, ACUTE\n ICU Care\n Nutrition:\n TPN w/ Lipids - 05:03 PM 73 mL/hour\n Glycemic Control:\n Lines:\n Multi Lumen - 02:02 PM\n Dialysis Catheter - 04:56 PM\n Arterial Line - 01:30 PM\n 20 Gauge - 11:15 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": "2131-05-31 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 677938, "text": "Chief Complaint: Necrotizing pancreatitis c/b SIRS, ARDS, cerebral\n edema, ARF\n 24 Hour Events:\n - CT abd pancreatic cyst, Gi will re-eval in AM\n - CTH shows improvement\n - Pressor requirement increasing\n - Transfused 1 unit PRBC overnight for hct 23\n - dc abx\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 07:50 AM\n Meropenem - 02:45 AM\n Infusions:\n Fentanyl (Concentrate) - 25 mcg/hour\n Calcium Gluconate (CRRT) - 1.6 grams/hour\n KCl (CRRT) - 3 mEq./hour\n Norepinephrine - 0.09 mcg/Kg/min\n Other ICU medications:\n Pantoprazole (Protonix) - 08:34 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:17 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.1\nC (98.8\n Tcurrent: 36.7\nC (98\n HR: 107 (99 - 110) bpm\n BP: 108/58(74) {82/38(56) - 115/62(79)} mmHg\n RR: 30 (14 - 33) insp/min\n SpO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 128 kg (admission): 113.5 kg\n Height: 67 Inch\n CVP: 15 (9 - 21)mmHg\n Total In:\n 8,648 mL\n 3,225 mL\n PO:\n TF:\n IVF:\n 7,125 mL\n 2,419 mL\n Blood products:\n 277 mL\n 282 mL\n Total out:\n 8,471 mL\n 3,487 mL\n Urine:\n 71 mL\n NG:\n 450 mL\n Stool:\n Drains:\n Balance:\n 177 mL\n -262 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 30\n RR (Spontaneous): 0\n PEEP: 12 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10\n PIP: 23 cmH2O\n Plateau: 19 cmH2O\n SpO2: 100%\n ABG: 7.43/48/76./27/6\n Ve: 12.5 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 60 K/uL\n 8.6 g/dL\n 150 mg/dL\n 2.0 mg/dL\n 27 mEq/L\n 4.3 mEq/L\n 24 mg/dL\n 102 mEq/L\n 140 mEq/L\n 25.7 %\n 31.2 K/uL\n [image002.jpg]\n 07:59 AM\n 10:44 AM\n 10:50 AM\n 01:51 PM\n 04:00 PM\n 04:02 PM\n 10:23 PM\n 10:37 PM\n 04:00 AM\n 04:07 AM\n WBC\n 36.3\n 32.8\n 31.2\n Hct\n 25.7\n 24.4\n 23.8\n 25.7\n Plt\n 48\n 54\n 60\n Cr\n 1.8\n 2.2\n 1.8\n 2.0\n TCO2\n 39\n 34\n 31\n 34\n 34\n 33\n Glucose\n 114\n 108\n 97\n 133\n 120\n 165\n 161\n 150\n Other labs: PT / PTT / INR:15.7/43.4/1.4, ALT / AST:23/269, Alk Phos /\n T Bili:138/14.8, Amylase / Lipase:19/35, Differential-Neuts:55.0 %,\n Band:1.0 %, Lymph:16.0 %, Mono:7.0 %, Eos:6.0 %, D-dimer:6389 ng/mL,\n Fibrinogen:293 mg/dL, Lactic Acid:1.5 mmol/L, Albumin:1.6 g/dL, LDH:607\n IU/L, Ca++:9.5 mg/dL, Mg++:2.0 mg/dL, PO4:4.1 mg/dL\n Imaging: CTH: 1. No acute intracranial hemorrhage, shift of normally\n midline structures or territorial infarction.\n 2. Interval improvement in the -white matter differentiation,\n particularly in the deep -white matter interface as well as at the\n vertex.\n CTAP: Gastric pseudocyst, stable peripancreatic fluid collections.\n Assessment and Plan\n Mr. is a 28 year old gentleman with alcoholic hepatitis and\n necrotizing pancreatitis complicated by ARDS, SIRS, and UGIB.\n # Anemia: Initially p/w hematemesis and EGD showed diuelafoy's lesion.\n Hct continues to trend down (25->24->23), now s/p 1 unit PRBC\n overnight. CTAP with gastric pseudocyst but per d/w radiology now\n definitive explanation for hct drop. GI to re-eval this morning.\n - Trend CBC Q8H, transfuse for hct<21 or plt<50\n - Follow-up with GI regarding futher diagnostic and therapeutic\n interventions\n - CVVH at even balance for now\n # Neuro: Initially dilated pupils with CT showing cerebral edema. Neuro\n exam now stable. Repeat CTH demonstrates interval improvement.\n - Continue leviteracetam\n - Wean sedation as possible\n - Neuro recs if any\n # Respiratory Failure: ARDS secondary to necrotizing pancreatitis\n compounded by hypoxia, tachypnea in setting of anion gap metabolic\n acidosis, increased abdominal pressure, and EtOH withdrawl. PEEP\n decreased to 12 from 20 and FiO2 to 50%.\n - Wean FiO2 and PEEP, goal PaO2>60-65%\n # Leukocytosis: Trendingd own. Initial concern for infection but normal\n cx suggests that this may be inflammatory reaction. No eos on diff.\n Appreciate ID input, no antibiotic indication at this time.\n Antibiotics now discontinued.\n - Trend fever curve and WBC.\n - Follow-up culture data\n # Necrotizing pancreatitis/SIRS: Secondary to alcohol complicated by\n SIRS and ARDS. Patient continues to have pressor requirement, with neo\n +/- levo. Aggressive volume resuscitation with >50L.\n - Wean pressors with goal MAP >65\n # Hyponatremia: In setting of decreased effective circulating volume\n in setting of SIRS and IABP. Patient has received hypertonic saline\n boluses with improvement in serum sodium and osm.\n - Given improvement in neuro exam, hold hypertonic saline.\n # Acute renal failure: Patient had HD line placed and on CVVH. CVVH\n with even TBB pending assessment of hemorrhage.\n - CVVH per renal.\n - Trend chemistries\n #Thrombocytopenia: Platelets stable. No clear etiology at this time.\n DIC panel and HIT PF4 antibody negative.\n - Trend plt, transfuse for plt<10 or <50 if signs of hemorrhage.\n # Wound care: Per wound care recs.\n # Acute hepatitis: Likely alcoholic hepatitis with fatty infiltration,\n and no evidence of distal obstruction. RUQ u/s shows marked liver\n echogenicity but no ascites.\n - Trend LFTs\n # Alcoholism: Patient describes history of withdrawal symptoms, but\n not prior seizure. Last drink was night prior to presentation.\n Tachycardia, weakness, and elevated lactate could be consistent with\n thiamine deficiency.\n - Thiamine, vb12, folate\n - Valium with CIWA > 10\n FEN: Restart TPN without heparin, replete as necessary.\n PPx: IV PPI. SCD on arm if possible, hold heparin.\n Access: RIJ (quad), LIJ (HD), left radial a-line\n Dispo: ICU level of care\n ICU Care\n Nutrition:\n TPN w/ Lipids - 05:03 PM 73 mL/hour\n Glycemic Control:\n Lines:\n Multi Lumen - 02:02 PM\n Dialysis Catheter - 04:56 PM\n Arterial Line - 01:30 PM\n 20 Gauge - 11:15 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": "2131-05-31 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 677939, "text": "Chief Complaint: Necrotizing pancreatitis c/b SIRS, ARDS, cerebral\n edema, ARF\n 24 Hour Events:\n - CT abd pancreatic cyst, Gi will re-eval in AM\n - CTH shows improvement\n - Pressor requirement increasing\n - Transfused 1 unit PRBC overnight for hct 23\n - dc abx\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 07:50 AM\n Meropenem - 02:45 AM\n Infusions:\n Fentanyl (Concentrate) - 25 mcg/hour\n Calcium Gluconate (CRRT) - 1.6 grams/hour\n KCl (CRRT) - 3 mEq./hour\n Norepinephrine - 0.09 mcg/Kg/min\n Other ICU medications:\n Pantoprazole (Protonix) - 08:34 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:17 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.1\nC (98.8\n Tcurrent: 36.7\nC (98\n HR: 107 (99 - 110) bpm\n BP: 108/58(74) {82/38(56) - 115/62(79)} mmHg\n RR: 30 (14 - 33) insp/min\n SpO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 128 kg (admission): 113.5 kg\n Height: 67 Inch\n CVP: 15 (9 - 21)mmHg\n Total In:\n 8,648 mL\n 3,225 mL\n PO:\n TF:\n IVF:\n 7,125 mL\n 2,419 mL\n Blood products:\n 277 mL\n 282 mL\n Total out:\n 8,471 mL\n 3,487 mL\n Urine:\n 71 mL\n NG:\n 450 mL\n Stool:\n Drains:\n Balance:\n 177 mL\n -262 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 30\n RR (Spontaneous): 0\n PEEP: 12 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10\n PIP: 23 cmH2O\n Plateau: 19 cmH2O\n SpO2: 100%\n ABG: 7.43/48/76./27/6\n Ve: 12.5 L/min\n PaO2 / FiO2: 152\n Physical Examination\n Gen: Anasarca improved. Intubated.\n HEENT: ETT in place, scleral edema. Pupils 3->2 mm b/l.\n CV: Nl S1+S2\n Pulm: Rhonchorous throughout\n Abd: Distended, soft, minimal BS\n Ext: 3+ edema.\n Skin: Weeping blisters of LE b/l\n Neuro: Sedated\n Labs / Radiology\n 60 K/uL\n 8.6 g/dL\n 150 mg/dL\n 2.0 mg/dL\n 27 mEq/L\n 4.3 mEq/L\n 24 mg/dL\n 102 mEq/L\n 140 mEq/L\n 25.7 %\n 31.2 K/uL\n [image002.jpg]\n 07:59 AM\n 10:44 AM\n 10:50 AM\n 01:51 PM\n 04:00 PM\n 04:02 PM\n 10:23 PM\n 10:37 PM\n 04:00 AM\n 04:07 AM\n WBC\n 36.3\n 32.8\n 31.2\n Hct\n 25.7\n 24.4\n 23.8\n 25.7\n Plt\n 48\n 54\n 60\n Cr\n 1.8\n 2.2\n 1.8\n 2.0\n TCO2\n 39\n 34\n 31\n 34\n 34\n 33\n Glucose\n 114\n 108\n 97\n 133\n 120\n 165\n 161\n 150\n Other labs: PT / PTT / INR:15.7/43.4/1.4, ALT / AST:23/269, Alk Phos /\n T Bili:138/14.8, Amylase / Lipase:19/35, Differential-Neuts:55.0 %,\n Band:1.0 %, Lymph:16.0 %, Mono:7.0 %, Eos:6.0 %, D-dimer:6389 ng/mL,\n Fibrinogen:293 mg/dL, Lactic Acid:1.5 mmol/L, Albumin:1.6 g/dL, LDH:607\n IU/L, Ca++:9.5 mg/dL, Mg++:2.0 mg/dL, PO4:4.1 mg/dL\n Imaging: CTH: 1. No acute intracranial hemorrhage, shift of normally\n midline structures or territorial infarction.\n 2. Interval improvement in the -white matter differentiation,\n particularly in the deep -white matter interface as well as at the\n vertex.\n CTAP: Gastric pseudocyst, stable peripancreatic fluid collections.\n Assessment and Plan\n Mr. is a 28 year old gentleman with alcoholic hepatitis and\n necrotizing pancreatitis complicated by ARDS, SIRS, and UGIB.\n # Anemia: Initially p/w hematemesis and EGD showed diuelafoy's lesion.\n Hct continues to trend down (25->24->23), now s/p 1 unit PRBC\n overnight. CTAP with gastric pseudocyst but per d/w radiology now\n definitive explanation for hct drop. GI to re-eval this morning.\n - Trend CBC Q8H, transfuse for hct<21 or plt<50\n - Follow-up with GI regarding futher diagnostic and therapeutic\n interventions\n - CVVH at even balance for now\n # Neuro: Initially dilated pupils with CT showing cerebral edema. Neuro\n exam now stable. Repeat CTH demonstrates interval improvement.\n - Continue leviteracetam\n - Wean sedation as possible\n - Neuro recs if any\n # Respiratory Failure: ARDS secondary to necrotizing pancreatitis\n compounded by hypoxia, tachypnea in setting of anion gap metabolic\n acidosis, increased abdominal pressure, and EtOH withdrawl. PEEP\n decreased to 12 from 20 and FiO2 to 50%.\n - Wean FiO2 and PEEP, goal PaO2>60-65%\n # Leukocytosis: Trendingd own. Initial concern for infection but normal\n cx suggests that this may be inflammatory reaction. No eos on diff.\n Appreciate ID input, no antibiotic indication at this time.\n Antibiotics now discontinued.\n - Trend fever curve and WBC.\n - Follow-up culture data\n # Necrotizing pancreatitis/SIRS: Secondary to alcohol complicated by\n SIRS and ARDS. Patient continues to have pressor requirement, with neo\n +/- levo. Aggressive volume resuscitation with >50L.\n - Wean pressors with goal MAP >65\n # Hyponatremia: In setting of decreased effective circulating volume\n in setting of SIRS and IABP. Patient has received hypertonic saline\n boluses with improvement in serum sodium and osm.\n - Given improvement in neuro exam, hold hypertonic saline.\n # Acute renal failure: Patient had HD line placed and on CVVH. CVVH\n with even TBB pending assessment of hemorrhage.\n - CVVH per renal.\n - Trend chemistries\n #Thrombocytopenia: Platelets stable. No clear etiology at this time.\n DIC panel and HIT PF4 antibody negative.\n - Trend plt, transfuse for plt<10 or <50 if signs of hemorrhage.\n # Wound care: Per wound care recs.\n # Acute hepatitis: Likely alcoholic hepatitis with fatty infiltration,\n and no evidence of distal obstruction. RUQ u/s shows marked liver\n echogenicity but no ascites.\n - Trend LFTs\n # Alcoholism: Patient describes history of withdrawal symptoms, but\n not prior seizure. Last drink was night prior to presentation.\n Tachycardia, weakness, and elevated lactate could be consistent with\n thiamine deficiency.\n - Thiamine, vb12, folate\n - Valium with CIWA > 10\n FEN: Restart TPN without heparin, replete as necessary.\n PPx: IV PPI. SCD on arm if possible, hold heparin.\n Access: RIJ (quad), LIJ (HD), left radial a-line\n Dispo: ICU level of care\n ICU Care\n Nutrition:\n TPN w/ Lipids - 05:03 PM 73 mL/hour\n Glycemic Control:\n Lines:\n Multi Lumen - 02:02 PM\n Dialysis Catheter - 04:56 PM\n Arterial Line - 01:30 PM\n 20 Gauge - 11:15 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Respiratory ", "chartdate": "2131-05-29 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 677485, "text": "Demographics\n Day of intubation: \n Day of mechanical ventilation: 12\n Ideal body weight: 67.1 None\n Ideal tidal volume: 268.4 / 402.6 / 536.8 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Tube Type\n ETT:\n Position: 23 cm at teeth\n Route oral:\n Type: Standard\n Size: 7mm\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: 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 Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Reduce PEEP as tolerated; Comments: No vent changes\n made this shift. Esophageal balloon remains in place. No measurments.\n Reason for continuing current ventilatory support: Sedated / Paralyzed,\n Hemodynimic instability, Underlying illness not resolved\n" }, { "category": "Physician ", "chartdate": "2131-06-17 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 681329, "text": "Chief Complaint:\n 24 Hour Events:\n BLOOD CULTURED - At 11:30 AM\n PIV X2\n SPUTUM CULTURE - At 12:33 PM\n URINE CULTURE - At 12:33 PM\n FEVER - 101.2\nF - 08:00 AM\n \n - Renal recs: CVVH was started as he likely wouldn't tolerate HD due to\n low pressures.\n - Patient was continued on linezolid, aztreonam, and flagyl.\n - More tenderness in abd with concern for accalculus cholecystitis, but\n did not get HIDA scan as we would continue medical management. Will\n observe for now but if he decompensates, he may need a perc drain per\n IR.\n Allergies:\n Meropenem\n skin blisters a\n Last dose of Antibiotics:\n Ciprofloxacin - 12:34 PM\n Aztreonam - 08:05 PM\n Linezolid - 10:09 PM\n Metronidazole - 12:00 AM\n Infusions:\n Midazolam (Versed) - 1 mg/hour\n Fentanyl (Concentrate) - 50 mcg/hour\n Calcium Gluconate (CRRT) - 2.4 grams/hour\n Other ICU medications:\n Famotidine (Pepcid) - 01:30 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:34 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: 36.3\nC (97.3\n HR: 93 (85 - 108) bpm\n BP: 98/54(69) {81/38(52) - 124/70(91)} mmHg\n RR: 20 (19 - 32) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 103.1 kg (admission): 113.5 kg\n Height: 67 Inch\n Total In:\n 6,584 mL\n 2,432 mL\n PO:\n TF:\n 1,200 mL\n 278 mL\n IVF:\n 5,384 mL\n 2,154 mL\n Blood products:\n Total out:\n 6,966 mL\n 2,361 mL\n Urine:\n 487 mL\n 35 mL\n NG:\n Stool:\n Drains:\n Balance:\n -382 mL\n 71 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n Ventilator mode: Standby\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 0 (0 - 557) mL\n PS : 5 cmH2O\n RR (Set): 22\n RR (Spontaneous): 30\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 0 cmH2O\n SpO2: 100%\n ABG: 7.36/31/122/19/-6\n Ve: 13.5 L/min\n PaO2 / FiO2: 244\n Physical Examination\n GEN: Trached, sedated\n HEENT: icteric sclera. MMM\n NECK: Trach site with no oozing.\n LUNGS: Anterior auscultation with upper airway noise; good airway\n movement\n HEART: RRR, normal; S1, S2\n ABD: Distended. Grimmacing with palpation.\n EXTREM: 2+ edema, ulcers/lesions on legs with bandages C/D/I\n SKIN: Jaundice\n NEURO: Opening eyes to command. Purposeful movements of arms.\n Labs / Radiology\n 255 K/uL\n 7.7 g/dL\n 167 mg/dL\n 2.2 mg/dL\n 19 mEq/L\n 3.5 mEq/L\n 60 mg/dL\n 100 mEq/L\n 133 mEq/L\n 23.9 %\n 26.4 K/uL\n [image002.jpg]\n 06:31 PM\n 01:32 AM\n 03:05 AM\n 12:10 PM\n 01:36 PM\n 06:06 PM\n 06:23 PM\n 10:13 PM\n 04:13 AM\n 04:24 AM\n WBC\n 26.4\n Hct\n 23.2\n 23.9\n Plt\n 243\n 255\n Cr\n 2.0\n 2.4\n 2.2\n TCO2\n 17\n 16\n 18\n 19\n 19\n 18\n Glucose\n 166\n 154\n 162\n 220\n 67\n Other labs: PT / PTT / INR:16.1/32.9/1.4, CK / CKMB /\n Troponin-T:214/3/0.07, ALT / AST:211/247, Alk Phos / T Bili:564/29.7,\n Amylase / Lipase:51/41, Differential-Neuts:78.0 %, Band:3.0 %,\n Lymph:1.0 %, Mono:7.0 %, Eos:0.0 %, D-dimer:6389 ng/mL, Fibrinogen:502\n mg/dL, Lactic Acid:1.0 mmol/L, Albumin:2.0 g/dL, LDH:561 IU/L, Ca++:9.1\n mg/dL, Mg++:2.1 mg/dL, PO4:2.8 mg/dL\n Assessment and Plan\n 28M with alcoholic hepatitis and necrotizing pancreatitis complicated\n by ARDS, SIRS, ARF, UGIB, fevers.\n #. ID: No fevers since starting CVVH. RUQ u/s concerning for sludge and\n pt started flagyl.\n - Cte broad spectrum antibiotic coverage with linezolid and aztreonam\n (D1 ) and flagyl (added back )\n - Consider HIDA scan if bilirubin does not improve or hemodynamic\n instability over next few days as may need perc. drain\n - F/u WBC count, temp curve, and culture data\n - Cont steroid taper for possible adrenal insufficiency\n - Yeast in the urine- changed foley and re-cultured. If still with\n yeast will treat with anti-fungal.\n # Hyperbilirubinemia: T Bili stable. Has alcoholic hepatitis but was\n also on TPN. Bili. RUQ u/s with sludge concerning for cholestasis. Note\n that U/S also showed sludge.\n - Consider asking GI input for HIDA scan v. ERCP if hemodynamic\n instability\n - TPN stopped \n - Weaning off benzos\n #. Respiratory Failure: ARDS secondary to necrotizing pancreatitis. S/p\n trach placement on . Sutures out on . Currently on trach mask\n with good abg\n - Increasing fentanyl patch while decreasing gtt, continue methadone\n - Cte oob to chair daily\n - Consider down-size trach\n # Seizures: CT head without intracranial process. EEG showed occipital\n seizures which does not correlate with clinical symptoms, but repeat\n EEG on higher dose Keppra showed no seizures. As patient now with\n purposeful movements it may actually be patient waking up, not\n seizures.\n - Continue on higher dose keppra\n - F/u neuro recs\n - Wean off midazolam as tolerated with low dose valium to prevent\n withdrawal; monitor vitals\n #. Acute renal Failure: Appreciate renal recs.\n - Would dialyze for acidosis but likely does not need volume depletion\n as pressures borderline.\n - Cte CVVH while pressures low but consider HD when more stable\n tomorrow.\n - Aztreonam increased back to 2000mg q12h as back on CVVH\n - Will change Keppra to 1000mg Q24 with 500 mg after HD if he\n transitions to HD\n #. Adrenal Insufficiency: Unclear with stim if clear adrenal\n insufficiency but hypotension improving with steroids (lower pressor\n requirement) and improving eosinophilia\n - Weaned Hydrocort to 25mg Q8H (Day )\n ICU Care\n Nutrition:\n Nutren 2.0 () - 01:46 PM 50 mL/hour\n Glycemic Control: ISS\n Lines:\n Arterial Line - 08:15 PM\n PICC Line - 08:37 AM\n Dialysis Catheter - 08:55 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:ICU->screen for rehab tomorrow\n" }, { "category": "Respiratory ", "chartdate": "2131-06-19 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 681748, "text": "Demographics\n Day of intubation: 1\n Day of mechanical ventilation: 1\n Ideal body weight: 67.1 None\n Ideal tidal volume: 268.4 / 402.6 / 536.8 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type: Not applicable\n Size: Not applicable\n Tracheostomy tube:\n Type: Standard, Cuffed, Inner Cannula\n Manufacturer: Portex\n Size: 8.0mm\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 24 cmH2O\n Cuff volume: 8 mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Brown / Plug\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: High flow demand\n Assessment of breathing comfort: No response (sleeping / sedated)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Underlying illness\n not resolved\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments: Pt returned to PSV 10/5peep @ 60% due to a prolonged lo Pao2\n in the 50\n, RRT 17:49\n" }, { "category": "Nursing", "chartdate": "2131-06-20 00:00:00.000", "description": "Nursing Progress Note", "row_id": 681929, "text": " Problem\n condition update/rehab planning\n Assessment:\n Patient rested on vent over night\n CRRT\n More awake today, tracking at times and looking toward voices\n Afebrile\n Action:\n OOB/ trach collar wean today\n Speech and swallow consult, passy-muir valve placed\n Hemo tomorrow\n Rehab screen process started, still goal for early next week\n Response:\n Tolerating trach collar well\n Minimal secretions\n No further septic episodes\n Antibiotics adjusted for off CRRT\n Plan:\n Transition to hemo\n Define course of antibiotics\n Have several days of nonsymptomatic fevers\n Stable on trach collar\n Aggressive Pt/OT/ and speech therapy\n To rehab early next week.\n" }, { "category": "Respiratory ", "chartdate": "2131-06-20 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 681817, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 2\n Ideal body weight: 67.1 None\n Ideal tidal volume: 268.4 / 402.6 / 536.8 mL/kg\n Airway\n Tracheostomy tube:\n Type: Standard, Cuffed, Inner Cannula\n Manufacturer: Portex\n Size: 8.0mm\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 24 cmH2O\n Cuff volume: 8 mL /\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Clear\n Secretions\n Sputum color / consistency: Blood Tinged / Thick\n Sputum source/amount: Suctioned / Small\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n icu->ct scan->icu\n 1am\n none\n Comments/Plan\n Pt remains trached, vent supported overnight. Minimal change\n overnight. Plan to place back on trache mask later in day today. See\n flowsheet for further pt data. Will follow.\n 05:37\n" }, { "category": "Physician ", "chartdate": "2131-06-15 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 680956, "text": "Chief Complaint:\n 24 Hour Events:\n - LFTs rising including TB/DB. D/c TPN. Weaning off midazolam, placed\n on standing valium.\n - bronch washings: Pulmonary macrophages, bronchial epithelial\n cells, and inflammatory cells, including eosinophils. Neg for malignant\n cells.\n - R-sided PICC and HD tunneled cath placed by IR.\n - PT consult ordered.\n - Aztreonam changed to HD dosing per pharmacy but then since didnt get\n HD and will likely get CVVH tomorrow for borderline pressures changed\n back to 2gm Q12H\n - Fever to 102 at 8pm with tachycardia to 120s and BPs to 90s/50s.\n Blood, urine, sputum cultures sent. 500mL NS X 2 given with better BPs.\n Midazolam 1X dose given as well with better HRs. CXR looked better than\n prior with no edema nad no pna. RUQ U/S:Gallbladder nondistended, but\n lumen entirely replaced by echogenic material. Favor sludge, but could\n also reflect marked wall thickening related to third spacing. Started\n Cipro. Ordered HIDA for am.\n - On ABG 7.4/34/98 but then in setting of fever was tachypnic so\n went back up on PS 8/5 with RR 20. Weaned back to overnight with\n ABG 7.25/37/122.\n - Changed glargine to QD\n Allergies:\n Meropenem\n skin blisters a\n Last dose of Antibiotics:\n Metronidazole - 02:00 AM\n Aztreonam - 08:30 PM\n Linezolid - 10:00 PM\n Ciprofloxacin - 12:00 AM\n Infusions:\n Midazolam (Versed) - 3 mg/hour\n Fentanyl (Concentrate) - 100 mcg/hour\n Other ICU medications:\n Fentanyl - 12:23 PM\n Midazolam (Versed) - 05:45 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:14 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 39.1\nC (102.3\n Tcurrent: 36.6\nC (97.8\n HR: 101 (82 - 123) bpm\n BP: 100/53(69) {76/41(55) - 125/85(87)} mmHg\n RR: 27 (14 - 32) insp/min\n SpO2: 99%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 113 kg (admission): 113.5 kg\n Height: 67 Inch\n CVP: 9 (4 - 12)mmHg\n Total In:\n 7,376 mL\n 542 mL\n PO:\n TF:\n 501 mL\n 311 mL\n IVF:\n 5,412 mL\n 231 mL\n Blood products:\n Total out:\n 5,958 mL\n 0 mL\n Urine:\n 128 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,418 mL\n 542 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 400 (400 - 400) mL\n Vt (Spontaneous): 405 (405 - 640) mL\n PS : 5 cmH2O\n RR (Set): 22\n RR (Spontaneous): 29\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI Deferred: RR >35\n PIP: 11 cmH2O\n SpO2: 99%\n ABG: 7.35/37/122/16/-4\n Ve: 13.1 L/min\n PaO2 / FiO2: 244\n Physical Examination\n GEN: Intubated, sedated\n HEENT: icteric sclera. MMM\n NECK: Trach site with minimal oozing\n LUNGS: Anterior auscultation with upper airway noise; good airway\n movement\n HEART: RRR, normal; S1, S2\n ABD: Distended. NT.\n EXTREM: 2+ edema, ulcers/lesions on legs with bandages C/D/I\n SKIN: Jaundice\n NEURO: Mouth twitching. Arms jerking bilaterally.\n Labs / Radiology\n 194 K/uL\n 8.2 g/dL\n 178 mg/dL\n 1.5 mg/dL\n 16 mEq/L\n 4.4 mEq/L\n 72 mg/dL\n 99 mEq/L\n 132 mEq/L\n 25.8 %\n 21.7 K/uL\n [image002.jpg]\n 12:01 AM\n 03:25 AM\n 03:39 AM\n 06:10 PM\n 06:18 PM\n 07:58 PM\n 08:00 PM\n 01:31 AM\n 01:37 AM\n 04:30 AM\n WBC\n 22.3\n 24.4\n 21.7\n Hct\n 25.4\n 26.9\n 25.3\n 25.8\n Plt\n 142\n 193\n 194\n Cr\n 1.0\n 1.6\n 1.5\n TCO2\n 27\n 22\n 23\n 21\n 21\n Glucose\n 78\n 78\n 121\n 178\n Other labs: PT / PTT / INR:15.2/34.4/1.3, CK / CKMB /\n Troponin-T:214/3/0.07, ALT / AST:158/238, Alk Phos / T Bili:421/28.0,\n Amylase / Lipase:51/41, Differential-Neuts:68.0 %, Band:5.0 %,\n Lymph:7.0 %, Mono:4.0 %, Eos:0.0 %, D-dimer:6389 ng/mL, Fibrinogen:502\n mg/dL, Lactic Acid:1.1 mmol/L, Albumin:2.0 g/dL, LDH:706 IU/L, Ca++:8.3\n mg/dL, Mg++:2.4 mg/dL, PO4:3.5 mg/dL\n Assessment and Plan\n 28M with alcoholic hepatitis and necrotizing pancreatitis complicated\n by ARDS, SIRS, ARF, UGIB, fevers and eosinophilia\n #. ID: Had been afebrile on broad coverage for severe necrotizing\n pancreatitis but spiked fever overnight with decreased BP. RUQ u/s\n concerning for sludge and pt started on cipro. Of note, had stopped\n flagyl and vanc po yesterday as C. diff neg x 2. Blood/tissue/BAL cx\n NGTD. It is possible that previous fevers had been masked by CVVH,\n which pt did not undergo yesterday\n - Cte broad spectrum antibiotic coverage with linezolid and aztreonam\n (D1 ) and cipro (D1 )\n - Consider adding back flagyl for anaerobic coverage.\n - HIDA scan today\n - F/u WBC count, temp curve, and culture data\n - F/u ID recs\n - Cont steroid taper for possible adrenal insufficiency\n # Hyperbilirubinemia: Patient has had continuously increasing T Bili\n and alkaline phosphatase. Has alcoholic hepatitis but also on TPN. Bili\n stable today but increased alk phos and RUQ u/s with sludge concerning\n for cholestasis.\n - Check HIDA scan\n - TPN stopped yesterday\n - Weaning off benzos\n #. Respiratory Failure: ARDS secondary to necrotizing pancreatitis. S/p\n trach placement on . Sutures out on . ABG good on PS but\n transition to trach mask limited by respiratory rate.\n - Cont to wean vent with trach mask trial as tolerated\n - Increasing fentanyl patch while decreasing gtt, continue methadone\n # Seizures: Had increased twitching of head and arms yesterday with\n deviation of eyes to R. Was given Ativan x 2, Keppra dose increased.\n CT head without intracranial process. EEG showed occipital seizures\n which does not correlate with clinical symptoms. actually be\n patient waking up, not seizures.\n - F/u neuro recs\n - Wean off midazolam as tolerated with low dose valium to prevent\n withdrawal; monitor vitals\n - Consider d/c drugs that may lower seizure threshold\n #. Acute renal Failure: Appreciate renal recs. Cr improved on CVVH. Off\n sucralfate due to concern for electrolyte abnormalities.\n - Cte volume depletion with CVVH as long as pressor requirement does\n not increase\n - Plan for tunneled dialysis catheter today to transition to HD\n tomorrow; f/u Renal recs\n #. Adrenal Insufficiency: Unclear with stim if clear adrenal\n insufficiency but hypotension improving with steroids (lower pressor\n requirement) and improving eosinophilia\n - Cont hydrocortisone 50mg Q8H D \n #. Thrombocytopenia: Resolved\n - Monitor platelets daily and transfuse for plt <10 or <50 if signs of\n bleed\n # ?HLH: Elevated ferritin. Awaiting quantitated ferritin to r/o HLH.\n ICU Care\n Nutrition:\n Nutren 2.0 () - 02:00 PM 50 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 08:15 PM\n Multi Lumen - 10:00 PM\n Dialysis Catheter - 11:35 PM\n Prophylaxis:\n DVT: SQ heparin\n Stress ulcer: H2B\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n" }, { "category": "Physician ", "chartdate": "2131-06-15 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 680982, "text": "Chief Complaint:\n 24 Hour Events:\n - LFTs rising including TB/DB. D/c TPN. Weaning off midazolam, placed\n on standing valium.\n - bronch washings: Pulmonary macrophages, bronchial epithelial\n cells, and inflammatory cells, including eosinophils. Neg for malignant\n cells.\n - R-sided PICC and HD tunneled cath placed by IR.\n - PT consult ordered.\n - Aztreonam changed to HD dosing per pharmacy but then since didnt get\n HD and will likely get CVVH tomorrow for borderline pressures changed\n back to 2gm Q12H\n - Fever to 102 at 8pm with tachycardia to 120s and BPs to 90s/50s.\n Blood, urine, sputum cultures sent. 500mL NS X 2 given with better BPs.\n Midazolam 1X dose given as well with better HRs. CXR looked better than\n prior with no edema nad no pna. RUQ U/S:Gallbladder nondistended, but\n lumen entirely replaced by echogenic material. Favor sludge, but could\n also reflect marked wall thickening related to third spacing. Started\n Cipro. Ordered HIDA for am.\n - On ABG 7.4/34/98 but then in setting of fever was tachypnic so\n went back up on PS 8/5 with RR 20. Weaned back to overnight with\n ABG 7.25/37/122.\n - Changed glargine to QD\n Allergies:\n Meropenem\n skin blisters a\n Last dose of Antibiotics:\n Metronidazole - 02:00 AM\n Aztreonam - 08:30 PM\n Linezolid - 10:00 PM\n Ciprofloxacin - 12:00 AM\n Infusions:\n Midazolam (Versed) - 3 mg/hour\n Fentanyl (Concentrate) - 100 mcg/hour\n Other ICU medications:\n Fentanyl - 12:23 PM\n Midazolam (Versed) - 05:45 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:14 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 39.1\nC (102.3\n Tcurrent: 36.6\nC (97.8\n HR: 101 (82 - 123) bpm\n BP: 100/53(69) {76/41(55) - 125/85(87)} mmHg\n RR: 27 (14 - 32) insp/min\n SpO2: 99%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 113 kg (admission): 113.5 kg\n Height: 67 Inch\n CVP: 9 (4 - 12)mmHg\n Total In:\n 7,376 mL\n 542 mL\n PO:\n TF:\n 501 mL\n 311 mL\n IVF:\n 5,412 mL\n 231 mL\n Blood products:\n Total out:\n 5,958 mL\n 0 mL\n Urine:\n 128 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,418 mL\n 542 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 400 (400 - 400) mL\n Vt (Spontaneous): 405 (405 - 640) mL\n PS : 5 cmH2O\n RR (Set): 22\n RR (Spontaneous): 29\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI Deferred: RR >35\n PIP: 11 cmH2O\n SpO2: 99%\n ABG: 7.35/37/122/16/-4\n Ve: 13.1 L/min\n PaO2 / FiO2: 244\n Physical Examination\n GEN: Intubated, sedated\n HEENT: icteric sclera. MMM\n NECK: Trach site with no oozing.\n LUNGS: Anterior auscultation with upper airway noise; good airway\n movement\n HEART: RRR, normal; S1, S2\n ABD: Distended. NT.\n EXTREM: 2+ edema, ulcers/lesions on legs with bandages C/D/I\n SKIN: Jaundice\n NEURO: Mouth twitching. Arms jerking bilaterally. Did not open eyes to\n command.\n Labs / Radiology\n 194 K/uL\n 8.2 g/dL\n 178 mg/dL\n 1.5 mg/dL\n 16 mEq/L\n 4.4 mEq/L\n 72 mg/dL\n 99 mEq/L\n 132 mEq/L\n 25.8 %\n 21.7 K/uL\n [image002.jpg]\n 12:01 AM\n 03:25 AM\n 03:39 AM\n 06:10 PM\n 06:18 PM\n 07:58 PM\n 08:00 PM\n 01:31 AM\n 01:37 AM\n 04:30 AM\n WBC\n 22.3\n 24.4\n 21.7\n Hct\n 25.4\n 26.9\n 25.3\n 25.8\n Plt\n 142\n 193\n 194\n Cr\n 1.0\n 1.6\n 1.5\n TCO2\n 27\n 22\n 23\n 21\n 21\n Glucose\n 78\n 78\n 121\n 178\n Other labs: PT / PTT / INR:15.2/34.4/1.3, CK / CKMB /\n Troponin-T:214/3/0.07, ALT / AST:158/238, Alk Phos / T Bili:421/28.0,\n Amylase / Lipase:51/41, Differential-Neuts:68.0 %, Band:5.0 %,\n Lymph:7.0 %, Mono:4.0 %, Eos:0.0 %, D-dimer:6389 ng/mL, Fibrinogen:502\n mg/dL, Lactic Acid:1.1 mmol/L, Albumin:2.0 g/dL, LDH:706 IU/L, Ca++:8.3\n mg/dL, Mg++:2.4 mg/dL, PO4:3.5 mg/dL\n Assessment and Plan\n 28M with alcoholic hepatitis and necrotizing pancreatitis complicated\n by ARDS, SIRS, ARF, UGIB, fevers and eosinophilia\n #. ID: Had been afebrile on broad coverage for severe necrotizing\n pancreatitis but spiked fever overnight with decreased BP. RUQ u/s\n concerning for sludge and pt started on cipro. Of note, had stopped\n flagyl and vanc po yesterday as C. diff neg x 2. Blood/tissue/BAL cx\n NGTD. It is possible that previous fevers had been masked by CVVH,\n which pt did not undergo yesterday\n - Cte broad spectrum antibiotic coverage with linezolid and aztreonam\n (D1 ) and cipro (D1 )->consider d/c cipro today\n - Consider adding back flagyl for anaerobic coverage.\n - D/C CVL today if he has enough access\n - HIDA scan if bilirubin does not improve or hemodynamic instability\n over next few days\n - F/u WBC count, temp curve, and culture data\n - F/u ID recs\n - Cont steroid taper for possible adrenal insufficiency\n # Hyperbilirubinemia: Patient has had continuously increasing T Bili\n and alkaline phosphatase. Has alcoholic hepatitis but also on TPN. Bili\n stable today but increased alk phos and RUQ u/s with sludge concerning\n for cholestasis.\n - Check HIDA scan if bilirubin does not improve or hemodynamically\n unstable\n - TPN stopped yesterday\n - Weaning off benzos\n #. Respiratory Failure: ARDS secondary to necrotizing pancreatitis. S/p\n trach placement on . Sutures out on . ABG good on PS but\n transition to trach mask limited by respiratory rate.\n - Cont to wean vent with trach mask trial as tolerated\n - Increasing fentanyl patch while decreasing gtt, continue methadone\n - Attempt OOB to chair today to improve respiratory mechanics\n # Seizures: CT head without intracranial process. EEG showed occipital\n seizures which does not correlate with clinical symptoms. actually\n be patient waking up, not seizures.\n - Repeat EEG today on higher dose keppra\n - F/u neuro recs\n - Wean off midazolam as tolerated with low dose valium to prevent\n withdrawal; monitor vitals\n #. Acute renal Failure: Appreciate renal recs.\n - Currently euvolemic so would favor running him even today. Would\n dialyze for acidosis but likely does not need volume depletion today.\n - Plan for tunneled dialysis catheter today to transition to HD\n tomorrow; f/u Renal recs\n #. Adrenal Insufficiency: Unclear with stim if clear adrenal\n insufficiency but hypotension improving with steroids (lower pressor\n requirement) and improving eosinophilia\n - Cont hydrocortisone 50mg Q8H D ->consider wean down to 25mg\n \n # ?HLH: Elevated ferritin. Awaiting quantitated ferritin to r/o HLH.\n ICU Care\n Nutrition:\n Nutren 2.0 () - 02:00 PM 50 mL/hour. Will likely be d/c\n with doboff given severe pancreatitis/hepatitis and PEG higher risk.\n Glycemic Control: ISS\n Lines:\n Arterial Line - 08:15 PM\n Multi Lumen - 10:00 PM\n Dialysis Catheter - 11:35 PM\n Prophylaxis:\n DVT: SQ heparin\n Stress ulcer: H2B\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n" }, { "category": "Physician ", "chartdate": "2131-05-25 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 676899, "text": "Chief Complaint: Acute pancreatitis\n 24 Hour Events:\n - Changed hypertonic saline to continous 3%\n - Neuro/nsurg wanted repeat ct head\n - Decreased peep/fio2\n - HD line placed and CVVH started\n - EEG underway\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 12:00 PM\n Metronidazole - 02:36 AM\n Meropenem - 05:47 AM\n Infusions:\n Fentanyl (Concentrate) - 400 mcg/hour\n Midazolam (Versed) - 30 mg/hour\n Phenylephrine - 5 mcg/Kg/min\n Other ICU medications:\n Pantoprazole (Protonix) - 08:21 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 06:55 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.6\nC (99.6\n Tcurrent: 37.1\nC (98.7\n HR: 94 (93 - 106) bpm\n BP: 107/56(73) {82/43(56) - 130/69(90)} mmHg\n RR: 30 (0 - 31) insp/min\n SpO2: 98%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 156 kg (admission): 113.5 kg\n Height: 67 Inch\n CVP: 16 (15 - 25)mmHg\n Total In:\n 14,293 mL\n 2,159 mL\n PO:\n TF:\n IVF:\n 13,230 mL\n 1,835 mL\n Blood products:\n Total out:\n 1,413 mL\n 1,881 mL\n Urine:\n 164 mL\n 30 mL\n NG:\n 200 mL\n Stool:\n Drains:\n Balance:\n 12,880 mL\n 278 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 30\n RR (Spontaneous): 0\n PEEP: 20 cmH2O\n FiO2: 40%\n RSBI Deferred: PEEP > 10\n PIP: 42 cmH2O\n Plateau: 33 cmH2O\n Compliance: 30.8 cmH2O/mL\n SpO2: 98%\n ABG: 7.28/48/89./18/-4\n Ve: 11.8 L/min\n PaO2 / FiO2: 223\n Physical Examination\n Gen: Sedated\n HEENT: ETT in place.. Scleral edema. Pupils 7mm and minimally reactive\n worsened from yesterday.\n Chest: coarse BS bl, rhonchorous throughout\n CV: distant heart sounds, RRR, S1S2\n Abd: distended although improved from yesterday. -BS\n Ext: Anasarca\n Neuro: Sedated. Pupils 6 mm, reactive.\n Labs / Radiology\n 70 K/uL\n 10.3 g/dL\n 175 mg/dL\n 3.9 mg/dL\n 18 mEq/L\n 3.9 mEq/L\n 30 mg/dL\n 106 mEq/L\n 135 mEq/L\n 30.7 %\n 44.1 K/uL\n 06:30 PM\n 01:22 AM\n 01:32 AM\n 09:55 AM\n 04:11 PM\n 09:39 PM\n 10:00 PM\n 02:26 AM\n 04:29 AM\n 04:48 AM\n WBC\n 38.9\n 44.1\n Hct\n 31.0\n 30.4\n 30.7\n Plt\n 99\n 70\n Cr\n 3.8\n 4.0\n 3.9\n TCO2\n 21\n 17\n 17\n 21\n 20\n 24\n Glucose\n 105\n 142\n 131\n 173\n 175\n Other labs: PT / PTT / INR:18.7/58.3/1.7, ALT / AST:37/219, Alk Phos /\n T Bili:218/20.6, Amylase / Lipase:16/37, Differential-Neuts:75.0 %,\n Band:0.0 %, Lymph:4.0 %, Mono:12.0 %, Eos:6.0 %, D-dimer: ng/mL,\n Fibrinogen:402 mg/dL, Lactic Acid:1.7 mmol/L, Albumin:2.1 g/dL, LDH:624\n IU/L, Ca++:8.1 mg/dL, Mg++:2.4 mg/dL, PO4:3.2 mg/dL\n Assessment and Plan\n Mr. is a 28 year old gentleman with alcoholic hepatitis and\n necrotizing pancreatitis complicated by ARDS, SIRS, and UGIB.\n # Neuro: Patient with dilated pupils on high dose fentaynl gtt. CTH\n demonstrated loss of grey white differentiation with questionable\n effacement and possible seizure activity. Neuro and neurosurg consulted\n and patietn received ativan, keppra load, and hypertonic saline of\n hyponatremia. Patient converted to 3% IVF infusion.\n - Per neuro, keppra IV maintenance dose\n - Convert back to 23% hypertonic saline boluses Q3H with regular serum\n sodium checks.\n - EEG to be completed today\n - Per neurosurg, repeat CTH today if stable\n - Follow-up with neurosurg and neuro recs if any.\n - Consider mannitol if serum sodium does not improve.\n - Wean sedation (starting with fentanyl) as possible.\n # Respiratory Failure: ARDS secondary to necrotizing pancreatitis\n compounded by hypoxia, tachypnea in setting of anion gap metabolic\n acidosis, increased abdominal pressure, and EtOH withdrawl. PEEP\n decreased to 20 and FiO2 to 40%.\n - Wean FiO2 and PEEP, goal PaO2>60-65%\n # Leukocytosis: WBC up to 44.9 today. Concern for CVL infection, VAP,\n loculated effusion, sinusitis, or pancreatitis complication including\n abscess formation. CT chest with multifocal infiltrates that could\n represent VAP vs ARDS. CTAP did not demonstrate any new pancreatic\n fluid collections. On last differential, past had a predominantly left\n shift, although also with 6% eos suggesting possible drug reaction\n (?meropenem).\n - Continue empiric vancomycin, meropenem, and flagyl. AM vanco level\n today\n - Recheck differential, if elevated would consider drug reaction as\n potential etiology to leukocytosis and likely switch meropenem.\n - Follow-up culture data\n - Afrin and nasal saline spray\n - ID consult\n # Necrotizing pancreatitis/SIRS: Secondary to alcohol complicated by\n SIRS and ARDS. Patient continues to have pressor requirement, with neo\n +/- levo. Aggressive volume resuscitation with >58L. Patient\n without improvement with albumin trial, likely secondary to SIRS and\n increased vascular permeability.\n - Continue empiric antimicrobials.\n - Wean pressors as able, starting with levophed\n - Hypertonic saline as above in order to increase intravascular volume.\n - Monitor chemistries.\n - Follow-up with recs if any\n # Hyponatremia: In setting of decreased effective circulating volume in\n setting of SIRS and IABP. Patient received hypertonic saline overnight\n per neurosurgery. Serum sodium stable this morning.\n - Hypertonic saline as above.\n - Trend chemistries.\n - Follow-up with neurosurgery recs if any.\n # Acute renal failure: Patient had HD line placed and CVVH was\n initiated yesterday.\n - CVVH per renal.\n - Trend chemistries\n #Thrombocytopenia: Platelets stable. No clear etiology at this time.\n DIC panel and HIT PF4 antibody negative.\n - Trend plt, transfuse for plt<10 or <50 if signs of hemorrhage.\n # IAP elevation: Secondary to third spacing and edema. Per surgery, not\n a good surgical candidate at this time.\n # Acute hepatitis: Likely alcoholic hepatitis with fatty infiltration,\n and no evidence of distal obstruction. RUQ u/s shows marked liver\n echogenicity but no ascites.\n - Trend LFTs\n # Hematemesis: EGD showed diuelafoy's lesion. HCT stable since 2 units\n PRBC on .\n - Trend hct, transfuse for hct<21\n # Alcoholism: Patient describes history of withdrawal symptoms, but\n not prior seizure. Last drink was night prior to presentation.\n Tachycardia, weakness, and elevated lactate could be consistent with\n thiamine deficiency.\n - Thiamine, vb12, folate\n - Valium with CIWA > 10\n FEN: TPN, replete as necessary.\n PPx: Heparin and H2B in TPN\n Access: RIJ (quad), LIJ (HD), right radial a-line\n Dispo: ICU level of care\n ICU Care\n Nutrition:\n TPN without Lipids - 04:08 PM 47 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 01:35 PM\n Multi Lumen - 02:02 PM\n Dialysis Catheter - 04:56 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": "2131-05-27 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 677260, "text": "TITLE:\n 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 24 Hour Events:\n - cont hypertonic saline tx cont\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Meropenem - 02:04 AM\n Metronidazole - 02:30 AM\n Vancomycin - 08:00 AM\n Infusions:\n Norepinephrine - 0.03 mcg/Kg/min\n Phenylephrine - 1.7 mcg/Kg/min\n Fentanyl (Concentrate) - 250 mcg/hour\n KCl (CRRT) - 4 mEq./hour\n Midazolam (Versed) - 25 mg/hour\n Calcium Gluconate (CRRT) - 2 grams/hour\n Other ICU medications:\n Pantoprazole (Protonix) - 08:10 PM\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 09:23 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: 35.9\nC (96.6\n HR: 95 (90 - 100) bpm\n BP: 97/52(66) {92/50(64) - 113/71(85)} mmHg\n RR: 30 (28 - 33) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 140 kg (admission): 113.5 kg\n Height: 67 Inch\n CVP: 18 (17 - 21)mmHg\n Total In:\n 12,114 mL\n 4,497 mL\n PO:\n TF:\n IVF:\n 10,318 mL\n 3,944 mL\n Blood products:\n Total out:\n 18,126 mL\n 7,377 mL\n Urine:\n 238 mL\n 73 mL\n NG:\n 400 mL\n 150 mL\n Stool:\n Drains:\n Balance:\n -6,012 mL\n -2,880 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 30\n RR (Spontaneous): 0\n PEEP: 16 cmH2O\n FiO2: 40%\n RSBI Deferred: PEEP > 10\n PIP: 32 cmH2O\n Plateau: 28 cmH2O\n Compliance: 38.8 cmH2O/mL\n SpO2: 97%\n ABG: 7.37/47/81./23/0\n Ve: 12.1 L/min\n PaO2 / FiO2: 205\n Physical Examination\n General Appearance: Well nourished, total body fluid overload\n Eyes / Conjunctiva: PERRL, pupil 3mm b/l - smaller than prev\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Clear : anteriorly)\n Abdominal: Soft, No(t) Bowel sounds present, Distended\n Extremities: Right: 4+, Left: 4+, No(t) Cyanosis\n Skin: Not assessed\n Neurologic: No(t) Attentive, No(t) Follows simple commands, Responds\n to: Not assessed, No(t) Oriented (to): , Movement: Not assessed,\n Sedated, Tone: Not assessed\n Labs / Radiology\n 10.0 g/dL\n 67 K/uL\n 175 mg/dL\n 2.4 mg/dL\n 23 mEq/L\n 3.7 mEq/L\n 22 mg/dL\n 107 mEq/L\n 143 mEq/L\n 29.2 %\n 45.9 K/uL\n [image002.jpg]\n 02:08 AM\n 02:28 AM\n 10:00 AM\n 10:17 AM\n 04:06 PM\n 04:23 PM\n 09:57 PM\n 10:11 PM\n 04:39 AM\n 04:49 AM\n WBC\n 35.1\n 45.9\n Hct\n 29.9\n 29.2\n Plt\n 85\n 67\n Cr\n 2.9\n 2.9\n 2.8\n 2.6\n 2.4\n TCO2\n 25\n 26\n 25\n 28\n 28\n Glucose\n 182\n 170\n 187\n 174\n 192\n 174\n 188\n 176\n 187\n 175\n Other labs: PT / PTT / INR:19.5/53.6/1.8, ALT / AST:20/210, Alk Phos /\n T Bili:236/20.6, Amylase / Lipase:16/34, Differential-Neuts:71.0 %,\n Band:8.0 %, Lymph:6.0 %, Mono:4.0 %, Eos:2.0 %, D-dimer: ng/mL,\n Fibrinogen:402 mg/dL, Lactic Acid:1.8 mmol/L, Albumin:1.7 g/dL, LDH:742\n IU/L, Ca++:9.1 mg/dL, Mg++:1.7 mg/dL, PO4:2.6 mg/dL\n Assessment and Plan\n 28M h/o EtOH abuse, weakness, fatigue, UGIB c/b hematemesis / melena.\n Has developed massive fluid requirement, hypotension, ARDS in the\n setting of severe pancreatitis, alcoholic hepatitis and borderline\n renal function. Head CT with edema, on 23% NS for induced osmorx.\nCEREBRAL EDEMA\n - hypertonic (23%) saline q6h with frequent monitoring of Sosm and\n sodium for cerebral edema. Managing in setting of CVVH - renal aware\n and managing with knowledge of hypertonic saline tx\n -Pupils now more appropriately constricted given narcotics on board --\n suggestive of improvement in IC pressure.\n -Repeat imaging would be optimal but not yet realistic given pt\n acuity and accompanying risks of transferring for imaging\n -On keppra prophylactically\n -EEG initial read s evidence of sz activity- final read pending.\nARDS\n - low volume ventilation (400x30)\n - will continue to wean PEEP as tolerated. 20->16.\n - starting sedation wean though long road given large volume of\n distribution.\nSHOCK\n -cont require two pressors - some progress weaning\n -able to take 7 liters off\n -Continuing broad spectrum abx pend cx data for guidance.\n -Afebrile last 48hrs\n -CVVHD\n -Progress removing fluid - 7Liters off in last 24hr\n -weaning PEEP, FiO2 as tol\n -follow espophageal pressures as needed.\nPANCREATITIS\n -presumed due to EtOH\n -c/b ARDS\n -NPO\n - following\n -continue TPN with heparin\nEtOH HEPATITIS\nUGIB\n -Dieulafois lesion at GEJ\n -monitor serial HCT\n IMPAIRED SKIN INTEGRITY\n -cont large amount of oozing form skin breakdown in lower extremities\n Remainder of plan as outlined in resident note.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Arterial Line - 01:35 PM\n Multi Lumen - 02:02 PM\n Dialysis Catheter - 04:56 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: 55 minutes\n Patient is critically ill\n" }, { "category": "Nursing", "chartdate": "2131-05-29 00:00:00.000", "description": "Nursing Progress Note", "row_id": 677536, "text": "TITLE:\n Problem\n Cerebral edema\n Assessment:\n Pupils 2mm sluggish react no corneals.\n No gag, cough x 1 with suctioning.\n No spontaneous movement of extremeties, does not withdraw to painful\n stimuli. Tachypnea with suctioning.\n Action:\n Serum Osm and Na+ q6h. Hypertonic saline q6h overnight.\n Response:\n Serum osm 312 Na+ 148\n Plan:\n Continue q6h serum Na+ and Osm. . Continue hypertonic saline as\n ordered.\n Hypotension (not Shock)\n Assessment:\n Levophed at 0.04mcg/kg/min goal mbp > 60.Mbp down 50 while crrt system\n down\n Action:\n Titrated levophed to 0.08mcg/kg/min for goal mbp 60. Once crrt\n restarted pfr decreased to run even and accommodate bp until bp less\n labile.\n Response:\n Mbp improved with levophed increase and pfr decrease.\n Plan:\n Wean levo as tolerated for goal mean bp > 60. Increase crrt fluid\n removal as bp tolerates.\n Pancreatitis, acute\n Assessment:\n Tbili trending down. Remains jaundiced grossly edematous with multiple\n weeping sites ble and abdomen. Back and buttocks no breakdown\n noted.Total body balance remains > 54liters + since adm. 24hr fld\n balance 3.5liter negative.Tpn continues , ogt to lws with bilious,\n small amts of guiac + stool smearing, no active bowel sounds. Urine\n output remains negligible, crrt continues with goal fld removal\n -100-300/hr\n Action:\n Crrt labs q6h overnight. System down x1 for air in system(off x 2hrs).\n Crrt reinitiated @ 0345 . 30 mins after reinitiating bp and O2 sat\n drop, preoxygenated,lavage and suct for small amt of thick white\n secretions,O2sats remained low,pt light/ tachypneic -> midaz gtt\n increased back to 12mg and diazepam 10mg given for sedation. Fentanyl @\n 50mcg. Dr paged-> pcxr done . bbs clear w rhonchi lt base.\n Meticulous skin care with frequent pad changes under weepy sites ble\n and flank. Double guard cream to back and buttocks. Rt heel dk\n purple/red area, does not blanch-> elevated on 2pillows w bilat heels\n off the bed.\n Response:\n O2 sat improved with resedation, increase in fio2 and improved\n bp..Noticeable improvement in edema and decrease in weeping of bilat\n LE.\n Plan:\n Cont tpn. Cont q6h labs, Cont crrt & reattempt goal pfr -100 to\n -300cc/hr. Wound and skin consult for bilat lower extrems management. ?\n dermatology or plastics consult for further recs.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Fio2 @ 50% cmv 400x12 rr 30. Bbs clear w rhonchi lt base. Desats this\n am with pt breathing over ventilator\n Action:\n As above, additional sedation(diazepam) and midazolam increased to\n 12mg. fio2 increased to 60%. Pcxr done per Dr \n Response:\n Gradual recovery of O2 sat with multiple interventions. O2 sat now 97%\n Plan:\n Check pcxr results. Repeat abg and wean fio2 if O2 sats remain stable.\n Hold on weaning any sedation for now.Continue crrt with goal negative\n fld balance as tolerates.\n" }, { "category": "Physician ", "chartdate": "2131-06-18 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 681514, "text": "Chief Complaint:\n 24 Hour Events:\n - All Abx stopped yesterday.\n - HD not started due to fluid contamination of HD machines.\n - Fentanyl and midazolam decreased with slight increase in HR to 110s.\n Increased valium to 10mg TID\n - Tolerated trach mask throughout day\n Allergies:\n Meropenem\n skin blisters a\n Last dose of Antibiotics:\n Ciprofloxacin - 12:34 PM\n Linezolid - 10:09 PM\n Aztreonam - 07:45 AM\n Metronidazole - 08:30 AM\n Infusions:\n Fentanyl (Concentrate) - 25 mcg/hour\n KCl (CRRT) - 3 mEq./hour\n Calcium Gluconate (CRRT) - 2.4 grams/hour\n Other ICU medications:\n Famotidine (Pepcid) - 12:06 AM\n Heparin Sodium (Prophylaxis) - 04:02 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:23 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.3\nC (99.2\n Tcurrent: 36.2\nC (97.1\n HR: 101 (94 - 113) bpm\n BP: 113/59(78) {87/48(64) - 129/70(90)} mmHg\n RR: 23 (19 - 33) insp/min\n SpO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 99.7 kg (admission): 113.5 kg\n Height: 67 Inch\n Total In:\n 9,973 mL\n 2,424 mL\n PO:\n TF:\n 1,200 mL\n 319 mL\n IVF:\n 8,753 mL\n 2,085 mL\n Blood products:\n Total out:\n 11,007 mL\n 2,337 mL\n Urine:\n 77 mL\n 20 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,034 mL\n 87 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n Ventilator mode: Standby\n Vt (Spontaneous): 567 (567 - 567) mL\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 0 cmH2O\n SpO2: 100%\n ABG: 7.45/37/105/24/1\n PaO2 / FiO2: 210\n Physical Examination\n GEN: Trached, sedated.\n HEENT: Icteric sclera. MMM.\n NECK: Trach site with no oozing.\n LUNGS: Anterior auscultation with upper airway noise; good airway\n movement.\n HEART: RRR, normal S1, S2.\n ABD: Distended. Grimacing with palpation.\n EXTREM: 2+ edema, ulcers/lesions on legs with bandages C/D/I.\n SKIN: Jaundiced.\n NEURO: Opening eyes to command. Purposeful movements of arms.\n Labs / Radiology\n 321 K/uL\n 8.0 g/dL\n 165 mg/dL\n 0.6 mg/dL\n 24 mEq/L\n 4.0 mEq/L\n 33 mg/dL\n 99 mEq/L\n 134 mEq/L\n 24.8 %\n 30.5 K/uL\n [image002.jpg]\n 06:23 PM\n 10:13 PM\n 04:13 AM\n 04:24 AM\n 11:20 AM\n 04:55 PM\n 10:00 PM\n 10:30 PM\n 03:49 AM\n 03:56 AM\n WBC\n 24.9\n 30.5\n Hct\n 23.9\n 24.8\n Plt\n 255\n 321\n Cr\n 0.8\n 1.2\n 0.6\n TCO2\n 19\n 19\n 18\n 19\n 24\n 26\n 27\n Glucose\n 172\n 199\n 167\n 110\n 186\n 185\n 160\n 165\n Other labs: PT / PTT / INR:15.6/33.4/1.4, ALT / AST:211/223, Alk Phos /\n T Bili:588/27.9, LDH:517 IU/L, Ca++:8.3 mg/dL, Mg++:1.8 mg/dL, PO4:1.3\n mg/dL\n ucx: Pending. sputum cx: Pending. , , bcx:\n Pending.\n Assessment and Plan\n 28M with alcoholic hepatitis and necrotizing pancreatitis complicated\n by ARDS, SIRS, ARF, UGIB, fevers.\n #. ID: Necrotizing pancreatitis. All abx (linezolid/aztreo D1 and\n flagyl D1 ) discontinued yesterday as afebrile since restarting\n CVVH and appeared clinically improved. Remains afebrile but worsened\n leukocytosis today. RUQ u/s concerning for sludge since .\n - Restart abx coverage with aztreo and linezolid given necrotizing\n pancreatitis.\n - HIDA scan today for poss cholecystitis; if hemodynamic instability\n over next few days may need percutaneous drain\n - F/u WBC count, temp curve, and culture data\n - Cont steroid taper for possible adrenal insufficiency\n - Yeast in the urine- changed foley and re-cultured. If still with\n yeast will treat with anti-fungal.\n # Elevated LFTs: A/w alcoholic hepatitis but recent increase may be \n TPN, now discontinued. RUQ u/s showed sludge concerning for\n cholestasis but also seen on u/s. T Bili and transaminases\n stable today.\n - HIDA scan today\n - TPN stopped \n - Plan for Weaning off benzos\n #. Respiratory Failure: ARDS secondary to necrotizing pancreatitis. S/p\n trach placement on . Sutures out on . Currently on trach mask\n with good ABG.\n - Change gtt to PRN fentanyl boluses, continue methadone with wean\n tomorrow\n - goal to chair daily\n # Seizures: CT head without intracranial process. EEG showed occipital\n seizures which does not correlate with clinical symptoms, but repeat\n EEG on higher dose Keppra showed no seizures. As patient now with\n purposeful movements, this may actually be patient waking up, not\n seizures.\n - Continue keppra\n - Continue low dose valium to prevent withdrawal; Plan to wean valium\n in next few days.\n #. Acute renal Failure: Appreciate renal recs.\n - Touch base with renal about transition to HD\n - Would dialyze for acidosis but likely does not need volume depletion\n as pressures borderline.\n - Cont CVVH while pressures low but would favor HD trial today if\n available\n - Aztreonam 2000mg q12h while on CVVH\n - Will change Keppra to 1000mg Q24 with 500 mg after HD if he\n transitions to HD\n #. Adrenal Insufficiency: Unclear with stim if clear adrenal\n insufficiency but hypotension improving with steroids (lower pressor\n requirement) and improving eosinophilia\n - Cont weaning hydrocort; D2/3 of 25mg Q8H today.\n # PT and OT eval for placement\n ICU Care\n Nutrition:\n Nutren 2.0 () - 01:34 PM 50 mL/hour\n Glycemic Control: Glargine and RISS\n Lines:\n Arterial Line - 08:15 PM\n PICC Line - 08:37 AM\n Dialysis Catheter - 08:55 AM\n Prophylaxis:\n DVT: SQ Heparin\n Stress ulcer: H2 blocker\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU, screening for rehab\n" }, { "category": "Respiratory ", "chartdate": "2131-06-14 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 680712, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 28\n Ideal body weight: 67.1 None\n Ideal tidal volume: 268.4 / 402.6 / 536.8 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location:\n Reason:\n Tube Type\n Tracheostomy tube:\n Type: Standard\n Manufacturer: Portex\n Size: 8.0mm\n PMV: No\n Cuff Management:\n Vol/Press:\n Cuff pressure: 24 cmH2O\n Cuff volume: 8 mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Clear\n Comments:\n Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount: Suctioned / Small\n Comments: At second check, Pt became tachypneic and when suctioned,\n Bloody/bloody tinge secretions were suctioned. Secretions cleared up\n by last check\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated,\n Periodic SBT's for conditioning, Maintain PEEP at current level and\n reduce FiO2 as tolerated, Reduce PEEP as tolerated\n Reason for continuing current ventilatory support: Sedated / Paralyzed,\n Cannot protect airway, Cannot manage secretions, Underlying illness not\n resolved; Comments: Pt had a few episodes of tachypnea throughout\n shift. Pt suctioned and a few times, bloody secretions were suctioned,\n but secretions cleared by end of shift. Pt had rhonchi lung sounds\n which were alleviated with suctioning. SpO2/RR/Expiratory TV were\n within normal range all shift. Pt to continue current support and to\n be assessed by MD \nIDE RSBI- 46\n" }, { "category": "Physician ", "chartdate": "2131-06-05 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 678969, "text": "TITLE:\n Chief Complaint: Mr. is a 28 year old gentleman with alcoholic\n hepatitis and necrotizing pancreatitis complicated by ARDS, SIRS, ARF\n and UGIB.\n 24 Hour Events:\n BLOOD CULTURED - At 10:46 AM\n fungal bld culture\n FEVER - 102.4\nF - 08:00 AM\n Hospital day 19\n - ID: cont daptomycin, would not restart flagyl, recc sinus CT to r/o\n sinusitis, would change lines when able\n - heme/onc: eosinophilia may be secondary to infection vs stress\n response. still don't think he has DIC but want recheck of fibrinogen.\n re: restarting heparin, attg reccomends a lower dose in TPN to reduce\n bleeding risk (was getting 9000u); will let us know the dose later\n - thoracic surgery will place trach on \n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Metronidazole - 04:00 AM\n Daptomycin - 06:42 PM\n Infusions:\n Calcium Gluconate (CRRT) - 1.4 grams/hour\n Fentanyl (Concentrate) - 325 mcg/hour\n Midazolam (Versed) - 15 mg/hour\n Norepinephrine - 0.25 mcg/Kg/min\n KCl (CRRT) - 1 mEq./hour\n Other ICU medications:\n Pantoprazole (Protonix) - 08:16 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 07:40 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 39.1\nC (102.4\n Tcurrent: 35.7\nC (96.3\n HR: 96 (93 - 128) bpm\n BP: 113/64(83) {84/43(57) - 117/64(83)} mmHg\n RR: 20 (16 - 38) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 128 kg (admission): 113.5 kg\n Height: 67 Inch\n CVP: 15 (0 - 17)mmHg\n Total In:\n 10,084 mL\n 3,257 mL\n PO:\n TF:\n IVF:\n 8,252 mL\n 2,699 mL\n Blood products:\n Total out:\n 11,204 mL\n 5,005 mL\n Urine:\n 102 mL\n 100 mL\n NG:\n 250 mL\n 200 mL\n Stool:\n Drains:\n Balance:\n -1,120 mL\n -1,748 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 30\n RR (Spontaneous): 0\n PEEP: 12 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10\n PIP: 18 cmH2O\n Plateau: 22 cmH2O\n Compliance: 44.4 cmH2O/mL\n SpO2: 100%\n ABG: 7.30/48/84./21/-2\n Ve: 13 L/min\n PaO2 / FiO2: 168\n Physical Examination\n General Appearance: Overweight / Obese, No(t) Diaphoretic\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: Rhonchorous: )\n Abdominal: Soft\n Extremities: Right: 2+, Left: 2+\n Skin: Not assessed, Jaundice\n Neurologic: Responds to: Noxious stimuli, Movement: Non -purposeful,\n Tone: Not assessed\n Labs / Radiology\n 73 K/uL\n 8.1 g/dL\n 177 mg/dL\n 1.2 mg/dL\n 21 mEq/L\n 4.8 mEq/L\n 19 mg/dL\n 106 mEq/L\n 135 mEq/L\n 24.9 %\n 50.7 K/uL\n [image002.jpg]\n 07:42 PM\n 10:37 PM\n 02:03 AM\n 02:17 AM\n 11:05 AM\n 03:58 PM\n 09:00 PM\n 09:06 PM\n 02:35 AM\n 02:39 AM\n WBC\n 37.5\n 50.7\n Hct\n 23.9\n 24.4\n 24.9\n Plt\n 66\n 73\n Cr\n 1.6\n 1.4\n 1.2\n TCO2\n 25\n 27\n 24\n 22\n 23\n 25\n Glucose\n 128\n 125\n 106\n 119\n 144\n 177\n Other labs: PT / PTT / INR:17.4/40.1/1.6, CK / CKMB / Troponin-T:240//,\n ALT / AST:29/257, Alk Phos / T Bili:132/14.0, Amylase / Lipase:19/35,\n Differential-Neuts:38.0 %, Band:2.0 %, Lymph:14.0 %, Mono:5.0 %,\n Eos:26.0 %, D-dimer:6389 ng/mL, Fibrinogen:419 mg/dL, Lactic Acid:1.3\n mmol/L, Albumin:1.6 g/dL, LDH:607 IU/L, Ca++:8.7 mg/dL, Mg++:2.1 mg/dL,\n PO4:3.5 mg/dL\n Assessment and Plan\n Mr. is a 28 year old gentleman with alcoholic hepatitis and\n necrotizing pancreatitis complicated by ARDS, SIRS, ARF and UGIB.\n # Question sepsis/leukocytosis: Increasing hypotensive, tachycardic,\n and episodically febrile, with rising levophed requirement and rising\n white count. Multiple possible sources of new infection, including\n line infection, sinusitis, pancreatitis, and cellulitis. Hypotension\n also concerning for question PE but ruled out with negative CTA.\n Restarted daptomycin on to cover for MRSA and cellulitis and\n because of concern of drug reaction to vancomycin. Other antibiotic\n courses include Flagyl , ; Meropenem ;\n Vancomycin . Lines include RIJ (18 days) and left HD line (10\n days).\n - continue daptomycin\n - f/u culture data\n - ID recs\n - trend differential following eosinophilia closely\n - consider sinus CT and sinus drainage per ENT\n - Echo today for ? endocarditis\n - will speak with renal and ID about changing hemodialysis and other\n lines.\n - CT Torso with head and sinus for ? of infectious cause.\n # Respiratory Failure: ARDS secondary to necrotizing pancreatitis\n compounded by hypoxia, tachypnea in setting of anion gap metabolic\n acidosis, increased abdominal pressure, and EtOH withdrawal. PEEP\n decreased to 12 from 20 and FiO2 to 50%. Was tachypneic overnight on\n and sedation increased; CXR stable. IP recommending thoracic\n surgery for trach. Naloxone held yesterday given concern over\n systemic absorption resulting in tachypnea, although unlikely given\n that patient had episode of tachypnea prior to initiating naloxone.\n CTA neg for PE.\n - Wean FiO2 and PEEP, goal PaO2>60-65, SaO2>90%\n - Wean sedation as tolerated\n - tracheostomy later today with thoracic surgery\n # Anemia: Initially p/w hematemesis and EGD showed diuelafoy's lesion.\n Hct stable >24 hours s/p 4 units since . CTAP with new pancreatic\n pseudocyst but per d/w radiology no definitive explanation for hct\n drop. NG lavage negative. GI also doubts possibility of significant\n GI bleed, defer upper endoscopy for now. Appreciate hematology recs,\n do not feel that this is DIC.\n - CBC daily, transfuse for hct<21, plt<50\n - Follow-up heme and GI recs if any\n - Guaiac stools\n # Neuro: Initially dilated pupils with CT showing cerebral edema. Neuro\n exam now stable. Repeat CTH demonstrates interval improvement.\n - Continue leviteracetam\n - Wean sedation as possible\n - Neuro recs if any\n # Necrotizing pancreatitis/SIRS: Secondary to alcohol complicated by\n SIRS and ARDS. Patient continues to have pressor requirement, with neo\n +/- levo. Aggressive volume resuscitation with >50L but\n diuresing well. Also with new pseudocyst (3 cm x 3 cm) on abdominal CT\n on . Naloxone held yesterday given tachypnea. KUB unable to\n determine of OG is post-pyloric.\n - Wean pressors with goal MAP >65\n - Hold off on trophic feeds for now given uncertainty of OG placement.\n Will consider dobhoff placement in AM.\n # Hyponatremia: In setting of decreased effective circulating volume in\n setting of SIRS and IABP. Patient has received hypertonic saline\n boluses with improvement in serum sodium and osm.\n - Given improvement in neuro exam, continue to hold hypertonic saline.\n # Acute renal failure: Patient had HD line placed and on CVVH. CVVH\n with even TBB pending assessment of hemorrhage.\n - CVVH per renal.\n - Trend chemistries\n #Thrombocytopenia: Platelets stable but have trended down from a\n normal count on admission. No clear etiology at this time. DIC panel\n with elevated FDP but normal fibrinogen. HIT PF4 antibody negative.\n - Trend plt, transfuse for plt<10 or <50 if signs of hemorrhage.\n - consider resend HIT antibody.\n # Wound care: Per wound care recs.\n # Acute hepatitis: Likely alcoholic hepatitis with fatty infiltration,\n and no evidence of distal obstruction. RUQ u/s shows marked liver\n echogenicity but no ascites.\n - Trend LFTs\n # Alcoholism: Patient describes history of withdrawal symptoms, but\n not prior seizure. Last drink was night prior to presentation.\n Tachycardia, weakness, and elevated lactate could be consistent with\n thiamine deficiency.\n - Thiamine, vb12, folate\n - Valium with CIWA > 10\n FEN: TPN without heparin, replete as necessary.\n PPx: SCD, PPI\n Access: RIJ, LIJ, left radial arterial line\n Code: Full\n ICU Care\n Nutrition:\n TPN w/ Lipids - 05:50 PM 73 mL/hour\n Will try to get dobhoff tube per IR for enteral feeds.\n Glycemic Control:\n Lines:\n Multi Lumen - 02:02 PM\n Dialysis Catheter - 04:56 PM\n Arterial Line - 01:30 PM\n 20 Gauge - 03:56 PM\n Prophylaxis:\n DVT: , start heparin sub Q per Heme/onc recs.\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:ICU\n" }, { "category": "Physician ", "chartdate": "2131-06-08 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 679556, "text": "Chief Complaint:\n 24 Hour Events:\n - Hyperkalemia and ECG improved with CWH\n - OGT replaced with post-pyloric NGT\n - Methadone 5mg TID started\n - Carafate started and Pantoprazole d/c'd for ? PPI induced\n eosinophilia.\n - Leg biopsied by Derm.\n - Started micafungin per ID recs. Unable to reach HCP for HIV test\n consent.\n - This AM Hct of 20, transfusing 1 unit pRBC.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Micafungin - 08:00 PM\n Aztreonam - 09:00 PM\n Linezolid - 10:00 PM\n Metronidazole - 02:00 AM\n Vancomycin - 04:00 AM\n Infusions:\n Norepinephrine - 0.05 mcg/Kg/min\n Fentanyl (Concentrate) - 350 mcg/hour\n Midazolam (Versed) - 15 mg/hour\n KCl (CRRT) - 30 mEq./hour\n Calcium Gluconate (CRRT) - 1.4 grams/hour\n Other ICU medications:\n Carafate (Sucralfate) - 04:00 AM\n Heparin Sodium (Prophylaxis) - 04:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:49 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.9\nC (98.4\n Tcurrent: 36.8\nC (98.3\n HR: 96 (83 - 101) bpm\n BP: 98/52(65) {88/46(60) - 122/67(83)} mmHg\n RR: 30 (8 - 30) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 134 kg (admission): 113.5 kg\n Height: 67 Inch\n CVP: 12 (12 - 291)mmHg\n Total In:\n 9,121 mL\n 2,718 mL\n PO:\n TF:\n IVF:\n 7,364 mL\n 2,290 mL\n Blood products:\n 6 mL\n Total out:\n 11,625 mL\n 3,415 mL\n Urine:\n 122 mL\n 24 mL\n NG:\n 500 mL\n Stool:\n Drains:\n Balance:\n -2,504 mL\n -697 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 30\n RR (Spontaneous): 0\n PEEP: 10 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10\n PIP: 30 cmH2O\n Plateau: 24 cmH2O\n Compliance: 28.6 cmH2O/mL\n SpO2: 100%\n ABG: 7.35/51/86/24/0\n Ve: 11.9 L/min\n PaO2 / FiO2: 172\n Physical Examination\n GEN: Intubated, sedated\n HEENT: icteric sclera. MMM\n NECK: Sites clean/dry/no oozing\n LUNGS: Crackles bilaterally anteriorly.\n HEART: RRR\n ABD: Distended. NT.\n EXTREM: 2+ edema with weeping wounds without surrounding erythema,\n ulcers/lesions on legs with bandages C/D/I\n SKIN: Jaundice\n Labs / Radiology\n 58 K/uL\n 6.8 g/dL\n 231 mg/dL\n 1.5 mg/dL\n 24 mEq/L\n 3.8 mEq/L\n 36 mg/dL\n 96 mEq/L\n 131 mEq/L\n 20.7 %\n 56.6 K/uL\n [image002.jpg]\n 06:11 AM\n 09:52 AM\n 10:05 AM\n 03:52 PM\n 03:58 PM\n 09:57 PM\n 12:02 AM\n 03:36 AM\n 03:53 AM\n 04:48 AM\n WBC\n 48.4\n 56.6\n Hct\n 20.4\n 20.7\n Plt\n 45\n 58\n Cr\n 1.5\n TCO2\n 23\n 23\n 27\n 29\n 26\n 29\n Glucose\n 255\n 249\n 290\n \n 231\n Other labs: PT / PTT / INR:19.1/46.0/1.8, CK / CKMB /\n Troponin-T:214/3/0.07, ALT / AST:42/182, Alk Phos / T Bili:129/23.3,\n Amylase / Lipase:19/35, Differential-Neuts:58.0 %, Band:4.0 %,\n Lymph:4.0 %, Mono:11.0 %, Eos:9.0 %, D-dimer:6389 ng/mL, Fibrinogen:419\n mg/dL, Lactic Acid:2.0 mmol/L, Albumin:1.7 g/dL, LDH:821 IU/L, Ca++:7.9\n mg/dL, Mg++:1.7 mg/dL, PO4:4.1 mg/dL\n Micro: tissue gram stain w/o PML or microorg; cx pending.\n Assessment and Plan\n 28yo M with alcoholic hepatitis and necrotizing pancreatitis\n complicated by ARDS, SIRS, ARF, UGIB, fevers and eosinophilia.\n #. Fever: Afebrile x 35 h but source unclear. GPCs growing in\n peripheral blood are coag negative staph. Question of fever adrenal\n insufficiency; now on steroids.\n - CT abd with no change but continued colonic thickening consistent\n with infection.\n - F/u derm biopsy results to see if skin infection already on broad\n spectrum antibiotic coverage inc. skin flora coverage\n - Cte broad spectrum antibiotic coverage with aztreonam for extended GN\n coverage, linezolid for MRSA and VRE for bacteremia, flagyl IV, vanc\n PO/PR empirically per ID recs given increasing leukocytosis and colon\n inflammation on CT, micafungin for antifungal coverage\n - F/u cultures\n - Consider TEE to r/o vegetations as TTE was not a definitive study\n - Consent HIV\n - F/u ID recs; appreciate input\n #. Respiratory Failure: ARDS secondary to necrotizing pancreatitis.\n - Oxygenating well on 10 of PEEP. Goal is to wean down peep so can get\n trach placement as has been intubated many days.\n #. Adrenal Insufficiency: Unclear with stim if clear adrenal\n insufficiency but hypotension improving with steroids (lower pressor\n requirement) and improving eosinophilia\n - Will continue steroids IV X 5 days (day 3) then change to prednisone\n to taper\n #. Anemia: Hct lower this am. No clear source of bleeding except from\n NGT where had old blood suctioned up last pm. ?small bleed from Doboff\n placement.\n - recheck hemolysis labs\n - trend hcts Q6H, 1unit pRBCs now, guaiac stools and NGT aspirate\n - If not appropriate bump with blood consider scope to ensure doboff\n did not cause significant bleed\n - holding ppx with PPI or sucralfate given issues of eosinophilia and\n ARF\n #. Eosinophilia: Likely drug reaction (to vanc, ppi or dapto?) with\n parasitic or fungal infection also possible etiologies.\n - stim positive for adrenal insufficiency. Cte steroids.\n - Cte fungal coverage as above\n - Stopped PPI as can cause eosinophilia; will reassess tmrw\n #. Thrombocytopenia: Appreciate heme recs. Do not feel this is DIC.\n Recent decrease may be in setting of linezolid.\n - Monitor platelets daily and transfuse for plt <10 or <50 if signs of\n bleed\n - Would linezolid when/if able\n #. Acute renal Failure: Appreciate renal recs. Will continue CVVH. Stop\n sucralfate due to risk of electrolyte abnormalities.\n #. Wounds: Derm biopsy pending but likely edema caused wounds\n #. Agitation: Added methadone to given decreased sensitivity to\n fentanyl; titrate prn\n ICU Care\n Nutrition:\n F/U nutrition recs re:TFs this am\n Glycemic Control: ISS\n Lines:\n Arterial Line - 08:15 PM\n Multi Lumen - 10:00 PM\n Dialysis Catheter - 11:35 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: Holding PPI and sucralfate for now\n VAP: HOB elevation, Mouth care\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:ICU\n" }, { "category": "Physician ", "chartdate": "2131-06-08 00:00:00.000", "description": "Physician Resident/Attending Progress Note - MICU", "row_id": 679640, "text": "Chief Complaint:\n 24 Hour Events:\n - Hyperkalemia and ECG improved with CWH\n - OGT replaced with post-pyloric NGT\n - Methadone 5mg TID started\n - Carafate started and Pantoprazole d/c'd for ? PPI induced\n eosinophilia.\n - Leg biopsied by Derm.\n - Started micafungin per ID recs. Unable to reach HCP for HIV test\n consent.\n - This AM Hct of 20, transfusing 1 unit pRBC.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Micafungin - 08:00 PM\n Aztreonam - 09:00 PM\n Linezolid - 10:00 PM\n Metronidazole - 02:00 AM\n Vancomycin - 04:00 AM\n Infusions:\n Norepinephrine - 0.05 mcg/Kg/min\n Fentanyl (Concentrate) - 350 mcg/hour\n Midazolam (Versed) - 15 mg/hour\n KCl (CRRT) - 30 mEq./hour\n Calcium Gluconate (CRRT) - 1.4 grams/hour\n Other ICU medications:\n Carafate (Sucralfate) - 04:00 AM\n Heparin Sodium (Prophylaxis) - 04:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:49 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.9\nC (98.4\n Tcurrent: 36.8\nC (98.3\n HR: 96 (83 - 101) bpm\n BP: 98/52(65) {88/46(60) - 122/67(83)} mmHg\n RR: 30 (8 - 30) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 134 kg (admission): 113.5 kg\n Height: 67 Inch\n CVP: 12 (12 - 291)mmHg\n Total In:\n 9,121 mL\n 2,718 mL\n PO:\n TF:\n IVF:\n 7,364 mL\n 2,290 mL\n Blood products:\n 6 mL\n Total out:\n 11,625 mL\n 3,415 mL\n Urine:\n 122 mL\n 24 mL\n NG:\n 500 mL\n Stool:\n Drains:\n Balance:\n -2,504 mL\n -697 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 30\n RR (Spontaneous): 0\n PEEP: 10 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10\n PIP: 30 cmH2O\n Plateau: 24 cmH2O\n Compliance: 28.6 cmH2O/mL\n SpO2: 100%\n ABG: 7.35/51/86/24/0\n Ve: 11.9 L/min\n PaO2 / FiO2: 172\n Physical Examination\n GEN: Intubated, sedated\n HEENT: icteric sclera. MMM\n NECK: Sites clean/dry/no oozing\n LUNGS: Crackles bilaterally anteriorly.\n HEART: RRR\n ABD: Distended. NT.\n EXTREM: 2+ edema with weeping wounds without surrounding erythema,\n ulcers/lesions on legs with bandages C/D/I\n SKIN: Jaundice\n Labs / Radiology\n 58 K/uL\n 6.8 g/dL\n 231 mg/dL\n 1.5 mg/dL\n 24 mEq/L\n 3.8 mEq/L\n 36 mg/dL\n 96 mEq/L\n 131 mEq/L\n 20.7 %\n 56.6 K/uL\n [image002.jpg]\n 06:11 AM\n 09:52 AM\n 10:05 AM\n 03:52 PM\n 03:58 PM\n 09:57 PM\n 12:02 AM\n 03:36 AM\n 03:53 AM\n 04:48 AM\n WBC\n 48.4\n 56.6\n Hct\n 20.4\n 20.7\n Plt\n 45\n 58\n Cr\n 1.5\n TCO2\n 23\n 23\n 27\n 29\n 26\n 29\n Glucose\n 255\n 249\n 290\n \n 231\n Other labs: PT / PTT / INR:19.1/46.0/1.8, CK / CKMB /\n Troponin-T:214/3/0.07, ALT / AST:42/182, Alk Phos / T Bili:129/23.3,\n Amylase / Lipase:19/35, Differential-Neuts:58.0 %, Band:4.0 %,\n Lymph:4.0 %, Mono:11.0 %, Eos:9.0 %, D-dimer:6389 ng/mL, Fibrinogen:419\n mg/dL, Lactic Acid:2.0 mmol/L, Albumin:1.7 g/dL, LDH:821 IU/L, Ca++:7.9\n mg/dL, Mg++:1.7 mg/dL, PO4:4.1 mg/dL\n Micro: tissue gram stain w/o PML or microorg; cx pending.\n Assessment and Plan\n 28yo M with alcoholic hepatitis and necrotizing pancreatitis\n complicated by ARDS, SIRS, ARF, UGIB, fevers and eosinophilia.\n #. Fever: Afebrile x 35 h but source unclear. GPCs growing in\n peripheral blood are coag negative staph. Question of fever adrenal\n insufficiency; now on steroids.\n - CT abd with no change but continued colonic thickening consistent\n with infection.\n - F/u derm biopsy results to see if skin infection already on broad\n spectrum antibiotic coverage inc. skin flora coverage\n - Cte broad spectrum antibiotic coverage with aztreonam for extended GN\n coverage, linezolid for MRSA and VRE for bacteremia, flagyl IV, vanc\n PO/PR empirically per ID recs given increasing leukocytosis and colon\n inflammation on CT, micafungin for antifungal coverage\n - F/u cultures\n - Consider TEE to r/o vegetations as TTE was not a definitive study\n - Consent HIV\n - F/u ID recs; appreciate input\n #. Respiratory Failure: ARDS secondary to necrotizing pancreatitis.\n - Oxygenating well on 10 of PEEP. Goal is to wean down peep so can get\n trach placement as has been intubated many days.\n #. Adrenal Insufficiency: Unclear with stim if clear adrenal\n insufficiency but hypotension improving with steroids (lower pressor\n requirement) and improving eosinophilia\n - Will continue steroids IV X 5 days (day 3) then change to prednisone\n to taper\n #. Anemia: Hct lower this am. No clear source of bleeding except from\n NGT where had old blood suctioned up last pm. ?small bleed from Doboff\n placement.\n - recheck hemolysis labs\n - trend hcts Q6H, 1unit pRBCs now, guaiac stools and NGT aspirate\n - If not appropriate bump with blood consider scope to ensure doboff\n did not cause significant bleed\n - holding ppx with PPI or sucralfate given issues of eosinophilia and\n ARF\n #. Eosinophilia: Likely drug reaction (to vanc, ppi or dapto?) with\n parasitic or fungal infection also possible etiologies.\n - stim positive for adrenal insufficiency. Cte steroids.\n - Cte fungal coverage as above\n - Stopped PPI as can cause eosinophilia; will reassess tmrw\n #. Thrombocytopenia: Appreciate heme recs. Do not feel this is DIC.\n Recent decrease may be in setting of linezolid.\n - Monitor platelets daily and transfuse for plt <10 or <50 if signs of\n bleed\n - Would linezolid when/if able\n #. Acute renal Failure: Appreciate renal recs. Will continue CVVH. Stop\n sucralfate due to risk of electrolyte abnormalities.\n #. Wounds: Derm biopsy pending but likely edema caused wounds\n #. Agitation: Added methadone to given decreased sensitivity to\n fentanyl; titrate prn\n ICU Care\n Nutrition:\n F/U nutrition recs re:TFs this am\n Glycemic Control: ISS\n Lines:\n Arterial Line - 08:15 PM\n Multi Lumen - 10:00 PM\n Dialysis Catheter - 11:35 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: Holding PPI and sucralfate for now\n VAP: HOB elevation, Mouth care\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:ICU\n ------ Protected Section ------\n MICU ATTENDING ADDENDUM\n I saw and examined the patient, and was physically present with the ICU\n resident for key portions of the services provided. I agree with his\n note above, including assessment and plan.\n 28yo man with necrotizing pancreatitis (EtOH), liver failure, ARDS, ARF\n on CVVHD, shock, cerebral edema (which improved), colitis. Persistent\n hypotension, resp failure, anemia, thrombocytopenia (slowly improving),\n renal failure on CVVHD, intermittent fevers with episodic\n tachypnea/tachycardia/hypoxia.\n * postpyloric tube placed, OGT removed\n * CVVH re-started night of \n * methadone started 5mg tid,\n * pantoprazole changed to sucralfate\n * afebrile 98.4 - since noon on !! (Though back on CVVH)\n * -2.5L/24 on CVVH\n * vent 0.5/400/30/PEEP10 7.35/51/86, PEEP reduced to 8\n * levophed at 0.04mcg/kg/min\n * wbc 57, plts 58\n * Started hydrocortisone 100 q8 on \n * Derm biopsy of LE pending\n Exam unchanged: sedated on fent, reduced to 300mcg/h and versed 15mg/h,\n remains unresponsive with sluggish but reactive pupils, anasarca with\n weeping of fluid from bilat LEs, jaundiced, scleral edema, abd obese,\n firm.\n A/P:\n 1. Resp failure, ARDS. Improved with PEEP coming down. Trach\n today.\n 2. Sepsis: linezolid ()/aztreonam ()/IV, PO, PR flagyl (IV\n and PO/PR ), micafungin () for GPC bacteremia found while on\n dapto and empirically for CDiff.\n 3. Possible adrenal insufficiency: stim 17.9\n 18.5 which is\n tough to interpret: adrenal insufficiency vs already maximally\n stimulated. Probably can\nt attribute improvement simply to\n linezolid/aztreonam since they were both started hours prior to\n improvement in fever and hypotension. 5d course of hydrocortisone,\n started hydrocortisone .\n 4. Eosinophilia unexplained. BAL fluid showed 19% eosinophila as\n well. Med effect? PPI changed to sucralfate for PPI holiday 48h to\n evaluate whether this is causing eosinophilia. Since it is delivered\n postpyloric it may not have much effect, plan to change back to PPI\n after assess effect on thrombocytopenia, eos\n 5. Anemia: cycle hct, check OG tube lavage for e/o blood\n 6. Sedation: weaning fentanyl on PO methadone: increase to 20 tid\n (goal 20 qid) and wean fentanyl by 20% q 4h if tolerates\n 7. derm consult- biopsy done \n Critically ill, 50 minutes.\n ------ Protected Section Addendum Entered By: , MD\n on: 18:20 ------\n" }, { "category": "Nutrition", "chartdate": "2131-06-09 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 679822, "text": "Nutrition consulted for tube feed recommendations earlier today. Spoke\n c/ team, they wish to trial trophic tube feeds. Replete c/ Fiber\n @ mL/hr was verbally recommended. Will need to monitor\n tolerance/abd exam closely for intolerance given patient on pressor\n support and findings on last ACT. Would hold feeds if there is any\n change in abdominal exam. When abd exam WNL, then would trial Vivonex,\n an elemental formula which may increase tolerance. Please page c/ ?\n #\n" }, { "category": "Physician ", "chartdate": "2131-06-07 00:00:00.000", "description": "Attending Note", "row_id": 679341, "text": "MICU ATTENDING ADDENDUM\n I saw and examined the patient, and was physically present with the ICU\n resident for key portions of the services provided. I agree with his\n note above, including assessment and plan.\n 28yo man with necrotizing pancreatitis (EtOH), liver failure, ARDS, ARF\n on CVVHD, shock, cerebral edema (which improved), colitis. Persistent\n hypotension, resp failure, anemia, thrombocytopenia (slowly improving),\n renal failure on CVVHD, persistent fevers with episodic\n tachypnea/tachycardia/hypoxia.\n * Bronchoscopy yesterday no significant secretions. BAL cx neg so\n far.\n * Daptomycin changed to linezolid for new GPC blood cx (from\n peripheral stick) result which grew on dapto.\n * Widened QRS occurred in setting of K 6.7, EKG still widened but\n improved after a few hours of CVVH, repeat K 5.2 this morning at\n 9:30am.\n * HD placed in right IJ, CVVH restarted\n * Trop 0.07, CK 220-314 with MB peak 3%\n * Tm 103\n * Started hydrocortisone 100 q8 on \n * Levophed down to 0.08\n * Fio2 increased to 0.8, Vt 400/30/PEEP 15 ABG 7.21/44/95,\n 7/30/45/114, fiO2 down to 0.5\n * I/O 3.7/400 (60cc of that urine and total 395cc urine over 24h)\n * WBC 69, 21% eos\n * Plt stable at 77\n * Sedated on fent 350mcg/h and versed 15mg/h\n CXR improvement of bilateral opacification, c/w removal of fluid\n Exam unchanged: anasarca with weeping of fluid from bilat LEs,\n jaundiced, scleral edema, PERRL more sluggish, sedated and\n unresponsive. Abd obese, firm.\n A/P:\n 1. Resp failure, ARDS. Trach deferred due to worsened\n hypotension, worse hypoxemia requiring higher PEEP\n 2. linezolid/aztreonam/IV flagyl for GPC bacteremia found while\n on dapto. IV flagyl empirically for CDiff. Adding PO/PR vanco and\n antifungals empirically.\n 3. Improved hypotension. Possible adrenal insufficiency: \n stim 17.9\n 18.5 which is tough to interpret: adrenal insufficiency vs\n already maximally stimulated. Probably can\nt attribute improvement\n simply to linezolid/aztreonam since they were both started yesterday.\n Will continue 5d course of hydrocortisone.\n 4. Resp failure: titrate fiO2, PEEP down if possible\n 5. Eosinophilia unexplained. BAL fluid showed 19% eosinophila as\n well. Med effect? Will try changing PPI to sucralfate for PPI holiday\n 48h to evaluate whether this is causing eosinophilia.\n 6. IR to place postpyloric dobhoff today\n 7. sedation: may need to increase fentanyl or even paralyze if he\n is dysynchronous with vent. Today better than yesterday. After\n postpyloric dobhoff placed will try to add methadone for better control\n of sedation\n 8. derm consult\n Discussed with pt\ns mother, who was present during my exam.\n Critically ill, 45 minutes.\n" }, { "category": "Physician ", "chartdate": "2131-06-07 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 679342, "text": "Chief Complaint:\n 24 Hour Events:\n BRONCHOSCOPY - At 05:32 PM\n EKG - At 08:00 PM\n EKG - At 09:04 PM\n DIALYSIS CATHETER - START 11:35 PM\n EKG - At 04:15 AM\n FEVER - 103.0\nF - 12:00 PM\n :\n - Bronched. Secretions not seen. BAL from RLL and trach wash sent for\n bacterial and fungal cx, cell count, cytology.\n - ID recommended adding flagyl IV.\n - peripheral bcx growing GPC. D/c'd dapto and started linezolid\n given possibility of enterococcus.\n - Pt alarming for ST elevations on tele. EKG with ?STE in V2. Repeat\n EKG with ?STE in V1-V3 with scooped T segments. Cardiac enyzmes mildly\n elevated with CK 220 but MB 2 and Trop 0.07. EKGs faxed to Cards who\n thought more c/w metabolic changes given acidemia and increasing K.\n Given kayexalate pr, then calcium chloride, dextrose, insulin. Placed\n RIJ for CVVH with DDAVP given beforehand. Repeat EKG improved.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Daptomycin - 06:42 PM\n Aztreonam - 08:00 PM\n Linezolid - 10:05 PM\n Metronidazole - 02:00 AM\n Infusions:\n Norepinephrine - 0.14 mcg/Kg/min\n Fentanyl (Concentrate) - 350 mcg/hour\n Calcium Gluconate (CRRT) - 1.4 grams/hour\n Midazolam (Versed) - 15 mg/hour\n Other ICU medications:\n Dextrose 50% - 10:25 PM\n Heparin Sodium (Prophylaxis) - 04:30 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 07:28 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 39.4\nC (103\n Tcurrent: 37\nC (98.6\n HR: 99 (99 - 125) bpm\n BP: 107/61(77) {93/51(65) - 132/85(97)} mmHg\n RR: 14 (14 - 39) insp/min\n SpO2: 99%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 134 kg (admission): 113.5 kg\n Height: 67 Inch\n CVP: 291 (0 - 291)mmHg\n Total In:\n 3,728 mL\n 1,957 mL\n PO:\n TF:\n IVF:\n 1,920 mL\n 1,412 mL\n Blood products:\n Total out:\n 595 mL\n 2,839 mL\n Urine:\n 395 mL\n 60 mL\n NG:\n 200 mL\n 200 mL\n Stool:\n Drains:\n Balance:\n 3,133 mL\n -882 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 30\n RR (Spontaneous): 0\n PEEP: 15 cmH2O\n FiO2: 80%\n RSBI Deferred: PEEP > 10\n PIP: 29 cmH2O\n Plateau: 23 cmH2O\n SpO2: 99%\n ABG: 7.25/50/106/19/-5\n Ve: 10.9 L/min\n PaO2 / FiO2: 133\n Physical Examination\n GEN: Intubated, sedated\n HEENT: icteric sclera. MMM\n NECK: Sites clean/dry/no oozing\n LUNGS: Crackles bilaterally anteriorly.\n HEART: RRR\n ABD: Distended. NT.\n EXTREM: 2+ edema with weeping wounds without surrounding erythema\n SKIN: Jaundice\n Labs / Radiology\n 77 K/uL\n 7.3 g/dL\n 233 mg/dL\n 3.0 mg/dL\n 19 mEq/L\n 6.1 mEq/L\n 40 mg/dL\n 102 mEq/L\n 131 mEq/L\n 26.0 %\n 69.0 K/uL\n [image002.jpg]\n 12:47 PM\n 02:12 PM\n 03:38 PM\n 06:35 PM\n 08:42 PM\n 08:53 PM\n 02:05 AM\n 02:12 AM\n 06:02 AM\n 06:11 AM\n WBC\n 69.0\n Hct\n 26.0\n Plt\n 77\n Cr\n 2.4\n 2.7\n 3.3\n 3.0\n TropT\n 0.07\n 0.06\n 0.07\n TCO2\n 21\n 19\n 20\n 23\n 19\n 23\n Glucose\n 145\n 200\n 191\n 233\n Other labs: PT / PTT / INR:19.8/63.8/1.8, CK / CKMB /\n Troponin-T:214/3/0.07, ALT / AST:43/205, Alk Phos / T Bili:145/23.0,\n Amylase / Lipase:19/35, Differential-Neuts:49.0 %, Band:0.0 %,\n Lymph:9.0 %, Mono:7.0 %, Eos:21.0 %, D-dimer:6389 ng/mL, Fibrinogen:419\n mg/dL, Lactic Acid:2.2 mmol/L, Albumin:1.7 g/dL, LDH:821 IU/L, Ca++:8.3\n mg/dL, Mg++:2.2 mg/dL, PO4:7.2 mg/dL\n Assessment and Plan\n 28yo M with alcoholic hepatitis and necrotizing pancreatitis\n complicated by ARDS, SIRS, ARF, UGIB, fevers and eosinophilia.\n #. Fever: Bronchoscopy without signs of pneumonia. GPCs growing\n in peripheral blood cx and dapto was changed to linezolid given concern\n for VRE. He is also on aztreonam for extended GN coverage. CT abd with\n no change but continued colonic thickening consistent with infection.\n Other source could be skin as extensive break down although no sign of\n infection superimposed on breakdown and on broad gram positive\n coverage.\n - Cte broad spectrum antibiotic coverage with aztreonam and linezolid\n for MRSA and VRE for bacteremia\n - F/U cultures\n - Consider TEE to r/o vegetations as TTE was not a definitive study and\n now with GPC in blood cx.\n - appreciate ID recs. Added Vanc PO/PR empirically per ID recs given\n increasing leukocytosis and colon inflammation on CT. Will start\n anti-fungal today empirically as bowel wall may be compromised.\n - New IJ placed for emergent CVVH\n #. Respiratory Failure: ARDS secondary to necrotizing pancreatitis.\n PEEP at 15 currently. Cannot be trached with such a high peep according\n to thoracics so did not get trach yet. Hypoxia slightly better today\n and able to wean down FiO2 after volume taken off with CVVH\n - Hold off on trach given elevated PEEP (goal PEEP\n #. Adrenal Insufficiency: Unclear with stim if clear adrenal\n insufficiency but hypotension improving with steroids (lower pressor\n requirement) and improving eosinophilia\n - Will continue steroids Iv X 5 days (day 2) then change to prednisone\n to taper\n #. Anemia: Hcts stable and no RP bleed seen on CT.\n - trend hcts\n - f/u heme recs\n - guaiac stools\n #. Eosinophilia: Likely drug reaction (to vanc, ppi or dapto?) with\n parasitic or fungal infection also possible etiologies.\n - stim positive for adrenal insufficiency. Cte steroids.\n - cte linezolid for GPCs in blood and aztreonam GNegs\n - Start fungal coverage as above\n - once has doboff will stop ppi and start sucralfate instead\n #. Thrombocytopenia: Appreciate heme recs. Do not feel this is DIC.\n - Monitor platelets daily and transfuse for plt <10 or <50 if signs of\n bleed\n #. Acute renal Failure:\n - Restarted CVVH for hyperkalemia\n #. Hyperkalemia: Likely in setting of ARF after stopping CVVH.\n - Restarted CVVH for hyperkalemia with ECG changes\n #. Wounds: Wound care suggested dermatology consult for non-healing\n wounds. Derm to staff today.\n ICU Care\n Nutrition:\n TPN w/ Lipids - 04:05 PM 73. mL/hour.\n Post-pyloric doboff placement today.\n Glycemic Control:\n Lines:\n 20 Gauge - 03:56 PM\n Arterial Line - 08:15 PM\n Multi Lumen - 10:00 PM\n Dialysis Catheter - 11:35 PM\n Prophylaxis:\n DVT: SQ UF Heparin \n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:ICU\n" }, { "category": "Respiratory ", "chartdate": "2131-06-02 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 678420, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 16\n Ideal body weight: 67.1 None\n Ideal tidal volume: 268.4 / 402.6 / 536.8 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: 23 cm at teeth\n Route:\n Type: Standard\n Size: 7mm\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Tan / Thick\n Sputum source/amount: Suctioned / Scant\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Nasal flaring, Gasping efforts;\n Comments: at times\n Assessment of breathing comfort: No response (sleeping / sedated)\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously, Abnormal trigger\n efforts (efforts during inspiratory)\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Utilize ARDSnet protocol\n Reason for continuing current ventilatory support: Hemodynimic\n instability, Underlying illness not resolved\n" }, { "category": "Nursing", "chartdate": "2131-06-02 00:00:00.000", "description": "Nursing Progress Note", "row_id": 678421, "text": " Problem\n in neuro status\n Assessment:\n Patient on fent 340/versed 17 this am\n Patient with +corneal/+papillary\n Very poor cough and no gag\n Some movement of arms when legs moved (?pain response)\n Action:\n Fentanyl decreased to 250 mcg/\n Response:\n Heart rate increased, ?due to decreased sedation vs. fluid removal\n Plan:\n No further weaning of sedation.\n Continue with fluid removal with small increase in pressor support if\n needed.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Patient remains intubated, on .5/x30/400/+12\n Good abgs and sats\n Action:\n No weaning today\n Response:\n Stable abgs\n Plan:\n CRRT to take off as much fluid as possible.\n IP into evaluate patient for future trach.\n ?Weaning PEEP to 12 tomorrow.\n Gastrointestinal bleed, upper (Melena, GI Bleed, GIB)\n Assessment:\n Belly soft, Hct stable\n Action:\n Seen by heme /onc. This afternoon\n Response:\n Bone marrow working appropriately in setting of sever stress\n Hct stable\n No evidence of DIC\n Plan:\n Check hcts. , heme/onc to follow\n" }, { "category": "Nursing", "chartdate": "2131-06-04 00:00:00.000", "description": "Nursing Progress Note", "row_id": 678831, "text": "Hypotension (not Shock)\n Assessment:\n Labile bp on levo gtt to keep map >65..on fent & versed gtt for\n sedation\n Action:\n levo gtt increased to 0.2 ..fent gtt down 325mcg\n Response:\n sbp >90/ does drop to 80/\ns at times\n Plan:\n wean fent as tol but keep comf\n Respiratory failure, acute (not ARDS/)\n Assessment:\n remains vented with labile sat\ns when tachypneic\n Action:\n suctioned for sm amt yellow/white ..on rotating bed\n Response:\n abg\ns improving thru day\n Plan:\n continue with abg\ns q6h..good pulmonary toilet..rotating bed\n SEPSIS\n Assessment: febrile to 102.4..wbc\ns 35\n Action : fungal bld culture sent..ho aware..tylenol given\n Response : afebrile by\n 1600\n Plan : monitor wbc\ns & temps\n closely..may pan culture if spikes again(bld cultures we\nre done @ \n )\n" }, { "category": "Nutrition", "chartdate": "2131-06-08 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 679563, "text": "Objective\n Pertinent medications: Fentanyl, Versed, Norepinephrine, RISS, others\n noted\n Labs:\n Value\n Date\n Glucose\n 187 mg/dL\n 10:28 AM\n Glucose Finger Stick\n 213\n 04:00 AM\n BUN\n 35 mg/dL\n 10:20 AM\n Creatinine\n 1.9 mg/dL\n 10:20 AM\n Sodium\n 133 mEq/L\n 10:20 AM\n Potassium\n 3.6 mEq/L\n 10:20 AM\n Chloride\n 97 mEq/L\n 10:20 AM\n TCO2\n 26 mEq/L\n 10:20 AM\n PO2 (arterial)\n 92. mm Hg\n 10:28 AM\n PCO2 (arterial)\n 50 mm Hg\n 10:28 AM\n pH (arterial)\n 7.37 units\n 10:28 AM\n pH (venous)\n 7.25 units\n 10:31 AM\n pH (urine)\n 7.0 units\n 10:07 PM\n CO2 (Calc) arterial\n 30 mEq/L\n 10:28 AM\n Albumin\n 1.7 g/dL\n 02:35 AM\n Calcium non-ionized\n 7.5 mg/dL\n 10:20 AM\n Phosphorus\n 3.0 mg/dL\n 10:20 AM\n Ionized Calcium\n 1.01 mmol/L\n 10:28 AM\n Magnesium\n 2.0 mg/dL\n 10:20 AM\n ALT\n 42 IU/L\n 03:36 AM\n Alkaline Phosphate\n 129 IU/L\n 03:36 AM\n AST\n 182 IU/L\n 03:36 AM\n Amylase\n 19 IU/L\n 04:00 AM\n Total Bilirubin\n 23.3 mg/dL\n 03:36 AM\n Triglyceride\n 154 mg/dL\n 02:10 AM\n WBC\n 56.6 K/uL\n 04:48 AM\n Hgb\n 6.8 g/dL\n 04:48 AM\n Hematocrit\n 20.7 %\n 04:48 AM\n Current diet order / nutrition support: TPN: 70kg 3-in-1 = 1783kcals\n GI: softly distended, + bowel sounds\n Assessment of Nutritional Status\n Consult received for tube feed recommendations; post-pyloric feeding\n tube placed . Would not recommend starting tube feeds at this time\n based on findings of abd CT, however if team decides to start them,\n recommend using an elemental formula to start with. If patient\n tolerates advancement of elemental feeds, the switch can be made to a\n more standard formula.\n Medical Nutrition Therapy Plan - Recommend the Following\n 1) Recommend starting Vivonex @ 10cc/hr. If this is tolerated\n for 24hrs, recommend advancing slowly (by 10cc q12hrs) to goal of\n 75cc/hr.\n 2) Will follow tolerance and need for possible TPN wean.\n 3) Monitor abd exam closely for s/s of intolerance. No residual\n checks with post-pyloric feeding tube.\n Following, please page with any questions. #\n" }, { "category": "Nursing", "chartdate": "2131-06-03 00:00:00.000", "description": "Nursing Progress Note", "row_id": 678483, "text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n - Received on CMV 50 % 400x30 PEEP 12\n - RR 30-34\n - O2SAT > 97%\n - No apparent distress\n - Well sedated\n - ABG shows adequate oxygenation and ventilation\n - Naloxone ( po dose for gi motility) held previous shift d/t\n difficult with sedation previous night\n Action:\n - Sedation titrated down slightly overnight\n - No vent changes made\n - Suctioned for minimal secretions\n - CXR this am\n - Micu HO contact and MD cont to hold naloxone\n Response:\n - Remains stable on current vent status\n - Well sedated and compliant with ventilator\n Plan:\n Follow up with team this morning re: switch to standing reglan.\n Continue to titrate down on sedation as tolerated. Follow ABG\ns and\n wean ventilator as tolerated. Provide support to patient and family.\n Impaired Skin Integrity\n Assessment:\n - Multiple blistered and open areas on blu and right side of abdomen\n - Red and darkened areas on bil heels\n Action:\n - Skin care per wound care nurses recommendations\n - On rotating bed for respiratory and skin protection\n - Daptomycin for suspected cellulitis to BLE\n Response:\n - Skin appears improved from previous dressing change\n Plan:\n Continue on constant rotation, turn and assess skin prn, dressing\n changes per wound care\ns recommendations. Dermatology and ID\n following.\n Sepsis, Severe (with organ dysfunction)\n Assessment:\n -Received on 0.11 mcg/kg levophed gtt\n -3 liters negative this evening and maintained at 3 liters negative d/t\n increased HR and levophed requirement\n - Opens eyes to pain but not otherwise responsive\n - BUE tremors with stimulation but no purposeful movement\n - WBC up to 37 (from 28)\n - HCT, Plt, and coags stable\n Action:\n - Able to titrate levophed down over course of evening\n - Tolerating fluid removal at 150-200 cc/hr\n - Sedation weaned down very slowly\n Response:\n - MAP maintaining > 60 on low dose levo and tolerating fluid removal\n - Wakes consistently to discomfort but compliant with vent and appears\n comfortable at rest\n Plan:\n Continue to take off fluid as tolerated, titrate levophed, wake slowly\n as tolerated, follow up with MICU regarding increased WBC.\n" }, { "category": "Physician ", "chartdate": "2131-06-05 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 678938, "text": "TITLE:\n Chief Complaint: Mr. is a 28 year old gentleman with alcoholic\n hepatitis and necrotizing pancreatitis complicated by ARDS, SIRS, ARF\n and UGIB.\n 24 Hour Events:\n BLOOD CULTURED - At 10:46 AM\n fungal bld culture\n FEVER - 102.4\nF - 08:00 AM\n - ID: cont daptomycin, would not restart flagyl, recc sinus CT to r/o\n sinusitis, would change lines when able\n - heme/onc: eosinophilia may be secondary to infection vs stress\n response. still don't think he has DIC but want recheck of fibrinogen.\n re: restarting heparin, attg reccomends a lower dose in TPN to reduce\n bleeding risk (was getting 9000u); will let us know the dose tomorrow\n - thoracic surgery will place trach on \n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Metronidazole - 04:00 AM\n Daptomycin - 06:42 PM\n Infusions:\n Calcium Gluconate (CRRT) - 1.4 grams/hour\n Fentanyl (Concentrate) - 325 mcg/hour\n Midazolam (Versed) - 15 mg/hour\n Norepinephrine - 0.25 mcg/Kg/min\n KCl (CRRT) - 1 mEq./hour\n Other ICU medications:\n Pantoprazole (Protonix) - 08:16 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 07:40 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 39.1\nC (102.4\n Tcurrent: 35.7\nC (96.3\n HR: 96 (93 - 128) bpm\n BP: 113/64(83) {84/43(57) - 117/64(83)} mmHg\n RR: 20 (16 - 38) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 128 kg (admission): 113.5 kg\n Height: 67 Inch\n CVP: 15 (0 - 17)mmHg\n Total In:\n 10,084 mL\n 3,257 mL\n PO:\n TF:\n IVF:\n 8,252 mL\n 2,699 mL\n Blood products:\n Total out:\n 11,204 mL\n 5,005 mL\n Urine:\n 102 mL\n 100 mL\n NG:\n 250 mL\n 200 mL\n Stool:\n Drains:\n Balance:\n -1,120 mL\n -1,748 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 30\n RR (Spontaneous): 0\n PEEP: 12 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10\n PIP: 18 cmH2O\n Plateau: 22 cmH2O\n Compliance: 44.4 cmH2O/mL\n SpO2: 100%\n ABG: 7.30/48/84./21/-2\n Ve: 13 L/min\n PaO2 / FiO2: 168\n Physical Examination\n General Appearance: Overweight / Obese, No(t) Diaphoretic\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: Rhonchorous: )\n Abdominal: Soft\n Extremities: Right: 2+, Left: 2+\n Skin: Not assessed, Jaundice\n Neurologic: Responds to: Noxious stimuli, Movement: Non -purposeful,\n Tone: Not assessed\n Labs / Radiology\n 73 K/uL\n 8.1 g/dL\n 177 mg/dL\n 1.2 mg/dL\n 21 mEq/L\n 4.8 mEq/L\n 19 mg/dL\n 106 mEq/L\n 135 mEq/L\n 24.9 %\n 50.7 K/uL\n [image002.jpg]\n 07:42 PM\n 10:37 PM\n 02:03 AM\n 02:17 AM\n 11:05 AM\n 03:58 PM\n 09:00 PM\n 09:06 PM\n 02:35 AM\n 02:39 AM\n WBC\n 37.5\n 50.7\n Hct\n 23.9\n 24.4\n 24.9\n Plt\n 66\n 73\n Cr\n 1.6\n 1.4\n 1.2\n TCO2\n 25\n 27\n 24\n 22\n 23\n 25\n Glucose\n 128\n 125\n 106\n 119\n 144\n 177\n Other labs: PT / PTT / INR:17.4/40.1/1.6, CK / CKMB / Troponin-T:240//,\n ALT / AST:29/257, Alk Phos / T Bili:132/14.0, Amylase / Lipase:19/35,\n Differential-Neuts:38.0 %, Band:2.0 %, Lymph:14.0 %, Mono:5.0 %,\n Eos:26.0 %, D-dimer:6389 ng/mL, Fibrinogen:419 mg/dL, Lactic Acid:1.3\n mmol/L, Albumin:1.6 g/dL, LDH:607 IU/L, Ca++:8.7 mg/dL, Mg++:2.1 mg/dL,\n PO4:3.5 mg/dL\n Assessment and Plan\n Mr. is a 28 year old gentleman with alcoholic hepatitis and\n necrotizing pancreatitis complicated by ARDS, SIRS, ARF and UGIB.\n # Tachypnea, tachycardia, hypotension: reflect inadequate sedation\n with resulting tachypnea, breathstacking leading to hypotension.\n Alternatively and more concerning, may suggest PE given that patient\n has only been on SCDs given recent hct drop.\n - Upper and lower extremity U/S\n - If U/S negative, will order CTA to r/o PE\n - Titrate sedation.\n # Anemia: Initially p/w hematemesis and EGD showed diuelafoy's lesion.\n Hct stable >24 hours s/p 4 units since . CTAP with new pancreatic\n pseudocyst but per d/w radiology no definitive explanation for hct\n drop. NG lavage negative. GI also doubts possibility of significant\n GI bleed, defer upper endoscopy for now. Appreciate hematology recs,\n do not feel that this is DIC.\n - CBC Q12H, transfuse for hct<21, plt<50\n - Follow-up heme and GI recs if any\n - Guaiac stools\n - Per heme, send ADAT\n # Respiratory Failure: ARDS secondary to necrotizing pancreatitis\n compounded by hypoxia, tachypnea in setting of anion gap metabolic\n acidosis, increased abdominal pressure, and EtOH withdrawal. PEEP\n decreased to 12 from 20 and FiO2 to 50%. Was tachypneic overnight on\n and sedation increased; CXR stable. IP recommending thoracic\n surgery for trach. Naloxone held yesterday given concern over\n systemic absorption resulting in tachypnea, although unlikely given\n that patient had episode of tachypnea prior to initiating naloxone.\n - Wean FiO2 and PEEP, goal PaO2>60-65%\n - Wean sedation as tolerated\n - Discuss with thoracic surgery\n # Leukocytosis: Leukocytosis worse this AM to 37 from 28 with 15% eos.\n Afebrile in last 24 hours. Per ID, started on dpatomycin and flagyl for\n ? C.diff and possible cellulitis. Negative cultures and C.diff x1 with\n 2nd pending.\n - Continue daptomycin, d/c flagyl.\n - Follow-up ID recs if any\n - Follow-up culture data.\n # Neuro: Initially dilated pupils with CT showing cerebral edema. Neuro\n exam now stable. Repeat CTH demonstrates interval improvement.\n - Continue leviteracetam\n - Wean sedation as possible\n - Neuro recs if any\n # Necrotizing pancreatitis/SIRS: Secondary to alcohol complicated by\n SIRS and ARDS. Patient continues to have pressor requirement, with neo\n +/- levo. Aggressive volume resuscitation with >50L but\n diuresing well. Also with new pseudocyst (3 cm x 3 cm) on abdominal CT\n on . Naloxone held yesterday given tachypnea. KUB unable to\n determine of OG is post-pyloric.\n - Wean pressors with goal MAP >65\n - Hold off on trophic feeds for now given uncertainty of OG placement.\n Will consider dobhoff placement in AM.\n # Hyponatremia: In setting of decreased effective circulating volume in\n setting of SIRS and IABP. Patient has received hypertonic saline\n boluses with improvement in serum sodium and osm.\n - Given improvement in neuro exam, continue to hold hypertonic saline.\n # Acute renal failure: Patient had HD line placed and on CVVH. CVVH\n with even TBB pending assessment of hemorrhage.\n - CVVH per renal.\n - Trend chemistries\n #Thrombocytopenia: Platelets stable but have trended down from a\n normal count on admission. No clear etiology at this time. DIC panel\n with elevated FDP but normal fibrinogen. HIT PF4 antibody negative.\n - Trend plt, transfuse for plt<10 or <50 if signs of hemorrhage.\n # Wound care: Per wound care recs.\n # Acute hepatitis: Likely alcoholic hepatitis with fatty infiltration,\n and no evidence of distal obstruction. RUQ u/s shows marked liver\n echogenicity but no ascites.\n - Trend LFTs\n # Alcoholism: Patient describes history of withdrawal symptoms, but\n not prior seizure. Last drink was night prior to presentation.\n Tachycardia, weakness, and elevated lactate could be consistent with\n thiamine deficiency.\n - Thiamine, vb12, folate\n - Valium with CIWA > 10\n FEN: TPN without heparin, replete as necessary.\n PPx: SCD, PPI\n Access: RIJ, LIJ, left radial arterial line\n Code: Full\n ICU Care\n Nutrition:\n TPN w/ Lipids - 05:50 PM 73 mL/hour\n Glycemic Control:\n Lines:\n Multi Lumen - 02:02 PM\n Dialysis Catheter - 04:56 PM\n Arterial Line - 01:30 PM\n 20 Gauge - 03:56 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:ICU\n" }, { "category": "Physician ", "chartdate": "2131-06-05 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 678945, "text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n ULTRASOUND - At 12:40 PM\n BLOOD CULTURED - At 08:30 PM\n via dialysis cath, tlc and periph\n \n - heme: no dic, check fibrinogen, indirect coombs\n - ID: can dc dapto and flagyl if cx are negative\n - IP: would not do trach, rec calling CT \n - restarted UF\n - pm HCT stable\n - held naloxone and weaning sedatives\n \n - BCx (): GPC pairs and clusters, 1/2 bottles from HD line. d/w\n pharmacy, dapto increased to 750 mg Q24H. Order placed to check CK\n tomorrow.\n - LE/UE U/S negative for DVT. CTA negative for PE.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Metronidazole - 04:00 AM\n Daptomycin - 05:50 PM\n Infusions:\n Calcium Gluconate (CRRT) - 1 grams/hour\n KCl (CRRT) - 1 mEq./hour\n Norepinephrine - 0.12 mcg/Kg/min\n Fentanyl (Concentrate) - 350 mcg/hour\n Other ICU medications:\n Pantoprazole (Protonix) - 09:30 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:12 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.1\nC (98.8\n Tcurrent: 36.7\nC (98\n HR: 104 (95 - 119) bpm\n BP: 111/58(75) {78/34(49) - 112/59(78)} mmHg\n RR: 33 (27 - 43) insp/min\n SpO2: 98%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 128 kg (admission): 113.5 kg\n Height: 67 Inch\n CVP: 17 (7 - 17)mmHg\n Total In:\n 7,814 mL\n 2,885 mL\n PO:\n TF:\n IVF:\n 6,266 mL\n 2,362 mL\n Blood products:\n Total out:\n 8,470 mL\n 3,478 mL\n Urine:\n 376 mL\n 45 mL\n NG:\n 600 mL\n Stool:\n Drains:\n Balance:\n -656 mL\n -593 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 30\n RR (Spontaneous): 0\n PEEP: 12 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10\n PIP: 23 cmH2O\n Plateau: 18 cmH2O\n SpO2: 98%\n ABG: 7.36/46/75/23/0\n Ve: 14.5 L/min\n PaO2 / FiO2: 150\n Physical Examination\n General Appearance: Overweight / Obese, anasarca\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: Rhonchorous: )\n Abdominal: Soft, Obese\n Extremities: Right: 2+, Left: 2+\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Non -purposeful,\n Sedated, Tone: Not assessed\n Labs / Radiology\n 66 K/uL\n 8.0 g/dL\n 125 mg/dL\n 1.6 mg/dL\n 23 mEq/L\n 4.7 mEq/L\n 22 mg/dL\n 105 mEq/L\n 136 mEq/L\n 24.4 %\n 37.5 K/uL\n [image002.jpg]\n 10:34 PM\n 02:38 AM\n 04:01 AM\n 09:26 AM\n 10:59 AM\n 01:05 PM\n 07:42 PM\n 10:37 PM\n 02:03 AM\n 02:17 AM\n WBC\n 37.2\n 37.5\n Hct\n 24.4\n 23.9\n 24.4\n Plt\n 77\n 66\n Cr\n 1.8\n 1.6\n TCO2\n 27\n 26\n 26\n 21\n 23\n 25\n 27\n Glucose\n 123\n 139\n 103\n 96\n 97\n 128\n 125\n Other labs: PT / PTT / INR:15.8/39.1/1.4, CK / CKMB / Troponin-T:240//,\n ALT / AST:29/257, Alk Phos / T Bili:132/14.0, Amylase / Lipase:19/35,\n Differential-Neuts:37.0 %, Band:18.0 %, Lymph:7.0 %, Mono:2.0 %,\n Eos:15.0 %, D-dimer:6389 ng/mL, Fibrinogen:293 mg/dL, Lactic Acid:1.3\n mmol/L, Albumin:1.6 g/dL, LDH:607 IU/L, Ca++:8.9 mg/dL, Mg++:2.2 mg/dL,\n PO4:4.1 mg/dL\n Assessment and Plan\n Mr. is a 28 year old gentleman with alcoholic hepatitis and\n necrotizing pancreatitis complicated by ARDS, SIRS, ARF and UGIB.\n # Question sepsis/leukocytosis: Increasing hypotensive, tachycardic,\n and episodically febrile, with rising levophed requirement and rising\n white count. Multiple possible sources of new infection, including\n line infection, sinusitis, pancreatitis, and cellulitis. Hypotension\n also concerning for question PE but ruled out with negative CTA.\n Restarted daptomycin on to cover for MRSA and cellulitis and\n because of concern of drug reaction to vancomycin. Other antibiotic\n courses include Flagyl , ; Meropenem ;\n Vancomycin . Lines include RIJ (18 days) and left HD line (10\n days).\n - continue daptomycin\n - hold off on restarting flagyl\n - f/u culture data\n - ID reccs\n - trend differential following eosinophilia closely\n - consider sinus CT and sinus drainage per ENT\n # Respiratory Failure: ARDS secondary to necrotizing pancreatitis\n compounded by hypoxia, tachypnea in setting of anion gap metabolic\n acidosis, increased abdominal pressure, and EtOH withdrawal. PEEP\n decreased to 12 from 20 and FiO2 to 50%. Was tachypneic overnight on\n and sedation increased; CXR stable. IP recommending thoracic\n surgery for trach. Naloxone held yesterday given concern over\n systemic absorption resulting in tachypnea, although unlikely given\n that patient had episode of tachypnea prior to initiating naloxone.\n CTA neg for PE.\n - Wean FiO2 and PEEP, goal PaO2>60-65, SaO2>90%\n - Wean sedation as tolerated\n - tracheostomy today with thoracic surgery\n # Anemia: Initially p/w hematemesis and EGD showed diuelafoy's lesion.\n Hct stable >24 hours s/p 4 units since . CTAP with new pancreatic\n pseudocyst but per d/w radiology no definitive explanation for hct\n drop. NG lavage negative. GI also doubts possibility of significant\n GI bleed, defer upper endoscopy for now. Appreciate hematology recs,\n do not feel that this is DIC.\n - CBC daily, transfuse for hct<21, plt<50\n - Follow-up heme and GI recs if any\n - Guaiac stools\n - Per heme, send ADAT\n # Neuro: Initially dilated pupils with CT showing cerebral edema. Neuro\n exam now stable. Repeat CTH demonstrates interval improvement.\n - Continue leviteracetam\n - Wean sedation as possible\n - Neuro recs if any\n # Necrotizing pancreatitis/SIRS: Secondary to alcohol complicated by\n SIRS and ARDS. Patient continues to have pressor requirement, with neo\n +/- levo. Aggressive volume resuscitation with >50L but\n diuresing well. Also with new pseudocyst (3 cm x 3 cm) on abdominal CT\n on . Naloxone held yesterday given tachypnea. KUB unable to\n determine of OG is post-pyloric.\n - Wean pressors with goal MAP >65\n - Hold off on trophic feeds for now given uncertainty of OG placement.\n Will consider dobhoff placement in AM.\n # Hyponatremia: In setting of decreased effective circulating volume in\n setting of SIRS and IABP. Patient has received hypertonic saline\n boluses with improvement in serum sodium and osm.\n - Given improvement in neuro exam, continue to hold hypertonic saline.\n # Acute renal failure: Patient had HD line placed and on CVVH. CVVH\n with even TBB pending assessment of hemorrhage.\n - CVVH per renal.\n - Trend chemistries\n #Thrombocytopenia: Platelets stable but have trended down from a\n normal count on admission. No clear etiology at this time. DIC panel\n with elevated FDP but normal fibrinogen. HIT PF4 antibody negative.\n - Trend plt, transfuse for plt<10 or <50 if signs of hemorrhage.\n # Wound care: Per wound care recs.\n # Acute hepatitis: Likely alcoholic hepatitis with fatty infiltration,\n and no evidence of distal obstruction. RUQ u/s shows marked liver\n echogenicity but no ascites.\n - Trend LFTs\n # Alcoholism: Patient describes history of withdrawal symptoms, but\n not prior seizure. Last drink was night prior to presentation.\n Tachycardia, weakness, and elevated lactate could be consistent with\n thiamine deficiency.\n - Thiamine, vb12, folate\n - Valium with CIWA > 10\n FEN: TPN without heparin, replete as necessary.\n PPx: SCD, PPI\n Access: RIJ, LIJ, left radial arterial line\n Code: Full\n ICU Care\n Nutrition:\n TPN w/ Lipids - 06:35 PM 73 mL/hour\n Glycemic Control:\n Lines:\n Multi Lumen - 02:02 PM\n Dialysis Catheter - 04:56 PM\n Arterial Line - 01:30 PM\n 20 Gauge - 03:56 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2131-06-05 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 678946, "text": "TITLE:\n Chief Complaint: Mr. is a 28 year old gentleman with alcoholic\n hepatitis and necrotizing pancreatitis complicated by ARDS, SIRS, ARF\n and UGIB.\n 24 Hour Events:\n BLOOD CULTURED - At 10:46 AM\n fungal bld culture\n FEVER - 102.4\nF - 08:00 AM\n - ID: cont daptomycin, would not restart flagyl, recc sinus CT to r/o\n sinusitis, would change lines when able\n - heme/onc: eosinophilia may be secondary to infection vs stress\n response. still don't think he has DIC but want recheck of fibrinogen.\n re: restarting heparin, attg reccomends a lower dose in TPN to reduce\n bleeding risk (was getting 9000u); will let us know the dose tomorrow\n - thoracic surgery will place trach on \n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Metronidazole - 04:00 AM\n Daptomycin - 06:42 PM\n Infusions:\n Calcium Gluconate (CRRT) - 1.4 grams/hour\n Fentanyl (Concentrate) - 325 mcg/hour\n Midazolam (Versed) - 15 mg/hour\n Norepinephrine - 0.25 mcg/Kg/min\n KCl (CRRT) - 1 mEq./hour\n Other ICU medications:\n Pantoprazole (Protonix) - 08:16 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 07:40 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 39.1\nC (102.4\n Tcurrent: 35.7\nC (96.3\n HR: 96 (93 - 128) bpm\n BP: 113/64(83) {84/43(57) - 117/64(83)} mmHg\n RR: 20 (16 - 38) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 128 kg (admission): 113.5 kg\n Height: 67 Inch\n CVP: 15 (0 - 17)mmHg\n Total In:\n 10,084 mL\n 3,257 mL\n PO:\n TF:\n IVF:\n 8,252 mL\n 2,699 mL\n Blood products:\n Total out:\n 11,204 mL\n 5,005 mL\n Urine:\n 102 mL\n 100 mL\n NG:\n 250 mL\n 200 mL\n Stool:\n Drains:\n Balance:\n -1,120 mL\n -1,748 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 30\n RR (Spontaneous): 0\n PEEP: 12 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10\n PIP: 18 cmH2O\n Plateau: 22 cmH2O\n Compliance: 44.4 cmH2O/mL\n SpO2: 100%\n ABG: 7.30/48/84./21/-2\n Ve: 13 L/min\n PaO2 / FiO2: 168\n Physical Examination\n General Appearance: Overweight / Obese, No(t) Diaphoretic\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: Rhonchorous: )\n Abdominal: Soft\n Extremities: Right: 2+, Left: 2+\n Skin: Not assessed, Jaundice\n Neurologic: Responds to: Noxious stimuli, Movement: Non -purposeful,\n Tone: Not assessed\n Labs / Radiology\n 73 K/uL\n 8.1 g/dL\n 177 mg/dL\n 1.2 mg/dL\n 21 mEq/L\n 4.8 mEq/L\n 19 mg/dL\n 106 mEq/L\n 135 mEq/L\n 24.9 %\n 50.7 K/uL\n [image002.jpg]\n 07:42 PM\n 10:37 PM\n 02:03 AM\n 02:17 AM\n 11:05 AM\n 03:58 PM\n 09:00 PM\n 09:06 PM\n 02:35 AM\n 02:39 AM\n WBC\n 37.5\n 50.7\n Hct\n 23.9\n 24.4\n 24.9\n Plt\n 66\n 73\n Cr\n 1.6\n 1.4\n 1.2\n TCO2\n 25\n 27\n 24\n 22\n 23\n 25\n Glucose\n 128\n 125\n 106\n 119\n 144\n 177\n Other labs: PT / PTT / INR:17.4/40.1/1.6, CK / CKMB / Troponin-T:240//,\n ALT / AST:29/257, Alk Phos / T Bili:132/14.0, Amylase / Lipase:19/35,\n Differential-Neuts:38.0 %, Band:2.0 %, Lymph:14.0 %, Mono:5.0 %,\n Eos:26.0 %, D-dimer:6389 ng/mL, Fibrinogen:419 mg/dL, Lactic Acid:1.3\n mmol/L, Albumin:1.6 g/dL, LDH:607 IU/L, Ca++:8.7 mg/dL, Mg++:2.1 mg/dL,\n PO4:3.5 mg/dL\n Assessment and Plan\n Mr. is a 28 year old gentleman with alcoholic hepatitis and\n necrotizing pancreatitis complicated by ARDS, SIRS, ARF and UGIB.\n # Question sepsis/leukocytosis: Increasing hypotensive, tachycardic,\n and episodically febrile, with rising levophed requirement and rising\n white count. Multiple possible sources of new infection, including\n line infection, sinusitis, pancreatitis, and cellulitis. Hypotension\n also concerning for question PE but ruled out with negative CTA.\n Restarted daptomycin on to cover for MRSA and cellulitis and\n because of concern of drug reaction to vancomycin. Other antibiotic\n courses include Flagyl , ; Meropenem ;\n Vancomycin . Lines include RIJ (18 days) and left HD line (10\n days).\n - continue daptomycin\n - hold off on restarting flagyl\n - f/u culture data\n - ID reccs\n - trend differential following eosinophilia closely\n - consider sinus CT and sinus drainage per ENT\n # Respiratory Failure: ARDS secondary to necrotizing pancreatitis\n compounded by hypoxia, tachypnea in setting of anion gap metabolic\n acidosis, increased abdominal pressure, and EtOH withdrawal. PEEP\n decreased to 12 from 20 and FiO2 to 50%. Was tachypneic overnight on\n and sedation increased; CXR stable. IP recommending thoracic\n surgery for trach. Naloxone held yesterday given concern over\n systemic absorption resulting in tachypnea, although unlikely given\n that patient had episode of tachypnea prior to initiating naloxone.\n CTA neg for PE.\n - Wean FiO2 and PEEP, goal PaO2>60-65, SaO2>90%\n - Wean sedation as tolerated\n - tracheostomy today with thoracic surgery\n # Anemia: Initially p/w hematemesis and EGD showed diuelafoy's lesion.\n Hct stable >24 hours s/p 4 units since . CTAP with new pancreatic\n pseudocyst but per d/w radiology no definitive explanation for hct\n drop. NG lavage negative. GI also doubts possibility of significant\n GI bleed, defer upper endoscopy for now. Appreciate hematology recs,\n do not feel that this is DIC.\n - CBC daily, transfuse for hct<21, plt<50\n - Follow-up heme and GI recs if any\n - Guaiac stools\n - Per heme, send ADAT\n # Neuro: Initially dilated pupils with CT showing cerebral edema. Neuro\n exam now stable. Repeat CTH demonstrates interval improvement.\n - Continue leviteracetam\n - Wean sedation as possible\n - Neuro recs if any\n # Necrotizing pancreatitis/SIRS: Secondary to alcohol complicated by\n SIRS and ARDS. Patient continues to have pressor requirement, with neo\n +/- levo. Aggressive volume resuscitation with >50L but\n diuresing well. Also with new pseudocyst (3 cm x 3 cm) on abdominal CT\n on . Naloxone held yesterday given tachypnea. KUB unable to\n determine of OG is post-pyloric.\n - Wean pressors with goal MAP >65\n - Hold off on trophic feeds for now given uncertainty of OG placement.\n Will consider dobhoff placement in AM.\n # Hyponatremia: In setting of decreased effective circulating volume in\n setting of SIRS and IABP. Patient has received hypertonic saline\n boluses with improvement in serum sodium and osm.\n - Given improvement in neuro exam, continue to hold hypertonic saline.\n # Acute renal failure: Patient had HD line placed and on CVVH. CVVH\n with even TBB pending assessment of hemorrhage.\n - CVVH per renal.\n - Trend chemistries\n #Thrombocytopenia: Platelets stable but have trended down from a\n normal count on admission. No clear etiology at this time. DIC panel\n with elevated FDP but normal fibrinogen. HIT PF4 antibody negative.\n - Trend plt, transfuse for plt<10 or <50 if signs of hemorrhage.\n # Wound care: Per wound care recs.\n # Acute hepatitis: Likely alcoholic hepatitis with fatty infiltration,\n and no evidence of distal obstruction. RUQ u/s shows marked liver\n echogenicity but no ascites.\n - Trend LFTs\n # Alcoholism: Patient describes history of withdrawal symptoms, but\n not prior seizure. Last drink was night prior to presentation.\n Tachycardia, weakness, and elevated lactate could be consistent with\n thiamine deficiency.\n - Thiamine, vb12, folate\n - Valium with CIWA > 10\n FEN: TPN without heparin, replete as necessary.\n PPx: SCD, PPI\n Access: RIJ, LIJ, left radial arterial line\n Code: Full\n ICU Care\n Nutrition:\n TPN w/ Lipids - 05:50 PM 73 mL/hour\n Glycemic Control:\n Lines:\n Multi Lumen - 02:02 PM\n Dialysis Catheter - 04:56 PM\n Arterial Line - 01:30 PM\n 20 Gauge - 03:56 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:ICU\n" }, { "category": "Physician ", "chartdate": "2131-06-06 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 679139, "text": "Chief Complaint:\n 24 Hour Events:\n - Sinus CT showed opacification in right side sinuses. ENT will swab\n meatus but did not think draining it would help and did not think\n fevers and eosinophilia from this.\n - CT Abdomen grossly unchanged from prior with thickening of the cecum\n consistent with infection, necrotizing pancreatitis, no abscess\n - Heme recommended Heparin 5000 and stim for am because\n adrenal insufficiency can cause eosinophilia\n - ID recommended PO/PR vanc if abdominal CT showed difference from\n prior or developed diarrhea\n - TTE with normal valves and nl/hyperdynamic EF but could not rule out\n vegetation.\n - IJ d/c'd and cultured\n - CVL placed over wire into HD site (left IJ)\n - HD line d/c'd and cultured\n - Spiked temp to 101.6 at MN. Cement-like secretions from ETT.\n - thoracics never did trach because peep high (want it to be 5)\n - O2 sats lower with Po2 in 60s this am. Cement like secretions from\n ETT. Concern for VAP so started aztreonam\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Daptomycin - 06:42 PM\n Infusions:\n Fentanyl (Concentrate) - 325 mcg/hour\n Midazolam (Versed) - 15 mg/hour\n Norepinephrine - 0.3 mcg/Kg/min\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 04:30 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 06:32 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.4\nC (101.1\n Tcurrent: 38.3\nC (101\n HR: 120 (95 - 121) bpm\n BP: 101/55(71) {86/42(61) - 117/61(79)} mmHg\n RR: 34 (22 - 41) insp/min\n SpO2: 94%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 84 kg (admission): 113.5 kg\n Height: 67 Inch\n CVP: 19 (12 - 22)mmHg\n Total In:\n 7,831 mL\n 824 mL\n PO:\n TF:\n IVF:\n 6,067 mL\n 349 mL\n Blood products:\n Total out:\n 11,152 mL\n 245 mL\n Urine:\n 195 mL\n 45 mL\n NG:\n 350 mL\n 200 mL\n Stool:\n Drains:\n Balance:\n -3,321 mL\n 579 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 30\n RR (Spontaneous): 0\n PEEP: 12 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10, Hemodynamic Instability\n PIP: 16 cmH2O\n Plateau: 19 cmH2O\n Compliance: 66.7 cmH2O/mL\n SpO2: 94%\n ABG: 7.35/41/63/21/-2\n Ve: 14.4 L/min\n PaO2 / FiO2: 126\n Physical Examination\n GEN: Intubated, sedated\n HEENT: icteric sclera. MMM\n NECK: Sites clean/dry/no oozing\n LUNGS: Crackles bilaterally anteriorly.\n HEART: RRR\n ABD: Distended. NT.\n EXTREM: 2+ edema with weeping wounds without surrounding erythema\n SKIN: Jaundice\n Labs / Radiology\n 79 K/uL\n 7.3 g/dL\n 93 mg/dL\n 1.8 mg/dL\n 21 mEq/L\n 5.5 mEq/L\n 26 mg/dL\n 103 mEq/L\n 133 mEq/L\n 23.0 %\n 50.7 K/uL\n [image002.jpg]\n 11:05 AM\n 03:58 PM\n 09:00 PM\n 09:06 PM\n 02:35 AM\n 02:39 AM\n 08:24 AM\n 02:56 PM\n 04:02 AM\n 04:11 AM\n WBC\n 50.7\n 50.7\n Hct\n 24.9\n 23.0\n Plt\n 73\n 79\n Cr\n 1.4\n 1.2\n 1.8\n TCO2\n 24\n 22\n 23\n 25\n 23\n 21\n 24\n Glucose\n 106\n 119\n 144\n 177\n 144\n 135\n 93\n Other labs: PT / PTT / INR:17.4/40.1/1.6, CK / CKMB / Troponin-T:256//,\n ALT / AST:36/205, Alk Phos / T Bili:138/17.6, Amylase / Lipase:19/35,\n Differential-Neuts:38.0 %, Band:2.0 %, Lymph:14.0 %, Mono:5.0 %,\n Eos:26.0 %, D-dimer:6389 ng/mL, Fibrinogen:419 mg/dL, Lactic Acid:2.4\n mmol/L, Albumin:1.7 g/dL, LDH:821 IU/L, Ca++:8.8 mg/dL, Mg++:2.0 mg/dL,\n PO4:4.3 mg/dL\n Assessment and Plan\n 28yo M with alcoholic hepatitis and necrotizing pancreatitis\n complicated by ARDS, SIRS, ARF, UGIB, fevers and eosinophilia.\n #. Fever: New for him in the last few days. concerning for sepsis given\n increasing pressor requirement and tachycardia. Possible source is VAP\n as has had cement-like secretions from ETT and increasing O2\n requirement necessitating increasing his peep. Started on aztreonam\n this morning for extended GN coverage. CT abd with no change but\n continued colonic thickening consistent with infection. Other source\n could be skin as extensive break down although no sign of infection\n superimposed on breakdown and on broad gram positive coverage.\n - Cte broad spectrum gram negative coverage with aztreonam for\n pseudomonal coverage and VAP\n -Would obtain bronch for washings/cultures as unable to culture\n secretions from ETT because too thick\n - F/U cultures\n - Consider TEE to r/o vegetations as TTE was not a definitive study if\n bronch negative or continues to spike through dapto/aztreonam\n - Cte dapto for now\n - appreciate ID recs. consider vanc po/pr for colonic thickening if\n decompensates further or has diarrhea but for now has other source of\n fevers and Abd CT unchanged so will hold further abx treatment.\n - Lines changed over wire and HD line pulled last night. All line\n cultures pending.\n #. Respiratory Failure: ARDS secondary to necrotizing pancreatitis.\n PEEP at 20 currently. Cannot be trached with such a high peep according\n to thoracics so did not get trach last pm. Hypoxic on morning blood\n gas.\n - Would favor inc. FiO2 rather than peep given need to wean peep for\n trach placement but if unable to achieve good O2 sats will need to inc\n peep\n - F/U thoracic recs re: trach as has been intubated many days now\n #. Anemia: Hcts stable and no RP bleed seen on CT.\n - trend hcts\n - f/u heme recs\n - guaiac stools\n #. Eosinophilia: Likely drug reaction (to vanc?) with less likely\n etiology being infection.\n - appreciate heme recs\n - Will stim this am to r/o adrenal insufficiency as cause of\n eosinophilia\n - cte dapto instead of vanc for treatment of GPCs in blood\n #. Thrombocytopenia: Appreciate heme recs. Do not feel this is DIC.\n - Restarted heparin at low dose for dvt ppx\n - Monitor platelets daily and transfuse for plt <10 or <50 if signs of\n bleed\n #. Acute renal Failure:\n - Patient taking CVVH holiday as HD line had to be pulled in setting\n of fever and sepsis so creatinine slowly rising\n - f/u renal recs re:replacing HD line and starting CVVH\n #. Hyperkalemia: Likely in setting of ARF after stopping CVVH.\n - Will give kayexalate\n - Will follow up renal recs re: restarting HD\n #. Wounds: Wound care suggested dermatology consult for non-healing\n wounds.\n ICU Care\n Nutrition: Started TPN yesterday\n TPN w/ Lipids - 04:54 PM 73 mL/hour\n Glycemic Control:\n Lines:\n 20 Gauge - 03:56 PM\n Arterial Line - 08:15 PM\n Multi Lumen - 10:00 PM\n Prophylaxis:\n DVT: hep sc BID\n Stress ulcer: ppi\n VAP: mouth care\n Comments:\n Communication: Comments: with family\n Code status: Full code\n Disposition: ICU\n" }, { "category": "Nursing", "chartdate": "2131-06-03 00:00:00.000", "description": "Nursing Progress Note", "row_id": 678610, "text": "Sepsis, Severe (with organ dysfunction)\n Assessment:\n Remains on levo\n One episode of hypotension today to mid 70/s along with acute tachypnea\n and hypoxia--?cause\n +Blood culture from dialysis line, WBC elevated today\n Action:\n Levo increased to 0.19 from 0.09 +\n Response:\n Improved blood pressure\n Plan:\n Continue w/ levo at current does\n Wean if possible\n Continue to run patient even to slightly negative on CRRT\n ?Change lines\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Patient tacypnic, hypotensive and hypoxic this am.\n Sats to 85, blood pressure to 70/ and resp. rate around 50\n ?Waking , overbreathing causing decreasing sats and hypotension\n Action:\n Levo to .19,\n Midaz. 5 mg bolus\n Fentanyl up to 350\n Abg done, then fio2 to 100\n MICU team into eavluate\n Response:\n Slowly improving resp. rate to low 40s\n Blood pressure to 90/\n Improved sats\n Plan:\n slowly wean fio2\n Lower extremity ultrasounds--?PE\n CTA of chest this afternoon\n Problem\n Alteration in neuro status\n Assessment:\n Remains sedated on fent/versed\n Gag reflex improving, impaired cough\n Pupils equal and sluggishly reactive\n Tachypnic early today--?due to decreasing sedation\n Action:\n Fent/Versed increased\n Response:\n Less tachypnic\n Plan:\n Keep on current sedation, increase if needed.\n" }, { "category": "Physician ", "chartdate": "2131-06-05 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 678966, "text": "TITLE:\n Chief Complaint: Mr. is a 28 year old gentleman with alcoholic\n hepatitis and necrotizing pancreatitis complicated by ARDS, SIRS, ARF\n and UGIB.\n 24 Hour Events:\n BLOOD CULTURED - At 10:46 AM\n fungal bld culture\n FEVER - 102.4\nF - 08:00 AM\n Hospital day 19\n - ID: cont daptomycin, would not restart flagyl, recc sinus CT to r/o\n sinusitis, would change lines when able\n - heme/onc: eosinophilia may be secondary to infection vs stress\n response. still don't think he has DIC but want recheck of fibrinogen.\n re: restarting heparin, attg reccomends a lower dose in TPN to reduce\n bleeding risk (was getting 9000u); will let us know the dose later\n - thoracic surgery will place trach on \n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Metronidazole - 04:00 AM\n Daptomycin - 06:42 PM\n Infusions:\n Calcium Gluconate (CRRT) - 1.4 grams/hour\n Fentanyl (Concentrate) - 325 mcg/hour\n Midazolam (Versed) - 15 mg/hour\n Norepinephrine - 0.25 mcg/Kg/min\n KCl (CRRT) - 1 mEq./hour\n Other ICU medications:\n Pantoprazole (Protonix) - 08:16 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 07:40 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 39.1\nC (102.4\n Tcurrent: 35.7\nC (96.3\n HR: 96 (93 - 128) bpm\n BP: 113/64(83) {84/43(57) - 117/64(83)} mmHg\n RR: 20 (16 - 38) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 128 kg (admission): 113.5 kg\n Height: 67 Inch\n CVP: 15 (0 - 17)mmHg\n Total In:\n 10,084 mL\n 3,257 mL\n PO:\n TF:\n IVF:\n 8,252 mL\n 2,699 mL\n Blood products:\n Total out:\n 11,204 mL\n 5,005 mL\n Urine:\n 102 mL\n 100 mL\n NG:\n 250 mL\n 200 mL\n Stool:\n Drains:\n Balance:\n -1,120 mL\n -1,748 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 30\n RR (Spontaneous): 0\n PEEP: 12 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10\n PIP: 18 cmH2O\n Plateau: 22 cmH2O\n Compliance: 44.4 cmH2O/mL\n SpO2: 100%\n ABG: 7.30/48/84./21/-2\n Ve: 13 L/min\n PaO2 / FiO2: 168\n Physical Examination\n General Appearance: Overweight / Obese, No(t) Diaphoretic\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: Rhonchorous: )\n Abdominal: Soft\n Extremities: Right: 2+, Left: 2+\n Skin: Not assessed, Jaundice\n Neurologic: Responds to: Noxious stimuli, Movement: Non -purposeful,\n Tone: Not assessed\n Labs / Radiology\n 73 K/uL\n 8.1 g/dL\n 177 mg/dL\n 1.2 mg/dL\n 21 mEq/L\n 4.8 mEq/L\n 19 mg/dL\n 106 mEq/L\n 135 mEq/L\n 24.9 %\n 50.7 K/uL\n [image002.jpg]\n 07:42 PM\n 10:37 PM\n 02:03 AM\n 02:17 AM\n 11:05 AM\n 03:58 PM\n 09:00 PM\n 09:06 PM\n 02:35 AM\n 02:39 AM\n WBC\n 37.5\n 50.7\n Hct\n 23.9\n 24.4\n 24.9\n Plt\n 66\n 73\n Cr\n 1.6\n 1.4\n 1.2\n TCO2\n 25\n 27\n 24\n 22\n 23\n 25\n Glucose\n 128\n 125\n 106\n 119\n 144\n 177\n Other labs: PT / PTT / INR:17.4/40.1/1.6, CK / CKMB / Troponin-T:240//,\n ALT / AST:29/257, Alk Phos / T Bili:132/14.0, Amylase / Lipase:19/35,\n Differential-Neuts:38.0 %, Band:2.0 %, Lymph:14.0 %, Mono:5.0 %,\n Eos:26.0 %, D-dimer:6389 ng/mL, Fibrinogen:419 mg/dL, Lactic Acid:1.3\n mmol/L, Albumin:1.6 g/dL, LDH:607 IU/L, Ca++:8.7 mg/dL, Mg++:2.1 mg/dL,\n PO4:3.5 mg/dL\n Assessment and Plan\n Mr. is a 28 year old gentleman with alcoholic hepatitis and\n necrotizing pancreatitis complicated by ARDS, SIRS, ARF and UGIB.\n # Question sepsis/leukocytosis: Increasing hypotensive, tachycardic,\n and episodically febrile, with rising levophed requirement and rising\n white count. Multiple possible sources of new infection, including\n line infection, sinusitis, pancreatitis, and cellulitis. Hypotension\n also concerning for question PE but ruled out with negative CTA.\n Restarted daptomycin on to cover for MRSA and cellulitis and\n because of concern of drug reaction to vancomycin. Other antibiotic\n courses include Flagyl , ; Meropenem ;\n Vancomycin . Lines include RIJ (18 days) and left HD line (10\n days).\n - continue daptomycin\n - hold off on restarting flagyl\n - f/u culture data\n - ID reccs\n - trend differential following eosinophilia closely\n - consider sinus CT and sinus drainage per ENT\n # Respiratory Failure: ARDS secondary to necrotizing pancreatitis\n compounded by hypoxia, tachypnea in setting of anion gap metabolic\n acidosis, increased abdominal pressure, and EtOH withdrawal. PEEP\n decreased to 12 from 20 and FiO2 to 50%. Was tachypneic overnight on\n and sedation increased; CXR stable. IP recommending thoracic\n surgery for trach. Naloxone held yesterday given concern over\n systemic absorption resulting in tachypnea, although unlikely given\n that patient had episode of tachypnea prior to initiating naloxone.\n CTA neg for PE.\n - Wean FiO2 and PEEP, goal PaO2>60-65, SaO2>90%\n - Wean sedation as tolerated\n - tracheostomy later today with thoracic surgery\n # Anemia: Initially p/w hematemesis and EGD showed diuelafoy's lesion.\n Hct stable >24 hours s/p 4 units since . CTAP with new pancreatic\n pseudocyst but per d/w radiology no definitive explanation for hct\n drop. NG lavage negative. GI also doubts possibility of significant\n GI bleed, defer upper endoscopy for now. Appreciate hematology recs,\n do not feel that this is DIC.\n - CBC daily, transfuse for hct<21, plt<50\n - Follow-up heme and GI recs if any\n - Guaiac stools\n - Per heme, send ADAT\n # Neuro: Initially dilated pupils with CT showing cerebral edema. Neuro\n exam now stable. Repeat CTH demonstrates interval improvement.\n - Continue leviteracetam\n - Wean sedation as possible\n - Neuro recs if any\n # Necrotizing pancreatitis/SIRS: Secondary to alcohol complicated by\n SIRS and ARDS. Patient continues to have pressor requirement, with neo\n +/- levo. Aggressive volume resuscitation with >50L but\n diuresing well. Also with new pseudocyst (3 cm x 3 cm) on abdominal CT\n on . Naloxone held yesterday given tachypnea. KUB unable to\n determine of OG is post-pyloric.\n - Wean pressors with goal MAP >65\n - Hold off on trophic feeds for now given uncertainty of OG placement.\n Will consider dobhoff placement in AM.\n # Hyponatremia: In setting of decreased effective circulating volume in\n setting of SIRS and IABP. Patient has received hypertonic saline\n boluses with improvement in serum sodium and osm.\n - Given improvement in neuro exam, continue to hold hypertonic saline.\n # Acute renal failure: Patient had HD line placed and on CVVH. CVVH\n with even TBB pending assessment of hemorrhage.\n - CVVH per renal.\n - Trend chemistries\n #Thrombocytopenia: Platelets stable but have trended down from a\n normal count on admission. No clear etiology at this time. DIC panel\n with elevated FDP but normal fibrinogen. HIT PF4 antibody negative.\n - Trend plt, transfuse for plt<10 or <50 if signs of hemorrhage.\n # Wound care: Per wound care recs.\n # Acute hepatitis: Likely alcoholic hepatitis with fatty infiltration,\n and no evidence of distal obstruction. RUQ u/s shows marked liver\n echogenicity but no ascites.\n - Trend LFTs\n # Alcoholism: Patient describes history of withdrawal symptoms, but\n not prior seizure. Last drink was night prior to presentation.\n Tachycardia, weakness, and elevated lactate could be consistent with\n thiamine deficiency.\n - Thiamine, vb12, folate\n - Valium with CIWA > 10\n FEN: TPN without heparin, replete as necessary.\n PPx: SCD, PPI\n Access: RIJ, LIJ, left radial arterial line\n Code: Full\n ICU Care\n Nutrition:\n TPN w/ Lipids - 05:50 PM 73 mL/hour\n Glycemic Control:\n Lines:\n Multi Lumen - 02:02 PM\n Dialysis Catheter - 04:56 PM\n Arterial Line - 01:30 PM\n 20 Gauge - 03:56 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": "2131-06-08 00:00:00.000", "description": "Nursing Progress Note", "row_id": 679632, "text": "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 Sepsis, Severe (with organ dysfunction)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Physician ", "chartdate": "2131-06-10 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 679950, "text": "Chief Complaint: Pacreatitis\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 Levophed requirement continuing\n CVVH with negative 700cc overnight\n Patient has had decrease in WBC count to 29.1\n History obtained from Patient\n Allergies:\n Meropenem\n skin blisters a\n Last dose of Antibiotics:\n Micafungin - 11:00 PM\n Aztreonam - 08:00 AM\n Metronidazole - 10:00 AM\n Linezolid - 10:31 AM\n Vancomycin - 10:32 AM\n Infusions:\n Midazolam (Versed) - 12 mg/hour\n Calcium Gluconate (CRRT) - 1.6 grams/hour\n Norepinephrine - 0.02 mcg/Kg/min\n Fentanyl (Concentrate) - 150 mcg/hour\n KCl (CRRT) - 3 mEq./hour\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: Fever, 99.8\n Genitourinary: Dialysis\n Flowsheet Data as of 11:23 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.7\nC (99.8\n Tcurrent: 36.5\nC (97.7\n HR: 84 (80 - 104) bpm\n BP: 120/68(86) {84/42(54) - 128/75(93)} mmHg\n RR: 16 (0 - 28) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 134 kg (admission): 113.5 kg\n Height: 67 Inch\n CVP: 11 (10 - 19)mmHg\n Total In:\n 9,393 mL\n 5,298 mL\n PO:\n TF:\n 148 mL\n 225 mL\n IVF:\n 7,336 mL\n 4,220 mL\n Blood products:\n Total out:\n 10,064 mL\n 5,576 mL\n Urine:\n 23 mL\n 43 mL\n NG:\n Stool:\n Drains:\n Balance:\n -671 mL\n -278 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 26\n RR (Spontaneous): 3\n PEEP: 8 cmH2O\n FiO2: 50%\n RSBI: 45\n PIP: 23 cmH2O\n Plateau: 20 cmH2O\n SpO2: 100%\n ABG: 7.36/44/90./23/0\n Ve: 12.7 L/min\n PaO2 / FiO2: 180\n Physical Examination\n Cardiovascular: (S2: Distant)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Dullness : ),\n (Breath Sounds: Diminished: )\n Abdominal: Soft, Non-tender\n Extremities: Right: 3+, Left: 3+\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 7.7 g/dL\n 61 K/uL\n 166 mg/dL\n 0.9 mg/dL\n 23 mEq/L\n 3.9 mEq/L\n 40 mg/dL\n 98 mEq/L\n 134 mEq/L\n 23.4 %\n 29.1 K/uL\n [image002.jpg]\n 08:11 AM\n 12:31 PM\n 04:16 PM\n 06:28 PM\n 08:15 PM\n 02:23 AM\n 02:43 AM\n 05:01 AM\n 08:15 AM\n 08:34 AM\n WBC\n 29.1\n Hct\n 23.3\n 23.6\n 23.4\n Plt\n 66\n 61\n Cr\n 1.5\n 0.9\n TCO2\n 25\n 24\n 27\n 25\n 21\n 26\n Glucose\n 149\n 184\n 166\n Other labs: PT / PTT / INR:16.1/43.4/1.4, CK / CKMB /\n Troponin-T:214/3/0.07, ALT / AST:55/193, Alk Phos / T Bili:138/25.0,\n Amylase / Lipase:19/35, Differential-Neuts:65.0 %, Band:12.0 %,\n Lymph:3.0 %, Mono:7.0 %, Eos:2.0 %, D-dimer:6389 ng/mL, Fibrinogen:502\n mg/dL, Lactic Acid:1.6 mmol/L, Albumin:2.0 g/dL, LDH:789 IU/L, Ca++:8.8\n mg/dL, Mg++:2.0 mg/dL, PO4:2.7 mg/dL\n Fluid analysis / Other labs: 7.36/36/78-->\n Imaging: CXR-small effusions, likley -basilar consolidations.\n Microbiology: No new culture results\n Assessment and Plan\n 28 yo male with initial presentaiton with pancreatitis now with\n prolonged hospital course complicated by and requiring treatment for-->\n 1) RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)-\n -CVVH to continue with goal negative fluid balance today\n -He has been able to continue to tolerate early negative fluid balance.\n -Based up on his physical exam this morning (reasonable skin turgor)\n and X-ray->mild effusions do hope to be able to achieve reasonable\n response with negative fluid balance and capacity to move to decrease\n in PEEP as possible.\n 2)Respiratory Failure-\n -PEEP able to be decreased in the setting of early ability to move to\n diuresis\n -Versed for sedation\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)-\n -Will attempt to wean Levophed as possible\n -Hydrocort 100mg q 8 hours\n -Flagyl/Linezolid/Aztreonam/Micafungin all to continue\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n IMPAIRED SKIN INTEGRITY\n HEPATITIS, ACUTE TOXIC (INCLUDING ALCOHOLIC, ACETAMINOPHEN, ETC.)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ICU Care\n Nutrition:\n TPN w/ Lipids - 05:28 PM 76 mL/hour\n Fibersource HN (Full) - 04:35 AM 20 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 08:15 PM\n Multi Lumen - 10:00 PM\n Dialysis Catheter - 11:35 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 Blocker in TPN\n VAP: per protocol\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 45 minutes\n" }, { "category": "Respiratory ", "chartdate": "2131-06-10 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 679879, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 24\n Ideal body weight: 67.1 None\n Ideal tidal volume: 268.4 / 402.6 / 536.8 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location:\n Reason:\n Tube Type\n Tracheostomy tube:\n Type: Standard\n Manufacturer: Portex\n Size: 8.0mm\n PMV: No\n Cuff Management:\n Vol/Press:\n Cuff pressure: 29 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Clear\n Comments:\n Secretions\n Sputum color / consistency: Bloody / Thick\n Sputum source/amount: Suctioned / Small\n Comments: PT WAS SUCTIONED ALL SHIFT, FOR SMALL AMOUNTS OF BLOODY/BL\n TINGE\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated,\n Maintain PEEP at current level and reduce FiO2 as tolerated, Reduce\n PEEP as tolerated, Adjust Min. ventilation to control pH\n Reason for continuing current ventilatory support: Sedated / Paralyzed,\n Cannot protect airway, Cannot manage secretions, Underlying illness not\n resolved; Comments: Pt remains on full support on vent. Pt had rhonchi\n lung sounds all shift, which tunred to clear lung sounds by end of\n shift. Pt still has bloody secretions, but no adventitious\n secretions. Pt scored a strong RSBI of 47, showing good spontaneous\n respiratort drive. Pt to continue current support and be assessed by\n MD team.\n BEDSIDE RSBI- 45\n" }, { "category": "Nursing", "chartdate": "2131-06-04 00:00:00.000", "description": "Nursing Progress Note", "row_id": 678813, "text": "Hypotension (not Shock)\n Assessment:\n Labile bp on levo gtt to keep map\n Action:\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2131-06-04 00:00:00.000", "description": "Nursing Progress Note", "row_id": 678817, "text": "Hypotension (not Shock)\n Assessment:\n Labile bp on levo gtt to keep map >65..on fent & versed gtt for\n sedation\n Action:\n levo gtt increased to 0.2 ..fent gtt down 325mcg\n Response:\n sbp >90/ does drop to 80/\ns at times\n Plan:\n wean fent as tol but keep comf\n Respiratory failure, acute (not ARDS/)\n Assessment:\n remains vented with labile sat\ns when tachypneic\n Action:\n suctioned for sm amt yellow/white\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2131-06-05 00:00:00.000", "description": "Nursing Progress Note", "row_id": 678923, "text": "TITLE:\n Hypotension (not Shock)\n Assessment:\n Spontaneous drop in sbp to 70\ns on levophed 0.20 mcg/kg/min\n Action:\n Decreased pfr to keep even transient and levophed increased to\n 0.25mcg/min\n Response:\n Sbp responded to 120\ns, pfr increased throughout remainder of shift and\n fld removal 1.1liters at midnight\n Plan:\n Wean levophed as bp tolerates providing able to cont to achieve\n negative fluid balance.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Abg and spo2 stable overnight on cmv tv 400 fio2 50% rr 30 peep 12.BBs\n clear dim at lt base. 0630 discoordinate with ventilator, spont\n breathing over vent 6-8 breaths . On fentanyl 3325mcg/hr and versed\n 15mg/hr\n Action:\n Vap bundle q4h, lavage and suct for sm amts of thick tan\n secretions.Rotating bed . Valium 10mg iv given for discooordinate\n breathing. No fentanyl or versed wean overnight as pt planned o.r.\n today.\n Response:\n Bbs remain dim at lt base otherwise clear. Spo2 adeq, slight metabolic\n acidosis.Tolerating lt to back rotation overnight. Discoordinate\n breathing resolved with valium x 1.\n Plan:\n Cont vap bundle, rotating bed. Cycle abgs q6h while on crrt. Wean fio2\n as tolerated. Trach planned for today in o.r.\n Sepsis, Severe (with organ dysfunction)\n Assessment:\n Tmax 98.8 wbc 50 this a.m. remains on daptomycin for + bl cult.\n Continues to be pressor dependent on levophed. CVVHDF continues i/o\n even at 1900. filter intact, rescue flushed q4h\n Action:\n sbp stable on levophed 0.25mcg/kg/m Goal Pfr 200-400cc net negative/hr\n Response:\n Tolerating aggressive fluid removal overnight net negative 1.7 liters\n by 0700 . Levophed remains at 0.25mcg/kg/m\n Plan:\n Cont fluid removal as tolerates until pt to o.r. for trach today.\n" }, { "category": "Physician ", "chartdate": "2131-06-06 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 679133, "text": "Chief Complaint:\n 24 Hour Events:\n - Sinus CT showed opacification in right side sinuses. ENT will swab\n meatus but did not think draining it would help and did not think\n fevers and eosinophilia from this.\n - CT Abdomen grossly unchanged from prior with thickening of the cecum\n consistent with infection, necrotizing pancreatitis, no abscess\n - Heme recommended Heparin 5000 and stim for am because\n adrenal insufficiency can cause eosinophilia\n - ID recommended PO/PR vanc if abdominal CT showed difference from\n prior or developed diarrhea\n - TTE with normal valves and nl/hyperdynamic EF but could not rule out\n vegetation.\n - IJ d/c'd and cultured\n - CVL placed over wire into HD site (left IJ)\n - HD line d/c'd and cultured\n - Spiked temp to 101.6 at MN. Cement-like secretions from ETT.\n - thoracics never did trach because peep high (want it to be 5)\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Daptomycin - 06:42 PM\n Infusions:\n Fentanyl (Concentrate) - 325 mcg/hour\n Midazolam (Versed) - 15 mg/hour\n Norepinephrine - 0.3 mcg/Kg/min\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 04:30 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 06:32 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.4\nC (101.1\n Tcurrent: 38.3\nC (101\n HR: 120 (95 - 121) bpm\n BP: 101/55(71) {86/42(61) - 117/61(79)} mmHg\n RR: 34 (22 - 41) insp/min\n SpO2: 94%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 84 kg (admission): 113.5 kg\n Height: 67 Inch\n CVP: 19 (12 - 22)mmHg\n Total In:\n 7,831 mL\n 824 mL\n PO:\n TF:\n IVF:\n 6,067 mL\n 349 mL\n Blood products:\n Total out:\n 11,152 mL\n 245 mL\n Urine:\n 195 mL\n 45 mL\n NG:\n 350 mL\n 200 mL\n Stool:\n Drains:\n Balance:\n -3,321 mL\n 579 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 30\n RR (Spontaneous): 0\n PEEP: 12 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10, Hemodynamic Instability\n PIP: 16 cmH2O\n Plateau: 19 cmH2O\n Compliance: 66.7 cmH2O/mL\n SpO2: 94%\n ABG: 7.35/41/63/21/-2\n Ve: 14.4 L/min\n PaO2 / FiO2: 126\n Physical Examination\n GEN: Intubated, sedated\n HEENT: icteric sclera. MMM\n NECK: Sites clean/dry/no oozing\n LUNGS:\n HEART:\n ABD:\n EXTREM: 2+ edema\n SKIN: Jaundice\n Labs / Radiology\n 79 K/uL\n 7.3 g/dL\n 93 mg/dL\n 1.8 mg/dL\n 21 mEq/L\n 5.5 mEq/L\n 26 mg/dL\n 103 mEq/L\n 133 mEq/L\n 23.0 %\n 50.7 K/uL\n [image002.jpg]\n 11:05 AM\n 03:58 PM\n 09:00 PM\n 09:06 PM\n 02:35 AM\n 02:39 AM\n 08:24 AM\n 02:56 PM\n 04:02 AM\n 04:11 AM\n WBC\n 50.7\n 50.7\n Hct\n 24.9\n 23.0\n Plt\n 73\n 79\n Cr\n 1.4\n 1.2\n 1.8\n TCO2\n 24\n 22\n 23\n 25\n 23\n 21\n 24\n Glucose\n 106\n 119\n 144\n 177\n 144\n 135\n 93\n Other labs: PT / PTT / INR:17.4/40.1/1.6, CK / CKMB / Troponin-T:256//,\n ALT / AST:36/205, Alk Phos / T Bili:138/17.6, Amylase / Lipase:19/35,\n Differential-Neuts:38.0 %, Band:2.0 %, Lymph:14.0 %, Mono:5.0 %,\n Eos:26.0 %, D-dimer:6389 ng/mL, Fibrinogen:419 mg/dL, Lactic Acid:2.4\n mmol/L, Albumin:1.7 g/dL, LDH:821 IU/L, Ca++:8.8 mg/dL, Mg++:2.0 mg/dL,\n PO4:4.3 mg/dL\n Assessment and Plan\n 28yo M with alcoholic hepatitis and necrotizing pancreatitis\n complicated by ARDS, SIRS, ARF, UGIB, fevers and eosinophilia.\n #. Fever: New for him in the last few days. concerning for sepsis given\n increasing pressor requirement and tachycardia. Possible source is VAP\n as has had cement-like secretions from ETT. CT abd with no change but\n continued colonic thickening consistent with infection. Other source\n could be skin as extensive break down although no sign of infection\n superimposed on breakdown and on broad gram positive coverage.\n - Would add gram negative coverage ?meropenem for pseudomonal coverage\n and VAP\n -Would obtain sputum culture and consider bronch for washings/cultures\n - F/U cultures\n - Consider TEE to r/o vegetations as TTE was not a definitive study\n - Cte dapto for now\n - appreciate ID recs. consider vanc po/pr for colonic thickening if\n decompensates further or has diarrhea.\n - Lines changed over wire and HD line pulled last night. All line\n cultures pending.\n #. Respiratory Failure: ARDS secondary to necrotizing pancreatitis.\n PEEP at 20 currently. Cannot be trached with such a high peep according\n to thoracics so did not get trach last pm.\n - F/U thoracic recs re: trach as has been intubated many days now\n - attempt to wean peep\n #. Anemia: Hcts stable and no RP bleed seen on CT.\n - trend hcts\n - f/u heme recs\n - guaiac stools\n #. Eosinophilia: Likely drug reaction (to vanc?) with less likely\n etiology being infection.\n - appreciate heme recs\n - Will stim this am to r/o adrenal insufficiency as cause of\n eosinophilia\n - cte dapto instead of vanc for treatment of GPCs in blood\n #. Thrombocytopenia: Appreciate heme recs. Do not feel this is DIC.\n - Restarted heparin at low dose for dvt ppx\n - Monitor platelets daily and transfuse for plt <10 or <50 if signs of\n bleed\n #. Acute renal Failure:\n - Patient taking CVVH holiday as HD line had to be pulled in setting\n of fever and sepsis so creatinine slowly rising\n - f/u renal recs re:replacing HD line and starting CVVH\n ICU Care\n Nutrition: Started TPN last pm.\n TPN w/ Lipids - 04:54 PM 73 mL/hour\n Glycemic Control:\n Lines:\n 20 Gauge - 03:56 PM\n Arterial Line - 08:15 PM\n Multi Lumen - 10:00 PM\n Prophylaxis:\n DVT: hep sc BID\n Stress ulcer: ppi\n VAP: mouth care\n Comments:\n Communication: Comments: with family\n Code status: Full code\n Disposition: ICU\n" }, { "category": "Physician ", "chartdate": "2131-06-06 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 679134, "text": "Chief Complaint:\n 24 Hour Events:\n - Sinus CT showed opacification in right side sinuses. ENT will swab\n meatus but did not think draining it would help and did not think\n fevers and eosinophilia from this.\n - CT Abdomen grossly unchanged from prior with thickening of the cecum\n consistent with infection, necrotizing pancreatitis, no abscess\n - Heme recommended Heparin 5000 and stim for am because\n adrenal insufficiency can cause eosinophilia\n - ID recommended PO/PR vanc if abdominal CT showed difference from\n prior or developed diarrhea\n - TTE with normal valves and nl/hyperdynamic EF but could not rule out\n vegetation.\n - IJ d/c'd and cultured\n - CVL placed over wire into HD site (left IJ)\n - HD line d/c'd and cultured\n - Spiked temp to 101.6 at MN. Cement-like secretions from ETT.\n - thoracics never did trach because peep high (want it to be 5)\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Daptomycin - 06:42 PM\n Infusions:\n Fentanyl (Concentrate) - 325 mcg/hour\n Midazolam (Versed) - 15 mg/hour\n Norepinephrine - 0.3 mcg/Kg/min\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 04:30 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 06:32 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.4\nC (101.1\n Tcurrent: 38.3\nC (101\n HR: 120 (95 - 121) bpm\n BP: 101/55(71) {86/42(61) - 117/61(79)} mmHg\n RR: 34 (22 - 41) insp/min\n SpO2: 94%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 84 kg (admission): 113.5 kg\n Height: 67 Inch\n CVP: 19 (12 - 22)mmHg\n Total In:\n 7,831 mL\n 824 mL\n PO:\n TF:\n IVF:\n 6,067 mL\n 349 mL\n Blood products:\n Total out:\n 11,152 mL\n 245 mL\n Urine:\n 195 mL\n 45 mL\n NG:\n 350 mL\n 200 mL\n Stool:\n Drains:\n Balance:\n -3,321 mL\n 579 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 30\n RR (Spontaneous): 0\n PEEP: 12 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10, Hemodynamic Instability\n PIP: 16 cmH2O\n Plateau: 19 cmH2O\n Compliance: 66.7 cmH2O/mL\n SpO2: 94%\n ABG: 7.35/41/63/21/-2\n Ve: 14.4 L/min\n PaO2 / FiO2: 126\n Physical Examination\n GEN: Intubated, sedated\n HEENT: icteric sclera. MMM\n NECK: Sites clean/dry/no oozing\n LUNGS:\n HEART:\n ABD:\n EXTREM: 2+ edema\n SKIN: Jaundice\n Labs / Radiology\n 79 K/uL\n 7.3 g/dL\n 93 mg/dL\n 1.8 mg/dL\n 21 mEq/L\n 5.5 mEq/L\n 26 mg/dL\n 103 mEq/L\n 133 mEq/L\n 23.0 %\n 50.7 K/uL\n [image002.jpg]\n 11:05 AM\n 03:58 PM\n 09:00 PM\n 09:06 PM\n 02:35 AM\n 02:39 AM\n 08:24 AM\n 02:56 PM\n 04:02 AM\n 04:11 AM\n WBC\n 50.7\n 50.7\n Hct\n 24.9\n 23.0\n Plt\n 73\n 79\n Cr\n 1.4\n 1.2\n 1.8\n TCO2\n 24\n 22\n 23\n 25\n 23\n 21\n 24\n Glucose\n 106\n 119\n 144\n 177\n 144\n 135\n 93\n Other labs: PT / PTT / INR:17.4/40.1/1.6, CK / CKMB / Troponin-T:256//,\n ALT / AST:36/205, Alk Phos / T Bili:138/17.6, Amylase / Lipase:19/35,\n Differential-Neuts:38.0 %, Band:2.0 %, Lymph:14.0 %, Mono:5.0 %,\n Eos:26.0 %, D-dimer:6389 ng/mL, Fibrinogen:419 mg/dL, Lactic Acid:2.4\n mmol/L, Albumin:1.7 g/dL, LDH:821 IU/L, Ca++:8.8 mg/dL, Mg++:2.0 mg/dL,\n PO4:4.3 mg/dL\n Assessment and Plan\n 28yo M with alcoholic hepatitis and necrotizing pancreatitis\n complicated by ARDS, SIRS, ARF, UGIB, fevers and eosinophilia.\n #. Fever: New for him in the last few days. concerning for sepsis given\n increasing pressor requirement and tachycardia. Possible source is VAP\n as has had cement-like secretions from ETT. CT abd with no change but\n continued colonic thickening consistent with infection. Other source\n could be skin as extensive break down although no sign of infection\n superimposed on breakdown and on broad gram positive coverage.\n - Would add gram negative coverage ?meropenem for pseudomonal coverage\n and VAP\n -Would obtain sputum culture and consider bronch for washings/cultures\n - F/U cultures\n - Consider TEE to r/o vegetations as TTE was not a definitive study\n - Cte dapto for now\n - appreciate ID recs. consider vanc po/pr for colonic thickening if\n decompensates further or has diarrhea.\n - Lines changed over wire and HD line pulled last night. All line\n cultures pending.\n #. Respiratory Failure: ARDS secondary to necrotizing pancreatitis.\n PEEP at 20 currently. Cannot be trached with such a high peep according\n to thoracics so did not get trach last pm. Hypoxic on morning blood\n gas.\n - Would favor inc. FiO2 rather than peep given need to wean peep for\n trach placement but if unable to achieve good O2 sats will need to inc\n peep\n - F/U thoracic recs re: trach as has been intubated many days now\n #. Anemia: Hcts stable and no RP bleed seen on CT.\n - trend hcts\n - f/u heme recs\n - guaiac stools\n #. Eosinophilia: Likely drug reaction (to vanc?) with less likely\n etiology being infection.\n - appreciate heme recs\n - Will stim this am to r/o adrenal insufficiency as cause of\n eosinophilia\n - cte dapto instead of vanc for treatment of GPCs in blood\n #. Thrombocytopenia: Appreciate heme recs. Do not feel this is DIC.\n - Restarted heparin at low dose for dvt ppx\n - Monitor platelets daily and transfuse for plt <10 or <50 if signs of\n bleed\n #. Acute renal Failure:\n - Patient taking CVVH holiday as HD line had to be pulled in setting\n of fever and sepsis so creatinine slowly rising\n - f/u renal recs re:replacing HD line and starting CVVH\n #. Hyperkalemia: Likely in setting of ARF after stopping CVVH.\n - Will give kayexalate\n - Will follow up renal recs re: restarting HD\n ICU Care\n Nutrition: Started TPN last pm.\n TPN w/ Lipids - 04:54 PM 73 mL/hour\n Glycemic Control:\n Lines:\n 20 Gauge - 03:56 PM\n Arterial Line - 08:15 PM\n Multi Lumen - 10:00 PM\n Prophylaxis:\n DVT: hep sc BID\n Stress ulcer: ppi\n VAP: mouth care\n Comments:\n Communication: Comments: with family\n Code status: Full code\n Disposition: ICU\n" }, { "category": "Physician ", "chartdate": "2131-06-02 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 678293, "text": "TITLE:\n Chief Complaint: Mr. is a 28 year old gentleman with alcoholic\n hepatitis and necrotizing pancreatitis complicated by ARDS, SIRS, and\n UGIB.\n 24 Hour Events:\n BLOOD CULTURED - At 04:02 AM\n periph and cl\n - Hct 25.7->23.9->24.2->24.1\n - PEEP 12->10, 0.5\n - 0200: Patient acutely became tachypneic to 60, dysynchronous on vent\n with high PIPs in setting of overbreathing. Nothing on suction. HR up\n to 120s, T 101. Patient opened his eyes and wiggled his left hand to\n command. Pan-cultured. Restarted midaz gtt. Given acetaminophen. CVVH\n switched to even. CXR shows no focal consolidation. Held off on\n restarting antibiotics. ABG 7.48/39/60, increased PEEP to 12.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Meropenem - 02:45 AM\n Metronidazole - 08:05 PM\n Daptomycin - 09:30 PM\n Infusions:\n KCl (CRRT) - 1 mEq./hour\n Midazolam (Versed) - 15 mg/hour\n Fentanyl (Concentrate) - 200 mcg/hour\n Norepinephrine - 0.09 mcg/Kg/min\n Calcium Gluconate (CRRT) - 1.4 grams/hour\n Other ICU medications:\n Pantoprazole (Protonix) - 08:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 10:37 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.3\nC (101\n Tcurrent: 37.6\nC (99.6\n HR: 112 (106 - 124) bpm\n BP: 105/57(74) {89/45(58) - 132/75(95)} mmHg\n RR: 50 (23 - 50) insp/min\n SpO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 128 kg (admission): 113.5 kg\n Height: 67 Inch\n CVP: 11 (5 - 18)mmHg\n Total In:\n 10,016 mL\n 8,464 mL\n PO:\n TF:\n IVF:\n 7,976 mL\n 6,443 mL\n Blood products:\n 282 mL\n 375 mL\n Total out:\n 11,260 mL\n 8,231 mL\n Urine:\n 135 mL\n 162 mL\n NG:\n 350 mL\n 100 mL\n Stool:\n Drains:\n Balance:\n -1,245 mL\n 233 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 30\n RR (Spontaneous): 0\n PEEP: 12 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10, RR >35\n PIP: 42 cmH2O\n Plateau: 13 cmH2O\n SpO2: 100%\n ABG: 7.43/40/112/26/1\n Ve: 22 L/min\n PaO2 / FiO2: 224\n Physical Examination\n General Appearance: Well nourished, Overweight / Obese, anasarca\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, OG tube\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: No(t)\n Bronchial: , Rhonchorous: )\n Abdominal: Soft, Non-tender, minimal bowel sounds\n Extremities: Right: 2+, Left: 2+\n Skin: Warm, Rash: bilateral legs\n Neurologic: Responds to: Noxious stimuli, Movement: Non -purposeful,\n Tone: Not assessed\n Labs / Radiology\n 63 K/uL\n 7.9 g/dL\n 159 mg/dL\n 2.0 mg/dL\n 26 mEq/L\n 4.8 mEq/L\n 24 mg/dL\n 103 mEq/L\n 137 mEq/L\n 26.5 %\n 27.2 K/uL\n [image002.jpg]\n 02:23 AM\n 05:56 AM\n 09:27 AM\n 02:33 PM\n 03:16 PM\n 03:36 PM\n 05:18 PM\n 07:13 PM\n 07:19 PM\n 10:09 PM\n Hct\n 22.6\n 26.5\n Plt\n 63\n TCO2\n 30\n 26\n 28\n 26\n 30\n 25\n 26\n 27\n Glucose\n 159\n Other labs: PT / PTT / INR:14.9/38.7/1.3, ALT / AST:29/257, Alk Phos /\n T Bili:132/14.0, Amylase / Lipase:19/35, Differential-Neuts:39.0 %,\n Band:3.0 %, Lymph:32.0 %, Mono:6.0 %, Eos:13.0 %, D-dimer:6389 ng/mL,\n Fibrinogen:293 mg/dL, Lactic Acid:1.5 mmol/L, Albumin:1.6 g/dL, LDH:607\n IU/L, Ca++:9.4 mg/dL, Mg++:2.0 mg/dL, PO4:3.4 mg/dL\n Assessment and Plan\n Mr. is a 28 year old gentleman with alcoholic hepatitis and\n necrotizing pancreatitis complicated by ARDS, SIRS, and UGIB.\n # Anemia: Initially p/w hematemesis and EGD showed diuelafoy's lesion.\n Hct continues to trend down (30->25->24), now s/p 3 units since .\n CTAP with new pancreatic pseudocyst but per d/w radiology no definitive\n explanation for hct drop. NG lavage negative. GI also doubts\n possibility of significant GI bleed, will not scope for now. Also on\n differential is DIC given occasional schistocytes seen on smear.\n - Trend CBC Q8H, transfuse for hct<21 or plt<50\n - GI reccs\n - consider heme-onc consult\n - CVVH at even to slightly negative balance for now\n - Hemolysis labs\n - consider heme-onc consult\n # Respiratory Failure: ARDS secondary to necrotizing pancreatitis\n compounded by hypoxia, tachypnea in setting of anion gap metabolic\n acidosis, increased abdominal pressure, and EtOH withdrawal. PEEP\n decreased to 12 from 20 and FiO2 to 50%.\n - Wean FiO2 and PEEP, goal PaO2>60-65%\n - wean sedation as tolerated\n # Leukocytosis: WBC count trending down but again with eosinophilia on\n and spiked fever in early a.m. Has been off meropenem/vanc since\n and flagyl since . CT abdomen shows bowel thickening thought\n to likely represent colitis and not bowel wall edema. Paranasal\n sinuses also opacified.\n - touch base with ID regarding restarting antibiotics\n - HD and CVL line culture\n - f/u culture data\n # Neuro: Initially dilated pupils with CT showing cerebral edema. Neuro\n exam now stable. Repeat CTH demonstrates interval improvement.\n - Continue leviteracetam\n - Wean sedation as possible\n - Neuro recs if any\n # Necrotizing pancreatitis/SIRS: Secondary to alcohol complicated by\n SIRS and ARDS. Patient continues to have pressor requirement, with neo\n +/- levo. Aggressive volume resuscitation with >50L but\n diuresing well. Also with new pseudocyst (3 cm x 3 cm) on abdominal CT\n on .\n - Wean pressors with goal MAP >65\n - advance OGT and assess for post-pyloric positioning\n - trophic tube feeds once OGT post-pyloric\n - naloxone po to promote bowel motility\n # Hyponatremia: In setting of decreased effective circulating volume\n in setting of SIRS and IABP. Patient has received hypertonic saline\n boluses with improvement in serum sodium and osm.\n - Given improvement in neuro exam, continue to hold hypertonic saline.\n # Acute renal failure: Patient had HD line placed and on CVVH. CVVH\n with even TBB pending assessment of hemorrhage.\n - CVVH per renal.\n - Trend chemistries\n #Thrombocytopenia: Platelets stable but have trended down from a\n normal count on admission. No clear etiology at this time. DIC panel\n with elevated FDP but normal fibrinogen. HIT PF4 antibody negative.\n - Trend plt, transfuse for plt<10 or <50 if signs of hemorrhage.\n # Wound care: Per wound care recs.\n # Acute hepatitis: Likely alcoholic hepatitis with fatty infiltration,\n and no evidence of distal obstruction. RUQ u/s shows marked liver\n echogenicity but no ascites.\n - Trend LFTs\n # Alcoholism: Patient describes history of withdrawal symptoms, but\n not prior seizure. Last drink was night prior to presentation.\n Tachycardia, weakness, and elevated lactate could be consistent with\n thiamine deficiency.\n - Thiamine, vb12, folate\n - Valium with CIWA > 10\n FEN: TPN without heparin, replete as necessary.\n ICU Care\n Nutrition:\n TPN w/ Lipids - 03:22 PM 73 mL/hour\n Glycemic Control:\n Lines:\n Multi Lumen - 02:02 PM\n Dialysis Catheter - 04:56 PM\n Arterial Line - 01:30 PM\n 20 Gauge - 11:15 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Respiratory ", "chartdate": "2131-06-04 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 678674, "text": "Demographics\n Day of intubation: 18\n Day of mechanical ventilation: 18\n Ideal body weight: 67.1 None\n Ideal tidal volume: 268.4 / 402.6 / 536.8 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location: ICU\n Reason: Re-intubation\n Tube Type\n ETT:\n Position: 23 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 28 cmH2O\n Cuff volume: 6 mL / Air\n Lung sounds\n RLL Lung Sounds: Clear\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 response (sleeping / sedated)\n Invasive ventilation assessment:\n Trigger work assessment: Abnormal trigger efforts (efforts during\n inspiratory)\n Dysynchrony assessment: Erratic exhaled Tidal Volumes\n Plan\n Next 24-48 hours: Reduce PEEP as tolerated\n Reason for continuing current ventilatory support: Cannot protect\n airway, Hemodynimic instability, Underlying illness not resolved\n" }, { "category": "Physician ", "chartdate": "2131-06-05 00:00:00.000", "description": "ICU Event Note", "row_id": 679048, "text": "Clinician: Attending\n I met with Mr family, including his brother and his parents, to\n discuss all details of his clinical status and recent studies, answer\n all questions, and discuss management plans. RN and resident\n were present for the end of the meeting.\n Total time spent: 60 minutes\n Patient is critically ill.\n" }, { "category": "Physician ", "chartdate": "2131-06-06 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 679125, "text": "Chief Complaint:\n 24 Hour Events:\n - Sinus CT showed opacification in right side sinuses. ENT will swab\n meatus but did not think draining it would help and did not think\n fevers and eosinophilia from this.\n - CT Abdomen grossly unchanged from prior with thickening of the cecum\n consistent with infection, necrotizing pancreatitis, no abscess\n - Heme recommended Heparin 5000 and stim for am because\n adrenal insufficiency can cause eosinophilia\n - ID recommended PO/PR vanc if abdominal CT showed difference from\n prior or developed diarrhea\n - TTE with normal valves and nl/hyperdynamic EF but could not rule out\n vegetation.\n - IJ d/c'd and cultured\n - CVL placed over wire into HD site (left IJ)\n - HD line d/c'd and cultured\n - Spiked temp to 101.6 at MN. Cement-like secretions from ETT.\n - thoracics never did trach because peep high (want it to be 5)\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Daptomycin - 06:42 PM\n Infusions:\n Fentanyl (Concentrate) - 325 mcg/hour\n Midazolam (Versed) - 15 mg/hour\n Norepinephrine - 0.3 mcg/Kg/min\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 04:30 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 06:32 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.4\nC (101.1\n Tcurrent: 38.3\nC (101\n HR: 120 (95 - 121) bpm\n BP: 101/55(71) {86/42(61) - 117/61(79)} mmHg\n RR: 34 (22 - 41) insp/min\n SpO2: 94%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 84 kg (admission): 113.5 kg\n Height: 67 Inch\n CVP: 19 (12 - 22)mmHg\n Total In:\n 7,831 mL\n 824 mL\n PO:\n TF:\n IVF:\n 6,067 mL\n 349 mL\n Blood products:\n Total out:\n 11,152 mL\n 245 mL\n Urine:\n 195 mL\n 45 mL\n NG:\n 350 mL\n 200 mL\n Stool:\n Drains:\n Balance:\n -3,321 mL\n 579 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 30\n RR (Spontaneous): 0\n PEEP: 12 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10, Hemodynamic Instability\n PIP: 16 cmH2O\n Plateau: 19 cmH2O\n Compliance: 66.7 cmH2O/mL\n SpO2: 94%\n ABG: 7.35/41/63/21/-2\n Ve: 14.4 L/min\n PaO2 / FiO2: 126\n Physical Examination\n GEN: Intubated, sedated\n HEENT: icteric sclera. MMM\n NECK: Sites clean/dry/no oozing\n LUNGS:\n HEART:\n ABD:\n EXTREM: 2+ edema\n SKIN: Jaundice\n Labs / Radiology\n 79 K/uL\n 7.3 g/dL\n 93 mg/dL\n 1.8 mg/dL\n 21 mEq/L\n 5.5 mEq/L\n 26 mg/dL\n 103 mEq/L\n 133 mEq/L\n 23.0 %\n 50.7 K/uL\n [image002.jpg]\n 11:05 AM\n 03:58 PM\n 09:00 PM\n 09:06 PM\n 02:35 AM\n 02:39 AM\n 08:24 AM\n 02:56 PM\n 04:02 AM\n 04:11 AM\n WBC\n 50.7\n 50.7\n Hct\n 24.9\n 23.0\n Plt\n 73\n 79\n Cr\n 1.4\n 1.2\n 1.8\n TCO2\n 24\n 22\n 23\n 25\n 23\n 21\n 24\n Glucose\n 106\n 119\n 144\n 177\n 144\n 135\n 93\n Other labs: PT / PTT / INR:17.4/40.1/1.6, CK / CKMB / Troponin-T:256//,\n ALT / AST:36/205, Alk Phos / T Bili:138/17.6, Amylase / Lipase:19/35,\n Differential-Neuts:38.0 %, Band:2.0 %, Lymph:14.0 %, Mono:5.0 %,\n Eos:26.0 %, D-dimer:6389 ng/mL, Fibrinogen:419 mg/dL, Lactic Acid:2.4\n mmol/L, Albumin:1.7 g/dL, LDH:821 IU/L, Ca++:8.8 mg/dL, Mg++:2.0 mg/dL,\n PO4:4.3 mg/dL\n Assessment and Plan\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n IMPAIRED SKIN INTEGRITY\n HEPATITIS, ACUTE TOXIC (INCLUDING ALCOHOLIC, ACETAMINOPHEN, ETC.)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ICU Care\n Nutrition:\n TPN w/ Lipids - 04:54 PM 73 mL/hour\n Glycemic Control:\n Lines:\n 20 Gauge - 03:56 PM\n Arterial Line - 08:15 PM\n Multi Lumen - 10:00 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": "2131-06-09 00:00:00.000", "description": "Physician Resident/Attending Progress Note - MICU", "row_id": 679795, "text": "Chief Complaint:\n 24 Hour Events:\n - Trach placed; PEEP decreased to 8\n - Methadone started and able to wean fentanyl down 350 -> 250\n - Levophed weaned down to 0.03 throughout day\n - Received 1 unit pRBC post trach with increase in Hct 21 -> 24\n - Received DDAVP x 1 dose for oozing around trach site\n - Increased ISS for hyperglycemia in setting of steroids\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 04:00 AM\n Aztreonam - 08:00 PM\n Micafungin - 09:00 PM\n Linezolid - 10:00 PM\n Metronidazole - 02:00 AM\n Infusions:\n Norepinephrine - 0.02 mcg/Kg/min\n Midazolam (Versed) - 15 mg/hour\n Calcium Gluconate (CRRT) - 2 grams/hour\n KCl (CRRT) - 4 mEq./hour\n Fentanyl (Concentrate) - 200 mcg/hour\n Other ICU medications:\n Carafate (Sucralfate) - 04:00 AM\n Heparin Sodium (Prophylaxis) - 04:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:11 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.1\nC (98.8\n Tcurrent: 36.2\nC (97.1\n HR: 82 (72 - 95) bpm\n BP: 102/59(71) {84/44(56) - 126/66(85)} mmHg\n RR: 21 (21 - 30) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 134 kg (admission): 113.5 kg\n Height: 67 Inch\n CVP: 13 (11 - 20)mmHg\n Total In:\n 11,098 mL\n 2,908 mL\n PO:\n TF:\n IVF:\n 8,814 mL\n 2,445 mL\n Blood products:\n 798 mL\n Total out:\n 12,489 mL\n 2,758 mL\n Urine:\n 24 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,391 mL\n 150 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 30\n RR (Spontaneous): 0\n PEEP: 8 cmH2O\n FiO2: 50%\n PIP: 24 cmH2O\n Plateau: 21 cmH2O\n Compliance: 30.8 cmH2O/mL\n SpO2: 98%\n ABG: 7.42/40/111/24/1\n Ve: 11.9 L/min\n PaO2 / FiO2: 222\n Physical Examination\n GEN: Intubated, sedated\n HEENT: icteric sclera. MMM\n NECK: Sites clean/dry/no oozing\n LUNGS: Crackles bilaterally anteriorly.\n HEART: RRR\n ABD: Distended. NT.\n EXTREM: 2+ edema with weeping wounds without surrounding erythema,\n ulcers/lesions on legs with bandages C/D/I\n SKIN: Jaundice\n Labs / Radiology\n 43 K/uL\n 8.3 g/dL\n 157 mg/dL\n 1.2 mg/dL\n 24 mEq/L\n 3.4 mEq/L\n 36 mg/dL\n 98 mEq/L\n 131 mEq/L\n 24.9 %\n 40.7 K/uL\n [image002.jpg]\n 10:28 AM\n 12:54 PM\n 06:02 PM\n 06:08 PM\n 09:18 PM\n 09:33 PM\n 12:23 AM\n 01:12 AM\n 01:57 AM\n 04:24 AM\n WBC\n 40.7\n Hct\n 22.3\n 21.7\n 24.6\n 24.9\n Plt\n 47\n 43\n Cr\n 1.2\n TCO2\n 30\n 29\n 29\n 27\n 26\n 27\n Glucose\n 187\n 194\n 186\n 181\n 157\n Other labs: PT / PTT / INR:17.5/38.7/1.6, CK / CKMB /\n Troponin-T:214/3/0.07, ALT / AST:49/186, Alk Phos / T Bili:133/26.8,\n Amylase / Lipase:19/35, Differential-Neuts:56.0 %, Band:14.0 %,\n Lymph:4.0 %, Mono:6.0 %, Eos:1.0 %, D-dimer:6389 ng/mL, Fibrinogen:502\n mg/dL, Lactic Acid:2.0 mmol/L, Albumin:1.7 g/dL, LDH:920 IU/L, Ca++:7.6\n mg/dL, Mg++:2.0 mg/dL, PO4:2.2 mg/dL\n tissue cx pending. BAL/asp: bact cx neg, fungal pending. \n coag neg staph x 1 bottle.\n Derm biopsy: mixed cells c/w either inflammatory, infectious, or\n reactive\n Assessment and Plan\n 28yo M with alcoholic hepatitis and necrotizing pancreatitis\n complicated by ARDS, SIRS, ARF, UGIB, fevers and eosinophilia.\n #. Fever: Afebrile x >2d; source unclear. Question of fever adrenal\n insufficiency; now on steroids. Concern for infection with increased\n bandemia today although leukocytosis improved. Blood/tissue/BAL cx\n NGTD, CT abd with persistent inflammation concerning for infection. CT\n sinuses w/ opacification of unclear time course.\n - Cte broad spectrum antibiotic coverage with aztreonam for extended GN\n coverage, linezolid for MRSA and VRE for bacteremia, flagyl IV, vanc PO\n empirically per ID recs given increasing leukocytosis and colon\n inflammation on CT, micafungin for antifungal coverage\n - F/u WBC and temp curve\n - F/u derm biopsy results to see if skin infection; already on broad\n spectrum antibiotic coverage inc. skin flora coverage\n - F/u cultures\n - F/u ID recs; question: how to down abx over next few days\n #. Respiratory Failure: ARDS secondary to necrotizing pancreatitis. S/p\n trach placement yesterday on PEEP 8\n - Sutures out on \n - Cont to wean as tolerated. Try pressure support today.\n - Cte to wean fentanyl\n #. Adrenal Insufficiency: Unclear with stim if clear adrenal\n insufficiency but hypotension improving with steroids (lower pressor\n requirement) and improving eosinophilia\n - Will continue steroids IV X 5 days (day 4) then change to prednisone\n to taper\n #. Eosinophilia: Adrenal insufficiency v. drug reaction (?PPI; vanc &\n dapto less likely d/t time course). Fungal and parasitic infection also\n possible etiologies.\n - stim positive for adrenal insufficiency. Cte steroids.\n - Off PPI, vanc, dapto\n - Cte fungal coverage as above\n #. Anemia: Hct stable since 1 unit pRBC and 1 dose DDAVP s/p trach with\n some oozing at site.\n - recheck hemolysis labs\n - trend hcts Q6H, 1unit pRBCs now, guaiac stools and NGT aspirate\n - If not appropriate bump with blood consider scope to ensure doboff\n did not cause significant bleed\n - holding ppx with PPI or sucralfate given issues of eosinophilia and\n ARF\n #. Thrombocytopenia: Appreciate heme recs. Do not feel this is DIC.\n Recent decrease may be in setting of linezolid.\n - Monitor platelets daily and transfuse for plt <10 or <50 if signs of\n bleed\n - Would d/c linezolid when/if able\n #. Acute renal Failure: Appreciate renal recs. Cr improved on CVVH. Off\n sucralfate due to concern for electrolyte abnormalities.\n - Cte volume depletion with CVVH as long as pressor requirement does\n not increase\n #. Wounds: Derm biopsy pending - inflammatory, infectious, or reactive.\n F/u recs.\n #. Agitation: Cont methadone given decreased sensitivity to fentanyl;\n titrate prn\n #. Glucose intolerance: In setting of steroids; adjust ISS prn\n ICU Care\n Nutrition:\n TPN w/ Lipids - 07:00 PM 75 mL/hour->start TFs today at slow\n rate\n Glycemic Control: ISS\n Lines:\n Arterial Line - 08:15 PM\n Multi Lumen - 10:00 PM\n Dialysis Catheter - 11:35 PM\n Prophylaxis:\n DVT: Pneumoboots\n Stress ulcer: Holding PPI and sucralfate for now. Try H2 blocker today\n in TPN.\n VAP: HOB elevation, Mouth care\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n ------ Protected Section ------\n MICU ATTENDING ADDENDUM\n I saw and examined the patient, and was physically present with the ICU\n 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: 28M alc hep, pancreatitis, refractory shock,\n ARDS - now tolerating aggressive fluid removal on low dose pressors.\n Trach yesterday.\n Exam notable for Tm 98.8 BP 110/50 HR 85 RR 30 with sat 96 on VAC\n 400x30 0.5 8 7.43/38/102. WD man, anasarca. Coarse BS B. Distant s1s2.\n Obese, no BS. 3+ edema. Labs notable for WBC 40K, HCT 24, lactate 2.0.\n CXR with , EKG .\n Agree with plan to manage resp failure with slow wean of sedation and\n RR to 26 until comfortable and overbreathing. For ongoing fevers\n and leukocytosis with pressor requirement, will continue steroids and\n broad antibiotic coverage. For ARF, continue CVVH with goal -250cc/h.\n For pancreatitis, initiate trophic post-pyloric TFs. Remainder of plan\n as outlined above. Plan d/w family at bedside.\n Patient is critically ill\n Total time: 50 min\n ------ Protected Section Addendum Entered By: , MD\n on: 12:09 PM ------\n" }, { "category": "Physician ", "chartdate": "2131-06-02 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 678390, "text": "TITLE:\n Chief Complaint: Mr. is a 28 year old gentleman with alcoholic\n hepatitis and necrotizing pancreatitis complicated by ARDS, SIRS, and\n UGIB.\n 24 Hour Events:\n ULTRASOUND - At 09:00 PM\n bil lower extremities r/o dvt\n - Hct 24 -> 22.6 -> transfused 1 u PRBC, DDAVP -> 26. Heme-onc to see\n pt on re: ?DIC.\n - hypotensive to SBP in 60s while getting CVVH, went up on pressors and\n stabilized\n - got tachypneic to 50s and we went up on fent/midaz significantly, but\n responded only marginally. got cxr (unchanged), ekg (unchanged).\n despite high RR did not drop PCO2 significantly so got LENIs to r/o DVT\n b/c of concern for PE, neg study. ?naloxone reaction.\n - started daptomycin and flagyl to cover for cellulitis and c. diff.\n didn't do vancomycin b/c of ?allergy in setting of eosinophilia.\n - called IP re: trach; will plan to do procedure on monday and family\n preferred not to do it today\n - surgery agrees w/ post-pyloric TFs. advanced OGT and gave reglan for\n motility.\n - small BM, sent c diff\n - surgery signed off, will come on a prn basis\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Daptomycin - 09:30 PM\n Metronidazole - 04:00 AM\n Infusions:\n Norepinephrine - 0.03 mcg/Kg/min\n Calcium Gluconate (CRRT) - 1.2 grams/hour\n KCl (CRRT) - 1 mEq./hour\n Fentanyl (Concentrate) - 350 mcg/hour\n Midazolam (Versed) - 17 mg/hour\n Other ICU medications:\n Pantoprazole (Protonix) - 08:00 PM\n Diazepam (Valium) - 11:56 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 07:52 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.7\nC (99.8\n Tcurrent: 36.8\nC (98.3\n HR: 104 (97 - 124) bpm\n BP: 100/53(69) {94/48(64) - 132/75(95)} mmHg\n RR: 38 (35 - 50) insp/min\n SpO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 128 kg (admission): 113.5 kg\n Height: 67 Inch\n CVP: 13 (5 - 13)mmHg\n Total In:\n 8,974 mL\n 2,969 mL\n PO:\n TF:\n IVF:\n 6,847 mL\n 2,400 mL\n Blood products:\n 375 mL\n Total out:\n 9,202 mL\n 3,954 mL\n Urine:\n 162 mL\n 75 mL\n NG:\n 100 mL\n 50 mL\n Stool:\n Drains:\n Balance:\n -228 mL\n -985 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 30\n RR (Spontaneous): 0\n PEEP: 12 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10, RR >35\n PIP: 29 cmH2O\n Plateau: 13 cmH2O\n SpO2: 100%\n ABG: 7.45/36/80./23/1\n Ve: 15.2 L/min\n PaO2 / FiO2: 160\n Physical Examination\n General Appearance: Well nourished, Overweight / Obese, anasarca\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: Rhonchorous: )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: 2+, Left: 2+\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 54 K/uL\n 8.2 g/dL\n 160 mg/dL\n 1.6 mg/dL\n 23 mEq/L\n 4.6 mEq/L\n 26 mg/dL\n 102 mEq/L\n 136 mEq/L\n 24.5 %\n 28.9 K/uL\n [image002.jpg]\n 09:27 AM\n 02:33 PM\n 03:16 PM\n 03:36 PM\n 05:18 PM\n 07:13 PM\n 07:19 PM\n 10:09 PM\n 03:05 AM\n 03:53 AM\n WBC\n 28.9\n Hct\n 22.6\n 26.5\n 24.5\n Plt\n 63\n 54\n Cr\n 1.6\n TCO2\n 28\n 26\n 30\n 25\n 26\n 27\n 26\n Glucose\n 159\n 177\n 160\n Other labs: PT / PTT / INR:15.8/40.5/1.4, ALT / AST:29/257, Alk Phos /\n T Bili:132/14.0, Amylase / Lipase:19/35, Differential-Neuts:37.0 %,\n Band:18.0 %, Lymph:7.0 %, Mono:2.0 %, Eos:15.0 %, D-dimer:6389 ng/mL,\n Fibrinogen:293 mg/dL, Lactic Acid:1.5 mmol/L, Albumin:1.6 g/dL, LDH:607\n IU/L, Ca++:9.1 mg/dL, Mg++:2.0 mg/dL, PO4:4.3 mg/dL\n Assessment and Plan\n Mr. is a 28 year old gentleman with alcoholic hepatitis and\n necrotizing pancreatitis complicated by ARDS, SIRS, and UGIB.\n # Anemia: Initially p/w hematemesis and EGD showed diuelafoy's lesion.\n Hct continues to trend down (30->25->24->26 with transfusion) now s/p 4\n units since . CTAP with new pancreatic pseudocyst but per d/w\n radiology no definitive explanation for hct drop. NG lavage negative.\n GI also doubts possibility of significant GI bleed, will not scope for\n now. Also on differential is DIC given occasional schistocytes seen on\n smear.\n - hct, transfuse for hct<21 (or Hct<25 and falling) or plt<50\n - GI reccs\n - heme-onc consult\n - CVVH for goal of -2L off per day\n - guaiac stools\n # Respiratory Failure: ARDS secondary to necrotizing pancreatitis\n compounded by hypoxia, tachypnea in setting of anion gap metabolic\n acidosis, increased abdominal pressure, and EtOH withdrawal. PEEP\n decreased to 12 from 20 and FiO2 to 50%. Was tachypneic overnight on\n and sedation increased; CXR stable. IP consulted regarding trach\n on Monday. Discussed with family.\n - Wean FiO2 and PEEP, goal PaO2>60-65%\n - wean sedation as tolerated\n - continue naloxone despite some concern that may have systemic\n absorption with resultant tachypnea\n - touch base with neuro re: possible neurologic cause for tachypnea\n - f/u IP reccs regarding trach\n # Leukocytosis: WBC count trending down but again with eosinophilia on\n and spiked fever in early a.m. on that day. Has been off\n meropenem/vanc since and flagyl since . CT abdomen shows\n bowel thickening thought to likely represent colitis and not bowel wall\n edema. Paranasal sinuses also opacified. Restarted daptomycin\n (instead of vanco because of concern for drug reaction; treating\n question line infection vs cellulites) and flagyl on per ID reccs.\n - continue daptomycin, flagyl per ID\n - check c. diff\n - f/u cx data (HD and CVL line culture pending)\n # Neuro: Initially dilated pupils with CT showing cerebral edema. Neuro\n exam now stable. Repeat CTH demonstrates interval improvement.\n - Continue leviteracetam\n - Wean sedation as possible\n - Neuro recs if any\n # Necrotizing pancreatitis/SIRS: Secondary to alcohol complicated by\n SIRS and ARDS. Patient continues to have pressor requirement, with neo\n +/- levo. Aggressive volume resuscitation with >50L but\n diuresing well. Also with new pseudocyst (3 cm x 3 cm) on abdominal CT\n on .\n - Wean pressors with goal MAP >65\n - place Duboff for post-pyloric trophic tube feeds\n - naloxone po to promote bowel motility\n # Hyponatremia: In setting of decreased effective circulating volume\n in setting of SIRS and IABP. Patient has received hypertonic saline\n boluses with improvement in serum sodium and osm.\n - Given improvement in neuro exam, continue to hold hypertonic saline.\n # Acute renal failure: Patient had HD line placed and on CVVH. CVVH\n with even TBB pending assessment of hemorrhage.\n - CVVH per renal.\n - Trend chemistries\n #Thrombocytopenia: Platelets stable but have trended down from a\n normal count on admission. No clear etiology at this time. DIC panel\n with elevated FDP but normal fibrinogen. HIT PF4 antibody negative.\n - Trend plt, transfuse for plt<10 or <50 if signs of hemorrhage.\n # Wound care: Per wound care recs.\n # Acute hepatitis: Likely alcoholic hepatitis with fatty infiltration,\n and no evidence of distal obstruction. RUQ u/s shows marked liver\n echogenicity but no ascites.\n - Trend LFTs\n # Alcoholism: Patient describes history of withdrawal symptoms, but\n not prior seizure. Last drink was night prior to presentation.\n Tachycardia, weakness, and elevated lactate could be consistent with\n thiamine deficiency.\n - Thiamine, vb12, folate\n - Valium with CIWA > 10\n FEN: TPN without heparin, replete as necessary.\n ICU Care\n Nutrition:\n TPN w/ Lipids - 03:22 PM 73 mL/hour\n Glycemic Control:\n Lines:\n Multi Lumen - 02:02 PM\n Dialysis Catheter - 04:56 PM\n Arterial Line - 01:30 PM\n 20 Gauge - 11:15 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2131-06-02 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 678407, "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 Nec panc\n EtOH abuse\n Respiratory failure\n Hematocrit falling\n Requiring less PEEP\n ARF on CVVH\n Cerebral edema\n UGI bleed\n 24 Hour Events:\n bil lower extremities r/o dvt negative\n transfused\n received ddAVP\n pressors increased\n persistent tachypnea\n PO narcan started\n Recent CT with colitis\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Daptomycin - 09:30 PM\n Metronidazole - 04:00 AM\n Infusions:\n Norepinephrine - 0.03 mcg/Kg/min\n Calcium Gluconate (CRRT) - 1.2 grams/hour\n KCl (CRRT) - 1 mEq./hour\n Midazolam (Versed) - 17 mg/hour\n Other ICU medications:\n Pantoprazole (Protonix) - 08:00 PM\n Diazepam (Valium) - 11:56 PM\n kepra\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 08:18 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.7\nC (99.8\n Tcurrent: 36.8\nC (98.3\n HR: 104 (97 - 124) bpm\n BP: 100/53(69) {94/48(64) - 132/75(95)} mmHg\n RR: 38 (35 - 50) insp/min\n SpO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 128 kg (admission): 113.5 kg\n Height: 67 Inch\n CVP: 13 (5 - 13)mmHg\n Total In:\n 8,974 mL\n 3,038 mL\n PO:\n TF:\n IVF:\n 6,847 mL\n 2,433 mL\n Blood products:\n 375 mL\n Total out:\n 9,202 mL\n 4,447 mL\n Urine:\n 162 mL\n 75 mL\n NG:\n 100 mL\n 50 mL\n Stool:\n Drains:\n Balance:\n -228 mL\n -1,409 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 30\n RR (Spontaneous): 0\n PEEP: 12 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10, RR >35\n PIP: 29 cmH2O\n SpO2: 100%\n ABG: 7.45/36/80./23/1\n Ve: 15.2 L/min\n PaO2 / FiO2: 160\n Physical Examination\n Intubated, sedated, unresponsive, pinpoint pupils\n Coarse vented BS\n Rrr\n Abd\n soft, absent bowel sounds\n Extrem - edematous\n Labs / Radiology\n CXR stable hazy infiltrates\n 8.2 g/dL\n 54 K/uL\n 160 mg/dL\n 1.6 mg/dL\n 23 mEq/L\n 4.6 mEq/L\n 26 mg/dL\n 102 mEq/L\n 136 mEq/L\n 24.5 %\n 28.9 K/uL\n [image002.jpg]\n 09:27 AM\n 02:33 PM\n 03:16 PM\n 03:36 PM\n 05:18 PM\n 07:13 PM\n 07:19 PM\n 10:09 PM\n 03:05 AM\n 03:53 AM\n WBC\n 28.9\n Hct\n 22.6\n 26.5\n 24.5\n Plt\n 63\n 54\n Cr\n 1.6\n TCO2\n 28\n 26\n 30\n 25\n 26\n 27\n 26\n Glucose\n 159\n 177\n 160\n Other labs: PT / PTT / INR:15.8/40.5/1.4, ALT / AST:29/257, Alk Phos /\n T Bili:132/14.0, Amylase / Lipase:19/35, Differential-Neuts:37.0 %,\n Band:18.0 %, Lymph:7.0 %, Mono:2.0 %, Eos:15.0 %, D-dimer:6389 ng/mL,\n Fibrinogen:293 mg/dL, Lactic Acid:1.5 mmol/L, Albumin:1.6 g/dL, LDH:607\n IU/L, Ca++:9.1 mg/dL, Mg++:2.0 mg/dL, PO4:4.3 mg/dL\n Assessment and Plan\n Shock\n slowly improving pressor needs, wean as tolerated\n Anemia, ? DIC\n heme to weigh in, no obvious evidence of GI bleed, cont\n PPI, follow CBC twice daily\n Cerebral edema\n most recent CT improved, cont to follow pupils\n HEPATITIS, ACUTE TOXIC (INCLUDING ALCOHOLIC, ACETAMINOPHEN, ETC.) -\n LFTs stable\n ARF, anasarca\n continue CVVH, increased volume removal\n RESPIRATORY FAILURE\n cont vent support, likely trach next week\n PANCREATITIS, ACUTE\n cont supportive care\n Ilieus\n cont PO narcan\n ICU Care\n Nutrition: TF\n TPN w/ Lipids - 03:22 PM 73 mL/hour\n Glycemic Control:\n Lines:\n Multi Lumen - 02:02 PM\n Dialysis Catheter - 04:56 PM\n Arterial Line - 01:30 PM\n 20 Gauge - 11:15 AM\n Prophylaxis:\n DVT: pneumoboot on right arm\n Stress ulcer: on PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition : icu\n Total time spent: 42\n" }, { "category": "Nursing", "chartdate": "2131-06-04 00:00:00.000", "description": "Nursing Progress Note", "row_id": 678806, "text": "Hypotension (not Shock)\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": "2131-06-05 00:00:00.000", "description": "Nursing Progress Note", "row_id": 679033, "text": " Problem - Sepsis\n Assessment:\n WBC 50 today\n Febrile to 102 2 days ago\n Action:\n Cultures sent from all lines today.\n Sinus/abd and pelvic ct done.\n Plan to change HD cath over wire to TLC\n Plan to dc right IJ quad cath\n Plan to place dialysis cath in IR along with feeding tube\n OK per renal for dialysis holiday.\n Response:\n Stable\n Plan:\n As listed above.\n Impaired Skin Integrity\n Assessment:\n Multiple areas over legs with open blisters,some oozing ,some not\n Action:\n Dressings changed with skin care RN\n Cleansed with Skin integrity wound cleanser\n Pat dry\n Adaptic applied to open areas\n Aloe vesta lotion to inctact areas\n Covered with soft sorb\n Fishnet dressing over so no tape on legs.\n Response:\n Improved healing, no evidence of infection on opened areas.\n Area of ereythema on thighs--?residual from drug rash\n Plan:\n Continue with skin care as above.\n Will switch out bed to triadyne roatate air mattress.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Resp. failure, requiring ventilation and elevated levels of PEEP\n Action:\n CRRT with goal of removing as much fluid as possible\n Taking 500-600cc/hr. off today\n PEEP to 10\n Response:\n Good abgs on 10 of PEEP\n Plan:\n Planned trach in OR this evening.\n" }, { "category": "Nursing", "chartdate": "2131-06-06 00:00:00.000", "description": "Nursing Progress Note", "row_id": 679117, "text": "Sepsis, Severe (with organ dysfunction)\n Assessment:\n Temp spike to 101.1 with associated tachycardia, tachypnia\n WBC count 50\n Levophed drip needed to be increased to keep MAP> 65\n Action:\n Tylenol given\n Repositioned q 2 hours\n Antibiotics as ordered\n VAP protocol\n Urine culture sent\n HD line changed over wire to Quad central line, confirmed by\n X-Ray\n Right IJ central line discontinued by MICU resident\n Both tips sent for culture\n Response:\n Remains febrile\n Awaiting am lab results\n Awaiting Cortisol stim test results\n Plan:\n Follow up on final CT scan results\n Follow up on all culture results\n Continue antibiotics, re-evaluate with ID\n Patient and family support\n Impaired Skin Integrity\n Assessment:\n Upper extremities improved, minimal drainage from puncture\n sites\n Lower extremities have also improved, with blisters that\n have popped weeping less serous fluid\n Inner thighs of both legs concerning due to firm, erythemic,\n and hot skin. Dr. aware and evaluated\n Heels improving as well,\n Action:\n Wounds cleaned with wound cleanser\n Dried\n Aquacel ag applied to open areas as skin where adaptic was\n appeared to be macerated\n Softsorb and then net stockings to hold in place\n Heels kept off bed with waffle boots\n Response:\n All impaired skin sites appear to be healing\n Plan:\n Continue with above treatment\n Continue to consult with skin care nurse\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Patient clearly working at breathing, using accessory\n muscles\n O2 sats dropping to 90%, especially when on right side\n Pt on AC, 50%, 10 peep, 30 x 400\n ABG: 7.35, 41, 63, -2, 24.\n Action:\n Pt placed on as far left and right as possible every 2 hours\n (not true swimmers due to edema, unable to safely keep patient over\n that far).\n VAP protocol\n Suctioned for small amounts of very thick tan sputum, almost\n unable to pass through suction catheter\n Recruitment maneuver x 2\n Response:\n Position changed to left side with O2 sats not improving.\n MICU team aware. To increase PEEP to 12.\n Plan:\n ? bronch today\n Trash in near future depending on pt\ns level of dependency\n on peep.\n Discuss plan with family/\n Pt and family support.\n" }, { "category": "Nursing", "chartdate": "2131-06-07 00:00:00.000", "description": "Nursing Progress Note", "row_id": 679285, "text": "Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Potassium level 6.7\n EKG changes notes\n Creatinine 3.3\n Minimal urine output\n Remains very fluid overloaded\n Action:\n New HD catheter placed by Dr. \n Placement confirmed by x-ray\n CRRT started @ 0200\n Kayexelate enema given for elevated potassium level.\n Insulin / dextrose / calcium given for elevated potassium.\n Response:\n 6am labs pending\n Repeat EKG shows improvement\n Plan:\n Continue CRRT to correct electrolytes, metabolic imbalance,\n and remove fluid, as much as patient will tolerate without having to\n significantly increase vasopressors per Dr. .\n Sepsis, Severe (with organ dysfunction)\n Assessment:\n Temp consistently ~ 100.4\n WBC this am 64\n Remains dependent on Levophed however weaning\n Action:\n Linezolid added to antibiotic regimen\n Steroids also started\n On rotating bed\n CRRT for fluid removal\n Response:\n Levophed weaned slightly\n Temp now 98.6\n Plan:\n Continue to follow up on culture results\n Continue antibiotics\n Follow up with ID\n Continue CRRT\n Impaired Skin Integrity\n Assessment:\n Popped blisters on legs from 3^rd spaced fluid are improving\n Lower legs / shins healing while thighs remain weepy and red\n Heels also improving, the area that is purple is shrinking\n Action:\n Legs wounds where aquacel ag was still attached where\n untouched. Aquacel left in place.\n Other areas cleansed with wound cleanser, and aquacel or\n adaptic, or just softsorb applied, depending on wound base and\n surrounding skin.\n Wrapped with kerlex gauze to keep in place\n Rotating air bed\n Waffle boots\n Response:\n Improving\n Plan:\n Continue with dressings noted in action plan\n Continue rotating air bed\n Continue waffle boots\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Labored breathing, using accessory muscles, flaring nostrils\n On AC, 80%, 12 peep, 30 x 400\n Breathing over the ventilator\n Rare cough, non productive but sounds congested\n Action:\n Recruitment maneuvers x2\n On rotating bed, as well as linen changes and full body turn\n q 4 hours\n VAP protocol\n ABX as ordered\n CRRT for fluid removal\n Response:\n more comfortably breathing, using less effort\n O2 sats 99%\n ABG: 7.25, 50, 106, -5, 23\n Plan:\n Wean FIO2 as patient will allow\n Continue rotating bed\n Continue VAP protocol\n" }, { "category": "Respiratory ", "chartdate": "2131-06-07 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 679286, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 21\n Ideal body weight: 67.1 None\n Ideal tidal volume: 268.4 / 402.6 / 536.8 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: 26 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 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 Assessment of breathing comfort: No response (sleeping / sedated)\n Plan\n Next 24-48 hours: Utilize ARDSnet protocol\n Reason for continuing current ventilatory support: Hemodynimic\n instability, Underlying illness not resolved\n Comments: Required recruitment manoeuvers overnight to maintain O2\n sats. Tolerated well with sat increasing from 80s up to mid 90s. This\n morning following dialysis, O2 sats greatly improved with PaO2 over\n 100.\n" }, { "category": "Physician ", "chartdate": "2131-06-11 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 680120, "text": "Chief Complaint:\n 24 Hour Events:\n - Tolerated CVVH with good diuresis\n - ID rec 1) continue Flagyl/Linezolid/Aztreonam/Micafungin, 2) consider\n heme re-consult for persistantly altered differential despite long\n course of ABX and ? hemophagocytic syndrome, 3) would add Cipro if\n clinical deterioration, and 4) consider change linezolid to dapto if\n TCP worsens.\n - Renal rec continue CVVH with UF 100 cc/hr as she tolerates.\n - PM Hct stable.\n - Pt became bronchospastic in evening with some oozing at trach site.\n CXR appeared improved if anything. Given bronchodilators with good\n effect\n Allergies:\n Meropenem\n skin blisters a\n Last dose of Antibiotics:\n Metronidazole - 10:00 AM\n Vancomycin - 04:39 PM\n Aztreonam - 09:30 PM\n Linezolid - 10:28 PM\n Micafungin - 12:04 AM\n Infusions:\n Norepinephrine - 0.03 mcg/Kg/min\n Fentanyl (Concentrate) - 100 mcg/hour\n Midazolam (Versed) - 10 mg/hour\n Calcium Gluconate (CRRT) - 1.6 grams/hour\n Other ICU medications:\n Fentanyl - 04:34 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:59 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.1\nC (98.8\n Tcurrent: 35.7\nC (96.3\n HR: 104 (84 - 107) bpm\n BP: 92/49(63) {91/48(62) - 129/74(93)} mmHg\n RR: 14 (9 - 28) insp/min\n SpO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 134 kg (admission): 113.5 kg\n Height: 67 Inch\n CVP: 20 (11 - 21)mmHg\n Total In:\n 10,596 mL\n 2,852 mL\n PO:\n TF:\n 480 mL\n 92 mL\n IVF:\n 8,289 mL\n 2,230 mL\n Blood products:\n Total out:\n 14,018 mL\n 4,260 mL\n Urine:\n 78 mL\n NG:\n Stool:\n Drains:\n Balance:\n -3,422 mL\n -1,408 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 24\n RR (Spontaneous): 0\n PEEP: 8 cmH2O\n FiO2: 40%\n RSBI Deferred: Unstable Airway\n PIP: 18 cmH2O\n SpO2: 100%\n ABG: 7.33/52/131/24/0\n Ve: 10.6 L/min\n PaO2 / FiO2: 328\n Physical Examination\n GEN: Intubated, sedated\n HEENT: icteric sclera. MMM\n NECK: Trach sites minimal oozing\n LUNGS: Crackles bilaterally anteriorly.\n HEART: RRR\n ABD: Distended. NT.\n EXTREM: 2+ edema, ulcers/lesions on legs with bandages C/D/I, Oozing\n from R groin ulcer\n SKIN: Jaundice\n Labs / Radiology\n 82 K/uL\n 8.1 g/dL\n 155 mg/dL\n 0.9 mg/dL\n 24 mEq/L\n 4.5 mEq/L\n 35 mg/dL\n 98 mEq/L\n 132 mEq/L\n 24.5 %\n 28.3 K/uL\n [image002.jpg]\n 08:15 AM\n 08:34 AM\n 02:08 PM\n 02:31 PM\n 05:15 PM\n 08:27 PM\n 08:36 PM\n 11:00 PM\n 02:20 AM\n 02:35 AM\n WBC\n 29.6\n 28.3\n Hct\n 23.9\n 24.5\n Plt\n 69\n 82\n Cr\n 0.9\n 0.9\n TCO2\n 26\n 25\n 25\n 27\n 27\n 29\n Glucose\n 166\n 177\n 131\n 155\n Other labs: PT / PTT / INR:16.1/37.7/1.4, CK / CKMB /\n Troponin-T:214/3/0.07, ALT / AST:74/206, Alk Phos / T Bili:172/28.5,\n Amylase / Lipase:19/35, Differential-Neuts:68.0 %, Band:5.0 %,\n Lymph:7.0 %, Mono:4.0 %, Eos:0.0 %, D-dimer:6389 ng/mL, Fibrinogen:502\n mg/dL, Lactic Acid:1.6 mmol/L, Albumin:2.0 g/dL, LDH:775 IU/L, Ca++:8.7\n mg/dL, Mg++:2.1 mg/dL, PO4:3.3 mg/dL\n Assessment and Plan\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n IMPAIRED SKIN INTEGRITY\n HEPATITIS, ACUTE TOXIC (INCLUDING ALCOHOLIC, ACETAMINOPHEN, ETC.)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ICU Care\n Nutrition:\n TPN w/ Lipids - 03:48 PM 76 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 08:15 PM\n Multi Lumen - 10:00 PM\n Dialysis Catheter - 11:35 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": "2131-06-11 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 680123, "text": "Chief Complaint:\n 24 Hour Events:\n - Tolerated CVVH with good diuresis\n - ID rec 1) continue Flagyl/Linezolid/Aztreonam/Micafungin, 2) consider\n heme re-consult for persistantly altered differential despite long\n course of ABX and ? hemophagocytic syndrome, 3) would add Cipro if\n clinical deterioration, and 4) consider change linezolid to dapto if\n TCP worsens.\n - Renal rec continue CVVH with UF 100 cc/hr as she tolerates.\n - PM Hct stable.\n - Pt became bronchospastic in evening with some oozing at trach site.\n CXR appeared improved if anything. Given bronchodilators with good\n effect\n Allergies:\n Meropenem\n skin blisters a\n Last dose of Antibiotics:\n Metronidazole - 10:00 AM\n Vancomycin - 04:39 PM\n Aztreonam - 09:30 PM\n Linezolid - 10:28 PM\n Micafungin - 12:04 AM\n Infusions:\n Norepinephrine - 0.03 mcg/Kg/min\n Fentanyl (Concentrate) - 100 mcg/hour\n Midazolam (Versed) - 10 mg/hour\n Calcium Gluconate (CRRT) - 1.6 grams/hour\n Other ICU medications:\n Fentanyl - 04:34 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:59 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.1\nC (98.8\n Tcurrent: 35.7\nC (96.3\n HR: 104 (84 - 107) bpm\n BP: 92/49(63) {91/48(62) - 129/74(93)} mmHg\n RR: 14 (9 - 28) insp/min\n SpO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 134 kg (admission): 113.5 kg\n Height: 67 Inch\n CVP: 20 (11 - 21)mmHg\n Total In:\n 10,596 mL\n 2,852 mL\n PO:\n TF:\n 480 mL\n 92 mL\n IVF:\n 8,289 mL\n 2,230 mL\n Blood products:\n Total out:\n 14,018 mL\n 4,260 mL\n Urine:\n 78 mL\n NG:\n Stool:\n Drains:\n Balance:\n -3,422 mL\n -1,408 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 24\n RR (Spontaneous): 0\n PEEP: 8 cmH2O\n FiO2: 40%\n RSBI Deferred: Unstable Airway\n PIP: 18 cmH2O\n SpO2: 100%\n ABG: 7.33/52/131/24/0\n Ve: 10.6 L/min\n PaO2 / FiO2: 328\n Physical Examination\n GEN: Intubated, sedated\n HEENT: icteric sclera. MMM\n NECK: Trach sites minimal oozing\n LUNGS: Crackles bilaterally anteriorly.\n HEART: RRR\n ABD: Distended. NT.\n EXTREM: 2+ edema, ulcers/lesions on legs with bandages C/D/I, Oozing\n from R groin ulcer\n SKIN: Jaundice\n Labs / Radiology\n 82 K/uL\n 8.1 g/dL\n 155 mg/dL\n 0.9 mg/dL\n 24 mEq/L\n 4.5 mEq/L\n 35 mg/dL\n 98 mEq/L\n 132 mEq/L\n 24.5 %\n 28.3 K/uL\n [image002.jpg]\n N:68 Band:5 L:7 M:4 E:0 Bas:0 Metas: 10 Myelos: 3 Promyel: 3 Nrbc: 15\n Ca: 8.7 Mg: 2.1 P: 3.3\n ALT: 74\n AP: 172\n Tbili: 28.5\n Alb:\n AST: 206\n LDH: 775\n Dbili:\n TProt:\n :\n Lip:\n PT: 16.1\n PTT: 37.7\n INR: 1.4\n 08:15 AM\n 08:34 AM\n 02:08 PM\n 02:31 PM\n 05:15 PM\n 08:27 PM\n 08:36 PM\n 11:00 PM\n 02:20 AM\n 02:35 AM\n WBC\n 29.6\n 28.3\n Hct\n 23.9\n 24.5\n Plt\n 69\n 82\n Cr\n 0.9\n 0.9\n TCO2\n 26\n 25\n 25\n 27\n 27\n 29\n Glucose\n 166\n 177\n 131\n 155\n Other labs: PT / PTT / INR:16.1/37.7/1.4, CK / CKMB /\n Troponin-T:214/3/0.07, ALT / AST:74/206, Alk Phos / T Bili:172/28.5,\n Amylase / Lipase:19/35, Differential-Neuts:68.0 %, Band:5.0 %,\n Lymph:7.0 %, Mono:4.0 %, Eos:0.0 %, D-dimer:6389 ng/mL, Fibrinogen:502\n mg/dL, Lactic Acid:1.6 mmol/L, Albumin:2.0 g/dL, LDH:775 IU/L, Ca++:8.7\n mg/dL, Mg++:2.1 mg/dL, PO4:3.3 mg/dL\n No new culture data\n Assessment and Plan\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n IMPAIRED SKIN INTEGRITY\n HEPATITIS, ACUTE TOXIC (INCLUDING ALCOHOLIC, ACETAMINOPHEN, ETC.)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n 28M with alcoholic hepatitis and necrotizing pancreatitis complicated\n by ARDS, SIRS, ARF, UGIB, fevers and eosinophilia.\n #. Fever: Afebrile x>3days - source unclear. Question of fever \n adrenal insufficiency; now on steroids. Concern for infection with\n increased bandemia today although leukocytosis improved.\n Blood/tissue/BAL cx NGTD, CT abd with persistent inflammation\n concerning for infection. CT sinuses w/ opacification of unclear time\n course.\n - Cte broad spectrum antibiotic coverage with aztreonam for extended GN\n coverage, linezolid for MRSA and VRE for bacteremia, flagyl IV, vanc PO\n empirically per ID recs given increasing leukocytosis and colon\n inflammation on CT, micafungin for antifungal coverage\n - F/u WBC and temp curve\n - F/u derm biopsy results to see if skin infection; already on broad\n spectrum antibiotic coverage inc. skin flora coverage\n - F/u cultures\n - F/u ID recs; question: how to down abx over next few days\n #. Respiratory Failure: ARDS secondary to necrotizing pancreatitis. S/p\n trach placement on \n - Sutures out on \n - Cont to wean as tolerated.\n - Cte to wean fentanyl\n #. Adrenal Insufficiency: Unclear with stim if clear adrenal\n insufficiency but hypotension improving with steroids (lower pressor\n requirement) and improving eosinophilia\n - Will continue steroids IV X 5 days (day 5) then change to prednisone\n to taper\n #. Eosinophilia: Adrenal insufficiency v. drug reaction (?PPI; vanc &\n dapto less likely d/t time course). Fungal and parasitic infection also\n possible etiologies.\n - stim positive for adrenal insufficiency. Cte steroids.\n - Off PPI, vanc, dapto\n - Cte fungal coverage as above\n #. Anemia: Hct stable since 1 unit pRBC and 1 dose DDAVP s/p trach with\n some oozing at site.\n - recheck hemolysis labs\n - trend hcts Q6H, 1unit pRBCs now, guaiac stools and NGT aspirate\n - If not appropriate bump with blood consider scope to ensure doboff\n did not cause significant bleed\n - holding ppx with PPI or sucralfate given issues of eosinophilia and\n ARF\n #. Thrombocytopenia: Appreciate heme recs. Do not feel this is DIC.\n - Monitor platelets daily and transfuse for plt <10 or <50 if signs of\n bleed\n - monitor daily\n #. Acute renal Failure: Appreciate renal recs. Cr improved on CVVH. Off\n sucralfate due to concern for electrolyte abnormalities.\n - Cte volume depletion with CVVH as long as pressor requirement does\n not increase\n #. Wounds: Derm biopsy pending - inflammatory, infectious, or reactive.\n F/u recs.\n #. Agitation: Cont methadone given decreased sensitivity to fentanyl;\n titrate prn\n #. Glucose intolerance: In setting of steroids; adjust ISS prn\n ICU Care\n Nutrition:\n TPN w/ Lipids - 03:48 PM 76 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 08:15 PM\n Multi Lumen - 10:00 PM\n Dialysis Catheter - 11:35 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Respiratory ", "chartdate": "2131-06-06 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 679212, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 20\n Ideal body weight: 67.1 None\n Ideal tidal volume: 268.4 / 402.6 / 536.8 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: 24 cm at teeth\n Route:\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 Comments:\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Moderate\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment: Vigorous inspiratory efforts\n Comments:\n Plan\n Next 24-48 hours: Maintain PEEP at current level and reduce FiO2 as\n tolerated\n Reason for continuing current ventilatory support: Sedated / Paralyzed,\n Intolerant of weaning attempts, Cannot protect airway, Hemodynimic\n instability, Underlying illness not resolved\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Bronchoscopy (1700)\n Comments:\n" }, { "category": "Respiratory ", "chartdate": "2131-06-07 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 679384, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 21\n Ideal body weight: 67.1 None\n Ideal tidal volume: 268.4 / 402.6 / 536.8 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: 24 cm at teeth\n Route:\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 Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Reduce PEEP as tolerated\n Reason for continuing current ventilatory support: Sedated / Paralyzed,\n Intolerant of weaning attempts, Underlying illness not resolved\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Interventional radiology\n 13:30\n Bedside Procedures:\n Comments:\n" }, { "category": "Physician ", "chartdate": "2131-06-09 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 679788, "text": "Chief Complaint:\n 24 Hour Events:\n - Trach placed; PEEP decreased to 8\n - Methadone started and able to wean fentanyl down 350 -> 250\n - Levophed weaned down to 0.03 throughout day\n - Received 1 unit pRBC post trach with increase in Hct 21 -> 24\n - Received DDAVP x 1 dose for oozing around trach site\n - Increased ISS for hyperglycemia in setting of steroids\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 04:00 AM\n Aztreonam - 08:00 PM\n Micafungin - 09:00 PM\n Linezolid - 10:00 PM\n Metronidazole - 02:00 AM\n Infusions:\n Norepinephrine - 0.02 mcg/Kg/min\n Midazolam (Versed) - 15 mg/hour\n Calcium Gluconate (CRRT) - 2 grams/hour\n KCl (CRRT) - 4 mEq./hour\n Fentanyl (Concentrate) - 200 mcg/hour\n Other ICU medications:\n Carafate (Sucralfate) - 04:00 AM\n Heparin Sodium (Prophylaxis) - 04:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:11 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.1\nC (98.8\n Tcurrent: 36.2\nC (97.1\n HR: 82 (72 - 95) bpm\n BP: 102/59(71) {84/44(56) - 126/66(85)} mmHg\n RR: 21 (21 - 30) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 134 kg (admission): 113.5 kg\n Height: 67 Inch\n CVP: 13 (11 - 20)mmHg\n Total In:\n 11,098 mL\n 2,908 mL\n PO:\n TF:\n IVF:\n 8,814 mL\n 2,445 mL\n Blood products:\n 798 mL\n Total out:\n 12,489 mL\n 2,758 mL\n Urine:\n 24 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,391 mL\n 150 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 30\n RR (Spontaneous): 0\n PEEP: 8 cmH2O\n FiO2: 50%\n PIP: 24 cmH2O\n Plateau: 21 cmH2O\n Compliance: 30.8 cmH2O/mL\n SpO2: 98%\n ABG: 7.42/40/111/24/1\n Ve: 11.9 L/min\n PaO2 / FiO2: 222\n Physical Examination\n GEN: Intubated, sedated\n HEENT: icteric sclera. MMM\n NECK: Sites clean/dry/no oozing\n LUNGS: Crackles bilaterally anteriorly.\n HEART: RRR\n ABD: Distended. NT.\n EXTREM: 2+ edema with weeping wounds without surrounding erythema,\n ulcers/lesions on legs with bandages C/D/I\n SKIN: Jaundice\n Labs / Radiology\n 43 K/uL\n 8.3 g/dL\n 157 mg/dL\n 1.2 mg/dL\n 24 mEq/L\n 3.4 mEq/L\n 36 mg/dL\n 98 mEq/L\n 131 mEq/L\n 24.9 %\n 40.7 K/uL\n [image002.jpg]\n 10:28 AM\n 12:54 PM\n 06:02 PM\n 06:08 PM\n 09:18 PM\n 09:33 PM\n 12:23 AM\n 01:12 AM\n 01:57 AM\n 04:24 AM\n WBC\n 40.7\n Hct\n 22.3\n 21.7\n 24.6\n 24.9\n Plt\n 47\n 43\n Cr\n 1.2\n TCO2\n 30\n 29\n 29\n 27\n 26\n 27\n Glucose\n 187\n 194\n 186\n 181\n 157\n Other labs: PT / PTT / INR:17.5/38.7/1.6, CK / CKMB /\n Troponin-T:214/3/0.07, ALT / AST:49/186, Alk Phos / T Bili:133/26.8,\n Amylase / Lipase:19/35, Differential-Neuts:56.0 %, Band:14.0 %,\n Lymph:4.0 %, Mono:6.0 %, Eos:1.0 %, D-dimer:6389 ng/mL, Fibrinogen:502\n mg/dL, Lactic Acid:2.0 mmol/L, Albumin:1.7 g/dL, LDH:920 IU/L, Ca++:7.6\n mg/dL, Mg++:2.0 mg/dL, PO4:2.2 mg/dL\n tissue cx pending. BAL/asp: bact cx neg, fungal pending. \n coag neg staph x 1 bottle.\n Derm biopsy: mixed cells c/w either inflammatory, infectious, or\n reactive\n Assessment and Plan\n 28yo M with alcoholic hepatitis and necrotizing pancreatitis\n complicated by ARDS, SIRS, ARF, UGIB, fevers and eosinophilia.\n #. Fever: Afebrile x >2d; source unclear. Question of fever adrenal\n insufficiency; now on steroids. Concern for infection with increased\n bandemia today although leukocytosis improved. Blood/tissue/BAL cx\n NGTD, CT abd with persistent inflammation concerning for infection. CT\n sinuses w/ opacification of unclear time course.\n - Cte broad spectrum antibiotic coverage with aztreonam for extended GN\n coverage, linezolid for MRSA and VRE for bacteremia, flagyl IV, vanc PO\n empirically per ID recs given increasing leukocytosis and colon\n inflammation on CT, micafungin for antifungal coverage\n - F/u WBC and temp curve\n - F/u derm biopsy results to see if skin infection; already on broad\n spectrum antibiotic coverage inc. skin flora coverage\n - F/u cultures\n - F/u ID recs; question: how to down abx over next few days\n #. Respiratory Failure: ARDS secondary to necrotizing pancreatitis. S/p\n trach placement yesterday on PEEP 8\n - Sutures out on \n - Cont to wean as tolerated. Try pressure support today.\n - Cte to wean fentanyl\n #. Adrenal Insufficiency: Unclear with stim if clear adrenal\n insufficiency but hypotension improving with steroids (lower pressor\n requirement) and improving eosinophilia\n - Will continue steroids IV X 5 days (day 4) then change to prednisone\n to taper\n #. Eosinophilia: Adrenal insufficiency v. drug reaction (?PPI; vanc &\n dapto less likely d/t time course). Fungal and parasitic infection also\n possible etiologies.\n - stim positive for adrenal insufficiency. Cte steroids.\n - Off PPI, vanc, dapto\n - Cte fungal coverage as above\n #. Anemia: Hct stable since 1 unit pRBC and 1 dose DDAVP s/p trach with\n some oozing at site.\n - recheck hemolysis labs\n - trend hcts Q6H, 1unit pRBCs now, guaiac stools and NGT aspirate\n - If not appropriate bump with blood consider scope to ensure doboff\n did not cause significant bleed\n - holding ppx with PPI or sucralfate given issues of eosinophilia and\n ARF\n #. Thrombocytopenia: Appreciate heme recs. Do not feel this is DIC.\n Recent decrease may be in setting of linezolid.\n - Monitor platelets daily and transfuse for plt <10 or <50 if signs of\n bleed\n - Would d/c linezolid when/if able\n #. Acute renal Failure: Appreciate renal recs. Cr improved on CVVH. Off\n sucralfate due to concern for electrolyte abnormalities.\n - Cte volume depletion with CVVH as long as pressor requirement does\n not increase\n #. Wounds: Derm biopsy pending - inflammatory, infectious, or reactive.\n F/u recs.\n #. Agitation: Cont methadone given decreased sensitivity to fentanyl;\n titrate prn\n #. Glucose intolerance: In setting of steroids; adjust ISS prn\n ICU Care\n Nutrition:\n TPN w/ Lipids - 07:00 PM 75 mL/hour->start TFs today at slow\n rate\n Glycemic Control: ISS\n Lines:\n Arterial Line - 08:15 PM\n Multi Lumen - 10:00 PM\n Dialysis Catheter - 11:35 PM\n Prophylaxis:\n DVT: Pneumoboots\n Stress ulcer: Holding PPI and sucralfate for now. Try H2 blocker today\n in TPN.\n VAP: HOB elevation, Mouth care\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n" }, { "category": "Nursing", "chartdate": "2131-06-11 00:00:00.000", "description": "Nursing Progress Note", "row_id": 680121, "text": "TITLE:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Trached on Cmv mode tv 400 rr 26 peep 8 fio2 40%. Grossly oozy serosang\n around trach site.Airway pressures acutely increased 40\ns and stacked\n breathing diffuse i/exp wheezes throughout. O2 sats remained > 96%. Pt\n opening eyes intermittently and discoordinately overbreathing vent.\n Action:\n RT paged and pt lavaged and suct for bloody secretions via trach. Albut\n mdi\ns given . Micu team paged and pt bolused w fentanyl 5o mcg per Dr\n . Fent gtt remain at 100mcg and versed at 10mg/hr. Thoracic team\n paged and evaluated trach area for potential suture, no definitve site\n noted to be oozing, surgical sponge around trach and gauze dsgs changed\n freq for oozing.. Hct\ns unchanged . Ddavp given for tracheal site\n bleeding.\n Response:\n Improvement in ventilation after mdi\ns and suct., recurrence of\n discoordinate breathing w increase airway pressures managed w mdi\n suctioning and bolus dose of fentanyl w good results. Tracheal area\n continues to ooze, freq trach care given,old clot left in place for\n hemostasis but site continues to ooze.\n Plan:\n Mdi\ns per RT for acute wheezing and increased airway pressures\n unresolved by suctioning. Maintain sedation with fentanyl, versed, and\n methadone.? thoracic to bronch to identify source of tracheal oozing.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Remains oliguric.Creat 0.9 this am on CRRT K2 and K4 bath as\n ordered.Levophed low dose at 0.03mcg/kg/min. Labs drawn q6h. Repleting\n K+ and Ca+ per crrt protocol slid scale.\n Action:\n Removing 200-400cc/hrly bp tolerating very well w mbp 80\ns, decreased\n levophed to 0.015mcg/kg/min\n Response:\n Mbp drifted to 50-60 and hr increased > 105 levophed increased back to\n 0.03mcg/kg/min and mbp improved> 60\n Plan:\n Attempt to have pfr 100-200cc/hr as tolerated.Labs q6h.\n" }, { "category": "Nursing", "chartdate": "2131-06-11 00:00:00.000", "description": "Nursing Progress Note", "row_id": 680234, "text": "Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n CRRT continues with BUN: Creatinine:\n Off CRRT for ~ 45 minutes Creatinine increased to\n Remains several kilograms positive\n Slight respiratory acidosis, metabolically stable\n Action:\n CRRT to remove as much fluid as possible without increasing\n vasopressors\n Q 6 hour lab monitoring\n Response:\n MN\n 1800 fluid balance negative\n No increase in vasopressor requirements\n Electrolytes acceptable\n Plan:\n Continue with CRRT to remove as much fluid as possible without having\n to increase vasopressors\n Continue q 6 hour monitoring of electrolytes, renal function, acid base\n balance\n Problem\n bleeding from Tracheostomy site\n Assessment:\n Constant oozing / bleeding from tracheostomy site continues\n INR 1.4\n HCT stable @ 24.9\n Platelets 82 from 69\n Action:\n Surgicell dressings were not removed in hopes of not dislodging any\n formed clot\n Area reinforced with more surgicell\n DSD\ns changed ~ q 5 hours to contain drainage\n MICU team to consult with Hematology\n Thoracic team has evaluated x2 this shift, no surgical intervention at\n this time\n HOB > 30 degrees\n Response:\n Continues to ooze / bleed, uncertain if slowing down or not\n No HCT drop from to \n Plan:\n Continue to monitor HCT daily\n Continue to reinforce dressing\n Continue to elevate HOB as tolerated with bed rotation and CRRT.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n In AM pt on AC, 40%, 8 peep, 24 x 400\n Appeared comfortably breathing, not using accessory muscles, not\n flaring nostrils as he has done in the past.\n Suctioned for thick bloody sputum\n Slight respiratory acidosis with PH 7.33, PaCo2 51, PaO2 125, BE 0, 28.\n Not breathing over ventilator.\n Action:\n Midazolam drip weaned to 5mg/hr\n Valium ordered ATC\n Vent setting changed to CPAP + PS, 40%, 8 peep, 10 PS\n VAP protocol\n Rotating bed\n Response:\n RR ~ 18, MV ~ 10, appears comfortable\n O2 Sats ~ 100%\n Plan:\n Continue to monitor respiratory status\nvs.\n sedation\n Recheck ABG and electrolytes @ \n VAP protocol\n Rotation on bed , pt in constant rotation\n Impaired Skin Integrity\n Assessment:\n Popped blisters and open areas on legs improving\n Much less weeping / drainage\n Heels remain intact with purple area unchanged\n Action:\n Cleansed with wound cleanser\n Aloe vesta applied to intact skin\n Minimal adaptic used on a few areas\n Covered with Softsorb\n Heels elevated off bed at all times with waffle boots\n Response:\n Legs improving\n Heels unchanged, not worsening\n No evidence of any new skin breakdown\n Plan:\n Continue rotating bed\n Continue excellent skin care,\n Continue q 12 hour dressing changes\n Continue keeping heels elevated off bed\n Sepsis, Severe (with organ dysfunction)\n Assessment:\n Afebrile\n WBC 28 from 29\n Levophed @ .03 mcg/kg/min and not increased in setting of fluid removal\n with CRRT\n Respiratory status improving\n Action:\n ABX ATC\n Stool sent for culture\n Response:\n Resolving sepsis\n Plan:\n Continue current treatment\n Follow up on culture results\n Continue to discuss with ID.\n Patient and family support.\n" }, { "category": "Respiratory ", "chartdate": "2131-06-03 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 678596, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 17\n Ideal body weight: 67.1 None\n Ideal tidal volume: 268.4 / 402.6 / 536.8 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type: Standard\n Size: 7mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 29 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Rhonchi\n Comments:\n Secretions\n Sputum color / consistency: Tan /\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, Nasal\n flaring\n Assessment of breathing comfort: No response (sleeping / sedated)\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Dysynchrony assessment: Possible air trapping\n Comments:\n Plan\n Next 24-48 hours: Utilize ARDSnet protocol\n Reason for continuing current ventilatory support: Intolerant of\n weaning attempts\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n CT\n 1630\n Bedside Procedures:\n Comments:\n Requiring increased fio2 today.\n" }, { "category": "Nursing", "chartdate": "2131-06-05 00:00:00.000", "description": "Nursing Progress Note", "row_id": 679032, "text": " Problem - Sepsis\n Assessment:\n WBC 50 today\n Febrile to 102 2 days ago\n Action:\n Cultures sent from all lines today.\n Sinus/abd and pelvic ct done.\n Plan to change HD cath over wire to TLC\n Plan to dc right IJ quad cath\n Plan to place dialysis cath in IR along with feeding tube\n OK per renal for dialysis holiday.\n Response:\n Stable\n Plan:\n As listed above.\n Impaired Skin Integrity\n Assessment:\n Multiple areas over legs with open blisters,some oozing ,some not\n Action:\n Dressings changed with skin care RN\n Cleansed with Skin integrity wound cleanser\n Pat dry\n Adaptic applied to open areas\n Aloe vesta lotion to inctact areas\n Covered with soft sorb\n Fishnet dressing over so no tape on legs.\n Response:\n Improved healing, no evidence of infection on opened areas.\n Area of ereythema on thighs--?residual from drug rash\n Plan:\n Continue with skin care as above.\n Will switch out bed to triadyne roatate air mattress.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Resp. failure, requiring ventilation and elevated levels of PEEP\n Action:\n CRRT with goal of removing as much fluid as possible\n Taking 500-600cc/hr. off today\n PEEP to 10\n Response:\n Good abgs on 10 of PEEP\n Plan:\n Planned trach in OR this evening.\n" }, { "category": "Nursing", "chartdate": "2131-06-06 00:00:00.000", "description": "Nursing Progress Note", "row_id": 679209, "text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Deteriorating resp. status\n Requiring increased PEEP\n Trach planned for today postponed indefinitly\n Action:\n PEEP to 15 after poor blood gas\n Bronch planned for this afternoon\n Response:\n Plan:\n Sepsis\n Assessment:\n Patient febrile past 24 hrs. w/tmax 103.2\n Action:\n MICU team aware\n Alcohol bath, ice and cooling blanket/Tylenol\n Response:\n Fever responded to above treatment, down to 100.3 in 90 mins.\n Plan:\n Check temp q 2 hrs.\n Repeat above treatments if necessary.\n All lines changed yesterday\n Plan to go to interventional radiology tomorrow for HD line placement\n and post pyloric feeding tube.\n Family consented.\n Impaired Skin Integrity\n Assessment:\n Lower extremities with multiple areas of blistering\n Action:\n dressings of adaptic/Aquacel ag applied\n Response:\n Improving healing\n Still with areas of draining serous-bloody drainage\n Plan:\n Continue with dressing changes as above.\n" }, { "category": "Nursing", "chartdate": "2131-06-04 00:00:00.000", "description": "Nursing Progress Note", "row_id": 678664, "text": "TITLE:\n Sepsis, Severe (with organ dysfunction)\n Assessment:\n Persistent elevation in wbc with positive bld cult from dialysis\n cath.Currently on daptomycin. Temp 96-98, bair hugger to maintain\n normothermia. Cont to make negligible uop, crrt i/o even at 1900 d/t\n pt off crrt earlier in day. Levophed at 0.15mcg/kg/min. Sedation\n fentanyl 350mcg/hr and versed 15mg/hr..\n Action:\n Blood cultures via dialysis cath, tlc, and periph iv. Bp stable, crrt\n run to achieve negative fld status by mn with net removal 100-300cc/hr\n Response:\n -600cc at mn, tolerating net negative fld 200-300cc/hr. levophed\n remains at 0.15mcg/kg/m\n Plan:\n cont crrt w net removal 200-300cc/hr as tolerates. Wean levophed if\n tolerates.Check for bld culture results.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Low tv ventilation@ 400.fio2 at 60% w pao2 94. rr 30 peep 12 w occas\n spontaneous breathing up to rr 45 with stimulation, tachypnea resolves\n w/o stimulation. Bbs\nclear, diminish lt base. Lavage and suct for\n scant amt of white secretions.Pao2 transient dip with turn and\n repositioning. Vap bundle.tolerating rotation 5mins rt and 20 mins to\n lt side\n Action:\n Weaned fio2 50%\n Response:\n Pao2 ->75\n Plan:\n Cont vap bundle, low tv ventilation. Rotating bed\n Impaired Skin Integrity\n Assessment:\n edematous, erythematous bilat legs ankles to groins bilat w blisters,\n small amts of serous to bld tinge drainage\n Action:\n old dressings-adaptic and sofsorb dressings removed, small to mod\n serous drainage from bilat extremeties .Area cleansed w wound cleanser\n and adaptic and sofsorb dressings replaced , flexinet dressing\n reapplied.\n Response:\n decreased amts of weeping noted from bilat leg dressing sites. No\n purulence. ? cellulitis given erythema/firm edema bilat legs.\n Plan:\n Cont to change dressings and prn.\n" }, { "category": "Nursing", "chartdate": "2131-06-10 00:00:00.000", "description": "Nursing Progress Note", "row_id": 679932, "text": "Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Remains on CRRT for goal 200-250 cc negative/hr\n Tolerating fluid removal on minimal amt of levophed\n Action:\n Fluid removal as recommended by renal\n Titrated levophed from 0.02-0.04 mcg/kg to maintain MAP > 60\n Q 6 labs/ ABG\n Response:\n BP became more labile this morning especially with repositioning\n Lytes WNL / BUN and creat trending down\n Plan:\n Currently taking off ~100 cc/hr due to labile blood pressure and\n currently already 1 liter negative for the day.\n Impaired Skin Integrity\n Assessment:\n Trach site with old blood upon initial assessment\n no active bleeding\n noted\n Blisters on legs improving\n Action:\n Trach care done and dressing changed at 2200\n Surgiseal around site and drain sponge placed over site\n BLE wounds cleansed with wound cleanser, intact skin covered with aloe\n vesta barrier cream, covered with soft sorb and wrapped in kerlex.\n Response:\n Trach site with increased bleeding at midnight until morning. MICU\n notified and given additional dose desmopressin. Thoracics HO also\n aware. Surgiseal saturated but not removed to not disrupt any clots.\n Trach site reinforced with drain sponges.\n Plan:\n Cont to monitor and treat skin as recomonded by skin care. Monitor\n trach site for bleeding and reinforce as needed.\n" }, { "category": "Physician ", "chartdate": "2131-06-12 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 680378, "text": "Chief Complaint:\n 24 Hour Events:\n STOOL CULTURE - At 01:21 PM\n for cdiff\n RESPIRATORY ARREST - At 07:28 PM\n team at bedside.\n BRONCHOSCOPY - At 08:14 PM\n Dr , time out done prior to proced\n BRONCHOSCOPY - At 08:48 PM\n Dr .\n - Concern for hemophagocytic syndrome - Checking ferritin (>);\n heme-onc consulted, feel hemophagocytic syndrome is unlikely.\n - Plan to increase insulin in TPN, but TPN recs not available in time\n - In anticipation of bzd withdrawal with weaning of midazolam, started\n valium 10mg PO TID. Plan to wean fentanyl, versed as tolerated in hopes\n of trying pressure support.\n - Per ID, restarted vanc PR; will restart ciprofloxacin if\n decompensates\n - Amylase 47, lipase 47\n - 6pm I/O -2L\n - 6pm Doing well on pressure support, versed weaned off. After incident\n below, restarted on assist control.\n - 7:30pm Respiratory distress - Initially with bronchospasm, then\n apneic and briefly without pulse (?minutes). Improved with deep suction\n - large clot removed with return of pulse, BP and improved ventilation.\n Thoracics performed bedside bronchoscopy - determined that trach is too\n short; on further reevaluation by attending, appropriate size and not\n needing replacement; clots removed with repeat bronchoscopy. Heme/onc\n aware, recommended Amicar for bleeding at trach site - started.\n Allergies:\n Meropenem\n skin blisters a\n Last dose of Antibiotics:\n Vancomycin - 04:00 PM\n Aztreonam - 09:24 PM\n Linezolid - 11:00 PM\n Micafungin - 12:33 AM\n Metronidazole - 02:01 AM\n Infusions:\n Fentanyl (Concentrate) - 100 mcg/hour\n Norepinephrine - 0.03 mcg/Kg/min\n Midazolam (Versed) - 5 mg/hour\n Calcium Gluconate (CRRT) - 1.6 grams/hour\n KCl (CRRT) - 2 mEq./hour\n Other ICU medications:\n Atropine - 07:30 PM\n Midazolam (Versed) - 09:03 PM\n Other medications:\n Changes to medical and family history:\n None\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Intubated, sedated.\n Flowsheet Data as of 06:08 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37\nC (98.6\n Tcurrent: 35.4\nC (95.8\n HR: 80 (30 - 126) bpm\n BP: 118/68(87) {59/41(47) - 168/94(124)} mmHg\n RR: 26 (10 - 31) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 123.3 kg (admission): 113.5 kg\n Height: 67 Inch\n CVP: 16 (14 - 49)mmHg\n Total In:\n 11,516 mL\n 2,538 mL\n PO:\n TF:\n 481 mL\n 91 mL\n IVF:\n 9,455 mL\n 2,234 mL\n Blood products:\n Total out:\n 13,098 mL\n 3,404 mL\n Urine:\n 65 mL\n 37 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,582 mL\n -866 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n Vt (Spontaneous): 725 (725 - 725) mL\n PS : 10 cmH2O\n RR (Set): 26\n RR (Spontaneous): 0\n PEEP: 8 cmH2O\n FiO2: 50%\n RSBI Deferred: Hemodynamic Instability\n PIP: 20 cmH2O\n SpO2: 100%\n ABG: 7.33/50/143/25/0\n Ve: 11.9 L/min\n PaO2 / FiO2: 286\n Physical Examination\n GEN: Intubated, sedated\n HEENT: icteric sclera. MMM\n NECK: Trach site with minimal oozing\n LUNGS: Anterior auscultation with upper airway noise; good airway\n movement\n HEART: , ; S1, S2\n ABD: Distended. NT.\n EXTREM: 2+ edema, ulcers/lesions on legs with bandages C/D/I\n SKIN: Jaundice\n Labs / Radiology\n 93 K/uL\n 7.8 g/dL\n 208 mg/dL\n 0.6 mg/dL\n 25 mEq/L\n 4.7 mEq/L\n 36 mg/dL\n 95 mEq/L\n 130 mEq/L\n 23.5 %\n 28.2 K/uL\n [image002.jpg]\n ALT: 97\n AP: 198\n Tbili: 28.7\n Alb:\n AST: 234\n LDH: 706\n Dbili:\n TProt:\n : 51\n Lip: 41\n PT: 15.8\n PTT: 33.2\n INR: 1.4\n 08:29 AM\n 08:42 AM\n 02:06 PM\n 02:20 PM\n 07:32 PM\n 07:44 PM\n 08:51 PM\n 01:27 AM\n 01:36 AM\n 05:36 AM\n WBC\n 28.2\n Hct\n 23.5\n Plt\n 93\n Cr\n 0.9\n 0.9\n 0.9\n 0.6\n TCO2\n 28\n 28\n 23\n 25\n 28\n 28\n Glucose\n 30\n 106\n 208\n Other labs: PT / PTT / INR:15.8/33.2/1.4, CK / CKMB /\n Troponin-T:214/3/0.07, ALT / AST:97/234, Alk Phos / T Bili:198/28.7,\n Amylase / Lipase:51/41, Differential-Neuts:68.0 %, Band:5.0 %,\n Lymph:7.0 %, Mono:4.0 %, Eos:0.0 %, D-dimer:6389 ng/mL, Fibrinogen:502\n mg/dL, Lactic Acid:1.5 mmol/L, Albumin:2.0 g/dL, LDH:706 IU/L, Ca++:8.8\n mg/dL, Mg++:2.0 mg/dL, PO4:3.5 mg/dL\n 4:11 pm TISSUE Source: Skin biopsy r/o HSV 1 and HSV2.\n GRAM STAIN (Final ):\n NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.\n NO MICROORGANISMS SEEN.\n TISSUE (Preliminary):\n REPORTED BY PHONE TO 11:30AM.\n Due to mixed bacterial types (>=3) an abbreviated workup is\n performed; P.aeruginosa, S.aureus and beta strep. are reported if\n present. Susceptibility will be performed on P.aeruginosa and\n S.aureus if sparse growth or greater..\n STAPHYLOCOCCUS, COAGULASE NEGATIVE. RARE GROWTH.\n ENTEROCOCCUS SP..\n Isolated from broth media only, INDICATING VERY LOW NUMBERS OF\n ORGANISMS.\n STAPHYLOCOCCUS, COAGULASE NEGATIVE.\n 2ND STRAIN Isolated from broth media only, INDICATING VERY LOW\n NUMBERS OF ORGANISMS.\n ANAEROBIC CULTURE (Preliminary): NO ANAEROBES ISOLATED.\n FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.\n ACID FAST SMEAR (Final ):\n NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.\n ACID FAST CULTURE (Preliminary):\n VIRAL CULTURE (Preliminary): No Virus isolated so far.\n Assessment and Plan\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n IMPAIRED SKIN INTEGRITY\n HEPATITIS, ACUTE TOXIC (INCLUDING ALCOHOLIC, ACETAMINOPHEN, ETC.)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n 28M with alcoholic hepatitis and necrotizing pancreatitis complicated\n by ARDS, SIRS, ARF, UGIB, fevers and eosinophilia\n #. Fever: Afebrile x>3days - source unclear. Question of fever \n adrenal insufficiency; now on steroids. Concern for infection with\n increased bandemia today although leukocytosis improved.\n Blood/tissue/BAL cx NGTD, CT abd with persistent inflammation\n concerning for infection. CT sinuses w/ opacification of unclear time\n course.\n - Cte broad spectrum antibiotic coverage with aztreonam for extended GN\n coverage, linezolid for MRSA and VRE for bacteremia, flagyl IV, vanc PO\n empirically per ID recs given increasing leukocytosis and colon\n inflammation on CT, micafungin for antifungal coverage\n - Per ID, add ciprofloxacin if decompensates. Also restart vancomycin\n PR\n - F/u WBC and temp curve\n - F/u derm biopsy results to see if skin infection; already on broad\n spectrum antibiotic coverage inc. skin flora coverage\n - F/u cultures\n - F/u ID recs; question: how to down abx over next few days\n #. Respiratory Failure: ARDS secondary to necrotizing pancreatitis. S/p\n trach placement on . Sutures out on \n - Decrease sedation (both fentanyl and versed) with goal of trying\n pressure support.\n - Continue valium standing (5-10mg q8 hours) to avoid benzo withdrawal\n - d/c midazolam to try to wean settings\n - Cont to wean as tolerated\n # Bleeding around trach site: Was given amicar yesterday\n - f/u Heme/Onc recs\n - complete 24hr cycle of amicar\n #. Adrenal Insufficiency: Unclear with stim if clear adrenal\n insufficiency but hypotension improving with steroids (lower pressor\n requirement) and improving eosinophilia\n - Will continue steroids IV X 5 days (day 5) then change to prednisone\n to taper\n #. Hyperbilirubinemia: Likely related to underlying shock liver and\n ?obstructive etiology from necrotizing pancreatitis. Continue to trend.\n #. Eosinophilia: Resolved. Adrenal insufficiency v. drug reaction\n (?PPI; vanc & dapto less likely d/t time course). Fungal and parasitic\n infection also possible etiologies.\n - stim positive for adrenal insufficiency. Cte steroids.\n - Off PPI, vanc, dapto\n - Cte fungal coverage as above\n #. Anemia: Hct stable since 1 unit pRBC and 1 dose DDAVP s/p trach with\n some oozing at site.\n - recheck hemolysis labs\n - trend hcts Q6H, 1unit pRBCs now, guaiac stools and NGT aspirate\n - If not appropriate bump with blood consider scope to ensure doboff\n did not cause significant bleed\n - holding ppx with PPI or sucralfate given issues of eosinophilia and\n ARF\n #. Thrombocytopenia: Appreciate heme recs. Do not feel this is DIC.\n - Monitor platelets daily and transfuse for plt <10 or <50 if signs of\n bleed\n - monitor daily\n #. Acute renal Failure: Appreciate renal recs. Cr improved on CVVH. Off\n sucralfate due to concern for electrolyte abnormalities.\n - Cte volume depletion with CVVH as long as pressor requirement does\n not increase\n #. Wounds: Derm biopsy pending - inflammatory, infectious, or reactive.\n F/u recs.\n #. Agitation: Cont methadone given decreased sensitivity to fentanyl;\n titrate prn\n #. Glucose intolerance: In setting of steroids; adjust ISS prn. As\n blood glucose continues to run high, will increase insulin included in\n TPN.\n ICU Care\n Nutrition:\n TPN w/ Lipids - 02:10 PM 35 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 08:15 PM\n Multi Lumen - 10:00 PM\n Dialysis Catheter - 11:35 PM\n Prophylaxis:\n DVT: Heparin in TPN\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n" }, { "category": "Physician ", "chartdate": "2131-06-12 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 680382, "text": "Chief Complaint:\n 24 Hour Events:\n STOOL CULTURE - At 01:21 PM\n for cdiff\n RESPIRATORY ARREST - At 07:28 PM\n team at bedside.\n BRONCHOSCOPY - At 08:14 PM\n Dr , time out done prior to proced\n BRONCHOSCOPY - At 08:48 PM\n Dr .\n - Concern for hemophagocytic syndrome - Checking ferritin (>);\n heme-onc consulted, feel hemophagocytic syndrome is unlikely.\n - Plan to increase insulin in TPN, but TPN recs not available in time\n - In anticipation of bzd withdrawal with weaning of midazolam, started\n valium 10mg PO TID. Plan to wean fentanyl, versed as tolerated in hopes\n of trying pressure support.\n - Per ID, restarted vanc PR; will restart ciprofloxacin if\n decompensates\n - Amylase 47, lipase 47\n - 6pm I/O -2L\n - 6pm Doing well on pressure support, versed weaned off. After incident\n below, restarted on assist control.\n - 7:30pm Respiratory distress - Initially with bronchospasm, then\n apneic and briefly without pulse (?minutes). Improved with deep suction\n - large clot removed with return of pulse, BP and improved ventilation.\n Thoracics performed bedside bronchoscopy - determined that trach is too\n short; on further reevaluation by attending, appropriate size and not\n needing replacement; clots removed with repeat bronchoscopy. Heme/onc\n aware, recommended Amicar for bleeding at trach site - started.\n Allergies:\n Meropenem\n skin blisters a\n Last dose of Antibiotics:\n Vancomycin - 04:00 PM\n Aztreonam - 09:24 PM\n Linezolid - 11:00 PM\n Micafungin - 12:33 AM\n Metronidazole - 02:01 AM\n Infusions:\n Fentanyl (Concentrate) - 100 mcg/hour\n Norepinephrine - 0.03 mcg/Kg/min\n Midazolam (Versed) - 5 mg/hour\n Calcium Gluconate (CRRT) - 1.6 grams/hour\n KCl (CRRT) - 2 mEq./hour\n Other ICU medications:\n Atropine - 07:30 PM\n Midazolam (Versed) - 09:03 PM\n Other medications:\n Changes to medical and family history:\n None\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Intubated, sedated.\n Flowsheet Data as of 06:08 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37\nC (98.6\n Tcurrent: 35.4\nC (95.8\n HR: 80 (30 - 126) bpm\n BP: 118/68(87) {59/41(47) - 168/94(124)} mmHg\n RR: 26 (10 - 31) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 123.3 kg (admission): 113.5 kg\n Height: 67 Inch\n CVP: 16 (14 - 49)mmHg\n Total In:\n 11,516 mL\n 2,538 mL\n PO:\n TF:\n 481 mL\n 91 mL\n IVF:\n 9,455 mL\n 2,234 mL\n Blood products:\n Total out:\n 13,098 mL\n 3,404 mL\n Urine:\n 65 mL\n 37 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,582 mL\n -866 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n Vt (Spontaneous): 725 (725 - 725) mL\n PS : 10 cmH2O\n RR (Set): 26\n RR (Spontaneous): 0\n PEEP: 8 cmH2O\n FiO2: 50%\n RSBI Deferred: Hemodynamic Instability\n PIP: 20 cmH2O\n SpO2: 100%\n ABG: 7.33/50/143/25/0\n Ve: 11.9 L/min\n PaO2 / FiO2: 286\n Physical Examination\n GEN: Intubated, sedated\n HEENT: icteric sclera. MMM\n NECK: Trach site with minimal oozing\n LUNGS: Anterior auscultation with upper airway noise; good airway\n movement\n HEART: , ; S1, S2\n ABD: Distended. NT.\n EXTREM: 2+ edema, ulcers/lesions on legs with bandages C/D/I\n SKIN: Jaundice\n Labs / Radiology\n 93 K/uL\n 7.8 g/dL\n 208 mg/dL\n 0.6 mg/dL\n 25 mEq/L\n 4.7 mEq/L\n 36 mg/dL\n 95 mEq/L\n 130 mEq/L\n 23.5 %\n 28.2 K/uL\n [image002.jpg]\n ALT: 97\n AP: 198\n Tbili: 28.7\n Alb:\n AST: 234\n LDH: 706\n Dbili:\n TProt:\n : 51\n Lip: 41\n PT: 15.8\n PTT: 33.2\n INR: 1.4\n 08:29 AM\n 08:42 AM\n 02:06 PM\n 02:20 PM\n 07:32 PM\n 07:44 PM\n 08:51 PM\n 01:27 AM\n 01:36 AM\n 05:36 AM\n WBC\n 28.2\n Hct\n 23.5\n Plt\n 93\n Cr\n 0.9\n 0.9\n 0.9\n 0.6\n TCO2\n 28\n 28\n 23\n 25\n 28\n 28\n Glucose\n 30\n 106\n 208\n Other labs: PT / PTT / INR:15.8/33.2/1.4, CK / CKMB /\n Troponin-T:214/3/0.07, ALT / AST:97/234, Alk Phos / T Bili:198/28.7,\n Amylase / Lipase:51/41, Differential-Neuts:68.0 %, Band:5.0 %,\n Lymph:7.0 %, Mono:4.0 %, Eos:0.0 %, D-dimer:6389 ng/mL, Fibrinogen:502\n mg/dL, Lactic Acid:1.5 mmol/L, Albumin:2.0 g/dL, LDH:706 IU/L, Ca++:8.8\n mg/dL, Mg++:2.0 mg/dL, PO4:3.5 mg/dL\n 4:11 pm TISSUE Source: Skin biopsy r/o HSV 1 and HSV2.\n GRAM STAIN (Final ):\n NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.\n NO MICROORGANISMS SEEN.\n TISSUE (Preliminary):\n REPORTED BY PHONE TO 11:30AM.\n Due to mixed bacterial types (>=3) an abbreviated workup is\n performed; P.aeruginosa, S.aureus and beta strep. are reported if\n present. Susceptibility will be performed on P.aeruginosa and\n S.aureus if sparse growth or greater..\n STAPHYLOCOCCUS, COAGULASE NEGATIVE. RARE GROWTH.\n ENTEROCOCCUS SP..\n Isolated from broth media only, INDICATING VERY LOW NUMBERS OF\n ORGANISMS.\n STAPHYLOCOCCUS, COAGULASE NEGATIVE.\n 2ND STRAIN Isolated from broth media only, INDICATING VERY LOW\n NUMBERS OF ORGANISMS.\n ANAEROBIC CULTURE (Preliminary): NO ANAEROBES ISOLATED.\n FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.\n ACID FAST SMEAR (Final ):\n NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.\n ACID FAST CULTURE (Preliminary):\n VIRAL CULTURE (Preliminary): No Virus isolated so far.\n Assessment and Plan\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n IMPAIRED SKIN INTEGRITY\n HEPATITIS, ACUTE TOXIC (INCLUDING ALCOHOLIC, ACETAMINOPHEN, ETC.)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n 28M with alcoholic hepatitis and necrotizing pancreatitis complicated\n by ARDS, SIRS, ARF, UGIB, fevers and eosinophilia\n #. Respiratory Failure: ARDS secondary to necrotizing pancreatitis. S/p\n trach placement on . Sutures out on \n - Decrease sedation (both fentanyl and versed) with goal of trying\n pressure support.\n - Continue valium standing (5-10mg q8 hours) to avoid benzo withdrawal\n - d/c midazolam to try to wean settings\n - Cont to wean as tolerated\n # Bleeding around trach site: Was given amicar yesterday\n - f/u Heme/Onc recs\n - complete 24hr cycle of amicar\n #. ID: Afebrile x>3days - source unclear. Question of fever adrenal\n insufficiency; now on steroids. Concern for infection with increased\n bandemia today although leukocytosis improved. Blood/tissue/BAL cx\n NGTD, CT abd with persistent inflammation concerning for infection. CT\n sinuses w/ opacification of unclear time course.\n - Cte broad spectrum antibiotic coverage with aztreonam for extended GN\n coverage, linezolid for MRSA and VRE for bacteremia, flagyl IV, vanc PO\n empirically per ID recs given increasing leukocytosis and colon\n inflammation on CT, micafungin for antifungal coverage\n - Per ID, add ciprofloxacin if decompensates. Also restart vancomycin\n PR\n - Send c diff\n - F/u WBC and temp curve\n - F/u derm biopsy results to see if skin infection; already on broad\n spectrum antibiotic coverage inc. skin flora coverage\n - F/u cultures\n - F/u ID recs; question: how to down abx over next few days\n #. Adrenal Insufficiency: Unclear with stim if clear adrenal\n insufficiency but hypotension improving with steroids (lower pressor\n requirement) and improving eosinophilia\n - wean to 75 mg Q8hr.\n #. Hyperbilirubinemia: Likely related to underlying shock liver and\n ?obstructive etiology from necrotizing pancreatitis. Continue to trend.\n #. Eosinophilia: Resolved. Adrenal insufficiency v. drug reaction\n (?PPI; vanc & dapto less likely d/t time course). Fungal and parasitic\n infection also possible etiologies.\n - stim positive for adrenal insufficiency. Cte steroids.\n - Off PPI, vanc, dapto\n - Cte fungal coverage as above\n #. Anemia: Hct stable since 1 unit pRBC and 1 dose DDAVP s/p trach with\n some oozing at site.\n - trend hcts Q6H, guaiac stools and NGT aspirate\n - If not appropriate bump with blood consider scope to ensure doboff\n did not cause significant bleed\n - holding ppx with PPI or sucralfate given issues of eosinophilia and\n ARF\n #. Thrombocytopenia: Appreciate heme recs. Do not feel this is DIC.\n - Monitor platelets daily and transfuse for plt <10 or <50 if signs of\n bleed\n - monitor daily\n #. Acute renal Failure: Appreciate renal recs. Cr improved on CVVH. Off\n sucralfate due to concern for electrolyte abnormalities.\n - Cte volume depletion with CVVH as long as pressor requirement does\n not increase\n #. Wounds: Derm biopsy pending - inflammatory, infectious, or reactive.\n F/u recs.\n #. Agitation: Cont methadone given decreased sensitivity to fentanyl;\n titrate prn\n #. Glucose intolerance: In setting of steroids; adjust ISS prn. As\n blood glucose continues to run high, will increase insulin included in\n TPN.\n ICU Care\n Nutrition:\n TPN w/ Lipids - 02:10 PM 35 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 08:15 PM\n Multi Lumen - 10:00 PM\n Dialysis Catheter - 11:35 PM\n Prophylaxis:\n DVT: Heparin SQ\n Stress ulcer: H2 Blocker\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n" }, { "category": "Physician ", "chartdate": "2131-06-12 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 680388, "text": "Chief Complaint:\n 24 Hour Events:\n STOOL CULTURE - At 01:21 PM\n for cdiff\n RESPIRATORY ARREST - At 07:28 PM\n team at bedside.\n BRONCHOSCOPY - At 08:14 PM\n Dr , time out done prior to proced\n BRONCHOSCOPY - At 08:48 PM\n Dr .\n - Concern for hemophagocytic syndrome - Checking ferritin (>);\n heme-onc consulted, feel hemophagocytic syndrome is unlikely.\n - Plan to increase insulin in TPN, but TPN recs not available in time\n - In anticipation of bzd withdrawal with weaning of midazolam, started\n valium 10mg PO TID. Plan to wean fentanyl, versed as tolerated in hopes\n of trying pressure support.\n - Per ID, restarted vanc PR; will restart ciprofloxacin if\n decompensates\n - Amylase 47, lipase 47\n - 6pm I/O -2L\n - 6pm Doing well on pressure support, versed weaned off. After incident\n below, restarted on assist control.\n - 7:30pm Respiratory distress - Initially with bronchospasm, then\n apneic and briefly without pulse (?minutes). Improved with deep suction\n - large clot removed with return of pulse, BP and improved ventilation.\n Thoracics performed bedside bronchoscopy - determined that trach is too\n short; on further reevaluation by attending, appropriate size and not\n needing replacement; clots removed with repeat bronchoscopy. Heme/onc\n aware, recommended Amicar for bleeding at trach site - started.\n Allergies:\n Meropenem\n skin blisters a\n Last dose of Antibiotics:\n Vancomycin - 04:00 PM\n Aztreonam - 09:24 PM\n Linezolid - 11:00 PM\n Micafungin - 12:33 AM\n Metronidazole - 02:01 AM\n Infusions:\n Fentanyl (Concentrate) - 100 mcg/hour\n Norepinephrine - 0.03 mcg/Kg/min\n Midazolam (Versed) - 5 mg/hour\n Calcium Gluconate (CRRT) - 1.6 grams/hour\n KCl (CRRT) - 2 mEq./hour\n Other ICU medications:\n Atropine - 07:30 PM\n Midazolam (Versed) - 09:03 PM\n Other medications:\n Changes to medical and family history:\n None\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Intubated, sedated.\n Flowsheet Data as of 06:08 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37\nC (98.6\n Tcurrent: 35.4\nC (95.8\n HR: 80 (30 - 126) bpm\n BP: 118/68(87) {59/41(47) - 168/94(124)} mmHg\n RR: 26 (10 - 31) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 123.3 kg (admission): 113.5 kg\n Height: 67 Inch\n CVP: 16 (14 - 49)mmHg\n Total In:\n 11,516 mL\n 2,538 mL\n PO:\n TF:\n 481 mL\n 91 mL\n IVF:\n 9,455 mL\n 2,234 mL\n Blood products:\n Total out:\n 13,098 mL\n 3,404 mL\n Urine:\n 65 mL\n 37 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,582 mL\n -866 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n Vt (Spontaneous): 725 (725 - 725) mL\n PS : 10 cmH2O\n RR (Set): 26\n RR (Spontaneous): 0\n PEEP: 8 cmH2O\n FiO2: 50%\n RSBI Deferred: Hemodynamic Instability\n PIP: 20 cmH2O\n SpO2: 100%\n ABG: 7.33/50/143/25/0\n Ve: 11.9 L/min\n PaO2 / FiO2: 286\n Physical Examination\n GEN: Intubated, sedated\n HEENT: icteric sclera. MMM\n NECK: Trach site with minimal oozing\n LUNGS: Anterior auscultation with upper airway noise; good airway\n movement\n HEART: , ; S1, S2\n ABD: Distended. NT.\n EXTREM: 2+ edema, ulcers/lesions on legs with bandages C/D/I\n SKIN: Jaundice\n Labs / Radiology\n 93 K/uL\n 7.8 g/dL\n 208 mg/dL\n 0.6 mg/dL\n 25 mEq/L\n 4.7 mEq/L\n 36 mg/dL\n 95 mEq/L\n 130 mEq/L\n 23.5 %\n 28.2 K/uL\n [image002.jpg]\n ALT: 97\n AP: 198\n Tbili: 28.7\n Alb:\n AST: 234\n LDH: 706\n Dbili:\n TProt:\n : 51\n Lip: 41\n PT: 15.8\n PTT: 33.2\n INR: 1.4\n 08:29 AM\n 08:42 AM\n 02:06 PM\n 02:20 PM\n 07:32 PM\n 07:44 PM\n 08:51 PM\n 01:27 AM\n 01:36 AM\n 05:36 AM\n WBC\n 28.2\n Hct\n 23.5\n Plt\n 93\n Cr\n 0.9\n 0.9\n 0.9\n 0.6\n TCO2\n 28\n 28\n 23\n 25\n 28\n 28\n Glucose\n 30\n 106\n 208\n Other labs: PT / PTT / INR:15.8/33.2/1.4, CK / CKMB /\n Troponin-T:214/3/0.07, ALT / AST:97/234, Alk Phos / T Bili:198/28.7,\n Amylase / Lipase:51/41, Differential-Neuts:68.0 %, Band:5.0 %,\n Lymph:7.0 %, Mono:4.0 %, Eos:0.0 %, D-dimer:6389 ng/mL, Fibrinogen:502\n mg/dL, Lactic Acid:1.5 mmol/L, Albumin:2.0 g/dL, LDH:706 IU/L, Ca++:8.8\n mg/dL, Mg++:2.0 mg/dL, PO4:3.5 mg/dL\n 4:11 pm TISSUE Source: Skin biopsy r/o HSV 1 and HSV2.\n GRAM STAIN (Final ):\n NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.\n NO MICROORGANISMS SEEN.\n TISSUE (Preliminary):\n REPORTED BY PHONE TO 11:30AM.\n Due to mixed bacterial types (>=3) an abbreviated workup is\n performed; P.aeruginosa, S.aureus and beta strep. are reported if\n present. Susceptibility will be performed on P.aeruginosa and\n S.aureus if sparse growth or greater..\n STAPHYLOCOCCUS, COAGULASE NEGATIVE. RARE GROWTH.\n ENTEROCOCCUS SP..\n Isolated from broth media only, INDICATING VERY LOW NUMBERS OF\n ORGANISMS.\n STAPHYLOCOCCUS, COAGULASE NEGATIVE.\n 2ND STRAIN Isolated from broth media only, INDICATING VERY LOW\n NUMBERS OF ORGANISMS.\n ANAEROBIC CULTURE (Preliminary): NO ANAEROBES ISOLATED.\n FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.\n ACID FAST SMEAR (Final ):\n NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.\n ACID FAST CULTURE (Preliminary):\n VIRAL CULTURE (Preliminary): No Virus isolated so far.\n Assessment and Plan\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n IMPAIRED SKIN INTEGRITY\n HEPATITIS, ACUTE TOXIC (INCLUDING ALCOHOLIC, ACETAMINOPHEN, ETC.)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n 28M with alcoholic hepatitis and necrotizing pancreatitis complicated\n by ARDS, SIRS, ARF, UGIB, fevers and eosinophilia\n #. Respiratory Failure: ARDS secondary to necrotizing pancreatitis. S/p\n trach placement on . Sutures out on \n - Decrease sedation (both fentanyl and versed) with goal of trying\n pressure support again today\n - Continue valium standing (5-10mg q8 hours) to avoid benzo withdrawal\n - Cont to wean as tolerated\n # Bleeding around trach site: Was given amicar yesterday\n - f/u Heme/Onc recs\n - complete 24hr cycle of amicar\n #. ID: Afebrile x>3days - source unclear. Question of fever adrenal\n insufficiency; now on steroids. Concern for infection with increased\n bandemia today although leukocytosis improved. Blood/tissue/BAL cx\n NGTD, CT abd with persistent inflammation concerning for infection. CT\n sinuses w/ opacification of unclear time course.\n - Cte broad spectrum antibiotic coverage with aztreonam for extended GN\n coverage, linezolid for MRSA and VRE for bacteremia, flagyl IV, vanc PO\n empirically per ID recs given increasing leukocytosis and colon\n inflammation on CT, micafungin for antifungal coverage\n - Per ID, add ciprofloxacin if decompensates. Also restart vancomycin\n PR\n - Send c diff, 2^nd sample\n - F/u WBC count, temp curve, and culture data\n - F/u ID recs; question: how to down abx over next few days\n #. Adrenal Insufficiency: Unclear with stim if clear adrenal\n insufficiency but hypotension improving with steroids (lower pressor\n requirement) and improving eosinophilia\n - wean to 75mg IV Q8hr\n #. Hyperbilirubinemia: Likely related to underlying shock liver and\n ?obstructive etiology from necrotizing pancreatitis. Continue to trend.\n #. Eosinophilia: Resolved. Adrenal insufficiency v. drug reaction\n (?PPI; vanc & dapto less likely d/t time course). Fungal and parasitic\n infection also possible etiologies.\n - stim positive for adrenal insufficiency. Cte steroids.\n - Off PPI, vanc, dapto\n - Cte fungal coverage as above\n #. Anemia: Hct slowly trending downwards, likely related to slow ooze\n from trach site\n - Hct , guaiac stools and NGT aspirate\n #. Thrombocytopenia: Appreciate heme recs. Do not feel this is DIC.\n - Monitor platelets daily and transfuse for plt <10 or <50 if signs of\n bleed\n - monitor daily\n #. Acute renal Failure: Appreciate renal recs. Cr improved on CVVH. Off\n sucralfate due to concern for electrolyte abnormalities.\n - Cte volume depletion with CVVH as long as pressor requirement does\n not increase\n - Begin thinking about placing tunneled dialysis catheter\n #. Agitation: Cont methadone, valium\n #. Glucose intolerance: In setting of steroids; adjust ISS prn. As\n blood glucose continues to run high, will increase insulin included in\n TPN.\n ICU Care\n Nutrition:\n TPN w/ Lipids - 02:10 PM 35 mL/hour\n Tubefeeds\n Now that he\ns having bowel movements, increase to goal\n Glycemic Control:\n Lines:\n Arterial Line - 08:15 PM\n Multi Lumen - 10:00 PM\n Dialysis Catheter - 11:35 PM\n Prophylaxis:\n DVT: Heparin SQ\n Stress ulcer: H2 Blocker\n VAP: Trach care\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n" }, { "category": "Physician ", "chartdate": "2131-06-04 00:00:00.000", "description": "Attending Note", "row_id": 678855, "text": "TITLE: Critical Care Staff\n MICU ATTENDING ADDENDUM\n I saw and examined the patient, and was physically present with the ICU\n resident for key portions of the services provided. I agree with his\n note above, including assessment and plan.\n * Worsened hypoxia. Dopplers neg UE and LE, CTA neg.\n * Episodic tachycardia, tachypnea, hypotension, hypoxemia.\n * CDiff cx neg.\n * Blood cx GPC prs, clusters . On daptomycin.\n * thrombocytopenia with plts remaining >50 since , slowly\n trending up but no sig rebound since heparin and vanco stopped. PF4\n neg x 2.\n AC 0.5/400/30/12\n CXR with progression of bilateral opacification\n Exam unchanged today.\n 28yo man with necrotizing pancreatitis (EtOH), liver failure, ARDS, ARF\n on CVVHD, shock, cerebral edema which has improved, colitis. Persistent\n hypotension, resp failure, anemia, thrombocytopenia, renal failure,\n persistent fevers with episodic tachypnea/tachycardia/hypoxia.\n 1. resp failure: plan for trach tomorrow.\n 2. hypotension, fevers: may be attributable to nec panc. GPC blood cx\n + (which may be contaminant as 1/6 bottles) on daptomycin. \n continue flagyl despite neg CDiff- discuss with ID. need to\n change lines. Right IJ, left HD line, RIJ 18d old, HD line 10d old.\n Surveillance cx neg yesterday from both lines. Plan for\n surveillance cx q48h. Sinusitis: afrin spray, discuss with ID\n whether benefit from sampling sinus collection.\n 3. eosinophilia: increasing percentage of diff, discuss with heme.\n 4. ileus: off PO narcan due to concern over episodes of tachypnea.\n nutrition: Attempt to place dobhoff postpyloric.\n 5. CVVH continues.\n 6. sedation: attempt to wean.\n Critically ill, 55 minutes\n" }, { "category": "Nursing", "chartdate": "2131-06-11 00:00:00.000", "description": "Nursing Progress Note", "row_id": 680085, "text": "TITLE:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n Sepsis, Severe (with organ dysfunction)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2131-06-11 00:00:00.000", "description": "Nursing Progress Note", "row_id": 680087, "text": "TITLE:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n Sepsis, Severe (with organ dysfunction)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2131-06-12 00:00:00.000", "description": "Nursing Progress Note", "row_id": 680474, "text": "Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Patient w/ ARF, on CRRT\n Action:\n Running CRRT to take off as much fluid as tolerates,\n Currently running around 300cc neg/hr\n Response:\n Tolerating well\n Levo @ .03, will keep here\n Plan:\n To IR tomorrow for perm. Tunneled dilyasis cath, for transition to\n hemo.\n Problem\n bleeding from trach\n Assessment:\n No bleeding noted from trach site this shift\n Some oral bleeding from lip and gums\n Difficult to suction out mouth due to patient\ns constant biting on\n suction\n No blood suctioned from trach\n Action:\n Amicar gtt resumed @1 mg/hr for 16 hrs. more\n Oral care as able\n Response:\n Stable\n Plan:\n Continue with amicar\n Notify MICU team if any increased bleeding from trach noted.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Switched from CMV to CPAP with 12 pressure support\n Versed off, on bolus doses if needed\n Action:\n Tolerating CPAP mode well with good blood gases\n Response:\n Will keep on current settings\n Plan:\n Continue to remove fluid with CRRT as tolerated\n CPAP mode as tolerates\n" }, { "category": "Respiratory ", "chartdate": "2131-06-12 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 680476, "text": "Demographics\n Day of mechanical ventilation: 26\n Ideal body weight: 67.1 None\n Ideal tidal volume: 268.4 / 402.6 / 536.8 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Tracheostomy tube:\n Type: Standard\n Manufacturer: Portex\n Size: 8.0mm\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: Bloody / Thin\n Sputum source/amount: Suctioned / Scant\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: pt weaned to PSV this shift,\n tolerating well w/ Vt ~600s RR mid teens maintaining Ve ~9L/M. SpO2\n 100%, minimal secretions.\n Assessment of breathing comfort: No claim of dyspnea\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: maintain support\n Reason for continuing current ventilatory support: Underlying illness\n not resolved\n" }, { "category": "Nursing", "chartdate": "2131-06-13 00:00:00.000", "description": "Nursing Progress Note", "row_id": 680543, "text": "TITLE:\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Crrt running net negative 300cc/hr. Net loss 5.7 liters @mn. Levophed\n at 0.03mcg/kg/m. Goal to remove as much fld as possible w/o increase\n pressor req.\n Action:\n Cont to run crrt net negative ~ 300cc/hr. High tmp and filter clotted\n at . Filter changed and crrt resumed at 2130. Pt hemodynamically\n stable on and off crrt. Labs q6h and crrt Ca+ and K+ titrated.\n Response:\n Tolerating crrt w net removal 300cc/hrly. Remains on same dose\n levophed.\n Plan:\n Npo for tunneled dialysis cath in IR today.\n Problem\n bleeding from trach and oral cavity\n Assessment:\n No bleeding noted at or around trach site.Oral cavity w blood and clots\n in small amts. Amicar gtt continuous at 1gm/hr. O2 sats stable without\n desaturation .\n Action:\n Trach care done, no oozing noted around trach site, tracheal suctioned\n for rust color sputum and no clots. Subglottal and oropharynx suct for\n small amts of clot and old blood q4h.\n Response:\n Bleeding resolved around trach site. Some bleeding continues orally.\n Hct stable.\n Plan:\n Cont Vap bundle, freq subglottal and oral/nasopharyngeal suct to remove\n old blood and clot in subglottal region. Cont amicar gtt. Cont to trend\n hcts\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Cpap mode 50% ps 12 peep 8 Stv500-700 w rr 12-18. Bbs clear but\n diminish bibasilarly. Sats stable > 95% throughout noc. Chest\n excursion gd.\n Action:\n Abg\ns q6h Vap bundle. Suct q4h and lavage for sm amts of rusty color\n sputum via trach. Oral suct for bld and clots in small amts.\n Response:\n Abg wnl. Tolerating cpap mode\n Plan:\n Cont to monitor abg, pt tolerance to cpap.Vap bundle. Freq oral and\n subglottal suction\n" }, { "category": "Nursing", "chartdate": "2131-06-13 00:00:00.000", "description": "Nursing Progress Note", "row_id": 680668, "text": " Problem\n Condition update\n Assessment:\n Remains on CRRT\n Remains on vent, trached and on weaning mode CPAP\n Neurologically more\nawake\n , yet still suspicious of underlying\n seizure activity\n Tube feeds advancing\n Family continues to be supportive\n Action:\n CRRT to take off as much fluid as patient can tolerate\n No weaning from vent today, good gases on much lower settings\n No bleeding from trach or mouth.\n Early am CT scan done after ?seizure activity\n Neurology to see patient this am--?seizsure vs. myoclonic movements\n Versed gtt restarted @ 3mg /hr\n EEG done this afternoon.\n Belly distended but soft, improving bowel sounds\n Stool large amount soft brown\nsent for cdif\n Response:\n Slowly improving\n Plan:\n Fluid removal as tolerated\n IR for Perm HD cath placement\n ?Trach collar wean soon\n PT/OT consults\n Awaiting cdif results.\n Continue w/family support.\n" }, { "category": "Respiratory ", "chartdate": "2131-06-05 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 678900, "text": "Demographics\n Day of intubation: 19\n Day of mechanical ventilation: 19\n Ideal body weight: 67.1 None\n Ideal tidal volume: 268.4 / 402.6 / 536.8 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location: ICU\n Reason: Re-intubation\n Tube Type\n ETT:\n Position: 23 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 28 cmH2O\n Cuff volume: 6 mL / Air\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: 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: Active exhalations, High flow\n demand; Comments: Patient somewhat dysynchronous with ventilator when\n sedation lightened.\n Assessment of breathing comfort: No response (sleeping / sedated)\n Invasive ventilation assessment:\n Trigger work assessment: Abnormal trigger efforts (efforts during\n inspiratory)\n Dysynchrony assessment: Erratic exhaled Tidal Volumes\n Plan\n Next 24-48 hours: Tracheostomy planned; Comments: Trach planned in O.R.\n today.\n Reason for continuing current ventilatory support: Cannot protect\n airway, Hemodynimic instability, Underlying illness not resolved.\n" }, { "category": "Respiratory ", "chartdate": "2131-06-06 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 679102, "text": "Demographics\n Day of intubation: 3\n Day of mechanical ventilation: 20\n Ideal body weight: 67.1 None\n Ideal tidal volume: 268.4 / 402.6 / 536.8 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location: ICU\n Reason: Re-intubation\n Tube Type\n ETT:\n Position: 26 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 28 cmH2O\n Cuff volume: 6 mL / Air\n Lung sounds\n RLL Lung Sounds: Rhonchi\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: Nasal flaring, Accessory muscle\n use, Frequent desaturation episodes, Tachypneic (RR> 35 b/min), Gasping\n efforts, High flow demand; Comments: tient dysynchronous with\n ventilator. Has increased work of breathing, nasal flaring and\n increased O2 requirements.\n Assessment of breathing comfort: No response (sleeping / sedated)\n Invasive ventilation assessment:\n Trigger work assessment: Abnormal trigger efforts (efforts during\n inspiratory)\n Dysynchrony assessment: Erratic exhaled Tidal Volumes\n Plan\n Next 24-48 hours: Maintain PEEP at current level and reduce FiO2 as\n tolerated, Tracheostomy planned\n Reason for continuing current ventilatory support: Hemodynimic\n instability, Underlying illness not resolved\n Respiratory Care Shift Procedures\n Bedside Procedures:\n Comments: Recruitment manuvers completed x2 with good effect in\n oxygenation.\n" }, { "category": "Nursing", "chartdate": "2131-06-07 00:00:00.000", "description": "Nursing Progress Note", "row_id": 679262, "text": "Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Potassium level 6.7\n EKG changes notes\n Creatinine 3.3\n Minimal urine output\n Remains very fluid overloaded\n Action:\n New HD catheter placed by Dr. \n Placement confirmed by x-ray\n CRRT started @ 0200\n Kayexelate enema given for elevated potassium level.\n Insulin / dextrose / calcium given for elevated potassium.\n Response:\n Plan:\n Sepsis, Severe (with organ dysfunction)\n Assessment:\n Temp consistently ~ 100.4\n WBC this am 64\n Remains dependent on Levophed however weaning\n Action:\n Linezolid added to antibiotic regimen\n Steroids also started\n On rotating bed\n Response:\n Levophed weaned slightly\n Plan:\n Continue to follow up on culture results\n Impaired Skin Integrity\n Assessment:\n Popped blisters on legs from 3^rd spaced fluid are improving\n Lower legs / shins healing while thighs remain weepy and red\n Heels also improving, the area that is purple is shrinking\n Action:\n Legs wounds where aquacel ag was still attached where\n untouched. Aquacel left in place.\n Other areas cleansed with wound cleanser, and aquacel or\n adaptic, or just softsorb applied, depending on wound base and\n surrounding skin.\n Wrapped with kerlex gauze to keep in place\n Rotating air bed\n Waffle boots\n Response:\n Improving\n Plan:\n Continue with dressings noted in action plan\n Continue rotating air bed\n Continue waffle boots\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Labored breathing, using accessory muscles, flaring nostrils\n On AC, 80%, 12 peep, 30 x 400\n Breathing over the ventilator\n Rare cough, non productive but sounds congested\n Action:\n Recruitment maneuvers x2\n On rotating bed, as well as linen changes and full body turn\n q 4 hours\n VAP protocol\n ABX as ordered\n CRRT for fluid removal\n Response:\n Plan:\n" }, { "category": "Respiratory ", "chartdate": "2131-06-01 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 678252, "text": "Demographics\n Day of mechanical ventilation: 15\n Ideal body weight: 67.1 None\n Ideal tidal volume: 268.4 / 402.6 / 536.8 mL/kg\n Airway\n Tube Type\n ETT:\n Position: 23 cm at teeth\n Type: Standard\n Size: 7mm\n :\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Clear\n Secretions\n Sputum color / consistency: Clear / Thick\n Sputum source/amount: Suctioned / Scant\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Active exhalations, High flow\n demand\n Assessment of breathing comfort: No response (sleeping / sedated)\n Plan\n Next 24-48 hours: Utilize ARDSnet protocol, Reduce PEEP as tolerated,\n Adjust Min. ventilation to control pH\n Reason for continuing current ventilatory support: Sedated / Paralyzed,\n Underlying illness not resolved\n" }, { "category": "Respiratory ", "chartdate": "2131-06-05 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 679011, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 19\n Ideal body weight: 67.1 None\n Ideal tidal volume: 268.4 / 402.6 / 536.8 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: 26 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 Comments:\n Secretions\n Sputum color / consistency: Brown / 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:\n Assessment of breathing comfort: No response (sleeping / sedated)\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Underlying illness\n not resolved\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n CT\n 1630\n Bedside Procedures:\n Comments:\n Pt on the vent changes made tol well. See respiratory page of meta\n vision for more information.\n" }, { "category": "Physician ", "chartdate": "2131-06-01 00:00:00.000", "description": "ICU Attending Note", "row_id": 678241, "text": "Clinician: Attending\n MICU ATTENDING NOTE\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, including assessment and plan.\n 28M with necrotizing pancreatitis (30-40% necrosis via CT), ARDS,\n septic shock, renal failure. Head CT revealed edema, treated with 23%\n NS for induced osmorx, stopped .\n WBC 36\n 31, plts increased at 60.\n 1. Shock, remains levophed dependent.\n 2. Thrombocytopenia present since . Improved since yesterday off\n heparin in TPN (prophylaxis).\n 3. Nutrition: TPN without heparin.\n 4. No clear source of bleed. NG lavage neg. Brown, g+ stool. No blood\n from ETT. Repeat DIC labs. be due to oozing from known\n gastritis.\n 5. Neuro: pupil exam stable. D/C hypertonic saline.\n 6. ARDS: continue weaning FiO2 followed by PEEP. PEEP was as high as\n 24, now 12. Not a candidate for trach at this time.\n 7. Weaning sedation. Off versed. Fent 50mcg.\n 8. Off antibiotics. Vanc/ stopped yesterday, flagyl stopped .\n Remains afebrile.\n 9. Skin breakdown- wound service recs.\n 10. Renal failure, on CVVHD. Much less anasarca.\n episode of awakening, followed command to wiggle fingers\n no transfusions yesterday, hct 25.7--> 23.8\n febrile\n 110/60 108\n AC 0.5/400/30/12 100% 7.46/35/75\n 10L/11.3L (135cc urine)\n more alert\n anasarca, but improved\n LFTs, bili stable\n abd CT final read: diffuse colon wall thickening, no sig change in\n pancreas but new 3x3 cm pseudocyst\n head CT: improved edema, opacification of paranasal sinuses\n CXR no sig change\n resp failure, ARDS slow progress on PEEP. Request trach, though will\n likely not be done until PEEP <10.\n mental status improving, trying to minimize sedation\n sedation- versed 2, fent 50. Stop versed, reevaluate.\n anemia: continue close monitoring with q8 hct, transfuse for <22\n pancreatitis- pseudocyst\n nutrition, on TPN, discuss trophic feeds with nutrition and increase\n insulin in TPN\n spiking low grade temps, off flagyl 3d, off meropenem 2d. Attributable\n to pancreatitis. Sinus consolidation unchanged since prior head CT,\n colitis on CT. Minimal stool but will try to send for CDiff. No sig\n resp secretions. Plan to hold off on restarting antibiotics, but will\n d/w ID.\n PO narcan for prolonged fentanyl.\n" }, { "category": "Respiratory ", "chartdate": "2131-06-02 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 678325, "text": "TITLE:\n Demographics\n Day of intubation: \n Day of mechanical ventilation: 16\n Ideal body weight: 67.1 None\n Ideal tidal volume: 268.4 / 402.6 / 536.8 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location: ICU\n Reason: Emergent (1st time)\n Tube Type\n ETT:\n Position: 23 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 29 cmH2O\n Lung sounds\n RLL Lung Sounds: Insp/Exp Wheeze\n RUL Lung Sounds: Diminished\n LUL Lung Sounds: Ins/Exp Wheeze\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: Tan / Thick\n Sputum source/amount: Suctioned / Scant\n Comments:\n Ventilation Assessment\n Level of breathing assistance: A/C 400x30/+12 peep/.5\n Visual assessment of breathing pattern: Nasal flaring, Accessory muscle\n use, Tachypneic (RR> 35 b/min), High flow demand\n Assessment of breathing comfort: appears dyspneic\n Invasive ventilation assessment:\n Trigger work assessment: Abnormal trigger efforts (efforts during\n inspiratory)\n Dysynchrony assessment: Frequent alarms (High pressure, High rate)\n Comments: maintaining Ve 16-22 L with RR ~30\ns to 50\n Plan\n Next 24-48 hours: Utilize ARDSnet protocol\n Reason for continuing current ventilatory support: Intolerant of\n weaning attempts\n Respiratory Care Shift Procedures\n Bedside Procedures: started MDI for wheezing; RSBI held d/t persistent\n tachpnea despite sedation\n" }, { "category": "Physician ", "chartdate": "2131-06-12 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 680344, "text": "Chief Complaint:\n 24 Hour Events:\n STOOL CULTURE - At 01:21 PM\n for cdiff\n RESPIRATORY ARREST - At 07:28 PM\n team at bedside.\n BRONCHOSCOPY - At 08:14 PM\n Dr , time out done prior to proced\n BRONCHOSCOPY - At 08:48 PM\n Dr .\n - Concern for hemophagocytic syndrome - Checking ferritin (>);\n heme-onc consulted, feel hemophagocytic syndrome is unlikely.\n - Plan to increase insulin in TPN, but TPN recs not available in time\n - In anticipation of bzd withdrawal with weaning of midazolam, started\n valium 10mg PO TID. Plan to wean fentanyl, versed as tolerated in hopes\n of trying pressure support.\n - Per ID, restarted vanc PR; will restart ciprofloxacin if\n decompensates\n - Amylase 47, lipase 47\n - 6pm I/O -2L\n - 6pm Doing well on pressure support, versed weaned off. After incident\n below, restarted on assist control.\n - 7:30pm Respiratory distress - Initially with bronchospasm, then\n apneic and briefly without pulse (?minutes). Improved with deep suction\n - large clot removed with return of pulse, BP and improved ventilation.\n Thoracics performed bedside bronchoscopy - determined that trach is too\n short; on further reevaluation by attending, appropriate size and not\n needing replacement; clots removed with repeat bronchoscopy. Heme/onc\n aware, recommended Amicar for bleeding at trach site - started.\n Allergies:\n Meropenem\n skin blisters a\n Last dose of Antibiotics:\n Vancomycin - 04:00 PM\n Aztreonam - 09:24 PM\n Linezolid - 11:00 PM\n Micafungin - 12:33 AM\n Metronidazole - 02:01 AM\n Infusions:\n Fentanyl (Concentrate) - 100 mcg/hour\n Norepinephrine - 0.03 mcg/Kg/min\n Midazolam (Versed) - 5 mg/hour\n Calcium Gluconate (CRRT) - 1.6 grams/hour\n KCl (CRRT) - 2 mEq./hour\n Other ICU medications:\n Atropine - 07:30 PM\n Midazolam (Versed) - 09:03 PM\n Other medications:\n Changes to medical and family history:\n None\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Intubated, sedated.\n Flowsheet Data as of 06:08 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37\nC (98.6\n Tcurrent: 35.4\nC (95.8\n HR: 80 (30 - 126) bpm\n BP: 118/68(87) {59/41(47) - 168/94(124)} mmHg\n RR: 26 (10 - 31) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 123.3 kg (admission): 113.5 kg\n Height: 67 Inch\n CVP: 16 (14 - 49)mmHg\n Total In:\n 11,516 mL\n 2,538 mL\n PO:\n TF:\n 481 mL\n 91 mL\n IVF:\n 9,455 mL\n 2,234 mL\n Blood products:\n Total out:\n 13,098 mL\n 3,404 mL\n Urine:\n 65 mL\n 37 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,582 mL\n -866 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n Vt (Spontaneous): 725 (725 - 725) mL\n PS : 10 cmH2O\n RR (Set): 26\n RR (Spontaneous): 0\n PEEP: 8 cmH2O\n FiO2: 50%\n RSBI Deferred: Hemodynamic Instability\n PIP: 20 cmH2O\n SpO2: 100%\n ABG: 7.33/50/143/25/0\n Ve: 11.9 L/min\n PaO2 / FiO2: 286\n Physical Examination\n GEN: Intubated, sedated\n HEENT: icteric sclera. MMM\n NECK: Trach site with minimal oozing\n LUNGS: Anterior auscultation with upper airway noise; good airway\n movement\n HEART: , ; S1, S2\n ABD: Distended. NT.\n EXTREM: 2+ edema, ulcers/lesions on legs with bandages C/D/I\n SKIN: Jaundice\n Labs / Radiology\n 93 K/uL\n 7.8 g/dL\n 208 mg/dL\n 0.6 mg/dL\n 25 mEq/L\n 4.7 mEq/L\n 36 mg/dL\n 95 mEq/L\n 130 mEq/L\n 23.5 %\n 28.2 K/uL\n [image002.jpg]\n ALT: 97\n AP: 198\n Tbili: 28.7\n Alb:\n AST: 234\n LDH: 706\n Dbili:\n TProt:\n : 51\n Lip: 41\n PT: 15.8\n PTT: 33.2\n INR: 1.4\n 08:29 AM\n 08:42 AM\n 02:06 PM\n 02:20 PM\n 07:32 PM\n 07:44 PM\n 08:51 PM\n 01:27 AM\n 01:36 AM\n 05:36 AM\n WBC\n 28.2\n Hct\n 23.5\n Plt\n 93\n Cr\n 0.9\n 0.9\n 0.9\n 0.6\n TCO2\n 28\n 28\n 23\n 25\n 28\n 28\n Glucose\n 30\n 106\n 208\n Other labs: PT / PTT / INR:15.8/33.2/1.4, CK / CKMB /\n Troponin-T:214/3/0.07, ALT / AST:97/234, Alk Phos / T Bili:198/28.7,\n Amylase / Lipase:51/41, Differential-Neuts:68.0 %, Band:5.0 %,\n Lymph:7.0 %, Mono:4.0 %, Eos:0.0 %, D-dimer:6389 ng/mL, Fibrinogen:502\n mg/dL, Lactic Acid:1.5 mmol/L, Albumin:2.0 g/dL, LDH:706 IU/L, Ca++:8.8\n mg/dL, Mg++:2.0 mg/dL, PO4:3.5 mg/dL\n 4:11 pm TISSUE Source: Skin biopsy r/o HSV 1 and HSV2.\n GRAM STAIN (Final ):\n NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.\n NO MICROORGANISMS SEEN.\n TISSUE (Preliminary):\n REPORTED BY PHONE TO 11:30AM.\n Due to mixed bacterial types (>=3) an abbreviated workup is\n performed; P.aeruginosa, S.aureus and beta strep. are reported if\n present. Susceptibility will be performed on P.aeruginosa and\n S.aureus if sparse growth or greater..\n STAPHYLOCOCCUS, COAGULASE NEGATIVE. RARE GROWTH.\n ENTEROCOCCUS SP..\n Isolated from broth media only, INDICATING VERY LOW NUMBERS OF\n ORGANISMS.\n STAPHYLOCOCCUS, COAGULASE NEGATIVE.\n 2ND STRAIN Isolated from broth media only, INDICATING VERY LOW\n NUMBERS OF ORGANISMS.\n ANAEROBIC CULTURE (Preliminary): NO ANAEROBES ISOLATED.\n FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.\n ACID FAST SMEAR (Final ):\n NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.\n ACID FAST CULTURE (Preliminary):\n VIRAL CULTURE (Preliminary): No Virus isolated so far.\n Assessment and Plan\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n IMPAIRED SKIN INTEGRITY\n HEPATITIS, ACUTE TOXIC (INCLUDING ALCOHOLIC, ACETAMINOPHEN, ETC.)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n 28M with alcoholic hepatitis and necrotizing pancreatitis complicated\n by ARDS, SIRS, ARF, UGIB, fevers and eosinophilia\n #. Fever: Afebrile x>3days - source unclear. Question of fever \n adrenal insufficiency; now on steroids. Concern for infection with\n increased bandemia today although leukocytosis improved.\n Blood/tissue/BAL cx NGTD, CT abd with persistent inflammation\n concerning for infection. CT sinuses w/ opacification of unclear time\n course.\n - Cte broad spectrum antibiotic coverage with aztreonam for extended GN\n coverage, linezolid for MRSA and VRE for bacteremia, flagyl IV, vanc PO\n empirically per ID recs given increasing leukocytosis and colon\n inflammation on CT, micafungin for antifungal coverage\n - Per ID, add ciprofloxacin if decompensates. Also restart vancomycin\n PR\n - F/u WBC and temp curve\n - F/u derm biopsy results to see if skin infection; already on broad\n spectrum antibiotic coverage inc. skin flora coverage\n - F/u cultures\n - F/u ID recs; question: how to down abx over next few days\n #. Respiratory Failure: ARDS secondary to necrotizing pancreatitis. S/p\n trach placement on . Sutures out on \n - Decrease sedation (both fentanyl and versed) with goal of trying\n pressure support. Given that patient may have withdrawal from\n benzodiazepenes with weaning of midazolam, start valium standing\n (5-10mg q8 hours)\n - Cont to wean as tolerated\n #. Adrenal Insufficiency: Unclear with stim if clear adrenal\n insufficiency but hypotension improving with steroids (lower pressor\n requirement) and improving eosinophilia\n - Will continue steroids IV X 5 days (day 5) then change to prednisone\n to taper\n #. Hyperbilirubinemia: Likely related to underlying shock liver and\n ?obstructive etiology from necrotizing pancreatitis. Continue to trend.\n #. Eosinophilia: Resolved. Adrenal insufficiency v. drug reaction\n (?PPI; vanc & dapto less likely d/t time course). Fungal and parasitic\n infection also possible etiologies.\n - stim positive for adrenal insufficiency. Cte steroids.\n - Off PPI, vanc, dapto\n - Cte fungal coverage as above\n #. Anemia: Hct stable since 1 unit pRBC and 1 dose DDAVP s/p trach with\n some oozing at site.\n - recheck hemolysis labs\n - trend hcts Q6H, 1unit pRBCs now, guaiac stools and NGT aspirate\n - If not appropriate bump with blood consider scope to ensure doboff\n did not cause significant bleed\n - holding ppx with PPI or sucralfate given issues of eosinophilia and\n ARF\n #. Thrombocytopenia: Appreciate heme recs. Do not feel this is DIC.\n - Monitor platelets daily and transfuse for plt <10 or <50 if signs of\n bleed\n - monitor daily\n #. Acute renal Failure: Appreciate renal recs. Cr improved on CVVH. Off\n sucralfate due to concern for electrolyte abnormalities.\n - Cte volume depletion with CVVH as long as pressor requirement does\n not increase\n #. Wounds: Derm biopsy pending - inflammatory, infectious, or reactive.\n F/u recs.\n #. Agitation: Cont methadone given decreased sensitivity to fentanyl;\n titrate prn\n #. Glucose intolerance: In setting of steroids; adjust ISS prn. As\n blood glucose continues to run high, will increase insulin included in\n TPN.\n ICU Care\n Nutrition:\n TPN w/ Lipids - 02:10 PM 35 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 08:15 PM\n Multi Lumen - 10:00 PM\n Dialysis Catheter - 11:35 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": "2131-06-13 00:00:00.000", "description": "Physician Resident/Attending Progress Note - MICU", "row_id": 680654, "text": "Chief Complaint:\n 24 Hour Events:\n \n - Amicar continued for 24 h (course up to 10d per Heme)\n - Tube feed goals increased to 50 cc/h\n - Midaz gtt d/c'd -> bolus with goal improved PS\n - ID: Cont current meds; consider cipro if decomp\n - Noted to have some bleeding from near back of mouth; likely from\n ulcer. Cont amicar and reassess in AM.\n - Had orofacial and bilat upper extrem twitching at 5am. Received\n ativan 2mg IV x 2 with persistence of mvts but gradually becoming more\n intermittent over 1/2 hour. Seen by Neuro who agreed w/ plan for CT\n head. Also recommended early keppra dose. Ativan prn for recurrent\n episode; if not responsive to 2 doses, restart versed gtt. Neuro to see\n this AM.\n Allergies:\n Meropenem\n skin blisters a\n Last dose of Antibiotics:\n Vancomycin - 04:00 PM\n Micafungin - 12:33 AM\n Aztreonam - 08:10 AM\n Linezolid - 10:15 PM\n Metronidazole - 02:12 AM\n Infusions:\n Norepinephrine - 0.03 mcg/Kg/min\n Fentanyl (Concentrate) - 100 mcg/hour\n Calcium Gluconate (CRRT) - 1.6 grams/hour\n KCl (CRRT) - 2 mEq./hour\n Other ICU medications:\n Famotidine (Pepcid) - 12:35 PM\n Heparin Sodium (Prophylaxis) - 12:35 PM\n Diazepam (Valium) - 10:23 PM\n Lorazepam (Ativan) - 04:45 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:57 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 HR: 85 (73 - 94) bpm\n BP: 136/76(98) {98/45(62) - 136/76(98)} mmHg\n RR: 19 (11 - 23) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 118.9 kg (admission): 113.5 kg\n Height: 67 Inch\n CVP: 6 (6 - 19)mmHg\n Total In:\n 10,200 mL\n 2,681 mL\n PO:\n TF:\n 481 mL\n IVF:\n 9,222 mL\n 2,191 mL\n Blood products:\n Total out:\n 15,987 mL\n 3,635 mL\n Urine:\n 162 mL\n NG:\n Stool:\n Drains:\n Balance:\n -5,787 mL\n -954 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 400 (400 - 400) mL\n Vt (Spontaneous): 709 (333 - 797) mL\n PS : 12 cmH2O\n RR (Set): 26\n RR (Spontaneous): 14\n PEEP: 8 cmH2O\n FiO2: 50%\n RSBI Deferred: Agitated\n PIP: 22 cmH2O\n SpO2: 100%\n ABG: 7.34/47/144/22/0\n Ve: 10.4 L/min\n PaO2 / FiO2: 288\n Physical Examination\n GEN: Intubated, sedated\n HEENT: icteric sclera. MMM\n NECK: Trach site with minimal oozing\n LUNGS: Anterior auscultation with upper airway noise; good airway\n movement\n HEART: , ; S1, S2\n ABD: Distended. NT.\n EXTREM: 2+ edema, ulcers/lesions on legs with bandages C/D/I\n SKIN: Jaundice\n NEURO: Mouth twitching. Arms jerking bilaterally.\n Labs / Radiology\n 118 K/uL\n 8.0 g/dL\n 136 mg/dL\n 1.0 mg/dL\n 22 mEq/L\n 3.9 mEq/L\n 35 mg/dL\n 96 mEq/L\n 132 mEq/L\n 23.9 %\n 21.8 K/uL\n [image002.jpg]\n 01:27 AM\n 01:36 AM\n 05:21 AM\n 05:36 AM\n 10:31 AM\n 04:07 PM\n 09:44 PM\n 09:51 PM\n 02:58 AM\n 03:09 AM\n WBC\n 28.2\n 21.8\n Hct\n 23.5\n 23.9\n Plt\n 93\n 118\n Cr\n 0.6\n 0.9\n 1.0\n 1.0\n TCO2\n 28\n 28\n 24\n 27\n 25\n 26\n Glucose\n 45\n 136\n Other labs: PT / PTT / INR:16.1/35.0/1.4, CK / CKMB /\n Troponin-T:214/3/0.07, ALT / AST:97/234, Alk Phos / T Bili:198/28.7,\n Amylase / Lipase:51/41, Differential-Neuts:68.0 %, Band:5.0 %,\n Lymph:7.0 %, Mono:4.0 %, Eos:0.0 %, D-dimer:6389 ng/mL, Fibrinogen:502\n mg/dL, Lactic Acid:1.2 mmol/L, Albumin:2.0 g/dL, LDH:706 IU/L, Ca++:8.8\n mg/dL, Mg++:1.9 mg/dL, PO4:3.4 mg/dL\n CT Head: ***Prelim read*** No hemorrhage or other acute intracranial\n process.\n Assessment and Plan\n 28M with alcoholic hepatitis and necrotizing pancreatitis complicated\n by ARDS, SIRS, ARF, UGIB, fevers and eosinophilia\n #. Respiratory Failure: ARDS secondary to necrotizing pancreatitis. S/p\n trach placement on . Sutures out on \n - Decrease PEEP today as tolerated\n - Cont to wean as tolerated\n - continue methadone to decrease fentanyl requirement\n # Seizures: Had increased twitching of head and arms yesterday with\n deviation of eyes to R. Was given Ativan x 2, Keppra dose early, and\n Neuro saw him and agreed that these are likely seizures. CT head\n without intracranial process.\n - Restart midazolam gtt as may be benzo withdrawal\n - EEG today to define if new focus of seizures\n - Consider d/c flagyl or other drugs that may lower seizure threshold\n - Consider load phosphenytoin\n # Bleeding around trach site: Amicar was continued for another 24 hrs\n with better hemostasis around trach\n - f/u Heme/Onc recs\n - completed amicar course\n #. ID: Afebrile.. Question of fever adrenal insufficiency; now on\n steroids. leukocytosis improved. Blood/tissue/BAL cx NGTD,\n - Cte broad spectrum antibiotic coverage with aztreonam for extended GN\n coverage, linezolid for MRSA and VRE for bacteremia, flagyl IV, vanc PO\n empirically per ID recs given increasing leukocytosis and colon\n inflammation on CT.\n - Per ID, add ciprofloxacin if decompensates. Also restart vancomycin\n PR\n - C diff negative, Send c diff, 2^nd sample. If negative d/c vanc po\n and flagyl\n - F/u WBC count, temp curve, and culture data\n - F/u ID recs; question: how to down abx over next few days\n #. Adrenal Insufficiency: Unclear with stim if clear adrenal\n insufficiency but hypotension improving with steroids (lower pressor\n requirement) and improving eosinophilia\n - weaned on to 75mg IV Q8hr continue this dose X 1 more day then\n down to 50mg \n #. Hyperbilirubinemia: Likely related to underlying shock liver, TPN,\n and ?obstructive etiology from necrotizing pancreatitis. Continue to\n trend.\n #. Anemia: stable\n - Hct QD, guaiac stools and NGT aspirate\n #. Thrombocytopenia: almost resolved\n - Monitor platelets daily and transfuse for plt <10 or <50 if signs of\n bleed\n - monitor daily\n #. Acute renal Failure: Appreciate renal recs. Cr improved on CVVH. Off\n sucralfate due to concern for electrolyte abnormalities.\n - Cte volume depletion with CVVH as long as pressor requirement does\n not increase\n - Begin thinking about placing tunneled dialysis catheter\n ICU Care\n Nutrition:\n TPN w/ Lipids - 05:00 PM 71 mL/hour\n TFs on hold for IR today\n Glycemic Control:\n Lines:\n Arterial Line - 08:15 PM\n Multi Lumen - 10:00 PM\n Dialysis Catheter - 11:35 PM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Other, Heparin in TPN)\n Stress ulcer: H2 blocker\n VAP: HOB elevation, Mouth care\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:ICU\n ------ Protected Section ------\n MICU ATTENDING ADDENDUM\n I saw and examined the patient, and was physically present with the ICU\n 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: 28M alcoholic hepatitis, pancreatitis,\n refractory shock, ARDS - now tolerating aggressive fluid removal and\n off pressors. WBC and sedation down. Some bleeding from mouth,\n resolved. This AM, apparent sz activity, keppra given early, ativan\n x6mg c improvement. CT head completed\n wet read neg but limited by\n artifact. Remains off pressors.\n Exam notable for Tm 98.6 BP 105/50 HR 90 CVP 12 RR 30 with sat 100 on\n PSV 12/8 7.34/47/144. WD man, anasarca, chemosis. Partial eye opening\n to command. Coarse BS B. Distant s1s2. Obese, no BS. 3+ edema. Labs\n notable for WBC 21K, HCT 23, Na 132, lactate 1.0. CXR with low volumes.\n Agree with plan to manage respiratory failure with slow wean of\n sedation and wean of PSV as mental status allows. Given new sz\n activity, will resume midazolam now, get EEG and neuro consult and\n cosider load with fosphenytoin. Will continue IV valium and methadone.\n Will d/c amicar for trach ooze today as this may lower sz threshold.\n For ongoing fevers and leukocytosis, will continue steroids (HC 75\n q8h) and broad antibiotic coverage. Will d/w ID re stepwise reduction\n in abx coverage as cultures to date have been unrevealing, and will\n limit exposure to meds that lower sz threshold. Will quantify ferritin\n (>)and d/w heme re HLH / BMBx, but suspect continuing supportive\n care is the best way forward. For ARF, continue CVVH with goal\n -250cc/h; will need tunnelled line today if stable. For pancreatitis,\n will increase post-pyloric TFs; he is now , be able to stop\n TPN tomorrow. Will increase insulin in TPN for persistent\n hyperglycemia. Remainder of plan as outlined above. Plan d/w family at\n bedside.\n Patient is critically ill\n Total time: 50 min\n ------ Protected Section Addendum Entered By: , MD\n on: 03:55 PM ------\n" }, { "category": "Physician ", "chartdate": "2131-06-08 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 679459, "text": "Chief Complaint:\n 24 Hour Events:\n EKG - At 11:41 AM\n FLUOROSCOPY - At 01:35 PM\n for post pyloric feeding\n :\n - Hyperkalemia and ECG improved with CVVH - renal recommended to\n continue CVVH.\n - Post-pyloric NG tube placed with OG tube d/c'd\n - Methadone 5mg TID started\n - Carafate started and Pantoprazole d/c'd for ? PPI induced\n eosinophilia.\n - ID recommended starting micofungin and flagyl.\n - ID also recommended HIV test which may be done via the health care\n proxy, but I left a message and did not get a call back.\n - Derm came by and biopsied leg - their suspicion was ulcers due to\n edema but will rule out other pathology.\n - This AM Hct of 20, transfusing 1 U. Consider desmopressin or plt\n transfusion.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Micafungin - 08:00 PM\n Aztreonam - 09:00 PM\n Linezolid - 10:00 PM\n Metronidazole - 02:00 AM\n Vancomycin - 04:00 AM\n Infusions:\n Norepinephrine - 0.05 mcg/Kg/min\n Fentanyl (Concentrate) - 350 mcg/hour\n Midazolam (Versed) - 15 mg/hour\n KCl (CRRT) - 30 mEq./hour\n Calcium Gluconate (CRRT) - 1.4 grams/hour\n Other ICU medications:\n Carafate (Sucralfate) - 04:00 AM\n Heparin Sodium (Prophylaxis) - 04:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:49 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.9\nC (98.4\n Tcurrent: 36.8\nC (98.3\n HR: 96 (83 - 101) bpm\n BP: 98/52(65) {88/46(60) - 122/67(83)} mmHg\n RR: 30 (8 - 30) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 134 kg (admission): 113.5 kg\n Height: 67 Inch\n CVP: 12 (12 - 291)mmHg\n Total In:\n 9,121 mL\n 2,718 mL\n PO:\n TF:\n IVF:\n 7,364 mL\n 2,290 mL\n Blood products:\n 6 mL\n Total out:\n 11,625 mL\n 3,415 mL\n Urine:\n 122 mL\n 24 mL\n NG:\n 500 mL\n Stool:\n Drains:\n Balance:\n -2,504 mL\n -697 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 30\n RR (Spontaneous): 0\n PEEP: 10 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10\n PIP: 30 cmH2O\n Plateau: 24 cmH2O\n Compliance: 28.6 cmH2O/mL\n SpO2: 100%\n ABG: 7.35/51/86/24/0\n Ve: 11.9 L/min\n PaO2 / FiO2: 172\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 58 K/uL\n 6.8 g/dL\n 231 mg/dL\n 1.5 mg/dL\n 24 mEq/L\n 3.8 mEq/L\n 36 mg/dL\n 96 mEq/L\n 131 mEq/L\n 20.7 %\n 56.6 K/uL\n [image002.jpg]\n 06:11 AM\n 09:52 AM\n 10:05 AM\n 03:52 PM\n 03:58 PM\n 09:57 PM\n 12:02 AM\n 03:36 AM\n 03:53 AM\n 04:48 AM\n WBC\n 48.4\n 56.6\n Hct\n 20.4\n 20.7\n Plt\n 45\n 58\n Cr\n 1.5\n TCO2\n 23\n 23\n 27\n 29\n 26\n 29\n Glucose\n 255\n 249\n 290\n \n 231\n Other labs: PT / PTT / INR:19.1/46.0/1.8, CK / CKMB /\n Troponin-T:214/3/0.07, ALT / AST:42/182, Alk Phos / T Bili:129/23.3,\n Amylase / Lipase:19/35, Differential-Neuts:58.0 %, Band:4.0 %,\n Lymph:4.0 %, Mono:11.0 %, Eos:9.0 %, D-dimer:6389 ng/mL, Fibrinogen:419\n mg/dL, Lactic Acid:2.0 mmol/L, Albumin:1.7 g/dL, LDH:821 IU/L, Ca++:7.9\n mg/dL, Mg++:1.7 mg/dL, PO4:4.1 mg/dL\n Assessment and Plan\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n IMPAIRED SKIN INTEGRITY\n HEPATITIS, ACUTE TOXIC (INCLUDING ALCOHOLIC, ACETAMINOPHEN, ETC.)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ICU Care\n Nutrition:\n TPN w/ Lipids - 03:10 PM 73. mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 08:15 PM\n Multi Lumen - 10:00 PM\n Dialysis Catheter - 11:35 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: Sucralafate\n VAP: HOB elevation, Mouth care\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:ICU\n" }, { "category": "Physician ", "chartdate": "2131-06-08 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 679460, "text": "Chief Complaint:\n 24 Hour Events:\n EKG - At 11:41 AM\n FLUOROSCOPY - At 01:35 PM\n for post pyloric feeding\n :\n - Hyperkalemia and ECG improved with CVVH - renal recommended to\n continue CVVH.\n - Post-pyloric NG tube placed with OG tube d/c'd\n - Methadone 5mg TID started\n - Carafate started and Pantoprazole d/c'd for ? PPI induced\n eosinophilia.\n - ID recommended starting micofungin and flagyl.\n - ID also recommended HIV test which may be done via the health care\n proxy, but I left a message and did not get a call back.\n - Derm came by and biopsied leg - their suspicion was ulcers due to\n edema but will rule out other pathology.\n - This AM Hct of 20, transfusing 1 U. Consider desmopressin or plt\n transfusion.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Micafungin - 08:00 PM\n Aztreonam - 09:00 PM\n Linezolid - 10:00 PM\n Metronidazole - 02:00 AM\n Vancomycin - 04:00 AM\n Infusions:\n Norepinephrine - 0.05 mcg/Kg/min\n Fentanyl (Concentrate) - 350 mcg/hour\n Midazolam (Versed) - 15 mg/hour\n KCl (CRRT) - 30 mEq./hour\n Calcium Gluconate (CRRT) - 1.4 grams/hour\n Other ICU medications:\n Carafate (Sucralfate) - 04:00 AM\n Heparin Sodium (Prophylaxis) - 04:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:49 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.9\nC (98.4\n Tcurrent: 36.8\nC (98.3\n HR: 96 (83 - 101) bpm\n BP: 98/52(65) {88/46(60) - 122/67(83)} mmHg\n RR: 30 (8 - 30) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 134 kg (admission): 113.5 kg\n Height: 67 Inch\n CVP: 12 (12 - 291)mmHg\n Total In:\n 9,121 mL\n 2,718 mL\n PO:\n TF:\n IVF:\n 7,364 mL\n 2,290 mL\n Blood products:\n 6 mL\n Total out:\n 11,625 mL\n 3,415 mL\n Urine:\n 122 mL\n 24 mL\n NG:\n 500 mL\n Stool:\n Drains:\n Balance:\n -2,504 mL\n -697 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 30\n RR (Spontaneous): 0\n PEEP: 10 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10\n PIP: 30 cmH2O\n Plateau: 24 cmH2O\n Compliance: 28.6 cmH2O/mL\n SpO2: 100%\n ABG: 7.35/51/86/24/0\n Ve: 11.9 L/min\n PaO2 / FiO2: 172\n Physical Examination\n GEN: Intubated, sedated\n HEENT: icteric sclera. MMM\n NECK: Sites clean/dry/no oozing\n LUNGS: Crackles bilaterally anteriorly.\n HEART: RRR\n ABD: Distended. NT.\n EXTREM: 2+ edema with weeping wounds without surrounding erythema\n SKIN: Jaundice\n Labs / Radiology\n 58 K/uL\n 6.8 g/dL\n 231 mg/dL\n 1.5 mg/dL\n 24 mEq/L\n 3.8 mEq/L\n 36 mg/dL\n 96 mEq/L\n 131 mEq/L\n 20.7 %\n 56.6 K/uL\n [image002.jpg]\n 06:11 AM\n 09:52 AM\n 10:05 AM\n 03:52 PM\n 03:58 PM\n 09:57 PM\n 12:02 AM\n 03:36 AM\n 03:53 AM\n 04:48 AM\n WBC\n 48.4\n 56.6\n Hct\n 20.4\n 20.7\n Plt\n 45\n 58\n Cr\n 1.5\n TCO2\n 23\n 23\n 27\n 29\n 26\n 29\n Glucose\n 255\n 249\n 290\n \n 231\n Other labs: PT / PTT / INR:19.1/46.0/1.8, CK / CKMB /\n Troponin-T:214/3/0.07, ALT / AST:42/182, Alk Phos / T Bili:129/23.3,\n Amylase / Lipase:19/35, Differential-Neuts:58.0 %, Band:4.0 %,\n Lymph:4.0 %, Mono:11.0 %, Eos:9.0 %, D-dimer:6389 ng/mL, Fibrinogen:419\n mg/dL, Lactic Acid:2.0 mmol/L, Albumin:1.7 g/dL, LDH:821 IU/L, Ca++:7.9\n mg/dL, Mg++:1.7 mg/dL, PO4:4.1 mg/dL\n Assessment and Plan\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n IMPAIRED SKIN INTEGRITY\n HEPATITIS, ACUTE TOXIC (INCLUDING ALCOHOLIC, ACETAMINOPHEN, ETC.)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ICU Care\n Nutrition:\n TPN w/ Lipids - 03:10 PM 73. mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 08:15 PM\n Multi Lumen - 10:00 PM\n Dialysis Catheter - 11:35 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: Sucralafate\n VAP: HOB elevation, Mouth care\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:ICU\n" }, { "category": "Physician ", "chartdate": "2131-06-08 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 679462, "text": "Chief Complaint:\n 24 Hour Events:\n EKG - At 11:41 AM\n FLUOROSCOPY - At 01:35 PM\n for post pyloric feeding\n :\n - Hyperkalemia and ECG improved with CVVH - renal recommended to\n continue CVVH.\n - Post-pyloric NG tube placed with OG tube d/c'd\n - Methadone 5mg TID started\n - Carafate started and Pantoprazole d/c'd for ? PPI induced\n eosinophilia.\n - ID recommended starting micofungin and flagyl.\n - ID also recommended HIV test which may be done via the health care\n proxy, but I left a message and did not get a call back.\n - Derm came by and biopsied leg - their suspicion was ulcers due to\n edema but will rule out other pathology.\n - This AM Hct of 20, transfusing 1 U. Consider desmopressin or plt\n transfusion.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Micafungin - 08:00 PM\n Aztreonam - 09:00 PM\n Linezolid - 10:00 PM\n Metronidazole - 02:00 AM\n Vancomycin - 04:00 AM\n Infusions:\n Norepinephrine - 0.05 mcg/Kg/min\n Fentanyl (Concentrate) - 350 mcg/hour\n Midazolam (Versed) - 15 mg/hour\n KCl (CRRT) - 30 mEq./hour\n Calcium Gluconate (CRRT) - 1.4 grams/hour\n Other ICU medications:\n Carafate (Sucralfate) - 04:00 AM\n Heparin Sodium (Prophylaxis) - 04:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:49 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.9\nC (98.4\n Tcurrent: 36.8\nC (98.3\n HR: 96 (83 - 101) bpm\n BP: 98/52(65) {88/46(60) - 122/67(83)} mmHg\n RR: 30 (8 - 30) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 134 kg (admission): 113.5 kg\n Height: 67 Inch\n CVP: 12 (12 - 291)mmHg\n Total In:\n 9,121 mL\n 2,718 mL\n PO:\n TF:\n IVF:\n 7,364 mL\n 2,290 mL\n Blood products:\n 6 mL\n Total out:\n 11,625 mL\n 3,415 mL\n Urine:\n 122 mL\n 24 mL\n NG:\n 500 mL\n Stool:\n Drains:\n Balance:\n -2,504 mL\n -697 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 30\n RR (Spontaneous): 0\n PEEP: 10 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10\n PIP: 30 cmH2O\n Plateau: 24 cmH2O\n Compliance: 28.6 cmH2O/mL\n SpO2: 100%\n ABG: 7.35/51/86/24/0\n Ve: 11.9 L/min\n PaO2 / FiO2: 172\n Physical Examination\n GEN: Intubated, sedated\n HEENT: icteric sclera. MMM\n NECK: Sites clean/dry/no oozing\n LUNGS: Crackles bilaterally anteriorly.\n HEART: RRR\n ABD: Distended. NT.\n EXTREM: 2+ edema with weeping wounds without surrounding erythema,\n ulcers/lesions on legs with bandages C/D/I\n SKIN: Jaundice\n Labs / Radiology\n 58 K/uL\n 6.8 g/dL\n 231 mg/dL\n 1.5 mg/dL\n 24 mEq/L\n 3.8 mEq/L\n 36 mg/dL\n 96 mEq/L\n 131 mEq/L\n 20.7 %\n 56.6 K/uL\n [image002.jpg]\n 06:11 AM\n 09:52 AM\n 10:05 AM\n 03:52 PM\n 03:58 PM\n 09:57 PM\n 12:02 AM\n 03:36 AM\n 03:53 AM\n 04:48 AM\n WBC\n 48.4\n 56.6\n Hct\n 20.4\n 20.7\n Plt\n 45\n 58\n Cr\n 1.5\n TCO2\n 23\n 23\n 27\n 29\n 26\n 29\n Glucose\n 255\n 249\n 290\n \n 231\n Other labs: PT / PTT / INR:19.1/46.0/1.8, CK / CKMB /\n Troponin-T:214/3/0.07, ALT / AST:42/182, Alk Phos / T Bili:129/23.3,\n Amylase / Lipase:19/35, Differential-Neuts:58.0 %, Band:4.0 %,\n Lymph:4.0 %, Mono:11.0 %, Eos:9.0 %, D-dimer:6389 ng/mL, Fibrinogen:419\n mg/dL, Lactic Acid:2.0 mmol/L, Albumin:1.7 g/dL, LDH:821 IU/L, Ca++:7.9\n mg/dL, Mg++:1.7 mg/dL, PO4:4.1 mg/dL\n Assessment and Plan\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n IMPAIRED SKIN INTEGRITY\n HEPATITIS, ACUTE TOXIC (INCLUDING ALCOHOLIC, ACETAMINOPHEN, ETC.)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n 28yo M with alcoholic hepatitis and necrotizing pancreatitis\n complicated by ARDS, SIRS, ARF, UGIB, fevers and eosinophilia.\n #. Fever: GPCs growing in peripheral blood are coag negative staph. He\n is also on aztreonam for extended GN coverage. CT abd with no change\n but continued colonic thickening consistent with infection. Other\n source could be skin as extensive break down although no sign of\n infection superimposed on breakdown and on broad gram positive\n coverage.\n - Cte broad spectrum antibiotic coverage with aztreonam and linezolid\n for MRSA and VRE for bacteremia\n - F/U cultures\n - Consider TEE to r/o vegetations as TTE was not a definitive study and\n now with GPC in blood cx.\n - appreciate ID recs. Added Vanc PO/PR empirically per ID recs given\n increasing leukocytosis and colon inflammation on CT. Will start\n anti-fungal today empirically as bowel wall may be compromised.\n - New IJ placed for emergent CVVH\n #. Respiratory Failure: ARDS secondary to necrotizing pancreatitis.\n PEEP at 15 currently. Cannot be trached with such a high peep according\n to thoracics so did not get trach yet. Hypoxia slightly better today\n and able to wean down FiO2 after volume taken off with CVVH\n - Hold off on trach given elevated PEEP (goal PEEP\n #. Adrenal Insufficiency: Unclear with stim if clear adrenal\n insufficiency but hypotension improving with steroids (lower pressor\n requirement) and improving eosinophilia\n - Will continue steroids Iv X 5 days (day 2) then change to prednisone\n to taper\n #. Anemia: Hcts stable and no RP bleed seen on CT.\n - trend hcts\n - f/u heme recs\n - guaiac stools\n #. Eosinophilia: Likely drug reaction (to vanc, ppi or dapto?) with\n parasitic or fungal infection also possible etiologies.\n - stim positive for adrenal insufficiency. Cte steroids.\n - cte linezolid for GPCs in blood and aztreonam GNegs\n - Start fungal coverage as above\n - once has doboff will stop ppi and start sucralfate instead\n #. Thrombocytopenia: Appreciate heme recs. Do not feel this is DIC.\n - Monitor platelets daily and transfuse for plt <10 or <50 if signs of\n bleed\n #. Acute renal Failure:\n - Restarted CVVH for hyperkalemia\n #. Hyperkalemia: Likely in setting of ARF after stopping CVVH.\n - Restarted CVVH for hyperkalemia with ECG changes\n #. Wounds: Wound care suggested dermatology consult for non-healing\n wounds. Derm to staff today.\n ICU Care\n Nutrition:\n TPN w/ Lipids - 03:10 PM 73. mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 08:15 PM\n Multi Lumen - 10:00 PM\n Dialysis Catheter - 11:35 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: Sucralafate\n VAP: HOB elevation, Mouth care\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:ICU\n" }, { "category": "Physician ", "chartdate": "2131-06-03 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 678498, "text": "Chief Complaint: Necrotizing pancreatitis, ARDS, SIRS, ARF, cerebral\n edema.\n 24 Hour Events:\n - Heme: no dic, check fibrinogen, indirect coombs\n - ID: can dc dapto and flagyl if cx are negative\n - IP: would not do trach, rec calling CT \n - restarted UF\n - pm HCT stable\n - held naloxone and weaning sedatives\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Daptomycin - 09:30 PM\n Metronidazole - 04:00 AM\n Infusions:\n Norepinephrine - 0.04 mcg/Kg/min\n Fentanyl (Concentrate) - 250 mcg/hour\n Midazolam (Versed) - 12 mg/hour\n Calcium Gluconate (CRRT) - 1.2 grams/hour\n KCl (CRRT) - 1 mEq./hour\n Other ICU medications:\n Pantoprazole (Protonix) - 08:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:38 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: 35.9\nC (96.7\n HR: 103 (100 - 117) bpm\n BP: 110/62(78) {87/46(60) - 113/65(92)} mmHg\n RR: 24 (24 - 38) insp/min\n SpO2: 98%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 128 kg (admission): 113.5 kg\n Height: 67 Inch\n CVP: 10 (5 - 17)mmHg\n Total In:\n 9,439 mL\n 2,671 mL\n PO:\n TF:\n IVF:\n 7,678 mL\n 2,187 mL\n Blood products:\n Total out:\n 12,968 mL\n 3,469 mL\n Urine:\n 145 mL\n 93 mL\n NG:\n 350 mL\n 250 mL\n Stool:\n Drains:\n Balance:\n -3,529 mL\n -798 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n Vt (Spontaneous): 535 (535 - 535) mL\n RR (Set): 30\n RR (Spontaneous): 0\n PEEP: 12 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10\n PIP: 22 cmH2O\n Plateau: 24 cmH2O\n SpO2: 98%\n ABG: 7.39/42/85./26/0\n Ve: 11.3 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 77 K/uL\n 8.2 g/dL\n 139 mg/dL\n 1.8 mg/dL\n 26 mEq/L\n 4.9 mEq/L\n 25 mg/dL\n 104 mEq/L\n 138 mEq/L\n 24.4 %\n 37.2 K/uL\n [image002.jpg]\n 07:19 PM\n 10:09 PM\n 03:05 AM\n 03:53 AM\n 10:55 AM\n 01:58 PM\n 04:00 PM\n 10:34 PM\n 02:38 AM\n 04:01 AM\n WBC\n 28.9\n 37.2\n Hct\n 24.5\n 24.6\n 24.4\n Plt\n 54\n 64\n 77\n Cr\n 1.6\n 1.8\n TCO2\n 26\n 27\n 26\n 25\n 28\n 27\n 26\n Glucose\n 159\n 177\n 160\n 119\n 130\n 123\n 139\n Other labs: PT / PTT / INR:15.8/39.1/1.4, ALT / AST:29/257, Alk Phos /\n T Bili:132/14.0, Amylase / Lipase:19/35, Differential-Neuts:37.0 %,\n Band:18.0 %, Lymph:7.0 %, Mono:2.0 %, Eos:15.0 %, D-dimer:6389 ng/mL,\n Fibrinogen:293 mg/dL, Lactic Acid:1.3 mmol/L, Albumin:1.6 g/dL, LDH:607\n IU/L, Ca++:9.4 mg/dL, Mg++:1.9 mg/dL, PO4:4.8 mg/dL\n Assessment and Plan\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n IMPAIRED HEALTH MAINTENANCE\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n IMPAIRED SKIN INTEGRITY\n HYPOTENSION (NOT SHOCK)\n HEPATITIS, ACUTE TOXIC (INCLUDING ALCOHOLIC, ACETAMINOPHEN, ETC.)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n PANCREATITIS, ACUTE\n ICU Care\n Nutrition:\n TPN w/ Lipids - 02:30 PM 73. mL/hour\n Glycemic Control:\n Lines:\n Multi Lumen - 02:02 PM\n Dialysis Catheter - 04:56 PM\n Arterial Line - 01:30 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2131-06-03 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 678505, "text": "Chief Complaint: Necrotizing pancreatitis, ARDS, SIRS, ARF, cerebral\n edema.\n 24 Hour Events:\n - Heme: no dic, check fibrinogen, indirect coombs\n - ID: can dc dapto and flagyl if cx are negative\n - IP: would not do trach, rec calling CT \n - restarted UF\n - pm HCT stable\n - held naloxone and weaning sedatives\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Daptomycin - 09:30 PM\n Metronidazole - 04:00 AM\n Infusions:\n Norepinephrine - 0.04 mcg/Kg/min\n Fentanyl (Concentrate) - 250 mcg/hour\n Midazolam (Versed) - 12 mg/hour\n Calcium Gluconate (CRRT) - 1.2 grams/hour\n KCl (CRRT) - 1 mEq./hour\n Other ICU medications:\n Pantoprazole (Protonix) - 08:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:38 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: 35.9\nC (96.7\n HR: 103 (100 - 117) bpm\n BP: 110/62(78) {87/46(60) - 113/65(92)} mmHg\n RR: 24 (24 - 38) insp/min\n SpO2: 98%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 128 kg (admission): 113.5 kg\n Height: 67 Inch\n CVP: 10 (5 - 17)mmHg\n Total In:\n 9,439 mL\n 2,671 mL\n PO:\n TF:\n IVF:\n 7,678 mL\n 2,187 mL\n Blood products:\n Total out:\n 12,968 mL\n 3,469 mL\n Urine:\n 145 mL\n 93 mL\n NG:\n 350 mL\n 250 mL\n Stool:\n Drains:\n Balance:\n -3,529 mL\n -798 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n Vt (Spontaneous): 535 (535 - 535) mL\n RR (Set): 30\n RR (Spontaneous): 0\n PEEP: 12 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10\n PIP: 22 cmH2O\n Plateau: 24 cmH2O\n SpO2: 98%\n ABG: 7.39/42/85./26/0\n Ve: 11.3 L/min\n PaO2 / FiO2: 170\n Physical Examination\n Gen: Anasarca improved. Intubated.\n HEENT: ETT in place, scleral edema. Pupils 3->2 mm b/l.\n CV: Nl S1+S2\n Pulm: Rhonchorous throughout\n Abd: Distended, soft, minimal BS\n Ext: 3+ edema.\n Skin: Weeping blisters of LE b/l\n Neuro: Sedated\n Labs / Radiology\n 77 K/uL\n 8.2 g/dL\n 139 mg/dL\n 1.8 mg/dL\n 26 mEq/L\n 4.9 mEq/L\n 25 mg/dL\n 104 mEq/L\n 138 mEq/L\n 24.4 %\n 37.2 K/uL\n [image002.jpg]\n 07:19 PM\n 10:09 PM\n 03:05 AM\n 03:53 AM\n 10:55 AM\n 01:58 PM\n 04:00 PM\n 10:34 PM\n 02:38 AM\n 04:01 AM\n WBC\n 28.9\n 37.2\n Hct\n 24.5\n 24.6\n 24.4\n Plt\n 54\n 64\n 77\n Cr\n 1.6\n 1.8\n TCO2\n 26\n 27\n 26\n 25\n 28\n 27\n 26\n Glucose\n 159\n 177\n 160\n 119\n 130\n 123\n 139\n Other labs: PT / PTT / INR:15.8/39.1/1.4, ALT / AST:29/257, Alk Phos /\n T Bili:132/14.0, Amylase / Lipase:19/35, Differential-Neuts:37.0 %,\n Band:18.0 %, Lymph:7.0 %, Mono:2.0 %, Eos:15.0 %, D-dimer:6389 ng/mL,\n Fibrinogen:293 mg/dL, Lactic Acid:1.3 mmol/L, Albumin:1.6 g/dL, LDH:607\n IU/L, Ca++:9.4 mg/dL, Mg++:1.9 mg/dL, PO4:4.8 mg/dL\n Assessment and Plan\n Mr. is a 28 year old gentleman with alcoholic hepatitis and\n necrotizing pancreatitis complicated by ARDS, SIRS, ARF and UGIB.\n # Anemia: Initially p/w hematemesis and EGD showed diuelafoy's lesion.\n Hct stable >24 hours s/p 4 units since . CTAP with new pancreatic\n pseudocyst but per d/w radiology no definitive explanation for hct\n drop. NG lavage negative. GI also doubts possibility of significant\n GI bleed, defer upper endoscopy for now. Appreciate hematology recs,\n do not feel that this is DIC.\n - CBC Q12H, transfuse for hct<21, plt<50\n - Follow-up heme and GI recs if any\n - Guaiac stools\n - Per heme, send ADAT\n # Respiratory Failure: ARDS secondary to necrotizing pancreatitis\n compounded by hypoxia, tachypnea in setting of anion gap metabolic\n acidosis, increased abdominal pressure, and EtOH withdrawal. PEEP\n decreased to 12 from 20 and FiO2 to 50%. Was tachypneic overnight on\n and sedation increased; CXR stable. IP recommending thoracic\n surgery for trach. Naloxone held yesterday given concern over\n systemic absorption resulting in tachypnea, although unlikely given\n that patient had episode of tachypnea prior to initiating naloxone.\n - Wean FiO2 and PEEP, goal PaO2>60-65%\n - Wean sedation as tolerated\n - Discuss with thoracic surgery\n # Leukocytosis: Leukocytosis worse this AM to 37 from 28 with 15% eos.\n Afebrile in last 24 hours. Per ID, started on dpatomycin and flagyl for\n ? C.diff and possible cellulitis. Negative cultures and C.diff x1 with\n 2^nd pending.\n - Continue daptomycin and flagyl for now, although can likely\n discontinue flagyl when 2^nd C.diff negative.\n - Follow-up ID recs if any\n - Follow-up culture data.\n # Neuro: Initially dilated pupils with CT showing cerebral edema. Neuro\n exam now stable. Repeat CTH demonstrates interval improvement.\n - Continue leviteracetam\n - Wean sedation as possible\n - Neuro recs if any\n # Necrotizing pancreatitis/SIRS: Secondary to alcohol complicated by\n SIRS and ARDS. Patient continues to have pressor requirement, with neo\n +/- levo. Aggressive volume resuscitation with >50L but\n diuresing well. Also with new pseudocyst (3 cm x 3 cm) on abdominal CT\n on . Naloxone held yesterday given tachypnea.\n - Place dobhoff today, discuss with Nutrition regarding starting\n trophic feeds.\n - Wean pressors with goal MAP >65\n # Hyponatremia: In setting of decreased effective circulating volume\n in setting of SIRS and IABP. Patient has received hypertonic saline\n boluses with improvement in serum sodium and osm.\n - Given improvement in neuro exam, continue to hold hypertonic saline.\n # Acute renal failure: Patient had HD line placed and on CVVH. CVVH\n with even TBB pending assessment of hemorrhage.\n - CVVH per renal.\n - Trend chemistries\n #Thrombocytopenia: Platelets stable but have trended down from a\n normal count on admission. No clear etiology at this time. DIC panel\n with elevated FDP but normal fibrinogen. HIT PF4 antibody negative.\n - Trend plt, transfuse for plt<10 or <50 if signs of hemorrhage.\n # Wound care: Per wound care recs.\n # Acute hepatitis: Likely alcoholic hepatitis with fatty infiltration,\n and no evidence of distal obstruction. RUQ u/s shows marked liver\n echogenicity but no ascites.\n - Trend LFTs\n # Alcoholism: Patient describes history of withdrawal symptoms, but\n not prior seizure. Last drink was night prior to presentation.\n Tachycardia, weakness, and elevated lactate could be consistent with\n thiamine deficiency.\n - Thiamine, vb12, folate\n - Valium with CIWA > 10\n FEN: TPN without heparin and trophic feeds when dobhoff placed, replete\n as necessary.\n PPx: SCD, PPI\n Access: RIJ, LIJ, left radial arterial line\n Code: Full\n Dispo: ICU level of care.\n ICU Care\n Nutrition:\n TPN w/ Lipids - 02:30 PM 73. mL/hour\n Glycemic Control:\n Lines:\n Multi Lumen - 02:02 PM\n Dialysis Catheter - 04:56 PM\n Arterial Line - 01:30 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2131-06-13 00:00:00.000", "description": "Nursing Progress Note", "row_id": 680539, "text": "TITLE:\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Action:\n Response:\n Plan:\n Problem - Description In Comments\n Assessment:\n Action:\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Respiratory ", "chartdate": "2131-06-01 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 678119, "text": "Demographics\n Day of intubation: \n Day of mechanical ventilation: 15\n Ideal body weight: 67.1 None\n Ideal tidal volume: 268.4 / 402.6 / 536.8 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Tube Type\n ETT:\n Position: 23 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 29 cmH2O\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Clear\n Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount: Suctioned / Small\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Tachypneic (RR> 35 b/min);\n Comments: Peep increased to 12 per PaO2 ABG.\n Assessment of breathing comfort: No response (sleeping / sedated)\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously, Abnormal trigger\n efforts (efforts during inspiratory)\n Dysynchrony assessment: Frequent alarms (High pressure, High rate, High\n min. ventilation)\n Comments: Pt became tachypneic around 0200. RR up to the 60's and very\n dyssynchronous and triggering high pressure, high RR and high MV\n alarms. Pt given more sedation and started on Midaz and pt returned to\n previous breathing pattern and appeared more synchronous and\n comfortable.\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Underlying illness\n not resolved\n" }, { "category": "Respiratory ", "chartdate": "2131-06-14 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 680840, "text": "Demographics\n Day of intubation: 28\n Day of mechanical ventilation: 28\n Ideal body weight: 67.1 None\n Ideal tidal volume: 268.4 / 402.6 / 536.8 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type:\n Size:\n Tracheostomy tube:\n Type: Standard, Cuffed, Inner Cannula\n Manufacturer: Portex\n Size: 8.0mm\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 24 cmH2O\n Cuff volume: 8 mL /\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: Intermittent invasive ventilation\n Visual assessment of breathing pattern:\n Assessment of breathing comfort: No response (sleeping / sedated)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Sedated / Paralyzed,\n Underlying illness not resolved\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Interventional radiology\n 0945-1330\n Permenent dialysis catheter and a PICC line placement.\n Bedside Procedures:\n Comments:\n To IR today as per Metavision.\n, RRT 17:15\n" }, { "category": "Respiratory ", "chartdate": "2131-06-09 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 679711, "text": "Demographics\n Day of mechanical ventilation: 23\n Ideal body weight: 67.1 None\n Ideal tidal volume: 268.4 / 402.6 / 536.8 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Tracheostomy tube:\n Type: Standard\n Manufacturer: Portex\n Size: 8.0mm\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 29 cmH2O\n Cuff volume: mL /\n Airway problems:\n 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: Bloody / Thick\n Sputum source/amount: Suctioned / Moderate\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Utilize ARDSnet protocol\n Reason for continuing current ventilatory support: Cannot protect\n airway, Cannot manage secretions, Underlying illness not resolved\n" }, { "category": "Nutrition", "chartdate": "2131-06-07 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 679346, "text": "Objective\n Current Wt: 134kg\n Pertinent medications: Fentanyl, Versed, Norepinephrine, RISS, ABx,\n RISS, others noted\n Labs:\n Value\n Date\n Glucose\n 249 mg/dL\n 10:05 AM\n Glucose Finger Stick\n 213\n 04:00 AM\n BUN\n 40 mg/dL\n 06:02 AM\n Creatinine\n 3.0 mg/dL\n 06:02 AM\n Sodium\n 133 mEq/L\n 09:52 AM\n Potassium\n 5.2 mEq/L\n 09:52 AM\n Chloride\n 100 mEq/L\n 09:52 AM\n TCO2\n 21 mEq/L\n 09:52 AM\n PO2 (arterial)\n 114 mm Hg\n 10:05 AM\n PCO2 (arterial)\n 45 mm Hg\n 10:05 AM\n pH (arterial)\n 7.30 units\n 10:05 AM\n pH (venous)\n 7.25 units\n 10:31 AM\n pH (urine)\n 7.0 units\n 10:07 PM\n CO2 (Calc) arterial\n 23 mEq/L\n 10:05 AM\n Albumin\n 1.7 g/dL\n 02:35 AM\n Calcium non-ionized\n 8.3 mg/dL\n 06:02 AM\n Phosphorus\n 7.2 mg/dL\n 06:02 AM\n Ionized Calcium\n 1.03 mmol/L\n 10:05 AM\n Magnesium\n 2.2 mg/dL\n 06:02 AM\n ALT\n 43 IU/L\n 02:05 AM\n Alkaline Phosphate\n 145 IU/L\n 02:05 AM\n AST\n 205 IU/L\n 02:05 AM\n Amylase\n 19 IU/L\n 04:00 AM\n Total Bilirubin\n 23.0 mg/dL\n 02:05 AM\n Triglyceride\n 154 mg/dL\n 02:10 AM\n WBC\n 69.0 K/uL\n 02:05 AM\n Hgb\n 7.3 g/dL\n 04:02 AM\n Hematocrit\n 26.0 %\n 02:05 AM\n Current diet order / nutrition support: TPN: 70 kg 3-in-1: 1750mL\n (298dextrose/105amino acid/ 35fat) = 1783kcals\n GI: abd soft, bowel sounds absent\n Assessment of Nutritional Status\n 28y.o. M with alcoholic hepatitis and necrotizing pancreatitis\n complicated by ARDS, SIRS, ARF, UGIB, fevers and eosinophilia. Patient\n had HD line placed so that CVVH could be restarted this a.m. Patient\n continues on TPN for nutrition support. TPN is at goal, which meets\n 100% of estimated needs. Monitoring daily weights, which seems to be\n confusing at this time due to discrepancies with the bed scale (On \n patient weighed 84kg, today patient weighs 134kg). The latter wt seems\n to be more accurate. Noted patient now with hyperglycemia; recommend\n increasing insulin in TPN daily to help with glycemic control. There\n was previous discussion of start of trophic tube feeds; do not\n recommend this at this time due to septic picture and Abd CT showing\n colonic thickening consistent with infection.\n Medical Nutrition Therapy Plan - Recommend the Following\n 1) Continue with TPN at goal. Will monitor FSBG and increase\n insulin in TPN daily prn.\n 2) Monitor lytes and chem. 10.\n 3) Hold off on enteral feeds.\n Following, will enter TPN recs daily. Page with any questions. #\n" }, { "category": "Nutrition", "chartdate": "2131-06-01 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 678210, "text": "Objective\n Pertinent medications: Norepinephrine, Fentanyl, Versed, HISS,\n Protonix, others noted\n Labs:\n Value\n Date\n Glucose\n 147 mg/dL\n 02:10 AM\n Glucose Finger Stick\n 182\n 10:00 AM\n BUN\n 24 mg/dL\n 02:10 AM\n Creatinine\n 2.0 mg/dL\n 02:10 AM\n Sodium\n 137 mEq/L\n 02:10 AM\n Potassium\n 4.1 mEq/L\n 09:27 AM\n Chloride\n 103 mEq/L\n 02:10 AM\n TCO2\n 26 mEq/L\n 02:10 AM\n PO2 (arterial)\n 77. mm Hg\n 09:27 AM\n PCO2 (arterial)\n 37 mm Hg\n 09:27 AM\n pH (arterial)\n 7.48 units\n 09:27 AM\n pH (venous)\n 7.25 units\n 10:31 AM\n pH (urine)\n 6.5 units\n 01:09 PM\n CO2 (Calc) arterial\n 28 mEq/L\n 09:27 AM\n Albumin\n 1.6 g/dL\n 04:00 AM\n Calcium non-ionized\n 9.4 mg/dL\n 02:10 AM\n Phosphorus\n 3.4 mg/dL\n 02:10 AM\n Ionized Calcium\n 1.08 mmol/L\n 09:27 AM\n Magnesium\n 2.0 mg/dL\n 02:10 AM\n ALT\n 29 IU/L\n 02:10 AM\n Alkaline Phosphate\n 132 IU/L\n 02:10 AM\n AST\n 257 IU/L\n 02:10 AM\n Amylase\n 19 IU/L\n 04:00 AM\n Total Bilirubin\n 14.0 mg/dL\n 02:10 AM\n WBC\n 27.2 K/uL\n 02:10 AM\n Hgb\n 7.9 g/dL\n 02:10 AM\n Hematocrit\n 23.8 %\n 02:10 AM\n Current diet order / nutrition support: TPN: 1750mL (298dextrose/\n 105amino acid/ 35fat) = 1783kcals\n GI: Abd softly distended, hypoactive bowel sounds\n Assessment of Nutritional Status\n Per discussion with MD, team would like to place a post-pyloric feeding\n tube and start trophic tube feeds. Recommend starting with an\n elemental formula to test GI tolerance. Rate should be advanced very\n slowly so that tolerance can be monitored closely using abd exam. TPN\n is meeting 100% of estimated needs right now, and this should not be\n weaned until patient is tolerating tube feeds.\n Medical Nutrition Therapy Plan - Recommend the Following\n 1) Once post-pyloric feeding tube is placed, recommend starting\n Vivonex @10cc/hr. Once this is tolerated for 24hrs, can start slow\n advance of 10cc q12hrs as tolerated to initial goal of 70cc/hr\n (1680kcals, 64g protein).\n 2) Continue with goal TPN until tube feeds are at 40cc/hr or\n above.\n 3) Will follow and make additional recommendations re: transition\n from TPN to tube feeds.\n Please page with any questions. #\n" }, { "category": "Physician ", "chartdate": "2131-06-04 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 678715, "text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n ULTRASOUND - At 12:40 PM\n BLOOD CULTURED - At 08:30 PM\n via dialysis cath, tlc and periph\n \n - heme: no dic, check fibrinogen, indirect coombs\n - ID: can dc dapto and flagyl if cx are negative\n - IP: would not do trach, rec calling CT \n - restarted UF\n - pm HCT stable\n - held naloxone and weaning sedatives\n \n - BCx (): GPC pairs and clusters, 1/2 bottles from HD line. d/w\n pharmacy, dapto increased to 750 mg Q24H. Order placed to check CK\n tomorrow.\n - LE/UE U/S negative for DVT. CTA negative for PE.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Metronidazole - 04:00 AM\n Daptomycin - 05:50 PM\n Infusions:\n Calcium Gluconate (CRRT) - 1 grams/hour\n KCl (CRRT) - 1 mEq./hour\n Norepinephrine - 0.12 mcg/Kg/min\n Fentanyl (Concentrate) - 350 mcg/hour\n Other ICU medications:\n Pantoprazole (Protonix) - 09:30 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:12 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.1\nC (98.8\n Tcurrent: 36.7\nC (98\n HR: 104 (95 - 119) bpm\n BP: 111/58(75) {78/34(49) - 112/59(78)} mmHg\n RR: 33 (27 - 43) insp/min\n SpO2: 98%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 128 kg (admission): 113.5 kg\n Height: 67 Inch\n CVP: 17 (7 - 17)mmHg\n Total In:\n 7,814 mL\n 2,885 mL\n PO:\n TF:\n IVF:\n 6,266 mL\n 2,362 mL\n Blood products:\n Total out:\n 8,470 mL\n 3,478 mL\n Urine:\n 376 mL\n 45 mL\n NG:\n 600 mL\n Stool:\n Drains:\n Balance:\n -656 mL\n -593 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 30\n RR (Spontaneous): 0\n PEEP: 12 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10\n PIP: 23 cmH2O\n Plateau: 18 cmH2O\n SpO2: 98%\n ABG: 7.36/46/75/23/0\n Ve: 14.5 L/min\n PaO2 / FiO2: 150\n Physical Examination\n General Appearance: Overweight / Obese, anasarca\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: Rhonchorous: )\n Abdominal: Soft, Obese\n Extremities: Right: 2+, Left: 2+\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Non -purposeful,\n Sedated, Tone: Not assessed\n Labs / Radiology\n 66 K/uL\n 8.0 g/dL\n 125 mg/dL\n 1.6 mg/dL\n 23 mEq/L\n 4.7 mEq/L\n 22 mg/dL\n 105 mEq/L\n 136 mEq/L\n 24.4 %\n 37.5 K/uL\n [image002.jpg]\n 10:34 PM\n 02:38 AM\n 04:01 AM\n 09:26 AM\n 10:59 AM\n 01:05 PM\n 07:42 PM\n 10:37 PM\n 02:03 AM\n 02:17 AM\n WBC\n 37.2\n 37.5\n Hct\n 24.4\n 23.9\n 24.4\n Plt\n 77\n 66\n Cr\n 1.8\n 1.6\n TCO2\n 27\n 26\n 26\n 21\n 23\n 25\n 27\n Glucose\n 123\n 139\n 103\n 96\n 97\n 128\n 125\n Other labs: PT / PTT / INR:15.8/39.1/1.4, CK / CKMB / Troponin-T:240//,\n ALT / AST:29/257, Alk Phos / T Bili:132/14.0, Amylase / Lipase:19/35,\n Differential-Neuts:37.0 %, Band:18.0 %, Lymph:7.0 %, Mono:2.0 %,\n Eos:15.0 %, D-dimer:6389 ng/mL, Fibrinogen:293 mg/dL, Lactic Acid:1.3\n mmol/L, Albumin:1.6 g/dL, LDH:607 IU/L, Ca++:8.9 mg/dL, Mg++:2.2 mg/dL,\n PO4:4.1 mg/dL\n Assessment and Plan\n Mr. is a 28 year old gentleman with alcoholic hepatitis and\n necrotizing pancreatitis complicated by ARDS, SIRS, ARF and UGIB.\n # Tachypnea, tachycardia, hypotension: reflect inadequate sedation\n with resulting tachypnea, breathstacking leading to hypotension.\n Alternatively and more concerning, may suggest PE given that patient\n has only been on SCDs given recent hct drop.\n - Upper and lower extremity U/S\n - If U/S negative, will order CTA to r/o PE\n - Titrate sedation.\n # Anemia: Initially p/w hematemesis and EGD showed diuelafoy's lesion.\n Hct stable >24 hours s/p 4 units since . CTAP with new pancreatic\n pseudocyst but per d/w radiology no definitive explanation for hct\n drop. NG lavage negative. GI also doubts possibility of significant\n GI bleed, defer upper endoscopy for now. Appreciate hematology recs,\n do not feel that this is DIC.\n - CBC Q12H, transfuse for hct<21, plt<50\n - Follow-up heme and GI recs if any\n - Guaiac stools\n - Per heme, send ADAT\n # Respiratory Failure: ARDS secondary to necrotizing pancreatitis\n compounded by hypoxia, tachypnea in setting of anion gap metabolic\n acidosis, increased abdominal pressure, and EtOH withdrawal. PEEP\n decreased to 12 from 20 and FiO2 to 50%. Was tachypneic overnight on\n and sedation increased; CXR stable. IP recommending thoracic\n surgery for trach. Naloxone held yesterday given concern over\n systemic absorption resulting in tachypnea, although unlikely given\n that patient had episode of tachypnea prior to initiating naloxone.\n - Wean FiO2 and PEEP, goal PaO2>60-65%\n - Wean sedation as tolerated\n - Discuss with thoracic surgery\n # Leukocytosis: Leukocytosis worse this AM to 37 from 28 with 15% eos.\n Afebrile in last 24 hours. Per ID, started on dpatomycin and flagyl for\n ? C.diff and possible cellulitis. Negative cultures and C.diff x1 with\n 2nd pending.\n - Continue daptomycin, d/c flagyl.\n - Follow-up ID recs if any\n - Follow-up culture data.\n # Neuro: Initially dilated pupils with CT showing cerebral edema. Neuro\n exam now stable. Repeat CTH demonstrates interval improvement.\n - Continue leviteracetam\n - Wean sedation as possible\n - Neuro recs if any\n # Necrotizing pancreatitis/SIRS: Secondary to alcohol complicated by\n SIRS and ARDS. Patient continues to have pressor requirement, with neo\n +/- levo. Aggressive volume resuscitation with >50L but\n diuresing well. Also with new pseudocyst (3 cm x 3 cm) on abdominal CT\n on . Naloxone held yesterday given tachypnea. KUB unable to\n determine of OG is post-pyloric.\n - Wean pressors with goal MAP >65\n - Hold off on trophic feeds for now given uncertainty of OG placement.\n Will consider dobhoff placement in AM.\n # Hyponatremia: In setting of decreased effective circulating volume in\n setting of SIRS and IABP. Patient has received hypertonic saline\n boluses with improvement in serum sodium and osm.\n - Given improvement in neuro exam, continue to hold hypertonic saline.\n # Acute renal failure: Patient had HD line placed and on CVVH. CVVH\n with even TBB pending assessment of hemorrhage.\n - CVVH per renal.\n - Trend chemistries\n #Thrombocytopenia: Platelets stable but have trended down from a\n normal count on admission. No clear etiology at this time. DIC panel\n with elevated FDP but normal fibrinogen. HIT PF4 antibody negative.\n - Trend plt, transfuse for plt<10 or <50 if signs of hemorrhage.\n # Wound care: Per wound care recs.\n # Acute hepatitis: Likely alcoholic hepatitis with fatty infiltration,\n and no evidence of distal obstruction. RUQ u/s shows marked liver\n echogenicity but no ascites.\n - Trend LFTs\n # Alcoholism: Patient describes history of withdrawal symptoms, but\n not prior seizure. Last drink was night prior to presentation.\n Tachycardia, weakness, and elevated lactate could be consistent with\n thiamine deficiency.\n - Thiamine, vb12, folate\n - Valium with CIWA > 10\n FEN: TPN without heparin, replete as necessary.\n PPx: SCD, PPI\n Access: RIJ, LIJ, left radial arterial line\n Code: Full\n ICU Care\n Nutrition:\n TPN w/ Lipids - 06:35 PM 73 mL/hour\n Glycemic Control:\n Lines:\n Multi Lumen - 02:02 PM\n Dialysis Catheter - 04:56 PM\n Arterial Line - 01:30 PM\n 20 Gauge - 03:56 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2131-06-06 00:00:00.000", "description": "Physician Resident/Attending Progress Note - MICU", "row_id": 679224, "text": "Chief Complaint:\n 24 Hour Events:\n - Sinus CT showed opacification in right side sinuses. ENT will swab\n meatus but did not think draining it would help and did not think\n fevers and eosinophilia from this.\n - CT Abdomen grossly unchanged from prior with thickening of the cecum\n consistent with infection, necrotizing pancreatitis, no abscess\n - Heme recommended Heparin 5000 and stim for am because\n adrenal insufficiency can cause eosinophilia\n - ID recommended PO/PR vanc if abdominal CT showed difference from\n prior or developed diarrhea\n - TTE with normal valves and nl/hyperdynamic EF but could not rule out\n vegetation.\n - IJ d/c'd and cultured\n - CVL placed over wire into HD site (left IJ)\n - HD line d/c'd and cultured\n - Spiked temp to 101.6 at MN. Cement-like secretions from ETT.\n - thoracics never did trach because peep high (want it to be 5)\n - O2 sats lower with Po2 in 60s this am. Cement like secretions from\n ETT. Concern for VAP so started aztreonam\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Daptomycin - 06:42 PM\n Infusions:\n Fentanyl (Concentrate) - 325 mcg/hour\n Midazolam (Versed) - 15 mg/hour\n Norepinephrine - 0.3 mcg/Kg/min\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 04:30 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 06:32 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.4\nC (101.1\n Tcurrent: 38.3\nC (101\n HR: 120 (95 - 121) bpm\n BP: 101/55(71) {86/42(61) - 117/61(79)} mmHg\n RR: 34 (22 - 41) insp/min\n SpO2: 94%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 84 kg (admission): 113.5 kg\n Height: 67 Inch\n CVP: 19 (12 - 22)mmHg\n Total In:\n 7,831 mL\n 824 mL\n PO:\n TF:\n IVF:\n 6,067 mL\n 349 mL\n Blood products:\n Total out:\n 11,152 mL\n 245 mL\n Urine:\n 195 mL\n 45 mL\n NG:\n 350 mL\n 200 mL\n Stool:\n Drains:\n Balance:\n -3,321 mL\n 579 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 30\n RR (Spontaneous): 0\n PEEP: 12 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10, Hemodynamic Instability\n PIP: 16 cmH2O\n Plateau: 19 cmH2O\n Compliance: 66.7 cmH2O/mL\n SpO2: 94%\n ABG: 7.35/41/63/21/-2\n Ve: 14.4 L/min\n PaO2 / FiO2: 126\n Physical Examination\n GEN: Intubated, sedated\n HEENT: icteric sclera. MMM\n NECK: Sites clean/dry/no oozing\n LUNGS: Crackles bilaterally anteriorly.\n HEART: RRR\n ABD: Distended. NT.\n EXTREM: 2+ edema with weeping wounds without surrounding erythema\n SKIN: Jaundice\n Labs / Radiology\n 79 K/uL\n 7.3 g/dL\n 93 mg/dL\n 1.8 mg/dL\n 21 mEq/L\n 5.5 mEq/L\n 26 mg/dL\n 103 mEq/L\n 133 mEq/L\n 23.0 %\n 50.7 K/uL\n 11:05 AM\n 03:58 PM\n 09:00 PM\n 09:06 PM\n 02:35 AM\n 02:39 AM\n 08:24 AM\n 02:56 PM\n 04:02 AM\n 04:11 AM\n WBC\n 50.7\n 50.7\n Hct\n 24.9\n 23.0\n Plt\n 73\n 79\n Cr\n 1.4\n 1.2\n 1.8\n TCO2\n 24\n 22\n 23\n 25\n 23\n 21\n 24\n Glucose\n 106\n 119\n 144\n 177\n 144\n 135\n 93\n Other labs: PT / PTT / INR:17.4/40.1/1.6, CK / CKMB / Troponin-T:256//,\n ALT / AST:36/205, Alk Phos / T Bili:138/17.6, Amylase / Lipase:19/35,\n Differential-Neuts:38.0 %, Band:2.0 %, Lymph:14.0 %, Mono:5.0 %,\n Eos:26.0 %, D-dimer:6389 ng/mL, Fibrinogen:419 mg/dL, Lactic Acid:2.4\n mmol/L, Albumin:1.7 g/dL, LDH:821 IU/L, Ca++:8.8 mg/dL, Mg++:2.0 mg/dL,\n PO4:4.3 mg/dL\n Assessment and Plan\n 28yo M with alcoholic hepatitis and necrotizing pancreatitis\n complicated by ARDS, SIRS, ARF, UGIB, fevers and eosinophilia.\n #. Fever: New for him in the last few days. concerning for sepsis given\n increasing pressor requirement and tachycardia. Possible source is VAP\n as has had cement-like secretions from ETT and increasing O2\n requirement necessitating increasing his peep. Started on aztreonam\n this morning for extended GN coverage. CT abd with no change but\n continued colonic thickening consistent with infection. Other source\n could be skin as extensive break down although no sign of infection\n superimposed on breakdown and on broad gram positive coverage.\n - Cte broad spectrum gram negative coverage with aztreonam for\n pseudomonal coverage and dapto for MRSA for presumed VAP\n -Would obtain bronch for washings/cultures as unable to culture\n secretions from ETT because too thick\n - F/U cultures\n - Consider TEE to r/o vegetations as TTE was not a definitive study if\n bronch negative or continues to spike through dapto/aztreonam\n - appreciate ID recs. consider vanc po/pr for colonic thickening if\n decompensates further or has diarrhea but for now has other source of\n fevers and Abd CT unchanged so will hold further abx treatment.\n - Lines changed over wire and HD line pulled last night. All line\n cultures pending.\n #. Respiratory Failure: ARDS secondary to necrotizing pancreatitis.\n PEEP at 20 currently. Cannot be trached with such a high peep according\n to thoracics so did not get trach last pm. Hypoxic on morning blood\n gas.\n - Would favor inc. FiO2 rather than peep given need to wean peep for\n trach placement but if unable to achieve good O2 sats will need to inc\n peep\n - Hold off on trach given new hypoxia and adrenal insufficiency.\n #. Anemia: Hcts stable and no RP bleed seen on CT.\n - trend hcts\n - f/u heme recs\n - guaiac stools\n #. Eosinophilia: Likely drug reaction (to vanc?) with less likely\n etiology being infection.\n - appreciate heme recs\n - stim positive for adrenal insufficiency. Will treat with\n steroids and hold off on trach as above. Cte to follow eosinophilia to\n see if improves with steroids.\n - cte dapto instead of vanc for treatment of GPCs in blood and\n aztreonam instead of meropenem for GNegs\n #. Thrombocytopenia: Appreciate heme recs. Do not feel this is DIC.\n - Restarted heparin at low dose for dvt ppx\n - Monitor platelets daily and transfuse for plt <10 or <50 if signs of\n bleed\n #. Acute renal Failure:\n - Patient taking CVVH holiday as HD line had to be pulled in setting\n of fever and sepsis so creatinine slowly rising\n - Renal would like HD line placed by IR likely early tomorrow am\n #. Hyperkalemia: Likely in setting of ARF after stopping CVVH.\n - Will follow up renal recs re: restarting HD\n #. Wounds: Wound care suggested dermatology consult for non-healing\n wounds. Will call today.\n ICU Care\n Nutrition:\n TPN w/ Lipids - 04:54 PM 73 mL/hour\n IR for doboff placement tomorrow am (when down there for HD line\n placement)\n Glycemic Control:\n Lines:\n 20 Gauge - 03:56 PM\n Arterial Line - 08:15 PM\n Multi Lumen - 10:00 PM\n Prophylaxis:\n DVT: hep sc BID\n Stress ulcer: ppi\n VAP: mouth care\n Comments:\n Communication: Comments: with family\n Code status: Full code\n Disposition: ICU\n ------ Protected Section ------\n TITLE: Critical Care Staff\n MICU ATTENDING ADDENDUM\n I saw and examined the patient, and was physically present with the ICU\n resident for key portions of the services provided. I agree with his\n note above, including assessment and plan.\n 28yo man with necrotizing pancreatitis (EtOH), liver failure, ARDS, ARF\n on CVVHD, shock, cerebral edema (which improved), colitis. Persistent\n hypotension, resp failure, anemia, thrombocytopenia (slowly improving),\n renal failure on CVVHD, persistent fevers with episodic\n tachypnea/tachycardia/hypoxia.\n Due to increase in fevers, marked leukocytosis, increased pressor\n requirement (now NE at 0.3mcg/kg/min) repeated search for undiagnosed\n source of infection.\n * Tm 101.1, more hypotensive with increase in levophed dose.\n * CT torso bibasilar dependent atelectasis/consolidation, pancolitis,\n no sig change in pancreatic inflammation\n * ARDS with persistent high PEEP, had decreased to 10 but required\n increase to 12 with recruitment maneuvers\n * Off CVVH since HD line removed yesterday\n * CDiff cx neg. Blood cx GPC prs, clusters . On daptomycin.\n Aztreonam added last night for thick resp secretions. TTE neg for\n vegations (but poor quality)\n * thrombocytopenia with plts remaining >50 since , slowly\n trending up but no sig rebound since heparin and vanco stopped. PF4\n neg .\n * Sedated on fent 325mcg/h and versed 15mg/h\n * stim 17.9\n 18.5 which is tough to interpret: adrenal\n insufficiency vs already maximally stimulated\n CXR with progression of bilateral opacification\n Exam unchanged: anasarca with weeping of fluid from bilat LEs,\n jaundiced, scleral edema, PERRL sluggish, sedated and unresponsive but\n nurses report agitation with lightening of sedation. Abd firm but\n nondistended, not tense.\n Labs: WBC 38\n 51 with 26% eos, hct stable at 25%, plts 73, increased\n from 40s over past week. Alb 1.6 .\n 1. resp failure: plan for trach tonight/tomorrow.\n 2. Sepsis: may be attributable to nec panc. GPC blood cx + (which may\n be contaminant as 1/6 bottles) on daptomycin.\n Need to remove lines. Will hold CVVH and d/c left IJ HD line.\n If we can resite IJ to left side after, we will also d/c right IJ.\n Surveillance cx neg to date.\n Plan for surveillance cx q48h\n CT scan today to r/o progression of nec pancreatitis, will\n scan chest and sinuses as well.\n echocardiogram\n 3. Eosinophilia: I believe this is going to be attributable to meds.\n The most likely culprits (which would be extremely rare) are\n heparin (though PF4 neg) and PPI. Have d/c PPI. Will be adding back\n heparin. Discuss with heme.\n 4. ileus.\n 5. CVVH sig volume off over the past 24 hrs (and 4.5L neg since\n midnight). Plan to change HD line to triple lumen and d/c right IJ\n as well, send all lines for cx.\n 6. will plan to place postpyloric dobhoff and new HD line by IR\n tomorrow.\n 7. sedation: attempt to wean.\n Critically ill, 65 minutes\n ------ Protected Section Addendum Entered By: , MD\n on: 18:05 ------\n ------ Added by auto log oyt ------\n ERROR: this note was logged out before I edited it so the lower portion\n is yesterday\ns note.\n A/P:\n 1. Resp failure, ARDS. Trach deferred due to worsened\n hypotension, worse hypoxemia requiring higher PEEP\n 2. sepsis with no clear source though I suspect line infection.\n Dapto/aztreonam as described. Will add IV flagyl on the suggestion of\n ID service.\n 3. Eosinophilia unexplained. Likely due to prolonged inflammation\n with demargination or med effect.\n 4. Bronchoscopy to w/u VAP and will also check for pulm eos.\n 5. CVVH will restart after HD line replaced, hopefully tomorrow.\n 6. sedation: may need to increase fentanyl or even paralyze if he\n is dysynchronous with vent. After postpyloric dobhoff placed will try\n to add methadone for better control of sedation.\n Bronchoscopy done, which showed essentially normal airways and no\n significant secretions.\n Discussed at length with pt\ns brother.\n Critically ill, 65 minutes, excluding procedure time.\n ------ Protected Section Addendum Entered By: , MD\n on: 18:32 ------\n" }, { "category": "Nursing", "chartdate": "2131-05-23 00:00:00.000", "description": "Nursing Progress Note", "row_id": 676434, "text": "Hypotension (not Shock)\n Assessment:\n Pt remains on high dose pressor requirement\n Goal MAP 65-70\n Creatinine still trending up U/O 10-25cc/hr\n WBC\ns elevated but remains afebrile\n Occasionally tachy with increased levo requirement\n Action:\n Neo/Levo weaned as tolerated\n Pt requiring no additional fluid overnoc\n CVP remains ^^24-26\n Response:\n Pt with occasionally tolerant with levo off\n Pt with increased uop with ^^ MAP\n Pt does require increase in pressors post turning\n Vanco started overnoc for gram + coverage\n Plan:\n Cont to monitor hemodynamics closely\n Monitor pt for s/s of sepsis\n Cont with abx\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt still with ^^ Peep requirement\n Lungs clear to very diminished at the bases\n ^^ WBC\ns as indicated above ? possible infiltrate on CXR\n Action:\n Swimmers position as tolerated\n Frequent percussion maximum ventilation\n Sxn for yellow thick secretions\n Response:\n Pt with fair tolerance to swimmers position\n Pt does require increased pressors requirement post turning\n Lung sounds ^^ aeration noted in lower lobes\n Pt started on vanco\n Repeat CXR pending\n Plan:\n f/u on sputum cx.\n Cont rotation and swimmers as tolerated\n Cont with current plan of care\n" }, { "category": "Nursing", "chartdate": "2131-05-25 00:00:00.000", "description": "Nursing Progress Note", "row_id": 676794, "text": "Hypotension (not Shock)\n Assessment:\n SBP initially labile with recent initiation of CRRT. Pt very sensitive\n to any activity/movement and drops SBP/MAP.\n Action:\n Neo and Levophed drips titrated as needed to maintain MAP >65. Per\n renal recs\n fluid removed @ 100cc/hr via CRRT. MICU and renal in\n agreement that they would like pt negative even if pressor requirement\n goes up.\n Response:\n Pt. remains maxed on Neo and on very low dose Levophed in order to take\n off 100cc/hr fluid via CRRT.\n Plan:\n Cont. to monitor hemodynamics closely, titrate pressors as needed,\n follow labs closely.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n ABGs stable, oxygenation slightly lower in mid 80s but acceptable per\n team. Lung sounds dim to bases. Sats 92-96%. Tolerating today\ns PEEP\n drop to 20.\n Action:\n None taken.\n Response:\n No vent changes overnight.\n Plan:\n Cont. to monitor.\n Problem\n Cerebral edema\n Assessment:\n Pupils remain 6mm and sluggish bilaterally. No response to pain,\n sedated on Fentanyl and Versed drips.\n Action:\n Response:\n Plan:\n" }, { "category": "Respiratory ", "chartdate": "2131-05-20 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 675540, "text": "Demographics\n Day of intubation: 3\n Day of mechanical ventilation: 3\n Ideal body weight: 67.1 None\n Ideal tidal volume: 268.4 / 402.6 / 536.8 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location: ICU\n Reason: Re-intubation\n Tube Type\n ETT:\n Position: 23 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Cuff volume: 6 mL / Air\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Crackles\n LUL Lung Sounds: Crackles\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 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: Sedated / Paralyzed,\n Hemodynimic instability, Underlying illness not resolved\n" }, { "category": "Nursing", "chartdate": "2131-05-20 00:00:00.000", "description": "Nursing Progress Note", "row_id": 675610, "text": "Hypotension (not Shock)\n Assessment:\n Neo gtt remains at 5mcg/kg/min\n Levophed gtt titrated to maintain MAP >65\n Aline at times with good waveform and NBP and ABP correlating\n Aline intermittently with narrow pulse pressure ? dampened waveform\n Per Dr following NBP pressures\n u/o <20 cc/hr for several hours\n Action:\n Titrating levophed as tolerated\n Able to wean off this am\n 2 liters LR bolus given for low urine outputs\n Response:\n Maintaining MAP >65\n Urine outputs improving after bolus\n Plan:\n Wean neo gtt as tolerated. Goal u/o >20cc/hr.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received on AC 400 x 30 Peep 24 FiO2 80%\n Lungs coarse bil and diminished at bases\n No spontaneous breaths noted\n appears synchronize with vent\n Improving oxygenation overnight\n Stable acidosis ph 7.27-7.29\n Action:\n FiO2 decreased to 70 %\n Placed in triadyne bed for constant rotation to improve oxygenation\n Response:\n Oxygenation remains improved\n Plan:\n Continue to wean ventilator settings as tolerated.\n" }, { "category": "Physician ", "chartdate": "2131-05-20 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 675612, "text": "Chief Complaint:\n 24 Hour Events:\n - Continued to require levophed and fluid boluses to maintain UOP.\n - Started meropenem.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Meropenem - 06:00 AM\n Infusions:\n Midazolam (Versed) - 20 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 07:45 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38\nC (100.4\n Tcurrent: 37\nC (98.6\n HR: 102 (101 - 120) bpm\n BP: 94/62(75) {68/50(58) - 114/84(96)} mmHg\n RR: 26 (0 - 32) insp/min\n SpO2: 92%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 111.3 kg (admission): 113.5 kg\n Height: 67 Inch\n CVP: 23 (19 - 39)mmHg\n Bladder pressure: 29 (24 - 29) mmHg\n Total In:\n 11,901 mL\n 3,743 mL\n PO:\n TF:\n IVF:\n 11,901 mL\n 3,743 mL\n Blood products:\n Total out:\n 501 mL\n 136 mL\n Urine:\n 501 mL\n 136 mL\n NG:\n Stool:\n Drains:\n Balance:\n 11,400 mL\n 3,607 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 30\n RR (Spontaneous): 0\n PEEP: 24 cmH2O\n FiO2: 70%\n RSBI Deferred: PEEP > 10\n PIP: 52 cmH2O\n Plateau: 42 cmH2O\n Compliance: 23.5 cmH2O/mL\n SpO2: 92%\n ABG: 7.29/43/82./19/-5\n Ve: 12.8 L/min\n PaO2 / FiO2: 119\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 80 K/uL\n 11.2 g/dL\n 120 mg/dL\n 1.9 mg/dL\n 19 mEq/L\n 4.1 mEq/L\n 13 mg/dL\n 101 mEq/L\n 129 mEq/L\n 32.9 %\n 17.0 K/uL\n [image002.jpg]\n 03:02 PM\n 03:11 PM\n 04:34 PM\n 06:16 PM\n 08:20 PM\n 10:06 PM\n 10:25 PM\n 01:59 AM\n 04:42 AM\n 04:55 AM\n WBC\n 18.8\n 17.5\n 17.0\n Hct\n 32.8\n 34.5\n 32.9\n Plt\n 109\n 92\n 80\n Cr\n 1.7\n 1.8\n 1.9\n TCO2\n 23\n 22\n 23\n 21\n 23\n 23\n 22\n Glucose\n 129\n 125\n 123\n 123\n 117\n 120\n Other labs: PT / PTT / INR:19.8/52.4/1.8, ALT / AST:108/331, Alk Phos /\n T Bili:212/14.3, Amylase / Lipase:45/268, Lactic Acid:2.5 mmol/L,\n Albumin:2.2 g/dL, LDH:616 IU/L, Ca++:7.6 mg/dL, Mg++:2.0 mg/dL, PO4:2.6\n mg/dL\n Assessment and Plan\n Mr. is a 28 year old gentleman with alchoholic hepatitis and\n necrotizing pancreatitis complicated by ARDS, SIRS, and UGIB.\n # Respiratory Failure: ARDS secondary to necrotizing pancreatis\n compounded by hypoxia, tachypnea in setting of anion gap metabolic\n acidosis, increased abdominal pressure, and EtOH withdrawl.\n - ARDS settings with goal pO2>70 and pH >7.25\n - Permissible tachypnea is tolerated in setting of AGMA. If patient\n has auto-peep and breath stacking would consider paralysis.\n - Monitor abdominal pressures\n - Recheck esophageal balloon pressure and adjust PEEP\n - Continue fentaynl and midaz for sedation.\n # Necrotizing pancreatitis/SIRS: Likely secondary to alchohol\n complicated by SIRS. Patient continues to have pressor requirement and\n volume rescuitation with +50L.\n - Continue empiric meropenem\n - Wean pressors, bolus IVF to maintain MAP>70 and UOP>20 cc/hr.\n - Monitor chemistries.\n # Acute renal failure: Creatinine continues to trend up with oliguria,\n likely secondary to SIRS/hypotension and IABP leading to ATN. Also\n concerning for HRS in setting of alc hep.\n - Urine lytes, eos, osm\n - Trend UOP, bolus IVF to maintain goal >20 cc/hr.\n # IAP elevation: Secondary to third spacing and edema. Per surgery, not\n a good surgical candidate at this time.\n # Acute hepatitis: Likely alcoholic hepatiis with fatty infiltration,\n and no evidence of distal obstruction. RUQ u/s shows marked liver\n echogenicity but no ascites.\n - f/u viral hepatitis panel, LFTs\n # Hematemesis: EGD showed diuelafoy's lesion. HCT stable since 2 units\n PRBC on .\n - Trend hct, transfuse for hct<21\n # Hyponatremia: In setting of decreased effective circulating volume in\n setting of SIRS and IABP.\n - Trend chemistries.\n # Alcoholism: Patient describes history of withdrawl symptoms, but not\n prior seizure. Last drink was night prior to presenation.\n Tachycardia, weakness, and elevated lactate could be consistent with\n thiamine deficiency.\n - Thiamine, vb12, folate\n - Valium with CIWA > 10\n FEN: IVF, replete electrolytes, NPO\n PPx: scds, PPI\n Access: RIJ, fem cordis, right radial art line.\n Code: Full Code\n Dispo: ICU level of care.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 16 Gauge - 01:50 PM\n Cordis/Introducer - 02:05 PM\n Arterial Line - 01:35 PM\n Multi Lumen - 02:02 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": "2131-05-23 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 676519, "text": "Chief Complaint:\n 24 Hour Events:\n - Started vanco to cover for line infection given leukocytosis\n - Renal consulted, prelim ATN on sediment\n - Pan-cultured inc sputum\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 10:00 PM\n Meropenem - 06:05 AM\n Infusions:\n Fentanyl (Concentrate) - 400 mcg/hour\n Phenylephrine - 4.8 mcg/Kg/min\n Midazolam (Versed) - 30 mg/hour\n Other ICU medications:\n Pantoprazole (Protonix) - 08:15 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:52 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: 36.7\nC (98.1\n HR: 106 (94 - 109) bpm\n BP: 97/67(79) {88/51(64) - 116/73(88)} mmHg\n RR: 15 (10 - 45) insp/min\n SpO2: 98%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 156 kg (admission): 113.5 kg\n Height: 67 Inch\n CVP: 25 (0 - 30)mmHg\n Bladder pressure: 20 (20 - 20) mmHg\n Total In:\n 2,301 mL\n 611 mL\n PO:\n TF:\n IVF:\n 2,201 mL\n 611 mL\n Blood products:\n 100 mL\n Total out:\n 1,236 mL\n 105 mL\n Urine:\n 561 mL\n 105 mL\n NG:\n 350 mL\n Stool:\n Drains:\n 325 mL\n Balance:\n 1,065 mL\n 506 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 30\n RR (Spontaneous): 0\n PEEP: 24 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10\n PIP: 46 cmH2O\n Plateau: 39 cmH2O\n Compliance: 28.6 cmH2O/mL\n SpO2: 98%\n ABG: 7.28/40/101/17/-7\n Ve: 12.1 L/min\n PaO2 / FiO2: 202\n Physical Examination\n Gen: sedated\n HEENT: intubated. Scleral edema\n Chest: coarse BS bl\n CV: distant heart sounds, RRR, S1S2\n Abd: distended, abdominal wall edema\n Ext: Anasarca\n Neuro: Sedated. Pupils 6 mm, reactive.\n Labs / Radiology\n 64 K/uL\n 10.4 g/dL\n 100 mg/dL\n 3.2 mg/dL\n 17 mEq/L\n 4.1 mEq/L\n 21 mg/dL\n 101 mEq/L\n 130 mEq/L\n 31.7 %\n 29.3 K/uL\n [image002.jpg]\n 03:01 AM\n 02:11 PM\n 08:20 PM\n 02:39 AM\n 10:29 AM\n 05:04 PM\n 05:54 PM\n 10:25 PM\n 03:01 AM\n 03:09 AM\n WBC\n 24.4\n 30.5\n 29.3\n Hct\n 34.0\n 32.9\n 32.2\n 31.7\n Plt\n 61\n 61\n 66\n 64\n Cr\n 2.1\n 3.0\n 3.2\n 3.2\n TCO2\n 20\n 19\n 19\n 18\n 19\n 20\n Glucose\n 103\n 94\n 106\n 93\n 100\n Other labs: PT / PTT / INR:19.0/42.6/1.8, ALT / AST:55/228, Alk Phos /\n T Bili:218/19.2, Amylase / Lipase:16/37, Differential-Neuts:64.0 %,\n Band:2.0 %, Lymph:11.0 %, Mono:8.0 %, Eos:3.0 %, D-dimer: ng/mL,\n Fibrinogen:402 mg/dL, Lactic Acid:2.1 mmol/L, Albumin:2.1 g/dL, LDH:576\n IU/L, Ca++:7.9 mg/dL, Mg++:2.3 mg/dL, PO4:3.1 mg/dL\n Assessment and Plan\n Mr. is a 28 year old gentleman with alcoholic hepatitis and\n necrotizing pancreatitis complicated by ARDS, SIRS, and UGIB.\n # Neuro: Patient with dilated pupils on high dose fentaynl gtt.\n Concerning for cerebral edema or other acute process.\n - Non-contrast CTH\n # Respiratory Failure: ARDS secondary to necrotizing pancreatitis\n compounded by hypoxia, tachypnea in setting of anion gap metabolic\n acidosis, increased abdominal pressure, and EtOH withdrawl. Rising WBC\n could also be secondary to VAP.\n - Continue current vent settings for now, recheck ABG\n - Continue to monitor IAP\n - Begin to wean sedation as tolerated. Would prefer to wean down\n fentanyl and then midaz.\n - send sputum Cx\n - Continue vanco and meropenem.\n # Leukocytosis: WBC up to 29 today. Patient continues to be afebrile.\n Concern for CVL infection, VAP, loculated effusion, or necrotizing\n pancreatitis complication including abscess formation.\n - Continue empiric vancomycin and meropenem, AM vanco level.\n - CT torso with PO contrast to assess for complication of pancreatitis\n including abscess or organization of right-sided pleural effusion.\n - Follow-up culture data\n # Necrotizing pancreatitis/SIRS: Likely secondary to alcohol\n complicated by SIRS and ARDS. Patient continues to have pressor\n requirement, with neo +/- levo. Aggressive volume resucsitation with\n >56. Patient without improvement with albumin trial, likely\n secondary to SIRS and increased vascular permeability.\n - Continue empiric meropenem for now.\n - Wean pressors as able, starting with levophed\n - Monitor chemistries.\n - Continue to hold MIVF, boluses PRN to maintain UOP>20 cc/hr although\n increase pressors first.\n - Follow-up with recs if any\n - CT torso as above.\n # Acute renal failure: Creatinine continues to trend up to 3.2 with\n oliguria, likely secondary to SIRS/hypotension and IABP leading to\n ATN. Appreciate renal recs - urine sediment consistent with ATN.\n - Follow-up renal recs, patient likely candidate for CVVH as\n creatinine, lytes, and BUN continue to rise.\n - Trend UOP, bolus IVF to maintain goal >20 cc/hr.\n #Thrombocytopenia: Platelets trending down over hospital course but\n stable today. No clear etiology at this time. DIC panel and HIT PF4\n antibody negative.\n - Trend plt\n # IAP elevation: Secondary to third spacing and edema. Per surgery, not\n a good surgical candidate at this time.\n # Acute hepatitis: Likely alcoholic hepatitis with fatty infiltration,\n and no evidence of distal obstruction. RUQ u/s shows marked liver\n echogenicity but no ascites.\n - Trend LFTs\n # Hematemesis: EGD showed diuelafoy's lesion. HCT stable since 2 units\n PRBC on .\n - Trend hct, transfuse for hct<21\n # Hyponatremia: In setting of decreased effective circulating volume in\n setting of SIRS and IABP.\n - Trend chemistries.\n # Alcoholism: Patient describes history of withdrawal symptoms, but\n not prior seizure. Last drink was night prior to presentation.\n Tachycardia, weakness, and elevated lactate could be consistent with\n thiamine deficiency.\n - Thiamine, vb12, folate\n - Valium with CIWA > 10\n FEN: NPO. TPN to start in AM.\n PPx: SCDs, PPI\n Access: RIJ, right radial a-line\n Dispo: ICU level of care\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Arterial Line - 01:35 PM\n Multi Lumen - 02:02 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Social Work", "chartdate": "2131-05-23 00:00:00.000", "description": "Social Work Progress Note", "row_id": 676520, "text": "Pt is a 28 yr old single gentleman who was brought to the emergency\n room by his friend. Pt admitted to the SICU and has been intubated and\n sedated since the time of his admission. Pt was alert upon arrival and\n gave a self report of his heavy alcohol use; 6 tall drinks per night.\n Pt\ns parents report last seeing their son on Mothers , . \n parents reports pt was complaining of not feeling well and that he was\n suffering from allergies. Parents report knowledge that pt does drink\n alcohol but where unaware as to the frequency and volume. Parents also\n report that their son reported that he was having difficulty again with\n his anxiety and was prescribed Prozac. Per mother she asked pt if he\n was in therapy to which the pt stated he was not. Pt has one sibling,\n an older brother who has been at the bedside around the clock; the\n parents and brother are .\n Pt\ns brother describes pt as a very private person. Brother reports\n that it has been a good experience to meet the pt\ns friends and learn\n more about his brother\ns work and social like as brother knows the pt\n to be more of . Brother feels that the pt may have felt like\nthe black sheep of the family\n as he did not go to medical school.\n Brother and friends report that the pt is very smart and that he did\n extremely well in his career in management however they believe that\n the pt did not take any time off of a job that was extremely\n stressful. Pt no longer employed at this job and it is yet unclear as\n to the circumstances of his termination with his employer.\n Family is understandably upset and concerned; they are working well\n with the medical team. Family has been to the pt\ns apartment and found\n that the pt stopped paying his COBRA payments in , brother has\n payments in the hopes that the policy will not terminate.\n Will continue to follow pt\ns progress and to support the pt\ns family\n throughout this medical admission.\n" }, { "category": "Physician ", "chartdate": "2131-06-06 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 679163, "text": "Chief Complaint:\n 24 Hour Events:\n - Sinus CT showed opacification in right side sinuses. ENT will swab\n meatus but did not think draining it would help and did not think\n fevers and eosinophilia from this.\n - CT Abdomen grossly unchanged from prior with thickening of the cecum\n consistent with infection, necrotizing pancreatitis, no abscess\n - Heme recommended Heparin 5000 and stim for am because\n adrenal insufficiency can cause eosinophilia\n - ID recommended PO/PR vanc if abdominal CT showed difference from\n prior or developed diarrhea\n - TTE with normal valves and nl/hyperdynamic EF but could not rule out\n vegetation.\n - IJ d/c'd and cultured\n - CVL placed over wire into HD site (left IJ)\n - HD line d/c'd and cultured\n - Spiked temp to 101.6 at MN. Cement-like secretions from ETT.\n - thoracics never did trach because peep high (want it to be 5)\n - O2 sats lower with Po2 in 60s this am. Cement like secretions from\n ETT. Concern for VAP so started aztreonam\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Daptomycin - 06:42 PM\n Infusions:\n Fentanyl (Concentrate) - 325 mcg/hour\n Midazolam (Versed) - 15 mg/hour\n Norepinephrine - 0.3 mcg/Kg/min\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 04:30 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 06:32 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.4\nC (101.1\n Tcurrent: 38.3\nC (101\n HR: 120 (95 - 121) bpm\n BP: 101/55(71) {86/42(61) - 117/61(79)} mmHg\n RR: 34 (22 - 41) insp/min\n SpO2: 94%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 84 kg (admission): 113.5 kg\n Height: 67 Inch\n CVP: 19 (12 - 22)mmHg\n Total In:\n 7,831 mL\n 824 mL\n PO:\n TF:\n IVF:\n 6,067 mL\n 349 mL\n Blood products:\n Total out:\n 11,152 mL\n 245 mL\n Urine:\n 195 mL\n 45 mL\n NG:\n 350 mL\n 200 mL\n Stool:\n Drains:\n Balance:\n -3,321 mL\n 579 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 30\n RR (Spontaneous): 0\n PEEP: 12 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10, Hemodynamic Instability\n PIP: 16 cmH2O\n Plateau: 19 cmH2O\n Compliance: 66.7 cmH2O/mL\n SpO2: 94%\n ABG: 7.35/41/63/21/-2\n Ve: 14.4 L/min\n PaO2 / FiO2: 126\n Physical Examination\n GEN: Intubated, sedated\n HEENT: icteric sclera. MMM\n NECK: Sites clean/dry/no oozing\n LUNGS: Crackles bilaterally anteriorly.\n HEART: RRR\n ABD: Distended. NT.\n EXTREM: 2+ edema with weeping wounds without surrounding erythema\n SKIN: Jaundice\n Labs / Radiology\n 79 K/uL\n 7.3 g/dL\n 93 mg/dL\n 1.8 mg/dL\n 21 mEq/L\n 5.5 mEq/L\n 26 mg/dL\n 103 mEq/L\n 133 mEq/L\n 23.0 %\n 50.7 K/uL\n 11:05 AM\n 03:58 PM\n 09:00 PM\n 09:06 PM\n 02:35 AM\n 02:39 AM\n 08:24 AM\n 02:56 PM\n 04:02 AM\n 04:11 AM\n WBC\n 50.7\n 50.7\n Hct\n 24.9\n 23.0\n Plt\n 73\n 79\n Cr\n 1.4\n 1.2\n 1.8\n TCO2\n 24\n 22\n 23\n 25\n 23\n 21\n 24\n Glucose\n 106\n 119\n 144\n 177\n 144\n 135\n 93\n Other labs: PT / PTT / INR:17.4/40.1/1.6, CK / CKMB / Troponin-T:256//,\n ALT / AST:36/205, Alk Phos / T Bili:138/17.6, Amylase / Lipase:19/35,\n Differential-Neuts:38.0 %, Band:2.0 %, Lymph:14.0 %, Mono:5.0 %,\n Eos:26.0 %, D-dimer:6389 ng/mL, Fibrinogen:419 mg/dL, Lactic Acid:2.4\n mmol/L, Albumin:1.7 g/dL, LDH:821 IU/L, Ca++:8.8 mg/dL, Mg++:2.0 mg/dL,\n PO4:4.3 mg/dL\n Assessment and Plan\n 28yo M with alcoholic hepatitis and necrotizing pancreatitis\n complicated by ARDS, SIRS, ARF, UGIB, fevers and eosinophilia.\n #. Fever: New for him in the last few days. concerning for sepsis given\n increasing pressor requirement and tachycardia. Possible source is VAP\n as has had cement-like secretions from ETT and increasing O2\n requirement necessitating increasing his peep. Started on aztreonam\n this morning for extended GN coverage. CT abd with no change but\n continued colonic thickening consistent with infection. Other source\n could be skin as extensive break down although no sign of infection\n superimposed on breakdown and on broad gram positive coverage.\n - Cte broad spectrum gram negative coverage with aztreonam for\n pseudomonal coverage and dapto for MRSA for presumed VAP\n -Would obtain bronch for washings/cultures as unable to culture\n secretions from ETT because too thick\n - F/U cultures\n - Consider TEE to r/o vegetations as TTE was not a definitive study if\n bronch negative or continues to spike through dapto/aztreonam\n - appreciate ID recs. consider vanc po/pr for colonic thickening if\n decompensates further or has diarrhea but for now has other source of\n fevers and Abd CT unchanged so will hold further abx treatment.\n - Lines changed over wire and HD line pulled last night. All line\n cultures pending.\n #. Respiratory Failure: ARDS secondary to necrotizing pancreatitis.\n PEEP at 20 currently. Cannot be trached with such a high peep according\n to thoracics so did not get trach last pm. Hypoxic on morning blood\n gas.\n - Would favor inc. FiO2 rather than peep given need to wean peep for\n trach placement but if unable to achieve good O2 sats will need to inc\n peep\n - Hold off on trach given new hypoxia and adrenal insufficiency.\n #. Anemia: Hcts stable and no RP bleed seen on CT.\n - trend hcts\n - f/u heme recs\n - guaiac stools\n #. Eosinophilia: Likely drug reaction (to vanc?) with less likely\n etiology being infection.\n - appreciate heme recs\n - stim positive for adrenal insufficiency. Will treat with\n steroids and hold off on trach as above. Cte to follow eosinophilia to\n see if improves with steroids.\n - cte dapto instead of vanc for treatment of GPCs in blood and\n aztreonam instead of meropenem for GNegs\n #. Thrombocytopenia: Appreciate heme recs. Do not feel this is DIC.\n - Restarted heparin at low dose for dvt ppx\n - Monitor platelets daily and transfuse for plt <10 or <50 if signs of\n bleed\n #. Acute renal Failure:\n - Patient taking CVVH holiday as HD line had to be pulled in setting\n of fever and sepsis so creatinine slowly rising\n - Renal would like HD line placed by IR likely early tomorrow am\n #. Hyperkalemia: Likely in setting of ARF after stopping CVVH.\n - Will follow up renal recs re: restarting HD\n #. Wounds: Wound care suggested dermatology consult for non-healing\n wounds. Will call today.\n ICU Care\n Nutrition:\n TPN w/ Lipids - 04:54 PM 73 mL/hour\n IR for doboff placement tomorrow am (when down there for HD line\n placement)\n Glycemic Control:\n Lines:\n 20 Gauge - 03:56 PM\n Arterial Line - 08:15 PM\n Multi Lumen - 10:00 PM\n Prophylaxis:\n DVT: hep sc BID\n Stress ulcer: ppi\n VAP: mouth care\n Comments:\n Communication: Comments: with family\n Code status: Full code\n Disposition: ICU\n" }, { "category": "Physician ", "chartdate": "2131-06-07 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 679308, "text": "Chief Complaint:\n 24 Hour Events:\n BRONCHOSCOPY - At 05:32 PM\n EKG - At 08:00 PM\n EKG - At 09:04 PM\n DIALYSIS CATHETER - START 11:35 PM\n EKG - At 04:15 AM\n FEVER - 103.0\nF - 12:00 PM\n :\n - Bronched. Secretions not seen. BAL from RLL and trach wash sent for\n bacterial and fungal cx, cell count, cytology.\n - ID recommended adding flagyl IV.\n - peripheral bcx growing GPC. D/c'd dapto and started linezolid\n given possibility of enterococcus.\n - Pt alarming for ST elevations on tele. EKG with ?STE in V2. Repeat\n EKG with ?STE in V1-V3 with scooped T segments. Cardiac enyzmes mildly\n elevated with CK 220 but MB 2 and Trop 0.07. EKGs faxed to Cards who\n thought more c/w metabolic changes given acidemia and increasing K.\n Given kayexalate pr, then calcium chloride, dextrose, insulin. Placed\n RIJ for CVVH with DDAVP given beforehand. Repeat EKG improved.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Daptomycin - 06:42 PM\n Aztreonam - 08:00 PM\n Linezolid - 10:05 PM\n Metronidazole - 02:00 AM\n Infusions:\n Norepinephrine - 0.14 mcg/Kg/min\n Fentanyl (Concentrate) - 350 mcg/hour\n Calcium Gluconate (CRRT) - 1.4 grams/hour\n Midazolam (Versed) - 15 mg/hour\n Other ICU medications:\n Dextrose 50% - 10:25 PM\n Heparin Sodium (Prophylaxis) - 04:30 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 07:28 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 39.4\nC (103\n Tcurrent: 37\nC (98.6\n HR: 99 (99 - 125) bpm\n BP: 107/61(77) {93/51(65) - 132/85(97)} mmHg\n RR: 14 (14 - 39) insp/min\n SpO2: 99%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 134 kg (admission): 113.5 kg\n Height: 67 Inch\n CVP: 291 (0 - 291)mmHg\n Total In:\n 3,728 mL\n 1,957 mL\n PO:\n TF:\n IVF:\n 1,920 mL\n 1,412 mL\n Blood products:\n Total out:\n 595 mL\n 2,839 mL\n Urine:\n 395 mL\n 60 mL\n NG:\n 200 mL\n 200 mL\n Stool:\n Drains:\n Balance:\n 3,133 mL\n -882 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 30\n RR (Spontaneous): 0\n PEEP: 15 cmH2O\n FiO2: 80%\n RSBI Deferred: PEEP > 10\n PIP: 29 cmH2O\n Plateau: 23 cmH2O\n SpO2: 99%\n ABG: 7.25/50/106/19/-5\n Ve: 10.9 L/min\n PaO2 / FiO2: 133\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 7.3 g/dL\n 233 mg/dL\n 3.0 mg/dL\n 19 mEq/L\n 6.1 mEq/L\n 40 mg/dL\n 102 mEq/L\n 131 mEq/L\n 26.0 %\n 69.0 K/uL\n [image002.jpg]\n 12:47 PM\n 02:12 PM\n 03:38 PM\n 06:35 PM\n 08:42 PM\n 08:53 PM\n 02:05 AM\n 02:12 AM\n 06:02 AM\n 06:11 AM\n WBC\n 69.0\n Hct\n 26.0\n Plt\n 77\n Cr\n 2.4\n 2.7\n 3.3\n 3.0\n TropT\n 0.07\n 0.06\n 0.07\n TCO2\n 21\n 19\n 20\n 23\n 19\n 23\n Glucose\n 145\n 200\n 191\n 233\n Other labs: PT / PTT / INR:19.8/63.8/1.8, CK / CKMB /\n Troponin-T:214/3/0.07, ALT / AST:43/205, Alk Phos / T Bili:145/23.0,\n Amylase / Lipase:19/35, Differential-Neuts:49.0 %, Band:0.0 %,\n Lymph:9.0 %, Mono:7.0 %, Eos:21.0 %, D-dimer:6389 ng/mL, Fibrinogen:419\n mg/dL, Lactic Acid:2.2 mmol/L, Albumin:1.7 g/dL, LDH:821 IU/L, Ca++:8.3\n mg/dL, Mg++:2.2 mg/dL, PO4:7.2 mg/dL\n Assessment and Plan\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n IMPAIRED SKIN INTEGRITY\n HEPATITIS, ACUTE TOXIC (INCLUDING ALCOHOLIC, ACETAMINOPHEN, ETC.)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ICU Care\n Nutrition:\n TPN w/ Lipids - 04:05 PM 73. mL/hour\n Glycemic Control:\n Lines:\n 20 Gauge - 03:56 PM\n Arterial Line - 08:15 PM\n Multi Lumen - 10:00 PM\n Dialysis Catheter - 11:35 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:ICU\n" }, { "category": "Physician ", "chartdate": "2131-06-07 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 679314, "text": "Chief Complaint:\n 24 Hour Events:\n BRONCHOSCOPY - At 05:32 PM\n EKG - At 08:00 PM\n EKG - At 09:04 PM\n DIALYSIS CATHETER - START 11:35 PM\n EKG - At 04:15 AM\n FEVER - 103.0\nF - 12:00 PM\n :\n - Bronched. Secretions not seen. BAL from RLL and trach wash sent for\n bacterial and fungal cx, cell count, cytology.\n - ID recommended adding flagyl IV.\n - peripheral bcx growing GPC. D/c'd dapto and started linezolid\n given possibility of enterococcus.\n - Pt alarming for ST elevations on tele. EKG with ?STE in V2. Repeat\n EKG with ?STE in V1-V3 with scooped T segments. Cardiac enyzmes mildly\n elevated with CK 220 but MB 2 and Trop 0.07. EKGs faxed to Cards who\n thought more c/w metabolic changes given acidemia and increasing K.\n Given kayexalate pr, then calcium chloride, dextrose, insulin. Placed\n RIJ for CVVH with DDAVP given beforehand. Repeat EKG improved.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Daptomycin - 06:42 PM\n Aztreonam - 08:00 PM\n Linezolid - 10:05 PM\n Metronidazole - 02:00 AM\n Infusions:\n Norepinephrine - 0.14 mcg/Kg/min\n Fentanyl (Concentrate) - 350 mcg/hour\n Calcium Gluconate (CRRT) - 1.4 grams/hour\n Midazolam (Versed) - 15 mg/hour\n Other ICU medications:\n Dextrose 50% - 10:25 PM\n Heparin Sodium (Prophylaxis) - 04:30 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 07:28 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 39.4\nC (103\n Tcurrent: 37\nC (98.6\n HR: 99 (99 - 125) bpm\n BP: 107/61(77) {93/51(65) - 132/85(97)} mmHg\n RR: 14 (14 - 39) insp/min\n SpO2: 99%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 134 kg (admission): 113.5 kg\n Height: 67 Inch\n CVP: 291 (0 - 291)mmHg\n Total In:\n 3,728 mL\n 1,957 mL\n PO:\n TF:\n IVF:\n 1,920 mL\n 1,412 mL\n Blood products:\n Total out:\n 595 mL\n 2,839 mL\n Urine:\n 395 mL\n 60 mL\n NG:\n 200 mL\n 200 mL\n Stool:\n Drains:\n Balance:\n 3,133 mL\n -882 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 30\n RR (Spontaneous): 0\n PEEP: 15 cmH2O\n FiO2: 80%\n RSBI Deferred: PEEP > 10\n PIP: 29 cmH2O\n Plateau: 23 cmH2O\n SpO2: 99%\n ABG: 7.25/50/106/19/-5\n Ve: 10.9 L/min\n PaO2 / FiO2: 133\n Physical Examination\n GEN: Intubated, sedated\n HEENT: icteric sclera. MMM\n NECK: Sites clean/dry/no oozing\n LUNGS: Crackles bilaterally anteriorly.\n HEART: RRR\n ABD: Distended. NT.\n EXTREM: 2+ edema with weeping wounds without surrounding erythema\n SKIN: Jaundice\n Labs / Radiology\n 77 K/uL\n 7.3 g/dL\n 233 mg/dL\n 3.0 mg/dL\n 19 mEq/L\n 6.1 mEq/L\n 40 mg/dL\n 102 mEq/L\n 131 mEq/L\n 26.0 %\n 69.0 K/uL\n [image002.jpg]\n 12:47 PM\n 02:12 PM\n 03:38 PM\n 06:35 PM\n 08:42 PM\n 08:53 PM\n 02:05 AM\n 02:12 AM\n 06:02 AM\n 06:11 AM\n WBC\n 69.0\n Hct\n 26.0\n Plt\n 77\n Cr\n 2.4\n 2.7\n 3.3\n 3.0\n TropT\n 0.07\n 0.06\n 0.07\n TCO2\n 21\n 19\n 20\n 23\n 19\n 23\n Glucose\n 145\n 200\n 191\n 233\n Other labs: PT / PTT / INR:19.8/63.8/1.8, CK / CKMB /\n Troponin-T:214/3/0.07, ALT / AST:43/205, Alk Phos / T Bili:145/23.0,\n Amylase / Lipase:19/35, Differential-Neuts:49.0 %, Band:0.0 %,\n Lymph:9.0 %, Mono:7.0 %, Eos:21.0 %, D-dimer:6389 ng/mL, Fibrinogen:419\n mg/dL, Lactic Acid:2.2 mmol/L, Albumin:1.7 g/dL, LDH:821 IU/L, Ca++:8.3\n mg/dL, Mg++:2.2 mg/dL, PO4:7.2 mg/dL\n Assessment and Plan\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n IMPAIRED SKIN INTEGRITY\n HEPATITIS, ACUTE TOXIC (INCLUDING ALCOHOLIC, ACETAMINOPHEN, ETC.)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n 28yo M with alcoholic hepatitis and necrotizing pancreatitis\n complicated by ARDS, SIRS, ARF, UGIB, fevers and eosinophilia.\n #. Fever: Bronchoscopy without signs of pneumonia. GPCs growing\n in peripheral blood cx and dapto was changed to linezolid given concern\n for VRE. He was also started on aztreonam for extended GN coverage. CT\n abd with no change but continued colonic thickening consistent with\n infection. Other source could be skin as extensive break down although\n no sign of infection superimposed on breakdown and on broad gram\n positive coverage.\n - Cte broad spectrum gram negative and pseudomonal coverage with\n aztreonam and linezolid for MRSA and VRE for bacterimia\n - F/U cultures\n - Consider TEE to r/o vegetations as TTE was not a definitive study and\n now with GPC in blood cx.\n - appreciate ID recs. consider vanc po/pr for colonic thickening if\n decompensates further or has diarrhea but for now has other source of\n fevers and Abd CT unchanged so will hold further abx treatment.\n - New IJ placed for emergent CVVH\n #. Respiratory Failure: ARDS secondary to necrotizing pancreatitis.\n PEEP at 15 currently. Cannot be trached with such a high peep according\n to thoracics so did not get trach yet.\n - Would favor inc. FiO2 rather than peep given need to wean peep for\n trach placement but if unable to achieve good O2 sats will need to inc\n peep\n - Hold off on trach given elevated PEEP.\n #. Anemia: Hcts stable and no RP bleed seen on CT.\n - trend hcts\n - f/u heme recs\n - guaiac stools\n #. Eosinophilia: Likely drug reaction (to vanc?) with less likely\n etiology being infection.\n - appreciate heme recs\n - stim positive for adrenal insufficiency. Cte to follow\n eosinophilia to see if improves with steroids.\n - cte linezolid for GPCs in blood and aztreonam GNegs\n #. Thrombocytopenia: Appreciate heme recs. Do not feel this is DIC.\n - Restarted heparin at low dose for dvt ppx\n - Monitor platelets daily and transfuse for plt <10 or <50 if signs of\n bleed\n #. Acute renal Failure:\n - Restarted CVVH for hyperkalemia\n - Renal would like HD line placed by IR\n will discuss timing of this.\n #. Hyperkalemia: Likely in setting of ARF after stopping CVVH.\n - Restarted CVVH for hyperkalemia with ECG changes\n #. Wounds: Wound care suggested dermatology consult for non-healing\n wounds. Will call today.\n ICU Care\n Nutrition:\n TPN w/ Lipids - 04:05 PM 73. mL/hour\n Glycemic Control:\n Lines:\n 20 Gauge - 03:56 PM\n Arterial Line - 08:15 PM\n Multi Lumen - 10:00 PM\n Dialysis Catheter - 11:35 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:ICU\n" }, { "category": "Physician ", "chartdate": "2131-05-21 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 675850, "text": "Chief Complaint:\n 24 Hour Events:\n D/c'd R femoral line\n D/c'd maintenence fluids, bolused prn hypotension\n ESOPHOGEAL BALLOON - At 08:45 AM\n CORDIS/INTRODUCER - STOP 02:05 PM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Meropenem - 12:15 AM\n Infusions:\n Fentanyl (Concentrate) - 300 mcg/hour\n Midazolam (Versed) - 20 mg/hour\n Phenylephrine - 5 mcg/Kg/min\n Other ICU medications:\n Pantoprazole (Protonix) - 08:41 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 05:19 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: 36.8\nC (98.3\n HR: 100 (94 - 106) bpm\n BP: 89/67(77) {72/47(56) - 104/68(79)} mmHg\n RR: 30 (0 - 30) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 111.3 kg (admission): 113.5 kg\n Height: 67 Inch\n CVP: 28 (19 - 35)mmHg\n Total In:\n 6,683 mL\n 1,180 mL\n PO:\n TF:\n IVF:\n 6,638 mL\n 1,180 mL\n Blood products:\n Total out:\n 416 mL\n 94 mL\n Urine:\n 416 mL\n 94 mL\n NG:\n Stool:\n Drains:\n Balance:\n 6,267 mL\n 1,086 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 30\n RR (Spontaneous): 0\n PEEP: 24 cmH2O\n FiO2: 70%\n RSBI Deferred: PEEP > 10, FiO2 > 60%, Hemodynamic Instability\n PIP: 46 cmH2O\n Plateau: 42 cmH2O\n Compliance: 23.5 cmH2O/mL\n SpO2: 97%\n ABG: 7.30/40/82./18/-5\n Ve: 11.7 L/min\n PaO2 / FiO2: 119\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 51 K/uL\n 11.0 g/dL\n 100 mg/dL\n 1.8 mg/dL\n 18 mEq/L\n 3.9 mEq/L\n 15 mg/dL\n 100 mEq/L\n 129 mEq/L\n 32.0 %\n 18.5 K/uL\n [image002.jpg]\n 04:55 AM\n 08:07 AM\n 10:04 AM\n 12:04 PM\n 02:30 PM\n 06:50 PM\n 09:15 PM\n 10:34 PM\n 02:42 AM\n 03:01 AM\n WBC\n 16.5\n 18.5\n Hct\n 31.5\n 31.4\n 32.0\n Plt\n 69\n 51\n Cr\n 2.2\n 1.8\n TCO2\n 22\n 21\n 22\n 21\n 21\n 20\n 20\n Glucose\n 108\n 107\n 97\n 100\n Other labs: PT / PTT / INR:20.9/47.6/2.0, ALT / AST:94/271, Alk Phos /\n T Bili:200/14.0, Amylase / Lipase:45/268, Lactic Acid:2.4 mmol/L,\n Albumin:2.2 g/dL, LDH:616 IU/L, Ca++:7.7 mg/dL, Mg++:1.9 mg/dL, PO4:2.4\n mg/dL\n Assessment and Plan\n Mr. is a 28 year old gentleman with alchoholic hepatitis and\n necrotizing pancreatitis complicated by ARDS, SIRS, and UGIB.\n # Respiratory Failure: ARDS secondary to necrotizing pancreatis\n compounded by hypoxia, tachypnea in setting of anion gap metabolic\n acidosis, increased abdominal pressure, and EtOH withdrawl.\n - APRV\n - Permissible tachypnea is tolerated in setting of AGMA. If patient\n has auto-peep and breath stacking would consider paralysis. Would\n permit PCO2 of ~70 and pH ~7.1 with goal PaO2>60.\n - Monitor abdominal pressures\n - Recheck esophageal balloon pressure and adjust vent settings as\n indicated\n - Continue fentanyl and midazolam for sedation.\n # Necrotizing pancreatitis/SIRS: Likely secondary to alchohol\n complicated by SIRS. Patient continues to have pressor requirement and\n volume rescuitation with >55L.\n - Continue empiric meropenem\n - Wean pressors, bolus IVF to maintain MAP>70 and UOP>20 cc/hr.\n - Monitor chemistries.\n - Continue to hold MIVF\n - Follow-up with recs if any\n # Acute renal failure: Creatinine continues to trend up with oliguria,\n likely secondary to SIRS/hypotension and IABP leading to ATN.\n - Urine lytes, eos, osm\n - Trend UOP, bolus IVF to maintain goal >20 cc/hr.\n # IAP elevation: Secondary to third spacing and edema. Per surgery, not\n a good surgical candidate at this time.\n # Acute hepatitis: Likely alcoholic hepatitis with fatty infiltration,\n and no evidence of distal obstruction. RUQ u/s shows marked liver\n echogenicity but no ascites.\n - Trend LFTs\n # Hematemesis: EGD showed diuelafoy's lesion. HCT stable since 2 units\n PRBC on .\n - Trend hct, transfuse for hct<21\n # Hyponatremia: In setting of decreased effective circulating volume in\n setting of SIRS and IABP.\n - Trend chemistries.\n # Alcoholism: Patient describes history of withdrawal symptoms, but\n not prior seizure. Last drink was night prior to presentation.\n Tachycardia, weakness, and elevated lactate could be consistent with\n thiamine deficiency.\n - Thiamine, vb12, folate\n - Valium with CIWA > 10\n FEN: IVF, replete electrolytes, NPO. Would consider starting TPN after\n 5-7 days\n PPx: SCDs, PPI\n Access: RIJ, right radial art line.\n Code: Full Code\n Dispo: ICU level of care.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Arterial Line - 01:35 PM\n Multi Lumen - 02:02 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": "2131-05-21 00:00:00.000", "description": "Nursing Progress Note", "row_id": 675863, "text": "TITLE:\n 28 yo gentleman w history etoh, presented to hospital with\n UGIB, hypotension systolic 50\ns and acute necrotizing pancreatitis\n Hypotension (not Shock)\n Assessment:\n Periods of hypotension with Mean bp < 60 on neosynephrine Very sedate\n (high dose fentanyl &versed gtts) pupils 2-4mm sluggish reactive, no\n gag, impaired cough, does not withdraw to pain\n Sr- no ectopics. Vigeleo co 4.7-7 range w svv cvp 23-30\n Anasarca with Uop 13-18cc/hr icteric urine\n Action:\n Notified Dr\n and Dr re: low bp\ns.Fluid bloused x 4 = total\n 1500 cc fld , Neo titrated from 4.4 to 5mcg/kg/min. fentanyl weaned to\n 300mcg/hr, versed remains at 20mg/hr.\n Response:\n Transient bp improvements with fluid boluses. Creat 1.8 this am.\n Plan:\n If persistent mbp < 60 may restart levophed ,please Call HO if\n requires levophed. Wean pressors once bp more stable. ? crrt later this\n week if low uop persists and creat continues to rise.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Intubated on fio2 70% peep 24 tv 400 rr 30 sedated on fentanyl and\n versed, not overbreathing ventilator. Bbs clear upper lobes and\n diminished bibasilarly.Orally suct for bloody secretions, sm amts of\n blood via lt nares. Triadyne bed with maximal side to side rotation.\n Action:\n Maximal rotation throughout the night, when supine bp drops and sats\n down to low 90\ns.Suctioned for no secretions. Lactates stable at\n 2.6-2.4, Dr aware. Brief desat to 90 with turning side to side for\n am care recovered within 5 mins.loose packing to bilat nares. Freq oral\n care. Am labs done\n Response:\n Abg adequate with fio2 decrease to 70%.Poorly tolerates supine\n position, bp and sats improved w maximal rotation side to side.Plt\n count down to 51k this am-Dr made aware.(receiving NO heparin\n products)\n Plan:\n Wean fio2 if tolerates. Pulm toilet, Vap bundle .Continue rotation with\n triadyne bed. Maintain fentanyl and versed sedation until ventilator\n requirements diminished. Continue to monitor labs and treat.\n ------ Protected Section ------\n Hypotension persists despite fluid resuscitation and max dose neo. Dr\n and Gross updated and levophed initiated at 0.04 mcg/kg/min with\n improvement in mbp > 60\n ------ Protected Section Addendum Entered By: , RN\n on: 06:07 ------\n" }, { "category": "Respiratory ", "chartdate": "2131-05-22 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 676150, "text": "Demographics\n Day of intubation: \n Day of mechanical ventilation: 0\n Ideal body weight: 67.1 None\n Ideal tidal volume: 268.4 / 402.6 / 536.8 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location: ED\n Reason: Emergent (1st time)\n Tube Type\n ETT:\n Position: 23 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7mm\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Small\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Tachypneic (RR> 35 b/min)\n Assessment of breathing comfort: No response (sleeping / sedated)\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Utilize ARDSnet protocol\n Reason for continuing current ventilatory support: Intolerant of\n weaning attempts, Hemodynimic instability, Underlying illness not\n resolved\n" }, { "category": "Physician ", "chartdate": "2131-05-24 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 676689, "text": "Chief Complaint:\n 24 Hour Events:\n - Had loss of /white matter differentiation on head ct, concern for\n cerebral edema. also had eye twitching at head CT suggestive of\n seizure. resolved with ativan 4 iv x 1, recurred later and responded\n to ativan 4 iv. neuro consulted and recc'd keppra (loaded), hypertonic\n saline (given; note in OMR), EEG on .\n - Ammonia 216 -> neuro thought ?ammonia-induced intracerebral edema,\n neurosurg c/s at their request for possible ICP monitor placement but\n neurosurg declined given elevated INR, wanted to see if hypertonic\n saline would work. mannitol avoided given renal failure.\n - Spiked at 1 a.m. -> bcx\n - Started flagyl for bowel wall thickening/possible colitis on abd CT\n - CT Chest with multifocal infiltrates\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 09:11 AM\n Metronidazole - 02:45 AM\n Meropenem - 06:21 AM\n Infusions:\n Fentanyl (Concentrate) - 400 mcg/hour\n Phenylephrine - 4.8 mcg/Kg/min\n Other ICU medications:\n Pantoprazole (Protonix) - 08:00 PM\n Lorazepam (Ativan) - 08:20 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:52 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.3\nC (101\n Tcurrent: 37.3\nC (99.2\n HR: 96 (96 - 113) bpm\n BP: 111/63(79) {86/52(67) - 120/71(86)} mmHg\n RR: 30 (8 - 40) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 156 kg (admission): 113.5 kg\n Height: 67 Inch\n CVP: 26 (20 - 26)mmHg\n Bladder pressure: 26 (26 - 26) mmHg\n Total In:\n 2,555 mL\n 709 mL\n PO:\n TF:\n IVF:\n 2,555 mL\n 709 mL\n Blood products:\n Total out:\n 643 mL\n 252 mL\n Urine:\n 343 mL\n 52 mL\n NG:\n 300 mL\n 200 mL\n Stool:\n Drains:\n Balance:\n 1,912 mL\n 457 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 30\n RR (Spontaneous): 0\n PEEP: 24 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10\n PIP: 42 cmH2O\n Plateau: 37 cmH2O\n Compliance: 30.8 cmH2O/mL\n SpO2: 98%\n ABG: 7.25/45/117/18/-7\n Ve: 11.8 L/min\n PaO2 / FiO2: 234\n Physical Examination\n Gen: Sedated\n HEENT: ETT in place.. Scleral edema\n Chest: coarse BS bl, rhonchorous throughout\n CV: distant heart sounds, RRR, S1S2\n Abd: distended, abdominal wall edema\n Ext: Anasarca\n Neuro: Sedated. Pupils 6 mm, reactive.\n Labs / Radiology\n 99 K/uL\n 10.0 g/dL\n 142 mg/dL\n 3.8 mg/dL\n 18 mEq/L\n 4.4 mEq/L\n 27 mg/dL\n 104 mEq/L\n 132 mEq/L\n 30.4 %\n 38.9 K/uL\n [image002.jpg]\n 05:04 PM\n 05:54 PM\n 10:25 PM\n 03:01 AM\n 03:09 AM\n 03:21 PM\n 03:39 PM\n 06:30 PM\n 01:22 AM\n 01:32 AM\n WBC\n 30.5\n 29.3\n 38.9\n Hct\n 32.2\n 31.7\n 31.0\n 30.4\n Plt\n 66\n 64\n 99\n Cr\n 3.2\n 3.2\n 3.7\n 3.8\n TCO2\n 18\n 19\n 20\n 18\n 21\n Glucose\n 106\n 93\n 100\n 84\n 78\n 105\n 142\n Other labs: PT / PTT / INR:18.6/41.5/1.7, ALT / AST:37/219, Alk Phos /\n T Bili:218/20.6, Amylase / Lipase:16/37, Differential-Neuts:75.0 %,\n Band:0.0 %, Lymph:4.0 %, Mono:12.0 %, Eos:6.0 %, D-dimer: ng/mL,\n Fibrinogen:402 mg/dL, Lactic Acid:1.9 mmol/L, Albumin:2.1 g/dL, LDH:624\n IU/L, Ca++:8.0 mg/dL, Mg++:2.6 mg/dL, PO4:3.8 mg/dL\n Imaging: CT Torso:\n 1. New multifocal airspace consolidation, suspicious for acute\n infiltrates.\n 2. Diffuse colonic wall thickening, which could reflect colitis.\n 3. Diffuse soft tissue edema.\n 4. Peripancreatic stranding, in keeping with pancreatitis. Extent of\n necrosis cannot be evaluated on a non-contrast exam. There are no new\n peripancreatic fluid collections.\n CTH:\n 1. Diffuse loss of -white matter differentiation concerning for\n global\n hypoxia or edema with hypodensities in bilateral thalami.\n 2. No hemorrhage, mass effect, or herniation.\n 3. Fluid seen in bilateral temporal subcutaneous tissue. Near-complete\n opacification of bilateral mastoid, maxillary, frontal, and ethmoid\n sinuses.\n Assessment and Plan\n Mr. is a 28 year old gentleman with alcoholic hepatitis and\n necrotizing pancreatitis complicated by ARDS, SIRS, and UGIB.\n # Neuro: Patient with dilated pupils on high dose fentaynl gtt. CTH\n yesterday demonstrated loss of grey white differentiation with\n questionable effacement and possible seizure activity. Neuro and\n neurosurg consulted and patietn received ativan, keppra load, and\n hypertonic saline of hyponatremia.\n - Follow-up with neuro regarding keppra maintenance dose in setting of\n rapidly changing renal function.\n - 23% hypertonic saline per neurosurg recs\n - EEG today\n - Follow-up with neurosurg recs and for possible ICP monitor.\n # Respiratory Failure: ARDS secondary to necrotizing pancreatitis\n compounded by hypoxia, tachypnea in setting of anion gap metabolic\n acidosis, increased abdominal pressure, and EtOH withdrawl.\n - Wean FiO2 and PEEP, goal PaO2>60-65%\n - Continue to monitor IAP\n - Continue vanco, meropenem, flagyl\n # Leukocytosis: WBC up to 38.9 today. Patient continues to be\n afebrile. Concern for CVL infection, VAP, loculated effusion,\n sinusitis, or pancreatitis complication including abscess formation.\n CT chest with multifocal infiltrates that could represent VAP vs ARDS.\n CTAP did not demonstrate any new pancreatic fluid collections. Patient\n spiked overnight and was started on flagyl.\n - Continue empiric vancomycin, meropenem, and flagyl. AM vanco level\n today\n - Follow-up culture data\n - Afrin and nasal saline spray\n # Necrotizing pancreatitis/SIRS: Likely secondary to alcohol\n complicated by SIRS and ARDS. Patient continues to have pressor\n requirement, with neo +/- levo. Aggressive volume resuscitation with\n >58L. Patient without improvement with albumin trial, likely\n secondary to SIRS and increased vascular permeability.\n - Continue empiric antimicrobials.\n - Wean pressors as able, starting with levophed\n - Hypertonic saline as above in order to increase intravascular volume.\n - Monitor chemistries.\n - Follow-up with recs if any\n # Hyponatremia: In setting of decreased effective circulating volume in\n setting of SIRS and IABP. Patient received hypertonic saline overnight\n per neurosurgery. Serum sodium stable this morning.\n - Hypertonic saline as above.\n - Trend chemistries.\n - Follow-up with neurosurgery recs if any.\n # Acute renal failure: Creatinine continues to trend up to 3.2 with\n oliguria, likely secondary to SIRS/hypotension and IABP leading to\n ATN. Appreciate renal recs - urine sediment consistent with ATN.\n - Plan for temp HD line placement today.\n - Follow-up renal recs, patient likely candidate for CVVH as\n creatinine, lytes, and BUN continue to rise.\n #Thrombocytopenia: Platelets trending down over hospital course but\n stable today. No clear etiology at this time. DIC panel and HIT PF4\n antibody negative.\n - Trend plt\n # IAP elevation: Secondary to third spacing and edema. Per surgery, not\n a good surgical candidate at this time.\n # Acute hepatitis: Likely alcoholic hepatitis with fatty infiltration,\n and no evidence of distal obstruction. RUQ u/s shows marked liver\n echogenicity but no ascites.\n - Trend LFTs\n # Hematemesis: EGD showed diuelafoy's lesion. HCT stable since 2 units\n PRBC on .\n - Trend hct, transfuse for hct<21\n # Alcoholism: Patient describes history of withdrawal symptoms, but\n not prior seizure. Last drink was night prior to presentation.\n Tachycardia, weakness, and elevated lactate could be consistent with\n thiamine deficiency.\n - Thiamine, vb12, folate\n - Valium with CIWA > 10\n FEN: TPN, replete as necessary\n PPx: Heparin in TPN, PPI\n Access: RIJ, right radial a-line\n Dispo: ICU level of care\n ICU Care\n Nutrition:\n TPN without Lipids - 04:55 PM\n Glycemic Control:\n Lines:\n Arterial Line - 01:35 PM\n Multi Lumen - 02:02 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": "2131-06-07 00:00:00.000", "description": "Nursing Progress Note", "row_id": 679290, "text": "28 year old male patient admitted with Dx of Necrotizing\n Pancreatitis now with worsening sepsis, ARDS, and renal failure.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Potassium level 6.7\n EKG changes notes\n Creatinine 3.3\n Minimal urine output\n Remains very fluid overloaded\n Action:\n New HD catheter placed by Dr. \n Placement confirmed by x-ray\n CRRT started @ 0200\n Kayexelate enema given for elevated potassium level.\n Insulin / dextrose / calcium given for elevated potassium.\n Response:\n 6am labs pending\n Repeat EKG shows improvement\n Plan:\n Continue CRRT to correct electrolytes, metabolic imbalance,\n and remove fluid, as much as patient will tolerate without having to\n significantly increase vasopressors per Dr. .\n Sepsis, Severe (with organ dysfunction)\n Assessment:\n Temp consistently ~ 100.4\n WBC this am 69 (50.7)\n Remains dependent on Levophed however weaning\n Action:\n Linezolid added to antibiotic regimen\n Steroids also started\n On rotating bed\n CRRT for fluid removal\n Response:\n Levophed weaned slightly\n Temp now 98.6\n Plan:\n Continue to follow up on culture results\n Continue antibiotics\n Follow up with ID\n Continue CRRT\n Impaired Skin Integrity\n Assessment:\n Popped blisters on legs from 3^rd spaced fluid are improving\n Lower legs / shins healing while thighs remain weepy and red\n Heels also improving, the area that is purple is shrinking\n Action:\n Legs wounds where aquacel ag was still attached where\n untouched. Aquacel left in place.\n Other areas cleansed with wound cleanser, and aquacel or\n adaptic, or just softsorb applied, depending on wound base and\n surrounding skin.\n Wrapped with kerlex gauze to keep in place\n Rotating air bed\n Waffle boots\n Response:\n Improving\n Plan:\n Continue with dressings noted in action plan\n Continue rotating air bed\n Continue waffle boots\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Labored breathing, using accessory muscles, flaring nostrils\n On AC, 80%, 12 peep, 30 x 400\n Breathing over the ventilator\n Rare cough, non productive but sounds congested\n Action:\n Recruitment maneuvers x2\n On rotating bed, as well as linen changes and full body turn\n q 4 hours\n VAP protocol\n ABX as ordered\n CRRT for fluid removal\n Response:\n more comfortably breathing, using less effort\n O2 sats 99%\n ABG: 7.25, 50, 106, -5, 23\n Plan:\n Wean FIO2 as patient will allow\n Continue rotating bed\n Continue VAP protocol\n Continue ABX\n" }, { "category": "Nursing", "chartdate": "2131-06-07 00:00:00.000", "description": "Nursing Progress Note", "row_id": 679395, "text": "Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Pt with acute EKG changes over noc K 6.7\n K this am 6.1 with improving EKG\n CRRT restarted at 0200 am per overnight ICU Attending\n NA 130\n Current goal to make keep pt neg as tolerated\n Action:\n K cont to trend down with CRRT last K 4.4\n EKG repeat showing marked improvement\n Cont to tolerate aggressive fluid removal with decreasing\n pressor requirement\n Response:\n Tolerating CRRT Lytes normalizing\n Cont to tolerate aggressive removal of fluid w/o increasing\n pressors\n Plan:\n Cont to tolerate fluid removal\n Cont to monitor labs per CRRT protocol\n Impaired Skin Integrity\n Assessment:\n Bilateral lower extremity bullae cont to ooze and bleed\n Bilateral heel ulcers remain unchanged\n Action:\n Derm into see pt\n Biopsy done\n Does not feel that is cellulitis\n Response:\n See Derm rec\n Bilateral lower extremity drsg \n :\n F/U derm rec\n Monitor for biopsy results\n Cont with current plan of care\n Sepsis, Severe (with organ dysfunction)\n Assessment:\n Afebrile this am ? if r/t CRRT\n Cont to tolerate Levo wean\n BAL + for eosinophils\n Action:\n Antifungals started per ID\n PO/PR Vanco started to CT scan showing thickening of\n cecum\n Aztreonam dose increased\n Cont to tolerate wean of Levo\n Post pyloric feeding tube placed to start sulcrafate\n Response:\n Levo down to .03mcgs/kg\n Remains afebrile\n Cont on steroids ? if steroids reason for improvement or abx\n Flexiseal placed\n Plan:\n Cont to monitor pt closely\n Cont to wean levo as tolerated\n Monitor WBC\ns esp eosinophils\n D/C PPI and start sulcrafate\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received on .80% 15 Peep\n Lungs clear to diminished at bases\n Minimal secretions\n Bloody oral secretions\n Remains tachypnic RR 30-32\n Cont with rotation\n Action:\n ABG\ns showing much improvement in PH as well as Pa02\n Fi02 weaned to .50\n Lung sounds and secretions remain unchanged\n Response:\n Tolerating rotation well\n Abg\ns still showing improved oxygenation\n ? wean peep in prep for trach\n Plan:\n Wean peep as tolerated\n F/U with BAL for any growth\n Cont with VAP care\n Cont Aztreonam for ? VAP\n" }, { "category": "Respiratory ", "chartdate": "2131-06-08 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 679450, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 22\n Ideal body weight: 67.1 None\n Ideal tidal volume: 268.4 / 402.6 / 536.8 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: 26 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7mm\n Lung sounds\n RLL Lung Sounds: Rhonchi\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Rhonchi\n Comments:\n Secretions\n Sputum color / consistency: 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 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: Hemodynimic\n instability, Underlying illness not resolved\n Comments Peep weaned overnight to 10. O2 sats stable with no episodes\n of desaturation.\n" }, { "category": "Physician ", "chartdate": "2131-05-22 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 676237, "text": "Chief Complaint:\n 24 Hour Events:\n - Restarted levophed.\n - weaned levo to 0.02\n - elevated ddimer, high fdps, high fibrinogen\n - wbc to 24, blood, urine, cdiff\n - albumin given\n - abx continued\n - bladder pressure at 20\n - FIO2 decreased from 60 to 50% at 9pm\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Meropenem - 05:54 AM\n Infusions:\n Norepinephrine - 0.02 mcg/Kg/min\n Phenylephrine - 5 mcg/Kg/min\n Fentanyl (Concentrate) - 300 mcg/hour\n Midazolam (Versed) - 20 mg/hour\n Other ICU medications:\n Pantoprazole (Protonix) - 08:22 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:06 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.4\nC (99.4\n Tcurrent: 37.2\nC (98.9\n HR: 101 (101 - 108) bpm\n BP: 105/62(77) {92/59(71) - 117/81(94)} mmHg\n RR: 15 (0 - 30) insp/min\n SpO2: 94%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 156 kg (admission): 113.5 kg\n Height: 67 Inch\n CVP: 23 (14 - 27)mmHg\n Bladder pressure: 20 (19 - 24) mmHg\n Total In:\n 2,817 mL\n 835 mL\n PO:\n TF:\n IVF:\n 2,817 mL\n 735 mL\n Blood products:\n 100 mL\n Total out:\n 830 mL\n 508 mL\n Urine:\n 530 mL\n 208 mL\n NG:\n 300 mL\n 100 mL\n Stool:\n Drains:\n 200 mL\n Balance:\n 1,987 mL\n 327 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 30\n RR (Spontaneous): 5\n PEEP: 24 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10\n PIP: 44 cmH2O\n Plateau: 40 cmH2O\n Compliance: 33.3 cmH2O/mL\n SpO2: 94%\n ABG: 7.29/38/86/18/-7\n Ve: 12.4 L/min\n PaO2 / FiO2: 172\n Physical Examination\n Gen: sedated\n HEENT: intubated\n Chest: coarse BS bl\n CV: distant heart sounds, RRR, S1S2\n Abd: distended, abdominal wall edema\n Ext: anasarca throughout\n Labs / Radiology\n 61 K/uL\n 10.6 g/dL\n 94 mg/dL\n 3.0 mg/dL\n 18 mEq/L\n 4.3 mEq/L\n 18 mg/dL\n 102 mEq/L\n 133 mEq/L\n 32.9 %\n 24.4 K/uL\n [image002.jpg]\n 12:04 PM\n 02:30 PM\n 06:50 PM\n 09:15 PM\n 10:34 PM\n 02:42 AM\n 03:01 AM\n 02:11 PM\n 08:20 PM\n 02:39 AM\n WBC\n 16.5\n 18.5\n 24.4\n Hct\n 31.5\n 31.4\n 32.0\n 34.0\n 32.9\n Plt\n 69\n 51\n 61\n 61\n Cr\n 2.2\n 1.8\n 2.1\n 3.0\n TCO2\n 21\n 21\n 20\n 20\n 19\n Glucose\n 107\n 97\n 100\n 103\n 94\n Other labs: PT / PTT / INR:20.9/47.6/2.0, ALT / AST:69/194, Alk Phos /\n T Bili:218/16.7, Amylase / Lipase:17/28, Differential-Neuts:64.0 %,\n Band:2.0 %, Lymph:11.0 %, Mono:8.0 %, Eos:3.0 %, D-dimer: ng/mL,\n Fibrinogen:402 mg/dL, Lactic Acid:2.1 mmol/L, Albumin:2.3 g/dL, LDH:494\n IU/L, Ca++:7.9 mg/dL, Mg++:2.2 mg/dL, PO4:2.7 mg/dL\n 8:20p\n _______________________________________________________________________\n pH\n 7.29\n pCO2\n 38\n pO2\n 86\n HCO3\n 19\n BaseXS\n -7\n HEPARIN DEPENDENT ANTIBODIES\n Results Pending\n Assessment and Plan\n Mr. is a 28 year old gentleman with alcoholic hepatitis and\n necrotizing pancreatitis complicated by ARDS, SIRS, and UGIB.\n # Respiratory Failure: ARDS secondary to necrotizing pancreatitis\n compounded by hypoxia, tachypnea in setting of anion gap metabolic\n acidosis, increased abdominal pressure, and EtOH withdrawl.\n - Continue current vent settings for now\n - check intraabdominal pressure\n - consider changing bed rotation parameters so only supine and\n left-sided to minimize pressure on IVC.\n - Begin to wean sedation as tolerated. Would prefer to wean down\n fentanyl and then midaxolam.\n # Necrotizing pancreatitis/SIRS: Likely secondary to alcohol\n complicated by SIRS. Patient continues to have pressor requirement and\n volume resucsitation with >54L.\n - Continue empiric meropenem for now. Will discuss with surgical team.\n - Wean pressors as able, starting with levophed\n - If hypotensive, consider using albumin 25-50 grams in preference to\n additional IVF boluses to maintain MAP>60 and UOP>20 cc/hr.\n - Monitor chemistries.\n - Continue to hold MIVF\n - Follow-up with recs if any\n # Acute renal failure: Creatinine continues to trend up with oliguria,\n likely secondary to SIRS/hypotension and IABP leading to ATN.\n - Urine lytes, eos, osm\n - Trend UOP, bolus IVF to maintain goal >20 cc/hr.\n #Thrombocytopenia: platelets trending down. No clear etiology at this\n time. Recommend checking DIC panel and HIT antibody.\n # IAP elevation: Secondary to third spacing and edema. Per surgery, not\n a good surgical candidate at this time.\n # Acute hepatitis: Likely alcoholic hepatitis with fatty infiltration,\n and no evidence of distal obstruction. RUQ u/s shows marked liver\n echogenicity but no ascites.\n - Trend LFTs\n # Hematemesis: EGD showed diuelafoy's lesion. HCT stable since 2 units\n PRBC on .\n - Trend hct, transfuse for hct<21\n # Hyponatremia: In setting of decreased effective circulating volume in\n setting of SIRS and IABP.\n - Trend chemistries.\n # Alcoholism: Patient describes history of withdrawal symptoms, but\n not prior seizure. Last drink was night prior to presentation.\n Tachycardia, weakness, and elevated lactate could be consistent with\n thiamine deficiency.\n - Thiamine, vb12, folate\n - Valium with CIWA > 10\n FEN: IVF, replete electrolytes, NPO. Would consider starting TPN after\n 5-7 days. If patient has no significant change over the next 1-2 days,\n may begin TPN on approximately .\n PPx: SCDs, PPI\n Access: RIJ, right radial art line.\n Code: Full Code\n Dispo: ICU level of care.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Arterial Line - 01:35 PM\n Multi Lumen - 02:02 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": "2131-06-01 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 678153, "text": "TITLE:\n Chief Complaint: Mr. is a 28 year old gentleman with alcoholic\n hepatitis and necrotizing pancreatitis complicated by ARDS, SIRS, and\n UGIB.\n 24 Hour Events:\n BLOOD CULTURED - At 04:02 AM\n periph and cl\n - Hct 25.7->23.9->24.2->24.1\n - PEEP 12->10, 0.5\n - 0200: Patient acutely became tachypneic to 60, dysynchronous on vent\n with high PIPs in setting of overbreathing. Nothing on suction. HR up\n to 120s, T 101. Patient opened his eyes and wiggled his left hand to\n command. Pan-cultured. Restarted midaz gtt. Given acetaminophen. CVVH\n switched to even. CXR shows no focal consolidation. Held off on\n restarting antibiotics. ABG 7.48/39/60, increased PEEP to 12.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 07:50 AM\n Meropenem - 02:45 AM\n Infusions:\n Fentanyl (Concentrate) - 50 mcg/hour\n Midazolam (Versed) - 2 mg/hour\n KCl (CRRT) - 1 mEq./hour\n Calcium Gluconate (CRRT) - 1.2 grams/hour\n Norepinephrine - 0.1 mcg/Kg/min\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:01 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.3\nC (101\n Tcurrent: 36.5\nC (97.7\n HR: 107 (98 - 119) bpm\n BP: 113/63(80) {89/45(58) - 114/63(80)} mmHg\n RR: 36 (17 - 40) insp/min\n SpO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 128 kg (admission): 113.5 kg\n Height: 67 Inch\n CVP: 17 (12 - 18)mmHg\n Total In:\n 10,016 mL\n 2,457 mL\n PO:\n TF:\n IVF:\n 7,976 mL\n 1,946 mL\n Blood products:\n 282 mL\n Total out:\n 11,260 mL\n 2,332 mL\n Urine:\n 135 mL\n 47 mL\n NG:\n 350 mL\n 100 mL\n Stool:\n Drains:\n Balance:\n -1,244 mL\n 125 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 30\n RR (Spontaneous): 0\n PEEP: 12 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10, RR >35\n PIP: 27 cmH2O\n Plateau: 20 cmH2O\n SpO2: 100%\n ABG: 7.46/35/75/26/1\n Ve: 15.2 L/min\n PaO2 / FiO2: 150\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 53 K/uL\n 7.9 g/dL\n 147 mg/dL\n 2.0 mg/dL\n 26 mEq/L\n 4.8 mEq/L\n 24 mg/dL\n 103 mEq/L\n 137 mEq/L\n 23.8 %\n 27.2 K/uL\n [image002.jpg]\n 04:07 AM\n 10:07 AM\n 10:18 AM\n 03:10 PM\n 04:00 PM\n 09:39 PM\n 09:57 PM\n 02:10 AM\n 02:23 AM\n 05:56 AM\n WBC\n 28.7\n 27.2\n Hct\n 23.9\n 24.2\n 24.1\n 23.8\n Plt\n 52\n 53\n Cr\n 2.0\n TCO2\n 33\n 31\n 28\n 30\n 30\n 26\n Glucose\n 150\n 159\n 136\n 130\n 147\n Other labs: PT / PTT / INR:14.9/38.7/1.3, ALT / AST:29/257, Alk Phos /\n T Bili:132/14.0, Amylase / Lipase:19/35, Differential-Neuts:39.0 %,\n Band:3.0 %, Lymph:32.0 %, Mono:6.0 %, Eos:13.0 %, D-dimer:6389 ng/mL,\n Fibrinogen:293 mg/dL, Lactic Acid:1.4 mmol/L, Albumin:1.6 g/dL, LDH:607\n IU/L, Ca++:9.4 mg/dL, Mg++:2.0 mg/dL, PO4:3.4 mg/dL\n Assessment and Plan\n Mr. is a 28 year old gentleman with alcoholic hepatitis and\n necrotizing pancreatitis complicated by ARDS, SIRS, and UGIB.\n # Anemia: Initially p/w hematemesis and EGD showed diuelafoy's lesion.\n Hct continues to trend down (25->24->23), now s/p 1 unit PRBC\n overnight. CTAP with gastric pseudocyst but per d/w radiology now\n definitive explanation for hct drop. GI to re-eval this morning.\n - Trend CBC Q8H, transfuse for hct<21 or plt<50\n - Follow-up with GI regarding further diagnostic and therapeutic\n interventions\n - CVVH at even to slightly negative balance for now\n - Hemolysis labs\n # Neuro: Initially dilated pupils with CT showing cerebral edema. Neuro\n exam now stable. Repeat CTH demonstrates interval improvement.\n - Continue leviteracetam\n - Wean sedation as possible\n - Neuro recs if any\n # Respiratory Failure: ARDS secondary to necrotizing pancreatitis\n compounded by hypoxia, tachypnea in setting of anion gap metabolic\n acidosis, increased abdominal pressure, and EtOH withdrawl. PEEP\n decreased to 12 from 20 and FiO2 to 50%.\n - Wean FiO2 and PEEP, goal PaO2>60-65%\n # Leukocytosis: Trendingd own. Initial concern for infection but normal\n cx suggests that this may be inflammatory reaction. No eos on diff.\n Appreciate ID input, no antibiotic indication at this time.\n antibiotics now discontinued.\n - Trend fever curve and WBC.\n - Follow-up culture data\n # Necrotizing pancreatitis/SIRS: Secondary to alcohol complicated by\n SIRS and ARDS. Patient continues to have pressor requirement, with neo\n +/- levo. Aggressive volume resuscitation with >50L.\n - Wean pressors with goal MAP >65\n # Hyponatremia: In setting of decreased effective circulating volume\n in setting of SIRS and IABP. Patient has received hypertonic saline\n boluses with improvement in serum sodium and osm.\n - Given improvement in neuro exam, hold hypertonic saline.\n # Acute renal failure: Patient had HD line placed and on CVVH. CVVH\n with even TBB pending assessment of hemorrhage.\n - CVVH per renal.\n - Trend chemistries\n #Thrombocytopenia: Platelets stable. No clear etiology at this time.\n DIC panel and HIT PF4 antibody negative.\n - Trend plt, transfuse for plt<10 or <50 if signs of hemorrhage.\n # Wound care: Per wound care recs.\n # Acute hepatitis: Likely alcoholic hepatitis with fatty infiltration,\n and no evidence of distal obstruction. RUQ u/s shows marked liver\n echogenicity but no ascites.\n - Trend LFTs\n # Alcoholism: Patient describes history of withdrawal symptoms, but\n not prior seizure. Last drink was night prior to presentation.\n Tachycardia, weakness, and elevated lactate could be consistent with\n thiamine deficiency.\n - Thiamine, vb12, folate\n - Valium with CIWA > 10\n FEN: TPN without heparin, replete as necessary.\n PPx: IV PPI. SCD on arm, hold heparin.\n Access: RIJ (quad), LIJ (HD), left radial a-line\n Dispo: ICU level of care\n ICU Care\n Nutrition:\n TPN w/ Lipids - 04:14 PM 73 mL/hour\n Glycemic Control:\n Lines:\n Multi Lumen - 02:02 PM\n Dialysis Catheter - 04:56 PM\n Arterial Line - 01:30 PM\n 20 Gauge - 11:15 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2131-06-01 00:00:00.000", "description": "Nursing Progress Note", "row_id": 678287, "text": " Problem - Description In Comments\n Assessment:\n resp rate high 50\ns this pm, 02 sat down to 90 mid pm (pt\ns versed off\n per micu attending this am)\n Action:\n pt\ns eyes open more and non-focused, overbreathing vent with rate\n 50\ns-60, micu attending called, started back on sedation and fentanyl\n increased, ekg done, several abgs done\n Response:\n pt continues to overbreathe vsent, given boluses of versed and fent per\n okay of micu resident here in attendance\n Plan:\n continue to medicate for pain and anxiety,\n Hypotension (not Shock)\n Assessment:\n several episodes of hypotension this pm with sys high 60\n Action:\n Levo titrated up to 0.3 mcg/kg/min, fluid via rescue line,\n Response:\n sys increased to 110-120\ns within several minutes\n Plan:\n keep pt normotensive, try to titrate levo down and yet maintain map >\n 60\n Impaired Skin Integrity\n Assessment:\n multiple blisters of extremities with bullae, oozing lge amt\n serous-light bloody dge from various blisters along legs, erythematous\n area of abdomen\n Action:\n skin cleanser and aquacell dsg to various blisters, covered with net\n covering, no tape, evalfuated by I.D\n Response:\n pt remains with above-described areas of skin impairement\n Plan:\n continue with wound care recommendations of wound care nurse, and I.D.,\n Respiratory failure, acute (not ARDS/)\n Assessment:\n pt remains on cmv mode of ventilation with ards profile\n Action:\n frequent abgs this pm, suctioned prn, rotating bed to improve lung\n excursion\n Response:\n Last abgs sl improvement in p02, resp rate remains 50\n Plan:\n continue to monitor abgs, vent changes\n" }, { "category": "Physician ", "chartdate": "2131-06-01 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 678290, "text": "TITLE:\n Chief Complaint: Mr. is a 28 year old gentleman with alcoholic\n hepatitis and necrotizing pancreatitis complicated by ARDS, SIRS, and\n UGIB.\n 24 Hour Events:\n BLOOD CULTURED - At 04:02 AM\n periph and cl\n - Hct 25.7->23.9->24.2->24.1\n - PEEP 12->10, 0.5\n - 0200: Patient acutely became tachypneic to 60, dysynchronous on vent\n with high PIPs in setting of overbreathing. Nothing on suction. HR up\n to 120s, T 101. Patient opened his eyes and wiggled his left hand to\n command. Pan-cultured. Restarted midaz gtt. Given acetaminophen. CVVH\n switched to even. CXR shows no focal consolidation. Held off on\n restarting antibiotics. ABG 7.48/39/60, increased PEEP to 12.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Meropenem - 02:45 AM\n Metronidazole - 08:05 PM\n Daptomycin - 09:30 PM\n Infusions:\n KCl (CRRT) - 1 mEq./hour\n Midazolam (Versed) - 15 mg/hour\n Fentanyl (Concentrate) - 200 mcg/hour\n Norepinephrine - 0.09 mcg/Kg/min\n Calcium Gluconate (CRRT) - 1.4 grams/hour\n Other ICU medications:\n Pantoprazole (Protonix) - 08:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 10:37 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.3\nC (101\n Tcurrent: 37.6\nC (99.6\n HR: 112 (106 - 124) bpm\n BP: 105/57(74) {89/45(58) - 132/75(95)} mmHg\n RR: 50 (23 - 50) insp/min\n SpO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 128 kg (admission): 113.5 kg\n Height: 67 Inch\n CVP: 11 (5 - 18)mmHg\n Total In:\n 10,016 mL\n 8,464 mL\n PO:\n TF:\n IVF:\n 7,976 mL\n 6,443 mL\n Blood products:\n 282 mL\n 375 mL\n Total out:\n 11,260 mL\n 8,231 mL\n Urine:\n 135 mL\n 162 mL\n NG:\n 350 mL\n 100 mL\n Stool:\n Drains:\n Balance:\n -1,245 mL\n 233 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 30\n RR (Spontaneous): 0\n PEEP: 12 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10, RR >35\n PIP: 42 cmH2O\n Plateau: 13 cmH2O\n SpO2: 100%\n ABG: 7.43/40/112/26/1\n Ve: 22 L/min\n PaO2 / FiO2: 224\n Physical Examination\n General Appearance: Well nourished, Overweight / Obese, anasarca\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, OG tube\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: No(t)\n Bronchial: , Rhonchorous: )\n Abdominal: Soft, Non-tender, minimal bowel sounds\n Extremities: Right: 2+, Left: 2+\n Skin: Warm, Rash: bilateral legs\n Neurologic: Responds to: Noxious stimuli, Movement: Non -purposeful,\n Tone: Not assessed\n Labs / Radiology\n 63 K/uL\n 7.9 g/dL\n 159 mg/dL\n 2.0 mg/dL\n 26 mEq/L\n 4.8 mEq/L\n 24 mg/dL\n 103 mEq/L\n 137 mEq/L\n 26.5 %\n 27.2 K/uL\n [image002.jpg]\n 02:23 AM\n 05:56 AM\n 09:27 AM\n 02:33 PM\n 03:16 PM\n 03:36 PM\n 05:18 PM\n 07:13 PM\n 07:19 PM\n 10:09 PM\n Hct\n 22.6\n 26.5\n Plt\n 63\n TCO2\n 30\n 26\n 28\n 26\n 30\n 25\n 26\n 27\n Glucose\n 159\n Other labs: PT / PTT / INR:14.9/38.7/1.3, ALT / AST:29/257, Alk Phos /\n T Bili:132/14.0, Amylase / Lipase:19/35, Differential-Neuts:39.0 %,\n Band:3.0 %, Lymph:32.0 %, Mono:6.0 %, Eos:13.0 %, D-dimer:6389 ng/mL,\n Fibrinogen:293 mg/dL, Lactic Acid:1.5 mmol/L, Albumin:1.6 g/dL, LDH:607\n IU/L, Ca++:9.4 mg/dL, Mg++:2.0 mg/dL, PO4:3.4 mg/dL\n Assessment and Plan\n Resp failure, ARDS slow progress on PEEP. Request trach, though will\n likely not be done until PEEP <10.\n Septic shock, remains levophed dependent, with occasional fluctuations\n in dose but essentially stable.\n Exam indicates mental status improving, trying to minimize sedation\n Sedation- versed 2, fent 50. Stop versed, reevaluate, bolus as needed.\n PO narcan for prolonged fentanyl.\n Thrombocytopenia present since . Improved/stable since , off\n heparin in TPN.\n Anemia: continue close monitoring with q8 hct, transfuse for <22\n Pancreatitis- pseudocyst\n Spiking low grade temps, off flagyl , off meropenem . Fever\n attributable to pancreatitis. Sinus consolidation unchanged since prior\n head CT, colitis evident on CT. Minimal stool but will try to send for\n CDiff. No sig resp secretions. Plan to hold off on restarting\n antibiotics, but will d/w ID.\n Nutrition, on TPN, discuss trophic feeds with nutrition and increase\n insulin in TPN\n No clear source of bleed. NG lavage neg. Brown, g+ stool. No blood from\n ETT. Repeat DIC labs. be due to oozing from known gastritis. If\n continues to require transfusions today will consult hematology.\n Skin breakdown- wound service recs.\n Renal failure, on CVVHD. Much less anasarca.\n Mr. is a 28 year old gentleman with alcoholic hepatitis and\n necrotizing pancreatitis complicated by ARDS, SIRS, and UGIB.\n # Anemia: Initially p/w hematemesis and EGD showed diuelafoy's lesion.\n Hct continues to trend down (25->24->23), now s/p 1 unit PRBC\n overnight. CTAP with gastric pseudocyst but per d/w radiology now\n definitive explanation for hct drop. GI to re-eval this morning.\n - Trend CBC Q8H, transfuse for hct<21 or plt<50\n - Follow-up with GI regarding further diagnostic and therapeutic\n interventions\n - CVVH at even to slightly negative balance for now\n - Hemolysis labs\n # Neuro: Initially dilated pupils with CT showing cerebral edema. Neuro\n exam now stable. Repeat CTH demonstrates interval improvement.\n - Continue leviteracetam\n - Wean sedation as possible\n - Neuro recs if any\n # Respiratory Failure: ARDS secondary to necrotizing pancreatitis\n compounded by hypoxia, tachypnea in setting of anion gap metabolic\n acidosis, increased abdominal pressure, and EtOH withdrawl. PEEP\n decreased to 12 from 20 and FiO2 to 50%.\n - Wean FiO2 and PEEP, goal PaO2>60-65%\n # Leukocytosis: Trendingd own. Initial concern for infection but normal\n cx suggests that this may be inflammatory reaction. No eos on diff.\n Appreciate ID input, no antibiotic indication at this time.\n Antibiotics now discontinued.\n - Trend fever curve and WBC.\n - Follow-up culture data\n # Necrotizing pancreatitis/SIRS: Secondary to alcohol complicated by\n SIRS and ARDS. Patient continues to have pressor requirement, with neo\n +/- levo. Aggressive volume resuscitation with >50L.\n - Wean pressors with goal MAP >65\n # Hyponatremia: In setting of decreased effective circulating volume\n in setting of SIRS and IABP. Patient has received hypertonic saline\n boluses with improvement in serum sodium and osm.\n - Given improvement in neuro exam, hold hypertonic saline.\n # Acute renal failure: Patient had HD line placed and on CVVH. CVVH\n with even TBB pending assessment of hemorrhage.\n - CVVH per renal.\n - Trend chemistries\n #Thrombocytopenia: Platelets stable. No clear etiology at this time.\n DIC panel and HIT PF4 antibody negative.\n - Trend plt, transfuse for plt<10 or <50 if signs of hemorrhage.\n # Wound care: Per wound care recs.\n # Acute hepatitis: Likely alcoholic hepatitis with fatty infiltration,\n and no evidence of distal obstruction. RUQ u/s shows marked liver\n echogenicity but no ascites.\n - Trend LFTs\n # Alcoholism: Patient describes history of withdrawal symptoms, but\n not prior seizure. Last drink was night prior to presentation.\n Tachycardia, weakness, and elevated lactate could be consistent with\n thiamine deficiency.\n - Thiamine, vb12, folate\n - Valium with CIWA > 10\n FEN: TPN without heparin, replete as necessary.\n ICU Care\n Nutrition:\n TPN w/ Lipids - 03:22 PM 73 mL/hour\n Glycemic Control:\n Lines:\n Multi Lumen - 02:02 PM\n Dialysis Catheter - 04:56 PM\n Arterial Line - 01:30 PM\n 20 Gauge - 11:15 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2131-06-01 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 678291, "text": "TITLE:\n Chief Complaint: Mr. is a 28 year old gentleman with alcoholic\n hepatitis and necrotizing pancreatitis complicated by ARDS, SIRS, and\n UGIB.\n 24 Hour Events:\n BLOOD CULTURED - At 04:02 AM\n periph and cl\n - Hct 25.7->23.9->24.2->24.1\n - PEEP 12->10, 0.5\n - 0200: Patient acutely became tachypneic to 60, dysynchronous on vent\n with high PIPs in setting of overbreathing. Nothing on suction. HR up\n to 120s, T 101. Patient opened his eyes and wiggled his left hand to\n command. Pan-cultured. Restarted midaz gtt. Given acetaminophen. CVVH\n switched to even. CXR shows no focal consolidation. Held off on\n restarting antibiotics. ABG 7.48/39/60, increased PEEP to 12.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Meropenem - 02:45 AM\n Metronidazole - 08:05 PM\n Daptomycin - 09:30 PM\n Infusions:\n KCl (CRRT) - 1 mEq./hour\n Midazolam (Versed) - 15 mg/hour\n Fentanyl (Concentrate) - 200 mcg/hour\n Norepinephrine - 0.09 mcg/Kg/min\n Calcium Gluconate (CRRT) - 1.4 grams/hour\n Other ICU medications:\n Pantoprazole (Protonix) - 08:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 10:37 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.3\nC (101\n Tcurrent: 37.6\nC (99.6\n HR: 112 (106 - 124) bpm\n BP: 105/57(74) {89/45(58) - 132/75(95)} mmHg\n RR: 50 (23 - 50) insp/min\n SpO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 128 kg (admission): 113.5 kg\n Height: 67 Inch\n CVP: 11 (5 - 18)mmHg\n Total In:\n 10,016 mL\n 8,464 mL\n PO:\n TF:\n IVF:\n 7,976 mL\n 6,443 mL\n Blood products:\n 282 mL\n 375 mL\n Total out:\n 11,260 mL\n 8,231 mL\n Urine:\n 135 mL\n 162 mL\n NG:\n 350 mL\n 100 mL\n Stool:\n Drains:\n Balance:\n -1,245 mL\n 233 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 30\n RR (Spontaneous): 0\n PEEP: 12 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10, RR >35\n PIP: 42 cmH2O\n Plateau: 13 cmH2O\n SpO2: 100%\n ABG: 7.43/40/112/26/1\n Ve: 22 L/min\n PaO2 / FiO2: 224\n Physical Examination\n General Appearance: Well nourished, Overweight / Obese, anasarca\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, OG tube\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: No(t)\n Bronchial: , Rhonchorous: )\n Abdominal: Soft, Non-tender, minimal bowel sounds\n Extremities: Right: 2+, Left: 2+\n Skin: Warm, Rash: bilateral legs\n Neurologic: Responds to: Noxious stimuli, Movement: Non -purposeful,\n Tone: Not assessed\n Labs / Radiology\n 63 K/uL\n 7.9 g/dL\n 159 mg/dL\n 2.0 mg/dL\n 26 mEq/L\n 4.8 mEq/L\n 24 mg/dL\n 103 mEq/L\n 137 mEq/L\n 26.5 %\n 27.2 K/uL\n [image002.jpg]\n 02:23 AM\n 05:56 AM\n 09:27 AM\n 02:33 PM\n 03:16 PM\n 03:36 PM\n 05:18 PM\n 07:13 PM\n 07:19 PM\n 10:09 PM\n Hct\n 22.6\n 26.5\n Plt\n 63\n TCO2\n 30\n 26\n 28\n 26\n 30\n 25\n 26\n 27\n Glucose\n 159\n Other labs: PT / PTT / INR:14.9/38.7/1.3, ALT / AST:29/257, Alk Phos /\n T Bili:132/14.0, Amylase / Lipase:19/35, Differential-Neuts:39.0 %,\n Band:3.0 %, Lymph:32.0 %, Mono:6.0 %, Eos:13.0 %, D-dimer:6389 ng/mL,\n Fibrinogen:293 mg/dL, Lactic Acid:1.5 mmol/L, Albumin:1.6 g/dL, LDH:607\n IU/L, Ca++:9.4 mg/dL, Mg++:2.0 mg/dL, PO4:3.4 mg/dL\n Assessment and Plan\n Resp failure, ARDS slow progress on PEEP. Request trach, though will\n likely not be done until PEEP <10.\n Septic shock, remains levophed dependent, with occasional fluctuations\n in dose but essentially stable.\n Exam indicates mental status improving, trying to minimize sedation\n Sedation- versed 2, fent 50. Stop versed, reevaluate, bolus as needed.\n PO narcan for prolonged fentanyl.\n Thrombocytopenia present since . Improved/stable since , off\n heparin in TPN.\n Anemia: continue close monitoring with q8 hct, transfuse for <22\n Pancreatitis- pseudocyst\n Spiking low grade temps, off flagyl , off meropenem . Fever\n attributable to pancreatitis. Sinus consolidation unchanged since prior\n head CT, colitis evident on CT. Minimal stool but will try to send for\n CDiff. No sig resp secretions. Plan to hold off on restarting\n antibiotics, but will d/w ID.\n Nutrition, on TPN, discuss trophic feeds with nutrition and increase\n insulin in TPN\n No clear source of bleed. NG lavage neg. Brown, g+ stool. No blood from\n ETT. Repeat DIC labs. be due to oozing from known gastritis. If\n continues to require transfusions today will consult hematology.\n Skin breakdown- wound service recs.\n Renal failure, on CVVHD. Much less anasarca.\n Mr. is a 28 year old gentleman with alcoholic hepatitis and\n necrotizing pancreatitis complicated by ARDS, SIRS, and UGIB.\n # Anemia: Initially p/w hematemesis and EGD showed diuelafoy's lesion.\n Hct continues to trend down (30->25->24), now s/p 3 units since .\n CTAP with new pancreatic pseudocyst but per d/w radiology no definitive\n explanation for hct drop. GI also doubts possibility of significant GI\n bleed, will not scope for now. Also on differential is DIC given\n occasional schistocytes seen on smear.\n - Trend CBC Q8H, transfuse for hct<21 or plt<50\n - GI reccs\n - consider heme-onc consult\n - CVVH at even to slightly negative balance for now\n - Hemolysis labs\n # Respiratory Failure: ARDS secondary to necrotizing pancreatitis\n compounded by hypoxia, tachypnea in setting of anion gap metabolic\n acidosis, increased abdominal pressure, and EtOH withdrawal. PEEP\n decreased to 12 from 20 and FiO2 to 50%.\n - Wean FiO2 and PEEP, goal PaO2>60-65%\n - wean sedation as tolerated\n # Leukocytosis: WBC count trending down but again with eosinophilia on\n and spiked fever in early a.m. Concerning given that and spiked\n Trendingd own. Initial concern for infection but normal cx suggests\n that this may be inflammatory reaction. No eos on diff. Appreciate ID\n input, no antibiotic indication at this time. Antibiotics now\n discontinued.\n - Trend fever curve and WBC.\n - Follow-up culture data\n # Neuro: Initially dilated pupils with CT showing cerebral edema. Neuro\n exam now stable. Repeat CTH demonstrates interval improvement.\n - Continue leviteracetam\n - Wean sedation as possible\n - Neuro recs if any\n # Necrotizing pancreatitis/SIRS: Secondary to alcohol complicated by\n SIRS and ARDS. Patient continues to have pressor requirement, with neo\n +/- levo. Aggressive volume resuscitation with >50L.\n - Wean pressors with goal MAP >65\n # Hyponatremia: In setting of decreased effective circulating volume\n in setting of SIRS and IABP. Patient has received hypertonic saline\n boluses with improvement in serum sodium and osm.\n - Given improvement in neuro exam, hold hypertonic saline.\n # Acute renal failure: Patient had HD line placed and on CVVH. CVVH\n with even TBB pending assessment of hemorrhage.\n - CVVH per renal.\n - Trend chemistries\n #Thrombocytopenia: Platelets stable. No clear etiology at this time.\n DIC panel and HIT PF4 antibody negative.\n - Trend plt, transfuse for plt<10 or <50 if signs of hemorrhage.\n # Wound care: Per wound care recs.\n # Acute hepatitis: Likely alcoholic hepatitis with fatty infiltration,\n and no evidence of distal obstruction. RUQ u/s shows marked liver\n echogenicity but no ascites.\n - Trend LFTs\n # Alcoholism: Patient describes history of withdrawal symptoms, but\n not prior seizure. Last drink was night prior to presentation.\n Tachycardia, weakness, and elevated lactate could be consistent with\n thiamine deficiency.\n - Thiamine, vb12, folate\n - Valium with CIWA > 10\n FEN: TPN without heparin, replete as necessary.\n ICU Care\n Nutrition:\n TPN w/ Lipids - 03:22 PM 73 mL/hour\n Glycemic Control:\n Lines:\n Multi Lumen - 02:02 PM\n Dialysis Catheter - 04:56 PM\n Arterial Line - 01:30 PM\n 20 Gauge - 11:15 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2131-06-02 00:00:00.000", "description": "Nursing Progress Note", "row_id": 678342, "text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n - Received on CMV 50 % 400x30 PEEP 12\n - Extremely under sedated, received with RR over 60 and PIP\ns in the\n 50\n - Discoordinate with ventilator\n - Sats remained 100% and abg indicated adequate oxygenation and\n ventilation despite discoordination with ventilator\n - Patient appeared to be in distress + nasal flaring, eyes wide open\n although not focused\n - CXR done\n - BLE US done to R/O DVT\n Action:\n - Aggressivley titrated up on sedation with multiple bolus of fentanyl\n and versed per MICU HO who was in attendance at this time\n - Fentanyl gtt up to 400 mcg (from 75mcg) /hr and Versed at 20 (up\n from 12) mg/hr.\n - Pharmacy contaced re: effect from po naloxone ( started this\n afternoon to increase GI motility) on sedation\n - MICU HO contact as opiod blocking effects could not be ruled out\n despite low dose naloxone\n - Naloxone dose held overnight and raglan gave instead per order\n - No acute changes on CXR\n Response:\n - Over night pt slowly became more adequately sedated\n - RR down to high 30\n low 40\n - PIP\ns down to mid 20\n - Patient appears much more comfortable\n - ABG\ns remain acceptable\n Plan:\n Follow up with team this morning regarding possiblilty of naloxone\n effect and maybe switch to standing raglan. Continue to titrate down on\n sedation as tolerated. Provide support to patient and family.\n Impaired Skin Integrity\n Assessment:\n - Multiple blistered and open areas on blu and right side of abdomen\n - Red and darkened areas on bil heels\n Action:\n - Skin care per wound care nurses recommendations\n - On rotating bed for respiratory and skin protection\n - Manual turn q4 for back care and linen change\n - Daptomycin started per ID recomondations for suspected cellulitis to\n BLE\n Response:\n - No changes in skin integrity this shift\n Plan:\n Continue on constant rotation, turn and assess skin prn, dressing\n changes per wound care\ns recomondations. Dermatology and ID following.\n Sepsis, Severe (with organ dysfunction)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Physician ", "chartdate": "2131-05-22 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 676232, "text": "Chief Complaint:\n 24 Hour Events:\n - Restarted levophed.\n - weaned levo to 0.02\n - elevated ddimer, high fdps, high fibrinogen\n - wbc to 24, blood, urine, cdiff\n - albumin given\n - abx continued\n - bladder pressure at 20\n - FIO2 decreased from 60 to 50% at 9pm\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Meropenem - 05:54 AM\n Infusions:\n Norepinephrine - 0.02 mcg/Kg/min\n Phenylephrine - 5 mcg/Kg/min\n Fentanyl (Concentrate) - 300 mcg/hour\n Midazolam (Versed) - 20 mg/hour\n Other ICU medications:\n Pantoprazole (Protonix) - 08:22 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:06 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.4\nC (99.4\n Tcurrent: 37.2\nC (98.9\n HR: 101 (101 - 108) bpm\n BP: 105/62(77) {92/59(71) - 117/81(94)} mmHg\n RR: 15 (0 - 30) insp/min\n SpO2: 94%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 156 kg (admission): 113.5 kg\n Height: 67 Inch\n CVP: 23 (14 - 27)mmHg\n Bladder pressure: 20 (19 - 24) mmHg\n Total In:\n 2,817 mL\n 835 mL\n PO:\n TF:\n IVF:\n 2,817 mL\n 735 mL\n Blood products:\n 100 mL\n Total out:\n 830 mL\n 508 mL\n Urine:\n 530 mL\n 208 mL\n NG:\n 300 mL\n 100 mL\n Stool:\n Drains:\n 200 mL\n Balance:\n 1,987 mL\n 327 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 30\n RR (Spontaneous): 5\n PEEP: 24 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10\n PIP: 44 cmH2O\n Plateau: 40 cmH2O\n Compliance: 33.3 cmH2O/mL\n SpO2: 94%\n ABG: 7.29/38/86/18/-7\n Ve: 12.4 L/min\n PaO2 / FiO2: 172\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 61 K/uL\n 10.6 g/dL\n 94 mg/dL\n 3.0 mg/dL\n 18 mEq/L\n 4.3 mEq/L\n 18 mg/dL\n 102 mEq/L\n 133 mEq/L\n 32.9 %\n 24.4 K/uL\n [image002.jpg]\n 12:04 PM\n 02:30 PM\n 06:50 PM\n 09:15 PM\n 10:34 PM\n 02:42 AM\n 03:01 AM\n 02:11 PM\n 08:20 PM\n 02:39 AM\n WBC\n 16.5\n 18.5\n 24.4\n Hct\n 31.5\n 31.4\n 32.0\n 34.0\n 32.9\n Plt\n 69\n 51\n 61\n 61\n Cr\n 2.2\n 1.8\n 2.1\n 3.0\n TCO2\n 21\n 21\n 20\n 20\n 19\n Glucose\n 107\n 97\n 100\n 103\n 94\n Other labs: PT / PTT / INR:20.9/47.6/2.0, ALT / AST:69/194, Alk Phos /\n T Bili:218/16.7, Amylase / Lipase:17/28, Differential-Neuts:64.0 %,\n Band:2.0 %, Lymph:11.0 %, Mono:8.0 %, Eos:3.0 %, D-dimer: ng/mL,\n Fibrinogen:402 mg/dL, Lactic Acid:2.1 mmol/L, Albumin:2.3 g/dL, LDH:494\n IU/L, Ca++:7.9 mg/dL, Mg++:2.2 mg/dL, PO4:2.7 mg/dL\n 8:20p\n _______________________________________________________________________\n pH\n 7.29\n pCO2\n 38\n pO2\n 86\n HCO3\n 19\n BaseXS\n -7\n HEPARIN DEPENDENT ANTIBODIES\n Results Pending\n Assessment and Plan\n Mr. is a 28 year old gentleman with alcoholic hepatitis and\n necrotizing pancreatitis complicated by ARDS, SIRS, and UGIB.\n # Respiratory Failure: ARDS secondary to necrotizing pancreatitis\n compounded by hypoxia, tachypnea in setting of anion gap metabolic\n acidosis, increased abdominal pressure, and EtOH withdrawl.\n - Continue current vent settings for now\n - check intraabdominal pressure\n - consider changing bed rotation parameters so only supine and\n left-sided to minimize pressure on IVC.\n - Begin to wean sedation as tolerated. Would prefer to wean down\n fentanyl and then midaxolam.\n # Necrotizing pancreatitis/SIRS: Likely secondary to alcohol\n complicated by SIRS. Patient continues to have pressor requirement and\n volume resucsitation with >54L.\n - Continue empiric meropenem for now. Will discuss with surgical team.\n - Wean pressors as able, starting with levophed\n - If hypotensive, consider using albumin 25-50 grams in preference to\n additional IVF boluses to maintain MAP>60 and UOP>20 cc/hr.\n - Monitor chemistries.\n - Continue to hold MIVF\n - Follow-up with recs if any\n # Acute renal failure: Creatinine continues to trend up with oliguria,\n likely secondary to SIRS/hypotension and IABP leading to ATN.\n - Urine lytes, eos, osm\n - Trend UOP, bolus IVF to maintain goal >20 cc/hr.\n #Thrombocytopenia: platelets trending down. No clear etiology at this\n time. Recommend checking DIC panel and HIT antibody.\n # IAP elevation: Secondary to third spacing and edema. Per surgery, not\n a good surgical candidate at this time.\n # Acute hepatitis: Likely alcoholic hepatitis with fatty infiltration,\n and no evidence of distal obstruction. RUQ u/s shows marked liver\n echogenicity but no ascites.\n - Trend LFTs\n # Hematemesis: EGD showed diuelafoy's lesion. HCT stable since 2 units\n PRBC on .\n - Trend hct, transfuse for hct<21\n # Hyponatremia: In setting of decreased effective circulating volume in\n setting of SIRS and IABP.\n - Trend chemistries.\n # Alcoholism: Patient describes history of withdrawal symptoms, but\n not prior seizure. Last drink was night prior to presentation.\n Tachycardia, weakness, and elevated lactate could be consistent with\n thiamine deficiency.\n - Thiamine, vb12, folate\n - Valium with CIWA > 10\n FEN: IVF, replete electrolytes, NPO. Would consider starting TPN after\n 5-7 days. If patient has no significant change over the next 1-2 days,\n may begin TPN on approximately .\n PPx: SCDs, PPI\n Access: RIJ, right radial art line.\n Code: Full Code\n Dispo: ICU level of care.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Arterial Line - 01:35 PM\n Multi Lumen - 02:02 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": "2131-06-02 00:00:00.000", "description": "Nursing Progress Note", "row_id": 678356, "text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n - Received on CMV 50 % 400x30 PEEP 12\n - Extremely under sedated, received with RR over 60 and PIP\ns in the\n 50\n - Discoordinate with ventilator\n - Sats remained 100% and abg indicated adequate oxygenation and\n ventilation despite discoordination with ventilator\n - Patient appeared to be in distress + nasal flaring, eyes wide open\n although not focused\n - CXR done\n - BLE US done to R/O DVT\n Action:\n - Aggressivley titrated up on sedation with multiple bolus of fentanyl\n and versed per MICU HO who was in attendance at this time\n - Fentanyl gtt up to 400 mcg (from 75mcg) /hr and Versed at 20 (up\n from 12) mg/hr.\n - Pharmacy contaced re: effect from po naloxone ( started this\n afternoon to increase GI motility) on sedation\n - MICU HO contact as opiod blocking effects could not be ruled out\n despite low dose naloxone\n - Naloxone dose held overnight and raglan gave instead per order\n - No acute changes on CXR\n Response:\n - Over night pt slowly became more adequately sedated\n - RR down to high 30\n low 40\n - PIP\ns down to mid 20\n - Patient appears much more comfortable\n - ABG\ns remain acceptable\n Plan:\n Follow up with team this morning regarding possiblilty of naloxone\n effect and maybe switch to standing raglan. Continue to titrate down on\n sedation as tolerated. Provide support to patient and family.\n Impaired Skin Integrity\n Assessment:\n - Multiple blistered and open areas on blu and right side of abdomen\n - Red and darkened areas on bil heels\n Action:\n - Skin care per wound care nurses recommendations\n - On rotating bed for respiratory and skin protection\n - Manual turn q4 for back care and linen change\n - Daptomycin started per ID recomondations for suspected cellulitis to\n BLE\n Response:\n - No changes in skin integrity this shift\n Plan:\n Continue on constant rotation, turn and assess skin prn, dressing\n changes per wound care\ns recommendations. Dermatology and ID\n following.\n Sepsis, Severe (with organ dysfunction)\n Assessment:\n Received on levophed at 0.175 mcg/kg\n CRRT running with even fluid balance this evening\n WBC 28 this am\n Labs concerning for DIC\n HCT 26 post transfusion ( up from 22)PLT 63\n Action:\n Levophed titrated down to .03 mcg/kg this am\n Able to removed 100-150 cc/fluid an hour\n Hematology consulted\n Smear sent to for eval by hematology\n Response:\n BP stable\n HCT 24 this am ,PLT 53\n No signs/symtoms of large blood loss\n Stools + occult blood but no obvious blood noted\n Plan:\n Continue to take off fluid as tolerated, titrate levophed, awaiting\n hematology and dic work up.\n" }, { "category": "Physician ", "chartdate": "2131-06-02 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 678370, "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 Nec panc\n EtOH abuse\n Respiratpry failure\n Hematocrit falling\n Requiring less PEEP\n ARF on CVVH\n Cerebral edema\n 24 Hour Events:\n bil lower extremities r/o dvt negative\n transfused\n received ddAVP\n pressors increased\n persistent tachypnea\n PO narcan started\n Recent CT with colitis\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Daptomycin - 09:30 PM\n Metronidazole - 04:00 AM\n Infusions:\n Norepinephrine - 0.03 mcg/Kg/min\n Calcium Gluconate (CRRT) - 1.2 grams/hour\n KCl (CRRT) - 1 mEq./hour\n Midazolam (Versed) - 17 mg/hour\n Other ICU medications:\n Pantoprazole (Protonix) - 08:00 PM\n Diazepam (Valium) - 11:56 PM\n kepra\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 08:18 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.7\nC (99.8\n Tcurrent: 36.8\nC (98.3\n HR: 104 (97 - 124) bpm\n BP: 100/53(69) {94/48(64) - 132/75(95)} mmHg\n RR: 38 (35 - 50) insp/min\n SpO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 128 kg (admission): 113.5 kg\n Height: 67 Inch\n CVP: 13 (5 - 13)mmHg\n Total In:\n 8,974 mL\n 3,038 mL\n PO:\n TF:\n IVF:\n 6,847 mL\n 2,433 mL\n Blood products:\n 375 mL\n Total out:\n 9,202 mL\n 4,447 mL\n Urine:\n 162 mL\n 75 mL\n NG:\n 100 mL\n 50 mL\n Stool:\n Drains:\n Balance:\n -228 mL\n -1,409 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 30\n RR (Spontaneous): 0\n PEEP: 12 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10, RR >35\n PIP: 29 cmH2O\n SpO2: 100%\n ABG: 7.45/36/80./23/1\n Ve: 15.2 L/min\n PaO2 / FiO2: 160\n Physical Examination\n Intubated, sedated\n Labs / Radiology\n 8.2 g/dL\n 54 K/uL\n 160 mg/dL\n 1.6 mg/dL\n 23 mEq/L\n 4.6 mEq/L\n 26 mg/dL\n 102 mEq/L\n 136 mEq/L\n 24.5 %\n 28.9 K/uL\n [image002.jpg]\n 09:27 AM\n 02:33 PM\n 03:16 PM\n 03:36 PM\n 05:18 PM\n 07:13 PM\n 07:19 PM\n 10:09 PM\n 03:05 AM\n 03:53 AM\n WBC\n 28.9\n Hct\n 22.6\n 26.5\n 24.5\n Plt\n 63\n 54\n Cr\n 1.6\n TCO2\n 28\n 26\n 30\n 25\n 26\n 27\n 26\n Glucose\n 159\n 177\n 160\n Other labs: PT / PTT / INR:15.8/40.5/1.4, ALT / AST:29/257, Alk Phos /\n T Bili:132/14.0, Amylase / Lipase:19/35, Differential-Neuts:37.0 %,\n Band:18.0 %, Lymph:7.0 %, Mono:2.0 %, Eos:15.0 %, D-dimer:6389 ng/mL,\n Fibrinogen:293 mg/dL, Lactic Acid:1.5 mmol/L, Albumin:1.6 g/dL, LDH:607\n IU/L, Ca++:9.1 mg/dL, Mg++:2.0 mg/dL, PO4:4.3 mg/dL\n Assessment and Plan\n Shock\n Anemia\n Cerebral edema\n ? DIC\n HEPATITIS, ACUTE TOXIC (INCLUDING ALCOHOLIC, ACETAMINOPHEN, ETC.)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n PANCREATITIS, ACUTE\n ICU Care\n Nutrition: TF\n TPN w/ Lipids - 03:22 PM 73 mL/hour\n Glycemic Control:\n Lines:\n Multi Lumen - 02:02 PM\n Dialysis Catheter - 04:56 PM\n Arterial Line - 01:30 PM\n 20 Gauge - 11:15 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition : icu\n Total time spent:\n" }, { "category": "Physician ", "chartdate": "2131-06-02 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 678372, "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 Nec panc\n EtOH abuse\n Respiratpry failure\n Hematocrit falling\n Requiring less PEEP\n ARF on CVVH\n Cerebral edema\n UGI bleed\n 24 Hour Events:\n bil lower extremities r/o dvt negative\n transfused\n received ddAVP\n pressors increased\n persistent tachypnea\n PO narcan started\n Recent CT with colitis\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Daptomycin - 09:30 PM\n Metronidazole - 04:00 AM\n Infusions:\n Norepinephrine - 0.03 mcg/Kg/min\n Calcium Gluconate (CRRT) - 1.2 grams/hour\n KCl (CRRT) - 1 mEq./hour\n Midazolam (Versed) - 17 mg/hour\n Other ICU medications:\n Pantoprazole (Protonix) - 08:00 PM\n Diazepam (Valium) - 11:56 PM\n kepra\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 08:18 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.7\nC (99.8\n Tcurrent: 36.8\nC (98.3\n HR: 104 (97 - 124) bpm\n BP: 100/53(69) {94/48(64) - 132/75(95)} mmHg\n RR: 38 (35 - 50) insp/min\n SpO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 128 kg (admission): 113.5 kg\n Height: 67 Inch\n CVP: 13 (5 - 13)mmHg\n Total In:\n 8,974 mL\n 3,038 mL\n PO:\n TF:\n IVF:\n 6,847 mL\n 2,433 mL\n Blood products:\n 375 mL\n Total out:\n 9,202 mL\n 4,447 mL\n Urine:\n 162 mL\n 75 mL\n NG:\n 100 mL\n 50 mL\n Stool:\n Drains:\n Balance:\n -228 mL\n -1,409 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 30\n RR (Spontaneous): 0\n PEEP: 12 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10, RR >35\n PIP: 29 cmH2O\n SpO2: 100%\n ABG: 7.45/36/80./23/1\n Ve: 15.2 L/min\n PaO2 / FiO2: 160\n Physical Examination\n Intubated, sedated, unresponsive, pinpoint pupils\n Coarse vented BS\n Rrr\n Abd\n soft, absent bowel sounds\n Extrem - edematous\n Labs / Radiology\n CXR stable hazy infiltrates\n 8.2 g/dL\n 54 K/uL\n 160 mg/dL\n 1.6 mg/dL\n 23 mEq/L\n 4.6 mEq/L\n 26 mg/dL\n 102 mEq/L\n 136 mEq/L\n 24.5 %\n 28.9 K/uL\n [image002.jpg]\n 09:27 AM\n 02:33 PM\n 03:16 PM\n 03:36 PM\n 05:18 PM\n 07:13 PM\n 07:19 PM\n 10:09 PM\n 03:05 AM\n 03:53 AM\n WBC\n 28.9\n Hct\n 22.6\n 26.5\n 24.5\n Plt\n 63\n 54\n Cr\n 1.6\n TCO2\n 28\n 26\n 30\n 25\n 26\n 27\n 26\n Glucose\n 159\n 177\n 160\n Other labs: PT / PTT / INR:15.8/40.5/1.4, ALT / AST:29/257, Alk Phos /\n T Bili:132/14.0, Amylase / Lipase:19/35, Differential-Neuts:37.0 %,\n Band:18.0 %, Lymph:7.0 %, Mono:2.0 %, Eos:15.0 %, D-dimer:6389 ng/mL,\n Fibrinogen:293 mg/dL, Lactic Acid:1.5 mmol/L, Albumin:1.6 g/dL, LDH:607\n IU/L, Ca++:9.1 mg/dL, Mg++:2.0 mg/dL, PO4:4.3 mg/dL\n Assessment and Plan\n Shock\n slowly improving pressor needs, wean as tolerated\n Anemia, ? DIC\n heme to weigh in, no obvious evidence of GI bleed, cont\n PPI, follow CBC twice daily\n Cerebral edema\n most recent CT improved, cont to follow pupils\n HEPATITIS, ACUTE TOXIC (INCLUDING ALCOHOLIC, ACETAMINOPHEN, ETC.)\n ARF, anasarca\n continue CVVH, increased volume removal\n RESPIRATORY FAILURE\n cont vent support, likely trach next week\n PANCREATITIS, ACUTE\n cont supportive care\n Ilieus\n cont PO narcan\n ICU Care\n Nutrition: TF\n TPN w/ Lipids - 03:22 PM 73 mL/hour\n Glycemic Control:\n Lines:\n Multi Lumen - 02:02 PM\n Dialysis Catheter - 04:56 PM\n Arterial Line - 01:30 PM\n 20 Gauge - 11:15 AM\n Prophylaxis:\n DVT: pneumoboot on right arm\n Stress ulcer: on PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition : icu\n Total time spent: 42\n" }, { "category": "Physician ", "chartdate": "2131-05-21 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 675843, "text": "Chief Complaint:\n 24 Hour Events:\n Started meropenem\n D/c'd R femoral line\n D/c'd maintenence fluids, bolused prn hypotension\n ESOPHOGEAL BALLOON - At 08:45 AM\n CORDIS/INTRODUCER - STOP 02:05 PM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Meropenem - 12:15 AM\n Infusions:\n Fentanyl (Concentrate) - 300 mcg/hour\n Midazolam (Versed) - 20 mg/hour\n Phenylephrine - 5 mcg/Kg/min\n Other ICU medications:\n Pantoprazole (Protonix) - 08:41 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 05:19 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: 36.8\nC (98.3\n HR: 100 (94 - 106) bpm\n BP: 89/67(77) {72/47(56) - 104/68(79)} mmHg\n RR: 30 (0 - 30) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 111.3 kg (admission): 113.5 kg\n Height: 67 Inch\n CVP: 28 (19 - 35)mmHg\n Total In:\n 6,683 mL\n 1,180 mL\n PO:\n TF:\n IVF:\n 6,638 mL\n 1,180 mL\n Blood products:\n Total out:\n 416 mL\n 94 mL\n Urine:\n 416 mL\n 94 mL\n NG:\n Stool:\n Drains:\n Balance:\n 6,267 mL\n 1,086 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 30\n RR (Spontaneous): 0\n PEEP: 24 cmH2O\n FiO2: 70%\n RSBI Deferred: PEEP > 10, FiO2 > 60%, Hemodynamic Instability\n PIP: 46 cmH2O\n Plateau: 42 cmH2O\n Compliance: 23.5 cmH2O/mL\n SpO2: 97%\n ABG: 7.30/40/82./18/-5\n Ve: 11.7 L/min\n PaO2 / FiO2: 119\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 51 K/uL\n 11.0 g/dL\n 100 mg/dL\n 1.8 mg/dL\n 18 mEq/L\n 3.9 mEq/L\n 15 mg/dL\n 100 mEq/L\n 129 mEq/L\n 32.0 %\n 18.5 K/uL\n [image002.jpg]\n 04:55 AM\n 08:07 AM\n 10:04 AM\n 12:04 PM\n 02:30 PM\n 06:50 PM\n 09:15 PM\n 10:34 PM\n 02:42 AM\n 03:01 AM\n WBC\n 16.5\n 18.5\n Hct\n 31.5\n 31.4\n 32.0\n Plt\n 69\n 51\n Cr\n 2.2\n 1.8\n TCO2\n 22\n 21\n 22\n 21\n 21\n 20\n 20\n Glucose\n 108\n 107\n 97\n 100\n Other labs: PT / PTT / INR:20.9/47.6/2.0, ALT / AST:94/271, Alk Phos /\n T Bili:200/14.0, Amylase / Lipase:45/268, Lactic Acid:2.4 mmol/L,\n Albumin:2.2 g/dL, LDH:616 IU/L, Ca++:7.7 mg/dL, Mg++:1.9 mg/dL, PO4:2.4\n mg/dL\n Assessment and Plan\n HYPOTENSION (NOT SHOCK)\n HEPATITIS, ACUTE TOXIC (INCLUDING ALCOHOLIC, ACETAMINOPHEN, ETC.)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ALCOHOL WITHDRAWAL (INCLUDING DELIRIUM TREMENS, DTS, SEIZURES)\n PANCREATITIS, ACUTE\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Arterial Line - 01:35 PM\n Multi Lumen - 02:02 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": "2131-05-22 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 676229, "text": "Chief Complaint:\n 24 Hour Events:\n - Restarted levophed.\n - weaned levo to 0.02\n - elevated ddimer, high fdps, high fibrinogen\n - wbc to 24, blood, urine, cdiff\n - albumin given\n - abx continued\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Meropenem - 05:54 AM\n Infusions:\n Norepinephrine - 0.02 mcg/Kg/min\n Phenylephrine - 5 mcg/Kg/min\n Fentanyl (Concentrate) - 300 mcg/hour\n Midazolam (Versed) - 20 mg/hour\n Other ICU medications:\n Pantoprazole (Protonix) - 08:22 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:06 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.4\nC (99.4\n Tcurrent: 37.2\nC (98.9\n HR: 101 (101 - 108) bpm\n BP: 105/62(77) {92/59(71) - 117/81(94)} mmHg\n RR: 15 (0 - 30) insp/min\n SpO2: 94%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 156 kg (admission): 113.5 kg\n Height: 67 Inch\n CVP: 23 (14 - 27)mmHg\n Bladder pressure: 20 (19 - 24) mmHg\n Total In:\n 2,817 mL\n 835 mL\n PO:\n TF:\n IVF:\n 2,817 mL\n 735 mL\n Blood products:\n 100 mL\n Total out:\n 830 mL\n 508 mL\n Urine:\n 530 mL\n 208 mL\n NG:\n 300 mL\n 100 mL\n Stool:\n Drains:\n 200 mL\n Balance:\n 1,987 mL\n 327 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 30\n RR (Spontaneous): 5\n PEEP: 24 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10\n PIP: 44 cmH2O\n Plateau: 40 cmH2O\n Compliance: 33.3 cmH2O/mL\n SpO2: 94%\n ABG: 7.29/38/86/18/-7\n Ve: 12.4 L/min\n PaO2 / FiO2: 172\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 61 K/uL\n 10.6 g/dL\n 94 mg/dL\n 3.0 mg/dL\n 18 mEq/L\n 4.3 mEq/L\n 18 mg/dL\n 102 mEq/L\n 133 mEq/L\n 32.9 %\n 24.4 K/uL\n [image002.jpg]\n 12:04 PM\n 02:30 PM\n 06:50 PM\n 09:15 PM\n 10:34 PM\n 02:42 AM\n 03:01 AM\n 02:11 PM\n 08:20 PM\n 02:39 AM\n WBC\n 16.5\n 18.5\n 24.4\n Hct\n 31.5\n 31.4\n 32.0\n 34.0\n 32.9\n Plt\n 69\n 51\n 61\n 61\n Cr\n 2.2\n 1.8\n 2.1\n 3.0\n TCO2\n 21\n 21\n 20\n 20\n 19\n Glucose\n 107\n 97\n 100\n 103\n 94\n Other labs: PT / PTT / INR:20.9/47.6/2.0, ALT / AST:69/194, Alk Phos /\n T Bili:218/16.7, Amylase / Lipase:17/28, Differential-Neuts:64.0 %,\n Band:2.0 %, Lymph:11.0 %, Mono:8.0 %, Eos:3.0 %, D-dimer: ng/mL,\n Fibrinogen:402 mg/dL, Lactic Acid:2.1 mmol/L, Albumin:2.3 g/dL, LDH:494\n IU/L, Ca++:7.9 mg/dL, Mg++:2.2 mg/dL, PO4:2.7 mg/dL\n Assessment and Plan\n HYPOTENSION (NOT SHOCK)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n PANCREATITIS, ACUTE\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Arterial Line - 01:35 PM\n Multi Lumen - 02:02 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": "2131-05-24 00:00:00.000", "description": "Nursing Progress Note", "row_id": 676648, "text": "Pancreatitis, acute\n Assessment:\n T max 101.0\n Pupils large ~ 7mm, some times brisk, some times sluggish\n Noted cerebral edema on CT scan\n Noted to have left facial twitch, appears to be seizure\n activity.\n RR in 40\ns prior to interventions to lower cerebral edema\n Fluid balance MN\n 0600 +464, LOS + 58 liters of fluid\n Anasarca, legs with 3^rd spaced blisters weeping large\n amount of unquantifiable fluid loss\n WBC count significant increase\n Elevated ammonia level\n Sedated on Fentanyl and Midazolam\n Action:\n Blood cultures x1 from central line\n Hypertonic saline x1\n Ativan 4mg x1\n Loaded with Keppra x1\n Attempted to weigh patient, bed scale not working\n Bed on q 20 minute turning, as well as full turn and linen\n change q 4 hours, frequent linen changes under extremities.\n VAP protocol\n Antibiotics ATC\n Levophed weaned off\n Response:\n Pupils still are dilated, brisk to sluggish\n Respiratory rate improved to ~ 30 after intervention\n No further skin breakdown noted\n MAP remains > 65 off levophed, remains on Neo\n Plan:\n ? CRRT today for rising creatinine, rising fluid overload\n ? bolt to monitor known cerebral edema\n ? further hypertonic saline administration due to cerebral\n edema\n Contact bed company to fix bed scale is this is a very\n necessary assessment\n Continued patient and family support\n Social work\n" }, { "category": "Nursing", "chartdate": "2131-06-01 00:00:00.000", "description": "Nursing Progress Note", "row_id": 678144, "text": "Sepsis, Severe (with organ dysfunction)\n Assessment:\n Temp 101. tachy 120st, rr40-50 sb/p 86/\n Cvp 12-15. min. urine output\n Scant dark icteric urines.\n Action:\n Tylenol 650mg via ngt. Cool bath given Bld cx x2\n Cxr done. Levo titrated to keep map>60\n Crrt running w/ no problems removing -50-100cc.\n se:\n With temp down to 98.0-> hr low 100\ns and b/p stable-very levo\n dependent but weaned down slightly\n Pt 1200cc negative fliud balance yesterday.\n Plan:\n Cont. to remove fliud as tolerated without having to increase pressor\n Check pending cx\n Gastrointestinal bleed, upper (Melena, GI Bleed, GIB)\n Assessment:\n Abd. Distended. Ngt drge clear yellow mod amt\n Bm x1-tarry black stool\n Action:\n Hcts check q6hrs.\n Response:\n Hct stable 24.0-23.8\n Plan:\n Cont to monitor for signs of bleeding.\n" }, { "category": "Nursing", "chartdate": "2131-06-03 00:00:00.000", "description": "Nursing Progress Note", "row_id": 678464, "text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n - Received on CMV 50 % 400x30 PEEP 12\n - RR 30-34\n - O2SAT > 97%\n - No apparent distress\n - Well sedated\n Action:\n - Aggressivley titrated up on sedation with multiple bolus of fentanyl\n and versed per MICU HO who was in attendance at this time\n - Fentanyl gtt up to 400 mcg (from 75mcg) /hr and Versed at 20 (up\n from 12) mg/hr.\n - Pharmacy contaced re: effect from po naloxone ( started this\n afternoon to increase GI motility) on sedation\n - MICU HO contact as opiod blocking effects could not be ruled out\n despite low dose naloxone\n - Naloxone dose held overnight and raglan gave instead per order\n - No acute changes on CXR\n Response:\n - Over night pt slowly became more adequately sedated\n - RR down to high 30\n low 40\n - PIP\ns down to mid 20\n - Patient appears much more comfortable\n - ABG\ns remain acceptable\n Plan:\n Follow up with team this morning regarding possiblilty of naloxone\n effect and maybe switch to standing raglan. Continue to titrate down on\n sedation as tolerated. Provide support to patient and family.\n Impaired Skin Integrity\n Assessment:\n - Multiple blistered and open areas on blu and right side of abdomen\n - Red and darkened areas on bil heels\n Action:\n - Skin care per wound care nurses recommendations\n - On rotating bed for respiratory and skin protection\n - Manual turn q4 for back care and linen change\n - Daptomycin started per ID recomondations for suspected cellulitis to\n BLE\n Response:\n - No changes in skin integrity this shift\n Plan:\n Continue on constant rotation, turn and assess skin prn, dressing\n changes per wound care\ns recommendations. Dermatology and ID\n following.\n Sepsis, Severe (with organ dysfunction)\n Assessment:\n Received on levophed at 0.175 mcg/kg\n CRRT running with even fluid balance this evening\n WBC 28 this am\n Labs concerning for DIC\n HCT 26 post transfusion ( up from 22)PLT 63\n Action:\n Levophed titrated down to .03 mcg/kg this am\n Able to removed 100-150 cc/fluid an hour\n Hematology consulted\n Smear sent to for eval by hematology\n Response:\n BP stable\n HCT 24 this am ,PLT 53\n No signs/symtoms of large blood loss\n Stools + occult blood but no obvious blood noted\n Plan:\n Continue to take off fluid as tolerated, titrate levophed, awaiting\n hematology and dic work up.\n" }, { "category": "Respiratory ", "chartdate": "2131-05-21 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 675845, "text": "Demographics\n Day of intubation: 4\n Day of mechanical ventilation: 4\n Ideal body weight: 67.1 None\n Ideal tidal volume: 268.4 / 402.6 / 536.8 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location: ICU\n Reason: Re-intubation\n Tube Type\n ETT:\n Position: 22 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 28 cmH2O\n Cuff volume: 6 mL / Air\n Lung sounds\n RLL Lung Sounds: Crackles\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Crackles\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: Utilize ARDSnet protocol, Maintain PEEP at current\n level and reduce FiO2 as tolerated\n Reason for continuing current ventilatory support: Underlying illness\n not resolved\n" }, { "category": "Nursing", "chartdate": "2131-05-22 00:00:00.000", "description": "Nursing Progress Note", "row_id": 676198, "text": "TITLE:\n Hypotension (not Shock)\n Assessment:\n mean bp fluctuating between 60-70. Neosynephrine at 5mcg/kg/m and\n levophed 0.02. Uop marginal at 15-20cc/hr, with 1 hr episode no urine\n output (foley patent & irrigated freely)\n Action:\n levophed titrated to 0.04 mcg to achieve goal mbp >70, uop still\n remained low, albumin 25gm iv x1\n Response:\n decreased levo to 0.03 mcg\nmbp still >70. little urinary output\n response to albumin. Creat rising 3.0 today.Wt increased 8kg in 24hrs\n Plan:\n Needs evaluation for crrt.\ntotal body weight increase 43Kg since\n adm.Wean levophed before neo for goal mbp >70 .\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Remains sedated on fentanyl 225mcg and versed 20 mg/hr/PaO2 86 on fio2\n 60% peep24.O2sats 94-96% bbs coarse to clear upper lobes diminish lower\n lobes bilat. Triadyne w rotation/percussion continues with\n readjustments made to Lt side > rt side rotation\n Action:\n HO made aware abg results->fio2 decr to 50%, per Dr , follow O2\n sats no need to repeat abg if sat > 94%. Suctioning for sm amts of\n bilious. Vap bundle, suct orally for sm amts frothy blood tinge\n secretions.\n Response:\n Breath sounds clearer after suctioning (tolerated well w/o desats).\n Tolerating change in rotation. Sats > 94% on 50%\n Plan:\n Cont to wean fio2 as tol..Wean fentanyl as tolerated allowing\n 1-2breaths over set rate max.. Vap bundle.\n Pancreatitis, acute\n Assessment:\n Abd firm distended no active bowel sounds present. Ngt to lws w bilious\n to brown drainage.\n Action:\n Protonix . Bladder pressure 19 overnight. Lft\ns sent w am labs. D\n dimer elevated\n Response:\n Ast , alt and alk phos trending down. Total bili increased to 16.7\n today\n Plan:\n Continue to follow bladder pressures. Monitor labs. Monitor for signs\n of bleeding.\n" }, { "category": "Nursing", "chartdate": "2131-05-24 00:00:00.000", "description": "Nursing Progress Note", "row_id": 676641, "text": " Problem\n altered neurological function\n Assessment:\n Without corneal/gag and cough reflexed.\n Pupiles , reactive (left brisk, right sluggish)\n Concern for cerebral edema\n Seizure activity with twitching of eyes/forehead and right arm\n Action:\n Head CT done\n Neuro consulted\n Versed 6 mg/ Ativan 4 mg given\n Response:\n Neuro at bedside at this \n further seizure activity since loraz. given\n Awaiting recommendations.\n Plan:\n Follow neuro recommendations.\n Impaired Skin Integrity\n Assessment:\n Multiple areas of open/broken blisters on arms/legs\n Action:\n Areas left open to drain\n Covered with pads to absorb drainage\n Response:\n Tolerating well\n No areas of infection noted\n Plan:\n Nystatin order for groin.\n Continue to allow skin to drian.\n Hypotension (not Shock)\n Assessment:\n On neo and levo .04\n Maintaining sbp>100\n Action:\n Keeping pressors at current does\n Only wean if significant increase in blood pressure.\n Response:\n Stable\n Plan:\n Pressors as needed\n Call MICU team with any hypotension\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Vented on CMV ./+24\n Action:\n No changes in vent\n Response:\n Gases stable\n Plan:\n Keep on current settings.\n" }, { "category": "Physician ", "chartdate": "2131-06-01 00:00:00.000", "description": "ICU Attending Note", "row_id": 678269, "text": "MICU ATTENDING NOTE\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, including assessment and plan.\n 28M with necrotizing pancreatitis (30-40% necrosis via CT), ARDS,\n septic shock, renal failure. Head CT revealed edema, treated with 23%\n NS for induced osmorx, stopped .\n Events:\n episode of awakening, followed command to wiggle fingers\n no transfusions yesterday, hct 25.7--> 23.8%\n platelets roughly stable at 63K\n low grade fever\n 110/60 108\n AC 0.5/400/30/12 100% 7.46/35/75\n 10L/11.3L (135cc urine)\n more alert\n anasarca, but improved\n LFTs, bili stable\n abd CT final read: diffuse colon wall thickening, no sig change in\n pancreas but new 3x3 cm pseudocyst\n head CT: improved edema, opacification of paranasal sinuses\n CXR no sig change\n * Resp failure, ARDS slow progress on PEEP. Request trach, though\n will likely not be done until PEEP <10.\n * Septic shock, remains levophed dependent, with occasional\n fluctuations in dose but essentially stable.\n * Exam indicates mental status improving, trying to minimize sedation\n * Sedation- versed 2, fent 50. Stop versed, reevaluate, bolus as\n needed. PO narcan for prolonged fentanyl.\n * Thrombocytopenia present since . Improved/stable since ,\n off heparin in TPN.\n * Anemia: continue close monitoring with q8 hct, transfuse for <22\n * Pancreatitis- pseudocyst\n * Spiking low grade temps, off flagyl , off meropenem . Fever\n attributable to pancreatitis. Sinus consolidation unchanged since\n prior head CT, colitis evident on CT. Minimal stool but will try to\n send for CDiff. No sig resp secretions. Plan to hold off on\n restarting antibiotics, but will d/w ID.\n * Nutrition, on TPN, discuss trophic feeds with nutrition and\n increase insulin in TPN\n * No clear source of bleed. NG lavage neg. Brown, g+ stool. No blood\n from ETT. Repeat DIC labs. be due to oozing from known\n gastritis. If continues to require transfusions today will consult\n hematology.\n * Skin breakdown- wound service recs.\n * Renal failure, on CVVHD. Much less anasarca.\n 50 minutes critical care time\n" }, { "category": "Nursing", "chartdate": "2131-06-02 00:00:00.000", "description": "Nursing Progress Note", "row_id": 678336, "text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n Impaired Skin Integrity\n Assessment:\n Action:\n Response:\n Plan:\n Sepsis, Severe (with organ dysfunction)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Physician ", "chartdate": "2131-05-22 00:00:00.000", "description": "Physician Resident/Attending Progress Note - MICU", "row_id": 676337, "text": "Chief Complaint:\n 24 Hour Events:\n - Restarted levophed.\n - weaned levo to 0.02\n - elevated ddimer, high fdps, high fibrinogen\n - wbc to 24, blood, urine, cdiff\n - albumin given\n - abx continued\n - bladder pressure at 20\n - FIO2 decreased from 60 to 50% at 9pm\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Meropenem - 05:54 AM\n Infusions:\n Norepinephrine - 0.02 mcg/Kg/min\n Phenylephrine - 5 mcg/Kg/min\n Fentanyl (Concentrate) - 300 mcg/hour\n Midazolam (Versed) - 20 mg/hour\n Other ICU medications:\n Pantoprazole (Protonix) - 08:22 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:06 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.4\nC (99.4\n Tcurrent: 37.2\nC (98.9\n HR: 101 (101 - 108) bpm\n BP: 105/62(77) {92/59(71) - 117/81(94)} mmHg\n RR: 15 (0 - 30) insp/min\n SpO2: 94%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 156 kg (admission): 113.5 kg\n Height: 67 Inch\n CVP: 23 (14 - 27)mmHg\n Bladder pressure: 20 (19 - 24) mmHg\n Total In:\n 2,817 mL\n 835 mL\n PO:\n TF:\n IVF:\n 2,817 mL\n 735 mL\n Blood products:\n 100 mL\n Total out:\n 830 mL\n 508 mL\n Urine:\n 530 mL\n 208 mL\n NG:\n 300 mL\n 100 mL\n Stool:\n Drains:\n 200 mL\n Balance:\n 1,987 mL\n 327 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 30\n RR (Spontaneous): 5\n PEEP: 24 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10\n PIP: 44 cmH2O\n Plateau: 40 cmH2O\n Compliance: 33.3 cmH2O/mL\n SpO2: 94%\n ABG: 7.29/38/86/18/-7\n Ve: 12.4 L/min\n PaO2 / FiO2: 172\n Physical Examination\n Gen: sedated\n HEENT: intubated\n Chest: coarse BS bl\n CV: distant heart sounds, RRR, S1S2\n Abd: distended, abdominal wall edema\n Ext: anasarca throughout\n Labs / Radiology\n 61 K/uL\n 10.6 g/dL\n 94 mg/dL\n 3.0 mg/dL\n 18 mEq/L\n 4.3 mEq/L\n 18 mg/dL\n 102 mEq/L\n 133 mEq/L\n 32.9 %\n 24.4 K/uL\n [image002.jpg]\n 12:04 PM\n 02:30 PM\n 06:50 PM\n 09:15 PM\n 10:34 PM\n 02:42 AM\n 03:01 AM\n 02:11 PM\n 08:20 PM\n 02:39 AM\n WBC\n 16.5\n 18.5\n 24.4\n Hct\n 31.5\n 31.4\n 32.0\n 34.0\n 32.9\n Plt\n 69\n 51\n 61\n 61\n Cr\n 2.2\n 1.8\n 2.1\n 3.0\n TCO2\n 21\n 21\n 20\n 20\n 19\n Glucose\n 107\n 97\n 100\n 103\n 94\n Other labs: PT / PTT / INR:20.9/47.6/2.0, ALT / AST:69/194, Alk Phos /\n T Bili:218/16.7, Amylase / Lipase:17/28, Differential-Neuts:64.0 %,\n Band:2.0 %, Lymph:11.0 %, Mono:8.0 %, Eos:3.0 %, D-dimer: ng/mL,\n Fibrinogen:402 mg/dL, Lactic Acid:2.1 mmol/L, Albumin:2.3 g/dL, LDH:494\n IU/L, Ca++:7.9 mg/dL, Mg++:2.2 mg/dL, PO4:2.7 mg/dL\n 8:20p\n _______________________________________________________________________\n pH\n 7.29\n pCO2\n 38\n pO2\n 86\n HCO3\n 19\n BaseXS\n -7\n HEPARIN DEPENDENT ANTIBODIES\n Results Pending\n Assessment and Plan\n Mr. is a 28 year old gentleman with alcoholic hepatitis and\n necrotizing pancreatitis complicated by ARDS, SIRS, and UGIB.\n # Respiratory Failure: ARDS secondary to necrotizing pancreatitis\n compounded by hypoxia, tachypnea in setting of anion gap metabolic\n acidosis, increased abdominal pressure, and EtOH withdrawl. Rising WBC\n could also suggest secondary VAP. Patient w/ some dysychrony w/\n reduction of sedation.\n - Continue current vent settings for now, recheck ABG\n - intra-abdominal pressures improved\n - Begin to wean sedation as tolerated. Would prefer to wean down\n fentanyl and then midaxolam.\n - send sputum Cx\n # Necrotizing pancreatitis/SIRS: Likely secondary to alcohol\n complicated by SIRS. Patient continues to have pressor requirement,\n with neo +/- levo. Volume resucsitation with >54L.\n - Continue empiric meropenem for now.\n - Wean pressors as able, starting with levophed\n - no improvement with albumin trial yesterday\n - Monitor chemistries.\n - Continue to hold MIVF, boluses PRN\n - Follow-up with recs if any\n # Acute renal failure: Creatinine continues to trend up with oliguria,\n likely secondary to SIRS/hypotension and IABP leading to ATN. Cr now\n up to 3.0\n - Urine lytes, eos, osm sent yesterday\n - renal c/s, w/ likely need for CVVH in the near future\n - Trend UOP, bolus IVF to maintain goal >20 cc/hr.\n # Leukocytosis: Rise of WBC to 24 from 16 two days prior. Patient has\n been afebrile, but have concern for a potential blossoming infection\n already on meropeneum. Will resend cultures and have low threshold to\n started coverage for potential line infection.\n #Thrombocytopenia: platelets trending down, but pleatued today. No\n clear etiology at this time. DIC panel negative, and HIT antibody\n pending.\n # IAP elevation: Secondary to third spacing and edema. Per surgery, not\n a good surgical candidate at this time.\n # Acute hepatitis: Likely alcoholic hepatitis with fatty infiltration,\n and no evidence of distal obstruction. RUQ u/s shows marked liver\n echogenicity but no ascites.\n - Trend LFTs\n # Hematemesis: EGD showed diuelafoy's lesion. HCT stable since 2 units\n PRBC on .\n - Trend hct, transfuse for hct<21\n # Hyponatremia: In setting of decreased effective circulating volume in\n setting of SIRS and IABP.\n - Trend chemistries.\n # Alcoholism: Patient describes history of withdrawal symptoms, but\n not prior seizure. Last drink was night prior to presentation.\n Tachycardia, weakness, and elevated lactate could be consistent with\n thiamine deficiency.\n - Thiamine, vb12, folate\n - Valium with CIWA > 10\n FEN: IVF, replete electrolytes, NPO. Would consider starting TPN after\n 5-7 days. If patient has no significant change over the next 1-2 days,\n may begin TPN on approximately . Getting nutrition recs, and will\n setting if want to do TPN vs. post-jejunum NG. Feel pt likely too\n unstable to have NG placed in IR.\n PPx: SCDs, PPI\n Access: RIJ, right radial art line.\n Code: Full Code\n Dispo: ICU level of care.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Arterial Line - 01:35 PM\n Multi Lumen - 02:02 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n ------ Protected Section ------\n MICU ATTENDING ADDENDUM\n I saw and examined the patient, and was physically present with the ICU\n team for the key portions of the services provided. I agree with the\n note above, including the assessment and plan. I would emphasize and\n add the following points: 28M EtOH abuse, weakness, fatigue, UGIB c/b\n hematemesis / melena. Has developed massive fluid requirement,\n hypotension, ARDS in the setting of severe pancreatitis, alcoholic\n hepatitis and borderline renal function. Creatinine up o/n, as is WBC.\n Off levophed, UOP up slightly, FiO2 requirement is drifiting down.\n Exam notable for Tm 99.4 BP 103/68 HR 110 RR 35 with sat 100 on VAC\n 400x30/24 0.5 24 7.29/38/86 CVP 23 IAP 20. +TBB 55L. Sedated, min\n responsive. Hyperdynamic. Bronchial BS B. RRR s1s2. Distended, minimal\n bowel sounds. Massive edema. Labs notable for WBC 24K, HCT 32, K+ 4.1,\n Cr 3.0, lactate 2.1, INR 2.0. CXR with worsening ARDS R>L.\n Agree with plan to manage respiratory failure with low volume\n ventilation for ARDS (400x30); will attempt to wean PEEP if we can keep\n FiO2 <0.5. For , hold on further fluids and give albumin for\n volume expansion if UOP <20cc/h. ARF is progressive though UOP is up\n slightly this AM. Will notify renal of his issues, may need to consider\n CVVH, RD meds. WBC is up - will recheck this PM, pancx, and start vanco\n if he spikes or if WBC continues to rise. Pancreatitis likely due to\n EtOH, NPO, following; will continue meropenem for now. Can't use\n gut for now; may need TPN in the next few days. Alcoholic hepatitis is\n improving by numbers\n will provide supportive care and follow labs\n while holding off on steroids given ongoing GIB. UGIB from Dieulafois\n lesion at GEJ appears stable, will monitor serial HCT and continue PPI\n IV. Thrombocytopenia is stable, await HIT. Above d/w family in family\n mtg. Remainder of plan as outlined above.\n Patient is critically ill\n Total time: 60 min\n ------ Protected Section Addendum Entered By: , MD\n on: 04:39 PM ------\n" }, { "category": "Nursing", "chartdate": "2131-05-22 00:00:00.000", "description": "Nursing Progress Note", "row_id": 676344, "text": "Impaired Skin Integrity\n Assessment:\n - Pt has generalized anasarca with a tbb of +55 L. Patient\n posterior side is intact, but patient\ns lower extremities are extremely\n fluid overloaded and patient has diffuse blistering throughout lower\n extremities, oozing serous fluid.\n - Patient has two old puncture sites, one in R antecubital\n (former peripheral IV site) and one in R groin (former cordis site)\n draining serous fluid.\n Action:\n - Lower extremities cleansed with normal saline; gently patted\n dry; adaptic/Vaseline gauze and softsorb applied and covered with net\n mesh to keep softsorbs intact.\n - Both puncture sites covered with drainage bags to catch\n serous output.\n Response:\n - Patient\ns blistering/oozing of serous fluid remains.\n - Drainage bags on puncture sites intact/surrounding skin\n appears intact.\n Plan:\n - Continue cleanse/treatment, relieve areas of pressure, ?\n consult wound care nurse for further treatment.\n - Continue to monitor skin integrity.\n Hypotension (not Shock)\n Assessment:\n - Pt on max neo and low dose levo to achieve MAP >70\n - Urine output average 25 cc/hour\n Action:\n - Levophed weaned to off this morning\n Response:\n - After several hours off levo, patient\ns MAP dropped to\n 60-65 and correspondingly, urine output\n Decreased to 10-11 cc/hour, so levo turned back on to\n 0.02\n Plan:\n - Continue to keep MAP >70, monitor perfusion, urine output\n Respiratory failure, acute (not ARDS/)\n Assessment:\n - This morning, patient dysynchronous and overbreathing\n ventilator by 5-7 breaths per minute.\n - Lung sounds rhonchorous, diminished in bases\n Action:\n - Increased patient\ns fentanyl gtt to 300 from 225 to improve\n synchrony with vent\n - Adjusted patient\ns position into modified swimmer\n position, left side down, to help aerate R lung and improve perfusion\n with L lung\n - Moved patient onto a larger bed to provide more efficient\n rotating\n - Sent sputum culture\n Response:\n - ABG improved to 122 from 86\n - Patient more synchronous with vent\n - Tolerating rotating\n Plan:\n - No vent changes for today\n - Follow up sputum culture.\n Pancreatitis, acute\n Assessment:\n - Abd firm distended no active bowel sounds present. Ngt to lws w\n bilious to brown drainage, lightening up slightly as shift continues.\n Action:\n - Bladder pressure 20 this shift. Repeated CBC/lytes\n pending.\n Nutrition consulted.\n Response:\n - Team expects patient\ns bilirubin to remain elevated for a long time\n (up to weeks) r/t pancreatitis.\n Plan:\n - Continue to follow bladder pressures. Monitor labs. Monitor for signs\n of bleeding. ? TPN versus jejunum feeding\n per MICU attending will\n decide on this matter tomorrow. Surgery still consulting.\n" }, { "category": "Physician ", "chartdate": "2131-05-24 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 676638, "text": "Chief Complaint:\n 24 Hour Events:\n - Had loss of /white matter differentiation on head ct, concern for\n cerebral edema. also had eye twitching at head CT suggestive of\n seizure. resolved with ativan 4 iv x 1, recurred later and responded\n to ativan 4 iv. neuro consulted and recc'd keppra (loaded), hypertonic\n saline (given; note in OMR), EEG on .\n - Ammonia 216 -> neuro thought ?ammonia-induced intracerebral edema,\n neurosurg c/s at their request for possible ICP monitor placement but\n neurosurg declined given elevated INR, wanted to see if hypertonic\n saline would work. mannitol avoided given renal failure.\n - Spiked at 1 a.m. -> bcx\n - Started flagyl for bowel wall thickening/possible colitis on abd CT\n - CT Chest with multifocal infiltrates\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 09:11 AM\n Metronidazole - 02:45 AM\n Meropenem - 06:21 AM\n Infusions:\n Fentanyl (Concentrate) - 400 mcg/hour\n Phenylephrine - 4.8 mcg/Kg/min\n Other ICU medications:\n Pantoprazole (Protonix) - 08:00 PM\n Lorazepam (Ativan) - 08:20 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:52 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.3\nC (101\n Tcurrent: 37.3\nC (99.2\n HR: 96 (96 - 113) bpm\n BP: 111/63(79) {86/52(67) - 120/71(86)} mmHg\n RR: 30 (8 - 40) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 156 kg (admission): 113.5 kg\n Height: 67 Inch\n CVP: 26 (20 - 26)mmHg\n Bladder pressure: 26 (26 - 26) mmHg\n Total In:\n 2,555 mL\n 709 mL\n PO:\n TF:\n IVF:\n 2,555 mL\n 709 mL\n Blood products:\n Total out:\n 643 mL\n 252 mL\n Urine:\n 343 mL\n 52 mL\n NG:\n 300 mL\n 200 mL\n Stool:\n Drains:\n Balance:\n 1,912 mL\n 457 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 30\n RR (Spontaneous): 0\n PEEP: 24 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10\n PIP: 42 cmH2O\n Plateau: 37 cmH2O\n Compliance: 30.8 cmH2O/mL\n SpO2: 98%\n ABG: 7.25/45/117/18/-7\n Ve: 11.8 L/min\n PaO2 / FiO2: 234\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 99 K/uL\n 10.0 g/dL\n 142 mg/dL\n 3.8 mg/dL\n 18 mEq/L\n 4.4 mEq/L\n 27 mg/dL\n 104 mEq/L\n 132 mEq/L\n 30.4 %\n 38.9 K/uL\n [image002.jpg]\n 05:04 PM\n 05:54 PM\n 10:25 PM\n 03:01 AM\n 03:09 AM\n 03:21 PM\n 03:39 PM\n 06:30 PM\n 01:22 AM\n 01:32 AM\n WBC\n 30.5\n 29.3\n 38.9\n Hct\n 32.2\n 31.7\n 31.0\n 30.4\n Plt\n 66\n 64\n 99\n Cr\n 3.2\n 3.2\n 3.7\n 3.8\n TCO2\n 18\n 19\n 20\n 18\n 21\n Glucose\n 106\n 93\n 100\n 84\n 78\n 105\n 142\n Other labs: PT / PTT / INR:18.6/41.5/1.7, ALT / AST:37/219, Alk Phos /\n T Bili:218/20.6, Amylase / Lipase:16/37, Differential-Neuts:75.0 %,\n Band:0.0 %, Lymph:4.0 %, Mono:12.0 %, Eos:6.0 %, D-dimer: ng/mL,\n Fibrinogen:402 mg/dL, Lactic Acid:1.9 mmol/L, Albumin:2.1 g/dL, LDH:624\n IU/L, Ca++:8.0 mg/dL, Mg++:2.6 mg/dL, PO4:3.8 mg/dL\n Imaging: CT Torso:\n 1. New multifocal airspace consolidation, suspicious for acute\n infiltrates.\n 2. Diffuse colonic wall thickening, which could reflect colitis.\n 3. Diffuse soft tissue edema.\n 4. Peripancreatic stranding, in keeping with pancreatitis. Extent of\n necrosis cannot be evaluated on a non-contrast exam. There are no new\n peripancreatic fluid collections.\n CTH:\n 1. Diffuse loss of -white matter differentiation concerning for\n global\n hypoxia or edema with hypodensities in bilateral thalami.\n 2. No hemorrhage, mass effect, or herniation.\n 3. Fluid seen in bilateral temporal subcutaneous tissue. Near-complete\n opacification of bilateral mastoid, maxillary, frontal, and ethmoid\n sinuses.\n Assessment and Plan\n Mr. is a 28 year old gentleman with alcoholic hepatitis and\n necrotizing pancreatitis complicated by ARDS, SIRS, and UGIB.\n # Neuro: Patient with dilated pupils on high dose fentaynl gtt. CTH\n yesterday demonstrated loss of grey white differentiation with\n questionable effacement and possible seizure activity. Neuro and\n neurosurg consulted and patietn received ativan, keppra load, and\n hypertonic saline of hyponatremia.\n - Follow-up with neuro regarding keppra maintenance dose\n - EEG today\n - Follow-up with neurosurg recs and for possible ICP monitor.\n # Respiratory Failure: ARDS secondary to necrotizing pancreatitis\n compounded by hypoxia, tachypnea in setting of anion gap metabolic\n acidosis, increased abdominal pressure, and EtOH withdrawl.\n - Continue current vent settings\n - Continue to monitor IAP\n - Wean sedation as tolerated. Would prefer to wean down fentanyl and\n then midaz.\n - send sputum Cx\n - Continue vanco, meropenem, flagyl\n # Leukocytosis: WBC up to 38.9 today. Patient continues to be\n afebrile. Concern for CVL infection, VAP, loculated effusion, or\n necrotizing pancreatitis complication including abscess formation. CT\n chest with multifocal infiltrates that could represent VAP vs ARDS.\n CTAP did not demonstrate any new pancreatic fluid collections. Patient\n spiked overnight and was started on flagyl.\n - Continue empiric vancomycin, meropenem, and flagyl AM vanco level\n today\n - Follow-up culture data\n # Necrotizing pancreatitis/SIRS: Likely secondary to alcohol\n complicated by SIRS and ARDS. Patient continues to have pressor\n requirement, with neo +/- levo. Aggressive volume resucsitation with\n >58L. Patient without improvement with albumin trial, likely\n secondary to SIRS and increased vascular permeability.\n - Continue empiric antimicrobials.\n - Wean pressors as able, starting with levophed\n - Monitor chemistries.\n - Continue to hold MIVF, boluses PRN to maintain UOP>20 cc/hr although\n increase pressors first.\n - Follow-up with recs if any\n # Hyponatremia: In setting of decreased effective circulating volume in\n setting of SIRS and IABP. Patient received hypertonic saline overnight\n per neurosurgery. Serum sodium stable this morning.\n - Trend chemistries.\n - Hold on additional hypertonic saline pushes given minimal benefit in\n hyponatremia correction.\n - Follow-up with neurosurgery recs if any.\n # Acute renal failure: Creatinine continues to trend up to 3.2 with\n oliguria, likely secondary to SIRS/hypotension and IABP leading to\n ATN. Appreciate renal recs - urine sediment consistent with ATN.\n - Follow-up renal recs, patient likely candidate for CVVH as\n creatinine, lytes, and BUN continue to rise.\n - Trend UOP, bolus IVF to maintain goal >20 cc/hr.\n #Thrombocytopenia: Platelets trending down over hospital course but\n stable today. No clear etiology at this time. DIC panel and HIT PF4\n antibody negative.\n - Trend plt\n # IAP elevation: Secondary to third spacing and edema. Per surgery, not\n a good surgical candidate at this time.\n # Acute hepatitis: Likely alcoholic hepatitis with fatty infiltration,\n and no evidence of distal obstruction. RUQ u/s shows marked liver\n echogenicity but no ascites.\n - Trend LFTs\n # Hematemesis: EGD showed diuelafoy's lesion. HCT stable since 2 units\n PRBC on .\n - Trend hct, transfuse for hct<21\n # Alcoholism: Patient describes history of withdrawal symptoms, but\n not prior seizure. Last drink was night prior to presentation.\n Tachycardia, weakness, and elevated lactate could be consistent with\n thiamine deficiency.\n - Thiamine, vb12, folate\n - Valium with CIWA > 10\n FEN: TPN, replete as necessary\n PPx: SCDs, PPI\n Access: RIJ, right radial a-line\n Dispo: ICU level of care\n ICU Care\n Nutrition:\n TPN without Lipids - 04:55 PM\n Glycemic Control:\n Lines:\n Arterial Line - 01:35 PM\n Multi Lumen - 02:02 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": "2131-06-02 00:00:00.000", "description": "Nursing Progress Note", "row_id": 678332, "text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n Impaired Skin Integrity\n Assessment:\n Action:\n Response:\n Plan:\n Sepsis, Severe (with organ dysfunction)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2131-06-03 00:00:00.000", "description": "Nursing Progress Note", "row_id": 678554, "text": "Sepsis, Severe (with organ dysfunction)\n Assessment:\n Action:\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Patient tacypnic, hypotensive and hypoxic this am.\n Sats to 85, blood pressure to 70/ and resp. rate around 50\n ?Waking , overbreathing causing decreasing sats and hypotension\n Action:\n Levo to .19,\n Midaz. 5 mg bolus\n Fentanyl up to 350\n Abg done, then fio2 to 100\n MICU team into eavluate\n Response:\n Slowly improving resp. rate to low 40s\n Blood pressure to 90/\n Improved sats\n Plan:\n slowly wean fio2\n Lower extremity ultrasounds--?PE\n ?CTA of chest\n Problem\n Alteration in neuro status\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Physician ", "chartdate": "2131-06-03 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 678559, "text": "Chief Complaint: Necrotizing pancreatitis, ARDS, SIRS, ARF, cerebral\n edema.\n 24 Hour Events:\n - Heme: no dic, check fibrinogen, indirect coombs\n - ID: can dc dapto and flagyl if cx are negative\n - IP: would not do trach, rec calling CT \n - restarted UF\n - pm HCT stable\n - held naloxone and weaning sedatives\n - This AM, pt with inc O2 requirement, hypotension, tachypnea.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Daptomycin - 09:30 PM\n Metronidazole - 04:00 AM\n Infusions:\n Norepinephrine - 0.04 mcg/Kg/min\n Fentanyl (Concentrate) - 250 mcg/hour\n Midazolam (Versed) - 12 mg/hour\n Calcium Gluconate (CRRT) - 1.2 grams/hour\n KCl (CRRT) - 1 mEq./hour\n Other ICU medications:\n Pantoprazole (Protonix) - 08:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:38 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: 35.9\nC (96.7\n HR: 103 (100 - 117) bpm\n BP: 110/62(78) {87/46(60) - 113/65(92)} mmHg\n RR: 24 (24 - 38) insp/min\n SpO2: 98%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 128 kg (admission): 113.5 kg\n Height: 67 Inch\n CVP: 10 (5 - 17)mmHg\n Total In:\n 9,439 mL\n 2,671 mL\n PO:\n TF:\n IVF:\n 7,678 mL\n 2,187 mL\n Blood products:\n Total out:\n 12,968 mL\n 3,469 mL\n Urine:\n 145 mL\n 93 mL\n NG:\n 350 mL\n 250 mL\n Stool:\n Drains:\n Balance:\n -3,529 mL\n -798 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n Vt (Spontaneous): 535 (535 - 535) mL\n RR (Set): 30\n RR (Spontaneous): 0\n PEEP: 12 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10\n PIP: 22 cmH2O\n Plateau: 24 cmH2O\n SpO2: 98%\n ABG: 7.39/42/85./26/0\n Ve: 11.3 L/min\n PaO2 / FiO2: 170\n Physical Examination\n Gen: Anasarca improved. Intubated.\n HEENT: ETT in place, scleral edema. Pupils 3->2 mm b/l.\n CV: Nl S1+S2\n Pulm: Rhonchorous throughout\n Abd: Distended, soft, minimal BS\n Ext: 3+ edema.\n Skin: Weeping blisters of LE b/l\n Neuro: Sedated\n Labs / Radiology\n 77 K/uL\n 8.2 g/dL\n 139 mg/dL\n 1.8 mg/dL\n 26 mEq/L\n 4.9 mEq/L\n 25 mg/dL\n 104 mEq/L\n 138 mEq/L\n 24.4 %\n 37.2 K/uL\n [image002.jpg]\n 07:19 PM\n 10:09 PM\n 03:05 AM\n 03:53 AM\n 10:55 AM\n 01:58 PM\n 04:00 PM\n 10:34 PM\n 02:38 AM\n 04:01 AM\n WBC\n 28.9\n 37.2\n Hct\n 24.5\n 24.6\n 24.4\n Plt\n 54\n 64\n 77\n Cr\n 1.6\n 1.8\n TCO2\n 26\n 27\n 26\n 25\n 28\n 27\n 26\n Glucose\n 159\n 177\n 160\n 119\n 130\n 123\n 139\n Other labs: PT / PTT / INR:15.8/39.1/1.4, ALT / AST:29/257, Alk Phos /\n T Bili:132/14.0, Amylase / Lipase:19/35, Differential-Neuts:37.0 %,\n Band:18.0 %, Lymph:7.0 %, Mono:2.0 %, Eos:15.0 %, D-dimer:6389 ng/mL,\n Fibrinogen:293 mg/dL, Lactic Acid:1.3 mmol/L, Albumin:1.6 g/dL, LDH:607\n IU/L, Ca++:9.4 mg/dL, Mg++:1.9 mg/dL, PO4:4.8 mg/dL\n Assessment and Plan\n Mr. is a 28 year old gentleman with alcoholic hepatitis and\n necrotizing pancreatitis complicated by ARDS, SIRS, ARF and UGIB.\n # Tachypnea, tachycardia, hypotension: reflect inadequate sedation\n with resulting tachypnea, breathstacking leading to hypotension.\n Alternatively and more concerning, may suggest PE given that patient\n has only been on SCDs given recent hct drop.\n - Upper and lower extremity U/S\n - If U/S negative, will order CTA to r/o PE\n - Titrate sedation.\n # Anemia: Initially p/w hematemesis and EGD showed diuelafoy's lesion.\n Hct stable >24 hours s/p 4 units since . CTAP with new pancreatic\n pseudocyst but per d/w radiology no definitive explanation for hct\n drop. NG lavage negative. GI also doubts possibility of significant\n GI bleed, defer upper endoscopy for now. Appreciate hematology recs,\n do not feel that this is DIC.\n - CBC Q12H, transfuse for hct<21, plt<50\n - Follow-up heme and GI recs if any\n - Guaiac stools\n - Per heme, send ADAT\n # Respiratory Failure: ARDS secondary to necrotizing pancreatitis\n compounded by hypoxia, tachypnea in setting of anion gap metabolic\n acidosis, increased abdominal pressure, and EtOH withdrawal. PEEP\n decreased to 12 from 20 and FiO2 to 50%. Was tachypneic overnight on\n and sedation increased; CXR stable. IP recommending thoracic\n surgery for trach. Naloxone held yesterday given concern over\n systemic absorption resulting in tachypnea, although unlikely given\n that patient had episode of tachypnea prior to initiating naloxone.\n - Wean FiO2 and PEEP, goal PaO2>60-65%\n - Wean sedation as tolerated\n - Discuss with thoracic surgery\n # Leukocytosis: Leukocytosis worse this AM to 37 from 28 with 15% eos.\n Afebrile in last 24 hours. Per ID, started on dpatomycin and flagyl for\n ? C.diff and possible cellulitis. Negative cultures and C.diff x1 with\n 2^nd pending.\n - Continue daptomycin, d/c flagyl.\n - Follow-up ID recs if any\n - Follow-up culture data.\n # Neuro: Initially dilated pupils with CT showing cerebral edema. Neuro\n exam now stable. Repeat CTH demonstrates interval improvement.\n - Continue leviteracetam\n - Wean sedation as possible\n - Neuro recs if any\n # Necrotizing pancreatitis/SIRS: Secondary to alcohol complicated by\n SIRS and ARDS. Patient continues to have pressor requirement, with neo\n +/- levo. Aggressive volume resuscitation with >50L but\n diuresing well. Also with new pseudocyst (3 cm x 3 cm) on abdominal CT\n on . Naloxone held yesterday given tachypnea. KUB unable to\n determine of OG is post-pyloric.\n - Wean pressors with goal MAP >65\n - Hold off on trophic feeds for now given uncertainty of OG placement.\n Will consider dobhoff placement in AM.\n # Hyponatremia: In setting of decreased effective circulating volume\n in setting of SIRS and IABP. Patient has received hypertonic saline\n boluses with improvement in serum sodium and osm.\n - Given improvement in neuro exam, continue to hold hypertonic saline.\n # Acute renal failure: Patient had HD line placed and on CVVH. CVVH\n with even TBB pending assessment of hemorrhage.\n - CVVH per renal.\n - Trend chemistries\n #Thrombocytopenia: Platelets stable but have trended down from a\n normal count on admission. No clear etiology at this time. DIC panel\n with elevated FDP but normal fibrinogen. HIT PF4 antibody negative.\n - Trend plt, transfuse for plt<10 or <50 if signs of hemorrhage.\n # Wound care: Per wound care recs.\n # Acute hepatitis: Likely alcoholic hepatitis with fatty infiltration,\n and no evidence of distal obstruction. RUQ u/s shows marked liver\n echogenicity but no ascites.\n - Trend LFTs\n # Alcoholism: Patient describes history of withdrawal symptoms, but\n not prior seizure. Last drink was night prior to presentation.\n Tachycardia, weakness, and elevated lactate could be consistent with\n thiamine deficiency.\n - Thiamine, vb12, folate\n - Valium with CIWA > 10\n FEN: TPN without heparin, replete as necessary.\n PPx: SCD, PPI\n Access: RIJ, LIJ, left radial arterial line\n Code: Full\n Dispo: ICU level of care.\n ICU Care\n Nutrition:\n TPN w/ Lipids - 02:30 PM 73. mL/hour\n Glycemic Control:\n Lines:\n Multi Lumen - 02:02 PM\n Dialysis Catheter - 04:56 PM\n Arterial Line - 01:30 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2131-06-03 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 678572, "text": "Chief Complaint: respiratory failure, shock\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI: seen by heme\n not thought to be in DIC\n this morning\n tachypnea, tachycardia, hypotensionm hypoxemia\n now on\n 100% O2 and levphed dose up to 0.13.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Daptomycin - 09:30 PM\n Metronidazole - 04:00 AM\n Infusions:\n Norepinephrine - 0.04 mcg/Kg/min\n Midazolam (Versed) - 12 mg/hour\n Other ICU medications:\n Pantoprazole (Protonix) - 08:00 PM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:58 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: 35.9\nC (96.7\n HR: 117 (100 - 117) bpm\n BP: 92/52(67) {87/46(60) - 113/65(92)} mmHg\n RR: 44 (24 - 44) insp/min\n SpO2: 96%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 128 kg (admission): 113.5 kg\n Height: 67 Inch\n CVP: 10 (5 - 17)mmHg\n Total In:\n 9,439 mL\n 2,782 mL\n PO:\n TF:\n IVF:\n 7,678 mL\n 2,199 mL\n Blood products:\n Total out:\n 12,968 mL\n 4,060 mL\n Urine:\n 145 mL\n 183 mL\n NG:\n 350 mL\n 250 mL\n Stool:\n Drains:\n Balance:\n -3,529 mL\n -1,276 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n Vt (Spontaneous): 535 (535 - 535) mL\n RR (Set): 30\n RR (Spontaneous): 0\n PEEP: 12 cmH2O\n FiO2: 100%\n RSBI Deferred: PEEP > 10\n PIP: 22 cmH2O\n Plateau: 24 cmH2O\n SpO2: 100%\n ABG: 7.39/42/85./26/0\n Ve: 11.3 L/min\n PaO2 / FiO2: 170\n Physical Examination\n intubated, sedated, unresponsive, Anasarca\n pupils pinpoint\n lungs clear\n tachycardic\n abd benign\n extrem edematous\n Labs / Radiology\n 8.2 g/dL\n 77 K/uL\n 139 mg/dL\n 1.8 mg/dL\n 26 mEq/L\n 4.9 mEq/L\n 25 mg/dL\n 104 mEq/L\n 138 mEq/L\n 24.4 %\n 37.2 K/uL\n [image002.jpg]\n 07:19 PM\n 10:09 PM\n 03:05 AM\n 03:53 AM\n 10:55 AM\n 01:58 PM\n 04:00 PM\n 10:34 PM\n 02:38 AM\n 04:01 AM\n WBC\n 28.9\n 37.2\n Hct\n 24.5\n 24.6\n 24.4\n Plt\n 54\n 64\n 77\n Cr\n 1.6\n 1.8\n TCO2\n 26\n 27\n 26\n 25\n 28\n 27\n 26\n Glucose\n 159\n 177\n 160\n 119\n 130\n 123\n 139\n Other labs: PT / PTT / INR:15.8/39.1/1.4, ALT / AST:29/257, Alk Phos /\n T Bili:132/14.0, Amylase / Lipase:19/35, Differential-Neuts:37.0 %,\n Band:18.0 %, Lymph:7.0 %, Mono:2.0 %, Eos:15.0 %, D-dimer:6389 ng/mL,\n Fibrinogen:293 mg/dL, Lactic Acid:1.3 mmol/L, Albumin:1.6 g/dL, LDH:607\n IU/L, Ca++:9.4 mg/dL, Mg++:1.9 mg/dL, PO4:4.8 mg/dL\n CXR low lung volumes, slowly improving diffuse infiltrates\n Assessment and Plan\n shock - another relatively acute episode of hypotension accompanied\n by tachycardia, tachypnea, hypoxemia\n concerning for PE, repeat lower\n and upper ultrasounds\n if neg do CT-A\n Eosinophilia, leukocytosis\n stop flagyl today, follow\n HEPATITIS, ACUTE TOXIC (INCLUDING ALCOHOLIC, ACETAMINOPHEN, ETC.)\n continue supportive care\n RESPIRATORY FAILURE due to ARDS\n on maximal vent support currently,\n wean as tolerated\n PANCREATITIS, ACUTE\n enzymes normal now for nearly 2 weeks, start\n TF\n cerebral edema, seizure\n cont kepra\n ARF\n continue CVVH, hold off on volume removal until BP stabilizes\n ICU Care\n Nutrition:\n TPN w/ Lipids - 02:30 PM 73. mL/hour\n Glycemic Control:\n Lines:\n Multi Lumen - 02:02 PM\n Dialysis Catheter - 04:56 PM\n Arterial Line - 01:30 PM\n Prophylaxis:\n DVT: boots\n Stress ulcer: ppi\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition : icu\n Total time spent: 40\n" }, { "category": "Nursing", "chartdate": "2131-06-03 00:00:00.000", "description": "Nursing Progress Note", "row_id": 678577, "text": "Sepsis, Severe (with organ dysfunction)\n Assessment:\n Remains on levo\n One episode of hypotension today to mid 70/s along with acute tachypnea\n and hypoxia--?cause\n Action:\n Levo increased to 0.19 from 0.09 +\n Response:\n Improved blood pressure\n Plan:\n Continue w/ levo at current does\n Wean if possible\n Continue to run patient even to slightly negative on CRRT\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Patient tacypnic, hypotensive and hypoxic this am.\n Sats to 85, blood pressure to 70/ and resp. rate around 50\n ?Waking , overbreathing causing decreasing sats and hypotension\n Action:\n Levo to .19,\n Midaz. 5 mg bolus\n Fentanyl up to 350\n Abg done, then fio2 to 100\n MICU team into eavluate\n Response:\n Slowly improving resp. rate to low 40s\n Blood pressure to 90/\n Improved sats\n Plan:\n slowly wean fio2\n Lower extremity ultrasounds--?PE\n ?CTA of chest\n Problem\n Alteration in neuro status\n Assessment:\n Remains sedated on fent/versed\n Gag reflex improving, impaired cough\n Pupils equal and sluggishly reactive\n Tachypnic early today--?due to decreasing sedation\n Action:\n Fent/Versed increased\n Response:\n Less tachypnic\n Plan:\n Keep on current sedation, increase if needed.\n" }, { "category": "Nursing", "chartdate": "2131-05-21 00:00:00.000", "description": "Nursing Progress Note", "row_id": 675833, "text": "TITLE:\n 28 yo gentleman w history etoh, presented to hospital with\n UGIB, hypotension systolic 50\ns and acute necrotizing pancreatitis\n Hypotension (not Shock)\n Assessment:\n Periods of hypotension with Mean bp < 60 on neosynephrine Very sedate\n (high dose fentanyl &versed gtts) pupils 2-4mm sluggish reactive, no\n gag, impaired cough, does not withdraw to pain\n Sr- no ectopics. Vigeleo co 4.7-7 range w svv cvp 23-30\n Anasarca with Uop 13-18cc/hr icteric urine\n Action:\n Notified Dr\n and Dr re: low bp\ns.Fluid bloused x 4 = total\n 1500 cc fld , Neo titrated from 4.4 to 5mcg/kg/min. fentanyl weaned to\n 300mcg/hr, versed remains at 20mg/hr.\n Response:\n Transient bp improvements with fluid boluses. Creat 1.8 this am.\n Plan:\n If persistent mbp < 60 may restart levophed ,please Call HO if\n requires levophed. Wean pressors once bp more stable. ? crrt later this\n week if low uop persists and creat continues to rise.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Intubated on fio2 70% peep 24 tv 400 rr 30 sedated on fentanyl and\n versed, not overbreathing ventilator. Bbs clear upper lobes and\n diminished bibasilarly.Orally suct for bloody secretions, sm amts of\n blood via lt nares. Triadyne bed with maximal side to side rotation.\n Action:\n Maximal rotation throughout the night, when supine bp drops and sats\n down to low 90\ns.Suctioned for no secretions. Lactates stable at\n 2.6-2.4, Dr aware. Brief desat to 90 with turning side to side for\n am care recovered within 5 mins.loose packing to bilat nares. Freq oral\n care. Am labs done\n Response:\n Abg adequate with fio2 decrease to 70%.Poorly tolerates supine\n position, bp and sats improved w maximal rotation side to side.Plt\n count down to 51k this am-Dr made aware.(receiving NO heparin\n products)\n Plan:\n Wean fio2 if tolerates. Pulm toilet, Vap bundle .Continue rotation with\n triadyne bed. Maintain fentanyl and versed sedation until ventilator\n requirements diminished. Continue to monitor labs and treat.\n" }, { "category": "Physician ", "chartdate": "2131-05-23 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 676456, "text": "Chief Complaint:\n 24 Hour Events:\n - Started vanco to cover for line infection given leukocytosis\n - Renal consulted, prelim ATN on sediment\n - Pan-cultured inc sputum\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 10:00 PM\n Meropenem - 06:05 AM\n Infusions:\n Fentanyl (Concentrate) - 400 mcg/hour\n Phenylephrine - 4.8 mcg/Kg/min\n Midazolam (Versed) - 30 mg/hour\n Other ICU medications:\n Pantoprazole (Protonix) - 08:15 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:52 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: 36.7\nC (98.1\n HR: 106 (94 - 109) bpm\n BP: 97/67(79) {88/51(64) - 116/73(88)} mmHg\n RR: 15 (10 - 45) insp/min\n SpO2: 98%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 156 kg (admission): 113.5 kg\n Height: 67 Inch\n CVP: 25 (0 - 30)mmHg\n Bladder pressure: 20 (20 - 20) mmHg\n Total In:\n 2,301 mL\n 611 mL\n PO:\n TF:\n IVF:\n 2,201 mL\n 611 mL\n Blood products:\n 100 mL\n Total out:\n 1,236 mL\n 105 mL\n Urine:\n 561 mL\n 105 mL\n NG:\n 350 mL\n Stool:\n Drains:\n 325 mL\n Balance:\n 1,065 mL\n 506 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 30\n RR (Spontaneous): 0\n PEEP: 24 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10\n PIP: 46 cmH2O\n Plateau: 39 cmH2O\n Compliance: 28.6 cmH2O/mL\n SpO2: 98%\n ABG: 7.28/40/101/17/-7\n Ve: 12.1 L/min\n PaO2 / FiO2: 202\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 64 K/uL\n 10.4 g/dL\n 100 mg/dL\n 3.2 mg/dL\n 17 mEq/L\n 4.1 mEq/L\n 21 mg/dL\n 101 mEq/L\n 130 mEq/L\n 31.7 %\n 29.3 K/uL\n [image002.jpg]\n 03:01 AM\n 02:11 PM\n 08:20 PM\n 02:39 AM\n 10:29 AM\n 05:04 PM\n 05:54 PM\n 10:25 PM\n 03:01 AM\n 03:09 AM\n WBC\n 24.4\n 30.5\n 29.3\n Hct\n 34.0\n 32.9\n 32.2\n 31.7\n Plt\n 61\n 61\n 66\n 64\n Cr\n 2.1\n 3.0\n 3.2\n 3.2\n TCO2\n 20\n 19\n 19\n 18\n 19\n 20\n Glucose\n 103\n 94\n 106\n 93\n 100\n Other labs: PT / PTT / INR:19.0/42.6/1.8, ALT / AST:55/228, Alk Phos /\n T Bili:218/19.2, Amylase / Lipase:16/37, Differential-Neuts:64.0 %,\n Band:2.0 %, Lymph:11.0 %, Mono:8.0 %, Eos:3.0 %, D-dimer: ng/mL,\n Fibrinogen:402 mg/dL, Lactic Acid:2.1 mmol/L, Albumin:2.1 g/dL, LDH:576\n IU/L, Ca++:7.9 mg/dL, Mg++:2.3 mg/dL, PO4:3.1 mg/dL\n Assessment and Plan\n Mr. is a 28 year old gentleman with alcoholic hepatitis and\n necrotizing pancreatitis complicated by ARDS, SIRS, and UGIB.\n # Respiratory Failure: ARDS secondary to necrotizing pancreatitis\n compounded by hypoxia, tachypnea in setting of anion gap metabolic\n acidosis, increased abdominal pressure, and EtOH withdrawl. Rising WBC\n could also suggest secondary VAP. Patient w/ some dysychrony w/\n reduction of sedation.\n - Continue current vent settings for now, recheck ABG\n - Continue to monitor IAP\n - Begin to wean sedation as tolerated. Would prefer to wean down\n fentanyl and then midaz.\n - send sputum Cx\n - Continue vanco and meropenem.\n # Leukocytosis: WBC up to 29 today. Patient continues to be afebrile.\n Concern for CVL infection, VAP, or necrotizing pancreatitis\n complication including abscess formation.\n - Continue empiric vancomycin and meropenem\n - Follow-up culture data\n - Consider reimaging of abdomen when stable, although patient is not a\n good surgical candidate.\n # Necrotizing pancreatitis/SIRS: Likely secondary to alcohol\n complicated by SIRS and ARDS. Patient continues to have pressor\n requirement, with neo +/- levo. Aggressive volume resucsitation with\n >56. Patient without improvement with albumin trial, likely\n secondary to SIRS and increased vascular permeability.\n - Continue empiric meropenem for now.\n - Wean pressors as able, starting with levophed\n - Monitor chemistries.\n - Continue to hold MIVF, boluses PRN to maintain UOP>20 cc/hr\n - Follow-up with recs if any\n # Acute renal failure: Creatinine continues to trend up to 3.2 with\n oliguria, likely secondary to SIRS/hypotension and IABP leading to\n ATN. Appreciate renal recs - urine sediment consistent with ATN.\n - Follow-up renal recs, patient likey candidate for CVVH as creatinine,\n lytes, and BUN continue to rise.\n - Trend UOP, bolus IVF to maintain goal >20 cc/hr.\n #Thrombocytopenia: Platelets trending down over hospital course but\n stable today. No clear etiology at this time. DIC panel and HIT PF4\n antibody negative.\n # IAP elevation: Secondary to third spacing and edema. Per surgery, not\n a good surgical candidate at this time.\n # Acute hepatitis: Likely alcoholic hepatitis with fatty infiltration,\n and no evidence of distal obstruction. RUQ u/s shows marked liver\n echogenicity but no ascites.\n - Trend LFTs\n # Hematemesis: EGD showed diuelafoy's lesion. HCT stable since 2 units\n PRBC on .\n - Trend hct, transfuse for hct<21\n # Hyponatremia: In setting of decreased effective circulating volume in\n setting of SIRS and IABP.\n - Trend chemistries.\n # Alcoholism: Patient describes history of withdrawal symptoms, but\n not prior seizure. Last drink was night prior to presentation.\n Tachycardia, weakness, and elevated lactate could be consistent with\n thiamine deficiency.\n - Thiamine, vb12, folate\n - Valium with CIWA > 10\n FEN: NPO. Nutrition consult for TPN recs. IVF boluses prn.\n PPx: SCDs, PPI\n Access: RIJ, right radial a-line\n Dispo: ICU level of care\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Arterial Line - 01:35 PM\n Multi Lumen - 02:02 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": "2131-06-04 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 678771, "text": "Objective\n Pertinent medications: Fentanyl, Versed, Norepinephrine, HISS,\n Protonix, ABx, others noted\n Labs:\n Value\n Date\n Glucose\n 106 mg/dL\n 11:05 AM\n Glucose Finger Stick\n 152\n 10:00 AM\n BUN\n 22 mg/dL\n 02:03 AM\n Creatinine\n 1.6 mg/dL\n 02:03 AM\n Sodium\n 136 mEq/L\n 02:03 AM\n Potassium\n 4.9 mEq/L\n 11:05 AM\n Chloride\n 105 mEq/L\n 02:03 AM\n TCO2\n 23 mEq/L\n 02:03 AM\n PO2 (arterial)\n 70 mm Hg\n 11:05 AM\n PCO2 (arterial)\n 42 mm Hg\n 11:05 AM\n pH (arterial)\n 7.35 units\n 11:05 AM\n pH (venous)\n 7.25 units\n 10:31 AM\n pH (urine)\n 5.0 units\n 12:30 AM\n CO2 (Calc) arterial\n 24 mEq/L\n 11:05 AM\n Albumin\n 1.6 g/dL\n 04:00 AM\n Calcium non-ionized\n 8.9 mg/dL\n 02:03 AM\n Phosphorus\n 4.1 mg/dL\n 02:03 AM\n Ionized Calcium\n 1.12 mmol/L\n 11:05 AM\n Magnesium\n 2.2 mg/dL\n 02:03 AM\n ALT\n 29 IU/L\n 02:10 AM\n Alkaline Phosphate\n 132 IU/L\n 02:10 AM\n AST\n 257 IU/L\n 02:10 AM\n Amylase\n 19 IU/L\n 04:00 AM\n Total Bilirubin\n 14.0 mg/dL\n 02:10 AM\n Triglyceride\n 154 mg/dL\n 02:10 AM\n Current diet order / nutrition support: TPN: 70kg 3-in-1: 1750mL\n (298dextrose/ 105amino acid/ 35fat) = 1783kcals\n GI: abd soft, bowel sounds negative\n Assessment of Nutritional Status\n Tube feeds have not been started yet as KUB was unable to determine if\n feeding tube was post-pyloric. The feeding tube should be confirmed as\n post-pyloric before use due to pancreatitis. TPN continues at goal,\n which provides 100% of estimated calorie and protein needs. CRRT\n continues with goal of fluid removal. Triglycerides were checked ,\n and are WNL.\n Medical Nutrition Therapy Plan - Recommend the Following\n 1) Continue with TPN at goal.\n 2) Will continue to follow feeding tube placement into\n post-pyloric position. If this is obtained, recommend starting Vivonex\n @ 10cc/hr.\n 3) Monitor fluid and renal function. Will adjust TPN\n macronutrients and lytes as needed.\n Following\n Please page with any questions. #\n" }, { "category": "Nursing", "chartdate": "2131-05-24 00:00:00.000", "description": "Nursing Progress Note", "row_id": 676633, "text": "Pancreatitis, acute\n Assessment:\n T max 101.0\n Pupils large ~ 7mm, some times brisk, some times sluggish\n Noted cerebral edema on CT scan\n Noted to have left facial twitch, appears to be seizure activity.\n RR in 40\ns prior to interventions to lower cerebral edema\n Fluid balance MN\n 0600 +464, LOS + 58 liters of fluid\n Action:\n Blood cultures x1 from central line\n Hypertonic saline x1\n Ativan 4mg x1\n Loaded with Keppra x1\n Attempted to weigh patient, bed scale not working\n Response:\n Pupils still are dilated, brisk to sluggish\n Respiratory rate improved to ~ 30\n Plan:\n ? CRRT today for rising creatinine, rising fluid overload\n ? bolt to monitor known cerebral edema\n ? further hypertonic saline administration due to\n" }, { "category": "Nursing", "chartdate": "2131-05-24 00:00:00.000", "description": "Nursing Progress Note", "row_id": 676741, "text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Patient vented on large amounts of PEEP/Fio2 @50%\n Action:\n Fio2 to .4, and slowly weaning PEEP in increments\n Possibly starting CVVHD today for gentle fluid removal\n Response:\n Tolerating decreased Fio2 and decreased PEEP well so far.\n Dialysis cath placed, (left IJ) confirmed w/xray\n Plan:\n Wean vent as tolerated\n CVVHD\n labs per CVVHD protocols\n Try to take fluid off as tolerated\n Hypotension (not Shock)\n Assessment:\n Remains on neo @ 5\n Levo off\n Action:\n Tried to slowly wean neo\n Response:\n Systolic blood pressure to 70s\nresponded well to increase in neo\n Plan:\n No futher weaning of gtts.\n Keep at current doses\n Problem\n Cerebral Edema\n Assessment:\n Patient still without most deep reflexes, other than pupillary reaction\n to light, and pupils very dilated and sluggish at best.\n Action:\n Hypertonic NS ordered q 6 hrs. for 24 hrs.\n EEG done\n CVVHD to take fluids off as toelrated\n Response:\n Ongoing assessment\n No change in reflexes.\n Plan:\n Keppra\n Hypertonic NS\n CVVHD\n Close monitoring for seizure activity\n Call with any changes.\n" }, { "category": "Physician ", "chartdate": "2131-06-03 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 678529, "text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Daptomycin - 09:30 PM\n Metronidazole - 04:00 AM\n Infusions:\n Norepinephrine - 0.04 mcg/Kg/min\n Midazolam (Versed) - 12 mg/hour\n Other ICU medications:\n Pantoprazole (Protonix) - 08:00 PM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:58 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: 35.9\nC (96.7\n HR: 101 (100 - 117) bpm\n BP: 92/52(67) {87/46(60) - 113/65(92)} mmHg\n RR: 30 (24 - 38) insp/min\n SpO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 128 kg (admission): 113.5 kg\n Height: 67 Inch\n CVP: 10 (5 - 17)mmHg\n Total In:\n 9,439 mL\n 2,782 mL\n PO:\n TF:\n IVF:\n 7,678 mL\n 2,199 mL\n Blood products:\n Total out:\n 12,968 mL\n 4,060 mL\n Urine:\n 145 mL\n 183 mL\n NG:\n 350 mL\n 250 mL\n Stool:\n Drains:\n Balance:\n -3,529 mL\n -1,276 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n Vt (Spontaneous): 535 (535 - 535) mL\n RR (Set): 30\n RR (Spontaneous): 0\n PEEP: 12 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10\n PIP: 22 cmH2O\n Plateau: 24 cmH2O\n SpO2: 100%\n ABG: 7.39/42/85./26/0\n Ve: 11.3 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 8.2 g/dL\n 77 K/uL\n 139 mg/dL\n 1.8 mg/dL\n 26 mEq/L\n 4.9 mEq/L\n 25 mg/dL\n 104 mEq/L\n 138 mEq/L\n 24.4 %\n 37.2 K/uL\n [image002.jpg]\n 07:19 PM\n 10:09 PM\n 03:05 AM\n 03:53 AM\n 10:55 AM\n 01:58 PM\n 04:00 PM\n 10:34 PM\n 02:38 AM\n 04:01 AM\n WBC\n 28.9\n 37.2\n Hct\n 24.5\n 24.6\n 24.4\n Plt\n 54\n 64\n 77\n Cr\n 1.6\n 1.8\n TCO2\n 26\n 27\n 26\n 25\n 28\n 27\n 26\n Glucose\n 159\n 177\n 160\n 119\n 130\n 123\n 139\n Other labs: PT / PTT / INR:15.8/39.1/1.4, ALT / AST:29/257, Alk Phos /\n T Bili:132/14.0, Amylase / Lipase:19/35, Differential-Neuts:37.0 %,\n Band:18.0 %, Lymph:7.0 %, Mono:2.0 %, Eos:15.0 %, D-dimer:6389 ng/mL,\n Fibrinogen:293 mg/dL, Lactic Acid:1.3 mmol/L, Albumin:1.6 g/dL, LDH:607\n IU/L, Ca++:9.4 mg/dL, Mg++:1.9 mg/dL, PO4:4.8 mg/dL\n Assessment and Plan\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n IMPAIRED HEALTH MAINTENANCE\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n IMPAIRED SKIN INTEGRITY\n HYPOTENSION (NOT SHOCK)\n HEPATITIS, ACUTE TOXIC (INCLUDING ALCOHOLIC, ACETAMINOPHEN, ETC.)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n PANCREATITIS, ACUTE\n ICU Care\n Nutrition:\n TPN w/ Lipids - 02:30 PM 73. mL/hour\n Glycemic Control:\n Lines:\n Multi Lumen - 02:02 PM\n Dialysis Catheter - 04:56 PM\n Arterial Line - 01:30 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :\n Total time spent:\n" }, { "category": "Physician ", "chartdate": "2131-06-03 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 678544, "text": "Chief Complaint: respiratory failure, shock\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI: seen by heme\n this morning\n tachypnea, tachycardia, hypotensionm hypoxemia\n 24 Hour Events:\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Daptomycin - 09:30 PM\n Metronidazole - 04:00 AM\n Infusions:\n Norepinephrine - 0.04 mcg/Kg/min\n Midazolam (Versed) - 12 mg/hour\n Other ICU medications:\n Pantoprazole (Protonix) - 08:00 PM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:58 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: 35.9\nC (96.7\n HR: 101 (100 - 117) bpm\n BP: 92/52(67) {87/46(60) - 113/65(92)} mmHg\n RR: 30 (24 - 38) insp/min\n SpO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 128 kg (admission): 113.5 kg\n Height: 67 Inch\n CVP: 10 (5 - 17)mmHg\n Total In:\n 9,439 mL\n 2,782 mL\n PO:\n TF:\n IVF:\n 7,678 mL\n 2,199 mL\n Blood products:\n Total out:\n 12,968 mL\n 4,060 mL\n Urine:\n 145 mL\n 183 mL\n NG:\n 350 mL\n 250 mL\n Stool:\n Drains:\n Balance:\n -3,529 mL\n -1,276 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n Vt (Spontaneous): 535 (535 - 535) mL\n RR (Set): 30\n RR (Spontaneous): 0\n PEEP: 12 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10\n PIP: 22 cmH2O\n Plateau: 24 cmH2O\n SpO2: 100%\n ABG: 7.39/42/85./26/0\n Ve: 11.3 L/min\n PaO2 / FiO2: 170\n Physical Examination\n intubated, sedated, unresponsive\n Labs / Radiology\n 8.2 g/dL\n 77 K/uL\n 139 mg/dL\n 1.8 mg/dL\n 26 mEq/L\n 4.9 mEq/L\n 25 mg/dL\n 104 mEq/L\n 138 mEq/L\n 24.4 %\n 37.2 K/uL\n [image002.jpg]\n 07:19 PM\n 10:09 PM\n 03:05 AM\n 03:53 AM\n 10:55 AM\n 01:58 PM\n 04:00 PM\n 10:34 PM\n 02:38 AM\n 04:01 AM\n WBC\n 28.9\n 37.2\n Hct\n 24.5\n 24.6\n 24.4\n Plt\n 54\n 64\n 77\n Cr\n 1.6\n 1.8\n TCO2\n 26\n 27\n 26\n 25\n 28\n 27\n 26\n Glucose\n 159\n 177\n 160\n 119\n 130\n 123\n 139\n Other labs: PT / PTT / INR:15.8/39.1/1.4, ALT / AST:29/257, Alk Phos /\n T Bili:132/14.0, Amylase / Lipase:19/35, Differential-Neuts:37.0 %,\n Band:18.0 %, Lymph:7.0 %, Mono:2.0 %, Eos:15.0 %, D-dimer:6389 ng/mL,\n Fibrinogen:293 mg/dL, Lactic Acid:1.3 mmol/L, Albumin:1.6 g/dL, LDH:607\n IU/L, Ca++:9.4 mg/dL, Mg++:1.9 mg/dL, PO4:4.8 mg/dL\n Assessment and Plan\n shock - another relatively acute episode of hypotension accompanied\n by\n eosinophilia\n stop flagyl today, follow\n HEPATITIS, ACUTE TOXIC (INCLUDING ALCOHOLIC, ACETAMINOPHEN, ETC.)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n PANCREATITIS, ACUTE\n cerebral edema, seizure\n cont kepra\n ARF\n continue CVVH, hold off on volume removal until BP stabilizes\n ICU Care\n Nutrition:\n TPN w/ Lipids - 02:30 PM 73. mL/hour\n Glycemic Control:\n Lines:\n Multi Lumen - 02:02 PM\n Dialysis Catheter - 04:56 PM\n Arterial Line - 01:30 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :\n Total time spent:\n" }, { "category": "Respiratory ", "chartdate": "2131-05-21 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 676051, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 0\n Ideal body weight: 67.1 None\n Ideal tidal volume: 268.4 / 402.6 / 536.8 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type: Standard\n Size: 7mm\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Green / Thin\n Sputum source/amount: Suctioned / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Maintain PEEP at current level and reduce FiO2 as\n tolerated\n Reason for continuing current ventilatory support: Sedated / Paralyzed,\n Hemodynimic instability, Underlying illness not resolved\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n" }, { "category": "Respiratory ", "chartdate": "2131-05-23 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 676570, "text": "Demographics\n Ideal body weight: 67.1 None\n Ideal tidal volume: 268.4 / 402.6 / 536.8 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Tube Type\n ETT:\n Position: 24 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7mm\n Lung sounds\n RLL Lung Sounds: Rhonchi\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Rhonchi\n Secretions\n Sputum color / consistency: Green / Thick\n Sputum source/amount: Suctioned / Scant\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Intercostal retractions\n Assessment of breathing comfort: No response (sleeping / sedated)\n Invasive ventilation assessment:\n Trigger work assessment: Frequent failed trigger efforts\n Plan\n Next 24-48 hours: Utilize ARDSnet protocol, Maintain PEEP at current\n level and reduce FiO2 as tolerated\n Reason for continuing current ventilatory support: Sedated, Underlying\n illness not resolved\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n CT\n 1400\n No complications.\n" }, { "category": "Respiratory ", "chartdate": "2131-05-24 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 676733, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 0\n Ideal body weight: 67.1 None\n Ideal tidal volume: 268.4 / 402.6 / 536.8 mL/kg\n Airway\n Tube Type\n ETT:\n Position: 24 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7mm\n :\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Diminished\n LUL Lung Sounds: Diminished\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Tan / Thick\n :\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment: Not triggering\n Plan\n Next 24-48 hours: Utilize ARDSnet protocol, Reduce PEEP as tolerated\n Reason for continuing current ventilatory support: Underlying illness\n not resolved\n Respiratory Care Shift Procedures\n Bedside Procedures:\n Pleural pressure measurement (1000)\n Comments: Transpulmonary Ins hold 6.8. Exp hold -1.1\n" }, { "category": "Nursing", "chartdate": "2131-05-25 00:00:00.000", "description": "Nursing Progress Note", "row_id": 676807, "text": "Hypotension (not Shock)\n Assessment:\n SBP initially labile with recent initiation of CRRT. Pt very sensitive\n to any activity/movement and drops SBP/MAP.\n Action:\n Neo and Levophed drips titrated as needed to maintain MAP >65. Per\n renal recs\n fluid removed @ 100cc/hr via CRRT. MICU and renal in\n agreement that they would like pt negative even if pressor requirement\n goes up.\n Response:\n Pt. remains maxed on Neo and on very low dose Levophed in order to take\n off 100cc/hr fluid via CRRT.\n Plan:\n Cont. to monitor hemodynamics closely, titrate pressors as needed,\n follow labs closely.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n ABGs stable, oxygenation slightly lower in mid 80s but acceptable per\n team. Lung sounds dim to bases. Sats 92-96%. Tolerating today\ns PEEP\n drop to 20.\n Action:\n None taken.\n Response:\n No vent changes overnight.\n Plan:\n Cont. to monitor.\n Problem\n Cerebral edema\n Assessment:\n Pupils remain 6mm and sluggish bilaterally. No response to pain, no\n deep reflexes. limited neuro exam, sedated on Fentanyl and Versed\n drips. No seizure activity.\n Action:\n Neuro status closely monitored, begun on 3% NaCl drip, sodium and\n lytes monitored frequently. Cont. EEG in place.\n Response:\n No change in neuro status overnight.\n Plan:\n Cont. per above measures, to have head CT today to further assess\n cerebral edema.\n" }, { "category": "Nursing", "chartdate": "2131-05-20 00:00:00.000", "description": "Nursing Progress Note", "row_id": 675756, "text": "Hypotension (not Shock)\n Assessment:\n Pt cont to be pressor dependant\n SBP goal Map >60-65\n Creatinine over noc ^^1.9\n U/O cont to decrease\n Cont to be grossly edematous\n Remains Afebrile\n WBC\ns trending down\n Action:\n Levo titrated to off\n Neo decreased to 4.4\n Fent gtt titrated to Breathes over the vent\n Midaz unchanged and most likely will still require heroic\n doses of benzo\ns tolerance while intubated\n Fluid Bolus for low urine output\n Response:\n Has tolerated pressor weaning\n Fent down to 400mcg from 500mcg with RR 31\n U/o cont to be marginal despite bolus Creatinine ^^2.2\n Plan:\n Cont to monitor hemodynamics closely\n Vigelence monitor at bedside ? accuracy positional\n aline\n Cont to monitor renal function closely possible CVVH\n Tues/Wednesday if Creatinine cont to rise and u/o remains minimal\n despite decreases pressor requirements if tolerated\n Cont to wean pressors as tolerated.\n Respiratory failure, acute (ARDS/)\n Assessment:\n Pt with acute desaturation this am to 86% (see Medivision)\n Esophageal Ballon re-assed\n Cont to be sxn for green (bilious like) secretions\n Pt placed on 100% Fi02\n PIP\ns as high as 45-50\n Lungs clear to very diminished at the bases\n ? recruitment breathes or change in mode of ventilation\n Action:\n Esophageal ballon reassed\n Frequent abg\ns goal Pa02 >60\n CXR\n Response:\n ? cause of desaturation\n Pt Pa02 70 post episode on .100%\n Tolerated Esophageal study well and study + for adequate\n lung compliance. ? if desat due to fluid shifts related to rotation or\n atelectasis.\n Pa02 recovered with out Ventilatory intervention\n Fi02 down to 80% peep 24 TV 400X30\n Tolerating Rotation with ^^ 02sats to 95-96%\n Plan:\n Cont to monitor resp status closely\n Cont on protective settings\n If pa02 drops <60 ? decreasing TV to 380 or APRV settings\n MD \n Will tolerate low PH in the setting of permissive\n hypercapnia as long as pressor requirement does not increase.\n Cont with Triadyne bed and rotation as tolerated\n Pancreatitis, acute\n Assessment:\n Abd remains firm and distended\n OGT to LCS\n Amylase and lipase trending down\n IABP remain 24-27\n Action:\n Cont to asses Abd and monitor for s/s of infection\n Response:\n Pancreatitis remains stable\n ? TPN by RN but MICU would like to wait for a couple more\n days\n Enzymes and LFT\ns cont to improving TBILI down to 14\n Plan:\n Cont to monitor\n Meropenum for ppf\n ***Family at bedside all day and updated frequently by MD and\n this RN. SW involved. Pt with multiple friends visiting during the\n day. Pt\ns father and brother cont to be visible distraught over\n current situation but are becoming more realistic as to the long\n course pt with have to endure before seeing strong signs of\n improvement. Family very concerned about Renal status and MD \n did prepare them for possibility of CVVH if pre-renal state does become\n ARF. Family upset but understands severity of pt\ns condition. Cont\n support to family during this difficult time.\n" }, { "category": "Nursing", "chartdate": "2131-05-21 00:00:00.000", "description": "Nursing Progress Note", "row_id": 675818, "text": "TITLE:\n Hypotension (not Shock)\n Assessment:\n Periods of hypotension with Mean bp < 60 on neosynephrine Very sedate\n (high dose fentanyl &versed gtts) pupils 2-4mm sluggish reactive, no\n gag, impaired cough, does not withdraw to pain\n Sr- no ectopics. Vigeleo co 4.7-7 range w svv cvp 23-30\n Anasarca with Uop 13-18cc/hr icteric urine\n Action:\n Notified Dr\n and Dr re: low bp\ns.Fluid bloused x 4 = total\n 1500 cc fld , Neo titrated from 4.4 to 5mcg/kg/min. fentanyl weaned to\n 300mcg/hr, versed remains at 20mg/hr.\n Response:\n Transient bp improvements with fluid boluses. Creat 1.8 this am.\n Plan:\n If persistent mbp < 60 may restart levophed ,please Call HO if\n requires levophed.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Intubated on fio2 70% peep 24 tv 400 rr 30 sedated on fentanyl and\n versed, not overbreathing ventilator. Bbs clear upper lobes and\n diminished bibasilarly. Triadyne bed with maximal side to side\n rotation.\n Action:\n Maximal rotation throughout the night, when supine bp drops and sats\n down to low 90\ns.Suctioned for no secretions. Lactates stable at\n 2.6-2.4, Dr aware. Brief desat to 90 with turning side to side for\n am care recovered within 5 mins.\n Response:\n Abg adequate with fio2 decrease to 70%.Poorly tolerates supine\n position, bp amd sats improved w maximal rotation side to side.\n Plan:\n Wean fio2 if tolerates. Maintain fentanyl and versed sedation until\n ventilator requirements diminished\n" }, { "category": "Respiratory ", "chartdate": "2131-06-04 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 678843, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 18\n Ideal body weight: 67.1 None\n Ideal tidal volume: 268.4 / 402.6 / 536.8 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type: Standard\n Size: 7mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 29 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Clear\n Comments:\n Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount: Suctioned / Scant\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n 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: Hemodynimic\n instability, Underlying illness not resolved\n" }, { "category": "Nursing", "chartdate": "2131-05-21 00:00:00.000", "description": "Nursing Progress Note", "row_id": 676053, "text": "Hypotension (not Shock)\n Assessment:\n MAP 65-75 on 5mcg/kg/min of Neo and 0.04mcg/kg/min of Levophed.\n Action:\n Levophed slowly weaned to keep MAP about 70.\n Response:\n Levophed weaned to 0.02mcg/kg/min.\n Plan:\n Continue to wean pressors to keep MAP about 70 and urine output between\n 25-30cc/hr. Creatinine increased from 1.8 to 2.1 this afternoon. Pt\n still has a 50kg positive fluid balance. ?Renal consult.\n Pancreatitis, acute\n Assessment:\n Amylase 22, lipase 43, LFT\ns trending down, total bil increased to 15,\n direct bili 11.4, albumin 1.9 Abd is firm and distended with absent to\n hypoactive BSX4. NGT to LWCS with small amounts of bilious drainage.\n Action:\n Repeat labs in the morning. Discuss with MICU team about administering\n Albumin.\n Response:\n Awaiting orders from MICU for Albumin.\n Plan:\n Continue to closely monitor hemodynamics, repeat labs.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Lungs are clear to coarse. Suctioned infrequently for scant to small\n amounts of bilious drainage. FiO2 weaned from .70 to .60.\n Action:\n MICu team aware of bilious secretions.\n Response:\n No intervention at this time. O2 sat remains 93-96%.\n Plan:\n Continue to slowly wean vent as tolerates, continue to monitor\n secretions and suction as needed.\n" }, { "category": "Physician ", "chartdate": "2131-05-24 00:00:00.000", "description": "Physician Resident/Attending Progress Note - MICU", "row_id": 676727, "text": "Chief Complaint:\n 24 Hour Events:\n - Had loss of /white matter differentiation on head ct, concern for\n cerebral edema. also had eye twitching at head CT suggestive of\n seizure. resolved with ativan 4 iv x 1, recurred later and responded\n to ativan 4 iv. neuro consulted and recc'd keppra (loaded), hypertonic\n saline (given; note in OMR), EEG on .\n - Ammonia 216 -> neuro thought ?ammonia-induced intracerebral edema,\n neurosurg c/s at their request for possible ICP monitor placement but\n neurosurg declined given elevated INR, wanted to see if hypertonic\n saline would work. mannitol avoided given renal failure.\n - Spiked at 1 a.m. -> bcx\n - Started flagyl for bowel wall thickening/possible colitis on abd CT\n - CT Chest with multifocal infiltrates\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 09:11 AM\n Metronidazole - 02:45 AM\n Meropenem - 06:21 AM\n Infusions:\n Fentanyl (Concentrate) - 400 mcg/hour\n Phenylephrine - 4.8 mcg/Kg/min\n Other ICU medications:\n Pantoprazole (Protonix) - 08:00 PM\n Lorazepam (Ativan) - 08:20 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:52 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.3\nC (101\n Tcurrent: 37.3\nC (99.2\n HR: 96 (96 - 113) bpm\n BP: 111/63(79) {86/52(67) - 120/71(86)} mmHg\n RR: 30 (8 - 40) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 156 kg (admission): 113.5 kg\n Height: 67 Inch\n CVP: 26 (20 - 26)mmHg\n Bladder pressure: 26 (26 - 26) mmHg\n Total In:\n 2,555 mL\n 709 mL\n PO:\n TF:\n IVF:\n 2,555 mL\n 709 mL\n Blood products:\n Total out:\n 643 mL\n 252 mL\n Urine:\n 343 mL\n 52 mL\n NG:\n 300 mL\n 200 mL\n Stool:\n Drains:\n Balance:\n 1,912 mL\n 457 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 30\n RR (Spontaneous): 0\n PEEP: 24 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10\n PIP: 42 cmH2O\n Plateau: 37 cmH2O\n Compliance: 30.8 cmH2O/mL\n SpO2: 98%\n ABG: 7.25/45/117/18/-7\n Ve: 11.8 L/min\n PaO2 / FiO2: 234\n Physical Examination\n Gen: Sedated\n HEENT: ETT in place.. Scleral edema\n Chest: coarse BS bl, rhonchorous throughout\n CV: distant heart sounds, RRR, S1S2\n Abd: distended, abdominal wall edema\n Ext: Anasarca\n Neuro: Sedated. Pupils 6 mm, reactive.\n Labs / Radiology\n 99 K/uL\n 10.0 g/dL\n 142 mg/dL\n 3.8 mg/dL\n 18 mEq/L\n 4.4 mEq/L\n 27 mg/dL\n 104 mEq/L\n 132 mEq/L\n 30.4 %\n 38.9 K/uL\n [image002.jpg]\n 05:04 PM\n 05:54 PM\n 10:25 PM\n 03:01 AM\n 03:09 AM\n 03:21 PM\n 03:39 PM\n 06:30 PM\n 01:22 AM\n 01:32 AM\n WBC\n 30.5\n 29.3\n 38.9\n Hct\n 32.2\n 31.7\n 31.0\n 30.4\n Plt\n 66\n 64\n 99\n Cr\n 3.2\n 3.2\n 3.7\n 3.8\n TCO2\n 18\n 19\n 20\n 18\n 21\n Glucose\n 106\n 93\n 100\n 84\n 78\n 105\n 142\n Other labs: PT / PTT / INR:18.6/41.5/1.7, ALT / AST:37/219, Alk Phos /\n T Bili:218/20.6, Amylase / Lipase:16/37, Differential-Neuts:75.0 %,\n Band:0.0 %, Lymph:4.0 %, Mono:12.0 %, Eos:6.0 %, D-dimer: ng/mL,\n Fibrinogen:402 mg/dL, Lactic Acid:1.9 mmol/L, Albumin:2.1 g/dL, LDH:624\n IU/L, Ca++:8.0 mg/dL, Mg++:2.6 mg/dL, PO4:3.8 mg/dL\n Imaging: CT Torso:\n 1. New multifocal airspace consolidation, suspicious for acute\n infiltrates.\n 2. Diffuse colonic wall thickening, which could reflect colitis.\n 3. Diffuse soft tissue edema.\n 4. Peripancreatic stranding, in keeping with pancreatitis. Extent of\n necrosis cannot be evaluated on a non-contrast exam. There are no new\n peripancreatic fluid collections.\n CTH:\n 1. Diffuse loss of -white matter differentiation concerning for\n global\n hypoxia or edema with hypodensities in bilateral thalami.\n 2. No hemorrhage, mass effect, or herniation.\n 3. Fluid seen in bilateral temporal subcutaneous tissue. Near-complete\n opacification of bilateral mastoid, maxillary, frontal, and ethmoid\n sinuses.\n Assessment and Plan\n Mr. is a 28 year old gentleman with alcoholic hepatitis and\n necrotizing pancreatitis complicated by ARDS, SIRS, and UGIB.\n # Neuro: Patient with dilated pupils on high dose fentaynl gtt. CTH\n yesterday demonstrated loss of grey white differentiation with\n questionable effacement and possible seizure activity. Neuro and\n neurosurg consulted and patietn received ativan, keppra load, and\n hypertonic saline of hyponatremia.\n - Follow-up with neuro regarding keppra maintenance dose in setting of\n rapidly changing renal function.\n - 23% hypertonic saline per neurosurg recs\n - EEG today\n - Follow-up with neurosurg recs and for possible ICP monitor.\n # Respiratory Failure: ARDS secondary to necrotizing pancreatitis\n compounded by hypoxia, tachypnea in setting of anion gap metabolic\n acidosis, increased abdominal pressure, and EtOH withdrawl.\n - Wean FiO2 and PEEP, goal PaO2>60-65%\n - Continue to monitor IAP\n - Continue vanco, meropenem, flagyl\n # Leukocytosis: WBC up to 38.9 today. Patient continues to be\n afebrile. Concern for CVL infection, VAP, loculated effusion,\n sinusitis, or pancreatitis complication including abscess formation.\n CT chest with multifocal infiltrates that could represent VAP vs ARDS.\n CTAP did not demonstrate any new pancreatic fluid collections. Patient\n spiked overnight and was started on flagyl.\n - Continue empiric vancomycin, meropenem, and flagyl. AM vanco level\n today\n - Follow-up culture data\n - Afrin and nasal saline spray\n # Necrotizing pancreatitis/SIRS: Likely secondary to alcohol\n complicated by SIRS and ARDS. Patient continues to have pressor\n requirement, with neo +/- levo. Aggressive volume resuscitation with\n >58L. Patient without improvement with albumin trial, likely\n secondary to SIRS and increased vascular permeability.\n - Continue empiric antimicrobials.\n - Wean pressors as able, starting with levophed\n - Hypertonic saline as above in order to increase intravascular volume.\n - Monitor chemistries.\n - Follow-up with recs if any\n # Hyponatremia: In setting of decreased effective circulating volume in\n setting of SIRS and IABP. Patient received hypertonic saline overnight\n per neurosurgery. Serum sodium stable this morning.\n - Hypertonic saline as above.\n - Trend chemistries.\n - Follow-up with neurosurgery recs if any.\n # Acute renal failure: Creatinine continues to trend up to 3.2 with\n oliguria, likely secondary to SIRS/hypotension and IABP leading to\n ATN. Appreciate renal recs - urine sediment consistent with ATN.\n - Plan for temp HD line placement today.\n - Follow-up renal recs, patient likely candidate for CVVH as\n creatinine, lytes, and BUN continue to rise.\n #Thrombocytopenia: Platelets trending down over hospital course but\n stable today. No clear etiology at this time. DIC panel and HIT PF4\n antibody negative.\n - Trend plt\n # IAP elevation: Secondary to third spacing and edema. Per surgery, not\n a good surgical candidate at this time.\n # Acute hepatitis: Likely alcoholic hepatitis with fatty infiltration,\n and no evidence of distal obstruction. RUQ u/s shows marked liver\n echogenicity but no ascites.\n - Trend LFTs\n # Hematemesis: EGD showed diuelafoy's lesion. HCT stable since 2 units\n PRBC on .\n - Trend hct, transfuse for hct<21\n # Alcoholism: Patient describes history of withdrawal symptoms, but\n not prior seizure. Last drink was night prior to presentation.\n Tachycardia, weakness, and elevated lactate could be consistent with\n thiamine deficiency.\n - Thiamine, vb12, folate\n - Valium with CIWA > 10\n FEN: TPN, replete as necessary\n PPx: Heparin in TPN, PPI\n Access: RIJ, right radial a-line\n Dispo: ICU level of care\n ICU Care\n Nutrition:\n TPN without Lipids - 04:55 PM\n Glycemic Control:\n Lines:\n Arterial Line - 01:35 PM\n Multi Lumen - 02:02 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n ------ Protected Section ------\n MICU ATTENDING ADDENDUM\n I saw and examined the patient, and was physically present with the ICU\n team for the key portions of the services provided. I agree with the\n note above, including the assessment and plan. I would emphasize and\n add the following points: 28M EtOH abuse, weakness, fatigue, UGIB c/b\n hematemesis / melena. Has developed massive fluid requirement,\n hypotension, ARDS in the setting of severe pancreatitis, alcoholic\n hepatitis and borderline renal function. Creatinine up o/n, as is WBC.\n Pan cx, started on vanco. Head CT with edema, seen by neuro and\n neurosurg, started on 23% NS for induced osmorx c goal Na >150. NH3\n 216. Now febrile on / vanco / flagyl. TPN started. Off levophed.\n Exam notable for Tm 101.0 BP 100/50 HR 94 RR 32 with sat 98 on VAC\n 400x32/30 0.5 24 7.28/40/101 CVP 25 IAP 25. +TBB 57L. Sedated, min\n responsive, pupils 6 to 4B. Hyperdynamic. Bronchial BS B. RRR s1s2.\n Distended, minimal bowel sounds. Massive edema. Labs notable for WBC\n 38K, HCT 30, K+ 4.4, Cr 3.8, lactate 1.9, INR 1.7. CXR with worsening\n ARDS R>L.\n Agree with plan to continue 23% saline q6h with frequent monitoring of\n osm and sodium for early edema - appreciate nsurg and neuro input; hold\n on bolt for now. Will also check EEG and continue keppra with plan for\n f/u CT if his exam progresses or when more stable to travel. Will\n manage ARDS with low volume ventilation (400x30); will attempt to wean\n PEEP if we can keep FiO2 <0.5 after recheck of balloon numbers. For\n , hold on further fluids and increase pressors if UOP\n <20cc/h. have evolving sepsis based upon WBC and fever - continue\n triple abx and max supportive care while following culture data. Will\n treat sinusitis and follow eos - may need to transition to zosyn\n for possible drug reaction. ARF is progressive and UOP down, renal\n following, will place HD catheter for CVVH and start today. Will dose\n vanco to level. Pancreatitis likely due to EtOH, NPO, following.\n Can't use gut for now; will try to pass Doboff and allow this to drift\n into post pyloric position. Alcoholic hepatitis is stable. UGIB from\n Dieulafois lesion at GEJ appears stable, will monitor serial HCT and\n continue PPI IV. Thrombocytopenia is improving, HIT, resume heparin in\n TPN. Above d/w family in family mtg. Remainder of plan as outlined\n above.\n Patient is critically ill\n Total time: 60 min\n ------ Protected Section Addendum Entered By: , MD\n on: 04:31 PM ------\n" }, { "category": "Physician ", "chartdate": "2131-06-05 00:00:00.000", "description": "Physician Resident/Attending Progress Note - MICU", "row_id": 679007, "text": "TITLE:\n Chief Complaint: Mr. is a 28 year old gentleman with alcoholic\n hepatitis and necrotizing pancreatitis complicated by ARDS, SIRS, ARF\n and UGIB.\n 24 Hour Events:\n BLOOD CULTURED - At 10:46 AM\n fungal bld culture\n FEVER - 102.4\nF - 08:00 AM\n Hospital day 19\n - ID: cont daptomycin, would not restart flagyl, recc sinus CT to r/o\n sinusitis, would change lines when able\n - heme/onc: eosinophilia may be secondary to infection vs stress\n response. still don't think he has DIC but want recheck of fibrinogen.\n re: restarting heparin, attg reccomends a lower dose in TPN to reduce\n bleeding risk (was getting 9000u); will let us know the dose later\n - thoracic surgery will place trach on \n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Metronidazole - 04:00 AM\n Daptomycin - 06:42 PM\n Infusions:\n Calcium Gluconate (CRRT) - 1.4 grams/hour\n Fentanyl (Concentrate) - 325 mcg/hour\n Midazolam (Versed) - 15 mg/hour\n Norepinephrine - 0.25 mcg/Kg/min\n KCl (CRRT) - 1 mEq./hour\n Other ICU medications:\n Pantoprazole (Protonix) - 08:16 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 07:40 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 39.1\nC (102.4\n Tcurrent: 35.7\nC (96.3\n HR: 96 (93 - 128) bpm\n BP: 113/64(83) {84/43(57) - 117/64(83)} mmHg\n RR: 20 (16 - 38) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 128 kg (admission): 113.5 kg\n Height: 67 Inch\n CVP: 15 (0 - 17)mmHg\n Total In:\n 10,084 mL\n 3,257 mL\n PO:\n TF:\n IVF:\n 8,252 mL\n 2,699 mL\n Blood products:\n Total out:\n 11,204 mL\n 5,005 mL\n Urine:\n 102 mL\n 100 mL\n NG:\n 250 mL\n 200 mL\n Stool:\n Drains:\n Balance:\n -1,120 mL\n -1,748 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 30\n RR (Spontaneous): 0\n PEEP: 12 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10\n PIP: 18 cmH2O\n Plateau: 22 cmH2O\n Compliance: 44.4 cmH2O/mL\n SpO2: 100%\n ABG: 7.30/48/84./21/-2\n Ve: 13 L/min\n PaO2 / FiO2: 168\n Physical Examination\n General Appearance: Overweight / Obese, No(t) Diaphoretic\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: Rhonchorous: )\n Abdominal: Soft\n Extremities: Right: 2+, Left: 2+\n Skin: Not assessed, Jaundice\n Neurologic: Responds to: Noxious stimuli, Movement: Non -purposeful,\n Tone: Not assessed\n Labs / Radiology\n 73 K/uL\n 8.1 g/dL\n 177 mg/dL\n 1.2 mg/dL\n 21 mEq/L\n 4.8 mEq/L\n 19 mg/dL\n 106 mEq/L\n 135 mEq/L\n 24.9 %\n 50.7 K/uL\n [image002.jpg]\n 07:42 PM\n 10:37 PM\n 02:03 AM\n 02:17 AM\n 11:05 AM\n 03:58 PM\n 09:00 PM\n 09:06 PM\n 02:35 AM\n 02:39 AM\n WBC\n 37.5\n 50.7\n Hct\n 23.9\n 24.4\n 24.9\n Plt\n 66\n 73\n Cr\n 1.6\n 1.4\n 1.2\n TCO2\n 25\n 27\n 24\n 22\n 23\n 25\n Glucose\n 128\n 125\n 106\n 119\n 144\n 177\n Other labs: PT / PTT / INR:17.4/40.1/1.6, CK / CKMB / Troponin-T:240//,\n ALT / AST:29/257, Alk Phos / T Bili:132/14.0, Amylase / Lipase:19/35,\n Differential-Neuts:38.0 %, Band:2.0 %, Lymph:14.0 %, Mono:5.0 %,\n Eos:26.0 %, D-dimer:6389 ng/mL, Fibrinogen:419 mg/dL, Lactic Acid:1.3\n mmol/L, Albumin:1.6 g/dL, LDH:607 IU/L, Ca++:8.7 mg/dL, Mg++:2.1 mg/dL,\n PO4:3.5 mg/dL\n Assessment and Plan\n Mr. is a 28 year old gentleman with alcoholic hepatitis and\n necrotizing pancreatitis complicated by ARDS, SIRS, ARF and UGIB.\n # Question sepsis/leukocytosis: Increasing hypotensive, tachycardic,\n and episodically febrile, with rising levophed requirement and rising\n white count. Multiple possible sources of new infection, including\n line infection, sinusitis, pancreatitis, and cellulitis. Hypotension\n also concerning for question PE but ruled out with negative CTA.\n Restarted daptomycin on to cover for MRSA and cellulitis and\n because of concern of drug reaction to vancomycin. Other antibiotic\n courses include Flagyl , ; Meropenem ;\n Vancomycin . Lines include RIJ (18 days) and left HD line (10\n days).\n - continue daptomycin\n - f/u culture data\n - ID recs\n - trend differential following eosinophilia closely\n - consider sinus CT and sinus drainage per ENT\n - Echo today for ? endocarditis\n - will speak with renal and ID about changing hemodialysis and other\n lines.\n - CT Torso with head and sinus for ? of infectious cause.\n # Respiratory Failure: ARDS secondary to necrotizing pancreatitis\n compounded by hypoxia, tachypnea in setting of anion gap metabolic\n acidosis, increased abdominal pressure, and EtOH withdrawal. PEEP\n decreased to 12 from 20 and FiO2 to 50%. Was tachypneic overnight on\n and sedation increased; CXR stable. IP recommending thoracic\n surgery for trach. Naloxone held yesterday given concern over\n systemic absorption resulting in tachypnea, although unlikely given\n that patient had episode of tachypnea prior to initiating naloxone.\n CTA neg for PE.\n - Wean FiO2 and PEEP, goal PaO2>60-65, SaO2>90%\n - Wean sedation as tolerated\n - tracheostomy later today with thoracic surgery\n # Anemia: Initially p/w hematemesis and EGD showed diuelafoy's lesion.\n Hct stable >24 hours s/p 4 units since . CTAP with new pancreatic\n pseudocyst but per d/w radiology no definitive explanation for hct\n drop. NG lavage negative. GI also doubts possibility of significant\n GI bleed, defer upper endoscopy for now. Appreciate hematology recs,\n do not feel that this is DIC.\n - CBC daily, transfuse for hct<21, plt<50\n - Follow-up heme and GI recs if any\n - Guaiac stools\n # Neuro: Initially dilated pupils with CT showing cerebral edema. Neuro\n exam now stable. Repeat CTH demonstrates interval improvement.\n - Continue leviteracetam\n - Wean sedation as possible\n - Neuro recs if any\n # Necrotizing pancreatitis/SIRS: Secondary to alcohol complicated by\n SIRS and ARDS. Patient continues to have pressor requirement, with neo\n +/- levo. Aggressive volume resuscitation with >50L but\n diuresing well. Also with new pseudocyst (3 cm x 3 cm) on abdominal CT\n on . Naloxone held yesterday given tachypnea. KUB unable to\n determine of OG is post-pyloric.\n - Wean pressors with goal MAP >65\n - Hold off on trophic feeds for now given uncertainty of OG placement.\n Will consider dobhoff placement in AM.\n # Hyponatremia: In setting of decreased effective circulating volume in\n setting of SIRS and IABP. Patient has received hypertonic saline\n boluses with improvement in serum sodium and osm.\n - Given improvement in neuro exam, continue to hold hypertonic saline.\n # Acute renal failure: Patient had HD line placed and on CVVH. CVVH\n with even TBB pending assessment of hemorrhage.\n - CVVH per renal.\n - Trend chemistries\n #Thrombocytopenia: Platelets stable but have trended down from a\n normal count on admission. No clear etiology at this time. DIC panel\n with elevated FDP but normal fibrinogen. HIT PF4 antibody negative.\n - Trend plt, transfuse for plt<10 or <50 if signs of hemorrhage.\n - consider resend HIT antibody.\n # Wound care: Per wound care recs.\n # Acute hepatitis: Likely alcoholic hepatitis with fatty infiltration,\n and no evidence of distal obstruction. RUQ u/s shows marked liver\n echogenicity but no ascites.\n - Trend LFTs\n # Alcoholism: Patient describes history of withdrawal symptoms, but\n not prior seizure. Last drink was night prior to presentation.\n Tachycardia, weakness, and elevated lactate could be consistent with\n thiamine deficiency.\n - Thiamine, vb12, folate\n - Valium with CIWA > 10\n FEN: TPN without heparin, replete as necessary.\n PPx: SCD, PPI\n Access: RIJ, LIJ, left radial arterial line\n Code: Full\n ICU Care\n Nutrition:\n TPN w/ Lipids - 05:50 PM 73 mL/hour\n Will try to get dobhoff tube per IR for enteral feeds.\n Glycemic Control:\n Lines:\n Multi Lumen - 02:02 PM\n Dialysis Catheter - 04:56 PM\n Arterial Line - 01:30 PM\n 20 Gauge - 03:56 PM\n Prophylaxis:\n DVT: , start heparin sub Q per Heme/onc recs.\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:ICU\n ------ Protected Section ------\n TITLE: Critical Care Staff\n MICU ATTENDING ADDENDUM\n I saw and examined the patient, and was physically present with the ICU\n resident for key portions of the services provided. I agree with his\n note above, including assessment and plan.\n 28yo man with necrotizing pancreatitis (EtOH), liver failure, ARDS, ARF\n on CVVHD, shock, cerebral edema (which improved), colitis. Persistent\n hypotension, resp failure, anemia, thrombocytopenia, renal failure,\n persistent fevers with episodic tachypnea/tachycardia/hypoxia.\n I am very concerned that his fevers, marked leukocytosis, increased\n pressor requirement (now NE at 0.25mcg/kg/min) are indicative of a new\n source of infection/sepsis.\n * Tm 102.4 yesterday morning\n * CTA neg for PE which was done in the setting of episodic tachypnea,\n tachycardia, hypoxemia\n * ARDS with persistent moderately high PEEP AC 0.5/400.30/12\n * I/O 1L/24, -2L since midnight\n * CDiff cx neg. Blood cx GPC prs, clusters . On daptomycin.\n * thrombocytopenia with plts remaining >50 since , slowly\n trending up but no sig rebound since heparin and vanco stopped. PF4\n neg .\n * Sedated on fent 325mcg/h and versed 15mg/h\n CXR with progression of bilateral opacification\n Exam unchanged: anasarca with weeping of fluid from bilat LEs,\n jaundiced, scleral edema, PERRL sluggish, sedated and unresponsive but\n nurses report agitation with lightening of sedation. Abd firm but\n nondistended, not tense.\n Labs: WBC 38\n 51 with 26% eos, hct stable at 25%, plts 73, increased\n from 40s over past week. Alb 1.6 .\n 1. resp failure: plan for trach tonight/tomorrow.\n 2. Sepsis: may be attributable to nec panc. GPC blood cx + (which may\n be contaminant as 1/6 bottles) on daptomycin.\n Need to remove lines. Will hold CVVH and d/c left IJ HD line.\n If we can resite IJ to left side after, we will also d/c right IJ.\n Surveillance cx neg to date.\n Plan for surveillance cx q48h\n CT scan today to r/o progression of nec pancreatitis, will\n scan chest and sinuses as well.\n echocardiogram\n 3. Eosinophilia: I believe this is going to be attributable to meds.\n The most likely culprits (which would be extremely rare) are\n heparin (though PF4 neg) and PPI. Have d/c PPI. Will be adding back\n heparin. Discuss with heme.\n 4. ileus.\n 5. CVVH sig volume off over the past 24 hrs (and 4.5L neg since\n midnight). Plan to change HD line to triple lumen and d/c right IJ\n as well, send all lines for cx.\n 6. will plan to place postpyloric dobhoff and new HD line by IR\n tomorrow.\n 7. sedation: attempt to wean.\n Critically ill, 65 minutes\n ------ Protected Section Addendum Entered By: , MD\n on: 16:00 ------\n" }, { "category": "Nursing", "chartdate": "2131-06-05 00:00:00.000", "description": "Nursing Progress Note", "row_id": 679010, "text": " Problem - Description In Comments\n Assessment:\n Action:\n Response:\n Plan:\n Impaired Skin Integrity\n Assessment:\n Multiple areas over legs with open blisters,some oozing ,some not\n Action:\n Dressings changed with skin care RN\n Cleansed with Skinintegrity wound cleanser\n Pat dry\n Adaptic applied to open areas\n Aloe vesta lotion to inctact areas\n Covered with soft sorb\n Fishnet dressing over so no tape on legs.\n Response:\n Improved healing, no evidence of infection on opened areas.\n Area of ereythema on thighs--?residual from drug rash\n Plan:\n Continue with skin care as above.\n Will switch out bed to triadyne roatate air mattress.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nutrition", "chartdate": "2131-05-22 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 676329, "text": "Subjective Pt intubated/sedated\n Objective\n Current Wt: 156 kg\n Admit Wt: 113.5 kg\n Wt Change : increase of 42.5 kg (fluid)\n Patient has RIJ line\n Pertinent medications: fentanyl, midazolam, protonix, Abx,\n norephinephrine, phenylephrine, RISS, cyanocobalamin, MVI, others noted\n Labs:\n Value\n Date\n Glucose\n 94 mg/dL\n 02:39 AM\n Glucose Finger Stick\n 122\n 10:00 AM\n BUN\n 18 mg/dL\n 02:39 AM\n Creatinine\n 3.0 mg/dL\n 02:39 AM\n Sodium\n 133 mEq/L\n 02:39 AM\n Potassium\n 4.3 mEq/L\n 02:39 AM\n Chloride\n 102 mEq/L\n 02:39 AM\n TCO2\n 18 mEq/L\n 02:39 AM\n PO2 (arterial)\n 122 mm Hg\n 10:29 AM\n PCO2 (arterial)\n 39 mm Hg\n 10:29 AM\n pH (arterial)\n 7.27 units\n 10:29 AM\n pH (venous)\n 7.25 units\n 10:31 AM\n pH (urine)\n 6.5 units\n 02:58 PM\n CO2 (Calc) arterial\n 19 mEq/L\n 10:29 AM\n Albumin\n 2.3 g/dL\n 02:39 AM\n Calcium non-ionized\n 7.9 mg/dL\n 02:39 AM\n Phosphorus\n 2.7 mg/dL\n 02:39 AM\n Ionized Calcium\n 1.08 mmol/L\n 10:29 AM\n Magnesium\n 2.2 mg/dL\n 02:39 AM\n ALT\n 69 IU/L\n 02:39 AM\n Alkaline Phosphate\n 218 IU/L\n 02:39 AM\n AST\n 194 IU/L\n 02:39 AM\n Amylase\n 17 IU/L\n 02:39 AM\n Total Bilirubin\n 16.7 mg/dL\n 02:39 AM\n WBC\n 24.4 K/uL\n 02:39 AM\n Hgb\n 10.6 g/dL\n 02:39 AM\n Hematocrit\n 32.9 %\n 02:39 AM\n Current diet order / nutrition support: NPO\n GI: abd firm, distended, bowel sounds absent\n Assessment of Nutritional Status\n Consult received for TPN recs for this 28 year old male with h/o ETOH\n abuse p/w acute hepatitis, pancreatitis, and hyponatremia. Patient\n remains intubated/sedated, and on multiple pressors. RN, patient\n is currently not stable enough to place a post-pyloric feeding tube\n therefore TPN required for nutrition support. TPN likely to start\n tomorrow. When placement is possible, recommend tube feeds via NJ tube\n (with tip placed past the ligament of trietz to avoid pancreas\n stimulation) over TPN. Will provide recommendations below.\n Medical Nutrition Therapy Plan - Recommend the Following\n 1. When TPN is initiated, recommend start Day 1 standard with\n lytes based on am labs. Will advance TPN based on am\n labs/FSBG/triglyceride levels. Recommend TPN goal: 70kg 3-in-1\n providing 1750 kcal and 105g protein.\n 2. When NJ tube placement is possible, recommend placing NJ tube\n (with tip past the ligament of trietz), with goal: Replete with Fiber @\n 70 ml/hr (1680 kcals/104g protein).\n 3. CHEM 10 labs daily. Monitor and replete lytes PRN\n 4. FSBG q6h. Correct with RISS\n 5. Check triglyercides. If <400, ok to add lipid to TPN\n 6. Will follow\n 7. Electronically signed by , Dietetic Intern\n 15:30\n 8.\n 9.\n 10. ------ Protected Section ------\n 11.\n 12. Agree with above note. #\n 13. ------ Protected Section Addendum Entered By: , RD,\n on: 15:59 ------\n 14.\n 15.\n 16. Electronically signed by , RD, \n 15:59\n 17.\n 18.\n" }, { "category": "Nursing", "chartdate": "2131-06-06 00:00:00.000", "description": "Nursing Progress Note", "row_id": 679086, "text": "Sepsis, Severe (with organ dysfunction)\n Assessment:\n Temp spike to 101.1 with associated tachycardia, tachypnia\n WBC count 50\n Levophed drip needed to keep MAP> 65\n Action:\n Tylenol given\n Repositioned q 2 hours\n Antibiotics as ordered\n VAP protocol\n Urine culture sent\n HD line changed over wire to Quad central line, confirmed by\n X-Ray\n Right IJ central line discontinued by MICU resident\n Response:\n Remains febrile\n Awaiting am lab results\n Awaiting Cortisol stim test results\n Plan:\n Follow up on final CT scan results\n Follow up on all culture results\n Continue antibiotics, re-evaluate with ID\n Patient and family support\n Impaired Skin Integrity\n Assessment:\n Upper extremities improved, minimal drainage from puncture\n sites\n Lower extremities have also improved, with blisters that\n have popped weeping less serous fluid\n Inner thighs of both legs concerning due to firm, erythemic,\n and hot skin. Dr. and evaluated\n Heels improving as well,\n Action:\n Wounds cleaned with wound cleanser\n Dried\n Aquacel ag applied to open areas as skin where adaptic was\n appeared to be macerated\n Softsorb and then net stockings to hold in place\n Heels kept off bed with waffle boots\n Response:\n All impaired skin sites appear to be healing\n Plan:\n Continue with above treatment\n Continue to consult with skin care nurse\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Patient clearly working at breathing, using accessory\n muscles\n O2 sats dropping to 90%, especially when on right side\n Pt on AC, 50%, 10 peep, 30 x 400\n Action:\n Pt placed on as far left and right as possible every 2 hours\n (not true swimmers due to edema, unable to safely keep patient over\n that far).\n VAP protocol\n Suctioned for small amounts of very thick tan sputum, almost\n unable to pass through suction catheter\n Recruitment maneuver x 2\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2131-05-22 00:00:00.000", "description": "Nursing Progress Note", "row_id": 676307, "text": "Impaired Skin Integrity\n Assessment:\n - Pt has generalized anasarca with a tbb of +55 L. Patient\n posterior side is intact, but patient\ns lower extremities are extremely\n fluid overloaded and patient has diffuse blistering throughout lower\n extremities, oozing serous fluid.\n - Patient has two old puncture sites, one in R antecubital\n (former peripheral IV site) and one in R groin (former cordis site)\n draining serous fluid.\n Action:\n - Lower extremities cleansed with normal saline; gently patted\n dry; adaptic/Vaseline gauze and softsorb applied and covered with net\n mesh to keep softsorbs intact.\n - Both puncture sites covered with drainage bags to catch\n serous output.\n Response:\n - Patient\ns blistering/oozing of serous fluid remains.\n - Drainage bags on puncture sites intact/surrounding skin\n appears intact.\n Plan:\n - Continue cleanse/treatment, relieve areas of pressure, ?\n consult wound care nurse for further treatment.\n - Continue to monitor skin integrity.\n Hypotension (not Shock)\n Assessment:\n - Pt on max neo and low dose levo to achieve MAP >70\n - Urine output average 25 cc/hour\n Action:\n - Levophed weaned to off this morning\n Response:\n - After several hours off levo, patient\ns MAP dropped to\n 60-65 and correspondingly, urine output\n Decreased to 10-11 cc/hour, so levo turned back on to\n 0.02\n Plan:\n - Continue to keep MAP >70, monitor perfusion, urine output\n Respiratory failure, acute (not ARDS/)\n Assessment:\n - This morning, patient dysynchronous and overbreathing\n ventilator by 5-7 breaths per minute.\n - Lung sounds rhonchorous, diminished in bases\n Action:\n - Increased patient\ns fentanyl gtt to 300 from 225 to improve\n synchrony with vent\n - Adjusted patient\ns position into modified swimmer\n position, left side down, to help aerate R lung and improve perfusion\n with L lung\n - Moved patient onto a larger bed to provide more efficient\n rotating\n - Sent sputum culture\n Response:\n - ABG improved to 122 from 86\n - Patient more synchronous with vent\n - Tolerating rotating\n Plan:\n - No vent changes for today\n - Follow up sputum culture.\n Pancreatitis, acute\n Assessment:\n Abd firm distended no active bowel sounds present. Ngt to lws w bilious\n to brown drainage.\n Action:\n Protonix . Bladder pressure 19 overnight. Lft\ns sent w am labs. D\n dimer elevated\n Response:\n Ast , alt and alk phos trending down. Total bili increased to 16.7\n today\n Plan:\n Continue to follow bladder pressures. Monitor labs. Monitor for signs\n of bleeding.\n" }, { "category": "Nutrition", "chartdate": "2131-05-22 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 676311, "text": "Subjective Pt intubated/sedated. RN, likely to start TPN tomorrow\n at this point in time, patient is too unstable to place a\n post-pyloric feeding tube. HCT remains stable.\n Objective\n Current Wt: 156 kg\n Admit Wt: 113.5 kg\n Wt Change : increase of 42.5 kg (fluid)\n Patient has RIJ line\n Pertinent medications: fentanyl, midazolam, protonix, Abx,\n norephinephrine, phenylephrine, RISS, cyanocobalamin, MVI, others noted\n Labs:\n Value\n Date\n Glucose\n 94 mg/dL\n 02:39 AM\n Glucose Finger Stick\n 122\n 10:00 AM\n BUN\n 18 mg/dL\n 02:39 AM\n Creatinine\n 3.0 mg/dL\n 02:39 AM\n Sodium\n 133 mEq/L\n 02:39 AM\n Potassium\n 4.3 mEq/L\n 02:39 AM\n Chloride\n 102 mEq/L\n 02:39 AM\n TCO2\n 18 mEq/L\n 02:39 AM\n PO2 (arterial)\n 122 mm Hg\n 10:29 AM\n PCO2 (arterial)\n 39 mm Hg\n 10:29 AM\n pH (arterial)\n 7.27 units\n 10:29 AM\n pH (venous)\n 7.25 units\n 10:31 AM\n pH (urine)\n 6.5 units\n 02:58 PM\n CO2 (Calc) arterial\n 19 mEq/L\n 10:29 AM\n Albumin\n 2.3 g/dL\n 02:39 AM\n Calcium non-ionized\n 7.9 mg/dL\n 02:39 AM\n Phosphorus\n 2.7 mg/dL\n 02:39 AM\n Ionized Calcium\n 1.08 mmol/L\n 10:29 AM\n Magnesium\n 2.2 mg/dL\n 02:39 AM\n ALT\n 69 IU/L\n 02:39 AM\n Alkaline Phosphate\n 218 IU/L\n 02:39 AM\n AST\n 194 IU/L\n 02:39 AM\n Amylase\n 17 IU/L\n 02:39 AM\n Total Bilirubin\n 16.7 mg/dL\n 02:39 AM\n WBC\n 24.4 K/uL\n 02:39 AM\n Hgb\n 10.6 g/dL\n 02:39 AM\n Hematocrit\n 32.9 %\n 02:39 AM\n Current diet order / nutrition support: NPO\n GI: abd firm, distended, bowel sounds absent\n Assessment of Nutritional Status\n Consult received for TPN recs for this 28 year old male with h/o ETOH\n abuse p/w acute hepatitis, pancreatitis, and hyponatremia. Patient\n remains intubated/sedated, and on multiple pressors. Currently,\n patient is not stable enough to place a post-pyloric feeding tube\n therefore TPN required for nutrition support. When placement is\n possible, recommend tube feeds via NJ tube (with tip placed past the\n ligament of trietz to avoid pancreas stimulation) over TPN. Will\n provide recs below.\n Medical Nutrition Therapy Plan - Recommend the Following\n 1. When TPN is initiated, recommend start Day 1 standard with\n lytes based on am labs. Will advance TPN based on am\n labs/FSBG/triglyceride levels. Recommend TPN goal: 70kg 3-in-1.\n 2. When NJ tube placement is possible, recommend placing NJ tube\n (with tip past the ligament of trietz), with goal: Replete with Fiber @\n 70 ml/hr (1680 kcals/104g protein). Recommend discontinuing TPN once\n tolerance at goal is established.\n 3. CHEM 10 labs daily. Monitor and replete lytes PRN\n 4. FSBG q6h. Correct with RISS\n 5. Check triglyercides. If <400, ok to add lipid to TPN\n 6. Will follow\n" }, { "category": "Nutrition", "chartdate": "2131-05-22 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 676316, "text": "Subjective Pt intubated/sedated\n Objective\n Current Wt: 156 kg\n Admit Wt: 113.5 kg\n Wt Change : increase of 42.5 kg (fluid)\n Patient has RIJ line\n Pertinent medications: fentanyl, midazolam, protonix, Abx,\n norephinephrine, phenylephrine, RISS, cyanocobalamin, MVI, others noted\n Labs:\n Value\n Date\n Glucose\n 94 mg/dL\n 02:39 AM\n Glucose Finger Stick\n 122\n 10:00 AM\n BUN\n 18 mg/dL\n 02:39 AM\n Creatinine\n 3.0 mg/dL\n 02:39 AM\n Sodium\n 133 mEq/L\n 02:39 AM\n Potassium\n 4.3 mEq/L\n 02:39 AM\n Chloride\n 102 mEq/L\n 02:39 AM\n TCO2\n 18 mEq/L\n 02:39 AM\n PO2 (arterial)\n 122 mm Hg\n 10:29 AM\n PCO2 (arterial)\n 39 mm Hg\n 10:29 AM\n pH (arterial)\n 7.27 units\n 10:29 AM\n pH (venous)\n 7.25 units\n 10:31 AM\n pH (urine)\n 6.5 units\n 02:58 PM\n CO2 (Calc) arterial\n 19 mEq/L\n 10:29 AM\n Albumin\n 2.3 g/dL\n 02:39 AM\n Calcium non-ionized\n 7.9 mg/dL\n 02:39 AM\n Phosphorus\n 2.7 mg/dL\n 02:39 AM\n Ionized Calcium\n 1.08 mmol/L\n 10:29 AM\n Magnesium\n 2.2 mg/dL\n 02:39 AM\n ALT\n 69 IU/L\n 02:39 AM\n Alkaline Phosphate\n 218 IU/L\n 02:39 AM\n AST\n 194 IU/L\n 02:39 AM\n Amylase\n 17 IU/L\n 02:39 AM\n Total Bilirubin\n 16.7 mg/dL\n 02:39 AM\n WBC\n 24.4 K/uL\n 02:39 AM\n Hgb\n 10.6 g/dL\n 02:39 AM\n Hematocrit\n 32.9 %\n 02:39 AM\n Current diet order / nutrition support: NPO\n GI: abd firm, distended, bowel sounds absent\n Assessment of Nutritional Status\n Consult received for TPN recs for this 28 year old male with h/o ETOH\n abuse p/w acute hepatitis, pancreatitis, and hyponatremia. Patient\n remains intubated/sedated, and on multiple pressors. RN, patient\n is currently not stable enough to place a post-pyloric feeding tube\n therefore TPN required for nutrition support. TPN likely to start\n tomorrow. When placement is possible, recommend tube feeds via NJ tube\n (with tip placed past the ligament of trietz to avoid pancreas\n stimulation) over TPN. Will provide recommendations below.\n Medical Nutrition Therapy Plan - Recommend the Following\n 1. When TPN is initiated, recommend start Day 1 standard with\n lytes based on am labs. Will advance TPN based on am\n labs/FSBG/triglyceride levels. Recommend TPN goal: 70kg 3-in-1\n providing 1750 kcal and 105g protein.\n 2. When NJ tube placement is possible, recommend placing NJ tube\n (with tip past the ligament of trietz), with goal: Replete with Fiber @\n 70 ml/hr (1680 kcals/104g protein).\n 3. CHEM 10 labs daily. Monitor and replete lytes PRN\n 4. FSBG q6h. Correct with RISS\n 5. Check triglyercides. If <400, ok to add lipid to TPN\n 6. Will follow\n 7. Electronically signed by , Dietetic Intern\n 15:30\n 8.\n 9.\n" }, { "category": "Respiratory ", "chartdate": "2131-05-24 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 676623, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 0\n Ideal body weight: 67.1 None\n Ideal tidal volume: 268.4 / 402.6 / 536.8 mL/kg\n Airway\n 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: 7mm\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Diminished\n LUL Lung Sounds: Diminished\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: /\n Sputum source/amount: Suctioned / None\n Comments: sputum appears to be bile\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Utilize ARDSnet protocol, Maintain PEEP at current\n level and reduce FiO2 as tolerated\n Reason for continuing current ventilatory support: Underlying illness\n not resolved\n Comments: Pt. remains sedated and intubated on A/C overnoc, Abg\n metabolic acidosis. No vent changes this shift. Maintain ARDS net\n protocol.\n" }, { "category": "Physician ", "chartdate": "2131-05-20 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 675650, "text": "Chief Complaint:\n 24 Hour Events:\n - Continued to require levophed and fluid boluses to maintain UOP.\n - Started meropenem.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Meropenem - 06:00 AM\n Infusions:\n Midazolam (Versed) - 20 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 07:45 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38\nC (100.4\n Tcurrent: 37\nC (98.6\n HR: 102 (101 - 120) bpm\n BP: 94/62(75) {68/50(58) - 114/84(96)} mmHg\n RR: 26 (0 - 32) insp/min\n SpO2: 92%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 111.3 kg (admission): 113.5 kg\n Height: 67 Inch\n CVP: 23 (19 - 39)mmHg\n Bladder pressure: 29 (24 - 29) mmHg\n Total In:\n 11,901 mL\n 3,743 mL\n PO:\n TF:\n IVF:\n 11,901 mL\n 3,743 mL\n Blood products:\n Total out:\n 501 mL\n 136 mL\n Urine:\n 501 mL\n 136 mL\n NG:\n Stool:\n Drains:\n Balance:\n 11,400 mL\n 3,607 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 30\n RR (Spontaneous): 0\n PEEP: 24 cmH2O\n FiO2: 70%\n RSBI Deferred: PEEP > 10\n PIP: 52 cmH2O\n Plateau: 42 cmH2O\n Compliance: 23.5 cmH2O/mL\n SpO2: 92%\n ABG: 7.29/43/82./19/-5\n Ve: 12.8 L/min\n PaO2 / FiO2: 119\n Physical Examination\n General: Sedated\n HEENT: ETT in place.\n Lungs: Rales bilaterally on anterior auscultation.\n CV: Tachy S1+S2\n Abdomen: Distended, -BS\n Ext: 2+ edema b/l.\n Neuro: sedated\n Labs / Radiology\n 80 K/uL\n 11.2 g/dL\n 120 mg/dL\n 1.9 mg/dL\n 19 mEq/L\n 4.1 mEq/L\n 13 mg/dL\n 101 mEq/L\n 129 mEq/L\n 32.9 %\n 17.0 K/uL\n [image002.jpg]\n 03:02 PM\n 03:11 PM\n 04:34 PM\n 06:16 PM\n 08:20 PM\n 10:06 PM\n 10:25 PM\n 01:59 AM\n 04:42 AM\n 04:55 AM\n WBC\n 18.8\n 17.5\n 17.0\n Hct\n 32.8\n 34.5\n 32.9\n Plt\n 109\n 92\n 80\n Cr\n 1.7\n 1.8\n 1.9\n TCO2\n 23\n 22\n 23\n 21\n 23\n 23\n 22\n Glucose\n 129\n 125\n 123\n 123\n 117\n 120\n Other labs: PT / PTT / INR:19.8/52.4/1.8, ALT / AST:108/331, Alk Phos /\n T Bili:212/14.3, Amylase / Lipase:45/268, Lactic Acid:2.5 mmol/L,\n Albumin:2.2 g/dL, LDH:616 IU/L, Ca++:7.6 mg/dL, Mg++:2.0 mg/dL, PO4:2.6\n mg/dL\n Assessment and Plan\n Mr. is a 28 year old gentleman with alchoholic hepatitis and\n necrotizing pancreatitis complicated by ARDS, SIRS, and UGIB.\n # Respiratory Failure: ARDS secondary to necrotizing pancreatis\n compounded by hypoxia, tachypnea in setting of anion gap metabolic\n acidosis, increased abdominal pressure, and EtOH withdrawl.\n - APRV\n - Permissible tachypnea is tolerated in setting of AGMA. If patient\n has auto-peep and breath stacking would consider paralysis. Would\n permit PCO2 of ~70 and pH ~7.1 with goal PaO2>60.\n - Monitor abdominal pressures\n - Recheck esophageal balloon pressure and adjust vent settings as\n indicated\n - Continue fentaynl and midaz for sedation.\n # Necrotizing pancreatitis/SIRS: Likely secondary to alchohol\n complicated by SIRS. Patient continues to have pressor requirement and\n volume rescuitation with +50L.\n - Continue empiric meropenem\n - Wean pressors, bolus IVF to maintain MAP>70 and UOP>20 cc/hr.\n - Monitor chemistries.\n - Hold MIVF\n - Follow-up with recs if any\n # Acute renal failure: Creatinine continues to trend up with oliguria,\n likely secondary to SIRS/hypotension and IABP leading to ATN.\n - Urine lytes, eos, osm\n - Trend UOP, bolus IVF to maintain goal >20 cc/hr.\n # IAP elevation: Secondary to third spacing and edema. Per surgery, not\n a good surgical candidate at this time.\n # Acute hepatitis: Likely alcoholic hepatiis with fatty infiltration,\n and no evidence of distal obstruction. RUQ u/s shows marked liver\n echogenicity but no ascites.\n - Trend LFTs\n # Hematemesis: EGD showed diuelafoy's lesion. HCT stable since 2 units\n PRBC on .\n - Trend hct, transfuse for hct<21\n # Hyponatremia: In setting of decreased effective circulating volume in\n setting of SIRS and IABP.\n - Trend chemistries.\n # Alcoholism: Patient describes history of withdrawal symptoms, but\n not prior seizure. Last drink was night prior to presentation.\n Tachycardia, weakness, and elevated lactate could be consistent with\n thiamine deficiency.\n - Thiamine, vb12, folate\n - Valium with CIWA > 10\n FEN: IVF, replete electrolytes, NPO. Would consider starting TPN after\n 5-7 days\n PPx: SCDs, PPI\n Access: RIJ, fem cordis, right radial art line. Plan to d/c cordis\n today.\n Code: Full Code\n Dispo: ICU level of care.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 16 Gauge - 01:50 PM\n Cordis/Introducer - 02:05 PM\n Arterial Line - 01:35 PM\n Multi Lumen - 02:02 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": "2131-05-20 00:00:00.000", "description": "Physician Resident/Attending Progress Note - MICU", "row_id": 675660, "text": "Chief Complaint:\n 24 Hour Events:\n - Continued to require levophed and fluid boluses to maintain UOP.\n - Started meropenem.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Meropenem - 06:00 AM\n Infusions:\n Midazolam (Versed) - 20 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 07:45 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38\nC (100.4\n Tcurrent: 37\nC (98.6\n HR: 102 (101 - 120) bpm\n BP: 94/62(75) {68/50(58) - 114/84(96)} mmHg\n RR: 26 (0 - 32) insp/min\n SpO2: 92%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 111.3 kg (admission): 113.5 kg\n Height: 67 Inch\n CVP: 23 (19 - 39)mmHg\n Bladder pressure: 29 (24 - 29) mmHg\n Total In:\n 11,901 mL\n 3,743 mL\n PO:\n TF:\n IVF:\n 11,901 mL\n 3,743 mL\n Blood products:\n Total out:\n 501 mL\n 136 mL\n Urine:\n 501 mL\n 136 mL\n NG:\n Stool:\n Drains:\n Balance:\n 11,400 mL\n 3,607 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 30\n RR (Spontaneous): 0\n PEEP: 24 cmH2O\n FiO2: 70%\n RSBI Deferred: PEEP > 10\n PIP: 52 cmH2O\n Plateau: 42 cmH2O\n Compliance: 23.5 cmH2O/mL\n SpO2: 92%\n ABG: 7.29/43/82./19/-5\n Ve: 12.8 L/min\n PaO2 / FiO2: 119\n Physical Examination\n General: Sedated\n HEENT: ETT in place.\n Lungs: Rales bilaterally on anterior auscultation.\n CV: Tachy S1+S2\n Abdomen: Distended, -BS\n Ext: 2+ edema b/l.\n Neuro: sedated\n Labs / Radiology\n 80 K/uL\n 11.2 g/dL\n 120 mg/dL\n 1.9 mg/dL\n 19 mEq/L\n 4.1 mEq/L\n 13 mg/dL\n 101 mEq/L\n 129 mEq/L\n 32.9 %\n 17.0 K/uL\n [image002.jpg]\n 03:02 PM\n 03:11 PM\n 04:34 PM\n 06:16 PM\n 08:20 PM\n 10:06 PM\n 10:25 PM\n 01:59 AM\n 04:42 AM\n 04:55 AM\n WBC\n 18.8\n 17.5\n 17.0\n Hct\n 32.8\n 34.5\n 32.9\n Plt\n 109\n 92\n 80\n Cr\n 1.7\n 1.8\n 1.9\n TCO2\n 23\n 22\n 23\n 21\n 23\n 23\n 22\n Glucose\n 129\n 125\n 123\n 123\n 117\n 120\n Other labs: PT / PTT / INR:19.8/52.4/1.8, ALT / AST:108/331, Alk Phos /\n T Bili:212/14.3, Amylase / Lipase:45/268, Lactic Acid:2.5 mmol/L,\n Albumin:2.2 g/dL, LDH:616 IU/L, Ca++:7.6 mg/dL, Mg++:2.0 mg/dL, PO4:2.6\n mg/dL\n Assessment and Plan\n Mr. is a 28 year old gentleman with alchoholic hepatitis and\n necrotizing pancreatitis complicated by ARDS, SIRS, and UGIB.\n # Respiratory Failure: ARDS secondary to necrotizing pancreatis\n compounded by hypoxia, tachypnea in setting of anion gap metabolic\n acidosis, increased abdominal pressure, and EtOH withdrawl.\n - APRV\n - Permissible tachypnea is tolerated in setting of AGMA. If patient\n has auto-peep and breath stacking would consider paralysis. Would\n permit PCO2 of ~70 and pH ~7.1 with goal PaO2>60.\n - Monitor abdominal pressures\n - Recheck esophageal balloon pressure and adjust vent settings as\n indicated\n - Continue fentaynl and midaz for sedation.\n # Necrotizing pancreatitis/SIRS: Likely secondary to alchohol\n complicated by SIRS. Patient continues to have pressor requirement and\n volume rescuitation with +50L.\n - Continue empiric meropenem\n - Wean pressors, bolus IVF to maintain MAP>70 and UOP>20 cc/hr.\n - Monitor chemistries.\n - Hold MIVF\n - Follow-up with recs if any\n # Acute renal failure: Creatinine continues to trend up with oliguria,\n likely secondary to SIRS/hypotension and IABP leading to ATN.\n - Urine lytes, eos, osm\n - Trend UOP, bolus IVF to maintain goal >20 cc/hr.\n # IAP elevation: Secondary to third spacing and edema. Per surgery, not\n a good surgical candidate at this time.\n # Acute hepatitis: Likely alcoholic hepatiis with fatty infiltration,\n and no evidence of distal obstruction. RUQ u/s shows marked liver\n echogenicity but no ascites.\n - Trend LFTs\n # Hematemesis: EGD showed diuelafoy's lesion. HCT stable since 2 units\n PRBC on .\n - Trend hct, transfuse for hct<21\n # Hyponatremia: In setting of decreased effective circulating volume in\n setting of SIRS and IABP.\n - Trend chemistries.\n # Alcoholism: Patient describes history of withdrawal symptoms, but\n not prior seizure. Last drink was night prior to presentation.\n Tachycardia, weakness, and elevated lactate could be consistent with\n thiamine deficiency.\n - Thiamine, vb12, folate\n - Valium with CIWA > 10\n FEN: IVF, replete electrolytes, NPO. Would consider starting TPN after\n 5-7 days\n PPx: SCDs, PPI\n Access: RIJ, fem cordis, right radial art line. Plan to d/c cordis\n today.\n Code: Full Code\n Dispo: ICU level of care.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 16 Gauge - 01:50 PM\n Cordis/Introducer - 02:05 PM\n Arterial Line - 01:35 PM\n Multi Lumen - 02:02 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n ------ Protected Section ------\n MICU ATTENDING ADDENDUM\n I saw and examined the patient, and was physically present with the ICU\n team for the key portions of the services provided. I agree with the\n note above, including the assessment and plan. I would emphasize and\n add the following points: 28M EtOH abuse, weakness, fatigue, UGIB c/b\n hematemesis / melena. Has developed massive fluid requirement,\n hypotension, ARDS in the setting of severe pancreatitis, alcoholic\n hepatitis and borderline renal function. Transient desat this AM, now\n on 100%.\n Exam notable for Tm 99.9 BP 95/50 HR 115 RR 35 with sat 100 on VAC\n 400x32/24 1.0 20 7.30/35/87 CVP 18 IAP 31. +TBB 50L UOP 1.4 - stable.\n Sedated, unresponsive. Hyperdynamic. Bronchial BS B. RRR s1s2.\n Distended, minimal bowel sounds. Massive edema. Labs notable for WBC\n 17K, HCT 32, K+ 4.1, Cr 1.9, lactate 2.1, INR 2.0. CXR with worsening\n ARDS.\n Agree with plan to manage respiratory failure with low volume\n ventilation for ARDS (380x36); will follow titrate PEEP based upon\n esoph balloon\n keep at 24 for now and consider APRV if unable to meet\n goal PaO2 >60. Will allow PCO2 to trend up for now as we are unable to\n increase RR without autopeep. Will continue to hold off on paralysis\n unless asynchrony is a limiting factor. He has received 50L IVF over\n the course of his admission, and we are finally able to start weaning\n pressors. Will d/c standing fluid and provide IVF bolus PRN hypotension\n or low UOP. Will also attempt to decrease fentanyl as able with goal\n overbreaths per minute. UGIB from Dieulafois lesion at GEJ appears\n stable, will monitor serial HCT and continue PPI IV. Will check HCT q8h\n and recheck coags this PM, but will hold on FFP for now. Pancreatitis\n likely due to EtOH - NPO, following, will continue meropenem for\n now. Can't use gut given profound ileus from pancreatitis, narcotic and\n critical illness; may need TPN in the next few days. Alcoholic\n hepatitis is improving by numbers\n will provide supportive care and\n follow labs while holding off on steroids given ongoing GIB. Can d/c\n cordis. Above d/w family at bedside. Remainder of plan as outlined\n above.\n Patient is critically ill\n Total time: 60 min\n ------ Protected Section Addendum Entered By: , MD\n on: 01:02 PM ------\n" }, { "category": "Nursing", "chartdate": "2131-05-21 00:00:00.000", "description": "Nursing Progress Note", "row_id": 675811, "text": "TITLE:\n Hypotension (not Shock)\n Assessment:\n Mean bp < 60 on neosynephrine\n Sr- no ectopics\n Action:\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2131-05-21 00:00:00.000", "description": "Nursing Progress Note", "row_id": 675812, "text": "TITLE:\n Hypotension (not Shock)\n Assessment:\n Mean bp < 60 on neosynephrine Very sedate (high dose fentanyl &versed\n gtts) pupils 2-4mm sluggish reactive, no gag, impaired cough, does not\n withdraw to pain\n Sr- no ectopics. Vigeleo co 4.7-7 range w svv cvp 23-30\n Uop 13-18cc/hr icteric urine\n Action:\n Fluid bloused x 3 = total 1300 cc fld , Neo titrated from 4.4 to\n 5mcg/kg/min.\n Response:\n Transient bp improvements with fluid boluses.Notified Dr and Dr\n re: low bp with low uop. restart levophed if mbp\n continuously <60\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2131-06-06 00:00:00.000", "description": "Nursing Progress Note", "row_id": 679084, "text": "Sepsis, Severe (with organ dysfunction)\n Assessment:\n Temp spike to 101.1 with associated tachycardia, tachypnia\n WBC count 50\n Levophed drip needed to keep MAP> 65\n Action:\n Tylenol given\n Repositioned q 2 hours\n Antibiotics as ordered\n VAP protocol\n Urine culture sent\n HD line changed over wire to Quad central line, confirmed by\n X-Ray\n Right IJ central line discontinued by MICU resident\n Response:\n Remains febrile\n Awaiting am lab results\n Awaiting Cortisol stim test results\n Plan:\n Follow up on final CT scan results\n Follow up on all culture results\n Continue antibiotics, re-evaluate with ID\n Patient and family support\n Impaired Skin Integrity\n Assessment:\n Upper extremities improved, minimal drainage from puncture sites\n Lower extremities have also improved, with blisters that have popped\n weeping less serous fluid\n Inner thighs of both legs concerning due to firm, erythemic, and hot\n skin. Dr. and evaluated\n Heels improving as well,\n Action:\n Wounds cleaned with wound cleanser\n Dried\n Aquacel ag applied to open areas as skin where adaptic was appeared to\n be maserated\n Softsorb and then net stockings to hold in place\n Heels kept off bed with waffle boots\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2131-06-06 00:00:00.000", "description": "Nursing Progress Note", "row_id": 679188, "text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n Sepsis\n Assessment:\n Patient febrile past 24 hrs. w/tmax 103.2\n Action:\n MICU team aware\n Alcohol bath, ice and cooling blanket/Tylenol\n Response:\n Fever responded to above treatment, down to 100.3 in 90 mins.\n Plan:\n Check temp q 2 hrs.\n Repeat above treatments if necessary.\n Impaired Skin Integrity\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Physician ", "chartdate": "2131-05-21 00:00:00.000", "description": "Physician Resident/Attending Progress Note - MICU", "row_id": 676087, "text": "Chief Complaint:\n 24 Hour Events:\n D/c'd R femoral line\n D/c'd maintenence fluids, bolused prn hypotension. Levophed restarted\n am of .\n ESOPHOGEAL BALLOON - At 08:45 AM\n CORDIS/INTRODUCER - STOP 02:05 PM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Meropenem - 12:15 AM\n Infusions:\n Fentanyl (Concentrate) - 300 mcg/hour\n Midazolam (Versed) - 20 mg/hour\n Phenylephrine - 5 mcg/Kg/min\n Other ICU medications:\n Pantoprazole (Protonix) - 08:41 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 05:19 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: 36.8\nC (98.3\n HR: 100 (94 - 106) bpm\n BP: 89/67(77) {72/47(56) - 104/68(79)} mmHg\n RR: 30 (0 - 30) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 111.3 kg (admission): 113.5 kg\n Height: 67 Inch\n CVP: 28 (19 - 35)mmHg\n Total In:\n 6,683 mL\n 1,180 mL\n PO:\n TF:\n IVF:\n 6,638 mL\n 1,180 mL\n Blood products:\n Total out:\n 416 mL\n 94 mL\n Urine:\n 416 mL\n 94 mL\n NG:\n Stool:\n Drains:\n Balance:\n 6,267 mL\n 1,086 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 30\n RR (Spontaneous): 0\n PEEP: 24 cmH2O\n FiO2: 70%\n RSBI Deferred: PEEP > 10, FiO2 > 60%, Hemodynamic Instability\n PIP: 46 cmH2O\n Plateau: 42 cmH2O\n Compliance: 23.5 cmH2O/mL\n SpO2: 97%\n ABG: 7.30/40/82./18/-5\n Ve: 11.7 L/min\n PaO2 / FiO2: 119\n Physical Examination\n Gen: sedated\n HEENT: intubated\n Chest: coarse BS bl\n CV: distant heart sounds, RRR, S1S2\n Abd: distended, abdominal wall edema\n Ext: anasarca throughout\n Labs / Radiology\n 51 K/uL\n 11.0 g/dL\n 100 mg/dL\n 1.8 mg/dL\n 18 mEq/L\n 3.9 mEq/L\n 15 mg/dL\n 100 mEq/L\n 129 mEq/L\n 32.0 %\n 18.5 K/uL\n [image002.jpg]\n 04:55 AM\n 08:07 AM\n 10:04 AM\n 12:04 PM\n 02:30 PM\n 06:50 PM\n 09:15 PM\n 10:34 PM\n 02:42 AM\n 03:01 AM\n WBC\n 16.5\n 18.5\n Hct\n 31.5\n 31.4\n 32.0\n Plt\n 69\n 51\n Cr\n 2.2\n 1.8\n TCO2\n 22\n 21\n 22\n 21\n 21\n 20\n 20\n Glucose\n 108\n 107\n 97\n 100\n Other labs: PT / PTT / INR:20.9/47.6/2.0, ALT / AST:94/271, Alk Phos /\n T Bili:200/14.0, Amylase / Lipase:45/268, Lactic Acid:2.4 mmol/L,\n Albumin:2.2 g/dL, LDH:616 IU/L, Ca++:7.7 mg/dL, Mg++:1.9 mg/dL, PO4:2.4\n mg/dL\n Assessment and Plan\n Mr. is a 28 year old gentleman with alcoholic hepatitis and\n necrotizing pancreatitis complicated by ARDS, SIRS, and UGIB.\n # Respiratory Failure: ARDS secondary to necrotizing pancreatitis\n compounded by hypoxia, tachypnea in setting of anion gap metabolic\n acidosis, increased abdominal pressure, and EtOH withdrawl.\n - Continue current vent settings for now\n - check intraabdominal pressure\n - consider changing bed rotation parameters so only supine and\n left-sided to minimize pressure on IVC.\n - Begin to wean sedation as tolerated. Would prefer to wean down\n fentanyl and then midaxolam.\n # Necrotizing pancreatitis/SIRS: Likely secondary to alcohol\n complicated by SIRS. Patient continues to have pressor requirement and\n volume resucsitation with >54L.\n - Continue empiric meropenem for now. Will discuss with surgical team.\n - Wean pressors as able, starting with levophed\n - If hypotensive, consider using albumin 25-50 grams in preference to\n additional IVF boluses to maintain MAP>60 and UOP>20 cc/hr.\n - Monitor chemistries.\n - Continue to hold MIVF\n - Follow-up with recs if any\n # Acute renal failure: Creatinine continues to trend up with oliguria,\n likely secondary to SIRS/hypotension and IABP leading to ATN.\n - Urine lytes, eos, osm\n - Trend UOP, bolus IVF to maintain goal >20 cc/hr.\n #Thrombocytopenia: platelets trending down. No clear etiology at this\n time. Recommend checking DIC panel and HIT antibody.\n # IAP elevation: Secondary to third spacing and edema. Per surgery, not\n a good surgical candidate at this time.\n # Acute hepatitis: Likely alcoholic hepatitis with fatty infiltration,\n and no evidence of distal obstruction. RUQ u/s shows marked liver\n echogenicity but no ascites.\n - Trend LFTs\n # Hematemesis: EGD showed diuelafoy's lesion. HCT stable since 2 units\n PRBC on .\n - Trend hct, transfuse for hct<21\n # Hyponatremia: In setting of decreased effective circulating volume in\n setting of SIRS and IABP.\n - Trend chemistries.\n # Alcoholism: Patient describes history of withdrawal symptoms, but\n not prior seizure. Last drink was night prior to presentation.\n Tachycardia, weakness, and elevated lactate could be consistent with\n thiamine deficiency.\n - Thiamine, vb12, folate\n - Valium with CIWA > 10\n FEN: IVF, replete electrolytes, NPO. Would consider starting TPN after\n 5-7 days. If patient has no significant change over the next 1-2 days,\n may begin TPN on approximately .\n PPx: SCDs, PPI\n Access: RIJ, right radial art line.\n Code: Full Code\n Dispo: ICU level of care.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Arterial Line - 01:35 PM\n Multi Lumen - 02:02 PM\n Prophylaxis:\n DVT: SCD\n Stress ulcer: PPI\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: 28M EtOH abuse, weakness, fatigue, UGIB c/b\n hematemesis / melena. Has developed massive fluid requirement,\n hypotension, ARDS in the setting of severe pancreatitis, alcoholic\n hepatitis and borderline renal function.\n Exam notable for Tm 99.9 BP 95/50 HR 115 RR 35 with sat 100 on VAC\n 400x32/24 0.7 24 7.30/35/87 CVP 18 IAP 31. +TBB 50L UOP 1.4 - stable.\n Sedated, min responsive. Hyperdynamic. Bronchial BS B. RRR s1s2.\n Distended, minimal bowel sounds. Massive edema. Labs notable for WBC\n 17K, HCT 32, K+ 4.1, Cr 1.8, lactate 2.1, INR 2.0. CXR with worsening\n ARDS.\n Agree with plan to manage respiratory failure with low volume\n ventilation for ARDS (400x30); will follow titrate PEEP based upon\n esoph balloon\n keep at 24 for now and consider APRV if unable to meet\n goal PaO2 >60. For , hold on further fluids and give albumin\n for volume expansion if UOP <20cc/h. UGIB from Dieulafois lesion at GEJ\n appears stable, will monitor serial HCT and continue PPI IV. Will check\n HCT and recheck coags this PM, but will hold on FFP for now.\n Pancreatitis likely due to EtOH, NPO, following; will continue\n meropenem for now. Can't use gut for now; may need TPN in the next few\n days. Alcoholic hepatitis is improving by numbers\n will provide\n supportive care and follow labs while holding off on steroids given\n ongoing GIB. Can d/c cordis. Above d/w family in family mtg with\n . Remainder of plan as outlined above.\n Patient is critically ill\n Total time: 60 min\n ------ Protected Section Addendum Entered By: , MD\n on: 07:16 PM ------\n" }, { "category": "Nursing", "chartdate": "2131-06-24 00:00:00.000", "description": "Nursing Progress Note", "row_id": 682801, "text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Patient on CPAP 5/5 this morning\n Lungs clear, small amount of thick rust secretions\n Action:\n Patient placed on trach collar early this am\n Response:\n Tolerating well\n No abgs yet\n Patient able to cough and raise most secretions\n Plan:\n Keep on trach collar as long as possible\n One abg check later this afternoon\n Hypotension (not Shock)\n Assessment:\n Blood pressure dropping this afternoon\n More febrile as well\n Action:\n MICU team aware\n Levo started, very low dose\n Response:\n Pressure immediately responded to levo\n Plan:\n Titrate off as tolerated.\n" }, { "category": "Respiratory ", "chartdate": "2131-06-25 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 682970, "text": "Day of mechanical ventilation: 3\n Tracheostomy tube:\n Type: Standard, Cuffed\n Manufacturer: Portex\n Size: 8\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Rhonchi\n Secretions\n Sputum color / consistency: Tan / Thick\n Sputum source/amount: Suctioned / Moderate\n Comments:\n Pt weaned back to 40% trach collar. To remain on collar as tolerated.\n Off pressors.\n" }, { "category": "Physician ", "chartdate": "2131-06-26 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 683033, "text": "Chief Complaint:\n 24 Hour Events:\n \n - Sent sputum cx for tachypnea early AM of .\n - Weaned down to trach mask by early afternoon.\n - IR stated it would be very high risk to sample peri-pancreatic fluid\n collection - would likely need to paralyze him as needle would pass\n between dilated splancnic vessels.\n - Renal: plan for HD tomorrow if BP can tolerate it - otherwise may\n need CVVH.\n - ID: recommended d/c'ing aztreonam due to improving fever curve and\n WBC. Also added galactomanan and beta-glucan.\n Allergies:\n Meropenem\n skin blisters a\n Last dose of Antibiotics:\n Metronidazole - 12:00 AM\n Linezolid - 11:51 AM\n Aztreonam - 02:39 PM\n Micafungin - 10:48 PM\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 07:50 PM\n Heparin Sodium (Prophylaxis) - 03:50 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:22 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.1\nC (100.6\n Tcurrent: 37.3\nC (99.2\n HR: 111 (106 - 119) bpm\n BP: 94/55(68) {90/47(60) - 136/71(91)} mmHg\n RR: 30 (20 - 40) insp/min\n SpO2: 98%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 104.5 kg (admission): 113.5 kg\n Height: 67 Inch\n Total In:\n 2,204 mL\n 319 mL\n PO:\n TF:\n 1,205 mL\n 266 mL\n IVF:\n 939 mL\n 53 mL\n Blood products:\n Total out:\n 581 mL\n 175 mL\n Urine:\n 381 mL\n 175 mL\n NG:\n 200 mL\n Stool:\n Drains:\n Balance:\n 1,623 mL\n 144 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n Ventilator mode: Standby\n Vt (Set): 400 (400 - 400) mL\n PS : 5 cmH2O\n RR (Set): 18\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 40%\n PIP: 11 cmH2O\n Plateau: 21 cmH2O\n SpO2: 98%\n ABG: 7.39/39/81./23/0\n Ve: 10.3 L/min\n PaO2 / FiO2: 203\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 228 K/uL\n 6.7 g/dL\n 128 mg/dL\n 3.0 mg/dL\n 23 mEq/L\n 3.3 mEq/L\n 79 mg/dL\n 101 mEq/L\n 136 mEq/L\n 22.5 %\n 15.0 K/uL\n [image002.jpg]\n 01:50 AM\n 03:18 AM\n 03:44 PM\n 01:38 AM\n 06:00 AM\n 01:12 AM\n 06:06 AM\n 02:38 PM\n 02:00 AM\n 02:49 AM\n WBC\n 30.9\n 27.6\n 18.9\n 15.0\n Hct\n 22.2\n 24.0\n 22.2\n 22.5\n Plt\n 28\n Cr\n 2.8\n 1.6\n 2.7\n 3.0\n TCO2\n 27\n 22\n 26\n 18\n 21\n 24\n Glucose\n 170\n 95\n 170\n 121\n 128\n Other labs: PT / PTT / INR:14.3/31.5/1.2, CK / CKMB /\n Troponin-T:214/3/0.07, ALT / AST:67/73, Alk Phos / T Bili:400/6.8,\n Amylase / Lipase:77/88, Differential-Neuts:84.0 %, Band:0.0 %,\n Lymph:7.0 %, Mono:5.0 %, Eos:3.0 %, D-dimer:6389 ng/mL, Fibrinogen:541\n mg/dL, Lactic Acid:2.6 mmol/L, Albumin:2.3 g/dL, LDH:331 IU/L, Ca++:8.6\n mg/dL, Mg++:2.1 mg/dL, PO4:3.7 mg/dL\n Assessment and Plan\n FEVER, UNKNOWN ORIGIN (FUO, HYPERTHERMIA, PYREXIA)\n AROUSAL, ATTENTION, AND COGNITION, IMPAIRED\n BALANCE, IMPAIRED\n MOTOR FUNCTION, IMPAIRED\n MUSCLE PERFORMACE, IMPAIRED\n RESPIRATION / GAS EXCHANGE, IMPAIRED\n SEIZURE, WITHOUT STATUS EPILEPTICUS\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n IMPAIRED SKIN INTEGRITY\n HEPATITIS, ACUTE TOXIC (INCLUDING ALCOHOLIC, ACETAMINOPHEN, ETC.)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ICU Care\n Nutrition:\n Nutren 2.0 () - 01:30 PM 50 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 08:15 PM\n PICC Line - 08:37 AM\n Dialysis Catheter - 08:55 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP: HOB elevation, Mouth care\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:ICU\n" }, { "category": "Physician ", "chartdate": "2131-06-26 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 683034, "text": "Chief Complaint:\n 24 Hour Events:\n \n - Sent sputum cx for tachypnea early AM of .\n - Weaned down to trach mask by early afternoon.\n - IR stated it would be very high risk to sample peri-pancreatic fluid\n collection - would likely need to paralyze him as needle would pass\n between dilated splancnic vessels.\n - Renal: plan for HD tomorrow if BP can tolerate it - otherwise may\n need CVVH.\n - ID: recommended d/c'ing aztreonam due to improving fever curve and\n WBC. Also added galactomanan and beta-glucan.\n Allergies:\n Meropenem\n skin blisters a\n Last dose of Antibiotics:\n Metronidazole - 12:00 AM\n Linezolid - 11:51 AM\n Aztreonam - 02:39 PM\n Micafungin - 10:48 PM\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 07:50 PM\n Heparin Sodium (Prophylaxis) - 03:50 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:22 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.1\nC (100.6\n Tcurrent: 37.3\nC (99.2\n HR: 111 (106 - 119) bpm\n BP: 94/55(68) {90/47(60) - 136/71(91)} mmHg\n RR: 30 (20 - 40) insp/min\n SpO2: 98%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 104.5 kg (admission): 113.5 kg\n Height: 67 Inch\n Total In:\n 2,204 mL\n 319 mL\n PO:\n TF:\n 1,205 mL\n 266 mL\n IVF:\n 939 mL\n 53 mL\n Blood products:\n Total out:\n 581 mL\n 175 mL\n Urine:\n 381 mL\n 175 mL\n NG:\n 200 mL\n Stool:\n Drains:\n Balance:\n 1,623 mL\n 144 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n Ventilator mode: Standby\n Vt (Set): 400 (400 - 400) mL\n PS : 5 cmH2O\n RR (Set): 18\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 40%\n PIP: 11 cmH2O\n Plateau: 21 cmH2O\n SpO2: 98%\n ABG: 7.39/39/81./23/0\n Ve: 10.3 L/min\n PaO2 / FiO2: 203\n Physical Examination\n Gen: lying in bed, eyes open to command, voice\n HEENT: trach\n CV: tachy RR\n Chest: good air movement\n Abd: soft +BS\n Ext: edema\n Neuro: eye open, squeeze hand to command, not answering more involved\n ?s or following more complex commands\n Labs / Radiology\n 228 K/uL\n 6.7 g/dL\n 128 mg/dL\n 3.0 mg/dL\n 23 mEq/L\n 3.3 mEq/L\n 79 mg/dL\n 101 mEq/L\n 136 mEq/L\n 22.5 %\n 15.0 K/uL\n [image002.jpg]\n 01:50 AM\n 03:18 AM\n 03:44 PM\n 01:38 AM\n 06:00 AM\n 01:12 AM\n 06:06 AM\n 02:38 PM\n 02:00 AM\n 02:49 AM\n WBC\n 30.9\n 27.6\n 18.9\n 15.0\n Hct\n 22.2\n 24.0\n 22.2\n 22.5\n Plt\n 28\n Cr\n 2.8\n 1.6\n 2.7\n 3.0\n TCO2\n 27\n 22\n 26\n 18\n 21\n 24\n Glucose\n 170\n 95\n 170\n 121\n 128\n Other labs: PT / PTT / INR:14.3/31.5/1.2, CK / CKMB /\n Troponin-T:214/3/0.07, ALT / AST:67/73, Alk Phos / T Bili:400/6.8,\n Amylase / Lipase:77/88, Differential-Neuts:84.0 %, Band:0.0 %,\n Lymph:7.0 %, Mono:5.0 %, Eos:3.0 %, D-dimer:6389 ng/mL, Fibrinogen:541\n mg/dL, Lactic Acid:2.6 mmol/L, Albumin:2.3 g/dL, LDH:331 IU/L, Ca++:8.6\n mg/dL, Mg++:2.1 mg/dL, PO4:3.7 mg/dL\n Assessment and Plan\n FEVER, UNKNOWN ORIGIN (FUO, HYPERTHERMIA, PYREXIA)\n AROUSAL, ATTENTION, AND COGNITION, IMPAIRED\n BALANCE, IMPAIRED\n MOTOR FUNCTION, IMPAIRED\n MUSCLE PERFORMACE, IMPAIRED\n RESPIRATION / GAS EXCHANGE, IMPAIRED\n SEIZURE, WITHOUT STATUS EPILEPTICUS\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n IMPAIRED SKIN INTEGRITY\n HEPATITIS, ACUTE TOXIC (INCLUDING ALCOHOLIC, ACETAMINOPHEN, ETC.)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ICU Care\n Nutrition:\n Nutren 2.0 () - 01:30 PM 50 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 08:15 PM\n PICC Line - 08:37 AM\n Dialysis Catheter - 08:55 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP: HOB elevation, Mouth care\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:ICU\n" }, { "category": "Physician ", "chartdate": "2131-06-26 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 683035, "text": "Chief Complaint:\n 24 Hour Events:\n \n - Sent sputum cx for tachypnea early AM of .\n - Weaned down to trach mask by early afternoon.\n - IR stated it would be very high risk to sample peri-pancreatic fluid\n collection - would likely need to paralyze him as needle would pass\n between dilated splancnic vessels.\n - Renal: plan for HD tomorrow if BP can tolerate it - otherwise may\n need CVVH.\n - ID: recommended d/c'ing aztreonam due to improving fever curve and\n WBC. Also added galactomanan and beta-glucan.\n Allergies:\n Meropenem\n skin blisters a\n Last dose of Antibiotics:\n Metronidazole - 12:00 AM\n Linezolid - 11:51 AM\n Aztreonam - 02:39 PM\n Micafungin - 10:48 PM\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 07:50 PM\n Heparin Sodium (Prophylaxis) - 03:50 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:22 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.1\nC (100.6\n Tcurrent: 37.3\nC (99.2\n HR: 111 (106 - 119) bpm\n BP: 94/55(68) {90/47(60) - 136/71(91)} mmHg\n RR: 30 (20 - 40) insp/min\n SpO2: 98%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 104.5 kg (admission): 113.5 kg\n Height: 67 Inch\n Total In:\n 2,204 mL\n 319 mL\n PO:\n TF:\n 1,205 mL\n 266 mL\n IVF:\n 939 mL\n 53 mL\n Blood products:\n Total out:\n 581 mL\n 175 mL\n Urine:\n 381 mL\n 175 mL\n NG:\n 200 mL\n Stool:\n Drains:\n Balance:\n 1,623 mL\n 144 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n Ventilator mode: Standby\n Vt (Set): 400 (400 - 400) mL\n PS : 5 cmH2O\n RR (Set): 18\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 40%\n PIP: 11 cmH2O\n Plateau: 21 cmH2O\n SpO2: 98%\n ABG: 7.39/39/81./23/0\n Ve: 10.3 L/min\n PaO2 / FiO2: 203\n Physical Examination\n Gen: lying in bed, eyes open to command, voice\n HEENT: trach\n CV: tachy RR\n Chest: good air movement\n Abd: soft +BS\n Ext: edema\n Neuro: eye open, squeeze hand to command, not answering more involved\n ?s or following more complex commands\n Labs / Radiology\n 228 K/uL\n 6.7 g/dL\n 128 mg/dL\n 3.0 mg/dL\n 23 mEq/L\n 3.3 mEq/L\n 79 mg/dL\n 101 mEq/L\n 136 mEq/L\n 22.5 %\n 15.0 K/uL\n [image002.jpg]\n 01:50 AM\n 03:18 AM\n 03:44 PM\n 01:38 AM\n 06:00 AM\n 01:12 AM\n 06:06 AM\n 02:38 PM\n 02:00 AM\n 02:49 AM\n WBC\n 30.9\n 27.6\n 18.9\n 15.0\n Hct\n 22.2\n 24.0\n 22.2\n 22.5\n Plt\n 28\n Cr\n 2.8\n 1.6\n 2.7\n 3.0\n TCO2\n 27\n 22\n 26\n 18\n 21\n 24\n Glucose\n 170\n 95\n 170\n 121\n 128\n Other labs: PT / PTT / INR:14.3/31.5/1.2, CK / CKMB /\n Troponin-T:214/3/0.07, ALT / AST:67/73, Alk Phos / T Bili:400/6.8,\n Amylase / Lipase:77/88, Differential-Neuts:84.0 %, Band:0.0 %,\n Lymph:7.0 %, Mono:5.0 %, Eos:3.0 %, D-dimer:6389 ng/mL, Fibrinogen:541\n mg/dL, Lactic Acid:2.6 mmol/L, Albumin:2.3 g/dL, LDH:331 IU/L, Ca++:8.6\n mg/dL, Mg++:2.1 mg/dL, PO4:3.7 mg/dL\n Assessment and Plan\n 28M with alcoholic hepatitis and necrotizing pancreatitis complicated\n by ARDS, SIRS, ARF, UGIB, fevers.\n #. Respiratory Failure: ARDS secondary to necrotizing pancreatitis. S/p\n trach placement on . bronch without obvious source of\n bleeding and with only thin secretions throughout; no further reports\n of bleeding since. Now off methadone since . Tachypnea this AM of\n unclear etiology, possible mucous/clot plugging. ?central\n hyperventilation event. Would be transient for PE.\n - Wean off vent to trach mask and recheck ABG\n - F/u CXR final read\n - Sputum cx\n - Wean valium to (D2/3), decrease to daily on \n - Cont fentanyl boluses prn (not requiring)\n - Trach care, OOB to chair daily\n - DDAVP if acute bleeding (max few doses). Had required amicar shortly\n after trach for continued bleeding but complicated by seizure shortly\n after starting this.\n #. Fevers/leukocytosis: Fevers off CVVH with stable-improving\n leukocytosis. Possible that continued fevers necrotizing\n pancreatitis. Surgery was consulted for fluid collections peri-pancreas\n but felt to not be infected. CMV positive, but likely not contributing\n to current illness per ID. Also with persistent yeast in ucx,\n persistent colonic inflammation on CT with neg C. diff x 3, and concern\n for serotonin syndrome with linezolid and pressors, now discontinued.\n On aztreonam (since ) and micafungin (since ). In setting of\n fevers and hypotension, Cipro was started , but d/c\ned . Flagyl\n (since ) and po vanc (since ) discontinued . Linezolid\n started and stopped .\n - ID would prefer to wean off micafungin last\n - Consider d/c aztreonam today; will f/u with ID\n - Ordered for CMV VL on \n - D/w IR if abd fluid collection is drainable in case we want to drain\n it later. Currently hesitant given unclear benefit for a procedure that\n could further complicate his ICU course.\n - D/c a-line when able as has been in since \n - Follow WBC count, temp curve, and culture data\n - Send bcx from HD line as none yet pending\n # Abd tenderness: Likely secondary to necrotizing pancreatitis, now\n able to react as mental status improves. Concern for obstruction given\n emesis this AM but abd xray on our read does not appear c/w this and\n reported to have had BMs. Also has h/o colitis but C. diff neg x 3.\n - F/u abd XR\n - Management of pancreatitis as above\n # Shock: Cont to have hypotension in setting of fevers although only\n intermittent need for pressors and resolved without change in abx\n regimen.\n - If requires pressors without fever, consider other etiologies of\n hypotension including cardiogenic. Consider IVF if BPs drop to see if\n fluid responsive prior to starting levophed again although hypotensive\n events have not occurred in close proximity time-wise to HD sessions\n - Weaned off steroids on \n - Keep a-line until off pressors x 24 h but d/c when possible\n - Infectious w/u as above\n # Elevated LFTs: A/w alcoholic hepatitis. RUQ u/s showed sludge\n concerning for cholestasis but also seen on u/s. HIDA neg.\n TPN stopped . LFTs downtrending as of yesterday.\n - Weaning off benzos: valium 5mg D \n - Continue to trend\n #. Acute renal Failure: Multifactorial including ATN from hypotension.\n - HD per renal\n - F/u Renal recs\n #. Adrenal Insufficiency: Unclear with stim if adrenally\n insufficient but hypotension initially improved with steroids (lower\n pressor requirement) and eosinophilia resolved. He has now weaned off\n steroids completely.\n - Last dose prednisone was \n # Seizures: CT head without intracranial process. EEG showed occipital\n seizures which does not correlate with clinical symptoms, but repeat\n EEG on higher dose Keppra showed no seizures. As patient now with\n purposeful movements, this may actually be patient waking up, not\n seizures.\n - Continue keppra at HD dosing\n # Altered Mental Status: Continue to reassess as weaning off sedatives.\n - Off of methadone as of \n - Cont to wean valium as above\n - Will ask Neuro for input re: prognostication if MS with no further\n improvement by end of week\n # Low ionized calcium: be spurious as Ca with Chem 10 nl.\n - Recheck w/ next ABG\n ICU Care\n Nutrition:\n Nutren 2.0 () - 01:30 PM 50 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 08:15 PM\n PICC Line - 08:37 AM\n Dialysis Catheter - 08:55 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP: HOB elevation, Mouth care\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:ICU\n" }, { "category": "Nursing", "chartdate": "2131-06-26 00:00:00.000", "description": "Nursing Progress Note", "row_id": 683031, "text": "TITLE:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Trach collar at 40%. Bbs coarse to clear , diminished at bases\n bilateral. Resp rate variable. Mid 30\ns to 20\n Action:\n Oob to chair early evening with rr from mid 30\ns to 20\ns once\n oob. Strong prod cough for thick white to bl tinged sputum, suctioned\n for sm to mod thick white secretions.Vap bundle. Trach care done.\n Response:\n Adeq abg on trach collar.40%\n Plan:\n Check with speech and swallow re: PMV trials. Pulm toilet, oob to chair\n as tol. Vap bundle\n Hypotension (not Shock)\n Assessment:\n Mbp > 60 off levophed\n Action:\n No interventions necessary for bp management\n Response:\n Continue to monitor for hypotension and rx with levophed as needed\n Plan:\n Planned HD today, may need standby levophed for potential hypotension\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Making small amts icteric urine w sediment. Creat 3.0 this am.\n Action:\n Cont to minimize fluids. Trend labs.\n Response:\n Creat and Bun trending back up.\n Plan:\n HD planned today. Extra dose Keppra to be dosed post HD .\n" }, { "category": "Rehab Services", "chartdate": "2131-06-26 00:00:00.000", "description": "Physical Therapy Progress Note", "row_id": 683164, "text": "Subjective:\n n/a\n Objective:\n Follow up PT visit to address goals of: . Patient seen today\n for balance training, patient education\n Updated medical status: extubated. on trach mask\n Activity\n Clarification\n I\n S\n CG\n Min\n Mod\n Max\n Rolling:\n Total A x 2\n\n\n\n\n\n\n Supine/\n Sidelying to Sit:\n Total A x 2\n\n\n\n\n\n\n Transfer:\n NT\n\n\n\n\n\n\n Sit to Stand:\n\n\n\n\n\n Ambulation:\n\n\n\n\n\n Stairs:\n\n\n\n\n\n Aerobic Activity Response:\n Position\n HR\n BP\n RR\n O[2] sat\n RPE\n Rest\n Supine\n 105\n 136/70\n 22\n 97 on 40 % TM\n Activity\n Sit\n 114\n 134/64\n 30\n 91-93\n Recovery\n Supine\n 106\n 133/71\n 22\n 96\n Total distance walked:\n Minutes:\n Gait: NT\n Balance: S to max A to sit EOB. Maintained sitting EOB with S for 30\n sec. only, otherwise needed max A posterior trunk bias\n Education / Communication: Pt. edu re; POC, coughing; RN comm re; Pt.\n status, positioning\n Other: Alert, visually tracking therapist across midline, no response\n noted to commands. not verbalizing\n Assessment: Pt. is 28 y.o. male with acute pancreatitis c/b PEA arrest\n that continues to p/w improved arousal, and alertness, however progress\n with mobility is limited by impaired cognition. Continue to recommend\n rehab placement upon d/c.\n Anticipated Discharge: Rehab\n Plan: bed mobility, therex, positioning, balance re-edu\n Face time: 16:20-17:04\n" }, { "category": "Respiratory ", "chartdate": "2131-07-04 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 685049, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 0\n Ideal body weight: 67.1 None\n Ideal tidal volume: 268.4 / 402.6 / 536.8 mL/kg\n Airway\n Airway Placement Data\n Tracheostomy tube:\n Type: Cuffed\n Manufacturer: Portex\n Size: 8.0mm\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Cuff volume: 5 mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: /\n Sputum source/amount: /\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Unassisted spontaneous breathing\n Visual assessment of breathing pattern:\n Assessment of breathing comfort: No claim of dyspnea)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: trach collar\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n" }, { "category": "Physician ", "chartdate": "2131-06-24 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 682692, "text": "Chief Complaint:\n 24 Hour Events:\n - Per ID recs, flagyl and po vanc discontinued; also consider seratonin\n syndrome from interaction between linezolid and pressors and d/c\n linezolid today if WBCs stable tomorrow. Mycolytic bcx sent; consider\n TTE for possible fungal infection and consider IR-guided aspiration of\n abdominal cyst.\n - Spiked temp to 102 at 3pm, hypotensive to 70s, tachycardic,\n tachypneic. Blood gas with PCO2 25. Put back on pressure support and\n pressors transiently.\n - Renal: Linezolid dose changed to after HD on HD days\n Allergies:\n Meropenem\n skin blisters a\n Last dose of Antibiotics:\n Vancomycin - 02:18 PM\n Ciprofloxacin - 08:00 PM\n Linezolid - 12:50 PM\n Aztreonam - 02:00 PM\n Micafungin - 10:30 PM\n Metronidazole - 12:00 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 12:50 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:45 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 39.1\nC (102.4\n Tcurrent: 37.2\nC (99\n HR: 99 (96 - 118) bpm\n BP: 121/60(80) {83/44(59) - 145/76(99)} mmHg\n RR: 22 (19 - 41) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 104 kg (admission): 113.5 kg\n Height: 67 Inch\n Total In:\n 2,791 mL\n 411 mL\n PO:\n TF:\n 1,205 mL\n 277 mL\n IVF:\n 1,525 mL\n 135 mL\n Blood products:\n Total out:\n 1,796 mL\n 60 mL\n Urine:\n 296 mL\n 60 mL\n NG:\n Stool:\n Drains:\n Balance:\n 995 mL\n 351 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 427 (174 - 530) mL\n PS : 5 cmH2O\n RR (Spontaneous): 30\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 45\n PIP: 11 cmH2O\n SpO2: 100%\n ABG: 7.51/27/73./24/0\n Ve: 15.5 L/min\n PaO2 / FiO2: 183\n Physical Examination\n GEN: Trached.\n HEENT: Icteric sclera. MMM.\n NECK: Trach site with no oozing.\n LUNGS: Anterior auscultation with upper airway noise; good airway\n movement.\n HEART: RRR, normal S1, S2.\n ABD: Distended. Firm, but unchanged.\n EXTREM: 2+ edema, ulcers/lesions on legs with bandages C/D/I.\n SKIN: Jaundiced.\n NEURO: Twitching mouth and arms. Opens eyes, squeezes hand to command.\n Labs / Radiology\n 268 K/uL\n 7.3 g/dL\n 170 mg/dL\n 1.6 mg/dL\n 24 mEq/L\n 3.4 mEq/L\n 39 mg/dL\n 101 mEq/L\n 137 mEq/L\n 24.0 %\n 27.6 K/uL\n [image002.jpg]\n 02:50 AM\n 05:09 PM\n 05:55 PM\n 05:57 PM\n 09:02 PM\n 01:42 AM\n 01:50 AM\n 03:18 AM\n 03:44 PM\n 01:38 AM\n WBC\n 34.0\n 35.7\n 30.9\n 27.6\n Hct\n 21.6\n 23.1\n 22.2\n 24.0\n Plt\n 291\n 305\n 264\n 268\n Cr\n 1.2\n 1.8\n 2.8\n 1.6\n TCO2\n 20\n 22\n 21\n 27\n 22\n Glucose\n 126\n 136\n 170\n 95\n 170\n Other labs: PT / PTT / INR:15.9/35.0/1.4,, Ca++:8.1 mg/dL, Mg++:1.9\n mg/dL, PO4:2.0 mg/dL\n Assessment and Plan\n 28M with alcoholic hepatitis and necrotizing pancreatitis complicated\n by ARDS, SIRS, ARF, UGIB, fevers.\n #. Fevers/leukocytosis: Fevers off CVVH with stable-improving\n leukocytosis. Possible that continued fevers necrotizing\n pancreatitis. Surgery was consulted for fluid collections peri-pancreas\n but felt to not be infected. CMV positive, but likely not contributing\n to current illness per ID. Also with persistent yeast in ucx,\n persistent colonic inflammation on CT with neg C. diff x 3, and concern\n for serotonin syndrome with linezolid and pressors. On aztreonam and\n linezolid (since ) and micafungin (since ). In setting of fevers\n and hypotension, Cipro was started , but d/c\ned . Flagyl (since\n ) and po vanc (since ) discontinued .\n - D/c linezolid today given concern for serotonin syndrome/drug fever.\n - Cont aztreonam and micafungin for now\n - D/w IR if abd fluid collection is drainable in case we want to drain\n it later. Currently do not want to operate on abdomen with pancreatitis\n changes.\n - Recheck CMV VL on \n - Follow WBC count, temp curve, and culture data\n - F/u ID recs\n # Shock: Cont to have hypotension in setting of fevers. Treating for\n infection as above.\n - If requires pressors without fever, consider other etiologies of\n hypotension including cardiogenic. Consider IVF if BPs drop to see if\n fluid responsive prior to starting levophed again.\n - Last dose of prednisone taper today (5mg D3/3)\n - Keep a-line until off pressors x 24 h\n - Infectious w/u as above\n # Elevated LFTs: A/w alcoholic hepatitis. RUQ u/s showed sludge\n concerning for cholestasis but also seen on u/s. HIDA neg.\n TPN stopped . LFTs downtrending as of yesterday.\n - Weaning off benzos: decrease valium to 5mg today\n - Continue to trend\n #. Respiratory Failure: ARDS secondary to necrotizing pancreatitis. S/p\n trach placement on . bronch without obvious source of\n bleeding and with only thin secretions throughout; no further reports\n of bleeding since.\n - DDAVP if acute bleeding (max few doses). Had required amicar shortly\n after trach for continued bleeding but complicated by seizure shortly\n after starting this.\n - Discontinue methadone today\n - Wean valium to today\n - Cont fentanyl boluses prn\n - Trach care\n - Cont OOB to chair daily\n #. Acute renal Failure: Multifactorial including ATN from hypotension\n - F/u Renal recs re: HD\n #. Adrenal Insufficiency: Unclear with stim if clear adrenal\n insufficiency but hypotension improving with steroids (lower pressor\n requirement) and eosinophilia resolved.\n - Last dose prednisone 5mg today\n # Seizures: CT head without intracranial process. EEG showed occipital\n seizures which does not correlate with clinical symptoms, but repeat\n EEG on higher dose Keppra showed no seizures. As patient now with\n purposeful movements, this may actually be patient waking up, not\n seizures.\n - Continue keppra at HD dosing\n # Altered Mental Status:\n - Discontinue methadone today\n - Wean valium to today\n ICU Care\n Nutrition:\n Nutren 2.0 () - 01:49 PM 50 mL/hour\n Glycemic Control: ISS\n Lines:\n Arterial Line - 08:15 PM\n PICC Line - 08:37 AM\n Dialysis Catheter - 08:55 AM\n Prophylaxis:\n DVT: SQ heparin\n Stress ulcer: H2B\n VAP:\n Comments:\n Communication: Comments: With brother.\n status: Full code\n Disposition: ICU\n" }, { "category": "Physician ", "chartdate": "2131-06-21 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 682081, "text": "Chief Complaint:\n 24 Hour Events:\n - Renal deferred starting HD given hypotension yesterday with plan to\n start today.\n - Surgery recommended starting antifungal but not draining fluid\n collection around pancreas which appeared sterile to them given absence\n of gas.\n - ID recommended broadening antibiotic coverage to micafungin, vanc po,\n and cipro for double GN coverage. Thought fluid collection should\n drained by IR. Also would check surveillance cx, CMV VL, recheck C.\n diff, c/s GI re: colonoscopy for biopsy of colitis, d/c A-line and\n foley if able.\n - Abx coverage broadened to micafungin and vanc po.\n - Speech evaluated for Passy-Muir valve but pt couldn't tolerate.\n - Methadone, hydrocort, and valium weaned down.\n - Neuro saw pt and thought making slow progress; will continue to\n follow for prognostication.\n Allergies:\n Meropenem\n skin blisters a\n Last dose of Antibiotics:\n Micafungin - 09:30 PM\n Linezolid - 12:40 AM\n Aztreonam - 02:25 AM\n Vancomycin - 02:26 AM\n Metronidazole - 04:16 AM\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 12:00 AM\n Heparin Sodium (Prophylaxis) - 04:16 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 04:37 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.9\nC (100.2\n Tcurrent: 37.9\nC (100.2\n HR: 110 (89 - 116) bpm\n BP: 99/54(68) {99/52(68) - 139/72(94)} mmHg\n RR: 26 (22 - 34) insp/min\n SpO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 100.7 kg (admission): 113.5 kg\n Height: 67 Inch\n Total In:\n 2,814 mL\n 886 mL\n PO:\n TF:\n 1,100 mL\n 230 mL\n IVF:\n 1,564 mL\n 596 mL\n Blood products:\n Total out:\n 330 mL\n 130 mL\n Urine:\n 330 mL\n 130 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,484 mL\n 756 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n SpO2: 100%\n ABG: 7.39/32/92./18/-4\n PaO2 / FiO2: 186\n Physical Examination\n GEN: Trached.\n HEENT: Icteric sclera. MMM.\n NECK: Trach site with no oozing.\n LUNGS: Anterior auscultation with upper airway noise; good airway\n movement.\n HEART: RRR, normal S1, S2.\n ABD: Distended. Firm, but unchanged.\n EXTREM: 2+ edema, ulcers/lesions on legs with bandages C/D/I.\n SKIN: Jaundiced.\n NEURO: Twitching mouth. Opens eyes, squeezes hand to command.\n Labs / Radiology\n 277 K/uL\n 7.0 g/dL\n 132 mg/dL\n 2.4 mg/dL\n 18 mEq/L\n 3.9 mEq/L\n 82 mg/dL\n 99 mEq/L\n 131 mEq/L\n 22.6 %\n 38.6 K/uL\n [image002.jpg]\n 10:53 AM\n 12:57 PM\n 03:00 PM\n 10:13 PM\n 10:23 PM\n 03:00 AM\n 03:15 AM\n 04:57 PM\n 02:28 AM\n 02:50 AM\n WBC\n 38.5\n 38.5\n Hct\n 22.7\n 22.7\n 22.6\n Plt\n 282\n 282\n 277\n Cr\n 1.2\n 1.8\n 2.4\n TCO2\n 23\n 22\n 18\n 25\n 23\n 20\n Glucose\n 114\n 121\n 140\n 135\n 141\n 132\n Other labs: PT / PTT / INR:15.0/33.3/1.3, CK / CKMB /\n Troponin-T:214/3/0.07, ALT / AST:181/177, Alk Phos / T Bili:455/15.9,\n Amylase / Lipase:77/141, Differential-Neuts:90.0 %, Band:0.0 %,\n Lymph:3.0 %, Mono:5.0 %, Eos:1.0 %, D-dimer:6389 ng/mL, Fibrinogen:502\n mg/dL, Lactic Acid:1.4 mmol/L, Albumin:2.0 g/dL, LDH:529 IU/L, Ca++:8.6\n mg/dL, Mg++:2.3 mg/dL, PO4:3.0 mg/dL\n Assessment and Plan\n 28M with alcoholic hepatitis and necrotizing pancreatitis complicated\n by ARDS, SIRS, ARF, UGIB, fevers.\n #. ID: Persistent leukocytosis and fevers now that off CVVH. Possible\n that continued fevers necrotizing pancreatitis. Also with\n persistent yeast in ucx, persistent colonic inflammation on CT. On\n aztreonam, linezolid (since ) and flagyl (since ). Started\n micafungin and po vanc yesterday.\n - New fluid collection peri-pancreas\n unclear if infected. Per Surgery\n with no role for fluid drainage at this time.\n - Cont broad coverage with linezolid (-), aztreo (-), flagyl\n (-), mica (-), vanc po (-).\n - Follow WBC count, temp curve, and culture data\n # Shock: Patient had transient pressor requirement last pm in setting\n of fever. When fever resolved pressor requirement did as well. Likely\n septic shock. Will treat for infection as above. If requires pressors\n without fever consider other etiologies of hypotension including\n cardiogenic.\n - Cont weaning steroids\n - ?D/c a-line\n # Elevated LFTs: A/w alcoholic hepatitis. RUQ u/s showed sludge\n concerning for cholestasis but also seen on u/s. T Bili and\n transaminases improving today.\n - HIDA neg\n - TPN stopped \n - weaning off benzos\n #. Respiratory Failure: ARDS secondary to necrotizing pancreatitis. S/p\n trach placement on .\n - Cte fentanyl boluses and alternatingly wean methadone and valium as\n tolerate.\n - Cte OOB to chair daily\n #. Acute renal Failure: Multifactorial inc. ATN from hypotension\n - Was supposed to transition to HD today but pressures not able to\n tolerate. No need for filtration so will reassess tmrw.\n - Aztreonam 2000mg q12h while on CVVH. Change after aztreonam.\n - Will change Keppra to 1000mg Q24 with 500 mg after HD when able to\n tolerate HD\n #. Adrenal Insufficiency: Unclear with stim if clear adrenal\n insufficiency but hypotension improving with steroids (lower pressor\n requirement) and eosinophilia resolved.\n - Cont weaning hydrocort to q12h today\n # Seizures: CT head without intracranial process. EEG showed occipital\n seizures which does not correlate with clinical symptoms, but repeat\n EEG on higher dose Keppra showed no seizures. As patient now with\n purposeful movements, this may actually be patient waking up, not\n seizures.\n - Continue keppra (change dosing if changes to HD)\n - Wean valium today\n ICU Care\n Nutrition:\n Nutren 2.0 () - 01:56 AM 50 mL/hour\n Glycemic Control: ISS\n Lines:\n Arterial Line - 08:15 PM\n PICC Line - 08:37 AM\n Dialysis Catheter - 08:55 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP:\n Comments:\n Communication: Comments: With brother\n status: Full code\n Disposition:ICU pending HD trial ; in screening process.\n" }, { "category": "Physician ", "chartdate": "2131-06-21 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 682084, "text": "Chief Complaint:\n 24 Hour Events:\n - Renal deferred starting HD given hypotension yesterday with plan to\n start today.\n - Surgery recommended starting antifungal but not draining fluid\n collection around pancreas which appeared sterile to them given absence\n of gas.\n - ID recommended broadening antibiotic coverage to micafungin, vanc po,\n and cipro for double GN coverage. Thought fluid collection should\n drained by IR. Also would check surveillance cx, CMV VL, recheck C.\n diff, c/s GI re: colonoscopy for biopsy of colitis, d/c A-line and\n foley if able.\n - Abx coverage broadened to micafungin and vanc po.\n - Speech evaluated for Passy-Muir valve but pt couldn't tolerate.\n - Methadone, hydrocort, and valium weaned down.\n - Neuro saw pt and thought making slow progress; will continue to\n follow for prognostication.\n Allergies:\n Meropenem\n skin blisters a\n Last dose of Antibiotics:\n Micafungin - 09:30 PM\n Linezolid - 12:40 AM\n Aztreonam - 02:25 AM\n Vancomycin - 02:26 AM\n Metronidazole - 04:16 AM\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 12:00 AM\n Heparin Sodium (Prophylaxis) - 04:16 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 04:37 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.9\nC (100.2\n Tcurrent: 37.9\nC (100.2\n HR: 110 (89 - 116) bpm\n BP: 99/54(68) {99/52(68) - 139/72(94)} mmHg\n RR: 26 (22 - 34) insp/min\n SpO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 100.7 kg (admission): 113.5 kg\n Height: 67 Inch\n Total In:\n 2,814 mL\n 886 mL\n PO:\n TF:\n 1,100 mL\n 230 mL\n IVF:\n 1,564 mL\n 596 mL\n Blood products:\n Total out:\n 330 mL\n 130 mL\n Urine:\n 330 mL\n 130 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,484 mL\n 756 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n SpO2: 100%\n ABG: 7.39/32/92./18/-4\n PaO2 / FiO2: 186\n Physical Examination\n GEN: Trached.\n HEENT: Icteric sclera. MMM.\n NECK: Trach site with no oozing.\n LUNGS: Anterior auscultation with upper airway noise; good airway\n movement.\n HEART: RRR, normal S1, S2.\n ABD: Distended. Firm, but unchanged.\n EXTREM: 2+ edema, ulcers/lesions on legs with bandages C/D/I.\n SKIN: Jaundiced.\n NEURO: Twitching mouth. Opens eyes, squeezes hand to command.\n Labs / Radiology\n 277 K/uL\n 7.0 g/dL\n 132 mg/dL\n 2.4 mg/dL\n 18 mEq/L\n 3.9 mEq/L\n 82 mg/dL\n 99 mEq/L\n 131 mEq/L\n 22.6 %\n 38.6 K/uL\n [image002.jpg]\n 10:53 AM\n 12:57 PM\n 03:00 PM\n 10:13 PM\n 10:23 PM\n 03:00 AM\n 03:15 AM\n 04:57 PM\n 02:28 AM\n 02:50 AM\n WBC\n 38.5\n 38.5\n Hct\n 22.7\n 22.7\n 22.6\n Plt\n 282\n 282\n 277\n Cr\n 1.2\n 1.8\n 2.4\n TCO2\n 23\n 22\n 18\n 25\n 23\n 20\n Glucose\n 114\n 121\n 140\n 135\n 141\n 132\n Other labs: PT / PTT / INR:15.0/33.3/1.3, CK / CKMB /\n Troponin-T:214/3/0.07, ALT / AST:181/177, Alk Phos / T Bili:455/15.9,\n Amylase / Lipase:77/141, Differential-Neuts:90.0 %, Band:0.0 %,\n Lymph:3.0 %, Mono:5.0 %, Eos:1.0 %, D-dimer:6389 ng/mL, Fibrinogen:502\n mg/dL, Lactic Acid:1.4 mmol/L, Albumin:2.0 g/dL, LDH:529 IU/L, Ca++:8.6\n mg/dL, Mg++:2.3 mg/dL, PO4:3.0 mg/dL\n Assessment and Plan\n 28M with alcoholic hepatitis and necrotizing pancreatitis complicated\n by ARDS, SIRS, ARF, UGIB, fevers.\n #. ID: Persistent leukocytosis and fevers now that off CVVH. Possible\n that continued fevers necrotizing pancreatitis. Also with\n persistent yeast in ucx, persistent colonic inflammation on CT. On\n aztreonam, linezolid (since ) and flagyl (since ). Started\n micafungin and po vanc yesterday.\n - New fluid collection peri-pancreas\n unclear if infected. Per Surgery\n with no role for fluid drainage at this time.\n - f/u ID recs\n - Cont broad coverage with linezolid (-), aztreo (-), flagyl\n (-), mica (-), vanc po (-).\n - f/u c diff, if neg x2-3 can d/c po vanc\n - Follow WBC count, temp curve, and culture data\n # Shock: Patient had transient pressor requirement last pm in setting\n of fever. When fever resolved pressor requirement did as well. Likely\n septic shock. Will treat for infection as above. If requires pressors\n without fever consider other etiologies of hypotension including\n cardiogenic.\n - Cont weaning steroids\n change to PO prednisone 5 mg in AM of \n - D/c a-line\n check VBG and ABG simultaneously\n # Elevated LFTs: A/w alcoholic hepatitis. RUQ u/s showed sludge\n concerning for cholestasis but also seen on u/s. T Bili and\n transaminases improving today.\n - HIDA neg\n - TPN stopped \n - weaning off benzos\n 5 mg valium\n #. Respiratory Failure: ARDS secondary to necrotizing pancreatitis. S/p\n trach placement on .\n - Cte fentanyl boluses and alternatingly wean methadone and valium as\n tolerate.\n - Cte OOB to chair daily\n - Wean methadone to \n #. Acute renal Failure: Multifactorial inc. ATN from hypotension\n - Was supposed to transition to HD today but pressures not able to\n tolerate. No need for filtration so will reassess tmrw.\n - Aztreonam 2000mg q12h while on CVVH. Change after aztreonam.\n - continue Keppra at 1000mg Q24 with 500 mg after HD\n #. Adrenal Insufficiency: Unclear with stim if clear adrenal\n insufficiency but hypotension improving with steroids (lower pressor\n requirement) and eosinophilia resolved.\n - Cont weaning hydrocort to q12h today\n - transition to PO prednisone 5 mg daily in AM of \n # Seizures: CT head without intracranial process. EEG showed occipital\n seizures which does not correlate with clinical symptoms, but repeat\n EEG on higher dose Keppra showed no seizures. As patient now with\n purposeful movements, this may actually be patient waking up, not\n seizures.\n - Continue keppra at HD dosing\n - Wean valium today\n ICU Care\n Nutrition:\n Nutren 2.0 () - 01:56 AM 50 mL/hour\n Glycemic Control: ISS\n Lines:\n Arterial Line - 08:15 PM\n PICC Line - 08:37 AM\n Dialysis Catheter - 08:55 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP:\n Comments:\n Communication: Comments: With brother\n status: Full code\n Disposition:ICU pending HD trial ; in screening process with goal for\n d/c on Monday.\n" }, { "category": "Nursing", "chartdate": "2131-06-24 00:00:00.000", "description": "Nursing Progress Note", "row_id": 682679, "text": "Hypotension (not Shock)\n Assessment:\n SBP running 110-130s, MAPs maintaining >65\n Action:\n Weaned off levophed\n Response:\n SBP maintained >65 without levophed\n Plan:\n Continue to monitor BP closely\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt remained on CPAP 5 peep/ 5 pressure support with 40% fio2.\n Action:\n ABG drawn in AM. Pt required suctioning every 3-4 hours for slightly\n blood tinged sputum\n Response:\n Pox 98-100%, ABG wnl. RR 20-30s at rest but can elevate into 40s with\n activity/suctioning.\n Plan:\n Plan to change patient back over to trach mask\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Pt had HD last . Pt with minimal icteric urine output (15-20cc\n every hours0 BUN/Creatinine improving\n Action:\n Monitoring urine output and lab values\n Response:\n Pt stable at present\n Plan:\n Continue to follow labs. HD likely tomorrow\n" }, { "category": "Nursing", "chartdate": "2131-06-24 00:00:00.000", "description": "Nursing Progress Note", "row_id": 682680, "text": "Hypotension (not Shock)\n Assessment:\n SBP running 110-130s, MAPs maintaining >65\n Action:\n Weaned off levophed\n Response:\n SBP maintained >65 without levophed\n Plan:\n Continue to monitor BP closely\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt remained on CPAP 5 peep/ 5 pressure support with 40% fio2.\n Action:\n ABG drawn in AM. Pt required suctioning every 3-4 hours for slightly\n blood tinged sputum\n Response:\n Pox 98-100%, ABG wnl. RR 20-30s at rest but can elevate into 40s with\n activity/suctioning.\n Plan:\n Plan to change patient back over to trach mask\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Pt had HD last . Pt with minimal icteric urine output (15-20cc\n every hours0 BUN/Creatinine improving\n Action:\n Monitoring urine output and lab values\n Response:\n Pt stable at present\n Plan:\n Continue to follow labs. HD likely tomorrow\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n elevated temperature up to 102 on prior shift\n Action:\n Cooling blanket device on patient\n Response:\n Temp down to 99.8 and cooling blanket removed\n Plan:\n Follow temps / temps r/t possible pancreatic abscess\n" }, { "category": "Nursing", "chartdate": "2131-06-21 00:00:00.000", "description": "Nursing Progress Note", "row_id": 682158, "text": "Sepsis, Severe (with organ dysfunction)\n Assessment:\n WBC 38. Tmax 101.2\n SBP 100s this a.m. Was alert and bright this a.m.\n Hemodialysis this a.m.\n Hypotensive and febrile at 1700.\n Action:\n Dialyzed for 1L of fluid.\n IV ABX continue as ordered. Cipro added as well PO ABX.\n Levo started to maintain MAP >60 as well as 250 NS bolus given. Calcium\n repleted. Lytes sent.\n OOB to chair this am. Tylenol given for temp.\n Cultured (peripherally and a line).\n VBG & ABG sent though results are inconclusive. Follow abgs for now.\n Response:\n Tolerated dialysis well today though dropped SBP 2 hours after to\n SBPs70s with MAPs in 50s.\n Responds well to Levophed.\n ABG wnl. Tolerating trach mask well. Sats remain wnl.\n Plan:\n Maintain MAP>60. Follow up with labs and temp. Urine culture and u/a\n awaiting to be sent.\n Family updated re: POC.\n" }, { "category": "Nursing", "chartdate": "2131-06-25 00:00:00.000", "description": "Nursing Progress Note", "row_id": 682847, "text": "TITLE:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received on trach collar 40% Bbs coarse to clear and diminish at bases.\n Coughing and raising thick tan to clear sputum. Becomes tachypneic\n transiently with turning and repositioning.\n Action:\n tracheal suct x2 for small amts thick clear to white secretions. Trach\n care done.Vap bundle q4h\n Response:\n O2 sats > 98% throughout the noc. Remains on trach collar w no signs of\n resp distress.\n Plan:\n Cont Pulm toilet, trach care, vap bundle. Suct prn congestion.? PMV\n trial\n Hypotension (not Shock)\n Assessment:\n received on low dose levo 0.03mcg/kg/m sbp > 100 on same w mbp 70\n sinus tach 110-115\n Action:\n Weaned levo off for goal mbp > or (=) to 60 per MICU\n Response:\n mbp remains >/= to 60, hr\ns essentially unchanged off levophed\n Plan:\n Levophed standby for mbp consistently < 60\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Tmax 100.7 po\n Action:\n tylenol 650mg per feed tube, daily surveillance blood cultures sent\n Response:\n Temp transiently down to 99.7 po after tylenol\n Plan:\n Repeat tylenol q6h prn for temp > 101. Check with team re: urine/sputum\n culture if temp spikes > 101.5\n ------ Protected Section ------\n Temp trending up 101.2 po w consequent Mbp < 60 with systolic 80.\n Levophed resumed at 0.05mcg/kg/m. Tylenol per ft given.\n ------ Protected Section Addendum Entered By: , RN\n on: 02:48 ------\n" }, { "category": "Nursing", "chartdate": "2131-06-21 00:00:00.000", "description": "Nursing Progress Note", "row_id": 682157, "text": "Sepsis, Severe (with organ dysfunction)\n Assessment:\n WBC 38. Tmax 101.2\n SBP 100s this a.m. Was alert and bright this a.m.\n Hemodialysis this a.m.\n Hypotensive and febrile at 1700.\n Action:\n Dialyzed for 1L of fluid.\n IV ABX continue as ordered. Cipro added as well PO ABX.\n Levo started to maintain MAP >60 as well as 250 NS bolus given. Calcium\n repleted. Lytes sent.\n OOB to chair this am. Tylenol given for temp.\n Cultured (peripherally and a line).\n VBG & ABG sent though results are inconclusive. Follow abgs for now.\n Response:\n Tolerated dialysis well today though dropped SBP 2 hours after to\n SBPs70s with MAPs in 50s.\n Responds well to Levophed.\n ABG wnl. Tolerating trach mask well. Sats remain wnl.\n Plan:\n Maintain MAP>60. Follow up with labs and temp. Urine culture and u/a\n awaiting to be sent.\n Family updated re: POC.\n" }, { "category": "Nutrition", "chartdate": "2131-06-22 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 682292, "text": "Subjective: Did not talk to patient\n asleep.\n Objective\n Current Wt: 100.7kg ()\n Adm Wt: 113.5kg\n Pertinent medications: Levophed, RISS, ABx, Pepcid, heparin, Glargine,\n Prednisone, methadone, others noted\n Labs:\n Value\n Date\n Glucose\n 136 mg/dL\n 01:42 AM\n Glucose Finger Stick\n 208\n 04:00 AM\n BUN\n 43 mg/dL\n 01:42 AM\n Creatinine\n 1.8 mg/dL\n 01:42 AM\n Sodium\n 136 mEq/L\n 01:42 AM\n Potassium\n 3.3 mEq/L\n 01:42 AM\n Chloride\n 99 mEq/L\n 01:42 AM\n TCO2\n 25 mEq/L\n 01:42 AM\n PO2 (arterial)\n 110 mm Hg\n 01:50 AM\n PO2 (venous)\n 91. mm Hg\n 05:13 PM\n PCO2 (arterial)\n 40 mm Hg\n 01:50 AM\n PCO2 (venous)\n 41 mm Hg\n 05:13 PM\n pH (arterial)\n 7.42 units\n 01:50 AM\n pH (venous)\n 7.43 units\n 05:13 PM\n pH (urine)\n 5.5 units\n 01:42 AM\n CO2 (Calc) arterial\n 27 mEq/L\n 01:50 AM\n CO2 (Calc) venous\n 28 mEq/L\n 05:13 PM\n Albumin\n 2.3 g/dL\n 01:42 AM\n Calcium non-ionized\n 9.1 mg/dL\n 01:42 AM\n Phosphorus\n 1.7 mg/dL\n 01:42 AM\n Ionized Calcium\n 1.24 mmol/L\n 01:50 AM\n Magnesium\n 2.3 mg/dL\n 01:42 AM\n ALT\n 156 IU/L\n 01:42 AM\n Alkaline Phosphate\n 487 IU/L\n 01:42 AM\n AST\n 151 IU/L\n 01:42 AM\n Amylase\n 77 IU/L\n 03:49 AM\n Total Bilirubin\n 12.6 mg/dL\n 01:42 AM\n Triglyceride\n 154 mg/dL\n 02:10 AM\n WBC\n 35.7 K/uL\n 01:42 AM\n Hgb\n 7.1 g/dL\n 01:42 AM\n Hematocrit\n 23.1 %\n 01:42 AM\n Current diet order / nutrition support: Tube Feeds: 3/4 strength Nutren\n 2.0 @ 50cc/hr + 50g Beneprotein (1962kcals, 115g protein)\n Diet: NPO\n GI: Post pyloric feeding tube, + loose, guaiac positive stool\n Assessment of Nutritional Status\n Patient is tolerating tube feeds via post pyloric feeding tube at goal,\n which meet 100% of estimated needs at 25kcals/kg adjusted wt and 1.45g\n protein/kg adjusted wt. HD done yesterday, 1L removed. Current\n formula with added protein is appropriate given need for fluid\n restricted formula and increased protein needs due to dialysis. Noted\n that Phos and K are low post-dialysis.\n Medical Nutrition Therapy Plan - Recommend the Following\n 1) Continue with tube feeds at goal.\n 2) Monitor tolerance with abd exam and stool o/p.\n 3) Montior lytes, replete if needed.\n 4) Please page with questions. #\n" }, { "category": "Nursing", "chartdate": "2131-06-27 00:00:00.000", "description": "Nursing Progress Note", "row_id": 683236, "text": "Arousal, Attention, and Cognition, Impaired\n Assessment:\n pt\ns eyes frequently open, not on sedation\n Action:\n q 4 hr neuro eval,\n Response:\n pt appears to track speaker but does not follow commands, withdraws\n feet slightly to nailbed pressure, withdraws upper extremities sl more\n briskly than lower, perl #3 and brisk\n Plan:\n continue with frequent neuro evaluations\n Impaired Skin Integrity\n Assessment:\n healing bullae and vesicles on legs, one weeping area rt upper\n thigh-scant sero-sange dge,\n Action:\n wound cleanser followed by adaptic and dsd\n Response:\n dsg intact and dry\n Plan:\n continue to monitor and treat open areas\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n pt has had hx of anuria and oliguria\n Action:\n pt had been on cvvh and also hemodialysis\n Response:\n pt is now producing icteric urine, approx 30-50cc/hr, 100cc noted in\n one hr\n Plan:\n continue to monitor u/o, ? hemodialysis today according to Micu intern\n Hepatitis, acute toxic (including alcoholic, acetaminophen, etc.)\n Assessment:\n Action:\n Response:\n Plan:\n Muscle Performace, Impaired\n Assessment:\n pt withdraws extremities to nailbed stimuli, very little spontaneous\n movement noted, none seen with lower extremities except to stimulation\n Action:\n neuro eval q 4 hrs, pt repositioned frequently, withdrawal tested\n Response:\n pt remains as described, micu team in and informed (no change from\n previous exams according to micu team)\n Plan:\n continue to ascertain and encourage any spontaneous movement, perform\n rom, protect skin and muscle from atrophy\n" }, { "category": "Nursing", "chartdate": "2131-06-22 00:00:00.000", "description": "Nursing Progress Note", "row_id": 682357, "text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Remains on trach mask 40%, changed from moist O2 to dry to\n help with secretions\n Sxn for minimal thin white secretions\n Lungs clear\n Pt with strong cough, able to expectorate secretion to top\n of trach\n Sats Remain >98%\n Around trach noted to be bloody/ moderate amts mucous\n Action:\n Pt uncooperative with mouth care\n OOB to chair\n Pt bronched by Dr. for minimal secretions\n Response:\n Amt of bloody secretions decreasing\n Plan:\n Cont with pulmonary toilet\n OOB to chair as tolerated\n Monitor for s/s of increased respiratory decreased\n Fever,Unknown\n Assessment:\n Febrile Tmax 102.1\n Cultured \n UA sent overnoc \n ABX cont\n Low dose levo for MAP <60\n Action:\n Tylenol for temp\n Pt now off oral vanco as CDIFF has been negative, 3^rd\n sample sent today \n Cipro stopped as well\n Response:\n Unable to wean levo despite slow attempts made\n Lactate/ WBC cont to be elevated\n Plan:\n Cont to monitor closely for increased s/s of organ\n dysfunction\n Cont with current plan of care\n Arousal, Attention, and Cognition, Impaired\n Assessment:\n Pt less alert today\n Open eyes to voice occasionally, otherwise opens eyes to\n noxious stimuli\n ?Attempts to follow commands, some tracking\n Twitches/tremors noted\n Action:\n Cont to try to stimulate pt\n Involve pt in activity and plan of care\n Methadone changed to 5mg for to be changed to once\n daily starting \n Response:\n Cognition questionable today, however pt is febrile\n Plan:\n Cont to monitor mental status closely\n Cont support to family\n Cont with current plan of care\n" }, { "category": "Physician ", "chartdate": "2131-06-26 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 683078, "text": "Chief Complaint:\n 24 Hour Events:\n \n - Sent sputum cx for tachypnea early AM of .\n - Weaned down to trach mask by early afternoon.\n - IR stated it would be very high risk to sample peri-pancreatic fluid\n collection - would likely need to paralyze him as needle would pass\n between dilated splancnic vessels.\n - Renal: plan for HD tomorrow if BP can tolerate it - otherwise may\n need CVVH.\n - ID: recommended d/c'ing aztreonam due to improving fever curve and\n WBC. Also added galactomanan and beta-glucan.\n Allergies:\n Meropenem\n skin blisters a\n Last dose of Antibiotics:\n Metronidazole - 12:00 AM\n Linezolid - 11:51 AM\n Aztreonam - 02:39 PM\n Micafungin - 10:48 PM\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 07:50 PM\n Heparin Sodium (Prophylaxis) - 03:50 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:22 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.1\nC (100.6\n Tcurrent: 37.3\nC (99.2\n HR: 111 (106 - 119) bpm\n BP: 94/55(68) {90/47(60) - 136/71(91)} mmHg\n RR: 30 (20 - 40) insp/min\n SpO2: 98%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 104.5 kg (admission): 113.5 kg\n Height: 67 Inch\n Total In:\n 2,204 mL\n 319 mL\n PO:\n TF:\n 1,205 mL\n 266 mL\n IVF:\n 939 mL\n 53 mL\n Blood products:\n Total out:\n 581 mL\n 175 mL\n Urine:\n 381 mL\n 175 mL\n NG:\n 200 mL\n Stool:\n Drains:\n Balance:\n 1,623 mL\n 144 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n Ventilator mode: Standby\n Vt (Set): 400 (400 - 400) mL\n PS : 5 cmH2O\n RR (Set): 18\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 40%\n PIP: 11 cmH2O\n Plateau: 21 cmH2O\n SpO2: 98%\n ABG: 7.39/39/81./23/0\n Ve: 10.3 L/min\n PaO2 / FiO2: 203\n Physical Examination\n Gen: lying in bed, eyes open to command, voice\n HEENT: trach\n CV: tachy RR\n Chest: good air movement\n Abd: soft +BS\n Ext: edema\n Neuro: eye open, squeeze hand to command, not answering more involved\n ?s or following more complex commands\n Labs / Radiology\n 228 K/uL\n 6.7 g/dL\n 128 mg/dL\n 3.0 mg/dL\n 23 mEq/L\n 3.3 mEq/L\n 79 mg/dL\n 101 mEq/L\n 136 mEq/L\n 22.5 %\n 15.0 K/uL\n [image002.jpg]\n 01:50 AM\n 03:18 AM\n 03:44 PM\n 01:38 AM\n 06:00 AM\n 01:12 AM\n 06:06 AM\n 02:38 PM\n 02:00 AM\n 02:49 AM\n WBC\n 30.9\n 27.6\n 18.9\n 15.0\n Hct\n 22.2\n 24.0\n 22.2\n 22.5\n Plt\n 28\n Cr\n 2.8\n 1.6\n 2.7\n 3.0\n TCO2\n 27\n 22\n 26\n 18\n 21\n 24\n Glucose\n 170\n 95\n 170\n 121\n 128\n Other labs: PT / PTT / INR:14.3/31.5/1.2, CK / CKMB /\n Troponin-T:214/3/0.07, ALT / AST:67/73, Alk Phos / T Bili:400/6.8,\n Amylase / Lipase:77/88, Differential-Neuts:84.0 %, Band:0.0 %,\n Lymph:7.0 %, Mono:5.0 %, Eos:3.0 %, D-dimer:6389 ng/mL, Fibrinogen:541\n mg/dL, Lactic Acid:2.6 mmol/L, Albumin:2.3 g/dL, LDH:331 IU/L, Ca++:8.6\n mg/dL, Mg++:2.1 mg/dL, PO4:3.7 mg/dL\\\n Ca: 8.6 Mg: 2.1 P: 3.7\n ALT: 67\n AP: 400\n Tbili: 6.8\n Alb:\n AST: 73\n LDH: 331\n Dbili:\n TProt:\n :\n Lip:\n PT: 14.3\n PTT: 31.5\n INR: 1.2\n Assessment and Plan\n 28M with alcoholic hepatitis and necrotizing pancreatitis complicated\n by ARDS, SIRS, ARF, UGIB, fevers.\n #. Fevers/leukocytosis: Fevers off CVVH with improving leukocytosis.\n Possible that continued fevers necrotizing pancreatitis. Surgery\n was consulted for peri-pancreatic fluid collections but felt to not be\n infected. Discussed draining with IR, and felt difficult to access,\n and will not try unless felt necessary by surgery. CMV positive, but\n likely not contributing to current illness per ID. Also with\n persistent yeast in ucx, persistent colonic inflammation on CT with neg\n C. diff x 3, and concern for serotonin syndrome with linezolid and\n pressors, now discontinued. On micafungin (since ). In setting of\n fevers and hypotension, Cipro was started , but d/c\ned . Flagyl\n (since ) and po vanc (since ) discontinued . Linezolid\n started and stopped . Aztreonam started and stopped\n . ID prefers to wean micafungin last.\n - sputum culture with +, unclear if contaminant as respiratory\n function improving, though remains tachypneic. If true infection,\n would suggest resistance to aztreonam. Will f/u sensitivities and d/w\n ID.\n - f/u CMV VL on \n - d/c a-line when able as has been in since \n - f/u WBC count, temp curve, and culture data\n - send surveillance blood, urine, stool cultures today.\n # Abd tenderness: Likely secondary to necrotizing pancreatitis, now\n able to react as mental status improves. Concern for obstruction given\n emesis this but abd xray without SBO. Also has h/o colitis but C.\n diff neg x 3.\n - Management of pancreatitis as above\n #. Respiratory Failure: initially ARDS secondary to necrotizing\n pancreatitis. s/p trach placement on . bronch without\n obvious source of bleeding and with only thin secretions throughout; no\n further reports of bleeding since. Off methadone since . Tachypnea\n of unclear etiology, possible mucous/clot plugging vs ?central\n hyperventilation event, though sputum now growing 2+ . Overnight\n weaned back to trach mask, and doing well this AM.\n - f/u sputum cx sensitivities (colonized vs infection), and discuss GN\n coverage with ID.\n - Wean valium to (D3/3), decrease to daily for tomorrow dose.\n - Cont fentanyl boluses prn (not requiring)\n - Trach care, OOB to chair daily\n - DDAVP if acute bleeding (max few doses). Had required amicar shortly\n after trach for continued bleeding but complicated by seizure shortly\n after starting this.\n # Shock: Patient remained off pressors over last PM and was afebrile.\n - Weaned off steroids on \n - Keep a-line until off pressors x 24 h but d/c when possible\n - Infectious w/u as above\n # Elevated LFTs: A/w alcoholic hepatitis. RUQ u/s showed sludge\n concerning for cholestasis but also seen on u/s. HIDA neg.\n TPN stopped . LFTs continue to trend down.\n - Weaning off benzos: valium 5mg D \n - Continue to trend\n #. Acute renal Failure: Multifactorial including ATN from hypotension.\n - HD per renal\n - F/u Renal recs\n #. Adrenal Insufficiency: Unclear with stim if adrenally\n insufficient but hypotension initially improved with steroids (lower\n pressor requirement) and eosinophilia resolved. He has now weaned off\n steroids completely.\n - Last dose prednisone was \n # Seizures: CT head without intracranial process. EEG showed occipital\n seizures which does not correlate with clinical symptoms, but repeat\n EEG on higher dose Keppra showed no seizures. As patient now with\n purposeful movements, this may actually be patient waking up, not\n seizures.\n - Continue keppra at HD dosing\n # Altered Mental Status: Continue to reassess as weaning off sedatives.\n - Off of methadone as of \n - Cont to wean valium as above\n - Will ask Neuro for input re: prognostication if MS with no further\n improvement by end of week\n ICU Care\n Nutrition:\n Nutren 2.0 () - 01:30 PM 50 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 08:15 PM\n PICC Line - 08:37 AM\n Dialysis Catheter - 08:55 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP: HOB elevation, Mouth care\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:ICU\n" }, { "category": "Physician ", "chartdate": "2131-06-26 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 683140, "text": "Chief Complaint: resp failure, pancreatitis\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 stayed off vent\n No pressors overnight\n OOB to chair with PT\n Allergies:\n Meropenem\n skin blisters a\n Last dose of Antibiotics:\n Metronidazole - 12:00 AM\n Linezolid - 11:51 AM\n Aztreonam - 02:39 PM\n Micafungin - 10:48 PM\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 07:50 PM\n Heparin Sodium (Prophylaxis) - 03:50 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 10:41 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.1\nC (100.6\n Tcurrent: 37.3\nC (99.1\n HR: 112 (106 - 119) bpm\n BP: 109/61(77) {90/47(60) - 135/71(91)} mmHg\n RR: 32 (20 - 40) insp/min\n SpO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 104.5 kg (admission): 113.5 kg\n Height: 67 Inch\n Total In:\n 2,205 mL\n 740 mL\n PO:\n TF:\n 1,205 mL\n 533 mL\n IVF:\n 940 mL\n 207 mL\n Blood products:\n Total out:\n 581 mL\n 280 mL\n Urine:\n 381 mL\n 280 mL\n NG:\n 200 mL\n Stool:\n Drains:\n Balance:\n 1,624 mL\n 460 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n Ventilator mode: Standby\n Vt (Set): 400 (400 - 400) mL\n PS : 5 cmH2O\n RR (Set): 18\n RR (Spontaneous): 29\n PEEP: 5 cmH2O\n FiO2: 40%\n PIP: 11 cmH2O\n SpO2: 100%\n ABG: 7.39/39/81./23/0\n Ve: 10.3 L/min\n PaO2 / FiO2: 203\n Physical Examination\n Gen: sitting in bed, more alert, tracking but not following commands\n HEENT: trach in place\n CV: tachy RR\n Chest: good air movement,\n Abd: soft +BS\n Ext: edema\n Labs / Radiology\n 6.7 g/dL\n 228 K/uL\n 128 mg/dL\n 3.0 mg/dL\n 23 mEq/L\n 3.3 mEq/L\n 79 mg/dL\n 101 mEq/L\n 136 mEq/L\n 22.5 %\n 15.0 K/uL\n [image002.jpg]\n 01:50 AM\n 03:18 AM\n 03:44 PM\n 01:38 AM\n 06:00 AM\n 01:12 AM\n 06:06 AM\n 02:38 PM\n 02:00 AM\n 02:49 AM\n WBC\n 30.9\n 27.6\n 18.9\n 15.0\n Hct\n 22.2\n 24.0\n 22.2\n 22.5\n Plt\n 28\n Cr\n 2.8\n 1.6\n 2.7\n 3.0\n TCO2\n 27\n 22\n 26\n 18\n 21\n 24\n Glucose\n 170\n 95\n 170\n 121\n 128\n Other labs: PT / PTT / INR:14.3/31.5/1.2, CK / CKMB /\n Troponin-T:214/3/0.07, ALT / AST:67/73, Alk Phos / T Bili:400/6.8,\n Amylase / Lipase:77/88, Differential-Neuts:84.0 %, Band:0.0 %,\n Lymph:7.0 %, Mono:5.0 %, Eos:3.0 %, D-dimer:6389 ng/mL, Fibrinogen:541\n mg/dL, Lactic Acid:2.6 mmol/L, Albumin:2.3 g/dL, LDH:331 IU/L, Ca++:8.6\n mg/dL, Mg++:2.1 mg/dL, PO4:3.7 mg/dL\n Assessment and Plan\n FEVER, UNKNOWN ORIGIN (FUO, HYPERTHERMIA, PYREXIA)\n AROUSAL, ATTENTION, AND COGNITION, IMPAIRED\n BALANCE, IMPAIRED\n MOTOR FUNCTION, IMPAIRED\n MUSCLE PERFORMACE, IMPAIRED\n RESPIRATION / GAS EXCHANGE, IMPAIRED\n SEIZURE, WITHOUT STATUS EPILEPTICUS\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n IMPAIRED SKIN INTEGRITY\n HEPATITIS, ACUTE TOXIC (INCLUDING ALCOHOLIC, ACETAMINOPHEN, ETC.)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n 1. Cyclical fevers\n overall trend is down and WBC trend is down.\n We have been weaning off ABX since nothing has grown\n will continue\n only micafungin while monitoring culture data. Possible repeat imaging\n this week of pancreas but we are loathe to initiate empiric panc\n drainage if there is another possible source as this can lead to long\n term complications. Spoke with in IR who felt it would\n be a very high risk procedure- esp to injure portal circ.\n and he\n would not recc and only do in conjunction with Dr .\n Will get blood cx off HD line\n 2. Hypotension: none in almost 24 hrs\n 3. Resp Failure: back on trach mask, hold on this\n 4. Given possibility of sz activity, will continue keppra and\n valium at current doses.\n 5. For ARF, HD in AM\n 6. For pancreatitis, will continue post-pyloric TFs, and will\n continue to hold off on any drainage of new peripancreatic fluid\n collection but will discuss with Dr \n ICU Care\n Nutrition: Nutren 2.0 () - 01:30 PM 50 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 08:15 PM\n PICC Line - 08:37 AM\n Dialysis Catheter - 08:55 AM\n Prophylaxis:\n DVT: boots\n Stress ulcer: PPI\n Communication: brother updated yesterday by team\n Code status: Full code\n Disposition :ICU\n Total time spent: 35\n" }, { "category": "Physician ", "chartdate": "2131-06-21 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 682049, "text": "Chief Complaint:\n 24 Hour Events:\n - Renal deferred starting HD given hypotension yesterday with plan to\n start today.\n - Surgery recommended starting antifungal but not draining fluid\n collection around pancreas which appeared sterile to them given absence\n of gas.\n - ID recommended broadening antibiotic coverage to micafungin, vanc po,\n and cipro for double GN coverage. Thought fluid collection should\n drained by IR. Also would check surveillance cx, CMV VL, recheck C.\n diff, c/s GI re: colonoscopy for biopsy of colitis, d/c A-line and\n foley if able.\n - Abx coverage broadened to micafungin and vanc po.\n - Speech evaluated for Passy-Muir valve but pt couldn't tolerate.\n - Methadone, hydrocort, and valium weaned down.\n - Neuro saw pt and thought making slow progress; will continue to\n follow for prognostication.\n Allergies:\n Meropenem\n skin blisters a\n Last dose of Antibiotics:\n Micafungin - 09:30 PM\n Linezolid - 12:40 AM\n Aztreonam - 02:25 AM\n Vancomycin - 02:26 AM\n Metronidazole - 04:16 AM\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 12:00 AM\n Heparin Sodium (Prophylaxis) - 04:16 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 04:37 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.9\nC (100.2\n Tcurrent: 37.9\nC (100.2\n HR: 110 (89 - 116) bpm\n BP: 99/54(68) {99/52(68) - 139/72(94)} mmHg\n RR: 26 (22 - 34) insp/min\n SpO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 100.7 kg (admission): 113.5 kg\n Height: 67 Inch\n Total In:\n 2,814 mL\n 886 mL\n PO:\n TF:\n 1,100 mL\n 230 mL\n IVF:\n 1,564 mL\n 596 mL\n Blood products:\n Total out:\n 330 mL\n 130 mL\n Urine:\n 330 mL\n 130 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,484 mL\n 756 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n SpO2: 100%\n ABG: 7.39/32/92./18/-4\n PaO2 / FiO2: 186\n Physical Examination\n GEN: Trached.\n HEENT: Icteric sclera. MMM.\n NECK: Trach site with no oozing.\n LUNGS: Anterior auscultation with upper airway noise; good airway\n movement.\n HEART: RRR, normal S1, S2.\n ABD: Distended. Firm, but unchanged.\n EXTREM: 2+ edema, ulcers/lesions on legs with bandages C/D/I.\n SKIN: Jaundiced.\n NEURO: Twitching mouth. Opens eyes, squeezes hand to command.\n Labs / Radiology\n 277 K/uL\n 7.0 g/dL\n 132 mg/dL\n 2.4 mg/dL\n 18 mEq/L\n 3.9 mEq/L\n 82 mg/dL\n 99 mEq/L\n 131 mEq/L\n 22.6 %\n 38.6 K/uL\n [image002.jpg]\n 10:53 AM\n 12:57 PM\n 03:00 PM\n 10:13 PM\n 10:23 PM\n 03:00 AM\n 03:15 AM\n 04:57 PM\n 02:28 AM\n 02:50 AM\n WBC\n 38.5\n 38.5\n Hct\n 22.7\n 22.7\n 22.6\n Plt\n 282\n 282\n 277\n Cr\n 1.2\n 1.8\n 2.4\n TCO2\n 23\n 22\n 18\n 25\n 23\n 20\n Glucose\n 114\n 121\n 140\n 135\n 141\n 132\n Other labs: PT / PTT / INR:15.0/33.3/1.3, CK / CKMB /\n Troponin-T:214/3/0.07, ALT / AST:181/177, Alk Phos / T Bili:455/15.9,\n Amylase / Lipase:77/141, Differential-Neuts:90.0 %, Band:0.0 %,\n Lymph:3.0 %, Mono:5.0 %, Eos:1.0 %, D-dimer:6389 ng/mL, Fibrinogen:502\n mg/dL, Lactic Acid:1.4 mmol/L, Albumin:2.0 g/dL, LDH:529 IU/L, Ca++:8.6\n mg/dL, Mg++:2.3 mg/dL, PO4:3.0 mg/dL\n Assessment and Plan\n 28M with alcoholic hepatitis and necrotizing pancreatitis complicated\n by ARDS, SIRS, ARF, UGIB, fevers.\n #. ID: Persistent leukocytosis and fevers now that off CVVH. Possible\n that continued fevers necrotizing pancreatitis. Also with\n persistent yeast in ucx, persistent colonic inflammation on CT. On\n aztreonam, linezolid (since ) and flagyl (since ). Started\n micafungin and po vanc yesterday.\n - New fluid collection peri-pancreas\n unclear if infected. Per Surgery\n with no role for fluid drainage at this time.\n - Cont broad coverage with linezolid (-), aztreo (-), flagyl\n (-), mica (-), vanc po (-).\n - Follow WBC count, temp curve, and culture data\n # Shock: Patient had transient pressor requirement last pm in setting\n of fever. When fever resolved pressor requirement did as well. Likely\n septic shock. Will treat for infection as above. If requires pressors\n without fever consider other etiologies of hypotension including\n cardiogenic.\n - Cont weaning steroids\n - ?D/c a-line\n # Elevated LFTs: A/w alcoholic hepatitis. RUQ u/s showed sludge\n concerning for cholestasis but also seen on u/s. T Bili and\n transaminases improving today.\n - HIDA neg\n - TPN stopped \n - weaning off benzos\n #. Respiratory Failure: ARDS secondary to necrotizing pancreatitis. S/p\n trach placement on .\n - Cte fentanyl boluses and alternatingly wean methadone and valium as\n tolerate.\n - Cte OOB to chair daily\n #. Acute renal Failure: Multifactorial inc. ATN from hypotension\n - Was supposed to transition to HD today but pressures not able to\n tolerate. No need for filtration so will reassess tmrw.\n - Aztreonam 2000mg q12h while on CVVH. Change after aztreonam.\n - Will change Keppra to 1000mg Q24 with 500 mg after HD when able to\n tolerate HD\n #. Adrenal Insufficiency: Unclear with stim if clear adrenal\n insufficiency but hypotension improving with steroids (lower pressor\n requirement) and eosinophilia resolved.\n - Cont weaning hydrocort to q12h today\n # Seizures: CT head without intracranial process. EEG showed occipital\n seizures which does not correlate with clinical symptoms, but repeat\n EEG on higher dose Keppra showed no seizures. As patient now with\n purposeful movements, this may actually be patient waking up, not\n seizures.\n - Continue keppra (change dosing if changes to HD)\n - Wean valium today\n ICU Care\n Nutrition:\n Nutren 2.0 () - 01:56 AM 50 mL/hour\n Glycemic Control: ISS\n Lines:\n Arterial Line - 08:15 PM\n PICC Line - 08:37 AM\n Dialysis Catheter - 08:55 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP:\n Comments:\n Communication: Comments: With brother\n status: Full code\n Disposition:ICU pending HD trial ; in screening process.\n" }, { "category": "Respiratory ", "chartdate": "2131-06-22 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 682360, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 0\n Ideal body weight: 67.1 None\n Ideal tidal volume: 268.4 / 402.6 / 536.8 mL/kg\n Tracheostomy tube:\n Type:\n Manufacturer: Portex\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Cuff volume: 5 mL /\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Clear / Thin\n Sputum source/amount: Suctioned / Moderate\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Unassisted spontaneous breathing\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No claim of dyspnea)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Respiratory Care Shift Procedures\n Bedside Procedures:\n Bronchoscopy (1500)\n Comments:\n Leave aerosol dry until pt receives HD. Monitor secrections.\n" }, { "category": "Physician ", "chartdate": "2131-06-26 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 683108, "text": "Chief Complaint: resp failure, pancreatitis\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 stayed off vent\n No pressors overnight\n OOB to chair with PT\n Allergies:\n Meropenem\n skin blisters a\n Last dose of Antibiotics:\n Metronidazole - 12:00 AM\n Linezolid - 11:51 AM\n Aztreonam - 02:39 PM\n Micafungin - 10:48 PM\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 07:50 PM\n Heparin Sodium (Prophylaxis) - 03:50 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 10:41 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.1\nC (100.6\n Tcurrent: 37.3\nC (99.1\n HR: 112 (106 - 119) bpm\n BP: 109/61(77) {90/47(60) - 135/71(91)} mmHg\n RR: 32 (20 - 40) insp/min\n SpO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 104.5 kg (admission): 113.5 kg\n Height: 67 Inch\n Total In:\n 2,205 mL\n 740 mL\n PO:\n TF:\n 1,205 mL\n 533 mL\n IVF:\n 940 mL\n 207 mL\n Blood products:\n Total out:\n 581 mL\n 280 mL\n Urine:\n 381 mL\n 280 mL\n NG:\n 200 mL\n Stool:\n Drains:\n Balance:\n 1,624 mL\n 460 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n Ventilator mode: Standby\n Vt (Set): 400 (400 - 400) mL\n PS : 5 cmH2O\n RR (Set): 18\n RR (Spontaneous): 29\n PEEP: 5 cmH2O\n FiO2: 40%\n PIP: 11 cmH2O\n SpO2: 100%\n ABG: 7.39/39/81./23/0\n Ve: 10.3 L/min\n PaO2 / FiO2: 203\n Physical Examination\n Labs / Radiology\n 6.7 g/dL\n 228 K/uL\n 128 mg/dL\n 3.0 mg/dL\n 23 mEq/L\n 3.3 mEq/L\n 79 mg/dL\n 101 mEq/L\n 136 mEq/L\n 22.5 %\n 15.0 K/uL\n [image002.jpg]\n 01:50 AM\n 03:18 AM\n 03:44 PM\n 01:38 AM\n 06:00 AM\n 01:12 AM\n 06:06 AM\n 02:38 PM\n 02:00 AM\n 02:49 AM\n WBC\n 30.9\n 27.6\n 18.9\n 15.0\n Hct\n 22.2\n 24.0\n 22.2\n 22.5\n Plt\n 28\n Cr\n 2.8\n 1.6\n 2.7\n 3.0\n TCO2\n 27\n 22\n 26\n 18\n 21\n 24\n Glucose\n 170\n 95\n 170\n 121\n 128\n Other labs: PT / PTT / INR:14.3/31.5/1.2, CK / CKMB /\n Troponin-T:214/3/0.07, ALT / AST:67/73, Alk Phos / T Bili:400/6.8,\n Amylase / Lipase:77/88, Differential-Neuts:84.0 %, Band:0.0 %,\n Lymph:7.0 %, Mono:5.0 %, Eos:3.0 %, D-dimer:6389 ng/mL, Fibrinogen:541\n mg/dL, Lactic Acid:2.6 mmol/L, Albumin:2.3 g/dL, LDH:331 IU/L, Ca++:8.6\n mg/dL, Mg++:2.1 mg/dL, PO4:3.7 mg/dL\n Assessment and Plan\n FEVER, UNKNOWN ORIGIN (FUO, HYPERTHERMIA, PYREXIA)\n AROUSAL, ATTENTION, AND COGNITION, IMPAIRED\n BALANCE, IMPAIRED\n MOTOR FUNCTION, IMPAIRED\n MUSCLE PERFORMACE, IMPAIRED\n RESPIRATION / GAS EXCHANGE, IMPAIRED\n SEIZURE, WITHOUT STATUS EPILEPTICUS\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n IMPAIRED SKIN INTEGRITY\n HEPATITIS, ACUTE TOXIC (INCLUDING ALCOHOLIC, ACETAMINOPHEN, ETC.)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n 1. Cyclical fevers during which he requires vasopressor support:\n DDx SIRS, line infections, panc necrrosis with infection, PNA, drug\n fever, serotonin syndrome. At this point he has been\n pan cultured\n nothing new. In conjunction with ID consultants we have been weaning\n off ABX since nothing has grown\n will continue aztreonam / micafungin\n for while monitoring culture data. Possible repeat imaging this week of\n pancreas but we are loathe to initiate empiric panc drainage if there\n is another possible source as this can lead to long term complications.\n However, if fevers persist and no other source can be found we may be\n forced.\n 2. Hypotension: transient this AM and short period overnight when\n febrile\n 3. Resp Failure: Put back on vent for tachypnea and hypoxemia\n overnight- but better this AM and trying back on TM. CXR without acute\n change but low lung volumes off + pressure. Ongoing TM trials and\n sedation wean - will get OOB to chair today, and wean methadone\n 4. Given possibility of sz activity, will continue keppra and\n valium at current doses.\n 5. For ARF, HD today\n 6. For pancreatitis, will continue post-pyloric TFs, and will\n continue to hold off on any drainage of new peripancreatic fluid\n collection but will discuss with Dr \n ICU Care\n Nutrition:\n Nutren 2.0 () - 01:30 PM 50 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 08:15 PM\n PICC Line - 08:37 AM\n Dialysis Catheter - 08:55 AM\n Prophylaxis:\n DVT: boots\n Stress ulcer: PPI\n Communication: brother updated yesterday by team\n Code status: Full code\n Disposition :ICU\n Total time spent:\n" }, { "category": "Physician ", "chartdate": "2131-06-26 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 683110, "text": "Chief Complaint:\n 24 Hour Events:\n \n - Sent sputum cx for tachypnea early AM of .\n - Weaned down to trach mask by early afternoon.\n - IR stated it would be very high risk to sample peri-pancreatic fluid\n collection - would likely need to paralyze him as needle would pass\n between dilated splancnic vessels.\n - Renal: plan for HD tomorrow if BP can tolerate it - otherwise may\n need CVVH.\n - ID: recommended d/c'ing aztreonam due to improving fever curve and\n WBC. Also added galactomanan and beta-glucan.\n Allergies:\n Meropenem\n skin blisters a\n Last dose of Antibiotics:\n Metronidazole - 12:00 AM\n Linezolid - 11:51 AM\n Aztreonam - 02:39 PM\n Micafungin - 10:48 PM\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 07:50 PM\n Heparin Sodium (Prophylaxis) - 03:50 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:22 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.1\nC (100.6\n Tcurrent: 37.3\nC (99.2\n HR: 111 (106 - 119) bpm\n BP: 94/55(68) {90/47(60) - 136/71(91)} mmHg\n RR: 30 (20 - 40) insp/min\n SpO2: 98%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 104.5 kg (admission): 113.5 kg\n Height: 67 Inch\n Total In:\n 2,204 mL\n 319 mL\n PO:\n TF:\n 1,205 mL\n 266 mL\n IVF:\n 939 mL\n 53 mL\n Blood products:\n Total out:\n 581 mL\n 175 mL\n Urine:\n 381 mL\n 175 mL\n NG:\n 200 mL\n Stool:\n Drains:\n Balance:\n 1,623 mL\n 144 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n Ventilator mode: Standby\n Vt (Set): 400 (400 - 400) mL\n PS : 5 cmH2O\n RR (Set): 18\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 40%\n PIP: 11 cmH2O\n Plateau: 21 cmH2O\n SpO2: 98%\n ABG: 7.39/39/81./23/0\n Ve: 10.3 L/min\n PaO2 / FiO2: 203\n Physical Examination\n Gen: lying in bed, eyes open to command, voice\n HEENT: trach\n CV: tachy RR\n Chest: good air movement\n Abd: soft +BS\n Ext: edema\n Neuro: eye open, squeeze hand to command, not answering more involved\n ?s or following more complex commands\n Labs / Radiology\n 228 K/uL\n 6.7 g/dL\n 128 mg/dL\n 3.0 mg/dL\n 23 mEq/L\n 3.3 mEq/L\n 79 mg/dL\n 101 mEq/L\n 136 mEq/L\n 22.5 %\n 15.0 K/uL\n [image002.jpg]\n 01:50 AM\n 03:18 AM\n 03:44 PM\n 01:38 AM\n 06:00 AM\n 01:12 AM\n 06:06 AM\n 02:38 PM\n 02:00 AM\n 02:49 AM\n WBC\n 30.9\n 27.6\n 18.9\n 15.0\n Hct\n 22.2\n 24.0\n 22.2\n 22.5\n Plt\n 28\n Cr\n 2.8\n 1.6\n 2.7\n 3.0\n TCO2\n 27\n 22\n 26\n 18\n 21\n 24\n Glucose\n 170\n 95\n 170\n 121\n 128\n Other labs: PT / PTT / INR:14.3/31.5/1.2, CK / CKMB /\n Troponin-T:214/3/0.07, ALT / AST:67/73, Alk Phos / T Bili:400/6.8,\n Amylase / Lipase:77/88, Differential-Neuts:84.0 %, Band:0.0 %,\n Lymph:7.0 %, Mono:5.0 %, Eos:3.0 %, D-dimer:6389 ng/mL, Fibrinogen:541\n mg/dL, Lactic Acid:2.6 mmol/L, Albumin:2.3 g/dL, LDH:331 IU/L, Ca++:8.6\n mg/dL, Mg++:2.1 mg/dL, PO4:3.7 mg/dL\\\n Ca: 8.6 Mg: 2.1 P: 3.7\n ALT: 67\n AP: 400\n Tbili: 6.8\n Alb:\n AST: 73\n LDH: 331\n Dbili:\n TProt:\n :\n Lip:\n PT: 14.3\n PTT: 31.5\n INR: 1.2\n Assessment and Plan\n 28M with alcoholic hepatitis and necrotizing pancreatitis complicated\n by ARDS, SIRS, ARF, UGIB, fevers.\n #. Fevers/leukocytosis: Fevers off CVVH with improving leukocytosis.\n Possible that continued fevers necrotizing pancreatitis. Surgery\n was consulted for peri-pancreatic fluid collections but felt to not be\n infected. Discussed draining with IR, and felt difficult to access,\n and will not try unless felt necessary by surgery. CMV positive, but\n likely not contributing to current illness per ID. Also with\n persistent yeast in ucx, persistent colonic inflammation on CT with neg\n C. diff x 3, and concern for serotonin syndrome with linezolid and\n pressors, now discontinued. On micafungin (since ). In setting of\n fevers and hypotension, Cipro was started , but d/c\ned . Flagyl\n (since ) and po vanc (since ) discontinued . Linezolid\n started and stopped . Aztreonam started and stopped\n . ID prefers to wean micafungin last.\n - sputum culture with +, unclear if contaminant as respiratory\n function improving, though remains tachypneic. If true infection,\n would suggest resistance to aztreonam. Will f/u sensitivities and d/w\n ID.\n - f/u CMV VL on \n - d/c a-line when able as has been in since \n - f/u WBC count, temp curve, and culture data\n - will get blood cx from a-line tomorrow\n # Abd tenderness: Likely secondary to necrotizing pancreatitis, now\n able to react as mental status improves. Concern for obstruction given\n emesis this but abd xray without SBO. Also has h/o colitis but C.\n diff neg x 3.\n - Management of pancreatitis as above\n #. Respiratory Failure: initially ARDS secondary to necrotizing\n pancreatitis. s/p trach placement on . bronch without\n obvious source of bleeding and with only thin secretions throughout; no\n further reports of bleeding since. Off methadone since . Tachypnea\n of unclear etiology, possible mucous/clot plugging vs ?central\n hyperventilation event, though sputum now growing 2+ . Overnight\n weaned back to trach mask, and doing well this AM.\n - f/u sputum cx sensitivities (colonized vs infection), and discuss GN\n coverage with ID.\n - Wean valium to (D3/3), decrease to daily for tomorrow dose.\n - Cont fentanyl boluses prn (not requiring)\n - Trach care, OOB to chair daily\n - DDAVP if acute bleeding (max few doses). Had required amicar shortly\n after trach for continued bleeding but complicated by seizure shortly\n after starting this.\n # Shock: Patient remained off pressors over last PM and was afebrile.\n - Weaned off steroids on \n - Keep a-line until off pressors x 24 h but d/c when possible\n - Infectious w/u as above\n # Elevated LFTs: A/w alcoholic hepatitis. RUQ u/s showed sludge\n concerning for cholestasis but also seen on u/s. HIDA neg.\n TPN stopped . LFTs continue to trend down.\n - Weaning off benzos: valium 5mg D \n - Continue to trend\n #. Acute renal Failure: Multifactorial including ATN from hypotension.\n - Renal to hold off on HD today secondary to pts pressures. Plan to\n dialyze tomorrow.\n - F/u Renal recs\n #. Adrenal Insufficiency: Unclear with stim if adrenally\n insufficient but hypotension initially improved with steroids (lower\n pressor requirement) and eosinophilia resolved. He has now weaned off\n steroids completely.\n - Last dose prednisone was \n # Seizures: CT head without intracranial process. EEG showed occipital\n seizures which does not correlate with clinical symptoms, but repeat\n EEG on higher dose Keppra showed no seizures. As patient now with\n purposeful movements, this may actually be patient waking up, not\n seizures.\n - Continue keppra at HD dosing\n # Altered Mental Status: Continue to reassess as weaning off sedatives.\n - Off of methadone as of \n - Cont to wean valium as above\n - Will ask Neuro for input re: prognostication if MS with no further\n improvement by end of week\n ICU Care\n Nutrition:\n Nutren 2.0 () - 01:30 PM 50 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 08:15 PM\n PICC Line - 08:37 AM\n Dialysis Catheter - 08:55 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP: HOB elevation, Mouth care\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n" }, { "category": "Physician ", "chartdate": "2131-06-26 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 683111, "text": "Chief Complaint: resp failure, pancreatitis\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 stayed off vent\n No pressors overnight\n OOB to chair with PT\n Allergies:\n Meropenem\n skin blisters a\n Last dose of Antibiotics:\n Metronidazole - 12:00 AM\n Linezolid - 11:51 AM\n Aztreonam - 02:39 PM\n Micafungin - 10:48 PM\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 07:50 PM\n Heparin Sodium (Prophylaxis) - 03:50 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 10:41 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.1\nC (100.6\n Tcurrent: 37.3\nC (99.1\n HR: 112 (106 - 119) bpm\n BP: 109/61(77) {90/47(60) - 135/71(91)} mmHg\n RR: 32 (20 - 40) insp/min\n SpO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 104.5 kg (admission): 113.5 kg\n Height: 67 Inch\n Total In:\n 2,205 mL\n 740 mL\n PO:\n TF:\n 1,205 mL\n 533 mL\n IVF:\n 940 mL\n 207 mL\n Blood products:\n Total out:\n 581 mL\n 280 mL\n Urine:\n 381 mL\n 280 mL\n NG:\n 200 mL\n Stool:\n Drains:\n Balance:\n 1,624 mL\n 460 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n Ventilator mode: Standby\n Vt (Set): 400 (400 - 400) mL\n PS : 5 cmH2O\n RR (Set): 18\n RR (Spontaneous): 29\n PEEP: 5 cmH2O\n FiO2: 40%\n PIP: 11 cmH2O\n SpO2: 100%\n ABG: 7.39/39/81./23/0\n Ve: 10.3 L/min\n PaO2 / FiO2: 203\n Physical Examination\n Gen: sitting in bed, more alert, tracking but not following commands\n HEENT: trach in place\n CV: tachy RR\n Chest: good air movement,\n Abd: soft +BS\n Ext: edema\n Labs / Radiology\n 6.7 g/dL\n 228 K/uL\n 128 mg/dL\n 3.0 mg/dL\n 23 mEq/L\n 3.3 mEq/L\n 79 mg/dL\n 101 mEq/L\n 136 mEq/L\n 22.5 %\n 15.0 K/uL\n [image002.jpg]\n 01:50 AM\n 03:18 AM\n 03:44 PM\n 01:38 AM\n 06:00 AM\n 01:12 AM\n 06:06 AM\n 02:38 PM\n 02:00 AM\n 02:49 AM\n WBC\n 30.9\n 27.6\n 18.9\n 15.0\n Hct\n 22.2\n 24.0\n 22.2\n 22.5\n Plt\n 28\n Cr\n 2.8\n 1.6\n 2.7\n 3.0\n TCO2\n 27\n 22\n 26\n 18\n 21\n 24\n Glucose\n 170\n 95\n 170\n 121\n 128\n Other labs: PT / PTT / INR:14.3/31.5/1.2, CK / CKMB /\n Troponin-T:214/3/0.07, ALT / AST:67/73, Alk Phos / T Bili:400/6.8,\n Amylase / Lipase:77/88, Differential-Neuts:84.0 %, Band:0.0 %,\n Lymph:7.0 %, Mono:5.0 %, Eos:3.0 %, D-dimer:6389 ng/mL, Fibrinogen:541\n mg/dL, Lactic Acid:2.6 mmol/L, Albumin:2.3 g/dL, LDH:331 IU/L, Ca++:8.6\n mg/dL, Mg++:2.1 mg/dL, PO4:3.7 mg/dL\n Assessment and Plan\n FEVER, UNKNOWN ORIGIN (FUO, HYPERTHERMIA, PYREXIA)\n AROUSAL, ATTENTION, AND COGNITION, IMPAIRED\n BALANCE, IMPAIRED\n MOTOR FUNCTION, IMPAIRED\n MUSCLE PERFORMACE, IMPAIRED\n RESPIRATION / GAS EXCHANGE, IMPAIRED\n SEIZURE, WITHOUT STATUS EPILEPTICUS\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n IMPAIRED SKIN INTEGRITY\n HEPATITIS, ACUTE TOXIC (INCLUDING ALCOHOLIC, ACETAMINOPHEN, ETC.)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n 1. Cyclical fevers\n overall trend is down and WBC trend is down.\n We have been weaning off ABX since nothing has grown\n will continue\n only micafungin for while monitoring culture data. Possible repeat\n imaging this week of pancreas but we are loathe to initiate empiric\n panc drainage if there is another possible source as this can lead to\n long term complications. Spoke with in IR who felt it\n would be a very high risk procedure- esp to injure portal circ.\n and\n he would not recc and only do in conjunction with Dr .\n Will get blood cx off HD line\n 2. Hypotension: none in almost 24 hrs\n 3. Resp Failure: back on trach mask, hold in this\n 4. Given possibility of sz activity, will continue keppra and\n valium at current doses.\n 5. For ARF, HD in AM\n 6. For pancreatitis, will continue post-pyloric TFs, and will\n continue to hold off on any drainage of new peripancreatic fluid\n collection but will discuss with Dr \n ICU Care\n Nutrition: Nutren 2.0 () - 01:30 PM 50 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 08:15 PM\n PICC Line - 08:37 AM\n Dialysis Catheter - 08:55 AM\n Prophylaxis:\n DVT: boots\n Stress ulcer: PPI\n Communication: brother updated yesterday by team\n Code status: Full code\n Disposition :ICU\n Total time spent:\n" }, { "category": "Physician ", "chartdate": "2131-06-26 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 683114, "text": "Chief Complaint:\n 24 Hour Events:\n \n - Sent sputum cx for tachypnea early AM of .\n - Weaned down to trach mask by early afternoon.\n - IR stated it would be very high risk to sample peri-pancreatic fluid\n collection - would likely need to paralyze him as needle would pass\n between dilated splancnic vessels.\n - Renal: plan for HD tomorrow if BP can tolerate it - otherwise may\n need CVVH.\n - ID: recommended d/c'ing aztreonam due to improving fever curve and\n WBC. Also added galactomanan and beta-glucan.\n Allergies:\n Meropenem\n skin blisters a\n Last dose of Antibiotics:\n Metronidazole - 12:00 AM\n Linezolid - 11:51 AM\n Aztreonam - 02:39 PM\n Micafungin - 10:48 PM\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 07:50 PM\n Heparin Sodium (Prophylaxis) - 03:50 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:22 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.1\nC (100.6\n Tcurrent: 37.3\nC (99.2\n HR: 111 (106 - 119) bpm\n BP: 94/55(68) {90/47(60) - 136/71(91)} mmHg\n RR: 30 (20 - 40) insp/min\n SpO2: 98%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 104.5 kg (admission): 113.5 kg\n Height: 67 Inch\n Total In:\n 2,204 mL\n 319 mL\n PO:\n TF:\n 1,205 mL\n 266 mL\n IVF:\n 939 mL\n 53 mL\n Blood products:\n Total out:\n 581 mL\n 175 mL\n Urine:\n 381 mL\n 175 mL\n NG:\n 200 mL\n Stool:\n Drains:\n Balance:\n 1,623 mL\n 144 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n Ventilator mode: Standby\n Vt (Set): 400 (400 - 400) mL\n PS : 5 cmH2O\n RR (Set): 18\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 40%\n PIP: 11 cmH2O\n Plateau: 21 cmH2O\n SpO2: 98%\n ABG: 7.39/39/81./23/0\n Ve: 10.3 L/min\n PaO2 / FiO2: 203\n Physical Examination\n Gen: lying in bed, eyes open to command, voice\n HEENT: trach\n CV: tachy RR\n Chest: good air movement\n Abd: soft +BS\n Ext: edema\n Neuro: eye open, squeeze hand to command, not answering more involved\n ?s or following more complex commands\n Labs / Radiology\n 228 K/uL\n 6.7 g/dL\n 128 mg/dL\n 3.0 mg/dL\n 23 mEq/L\n 3.3 mEq/L\n 79 mg/dL\n 101 mEq/L\n 136 mEq/L\n 22.5 %\n 15.0 K/uL\n [image002.jpg]\n 01:50 AM\n 03:18 AM\n 03:44 PM\n 01:38 AM\n 06:00 AM\n 01:12 AM\n 06:06 AM\n 02:38 PM\n 02:00 AM\n 02:49 AM\n WBC\n 30.9\n 27.6\n 18.9\n 15.0\n Hct\n 22.2\n 24.0\n 22.2\n 22.5\n Plt\n 28\n Cr\n 2.8\n 1.6\n 2.7\n 3.0\n TCO2\n 27\n 22\n 26\n 18\n 21\n 24\n Glucose\n 170\n 95\n 170\n 121\n 128\n Other labs: PT / PTT / INR:14.3/31.5/1.2, CK / CKMB /\n Troponin-T:214/3/0.07, ALT / AST:67/73, Alk Phos / T Bili:400/6.8,\n Amylase / Lipase:77/88, Differential-Neuts:84.0 %, Band:0.0 %,\n Lymph:7.0 %, Mono:5.0 %, Eos:3.0 %, D-dimer:6389 ng/mL, Fibrinogen:541\n mg/dL, Lactic Acid:2.6 mmol/L, Albumin:2.3 g/dL, LDH:331 IU/L, Ca++:8.6\n mg/dL, Mg++:2.1 mg/dL, PO4:3.7 mg/dL\\\n Ca: 8.6 Mg: 2.1 P: 3.7\n ALT: 67\n AP: 400\n Tbili: 6.8\n Alb:\n AST: 73\n LDH: 331\n Dbili:\n TProt:\n :\n Lip:\n PT: 14.3\n PTT: 31.5\n INR: 1.2\n Assessment and Plan\n 28M with alcoholic hepatitis and necrotizing pancreatitis complicated\n by ARDS, SIRS, ARF, UGIB, fevers.\n #. Fevers/leukocytosis: Fevers off CVVH with improving leukocytosis.\n Possible that continued fevers necrotizing pancreatitis. Surgery\n was consulted for peri-pancreatic fluid collections but felt to not be\n infected. Discussed draining with IR, and felt difficult to access,\n and will not try unless felt necessary by surgery. CMV positive, but\n likely not contributing to current illness per ID. Also with\n persistent yeast in ucx, persistent colonic inflammation on CT with neg\n C. diff x 3, and concern for serotonin syndrome with linezolid and\n pressors, now discontinued. On micafungin (since ). In setting of\n fevers and hypotension, Cipro was started , but d/c\ned . Flagyl\n (since ) and po vanc (since ) discontinued . Linezolid\n started and stopped . Aztreonam started and stopped\n . ID prefers to wean micafungin last.\n - sputum culture with +, unclear if contaminant as respiratory\n function improving, though remains tachypneic. If true infection,\n would suggest resistance to aztreonam. Will f/u sensitivities and d/w\n ID.\n - f/u CMV VL on \n - d/c a-line when able as has been in since \n - f/u WBC count, temp curve, and culture data\n - blood, urine, and stool cx today\n - will get blood cx from a-line tomorrow\n # Abd tenderness: Likely secondary to necrotizing pancreatitis, now\n able to react as mental status improves. Concern for obstruction given\n emesis this but abd xray without SBO. Also has h/o colitis but C.\n diff neg x 3.\n - Management of pancreatitis as above\n #. Respiratory Failure: initially ARDS secondary to necrotizing\n pancreatitis. s/p trach placement on . bronch without\n obvious source of bleeding and with only thin secretions throughout; no\n further reports of bleeding since. Off methadone since . Tachypnea\n of unclear etiology, possible mucous/clot plugging vs ?central\n hyperventilation event, though sputum now growing 2+ . Overnight\n weaned back to trach mask, and doing well this AM.\n - f/u sputum cx sensitivities (colonized vs infection), and discuss GN\n coverage with ID.\n - Wean valium to (D3/3), decrease to daily for tomorrow dose.\n - Cont fentanyl boluses prn (not requiring)\n - Trach care, OOB to chair daily\n - DDAVP if acute bleeding (max few doses). Had required amicar shortly\n after trach for continued bleeding but complicated by seizure shortly\n after starting this.\n # Shock: Patient remained off pressors over last PM and was afebrile.\n - Weaned off steroids on \n - Keep a-line until off pressors x 24 h but d/c when possible\n - Infectious w/u as above\n # Elevated LFTs: A/w alcoholic hepatitis. RUQ u/s showed sludge\n concerning for cholestasis but also seen on u/s. HIDA neg.\n TPN stopped . LFTs continue to trend down.\n - Weaning off benzos: valium 5mg D \n - Continue to trend\n #. Acute renal Failure: Multifactorial including ATN from hypotension.\n - Renal to hold off on HD today secondary to pts pressures. Plan to\n dialyze tomorrow.\n - F/u Renal recs\n #. Adrenal Insufficiency: Unclear with stim if adrenally\n insufficient but hypotension initially improved with steroids (lower\n pressor requirement) and eosinophilia resolved. He has now weaned off\n steroids completely.\n - Last dose prednisone was \n # Seizures: CT head without intracranial process. EEG showed occipital\n seizures which does not correlate with clinical symptoms, but repeat\n EEG on higher dose Keppra showed no seizures. As patient now with\n purposeful movements, this may actually be patient waking up, not\n seizures.\n - Continue keppra at HD dosing\n # Altered Mental Status: Continue to reassess as weaning off sedatives.\n - Off of methadone as of \n - Cont to wean valium as above\n - Will ask Neuro for input re: prognostication if MS with no further\n improvement by end of week\n ICU Care\n Nutrition:\n Nutren 2.0 () - 01:30 PM 50 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 08:15 PM\n PICC Line - 08:37 AM\n Dialysis Catheter - 08:55 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP: HOB elevation, Mouth care\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n" }, { "category": "Physician ", "chartdate": "2131-06-26 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 683116, "text": "Chief Complaint:\n 24 Hour Events:\n \n - Sent sputum cx for tachypnea early AM of .\n - Weaned down to trach mask by early afternoon.\n - IR stated it would be very high risk to sample peri-pancreatic fluid\n collection - would likely need to paralyze him as needle would pass\n between dilated splancnic vessels.\n - Renal: plan for HD tomorrow if BP can tolerate it - otherwise may\n need CVVH.\n - ID: recommended d/c'ing aztreonam due to improving fever curve and\n WBC. Also added galactomanan and beta-glucan.\n Allergies:\n Meropenem\n skin blisters a\n Last dose of Antibiotics:\n Metronidazole - 12:00 AM\n Linezolid - 11:51 AM\n Aztreonam - 02:39 PM\n Micafungin - 10:48 PM\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 07:50 PM\n Heparin Sodium (Prophylaxis) - 03:50 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:22 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.1\nC (100.6\n Tcurrent: 37.3\nC (99.2\n HR: 111 (106 - 119) bpm\n BP: 94/55(68) {90/47(60) - 136/71(91)} mmHg\n RR: 30 (20 - 40) insp/min\n SpO2: 98%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 104.5 kg (admission): 113.5 kg\n Height: 67 Inch\n Total In:\n 2,204 mL\n 319 mL\n PO:\n TF:\n 1,205 mL\n 266 mL\n IVF:\n 939 mL\n 53 mL\n Blood products:\n Total out:\n 581 mL\n 175 mL\n Urine:\n 381 mL\n 175 mL\n NG:\n 200 mL\n Stool:\n Drains:\n Balance:\n 1,623 mL\n 144 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n Ventilator mode: Standby\n Vt (Set): 400 (400 - 400) mL\n PS : 5 cmH2O\n RR (Set): 18\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 40%\n PIP: 11 cmH2O\n Plateau: 21 cmH2O\n SpO2: 98%\n ABG: 7.39/39/81./23/0\n Ve: 10.3 L/min\n PaO2 / FiO2: 203\n Physical Examination\n Gen: lying in bed, eyes open to command, voice\n HEENT: trach\n CV: tachy RR\n Chest: good air movement\n Abd: soft +BS\n Ext: edema\n Neuro: eye open, squeeze hand to command, not answering more involved\n ?s or following more complex commands\n Labs / Radiology\n 228 K/uL\n 6.7 g/dL\n 128 mg/dL\n 3.0 mg/dL\n 23 mEq/L\n 3.3 mEq/L\n 79 mg/dL\n 101 mEq/L\n 136 mEq/L\n 22.5 %\n 15.0 K/uL\n [image002.jpg]\n 01:50 AM\n 03:18 AM\n 03:44 PM\n 01:38 AM\n 06:00 AM\n 01:12 AM\n 06:06 AM\n 02:38 PM\n 02:00 AM\n 02:49 AM\n WBC\n 30.9\n 27.6\n 18.9\n 15.0\n Hct\n 22.2\n 24.0\n 22.2\n 22.5\n Plt\n 28\n Cr\n 2.8\n 1.6\n 2.7\n 3.0\n TCO2\n 27\n 22\n 26\n 18\n 21\n 24\n Glucose\n 170\n 95\n 170\n 121\n 128\n Other labs: PT / PTT / INR:14.3/31.5/1.2, CK / CKMB /\n Troponin-T:214/3/0.07, ALT / AST:67/73, Alk Phos / T Bili:400/6.8,\n Amylase / Lipase:77/88, Differential-Neuts:84.0 %, Band:0.0 %,\n Lymph:7.0 %, Mono:5.0 %, Eos:3.0 %, D-dimer:6389 ng/mL, Fibrinogen:541\n mg/dL, Lactic Acid:2.6 mmol/L, Albumin:2.3 g/dL, LDH:331 IU/L, Ca++:8.6\n mg/dL, Mg++:2.1 mg/dL, PO4:3.7 mg/dL\\\n Ca: 8.6 Mg: 2.1 P: 3.7\n ALT: 67\n AP: 400\n Tbili: 6.8\n Alb:\n AST: 73\n LDH: 331\n Dbili:\n TProt:\n :\n Lip:\n PT: 14.3\n PTT: 31.5\n INR: 1.2\n Assessment and Plan\n 28M with alcoholic hepatitis and necrotizing pancreatitis complicated\n by ARDS, SIRS, ARF, UGIB, fevers.\n #. Fevers/leukocytosis: Fevers off CVVH with improving leukocytosis.\n Possible that continued fevers necrotizing pancreatitis. Surgery\n was consulted for peri-pancreatic fluid collections but felt to not be\n infected. Discussed draining with IR, and felt difficult to access,\n and will not try unless felt necessary by surgery. CMV positive, but\n likely not contributing to current illness per ID. Also with\n persistent yeast in ucx, persistent colonic inflammation on CT with neg\n C. diff x 3, and concern for serotonin syndrome with linezolid and\n pressors, now discontinued. On micafungin (since ). In setting of\n fevers and hypotension, Cipro was started , but d/c\ned . Flagyl\n (since ) and po vanc (since ) discontinued . Linezolid\n started and stopped . Aztreonam started and stopped\n . ID prefers to wean micafungin last.\n - sputum culture with +, unclear if contaminant as respiratory\n function improving, though remains tachypneic. If true infection,\n might suggest resistance to aztreonam. Will f/u sensitivities and d/w\n ID, but hold off on additional abx for now (no change in sputum\n characteristics, and tolerating TM now).\n - f/u CMV VL on \n - d/c a-line when able as has been in since \n - f/u WBC count, temp curve, and culture data\n - blood, urine, and stool cx today\n - will get blood cx from a-line tomorrow\n # Abd tenderness: Likely secondary to necrotizing pancreatitis, now\n able to react as mental status improves. Concern for obstruction given\n emesis this but abd xray without SBO. Also has h/o colitis but C.\n diff neg x 3.\n - Management of pancreatitis as above\n #. Respiratory Failure: initially ARDS secondary to necrotizing\n pancreatitis. s/p trach placement on . bronch without\n obvious source of bleeding and with only thin secretions throughout; no\n further reports of bleeding since. Off methadone since . Tachypnea\n of unclear etiology, possible mucous/clot plugging vs ?central\n hyperventilation event, though sputum now growing 2+ . Overnight\n weaned back to trach mask, and doing well this AM.\n - f/u sputum cx sensitivities (colonized vs infection), and discuss GN\n coverage with ID.\n - Wean valium to (D3/3), decrease to daily for tomorrow dose.\n - Cont fentanyl boluses prn (not requiring)\n - Trach care, OOB to chair daily\n - DDAVP if acute bleeding (max few doses). Had required amicar shortly\n after trach for continued bleeding but complicated by seizure shortly\n after starting this.\n # Shock: Patient remained off pressors over last PM and was afebrile.\n - Weaned off steroids on \n - Keep a-line until off pressors x 24 h but d/c when possible\n - Infectious w/u as above\n # Elevated LFTs: A/w alcoholic hepatitis. RUQ u/s showed sludge\n concerning for cholestasis but also seen on u/s. HIDA neg.\n TPN stopped . LFTs continue to trend down.\n - Weaning off benzos: valium 5mg D \n - Continue to trend\n #. Acute renal Failure: Multifactorial including ATN from hypotension.\n - Renal to hold off on HD today secondary to pts pressures. Plan to\n dialyze tomorrow.\n - F/u Renal recs\n #. Adrenal Insufficiency: Unclear with stim if adrenally\n insufficient but hypotension initially improved with steroids (lower\n pressor requirement) and eosinophilia resolved. He has now weaned off\n steroids completely.\n - Last dose prednisone was \n # Seizures: CT head without intracranial process. EEG showed occipital\n seizures which does not correlate with clinical symptoms, but repeat\n EEG on higher dose Keppra showed no seizures. As patient now with\n purposeful movements, this may actually be patient waking up, not\n seizures. Current tonic jerking of hands may represent mild withdrawl,\n so will continue valium dosing for now.\n - Continue keppra at HD dosing\n # Altered Mental Status: Continue to reassess as weaning off sedatives.\n - Off of methadone as of \n - Cont to wean valium as above, keep current dose for now.\n - Will ask Neuro for input re: prognostication if MS with no further\n improvement by end of week\n ICU Care\n Nutrition:\n Nutren 2.0 () - 01:30 PM 50 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 08:15 PM\n PICC Line - 08:37 AM\n Dialysis Catheter - 08:55 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP: HOB elevation, Mouth care\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n" }, { "category": "Physician ", "chartdate": "2131-06-22 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 682264, "text": "Chief Complaint:\n 24 Hour Events:\n INVASIVE VENTILATION - STOP 08:22 AM\n received on TM\n STOOL CULTURE - At 12:11 PM\n BLOOD CULTURED - At 05:11 PM\n URINE CULTURE - At 02:20 AM\n FEVER - 101.2\nF - 08:00 PM\n \n - Underwent HD\n - 2 hours after HD, SBP dropped to 80s, HR in 110s but came up on own\n to low 100s. Spiked fever 101.2. Sent bcx and ucx. Started cipro IV.\n Received 250cc for BP 80s (MAP 55-60) but BP still declining so started\n on levophed.\n - Suctioned clots and blood from trach and oropharynx. Noted to have\n bleeding from gums. Given DDAVP 30mg IV x 1. Hct and coags stable.\n Allergies:\n Meropenem\n skin blisters a\n Last dose of Antibiotics:\n Micafungin - 09:30 PM\n Vancomycin - 02:18 PM\n Aztreonam - 03:18 PM\n Ciprofloxacin - 08:00 PM\n Linezolid - 12:33 AM\n Metronidazole - 05:14 AM\n Infusions:\n Norepinephrine - 0.03 mcg/Kg/min\n Other ICU medications:\n Famotidine (Pepcid) - 12:33 AM\n Heparin Sodium (Prophylaxis) - 05:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:41 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: 38.2\nC (100.8\n HR: 106 (101 - 116) bpm\n BP: 105/58(72) {75/40(57) - 125/67(85)} mmHg\n RR: 30 (21 - 42) insp/min\n SpO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 100.7 kg (admission): 113.5 kg\n Height: 67 Inch\n Total In:\n 3,740 mL\n 1,111 mL\n PO:\n TF:\n 1,200 mL\n 333 mL\n IVF:\n 2,270 mL\n 658 mL\n Blood products:\n Total out:\n 1,405 mL\n 60 mL\n Urine:\n 405 mL\n 60 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,335 mL\n 1,051 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n SpO2: 100%\n ABG: 7.42/40/110/25/0\n PaO2 / FiO2: 220\n Physical Examination\n GEN: Trached.\n HEENT: Icteric sclera. MMM.\n NECK: Trach site with no oozing.\n LUNGS: Anterior auscultation with upper airway noise; good airway\n movement.\n HEART: RRR, normal S1, S2.\n ABD: Distended. Firm, but unchanged.\n EXTREM: 2+ edema, ulcers/lesions on legs with bandages C/D/I.\n SKIN: Jaundiced.\n NEURO: Twitching mouth and arms. ? clonus. Opens eyes, squeezes hand to\n command.\n Labs / Radiology\n 305 K/uL\n 7.1 g/dL\n 136 mg/dL\n 1.8 mg/dL\n 25 mEq/L\n 3.3 mEq/L\n 43 mg/dL\n 99 mEq/L\n 136 mEq/L\n 23.1 %\n 35.7 K/uL\n [image002.jpg]\n Ca: 9.1 Mg: 2.3 P: 1.7\n ALT: 156\n AP: 487\n Tbili: 12.6\n Alb: 2.3\n AST: 151\n LDH:\n Dbili:\n TProt:\n :\n Lip: 88\n 03:15 AM\n 04:57 PM\n 02:28 AM\n 02:50 AM\n 05:09 PM\n 05:55 PM\n 05:57 PM\n 09:02 PM\n 01:42 AM\n 01:50 AM\n WBC\n 38.5\n 38.6\n 34.0\n 35.7\n Hct\n 22.7\n 22.6\n 21.6\n 23.1\n Plt\n 282\n 277\n 291\n 305\n Cr\n 2.4\n 1.2\n 1.8\n TCO2\n 23\n 20\n 22\n 21\n 27\n Glucose\n 132\n 126\n 136\n Other labs: PT / PTT / INR:15.6/34.5/1.4, CK / CKMB /\n Troponin-T:214/3/0.07, ALT / AST:156/151, Alk Phos / T Bili:487/12.6,\n Amylase / Lipase:77/88, Differential-Neuts:80.0 %, Band:6.0 %,\n Lymph:3.0 %, Mono:1.0 %, Eos:1.0 %, D-dimer:6389 ng/mL, Fibrinogen:541\n mg/dL, Lactic Acid:2.4 mmol/L, Albumin:2.3 g/dL, LDH:529 IU/L, Ca++:9.1\n mg/dL, Mg++:2.3 mg/dL, PO4:1.7 mg/dL\n Assessment and Plan\n 28M with alcoholic hepatitis and necrotizing pancreatitis complicated\n by ARDS, SIRS, ARF, UGIB, fevers.\n #. ID: Persistent leukocytosis and fevers now that off CVVH. Possible\n that continued fevers necrotizing pancreatitis. Also with\n persistent yeast in ucx, persistent colonic inflammation on CT. On\n aztreonam, linezolid (since ) and flagyl (since ). Started\n micafungin and po vanc . In setting of fevers and hypotension,\n Cipro was started .\n - New fluid collection peri-pancreas\n unclear if infected. Per Surgery\n with no role for fluid drainage at this time.\n - f/u ID recs\n - Cont broad coverage with linezolid (-), aztreo (-), flagyl\n (-), mica (-), vanc po (-).\n - f/u c diff, if neg x2-3 can d/c po vanc\n - Follow WBC count, temp curve, and culture data\n # Shock: Pressures dropped to 70/40 again in setting of fever. Likely\n septic shock. Will treat for infection as above. If requires pressors\n without fever consider other etiologies of hypotension including\n cardiogenic.\n - Cont weaning steroids\n change to PO prednisone 5 mg in AM of \n - D/c a-line\n check VBG and ABG simultaneously\n # Elevated LFTs: A/w alcoholic hepatitis. RUQ u/s showed sludge\n concerning for cholestasis but also seen on u/s. T Bili and\n transaminases improving today.\n - HIDA neg\n - TPN stopped \n - weaning off benzos\n 5 mg valium\n #. Respiratory Failure: ARDS secondary to necrotizing pancreatitis. S/p\n trach placement on .\n - Cte fentanyl boluses and alternatingly wean methadone and valium as\n tolerate.\n - Cte OOB to chair daily\n - Wean methadone to \n #. Acute renal Failure: Multifactorial inc. ATN from hypotension\n - Was supposed to transition to HD today but pressures not able to\n tolerate. No need for filtration so will reassess tmrw.\n - Aztreonam 2000mg q12h while on CVVH. Change after aztreonam.\n - continue Keppra at 1000mg Q24 with 500 mg after HD\n #. Adrenal Insufficiency: Unclear with stim if clear adrenal\n insufficiency but hypotension improving with steroids (lower pressor\n requirement) and eosinophilia resolved.\n - Cont weaning hydrocort to q12h today\n - transition to PO prednisone 5 mg daily in AM of \n # Seizures: CT head without intracranial process. EEG showed occipital\n seizures which does not correlate with clinical symptoms, but repeat\n EEG on higher dose Keppra showed no seizures. As patient now with\n purposeful movements, this may actually be patient waking up, not\n seizures.\n - Continue keppra at HD dosing\n - Wean valium today\n ICU Care\n Nutrition:\n Nutren 2.0 () - 01:47 AM 50 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 08:15 PM\n PICC Line - 08:37 AM\n Dialysis Catheter - 08:55 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP: HOB elevation\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:ICU\n" }, { "category": "Physician ", "chartdate": "2131-06-22 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 682265, "text": "Chief Complaint:\n 24 Hour Events:\n INVASIVE VENTILATION - STOP 08:22 AM\n received on TM\n STOOL CULTURE - At 12:11 PM\n BLOOD CULTURED - At 05:11 PM\n URINE CULTURE - At 02:20 AM\n FEVER - 101.2\nF - 08:00 PM\n \n - Underwent HD\n - 2 hours after HD, SBP dropped to 80s, HR in 110s but came up on own\n to low 100s. Spiked fever 101.2. Sent bcx and ucx. Started cipro IV.\n Received 250cc for BP 80s (MAP 55-60) but BP still declining so started\n on levophed.\n - Suctioned clots and blood from trach and oropharynx. Noted to have\n bleeding from gums. Given DDAVP 30mg IV x 1. Hct and coags stable.\n Allergies:\n Meropenem\n skin blisters a\n Last dose of Antibiotics:\n Micafungin - 09:30 PM\n Vancomycin - 02:18 PM\n Aztreonam - 03:18 PM\n Ciprofloxacin - 08:00 PM\n Linezolid - 12:33 AM\n Metronidazole - 05:14 AM\n Infusions:\n Norepinephrine - 0.03 mcg/Kg/min\n Other ICU medications:\n Famotidine (Pepcid) - 12:33 AM\n Heparin Sodium (Prophylaxis) - 05:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:41 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: 38.2\nC (100.8\n HR: 106 (101 - 116) bpm\n BP: 105/58(72) {75/40(57) - 125/67(85)} mmHg\n RR: 30 (21 - 42) insp/min\n SpO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 100.7 kg (admission): 113.5 kg\n Height: 67 Inch\n Total In:\n 3,740 mL\n 1,111 mL\n PO:\n TF:\n 1,200 mL\n 333 mL\n IVF:\n 2,270 mL\n 658 mL\n Blood products:\n Total out:\n 1,405 mL\n 60 mL\n Urine:\n 405 mL\n 60 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,335 mL\n 1,051 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n SpO2: 100%\n ABG: 7.42/40/110/25/0\n PaO2 / FiO2: 220\n Physical Examination\n GEN: Trached.\n HEENT: Icteric sclera. MMM.\n NECK: Trach site with no oozing.\n LUNGS: Anterior auscultation with upper airway noise; good airway\n movement.\n HEART: RRR, normal S1, S2.\n ABD: Distended. Firm, but unchanged.\n EXTREM: 2+ edema, ulcers/lesions on legs with bandages C/D/I.\n SKIN: Jaundiced.\n NEURO: Twitching mouth and arms. ? clonus. Opens eyes, squeezes hand to\n command.\n Labs / Radiology\n 305 K/uL\n 7.1 g/dL\n 136 mg/dL\n 1.8 mg/dL\n 25 mEq/L\n 3.3 mEq/L\n 43 mg/dL\n 99 mEq/L\n 136 mEq/L\n 23.1 %\n 35.7 K/uL\n [image002.jpg]\n Ca: 9.1 Mg: 2.3 P: 1.7\n ALT: 156\n AP: 487\n Tbili: 12.6\n Alb: 2.3\n AST: 151\n LDH:\n Dbili:\n TProt:\n :\n Lip: 88\n 03:15 AM\n 04:57 PM\n 02:28 AM\n 02:50 AM\n 05:09 PM\n 05:55 PM\n 05:57 PM\n 09:02 PM\n 01:42 AM\n 01:50 AM\n WBC\n 38.5\n 38.6\n 34.0\n 35.7\n Hct\n 22.7\n 22.6\n 21.6\n 23.1\n Plt\n 282\n 277\n 291\n 305\n Cr\n 2.4\n 1.2\n 1.8\n TCO2\n 23\n 20\n 22\n 21\n 27\n Glucose\n 132\n 126\n 136\n Other labs: PT / PTT / INR:15.6/34.5/1.4, CK / CKMB /\n Troponin-T:214/3/0.07, ALT / AST:156/151, Alk Phos / T Bili:487/12.6,\n Amylase / Lipase:77/88, Differential-Neuts:80.0 %, Band:6.0 %,\n Lymph:3.0 %, Mono:1.0 %, Eos:1.0 %, D-dimer:6389 ng/mL, Fibrinogen:541\n mg/dL, Lactic Acid:2.4 mmol/L, Albumin:2.3 g/dL, LDH:529 IU/L, Ca++:9.1\n mg/dL, Mg++:2.3 mg/dL, PO4:1.7 mg/dL\n URINE CULTURE-PENDING\n CLOSTRIDIUM DIFFICILE TOXIN A & B - NEGATIVE\n Blood Culture, Routine-PENDING\n Blood Culture, Routine-PENDING\n CMV Viral Load-PENDING\n CMV IgG ANTIBODY-PENDING; CMV IgM ANTIBODY-PENDING\n CLOSTRIDIUM DIFFICILE TOXIN A & B - NEGATIVE\n URINE CULTURE-FINAL {YEAST}\n Assessment and Plan\n 28M with alcoholic hepatitis and necrotizing pancreatitis complicated\n by ARDS, SIRS, ARF, UGIB, fevers.\n #. ID: Persistent leukocytosis and fevers now that off CVVH. Possible\n that continued fevers necrotizing pancreatitis. Also with\n persistent yeast in ucx, persistent colonic inflammation on CT. On\n aztreonam, linezolid (since ) and flagyl (since ). Started\n micafungin and po vanc . In setting of fevers and hypotension,\n Cipro was started .\n - New fluid collection peri-pancreas\n unclear if infected. Per Surgery\n with no role for fluid drainage at this time.\n - f/u ID recs\n - Cont broad coverage with linezolid (-), aztreo (-), flagyl\n (-), mica (-), vanc po (-), Cipro IV ( -).\n - f/u c diff (neg x2), if neg x3 can d/c po vanc\n - Follow WBC count, temp curve, and culture data\n # Shock: Pressures dropped to 70/40 again in setting of fever. Likely\n septic shock. Will treat for infection as above. If requires pressors\n without fever consider other etiologies of hypotension including\n cardiogenic.\n - Cont weaning steroids\n change to PO prednisone 5 mg in AM of \n - Kept a-line as he became febrile and hypotensive again\n - Infectious w/u as above\n # Elevated LFTs: A/w alcoholic hepatitis. RUQ u/s showed sludge\n concerning for cholestasis but also seen on u/s. HIDA neg.\n TPN stopped . T Bili and transaminases improving today.\n - weaning off benzos\n 5 mg valium\n - continue to trend\n #. Respiratory Failure: ARDS secondary to necrotizing pancreatitis. S/p\n trach placement on .\n - Cte fentanyl boluses\n - wean methadone and valium as tolerate.\n - Cte OOB to chair daily\n #. Acute renal Failure: Multifactorial inc. ATN from hypotension\n - Was supposed to transition to HD today but pressures not able to\n tolerate. No need for filtration so will reassess tmrw.\n - Aztreonam 2000mg q12h while on CVVH.\n - continue Keppra at 1000mg Q24 with 500 mg after HD\n #. Adrenal Insufficiency: Unclear with stim if clear adrenal\n insufficiency but hypotension improving with steroids (lower pressor\n requirement) and eosinophilia resolved.\n - Cont weaning hydrocort to q12h today\n - transition to PO prednisone 5 mg daily in AM of \n # Seizures: CT head without intracranial process. EEG showed occipital\n seizures which does not correlate with clinical symptoms, but repeat\n EEG on higher dose Keppra showed no seizures. As patient now with\n purposeful movements, this may actually be patient waking up, not\n seizures.\n - Continue keppra at HD dosing\n - Wean valium today\n ICU Care\n Nutrition:\n Nutren 2.0 () - 01:47 AM 50 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 08:15 PM\n PICC Line - 08:37 AM\n Dialysis Catheter - 08:55 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP: HOB elevation\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n" }, { "category": "Physician ", "chartdate": "2131-06-22 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 682267, "text": "Chief Complaint:\n 24 Hour Events:\n INVASIVE VENTILATION - STOP 08:22 AM\n received on TM\n STOOL CULTURE - At 12:11 PM\n BLOOD CULTURED - At 05:11 PM\n URINE CULTURE - At 02:20 AM\n FEVER - 101.2\nF - 08:00 PM\n \n - Underwent HD\n - 2 hours after HD, SBP dropped to 80s, HR in 110s but came up on own\n to low 100s. Spiked fever 101.2. Sent bcx and ucx. Started cipro IV.\n Received 250cc for BP 80s (MAP 55-60) but BP still declining so started\n on levophed.\n - Suctioned clots and blood from trach and oropharynx. Noted to have\n bleeding from gums. Given DDAVP 30mg IV x 1. Hct and coags stable.\n Allergies:\n Meropenem\n skin blisters a\n Last dose of Antibiotics:\n Micafungin - 09:30 PM\n Vancomycin - 02:18 PM\n Aztreonam - 03:18 PM\n Ciprofloxacin - 08:00 PM\n Linezolid - 12:33 AM\n Metronidazole - 05:14 AM\n Infusions:\n Norepinephrine - 0.03 mcg/Kg/min\n Other ICU medications:\n Famotidine (Pepcid) - 12:33 AM\n Heparin Sodium (Prophylaxis) - 05:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:41 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: 38.2\nC (100.8\n HR: 106 (101 - 116) bpm\n BP: 105/58(72) {75/40(57) - 125/67(85)} mmHg\n RR: 30 (21 - 42) insp/min\n SpO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 100.7 kg (admission): 113.5 kg\n Height: 67 Inch\n Total In:\n 3,740 mL\n 1,111 mL\n PO:\n TF:\n 1,200 mL\n 333 mL\n IVF:\n 2,270 mL\n 658 mL\n Blood products:\n Total out:\n 1,405 mL\n 60 mL\n Urine:\n 405 mL\n 60 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,335 mL\n 1,051 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n SpO2: 100%\n ABG: 7.42/40/110/25/0\n PaO2 / FiO2: 220\n Physical Examination\n GEN: Trached.\n HEENT: Icteric sclera. MMM.\n NECK: Trach site with no oozing.\n LUNGS: Anterior auscultation with upper airway noise; good airway\n movement.\n HEART: RRR, normal S1, S2.\n ABD: Distended. Firm, but unchanged.\n EXTREM: 2+ edema, ulcers/lesions on legs with bandages C/D/I.\n SKIN: Jaundiced.\n NEURO: Twitching mouth and arms. ? clonus. Opens eyes, squeezes hand to\n command.\n Labs / Radiology\n 305 K/uL\n 7.1 g/dL\n 136 mg/dL\n 1.8 mg/dL\n 25 mEq/L\n 3.3 mEq/L\n 43 mg/dL\n 99 mEq/L\n 136 mEq/L\n 23.1 %\n 35.7 K/uL\n [image002.jpg]\n Ca: 9.1 Mg: 2.3 P: 1.7\n ALT: 156\n AP: 487\n Tbili: 12.6\n Alb: 2.3\n AST: 151\n LDH:\n Dbili:\n TProt:\n :\n Lip: 88\n 03:15 AM\n 04:57 PM\n 02:28 AM\n 02:50 AM\n 05:09 PM\n 05:55 PM\n 05:57 PM\n 09:02 PM\n 01:42 AM\n 01:50 AM\n WBC\n 38.5\n 38.6\n 34.0\n 35.7\n Hct\n 22.7\n 22.6\n 21.6\n 23.1\n Plt\n 282\n 277\n 291\n 305\n Cr\n 2.4\n 1.2\n 1.8\n TCO2\n 23\n 20\n 22\n 21\n 27\n Glucose\n 132\n 126\n 136\n Other labs: PT / PTT / INR:15.6/34.5/1.4, CK / CKMB /\n Troponin-T:214/3/0.07, ALT / AST:156/151, Alk Phos / T Bili:487/12.6,\n Amylase / Lipase:77/88, Differential-Neuts:80.0 %, Band:6.0 %,\n Lymph:3.0 %, Mono:1.0 %, Eos:1.0 %, D-dimer:6389 ng/mL, Fibrinogen:541\n mg/dL, Lactic Acid:2.4 mmol/L, Albumin:2.3 g/dL, LDH:529 IU/L, Ca++:9.1\n mg/dL, Mg++:2.3 mg/dL, PO4:1.7 mg/dL\n URINE CULTURE-PENDING\n CLOSTRIDIUM DIFFICILE TOXIN A & B - NEGATIVE\n Blood Culture, Routine-PENDING\n Blood Culture, Routine-PENDING\n CMV Viral Load-PENDING\n CMV IgG ANTIBODY-PENDING; CMV IgM ANTIBODY-PENDING\n CLOSTRIDIUM DIFFICILE TOXIN A & B - NEGATIVE\n URINE CULTURE-FINAL {YEAST}\n Assessment and Plan\n 28M with alcoholic hepatitis and necrotizing pancreatitis complicated\n by ARDS, SIRS, ARF, UGIB, fevers.\n #. ID: Persistent leukocytosis and fevers now that off CVVH. Possible\n that continued fevers necrotizing pancreatitis. Also with\n persistent yeast in ucx, persistent colonic inflammation on CT. On\n aztreonam, linezolid (since ) and flagyl (since ). Started\n micafungin and po vanc . In setting of fevers and hypotension,\n Cipro was started .\n - New fluid collection peri-pancreas\n unclear if infected. Per Surgery\n with no role for fluid drainage at this time.\n - f/u ID recs\n - Cont broad coverage with linezolid (-), aztreo (-), flagyl\n (-), mica (-), vanc po (-), Cipro IV ( -).\n - f/u c diff (neg x2), if neg x3 can d/c po vanc\n - Follow WBC count, temp curve, and culture data\n # Shock: Pressures dropped to 70/40 again in setting of fever. Likely\n septic shock. Will treat for infection as above. If requires pressors\n without fever consider other etiologies of hypotension including\n cardiogenic.\n - Cont weaning steroids\n change to PO prednisone 5 mg in AM of \n - Kept a-line as he became febrile and hypotensive again\n - Infectious w/u as above\n # Elevated LFTs: A/w alcoholic hepatitis. RUQ u/s showed sludge\n concerning for cholestasis but also seen on u/s. HIDA neg.\n TPN stopped . T Bili and transaminases improving today.\n - weaning off benzos\n 5 mg valium\n - continue to trend\n #. Respiratory Failure: ARDS secondary to necrotizing pancreatitis. S/p\n trach placement on . Continues to have blood/clots suctioned from\n trach\n - DDAVP if acute bleeding. Had required amicar shortly after trach for\n continued bleeding but complicated by seizure shortly after starting\n this.\n - Cte fentanyl boluses\n - wean methadone and valium as tolerate.\n - Cte OOB to chair daily\n #. Acute renal Failure: Multifactorial inc. ATN from hypotension\n - Was supposed to transition to HD today but pressures not able to\n tolerate. No need for filtration so will reassess tmrw.\n - Aztreonam 2000mg q12h while on CVVH.\n - continue Keppra at 1000mg Q24 with 500 mg after HD\n #. Adrenal Insufficiency: Unclear with stim if clear adrenal\n insufficiency but hypotension improving with steroids (lower pressor\n requirement) and eosinophilia resolved.\n - transition to PO prednisone 5 mg daily today\n # Seizures: CT head without intracranial process. EEG showed occipital\n seizures which does not correlate with clinical symptoms, but repeat\n EEG on higher dose Keppra showed no seizures. As patient now with\n purposeful movements, this may actually be patient waking up, not\n seizures.\n - Continue keppra at HD dosing\n ICU Care\n Nutrition:\n Nutren 2.0 () - 01:47 AM 50 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 08:15 PM\n PICC Line - 08:37 AM\n Dialysis Catheter - 08:55 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP: HOB elevation\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n" }, { "category": "Physician ", "chartdate": "2131-06-22 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 682278, "text": "Chief Complaint:\n 24 Hour Events:\n INVASIVE VENTILATION - STOP 08:22 AM\n received on TM\n STOOL CULTURE - At 12:11 PM\n BLOOD CULTURED - At 05:11 PM\n URINE CULTURE - At 02:20 AM\n FEVER - 101.2\nF - 08:00 PM\n \n - Underwent HD\n - 2 hours after HD, SBP dropped to 80s, HR in 110s but came up on own\n to low 100s. Spiked fever 101.2. Sent bcx and ucx. Started cipro IV.\n Received 250cc for BP 80s (MAP 55-60) but BP still declining so started\n on levophed.\n - Suctioned clots and blood from trach and oropharynx. Noted to have\n bleeding from gums. Given DDAVP 30mg IV x 1. Hct and coags stable.\n Allergies:\n Meropenem\n skin blisters a\n Last dose of Antibiotics:\n Micafungin - 09:30 PM\n Vancomycin - 02:18 PM\n Aztreonam - 03:18 PM\n Ciprofloxacin - 08:00 PM\n Linezolid - 12:33 AM\n Metronidazole - 05:14 AM\n Infusions:\n Norepinephrine - 0.03 mcg/Kg/min\n Other ICU medications:\n Famotidine (Pepcid) - 12:33 AM\n Heparin Sodium (Prophylaxis) - 05:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:41 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: 38.2\nC (100.8\n HR: 106 (101 - 116) bpm\n BP: 105/58(72) {75/40(57) - 125/67(85)} mmHg\n RR: 30 (21 - 42) insp/min\n SpO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 100.7 kg (admission): 113.5 kg\n Height: 67 Inch\n Total In:\n 3,740 mL\n 1,111 mL\n PO:\n TF:\n 1,200 mL\n 333 mL\n IVF:\n 2,270 mL\n 658 mL\n Blood products:\n Total out:\n 1,405 mL\n 60 mL\n Urine:\n 405 mL\n 60 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,335 mL\n 1,051 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n SpO2: 100%\n ABG: 7.42/40/110/25/0\n PaO2 / FiO2: 220\n Physical Examination\n GEN: Trached.\n HEENT: Icteric sclera. MMM.\n NECK: Trach site with no oozing.\n LUNGS: Anterior auscultation with upper airway noise; good airway\n movement.\n HEART: RRR, normal S1, S2.\n ABD: Distended. Firm, but unchanged.\n EXTREM: 2+ edema, ulcers/lesions on legs with bandages C/D/I.\n SKIN: Jaundiced.\n NEURO: Twitching mouth and arms. ? clonus. Opens eyes, squeezes hand to\n command.\n Labs / Radiology\n 305 K/uL\n 7.1 g/dL\n 136 mg/dL\n 1.8 mg/dL\n 25 mEq/L\n 3.3 mEq/L\n 43 mg/dL\n 99 mEq/L\n 136 mEq/L\n 23.1 %\n 35.7 K/uL\n [image002.jpg]\n Ca: 9.1 Mg: 2.3 P: 1.7\n ALT: 156\n AP: 487\n Tbili: 12.6\n Alb: 2.3\n AST: 151\n LDH:\n Dbili:\n TProt:\n :\n Lip: 88\n 03:15 AM\n 04:57 PM\n 02:28 AM\n 02:50 AM\n 05:09 PM\n 05:55 PM\n 05:57 PM\n 09:02 PM\n 01:42 AM\n 01:50 AM\n WBC\n 38.5\n 38.6\n 34.0\n 35.7\n Hct\n 22.7\n 22.6\n 21.6\n 23.1\n Plt\n 282\n 277\n 291\n 305\n Cr\n 2.4\n 1.2\n 1.8\n TCO2\n 23\n 20\n 22\n 21\n 27\n Glucose\n 132\n 126\n 136\n Other labs: PT / PTT / INR:15.6/34.5/1.4, CK / CKMB /\n Troponin-T:214/3/0.07, ALT / AST:156/151, Alk Phos / T Bili:487/12.6,\n Amylase / Lipase:77/88, Differential-Neuts:80.0 %, Band:6.0 %,\n Lymph:3.0 %, Mono:1.0 %, Eos:1.0 %, D-dimer:6389 ng/mL, Fibrinogen:541\n mg/dL, Lactic Acid:2.4 mmol/L, Albumin:2.3 g/dL, LDH:529 IU/L, Ca++:9.1\n mg/dL, Mg++:2.3 mg/dL, PO4:1.7 mg/dL\n URINE CULTURE-PENDING\n CLOSTRIDIUM DIFFICILE TOXIN A & B - NEGATIVE\n Blood Culture, Routine-PENDING\n Blood Culture, Routine-PENDING\n CMV Viral Load-PENDING\n CMV IgG ANTIBODY-PENDING; CMV IgM ANTIBODY-PENDING\n CLOSTRIDIUM DIFFICILE TOXIN A & B - NEGATIVE\n URINE CULTURE-FINAL {YEAST}\n Assessment and Plan\n 28M with alcoholic hepatitis and necrotizing pancreatitis complicated\n by ARDS, SIRS, ARF, UGIB, fevers.\n #. ID: Persistent leukocytosis and fevers now that off CVVH. Possible\n that continued fevers necrotizing pancreatitis. Also with\n persistent yeast in ucx, persistent colonic inflammation on CT. On\n aztreonam, linezolid (since ) and flagyl (since ). Started\n micafungin and po vanc . In setting of fevers and hypotension,\n Cipro was started .\n - New fluid collection peri-pancreas but would hold off on fluid\n drainage\n - Check CXR\n - Bronch today\n - Cont broad coverage with linezolid (-), aztreo (-), flagyl\n (-), mica (-). D/c vanc po (-), Cipro IV ( -).\n - F/u c diff (neg x2), if neg x3 can d/c po vanc\n - Follow WBC count, temp curve, and culture data\n - F/u ID recs\n # Shock: Pressures dropped to 70/40 again in setting of fever. Likely\n septic shock. Will treat for infection as above. If requires pressors\n without fever consider other etiologies of hypotension including\n cardiogenic.\n - Cont weaning steroids; change to PO prednisone 5 mg today\n - Keep a-line until off pressors x 24 h\n - Infectious w/u as above\n # Elevated LFTs: A/w alcoholic hepatitis. RUQ u/s showed sludge\n concerning for cholestasis but also seen on u/s. HIDA neg.\n TPN stopped . T Bili and transaminases improving today.\n - weaning off benzos - 5 mg valium today\n - continue to trend\n #. Respiratory Failure: ARDS secondary to necrotizing pancreatitis. S/p\n trach placement on . Continues to have blood/clots suctioned from\n trach\n - DDAVP if acute bleeding (max few doses). Had required amicar shortly\n after trach for continued bleeding but complicated by seizure shortly\n after starting this.\n - Cte fentanyl boluses\n - Wean methadone and valium as tolerated\n - Cte OOB to chair daily\n - Trach\n #. Acute renal Failure: Multifactorial inc. ATN from hypotension\n - Was supposed to transition to HD today but pressures not able to\n tolerate. No need for filtration so will reassess tmrw.\n - Aztreonam 2000mg q12h while on CVVH.\n - continue Keppra at 1000mg Q24 with 500 mg after HD\n #. Adrenal Insufficiency: Unclear with stim if clear adrenal\n insufficiency but hypotension improving with steroids (lower pressor\n requirement) and eosinophilia resolved.\n - transition to PO prednisone 5 mg daily today\n # Seizures: CT head without intracranial process. EEG showed occipital\n seizures which does not correlate with clinical symptoms, but repeat\n EEG on higher dose Keppra showed no seizures. As patient now with\n purposeful movements, this may actually be patient waking up, not\n seizures.\n - Continue keppra at HD dosing\n # Altered Mental Status:\n - Titrate down sedating meds; decrease methadone to today and qd\n tomorrow\n ICU Care\n Nutrition:\n Nutren 2.0 () - 01:47 AM 50 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 08:15 PM\n PICC Line - 08:37 AM\n Dialysis Catheter - 08:55 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP: HOB elevation\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU, d/c to Rehab when stable on HD\n" }, { "category": "Physician ", "chartdate": "2131-06-22 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 682279, "text": "Chief Complaint:\n 24 Hour Events:\n INVASIVE VENTILATION - STOP 08:22 AM\n received on TM\n STOOL CULTURE - At 12:11 PM\n BLOOD CULTURED - At 05:11 PM\n URINE CULTURE - At 02:20 AM\n FEVER - 101.2\nF - 08:00 PM\n \n - Underwent HD\n - 2 hours after HD, SBP dropped to 80s, HR in 110s but came up on own\n to low 100s. Spiked fever 101.2. Sent bcx and ucx. Started cipro IV.\n Received 250cc for BP 80s (MAP 55-60) but BP still declining so started\n on levophed.\n - Suctioned clots and blood from trach and oropharynx. Noted to have\n bleeding from gums. Given DDAVP 30mg IV x 1. Hct and coags stable.\n Allergies:\n Meropenem\n skin blisters a\n Last dose of Antibiotics:\n Micafungin - 09:30 PM\n Vancomycin - 02:18 PM\n Aztreonam - 03:18 PM\n Ciprofloxacin - 08:00 PM\n Linezolid - 12:33 AM\n Metronidazole - 05:14 AM\n Infusions:\n Norepinephrine - 0.03 mcg/Kg/min\n Other ICU medications:\n Famotidine (Pepcid) - 12:33 AM\n Heparin Sodium (Prophylaxis) - 05:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:41 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: 38.2\nC (100.8\n HR: 106 (101 - 116) bpm\n BP: 105/58(72) {75/40(57) - 125/67(85)} mmHg\n RR: 30 (21 - 42) insp/min\n SpO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 100.7 kg (admission): 113.5 kg\n Height: 67 Inch\n Total In:\n 3,740 mL\n 1,111 mL\n PO:\n TF:\n 1,200 mL\n 333 mL\n IVF:\n 2,270 mL\n 658 mL\n Blood products:\n Total out:\n 1,405 mL\n 60 mL\n Urine:\n 405 mL\n 60 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,335 mL\n 1,051 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n SpO2: 100%\n ABG: 7.42/40/110/25/0\n PaO2 / FiO2: 220\n Physical Examination\n GEN: Trached.\n HEENT: Icteric sclera. MMM.\n NECK: Trach site with no oozing.\n LUNGS: Anterior auscultation with upper airway noise; good airway\n movement.\n HEART: RRR, normal S1, S2.\n ABD: Distended. Firm, but unchanged.\n EXTREM: 2+ edema, ulcers/lesions on legs with bandages C/D/I.\n SKIN: Jaundiced.\n NEURO: Twitching mouth and arms. ? clonus. Opens eyes, squeezes hand to\n command.\n Labs / Radiology\n 305 K/uL\n 7.1 g/dL\n 136 mg/dL\n 1.8 mg/dL\n 25 mEq/L\n 3.3 mEq/L\n 43 mg/dL\n 99 mEq/L\n 136 mEq/L\n 23.1 %\n 35.7 K/uL\n [image002.jpg]\n Ca: 9.1 Mg: 2.3 P: 1.7\n ALT: 156\n AP: 487\n Tbili: 12.6\n Alb: 2.3\n AST: 151\n LDH:\n Dbili:\n TProt:\n :\n Lip: 88\n 03:15 AM\n 04:57 PM\n 02:28 AM\n 02:50 AM\n 05:09 PM\n 05:55 PM\n 05:57 PM\n 09:02 PM\n 01:42 AM\n 01:50 AM\n WBC\n 38.5\n 38.6\n 34.0\n 35.7\n Hct\n 22.7\n 22.6\n 21.6\n 23.1\n Plt\n 282\n 277\n 291\n 305\n Cr\n 2.4\n 1.2\n 1.8\n TCO2\n 23\n 20\n 22\n 21\n 27\n Glucose\n 132\n 126\n 136\n Other labs: PT / PTT / INR:15.6/34.5/1.4, CK / CKMB /\n Troponin-T:214/3/0.07, ALT / AST:156/151, Alk Phos / T Bili:487/12.6,\n Amylase / Lipase:77/88, Differential-Neuts:80.0 %, Band:6.0 %,\n Lymph:3.0 %, Mono:1.0 %, Eos:1.0 %, D-dimer:6389 ng/mL, Fibrinogen:541\n mg/dL, Lactic Acid:2.4 mmol/L, Albumin:2.3 g/dL, LDH:529 IU/L, Ca++:9.1\n mg/dL, Mg++:2.3 mg/dL, PO4:1.7 mg/dL\n URINE CULTURE-PENDING\n CLOSTRIDIUM DIFFICILE TOXIN A & B - NEGATIVE\n Blood Culture, Routine-PENDING\n Blood Culture, Routine-PENDING\n CMV Viral Load-PENDING\n CMV IgG ANTIBODY-PENDING; CMV IgM ANTIBODY-PENDING\n CLOSTRIDIUM DIFFICILE TOXIN A & B - NEGATIVE\n URINE CULTURE-FINAL {YEAST}\n Assessment and Plan\n 28M with alcoholic hepatitis and necrotizing pancreatitis complicated\n by ARDS, SIRS, ARF, UGIB, fevers.\n #. ID: Persistent leukocytosis and fevers now that off CVVH. Possible\n that continued fevers necrotizing pancreatitis. Also with\n persistent yeast in ucx, persistent colonic inflammation on CT. On\n aztreonam, linezolid (since ) and flagyl (since ). Started\n micafungin and po vanc . In setting of fevers and hypotension,\n Cipro was started .\n - New fluid collection peri-pancreas but would hold off on fluid\n drainage\n - Check CXR\n - Bronch today\n - Cont broad coverage with linezolid (-), aztreo (-), flagyl\n (-), mica (-). D/c vanc po (-), Cipro IV ( -).\n - F/u c diff (neg x2), if neg x3 can d/c po vanc\n - Follow WBC count, temp curve, and culture data\n - F/u ID recs\n # Shock: Pressures dropped to 70/40 again in setting of fever. Likely\n septic shock. Will treat for infection as above. If requires pressors\n without fever consider other etiologies of hypotension including\n cardiogenic.\n - Cont weaning steroids; change to PO prednisone 5 mg today\n - Keep a-line until off pressors x 24 h\n - Infectious w/u as above\n # Elevated LFTs: A/w alcoholic hepatitis. RUQ u/s showed sludge\n concerning for cholestasis but also seen on u/s. HIDA neg.\n TPN stopped . T Bili and transaminases improving today.\n - weaning off benzos - 5 mg valium today\n - continue to trend\n #. Respiratory Failure: ARDS secondary to necrotizing pancreatitis. S/p\n trach placement on . Continues to have blood/clots suctioned from\n trach\n - DDAVP if acute bleeding (max few doses). Had required amicar shortly\n after trach for continued bleeding but complicated by seizure shortly\n after starting this.\n - Cte fentanyl boluses\n - Wean methadone and valium as tolerated\n - Cte OOB to chair daily\n - Trach\n #. Acute renal Failure: Multifactorial inc. ATN from hypotension\n - Was supposed to transition to HD today but pressures not able to\n tolerate. No need for filtration so will reassess tmrw.\n - Aztreonam 2000mg q12h while on CVVH.\n - continue Keppra at 1000mg Q24 with 500 mg after HD\n #. Adrenal Insufficiency: Unclear with stim if clear adrenal\n insufficiency but hypotension improving with steroids (lower pressor\n requirement) and eosinophilia resolved.\n - transition to PO prednisone 5 mg daily today\n # Seizures: CT head without intracranial process. EEG showed occipital\n seizures which does not correlate with clinical symptoms, but repeat\n EEG on higher dose Keppra showed no seizures. As patient now with\n purposeful movements, this may actually be patient waking up, not\n seizures.\n - Continue keppra at HD dosing\n # Altered Mental Status:\n - Titrate down sedating meds; decrease methadone to today and qd\n tomorrow\n ICU Care\n Nutrition:\n Nutren 2.0 () - 01:47 AM 50 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 08:15 PM\n PICC Line - 08:37 AM\n Dialysis Catheter - 08:55 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP: HOB elevation\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU, d/c to Rehab when stable on HD\n" }, { "category": "Physician ", "chartdate": "2131-06-27 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 683217, "text": "Chief Complaint:\n 24 Hour Events:\n - ID: feels sputum likely contaminant; no new abx recs; consider CT\n chest\n - renal: improved UOP encouraging; will likely need HD on Wed\n - blood, urine, stool cx ordered. U/A weakly positive; will follow\n culture.\n - sputum cx from showing moderate oropharyngeal flora; to be\n repeated.\n Allergies:\n Meropenem\n skin blisters\n Last dose of Antibiotics:\n Linezolid - 11:51 AM\n Aztreonam - 02:39 PM\n Micafungin - 10:48 PM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 03:36 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: 37.8\nC (100.1\n HR: 109 (104 - 118) bpm\n BP: 125/67(85) {94/50(64) - 145/77(98)} mmHg\n RR: 20 (19 - 39) insp/min\n SpO2: 98%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 104.5 kg (admission): 113.5 kg\n Height: 67 Inch\n Total In:\n 1,690 mL\n 215 mL\n PO:\n TF:\n 1,200 mL\n 179 mL\n IVF:\n 440 mL\n 36 mL\n Blood products:\n Total out:\n 897 mL\n 240 mL\n Urine:\n 897 mL\n 240 mL\n NG:\n Stool:\n Drains:\n Balance:\n 793 mL\n -25 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n Ventilator mode: Standby\n RR (Spontaneous): 30\n FiO2: 40%\n SpO2: 98%\n ABG: ////\n Physical Examination\n Labs / Radiology\n 225 K/uL\n 6.8 g/dL\n 128 mg/dL\n 3.0 mg/dL\n 23 mEq/L\n 3.3 mEq/L\n 79 mg/dL\n 101 mEq/L\n 136 mEq/L\n 22.1 %\n 15.0 K/uL\n [image002.jpg]\n 03:18 AM\n 03:44 PM\n 01:38 AM\n 06:00 AM\n 01:12 AM\n 06:06 AM\n 02:38 PM\n 02:00 AM\n 02:49 AM\n 01:51 AM\n WBC\n 30.9\n 27.6\n 18.9\n 15.0\n Hct\n 22.2\n 24.0\n 22.2\n 22.5\n 22.1\n Plt\n 28\n 225\n Cr\n 2.8\n 1.6\n 2.7\n 3.0\n TCO2\n 22\n 26\n 18\n 21\n 24\n Glucose\n 170\n 95\n 170\n 121\n 128\n Other labs: PT / PTT / INR:14.3/31.5/1.2, CK / CKMB /\n Troponin-T:214/3/0.07, ALT / AST:67/73, Alk Phos / T Bili:400/6.8,\n Amylase / Lipase:77/88, Differential-Neuts:84.3 %, Band:0.0 %,\n Lymph:9.3 %, Mono:1.7 %, Eos:4.3 %, D-dimer:6389 ng/mL, Fibrinogen:541\n mg/dL, Lactic Acid:2.6 mmol/L, Albumin:2.3 g/dL, LDH:331 IU/L, Ca++:8.6\n mg/dL, Mg++:2.1 mg/dL, PO4:3.7 mg/dL\n Assessment and Plan\n 28 year old male with a history of alcoholism presenting with acute\n hepatitis, pancreatitis, and UGIB.\n .\n # Hematemesis: Given alcohol history, potential consideration for\n varriceal bleed. No known prior history of hepatic cirrhosis, but\n elevated INR and fatty liver infilatration would be consistent. Also\n should consider PUD or alcoholic gastritis. Hct was WNL on\n presentation, but patient markedly contracted. Continued bright red\n blood on NG lavage suggests some degree of continued active bleeding.\n -- hepatology consulted, EGD\n -- access with 2 large bore IVs and a cordis, T + C x 3 units\n -- IV PPI + PPI gtt\n -- octreotide for now until varrices are ruled out.\n .\n # Pancreatitis: Most likely alcoholic in etiology, with elevated\n lipase to 1600 and CT findings consistent without necrosis, cycts, or\n phlemgon. Only mild epigastric tenderness and no complaints of\n abdominal pain.\n -- continue aggessive hydration\n -- serial abdominal exams\n -- trend lipase\n -- no evidence of obstruction, holding off on further imaging at this\n time\n -- check am lipid panel\n .\n # Acute Hepatitis: Likely alcoholic hepatitis. CT scan shows fatty\n infiltration, and no evidence of distal ostruction.\n - check viral hepatitis panel, although degree of transaminitis not\n consistant with such an etiology.\n - holding off on further imaging for now, f/u final CT read\n - hepatology following\n - avoid hepatically cleared meds\n - trend LFTs\n .\n # Leukocytosis: Marked leukocytosis with low grade temperature. UA\n consistent with UTI, but also may be stress response. Off Abx except\n for micafungin.\n -- f/u blood cultures and urine culture\n -- f/u final CT read\n .\n # Hyponatremia: Most likely due to volume depletion in the setting of\n inability to tolerate POs. Patient markedly dry on exam. also\n reflect a more chronic long-term liver disease.\n - fluid repleation as given above\n - if not correcting, will pursue furhter workup with urine lytes.\n # Alcoholism: Patient describes history of withdrawl symptoms, but not\n prior seizure. Last drink was night prior to presenation.\n Tachycardia, weakness, and elevated lactate could be consistent with\n thiamine deficiency.\n - repleate thiamine, vb12, folate\n - ativan with CIWA > 10\n - addictions consult\n .\n # FEN: IVF, replete electrolytes, NPO\n .\n # Prophylaxis: scds, PPI gtt\n .\n # Access: peripherals and femoral cortis\n .\n # Code: Full Code\n .\n # Disposition: MICU for now\n ICU Care\n Nutrition:\n Nutren 2.0 () - 01:30 PM 50 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 08:15 PM\n PICC Line - 08:37 AM\n Dialysis Catheter - 08:55 AM\n Prophylaxis:\n DVT: SQ UF Heparin, SCDs\n Stress ulcer: PPI\n VAP: HOB elevation\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n" }, { "category": "Physician ", "chartdate": "2131-06-27 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 683218, "text": "Chief Complaint:\n 24 Hour Events:\n - ID: feels sputum likely contaminant; no new abx recs; consider CT\n chest\n - renal: improved UOP encouraging; will likely need HD on Wed\n - blood, urine, stool cx ordered. U/A weakly positive; will follow\n culture.\n - sputum cx from showing moderate oropharyngeal flora; to be\n repeated.\n Allergies:\n Meropenem\n skin blisters\n Last dose of Antibiotics:\n Linezolid - 11:51 AM\n Aztreonam - 02:39 PM\n Micafungin - 10:48 PM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 03:36 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: 37.8\nC (100.1\n HR: 109 (104 - 118) bpm\n BP: 125/67(85) {94/50(64) - 145/77(98)} mmHg\n RR: 20 (19 - 39) insp/min\n SpO2: 98%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 104.5 kg (admission): 113.5 kg\n Height: 67 Inch\n Total In:\n 1,690 mL\n 215 mL\n PO:\n TF:\n 1,200 mL\n 179 mL\n IVF:\n 440 mL\n 36 mL\n Blood products:\n Total out:\n 897 mL\n 240 mL\n Urine:\n 897 mL\n 240 mL\n NG:\n Stool:\n Drains:\n Balance:\n 793 mL\n -25 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n Ventilator mode: Standby\n RR (Spontaneous): 30\n FiO2: 40%\n SpO2: 98%\n ABG: ////\n Physical Examination\n Labs / Radiology\n 225 K/uL\n 6.8 g/dL\n 128 mg/dL\n 3.0 mg/dL\n 23 mEq/L\n 3.3 mEq/L\n 79 mg/dL\n 101 mEq/L\n 136 mEq/L\n 22.1 %\n 15.0 K/uL\n [image002.jpg]\n 03:18 AM\n 03:44 PM\n 01:38 AM\n 06:00 AM\n 01:12 AM\n 06:06 AM\n 02:38 PM\n 02:00 AM\n 02:49 AM\n 01:51 AM\n WBC\n 30.9\n 27.6\n 18.9\n 15.0\n Hct\n 22.2\n 24.0\n 22.2\n 22.5\n 22.1\n Plt\n 28\n 225\n Cr\n 2.8\n 1.6\n 2.7\n 3.0\n TCO2\n 22\n 26\n 18\n 21\n 24\n Glucose\n 170\n 95\n 170\n 121\n 128\n Other labs: PT / PTT / INR:14.3/31.5/1.2, CK / CKMB /\n Troponin-T:214/3/0.07, ALT / AST:67/73, Alk Phos / T Bili:400/6.8,\n Amylase / Lipase:77/88, Differential-Neuts:84.3 %, Band:0.0 %,\n Lymph:9.3 %, Mono:1.7 %, Eos:4.3 %, D-dimer:6389 ng/mL, Fibrinogen:541\n mg/dL, Lactic Acid:2.6 mmol/L, Albumin:2.3 g/dL, LDH:331 IU/L, Ca++:8.6\n mg/dL, Mg++:2.1 mg/dL, PO4:3.7 mg/dL\n Assessment and Plan\n 28 year old male with a history of alcoholism presenting with acute\n hepatitis, pancreatitis, and UGIB.\n .\n # Hematemesis: Given alcohol history, potential consideration for\n varriceal bleed. No known prior history of hepatic cirrhosis, but\n elevated INR and fatty liver infilatration would be consistent. Also\n should consider PUD or alcoholic gastritis. Hct was WNL on\n presentation, but patient markedly contracted. Continued bright red\n blood on NG lavage suggests some degree of continued active bleeding.\n -- hepatology consulted, EGD\n -- access with 2 large bore IVs and a cordis, T + C x 3 units\n -- IV PPI + PPI gtt\n -- octreotide for now until varrices are ruled out.\n .\n # Pancreatitis: Most likely alcoholic in etiology, with elevated\n lipase to 1600 and CT findings consistent without necrosis, cycts, or\n phlemgon. Only mild epigastric tenderness and no complaints of\n abdominal pain.\n -- continue aggessive hydration\n -- serial abdominal exams\n -- trend lipase\n -- no evidence of obstruction, holding off on further imaging at this\n time\n -- check am lipid panel\n .\n # Acute Hepatitis: Likely alcoholic hepatitis. CT scan shows fatty\n infiltration, and no evidence of distal ostruction.\n - check viral hepatitis panel, although degree of transaminitis not\n consistant with such an etiology.\n - holding off on further imaging for now, f/u final CT read\n - hepatology following\n - avoid hepatically cleared meds\n - trend LFTs\n .\n # Leukocytosis: Marked leukocytosis with low grade temperature. UA\n consistent with UTI, but also may be stress response. Off Abx except\n for micafungin.\n -- f/u blood cultures and urine culture\n -- f/u final CT read\n .\n # Hyponatremia: Most likely due to volume depletion in the setting of\n inability to tolerate POs. Patient markedly dry on exam. also\n reflect a more chronic long-term liver disease.\n - fluid repleation as given above\n - if not correcting, will pursue furhter workup with urine lytes.\n # Alcoholism: Patient describes history of withdrawl symptoms, but not\n prior seizure. Last drink was night prior to presenation.\n Tachycardia, weakness, and elevated lactate could be consistent with\n thiamine deficiency.\n - repleate thiamine, vb12, folate\n - ativan with CIWA > 10\n - addictions consult\n .\n # FEN: IVF, replete electrolytes, NPO\n .\n # Prophylaxis: scds, PPI gtt\n .\n # Access: peripherals and femoral cortis\n .\n # Code: Full Code\n .\n # Disposition: MICU for now\n ICU Care\n Nutrition:\n Nutren 2.0 () - 01:30 PM 50 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 08:15 PM\n PICC Line - 08:37 AM\n Dialysis Catheter - 08:55 AM\n Prophylaxis:\n DVT: SQ UF Heparin, SCDs\n Stress ulcer: PPI\n VAP: HOB elevation\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n" }, { "category": "Respiratory ", "chartdate": "2131-06-27 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 683219, "text": "Demographics\n Day of intubation: \n Day of mechanical ventilation: 5\n Ideal body weight: 67.1 None\n Ideal tidal volume: 268.4 / 402.6 / 536.8 mL/kg\n Airway\n Airway Placement Data\n Tube Type\n Tracheostomy tube:\n Type: Standard\n Manufacturer: Portex\n Size: 8.0mm\n PMV: No\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: Clear / Thick\n Sputum source/amount: Suctioned / Small\n Ventilation Assessment\n Level of breathing assistance: Unassisted spontaneous breathing\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Bedside Procedures:\n Sputum Culture\n" }, { "category": "Rehab Services", "chartdate": "2131-06-27 00:00:00.000", "description": "Physical Therapy Progress Note", "row_id": 683331, "text": "Subjective:\n trach\n Objective:\n Follow up PT visit to address goals of: . Patient seen today\n for balance training\n Updated medical status: no new imaging or labs\n Activity\n Clarification\n I\n S\n CG\n Min\n Mod\n Max\n Rolling:\n\n\n\n\n\n Supine/\n Sidelying to Sit:\n total assist\n\n\n\n\n\n\n Transfer:\n\n\n\n\n\n Sit to Stand:\n\n\n\n\n\n Ambulation:\n\n\n\n\n\n Stairs:\n\n\n\n\n\n Aerobic Activity Response:\n Position\n HR\n BP\n RR\n O[2] sat\n RPE\n Rest\n Supine\n 112\n 130/76\n 100% on TM\n Activity\n 124\n 124/72\n 99% on TM\n Recovery\n /\n Total distance walked:\n Minutes:\n Gait: not assessed. Total assist for all mobility\n Balance: Maintains static sitting at edge of bed with CG for several\n minutes at a time, initiates sit-to-supine movement. Min-mod A at\n times.\n Education / Communication: Reviewed PT and provided encouragement.\n Communicated with nsg re: status.\n Other: Patient not following any commands, except attempted to lay down\n from sitting when told, ? if spontaneous. Reflexive gripping B hands.\n Able to track both directions and maintain eye contact 1-2 seconds.\n Tremulous B UE's when sitting EOB.\n On 40% FIO2 via trach mask, frequent coughing at EOB, productive of\n min-mod amount thick yellow sputum.\n Assessment: 28 yo M with acute pancreatitis making slow steady progress\n in PT, especially with sitting balance. Still not following commands\n but initiating movement at times, appears to understand verbal commands\n at times. Continues to be well below his baseline, continue to\n recommend rehab upon d/c.\n Anticipated Discharge: Rehab\n Plan: continue with \n" }, { "category": "Physician ", "chartdate": "2131-06-27 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 683321, "text": "Chief Complaint: pancreatitis, resp failure,\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n remains off vent and pressors\n Allergies:\n Meropenem\n skin blisters a\n Last dose of Antibiotics:\n Linezolid - 11:51 AM\n Aztreonam - 02:39 PM\n Micafungin - 10:48 PM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 04:00 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 Flowsheet Data as of 09:23 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: 37.6\nC (99.6\n HR: 105 (104 - 118) bpm\n BP: 135/72(94) {120/65(83) - 145/77(98)} mmHg\n RR: 18 (18 - 39) insp/min\n SpO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 104.5 kg (admission): 113.5 kg\n Height: 67 Inch\n Total In:\n 1,691 mL\n 662 mL\n PO:\n TF:\n 1,200 mL\n 468 mL\n IVF:\n 441 mL\n 194 mL\n Blood products:\n Total out:\n 897 mL\n 590 mL\n Urine:\n 897 mL\n 590 mL\n NG:\n Stool:\n Drains:\n Balance:\n 794 mL\n 72 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n Ventilator mode: Standby\n RR (Spontaneous): 19\n FiO2: 40%\n SpO2: 100%\n ABG: ///20/\n Physical Examination\n Gen: up in chair, eyes open\n CV: RR\n Chest: good air movement\n Abd: distended +BS\n Ext: 3+ edema\n Neuro: eyes open, will blink/ to command, weak grasp, doe not\n follow\n Labs / Radiology\n 6.8 g/dL\n 225 K/uL\n 80 mg/dL\n 2.9 mg/dL\n 20 mEq/L\n 3.1 mEq/L\n 88 mg/dL\n 106 mEq/L\n 140 mEq/L\n 22.1 %\n 12.6 K/uL\n [image002.jpg]\n 03:18 AM\n 03:44 PM\n 01:38 AM\n 06:00 AM\n 01:12 AM\n 06:06 AM\n 02:38 PM\n 02:00 AM\n 02:49 AM\n 01:51 AM\n WBC\n 30.9\n 27.6\n 18.9\n 15.0\n 12.6\n Hct\n 22.2\n 24.0\n 22.2\n 22.5\n 22.1\n Plt\n 28\n 225\n Cr\n 2.8\n 1.6\n 2.7\n 3.0\n 2.9\n TCO2\n 22\n 26\n 18\n 21\n 24\n Glucose\n 170\n 95\n 170\n 121\n 128\n 80\n Other labs: PT / PTT / INR:13.6/28.0/1.2, CK / CKMB /\n Troponin-T:214/3/0.07, ALT / AST:65/86, Alk Phos / T Bili:429/5.6,\n Amylase / Lipase:77/88, Differential-Neuts:84.3 %, Band:0.0 %,\n Lymph:9.3 %, Mono:1.7 %, Eos:4.3 %, D-dimer:6389 ng/mL, Fibrinogen:541\n mg/dL, Lactic Acid:2.6 mmol/L, Albumin:2.3 g/dL, LDH:312 IU/L, Ca++:8.6\n mg/dL, Mg++:2.0 mg/dL, PO4:3.0 mg/dL\n Assessment and Plan\n FEVER, UNKNOWN ORIGIN (FUO, HYPERTHERMIA, PYREXIA)\n AROUSAL, ATTENTION, AND COGNITION, IMPAIRED\n BALANCE, IMPAIRED\n MOTOR FUNCTION, IMPAIRED\n MUSCLE PERFORMACE, IMPAIRED\n RESPIRATION / GAS EXCHANGE, IMPAIRED\n SEIZURE, WITHOUT STATUS EPILEPTICUS\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n IMPAIRED SKIN INTEGRITY\n HEPATITIS, ACUTE TOXIC (INCLUDING ALCOHOLIC, ACETAMINOPHEN, ETC.)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n 1. Cyclical fevers\n overall trend is down and WBC trend is\n down. We have been weaning off ABX since nothing has grown\n will\n continue only micafungin while monitoring culture data. Will get blood\n cx off HD line. Does have GNR in sputum but is likely colonized\n will\n repeat CXR but would need temps and leukocytosis to make criteria for a\n PNA\n 2. Hypotension: resolved\n watch carefully.\n 3. Resp Failure: back on trach mask\n 4. Altered Mental status: Given possibility of sz activity, will\n continue keppra. Speak w Neuro re role of imaging. Unclear how much of\n this is late drug wash out and how much is underlying neuron injury\n that is potentially rehab\n 5. For ARF: making good urine this AM, may even be able to hold\n off on HD\n 6. For pancreatitis, will continue post-pyloric TFs, and\n will continue to hold off on any drainage of new peripancreatic fluid\n collection but will discuss with Dr \n Remaining issues as per Housestaff\n ICU Care\n Nutrition: Nutren 2.0 () - 01:30 PM 50 mL/hour\n Glycemic Control:\n Lines: Arterial Line - 08:15 PM\n PICC Line - 08:37 AM\n Dialysis Catheter - 08:55 AM\n Prophylaxis:\n DVT: sc hep\n Stress ulcer: PPI\n VAP: HOB and chlorx\n Communication: will touch base w family be able to rehab soon\n Code status: Full code\n Disposition : ICU\n Total time spent:\n" }, { "category": "Physician ", "chartdate": "2131-06-22 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 682246, "text": "Chief Complaint:\n 24 Hour Events:\n INVASIVE VENTILATION - STOP 08:22 AM\n received on TM\n STOOL CULTURE - At 12:11 PM\n BLOOD CULTURED - At 05:11 PM\n URINE CULTURE - At 02:20 AM\n FEVER - 101.2\nF - 08:00 PM\n \n - Underwent HD\n - 2 hours after HD, SBP dropped to 80s, HR in 110s but came up on own\n to low 100s. Spiked fever 101.2. Sent bcx and ucx. Started cipro IV.\n Received 250cc for BP 80s (MAP 55-60) but BP still declining so started\n on levophed.\n - Suctioned clots and blood from trach and oropharynx. Noted to have\n bleeding from gums. Given DDAVP 30mg IV x 1. Hct and coags stable.\n Allergies:\n Meropenem\n skin blisters a\n Last dose of Antibiotics:\n Micafungin - 09:30 PM\n Vancomycin - 02:18 PM\n Aztreonam - 03:18 PM\n Ciprofloxacin - 08:00 PM\n Linezolid - 12:33 AM\n Metronidazole - 05:14 AM\n Infusions:\n Norepinephrine - 0.03 mcg/Kg/min\n Other ICU medications:\n Famotidine (Pepcid) - 12:33 AM\n Heparin Sodium (Prophylaxis) - 05:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:41 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: 38.2\nC (100.8\n HR: 106 (101 - 116) bpm\n BP: 105/58(72) {75/40(57) - 125/67(85)} mmHg\n RR: 30 (21 - 42) insp/min\n SpO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 100.7 kg (admission): 113.5 kg\n Height: 67 Inch\n Total In:\n 3,740 mL\n 1,111 mL\n PO:\n TF:\n 1,200 mL\n 333 mL\n IVF:\n 2,270 mL\n 658 mL\n Blood products:\n Total out:\n 1,405 mL\n 60 mL\n Urine:\n 405 mL\n 60 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,335 mL\n 1,051 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n SpO2: 100%\n ABG: 7.42/40/110/25/0\n PaO2 / FiO2: 220\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 305 K/uL\n 7.1 g/dL\n 136 mg/dL\n 1.8 mg/dL\n 25 mEq/L\n 3.3 mEq/L\n 43 mg/dL\n 99 mEq/L\n 136 mEq/L\n 23.1 %\n 35.7 K/uL\n [image002.jpg]\n 03:15 AM\n 04:57 PM\n 02:28 AM\n 02:50 AM\n 05:09 PM\n 05:55 PM\n 05:57 PM\n 09:02 PM\n 01:42 AM\n 01:50 AM\n WBC\n 38.5\n 38.6\n 34.0\n 35.7\n Hct\n 22.7\n 22.6\n 21.6\n 23.1\n Plt\n 282\n 277\n 291\n 305\n Cr\n 2.4\n 1.2\n 1.8\n TCO2\n 23\n 20\n 22\n 21\n 27\n Glucose\n 132\n 126\n 136\n Other labs: PT / PTT / INR:15.6/34.5/1.4, CK / CKMB /\n Troponin-T:214/3/0.07, ALT / AST:156/151, Alk Phos / T Bili:487/12.6,\n Amylase / Lipase:77/88, Differential-Neuts:80.0 %, Band:6.0 %,\n Lymph:3.0 %, Mono:1.0 %, Eos:1.0 %, D-dimer:6389 ng/mL, Fibrinogen:541\n mg/dL, Lactic Acid:2.4 mmol/L, Albumin:2.3 g/dL, LDH:529 IU/L, Ca++:9.1\n mg/dL, Mg++:2.3 mg/dL, PO4:1.7 mg/dL\n Assessment and Plan\n AROUSAL, ATTENTION, AND COGNITION, IMPAIRED\n BALANCE, IMPAIRED\n MOTOR FUNCTION, IMPAIRED\n MUSCLE PERFORMACE, IMPAIRED\n RESPIRATION / GAS EXCHANGE, IMPAIRED\n SEIZURE, WITHOUT STATUS EPILEPTICUS\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n IMPAIRED SKIN INTEGRITY\n HEPATITIS, ACUTE TOXIC (INCLUDING ALCOHOLIC, ACETAMINOPHEN, ETC.)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ICU Care\n Nutrition:\n Nutren 2.0 () - 01:47 AM 50 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 08:15 PM\n PICC Line - 08:37 AM\n Dialysis Catheter - 08:55 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP: HOB elevation\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:ICU\n" }, { "category": "Physician ", "chartdate": "2131-06-22 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 682247, "text": "Chief Complaint:\n 24 Hour Events:\n INVASIVE VENTILATION - STOP 08:22 AM\n received on TM\n STOOL CULTURE - At 12:11 PM\n BLOOD CULTURED - At 05:11 PM\n URINE CULTURE - At 02:20 AM\n FEVER - 101.2\nF - 08:00 PM\n \n - Underwent HD\n - 2 hours after HD, SBP dropped to 80s, HR in 110s but came up on own\n to low 100s. Spiked fever 101.2. Sent bcx and ucx. Started cipro IV.\n Received 250cc for BP 80s (MAP 55-60) but BP still declining so started\n on levophed.\n - Suctioned clots and blood from trach and oropharynx. Noted to have\n bleeding from gums. Given DDAVP 30mg IV x 1. Hct and coags stable.\n Allergies:\n Meropenem\n skin blisters a\n Last dose of Antibiotics:\n Micafungin - 09:30 PM\n Vancomycin - 02:18 PM\n Aztreonam - 03:18 PM\n Ciprofloxacin - 08:00 PM\n Linezolid - 12:33 AM\n Metronidazole - 05:14 AM\n Infusions:\n Norepinephrine - 0.03 mcg/Kg/min\n Other ICU medications:\n Famotidine (Pepcid) - 12:33 AM\n Heparin Sodium (Prophylaxis) - 05:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:41 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: 38.2\nC (100.8\n HR: 106 (101 - 116) bpm\n BP: 105/58(72) {75/40(57) - 125/67(85)} mmHg\n RR: 30 (21 - 42) insp/min\n SpO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 100.7 kg (admission): 113.5 kg\n Height: 67 Inch\n Total In:\n 3,740 mL\n 1,111 mL\n PO:\n TF:\n 1,200 mL\n 333 mL\n IVF:\n 2,270 mL\n 658 mL\n Blood products:\n Total out:\n 1,405 mL\n 60 mL\n Urine:\n 405 mL\n 60 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,335 mL\n 1,051 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n SpO2: 100%\n ABG: 7.42/40/110/25/0\n PaO2 / FiO2: 220\n Physical Examination\n GEN: Trached.\n HEENT: Icteric sclera. MMM.\n NECK: Trach site with no oozing.\n LUNGS: Anterior auscultation with upper airway noise; good airway\n movement.\n HEART: RRR, normal S1, S2.\n ABD: Distended. Firm, but unchanged.\n EXTREM: 2+ edema, ulcers/lesions on legs with bandages C/D/I.\n SKIN: Jaundiced.\n NEURO: Twitching mouth and arms. ? clonus. Opens eyes, squeezes hand to\n command.\n Labs / Radiology\n 305 K/uL\n 7.1 g/dL\n 136 mg/dL\n 1.8 mg/dL\n 25 mEq/L\n 3.3 mEq/L\n 43 mg/dL\n 99 mEq/L\n 136 mEq/L\n 23.1 %\n 35.7 K/uL\n [image002.jpg]\n 03:15 AM\n 04:57 PM\n 02:28 AM\n 02:50 AM\n 05:09 PM\n 05:55 PM\n 05:57 PM\n 09:02 PM\n 01:42 AM\n 01:50 AM\n WBC\n 38.5\n 38.6\n 34.0\n 35.7\n Hct\n 22.7\n 22.6\n 21.6\n 23.1\n Plt\n 282\n 277\n 291\n 305\n Cr\n 2.4\n 1.2\n 1.8\n TCO2\n 23\n 20\n 22\n 21\n 27\n Glucose\n 132\n 126\n 136\n Other labs: PT / PTT / INR:15.6/34.5/1.4, CK / CKMB /\n Troponin-T:214/3/0.07, ALT / AST:156/151, Alk Phos / T Bili:487/12.6,\n Amylase / Lipase:77/88, Differential-Neuts:80.0 %, Band:6.0 %,\n Lymph:3.0 %, Mono:1.0 %, Eos:1.0 %, D-dimer:6389 ng/mL, Fibrinogen:541\n mg/dL, Lactic Acid:2.4 mmol/L, Albumin:2.3 g/dL, LDH:529 IU/L, Ca++:9.1\n mg/dL, Mg++:2.3 mg/dL, PO4:1.7 mg/dL\n Assessment and Plan\n AROUSAL, ATTENTION, AND COGNITION, IMPAIRED\n BALANCE, IMPAIRED\n MOTOR FUNCTION, IMPAIRED\n MUSCLE PERFORMACE, IMPAIRED\n RESPIRATION / GAS EXCHANGE, IMPAIRED\n SEIZURE, WITHOUT STATUS EPILEPTICUS\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n IMPAIRED SKIN INTEGRITY\n HEPATITIS, ACUTE TOXIC (INCLUDING ALCOHOLIC, ACETAMINOPHEN, ETC.)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ICU Care\n Nutrition:\n Nutren 2.0 () - 01:47 AM 50 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 08:15 PM\n PICC Line - 08:37 AM\n Dialysis Catheter - 08:55 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP: HOB elevation\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:ICU\n" }, { "category": "Physician ", "chartdate": "2131-06-22 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 682249, "text": "Chief Complaint:\n 24 Hour Events:\n INVASIVE VENTILATION - STOP 08:22 AM\n received on TM\n STOOL CULTURE - At 12:11 PM\n BLOOD CULTURED - At 05:11 PM\n URINE CULTURE - At 02:20 AM\n FEVER - 101.2\nF - 08:00 PM\n \n - Underwent HD\n - 2 hours after HD, SBP dropped to 80s, HR in 110s but came up on own\n to low 100s. Spiked fever 101.2. Sent bcx and ucx. Started cipro IV.\n Received 250cc for BP 80s (MAP 55-60) but BP still declining so started\n on levophed.\n - Suctioned clots and blood from trach and oropharynx. Noted to have\n bleeding from gums. Given DDAVP 30mg IV x 1. Hct and coags stable.\n Allergies:\n Meropenem\n skin blisters a\n Last dose of Antibiotics:\n Micafungin - 09:30 PM\n Vancomycin - 02:18 PM\n Aztreonam - 03:18 PM\n Ciprofloxacin - 08:00 PM\n Linezolid - 12:33 AM\n Metronidazole - 05:14 AM\n Infusions:\n Norepinephrine - 0.03 mcg/Kg/min\n Other ICU medications:\n Famotidine (Pepcid) - 12:33 AM\n Heparin Sodium (Prophylaxis) - 05:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:41 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: 38.2\nC (100.8\n HR: 106 (101 - 116) bpm\n BP: 105/58(72) {75/40(57) - 125/67(85)} mmHg\n RR: 30 (21 - 42) insp/min\n SpO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 100.7 kg (admission): 113.5 kg\n Height: 67 Inch\n Total In:\n 3,740 mL\n 1,111 mL\n PO:\n TF:\n 1,200 mL\n 333 mL\n IVF:\n 2,270 mL\n 658 mL\n Blood products:\n Total out:\n 1,405 mL\n 60 mL\n Urine:\n 405 mL\n 60 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,335 mL\n 1,051 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n SpO2: 100%\n ABG: 7.42/40/110/25/0\n PaO2 / FiO2: 220\n Physical Examination\n GEN: Trached.\n HEENT: Icteric sclera. MMM.\n NECK: Trach site with no oozing.\n LUNGS: Anterior auscultation with upper airway noise; good airway\n movement.\n HEART: RRR, normal S1, S2.\n ABD: Distended. Firm, but unchanged.\n EXTREM: 2+ edema, ulcers/lesions on legs with bandages C/D/I.\n SKIN: Jaundiced.\n NEURO: Twitching mouth and arms. ? clonus. Opens eyes, squeezes hand to\n command.\n Labs / Radiology\n 305 K/uL\n 7.1 g/dL\n 136 mg/dL\n 1.8 mg/dL\n 25 mEq/L\n 3.3 mEq/L\n 43 mg/dL\n 99 mEq/L\n 136 mEq/L\n 23.1 %\n 35.7 K/uL\n [image002.jpg]\n 03:15 AM\n 04:57 PM\n 02:28 AM\n 02:50 AM\n 05:09 PM\n 05:55 PM\n 05:57 PM\n 09:02 PM\n 01:42 AM\n 01:50 AM\n WBC\n 38.5\n 38.6\n 34.0\n 35.7\n Hct\n 22.7\n 22.6\n 21.6\n 23.1\n Plt\n 282\n 277\n 291\n 305\n Cr\n 2.4\n 1.2\n 1.8\n TCO2\n 23\n 20\n 22\n 21\n 27\n Glucose\n 132\n 126\n 136\n Other labs: PT / PTT / INR:15.6/34.5/1.4, CK / CKMB /\n Troponin-T:214/3/0.07, ALT / AST:156/151, Alk Phos / T Bili:487/12.6,\n Amylase / Lipase:77/88, Differential-Neuts:80.0 %, Band:6.0 %,\n Lymph:3.0 %, Mono:1.0 %, Eos:1.0 %, D-dimer:6389 ng/mL, Fibrinogen:541\n mg/dL, Lactic Acid:2.4 mmol/L, Albumin:2.3 g/dL, LDH:529 IU/L, Ca++:9.1\n mg/dL, Mg++:2.3 mg/dL, PO4:1.7 mg/dL\n Assessment and Plan\n 28M with alcoholic hepatitis and necrotizing pancreatitis complicated\n by ARDS, SIRS, ARF, UGIB, fevers.\n #. ID: Persistent leukocytosis and fevers now that off CVVH. Possible\n that continued fevers necrotizing pancreatitis. Also with\n persistent yeast in ucx, persistent colonic inflammation on CT. On\n aztreonam, linezolid (since ) and flagyl (since ). Started\n micafungin and po vanc yesterday.\n - New fluid collection peri-pancreas\n unclear if infected. Per Surgery\n with no role for fluid drainage at this time.\n - f/u ID recs\n - Cont broad coverage with linezolid (-), aztreo (-), flagyl\n (-), mica (-), vanc po (-).\n - f/u c diff, if neg x2-3 can d/c po vanc\n - Follow WBC count, temp curve, and culture data\n # Shock: Patient had transient pressor requirement last pm in setting\n of fever. When fever resolved pressor requirement did as well. Likely\n septic shock. Will treat for infection as above. If requires pressors\n without fever consider other etiologies of hypotension including\n cardiogenic.\n - Cont weaning steroids\n change to PO prednisone 5 mg in AM of \n - D/c a-line\n check VBG and ABG simultaneously\n # Elevated LFTs: A/w alcoholic hepatitis. RUQ u/s showed sludge\n concerning for cholestasis but also seen on u/s. T Bili and\n transaminases improving today.\n - HIDA neg\n - TPN stopped \n - weaning off benzos\n 5 mg valium\n #. Respiratory Failure: ARDS secondary to necrotizing pancreatitis. S/p\n trach placement on .\n - Cte fentanyl boluses and alternatingly wean methadone and valium as\n tolerate.\n - Cte OOB to chair daily\n - Wean methadone to \n #. Acute renal Failure: Multifactorial inc. ATN from hypotension\n - Was supposed to transition to HD today but pressures not able to\n tolerate. No need for filtration so will reassess tmrw.\n - Aztreonam 2000mg q12h while on CVVH. Change after aztreonam.\n - continue Keppra at 1000mg Q24 with 500 mg after HD\n #. Adrenal Insufficiency: Unclear with stim if clear adrenal\n insufficiency but hypotension improving with steroids (lower pressor\n requirement) and eosinophilia resolved.\n - Cont weaning hydrocort to q12h today\n - transition to PO prednisone 5 mg daily in AM of \n # Seizures: CT head without intracranial process. EEG showed occipital\n seizures which does not correlate with clinical symptoms, but repeat\n EEG on higher dose Keppra showed no seizures. As patient now with\n purposeful movements, this may actually be patient waking up, not\n seizures.\n - Continue keppra at HD dosing\n - Wean valium today\n ICU Care\n Nutrition:\n Nutren 2.0 () - 01:47 AM 50 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 08:15 PM\n PICC Line - 08:37 AM\n Dialysis Catheter - 08:55 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP: HOB elevation\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:ICU\n" }, { "category": "Physician ", "chartdate": "2131-06-22 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 682251, "text": "Chief Complaint:\n 24 Hour Events:\n INVASIVE VENTILATION - STOP 08:22 AM\n received on TM\n STOOL CULTURE - At 12:11 PM\n BLOOD CULTURED - At 05:11 PM\n URINE CULTURE - At 02:20 AM\n FEVER - 101.2\nF - 08:00 PM\n \n - Underwent HD\n - 2 hours after HD, SBP dropped to 80s, HR in 110s but came up on own\n to low 100s. Spiked fever 101.2. Sent bcx and ucx. Started cipro IV.\n Received 250cc for BP 80s (MAP 55-60) but BP still declining so started\n on levophed.\n - Suctioned clots and blood from trach and oropharynx. Noted to have\n bleeding from gums. Given DDAVP 30mg IV x 1. Hct and coags stable.\n Allergies:\n Meropenem\n skin blisters a\n Last dose of Antibiotics:\n Micafungin - 09:30 PM\n Vancomycin - 02:18 PM\n Aztreonam - 03:18 PM\n Ciprofloxacin - 08:00 PM\n Linezolid - 12:33 AM\n Metronidazole - 05:14 AM\n Infusions:\n Norepinephrine - 0.03 mcg/Kg/min\n Other ICU medications:\n Famotidine (Pepcid) - 12:33 AM\n Heparin Sodium (Prophylaxis) - 05:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:41 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: 38.2\nC (100.8\n HR: 106 (101 - 116) bpm\n BP: 105/58(72) {75/40(57) - 125/67(85)} mmHg\n RR: 30 (21 - 42) insp/min\n SpO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 100.7 kg (admission): 113.5 kg\n Height: 67 Inch\n Total In:\n 3,740 mL\n 1,111 mL\n PO:\n TF:\n 1,200 mL\n 333 mL\n IVF:\n 2,270 mL\n 658 mL\n Blood products:\n Total out:\n 1,405 mL\n 60 mL\n Urine:\n 405 mL\n 60 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,335 mL\n 1,051 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n SpO2: 100%\n ABG: 7.42/40/110/25/0\n PaO2 / FiO2: 220\n Physical Examination\n GEN: Trached.\n HEENT: Icteric sclera. MMM.\n NECK: Trach site with no oozing.\n LUNGS: Anterior auscultation with upper airway noise; good airway\n movement.\n HEART: RRR, normal S1, S2.\n ABD: Distended. Firm, but unchanged.\n EXTREM: 2+ edema, ulcers/lesions on legs with bandages C/D/I.\n SKIN: Jaundiced.\n NEURO: Twitching mouth and arms. ? clonus. Opens eyes, squeezes hand to\n command.\n Labs / Radiology\n 305 K/uL\n 7.1 g/dL\n 136 mg/dL\n 1.8 mg/dL\n 25 mEq/L\n 3.3 mEq/L\n 43 mg/dL\n 99 mEq/L\n 136 mEq/L\n 23.1 %\n 35.7 K/uL\n [image002.jpg]\n 03:15 AM\n 04:57 PM\n 02:28 AM\n 02:50 AM\n 05:09 PM\n 05:55 PM\n 05:57 PM\n 09:02 PM\n 01:42 AM\n 01:50 AM\n WBC\n 38.5\n 38.6\n 34.0\n 35.7\n Hct\n 22.7\n 22.6\n 21.6\n 23.1\n Plt\n 282\n 277\n 291\n 305\n Cr\n 2.4\n 1.2\n 1.8\n TCO2\n 23\n 20\n 22\n 21\n 27\n Glucose\n 132\n 126\n 136\n Other labs: PT / PTT / INR:15.6/34.5/1.4, CK / CKMB /\n Troponin-T:214/3/0.07, ALT / AST:156/151, Alk Phos / T Bili:487/12.6,\n Amylase / Lipase:77/88, Differential-Neuts:80.0 %, Band:6.0 %,\n Lymph:3.0 %, Mono:1.0 %, Eos:1.0 %, D-dimer:6389 ng/mL, Fibrinogen:541\n mg/dL, Lactic Acid:2.4 mmol/L, Albumin:2.3 g/dL, LDH:529 IU/L, Ca++:9.1\n mg/dL, Mg++:2.3 mg/dL, PO4:1.7 mg/dL\n Assessment and Plan\n 28M with alcoholic hepatitis and necrotizing pancreatitis complicated\n by ARDS, SIRS, ARF, UGIB, fevers.\n #. ID: Persistent leukocytosis and fevers now that off CVVH. Possible\n that continued fevers necrotizing pancreatitis. Also with\n persistent yeast in ucx, persistent colonic inflammation on CT. On\n aztreonam, linezolid (since ) and flagyl (since ). Started\n micafungin and po vanc . In setting of fevers and hypotension,\n Cipro was started .\n - New fluid collection peri-pancreas\n unclear if infected. Per Surgery\n with no role for fluid drainage at this time.\n - f/u ID recs\n - Cont broad coverage with linezolid (-), aztreo (-), flagyl\n (-), mica (-), vanc po (-).\n - f/u c diff, if neg x2-3 can d/c po vanc\n - Follow WBC count, temp curve, and culture data\n # Shock: Pressures dropped to 70/40 again in setting of fever. Likely\n septic shock. Will treat for infection as above. If requires pressors\n without fever consider other etiologies of hypotension including\n cardiogenic.\n - Cont weaning steroids\n change to PO prednisone 5 mg in AM of \n - D/c a-line\n check VBG and ABG simultaneously\n # Elevated LFTs: A/w alcoholic hepatitis. RUQ u/s showed sludge\n concerning for cholestasis but also seen on u/s. T Bili and\n transaminases improving today.\n - HIDA neg\n - TPN stopped \n - weaning off benzos\n 5 mg valium\n #. Respiratory Failure: ARDS secondary to necrotizing pancreatitis. S/p\n trach placement on .\n - Cte fentanyl boluses and alternatingly wean methadone and valium as\n tolerate.\n - Cte OOB to chair daily\n - Wean methadone to \n #. Acute renal Failure: Multifactorial inc. ATN from hypotension\n - Was supposed to transition to HD today but pressures not able to\n tolerate. No need for filtration so will reassess tmrw.\n - Aztreonam 2000mg q12h while on CVVH. Change after aztreonam.\n - continue Keppra at 1000mg Q24 with 500 mg after HD\n #. Adrenal Insufficiency: Unclear with stim if clear adrenal\n insufficiency but hypotension improving with steroids (lower pressor\n requirement) and eosinophilia resolved.\n - Cont weaning hydrocort to q12h today\n - transition to PO prednisone 5 mg daily in AM of \n # Seizures: CT head without intracranial process. EEG showed occipital\n seizures which does not correlate with clinical symptoms, but repeat\n EEG on higher dose Keppra showed no seizures. As patient now with\n purposeful movements, this may actually be patient waking up, not\n seizures.\n - Continue keppra at HD dosing\n - Wean valium today\n ICU Care\n Nutrition:\n Nutren 2.0 () - 01:47 AM 50 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 08:15 PM\n PICC Line - 08:37 AM\n Dialysis Catheter - 08:55 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP: HOB elevation\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:ICU\n" }, { "category": "Physician ", "chartdate": "2131-06-21 00:00:00.000", "description": "Physician Resident/Attending Progress Note - MICU", "row_id": 682124, "text": "Chief Complaint:\n 24 Hour Events:\n - Renal deferred starting HD given hypotension yesterday with plan to\n start today.\n - Surgery recommended starting antifungal but not draining fluid\n collection around pancreas which appeared sterile to them given absence\n of gas.\n - ID recommended broadening antibiotic coverage to micafungin, vanc po,\n and cipro for double GN coverage. Thought fluid collection should\n drained by IR. Also would check surveillance cx, CMV VL, recheck C.\n diff, c/s GI re: colonoscopy for biopsy of colitis, d/c A-line and\n foley if able.\n - Abx coverage broadened to micafungin and vanc po.\n - Speech evaluated for Passy-Muir valve but pt couldn't tolerate.\n - Methadone, hydrocort, and valium weaned down.\n - Neuro saw pt and thought making slow progress; will continue to\n follow for prognostication.\n Allergies:\n Meropenem\n skin blisters a\n Last dose of Antibiotics:\n Micafungin - 09:30 PM\n Linezolid - 12:40 AM\n Aztreonam - 02:25 AM\n Vancomycin - 02:26 AM\n Metronidazole - 04:16 AM\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 12:00 AM\n Heparin Sodium (Prophylaxis) - 04:16 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 04:37 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.9\nC (100.2\n Tcurrent: 37.9\nC (100.2\n HR: 110 (89 - 116) bpm\n BP: 99/54(68) {99/52(68) - 139/72(94)} mmHg\n RR: 26 (22 - 34) insp/min\n SpO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 100.7 kg (admission): 113.5 kg\n Height: 67 Inch\n Total In:\n 2,814 mL\n 886 mL\n PO:\n TF:\n 1,100 mL\n 230 mL\n IVF:\n 1,564 mL\n 596 mL\n Blood products:\n Total out:\n 330 mL\n 130 mL\n Urine:\n 330 mL\n 130 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,484 mL\n 756 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n SpO2: 100%\n ABG: 7.39/32/92./18/-4\n PaO2 / FiO2: 186\n Physical Examination\n GEN: Trached.\n HEENT: Icteric sclera. MMM.\n NECK: Trach site with no oozing.\n LUNGS: Anterior auscultation with upper airway noise; good airway\n movement.\n HEART: RRR, normal S1, S2.\n ABD: Distended. Firm, but unchanged.\n EXTREM: 2+ edema, ulcers/lesions on legs with bandages C/D/I.\n SKIN: Jaundiced.\n NEURO: Twitching mouth. Opens eyes, squeezes hand to command.\n Labs / Radiology\n 277 K/uL\n 7.0 g/dL\n 132 mg/dL\n 2.4 mg/dL\n 18 mEq/L\n 3.9 mEq/L\n 82 mg/dL\n 99 mEq/L\n 131 mEq/L\n 22.6 %\n 38.6 K/uL\n [image002.jpg]\n 10:53 AM\n 12:57 PM\n 03:00 PM\n 10:13 PM\n 10:23 PM\n 03:00 AM\n 03:15 AM\n 04:57 PM\n 02:28 AM\n 02:50 AM\n WBC\n 38.5\n 38.5\n Hct\n 22.7\n 22.7\n 22.6\n Plt\n 282\n 282\n 277\n Cr\n 1.2\n 1.8\n 2.4\n TCO2\n 23\n 22\n 18\n 25\n 23\n 20\n Glucose\n 114\n 121\n 140\n 135\n 141\n 132\n Other labs: PT / PTT / INR:15.0/33.3/1.3, CK / CKMB /\n Troponin-T:214/3/0.07, ALT / AST:181/177, Alk Phos / T Bili:455/15.9,\n Amylase / Lipase:77/141, Differential-Neuts:90.0 %, Band:0.0 %,\n Lymph:3.0 %, Mono:5.0 %, Eos:1.0 %, D-dimer:6389 ng/mL, Fibrinogen:502\n mg/dL, Lactic Acid:1.4 mmol/L, Albumin:2.0 g/dL, LDH:529 IU/L, Ca++:8.6\n mg/dL, Mg++:2.3 mg/dL, PO4:3.0 mg/dL\n Assessment and Plan\n 28M with alcoholic hepatitis and necrotizing pancreatitis complicated\n by ARDS, SIRS, ARF, UGIB, fevers.\n #. ID: Persistent leukocytosis and fevers now that off CVVH. Possible\n that continued fevers necrotizing pancreatitis. Also with\n persistent yeast in ucx, persistent colonic inflammation on CT. On\n aztreonam, linezolid (since ) and flagyl (since ). Started\n micafungin and po vanc yesterday.\n - New fluid collection peri-pancreas\n unclear if infected. Per Surgery\n with no role for fluid drainage at this time.\n - f/u ID recs\n - Cont broad coverage with linezolid (-), aztreo (-), flagyl\n (-), mica (-), vanc po (-).\n - f/u c diff, if neg x2-3 can d/c po vanc\n - Follow WBC count, temp curve, and culture data\n # Shock: Patient had transient pressor requirement last pm in setting\n of fever. When fever resolved pressor requirement did as well. Likely\n septic shock. Will treat for infection as above. If requires pressors\n without fever consider other etiologies of hypotension including\n cardiogenic.\n - Cont weaning steroids\n change to PO prednisone 5 mg in AM of \n - D/c a-line\n check VBG and ABG simultaneously\n # Elevated LFTs: A/w alcoholic hepatitis. RUQ u/s showed sludge\n concerning for cholestasis but also seen on u/s. T Bili and\n transaminases improving today.\n - HIDA neg\n - TPN stopped \n - weaning off benzos\n 5 mg valium\n #. Respiratory Failure: ARDS secondary to necrotizing pancreatitis. S/p\n trach placement on .\n - Cte fentanyl boluses and alternatingly wean methadone and valium as\n tolerate.\n - Cte OOB to chair daily\n - Wean methadone to \n #. Acute renal Failure: Multifactorial inc. ATN from hypotension\n - Was supposed to transition to HD today but pressures not able to\n tolerate. No need for filtration so will reassess tmrw.\n - Aztreonam 2000mg q12h while on CVVH. Change after aztreonam.\n - continue Keppra at 1000mg Q24 with 500 mg after HD\n #. Adrenal Insufficiency: Unclear with stim if clear adrenal\n insufficiency but hypotension improving with steroids (lower pressor\n requirement) and eosinophilia resolved.\n - Cont weaning hydrocort to q12h today\n - transition to PO prednisone 5 mg daily in AM of \n # Seizures: CT head without intracranial process. EEG showed occipital\n seizures which does not correlate with clinical symptoms, but repeat\n EEG on higher dose Keppra showed no seizures. As patient now with\n purposeful movements, this may actually be patient waking up, not\n seizures.\n - Continue keppra at HD dosing\n - Wean valium today\n ICU Care\n Nutrition:\n Nutren 2.0 () - 01:56 AM 50 mL/hour\n Glycemic Control: ISS\n Lines:\n Arterial Line - 08:15 PM\n PICC Line - 08:37 AM\n Dialysis Catheter - 08:55 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP:\n Comments:\n Communication: Comments: With brother\n status: Full code\n Disposition:ICU pending HD trial ; in screening process with goal for\n d/c on Monday.\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: 28M alcoholic hepatitis, pancreatitis,\n refractory shock, ARDS. Febrile with transient pressor requirement\n yesterday, resolved; also on vent o/n for hypoxemia. Labs stable /\n improving, as is mental status. Tolerating HD this AM.\n Exam notable for Tm 100.2 BP 110/60 HR 100-110 RR 18 with sat 100 on TM\n 0.4 7.39/32/93. WD man, chemosis. Follows some commands. Coarse BS B.\n Distant s1s2. Obese, + BS. 3+ edema. Labs notable for WBC 38K, HCT 23,\n TB 15.\n Agree with plan to manage respiratory failure with ongoing TM trials\n and sedation wean - will get OOB to chair today, and will decrease\n methadone to . Given question of sz activity, will continue keppra\n and valium. For shock (resolved), will continue to wean steroids\n (change to pred 5 in AM) and will continue linezolid / aztreonam /\n flagyl / micafungin / vanco PO while monitoring LFTs, which are\n improving off TPN. For ARF, change CVVH to HD; UOP is increased at\n least so far this AM. For pancreatitis, will continue post-pyloric TFs.\n Will hold off on any drainage of new peripancreatic fluid collection\n plan d/w ID attending directly. Remainder of plan as outlined above.\n Total time: 35 min\n ------ Protected Section Addendum Entered By: , MD\n on: 05:08 PM ------\n" }, { "category": "Nursing", "chartdate": "2131-06-21 00:00:00.000", "description": "Nursing Progress Note", "row_id": 682146, "text": "Sepsis, Severe (with organ dysfunction)\n Assessment:\n WBC 38. Tmax 101.2\n SBP 100s this a.m. Was alert and bright this a.m.\n Hemodialysis this a.m.\n Hypotensive and febrile at 1700.\n Action:\n Dialyzed for 1L of fluid.\n IV ABX continue as ordered. Cipro added as well PO ABX.\n Levo started to maintain MAP >60.\n OOB to chair this am.\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2131-06-24 00:00:00.000", "description": "Nursing Progress Note", "row_id": 682765, "text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Patient on CPAP 5/5 this morning\n Lungs clear, small amount of thick rust secretions\n Action:\n Patient placed on trach collar early this am\n Response:\n Tolerating well\n No abgs yet\n Patient able to cough and raise most secretions\n Plan:\n Keep on trach collar as long as possible\n One abg check later this afternoon\n Hypotension (not Shock)\n Assessment:\n Blood pressure dropping this afternoon\n More febrile as well\n Action:\n MICU team aware\n Levo started, very low dose\n Response:\n Pressure immediately responded to levo\n Plan:\n Titrate off as tolerated.\n" }, { "category": "Physician ", "chartdate": "2131-06-24 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 682766, "text": "Chief Complaint:\n 24 Hour Events:\n - Per ID recs, flagyl and po vanc discontinued; also consider seratonin\n syndrome from interaction between linezolid and pressors and d/c\n linezolid today if WBCs stable tomorrow. Mycolytic bcx sent; consider\n TTE for possible fungal infection and consider IR-guided aspiration of\n abdominal cyst.\n - Spiked temp to 102 at 3pm, hypotensive to 70s, tachycardic,\n tachypneic. Blood gas with PCO2 25. Put back on pressure support and\n pressors transiently.\n - Renal: Linezolid dose changed to after HD on HD days\n Allergies:\n Meropenem\n skin blisters a\n Last dose of Antibiotics:\n Vancomycin - 02:18 PM\n Ciprofloxacin - 08:00 PM\n Linezolid - 12:50 PM\n Aztreonam - 02:00 PM\n Micafungin - 10:30 PM\n Metronidazole - 12:00 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 12:50 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:45 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 39.1\nC (102.4\n Tcurrent: 37.2\nC (99\n HR: 99 (96 - 118) bpm\n BP: 121/60(80) {83/44(59) - 145/76(99)} mmHg\n RR: 22 (19 - 41) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 104 kg (admission): 113.5 kg\n Height: 67 Inch\n Total In:\n 2,791 mL\n 411 mL\n PO:\n TF:\n 1,205 mL\n 277 mL\n IVF:\n 1,525 mL\n 135 mL\n Blood products:\n Total out:\n 1,796 mL\n 60 mL\n Urine:\n 296 mL\n 60 mL\n NG:\n Stool:\n Drains:\n Balance:\n 995 mL\n 351 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 427 (174 - 530) mL\n PS : 5 cmH2O\n RR (Spontaneous): 30\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 45\n PIP: 11 cmH2O\n SpO2: 100%\n ABG: 7.51/27/73./24/0\n Ve: 15.5 L/min\n PaO2 / FiO2: 183\n Physical Examination\n GEN: Trached.\n HEENT: Icteric sclera. MMM.\n NECK: Trach site with no oozing.\n LUNGS: Anterior auscultation with upper airway noise; good airway\n movement.\n HEART: RRR, normal S1, S2.\n ABD: Distended. Firm, but unchanged.\n EXTREM: 2+ edema, ulcers/lesions on legs with bandages C/D/I.\n SKIN: Jaundiced.\n NEURO: Opens eyes and ?lightly squeezing hand to command.\n Labs / Radiology\n 268 K/uL\n 7.3 g/dL\n 170 mg/dL\n 1.6 mg/dL\n 24 mEq/L\n 3.4 mEq/L\n 39 mg/dL\n 101 mEq/L\n 137 mEq/L\n 24.0 %\n 27.6 K/uL\n [image002.jpg]\n 02:50 AM\n 05:09 PM\n 05:55 PM\n 05:57 PM\n 09:02 PM\n 01:42 AM\n 01:50 AM\n 03:18 AM\n 03:44 PM\n 01:38 AM\n WBC\n 34.0\n 35.7\n 30.9\n 27.6\n Hct\n 21.6\n 23.1\n 22.2\n 24.0\n Plt\n 291\n 305\n 264\n 268\n Cr\n 1.2\n 1.8\n 2.8\n 1.6\n TCO2\n 20\n 22\n 21\n 27\n 22\n Glucose\n 126\n 136\n 170\n 95\n 170\n Other labs: PT / PTT / INR:15.9/35.0/1.4,, Ca++:8.1 mg/dL, Mg++:1.9\n mg/dL, PO4:2.0 mg/dL\n Assessment and Plan\n 28M with alcoholic hepatitis and necrotizing pancreatitis complicated\n by ARDS, SIRS, ARF, UGIB, fevers.\n #. Fevers/leukocytosis: Fevers off CVVH with stable-improving\n leukocytosis. Possible that continued fevers necrotizing\n pancreatitis. Surgery was consulted for fluid collections peri-pancreas\n but felt to not be infected. CMV positive, but likely not contributing\n to current illness per ID. Also with persistent yeast in ucx,\n persistent colonic inflammation on CT with neg C. diff x 3, and concern\n for serotonin syndrome with linezolid and pressors. On aztreonam and\n linezolid (since ) and micafungin (since ). In setting of fevers\n and hypotension, Cipro was started , but d/c\ned . Flagyl (since\n ) and po vanc (since ) discontinued .\n - Likely linezolid today given concern for serotonin syndrome/drug\n fever\n will d/w ID whether he should be on another abx for gram\n positive coverage\n - Cont aztreonam and micafungin for now\n - D/w IR on Monday if abd fluid collection is drainable in case we want\n to drain it later. Currently hesitant given unclear benefit for a\n procedure that could further complicate his ICU course.\n - Recheck CMV VL on \n - Follow WBC count, temp curve, and culture data\n - F/u ID recs\n # Shock: Cont to have hypotension in setting of fevers although only\n intermittent need for pressors and resolved without change in abx\n regimen.\n - If requires pressors without fever, consider other etiologies of\n hypotension including cardiogenic. Consider IVF if BPs drop to see if\n fluid responsive prior to starting levophed again although hypotensive\n events have not occurred in close proximity time-wise to HD sessions\n - Last dose of prednisone taper today (5mg D3/3)\n - Keep a-line until off pressors x 24 h\n - Infectious w/u as above\n # Elevated LFTs: A/w alcoholic hepatitis. RUQ u/s showed sludge\n concerning for cholestasis but also seen on u/s. HIDA neg.\n TPN stopped . LFTs downtrending as of yesterday.\n - Weaning off benzos: decrease valium to 5mg today\n - Continue to trend\n #. Respiratory Failure: ARDS secondary to necrotizing pancreatitis. S/p\n trach placement on . bronch without obvious source of\n bleeding and with only thin secretions throughout; no further reports\n of bleeding since.\n - DDAVP if acute bleeding (max few doses). Had required amicar shortly\n after trach for continued bleeding but complicated by seizure shortly\n after starting this.\n - Discontinue methadone today\n - Wean valium to today\n - Cont fentanyl boluses prn\n - Trach care\n - Cont OOB to chair daily\n #. Acute renal Failure: Multifactorial including ATN from hypotension.\n - No HD today\n - F/u Renal recs\n #. Adrenal Insufficiency: Unclear with stim if clear adrenal\n insufficiency but hypotension improving with steroids (lower pressor\n requirement) and eosinophilia resolved.\n - Last dose prednisone 5mg today\n # Seizures: CT head without intracranial process. EEG showed occipital\n seizures which does not correlate with clinical symptoms, but repeat\n EEG on higher dose Keppra showed no seizures. As patient now with\n purposeful movements, this may actually be patient waking up, not\n seizures.\n - Continue keppra at HD dosing\n # Altered Mental Status: Continue to assess as weaning off sedatives\n - Discontinue methadone today\n - Wean valium to today\n ICU Care\n Nutrition:\n Nutren 2.0 () - 01:49 PM 50 mL/hour\n Glycemic Control: ISS\n Lines:\n Arterial Line - 08:15 PM\n PICC Line - 08:37 AM\n Dialysis Catheter - 08:55 AM\n Prophylaxis:\n DVT: SQ heparin\n Stress ulcer: H2B\n VAP:\n Comments:\n Communication: Comments: With brother.\n status: Full code\n Disposition: ICU\n" }, { "category": "Nursing", "chartdate": "2131-06-22 00:00:00.000", "description": "Nursing Progress Note", "row_id": 682239, "text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Remains on trach mask\n Pt with noted increased bloody secretions\n Expectorated large quarter + size clot\n Sxn for large amts of oral bloody secretions\n Lungs clear\n Sats Remain >98%\n ABG within normal range\n Action:\n MICU resident aware of bloody secretions\n Pt also noted to have large clots in pockets in mouth\n Pt at times uncooperative with mouth care\n Labs resent\n DDAVP given\n Response:\n Amt of bloody secretions decreasing\n Pt still able to expectorate secretions but does require\n frequent sxn of mouth\n Plan:\n Cont with pulmonary toilet\n OOB to chair as tolerated\n Monitor for s/s of increased respiratory decreased\n Fever,Unknown\n Assessment:\n Febrile Tmax 101.2\n Cultured on days\n UA sent overnoc\n ABX cont\n WBC\ns remain in 30\n Temp decreased to 100.8\n Low dose levo for MAP <60\n Action:\n Cipro started\n Differential sent\n Tylenol for temp\n Response:\n Cont to be febrile to low grade temps\n Unable to wean levo\n Lactate 2.4\n WBC\ns remain in the 30\n Plan:\n Cont to monitor closely for increased s/s of organ\n dysfunction\n Cont with current plan of care\n Arousal, Attention, and Cognition, Impaired\n Assessment:\n Pt cont to be alert\n Open eyes to voice\n Attempts to follow commands\n Gesturing at times\n Action:\n Cont to try to stimulate pt\n Involve pt in activity and plan of care\n Methadone/Diazapam now at 5mg Q 8hrs\n Response:\n Cognition cont to improve\n Pt smiling at times and tracking with eyes\n Plan:\n Cont to monitor mentals status closely\n Cont support to family as mental status improved\n Cont with current plan of care\n" }, { "category": "Physician ", "chartdate": "2131-06-24 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 682747, "text": "Chief Complaint: hypotension, pancreatitis,\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 INVASIVE VENTILATION - START 04:22 PM\n FEVER - 102.4\nF - 06:00 PM - dropped BP and req pressors\n for 3 hours, off now\n Allergies:\n Meropenem\n skin blisters a\n Last dose of Antibiotics:\n Vancomycin - 02:18 PM\n Ciprofloxacin - 08:00 PM\n Linezolid - 12:50 PM\n Aztreonam - 02:00 PM\n Micafungin - 10:30 PM\n Metronidazole - 12:00 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 12:50 PM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: Fever\n Flowsheet Data as of 11:02 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 39.1\nC (102.4\n Tcurrent: 37.4\nC (99.4\n HR: 112 (96 - 118) bpm\n BP: 106/53(69) {83/44(59) - 145/76(99)} mmHg\n RR: 31 (19 - 41) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 104 kg (admission): 113.5 kg\n Height: 67 Inch\n Total In:\n 2,792 mL\n 858 mL\n PO:\n TF:\n 1,205 mL\n 548 mL\n IVF:\n 1,526 mL\n 310 mL\n Blood products:\n Total out:\n 1,796 mL\n 116 mL\n Urine:\n 296 mL\n 116 mL\n NG:\n Stool:\n Drains:\n Balance:\n 996 mL\n 742 mL\n Respiratory support\n O2 Delivery Device: Trach mask , Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 427 (174 - 530) mL\n PS : 5 cmH2O\n RR (Spontaneous): 30\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 45\n PIP: 11 cmH2O\n SpO2: 99%\n ABG: 7.42/39/134/24/1\n Ve: 15.5 L/min\n PaO2 / FiO2: 335\n Physical Examination\n Labs / Radiology\n 7.3 g/dL\n 268 K/uL\n 170 mg/dL\n 1.6 mg/dL\n 24 mEq/L\n 3.4 mEq/L\n 39 mg/dL\n 101 mEq/L\n 137 mEq/L\n 24.0 %\n 27.6 K/uL\n [image002.jpg]\n 05:09 PM\n 05:55 PM\n 05:57 PM\n 09:02 PM\n 01:42 AM\n 01:50 AM\n 03:18 AM\n 03:44 PM\n 01:38 AM\n 06:00 AM\n WBC\n 34.0\n 35.7\n 30.9\n 27.6\n Hct\n 21.6\n 23.1\n 22.2\n 24.0\n Plt\n 291\n 305\n 264\n 268\n Cr\n 1.2\n 1.8\n 2.8\n 1.6\n TCO2\n 22\n 21\n 27\n 22\n 26\n Glucose\n 126\n 136\n 170\n 95\n 170\n Other labs: PT / PTT / INR:15.9/35.0/1.4, CK / CKMB /\n Troponin-T:214/3/0.07, ALT / AST:105/95, Alk Phos / T Bili:391/10.2,\n Amylase / Lipase:77/88, Differential-Neuts:80.0 %, Band:6.0 %,\n Lymph:3.0 %, Mono:1.0 %, Eos:1.0 %, D-dimer:6389 ng/mL, Fibrinogen:541\n mg/dL, Lactic Acid:2.6 mmol/L, Albumin:2.3 g/dL, LDH:529 IU/L, Ca++:8.1\n mg/dL, Mg++:1.9 mg/dL, PO4:2.0 mg/dL\n Assessment and Plan\n FEVER, UNKNOWN ORIGIN (FUO, HYPERTHERMIA, PYREXIA)\n AROUSAL, ATTENTION, AND COGNITION, IMPAIRED\n BALANCE, IMPAIRED\n MOTOR FUNCTION, IMPAIRED\n MUSCLE PERFORMACE, IMPAIRED\n RESPIRATION / GAS EXCHANGE, IMPAIRED\n SEIZURE, WITHOUT STATUS EPILEPTICUS\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n IMPAIRED SKIN INTEGRITY\n HEPATITIS, ACUTE TOXIC (INCLUDING ALCOHOLIC, ACETAMINOPHEN, ETC.)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n 1. Resp Failure: Agree with plan to manage respiratory failure\n with ongoing TM trials and sedation wean - will get OOB to chair today,\n and will decrease methadone to .\n 2. Given possibility of sz activity, will continue keppra and\n valium at current doses.\n 3. For shock (resolved), will continue to wean steroids (change\n to pred 5 today) and will continue linezolid / aztreonam / micafungin\n while monitoring culture data. LFTs are improving off TPN. be able\n to wean ABX if remains stable from WBC and fever standpoint. Drug fever\n also a possibility given multi neg C diff\n could start by peeling off\n po Vanco and Flagyl. Dsicussed with ID Attg at bedside. Possible\n repeat imaging in a week of pancreas.\n 4. For ARF, HD today.\n 5. For pancreatitis, will continue post-pyloric TFs, and will\n continue to hold off on any drainage of new peripancreatic fluid\n collection.\n Remainder of plan as outlined above.\n ICU Care\n Nutrition:\n Nutren 2.0 () - 01:49 PM 50 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 08:15 PM\n PICC Line - 08:37 AM\n Dialysis Catheter - 08:55 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 35 minutes\n Patient is critically ill\n" }, { "category": "Physician ", "chartdate": "2131-06-24 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 682751, "text": "Chief Complaint: hypotension, pancreatitis,\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 INVASIVE VENTILATION - START 04:22 PM\n FEVER - 102.4\nF - 06:00 PM - dropped BP and req pressors\n for 3 hours, off now\n Allergies:\n Meropenem\n skin blisters a\n Last dose of Antibiotics:\n Vancomycin - 02:18 PM\n Ciprofloxacin - 08:00 PM\n Linezolid - 12:50 PM\n Aztreonam - 02:00 PM\n Micafungin - 10:30 PM\n Metronidazole - 12:00 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 12:50 PM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: Fever\n Flowsheet Data as of 11:02 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 39.1\nC (102.4\n Tcurrent: 37.4\nC (99.4\n HR: 112 (96 - 118) bpm\n BP: 106/53(69) {83/44(59) - 145/76(99)} mmHg\n RR: 31 (19 - 41) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 104 kg (admission): 113.5 kg\n Height: 67 Inch\n Total In:\n 2,792 mL\n 858 mL\n PO:\n TF:\n 1,205 mL\n 548 mL\n IVF:\n 1,526 mL\n 310 mL\n Blood products:\n Total out:\n 1,796 mL\n 116 mL\n Urine:\n 296 mL\n 116 mL\n NG:\n Stool:\n Drains:\n Balance:\n 996 mL\n 742 mL\n Respiratory support\n O2 Delivery Device: Trach mask , Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 427 (174 - 530) mL\n PS : 5 cmH2O\n RR (Spontaneous): 30\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 45\n PIP: 11 cmH2O\n SpO2: 99%\n ABG: 7.42/39/134/24/1\n Ve: 15.5 L/min\n PaO2 / FiO2: 335\n Physical Examination\n Gen: lying in bed, eyes open to command but did not follow more\n HEENT: trach\n CV: tachy RR\n Chest: good air movement\n Abd: soft +BS\n Ext: edema\n Neuro: eye open, squeeze hand to command, not answering more involved\n ?s or following more complex commands\n Labs / Radiology\n 7.3 g/dL\n 268 K/uL\n 170 mg/dL\n 1.6 mg/dL\n 24 mEq/L\n 3.4 mEq/L\n 39 mg/dL\n 101 mEq/L\n 137 mEq/L\n 24.0 %\n 27.6 K/uL\n [image002.jpg]\n 05:09 PM\n 05:55 PM\n 05:57 PM\n 09:02 PM\n 01:42 AM\n 01:50 AM\n 03:18 AM\n 03:44 PM\n 01:38 AM\n 06:00 AM\n WBC\n 34.0\n 35.7\n 30.9\n 27.6\n Hct\n 21.6\n 23.1\n 22.2\n 24.0\n Plt\n 291\n 305\n 264\n 268\n Cr\n 1.2\n 1.8\n 2.8\n 1.6\n TCO2\n 22\n 21\n 27\n 22\n 26\n Glucose\n 126\n 136\n 170\n 95\n 170\n Other labs: PT / PTT / INR:15.9/35.0/1.4, CK / CKMB /\n Troponin-T:214/3/0.07, ALT / AST:105/95, Alk Phos / T Bili:391/10.2,\n Amylase / Lipase:77/88, Differential-Neuts:80.0 %, Band:6.0 %,\n Lymph:3.0 %, Mono:1.0 %, Eos:1.0 %, D-dimer:6389 ng/mL, Fibrinogen:541\n mg/dL, Lactic Acid:2.6 mmol/L, Albumin:2.3 g/dL, LDH:529 IU/L, Ca++:8.1\n mg/dL, Mg++:1.9 mg/dL, PO4:2.0 mg/dL\n Assessment and Plan\n FEVER, UNKNOWN ORIGIN (FUO, HYPERTHERMIA, PYREXIA)\n AROUSAL, ATTENTION, AND COGNITION, IMPAIRED\n BALANCE, IMPAIRED\n MOTOR FUNCTION, IMPAIRED\n MUSCLE PERFORMACE, IMPAIRED\n RESPIRATION / GAS EXCHANGE, IMPAIRED\n SEIZURE, WITHOUT STATUS EPILEPTICUS\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n IMPAIRED SKIN INTEGRITY\n HEPATITIS, ACUTE TOXIC (INCLUDING ALCOHOLIC, ACETAMINOPHEN, ETC.)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n 1. Resp Failure: Agree with plan to manage respiratory failure\n with ongoing TM trials and sedation wean - will get OOB to chair today,\n and wean methadone\n 2. Given possibility of sz activity, will continue keppra and\n valium at current doses.\n 3. Cyclical fevers: DDx SIRS, line infections, panc necorsis with\n infection, PNA, drug fever, serotonin syndrome\n pan cultured\n nothing\n new. At this point we have been weaning off ABX since nothing has grown\n will continue aztreonam / micafungin while monitoring culture data.\n Possible repeat imaging in a week of pancreas.\n 4. For ARF, HD yesterday\n 5. For pancreatitis, will continue post-pyloric TFs, and will\n continue to hold off on any drainage of new peripancreatic fluid\n collection.\n Remainder of plan as outlined above.\n ICU Care\n Nutrition:\n Nutren 2.0 () - 01:49 PM 50 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 08:15 PM\n PICC Line - 08:37 AM\n Dialysis Catheter - 08:55 AM\n Prophylaxis:\n DVT: sc hep\n Stress ulcer:\n Communication: with father and brother\n status: Full code\n Disposition :ICU\n Total time spent: 35 minutes\n Patient is critically ill\n" }, { "category": "Physician ", "chartdate": "2131-06-24 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 682759, "text": "Chief Complaint: hypotension, pancreatitis,\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 INVASIVE VENTILATION - START 04:22 PM\n FEVER - 102.4\nF - 06:00 PM - dropped BP and req pressors\n for 3 hours, off now. Similar pattern to last 2 nights\n Allergies:\n Meropenem\n skin blisters a\n Last dose of Antibiotics:\n Vancomycin - 02:18 PM\n Ciprofloxacin - 08:00 PM\n Linezolid - 12:50 PM\n Aztreonam - 02:00 PM\n Micafungin - 10:30 PM\n Metronidazole - 12:00 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 12:50 PM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: Fever\n Flowsheet Data as of 11:02 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 39.1\nC (102.4\n Tcurrent: 37.4\nC (99.4\n HR: 112 (96 - 118) bpm\n BP: 106/53(69) {83/44(59) - 145/76(99)} mmHg\n RR: 31 (19 - 41) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 104 kg (admission): 113.5 kg\n Height: 67 Inch\n Total In:\n 2,792 mL\n 858 mL\n PO:\n TF:\n 1,205 mL\n 548 mL\n IVF:\n 1,526 mL\n 310 mL\n Blood products:\n Total out:\n 1,796 mL\n 116 mL\n Urine:\n 296 mL\n 116 mL\n NG:\n Stool:\n Drains:\n Balance:\n 996 mL\n 742 mL\n Respiratory support\n O2 Delivery Device: Trach mask , Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 427 (174 - 530) mL\n PS : 5 cmH2O\n RR (Spontaneous): 30\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 45\n PIP: 11 cmH2O\n SpO2: 99%\n ABG: 7.42/39/134/24/1\n Ve: 15.5 L/min\n PaO2 / FiO2: 335\n Physical Examination\n Gen: lying in bed, eyes open to command, voice\n HEENT: trach\n CV: tachy RR\n Chest: good air movement\n Abd: soft +BS\n Ext: edema\n Neuro: eye open, squeeze hand to command, not answering more involved\n ?s or following more complex commands\n Labs / Radiology\n 7.3 g/dL\n 268 K/uL\n 170 mg/dL\n 1.6 mg/dL\n 24 mEq/L\n 3.4 mEq/L\n 39 mg/dL\n 101 mEq/L\n 137 mEq/L\n 24.0 %\n 27.6 K/uL\n [image002.jpg]\n 05:09 PM\n 05:55 PM\n 05:57 PM\n 09:02 PM\n 01:42 AM\n 01:50 AM\n 03:18 AM\n 03:44 PM\n 01:38 AM\n 06:00 AM\n WBC\n 34.0\n 35.7\n 30.9\n 27.6\n Hct\n 21.6\n 23.1\n 22.2\n 24.0\n Plt\n 291\n 305\n 264\n 268\n Cr\n 1.2\n 1.8\n 2.8\n 1.6\n TCO2\n 22\n 21\n 27\n 22\n 26\n Glucose\n 126\n 136\n 170\n 95\n 170\n Other labs: PT / PTT / INR:15.9/35.0/1.4, CK / CKMB /\n Troponin-T:214/3/0.07, ALT / AST:105/95, Alk Phos / T Bili:391/10.2,\n Amylase / Lipase:77/88, Differential-Neuts:80.0 %, Band:6.0 %,\n Lymph:3.0 %, Mono:1.0 %, Eos:1.0 %, D-dimer:6389 ng/mL, Fibrinogen:541\n mg/dL, Lactic Acid:2.6 mmol/L, Albumin:2.3 g/dL, LDH:529 IU/L, Ca++:8.1\n mg/dL, Mg++:1.9 mg/dL, PO4:2.0 mg/dL\n Assessment and Plan\n FEVER, UNKNOWN ORIGIN (FUO, HYPERTHERMIA, PYREXIA)\n AROUSAL, ATTENTION, AND COGNITION, IMPAIRED\n BALANCE, IMPAIRED\n MOTOR FUNCTION, IMPAIRED\n MUSCLE PERFORMACE, IMPAIRED\n RESPIRATION / GAS EXCHANGE, IMPAIRED\n SEIZURE, WITHOUT STATUS EPILEPTICUS\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n IMPAIRED SKIN INTEGRITY\n HEPATITIS, ACUTE TOXIC (INCLUDING ALCOHOLIC, ACETAMINOPHEN, ETC.)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n 1. Cyclical feversduring which he requires vasopressor support:\n DDx SIRS, line infections, panc necrrosis with infection, PNA, drug\n fever, serotonin syndrome. At this point he has been\n pan cultured\n nothing new. conjunction with ID consultants we have been weaning\n off ABX since nothing has grown\n will continue aztreonam / micafungin\n for while monitoring culture data. Possible repeat imaging in a week of\n pancreas but we are loathe to initiate empiric panc drainage if there\n is another possible source as this can can lead to long term\n complications. However, if fevers persist and no other source can be\n found we may be forced.\n 2. Resp Failure: Agree with plan to manage respiratory failure\n with ongoing TM trials and sedation wean - will get OOB to chair today,\n and wean methadone\n 3. Given possibility of sz activity, will continue keppra and\n valium at current doses.\n 4. For ARF, HD yesterday\n 5. For pancreatitis, will continue post-pyloric TFs, and will\n continue to hold off on any drainage of new peripancreatic fluid\n collection.\n Remainder of plan as outlined by Housestaff\n ICU Care\n Nutrition:\n Nutren 2.0 () - 01:49 PM 50 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 08:15 PM\n PICC Line - 08:37 AM\n Dialysis Catheter - 08:55 AM\n Prophylaxis:\n DVT: sc hep\n Stress ulcer:\n Communication: with father and brother\n status: Full code\n Disposition :ICU\n Total time spent: 35 minutes\n Patient is critically ill\n" }, { "category": "Physician ", "chartdate": "2131-06-25 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 682863, "text": "Chief Complaint:\n 24 Hour Events:\n FEVER - 101.5\nF - 04:00 PM\n \n - Weaned down valium; discontinued methadone\n - Last day predisone today. Dad inquiring as to whether prednisone\n taper too fast given worsening BP and mental status since taper.\n - Discontinued linezolid as\n - ID: Consider tapering off abx, sample fluids if worsens, check cmv\n viral load next week. Consider changing foley (changed last wk with Ucx\n still growing yeast). Per attg, would d/c micafungin left given \n concern for risk, h/o TPN, steroids, TPN, yeast in urine.\n - Fever to 101 at 3pm with drop in SBP to low 80s; started on low dose\n pressors\n - Renal: Nothing new\n - Pt became acutely and persistently tachypneic in AM although\n maintaining sats, BP and afebrile. No output w/ suctioning. Started on\n PS 5/5 but RR 40s so switched to A/C 400/18/5/40 with improvement.\n Noted to have small emesis, also abd pain so CXR and AXR ordered.\n Allergies:\n Meropenem\n skin blisters a\n Last dose of Antibiotics:\n Metronidazole - 12:00 AM\n Linezolid - 11:51 AM\n Micafungin - 10:04 PM\n Aztreonam - 01:48 AM\n Infusions:\n Norepinephrine - 0.09 mcg/Kg/min\n Other ICU medications:\n Famotidine (Pepcid) - 08:21 AM\n Heparin Sodium (Prophylaxis) - 12:21 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 06:39 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.6\nC (101.5\n Tcurrent: 37.7\nC (99.9\n HR: 115 (98 - 117) bpm\n BP: 95/53(66) {79/43(31) - 122/75(90)} mmHg\n RR: 30 (19 - 40) insp/min\n SpO2: 97%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 104 kg (admission): 113.5 kg\n Height: 67 Inch\n Total In:\n 2,202 mL\n 602 mL\n PO:\n TF:\n 1,204 mL\n 331 mL\n IVF:\n 998 mL\n 211 mL\n Blood products:\n Total out:\n 256 mL\n 95 mL\n Urine:\n 256 mL\n 95 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,946 mL\n 507 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 18\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 40%\n PIP: 21 cmH2O\n Plateau: 17 cmH2O\n SpO2: 97%\n ABG: 7.42/27/67/22/-4\n Ve: 13.7 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 230 K/uL\n 6.7 g/dL\n 121 mg/dL\n 2.7 mg/dL\n 22 mEq/L\n 3.7 mEq/L\n 61 mg/dL\n 102 mEq/L\n 137 mEq/L\n 22.2 %\n 18.9 K/uL\n [image002.jpg]\n 05:57 PM\n 09:02 PM\n 01:42 AM\n 01:50 AM\n 03:18 AM\n 03:44 PM\n 01:38 AM\n 06:00 AM\n 01:12 AM\n 06:06 AM\n WBC\n 34.0\n 35.7\n 30.9\n 27.6\n 18.9\n Hct\n 21.6\n 23.1\n 22.2\n 24.0\n 22.2\n Plt\n 291\n 305\n 264\n 268\n 230\n Cr\n 1.2\n 1.8\n 2.8\n 1.6\n 2.7\n TCO2\n 27\n 22\n 26\n 18\n Glucose\n 126\n 136\n 170\n 95\n 170\n 121\n Other labs: PT / PTT / INR:15.3/34.3/1.3, CK / CKMB /\n Troponin-T:214/3/0.07, ALT / AST:81/79, Alk Phos / T Bili:422/8.5,\n Amylase / Lipase:77/88, Differential-Neuts:86.0 %, Band:2.0 %,\n Lymph:3.0 %, Mono:4.0 %, Eos:2.0 %, D-dimer:6389 ng/mL, Fibrinogen:541\n mg/dL, Lactic Acid:2.6 mmol/L, Albumin:2.3 g/dL, LDH:529 IU/L, Ca++:8.4\n mg/dL, Mg++:2.0 mg/dL, PO4:2.3 mg/dL\n Assessment and Plan\n FEVER, UNKNOWN ORIGIN (FUO, HYPERTHERMIA, PYREXIA)\n AROUSAL, ATTENTION, AND COGNITION, IMPAIRED\n BALANCE, IMPAIRED\n MOTOR FUNCTION, IMPAIRED\n MUSCLE PERFORMACE, IMPAIRED\n RESPIRATION / GAS EXCHANGE, IMPAIRED\n SEIZURE, WITHOUT STATUS EPILEPTICUS\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n IMPAIRED SKIN INTEGRITY\n HEPATITIS, ACUTE TOXIC (INCLUDING ALCOHOLIC, ACETAMINOPHEN, ETC.)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ICU Care\n Nutrition:\n Nutren 2.0 () - 01:41 PM 50 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 08:15 PM\n PICC Line - 08:37 AM\n Dialysis Catheter - 08:55 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:ICU\n" }, { "category": "Physician ", "chartdate": "2131-06-25 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 682864, "text": "Chief Complaint:\n 24 Hour Events:\n FEVER - 101.5\nF - 04:00 PM\n \n - Weaned down valium; discontinued methadone\n - Last day predisone today. Dad inquiring as to whether prednisone\n taper too fast given worsening BP and mental status since taper.\n - Discontinued linezolid as\n - ID: Consider tapering off abx, sample fluids if worsens, check cmv\n viral load next week. Consider changing foley (changed last wk with Ucx\n still growing yeast). Per attg, would d/c micafungin left given \n concern for risk, h/o TPN, steroids, TPN, yeast in urine.\n - Fever to 101 at 3pm with drop in SBP to low 80s; started on low dose\n pressors\n - Renal: Nothing new\n - Pt became acutely and persistently tachypneic in AM although\n maintaining sats, BP and afebrile. No output w/ suctioning. Started on\n PS 5/5 but RR 40s so switched to A/C 400/18/5/40 with improvement.\n Noted to have small emesis, also abd pain so CXR and AXR ordered.\n Allergies:\n Meropenem\n skin blisters a\n Last dose of Antibiotics:\n Metronidazole - 12:00 AM\n Linezolid - 11:51 AM\n Micafungin - 10:04 PM\n Aztreonam - 01:48 AM\n Infusions:\n Norepinephrine - 0.09 mcg/Kg/min\n Other ICU medications:\n Famotidine (Pepcid) - 08:21 AM\n Heparin Sodium (Prophylaxis) - 12:21 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 06:39 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.6\nC (101.5\n Tcurrent: 37.7\nC (99.9\n HR: 115 (98 - 117) bpm\n BP: 95/53(66) {79/43(31) - 122/75(90)} mmHg\n RR: 30 (19 - 40) insp/min\n SpO2: 97%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 104 kg (admission): 113.5 kg\n Height: 67 Inch\n Total In:\n 2,202 mL\n 602 mL\n PO:\n TF:\n 1,204 mL\n 331 mL\n IVF:\n 998 mL\n 211 mL\n Blood products:\n Total out:\n 256 mL\n 95 mL\n Urine:\n 256 mL\n 95 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,946 mL\n 507 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 18\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 40%\n PIP: 21 cmH2O\n Plateau: 17 cmH2O\n SpO2: 97%\n ABG: 7.42/27/67/22/-4\n Ve: 13.7 L/min\n PaO2 / FiO2: 168\n Physical Examination\n Gen: lying in bed, eyes open to command, voice\n HEENT: trach\n CV: tachy RR\n Chest: good air movement\n Abd: soft +BS\n Ext: edema\n Neuro: eye open, squeeze hand to command, not answering more involved\n ?s or following more complex commands\n Labs / Radiology\n 230 K/uL\n 6.7 g/dL\n 121 mg/dL\n 2.7 mg/dL\n 22 mEq/L\n 3.7 mEq/L\n 61 mg/dL\n 102 mEq/L\n 137 mEq/L\n 22.2 %\n 18.9 K/uL\n [image002.jpg]\n 05:57 PM\n 09:02 PM\n 01:42 AM\n 01:50 AM\n 03:18 AM\n 03:44 PM\n 01:38 AM\n 06:00 AM\n 01:12 AM\n 06:06 AM\n WBC\n 34.0\n 35.7\n 30.9\n 27.6\n 18.9\n Hct\n 21.6\n 23.1\n 22.2\n 24.0\n 22.2\n Plt\n 291\n 305\n 264\n 268\n 230\n Cr\n 1.2\n 1.8\n 2.8\n 1.6\n 2.7\n TCO2\n 27\n 22\n 26\n 18\n Glucose\n 126\n 136\n 170\n 95\n 170\n 121\n Other labs: PT / PTT / INR:15.3/34.3/1.3, CK / CKMB /\n Troponin-T:214/3/0.07, ALT / AST:81/79, Alk Phos / T Bili:422/8.5,\n Amylase / Lipase:77/88, Differential-Neuts:86.0 %, Band:2.0 %,\n Lymph:3.0 %, Mono:4.0 %, Eos:2.0 %, D-dimer:6389 ng/mL, Fibrinogen:541\n mg/dL, Lactic Acid:2.6 mmol/L, Albumin:2.3 g/dL, LDH:529 IU/L, Ca++:8.4\n mg/dL, Mg++:2.0 mg/dL, PO4:2.3 mg/dL\n Assessment and Plan\n FEVER, UNKNOWN ORIGIN (FUO, HYPERTHERMIA, PYREXIA)\n AROUSAL, ATTENTION, AND COGNITION, IMPAIRED\n BALANCE, IMPAIRED\n MOTOR FUNCTION, IMPAIRED\n MUSCLE PERFORMACE, IMPAIRED\n RESPIRATION / GAS EXCHANGE, IMPAIRED\n SEIZURE, WITHOUT STATUS EPILEPTICUS\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n IMPAIRED SKIN INTEGRITY\n HEPATITIS, ACUTE TOXIC (INCLUDING ALCOHOLIC, ACETAMINOPHEN, ETC.)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ICU Care\n Nutrition:\n Nutren 2.0 () - 01:41 PM 50 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 08:15 PM\n PICC Line - 08:37 AM\n Dialysis Catheter - 08:55 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:ICU\n" }, { "category": "Physician ", "chartdate": "2131-06-25 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 682913, "text": "Chief Complaint: pancreatitis, resp failure\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n FEVER - 101.5\nF - 04:00 PM\n Tachypnea and put back on AC vent\n before spiking fevers\n Allergies:\n Meropenem\n skin blisters a\n Last dose of Antibiotics:\n Metronidazole - 12:00 AM\n Linezolid - 11:51 AM\n Micafungin - 10:04 PM\n Aztreonam - 01:48 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 12:21 PM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: Fever\n Flowsheet Data as of 11:02 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.6\nC (101.5\n Tcurrent: 37.9\nC (100.2\n HR: 113 (108 - 117) bpm\n BP: 109/59(74) {79/43(31) - 136/75(90)} mmHg\n RR: 25 (23 - 40) insp/\n SpO2: 100%\n Heart rhythm: SB (Sinus Bradycardia)\n Wgt (current): 104 kg (admission): 113.5 kg\n Height: 67 Inch\n Total In:\n 2,202 mL\n 1,169 mL\n PO:\n TF:\n 1,204 mL\n 550 mL\n IVF:\n 998 mL\n 559 mL\n Blood products:\n Total out:\n 256 mL\n 135 mL\n Urine:\n 256 mL\n 135 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,946 mL\n 1,034 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 18\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 40%\n PIP: 24 cmH2O\n Plateau: 21 cmH2O\n SpO2: 100%\n ABG: 7.42/27/67/22/-4\n Ve: 13.8 L/\n PaO2 / FiO2: 168\n Physical Examination\n Labs / Radiology\n 6.7 g/dL\n 230 K/uL\n 121 mg/dL\n 2.7 mg/dL\n 22 mEq/L\n 3.7 mEq/L\n 61 mg/dL\n 102 mEq/L\n 137 mEq/L\n 22.2 %\n 18.9 K/uL\n [image002.jpg]\n 05:57 PM\n 09:02 PM\n 01:42 AM\n 01:50 AM\n 03:18 AM\n 03:44 PM\n 01:38 AM\n 06:00 AM\n 01:12 AM\n 06:06 AM\n WBC\n 34.0\n 35.7\n 30.9\n 27.6\n 18.9\n Hct\n 21.6\n 23.1\n 22.2\n 24.0\n 22.2\n Plt\n 291\n 305\n 264\n 268\n 230\n Cr\n 1.2\n 1.8\n 2.8\n 1.6\n 2.7\n TCO2\n 27\n 22\n 26\n 18\n Glucose\n 126\n 136\n 170\n 95\n 170\n 121\n Other labs: PT / PTT / INR:15.3/34.3/1.3, CK / CKMB /\n Troponin-T:214/3/0.07, ALT / AST:81/79, Alk Phos / T Bili:422/8.5,\n Amylase / Lipase:77/88, Differential-Neuts:86.0 %, Band:2.0 %,\n Lymph:3.0 %, Mono:4.0 %, Eos:2.0 %, D-dimer:6389 ng/mL, Fibrinogen:541\n mg/dL, Lactic Acid:2.6 mmol/L, Albumin:2.3 g/dL, LDH:529 IU/L, Ca++:8.4\n mg/dL, Mg++:2.0 mg/dL, PO4:2.3 mg/dL\n Assessment and Plan\n FEVER, UNKNOWN ORIGIN (FUO, HYPERTHERMIA, PYREXIA)\n AROUSAL, ATTENTION, AND COGNITION, IMPAIRED\n BALANCE, IMPAIRED\n MOTOR FUNCTION, IMPAIRED\n MUSCLE PERFORMACE, IMPAIRED\n RESPIRATION / GAS EXCHANGE, IMPAIRED\n SEIZURE, WITHOUT STATUS EPILEPTICU\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n IMPAIRED SKIN INTEGRITY\n HEPATITIS, ACUTE TOXIC (INCLUDING ALCOHOLIC, ACETAMINOPHEN, ETC.)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n 1. Cyclical feversduring which he requires vasopressor support:\n DDx SIRS, line infections, panc necrrosis with infection, PNA, drug\n fever, serotonin syndrome. At this point he has been\n pan cultured\n nothing new. conjunction with ID consultants we have been weaning\n off ABX since nothing has grown\n will continue aztreonam / micafungin\n for while monitoring culture data. Possible repeat imaging in a week of\n pancreas but we are loathe to initiate empiric panc drainage if there\n is another possible source as this can can lead to long term\n complications. However, if fevers persist and no other source can be\n found we may be forced.\n 2. Resp Failure: Agree with plan to manage respiratory failure\n with ongoing TM trials and sedation wean - will get OOB to chair today,\n and wean methadone\n 3. Given possibility of sz activity, will continue keppra and\n valium at current doses.\n 4. For ARF, HD yesterday\n 5. For pancreatitis, will continue post-pyloric TFs, and will\n continue to hold off on any drainage of new peripancreatic fluid\n collection.\n ICU Care\n Nutrition:\n Nutren 2.0 () - 01:41 PM 50 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 08:15 PM\n PICC Line - 08:37 AM\n Dialysis Catheter - 08:55 AM\n Prophylaxis:\n DVT: sc hep\n Stress ulcer: PPI\n VAP: HOB chlorhex\n Communication: I spoke with brother for 45 last PM updating him on\n plans of care including fevers\n Code status: Full code\n Disposition :ICU\n Total time spent: 40 minutes\n Patient is critically ill\n" }, { "category": "Nursing", "chartdate": "2131-06-23 00:00:00.000", "description": "Nursing Progress Note", "row_id": 682454, "text": "The patient is a 28 year old male with a history of alcohol abuse who\n walked into the ED with the complaint of hematemesis. The patient has\n been a significant drinker for 5-6 years, reporting drinking 6 mixed\n drinks a day, with tremulations on withdrawl, but no prior seizure. For\n the last week, he has felt increasing weakness and fatigue, and has\n become slightly disoriented and confused. He reports no head trauma. 3\n days prior to presentation, he began to notice that he was coughing up\n blood and mild epigastric tenderness. These episodes were occuring \n times per day. He additonally noted black tarry stools, but unable to\n quantify the number of bowel movements. With mild abdominal discomfort,\n nausea, and hematemesis, the patient was unable to tolerate a PO diet,\n but continued to drink. His last drink was the night prior to\n presentation.\n Sepsis, Severe (with organ dysfunction)\n Assessment:\n Febrile 101.9\n Action:\n Response:\n Plan:\n Hypotension (not Shock)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2131-06-23 00:00:00.000", "description": "Nursing Progress Note", "row_id": 682580, "text": "Respiration / Gas Exchange, Impaired\n Assessment:\n Patient more tachypnic today, with resp. rate mid 40s-50s especially\n with fever\n Abgs done when patient dropped pressure\n Suctioned for mod amounts loose tan /rust secretions\n Patient able to cough most of them, just superficially suction needed\n Action:\n Patient very alkalotic with pH 7.51, pCO2 27\n House staff aware\n Placed back on cpap 5/5\n Response:\n Plan:\n Hypotension (not Shock)\n Assessment:\n Febrile today to 101.5\n Symptomatic with pressure dropping to 70/ systolic\n Initially alert and interactive, but later much less so\n Action:\n Levo started at .09 max dose\n Response:\n Blood pressure immediately improved,\n Able to wean levo within 15 minutes\n Currently on .04\n Blood cultures done\n Plan:\n Continue with levo support as needed\n Family in during this episode, aware of pattern of\n temp/hypotension/small pressor requirements\n" }, { "category": "Physician ", "chartdate": "2131-06-25 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 682865, "text": "Chief Complaint:\n 24 Hour Events:\n FEVER - 101.5\nF - 04:00 PM\n \n - Weaned down valium; discontinued methadone\n - Last day predisone today. Dad inquiring as to whether prednisone\n taper too fast given worsening BP and mental status since taper.\n - Discontinued linezolid as\n - ID: Consider tapering off abx, sample fluids if worsens, check cmv\n viral load next week. Consider changing foley (changed last wk with Ucx\n still growing yeast). Per attg, would d/c micafungin left given \n concern for risk, h/o TPN, steroids, TPN, yeast in urine.\n - Fever to 101 at 3pm with drop in SBP to low 80s; started on low dose\n pressors\n - Renal: Nothing new\n - Pt became acutely and persistently tachypneic in AM although\n maintaining sats, BP and afebrile. No output w/ suctioning. Started on\n PS 5/5 but RR 40s so switched to A/C 400/18/5/40 with improvement.\n Noted to have small emesis, also abd pain so CXR and AXR ordered.\n Allergies:\n Meropenem\n skin blisters a\n Last dose of Antibiotics:\n Metronidazole - 12:00 AM\n Linezolid - 11:51 AM\n Micafungin - 10:04 PM\n Aztreonam - 01:48 AM\n Infusions:\n Norepinephrine - 0.09 mcg/Kg/min\n Other ICU medications:\n Famotidine (Pepcid) - 08:21 AM\n Heparin Sodium (Prophylaxis) - 12:21 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 06:39 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.6\nC (101.5\n Tcurrent: 37.7\nC (99.9\n HR: 115 (98 - 117) bpm\n BP: 95/53(66) {79/43(31) - 122/75(90)} mmHg\n RR: 30 (19 - 40) insp/min\n SpO2: 97%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 104 kg (admission): 113.5 kg\n Height: 67 Inch\n Total In:\n 2,202 mL\n 602 mL\n PO:\n TF:\n 1,204 mL\n 331 mL\n IVF:\n 998 mL\n 211 mL\n Blood products:\n Total out:\n 256 mL\n 95 mL\n Urine:\n 256 mL\n 95 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,946 mL\n 507 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 18\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 40%\n PIP: 21 cmH2O\n Plateau: 17 cmH2O\n SpO2: 97%\n ABG: 7.42/27/67/22/-4\n Ve: 13.7 L/min\n PaO2 / FiO2: 168\n Physical Examination\n Gen: lying in bed, eyes open to command, voice\n HEENT: trach\n CV: tachy RR\n Chest: good air movement\n Abd: soft +BS\n Ext: edema\n Neuro: eye open, squeeze hand to command, not answering more involved\n ?s or following more complex commands\n Labs / Radiology\n 230 K/uL\n 6.7 g/dL\n 121 mg/dL\n 2.7 mg/dL\n 22 mEq/L\n 3.7 mEq/L\n 61 mg/dL\n 102 mEq/L\n 137 mEq/L\n 22.2 %\n 18.9 K/uL\n [image002.jpg]\n 05:57 PM\n 09:02 PM\n 01:42 AM\n 01:50 AM\n 03:18 AM\n 03:44 PM\n 01:38 AM\n 06:00 AM\n 01:12 AM\n 06:06 AM\n WBC\n 34.0\n 35.7\n 30.9\n 27.6\n 18.9\n Hct\n 21.6\n 23.1\n 22.2\n 24.0\n 22.2\n Plt\n 291\n 305\n 264\n 268\n 230\n Cr\n 1.2\n 1.8\n 2.8\n 1.6\n 2.7\n TCO2\n 27\n 22\n 26\n 18\n Glucose\n 126\n 136\n 170\n 95\n 170\n 121\n Other labs: PT / PTT / INR:15.3/34.3/1.3, CK / CKMB /\n Troponin-T:214/3/0.07, ALT / AST:81/79, Alk Phos / T Bili:422/8.5,\n Amylase / Lipase:77/88, Differential-Neuts:86.0 %, Band:2.0 %,\n Lymph:3.0 %, Mono:4.0 %, Eos:2.0 %, D-dimer:6389 ng/mL, Fibrinogen:541\n mg/dL, Lactic Acid:2.6 mmol/L, Albumin:2.3 g/dL, LDH:529 IU/L, Ca++:8.4\n mg/dL, Mg++:2.0 mg/dL, PO4:2.3 mg/dL\n Assessment and Plan\n 28M with alcoholic hepatitis and necrotizing pancreatitis complicated\n by ARDS, SIRS, ARF, UGIB, fevers.\n #. Fevers/leukocytosis: Fevers off CVVH with stable-improving\n leukocytosis. Possible that continued fevers necrotizing\n pancreatitis. Surgery was consulted for fluid collections peri-pancreas\n but felt to not be infected. CMV positive, but likely not contributing\n to current illness per ID. Also with persistent yeast in ucx,\n persistent colonic inflammation on CT with neg C. diff x 3, and concern\n for serotonin syndrome with linezolid and pressors. On aztreonam (since\n ) and micafungin (since ). In setting of fevers and hypotension,\n Cipro was started , but d/c\ned . Flagyl (since ) and po\n vanc (since ) discontinued . Linezolid started and stopped\n .\n - ID would prefer to keep micafungin\n - Consider d/c aztreonam today\n - D/w IR if abd fluid collection is drainable in case we want to drain\n it later. Currently hesitant given unclear benefit for a procedure that\n could further complicate his ICU course.\n - Recheck CMV VL on \n - Follow WBC count, temp curve, and culture data\n - F/u ID recs\n # Shock: Cont to have hypotension in setting of fevers although only\n intermittent need for pressors and resolved without change in abx\n regimen.\n - If requires pressors without fever, consider other etiologies of\n hypotension including cardiogenic. Consider IVF if BPs drop to see if\n fluid responsive prior to starting levophed again although hypotensive\n events have not occurred in close proximity time-wise to HD sessions\n - Weaned off steroids on \n - Keep a-line until off pressors x 24 h\n - Infectious w/u as above\n # Elevated LFTs: A/w alcoholic hepatitis. RUQ u/s showed sludge\n concerning for cholestasis but also seen on u/s. HIDA neg.\n TPN stopped . LFTs downtrending as of yesterday.\n - Weaning off benzos: decrease valium to 5mg today\n - Continue to trend\n #. Respiratory Failure: ARDS secondary to necrotizing pancreatitis. S/p\n trach placement on . bronch without obvious source of\n bleeding and with only thin secretions throughout; no further reports\n of bleeding since. Now off methadone since .\n - DDAVP if acute bleeding (max few doses). Had required amicar shortly\n after trach for continued bleeding but complicated by seizure shortly\n after starting this.\n - Wean valium to today\n - Cont fentanyl boluses prn\n - Trach care\n - Cont OOB to chair daily\n #. Acute renal Failure: Multifactorial including ATN from hypotension.\n - HD per renal\n - F/u Renal recs\n #. Adrenal Insufficiency: Unclear with stim if adrenally\n insufficient but hypotension initially improved with steroids (lower\n pressor requirement) and eosinophilia resolved. He has now weaned off\n steroids completely.\n - Last dose prednisone was \n # Seizures: CT head without intracranial process. EEG showed occipital\n seizures which does not correlate with clinical symptoms, but repeat\n EEG on higher dose Keppra showed no seizures. As patient now with\n purposeful movements, this may actually be patient waking up, not\n seizures.\n - Continue keppra at HD dosing\n # Altered Mental Status: Continue to assess as weaning off sedatives\n - off of methadone as of \n - Wean valium today\n ICU Care\n Nutrition:\n Nutren 2.0 () - 01:41 PM 50 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 08:15 PM\n PICC Line - 08:37 AM\n Dialysis Catheter - 08:55 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:ICU\n" }, { "category": "Physician ", "chartdate": "2131-06-25 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 682880, "text": "Chief Complaint:\n 24 Hour Events:\n FEVER - 101.5\nF - 04:00 PM\n \n - Weaned down valium; discontinued methadone\n - Last day predisone today. Dad inquiring as to whether prednisone\n taper too fast given worsening BP and mental status since taper.\n - Discontinued linezolid as\n - ID: Consider tapering off abx, sample fluids if worsens, check cmv\n viral load next week. Consider changing foley (changed last wk with Ucx\n still growing yeast). Per attg, would d/c micafungin left given \n concern for risk, h/o TPN, steroids, TPN, yeast in urine.\n - Fever to 101 at 3pm with drop in SBP to low 80s; started on low dose\n pressors\n - Renal: Nothing new\n - Pt became acutely and persistently tachypneic in AM although\n maintaining sats, BP and afebrile. No output w/ suctioning. Started on\n PS 5/5 but RR 40s so switched to A/C 400/18/5/40 with improvement.\n Noted to have small emesis, also abd pain so CXR and AXR ordered.\n Allergies:\n Meropenem\n skin blisters a\n Last dose of Antibiotics:\n Metronidazole - 12:00 AM\n Linezolid - 11:51 AM\n Micafungin - 10:04 PM\n Aztreonam - 01:48 AM\n Infusions:\n Norepinephrine - 0.09 mcg/Kg/min\n Other ICU medications:\n Famotidine (Pepcid) - 08:21 AM\n Heparin Sodium (Prophylaxis) - 12:21 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 06:39 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.6\nC (101.5\n Tcurrent: 37.7\nC (99.9\n HR: 115 (98 - 117) bpm\n BP: 95/53(66) {79/43(31) - 122/75(90)} mmHg\n RR: 30 (19 - 40) insp/min\n SpO2: 97%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 104 kg (admission): 113.5 kg\n Height: 67 Inch\n Total In:\n 2,202 mL\n 602 mL\n PO:\n TF:\n 1,204 mL\n 331 mL\n IVF:\n 998 mL\n 211 mL\n Blood products:\n Total out:\n 256 mL\n 95 mL\n Urine:\n 256 mL\n 95 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,946 mL\n 507 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 18\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 40%\n PIP: 21 cmH2O\n Plateau: 17 cmH2O\n SpO2: 97%\n ABG: 7.42/27/67/22/-4\n Ve: 13.7 L/min\n PaO2 / FiO2: 168\n Physical Examination\n Gen: lying in bed, eyes open to command, voice\n HEENT: trach\n CV: tachy RR\n Chest: good air movement\n Abd: soft +BS\n Ext: edema\n Neuro: eye open, squeeze hand to command, not answering more involved\n ?s or following more complex commands\n Labs / Radiology\n 230 K/uL\n 6.7 g/dL\n 121 mg/dL\n 2.7 mg/dL\n 22 mEq/L\n 3.7 mEq/L\n 61 mg/dL\n 102 mEq/L\n 137 mEq/L\n 22.2 %\n 18.9 K/uL\n [image002.jpg]\n 05:57 PM\n 09:02 PM\n 01:42 AM\n 01:50 AM\n 03:18 AM\n 03:44 PM\n 01:38 AM\n 06:00 AM\n 01:12 AM\n 06:06 AM\n WBC\n 34.0\n 35.7\n 30.9\n 27.6\n 18.9\n Hct\n 21.6\n 23.1\n 22.2\n 24.0\n 22.2\n Plt\n 291\n 305\n 264\n 268\n 230\n Cr\n 1.2\n 1.8\n 2.8\n 1.6\n 2.7\n TCO2\n 27\n 22\n 26\n 18\n Glucose\n 126\n 136\n 170\n 95\n 170\n 121\n Other labs: PT / PTT / INR:15.3/34.3/1.3, CK / CKMB /\n Troponin-T:214/3/0.07, ALT / AST:81/79, Alk Phos / T Bili:422/8.5,\n Amylase / Lipase:77/88, Differential-Neuts:86.0 %, Band:2.0 %,\n Lymph:3.0 %, Mono:4.0 %, Eos:2.0 %, D-dimer:6389 ng/mL, Fibrinogen:541\n mg/dL, Lactic Acid:2.6 mmol/L, Albumin:2.3 g/dL, LDH:529 IU/L, Ca++:8.4\n mg/dL, Mg++:2.0 mg/dL, PO4:2.3 mg/dL\n Ca: 8.4 Mg: 2.0 P: 2.3\n ALT: 81\n AP: 422\n Tbili: 8.5\n Alb:\n AST: 79\n LDH:\n Dbili:\n TProt:\n :\n Lip:\n Daily mycolytic and blood cx remain negative\n CXR\n increased pulm edema per my read\n Abd x-ray\n no apparent air fluid levels or free air per my read\n Assessment and Plan\n 28M with alcoholic hepatitis and necrotizing pancreatitis complicated\n by ARDS, SIRS, ARF, UGIB, fevers.\n #. Fevers/leukocytosis: Fevers off CVVH with stable-improving\n leukocytosis. Possible that continued fevers necrotizing\n pancreatitis. Surgery was consulted for fluid collections peri-pancreas\n but felt to not be infected. CMV positive, but likely not contributing\n to current illness per ID. Also with persistent yeast in ucx,\n persistent colonic inflammation on CT with neg C. diff x 3, and concern\n for serotonin syndrome with linezolid and pressors. On aztreonam (since\n ) and micafungin (since ). In setting of fevers and hypotension,\n Cipro was started , but d/c\ned . Flagyl (since ) and po\n vanc (since ) discontinued . Linezolid started and stopped\n .\n - ID would prefer to keep micafungin\n - Consider d/c aztreonam today\n - D/w IR if abd fluid collection is drainable in case we want to drain\n it later. Currently hesitant given unclear benefit for a procedure that\n could further complicate his ICU course.\n - Recheck CMV VL on \n - Follow WBC count, temp curve, and culture data\n - F/u ID recs\n # Shock: Cont to have hypotension in setting of fevers although only\n intermittent need for pressors and resolved without change in abx\n regimen.\n - If requires pressors without fever, consider other etiologies of\n hypotension including cardiogenic. Consider IVF if BPs drop to see if\n fluid responsive prior to starting levophed again although hypotensive\n events have not occurred in close proximity time-wise to HD sessions\n - Weaned off steroids on \n - Keep a-line until off pressors x 24 h\n - Infectious w/u as above\n # Elevated LFTs: A/w alcoholic hepatitis. RUQ u/s showed sludge\n concerning for cholestasis but also seen on u/s. HIDA neg.\n TPN stopped . LFTs downtrending as of yesterday.\n - Weaning off benzos: decrease valium to 5mg today\n - Continue to trend\n #. Respiratory Failure: ARDS secondary to necrotizing pancreatitis. S/p\n trach placement on . bronch without obvious source of\n bleeding and with only thin secretions throughout; no further reports\n of bleeding since. Now off methadone since .\n - DDAVP if acute bleeding (max few doses). Had required amicar shortly\n after trach for continued bleeding but complicated by seizure shortly\n after starting this.\n - Wean valium to today\n - Cont fentanyl boluses prn\n - Trach care\n - Cont OOB to chair daily\n #. Acute renal Failure: Multifactorial including ATN from hypotension.\n - HD per renal\n - F/u Renal recs\n #. Adrenal Insufficiency: Unclear with stim if adrenally\n insufficient but hypotension initially improved with steroids (lower\n pressor requirement) and eosinophilia resolved. He has now weaned off\n steroids completely.\n - Last dose prednisone was \n # Seizures: CT head without intracranial process. EEG showed occipital\n seizures which does not correlate with clinical symptoms, but repeat\n EEG on higher dose Keppra showed no seizures. As patient now with\n purposeful movements, this may actually be patient waking up, not\n seizures.\n - Continue keppra at HD dosing\n # Altered Mental Status: Continue to assess as weaning off sedatives\n - off of methadone as of \n - Wean valium today\n ICU Care\n Nutrition:\n Nutren 2.0 () - 01:41 PM 50 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 08:15 PM\n PICC Line - 08:37 AM\n Dialysis Catheter - 08:55 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:ICU\n" }, { "category": "Physician ", "chartdate": "2131-07-04 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 684853, "text": "Chief Complaint:\n 24 Hour Events:\n ULTRASOUND - At 02:17 PM\n PAN CULTURE - At 08:50 PM\n FEVER - 101.9\nF - 08:00 PM\n -2100: Called for temp spike to 101.9. Blood/Urine/Sputum Cx sent.\n Allergies:\n Meropenem\n skin blisters a\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 12:21 PM\n Furosemide (Lasix) - 12:45 PM\n Heparin Sodium (Prophylaxis) - 05:30 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 06:19 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.8\nC (101.9\n Tcurrent: 37\nC (98.6\n HR: 111 (109 - 129) bpm\n BP: 125/91(99) {101/54(74) - 138/91(117)} mmHg\n RR: 44 (27 - 59) insp/min\n SpO2: 98%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 99.1 kg (admission): 113.5 kg\n Height: 67 Inch\n Total In:\n 4,882 mL\n 966 mL\n PO:\n TF:\n 1,200 mL\n 315 mL\n IVF:\n 2,032 mL\n 51 mL\n Blood products:\n Total out:\n 2,575 mL\n 710 mL\n Urine:\n 2,575 mL\n 710 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,307 mL\n 256 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n SpO2: 98%\n ABG: ///18/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 349 K/uL\n 6.8 g/dL\n 111 mg/dL\n 1.0 mg/dL\n 18 mEq/L\n 4.4 mEq/L\n 48 mg/dL\n 115 mEq/L\n 142 mEq/L\n 23.6 %\n 11.6 K/uL\n [image002.jpg]\n 10:00 PM\n 02:32 AM\n 04:25 AM\n 03:56 PM\n 02:32 AM\n 08:00 PM\n 12:35 AM\n 03:21 AM\n 04:44 PM\n 02:42 AM\n WBC\n 10.9\n 11.0\n 10.5\n 11.1\n 11.6\n Hct\n 22.2\n 22.5\n 22.3\n 22.1\n 23.6\n Plt\n 290\n 310\n 327\n 341\n 349\n Cr\n 1.9\n 1.6\n 1.3\n 1.2\n 1.2\n 1.1\n 1.0\n 1.0\n TCO2\n 20\n Glucose\n 177\n 116\n 161\n 97\n 93\n 147\n 187\n 111\n Other labs: PT / PTT / INR:13.6/28.0/1.2, CK / CKMB /\n Troponin-T:214/3/0.07, ALT / AST:60/85, Alk Phos / T Bili:247/2.8,\n Amylase / Lipase:78/91, Differential-Neuts:57.0 %, Band:4.0 %,\n Lymph:23.0 %, Mono:4.0 %, Eos:3.0 %, D-dimer:6389 ng/mL, Fibrinogen:541\n mg/dL, Lactic Acid:2.6 mmol/L, Albumin:2.4 g/dL, LDH:437 IU/L, Ca++:9.2\n mg/dL, Mg++:1.8 mg/dL, PO4:4.2 mg/dL\n Assessment and Plan\n FEVER, UNKNOWN ORIGIN (FUO, HYPERTHERMIA, PYREXIA)\n AROUSAL, ATTENTION, AND COGNITION, IMPAIRED\n BALANCE, IMPAIRED\n MOTOR FUNCTION, IMPAIRED\n MUSCLE PERFORMACE, IMPAIRED\n RESPIRATION / GAS EXCHANGE, IMPAIRED\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n IMPAIRED SKIN INTEGRITY\n HEPATITIS, ACUTE TOXIC (INCLUDING ALCOHOLIC, ACETAMINOPHEN, ETC.)\n ICU Care\n Nutrition:\n Nutren 2.0 () - 12:21 PM 50 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n PICC Line - 08:37 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:ICU\n" }, { "category": "Physician ", "chartdate": "2131-07-04 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 684857, "text": "Chief Complaint:\n 24 Hour Events:\n ULTRASOUND - At 02:17 PM\n PAN CULTURE - At 08:50 PM\n FEVER - 101.9\nF - 08:00 PM\n -2100: Called for temp spike to 101.9. Blood/Urine/Sputum Cx sent.\n Allergies:\n Meropenem\n skin blisters a\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 12:21 PM\n Furosemide (Lasix) - 12:45 PM\n Heparin Sodium (Prophylaxis) - 05:30 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 06:19 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.8\nC (101.9\n Tcurrent: 37\nC (98.6\n HR: 111 (109 - 129) bpm\n BP: 125/91(99) {101/54(74) - 138/91(117)} mmHg\n RR: 44 (27 - 59) insp/min\n SpO2: 98%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 99.1 kg (admission): 113.5 kg\n Height: 67 Inch\n Total In:\n 4,882 mL\n 966 mL\n PO:\n TF:\n 1,200 mL\n 315 mL\n IVF:\n 2,032 mL\n 51 mL\n Blood products:\n Total out:\n 2,575 mL\n 710 mL\n Urine:\n 2,575 mL\n 710 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,307 mL\n 256 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n SpO2: 98%\n ABG: ///18/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 349 K/uL\n 6.8 g/dL\n 111 mg/dL\n 1.0 mg/dL\n 18 mEq/L\n 4.4 mEq/L\n 48 mg/dL\n 115 mEq/L\n 142 mEq/L\n 23.6 %\n 11.6 K/uL\n [image002.jpg]\n 10:00 PM\n 02:32 AM\n 04:25 AM\n 03:56 PM\n 02:32 AM\n 08:00 PM\n 12:35 AM\n 03:21 AM\n 04:44 PM\n 02:42 AM\n WBC\n 10.9\n 11.0\n 10.5\n 11.1\n 11.6\n Hct\n 22.2\n 22.5\n 22.3\n 22.1\n 23.6\n Plt\n 290\n 310\n 327\n 341\n 349\n Cr\n 1.9\n 1.6\n 1.3\n 1.2\n 1.2\n 1.1\n 1.0\n 1.0\n TCO2\n 20\n Glucose\n 177\n 116\n 161\n 97\n 93\n 147\n 187\n 111\n Other labs: PT / PTT / INR:13.6/28.0/1.2, CK / CKMB /\n Troponin-T:214/3/0.07, ALT / AST:60/85, Alk Phos / T Bili:247/2.8,\n Amylase / Lipase:78/91, Differential-Neuts:57.0 %, Band:4.0 %,\n Lymph:23.0 %, Mono:4.0 %, Eos:3.0 %, D-dimer:6389 ng/mL, Fibrinogen:541\n mg/dL, Lactic Acid:2.6 mmol/L, Albumin:2.4 g/dL, LDH:437 IU/L, Ca++:9.2\n mg/dL, Mg++:1.8 mg/dL, PO4:4.2 mg/dL\n Assessment and Plan\n FEVER, UNKNOWN ORIGIN (FUO, HYPERTHERMIA, PYREXIA)\n AROUSAL, ATTENTION, AND COGNITION, IMPAIRED\n BALANCE, IMPAIRED\n MOTOR FUNCTION, IMPAIRED\n MUSCLE PERFORMACE, IMPAIRED\n RESPIRATION / GAS EXCHANGE, IMPAIRED\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n IMPAIRED SKIN INTEGRITY\n HEPATITIS, ACUTE TOXIC (INCLUDING ALCOHOLIC, ACETAMINOPHEN, ETC.)\n 28 year old male with a history of alcoholism presenting with acute\n hepatitis, pancreatitis, and UGIB, with persistent cyclic\n fevers/leukocytosis and anoxic brain injury.\n # Cyclic fevers/leukocytosis\n Tmax 100.9 overnight. WBC at 11.1.\n - will tolerate slight fevers as long as patient does not have clinical\n deterioration (hypotension/other) or WBC elevations\n - off abx\n - Cdiff negative \n - sputum cultures\n moderate growth GNR resembling acinetobacter\n (susceptibilities done). Likely colonization.\n - will recheck sputum cultures\n - blood cultures pending from & \n - will not start gancyclovir at this point - CMV not likely cause of\n fevers. Will continue to follow LFTs and if rising will see if\n correlates with CMV viral load. If so, will discuss with renal and ID.\n -CMV viral load to be drawn with 7/1 AM labs.\n - Will order an abdominal CT in the next few days to reevaluate\n peripancreatic fluid.\n # Respiratory failure\n Pt is on trach mask at 40% FIO2.\n - Pt is still tachypneic. (RR 27-40).\n - Considering pt\ns neuro findings, this may be centrally-driven.\n # Acute renal failure\n - pt put out 0.75 L urine yesterday;\n -Cr now 1.1 continuing to trend down.\n - will continue to follow UOP, BUN, and Cr\n # Mental status/anoxic brain injury\n pt had MRI that showed diffuse\n subacute anoxic injury involving the basal ganglia and cortex\n - poor prognosis per neuro with likely long term prognosis persistent\n vegetative state.\n - Family requesting second opinion regarding long term prognosis. This\n will be coordinated by attending physician . .\n # Anemia\n - Hct stable\n - continue to monitor Hct\n # Acute Hepatitis: Likely alcoholic hepatitis. CT scan shows fatty\n infiltration, and no evidence of distal obstruction.\n - will continue to trend LFT\ns and correlate with CMV load\n - check LFT\ns with 7/1 AM labs to correlate with CMV load\n # FEN: IVF, replete electrolytes, Nutren at 50 ml/hr. Given volume\n status will discuss with nutrition if possible to concentrate further.\n ICU Care\n Nutrition:\n Nutren 2.0 () - 12:21 PM 50 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n PICC Line - 08:37 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:ICU\n" }, { "category": "Nursing", "chartdate": "2131-07-04 00:00:00.000", "description": "Nursing Progress Note", "row_id": 684878, "text": "Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Temp spike to 101.9 in evening. Patient tachypneic with RR ~ 40 and\n tachycardic to 120\n Action:\n Micu team notified. Patient pan cultured. Tylenol given.\n Response:\n Patient now normothermic. HR 110-120 sinus tach. RR 30\ns (patient\n recent baseline).\n Plan:\n Await culture results. ? abdominal ct scan.\n" }, { "category": "Physician ", "chartdate": "2131-06-22 00:00:00.000", "description": "Physician Resident/Attending Progress Note - MICU", "row_id": 682326, "text": "Chief Complaint:\n 24 Hour Events:\n INVASIVE VENTILATION - STOP 08:22 AM\n received on TM\n STOOL CULTURE - At 12:11 PM\n BLOOD CULTURED - At 05:11 PM\n URINE CULTURE - At 02:20 AM\n FEVER - 101.2\nF - 08:00 PM\n \n - Underwent HD\n - 2 hours after HD, SBP dropped to 80s, HR in 110s but came up on own\n to low 100s. Spiked fever 101.2. Sent bcx and ucx. Started cipro IV.\n Received 250cc for BP 80s (MAP 55-60) but BP still declining so started\n on levophed.\n - Suctioned clots and blood from trach and oropharynx. Noted to have\n bleeding from gums. Given DDAVP 30mg IV x 1. Hct and coags stable.\n Allergies:\n Meropenem\n skin blisters a\n Last dose of Antibiotics:\n Micafungin - 09:30 PM\n Vancomycin - 02:18 PM\n Aztreonam - 03:18 PM\n Ciprofloxacin - 08:00 PM\n Linezolid - 12:33 AM\n Metronidazole - 05:14 AM\n Infusions:\n Norepinephrine - 0.03 mcg/Kg/min\n Other ICU medications:\n Famotidine (Pepcid) - 12:33 AM\n Heparin Sodium (Prophylaxis) - 05:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:41 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: 38.2\nC (100.8\n HR: 106 (101 - 116) bpm\n BP: 105/58(72) {75/40(57) - 125/67(85)} mmHg\n RR: 30 (21 - 42) insp/min\n SpO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 100.7 kg (admission): 113.5 kg\n Height: 67 Inch\n Total In:\n 3,740 mL\n 1,111 mL\n PO:\n TF:\n 1,200 mL\n 333 mL\n IVF:\n 2,270 mL\n 658 mL\n Blood products:\n Total out:\n 1,405 mL\n 60 mL\n Urine:\n 405 mL\n 60 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,335 mL\n 1,051 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n SpO2: 100%\n ABG: 7.42/40/110/25/0\n PaO2 / FiO2: 220\n Physical Examination\n GEN: Trached.\n HEENT: Icteric sclera. MMM.\n NECK: Trach site with no oozing.\n LUNGS: Anterior auscultation with upper airway noise; good airway\n movement.\n HEART: RRR, normal S1, S2.\n ABD: Distended. Firm, but unchanged.\n EXTREM: 2+ edema, ulcers/lesions on legs with bandages C/D/I.\n SKIN: Jaundiced.\n NEURO: Twitching mouth and arms. ? clonus. Opens eyes, squeezes hand to\n command.\n Labs / Radiology\n 305 K/uL\n 7.1 g/dL\n 136 mg/dL\n 1.8 mg/dL\n 25 mEq/L\n 3.3 mEq/L\n 43 mg/dL\n 99 mEq/L\n 136 mEq/L\n 23.1 %\n 35.7 K/uL\n [image002.jpg]\n Ca: 9.1 Mg: 2.3 P: 1.7\n ALT: 156\n AP: 487\n Tbili: 12.6\n Alb: 2.3\n AST: 151\n LDH:\n Dbili:\n TProt:\n :\n Lip: 88\n 03:15 AM\n 04:57 PM\n 02:28 AM\n 02:50 AM\n 05:09 PM\n 05:55 PM\n 05:57 PM\n 09:02 PM\n 01:42 AM\n 01:50 AM\n WBC\n 38.5\n 38.6\n 34.0\n 35.7\n Hct\n 22.7\n 22.6\n 21.6\n 23.1\n Plt\n 282\n 277\n 291\n 305\n Cr\n 2.4\n 1.2\n 1.8\n TCO2\n 23\n 20\n 22\n 21\n 27\n Glucose\n 132\n 126\n 136\n Other labs: PT / PTT / INR:15.6/34.5/1.4, CK / CKMB /\n Troponin-T:214/3/0.07, ALT / AST:156/151, Alk Phos / T Bili:487/12.6,\n Amylase / Lipase:77/88, Differential-Neuts:80.0 %, Band:6.0 %,\n Lymph:3.0 %, Mono:1.0 %, Eos:1.0 %, D-dimer:6389 ng/mL, Fibrinogen:541\n mg/dL, Lactic Acid:2.4 mmol/L, Albumin:2.3 g/dL, LDH:529 IU/L, Ca++:9.1\n mg/dL, Mg++:2.3 mg/dL, PO4:1.7 mg/dL\n URINE CULTURE-PENDING\n CLOSTRIDIUM DIFFICILE TOXIN A & B - NEGATIVE\n Blood Culture, Routine-PENDING\n Blood Culture, Routine-PENDING\n CMV Viral Load-PENDING\n CMV IgG ANTIBODY-PENDING; CMV IgM ANTIBODY-PENDING\n CLOSTRIDIUM DIFFICILE TOXIN A & B - NEGATIVE\n URINE CULTURE-FINAL {YEAST}\n Assessment and Plan\n 28M with alcoholic hepatitis and necrotizing pancreatitis complicated\n by ARDS, SIRS, ARF, UGIB, fevers.\n #. ID: Persistent leukocytosis and fevers now that off CVVH. Possible\n that continued fevers necrotizing pancreatitis. Also with\n persistent yeast in ucx, persistent colonic inflammation on CT. On\n aztreonam, linezolid (since ) and flagyl (since ). Started\n micafungin and po vanc . In setting of fevers and hypotension,\n Cipro was started .\n - New fluid collection peri-pancreas but would hold off on fluid\n drainage\n - Check CXR\n - Bronch today\n - Cont broad coverage with linezolid (-), aztreo (-), flagyl\n (-), mica (-). D/c vanc po (-), Cipro IV ( -).\n - F/u c diff (neg x2), if neg x3 can d/c po vanc\n - Follow WBC count, temp curve, and culture data\n - F/u ID recs\n # Shock: Pressures dropped to 70/40 again in setting of fever. Likely\n septic shock. Will treat for infection as above. If requires pressors\n without fever consider other etiologies of hypotension including\n cardiogenic.\n - Cont weaning steroids; change to PO prednisone 5 mg today\n - Keep a-line until off pressors x 24 h\n - Infectious w/u as above\n # Elevated LFTs: A/w alcoholic hepatitis. RUQ u/s showed sludge\n concerning for cholestasis but also seen on u/s. HIDA neg.\n TPN stopped . T Bili and transaminases improving today.\n - weaning off benzos - 5 mg valium today\n - continue to trend\n #. Respiratory Failure: ARDS secondary to necrotizing pancreatitis. S/p\n trach placement on . Continues to have blood/clots suctioned from\n trach\n - DDAVP if acute bleeding (max few doses). Had required amicar shortly\n after trach for continued bleeding but complicated by seizure shortly\n after starting this.\n - Cte fentanyl boluses\n - Wean methadone and valium as tolerated\n - Cte OOB to chair daily\n - Trach\n #. Acute renal Failure: Multifactorial inc. ATN from hypotension\n - Was supposed to transition to HD today but pressures not able to\n tolerate. No need for filtration so will reassess tmrw.\n - Aztreonam 2000mg q12h while on CVVH.\n - continue Keppra at 1000mg Q24 with 500 mg after HD\n #. Adrenal Insufficiency: Unclear with stim if clear adrenal\n insufficiency but hypotension improving with steroids (lower pressor\n requirement) and eosinophilia resolved.\n - transition to PO prednisone 5 mg daily today\n # Seizures: CT head without intracranial process. EEG showed occipital\n seizures which does not correlate with clinical symptoms, but repeat\n EEG on higher dose Keppra showed no seizures. As patient now with\n purposeful movements, this may actually be patient waking up, not\n seizures.\n - Continue keppra at HD dosing\n # Altered Mental Status:\n - Titrate down sedating meds; decrease methadone to today and qd\n tomorrow\n ICU Care\n Nutrition:\n Nutren 2.0 () - 01:47 AM 50 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 08:15 PM\n PICC Line - 08:37 AM\n Dialysis Catheter - 08:55 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP: HOB elevation\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU, d/c to Rehab when stable on HD\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: 28M alcoholic hepatitis, pancreatitis,\n refractory shock, ARDS. Febrile with transient pressor requirement\n yesterday after HD, resolved; also c some clot from OP / trach tube.\n Labs stable / improving, as is mental status.\n Exam notable for Tm 101.2 BP 112/60 HR 100-110 RR 18 with sat 100 on TM\n 0.4 7.39/32/93. WD man, chemosis. Follows some commands. Coarse BS B.\n Distant s1s2. Obese, + BS. 2+ edema. Labs notable for WBC 35K, HCT 23,\n TB 12. C. diff neg x2.\n Agree with plan to manage respiratory failure with ongoing TM trials\n and sedation wean - will get OOB to chair today, and will decrease\n methadone to . For hemoptysis, will check CXR and bronch today - TFs\n on hold. Given possibility of sz activity, will continue keppra and\n valium at current doses. For shock (resolved), will continue to wean\n steroids (change to pred 5 today) and will continue linezolid /\n aztreonam / flagyl / micafungin / cipro / vanco PO while monitoring\n culture data. LFTs are improving off TPN. For ARF, HD per renal team.\n For pancreatitis, will continue post-pyloric TFs, and will continue to\n hold off on any drainage of new peripancreatic fluid collection.\n Remainder of plan as outlined above.\n Total time: 35 min\n ------ Protected Section Addendum Entered By: , MD\n on: 01:59 PM ------\n" }, { "category": "Respiratory ", "chartdate": "2131-06-23 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 682453, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 0\n Ideal body weight: 67.1 None\n Ideal tidal volume: 268.4 / 402.6 / 536.8 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Tube Type\n Tracheostomy tube:\n Type: Standard, Cuffed\n Manufacturer: Portex\n Size: 8.0mm\n PMV:\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: /\n Sputum source/amount: /\n Ventilation Assessment\n Level of breathing assistance: Unassisted spontaneous breathing\n Visual assessment of breathing pattern: Normal quiet breathing,\n Accessory muscle use\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: observe WOB.\n Reason for continuing current ventilatory support:\n" }, { "category": "Nursing", "chartdate": "2131-06-25 00:00:00.000", "description": "Nursing Progress Note", "row_id": 682978, "text": "Hypotension (not Shock)\n Assessment:\n On low dose levo this am\n Low grade fevers, no fever spike yet\n Action:\n Levo weaned to off\n Response:\n Tolerating well\n Plan:\n Goal to keep levo off as tolerated.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n On vent this am, cmv\n Action:\n Weaned to cpap and then to trach collar this afternoon\n Response:\n Ongoing at present\n Baseline abg sent per MICU team pre trach collar\n Plan:\n Keep on trach collar as much as possible\n" }, { "category": "Respiratory ", "chartdate": "2131-06-26 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 683047, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 4\n Ideal body weight: 67.1 None\n Ideal tidal volume: 268.4 / 402.6 / 536.8 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Tube Type\n Tracheostomy tube:\n Type: Standard, Cuffed\n Manufacturer: Portex\n Size: 8.0mm\n PMV: No\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Cuff volume: 7 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: Blood Tinged / Thick\n Sputum source/amount: Expectorated / Small\n Ventilation Assessment\n Level of breathing assistance: Intermittent invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing;\n Comments: Taken off vent/assisted support & PSV to ^TC since yesterday\n aft.\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: Place on vent suport if increase WOB & Continue pulm\n toilet PRN only.\n Reason for continuing current ventilatory support:\n" }, { "category": "Case Management ", "chartdate": "2131-07-03 00:00:00.000", "description": "Case Management Discharge Planning - Update", "row_id": 684779, "text": "TITLE: Case Management Discharge Planning Update\n NCM notified yesterday afternoon that the patient would likely be ready\n today for transfer to LTACH. NCM notified , Rehab and\n of the patient\ns status.\n Rehab had previously clinically accepted the patient when he was\n vented and more critically ill. They have now withdrawn their clinical\n acceptance as they believe the patient now presents more as a chronic\n patient and they are not able to meet his needs on the MACU.\n did not respond with a bed offer.\n , which the patient\ns brother has indicated is the\n family\ns first choice, offered a bed today for 3 PM. NCM called \n and let him know of this, asking for a return call to confirm that he\n wanted to accept the bed. NCM did not receive a return call.\n When this NCM notified the MICU team of the patient\ns bed offer, she\n was made aware that the patient was not quite ready for transfer as he\n had become more tachycardic and tachypneic with increased secretions.\n In addition, the patient\ns family has requested a second opinion from\n neurology on the patient\ns prognosis for meaningful recovery and that\n has not yet occurred. NCM informed of the change in plans.\n NCM will f/u with the MICU team as well as in the AM to assess\n both the patient\ns readiness for discharge as well as bed\n availability. Unfortunately, there is no guarantee that the bed\n available today will also be available tomorrow.\n Please call/page with any questions.\n , RN, BSN\n MICU Service Case Manager\n Phone: \n Pager: \n" }, { "category": "Case Management ", "chartdate": "2131-07-03 00:00:00.000", "description": "Case Management Discharge Planning - Update", "row_id": 684780, "text": "TITLE: Case Management Discharge Planning Update\n NCM notified yesterday afternoon that the patient would likely be ready\n today for transfer to LTACH. NCM notified , Rehab and\n of the patient\ns status.\n Rehab had previously clinically accepted the patient when he was\n vented and more critically ill. They have now withdrawn their clinical\n acceptance as they believe the patient now presents more as a chronic\n patient and they are not able to meet his needs on the MACU.\n did not respond with a bed offer.\n , which the patient\ns brother has indicated is the\n family\ns first choice, offered a bed today for 3 PM. NCM called \n and let him know of this, asking for a return call to confirm that he\n wanted to accept the bed. NCM did not receive a return call.\n When this NCM notified the MICU team of the patient\ns bed offer, she\n was made aware that the patient was not quite ready for transfer as he\n had become more tachycardic and tachypneic with increased secretions.\n In addition, the patient\ns family has requested a second opinion from\n neurology on the patient\ns prognosis for meaningful recovery and that\n has not yet occurred. NCM informed of the change in plans.\n NCM will f/u with the MICU team as well as in the AM to assess\n both the patient\ns readiness for discharge as well as bed\n availability. Unfortunately, there is no guarantee that the bed\n available today will also be available tomorrow.\n Please call/page with any questions.\n , RN, BSN\n MICU Service Case Manager\n Phone: \n Pager: \n ------ Protected Section ------\n It should be noted that and Rehab have\n re-screened the patient and both have declined to offer a bed\n indicating that given the patient\ns poor neurological prognosis and\n continuing high level medical needs, the patient is more\n LTACH-appropriate. NCM has informed the patient\ns brother of\n these denials.\n ------ Protected Section Addendum Entered By: , RN\n on: 10:13 PM ------\n" }, { "category": "Nursing", "chartdate": "2131-06-25 00:00:00.000", "description": "Nursing Progress Note", "row_id": 682857, "text": "TITLE:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received on trach collar 40% Bbs coarse to clear and diminish at bases.\n Coughing and raising thick tan to clear sputum. Becomes tachypneic\n transiently with turning and repositioning.\n Action:\n tracheal suct x2 for small amts thick clear to white secretions. Trach\n care done.Vap bundle q4h\n Response:\n O2 sats > 98% throughout the noc. Remains on trach collar w no signs of\n resp distress.\n Plan:\n Cont Pulm toilet, trach care, vap bundle. Suct prn congestion.? PMV\n trial\n Hypotension (not Shock)\n Assessment:\n received on low dose levo 0.03mcg/kg/m sbp > 100 on same w mbp 70\n sinus tach 110-115\n Action:\n Weaned levo off for goal mbp > or (=) to 60 per MICU\n Response:\n mbp remains >/= to 60, hr\ns essentially unchanged off levophed\n Plan:\n Levophed standby for mbp consistently < 60\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Tmax 100.7 po\n Action:\n tylenol 650mg per feed tube, daily surveillance blood cultures sent\n Response:\n Temp transiently down to 99.7 po after tylenol\n Plan:\n Repeat tylenol q6h prn for temp > 101. Check with team re: urine/sputum\n culture if temp spikes > 101.5\n ------ Protected Section ------\n Temp trending up 101.2 po w consequent Mbp < 60 with systolic 80.\n Levophed resumed at 0.05mcg/kg/m. Tylenol per ft given.\n ------ Protected Section Addendum Entered By: , RN\n on: 02:48 ------\n Resp status: tachypneic to 40-50 without desats(sat 95%). Suct for\n small amts clear to scant bl tinged secretions. RT here to eval and Dr\n paged. Pt back on ventilator w attempt at cpap w/o improvement in\n rr.Placed on cmv mode with improvement in rr to mid 20\ns to 30.\n Concomittent to increased rr , pt w small amt of ? regurg\n bilious,yankauer readily available and oral cavity suct for small amt\n of ? bilious , tf turned to off (residuals negligible)per Dr \n for now and portable cxr and abd xray obtained.\n ------ Protected Section Addendum Entered By: , RN\n on: 06:22 ------\n" }, { "category": "Physician ", "chartdate": "2131-07-05 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 685115, "text": "Chief Complaint:\n 24 Hour Events:\n Allergies:\n Meropenem\n skin blisters a\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 12:02 PM\n Famotidine (Pepcid) - 12:03 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 06:37 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.7\nC (99.8\n Tcurrent: 37.6\nC (99.6\n HR: 123 (110 - 125) bpm\n BP: 121/69(83) {99/62(79) - 144/100(106)} mmHg\n RR: 34 (30 - 46) insp/min\n SpO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 99.1 kg (admission): 113.5 kg\n Height: 67 Inch\n Total In:\n 2,401 mL\n 529 mL\n PO:\n TF:\n 1,200 mL\n 329 mL\n IVF:\n 151 mL\n Blood products:\n Total out:\n 2,670 mL\n 450 mL\n Urine:\n 2,670 mL\n 450 mL\n NG:\n Stool:\n Drains:\n Balance:\n -269 mL\n 80 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n SpO2: 100%\n ABG: ///17/\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 367 K/uL\n 6.9 g/dL\n 115 mg/dL\n 0.8 mg/dL\n 17 mEq/L\n 4.2 mEq/L\n 38 mg/dL\n 116 mEq/L\n 142 mEq/L\n 22.4 %\n 10.3 K/uL\n [image002.jpg]\n 02:32 AM\n 04:25 AM\n 03:56 PM\n 02:32 AM\n 08:00 PM\n 12:35 AM\n 03:21 AM\n 04:44 PM\n 02:42 AM\n 04:46 AM\n WBC\n 10.9\n 11.0\n 10.5\n 11.1\n 11.6\n 10.3\n Hct\n 22.2\n 22.5\n 22.3\n 22.1\n 23.6\n 22.4\n Plt\n 290\n 310\n 327\n \n Cr\n 1.9\n 1.6\n 1.3\n 1.2\n 1.2\n 1.1\n 1.0\n 1.0\n 0.8\n TCO2\n 20\n Glucose\n 116\n 161\n 97\n 93\n 147\n 187\n 111\n 115\n Other labs: PT / PTT / INR:13.6/28.0/1.2, CK / CKMB /\n Troponin-T:214/3/0.07, ALT / AST:60/85, Alk Phos / T Bili:247/2.8,\n Amylase / Lipase:78/91, Differential-Neuts:57.0 %, Band:4.0 %,\n Lymph:23.0 %, Mono:4.0 %, Eos:3.0 %, D-dimer:6389 ng/mL, Fibrinogen:541\n mg/dL, Lactic Acid:2.6 mmol/L, Albumin:2.4 g/dL, LDH:437 IU/L, Ca++:9.2\n mg/dL, Mg++:1.8 mg/dL, PO4:4.2 mg/dL\n Assessment and Plan\n FEVER, UNKNOWN ORIGIN (FUO, HYPERTHERMIA, PYREXIA)\n AROUSAL, ATTENTION, AND COGNITION, IMPAIRED\n BALANCE, IMPAIRED\n MOTOR FUNCTION, IMPAIRED\n MUSCLE PERFORMACE, IMPAIRED\n RESPIRATION / GAS EXCHANGE, IMPAIRED\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n IMPAIRED SKIN INTEGRITY\n HEPATITIS, ACUTE TOXIC (INCLUDING ALCOHOLIC, ACETAMINOPHEN, ETC.)\n ICU Care\n Nutrition:\n Nutren 2.0 () - 12:21 PM 50 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 08:37 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Social Work", "chartdate": "2131-06-21 00:00:00.000", "description": "Social Work Progress Note", "row_id": 682110, "text": "Ongoing meetings with pt\ns parents and brother who are following pt\n progress very closely. Family happy with pt\ns progress. Son has\n requested counseling session for family, offered 2 times that will not\n work for family however we are looking toward early next week to sit\n down. Family beginning to anticipate talking with pt and want to be\n prepared\nwe \nt know what to say to him or how he will respond to\n us\n. Normalized family\ns anticipatory anxiety, assured them that we\n will meet at their convience. Have invited addictions specialist to\n sit in the family meeting as well.\n Family also starting to voice some hesitancy re: pt\ns readiness for\n rehab. Rehab screens have been initiated which has given family hope\n and ambivalence at the same time.\n Family working well with medical team\n" }, { "category": "Physician ", "chartdate": "2131-06-23 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 682546, "text": "Chief Complaint: resp failure, pancreatitis\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 BRONCHOSCOPY - At 02:45 PM\n BLOOD CULTURED - At 09:40 PM\n FEVER - 102.0\nF - 08:00 PM\n Allergies:\n Meropenem\n skin blisters a\n Last dose of Antibiotics:\n Vancomycin - 02:18 PM\n Ciprofloxacin - 08:00 PM\n Micafungin - 10:08 PM\n Linezolid - 12:25 AM\n Aztreonam - 02:02 AM\n Metronidazole - 04:22 AM\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 08:07 PM\n Heparin Sodium (Prophylaxis) - 04:23 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 10:50 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.9\nC (102\n Tcurrent: 38.4\nC (101.2\n HR: 112 (101 - 120) bpm\n BP: 107/63(77) {70/46(45) - 129/72(88)} mmHg\n RR: 32 (26 - 40) insp/min\n SpO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 103.9 kg (admission): 113.5 kg\n Height: 67 Inch\n Total In:\n 2,903 mL\n 1,308 mL\n PO:\n TF:\n 975 mL\n 540 mL\n IVF:\n 1,598 mL\n 708 mL\n Blood products:\n Total out:\n 253 mL\n 215 mL\n Urine:\n 253 mL\n 215 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,650 mL\n 1,093 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n SpO2: 100%\n ABG: ///22/\n Physical Examination\n Gen: lying in bed, getting HD< eye open\n HEENT: trach\n CV: tachy RR\n Chest: good air movement\n Abd: soft +BS\n Ext: edema\n Neuro: eye open, squeeze hand to command, not answering more involved\n ?s or following more complex commands\n Labs / Radiology\n 6.6 g/dL\n 264 K/uL\n 170 mg/dL\n 2.8 mg/dL\n 22 mEq/L\n 3.3 mEq/L\n 64 mg/dL\n 98 mEq/L\n 132 mEq/L\n 22.2 %\n 30.9 K/uL\n [image002.jpg]\n 04:57 PM\n 02:28 AM\n 02:50 AM\n 05:09 PM\n 05:55 PM\n 05:57 PM\n 09:02 PM\n 01:42 AM\n 01:50 AM\n 03:18 AM\n WBC\n 38.5\n 38.6\n 34.0\n 35.7\n 30.9\n Hct\n 22.7\n 22.6\n 21.6\n 23.1\n 22.2\n Plt\n 282\n 277\n 291\n 305\n 264\n Cr\n 2.4\n 1.2\n 1.8\n 2.8\n TCO2\n 20\n 22\n 21\n 27\n Glucose\n 132\n 126\n 136\n 170\n Other labs: PT / PTT / INR:15.8/39.1/1.4, CK / CKMB /\n Troponin-T:214/3/0.07, ALT / AST:121/118, Alk Phos / T Bili:379/10.8,\n Amylase / Lipase:77/88, Differential-Neuts:80.0 %, Band:6.0 %,\n Lymph:3.0 %, Mono:1.0 %, Eos:1.0 %, D-dimer:6389 ng/mL, Fibrinogen:541\n mg/dL, Lactic Acid:2.4 mmol/L, Albumin:2.3 g/dL, LDH:529 IU/L, Ca++:8.3\n mg/dL, Mg++:2.2 mg/dL, PO4:2.9 mg/dL\n Assessment and Plan\n AROUSAL, ATTENTION, AND COGNITION, IMPAIRED\n BALANCE, IMPAIRED\n MOTOR FUNCTION, IMPAIRED\n MUSCLE PERFORMACE, IMPAIRED\n RESPIRATION / GAS EXCHANGE, IMPAIRED\n SEIZURE, WITHOUT STATUS EPILEPTICUS\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n IMPAIRED SKIN INTEGRITY\n HEPATITIS, ACUTE TOXIC (INCLUDING ALCOHOLIC, ACETAMINOPHEN, ETC.)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n 1. Resp Failure: Agree with plan to manage respiratory failure\n with ongoing TM trials and sedation wean - will get OOB to chair today,\n and will decrease methadone to .\n 2. Given possibility of sz activity, will continue keppra and\n valium at current doses.\n 3. For shock (resolved), will continue to wean steroids (change\n to pred 5 today) and will continue linezolid / aztreonam / flagyl /\n micafungin / cipro / vanco PO while monitoring culture data. LFTs are\n improving off TPN. be able to wean ABX if remains stable from WBC\n and fever standpoint. Drug fever also a possibility given multi neg C\n diff\n could start by peeling off po Vanco and Flagyl. Dsicussed with\n ID Attg at bedside. Possible repeat imaging in a week of pancreas.\n 4. For ARF, HD today.\n 5. For pancreatitis, will continue post-pyloric TFs, and will\n continue to hold off on any drainage of new peripancreatic fluid\n collection.\n Remainder of plan as outlined above.\n ICU Care\n Nutrition: Nutren 2.0 () - 02:00 PM 50 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 08:15 PM\n PICC Line - 08:37 AM\n Dialysis Catheter - 08:55 AM\n Prophylaxis:\n DVT: sc hep\n Stress ulcer: PPI\n VAP: HOB\n Communication: with family daily\n dad and brother\n status: Full code\n Disposition :ICU\n Total time spent: 45 minutes\n Patient is critically ill\n" }, { "category": "Physician ", "chartdate": "2131-06-23 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 682530, "text": "Chief Complaint:\n 24 Hour Events:\n BRONCHOSCOPY - At 02:45 PM\n BLOOD CULTURED - At 09:40 PM\n FEVER - 102.0\nF - 08:00 PM\n \n - Febrile again to 102, requireing levophed.\n - ID recommended asking IR if tap of fluid collections is even\n possible. If not, would re-image in a few days to see if fluid\n collections are evolving.\n - CMV VL - ID said likely shedding post-infection - re-check in 1 week\n and re-eval at that time.\n - Bronch showed thin secretions possibly to volume overload. Also\n small lesion at take-off of RML, but not concerning for source of\n bleeding. He was put on dry trach mask in attempt to dry some\n secretions.\n Allergies:\n Meropenem\n skin blisters a\n Last dose of Antibiotics:\n Vancomycin - 02:18 PM\n Ciprofloxacin - 08:00 PM\n Micafungin - 10:08 PM\n Linezolid - 12:25 AM\n Aztreonam - 02:02 AM\n Metronidazole - 04:22 AM\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 08:07 PM\n Heparin Sodium (Prophylaxis) - 04:23 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 12 AM\n Tmax: 38.9\nC (102\n Tcurrent: 37.7\nC (99.8\n HR: 108 (101 - 120) bpm\n BP: 114/59(76) {70/46(45) - 129/72(88)} mmHg\n RR: 34 (26 - 40) insp/min\n SpO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 103.9 kg (admission): 113.5 kg\n Height: 67 Inch\n Total In:\n 2,903 mL\n 990 mL\n PO:\n TF:\n 975 mL\n 358 mL\n IVF:\n 1,598 mL\n 572 mL\n Blood products:\n Total out:\n 253 mL\n 170 mL\n Urine:\n 253 mL\n 170 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,650 mL\n 821 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n SpO2: 100%\n ABG: ///22/\n Physical Examination\n GEN: Trached.\n HEENT: Icteric sclera. MMM.\n NECK: Trach site with no oozing.\n LUNGS: Anterior auscultation with upper airway noise; good airway\n movement.\n HEART: RRR, normal S1, S2.\n ABD: Distended. Firm, but unchanged.\n EXTREM: 2+ edema, ulcers/lesions on legs with bandages C/D/I.\n SKIN: Jaundiced.\n NEURO: Twitching mouth and arms. ? clonus. Opens eyes, squeezes hand to\n command.\n Labs / Radiology\n 264 K/uL\n 6.6 g/dL\n 170 mg/dL\n 2.8 mg/dL\n 22 mEq/L\n 3.3 mEq/L\n 64 mg/dL\n 98 mEq/L\n 132 mEq/L\n 22.2 %\n 30.9 K/uL\n [image002.jpg]\n 04:57 PM\n 02:28 AM\n 02:50 AM\n 05:09 PM\n 05:55 PM\n 05:57 PM\n 09:02 PM\n 01:42 AM\n 01:50 AM\n 03:18 AM\n WBC\n 38.5\n 38.6\n 34.0\n 35.7\n 30.9\n Hct\n 22.7\n 22.6\n 21.6\n 23.1\n 22.2\n Plt\n 282\n 277\n 291\n 305\n 264\n Cr\n 2.4\n 1.2\n 1.8\n 2.8\n TCO2\n 20\n 22\n 21\n 27\n Glucose\n 132\n 126\n 136\n 170\n Other labs: PT / PTT / INR:15.8/39.1/1.4, CK / CKMB /\n Troponin-T:214/3/0.07, ALT / AST:121/118, Alk Phos / T Bili:379/10.8,\n Amylase / Lipase:77/88, Differential-Neuts:80.0 %, Band:6.0 %,\n Lymph:3.0 %, Mono:1.0 %, Eos:1.0 %, D-dimer:6389 ng/mL, Fibrinogen:541\n mg/dL, Lactic Acid:2.4 mmol/L, Albumin:2.3 g/dL, LDH:529 IU/L, Ca++:8.3\n mg/dL, Mg++:2.2 mg/dL, PO4:2.9 mg/dL\n Ca: 8.3 Mg: 2.2 P: 2.9\n ALT: 121\n AP: 379\n Tbili: 10.8\n Alb:\n AST: 118\n LDH:\n Dbili:\n TProt:\n :\n Lip:\n CMV VL - 7,210 copies/ml\n CMV IgG\n positive\n CMV IgM\n Negative\n C diff negative x3\n Assessment and Plan\n 28M with alcoholic hepatitis and necrotizing pancreatitis complicated\n by ARDS, SIRS, ARF, UGIB, fevers.\n #. ID: Persistent leukocytosis and fevers now that off CVVH. Possible\n that continued fevers necrotizing pancreatitis. Also with\n persistent yeast in ucx, persistent colonic inflammation on CT, and\n pancreatic fluid collections. On aztreonam, linezolid (since ) and\n flagyl (since ). Started micafungin and po vanc . In setting\n of fevers and hypotension, Cipro was started , but d/c\ned. Surgery\n was consulted for new fluid collection peri-pancreas but they feel they\n are not infected (no gas on CT) and would hold off on fluid drainage.\n CMV positive, but likely not contributing to current illness per ID.\n - Cont broad coverage with linezolid (-), aztreo (-), flagyl\n (-), mica (-). D/c vanc po (-).\n - C diff neg x3 -> likely d/c po vanc\n - Recheck CMV VL on \n - Follow WBC count, temp curve, and culture data\n - F/u ID recs\n # Shock: Pressures dropped again in setting of fever. Will treat for\n infection as above. If requires pressors without fever consider other\n etiologies of hypotension including cardiogenic.\n - Cont weaning steroids; change to PO prednisone 5 mg today\n - Keep a-line until off pressors x 24 h\n - Infectious w/u as above\n # Elevated LFTs: A/w alcoholic hepatitis. RUQ u/s showed sludge\n concerning for cholestasis but also seen on u/s. HIDA neg.\n TPN stopped . T Bili and transaminases improving today.\n - weaning off benzos - 5 mg valium today\n - continue to trend\n #. Respiratory Failure: ARDS secondary to necrotizing pancreatitis. S/p\n trach placement on . Bronch without obvious source of bleeding\n and with only thin secretions throughout.\n - DDAVP if acute bleeding (max few doses). Had required amicar shortly\n after trach for continued bleeding but complicated by seizure shortly\n after starting this.\n - Cte fentanyl boluses\n - Wean methadone and valium as tolerated\n - Cte OOB to chair daily\n - Trach care\n #. Acute renal Failure: Multifactorial inc. ATN from hypotension\n - Was supposed to transition to HD today but pressures not able to\n tolerate. No need for filtration so will reassess tmrw.\n - Aztreonam 2000mg q12h while on CVVH.\n - continue Keppra at 1000mg Q24 with 500 mg after HD\n #. Adrenal Insufficiency: Unclear with stim if clear adrenal\n insufficiency but hypotension improving with steroids (lower pressor\n requirement) and eosinophilia resolved.\n - transition to PO prednisone 5 mg daily today\n # Seizures: CT head without intracranial process. EEG showed occipital\n seizures which does not correlate with clinical symptoms, but repeat\n EEG on higher dose Keppra showed no seizures. As patient now with\n purposeful movements, this may actually be patient waking up, not\n seizures.\n - Continue keppra at HD dosing\n # Altered Mental Status:\n - Titrate down sedating meds; decrease methadone to today and qd\n tomorrow\n ICU Care\n Nutrition:\n Nutren 2.0 () - 02:00 PM 50 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 08:15 PM\n PICC Line - 08:37 AM\n Dialysis Catheter - 08:55 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP: HOB elevation\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:ICU\n" }, { "category": "Physician ", "chartdate": "2131-06-23 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 682551, "text": "Chief Complaint:\n 24 Hour Events:\n BRONCHOSCOPY - At 02:45 PM\n BLOOD CULTURED - At 09:40 PM\n FEVER - 102.0\nF - 08:00 PM\n \n - Febrile again to 102, requireing levophed.\n - ID recommended asking IR if tap of fluid collections is even\n possible. If not, would re-image in a few days to see if fluid\n collections are evolving.\n - CMV VL - ID said likely shedding post-infection - re-check in 1 week\n and re-eval at that time.\n - Bronch showed thin secretions possibly to volume overload. Also\n small lesion at take-off of RML, but not concerning for source of\n bleeding. He was put on dry trach mask in attempt to dry some\n secretions.\n Allergies:\n Meropenem\n skin blisters a\n Last dose of Antibiotics:\n Vancomycin - 02:18 PM\n Ciprofloxacin - 08:00 PM\n Micafungin - 10:08 PM\n Linezolid - 12:25 AM\n Aztreonam - 02:02 AM\n Metronidazole - 04:22 AM\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 08:07 PM\n Heparin Sodium (Prophylaxis) - 04:23 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 12 AM\n Tmax: 38.9\nC (102\n Tcurrent: 37.7\nC (99.8\n HR: 108 (101 - 120) bpm\n BP: 114/59(76) {70/46(45) - 129/72(88)} mmHg\n RR: 34 (26 - 40) insp/min\n SpO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 103.9 kg (admission): 113.5 kg\n Height: 67 Inch\n Total In:\n 2,903 mL\n 990 mL\n PO:\n TF:\n 975 mL\n 358 mL\n IVF:\n 1,598 mL\n 572 mL\n Blood products:\n Total out:\n 253 mL\n 170 mL\n Urine:\n 253 mL\n 170 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,650 mL\n 821 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n SpO2: 100%\n ABG: ///22/\n Physical Examination\n GEN: Trached.\n HEENT: Icteric sclera. MMM.\n NECK: Trach site with no oozing.\n LUNGS: Anterior auscultation with upper airway noise; good airway\n movement.\n HEART: RRR, normal S1, S2.\n ABD: Distended. Firm, but unchanged.\n EXTREM: 2+ edema, ulcers/lesions on legs with bandages C/D/I.\n SKIN: Jaundiced.\n NEURO: Twitching mouth and arms. Opens eyes, squeezes hand to command.\n Labs / Radiology\n 264 K/uL\n 6.6 g/dL\n 170 mg/dL\n 2.8 mg/dL\n 22 mEq/L\n 3.3 mEq/L\n 64 mg/dL\n 98 mEq/L\n 132 mEq/L\n 22.2 %\n 30.9 K/uL\n [image002.jpg]\n 04:57 PM\n 02:28 AM\n 02:50 AM\n 05:09 PM\n 05:55 PM\n 05:57 PM\n 09:02 PM\n 01:42 AM\n 01:50 AM\n 03:18 AM\n WBC\n 38.5\n 38.6\n 34.0\n 35.7\n 30.9\n Hct\n 22.7\n 22.6\n 21.6\n 23.1\n 22.2\n Plt\n 282\n 277\n 291\n 305\n 264\n Cr\n 2.4\n 1.2\n 1.8\n 2.8\n TCO2\n 20\n 22\n 21\n 27\n Glucose\n 132\n 126\n 136\n 170\n Other labs: PT / PTT / INR:15.8/39.1/1.4, CK / CKMB /\n Troponin-T:214/3/0.07, ALT / AST:121/118, Alk Phos / T Bili:379/10.8,\n Amylase / Lipase:77/88, Differential-Neuts:80.0 %, Band:6.0 %,\n Lymph:3.0 %, Mono:1.0 %, Eos:1.0 %, D-dimer:6389 ng/mL, Fibrinogen:541\n mg/dL, Lactic Acid:2.4 mmol/L, Albumin:2.3 g/dL, LDH:529 IU/L, Ca++:8.3\n mg/dL, Mg++:2.2 mg/dL, PO4:2.9 mg/dL\n Ca: 8.3 Mg: 2.2 P: 2.9\n ALT: 121\n AP: 379\n Tbili: 10.8\n Alb:\n AST: 118\n LDH:\n Dbili:\n TProt:\n :\n Lip:\n CMV VL - 7,210 copies/ml\n CMV IgG\n positive\n CMV IgM\n Negative\n C diff negative x3\n Assessment and Plan\n 28M with alcoholic hepatitis and necrotizing pancreatitis complicated\n by ARDS, SIRS, ARF, UGIB, fevers.\n #. ID: Persistent leukocytosis and fevers now that off CVVH. Possible\n that continued fevers necrotizing pancreatitis. Also with\n persistent yeast in ucx, persistent colonic inflammation on CT, and\n pancreatic fluid collections. On aztreonam, linezolid (since ) and\n flagyl (since ). Started micafungin and po vanc . In setting\n of fevers and hypotension, Cipro was started , but d/c\ned. Surgery\n was consulted for new fluid collection peri-pancreas but they feel they\n are not infected (no gas on CT) and would hold off on fluid drainage.\n CMV positive, but likely not contributing to current illness per ID.\n - Cont broad coverage with linezolid (-), aztreo (-), mica\n (-). D/c vanc po (). D/C flagyl (),\n - C diff neg x3 -> d/c po vanc and iv flagyl today.\n - Consider drug fever and attempt to wean off abx over next few days if\n WBCs continue to decrease (also may have fevers from pancreatitis as\n well). Next abx to wean would be linezolid.\n - Recheck CMV VL on \n - Follow WBC count, temp curve, and culture data\n - F/u ID recs\n - D/W IR if fluid collection in abd is drainable in case we want to\n drain it later. Currently do not want to operate on abdomen with\n pancreatitis changes.\n # Shock: Pressures dropped again in setting of fever. Will treat for\n infection as above. If requires pressors without fever consider other\n etiologies of hypotension including cardiogenic. Consider IVF today if\n BPs drop to see if fluid responsive prior to starting levophed again.\n - Cont weaning steroids; change to PO prednisone 5 mg today\n - Keep a-line until off pressors x 24 h\n - Infectious w/u as above\n # Elevated LFTs: A/w alcoholic hepatitis. RUQ u/s showed sludge\n concerning for cholestasis but also seen on u/s. HIDA neg.\n TPN stopped . T Bili and transaminases improving today.\n - weaning off benzos - 5 mg valium today\n - continue to trend\n #. Respiratory Failure: ARDS secondary to necrotizing pancreatitis. S/p\n trach placement on . Bronch without obvious source of bleeding\n and with only thin secretions throughout.\n - DDAVP if acute bleeding (max few doses). Had required amicar shortly\n after trach for continued bleeding but complicated by seizure shortly\n after starting this.\n - Cte fentanyl boluses\n - Wean methadone and valium as tolerated\n - Cte OOB to chair daily\n - Trach care\n #. Acute renal Failure: Multifactorial inc. ATN from hypotension\n - Hd today\n - Aztreonam 2000mg q12h while on CVVH.\n - continue Keppra at 1000mg Q24 with 500 mg after HD\n - F/u Renal recs\n #. Adrenal Insufficiency: Unclear with stim if clear adrenal\n insufficiency but hypotension improving with steroids (lower pressor\n requirement) and eosinophilia resolved.\n - transition to PO prednisone 5 mg daily today\n # Seizures: CT head without intracranial process. EEG showed occipital\n seizures which does not correlate with clinical symptoms, but repeat\n EEG on higher dose Keppra showed no seizures. As patient now with\n purposeful movements, this may actually be patient waking up, not\n seizures.\n - Continue keppra at HD dosing\n # Altered Mental Status:\n - Titrate down sedating meds; decrease methadone to today and qd\n tomorrow\n ICU Care\n Nutrition:\n Nutren 2.0 () - 02:00 PM 50 mL/hour\n Glycemic Control: ISS\n Lines:\n Arterial Line - 08:15 PM\n PICC Line - 08:37 AM\n Dialysis Catheter - 08:55 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP: HOB elevation\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:ICU\n" }, { "category": "Physician ", "chartdate": "2131-06-23 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 682490, "text": "Chief Complaint:\n 24 Hour Events:\n BRONCHOSCOPY - At 02:45 PM\n BLOOD CULTURED - At 09:40 PM\n FEVER - 102.0\nF - 08:00 PM\n \n - Febrile again to 102, requireing levophed.\n - ID recommended asking IR if tap of fluid collections is even\n possible. If not, would re-image in a few days to see if fluid\n collections are evolving.\n - CMV VL 7,210 copies/ml - ID said likely shedding post-infection -\n re-check in 1 week and re-eval at that time.\n - Bronch showed thin secretions possibly to volume overload. Also\n small lesion at take-off of RML, but not concerning for source of\n bleeding. He was put on dry trach mask in attempt to dry some\n secretions.\n Allergies:\n Meropenem\n skin blisters a\n Last dose of Antibiotics:\n Vancomycin - 02:18 PM\n Ciprofloxacin - 08:00 PM\n Micafungin - 10:08 PM\n Linezolid - 12:25 AM\n Aztreonam - 02:02 AM\n Metronidazole - 04:22 AM\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 08:07 PM\n Heparin Sodium (Prophylaxis) - 04:23 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 12 AM\n Tmax: 38.9\nC (102\n Tcurrent: 37.7\nC (99.8\n HR: 108 (101 - 120) bpm\n BP: 114/59(76) {70/46(45) - 129/72(88)} mmHg\n RR: 34 (26 - 40) insp/min\n SpO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 103.9 kg (admission): 113.5 kg\n Height: 67 Inch\n Total In:\n 2,903 mL\n 990 mL\n PO:\n TF:\n 975 mL\n 358 mL\n IVF:\n 1,598 mL\n 572 mL\n Blood products:\n Total out:\n 253 mL\n 170 mL\n Urine:\n 253 mL\n 170 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,650 mL\n 821 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n SpO2: 100%\n ABG: ///22/\n Physical Examination\n GEN: Trached.\n HEENT: Icteric sclera. MMM.\n NECK: Trach site with no oozing.\n LUNGS: Anterior auscultation with upper airway noise; good airway\n movement.\n HEART: RRR, normal S1, S2.\n ABD: Distended. Firm, but unchanged.\n EXTREM: 2+ edema, ulcers/lesions on legs with bandages C/D/I.\n SKIN: Jaundiced.\n NEURO: Twitching mouth and arms. ? clonus. Opens eyes, squeezes hand to\n command.\n Labs / Radiology\n 264 K/uL\n 6.6 g/dL\n 170 mg/dL\n 2.8 mg/dL\n 22 mEq/L\n 3.3 mEq/L\n 64 mg/dL\n 98 mEq/L\n 132 mEq/L\n 22.2 %\n 30.9 K/uL\n [image002.jpg]\n 04:57 PM\n 02:28 AM\n 02:50 AM\n 05:09 PM\n 05:55 PM\n 05:57 PM\n 09:02 PM\n 01:42 AM\n 01:50 AM\n 03:18 AM\n WBC\n 38.5\n 38.6\n 34.0\n 35.7\n 30.9\n Hct\n 22.7\n 22.6\n 21.6\n 23.1\n 22.2\n Plt\n 282\n 277\n 291\n 305\n 264\n Cr\n 2.4\n 1.2\n 1.8\n 2.8\n TCO2\n 20\n 22\n 21\n 27\n Glucose\n 132\n 126\n 136\n 170\n Other labs: PT / PTT / INR:15.8/39.1/1.4, CK / CKMB /\n Troponin-T:214/3/0.07, ALT / AST:121/118, Alk Phos / T Bili:379/10.8,\n Amylase / Lipase:77/88, Differential-Neuts:80.0 %, Band:6.0 %,\n Lymph:3.0 %, Mono:1.0 %, Eos:1.0 %, D-dimer:6389 ng/mL, Fibrinogen:541\n mg/dL, Lactic Acid:2.4 mmol/L, Albumin:2.3 g/dL, LDH:529 IU/L, Ca++:8.3\n mg/dL, Mg++:2.2 mg/dL, PO4:2.9 mg/dL\n Assessment and Plan\n 28M with alcoholic hepatitis and necrotizing pancreatitis complicated\n by ARDS, SIRS, ARF, UGIB, fevers.\n #. ID: Persistent leukocytosis and fevers now that off CVVH. Possible\n that continued fevers necrotizing pancreatitis. Also with\n persistent yeast in ucx, persistent colonic inflammation on CT, and\n pancreatic fluid collections. On aztreonam, linezolid (since ) and\n flagyl (since ). Started micafungin and po vanc . In setting\n of fevers and hypotension, Cipro was started , but d/c\ned. Surgery\n was consulted for new fluid collection peri-pancreas but they feel they\n are not infected (no gas on CT) and would hold off on fluid drainage.\n - Cont broad coverage with linezolid (-), aztreo (-), flagyl\n (-), mica (-). D/c vanc po (-), Cipro IV ( -).\n - F/u c diff (neg x2), if neg x3 can d/c po vanc\n - Follow WBC count, temp curve, and culture data\n - F/u ID recs\n # Shock: Pressures dropped to 70/40 again in setting of fever. Likely\n septic shock. Will treat for infection as above. If requires pressors\n without fever consider other etiologies of hypotension including\n cardiogenic.\n - Cont weaning steroids; change to PO prednisone 5 mg today\n - Keep a-line until off pressors x 24 h\n - Infectious w/u as above\n # Elevated LFTs: A/w alcoholic hepatitis. RUQ u/s showed sludge\n concerning for cholestasis but also seen on u/s. HIDA neg.\n TPN stopped . T Bili and transaminases improving today.\n - weaning off benzos - 5 mg valium today\n - continue to trend\n #. Respiratory Failure: ARDS secondary to necrotizing pancreatitis. S/p\n trach placement on . Bronch without obvious source of bleeding\n and with only thin secretions throughout.\n - DDAVP if acute bleeding (max few doses). Had required amicar shortly\n after trach for continued bleeding but complicated by seizure shortly\n after starting this.\n - Cte fentanyl boluses\n - Wean methadone and valium as tolerated\n - Cte OOB to chair daily\n - Trach care\n #. Acute renal Failure: Multifactorial inc. ATN from hypotension\n - Was supposed to transition to HD today but pressures not able to\n tolerate. No need for filtration so will reassess tmrw.\n - Aztreonam 2000mg q12h while on CVVH.\n - continue Keppra at 1000mg Q24 with 500 mg after HD\n #. Adrenal Insufficiency: Unclear with stim if clear adrenal\n insufficiency but hypotension improving with steroids (lower pressor\n requirement) and eosinophilia resolved.\n - transition to PO prednisone 5 mg daily today\n # Seizures: CT head without intracranial process. EEG showed occipital\n seizures which does not correlate with clinical symptoms, but repeat\n EEG on higher dose Keppra showed no seizures. As patient now with\n purposeful movements, this may actually be patient waking up, not\n seizures.\n - Continue keppra at HD dosing\n # Altered Mental Status:\n - Titrate down sedating meds; decrease methadone to today and qd\n tomorrow\n ICU Care\n Nutrition:\n Nutren 2.0 () - 02:00 PM 50 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 08:15 PM\n PICC Line - 08:37 AM\n Dialysis Catheter - 08:55 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP: HOB elevation\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:ICU\n" }, { "category": "Physician ", "chartdate": "2131-06-23 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 682497, "text": "Chief Complaint:\n 24 Hour Events:\n BRONCHOSCOPY - At 02:45 PM\n BLOOD CULTURED - At 09:40 PM\n FEVER - 102.0\nF - 08:00 PM\n \n - Febrile again to 102, requireing levophed.\n - ID recommended asking IR if tap of fluid collections is even\n possible. If not, would re-image in a few days to see if fluid\n collections are evolving.\n - CMV VL - ID said likely shedding post-infection - re-check in 1 week\n and re-eval at that time.\n - Bronch showed thin secretions possibly to volume overload. Also\n small lesion at take-off of RML, but not concerning for source of\n bleeding. He was put on dry trach mask in attempt to dry some\n secretions.\n Allergies:\n Meropenem\n skin blisters a\n Last dose of Antibiotics:\n Vancomycin - 02:18 PM\n Ciprofloxacin - 08:00 PM\n Micafungin - 10:08 PM\n Linezolid - 12:25 AM\n Aztreonam - 02:02 AM\n Metronidazole - 04:22 AM\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 08:07 PM\n Heparin Sodium (Prophylaxis) - 04:23 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 12 AM\n Tmax: 38.9\nC (102\n Tcurrent: 37.7\nC (99.8\n HR: 108 (101 - 120) bpm\n BP: 114/59(76) {70/46(45) - 129/72(88)} mmHg\n RR: 34 (26 - 40) insp/min\n SpO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 103.9 kg (admission): 113.5 kg\n Height: 67 Inch\n Total In:\n 2,903 mL\n 990 mL\n PO:\n TF:\n 975 mL\n 358 mL\n IVF:\n 1,598 mL\n 572 mL\n Blood products:\n Total out:\n 253 mL\n 170 mL\n Urine:\n 253 mL\n 170 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,650 mL\n 821 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n SpO2: 100%\n ABG: ///22/\n Physical Examination\n GEN: Trached.\n HEENT: Icteric sclera. MMM.\n NECK: Trach site with no oozing.\n LUNGS: Anterior auscultation with upper airway noise; good airway\n movement.\n HEART: RRR, normal S1, S2.\n ABD: Distended. Firm, but unchanged.\n EXTREM: 2+ edema, ulcers/lesions on legs with bandages C/D/I.\n SKIN: Jaundiced.\n NEURO: Twitching mouth and arms. ? clonus. Opens eyes, squeezes hand to\n command.\n Labs / Radiology\n 264 K/uL\n 6.6 g/dL\n 170 mg/dL\n 2.8 mg/dL\n 22 mEq/L\n 3.3 mEq/L\n 64 mg/dL\n 98 mEq/L\n 132 mEq/L\n 22.2 %\n 30.9 K/uL\n [image002.jpg]\n 04:57 PM\n 02:28 AM\n 02:50 AM\n 05:09 PM\n 05:55 PM\n 05:57 PM\n 09:02 PM\n 01:42 AM\n 01:50 AM\n 03:18 AM\n WBC\n 38.5\n 38.6\n 34.0\n 35.7\n 30.9\n Hct\n 22.7\n 22.6\n 21.6\n 23.1\n 22.2\n Plt\n 282\n 277\n 291\n 305\n 264\n Cr\n 2.4\n 1.2\n 1.8\n 2.8\n TCO2\n 20\n 22\n 21\n 27\n Glucose\n 132\n 126\n 136\n 170\n Other labs: PT / PTT / INR:15.8/39.1/1.4, CK / CKMB /\n Troponin-T:214/3/0.07, ALT / AST:121/118, Alk Phos / T Bili:379/10.8,\n Amylase / Lipase:77/88, Differential-Neuts:80.0 %, Band:6.0 %,\n Lymph:3.0 %, Mono:1.0 %, Eos:1.0 %, D-dimer:6389 ng/mL, Fibrinogen:541\n mg/dL, Lactic Acid:2.4 mmol/L, Albumin:2.3 g/dL, LDH:529 IU/L, Ca++:8.3\n mg/dL, Mg++:2.2 mg/dL, PO4:2.9 mg/dL\n Ca: 8.3 Mg: 2.2 P: 2.9\n ALT: 121\n AP: 379\n Tbili: 10.8\n Alb:\n AST: 118\n LDH:\n Dbili:\n TProt:\n :\n Lip:\n CMV VL - 7,210 copies/ml\n CMV IgG\n positive\n CMV IgM\n Negative\nSputum - PSEUDOMONAS AERUGINOSA. MODERATE GROWTH.\n SENSITIVITIES: MIC expressed in MCG/ML\n _________________________________________________________\n PSEUDOMONAS AERUGINOSA\n |\nCEFEPIME-------------- 8 S\nCEFTAZIDIME----------- 16 I\nCIPROFLOXACIN--------- =>4 R\nGENTAMICIN------------ 4 S\nMEROPENEM------------- 8 I\nPIPERACILLIN---------- 16 S\nPIPERACILLIN/TAZO----- 64 S\nTOBRAMYCIN------------ <=1 S\nSputum - PMNs and <10 epithelial cells/100X field.\n 2+ (1-5 per 1000X FIELD): GRAM NEGATIVE ROD(S).\n Assessment and Plan\n 28M with alcoholic hepatitis and necrotizing pancreatitis complicated\n by ARDS, SIRS, ARF, UGIB, fevers.\n #. ID: Persistent leukocytosis and fevers now that off CVVH. Possible\n that continued fevers necrotizing pancreatitis. Also with\n persistent yeast in ucx, persistent colonic inflammation on CT, and\n pancreatic fluid collections. On aztreonam, linezolid (since ) and\n flagyl (since ). Started micafungin and po vanc . In setting\n of fevers and hypotension, Cipro was started , but d/c\ned. Surgery\n was consulted for new fluid collection peri-pancreas but they feel they\n are not infected (no gas on CT) and would hold off on fluid drainage.\n - Cont broad coverage with linezolid (-), aztreo (-), flagyl\n (-), mica (-). D/c vanc po (-).\n - C diff neg x3 -> likely d/c po vanc\n - Follow WBC count, temp curve, and culture data\n - F/u ID recs\n # Shock: Pressures dropped again in setting of fever. Will treat for\n infection as above. If requires pressors without fever consider other\n etiologies of hypotension including cardiogenic.\n - Cont weaning steroids; change to PO prednisone 5 mg today\n - Keep a-line until off pressors x 24 h\n - Infectious w/u as above\n # Elevated LFTs: A/w alcoholic hepatitis. RUQ u/s showed sludge\n concerning for cholestasis but also seen on u/s. HIDA neg.\n TPN stopped . T Bili and transaminases improving today.\n - weaning off benzos - 5 mg valium today\n - continue to trend\n #. Respiratory Failure: ARDS secondary to necrotizing pancreatitis. S/p\n trach placement on . Bronch without obvious source of bleeding\n and with only thin secretions throughout.\n - DDAVP if acute bleeding (max few doses). Had required amicar shortly\n after trach for continued bleeding but complicated by seizure shortly\n after starting this.\n - Cte fentanyl boluses\n - Wean methadone and valium as tolerated\n - Cte OOB to chair daily\n - Trach care\n #. Acute renal Failure: Multifactorial inc. ATN from hypotension\n - Was supposed to transition to HD today but pressures not able to\n tolerate. No need for filtration so will reassess tmrw.\n - Aztreonam 2000mg q12h while on CVVH.\n - continue Keppra at 1000mg Q24 with 500 mg after HD\n #. Adrenal Insufficiency: Unclear with stim if clear adrenal\n insufficiency but hypotension improving with steroids (lower pressor\n requirement) and eosinophilia resolved.\n - transition to PO prednisone 5 mg daily today\n # Seizures: CT head without intracranial process. EEG showed occipital\n seizures which does not correlate with clinical symptoms, but repeat\n EEG on higher dose Keppra showed no seizures. As patient now with\n purposeful movements, this may actually be patient waking up, not\n seizures.\n - Continue keppra at HD dosing\n # Altered Mental Status:\n - Titrate down sedating meds; decrease methadone to today and qd\n tomorrow\n ICU Care\n Nutrition:\n Nutren 2.0 () - 02:00 PM 50 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 08:15 PM\n PICC Line - 08:37 AM\n Dialysis Catheter - 08:55 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP: HOB elevation\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:ICU\n" }, { "category": "Physician ", "chartdate": "2131-06-23 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 682537, "text": "Chief Complaint: resp failure, pancreatitis\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 BRONCHOSCOPY - At 02:45 PM\n BLOOD CULTURED - At 09:40 PM\n FEVER - 102.0\nF - 08:00 PM\n Allergies:\n Meropenem\n skin blisters a\n Last dose of Antibiotics:\n Vancomycin - 02:18 PM\n Ciprofloxacin - 08:00 PM\n Micafungin - 10:08 PM\n Linezolid - 12:25 AM\n Aztreonam - 02:02 AM\n Metronidazole - 04:22 AM\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 08:07 PM\n Heparin Sodium (Prophylaxis) - 04:23 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 10:50 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.9\nC (102\n Tcurrent: 38.4\nC (101.2\n HR: 112 (101 - 120) bpm\n BP: 107/63(77) {70/46(45) - 129/72(88)} mmHg\n RR: 32 (26 - 40) insp/min\n SpO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 103.9 kg (admission): 113.5 kg\n Height: 67 Inch\n Total In:\n 2,903 mL\n 1,308 mL\n PO:\n TF:\n 975 mL\n 540 mL\n IVF:\n 1,598 mL\n 708 mL\n Blood products:\n Total out:\n 253 mL\n 215 mL\n Urine:\n 253 mL\n 215 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,650 mL\n 1,093 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n SpO2: 100%\n ABG: ///22/\n Physical Examination\n Gen\n HEENT\n CV\n Chest\n Abd\n Ext\n Labs / Radiology\n 6.6 g/dL\n 264 K/uL\n 170 mg/dL\n 2.8 mg/dL\n 22 mEq/L\n 3.3 mEq/L\n 64 mg/dL\n 98 mEq/L\n 132 mEq/L\n 22.2 %\n 30.9 K/uL\n [image002.jpg]\n 04:57 PM\n 02:28 AM\n 02:50 AM\n 05:09 PM\n 05:55 PM\n 05:57 PM\n 09:02 PM\n 01:42 AM\n 01:50 AM\n 03:18 AM\n WBC\n 38.5\n 38.6\n 34.0\n 35.7\n 30.9\n Hct\n 22.7\n 22.6\n 21.6\n 23.1\n 22.2\n Plt\n 282\n 277\n 291\n 305\n 264\n Cr\n 2.4\n 1.2\n 1.8\n 2.8\n TCO2\n 20\n 22\n 21\n 27\n Glucose\n 132\n 126\n 136\n 170\n Other labs: PT / PTT / INR:15.8/39.1/1.4, CK / CKMB /\n Troponin-T:214/3/0.07, ALT / AST:121/118, Alk Phos / T Bili:379/10.8,\n Amylase / Lipase:77/88, Differential-Neuts:80.0 %, Band:6.0 %,\n Lymph:3.0 %, Mono:1.0 %, Eos:1.0 %, D-dimer:6389 ng/mL, Fibrinogen:541\n mg/dL, Lactic Acid:2.4 mmol/L, Albumin:2.3 g/dL, LDH:529 IU/L, Ca++:8.3\n mg/dL, Mg++:2.2 mg/dL, PO4:2.9 mg/dL\n Assessment and Plan\n AROUSAL, ATTENTION, AND COGNITION, IMPAIRED\n BALANCE, IMPAIRED\n MOTOR FUNCTION, IMPAIRED\n MUSCLE PERFORMACE, IMPAIRED\n RESPIRATION / GAS EXCHANGE, IMPAIRED\n SEIZURE, WITHOUT STATUS EPILEPTICUS\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n IMPAIRED SKIN INTEGRITY\n HEPATITIS, ACUTE TOXIC (INCLUDING ALCOHOLIC, ACETAMINOPHEN, ETC.)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n 1. Resp Failure: Agree with plan to manage respiratory failure\n with ongoing TM trials and sedation wean - will get OOB to chair today,\n and will decrease methadone to .\n 2. Given possibility of sz activity, will continue keppra and\n valium at current doses.\n 3. For shock (resolved), will continue to wean steroids (change\n to pred 5 today) and will continue linezolid / aztreonam / flagyl /\n micafungin / cipro / vanco PO while monitoring culture data. LFTs are\n improving off TPN. be able to wean ABX if remains stable from WBC\n and fever standpoint. Flagyl off first, Mica would be very last to go.\n Possibel repeat imaiging in a week of pancreas.\n 4. For ARF, HD per renal team. For pancreatitis, will continue\n post-pyloric TFs, and will continue to hold off on any drainage of new\n peripancreatic fluid collection. Remainder of plan as outlined above.\n Remaining issues as per Housestaff\n ICU Care\n Nutrition: Nutren 2.0 () - 02:00 PM 50 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 08:15 PM\n PICC Line - 08:37 AM\n Dialysis Catheter - 08:55 AM\n Prophylaxis:\n DVT: sc hep\n Stress ulcer: PPI\n VAP: HOB\n Communication: with family daily\n Code status: Full code\n Disposition :ICU\n Total time spent: 45 minutes\n Patient is critically ill\n" }, { "category": "Physician ", "chartdate": "2131-06-23 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 682540, "text": "Chief Complaint: resp failure, pancreatitis\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 BRONCHOSCOPY - At 02:45 PM\n BLOOD CULTURED - At 09:40 PM\n FEVER - 102.0\nF - 08:00 PM\n Allergies:\n Meropenem\n skin blisters a\n Last dose of Antibiotics:\n Vancomycin - 02:18 PM\n Ciprofloxacin - 08:00 PM\n Micafungin - 10:08 PM\n Linezolid - 12:25 AM\n Aztreonam - 02:02 AM\n Metronidazole - 04:22 AM\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 08:07 PM\n Heparin Sodium (Prophylaxis) - 04:23 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 10:50 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.9\nC (102\n Tcurrent: 38.4\nC (101.2\n HR: 112 (101 - 120) bpm\n BP: 107/63(77) {70/46(45) - 129/72(88)} mmHg\n RR: 32 (26 - 40) insp/min\n SpO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 103.9 kg (admission): 113.5 kg\n Height: 67 Inch\n Total In:\n 2,903 mL\n 1,308 mL\n PO:\n TF:\n 975 mL\n 540 mL\n IVF:\n 1,598 mL\n 708 mL\n Blood products:\n Total out:\n 253 mL\n 215 mL\n Urine:\n 253 mL\n 215 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,650 mL\n 1,093 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n SpO2: 100%\n ABG: ///22/\n Physical Examination\n Gen: lying in bed, getting HD< eye open\n HEENT: trach\n CV: tachy RR\n Chest: good air movement\n Abd: soft +BS\n Ext: edema\n Neuro: eye open, squeeze hand to command, not answering more involved\n ?s or following more complex commands\n Labs / Radiology\n 6.6 g/dL\n 264 K/uL\n 170 mg/dL\n 2.8 mg/dL\n 22 mEq/L\n 3.3 mEq/L\n 64 mg/dL\n 98 mEq/L\n 132 mEq/L\n 22.2 %\n 30.9 K/uL\n [image002.jpg]\n 04:57 PM\n 02:28 AM\n 02:50 AM\n 05:09 PM\n 05:55 PM\n 05:57 PM\n 09:02 PM\n 01:42 AM\n 01:50 AM\n 03:18 AM\n WBC\n 38.5\n 38.6\n 34.0\n 35.7\n 30.9\n Hct\n 22.7\n 22.6\n 21.6\n 23.1\n 22.2\n Plt\n 282\n 277\n 291\n 305\n 264\n Cr\n 2.4\n 1.2\n 1.8\n 2.8\n TCO2\n 20\n 22\n 21\n 27\n Glucose\n 132\n 126\n 136\n 170\n Other labs: PT / PTT / INR:15.8/39.1/1.4, CK / CKMB /\n Troponin-T:214/3/0.07, ALT / AST:121/118, Alk Phos / T Bili:379/10.8,\n Amylase / Lipase:77/88, Differential-Neuts:80.0 %, Band:6.0 %,\n Lymph:3.0 %, Mono:1.0 %, Eos:1.0 %, D-dimer:6389 ng/mL, Fibrinogen:541\n mg/dL, Lactic Acid:2.4 mmol/L, Albumin:2.3 g/dL, LDH:529 IU/L, Ca++:8.3\n mg/dL, Mg++:2.2 mg/dL, PO4:2.9 mg/dL\n Assessment and Plan\n AROUSAL, ATTENTION, AND COGNITION, IMPAIRED\n BALANCE, IMPAIRED\n MOTOR FUNCTION, IMPAIRED\n MUSCLE PERFORMACE, IMPAIRED\n RESPIRATION / GAS EXCHANGE, IMPAIRED\n SEIZURE, WITHOUT STATUS EPILEPTICUS\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n IMPAIRED SKIN INTEGRITY\n HEPATITIS, ACUTE TOXIC (INCLUDING ALCOHOLIC, ACETAMINOPHEN, ETC.)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n 1. Resp Failure: Agree with plan to manage respiratory failure\n with ongoing TM trials and sedation wean - will get OOB to chair today,\n and will decrease methadone to .\n 2. Given possibility of sz activity, will continue keppra and\n valium at current doses.\n 3. For shock (resolved), will continue to wean steroids (change\n to pred 5 today) and will continue linezolid / aztreonam / flagyl /\n micafungin / cipro / vanco PO while monitoring culture data. LFTs are\n improving off TPN. be able to wean ABX if remains stable from WBC\n and fever standpoint. Drug fever also a possibility given multi neg C\n diff\n could start by peeling off po Vanco and Flagyl. Possible repeat\n imaiging in a week of pancreas.\n 4. For ARF, HD per renal team. HC today\n 5. For pancreatitis, will continue post-pyloric TFs, and will\n continue to hold off on any drainage of new peripancreatic fluid\n collection.\n Remainder of plan as outlined above.\n ICU Care\n Nutrition: Nutren 2.0 () - 02:00 PM 50 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 08:15 PM\n PICC Line - 08:37 AM\n Dialysis Catheter - 08:55 AM\n Prophylaxis:\n DVT: sc hep\n Stress ulcer: PPI\n VAP: HOB\n Communication: with family daily\n dad and brother\n status: Full code\n Disposition :ICU\n Total time spent: 45 minutes\n Patient is critically ill\n" }, { "category": "Physician ", "chartdate": "2131-06-23 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 682509, "text": "Chief Complaint:\n 24 Hour Events:\n BRONCHOSCOPY - At 02:45 PM\n BLOOD CULTURED - At 09:40 PM\n FEVER - 102.0\nF - 08:00 PM\n \n - Febrile again to 102, requireing levophed.\n - ID recommended asking IR if tap of fluid collections is even\n possible. If not, would re-image in a few days to see if fluid\n collections are evolving.\n - CMV VL - ID said likely shedding post-infection - re-check in 1 week\n and re-eval at that time.\n - Bronch showed thin secretions possibly to volume overload. Also\n small lesion at take-off of RML, but not concerning for source of\n bleeding. He was put on dry trach mask in attempt to dry some\n secretions.\n Allergies:\n Meropenem\n skin blisters a\n Last dose of Antibiotics:\n Vancomycin - 02:18 PM\n Ciprofloxacin - 08:00 PM\n Micafungin - 10:08 PM\n Linezolid - 12:25 AM\n Aztreonam - 02:02 AM\n Metronidazole - 04:22 AM\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 08:07 PM\n Heparin Sodium (Prophylaxis) - 04:23 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 12 AM\n Tmax: 38.9\nC (102\n Tcurrent: 37.7\nC (99.8\n HR: 108 (101 - 120) bpm\n BP: 114/59(76) {70/46(45) - 129/72(88)} mmHg\n RR: 34 (26 - 40) insp/min\n SpO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 103.9 kg (admission): 113.5 kg\n Height: 67 Inch\n Total In:\n 2,903 mL\n 990 mL\n PO:\n TF:\n 975 mL\n 358 mL\n IVF:\n 1,598 mL\n 572 mL\n Blood products:\n Total out:\n 253 mL\n 170 mL\n Urine:\n 253 mL\n 170 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,650 mL\n 821 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n SpO2: 100%\n ABG: ///22/\n Physical Examination\n GEN: Trached.\n HEENT: Icteric sclera. MMM.\n NECK: Trach site with no oozing.\n LUNGS: Anterior auscultation with upper airway noise; good airway\n movement.\n HEART: RRR, normal S1, S2.\n ABD: Distended. Firm, but unchanged.\n EXTREM: 2+ edema, ulcers/lesions on legs with bandages C/D/I.\n SKIN: Jaundiced.\n NEURO: Twitching mouth and arms. ? clonus. Opens eyes, squeezes hand to\n command.\n Labs / Radiology\n 264 K/uL\n 6.6 g/dL\n 170 mg/dL\n 2.8 mg/dL\n 22 mEq/L\n 3.3 mEq/L\n 64 mg/dL\n 98 mEq/L\n 132 mEq/L\n 22.2 %\n 30.9 K/uL\n [image002.jpg]\n 04:57 PM\n 02:28 AM\n 02:50 AM\n 05:09 PM\n 05:55 PM\n 05:57 PM\n 09:02 PM\n 01:42 AM\n 01:50 AM\n 03:18 AM\n WBC\n 38.5\n 38.6\n 34.0\n 35.7\n 30.9\n Hct\n 22.7\n 22.6\n 21.6\n 23.1\n 22.2\n Plt\n 282\n 277\n 291\n 305\n 264\n Cr\n 2.4\n 1.2\n 1.8\n 2.8\n TCO2\n 20\n 22\n 21\n 27\n Glucose\n 132\n 126\n 136\n 170\n Other labs: PT / PTT / INR:15.8/39.1/1.4, CK / CKMB /\n Troponin-T:214/3/0.07, ALT / AST:121/118, Alk Phos / T Bili:379/10.8,\n Amylase / Lipase:77/88, Differential-Neuts:80.0 %, Band:6.0 %,\n Lymph:3.0 %, Mono:1.0 %, Eos:1.0 %, D-dimer:6389 ng/mL, Fibrinogen:541\n mg/dL, Lactic Acid:2.4 mmol/L, Albumin:2.3 g/dL, LDH:529 IU/L, Ca++:8.3\n mg/dL, Mg++:2.2 mg/dL, PO4:2.9 mg/dL\n Ca: 8.3 Mg: 2.2 P: 2.9\n ALT: 121\n AP: 379\n Tbili: 10.8\n Alb:\n AST: 118\n LDH:\n Dbili:\n TProt:\n :\n Lip:\n CMV VL - 7,210 copies/ml\n CMV IgG\n positive\n CMV IgM\n Negative\nSputum - PSEUDOMONAS AERUGINOSA. MODERATE GROWTH.\n SENSITIVITIES: MIC expressed in MCG/ML\n _________________________________________________________\n PSEUDOMONAS AERUGINOSA\n |\nCEFEPIME-------------- 8 S\nCEFTAZIDIME----------- 16 I\nCIPROFLOXACIN--------- =>4 R\nGENTAMICIN------------ 4 S\nMEROPENEM------------- 8 I\nPIPERACILLIN---------- 16 S\nPIPERACILLIN/TAZO----- 64 S\nTOBRAMYCIN------------ <=1 S\nSputum - PMNs and <10 epithelial cells/100X field.\n 2+ (1-5 per 1000X FIELD): GRAM NEGATIVE ROD(S).\n Assessment and Plan\n 28M with alcoholic hepatitis and necrotizing pancreatitis complicated\n by ARDS, SIRS, ARF, UGIB, fevers.\n #. ID: Persistent leukocytosis and fevers now that off CVVH. Possible\n that continued fevers necrotizing pancreatitis. Also with\n persistent yeast in ucx, persistent colonic inflammation on CT, and\n pancreatic fluid collections. On aztreonam, linezolid (since ) and\n flagyl (since ). Started micafungin and po vanc . In setting\n of fevers and hypotension, Cipro was started , but d/c\ned. Surgery\n was consulted for new fluid collection peri-pancreas but they feel they\n are not infected (no gas on CT) and would hold off on fluid drainage.\n CMV positive, but likely not contributing to current illness per ID.\n - Cont broad coverage with linezolid (-), aztreo (-), flagyl\n (-), mica (-). D/c vanc po (-).\n - C diff neg x3 -> likely d/c po vanc\n - Recheck CMV VL on \n - Follow WBC count, temp curve, and culture data\n - F/u ID recs\n # Shock: Pressures dropped again in setting of fever. Will treat for\n infection as above. If requires pressors without fever consider other\n etiologies of hypotension including cardiogenic.\n - Cont weaning steroids; change to PO prednisone 5 mg today\n - Keep a-line until off pressors x 24 h\n - Infectious w/u as above\n # Elevated LFTs: A/w alcoholic hepatitis. RUQ u/s showed sludge\n concerning for cholestasis but also seen on u/s. HIDA neg.\n TPN stopped . T Bili and transaminases improving today.\n - weaning off benzos - 5 mg valium today\n - continue to trend\n #. Respiratory Failure: ARDS secondary to necrotizing pancreatitis. S/p\n trach placement on . Bronch without obvious source of bleeding\n and with only thin secretions throughout.\n - DDAVP if acute bleeding (max few doses). Had required amicar shortly\n after trach for continued bleeding but complicated by seizure shortly\n after starting this.\n - Cte fentanyl boluses\n - Wean methadone and valium as tolerated\n - Cte OOB to chair daily\n - Trach care\n #. Acute renal Failure: Multifactorial inc. ATN from hypotension\n - Was supposed to transition to HD today but pressures not able to\n tolerate. No need for filtration so will reassess tmrw.\n - Aztreonam 2000mg q12h while on CVVH.\n - continue Keppra at 1000mg Q24 with 500 mg after HD\n #. Adrenal Insufficiency: Unclear with stim if clear adrenal\n insufficiency but hypotension improving with steroids (lower pressor\n requirement) and eosinophilia resolved.\n - transition to PO prednisone 5 mg daily today\n # Seizures: CT head without intracranial process. EEG showed occipital\n seizures which does not correlate with clinical symptoms, but repeat\n EEG on higher dose Keppra showed no seizures. As patient now with\n purposeful movements, this may actually be patient waking up, not\n seizures.\n - Continue keppra at HD dosing\n # Altered Mental Status:\n - Titrate down sedating meds; decrease methadone to today and qd\n tomorrow\n ICU Care\n Nutrition:\n Nutren 2.0 () - 02:00 PM 50 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 08:15 PM\n PICC Line - 08:37 AM\n Dialysis Catheter - 08:55 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP: HOB elevation\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:ICU\n" }, { "category": "Nursing", "chartdate": "2131-06-23 00:00:00.000", "description": "Nursing Progress Note", "row_id": 682609, "text": "Respiration / Gas Exchange, Impaired\n Assessment:\n Patient more tachypnic today, with resp. rate mid 40s-50s especially\n with fever\n Abgs done when patient dropped pressure\n Suctioned for mod amounts loose tan /rust secretions\n Patient able to cough most of them, just superficially suction needed\n Action:\n Patient very alkalotic with pH 7.51, pCO2 27\n House staff aware\n Placed back on cpap \n Response:\n Lower resp rate\n More comfortable\n Plan:\n Check abg later in the shift\n Keep on CPAP overnight\n Hypotension (not Shock)\n Assessment:\n Febrile today to 102.4\n Symptomatic with pressure dropping to 70/ systolic\n Initially alert and interactive, but later much less so\n Action:\n Levo started at .09 max dose\n Tylenol 650 mg given\n Cooling blanket and ice packs applied\n Response:\n Blood pressure immediately improved,\n Able to wean levo within 15 minutes\n Currently on .04\n Blood cultures done\n Plan:\n Continue with levo support as needed\n Family in during this episode, aware of pattern of\n temp/hypotension/small pressor requirements\n" }, { "category": "Nursing", "chartdate": "2131-06-24 00:00:00.000", "description": "Nursing Progress Note", "row_id": 682665, "text": "Hypotension (not Shock)\n Assessment:\n Action:\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Physician ", "chartdate": "2131-06-24 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 682666, "text": "Chief Complaint:\n 24 Hour Events:\n - ID: consider seratonin syndrome from interaction between linezolid\n and pressors. Would d/c vanc po and flagyl. If WBCs stable would d/c\n linezolid tomorrow. consider mycolytic bcx and TTE for possible fungal\n infection. Talk to IR to see if they would tap the cyst in abdomen (we\n never called them)\n - Flagyl and PO vanc d/c'd.\n - Spiked temp to 102 at 3pm, hypotensive to 70s, tachycardic,\n tachypneic. Blood gas with PCO2 25. Put back on pressure support and\n pressors transiently.\n - Renal: Change linezolid dose to after HD on HD days\n - Neuro: No recs\n Allergies:\n Meropenem\n skin blisters a\n Last dose of Antibiotics:\n Vancomycin - 02:18 PM\n Ciprofloxacin - 08:00 PM\n Linezolid - 12:50 PM\n Aztreonam - 02:00 PM\n Micafungin - 10:30 PM\n Metronidazole - 12:00 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 12:50 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:45 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 39.1\nC (102.4\n Tcurrent: 37.2\nC (99\n HR: 99 (96 - 118) bpm\n BP: 121/60(80) {83/44(59) - 145/76(99)} mmHg\n RR: 22 (19 - 41) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 104 kg (admission): 113.5 kg\n Height: 67 Inch\n Total In:\n 2,791 mL\n 411 mL\n PO:\n TF:\n 1,205 mL\n 277 mL\n IVF:\n 1,525 mL\n 135 mL\n Blood products:\n Total out:\n 1,796 mL\n 60 mL\n Urine:\n 296 mL\n 60 mL\n NG:\n Stool:\n Drains:\n Balance:\n 995 mL\n 351 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 427 (174 - 530) mL\n PS : 5 cmH2O\n RR (Spontaneous): 30\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 45\n PIP: 11 cmH2O\n SpO2: 100%\n ABG: 7.51/27/73./24/0\n Ve: 15.5 L/min\n PaO2 / FiO2: 183\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 268 K/uL\n 7.3 g/dL\n 170 mg/dL\n 1.6 mg/dL\n 24 mEq/L\n 3.4 mEq/L\n 39 mg/dL\n 101 mEq/L\n 137 mEq/L\n 24.0 %\n 27.6 K/uL\n [image002.jpg]\n 02:50 AM\n 05:09 PM\n 05:55 PM\n 05:57 PM\n 09:02 PM\n 01:42 AM\n 01:50 AM\n 03:18 AM\n 03:44 PM\n 01:38 AM\n WBC\n 34.0\n 35.7\n 30.9\n 27.6\n Hct\n 21.6\n 23.1\n 22.2\n 24.0\n Plt\n 291\n 305\n 264\n 268\n Cr\n 1.2\n 1.8\n 2.8\n 1.6\n TCO2\n 20\n 22\n 21\n 27\n 22\n Glucose\n 126\n 136\n 170\n 95\n 170\n Other labs: PT / PTT / INR:15.9/35.0/1.4, CK / CKMB /\n Troponin-T:214/3/0.07, ALT / AST:121/118, Alk Phos / T Bili:379/10.8,\n Amylase / Lipase:77/88, Differential-Neuts:80.0 %, Band:6.0 %,\n Lymph:3.0 %, Mono:1.0 %, Eos:1.0 %, D-dimer:6389 ng/mL, Fibrinogen:541\n mg/dL, Lactic Acid:2.6 mmol/L, Albumin:2.3 g/dL, LDH:529 IU/L, Ca++:8.1\n mg/dL, Mg++:1.9 mg/dL, PO4:2.0 mg/dL\n Assessment and Plan\n AROUSAL, ATTENTION, AND COGNITION, IMPAIRED\n BALANCE, IMPAIRED\n MOTOR FUNCTION, IMPAIRED\n MUSCLE PERFORMACE, IMPAIRED\n RESPIRATION / GAS EXCHANGE, IMPAIRED\n SEIZURE, WITHOUT STATUS EPILEPTICUS\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n IMPAIRED SKIN INTEGRITY\n HEPATITIS, ACUTE TOXIC (INCLUDING ALCOHOLIC, ACETAMINOPHEN, ETC.)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ICU Care\n Nutrition:\n Nutren 2.0 () - 01:49 PM 50 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 08:15 PM\n PICC Line - 08:37 AM\n Dialysis Catheter - 08:55 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": "2131-06-24 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 682667, "text": "Chief Complaint:\n 24 Hour Events:\n - ID: consider seratonin syndrome from interaction between linezolid\n and pressors. Would d/c vanc po and flagyl. If WBCs stable would d/c\n linezolid tomorrow. consider mycolytic bcx and TTE for possible fungal\n infection. Talk to IR to see if they would tap the cyst in abdomen (we\n never called them)\n - Flagyl and PO vanc d/c'd.\n - Spiked temp to 102 at 3pm, hypotensive to 70s, tachycardic,\n tachypneic. Blood gas with PCO2 25. Put back on pressure support and\n pressors transiently.\n - Renal: Change linezolid dose to after HD on HD days\n - Neuro: No recs\n Allergies:\n Meropenem\n skin blisters a\n Last dose of Antibiotics:\n Vancomycin - 02:18 PM\n Ciprofloxacin - 08:00 PM\n Linezolid - 12:50 PM\n Aztreonam - 02:00 PM\n Micafungin - 10:30 PM\n Metronidazole - 12:00 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 12:50 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:45 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 39.1\nC (102.4\n Tcurrent: 37.2\nC (99\n HR: 99 (96 - 118) bpm\n BP: 121/60(80) {83/44(59) - 145/76(99)} mmHg\n RR: 22 (19 - 41) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 104 kg (admission): 113.5 kg\n Height: 67 Inch\n Total In:\n 2,791 mL\n 411 mL\n PO:\n TF:\n 1,205 mL\n 277 mL\n IVF:\n 1,525 mL\n 135 mL\n Blood products:\n Total out:\n 1,796 mL\n 60 mL\n Urine:\n 296 mL\n 60 mL\n NG:\n Stool:\n Drains:\n Balance:\n 995 mL\n 351 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 427 (174 - 530) mL\n PS : 5 cmH2O\n RR (Spontaneous): 30\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 45\n PIP: 11 cmH2O\n SpO2: 100%\n ABG: 7.51/27/73./24/0\n Ve: 15.5 L/min\n PaO2 / FiO2: 183\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 268 K/uL\n 7.3 g/dL\n 170 mg/dL\n 1.6 mg/dL\n 24 mEq/L\n 3.4 mEq/L\n 39 mg/dL\n 101 mEq/L\n 137 mEq/L\n 24.0 %\n 27.6 K/uL\n [image002.jpg]\n 02:50 AM\n 05:09 PM\n 05:55 PM\n 05:57 PM\n 09:02 PM\n 01:42 AM\n 01:50 AM\n 03:18 AM\n 03:44 PM\n 01:38 AM\n WBC\n 34.0\n 35.7\n 30.9\n 27.6\n Hct\n 21.6\n 23.1\n 22.2\n 24.0\n Plt\n 291\n 305\n 264\n 268\n Cr\n 1.2\n 1.8\n 2.8\n 1.6\n TCO2\n 20\n 22\n 21\n 27\n 22\n Glucose\n 126\n 136\n 170\n 95\n 170\n Other labs: PT / PTT / INR:15.9/35.0/1.4, CK / CKMB /\n Troponin-T:214/3/0.07, ALT / AST:121/118, Alk Phos / T Bili:379/10.8,\n Amylase / Lipase:77/88, Differential-Neuts:80.0 %, Band:6.0 %,\n Lymph:3.0 %, Mono:1.0 %, Eos:1.0 %, D-dimer:6389 ng/mL, Fibrinogen:541\n mg/dL, Lactic Acid:2.6 mmol/L, Albumin:2.3 g/dL, LDH:529 IU/L, Ca++:8.1\n mg/dL, Mg++:1.9 mg/dL, PO4:2.0 mg/dL\n Assessment and Plan\n 28M with alcoholic hepatitis and necrotizing pancreatitis complicated\n by ARDS, SIRS, ARF, UGIB, fevers.\n #. ID: Persistent leukocytosis and fevers now that off CVVH. Possible\n that continued fevers necrotizing pancreatitis. Also with\n persistent yeast in ucx, persistent colonic inflammation on CT, and\n pancreatic fluid collections. On aztreonam, linezolid (since ) and\n flagyl (since ). Started micafungin and po vanc . In setting\n of fevers and hypotension, Cipro was started , but d/c\ned. Surgery\n was consulted for new fluid collection peri-pancreas but they feel they\n are not infected (no gas on CT) and would hold off on fluid drainage.\n CMV positive, but likely not contributing to current illness per ID.\n - Cont broad coverage with linezolid (-), aztreo (-), mica\n (-). D/c vanc po (). D/C flagyl (),\n - C diff neg x3 -> d/c po vanc and iv flagyl today.\n - Consider drug fever and attempt to wean off abx over next few days if\n WBCs continue to decrease (also may have fevers from pancreatitis as\n well). Next abx to wean would be linezolid.\n - Recheck CMV VL on \n - Follow WBC count, temp curve, and culture data\n - F/u ID recs\n - D/W IR if fluid collection in abd is drainable in case we want to\n drain it later. Currently do not want to operate on abdomen with\n pancreatitis changes.\n # Shock: Pressures dropped again in setting of fever. Will treat for\n infection as above. If requires pressors without fever consider other\n etiologies of hypotension including cardiogenic. Consider IVF today if\n BPs drop to see if fluid responsive prior to starting levophed again.\n - Cont weaning steroids; change to PO prednisone 5 mg today\n - Keep a-line until off pressors x 24 h\n - Infectious w/u as above\n # Elevated LFTs: A/w alcoholic hepatitis. RUQ u/s showed sludge\n concerning for cholestasis but also seen on u/s. HIDA neg.\n TPN stopped . T Bili and transaminases improving today.\n - weaning off benzos - 5 mg valium today\n - continue to trend\n #. Respiratory Failure: ARDS secondary to necrotizing pancreatitis. S/p\n trach placement on . Bronch without obvious source of bleeding\n and with only thin secretions throughout.\n - DDAVP if acute bleeding (max few doses). Had required amicar shortly\n after trach for continued bleeding but complicated by seizure shortly\n after starting this.\n - Cte fentanyl boluses\n - Wean methadone and valium as tolerated\n - Cte OOB to chair daily\n - Trach care\n #. Acute renal Failure: Multifactorial inc. ATN from hypotension\n - Hd today\n - Aztreonam 2000mg q12h while on CVVH.\n - continue Keppra at 1000mg Q24 with 500 mg after HD\n - F/u Renal recs\n #. Adrenal Insufficiency: Unclear with stim if clear adrenal\n insufficiency but hypotension improving with steroids (lower pressor\n requirement) and eosinophilia resolved.\n - transition to PO prednisone 5 mg daily today\n # Seizures: CT head without intracranial process. EEG showed occipital\n seizures which does not correlate with clinical symptoms, but repeat\n EEG on higher dose Keppra showed no seizures. As patient now with\n purposeful movements, this may actually be patient waking up, not\n seizures.\n - Continue keppra at HD dosing\n # Altered Mental Status:\n - Titrate down sedating meds; decrease methadone to today and qd\n tomorrow\n ICU Care\n Nutrition:\n Nutren 2.0 () - 01:49 PM 50 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 08:15 PM\n PICC Line - 08:37 AM\n Dialysis Catheter - 08:55 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": "2131-06-23 00:00:00.000", "description": "Nursing Progress Note", "row_id": 682477, "text": "The patient is a 28 year old male with a history of alcohol abuse who\n walked into the ED with the complaint of hematemesis. The patient has\n been a significant drinker for 5-6 years, reporting drinking 6 mixed\n drinks a day, with tremulations on withdrawl, but no prior seizure. For\n the last week, he has felt increasing weakness and fatigue, and has\n become slightly disoriented and confused. He reports no head trauma. 3\n days prior to presentation, he began to notice that he was coughing up\n blood and mild epigastric tenderness. These episodes were occuring \n times per day. He additonally noted black tarry stools, but unable to\n quantify the number of bowel movements. With mild abdominal discomfort,\n nausea, and hematemesis, the patient was unable to tolerate a PO diet,\n but continued to drink. His last drink was the night prior to\n presentation.\n Sepsis, Severe (with organ dysfunction)\n Assessment:\n Febrile 101.9\n Action:\n Ice packs placed underarms, groin, blood cults drawn x2\n Response:\n Low grade temp for rest of shift\n Plan:\n Continue to monitor VS, administer abx as ordered\n Hypotension (not Shock)\n Assessment:\n BP 80s/50s at start of shift, temp > 101, on levophed at .05 mcg/kg/min\n Action:\n BP up 120/60s with temp decrease to 99.6, levophed weaned to off\n Response:\n SBP stable for rest of shift\n Plan:\n Continue to monitor VS, titrate pressors as needed\n" }, { "category": "Respiratory ", "chartdate": "2131-06-23 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 682608, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 1\n Ideal body weight: 67.1 None\n Ideal tidal volume: 268.4 / 402.6 / 536.8 mL/kg\n Tracheostomy tube:\n Type: Standard\n Manufacturer: Portex\n Size: 8.0mm\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Cuff volume: 3 mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Brown / Thick\n Sputum source/amount: Suctioned / Moderate\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Tachypneic (RR> 35 b/min)\n Assessment of breathing comfort: No claim of dyspnea)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Dysynchrony assessment: Frequent alarms (High rate, High min.\n ventilation)\n Comments:\n Pt with high respiratory rate on and off vent.\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Underlying illness\n not resolved\n" }, { "category": "Respiratory ", "chartdate": "2131-06-24 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 682663, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 2\n Ideal body weight: 67.1 None\n Ideal tidal volume: 268.4 / 402.6 / 536.8 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Tube Type\n Tracheostomy tube:\n Type: Standard, Cuffed\n Manufacturer: Portex\n Size: 8.0mm\n PMV: No\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Cuff volume: 3 mL /\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: Brown / Thin\n Sputum source/amount: Suctioned / Scant\n Ventilation Assessment\n Level of breathing assistance: Intermittent invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated;\n Comments: RSBI done ~45.\n Reason for continuing current ventilatory support: Underlying illness\n not resolved; Comments: Likely try back on TC during the day!\n" }, { "category": "Respiratory ", "chartdate": "2131-06-24 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 682782, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 2\n Ideal body weight: 67.1 None\n Ideal tidal volume: 268.4 / 402.6 / 536.8 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location:\n Reason:\n Tube Type\n Tracheostomy tube:\n Type: Standard, Cuffed\n Manufacturer: Portex\n Size: 8.0mm\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Cuff volume: 7 mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Blood Tinged / 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 claim of dyspnea)\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated;\n Comments: trach collar trial as tol\n Reason for continuing current ventilatory support: Underlying illness\n not resolved\n" }, { "category": "Nursing", "chartdate": "2131-06-25 00:00:00.000", "description": "Nursing Progress Note", "row_id": 682836, "text": "TITLE:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received on trach collar 40% Bbs coarse to clear and diminish at bases.\n Coughing and raising thick tan to clear sputum. Becomes tachypneic\n transiently with turning and repositioning.\n Action:\n tracheal suct x2 for small amts thick clear to white secretions. Trach\n care done.Vap bundle q4h\n Response:\n O2 sats > 98% throughout the noc. Remains on trach collar w no signs of\n resp distress.\n Plan:\n Cont Pulm toilet, trach care, vap bundle. Suct prn congestion.? PMV\n trial\n Hypotension (not Shock)\n Assessment:\n received on low dose levo 0.03mcg/kg/m sbp > 100 on same w mbp 70\n sinus tach 110-115\n Action:\n Weaned levo off for goal mbp > or (=) to 60 per MICU\n Response:\n mbp remains >/= to 60, hr\ns essentially unchanged off levophed\n Plan:\n Levophed standby for mbp consistently < 60\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Tmax 100.7 po\n Action:\n tylenol 650mg per feed tube, daily surveillance blood cultures sent\n Response:\n Temp transiently down to 99.7 po after tylenol\n Plan:\n Repeat tylenol q6h prn for temp > 101. Check with team re: urine/sputum\n culture if temp spikes > 101.5\n" }, { "category": "Nursing", "chartdate": "2131-06-25 00:00:00.000", "description": "Nursing Progress Note", "row_id": 682937, "text": "Hypotension (not Shock)\n Assessment:\n On low dose levo this am\n Low grade fevers, no fever spike yet\n Action:\n Levo weaned to off\n Response:\n Tolerating well\n Plan:\n Goal to keep levo off as tolerated.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n On vent this am, cmv\n Action:\n Weaned to cpap and then to trach collar this afternoon\n Response:\n Ongoing at present\n Baseline abg sent per MICU team pre trach collar\n Plan:\n Keep on trach collar as much as possible\n" }, { "category": "Physician ", "chartdate": "2131-06-26 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 683071, "text": "Chief Complaint:\n 24 Hour Events:\n \n - Sent sputum cx for tachypnea early AM of .\n - Weaned down to trach mask by early afternoon.\n - IR stated it would be very high risk to sample peri-pancreatic fluid\n collection - would likely need to paralyze him as needle would pass\n between dilated splancnic vessels.\n - Renal: plan for HD tomorrow if BP can tolerate it - otherwise may\n need CVVH.\n - ID: recommended d/c'ing aztreonam due to improving fever curve and\n WBC. Also added galactomanan and beta-glucan.\n Allergies:\n Meropenem\n skin blisters a\n Last dose of Antibiotics:\n Metronidazole - 12:00 AM\n Linezolid - 11:51 AM\n Aztreonam - 02:39 PM\n Micafungin - 10:48 PM\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 07:50 PM\n Heparin Sodium (Prophylaxis) - 03:50 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:22 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.1\nC (100.6\n Tcurrent: 37.3\nC (99.2\n HR: 111 (106 - 119) bpm\n BP: 94/55(68) {90/47(60) - 136/71(91)} mmHg\n RR: 30 (20 - 40) insp/min\n SpO2: 98%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 104.5 kg (admission): 113.5 kg\n Height: 67 Inch\n Total In:\n 2,204 mL\n 319 mL\n PO:\n TF:\n 1,205 mL\n 266 mL\n IVF:\n 939 mL\n 53 mL\n Blood products:\n Total out:\n 581 mL\n 175 mL\n Urine:\n 381 mL\n 175 mL\n NG:\n 200 mL\n Stool:\n Drains:\n Balance:\n 1,623 mL\n 144 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n Ventilator mode: Standby\n Vt (Set): 400 (400 - 400) mL\n PS : 5 cmH2O\n RR (Set): 18\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 40%\n PIP: 11 cmH2O\n Plateau: 21 cmH2O\n SpO2: 98%\n ABG: 7.39/39/81./23/0\n Ve: 10.3 L/min\n PaO2 / FiO2: 203\n Physical Examination\n Gen: lying in bed, eyes open to command, voice\n HEENT: trach\n CV: tachy RR\n Chest: good air movement\n Abd: soft +BS\n Ext: edema\n Neuro: eye open, squeeze hand to command, not answering more involved\n ?s or following more complex commands\n Labs / Radiology\n 228 K/uL\n 6.7 g/dL\n 128 mg/dL\n 3.0 mg/dL\n 23 mEq/L\n 3.3 mEq/L\n 79 mg/dL\n 101 mEq/L\n 136 mEq/L\n 22.5 %\n 15.0 K/uL\n [image002.jpg]\n 01:50 AM\n 03:18 AM\n 03:44 PM\n 01:38 AM\n 06:00 AM\n 01:12 AM\n 06:06 AM\n 02:38 PM\n 02:00 AM\n 02:49 AM\n WBC\n 30.9\n 27.6\n 18.9\n 15.0\n Hct\n 22.2\n 24.0\n 22.2\n 22.5\n Plt\n 28\n Cr\n 2.8\n 1.6\n 2.7\n 3.0\n TCO2\n 27\n 22\n 26\n 18\n 21\n 24\n Glucose\n 170\n 95\n 170\n 121\n 128\n Other labs: PT / PTT / INR:14.3/31.5/1.2, CK / CKMB /\n Troponin-T:214/3/0.07, ALT / AST:67/73, Alk Phos / T Bili:400/6.8,\n Amylase / Lipase:77/88, Differential-Neuts:84.0 %, Band:0.0 %,\n Lymph:7.0 %, Mono:5.0 %, Eos:3.0 %, D-dimer:6389 ng/mL, Fibrinogen:541\n mg/dL, Lactic Acid:2.6 mmol/L, Albumin:2.3 g/dL, LDH:331 IU/L, Ca++:8.6\n mg/dL, Mg++:2.1 mg/dL, PO4:3.7 mg/dL\\\n Ca: 8.6 Mg: 2.1 P: 3.7\n ALT: 67\n AP: 400\n Tbili: 6.8\n Alb:\n AST: 73\n LDH: 331\n Dbili:\n TProt:\n :\n Lip:\n PT: 14.3\n PTT: 31.5\n INR: 1.2\n Assessment and Plan\n 28M with alcoholic hepatitis and necrotizing pancreatitis complicated\n by ARDS, SIRS, ARF, UGIB, fevers.\n #. Fevers/leukocytosis: Fevers off CVVH with stable-improving\n leukocytosis. Possible that continued fevers necrotizing\n pancreatitis. Surgery was consulted for fluid collections peri-pancreas\n but felt to not be infected. CMV positive, but likely not contributing\n to current illness per ID. Also with persistent yeast in ucx,\n persistent colonic inflammation on CT with neg C. diff x 3, and concern\n for serotonin syndrome with linezolid and pressors, now discontinued.\n On aztreonam (since ) and micafungin (since ). In setting of\n fevers and hypotension, Cipro was started , but d/c\ned . Flagyl\n (since ) and po vanc (since ) discontinued . Linezolid\n started and stopped .\n - ID would prefer to wean off micafungin last\n - Consider d/c aztreonam today; will f/u with ID\n - Ordered for CMV VL on \n - D/w IR if abd fluid collection is drainable in case we want to drain\n it later. Currently hesitant given unclear benefit for a procedure that\n could further complicate his ICU course.\n - D/c a-line when able as has been in since \n - Follow WBC count, temp curve, and culture data\n - Send bcx from HD line as none yet pending\n # Abd tenderness: Likely secondary to necrotizing pancreatitis, now\n able to react as mental status improves. Concern for obstruction given\n emesis this AM but abd xray on our read does not appear c/w this and\n reported to have had BMs. Also has h/o colitis but C. diff neg x 3.\n - F/u abd XR\n - Management of pancreatitis as above\n #. Respiratory Failure: ARDS secondary to necrotizing pancreatitis. s/p\n trach placement on . bronch without obvious source of\n bleeding and with only thin secretions throughout; no further reports\n of bleeding since. Off methadone since . Tachypnea of unclear\n etiology, possible mucous/clot plugging vs ?central hyperventilation\n event, though sputum now growing 2+ GNRs. Overnight weaned back to\n trach mask, and doing well this AM.\n - f/u sputum cx sensitivities (colonized vs infection), and discuss GN\n coverage with ID.\n - Wean valium to (D3/3), decrease to daily for tomorrow dose.\n - Cont fentanyl boluses prn (not requiring)\n - Trach care, OOB to chair daily\n - DDAVP if acute bleeding (max few doses). Had required amicar shortly\n after trach for continued bleeding but complicated by seizure shortly\n after starting this.\n # Shock: Patient remained off pressors over last PM and was afebrile.\n - Weaned off steroids on \n - Keep a-line until off pressors x 24 h but d/c when possible\n - Infectious w/u as above\n # Elevated LFTs: A/w alcoholic hepatitis. RUQ u/s showed sludge\n concerning for cholestasis but also seen on u/s. HIDA neg.\n TPN stopped . LFTs continue to trend down.\n - Weaning off benzos: valium 5mg D \n - Continue to trend\n #. Acute renal Failure: Multifactorial including ATN from hypotension.\n - HD per renal\n - F/u Renal recs\n #. Adrenal Insufficiency: Unclear with stim if adrenally\n insufficient but hypotension initially improved with steroids (lower\n pressor requirement) and eosinophilia resolved. He has now weaned off\n steroids completely.\n - Last dose prednisone was \n # Seizures: CT head without intracranial process. EEG showed occipital\n seizures which does not correlate with clinical symptoms, but repeat\n EEG on higher dose Keppra showed no seizures. As patient now with\n purposeful movements, this may actually be patient waking up, not\n seizures.\n - Continue keppra at HD dosing\n # Altered Mental Status: Continue to reassess as weaning off sedatives.\n - Off of methadone as of \n - Cont to wean valium as above\n - Will ask Neuro for input re: prognostication if MS with no further\n improvement by end of week\n ICU Care\n Nutrition:\n Nutren 2.0 () - 01:30 PM 50 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 08:15 PM\n PICC Line - 08:37 AM\n Dialysis Catheter - 08:55 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP: HOB elevation, Mouth care\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:ICU\n" }, { "category": "Physician ", "chartdate": "2131-06-25 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 682919, "text": "Chief Complaint: pancreatitis, resp failure\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n FEVER - 101.5\nF - 04:00 PM\n Tachypnea and put back on AC vent\n before spiking fevers\n Allergies:\n Meropenem\n skin blisters a\n Last dose of Antibiotics:\n Metronidazole - 12:00 AM\n Linezolid - 11:51 AM\n Micafungin - 10:04 PM\n Aztreonam - 01:48 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 12:21 PM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: Fever\n Flowsheet Data as of 11:02 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.6\nC (101.5\n Tcurrent: 37.9\nC (100.2\n HR: 113 (108 - 117) bpm\n BP: 109/59(74) {79/43(31) - 136/75(90)} mmHg\n RR: 25 (23 - 40) insp/\n SpO2: 100%\n Heart rhythm: SB (Sinus Bradycardia)\n Wgt (current): 104 kg (admission): 113.5 kg\n Height: 67 Inch\n Total In:\n 2,202 mL\n 1,169 mL\n PO:\n TF:\n 1,204 mL\n 550 mL\n IVF:\n 998 mL\n 559 mL\n Blood products:\n Total out:\n 256 mL\n 135 mL\n Urine:\n 256 mL\n 135 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,946 mL\n 1,034 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 18\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 40%\n PIP: 24 cmH2O\n Plateau: 21 cmH2O\n SpO2: 100%\n ABG: 7.42/27/67/22/-4\n Ve: 13.8 L/\n PaO2 / FiO2: 168\n Physical Examination\n Gen: sitting up on side of bed with PT\n : trach in place\n CV: tachy RR\n Chest: good air movement, birnhcial BS left base, dimished at right\n Abd: soft +BS\n Ext: edema\n Neuro: eye open, sitting up w PT but not participatory\n Labs / Radiology\n 6.7 g/dL\n 230 K/uL\n 121 mg/dL\n 2.7 mg/dL\n 22 mEq/L\n 3.7 mEq/L\n 61 mg/dL\n 102 mEq/L\n 137 mEq/L\n 22.2 %\n 18.9 K/uL\n [image002.jpg]\n 05:57 PM\n 09:02 PM\n 01:42 AM\n 01:50 AM\n 03:18 AM\n 03:44 PM\n 01:38 AM\n 06:00 AM\n 01:12 AM\n 06:06 AM\n WBC\n 34.0\n 35.7\n 30.9\n 27.6\n 18.9\n Hct\n 21.6\n 23.1\n 22.2\n 24.0\n 22.2\n Plt\n 291\n 305\n 264\n 268\n 230\n Cr\n 1.2\n 1.8\n 2.8\n 1.6\n 2.7\n TCO2\n 27\n 22\n 26\n 18\n Glucose\n 126\n 136\n 170\n 95\n 170\n 121\n Other labs: PT / PTT / INR:15.3/34.3/1.3, CK / CKMB /\n Troponin-T:214/3/0.07, ALT / AST:81/79, Alk Phos / T Bili:422/8.5,\n Amylase / Lipase:77/88, Differential-Neuts:86.0 %, Band:2.0 %,\n Lymph:3.0 %, Mono:4.0 %, Eos:2.0 %, D-dimer:6389 ng/mL, Fibrinogen:541\n mg/dL, Lactic Acid:2.6 mmol/L, Albumin:2.3 g/dL, LDH:529 IU/L, Ca++:8.4\n mg/dL, Mg++:2.0 mg/dL, PO4:2.3 mg/dL\n Assessment and Plan\n FEVER, UNKNOWN ORIGIN (FUO, HYPERTHERMIA, PYREXIA)\n AROUSAL, ATTENTION, AND COGNITION, IMPAIRED\n BALANCE, IMPAIRED\n MOTOR FUNCTION, IMPAIRED\n MUSCLE PERFORMACE, IMPAIRED\n RESPIRATION / GAS EXCHANGE, IMPAIRED\n SEIZURE, WITHOUT STATUS EPILEPTICU\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n IMPAIRED SKIN INTEGRITY\n HEPATITIS, ACUTE TOXIC (INCLUDING ALCOHOLIC, ACETAMINOPHEN, ETC.)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n 1. Cyclical fevers during which he requires vasopressor support:\n DDx SIRS, line infections, panc necrrosis with infection, PNA, drug\n fever, serotonin syndrome. At this point he has been\n pan cultured\n nothing new. In conjunction with ID consultants we have been weaning\n off ABX since nothing has grown\n will continue aztreonam / micafungin\n for while monitoring culture data. Possible repeat imaging in a week of\n pancreas but we are loathe to initiate empiric panc drainage if there\n is another possible source as this can lead to long term complications.\n However, if fevers persist and no other source can be found we may be\n forced.\n 2. Resp Failure: Agree with plan to manage respiratory failure\n with ongoing TM trials and sedation wean - will get OOB to chair today,\n and wean methadone\n 3. Given possibility of sz activity, will continue keppra and\n valium at current doses.\n 4. For ARF, HD yesterday\n 5. For pancreatitis, will continue post-pyloric TFs, and will\n continue to hold off on any drainage of new peripancreatic fluid\n collection.\n ICU Care\n Nutrition:\n Nutren 2.0 () - 01:41 PM 50 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 08:15 PM\n PICC Line - 08:37 AM\n Dialysis Catheter - 08:55 AM\n Prophylaxis:\n DVT: sc hep\n Stress ulcer: PPI\n VAP: HOB chlorhex\n Communication: I spoke with brother for 45 last PM updating him on\n plans of care including fevers\n Code status: Full code\n Disposition :ICU\n Total time spent: 40 minutes\n Patient is critically ill\n" }, { "category": "Physician ", "chartdate": "2131-06-25 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 682920, "text": "Chief Complaint:\n 24 Hour Events:\n FEVER - 101.5\nF - 04:00 PM\n \n - Weaned down valium; discontinued methadone\n - Last day predisone today. Dad inquiring as to whether prednisone\n taper too fast given worsening BP and mental status since taper.\n - Discontinued linezolid as WBC improved\n - ID: Consider tapering off abx, sample fluids if worsens, recheck CMV\n viral load next week. Consider changing foley (changed last wk with Ucx\n still growing yeast). Per attg, would d/c micafungin left given \n concern for risk, h/o TPN, steroids, yeast in urine.\n - Fever to 101 at 3pm with drop in SBP to low 80s; required low dose\n pressors but weaned off after 4-5 hours.\n - Pt became acutely and persistently tachypneic in AM although\n maintaining sats, BP and afebrile. No output w/ suctioning. Started on\n PS 5/5 but RR 40s so switched to A/C 400/18/5/40 with improvement.\n Noted to have small emesis, also abd pain so CXR and AXR ordered.\n Allergies:\n Meropenem\n skin blisters a\n Last dose of Antibiotics:\n Metronidazole - 12:00 AM\n Linezolid - 11:51 AM\n Micafungin - 10:04 PM\n Aztreonam - 01:48 AM\n Infusions:\n Norepinephrine - 0.09 mcg/Kg/\n Other ICU medications:\n Famotidine (Pepcid) - 08:21 AM\n Heparin Sodium (Prophylaxis) - 12:21 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 06:39 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.6\nC (101.5\n Tcurrent: 37.7\nC (99.9\n HR: 115 (98 - 117) bpm\n BP: 95/53(66) {79/43(31) - 122/75(90)} mmHg\n RR: 30 (19 - 40) insp/\n SpO2: 97%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 104 kg (admission): 113.5 kg\n Height: 67 Inch\n Total In:\n 2,202 mL\n 602 mL\n PO:\n TF:\n 1,204 mL\n 331 mL\n IVF:\n 998 mL\n 211 mL\n Blood products:\n Total out:\n 256 mL\n 95 mL\n Urine:\n 256 mL\n 95 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,946 mL\n 507 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 18\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 40%\n PIP: 21 cmH2O\n Plateau: 17 cmH2O\n SpO2: 97%\n ABG: 7.42/27/67/22/-4\n Ve: 13.7 L/\n PaO2 / FiO2: 168\n Physical Examination\n Gen: lying in bed, eyes open to command, voice\n : trach\n CV: tachy RR\n Chest: good air movement\n Abd: soft +BS\n Ext: edema\n Neuro: eye open, squeeze hand to command, not answering more involved\n ?s or following more complex commands\n Labs / Radiology\n 230 K/uL\n 6.7 g/dL\n 121 mg/dL\n 2.7 mg/dL\n 22 mEq/L\n 3.7 mEq/L\n 61 mg/dL\n 102 mEq/L\n 137 mEq/L\n 22.2 %\n 18.9 K/uL\n [image002.jpg]\n 05:57 PM\n 09:02 PM\n 01:42 AM\n 01:50 AM\n 03:18 AM\n 03:44 PM\n 01:38 AM\n 06:00 AM\n 01:12 AM\n 06:06 AM\n WBC\n 34.0\n 35.7\n 30.9\n 27.6\n 18.9\n Hct\n 21.6\n 23.1\n 22.2\n 24.0\n 22.2\n Plt\n 291\n 305\n 264\n 268\n 230\n Cr\n 1.2\n 1.8\n 2.8\n 1.6\n 2.7\n TCO2\n 27\n 22\n 26\n 18\n Glucose\n 126\n 136\n 170\n 95\n 170\n 121\n Other labs: PT / PTT / INR:15.3/34.3/1.3, CK / CKMB /\n Troponin-T:214/3/0.07, ALT / AST:81/79, Alk Phos / T Bili:422/8.5,\n Amylase / Lipase:77/88, Differential-Neuts:86.0 %, Band:2.0 %,\n Lymph:3.0 %, Mono:4.0 %, Eos:2.0 %, D-dimer:6389 ng/mL, Fibrinogen:541\n mg/dL, Lactic Acid:2.6 mmol/L, Albumin:2.3 g/dL, LDH:529 IU/L, Ca++:8.4\n mg/dL, Mg++:2.0 mg/dL, PO4:2.3 mg/dL\n Ca: 8.4 Mg: 2.0 P: 2.3\n ALT: 81\n AP: 422\n Tbili: 8.5\n Alb:\n AST: 79\n LDH:\n Dbili:\n TProt:\n :\n Lip:\n Daily mycolytic and blood cx remain negative\n CXR\n increased pulm edema per my read\n Abd x-ray\n no apparent air fluid levels or free air per my read\n Assessment and Plan\n 28M with alcoholic hepatitis and necrotizing pancreatitis complicated\n by ARDS, SIRS, ARF, UGIB, fevers.\n #. Respiratory Failure: ARDS secondary to necrotizing pancreatitis. S/p\n trach placement on . bronch without obvious source of\n bleeding and with only thin secretions throughout; no further reports\n of bleeding since. Now off methadone since . Tachypnea this AM of\n unclear etiology, possible mucous/clot plugging. ?central\n hyperventilation event. Would be transient for PE.\n - Wean off vent to trach mask and recheck ABG\n - F/u CXR final read\n - Sputum cx\n - Wean valium to (D2/3), decrease to daily on \n - Cont fentanyl boluses prn (not requiring)\n - Trach care, OOB to chair daily\n - DDAVP if acute bleeding (max few doses). Had required amicar shortly\n after trach for continued bleeding but complicated by seizure shortly\n after starting this.\n #. Fevers/leukocytosis: Fevers off CVVH with stable-improving\n leukocytosis. Possible that continued fevers necrotizing\n pancreatitis. Surgery was consulted for fluid collections peri-pancreas\n but felt to not be infected. CMV positive, but likely not contributing\n to current illness per ID. Also with persistent yeast in ucx,\n persistent colonic inflammation on CT with neg C. diff x 3, and concern\n for serotonin syndrome with linezolid and pressors, now discontinued.\n On aztreonam (since ) and micafungin (since ). In setting of\n fevers and hypotension, Cipro was started , but d/c\ned . Flagyl\n (since ) and po vanc (since ) discontinued . Linezolid\n started and stopped .\n - ID would prefer to wean off micafungin last\n - Consider d/c aztreonam today; will f/u with ID\n - Ordered for CMV VL on \n - D/w IR if abd fluid collection is drainable in case we want to drain\n it later. Currently hesitant given unclear benefit for a procedure that\n could further complicate his ICU course.\n - D/c a-line when able as has been in since \n - Follow WBC count, temp curve, and culture data\n - Send bcx from HD line as none yet pending\n # Abd tenderness: Likely secondary to necrotizing pancreatitis, now\n able to react as mental status improves. Concern for obstruction given\n emesis this AM but abd xray on our read does not appear c/w this and\n reported to have had BMs. Also has h/o colitis but C. diff neg x 3.\n - F/u abd XR\n - Management of pancreatitis as above\n # Shock: Cont to have hypotension in setting of fevers although only\n intermittent need for pressors and resolved without change in abx\n regimen.\n - If requires pressors without fever, consider other etiologies of\n hypotension including cardiogenic. Consider IVF if BPs drop to see if\n fluid responsive prior to starting levophed again although hypotensive\n events have not occurred in close proximity time-wise to HD sessions\n - Weaned off steroids on \n - Keep a-line until off pressors x 24 h but d/c when possible\n - Infectious w/u as above\n # Elevated LFTs: A/w alcoholic hepatitis. RUQ u/s showed sludge\n concerning for cholestasis but also seen on u/s. HIDA neg.\n TPN stopped . LFTs downtrending as of yesterday.\n - Weaning off benzos: valium 5mg D \n - Continue to trend\n #. Acute renal Failure: Multifactorial including ATN from hypotension.\n - HD per renal\n - F/u Renal recs\n #. Adrenal Insufficiency: Unclear with stim if adrenally\n insufficient but hypotension initially improved with steroids (lower\n pressor requirement) and eosinophilia resolved. He has now weaned off\n steroids completely.\n - Last dose prednisone was \n # Seizures: CT head without intracranial process. EEG showed occipital\n seizures which does not correlate with clinical symptoms, but repeat\n EEG on higher dose Keppra showed no seizures. As patient now with\n purposeful movements, this may actually be patient waking up, not\n seizures.\n - Continue keppra at HD dosing\n # Altered Mental Status: Continue to reassess as weaning off sedatives.\n - Off of methadone as of \n - Cont to wean valium as above\n - Will ask Neuro for input re: prognostication if MS with no further\n improvement by end of week\n # Low ionized calcium: be spurious as Ca with Chem 10 nl.\n - Recheck w/ next ABG\n ICU Care\n Nutrition:\n Nutren 2.0 () - 01:41 PM 50 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 08:15 PM\n PICC Line - 08:37 AM\n Dialysis Catheter - 08:55 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:ICU\n" }, { "category": "Rehab Services", "chartdate": "2131-06-25 00:00:00.000", "description": "Physical Therapy Evaluation Note", "row_id": 682924, "text": "Attending Physician: \n Referral date: \n Medical Diagnosis / ICD 9: pancreatitis / 577.0\n Reason of referral: Re-Eval\n History of Present Illness / Subjective Complaint: 28 yo M with\n alcoholic hepatitis and necrotizing pancreatitis complicated by ARDS,\n ARF, UGIB and fevers. Patient with increased respiratory distress and\n secretions overnight requiring re-intubation early this morning.\n Past Medical / Surgical History: see initial eval\n Medications: tylenol, heparin, fentanyl, norepinephrine, diazepam,\n albuterol\n Radiology: CXR - Low lung volumes and bilateral pleural effusions\n persist.\n Labs:\n 22.2\n 6.7\n 230\n 18.9\n [image002.jpg]\n Other labs:\n Activity Orders: Bedrest, OK for edge of bed\n Social / Occupational History: see initial eval\n Living Environment: see initial eval\n Prior Functional Status / Activity Level: see initial eval\n Objective Test\n Arousal / Attention / Cognition / Communication: alert, intubated and\n not attempting to communicate, following <10% of commands. Tracking in\n all directions but no sustained focus.\n Hemodynamic Response\n Aerobic Capacity\n HR\n BP\n RR\n O[2 ]sat\n HR\n BP\n RR\n O[2] sat\n RPE\n Supine\n /\n Rest\n 112\n 110/63\n 100% on CMV\n Sit\n /\n Activity\n 120\n 105/47\n 100% on CMV\n Stand\n /\n Recovery\n 116\n 117/62\n 100% on CMV\n Total distance walked:\n Minutes:\n Pulmonary Status: On CMV with 40% FIO2 via trach. Diminished BS\n bilaterally, patient coughing over the vent with initial upright\n positioning at edge of bed.\n Integumentary / Vascular: L radial a-line, R PICC, R subclavian\n dialysis catheter, foley, NG tube to suction. R LE with dressing\n intact. Jaundice sclera. B UE edema.\n Sensory Integrity: inable to assess cognitive status\n Pain / Limiting Symptoms: unable to assess\n Posture: Cervical lateral flexion to the L\n Range of Motion\n Muscle Performance\n B LE's grossly WNL, able to passively bring neck to neutral\n unable to assess\n Motor Function: patient able to squeeze with both hands on command,\n L>R. Some spontaneous movement noted B UE's. No movement noted B\n LE's. Tremulous with mobility B UE's.\n Functional Status:\n Activity\n Clarification\n I\n S\n CG\n Min\n Mod\n Max\n Gait, Locomotion: total assist of 2 people for all mobility, got to\n edge of bed.\n Rolling:\n\n\n\n\n\n\n Supine /\n Sidelying to Sit:\n\n\n\n\n\n Transfer:\n\n\n\n\n\n Sit to Stand:\n\n\n\n\n\n Ambulation:\n\n\n\n\n\n Stairs:\n\n\n\n\n\n Balance: Max A to maintain static sitting at edge of bed with L lateral\n , A dynamic sitting activities. Tolerated sitting at edge of\n bed <10 min.\n Education / Communication: Reviewed PT with patient, spoke with\n patient's mother re: PT role. Communicated with nsg re: status\n Intervention:\n Other:\n Diagnosis:\n 1.\n Arousal, Attention, and Cognition, Impaired\n 2.\n Balance, Impaired\n 3.\n Motor Function, Impaired\n 4.\n Impaired endurance\n 5.\n Respiration / Gas Exchange, Impaired\n Clinical impression / Prognosis: 28 yo M with acute pancreatitis p/w\n above impairments a/w ventilatory pump dysfunction. He is making\n minimal progress in PT but cognitive status has improved since initial\n evaluation. He continues to be limited by respiratory status as well\n as impaired cognition, and is not able to participate in any mobility\n at this time. Given his age and prior level of function would\n anticipate good rehab potential however prognosis remains guarded given\n his prolonged and complicated hospital course. Continue to recommend\n rehab upon d/c, PT to continue to follow at acute level to progress as\n able.\n Goals\n Time frame: 1 week\n 1.\n Follows 50% of simple commands\n 2.\n Maintains static sitting with mod A\n 3.\n Moves all extremities volitionally\n 4.\n Tolerates trach mask >/= 8 hours/day\n 5.\n Tolerates OOB >/= 4 hours/day\n 6.\n Anticipated Discharge: Rehab\n Treatment Plan:\n Frequency / Duration: 3-5x/wk\n bed mobility, transfers, balance, strengthening, endurance, education,\n pulmonary hygiene, d/c planning\n Patient agrees with the above goals and is willing to participate in\n the rehabilitation program.\n" }, { "category": "Physician ", "chartdate": "2131-06-25 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 682929, "text": "Chief Complaint: pancreatitis, resp failure\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n FEVER - 101.5\nF - 04:00 PM\n Tachypnea and put back on AC vent\n before spiking fevers\n Allergies:\n Meropenem\n skin blisters a\n Last dose of Antibiotics:\n Metronidazole - 12:00 AM\n Linezolid - 11:51 AM\n Micafungin - 10:04 PM\n Aztreonam - 01:48 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 12:21 PM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: Fever\n Flowsheet Data as of 11:02 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.6\nC (101.5\n Tcurrent: 37.9\nC (100.2\n HR: 113 (108 - 117) bpm\n BP: 109/59(74) {79/43(31) - 136/75(90)} mmHg\n RR: 25 (23 - 40) insp/\n SpO2: 100%\n Heart rhythm: SB (Sinus Bradycardia)\n Wgt (current): 104 kg (admission): 113.5 kg\n Height: 67 Inch\n Total In:\n 2,202 mL\n 1,169 mL\n PO:\n TF:\n 1,204 mL\n 550 mL\n IVF:\n 998 mL\n 559 mL\n Blood products:\n Total out:\n 256 mL\n 135 mL\n Urine:\n 256 mL\n 135 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,946 mL\n 1,034 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 18\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 40%\n PIP: 24 cmH2O\n Plateau: 21 cmH2O\n SpO2: 100%\n ABG: 7.42/27/67/22/-4\n Ve: 13.8 L/\n PaO2 / FiO2: 168\n Physical Examination\n Gen: sitting up on side of bed with PT\n : trach in place\n CV: tachy RR\n Chest: good air movement, birnhcial BS left base, dimished at right\n Abd: soft +BS\n Ext: edema\n Neuro: eye open, sitting up w PT but not participatory\n Labs / Radiology\n 6.7 g/dL\n 230 K/uL\n 121 mg/dL\n 2.7 mg/dL\n 22 mEq/L\n 3.7 mEq/L\n 61 mg/dL\n 102 mEq/L\n 137 mEq/L\n 22.2 %\n 18.9 K/uL\n [image002.jpg]\n 05:57 PM\n 09:02 PM\n 01:42 AM\n 01:50 AM\n 03:18 AM\n 03:44 PM\n 01:38 AM\n 06:00 AM\n 01:12 AM\n 06:06 AM\n WBC\n 34.0\n 35.7\n 30.9\n 27.6\n 18.9\n Hct\n 21.6\n 23.1\n 22.2\n 24.0\n 22.2\n Plt\n 291\n 305\n 264\n 268\n 230\n Cr\n 1.2\n 1.8\n 2.8\n 1.6\n 2.7\n TCO2\n 27\n 22\n 26\n 18\n Glucose\n 126\n 136\n 170\n 95\n 170\n 121\n Other labs: PT / PTT / INR:15.3/34.3/1.3, CK / CKMB /\n Troponin-T:214/3/0.07, ALT / AST:81/79, Alk Phos / T Bili:422/8.5,\n Amylase / Lipase:77/88, Differential-Neuts:86.0 %, Band:2.0 %,\n Lymph:3.0 %, Mono:4.0 %, Eos:2.0 %, D-dimer:6389 ng/mL, Fibrinogen:541\n mg/dL, Lactic Acid:2.6 mmol/L, Albumin:2.3 g/dL, LDH:529 IU/L, Ca++:8.4\n mg/dL, Mg++:2.0 mg/dL, PO4:2.3 mg/dL\n Assessment and Plan\n FEVER, UNKNOWN ORIGIN (FUO, HYPERTHERMIA, PYREXIA)\n AROUSAL, ATTENTION, AND COGNITION, IMPAIRED\n BALANCE, IMPAIRED\n MOTOR FUNCTION, IMPAIRED\n MUSCLE PERFORMACE, IMPAIRED\n RESPIRATION / GAS EXCHANGE, IMPAIRED\n SEIZURE, WITHOUT STATUS EPILEPTICU\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n IMPAIRED SKIN INTEGRITY\n HEPATITIS, ACUTE TOXIC (INCLUDING ALCOHOLIC, ACETAMINOPHEN, ETC.)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n 1. Cyclical fevers during which he requires vasopressor support:\n DDx SIRS, line infections, panc necrrosis with infection, PNA, drug\n fever, serotonin syndrome. At this point he has been\n pan cultured\n nothing new. In conjunction with ID consultants we have been weaning\n off ABX since nothing has grown\n will continue aztreonam / micafungin\n for while monitoring culture data. Possible repeat imaging this week of\n pancreas but we are loathe to initiate empiric panc drainage if there\n is another possible source as this can lead to long term complications.\n However, if fevers persist and no other source can be found we may be\n forced.\n 2. Hypotension: transient this AM and short period overnight when\n febrile\n 3. Resp Failure: Put back on vent for tachypnea and hypoxemia\n overnight- but better this AM and trying back on TM. CXR without acute\n change but low lung volumes off + pressure. Ongoing TM trials and\n sedation wean - will get OOB to chair today, and wean methadone\n 4. Given possibility of sz activity, will continue keppra and\n valium at current doses.\n 5. For ARF, HD today\n 6. For pancreatitis, will continue post-pyloric TFs, and will\n continue to hold off on any drainage of new peripancreatic fluid\n collection but will discuss with Dr \n ICU Care\n Nutrition:\n Nutren 2.0 () - 01:41 PM 50 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 08:15 PM\n PICC Line - 08:37 AM\n Dialysis Catheter - 08:55 AM\n Prophylaxis:\n DVT: sc hep\n Stress ulcer: PPI\n VAP: HOB chlorhex\n Communication: I spoke with brother for 45 last PM updating him on\n plans of care including fevers\n Code status: Full code\n Disposition :ICU\n Total time spent: 40 minutes\n Patient is critically ill\n" }, { "category": "Physician ", "chartdate": "2131-06-26 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 683062, "text": "Chief Complaint:\n 24 Hour Events:\n \n - Sent sputum cx for tachypnea early AM of .\n - Weaned down to trach mask by early afternoon.\n - IR stated it would be very high risk to sample peri-pancreatic fluid\n collection - would likely need to paralyze him as needle would pass\n between dilated splancnic vessels.\n - Renal: plan for HD tomorrow if BP can tolerate it - otherwise may\n need CVVH.\n - ID: recommended d/c'ing aztreonam due to improving fever curve and\n WBC. Also added galactomanan and beta-glucan.\n Allergies:\n Meropenem\n skin blisters a\n Last dose of Antibiotics:\n Metronidazole - 12:00 AM\n Linezolid - 11:51 AM\n Aztreonam - 02:39 PM\n Micafungin - 10:48 PM\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 07:50 PM\n Heparin Sodium (Prophylaxis) - 03:50 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:22 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.1\nC (100.6\n Tcurrent: 37.3\nC (99.2\n HR: 111 (106 - 119) bpm\n BP: 94/55(68) {90/47(60) - 136/71(91)} mmHg\n RR: 30 (20 - 40) insp/min\n SpO2: 98%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 104.5 kg (admission): 113.5 kg\n Height: 67 Inch\n Total In:\n 2,204 mL\n 319 mL\n PO:\n TF:\n 1,205 mL\n 266 mL\n IVF:\n 939 mL\n 53 mL\n Blood products:\n Total out:\n 581 mL\n 175 mL\n Urine:\n 381 mL\n 175 mL\n NG:\n 200 mL\n Stool:\n Drains:\n Balance:\n 1,623 mL\n 144 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n Ventilator mode: Standby\n Vt (Set): 400 (400 - 400) mL\n PS : 5 cmH2O\n RR (Set): 18\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 40%\n PIP: 11 cmH2O\n Plateau: 21 cmH2O\n SpO2: 98%\n ABG: 7.39/39/81./23/0\n Ve: 10.3 L/min\n PaO2 / FiO2: 203\n Physical Examination\n Gen: lying in bed, eyes open to command, voice\n HEENT: trach\n CV: tachy RR\n Chest: good air movement\n Abd: soft +BS\n Ext: edema\n Neuro: eye open, squeeze hand to command, not answering more involved\n ?s or following more complex commands\n Labs / Radiology\n 228 K/uL\n 6.7 g/dL\n 128 mg/dL\n 3.0 mg/dL\n 23 mEq/L\n 3.3 mEq/L\n 79 mg/dL\n 101 mEq/L\n 136 mEq/L\n 22.5 %\n 15.0 K/uL\n [image002.jpg]\n 01:50 AM\n 03:18 AM\n 03:44 PM\n 01:38 AM\n 06:00 AM\n 01:12 AM\n 06:06 AM\n 02:38 PM\n 02:00 AM\n 02:49 AM\n WBC\n 30.9\n 27.6\n 18.9\n 15.0\n Hct\n 22.2\n 24.0\n 22.2\n 22.5\n Plt\n 28\n Cr\n 2.8\n 1.6\n 2.7\n 3.0\n TCO2\n 27\n 22\n 26\n 18\n 21\n 24\n Glucose\n 170\n 95\n 170\n 121\n 128\n Other labs: PT / PTT / INR:14.3/31.5/1.2, CK / CKMB /\n Troponin-T:214/3/0.07, ALT / AST:67/73, Alk Phos / T Bili:400/6.8,\n Amylase / Lipase:77/88, Differential-Neuts:84.0 %, Band:0.0 %,\n Lymph:7.0 %, Mono:5.0 %, Eos:3.0 %, D-dimer:6389 ng/mL, Fibrinogen:541\n mg/dL, Lactic Acid:2.6 mmol/L, Albumin:2.3 g/dL, LDH:331 IU/L, Ca++:8.6\n mg/dL, Mg++:2.1 mg/dL, PO4:3.7 mg/dL\\\n Ca: 8.6 Mg: 2.1 P: 3.7\n ALT: 67\n AP: 400\n Tbili: 6.8\n Alb:\n AST: 73\n LDH: 331\n Dbili:\n TProt:\n :\n Lip:\n PT: 14.3\n PTT: 31.5\n INR: 1.2\n Assessment and Plan\n 28M with alcoholic hepatitis and necrotizing pancreatitis complicated\n by ARDS, SIRS, ARF, UGIB, fevers.\n #. Fevers/leukocytosis: Fevers off CVVH with stable-improving\n leukocytosis. Possible that continued fevers necrotizing\n pancreatitis. Surgery was consulted for fluid collections peri-pancreas\n but felt to not be infected. CMV positive, but likely not contributing\n to current illness per ID. Also with persistent yeast in ucx,\n persistent colonic inflammation on CT with neg C. diff x 3, and concern\n for serotonin syndrome with linezolid and pressors, now discontinued.\n On aztreonam (since ) and micafungin (since ). In setting of\n fevers and hypotension, Cipro was started , but d/c\ned . Flagyl\n (since ) and po vanc (since ) discontinued . Linezolid\n started and stopped .\n - ID would prefer to wean off micafungin last\n - Consider d/c aztreonam today; will f/u with ID\n - Ordered for CMV VL on \n - D/w IR if abd fluid collection is drainable in case we want to drain\n it later. Currently hesitant given unclear benefit for a procedure that\n could further complicate his ICU course.\n - D/c a-line when able as has been in since \n - Follow WBC count, temp curve, and culture data\n - Send bcx from HD line as none yet pending\n # Abd tenderness: Likely secondary to necrotizing pancreatitis, now\n able to react as mental status improves. Concern for obstruction given\n emesis this AM but abd xray on our read does not appear c/w this and\n reported to have had BMs. Also has h/o colitis but C. diff neg x 3.\n - F/u abd XR\n - Management of pancreatitis as above\n #. Respiratory Failure: ARDS secondary to necrotizing pancreatitis. S/p\n trach placement on . bronch without obvious source of\n bleeding and with only thin secretions throughout; no further reports\n of bleeding since. Now off methadone since . Tachypnea this AM of\n unclear etiology, possible mucous/clot plugging. ?central\n hyperventilation event. Would be transient for PE.\n - Wean off vent to trach mask and recheck ABG\n - F/u CXR final read\n - Sputum cx\n - Wean valium to (D2/3), decrease to daily on \n - Cont fentanyl boluses prn (not requiring)\n - Trach care, OOB to chair daily\n - DDAVP if acute bleeding (max few doses). Had required amicar shortly\n after trach for continued bleeding but complicated by seizure shortly\n after starting this.\n # Shock: Patient remained off pressors over last PM and was afebrile.\n - Weaned off steroids on \n - Keep a-line until off pressors x 24 h but d/c when possible\n - Infectious w/u as above\n # Elevated LFTs: A/w alcoholic hepatitis. RUQ u/s showed sludge\n concerning for cholestasis but also seen on u/s. HIDA neg.\n TPN stopped . LFTs downtrending as of yesterday.\n - Weaning off benzos: valium 5mg D \n - Continue to trend\n #. Acute renal Failure: Multifactorial including ATN from hypotension.\n - HD likely today per renal\n - F/u Renal recs\n #. Adrenal Insufficiency: Unclear with stim if adrenally\n insufficient but hypotension initially improved with steroids (lower\n pressor requirement) and eosinophilia resolved. He has now weaned off\n steroids completely.\n - Last dose prednisone was \n # Seizures: CT head without intracranial process. EEG showed occipital\n seizures which does not correlate with clinical symptoms, but repeat\n EEG on higher dose Keppra showed no seizures. As patient now with\n purposeful movements, this may actually be patient waking up, not\n seizures.\n - Continue keppra at HD dosing\n # Altered Mental Status: Continue to reassess as weaning off sedatives.\n - Off of methadone as of \n - Cont to wean valium as above\n - Will ask Neuro for input re: prognostication if MS with no further\n improvement by end of week\n ICU Care\n Nutrition:\n Nutren 2.0 () - 01:30 PM 50 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 08:15 PM\n PICC Line - 08:37 AM\n Dialysis Catheter - 08:55 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP: HOB elevation, Mouth care\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:ICU\n" }, { "category": "Nutrition", "chartdate": "2131-06-27 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 683304, "text": "Objective\n Current Wt: 105.8kg\n Pertinent medications: Glargine, RISS, Heparin, Famotidine, others\n noted\n Labs:\n Value\n Date\n Glucose\n 80 mg/dL\n 01:51 AM\n Glucose Finger Stick\n 179\n 10:00 AM\n BUN\n 88 mg/dL\n 01:51 AM\n Creatinine\n 2.9 mg/dL\n 01:51 AM\n Sodium\n 140 mEq/L\n 01:51 AM\n Potassium\n 3.1 mEq/L\n 01:51 AM\n Chloride\n 106 mEq/L\n 01:51 AM\n TCO2\n 20 mEq/L\n 01:51 AM\n PO2 (arterial)\n 81. mm Hg\n 02:49 AM\n PO2 (venous)\n 91. mm Hg\n 05:13 PM\n PCO2 (arterial)\n 39 mm Hg\n 02:49 AM\n PCO2 (venous)\n 41 mm Hg\n 05:13 PM\n pH (arterial)\n 7.39 units\n 02:49 AM\n pH (venous)\n 7.43 units\n 05:13 PM\n pH (urine)\n 5.5 units\n 01:41 PM\n CO2 (Calc) arterial\n 24 mEq/L\n 02:49 AM\n CO2 (Calc) venous\n 28 mEq/L\n 05:13 PM\n Albumin\n 2.3 g/dL\n 01:42 AM\n Calcium non-ionized\n 8.6 mg/dL\n 01:51 AM\n Phosphorus\n 3.0 mg/dL\n 01:51 AM\n Ionized Calcium\n 1.04 mmol/L\n 02:38 PM\n Magnesium\n 2.0 mg/dL\n 01:51 AM\n ALT\n 65 IU/L\n 01:51 AM\n Alkaline Phosphate\n 429 IU/L\n 01:51 AM\n AST\n 86 IU/L\n 01:51 AM\n Amylase\n 77 IU/L\n 03:49 AM\n Total Bilirubin\n 5.6 mg/dL\n 01:51 AM\n Triglyceride\n 154 mg/dL\n 02:10 AM\n WBC\n 12.6 K/uL\n 01:51 AM\n Hgb\n 6.8 g/dL\n 01:51 AM\n Hematocrit\n 22.1 %\n 01:51 AM\n Current diet order / nutrition support: Tube Feeds: 3/4 strength Nutren\n 2.0 @ 50cc/hr + 50g Beneprotein (1962kcals, 115g protein)\n GI: abd soft, + bowel sounds\n Assessment of Nutritional Status\n Patient continues on tube feeds at goal, meeting 100% of estimated\n needs. Renal function improving, and team is holding off on HD for\n now. Based on renal function, patient may need decreased protein in\n his tube feeds if he is no longer going to receive HD. Will provide\n recommendations below. Noted K is low.\n Medical Nutrition Therapy Plan - Recommend the Following\n 1) If a lower protein tube feeding is needed, recommend\n decreasing the amount of Beneprotein to 30g, which will provide\n 1889kcals & 98g protein with tube feeds.\n 2) Please replete lytes as needed, namely K.\n 3) Monitor hydration/lytes.\n Following - #\n" }, { "category": "Rehab Services", "chartdate": "2131-06-25 00:00:00.000", "description": "PMV Follow-Up", "row_id": 682917, "text": "TITLE: PMV FOLLOW-UP\nWe returned to reassess patient's candidacy to re-attempt PMV\nplacement, however RN reported patient has been noted with\nincreased secretions and decline in status requiring return to\nthe vent. Patient is not appropriate for PMV trial at this time.\nWe will follow-up later this week to re-attempt if patient's\nstatus improves and he returns to trach collar.\n_______________________________\n , MS, CCC-SLP\nPager #\n" }, { "category": "Physician ", "chartdate": "2131-06-27 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 683289, "text": "Chief Complaint:\n 24 Hour Events:\n - ID: feels sputum likely contaminant; no new abx recs; consider CT\n chest\n - renal: improved UOP encouraging; will likely need HD on Wed\n - blood, urine, stool cx ordered. U/A weakly positive; will follow\n culture.\n - sputum cx from showing moderate oropharyngeal flora; to be\n repeated.\n Allergies:\n Meropenem\n skin blisters\n Last dose of Antibiotics:\n Linezolid - 11:51 AM\n Aztreonam - 02:39 PM\n Micafungin - 10:48 PM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 03:36 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: 37.8\nC (100.1\n HR: 109 (104 - 118) bpm\n BP: 125/67(85) {94/50(64) - 145/77(98)} mmHg\n RR: 20 (19 - 39) insp/min\n SpO2: 98%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 104.5 kg (admission): 113.5 kg\n Height: 67 Inch\n Total In:\n 1,690 mL\n 215 mL\n PO:\n TF:\n 1,200 mL\n 179 mL\n IVF:\n 440 mL\n 36 mL\n Blood products:\n Total out:\n 897 mL\n 240 mL\n Urine:\n 897 mL\n 240 mL\n NG:\n Stool:\n Drains:\n Balance:\n 793 mL\n -25 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n Ventilator mode: Standby\n RR (Spontaneous): 30\n FiO2: 40%\n SpO2: 98%\n ABG: ////\n Physical Examination\n Labs / Radiology\n 225 K/uL\n 6.8 g/dL\n 128 mg/dL\n 3.0 mg/dL\n 23 mEq/L\n 3.3 mEq/L\n 79 mg/dL\n 101 mEq/L\n 136 mEq/L\n 22.1 %\n 15.0 K/uL\n [image002.jpg]\n 03:18 AM\n 03:44 PM\n 01:38 AM\n 06:00 AM\n 01:12 AM\n 06:06 AM\n 02:38 PM\n 02:00 AM\n 02:49 AM\n 01:51 AM\n WBC\n 30.9\n 27.6\n 18.9\n 15.0\n Hct\n 22.2\n 24.0\n 22.2\n 22.5\n 22.1\n Plt\n 28\n 225\n Cr\n 2.8\n 1.6\n 2.7\n 3.0\n TCO2\n 22\n 26\n 18\n 21\n 24\n Glucose\n 170\n 95\n 170\n 121\n 128\n Other labs: PT / PTT / INR:14.3/31.5/1.2, CK / CKMB /\n Troponin-T:214/3/0.07, ALT / AST:67/73, Alk Phos / T Bili:400/6.8,\n Amylase / Lipase:77/88, Differential-Neuts:84.3 %, Band:0.0 %,\n Lymph:9.3 %, Mono:1.7 %, Eos:4.3 %, D-dimer:6389 ng/mL, Fibrinogen:541\n mg/dL, Lactic Acid:2.6 mmol/L, Albumin:2.3 g/dL, LDH:331 IU/L, Ca++:8.6\n mg/dL, Mg++:2.1 mg/dL, PO4:3.7 mg/dL\n Assessment and Plan\n 28 year old male with a history of alcoholism presenting with acute\n hepatitis, pancreatitis, and UGIB.\n .\n # Persistent Fever / Leukocytosis: Marked leukocytosis with low grade\n temperature. UA consistent with UTI, but also may be stress response.\n Off Abx except for micafungin.\n -- f/u blood cultures and urine culture\n -- sputum culture likely a contaminent\n -- f/u final CT read\n .\n # Neuro\n -- need to discuss with neuro their recommendations for patient\n # Pancreatitis: Most likely alcoholic in etiology, with elevated\n lipase to 1600 and CT findings consistent without necrosis, cycts, or\n phlemgon. Only mild epigastric tenderness and no complaints of\n abdominal pain.\n -- continue aggessive hydration\n -- serial abdominal exams\n -- trend lipase\n -- no evidence of obstruction, holding off on further imaging at this\n time\n -- check am lipid panel\n .\n # Acute Hepatitis: Likely alcoholic hepatitis. CT scan shows fatty\n infiltration, and no evidence of distal ostruction.\n - check viral hepatitis panel, although degree of transaminitis not\n consistant with such an etiology.\n - holding off on further imaging for now, f/u final CT read\n - hepatology following\n - avoid hepatically cleared meds\n - trend LFTs\n .\n # Hematemesis: Given alcohol history, potential consideration for\n varriceal bleed. No known prior history of hepatic cirrhosis, but\n elevated INR and fatty liver infilatration would be consistent. Also\n should consider PUD or alcoholic gastritis. Hct was WNL on\n presentation, but patient markedly contracted. Continued bright red\n blood on NG lavage suggests some degree of continued active bleeding.\n -- hepatology consulted, EGD\n -- access with 2 large bore IVs and a cordis, T + C x 3 units\n -- IV PPI + PPI gtt\n -- octreotide for now until varrices are ruled out.\n .\n # Hyponatremia: Most likely due to volume depletion in the setting of\n inability to tolerate POs. Patient markedly dry on exam. also\n reflect a more chronic long-term liver disease.\n - fluid repleation as given above\n - if not correcting, will pursue furhter workup with urine lytes.\n # Alcoholism: Patient describes history of withdrawl symptoms, but not\n prior seizure. Last drink was night prior to presenation.\n Tachycardia, weakness, and elevated lactate could be consistent with\n thiamine deficiency.\n - repleate thiamine, vb12, folate\n - ativan with CIWA > 10\n - addictions consult\n .\n # FEN: IVF, replete electrolytes, NPO\n .\n # Prophylaxis: scds, PPI gtt\n .\n # Access: peripherals and femoral cortis\n .\n # Code: Full Code\n .\n # Disposition: MICU for now\n ICU Care\n Nutrition:\n Nutren 2.0 () - 01:30 PM 50 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 08:15 PM\n PICC Line - 08:37 AM\n Dialysis Catheter - 08:55 AM\n Prophylaxis:\n DVT: SQ UF Heparin, SCDs\n Stress ulcer: PPI\n VAP: HOB elevation\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n" }, { "category": "Physician ", "chartdate": "2131-06-27 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 683290, "text": "Chief Complaint: pancreatitis, resp failure,\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n remains off vent and pressors\n Allergies:\n Meropenem\n skin blisters a\n Last dose of Antibiotics:\n Linezolid - 11:51 AM\n Aztreonam - 02:39 PM\n Micafungin - 10:48 PM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 04:00 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 Flowsheet Data as of 09:23 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: 37.6\nC (99.6\n HR: 105 (104 - 118) bpm\n BP: 135/72(94) {120/65(83) - 145/77(98)} mmHg\n RR: 18 (18 - 39) insp/min\n SpO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 104.5 kg (admission): 113.5 kg\n Height: 67 Inch\n Total In:\n 1,691 mL\n 662 mL\n PO:\n TF:\n 1,200 mL\n 468 mL\n IVF:\n 441 mL\n 194 mL\n Blood products:\n Total out:\n 897 mL\n 590 mL\n Urine:\n 897 mL\n 590 mL\n NG:\n Stool:\n Drains:\n Balance:\n 794 mL\n 72 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n Ventilator mode: Standby\n RR (Spontaneous): 19\n FiO2: 40%\n SpO2: 100%\n ABG: ///20/\n Physical Examination\n Gen: up in chair, eyes open\n CV: RR\n Chest: good air movement\n Abd: distended +BS\n Ext: 3+ edema\n Neuro: eyes open, will blink/ to command, weak grasp, doe not\n follow\n Labs / Radiology\n 6.8 g/dL\n 225 K/uL\n 80 mg/dL\n 2.9 mg/dL\n 20 mEq/L\n 3.1 mEq/L\n 88 mg/dL\n 106 mEq/L\n 140 mEq/L\n 22.1 %\n 12.6 K/uL\n [image002.jpg]\n 03:18 AM\n 03:44 PM\n 01:38 AM\n 06:00 AM\n 01:12 AM\n 06:06 AM\n 02:38 PM\n 02:00 AM\n 02:49 AM\n 01:51 AM\n WBC\n 30.9\n 27.6\n 18.9\n 15.0\n 12.6\n Hct\n 22.2\n 24.0\n 22.2\n 22.5\n 22.1\n Plt\n 28\n 225\n Cr\n 2.8\n 1.6\n 2.7\n 3.0\n 2.9\n TCO2\n 22\n 26\n 18\n 21\n 24\n Glucose\n 170\n 95\n 170\n 121\n 128\n 80\n Other labs: PT / PTT / INR:13.6/28.0/1.2, CK / CKMB /\n Troponin-T:214/3/0.07, ALT / AST:65/86, Alk Phos / T Bili:429/5.6,\n Amylase / Lipase:77/88, Differential-Neuts:84.3 %, Band:0.0 %,\n Lymph:9.3 %, Mono:1.7 %, Eos:4.3 %, D-dimer:6389 ng/mL, Fibrinogen:541\n mg/dL, Lactic Acid:2.6 mmol/L, Albumin:2.3 g/dL, LDH:312 IU/L, Ca++:8.6\n mg/dL, Mg++:2.0 mg/dL, PO4:3.0 mg/dL\n Assessment and Plan\n FEVER, UNKNOWN ORIGIN (FUO, HYPERTHERMIA, PYREXIA)\n AROUSAL, ATTENTION, AND COGNITION, IMPAIRED\n BALANCE, IMPAIRED\n MOTOR FUNCTION, IMPAIRED\n MUSCLE PERFORMACE, IMPAIRED\n RESPIRATION / GAS EXCHANGE, IMPAIRED\n SEIZURE, WITHOUT STATUS EPILEPTICUS\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n IMPAIRED SKIN INTEGRITY\n HEPATITIS, ACUTE TOXIC (INCLUDING ALCOHOLIC, ACETAMINOPHEN, ETC.)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n 1. Cyclical fevers\n overall trend is down and WBC trend is down.\n We have been weaning off ABX since nothing has grown\n will continue\n only micafungin while monitoring culture data. Possible repeat imaging\n this week of pancreas but we are loathe to initiate empiric panc\n drainage if there is another possible source as this can lead to long\n term complications. Spoke with in IR who felt it would\n be a very high risk procedure- esp to injure portal circ.\n and he\n would not recc and only do in conjunction with Dr .\n Will get blood cx off HD line\n 2. Hypotension: resolved\n 3. Resp Failure: back on trach mask, hold on this\n 4. Given possibility of sz activity, will continue keppra and\n valium at current doses.\n 5. For ARF: making good urine this AM, may even be able to hold\n off on HD\n 6. For pancreatitis, will continue post-pyloric TFs, and will\n continue to hold off on any drainage of new peripancreatic fluid\n collection but will discuss with Dr \n ICU Care\n Nutrition:\n Nutren 2.0 () - 01:30 PM 50 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 08:15 PM\n PICC Line - 08:37 AM\n Dialysis Catheter - 08:55 AM\n Prophylaxis:\n DVT: sc hep\n Stress ulcer: PPI\n VAP: HOB and chlorx\n Comments:\n Communication: will touch base w family\n Code status: Full code\n Disposition : ICU\n Total time spent:\n" }, { "category": "Physician ", "chartdate": "2131-06-27 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 683291, "text": "Chief Complaint:\n 24 Hour Events:\n - ID: feels sputum likely contaminant; no new abx recs; consider CT\n chest\n - renal: improved UOP encouraging; will likely need HD on Wed\n - blood, urine, stool cx ordered. U/A weakly positive; will follow\n culture.\n - sputum cx from showing moderate oropharyngeal flora; to be\n repeated.\n Allergies:\n Meropenem\n skin blisters\n Last dose of Antibiotics:\n Linezolid - 11:51 AM\n Aztreonam - 02:39 PM\n Micafungin - 10:48 PM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 03:36 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: 37.8\nC (100.1\n HR: 109 (104 - 118) bpm\n BP: 125/67(85) {94/50(64) - 145/77(98)} mmHg\n RR: 20 (19 - 39) insp/min\n SpO2: 98%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 104.5 kg (admission): 113.5 kg\n Height: 67 Inch\n Total In:\n 1,690 mL\n 215 mL\n PO:\n TF:\n 1,200 mL\n 179 mL\n IVF:\n 440 mL\n 36 mL\n Blood products:\n Total out:\n 897 mL\n 240 mL\n Urine:\n 897 mL\n 240 mL\n NG:\n Stool:\n Drains:\n Balance:\n 793 mL\n -25 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n Ventilator mode: Standby\n RR (Spontaneous): 30\n FiO2: 40%\n SpO2: 98%\n ABG: ////\n Physical Examination\n Labs / Radiology\n 225 K/uL\n 6.8 g/dL\n 128 mg/dL\n 3.0 mg/dL\n 23 mEq/L\n 3.3 mEq/L\n 79 mg/dL\n 101 mEq/L\n 136 mEq/L\n 22.1 %\n 15.0 K/uL\n [image002.jpg]\n 03:18 AM\n 03:44 PM\n 01:38 AM\n 06:00 AM\n 01:12 AM\n 06:06 AM\n 02:38 PM\n 02:00 AM\n 02:49 AM\n 01:51 AM\n WBC\n 30.9\n 27.6\n 18.9\n 15.0\n Hct\n 22.2\n 24.0\n 22.2\n 22.5\n 22.1\n Plt\n 28\n 225\n Cr\n 2.8\n 1.6\n 2.7\n 3.0\n TCO2\n 22\n 26\n 18\n 21\n 24\n Glucose\n 170\n 95\n 170\n 121\n 128\n Other labs: PT / PTT / INR:14.3/31.5/1.2, CK / CKMB /\n Troponin-T:214/3/0.07, ALT / AST:67/73, Alk Phos / T Bili:400/6.8,\n Amylase / Lipase:77/88, Differential-Neuts:84.3 %, Band:0.0 %,\n Lymph:9.3 %, Mono:1.7 %, Eos:4.3 %, D-dimer:6389 ng/mL, Fibrinogen:541\n mg/dL, Lactic Acid:2.6 mmol/L, Albumin:2.3 g/dL, LDH:331 IU/L, Ca++:8.6\n mg/dL, Mg++:2.1 mg/dL, PO4:3.7 mg/dL\n Assessment and Plan\n 28 year old male with a history of alcoholism presenting with acute\n hepatitis, pancreatitis, and UGIB.\n .\n # Persistent Fever / Leukocytosis: Marked leukocytosis with low grade\n temperature. UA consistent with UTI, but also may be stress response.\n Off Abx except for micafungin.\n -- f/u blood cultures and urine culture\n -- sputum culture likely a contaminent\n -- f/u final CT read\n .\n # Neuro\n -- need to discuss with neuro their recommendations for patient\n # Pancreatitis: Most likely alcoholic in etiology, with elevated\n lipase to 1600 and CT findings consistent without necrosis, cycts, or\n phlemgon. Only mild epigastric tenderness and no complaints of\n abdominal pain.\n -- continue aggessive hydration\n -- serial abdominal exams\n -- trend lipase\n -- no evidence of obstruction, holding off on further imaging at this\n time\n -- check am lipid panel\n .\n # Acute Hepatitis: Likely alcoholic hepatitis. CT scan shows fatty\n infiltration, and no evidence of distal ostruction.\n - check viral hepatitis panel, although degree of transaminitis not\n consistant with such an etiology.\n - holding off on further imaging for now, f/u final CT read\n - hepatology following\n - avoid hepatically cleared meds\n - trend LFTs\n .\n # Hyponatremia: Most likely due to volume depletion in the setting of\n inability to tolerate POs. Patient markedly dry on exam. also\n reflect a more chronic long-term liver disease.\n - fluid repleation as given above\n - if not correcting, will pursue furhter workup with urine lytes.\n # Alcoholism: Patient describes history of withdrawl symptoms, but not\n prior seizure. Last drink was night prior to presenation.\n Tachycardia, weakness, and elevated lactate could be consistent with\n thiamine deficiency.\n - repleate thiamine, vb12, folate\n - ativan with CIWA > 10\n - addictions consult\n .\n # FEN: IVF, replete electrolytes, NPO\n .\n # Prophylaxis: scds, PPI gtt\n .\n # Access: peripherals and femoral cortis\n .\n # Code: Full Code\n .\n # Disposition: MICU for now\n ICU Care\n Nutrition:\n Nutren 2.0 () - 01:30 PM 50 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 08:15 PM\n PICC Line - 08:37 AM\n Dialysis Catheter - 08:55 AM\n Prophylaxis:\n DVT: SQ UF Heparin, SCDs\n Stress ulcer: PPI\n VAP: HOB elevation\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n" }, { "category": "Physician ", "chartdate": "2131-06-27 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 683293, "text": "Chief Complaint:\n 24 Hour Events:\n - ID: feels sputum likely contaminant; no new abx recs; consider CT\n chest or repeat CXR\n - renal: improved UOP encouraging; may not need HD today\n - blood, urine, stool cx ordered. U/A weakly positive; will follow\n culture.\n - sputum cx from showing moderate oropharyngeal flora; to be\n repeated.\n Allergies:\n Meropenem\n skin blisters\n Last dose of Antibiotics:\n Linezolid - 11:51 AM\n Aztreonam - 02:39 PM\n Micafungin - 10:48 PM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 03:36 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: 37.8\nC (100.1\n HR: 109 (104 - 118) bpm\n BP: 125/67(85) {94/50(64) - 145/77(98)} mmHg\n RR: 20 (19 - 39) insp/min\n SpO2: 98%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 104.5 kg (admission): 113.5 kg\n Height: 67 Inch\n Total In:\n 1,690 mL\n 215 mL\n PO:\n TF:\n 1,200 mL\n 179 mL\n IVF:\n 440 mL\n 36 mL\n Blood products:\n Total out:\n 897 mL\n 240 mL\n Urine:\n 897 mL\n 240 mL\n NG:\n Stool:\n Drains:\n Balance:\n 793 mL\n -25 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n Ventilator mode: Standby\n RR (Spontaneous): 30\n FiO2: 40%\n SpO2: 98%\n ABG: ////\n Physical Examination\n Labs / Radiology\n 225 K/uL\n 6.8 g/dL\n 128 mg/dL\n 3.0 mg/dL\n 23 mEq/L\n 3.3 mEq/L\n 79 mg/dL\n 101 mEq/L\n 136 mEq/L\n 22.1 %\n 15.0 K/uL\n [image002.jpg]\n 03:18 AM\n 03:44 PM\n 01:38 AM\n 06:00 AM\n 01:12 AM\n 06:06 AM\n 02:38 PM\n 02:00 AM\n 02:49 AM\n 01:51 AM\n WBC\n 30.9\n 27.6\n 18.9\n 15.0\n Hct\n 22.2\n 24.0\n 22.2\n 22.5\n 22.1\n Plt\n 28\n 225\n Cr\n 2.8\n 1.6\n 2.7\n 3.0\n TCO2\n 22\n 26\n 18\n 21\n 24\n Glucose\n 170\n 95\n 170\n 121\n 128\n Other labs: PT / PTT / INR:14.3/31.5/1.2, CK / CKMB /\n Troponin-T:214/3/0.07, ALT / AST:67/73, Alk Phos / T Bili:400/6.8,\n Amylase / Lipase:77/88, Differential-Neuts:84.3 %, Band:0.0 %,\n Lymph:9.3 %, Mono:1.7 %, Eos:4.3 %, D-dimer:6389 ng/mL, Fibrinogen:541\n mg/dL, Lactic Acid:2.6 mmol/L, Albumin:2.3 g/dL, LDH:331 IU/L, Ca++:8.6\n mg/dL, Mg++:2.1 mg/dL, PO4:3.7 mg/dL\n Assessment and Plan\n 28 year old male with a history of alcoholism presenting with acute\n hepatitis, pancreatitis, and UGIB.\n .\n # Persistent Fever / Leukocytosis: Marked leukocytosis with low grade\n temperature. UA consistent with UTI, but also may be stress response.\n Off Abx except for micafungin.\n -- f/u blood cultures and urine culture\n -- sputum culture from showing 4+ GNR likely a contaminant\n -- f/u final CT read\n -- appreciate ID recs\n .\n # Neuro\n -- need to discuss with neuro re: their recommendations for patient\n (particularly with valium dosing, EEG, and future imaging).\n # Pancreatitis: Most likely alcoholic in etiology, with elevated\n lipase to 1600 and CT findings consistent without necrosis, cycts, or\n phlemgon. Only mild epigastric tenderness and no complaints of\n abdominal pain.\n -- continue aggessive hydration\n -- serial abdominal exams\n -- trend lipase\n -- no evidence of obstruction, holding off on further imaging at this\n time\n -- check am lipid panel\n .\n # Acute Hepatitis: Likely alcoholic hepatitis. CT scan shows fatty\n infiltration, and no evidence of distal ostruction.\n - check viral hepatitis panel, although degree of transaminitis not\n consistant with such an etiology.\n - holding off on further imaging for now, f/u final CT read\n - hepatology following\n - avoid hepatically cleared meds\n - trend LFTs\n .\n # Hyponatremia: Most likely due to volume depletion in the setting of\n inability to tolerate POs. Patient markedly dry on exam. also\n reflect a more chronic long-term liver disease.\n - fluid repleation as given above\n - if not correcting, will pursue further workup with urine lytes.\n # Alcoholism: Patient describes history of withdrawal symptoms, but\n not prior seizure. Last drink was night prior to presentation.\n Tachycardia, weakness, and elevated lactate could be consistent with\n thiamine deficiency.\n - repleate thiamine, vb12, folate\n - ativan with CIWA > 10\n - addictions consult\n # Trach care\n may need to have trach sutures removed. Will discuss\n with team.\n .\n # FEN: IVF, replete electrolytes, NPO\n .\n # Prophylaxis: scds, PPI gtt\n .\n # Access: peripherals and femoral cortis\n .\n # Code: Full Code\n .\n # Disposition: MICU for now\n ICU Care\n Nutrition:\n Nutren 2.0 () - 01:30 PM 50 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 08:15 PM\n PICC Line - 08:37 AM\n Dialysis Catheter - 08:55 AM\n Prophylaxis:\n DVT: SQ UF Heparin, SCDs\n Stress ulcer: PPI\n VAP: HOB elevation\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n" }, { "category": "Nursing", "chartdate": "2131-06-26 00:00:00.000", "description": "Nursing Progress Note", "row_id": 683179, "text": "Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Cr 3.0. Lytes fairly normal. Tbili trending down and LFTs trending down\n as well.\n u/o has increased to approx 20-40 ccs per hour today.\n HD planned for this shift, in the a.m.\n Action:\n per Renal, d/t increasing u/o and lytes ok, held off on HD today. Plan\n for HD tomorrow.\n Closely followed urine output.\n u/a & c&s sent.\n Response:\n u/o remains 20-40 an hour, sometimes even up to 60-80 ccs/hr.\n urine clearer in appearance as well.\n Plan:\n Cont to closely monitor u/o. D/w team need for HD tomorrow pending labs\n and clinical picture.\n Cultures to be drawn from HD line when accessed by dialysis nurse.\n Provide comfort and support.\n Impaired Skin Integrity\n Assessment:\n LE open blisters with adaptec and DSDs.\n Waffle boots in place. Heels with DTIs.\n Otherwise, skin intact, no noted impairments on back and/or coccyx\n fingersticks elevated.\n Action:\n Dsg\ns changed this a.m.\n heels elevated off bed.\n frequent turning and aloe vesta applied.\n SS insulin.\n Response:\n Skin remains relatively intact.\n Skin impairments on LE much improved since last week. Only one open,\n oozing site.\n FS 125 this afternoon.\n Plan:\n continue with current skin regimen. Provide comfort and support.\n Closely monitor FS and nutritional status.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n 40% TM all day.\n sats 94-98. Suctioning mod amounts of thick tan secretions.\n Able to cough up a fair amount of secretions on his own.\n RR 20-30s though more tachypneic this morning.\n Action:\n OOB to chair this a.m.\n Frequent suctioning and trach care done.\n Response:\n Sats remain unchanged. RR within 20s the rest of the day.\n Secretions remain unchanged (in amount and appearance) from previous\n days.\n Appears comfortable on trach mask though slightly tired.\n Plan:\n Continue to closely monitor respiratory status.\n If pt continues to be more lethargic, ? ABG to assess acid base\n balance.\n D/w team prior to putting back on vent if needed.\n Provide comfort and support.\n Family updated re: POC.\n" }, { "category": "Nursing", "chartdate": "2131-06-26 00:00:00.000", "description": "Nursing Progress Note", "row_id": 683180, "text": "Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Cr 3.0. Lytes fairly normal. Tbili trending down and LFTs trending down\n as well.\n u/o has increased to approx 20-40 ccs per hour today.\n HD planned for this shift, in the a.m.\n Action:\n per Renal, d/t increasing u/o and lytes ok, held off on HD today. Plan\n for HD tomorrow.\n Closely followed urine output.\n u/a & c&s sent.\n Response:\n u/o remains 20-40 an hour, sometimes even up to 60-80 ccs/hr.\n urine clearer in appearance as well.\n Plan:\n Cont to closely monitor u/o. D/w team need for HD tomorrow pending labs\n and clinical picture.\n Cultures to be drawn from HD line when accessed by dialysis nurse.\n Provide comfort and support.\n Impaired Skin Integrity\n Assessment:\n LE open blisters with adaptec and DSDs.\n Waffle boots in place. Heels with DTIs.\n Otherwise, skin intact, no noted impairments on back and/or coccyx\n fingersticks elevated.\n Action:\n Dsg\ns changed this a.m.\n heels elevated off bed.\n frequent turning and aloe vesta applied.\n SS insulin.\n Response:\n Skin remains relatively intact.\n Skin impairments on LE much improved since last week. Only one open,\n oozing site.\n FS 125 this afternoon.\n Plan:\n continue with current skin regimen. Provide comfort and support.\n Closely monitor FS and nutritional status.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n 40% TM all day.\n sats 94-98. Suctioning mod amounts of thick tan secretions.\n Able to cough up a fair amount of secretions on his own.\n RR 20-30s though more tachypneic this morning.\n Action:\n OOB to chair this a.m.\n Frequent suctioning and trach care done.\n Response:\n Sats remain unchanged. RR within 20s the rest of the day.\n Secretions remain unchanged (in amount and appearance) from previous\n days.\n Appears comfortable on trach mask though slightly tired.\n Plan:\n Continue to closely monitor respiratory status.\n If pt continues to be more lethargic, ? ABG to assess acid base\n balance.\n D/w team prior to putting back on vent if needed.\n Provide comfort and support.\n Family updated re: POC.\n" }, { "category": "Respiratory ", "chartdate": "2131-06-26 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 683188, "text": "Day of mechanical ventilation: 4\n Tracheostomy tube:\n Type: Standard, Cuffed\n Manufacturer: Portex\n Size: 8.0\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Clear\n Secretions\n Sputum color / consistency: Tan / Thick\n Sputum source/amount: Suctioned / Moderate\n Comments:\n Pt on 40% trach collar all shift with little distress but now appears\n to be tiring. need vent over night. Still ? of seizure activity and\n will need HD tomorrow.\n" }, { "category": "Respiratory ", "chartdate": "2131-06-22 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 682183, "text": "Airway\n Tube Type\n Tracheostomy tube:\n Type: Standard\n Manufacturer: Portex\n Size: 8.0mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Cuff volume: 3 mL /\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Clear\n Secretions\n Sputum color / consistency: Bloody / Thick\n Sputum source/amount: Suctioned / Moderate\n Comments: Pt also expectorating thick blood plugs.\n" }, { "category": "Respiratory ", "chartdate": "2131-07-03 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 684707, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 0\n Ideal body weight: 67.1 None\n Ideal tidal volume: 268.4 / 402.6 / 536.8 mL/kg\n Airway\n Airway Placement Data\n Tracheostomy tube:\n Type: Cuffed\n Manufacturer: Portex\n Size: 8.0mm\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Cuff volume: 5 mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Rhonchi\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Rhonchi\n Comments:\n Secretions\n Sputum color / consistency: White / Thin\n Sputum source/amount: Suctioned / Copious\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Unassisted spontaneous breathing\n Visual assessment of breathing pattern:\n Assessment of breathing comfort: No response (sleeping / sedated)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Pt remains on trach collar\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": "2131-06-28 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 683539, "text": "Chief Complaint: pancreatitis, resp failure\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n BLOOD CULTURED - At 03:54 PM\n from HD line x 2, one each port\n MAGNETIC RESONANCE IMAGING - At 05:15 PM\n STOOL CULTURE - At 06:01 PM\n cdiff\n Allergies:\n Meropenem\n skin blisters a\n Last dose of Antibiotics:\n Aztreonam - 02:39 PM\n Micafungin - 10:00 PM\n Infusions:\n Other ICU medications:\n Fentanyl - 08:30 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 11:20 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.4\nC (101.1\n Tcurrent: 38.3\nC (101\n HR: 125 (109 - 125) bpm\n BP: 133/76(95) {106/61(76) - 144/77(98)} mmHg\n RR: 31 (21 - 42) insp/min\n SpO2: 96%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 103.9 kg (admission): 113.5 kg\n Height: 67 Inch\n Total In:\n 1,525 mL\n 664 mL\n PO:\n TF:\n 1,201 mL\n 564 mL\n IVF:\n 264 mL\n 100 mL\n Blood products:\n Total out:\n 1,440 mL\n 700 mL\n Urine:\n 1,440 mL\n 700 mL\n NG:\n Stool:\n Drains:\n Balance:\n 85 mL\n -36 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n SpO2: 96%\n ABG: 7.41/33/122/20/-2\n PaO2 / FiO2: 305\n Physical Examination\n Gen: in bed, eyes open, alert but very tachypneic\n CV: RR\n Chest: good air movement\n Abd: distended +BS\n Ext: 3+ edema\n Neuro: eyes open, will blink/ to command, weak grasp, dose not\n follow\n Labs / Radiology\n 6.5 g/dL\n 227 K/uL\n 192 mg/dL\n 2.6 mg/dL\n 20 mEq/L\n 3.4 mEq/L\n 94 mg/dL\n 108 mEq/L\n 140 mEq/L\n 21.5 %\n 10.2 K/uL\n [image002.jpg]\n 01:12 AM\n 06:06 AM\n 02:38 PM\n 02:00 AM\n 02:49 AM\n 01:51 AM\n 03:26 PM\n 03:37 PM\n 03:15 AM\n 03:19 AM\n WBC\n 18.9\n 15.0\n 12.6\n 10.2\n Hct\n 22.2\n 22.5\n 22.1\n 21.5\n Plt\n 230\n 228\n 225\n 227\n Cr\n 2.7\n 3.0\n 2.9\n 2.7\n 2.6\n TCO2\n 18\n 21\n 24\n 23\n 22\n Glucose\n 121\n 128\n 80\n 129\n 194\n 192\n Other labs: PT / PTT / INR:13.6/28.0/1.2, CK / CKMB /\n Troponin-T:214/3/0.07, ALT / AST:75/115, Alk Phos / T Bili:408/5.5,\n Amylase / Lipase:77/88, Differential-Neuts:84.3 %, Band:0.0 %,\n Lymph:9.3 %, Mono:1.7 %, Eos:4.3 %, D-dimer:6389 ng/mL, Fibrinogen:541\n mg/dL, Lactic Acid:2.6 mmol/L, Albumin:2.3 g/dL, LDH:312 IU/L, Ca++:8.6\n mg/dL, Mg++:2.0 mg/dL, PO4:2.7 mg/dL\n Assessment and Plan\n FEVER, UNKNOWN ORIGIN (FUO, HYPERTHERMIA, PYREXIA)\n AROUSAL, ATTENTION, AND COGNITION, IMPAIRED\n BALANCE, IMPAIRED\n MOTOR FUNCTION, IMPAIRED\n MUSCLE PERFORMACE, IMPAIRED\n RESPIRATION / GAS EXCHANGE, IMPAIRED\n SEIZURE, WITHOUT STATUS EPILEPTICUS\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n IMPAIRED SKIN INTEGRITY\n HEPATITIS, ACUTE TOXIC (INCLUDING ALCOHOLIC, ACETAMINOPHEN, ETC.)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n 1. Cyclical fevers\n single spike today after 3 days without.\n WBC trend is down and hemodynamically stable. We have been weaning off\n ABX since nothing has grown\n will continue only micafungin while\n monitoring culture data. Will got blood cx off HD line. Does have GNR\n in sputum but is likely colonized\n repeat CXR without infiltrate. For\n now would not empirically Rx for GNR PNA unless CXR change with phlegm\n chage and infiltrates but will follow closely. ABd still a potential\n culprit re pancreatic fluid collection but again this is one fever-\n lets follow clinically and re eval.\n 2. Hypotension: resolved\n watch carefully now that he is spiking\n as he has a tendency to drop his MAPs\n 3. Resp Failure: on trach mask and holding his own, though is\n tachyneic this AM w fevers\n 4. Altered Mental status: Given possibility of sz activity, will\n continue keppra. MRI and EEH done to help with work up\n 5. For ARF: making good urine this AM, hold off on HD\n 6. For pancreatitis, will continue post-pyloric TFs, and will\n continue to hold off on any drainage of new peripancreatic fluid\n collection but will discuss with Dr \n Remaining issues as per Housestaff\n ICU Care\n Nutrition: Nutren 2.0 () - 01:27 PM 50 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 08:15 PM\n PICC Line - 08:37 AM\n Dialysis Catheter - 08:55 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n Communication: spoke with brother last night and updated he\n will be present this afternoon\n Code status: Full code\n Disposition :ICU\n Total time spent:\n" }, { "category": "Nursing", "chartdate": "2131-07-03 00:00:00.000", "description": "Nursing Progress Note", "row_id": 684758, "text": "Arousal, Attention, and Cognition, Impaired\n Assessment:\n -Opens eyes spontaneously, track, does not follow commands,\n occasionally appears to make a facial expressions.\n -PERRLA, 3-4mm bilaterally,brisk.\n -Spontaneously lifts and holds R+LUE, moving R-LLE on bed.\n -Intermittent tremors in all four extremities-No seizure activity\n noted.\n -Tachypneic to the 50\ns, MD Team notified. Question of Neurogenic.\n POX: 97-100%.\n -LS: Rhonchi throughout.\n Action:\n -Neuro exam q 4. Frequent reorientation and passive ROM to all\n extremities.\n -Aggressive pulmonary hygiene/trach care for copious amounts of thin\n white/blood tinged/pale yellow secretions.\n -Keppra given.\n -Aggressive skin care to back/, peri-anal area and extremities.\n Response:\n -Continues to have copious amounts of secretions-LS clear with\n suctioning.\n -Skin remains intact.\n -Continue Keppra for seizure prophylaxes.\n Plan:\n rehab screening.\n -Aggressive pulmonary hygiene.\n -Provided supportive care to patient and family.\n -Plan family meeting with MD tonight ().\n Problem - \n Assessment:\n -Serum NA 147.\n Action:\n -Continues D5W at 75cc/h.\n -Free water boluses increased to 150cc every two hours for\n hypernatremia.\n -Repeat labs at 1700 pending.\n Response:\n -Repeat labs pending.\n Plan:\n -Continue to closely follow and trend serum sodium\ns and chlorides\n notified MICU MD .\n Continue to provide supportive care to patient and family. Social work\n to follow.\n" }, { "category": "Physician ", "chartdate": "2131-07-01 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 684160, "text": "Chief Complaint:\n 24 Hour Events:\n INVASIVE VENTILATION - STOP 06:43 PM\n has been off ventilator for a couple of days. currently on TM.\n FEVER - 101.7\nF - 04:00 PM\n - d/c'ed micafungin as per ID, as unclear if helping or not. Will see\n how he does off micafungin over weekend, if doing poorly, consider\n further imaging prior to Monday.\n - Dr. will email Dr. to ensure that micafungin plan\n is okay.\n - CMV VL ordered 5 days from now, as per ID\n - neurology had sobering and extensive discussion with family re: poor\n prognosis and long term plan\n - will tolerate low grade temps given lack of source and known necrotic\n pancreas\n - K and phos repleted and look fine\n - HD line and a line d/c'ed\n - will d/c foley and try condom cath\n Allergies:\n Meropenem\n skin blisters a\n Last dose of Antibiotics:\n Micafungin - 10:00 PM\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 01:00 PM\n Heparin Sodium (Prophylaxis) - 04:15 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:39 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.7\nC (101.7\n Tcurrent: 36.2\nC (97.2\n HR: 108 (108 - 128) bpm\n BP: 124/71(81) {93/44(54) - 139/86(118)} mmHg\n RR: 27 (27 - 40) insp/min\n SpO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 103.3 kg (admission): 113.5 kg\n Height: 67 Inch\n Total In:\n 2,113 mL\n 382 mL\n PO:\n TF:\n 1,203 mL\n 382 mL\n IVF:\n Blood products:\n Total out:\n 1,655 mL\n 520 mL\n Urine:\n 1,655 mL\n 520 mL\n NG:\n Stool:\n Drains:\n Balance:\n 458 mL\n -138 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n SpO2: 100%\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 310 K/uL\n 6.8 g/dL\n 161 mg/dL\n 1.6 mg/dL\n 19 mEq/L\n 5.1 mEq/L\n 87 mg/dL\n 120 mEq/L\n 149 mEq/L\n 22.5 %\n 11.0 K/uL\n [image002.jpg]\n 03:37 PM\n 03:15 AM\n 03:19 AM\n 10:00 AM\n 04:00 PM\n 02:16 AM\n 04:14 PM\n 10:00 PM\n 02:32 AM\n 04:25 AM\n WBC\n 10.2\n 11.4\n 10.9\n 11.0\n Hct\n 21.5\n 21.7\n 22.2\n 22.5\n Plt\n 227\n 266\n 290\n 310\n Cr\n 2.6\n 2.1\n 2.0\n 1.9\n 1.6\n TCO2\n 23\n 22\n Glucose\n 194\n 192\n 200\n 211\n 98\n 151\n 177\n 116\n 161\n Other labs: PT / PTT / INR:13.6/28.0/1.2, CK / CKMB /\n Troponin-T:214/3/0.07, ALT / AST:91/137, Alk Phos / T Bili:318/4.1,\n Amylase / Lipase:78/91, Differential-Neuts:57.0 %, Band:4.0 %,\n Lymph:23.0 %, Mono:4.0 %, Eos:3.0 %, D-dimer:6389 ng/mL, Fibrinogen:541\n mg/dL, Lactic Acid:2.6 mmol/L, Albumin:2.3 g/dL, LDH:437 IU/L, Ca++:9.4\n mg/dL, Mg++:2.1 mg/dL, PO4:4.5 mg/dL\n Assessment and Plan\n FEVER, UNKNOWN ORIGIN (FUO, HYPERTHERMIA, PYREXIA)\n AROUSAL, ATTENTION, AND COGNITION, IMPAIRED\n BALANCE, IMPAIRED\n MOTOR FUNCTION, IMPAIRED\n MUSCLE PERFORMACE, IMPAIRED\n RESPIRATION / GAS EXCHANGE, IMPAIRED\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n IMPAIRED SKIN INTEGRITY\n HEPATITIS, ACUTE TOXIC (INCLUDING ALCOHOLIC, ACETAMINOPHEN, ETC.)\n ICU Care\n Nutrition:\n Nutren 2.0 () - 01:12 PM 50 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n PICC Line - 08:37 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:ICU\n" }, { "category": "Physician ", "chartdate": "2131-07-01 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 684162, "text": "Chief Complaint:\n 24 Hour Events:\n INVASIVE VENTILATION - STOP 06:43 PM\n has been off ventilator for a couple of days. currently on TM.\n FEVER - 101.7\nF - 04:00 PM\n Allergies:\n Meropenem\n skin blisters a\n Last dose of Antibiotics:\n Micafungin - 10:00 PM\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 01:00 PM\n Heparin Sodium (Prophylaxis) - 04:15 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:39 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.7\nC (101.7\n Tcurrent: 36.2\nC (97.2\n HR: 108 (108 - 128) bpm\n BP: 124/71(81) {93/44(54) - 139/86(118)} mmHg\n RR: 27 (27 - 40) insp/min\n SpO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 103.3 kg (admission): 113.5 kg\n Height: 67 Inch\n Total In:\n 2,113 mL\n 382 mL\n PO:\n TF:\n 1,203 mL\n 382 mL\n IVF:\n Blood products:\n Total out:\n 1,655 mL\n 520 mL\n Urine:\n 1,655 mL\n 520 mL\n NG:\n Stool:\n Drains:\n Balance:\n 458 mL\n -138 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n SpO2: 100%\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 310 K/uL\n 6.8 g/dL\n 161 mg/dL\n 1.6 mg/dL\n 19 mEq/L\n 5.1 mEq/L\n 87 mg/dL\n 120 mEq/L\n 149 mEq/L\n 22.5 %\n 11.0 K/uL\n [image002.jpg]\n 03:37 PM\n 03:15 AM\n 03:19 AM\n 10:00 AM\n 04:00 PM\n 02:16 AM\n 04:14 PM\n 10:00 PM\n 02:32 AM\n 04:25 AM\n WBC\n 10.2\n 11.4\n 10.9\n 11.0\n Hct\n 21.5\n 21.7\n 22.2\n 22.5\n Plt\n 227\n 266\n 290\n 310\n Cr\n 2.6\n 2.1\n 2.0\n 1.9\n 1.6\n TCO2\n 23\n 22\n Glucose\n 194\n 192\n 200\n 211\n 98\n 151\n 177\n 116\n 161\n Other labs: PT / PTT / INR:13.6/28.0/1.2, CK / CKMB /\n Troponin-T:214/3/0.07, ALT / AST:91/137, Alk Phos / T Bili:318/4.1,\n Amylase / Lipase:78/91, Differential-Neuts:57.0 %, Band:4.0 %,\n Lymph:23.0 %, Mono:4.0 %, Eos:3.0 %, D-dimer:6389 ng/mL, Fibrinogen:541\n mg/dL, Lactic Acid:2.6 mmol/L, Albumin:2.3 g/dL, LDH:437 IU/L, Ca++:9.4\n mg/dL, Mg++:2.1 mg/dL, PO4:4.5 mg/dL\n Assessment and Plan\n 28 year old male with a history of alcoholism presenting with acute\n hepatitis, pancreatitis, and UGIB, with persistent cyclic\n fevers/leukocytosis.\n # Cyclic fevers/leukocytosis\n Pt had temp to 101.7 yesterday. WBC at\n 11\n still stable/trending down.\n - will tolerate slight fevers as long as patient does not have clinical\n deterioration or WBC elevations\n - Cdiff negative\n - sputum cultures\n moderate growth GNR resembling acinetobacter\n (susceptibilities done)\n - blood cultures pending\n - will not start gancyclovir at this point - CMV not likely cause of\n fevers. Per yesterday\ns progress note, will follow LFTs and if rising\n will see if correlates with CMV viral load. If so, will discuss with\n renal and ID.\n - will order an abdominal CT in the next few days to reevaluate\n peripancreatic fluid.\n # Respiratory failure\n on trach mask at 40% FIO2, tachypnic this AM.\n -Tachypnea may be centrally driven cerebral injury\n # Acute renal failure\n stable and UOP continues improving (currently\n ~60 cc/hr over last 24hrs.).\n -Cont. to follow UOP\n -Will follow lytes as may over correct with return of function.\n # Altered mental status\n Given possibility of seizure activity, will\n continue keppra. MRI showing cerebral edema, poor prognosis as per\n neuro. EEG shows encephalopathy. Family meeting with Neuro\n yesterday. Full recovery to baseline unlikely, and longterm meaningful\n survival low due to cerebral injury.\n -Will need neuro rehab.\n # Anemia\n Hctstable. Will hold off transfusing and cont to follow.\n # Acute Hepatitis: Likely alcoholic hepatitis. CT scan shows fatty\n infiltration, and no evidence of distal obstruction.\n - Continue to trend LFTs\n - Will correlate LFTs with CMV viral load if they continue to rise.\n -If CMV likely cause may need to start gancyclovir however as this is\n nephrotoxic will need to discuss with ID/Renal\n # FEN: IVF, replete electrolytes, NPO\n ICU Care\n Nutrition:\n Nutren 2.0 () - 01:12 PM 50 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n PICC Line - 08:37 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:ICU\n" }, { "category": "Physician ", "chartdate": "2131-07-01 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 684163, "text": "Chief Complaint:\n 24 Hour Events:\n INVASIVE VENTILATION - STOP 06:43 PM\n has been off ventilator for a couple of days. currently on TM.\n FEVER - 101.7\nF - 04:00 PM\n Allergies:\n Meropenem\n skin blisters a\n Last dose of Antibiotics:\n Micafungin - 10:00 PM\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 01:00 PM\n Heparin Sodium (Prophylaxis) - 04:15 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:39 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.7\nC (101.7\n Tcurrent: 36.2\nC (97.2\n HR: 108 (108 - 128) bpm\n BP: 124/71(81) {93/44(54) - 139/86(118)} mmHg\n RR: 27 (27 - 40) insp/min\n SpO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 103.3 kg (admission): 113.5 kg\n Height: 67 Inch\n Total In:\n 2,113 mL\n 382 mL\n PO:\n TF:\n 1,203 mL\n 382 mL\n IVF:\n Blood products:\n Total out:\n 1,655 mL\n 520 mL\n Urine:\n 1,655 mL\n 520 mL\n NG:\n Stool:\n Drains:\n Balance:\n 458 mL\n -138 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n SpO2: 100%\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 310 K/uL\n 6.8 g/dL\n 161 mg/dL\n 1.6 mg/dL\n 19 mEq/L\n 5.1 mEq/L\n 87 mg/dL\n 120 mEq/L\n 149 mEq/L\n 22.5 %\n 11.0 K/uL\n [image002.jpg]\n 03:37 PM\n 03:15 AM\n 03:19 AM\n 10:00 AM\n 04:00 PM\n 02:16 AM\n 04:14 PM\n 10:00 PM\n 02:32 AM\n 04:25 AM\n WBC\n 10.2\n 11.4\n 10.9\n 11.0\n Hct\n 21.5\n 21.7\n 22.2\n 22.5\n Plt\n 227\n 266\n 290\n 310\n Cr\n 2.6\n 2.1\n 2.0\n 1.9\n 1.6\n TCO2\n 23\n 22\n Glucose\n 194\n 192\n 200\n 211\n 98\n 151\n 177\n 116\n 161\n Other labs: PT / PTT / INR:13.6/28.0/1.2, CK / CKMB /\n Troponin-T:214/3/0.07, ALT / AST:91/137, Alk Phos / T Bili:318/4.1,\n Amylase / Lipase:78/91, Differential-Neuts:57.0 %, Band:4.0 %,\n Lymph:23.0 %, Mono:4.0 %, Eos:3.0 %, D-dimer:6389 ng/mL, Fibrinogen:541\n mg/dL, Lactic Acid:2.6 mmol/L, Albumin:2.3 g/dL, LDH:437 IU/L, Ca++:9.4\n mg/dL, Mg++:2.1 mg/dL, PO4:4.5 mg/dL\n Assessment and Plan\n 28 year old male with a history of alcoholism presenting with acute\n hepatitis, pancreatitis, and UGIB, with persistent cyclic\n fevers/leukocytosis.\n # Cyclic fevers/leukocytosis\n Pt had temp to 101.7 yesterday. WBC at\n 11\n still stable/trending down.\n - will tolerate slight fevers as long as patient does not have clinical\n deterioration or WBC elevations\n - Cdiff negative\n - sputum cultures\n moderate growth GNR resembling acinetobacter\n (susceptibilities done)\n - blood cultures pending\n - will not start gancyclovir at this point - CMV not likely cause of\n fevers. Per yesterday\ns progress note, will follow LFTs and if rising\n will see if correlates with CMV viral load. If so, will discuss with\n renal and ID.\n - will order an abdominal CT in the next few days to reevaluate\n peripancreatic fluid.\n # Respiratory failure\n on trach mask at 40% FIO2, tachypnic this AM.\n -Tachypnea may be centrally driven cerebral injury\n # Acute renal failure\n stable and UOP continues improving (currently\n ~60 cc/hr over last 24hrs.).\n -Cont. to follow UOP\n -Will follow lytes as may over correct with return of function.\n # Altered mental status\n Given possibility of seizure activity, will\n continue keppra. MRI showing cerebral edema, poor prognosis as per\n neuro. EEG shows encephalopathy. Family meeting with Neuro\n yesterday. Full recovery to baseline unlikely, and longterm meaningful\n survival low due to cerebral injury.\n -Will need neuro rehab.\n # Anemia\n Hctstable. Will hold off transfusing and cont to follow.\n # Acute Hepatitis: Likely alcoholic hepatitis. CT scan shows fatty\n infiltration, and no evidence of distal obstruction.\n - Continue to trend LFTs\n - Will correlate LFTs with CMV viral load if they continue to rise.\n -If CMV likely cause may need to start gancyclovir however as this is\n nephrotoxic will need to discuss with ID/Renal\n # FEN: IVF, replete electrolytes, NPO\n ICU Care\n Nutrition:\n Nutren 2.0 () - 01:12 PM 50 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n PICC Line - 08:37 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:ICU\n" }, { "category": "Physician ", "chartdate": "2131-07-01 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 684164, "text": "Chief Complaint:\n 24 Hour Events:\n INVASIVE VENTILATION - STOP 06:43 PM\n has been off ventilator for a couple of days. currently on TM.\n FEVER - 101.7\nF - 04:00 PM\n Allergies:\n Meropenem\n skin blisters a\n Last dose of Antibiotics:\n Micafungin - 10:00 PM\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 01:00 PM\n Heparin Sodium (Prophylaxis) - 04:15 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:39 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.7\nC (101.7\n Tcurrent: 36.2\nC (97.2\n HR: 108 (108 - 128) bpm\n BP: 124/71(81) {93/44(54) - 139/86(118)} mmHg\n RR: 27 (27 - 40) insp/min\n SpO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 103.3 kg (admission): 113.5 kg\n Height: 67 Inch\n Total In:\n 2,113 mL\n 382 mL\n PO:\n TF:\n 1,203 mL\n 382 mL\n IVF:\n Blood products:\n Total out:\n 1,655 mL\n 520 mL\n Urine:\n 1,655 mL\n 520 mL\n NG:\n Stool:\n Drains:\n Balance:\n 458 mL\n -138 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n SpO2: 100%\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 310 K/uL\n 6.8 g/dL\n 161 mg/dL\n 1.6 mg/dL\n 19 mEq/L\n 5.1 mEq/L\n 87 mg/dL\n 120 mEq/L\n 149 mEq/L\n 22.5 %\n 11.0 K/uL\n [image002.jpg]\n 03:37 PM\n 03:15 AM\n 03:19 AM\n 10:00 AM\n 04:00 PM\n 02:16 AM\n 04:14 PM\n 10:00 PM\n 02:32 AM\n 04:25 AM\n WBC\n 10.2\n 11.4\n 10.9\n 11.0\n Hct\n 21.5\n 21.7\n 22.2\n 22.5\n Plt\n 227\n 266\n 290\n 310\n Cr\n 2.6\n 2.1\n 2.0\n 1.9\n 1.6\n TCO2\n 23\n 22\n Glucose\n 194\n 192\n 200\n 211\n 98\n 151\n 177\n 116\n 161\n Other labs: PT / PTT / INR:13.6/28.0/1.2, CK / CKMB /\n Troponin-T:214/3/0.07, ALT / AST:91/137, Alk Phos / T Bili:318/4.1,\n Amylase / Lipase:78/91, Differential-Neuts:57.0 %, Band:4.0 %,\n Lymph:23.0 %, Mono:4.0 %, Eos:3.0 %, D-dimer:6389 ng/mL, Fibrinogen:541\n mg/dL, Lactic Acid:2.6 mmol/L, Albumin:2.3 g/dL, LDH:437 IU/L, Ca++:9.4\n mg/dL, Mg++:2.1 mg/dL, PO4:4.5 mg/dL\n Assessment and Plan\n 28 year old male with a history of alcoholism presenting with acute\n hepatitis, pancreatitis, and UGIB, with persistent cyclic\n fevers/leukocytosis.\n # Cyclic fevers/leukocytosis\n Pt had temp to 101.7 yesterday. WBC at\n 11\n still stable/trending down.\n - will tolerate slight fevers as long as patient does not have clinical\n deterioration or WBC elevations\n - Cdiff negative\n - sputum cultures\n moderate growth GNR resembling acinetobacter\n (susceptibilities done)\n - blood cultures pending\n - will not start gancyclovir at this point - CMV not likely cause of\n fevers. Per yesterday\ns progress note, will follow LFTs and if rising\n will see if correlates with CMV viral load. If so, will discuss with\n renal and ID.\n - will order an abdominal CT in the next few days to reevaluate\n peripancreatic fluid.\n # Respiratory failure\n Pt is on trach mask at 40% FIO2.\n - Pt is still tachypneic. (RR 27-40).\n - Considering pt\ns neuro findings, this may be a centrally-driven.\n # Acute renal failure\n -\n - will continue to follow UOP, BUN, and Cr\n # Altered mental status\n Given possibility of seizure activity, will\n continue keppra. MRI showing cerebral edema, poor prognosis as per\n neuro. EEG shows encephalopathy. Family meeting with Neuro\n yesterday. Full recovery to baseline unlikely, and longterm meaningful\n survival low due to cerebral injury.\n -Will need neuro rehab.\n # Anemia\n Hctstable. Will hold off transfusing and cont to follow.\n # Acute Hepatitis: Likely alcoholic hepatitis. CT scan shows fatty\n infiltration, and no evidence of distal obstruction.\n - Continue to trend LFTs\n - Will correlate LFTs with CMV viral load if they continue to rise.\n -If CMV likely cause may need to start gancyclovir however as this is\n nephrotoxic will need to discuss with ID/Renal\n # FEN: IVF, replete electrolytes, NPO\n ICU Care\n Nutrition:\n Nutren 2.0 () - 01:12 PM 50 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n PICC Line - 08:37 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:ICU\n" }, { "category": "Physician ", "chartdate": "2131-07-01 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 684166, "text": "Chief Complaint:\n 24 Hour Events:\n INVASIVE VENTILATION - STOP 06:43 PM\n has been off ventilator for a couple of days. currently on TM.\n FEVER - 101.7\nF - 04:00 PM\n Allergies:\n Meropenem\n skin blisters a\n Last dose of Antibiotics:\n Micafungin - 10:00 PM\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 01:00 PM\n Heparin Sodium (Prophylaxis) - 04:15 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:39 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.7\nC (101.7\n Tcurrent: 36.2\nC (97.2\n HR: 108 (108 - 128) bpm\n BP: 124/71(81) {93/44(54) - 139/86(118)} mmHg\n RR: 27 (27 - 40) insp/min\n SpO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 103.3 kg (admission): 113.5 kg\n Height: 67 Inch\n Total In:\n 2,113 mL\n 382 mL\n PO:\n TF:\n 1,203 mL\n 382 mL\n IVF:\n Blood products:\n Total out:\n 1,655 mL\n 520 mL\n Urine:\n 1,655 mL\n 520 mL\n NG:\n Stool:\n Drains:\n Balance:\n 458 mL\n -138 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n SpO2: 100%\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 310 K/uL\n 6.8 g/dL\n 161 mg/dL\n 1.6 mg/dL\n 19 mEq/L\n 5.1 mEq/L\n 87 mg/dL\n 120 mEq/L\n 149 mEq/L\n 22.5 %\n 11.0 K/uL\n [image002.jpg]\n 03:37 PM\n 03:15 AM\n 03:19 AM\n 10:00 AM\n 04:00 PM\n 02:16 AM\n 04:14 PM\n 10:00 PM\n 02:32 AM\n 04:25 AM\n WBC\n 10.2\n 11.4\n 10.9\n 11.0\n Hct\n 21.5\n 21.7\n 22.2\n 22.5\n Plt\n 227\n 266\n 290\n 310\n Cr\n 2.6\n 2.1\n 2.0\n 1.9\n 1.6\n TCO2\n 23\n 22\n Glucose\n 194\n 192\n 200\n 211\n 98\n 151\n 177\n 116\n 161\n Other labs: PT / PTT / INR:13.6/28.0/1.2, CK / CKMB /\n Troponin-T:214/3/0.07, ALT / AST:91/137, Alk Phos / T Bili:318/4.1,\n Amylase / Lipase:78/91, Differential-Neuts:57.0 %, Band:4.0 %,\n Lymph:23.0 %, Mono:4.0 %, Eos:3.0 %, D-dimer:6389 ng/mL, Fibrinogen:541\n mg/dL, Lactic Acid:2.6 mmol/L, Albumin:2.3 g/dL, LDH:437 IU/L, Ca++:9.4\n mg/dL, Mg++:2.1 mg/dL, PO4:4.5 mg/dL\n Assessment and Plan\n 28 year old male with a history of alcoholism presenting with acute\n hepatitis, pancreatitis, and UGIB, with persistent cyclic\n fevers/leukocytosis.\n # Cyclic fevers/leukocytosis\n Pt had temp to 101.7 yesterday. WBC at\n 11\n still stable/trending down.\n - will tolerate slight fevers as long as patient does not have clinical\n deterioration or WBC elevations\n - Cdiff negative\n - sputum cultures\n moderate growth GNR resembling acinetobacter\n (susceptibilities done)\n - blood cultures pending\n - will not start gancyclovir at this point - CMV not likely cause of\n fevers. Per yesterday\ns progress note, will follow LFTs and if rising\n will see if correlates with CMV viral load. If so, will discuss with\n renal and ID.\n - will order an abdominal CT in the next few days to reevaluate\n peripancreatic fluid.\n # Respiratory failure\n Pt is on trach mask at 40% FIO2.\n - Pt is still tachypneic. (RR 27-40).\n - Considering pt\ns neuro findings, this may be a centrally-driven.\n # Acute renal failure\n - pt put out 1.6 L urine yesterday\n - will continue to follow UOP, BUN, and Cr\n # Altered mental status\n pt had MRI that showed diffuse subacute\n anoxic injury involving the basal ganglia and cortex\n - poor prognosis per neuro.\n - pt will need neuro rehab upon discharge from the MICU\n # Anemia\n - Hct stable\n - continue to monitor Hct\n # Acute Hepatitis: Likely alcoholic hepatitis. CT scan shows fatty\n infiltration, and no evidence of distal obstruction.\n - will continue to trend LFT\n - will also observe whether any rises in LFT\ns are correlated with\n rises in CMV titer\n # FEN: IVF, replete electrolytes, Nutren at 50 ml/hr\n ICU Care\n Nutrition:\n Nutren 2.0 () - 01:12 PM 50 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n PICC Line - 08:37 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:ICU\n" }, { "category": "Rehab Services", "chartdate": "2131-07-04 00:00:00.000", "description": "PMV Follow-Up", "row_id": 684982, "text": "TITLE: PMV FOLLOW-UP\nAttempted to see patient for repeat PMV evaluation. Spoke with RN\nwho reported patient continues with increased secretions\nrequiring frequent suctioning. Patient was sleeping upon arrival,\nand was unarousable to maximum verbal and tactile cues, movement,\nand tracheal suctioning. Patient's vital signs were O2 sats 100%\non trach collar and RR low 30s. Cuff deflation was attempted and\ntracheal suctioning provided returned moderate amount of thick\nsecretions. O2 sats were noted to slowly desaturate within the\n90s while RR increased to 47/48. O2 sats were noted to rise\ntoward 100% and RR did reduce, however vital signs continued to\nfluctuate and could not stabilize with cuff deflated. Patient\nremained asleep and cuff was reinflated and vitals returned to\nand stablized at 100% O2 and 32 RR.\nSUMMARY/RECOMMENDATIONS:\nPatient was sleeping and unarousable despite maximum cues and\nvital signs could not stabilize with cuff deflated during today's\ntrial. PMV was not attempted fluctuating vitals with cuff\ndeflated and patient not awake. We will continue to follow and\nre-attempt cuff deflation and PMV evaluation when patient is more\nawake and alert.\n_______________________________\n , MS, CCC-SLP\nPager #\nFace Time: 1325-1340\nTotal Time: 40 minutes\n" }, { "category": "Physician ", "chartdate": "2131-07-04 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 684983, "text": "Chief Complaint:\n 24 Hour Events:\n ULTRASOUND - At 02:17 PM\n PAN CULTURE - At 08:50 PM\n FEVER - 101.9\nF - 08:00 PM\n -2100: Called for temp spike to 101.9. Blood/Urine/Sputum Cx sent.\n Allergies:\n Meropenem\n skin blisters a\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 12:21 PM\n Furosemide (Lasix) - 12:45 PM\n Heparin Sodium (Prophylaxis) - 05:30 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 06:19 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.8\nC (101.9\n Tcurrent: 37\nC (98.6\n HR: 111 (109 - 129) bpm\n BP: 125/91(99) {101/54(74) - 138/91(117)} mmHg\n RR: 44 (27 - 59) insp/min\n SpO2: 98%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 99.1 kg (admission): 113.5 kg\n Height: 67 Inch\n Total In:\n 4,882 mL\n 966 mL\n PO:\n TF:\n 1,200 mL\n 315 mL\n IVF:\n 2,032 mL\n 51 mL\n Blood products:\n Total out:\n 2,575 mL\n 710 mL\n Urine:\n 2,575 mL\n 710 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,307 mL\n 256 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n SpO2: 98%\n ABG: ///18/\n Physical Examination\n General\n Alert, Tracks with his eyes\n CV\n RRR; no murmurs, rubs, or gallops\n Resp\n clear to auscultation bilaterally\n Abdomen\n soft; non-tender; non-distended\n Extremities\n some slight pitting edema in the LE\ns bilaterally\n Labs / Radiology\n 349 K/uL\n 6.8 g/dL\n 111 mg/dL\n 1.0 mg/dL\n 18 mEq/L\n 4.4 mEq/L\n 48 mg/dL\n 115 mEq/L\n 142 mEq/L\n 23.6 %\n 11.6 K/uL\n [image002.jpg]\n 10:00 PM\n 02:32 AM\n 04:25 AM\n 03:56 PM\n 02:32 AM\n 08:00 PM\n 12:35 AM\n 03:21 AM\n 04:44 PM\n 02:42 AM\n WBC\n 10.9\n 11.0\n 10.5\n 11.1\n 11.6\n Hct\n 22.2\n 22.5\n 22.3\n 22.1\n 23.6\n Plt\n 290\n 310\n 327\n 341\n 349\n Cr\n 1.9\n 1.6\n 1.3\n 1.2\n 1.2\n 1.1\n 1.0\n 1.0\n TCO2\n 20\n Glucose\n 177\n 116\n 161\n 97\n 93\n 147\n 187\n 111\n Other labs: PT / PTT / INR:13.6/28.0/1.2, CK / CKMB /\n Troponin-T:214/3/0.07, ALT / AST:60/85, Alk Phos / T Bili:247/2.8,\n Amylase / Lipase:78/91, Differential-Neuts:57.0 %, Band:4.0 %,\n Lymph:23.0 %, Mono:4.0 %, Eos:3.0 %, D-dimer:6389 ng/mL, Fibrinogen:541\n mg/dL, Lactic Acid:2.6 mmol/L, Albumin:2.4 g/dL, LDH:437 IU/L, Ca++:9.2\n mg/dL, Mg++:1.8 mg/dL, PO4:4.2 mg/dL\n Echo () - The left atrium is normal in size. Overall left\n ventricular systolic function is normal (LVEF>55%). Tissue Doppler\n imaging suggests a normal left ventricular filling pressure\n (PCWP<12mmHg). Right ventricular chamber size and free wall motion are\n normal. The aortic valve leaflets (3) appear structurally normal with\n good leaflet excursion and no aortic regurgitation. The mitral valve\n appears structurally normal with trivial mitral regurgitation. There is\n no pericardial effusion. No vegetation seen (cannot definitively\n exclude).\n Compared with the prior study (images reviewed) of , there is\n no significant change.\nSputum culture PRELIM\n multiple organisms c/w oropharyngeal flora\nBlood/urine cx and CMV VL\n PENDING\n Assessment and Plan\n 28 year old male with a history of alcoholism presenting with acute\n hepatitis, pancreatitis, and UGIB, with persistent cyclic\n fevers/leukocytosis and anoxic brain injury.\n # Cyclic fevers/leukocytosis\n - Pt spiked a fever to 101.9 last night. Pan cultures done. WBC 11.6\n - Prelim sputum culture c/w oropharyngeal flora\n will f/u\n - Blood and urine cx still pending\n will f/u\n - CMV VL pending\n if increased, will check to see if it correlates\n with an increase in LFTs\n if so, will consider tx of CMV\n - will also consider tx of CMV if pt continues to have fevers, has\n clinical deterioration, or has end organ dysfunction\n # Respiratory failure\n Pt is on trach mask at 40% FIO2.\n - Pt is still tachypneic. (RR 27-59).\n - Considering pt\ns neuro findings, this may be centrally-driven.\n - also be d/t an infectious process, although clear CXR makes this\n unlikely\n will follow up culture data\n # Acute renal failure\n - pt put out 2.6 L urine yesterday.\n I/O net positive 2.3 L\n -Cr improved at 1.0.\n - will continue to follow UOP, BUN, and Cr\n - Will start pt on PO lasix at 40 mg daily\n - will also decrease free water boluses to 100mL q4 hrs\n # Mental status/anoxic brain injury\n pt had MRI that showed diffuse\n subacute anoxic injury involving the basal ganglia and cortex\n - poor prognosis per neuro with likely long term prognosis persistent\n vegetative state.\n - F/u second neuron opinion\n # Anemia\n - Hct stable\n - continue to monitor Hct\n # Acute Hepatitis: Likely alcoholic hepatitis. CT scan shows fatty\n infiltration, and no evidence of distal obstruction.\n - will continue to trend LFT\ns and correlate with CMV load\n - AST/ALT on were 60 and 85, which is improved from previous\n overall\n will correlated with CMV VL\n # FEN: IVF, replete electrolytes, Nutren at 50 ml/hr. Given volume\n status will discuss with nutrition if possible to concentrate further.\n ICU Care\n Nutrition:\n Nutren 2.0 () - 12:21 PM 50 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n PICC Line - 08:37 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:ICU\n" }, { "category": "Respiratory ", "chartdate": "2131-06-29 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 683783, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 7\n Ideal body weight: 67.1 None\n Ideal tidal volume: 268.4 / 402.6 / 536.8 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location:\n Reason:\n Tube Type\n Tracheostomy tube:\n Type: Cuffed\n Manufacturer: Portex\n Size: 8.0mm\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Cuff volume: 6 mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: 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: Expectorated / Small\n Comments:\n Comments: Pt remains on 40% trach collar tol well with spo2 upper 90s\n RR mid to low 20s. BS clear to slightly course sxing for small amts of\n thick white secretions x1 by RT. Pt has good productive cough and is\n able to expectorate most secretions on own. Will cont to follow.\n" }, { "category": "Nursing", "chartdate": "2131-06-29 00:00:00.000", "description": "Nursing Progress Note", "row_id": 683787, "text": " Problem\n Discharge goals/rehab screening\n Assessment:\n Patient medically continues to improve\n Neuo remains stable\n Off vent, off dialysis\n Need to begin more aggressive rehab screen\n Need plan in place for antibiotic/anti fungal coverage considering\n patient does daily spike temps\n yet continues to have negative culture data\n Action:\n Page 2 done\n MICU case manager to be contact by MICU team\n Family to have meeting w/attending neurologist to discuss\n prognosis/expected neuro recovery\n Response:\n Plan:\n Set future goal for rehab\n Have family/case management work together to find appropriate facility\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Remains off vent\n Contiues to have a lot of secretions\n Able to cough and raise most of them\n Action:\n Suction as needed\n Frequent trach care and changing of allevyn dressing\n a line out per team, long term trach patient\n Response:\n stable\n Plan:\n as above\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n ARF resolving\n Dialysis cath out\n K/Phos low\n Sodium rising\n Action:\n Electrolyte repletion\n Free H2O bloluses\n250cc/q6 hrs.\n Response:\n Labs pending.\n Plan:\n Treat labs\n Monitor labs\n Call ho with critical results\n" }, { "category": "Physician ", "chartdate": "2131-07-04 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 684966, "text": "Chief Complaint:\n HPI:\n 24 Hour Events:\n ULTRASOUND - At 02:17 PM\n PAN CULTURE - At 08:50 PM\n FEVER - 101.9\nF - 08:00 PM\n Allergies:\n Meropenem\n skin blisters a\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 12:21 PM\n Furosemide (Lasix) - 12:45 PM\n Heparin Sodium (Prophylaxis) - 05:30 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 11:04 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.8\nC (101.9\n Tcurrent: 37.3\nC (99.1\n HR: 115 (109 - 129) bpm\n BP: 127/80(90) {101/61(75) - 144/91(117)} mmHg\n RR: 39 (27 - 59) insp/min\n SpO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 99.1 kg (admission): 113.5 kg\n Height: 67 Inch\n Total In:\n 4,882 mL\n 1,454 mL\n PO:\n TF:\n 1,200 mL\n 553 mL\n IVF:\n 2,032 mL\n 151 mL\n Blood products:\n Total out:\n 2,575 mL\n 1,150 mL\n Urine:\n 2,575 mL\n 1,150 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,307 mL\n 304 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n SpO2: 100%\n ABG: ///18/\n Physical Examination\n Gen: sitting in bed, tachypneic but less secretions\n CV: RR\n Chest: coarse bs bilat\n Abd soft +BS\n Ext: 1+ edema\n Neuro: eyes open, slightly tremulous\n Labs / Radiology\n 6.8 g/dL\n 349 K/uL\n 111 mg/dL\n 1.0 mg/dL\n 18 mEq/L\n 4.4 mEq/L\n 48 mg/dL\n 115 mEq/L\n 142 mEq/L\n 23.6 %\n 11.6 K/uL\n [image002.jpg]\n 10:00 PM\n 02:32 AM\n 04:25 AM\n 03:56 PM\n 02:32 AM\n 08:00 PM\n 12:35 AM\n 03:21 AM\n 04:44 PM\n 02:42 AM\n WBC\n 10.9\n 11.0\n 10.5\n 11.1\n 11.6\n Hct\n 22.2\n 22.5\n 22.3\n 22.1\n 23.6\n Plt\n 290\n 310\n 327\n 341\n 349\n Cr\n 1.9\n 1.6\n 1.3\n 1.2\n 1.2\n 1.1\n 1.0\n 1.0\n TCO2\n 20\n Glucose\n 177\n 116\n 161\n 97\n 93\n 147\n 187\n 111\n Other labs: PT / PTT / INR:13.6/28.0/1.2, CK / CKMB /\n Troponin-T:214/3/0.07, ALT / AST:60/85, Alk Phos / T Bili:247/2.8,\n Amylase / Lipase:78/91, Differential-Neuts:57.0 %, Band:4.0 %,\n Lymph:23.0 %, Mono:4.0 %, Eos:3.0 %, D-dimer:6389 ng/mL, Fibrinogen:541\n mg/dL, Lactic Acid:2.6 mmol/L, Albumin:2.4 g/dL, LDH:437 IU/L, Ca++:9.2\n mg/dL, Mg++:1.8 mg/dL, PO4:4.2 mg/dL\n Assessment and Plan\n FEVER, UNKNOWN ORIGIN (FUO, HYPERTHERMIA, PYREXIA)\n AROUSAL, ATTENTION, AND COGNITION, IMPAIRED\n BALANCE, IMPAIRED\n MOTOR FUNCTION, IMPAIRED\n MUSCLE PERFORMACE, IMPAIRED\n RESPIRATION / GAS EXCHANGE, IMPAIRED\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n IMPAIRED SKIN INTEGRITY\n HEPATITIS, ACUTE TOXIC (INCLUDING ALCOHOLIC, ACETAMINOPHEN, ETC.)\n 1. Cyclical fevers: Temp to 101.9 again last PM but stable\n WBC and CXR, pan cx. stable off all ABX, CXR is improved and no focal\n sources. Overall stable WBC and this could be central. We will follow\n cx, follow up CMV viral load, LFTS, we can consider abd imaging but my\n sense is that in the absence of exam change IR or surgery would be\n loathe to intervent on pancreas unless systemically ill and thus\n imaging alone is not helpful at this point. Should fevers persist or he\n deteriorate we can re evaluate.\n 2. Resp Failure: yesterday with increased frothy pink sputum, ?\n volume overload. But CXR without infiltrate and echo WNL. He is\n positive everyday so may just be secrtions\n we will start lasix to\n keep closer to even and reduce obligate ins.\n 3. Altered Mental status: MRI with concerning anoxic features and\n prognosis from Dr was he could improve slightly but unlikely to\n recover dramatically. Family would like 2nd opinion and we will contact\n Dr who will see him today.\n 4. ARF: resolved, off HD, start po lasix to match I and O\n more closely\n 5. Transaminitis: follow LFTS and CMV viral load\n 6. CMV: need toclarify with ID what pregnant healthcare\n workers need to do as precautions\n Remaining issues as per Housestaff\n ICU Care\n Nutrition:\n Nutren 2.0 () - 12:21 PM 50 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 08:37 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n Communication: spoke for 15 min last PM as did Dr\n \n status: Full code\n Disposition : ICU\n screening for rehabs but needs stable resp status,\n neg fever work up\n Total time spent:\n" }, { "category": "Nursing", "chartdate": "2131-07-04 00:00:00.000", "description": "Nursing Progress Note", "row_id": 685039, "text": " Problem\n anoxic brain injury secondary to cerebral edema\n Assessment:\n Alert most of the time\n Appeared to slightly open mouth when asked to take\n temperature\n Squeezes hand but does not let go when asked\n PERL\n Productive cough, clears secretions\n Stooling x1, guiac + stool\n Renal function improved, creatinine 1.0, producing urine\n Fluid balance MN\n 180 even (x1 dose PO lasix)\n Action:\n Free water boluses decreased\n PO lasix started daily\n OOB to chair\n Worked with PT\n Speech pathology visited and attempted -muir valve\n Second Neurology opinion obtained\n Response:\n Afebrile\n Neurologically slightly improved\n Renal function improved\n Plan:\n Continue plan outlined in action section\n Patient and family support\n" }, { "category": "Respiratory ", "chartdate": "2131-07-05 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 685088, "text": "Tracheostomy tube:\n Type: Cuffed\n Manufacturer: Portex\n Size: 8.0mm\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Cuff volume: 5 mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Rhonchi\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Rhonchi\n Comments:\n Secretions\n Sputum color / consistency: Blood Tinged /\n Sputum source/amount: Suctioned / Moderate\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Unassisted spontaneous breathing\n Visual assessment of breathing pattern: Tachypneic (RR> 35 b/min)\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours:\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments: Pt remains on t-collar 50%. Suctioned prn for bld tinged\n secretions. H20 filled. All equipment present.\n" }, { "category": "Physician ", "chartdate": "2131-07-04 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 684940, "text": "Chief Complaint:\n HPI:\n 24 Hour Events:\n ULTRASOUND - At 02:17 PM\n PAN CULTURE - At 08:50 PM\n FEVER - 101.9\nF - 08:00 PM\n Allergies:\n Meropenem\n skin blisters a\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 12:21 PM\n Furosemide (Lasix) - 12:45 PM\n Heparin Sodium (Prophylaxis) - 05:30 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 11:04 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.8\nC (101.9\n Tcurrent: 37.3\nC (99.1\n HR: 115 (109 - 129) bpm\n BP: 127/80(90) {101/61(75) - 144/91(117)} mmHg\n RR: 39 (27 - 59) insp/min\n SpO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 99.1 kg (admission): 113.5 kg\n Height: 67 Inch\n Total In:\n 4,882 mL\n 1,454 mL\n PO:\n TF:\n 1,200 mL\n 553 mL\n IVF:\n 2,032 mL\n 151 mL\n Blood products:\n Total out:\n 2,575 mL\n 1,150 mL\n Urine:\n 2,575 mL\n 1,150 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,307 mL\n 304 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n SpO2: 100%\n ABG: ///18/\n Physical Examination\n Labs / Radiology\n 6.8 g/dL\n 349 K/uL\n 111 mg/dL\n 1.0 mg/dL\n 18 mEq/L\n 4.4 mEq/L\n 48 mg/dL\n 115 mEq/L\n 142 mEq/L\n 23.6 %\n 11.6 K/uL\n [image002.jpg]\n 10:00 PM\n 02:32 AM\n 04:25 AM\n 03:56 PM\n 02:32 AM\n 08:00 PM\n 12:35 AM\n 03:21 AM\n 04:44 PM\n 02:42 AM\n WBC\n 10.9\n 11.0\n 10.5\n 11.1\n 11.6\n Hct\n 22.2\n 22.5\n 22.3\n 22.1\n 23.6\n Plt\n 290\n 310\n 327\n 341\n 349\n Cr\n 1.9\n 1.6\n 1.3\n 1.2\n 1.2\n 1.1\n 1.0\n 1.0\n TCO2\n 20\n Glucose\n 177\n 116\n 161\n 97\n 93\n 147\n 187\n 111\n Other labs: PT / PTT / INR:13.6/28.0/1.2, CK / CKMB /\n Troponin-T:214/3/0.07, ALT / AST:60/85, Alk Phos / T Bili:247/2.8,\n Amylase / Lipase:78/91, Differential-Neuts:57.0 %, Band:4.0 %,\n Lymph:23.0 %, Mono:4.0 %, Eos:3.0 %, D-dimer:6389 ng/mL, Fibrinogen:541\n mg/dL, Lactic Acid:2.6 mmol/L, Albumin:2.4 g/dL, LDH:437 IU/L, Ca++:9.2\n mg/dL, Mg++:1.8 mg/dL, PO4:4.2 mg/dL\n Assessment and Plan\n FEVER, UNKNOWN ORIGIN (FUO, HYPERTHERMIA, PYREXIA)\n AROUSAL, ATTENTION, AND COGNITION, IMPAIRED\n BALANCE, IMPAIRED\n MOTOR FUNCTION, IMPAIRED\n MUSCLE PERFORMACE, IMPAIRED\n RESPIRATION / GAS EXCHANGE, IMPAIRED\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n IMPAIRED SKIN INTEGRITY\n HEPATITIS, ACUTE TOXIC (INCLUDING ALCOHOLIC, ACETAMINOPHEN, ETC.)\n 1. Cyclical fevers: stable off all ABX, CXR is improved and\n no focal sources. Overall stable WBC and this could be central. Should\n he spike and leukocytosis will pan cx, consider repeat abd imaging.\n 2. Resp Failure: today with increased frothy pink sputum, ?\n volume overload. Will RX lasix, stat CXR, positive pressure if need\n be. Would repeat echo since he has been persistenyl tachy and could\n have cardiomyopathy\n no echo since \n 3. Altered Mental status: MRI with concerning anoxic features and\n prognosis from Dr was he could improve slightly but unlikely to\n recover dramatically. Family would like 2nd opinion and we will contact\n Dr who had seen him previously.\n 4. ARF: resolved, off HD, start po lasix to match I and O\n more closely\n 5. Transaminitis: follow LFTS and CMV viral load\n Remaining issues as per Housestaff\n ICU Care\n Nutrition:\n Nutren 2.0 () - 12:21 PM 50 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 08:37 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": "Case Management ", "chartdate": "2131-07-05 00:00:00.000", "description": "Case Management Discharge Plan", "row_id": 685209, "text": "TITLE: Case Management Discharge Plan - Update\n Patient has been offered a bed at and . NCM\n spoke with the MICU team and the patient is ready for transfer. NCM\n also spoke with the patient\ns brother who has accepted the bed at\n which is in a private room.\n NCM has informed the MICU team and the patient\ns nurse in the\n SICU. Transportation via ACLS ambulance will be booked by UCo.\n Discharge summary and patient care referral forms to accompany the\n patient.\n Transfer scheduled for 3:30 PM today.\n Please call/page with any questions.\n , RN, BSN\n MICU Service Case Manager\n Phone: \n Pager: \n" }, { "category": "Physician ", "chartdate": "2131-06-30 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 683975, "text": "Chief Complaint:\n 24 Hour Events:\n - d/c'ed micafungin as per ID, as unclear if helping or not. Will see\n how he does off micafungin over weekend, if doing poorly, consider\n further imaging prior to Monday.\n - Dr. will email Dr. to ensure that micafungin plan\n is okay.\n - CMV VL ordered 5 days from now, as per ID\n - neurology had sobering and extensive discussion with family re: poor\n prognosis and long term plan\n - will tolerate low grade temps given lack of source and known necrotic\n pancreas\n - K and phos repleted and look fine\n - HD line and a line d/c'ed\n - will d/c foley and try condom cath\n Allergies:\n Meropenem\n skin blisters a\n Last dose of Antibiotics:\n Micafungin - 10:00 PM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 04:30 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:52 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.6\nC (101.5\n Tcurrent: 38.2\nC (100.7\n HR: 115 (114 - 124) bpm\n BP: 123/53(69) {93/39(56) - 144/119(123)} mmHg\n RR: 34 (29 - 40) insp/min\n SpO2: 99%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 103.3 kg (admission): 113.5 kg\n Height: 67 Inch\n Total In:\n 1,964 mL\n 543 mL\n PO:\n TF:\n 1,204 mL\n 293 mL\n IVF:\n 200 mL\n Blood products:\n Total out:\n 1,375 mL\n 460 mL\n Urine:\n 1,375 mL\n 460 mL\n NG:\n Stool:\n Drains:\n Balance:\n 589 mL\n 83 mL\n Respiratory support\n O2 Delivery Device: Trach mask , Tracheostomy tube\n SpO2: 99%\n ABG: ///22/\n Physical Examination\n General: Alert, NAD\n HEENT: markedly MMM\n Neck: supple, unable to assess JVP 2/2 edema, no LAD\n Lungs: Coarse upper airway sounds transmitted throughout. No\n rales/wheezes.\n CV: tachycardic with normal rhytyhm, normal S1 + S2, no murmurs, rubs,\n gallops\n Abdomen: soft/NT/ND/NABS, no organomegaly\n Ext: Warm, well perfused, 2+ pulses, no clubbing. 3+ edema.\n Labs / Radiology\n 290 K/uL\n 6.5 g/dL\n 116 mg/dL\n 1.9 mg/dL\n 22 mEq/L\n 3.8 mEq/L\n 91 mg/dL\n 117 mEq/L\n 148 mEq/L\n 22.2 %\n 10.9 K/uL\n [image002.jpg]\n 03:26 PM\n 03:37 PM\n 03:15 AM\n 03:19 AM\n 10:00 AM\n 04:00 PM\n 02:16 AM\n 04:14 PM\n 10:00 PM\n 02:32 AM\n WBC\n 10.2\n 11.4\n 10.9\n Hct\n 21.5\n 21.7\n 22.2\n Plt\n 227\n 266\n 290\n Cr\n 2.7\n 2.6\n 2.1\n 2.0\n 1.9\n TCO2\n 23\n 22\n Glucose\n 129\n 194\n 192\n 200\n 7\n 116\n Other labs: PT / PTT / INR:13.6/28.0/1.2, CK / CKMB /\n Troponin-T:214/3/0.07, ALT / AST:88/136, Alk Phos / T Bili:341/4.7,\n Amylase / Lipase:102/114, Differential-Neuts:57.0 %, Band:4.0 %,\n Lymph:23.0 %, Mono:4.0 %, Eos:3.0 %, D-dimer:6389 ng/mL, Fibrinogen:541\n mg/dL, Lactic Acid:2.6 mmol/L, Albumin:2.3 g/dL, LDH:312 IU/L, Ca++:9.0\n mg/dL, Mg++:2.0 mg/dL, PO4:3.4 mg/dL\n Assessment and Plan\n 28 year old male with a history of alcoholism presenting with acute\n hepatitis, pancreatitis, and UGIB, with persistent cyclic\n fevers/leukocytosis.\n # Cyclic fevers/leukocytosis\n febrile to 101.5 yesterday AM, but WBC\n continues trending down. Sputum with 4+ GNR likely colonizer, as per\n ID, and sputum consistency remains unchanged. CXR from without\n obvious pneumonia. C diff neg on . U/A weakly positive; cx\n showing 10k yeast. Other source lower on ddx includes peripancreatic\n fluid collection and central fevers.\n -ID recs CT abd to eval peripancreatic collection.\n -D/C a-line and HD line yesterday\n -Will not start gancyclovir as CMV not likely cause of fevers, but will\n follow LFTs and if rising will see if correlates with CMV viral load.\n If correlation will will discuss starting gancyclovir with ID and\n renal.\n # Respiratory failure\n on trach mask at 40% FIO2, tachypnic this AM.\n -Tachypnea may be centrally driven cerebral injury\n # Acute renal failure\n stable and UOP continues improving (currently\n ~60 cc/hr over last 24hrs.).\n -Cont. to follow UOP\n -Will follow lytes as may over correct with return of function.\n # Altered mental status\n Given possibility of seizure activity, will\n continue keppra. MRI showing cerebral edema, poor prognosis as per\n neuro. EEG shows encephalopathy. Family meeting with Neuro\n yesterday. Full recovery to baseline unlikely, and longterm meaningful\n survival low due to cerebral injury.\n -Will need neuro rehab.\n # Anemia\n Hctstable. Will hold off transfusing and cont to follow.\n # Acute Hepatitis: Likely alcoholic hepatitis. CT scan shows fatty\n infiltration, and no evidence of distal obstruction.\n - Continue to trend LFTs\n - Will correlate LFTs with CMV viral load if they continue to rise.\n -If CMV likely cause may need to start gancyclovir however as this is\n nephrotoxic will need to discuss with ID/Renal\n # FEN: IVF, replete electrolytes, NPO\n ICU Care\n Nutrition: via NGT Nutren 2.0 () - 01:18 PM 50 mL/hour\n Glycemic Control: SSI/Lantus\n Lines:\n PICC Line - 08:37 AM\n Prophylaxis:\n DVT: Heparin\n Stress ulcer: H2\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2131-06-30 00:00:00.000", "description": "Physician Resident/Attending Progress Note - MICU", "row_id": 683976, "text": "Chief Complaint:\n 24 Hour Events:\n - d/c'ed micafungin as per ID, as unclear if helping or not. Will see\n how he does off micafungin over weekend, if doing poorly, consider\n further imaging prior to Monday.\n - Dr. will email Dr. to ensure that micafungin plan\n is okay.\n - CMV VL ordered 5 days from now, as per ID\n - neurology had sobering and extensive discussion with family re: poor\n prognosis and long term plan\n - will tolerate low grade temps given lack of source and known necrotic\n pancreas\n - K and phos repleted and look fine\n - HD line and a line d/c'ed\n - will d/c foley and try condom cath\n Allergies:\n Meropenem\n skin blisters a\n Last dose of Antibiotics:\n Micafungin - 10:00 PM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 04:30 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:52 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.6\nC (101.5\n Tcurrent: 38.2\nC (100.7\n HR: 115 (114 - 124) bpm\n BP: 123/53(69) {93/39(56) - 144/119(123)} mmHg\n RR: 34 (29 - 40) insp/min\n SpO2: 99%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 103.3 kg (admission): 113.5 kg\n Height: 67 Inch\n Total In:\n 1,964 mL\n 543 mL\n PO:\n TF:\n 1,204 mL\n 293 mL\n IVF:\n 200 mL\n Blood products:\n Total out:\n 1,375 mL\n 460 mL\n Urine:\n 1,375 mL\n 460 mL\n NG:\n Stool:\n Drains:\n Balance:\n 589 mL\n 83 mL\n Respiratory support\n O2 Delivery Device: Trach mask , Tracheostomy tube\n SpO2: 99%\n ABG: ///22/\n Physical Examination\n General: Alert, NAD\n HEENT: markedly MMM\n Neck: supple, unable to assess JVP 2/2 edema, no LAD\n Lungs: Coarse upper airway sounds transmitted throughout. No\n rales/wheezes.\n CV: tachycardic with normal rhytyhm, normal S1 + S2, no murmurs, rubs,\n gallops\n Abdomen: soft/NT/ND/NABS, no organomegaly\n Ext: Warm, well perfused, 2+ pulses, no clubbing. 3+ edema.\n Labs / Radiology\n 290 K/uL\n 6.5 g/dL\n 116 mg/dL\n 1.9 mg/dL\n 22 mEq/L\n 3.8 mEq/L\n 91 mg/dL\n 117 mEq/L\n 148 mEq/L\n 22.2 %\n 10.9 K/uL\n [image002.jpg]\n 03:26 PM\n 03:37 PM\n 03:15 AM\n 03:19 AM\n 10:00 AM\n 04:00 PM\n 02:16 AM\n 04:14 PM\n 10:00 PM\n 02:32 AM\n WBC\n 10.2\n 11.4\n 10.9\n Hct\n 21.5\n 21.7\n 22.2\n Plt\n 227\n 266\n 290\n Cr\n 2.7\n 2.6\n 2.1\n 2.0\n 1.9\n TCO2\n 23\n 22\n Glucose\n 129\n 194\n 192\n 200\n 7\n 116\n Other labs: PT / PTT / INR:13.6/28.0/1.2, CK / CKMB /\n Troponin-T:214/3/0.07, ALT / AST:88/136, Alk Phos / T Bili:341/4.7,\n Amylase / Lipase:102/114, Differential-Neuts:57.0 %, Band:4.0 %,\n Lymph:23.0 %, Mono:4.0 %, Eos:3.0 %, D-dimer:6389 ng/mL, Fibrinogen:541\n mg/dL, Lactic Acid:2.6 mmol/L, Albumin:2.3 g/dL, LDH:312 IU/L, Ca++:9.0\n mg/dL, Mg++:2.0 mg/dL, PO4:3.4 mg/dL\n Assessment and Plan\n 28 year old male with a history of alcoholism presenting with acute\n hepatitis, pancreatitis, and UGIB, with persistent cyclic\n fevers/leukocytosis.\n # Cyclic fevers/leukocytosis\n febrile to 101.5 yesterday AM, but WBC\n continues trending down. Sputum with 4+ GNR likely colonizer, as per\n ID, and sputum consistency remains unchanged. CXR from without\n obvious pneumonia. C diff neg on . U/A weakly positive; cx\n showing 10k yeast. Other source lower on ddx includes peripancreatic\n fluid collection and central fevers.\n -ID recs CT abd to eval peripancreatic collection.\n -D/C a-line and HD line yesterday\n -Will not start gancyclovir as CMV not likely cause of fevers, but will\n follow LFTs and if rising will see if correlates with CMV viral load.\n If correlation will will discuss starting gancyclovir with ID and\n renal.\n # Respiratory failure\n on trach mask at 40% FIO2, tachypnic this AM.\n -Tachypnea may be centrally driven cerebral injury\n # Acute renal failure\n stable and UOP continues improving (currently\n ~60 cc/hr over last 24hrs.).\n -Cont. to follow UOP\n -Will follow lytes as may over correct with return of function.\n # Altered mental status\n Given possibility of seizure activity, will\n continue keppra. MRI showing cerebral edema, poor prognosis as per\n neuro. EEG shows encephalopathy. Family meeting with Neuro\n yesterday. Full recovery to baseline unlikely, and longterm meaningful\n survival low due to cerebral injury.\n -Will need neuro rehab.\n # Anemia\n Hctstable. Will hold off transfusing and cont to follow.\n # Acute Hepatitis: Likely alcoholic hepatitis. CT scan shows fatty\n infiltration, and no evidence of distal obstruction.\n - Continue to trend LFTs\n - Will correlate LFTs with CMV viral load if they continue to rise.\n -If CMV likely cause may need to start gancyclovir however as this is\n nephrotoxic will need to discuss with ID/Renal\n # FEN: IVF, replete electrolytes, NPO\n ICU Care\n Nutrition: via NGT Nutren 2.0 () - 01:18 PM 50 mL/hour\n Glycemic Control: SSI/Lantus\n Lines:\n PICC Line - 08:37 AM\n Prophylaxis:\n DVT: Heparin\n Stress ulcer: H2\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n ------ Protected Section ------\n Critical Care Attending\n I saw and examined the patient, and was physically present with the ICU\n resident for the key portions of the services provided. I agree with\n his/her note above, including the assessment and plan. I would\n add/emphasize the following:\n Complex 28 yo male w/h/o alcohol use, pancreatitis, hepatitis, brain\n injury with poor prognosis. Overnight continues with cyclic fevers and\n intermittent tachycardia and tachypnea.\n On exam today, sitting out of bed, intermittently tachypneic. No\n definite response to voice or command. Lungs with coarse breath sounds\n bilaterally. Tachycardic w/o murmur. Abd distended, 3+ edema\n bilaterally.\n In summary 28 yo male with h/o pancreatitis, hepatitis and cyclic\n fevers without obvious source. All antibiotics have been stopped and we\n are following fever curve and reculturing if spikes again today.\n Appreciate infectious disease and surgical service input. Neurology\n service had family meeting yesterday and suggested limited chance for\n meaningful recovery. Acute rehab hospitals to rescreen patient at\n request of family.\n , MD\n ------ Protected Section Addendum Entered By: , MD\n on: 13:14 ------\n" }, { "category": "General", "chartdate": "2131-07-01 00:00:00.000", "description": "Generic Note", "row_id": 684134, "text": "TITLE:\n Respiratory Care;\n Pt trached with #8 portex, on 40% aerosol trach mask. Has very strong\n cough to raise secretions, suctioned also for small amts lt yellow\n secretions.\n" }, { "category": "Respiratory ", "chartdate": "2131-07-04 00:00:00.000", "description": "Generic Note", "row_id": 684803, "text": "TITLE:Resp Care Note, Pt remains on t-collar 50%.Strong prod cough\n thick bld tinged secretions. Tachypenic with RR 30\ns.MDI given x 1\n without change. BS rhonchi throughout. H20 filled. All equipment\n present. Will cont to monitor resp status.\n" }, { "category": "Rehab Services", "chartdate": "2131-07-04 00:00:00.000", "description": "Physical Therapy Evaluation Note", "row_id": 684906, "text": "Attending Physician: \n Referral date: \n Medical Diagnosis / ICD 9: pancreatitis / 577.0\n Reason of referral: Re-Eval\n History of Present Illness / Subjective Complaint: 28 yo M with\n alcoholic hepatitis and necrotizing pancreatitis complicated by ARDS,\n UGIB and persistent fevers, extubated . MR showing concern for\n significant anoxic brain injury.\n Past Medical / Surgical History: see initial eval\n Medications: albuterol, heparin, fentanyl, diazepam, tylenol,\n furosemide\n Radiology: CXR - Persistent low lung volumes and left basilar\n atelectasis.\n Labs:\n 23.6\n 6.8\n 349\n 11.6\n [image002.jpg]\n Other labs:\n Activity Orders: OOB with assist\n Social / Occupational History: see initial eval\n Living Environment: see initial eval\n Prior Functional Status / Activity Level: see initial eval\n Objective Test\n Arousal / Attention / Cognition / Communication: alert, non-verbal nor\n attempting communication, maintains gaze/focusing up to 5 seconds and\n tracking in all directions, following 5% of commands.\n Hemodynamic Response\n Aerobic Capacity\n HR\n BP\n RR\n O[2 ]sat\n HR\n BP\n RR\n O[2] sat\n RPE\n Supine\n /\n Rest\n 112\n 143/71\n 30\n 100% on TM\n Sit\n /\n Activity\n 120\n 140/61\n 48\n 90% on TM\n Stand\n /\n Recovery\n 115\n 111/88\n 100% on TM\n Total distance walked:\n Minutes:\n Pulmonary Status: increased tacypnea with mobility, frequent coughing-\n productive of small-mod amount thick yellow secretions. On 50% FIO2\n via trach mask.\n Integumentary / Vascular: 3+ peripheral edema in all extremeties, R\n antecuve PICC, foley, trach\n Sensory Integrity: unable to accurately assess cognitive status\n Pain / Limiting Symptoms: unable to assess, patient grimacing to pain\n with LE ROM\n Posture: mild kyphosis in sitting, L lateral neck flexion in sitting\n Range of Motion\n Muscle Performance\n B LE's with general tightness and decreased ROM\n unable to accurately assess cognitive status\n Motor Function: significant tremor in all extremeties, increasing with\n mobility\n Functional Status:\n Activity\n Clarification\n I\n S\n CG\n Min\n Mod\n Max\n Gait, Locomotion: patient able to grasp bedrail with rolling, initiates\n sit-to-supine. Otherwise total assist for all mobility, slide transfer\n to stretcher chair.\n Rolling:\n\n\n\n\n\n T\n Supine /\n Sidelying to Sit:\n\n\n\n\n\n Transfer:\n\n\n\n\n\n Sit to Stand:\n\n\n\n\n\n Ambulation:\n\n\n\n\n\n Stairs:\n\n\n\n\n\n Balance: CG-min A static sitting, min-mod A dynamic sitting, L lateral\n bias with LOB to left, + postural reactions to LOB in all directions-\n UE extension, trunk flexion.\n Education / Communication: Reviewed PT and communicated with nsg\n re: status\n Intervention:\n Other:\n Diagnosis:\n 1.\n Arousal, Attention, and Cognition, Impaired\n 2.\n Balance, Impaired\n 3.\n Motor Function, Impaired\n 4.\n Muscle Performace, Impaired\n 5.\n Respiration / Gas Exchange, Impaired\n Clinical impression / Prognosis:\n Goals\n Time frame: 1 week\n 1.\n Max A x2 supine<->sitting, max A rolling\n 2.\n S static sitting, CG/min A dynamic sitting\n 3.\n Tolerates OOB >/= 4 hours/day\n 4.\n Clears secretions consistently with min cues via coughing\n 5.\n 6.\n Anticipated Discharge: Rehab\n Treatment Plan:\n Frequency / Duration: daily M-F\n T Patient agrees with the above goals and is willing to participate in\n the rehabilitation program.\n" }, { "category": "Nutrition", "chartdate": "2131-07-04 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 684917, "text": "Subjective: unable to speak with patient.\n Objective\n Current Wt: 99.1kg\n Pertinent medications: lasix, RISS, glargine, others noted\n Labs:\n Value\n Date\n Glucose\n 111 mg/dL\n 02:42 AM\n Glucose Finger Stick\n 247\n 10:00 PM\n BUN\n 48 mg/dL\n 02:42 AM\n Creatinine\n 1.0 mg/dL\n 02:42 AM\n Sodium\n 142 mEq/L\n 02:42 AM\n Potassium\n 4.4 mEq/L\n 02:42 AM\n Chloride\n 115 mEq/L\n 02:42 AM\n TCO2\n 18 mEq/L\n 02:42 AM\n PO2 (arterial)\n 89. mm Hg\n 03:56 PM\n PO2 (venous)\n 91. mm Hg\n 05:13 PM\n PCO2 (arterial)\n 35 mm Hg\n 03:56 PM\n PCO2 (venous)\n 41 mm Hg\n 05:13 PM\n pH (arterial)\n 7.35 units\n 03:56 PM\n pH (venous)\n 7.43 units\n 05:13 PM\n pH (urine)\n 6.5 units\n 09:09 PM\n CO2 (Calc) arterial\n 20 mEq/L\n 03:56 PM\n CO2 (Calc) venous\n 28 mEq/L\n 05:13 PM\n Albumin\n 2.4 g/dL\n 02:42 AM\n Calcium non-ionized\n 9.2 mg/dL\n 03:21 AM\n Phosphorus\n 4.2 mg/dL\n 03:21 AM\n Ionized Calcium\n 1.20 mmol/L\n 03:19 AM\n Magnesium\n 1.8 mg/dL\n 03:21 AM\n ALT\n 60 IU/L\n 02:42 AM\n Alkaline Phosphate\n 247 IU/L\n 02:42 AM\n AST\n 85 IU/L\n 02:42 AM\n Amylase\n 78 IU/L\n 04:25 AM\n Total Bilirubin\n 2.8 mg/dL\n 02:42 AM\n Triglyceride\n 154 mg/dL\n 02:10 AM\n WBC\n 11.6 K/uL\n 02:42 AM\n Hgb\n 6.8 g/dL\n 02:42 AM\n Hematocrit\n 23.6 %\n 02:42 AM\n Current diet order / nutrition support: Tube feeds: 3/4 strength Nutren\n 2.0 @ 50cc/hr + 50g Beneprotein (1962kcals, 15g protein)\n Diet: NPO\n GI: abd soft, + bowel sounds\n Assessment of Nutritional Status\n Patient continues on tube feeding at goal, also receiving 150cc H20\n flushes q2hrs via post pyloric feeding tube to treat hypernatremia. Na\n today is 142, so recommend decreasing volume of H20 flushes to 100cc\n q2hrs. Will continue to monitor lytes and adjust the volume and\n frequency of H20 flushes as needed to maintain adequate hydration.\n Noted that patient is receiving Lasix. Also noted that PMV trial was\n not done due to RR and need for frequent suctioning.\n Following - #\n" }, { "category": "Rehab Services", "chartdate": "2131-07-04 00:00:00.000", "description": "Physical Therapy Evaluation Note", "row_id": 684919, "text": "Attending Physician: \n Referral date: \n Medical Diagnosis / ICD 9: pancreatitis / 577.0\n Reason of referral: Re-Eval\n History of Present Illness / Subjective Complaint: 28 yo M with\n alcoholic hepatitis and necrotizing pancreatitis complicated by ARDS,\n UGIB and persistent fevers, extubated . MR showing concern for\n significant anoxic brain injury.\n Past Medical / Surgical History: see initial eval\n Medications: albuterol, heparin, fentanyl, diazepam, tylenol,\n furosemide\n Radiology: CXR - Persistent low lung volumes and left basilar\n atelectasis.\n Labs:\n 23.6\n 6.8\n 349\n 11.6\n [image002.jpg]\n Other labs:\n Activity Orders: OOB with assist\n Social / Occupational History: see initial eval\n Living Environment: see initial eval\n Prior Functional Status / Activity Level: see initial eval\n Objective Test\n Arousal / Attention / Cognition / Communication: alert, non-verbal nor\n attempting communication, maintains gaze/focusing up to 5 seconds and\n tracking in all directions, following 5% of commands.\n Hemodynamic Response\n Aerobic Capacity\n HR\n BP\n RR\n O[2 ]sat\n HR\n BP\n RR\n O[2] sat\n RPE\n Supine\n /\n Rest\n 112\n 143/71\n 30\n 100% on TM\n Sit\n /\n Activity\n 120\n 140/61\n 48\n 90% on TM\n Stand\n /\n Recovery\n 115\n 111/88\n 100% on TM\n Total distance walked:\n Minutes:\n Pulmonary Status: increased tachypnea with mobility, frequent coughing-\n productive of small-mod amount thick yellow secretions. On 50% FIO2\n via trach mask.\n Integumentary / Vascular: 3+ peripheral edema in all extremities, R\n antecube PICC, foley, trach\n Sensory Integrity: unable to accurately assess cognitive status\n Pain / Limiting Symptoms: unable to assess, patient grimacing to pain\n with LE ROM\n Posture: mild kyphosis in sitting, L lateral neck flexion in sitting\n Range of Motion\n Muscle Performance\n B LE's with general tightness and decreased ROM\n unable to accurately assess cognitive status\n Motor Function: significant tremor in all extremities, increasing with\n mobility. Spontaneous movement in B UE\ns, purposeful movement RUE and\n RLE.\n Functional Status:\n Activity\n Clarification\n I\n S\n CG\n Min\n Mod\n Max\n Gait, Locomotion: patient able to grasp bedrail with rolling, initiates\n sit-to-supine. Otherwise total assist for all mobility, slide transfer\n to stretcher chair.\n Rolling:\n\n\n\n\n\n T\n Supine /\n Sidelying to Sit:\n\n\n\n\n\n Transfer:\n\n\n\n\n\n Sit to Stand:\n\n\n\n\n\n Ambulation:\n\n\n\n\n\n Stairs:\n\n\n\n\n\n Balance: CG-min A static sitting, min-mod A dynamic sitting, L lateral\n bias with LOB to left, + postural reactions to LOB in all directions-\n UE extension, trunk flexion.\n Education / Communication: Reviewed PT and communicated with nsg\n re: status\n Intervention:\n Other:\n Diagnosis:\n 1.\n Arousal, Attention, and Cognition, Impaired\n 2.\n Balance, Impaired\n 3.\n Motor Function, Impaired\n 4.\n Muscle Performace, Impaired\n 5.\n Respiration / Gas Exchange, Impaired\n Clinical impression / Prognosis: 28 yo M with acute pancreatitis p/w\n above impairments a/w deconditioning. He is most limited by cognitive\n impairment, as well as significant tremor with initiation of movement\n and with sustained with passive movement. He is making small\n improvements weekly with cognitive status in that he is moving his\n R-sided extremeties with purpose. He continues to be well below his\n baseline and would continue to recommend eventual transition to acute\n rehab services to progress as able.\n Goals\n Time frame: 1 week\n 1.\n Max A x2 supine<->sitting, max A rolling\n 2.\n S static sitting, CG/min A dynamic sitting\n 3.\n Tolerates OOB >/= 4 hours/day\n 4.\n Clears secretions consistently with min cues via coughing\n 5.\n 6.\n Anticipated Discharge: Rehab\n Treatment Plan:\n Frequency / Duration: daily M-F\n T Patient agrees with the above goals and is willing to participate in\n the rehabilitation program.\n" }, { "category": "Physician ", "chartdate": "2131-06-30 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 683963, "text": "Chief Complaint:\n 24 Hour Events:\n - d/c'ed micafungin as per ID, as unclear if helping or not. Will see\n how he does off micafungin over weekend, if doing poorly, consider\n further imaging prior to Monday.\n - Dr. will email Dr. to ensure that micafungin plan\n is okay.\n - CMV VL ordered 5 days from now, as per ID\n - neurology had sobering and extensive discussion with family re: poor\n prognosis and long term plan\n - will tolerate low grade temps given lack of source and known necrotic\n pancreas\n - K and phos repleted and look fine\n - HD line and a line d/c'ed\n - will d/c foley and try condom cath\n Allergies:\n Meropenem\n skin blisters a\n Last dose of Antibiotics:\n Micafungin - 10:00 PM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 04:30 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:52 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.6\nC (101.5\n Tcurrent: 38.2\nC (100.7\n HR: 115 (114 - 124) bpm\n BP: 123/53(69) {93/39(56) - 144/119(123)} mmHg\n RR: 34 (29 - 40) insp/min\n SpO2: 99%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 103.3 kg (admission): 113.5 kg\n Height: 67 Inch\n Total In:\n 1,964 mL\n 543 mL\n PO:\n TF:\n 1,204 mL\n 293 mL\n IVF:\n 200 mL\n Blood products:\n Total out:\n 1,375 mL\n 460 mL\n Urine:\n 1,375 mL\n 460 mL\n NG:\n Stool:\n Drains:\n Balance:\n 589 mL\n 83 mL\n Respiratory support\n O2 Delivery Device: Trach mask , Tracheostomy tube\n SpO2: 99%\n ABG: ///22/\n Physical Examination\n General: Alert, NAD\n HEENT: markedly MMM\n Neck: supple, unable to assess JVP 2/2 edema, no LAD\n Lungs: Coarse upper airway sounds transmitted throughout. No\n rales/wheezes.\n CV: tachycardic with normal rhytyhm, normal S1 + S2, no murmurs, rubs,\n gallops\n Abdomen: soft/NT/ND/NABS, no organomegaly\n Ext: Warm, well perfused, 2+ pulses, no clubbing. 3+ edema.\n Labs / Radiology\n 290 K/uL\n 6.5 g/dL\n 116 mg/dL\n 1.9 mg/dL\n 22 mEq/L\n 3.8 mEq/L\n 91 mg/dL\n 117 mEq/L\n 148 mEq/L\n 22.2 %\n 10.9 K/uL\n [image002.jpg]\n 03:26 PM\n 03:37 PM\n 03:15 AM\n 03:19 AM\n 10:00 AM\n 04:00 PM\n 02:16 AM\n 04:14 PM\n 10:00 PM\n 02:32 AM\n WBC\n 10.2\n 11.4\n 10.9\n Hct\n 21.5\n 21.7\n 22.2\n Plt\n 227\n 266\n 290\n Cr\n 2.7\n 2.6\n 2.1\n 2.0\n 1.9\n TCO2\n 23\n 22\n Glucose\n 129\n 194\n 192\n 200\n 7\n 116\n Other labs: PT / PTT / INR:13.6/28.0/1.2, CK / CKMB /\n Troponin-T:214/3/0.07, ALT / AST:88/136, Alk Phos / T Bili:341/4.7,\n Amylase / Lipase:102/114, Differential-Neuts:57.0 %, Band:4.0 %,\n Lymph:23.0 %, Mono:4.0 %, Eos:3.0 %, D-dimer:6389 ng/mL, Fibrinogen:541\n mg/dL, Lactic Acid:2.6 mmol/L, Albumin:2.3 g/dL, LDH:312 IU/L, Ca++:9.0\n mg/dL, Mg++:2.0 mg/dL, PO4:3.4 mg/dL\n Assessment and Plan\n 28 year old male with a history of alcoholism presenting with acute\n hepatitis, pancreatitis, and UGIB, with persistent cyclic\n fevers/leukocytosis.\n # Cyclic fevers/leukocytosis\n febrile to 101.5 yesterday AM, but WBC\n continues trending down. Sputum with 4+ GNR likely colonizer, as per\n ID, and sputum consistency remains unchanged. CXR from without\n obvious pneumonia. C diff neg on . U/A weakly positive; cx\n showing 10k yeast. Other source lower on ddx includes peripancreatic\n fluid collection and central fevers.\n -ID recs CT abd to eval peripancreatic collection.\n -D/C a-line and HD line yesterday\n -Will not start gancyclovir as CMV not likely cause of fevers, but will\n follow LFTs and if rising will see if correlates with CMV viral load.\n If correlation will will discuss starting gancyclovir with ID and\n renal.\n # Respiratory failure\n on trach mask at 40% FIO2, tachypnic this AM.\n -Tachypnea may be centrally driven cerebral injury\n # Acute renal failure\n stable and UOP continues improving (currently\n ~60 cc/hr over last 24hrs.).\n -Cont. to follow UOP\n -Will follow lytes as may over correct with return of function.\n # Altered mental status\n Given possibility of seizure activity, will\n continue keppra. MRI showing cerebral edema, poor prognosis as per\n neuro. EEG shows encephalopathy. Family meeting with Neuro\n yesterday. Full recovery to baseline unlikely, and longterm meaningful\n survival low due to cerebral injury.\n -Will need neuro rehab.\n # Anemia\n Hctstable. Will hold off transfusing and cont to follow.\n # Acute Hepatitis: Likely alcoholic hepatitis. CT scan shows fatty\n infiltration, and no evidence of distal ostruction.\n - Continue to trend LFTs\n - Will correlate LFTs with CMV viral load if they continue to rise.\n -If CMV likely cause may need to start gancyclovir however as this is\n nephrotoxic will need to discuss with ID/Renal\n # FEN: IVF, replete electrolytes, NPO\n ICU Care\n Nutrition: via NGT Nutren 2.0 () - 01:18 PM 50 mL/hour\n Glycemic Control: SSI/Lantus\n Lines:\n PICC Line - 08:37 AM\n Prophylaxis:\n DVT: Heparin\n Stress ulcer: H2\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2131-07-02 00:00:00.000", "description": "Nursing Progress Note", "row_id": 684311, "text": "TITLE:\n Arousal, Attention, and Cognition, Impaired\n Assessment:\n Opens eyes spontaneously, intermittently tracking, does not move or\n follow any commands. Non purposeful Spont movement of upper extremeties\n occasionally, moves lower extremeties minimal. Pupils 4mm brisk equal.\n Tachypneic 50-60 at begin of shift on 40%Trach mask w O2 sats dip to\n 92-93% on same. Strong productive/congested cough. Stooling q2-4hr for\n loose brown stool. Condom cath w icteric urine.\n Action:\n Suctioned for copious amts of thick yellow/white sputum at begin of\n shift, TM increased to 50% O2 . BBs coarse to clear but dim at bases.\n Condom cath leaked several times, ? Ho re: foley cath placemnt, not at\n this time per team. FIB for urine collection in place.Turned and\n repositioned q2h, double guard to back and buttocks.Oral care w vap\n bundle q4h. Family in to visit early evening,understand prognosis and\n would like to speak with Dr re: pt condition update and goals\n of care for rehab placement.\n Response:\n Tachypnea improved w rr down to low 30\ns high 20\ns at rest. Sats remain\n 96-100% on 50 % TM. Skin intact.\n Plan:\n ? replace foley cath if current collection system leaks.Cont pulm\n toilet, VAP bundle. Cont to provide emotional support to family.\n Encourage family in practicing gd self\ncare. Contact SW for further\n support as needed.\n Problem\n hypernatremia\n Assessment:\n Serum Na+ 152 at 1900\n Action:\n MICU team notified of serum Na results and free water boluses increased\n to 400cc q4h. AM labs sent\n Response:\n Repeat serum Na+ 152\n Plan:\n Cont free water boluses as ordered. Check with team re: frequency of\n labs to reevaluate serum Na+\n" }, { "category": "Physician ", "chartdate": "2131-07-05 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 685186, "text": "Chief Complaint: pancreatitis, resp failure,\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n Long family meeting with Dr Neuro\n prognosis- confirms severe anxia but extent of recovery remains to be\n seen. He is LTAC candidate.\n Allergies:\n Meropenem\n skin blisters a\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 12:02 PM\n Famotidine (Pepcid) - 12:03 PM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 11:11 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.7\nC (99.9\n Tcurrent: 37.7\nC (99.9\n HR: 123 (110 - 125) bpm\n BP: 130/85(91) {99/58(77) - 144/100(106)} mmHg\n RR: 28 (28 - 46) insp/min\n SpO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 98.6 kg (admission): 113.5 kg\n Height: 67 Inch\n Total In:\n 2,401 mL\n 888 mL\n PO:\n TF:\n 1,200 mL\n 558 mL\n IVF:\n 151 mL\n Blood products:\n Total out:\n 2,670 mL\n 950 mL\n Urine:\n 2,670 mL\n 950 mL\n NG:\n Stool:\n Drains:\n Balance:\n -269 mL\n -62 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n SpO2: 100%\n ABG: ///17/\n Physical Examination\n Gen: sitting in bed, tachypneic but less secretions\n CV: RR\n Chest: coarse bs bilat\n Abd soft +BS\n Ext: 1+ edema\n Neuro: eyes open, slightly tremulous\n Labs / Radiology\n 6.9 g/dL\n 367 K/uL\n 115 mg/dL\n 0.8 mg/dL\n 17 mEq/L\n 4.2 mEq/L\n 38 mg/dL\n 116 mEq/L\n 142 mEq/L\n 22.4 %\n 10.3 K/uL\n [image002.jpg]\n 02:32 AM\n 04:25 AM\n 03:56 PM\n 02:32 AM\n 08:00 PM\n 12:35 AM\n 03:21 AM\n 04:44 PM\n 02:42 AM\n 04:46 AM\n WBC\n 10.9\n 11.0\n 10.5\n 11.1\n 11.6\n 10.3\n Hct\n 22.2\n 22.5\n 22.3\n 22.1\n 23.6\n 22.4\n Plt\n 290\n 310\n 327\n \n Cr\n 1.9\n 1.6\n 1.3\n 1.2\n 1.2\n 1.1\n 1.0\n 1.0\n 0.8\n TCO2\n 20\n Glucose\n 116\n 161\n 97\n 93\n 147\n 187\n 111\n 115\n Other labs: PT / PTT / INR:13.6/28.0/1.2, CK / CKMB /\n Troponin-T:214/3/0.07, ALT / AST:60/85, Alk Phos / T Bili:247/2.8,\n Amylase / Lipase:78/91, Differential-Neuts:57.0 %, Band:4.0 %,\n Lymph:23.0 %, Mono:4.0 %, Eos:3.0 %, D-dimer:6389 ng/mL, Fibrinogen:541\n mg/dL, Lactic Acid:2.6 mmol/L, Albumin:2.4 g/dL, LDH:437 IU/L, Ca++:9.2\n mg/dL, Mg++:1.8 mg/dL, PO4:4.2 mg/dL\n Assessment and Plan\n FEVER, UNKNOWN ORIGIN (FUO, HYPERTHERMIA, PYREXIA)\n AROUSAL, ATTENTION, AND COGNITION, IMPAIRED\n BALANCE, IMPAIRED\n MOTOR FUNCTION, IMPAIRED\n MUSCLE PERFORMACE, IMPAIRED\n RESPIRATION / GAS EXCHANGE, IMPAIRED\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n IMPAIRED SKIN INTEGRITY\n HEPATITIS, ACUTE TOXIC (INCLUDING ALCOHOLIC, ACETAMINOPHEN, ETC.)\n 1. Cyclical fevers: Temp to 101.9 again last PM but stable\n WBC and CXR, pan cx. stable off all ABX, CXR is improved and no focal\n sources. Overall stable WBC and this could be central. We will follow\n cx, follow up CMV viral load, LFTS, we can consider abd imaging but my\n sense is that in the absence of exam change IR or surgery would be\n loathe to intervent on pancreas unless systemically ill and thus\n imaging alone is not helpful at this point. Should fevers persist or he\n deteriorate we can re evaluate.\n 2. Resp Failure: yesterday with increased frothy pink sputum, ?\n volume overload. But CXR without infiltrate and echo WNL. He is\n positive everyday so may just be secrtions\n we will start lasix to\n keep closer to even and reduce obligate ins.\n 3. Altered Mental status: MRI with concerning anoxic features and\n prognosis from Dr was he could improve slightly but unlikely to\n recover dramatically. Family would like 2nd opinion and we will contact\n Dr who will see him today.\n 4. ARF: resolved, off HD, start po lasix to match I and O\n more closely\n 5. Transaminitis: follow LFTS and CMV viral load\n 6. CMV: need toclarify with ID what pregnant healthcare\n workers need to do as precautions\n Remaining issues as per Housestaff\n ICU Care\n Nutrition:\n Nutren 2.0 () - 12:21 PM 50 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 08:37 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n Communication: with family I will call \n Code status: Full code\n Disposition :ICU\n Total time spent:\n" }, { "category": "Physician ", "chartdate": "2131-07-05 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 685187, "text": "Chief Complaint: pancreatitis, resp failure,\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n Long family meeting with Dr Neuro\n prognosis- confirms severe anoxia but extent of recovery remains to be\n seen. He is LTAC candidate.\n Allergies:\n Meropenem\n skin blisters a\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 12:02 PM\n Famotidine (Pepcid) - 12:03 PM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 11:11 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.7\nC (99.9\n Tcurrent: 37.7\nC (99.9\n HR: 123 (110 - 125) bpm\n BP: 130/85(91) {99/58(77) - 144/100(106)} mmHg\n RR: 28 (28 - 46) insp/min\n SpO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 98.6 kg (admission): 113.5 kg\n Height: 67 Inch\n Total In:\n 2,401 mL\n 888 mL\n PO:\n TF:\n 1,200 mL\n 558 mL\n IVF:\n 151 mL\n Blood products:\n Total out:\n 2,670 mL\n 950 mL\n Urine:\n 2,670 mL\n 950 mL\n NG:\n Stool:\n Drains:\n Balance:\n -269 mL\n -62 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n SpO2: 100%\n ABG: ///17/\n Physical Examination\n Gen: sitting in bed, tachypneic but less secretions\n CV: RR\n Chest: coarse bs bilat\n Abd soft +BS\n Ext: 1+ edema\n Neuro: eyes open, slightly tremulous, answers yes no mouthing to ?S\n somewhat reliably which is a change\n Labs / Radiology\n 6.9 g/dL\n 367 K/uL\n 115 mg/dL\n 0.8 mg/dL\n 17 mEq/L\n 4.2 mEq/L\n 38 mg/dL\n 116 mEq/L\n 142 mEq/L\n 22.4 %\n 10.3 K/uL\n [image002.jpg]\n 02:32 AM\n 04:25 AM\n 03:56 PM\n 02:32 AM\n 08:00 PM\n 12:35 AM\n 03:21 AM\n 04:44 PM\n 02:42 AM\n 04:46 AM\n WBC\n 10.9\n 11.0\n 10.5\n 11.1\n 11.6\n 10.3\n Hct\n 22.2\n 22.5\n 22.3\n 22.1\n 23.6\n 22.4\n Plt\n 290\n 310\n 327\n \n Cr\n 1.9\n 1.6\n 1.3\n 1.2\n 1.2\n 1.1\n 1.0\n 1.0\n 0.8\n TCO2\n 20\n Glucose\n 116\n 161\n 97\n 93\n 147\n 187\n 111\n 115\n Other labs: PT / PTT / INR:13.6/28.0/1.2, CK / CKMB /\n Troponin-T:214/3/0.07, ALT / AST:60/85, Alk Phos / T Bili:247/2.8,\n Amylase / Lipase:78/91, Differential-Neuts:57.0 %, Band:4.0 %,\n Lymph:23.0 %, Mono:4.0 %, Eos:3.0 %, D-dimer:6389 ng/mL, Fibrinogen:541\n mg/dL, Lactic Acid:2.6 mmol/L, Albumin:2.4 g/dL, LDH:437 IU/L, Ca++:9.2\n mg/dL, Mg++:1.8 mg/dL, PO4:4.2 mg/dL\n Assessment and Plan\n FEVER, UNKNOWN ORIGIN (FUO, HYPERTHERMIA, PYREXIA)\n AROUSAL, ATTENTION, AND COGNITION, IMPAIRED\n BALANCE, IMPAIRED\n MOTOR FUNCTION, IMPAIRED\n MUSCLE PERFORMACE, IMPAIRED\n RESPIRATION / GAS EXCHANGE, IMPAIRED\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n IMPAIRED SKIN INTEGRITY\n HEPATITIS, ACUTE TOXIC (INCLUDING ALCOHOLIC, ACETAMINOPHEN, ETC.)\n 1. Cyclical fevers: afebrile for these 24 hours, never\n started ABX< no new cx data. We will follow cx, follow up CMV viral\n load, LFTS. The question of repeat abd imaging has been raised but my\n sense is that in the absence of exam change, systemic illness, IR or\n surgery would be loathe to intervent on pancreas and thus imaging alone\n is not helpful at this point. Should fevers persist or he deteriorate\n we can re evaluate.\n 2. Resp Failure; remains on trach mask, less secretions,\n persistent tachypnea\n some appears to be central mediated.\n 3. Altered Mental status: MRI with concerning anoxic features and\n prognosis from Dr was he could improve slightly but unlikely to\n recover dramatically. Family wanted 2nd opinion and we contact Dr\n who then refrred to Dr . 90 min meeting\n completed yesterday and she stated his injury is severe his prognosis\n for neuron recovery is poor for return to full basleine but needs time\n to see extent of his recovery. Agrees with LTAC until can meet criteria\n for Acute neuro rehab.\n 4. ARF: resolved, off HD, start po lasix to match I and O\n more closely\n 5. Transaminitis: LFTS down and CMV viral load Standard\n precautions for all HCW\n Remaining issues as per Housestaff\n ICU Care\n Nutrition:\n Nutren 2.0 () - 12:21 PM 50 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 08:37 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n Communication: with family I will call re potential LTAC transfer\n Code status: Full code\n Disposition :ICU\n Total time spent:\n" }, { "category": "Physician ", "chartdate": "2131-07-05 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 685188, "text": "Chief Complaint:\n 24 Hour Events:\n \n - primary neuro team signed off\n - started on oral Lasix - even on I/O's as of 1530\n - 2300: nursing reports that pt had a medium-sized rusty-colored stool\n Allergies:\n Meropenem\n skin blisters a\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Famotidine\n Acetaminophen\n Albuterol Inhaler\n Diazepam\n Famotidine\n Fentanyl Citrate\n Furosemide\n Heparin\n Insulin\n LeVETiracetam\n Other medications:\n Changes to medical 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: 37.7\nC (99.8\n Tcurrent: 37.6\nC (99.6\n HR: 123 (110 - 125) bpm\n BP: 121/69(83) {99/62(79) - 144/100(106)} mmHg\n RR: 34 (30 - 46) insp/min\n SpO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 99.1 kg (admission): 113.5 kg\n Height: 67 Inch\n Total In:\n 2,401 mL\n 529 mL\n PO:\n TF:\n 1,200 mL\n 329 mL\n IVF:\n 151 mL\n Blood products:\n Total out:\n 2,670 mL\n 450 mL\n Urine:\n 2,670 mL\n 450 mL\n NG:\n Stool:\n Drains:\n Balance:\n -269 mL\n 80 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n SpO2: 100%\n ABG: ///17/\n Physical Examination\n General: Alert, non-verbal\n HEENT: Scleral icterus, MMM\n Neck: supple, edematous, no LAD\n Lungs: Tachypnic ronchi\n CV: tachycardic with normal rhytyhm, normal S1 + S2, no murmurs, rubs,\n gallops\n Abdomen: soft, non-tender, non-distended, NABS\n Ext: 3+ Bilat LE edema, 2+ bilat UE edema..\n Labs / Radiology\n 367 K/uL\n 6.9 g/dL\n 115 mg/dL\n 0.8 mg/dL\n 17 mEq/L\n 4.2 mEq/L\n 38 mg/dL\n 116 mEq/L\n 142 mEq/L\n 22.4 %\n 10.3 K/uL\n [image002.jpg]\n 02:32 AM\n 04:25 AM\n 03:56 PM\n 02:32 AM\n 08:00 PM\n 12:35 AM\n 03:21 AM\n 04:44 PM\n 02:42 AM\n 04:46 AM\n WBC\n 10.9\n 11.0\n 10.5\n 11.1\n 11.6\n 10.3\n Hct\n 22.2\n 22.5\n 22.3\n 22.1\n 23.6\n 22.4\n Plt\n 290\n 310\n 327\n \n Cr\n 1.9\n 1.6\n 1.3\n 1.2\n 1.2\n 1.1\n 1.0\n 1.0\n 0.8\n TCO2\n 20\n Glucose\n 116\n 161\n 97\n 93\n 147\n 187\n 111\n 115\n Other labs: PT / PTT / INR:13.6/28.0/1.2, CK / CKMB /\n Troponin-T:214/3/0.07, ALT / AST:60/85, Alk Phos / T Bili:247/2.8,\n Amylase / Lipase:78/91, Differential-Neuts:57.0 %, Band:4.0 %,\n Lymph:23.0 %, Mono:4.0 %, Eos:3.0 %, D-dimer:6389 ng/mL, Fibrinogen:541\n mg/dL, Lactic Acid:2.6 mmol/L, Albumin:2.4 g/dL, LDH:437 IU/L, Ca++:9.2\n mg/dL, Mg++:1.8 mg/dL, PO4:4.2 mg/dL\n Assessment and Plan\n 28 year old male with a history of alcoholism presenting with acute\n hepatitis, pancreatitis, and UGIB, with persistent cyclic\n fevers/leukocytosis and anoxic brain injury.\n # Cyclic fevers/leukocytosis\n - Tmax 99.8 over past 24hrs. WBC 10.3\n - Prelim sputum culture c/w oropharyngeal flora\n continues to be same\n as priors and thought to be colonization\n - Blood and urine cx still pending from . Prior blood cx are\n negative.\n - CMV VL pending\n LFT\ns were down making a correlation between an\n increased VL and LFT\ns moot/negative but will follow up VL\n - will consider tx of CMV if pt continues to have fevers, has clinical\n deterioration, or has end organ dysfunction\n - be due to necrotic pancreas or process in the peripancreatic\n fluid and thus may still require a CT if Pt develops high fevers.\n # Respiratory failure\n Pt is on trach mask at 40% FIO2.\n - Pt is still tachypneic. (RR 27-59).\n - Considering pt\ns neuro findings, this may be centrally-driven.\n # Acute renal failure\n - pt put out 2.6 L urine yesterday.\n I/O net positive 2.3 L\n -Cr improved at 0.8\n - will continue to follow UOP, BUN, and Cr\n - Will start pt on PO lasix at 40 mg daily\n # Mental status/anoxic brain injury\n pt had MRI that showed diffuse\n subacute anoxic injury involving the basal ganglia and cortex\n - poor prognosis per neuro with likely long term prognosis persistent\n vegetative state.\n - Second neuro opinion appreciated and noted that while it is hopeful\n it is unlikely to recover to baseline function and at present Pt should\n be placed at a facility that can monitor his progress such that if he\n achieves a level of function at which he is able to participate in\n neuro rehab he could be transferred to a facility able to provide said\n services.\n - Will decrease diazepam to 5mg qhs from q12hr as this may contribute\n to his mental status.\n # Anemia\n - Hct stable\n - continue to monitor Hct\n # Acute Hepatitis: Likely alcoholic hepatitis. CT scan shows fatty\n infiltration, and no evidence of distal obstruction.\n -- CMV VL pending\n LFT\ns were down making a correlation between an\n increased VL and LFT\ns moot/negative but will follow up VL\n - AST/ALT on were 60 and 85, which is improved from previous\n overall\n # FEN: IVF, replete electrolytes PRN, Nutren at 50 ml/hr.\n ICU Care\n Nutrition:\n Nutren 2.0 () - 12:21 PM 50 mL/hour\n Glycemic Control: Insulin\n Lines:\n PICC Line - 08:37 AM\n Prophylaxis:\n DVT: Heparin\n Stress ulcer: Famotidine\n VAP: oral care / elevated HOB\n Comments:\n Communication: With Family (Pts Brother / Father) Comments:\n Code status: Full code\n Disposition: Rehab when placement found\n" }, { "category": "Physician ", "chartdate": "2131-07-02 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 684423, "text": "Chief Complaint: resp failure, pancreatitis\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 Meropenem\n skin blisters a\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 04:11 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 01:18 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.8\nC (100\n Tcurrent: 37.4\nC (99.3\n HR: 121 (113 - 123) bpm\n BP: 107/74(83) {91/39(61) - 143/92(118)} mmHg\n RR: 28 (28 - 45) insp/min\n SpO2: 97%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 103.3 kg (admission): 113.5 kg\n Height: 67 Inch\n Total In:\n 2,317 mL\n 2,078 mL\n PO:\n TF:\n 1,217 mL\n 628 mL\n IVF:\n 100 mL\n 100 mL\n Blood products:\n Total out:\n 1,225 mL\n 350 mL\n Urine:\n 1,225 mL\n 350 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,092 mL\n 1,728 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n SpO2: 97%\n ABG: 7.35/35/89./20/-5\n PaO2 / FiO2: 178\n Physical Examination\n Labs / Radiology\n 6.8 g/dL\n 327 K/uL\n 97 mg/dL\n 1.3 mg/dL\n 20 mEq/L\n 4.8 mEq/L\n 75 mg/dL\n 124 mEq/L\n 152 mEq/L\n 22.3 %\n 10.5 K/uL\n [image002.jpg]\n 03:19 AM\n 10:00 AM\n 04:00 PM\n 02:16 AM\n 04:14 PM\n 10:00 PM\n 02:32 AM\n 04:25 AM\n 03:56 PM\n 02:32 AM\n WBC\n 11.4\n 10.9\n 11.0\n 10.5\n Hct\n 21.7\n 22.2\n 22.5\n 22.3\n Plt\n 266\n 290\n 310\n 327\n Cr\n 2.1\n 2.0\n 1.9\n 1.6\n 1.3\n TCO2\n 22\n 20\n Glucose\n 192\n 200\n 211\n 98\n 151\n 177\n 116\n 161\n 97\n Other labs: PT / PTT / INR:13.6/28.0/1.2, CK / CKMB /\n Troponin-T:214/3/0.07, ALT / AST:91/137, Alk Phos / T Bili:318/4.1,\n Amylase / Lipase:78/91, Differential-Neuts:57.0 %, Band:4.0 %,\n Lymph:23.0 %, Mono:4.0 %, Eos:3.0 %, D-dimer:6389 ng/mL, Fibrinogen:541\n mg/dL, Lactic Acid:2.6 mmol/L, Albumin:2.3 g/dL, LDH:437 IU/L, Ca++:9.1\n mg/dL, Mg++:2.0 mg/dL, PO4:4.9 mg/dL\n Assessment and Plan\n FEVER, UNKNOWN ORIGIN (FUO, HYPERTHERMIA, PYREXIA)\n AROUSAL, ATTENTION, AND COGNITION, IMPAIRED\n BALANCE, IMPAIRED\n MOTOR FUNCTION, IMPAIRED\n MUSCLE PERFORMACE, IMPAIRED\n RESPIRATION / GAS EXCHANGE, IMPAIRED\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n IMPAIRED SKIN INTEGRITY\n HEPATITIS, ACUTE TOXIC (INCLUDING ALCOHOLIC, ACETAMINOPHEN, ETC.)\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 08:37 AM\n Prophylaxis:\n DVT: sc hep\n Stress ulcer: PPI\n Communication: Comments:\n Code status: Full code\n Disposition :\n Total time spent:\n" }, { "category": "Physician ", "chartdate": "2131-07-02 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 684424, "text": "Chief Complaint: resp failure, pancreatitis\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 Meropenem\n skin blisters a\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 04:11 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 01:18 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.8\nC (100\n Tcurrent: 37.4\nC (99.3\n HR: 121 (113 - 123) bpm\n BP: 107/74(83) {91/39(61) - 143/92(118)} mmHg\n RR: 28 (28 - 45) insp/min\n SpO2: 97%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 103.3 kg (admission): 113.5 kg\n Height: 67 Inch\n Total In:\n 2,317 mL\n 2,078 mL\n PO:\n TF:\n 1,217 mL\n 628 mL\n IVF:\n 100 mL\n 100 mL\n Blood products:\n Total out:\n 1,225 mL\n 350 mL\n Urine:\n 1,225 mL\n 350 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,092 mL\n 1,728 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n SpO2: 97%\n ABG: 7.35/35/89./20/-5\n PaO2 / FiO2: 178\n Physical Examination\n Labs / Radiology\n 6.8 g/dL\n 327 K/uL\n 97 mg/dL\n 1.3 mg/dL\n 20 mEq/L\n 4.8 mEq/L\n 75 mg/dL\n 124 mEq/L\n 152 mEq/L\n 22.3 %\n 10.5 K/uL\n [image002.jpg]\n 03:19 AM\n 10:00 AM\n 04:00 PM\n 02:16 AM\n 04:14 PM\n 10:00 PM\n 02:32 AM\n 04:25 AM\n 03:56 PM\n 02:32 AM\n WBC\n 11.4\n 10.9\n 11.0\n 10.5\n Hct\n 21.7\n 22.2\n 22.5\n 22.3\n Plt\n 266\n 290\n 310\n 327\n Cr\n 2.1\n 2.0\n 1.9\n 1.6\n 1.3\n TCO2\n 22\n 20\n Glucose\n 192\n 200\n 211\n 98\n 151\n 177\n 116\n 161\n 97\n Other labs: PT / PTT / INR:13.6/28.0/1.2, CK / CKMB /\n Troponin-T:214/3/0.07, ALT / AST:91/137, Alk Phos / T Bili:318/4.1,\n Amylase / Lipase:78/91, Differential-Neuts:57.0 %, Band:4.0 %,\n Lymph:23.0 %, Mono:4.0 %, Eos:3.0 %, D-dimer:6389 ng/mL, Fibrinogen:541\n mg/dL, Lactic Acid:2.6 mmol/L, Albumin:2.3 g/dL, LDH:437 IU/L, Ca++:9.1\n mg/dL, Mg++:2.0 mg/dL, PO4:4.9 mg/dL\n Assessment and Plan\n FEVER, UNKNOWN ORIGIN (FUO, HYPERTHERMIA, PYREXIA)\n AROUSAL, ATTENTION, AND COGNITION, IMPAIRED\n BALANCE, IMPAIRED\n MOTOR FUNCTION, IMPAIRED\n MUSCLE PERFORMACE, IMPAIRED\n RESPIRATION / GAS EXCHANGE, IMPAIRED\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n IMPAIRED SKIN INTEGRITY\n HEPATITIS, ACUTE TOXIC (INCLUDING ALCOHOLIC, ACETAMINOPHEN, ETC.)\n 1. Cyclical fevers: stable off all ABX, CXR is improved and\n no focal sources. Overall stable WBC and this could be central. Should\n he spike and leukocytosis will pan cx,\n 2. Resp Failure: on trach mask and holding his own, though is\n tachyneic at times\n again wonder if this is central\n 3. Altered Mental status: MRI with concerning anxois findings,\n await final read of EEG. Dr to see and discuss prognosis. His\n brother would like to meet w Dr today\n 4. For ARF: off HD, watching UOP\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 08:37 AM\n Prophylaxis:\n DVT: sc hep\n Stress ulcer: PPI\n Communication: Comments:\n Code status: Full code\n Disposition :\n Total time spent:\n" }, { "category": "Physician ", "chartdate": "2131-07-04 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 684885, "text": "Chief Complaint:\n 24 Hour Events:\n ULTRASOUND - At 02:17 PM\n PAN CULTURE - At 08:50 PM\n FEVER - 101.9\nF - 08:00 PM\n -2100: Called for temp spike to 101.9. Blood/Urine/Sputum Cx sent.\n Allergies:\n Meropenem\n skin blisters a\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 12:21 PM\n Furosemide (Lasix) - 12:45 PM\n Heparin Sodium (Prophylaxis) - 05:30 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 06:19 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.8\nC (101.9\n Tcurrent: 37\nC (98.6\n HR: 111 (109 - 129) bpm\n BP: 125/91(99) {101/54(74) - 138/91(117)} mmHg\n RR: 44 (27 - 59) insp/min\n SpO2: 98%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 99.1 kg (admission): 113.5 kg\n Height: 67 Inch\n Total In:\n 4,882 mL\n 966 mL\n PO:\n TF:\n 1,200 mL\n 315 mL\n IVF:\n 2,032 mL\n 51 mL\n Blood products:\n Total out:\n 2,575 mL\n 710 mL\n Urine:\n 2,575 mL\n 710 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,307 mL\n 256 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n SpO2: 98%\n ABG: ///18/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 349 K/uL\n 6.8 g/dL\n 111 mg/dL\n 1.0 mg/dL\n 18 mEq/L\n 4.4 mEq/L\n 48 mg/dL\n 115 mEq/L\n 142 mEq/L\n 23.6 %\n 11.6 K/uL\n [image002.jpg]\n 10:00 PM\n 02:32 AM\n 04:25 AM\n 03:56 PM\n 02:32 AM\n 08:00 PM\n 12:35 AM\n 03:21 AM\n 04:44 PM\n 02:42 AM\n WBC\n 10.9\n 11.0\n 10.5\n 11.1\n 11.6\n Hct\n 22.2\n 22.5\n 22.3\n 22.1\n 23.6\n Plt\n 290\n 310\n 327\n 341\n 349\n Cr\n 1.9\n 1.6\n 1.3\n 1.2\n 1.2\n 1.1\n 1.0\n 1.0\n TCO2\n 20\n Glucose\n 177\n 116\n 161\n 97\n 93\n 147\n 187\n 111\n Other labs: PT / PTT / INR:13.6/28.0/1.2, CK / CKMB /\n Troponin-T:214/3/0.07, ALT / AST:60/85, Alk Phos / T Bili:247/2.8,\n Amylase / Lipase:78/91, Differential-Neuts:57.0 %, Band:4.0 %,\n Lymph:23.0 %, Mono:4.0 %, Eos:3.0 %, D-dimer:6389 ng/mL, Fibrinogen:541\n mg/dL, Lactic Acid:2.6 mmol/L, Albumin:2.4 g/dL, LDH:437 IU/L, Ca++:9.2\n mg/dL, Mg++:1.8 mg/dL, PO4:4.2 mg/dL\n Echo () - The left atrium is normal in size. Overall left\n ventricular systolic function is normal (LVEF>55%). Tissue Doppler\n imaging suggests a normal left ventricular filling pressure\n (PCWP<12mmHg). Right ventricular chamber size and free wall motion are\n normal. The aortic valve leaflets (3) appear structurally normal with\n good leaflet excursion and no aortic regurgitation. The mitral valve\n appears structurally normal with trivial mitral regurgitation. There is\n no pericardial effusion. No vegetation seen (cannot definitively\n exclude).\n Compared with the prior study (images reviewed) of , there is\n no significant change.\nSputum culture PRELIM\n multiple organisms c/w oropharyngeal flora\nBlood/urine cx and CMV VL - PENDING\n Assessment and Plan\n 28 year old male with a history of alcoholism presenting with acute\n hepatitis, pancreatitis, and UGIB, with persistent cyclic\n fevers/leukocytosis and anoxic brain injury.\n # Cyclic fevers/leukocytosis\n - Pt spiked a fever to 101.9 last night. Pan cultures done. WBC 11.6\n - Prelim sputum culture c/w oropharyngeal flora\n will f/u\n - Blood and urine cx still pending\n will f/u\n - CMV VL pending\n if increased, will check to see if it correlates\n with an increase in LFTs\n if so, will consider tx of CMV\n - will also consider tx of CMV if pt continues to have fevers, has\n clinical deterioration, or has end organ disfunction\n # Respiratory failure\n Pt is on trach mask at 40% FIO2.\n - Pt is still tachypneic. (RR 27-59).\n - Considering pt\ns neuro findings, this may be centrally-driven.\n - also be d/t an infectious process\n will follow up culture data\n # Acute renal failure\n - pt put out 2.6 L urine yesterday.\n I/O net positive 2.3 L\n -Cr improved at 1.0.\n - will continue to follow UOP, BUN, and Cr\n - Will give pt another dose of Lasix today - 40 mg IV to try to get\n some fluid off\n # Mental status/anoxic brain injury\n pt had MRI that showed diffuse\n subacute anoxic injury involving the basal ganglia and cortex\n - poor prognosis per neuro with likely long term prognosis persistent\n vegetative state.\n - Family requesting second opinion regarding long term prognosis. This\n will be coordinated by attending physician . .\n # Anemia\n - Hct stable\n - continue to monitor Hct\n # Acute Hepatitis: Likely alcoholic hepatitis. CT scan shows fatty\n infiltration, and no evidence of distal obstruction.\n - will continue to trend LFT\ns and correlate with CMV load\n - AST/ALT on were 60 and 85, which is improved from previous\n overall\n will correlated with CMV VL\n # FEN: IVF, replete electrolytes, Nutren at 50 ml/hr. Given volume\n status will discuss with nutrition if possible to concentrate further.\n ICU Care\n Nutrition:\n Nutren 2.0 () - 12:21 PM 50 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n PICC Line - 08:37 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:ICU\n" }, { "category": "Physician ", "chartdate": "2131-07-04 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 684887, "text": "Chief Complaint:\n 24 Hour Events:\n ULTRASOUND - At 02:17 PM\n PAN CULTURE - At 08:50 PM\n FEVER - 101.9\nF - 08:00 PM\n -2100: Called for temp spike to 101.9. Blood/Urine/Sputum Cx sent.\n Allergies:\n Meropenem\n skin blisters a\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 12:21 PM\n Furosemide (Lasix) - 12:45 PM\n Heparin Sodium (Prophylaxis) - 05:30 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 06:19 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.8\nC (101.9\n Tcurrent: 37\nC (98.6\n HR: 111 (109 - 129) bpm\n BP: 125/91(99) {101/54(74) - 138/91(117)} mmHg\n RR: 44 (27 - 59) insp/min\n SpO2: 98%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 99.1 kg (admission): 113.5 kg\n Height: 67 Inch\n Total In:\n 4,882 mL\n 966 mL\n PO:\n TF:\n 1,200 mL\n 315 mL\n IVF:\n 2,032 mL\n 51 mL\n Blood products:\n Total out:\n 2,575 mL\n 710 mL\n Urine:\n 2,575 mL\n 710 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,307 mL\n 256 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n SpO2: 98%\n ABG: ///18/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 349 K/uL\n 6.8 g/dL\n 111 mg/dL\n 1.0 mg/dL\n 18 mEq/L\n 4.4 mEq/L\n 48 mg/dL\n 115 mEq/L\n 142 mEq/L\n 23.6 %\n 11.6 K/uL\n [image002.jpg]\n 10:00 PM\n 02:32 AM\n 04:25 AM\n 03:56 PM\n 02:32 AM\n 08:00 PM\n 12:35 AM\n 03:21 AM\n 04:44 PM\n 02:42 AM\n WBC\n 10.9\n 11.0\n 10.5\n 11.1\n 11.6\n Hct\n 22.2\n 22.5\n 22.3\n 22.1\n 23.6\n Plt\n 290\n 310\n 327\n 341\n 349\n Cr\n 1.9\n 1.6\n 1.3\n 1.2\n 1.2\n 1.1\n 1.0\n 1.0\n TCO2\n 20\n Glucose\n 177\n 116\n 161\n 97\n 93\n 147\n 187\n 111\n Other labs: PT / PTT / INR:13.6/28.0/1.2, CK / CKMB /\n Troponin-T:214/3/0.07, ALT / AST:60/85, Alk Phos / T Bili:247/2.8,\n Amylase / Lipase:78/91, Differential-Neuts:57.0 %, Band:4.0 %,\n Lymph:23.0 %, Mono:4.0 %, Eos:3.0 %, D-dimer:6389 ng/mL, Fibrinogen:541\n mg/dL, Lactic Acid:2.6 mmol/L, Albumin:2.4 g/dL, LDH:437 IU/L, Ca++:9.2\n mg/dL, Mg++:1.8 mg/dL, PO4:4.2 mg/dL\n Echo () - The left atrium is normal in size. Overall left\n ventricular systolic function is normal (LVEF>55%). Tissue Doppler\n imaging suggests a normal left ventricular filling pressure\n (PCWP<12mmHg). Right ventricular chamber size and free wall motion are\n normal. The aortic valve leaflets (3) appear structurally normal with\n good leaflet excursion and no aortic regurgitation. The mitral valve\n appears structurally normal with trivial mitral regurgitation. There is\n no pericardial effusion. No vegetation seen (cannot definitively\n exclude).\n Compared with the prior study (images reviewed) of , there is\n no significant change.\nSputum culture PRELIM\n multiple organisms c/w oropharyngeal flora\nBlood/urine cx and CMV VL\n PENDING\nNeurology consult (Dr. - There are still metabolic abnormalities which\nmay play some role in the neurological assessment, however, the likelihood of me\naningful recovery is low and examination at present suggests that the probable o\nutcome will be a persistent vegetative state. Plan at this point should be to tr\neat the toxic metabolic infectious factors and and any ongoing seizures.\n Assessment and Plan\n 28 year old male with a history of alcoholism presenting with acute\n hepatitis, pancreatitis, and UGIB, with persistent cyclic\n fevers/leukocytosis and anoxic brain injury.\n # Cyclic fevers/leukocytosis\n - Pt spiked a fever to 101.9 last night. Pan cultures done. WBC 11.6\n - Prelim sputum culture c/w oropharyngeal flora\n will f/u\n - Blood and urine cx still pending\n will f/u\n - CMV VL pending\n if increased, will check to see if it correlates\n with an increase in LFTs\n if so, will consider tx of CMV\n - will also consider tx of CMV if pt continues to have fevers, has\n clinical deterioration, or has end organ disfunction\n # Respiratory failure\n Pt is on trach mask at 40% FIO2.\n - Pt is still tachypneic. (RR 27-59).\n - Considering pt\ns neuro findings, this may be centrally-driven.\n - also be d/t an infectious process\n will follow up culture data\n # Acute renal failure\n - pt put out 2.6 L urine yesterday.\n I/O net positive 2.3 L\n -Cr improved at 1.0.\n - will continue to follow UOP, BUN, and Cr\n - Will give pt another dose of Lasix today - 40 mg IV to try to get\n some fluid off\n # Mental status/anoxic brain injury\n pt had MRI that showed diffuse\n subacute anoxic injury involving the basal ganglia and cortex\n - poor prognosis per neuro with likely long term prognosis persistent\n vegetative state.\n - Family requesting second opinion regarding long term prognosis. This\n will be coordinated by attending physician . .\n # Anemia\n - Hct stable\n - continue to monitor Hct\n # Acute Hepatitis: Likely alcoholic hepatitis. CT scan shows fatty\n infiltration, and no evidence of distal obstruction.\n - will continue to trend LFT\ns and correlate with CMV load\n - AST/ALT on were 60 and 85, which is improved from previous\n overall\n will correlated with CMV VL\n # FEN: IVF, replete electrolytes, Nutren at 50 ml/hr. Given volume\n status will discuss with nutrition if possible to concentrate further.\n ICU Care\n Nutrition:\n Nutren 2.0 () - 12:21 PM 50 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n PICC Line - 08:37 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:ICU\n" }, { "category": "Physician ", "chartdate": "2131-07-04 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 684888, "text": "Chief Complaint:\n 24 Hour Events:\n ULTRASOUND - At 02:17 PM\n PAN CULTURE - At 08:50 PM\n FEVER - 101.9\nF - 08:00 PM\n -2100: Called for temp spike to 101.9. Blood/Urine/Sputum Cx sent.\n Allergies:\n Meropenem\n skin blisters a\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 12:21 PM\n Furosemide (Lasix) - 12:45 PM\n Heparin Sodium (Prophylaxis) - 05:30 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 06:19 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.8\nC (101.9\n Tcurrent: 37\nC (98.6\n HR: 111 (109 - 129) bpm\n BP: 125/91(99) {101/54(74) - 138/91(117)} mmHg\n RR: 44 (27 - 59) insp/min\n SpO2: 98%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 99.1 kg (admission): 113.5 kg\n Height: 67 Inch\n Total In:\n 4,882 mL\n 966 mL\n PO:\n TF:\n 1,200 mL\n 315 mL\n IVF:\n 2,032 mL\n 51 mL\n Blood products:\n Total out:\n 2,575 mL\n 710 mL\n Urine:\n 2,575 mL\n 710 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,307 mL\n 256 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n SpO2: 98%\n ABG: ///18/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 349 K/uL\n 6.8 g/dL\n 111 mg/dL\n 1.0 mg/dL\n 18 mEq/L\n 4.4 mEq/L\n 48 mg/dL\n 115 mEq/L\n 142 mEq/L\n 23.6 %\n 11.6 K/uL\n [image002.jpg]\n 10:00 PM\n 02:32 AM\n 04:25 AM\n 03:56 PM\n 02:32 AM\n 08:00 PM\n 12:35 AM\n 03:21 AM\n 04:44 PM\n 02:42 AM\n WBC\n 10.9\n 11.0\n 10.5\n 11.1\n 11.6\n Hct\n 22.2\n 22.5\n 22.3\n 22.1\n 23.6\n Plt\n 290\n 310\n 327\n 341\n 349\n Cr\n 1.9\n 1.6\n 1.3\n 1.2\n 1.2\n 1.1\n 1.0\n 1.0\n TCO2\n 20\n Glucose\n 177\n 116\n 161\n 97\n 93\n 147\n 187\n 111\n Other labs: PT / PTT / INR:13.6/28.0/1.2, CK / CKMB /\n Troponin-T:214/3/0.07, ALT / AST:60/85, Alk Phos / T Bili:247/2.8,\n Amylase / Lipase:78/91, Differential-Neuts:57.0 %, Band:4.0 %,\n Lymph:23.0 %, Mono:4.0 %, Eos:3.0 %, D-dimer:6389 ng/mL, Fibrinogen:541\n mg/dL, Lactic Acid:2.6 mmol/L, Albumin:2.4 g/dL, LDH:437 IU/L, Ca++:9.2\n mg/dL, Mg++:1.8 mg/dL, PO4:4.2 mg/dL\n Echo () - The left atrium is normal in size. Overall left\n ventricular systolic function is normal (LVEF>55%). Tissue Doppler\n imaging suggests a normal left ventricular filling pressure\n (PCWP<12mmHg). Right ventricular chamber size and free wall motion are\n normal. The aortic valve leaflets (3) appear structurally normal with\n good leaflet excursion and no aortic regurgitation. The mitral valve\n appears structurally normal with trivial mitral regurgitation. There is\n no pericardial effusion. No vegetation seen (cannot definitively\n exclude).\n Compared with the prior study (images reviewed) of , there is\n no significant change.\nSputum culture PRELIM\n multiple organisms c/w oropharyngeal flora\nBlood/urine cx and CMV VL\n PENDING\nNeurology consult (Dr. - There are still metabolic abnormalities which\nmay play some role in the neurological assessment, however, the likelihood of me\naningful recovery is low and examination at present suggests that the probable o\nutcome will be a persistent vegetative state. Plan at this point should be to tr\neat the toxic metabolic infectious factors and and any ongoing seizures.\n Assessment and Plan\n 28 year old male with a history of alcoholism presenting with acute\n hepatitis, pancreatitis, and UGIB, with persistent cyclic\n fevers/leukocytosis and anoxic brain injury.\n # Cyclic fevers/leukocytosis\n - Pt spiked a fever to 101.9 last night. Pan cultures done. WBC 11.6\n - Prelim sputum culture c/w oropharyngeal flora\n will f/u\n - Blood and urine cx still pending\n will f/u\n - CMV VL pending\n if increased, will check to see if it correlates\n with an increase in LFTs\n if so, will consider tx of CMV\n - will also consider tx of CMV if pt continues to have fevers, has\n clinical deterioration, or has end organ disfunction\n - CT abdomen?\n # Respiratory failure\n Pt is on trach mask at 40% FIO2.\n - Pt is still tachypneic. (RR 27-59).\n - Considering pt\ns neuro findings, this may be centrally-driven.\n - also be d/t an infectious process\n will follow up culture data\n # Acute renal failure\n - pt put out 2.6 L urine yesterday.\n I/O net positive 2.3 L\n -Cr improved at 1.0.\n - will continue to follow UOP, BUN, and Cr\n - Will give pt another dose of Lasix today - 40 mg IV to try to get\n some fluid off\n # Mental status/anoxic brain injury\n pt had MRI that showed diffuse\n subacute anoxic injury involving the basal ganglia and cortex\n - poor prognosis per neuro with likely long term prognosis persistent\n vegetative state.\n - Second neuro opinion confirmed poor prognosis\n # Anemia\n - Hct stable\n - continue to monitor Hct\n # Acute Hepatitis: Likely alcoholic hepatitis. CT scan shows fatty\n infiltration, and no evidence of distal obstruction.\n - will continue to trend LFT\ns and correlate with CMV load\n - AST/ALT on were 60 and 85, which is improved from previous\n overall\n will correlated with CMV VL\n # FEN: IVF, replete electrolytes, Nutren at 50 ml/hr. Given volume\n status will discuss with nutrition if possible to concentrate further.\n ICU Care\n Nutrition:\n Nutren 2.0 () - 12:21 PM 50 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n PICC Line - 08:37 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:ICU\n" }, { "category": "Social Work", "chartdate": "2131-07-04 00:00:00.000", "description": "Social Work Progress Note", "row_id": 685008, "text": "Met yesterday with pt\ns mother and brother, both at bedside, very\n somber after learning of pt\ns MRI results. Pt has suffered and anoxic\n brain injury which will significantly impact his rehab potential.\n Met today with pt\ns father who reports that a second opinion has been\n requested re: of the MRI, father advocating also for aggressive\n neuro-rehab.\n Have discussed with family some of the long term issues that will now\n need to be addressed with re: to decision making and insurance\n coverage. Pt\ns brother will assume much of the responsibility for\n above with the support of his parents.\n" }, { "category": "Respiratory ", "chartdate": "2131-07-01 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 684244, "text": "Tracheostomy tube:\n Type: Cuffed\n Manufacturer: Portex\n Size: 8.0mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Cuff volume: 6 mL /\n Airway problems: Skin breakdown around trache site,\n wound dressing placed on site. Inner cannula changed.\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Crackles\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: sputum specimen obtained. Strong cough, able to mobilize most\n of secretions.\n Ventilation Assessment\n Level of breathing assistance: Unassisted spontaneous breathing\n Visual assessment of breathing pattern: Nasal flaring, Tachypneic (RR>\n 35 b/min), shallow pattern. CXR done this afternoon.\n Bedside Procedures:\n ABG puncture (16:00) - 7.35/35/89/20/-5\n" }, { "category": "Nursing", "chartdate": "2131-07-02 00:00:00.000", "description": "Nursing Progress Note", "row_id": 684495, "text": "Arousal, Attention, and Cognition, Impaired\n Assessment:\n Cont to track around room\n Facial expressions noted\n Lift and holds upper extremities spontaneously\n Not following commands\n Action:\n OOB to chair\n PT at bedside\n Response:\n Neuro unchanged\n Plan:\n Cont with to monitor neuro status\n Rehab screening\n" }, { "category": "Physician ", "chartdate": "2131-07-03 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 684667, "text": "Chief Complaint:\n 24 Hour Events:\n - started on free water by IVF to correct hypernatremia\n - increased free water rate and repeated lytes at 0030 hrs\n - had lengthy discussion w/ family, who wants a 2nd opinion on\n potential for neuro recovery\n - speech and swallow eval for -muir valve entered\n - told by RN that pt had foley put back in\n Allergies:\n Meropenem\n skin blisters a\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Acetaminophen\n Albuterol Inhaler\n Diazepam\n Famotidine\n Fentanyl Citrate\n Heparin\n Insulin\n LeVETiracetam\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:16 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.3\nC (100.9\n Tcurrent: 37.7\nC (99.9\n HR: 116 (111 - 123) bpm\n BP: 134/70(86) {92/61(70) - 138/106(113)} mmHg\n RR: 37 (28 - 48) insp/min\n SpO2: 95%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 99.5 kg (admission): 113.5 kg\n Height: 67 Inch\n Total In:\n 4,550 mL\n 1,351 mL\n PO:\n TF:\n 1,200 mL\n 263 mL\n IVF:\n 1,100 mL\n 788 mL\n Blood products:\n Total out:\n 750 mL\n 450 mL\n Urine:\n 750 mL\n 450 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,800 mL\n 901 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n SpO2: 95%\n ABG: ///18/\n Physical Examination\n General: Alert, non-verbal, NAD\n HEENT: Scleral icterus, MMM\n Neck: supple, JVP difficult to assess given edema, no LAD, trach in\n place.\n Lungs: tachypnic Ronchi bilat.\n CV: tachycardic with normal rhytyhm, normal S1 + S2, no murmurs, rubs,\n gallops\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness or guarding.\n Ext: Warm, well perfused, 2+ pulses, 3+ edema..\n Labs / Radiology\n 341 K/uL\n 6.7 g/dL\n 147 mg/dL\n 1.1 mg/dL\n 18 mEq/L\n 4.7 mEq/L\n 61 mg/dL\n 120 mEq/L\n 147 mEq/L\n 22.1 %\n 11.1 K/uL\n [image002.jpg]\n 02:16 AM\n 04:14 PM\n 10:00 PM\n 02:32 AM\n 04:25 AM\n 03:56 PM\n 02:32 AM\n 08:00 PM\n 12:35 AM\n 03:21 AM\n WBC\n 11.4\n 10.9\n 11.0\n 10.5\n 11.1\n Hct\n 21.7\n 22.2\n 22.5\n 22.3\n 22.1\n Plt\n 266\n 290\n 310\n 327\n 341\n Cr\n 2.1\n 2.0\n 1.9\n 1.6\n 1.3\n 1.2\n 1.2\n 1.1\n TCO2\n 20\n Glucose\n 98\n 151\n 177\n 116\n 161\n 97\n 93\n 147\n Other labs: PT / PTT / INR:13.6/28.0/1.2, CK / CKMB /\n Troponin-T:214/3/0.07, ALT / AST:91/137, Alk Phos / T Bili:318/4.1,\n Amylase / Lipase:78/91, Differential-Neuts:57.0 %, Band:4.0 %,\n Lymph:23.0 %, Mono:4.0 %, Eos:3.0 %, D-dimer:6389 ng/mL, Fibrinogen:541\n mg/dL, Lactic Acid:2.6 mmol/L, Albumin:2.3 g/dL, LDH:437 IU/L, Ca++:9.2\n mg/dL, Mg++:1.8 mg/dL, PO4:4.2 mg/dL\n Assessment and Plan\n 28 year old male with a history of alcoholism presenting with acute\n hepatitis, pancreatitis, and UGIB, with persistent cyclic\n fevers/leukocytosis and anoxic brain injury.\n # Cyclic fevers/leukocytosis\n Tmax 100.9 overnight. WBC at 11.1.\n - will tolerate slight fevers as long as patient does not have clinical\n deterioration (hypotension/other) or WBC elevations\n - off abx\n - Cdiff negative \n - sputum cultures\n moderate growth GNR resembling acinetobacter\n (susceptibilities done). Likely colonization.\n - will recheck sputum cultures\n - blood cultures pending from & \n - will not start gancyclovir at this point - CMV not likely cause of\n fevers. Will continue to follow LFTs and if rising will see if\n correlates with CMV viral load. If so, will discuss with renal and ID.\n -CMV viral load to be drawn with 7/1 AM labs.\n - Will order an abdominal CT in the next few days to reevaluate\n peripancreatic fluid.\n # Respiratory failure\n Pt is on trach mask at 40% FIO2.\n - Pt is still tachypneic. (RR 27-40).\n - Considering pt\ns neuro findings, this may be centrally-driven.\n # Acute renal failure\n - pt put out 0.75 L urine yesterday;\n -Cr now 1.1 continuing to trend down.\n - will continue to follow UOP, BUN, and Cr\n # Mental status/anoxic brain injury\n pt had MRI that showed diffuse\n subacute anoxic injury involving the basal ganglia and cortex\n - poor prognosis per neuro with likely long term prognosis persistent\n vegetative state.\n - Family requesting second opinion regarding long term prognosis. This\n will be coordinated by attending physician . .\n # Anemia\n - Hct stable\n - continue to monitor Hct\n # Acute Hepatitis: Likely alcoholic hepatitis. CT scan shows fatty\n infiltration, and no evidence of distal obstruction.\n - will continue to trend LFT\ns and correlate with CMV load\n - check LFT\ns with 7/1 AM labs to correlate with CMV load\n # FEN: IVF, replete electrolytes, Nutren at 50 ml/hr. Given volume\n status will discuss with nutrition if possible to concentrate further.\n ICU Care\n Nutrition:\n Nutren 2.0 () - 12:28 PM 50 mL/hour\n Glycemic Control: insulin\n Lines:\n PICC Line - 08:37 AM\n Prophylaxis:\n DVT: Heparin\n Stress ulcer: Famotidine\n VAP:\n Comments:\n Communication: With Family.:\n Code status: Full code\n Disposition: MICU pending neuro second opinion.\n" }, { "category": "Physician ", "chartdate": "2131-07-05 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 685124, "text": "Chief Complaint:\n 24 Hour Events:\n \n - primary neuro team signed off\n - started on oral Lasix - even on I/O's as of 1530\n - 2300: nursing reports that pt had a medium-sized rusty-colored stool\n Allergies:\n Meropenem\n skin blisters a\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 12:02 PM\n Famotidine (Pepcid) - 12:03 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 06:37 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.7\nC (99.8\n Tcurrent: 37.6\nC (99.6\n HR: 123 (110 - 125) bpm\n BP: 121/69(83) {99/62(79) - 144/100(106)} mmHg\n RR: 34 (30 - 46) insp/min\n SpO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 99.1 kg (admission): 113.5 kg\n Height: 67 Inch\n Total In:\n 2,401 mL\n 529 mL\n PO:\n TF:\n 1,200 mL\n 329 mL\n IVF:\n 151 mL\n Blood products:\n Total out:\n 2,670 mL\n 450 mL\n Urine:\n 2,670 mL\n 450 mL\n NG:\n Stool:\n Drains:\n Balance:\n -269 mL\n 80 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n SpO2: 100%\n ABG: ///17/\n Physical Examination\n General: Alert, non-verbal\n HEENT: Scleral icterus, MMM\n Neck: supple, edematous, no LAD\n Lungs: Tachypnic ronchi\n CV: tachycardic with normal rhytyhm, normal S1 + S2, no murmurs, rubs,\n gallops\n Abdomen: soft, non-tender, non-distended, NABS\n Ext: 3+ Bilat LE edema, 2+ bilat UE edema..\n Labs / Radiology\n 367 K/uL\n 6.9 g/dL\n 115 mg/dL\n 0.8 mg/dL\n 17 mEq/L\n 4.2 mEq/L\n 38 mg/dL\n 116 mEq/L\n 142 mEq/L\n 22.4 %\n 10.3 K/uL\n [image002.jpg]\n 02:32 AM\n 04:25 AM\n 03:56 PM\n 02:32 AM\n 08:00 PM\n 12:35 AM\n 03:21 AM\n 04:44 PM\n 02:42 AM\n 04:46 AM\n WBC\n 10.9\n 11.0\n 10.5\n 11.1\n 11.6\n 10.3\n Hct\n 22.2\n 22.5\n 22.3\n 22.1\n 23.6\n 22.4\n Plt\n 290\n 310\n 327\n \n Cr\n 1.9\n 1.6\n 1.3\n 1.2\n 1.2\n 1.1\n 1.0\n 1.0\n 0.8\n TCO2\n 20\n Glucose\n 116\n 161\n 97\n 93\n 147\n 187\n 111\n 115\n Other labs: PT / PTT / INR:13.6/28.0/1.2, CK / CKMB /\n Troponin-T:214/3/0.07, ALT / AST:60/85, Alk Phos / T Bili:247/2.8,\n Amylase / Lipase:78/91, Differential-Neuts:57.0 %, Band:4.0 %,\n Lymph:23.0 %, Mono:4.0 %, Eos:3.0 %, D-dimer:6389 ng/mL, Fibrinogen:541\n mg/dL, Lactic Acid:2.6 mmol/L, Albumin:2.4 g/dL, LDH:437 IU/L, Ca++:9.2\n mg/dL, Mg++:1.8 mg/dL, PO4:4.2 mg/dL\n Assessment and Plan\n 28 year old male with a history of alcoholism presenting with acute\n hepatitis, pancreatitis, and UGIB, with persistent cyclic\n fevers/leukocytosis and anoxic brain injury.\n # Cyclic fevers/leukocytosis\n - Tmax 99.8 over past 24hrs. WBC 10.3\n - Prelim sputum culture c/w oropharyngeal flora\n continues to be same\n as priors and thought to be colonization\n - Blood and urine cx still pending from . Prior blood cx are\n negative.\n - CMV VL pending\n LFT\ns were down making a correlation between an\n increased VL and LFT\ns moot/negative but will follow up VL\n - will consider tx of CMV if pt continues to have fevers, has clinical\n deterioration, or has end organ dysfunction\n - be due to necrotic pancreas or process in the peripancreatic\n fluid and thus may still require an CT.\n # Respiratory failure\n Pt is on trach mask at 40% FIO2.\n - Pt is still tachypneic. (RR 27-59).\n - Considering pt\ns neuro findings, this may be centrally-driven.\n - also be d/t an infectious process, although clear CXR makes this\n unlikely and negative blood cx.\n will follow up culture data\n # Acute renal failure\n - pt put out 2.6 L urine yesterday.\n I/O net positive 2.3 L\n -Cr improved at 0.8\n - will continue to follow UOP, BUN, and Cr\n - Will start pt on PO lasix at 40 mg daily\n - will also decrease free water boluses to 100mL q4 hrs\n # Mental status/anoxic brain injury\n pt had MRI that showed diffuse\n subacute anoxic injury involving the basal ganglia and cortex\n - poor prognosis per neuro with likely long term prognosis persistent\n vegetative state.\n - Second neuro opinion appreciated and nonted that while it is hopeful\n it is unlikely to recover to baseline function and at present Pt should\n be placed at a facility that can monitor his progress such that if he\n achieves a level of function at which he is able to participate in\n neuro rehab he could be transferred to a facility able to provide said\n services.\n # Anemia\n - Hct stable\n - continue to monitor Hct\n # Acute Hepatitis: Likely alcoholic hepatitis. CT scan shows fatty\n infiltration, and no evidence of distal obstruction.\n - will continue to trend LFT\ns and correlate with CMV load\n - AST/ALT on were 60 and 85, which is improved from previous\n overall\n # FEN: IVF, replete electrolytes PRN, Nutren at 50 ml/hr.\n ICU Care\n Nutrition:\n Nutren 2.0 () - 12:21 PM 50 mL/hour\n Glycemic Control: Insulin\n Lines:\n PICC Line - 08:37 AM\n Prophylaxis:\n DVT: Heparin\n Stress ulcer: Famotidine\n VAP: oral care / elevated HOB\n Comments:\n Communication: With Family (Pts Brother / Father) Comments:\n Code status: Full code\n Disposition: Rehab when placement found\n" }, { "category": "Rehab Services", "chartdate": "2131-07-05 00:00:00.000", "description": "Physical Therapy Progress Note", "row_id": 685165, "text": "Subjective:\n None\n Objective:\n Follow up PT visit to address goals of: . Patient seen today\n for balance training, therapeutic exercise , patient education\n Updated medical status: No updated medical status\n Activity\n Clarification\n I\n S\n CG\n Min\n Mod\n Total\n Rolling:\n\n\n\n\n T\n Supine/\n Sidelying to Sit:\n\n\n\n\n X2\n Transfer:\n\n\n\n\n\n Sit to Stand:\n\n\n\n\n\n Ambulation:\n\n\n\n\n\n Stairs:\n\n\n\n\n\n Aerobic Activity Response:\n Position\n HR\n BP\n RR\n O[2] sat\n RPE\n Rest\n Supine\n 123\n 130/85\n 29\n 100% on 50% FiO2\n Activity\n /\n Recovery\n Supine\n 122\n 128/71\n 32\n 100% on 50% FiO2\n Total distance walked: NA\n Minutes:\n Gait: NA\n Balance: Maintained sitting EOB with close supervision - mod A while\n reaching with UE's for object and single UE support.\n Education / Communication: Pt education re: PT role, POC, techniques\n with mobility, deep breathing\n Communication with RN re: updated pt status\n Other: Pt consistently responding to simple commands and initiating\n reaching with BUE's 75% of the time with tactile and visual cueing. Pt\n also tracking objects 75% of the time and nodding.\n Assessment: Pt is a 28 yo male admitted with acute hepatitis and\n pancreatitis, with cerebral edema s/p PEA arrest. He is making slow,\n steady gains with mobility and arousal during PT. Pt continues to\n present well below baseline with all mobility and cognition and will\n benefit from d/c to rehab to maximize functional independence.\n Anticipated Discharge: Rehab\n Plan: bed mobility, sitting balance, functional tasks BLE's and ,\n pt education\n Signed by: , PT/s \n" }, { "category": "Rehab Services", "chartdate": "2131-07-05 00:00:00.000", "description": "Physical Therapy Progress Note", "row_id": 685169, "text": "Subjective:\n None\n Objective:\n Follow up PT visit to address goals of: . Patient seen today\n for balance training, therapeutic exercise , patient education\n Updated medical status: No updated medical status\n Activity\n Clarification\n I\n S\n CG\n Min\n Mod\n Total\n Rolling:\n\n\n\n\n T\n Supine/\n Sidelying to Sit:\n\n\n\n\n X2\n Transfer:\n\n\n\n\n\n Sit to Stand:\n\n\n\n\n\n Ambulation:\n\n\n\n\n\n Stairs:\n\n\n\n\n\n Aerobic Activity Response:\n Position\n HR\n BP\n RR\n O[2] sat\n RPE\n Rest\n Supine\n 123\n 130/85\n 29\n 100% on 50% FiO2\n Activity\n /\n Recovery\n Supine\n 122\n 128/71\n 32\n 100% on 50% FiO2\n Total distance walked: NA\n Minutes:\n Gait: NA\n Balance: Maintained sitting EOB with close supervision at times,\n otherwise mod A while reaching with UE's for object and single UE\n support.\n Education / Communication: Pt education re: PT role, POC, techniques\n with mobility, deep breathing\n Communication with RN re: updated pt status\n Other: Pt responding to most simple commands and initiating reaching\n with BUE's 50% of the time with tactile and visual cueing. Pt also\n tracking objects 75% of the time and nodding to questions. Initiates R\n knee extension on command\n Assessment: Pt is a 28 yo male admitted with acute hepatitis and\n pancreatitis, with cerebral edema s/p PEA arrest. He is making slow,\n steady gains with mobility and arousal during PT. Pt continues to\n present well below baseline with all mobility and cognition and will\n benefit from d/c to rehab to maximize functional independence.\n Anticipated Discharge: Rehab\n Plan: bed mobility, sitting balance, functional tasks BLE's and ,\n pt education\n Eval performed by: , PT/s x31291\n" }, { "category": "Physician ", "chartdate": "2131-07-05 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 685174, "text": "Chief Complaint: pancreatitis, resp failure,\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n Long family meeting with Dr Neuro\n prognosis- confirms severe anxia but extent of recovery remains to be\n seen. He is LTAC candidate.\n Allergies:\n Meropenem\n skin blisters a\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 12:02 PM\n Famotidine (Pepcid) - 12:03 PM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 11:11 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.7\nC (99.9\n Tcurrent: 37.7\nC (99.9\n HR: 123 (110 - 125) bpm\n BP: 130/85(91) {99/58(77) - 144/100(106)} mmHg\n RR: 28 (28 - 46) insp/min\n SpO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 98.6 kg (admission): 113.5 kg\n Height: 67 Inch\n Total In:\n 2,401 mL\n 888 mL\n PO:\n TF:\n 1,200 mL\n 558 mL\n IVF:\n 151 mL\n Blood products:\n Total out:\n 2,670 mL\n 950 mL\n Urine:\n 2,670 mL\n 950 mL\n NG:\n Stool:\n Drains:\n Balance:\n -269 mL\n -62 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n SpO2: 100%\n ABG: ///17/\n Physical Examination\n Gen: sitting in bed, tachypneic but less secretions\n CV: RR\n Chest: coarse bs bilat\n Abd soft +BS\n Ext: 1+ edema\n Neuro: eyes open, slightly tremulous\n Labs / Radiology\n 6.9 g/dL\n 367 K/uL\n 115 mg/dL\n 0.8 mg/dL\n 17 mEq/L\n 4.2 mEq/L\n 38 mg/dL\n 116 mEq/L\n 142 mEq/L\n 22.4 %\n 10.3 K/uL\n [image002.jpg]\n 02:32 AM\n 04:25 AM\n 03:56 PM\n 02:32 AM\n 08:00 PM\n 12:35 AM\n 03:21 AM\n 04:44 PM\n 02:42 AM\n 04:46 AM\n WBC\n 10.9\n 11.0\n 10.5\n 11.1\n 11.6\n 10.3\n Hct\n 22.2\n 22.5\n 22.3\n 22.1\n 23.6\n 22.4\n Plt\n 290\n 310\n 327\n \n Cr\n 1.9\n 1.6\n 1.3\n 1.2\n 1.2\n 1.1\n 1.0\n 1.0\n 0.8\n TCO2\n 20\n Glucose\n 116\n 161\n 97\n 93\n 147\n 187\n 111\n 115\n Other labs: PT / PTT / INR:13.6/28.0/1.2, CK / CKMB /\n Troponin-T:214/3/0.07, ALT / AST:60/85, Alk Phos / T Bili:247/2.8,\n Amylase / Lipase:78/91, Differential-Neuts:57.0 %, Band:4.0 %,\n Lymph:23.0 %, Mono:4.0 %, Eos:3.0 %, D-dimer:6389 ng/mL, Fibrinogen:541\n mg/dL, Lactic Acid:2.6 mmol/L, Albumin:2.4 g/dL, LDH:437 IU/L, Ca++:9.2\n mg/dL, Mg++:1.8 mg/dL, PO4:4.2 mg/dL\n Assessment and Plan\n FEVER, UNKNOWN ORIGIN (FUO, HYPERTHERMIA, PYREXIA)\n AROUSAL, ATTENTION, AND COGNITION, IMPAIRED\n BALANCE, IMPAIRED\n MOTOR FUNCTION, IMPAIRED\n MUSCLE PERFORMACE, IMPAIRED\n RESPIRATION / GAS EXCHANGE, IMPAIRED\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n IMPAIRED SKIN INTEGRITY\n HEPATITIS, ACUTE TOXIC (INCLUDING ALCOHOLIC, ACETAMINOPHEN, ETC.)\n 1. Cyclical fevers: Temp to 101.9 again last PM but stable\n WBC and CXR, pan cx. stable off all ABX, CXR is improved and no focal\n sources. Overall stable WBC and this could be central. We will follow\n cx, follow up CMV viral load, LFTS, we can consider abd imaging but my\n sense is that in the absence of exam change IR or surgery would be\n loathe to intervent on pancreas unless systemically ill and thus\n imaging alone is not helpful at this point. Should fevers persist or he\n deteriorate we can re evaluate.\n 2. Resp Failure: yesterday with increased frothy pink sputum, ?\n volume overload. But CXR without infiltrate and echo WNL. He is\n positive everyday so may just be secrtions\n we will start lasix to\n keep closer to even and reduce obligate ins.\n 3. Altered Mental status: MRI with concerning anoxic features and\n prognosis from Dr was he could improve slightly but unlikely to\n recover dramatically. Family would like 2nd opinion and we will contact\n Dr who will see him today.\n 4. ARF: resolved, off HD, start po lasix to match I and O\n more closely\n 5. Transaminitis: follow LFTS and CMV viral load\n 6. CMV: need toclarify with ID what pregnant healthcare\n workers need to do as precautions\n Remaining issues as per Housestaff\n ICU Care\n Nutrition:\n Nutren 2.0 () - 12:21 PM 50 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 08:37 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n Communication: with family I will call \n Code status: Full code\n Disposition :ICU\n Total time spent:\n" }, { "category": "Nursing", "chartdate": "2131-07-01 00:00:00.000", "description": "Nursing Progress Note", "row_id": 684242, "text": "Arousal, Attention, and Cognition, Impaired\n Assessment:\n Patient eyes open with occasional tracking, does not follow commands\n body tremors continuous, rrate 30\ns to 40\ns abdominal breathing noted\n O2 sat 95-100%, skin tight abd distended.\n Action:\n MIcu team increased flushes to 300, chest x-ray ordered and obtained,\n abg drawn and sent, sputum obtained for culture.\n Response:\n Frequent suctioning required with thick white sputum, neuro status\n remains unchanged.\n Plan:\n Notify teams of any changes provide comfort and support as needed.\n" }, { "category": "Physician ", "chartdate": "2131-07-03 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 684651, "text": "Chief Complaint: resp 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 tachypnea\n req suctioning\n Allergies:\n Meropenem\n skin blisters a\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 07:54 PM\n Other medications:\n Diazepam\n Tylenol\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 11:48 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.3\nC (100.9\n Tcurrent: 38.1\nC (100.5\n HR: 125 (111 - 127) bpm\n BP: 123/65(78) {106/54(74) - 138/106(113)} mmHg\n RR: 43 (28 - 57) insp/min\n SpO2: 98%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 99.5 kg (admission): 113.5 kg\n Height: 67 Inch\n Total In:\n 4,550 mL\n 2,439 mL\n PO:\n TF:\n 1,200 mL\n 589 mL\n IVF:\n 1,100 mL\n 1,100 mL\n Blood products:\n Total out:\n 750 mL\n 1,200 mL\n Urine:\n 750 mL\n 1,200 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,800 mL\n 1,239 mL\n Respiratory support\n O2 Delivery Device: Aerosol-cool\n SpO2: 98%\n ABG: ///18/\n Physical Examination\n Gen: sitting up in chair, tachypneic\n CV: RR\n Chest: coarse bs bilat\n Abd soft +BS\n Ext: 1+ edema\n Neuro: eyes open, slightly tremulous\n Labs / Radiology\n 6.7 g/dL\n 341 K/uL\n 147 mg/dL\n 1.1 mg/dL\n 18 mEq/L\n 4.7 mEq/L\n 61 mg/dL\n 120 mEq/L\n 147 mEq/L\n 22.1 %\n 11.1 K/uL\n [image002.jpg]\n 02:16 AM\n 04:14 PM\n 10:00 PM\n 02:32 AM\n 04:25 AM\n 03:56 PM\n 02:32 AM\n 08:00 PM\n 12:35 AM\n 03:21 AM\n WBC\n 11.4\n 10.9\n 11.0\n 10.5\n 11.1\n Hct\n 21.7\n 22.2\n 22.5\n 22.3\n 22.1\n Plt\n 266\n 290\n 310\n 327\n 341\n Cr\n 2.1\n 2.0\n 1.9\n 1.6\n 1.3\n 1.2\n 1.2\n 1.1\n TCO2\n 20\n Glucose\n 98\n 151\n 177\n 116\n 161\n 97\n 93\n 147\n Other labs: PT / PTT / INR:13.6/28.0/1.2, CK / CKMB /\n Troponin-T:214/3/0.07, ALT / AST:91/137, Alk Phos / T Bili:318/4.1,\n Amylase / Lipase:78/91, Differential-Neuts:57.0 %, Band:4.0 %,\n Lymph:23.0 %, Mono:4.0 %, Eos:3.0 %, D-dimer:6389 ng/mL, Fibrinogen:541\n mg/dL, Lactic Acid:2.6 mmol/L, Albumin:2.3 g/dL, LDH:437 IU/L, Ca++:9.2\n mg/dL, Mg++:1.8 mg/dL, PO4:4.2 mg/dL\n Assessment and Plan\n FEVER, UNKNOWN ORIGIN (FUO, HYPERTHERMIA, PYREXIA)\n AROUSAL, ATTENTION, AND COGNITION, IMPAIRED\n BALANCE, IMPAIRED\n MOTOR FUNCTION, IMPAIRED\n MUSCLE PERFORMACE, IMPAIRED\n RESPIRATION / GAS EXCHANGE, IMPAIRED\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n IMPAIRED SKIN INTEGRITY\n HEPATITIS, ACUTE TOXIC (INCLUDING ALCOHOLIC, ACETAMINOPHEN, ETC.)\n 1. Cyclical fevers: stable off all ABX, CXR is improved and\n no focal sources. Overall stable WBC and this could be central. Should\n he spike and leukocytosis will pan cx, consider repeat abd imaging.\n 2. Resp Failure: on trach mask and holding his own, though is\n tachyneic at times\n again wonder if this is central\n 3. Altered Mental status: MRI with concerning anoxic feautures\n and prognosis from Dr was he could improve slightly but\n unlikely to recover dramatically.\n 4. For ARF: off HD, watching UOP\n Remaining issues as per Housestaff\n ICU Care\n Nutrition: Nutren 2.0 () - 12:28 PM 50 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 08:37 AM\n Prophylaxis:\n DVT: sc hep\n Stress ulcer: PPI\n VAP: HOB chlorhex\n Communication: met with brother and pt they would like a 2^nd\n opinion from neuro - we will arrange today\n Code status: Full code\n Disposition :ICU\n Total time spent:\n" }, { "category": "Nursing", "chartdate": "2131-07-05 00:00:00.000", "description": "Nursing Progress Note", "row_id": 685137, "text": " Problem\n anoxic brain injury\n Assessment:\n Opens eyes and is alert and tracking\n This morning mouthing words and nodding\n Moves bil upper extremities spontaneously but not to command\n Withdraws bil lower extremites to nail bed\n Action:\n Reorient frequently\n Promote rest\n Response:\n More responsive this morning\n Plan:\n Plan for rehab.\n" }, { "category": "Respiratory ", "chartdate": "2131-07-03 00:00:00.000", "description": "Generic Note", "row_id": 684531, "text": "TITLE: Pt remains on t-collar 50%.Suctioned for mod amts thick yellow\n secretions. Tachypenic at times in the 30\ns.Sats 99%. H20 filled. All\n equipment present. Will cont to monitor resp status.\n" }, { "category": "Social Work", "chartdate": "2131-07-03 00:00:00.000", "description": "Social Work Progress Note", "row_id": 684601, "text": "Met with pt\ns mother and brother yesterday. Family met with\n neurologist on last Friday pm to discuss the pt\ns MRI report. Findings\n on the MRI suggest that pt has had an anoxic brain injury that will\n significantly impede pt\ns rehab potential. Family understandable\n upset, mother looks numb and cannot express herself other than tears.\n Brother is struggling to accept outcome, is more hopeful and would like\n pt to have an opportunity to try an aggressive form of neuro-rehab to\n maximize pt\ns potential. Per family father is\nin denial\n Offered support and will continue to reach out to family during this\n time.\n Will seek counseling support for family closer to their home.\n" }, { "category": "Rehab Services", "chartdate": "2131-07-03 00:00:00.000", "description": "PMV Follow Up", "row_id": 684631, "text": "TITLE:\nPMV FOLLOW UP\nHISTORY:\nThank you for consulting on this 28-year-old male who presented\nto ED on complaints of weakness, fatigue and\nconfusion for ~1 week, 2 days of melena and hematemesis. Patient\nwas found with grade 3 esophagitis in the lower\nand middle third of the esophagus; friability, erythema,\ncongestion and erosion in the whole stomach compatible with\nmoderately severe gastritis via EGD. CT scan revealed acute\npancreatitis with peripancreatic stranding and 30% necrosis.\nHospital course c/b continuous pressor requirement, alcoholic\nhepatitis, necrotizing pancreatitis, acute renal failure\nrequiring CVVHD, cerebral edema, ARDS, coagulopathy and\nthrombocytopenia thought to be due to liver failure (vs DIC) and\npossibly adrenal insufficiency. Patient was unable to wean from\nvent and underwent tracheostomy on and s/p bronchoscopy on\n clot resulting in brief PEA arrest. CVVH was\ndiscontinued on and patient to begin HD. Patient has been\ntolerating trach mask since and we were consulted to\nevaluate patient's ability to tolerate a Passy-Muir Speaking\nValve (PMV).\nPt was initially seen for the valve trial, but had\ndifficulty managing secretions and had audible breathstacking\nwith the valve in place. We returned on for another attempt,\nbut pt's secretions had increased and he was again requiring vent\nsupport to maintain respiratory status. Pt returned to trach\ncollar later that day, but RT reports he has had several declines\nrequiring return to the vent.\nNeurology has continued to follow the pt and recent MRI has\ndemonstrated diffuse, subacute anoxic injury involving the basal\nganglia and cortex with poor prognosis which has been discussed\nwith the pt's family. In the context of d/c planning and\nimprovements in MS, we were asked to reattempt the PMV.\nPMH:\nalcohol dependency\ndepression\nDEFERRED EVALUATION:\nPt continues to require suctioning every 30 minutes and is\ncurrently on T tube O2 with inline suctioning. RR was in the low\n50s when I arrived, not improved with deep suctioning. Secretions\ncontinued to accumulate 5 minutes after suctioning. I discussed\nwith RT and RN and we all agree pt is not yet appropriate for a\ntrial given his RR. If he can tolerate the valve, it could\npossibly improve independent management of his secretions, but\ncuff deflation was felt to be unsafe current RR / WOB. We\nwill continue to follow.\nThese recommendations were shared with the patient, nurse and\nmedical team.\n_______________________________________\n , M.S., CCC-SLP\nPager #\nTotal time: 30 minutes\n [BUTTON Input] (not implemented)_____\n 10:48\n" }, { "category": "Physician ", "chartdate": "2131-07-03 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 684645, "text": "Chief Complaint: resp 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 tachypnea\n req suctioning\n Allergies:\n Meropenem\n skin blisters a\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 07:54 PM\n Other medications:\n Diazepam\n Tylenol\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 11:48 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.3\nC (100.9\n Tcurrent: 38.1\nC (100.5\n HR: 125 (111 - 127) bpm\n BP: 123/65(78) {106/54(74) - 138/106(113)} mmHg\n RR: 43 (28 - 57) insp/min\n SpO2: 98%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 99.5 kg (admission): 113.5 kg\n Height: 67 Inch\n Total In:\n 4,550 mL\n 2,439 mL\n PO:\n TF:\n 1,200 mL\n 589 mL\n IVF:\n 1,100 mL\n 1,100 mL\n Blood products:\n Total out:\n 750 mL\n 1,200 mL\n Urine:\n 750 mL\n 1,200 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,800 mL\n 1,239 mL\n Respiratory support\n O2 Delivery Device: Aerosol-cool\n SpO2: 98%\n ABG: ///18/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 6.7 g/dL\n 341 K/uL\n 147 mg/dL\n 1.1 mg/dL\n 18 mEq/L\n 4.7 mEq/L\n 61 mg/dL\n 120 mEq/L\n 147 mEq/L\n 22.1 %\n 11.1 K/uL\n [image002.jpg]\n 02:16 AM\n 04:14 PM\n 10:00 PM\n 02:32 AM\n 04:25 AM\n 03:56 PM\n 02:32 AM\n 08:00 PM\n 12:35 AM\n 03:21 AM\n WBC\n 11.4\n 10.9\n 11.0\n 10.5\n 11.1\n Hct\n 21.7\n 22.2\n 22.5\n 22.3\n 22.1\n Plt\n 266\n 290\n 310\n 327\n 341\n Cr\n 2.1\n 2.0\n 1.9\n 1.6\n 1.3\n 1.2\n 1.2\n 1.1\n TCO2\n 20\n Glucose\n 98\n 151\n 177\n 116\n 161\n 97\n 93\n 147\n Other labs: PT / PTT / INR:13.6/28.0/1.2, CK / CKMB /\n Troponin-T:214/3/0.07, ALT / AST:91/137, Alk Phos / T Bili:318/4.1,\n Amylase / Lipase:78/91, Differential-Neuts:57.0 %, Band:4.0 %,\n Lymph:23.0 %, Mono:4.0 %, Eos:3.0 %, D-dimer:6389 ng/mL, Fibrinogen:541\n mg/dL, Lactic Acid:2.6 mmol/L, Albumin:2.3 g/dL, LDH:437 IU/L, Ca++:9.2\n mg/dL, Mg++:1.8 mg/dL, PO4:4.2 mg/dL\n Assessment and Plan\n FEVER, UNKNOWN ORIGIN (FUO, HYPERTHERMIA, PYREXIA)\n AROUSAL, ATTENTION, AND COGNITION, IMPAIRED\n BALANCE, IMPAIRED\n MOTOR FUNCTION, IMPAIRED\n MUSCLE PERFORMACE, IMPAIRED\n RESPIRATION / GAS EXCHANGE, IMPAIRED\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n IMPAIRED SKIN INTEGRITY\n HEPATITIS, ACUTE TOXIC (INCLUDING ALCOHOLIC, ACETAMINOPHEN, ETC.)\n 1. Cyclical fevers: stable off all ABX, CXR is improved and\n no focal sources. Overall stable WBC and this could be central. Should\n he spike and leukocytosis will pan cx, consider repeat abd imaging.\n 2. Resp Failure: on trach mask and holding his own, though is\n tachyneic at times\n again wonder if this is central\n 3. Altered Mental status: MRI with concerning anoxic feautures\n and prognosis from Dr was he could improve slightly but\n unlikely to recover dramatically.\n 4. For ARF: off HD, watching UOP\n Remaining issues as per Housestaff\n ICU Care\n Nutrition:\n Nutren 2.0 () - 12:28 PM 50 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 08:37 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent:\n" }, { "category": "Nursing", "chartdate": "2131-06-27 00:00:00.000", "description": "Nursing Progress Note", "row_id": 683382, "text": "Arousal, Attention, and Cognition, Impaired\n Assessment:\n Alert most of the time, otherwise easily arousable to voice\n Tracks voices and people at times\n PERL\n does not follow commands\n does not appear to have purposeful movements\n remains tremulous when stimulated\n + cough\n Action:\n frequent verbal stimulation and orienting\n OOB to chair\n Dangled at side of bed with physical therapy\n MRI of head\n EEG ordered\n anti-epileptics as ordered\n Response:\n neuro status unchanged\n Plan:\n continue to evaluate\n follow up on MRI results\n patient and family support\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Creatinine continues to slowly decrease, 2.7 at 1530\n urine output 30-100 cc\ns / hr\n fluid balance MN\n 1800 even\n Normal acid base balance / mild respiratory alkalosis (abg:\n 7.44, 33, 105, 0, 23).\n Action:\n HD not done today per renal\n Response:\n slowly improving renal function\n Plan:\n continue to monitor renal status\n continue to monitor fluid balance\n continue to follow with renal team\n ? Discontinue HD catheter if no HD by Friday .\n" }, { "category": "Physician ", "chartdate": "2131-07-03 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 684596, "text": "Chief Complaint:\n 24 Hour Events:\n - started on free water by IVF to correct hypernatremia\n - increased free water rate and repeated lytes at 0030 hrs\n - had lengthy discussion w/ family, who wants a 2nd opinion on\n potential for neuro recovery\n - speech and swallow eval for -muir valve entered\n - told by RN that pt had foley put back in\n Allergies:\n Meropenem\n skin blisters a\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Acetaminophen\n Albuterol Inhaler\n Diazepam\n Famotidine\n Fentanyl Citrate\n Heparin\n Insulin\n LeVETiracetam\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:16 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.3\nC (100.9\n Tcurrent: 37.7\nC (99.9\n HR: 116 (111 - 123) bpm\n BP: 134/70(86) {92/61(70) - 138/106(113)} mmHg\n RR: 37 (28 - 48) insp/min\n SpO2: 95%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 99.5 kg (admission): 113.5 kg\n Height: 67 Inch\n Total In:\n 4,550 mL\n 1,351 mL\n PO:\n TF:\n 1,200 mL\n 263 mL\n IVF:\n 1,100 mL\n 788 mL\n Blood products:\n Total out:\n 750 mL\n 450 mL\n Urine:\n 750 mL\n 450 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,800 mL\n 901 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n SpO2: 95%\n ABG: ///18/\n Physical Examination\n General: Alert, non-verbal, NAD\n HEENT: Scleral icterus, MMM\n Neck: supple, JVP difficult to assess given edema, no LAD, trach in\n place.\n Lungs: tachypnic Ronchi bilat.\n CV: tachycardic with normal rhytyhm, normal S1 + S2, no murmurs, rubs,\n gallops\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness or guarding.\n Ext: Warm, well perfused, 2+ pulses, 3+ edema..\n Labs / Radiology\n 341 K/uL\n 6.7 g/dL\n 147 mg/dL\n 1.1 mg/dL\n 18 mEq/L\n 4.7 mEq/L\n 61 mg/dL\n 120 mEq/L\n 147 mEq/L\n 22.1 %\n 11.1 K/uL\n [image002.jpg]\n 02:16 AM\n 04:14 PM\n 10:00 PM\n 02:32 AM\n 04:25 AM\n 03:56 PM\n 02:32 AM\n 08:00 PM\n 12:35 AM\n 03:21 AM\n WBC\n 11.4\n 10.9\n 11.0\n 10.5\n 11.1\n Hct\n 21.7\n 22.2\n 22.5\n 22.3\n 22.1\n Plt\n 266\n 290\n 310\n 327\n 341\n Cr\n 2.1\n 2.0\n 1.9\n 1.6\n 1.3\n 1.2\n 1.2\n 1.1\n TCO2\n 20\n Glucose\n 98\n 151\n 177\n 116\n 161\n 97\n 93\n 147\n Other labs: PT / PTT / INR:13.6/28.0/1.2, CK / CKMB /\n Troponin-T:214/3/0.07, ALT / AST:91/137, Alk Phos / T Bili:318/4.1,\n Amylase / Lipase:78/91, Differential-Neuts:57.0 %, Band:4.0 %,\n Lymph:23.0 %, Mono:4.0 %, Eos:3.0 %, D-dimer:6389 ng/mL, Fibrinogen:541\n mg/dL, Lactic Acid:2.6 mmol/L, Albumin:2.3 g/dL, LDH:437 IU/L, Ca++:9.2\n mg/dL, Mg++:1.8 mg/dL, PO4:4.2 mg/dL\n Assessment and Plan\n 28 year old male with a history of alcoholism presenting with acute\n hepatitis, pancreatitis, and UGIB, with persistent cyclic\n fevers/leukocytosis and anoxic brain injury.\n # Cyclic fevers/leukocytosis\n Tmax 100.9 overnight. WBC at 11.1.\n - will tolerate slight fevers as long as patient does not have clinical\n deterioration (hypotension/other) or WBC elevations\n - off abx\n - Cdiff negative \n - sputum cultures\n moderate growth GNR resembling acinetobacter\n (susceptibilities done). Likely colonization.\n - will recheck sputum cultures\n - blood cultures pending from & \n - will not start gancyclovir at this point - CMV not likely cause of\n fevers. Will continue to follow LFTs and if rising will see if\n correlates with CMV viral load. If so, will discuss with renal and ID.\n -CMV viral load to be drawn with 7/1 AM labs.\n - Will order an abdominal CT in the next few days to reevaluate\n peripancreatic fluid.\n # Respiratory failure\n Pt is on trach mask at 40% FIO2.\n - Pt is still tachypneic. (RR 27-40).\n - Considering pt\ns neuro findings, this may be centrally-driven.\n # Acute renal failure\n - pt put out 0.75 L urine yesterday;\n -Cr now 1.1 continuing to trend down.\n - will continue to follow UOP, BUN, and Cr\n # Altered mental status/anoxic brain injury\n pt had MRI that showed\n diffuse subacute anoxic injury involving the basal ganglia and cortex\n - poor prognosis per neuro with likely long term prognosis persistent\n vegetative state.\n - pt will need neuro rehab upon discharge from the MICU\n # Anemia\n - Hct stable\n - continue to monitor Hct\n # Acute Hepatitis: Likely alcoholic hepatitis. CT scan shows fatty\n infiltration, and no evidence of distal obstruction.\n - will continue to trend LFT\ns and correlate with CMV load\n - check LFT\ns with 7/1 AM labs to correlate with CMV load\n # FEN: IVF, replete electrolytes, Nutren at 50 ml/hr\n ICU Care\n Nutrition:\n Nutren 2.0 () - 12:28 PM 50 mL/hour\n Glycemic Control: insulin\n Lines:\n PICC Line - 08:37 AM\n Prophylaxis:\n DVT: Heparin\n Stress ulcer: Famotidine\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Respiratory ", "chartdate": "2131-06-27 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 683380, "text": "Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Clear\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Moderate\n Comments:\n Pt continues on 40% trach collar without distress unless placed supine.\n Secretions lightening in volume and color. MS still in doubt\n slow\n drug clearance v neuronal injury. MRI this afternoon for further\n evaluation\n read pending. Continue with humidified O2.\n" }, { "category": "General", "chartdate": "2131-06-28 00:00:00.000", "description": "Generic Note", "row_id": 683434, "text": "TITLE: Respiratory Care\n ~Pt continues to be on trach mask without complications. Expectorates\n yellow sputum. Saturation in the upper 90\ns throughout shift. Breath\n sounds mostly clear. #8 portex cuffed\n" }, { "category": "Physician ", "chartdate": "2131-07-03 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 684545, "text": "Chief Complaint:\n 24 Hour Events:\n - started on free water by IVF to correct hypernatremia\n - increased free water rate and repeated lytes at 0030 hrs\n - had lengthy discussion w/ family, who wants a 2nd opinion on\n potential for neuro recovery\n - speech and swallow eval for -muir valve entered\n - told by RN that pt had foley put back in\n Allergies:\n Meropenem\n skin blisters a\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 07:54 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 05:16 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.3\nC (100.9\n Tcurrent: 37.7\nC (99.9\n HR: 116 (111 - 123) bpm\n BP: 134/70(86) {92/61(70) - 138/106(113)} mmHg\n RR: 37 (28 - 48) insp/min\n SpO2: 95%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 99.5 kg (admission): 113.5 kg\n Height: 67 Inch\n Total In:\n 4,550 mL\n 1,351 mL\n PO:\n TF:\n 1,200 mL\n 263 mL\n IVF:\n 1,100 mL\n 788 mL\n Blood products:\n Total out:\n 750 mL\n 450 mL\n Urine:\n 750 mL\n 450 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,800 mL\n 901 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n SpO2: 95%\n ABG: ///18/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 341 K/uL\n 6.7 g/dL\n 147 mg/dL\n 1.1 mg/dL\n 18 mEq/L\n 4.7 mEq/L\n 61 mg/dL\n 120 mEq/L\n 147 mEq/L\n 22.1 %\n 11.1 K/uL\n [image002.jpg]\n 02:16 AM\n 04:14 PM\n 10:00 PM\n 02:32 AM\n 04:25 AM\n 03:56 PM\n 02:32 AM\n 08:00 PM\n 12:35 AM\n 03:21 AM\n WBC\n 11.4\n 10.9\n 11.0\n 10.5\n 11.1\n Hct\n 21.7\n 22.2\n 22.5\n 22.3\n 22.1\n Plt\n 266\n 290\n 310\n 327\n 341\n Cr\n 2.1\n 2.0\n 1.9\n 1.6\n 1.3\n 1.2\n 1.2\n 1.1\n TCO2\n 20\n Glucose\n 98\n 151\n 177\n 116\n 161\n 97\n 93\n 147\n Other labs: PT / PTT / INR:13.6/28.0/1.2, CK / CKMB /\n Troponin-T:214/3/0.07, ALT / AST:91/137, Alk Phos / T Bili:318/4.1,\n Amylase / Lipase:78/91, Differential-Neuts:57.0 %, Band:4.0 %,\n Lymph:23.0 %, Mono:4.0 %, Eos:3.0 %, D-dimer:6389 ng/mL, Fibrinogen:541\n mg/dL, Lactic Acid:2.6 mmol/L, Albumin:2.3 g/dL, LDH:437 IU/L, Ca++:9.2\n mg/dL, Mg++:1.8 mg/dL, PO4:4.2 mg/dL\n Assessment and Plan\n FEVER, UNKNOWN ORIGIN (FUO, HYPERTHERMIA, PYREXIA)\n AROUSAL, ATTENTION, AND COGNITION, IMPAIRED\n BALANCE, IMPAIRED\n MOTOR FUNCTION, IMPAIRED\n MUSCLE PERFORMACE, IMPAIRED\n RESPIRATION / GAS EXCHANGE, IMPAIRED\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n IMPAIRED SKIN INTEGRITY\n HEPATITIS, ACUTE TOXIC (INCLUDING ALCOHOLIC, ACETAMINOPHEN, ETC.)\n ICU Care\n Nutrition:\n Nutren 2.0 () - 12:28 PM 50 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 08:37 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": "2131-06-28 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 683507, "text": "Chief Complaint: pancreatitis, resp failure\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n BLOOD CULTURED - At 03:54 PM\n from HD line x 2, one each port\n MAGNETIC RESONANCE IMAGING - At 05:15 PM\n STOOL CULTURE - At 06:01 PM\n cdiff\n Allergies:\n Meropenem\n skin blisters a\n Last dose of Antibiotics:\n Aztreonam - 02:39 PM\n Micafungin - 10:00 PM\n Infusions:\n Other ICU medications:\n Fentanyl - 08:30 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 11:20 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.4\nC (101.1\n Tcurrent: 38.3\nC (101\n HR: 125 (109 - 125) bpm\n BP: 133/76(95) {106/61(76) - 144/77(98)} mmHg\n RR: 31 (21 - 42) insp/min\n SpO2: 96%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 103.9 kg (admission): 113.5 kg\n Height: 67 Inch\n Total In:\n 1,525 mL\n 664 mL\n PO:\n TF:\n 1,201 mL\n 564 mL\n IVF:\n 264 mL\n 100 mL\n Blood products:\n Total out:\n 1,440 mL\n 700 mL\n Urine:\n 1,440 mL\n 700 mL\n NG:\n Stool:\n Drains:\n Balance:\n 85 mL\n -36 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n SpO2: 96%\n ABG: 7.41/33/122/20/-2\n PaO2 / FiO2: 305\n Physical Examination\n Labs / Radiology\n 6.5 g/dL\n 227 K/uL\n 192 mg/dL\n 2.6 mg/dL\n 20 mEq/L\n 3.4 mEq/L\n 94 mg/dL\n 108 mEq/L\n 140 mEq/L\n 21.5 %\n 10.2 K/uL\n [image002.jpg]\n 01:12 AM\n 06:06 AM\n 02:38 PM\n 02:00 AM\n 02:49 AM\n 01:51 AM\n 03:26 PM\n 03:37 PM\n 03:15 AM\n 03:19 AM\n WBC\n 18.9\n 15.0\n 12.6\n 10.2\n Hct\n 22.2\n 22.5\n 22.1\n 21.5\n Plt\n 230\n 228\n 225\n 227\n Cr\n 2.7\n 3.0\n 2.9\n 2.7\n 2.6\n TCO2\n 18\n 21\n 24\n 23\n 22\n Glucose\n 121\n 128\n 80\n 129\n 194\n 192\n Other labs: PT / PTT / INR:13.6/28.0/1.2, CK / CKMB /\n Troponin-T:214/3/0.07, ALT / AST:75/115, Alk Phos / T Bili:408/5.5,\n Amylase / Lipase:77/88, Differential-Neuts:84.3 %, Band:0.0 %,\n Lymph:9.3 %, Mono:1.7 %, Eos:4.3 %, D-dimer:6389 ng/mL, Fibrinogen:541\n mg/dL, Lactic Acid:2.6 mmol/L, Albumin:2.3 g/dL, LDH:312 IU/L, Ca++:8.6\n mg/dL, Mg++:2.0 mg/dL, PO4:2.7 mg/dL\n Assessment and Plan\n FEVER, UNKNOWN ORIGIN (FUO, HYPERTHERMIA, PYREXIA)\n AROUSAL, ATTENTION, AND COGNITION, IMPAIRED\n BALANCE, IMPAIRED\n MOTOR FUNCTION, IMPAIRED\n MUSCLE PERFORMACE, IMPAIRED\n RESPIRATION / GAS EXCHANGE, IMPAIRED\n SEIZURE, WITHOUT STATUS EPILEPTICUS\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n IMPAIRED SKIN INTEGRITY\n HEPATITIS, ACUTE TOXIC (INCLUDING ALCOHOLIC, ACETAMINOPHEN, ETC.)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n 1. Cyclical fevers\n overall trend is down and WBC trend is\n down. We have been weaning off ABX since nothing has grown\n will\n continue only micafungin while monitoring culture data. Will get blood\n cx off HD line. Does have GNR in sputum but is likely colonized\n will\n repeat CXR but would need temps and leukocytosis to make criteria for a\n PNA\n 2. Hypotension: resolved\n watch carefully now that he is spiking\n as he has a tendency to drop his MAPs\n 3. Resp Failure: on trach mask and holding his own, though is\n tachyneic this AM w fevers\n 4. Altered Mental status: Given possibility of sz activity, will\n continue keppra. Speak w Neuro re role of imaging. Unclear how much of\n this is late drug wash out and how much is underlying neuron injury\n that is potentially rehab\n 5. For ARF: making good urine this AM, may even be able to hold\n off on HD\n 6. For pancreatitis, will continue post-pyloric TFs, and will\n continue to hold off on any drainage of new peripancreatic fluid\n collection but will discuss with Dr \n ICU Care\n Nutrition: Nutren 2.0 () - 01:27 PM 50 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 08:15 PM\n PICC Line - 08:37 AM\n Dialysis Catheter - 08:55 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n Communication: spoke with brother last night\n Code status: Full code\n Disposition :ICU\n Total time spent:\n" }, { "category": "Physician ", "chartdate": "2131-06-28 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 683508, "text": "Chief Complaint: pancreatitis, resp failure\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n BLOOD CULTURED - At 03:54 PM\n from HD line x 2, one each port\n MAGNETIC RESONANCE IMAGING - At 05:15 PM\n STOOL CULTURE - At 06:01 PM\n cdiff\n Allergies:\n Meropenem\n skin blisters a\n Last dose of Antibiotics:\n Aztreonam - 02:39 PM\n Micafungin - 10:00 PM\n Infusions:\n Other ICU medications:\n Fentanyl - 08:30 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 11:20 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.4\nC (101.1\n Tcurrent: 38.3\nC (101\n HR: 125 (109 - 125) bpm\n BP: 133/76(95) {106/61(76) - 144/77(98)} mmHg\n RR: 31 (21 - 42) insp/min\n SpO2: 96%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 103.9 kg (admission): 113.5 kg\n Height: 67 Inch\n Total In:\n 1,525 mL\n 664 mL\n PO:\n TF:\n 1,201 mL\n 564 mL\n IVF:\n 264 mL\n 100 mL\n Blood products:\n Total out:\n 1,440 mL\n 700 mL\n Urine:\n 1,440 mL\n 700 mL\n NG:\n Stool:\n Drains:\n Balance:\n 85 mL\n -36 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n SpO2: 96%\n ABG: 7.41/33/122/20/-2\n PaO2 / FiO2: 305\n Physical Examination\n Gen: in bed, eyes open, alert but very tachypneic\n CV: RR\n Chest: good air movement\n Abd: distended +BS\n Ext: 3+ edema\n Neuro: eyes open, will blink/ to command, weak grasp, dose not\n follow\n Labs / Radiology\n 6.5 g/dL\n 227 K/uL\n 192 mg/dL\n 2.6 mg/dL\n 20 mEq/L\n 3.4 mEq/L\n 94 mg/dL\n 108 mEq/L\n 140 mEq/L\n 21.5 %\n 10.2 K/uL\n [image002.jpg]\n 01:12 AM\n 06:06 AM\n 02:38 PM\n 02:00 AM\n 02:49 AM\n 01:51 AM\n 03:26 PM\n 03:37 PM\n 03:15 AM\n 03:19 AM\n WBC\n 18.9\n 15.0\n 12.6\n 10.2\n Hct\n 22.2\n 22.5\n 22.1\n 21.5\n Plt\n 230\n 228\n 225\n 227\n Cr\n 2.7\n 3.0\n 2.9\n 2.7\n 2.6\n TCO2\n 18\n 21\n 24\n 23\n 22\n Glucose\n 121\n 128\n 80\n 129\n 194\n 192\n Other labs: PT / PTT / INR:13.6/28.0/1.2, CK / CKMB /\n Troponin-T:214/3/0.07, ALT / AST:75/115, Alk Phos / T Bili:408/5.5,\n Amylase / Lipase:77/88, Differential-Neuts:84.3 %, Band:0.0 %,\n Lymph:9.3 %, Mono:1.7 %, Eos:4.3 %, D-dimer:6389 ng/mL, Fibrinogen:541\n mg/dL, Lactic Acid:2.6 mmol/L, Albumin:2.3 g/dL, LDH:312 IU/L, Ca++:8.6\n mg/dL, Mg++:2.0 mg/dL, PO4:2.7 mg/dL\n Assessment and Plan\n FEVER, UNKNOWN ORIGIN (FUO, HYPERTHERMIA, PYREXIA)\n AROUSAL, ATTENTION, AND COGNITION, IMPAIRED\n BALANCE, IMPAIRED\n MOTOR FUNCTION, IMPAIRED\n MUSCLE PERFORMACE, IMPAIRED\n RESPIRATION / GAS EXCHANGE, IMPAIRED\n SEIZURE, WITHOUT STATUS EPILEPTICUS\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n IMPAIRED SKIN INTEGRITY\n HEPATITIS, ACUTE TOXIC (INCLUDING ALCOHOLIC, ACETAMINOPHEN, ETC.)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n 1. Cyclical fevers\n overall trend is down and WBC trend is\n down. We have been weaning off ABX since nothing has grown\n will\n continue only micafungin while monitoring culture data. Will get blood\n cx off HD line. Does have GNR in sputum but is likely colonized\n will\n repeat CXR but would need temps and leukocytosis to make criteria for a\n PNA\n 2. Hypotension: resolved\n watch carefully now that he is spiking\n as he has a tendency to drop his MAPs\n 3. Resp Failure: on trach mask and holding his own, though is\n tachyneic this AM w fevers\n 4. Altered Mental status: Given possibility of sz activity, will\n continue keppra. Speak w Neuro re role of imaging. Unclear how much of\n this is late drug wash out and how much is underlying neuron injury\n that is potentially rehab\n 5. For ARF: making good urine this AM, may even be able to hold\n off on HD\n 6. For pancreatitis, will continue post-pyloric TFs, and will\n continue to hold off on any drainage of new peripancreatic fluid\n collection but will discuss with Dr \n ICU Care\n Nutrition: Nutren 2.0 () - 01:27 PM 50 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 08:15 PM\n PICC Line - 08:37 AM\n Dialysis Catheter - 08:55 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n Communication: spoke with brother last night\n Code status: Full code\n Disposition :ICU\n Total time spent:\n" }, { "category": "Physician ", "chartdate": "2131-06-16 00:00:00.000", "description": "Physician Resident/Attending Progress Note - MICU", "row_id": 681212, "text": "Chief Complaint:\n 24 Hour Events:\n PICC LINE - START 08:37 AM\n placed in IR\n DIALYSIS CATHETER - START 08:55 AM\n MULTI LUMEN - STOP 12:32 PM\n HD catheter removed and this line placed over wire\n \n - Aztreonam dose decreased yesterday as not on CVVH\n - Pt hypotensive to SBP 70s yesterday; given 500cc bolus with\n improvement. Cipro changed to flagyl.\n - Repeat EEG without seizures on higher dose of keppra.\n Allergies:\n Meropenem\n skin blisters a\n Last dose of Antibiotics:\n Ciprofloxacin - 12:34 PM\n Aztreonam - 08:00 PM\n Linezolid - 10:07 PM\n Metronidazole - 12:00 AM\n Infusions:\n Midazolam (Versed) - 2 mg/hour\n Fentanyl (Concentrate) - 100 mcg/hour\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:00 PM\n Famotidine (Pepcid) - 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 06:57 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.3\nC (101\n Tcurrent: 37.8\nC (100.1\n HR: 93 (93 - 117) bpm\n BP: 81/38(52) {76/38(52) - 137/78(212)} mmHg\n RR: 32 (21 - 44) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 103.1 kg (admission): 113.5 kg\n Height: 67 Inch\n CVP: 10 (7 - 12)mmHg\n Total In:\n 3,899 mL\n 593 mL\n PO:\n TF:\n 1,203 mL\n 346 mL\n IVF:\n 2,696 mL\n 247 mL\n Blood products:\n Total out:\n 425 mL\n 135 mL\n Urine:\n 425 mL\n 135 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,474 mL\n 458 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 582 (391 - 582) mL\n PS : 5 cmH2O\n RR (Set): 22\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 55\n PIP: 13 cmH2O\n SpO2: 100%\n ABG: 7.34/30/113/16/-8\n Ve: 13.1 L/min\n PaO2 / FiO2: 226\n Physical Examination\n GEN: Trached, sedated\n HEENT: icteric sclera. MMM\n NECK: Trach site with no oozing.\n LUNGS: Anterior auscultation with upper airway noise; good airway\n movement\n HEART: RRR, normal; S1, S2\n ABD: Distended. Grimmacing with palpation.\n EXTREM: 2+ edema, ulcers/lesions on legs with bandages C/D/I\n SKIN: Jaundice\n NEURO: No twitching today. Did not open eyes to command.\n Labs / Radiology\n 243 K/uL\n 7.7 g/dL\n 154 mg/dL\n 2.4 mg/dL\n 16 mEq/L\n 4.7 mEq/L\n 120 mg/dL\n 97 mEq/L\n 130 mEq/L\n 23.2 %\n 26.4 K/uL\n [image002.jpg]\n 06:18 PM\n 07:58 PM\n 08:00 PM\n 01:31 AM\n 01:37 AM\n 04:30 AM\n 12:35 PM\n 06:31 PM\n 01:32 AM\n 03:05 AM\n WBC\n 24.4\n 21.7\n 26.4\n Hct\n 25.3\n 25.8\n 23.2\n Plt\n 193\n 194\n 243\n Cr\n 1.5\n 2.0\n 2.4\n TCO2\n 22\n 23\n 21\n 21\n 20\n 17\n Glucose\n 178\n 166\n 154\n Other labs: PT / PTT / INR:16.5/36.2/1.5, CK / CKMB /\n Troponin-T:214/3/0.07, ALT / AST:184/250, Alk Phos / T Bili:538/30.0,\n Albumin:2.0 g/dL, LDH:706 IU/L, Ca++:8.5 mg/dL, Mg++:2.6 mg/dL, PO4:4.8\n mg/dL. Ferritin 2660\n Assessment and Plan\n 28M with alcoholic hepatitis and necrotizing pancreatitis complicated\n by ARDS, SIRS, ARF, UGIB, fevers.\n #. ID: Febrile now for 2 days, increased WBC, with decreased BP. RUQ\n u/s concerning for sludge and pt started on cipro; changed to flagyl\n yesterday. Of note, had stopped flagyl and vanc po as C. diff neg\n x 2. Blood/tissue/BAL cx NGTD. It is possible that previous fevers had\n been masked by CVVH, which he had been held x 2 days although restarted\n today.\n - Cte broad spectrum antibiotic coverage with linezolid and aztreonam\n (D1 ) and flagyl (added back )\n - Consider HIDA scan if bilirubin does not improve or hemodynamic\n instability over next few days.\n - F/u WBC count, temp curve, and culture data\n - Cont steroid taper for possible adrenal insufficiency\n # Hyperbilirubinemia: Patient has had continuously increasing T Bili\n and alkaline phosphatase. Has alcoholic hepatitis but also on TPN. Bili\n stable today but increased alk phos and RUQ u/s with sludge concerning\n for cholestasis. Note that U/S also showed sludge.\n - Consider asking GI input for HIDA scan v. ERCP\n - TPN stopped \n - Weaning off benzos\n #. Respiratory Failure: ARDS secondary to necrotizing pancreatitis. S/p\n trach placement on . Sutures out on . Currently on pressure\n support.\n - Cont to wean vent with trach mask trials v CPAP trials as tolerated\n - Increasing fentanyl patch while decreasing gtt, continue methadone\n - Attempt OOB to chair to improve respiratory mechanics\n # Seizures: CT head without intracranial process. EEG showed occipital\n seizures which does not correlate with clinical symptoms, but repeat\n EEG on higher dose Keppra showed no seizures. actually be\n patient waking up, not seizures.\n - Continue on higher dose keppra\n - F/u neuro recs\n - Wean off midazolam as tolerated with low dose valium to prevent\n withdrawal; monitor vitals\n #. Acute renal Failure: Appreciate renal recs.\n - Would dialyze for acidosis but likely does not need volume depletion.\n - Likely transition to HD today; f/u Renal recs\n - Aztreonam increased back to 2000mg q12h as back on CVVH\n - Will change Keppra to 1000mg Q24 with 500 mg after HD if he\n transitions to HD\n #. Adrenal Insufficiency: Unclear with stim if clear adrenal\n insufficiency but hypotension improving with steroids (lower pressor\n requirement) and improving eosinophilia\n - Weaned Hydrocort to 25mg Q8H today\n # ?HLH: Quantitative ferritin of 2660. Unlikely to have HLH.\n # Eosinophilia: Resolved on steroids and s/p med changes.\n ICU Care\n Nutrition:\n Nutren 2.0 () - 01:53 PM 50 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 08:15 PM\n PICC Line - 08:37 AM\n Dialysis Catheter - 08:55 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:ICU\n ------ 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: 28M alcoholic hepatitis, pancreatitis,\n refractory shock, ARDS - now tolerating aggressive fluid removal and\n off pressors.\n USG c likely GB sludge.\n EEG neg for sz activity loaded on Keppra\n Tolerated trach mask x 2 hours yesterday.\n Temp spike 101.2 off CVVH. Hypotension, precluding HD, decision made to\n continue CVVH rather than transitioning.\n Off TPN- tolerating TF.\n PS 0.5/5/5.\n Anasarca (though much improved since I last saw him 1 week ago),\n chemosis. Partial eye opening to command. Coarse BS B. Distant s1s2.\n Obese, + BS. 3+ edema. Labs notable for WBC 26K, bicarb 16 (since off\n CVVH)\n Abx: Aztreonam/flagyl/linezolid\n hydrocortisone 25 q 8h (reduced from 50 q8 yesterday)\n 1. Agree with plan to manage respiratory failure with slow wean\n of sedation and wean of PSV to TM trials as mental status allows - will\n try to get OOB to chair.\n 2. shock (resolved), continue to wean steroids (HC 25 q8h) and will\n continue abx while monitoring LFTs and RUQ exam. Gall bladder\n sludge was present on USG but concern for cholecystitis with\n worse leukocytosis, fevers, hypotension, abd exam more TTP\n (grimaces to palpation, though difficult to interpret).\n Transaminitis worsening. Monitor, will consider HIDA or eval by GI\n for possible ERCP but I strongly favor conservative management\n given that these procedures might make him worse and he is unlikely\n to have obstruction.\n 3. ARF, could not change CVVH to HD, CVVH restarted.\n 4. For pancreatitis, will increase post-pyloric TFs to goal\n 5. Ileus: he is now stooling with good bowel sounds.\n 6. Patient is critically ill\n 7. resp failure: minimal settings on PSV. Trach mask.\n Pt is critically ill.\n Total time: 40 min\n ------ Protected Section Addendum Entered By: , MD\n on: 18:33 ------\n" }, { "category": "Physician ", "chartdate": "2131-06-28 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 683472, "text": "Chief Complaint:\n 24 Hour Events:\n - remains off vent and off pressors\n -Repeat CXR shows interval improvement in right lung fields; diaphrams\n more clearly visualized (possible clearing of pleural effusions).\n -Awaiting culture results\n -MRI done, EEG ordered\n -Per renal hold HD, if continues to produce urine will d/c HD line Fri.\n - Blood cx from HD line x 2, one from each port, on \n -Removed trach sutures\n Allergies:\n Meropenem\n skin blisters\n Last dose of Antibiotics:\n Aztreonam - 02:39 PM\n Micafungin - 10:00 PM\n Infusions:\n Other ICU medications:\n Fentanyl - 01:00 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 05:51 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38\nC (100.4\n Tcurrent: 37.8\nC (100.1\n HR: 116 (105 - 121) bpm\n BP: 117/70(86) {108/63(79) - 144/77(98)} mmHg\n RR: 32 (18 - 40) insp/min\n SpO2: 97%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 103.9 kg (admission): 113.5 kg\n Height: 67 Inch\n Total In:\n 1,525 mL\n 291 mL\n PO:\n TF:\n 1,201 mL\n 291 mL\n IVF:\n 264 mL\n Blood products:\n Total out:\n 1,440 mL\n 375 mL\n Urine:\n 1,440 mL\n 375 mL\n NG:\n Stool:\n Drains:\n Balance:\n 85 mL\n -84 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n SpO2: 97%\n ABG: 7.41/33/122/20/-2\n PaO2 / FiO2: 305\n Physical Examination\n Labs / Radiology\n 227 K/uL\n 6.5 g/dL\n 192 mg/dL\n 2.6 mg/dL\n 20 mEq/L\n 3.6 mEq/L\n 94 mg/dL\n 115 mEq/L\n 150 mEq/L\n 21.5 %\n 10.2 K/uL\n [image002.jpg]\n 01:12 AM\n 06:06 AM\n 02:38 PM\n 02:00 AM\n 02:49 AM\n 01:51 AM\n 03:26 PM\n 03:37 PM\n 03:15 AM\n 03:19 AM\n WBC\n 18.9\n 15.0\n 12.6\n 10.2\n Hct\n 22.2\n 22.5\n 22.1\n 21.5\n Plt\n 230\n 228\n 225\n 227\n Cr\n 2.7\n 3.0\n 2.9\n 2.7\n 2.6\n TCO2\n 18\n 21\n 24\n 23\n 22\n Glucose\n 121\n 128\n 80\n 129\n 194\n 192\n Other labs: PT / PTT / INR:13.6/28.0/1.2, CK / CKMB /\n Troponin-T:214/3/0.07, ALT / AST:75/115, Alk Phos / T Bili:408/5.5,\n Amylase / Lipase:77/88, Differential-Neuts:84.3 %, Band:0.0 %,\n Lymph:9.3 %, Mono:1.7 %, Eos:4.3 %, D-dimer:6389 ng/mL, Fibrinogen:541\n mg/dL, Lactic Acid:2.6 mmol/L, Albumin:2.3 g/dL, LDH:312 IU/L, Ca++:8.6\n mg/dL, Mg++:2.0 mg/dL, PO4:2.7 mg/dL\n Assessment and Plan\n 28 year old male with a history of alcoholism presenting with acute\n hepatitis, pancreatitis, and UGIB, with persistent cyclic\n fevers/leukocytosis.\n # Cyclic fevers/leukocytosis\nlow grade temp to 100.4 overnight, but\n overall fever curve stable to improving. WBC trending down. Sputum\n with 4+ GNR likely colonizer, as per ID. U/A weakly positive; will\n follow cx. Weaning off abx and currently only on micafungin as pt has\n been cx negative. HD line cultured x 2 yesterday. Will follow\n remainder of cx.\n # Hypotension\n resolved, cont to monitor.\n # Respiratory failure\n on trach mask at 40% FIO2\n # Acute renal failure\n stable and UOP improving (currently 30-60\n cc/hr). Per renal, hold off HD and d/c HD line Fri if UOP stays as\n such.\n # Altered mental status\n Given possibility of seizure activity, will\n continue keppra. MRI done, and EEG pending. Unclear how much of this is\n medication induced and how much is rehab correctable.\n # Hypernatremia\n - will calculate free water deficit and start free water boluses\n # Hematemesis: resolved. Given alcohol history, potential\n consideration for variceal bleed. No known prior history of hepatic\n cirrhosis, but elevated INR and fatty liver infilatration would be\n consistent. Also should consider PUD or alcoholic gastritis. Hct was\n WNL on presentation, but patient markedly contracted. Continued bright\n red blood on NG lavage suggests some degree of continued active\n bleeding.\n -- hepatology consulted, EGD showing diulefoy lesion\n -- access with 2 large bore IVs and a cordis, T + C x 3 units\n -- IV PPI + PPI gtt\n .\n # Pancreatitis: Most likely alcoholic in etiology, with elevated lipase\n to 1600 and CT findings consistent without necrosis, cycts, or\n phlemgon. Only mild epigastric tenderness and no complaints of\n abdominal pain.\n -- continue aggessive hydration\n -- serial abdominal exams\n -- trend lipase\n -- no evidence of obstruction, holding off on further imaging at this\n time\n -- cont post pyloric TF\n -- to hold off on any drainage of new peripancreatic fluid collection\n but will discuss with Dr \n # Acute Hepatitis: Likely alcoholic hepatitis. CT scan shows fatty\n infiltration, and no evidence of distal ostruction.\n - check viral hepatitis panel, although degree of transaminitis not\n consistant with such an etiology.\n - holding off on further imaging for now, f/u final CT read\n - hepatology following\n - avoid hepatically cleared meds\n - trend LFTs\n # Alcoholism: Patient describes history of withdrawal symptoms, but\n not prior seizure. Last drink was night prior to presentation.\n Tachycardia, weakness, and elevated lactate could be consistent with\n thiamine deficiency.\n - repleate thiamine, vb12, folate\n - ativan with CIWA > 10\n - addictions consult\n # FEN: IVF, replete electrolytes, NPO\n # Prophylaxis: scds, PPI gtt\n # Access: peripherals and femoral cortis\n # Code: Full Code\n # Disposition: MICU for now\n ICU Care\n Nutrition:\n Nutren 2.0 () - 01:27 PM 50 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 08:15 PM\n PICC Line - 08:37 AM\n Dialysis Catheter - 08:55 AM\n Prophylaxis:\n DVT: heparin\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: MICU for now, long term rehab\n" }, { "category": "Physician ", "chartdate": "2131-06-28 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 683477, "text": "Chief Complaint:\n 24 Hour Events:\n - remains off vent and off pressors\n -Repeat CXR shows interval improvement in right lung fields; diaphrams\n more clearly visualized (possible clearing of pleural effusions).\n -Awaiting culture results\n -MRI done, EEG ordered\n -Per renal hold HD, if continues to produce urine will d/c HD line Fri.\n - Blood cx from HD line x 2, one from each port, on \n -Removed trach sutures\n Allergies:\n Meropenem\n skin blisters\n Last dose of Antibiotics:\n Aztreonam - 02:39 PM\n Micafungin - 10:00 PM\n Infusions:\n Other ICU medications:\n Fentanyl - 01:00 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 05:51 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38\nC (100.4\n Tcurrent: 37.8\nC (100.1\n HR: 116 (105 - 121) bpm\n BP: 117/70(86) {108/63(79) - 144/77(98)} mmHg\n RR: 32 (18 - 40) insp/min\n SpO2: 97%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 103.9 kg (admission): 113.5 kg\n Height: 67 Inch\n Total In:\n 1,525 mL\n 291 mL\n PO:\n TF:\n 1,201 mL\n 291 mL\n IVF:\n 264 mL\n Blood products:\n Total out:\n 1,440 mL\n 375 mL\n Urine:\n 1,440 mL\n 375 mL\n NG:\n Stool:\n Drains:\n Balance:\n 85 mL\n -84 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n SpO2: 97%\n ABG: 7.41/33/122/20/-2\n PaO2 / FiO2: 305\n Physical Examination\n Labs / Radiology\n 227 K/uL\n 6.5 g/dL\n 192 mg/dL\n 2.6 mg/dL\n 20 mEq/L\n 3.6 mEq/L\n 94 mg/dL\n 115 mEq/L\n 150 mEq/L\n 21.5 %\n 10.2 K/uL\n [image002.jpg]\n 01:12 AM\n 06:06 AM\n 02:38 PM\n 02:00 AM\n 02:49 AM\n 01:51 AM\n 03:26 PM\n 03:37 PM\n 03:15 AM\n 03:19 AM\n WBC\n 18.9\n 15.0\n 12.6\n 10.2\n Hct\n 22.2\n 22.5\n 22.1\n 21.5\n Plt\n 230\n 228\n 225\n 227\n Cr\n 2.7\n 3.0\n 2.9\n 2.7\n 2.6\n TCO2\n 18\n 21\n 24\n 23\n 22\n Glucose\n 121\n 128\n 80\n 129\n 194\n 192\n Other labs: PT / PTT / INR:13.6/28.0/1.2, CK / CKMB /\n Troponin-T:214/3/0.07, ALT / AST:75/115, Alk Phos / T Bili:408/5.5,\n Amylase / Lipase:77/88, Differential-Neuts:84.3 %, Band:0.0 %,\n Lymph:9.3 %, Mono:1.7 %, Eos:4.3 %, D-dimer:6389 ng/mL, Fibrinogen:541\n mg/dL, Lactic Acid:2.6 mmol/L, Albumin:2.3 g/dL, LDH:312 IU/L, Ca++:8.6\n mg/dL, Mg++:2.0 mg/dL, PO4:2.7 mg/dL\n Assessment and Plan\n 28 year old male with a history of alcoholism presenting with acute\n hepatitis, pancreatitis, and UGIB, with persistent cyclic\n fevers/leukocytosis.\n # Cyclic fevers/leukocytosis\nlow grade temp to 100.4 overnight, but\n overall fever curve stable to improving. WBC trending down. Sputum\n with 4+ GNR likely colonizer, as per ID. U/A weakly positive; will\n follow cx. Weaning off abx and currently only on micafungin as pt has\n been cx negative. HD line cultured x 2 yesterday. Will follow\n remainder of cx.\n # Hypotension\n resolved, cont to monitor.\n # Respiratory failure\n on trach mask at 40% FIO2\n # Acute renal failure\n stable and UOP improving (currently 30-60\n cc/hr). Per renal, hold off HD and d/c HD line Fri if UOP stays as\n such.\n # Altered mental status\n Given possibility of seizure activity, will\n continue keppra. MRI done, and EEG pending. Unclear how much of this is\n medication induced and how much is rehab correctable.\n # Hypernatremia\n - will calculate free water deficit and start free water boluses\n # Hematemesis: resolved. Given alcohol history, potential\n consideration for variceal bleed. No known prior history of hepatic\n cirrhosis, but elevated INR and fatty liver infilatration would be\n consistent. Also should consider PUD or alcoholic gastritis. Hct was\n WNL on presentation, but patient markedly contracted. Continued bright\n red blood on NG lavage suggests some degree of continued active\n bleeding.\n -- hepatology consulted, EGD showing diulefoy lesion\n -- access with 2 large bore IVs and a cordis, T + C x 3 units\n -- IV PPI + PPI gtt\n .\n # Pancreatitis: Most likely alcoholic in etiology, with elevated lipase\n to 1600 and CT findings consistent without necrosis, cycts, or\n phlemgon. Only mild epigastric tenderness and no complaints of\n abdominal pain.\n -- continue aggessive hydration\n -- serial abdominal exams\n -- trend lipase\n -- no evidence of obstruction, holding off on further imaging at this\n time\n -- cont post pyloric TF\n -- to hold off on any drainage of new peripancreatic fluid collection\n but will discuss with Dr \n # Acute Hepatitis: Likely alcoholic hepatitis. CT scan shows fatty\n infiltration, and no evidence of distal ostruction.\n - check viral hepatitis panel, although degree of transaminitis not\n consistant with such an etiology.\n - holding off on further imaging for now, f/u final CT read\n - hepatology following\n - avoid hepatically cleared meds\n - trend LFTs\n # Alcoholism: Patient describes history of withdrawal symptoms, but\n not prior seizure. Last drink was night prior to presentation.\n Tachycardia, weakness, and elevated lactate could be consistent with\n thiamine deficiency.\n - repleate thiamine, vb12, folate\n - ativan with CIWA > 10\n - addictions consult\n # FEN: IVF, replete electrolytes, NPO\n # Prophylaxis: scds, PPI gtt\n # Access: peripherals and femoral cortis\n # Code: Full Code\n # Disposition: MICU for now\n ICU Care\n Nutrition:\n Nutren 2.0 () - 01:27 PM 50 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 08:15 PM\n PICC Line - 08:37 AM\n Dialysis Catheter - 08:55 AM\n Prophylaxis:\n DVT: heparin\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: MICU for now, long term rehab\n" }, { "category": "Nursing", "chartdate": "2131-06-28 00:00:00.000", "description": "Nursing Progress Note", "row_id": 683430, "text": "Arousal, Attention, and Cognition, Impaired\n Assessment:\n Alert/Arouses to voice\n Tracking around room\n No noted purposeful movements\n Remains tremulous when touched\n Did at times appear like he might be attempting to mouth\n words\n Pt did squeeze RN\ns hand to command X1\n Action:\n Cont neuro assessments\n Cont to stimulate and encourage interaction\n Turned and repositioned\n Passive ROM\n Response:\n Unchanged\n Plan:\n Cont with PT/OT\n OOB to chair in am\n Cont to stimulate and encourage social interaction\n Supportive care to pt and family\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Creatinine this am 2.6\n Cont to have adequate u/o\n Wt this am 103.9 down for 105 on \n ABG Resp Alkolosis with BE -2\n + Only 85cc at MN\n Action:\n No HD at this time\n Response:\n Renal status slowly improving\n Plan:\n Cont to asses renal status closely\n Monitor electrolytes closely\n Monitor U/O\n Plan on removing HD catheter on Friday if Renal status cont\n to improve and HD not required\n Impaired Skin Integrity (Tracheostomy Site)\n Assessment:\n Sutures removed from trach site by MICU team\n Once sutures removed able to closely asses site\n Skin under trach flaps excoriated with multiple open red\n areas\n Action:\n Skin under trach flaps cleaned with NS and allevyn trach\n applied\n During cleaning of pt\ns trach pt + grimacing and HR/BP\n increased pt visible in pain Fent IV given\n Response:\n Site cleaned and cont to be monitored\n + effect from fent pt may need to be pre-medicated for trach\n care\n Plan:\n Cont to diligent monitoring of site\n Monitor open areas for s/s of infection\n" }, { "category": "Physician ", "chartdate": "2131-06-17 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 681282, "text": "Chief Complaint:\n 24 Hour Events:\n BLOOD CULTURED - At 11:30 AM\n PIV X2\n SPUTUM CULTURE - At 12:33 PM\n URINE CULTURE - At 12:33 PM\n FEVER - 101.2\nF - 08:00 AM\n \n - Renal recs: CVVH was started as he likely wouldn't tolerate HD due to\n low pressures.\n - Patient was continued on linezolid, aztreonam, and flagyl.\n - More tenderness in abd with concern for accalculus cholecystitis, but\n did not get HIDA scan as we would continue medical management. Will\n observe for now but if he decompensates, he may need a perc drain per\n IR.\n Allergies:\n Meropenem\n skin blisters a\n Last dose of Antibiotics:\n Ciprofloxacin - 12:34 PM\n Aztreonam - 08:05 PM\n Linezolid - 10:09 PM\n Metronidazole - 12:00 AM\n Infusions:\n Midazolam (Versed) - 1 mg/hour\n Fentanyl (Concentrate) - 50 mcg/hour\n Calcium Gluconate (CRRT) - 2.4 grams/hour\n Other ICU medications:\n Famotidine (Pepcid) - 01:30 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:34 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: 36.3\nC (97.3\n HR: 93 (85 - 108) bpm\n BP: 98/54(69) {81/38(52) - 124/70(91)} mmHg\n RR: 20 (19 - 32) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 103.1 kg (admission): 113.5 kg\n Height: 67 Inch\n Total In:\n 6,584 mL\n 2,432 mL\n PO:\n TF:\n 1,200 mL\n 278 mL\n IVF:\n 5,384 mL\n 2,154 mL\n Blood products:\n Total out:\n 6,966 mL\n 2,361 mL\n Urine:\n 487 mL\n 35 mL\n NG:\n Stool:\n Drains:\n Balance:\n -382 mL\n 71 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n Ventilator mode: Standby\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 0 (0 - 557) mL\n PS : 5 cmH2O\n RR (Set): 22\n RR (Spontaneous): 30\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 0 cmH2O\n SpO2: 100%\n ABG: 7.36/31/122/19/-6\n Ve: 13.5 L/min\n PaO2 / FiO2: 244\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 255 K/uL\n 7.7 g/dL\n 167 mg/dL\n 2.2 mg/dL\n 19 mEq/L\n 3.5 mEq/L\n 60 mg/dL\n 100 mEq/L\n 133 mEq/L\n 23.9 %\n 26.4 K/uL\n [image002.jpg]\n 06:31 PM\n 01:32 AM\n 03:05 AM\n 12:10 PM\n 01:36 PM\n 06:06 PM\n 06:23 PM\n 10:13 PM\n 04:13 AM\n 04:24 AM\n WBC\n 26.4\n Hct\n 23.2\n 23.9\n Plt\n 243\n 255\n Cr\n 2.0\n 2.4\n 2.2\n TCO2\n 17\n 16\n 18\n 19\n 19\n 18\n Glucose\n 166\n 154\n 162\n 220\n 67\n Other labs: PT / PTT / INR:16.1/32.9/1.4, CK / CKMB /\n Troponin-T:214/3/0.07, ALT / AST:211/247, Alk Phos / T Bili:564/29.7,\n Amylase / Lipase:51/41, Differential-Neuts:78.0 %, Band:3.0 %,\n Lymph:1.0 %, Mono:7.0 %, Eos:0.0 %, D-dimer:6389 ng/mL, Fibrinogen:502\n mg/dL, Lactic Acid:1.0 mmol/L, Albumin:2.0 g/dL, LDH:561 IU/L, Ca++:9.1\n mg/dL, Mg++:2.1 mg/dL, PO4:2.8 mg/dL\n Assessment and Plan\n AROUSAL, ATTENTION, AND COGNITION, IMPAIRED\n BALANCE, IMPAIRED\n MOTOR FUNCTION, IMPAIRED\n MUSCLE PERFORMACE, IMPAIRED\n RESPIRATION / GAS EXCHANGE, IMPAIRED\n SEIZURE, WITHOUT STATUS EPILEPTICUS\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n IMPAIRED SKIN INTEGRITY\n HEPATITIS, ACUTE TOXIC (INCLUDING ALCOHOLIC, ACETAMINOPHEN, ETC.)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ICU Care\n Nutrition:\n Nutren 2.0 () - 01:46 PM 50 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 08:15 PM\n PICC Line - 08:37 AM\n Dialysis Catheter - 08:55 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:ICU\n" }, { "category": "Physician ", "chartdate": "2131-06-17 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 681283, "text": "Chief Complaint:\n 24 Hour Events:\n BLOOD CULTURED - At 11:30 AM\n PIV X2\n SPUTUM CULTURE - At 12:33 PM\n URINE CULTURE - At 12:33 PM\n FEVER - 101.2\nF - 08:00 AM\n \n - Renal recs: CVVH was started as he likely wouldn't tolerate HD due to\n low pressures.\n - Patient was continued on linezolid, aztreonam, and flagyl.\n - More tenderness in abd with concern for accalculus cholecystitis, but\n did not get HIDA scan as we would continue medical management. Will\n observe for now but if he decompensates, he may need a perc drain per\n IR.\n Allergies:\n Meropenem\n skin blisters a\n Last dose of Antibiotics:\n Ciprofloxacin - 12:34 PM\n Aztreonam - 08:05 PM\n Linezolid - 10:09 PM\n Metronidazole - 12:00 AM\n Infusions:\n Midazolam (Versed) - 1 mg/hour\n Fentanyl (Concentrate) - 50 mcg/hour\n Calcium Gluconate (CRRT) - 2.4 grams/hour\n Other ICU medications:\n Famotidine (Pepcid) - 01:30 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:34 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: 36.3\nC (97.3\n HR: 93 (85 - 108) bpm\n BP: 98/54(69) {81/38(52) - 124/70(91)} mmHg\n RR: 20 (19 - 32) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 103.1 kg (admission): 113.5 kg\n Height: 67 Inch\n Total In:\n 6,584 mL\n 2,432 mL\n PO:\n TF:\n 1,200 mL\n 278 mL\n IVF:\n 5,384 mL\n 2,154 mL\n Blood products:\n Total out:\n 6,966 mL\n 2,361 mL\n Urine:\n 487 mL\n 35 mL\n NG:\n Stool:\n Drains:\n Balance:\n -382 mL\n 71 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n Ventilator mode: Standby\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 0 (0 - 557) mL\n PS : 5 cmH2O\n RR (Set): 22\n RR (Spontaneous): 30\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 0 cmH2O\n SpO2: 100%\n ABG: 7.36/31/122/19/-6\n Ve: 13.5 L/min\n PaO2 / FiO2: 244\n Physical Examination\n GEN: Trached, sedated\n HEENT: icteric sclera. MMM\n NECK: Trach site with no oozing.\n LUNGS: Anterior auscultation with upper airway noise; good airway\n movement\n HEART: RRR, normal; S1, S2\n ABD: Distended. Grimmacing with palpation.\n EXTREM: 2+ edema, ulcers/lesions on legs with bandages C/D/I\n SKIN: Jaundice\n NEURO: No twitching today. Did not open eyes to command.\n Labs / Radiology\n 255 K/uL\n 7.7 g/dL\n 167 mg/dL\n 2.2 mg/dL\n 19 mEq/L\n 3.5 mEq/L\n 60 mg/dL\n 100 mEq/L\n 133 mEq/L\n 23.9 %\n 26.4 K/uL\n [image002.jpg]\n 06:31 PM\n 01:32 AM\n 03:05 AM\n 12:10 PM\n 01:36 PM\n 06:06 PM\n 06:23 PM\n 10:13 PM\n 04:13 AM\n 04:24 AM\n WBC\n 26.4\n Hct\n 23.2\n 23.9\n Plt\n 243\n 255\n Cr\n 2.0\n 2.4\n 2.2\n TCO2\n 17\n 16\n 18\n 19\n 19\n 18\n Glucose\n 166\n 154\n 162\n 220\n 67\n Other labs: PT / PTT / INR:16.1/32.9/1.4, CK / CKMB /\n Troponin-T:214/3/0.07, ALT / AST:211/247, Alk Phos / T Bili:564/29.7,\n Amylase / Lipase:51/41, Differential-Neuts:78.0 %, Band:3.0 %,\n Lymph:1.0 %, Mono:7.0 %, Eos:0.0 %, D-dimer:6389 ng/mL, Fibrinogen:502\n mg/dL, Lactic Acid:1.0 mmol/L, Albumin:2.0 g/dL, LDH:561 IU/L, Ca++:9.1\n mg/dL, Mg++:2.1 mg/dL, PO4:2.8 mg/dL\n Assessment and Plan\n AROUSAL, ATTENTION, AND COGNITION, IMPAIRED\n BALANCE, IMPAIRED\n MOTOR FUNCTION, IMPAIRED\n MUSCLE PERFORMACE, IMPAIRED\n RESPIRATION / GAS EXCHANGE, IMPAIRED\n SEIZURE, WITHOUT STATUS EPILEPTICUS\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n IMPAIRED SKIN INTEGRITY\n HEPATITIS, ACUTE TOXIC (INCLUDING ALCOHOLIC, ACETAMINOPHEN, ETC.)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ICU Care\n Nutrition:\n Nutren 2.0 () - 01:46 PM 50 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 08:15 PM\n PICC Line - 08:37 AM\n Dialysis Catheter - 08:55 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:ICU\n" }, { "category": "Physician ", "chartdate": "2131-06-17 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 681284, "text": "Chief Complaint:\n 24 Hour Events:\n BLOOD CULTURED - At 11:30 AM\n PIV X2\n SPUTUM CULTURE - At 12:33 PM\n URINE CULTURE - At 12:33 PM\n FEVER - 101.2\nF - 08:00 AM\n \n - Renal recs: CVVH was started as he likely wouldn't tolerate HD due to\n low pressures.\n - Patient was continued on linezolid, aztreonam, and flagyl.\n - More tenderness in abd with concern for accalculus cholecystitis, but\n did not get HIDA scan as we would continue medical management. Will\n observe for now but if he decompensates, he may need a perc drain per\n IR.\n Allergies:\n Meropenem\n skin blisters a\n Last dose of Antibiotics:\n Ciprofloxacin - 12:34 PM\n Aztreonam - 08:05 PM\n Linezolid - 10:09 PM\n Metronidazole - 12:00 AM\n Infusions:\n Midazolam (Versed) - 1 mg/hour\n Fentanyl (Concentrate) - 50 mcg/hour\n Calcium Gluconate (CRRT) - 2.4 grams/hour\n Other ICU medications:\n Famotidine (Pepcid) - 01:30 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:34 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: 36.3\nC (97.3\n HR: 93 (85 - 108) bpm\n BP: 98/54(69) {81/38(52) - 124/70(91)} mmHg\n RR: 20 (19 - 32) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 103.1 kg (admission): 113.5 kg\n Height: 67 Inch\n Total In:\n 6,584 mL\n 2,432 mL\n PO:\n TF:\n 1,200 mL\n 278 mL\n IVF:\n 5,384 mL\n 2,154 mL\n Blood products:\n Total out:\n 6,966 mL\n 2,361 mL\n Urine:\n 487 mL\n 35 mL\n NG:\n Stool:\n Drains:\n Balance:\n -382 mL\n 71 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n Ventilator mode: Standby\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 0 (0 - 557) mL\n PS : 5 cmH2O\n RR (Set): 22\n RR (Spontaneous): 30\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 0 cmH2O\n SpO2: 100%\n ABG: 7.36/31/122/19/-6\n Ve: 13.5 L/min\n PaO2 / FiO2: 244\n Physical Examination\n GEN: Trached, sedated\n HEENT: icteric sclera. MMM\n NECK: Trach site with no oozing.\n LUNGS: Anterior auscultation with upper airway noise; good airway\n movement\n HEART: RRR, normal; S1, S2\n ABD: Distended. Grimmacing with palpation.\n EXTREM: 2+ edema, ulcers/lesions on legs with bandages C/D/I\n SKIN: Jaundice\n NEURO: No twitching today. Did not open eyes to command.\n Labs / Radiology\n 255 K/uL\n 7.7 g/dL\n 167 mg/dL\n 2.2 mg/dL\n 19 mEq/L\n 3.5 mEq/L\n 60 mg/dL\n 100 mEq/L\n 133 mEq/L\n 23.9 %\n 26.4 K/uL\n [image002.jpg]\n 06:31 PM\n 01:32 AM\n 03:05 AM\n 12:10 PM\n 01:36 PM\n 06:06 PM\n 06:23 PM\n 10:13 PM\n 04:13 AM\n 04:24 AM\n WBC\n 26.4\n Hct\n 23.2\n 23.9\n Plt\n 243\n 255\n Cr\n 2.0\n 2.4\n 2.2\n TCO2\n 17\n 16\n 18\n 19\n 19\n 18\n Glucose\n 166\n 154\n 162\n 220\n 67\n Other labs: PT / PTT / INR:16.1/32.9/1.4, CK / CKMB /\n Troponin-T:214/3/0.07, ALT / AST:211/247, Alk Phos / T Bili:564/29.7,\n Amylase / Lipase:51/41, Differential-Neuts:78.0 %, Band:3.0 %,\n Lymph:1.0 %, Mono:7.0 %, Eos:0.0 %, D-dimer:6389 ng/mL, Fibrinogen:502\n mg/dL, Lactic Acid:1.0 mmol/L, Albumin:2.0 g/dL, LDH:561 IU/L, Ca++:9.1\n mg/dL, Mg++:2.1 mg/dL, PO4:2.8 mg/dL\n Assessment and Plan\n 28M with alcoholic hepatitis and necrotizing pancreatitis complicated\n by ARDS, SIRS, ARF, UGIB, fevers.\n #. ID: Febrile now for 2 days, increased WBC, with decreased BP. RUQ\n u/s concerning for sludge and pt started on cipro; changed to flagyl\n yesterday. Of note, had stopped flagyl and vanc po as C. diff neg\n x 2. Blood/tissue/BAL cx NGTD. It is possible that previous fevers had\n been masked by CVVH, which he had been held x 2 days although restarted\n today.\n - Cte broad spectrum antibiotic coverage with linezolid and aztreonam\n (D1 ) and flagyl (added back )\n - Consider HIDA scan if bilirubin does not improve or hemodynamic\n instability over next few days.\n - F/u WBC count, temp curve, and culture data\n - Cont steroid taper for possible adrenal insufficiency\n # Hyperbilirubinemia: Patient has had continuously increasing T Bili\n and alkaline phosphatase. Has alcoholic hepatitis but also on TPN. Bili\n stable today but increased alk phos and RUQ u/s with sludge concerning\n for cholestasis. Note that U/S also showed sludge.\n - Consider asking GI input for HIDA scan v. ERCP\n - TPN stopped \n - Weaning off benzos\n #. Respiratory Failure: ARDS secondary to necrotizing pancreatitis. S/p\n trach placement on . Sutures out on . Currently on pressure\n support.\n - Cont to wean vent with trach mask trials v CPAP trials as tolerated\n - Increasing fentanyl patch while decreasing gtt, continue methadone\n - Attempt OOB to chair to improve respiratory mechanics\n # Seizures: CT head without intracranial process. EEG showed occipital\n seizures which does not correlate with clinical symptoms, but repeat\n EEG on higher dose Keppra showed no seizures. actually be\n patient waking up, not seizures.\n - Continue on higher dose keppra\n - F/u neuro recs\n - Wean off midazolam as tolerated with low dose valium to prevent\n withdrawal; monitor vitals\n #. Acute renal Failure: Appreciate renal recs.\n - Would dialyze for acidosis but likely does not need volume depletion.\n - Likely transition to HD today; f/u Renal recs\n - Aztreonam increased back to 2000mg q12h as back on CVVH\n - Will change Keppra to 1000mg Q24 with 500 mg after HD if he\n transitions to HD\n #. Adrenal Insufficiency: Unclear with stim if clear adrenal\n insufficiency but hypotension improving with steroids (lower pressor\n requirement) and improving eosinophilia\n - Weaned Hydrocort to 25mg Q8H today\n # ?HLH: Quantitative ferritin of 2660. Unlikely to have HLH.\n # Eosinophilia: Resolved on steroids and s/p med changes.\n ICU Care\n Nutrition:\n Nutren 2.0 () - 01:46 PM 50 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 08:15 PM\n PICC Line - 08:37 AM\n Dialysis Catheter - 08:55 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:ICU\n" }, { "category": "Nursing", "chartdate": "2131-07-03 00:00:00.000", "description": "Nursing Progress Note", "row_id": 684697, "text": "Arousal, Attention, and Cognition, Impaired\n Assessment:\n Action:\n Response:\n Plan:\n Problem - Description In Comments\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Rehab Services", "chartdate": "2131-06-28 00:00:00.000", "description": "PMV Follow Up", "row_id": 683501, "text": "TITLE:\nPASSY-MUIR VALVE FOLLOW UP\nHISTORY:\nThank you for consulting on this 28-year-old male who presented\nto ED on complaints of weakness, fatigue and\nconfusion for ~1 week, 2 days of melena and hematemesis. Patient\nwas found with grade 3 esophagitis in the lower\nand middle third of the esophagus; friability, erythema,\ncongestion and erosion in the whole stomach compatible with\nmoderately severe gastritis via EGD. CT scan revealed acute\npancreatitis with peripancreatic stranding and 30% necrosis.\nHospital course c/b continuous pressor requirement, alcoholic\nhepatitis, necrotizing pancreatitis, acute renal failure\nrequiring CVVHD, cerebral edema, ARDS, coagulopathy and\nthrombocytopenia thought to be due to liver failure (vs DIC) and\npossibly adrenal insufficiency. Patient was unable to wean from\nvent and underwent tracheostomy on and s/p bronchoscopy on\n clot resulting in brief PEA arrest. CVVH was\ndiscontinued on and patient to begin HD. Patient has been\ntolerating trach mask since and we were consulted to\nevaluate patient's ability to tolerate a Passy-Muir Speaking\nValve (PMV).\nPt was initially seen for the valve trial, but had\ndifficulty managing secretions and had audible breathstacking\nwith the valve in place. We returned on for another attempt,\nbut pt's secretions had increased and he was again requiring vent\nsupport to maintain respiratory status. Pt returned to trach\ncollar later that day, but RT reports he has had several declines\nrequiring return to the vent.\nPMH:\nalcohol dependency\ndepression\nDEFERRED EVALUATION:\nI returned to try to repeat the evaluation, but pt has had\nincreased secretions, is spiking fevers and is tachypneic. Pt is\nscheduled for CXR for further evaluation of changes later today.\nAfter discussion with RT, it was determined repeat evaluation was\nnot appropriate at this time. Pt is also not appropriate for\ntrach downsize as he has required return to the vent on more than\none occasion. We will continue to follow.\n_______________________________________\n , M.S., CCC-SLP\nPager #\nTotal time: 20 minutes\n [BUTTON Input] (not implemented)_____\n 10:32\n" }, { "category": "Nursing", "chartdate": "2131-06-28 00:00:00.000", "description": "Nursing Progress Note", "row_id": 683591, "text": "Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n T max 101.3\n tachycardic in 120\n tachypnic to 40\n Action:\n Tylenol given\n peripheral blood cultures x1 sent\n frequent monitoring\n Response:\n current temp 100.0\n tachycardia improved\n tachypnia improved\n Plan:\n follow up on blood culture\n continue to monitor\n Impaired Skin Integrity\n Assessment:\n scabbed legs improving\n no open areas that require dressings\n skin is peeling\n heels improving\n Action:\n aloe vesta applied to legs and arms\n repositioned frequently\n OOB to chair\n worked with physical therapy\n Response:\n skin is improving\n Plan:\n continue with plan noted in action section\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n urine output 30-100 cc\ns/hr\n fluid balance MN\n 1800 even\n urine becoming less icteric, more amber in color\n Creatinine on slow decline without HD\n Action:\n Monitor I+O\n Monitor labs\n Response:\n Renal function continues to improve\n Plan:\n Continue to follow up with renal team\n Continue to monitor labs, urine output, renal function.\n Patient and family support\n" }, { "category": "Nursing", "chartdate": "2131-06-28 00:00:00.000", "description": "Nursing Progress Note", "row_id": 683427, "text": "Arousal, Attention, and Cognition, Impaired\n Assessment:\n Alert/Arouses to voice\n Tracking around room\n No noted purposeful movements\n Remains tremulous when touched\n Did at times appear like he might be attempting to mouth\n words\n Pt did squeeze RN\ns hand to command X1\n Action:\n Cont neuro assessments\n Cont to stimulate and encourage interaction\n Turned and repositioned\n Passive ROM\n Response:\n Unchanged\n Plan:\n Cont with PT/OT\n OOB to chair in am\n Cont to stimulate and encourage social interaction\n Supportive care to pt and family\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Creatinine this am 2.6\n Cont to have adequate u/o\n Wt this am 103.9 down for 105 on \n ABG Resp Alkolosis with BE -2\n Action:\n Response:\n Plan:\n Impaired Skin Integrity\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2131-06-17 00:00:00.000", "description": "Nursing Progress Note", "row_id": 681370, "text": "Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Continues of CRRT\n Bicarb this am 19\n Calcium gtt ^ 60ml/hr\n Fluid removal as tolerated\n U/O minimal Remain Icteric and cloudy\n Action:\n Discussed with Renal this am about Bicarb and Calcium\n Replacement fluid changed to B32 K2 Calcium Scale revised\n Goal -100cc/hr or more as tolerated\n Response:\n Bicarb up to 24 Calcium gtt decreased\n Foley cath changed per MICU\n Tolerating fluid removal well\n Tachycardic this pm ? if due to fluid removal\n 200cc bolus given with no change in HR per MICU\n Possible ^ HR r/t decrease in sedative medications and pt\n becoming more awake\n Plan:\n Cont CRRT until filter needs to be changed\n ABG/Potassium/Ionized Ca q6hrs or as needed\n Needs to have U/A sent now that foley has been changed\n ------ Protected Section ------\n Addendum:\n Pt now on minimal sedative meds.\n Pt more awake opens eyes to voice and is tracking\n Still not following commands\n Does withdraw to pain\n Pt cont on trach mask for >24 discussed with MICU need to facilitate\n Rehab screening\n This RN also spoke with family today RE: Rehab and that pt will soon\n be ready to go if he tolerated HD this week\n Family is aware is will be looking into area rehabs for placement.\n Pt will need to have PT/OT c/s this week. Plan to do HD ASAP so pt can\n get OOB.\n Cont with current plan of care\n ------ Protected Section Addendum Entered By: , RN\n on: 17:58 ------\n" }, { "category": "Physician ", "chartdate": "2131-06-18 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 681450, "text": "Chief Complaint:\n 24 Hour Events:\n - Fentanyl and midazolam decreased with slight increase in HR to 110s.\n Increased valium to 10mg TID\n - Tolerated trach mask throughout day\n Allergies:\n Meropenem\n skin blisters a\n Last dose of Antibiotics:\n Ciprofloxacin - 12:34 PM\n Linezolid - 10:09 PM\n Aztreonam - 07:45 AM\n Metronidazole - 08:30 AM\n Infusions:\n Fentanyl (Concentrate) - 25 mcg/hour\n KCl (CRRT) - 3 mEq./hour\n Calcium Gluconate (CRRT) - 2.4 grams/hour\n Other ICU medications:\n Famotidine (Pepcid) - 12:06 AM\n Heparin Sodium (Prophylaxis) - 04:02 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:23 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.3\nC (99.2\n Tcurrent: 36.2\nC (97.1\n HR: 101 (94 - 113) bpm\n BP: 113/59(78) {87/48(64) - 129/70(90)} mmHg\n RR: 23 (19 - 33) insp/min\n SpO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 99.7 kg (admission): 113.5 kg\n Height: 67 Inch\n Total In:\n 9,973 mL\n 2,424 mL\n PO:\n TF:\n 1,200 mL\n 319 mL\n IVF:\n 8,753 mL\n 2,085 mL\n Blood products:\n Total out:\n 11,007 mL\n 2,337 mL\n Urine:\n 77 mL\n 20 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,034 mL\n 87 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n Ventilator mode: Standby\n Vt (Spontaneous): 567 (567 - 567) mL\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 0 cmH2O\n SpO2: 100%\n ABG: 7.45/37/105/24/1\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 321 K/uL\n 8.0 g/dL\n 165 mg/dL\n 0.6 mg/dL\n 24 mEq/L\n 4.0 mEq/L\n 33 mg/dL\n 99 mEq/L\n 134 mEq/L\n 24.8 %\n 30.5 K/uL\n [image002.jpg]\n 06:23 PM\n 10:13 PM\n 04:13 AM\n 04:24 AM\n 11:20 AM\n 04:55 PM\n 10:00 PM\n 10:30 PM\n 03:49 AM\n 03:56 AM\n WBC\n 24.9\n 30.5\n Hct\n 23.9\n 24.8\n Plt\n 255\n 321\n Cr\n 0.8\n 1.2\n 0.6\n TCO2\n 19\n 19\n 18\n 19\n 24\n 26\n 27\n Glucose\n 172\n 199\n 167\n 110\n 186\n 185\n 160\n 165\n Other labs: PT / PTT / INR:15.6/33.4/1.4, CK / CKMB /\n Troponin-T:214/3/0.07, ALT / AST:211/223, Alk Phos / T Bili:588/27.9,\n Amylase / Lipase:51/41, Differential-Neuts:78.0 %, Band:3.0 %,\n Lymph:1.0 %, Mono:7.0 %, Eos:0.0 %, D-dimer:6389 ng/mL, Fibrinogen:502\n mg/dL, Lactic Acid:1.0 mmol/L, Albumin:2.0 g/dL, LDH:517 IU/L, Ca++:8.3\n mg/dL, Mg++:1.8 mg/dL, PO4:1.3 mg/dL\n Assessment and Plan\n AROUSAL, ATTENTION, AND COGNITION, IMPAIRED\n BALANCE, IMPAIRED\n MOTOR FUNCTION, IMPAIRED\n MUSCLE PERFORMACE, IMPAIRED\n RESPIRATION / GAS EXCHANGE, IMPAIRED\n SEIZURE, WITHOUT STATUS EPILEPTICUS\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n IMPAIRED SKIN INTEGRITY\n HEPATITIS, ACUTE TOXIC (INCLUDING ALCOHOLIC, ACETAMINOPHEN, ETC.)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ICU Care\n Nutrition:\n Nutren 2.0 () - 01:34 PM 50 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 08:15 PM\n PICC Line - 08:37 AM\n Dialysis Catheter - 08:55 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": "2131-06-18 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 681451, "text": "Chief Complaint:\n 24 Hour Events:\n - Fentanyl and midazolam decreased with slight increase in HR to 110s.\n Increased valium to 10mg TID\n - Tolerated trach mask throughout day\n Allergies:\n Meropenem\n skin blisters a\n Last dose of Antibiotics:\n Ciprofloxacin - 12:34 PM\n Linezolid - 10:09 PM\n Aztreonam - 07:45 AM\n Metronidazole - 08:30 AM\n Infusions:\n Fentanyl (Concentrate) - 25 mcg/hour\n KCl (CRRT) - 3 mEq./hour\n Calcium Gluconate (CRRT) - 2.4 grams/hour\n Other ICU medications:\n Famotidine (Pepcid) - 12:06 AM\n Heparin Sodium (Prophylaxis) - 04:02 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:23 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.3\nC (99.2\n Tcurrent: 36.2\nC (97.1\n HR: 101 (94 - 113) bpm\n BP: 113/59(78) {87/48(64) - 129/70(90)} mmHg\n RR: 23 (19 - 33) insp/min\n SpO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 99.7 kg (admission): 113.5 kg\n Height: 67 Inch\n Total In:\n 9,973 mL\n 2,424 mL\n PO:\n TF:\n 1,200 mL\n 319 mL\n IVF:\n 8,753 mL\n 2,085 mL\n Blood products:\n Total out:\n 11,007 mL\n 2,337 mL\n Urine:\n 77 mL\n 20 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,034 mL\n 87 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n Ventilator mode: Standby\n Vt (Spontaneous): 567 (567 - 567) mL\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 0 cmH2O\n SpO2: 100%\n ABG: 7.45/37/105/24/1\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 321 K/uL\n 8.0 g/dL\n 165 mg/dL\n 0.6 mg/dL\n 24 mEq/L\n 4.0 mEq/L\n 33 mg/dL\n 99 mEq/L\n 134 mEq/L\n 24.8 %\n 30.5 K/uL\n [image002.jpg]\n 06:23 PM\n 10:13 PM\n 04:13 AM\n 04:24 AM\n 11:20 AM\n 04:55 PM\n 10:00 PM\n 10:30 PM\n 03:49 AM\n 03:56 AM\n WBC\n 24.9\n 30.5\n Hct\n 23.9\n 24.8\n Plt\n 255\n 321\n Cr\n 0.8\n 1.2\n 0.6\n TCO2\n 19\n 19\n 18\n 19\n 24\n 26\n 27\n Glucose\n 172\n 199\n 167\n 110\n 186\n 185\n 160\n 165\n Other labs: PT / PTT / INR:15.6/33.4/1.4, CK / CKMB /\n Troponin-T:214/3/0.07, ALT / AST:211/223, Alk Phos / T Bili:588/27.9,\n Amylase / Lipase:51/41, Differential-Neuts:78.0 %, Band:3.0 %,\n Lymph:1.0 %, Mono:7.0 %, Eos:0.0 %, D-dimer:6389 ng/mL, Fibrinogen:502\n mg/dL, Lactic Acid:1.0 mmol/L, Albumin:2.0 g/dL, LDH:517 IU/L, Ca++:8.3\n mg/dL, Mg++:1.8 mg/dL, PO4:1.3 mg/dL\n Assessment and Plan\n 28M with alcoholic hepatitis and necrotizing pancreatitis complicated\n by ARDS, SIRS, ARF, UGIB, fevers.\n #. ID: No fevers since starting CVVH. RUQ u/s concerning for sludge and\n pt started flagyl.\n - Cte broad spectrum antibiotic coverage with linezolid and aztreonam\n (D1 ) and flagyl (added back )\n - Consider HIDA scan if bilirubin does not improve or hemodynamic\n instability over next few days as may need perc. drain\n - F/u WBC count, temp curve, and culture data\n - Cont steroid taper for possible adrenal insufficiency\n - Yeast in the urine- changed foley and re-cultured. If still with\n yeast will treat with anti-fungal.\n # Hyperbilirubinemia: T Bili stable. Has alcoholic hepatitis but was\n also on TPN. Bili. RUQ u/s with sludge concerning for cholestasis. Note\n that U/S also showed sludge.\n - Consider asking GI input for HIDA scan v. ERCP if hemodynamic\n instability\n - TPN stopped \n - Weaning off benzos\n #. Respiratory Failure: ARDS secondary to necrotizing pancreatitis. S/p\n trach placement on . Sutures out on . Currently on trach mask\n with good abg\n - Increasing fentanyl patch while decreasing gtt, continue methadone\n - Cte oob to chair daily\n - Consider down-size trach\n # Seizures: CT head without intracranial process. EEG showed occipital\n seizures which does not correlate with clinical symptoms, but repeat\n EEG on higher dose Keppra showed no seizures. As patient now with\n purposeful movements it may actually be patient waking up, not\n seizures.\n - Continue on higher dose keppra\n - F/u neuro recs\n - Wean off midazolam as tolerated with low dose valium to prevent\n withdrawal; monitor vitals\n #. Acute renal Failure: Appreciate renal recs.\n - Would dialyze for acidosis but likely does not need volume depletion\n as pressures borderline.\n - Cte CVVH while pressures low but consider HD when more stable\n tomorrow.\n - Aztreonam increased back to 2000mg q12h as back on CVVH\n - Will change Keppra to 1000mg Q24 with 500 mg after HD if he\n transitions to HD\n #. Adrenal Insufficiency: Unclear with stim if clear adrenal\n insufficiency but hypotension improving with steroids (lower pressor\n requirement) and improving eosinophilia\n - Weaned Hydrocort to 25mg Q8H (Day )\n ICU Care\n Nutrition:\n Nutren 2.0 () - 01:34 PM 50 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 08:15 PM\n PICC Line - 08:37 AM\n Dialysis Catheter - 08:55 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": "2131-06-19 00:00:00.000", "description": "Physician Resident/Attending Progress Note - MICU", "row_id": 681741, "text": "Chief Complaint:\n 24 Hour Events:\n NUCLEAR MEDICINE - At 05:40 PM\n \n - Restarted on linezolid, aztreonam, and flagyl given increased\n leukocytosis/left shift\n - Pt to continue CVVH until filter clogs per Renal\n - Fentanyl gtt changed to prn boluses\n - PT/OT consulted; case manager starting Rehab screening\n - HIDA scan done. On return, more tachypneic with RR in 30s. ABG c/w\n resp alkalosis: 7.45/33/115 10am -> 7.50/30/55/24 6pm -> 7.49/25/66/20\n 6:30pm. Trach suctioned with no output. Given fentanyl bolus as\n appeared more uncomfortable. I/O net positive 670 cc -> CVVH rate\n increased as SBP 120s. Had clot when resuctioned. CXR showed mild fluid\n at bases with more plump pulm vasculature; smaller volumes likely c/w\n expiration - no collapse. Repeat ABG 7.46/37/180/27.\n Allergies:\n Meropenem\n skin blisters a\n Last dose of Antibiotics:\n Linezolid - 12:42 PM\n Aztreonam - 02:57 AM\n Metronidazole - 04:00 AM\n Infusions:\n Calcium Gluconate (CRRT) - 1.6 grams/hour\n Other ICU medications:\n Fentanyl - 07:09 PM\n Famotidine (Pepcid) - 12:08 AM\n Heparin Sodium (Prophylaxis) - 04:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:26 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37\nC (98.6\n Tcurrent: 35.9\nC (96.7\n HR: 95 (90 - 118) bpm\n BP: 126/70(91) {107/56(72) - 133/78(99)} mmHg\n RR: 30 (21 - 36) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 100.4 kg (admission): 113.5 kg\n Height: 67 Inch\n Total In:\n 8,831 mL\n 2,834 mL\n PO:\n TF:\n 995 mL\n 371 mL\n IVF:\n 7,796 mL\n 2,463 mL\n Blood products:\n Total out:\n 8,370 mL\n 2,381 mL\n Urine:\n 85 mL\n 35 mL\n NG:\n Stool:\n Drains:\n Balance:\n 461 mL\n 453 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n SpO2: 99%\n ABG: 7.44/39/125/25/2\n PaO2 / FiO2: 179\n Physical Examination\n GEN: Trached, sedated.\n HEENT: Icteric sclera. MMM.\n NECK: Trach site with no oozing.\n LUNGS: Anterior auscultation with upper airway noise; good airway\n movement.\n HEART: RRR, normal S1, S2.\n ABD: Distended. Firm, but unchanged.\n EXTREM: 2+ edema, ulcers/lesions on legs with bandages C/D/I.\n SKIN: Jaundiced.\n NEURO: Twitching mouth. No purposeful movements today.\n Labs / Radiology\n 334 K/uL\n 8.0 g/dL\n 151 mg/dL\n 0.6 mg/dL\n 25 mEq/L\n 3.9 mEq/L\n 29 mg/dL\n 98 mEq/L\n 132 mEq/L\n 24.6 %\n 34.9 K/uL\n [image002.jpg]\n Ca: 8.8 Mg: 1.8 P: 1.7\n ALT: 214\n AP: 519\n Tbili: 24.8\n Alb:\n AST: 227\n LDH: 529\n Dbili:\n TProt:\n :\n Lip:\n 10:30 PM\n 03:49 AM\n 03:56 AM\n 10:08 AM\n 06:00 PM\n 06:25 PM\n 08:18 PM\n 10:56 PM\n 02:58 AM\n 03:10 AM\n WBC\n 30.5\n 34.9\n Hct\n 24.8\n 24.6\n Plt\n 321\n 334\n Cr\n 0.6\n 0.6\n TCO2\n 26\n 27\n 24\n 24\n 20\n 27\n 26\n 27\n Glucose\n 185\n 160\n 165\n 156\n 116\n 112\n 151\n Other labs: PT / PTT / INR:15.0/33.3/1.3, CK / CKMB /\n Troponin-T:214/3/0.07, ALT / AST:214/227, Alk Phos / T Bili:519/24.8,\n Amylase / Lipase:77/68, Differential-Neuts:78.0 %, Band:9.0 %,\n Lymph:2.0 %, Mono:3.0 %, Eos:0.0 %, D-dimer:6389 ng/mL, Fibrinogen:502\n mg/dL, Lactic Acid:1.0 mmol/L, Albumin:2.0 g/dL, LDH:529 IU/L, Ca++:8.8\n mg/dL, Mg++:1.8 mg/dL, PO4:1.7 mg/dL\n U Cx with yeast persistently after foley changed and Blood Cx pending\n HIDA scan: Non-visualization of GB. Contrast in bowel consistent with\n patent common BD\n Assessment and Plan\n 28M with alcoholic hepatitis and necrotizing pancreatitis complicated\n by ARDS, SIRS, ARF, UGIB, fevers.\n #. ID: Persistent leukocytosis. Necrotizing pancreatitis. All abx\n (linezolid/aztreo D1 and flagyl D1 ) discontinued as\n appeared clinically improved, but WBC trended back up. Remains afebrile\n (but on CVVH) but worsened leukocytosis today. HIDA neg.\n - F/U fever curve after cvvh d/c\nd. If spikes or HD instability abd ct.\n - Continue abx coverage with aztreo, flagyl, and linezolid given\n necrotizing pancreatitis.\n - F/u WBC count, temp curve, and culture data\n - taper steroids to 12.5 mg today\n - added on diff to CBC from this am as may have increasing eosinophilia\n as cause of leukocytosis\n - Yeast in the urine- changed foley and re-cultured with persistent\n yeast but oliguric so unclear if true infection.\n # Elevated LFTs: A/w alcoholic hepatitis but recent increase may be \n TPN, now discontinued. RUQ u/s showed sludge concerning for\n cholestasis but also seen on u/s. T Bili and transaminases\n stable today.\n - HIDA neg\n - TPN stopped \n - Plan for weaning off benzos\n #. Respiratory Failure: ARDS secondary to necrotizing pancreatitis. S/p\n trach placement on . Sutures out on .\n - worse after HIDA likely from laying flat. Will repeat CXR to ensure\n trach in place.\n - Change gtt to PRN fentanyl boluses, continue methadone with wean\n tomorrow\n - goal to chair daily\n # Seizures: CT head without intracranial process. EEG showed occipital\n seizures which does not correlate with clinical symptoms, but repeat\n EEG on higher dose Keppra showed no seizures. As patient now with\n purposeful movements, this may actually be patient waking up, not\n seizures.\n - Continue keppra\n - Continue low dose valium to prevent withdrawal; Plan to wean valium\n today\n #. Acute renal Failure: Appreciate renal recs.\n - Transition to HD tomorrow\n - Would dialyze for acidosis but likely does not need volume depletion\n as pressures borderline.\n - Aztreonam 2000mg q12h while on CVVH\n - Will change Keppra to 1000mg Q24 with 500 mg after HD if he\n transitions to HD\n #. Adrenal Insufficiency: Unclear with stim if clear adrenal\n insufficiency but hypotension improving with steroids (lower pressor\n requirement) and improving eosinophilia\n - Cont weaning hydrocort; D3/3 of 25mg Q8H today. Change to 12.5 today\n # PT and OT eval for placement\n ICU Care\n Nutrition:\n Nutren 2.0 () - 05:40 PM 50 mL/hour\n Glycemic Control: ISS\n Lines:\n Arterial Line - 08:15 PM\n PICC Line - 08:37 AM\n Dialysis Catheter - 08:55 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP: HOB elevation\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:ICU pending placement\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: 28M alcoholic hepatitis, pancreatitis,\n refractory shock, ARDS. USG c likely GB sludge, now off abx but WBC/\n bands are trending up. Mental status slowly resolving as we wean\n sedation. Now on TM x >24h, back on abx with rising WBC count.\n Exam notable for Tm 98.6 BP 110/60 HR 100-110 CVP 9 RR 23 with sat 100\n on 0.7TM 7.44/39/125. WD man, chemosis. Follows some commands. Coarse\n BS B. Distant s1s2. Obese, + BS. 3+ edema. Labs notable for WBC 34K,\n HCT 24, Na 132, TB 27. CXR pending.\n Agree with plan to manage respiratory failure with ongoing TM trials\n and sedation wean - will get OOB to chair today, and will continue\n sedation wean. Given question of sz activity, will continue valium PGT\n and keppra. For shock (resolved), will continue to wean steroids\n (HC 12.5 q8h) and will continue linezolid / aztreonam / flagyl while\n monitoring LFTs. If he spikes or goes back on pressors, will need to\n recheck abd CT re collection. For ARF, change CVVH to HD (first run\n tomorrow); will try to run even. For pancreatitis, will continue\n post-pyloric TFs; he is stooling with good bowel sounds. Needs PT eval\n and rehab screening. Plan d/w family at bedside. Remainder of plan as\n outlined above.\n Patient is critically ill\n Total time: 40 min\n ------ Protected Section Addendum Entered By: , MD\n on: 05:06 PM ------\n" }, { "category": "Physician ", "chartdate": "2131-06-28 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 683519, "text": "Chief Complaint:\n 24 Hour Events:\n - remains off vent and off pressors\n -MRI and EEG done\n - Per renal hold HD, if continues to produce urine will d/c HD line\n Fri.\n - Blood cx from HD line x 2, one from each port, on \n - Removed trach sutures\n Allergies:\n Meropenem\n skin blisters\n Last dose of Antibiotics:\n Aztreonam - 02:39 PM\n Micafungin - 10:00 PM\n Infusions:\n Other ICU medications:\n Fentanyl - 01:00 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 05:51 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: (101.2\n Tcurrent: 37.8\nC (100.1\n HR: 116 (105 - 121) bpm\n BP: 117/70(86) {108/63(79) - 144/77(98)} mmHg\n RR: 32 (18 - 40) insp/min\n SpO2: 97%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 103.9 kg (admission): 113.5 kg\n Height: 67 Inch\n Total In:\n 1,525 mL\n 291 mL\n PO:\n TF:\n 1,201 mL\n 291 mL\n IVF:\n 264 mL\n Blood products:\n Total out:\n 1,440 mL\n 375 mL\n Urine:\n 1,440 mL\n 375 mL\n NG:\n Stool:\n Drains:\n Balance:\n 85 mL\n -84 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n SpO2: 97%\n ABG: 7.41/33/122/20/-2\n PaO2 / FiO2: 305\n Physical Examination\n Labs / Radiology\n 227 K/uL\n 6.5 g/dL\n 192 mg/dL\n 2.6 mg/dL\n 20 mEq/L\n 3.4 mEq/L\n 94 mg/dL\n 115 mEq/L\n 140 mEq/L\n 21.5 %\n 10.2 K/uL\n [image002.jpg]\n 01:12 AM\n 06:06 AM\n 02:38 PM\n 02:00 AM\n 02:49 AM\n 01:51 AM\n 03:26 PM\n 03:37 PM\n 03:15 AM\n 03:19 AM\n WBC\n 18.9\n 15.0\n 12.6\n 10.2\n Hct\n 22.2\n 22.5\n 22.1\n 21.5\n Plt\n 230\n 228\n 225\n 227\n Cr\n 2.7\n 3.0\n 2.9\n 2.7\n 2.6\n TCO2\n 18\n 21\n 24\n 23\n 22\n Glucose\n 121\n 128\n 80\n 129\n 194\n 192\n Other labs: PT / PTT / INR:13.6/28.0/1.2, CK / CKMB /\n Troponin-T:214/3/0.07, ALT / AST:75/115, Alk Phos / T Bili:408/5.5,\n Amylase / Lipase:77/88, Differential-Neuts:84.3 %, Band:0.0 %,\n Lymph:9.3 %, Mono:1.7 %, Eos:4.3 %, D-dimer:6389 ng/mL, Fibrinogen:541\n mg/dL, Lactic Acid:2.6 mmol/L, Albumin:2.3 g/dL, LDH:312 IU/L, Ca++:8.6\n mg/dL, Mg++:2.0 mg/dL, PO4:2.7 mg/dL\n Assessment and Plan\n 28 year old male with a history of alcoholism presenting with acute\n hepatitis, pancreatitis, and UGIB, with persistent cyclic\n fevers/leukocytosis.\n # Cyclic fevers/leukocytosis\n febrile to 101.2 overnight, but WBC\n trending down. Sputum with 4+ GNR likely colonizer, as per ID. Sputum\n consistency unchanged. CXR without overt pneumonia. C diff neg on\n . U/A weakly positive; cx showing 10k yeast. Weaning off abx and\n currently only on micafungin as pt has been cx negative. HD line\n cultured x 2 yesterday. Given temp , draw another set of\n blood cx and order CXR. Consider CT chest and Abx if clinically\n deteriorates. Other source lower on ddx includes peripancreatic fluid\n collection. Hesitant to re-do CT A/P given the contrast required.\n # Hypotension\n resolved, cont to monitor.\n # Respiratory failure\n on trach mask at 40% FIO2, tachypnic this AM.\n Will call thoracics re: position of trach (position seems low on cxr,\n marked on radiology report).\n # Acute renal failure\n stable and UOP improving (currently 30-60\n cc/hr). Per renal, hold off HD and d/c HD line Fri if UOP stays as\n such.\n # Altered mental status\n Given possibility of seizure activity, will\n continue keppra. MRI showing cerebral edema, poor prognosis as per\n neuro. EEG completed and report pending. Unclear how much of this is\n medication induced and how much is rehab correctable; would appreciate\n neuro recs regarding potential rehab.\n # Hyponatremia\n - correcting on free water boluses\n # Anemia\n stable. Will hold off transfusing given that pt currently\n febrile.\n # Hematemesis: resolved. Given alcohol history, potential\n consideration for variceal bleed. No known prior history of hepatic\n cirrhosis, but elevated INR and fatty liver infilatration would be\n consistent. Also should consider PUD or alcoholic gastritis. Hct was\n WNL on presentation, but patient markedly contracted. Continued bright\n red blood on NG lavage suggests some degree of continued active\n bleeding.\n -- hepatology consulted, EGD showing diulefoy lesion\n -- access with 2 large bore IVs and a cordis, T + C x 3 units\n -- IV PPI + PPI gtt\n .\n # Pancreatitis: Most likely alcoholic in etiology, with elevated lipase\n to 1600 and CT findings consistent without necrosis, cycts, or\n phlemgon. Only mild epigastric tenderness and no complaints of\n abdominal pain.\n -- continue aggessive hydration\n -- serial abdominal exams\n -- trend lipase\n -- no evidence of obstruction, holding off on further imaging at this\n time\n -- cont post pyloric TF\n -- to hold off on any drainage of new peripancreatic fluid collection\n but will discuss with Dr \n # Acute Hepatitis: Likely alcoholic hepatitis. CT scan shows fatty\n infiltration, and no evidence of distal ostruction.\n - check viral hepatitis panel, although degree of transaminitis not\n consistant with such an etiology.\n - holding off on further imaging for now, f/u final CT read\n - hepatology following\n - avoid hepatically cleared meds\n - trend LFTs\n # Alcoholism: Patient describes history of withdrawal symptoms, but\n not prior seizure. Last drink was night prior to presentation.\n Tachycardia, weakness, and elevated lactate could be consistent with\n thiamine deficiency.\n - repleate thiamine, vb12, folate\n - ativan with CIWA > 10\n - addictions consult\n # FEN: IVF, replete electrolytes, NPO\n # Prophylaxis: scds, PPI gtt\n # Access: PICC, HD, a-line\n # Code: Full Code\n # Disposition: MICU for now\n ICU Care\n Nutrition:\n Nutren 2.0 () - 01:27 PM 50 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 08:15 PM\n PICC Line - 08:37 AM\n Dialysis Catheter - 08:55 AM\n Prophylaxis:\n DVT: heparin\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: MICU for now, long term rehab\n" }, { "category": "Nursing", "chartdate": "2131-06-18 00:00:00.000", "description": "Nursing Progress Note", "row_id": 681440, "text": "Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n On CRRT. Goal negative.\n Hemodynamically stable. Sedated on Fent/Versed.\n Hypotensive to high 80s x1 this shift.\n u/o marginal- approx ccs/hr. icteric & clear.\n Replacement fluid split- PBP K4B22 & replacement K2B32\n Action:\n Negative one liter yesterday.\n Flushed CRRT and gave pt small 200 cc boluses for transient\n hypotension.\n Bair hugger in place.\n Midaz weaned off and PO valium increased.\n Response:\n Responded well to fluid boluses.\n Tolerating CRRT well.\n u/o remains marginal.\n Bicarb 24. BUN/CR down to 60/0.6. ABGs wnl.\n Remains tremulous, more so when doses of methadone and valium are due.\n Slightly more alert/awake than yesterday. Occasionally tracking.\n Plan:\n D/w renal and MICU CRRT goals.\n Discuss ? HD in the coming days vs. CRRT.\n ? attempt to wean sedation further to assist with blood pressure\n management.\n Closely monitor temp & white count in light of recent temp spikes and\n CRRT use.\n Respiration / Gas Exchange, Impaired\n Assessment:\n Min oral secretions though pt at times biting down and preventing oral\n care.\n On TM 50% since this afternoon.\n ABGs wnl. RR 20s.\n When agitated or with stimulation. RR up to 30s though self resolves.\n LS clear, at times rhonchorous and wheezy.\n Action:\n Trach mask continued.\n Inhalers prn.\n Suctioned for scant amount of secretions.\n T&P frequently.\n Serial ABGs.\n Small plug suctioned out.\n Response:\n Continues to tolerate trach mask well. Not tachypneic, sats 98-100.\n ABGs wnl.\n Plan:\n Continue to closely monitor respiratory status. Frequent suctioning to\n check for clots/secretions/plugs.\n Serial gases. Provide orientation and redirection as needed. Provide\n comfort and support. Place back on vent if respiratory status changes.\n Impaired Skin Integrity\n Assessment:\n Multiple open, blisters to bilateral lower extremities and abdomen.\n Skin dry & peeling.\n Deep tissue injury to bilateral heels.\n +1 generalized edema.\n TF at goal rate. Loose green liquid/mucoid stool x2 this shift.\n FS elevated 170-270.\n Action:\n Aloe Vesta cream applied to all areas after cleaning site.\n Dressing applied on both knee/calf areas.\n Waffle boots in place, elevating heels.\n TF continues. Aloevesta to sacrum/coccyx as well.\n SQ Insulin sliding scale.\n Response:\n Skin remains unchanged though no new areas are noted.\n Tolerating TF well.\n Plan:\n Continue with good skin care- frequent turning, elevation of heels.\n Ensure adequate glucose control. Continually re-apply aloe vesta and\n keep skin moist.\n Provide comfort and support.\n" }, { "category": "Nursing", "chartdate": "2131-06-19 00:00:00.000", "description": "Nursing Progress Note", "row_id": 681736, "text": "Sepsis, ongoing, pancreatitis\n Assessment:\n Fever spike today to 101.4\n Symptomatic with hypotension to 75/\n Tachy to 121\n Action:\n .9NS 500c fluid bolus given\n Tylenol given\n Blood cultures\nperipheral and from dialysis cath (PICC line didn\n draw)\n Urine culture sent\n Low dose levo started\n Response:\n Blood pressure responded to levo\n Plan:\n Abd/pelvic ct this pm with iv/po contrast.\n Family aware of fever\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Poor abgs after return from HIDA scan\n Bagged, suctioned for small amount clear to tan sputum, no plugs noted.\n Inhalers given\n No improvement after these interventions\n Action:\n Placed back on vent. .6 CPAP \n Response:\n Po2 increased to 91, Still tachy\n Plan:\n Keep on vent overnight.\n" }, { "category": "Physician ", "chartdate": "2131-06-28 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 683465, "text": "Chief Complaint:\n 24 Hour Events:\n - remains off vent and off pressors\n -Repeat CXR shows interval improvement in right lung fields; diaphrams\n more clearly visualized (possible clearing of pleural effusions).\n -Awaiting culture results\n -MRI and EEG ordered\n -Per renal hold HD, if continues to produce urine will d/c HD line\n after 2 days.\n - Blood cx from HD line x 2, one from each port, on \n -Removed trach sutures\n Allergies:\n Meropenem\n skin blisters\n Last dose of Antibiotics:\n Aztreonam - 02:39 PM\n Micafungin - 10:00 PM\n Infusions:\n Other ICU medications:\n Fentanyl - 01:00 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 05:51 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38\nC (100.4\n Tcurrent: 37.8\nC (100.1\n HR: 116 (105 - 121) bpm\n BP: 117/70(86) {108/63(79) - 144/77(98)} mmHg\n RR: 32 (18 - 40) insp/min\n SpO2: 97%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 103.9 kg (admission): 113.5 kg\n Height: 67 Inch\n Total In:\n 1,525 mL\n 291 mL\n PO:\n TF:\n 1,201 mL\n 291 mL\n IVF:\n 264 mL\n Blood products:\n Total out:\n 1,440 mL\n 375 mL\n Urine:\n 1,440 mL\n 375 mL\n NG:\n Stool:\n Drains:\n Balance:\n 85 mL\n -84 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n SpO2: 97%\n ABG: 7.41/33/122/20/-2\n PaO2 / FiO2: 305\n Physical Examination\n Labs / Radiology\n 227 K/uL\n 6.5 g/dL\n 192 mg/dL\n 2.6 mg/dL\n 20 mEq/L\n 3.6 mEq/L\n 94 mg/dL\n 115 mEq/L\n 150 mEq/L\n 21.5 %\n 10.2 K/uL\n [image002.jpg]\n 01:12 AM\n 06:06 AM\n 02:38 PM\n 02:00 AM\n 02:49 AM\n 01:51 AM\n 03:26 PM\n 03:37 PM\n 03:15 AM\n 03:19 AM\n WBC\n 18.9\n 15.0\n 12.6\n 10.2\n Hct\n 22.2\n 22.5\n 22.1\n 21.5\n Plt\n 230\n 228\n 225\n 227\n Cr\n 2.7\n 3.0\n 2.9\n 2.7\n 2.6\n TCO2\n 18\n 21\n 24\n 23\n 22\n Glucose\n 121\n 128\n 80\n 129\n 194\n 192\n Other labs: PT / PTT / INR:13.6/28.0/1.2, CK / CKMB /\n Troponin-T:214/3/0.07, ALT / AST:75/115, Alk Phos / T Bili:408/5.5,\n Amylase / Lipase:77/88, Differential-Neuts:84.3 %, Band:0.0 %,\n Lymph:9.3 %, Mono:1.7 %, Eos:4.3 %, D-dimer:6389 ng/mL, Fibrinogen:541\n mg/dL, Lactic Acid:2.6 mmol/L, Albumin:2.3 g/dL, LDH:312 IU/L, Ca++:8.6\n mg/dL, Mg++:2.0 mg/dL, PO4:2.7 mg/dL\n Assessment and Plan\n 28 year old male with a history of alcoholism presenting with acute\n hepatitis, pancreatitis, and UGIB, with persistent cyclic\n fevers/leukocytosis.\n # Cyclic fevers/leukocytosis\nlow grade temp to 100.4 overnight, but\n overall fever curve stable to improving. WBC trending down. Sputum\n with 4+ GNR likely colonizer, as per ID. U/A weakly positive; will\n follow cx. Weaning off abx and currently only on micafungin as pt has\n been cx negative. HD line cultured x 2 yesterday. Will follow\n remainder of cx.\n # Hypotension\n resolved, cont to monitor.\n # Respiratory failure\n on trach mask at 40% FIO2\n # Acute renal failure\n stable and UOP improving. Per renal, may be\n able to hold off HD and d/c HD line if UOP stays as such.\n # Altered mental status\n Given possibility of seizure activity, will\n continue keppra. MRI and EEG. Unclear how much of this is medication\n induced and how much is rehab correctable.\n # Hypernatremia\n - will calculate free water deficit and start free water boluses\n # Hematemesis: resolved. Given alcohol history, potential\n consideration for variceal bleed. No known prior history of hepatic\n cirrhosis, but elevated INR and fatty liver infilatration would be\n consistent. Also should consider PUD or alcoholic gastritis. Hct was\n WNL on presentation, but patient markedly contracted. Continued bright\n red blood on NG lavage suggests some degree of continued active\n bleeding.\n -- hepatology consulted, EGD showing diulefoy lesion\n -- access with 2 large bore IVs and a cordis, T + C x 3 units\n -- IV PPI + PPI gtt\n .\n # Pancreatitis: Most likely alcoholic in etiology, with elevated lipase\n to 1600 and CT findings consistent without necrosis, cycts, or\n phlemgon. Only mild epigastric tenderness and no complaints of\n abdominal pain.\n -- continue aggessive hydration\n -- serial abdominal exams\n -- trend lipase\n -- no evidence of obstruction, holding off on further imaging at this\n time\n -- cont post pyloric TF\n -- to hold off on any drainage of new peripancreatic fluid collection\n but will discuss with Dr \n # Acute Hepatitis: Likely alcoholic hepatitis. CT scan shows fatty\n infiltration, and no evidence of distal ostruction.\n - check viral hepatitis panel, although degree of transaminitis not\n consistant with such an etiology.\n - holding off on further imaging for now, f/u final CT read\n - hepatology following\n - avoid hepatically cleared meds\n - trend LFTs\n # Alcoholism: Patient describes history of withdrawal symptoms, but\n not prior seizure. Last drink was night prior to presentation.\n Tachycardia, weakness, and elevated lactate could be consistent with\n thiamine deficiency.\n - repleate thiamine, vb12, folate\n - ativan with CIWA > 10\n - addictions consult\n # FEN: IVF, replete electrolytes, NPO\n # Prophylaxis: scds, PPI gtt\n # Access: peripherals and femoral cortis\n # Code: Full Code\n # Disposition: MICU for now\n ICU Care\n Nutrition:\n Nutren 2.0 () - 01:27 PM 50 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 08:15 PM\n PICC Line - 08:37 AM\n Dialysis Catheter - 08:55 AM\n Prophylaxis:\n DVT: heparin\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: MICU for now, long term rehab\n" }, { "category": "Nursing", "chartdate": "2131-06-29 00:00:00.000", "description": "Nursing Progress Note", "row_id": 683648, "text": "Arousal, Attention, and Cognition, Impaired\n Assessment:\n Pt appearing more alert\n Tracking around room\n Attempted to mouth words X1\n No noted purposeful movements\n Flex/withdraws to pain\n Action:\n Cont stimulation\n Passive range of motion\n Response:\n Physical mobility unchanged\n Does appear more alert\n Plan:\n Cont with aggressive PT\n OOB to chair\n Encourage cont stimulation\n cont with rehab screening\n Family meeting today with MICU/Neurology Attending and\n family in Re: MRI and EEG results\n" }, { "category": "Physician ", "chartdate": "2131-06-29 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 683636, "text": "Chief Complaint:\n 24 Hour Events:\n EEG - At 08:30 AM\n FEVER - 101.3\nF - 12:00 PM\n \n - blood cultures x 2\n - renal: if UOP adequate and Cr stable, can pull HD line Fri\n - neuro - plan for family meeting tomorrow, MRI showed diffuse subacute\n anoxic injury\n Allergies:\n Meropenem\n skin blisters a\n Last dose of Antibiotics:\n Micafungin - 10:00 PM\n Infusions:\n Other ICU medications:\n Fentanyl - 08:30 AM\n Heparin Sodium (Prophylaxis) - 11:36 AM\n Famotidine (Pepcid) - 11:37 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 04:56 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.5\nC (101.3\n Tcurrent: 37.4\nC (99.4\n HR: 115 (110 - 125) bpm\n BP: 121/69(86) {106/61(76) - 148/77(100)} mmHg\n RR: 31 (23 - 42) insp/min\n SpO2: 97%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 103.9 kg (admission): 113.5 kg\n Height: 67 Inch\n Total In:\n 1,360 mL\n 306 mL\n PO:\n TF:\n 1,200 mL\n 246 mL\n IVF:\n 100 mL\n Blood products:\n Total out:\n 1,640 mL\n 100 mL\n Urine:\n 1,640 mL\n 100 mL\n NG:\n Stool:\n Drains:\n Balance:\n -280 mL\n 206 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n SpO2: 97%\n ABG: ///21/\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 266 K/uL\n 6.6 g/dL\n 98 mg/dL\n 2.1 mg/dL\n 21 mEq/L\n 3.4 mEq/L\n 90 mg/dL\n 113 mEq/L\n 146 mEq/L\n 21.7 %\n 11.4 K/uL\n [image002.jpg]\n 02:00 AM\n 02:49 AM\n 01:51 AM\n 03:26 PM\n 03:37 PM\n 03:15 AM\n 03:19 AM\n 10:00 AM\n 04:00 PM\n 02:16 AM\n WBC\n 15.0\n 12.6\n 10.2\n 11.4\n Hct\n 22.5\n 22.1\n 21.5\n 21.7\n Plt\n 66\n Cr\n 3.0\n 2.9\n 2.7\n 2.6\n 2.1\n TCO2\n 24\n 23\n 22\n Glucose\n 128\n 80\n 129\n 194\n 192\n 200\n 211\n 98\n Other labs: PT / PTT / INR:13.6/28.0/1.2, CK / CKMB /\n Troponin-T:214/3/0.07, ALT / AST:75/115, Alk Phos / T Bili:408/5.5,\n Amylase / Lipase:77/88, Differential-Neuts:84.3 %, Band:0.0 %,\n Lymph:9.3 %, Mono:1.7 %, Eos:4.3 %, D-dimer:6389 ng/mL, Fibrinogen:541\n mg/dL, Lactic Acid:2.6 mmol/L, Albumin:2.3 g/dL, LDH:312 IU/L, Ca++:8.6\n mg/dL, Mg++:1.9 mg/dL, PO4:2.3 mg/dL\n Assessment and Plan\n FEVER, UNKNOWN ORIGIN (FUO, HYPERTHERMIA, PYREXIA)\n AROUSAL, ATTENTION, AND COGNITION, IMPAIRED\n BALANCE, IMPAIRED\n MOTOR FUNCTION, IMPAIRED\n MUSCLE PERFORMACE, IMPAIRED\n RESPIRATION / GAS EXCHANGE, IMPAIRED\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n IMPAIRED SKIN INTEGRITY\n HEPATITIS, ACUTE TOXIC (INCLUDING ALCOHOLIC, ACETAMINOPHEN, ETC.)\n ICU Care\n Nutrition:\n Nutren 2.0 () - 01:27 PM 50 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 08:15 PM\n PICC Line - 08:37 AM\n Dialysis Catheter - 08:55 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:ICU\n" }, { "category": "Physician ", "chartdate": "2131-06-29 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 683637, "text": "Chief Complaint:\n 24 Hour Events:\n EEG - At 08:30 AM\n FEVER - 101.3\nF - 12:00 PM\n \n - blood cultures x 2\n - renal: if UOP adequate and Cr stable, can pull HD line Fri\n - neuro - plan for family meeting tomorrow, MRI showed diffuse subacute\n anoxic injury\n Allergies:\n Meropenem\n skin blisters a\n Last dose of Antibiotics:\n Micafungin - 10:00 PM\n Infusions:\n Other ICU medications:\n Fentanyl - 08:30 AM\n Heparin Sodium (Prophylaxis) - 11:36 AM\n Famotidine (Pepcid) - 11:37 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 04:56 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.5\nC (101.3\n Tcurrent: 37.4\nC (99.4\n HR: 115 (110 - 125) bpm\n BP: 121/69(86) {106/61(76) - 148/77(100)} mmHg\n RR: 31 (23 - 42) insp/min\n SpO2: 97%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 103.9 kg (admission): 113.5 kg\n Height: 67 Inch\n Total In:\n 1,360 mL\n 306 mL\n PO:\n TF:\n 1,200 mL\n 246 mL\n IVF:\n 100 mL\n Blood products:\n Total out:\n 1,640 mL\n 100 mL\n Urine:\n 1,640 mL\n 100 mL\n NG:\n Stool:\n Drains:\n Balance:\n -280 mL\n 206 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n SpO2: 97%\n ABG: ///21/\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 266 K/uL\n 6.6 g/dL\n 98 mg/dL\n 2.1 mg/dL\n 21 mEq/L\n 3.4 mEq/L\n 90 mg/dL\n 113 mEq/L\n 146 mEq/L\n 21.7 %\n 11.4 K/uL\n [image002.jpg]\n 02:00 AM\n 02:49 AM\n 01:51 AM\n 03:26 PM\n 03:37 PM\n 03:15 AM\n 03:19 AM\n 10:00 AM\n 04:00 PM\n 02:16 AM\n WBC\n 15.0\n 12.6\n 10.2\n 11.4\n Hct\n 22.5\n 22.1\n 21.5\n 21.7\n Plt\n 66\n Cr\n 3.0\n 2.9\n 2.7\n 2.6\n 2.1\n TCO2\n 24\n 23\n 22\n Glucose\n 128\n 80\n 129\n 194\n 192\n 200\n 211\n 98\n Other labs: PT / PTT / INR:13.6/28.0/1.2, CK / CKMB /\n Troponin-T:214/3/0.07, ALT / AST:75/115, Alk Phos / T Bili:408/5.5,\n Amylase / Lipase:77/88, Differential-Neuts:84.3 %, Band:0.0 %,\n Lymph:9.3 %, Mono:1.7 %, Eos:4.3 %, D-dimer:6389 ng/mL, Fibrinogen:541\n mg/dL, Lactic Acid:2.6 mmol/L, Albumin:2.3 g/dL, LDH:312 IU/L, Ca++:8.6\n mg/dL, Mg++:1.9 mg/dL, PO4:2.3 mg/dL\n Assessment and Plan\n FEVER, UNKNOWN ORIGIN (FUO, HYPERTHERMIA, PYREXIA)\n AROUSAL, ATTENTION, AND COGNITION, IMPAIRED\n BALANCE, IMPAIRED\n MOTOR FUNCTION, IMPAIRED\n MUSCLE PERFORMACE, IMPAIRED\n RESPIRATION / GAS EXCHANGE, IMPAIRED\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n IMPAIRED SKIN INTEGRITY\n HEPATITIS, ACUTE TOXIC (INCLUDING ALCOHOLIC, ACETAMINOPHEN, ETC.)\n 28 year old male with a history of alcoholism presenting with acute\n hepatitis, pancreatitis, and UGIB, with persistent cyclic\n fevers/leukocytosis.\n # Cyclic fevers/leukocytosis\n febrile to 101.2 overnight, but WBC\n trending down. Sputum with 4+ GNR likely colonizer, as per ID. Sputum\n consistency unchanged. CXR without overt pneumonia. C diff neg on\n . U/A weakly positive; cx showing 10k yeast. Weaning off abx and\n currently only on micafungin as pt has been cx negative. HD line\n cultured x 2 yesterday. Given temp , draw another set of\n blood cx and order CXR. Consider CT chest and Abx if clinically\n deteriorates. Other source lower on ddx includes peripancreatic fluid\n collection. Hesitant to re-do CT A/P given the contrast required.\n # Hypotension\n resolved, cont to monitor.\n # Respiratory failure\n on trach mask at 40% FIO2, tachypnic this AM.\n Will call thoracics re: position of trach (position seems low on cxr,\n marked on radiology report).\n # Acute renal failure\n stable and UOP improving (currently 30-60\n cc/hr). Per renal, hold off HD and d/c HD line Fri if UOP stays as\n such.\n # Altered mental status\n Given possibility of seizure activity, will\n continue keppra. MRI showing cerebral edema, poor prognosis as per\n neuro. EEG completed and report pending. Unclear how much of this is\n medication induced and how much is rehab correctable; would appreciate\n neuro recs regarding potential rehab.\n # Hyponatremia\n - correcting on free water boluses\n # Anemia\n stable. Will hold off transfusing given that pt currently\n febrile.\n # Hematemesis: resolved. Given alcohol history, potential\n consideration for variceal bleed. No known prior history of hepatic\n cirrhosis, but elevated INR and fatty liver infilatration would be\n consistent. Also should consider PUD or alcoholic gastritis. Hct was\n WNL on presentation, but patient markedly contracted. Continued bright\n red blood on NG lavage suggests some degree of continued active\n bleeding.\n -- hepatology consulted, EGD showing diulefoy lesion\n -- access with 2 large bore IVs and a cordis, T + C x 3 units\n -- IV PPI + PPI gtt\n .\n # Pancreatitis: Most likely alcoholic in etiology, with elevated lipase\n to 1600 and CT findings consistent without necrosis, cycts, or\n phlemgon. Only mild epigastric tenderness and no complaints of\n abdominal pain.\n -- continue aggessive hydration\n -- serial abdominal exams\n -- trend lipase\n -- no evidence of obstruction, holding off on further imaging at this\n time\n -- cont post pyloric TF\n -- to hold off on any drainage of new peripancreatic fluid collection\n but will discuss with Dr \n # Acute Hepatitis: Likely alcoholic hepatitis. CT scan shows fatty\n infiltration, and no evidence of distal ostruction.\n - check viral hepatitis panel, although degree of transaminitis not\n consistant with such an etiology.\n - holding off on further imaging for now, f/u final CT read\n - hepatology following\n - avoid hepatically cleared meds\n - trend LFTs\n # Alcoholism: Patient describes history of withdrawal symptoms, but\n not prior seizure. Last drink was night prior to presentation.\n Tachycardia, weakness, and elevated lactate could be consistent with\n thiamine deficiency.\n - repleate thiamine, vb12, folate\n - ativan with CIWA > 10\n - addictions consult\n # FEN: IVF, replete electrolytes, NPO\n ICU Care\n Nutrition:\n Nutren 2.0 () - 01:27 PM 50 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 08:15 PM\n PICC Line - 08:37 AM\n Dialysis Catheter - 08:55 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:ICU\n" }, { "category": "Respiratory ", "chartdate": "2131-06-29 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 683665, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 7\n Ideal body weight: 67.1 None\n Ideal tidal volume: 268.4 / 402.6 / 536.8 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Tube Type\n Tracheostomy tube:\n Type: Cuffed\n Manufacturer: Portex\n Size: 8.0mm\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Cuff volume: 7 mL /\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Clear\n Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount: Expectorated / Moderate\n Comments: has very good cough\n Ventilation Assessment\n Level of breathing assistance: Unassisted spontaneous breathing\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No claim of dyspnea)\n Plan\n Next 24-48 hours: continue on Trach mask and monitor secretions\n" }, { "category": "Physician ", "chartdate": "2131-06-20 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 681847, "text": "Chief Complaint:\n 24 Hour Events:\n NUCLEAR MEDICINE - At 09:57 AM\n INVASIVE VENTILATION - START 01:35 PM\n FEVER - 101.4\nF - 06:00 PM\n \n - Spiked fever to 101.4 and became hypotensive to 70/40 requiring\n pressors, but weaned off once he defervesced. He was put back on the\n vent for tachypnea and hypoxia 7.49/29/53.\n - CT abd/pelv ordered to visualize pancrease.\n - hopefully switch to HD, but pressures still low so unlikely\n - Methadone dose decreased\n Allergies:\n Meropenem\n skin blisters a\n Last dose of Antibiotics:\n Linezolid - 12:15 AM\n Aztreonam - 02:34 AM\n Metronidazole - 04:00 AM\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 12:14 AM\n Heparin Sodium (Prophylaxis) - 04:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:54 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.6\nC (101.4\n Tcurrent: 36.9\nC (98.5\n HR: 89 (89 - 119) bpm\n BP: 123/59(78) {78/43(56) - 128/73(94)} mmHg\n RR: 22 (20 - 35) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 100.4 kg (admission): 113.5 kg\n Height: 67 Inch\n Total In:\n 5,341 mL\n 828 mL\n PO:\n TF:\n 883 mL\n 195 mL\n IVF:\n 4,457 mL\n 633 mL\n Blood products:\n Total out:\n 3,487 mL\n 0 mL\n Urine:\n 135 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,854 mL\n 828 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 510 (428 - 6,000) mL\n PS : 5 cmH2O\n RR (Set): 16\n RR (Spontaneous): 21\n PEEP: 5 cmH2O\n FiO2: 60%\n RSBI: 57\n PIP: 16 cmH2O\n SpO2: 100%\n ABG: 7.41/35/146/22/-1\n Ve: 10.6 L/min\n PaO2 / FiO2: 243\n Physical Examination\n GEN: Trached, sedated.\n HEENT: Icteric sclera. MMM.\n NECK: Trach site with no oozing.\n LUNGS: Anterior auscultation with upper airway noise; good airway\n movement.\n HEART: RRR, normal S1, S2.\n ABD: Distended. Firm, but unchanged.\n EXTREM: 2+ edema, ulcers/lesions on legs with bandages C/D/I.\n SKIN: Jaundiced.\n NEURO: Twitching mouth. No purposeful movements today.\n Labs / Radiology\n 282 K/uL\n 7.3 g/dL\n 141 mg/dL\n 1.8 mg/dL\n 22 mEq/L\n 4.4 mEq/L\n 56 mg/dL\n 97 mEq/L\n 131 mEq/L\n 22.7 %\n 38.5 K/uL\n [image002.jpg]\n 10:56 PM\n 02:58 AM\n 03:10 AM\n 10:53 AM\n 12:57 PM\n 03:00 PM\n 10:13 PM\n 10:23 PM\n 03:00 AM\n 03:15 AM\n WBC\n 34.9\n 38.5\n Hct\n 24.6\n 22.7\n Plt\n 334\n 282\n Cr\n 0.6\n 1.2\n 1.8\n TCO2\n 26\n 27\n 23\n 22\n 18\n 25\n 23\n Glucose\n 151\n 114\n 121\n 140\n 135\n 141\n Other labs: PT / PTT / INR:15.0/33.3/1.3, CK / CKMB /\n Troponin-T:214/3/0.07, ALT / AST:204/226, Alk Phos / T Bili:446/20.1,\n Amylase / Lipase:77/68, Differential-Neuts:90.0 %, Band:0.0 %,\n Lymph:3.0 %, Mono:5.0 %, Eos:1.0 %, D-dimer:6389 ng/mL, Fibrinogen:502\n mg/dL, Lactic Acid:1.1 mmol/L, Albumin:2.0 g/dL, LDH:529 IU/L, Ca++:8.9\n mg/dL, Mg++:2.4 mg/dL, PO4:2.8 mg/dL\n CT ABD/PELVIS wet read:\n 1. large bore central catheter in RA. post-pyloric feeding tube at\n ligament\n of Treitz.\n 2. compared to CT , bibasilar consolidation little changed,\n likely\n atelectasis. round glass density of lungs slightly improved.\n 3. fatty liver w/focal sparing along GB fossa. high density in GB ?IV\n contrast\n or sludge.\n 4. continued evolution of areas of necrosis within the pancreas. new\n fluid\n collection anterior to superior segment of duodenum 5.6 x 2.9 cm\n (2:36), and\n along pancreatic uncinate 2.2 x 1.9 cm (2:44). Persistent attenuation\n of\n splenic vein; SMA, SMV, PV remain patent; no pseudoaneurysm seen.\n 5. Unchanged diffuse colonic bowel wall thickening for which an\n infectious\n etiology is not excluded.\n Assessment and Plan\n 28M with alcoholic hepatitis and necrotizing pancreatitis complicated\n by ARDS, SIRS, ARF, UGIB, fevers.\n #. ID: Persistent leukocytosis and fevers now that off CVVH. On\n aztreonam, linezolid (since ) and flagyl (since ). be \n pancreatitis.\n - Abd Ct with ?new abscess near pancreas. Will call rads for FR. If\n abscess will cls surgery for percutaneous drain.\n - consider add po vanc for cdiff colitis given persistent colonic\n inflammation on CT and high wbcs\n - UA with mod yeast persistent after multiple foley changes. Will\n consider anti-fungal but given liver function will likely need very low\n dose\n - Continue abx coverage with aztreo, flagyl, and linezolid given\n necrotizing pancreatitis.\n - F/u WBC count, temp curve, and culture data\n - diff with neutrophilia but no bands and no eos yesterday\n # Shock: Patient had transient pressor requirement last pm in setting\n of fever. When fever resolved pressor requirement did as well. Likely\n septic shock. Will treat for infection as above. If requires pressors\n without fever consider other etiologies of hypotension including\n cardiogenic.\n # Elevated LFTs: A/w alcoholic hepatitis. RUQ u/s showed sludge\n concerning for cholestasis but also seen on u/s. T Bili and\n transaminases improving today.\n - HIDA neg\n - TPN stopped \n - weaning off benzos\n #. Respiratory Failure: ARDS secondary to necrotizing pancreatitis. S/p\n trach placement on .\n - Cte fentanyl boluses and wean methadone as able today.\n - goal to chair daily\n # Seizures: CT head without intracranial process. EEG showed occipital\n seizures which does not correlate with clinical symptoms, but repeat\n EEG on higher dose Keppra showed no seizures. As patient now with\n purposeful movements, this may actually be patient waking up, not\n seizures.\n - Continue keppra (change dosing if changes to HD)\n - Wean valium\n #. Acute renal Failure: Multifactorial inc. ATN from hypotension\n - Was supposed to transition to HD today but may not tolerate given\n pressor req overnight during febrile episode. Will f/u renal recs today\n re:HD\n - Aztreonam 2000mg q12h while on CVVH. Change after aztreonam.\n - Will change Keppra to 1000mg Q24 with 500 mg after HD if able to\n tolerate HD today\n #. Adrenal Insufficiency: Unclear with stim if clear adrenal\n insufficiency but hypotension improving with steroids (lower pressor\n requirement) and eosinophilia resolved.\n - Cont weaning hydrocort; D2/3 on 12.5mg hydrocort. Taper tomorrow.\n ICU Care\n Nutrition:\n Nutren 2.0 () - 02:00 AM 50 mL/hour\n Glycemic Control: ISS\n Lines:\n Arterial Line - 08:15 PM\n PICC Line - 08:37 AM\n Dialysis Catheter - 08:55 AM\n Prophylaxis:\n DVT: hep sc\n Stress ulcer: famotidine\n VAP:\n Comments:\n Communication: Comments: with brother\n status: Full code\n Disposition: ICU\n" }, { "category": "Physician ", "chartdate": "2131-06-20 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 681874, "text": "Chief Complaint:\n 24 Hour Events:\n NUCLEAR MEDICINE - At 09:57 AM\n INVASIVE VENTILATION - START 01:35 PM\n FEVER - 101.4\nF - 06:00 PM\n - Methadone dose decreased.\n - Spiked fever to 101.4 and became hypotensive to 70/40 requiring\n pressors, but weaned off once he defervesced. He was put back on the\n vent for tachypnea and hypoxia with ABG 7.49/29/53. CT abd/pelvis done\n to evaluate pancreas.\n - Unable to switch to HD due to continued low pressures yesterday.\n Allergies:\n Meropenem\n skin blisters a\n Last dose of Antibiotics:\n Linezolid - 12:15 AM\n Aztreonam - 02:34 AM\n Metronidazole - 04:00 AM\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 12:14 AM\n Heparin Sodium (Prophylaxis) - 04:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:54 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.6\nC (101.4\n Tcurrent: 36.9\nC (98.5\n HR: 89 (89 - 119) bpm\n BP: 123/59(78) {78/43(56) - 128/73(94)} mmHg\n RR: 22 (20 - 35) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 100.4 kg (admission): 113.5 kg\n Height: 67 Inch\n Total In:\n 5,341 mL\n 828 mL\n PO:\n TF:\n 883 mL\n 195 mL\n IVF:\n 4,457 mL\n 633 mL\n Blood products:\n Total out:\n 3,487 mL\n 0 mL\n Urine:\n 135 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,854 mL\n 828 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 510 (428 - 6,000) mL\n PS : 5 cmH2O\n RR (Set): 16\n RR (Spontaneous): 21\n PEEP: 5 cmH2O\n FiO2: 60%\n RSBI: 57\n PIP: 16 cmH2O\n SpO2: 100%\n ABG: 7.41/35/146/22/-1\n Ve: 10.6 L/min\n PaO2 / FiO2: 243\n Physical Examination\n GEN: Trached.\n HEENT: Icteric sclera. MMM.\n NECK: Trach site with no oozing.\n LUNGS: Anterior auscultation with upper airway noise; good airway\n movement.\n HEART: RRR, normal S1, S2.\n ABD: Distended. Firm, but unchanged.\n EXTREM: 2+ edema, ulcers/lesions on legs with bandages C/D/I.\n SKIN: Jaundiced.\n NEURO: Twitching mouth. Opens eyes, squeezes hand to command.\n Labs / Radiology\n 282 K/uL\n 7.3 g/dL\n 141 mg/dL\n 1.8 mg/dL\n 22 mEq/L\n 4.4 mEq/L\n 56 mg/dL\n 97 mEq/L\n 131 mEq/L\n 22.7 %\n 38.5 K/uL\n [image002.jpg]\n 10:56 PM\n 02:58 AM\n 03:10 AM\n 10:53 AM\n 12:57 PM\n 03:00 PM\n 10:13 PM\n 10:23 PM\n 03:00 AM\n 03:15 AM\n WBC\n 34.9\n 38.5\n Hct\n 24.6\n 22.7\n Plt\n 334\n 282\n Cr\n 0.6\n 1.2\n 1.8\n TCO2\n 26\n 27\n 23\n 22\n 18\n 25\n 23\n Glucose\n 151\n 114\n 121\n 140\n 135\n 141\n Other labs: PT / PTT / INR:15.0/33.3/1.3, CK / CKMB /\n Troponin-T:214/3/0.07, ALT / AST:204/226, Alk Phos / T Bili:446/20.1,\n Amylase / Lipase:77/68, Differential-Neuts:90.0 %, Band:0.0 %,\n Lymph:3.0 %, Mono:5.0 %, Eos:1.0 %, D-dimer:6389 ng/mL, Fibrinogen:502\n mg/dL, Lactic Acid:1.1 mmol/L, Albumin:2.0 g/dL, LDH:529 IU/L, Ca++:8.9\n mg/dL, Mg++:2.4 mg/dL, PO4:2.8 mg/dL\n CT ABD/PELVIS wet read:\n 1. large bore central catheter in RA. post-pyloric feeding tube at\n ligament of Treitz\n 2. compared to CT , bibasilar consolidation little changed,\n likely atelectasis. round glass density of lungs slightly improved.\n 3. fatty liver w/focal sparing along GB fossa. high density in GB ?IV\n contrast or sludge.\n 4. continued evolution of areas of necrosis within the pancreas. new\n fluid collection anterior to superior segment of duodenum 5.6 x 2.9 cm\n (2:36), and along pancreatic uncinate 2.2 x 1.9 cm (2:44). Persistent\n attenuation of splenic vein; SMA, SMV, PV remain patent; no\n pseudoaneurysm seen. 5. Unchanged diffuse colonic bowel wall thickening\n for which an infectious etiology is not excluded.\n Assessment and Plan\n 28M with alcoholic hepatitis and necrotizing pancreatitis complicated\n by ARDS, SIRS, ARF, UGIB, fevers.\n #. ID: Persistent leukocytosis and fevers now that off CVVH. On\n aztreonam, linezolid (since ) and flagyl (since ). Likely to\n have continued fevers necrotizing pancreatitis.\n - Abd CT with ?new abscess near pancreas. F/u final read but reviewed\n by Surgery with no role for surgical intervention\n - Given necrotizing pancreatitis and UA with mod yeast persistent after\n multiple foley changes, will restart anti-fungal but given liver\n function will likely need very low dose\n - Continue abx coverage with aztreo, flagyl, and linezolid given\n necrotizing pancreatitis.\n - Consider add po vanc for cdiff colitis given persistent colonic\n inflammation on CT and high wbcs\n - F/u WBC count, temp curve, and culture data\n - Diff with neutrophilia but no bands and no eos yesterday\n .\n # Shock: Patient had transient pressor requirement last pm in setting\n of fever. When fever resolved pressor requirement did as well. Likely\n septic shock. Will treat for infection as above. If requires pressors\n without fever consider other etiologies of hypotension including\n cardiogenic.\n - Cont weaning steroids\n .\n # Elevated LFTs: A/w alcoholic hepatitis. RUQ u/s showed sludge\n concerning for cholestasis but also seen on u/s. T Bili and\n transaminases improving today.\n - HIDA neg\n - TPN stopped \n - weaning off benzos\n #. Respiratory Failure: ARDS secondary to necrotizing pancreatitis. S/p\n trach placement on .\n - Cte fentanyl boluses and alternatingly wean methadone and valium as\n tolerate.\n - Cte OOB to chair daily\n #. Acute renal Failure: Multifactorial inc. ATN from hypotension\n - Was supposed to transition to HD today but pressures not able to\n tolerate. No need for filtration so will reassess tmrw.\n - Aztreonam 2000mg q12h while on CVVH. Change after aztreonam.\n - Will change Keppra to 1000mg Q24 with 500 mg after HD when able to\n tolerate HD\n #. Adrenal Insufficiency: Unclear with stim if clear adrenal\n insufficiency but hypotension improving with steroids (lower pressor\n requirement) and eosinophilia resolved.\n - Cont weaning hydrocort to q12h today\n # Seizures: CT head without intracranial process. EEG showed occipital\n seizures which does not correlate with clinical symptoms, but repeat\n EEG on higher dose Keppra showed no seizures. As patient now with\n purposeful movements, this may actually be patient waking up, not\n seizures.\n - Continue keppra (change dosing if changes to HD)\n - Wean valium today\n ICU Care\n Nutrition:\n Nutren 2.0 () - 02:00 AM 50 mL/hour\n Glycemic Control: ISS\n Lines:\n Arterial Line - 08:15 PM\n PICC Line - 08:37 AM\n Dialysis Catheter - 08:55 AM\n Prophylaxis:\n DVT: hep sc\n Stress ulcer: famotidine\n VAP:\n Comments:\n Communication: Comments: with brother\n status: Full code\n Disposition: ICU pending HD trial ; in screening process.\n" }, { "category": "Physician ", "chartdate": "2131-07-03 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 684671, "text": "Chief Complaint: resp 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 tachypnea\n req suctioning\n Allergies:\n Meropenem\n skin blisters a\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 07:54 PM\n Other medications:\n Diazepam\n Tylenol\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 11:48 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.3\nC (100.9\n Tcurrent: 38.1\nC (100.5\n HR: 125 (111 - 127) bpm\n BP: 123/65(78) {106/54(74) - 138/106(113)} mmHg\n RR: 43 (28 - 57) insp/min\n SpO2: 98%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 99.5 kg (admission): 113.5 kg\n Height: 67 Inch\n Total In:\n 4,550 mL\n 2,439 mL\n PO:\n TF:\n 1,200 mL\n 589 mL\n IVF:\n 1,100 mL\n 1,100 mL\n Blood products:\n Total out:\n 750 mL\n 1,200 mL\n Urine:\n 750 mL\n 1,200 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,800 mL\n 1,239 mL\n Respiratory support\n O2 Delivery Device: Aerosol-cool\n SpO2: 98%\n ABG: ///18/\n Physical Examination\n Gen: lying in bed, tachypneic pink frothy secretions\n CV: RR\n Chest: coarse bs bilat\n Abd soft +BS\n Ext: 1+ edema\n Neuro: eyes open, slightly tremulous\n Labs / Radiology\n 6.7 g/dL\n 341 K/uL\n 147 mg/dL\n 1.1 mg/dL\n 18 mEq/L\n 4.7 mEq/L\n 61 mg/dL\n 120 mEq/L\n 147 mEq/L\n 22.1 %\n 11.1 K/uL\n [image002.jpg]\n 02:16 AM\n 04:14 PM\n 10:00 PM\n 02:32 AM\n 04:25 AM\n 03:56 PM\n 02:32 AM\n 08:00 PM\n 12:35 AM\n 03:21 AM\n WBC\n 11.4\n 10.9\n 11.0\n 10.5\n 11.1\n Hct\n 21.7\n 22.2\n 22.5\n 22.3\n 22.1\n Plt\n 266\n 290\n 310\n 327\n 341\n Cr\n 2.1\n 2.0\n 1.9\n 1.6\n 1.3\n 1.2\n 1.2\n 1.1\n TCO2\n 20\n Glucose\n 98\n 151\n 177\n 116\n 161\n 97\n 93\n 147\n Other labs: PT / PTT / INR:13.6/28.0/1.2, CK / CKMB /\n Troponin-T:214/3/0.07, ALT / AST:91/137, Alk Phos / T Bili:318/4.1,\n Amylase / Lipase:78/91, Differential-Neuts:57.0 %, Band:4.0 %,\n Lymph:23.0 %, Mono:4.0 %, Eos:3.0 %, D-dimer:6389 ng/mL, Fibrinogen:541\n mg/dL, Lactic Acid:2.6 mmol/L, Albumin:2.3 g/dL, LDH:437 IU/L, Ca++:9.2\n mg/dL, Mg++:1.8 mg/dL, PO4:4.2 mg/dL\n Assessment and Plan\n FEVER, UNKNOWN ORIGIN (FUO, HYPERTHERMIA, PYREXIA)\n AROUSAL, ATTENTION, AND COGNITION, IMPAIRED\n BALANCE, IMPAIRED\n MOTOR FUNCTION, IMPAIRED\n MUSCLE PERFORMACE, IMPAIRED\n RESPIRATION / GAS EXCHANGE, IMPAIRED\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n IMPAIRED SKIN INTEGRITY\n HEPATITIS, ACUTE TOXIC (INCLUDING ALCOHOLIC, ACETAMINOPHEN, ETC.)\n 1. Cyclical fevers: stable off all ABX, CXR is improved and\n no focal sources. Overall stable WBC and this could be central. Should\n he spike and leukocytosis will pan cx, consider repeat abd imaging.\n 2. Resp Failure: today with increased frothy pink sputum, ?\n volume overload. Will RX lasix, stat CXR, positive pressure if need\n be. Would repeat echo since he has been persistenyl tachy and could\n have cardiomyopathy\n no echo since \n 3. Altered Mental status: MRI with concerning anoxic feautures\n and prognosis from Dr was he could improve slightly but\n unlikely to recover dramatically. Family would like 2^nd opinion and we\n will contact Dr who had seen him previously.\n 4. For ARF: off HD, watching UOP\n Remaining issues as per Housestaff\n ICU Care\n Nutrition: Nutren 2.0 () - 12:28 PM 50 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 08:37 AM\n Prophylaxis:\n DVT: sc hep\n Stress ulcer: PPI\n VAP: HOB chlorhex\n Communication: met with brother and pt they would like a 2^nd\n opinion from neuro - we will arrange today\n Code status: Full code\n Disposition :ICU\n Total time spent: 35\n" }, { "category": "Rehab Services", "chartdate": "2131-06-28 00:00:00.000", "description": "Physical Therapy Progress Note", "row_id": 683573, "text": "Subjective:\n Objective:\n Follow up PT visit to address goals of: . Patient seen today\n for balance training\n Updated medical status: MR head - Findings consistent with subacute\n anoxic brain injury. There is diffuse edema seen involving the cortical\n ribbon and basal ganglia\n Activity\n Clarification\n I\n S\n CG\n Min\n Mod\n Max\n Rolling:\n\n\n\n\n\n Supine/\n Sidelying to Sit:\n\n\n\n\n T\n Transfer:\n\n\n\n\n\n Sit to Stand:\n\n\n\n\n\n Ambulation:\n\n\n\n\n\n Stairs:\n\n\n\n\n\n Aerobic Activity Response:\n Position\n HR\n BP\n RR\n O[2] sat\n RPE\n Rest\n Sit\n 115\n 124/70\n 100% on TM\n Activity\n Sit\n 120\n 140/73\n 95% on TM\n Recovery\n /\n Total distance walked:\n Minutes:\n Gait: not assessed\n Balance: able to maintain static sitting at edge of bed with CG x10\n minutes with and without UE support. Min A dynamic sitting activities.\n Education / Communication: Reviewed PT with patient and his\n brother. Communicated with nsg re: status.\n Other: Following 15-10% of simple commands: hand squeeze and release,\n purposeful reaching with B UE's, tracking in all directions and\n maintaining eye contact for up to 5 seconds.\n Mod intention tremor with B UE/LE's.\n No active movement in LE's, but initiates movement with trunk.\n On trach mask at 40% FIO2, strong coughing, productive of mod amt thick\n secretions.\n Assessment: 28 yo M with acute pancreatitis making daily small gains in\n PT, today able to follow several simple commands and initiate\n purposeful movement/reaching on commands with B UE's. He continues to\n be well below his baseline and is limited by significant\n myopathy/myoclonus, would continue to recommend rehab, and because he\n is now making daily gains, would recommend acute rehab. PT to continue\n to follow-up daily to progress as able.\n Anticipated Discharge: Rehab\n Plan: continue with \n" }, { "category": "Respiratory ", "chartdate": "2131-06-28 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 683574, "text": "Airway\n Tracheostomy tube:\n Type: Standard\n Manufacturer: Portex\n Size: 8.0mm\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Cuff volume: 7 mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Clear\n Comments:\n Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount: Suctioned / Scant\n Comments: pt has strong productive cough this am secretions were blood\n tinged in color\n Ventilation Assessment\n Level of breathing assistance: Unassisted spontaneous breathing\n Visual assessment of breathing pattern: Tachypneic (RR> 35 b/min);\n Comments: pt remains on TM all shift satting >95% though he was\n tachypnic possibly due to fevers\n Plan\n Next 24-48 hours: plan to continue TM as tolerated\n" }, { "category": "Physician ", "chartdate": "2131-06-29 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 683748, "text": "Chief Complaint:\n 24 Hour Events:\n EEG - At 08:30 AM\n FEVER - 101.3\nF - 12:00 PM\n \n - blood cultures x 2\n - renal: if UOP adequate and Cr stable, can pull HD line Fri\n - neuro - plan for family meeting tomorrow, MRI showed diffuse subacute\n anoxic injury\n Allergies:\n Meropenem\n skin blisters a\n Last dose of Antibiotics:\n Micafungin - 10:00 PM\n Infusions:\n Other ICU medications:\n Fentanyl - 08:30 AM\n Heparin Sodium (Prophylaxis) - 11:36 AM\n Famotidine (Pepcid) - 11:37 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 04:56 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.5\nC (101.3\n Tcurrent: 37.4\nC (99.4\n HR: 115 (110 - 125) bpm\n BP: 121/69(86) {106/61(76) - 148/77(100)} mmHg\n RR: 31 (23 - 42) insp/min\n SpO2: 97%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 103.9 kg (admission): 113.5 kg\n Height: 67 Inch\n Total In:\n 1,360 mL\n 306 mL\n PO:\n TF:\n 1,200 mL\n 246 mL\n IVF:\n 100 mL\n Blood products:\n Total out:\n 1,640 mL\n 100 mL\n Urine:\n 1,640 mL\n 100 mL\n NG:\n Stool:\n Drains:\n Balance:\n -280 mL\n 206 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n SpO2: 97%\n ABG: ///21/\n Physical Examination\n Gen: in bed, eyes open, alert but very tachypneic\n CV: RR nl s1/s2\n Chest: good air movement\n Abd: distended +BS\n Ext: 3+ edema\n Neuro: eyes open, will blink/ to command, weak grasp\n Labs / Radiology\n 266 K/uL\n 6.6 g/dL\n 98 mg/dL\n 2.1 mg/dL\n 21 mEq/L\n 3.4 mEq/L\n 90 mg/dL\n 113 mEq/L\n 146 mEq/L\n 21.7 %\n 11.4 K/uL\n [image002.jpg]\n 02:00 AM\n 02:49 AM\n 01:51 AM\n 03:26 PM\n 03:37 PM\n 03:15 AM\n 03:19 AM\n 10:00 AM\n 04:00 PM\n 02:16 AM\n WBC\n 15.0\n 12.6\n 10.2\n 11.4\n Hct\n 22.5\n 22.1\n 21.5\n 21.7\n Plt\n 66\n Cr\n 3.0\n 2.9\n 2.7\n 2.6\n 2.1\n TCO2\n 24\n 23\n 22\n Glucose\n 128\n 80\n 129\n 194\n 192\n 200\n 211\n 98\n Other labs: PT / PTT / INR:13.6/28.0/1.2, CK / CKMB /\n Troponin-T:214/3/0.07, ALT / AST:75/115, Alk Phos / T Bili:408/5.5,\n Amylase / Lipase:77/88, Differential-Neuts:84.3 %, Band:0.0 %,\n Lymph:9.3 %, Mono:1.7 %, Eos:4.3 %, D-dimer:6389 ng/mL, Fibrinogen:541\n mg/dL, Lactic Acid:2.6 mmol/L, Albumin:2.3 g/dL, LDH:312 IU/L, Ca++:8.6\n mg/dL, Mg++:1.9 mg/dL, PO4:2.3 mg/dL\n Assessment and Plan\n 28 year old male with a history of alcoholism presenting with acute\n hepatitis, pancreatitis, and UGIB, with persistent cyclic\n fevers/leukocytosis.\n # Cyclic fevers/leukocytosis\n febrile to 101.3 yesterday AM, but WBC\n continues trending down. Sputum with 4+ GNR likely colonizer, as per\n ID, and sputum consistency remains unchanged. CXR without obvious\n pneumonia. C diff neg on . U/A weakly positive; cx showing 10k\n yeast. On micafungin as pt has been cx negative. Other source lower\n on ddx includes peripancreatic fluid collection.\n -ID recs CT abd to eval peripancreatic collection.\n -D/C a-line and HD line\n -Will not start gancyclovir as CMV not likely cause of fevers, but will\n follow LFTs and if rising will see if correlates with CMV viral load.\n If correlation will will discuss starting gancyclovir with ID and\n renal.\n -Will continue micofungin but will discuss plan with ID. Likely\n continue for 2 weeks and CT at that time. Will need to discuss\n criteria for d/cing micofungin with /ID.\n # Respiratory failure\n on trach mask at 40% FIO2, tachypnic this AM.\n -Tachypnea may be centrally driven cerebral injury\n # Acute renal failure\n stable and UOP improving (currently >60 cc/hr\n over last 24hrs.).\n -After renal sees Pt today will likely d/c HD line.\n -Cont. to follow UOP\n # Altered mental status\n Given possibility of seizure activity, will\n continue keppra. MRI showing cerebral edema, poor prognosis as per\n neuro. EEG completed and report pending. Unclear how much of this is\n medication induced and how much is rehab correctable; would appreciate\n neuro recs regarding potential rehab.\n -Family meeting today with Neuro to discuss\n -Will need neuron rehab.\n # Hyponatremia\n - Correcting. Will start free water boluses to prevent overcorrection.\n # Anemia\n stable. Will hold off transfusing and cont to follow.\n # Acute Hepatitis: Likely alcoholic hepatitis. CT scan shows fatty\n infiltration, and no evidence of distal ostruction.\n - trend LFTs\n - Will correlate LFTs with CMV viral load if they continue to rise.\n -If CMV likely cause may need to start gancyclovir however as this is\n nephrotoxic will need to discuss with ID/Renal\n # FEN: IVF, replete electrolytes, NPO\n ICU Care\n Nutrition: Nutren 2.0 () - 01:27 PM 50 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 08:15 PM\n PICC Line - 08:37 AM\n Dialysis Catheter - 08:55 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:ICU\n" }, { "category": "Physician ", "chartdate": "2131-06-30 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 683913, "text": "Chief Complaint:\n 24 Hour Events:\n - d/c'ed micafungin as per ID, as unclear if helping or not. Will see\n how he does off micafungin over weekend, if doing poorly, consider\n further imaging prior to Monday.\n - Dr. will email Dr. to ensure that micafungin plan\n is okay.\n - CMV VL ordered 5 days from now, as per ID\n - neurology had sobering and extensive discussion with family re: poor\n prognosis and long term plan\n - will tolerate low grade temps given lack of source and known necrotic\n pancreas\n - K and phos repleted and look fine\n - HD line and a line d/c'ed\n - will d/c foley and try condom cath\n Allergies:\n Meropenem\n skin blisters a\n Last dose of Antibiotics:\n Micafungin - 10:00 PM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 04:30 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:52 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.6\nC (101.5\n Tcurrent: 38.2\nC (100.7\n HR: 115 (114 - 124) bpm\n BP: 123/53(69) {93/39(56) - 144/119(123)} mmHg\n RR: 34 (29 - 40) insp/min\n SpO2: 99%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 103.3 kg (admission): 113.5 kg\n Height: 67 Inch\n Total In:\n 1,964 mL\n 543 mL\n PO:\n TF:\n 1,204 mL\n 293 mL\n IVF:\n 200 mL\n Blood products:\n Total out:\n 1,375 mL\n 460 mL\n Urine:\n 1,375 mL\n 460 mL\n NG:\n Stool:\n Drains:\n Balance:\n 589 mL\n 83 mL\n Respiratory support\n O2 Delivery Device: Trach mask , Tracheostomy tube\n SpO2: 99%\n ABG: ///22/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 290 K/uL\n 6.5 g/dL\n 116 mg/dL\n 1.9 mg/dL\n 22 mEq/L\n 3.8 mEq/L\n 91 mg/dL\n 117 mEq/L\n 148 mEq/L\n 22.2 %\n 10.9 K/uL\n [image002.jpg]\n 03:26 PM\n 03:37 PM\n 03:15 AM\n 03:19 AM\n 10:00 AM\n 04:00 PM\n 02:16 AM\n 04:14 PM\n 10:00 PM\n 02:32 AM\n WBC\n 10.2\n 11.4\n 10.9\n Hct\n 21.5\n 21.7\n 22.2\n Plt\n 227\n 266\n 290\n Cr\n 2.7\n 2.6\n 2.1\n 2.0\n 1.9\n TCO2\n 23\n 22\n Glucose\n 129\n 194\n 192\n 200\n 7\n 116\n Other labs: PT / PTT / INR:13.6/28.0/1.2, CK / CKMB /\n Troponin-T:214/3/0.07, ALT / AST:88/136, Alk Phos / T Bili:341/4.7,\n Amylase / Lipase:102/114, Differential-Neuts:57.0 %, Band:4.0 %,\n Lymph:23.0 %, Mono:4.0 %, Eos:3.0 %, D-dimer:6389 ng/mL, Fibrinogen:541\n mg/dL, Lactic Acid:2.6 mmol/L, Albumin:2.3 g/dL, LDH:312 IU/L, Ca++:9.0\n mg/dL, Mg++:2.0 mg/dL, PO4:3.4 mg/dL\n Assessment and Plan\n 28 year old male with a history of alcoholism presenting with acute\n hepatitis, pancreatitis, and UGIB, with persistent cyclic\n fevers/leukocytosis.\n # Cyclic fevers/leukocytosis\n febrile to 101.5 yesterday AM, but WBC\n continues trending down. Sputum with 4+ GNR likely colonizer, as per\n ID, and sputum consistency remains unchanged. CXR without obvious\n pneumonia. C diff neg on . U/A weakly positive; cx showing 10k\n yeast. On micafungin as pt has been cx negative. Other source lower\n on ddx includes peripancreatic fluid collection.\n -ID recs CT abd to eval peripancreatic collection.\n -D/C a-line and HD line\n -Will not start gancyclovir as CMV not likely cause of fevers, but will\n follow LFTs and if rising will see if correlates with CMV viral load.\n If correlation will will discuss starting gancyclovir with ID and\n renal.\n -Will continue micofungin but will discuss plan with ID. Likely\n continue for 2 weeks and CT at that time. Will need to discuss\n criteria for d/cing micofungin with /ID.\n # Respiratory failure\n on trach mask at 40% FIO2, tachypnic this AM.\n -Tachypnea may be centrally driven cerebral injury\n # Acute renal failure\n stable and UOP improving (currently >60 cc/hr\n over last 24hrs.).\n -After renal sees Pt today will likely d/c HD line.\n -Cont. to follow UOP\n # Altered mental status\n Given possibility of seizure activity, will\n continue keppra. MRI showing cerebral edema, poor prognosis as per\n neuro. EEG completed and report pending. Unclear how much of this is\n medication induced and how much is rehab correctable; would appreciate\n neuro recs regarding potential rehab.\n -Family meeting today with Neuro to discuss\n -Will need neuron rehab.\n # Hyponatremia\n - Correcting. Will start free water boluses to prevent overcorrection.\n # Anemia\n stable. Will hold off transfusing and cont to follow.\n # Acute Hepatitis: Likely alcoholic hepatitis. CT scan shows fatty\n infiltration, and no evidence of distal ostruction.\n - trend LFTs\n - Will correlate LFTs with CMV viral load if they continue to rise.\n -If CMV likely cause may need to start gancyclovir however as this is\n nephrotoxic will need to discuss with ID/Renal\n # FEN: IVF, replete electrolytes, NPO\n ICU Care\n Nutrition:\n Nutren 2.0 () - 01:18 PM 50 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 08:37 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": "2131-06-30 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 683923, "text": "Chief Complaint:\n 24 Hour Events:\n - d/c'ed micafungin as per ID, as unclear if helping or not. Will see\n how he does off micafungin over weekend, if doing poorly, consider\n further imaging prior to Monday.\n - Dr. will email Dr. to ensure that micafungin plan\n is okay.\n - CMV VL ordered 5 days from now, as per ID\n - neurology had sobering and extensive discussion with family re: poor\n prognosis and long term plan\n - will tolerate low grade temps given lack of source and known necrotic\n pancreas\n - K and phos repleted and look fine\n - HD line and a line d/c'ed\n - will d/c foley and try condom cath\n Allergies:\n Meropenem\n skin blisters a\n Last dose of Antibiotics:\n Micafungin - 10:00 PM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 04:30 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:52 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.6\nC (101.5\n Tcurrent: 38.2\nC (100.7\n HR: 115 (114 - 124) bpm\n BP: 123/53(69) {93/39(56) - 144/119(123)} mmHg\n RR: 34 (29 - 40) insp/min\n SpO2: 99%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 103.3 kg (admission): 113.5 kg\n Height: 67 Inch\n Total In:\n 1,964 mL\n 543 mL\n PO:\n TF:\n 1,204 mL\n 293 mL\n IVF:\n 200 mL\n Blood products:\n Total out:\n 1,375 mL\n 460 mL\n Urine:\n 1,375 mL\n 460 mL\n NG:\n Stool:\n Drains:\n Balance:\n 589 mL\n 83 mL\n Respiratory support\n O2 Delivery Device: Trach mask , Tracheostomy tube\n SpO2: 99%\n ABG: ///22/\n Physical Examination\n General: Alert, NAD\n HEENT: markedly MMM\n Neck: supple, unable to assess JVP 2/2 edema, no LAD\n Lungs: Coarse upper airway sounds transmitted throughout. No\n rales/wheezes.\n CV: tachycardic with normal rhytyhm, normal S1 + S2, no murmurs, rubs,\n gallops\n Abdomen: soft/NT/ND/NABS, no organomegaly\n Ext: Warm, well perfused, 2+ pulses, no clubbing. 3+ edema.\n Labs / Radiology\n 290 K/uL\n 6.5 g/dL\n 116 mg/dL\n 1.9 mg/dL\n 22 mEq/L\n 3.8 mEq/L\n 91 mg/dL\n 117 mEq/L\n 148 mEq/L\n 22.2 %\n 10.9 K/uL\n [image002.jpg]\n 03:26 PM\n 03:37 PM\n 03:15 AM\n 03:19 AM\n 10:00 AM\n 04:00 PM\n 02:16 AM\n 04:14 PM\n 10:00 PM\n 02:32 AM\n WBC\n 10.2\n 11.4\n 10.9\n Hct\n 21.5\n 21.7\n 22.2\n Plt\n 227\n 266\n 290\n Cr\n 2.7\n 2.6\n 2.1\n 2.0\n 1.9\n TCO2\n 23\n 22\n Glucose\n 129\n 194\n 192\n 200\n 7\n 116\n Other labs: PT / PTT / INR:13.6/28.0/1.2, CK / CKMB /\n Troponin-T:214/3/0.07, ALT / AST:88/136, Alk Phos / T Bili:341/4.7,\n Amylase / Lipase:102/114, Differential-Neuts:57.0 %, Band:4.0 %,\n Lymph:23.0 %, Mono:4.0 %, Eos:3.0 %, D-dimer:6389 ng/mL, Fibrinogen:541\n mg/dL, Lactic Acid:2.6 mmol/L, Albumin:2.3 g/dL, LDH:312 IU/L, Ca++:9.0\n mg/dL, Mg++:2.0 mg/dL, PO4:3.4 mg/dL\n Assessment and Plan\n 28 year old male with a history of alcoholism presenting with acute\n hepatitis, pancreatitis, and UGIB, with persistent cyclic\n fevers/leukocytosis.\n # Cyclic fevers/leukocytosis\n febrile to 101.5 yesterday AM, but WBC\n continues trending down. Sputum with 4+ GNR likely colonizer, as per\n ID, and sputum consistency remains unchanged. CXR from without\n obvious pneumonia. C diff neg on . U/A weakly positive; cx\n showing 10k yeast. Other source lower on ddx includes peripancreatic\n fluid collection and central fevers.\n -ID recs CT abd to eval peripancreatic collection.\n -D/C a-line and HD line yesterday\n -Will not start gancyclovir as CMV not likely cause of fevers, but will\n follow LFTs and if rising will see if correlates with CMV viral load.\n If correlation will will discuss starting gancyclovir with ID and\n renal.\n # Respiratory failure\n on trach mask at 40% FIO2, tachypnic this AM.\n -Tachypnea may be centrally driven cerebral injury\n # Acute renal failure\n stable and UOP continues improving (currently\n ~60 cc/hr over last 24hrs.).\n -Cont. to follow UOP\n -Will follow Na as may over correct with return of function.\n # Altered mental status\n Given possibility of seizure activity, will\n continue keppra. MRI showing cerebral edema, poor prognosis as per\n neuro. EEG shows encephalopathy. Family meeting with Neuro\n yesterday. Full recovery to baseline unlikely, and longterm meaningful\n survival low due to cerebral injury. .\n -Family meeting today with Neuro to discuss\n -Will need neuro\n # Anemia\n Hctstable. Will hold off transfusing and cont to follow.\n # Acute Hepatitis: Likely alcoholic hepatitis. CT scan shows fatty\n infiltration, and no evidence of distal ostruction.\n - Continue to trend LFTs\n - Will correlate LFTs with CMV viral load if they continue to rise.\n -If CMV likely cause may need to start gancyclovir however as this is\n nephrotoxic will need to discuss with ID/Renal\n # FEN: IVF, replete electrolytes, NPO\n ICU Care\n Nutrition:\n Nutren 2.0 () - 01:18 PM 50 mL/hour\n Glycemic Control: SSI/Lantus\n Lines:\n PICC Line - 08:37 AM\n Prophylaxis:\n DVT: Heparin\n Stress ulcer: H2\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2131-06-30 00:00:00.000", "description": "Nursing Progress Note", "row_id": 683928, "text": "TITLE:\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n ARF resolving. Sodium rising. Continues to make > 30cc/hr urine,\n becoming less icteric.\n Action:\n Free water boluses q6h-250cc per ppft.\n Response:\n Na+ improving with free water boluses. Continues to make adeq uop.\n Plan:\n Trend labs. Treat electrolyte imbalances as ordered.Cont to monitor\n renal function and uop closely.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Remains off vent, tachypneic to 40\ns to 50 at times without desat ?\n central neuro issue vs pure respiratory component. Trach collar at 40%.\n Continues to have lot of secretions. Able to clear most of secretions.\n Tracheal area w moist skin breakdown around trach. O2 sats 98-100%\n Action:\n Allevyn dressing changed and freq meticulous trach care to keep trach\n area as dry as possible.Vap bundle.\n Response:\n Maintained adeq sats overnight. Lungs clearer after suctioning.\n Tachypnea persists despite freq pulm toilet.\n Plan:\n Cont to assess resp status for compromise. Cont aggressive pulm toilet.\n Contact MICU team if req placing back on vent. Freq trach care\n Problem\n Discharge goals/rehab screening\n Assessment:\n Pt medically continues to improve. Off dialysis, off vent. Micafungin\n dc\nd by MICU team. Continues to spike temps in setting of stablilizing\n wbc and negative culture data thus far. Neuro exam continues to be\n concerning, tracks but does not follow commands, infrequent spontaneous\n movement of extremeties, does not withdraw to deep nailbed pressure.\n Need to begin rehab screen plan for appropriate placement.\n Action:\n Family meeting w attending neurologist Dr and Neurology\n fellow to d/w family( Pt\ns brother and mother) multiple poor prognostic\n indicators for any reasonable neurologic recovery. Dr cited\n persistence of Mri reflecting atrophy and anoxic brain injury\n as well as poor EEG test results, in presence of pt\ns poor neurologic\n exam to be reasons for his . Dr added that while\n systemic issues of infection or metabolic imbalances may skew the\n picture slightly the outlook is still rather grim and pt most likely\n will remain in a persistent vegetative state.\n Response:\n Family appropriately grief stricken with Dr \n and\n discussion and asking appropriate questions. Dr and Neuro\n Fellow spent time at length to attempt to answer any questions the\n family had at this time .Emotional support offered to family .\n Plan:\n Continue to provide emotional support to family. Consult social work\n for any additional supports that may be offered to the family. Screen\n for appropriate rehab placement once stable off antibiotics.\n" }, { "category": "Physician ", "chartdate": "2131-06-20 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 681869, "text": "Chief Complaint:\n 24 Hour Events:\n NUCLEAR MEDICINE - At 09:57 AM\n INVASIVE VENTILATION - START 01:35 PM\n FEVER - 101.4\nF - 06:00 PM\n \n - Spiked fever to 101.4 and became hypotensive to 70/40 requiring\n pressors, but weaned off once he defervesced. He was put back on the\n vent for tachypnea and hypoxia 7.49/29/53.\n - CT abd/pelv ordered to visualize pancrease.\n - hopefully switch to HD, but pressures still low so unlikely\n - Methadone dose decreased\n Allergies:\n Meropenem\n skin blisters a\n Last dose of Antibiotics:\n Linezolid - 12:15 AM\n Aztreonam - 02:34 AM\n Metronidazole - 04:00 AM\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 12:14 AM\n Heparin Sodium (Prophylaxis) - 04:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:54 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.6\nC (101.4\n Tcurrent: 36.9\nC (98.5\n HR: 89 (89 - 119) bpm\n BP: 123/59(78) {78/43(56) - 128/73(94)} mmHg\n RR: 22 (20 - 35) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 100.4 kg (admission): 113.5 kg\n Height: 67 Inch\n Total In:\n 5,341 mL\n 828 mL\n PO:\n TF:\n 883 mL\n 195 mL\n IVF:\n 4,457 mL\n 633 mL\n Blood products:\n Total out:\n 3,487 mL\n 0 mL\n Urine:\n 135 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,854 mL\n 828 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 510 (428 - 6,000) mL\n PS : 5 cmH2O\n RR (Set): 16\n RR (Spontaneous): 21\n PEEP: 5 cmH2O\n FiO2: 60%\n RSBI: 57\n PIP: 16 cmH2O\n SpO2: 100%\n ABG: 7.41/35/146/22/-1\n Ve: 10.6 L/min\n PaO2 / FiO2: 243\n Physical Examination\n GEN: Trached, sedated.\n HEENT: Icteric sclera. MMM.\n NECK: Trach site with no oozing.\n LUNGS: Anterior auscultation with upper airway noise; good airway\n movement.\n HEART: RRR, normal S1, S2.\n ABD: Distended. Firm, but unchanged.\n EXTREM: 2+ edema, ulcers/lesions on legs with bandages C/D/I.\n SKIN: Jaundiced.\n NEURO: Twitching mouth. No purposeful movements today.\n Labs / Radiology\n 282 K/uL\n 7.3 g/dL\n 141 mg/dL\n 1.8 mg/dL\n 22 mEq/L\n 4.4 mEq/L\n 56 mg/dL\n 97 mEq/L\n 131 mEq/L\n 22.7 %\n 38.5 K/uL\n [image002.jpg]\n 10:56 PM\n 02:58 AM\n 03:10 AM\n 10:53 AM\n 12:57 PM\n 03:00 PM\n 10:13 PM\n 10:23 PM\n 03:00 AM\n 03:15 AM\n WBC\n 34.9\n 38.5\n Hct\n 24.6\n 22.7\n Plt\n 334\n 282\n Cr\n 0.6\n 1.2\n 1.8\n TCO2\n 26\n 27\n 23\n 22\n 18\n 25\n 23\n Glucose\n 151\n 114\n 121\n 140\n 135\n 141\n Other labs: PT / PTT / INR:15.0/33.3/1.3, CK / CKMB /\n Troponin-T:214/3/0.07, ALT / AST:204/226, Alk Phos / T Bili:446/20.1,\n Amylase / Lipase:77/68, Differential-Neuts:90.0 %, Band:0.0 %,\n Lymph:3.0 %, Mono:5.0 %, Eos:1.0 %, D-dimer:6389 ng/mL, Fibrinogen:502\n mg/dL, Lactic Acid:1.1 mmol/L, Albumin:2.0 g/dL, LDH:529 IU/L, Ca++:8.9\n mg/dL, Mg++:2.4 mg/dL, PO4:2.8 mg/dL\n CT ABD/PELVIS wet read:\n 1. large bore central catheter in RA. post-pyloric feeding tube at\n ligament\n of Treitz.\n 2. compared to CT , bibasilar consolidation little changed,\n likely\n atelectasis. round glass density of lungs slightly improved.\n 3. fatty liver w/focal sparing along GB fossa. high density in GB ?IV\n contrast\n or sludge.\n 4. continued evolution of areas of necrosis within the pancreas. new\n fluid\n collection anterior to superior segment of duodenum 5.6 x 2.9 cm\n (2:36), and\n along pancreatic uncinate 2.2 x 1.9 cm (2:44). Persistent attenuation\n of\n splenic vein; SMA, SMV, PV remain patent; no pseudoaneurysm seen.\n 5. Unchanged diffuse colonic bowel wall thickening for which an\n infectious\n etiology is not excluded.\n Assessment and Plan\n 28M with alcoholic hepatitis and necrotizing pancreatitis complicated\n by ARDS, SIRS, ARF, UGIB, fevers.\n #. ID: Persistent leukocytosis and fevers now that off CVVH. On\n aztreonam, linezolid (since ) and flagyl (since ). be \n pancreatitis.\n - Abd Ct with ?new abscess near pancreas. Will call rads for FR. If\n abscess will cls surgery for percutaneous drain.\n - consider add po vanc for cdiff colitis given persistent colonic\n inflammation on CT and high wbcs\n - UA with mod yeast persistent after multiple foley changes. Will\n consider anti-fungal but given liver function will likely need very low\n dose\n - Continue abx coverage with aztreo, flagyl, and linezolid given\n necrotizing pancreatitis.\n - F/u WBC count, temp curve, and culture data\n - diff with neutrophilia but no bands and no eos yesterday\n # Shock: Patient had transient pressor requirement last pm in setting\n of fever. When fever resolved pressor requirement did as well. Likely\n septic shock. Will treat for infection as above. If requires pressors\n without fever consider other etiologies of hypotension including\n cardiogenic.\n # Elevated LFTs: A/w alcoholic hepatitis. RUQ u/s showed sludge\n concerning for cholestasis but also seen on u/s. T Bili and\n transaminases improving today.\n - HIDA neg\n - TPN stopped \n - weaning off benzos\n #. Respiratory Failure: ARDS secondary to necrotizing pancreatitis. S/p\n trach placement on .\n - Cte fentanyl boluses and wean methadone as able today.\n - goal to chair daily\n # Seizures: CT head without intracranial process. EEG showed occipital\n seizures which does not correlate with clinical symptoms, but repeat\n EEG on higher dose Keppra showed no seizures. As patient now with\n purposeful movements, this may actually be patient waking up, not\n seizures.\n - Continue keppra (change dosing if changes to HD)\n - Wean valium\n #. Acute renal Failure: Multifactorial inc. ATN from hypotension\n - Was supposed to transition to HD today but may not tolerate given\n pressor req overnight during febrile episode. Will f/u renal recs today\n re:HD\n - Aztreonam 2000mg q12h while on CVVH. Change after aztreonam.\n - Will change Keppra to 1000mg Q24 with 500 mg after HD if able to\n tolerate HD today\n #. Adrenal Insufficiency: Unclear with stim if clear adrenal\n insufficiency but hypotension improving with steroids (lower pressor\n requirement) and eosinophilia resolved.\n - Cont weaning hydrocort; D2/3 on 12.5mg hydrocort. Taper tomorrow.\n ICU Care\n Nutrition:\n Nutren 2.0 () - 02:00 AM 50 mL/hour\n Glycemic Control: ISS\n Lines:\n Arterial Line - 08:15 PM\n PICC Line - 08:37 AM\n Dialysis Catheter - 08:55 AM\n Prophylaxis:\n DVT: hep sc\n Stress ulcer: famotidine\n VAP:\n Comments:\n Communication: Comments: with brother\n status: Full code\n Disposition: ICU\n" }, { "category": "Physician ", "chartdate": "2131-06-20 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 681870, "text": "Chief Complaint:\n 24 Hour Events:\n NUCLEAR MEDICINE - At 09:57 AM\n INVASIVE VENTILATION - START 01:35 PM\n FEVER - 101.4\nF - 06:00 PM\n - Methadone dose decreased.\n - Spiked fever to 101.4 and became hypotensive to 70/40 requiring\n pressors, but weaned off once he defervesced. He was put back on the\n vent for tachypnea and hypoxia with ABG 7.49/29/53. CT abd/pelvis done\n to evaluate pancreas.\n - Unable to switch to HD due to continued low pressures yesterday.\n Allergies:\n Meropenem\n skin blisters a\n Last dose of Antibiotics:\n Linezolid - 12:15 AM\n Aztreonam - 02:34 AM\n Metronidazole - 04:00 AM\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 12:14 AM\n Heparin Sodium (Prophylaxis) - 04:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:54 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.6\nC (101.4\n Tcurrent: 36.9\nC (98.5\n HR: 89 (89 - 119) bpm\n BP: 123/59(78) {78/43(56) - 128/73(94)} mmHg\n RR: 22 (20 - 35) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 100.4 kg (admission): 113.5 kg\n Height: 67 Inch\n Total In:\n 5,341 mL\n 828 mL\n PO:\n TF:\n 883 mL\n 195 mL\n IVF:\n 4,457 mL\n 633 mL\n Blood products:\n Total out:\n 3,487 mL\n 0 mL\n Urine:\n 135 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,854 mL\n 828 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 510 (428 - 6,000) mL\n PS : 5 cmH2O\n RR (Set): 16\n RR (Spontaneous): 21\n PEEP: 5 cmH2O\n FiO2: 60%\n RSBI: 57\n PIP: 16 cmH2O\n SpO2: 100%\n ABG: 7.41/35/146/22/-1\n Ve: 10.6 L/min\n PaO2 / FiO2: 243\n Physical Examination\n GEN: Trached, sedated.\n HEENT: Icteric sclera. MMM.\n NECK: Trach site with no oozing.\n LUNGS: Anterior auscultation with upper airway noise; good airway\n movement.\n HEART: RRR, normal S1, S2.\n ABD: Distended. Firm, but unchanged.\n EXTREM: 2+ edema, ulcers/lesions on legs with bandages C/D/I.\n SKIN: Jaundiced.\n NEURO: Twitching mouth. No purposeful movements today.\n Labs / Radiology\n 282 K/uL\n 7.3 g/dL\n 141 mg/dL\n 1.8 mg/dL\n 22 mEq/L\n 4.4 mEq/L\n 56 mg/dL\n 97 mEq/L\n 131 mEq/L\n 22.7 %\n 38.5 K/uL\n [image002.jpg]\n 10:56 PM\n 02:58 AM\n 03:10 AM\n 10:53 AM\n 12:57 PM\n 03:00 PM\n 10:13 PM\n 10:23 PM\n 03:00 AM\n 03:15 AM\n WBC\n 34.9\n 38.5\n Hct\n 24.6\n 22.7\n Plt\n 334\n 282\n Cr\n 0.6\n 1.2\n 1.8\n TCO2\n 26\n 27\n 23\n 22\n 18\n 25\n 23\n Glucose\n 151\n 114\n 121\n 140\n 135\n 141\n Other labs: PT / PTT / INR:15.0/33.3/1.3, CK / CKMB /\n Troponin-T:214/3/0.07, ALT / AST:204/226, Alk Phos / T Bili:446/20.1,\n Amylase / Lipase:77/68, Differential-Neuts:90.0 %, Band:0.0 %,\n Lymph:3.0 %, Mono:5.0 %, Eos:1.0 %, D-dimer:6389 ng/mL, Fibrinogen:502\n mg/dL, Lactic Acid:1.1 mmol/L, Albumin:2.0 g/dL, LDH:529 IU/L, Ca++:8.9\n mg/dL, Mg++:2.4 mg/dL, PO4:2.8 mg/dL\n CT ABD/PELVIS wet read:\n 1. large bore central catheter in RA. post-pyloric feeding tube at\n ligament of Treitz\n 2. compared to CT , bibasilar consolidation little changed,\n likely atelectasis. round glass density of lungs slightly improved.\n 3. fatty liver w/focal sparing along GB fossa. high density in GB ?IV\n contrast or sludge.\n 4. continued evolution of areas of necrosis within the pancreas. new\n fluid collection anterior to superior segment of duodenum 5.6 x 2.9 cm\n (2:36), and along pancreatic uncinate 2.2 x 1.9 cm (2:44). Persistent\n attenuation of splenic vein; SMA, SMV, PV remain patent; no\n pseudoaneurysm seen. 5. Unchanged diffuse colonic bowel wall thickening\n for which an infectious etiology is not excluded.\n Assessment and Plan\n 28M with alcoholic hepatitis and necrotizing pancreatitis complicated\n by ARDS, SIRS, ARF, UGIB, fevers.\n #. ID: Persistent leukocytosis and fevers now that off CVVH. On\n aztreonam, linezolid (since ) and flagyl (since ). be \n pancreatitis.\n - Abd Ct with ?new abscess near pancreas. Will call rads for FR. If\n abscess will cls surgery for percutaneous drain.\n - consider add po vanc for cdiff colitis given persistent colonic\n inflammation on CT and high wbcs\n - UA with mod yeast persistent after multiple foley changes. Will\n consider anti-fungal but given liver function will likely need very low\n dose\n - Continue abx coverage with aztreo, flagyl, and linezolid given\n necrotizing pancreatitis.\n - F/u WBC count, temp curve, and culture data\n - diff with neutrophilia but no bands and no eos yesterday\n # Shock: Patient had transient pressor requirement last pm in setting\n of fever. When fever resolved pressor requirement did as well. Likely\n septic shock. Will treat for infection as above. If requires pressors\n without fever consider other etiologies of hypotension including\n cardiogenic.\n # Elevated LFTs: A/w alcoholic hepatitis. RUQ u/s showed sludge\n concerning for cholestasis but also seen on u/s. T Bili and\n transaminases improving today.\n - HIDA neg\n - TPN stopped \n - weaning off benzos\n #. Respiratory Failure: ARDS secondary to necrotizing pancreatitis. S/p\n trach placement on .\n - Cte fentanyl boluses and wean methadone as able today.\n - goal to chair daily\n # Seizures: CT head without intracranial process. EEG showed occipital\n seizures which does not correlate with clinical symptoms, but repeat\n EEG on higher dose Keppra showed no seizures. As patient now with\n purposeful movements, this may actually be patient waking up, not\n seizures.\n - Continue keppra (change dosing if changes to HD)\n - Wean valium\n #. Acute renal Failure: Multifactorial inc. ATN from hypotension\n - Was supposed to transition to HD today but may not tolerate given\n pressor req overnight during febrile episode. Will f/u renal recs today\n re:HD\n - Aztreonam 2000mg q12h while on CVVH. Change after aztreonam.\n - Will change Keppra to 1000mg Q24 with 500 mg after HD if able to\n tolerate HD today\n #. Adrenal Insufficiency: Unclear with stim if clear adrenal\n insufficiency but hypotension improving with steroids (lower pressor\n requirement) and eosinophilia resolved.\n - Cont weaning hydrocort; D2/3 on 12.5mg hydrocort. Taper tomorrow.\n ICU Care\n Nutrition:\n Nutren 2.0 () - 02:00 AM 50 mL/hour\n Glycemic Control: ISS\n Lines:\n Arterial Line - 08:15 PM\n PICC Line - 08:37 AM\n Dialysis Catheter - 08:55 AM\n Prophylaxis:\n DVT: hep sc\n Stress ulcer: famotidine\n VAP:\n Comments:\n Communication: Comments: with brother\n status: Full code\n Disposition: ICU\n" }, { "category": "Nursing", "chartdate": "2131-06-14 00:00:00.000", "description": "Nursing Progress Note", "row_id": 680865, "text": "Hypotension (not Shock)\n Assessment:\n Hypotensive to 70\ns systolic this afternoon with tachycardia to 120\n Action:\n Bolused x2 with NS\n Response:\n Improved BP to 90\ns sys.\n Plan:\n F/u with medical team regarding hypotension. Consider maintenance IVF\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Stable resp status on CPAP 8/5\n Action:\n Weaned to CPAP 5/5, suctioned for thick tan secretions, no plugs or\n blood tinged sputum.\n Response:\n Stable ABG, sat 100%\n Plan:\n Trach mask at 0400 if stable vital signs, in particular HR, ABG 2hrs\n after trach mask trial.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n CRRT stopped this am pre Interventional radiology.\n Action:\n IR for permanent dialysis catheter, right PICC line placed as well.\n Response:\n Tolerated procedure well with PRN blousing of Midaz and Fentanyl. Renal\n fellow in to assess this pm.\n Plan:\n Assess labs/fluid balance and further need for dialysis. Plan on HD if\n stable but in lieu of hypotension it warrants further f/u.\n Seizure, without status epilepticus\n Assessment:\n Continues with all over twitching with more pronounced jerky twitching\n in upper body. Tremors are rhythmic.\n Weaning Versed gtt.\n Action:\n Continuous EEG overnight. Medicated with 3mg Versed bolus per Dr.\n when witnessed very aggressive face jerking. Versed titrated up\n again.\n Response:\n More relaxed after versed bolus.\n Plan:\n Continue Versed gtt.\n" }, { "category": "Case Management ", "chartdate": "2131-06-30 00:00:00.000", "description": "Discharge Planning Note", "row_id": 683943, "text": "TITLE: Discharge Planning Update\n Patient is a 28 year old male with a history of alcoholism presenting\n with acute hepatitis, pancreatitis, and UGIB, with persistent cyclic\n fevers/leukocytosis.\n NCM spoke with the MICU team about patient\ns readiness for discharge to\n a facility that can meet the patient\ns medical needs as well as provide\n an appropriate level of rehab. The patient has been clinically\n accepted at , Rehab and . NCM has asked\n all to update their screens on the patient in readiness for discharge.\n NCM also spoke with the patient\ns brother who is his HCP. \n requested that the patient be re-referred to acute rehabs given the\n patient\ns acute rehab needs and improvements in his medical status.\n NCM requested that and Rehab re-evaluate the\n patient. will see the patient on , ^th.\n NCM will continue to follow for discharge planning needs. Please\n call/page for any questions.\n , RN, BSN\n Phone: \n Pager: \n" }, { "category": "Nursing", "chartdate": "2131-06-20 00:00:00.000", "description": "Nursing Progress Note", "row_id": 681840, "text": "Respiration / Gas Exchange, Impaired\n Assessment:\n Afternoon ABG: 7.51, 27, 54, 0, 22 on trach mask\n Tachycardic, tachypnic, febrile\n Action:\n Place on CPAP + PS, 5 peep, 10 ps\n VAP protocol\n Repositioned frequently\n Response:\n 7.41, 35, 146, -1, 23\n HR in 90\ns NSR\n RR ~ 22\n Patient appears comfortable\n Plan:\n Pressure support decreased to 5\n Will recheck ABG\n Place back on trach mask when appropriate\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n ~ 80 cc\ns for urine output for 12 hours\n Icteric urine with sediment\n /Action:\n CRRT was stopped \n Response:\n Creatinine 1.8 (1.2).\n Fluid balance + ~ 1000 cc\ns MN\n 0600\n Plan:\n Attempt hemodialysis if possible\n Patient currently off vasopressors\n Arousal, Attention, and Cognition, Impaired\n Assessment:\n Wakes to voice, opens eyes\n Tracks\n MAE, withdraws\n Does not follow commands\n Action:\n Q 4 hour neuro exam\n Patient and family support\n Response:\n Unchanged from beginning of shift\n Plan:\n Continue neuro checks\n Continue to encourage patient to communicate, move extremities\n Hypotension (not Shock)\n Assessment:\n Start of shift patient requiring levophed to support blood pressure\n Action:\n Levophed weaned off\n CT scan of abdomen and pelvis done\n Response:\n CT results pending\\\n Remains off vasopressors\n No fever\n Plan:\n Continue to wean vent to collar\n" }, { "category": "Physician ", "chartdate": "2131-06-28 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 683453, "text": "Chief Complaint:\n 24 Hour Events:\n -Repeat CXR shows interval improvement in right lung fields, and\n diaphrams more clearly visualized which may represent clearing of\n pleural effusions.\n -Awaiting culture results\n -MRI and EEG ordered\n - MRI at 6/24 on 5:15 pm\n -Per renal hold HD, if continues to produce urine will d/c HD line\n after 2 days.\n - Blood cx from HD line x 2, one from each port, on \n -Removed trach sutures.\n Allergies:\n Meropenem\n skin blisters a\n Last dose of Antibiotics:\n Aztreonam - 02:39 PM\n Micafungin - 10:00 PM\n Infusions:\n Other ICU medications:\n Fentanyl - 01:00 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 05:51 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38\nC (100.4\n Tcurrent: 37.8\nC (100.1\n HR: 116 (105 - 121) bpm\n BP: 117/70(86) {108/63(79) - 144/77(98)} mmHg\n RR: 32 (18 - 40) insp/min\n SpO2: 97%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 103.9 kg (admission): 113.5 kg\n Height: 67 Inch\n Total In:\n 1,525 mL\n 291 mL\n PO:\n TF:\n 1,201 mL\n 291 mL\n IVF:\n 264 mL\n Blood products:\n Total out:\n 1,440 mL\n 375 mL\n Urine:\n 1,440 mL\n 375 mL\n NG:\n Stool:\n Drains:\n Balance:\n 85 mL\n -84 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n SpO2: 97%\n ABG: 7.41/33/122/20/-2\n PaO2 / FiO2: 305\n Physical Examination\n Labs / Radiology\n 227 K/uL\n 6.5 g/dL\n 192 mg/dL\n 2.6 mg/dL\n 20 mEq/L\n 3.6 mEq/L\n 94 mg/dL\n 115 mEq/L\n 150 mEq/L\n 21.5 %\n 10.2 K/uL\n [image002.jpg]\n 01:12 AM\n 06:06 AM\n 02:38 PM\n 02:00 AM\n 02:49 AM\n 01:51 AM\n 03:26 PM\n 03:37 PM\n 03:15 AM\n 03:19 AM\n WBC\n 18.9\n 15.0\n 12.6\n 10.2\n Hct\n 22.2\n 22.5\n 22.1\n 21.5\n Plt\n 230\n 228\n 225\n 227\n Cr\n 2.7\n 3.0\n 2.9\n 2.7\n 2.6\n TCO2\n 18\n 21\n 24\n 23\n 22\n Glucose\n 121\n 128\n 80\n 129\n 194\n 192\n Other labs: PT / PTT / INR:13.6/28.0/1.2, CK / CKMB /\n Troponin-T:214/3/0.07, ALT / AST:75/115, Alk Phos / T Bili:408/5.5,\n Amylase / Lipase:77/88, Differential-Neuts:84.3 %, Band:0.0 %,\n Lymph:9.3 %, Mono:1.7 %, Eos:4.3 %, D-dimer:6389 ng/mL, Fibrinogen:541\n mg/dL, Lactic Acid:2.6 mmol/L, Albumin:2.3 g/dL, LDH:312 IU/L, Ca++:8.6\n mg/dL, Mg++:2.0 mg/dL, PO4:2.7 mg/dL\n Assessment and Plan\n 28 year old male with a history of alcoholism presenting with acute\n hepatitis, pancreatitis, and UGIB, with persistent fevers/leukocytosis.\n # Respiratory failure\n .\n # Leukocytosis: Marked leukocytosis with low grade temperature. UA\n consistent with UTI, but also may be stress response. Started on\n empiric cipro/flagyl to cover GI source.\n -- f/u blood cultures and urine culture\n -- continue cipro/flagyl for now\n -- f/u final CT read\n # Hematemesis: Given alcohol history, potential consideration for\n varriceal bleed. No known prior history of hepatic cirrhosis, but\n elevated INR and fatty liver infilatration would be consistent. Also\n should consider PUD or alcoholic gastritis. Hct was WNL on\n presentation, but patient markedly contracted. Continued bright red\n blood on NG lavage suggests some degree of continued active bleeding.\n -- hepatology consulted, EGD today\n -- access with 2 large bore IVs and a cordis, T + C x 3 units\n -- IV PPI + PPI gtt\n -- octreotide for now until varrices are ruled out.\n .\n # Pancreatitis: Most likely alcoholic in etiology, with elevated\n lipase to 1600 and CT findings consistent without necrosis, cycts, or\n phlemgon. Only mild epigastric tenderness and no complaints of\n abdominal pain.\n -- continue aggessive hydration\n -- serial abdominal exams\n -- trend lipase\n -- no evidence of obstruction, holding off on further imaging at this\n time\n -- check am lipid panel\n .\n # Acute Hepatitis: Likely alcoholic hepatitis. CT scan shows fatty\n infiltration, and no evidence of distal ostruction.\n - check viral hepatitis panel, although degree of transaminitis not\n consistant with such an etiology.\n - holding off on furhter imaging for now, f/u final CT read\n - hepatology following\n - avoid hepatically cleared meds\n - trend LFTs\n .\n # Hyponatremia: Most likely due to volume depletion in the setting of\n inability to tolerate POs. Patient markedly dry on exam. also\n reflect a more chronic long-term liver disease.\n - fluid repleation as given above\n - if not correcting, will pursue furhter workup with urine lytes.\n # Alcoholism: Patient describes history of withdrawl symptoms, but not\n prior seizure. Last drink was night prior to presenation.\n Tachycardia, weakness, and elevated lactate could be consistent with\n thiamine deficiency.\n - repleate thiamine, vb12, folate\n - ativan with CIWA > 10\n - addictions consult\n .\n # FEN: IVF, replete electrolytes, NPO\n .\n # Prophylaxis: scds, PPI gtt\n .\n # Access: peripherals and femoral cortis\n .\n # Code: Full Code\n .\n # Disposition: MICU for now\n AROUSAL, ATTENTION, AND COGNITION, IMPAIRED\n BALANCE, IMPAIRED\n MOTOR FUNCTION, IMPAIRED\n MUSCLE PERFORMACE, IMPAIRED\n RESPIRATION / GAS EXCHANGE, IMPAIRED\n SEIZURE, WITHOUT STATUS EPILEPTICUS\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n IMPAIRED SKIN INTEGRITY\n HEPATITIS, ACUTE TOXIC (INCLUDING ALCOHOLIC, ACETAMINOPHEN, ETC.)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ICU Care\n Nutrition:\n Nutren 2.0 () - 01:27 PM 50 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 08:15 PM\n PICC Line - 08:37 AM\n Dialysis Catheter - 08:55 AM\n Prophylaxis:\n DVT: heparin\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2131-06-30 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 683872, "text": "Chief Complaint:\n 24 Hour Events:\n DIALYSIS CATHETER - STOP 03:35 PM\n ARTERIAL LINE - STOP 03:37 PM\n FEVER - 101.5\nF - 12:00 PM\n Allergies:\n Meropenem\n skin blisters a\n Last dose of Antibiotics:\n Micafungin - 10:00 PM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 04:30 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:52 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.6\nC (101.5\n Tcurrent: 38.2\nC (100.7\n HR: 115 (114 - 124) bpm\n BP: 123/53(69) {93/39(56) - 144/119(123)} mmHg\n RR: 34 (29 - 40) insp/min\n SpO2: 99%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 103.3 kg (admission): 113.5 kg\n Height: 67 Inch\n Total In:\n 1,964 mL\n 543 mL\n PO:\n TF:\n 1,204 mL\n 293 mL\n IVF:\n 200 mL\n Blood products:\n Total out:\n 1,375 mL\n 460 mL\n Urine:\n 1,375 mL\n 460 mL\n NG:\n Stool:\n Drains:\n Balance:\n 589 mL\n 83 mL\n Respiratory support\n O2 Delivery Device: Trach mask , Tracheostomy tube\n SpO2: 99%\n ABG: ///22/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 290 K/uL\n 6.5 g/dL\n 116 mg/dL\n 1.9 mg/dL\n 22 mEq/L\n 3.8 mEq/L\n 91 mg/dL\n 117 mEq/L\n 148 mEq/L\n 22.2 %\n 10.9 K/uL\n [image002.jpg]\n 03:26 PM\n 03:37 PM\n 03:15 AM\n 03:19 AM\n 10:00 AM\n 04:00 PM\n 02:16 AM\n 04:14 PM\n 10:00 PM\n 02:32 AM\n WBC\n 10.2\n 11.4\n 10.9\n Hct\n 21.5\n 21.7\n 22.2\n Plt\n 227\n 266\n 290\n Cr\n 2.7\n 2.6\n 2.1\n 2.0\n 1.9\n TCO2\n 23\n 22\n Glucose\n 129\n 194\n 192\n 200\n 7\n 116\n Other labs: PT / PTT / INR:13.6/28.0/1.2, CK / CKMB /\n Troponin-T:214/3/0.07, ALT / AST:88/136, Alk Phos / T Bili:341/4.7,\n Amylase / Lipase:102/114, Differential-Neuts:57.0 %, Band:4.0 %,\n Lymph:23.0 %, Mono:4.0 %, Eos:3.0 %, D-dimer:6389 ng/mL, Fibrinogen:541\n mg/dL, Lactic Acid:2.6 mmol/L, Albumin:2.3 g/dL, LDH:312 IU/L, Ca++:9.0\n mg/dL, Mg++:2.0 mg/dL, PO4:3.4 mg/dL\n Assessment and Plan\n ICU Care\n Nutrition:\n Nutren 2.0 () - 01:18 PM 50 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 08:37 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": "2131-06-30 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 683874, "text": "Chief Complaint:\n 24 Hour Events:\n DIALYSIS CATHETER - STOP 03:35 PM\n ARTERIAL LINE - STOP 03:37 PM\n FEVER - 101.5\nF - 12:00 PM\n Allergies:\n Meropenem\n skin blisters a\n Last dose of Antibiotics:\n Micafungin - 10:00 PM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 04:30 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:52 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.6\nC (101.5\n Tcurrent: 38.2\nC (100.7\n HR: 115 (114 - 124) bpm\n BP: 123/53(69) {93/39(56) - 144/119(123)} mmHg\n RR: 34 (29 - 40) insp/min\n SpO2: 99%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 103.3 kg (admission): 113.5 kg\n Height: 67 Inch\n Total In:\n 1,964 mL\n 543 mL\n PO:\n TF:\n 1,204 mL\n 293 mL\n IVF:\n 200 mL\n Blood products:\n Total out:\n 1,375 mL\n 460 mL\n Urine:\n 1,375 mL\n 460 mL\n NG:\n Stool:\n Drains:\n Balance:\n 589 mL\n 83 mL\n Respiratory support\n O2 Delivery Device: Trach mask , Tracheostomy tube\n SpO2: 99%\n ABG: ///22/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 290 K/uL\n 6.5 g/dL\n 116 mg/dL\n 1.9 mg/dL\n 22 mEq/L\n 3.8 mEq/L\n 91 mg/dL\n 117 mEq/L\n 148 mEq/L\n 22.2 %\n 10.9 K/uL\n [image002.jpg]\n 03:26 PM\n 03:37 PM\n 03:15 AM\n 03:19 AM\n 10:00 AM\n 04:00 PM\n 02:16 AM\n 04:14 PM\n 10:00 PM\n 02:32 AM\n WBC\n 10.2\n 11.4\n 10.9\n Hct\n 21.5\n 21.7\n 22.2\n Plt\n 227\n 266\n 290\n Cr\n 2.7\n 2.6\n 2.1\n 2.0\n 1.9\n TCO2\n 23\n 22\n Glucose\n 129\n 194\n 192\n 200\n 7\n 116\n Other labs: PT / PTT / INR:13.6/28.0/1.2, CK / CKMB /\n Troponin-T:214/3/0.07, ALT / AST:88/136, Alk Phos / T Bili:341/4.7,\n Amylase / Lipase:102/114, Differential-Neuts:57.0 %, Band:4.0 %,\n Lymph:23.0 %, Mono:4.0 %, Eos:3.0 %, D-dimer:6389 ng/mL, Fibrinogen:541\n mg/dL, Lactic Acid:2.6 mmol/L, Albumin:2.3 g/dL, LDH:312 IU/L, Ca++:9.0\n mg/dL, Mg++:2.0 mg/dL, PO4:3.4 mg/dL\n Assessment and Plan\n 28 year old male with a history of alcoholism presenting with acute\n hepatitis, pancreatitis, and UGIB, with persistent cyclic\n fevers/leukocytosis.\n # Cyclic fevers/leukocytosis\n febrile to 101.3 yesterday AM, but WBC\n continues trending down. Sputum with 4+ GNR likely colonizer, as per\n ID, and sputum consistency remains unchanged. CXR without obvious\n pneumonia. C diff neg on . U/A weakly positive; cx showing 10k\n yeast. On micafungin as pt has been cx negative. Other source lower\n on ddx includes peripancreatic fluid collection.\n -ID recs CT abd to eval peripancreatic collection.\n -D/C a-line and HD line\n -Will not start gancyclovir as CMV not likely cause of fevers, but will\n follow LFTs and if rising will see if correlates with CMV viral load.\n If correlation will will discuss starting gancyclovir with ID and\n renal.\n -Will continue micofungin but will discuss plan with ID. Likely\n continue for 2 weeks and CT at that time. Will need to discuss\n criteria for d/cing micofungin with /ID.\n # Respiratory failure\n on trach mask at 40% FIO2, tachypnic this AM.\n -Tachypnea may be centrally driven cerebral injury\n # Acute renal failure\n stable and UOP improving (currently >60 cc/hr\n over last 24hrs.).\n -After renal sees Pt today will likely d/c HD line.\n -Cont. to follow UOP\n # Altered mental status\n Given possibility of seizure activity, will\n continue keppra. MRI showing cerebral edema, poor prognosis as per\n neuro. EEG completed and report pending. Unclear how much of this is\n medication induced and how much is rehab correctable; would appreciate\n neuro recs regarding potential rehab.\n -Family meeting today with Neuro to discuss\n -Will need neuron rehab.\n # Hyponatremia\n - Correcting. Will start free water boluses to prevent overcorrection.\n # Anemia\n stable. Will hold off transfusing and cont to follow.\n # Acute Hepatitis: Likely alcoholic hepatitis. CT scan shows fatty\n infiltration, and no evidence of distal ostruction.\n - trend LFTs\n - Will correlate LFTs with CMV viral load if they continue to rise.\n -If CMV likely cause may need to start gancyclovir however as this is\n nephrotoxic will need to discuss with ID/Renal\n # FEN: IVF, replete electrolytes, NPO\n ICU Care\n Nutrition:\n Nutren 2.0 () - 01:18 PM 50 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 08:37 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": "2131-06-30 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 683875, "text": "Chief Complaint:\n 24 Hour Events:\n - d/c'ed micafungin as per ID, as unclear if helping or not. Will see\n how he does off micafungin over weekend, if doing poorly, consider\n further imaging prior to Monday.\n - Dr. will email Dr. to ensure that micafungin plan\n is okay.\n - CMV VL ordered 5 days from now, as per ID\n - neurology had sobering and extensive discussion with family re: poor\n prognosis and long term plan\n - will tolerate low grade temps given lack of source and known necrotic\n pancreas\n - K and phos repleted and look fine\n - HD line and a line d/c'ed\n - will d/c foley and try condom cath\n Allergies:\n Meropenem\n skin blisters a\n Last dose of Antibiotics:\n Micafungin - 10:00 PM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 04:30 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:52 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.6\nC (101.5\n Tcurrent: 38.2\nC (100.7\n HR: 115 (114 - 124) bpm\n BP: 123/53(69) {93/39(56) - 144/119(123)} mmHg\n RR: 34 (29 - 40) insp/min\n SpO2: 99%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 103.3 kg (admission): 113.5 kg\n Height: 67 Inch\n Total In:\n 1,964 mL\n 543 mL\n PO:\n TF:\n 1,204 mL\n 293 mL\n IVF:\n 200 mL\n Blood products:\n Total out:\n 1,375 mL\n 460 mL\n Urine:\n 1,375 mL\n 460 mL\n NG:\n Stool:\n Drains:\n Balance:\n 589 mL\n 83 mL\n Respiratory support\n O2 Delivery Device: Trach mask , Tracheostomy tube\n SpO2: 99%\n ABG: ///22/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 290 K/uL\n 6.5 g/dL\n 116 mg/dL\n 1.9 mg/dL\n 22 mEq/L\n 3.8 mEq/L\n 91 mg/dL\n 117 mEq/L\n 148 mEq/L\n 22.2 %\n 10.9 K/uL\n [image002.jpg]\n 03:26 PM\n 03:37 PM\n 03:15 AM\n 03:19 AM\n 10:00 AM\n 04:00 PM\n 02:16 AM\n 04:14 PM\n 10:00 PM\n 02:32 AM\n WBC\n 10.2\n 11.4\n 10.9\n Hct\n 21.5\n 21.7\n 22.2\n Plt\n 227\n 266\n 290\n Cr\n 2.7\n 2.6\n 2.1\n 2.0\n 1.9\n TCO2\n 23\n 22\n Glucose\n 129\n 194\n 192\n 200\n 7\n 116\n Other labs: PT / PTT / INR:13.6/28.0/1.2, CK / CKMB /\n Troponin-T:214/3/0.07, ALT / AST:88/136, Alk Phos / T Bili:341/4.7,\n Amylase / Lipase:102/114, Differential-Neuts:57.0 %, Band:4.0 %,\n Lymph:23.0 %, Mono:4.0 %, Eos:3.0 %, D-dimer:6389 ng/mL, Fibrinogen:541\n mg/dL, Lactic Acid:2.6 mmol/L, Albumin:2.3 g/dL, LDH:312 IU/L, Ca++:9.0\n mg/dL, Mg++:2.0 mg/dL, PO4:3.4 mg/dL\n Assessment and Plan\n 28 year old male with a history of alcoholism presenting with acute\n hepatitis, pancreatitis, and UGIB, with persistent cyclic\n fevers/leukocytosis.\n # Cyclic fevers/leukocytosis\n febrile to 101.3 yesterday AM, but WBC\n continues trending down. Sputum with 4+ GNR likely colonizer, as per\n ID, and sputum consistency remains unchanged. CXR without obvious\n pneumonia. C diff neg on . U/A weakly positive; cx showing 10k\n yeast. On micafungin as pt has been cx negative. Other source lower\n on ddx includes peripancreatic fluid collection.\n -ID recs CT abd to eval peripancreatic collection.\n -D/C a-line and HD line\n -Will not start gancyclovir as CMV not likely cause of fevers, but will\n follow LFTs and if rising will see if correlates with CMV viral load.\n If correlation will will discuss starting gancyclovir with ID and\n renal.\n -Will continue micofungin but will discuss plan with ID. Likely\n continue for 2 weeks and CT at that time. Will need to discuss\n criteria for d/cing micofungin with /ID.\n # Respiratory failure\n on trach mask at 40% FIO2, tachypnic this AM.\n -Tachypnea may be centrally driven cerebral injury\n # Acute renal failure\n stable and UOP improving (currently >60 cc/hr\n over last 24hrs.).\n -After renal sees Pt today will likely d/c HD line.\n -Cont. to follow UOP\n # Altered mental status\n Given possibility of seizure activity, will\n continue keppra. MRI showing cerebral edema, poor prognosis as per\n neuro. EEG completed and report pending. Unclear how much of this is\n medication induced and how much is rehab correctable; would appreciate\n neuro recs regarding potential rehab.\n -Family meeting today with Neuro to discuss\n -Will need neuron rehab.\n # Hyponatremia\n - Correcting. Will start free water boluses to prevent overcorrection.\n # Anemia\n stable. Will hold off transfusing and cont to follow.\n # Acute Hepatitis: Likely alcoholic hepatitis. CT scan shows fatty\n infiltration, and no evidence of distal ostruction.\n - trend LFTs\n - Will correlate LFTs with CMV viral load if they continue to rise.\n -If CMV likely cause may need to start gancyclovir however as this is\n nephrotoxic will need to discuss with ID/Renal\n # FEN: IVF, replete electrolytes, NPO\n ICU Care\n Nutrition:\n Nutren 2.0 () - 01:18 PM 50 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 08:37 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": "2131-07-01 00:00:00.000", "description": "Nursing Progress Note", "row_id": 684107, "text": "Arousal, Attention, and Cognition, Impaired\n Assessment:\n eyes open, tracking occasionally.\n Purposeful movement of RUE. On TM, able to raise secretions\n effectively.\n tremulous with movement/turning.\n Action:\n cont to follow neuro status.\n provide comfort and support.\n Response:\n cont to closely monitor and follow closely.\n Plan:\n Neuro spoke to family re: prognosis. ? SW to discuss with family on\n Monday.\n Continue with frequenting turning and suctioning as currently being\n done. Encourage interactions as much as possible.\n Provide comfort and support to family.\n Afebrile. Stooling q2 hours- small brown semiformed stool. TF\n continues.\n" }, { "category": "Rehab Services", "chartdate": "2131-06-20 00:00:00.000", "description": "Occupational Therapy Evaluation Note", "row_id": 681950, "text": "History\n Attending M.D.: \n Referral Date: \n Reason for Referral: eval and treat\n Medical Dx / ICD - 9: 038.9\n Activity Orders: ok for OOB RN\n HPI / Subjective Complaint: 28 yo gentleman with hx EtOH abuse,\n depression, admitted with hematemesis , found to have acute EtOH\n hepatitis, severe necrotizing pancreatitis, complicated hospital course\n with multiorgan failure, acute renal failure on CVVH, and ARDS, unable\n to wean from vent requiring trach. Pt had cardiopulmonary arrest\n secondary to the presence of clot in his tracheostomy tube . Also\n questionable seizure activity, head CT unremarkable. CVVHD stopped\n , and plan to start HD.\n Past Medical / Surgical History: etoh, depression\n Medications: acetaminophen, heparin, flagyl, diazepam\n Labs\n Hematocrit (serum): 22.7 ...\n Hemoglobin: 7.3 ... g/dl\n WBC: 38.5 ...\n Platelet Count: 282 ...\n Radiology\n Radiology: Head CT neg\n CT: continued evolution of necrosis of pancreatitis, fatty liver\n Occupational History\n Performance Patterns: unknown\n Baseline Occupational Performance: I PTA\n Current Activities of Daily Living\n Self Feeding: (Dependent)\n Grooming: (Dependent)\n UE Bathing: (Dependent)\n LE Bathing: (Dependent)\n UE Dressing: (Dependent)\n LE Dressing: (Dependent)\n Toileting: (Dependent)\n Performance Skills\n Process Skills: pt alert, nodding inconsistently, tracking, smiling\n occasionally, not following commands, no attempts to catch ball when\n thrown at him\n Motor Skills - Functional Transfers\n Rolling: (max A) x 2\n Supine / Side-lying to Sit: (max A) x2\n Functional Balance: pt requires mod-max A sitting , pt has postural\n responses at \n Aerobic Capacity: Rest\n Rest HR: 98\n Rest BP: 121/59\n Rest RR: 28\n Rest O2 sat: 100 %\n Supplemental O2: 60 % Trach mask\n Aerobic Capacity: Activity\n Activity HR: 100\n Activity BP: 123/62\n Activity RR: 40\n Activity O2 sat: 100 %\n Supplemental O2: 60 % trach mask\n Aerobic Capacity: Recovery\n Recovery HR: 101\n Recovery BP: 124/63\n Recovery RR: 30\n Recovery O2 sat: 100 %\n Supplemental O2: 60 % trach mask\n Range of Motion\n Range of Motion: B UE ROM WFL but with difficulty\n Muscle Performance: strength, power, endurance\n Muscle Performance: observed L UE moving minimally against gravity,\n otherwise no active movement noted\n Additional Performance Skills\n Motor Control: B UE tremor noted at rest, increasing with light touch\n to B UE\n Coordination: impaired\n Limiting Symptoms: no c/o pain but grimacing with UE ROM\n Integumentary: Jaundice eyes/skin, foley, aline, piv, central line\n Team Communication: with RN, with PT\n Education: Role of OT, orientation\n Diagnosis\n Diagnosis 1: decreased adls\n Diagnosis 2: decreased balance\n Diagnosis 3: decreased functional mobility\n Clinical Impression / Prognosis\n Clinical Impression / Prognosis: 28 year old male with necrotizing\n pancreatitis who present as above. Pt demonstrates decreased ability\n to follow commands, decreased strength, decreased ability to make needs\n known. Pt is currently functioning well below his baseline and will\n need continued daily therapy to progress. Recommend a d/c to rehab\n once medically stable to maximize capabilities.\n Goals: patient / family, objective, measurable\n Goal 1: sit mod A x 10 minutes for adls\n Goal 2: max a wash face\n Goal 3: mod A rolling for hygiene\n Time Frame (expected attainment): By one week\n Anticipated Discharge: Rehab\n Treatment Plan: Interventions; patient / family education, community\n resources\n Treatment Plan: f/u for adls, functional mobility, cognition, d/c\n planning, Pt co-op to see for ROM\n Frequency / Duration: x week\n Therapist Information\n Therapist's Name: \n Date: \n Time: 1220-1244\n Pager #: \n" }, { "category": "Respiratory ", "chartdate": "2131-06-20 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 681953, "text": "Airway\n Airway Placement Data\n Known difficult intubation: No\n Tube Type\n Tracheostomy tube:\n Type: Standard, Cuffed, Inner Cannula\n Manufacturer: Portex\n Size: 8.0mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 24 cmH2O\n Cuff volume: 8 mL /\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount: Suctioned / Scant\n Ventilation Assessment\n Level of breathing assistance: Pt came off ventilator at 8:30am, pt\n doing well and tolerating trach collar well, no increased WOB noted,\n Spo2 100% on 50% Fio2.\n Comments: per MICU Team pt to stay off ventilator as tolerated, may go\n back on vent if needed.\n Plan\n Next 24-48 hours:\n Reason for continuing current ventilatory support: only if pt in acute\n respiratory distress.\n ------ Protected Section ------\n PMV trial done today, however, pt stacking breaths, Speech recommended\n not to use PMV as this time, pt will be reassed.\n ------ Protected Section Addendum Entered By: ,\n on: 17:36 ------\n" }, { "category": "Physician ", "chartdate": "2131-06-21 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 682007, "text": "Chief Complaint:\n 24 Hour Events:\n - Renal deferred starting HD given hypotension yesterday. will start in\n am\n - Sgy said would not drain abscess as looks sterile (no gas) if\n anything to be started would start anti-fungal\n - ID: Start mica, vanc po, cipro for double GN coverage, check CMV VL,\n cls GI re:c-scope for inflammation as may be able to biopsy, check\n C.diff again, more freq bcx, d/c a-line and foley if able\n - We started mica, po vanc. Did not start cipro.\n - Speech eval'd for valve but he couldn't tolerate it\n - methadone, hydrocort, and valium weaned down.\n - Neuro saw him and thought making slow progress. Will continue to\n follow for prognostication (is that a word?)\n Allergies:\n Meropenem\n skin blisters a\n Last dose of Antibiotics:\n Micafungin - 09:30 PM\n Linezolid - 12:40 AM\n Aztreonam - 02:25 AM\n Vancomycin - 02:26 AM\n Metronidazole - 04:16 AM\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 12:00 AM\n Heparin Sodium (Prophylaxis) - 04:16 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 04:37 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.9\nC (100.2\n Tcurrent: 37.9\nC (100.2\n HR: 110 (89 - 116) bpm\n BP: 99/54(68) {99/52(68) - 139/72(94)} mmHg\n RR: 26 (22 - 34) insp/min\n SpO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 100.7 kg (admission): 113.5 kg\n Height: 67 Inch\n Total In:\n 2,814 mL\n 886 mL\n PO:\n TF:\n 1,100 mL\n 230 mL\n IVF:\n 1,564 mL\n 596 mL\n Blood products:\n Total out:\n 330 mL\n 130 mL\n Urine:\n 330 mL\n 130 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,484 mL\n 756 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n SpO2: 100%\n ABG: 7.39/32/92./18/-4\n PaO2 / FiO2: 186\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 277 K/uL\n 7.0 g/dL\n 132 mg/dL\n 2.4 mg/dL\n 18 mEq/L\n 3.9 mEq/L\n 82 mg/dL\n 99 mEq/L\n 131 mEq/L\n 22.6 %\n 38.6 K/uL\n [image002.jpg]\n 10:53 AM\n 12:57 PM\n 03:00 PM\n 10:13 PM\n 10:23 PM\n 03:00 AM\n 03:15 AM\n 04:57 PM\n 02:28 AM\n 02:50 AM\n WBC\n 38.5\n 38.5\n Hct\n 22.7\n 22.7\n 22.6\n Plt\n 282\n 282\n 277\n Cr\n 1.2\n 1.8\n 2.4\n TCO2\n 23\n 22\n 18\n 25\n 23\n 20\n Glucose\n 114\n 121\n 140\n 135\n 141\n 132\n Other labs: PT / PTT / INR:15.0/33.3/1.3, CK / CKMB /\n Troponin-T:214/3/0.07, ALT / AST:181/177, Alk Phos / T Bili:455/15.9,\n Amylase / Lipase:77/141, Differential-Neuts:90.0 %, Band:0.0 %,\n Lymph:3.0 %, Mono:5.0 %, Eos:1.0 %, D-dimer:6389 ng/mL, Fibrinogen:502\n mg/dL, Lactic Acid:1.4 mmol/L, Albumin:2.0 g/dL, LDH:529 IU/L, Ca++:8.6\n mg/dL, Mg++:2.3 mg/dL, PO4:3.0 mg/dL\n Assessment and Plan\n 28M with alcoholic hepatitis and necrotizing pancreatitis complicated\n by ARDS, SIRS, ARF, UGIB, fevers.\n #. ID: Persistent leukocytosis and fevers now that off CVVH. On\n aztreonam, linezolid (since ) and flagyl (since ). Likely to\n have continued fevers necrotizing pancreatitis.\n - Abd CT with ?new abscess near pancreas. F/u final read but reviewed\n by Surgery with no role for surgical intervention\n - Given necrotizing pancreatitis and UA with mod yeast persistent after\n multiple foley changes, will restart anti-fungal but given liver\n function will likely need very low dose\n - Continue abx coverage with aztreo, flagyl, and linezolid given\n necrotizing pancreatitis.\n - Consider add po vanc for cdiff colitis given persistent colonic\n inflammation on CT and high wbcs\n - F/u WBC count, temp curve, and culture data\n - Diff with neutrophilia but no bands and no eos yesterday\n .\n # Shock: Patient had transient pressor requirement last pm in setting\n of fever. When fever resolved pressor requirement did as well. Likely\n septic shock. Will treat for infection as above. If requires pressors\n without fever consider other etiologies of hypotension including\n cardiogenic.\n - Cont weaning steroids\n .\n # Elevated LFTs: A/w alcoholic hepatitis. RUQ u/s showed sludge\n concerning for cholestasis but also seen on u/s. T Bili and\n transaminases improving today.\n - HIDA neg\n - TPN stopped \n - weaning off benzos\n #. Respiratory Failure: ARDS secondary to necrotizing pancreatitis. S/p\n trach placement on .\n - Cte fentanyl boluses and alternatingly wean methadone and valium as\n tolerate.\n - Cte OOB to chair daily\n #. Acute renal Failure: Multifactorial inc. ATN from hypotension\n - Was supposed to transition to HD today but pressures not able to\n tolerate. No need for filtration so will reassess tmrw.\n - Aztreonam 2000mg q12h while on CVVH. Change after aztreonam.\n - Will change Keppra to 1000mg Q24 with 500 mg after HD when able to\n tolerate HD\n #. Adrenal Insufficiency: Unclear with stim if clear adrenal\n insufficiency but hypotension improving with steroids (lower pressor\n requirement) and eosinophilia resolved.\n - Cont weaning hydrocort to q12h today\n # Seizures: CT head without intracranial process. EEG showed occipital\n seizures which does not correlate with clinical symptoms, but repeat\n EEG on higher dose Keppra showed no seizures. As patient now with\n purposeful movements, this may actually be patient waking up, not\n seizures.\n - Continue keppra (change dosing if changes to HD)\n - Wean valium today\n ICU Care\n Nutrition:\n Nutren 2.0 () - 01:56 AM 50 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 08:15 PM\n PICC Line - 08:37 AM\n Dialysis Catheter - 08:55 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:ICU\n" }, { "category": "Nursing", "chartdate": "2131-06-30 00:00:00.000", "description": "Nursing Progress Note", "row_id": 684019, "text": "Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Tmax 101.7. Tachypneic with RR 30\ns and Tachycardic with HR 120\ns. WBC\n 10.\n Action:\n Tylenol.\n Response:\n Plan:\n Arousal, Attention, and Cognition, Impaired\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2131-06-30 00:00:00.000", "description": "Nursing Progress Note", "row_id": 684022, "text": "Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Tmax 101.7. Tachypneic with RR 30\ns and Tachycardic with HR 120\ns. WBC\n 10.\n Action:\n Tylenol given. Frequent monitoring of temperature.\n Response:\n Await effect of Tylenol.\n Plan:\n Continue to follow temperature curve and other vs. Monitor labs.\n Arousal, Attention, and Cognition, Impaired\n Assessment:\n Pt alert and tracking with his eyes. No communication attempts.\n Non-purposeful spontaneous movements with UE. Does not withdraw to\n nail bed pressure LE. PERRL.\n Action:\n OOB to chair. Passive ROM.\n Response:\n Pt tolerating OOB to chair well.\n Plan:\n Continue with ROM and OOB as tolerated. PT. Neuro checks as ordered.\n" }, { "category": "Nursing", "chartdate": "2131-06-30 00:00:00.000", "description": "Nursing Progress Note", "row_id": 684013, "text": "Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Action:\n Response:\n Plan:\n Arousal, Attention, and Cognition, Impaired\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Physician ", "chartdate": "2131-06-16 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 681166, "text": "Chief Complaint:\n 24 Hour Events:\n PICC LINE - START 08:37 AM\n placed in IR\n DIALYSIS CATHETER - START 08:55 AM\n MULTI LUMEN - STOP 12:32 PM\n HD catheter removed and this line placed over wire\n \n - Aztreonam dose decreased yesterday as not on CVVH\n - Pt hypotensive to SBP 70s yesterday; given 500cc bolus with\n improvement. Cipro changed to flagyl.\n - Repeat EEG without seizures on higher dose of keppra.\n Allergies:\n Meropenem\n skin blisters a\n Last dose of Antibiotics:\n Ciprofloxacin - 12:34 PM\n Aztreonam - 08:00 PM\n Linezolid - 10:07 PM\n Metronidazole - 12:00 AM\n Infusions:\n Midazolam (Versed) - 2 mg/hour\n Fentanyl (Concentrate) - 100 mcg/hour\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:00 PM\n Famotidine (Pepcid) - 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 06:57 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.3\nC (101\n Tcurrent: 37.8\nC (100.1\n HR: 93 (93 - 117) bpm\n BP: 81/38(52) {76/38(52) - 137/78(212)} mmHg\n RR: 32 (21 - 44) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 103.1 kg (admission): 113.5 kg\n Height: 67 Inch\n CVP: 10 (7 - 12)mmHg\n Total In:\n 3,899 mL\n 593 mL\n PO:\n TF:\n 1,203 mL\n 346 mL\n IVF:\n 2,696 mL\n 247 mL\n Blood products:\n Total out:\n 425 mL\n 135 mL\n Urine:\n 425 mL\n 135 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,474 mL\n 458 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 582 (391 - 582) mL\n PS : 5 cmH2O\n RR (Set): 22\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 55\n PIP: 13 cmH2O\n SpO2: 100%\n ABG: 7.34/30/113/16/-8\n Ve: 13.1 L/min\n PaO2 / FiO2: 226\n Physical Examination\n GEN: Trached, sedated\n HEENT: icteric sclera. MMM\n NECK: Trach site with no oozing.\n LUNGS: Anterior auscultation with upper airway noise; good airway\n movement\n HEART: RRR, normal; S1, S2\n ABD: Distended. Grimmacing with palpation.\n EXTREM: 2+ edema, ulcers/lesions on legs with bandages C/D/I\n SKIN: Jaundice\n NEURO: No twitching today. Did not open eyes to command.\n Labs / Radiology\n 243 K/uL\n 7.7 g/dL\n 154 mg/dL\n 2.4 mg/dL\n 16 mEq/L\n 4.7 mEq/L\n 120 mg/dL\n 97 mEq/L\n 130 mEq/L\n 23.2 %\n 26.4 K/uL\n [image002.jpg]\n 06:18 PM\n 07:58 PM\n 08:00 PM\n 01:31 AM\n 01:37 AM\n 04:30 AM\n 12:35 PM\n 06:31 PM\n 01:32 AM\n 03:05 AM\n WBC\n 24.4\n 21.7\n 26.4\n Hct\n 25.3\n 25.8\n 23.2\n Plt\n 193\n 194\n 243\n Cr\n 1.5\n 2.0\n 2.4\n TCO2\n 22\n 23\n 21\n 21\n 20\n 17\n Glucose\n 178\n 166\n 154\n Other labs: PT / PTT / INR:16.5/36.2/1.5, CK / CKMB /\n Troponin-T:214/3/0.07, ALT / AST:184/250, Alk Phos / T Bili:538/30.0,\n Albumin:2.0 g/dL, LDH:706 IU/L, Ca++:8.5 mg/dL, Mg++:2.6 mg/dL, PO4:4.8\n mg/dL. Ferritin 2660\n Assessment and Plan\n 28M with alcoholic hepatitis and necrotizing pancreatitis complicated\n by ARDS, SIRS, ARF, UGIB, fevers.\n #. ID: Febrile now for 2 days, increased WBC, with decreased BP. RUQ\n u/s concerning for sludge and pt started on cipro; changed to flagyl\n yesterday. Of note, had stopped flagyl and vanc po as C. diff neg\n x 2. Blood/tissue/BAL cx NGTD. It is possible that previous fevers had\n been masked by CVVH, which he had been held x 2 days although restarted\n today.\n - Cte broad spectrum antibiotic coverage with linezolid and aztreonam\n (D1 ) and flagyl (added back )\n - Consider HIDA scan if bilirubin does not improve or hemodynamic\n instability over next few days.\n - F/u WBC count, temp curve, and culture data\n - Cont steroid taper for possible adrenal insufficiency\n # Hyperbilirubinemia: Patient has had continuously increasing T Bili\n and alkaline phosphatase. Has alcoholic hepatitis but also on TPN. Bili\n stable today but increased alk phos and RUQ u/s with sludge concerning\n for cholestasis. Note that U/S also showed sludge.\n - Consider asking GI input for HIDA scan v. ERCP\n - TPN stopped \n - Weaning off benzos\n #. Respiratory Failure: ARDS secondary to necrotizing pancreatitis. S/p\n trach placement on . Sutures out on . Currently on pressure\n support.\n - Cont to wean vent with trach mask trials v CPAP trials as tolerated\n - Increasing fentanyl patch while decreasing gtt, continue methadone\n - Attempt OOB to chair to improve respiratory mechanics\n # Seizures: CT head without intracranial process. EEG showed occipital\n seizures which does not correlate with clinical symptoms, but repeat\n EEG on higher dose Keppra showed no seizures. actually be\n patient waking up, not seizures.\n - Continue on higher dose keppra\n - F/u neuro recs\n - Wean off midazolam as tolerated with low dose valium to prevent\n withdrawal; monitor vitals\n #. Acute renal Failure: Appreciate renal recs.\n - Would dialyze for acidosis but likely does not need volume depletion.\n - Likely transition to HD today; f/u Renal recs\n - Aztreonam increased back to 2000mg q12h as back on CVVH\n - Will change Keppra to 1000mg Q24 with 500 mg after HD if he\n transitions to HD\n #. Adrenal Insufficiency: Unclear with stim if clear adrenal\n insufficiency but hypotension improving with steroids (lower pressor\n requirement) and improving eosinophilia\n - Weaned Hydrocort to 25mg Q8H today\n # ?HLH: Quantitative ferritin of 2660. Unlikely to have HLH.\n # Eosinophilia: Resolved on steroids and s/p med changes.\n ICU Care\n Nutrition:\n Nutren 2.0 () - 01:53 PM 50 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 08:15 PM\n PICC Line - 08:37 AM\n Dialysis Catheter - 08:55 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:ICU\n" }, { "category": "Nursing", "chartdate": "2131-06-17 00:00:00.000", "description": "Nursing Progress Note", "row_id": 681246, "text": "Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n On CRRT. Goal negative.\n Hemodynamically stable. Sedated on Fent/Versed.\n Hypotensive to high 80s x1 this shift.\n u/o marginal- approx ccs/hr. icteric & clear.\n Action:\n approx -30 ccs at midnight tonight.\n Flushed CRRT and gave pt small 200 cc bolus.\n Response:\n Plan:\n Respiration / Gas Exchange, Impaired\n Assessment:\n Mod oral secretions though pt continually biting down and preventing\n oral care.\n On TM 50% since this afternoon.\n ABGs wnl. RR 20s.\n When agitated or with stimulation. RR up to 30s though self resolves.\n LS clear, at times rhonchorous and wheezy.\n Action:\n Trach mask continued.\n Inhalers prn.\n Response:\n Plan:\n Impaired Skin Integrity\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Physician ", "chartdate": "2131-06-29 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 683707, "text": "Chief Complaint:\n 24 Hour Events:\n EEG - At 08:30 AM\n FEVER - 101.3\nF - 12:00 PM\n \n - blood cultures x 2\n - renal: if UOP adequate and Cr stable, can pull HD line Fri\n - neuro - plan for family meeting tomorrow, MRI showed diffuse subacute\n anoxic injury\n Allergies:\n Meropenem\n skin blisters a\n Last dose of Antibiotics:\n Micafungin - 10:00 PM\n Infusions:\n Other ICU medications:\n Fentanyl - 08:30 AM\n Heparin Sodium (Prophylaxis) - 11:36 AM\n Famotidine (Pepcid) - 11:37 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 04:56 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.5\nC (101.3\n Tcurrent: 37.4\nC (99.4\n HR: 115 (110 - 125) bpm\n BP: 121/69(86) {106/61(76) - 148/77(100)} mmHg\n RR: 31 (23 - 42) insp/min\n SpO2: 97%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 103.9 kg (admission): 113.5 kg\n Height: 67 Inch\n Total In:\n 1,360 mL\n 306 mL\n PO:\n TF:\n 1,200 mL\n 246 mL\n IVF:\n 100 mL\n Blood products:\n Total out:\n 1,640 mL\n 100 mL\n Urine:\n 1,640 mL\n 100 mL\n NG:\n Stool:\n Drains:\n Balance:\n -280 mL\n 206 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n SpO2: 97%\n ABG: ///21/\n Physical Examination\n Gen: in bed, eyes open, alert but very tachypneic\n CV: RR nl s1/s2\n Chest: good air movement\n Abd: distended +BS\n Ext: 3+ edema\n Neuro: eyes open, will blink/ to command, weak grasp\n Labs / Radiology\n 266 K/uL\n 6.6 g/dL\n 98 mg/dL\n 2.1 mg/dL\n 21 mEq/L\n 3.4 mEq/L\n 90 mg/dL\n 113 mEq/L\n 146 mEq/L\n 21.7 %\n 11.4 K/uL\n [image002.jpg]\n 02:00 AM\n 02:49 AM\n 01:51 AM\n 03:26 PM\n 03:37 PM\n 03:15 AM\n 03:19 AM\n 10:00 AM\n 04:00 PM\n 02:16 AM\n WBC\n 15.0\n 12.6\n 10.2\n 11.4\n Hct\n 22.5\n 22.1\n 21.5\n 21.7\n Plt\n 66\n Cr\n 3.0\n 2.9\n 2.7\n 2.6\n 2.1\n TCO2\n 24\n 23\n 22\n Glucose\n 128\n 80\n 129\n 194\n 192\n 200\n 211\n 98\n Other labs: PT / PTT / INR:13.6/28.0/1.2, CK / CKMB /\n Troponin-T:214/3/0.07, ALT / AST:75/115, Alk Phos / T Bili:408/5.5,\n Amylase / Lipase:77/88, Differential-Neuts:84.3 %, Band:0.0 %,\n Lymph:9.3 %, Mono:1.7 %, Eos:4.3 %, D-dimer:6389 ng/mL, Fibrinogen:541\n mg/dL, Lactic Acid:2.6 mmol/L, Albumin:2.3 g/dL, LDH:312 IU/L, Ca++:8.6\n mg/dL, Mg++:1.9 mg/dL, PO4:2.3 mg/dL\n Assessment and Plan\n FEVER, UNKNOWN ORIGIN (FUO, HYPERTHERMIA, PYREXIA)\n AROUSAL, ATTENTION, AND COGNITION, IMPAIRED\n BALANCE, IMPAIRED\n MOTOR FUNCTION, IMPAIRED\n MUSCLE PERFORMACE, IMPAIRED\n RESPIRATION / GAS EXCHANGE, IMPAIRED\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n IMPAIRED SKIN INTEGRITY\n HEPATITIS, ACUTE TOXIC (INCLUDING ALCOHOLIC, ACETAMINOPHEN, ETC.)\n 28 year old male with a history of alcoholism presenting with acute\n hepatitis, pancreatitis, and UGIB, with persistent cyclic\n fevers/leukocytosis.\n # Cyclic fevers/leukocytosis\n febrile to 101.3 yesterday AM, but WBC\n continues trending down. Sputum with 4+ GNR likely colonizer, as per\n ID, and sputum consistency remains unchanged. CXR without obvious\n pneumonia. C diff neg on . U/A weakly positive; cx showing 10k\n yeast. On micafungin as pt has been cx negative. Given temp spike,\n will draw another set of blood cx and order CXR. Consider CT. Other\n source lower on ddx includes peripancreatic fluid collection. Hesitant\n to re-do CT A/P given the contrast required.\n -ID recs CT abd to eval peripancreatic collection.\n -D/C a-line.\n -Will not start gancyclovir as CMV not likely cause of fevers, but will\n follow LFTs and if rising will see if correlates with CMV viral load.\n If correlation will will discuss starting gancyclovir with ID and\n renal.\n # Hypotension\n resolved, cont to monitor.\n # Respiratory failure\n on trach mask at 40% FIO2, tachypnic this AM.\n Will call thoracics re: position of trach (position seems low on cxr,\n marked on radiology report).\n # Acute renal failure\n stable and UOP improving (currently >60 cc/hr\n over last 24hrs.).\n -After renal sees Pt today will likely d/c HD line.\n # Altered mental status\n Given possibility of seizure activity, will\n continue keppra. MRI showing cerebral edema, poor prognosis as per\n neuro. EEG completed and report pending. Unclear how much of this is\n medication induced and how much is rehab correctable; would appreciate\n neuro recs regarding potential rehab.\n # Hyponatremia\n - correcting on free water boluses\n # Anemia\n stable. Will hold off transfusing given that pt currently\n febrile.\n # Hematemesis: resolved. Given alcohol history, potential\n consideration for variceal bleed. No known prior history of hepatic\n cirrhosis, but elevated INR and fatty liver infilatration would be\n consistent. Also should consider PUD or alcoholic gastritis. Hct was\n WNL on presentation, but patient markedly contracted. Continued bright\n red blood on NG lavage suggests some degree of continued active\n bleeding.\n -- hepatology consulted, EGD showing diulefoy lesion\n -- access with 2 large bore IVs and a cordis, T + C x 3 units\n -- IV PPI + PPI gtt\n .\n # Pancreatitis: Most likely alcoholic in etiology, with elevated lipase\n to 1600 and CT findings consistent without necrosis, cycts, or\n phlemgon. Only mild epigastric tenderness and no complaints of\n abdominal pain.\n -- continue aggessive hydration\n -- serial abdominal exams\n -- trend lipase\n -- no evidence of obstruction, holding off on further imaging at this\n time\n -- cont post pyloric TF\n -- to hold off on any drainage of new peripancreatic fluid collection\n but will discuss with Dr \n # Acute Hepatitis: Likely alcoholic hepatitis. CT scan shows fatty\n infiltration, and no evidence of distal ostruction.\n - check viral hepatitis panel, although degree of transaminitis not\n consistant with such an etiology.\n - holding off on further imaging for now, f/u final CT read\n - hepatology following\n - avoid hepatically cleared meds\n - trend LFTs\n # Alcoholism: Patient describes history of withdrawal symptoms, but\n not prior seizure. Last drink was night prior to presentation.\n Tachycardia, weakness, and elevated lactate could be consistent with\n thiamine deficiency.\n - repleate thiamine, vb12, folate\n - ativan with CIWA > 10\n - addictions consult\n # FEN: IVF, replete electrolytes, NPO\n ICU Care\n Nutrition:\n Nutren 2.0 () - 01:27 PM 50 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 08:15 PM\n PICC Line - 08:37 AM\n Dialysis Catheter - 08:55 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:ICU\n" }, { "category": "Physician ", "chartdate": "2131-06-29 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 683716, "text": "Chief Complaint: pancreatitis, resp failure, anoxic brain injruy\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 EEG - At 08:30 AM\n BLOOD CULTURED - At 09:00 PM\n Peripheral BC sent\n FEVER - 101.3\nF - 12:00 PM\n Allergies:\n Meropenem\n skin blisters a\n Last dose of Antibiotics:\n Micafungin - 10:00 PM\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 11:37 AM\n Heparin Sodium (Prophylaxis) - 04:00 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 Flowsheet Data as of 09:13 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.5\nC (101.3\n Tcurrent: 38.1\nC (100.5\n HR: 120 (110 - 125) bpm\n BP: 121/67(85) {110/61(76) - 148/77(100)} mmHg\n RR: 32 (23 - 37) insp/min\n SpO2: 96%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 103.3 kg (admission): 113.5 kg\n Height: 67 Inch\n Total In:\n 1,460 mL\n 519 mL\n PO:\n TF:\n 1,200 mL\n 459 mL\n IVF:\n 200 mL\n Blood products:\n Total out:\n 1,640 mL\n 645 mL\n Urine:\n 1,640 mL\n 645 mL\n NG:\n Stool:\n Drains:\n Balance:\n -180 mL\n -126 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n SpO2: 96%\n ABG: ///21/\n Physical Examination\n Labs / Radiology\n 6.6 g/dL\n 266 K/uL\n 98 mg/dL\n 2.1 mg/dL\n 21 mEq/L\n 3.4 mEq/L\n 90 mg/dL\n 113 mEq/L\n 146 mEq/L\n 21.7 %\n 11.4 K/uL\n [image002.jpg]\n 02:00 AM\n 02:49 AM\n 01:51 AM\n 03:26 PM\n 03:37 PM\n 03:15 AM\n 03:19 AM\n 10:00 AM\n 04:00 PM\n 02:16 AM\n WBC\n 15.0\n 12.6\n 10.2\n 11.4\n Hct\n 22.5\n 22.1\n 21.5\n 21.7\n Plt\n 66\n Cr\n 3.0\n 2.9\n 2.7\n 2.6\n 2.1\n TCO2\n 24\n 23\n 22\n Glucose\n 128\n 80\n 129\n 194\n 192\n 200\n 211\n 98\n Other labs: PT / PTT / INR:13.6/28.0/1.2, CK / CKMB /\n Troponin-T:214/3/0.07, ALT / AST:75/115, Alk Phos / T Bili:408/5.5,\n Amylase / Lipase:77/88, Differential-Neuts:84.3 %, Band:0.0 %,\n Lymph:9.3 %, Mono:1.7 %, Eos:4.3 %, D-dimer:6389 ng/mL, Fibrinogen:541\n mg/dL, Lactic Acid:2.6 mmol/L, Albumin:2.3 g/dL, LDH:312 IU/L, Ca++:8.6\n mg/dL, Mg++:1.9 mg/dL, PO4:2.3 mg/dL\n Assessment and Plan\n FEVER, UNKNOWN ORIGIN (FUO, HYPERTHERMIA, PYREXIA)\n AROUSAL, ATTENTION, AND COGNITION, IMPAIRED\n BALANCE, IMPAIRED\n MOTOR FUNCTION, IMPAIRED\n MUSCLE PERFORMACE, IMPAIRED\n RESPIRATION / GAS EXCHANGE, IMPAIRED\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n IMPAIRED SKIN INTEGRITY\n HEPATITIS, ACUTE TOXIC (INCLUDING ALCOHOLIC, ACETAMINOPHEN, ETC.)\n 1. Cyclical fevers\n single spike today after 3 days without.\n WBC trend is down and hemodynamically stable. We have been weaning off\n ABX since nothing has grown\n will continue only micafungin while\n monitoring culture data. Will got blood cx off HD line. Does have GNR\n in sputum but is likely colonized\n repeat CXR without infiltrate. For\n now would not empirically Rx for GNR PNA unless CXR change with phlegm\n chage and infiltrates but will follow closely. ABd still a potential\n culprit re pancreatic fluid collection but again this is one fever-\n lets follow clinically and re eval.\n 2. Hypotension: resolved\n watch carefully now that he is spiking\n as he has a tendency to drop his MAPs\n 3. Resp Failure: on trach mask and holding his own, though is\n tachyneic this AM w fevers\n 4. Altered Mental status: Given possibility of sz activity, will\n continue keppra. MRI and EEH done to help with work up\n 5. For ARF: making good urine this AM, hold off on HD\n 6. For pancreatitis, will continue post-pyloric TFs, and will\n continue to hold off on any drainage of new peripancreatic fluid\n collection but will discuss with Dr \n Remaining issues as per Housestaff\n ICU Care\n Nutrition:\n Nutren 2.0 () - 01:27 PM 50 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 08:15 PM\n PICC Line - 08:37 AM\n Dialysis Catheter - 08:55 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent:\n" }, { "category": "Physician ", "chartdate": "2131-06-29 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 683717, "text": "Chief Complaint: pancreatitis, resp failure, anoxic brain injruy\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 EEG - At 08:30 AM\n BLOOD CULTURED - At 09:00 PM\n Peripheral BC sent\n FEVER - 101.3\nF - 12:00 PM\n Allergies:\n Meropenem\n skin blisters a\n Last dose of Antibiotics:\n Micafungin - 10:00 PM\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 11:37 AM\n Heparin Sodium (Prophylaxis) - 04:00 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 Flowsheet Data as of 09:13 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.5\nC (101.3\n Tcurrent: 38.1\nC (100.5\n HR: 120 (110 - 125) bpm\n BP: 121/67(85) {110/61(76) - 148/77(100)} mmHg\n RR: 32 (23 - 37) insp/min\n SpO2: 96%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 103.3 kg (admission): 113.5 kg\n Height: 67 Inch\n Total In:\n 1,460 mL\n 519 mL\n PO:\n TF:\n 1,200 mL\n 459 mL\n IVF:\n 200 mL\n Blood products:\n Total out:\n 1,640 mL\n 645 mL\n Urine:\n 1,640 mL\n 645 mL\n NG:\n Stool:\n Drains:\n Balance:\n -180 mL\n -126 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n SpO2: 96%\n ABG: ///21/\n Physical Examination\n Labs / Radiology\n 6.6 g/dL\n 266 K/uL\n 98 mg/dL\n 2.1 mg/dL\n 21 mEq/L\n 3.4 mEq/L\n 90 mg/dL\n 113 mEq/L\n 146 mEq/L\n 21.7 %\n 11.4 K/uL\n [image002.jpg]\n 02:00 AM\n 02:49 AM\n 01:51 AM\n 03:26 PM\n 03:37 PM\n 03:15 AM\n 03:19 AM\n 10:00 AM\n 04:00 PM\n 02:16 AM\n WBC\n 15.0\n 12.6\n 10.2\n 11.4\n Hct\n 22.5\n 22.1\n 21.5\n 21.7\n Plt\n 66\n Cr\n 3.0\n 2.9\n 2.7\n 2.6\n 2.1\n TCO2\n 24\n 23\n 22\n Glucose\n 128\n 80\n 129\n 194\n 192\n 200\n 211\n 98\n Other labs: PT / PTT / INR:13.6/28.0/1.2, CK / CKMB /\n Troponin-T:214/3/0.07, ALT / AST:75/115, Alk Phos / T Bili:408/5.5,\n Amylase / Lipase:77/88, Differential-Neuts:84.3 %, Band:0.0 %,\n Lymph:9.3 %, Mono:1.7 %, Eos:4.3 %, D-dimer:6389 ng/mL, Fibrinogen:541\n mg/dL, Lactic Acid:2.6 mmol/L, Albumin:2.3 g/dL, LDH:312 IU/L, Ca++:8.6\n mg/dL, Mg++:1.9 mg/dL, PO4:2.3 mg/dL\n Assessment and Plan\n FEVER, UNKNOWN ORIGIN (FUO, HYPERTHERMIA, PYREXIA)\n AROUSAL, ATTENTION, AND COGNITION, IMPAIRED\n BALANCE, IMPAIRED\n MOTOR FUNCTION, IMPAIRED\n MUSCLE PERFORMACE, IMPAIRED\n RESPIRATION / GAS EXCHANGE, IMPAIRED\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n IMPAIRED SKIN INTEGRITY\n HEPATITIS, ACUTE TOXIC (INCLUDING ALCOHOLIC, ACETAMINOPHEN, ETC.)\n 1. Cyclical fevers\n single spike yesterday after 3 days\n without. WBC trend is down and hemodynamically stable. We have been\n weaning off ABX since nothing has grown\n will continue only micafungin\n while monitoring culture data. CXR without infiltrate. ABD still a\n potential culprit re pancreatic fluid collection but again this is one\n fever- lets follow clinically and re eval. Discuss with who is\n covering for role re imaging and his take on duration of Mica.\n CMV level slightly up- would not empirically treat\n trend lfts\n 2. Hypotension: resolved\n watch carefully now that he is spiking\n as he has a tendency to drop his MAPs\n 3. Resp Failure: on trach mask and holding his own, though is\n tachyneic at times\n 4. Altered Mental status: MRI with concerning anxois findings,\n await final read of EEG. Dr to see and discuss prognosis.\n 5. For ARF: making good urine this AM, hold off on HD, replete\n free water and lytes,\n 6. For pancreatitis, will continue post-pyloric TFs, and will\n continue to hold off on any drainage of new peripancreatic fluid\n collection but will discuss with Dr \n Remaining issues as per Housestaff\n ICU Care\n Nutrition:\n Nutren 2.0 () - 01:27 PM 50 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 08:15 PM\n PICC Line - 08:37 AM\n Dialysis Catheter - 08:55 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent:\n" }, { "category": "Physician ", "chartdate": "2131-06-29 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 683719, "text": "Chief Complaint: pancreatitis, resp failure, anoxic brain injruy\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 EEG - At 08:30 AM\n BLOOD CULTURED - At 09:00 PM\n Peripheral BC sent\n FEVER - 101.3\nF - 12:00 PM\n Allergies:\n Meropenem\n skin blisters a\n Last dose of Antibiotics:\n Micafungin - 10:00 PM\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 11:37 AM\n Heparin Sodium (Prophylaxis) - 04:00 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 Flowsheet Data as of 09:13 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.5\nC (101.3\n Tcurrent: 38.1\nC (100.5\n HR: 120 (110 - 125) bpm\n BP: 121/67(85) {110/61(76) - 148/77(100)} mmHg\n RR: 32 (23 - 37) insp/min\n SpO2: 96%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 103.3 kg (admission): 113.5 kg\n Height: 67 Inch\n Total In:\n 1,460 mL\n 519 mL\n PO:\n TF:\n 1,200 mL\n 459 mL\n IVF:\n 200 mL\n Blood products:\n Total out:\n 1,640 mL\n 645 mL\n Urine:\n 1,640 mL\n 645 mL\n NG:\n Stool:\n Drains:\n Balance:\n -180 mL\n -126 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n SpO2: 96%\n ABG: ///21/\n Physical Examination\n Gen: in bed, eyes open, alert coughing\n CV: RR\n Chest: good air movement but coarse BS\n Abd: distended +BS\n Ext: 3+ edema\n Neuro: eyes open, will blink/lcose to command, weak grasp,\n Labs / Radiology\n 6.6 g/dL\n 266 K/uL\n 98 mg/dL\n 2.1 mg/dL\n 21 mEq/L\n 3.4 mEq/L\n 90 mg/dL\n 113 mEq/L\n 146 mEq/L\n 21.7 %\n 11.4 K/uL\n [image002.jpg]\n 02:00 AM\n 02:49 AM\n 01:51 AM\n 03:26 PM\n 03:37 PM\n 03:15 AM\n 03:19 AM\n 10:00 AM\n 04:00 PM\n 02:16 AM\n WBC\n 15.0\n 12.6\n 10.2\n 11.4\n Hct\n 22.5\n 22.1\n 21.5\n 21.7\n Plt\n 66\n Cr\n 3.0\n 2.9\n 2.7\n 2.6\n 2.1\n TCO2\n 24\n 23\n 22\n Glucose\n 128\n 80\n 129\n 194\n 192\n 200\n 211\n 98\n Other labs: PT / PTT / INR:13.6/28.0/1.2, CK / CKMB /\n Troponin-T:214/3/0.07, ALT / AST:75/115, Alk Phos / T Bili:408/5.5,\n Amylase / Lipase:77/88, Differential-Neuts:84.3 %, Band:0.0 %,\n Lymph:9.3 %, Mono:1.7 %, Eos:4.3 %, D-dimer:6389 ng/mL, Fibrinogen:541\n mg/dL, Lactic Acid:2.6 mmol/L, Albumin:2.3 g/dL, LDH:312 IU/L, Ca++:8.6\n mg/dL, Mg++:1.9 mg/dL, PO4:2.3 mg/dL\n Assessment and Plan\n FEVER, UNKNOWN ORIGIN (FUO, HYPERTHERMIA, PYREXIA)\n AROUSAL, ATTENTION, AND COGNITION, IMPAIRED\n BALANCE, IMPAIRED\n MOTOR FUNCTION, IMPAIRED\n MUSCLE PERFORMACE, IMPAIRED\n RESPIRATION / GAS EXCHANGE, IMPAIRED\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n IMPAIRED SKIN INTEGRITY\n HEPATITIS, ACUTE TOXIC (INCLUDING ALCOHOLIC, ACETAMINOPHEN, ETC.)\n 1. Cyclical fevers\n single spike yesterday after 3 days\n without. WBC trend is down and hemodynamically stable. We have been\n weaning off ABX since nothing has grown\n will continue only micafungin\n while monitoring culture data. CXR without infiltrate. ABD still a\n potential culprit re pancreatic fluid collection but again this is one\n fever- lets follow clinically and re eval. Discuss with who is\n covering for role re imaging and his take on duration of Mica.\n CMV level slightly up- would not empirically treat\n trend lfts\n 2. Hypotension: resolved\n watch carefully now that he is spiking\n as he has a tendency to drop his MAPs\n 3. Resp Failure: on trach mask and holding his own, though is\n tachyneic at times\n 4. Altered Mental status: MRI with concerning anxois findings,\n await final read of EEG. Dr to see and discuss prognosis. His\n brother would like to meet w Dr today\n 5. For ARF: making good urine this AM, hold off on HD, replete\n free water and lytes,\n 6. For pancreatitis, will continue post-pyloric TFs, and will\n continue to hold off on any drainage of new peripancreatic fluid\n collection but will discuss with Dr \n Remaining issues as per Housestaff\n ICU Care\n Nutrition:\n Nutren 2.0 () - 01:27 PM 50 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 08:15 PM\n PICC Line - 08:37 AM\n Dialysis Catheter - 08:55 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent:\n" }, { "category": "Rehab Services", "chartdate": "2131-06-29 00:00:00.000", "description": "Physical Therapy Progress Note", "row_id": 683721, "text": "Subjective:\n Pt makes eye contact 25% of the time.\n Objective:\n Follow up PT visit to address goals of: . Patient seen today\n for balance training, therapeutic exercise (Bilateral UE, bilateral\n LE), patient education, other: (Bed mobility)\n Updated medical status: MRA: Likely subacute anoxic brain\n injury, increasing ventriculomegaly. Fever spike of unclear\n origin. EEG results pending. Pt showing signs of renal recovery. WBC\n 11.4, Hct 21.7, Hgb 6.6, Plt 266, Temp 98.2\n Activity\n Clarification\n I\n S\n CG\n Min\n Mod\n Max\n Rolling:\n\n\n\n\n T\n Supine/\n Sidelying to Sit:\n\n\n\n\n\n Transfer:\n\n\n\n\n\n Sit to Stand:\n\n\n\n\n\n Ambulation:\n\n\n\n\n\n Stairs:\n\n\n\n\n\n Aerobic Activity Response:\n Position\n HR\n BP\n RR\n O[2] sat\n RPE\n Rest\n Supine\n 122\n 110/62\n 40\n 95% on 40% TC\n Activity\n Supine\n 123\n /\n 30-47\n Recovery\n Supine\n 120\n 107/60\n 35\n 98% on 40% TC\n Total distance walked:\n Minutes:\n Gait: Not assessed\n Balance: Deferred secondary to tachycardia and tachypnea at rest.\n Education / Communication: Pt educated on PT plan of care,\n participation in task/activity.\n Other: Cognition: Pt follows commands 10% of the time, but decreases as\n session continues.Initially Pt able to track L to R, but then only\n tracks from R to just past midline with movement, but returns to R. Pt\n closes eyes during activity and needs sternal rub and cuticle pressure\n to re-orient to task.\n Pulmonary: Pt demonstrates spontaneous wet productive cough with yellow\n sputum. Cough strength improves with midline orientiation and HOB\n elevated. Pt does not follow cough commands.\n Motor Function/Control: Active assist for B UE for shoulder flexion.\n Myoclonus present in all extremities, worsens with cues to move\n extremities. With R-LE moved to EOB with feet hanging off edge, Pt\n makes attempt to prevent R-LE falling off of bed using hip flexors,\n internal rotation, and quad trace movements observed. Once on bed, Pt\n shows movement to internal rotation. Repeated on L with no reaction.\n With coughing and suction, B-LE internal rotation observed. Pt unable\n to move toes with cues.\n Assessment: 28 y/o M adm with acute pancreatitis needing intubation\n during admission who continues to perform below baseline. While LE\n movement observed, question purposeful versus spontaneous movement,\n although R LE appeared more purposeful versus L LE. In the setting of\n MRA results of anoxic brain injury and LE motor recovery, along with\n patient age and family support, Pt would benefit from acute rehab to\n optimize function. Pt's progress may be limited by decreased attention\n to task and following commands, functional and systemic changes in the\n setting of prolonged alcohol abuse, and his delayed progress during\n hospital stay. Pt will continue to benefit from PT to progress toward\n goals.\n Anticipated Discharge: Rehab\n Plan: Continue to follow pt daily as schedule permits\n Balance training\n Therex\n Bed mobility\n Pt Education\n RN Recommendations: lift or slideboard to stretcher chair for OOB\n c RN A x .\n Face Time: 8:38-9:19am\n , Pt/s \n" }, { "category": "Nursing", "chartdate": "2131-06-15 00:00:00.000", "description": "Nursing Progress Note", "row_id": 681024, "text": " Problem\n Condition update\n Assessment:\n Resp\nvent weaned to cpap 5/5/ this am\n Tunneled dialysis cath and PICC line placed in IR\n TPN off, on tube feeds at goal\n Belly soft, +bowel sounds and moving bowels (negative for cdif)\n Currently off dialysis, lytes okay and renal/MICU team to decide hemo\n vs. CRRT\n Can manage care of patient with PICC, and okay per team to remove CVL\n Action:\n OOB to chair today\n Trach collar wean for 2 hrs.\n Tube feeds remain at goal\n CVL out\n Response:\n Tolerated trach collar well with resp. rate 30-low 40s with good\n gases.\n At end of wean, resp. rate to mid 60s (?neuro in origin). Lungs clear\n Placed back of CPAP with 5-8 pressure support\n Plan:\n Continue with daily OOB and trach wean.\n Perhaps try trach collar wean twice during day\n Dialysis per renal\n Family support\n" }, { "category": "Physician ", "chartdate": "2131-07-02 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 684449, "text": "Chief Complaint:\n 24 Hour Events:\n -pt did cough up some yellowish sputum into trach mask - ordered sputum\n cultures\n -1530 - called to bedside because pt's mother concerned about his\n tachynpea - ordered a CXR and ABG\n - - called to bedside re: pt's tachypnea and tachycardia - breath\n sounds stable\n -at that time, also notified by RN that sodium is 152 - increased free\n water flushes to 400 q4hr\n Allergies:\n Meropenem\n skin blisters\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 04:11 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 05:56 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: 119 (105 - 122) bpm\n BP: 91/64(71) {91/39(61) - 143/107(118)} mmHg\n RR: 31 (27 - 45) insp/min\n SpO2: 99%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 103.3 kg (admission): 113.5 kg\n Height: 67 Inch\n Total In:\n 2,317 mL\n 697 mL\n PO:\n TF:\n 1,217 mL\n 297 mL\n IVF:\n 100 mL\n Blood products:\n Total out:\n 1,225 mL\n 350 mL\n Urine:\n 1,225 mL\n 350 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,092 mL\n 347 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n SpO2: 99%\n ABG: 7.35/35/89 /20/-5\n PaO2 / FiO2: 178\n Physical Examination\n General\n alert, does not respond to commands\n CV\n tachycardic, regular rhythm, no murmurs, rubs, or gallops\n Resp\n clear to auscultation anteriorly\n Abdomen\n soft, non-tender, distended, bowel sounds present\n Extremities\n 2+ pitting edema noted in the lower extremities\n Labs / Radiology\n 327 K/uL\n 6.8 g/dL\n 97 mg/dL\n 1.3 mg/dL\n 20 mEq/L\n 4.8 mEq/L\n 75 mg/dL\n 124 mEq/L\n 152 mEq/L\n 22.3 %\n 10.5 K/uL\n [image002.jpg]\n 03:19 AM\n 10:00 AM\n 04:00 PM\n 02:16 AM\n 04:14 PM\n 10:00 PM\n 02:32 AM\n 04:25 AM\n 03:56 PM\n 02:32 AM\n WBC\n 11.4\n 10.9\n 11.0\n 10.5\n Hct\n 21.7\n 22.2\n 22.5\n 22.3\n Plt\n 266\n 290\n 310\n 327\n Cr\n 2.1\n 2.0\n 1.9\n 1.6\n 1.3\n TCO2\n 22\n 20\n Glucose\n 192\n 200\n 211\n 98\n 151\n 177\n 116\n 161\n 97\n Other labs: PT / PTT / INR:13.6/28.0/1.2, CK / CKMB /\n Troponin-T:214/3/0.07, ALT / AST:91/137, Alk Phos / T Bili:318/4.1,\n Amylase / Lipase:78/91, Differential-Neuts:57.0 %, Band:4.0 %,\n Lymph:23.0 %, Mono:4.0 %, Eos:3.0 %, D-dimer:6389 ng/mL, Fibrinogen:541\n mg/dL, Lactic Acid:2.6 mmol/L, Albumin:2.3 g/dL, LDH:437 IU/L, Ca++:9.1\n mg/dL, Mg++:2.0 mg/dL, PO4:4.9 mg/dL\n Assessment and Plan\n 28 year old male with a history of alcoholism presenting with acute\n hepatitis, pancreatitis, and UGIB, with persistent cyclic\n fevers/leukocytosis and anoxic brain injury.\n # Cyclic fevers/leukocytosis\n Tmax 100.0 overnight. WBC at 10.5\n still stable/trending down.\n - will tolerate slight fevers as long as patient does not have clinical\n deterioration or WBC elevations\n - off abx\n - Cdiff negative \n - sputum cultures\n moderate growth GNR resembling acinetobacter\n (susceptibilities done). Likely colonization.\n - will recheck sputum cultures\n - blood cultures pending\n - will not start gancyclovir at this point - CMV not likely cause of\n fevers. Per yesterday\ns progress note, will follow LFTs and if rising\n will see if correlates with CMV viral load. If so, will discuss with\n renal and ID.\n - will order an abdominal CT in the next few days to reevaluate\n peripancreatic fluid.\n # Respiratory failure\n Pt is on trach mask at 40% FIO2.\n - Pt is still tachypneic. (RR 27-40).\n - Considering pt\ns neuro findings, this may be centrally-driven.\n # Acute renal failure\n - pt put out 1.5 L urine yesterday; good UOP\n - will continue to follow UOP, BUN, and Cr\n # Altered mental status/anoxic brain injury\n pt had MRI that showed\n diffuse subacute anoxic injury involving the basal ganglia and cortex\n - poor prognosis per neuro.\n - pt will need neuro rehab upon discharge from the MICU\n # Anemia\n - Hct stable\n - continue to monitor Hct\n # Acute Hepatitis: Likely alcoholic hepatitis. CT scan shows fatty\n infiltration, and no evidence of distal obstruction.\n - will continue to trend LFT\n - will also observe whether any rises in LFT\ns are correlated with\n rises in CMV titer\n # FEN: IVF, replete electrolytes, Nutren at 50 ml/hr\n ICU Care\n Nutrition:\n Nutren 2.0 () - 12:34 PM 50 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 08:37 AM\n Prophylaxis:\n DVT: heparin\n Stress ulcer: famotidine\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n" }, { "category": "Physician ", "chartdate": "2131-07-02 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 684456, "text": "Chief Complaint: resp failure, pancreatitis\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 Meropenem\n skin blisters a\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 04:11 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 01:18 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.8\nC (100\n Tcurrent: 37.4\nC (99.3\n HR: 121 (113 - 123) bpm\n BP: 107/74(83) {91/39(61) - 143/92(118)} mmHg\n RR: 28 (28 - 45) insp/min\n SpO2: 97%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 103.3 kg (admission): 113.5 kg\n Height: 67 Inch\n Total In:\n 2,317 mL\n 2,078 mL\n PO:\n TF:\n 1,217 mL\n 628 mL\n IVF:\n 100 mL\n 100 mL\n Blood products:\n Total out:\n 1,225 mL\n 350 mL\n Urine:\n 1,225 mL\n 350 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,092 mL\n 1,728 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n SpO2: 97%\n ABG: 7.35/35/89./20/-5\n PaO2 / FiO2: 178\n Physical Examination\n Gen: sitting up in chair, tachypneic\n CV: RR\n Chest: coarse bs bilat\n Abd soft +BS\n Ext: 1+ edema\n Neuro: eyes open, slightly tremulous\n Labs / Radiology\n 6.8 g/dL\n 327 K/uL\n 97 mg/dL\n 1.3 mg/dL\n 20 mEq/L\n 4.8 mEq/L\n 75 mg/dL\n 124 mEq/L\n 152 mEq/L\n 22.3 %\n 10.5 K/uL\n [image002.jpg]\n 03:19 AM\n 10:00 AM\n 04:00 PM\n 02:16 AM\n 04:14 PM\n 10:00 PM\n 02:32 AM\n 04:25 AM\n 03:56 PM\n 02:32 AM\n WBC\n 11.4\n 10.9\n 11.0\n 10.5\n Hct\n 21.7\n 22.2\n 22.5\n 22.3\n Plt\n 266\n 290\n 310\n 327\n Cr\n 2.1\n 2.0\n 1.9\n 1.6\n 1.3\n TCO2\n 22\n 20\n Glucose\n 192\n 200\n 211\n 98\n 151\n 177\n 116\n 161\n 97\n Other labs: PT / PTT / INR:13.6/28.0/1.2, CK / CKMB /\n Troponin-T:214/3/0.07, ALT / AST:91/137, Alk Phos / T Bili:318/4.1,\n Amylase / Lipase:78/91, Differential-Neuts:57.0 %, Band:4.0 %,\n Lymph:23.0 %, Mono:4.0 %, Eos:3.0 %, D-dimer:6389 ng/mL, Fibrinogen:541\n mg/dL, Lactic Acid:2.6 mmol/L, Albumin:2.3 g/dL, LDH:437 IU/L, Ca++:9.1\n mg/dL, Mg++:2.0 mg/dL, PO4:4.9 mg/dL\n Assessment and Plan\n FEVER, UNKNOWN ORIGIN (FUO, HYPERTHERMIA, PYREXIA)\n AROUSAL, ATTENTION, AND COGNITION, IMPAIRED\n BALANCE, IMPAIRED\n MOTOR FUNCTION, IMPAIRED\n MUSCLE PERFORMACE, IMPAIRED\n RESPIRATION / GAS EXCHANGE, IMPAIRED\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n IMPAIRED SKIN INTEGRITY\n HEPATITIS, ACUTE TOXIC (INCLUDING ALCOHOLIC, ACETAMINOPHEN, ETC.)\n 1. Cyclical fevers: stable off all ABX, CXR is improved and\n no focal sources. Overall stable WBC and this could be central. Should\n he spike and leukocytosis will pan cx, consider repeat abd imaging.\n 2. Resp Failure: on trach mask and holding his own, though is\n tachyneic at times\n again wonder if this is central\n 3. Altered Mental status: MRI with concerning anoxic feautures\n and prognosis from Dr was he could improve slightly but\n unlikely to recover dramatically.\n 4. For ARF: off HD, watching UOP\n Remaining issues as per Housestaff\n ICU Care\n Nutrition: TFs\n Glycemic Control:\n Lines:\n PICC Line - 08:37 AM\n Prophylaxis:\n DVT: sc hep\n Stress ulcer: PPI\n Communication: with family\n Code status: Full code\n Disposition : ICU but rescreen for rehab\n Total time spent:\n" }, { "category": "Physician ", "chartdate": "2131-07-03 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 684553, "text": "Chief Complaint:\n 24 Hour Events:\n - started on free water by IVF to correct hypernatremia\n - increased free water rate and repeated lytes at 0030 hrs\n - had lengthy discussion w/ family, who wants a 2nd opinion on\n potential for neuro recovery\n - speech and swallow eval for -muir valve entered\n - told by RN that pt had foley put back in\n Allergies:\n Meropenem\n skin blisters a\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 07:54 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 05:16 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.3\nC (100.9\n Tcurrent: 37.7\nC (99.9\n HR: 116 (111 - 123) bpm\n BP: 134/70(86) {92/61(70) - 138/106(113)} mmHg\n RR: 37 (28 - 48) insp/min\n SpO2: 95%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 99.5 kg (admission): 113.5 kg\n Height: 67 Inch\n Total In:\n 4,550 mL\n 1,351 mL\n PO:\n TF:\n 1,200 mL\n 263 mL\n IVF:\n 1,100 mL\n 788 mL\n Blood products:\n Total out:\n 750 mL\n 450 mL\n Urine:\n 750 mL\n 450 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,800 mL\n 901 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n SpO2: 95%\n ABG: ///18/\n Physical Examination\n Labs / Radiology\n 341 K/uL\n 6.7 g/dL\n 147 mg/dL\n 1.1 mg/dL\n 18 mEq/L\n 4.7 mEq/L\n 61 mg/dL\n 120 mEq/L\n 147 mEq/L\n 22.1 %\n 11.1 K/uL\n [image002.jpg]\n 02:16 AM\n 04:14 PM\n 10:00 PM\n 02:32 AM\n 04:25 AM\n 03:56 PM\n 02:32 AM\n 08:00 PM\n 12:35 AM\n 03:21 AM\n WBC\n 11.4\n 10.9\n 11.0\n 10.5\n 11.1\n Hct\n 21.7\n 22.2\n 22.5\n 22.3\n 22.1\n Plt\n 266\n 290\n 310\n 327\n 341\n Cr\n 2.1\n 2.0\n 1.9\n 1.6\n 1.3\n 1.2\n 1.2\n 1.1\n TCO2\n 20\n Glucose\n 98\n 151\n 177\n 116\n 161\n 97\n 93\n 147\n Other labs: PT / PTT / INR:13.6/28.0/1.2, CK / CKMB /\n Troponin-T:214/3/0.07, ALT / AST:91/137, Alk Phos / T Bili:318/4.1,\n Amylase / Lipase:78/91, Differential-Neuts:57.0 %, Band:4.0 %,\n Lymph:23.0 %, Mono:4.0 %, Eos:3.0 %, D-dimer:6389 ng/mL, Fibrinogen:541\n mg/dL, Lactic Acid:2.6 mmol/L, Albumin:2.3 g/dL, LDH:437 IU/L, Ca++:9.2\n mg/dL, Mg++:1.8 mg/dL, PO4:4.2 mg/dL\n Assessment and Plan\n 28 year old male with a history of alcoholism presenting with acute\n hepatitis, pancreatitis, and UGIB, with persistent cyclic\n fevers/leukocytosis and anoxic brain injury.\n # Cyclic fevers/leukocytosis\n Tmax 100.0 overnight. WBC at 10.5\n still stable/trending down.\n - will tolerate slight fevers as long as patient does not have clinical\n deterioration or WBC elevations\n - off abx\n - Cdiff negative \n - sputum cultures\n moderate growth GNR resembling acinetobacter\n (susceptibilities done). Likely colonization.\n - will recheck sputum cultures\n - blood cultures pending\n - will not start gancyclovir at this point - CMV not likely cause of\n fevers. Per yesterday\ns progress note, will follow LFTs and if rising\n will see if correlates with CMV viral load. If so, will discuss with\n renal and ID.\n - will order an abdominal CT in the next few days to reevaluate\n peripancreatic fluid.\n # Respiratory failure\n Pt is on trach mask at 40% FIO2.\n - Pt is still tachypneic. (RR 27-40).\n - Considering pt\ns neuro findings, this may be centrally-driven.\n # Acute renal failure\n - pt put out 1.5 L urine yesterday; good UOP\n - will continue to follow UOP, BUN, and Cr\n # Altered mental status/anoxic brain injury\n pt had MRI that showed\n diffuse subacute anoxic injury involving the basal ganglia and cortex\n - poor prognosis per neuro.\n - pt will need neuro rehab upon discharge from the MICU\n # Anemia\n - Hct stable\n - continue to monitor Hct\n # Acute Hepatitis: Likely alcoholic hepatitis. CT scan shows fatty\n infiltration, and no evidence of distal obstruction.\n - will continue to trend LFT\n - will also observe whether any rises in LFT\ns are correlated with\n rises in CMV titer\n # FEN: IVF, replete electrolytes, Nutren at 50 ml/hr\n ICU Care\n Nutrition:\n Nutren 2.0 () - 12:28 PM 50 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 08:37 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Rehab Services", "chartdate": "2131-06-15 00:00:00.000", "description": "Physical Therapy Evaluation Note", "row_id": 680998, "text": "Attending Physician: \n Referral date: \n Medical Diagnosis / ICD 9: pancreatitis /\n Reason of referral: Eval and tx\n History of Present Illness / Subjective Complaint: 28 yo gentleman with\n hx EtOH abuse, depression, admitted with hematemesis , found to\n have acute EtOH hepatitis, severe necrotizing pancreatitis, complicated\n hospital course with multiorgan failure, acute renal failure on CVVH,\n and ARDS, unable to wean from vent requiring trach. Pt had\n cardiopulmonary arrest secondary to the presence of clot in his\n tracheostomy tube . Also questionable seizure activity, head CT\n unremarkable. CVVHD stoped , and plan to start HD.\n Past Medical / Surgical History: EtOH, depression\n Medications: versed, fentynal, Diazepam , lasix, Aztreonam,\n Ciprofloxacin, Hydrocortisone\n Radiology: cxr : The lung opacities are unchanged\n as well. There is interval almost complete resolution of subcutaneous\n air as\n well as mediastinal air.\n Labs:\n 25.8\n 8.2\n 194\n 21.7\n [image002.jpg]\n Other labs:\n Activity Orders: Ok for OOB RN\n Social / Occupational History: Per chart pt has family involved in his\n care\n Living Environment: Unable to obtain information from patient\n Prior Functional Status / Activity Level: Assume indepentent PTA\n Objective Test\n Arousal / Attention / Cognition / Communication: Pt unable to follow\n commands, eyes briefly open when sitting at EOB. No attempts at\n communcitcation.\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 111\n 94/54\n 28\n 99% CPAP\n Rest\n /\n Sit\n 105\n 104/56\n 40\n 95% CPAP\n Activity\n /\n Stand\n /\n Recovery\n 108\n 93/52\n 99% CPAP\n Total distance walked:\n Minutes:\n Pulmonary Status: CPAP Peep5/Psup5. TV in supine .450-.500, TV sitting\n at EOB. 550-.600. TV in chair .460-.500. Shallow breathing pattern.\n Integumentary / Vascular: B LE with gauze dressing intact without signs\n of drainage, trach, NGT, foley, IJ, A-line, dialysis catheter,\n jaudenice.\n Sensory Integrity: Grimaces to nailbed pressure\n Pain / Limiting Symptoms: Pt tolerated evaluation\n Posture: recieved patient supine in bed\n Range of Motion\n Muscle Performance\n B UE and LE \n Pt spontaneouly moved L LE when sitting at EOB otherwise no active\n movement of any extremtily noted\n Motor Function: Pt with B UE tremor with ROM, No clonus B ankles.\n Functional Status:\n Activity\n Clarification\n I\n S\n CG\n Min\n Mod\n Max\n Gait, Locomotion: Transfer: Pt slide to stretcher chair with 3 person A\n Rolling:\n\n\n\n\n\n\n Supine /\n Sidelying to Sit:\n\n\n\n\n\n Transfer:\n\n\n\n\n\n Sit to Stand:\n\n\n\n\n\n Ambulation:\n\n\n\n\n\n Stairs:\n\n\n\n\n\n Balance: Pt demonstrated no psutral or balance reations at EOB.\n Required total A x 2 to achieve sitting at EOB and total A x 1 to\n maintain upright posture.\n Education / Communication: Pt status discussed with RN. Recommend\n nursing use slide board and strecher chair for transfers\n Intervention:\n Other:\n Diagnosis:\n 1.\n Arousal, Attention, and Cognition, Impaired\n 2.\n Balance, Impaired\n 3.\n Motor Function, Impaired\n 4.\n Muscle Performace, Impaired\n 5.\n Respiration / Gas Exchange, Impaired\n Clinical impression / Prognosis: 28 yo m admitted with necrotic\n pancreatisis with hospital course c/b ards, need for CVVHD, and pea\n arrest. Pt presents wtih above impairments c/w deconditioning.\n Evaluation was limited by patient being on versed, however it is safe\n to assume he has significant weakness and likely ICU related myopathy\n from prolonged bedrest and sedation. PT will f/u for further moiblity\n assessment as pt is able to participate. pt will require\n rehab upon discharge.\n Goals\n Time frame: 1wk\n 1.\n pt will maintain eyes open for > 20% of eval\n 2.\n Pt will follow commands\n 3.\n Pt will tolerate trach collar with SaO2> 94% t/o PT treatment\n 4.\n 5.\n 6.\n Anticipated Discharge: Rehab\n Treatment Plan:\n Frequency / Duration: 1-3x/wk\n f/u for further mobility assessment as sedatoin is weaned. rec use of\n stretcher chair and slide board\n Patient agrees with the above goals and is willing to participate in\n the rehabilitation program.\n" }, { "category": "Rehab Services", "chartdate": "2131-06-15 00:00:00.000", "description": "Physical Therapy Evaluation Note", "row_id": 681006, "text": "Attending Physician: \n Referral date: \n Medical Diagnosis / ICD 9: pancreatitis /\n Reason of referral: Eval and tx\n History of Present Illness / Subjective Complaint: 28 yo gentleman with\n hx EtOH abuse, depression, admitted with hematemesis , found to\n have acute EtOH hepatitis, severe necrotizing pancreatitis, complicated\n hospital course with multiorgan failure, acute renal failure on CVVH,\n and ARDS, unable to wean from vent requiring trach. Pt had\n cardiopulmonary arrest secondary to the presence of clot in his\n tracheostomy tube . Also questionable seizure activity, head CT\n unremarkable. CVVHD stopped , and plan to start HD.\n Past Medical / Surgical History: EtOH, depression\n Medications: versed, fentynal, Diazepam , lasix, Aztreonam,\n Ciprofloxacin, Hydrocortisone\n Radiology: cxr : The lung opacities are unchanged\n as well. There is interval almost complete resolution of subcutaneous\n air as\n well as mediastinal air.\n Labs:\n 25.8\n 8.2\n 194\n 21.7\n [image002.jpg]\n Other labs:\n Activity Orders: Ok for OOB RN\n Social / Occupational History: Per chart pt has family involved in his\n care\n Living Environment: Unable to obtain information from patient\n Prior Functional Status / Activity Level: Assume independent PTA\n Objective Test\n Arousal / Attention / Cognition / Communication: Pt unable to follow\n commands, eyes briefly open when sitting at EOB. No attempts at\n communication.\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 111\n 94/54\n 28\n 99% CPAP\n Rest\n /\n Sit\n 105\n 104/56\n 40\n 95% CPAP\n Activity\n /\n Stand\n /\n Recovery\n 108\n 93/52\n 99% CPAP\n Total distance walked:\n Minutes:\n Pulmonary Status: CPAP Peep5/Psup5. TV in supine .450-.500, TV sitting\n at EOB. 550-.600. TV in chair .460-.500. Shallow breathing pattern.\n Integumentary / Vascular: B LE with gauze dressing intact without signs\n of drainage, trach, NGT, foley, IJ, A-line, dialysis catheter,\n jaudenice.\n Sensory Integrity: Grimaces to nail bed pressure\n Pain / Limiting Symptoms: Pt tolerated evaluation\n Posture: received patient supine in bed\n Range of Motion\n Muscle Performance\n B UE and LE \n Pt spontaneously moved L LE when sitting at EOB otherwise no active\n movement of any extremity noted\n Motor Function: Pt with B UE tremor with ROM, No clonus B ankles.\n Functional Status:\n Activity\n Clarification\n I\n S\n CG\n Min\n Mod\n Max\n Gait, Locomotion: Transfer: Pt slide to stretcher chair with 3 person A\n Rolling:\n Total A\n\n\n\n\n\n\n Supine /\n Sidelying to Sit:\n Total A\n\n\n\n\n\n\n Transfer:\n\n\n\n\n\n Sit to Stand:\n\n\n\n\n\n Ambulation:\n\n\n\n\n\n Stairs:\n\n\n\n\n\n Balance: Pt demonstrated no postural or balance reactions at EOB.\n Required total A x 2 to achieve sitting at EOB and total A x 1 to\n maintain upright posture.\n Education / Communication: Pt status discussed with RN. Recommend\n nursing use slide board and stretcher chair for transfers\n Intervention:\n Other:\n Diagnosis:\n 1.\n Arousal, Attention, and Cognition, Impaired\n 2.\n Balance, Impaired\n 3.\n Motor Function, Impaired\n 4.\n Muscle Performance, Impaired\n 5.\n Respiration / Gas Exchange, Impaired\n Clinical impression / Prognosis: 28 yo m admitted with necrotic\n pancreatisis with hospital course c/b ards, need for CVVHD, and pea\n arrest. Pt presents with above impairments c/w deconditioning.\n Evaluation was limited by patient being on versed, however it is safe\n to assume he has significant weakness and likely ICU related myopathy\n from prolonged bedrest and sedation. PT will f/u for further mobility\n assessment as pt is able to participate. Anticipate pt will require\n rehab upon discharge.\n Goals\n Time frame: 1wk\n 1.\n pt will maintain eyes open for > 20% of eval\n 2.\n Pt will follow commands\n 3.\n Pt will tolerate trach collar with SaO2> 94% t/o PT treatment\n 4.\n 5.\n 6.\n Anticipated Discharge: Rehab\n Treatment Plan:\n Frequency / Duration: 1-3x/wk\n f/u for further mobility assessment as sedation is weaned. rec use of\n stretcher chair and slide board\n No due to mental status Patient agrees with the above goals and is\n willing to participate in the rehabilitation program.\n" }, { "category": "Physician ", "chartdate": "2131-06-16 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 681159, "text": "Chief Complaint:\n 24 Hour Events:\n PICC LINE - START 08:37 AM\n placed in IR\n DIALYSIS CATHETER - START 08:55 AM\n MULTI LUMEN - STOP 12:32 PM\n HD catheter removed and this line placed over wire\n \n - Renal: resume CVVH v. HD today depending on BP. Aztreonam decreased\n to 1000 q12 as off dialysis (no 500cc vials available).\n - SBP decreased to 70s. Given 500cc bolus with improvement. Changed\n cipro to flagyl.\n - Neuro: Repeat EEG without seizures.\n - Ferritin 2660\n Allergies:\n Meropenem\n skin blisters a\n Last dose of Antibiotics:\n Ciprofloxacin - 12:34 PM\n Aztreonam - 08:00 PM\n Linezolid - 10:07 PM\n Metronidazole - 12:00 AM\n Infusions:\n Midazolam (Versed) - 2 mg/hour\n Fentanyl (Concentrate) - 100 mcg/hour\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:00 PM\n Famotidine (Pepcid) - 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 06:57 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.3\nC (101\n Tcurrent: 37.8\nC (100.1\n HR: 93 (93 - 117) bpm\n BP: 81/38(52) {76/38(52) - 137/78(212)} mmHg\n RR: 32 (21 - 44) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 103.1 kg (admission): 113.5 kg\n Height: 67 Inch\n CVP: 10 (7 - 12)mmHg\n Total In:\n 3,899 mL\n 593 mL\n PO:\n TF:\n 1,203 mL\n 346 mL\n IVF:\n 2,696 mL\n 247 mL\n Blood products:\n Total out:\n 425 mL\n 135 mL\n Urine:\n 425 mL\n 135 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,474 mL\n 458 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 582 (391 - 582) mL\n PS : 5 cmH2O\n RR (Set): 22\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 55\n PIP: 13 cmH2O\n SpO2: 100%\n ABG: 7.34/30/113/16/-8\n Ve: 13.1 L/min\n PaO2 / FiO2: 226\n Physical Examination\n GEN: Trached, sedated\n HEENT: icteric sclera. MMM\n NECK: Trach site with no oozing.\n LUNGS: Anterior auscultation with upper airway noise; good airway\n movement\n HEART: RRR, normal; S1, S2\n ABD: Distended. Grimmacing with palpation.\n EXTREM: 2+ edema, ulcers/lesions on legs with bandages C/D/I\n SKIN: Jaundice\n NEURO: No twitching today. Did not open eyes to command.\n Labs / Radiology\n 243 K/uL\n 7.7 g/dL\n 154 mg/dL\n 2.4 mg/dL\n 16 mEq/L\n 4.7 mEq/L\n 120 mg/dL\n 97 mEq/L\n 130 mEq/L\n 23.2 %\n 26.4 K/uL\n [image002.jpg]\n 06:18 PM\n 07:58 PM\n 08:00 PM\n 01:31 AM\n 01:37 AM\n 04:30 AM\n 12:35 PM\n 06:31 PM\n 01:32 AM\n 03:05 AM\n WBC\n 24.4\n 21.7\n 26.4\n Hct\n 25.3\n 25.8\n 23.2\n Plt\n 193\n 194\n 243\n Cr\n 1.5\n 2.0\n 2.4\n TCO2\n 22\n 23\n 21\n 21\n 20\n 17\n Glucose\n 178\n 166\n 154\n Other labs: PT / PTT / INR:16.5/36.2/1.5, CK / CKMB /\n Troponin-T:214/3/0.07, ALT / AST:184/250, Alk Phos / T Bili:538/30.0,\n Amylase / Lipase:51/41, Differential-Neuts:68.0 %, Band:5.0 %,\n Lymph:7.0 %, Mono:4.0 %, Eos:0.0 %, D-dimer:6389 ng/mL, Fibrinogen:502\n mg/dL, Lactic Acid:1.4 mmol/L, Albumin:2.0 g/dL, LDH:706 IU/L, Ca++:8.5\n mg/dL, Mg++:2.6 mg/dL, PO4:4.8 mg/dL\n Assessment and Plan\n 28M with alcoholic hepatitis and necrotizing pancreatitis complicated\n by ARDS, SIRS, ARF, UGIB, fevers and eosinophilia\n #. ID: Febrile now for 2 days, increased WBC, with decreased BP. RUQ\n u/s concerning for sludge and pt started on cipro, but changed back to\n flagyl yesterday. Of note, had stopped flagyl and vanc po as C.\n diff neg x 2. Blood/tissue/BAL cx NGTD. It is possible that previous\n fevers had been masked by CVVH, which pt did not undergo yesterday\n - Cte broad spectrum antibiotic coverage with linezolid and aztreonam\n (D1 ) and flagyl (Added back ).\n - D/C CVL today if he has enough access\n - HIDA scan if bilirubin does not improve or hemodynamic instability\n over next few days\n - F/u WBC count, temp curve, and culture data\n - F/u ID recs\n - Cont steroid taper for possible adrenal insufficiency\n # Hyperbilirubinemia: Patient has had continuously increasing T Bili\n and alkaline phosphatase. Has alcoholic hepatitis but also on TPN. Bili\n stable today but increased alk phos and RUQ u/s with sludge concerning\n for cholestasis.\n - Check HIDA scan if bilirubin does not improve or hemodynamically\n unstable\n - TPN stopped \n - Weaning off benzos\n #. Respiratory Failure: ARDS secondary to necrotizing pancreatitis. S/p\n trach placement on . Sutures out on . ABG good on PS but\n transition to trach mask limited by respiratory rate.\n - Cont to wean vent with trach mask trial as tolerated\n - Increasing fentanyl patch while decreasing gtt, continue methadone\n - Attempt OOB to chair today to improve respiratory mechanics\n # Seizures: CT head without intracranial process. EEG showed occipital\n seizures which does not correlate with clinical symptoms, but repeat\n EEG on higher dose Keppra showed no seizures. actually be\n patient waking up, not seizures.\n - Continue on higher dose keppra\n - F/u neuro recs\n - Wean off midazolam as tolerated with low dose valium to prevent\n withdrawal; monitor vitals\n #. Acute renal Failure: Appreciate renal recs.\n - Would dialyze for acidosis but likely does not need volume depletion.\n - Likely transition to HD today; f/u Renal recs\n - will change Keppra to 1000mg Q24 with 500 mg after HD if he\n transitions to HD today.\n #. Adrenal Insufficiency: Unclear with stim if clear adrenal\n insufficiency but hypotension improving with steroids (lower pressor\n requirement) and improving eosinophilia\n - Wean Hydrocort to 25mg Q8H on \n # ?HLH: Quantitative ferritin of 2660.\n ICU Care\n Nutrition:\n Nutren 2.0 () - 01:53 PM 50 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 08:15 PM\n PICC Line - 08:37 AM\n Dialysis Catheter - 08:55 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:ICU\n" }, { "category": "Physician ", "chartdate": "2131-06-17 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 681313, "text": "Chief Complaint:\n 24 Hour Events:\n BLOOD CULTURED - At 11:30 AM\n PIV X2\n SPUTUM CULTURE - At 12:33 PM\n URINE CULTURE - At 12:33 PM\n FEVER - 101.2\nF - 08:00 AM\n \n - Renal recs: CVVH was started as he likely wouldn't tolerate HD due to\n low pressures.\n - Patient was continued on linezolid, aztreonam, and flagyl.\n - More tenderness in abd with concern for accalculus cholecystitis, but\n did not get HIDA scan as we would continue medical management. Will\n observe for now but if he decompensates, he may need a perc drain per\n IR.\n Allergies:\n Meropenem\n skin blisters a\n Last dose of Antibiotics:\n Ciprofloxacin - 12:34 PM\n Aztreonam - 08:05 PM\n Linezolid - 10:09 PM\n Metronidazole - 12:00 AM\n Infusions:\n Midazolam (Versed) - 1 mg/hour\n Fentanyl (Concentrate) - 50 mcg/hour\n Calcium Gluconate (CRRT) - 2.4 grams/hour\n Other ICU medications:\n Famotidine (Pepcid) - 01:30 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:34 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: 36.3\nC (97.3\n HR: 93 (85 - 108) bpm\n BP: 98/54(69) {81/38(52) - 124/70(91)} mmHg\n RR: 20 (19 - 32) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 103.1 kg (admission): 113.5 kg\n Height: 67 Inch\n Total In:\n 6,584 mL\n 2,432 mL\n PO:\n TF:\n 1,200 mL\n 278 mL\n IVF:\n 5,384 mL\n 2,154 mL\n Blood products:\n Total out:\n 6,966 mL\n 2,361 mL\n Urine:\n 487 mL\n 35 mL\n NG:\n Stool:\n Drains:\n Balance:\n -382 mL\n 71 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n Ventilator mode: Standby\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 0 (0 - 557) mL\n PS : 5 cmH2O\n RR (Set): 22\n RR (Spontaneous): 30\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 0 cmH2O\n SpO2: 100%\n ABG: 7.36/31/122/19/-6\n Ve: 13.5 L/min\n PaO2 / FiO2: 244\n Physical Examination\n GEN: Trached, sedated\n HEENT: icteric sclera. MMM\n NECK: Trach site with no oozing.\n LUNGS: Anterior auscultation with upper airway noise; good airway\n movement\n HEART: RRR, normal; S1, S2\n ABD: Distended. Grimmacing with palpation.\n EXTREM: 2+ edema, ulcers/lesions on legs with bandages C/D/I\n SKIN: Jaundice\n NEURO: Opening eyes to command. Purposeful movements of arms.\n Labs / Radiology\n 255 K/uL\n 7.7 g/dL\n 167 mg/dL\n 2.2 mg/dL\n 19 mEq/L\n 3.5 mEq/L\n 60 mg/dL\n 100 mEq/L\n 133 mEq/L\n 23.9 %\n 26.4 K/uL\n [image002.jpg]\n 06:31 PM\n 01:32 AM\n 03:05 AM\n 12:10 PM\n 01:36 PM\n 06:06 PM\n 06:23 PM\n 10:13 PM\n 04:13 AM\n 04:24 AM\n WBC\n 26.4\n Hct\n 23.2\n 23.9\n Plt\n 243\n 255\n Cr\n 2.0\n 2.4\n 2.2\n TCO2\n 17\n 16\n 18\n 19\n 19\n 18\n Glucose\n 166\n 154\n 162\n 220\n 67\n Other labs: PT / PTT / INR:16.1/32.9/1.4, CK / CKMB /\n Troponin-T:214/3/0.07, ALT / AST:211/247, Alk Phos / T Bili:564/29.7,\n Amylase / Lipase:51/41, Differential-Neuts:78.0 %, Band:3.0 %,\n Lymph:1.0 %, Mono:7.0 %, Eos:0.0 %, D-dimer:6389 ng/mL, Fibrinogen:502\n mg/dL, Lactic Acid:1.0 mmol/L, Albumin:2.0 g/dL, LDH:561 IU/L, Ca++:9.1\n mg/dL, Mg++:2.1 mg/dL, PO4:2.8 mg/dL\n Assessment and Plan\n 28M with alcoholic hepatitis and necrotizing pancreatitis complicated\n by ARDS, SIRS, ARF, UGIB, fevers.\n #. ID: Febrile now for 2 days, increased WBC, with decreased BP. RUQ\n u/s concerning for sludge and pt started flagyl. Of It is possible that\n previous fevers had been masked by CVVH, which he had been held x 2\n days. Since restarted yesterday no fevers.\n - Cte broad spectrum antibiotic coverage with linezolid and aztreonam\n (D1 ) and flagyl (added back )\n - Consider HIDA scan if bilirubin does not improve or hemodynamic\n instability over next few days as may need perc. drain\n - F/u WBC count, temp curve, and culture data\n - Cont steroid taper for possible adrenal insufficiency\n - Yeast in the urine- changed foley and re-cultured. If still with\n yeast will treat with anti-fungal.\n # Hyperbilirubinemia: T Bili stable. Has alcoholic hepatitis but was\n also on TPN. Bili. RUQ u/s with sludge concerning for cholestasis. Note\n that U/S also showed sludge.\n - Consider asking GI input for HIDA scan v. ERCP if hemodynamic\n instability\n - TPN stopped \n - Weaning off benzos\n #. Respiratory Failure: ARDS secondary to necrotizing pancreatitis. S/p\n trach placement on . Sutures out on . Currently on trach mask\n with good abg\n - Increasing fentanyl patch while decreasing gtt, continue methadone\n - Cte oob to chair daily\n # Seizures: CT head without intracranial process. EEG showed occipital\n seizures which does not correlate with clinical symptoms, but repeat\n EEG on higher dose Keppra showed no seizures. As patient now with\n purposeful movements it may actually be patient waking up, not\n seizures.\n - Continue on higher dose keppra\n - F/u neuro recs\n - Wean off midazolam as tolerated with low dose valium to prevent\n withdrawal; monitor vitals\n #. Acute renal Failure: Appreciate renal recs.\n - Would dialyze for acidosis but likely does not need volume depletion\n as pressures borderline.\n - Cte CVVH while pressures low but consider HD when more stable\n - Aztreonam increased back to 2000mg q12h as back on CVVH\n - Will change Keppra to 1000mg Q24 with 500 mg after HD if he\n transitions to HD\n #. Adrenal Insufficiency: Unclear with stim if clear adrenal\n insufficiency but hypotension improving with steroids (lower pressor\n requirement) and improving eosinophilia\n - Weaned Hydrocort to 25mg Q8H (Day )\n ICU Care\n Nutrition:\n Nutren 2.0 () - 01:46 PM 50 mL/hour\n Glycemic Control: ISS\n Lines:\n Arterial Line - 08:15 PM\n PICC Line - 08:37 AM\n Dialysis Catheter - 08:55 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:ICU\n" }, { "category": "Physician ", "chartdate": "2131-07-02 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 684335, "text": "Chief Complaint:\n 24 Hour Events:\n -pt did cough up some yellowish sputum into trach mask - ordered sputum\n cultures\n -1530 - called to bedside because pt's mother concerned about his\n tachynpea - ordered a CXR and ABG\n - - called to bedside re: pt's tachypnea and tachycardia - breath\n sounds stable\n -at that time, also notified by RN that sodium is 152 - increased free\n water flushes to 400 q4hr\n Allergies:\n Meropenem\n skin blisters a\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 04:11 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 05:56 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: 119 (105 - 122) bpm\n BP: 91/64(71) {91/39(61) - 143/107(118)} mmHg\n RR: 31 (27 - 45) insp/min\n SpO2: 99%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 103.3 kg (admission): 113.5 kg\n Height: 67 Inch\n Total In:\n 2,317 mL\n 697 mL\n PO:\n TF:\n 1,217 mL\n 297 mL\n IVF:\n 100 mL\n Blood products:\n Total out:\n 1,225 mL\n 350 mL\n Urine:\n 1,225 mL\n 350 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,092 mL\n 347 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n SpO2: 99%\n ABG: 7.35/35/89./20/-5\n PaO2 / FiO2: 178\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 327 K/uL\n 6.8 g/dL\n 97 mg/dL\n 1.3 mg/dL\n 20 mEq/L\n 4.8 mEq/L\n 75 mg/dL\n 124 mEq/L\n 152 mEq/L\n 22.3 %\n 10.5 K/uL\n [image002.jpg]\n 03:19 AM\n 10:00 AM\n 04:00 PM\n 02:16 AM\n 04:14 PM\n 10:00 PM\n 02:32 AM\n 04:25 AM\n 03:56 PM\n 02:32 AM\n WBC\n 11.4\n 10.9\n 11.0\n 10.5\n Hct\n 21.7\n 22.2\n 22.5\n 22.3\n Plt\n 266\n 290\n 310\n 327\n Cr\n 2.1\n 2.0\n 1.9\n 1.6\n 1.3\n TCO2\n 22\n 20\n Glucose\n 192\n 200\n 211\n 98\n 151\n 177\n 116\n 161\n 97\n Other labs: PT / PTT / INR:13.6/28.0/1.2, CK / CKMB /\n Troponin-T:214/3/0.07, ALT / AST:91/137, Alk Phos / T Bili:318/4.1,\n Amylase / Lipase:78/91, Differential-Neuts:57.0 %, Band:4.0 %,\n Lymph:23.0 %, Mono:4.0 %, Eos:3.0 %, D-dimer:6389 ng/mL, Fibrinogen:541\n mg/dL, Lactic Acid:2.6 mmol/L, Albumin:2.3 g/dL, LDH:437 IU/L, Ca++:9.1\n mg/dL, Mg++:2.0 mg/dL, PO4:4.9 mg/dL\n Assessment and Plan\n FEVER, UNKNOWN ORIGIN (FUO, HYPERTHERMIA, PYREXIA)\n AROUSAL, ATTENTION, AND COGNITION, IMPAIRED\n BALANCE, IMPAIRED\n MOTOR FUNCTION, IMPAIRED\n MUSCLE PERFORMACE, IMPAIRED\n RESPIRATION / GAS EXCHANGE, IMPAIRED\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n IMPAIRED SKIN INTEGRITY\n HEPATITIS, ACUTE TOXIC (INCLUDING ALCOHOLIC, ACETAMINOPHEN, ETC.)\n ICU Care\n Nutrition:\n Nutren 2.0 () - 12:34 PM 50 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 08:37 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": "2131-07-02 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 684337, "text": "Chief Complaint:\n 24 Hour Events:\n -pt did cough up some yellowish sputum into trach mask - ordered sputum\n cultures\n -1530 - called to bedside because pt's mother concerned about his\n tachynpea - ordered a CXR and ABG\n - - called to bedside re: pt's tachypnea and tachycardia - breath\n sounds stable\n -at that time, also notified by RN that sodium is 152 - increased free\n water flushes to 400 q4hr\n Allergies:\n Meropenem\n skin blisters a\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 04:11 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 05:56 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: 119 (105 - 122) bpm\n BP: 91/64(71) {91/39(61) - 143/107(118)} mmHg\n RR: 31 (27 - 45) insp/min\n SpO2: 99%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 103.3 kg (admission): 113.5 kg\n Height: 67 Inch\n Total In:\n 2,317 mL\n 697 mL\n PO:\n TF:\n 1,217 mL\n 297 mL\n IVF:\n 100 mL\n Blood products:\n Total out:\n 1,225 mL\n 350 mL\n Urine:\n 1,225 mL\n 350 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,092 mL\n 347 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n SpO2: 99%\n ABG: 7.35/35/89./20/-5\n PaO2 / FiO2: 178\n Physical Examination\n General\n alert, does not respond to commands\n CV\n RRR, no murmurs, rubs, or gallops\n Resp\n clear to auscultation anteriorly\n Abdomen\n soft, non-tender, non-distended, bowel sounds present\n Extremities\n pitting edema noted in the lower extremities\n Labs / Radiology\n 327 K/uL\n 6.8 g/dL\n 97 mg/dL\n 1.3 mg/dL\n 20 mEq/L\n 4.8 mEq/L\n 75 mg/dL\n 124 mEq/L\n 152 mEq/L\n 22.3 %\n 10.5 K/uL\n [image002.jpg]\n 03:19 AM\n 10:00 AM\n 04:00 PM\n 02:16 AM\n 04:14 PM\n 10:00 PM\n 02:32 AM\n 04:25 AM\n 03:56 PM\n 02:32 AM\n WBC\n 11.4\n 10.9\n 11.0\n 10.5\n Hct\n 21.7\n 22.2\n 22.5\n 22.3\n Plt\n 266\n 290\n 310\n 327\n Cr\n 2.1\n 2.0\n 1.9\n 1.6\n 1.3\n TCO2\n 22\n 20\n Glucose\n 192\n 200\n 211\n 98\n 151\n 177\n 116\n 161\n 97\n Other labs: PT / PTT / INR:13.6/28.0/1.2, CK / CKMB /\n Troponin-T:214/3/0.07, ALT / AST:91/137, Alk Phos / T Bili:318/4.1,\n Amylase / Lipase:78/91, Differential-Neuts:57.0 %, Band:4.0 %,\n Lymph:23.0 %, Mono:4.0 %, Eos:3.0 %, D-dimer:6389 ng/mL, Fibrinogen:541\n mg/dL, Lactic Acid:2.6 mmol/L, Albumin:2.3 g/dL, LDH:437 IU/L, Ca++:9.1\n mg/dL, Mg++:2.0 mg/dL, PO4:4.9 mg/dL\n Assessment and Plan\n FEVER, UNKNOWN ORIGIN (FUO, HYPERTHERMIA, PYREXIA)\n AROUSAL, ATTENTION, AND COGNITION, IMPAIRED\n BALANCE, IMPAIRED\n MOTOR FUNCTION, IMPAIRED\n MUSCLE PERFORMACE, IMPAIRED\n RESPIRATION / GAS EXCHANGE, IMPAIRED\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n IMPAIRED SKIN INTEGRITY\n HEPATITIS, ACUTE TOXIC (INCLUDING ALCOHOLIC, ACETAMINOPHEN, ETC.)\n ICU Care\n Nutrition:\n Nutren 2.0 () - 12:34 PM 50 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 08:37 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": "2131-07-02 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 684339, "text": "Chief Complaint:\n 24 Hour Events:\n -pt did cough up some yellowish sputum into trach mask - ordered sputum\n cultures\n -1530 - called to bedside because pt's mother concerned about his\n tachynpea - ordered a CXR and ABG\n - - called to bedside re: pt's tachypnea and tachycardia - breath\n sounds stable\n -at that time, also notified by RN that sodium is 152 - increased free\n water flushes to 400 q4hr\n Allergies:\n Meropenem\n skin blisters a\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 04:11 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 05:56 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: 119 (105 - 122) bpm\n BP: 91/64(71) {91/39(61) - 143/107(118)} mmHg\n RR: 31 (27 - 45) insp/min\n SpO2: 99%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 103.3 kg (admission): 113.5 kg\n Height: 67 Inch\n Total In:\n 2,317 mL\n 697 mL\n PO:\n TF:\n 1,217 mL\n 297 mL\n IVF:\n 100 mL\n Blood products:\n Total out:\n 1,225 mL\n 350 mL\n Urine:\n 1,225 mL\n 350 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,092 mL\n 347 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n SpO2: 99%\n ABG: 7.35/35/89./20/-5\n PaO2 / FiO2: 178\n Physical Examination\n General\n alert, does not respond to commands\n CV\n RRR, no murmurs, rubs, or gallops\n Resp\n clear to auscultation anteriorly\n Abdomen\n soft, non-tender, non-distended, bowel sounds present\n Extremities\n pitting edema noted in the lower extremities\n Labs / Radiology\n 327 K/uL\n 6.8 g/dL\n 97 mg/dL\n 1.3 mg/dL\n 20 mEq/L\n 4.8 mEq/L\n 75 mg/dL\n 124 mEq/L\n 152 mEq/L\n 22.3 %\n 10.5 K/uL\n [image002.jpg]\n 03:19 AM\n 10:00 AM\n 04:00 PM\n 02:16 AM\n 04:14 PM\n 10:00 PM\n 02:32 AM\n 04:25 AM\n 03:56 PM\n 02:32 AM\n WBC\n 11.4\n 10.9\n 11.0\n 10.5\n Hct\n 21.7\n 22.2\n 22.5\n 22.3\n Plt\n 266\n 290\n 310\n 327\n Cr\n 2.1\n 2.0\n 1.9\n 1.6\n 1.3\n TCO2\n 22\n 20\n Glucose\n 192\n 200\n 211\n 98\n 151\n 177\n 116\n 161\n 97\n Other labs: PT / PTT / INR:13.6/28.0/1.2, CK / CKMB /\n Troponin-T:214/3/0.07, ALT / AST:91/137, Alk Phos / T Bili:318/4.1,\n Amylase / Lipase:78/91, Differential-Neuts:57.0 %, Band:4.0 %,\n Lymph:23.0 %, Mono:4.0 %, Eos:3.0 %, D-dimer:6389 ng/mL, Fibrinogen:541\n mg/dL, Lactic Acid:2.6 mmol/L, Albumin:2.3 g/dL, LDH:437 IU/L, Ca++:9.1\n mg/dL, Mg++:2.0 mg/dL, PO4:4.9 mg/dL\n Assessment and Plan\n 28 year old male with a history of alcoholism presenting with acute\n hepatitis, pancreatitis, and UGIB, with persistent cyclic\n fevers/leukocytosis.\n # Cyclic fevers/leukocytosis\n Pt had temp to 101.7 yesterday. WBC at\n 11\n still stable/trending down.\n - will tolerate slight fevers as long as patient does not have clinical\n deterioration or WBC elevations\n - Cdiff negative\n - sputum cultures\n moderate growth GNR resembling acinetobacter\n (susceptibilities done)\n - will recheck sputum cultures\n - blood cultures pending\n - will not start gancyclovir at this point - CMV not likely cause of\n fevers. Per yesterday\ns progress note, will follow LFTs and if rising\n will see if correlates with CMV viral load. If so, will discuss with\n renal and ID.\n - will order an abdominal CT in the next few days to reevaluate\n peripancreatic fluid.\n # Respiratory failure\n Pt is on trach mask at 40% FIO2.\n - Pt is still tachypneic. (RR 27-40).\n - Considering pt\ns neuro findings, this may be centrally-driven.\n # Acute renal failure\n - pt put out 1.6 L urine yesterday\n - will continue to follow UOP, BUN, and Cr\n # Altered mental status\n pt had MRI that showed diffuse subacute\n anoxic injury involving the basal ganglia and cortex\n - poor prognosis per neuro.\n - pt will need neuro rehab upon discharge from the MICU\n # Anemia\n - Hct stable\n - continue to monitor Hct\n # Acute Hepatitis: Likely alcoholic hepatitis. CT scan shows fatty\n infiltration, and no evidence of distal obstruction.\n - will continue to trend LFT\n - will also observe whether any rises in LFT\ns are correlated with\n rises in CMV titer\n # FEN: IVF, replete electrolytes, Nutren at 50 ml/hr\n ICU Care\n Nutrition:\n Nutren 2.0 () - 12:34 PM 50 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 08:37 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": "2131-07-02 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 684341, "text": "Chief Complaint:\n 24 Hour Events:\n -pt did cough up some yellowish sputum into trach mask - ordered sputum\n cultures\n -1530 - called to bedside because pt's mother concerned about his\n tachynpea - ordered a CXR and ABG\n - - called to bedside re: pt's tachypnea and tachycardia - breath\n sounds stable\n -at that time, also notified by RN that sodium is 152 - increased free\n water flushes to 400 q4hr\n Allergies:\n Meropenem\n skin blisters\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 04:11 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 05:56 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: 119 (105 - 122) bpm\n BP: 91/64(71) {91/39(61) - 143/107(118)} mmHg\n RR: 31 (27 - 45) insp/min\n SpO2: 99%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 103.3 kg (admission): 113.5 kg\n Height: 67 Inch\n Total In:\n 2,317 mL\n 697 mL\n PO:\n TF:\n 1,217 mL\n 297 mL\n IVF:\n 100 mL\n Blood products:\n Total out:\n 1,225 mL\n 350 mL\n Urine:\n 1,225 mL\n 350 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,092 mL\n 347 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n SpO2: 99%\n ABG: 7.35/35/89 /20/-5\n PaO2 / FiO2: 178\n Physical Examination\n General\n alert, does not respond to commands\n CV\n tachycardic, regular rhythm, no murmurs, rubs, or gallops\n Resp\n clear to auscultation anteriorly\n Abdomen\n soft, non-tender, distended, bowel sounds present\n Extremities\n 2+ pitting edema noted in the lower extremities\n Labs / Radiology\n 327 K/uL\n 6.8 g/dL\n 97 mg/dL\n 1.3 mg/dL\n 20 mEq/L\n 4.8 mEq/L\n 75 mg/dL\n 124 mEq/L\n 152 mEq/L\n 22.3 %\n 10.5 K/uL\n [image002.jpg]\n 03:19 AM\n 10:00 AM\n 04:00 PM\n 02:16 AM\n 04:14 PM\n 10:00 PM\n 02:32 AM\n 04:25 AM\n 03:56 PM\n 02:32 AM\n WBC\n 11.4\n 10.9\n 11.0\n 10.5\n Hct\n 21.7\n 22.2\n 22.5\n 22.3\n Plt\n 266\n 290\n 310\n 327\n Cr\n 2.1\n 2.0\n 1.9\n 1.6\n 1.3\n TCO2\n 22\n 20\n Glucose\n 192\n 200\n 211\n 98\n 151\n 177\n 116\n 161\n 97\n Other labs: PT / PTT / INR:13.6/28.0/1.2, CK / CKMB /\n Troponin-T:214/3/0.07, ALT / AST:91/137, Alk Phos / T Bili:318/4.1,\n Amylase / Lipase:78/91, Differential-Neuts:57.0 %, Band:4.0 %,\n Lymph:23.0 %, Mono:4.0 %, Eos:3.0 %, D-dimer:6389 ng/mL, Fibrinogen:541\n mg/dL, Lactic Acid:2.6 mmol/L, Albumin:2.3 g/dL, LDH:437 IU/L, Ca++:9.1\n mg/dL, Mg++:2.0 mg/dL, PO4:4.9 mg/dL\n Assessment and Plan\n 28 year old male with a history of alcoholism presenting with acute\n hepatitis, pancreatitis, and UGIB, with persistent cyclic\n fevers/leukocytosis and anoxic brain injury.\n # Cyclic fevers/leukocytosis\n Tmax 100.0 overnight. WBC at 10.5\n still stable/trending down.\n - will tolerate slight fevers as long as patient does not have clinical\n deterioration or WBC elevations\n - off abx\n - Cdiff negative \n - sputum cultures\n moderate growth GNR resembling acinetobacter\n (susceptibilities done)\n - will recheck sputum cultures\n - blood cultures pending\n - will not start gancyclovir at this point - CMV not likely cause of\n fevers. Per yesterday\ns progress note, will follow LFTs and if rising\n will see if correlates with CMV viral load. If so, will discuss with\n renal and ID.\n - will order an abdominal CT in the next few days to reevaluate\n peripancreatic fluid.\n # Respiratory failure\n Pt is on trach mask at 40% FIO2.\n - Pt is still tachypneic. (RR 27-40).\n - Considering pt\ns neuro findings, this may be centrally-driven.\n # Acute renal failure\n - pt put out 1.5 L urine yesterday; good UOP\n - will continue to follow UOP, BUN, and Cr\n # Altered mental status\n pt had MRI that showed diffuse subacute\n anoxic injury involving the basal ganglia and cortex\n - poor prognosis per neuro.\n - pt will need neuro rehab upon discharge from the MICU\n # Anemia\n - Hct stable\n - continue to monitor Hct\n # Acute Hepatitis: Likely alcoholic hepatitis. CT scan shows fatty\n infiltration, and no evidence of distal obstruction.\n - will continue to trend LFT\n - will also observe whether any rises in LFT\ns are correlated with\n rises in CMV titer\n # FEN: IVF, replete electrolytes, Nutren at 50 ml/hr\n ICU Care\n Nutrition:\n Nutren 2.0 () - 12:34 PM 50 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 08:37 AM\n Prophylaxis:\n DVT: heparin\n Stress ulcer: famotidine\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2131-07-03 00:00:00.000", "description": "Nursing Progress Note", "row_id": 684557, "text": "TITLE:\n Arousal, Attention, and Cognition, Impaired\n Assessment:\n Opens eyes spontaneously, tracks but does not follow any\n commands, intermit making facial expressions.\n Perl @4mm brisk.\n Spont lifts and holds upper extremeties, moves ble on bed\n (occasional)\n Tremor noted of extremeties with movement., no sign \n activity , continues on daily keppra\n Tachypneic(? Neurogenic), O2 sats 95-100%\n Hypernatremic w serum Na+ 152\n Incontinent of loose brown stool(ppft w tf\ns at goal\n 50cc/hr)\n Action:\n Frequent suctioning and trach care for thick yellow to white\n secretions. water boluses 150cc/q2h in addition to iv flds increased\n to 150cc/hr d5w. Neurologically frequent orienting and stimulation\n with passive rom to all extremeties. Vap bundle w freq oral hygiene.\n Double guard to peri area\n Response:\n Serum Na+ down to 147 this am w chloride dwn to 120..BBS clear after\n suctioning , continues to have moderate amts of thick pale yellow\n secretions without desats. Skin intact back and buttocks\n Plan:\n Rehab screening in process. Cont w free water and d5w at 150cc/hr for\n hypernatremia. Trend Na+ and Cl labs, notify HO of results. Provide\n emotional support to family, encourage family to allow for time away\n from hospital for self care.\n" }, { "category": "Respiratory ", "chartdate": "2131-06-16 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 681154, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 30\n Ideal body weight: 67.1 None\n Ideal tidal volume: 268.4 / 402.6 / 536.8 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type:\n Size:\n Tracheostomy tube:\n Type: Standard, Inner Cannula, Perc Trach\n Manufacturer: Portex\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 24 cmH2O\n Cuff volume: 8 mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Rhonchi\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Rhonchi\n Comments:\n Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount: Suctioned / Scant\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Accessory muscle use\n Assessment of breathing comfort: No response (sleeping / sedated)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment: Abnormal trigger efforts (efforts during\n inspiratory)\n Dysynchrony assessment: Vigorous inspiratory efforts\n Comments:\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated;\n Comments: wean as tolerated\n Reason for continuing current ventilatory support: Sedated / Paralyzed,\n Intolerant of weaning attempts, Cannot protect airway\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n RSBI 55\n" }, { "category": "Physician ", "chartdate": "2131-07-01 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 684200, "text": "Chief Complaint:\n 24 Hour Events:\n INVASIVE VENTILATION - STOP 06:43 PM\n has been off ventilator for a couple of days. currently on TM.\n FEVER - 101.7\nF - 04:00 PM\n Allergies:\n Meropenem\n skin blisters a\n Last dose of Antibiotics:\n Micafungin - 10:00 PM\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 01:00 PM\n Heparin Sodium (Prophylaxis) - 04:15 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:39 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.7\nC (101.7\n Tcurrent: 36.2\nC (97.2\n HR: 108 (108 - 128) bpm\n BP: 124/71(81) {93/44(54) - 139/86(118)} mmHg\n RR: 27 (27 - 40) insp/min\n SpO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 103.3 kg (admission): 113.5 kg\n Height: 67 Inch\n Total In:\n 2,113 mL\n 382 mL\n PO:\n TF:\n 1,203 mL\n 382 mL\n IVF:\n Blood products:\n Total out:\n 1,655 mL\n 520 mL\n Urine:\n 1,655 mL\n 520 mL\n NG:\n Stool:\n Drains:\n Balance:\n 458 mL\n -138 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n SpO2: 100%\n ABG: ///19/\n Physical Examination\n General\n alert, does not respond to commands\n CV\n RRR, no murmurs, rubs, or gallops\n Resp\n clear to auscultation anteriorly\n Abdomen\n soft, non-tender, non-distended, bowel sounds present\n Extremities\n pitting edema noted in the lower extremities\n Labs / Radiology\n 310 K/uL\n 6.8 g/dL\n 161 mg/dL\n 1.6 mg/dL\n 19 mEq/L\n 5.1 mEq/L\n 87 mg/dL\n 120 mEq/L\n 149 mEq/L\n 22.5 %\n 11.0 K/uL\n [image002.jpg]\n 03:37 PM\n 03:15 AM\n 03:19 AM\n 10:00 AM\n 04:00 PM\n 02:16 AM\n 04:14 PM\n 10:00 PM\n 02:32 AM\n 04:25 AM\n WBC\n 10.2\n 11.4\n 10.9\n 11.0\n Hct\n 21.5\n 21.7\n 22.2\n 22.5\n Plt\n 227\n 266\n 290\n 310\n Cr\n 2.6\n 2.1\n 2.0\n 1.9\n 1.6\n TCO2\n 23\n 22\n Glucose\n 194\n 192\n 200\n 211\n 98\n 151\n 177\n 116\n 161\n Other labs: PT / PTT / INR:13.6/28.0/1.2, CK / CKMB /\n Troponin-T:214/3/0.07, ALT / AST:91/137, Alk Phos / T Bili:318/4.1,\n Amylase / Lipase:78/91, Differential-Neuts:57.0 %, Band:4.0 %,\n Lymph:23.0 %, Mono:4.0 %, Eos:3.0 %, D-dimer:6389 ng/mL, Fibrinogen:541\n mg/dL, Lactic Acid:2.6 mmol/L, Albumin:2.3 g/dL, LDH:437 IU/L, Ca++:9.4\n mg/dL, Mg++:2.1 mg/dL, PO4:4.5 mg/dL\n Assessment and Plan\n 28 year old male with a history of alcoholism presenting with acute\n hepatitis, pancreatitis, and UGIB, with persistent cyclic\n fevers/leukocytosis.\n # Cyclic fevers/leukocytosis\n Pt had temp to 101.7 yesterday. WBC at\n 11\n still stable/trending down.\n - will tolerate slight fevers as long as patient does not have clinical\n deterioration or WBC elevations\n - Cdiff negative\n - sputum cultures\n moderate growth GNR resembling acinetobacter\n (susceptibilities done)\n - will recheck sputum cultures\n - blood cultures pending\n - will not start gancyclovir at this point - CMV not likely cause of\n fevers. Per yesterday\ns progress note, will follow LFTs and if rising\n will see if correlates with CMV viral load. If so, will discuss with\n renal and ID.\n - will order an abdominal CT in the next few days to reevaluate\n peripancreatic fluid.\n # Respiratory failure\n Pt is on trach mask at 40% FIO2.\n - Pt is still tachypneic. (RR 27-40).\n - Considering pt\ns neuro findings, this may be centrally-driven.\n # Acute renal failure\n - pt put out 1.6 L urine yesterday\n - will continue to follow UOP, BUN, and Cr\n # Altered mental status\n pt had MRI that showed diffuse subacute\n anoxic injury involving the basal ganglia and cortex\n - poor prognosis per neuro.\n - pt will need neuro rehab upon discharge from the MICU\n # Anemia\n - Hct stable\n - continue to monitor Hct\n # Acute Hepatitis: Likely alcoholic hepatitis. CT scan shows fatty\n infiltration, and no evidence of distal obstruction.\n - will continue to trend LFT\n - will also observe whether any rises in LFT\ns are correlated with\n rises in CMV titer\n # FEN: IVF, replete electrolytes, Nutren at 50 ml/hr\n ICU Care\n Nutrition:\n Nutren 2.0 () - 01:12 PM 50 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n PICC Line - 08:37 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:ICU\n" }, { "category": "Physician ", "chartdate": "2131-07-01 00:00:00.000", "description": "Physician Resident/Attending Progress Note - MICU", "row_id": 684202, "text": "Chief Complaint:\n 24 Hour Events:\n INVASIVE VENTILATION - STOP 06:43 PM\n has been off ventilator for a couple of days. currently on TM.\n FEVER - 101.7\nF - 04:00 PM\n Allergies:\n Meropenem\n skin blisters a\n Last dose of Antibiotics:\n Micafungin - 10:00 PM\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 01:00 PM\n Heparin Sodium (Prophylaxis) - 04:15 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:39 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.7\nC (101.7\n Tcurrent: 36.2\nC (97.2\n HR: 108 (108 - 128) bpm\n BP: 124/71(81) {93/44(54) - 139/86(118)} mmHg\n RR: 27 (27 - 40) insp/min\n SpO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 103.3 kg (admission): 113.5 kg\n Height: 67 Inch\n Total In:\n 2,113 mL\n 382 mL\n PO:\n TF:\n 1,203 mL\n 382 mL\n IVF:\n Blood products:\n Total out:\n 1,655 mL\n 520 mL\n Urine:\n 1,655 mL\n 520 mL\n NG:\n Stool:\n Drains:\n Balance:\n 458 mL\n -138 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n SpO2: 100%\n ABG: ///19/\n Physical Examination\n General\n alert, does not respond to commands\n CV\n RRR, no murmurs, rubs, or gallops\n Resp\n clear to auscultation anteriorly\n Abdomen\n soft, non-tender, non-distended, bowel sounds present\n Extremities\n pitting edema noted in the lower extremities\n Labs / Radiology\n 310 K/uL\n 6.8 g/dL\n 161 mg/dL\n 1.6 mg/dL\n 19 mEq/L\n 5.1 mEq/L\n 87 mg/dL\n 120 mEq/L\n 149 mEq/L\n 22.5 %\n 11.0 K/uL\n [image002.jpg]\n 03:37 PM\n 03:15 AM\n 03:19 AM\n 10:00 AM\n 04:00 PM\n 02:16 AM\n 04:14 PM\n 10:00 PM\n 02:32 AM\n 04:25 AM\n WBC\n 10.2\n 11.4\n 10.9\n 11.0\n Hct\n 21.5\n 21.7\n 22.2\n 22.5\n Plt\n 227\n 266\n 290\n 310\n Cr\n 2.6\n 2.1\n 2.0\n 1.9\n 1.6\n TCO2\n 23\n 22\n Glucose\n 194\n 192\n 200\n 211\n 98\n 151\n 177\n 116\n 161\n Other labs: PT / PTT / INR:13.6/28.0/1.2, CK / CKMB /\n Troponin-T:214/3/0.07, ALT / AST:91/137, Alk Phos / T Bili:318/4.1,\n Amylase / Lipase:78/91, Differential-Neuts:57.0 %, Band:4.0 %,\n Lymph:23.0 %, Mono:4.0 %, Eos:3.0 %, D-dimer:6389 ng/mL, Fibrinogen:541\n mg/dL, Lactic Acid:2.6 mmol/L, Albumin:2.3 g/dL, LDH:437 IU/L, Ca++:9.4\n mg/dL, Mg++:2.1 mg/dL, PO4:4.5 mg/dL\n Assessment and Plan\n 28 year old male with a history of alcoholism presenting with acute\n hepatitis, pancreatitis, and UGIB, with persistent cyclic\n fevers/leukocytosis.\n # Cyclic fevers/leukocytosis\n Pt had temp to 101.7 yesterday. WBC at\n 11\n still stable/trending down.\n - will tolerate slight fevers as long as patient does not have clinical\n deterioration or WBC elevations\n - Cdiff negative\n - sputum cultures\n moderate growth GNR resembling acinetobacter\n (susceptibilities done)\n - will recheck sputum cultures\n - blood cultures pending\n - will not start gancyclovir at this point - CMV not likely cause of\n fevers. Per yesterday\ns progress note, will follow LFTs and if rising\n will see if correlates with CMV viral load. If so, will discuss with\n renal and ID.\n - will order an abdominal CT in the next few days to reevaluate\n peripancreatic fluid.\n # Respiratory failure\n Pt is on trach mask at 40% FIO2.\n - Pt is still tachypneic. (RR 27-40).\n - Considering pt\ns neuro findings, this may be centrally-driven.\n # Acute renal failure\n - pt put out 1.6 L urine yesterday\n - will continue to follow UOP, BUN, and Cr\n # Altered mental status\n pt had MRI that showed diffuse subacute\n anoxic injury involving the basal ganglia and cortex\n - poor prognosis per neuro.\n - pt will need neuro rehab upon discharge from the MICU\n # Anemia\n - Hct stable\n - continue to monitor Hct\n # Acute Hepatitis: Likely alcoholic hepatitis. CT scan shows fatty\n infiltration, and no evidence of distal obstruction.\n - will continue to trend LFT\n - will also observe whether any rises in LFT\ns are correlated with\n rises in CMV titer\n # FEN: IVF, replete electrolytes, Nutren at 50 ml/hr\n ICU Care\n Nutrition:\n Nutren 2.0 () - 01:12 PM 50 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n PICC Line - 08:37 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:ICU\n ------ Protected Section ------\n Critical Care Attending\n I saw and examined the patient, and was physically present with the ICU\n resident for the key portions of the services provided. I agree with\n his/her note above, including the assessment and plan. I would\n add/emphasize the following:\n Complex 28 yo male w/h/o alcohol use, pancreatitis, hepatitis, brain\n injury with poor prognosis. Overnight continues with cyclic fevers and\n intermittent tachycardia and tachypnea. No significant overnight\n events. Intermittent increased sputum production.\n On exam today, sitting out of bed, intermittently tachypneic. No\n definite response to voice or command. Lungs with coarse breath sounds\n bilaterally. Tachycardic w/o murmur. Abd distended, 3+ edema\n bilaterally.\n In summary 28 yo male with h/o pancreatitis, hepatitis and cyclic\n fevers without obvious source. All antibiotics have been stopped and we\n are following fever curve and reculturing if spikes again. Appreciate\n infectious disease and surgical service input. Neurology service had\n family meeting Friday and suggested limited chance for meaningful\n recovery. Acute rehab hospitals to rescreen patient at request of\n family.\n , MD\n ------ Protected Section Addendum Entered By: , MD\n on: 12:34 ------\n" }, { "category": "Nursing", "chartdate": "2131-07-03 00:00:00.000", "description": "Nursing Progress Note", "row_id": 684550, "text": "TITLE:\n Arousal, Attention, and Cognition, Impaired\n Assessment:\n Opens eyes spontaneously, tracks but does not follow any commands.\n Perl @4mm brisk. Spont moves\n Action:\n Response:\n Plan:\n" }, { "category": "Physician ", "chartdate": "2131-06-16 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 681143, "text": "Chief Complaint:\n 24 Hour Events:\n PICC LINE - START 08:37 AM\n placed in IR\n DIALYSIS CATHETER - START 08:55 AM\n MULTI LUMEN - STOP 12:32 PM\n HD catheter removed and this line placed over wire\n \n - Renal: Hold dialysis today; will resume CVVH v. HD in AM depending on\n BP. Aztreonam decreased to 1000 q12 as off dialysis (no 500cc vials\n available).\n - SBP decreased to 70s. Given 500cc bolus with improvement. Changed\n cipro to flagyl.\n - Neuro: EEG read has no seizures.\n - Ferritin 2660\n Allergies:\n Meropenem\n skin blisters a\n Last dose of Antibiotics:\n Ciprofloxacin - 12:34 PM\n Aztreonam - 08:00 PM\n Linezolid - 10:07 PM\n Metronidazole - 12:00 AM\n Infusions:\n Midazolam (Versed) - 2 mg/hour\n Fentanyl (Concentrate) - 100 mcg/hour\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:00 PM\n Famotidine (Pepcid) - 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 06:57 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.3\nC (101\n Tcurrent: 37.8\nC (100.1\n HR: 93 (93 - 117) bpm\n BP: 81/38(52) {76/38(52) - 137/78(212)} mmHg\n RR: 32 (21 - 44) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 103.1 kg (admission): 113.5 kg\n Height: 67 Inch\n CVP: 10 (7 - 12)mmHg\n Total In:\n 3,899 mL\n 593 mL\n PO:\n TF:\n 1,203 mL\n 346 mL\n IVF:\n 2,696 mL\n 247 mL\n Blood products:\n Total out:\n 425 mL\n 135 mL\n Urine:\n 425 mL\n 135 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,474 mL\n 458 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 582 (391 - 582) mL\n PS : 5 cmH2O\n RR (Set): 22\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 55\n PIP: 13 cmH2O\n SpO2: 100%\n ABG: 7.34/30/113/16/-8\n Ve: 13.1 L/min\n PaO2 / FiO2: 226\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 243 K/uL\n 7.7 g/dL\n 154 mg/dL\n 2.4 mg/dL\n 16 mEq/L\n 4.7 mEq/L\n 120 mg/dL\n 97 mEq/L\n 130 mEq/L\n 23.2 %\n 26.4 K/uL\n [image002.jpg]\n 06:18 PM\n 07:58 PM\n 08:00 PM\n 01:31 AM\n 01:37 AM\n 04:30 AM\n 12:35 PM\n 06:31 PM\n 01:32 AM\n 03:05 AM\n WBC\n 24.4\n 21.7\n 26.4\n Hct\n 25.3\n 25.8\n 23.2\n Plt\n 193\n 194\n 243\n Cr\n 1.5\n 2.0\n 2.4\n TCO2\n 22\n 23\n 21\n 21\n 20\n 17\n Glucose\n 178\n 166\n 154\n Other labs: PT / PTT / INR:16.5/36.2/1.5, CK / CKMB /\n Troponin-T:214/3/0.07, ALT / AST:184/250, Alk Phos / T Bili:538/30.0,\n Amylase / Lipase:51/41, Differential-Neuts:68.0 %, Band:5.0 %,\n Lymph:7.0 %, Mono:4.0 %, Eos:0.0 %, D-dimer:6389 ng/mL, Fibrinogen:502\n mg/dL, Lactic Acid:1.4 mmol/L, Albumin:2.0 g/dL, LDH:706 IU/L, Ca++:8.5\n mg/dL, Mg++:2.6 mg/dL, PO4:4.8 mg/dL\n Assessment and Plan\n AROUSAL, ATTENTION, AND COGNITION, IMPAIRED\n BALANCE, IMPAIRED\n MOTOR FUNCTION, IMPAIRED\n MUSCLE PERFORMACE, IMPAIRED\n RESPIRATION / GAS EXCHANGE, IMPAIRED\n SEIZURE, WITHOUT STATUS EPILEPTICUS\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n IMPAIRED SKIN INTEGRITY\n HEPATITIS, ACUTE TOXIC (INCLUDING ALCOHOLIC, ACETAMINOPHEN, ETC.)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ICU Care\n Nutrition:\n Nutren 2.0 () - 01:53 PM 50 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 08:15 PM\n PICC Line - 08:37 AM\n Dialysis Catheter - 08:55 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:ICU\n" }, { "category": "Physician ", "chartdate": "2131-06-16 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 681144, "text": "Chief Complaint:\n 24 Hour Events:\n PICC LINE - START 08:37 AM\n placed in IR\n DIALYSIS CATHETER - START 08:55 AM\n MULTI LUMEN - STOP 12:32 PM\n HD catheter removed and this line placed over wire\n \n - Renal: Hold dialysis today; will resume CVVH v. HD in AM depending on\n BP. Aztreonam decreased to 1000 q12 as off dialysis (no 500cc vials\n available).\n - SBP decreased to 70s. Given 500cc bolus with improvement. Changed\n cipro to flagyl.\n - Neuro: Repeat EEG without seizures.\n - Ferritin 2660\n Allergies:\n Meropenem\n skin blisters a\n Last dose of Antibiotics:\n Ciprofloxacin - 12:34 PM\n Aztreonam - 08:00 PM\n Linezolid - 10:07 PM\n Metronidazole - 12:00 AM\n Infusions:\n Midazolam (Versed) - 2 mg/hour\n Fentanyl (Concentrate) - 100 mcg/hour\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:00 PM\n Famotidine (Pepcid) - 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 06:57 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.3\nC (101\n Tcurrent: 37.8\nC (100.1\n HR: 93 (93 - 117) bpm\n BP: 81/38(52) {76/38(52) - 137/78(212)} mmHg\n RR: 32 (21 - 44) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 103.1 kg (admission): 113.5 kg\n Height: 67 Inch\n CVP: 10 (7 - 12)mmHg\n Total In:\n 3,899 mL\n 593 mL\n PO:\n TF:\n 1,203 mL\n 346 mL\n IVF:\n 2,696 mL\n 247 mL\n Blood products:\n Total out:\n 425 mL\n 135 mL\n Urine:\n 425 mL\n 135 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,474 mL\n 458 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 582 (391 - 582) mL\n PS : 5 cmH2O\n RR (Set): 22\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 55\n PIP: 13 cmH2O\n SpO2: 100%\n ABG: 7.34/30/113/16/-8\n Ve: 13.1 L/min\n PaO2 / FiO2: 226\n Physical Examination\n GEN: Intubated, sedated\n HEENT: icteric sclera. MMM\n NECK: Trach site with no oozing.\n LUNGS: Anterior auscultation with upper airway noise; good airway\n movement\n HEART: RRR, normal; S1, S2\n ABD: Distended. NT.\n EXTREM: 2+ edema, ulcers/lesions on legs with bandages C/D/I\n SKIN: Jaundice\n NEURO: Mouth twitching. Arms jerking bilaterally. Did not open eyes to\n command.\n Labs / Radiology\n 243 K/uL\n 7.7 g/dL\n 154 mg/dL\n 2.4 mg/dL\n 16 mEq/L\n 4.7 mEq/L\n 120 mg/dL\n 97 mEq/L\n 130 mEq/L\n 23.2 %\n 26.4 K/uL\n [image002.jpg]\n 06:18 PM\n 07:58 PM\n 08:00 PM\n 01:31 AM\n 01:37 AM\n 04:30 AM\n 12:35 PM\n 06:31 PM\n 01:32 AM\n 03:05 AM\n WBC\n 24.4\n 21.7\n 26.4\n Hct\n 25.3\n 25.8\n 23.2\n Plt\n 193\n 194\n 243\n Cr\n 1.5\n 2.0\n 2.4\n TCO2\n 22\n 23\n 21\n 21\n 20\n 17\n Glucose\n 178\n 166\n 154\n Other labs: PT / PTT / INR:16.5/36.2/1.5, CK / CKMB /\n Troponin-T:214/3/0.07, ALT / AST:184/250, Alk Phos / T Bili:538/30.0,\n Amylase / Lipase:51/41, Differential-Neuts:68.0 %, Band:5.0 %,\n Lymph:7.0 %, Mono:4.0 %, Eos:0.0 %, D-dimer:6389 ng/mL, Fibrinogen:502\n mg/dL, Lactic Acid:1.4 mmol/L, Albumin:2.0 g/dL, LDH:706 IU/L, Ca++:8.5\n mg/dL, Mg++:2.6 mg/dL, PO4:4.8 mg/dL\n Assessment and Plan\n AROUSAL, ATTENTION, AND COGNITION, IMPAIRED\n BALANCE, IMPAIRED\n MOTOR FUNCTION, IMPAIRED\n MUSCLE PERFORMACE, IMPAIRED\n RESPIRATION / GAS EXCHANGE, IMPAIRED\n SEIZURE, WITHOUT STATUS EPILEPTICUS\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n IMPAIRED SKIN INTEGRITY\n HEPATITIS, ACUTE TOXIC (INCLUDING ALCOHOLIC, ACETAMINOPHEN, ETC.)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ICU Care\n Nutrition:\n Nutren 2.0 () - 01:53 PM 50 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 08:15 PM\n PICC Line - 08:37 AM\n Dialysis Catheter - 08:55 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:ICU\n" }, { "category": "Physician ", "chartdate": "2131-06-16 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 681147, "text": "Chief Complaint:\n 24 Hour Events:\n PICC LINE - START 08:37 AM\n placed in IR\n DIALYSIS CATHETER - START 08:55 AM\n MULTI LUMEN - STOP 12:32 PM\n HD catheter removed and this line placed over wire\n \n - Renal: resume CVVH v. HD today depending on BP. Aztreonam decreased\n to 1000 q12 as off dialysis (no 500cc vials available).\n - SBP decreased to 70s. Given 500cc bolus with improvement. Changed\n cipro to flagyl.\n - Neuro: Repeat EEG without seizures.\n - Ferritin 2660\n Allergies:\n Meropenem\n skin blisters a\n Last dose of Antibiotics:\n Ciprofloxacin - 12:34 PM\n Aztreonam - 08:00 PM\n Linezolid - 10:07 PM\n Metronidazole - 12:00 AM\n Infusions:\n Midazolam (Versed) - 2 mg/hour\n Fentanyl (Concentrate) - 100 mcg/hour\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:00 PM\n Famotidine (Pepcid) - 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 06:57 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.3\nC (101\n Tcurrent: 37.8\nC (100.1\n HR: 93 (93 - 117) bpm\n BP: 81/38(52) {76/38(52) - 137/78(212)} mmHg\n RR: 32 (21 - 44) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 103.1 kg (admission): 113.5 kg\n Height: 67 Inch\n CVP: 10 (7 - 12)mmHg\n Total In:\n 3,899 mL\n 593 mL\n PO:\n TF:\n 1,203 mL\n 346 mL\n IVF:\n 2,696 mL\n 247 mL\n Blood products:\n Total out:\n 425 mL\n 135 mL\n Urine:\n 425 mL\n 135 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,474 mL\n 458 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 582 (391 - 582) mL\n PS : 5 cmH2O\n RR (Set): 22\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 55\n PIP: 13 cmH2O\n SpO2: 100%\n ABG: 7.34/30/113/16/-8\n Ve: 13.1 L/min\n PaO2 / FiO2: 226\n Physical Examination\n GEN: Intubated, sedated\n HEENT: icteric sclera. MMM\n NECK: Trach site with no oozing.\n LUNGS: Anterior auscultation with upper airway noise; good airway\n movement\n HEART: RRR, normal; S1, S2\n ABD: Distended. NT.\n EXTREM: 2+ edema, ulcers/lesions on legs with bandages C/D/I\n SKIN: Jaundice\n NEURO: Mouth twitching. Arms jerking bilaterally. Did not open eyes to\n command.\n Labs / Radiology\n 243 K/uL\n 7.7 g/dL\n 154 mg/dL\n 2.4 mg/dL\n 16 mEq/L\n 4.7 mEq/L\n 120 mg/dL\n 97 mEq/L\n 130 mEq/L\n 23.2 %\n 26.4 K/uL\n [image002.jpg]\n 06:18 PM\n 07:58 PM\n 08:00 PM\n 01:31 AM\n 01:37 AM\n 04:30 AM\n 12:35 PM\n 06:31 PM\n 01:32 AM\n 03:05 AM\n WBC\n 24.4\n 21.7\n 26.4\n Hct\n 25.3\n 25.8\n 23.2\n Plt\n 193\n 194\n 243\n Cr\n 1.5\n 2.0\n 2.4\n TCO2\n 22\n 23\n 21\n 21\n 20\n 17\n Glucose\n 178\n 166\n 154\n Other labs: PT / PTT / INR:16.5/36.2/1.5, CK / CKMB /\n Troponin-T:214/3/0.07, ALT / AST:184/250, Alk Phos / T Bili:538/30.0,\n Amylase / Lipase:51/41, Differential-Neuts:68.0 %, Band:5.0 %,\n Lymph:7.0 %, Mono:4.0 %, Eos:0.0 %, D-dimer:6389 ng/mL, Fibrinogen:502\n mg/dL, Lactic Acid:1.4 mmol/L, Albumin:2.0 g/dL, LDH:706 IU/L, Ca++:8.5\n mg/dL, Mg++:2.6 mg/dL, PO4:4.8 mg/dL\n Assessment and Plan\n 28M with alcoholic hepatitis and necrotizing pancreatitis complicated\n by ARDS, SIRS, ARF, UGIB, fevers and eosinophilia\n #. ID: Febrile now for 2 days with decreased BP. RUQ u/s concerning for\n sludge and pt started on cipro, but changed back to flagyl yesterday.\n Of note, had stopped flagyl and vanc po as C. diff neg x 2.\n Blood/tissue/BAL cx NGTD. It is possible that previous fevers had been\n masked by CVVH, which pt did not undergo yesterday\n - Cte broad spectrum antibiotic coverage with linezolid and aztreonam\n (D1 ) and flagyl (Added back ).\n - D/C CVL today if he has enough access\n - HIDA scan if bilirubin does not improve or hemodynamic instability\n over next few days\n - F/u WBC count, temp curve, and culture data\n - F/u ID recs\n - Cont steroid taper for possible adrenal insufficiency\n # Hyperbilirubinemia: Patient has had continuously increasing T Bili\n and alkaline phosphatase. Has alcoholic hepatitis but also on TPN. Bili\n stable today but increased alk phos and RUQ u/s with sludge concerning\n for cholestasis.\n - Check HIDA scan if bilirubin does not improve or hemodynamically\n unstable\n - TPN stopped \n - Weaning off benzos\n #. Respiratory Failure: ARDS secondary to necrotizing pancreatitis. S/p\n trach placement on . Sutures out on . ABG good on PS but\n transition to trach mask limited by respiratory rate.\n - Cont to wean vent with trach mask trial as tolerated\n - Increasing fentanyl patch while decreasing gtt, continue methadone\n - Attempt OOB to chair today to improve respiratory mechanics\n # Seizures: CT head without intracranial process. EEG showed occipital\n seizures which does not correlate with clinical symptoms, but repeat\n EEG on higher dose Keppra showed no seizures. actually be\n patient waking up, not seizures.\n - Continue on higher dose keppra\n - F/u neuro recs\n - Wean off midazolam as tolerated with low dose valium to prevent\n withdrawal; monitor vitals\n #. Acute renal Failure: Appreciate renal recs.\n - Would dialyze for acidosis but likely does not need volume depletion.\n - Likely transition to HD today; f/u Renal recs\n - will change Keppra to 1000mg Q24 with 500 mg after HD if he\n transitions to HD today.\n #. Adrenal Insufficiency: Unclear with stim if clear adrenal\n insufficiency but hypotension improving with steroids (lower pressor\n requirement) and improving eosinophilia\n - Wean Hydrocort to 25mg Q8H on \n # ?HLH: Quantitative ferritin of 2660.\n ICU Care\n Nutrition:\n Nutren 2.0 () - 01:53 PM 50 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 08:15 PM\n PICC Line - 08:37 AM\n Dialysis Catheter - 08:55 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:ICU\n" }, { "category": "Respiratory ", "chartdate": "2131-06-16 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 681222, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 30\n Ideal body weight: 67.1 None\n Ideal tidal volume: 268.4 / 402.6 / 536.8 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type:\n Size:\n Tracheostomy tube:\n Type: Standard, Cuffed, Inner Cannula\n Manufacturer: Portex\n Size: 8.0mm\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 24 cmH2O\n Cuff volume: 8 mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount: Suctioned / Scant\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern:\n Assessment of breathing comfort: No response (sleeping / sedated)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours:\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n Began shift on CMV rapidly weaned to PSV then trach mask.. ABG\ns are\n good on trach mask. Will continue as tolerated.\n Secretions are minimal.\n, RRT 19:38\n" }, { "category": "Respiratory ", "chartdate": "2131-06-17 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 681307, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 31\n Ideal body weight: 67.1 None\n Ideal tidal volume: 268.4 / 402.6 / 536.8 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type:\n Size:\n Tracheostomy tube:\n Type: Standard, Inner Cannula\n Manufacturer: Portex\n Size: 8.0mm\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 24 cmH2O\n Cuff volume: 8 mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Moderate\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Unassisted spontaneous breathing\n Visual assessment of breathing pattern:\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n Pt has been on TC since yesterday afternoon. Consider D/C of vent later\n today\n" }, { "category": "Physician ", "chartdate": "2131-06-18 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 681465, "text": "Chief Complaint:\n 24 Hour Events:\n - Fentanyl and midazolam decreased with slight increase in HR to 110s.\n Increased valium to 10mg TID\n - Tolerated trach mask throughout day\n Allergies:\n Meropenem\n skin blisters a\n Last dose of Antibiotics:\n Ciprofloxacin - 12:34 PM\n Linezolid - 10:09 PM\n Aztreonam - 07:45 AM\n Metronidazole - 08:30 AM\n Infusions:\n Fentanyl (Concentrate) - 25 mcg/hour\n KCl (CRRT) - 3 mEq./hour\n Calcium Gluconate (CRRT) - 2.4 grams/hour\n Other ICU medications:\n Famotidine (Pepcid) - 12:06 AM\n Heparin Sodium (Prophylaxis) - 04:02 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:23 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.3\nC (99.2\n Tcurrent: 36.2\nC (97.1\n HR: 101 (94 - 113) bpm\n BP: 113/59(78) {87/48(64) - 129/70(90)} mmHg\n RR: 23 (19 - 33) insp/min\n SpO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 99.7 kg (admission): 113.5 kg\n Height: 67 Inch\n Total In:\n 9,973 mL\n 2,424 mL\n PO:\n TF:\n 1,200 mL\n 319 mL\n IVF:\n 8,753 mL\n 2,085 mL\n Blood products:\n Total out:\n 11,007 mL\n 2,337 mL\n Urine:\n 77 mL\n 20 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,034 mL\n 87 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n Ventilator mode: Standby\n Vt (Spontaneous): 567 (567 - 567) mL\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 0 cmH2O\n SpO2: 100%\n ABG: 7.45/37/105/24/1\n PaO2 / FiO2: 210\n Physical Examination\n GEN: Trached, sedated.\n HEENT: Icteric sclera. MMM.\n NECK: Trach site with no oozing.\n LUNGS: Anterior auscultation with upper airway noise; good airway\n movement.\n HEART: RRR, normal S1, S2.\n ABD: Distended. Grimacing with palpation.\n EXTREM: 2+ edema, ulcers/lesions on legs with bandages C/D/I.\n SKIN: Jaundiced.\n NEURO: Opening eyes to command. Purposeful movements of arms.\n Labs / Radiology\n 321 K/uL\n 8.0 g/dL\n 165 mg/dL\n 0.6 mg/dL\n 24 mEq/L\n 4.0 mEq/L\n 33 mg/dL\n 99 mEq/L\n 134 mEq/L\n 24.8 %\n 30.5 K/uL\n [image002.jpg]\n 06:23 PM\n 10:13 PM\n 04:13 AM\n 04:24 AM\n 11:20 AM\n 04:55 PM\n 10:00 PM\n 10:30 PM\n 03:49 AM\n 03:56 AM\n WBC\n 24.9\n 30.5\n Hct\n 23.9\n 24.8\n Plt\n 255\n 321\n Cr\n 0.8\n 1.2\n 0.6\n TCO2\n 19\n 19\n 18\n 19\n 24\n 26\n 27\n Glucose\n 172\n 199\n 167\n 110\n 186\n 185\n 160\n 165\n Other labs: PT / PTT / INR:15.6/33.4/1.4, CK / CKMB /\n Troponin-T:214/3/0.07, ALT / AST:211/223, Alk Phos / T Bili:588/27.9,\n Amylase / Lipase:51/41, Differential-Neuts:78.0 %, Band:3.0 %,\n Lymph:1.0 %, Mono:7.0 %, Eos:0.0 %, D-dimer:6389 ng/mL, Fibrinogen:502\n mg/dL, Lactic Acid:1.0 mmol/L, Albumin:2.0 g/dL, LDH:517 IU/L, Ca++:8.3\n mg/dL, Mg++:1.8 mg/dL, PO4:1.3 mg/dL\n Assessment and Plan\n 28M with alcoholic hepatitis and necrotizing pancreatitis complicated\n by ARDS, SIRS, ARF, UGIB, fevers.\n #. ID: No fevers since starting CVVH. RUQ u/s concerning for sludge and\n pt started flagyl.\n - Cte broad spectrum antibiotic coverage with linezolid and aztreonam\n (D1 ) and flagyl (added back )\n - Consider HIDA scan if bilirubin does not improve or hemodynamic\n instability over next few days as may need perc. drain\n - F/u WBC count, temp curve, and culture data\n - Cont steroid taper for possible adrenal insufficiency\n - Yeast in the urine- changed foley and re-cultured. If still with\n yeast will treat with anti-fungal.\n # Elevated LFTs: T Bili and transaminases stable. A/w alcoholic\n hepatitis but recent increase may be TPN, now discontinued. RUQ u/s\n with sludge concerning for cholestasis. Note that U/S also\n showed sludge.\n - Consider asking GI input for HIDA scan v. ERCP if hemodynamically\n unstable\n - TPN stopped \n - Weaning off benzos\n #. Respiratory Failure: ARDS secondary to necrotizing pancreatitis. S/p\n trach placement on . Sutures out on . Currently on trach mask\n with good ABG.\n - Start fentanyl patch while decreasing gtt, continue methadone\n - Cont to chair daily\n - Consider down-size trach\n # Seizures: CT head without intracranial process. EEG showed occipital\n seizures which does not correlate with clinical symptoms, but repeat\n EEG on higher dose Keppra showed no seizures. As patient now with\n purposeful movements, this may actually be patient waking up, not\n seizures.\n - Continue on higher dose keppra\n - F/u neuro recs\n - Wean off midazolam as tolerated with low dose valium to prevent\n withdrawal; monitor vitals\n #. Acute renal Failure: Appreciate renal recs.\n - Would dialyze for acidosis but likely does not need volume depletion\n as pressures borderline.\n - Cont CVVH while pressures low but reassess for HD today\n - Aztreonam increased back to 2000mg q12h as back on CVVH\n - Will change Keppra to 1000mg Q24 with 500 mg after HD if he\n transitions to HD\n #. Adrenal Insufficiency: Unclear with stim if clear adrenal\n insufficiency but hypotension improving with steroids (lower pressor\n requirement) and improving eosinophilia\n - Cont weaning hydrocort; D2/3 of 25mg Q8H today.\n ICU Care\n Nutrition:\n Nutren 2.0 () - 01:34 PM 50 mL/hour\n Glycemic Control: Glargine and RISS\n Lines:\n Arterial Line - 08:15 PM\n PICC Line - 08:37 AM\n Dialysis Catheter - 08:55 AM\n Prophylaxis:\n DVT: SQ Heparin\n Stress ulcer: H2 blocker\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n" }, { "category": "Respiratory ", "chartdate": "2131-06-18 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 681473, "text": "Demographics\n Ideal body weight: 67.1 None\n Ideal tidal volume: 268.4 / 402.6 / 536.8 mL/kg\n Tracheostomy tube:\n Type: Standard, Inner Cannula\n Manufacturer: Portex\n Size: 8.0mm\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 24 cmH2O\n Cuff volume: 8 mL /\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount: Suctioned / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Unassisted spontaneous breathing\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 has weaned to trach collar, plan is to place in Rehab\n" }, { "category": "Echo", "chartdate": "2131-06-05 00:00:00.000", "description": "Report", "row_id": 88765, "text": "PATIENT/TEST INFORMATION:\nIndication: Endocarditis. Fever\nWeight (lb): 286\nBP (mm Hg): 101/53\nHR (bpm): 100\nStatus: Inpatient\nDate/Time: at 14:06\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size. Overall\nnormal LVEF (>55%). No resting LVOT gradient.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR. No AS. No AR.\n\nMITRAL VALVE: Normal mitral valve leaflets with trivial MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.\nIndeterminate PA systolic pressure.\n\nPULMONIC VALVE/PULMONARY ARTERY: No PS.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows. Suboptimal\nimage quality - ventilator. Resting tachycardia (HR>100bpm).\n\nConclusions:\nLeft ventricular wall thicknesses are normal. The left ventricular cavity size\nis normal. Overall left ventricular systolic function is normal/hyperdynamic\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 regurgitation. There is no aortic valve stenosis. No\naortic regurgitation is seen. The mitral valve appears structurally normal\nwith trivial mitral regurgitation. The pulmonary artery systolic pressure\ncould not be determined. There is no pericardial effusion.\n\nNo vegetation seen (cannot definitively exclude).\n\n\n" }, { "category": "Echo", "chartdate": "2131-07-03 00:00:00.000", "description": "Report", "row_id": 89625, "text": "PATIENT/TEST INFORMATION:\nIndication: Abnormal ECG. CMY.\nWeight (lb): 230\nBP (mm Hg): 105/73\nHR (bpm): 129\nStatus: Inpatient\nDate/Time: at 15:53\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT ATRIUM: Normal LA size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.\n\nLEFT VENTRICLE: Overall normal LVEF (>55%). TDI E/e' < 8, suggesting normal\nPCWP (<12mmHg).\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic diameter at the sinus level.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Normal mitral valve leaflets with trivial MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Borderline\nPA systolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS.\nPhysiologic PR.\n\nPERICARDIUM: No pericardial effusion.\n\nConclusions:\nThe left atrium is normal in size. Overall left ventricular systolic function\nis normal (LVEF>55%). Tissue Doppler imaging suggests a normal left\nventricular filling pressure (PCWP<12mmHg). Right ventricular chamber size and\nfree wall motion are normal. The aortic valve leaflets (3) appear structurally\nnormal with good leaflet excursion and no aortic regurgitation. The mitral\nvalve appears structurally normal with trivial mitral regurgitation. There is\nno pericardial effusion. No vegetation seen (cannot definitively exclude).\n\nCompared with the prior study (images reviewed) of , there is no\nsignificant change.\n\n\n" }, { "category": "Radiology", "chartdate": "2131-05-18 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1078549, "text": " 2:14 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please evaluate for lung pathology\n Admitting Diagnosis: PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 28 year old man with pancreatitis and hypoxia\n REASON FOR THIS EXAMINATION:\n please evaluate for lung pathology\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Pancreatitis with hypoxia.\n\n FINDINGS: In comparison with the study of , the endotracheal and\n nasogastric tubes have been removed. There are extremely low lung volumes.\n Some hazy opacification in the left lower hemithorax is consistent with\n pleural effusion. Opacification in the retrocardiac area raises a possibility\n of atelectasis or aspiration in this region.\n\n\n" }, { "category": "Radiology", "chartdate": "2131-05-17 00:00:00.000", "description": "CT ABDOMEN W/CONTRAST", "row_id": 1078426, "text": " 10:52 AM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: eval perf ulcer, acute path\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 28 year old man with diffuse TTP, vomiting blood and elevated wbc\n REASON FOR THIS EXAMINATION:\n eval perf ulcer, acute path\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: 12:21 PM\n Marked peripancreatic stranding suggestive of pancreatitis. On this single\n phase scan, there is no evidence of pancreatic necrosis, pseudoaneurym,\n pseudocyst or venous thrombosis. Liver is also markedly enlarged and diffusly\n fatty.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Abdominal pain.\n\n COMPARISON: No prior studies available for comparison.\n\n TECHNIQUE: Helical, axial CT images were acquired through the abdomen and\n pelvis following administration of 130 mL of intravenous Optiray contrast.\n Coronal and sagittal reformatted images were also reviewed.\n\n CT ABDOMEN WITH CONTRAST: Bibasilar atelectasis is noted. Cardiac apex is\n unremarkable. The stomach and proximal small bowel are unremarkable, though\n contain a nasogastric tube terminating in the duodenum. Diffuse peripancreatic\n stranding and fluid is suggestive of pancreatitis. There is no evidence of\n pseudocyst, pseudoaneurysm or venous thrombosis. On this single phase study,\n pancreatic necrosis is difficult to quantify though appears to show ~30-40%\n necrosis, primarily involving the body/tail. The spleen, adrenal glands,\n kidneys, and gallbladder are unremarkable. The liver is enlarged and\n diffusely hypodense representing extensive fatty infiltration. There is no\n free gas in the abdomen and there is no retroperitoneal lymphadenopathy.\n\n CT PELVIS WITH CONTRAST: A small amount of free fluid settles dependently in\n the pelvis. There is no free gas. The urinary bladder contains a Foley\n catheter and is otherwise unremarkable. The prostate and seminal vesicles are\n normal. The colon is predominantly collapsed and notable for diffuse mural\n fat, likely related to the patient's body habitus and history of alcohol\n abuse. There is no pelvic or inguinal lymphadenopathy.\n\n OSSEOUS FINDINGS: There are no suspicious sclerotic or lytic lesions.\n\n IMPRESSION:\n 1. Diffuse peripancreatic stranding which, in the setting of known alcohol\n use is likely indicative of pancreatitis. Necrosis is difficult to quantify\n though there appears to be roughly 30-40% necrosis.\n 2. Enlarged diffusely fatty infiltrated liver.\n 3. Orogastric tube terminating in the duodenum.\n (Over)\n\n 10:52 AM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: eval perf ulcer, acute path\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2131-05-18 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1078554, "text": " 3:19 AM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: pls evaluate ET tube placement\n Admitting Diagnosis: PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 28 year old man s/p intubation\n REASON FOR THIS EXAMINATION:\n pls evaluate ET tube placement\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Intubation.\n\n FINDINGS: In comparison with the earlier study of this date, there has been\n placement of an endotracheal tube with its tip at the upper clavicular level,\n approximately 6.7 cm above the carina. No change in the appearance of the\n heart and lungs.\n\n\n" }, { "category": "Radiology", "chartdate": "2131-05-19 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1078741, "text": " 4:19 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Assess for interval change\n Admitting Diagnosis: PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 28 year old man with alc hep, dieulefoys lesion intubated\n REASON FOR THIS EXAMINATION:\n Assess for interval change\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST DATED WITH COMPARISON STUDY OF ONE DAY EARLIER.\n\n INDICATION: Alcoholic hepatitis.\n\n FINDINGS: Indwelling devices remain in similar position. Development of\n bilateral asymmetrical airspace opacities in the perihilar regions, left\n greater than right, likely representing asymmetrical pulmonary edema and less\n likely an acute aspiration event. Increasing moderate left and\n small-to-moderate right pleural effusions, and possible ascites within imaged\n upper abdomen.\n\n\n" }, { "category": "Radiology", "chartdate": "2131-05-17 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1078436, "text": " 11:08 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for free air\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 28 year old man with abd pain\n REASON FOR THIS EXAMINATION:\n eval for free air\n ______________________________________________________________________________\n WET READ: 11:36 AM\n no acute process. low lung volumes.\n ______________________________________________________________________________\n FINAL REPORT\n CHEST X-RAY DATED \n\n HISTORY: 28-year-old man with abdominal pain. Question free air.\n\n COMPARISON: None.\n\n FINDINGS: A single AP semi-upright view of the chest was obtained. The\n cardiomediastinal silhouette is stable in size. The lung volumes are low.\n The lungs are clear bilaterally. There are no pleural effusions or\n pneumothorax. There is no free air under the hemidiaphragms. The osseous\n structures are intact.\n\n IMPRESSION:\n\n Low lung volumes with clear lungs. No free air noted under the\n hemidiaphragms.\n\n\n" }, { "category": "Radiology", "chartdate": "2131-05-18 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1078601, "text": " 9:06 AM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: Assess for interval change\n Admitting Diagnosis: PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 28 year old man with alc hep, dieulefoys lesion intubated\n REASON FOR THIS EXAMINATION:\n Assess for interval change\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Intubation.\n\n FINDINGS: In comparison with the earlier study of this date, the endotracheal\n tube has been repositioned so that the tip lies about 2.8 cm above the carina.\n Nasogastric tube has been inserted that extends well into the stomach.\n\n IMPRESSION: Little overall change in the appearance of the heart and lungs\n and the substantially low lung volumes.\n\n\n" }, { "category": "Radiology", "chartdate": "2131-05-17 00:00:00.000", "description": "LIVER OR GALLBLADDER US (SINGLE ORGAN)", "row_id": 1078523, "text": " 6:45 PM\n LIVER OR GALLBLADDER US (SINGLE ORGAN) Clip # \n Reason: please eval with doepplers for cirrhosis, vessel patency\n Admitting Diagnosis: PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 28 year old man with h/o EtOH abuse with elevated bilirubin\n REASON FOR THIS EXAMINATION:\n please eval with doepplers for cirrhosis, vessel patency\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): 10:30 PM\n PFI: Diffusely echogenic liver consistent with fatty infiltration although\n more severe liver disease cannot be excluded. There is no intrahepatic\n biliary ductal dilatation. The common bile duct measures 4 mm. There is\n normal flow in the portal vein.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 28-year-old male with history of alcohol abuse and elevated\n bilirubin.\n\n COMPARISON: CT dated .\n\n FINDINGS: Exam is markedly limited due to poor penetration. Within this\n limitations, the liver appears abnormal, with increased echogenicity but no\n focal lesions identified. This is consistent with fatty infiltration, as seen\n on recent CT. There is normal antegrade flow seen in the portal vein. There\n are no distinct portal triads identified, but there is no evidence for\n intrahepatic biliary ductal dilatation. The common bile duct measures 4 mm.\n Gallbladder demonstrates layering echogenic material, consistent with sludge.\n A small echogenic focus with no posterior shadowing may represent a polyp or a\n small stone. There is no ascites identified. The pancreas is not well\n visualized.\n\n IMPRESSION:\n Limited study demonstrating marked liver echogenicity, consistent with fatty\n infiltration, although more severe liver disease including significant hepatic\n fibrosis and cirrhosis cannot be excluded on this study. There is no\n intrahepatic biliary dilatation, and the common bile duct measures 4 mm. There\n is normal flow in the portal vein.\n\n\n" }, { "category": "Radiology", "chartdate": "2131-05-17 00:00:00.000", "description": "LIVER OR GALLBLADDER US (SINGLE ORGAN)", "row_id": 1078524, "text": ", F. MED SICU-A 6:45 PM\n LIVER OR GALLBLADDER US (SINGLE ORGAN) Clip # \n Reason: please eval with doepplers for cirrhosis, vessel patency\n Admitting Diagnosis: PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 28 year old man with h/o EtOH abuse with elevated bilirubin\n REASON FOR THIS EXAMINATION:\n please eval with doepplers for cirrhosis, vessel patency\n ______________________________________________________________________________\n PFI REPORT\n PFI: Diffusely echogenic liver consistent with fatty infiltration although\n more severe liver disease cannot be excluded. There is no intrahepatic\n biliary ductal dilatation. The common bile duct measures 4 mm. There is\n normal flow in the portal vein.\n\n" }, { "category": "Radiology", "chartdate": "2131-05-18 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1078675, "text": " 2:26 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: Confirm line placement\n Admitting Diagnosis: PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 28 year old man with RIJ CVL placement\n REASON FOR THIS EXAMINATION:\n Confirm line placement\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Follow up of a patient after right internal jugular\n line placement.\n\n Portable AP chest radiograph was compared to obtained at 10:29\n a.m.\n\n The ET tube tip is approximately 4.5 cm above the carina abutting the left\n tracheal wall. The right internal jugular line has been inserted with its tip\n at the cavoatrial junction. There is no pneumothorax or apical hematoma.\n There is no change in bilateral pleural effusions and bibasal atelectasis.\n The NG tube tip is in stomach.\n\n\n" }, { "category": "Radiology", "chartdate": "2131-05-17 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1078504, "text": " 3:40 PM\n CHEST (PORTABLE AP) Clip # \n Reason: pls evalutate ET tube\n Admitting Diagnosis: PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 28 year old man s/p intubation\n REASON FOR THIS EXAMINATION:\n pls evalutate ET tube\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST, \n\n Comparison study of earlier the same date.\n\n INDICATION: Intubation.\n\n FINDINGS: Endotracheal tube terminates at approximately the level of the\n medial clavicles, and a nasogastric tube courses below the diaphragm.\n Cardiomediastinal contours appear wider compared to the prior study, probably\n reflecting increased volume status of the patient. New hazy opacity in lower\n left hemithorax is likely a pleural effusion, and bilateral areas of\n retrocardiac opacification may reflect atelectasis and/or aspiration.\n\n\n" }, { "category": "Radiology", "chartdate": "2131-05-31 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1080691, "text": " 4:00 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Please evaluate for interval change.\n Admitting Diagnosis: PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 28 year old man with necrotizing pancreatitis and ARDS.\n REASON FOR THIS EXAMINATION:\n Please evaluate for interval change.\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 5:06 A.M., .\n\n HISTORY: Necrotizing pancreatitis and ARDS.\n\n IMPRESSION: AP chest compared to through 27:\n\n Lung volumes are low largely due to elevation of the diaphragm.\n Mild-to-moderate edema with basilar consolidation has not improved since . Heart size is normal and mediastinum is not dilated, suggesting the edema\n is not due to volume overload. ET tube, bilateral jugular lines and a\n nasogastric tube are in standard placements respectively. No pneumothorax.\n\n\n" }, { "category": "Radiology", "chartdate": "2131-06-01 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1081013, "text": " 6:32 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: interval change\n Admitting Diagnosis: PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 28 year old man with pancreatitis, ARDS, and SIRS, now with new tachypnea and\n worsening hypoxia.\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n WET READ: JXKc FRI 10:44 PM\n Stable mild edema with bibasilar opacities likely reflecting atelectasis. No\n pneumothorax. Left and right IJ lines are unchanged. Endotracheal tube tip\n appears to terminate 4 cm from the carina. Enteric tube is not definitively\n followed. A catheter overlies the right shoulder and extends into the neck,\n likely external. Correlate clinically. -jkang.\n ______________________________________________________________________________\n FINAL REPORT\n CHEST\n\n HISTORY: Pancreatitis and ARDS.\n\n One portable view. Comparison with . Lung volumes are low, as before.\n Bilateral pulmonary infiltrates persist. The heart and mediastinal structures\n are unchanged. An endotracheal tube, feeding tube, and bilateral internal\n jugular catheters remain in place. The tip of the feeding tube is not\n identified on this image. There is no definite interval change.\n\n IMPRESSION: No significant change.\n\n\n" }, { "category": "Radiology", "chartdate": "2131-06-04 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1081327, "text": " 8:20 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 28 year old man with pancreatitis, respiratory failure\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n EXAM: Portable AP chest .\n\n INDICATION: Pancreatitis and respiratory failure.\n\n FINDINGS: Comparison made to , 0518.\n\n Cardiomediastinal contours are unchanged. Multiple lines and support tubes\n remain in appropriate position. Lung volumes remain low, with scattered\n basilar opacities likely representing atelectasis, unchanged. Degree of\n volume overload is unchanged. There is no sizeable pleural effusion. There\n is no pneumothorax.\n\n\n" }, { "category": "Radiology", "chartdate": "2131-05-23 00:00:00.000", "description": "CT CHEST W/O CONTRAST", "row_id": 1079397, "text": " 2:05 PM\n CT CHEST W/O CONTRAST; CT ABDOMEN W/O CONTRAST Clip # \n CT PELVIS W/O CONTRAST\n Reason: ORAL CONTRAST; no IV contrastplease eval for fluid collectio\n Admitting Diagnosis: PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 28 year old man with nec pancreatitis on two pressors, /vanc and intubated\n on fent/versced now with dilated pupils and elevated wbcs\n REASON FOR THIS EXAMINATION:\n ORAL CONTRAST; no IV contrastplease eval for fluid collections near pancreas,\n ascites, or infections\n CONTRAINDICATIONS for IV CONTRAST:\n high cre\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): TKCb WED 4:16 PM\n PFI: Multifocal pneumonia. Diffuse, whole body subcutaneous edema, with\n moderate amount of free fluid within the pelvis. Diffuse colonic wall\n thickening, which could represent colitis.\n ______________________________________________________________________________\n FINAL REPORT\n TORSO CT WITHOUT CONTRAST, \n\n INDICATION: 28-year-old man with necrotizing pancreatitis. Elevated white\n blood cell count. Evaluate for infection.\n\n COMPARISON: .\n\n TECHNIQUE: Non-contrast CT of the chest, abdomen, and pelvis was performed\n using 5-mm axial slice thickness. Multiplanar reformats were created.\n\n FINDINGS:\n\n CHEST: There is multifocal airspace consolidation bilaterally. In addition,\n there is bibasilar atelectasis. An endotracheal tube is present, terminating\n in satisfactory position. Central line tip terminates within the SVC.\n Nasogastric tube is present and terminates within the stomach.\n\n The thoracic aorta is normal in contour and caliber throughout.\n\n ABDOMEN: Again identified is hepatomegaly and diffuse, severe fatty\n infiltration. Non-contrasted appearance of the spleen, kidneys, and adrenals\n is unremarkable. There is diffuse peripancreatic stranding as before.\n Evaluation for the extent of necrosis is not possible due to non-contrast\n technique. There are no definite new peripancreatic fluid collections.\n Gallbladder is unremarkable.\n\n There is no bowel obstruction. There is diffuse colonic wall thickening,\n which could reflect underlying colitis. The small bowel is collapsed and\n demonstrates no evidence of wall thickening.\n\n PELVIS: Bladder is decompressed by a Foley catheter. There is a small amount\n of air within the bladder. Note is made of free fluid within the pelvis.\n (Over)\n\n 2:05 PM\n CT CHEST W/O CONTRAST; CT ABDOMEN W/O CONTRAST Clip # \n CT PELVIS W/O CONTRAST\n Reason: ORAL CONTRAST; no IV contrastplease eval for fluid collectio\n Admitting Diagnosis: PANCREATITIS\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n There is diffuse soft tissue edema, compatible with anasarca.\n\n OSSEOUS STRUCTURES: There are no suspicious osseous lesions.\n\n IMPRESSION:\n 1. New multifocal airspace consolidation, suspicious for acute infiltrates.\n 2. Diffuse colonic wall thickening, which could reflect colitis.\n 3. Diffuse soft tissue edema.\n 4. Peripancreatic stranding, in keeping with pancreatitis. Extent of\n necrosis cannot be evaluated on a non-contrast exam. There are no new\n peripancreatic fluid collections.\n\n\n" }, { "category": "Radiology", "chartdate": "2131-05-23 00:00:00.000", "description": "CT ABDOMEN W/O CONTRAST", "row_id": 1079398, "text": ", F. MED SICU-A 2:05 PM\n CT CHEST W/O CONTRAST; CT ABDOMEN W/O CONTRAST Clip # \n CT PELVIS W/O CONTRAST\n Reason: ORAL CONTRAST; no IV contrastplease eval for fluid collectio\n Admitting Diagnosis: PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 28 year old man with nec pancreatitis on two pressors, /vanc and intubated\n on fent/versced now with dilated pupils and elevated wbcs\n REASON FOR THIS EXAMINATION:\n ORAL CONTRAST; no IV contrastplease eval for fluid collections near pancreas,\n ascites, or infections\n CONTRAINDICATIONS for IV CONTRAST:\n high cre\n ______________________________________________________________________________\n PFI REPORT\n PFI: Multifocal pneumonia. Diffuse, whole body subcutaneous edema, with\n moderate amount of free fluid within the pelvis. Diffuse colonic wall\n thickening, which could represent colitis.\n\n\n" }, { "category": "Radiology", "chartdate": "2131-05-27 00:00:00.000", "description": "PORTABLE ABDOMEN", "row_id": 1080100, "text": " 3:42 PM\n PORTABLE ABDOMEN Clip # \n Reason: please eval for bowel dilatation\n Admitting Diagnosis: PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 28 year old man with nec pancr on pressors, intubated for ards and no bm\n REASON FOR THIS EXAMINATION:\n please eval for bowel dilatation\n ______________________________________________________________________________\n FINAL REPORT\n ABDOMEN\n\n REASON FOR EXAM: Necrotizing pancreatitis with no bowel movements on\n narcotics. Evaluate for bowel dilatation.\n\n There is paucity of the bowel gas. There is no gas in any of the bowel loops.\n There are no pathologic calcifications within the abdomen. Osseous structures\n are unremarkable.\n\n" }, { "category": "Radiology", "chartdate": "2131-06-03 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1081158, "text": " 4:42 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval assesment\n Admitting Diagnosis: PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 28 year old man with pancreatitis, respiratory failure\n REASON FOR THIS EXAMINATION:\n interval assesment\n ______________________________________________________________________________\n FINAL REPORT\n CHEST\n\n HISTORY: Pancreatitis, respiratory failure.\n\n One view. Comparison with . Lung volumes are low, as before.\n Bilateral pulmonary infiltrates persist. The heart and mediastinal structures\n are unchanged. An endotracheal tube, nasogastric tube, and bilateral internal\n jugular catheters remain in place.\n\n IMPRESSION: No significant change.\n\n\n" }, { "category": "Radiology", "chartdate": "2131-06-01 00:00:00.000", "description": "P BILAT LOWER EXT VEINS PORT", "row_id": 1081024, "text": " 8:53 PM\n BILAT LOWER EXT VEINS PORT Clip # \n Reason: BLE SWELLING AND RED EVAL FOR DVT\n Admitting Diagnosis: PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 28 year old man with respiratory failure, pancreatitis, worsening tachypnea.\n REASON FOR THIS EXAMINATION:\n r/o dvt\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): JMGw FRI 10:35 PM\n PFI: Limited evaluation below the level of the mid SFV, however, no evidence\n for clot proximal to the superficial femoral veins bilaterally. Clot in\n distal or below the SFV cannot be fully excluded.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 28-year-old man with respiratory failure, pancreatitis and worsening\n tachypnea.\n\n BILATERAL LOWER EXTREMITY VENOUS ULTRASOUND\n\n COMPARISON: None.\n\n FINDINGS: Color and Doppler son of bilateral common femoral,\n superficial, and popliteal veins were performed. Study was technically\n limited due to patient's body habitus and vessels below the mid SFV were\n unable to be visualized. However, from the common femoral to the mid\n superficial femoral , -to-wall flow with normal Doppler pattern was\n visualized bilaterally. Evaluation for thrombus below the level of the mid\n SFV bilaterally cannot be fully excluded on this limited study.\n\n IMPRESSION: Limited bilateral lower extremity venous ultrasound. No thrombus\n is seen to the level of the mid SFV bilaterally; however thrombus below this\n level cannot be excluded bilaterally.\n DFDdp\n\n" }, { "category": "Radiology", "chartdate": "2131-05-26 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1079895, "text": " 4:38 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 28 year old man with nec. pancareatitis, renal failure, respiratory failure.\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Followup of the patient with necrotizing\n pancreatitis, renal failure and respiratory failure.\n\n Portable AP chest radiograph was compared to .\n\n The ET tube tip is high, 7.5 cm above the carina and above the clavicular head\n and should be advanced 2 cm. The right internal jugular line tip is at the\n mid SVC. The left internal jugular double-lumen line tip is at the cavoatrial\n junction. There is no change in mild pulmonary edema, bibasilar extensive\n atelectasis and large pleural effusions.\n\n\n" }, { "category": "Radiology", "chartdate": "2131-06-01 00:00:00.000", "description": "P BILAT LOWER EXT VEINS PORT", "row_id": 1081025, "text": ", MED SICU-A 8:53 PM\n BILAT LOWER EXT VEINS PORT Clip # \n Reason: BLE SWELLING AND RED EVAL FOR DVT\n Admitting Diagnosis: PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 28 year old man with respiratory failure, pancreatitis, worsening tachypnea.\n REASON FOR THIS EXAMINATION:\n r/o dvt\n ______________________________________________________________________________\n PFI REPORT\n PFI: Limited evaluation below the level of the mid SFV, however, no evidence\n for clot proximal to the superficial femoral veins bilaterally. Clot in\n distal or below the SFV cannot be fully excluded.\n DFDdp\n\n" }, { "category": "Radiology", "chartdate": "2131-05-24 00:00:00.000", "description": "BY DIFFERENT PHYSICIAN", "row_id": 1079623, "text": " 3:15 PM\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \n Reason: dialysis cath placement\n Admitting Diagnosis: PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 28 year old man with nec. pancareatitis, renal failure\n REASON FOR THIS EXAMINATION:\n dialysis cath placement\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE AP CHEST :\n\n INDICATION: New dialysis catheter placement.\n\n FINDINGS: Comparison made to , 05:04 hours. Left IJ hemodialysis\n catheter has been placed, tip in the proximal right atrium. There is no\n pneumothorax. Endotracheal tube remains in place, but has apparently been\n withdrawn, and now is situated above the thoracic inlet, roughly 7 cm above\n the carina. Cardiomediastinal contours are unchanged. Lung volumes remain\n low, but the lungs are grossly clear. There is no definite pleural effusion.\n\n IMPRESSION:\n\n 1) New left IJ hemodialysis catheter in place, tip in the proximal right\n atrium.\n\n 2) Endotracheal tube has been repositioned, with tip now above the thoracic\n inlet. Tube should be advanced several cm for more optimal positioning.\n\n Findings were called to RN in the surgical ICU at 16:15 hours on\n .\n\n\n" }, { "category": "Radiology", "chartdate": "2131-05-25 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1079694, "text": " 9:15 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval assesment\n Admitting Diagnosis: PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 28 year old man with necrotizing pancreatitis with evolving infiltrates.\n REASON FOR THIS EXAMINATION:\n interval assesment\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 9:25 A.M. \n\n HISTORY: Necrotizing pancreatitis.\n\n IMPRESSION: AP chest compared to :\n\n Lung volumes are very low and left lower lobe atelectasis has worsened.\n Moderate right pleural effusion stable. Pulmonary and mediastinal vascular\n engorgement have worsened and early interstitial edema has developed. Tip of\n the endotracheal tube at the upper margin of the clavicles is at least 7 cm\n from the carina, with the chin down, this is 5 cm above optimal placement.\n Right and left central venous jugular lines end low in the SVC. Heart size is\n normal. No pneumothorax. Dr. paged to report these findings.\n\n\n" }, { "category": "Radiology", "chartdate": "2131-06-05 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1081487, "text": " 3:27 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval assesment\n Admitting Diagnosis: PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 28 year old man with pancreatitis, respiratory failure\n REASON FOR THIS EXAMINATION:\n interval assesment\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 28-year-old man with pancreatitis, respiratory failure, interval\n assessment.\n\n COMPARISON: .\n\n SINGLE PORTABLE SUPINE CHEST RADIOGRAPH: A left IJ tip projecting over the\n right atrium. A right IJ tip projects over the lower SVC. An endotracheal\n tube is seen with tip 5.3 cm from the carina. An orogastric tube tip courses\n below the diaphragm. There are unchanged bibasilar opacities likely\n atelectasis. A right upper lobe ill-defined airspace opacification is\n increased in prominence. There is a small left pleural effusion. There is no\n pneumothorax. Osseous structures are grossly unremarkable.\n\n IMPRESSION:\n 1. Prominence of right upper lobe airspace opacification suggests asymmetric\n edema versus infection.\n\n 2. Unchanged bibasilar opacification likely atelectasis, and left pleural\n effusion.\n\n\n" }, { "category": "Radiology", "chartdate": "2131-06-03 00:00:00.000", "description": "CTA CHEST W&W/O C&RECONS, NON-CORONARY", "row_id": 1081241, "text": " 3:24 PM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \n Reason: Rule out PE.\n Admitting Diagnosis: PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 28 year old man with pancreatitis c/b ARDS, ARF, SIRS, GIB.\n REASON FOR THIS EXAMINATION:\n Rule out PE.\n CONTRAINDICATIONS for IV CONTRAST:\n ARF on CVVHD\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): CLxc SUN 7:47 PM\n No evidence of pulmonary embolus.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 28-year-old man with pancreatitis complicated by ARDS, acute renal\n failure, SIRS, GI bleed, rule out PE.\n\n TECHNIQUE: 2.5-mm contiguous axial images from the thoracic inlet through the\n adrenal glands with IV contrast were obtained. Coronal, sagittal and oblique\n MIP images were included in this study. Comparison is made to a prior CT\n torso without IV contrast dated .\n\n FINDINGS:\n There is no evidence of pulmonary embolus.\n\n Interval worsening of the consolidation of the posterior aspects of the\n bilateral upper and lower lobes since the prior CT Torso dated . This\n finding may represent atelectasis, however, a superimposed infection cannot be\n excluded. In addition, there are nonspecific ground- glass opacities\n throughout both lungs. No evidence of pericardial or pleural effusion.\n\n Heart and great vessels appear normal. Mediastinal and hilar lymph nodes\n measuring up to approximately 7 mm in short axis are visualized. The tips of\n the right and left IJ venous catheters are in the SVC. Nasogastric tube\n courses below the diaphragm.\n\n There is marked fatty infiltration of the liver.\n\n OSSEOUS STRUCTURES: No suspicious osteolytic or osteoblastic lesions. Mild\n degenerative changes are seen in the lower thoracic spine.\n\n IMPRESSION:\n\n 1. No evidence of pulmonary embolus.\n\n 2. Interval worsening of the consolidation of the dependent portions of the\n bilateral upper and lower lobes, which may represent atelectasis; however, a\n superimposed infection cannot be excluded.\n\n 3. Marked fatty infiltration of the liver.\n\n (Over)\n\n 3:24 PM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \n Reason: Rule out PE.\n Admitting Diagnosis: PANCREATITIS\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n These findings were discussed with Dr. at 6:20 p.m. on .\n\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2131-06-03 00:00:00.000", "description": "CTA CHEST W&W/O C&RECONS, NON-CORONARY", "row_id": 1081242, "text": ", MED SICU-A 3:24 PM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \n Reason: Rule out PE.\n Admitting Diagnosis: PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 28 year old man with pancreatitis c/b ARDS, ARF, SIRS, GIB.\n REASON FOR THIS EXAMINATION:\n Rule out PE.\n CONTRAINDICATIONS for IV CONTRAST:\n ARF on CVVHD\n ______________________________________________________________________________\n PFI REPORT\n No evidence of pulmonary embolus.\n\n" }, { "category": "Radiology", "chartdate": "2131-06-02 00:00:00.000", "description": "PORTABLE ABDOMEN", "row_id": 1081053, "text": " 4:12 AM\n PORTABLE ABDOMEN Clip # \n Reason: ?post pyloric position\n Admitting Diagnosis: PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 28 year old man with pancreatitis, s/p OGT advancement.\n REASON FOR THIS EXAMINATION:\n ?post pyloric position\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 28-year-old man with pancreatitis, status post OG tube advancement,\n question post-pyloric position.\n\n TECHNIQUE: A supine abdominal x-ray dated at 5:21 a.m. was\n obtained. Correlation is made to a prior CT scan of the abdomen and pelvis\n dated .\n\n FINDINGS: The tip of the orogastric tube projects over the right lateral\n aspect of the L2 vertebral body. There is a paucity of bowel gas. The soft\n tissues and osseous structures are unremarkable.\n\n IMPRESSION: The tip of the OG tube projects along the lateral aspect of the\n right L2 vertebral body. It is not possible to distinguish whether this tube\n is in the antrum of the stomach or proximal duodenum on this study.\n\n" }, { "category": "Radiology", "chartdate": "2131-05-22 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1079155, "text": " 4:07 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval assesment\n Admitting Diagnosis: PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 28 year old man with necrotizing pancreatitis and ARDS.\n REASON FOR THIS EXAMINATION:\n interval assesment\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): LCpc TUE 10:27 AM\n Decreased aeration of the right lung, mostly at the right apex, could be fluid\n tracking at the apex or complete collapse of the right upper lobe. Basilar\n opacities improved on the left.\n ______________________________________________________________________________\n FINAL REPORT\n CHEST PORTABLE AP\n\n REASON FOR EXAM: 28-year-old man with necrotizing pancreatitis and ARDS\n interval assessment.\n\n Since yesterday, aeration of the right lung decreased, mostly in the upper\n third, could be due to complete collapse/consolidation of the right upper lobe\n or fluid extending superiorly. Left basilar opacities improved, were likely\n atelectasis. Tubes and catheters are still in expected position. There is no\n other change.\n\n Dr. was paged at the time of dictation and results were discussed\n on the phone with .\n\n" }, { "category": "Radiology", "chartdate": "2131-05-22 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1079156, "text": ", F. MED SICU-A 4:07 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval assesment\n Admitting Diagnosis: PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 28 year old man with necrotizing pancreatitis and ARDS.\n REASON FOR THIS EXAMINATION:\n interval assesment\n ______________________________________________________________________________\n PFI REPORT\n Decreased aeration of the right lung, mostly at the right apex, could be fluid\n tracking at the apex or complete collapse of the right upper lobe. Basilar\n opacities improved on the left.\n\n" }, { "category": "Radiology", "chartdate": "2131-05-27 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1080030, "text": " 5:03 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 28 year old man with nec. pancareatitis, renal failure, respiratory failure.\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 5:59 A.M. \n\n HISTORY: Necrotizing pancreatitis and renal and respiratory failure.\n\n IMPRESSION: AP chest compared to through :\n\n Bibasilar opacification has progressed on the left since , stabilized on\n the right, there is at least a small volume of bilateral pleural effusion\n probably unchanged and mild interstitial edema new since but stable\n since . Heart is at best top normal size. No pneumothorax. ET tube\n tip at the upper margin of the clavicles is acceptable given elevation of the\n chin. Right jugular line ends low in the SVC and a nasogastric tube passes\n into the stomach and out of view.\n\n\n" }, { "category": "Radiology", "chartdate": "2131-06-03 00:00:00.000", "description": "P BILAT UP EXT VEINS US PORT", "row_id": 1081206, "text": " 10:41 AM\n BILAT UP EXT VEINS US PORT; -76 BY SAME PHYSICIAN # \n Reason: R/O DVT, SWELLING\n Admitting Diagnosis: PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 28 year old man with necrotizing pancreatitis.\n REASON FOR THIS EXAMINATION:\n Rule out DVT.\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): YMf SUN 2:16 PM\n PFI: Limited study, internal jugular veins not imaged. Elsewhere, no\n evidence of DVT.\n ______________________________________________________________________________\n FINAL REPORT\n BILATERAL UPPER EXTREMITY VENOUS ULTRASOUND\n\n INDICATION: 28-year-old male with necrotizing pancreatitis. Rule out DVT.\n\n COMPARISON: Not available at .\n\n FINDINGS: The study is limited by patient's inability to cooperate and\n multiple overlying bandages. -scale and color images of the right\n subclavian, axillary, brachial, basilic, and cephalic and left subclavian,\n axillary, brachial, basilic, and cephalic veins were obtained. These\n demonstrate normal flow, compressibility, and augmentation, where applicable.\n Images of the internal jugular veins were not obtained.\n\n IMPRESSION: Internal jugular veins not imaged due to limitations of the\n study. In subclavian, axillary, brachial, cephalic, and basilic veins\n bilaterally, no evidence of DVT.\n\n\n" }, { "category": "Radiology", "chartdate": "2131-05-30 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1080582, "text": " 12:18 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: Assess for interval change.\n Admitting Diagnosis: PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 28 year old man with necrotizing pancreatitis c/b ARDS, SIRS\n REASON FOR THIS EXAMINATION:\n Assess for interval change.\n CONTRAINDICATIONS for IV CONTRAST:\n On ARF on CVVH\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): YMf WED 2:44 PM\n 1. No acute intracranial hemorrhage, shift of normally midline structures or\n territorial infarction.\n\n 2. Interval improvement in the -white matter differentiation,\n particularly in the deep -white matter interface as well as at the vertex.\n ______________________________________________________________________________\n FINAL REPORT\n HEAD CT WITHOUT INTRAVENOUS CONTRAST.\n\n INDICATION: 28-year-old man necrotizing pancreatitis; previous findings\n concerning for global hypoxia or edema.\n\n COMPARISON: .\n\n TECHNIQUE: Non-contrast head CT.\n\n FINDINGS: There has been an interval improvement in degree of -white\n matter differentiation, in particular, at the deep -white matter interface\n of the basal ganglia, as well as the cortical ribbon at the vertex, where the\n sulci appear slightly less effaced. The lateral ventricular bodies also\n appear slightly larger. There is no shift of normally-midline structures,\n acute intracranial hemorrhage or major vascular territorial infarction.\n\n There is persistent mucosal thickening and aerosolized secretions in both\n maxillary sinuses, complete opacification of ethmoid air cells and sphenoid\n air cells. The frontal sinus is not pneumatized. The mastoid air cells are\n opacified bilaterally, and there is fluid in the nasal cavity. These findings\n likely related to prolonged intubation and supine positioning. There has been\n interval decrease in diffuse edema of the subcutaneous soft tissues. The\n appearance of the osseous structures is unremarkable.\n\n IMPRESSION:\n 1. Interval improvement in the -white matter differentiation, overall,\n suggesting slow resolution of diffuse cerebral edema.\n\n 2. No hemorrhage, herniation or evidence of acute vascular territorial\n infarction.\n\n 3. Persistent opacification of paranasal sinuses, nasal cavity and mastoid\n air cells, likely related to intubation and supine positioning.\n (Over)\n\n 12:18 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: Assess for interval change.\n Admitting Diagnosis: PANCREATITIS\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n COMMENT: These findings were discussed with Dr. (Neurology) by Dr. \n at 2:20 pm on ; additional specificity might be afforded by MRI with\n DWI, if warranted and feasible, on clinical grounds.\n\n\n" }, { "category": "Radiology", "chartdate": "2131-05-30 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1080511, "text": " 4:34 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 28 year old man with nec pancreatitis c/b sirs and ards.\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE AP PORTABLE VIEW OF THE CHEST.\n\n REASON FOR EXAM: Pancreatitis. Assess ARDS.\n\n Comparison is made with prior study of .\n\n ET tube is in standard position. NG tube tip is below the diaphragm, outside\n field of view.\n\n Left IJ catheter tip is in the lower SVC. There are lower lung volumes.\n Bibasilar atelectases greater on the side are stable. Perihilar bilateral\n opacities could be a combination of fluid in the fissure and/or atelectasis.\n Cardiomediastinal contours are unchanged. Presumed bilateral pleural\n effusions are difficult to assess.\n\n\n" }, { "category": "Radiology", "chartdate": "2131-05-30 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1080583, "text": ", MED SICU-A 12:18 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: Assess for interval change.\n Admitting Diagnosis: PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 28 year old man with necrotizing pancreatitis c/b ARDS, SIRS\n REASON FOR THIS EXAMINATION:\n Assess for interval change.\n CONTRAINDICATIONS for IV CONTRAST:\n On ARF on CVVH\n ______________________________________________________________________________\n PFI REPORT\n 1. No acute intracranial hemorrhage, shift of normally midline structures or\n territorial infarction.\n\n 2. Interval improvement in the -white matter differentiation,\n particularly in the deep -white matter interface as well as at the vertex.\n\n" }, { "category": "Radiology", "chartdate": "2131-05-30 00:00:00.000", "description": "CT ABD W&W/O C", "row_id": 1080584, "text": " 12:18 PM\n CT ABD W&W/O C; CT PELVIS W/CONTRAST Clip # \n Reason: Assess for new pancreatitic fluid collection, hemorrhage, RP\n Admitting Diagnosis: PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 28 year old man with necrotizing pancreatitis c/b ARDS, SIRS, ARF on CVVHD now\n with hct drop and increasing pressor requirement. Please do with IV and PO\n contrast.\n REASON FOR THIS EXAMINATION:\n Assess for new pancreatitic fluid collection, hemorrhage, RP bleed, cyst\n formation.\n CONTRAINDICATIONS for IV CONTRAST:\n ARF on CVVH;ARF on CVVH\n ______________________________________________________________________________\n FINAL REPORT\n CT ABDOMEN AND PELVIS.\n\n COMPARISON: and .\n\n HISTORY: 28-year-old male with necrotizing pancreatitis with ARDS, SIRS, ARS\n on hemofiltration, now with hematocrit drop and increasing pressor\n requirement. Evaluate for pancreatic fluid collection, hemorrhage, RP bleed or\n cyst formation.\n\n TECHNIQUE: MDCT axially acquired images through the abdomen and pelvis were\n obtained. Non-contrast and post-contrast arterial and venous phase imaging\n was performed. Coronal and sagittal reformats were performed.\n\n FINDINGS:\n\n CT ABDOMEN: There are bibasilar consolidations, which have slightly worsened\n in the left lung base. Patchy opacities in the lingula and right lung base\n are slightly improved to unchanged. There are small bilateral pleural\n effusions, unchanged. There is no pericardial effusion. The liver is markedly\n enlarged and demonstrates diffuse fatty infiltration, unchanged. The\n gallbladder is distended. The adrenal glands, spleen, and kidneys are\n unremarkable. There are multiple scattered mesenteric and retroperitoneal\n lymph nodes measuring up to 9 mm in short axis diameter, likely reactive.\n\n Multiple areas of hypoenhancement within the pancreas are similar in\n appearance, primarily in the tail, mid portion of the body and anterior\n portion of the uncinate process. These findings are consistent with areas of\n necrosis. Peripancreatic fluid collections are again identified, similar in\n size and extent when compared to most recent prior exam, but slightly\n increased and more well defined when compared to . There is a new\n fluid collection seen along the muscular and serosal aspect of the greater\n curvature of the stomach (3A, 53) measuring approximately 3.1 x 3.4 cm, likely\n representing development of a pseudocyst.\n\n The portal vein and SMV are patent. The splenic vein and artery appear mildly\n attenuated although patent, unchanged. There is no evidence of pseudoaneurysm\n identified.\n (Over)\n\n 12:18 PM\n CT ABD W&W/O C; CT PELVIS W/CONTRAST Clip # \n Reason: Assess for new pancreatitic fluid collection, hemorrhage, RP\n Admitting Diagnosis: PANCREATITIS\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n Within the stomach, there is high- density material, which likely represents\n oral contrast (3A, 45-55). An NG tube is seen terminating within the stomach.\n\n Small bowel loops are normal in caliber and without focal wall thickening.\n\n CT OF THE PELVIS: The colon demonstrates marked wall thickening extending\n from the ascending colon to the mid sigmoid, similar in appearance. There is\n a small- to- moderate amount of free fluid within the dependent portions of\n the pelvis, which measures simple fluid. There is no pelvic or inguinal\n lymphadenopathy. Foley catheter is identified within the bladder. There is no\n evidence of retroperitoneal hemorrhage. There is diffuse anasarca, slightly\n improved.\n\n BONE WINDOWS: There are no suspicious lytic or sclerotic lesions identified.\n\n IMPRESSION:\n 1. New 3.1 x 3.5 cm pseudocyst formation along the greater curvature of the\n stomach wall. The remainder of the peripancreatic fluid collections appears\n slightly more well defined, but not significantly changed in terms of size or\n extent.\n 2. Persistent areas of necrosis within the pancreas as described above, not\n significantly changed.\n 3. Mild attenuation of the splenic artery and vein, although the vessels\n remain patent. No evidence of pseudoaneurysm or retroperitoneal bleed.\n 4. Areas of bibasilar consolidation, slightly worse in the left lower lobe,\n but minimally improved to stable in the right lower lobe and lingula.\n 5. Fatty infiltration and diffuse enlargement of the liver.\n 6. Diffuse wall thickening of the colon extending down to the mid sigmoid.\n This raises the possibility of C. diff colitis and less likely third spacing.\n 7. Small-to-moderate amount of free fluid within the pelvis, not significantly\n changed to slightly increased.\n\n Findings were discussed with Dr. via telephone.\n\n\n" }, { "category": "ECG", "chartdate": "2131-06-12 00:00:00.000", "description": "Report", "row_id": 242039, "text": "Sinus rhythm. No diagnostic abnormality.\n\n" }, { "category": "ECG", "chartdate": "2131-06-07 00:00:00.000", "description": "Report", "row_id": 242040, "text": "Artifact is present. Sinus rhythm. Normal tracing. Compared to the previous\ntracing the QRS duration is shorter.\n\n" }, { "category": "ECG", "chartdate": "2131-06-07 00:00:00.000", "description": "Report", "row_id": 242041, "text": "Sinus tachycardia. Non-specific QRS widening. Compared to the previous\ntracing no diagnostic change.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2131-06-06 00:00:00.000", "description": "Report", "row_id": 242042, "text": "Sinus tachycardia. Borderline low QRS voltage in the limb leads. Non-specific\nQRS widening. Diffuse non-diagnostic repolarization abnormalities. Compared\nto the previous tracing of QRS width has increased. Otherwise, no\ndiagnostic change.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2131-06-01 00:00:00.000", "description": "Report", "row_id": 242043, "text": "Sinus tachycardia\nLow T wave amplitude is nonspecific\nSince previous tracing of , sinus tachycardia rate slower, and low T\nwave low amplitude now present\n\n" }, { "category": "ECG", "chartdate": "2131-05-17 00:00:00.000", "description": "Report", "row_id": 242044, "text": "Baseline artifact. Sinus tachycardia. Otherwise, within normal limits. No\nprevious tracing available for comparison.\n\n" }, { "category": "Radiology", "chartdate": "2131-05-28 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1080149, "text": " 4:23 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval assesment\n Admitting Diagnosis: PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 28 year old man with nec. pancareatitis, renal failure, respiratory failure\n (intubated).\n REASON FOR THIS EXAMINATION:\n interval assesment\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE AP PORTABLE VIEW OF THE CHEST\n\n REASON FOR EXAM: Respiratory failure, renal failure and pancreatitis.\n\n Comparison is made to prior study performed a day earlier.\n\n ET tube tip is 5.6 cm above the carina, right IJ catheter tip is in unchanged\n positionT there are low lung volumes with bibasilar atelectasis minimally\n improved on the left. Mild interstitial edema and small bilateral pleural\n effusions are stable since . There is no pneumothorax. Left IJ catheter\n tip is in the mid SVC.\n\n" }, { "category": "Radiology", "chartdate": "2131-06-05 00:00:00.000", "description": "CT CHEST W/CONTRAST", "row_id": 1081636, "text": " 4:31 PM\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: please evaluate for infection\n Admitting Diagnosis: PANCREATITIS\n Contrast: VISAPAQUE Amt: 100\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 28 year old man with pancreatitis, respiratory failure with fever, increasing\n leukocytosis, GPC+ bcx\n REASON FOR THIS EXAMINATION:\n please evaluate for infection\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 28-year-old male with pancreatitis, respiratory failure and\n fever, increasing leukocytosis. Evaluate for infection.\n\n COMPARISON: .\n\n TECHNIQUE: Contrast-enhanced MDCT-acquired axial images of the chest, abdomen\n and pelvis from the thoracic inlet to the pubic symphysis. Multiplanar\n reformatted images were obtained.\n\n CT OF THE CHEST WITH INTRAVENOUS CONTRAST: There is continued ground glass\n opacity and atelectasis/consolidation in the dependent portion of bilateral\n lungs. There is no pleural effusion or pneumothorax. The heart size is\n normal. The thoracic aorta is normal in caliber. No pericardial effusion is\n identified. There are bilateral internal jugular central venous catheters\n which terminate in the SVC. ET tube terminates 3.9 cm above the carina. Tip\n of feeding tube terminates in the distal second portion of the duodenum.\n Multiple small mediastinal lymph nodes are present, not significantly changed\n from prior exam.\n\n CT OF THE ABDOMEN WITH INTRAVENOUS CONTRAST: The liver is enlarged and is\n diffusely low in attenuation compatible with fatty infiltration. There is\n focal fatty sparing about the gallbladder fossa. The gallbladder, spleen,\n kidneys and right adrenal gland are unremarkable. The left adrenal gland\n remains thickened.\n\n The majority of the pancreas remains hypoenhancing with minimal enhancing\n tissue remaining in the uncinate process and the mid body. Peripancreatic\n fluid collections are minimally decreased in size compared to prior exam. The\n previously seen collection adjacent to the greater curvature of the stomach\n has resolved. Diffuse colonic bowel wall thickening is not significantly\n changed compared to prior exam. There is no evidence of bowel obstruction.\n\n The abdominal aorta is normal in caliber. The SMA, SMV, and portal vein are\n patent. The celiac artery and branches are diminutive. There is increased\n attenuation of the splenic vein. Multiple small retroperitoneal and mesenteric\n lymph nodes are again identified, none of which meet CT criteria for\n pathologic enlargement. There is no free air.\n\n (Over)\n\n 4:31 PM\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: please evaluate for infection\n Admitting Diagnosis: PANCREATITIS\n Contrast: VISAPAQUE Amt: 100\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n CT OF THE PELVIS WITH INTRAVENOUS CONTRAST: The rectum is unremarkable. There\n is mild bowel wall thickening involving the sigmoid colon. The bladder is\n collapsed and contains a Foley catheter. There is small amount of pelvic free\n fluid, minimally decreased since the prior exam. No lymphadenopathy is\n appreciated.\n\n BONE WINDOWS: No suspicious lytic or sclerotic lesion is identified. There\n is diffuse body wall anasarca.\n\n IMPRESSION:\n 1. Persistent atelectasis/consolidation in the dependent portions of the\n lungs bilaterally. Ground-glass opacity in the dependent portions of the\n lungs is suggestive of edema.\n\n 2. Diffuse fatty infiltration of the liver with areas of sparing about the\n gallbladder fossa.\n\n 3. Persistent area of necrosis within the pancreas as described above, not\n significantly changed. Minimally decreased peripancreatic fluid collection.\n Resolution of the collection previously seen adjacent to the greater curvature\n of the stomach.\n\n 4. Unchanged diffuse colonic bowel wall thickening for which an infectious\n etiology is not excluded.\n\n 5. Increased attenuation of the splenic vein. The SMA and SMV is patent. No\n evidence of pseudoaneurysm.\n\n" }, { "category": "Radiology", "chartdate": "2131-06-05 00:00:00.000", "description": "CT SINUS W/ CONTRAST", "row_id": 1081637, "text": " 4:32 PM\n CT SINUS W/ CONTRAST Clip # \n Reason: please evaluate for infection\n Admitting Diagnosis: PANCREATITIS\n Contrast: VISAPAQUE Amt: 100\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 28 year old man with pancreatitis, respiratory failure with fever, increasing\n leukocytosis, GPC+ bcx\n REASON FOR THIS EXAMINATION:\n please evaluate for infection\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 28-year-old male with pancreatitis, respiratory failure, fever,\n increasing leukocytosis, Gram-positive cocci bacteremia. Evaluate for\n infection.\n\n COMPARISON: Head CT from .\n\n TECHNIQUE: Contrast-enhanced MDCT-acquired axial images of the sinuses were\n obtained. Multiplanar reformatted images were created.\n\n FINDINGS: The left maxillary sinus shows moderate mucosal thickening and\n contains aerosolized secretions. The right maxillary sinus shows mild mucosal\n thickening. The ethmoid air cells, sphenoid sinuses and nasopharynx are\n nearly opacified. The frontal sinuses are not pneumatized. The right OMU is\n patent. The left infundibulum is obstructed. The ethmoid roof and lamina\n papyracea are intact. The nasal septum mildly deviates to the right. The\n mastoid air cells and middle ear cavity are fluid filled bilaterally. Soft\n tissue density is noted in the left external auditory canal likely\n representing cerumen. The visualized brain parenchyma and orbits are\n unremarkable. ET tube and OG tubes are identified.\n\n IMPRESSION:\n 1. Near-opacification of the nasopharynx, sphenoid sinuses and ethmoid air\n cells. Moderate-to-severe left maxillary sinus disease. Mild right maxillary\n sinus disease. Non-pneumatized frontal sinuses.\n 2. Persistent opacification of bilateral mastoid air cells and middle ear\n cavity.\n\n\n" }, { "category": "Radiology", "chartdate": "2131-05-23 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1079395, "text": " 2:03 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: edema, mass, bleed\n Admitting Diagnosis: PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 28 year old man with nec pancreatitis on two pressors, /vanc and intubated\n on fent/versced now with dilated pupils\n REASON FOR THIS EXAMINATION:\n edema, mass, bleed\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): JMGw WED 3:30 PM\n PFI: Diffuse loss of -white matter differentiation concerning for global\n hypoxic injury. No herniation, no shift of midline, no hemorrhage.\n Hypodensities in bilateral thalami. Fluid seen in bilateral temporal scalp\n tissue. Fluid opacification of bilateral mastoids, ethmoids frontal and\n maxillary sinuses..\n ______________________________________________________________________________\n FINAL REPORT\n HEAD CT: Contiguous axial imaging was performed through the brain without\n administration of intravenous contrast.\n\n HISTORY: 28-year-old man with necrotizing pancreatitis on two pressors,\n intubated, now with dilated pupils and edema. Evaluate for mass or bleed.\n\n COMPARISON: None.\n\n FINDINGS: There is diffuse loss of -white matter differentiation.\n Hypodensities are seen in the bilateral thalami. No hemorrhage, herniation or\n shift of midline. Sulci appear effaced. There is extensive fluid seen in\n bilateral temporal subcutaneous tissue. There is near-complete opacification\n of bilateral mastoid, frontal, ethmoid, and maxillary air cells. No fractures\n identified.\n\n IMPRESSION:\n 1. Diffuse loss of -white matter differentiation concerning for global\n hypoxia or edema with hypodensities in bilateral thalami.\n 2. No hemorrhage, mass effect, or herniation.\n 3. Fluid seen in bilateral temporal subcutaneous tissue. Near-complete\n opacification of bilateral mastoid, maxillary, frontal, and ethmoid sinuses.\n\n Findings of this study were communicated via telephone to Dr. at 2:45\n p.m. on .\n\n" }, { "category": "Radiology", "chartdate": "2131-05-23 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1079396, "text": ", F. MED SICU-A 2:03 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: edema, mass, bleed\n Admitting Diagnosis: PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 28 year old man with nec pancreatitis on two pressors, /vanc and intubated\n on fent/versced now with dilated pupils\n REASON FOR THIS EXAMINATION:\n edema, mass, bleed\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n PFI: Diffuse loss of -white matter differentiation concerning for global\n hypoxic injury. No herniation, no shift of midline, no hemorrhage.\n Hypodensities in bilateral thalami. Fluid seen in bilateral temporal scalp\n tissue. Fluid opacification of bilateral mastoids, ethmoids frontal and\n maxillary sinuses..\n\n" }, { "category": "Radiology", "chartdate": "2131-06-05 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1081564, "text": " 11:30 AM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: please evaluate ET tube placement\n Admitting Diagnosis: PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 28 year old man with pancreatitis, respiratory failure\n REASON FOR THIS EXAMINATION:\n please evaluate ET tube placement\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 11:40 A.M. ON \n\n HISTORY: 28-year-old man with pancreatitis and respiratory failure. Check ET\n tube placement.\n\n IMPRESSION: AP chest compared to at 4:29 a.m.:\n\n Tip of the endotracheal tube is at the level of the sternal notch, at least 68\n mm above the carina, 2 cm above optimal placement. Lung volumes are still\n low, but aeration at the base of the left lung is improving. Pleural\n effusion, if any, is minimal. Heart size is normal. Left internal jugular\n line ends at the superior cavoatrial junction, the right internal jugular line\n ends in the low SVC. Nasogastric tube passes into the stomach and out of\n view. No pneumothorax.\n\n\n" }, { "category": "Radiology", "chartdate": "2131-05-21 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1078984, "text": " 4:43 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Please evaluate for interval change.\n Admitting Diagnosis: PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 28 year old man with necrotizing pancreatitis and ARDS.\n REASON FOR THIS EXAMINATION:\n Please evaluate for interval change.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Necrotizing pancreatitis and ARDS.\n\n FINDINGS: In comparison with the study of , there is little change in the\n appearance of the monitoring and support devices. Extensive bibasilar changes\n are consistent with some combination of consolidation, atelectasis, and\n effusion. Diagnostic possibilities again include pulmonary edema, widespread\n infection, and ARDS.\n\n\n" }, { "category": "Radiology", "chartdate": "2131-06-02 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1081050, "text": " 4:10 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 28 year old man with pancreatitis, respiratory failure.\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n CHEST X-RAY\n\n HISTORY: Pancreatitis, respiratory failure, evaluate for interval change.\n\n One view. Comparison with . Lung volumes are somewhat low. Bilateral\n pulmonary infiltrates persist. Mediastinal structures are unchanged.\n Endotracheal tube, nasogastric tube and bilateral internal jugular catheters\n remain in place.\n\n IMPRESSION: No significant interval change.\n\n\n" }, { "category": "Radiology", "chartdate": "2131-05-24 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1079508, "text": " 4:14 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval assesment\n Admitting Diagnosis: PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 28 year old man with necrotizing pancreatitis with evolving infiltrates.\n REASON FOR THIS EXAMINATION:\n interval assesment\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): 4:13 PM\n PFI: Multifocal consolidations seen in the right middle lobe, right lower\n lobe, and left upper lobe/lingula are better seen in prior CT from .\n Small right pleural effusion. Low lung volumes.\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAM: Patient with necrotizing pancreatitis with evolving\n opacities.\n\n Comparison is made with prior study CT torso from and chest x-ray from\n and 20.\n\n Cardiac size is normal. There are low lung volumes. Small right pleural\n effusion is unchanged. ET tube is seen in standard position. Multifocal\n consolidations seen in the right middle lobe, lingula, and right lower lobe\n have progressed from the day before and CT torso. There is no pneumothorax.\n The tip of the NG tube is not clearly visualized, in the CT torso the tip\n projects in the stomach.\n\n" }, { "category": "Radiology", "chartdate": "2131-05-29 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1080291, "text": " 5:27 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess for interval change.\n Admitting Diagnosis: PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 28 year old man with nec pancreatitis c/b sirs and ards.\n REASON FOR THIS EXAMINATION:\n assess for interval change.\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 5:22 A.M., \n\n HISTORY: Necrotizing pancreatitis. ARDS.\n\n IMPRESSION: AP chest compared to through 25:\n\n Bibasilar atelectasis, severe on the right, moderate on the left, is unchanged\n for several days. A generalized ground-glass opacification in both lungs\n probably mild edema also stable. The heart is not enlarged. Bilateral\n pleural effusion is presumed but difficult to assess. ET tube, right internal\n jugular and left internal jugular lines are in standard placements and a\n nasogastric tube passes into the stomach and out of view. No pneumothorax.\n\n\n" }, { "category": "Radiology", "chartdate": "2131-06-01 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1080852, "text": " 2:45 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Assess for interval change.\n Admitting Diagnosis: PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 28 year old man with pancreatitis, ARDS, and SIRS\n REASON FOR THIS EXAMINATION:\n Assess for interval change.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 28-year-old man with pancreatitis, ARDS, SIRS, assess for\n interval change.\n\n COMPARISON: ; .\n\n SINGLE PORTABLE SUPINE CHEST RADIOGRAPH: Bilateral internal jugular catheter,\n endotracheal tube, and orogastric tube remain in similar position.\n Cardiomediastinal silhouette is unchanged. Low lung volumes limit assessment.\n Haziness suggests edema. Bibasal opacifications likely representing\n atelectasis are again seen, slightly improved on the right. There are small\n bilateral pleural effusions. There is no pneumothorax.\n\n IMPRESSION: Overall similar radiographic appearance of the chest.\n\n" }, { "category": "Radiology", "chartdate": "2131-05-23 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1079327, "text": " 4:21 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Please evaluate for interval change.\n Admitting Diagnosis: PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 28 year old man with necrotizing pancreatitis with evolving infiltrates.\n REASON FOR THIS EXAMINATION:\n Please evaluate for interval change.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 28-year-old male with necrotizing pancreatitis and evolving\n infiltrates to assess for interval change.\n\n TECHNIQUE: Single portable AP radiograph of the chest was performed.\n\n Comparison is made with prior radiograph dated .\n\n FINDINGS: The tip of the ET tube is approximately 69 mm from the carina. The\n right-sided central line has its tip projected over the cavoatrial junction.\n NG tube is seen traversing a course of the anticipated esophagus and the\n distal tip although not visualized most likely ends over the stomach. Lungs\n are of low volume. There is new opacification in the right lower lobe as well\n as the lateral segment of the right middle lobe. There is also atelectasis\n present at the left lung base. The cardiomediastinal silhouette is stable.\n\n CONCLUSION: New opacification in the right lower lobe as well as the lateral\n segment of the middle lobe is suggestive of atelectasis, given the pattern\n seen in multiple prior radiographs. Atelectasis is also present in the left\n lower lobe.\n\n" }, { "category": "Radiology", "chartdate": "2131-05-24 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1079509, "text": ", F. MED SICU-A 4:14 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval assesment\n Admitting Diagnosis: PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 28 year old man with necrotizing pancreatitis with evolving infiltrates.\n REASON FOR THIS EXAMINATION:\n interval assesment\n ______________________________________________________________________________\n PFI REPORT\n PFI: Multifocal consolidations seen in the right middle lobe, right lower\n lobe, and left upper lobe/lingula are better seen in prior CT from .\n Small right pleural effusion. Low lung volumes.\n\n" }, { "category": "Radiology", "chartdate": "2131-06-03 00:00:00.000", "description": "BILAT LOWER EXT VEINS", "row_id": 1081203, "text": " 10:35 AM\n BILAT LOWER EXT VEINS Clip # \n Reason: R/O DVT, SWELLING\n Admitting Diagnosis: PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 28 year old man with necrotizing pancreatitis.\n REASON FOR THIS EXAMINATION:\n Rule out DVT.\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): YMf SUN 4:41 PM\n\n PFI: Limited bilateral lower extremity venous ultrasound. No thrombus to the\n level of the left mid SFV and proximal right SFV, thrombus below this level\n cannot be excluded.\n ______________________________________________________________________________\n FINAL REPORT\n BILATERAL LOWER EXTREMITY VENOUS ULTRASOUND\n\n INDICATION: 28-year-old male with necrotizing pancreatitis. Rule out DVT.\n\n COMPARISON: .\n\n FINDINGS: Color and Doppler images of bilateral common femoral, proximal\n superficial veins, and left mid superficial veins were obtained. The study\n again was technically limited due to patient's body habitus and inability to\n cooperate, vessels below the mid left superficial femoral vein and proximal\n right superficial vein were not visualized. In the imaged vessels, there is\n normal flow, and incompressibility. Evaluation for thrombus below the level\n of the mid SFV cannot be fully excluded.\n\n IMPRESSION: Limited bilateral lower extremity venous ultrasound. No thrombus\n is seen to the level of the mid SFV on the left and proximal SFA on the right,\n however, thrombus below this level cannot be excluded.\n\n" }, { "category": "Radiology", "chartdate": "2131-06-03 00:00:00.000", "description": "BILAT LOWER EXT VEINS", "row_id": 1081204, "text": ", MED SICU-A 10:35 AM\n BILAT LOWER EXT VEINS Clip # \n Reason: R/O DVT, SWELLING\n Admitting Diagnosis: PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 28 year old man with necrotizing pancreatitis.\n REASON FOR THIS EXAMINATION:\n Rule out DVT.\n ______________________________________________________________________________\n PFI REPORT\n\n PFI: Limited bilateral lower extremity venous ultrasound. No thrombus to the\n level of the left mid SFV and proximal right SFV, thrombus below this level\n cannot be excluded.\n\n" }, { "category": "Radiology", "chartdate": "2131-06-03 00:00:00.000", "description": "P BILAT UP EXT VEINS US PORT", "row_id": 1081207, "text": ", MED SICU-A 10:41 AM\n BILAT UP EXT VEINS US PORT; -76 BY SAME PHYSICIAN # \n Reason: R/O DVT, SWELLING\n Admitting Diagnosis: PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 28 year old man with necrotizing pancreatitis.\n REASON FOR THIS EXAMINATION:\n Rule out DVT.\n ______________________________________________________________________________\n PFI REPORT\n PFI: Limited study, internal jugular veins not imaged. Elsewhere, no\n evidence of DVT.\n\n\n" }, { "category": "Radiology", "chartdate": "2131-06-29 00:00:00.000", "description": "REMOVE TUNNELED CENTRAL W/O PORT", "row_id": 1085746, "text": " 11:53 AM\n DIALYSIS REMOVE Clip # \n Reason: please discontinue line, thanks\n Admitting Diagnosis: PANCREATITIS\n ********************************* CPT Codes ********************************\n * REMOVE TUNNELED CENTRAL W/O PO *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 28 year old man with tunnelled cath, now resolved renal failure, no longer\n requiring HD\n REASON FOR THIS EXAMINATION:\n please discontinue line, thanks\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 28-year-old man with tunneled cath, now resolved renal failure,\n no longer requiring hemodialysis. Please discontinue the tunneled right IJ\n hemodialysis catheter.\n\n RADIOLOGISTS: , and . Dr. , the Attending\n Radiologist, was present and supervised the entire procedure.\n\n COMPARISON: None.\n\n PROCEDURE: A right IJ tunneled hemodialysis catheter was removed under\n standard sterile precautions after prepping the old catheter site with\n ChloraPrep solution. Anesthesia was provided with Lidocaine 1%. The removed\n catheter was inspected for continuity and was found to be intact. There was\n no oozing or infection at the tunnel site or the initial access site. The\n initial access site was covered with a Band- Aid. The patient tolerated the\n procedure well.\n\n IMPRESSION: Successful removal of the right sided tunneled hemodialysis\n catheter without immediate post-procedure complications.\n\n" }, { "category": "Radiology", "chartdate": "2131-06-27 00:00:00.000", "description": "MR HEAD W/O CONTRAST", "row_id": 1085475, "text": " 4:18 PM\n MR HEAD W/O CONTRAST; MRA BRAIN W/O CONTRAST Clip # \n Reason: please assess for edema, global damage,\n Admitting Diagnosis: PANCREATITIS\n ______________________________________________________________________________\n FINAL ADDENDUM\n\n Associated cerebral edema is better assessed with close followup CT Head\n without contrast and ICP monitoring, if necessary.\n\n\n\n\n 4:18 PM\n MR HEAD W/O CONTRAST; MRA BRAIN W/O CONTRAST Clip # \n Reason: please assess for edema, global damage,\n Admitting Diagnosis: PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 28 year old man with necrotizing pancreatitis, s/p cerebral edema, s/p PEA\n arrest and brief anoxic period, w/ persistent mental status change\n REASON FOR THIS EXAMINATION:\n please assess for edema, global damage,\n CONTRAINDICATIONS for IV CONTRAST:\n does have renal failure\n\n Yes to Choyke questions.\n ______________________________________________________________________________\n WET READ: 11:44 AM\n Findings consistent with subacute anoxic brain injury. There is diffuse edema\n seen involving the cortical ribbon and basal ganglia. Additionally, there is\n ventriculomegally which is new since admission CT scans, including prominence\n of the temporal horns. This may reflect volume loss.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 28-year-old male with necrotizing pancreatitis and cerebral\n edema, status post anoxic event approximately two weeks prior.\n\n COMPARISON: Prior CTs of the head dating back to and most\n recently dated .\n\n TECHNIQUE: Sagittal T1 and axial FLAIR, T2, gradient echo, and diffusion-\n weighted imaging was performed through the brain. Additionally, three-\n dimensional time-of-flight MR arteriography was performed through the brain\n with preparation and review of rotational reformats.\n\n FINDINGS:\n\n MRI BRAIN: There is increased FLAIR and T2 signal intensity involving the\n cerebral cortex quite diffusely in the frontal, parietal, temporal lobes,\n including the insular cortex and also part of the occipital lobes, caudate and\n lentiform nuclei and thalami bilaterally. There is no associated negative\n susceptibility. While there is increased signal on the DWI images, on the ADC\n sequence, the signal is only slightly hypointense indicating possible\n normalization on the ADC and hence, changes related to subacute ischemic\n changes likely related anoxic injury, which apparently has been 2 weeks\n earlier. Subtle t1 hyperitnensity in a few scattered locations of the cortex\n can relate to laminar necrosis, however, non-specific.\n\n Pl.note that the present study does not assess the actual perfusion in these\n locations.\n\n Also notable is diffuse ventriculomegaly, increased from prior Ct\n studies, more so in the temporal horns, likely due to volume loss.\n particularly involving the bilateral hippocampi, which can be particularly\n sensitive to ischemic/anoxic injury.\n (Over)\n\n 4:18 PM\n MR HEAD W/O CONTRAST; MRA BRAIN W/O CONTRAST Clip # \n Reason: please assess for edema, global damage,\n Admitting Diagnosis: PANCREATITIS\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n There is no evidence for hemorrhage, mass lesion, or mass effect. There is no\n shift of normally midline structures. There is no area of abnormal\n susceptibility on GRE imaging to suggest presence of blood products.\n\n The calvarium and extracranial soft tissues, including the globes and orbits,\n appear unremarkable. The major vascular flow voids appear normal.\n\n MRA BRAIN: The intracranial carotid and vertebral arteries and their major\n branches appear normal. There is no flow limiting vessel stenosis or\n occlusion. There is no evidence for aneurysm. Study soemwhat limited due to\n artifacts at the COW.\n\n IMPRESSION:\n\n 1. Findings described above likely diffuse subacute anoxic injury involving\n the basal ganglia and cortex, correlating with the history. Pl. note that the\n present study does not assess the perfusion in these locations and assessment\n is limited due to lack of corresponding abnormalities of ADC, which may be due\n to subacute stage. Radionuclide studies can be considered if perfusion\n assessment is desired.\n\n 2. Ventriculomegaly, increasing since the earleist study, in the setting of\n anoxic brain injury, this may be secondary to atrophy/volume loss in\n addition to systemic cause /medications.\n\n 3. Normal MRA of the brain without evidence for vessel occlusion, stenosis,\n or aneurysm formation as described above.\n\n\n" }, { "category": "Radiology", "chartdate": "2131-06-25 00:00:00.000", "description": "PORTABLE ABDOMEN", "row_id": 1085005, "text": " 6:02 AM\n PORTABLE ABDOMEN Clip # \n Reason: please evaluate for evidence of obstruction\n Admitting Diagnosis: PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 28 year old man with necrotizing pancreatitis, tachypnea, abdominal tenderness,\n ?aspiration\n REASON FOR THIS EXAMINATION:\n please evaluate for evidence of obstruction\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): JMGw MON 2:58 PM\n PFI: No obstruction.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 20-year-old man with necrotizing pancreatitis, tachypnea, abdominal\n tenderness and question of aspiration. Evaluate for obstruction.\n\n COMPARISON: CT abdomen and pelvis, .\n\n FINDINGS: Single supine abdominal radiograph was obtained. A nasogastric\n tube courses through the esophagus entering into the stomach and terminates in\n the post-pyloric position. Air is seen in the colon. There is no evidence\n for bowel obstruction. Supine technique limits evaluation for free intra-\n abdominal air, given these limitations, there is no evidence for free air.\n Osseous structures appear intact.\n\n IMPRESSION: No evidence of bowel obstruction. Feeding tube in a post-pyloric\n position.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2131-06-25 00:00:00.000", "description": "PORTABLE ABDOMEN", "row_id": 1085006, "text": ", F. MED SICU-A 6:02 AM\n PORTABLE ABDOMEN Clip # \n Reason: please evaluate for evidence of obstruction\n Admitting Diagnosis: PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 28 year old man with necrotizing pancreatitis, tachypnea, abdominal tenderness,\n ?aspiration\n REASON FOR THIS EXAMINATION:\n please evaluate for evidence of obstruction\n ______________________________________________________________________________\n PFI REPORT\n PFI: No obstruction.\n\n" }, { "category": "Radiology", "chartdate": "2131-06-25 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1085004, "text": " 6:02 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please evaluate for infiltrates, effusions, edema, or other\n Admitting Diagnosis: PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 28 year old man with necrotizing pancreatitis, tachypnea, ?aspiration\n REASON FOR THIS EXAMINATION:\n please evaluate for infiltrates, effusions, edema, or other interval change\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 6:14 \n\n HISTORY: Necrotizing pancreatitis. Tachypnea possible aspiration.\n\n IMPRESSION: Moderate cardiomegaly and mediastinal vascular engorgement have\n progressed since early , and mild pulmonary edema could be present in the\n left lung, partially obscured by moderate left pleural effusion. Lung volumes\n remain quite low. A large bore right internal jugular line ends in the right\n atrium, right PICC line at the junction of brachiocephalic veins, feeding tube\n passes into the stomach and out of view, tracheostomy tube in standard\n placement. No pneumothorax.\n\n\n" }, { "category": "Radiology", "chartdate": "2131-07-01 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1086041, "text": " 3:51 PM\n CHEST (PORTABLE AP) Clip # \n Reason: please evaluate for any infiltrates, effusions, or atelectas\n Admitting Diagnosis: PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 28 year old man with with respiratory failure, tracheostomy - also, having some\n tachypnea\n REASON FOR THIS EXAMINATION:\n please evaluate for any infiltrates, effusions, or atelectasis\n ______________________________________________________________________________\n FINAL REPORT\n\n STUDY: AP chest, .\n\n HISTORY: 28-year-old man with respiratory failure and tracheostomy. The\n patient with some tachypnea, evaluate for focal infiltrates.\n\n FINDINGS: Comparison is made to previous study from .\n\n The tracheostomy tube, nasogastric tube, and right-sided PIC line are\n unchanged in position and appropriately sited.\n\n The pulmonary edema has improved slightly since the prior study. There\n remains some opacities at the lung bases which are also slightly improved\n since the previous study. The right-sided vascular catheter has been removed\n in the interim. No pneumothoraces are seen.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2131-06-28 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1085532, "text": " 7:58 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval position/length of trach. (sutures removed last night a\n Admitting Diagnosis: PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 28 year old man with necrotizing pancreatitis, ? aspiration, trach'd\n REASON FOR THIS EXAMINATION:\n eval position/length of trach. (sutures removed last night and spacing guaze\n now in place)\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 28-year-old male with necrotizing pancreatitis with tracheostomy and\n possible aspiration. Here to evaluate position. The tracheostomy sutures\n were removed last night and spacing gauze now in place.\n\n COMPARISON: Chest radiographs of and .\n\n PORTABLE SUPINE CHEST RADIOGRAPH: The ET tube tip is located 6.1 cm above the\n carina projecting between the superior margin of the clavicles. Allowing for\n decreased lordotic positioning of the patient, the position of the ETT and the\n right upper extremity PICC which terminates in the region of the upper SVC are\n likely not changed. A nasoenteric feeding tube is seen coursing into the\n stomach and out of view inferiorly, previously shown to be post-pyloric. A\n right IJ dialysis catheter projects over the right atrium.\n\n Lung volumes remain very low. Allowing for now supine position, the\n cardiomediastinal contours are likely not changed. No new pulmonary edema or\n definite new pneumonia is seen although areas of retrocardiac density likely\n represent atelectasis. No supine evidence of large pneumothorax.\n\n IMPRESSION: Allowing for differences in patient positioning, support line\n positions likely unchanged. Lung volumes remain low.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2131-05-20 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1078861, "text": " 1:31 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Assess for interval change\n Admitting Diagnosis: PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 28 year old man with ARDS and necrotizing pancreatitis\n REASON FOR THIS EXAMINATION:\n Assess for interval change\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Followup of the patient with ARDS and necrotizing\n pancreatitis.\n\n Portable AP chest radiograph was compared to the prior study obtained on , at 04:48 a.m.\n\n The ET tube tip is almost 5 cm above the carina. The right internal jugular\n line tip is at the cavoatrial junction. There is interval worsening in the\n right perihilar consolidation with no change in left perihilar consolidation\n and bibasal consolidations and pleural effusions. Within the limitations of\n this study technique the cardiomediastinal silhouette appears to be unchanged.\n The differential diagnosis of these opacities might represent infection versus\n aspiration given its gradual progression, although underlying pulmonary edema\n cannot be excluded. Ascites is suspected in the upper abdomen.\n\n\n" }, { "category": "Radiology", "chartdate": "2131-07-05 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1086557, "text": " 4:04 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please eval for interval change\n Admitting Diagnosis: PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 28 year old man with resp failure, trach\n REASON FOR THIS EXAMINATION:\n please eval for interval change\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Respiratory failure, tracheostomy.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, there is no relevant\n change. Persistent low lung volumes, persistent bilateral basal atelectasis.\n Unchanged moderate cardiomegaly without overt signs of overhydration. No\n newly appeared focal parenchymal opacity suggesting pneumonia. Unchanged\n position and course of the monitoring and support devices.\n\n\n" }, { "category": "Radiology", "chartdate": "2131-06-27 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1085435, "text": " 1:18 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Please evaluate for interval change. Confirmatory study for\n Admitting Diagnosis: PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 28 year old man with necrotizing pancreatitis, ? aspiration, trach'd\n REASON FOR THIS EXAMINATION:\n Please evaluate for interval change. Confirmatory study for r/o GNR VAP.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Possible aspiration.\n\n FINDINGS: In comparison with study of , there is little change in the\n appearance of the monitoring and support devices. The hemidiaphragms are\n somewhat more sharply seen. This may reflect some clearing of the pleural\n effusions or simply reflect the more upright position. The pulmonary\n vasculature is essentially within normal limits at this time.\n\n\n" }, { "category": "Radiology", "chartdate": "2131-06-22 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1084596, "text": " 10:24 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ?pna\n Admitting Diagnosis: PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 28 year old man with nec pancreatitis and EtOH hepatitis with persistent fevers\n despite broad spec abx\n REASON FOR THIS EXAMINATION:\n ?pna\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 28-year-old male with necrotizing pancreatitis with persistent\n fevers despite broad-spectrum antibiotics.\n\n Single AP chest radiograph compared to shows no significant\n change. Low lung volumes and bilateral pleural effusions persist. The lungs\n are otherwise clear. The cardiomediastinal contour is stable. Tracheostomy\n terminates 4.8 cm above the carina. Tip of right IJ central venous catheter\n overlies the right atrium. A post-pyloric feeding tube is present.\n\n IMPRESSION: No change from .\n\n" }, { "category": "Radiology", "chartdate": "2131-06-29 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1085697, "text": " 4:58 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please assess for infiltrate, effusions\n Admitting Diagnosis: PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 28 year old man with respiratory failure, tracheostomy\n REASON FOR THIS EXAMINATION:\n please assess for infiltrate, effusions\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Followup of the patient with respiratory failure and\n tracheostomy.\n\n Portable AP chest radiograph was compared to .\n\n The tracheostomy tip is 6 cm above the carina. The Dobbhoff tube tip passes\n below the diaphragm with its tip below the inferior margin of the field of\n view. The dialysis catheter tip is in the proximal right atrium. There is\n slight interval worsening of pulmonary edema currently moderate and no change\n in bibasilar opacities and most likely present pleural effusion. The right\n PICC line tip is at the superior SVC.\n\n\n" }, { "category": "Radiology", "chartdate": "2131-07-04 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1086387, "text": " 4:37 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please eval for interval change\n Admitting Diagnosis: PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 28 year old man with respiratory failure, tracheostomy\n REASON FOR THIS EXAMINATION:\n please eval for interval change\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): DMFj WED 10:44 AM\n PFI: Persistent low lung volumes and bibasilar atelectasis.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 28-year-old male with history of pancreatitis and respiratory\n failure. Tracheostomy.\n\n COMPARISONS: Numerous priors, most recent .\n\n AP CHEST: Endotracheal tube and nasogastric feeding tube remain in position,\n unchanged. A right PICC tip projects over the upper SVC. The lung volumes\n are low. Streaky areas of bibasilar opacity likely represent atelectasis.\n Otherwise, the lungs are clear. There is no pneumothorax.\n\n IMPRESSION: Persistent low lung volumes and bibasilar atelectasis.\n\n\n" }, { "category": "Radiology", "chartdate": "2131-07-04 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1086388, "text": ", F. MED SICU-A 4:37 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please eval for interval change\n Admitting Diagnosis: PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 28 year old man with respiratory failure, tracheostomy\n REASON FOR THIS EXAMINATION:\n please eval for interval change\n ______________________________________________________________________________\n PFI REPORT\n PFI: Persistent low lung volumes and bibasilar atelectasis.\n\n\n" }, { "category": "Radiology", "chartdate": "2131-07-03 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1086299, "text": " 12:06 PM\n CHEST (PORTABLE AP) Clip # \n Reason: please evaluate for interval change\n Admitting Diagnosis: PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 28 year old man with respiratory failure, tracheostomy\n REASON FOR THIS EXAMINATION:\n please evaluate for interval change\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: 28-year-old male with respiratory failure, tracheostomy.\n Evaluate for interval change.\n\n Single AP chest radiographs compared to shows persistent low\n lung volumes and subsequent left basilar atelectasis. The upper lungs are\n clear. Cardiomediastinal contour is unchanged. NG tube, tracheostomy and\n right-sided PICC line are in stable position. There is no pneumothorax or\n pleural effusion.\n\n IMPRESSION: Persistent low lung volumes and left basilar atelectasis.\n\n" }, { "category": "Radiology", "chartdate": "2131-06-20 00:00:00.000", "description": "CT ABDOMEN W/CONTRAST", "row_id": 1084111, "text": " 12:50 AM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: S/P NECROTISING PANC. ? ABSCESS.\n Admitting Diagnosis: PANCREATITIS\n Field of view: 46 Contrast: VISAPAQUE Amt: 100\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 28 year old man with necrotizing pancreatitis, persistently febrile, increasing\n wbc\n REASON FOR THIS EXAMINATION:\n please assess for phelgmon, abcess, pseduocyst\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: AGLc WED 5:12 AM\n 1. large bore central catheter in RA. post-pyloric feeding tube at ligament\n of Treitz.\n 2. compared to CT , bibasilar consolidation little changed, likely\n atelectasis. round glass density of lungs slightly improved.\n 3. fatty liver w/focal sparing along GB fossa. high density in GB ?IV contrast\n or sludge.\n 4. continued evolution of areas of necrosis within the pancreas. new fluid\n collection anterior to superior segment of duodenum 5.6 x 2.9 cm (2:36), and\n along pancreatic uncinate 2.2 x 1.9 cm (2:44). Persistent attenuation of\n splenic vein; SMA, SMV, PV remain patent; no pseudoaneurysm seen.\n 5. Unchanged diffuse colonic bowel wall thickening for which an infectious\n etiology is not excluded.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 28-year-old man with necrotizing pancreatitis, persistently febrile,\n and increasing white blood cells. Please assess for phlegmon, abscess, or\n pseudocyst.\n\n TECHNIQUE: CT abdomen and pelvis with IV contrast. Coronal and sagittal\n reformatted images provided.\n\n COMPARISON: Compared to .\n\n FINDINGS: There are bibasilar consolidations at the lung bases, likely\n atelectasis. The liver is enlarged and is diffusely low in attenuation,\n compatible with fatty infiltration, however, some mild diffuse improvement in\n the attenuation is seen compared to prior CT. There is a post- pyloric feeding\n tube in place.\n\n There is high density material in the gallbladder. The kidneys show no obvious\n enhancement, and do not excrete contrast. These findings could suggest renal\n failure, if clinically correlated.\n\n There is continued evolution of the areas of necrosis within the pancreas. The\n majority of the pancreas remains hypoenhancing. There is a new fluid\n collection anterior to superior segment of the duodenum measuring 5.6 x 2.9\n cm, 2:36, and along pancreatic uncinate process, 2.2 x 1.9 cm, 2:44. There is\n significant fat stranding around the pancreas, with similar appearance\n compared to prior study. There is persistent attenuation of splenic vein; and\n (Over)\n\n 12:50 AM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: S/P NECROTISING PANC. ? ABSCESS.\n Admitting Diagnosis: PANCREATITIS\n Field of view: 46 Contrast: VISAPAQUE Amt: 100\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n SMA, SMV, and portal vein remain patent, with no pseudoaneurysm seen. There\n are no pathologically enlarged lymph nodes in the mesentery or\n retroperitoneum. The spleen, and right adrenal gland are unremarkable. The\n left adrenal gland remains thickened, as seen on prior study. The apperance\n of diffuse large bowel wall thickening seen on the prior scan could be due to\n collapsed colon, with a similar appearance. Multiple small retroperitoneal and\n mesenteric lymph nodes are seen, which do not meet the CT criteria for\n pathological enlargement. There is no free air.\n\n CT PELVIS: Rectum is unremarkable. There is apperance of mild bowel wall\n thickening involving the sigmoid colon, which could be due to collapsed colon,\n with a similar appearance compared to prior study. The bladder is with Foley\n catheter, and foci of air within which could be due to catheter placement.\n There are no pathologically enlarged lymph nodes in the pelvis or inguinal\n area.\n\n BONE WINDOWS: No suspicious lytic or sclerotic lesions are seen. There is\n diffuse body wall anasarca.\n\n IMPRESSION:\n\n 1. Persistent atelectasis/consolidation in the dependent portion of the lungs\n bilaterally.\n 2. Diffuse fatty infiltration of the liver.\n 3. Continued evolution of areas of necrosis within the pancreas. New fluid\n collection anterior to superior segment of the duodenum, 5.6 x 2.9 cm, and\n along pancreatic uncinate process, 2.2 x 1.9 cm.\n 4. Delayed enhancement of the kidneys, with no excretion of contrast, and\n dense material within the gallbladder; these findings could suggest renal\n failure, if clinically correlated.\n 5. Similar appearance of the colonic bowel wall, which could be due to bowel\n wall collapse; however, infectious etiology cannot be excluded.\n 6. Similar appearance of increased attenuation of the splenic vein. No\n evidence of pseudoaneurysm.\n\n\n" }, { "category": "Radiology", "chartdate": "2131-06-10 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1082446, "text": " 4:17 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval assessment\n Admitting Diagnosis: PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 28 year old man with necrotizing pancreatitis and VAP. Intubated\n REASON FOR THIS EXAMINATION:\n interval assessment\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Follow-up of pneumonia in a patient with necrotizing\n pancreatitis.\n\n Portable AP chest radiograph was compared to .\n\n The tracheostomy tube tip is approximately 6.5 cm above the carina. The\n Dobbhoff tube passes below the diaphragm with its tip below the inferior\n margin of the field. The left subclavian line tip is at the superior SVC. The\n right internal jugular line tip is at mid SVC. The cardiomediastinal\n silhouette is unchanged. The lung volumes remain low with bibasilar\n atelectasis and widespread parenchymal opacities that might represent some\n degree of volume overload versus infectious process.\n\n" }, { "category": "Radiology", "chartdate": "2131-06-13 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1082981, "text": " 5:54 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: please evaluate for bleed or acute event\n Admitting Diagnosis: PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 28 year old man with multiple medical issues, recent cerebral edema, and s/p\n anoxic event yesterday now with seizure-like mvts in head and upper extremities\n REASON FOR THIS EXAMINATION:\n please evaluate for bleed or acute event\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: A 28-year-old man with multiple medical issues and recent\n cerebral edema, with anoxic event yesterday and new seizure-like movements.\n\n COMPARISON: There is no hemorrhage, shift of normally midline structures or\n evidence of major vascular territorial infarction. The -white\n matter differentiation is maintained, and similar overall to the exam.\n The ventricles and sulci are normal in size and configuration. The basilar\n cisterns are preserved. There is no fracture. The mastoid air cells and\n paranasal sinuses are well aerated, with nasoenteric tube in place.\n\n IMPRESSION: No acute intracranial abnormality.\n\n" }, { "category": "Radiology", "chartdate": "2131-06-14 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1083294, "text": " 7:55 PM\n CHEST (PORTABLE AP); -59 DISTINCT PROCEDURAL SERVICE Clip # \n Reason: ?fluid overload, PNA\n Admitting Diagnosis: PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 28 year old man with necrotizing pancreatitis and alcoholic hepatitis with\n tachypnea and tachycardia\n REASON FOR THIS EXAMINATION:\n ?fluid overload, PNA\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Necrotizing pancreatitis, alcoholic hepatitis with tachypnea and\n tachycardia.\n\n COMPARISON: ; .\n\n SINGLE PORTABLE SEMI-UPRIGHT CHEST RADIOGRAPH: Cardiomediastinal contour is\n unchanged. Again seen is a tracheostomy tube, OG tube with tip projecting\n below the diaphragm out of the field of view, left internal jugular catheter\n with tip projecting over the mid SVC and right PICC with tip projecting over\n the upper SVC. There is an apparently new right internal jugular catheter\n with tip projecting over the right atrium. Left opacities have improved.\n There is probably a small left effusion. There is no pneumothorax.\n\n IMPRESSION: Improved appearance of bilateral lung opacities.\n\n" }, { "category": "Radiology", "chartdate": "2131-06-07 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1081928, "text": " 9:10 AM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: ?interval change\n Admitting Diagnosis: PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 28 year old man with necrotizing pancreatitis intubated\n REASON FOR THIS EXAMINATION:\n ?interval change\n ______________________________________________________________________________\n FINAL REPORT\n EXAM: Portable AP chest .\n\n INDICATION: Necrotizing pancreatitis.\n\n FINDINGS: Comparison made to multiple priors, most recently 0034.\n\n Multiple lines and support tubes remain in appropriate position. Since prior\n exam, lung volumes have improved, and the previously demonstrated widespread\n parenchymal opacities have also markedly improved. Residual asymmetric\n opacity at the right lung base could represent atelectasis. There is no\n pleural effusion or pneumothorax.\n\n IMPRESSION: Improved aeration, and marked interval improvement in widespread\n parenchymal opacities.\n\n\n" }, { "category": "Radiology", "chartdate": "2131-06-10 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1082534, "text": " 9:09 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: eval for infiltrate and trach positioning\n Admitting Diagnosis: PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 28 year old man with bleeding around trach site and with expiratory wheezing.\n REASON FOR THIS EXAMINATION:\n eval for infiltrate and trach positioning\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Bleeding around tracheostomy site, expiratory wheezing.\n Assessment for position.\n\n COMPARISON: , 5:25 a.m.\n\n FINDINGS: As compared to the previous examination, the monitoring and support\n devices, notably the tracheostomy tube, are in unchanged position. The tip of\n the tube projects roughly 7 cm above the carina, it is projecting at the level\n of the clavicles. The lung volumes are slightly higher than on the previous\n examination, the pre-existing retrocardiac atelectasis has resolved, the\n diaphragmatic contour on the left is completely visible. There is no evidence\n of pneumothorax and no evidence of focal parenchymal opacity suggesting\n pneumonia.\n\n\n" }, { "category": "Radiology", "chartdate": "2131-06-11 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1082739, "text": " 8:16 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Interval change?\n Admitting Diagnosis: PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 28 year old male with ARDS pancreatitis, now with acute respiratory\n distress; improved with suctioning clot\n REASON FOR THIS EXAMINATION:\n Interval change?\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Acute respiratory distress.\n\n Portable AP chest radiograph was compared to prior study obtained on .\n\n There is significant amount of subcutaneous emphysema demonstrated in the\n patient's neck as well as obscuring the patient chest. The linear lucencies\n surrounding the mediastinum as well as projecting over the mediastinum may\n represent pneumomediastinum. Known pneumothorax is demonstrated, although it\n cannot be excluded due to the presence of subcutaneous emphysema. The tubes\n and lines are grossly in unchanged position.\n\n IMPRESSION: New extensive subcutaneous air collection with questionable\n pneumomediastinum. Correlation with clinical symptoms and evaluation with\n chest CT might be suggested. This shows a possibility of tracheostomy leak or\n interstitial emphysema.\n\n\n" }, { "category": "Radiology", "chartdate": "2131-06-12 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1082778, "text": " 4:00 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for infiltrate\n Admitting Diagnosis: PANCREATITIS\n ______________________________________________________________________________\n FINAL ADDENDUM\n ADDENDUM: Findings were discussed with Dr. over the phone by\n Dr. approximately at 11:10 on .\n\n\n\n 4:00 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for infiltrate\n Admitting Diagnosis: PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 28 year old man with trachiostomy\n REASON FOR THIS EXAMINATION:\n eval for infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Followup of a patient with tracheostomy.\n\n Portable AP chest radiograph was compared to prior study obtained on , at 8:56 p.m.\n\n There is significant interval improvement in the subcutaneous emphysema and\n questionable pneumomediastinum seen on the current study definitely less\n severe than on the prior examinations. There is interval minimal change in\n bilateral basal consolidations that appears to be worsening since . The small amount of bilateral pleural effusion cannot be excluded and\n the cardiomediastinal silhouette is unchanged as well as the position of tubes\n and lines.\n\n" }, { "category": "Radiology", "chartdate": "2131-06-13 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1082978, "text": " 5:18 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for infiltrate\n Admitting Diagnosis: PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 28 year old man with trach\n REASON FOR THIS EXAMINATION:\n eval for infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Followup of the patient with tracheostomy.\n\n Portable AP chest radiograph was compared to prior study obtained on at 04:35 p.m.\n\n The tracheostomy is at the midline, 6.5 cm above the carina. The feeding tube\n tip passes below the diaphragm with its tip not included in the field of view.\n The right internal jugular line tip is at the cavoatrial junction.\n Cardiomediastinal silhouette is unchanged. The lung opacities are unchanged\n as well. There is interval almost complete resolution of subcutaneous air as\n well as mediastinal air.\n\n\n" }, { "category": "Radiology", "chartdate": "2131-06-07 00:00:00.000", "description": "NASO-INTESTINAL TUBE PLACEMENT (W/FLUORO)", "row_id": 1081994, "text": " 1:46 PM\n -INTESTINAL TUBE PLACEMENT (W/FLUORO) Clip # \n Reason: please place IR-guided dobhoff\n Admitting Diagnosis: PANCREATITIS\n Contrast: CONRAY Amt:\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 28 year old man with respiratory failure, intubated\n REASON FOR THIS EXAMINATION:\n please place IR-guided dobhoff\n ______________________________________________________________________________\n FINAL REPORT\n ERCP\n\n COMPARISON: None.\n\n HISTORY: A 28-year-old male with respiratory failure, intubated placement of\n Dobbhoff tube.\n\n FINDINGS: An 8 French -intestinal tube was advanced through the right\n naris and was placed in a post-pyloric position. 10 mL of contrast was\n instilled to confirm placement and third portion of the duodenum. Incidental\n note was made of an OG tube which is also post-pyloric in position and\n subsequently withdrawn to the level of the stomach. No immediate post-\n procedure complications.\n\n IMPRESSION:\n 1. Successful post-pyloric placement of NG tube.\n 2. Readjustment of OG tube to the level of the stomach.\n\n" }, { "category": "Radiology", "chartdate": "2131-06-20 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1084168, "text": " 8:40 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ?PNA\n Admitting Diagnosis: PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 28 year old man with nec pancreatitis and persistent fevers. s/p trach\n REASON FOR THIS EXAMINATION:\n ?PNA\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 28-year-old male with necrotizing pancreatitis and persistent fever\n status post tracheostomy, to assess for a cardiopulmonary process.\n\n TECHNIQUE: Single portable AP radiograph of the chest was performed.\n Comparison is made with prior exams dated .\n\n FINDINGS:\n\n The tracheostomy has its tip approximately 44 mm from the carina. The NG tube\n has its tip projected over the stomach. The lungs are of low volume. The\n heart is enlarged. The pulmonary vasculature is indistinct. There may be\n small bibasal effusions. The tip of the right jugular line is projected over\n the right atrium. The tip of the right PICC line is projected over the\n superior aspect of the SVC.\n\n CONCLUSION:\n\n Low lung volumes. Cardiomegaly with indistinct pulmonary vasculature and\n small bibasal effusions are suggestive of early/mild CHF.\n\n\n" }, { "category": "Radiology", "chartdate": "2131-06-18 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1083900, "text": " 7:19 PM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate for edema, infiltrate, interval change\n Admitting Diagnosis: PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 28 year old man with necrotizing pancreatitis and alcoholic hepatitis with\n tachypnea, decreased pO2\n REASON FOR THIS EXAMINATION:\n evaluate for edema, infiltrate, interval change\n ______________________________________________________________________________\n WET READ: CXWc MON 9:22 PM\n Hazy diaphragmatic contours and pulmonary vascular markings, without hilar\n enlargement could be related to respiratory motion or small amount of fluid\n overload. Very low lung volumes. Retrocardiac opacity likely atelectasis.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Necrotizing pancreatitis and alcoholic hepatitis with tachypnea and\n decreased pO2, to evaluate for edema and pneumonia.\n\n FINDINGS: In comparison with the study of , low lung volumes and\n respiratory motion somewhat degrades the image. Some bibasilar opacification\n is again seen, with obscuration of the hemidiaphragm. However, a full PA view\n without motion is necessary to ensure that this appearance is not related to\n an artifact.\n\n The Dobbhoff tube extends to the region of the ligament of Treitz. The other\n monitoring support devices remain in place.\n\n\n" }, { "category": "Radiology", "chartdate": "2131-06-14 00:00:00.000", "description": "P US ABD LIMIT, SINGLE ORGAN PORT", "row_id": 1083303, "text": " 9:25 PM\n US ABD LIMIT, SINGLE ORGAN PORT Clip # \n Reason: ?acalculous cholestasis\n Admitting Diagnosis: PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 28 year old man with necrotizing pancreatitis, fevers, and elevated Tbili\n REASON FOR THIS EXAMINATION:\n ?acalculous cholestasis\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): 11:35 PM\n Gallbladder nondistended, but lumen entirely replaced by echogenic material.\n Favor sludge, but could also reflect marked wall thickening related to third\n spacing.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: A 28-year-old man with necrotizing pancreatitis with fever and\n elevated bilirubin.\n\n COMPARISON: CT of and ultrasound of .\n\n RIGHT UPPER QUADRANT ULTRASOUND: The liver is markedly and diffusely\n increased in echogenicity consistent with fatty infiltration. There is no\n intra- or extra-hepatic biliary ductal dilatation. The common duct measures 3\n mm. The main portal vein demonstrates normal hepatopetal flow. There is a\n focal area of sparing of fatty infiltration near the gallbladder fossa. There\n is no ascites.\n\n The gallbladder is not distended, but its lumen is entirely replaced with\n echogenic material. It is unclear where the wall meets the intraluminal\n material and the wall thickness cannot be well assessed. However, there is no\n increased vascularity within the gallbladder wall. There are no shadowing\n gallstones. Evaluation of the abdominal midline is limited. The distal\n common duct is not visualized.\n\n IMPRESSION:\n Nondistended gallbladder, with lumen entirely replaced with echogenic\n material, likely sludge. No shadowing stones identified. No hyperemic\n thickened wall.\n\n\n" }, { "category": "Radiology", "chartdate": "2131-06-14 00:00:00.000", "description": "P US ABD LIMIT, SINGLE ORGAN PORT", "row_id": 1083304, "text": ", F. MED SICU-A 9:25 PM\n US ABD LIMIT, SINGLE ORGAN PORT Clip # \n Reason: ?acalculous cholestasis\n Admitting Diagnosis: PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 28 year old man with necrotizing pancreatitis, fevers, and elevated Tbili\n REASON FOR THIS EXAMINATION:\n ?acalculous cholestasis\n ______________________________________________________________________________\n PFI REPORT\n Gallbladder nondistended, but lumen entirely replaced by echogenic material.\n Favor sludge, but could also reflect marked wall thickening related to third\n spacing.\n\n" }, { "category": "Radiology", "chartdate": "2131-06-08 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1082186, "text": " 11:29 AM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: ?interval change\n Admitting Diagnosis: PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 28 year old man with necrotizing pancreatitis and VAP. Intubated.\n REASON FOR THIS EXAMINATION:\n ?interval change\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 11:47 A.M. ON \n\n HISTORY: Necrotizing pancreatitis and pneumonia.\n\n IMPRESSION: AP chest compared to at 12:34 a.m. and 9:20 a.m.:\n\n Pulmonary edema, which cleared on has recurred, relatively mild.\n Bibasilar consolidation, which persisted though improved as edema diminished,\n is stable on the right, and increased on the left. Heart size top normal is\n unchanged. ET tube in standard placement, nasogastric feeding tube passes\n into the stomach and out of view, left jugular line ends at the junction of\n brachiocephalic veins and right jugular line low in the SVC. No pneumothorax\n or appreciable pleural effusion.\n\n\n" }, { "category": "Radiology", "chartdate": "2131-06-18 00:00:00.000", "description": "GALLBLADDER SCAN", "row_id": 1083830, "text": "GALLBLADDER SCAN Clip # \n Reason: 28 YEAR OLD MAN WITH NECROTIZING PANCREATITIS, CONTINUED ELEVATED WBC, AND SLUDGE SEEN ON ABD U/S\n ______________________________________________________________________________\n FINAL REPORT\n\n RADIOPHARMACEUTICAL DATA:\n 4.3 mCi Tc-m DISIDA ();\n HISTORY: 28 year old man with necrotizing pancreatitis and multi-organ failure.\n Assess for cholecystitis.\n\n INTERPRETATION: Serial images over the abdomen for 60 minutes show markedly\n reduced hepatic tracer uptake with delayed clearance from the bloodpool. There\n is non-visualization of intra- or extra-hepatic bile ducts. The gallbladder is\n not seen in the first 60 minutes of imaging. Tracer activity is noted in the\n small bowel at 30 minutes, excluding bile duct obstruction.\n\n Delayed imaging performed at 24 hours demonstrates tracer accumulation in the\n right upper quadrant in a pattern consistent with accumulation in the colonic\n hepatic flexure with persistent non-visualization of the gallbladder.\n\n IMPRESSION:\n\n 1. Non-visualization of the gallbladder but cannot evaluate for cholecyctitis in\n the setting of poor hepatic function.\n\n 2. Tracer excretion into the bowel is observed, excluding common bile duct\n obstruction.\n\n\n , M.D.\n , M.D. Approved: FRI 3:09 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": "2131-06-07 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1081888, "text": " 12:34 AM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: please evaluate line and ET tube placement; interval change\n Admitting Diagnosis: PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 28 year old man, intubated, s/p RIJ placement\n REASON FOR THIS EXAMINATION:\n please evaluate line and ET tube placement; interval change\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Evaluation of right internal jugular line placement.\n\n Portable AP chest radiograph was compared to .\n\n The ET tube tip is 5.5 cm above the carina. The NG tube tip passes below the\n diaphragm terminating in the stomach. The right internal jugular line tip is\n at the cavoatrial junction, unchanged since the prior study. The\n cardiomediastinal silhouette is stable but there is interval development of\n widespread parenchymal opacities most likely given the relatively rapid\n development consistent with pulmonary edema. Possibilities would be rapidly\n progressing infection or pulmonary hemorrhage in appropriate clinical\n constellation.\n\n ADDENDUM: Findings were discussed with Dr. over the phone by Dr.\n at the time of dictation with recommendation to repeat the\n radiograph.\n\n" }, { "category": "Radiology", "chartdate": "2131-06-05 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1081670, "text": " 9:53 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: please evaluate left ij line placement.\n Admitting Diagnosis: PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 28 year old man with change of left hemodialysis catheter (HD catheter removed,\n TLC catheter placed over wire)\n REASON FOR THIS EXAMINATION:\n please evaluate left ij line placement.\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAM: Evaluate left IJ line placement.\n\n Comparison is made with prior study performed the same day earlier in the\n morning.\n\n Left IJ catheter tip is in the proximal SVC. Right IJ catheter tip is in\n unchanged position in the lower SVC or cavoatrial junction. ET tube is in the\n standard position. NG tube tip is out of view below the diaphragm. Cardiac\n size is top normal. There are low lung volumes. Mild bibasilar atelectasis\n greater on the left side. There is no pneumothorax or enlarging pleural\n effusions.\n\n" }, { "category": "Radiology", "chartdate": "2131-06-14 00:00:00.000", "description": "US GUID FOR VAS. ACCESS", "row_id": 1083185, "text": " 10:05 AM\n PICC LINE PLACMENT SCH Clip # \n Reason: Please Place L sided PICC\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 28 year old man with L IJ catheter in need of PICC line\n REASON FOR THIS EXAMINATION:\n Please Place L sided PICC\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): 6:09 PM\n PIC: PICC line ready for use.\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: Fluoroscopic and ultrasound-guided PICC line placement.\n\n INDICATION: PICC line needed for medication delivery.\n\n RADIOLOGISTS: Dr. and Dr. performed the procedure. Dr.\n , the attending interventional radiologist was present and supervising\n throughout.\n\n TECHNIQUE: Using sterile technique and local anesthesia, the right basilic\n vein was punctured under direct ultrasound guidance using a micropuncture set.\n Hard copies of ultrasound images were obtained before and immediately after\n establishing intravenous access. A peel-away sheath was then placed over a\n guidewire and a double-lumen PICC line measuring 40 cm in length was then\n placed through the peel-away sheath with its tip positioned in the SVC under\n fluoroscopic guidance. Position of the catheter was confirmed by fluoroscopic\n spot film of the chest. The peel-away sheath and guidewire was then removed.\n The catheter was secured to the skin, flushed, and a sterile dressing applied.\n The patient tolerated the procedure well. There were no immediate post-\n procedural complications.\n\n IMPRESSION:\n 1. Uncomplicated ultrasound and fluoroscopically guided double-lumen PICC\n line placement via the right basilic venous approach. Final internal length\n is 40 cm with the tip positioned in the SVC. The line is ready to use.\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2131-06-14 00:00:00.000", "description": "PICC W/O PORT", "row_id": 1083186, "text": ", F. MED SICU-A 10:05 AM\n PICC LINE PLACMENT SCH Clip # \n Reason: Please Place L sided PICC\n Admitting Diagnosis: PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 28 year old man with L IJ catheter in need of PICC line\n REASON FOR THIS EXAMINATION:\n Please Place L sided PICC\n ______________________________________________________________________________\n PFI REPORT\n PIC: PICC line ready for use.\n\n" }, { "category": "Radiology", "chartdate": "2131-06-14 00:00:00.000", "description": "EXCH CENTRAL TUNNELED W/O PORT", "row_id": 1083188, "text": " 10:13 AM\n TUNNELLED CATH PLACE SCH Clip # \n Reason: please place tunneled dialysis line. (now on amicar ooz\n Admitting Diagnosis: PANCREATITIS\n ********************************* CPT Codes ********************************\n * EXCH CENTRAL TUNNELED W/O PORT -78 RELATED PROCEDURE DURING POSTOPE *\n * FLUORO GUID PLCT/REPLCT/REMOVE -78 RELATED PROCEDURE DURING POSTOPE *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 28 year old man with ARF, anasarca.\n REASON FOR THIS EXAMINATION:\n please place tunneled dialysis line. (now on amicar oozing from trach\n site)\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): 11:36 AM\n Tunneled hemodialysis catheter is ready for use.\n ______________________________________________________________________________\n FINAL REPORT\n PROCEDURE: Tunneled dialysis catheter.\n\n INDICATION: Acute renal failure and anasarca. Need for long-term dialysis.\n\n COMPARISON: None available on PACS at the time of dictation.\n\n OPERATORS: Dr. and Dr. performed the procedure. Dr.\n , the attending radiologist, was present and supervising throughout.\n\n ANESTHESIA: Patient hemodynamic parameters were constantly monitored by ICU\n and radiological nursing staff. The patient was given conscious sedation,\n Versed and fentanyl, per ICU nursing staff. Total in-service time was 45\n minutes.\n\n PROCEDURE AND FINDINGS: After the risks and benefits of the procedure as well\n as the conscious sedation were explained, informed consent was obtained. The\n patient was brought to the angiographic suite and placed supine on the imaging\n table. The right neck and pre-existing temporary dialysis catheter was\n prepped and draped in standard sterile fashion. Heparin within the pre-\n existing ports was removed. A timeout was performed with two patient\n identifiers and then huddle. A tunnel was created with 20 cc local lidocaine\n with epinephrine. wire was placed through the pre-existing dialysis\n catheter and the catheter was pinch pulled. The tract was further dilated and\n a peel-away sheath was placed. A 19-cm tip-to-cuff, 24-cm total, 15.5 French\n dialysis catheter was placed over the peel-away sheath using flouroscopic\n guidance, and peel- away sheath was removed. A spot fluoroscopic film of the\n chest demonstrated final location of the tip within the right atrium. The\n wire was removed. The ports were easily aspirated and flushed. The catheter\n was secured to the skin. Sterile dressing was applied. There were no\n immediate post-procedural complications.\n\n IMPRESSION: Successful placement of a right tunneled hemodialysis catheter\n via the right IJ with tip of the catheter within the right atrium. The\n catheter is ready to use.\n (Over)\n\n 10:13 AM\n TUNNELLED CATH PLACE SCH Clip # \n Reason: please place tunneled dialysis line. (now on amicar ooz\n Admitting Diagnosis: PANCREATITIS\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2131-06-08 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1082287, "text": " 7:24 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: please eval s/p new trach\n Admitting Diagnosis: PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 28 year old man with new trach\n REASON FOR THIS EXAMINATION:\n please eval s/p new trach\n ______________________________________________________________________________\n WET READ: DXAe FRI 8:24 PM\n Mild bilateral pulmonary edema is minimally increased since 8 hours prior.\n Trach tube tip 4.5 cm above the carina. Otherwise little change.\n\n ______________________________________________________________________________\n FINAL REPORT\n CHEST SINGLE VIEW ON \n\n HISTORY: New trach.\n\n REFERENCE EXAM: at 1150.\n\n FINDINGS: There is a new tracheostomy tube in good location. There is\n bilateral hazy alveolar infiltrates left greater than right with hazy\n bilateral vasculature consistent with the patient's history of pulmonary\n edema. This is similar in appearance compared to the film from earlier the\n same day. Bilateral IJ lines are unchanged. The heart is mildly enlarged.\n\n IMPRESSION:\n 1. New tracheostomy tube in good location.\n 2. Continued CHF.\n\n\n" }, { "category": "Radiology", "chartdate": "2131-06-14 00:00:00.000", "description": "EXCH CENTRAL TUNNELED W/O PORT", "row_id": 1083189, "text": ", F. MED SICU-A 10:13 AM\n TUNNELLED CATH PLACE SCH Clip # \n Reason: please place tunneled dialysis line. (now on amicar ooz\n Admitting Diagnosis: PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 28 year old man with ARF, anasarca.\n REASON FOR THIS EXAMINATION:\n please place tunneled dialysis line. (now on amicar oozing from trach\n site)\n ______________________________________________________________________________\n PFI REPORT\n Tunneled hemodialysis catheter is ready for use.\n\n" }, { "category": "Radiology", "chartdate": "2131-06-19 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1084008, "text": " 12:00 PM\n CHEST (PORTABLE AP) Clip # \n Reason: ?interval change\n Admitting Diagnosis: PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 28 year old man with necrotizing pancreatitis and transaminitis with trach and\n new hypoxia\n REASON FOR THIS EXAMINATION:\n ?interval change\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Necrotizing pancreatitis with new hypoxia.\n\n FINDINGS: In comparison with the earlier study of this date, there is little\n change in the appearance of the monitoring and support devices. Areas of\n opacification are seen at the bases consistent with atelectasis.\n\n\n" } ]

[ { "category": "Physician ", "chartdate": "2120-04-20 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 323160, "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 50 yo male with met renal cell CA admitted with severe resp\n failure/PNA, cardiogenic/septic shock. RV hypoplasia\n 24 Hour Events:\n #Weaned abx: Bactrim to prophylaxis doses\n #Weaned stress dose steroids\n #Wean off dobutamine (has RV hypoplasia in the setting of\n COPD/hypoxia/pulmonary fibrosis)\n #Sedation: IV methadone\n #Lactulose added with BM this am\n History obtained from Medical records\n Allergies:\n Flagyl (Oral) (Metronidazole)\n Rash;\n Last dose of Antibiotics:\n Acyclovir - 04:30 PM\n Bactrim (SMX/TMP) - 09:00 AM\n Caspofungin - 08:00 PM\n Piperacillin/Tazobactam (Zosyn) - 10:00 PM\n Vancomycin - 08:05 AM\n Levofloxacin - 09:11 AM\n Infusions:\n Midazolam (Versed) - 10 mg/hour\n Fentanyl - 400 mcg/hour\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:15 PM\n Famotidine (Pepcid) - 08:06 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 10:50 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.3\nC (99.1\n Tcurrent: 37.1\nC (98.8\n HR: 67 (47 - 91) bpm\n BP: 133/60(83) {110/42(61) - 148/65(90)} mmHg\n RR: 26 (26 - 34) insp/min\n SpO2: 92%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 76.3 kg (admission): 76.3 kg\n Height: 68 Inch\n CVP: 314 (6 - 314)mmHg\n CO/CI (CCO): (4.3 L/min) / (2.3 L/min/m2)\n Total In:\n 5,654 mL\n 1,347 mL\n PO:\n TF:\n 128 mL\n IVF:\n 4,015 mL\n 939 mL\n Blood products:\n Total out:\n 3,280 mL\n 765 mL\n Urine:\n 3,280 mL\n 765 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,374 mL\n 582 mL\n Respiratory support\n Ventilator mode: PCV+\n PC : 28 cmH2O\n RR (Set): 30\n PEEP: 12 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10\n PIP: 39 cmH2O\n Plateau: 34 cmH2O\n SpO2: 92%\n ABG: 7.46/36/87./24/1\n Ve: 16.7 L/min\n PaO2 / FiO2: 176\n Physical Examination\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, No(t) NG\n tube, OG tube\n Peripheral 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 10.4 g/dL\n 136 K/uL\n 91 mg/dL\n 1.1 mg/dL\n 24 mEq/L\n 4.0 mEq/L\n 26 mg/dL\n 112 mEq/L\n 145 mEq/L\n 31.7 %\n 10.2 K/uL\n [image002.jpg]\n 12:10 PM\n 02:14 PM\n 08:25 PM\n 10:25 PM\n 03:04 AM\n 04:30 AM\n 04:46 AM\n 04:59 PM\n 03:12 AM\n 06:06 AM\n WBC\n 13.5\n 10.2\n Hct\n 31.8\n 31.7\n Plt\n 130\n 136\n Cr\n 1.0\n 1.1\n TCO2\n 23\n 22\n 23\n 24\n 26\n 25\n 26\n 26\n Glucose\n 98\n 91\n Other labs: PT / PTT / INR:14.6/29.1/1.3, CK / CKMB /\n Troponin-T:260/9/0.22, ALT / AST:57/31, Alk Phos / T Bili:70/0.4,\n Amylase / Lipase:53/22, Differential-Neuts:67.0 %, Band:2.0 %,\n Lymph:18.0 %, Mono:9.0 %, Eos:0.0 %, Lactic Acid:1.7 mmol/L,\n Albumin:2.7 g/dL, LDH:272 IU/L, Ca++:8.3 mg/dL, Mg++:2.3 mg/dL, PO4:2.8\n mg/dL\n Imaging: : continued bilateral infiltrates\n Microbiology: BdCx NGTD\n Assessment and Plan\n #Respiratory failure/ARDS: Remains vent-dependent on pressure control\n ventilation: Recheck ABG after decreasing vent rate. Want to decrease\n borderline transpulm pressure- likely will further reduce PC\n #ID: Causes of sepsis unclear. Continue antibiotics, f/u cultures.\n #Septic/cardiogenic shock:Off dobutamine. CI lower, but maintaining BP.\n Continue to monitor. Continue afterload reduction with Ace inhibitor\n #Sedation: On Methadone, versed/fentanyl. Current level of sedation\n adequate.\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 02:00 AM 20 mL/hour\n Comments: Had high residuals yesterday but improving; advance to goal\n as tolerated\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Multi Lumen - 11:24 PM\n Arterial Line - 12:14 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP: HOB elevation, Mouth care\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": "2120-04-21 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 323261, "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 met renal CA with PNA/unclear organisms\n 24 Hour Events:\n Vent: decreased rate/pressure on PC ventilation. Then, got agitated\n with desats-->R back up to 30. Improved with suctioning. ? new lingular\n process on CXR\n TF increased\n Allergies:\n Flagyl (Oral) (Metronidazole)\n Rash;\n Last dose of Antibiotics:\n Bactrim (SMX/TMP) - 09:00 AM\n Levofloxacin - 09:11 AM\n Caspofungin - 08:23 PM\n Piperacillin/Tazobactam (Zosyn) - 05:15 AM\n Acyclovir - 08:03 AM\n Vancomycin - 08:04 AM\n Infusions:\n Midazolam (Versed) - 10 mg/hour\n Fentanyl - 500 mcg/hour\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:22 PM\n Midazolam (Versed) - 01:15 AM\n Fentanyl - 01:15 AM\n Famotidine (Pepcid) - 08:03 AM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 10:52 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.4\nC (99.3\n Tcurrent: 37.4\nC (99.3\n HR: 43 (43 - 63) bpm\n BP: 136/64(84) {114/51(69) - 144/73(97)} mmHg\n RR: 30 (23 - 30) insp/min\n SpO2: 93%\n Heart rhythm: SB (Sinus Bradycardia)\n Wgt (current): 76.3 kg (admission): 76.3 kg\n Height: 68 Inch\n CVP: 20 (12 - 24)mmHg\n CO/CI (CCO): (4.5 L/min) / (2.4 L/min/m2)\n Total In:\n 3,451 mL\n 2,065 mL\n PO:\n TF:\n 485 mL\n 696 mL\n IVF:\n 2,506 mL\n 1,039 mL\n Blood products:\n Total out:\n 1,805 mL\n 1,100 mL\n Urine:\n 1,805 mL\n 1,100 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,646 mL\n 965 mL\n Respiratory support\n Ventilator mode: PCV+\n PC : 28 cmH2O\n RR (Set): 30\n PEEP: 12 cmH2O\n FiO2: 50%\n PIP: 39 cmH2O\n SpO2: 93%\n ABG: 7.41/40/85./26/0\n Ve: 12.7 L/min\n PaO2 / FiO2: 170\n Physical Examination\n General Appearance: No acute distress, Overweight / Obese, 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: Endotracheal tube, No(t) NG tube, OG tube\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: Present), (Left DP pulse:\n Present)\n Respiratory / Chest: (Expansion: Symmetric, No(t) Paradoxical), (Breath\n Sounds: Clear : )\n Abdominal: Soft, No(t) Non-tender, Bowel sounds present, Distended,\n No(t) Tender:\n Extremities: Right: Trace, Left: Trace, No(t) Cyanosis, No(t) Clubbing\n Musculoskeletal: No(t) Muscle wasting, No(t) Unable to stand\n Skin: Warm, No(t) Rash: , No(t) Jaundice\n Neurologic: Responds to: Tactile stimuli, Movement: No spontaneous\n movement, Sedated, Tone: Normal\n Labs / Radiology\n 10.3 g/dL\n 120 K/uL\n 122 mg/dL\n 1.0 mg/dL\n 26 mEq/L\n 3.9 mEq/L\n 26 mg/dL\n 110 mEq/L\n 142 mEq/L\n 31.2 %\n 12.1 K/uL\n [image002.jpg]\n 04:46 AM\n 04:59 PM\n 03:12 AM\n 06:06 AM\n 02:28 PM\n 06:28 PM\n 09:12 PM\n 01:58 AM\n 04:48 AM\n 05:04 AM\n WBC\n 10.2\n 12.1\n Hct\n 31.7\n 31.2\n Plt\n 136\n 120\n Cr\n 1.1\n 1.0\n TCO2\n 25\n 26\n 26\n 24\n 24\n 26\n 28\n 26\n Glucose\n 91\n 122\n Other labs: PT / PTT / INR:13.5/29.8/1.2, CK / CKMB /\n Troponin-T:260/9/0.22, ALT / AST:57/31, Alk Phos / T Bili:70/0.4,\n Amylase / Lipase:53/22, Differential-Neuts:67.0 %, Band:2.0 %,\n Lymph:18.0 %, Mono:9.0 %, Eos:0.0 %, Lactic Acid:1.3 mmol/L,\n Albumin:2.7 g/dL, LDH:272 IU/L, Ca++:7.5 mg/dL, Mg++:2.2 mg/dL, PO4:3.1\n mg/dL\n Imaging: CXR: bilteral infiltrates, possible increase lingular/r base\n Microbiology: galactomanan pending\n Assessment and Plan\n 50 year old male with hypoxic resp failure/PNA, COPD/pulm fibrosis, dil\n RV\n #Acute resp failure: Mixed picture with sepsis, cardiogenic.\n Minimal progress made on ventilator. Attempt diuresis.\n Will try decreasing driving pressure, no change in PEEP/FiO2\n #Sepsis: No recent fevers. Continue LVQ/vanc/zosyn for day\n course. Continue caspofungin\n Wean steroids (stress-dose + presumptive PCP)\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 07:51 AM 70 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Multi Lumen - 11:24 PM\n Arterial Line - 12:14 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 45 minutes\n Patient is critically ill\n" }, { "category": "Physician ", "chartdate": "2120-04-27 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 323904, "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 Hypotension overnight with IVF given and partial response\n 24 Hour Events:\n ARTERIAL LINE - STOP 08:00 AM\n History obtained from Medical records\n Patient unable to provide history: Sedated\n Allergies:\n Flagyl (Oral) (Metronidazole)\n Rash;\n Last dose of Antibiotics:\n Caspofungin - 09:28 PM\n Bactrim (SMX/TMP) - 08:16 AM\n Piperacillin/Tazobactam (Zosyn) - 06:02 AM\n Acyclovir - 08:25 AM\n Vancomycin - 08:30 AM\n Levofloxacin - 09:00 AM\n Infusions:\n Propofol - 25 mcg/Kg/min\n Other ICU medications:\n Lorazepam (Ativan) - 12:45 PM\n Heparin Sodium (Prophylaxis) - 08:00 PM\n Famotidine (Pepcid) - 08:00 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: Fever\n Cardiovascular: Tachycardia\n Flowsheet Data as of 10:35 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.7\nC (99.8\n Tcurrent: 36.6\nC (97.9\n HR: 67 (61 - 138) bpm\n BP: 116/67(79) {81/49(57) - 130/94(102)} mmHg\n RR: 18 (13 - 30) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 76.3 kg (admission): 76.3 kg\n Height: 68 Inch\n CVP: 10 (5 - 17)mmHg\n Total In:\n 5,572 mL\n 1,647 mL\n PO:\n TF:\n 311 mL\n 488 mL\n IVF:\n 4,766 mL\n 739 mL\n Blood products:\n Total out:\n 3,713 mL\n 1,190 mL\n Urine:\n 3,113 mL\n 1,190 mL\n NG:\n 600 mL\n Stool:\n Drains:\n Balance:\n 1,859 mL\n 457 mL\n Respiratory support\n Ventilator mode: PCV+\n Vt (Spontaneous): 470 (470 - 740) mL\n PC : 24 cmH2O\n PS : 20 cmH2O\n RR (Set): 30\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 60%\n RSBI Deferred: FiO2 > 60%\n PIP: 29 cmH2O\n Plateau: 27 cmH2O\n SpO2: 96%\n ABG: 7.38/49/67/23/2\n Ve: 15.6 L/min\n PaO2 / FiO2: 112\n Physical Examination\n General Appearance: Thin\n Head, Ears, Nose, Throat: Normocephalic\n Lymphatic: Trach in place\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: Dullnesst :\n ), (Breath Sounds: Diminished: )\n Extremities: Right: 1+, Left: 1+\n Skin: Not assessed\n Neurologic: Responds to: Verbal stimuli\nbut not directed, Movement: Not\n assessed, Tone: Not assessed\n Labs / Radiology\n 9.6 g/dL\n 145 K/uL\n 80 mg/dL\n 1.0 mg/dL\n 23 mEq/L\n 4.0 mEq/L\n 15 mg/dL\n 110 mEq/L\n 141 mEq/L\n 29.2 %\n 11.1 K/uL\n [image002.jpg]\n 10:07 PM\n 04:05 AM\n 04:29 AM\n 03:23 PM\n 06:00 PM\n 04:43 AM\n 02:25 PM\n 05:37 PM\n 09:20 PM\n 04:49 AM\n WBC\n 13.6\n 15.0\n 11.1\n Hct\n 31.6\n 34.0\n 28.1\n 31.5\n 29.2\n Plt\n 149\n 159\n 145\n Cr\n 1.0\n 1.0\n 1.0\n TCO2\n 34\n 35\n 27\n 30\n Glucose\n 70\n 76\n 65\n 80\n Other labs: PT / PTT / INR:13.7/42.1/1.2, CK / CKMB /\n Troponin-T:260/9/0.22, ALT / AST:57/31, Alk Phos / T Bili:70/0.4,\n Amylase / Lipase:53/22, Differential-Neuts:67.0 %, Band:2.0 %,\n Lymph:18.0 %, Mono:9.0 %, Eos:0.0 %, Lactic Acid:2.0 mmol/L,\n Albumin:2.6 g/dL, LDH:272 IU/L, Ca++:7.6 mg/dL, Mg++:2.2 mg/dL, PO4:2.4\n mg/dL\n Imaging: CXR--\n Patient with increased interstitial and some alveolar edema noted in\n background of fibrosis\n Assessment and Plan\n 50 yo male with history metastatic renal cell CA admit with respiratory\n failure and now s/p trach and PEG and prolonged vent weaning. He has\n been limited by persistent hypoxemia which may be related to underlying\n pulmonary disease in addition to loss of functional lung in the setting\n of prolonged intubation and will need to move to successful PSV wean\n with hemodynamic stability.\n Respiratory Failure-\n This is combination of chronic pulmonary disease and significant\n obstruction and restriction now with significant evidence of worsening\n of the pulmonary edema in the setting of fluid bolus over past 24\n hours. He had continued need for maximum support. This morning he has\n significant hypoxemia persisting and needs continued stable support.\n -Increase PEEP to 8 this am\n -Increase sedation to allow more passive ventilatory support\n -Will likely maintain PCV in place\n -Will move to diuresis if we can given hemodynamic instability\n -His leak from the ventilator\n Hypotension-\n He had significant sepsis and with an initial resolution. At this time\n he has had some intermittent hypotension which is likely due to\n vasodilatory effects of sedating medications and has had some evidence\n of increased volume overload with bolus treatment over past 24 hours.\n -ECG wtihout changes\n -IVF bolus as needed\n -ECHO if persistent\n Sepsis-\n Continue with broad spectrum ABX\n F/U culture results\n Altered Mental Status-\n -Methadone q 4 hours, Fentanyl as needed, Ativan as needed with goal to\n maintain stable sedation\n -Look to wean propofol as tolerated\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 03:48 AM 10 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Multi Lumen - 11:24 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Need for restraints reviewed\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 45 minutes\n Patient is critically ill\n" }, { "category": "Physician ", "chartdate": "2120-04-20 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 323173, "text": "Chief Complaint:\n 24 Hour Events:\n + bactrim d/c\n Beta glucan and galactomannan pending\n But\n BMT wanted to gold onto , will d/c sun if still no\n positive fungal cultures by then\n Hydrocortisone weaned to 50mg iv bid from qid\n Dobutamine weaned off, but C.I. dropped to 2.8 (from 3.5), so restarted\n overnight\n IV methadone started to wean fent / midaz; ECG without QTc prolongation\n Did NOT start propofol gtts (not close to extubation)\n FiO2 increased to 50% (from 40%) after sats fell (paO2 78 @ 9pm)\n Bradycardic overnight in 50\n increase to 90s w/ stimulation (bathing)\n Lactulose added to bowel regimen -> had bowel movement this morning per\n nursing\n Allergies:\n Flagyl (Oral) (Metronidazole)\n Rash;\n Last dose of Antibiotics:\n Acyclovir - 04:30 PM\n Bactrim (SMX/TMP) - 09:00 AM\n Levofloxacin - 10:30 AM\n Vancomycin - 08:00 PM\n - 08:00 PM\n Piperacillin/Tazobactam (Zosyn) - 10:00 PM\n Infusions:\n Dobutamine - 0.3 mcg/Kg/min\n Midazolam (Versed) - 10 mg/hour\n Other ICU medications:\n Famotidine (Pepcid) - 08:14 PM\n Heparin Sodium (Prophylaxis) - 08:15 PM\n Other medications:\n Lactulose / docusate / bisacodyl\n Captopril\n Tylenol prn\n Folic acid\n Albuterol\n Asa\n chlorhexidine\n Changes to medical 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: 37.3\nC (99.1\n Tcurrent: 36.7\nC (98.1\n HR: 52 (47 - 91) bpm\n BP: 119/51(71) {110/42(61) - 148/65(90)} mmHg\n RR: 34 (28 - 35) insp/min\n SpO2: 93%\n Heart rhythm: SB (Sinus Bradycardia)\n Wgt (current): 76.3 kg (admission): 76.3 kg\n Height: 68 Inch\n CVP: 7 (6 - 17)mmHg\n CO/CI (CCO): (5.1 L/min) / (2.7 L/min/m2)\n Total In:\n 5,654 mL\n 590 mL\n PO:\n TF:\n 59 mL\n IVF:\n 4,015 mL\n 402 mL\n Blood products:\n Total out:\n 3,280 mL\n 585 mL\n Urine:\n 3,280 mL\n 585 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,374 mL\n 5 mL\n Respiratory support\n Ventilator mode: PCV+\n PC : 28 cmH2O\n RR (Set): 24\n PEEP: 12 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10\n PIP: 39 cmH2O\n Plateau: 34 cmH2O\n SpO2: 93%\n ABG: 7.46/36/87./24/1\n Ve: 16.9 L/min\n PaO2 / FiO2: 176\n Physical Examination\n Gen:\n Labs / Radiology\n 136 K/uL\n 10.4 g/dL\n 91 mg/dL\n 1.1 mg/dL\n 24 mEq/L\n 4.0 mEq/L\n 26 mg/dL\n 112 mEq/L\n 145 mEq/L\n 31.7 %\n 10.2 K/uL\n [image002.jpg]\n 12:10 PM\n 02:14 PM\n 08:25 PM\n 10:25 PM\n 03:04 AM\n 04:30 AM\n 04:46 AM\n 04:59 PM\n 03:12 AM\n 06:06 AM\n WBC\n 13.5\n 10.2\n Hct\n 31.8\n 31.7\n Plt\n 130\n 136\n Cr\n 1.0\n 1.1\n TCO2\n 23\n 22\n 23\n 24\n 26\n 25\n 26\n 26\n Glucose\n 98\n 91\n Other labs: PT / PTT / INR:14.6/29.1/1.3, CK / CKMB /\n Troponin-T:260/9/0.22, ALT / AST:57/31, Alk Phos / T Bili:70/0.4,\n Amylase / Lipase:53/22, Differential-Neuts:67.0 %, Band:2.0 %,\n Lymph:18.0 %, Mono:9.0 %, Eos:0.0 %, Lactic Acid:1.7 mmol/L,\n Albumin:2.7 g/dL, LDH:272 IU/L, Ca++:8.3 mg/dL, Mg++:2.3 mg/dL, PO4:2.8\n mg/dL\n Micro\n Bl cx 4/14+ pending\n Negative legionella\n Rads\n Cxr \n SINGLE SEMI-UPRIGHT VIEW OF THE CHEST AT APPROXIMATELY 7 a.m.: This\n exam is\n largely unchanged from the prior exam. Endotracheal tube, nasogastric\n tube,\n feeding tube, and right internal jugular catheter are all in unchanged\n positions. Again, the feeding tube terminates above the GE junction.\n Lung volumes remain low and widespread interstitial thickening is\n consistent\n with diffuse fibrosis. A slight relative increase in air space opacity\n at the\n right lung base (most evident when in comparison to the scout film from\n the CT\n torso of ) is largely unchanged, as is a small right pleural\n effusion.\n Assessment and Plan\n 50M h/o metastatic renal CA s/p nephrectomy, IL-2, mini-allograft SCT,\n DLI x 2 last in , emphysema/pulmonary fibrosis on home 02\n presented to OSH with hypoxic respiratory failure, fevers and\n hypotension.\n # Respiratory failure:\n Pneumonia as likely source of resp failure and sepsis in patient with\n poor pulmonary reserve due to emphysema, ?GVHD, fibrosis.\n Pt was dysynchronous w/ vent yesterday w/ decreasing sedation of fent /\n midazolam although methadone was added; oxygenation seems to worsen\n when patient is dysynchronous / less sedated.\n Sats decreased overnight.\n Pt tolerated decrease in PEEP and Fi02 yesterday. Attempted to switch\n to A/C, however pt less sedated off pressors and pulling large TV\n (~1600), dysynchronous with vent.\n - Back on pressure control for now, based on transpulmonary pressure\n (10 and -2), will titrate down FiO2 as tolerated today. Can consider\n changing to PSV or SIMV with low set respiratory rate if tolerated.\n -Off cisatracurium since . Currently sedated on midazolam and\n fentanyl on maximal doses. Will try trial of methadone to help\n decrease versed/fentanyl doses today. Attempt wean as tolerated. Can\n consider propofol in addition in order to lower doses of\n versed/fentanyl.\n # Septic shock: On presentation to OSH pt hypotensive, hypoxic with\n fevers and leukocytosis. On arrival to ICU was intubated due to\n hypoxic respiratory failure and hypotensive requiring pressors. Likely\n pneumonia given hypoxia and possible opacities on CXR, although\n difficult to read due to fibrosis. No other apparent localizing\n symptoms. Ruled-out for flu at OSH. At this point, WBC and fever curve\n decreasing. Covered on broad spectrum antibiotics.\n - Legionella urine ag negative, all other cultures no growth to date.\n - Vanc, zosyn, levofloxacin, bactrim IV for PCP, to cover\n broadly given critical illness. As patient was on bactrim prophylaxis\n for PCP as outpatient and not on steroids, risk for PCP very low;\n therefore, will dc high dose bactrim and restart ppx dose.\n - D/C sun if cultures negative\n - Also on IV steroids for PCP and adrenal insufficiency, see below\n - Glucan, galactomannan pending\n - Follow WBC count, fever curve, decreasing\n - PPD negative\n - Continue acyclovir ppx, vanc/zosyn/levoflox\n # Cardiogenic shock: Patient found to have PAH and RV failure on ECHO.\n Started on dobutamine with improvement in CI as well as pressures.\n Also started on captopril for afterload reduction which enabled\n decrease in dobutamine with continued improvement in hemodynamics.\n - Wean dobutamine today\n - Continue to monitor UOP and CI. If UOP decreases, will consider lasix\n drip if patient becomes very positive\n # Cardiac: Patient with probable demand ischemia in setting of\n hypotension, tachycardia, and sepsis; less likely unstable plaque.\n - CE\ns trended down, have stopped following.\n - ASA\n - ACEI as above for afterload reduction\n - Consider diuresis if UOP tapers off to further decrease preload.\n # Hypotension: Improved. Likely a mixed picture. Initially pt\n presentation of acute hypoxia with leukocytosis and fevers with\n hypotension made a septic shock picture predominate, however after\n adequate fluid rescusitation pt continued to require 2 pressors. His\n TTE and vigileo monitoring were consistent with low cardiac output due\n to pt\ns severe pulmonary hypertension due to pulmonary fibrosis and\n subsequent RV hypokinesis, a non-fluid responsive state. Dobutamine\n challenge resulted in increased CO to normal range with ability to be\n weaned off both levophed and vasopressin and addition of captopril\n which led to decreased afterload allowed decrease in dobutamine. Also,\n initial concern for adrenal insufficiency as patient has one adrenal\n gland with a metastasis, though he does not clinically appear to be\n functionally adrenally insufficient at this point. UOP remains high at\n ~100-200cc/hour.\n - Continue dobutamine\n - Continue HD monitoring with Vigileo device\n - Treat broadly for infection per above\n - IV hydrocort Q6 for adrenal insufficiency, will start wean today with\n 50mg q12, and subsequent wean over next few days.\n - Initially concerned for PE, however have more likley explanations for\n hypotension as listed above, LENIs negative\n - Guaiac stools, HCT has been stable.\n # Metastatic renal CA: Recurrent disease s/p donor lymphocyte\n transplant .\n - BMT to follow\n - Continue acyclovir ppx for now, will discuss with BMT\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 02:00 AM 20 mL/hour\n Glycemic Control: ssi\n Lines:\n Multi Lumen - 11:24 PM\n Arterial Line - 12:14 AM\n Prophylaxis:\n DVT: sq heparin\n Stress ulcer: famotidine \n VAP: chlorhexidine\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: icu\n" }, { "category": "Physician ", "chartdate": "2120-04-18 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 322921, "text": "Chief Complaint: 50M h/o metastatic renal CA s/p nephrectomy, IL-2,\n mini-allograft SCT, DLI x 2 last in , emphysema/pulmonary fibrosis\n on home 02 presents with sepsis.\n 24 Hour Events:\n -Multiple family discussions, pt FULL CODE\n -Paralysis stopped\n -Started on Dobutamine infusion, MAP maintained at >65 after\n vasopressin stopped. Now off levophed\n -PEEP decreased to 14 from 16, Fi02 50% from 60%\n -UOP maintained >200cc/hr\n Allergies:\n Flagyl (Oral) (Metronidazole)\n Rash;\n Last dose of Antibiotics:\n Levofloxacin - 10:04 AM\n Vancomycin - 07:35 PM\n Bactrim (SMX/TMP) - 11:39 PM\n Acyclovir - 12:16 AM\n - 03:59 AM\n Piperacillin/Tazobactam (Zosyn) - 06:08 AM\n Infusions:\n Dobutamine - 1.5 mcg/Kg/min\n Midazolam (Versed) - 6 mg/hour\n Fentanyl - 400 mcg/hour\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 07:41 PM\n Famotidine (Pepcid) - 08:30 PM\n Other medications:\n Hydrocortisone 50mg IV Q6\n Acetaminophen prn\n Folic Acid\n Albuterol\n Asa\n ISS\n Docusate\n Senna\n Bisacodyl\n Chlorhexidine\n Changes to medical and family history: None\n Review of systems is unchanged from admission except as noted below\n Review of systems: Intubated, sedated\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: 36.6\nC (97.9\n Tcurrent: 36.1\nC (97\n HR: 67 (56 - 96) bpm\n BP: 117/60(76) {89/58(69) - 152/77(99)} mmHg\n RR: 34 (30 - 34) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 76.3 kg (admission): 76.3 kg\n Height: 68 Inch\n CVP: 17 (10 - 25)mmHg\n CO/CI (CCO): (4.7 L/min) / (2.5 L/min/m2)\n Total In:\n 6,194 mL\n 820 mL\n PO:\n TF:\n 890 mL\n 46 mL\n IVF:\n 4,814 mL\n 739 mL\n Blood products:\n Total out:\n 2,395 mL\n 2,690 mL\n Urine:\n 1,845 mL\n 2,580 mL\n NG:\n 550 mL\n 110 mL\n Stool:\n Drains:\n Balance:\n 3,799 mL\n -1,870 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: PCV+Assist\n PC : 24 cmH2O\n RR (Set): 34\n PEEP: 14 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10\n PIP: 38 cmH2O\n Plateau: 36 cmH2O\n SpO2: 96%\n ABG: 7.36/39/95./21/-2\n Ve: 15.9 L/min\n PaO2 / FiO2: 192\n Physical Examination\n General Appearance: Intubated, sedated\n Eyes / Conjunctiva: Pupils dilated\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube\n Lymphatic: No(t) Cervical WNL, No(t) Supraclavicular WNL, No(t)\n Cervical adenopathy\n Cardiovascular: (S1: Normal), (S2: Normal, Fixed), tachycardic. regular\n Peripheral Vascular: (Right radial pulse: Diminished), (Left radial\n pulse: Diminished), (Right DP pulse: Diminished), (Left DP pulse:\n Diminished)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Rhonchorous: ), coarse mechanical BS throughout all lung fields\n Abdominal: Soft, Non-tender, hypoactive bowel sounds\n Extremities: no edema, palpable distal pulses\n Skin: Not assessed\n Neurologic: Intubated, sedated, paralyzed\n Labs / Radiology\n 124 K/uL\n 11.3 g/dL\n 99 mg/dL\n 1.1 mg/dL\n 21 mEq/L\n 4.6 mEq/L\n 19 mg/dL\n 110 mEq/L\n 139 mEq/L\n 33.6 %\n 12.3 K/uL\n [image002.jpg]\n 06:59 PM\n 09:54 PM\n 11:52 PM\n 04:37 AM\n 04:52 AM\n 08:05 PM\n 10:19 PM\n 12:20 AM\n 04:38 AM\n 05:01 AM\n WBC\n 13.1\n 12.3\n Hct\n 35.4\n 33.6\n Plt\n 119\n 124\n Cr\n 1.1\n 1.1\n TropT\n 0.22\n TCO2\n 23\n 21\n 21\n 20\n 21\n 22\n 22\n 23\n Glucose\n 164\n 179\n 174\n 99\n Other labs: PT / PTT / INR:14.9/28.9/1.3, CK / CKMB /\n Troponin-T:260/9/0.22, ALT / AST:94/64, Alk Phos / T Bili:84/0.3,\n Amylase / Lipase:53/22, Differential-Neuts:67.0 %, Band:2.0 %,\n Lymph:18.0 %, Mono:9.0 %, Eos:0.0 %, Lactic Acid:1.7 mmol/L,\n Albumin:2.7 g/dL, LDH:274 IU/L, Ca++:8.1 mg/dL, Mg++:2.2 mg/dL, PO4:1.6\n mg/dL\n Assessment and Plan\n 50M h/o metastatic renal CA s/p nephrectomy, IL-2, mini-allograft SCT,\n DLI x 2 last in , emphysema/pulmonary fibrosis on home 02 presents\n with sepsis.\n # Sepsis: On presentation to OSH pt hypotensive, hypoxic with fevers\n and leukocytosis. Now with hypoxic respiratory failure, requiring\n pressors. Likely pneumonia given hypoxia and possible opacities on\n CXR, although difficult to read due to fibrosis. No other apparent\n localizing symptoms. Ruled-out for flu at OSH. Urine, GI sources less\n probable. Given immunocompromise from malignancy, at risk for PCP,\n , etc. Progression of GVHD could be contributing. Given tenuous\n respiratory status and requirments for high levels of PEEP a\n bronchoscopy would be too high risk for BAL and culture data.\n - Will attempt to obtain deep ET sputum for culture\n - legionella urine ag negative, all other cultures no growth to date.\n - Vanc, zosyn, levofloxacin, bactrim IV for PCP, to cover\n broadly for now given critical illness. Iv steroids for PCP and\n adrenal insufficiency as below.\n - glucan, galactomannan pending\n - CT chest and possible bronch when more stable\n - Follow WBC count, fever curve\n - PPD to be read \n # Respiratory failure: Pneumonia in patient with poor pulmonary reserve\n due to emphysema, ?GVHD, fibrosis. Avoid high pressures given fibrotic\n lungs, using pressure control ventilation. Tolerated decrease in Fi02\n from 100% to 60% yesterday, oxygenating well.\n -continue to wean FI02\n -will d/c cisatracurium infusion and use boluses as needed for\n paralysis should pt be dysynchronous with ventilator, otherwise will\n continue to manage sedation/pain with fentanyl/versed, increasing gtt\n as needed.\n - Continue mechanical ventilatory support, wean as tolerated\n -No proning for now as pt oxygenating well.\n # Hypotension: Likely sepsis, although probably component of\n hypovolemia as well. At risk for PE given malignancy. GI bleed unlikely\n as Hct stable. Adrenal insufficiency possible given s/p adrenelectomy\n with mets in remaining adrenal. Pt has dysfunctional RV with severe\n likely contributing to low CO. Set up vigileo device yesterday\n for non-invasive hemodynamic monitoring. Initially CI was 2.8, this am\n 1.8, a concerning decrease. His SV variability is low, indicating\n minimal fluid responsiveness.\n - start dobutamine in an attempt to increase CO, titrate to goal CO >4,\n CI >2.5, maintain on vasopressin and levophed. Monitor pressors if\n becomes hypotensive due to vasodilitory effect will discontinue.\n - No prostacyclin/NO for now due to concern that may increase mismatch\n and worsen hypoxia.\n - Consider PA catheter placement for more accurate hemodynamic\n monitoring, will continue to use vigileo for now.\n - Treat broadly for infection per above\n - IV hydrocort Q6 for adrenal insufficiency\n - LENIs to look for DVT negative.\n - Guaiac stools, HCT has been stable.\n # Cardiac: Patient with probable demand ischemia in setting of\n hypotension, tachycardia, and sepsis; less likely unstable plaque.\n - CE\ns this am trending down\n - ASA, hold on beta-blocker and statin\n - Repeat ECG in am\n # Metastatic renal CA: Recurrent disease s/p donor lymphocyte\n transplant .\n - BMT to follow\n - Avoid steroids given risk to graft\n - Continue acyclovir ppx for now, will discuss with BMT\n ICU Care\n ICU Care\n Nutrition: TF, tolerating with low residuals.\n Replete (Full) - 06:20 AM 40 mL/hour, advance as tolerated\n to goal of 70mL /hour\n Glycemic Control: ISS prn\n Lines:\n 20 Gauge - 09:10 PM\n Multi Lumen - 11:24 PM\n Arterial Line - 12:14 AM\n Prophylaxis:\n DVT: Hep SC, pneumoboots\n Stress ulcer: Ranitidine\n VAP: Chlorhexidine\n Comments:\n Communication: Comments: wife, \n Code status: Full code, have d/w family, will continue to readdress\n today\n Disposition: ICU\n" }, { "category": "Physician ", "chartdate": "2120-04-21 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 323260, "text": "Chief Complaint:\n 24 Hour Events:\n EKG - At 06:04 PM\n Vent changes:\n Decreased rr to 30 from 36, driving pressure to 26 from 28: 7.4/38/89\n Rate decreased to 26 from 30, patient\nagitated\n and , \n increased rr to 30 and temp 100% fio2.\n Overnight dropped tidal volumes, and change in compliance, was\n suctioned, ? mucous plug. Cxr obtained, w/ ? new L mid lung / lingula\n opacification.\n Driving pressure increased back to 28 in light of this.\n TV improved back to normal.\n TUBE feed rate increased\n Allergies:\n Flagyl (Oral) (Metronidazole)\n Rash;\n Last dose of Antibiotics:\n Bactrim (SMX/TMP) - 09:00 AM\n Levofloxacin - 09:11 AM\n Vancomycin - 08:00 PM\n Caspofungin - 08:23 PM\n Acyclovir - 12:17 AM\n Piperacillin/Tazobactam (Zosyn) - 05:15 AM\n Infusions:\n Fentanyl - 500 mcg/hour\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:22 PM\n Famotidine (Pepcid) - 08:23 PM\n Midazolam (Versed) - 01:15 AM\n Fentanyl - 01:15 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:07 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.3\nC (99.2\n Tcurrent: 37.2\nC (99\n HR: 48 (45 - 67) bpm\n BP: 114/51(69) {114/51(69) - 144/73(97)} mmHg\n RR: 30 (23 - 30) insp/min\n SpO2: 92%\n Heart rhythm: SB (Sinus Bradycardia)\n Wgt (current): 76.3 kg (admission): 76.3 kg\n Height: 68 Inch\n CVP: 15 (12 - 314)mmHg\n CO/CI (CCO): (4.5 L/min) / (2.4 L/min/m2)\n Total In:\n 3,451 mL\n 1,236 mL\n PO:\n TF:\n 485 mL\n 458 mL\n IVF:\n 2,506 mL\n 528 mL\n Blood products:\n Total out:\n 1,805 mL\n 600 mL\n Urine:\n 1,805 mL\n 600 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,646 mL\n 636 mL\n Respiratory support\n Ventilator mode: PCV+\n PC : 28 cmH2O\n RR (Set): 30\n PEEP: 12 cmH2O\n FiO2: 1%\n RSBI Deferred: PEEP > 10\n PIP: 39 cmH2O\n SpO2: 92%\n ABG: 7.41/40/85./26/0\n Ve: 15 L/min\n PaO2 / FiO2: 17,000\n Physical Examination\n Gen: eyes open, not following commands, some evidence of localization\n side to side when calling name\n Heent: pupils equal. Intubated, ng tube and esophageal balloon in\n place\n Cor: rrr, nls1s2 no mrg\n Pul: cta anteriorly\n Abd: moderately distended. Bowel sounds present, no guarding, no\n tenderness / facial grimacing w/ palpation, no masses\n Extreme: warm, 2+ pitting edema to mid-thigh\n Neuro: sedated, eyes open, not responding to commands,\n Labs / Radiology\n 120 K/uL\n 10.3 g/dL\n 122 mg/dL\n 1.0 mg/dL\n 26 mEq/L\n 3.9 mEq/L\n 26 mg/dL\n 110 mEq/L\n 142 mEq/L\n 31.2 %\n 12.1 K/uL\n [image002.jpg]\n 04:46 AM\n 04:59 PM\n 03:12 AM\n 06:06 AM\n 02:28 PM\n 06:28 PM\n 09:12 PM\n 01:58 AM\n 04:48 AM\n 05:04 AM\n WBC\n 10.2\n 12.1\n Hct\n 31.7\n 31.2\n Plt\n 136\n 120\n Cr\n 1.1\n 1.0\n TCO2\n 25\n 26\n 26\n 24\n 24\n 26\n 28\n 26\n Glucose\n 91\n 122\n Other labs: PT / PTT / INR:13.5/29.8/1.2, CK / CKMB /\n Troponin-T:260/9/0.22, ALT / AST:57/31, Alk Phos / T Bili:70/0.4,\n Amylase / Lipase:53/22, Differential-Neuts:67.0 %, Band:2.0 %,\n Lymph:18.0 %, Mono:9.0 %, Eos:0.0 %, Lactic Acid:1.3 mmol/L,\n Albumin:2.7 g/dL, LDH:272 IU/L, Ca++:7.5 mg/dL, Mg++:2.2 mg/dL, PO4:3.1\n mg/dL\n Micro\n Blood culture 4/15+ pending\n Urine culture final negative\n Legionella negative\n RADS\n \n Cxr\n Persistent abnormal interstitial pattern. Diagnostic considerations\n include\n pulmonary fibrosis.\n Support lines unchanged, allowing for differences in patient\n positioning. The\n feeding tube is again noted to terminate at the GE junction. The\n feeding tube\n should be advanced.\n **the\n feeding tube\n is actually the esophageal balloon in correct\n position. Ng tube is seen below diaphragm.\n Assessment and Plan\n 50M h/o metastatic renal CA s/p nephrectomy, IL-2, mini-allograft SCT,\n DLI x 2 last in , emphysema/pulmonary fibrosis on home 02\n presented to OSH with hypoxic respiratory failure, fevers and\n hypotension.\n # Respiratory failure:\n Pneumonia as likely source of resp failure and sepsis in patient with\n poor pulmonary reserve due to emphysema, ?GVHD, fibrosis.\n Overnight w/ ? mucous plugging and decreased compliance. Overall not\n tolerating vent wean well.\n Cont sedation w/ fent / midazolam / methadone; no urgency in relieving\n sedating w/ high vent needs.\n - eval PM ABG for possible vent wean\n # Septic shock:\n **Likely source pneumonia. On very broad coverage w/ vancomycin,\n levofloxacin, bactrim (now only ppx dosing), caspofungin.\n All other cultures pending. WBC and fever curve responding well.\n D/C caspo today, as this is unlikely acute fungal pneumonia, and more\n likely bacterial.\n Also, won\nt tolerate bronch at this point, plus diagnostic studies\n probably no longer useful (culture).\n - f/u cultures\n - Legionella urine ag negative, all other cultures no growth to date.\n - D/C caspofungin sun if cultures negative\n - Glucan, galactomannan pending\n - Follow WBC count, fever curve, decreasing\n - PPD negative\n - Continue acyclovir ppx, vanc/zosyn/levoflox\n **Hypotension\n Now improved BPs, off dobutamine.\n Shock likely mix of septic, cardiogenic, and metabolic (absolute\n adrenal insufficiency). CVP goal > 8, and meeting that criteria. From\n cardiac perspective, RV hypokinesis and dysfunction though to be \n high intrapulmonary pressures (hypoxia, pulmonary fibrosis). Now able\n to maintain BP off dobutamine. Although CI decreased, will cont to\n follow urine output and MAP trend.\n For endocrine, pt w/ hx of adrenalectomy and adrenal gland w/ mets.\n - cont IV hydrocortisone taerp.\n # Metastatic renal CA: Recurrent disease s/p donor lymphocyte\n transplant .\n - BMT to follow\n - Continue acyclovir ppx for now, will discuss with BMT\n # Sedation\n Goals of sedation have been clarified; being too light was causing\n problems w/ oxygenation. Pt also was requiring supra-normal levels of\n midaz/fentanyl. Now adequately sedated on midax / fent / methadone.\n Cont this regimen for now and hold off on further sedation until\n ventilatory needs decrease.\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 05:04 AM 70 mL/hour\n Glycemic Control: ssi\n Lines:\n Multi Lumen - 11:24 PM\n Arterial Line - 12:14 AM\n Prophylaxis:\n DVT: sq heparin\n Stress ulcer: famotidine\n VAP: vap bundle\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: icu\n" }, { "category": "Physician ", "chartdate": "2120-04-21 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 323265, "text": "Chief Complaint:\n 24 Hour Events:\n EKG - At 06:04 PM\n Vent changes:\n Decreased rr to 30 from 34, driving pressure to 26 from 28: 7.4/38/89\n Rate decreased to 26 from 30, patient\nagitated\n and , \n increased rr to 30 and temp 100% fio2.\n Overnight dropped tidal volumes, and change in compliance, was\n suctioned, ? mucous plug. Cxr obtained, w/ ? new L mid lung / lingula\n opacification.\n Driving pressure increased back to 28 in light of this.\n TV improved back to normal.\n NET CHANGE: RR to 30, pressure unchanged\n TUBE feed rate increased to goal 75 cc/ hr\n Allergies:\n Flagyl (Oral) (Metronidazole)\n Rash;\n Last dose of Antibiotics:\n Bactrim (SMX/TMP) - 09:00 AM\n Levofloxacin - 09:11 AM\n Vancomycin - 08:00 PM\n Caspofungin - 08:23 PM\n Acyclovir - 12:17 AM\n Piperacillin/Tazobactam (Zosyn) - 05:15 AM\n Infusions:\n Fentanyl - 500 mcg/hour\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:22 PM\n Famotidine (Pepcid) - 08:23 PM\n Midazolam (Versed) - 01:15 AM\n Fentanyl - 01:15 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:07 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.3\nC (99.2\n Tcurrent: 37.2\nC (99\n HR: 48 (45 - 67) bpm\n BP: 114/51(69) {114/51(69) - 144/73(97)} mmHg\n RR: 30 (23 - 30) insp/min\n SpO2: 92%\n Heart rhythm: SB (Sinus Bradycardia)\n Wgt (current): 76.3 kg (admission): 76.3 kg\n Height: 68 Inch\n CVP: 15 (12 - 314)mmHg\n CO/CI (CCO): (4.5 L/min) / (2.4 L/min/m2)\n Total In:\n 3,451 mL\n 1,236 mL\n PO:\n TF:\n 485 mL\n 458 mL\n IVF:\n 2,506 mL\n 528 mL\n Blood products:\n Total out:\n 1,805 mL\n 600 mL\n Urine:\n 1,805 mL\n 600 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,646 mL\n 636 mL\n Respiratory support\n Ventilator mode: PCV+\n PC : 28 cmH2O\n RR (Set): 30\n PEEP: 12 cmH2O\n FiO2: 1%\n RSBI Deferred: PEEP > 10\n PIP: 39 cmH2O\n SpO2: 92%\n ABG: 7.41/40/85./26/0\n Ve: 15 L/min\n PaO2 / FiO2: 17,000\n Physical Examination\n Gen: eyes open, not following commands, some evidence of localization\n side to side when calling name\n Heent: pupils equal. Intubated, ng tube and esophageal balloon in\n place\n Cor: rrr, nls1s2 no mr, + S4 gallop\n Pul: cta anteriorly\n Abd: moderately distended. Bowel sounds present, no guarding, no\n tenderness / facial grimacing w/ palpation, no masses\n Extreme: warm, 2+ pitting edema to mid-thigh\n Neuro: sedated, eyes open, not responding to commands,\n Labs / Radiology\n 120 K/uL\n 10.3 g/dL\n 122 mg/dL\n 1.0 mg/dL\n 26 mEq/L\n 3.9 mEq/L\n 26 mg/dL\n 110 mEq/L\n 142 mEq/L\n 31.2 %\n 12.1 K/uL\n [image002.jpg]\n 04:46 AM\n 04:59 PM\n 03:12 AM\n 06:06 AM\n 02:28 PM\n 06:28 PM\n 09:12 PM\n 01:58 AM\n 04:48 AM\n 05:04 AM\n WBC\n 10.2\n 12.1\n Hct\n 31.7\n 31.2\n Plt\n 136\n 120\n Cr\n 1.1\n 1.0\n TCO2\n 25\n 26\n 26\n 24\n 24\n 26\n 28\n 26\n Glucose\n 91\n 122\n Other labs: PT / PTT / INR:13.5/29.8/1.2, CK / CKMB /\n Troponin-T:260/9/0.22, ALT / AST:57/31, Alk Phos / T Bili:70/0.4,\n Amylase / Lipase:53/22, Differential-Neuts:67.0 %, Band:2.0 %,\n Lymph:18.0 %, Mono:9.0 %, Eos:0.0 %, Lactic Acid:1.3 mmol/L,\n Albumin:2.7 g/dL, LDH:272 IU/L, Ca++:7.5 mg/dL, Mg++:2.2 mg/dL, PO4:3.1\n mg/dL\n Micro\n Blood culture 4/15+ pending\n Urine culture final negative\n Legionella negative\n Beta glucan, galactomannan pending\n RADS\n \n Cxr\n Persistent abnormal interstitial pattern. Diagnostic considerations\n include\n pulmonary fibrosis.\n Support lines unchanged, allowing for differences in patient\n positioning. The\n feeding tube is again noted to terminate at the GE junction. The\n feeding tube\n should be advanced.\n **the\n feeding tube\n is actually the esophageal balloon in correct\n position. Ng tube is seen below diaphragm.\n Assessment and Plan\n 50M h/o metastatic renal CA s/p nephrectomy, IL-2, mini-allograft SCT,\n DLI x 2 last in , emphysema/pulmonary fibrosis on home 02\n presented to OSH with hypoxic respiratory failure, fevers and\n hypotension.\n # Respiratory failure:\n Pneumonia as likely source of resp failure and sepsis in patient with\n poor pulmonary reserve due to emphysema, ?GVHD, fibrosis.\n Overnight w/ ? mucous plugging and decreased compliance. Overall not\n tolerating vent wean well.\n Cont sedation w/ fent / midazolam / methadone; no urgency in relieving\n sedating w/ high vent needs.\n - diurese 500-1000mL in attempt improve oxygenation now that\n BP / shock has resolved\n - No changes to FiO2 / Peep until oxygenation improves\n - No change to A/C\n volume controlled setting\n - Decrease driving pressure and re-eval abg in attempt to\n reduce intrathoracic pressures and barotrauma\n # Shock:\n Multifactorial\n ** Sepsis\n Likely source pneumonia. On very broad coverage w/ vancomycin,\n levofloxacin, bactrim (now only ppx dosing), caspofungin.\n All other cultures pending. WBC and fever curve responding well.\n D/C caspo when beta glucan / galactomannan negative.\n - f/u cultures\n - Follow WBC count, fever curve, decreasing\n - PPD negative\n - Continue acyclovir ppx, vanc/zosyn/levoflox for 14 day course, now\n \n **Cardiogenic/\n ##Pump\n Now improved BPs, off dobutamine.\n W/ dilated hypokinetic RV, likely causative in hypotension. Now BP\n recovering well.\n Will increase ace-I for BP contol and afterload reduction, and titrate\n to effect.\n ##Rhythm\n Sinus bradycardia. ? med effect. Sustaining blood pressure well, no\n need for atropine.\n QTc: prolonged mimimally to 485. Cont check EKG w/ levofloxacin,\n methadone.\n **Endocrine\n ? absolute adrenal insufficiency\n Pt w/ hx of adrenalectomy and adrenal gland w/ mets.\n - 60 mg po prednisone today and cont w/ rapid PO pred taper\n # Metastatic renal CA: Recurrent disease s/p donor lymphocyte\n transplant .\n - BMT to follow\n - Continue acyclovir ppx for now, will discuss with BMT\n # Sedation\n Goals of sedation have been clarified; being too light was causing\n problems w/ oxygenation. Pt also was requiring supra-normal levels of\n midaz/fentanyl. Now adequately sedated on midax / fent / methadone.\n Cont this regimen for now and hold off on further sedation wean until\n ventilatory needs decrease.\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 05:04 AM 70 mL/hour\n Glycemic Control: ssi\n Lines:\n Multi Lumen - 11:24 PM\n Arterial Line - 12:14 AM\n Prophylaxis:\n DVT: sq heparin\n Stress ulcer: famotidine\n VAP: vap bundle\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: icu\n" }, { "category": "Physician ", "chartdate": "2120-04-30 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 324159, "text": "Chief Complaint: 50 y/o M w/ metastatic renal cell carcinoma s/p\n nephrectomy, IL-2, mini-SCT, DLI x2 in , pulmonary fibrosis on\n home O2 a/w hypoxic respiratory failure, sepsis, cardiogenic shock now\n with difficulty weaning the vent s/p trach and peg.\n 24 Hour Events:\n EKG - At 09:00 AM -> junctional rhythm, in and out of\n sinus overnight.\n TRANSTHORACIC ECHO - At 10:17 AM -> minimal increase in RV\n pressure overload, pleural effusion, no other new findings\n MULTI LUMEN - START 12:05 PM -> CXR shows in good\n position.\n ULTRASOUND - At 02:29 PM -> Clot in R-IJ, no LE DVT.\n Restarted heparing s/p mini-BAL.\n Hypotension/Pressors: Yesterday bolused with IVF's with goal CVP of\n mm Hg. Weaned off neo and later weaned of levophed. This AM off\n vasopressin. Repleted ionized calcium yeterday.\n .\n Respiratory: Improved on A/C during the day yeterday but overnight had\n difficulty maintaining adequate minute ventilation. ? of inadequate\n sedation/paralysis vs. some mild pulm edema after hydration. Changed\n back to pressure control transiently overnight. CVP at that time\n . Increased cisatracurium and patient improved with repeat ABG of\n 7.21/70/104/30 on A/C. Now on A/C with TV 340, RR 42, FiO2 70%, 6\n PEEP. Last transpulmonary pressure of 30mmHg.\n .\n ID: Started meropenem/linezolid/tobramycin and caspofungin as per ID\n team yesterday. Also given one dose IV Ig for severe sepsis in\n immunocompromised host.\n .\n Cardiac: Had TTE yesterday that showed mild increase in RV pressure\n overload and new pleural effusion.\n .\n Allergies:\n Flagyl (Oral) (Metronidazole)\n Rash;\n Last dose of Antibiotics:\n Acyclovir - 04:00 PM\n Levofloxacin - 08:00 AM\n Piperacillin/Tazobactam (Zosyn) - 06:32 AM\n Vancomycin - 08:00 AM\n Ciprofloxacin - 11:00 AM\n Metronidazole - 04:00 PM\n Meropenem - 05:00 AM\n Linezolid - 05:14 AM\n Infusions:\n Heparin Sodium - 1,200 units/hour\n Fentanyl (Concentrate) - 300 mcg/hour\n Midazolam (Versed) - 25 mg/hour\n Cisatracurium - 0.25 mg/Kg/hour\n Other ICU medications:\n Pantoprazole (Protonix) - 08:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:59 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.2\nC (99\n Tcurrent: 35.4\nC (95.7\n HR: 64 (64 - 104) bpm\n BP: 91/65(72) {84/58(64) - 124/75(87)} mmHg\n RR: 42 (0 - 42) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 76.3 kg (admission): 76.3 kg\n Height: 68 Inch\n CVP: 12 (-3 - 335)mmHg\n Total In:\n 9,039 mL\n 3,057 mL\n PO:\n TF:\n IVF:\n 9,039 mL\n 3,057 mL\n Blood products:\n Total out:\n 3,595 mL\n 450 mL\n Urine:\n 3,295 mL\n 450 mL\n NG:\n 300 mL\n Stool:\n Drains:\n Balance:\n 5,444 mL\n 2,607 mL\n Respiratory support\n Ventilator mode: PRVC/AC\n Vt (Set): 340 (340 - 360) mL\n PC : 38 cmH2O\n PS : 32 cmH2O\n PEEP: 6 cmH2O\n FiO2: 70%\n RSBI Deferred: FiO2 > 60%\n PIP: 38 cmH2O\n Plateau: 30 cmH2O\n Compliance: 17.9 cmH2O/mL\n SpO2: 96%\n ABG: 7.21/70/104/26/-1\n Ve: 15 L/min\n PaO2 / FiO2: 149\n Physical Examination\n General Appearance: Well nourished, sedated\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal), No(t) S3, No(t) S4, No(t)\n Rub, (Murmur: No(t) Systolic, No(t) Diastolic)\n Peripheral Vascular: 2+ radial pulses b/l, 2+ DP pulses b/l, no c/c,\n trace to 1+ b/l LE edema upper and lower.\n Respiratory / Chest: (Expansion: Symmetric), mechanical breath sounds,\n otherwise clear.\n Skin: ecchymoses over abdomen,\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 88 K/uL\n 8.1 g/dL\n 253 mg/dL\n 1.9 mg/dL\n 26 mEq/L\n 4.4 mEq/L\n 28 mg/dL\n 108 mEq/L\n 136 mEq/L\n 25.4 %\n 11.3 K/uL\n [image002.jpg]\n 03:11 PM\n 05:58 PM\n 08:48 PM\n 09:33 PM\n 01:17 AM\n 01:43 AM\n 01:59 AM\n 03:07 AM\n 04:27 AM\n 04:44 AM\n WBC\n 11.3\n Hct\n 30.4\n 27.6\n 25.4\n Plt\n 88\n Cr\n 1.9\n TCO2\n 28\n 29\n 30\n 28\n 30\n 29\n 30\n Glucose\n 253\n Other labs: PT / PTT / INR:13.7/40.1/1.2, CK / CKMB /\n Troponin-T:260/9/0.22, ALT / AST:2542/3606, Alk Phos / T Bili:146/0.9,\n Amylase / Lipase:50/19, Differential-Neuts:85.4 %, Band:0.0 %,\n Lymph:8.8 %, Mono:4.1 %, Eos:1.4 %, Lactic Acid:1.9 mmol/L, Albumin:2.7\n g/dL, LDH:1697 IU/L, Ca++:7.0 mg/dL, Mg++:2.0 mg/dL, PO4:4.7 mg/dL\n Assessment and Plan\n SHOCK, SEPTIC\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 02:03 PM\n 18 Gauge - 02:03 PM\n PICC Line - 04:30 PM\n Arterial Line - 04:30 AM\n Multi Lumen - 12:05 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": "2120-04-30 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 324169, "text": "Chief Complaint: 50 y/o M w/ metastatic renal cell carcinoma s/p\n nephrectomy, IL-2, mini-SCT, DLI x2 in , pulmonary fibrosis on\n home O2 a/w hypoxic respiratory failure, sepsis, cardiogenic shock now\n with difficulty weaning the vent s/p trach and peg.\n 24 Hour Events:\n EKG - At 09:00 AM -> junctional rhythm, in and out of\n sinus overnight.\n TRANSTHORACIC ECHO - At 10:17 AM -> minimal increase in RV\n pressure overload, pleural effusion, no other new findings\n MULTI LUMEN - START 12:05 PM -> CXR shows in good\n position.\n ULTRASOUND - At 02:29 PM -> Clot in R-IJ, no LE DVT.\n Restarted heparing s/p mini-BAL.\n Hypotension/Pressors: Yesterday bolused with IVF's with goal CVP of\n mm Hg. Weaned off neo and later weaned of levophed. This AM off\n vasopressin. Repleted ionized calcium yeterday.\n .\n Respiratory: Improved on A/C during the day yeterday but overnight had\n difficulty maintaining adequate minute ventilation. ? of inadequate\n sedation/paralysis vs. some mild pulm edema after hydration. Changed\n back to pressure control transiently overnight. CVP at that time\n . Increased cisatracurium and patient improved with repeat ABG of\n 7.21/70/104/30 on A/C. Now on A/C with TV 340, RR 42, FiO2 70%, 6\n PEEP. Last transpulmonary pressure of 30mmHg.\n .\n ID: Started meropenem/linezolid/tobramycin and caspofungin as per ID\n team yesterday. Also given one dose IV Ig for severe sepsis in\n immunocompromised host.\n .\n Cardiac: Had TTE yesterday that showed mild increase in RV pressure\n overload and new pleural effusion.\n .\n Allergies:\n Flagyl (Oral) (Metronidazole)\n Rash;\n Last dose of Antibiotics:\n Acyclovir - 04:00 PM\n Levofloxacin - 08:00 AM\n Piperacillin/Tazobactam (Zosyn) - 06:32 AM\n Vancomycin - 08:00 AM\n Ciprofloxacin - 11:00 AM\n Metronidazole - 04:00 PM\n Meropenem - 05:00 AM\n Linezolid - 05:14 AM\n Infusions:\n Heparin Sodium - 1,200 units/hour\n Fentanyl (Concentrate) - 300 mcg/hour\n Midazolam (Versed) - 25 mg/hour\n Cisatracurium - 0.25 mg/Kg/hour\n Other ICU medications:\n Pantoprazole (Protonix) - 08:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:59 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.2\nC (99\n Tcurrent: 35.4\nC (95.7\n HR: 64 (64 - 104) bpm\n BP: 91/65(72) {84/58(64) - 124/75(87)} mmHg\n RR: 42 (0 - 42) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 76.3 kg (admission): 76.3 kg\n Height: 68 Inch\n CVP: 12 mmHg\n Total In:\n 9,039 mL\n 3,057 mL\n PO:\n TF:\n IVF:\n 9,039 mL\n 3,057 mL\n Blood products:\n Total out:\n 3,595 mL\n 450 mL\n Urine:\n 3,295 mL\n 450 mL\n NG:\n 300 mL\n Stool:\n Drains:\n Balance:\n 5,444 mL\n 2,607 mL\n Respiratory support\n Ventilator mode: PRVC/AC\n Vt (Set): 340 (340 - 360) mL\n PC : 38 cmH2O\n PS : 32 cmH2O\n PEEP: 6 cmH2O\n FiO2: 70%\n RSBI Deferred: FiO2 > 60%\n PIP: 38 cmH2O\n Plateau: 30 cmH2O\n Compliance: 17.9 cmH2O/mL\n SpO2: 96%\n ABG: 7.21/70/104/26/-1\n Ve: 15 L/min\n PaO2 / FiO2: 149\n Physical Examination\n General Appearance: Well nourished, sedated\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal), No(t) S3, No(t) S4, No(t)\n Rub, (Murmur: No(t) Systolic, No(t) Diastolic)\n Peripheral Vascular: 2+ radial pulses b/l, 2+ DP pulses b/l, no c/c,\n trace to 1+ b/l LE edema upper and lower.\n Respiratory / Chest: (Expansion: Symmetric), mechanical breath sounds,\n otherwise clear.\n Skin: ecchymoses over abdomen,\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 88 K/uL\n 8.1 g/dL\n 253 mg/dL\n 1.9 mg/dL\n 26 mEq/L\n 4.4 mEq/L\n 28 mg/dL\n 108 mEq/L\n 136 mEq/L\n 25.4 %\n 11.3 K/uL\n [image002.jpg]\n 03:11 PM\n 05:58 PM\n 08:48 PM\n 09:33 PM\n 01:17 AM\n 01:43 AM\n 01:59 AM\n 03:07 AM\n 04:27 AM\n 04:44 AM\n WBC\n 11.3\n Hct\n 30.4\n 27.6\n 25.4\n Plt\n 88\n Cr\n 1.9\n TCO2\n 28\n 29\n 30\n 28\n 30\n 29\n 30\n Glucose\n 253\n Other labs: PT / PTT / INR:13.7/40.1/1.2, CK / CKMB /\n Troponin-T:260/9/0.22, ALT / AST:2542/3606, Alk Phos / T Bili:146/0.9,\n Amylase / Lipase:50/19, Differential-Neuts:85.4 %, Band:0.0 %,\n Lymph:8.8 %, Mono:4.1 %, Eos:1.4 %, Lactic Acid:1.9 mmol/L, Albumin:2.7\n g/dL, LDH:1697 IU/L, Ca++:7.0 mg/dL, Mg++:2.0 mg/dL, PO4:4.7 mg/dL\n Assessment and Plan\n SHOCK, SEPTIC\n 50 y/o M w/ metastatic renal cell carcinoma s/p nephrectomy, IL-2,\n mini-SCT, DLI x2 in , pulmonary fibrosis on home O2 a/w hypoxic\n respiratory failure, sepsis, cardiogenic shock now with difficulty\n weaning the vent s/p trach and peg.\n .\n #Hypotension: At this time feel sepsis with contribution of DVT/PE is\n most likely cause for hypotension. Patient improved overnight with\n decreased pressor requirement after fluid boluses and starting heparin\n gtt. Continue IVF\ns today with goal CVP 10-12 as tolerated by\n pulmonary status.\n - Sepsis: No clear source, ? GI/ C.Diff, afebrile last 24\n hours suggesting response to antibiotics. Will continue\n meropenem/linezolid/tobramycin/caspofungin/Flagyl and PO Vancomycin in\n addition to bactrim/acyclovir PPx. IV Ig given yesterday for severe\n sepsis in immunocompromised host. Will continue broad spectrum\n antibiotics today.\n - Treating empirically for C. Diff infection at this time.\n Restarted PO vancomycin as patient not retaining PR vancomycin. C.\n Diff negative x1, resend stool cultures. Consider d/c of PO vanco if\n stool toxin\ns negative.\n - Appreciate ID Rec\n - Cardiogenic Shock: Likely some component may be related to\n obstructive shock from PE, patient with mildly increase in RV pressure\n overload on last Echo so not clearly\n - Hypovolemic Shock: Less likely. With bloody NG lavage today\n after starting heparin. Q6h HCT and stop heparin gtt only for\n significant GI bleed.\n - Adrenal: Normal cortisol, and hypotension improving so not\n adding steroids at this point. Consider if patient decompensates or\n cannot be weaned of pressors.\n - Follow calcium and replete.\n - Continue acyclovir and bactrim PPx.\n .\n # Respiratory failure: Pneumonia with small PE likely source of resp\n failure and in patient with poor pulmonary reserve due to emphysema,\n ?GVHD, fibrosis. However, increasing CO2 requirement concerning for\n PE and with RIJ thrombosis by ultrasound. Will continue heparin gtt\n today. Adjust vent settings PRN with goal pH 7.2 or greater, and\n transpulmonary pressures of 25 or less.\n - continue heparin gtt at this time.\n - Maintain CVP 10-12 and would not diurese unless increasingly hypoxic\n and CVP elevated.\n - Treat PNA for planned 14 day course. See below. B-glucan,\n galactomannan negative, caspogungin d/c\n .\n # Sedation: continue fentanyl, cisatracurium, midazolam.\n - Goal to wean propofol as tolerated today, triglycerides mildly\n elevated at 182\n - Continue to check triglycerides twice weekly while on propofol. Last\n checked \n - Will bolus with versed/fentanyl prn agitation in an attempt to wean\n down level of propofol.\n - Continue to check daily ECG for QTc prolongation on methadone.\n - When able, will decrease methadone to q6H then to q8H\n .\n #Acute Liver Injury: Likely to hypotension. Trend LFT\ns. Review\n current medications for possible heaptotoxins.\n .\n # Acute Renal Failure: Likely to ATN. Renal dose meds. Urine\n lytes, Ua.\n - Continue IVF\ns, making good UOP.\n .\n # Anemia: Likely oozing in setting of heparin gtt. T. Bili normal this\n AM arguing against hemolysis but with elevated LDH will check\n haptoglobin. Will check q6H Hct today, and transfuse PRN for Hct < 21,\n or give blood if need to give IV fluids today.\n .\n #Thrombocytopenia: Low likelihood of HIT. be infection,\n medication effect, DIC. Will send smear, DIC labs today. Transfuse\n PRN for platelets < 50 given concern for active bleeding. Also d/c\n heparin gtt if platelets <50.\n .\n #GI Bleeding: IV PPI while on heparin gtt given black on lavage.\n Will follow and hold heparin for acute GI bleed. Q6H hematocrit for\n now.\n - continue to follow, transfuse PRN\n #DVT: R-IJ Thrombosis, continue heparin gtt.\n # Pump: As above. TTE w/ blown RV.\n # Rhythm: Sinus at times with junction rhythm on occasion. Continue to\n monitor. Telemetry/TTE.\n # Metastatic renal CA: Recurrent disease s/p donor lymphocyte\n transplant .\n - BMT to follow -> to give input on code status and discussions with\n family regarding severity of illness at this time.\n - Continue acyclovir and bactrim ppx\n # Access: Central line, PIV. A-Line.\n #CODE: DNR (Okay to intubate)\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 02:03 PM\n 18 Gauge - 02:03 PM\n PICC Line - 04:30 PM\n Arterial Line - 04:30 AM\n Multi Lumen - 12:05 PM\n Prophylaxis:\n DVT: Heparin gtt\n Stress ulcer: Protonix \n VAP: chlorhexedine\n Comments:\n Communication: Comments:\n Code status: DNR\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2120-04-28 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 323978, "text": "Chief Complaint:\n 24 Hour Events:\n ARTERIAL LINE - START 08:13 PM\n - replaced a-line\n -kept on 5 PEEP due to concern for increased leak around cuff\n -in PM, 02 sats improved, less agitated.\n Allergies:\n Flagyl (Oral) (Metronidazole)\n Rash;\n Last dose of Antibiotics:\n Bactrim (SMX/TMP) - 08:16 AM\n Levofloxacin - 09:00 AM\n Acyclovir - 04:00 PM\n Vancomycin - 08:08 PM\n Piperacillin/Tazobactam (Zosyn) - 06:06 AM\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 08:00 AM\n Lorazepam (Ativan) - 11:09 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:52 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.2\nC (98.9\n Tcurrent: 37.2\nC (98.9\n HR: 73 (60 - 99) bpm\n BP: 100/54(71) {84/40(48) - 106/60(75)} mmHg\n RR: 30 (0 - 30) insp/min\n SpO2: 91%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 76.3 kg (admission): 76.3 kg\n Height: 68 Inch\n CVP: 10 (8 - 310)mmHg\n Total In:\n 3,124 mL\n 464 mL\n PO:\n TF:\n 750 mL\n 77 mL\n IVF:\n 1,733 mL\n 287 mL\n Blood products:\n Total out:\n 2,900 mL\n 530 mL\n Urine:\n 2,900 mL\n 530 mL\n NG:\n Stool:\n Drains:\n Balance:\n 224 mL\n -66 mL\n Respiratory support\n Ventilator mode: PCV+\n PC : 24 cmH2O\n RR (Set): 30\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 60%\n RSBI Deferred: No Spon Resp\n PIP: 29 cmH2O\n Plateau: 26 cmH2O\n SpO2: 91%\n ABG: 7.36/51/105/25/1\n Ve: 10.2 L/min\n PaO2 / FiO2: 175\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 166 K/uL\n 10.0 g/dL\n 82 mg/dL\n 0.9 mg/dL\n 25 mEq/L\n 4.3 mEq/L\n 12 mg/dL\n 110 mEq/L\n 142 mEq/L\n 29.9 %\n 12.5 K/uL\n [image002.jpg]\n 03:23 PM\n 06:00 PM\n 04:43 AM\n 02:25 PM\n 05:37 PM\n 09:20 PM\n 04:49 AM\n 12:14 PM\n 03:59 AM\n 04:26 AM\n WBC\n 15.0\n 11.1\n 12.5\n Hct\n 34.0\n 28.1\n 31.5\n 29.2\n 29.9\n Plt\n 159\n 145\n 166\n Cr\n 1.0\n 1.0\n 0.9\n TCO2\n 27\n 30\n 28\n 30\n Glucose\n 76\n 65\n 80\n 82\n Other labs: PT / PTT / INR:13.7/42.1/1.2, CK / CKMB /\n Troponin-T:260/9/0.22, ALT / AST:57/31, Alk Phos / T Bili:70/0.4,\n Amylase / Lipase:53/22, Differential-Neuts:67.0 %, Band:2.0 %,\n Lymph:18.0 %, Mono:9.0 %, Eos:0.0 %, Lactic Acid:2.0 mmol/L,\n Albumin:2.6 g/dL, LDH:272 IU/L, Ca++:8.1 mg/dL, Mg++:2.2 mg/dL, PO4:2.4\n mg/dL\n Imaging: CXR : IMPRESSION: 1. The acute changes noted in both\n lungs favor edema, although aspiration cannot be completely excluded.\n 2. Chronic interstitial lung fibrotic disease.\n Microbiology: All micro NGTD\n Assessment and Plan\n 50M h/o metastatic renal CA s/p nephrectomy, IL-2, mini-allograft SCT,\n DLI x 2 last in , emphysema/pulmonary fibrosis on home 02\n presented to OSH with hypoxic respiratory failure, sepsis, cardiogenic\n shock, now improving but with difficulty weaning vent and s/p\n trach/PEG.\n # Respiratory failure: Pneumonia as likely source of resp failure and\n sepsis in patient with poor pulmonary reserve due to emphysema, ?GVHD,\n fibrosis. Patient is now s/p trach/PEG on . PEEP yesterday\n decreased to 5 yesterday after trach placement. Pt has small cuff\n leak. IP had evaluated this am and wanted to continue to monitor for\n now. This am pt agitated, low 02 sats. Has increasing Fi02\n requirement from 40% now up to 60%.\n - Continue PEEP of 5 on PCV given concern over cuff leak by RT, plan\n for replacement of cuff by IP after a few days when trach is not so\n new\n - Driving pressures maintained at 24. FiO2 at 60% now with sats in the\n low 90s. Last gas 7.36/51/105. Can consider decreasing FiO2 to 50%\n this morning.\n - Can attempt PS trial today if sedation weaned and patient alert\n enough to tolerate.\n - Treat PNA for planned 14 day course. B-glucan, galactomannan\n negative, caspogungin d/c\n # Sedation: Currently on methadone q4H, and propofol for sedation,\n currently at 35 mcg/kg/min. Off fent/versed drips, using fentanyl and\n lorazepam boluses for agitation.\n - Goal to wean propofol as tolerated today, triglycerides mildly\n elevated at 182\n - Continue to check triglycerides twice weekly while on propofol. Last\n checked \n - When able, will decrease methadone to q6H then to q8H\n # Shock: Multifactorial, resolved.\n ** Sepsis: Likely source pneumonia. On very broad coverage w/\n vancomycin, levofloxacin, zosyn, bactrim (now only ppx dosing). All\n cultures pending or no growth. WBC stable.\n - D/C'd caspo\n - F/u cultures - cont to culture with spikes.\n - Continue acyclovir and bactrim ppx, vanc/zosyn/levoflox for 14 day\n course, today is day 12.\n **Cardiogenic\n ## Pump: Now improved BPs, off dobutamine. On captopril for afterload\n reduction. Dilated hypokinetic RV, likely causative in hypotension.\n Currently on captopril 12.5mg TID decreased yesterday in the setting of\n hypotension requiring a fluid bolus. Will likely need repeat ECHO once\n acute issues resolved to assess for resolution of RV dysfunction.\n - Continue to monitor BP, can consider repeat ECHO to evaluate pump\n function.\n ## Rhythm: Sinus bradycardia likely secondary to sedatives; increases\n with agitation. Cont weaning sedation as tolerated. Continue to\n follow QTc for prolongation given methadone and levoflox, has been wnl\n **Endocrine: relative adrenal \n - Prednisone off\n # Metastatic renal CA: Recurrent disease s/p donor lymphocyte\n transplant .\n - BMT to follow\n - Continue acyclovir and bactrim ppx\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 02:13 AM 20 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Multi Lumen - 11:24 PM\n Arterial Line - 08:13 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:ICU\n" }, { "category": "Radiology", "chartdate": "2120-04-21 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1009867, "text": " 12:28 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Lung collapse, pneumothorax, position of ET tube, worsening\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50 year old man with ILD and superimposed PNA now with acute change in vent\n settings and decreased compliance.\n REASON FOR THIS EXAMINATION:\n Lung collapse, pneumothorax, position of ET tube, worsening parenchymal\n disease, effusions, pulmonary edema\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Pneumonia.\n\n Single portable radiograph of the chest demonstrates no change in the support\n lines when compared with . The feeding tube is again seen with its\n tip at the GE junction and should be advanced. Abnormal interstitial pattern\n and blunting of the bilateral costophrenic angles is unchanged. The\n cardiomediastinal contours are similar in appearance. The trachea is midline.\n Surgical clips project over the epigastrium.\n\n IMPRESSION:\n\n No interval change.\n\n\n" }, { "category": "Radiology", "chartdate": "2120-04-29 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1010895, "text": " 12:38 AM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: please eval for interval\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50 year old man with ARDS, now with increasing oxygen requirement and\n hypotension\n REASON FOR THIS EXAMINATION:\n please eval for interval\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Followup.\n\n FINDINGS: As compared to the previous radiograph, there is no relevant change\n in density and extent of the bilateral diffuse reticular opacities. The size\n of the cardiac silhouette is also unchanged.\n\n\n" }, { "category": "Radiology", "chartdate": "2120-04-29 00:00:00.000", "description": "P ABDOMEN (SUPINE & ERECT) PORT", "row_id": 1010936, "text": " 9:19 AM\n ABDOMEN (SUPINE & ERECT) PORT Clip # \n Reason: eval for free air\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50 year old man with multifactorial shock\n REASON FOR THIS EXAMINATION:\n eval for free air\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 50-year-old man, with multifactorial shock.\n\n COMPARISON: Abdominal radiograph of and CT torso of .\n\n SUPINE AND UPRIGHT VIEWS OF THE ABDOMEN: The abdomen is relatively gasless,\n making it difficult to assess bowel loops, however, no air-fluid levels are\n seen and no obviously distended loops of bowel are identified. Multiple\n surgical clips are again noted throughout the mid abdomen. Destructive lytic\n lesions are seen of the pubic rami bilaterally, better assessed on the recent\n CT torso. Additionally, diffuse interstitial opacities are present at both\n lung bases.\n\n There is no intraperitoneal free air.\n\n IMPRESSION: No evidence of bowel obstruction or intraperitoneal free air.\n\n\n" }, { "category": "Radiology", "chartdate": "2120-04-24 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1010294, "text": " 9:27 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for interval change and tubes, lines placement\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50 year old man with ARDS, sepsis and cardiogenic shock with baseline pulmonary\n fibrosis\n REASON FOR THIS EXAMINATION:\n eval for interval change and tubes, lines placement\n ______________________________________________________________________________\n FINAL REPORT\n PROCEDURE: Chest portable AP on .\n\n COMPARISON: Multiple previous chest radiographs including .\n\n HISTORY: 50-year-old man with ARDS, sepsis and cardiogenic shock with\n baseline pulmonary fibrosis, evaluate for change and line placement.\n\n FINDINGS:\n\n In the interim, there has been a decrease in pulmonary edema superimposed on\n the background of severe, chronic interstitial fibrosis. The right IJ line is\n stable in location, terminating in the caval/atrial junction. A feeding tube\n tip is out of view on this examination. Surgical clips in the left upper\n abdomen are again noted. An endotracheal tube is 4 cm from the carina.\n The heart size is normal. There is no pleural effusion.\n IMPRESSION:\n\n 1. Decrease in the bilateral pulmonary edema.\n\n 2. Chronic interstitial lung disease.\n\n 3. Lines and tubes are in satisfactory location.\n\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2120-04-16 00:00:00.000", "description": "P BILAT LOWER EXT VEINS PORT", "row_id": 1009223, "text": " 12:48 PM\n BILAT LOWER EXT VEINS PORT Clip # \n Reason: eval for DVT\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50 year old man with metastatic renal CA presented with hypoxemia, hypotension\n REASON FOR THIS EXAMINATION:\n eval for DVT\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 50-year-old man with metastatic renal CA presents with hypoxia\n and hypotension. Evaluate for DVT.\n\n COMPARISON: None.\n\n FINDINGS: scale, color and Doppler images obtained of the bilateral\n common femoral, superficial femoral and popliteal veins. There is evidence of\n normal flow, compressibility and augmentation. There is no evidence of\n intraluminal thrombosis. Additionally bilateral peroneal and tibial also\n demonstrate normal flow and compressibility.\n\n IMPRESSION: No evidence of DVT in bilateral lower extremity.\n\n\n" }, { "category": "Radiology", "chartdate": "2120-04-28 00:00:00.000", "description": "ABDOMEN U.S. (PORTABLE)", "row_id": 1010890, "text": " 10:30 PM\n ABDOMEN U.S. (PORTABLE) Clip # \n Reason: Please evaluate for e/o cholecystitis or other RUQ abnormali\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50 year old man with ARDS, sepsis, cardiogenic shock, with new fevers and\n hypotension with hypoxia with LFT abnormalities\n REASON FOR THIS EXAMINATION:\n Please evaluate for e/o cholecystitis or other RUQ abnormality\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 50-year-old man with ARDS and sepsis and new onset of hypotension\n and LFT abnormalities. Please evaluate for cholecystitis or other right upper\n quadrant abnormalities.\n\n Comparison is made to the recent CT of the torso performed on .\n\n Limited ultrasound of the right upper quadrant area was performed. Due to\n presence of the PEG tube, evaluation of the epigastrium was not possible. The\n liver has normal echogenicity with no focal lesion. The gallbladder contains\n sludge with no evidence of cholecystitis. No evidence of intra- and extra-\n hepatic bile duct dilatation is noted. The CBD is not dilated and measures 3\n mm. No evidence of ascites is noted within the right upper quadrant area.\n\n IMPRESSION:\n 1. Gallbladder sludge with no evidence of cholecystitis.\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2120-04-30 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1011065, "text": " 3:11 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Please evaluate for interval change, ? pulmonary edema\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50 year old man with pulmonary fibrosis, sepsis, hypoxia, RV dysfunction.\n REASON FOR THIS EXAMINATION:\n Please evaluate for interval change, ? pulmonary edema\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Pulmonary fibrosis with sepsis and hypoxia, to evaluate for change.\n\n FINDINGS: In comparison with the study of , there is little overall\n change. There is persistent diffuse prominence of interstitial markings\n consistent with the clinical diagnosis of severe interstitial fibrosis. No\n definite acute focal infiltrate is appreciated. Tubes remain in place.\n\n\n" }, { "category": "Radiology", "chartdate": "2120-04-16 00:00:00.000", "description": "BY SAME PHYSICIAN", "row_id": 1009176, "text": " 9:29 AM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: eval OG tube placement\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50 year old man with metastatic RCC now with respiratory failure s/p intubation\n REASON FOR THIS EXAMINATION:\n eval OG tube placement\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: Single portable AP chest radiograph.\n\n INDICATION: Metastatic renal cell carcinoma with respiratory failure.\n Evaluate orogastric tube placement.\n\n FINDINGS: Right internal jugular central venous catheter tip overlies right\n cavoatrial junction. Endotracheal tube tip is 5 cm from the carina. New\n orogastric tube tip and side port overlie the stomach. Bibasilar opacities\n have improved suggesting pulmonary edema as a cause. Diffuse honeycombing.\n\n IMPRESSION: Standard placement of orogastric tube with tip at the pylorus.\n Improved bibasilar opacities suggest improving pulmonary edema.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2120-04-29 00:00:00.000", "description": "R UNILAT UP EXT VEINS US RIGHT", "row_id": 1010988, "text": " 1:39 PM\n UNILAT UP EXT VEINS US RIGHT; -59 DISTINCT PROCEDURAL SERVICE Clip # \n Reason: Please evaluate for thrombosis in R-subclavian/IJ\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50 year old man with interstitial pulm fibrosis, vent failure, sepsis, w/ R-IJ\n clot by ultrasound.\n REASON FOR THIS EXAMINATION:\n Please evaluate for thrombosis in R-subclavian/IJ\n ______________________________________________________________________________\n FINAL REPORT\n RIGHT UPPER EXTREMITY VENOUS ULTRASOUND\n\n COMPARISON: None.\n\n HISTORY: 50-year-old male with interstitial pulmonary fibrosis, respiratory\n failure, and sepsis.\n\n FINDINGS: Within the right IJ, there is an echogenic focus partially\n obstructing the lumen consistent with a clot. Some flow is seen around this\n lesion. The IJ is unable to be compressed. Within the right subclavian, a\n PICC line is identified with flow around this line. There is normal\n compression of the right subclavian vein. The right axillary, brachial, and\n cephalic veins demonstrate normal compressibility and flow.\n\n IMPRESSION: Partial thrombosis of the right internal jugular vein with lack\n of compressibility and echogenic focus within the lumen is identified.\n\n These findings were communicated to Dr. at the time of review.\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2120-04-29 00:00:00.000", "description": "BILAT LOWER EXT VEINS", "row_id": 1010989, "text": " 1:40 PM\n BILAT LOWER EXT VEINS Clip # \n Reason: Evaluate for DVT\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50 year old man with new hypoxia, low-moderate suspicion for PE\n REASON FOR THIS EXAMINATION:\n Evaluate for DVT\n ______________________________________________________________________________\n FINAL REPORT\n BILATERAL LOWER EXTREMITY VENOUS ULTRASOUND\n\n COMPARISON: .\n\n -scale and Doppler son of bilateral common femoral, superficial\n femoral, and popliteal veins were performed. There is normal compressibility,\n flow, and augmentation.\n\n IMPRESSION: No evidence of DVT.\n\n\n" }, { "category": "Radiology", "chartdate": "2120-04-28 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1010868, "text": " 4:10 PM\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \n Reason: 42cm DL R basilic PICC placed - ? tip\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50 year old man with\n REASON FOR THIS EXAMINATION:\n 42cm DL R basilic PICC placed - ? tip\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: PICC line placed, check position.\n\n The exact position of the PICC line cannot be exactly determined. I think it\n lies in the mid-to-lower SVC. The left IJ line has been withdrawn.\n\n IMPRESSION: Exact position of PICC line uncertain but probably lies in lower\n SVC.\n\n\n" }, { "category": "Radiology", "chartdate": "2120-04-19 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1009636, "text": " 6:59 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please eval tubes, lines, for interval change\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50 year old man with COPD/pulm fibrosis and met RCC with sepsis\n REASON FOR THIS EXAMINATION:\n please eval tubes, lines, for interval change\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 50-year-old man with sepsis, and history of COPD, pulmonary\n fibrosis and metastatic renal cell cancer.\n\n COMPARISON: .\n\n SINGLE SEMI-UPRIGHT VIEW OF THE CHEST AT APPROXIMATELY 7 a.m.: This exam is\n largely unchanged from the prior exam. Endotracheal tube, nasogastric tube,\n feeding tube, and right internal jugular catheter are all in unchanged\n positions. Again, the feeding tube terminates above the GE junction.\n\n Lung volumes remain low and widespread interstitial thickening is consistent\n with diffuse fibrosis. A slight relative increase in air space opacity at the\n right lung base (most evident when in comparison to the scout film from the CT\n torso of ) is largely unchanged, as is a small right pleural effusion.\n\n" }, { "category": "Radiology", "chartdate": "2120-04-29 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1010912, "text": " 6:08 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for interval change\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Followup.\n\n COMPARISON: , 00:50 a.m.\n\n As compared to the previous radiograph, there is no major change. The extent\n and severity of the generalized mainly reticular opacities, the size of the\n cardiac silhouette is also unchanged. Unchanged position of the tracheostomy\n tube.\n\n\n" }, { "category": "Radiology", "chartdate": "2120-04-28 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1010818, "text": " 5:27 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for interval change\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50 year old man with hypoxia s/p trach/peg\n REASON FOR THIS EXAMINATION:\n eval for interval change\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Hypoxia, evaluate for change.\n\n CHEST:\n\n Comparison is made with the prior chest x-ray of . Current film is\n taken with less rotation than the prior chest x-ray. Allowing for this, there\n has been no significant change in the appearances within the lungs. Chronic\n interstitial changes are again noted. No evidence of acute failure or\n pneumonia is seen. The position of the tracheostomy tube remains\n satisfactory. A left IJ line is present with the tip in the distal SVC.\n\n IMPRESSION: No change.\n\n\n" }, { "category": "Radiology", "chartdate": "2120-04-17 00:00:00.000", "description": "PORTABLE ABDOMEN", "row_id": 1009451, "text": " 8:48 PM\n PORTABLE ABDOMEN Clip # \n Reason: evaluate for obstruction\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50 year old man with abdominal distension and high residuals and no BMs.\n REASON FOR THIS EXAMINATION:\n evaluate for obstruction\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Abdominal distention and high residuals, query obstruction.\n\n COMPARISON: and CT of .\n\n ABDOMEN, SINGLE VIEW: Surgical clips are seen projecting over the left\n abdomen consistent with a left nephrectomy and lymph node clearance. Expansile\n lytic lesions are seen in the pubic rami bilaterally as demonstrated in the\n prior CT. There is a relative gasless abdomen.\n\n IMPRESSION: No radiographic evidence for bowel obstruction but gasless\n abdomen raises the possibility of fluid filled loops which, if distended,\n would not be seen radiographically.\n\n" }, { "category": "Radiology", "chartdate": "2120-04-20 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1009769, "text": " 4:57 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval tubes, lines and for interval change\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50 year old man with COPD/pulm fibrosis and met RCC with sepsis\n REASON FOR THIS EXAMINATION:\n eval tubes, lines and for interval change\n ______________________________________________________________________________\n FINAL REPORT\n CHEST PORTABLE\n\n HISTORY: COPD and pulmonary fibrosis with sepsis. Evaluate lines and\n interval change.\n\n FINDINGS: Single frontal view of the chest is markedly limited in that a\n large portion of the left lung is excluded. Comparison is made to prior study\n . Endotracheal tube and right internal jugular central venous catheter\n are in place. ET tube terminates at the level of clavicular heads.\n Nasogastric tube and feeding tubes are seen in the esophagus. The NG tube\n extends into the stomach. The feeding tube terminates at the GE junction and\n should be advanced. Diffuse interstitial thickening is again noted,\n consistent with known pulmonary fibrosis. Bony structures are unchanged.\n\n IMPRESSION: Feeding tube terminates at the GE junction, and should be\n advanced. Findings discussed with the covering house officer, Dr.\n at time of interpretation.\n\n\n" }, { "category": "Radiology", "chartdate": "2120-04-30 00:00:00.000", "description": "P RENAL U.S. PORT", "row_id": 1011134, "text": " 12:57 PM\n RENAL U.S. PORT; -59 DISTINCT PROCEDURAL SERVICE Clip # \n DUPLEX DOP ABD/PEL LIMITED\n Reason: RCC RULE OUT THROMBUS AND ARF\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50 year old man with RCC on heparin and ARF, likely from hypotension (ATN), r/o\n clot given on anticoagulation\n REASON FOR THIS EXAMINATION:\n r/o thrombus\n ______________________________________________________________________________\n FINAL REPORT\n RENAL ULTRASOUND, PORTABLE\n\n INDICATION: 50-year-old man with RCC, on heparin and ARF likely from\n hypertension, rule out clot given on anticoagulation.\n\n RENAL ULTRASOUND: The patient is status post left nephrectomy. The right\n kidney measures 12.6 cm. There is no hydronephrosis. A 2.2-cm solid mass is\n seen in the upper pole of the right kidney, corresponding to the finding on\n CT. Doppler examination demonstrates normal arterial and venous flow with\n normal resistive indices. A small amount of free fluid is seen in the pelvis\n superior to the bladder.\n\n IMPRESSION:\n 1. Normal examination of the right kidney. In particular, no evidence for\n renal vein thrombosis.\n 2. Status post left nephrectomy.\n 3. Small amount of ascites in the pelvis.\n\n\n" }, { "category": "Radiology", "chartdate": "2120-04-27 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1010716, "text": " 4:59 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for infiltrate\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50 year old man with fever, trach\n REASON FOR THIS EXAMINATION:\n eval for infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n PROCEDURE: Chest portable AP on .\n\n COMPARISON: .\n\n HISTORY: 50-year-old man with fever, evaluate for infiltrate.\n\n FINDINGS:\n\n On today's examination, there is worsening opacification seen in both lungs,\n predominantly in the mid and lower regions. The chronic interstitial lung\n disease is stable. The heart size is within normal limits. Minimal IF\n present pleural effusion is again noted with no change. The ET tube is 4.6 cm\n from the carina.\n\n IMPRESSION:\n\n 1. The acute changes noted in both lungs favor edema, although aspiration\n cannot be completely excluded.\n\n 2. Chronic interstitial lung fibrotic disease.\n\n\n\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2120-04-29 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1010973, "text": " 12:28 PM\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \n Reason: line placement\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50 year old man with pulm fibrosis now w/ sepsis. Please evaluate for line\n placement, and interval change\n REASON FOR THIS EXAMINATION:\n line placement\n ______________________________________________________________________________\n FINAL REPORT\n PROCEDURE: Chest portable for line placement, .\n\n COMPARISON: Multiple previous chest radiographs including most recent\n performed six hours earlier.\n\n HISTORY: 50-year-old man with pulmonary fibrosis, now with sepsis. Evaluate\n for line placement and interval change.\n\n FINDINGS:\n\n A newly placed left internal jugular line terminates in the upper one-third of\n the SVC in a satisfactory location, no pneumothorax. Tracheostomy tube has\n tip at approximately 4.5 cm from the carina. Since the examination,\n there is mild increased opacity in both lungs superimposed to a known\n pulmonary fibrosis. Minimal right pleural effusion is again seen. Heart size\n is within normal limits.\n\n IMPRESSION:\n\n 1. Status post placement of a left internal line in satisfactory location. No\n pneumothorax\n\n 2. Mild difuse increased in lung opacity since examination might\n indicate superimposed process such as pneumonia or edema. Known fibrosis\n Of note there is no change from the study performed six hours earlier\n\n" }, { "category": "Radiology", "chartdate": "2120-04-22 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1009974, "text": " 5:26 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? interval change, tube/line placement.\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50 year old man with pulm fibrosis/emphysema, hypoxemic respiratory failure,\n doboff and esophageal balloon in place.\n REASON FOR THIS EXAMINATION:\n ? interval change, tube/line placement.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Hypoxemia.\n\n A single portable radiograph of the chest demonstrates nasogastric tube with\n its tip in the stomach. The second tube coursing along the esophagus\n represents an esophageal balloon. The tube tip is again seen at the level of\n the GE junction. The remaining support lines are unchanged. Abnormal\n interstitial pattern, bilateral pleural effusions, and airspace opacities\n involving both lungs remain unchanged. No pneumothorax. The\n cardiomediastinal contours are similar to that seen on the chest radiograph\n obtained five hours prior. Surgical staples project over the epigastrium.\n\n IMPRESSION:\n\n No interval change.\n\n\n" }, { "category": "Radiology", "chartdate": "2120-04-18 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1009480, "text": " 5:42 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please eval for interval change\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50 year old man with COPD/pulm fibrosis and met RCC with sepsis\n REASON FOR THIS EXAMINATION:\n please eval for interval change\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST OF \n\n COMPARISON: .\n\n INDICATION: Pulmonary fibrosis. Sepsis.\n\n Endotracheal tube and nasogastric tube are in standard position, but the\n feeding tube tip terminates just above the level of the diaphragm and could be\n advanced for standard positioning. Widespread pulmonary fibrosis is again\n demonstrated. New area of heterogeneous coalescing opacification is present\n in the right lower lobe, partially obscuring the right hemidiaphragm, and\n raising concern for either aspiration or an evolving infection. Persistent\n adjacent small right pleural effusion.\n\n\n" }, { "category": "Radiology", "chartdate": "2120-04-17 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1009333, "text": " 8:13 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? interval change\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50 year old man with COPD/pulm fibrosis and met RCC with sepsis\n REASON FOR THIS EXAMINATION:\n ? interval change\n ______________________________________________________________________________\n FINAL REPORT\n PROCEDURE: Chest portable AP on .\n\n COMPARISON: and .\n\n HISTORY: 50-year-old man with COPD and pulmonary fibrosis and metastases of\n renal cell carcinoma with sepsis, evaluate for interval change.\n\n FINDINGS:\n\n The patient has extensive chronic interstitial lung disease, predominantly\n seen in the upper lobes. In the right mid lung, the previously noted\n opacification has almost resolved on today's examination. The heart size is\n unremarkable. There is bilateral small pleural effusion and mild bibasilar\n atelectasis. A feeding tube is seen within a nasogastric drainage tube. The\n feeding tube tip is at the GE junction. The endotracheal tube is 4 cm from\n the carina. A right internal jugular line tip is unchanged in the mid SVC.\n\n IMPRESSION:\n 1. The feeding tube needs to be advanced as it is at the GE junction.\n 2. Chronic interstitial lung disease with superimposed opacification in the\n right lung that has cleared representing aspiration.\n\n This case was discussed by phone with .\n\n\n" }, { "category": "Radiology", "chartdate": "2120-04-16 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1009124, "text": " 12:27 AM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: eval line position\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50 year old man with sepsis s/p central line\n REASON FOR THIS EXAMINATION:\n eval line position\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Central line placement, to evaluate position.\n\n FINDINGS: In comparison with the study of , diffuse bilateral pulmonary\n opacifications persist. There has been placement of a right IJ catheter that\n extends to the lower portion of the SVC.\n\n\n" }, { "category": "Radiology", "chartdate": "2120-04-25 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1010442, "text": " 4:10 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Please eval for interval change\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50 year old man with ARDS, pulm fibrosis, sepsis and cardiogenic shock\n REASON FOR THIS EXAMINATION:\n Please eval for interval change\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 50-year-old male with ARDS, pulmonary fibrosis, sepsis and\n cardiogenic shock. Evaluate for interval change.\n\n COMPARISON: .\n\n SINGLE SUPINE VIEW OF THE CHEST: The endotracheal tube is in similar position\n 4.5 cm from the carina. A right internal jugular catheter tip terminates over\n the lower SVC. The cardiomediastinal silhouette is stable. There is similar\n diffuse interstitial opacity bilaterally consistent with fibrosis with a\n notable area of increased opacity over the right mid to lower lung which may\n represent superimposed consolidation. There is no evidence of pulmonary\n edema.\n\n" }, { "category": "Radiology", "chartdate": "2120-04-23 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1010099, "text": " 6:01 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval lung fields, tubes and lines\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50 year old man with pulmonary hypertension presented with mixed septic and\n cardiogenic shock, intubated\n REASON FOR THIS EXAMINATION:\n eval lung fields, tubes and lines\n ______________________________________________________________________________\n FINAL REPORT\n\n HISTORY: Septic shock.\n\n FINDINGS: In comparison with study of , there is little overall change.\n Lung volumes remain low and there is again widespread interstitial thickening\n consistent with diffuse fibrosis. Increased opacification behind the heart\n persists. Various tubes remain in place.\n\n" }, { "category": "Echo", "chartdate": "2120-04-29 00:00:00.000", "description": "Report", "row_id": 69451, "text": "PATIENT/TEST INFORMATION:\nIndication: Hypotension. Sepsis. Left ventricular function.\nWeight (lb): 167\nBP (mm Hg): 116/66\nHR (bpm): 103\nStatus: Inpatient\nDate/Time: at 10:30\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\n Billing error corrected. No changes made in the findings. WJM\nThis study was compared to the prior study of .\n\n\nLEFT ATRIUM: Normal LA and RA cavity sizes.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.\n\nLEFT VENTRICLE: Normal LV wall thickness, cavity size and regional/global\nsystolic function (LVEF >55%). Estimated cardiac index is normal\n(>=2.5L/min/m2). No resting LVOT gradient.\n\nRIGHT VENTRICLE: Markedly dilated RV cavity. Severe global RV free wall\nhypokinesis. Abnormal systolic septal motion/position consistent with RV\npressure overload.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. Trace AR.\n\nMITRAL VALVE: Normal mitral valve leaflets with trivial MR. No MVP.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR. Moderate PA\nsystolic hypertension.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor subcostal views. Suboptimal\nimage quality as the patient was difficult to position. Suboptimal image\nquality - ventilator. Resting tachycardia (HR>100bpm). Left pleural 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%) The estimated cardiac index is normal (>=2.5L/min/m2). The right\nventricular cavity is markedly dilated with severe global free wall\nhypokinesis. There is abnormal systolic septal motion/position consistent with\nright ventricular pressure overload. The aortic valve leaflets (3) appear\nstructurally normal with good leaflet excursion and no aortic stenosis. Trace\naortic regurgitation is seen. The mitral valve appears structurally normal\nwith trivial mitral regurgitation. There is no mitral valve prolapse. There is\nmoderate pulmonary artery systolic hypertension. There is no pericardial\neffusion. There is a prominent left pleural effusion.\n\nCompared with the prior study (images reviewed) of , a prominent left\npleural effusion is now seen and the right ventricle may be slightly larger.\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": "Echo", "chartdate": "2120-04-16 00:00:00.000", "description": "Report", "row_id": 69527, "text": "PATIENT/TEST INFORMATION:\nIndication: Biventricular function. Hypertension. Pulmonary fibrosis. Renal cell carcinoma.\nWeight (lb): 167\nBP (mm Hg): 115/73\nHR (bpm): 90\nStatus: Inpatient\nDate/Time: at 11:19\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the report of the prior study (images not\navailable) of .\n\n\nLEFT ATRIUM: Normal LA size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. The patient is mechanically\nventilated. Cannot assess RA pressure.\n\nLEFT VENTRICLE: Normal LV wall thickness and cavity size. Suboptimal technical\nquality, a focal LV wall motion abnormality cannot be fully excluded. Overall\nnormal LVEF (>55%). Transmitral Doppler and TVI c/w Grade I (mild) LV\ndiastolic dysfunction. No resting LVOT gradient.\n\nRIGHT VENTRICLE: Markedly dilated RV cavity. Mild global RV free wall\nhypokinesis. Abnormal systolic septal motion/position consistent with RV\npressure overload.\n\nAORTA: Normal aortic diameter at the sinus level. Normal ascending aorta\ndiameter.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. Mild (1+) MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR. Moderate PA\nsystolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS.\nPhysiologic PR. Dilated main PA.\n\nPERICARDIUM: No pericardial effusion.\n\nConclusions:\nThe left atrium is normal in size. Left ventricular wall thicknesses and\ncavity size are normal. Due to suboptimal technical quality, a focal wall\nmotion abnormality cannot be fully excluded. Overall left ventricular systolic\nfunction is normal (LVEF>55%). Transmitral Doppler and tissue velocity imaging\nare consistent with Grade I (mild) LV diastolic dysfunction. The right\nventricular cavity is markedly dilated with mild global free wall hypokinesis.\nThere is abnormal systolic septal motion/position consistent with right\nventricular pressure overload. The aortic valve leaflets (3) appear\nstructurally normal with good leaflet excursion and no aortic regurgitation.\nThe mitral valve leaflets are mildly thickened. There is no mitral valve\nprolapse. Mild (1+) mitral regurgitation is seen. There is moderate-to-severe\npulmonary artery systolic hypertension. The main pulmonary artery is dilated.\nThere is no pericardial effusion.\n\nIMPRESSION: Moderate right ventricular dilation with mild global RV\nhypokinesis and abnormal septal motion consistent with pressure overload.\nModerate to severe pulmonary hypertension. Preserved overall left ventricular\nfunction.\n\nCompared with the report of the prior study (images unavailable for review) of\n, estimated pulmonary artery pressures now reflect moderate to severe\nPA hypertension (previously not determined). The right ventricle is now\ndilated and mildly hypokinetic with evidence of pressure overload.\n\n\n" }, { "category": "Radiology", "chartdate": "2120-04-15 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1009118, "text": " 10:06 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for infiltrate, position of ET tube\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50 year old man with metastatic renal CA presents with sepsis, currently\n intubated\n REASON FOR THIS EXAMINATION:\n eval for infiltrate, position of ET tube\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: Single portable AP chest radiograph.\n\n INDICATION: Metastatic renal cell carcinoma and known pulmonary fibrosis with\n sepsis.\n\n COMPARISON: Chest radiograph and CT torso .\n\n FINDINGS: New endotracheal tube tip lies 3.5 cm from the carina. There is\n diffuse pulmonary fibrosis and honeycombing again noted. Increased opacity in\n a bibasilar distribution. Given underlying disease, small effusions cannot be\n excluded. No pneumothorax is present. Surgical clips are again noted\n overlying the abdomen.\n\n IMPRESSION:\n\n 1. Standard placement of endotracheal tube.\n\n 2. New consolidation versus edema in nondistorted lower lobes.\n\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2120-04-20 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1009806, "text": " 10:48 AM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: incomplete image this morning, please include full chest\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50 year old man with ARDS, cardiogenic shock, sepsis\n REASON FOR THIS EXAMINATION:\n incomplete image this morning, please include full chest\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Sepsis.\n\n A single portable radiograph of the chest is submitted. The right hemithorax\n is excluded. Again seen is a diffuse abnormal interstitial pattern,\n unchanged. The support lines remain in similar position, allowing for\n differences in patient orientation. No pneumothorax is detected. There is\n mild blunting of the left costophrenic angle. Surgical clips again project\n over the epigastrium and left upper quadrant.\n\n IMPRESSION:\n\n Persistent abnormal interstitial pattern. Diagnostic considerations include\n pulmonary fibrosis.\n\n Support lines unchanged, allowing for differences in patient positioning. The\n feeding tube is again noted to terminate at the GE junction. The feeding tube\n should be advanced.\n\n\n" }, { "category": "ECG", "chartdate": "2120-04-26 00:00:00.000", "description": "Report", "row_id": 165996, "text": "Sinus rhythm with diffuse ST-T wave changes. Compared to the previous tracing\nof the anterolateral ST-T wave changes are less prominent.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2120-04-26 00:00:00.000", "description": "Report", "row_id": 165997, "text": "Normal sinus rhythm. T wave inversions in leads V4-V6 are suggestive of\npossible anterolateral ischemia. Compared to the previous tracing the\nT wave abnormalities in the lateral precordial leads are new. Clinical\ncorrelation is suggested.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2120-04-25 00:00:00.000", "description": "Report", "row_id": 165998, "text": "Sinus bradycardia with non-specific ST-T wave abnormalities. Compared to the\nprevious tracing of no diagnostic interval change.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2120-04-23 00:00:00.000", "description": "Report", "row_id": 165999, "text": "Sinus tachycardia. Non-specific inferolateral ST-T wave changes. Compared to\nthe previous tracing of the rate has increased. There are non-specific\nST-T wave changes. Clinical correlation is suggested.\n\n" }, { "category": "ECG", "chartdate": "2120-04-22 00:00:00.000", "description": "Report", "row_id": 166000, "text": "Sinus bradycardia. Compared to the previous tracing of no major change.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2120-04-21 00:00:00.000", "description": "Report", "row_id": 166001, "text": "Sinus bradycardia. Anterior precordial T wave inversion. Compared to the\nprevious tracing of multiple abnormalities as previously noted persist\nwithout major change.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2120-04-29 00:00:00.000", "description": "Report", "row_id": 165995, "text": "Probable accelerated junctional rhythm. Non-specific ST-T wave changes.\nCompared to the previous tracing P waves are more difficult to discern.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2120-04-16 00:00:00.000", "description": "Report", "row_id": 162381, "text": "Sinus rhythm. Rightward axis. S1-Q3-T3 pattern. RSR' configuration\nin lead V1. Inferior and right precordial lead/anterior T wave abnormalities.\nFindings are non-specific but clinical correlation is suggested for possible\nright ventricular overload. Since the previous tracing of findings as\ndescribed are now present.\n\n" }, { "category": "Respiratory ", "chartdate": "2120-04-26 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 323764, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 12\n Ideal body weight: 69.9 None\n Ideal tidal volume: 279.6 / 419.4 / 559.2 mL/kg\n Airway\n Tube Trach\n Tracheostomy tube:\n Type: Standard, Cuffed, Perc Trach\n Manufacturer: Portex\n Size: 8.0mm\n PMV: No\n Management:\n Vol/Press:\n pressure: 50 cmH2O\n volume: mL /\n Airway problems: / valve leak\n Comments: Continuous leak, but able to keep Vt\n 350-500. IP and MD aware. ? To be changed out by IP today.\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Exp Wheeze\n LUL Lung Sounds: Crackles\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Blood Tinged / Thick\n Sputum source/amount: Suctioned / Scant\n Comment: Blood tinged plug taken out at beginning of shift.\n Plan\n Next 24-48 hours:\n Reason for continuing current ventilatory support: Pending procedure /\n OR, Cannot protect airway; Comments: ? to have trach changed out by IP.\n ? Need for longer trach\n" }, { "category": "Nutrition", "chartdate": "2120-04-16 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 322681, "text": "Subjective\n Patient intubated\n Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 173 cm\n 76.3 kg\n 76.3 kg ( 10:00 PM)\n 25\n Ideal body weight\n % Ideal body weight\n Adjusted weight\n Usual body weight\n % Usual body weight\n 70 kg\n 108\n Diagnosis: Sepsis\n PMH : metastatic renal cell carcinoma s/p nephrectomy, s/p mini allo\n SCT, IL-2, empysema/pulmonary fibrosis, ?GVHD/BOOP\n Food allergies and intolerances: Unable to assess\n Pertinent medications: senna/colace, folic acid, 2gm Calcium gluconate,\n fentanyl, versed, vasopressin, norepinephrine\n Labs:\n Value\n Date\n Glucose\n 67 mg/dL\n 03:31 AM\n Glucose Finger Stick\n 83\n 06:00 AM\n BUN\n 13 mg/dL\n 03:31 AM\n Creatinine\n 1.1 mg/dL\n 03:31 AM\n Sodium\n 143 mEq/L\n 03:31 AM\n Potassium\n 5.7 mEq/L\n 03:31 AM\n Chloride\n 116 mEq/L\n 03:31 AM\n Albumin\n 2.7 g/dL\n 03:31 AM\n Calcium non-ionized\n 6.1 mg/dL\n 03:31 AM\n Phosphorus\n 2.3 mg/dL\n 03:31 AM\n Ionized Calcium\n 1.06 mmol/L\n 01:08 PM\n Magnesium\n 1.9 mg/dL\n 03:31 AM\n Current diet order / nutrition support: NPO- Replete with fiber goal\n 70ml/hr - provides 1680kcal and 104g protein\n GI: Abdomen soft/distended with positive bowel sounds\n Assessment of Nutritional Status\n At risk for malnutrition\n Pt at risk due to: NPO / hypocaloric diet\n Estimated Nutritional Needs\n Calories: 1500-1900 (BEE x or / 20-25 cal/kg)\n Protein: 90-115 (1.2-1.5 g/kg)\n Fluid: per team\n Specifics:\n 50 year old male patient admitted with dyspnea x 2 weeks, transferred\n from OSH now intubated, septic. Consult received for tube feeding\n recommendations. Current tube feeding will provide adequate calorie and\n protein. Noted elevated potassium, will monitor for need to provide\n formula with less potassium. Will also monitor fluid status for need to\n change formula to more fluid restricted formula. Will follow patient\n closely.\n Medical Nutrition Therapy Plan - Recommend the Following\n 1. Start Replete with Fiber at 20ml/hr, advance by 20ml q6H to\n goal rate of 70ml/hr.\n 2. Monitor residuals q4H and hold if >150ml\n 3. Monitor lytes, replete PRN.\n 4. Monitor potassium, add kaexylate if remains elevated\n 13:45\n" }, { "category": "Physician ", "chartdate": "2120-04-19 00:00:00.000", "description": "ICU Attending Note", "row_id": 323053, "text": "Clinician: Attending\n 50 yo man with metastatic renal cell CA s/p allo- SCT with subsequent\n severe chronic resp failure thought to be emphysema and fibrosis of\n unclear etiology (CT from last spring demonstrates severe cystic and\n fibrotic changes with almost no normal appearing lung) presented with 2\n wk prodrome, now with catastrophic acute on chronic failure. CXR shows\n diffuse opacification. Severe septic shock. RV with global hypokinesis,\n dilated, mod-sev PAH\n Events:\n Weaned down Dobutamine to 1.0, remains off levophed, vasopressin.\n Afebrile\n Did not bronch due to resp events and sense that yield would be quite\n low given risk of procedure\n PC 16/PEEP12/0.5/34/TV500\n 7.39/40/113 this morning.\n Esoph balloon indicates transpulm pressure 10 and -2 mmHg.\n Exam sig for: arousable, reponds to voice with gaze despite fent\n 500/versed 12, no audible crackles, NABS, abd soft, minimal peripheral\n edema, no rashes\n - Cardiac index 3.6, based on vigileo, on Dobutamine 1.0\n mcg/kg/min\n - Remains afebrile\n - Stroke volume variability <10%, indicating adequately volume\n repleted (and possibly overloaded)\n - I/O 4/6.2L (2.2-)\n - WBC remains stable\n - No micro data\n Fent/Versed. H2blocker, hepsc, hydrocortisone 50mg q 6h, aspirin\n Abx: Vanco/Levoflox/Zosyn/Acyclovir/Bactrim/Caspofungin\n Admitted with what appeared to be septic picture, but now cardiogenic\n shock predominates. Resp failure much improved- TV much higher on lower\n driving pressure, PEEP much lower than on arrival.\n CARDIOGENIC SHOCK, PAH, RV FAILURE\n Doing well on captopril for afterload reduction, on low dose Dobutamine\n with great increase in cardiac index. Urine output is high at the\n moment, but if net +++ will consider adding Lasix gtt. Wean down\n dobutamine, following urine output and cardiac index.\n SEPTIC SHOCK\n No source identified for infection, may have been viral URI, but if he\n did have a component of septic shock, most likely source pneumonia. Was\n ruled out for influenza at OSH. Minimal respiratory secretions. Very\n broad coverage.\n Considering he was on bactrim for prophylaxis and not on steroids as\n outpt, risk for PCP very low. Will d/c Bactrim.\n D/C caspofungin.\n Continue vanc/zosyn/levoflox and prophylactic bactrim and acyclovir.\n Pending beta-glucan and galactomannan.\n RESP FAILURE\n Infection, sepsis, acute exacerbation of underlying chronic disease as\n well as cardiogenic shock, with severe PH and impaired LV filling and\n outflow.\n - reduce FiO2\n - switch from PC to AC vent if possible\n HYPOTENSION: multifactorial shock- cardiogenic, septic, possibly\n adrenal insufficiency.\n Wean down steroids to prednisone 50 .\n SEDATION\n Insufficiently sedated on extremely high dose fentanyl and versed.\n Start propofol. Add methadone 20mg IV tid and try to wean down/off\n fentanyl and versed. ECG while on methadone to observe QT interval.\n NUTRITION\n Has bowel sounds. Reattempt TF.\n HepSC, ranitidine, oral care, pneumoboots\n other issues per Dr note.\n Will meet with to update her on developments.\n Total time spent: 50 minutes\n Patient is critically ill.\n" }, { "category": "Nursing", "chartdate": "2120-04-19 00:00:00.000", "description": "Nursing Progress Note", "row_id": 323063, "text": "50 yo man with metastatic renal cell CA s/p allo- SCT with subsequent\n severe chronic resp failure thought to be emphysema and fibrosis of\n unclear etiology (CT from last spring demonstrates severe cystic and\n fibrotic changes with almost no normal appearing lung) presented with 2\n wk prodrome, now with catastrophic acute on chronic failure. CXR shows\n diffuse opacification. Severe septic shock. RV with global hypokinesis,\n dilated, mod-sev PAH. Trop peaked at 1.98 at OSH, highest here was\n 0.49. No longer thought to have PCP, Bactrim D/C\nd, back on\n prophylactic dose. Weaning steroids.\n Heart failure, right, isolated (Cor Pulmonale)\n Assessment:\n Currently on Dobuta at 1.0 mcg/kg/min. C.O. 4\ns-5. C.I. 2.6-3.4\n edema noted\n Action:\n No changes made to dobuta. Captopril 6.25mg given.\n Response:\n SBP 110\ns-140\ns. HR low 60\n110.\n Plan:\n Con\nt to monitor C.I. and C.O. via Vigileo monitor. Con\nt to titrate\n dobuta for C.I. >2.5\n Respiratory failure, acute (not ARDS/)\n Assessment:\n L.S course with diminished bases. Vent settings on PCV/40% fio2/34/12\n PEEP. O2 sats 93-97% - breathing in sync with vent\n Action:\n Fio2 lowered to 40% from 50%. ABG done. Suctioned for small amt brown\n think sputum. Methadone 20mg/hr q4h started to help with sedation and\n encourage synchronisity with the vent. Fent 500, Versed 12.\n Response:\n ABG: Pt. appears more comfortable and tolerateds turns better.\n Plan:\n Con\nt to monitor sats and ABG\ns. Wean vent as tolerated.\n" }, { "category": "General", "chartdate": "2120-04-17 00:00:00.000", "description": "ICU Event Note", "row_id": 322805, "text": "Clinician: Attending\n 50 yo man with metastatic renal cell CA s/p allo- SCT with subsequent\n severe chronic resp failure thought to be emphysema and fibrosis and\n possible GVHD/BOOP (CT from last spring demonstrates severe cystic and\n fibrotic changes with almost no normal appearing lung) presented with 2\n wk prodrome, now with catastrophic acute on chronic failure. CXR shows\n diffuse opacification. Severe septic shock, now on 2 pressors. Not\n recently on corticosteroids.\n Overnight events:\n - weaned off levophed, but restarted\n - LENI negative\n - RV with global hypokinesis, dilated, mod-sev PAH.\n - Cardiac index decreased from 2.8 to 2.0, approximately\n - I/O 5.5/0.8\n - PCV FiO2 0.6/24/PEEP 16/ TV 450ish 7.32/38/115, (7/27/43/111\n when on 0.8)\n - Remains paralyzed on cisatracurium\n - No new culture data. Legionella urine Ag negative.\n - WBC 20\n - HCO3 22\n - LDH increased from 505\n 856\n Fent 350/Versed 6. H2blocker, hepsc, hydrocortisone 50mg q 6h.\n Abx: Vanco/Levoflox/Vanco/Acyclovir/Bactrim/Caspofungin\n SEPTIC SHOCK\n Most likely source pneumonia. R/O for influenza at OSH.\n Cx pending. Markers pending.\n Bronch will probably not allow us to change his management- given his\n >48 of broad spectrum abx the most likely organism we will be able to\n obtain (if present) is PCP. the severity of his presentation I am\n not sure we will be able to remove any of his antibiotics, as he is\n improved.\n RESP FAILURE\n Infection, sepsis, acute exacerbation of underlying chronic disease as\n well as cardiogenic shock, with severe PH and impaired LV filling and\n outflow.\n - oxygenation currently adequate on high PEEP, with improved FiO2\n - stop paralysis and redose with boluses as needed\n - rescue strategy in some patients includes inhaled prostacyclin or NO,\n though he given his underlying severe lung disease these agents will\n probably worsen his hypoxia via worsened V/Q mismatch/shunt. Not\n indicated in PAH caused by pulm fibrosis, which is probably the major\n etiology of his PH, compounded by ARDS.\n - will trial Dobutamine, knowing that will have to likely increase\n norepinephrine.\n HYPOTENSION\n Septic and cardiogenic shock and RV failure. Has one adrenal gland with\n metastatic lesion.\n Fluid resuscitation. Received high dose steroids at OSH. Continuing\n high dose hydrocortisone.\n CARDIAC\n Severe PH with hypokinetic and dilated RV.\n Continue to check ECGs, cardiac enzymes.\n Aspirin.\n SEDATION with fent 350 /versed 6\n COLD FOOT- resolved- now warm bilaterally.\n other issues per Dr note.\n Total time spent: 60 minutes\n Patient is critically ill.\n" }, { "category": "Nursing", "chartdate": "2120-04-18 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 322962, "text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt vent dependent\n Action:\n Attempted to change mode of ventilation to A/C\n Response:\n Pt unable to tolerate volume mode able to decrease Peep to 12\n Plan:\n Cont to wean mech vent as tol\n Heart failure, right, isolated (Cor Pulmonale)\n Assessment:\n On dobutamine gtt off pressors, BP stable\n Action:\n Decreased dobutomine by 20%\n Response:\n Maint CI as well as BP\n Plan:\n Cont homdynamic monitering\n" }, { "category": "General", "chartdate": "2120-04-18 00:00:00.000", "description": "ICU Event Note", "row_id": 322965, "text": "Clinician: Attending\n Met with pt's wife and updated on his condition, management\n plans, answered all questions. Then met with with their daughter\n and explained the situation to her as well.\n Total time spent: 30 minutes\n Patient is critically ill.\n" }, { "category": "Nursing", "chartdate": "2120-04-20 00:00:00.000", "description": "Nursing Progress Note", "row_id": 323126, "text": "Heart failure, right, isolated (Cor Pulmonale)\n Assessment:\n SBP >130 and UO > 100cc/hr\n Action:\n Dobutamine weaning attempted @2300, Restarted @ 2330 0.3mcg/kg/min\n Response:\n Bradycardic to 45, CI <2.4 when dobutamine turned off\n Plan:\n Wean dobutamine, Goal CI >2.5, UO >40cc/hr\n Respiratory failure, acute (not ARDS/)\n Assessment:\n During personal care pt became awake moved UE and fighting on vent and\n desated to 80\n Action:\n Suctioned for thick yellow sec. Fio2 increased to 50%\n Response:\n Sats picked up to 92%\n Plan:\n Cont vent support and ABG in AM\n Pt is sedated on vent. Fentanyl wean to 400mcg/hr, versed cont as\n 10mg/hr. Pt awakened while doing personal care Open eyes but does not\n follow commands. Moved UE, No movements on LE noted. Fighting on vent\n and desated to 80\ns suctioned for yellow thick sec and Fio2 increased\n to 50% and received fentanyl bolus w/ that ha calms down, sats improved\n to 92% . Tube feeding replete w/ fiber 10cc/hr started @ 0200.\n" }, { "category": "Nutrition", "chartdate": "2120-04-19 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 323028, "text": "Subjective\n Patient intubated\n Objective\n Pertinent medications: dobutamine, fentanyl, versed\n Labs:\n Value\n Date\n Glucose\n 98 mg/dL\n 04:30 AM\n Glucose Finger Stick\n 125\n 06:00 AM\n BUN\n 22 mg/dL\n 04:30 AM\n Creatinine\n 1.0 mg/dL\n 04:30 AM\n Sodium\n 145 mEq/L\n 04:30 AM\n Potassium\n 4.2 mEq/L\n 04:30 AM\n Chloride\n 113 mEq/L\n 04:30 AM\n Albumin\n 2.7 g/dL\n 03:31 AM\n Calcium non-ionized\n 8.0 mg/dL\n 04:30 AM\n Phosphorus\n 2.5 mg/dL\n 04:30 AM\n Ionized Calcium\n 1.12 mmol/L\n 04:52 AM\n Magnesium\n 2.3 mg/dL\n 04:30 AM\n Current diet order / nutrition support: TPN - quickmix\n GI: Abdomen firm/distended with hypoactive bowel sounds\n Assessment of Nutritional Status\n Specifics:\n 50 year old male with metastatic renal cell carcinoma s/p nephrectomy,\n s/p allo-SCT, emphysema/pulmonary fibrosis on home 02 presenting with\n sepsis. Patient started on enteral nutrition, but was not tolerating\n with high residuals ?d/t ileus. Patient had TPN started last night.\n Recommend continuing with TPN until ileus resolves. Goal TPN is 1.7L\n (280gdex/ 100gAA/35g lipids) if TG<400. Provides 1702kcal and 100g\n protein. Consider aggressive bowel regimen and once ileus resolved,\n restart TF of Replete with Fiber to goal rate of 70ml/hr.\n Medical Nutrition Therapy Plan - Recommend the Following\n 1. TPN: day one standard TPN with non-standard lytes (20NaPO4,\n 10KAc, 10KPO4, 10Mg, 9Ca)\n 2. Please check TG to assess if lipids can be added to TPN\n 3. Once ileus resolved, start Replete with Fiber at 10ml/hr,\n advance by 20ml q6H to goal rate of 70ml/hr\n 10:15\n" }, { "category": "Physician ", "chartdate": "2120-04-19 00:00:00.000", "description": "ICU Attending Note", "row_id": 323029, "text": "Clinician: Attending\n 50 yo man with metastatic renal cell CA s/p allo- SCT with subsequent\n severe chronic resp failure thought to be emphysema and fibrosis of\n unclear etiology (CT from last spring demonstrates severe cystic and\n fibrotic changes with almost no normal appearing lung) presented with 2\n wk prodrome, now with catastrophic acute on chronic failure. CXR shows\n diffuse opacification. Severe septic shock. RV with global hypokinesis,\n dilated, mod-sev PAH. Trop peaked at 1.98 at OSH, highest here was\n 0.49.\n Events:\n Weaned down Dobutamine to 1.0, remains off levophed, vasopressin.\n Afebrile\n Did not bronch due to resp events and sense that yield would be quite\n low given risk of procedure\n PC 16/PEEP12/0.5/34/TV500\n 7.39/40/113 this morning.\n Esoph balloon indicates transpulm pressure 10 and -2 mmHg.\n Exam sig for: arousable, reponds to voice with gaze despite fent\n 500/versed 12, no audible crackles, NABS, abd soft, minimal peripheral\n edema, no rashes\n - Cardiac index 3.6, approximately, based on vigileo, on\n Dobutamine 1.0 mcg/kg/min\n - Remains afebrile\n - Stroke volume variability <10%, indicating adequately volume\n repleted (and possibly overloaded)\n - I/O 4/6.2L (2.2-)\n - WBC remains stable\n - No micro data\n Fent/Versed. H2blocker, hepsc, hydrocortisone 50mg q 6h, aspirin\n Abx: Vanco/Levoflox/Zosyn/Acyclovir/Bactrim/Caspofungin\n Admitted with what appeared to be septic picture, but now cardiogenic\n shock predominates. Resp failure much improved- TV much higher on lower\n driving pressure, PEEP much lower than on arrival.\n CARDIOGENIC SHOCK, PAH, RV FAILURE\n Doing well on captopril for afterload reduction, on low dose Dobutamine\n with great increase in cardiac index. Urine output is high at the\n moment, but if net +++ will consider adding Lasix gtt. Wean down\n dobutamine, following urine output and cardiac index.\n SEPTIC SHOCK\n Most likely source pneumonia. R/O for influenza at OSH.\n Very broad coverage.\n Considering he was on bactrim for prophylaxis and not on steroids as\n outpt, risk for PCP very low. Will d/c Bactrim.\n D/C caspofungin.\n Continue vanc/zosyn/levoflox and prophylactic bactrim and acyclovir.\n Pending beta-glucan and galactomannan.\n RESP FAILURE\n Infection, sepsis, acute exacerbation of underlying chronic disease as\n well as cardiogenic shock, with severe PH and impaired LV filling and\n outflow.\n - reduce FiO2\n - switch from PC to AC vent if possible\n HYPOTENSION: multifactorial shock- cardiogenic, septic, possibly\n adrenal insufficiency.\n Wean down steroids to prednisone 50 .\n SEDATION\n Insufficiently sedated on extremely high dose fentanyl and versed.\n Start propofol. Add methadone 20mg IV tid and try to wean down/off\n fentanyl and versed. ECG while on methadone to observe QT interval.\n NUTRITION\n Has bowel sounds. Reattempt TF.\n HepSC, ranitidine, oral care, pneumoboots\n other issues per Dr note.\n Will meet with to update her on developments.\n Total time spent: 50 minutes\n Patient is critically ill.\n" }, { "category": "Physician ", "chartdate": "2120-04-19 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 323047, "text": "Chief Complaint: 50M h/o metastatic renal CA s/p nephrectomy, IL-2,\n mini-allograft SCT, DLI x 2 last in , emphysema/pulmonary fibrosis\n on home 02 presents with hypotension, fevers, hypoxemic respiratory\n failure.\n 24 Hour Events:\n -dysynchronous on vent after rounds when on SIMV, put back on pressure\n control with normalization of ABG. Did well for most of the day.\n Overnight had mucous plugging with suctioning of sm amount thick\n sputum, after which pt transiently became dyscynchronous requiring\n increased sedation. PEEP increased to 12 from 10, Fi02 increased from\n 40% to 50%, driving pressure increased from 13 to 16, although down\n from 24 yesterday am.\n -decreased SVR, increased CO/CI after initiating ACEI, trial of\n decreasing dobutamine.\n -great UOP 100-200 cc/hour, no lasix for now\n -KUB read, no SBO\n Allergies:\n Flagyl (Oral) (Metronidazole)\n Rash;\n Last dose of Antibiotics:\n Levofloxacin - 10:14 AM\n Acyclovir - 04:30 PM\n Vancomycin - 08:15 PM\n Piperacillin/Tazobactam (Zosyn) - 10:13 PM\n Bactrim (SMX/TMP) - 12:02 AM\n - 03:58 AM\n Infusions:\n Dobutamine - 1 mcg/Kg/min\n Midazolam (Versed) - 12 mg/hour\n Fentanyl - 500 mcg/hour\n Other ICU medications:\n Famotidine (Pepcid) - 07:43 PM\n Heparin Sodium (Prophylaxis) - 09:00 PM\n Other medications:\n ISS\n ASA 325mg daily\n Docusate\n Chlorhexidine\n Folic Acid\n Hydrocortisone 50mg IV Q6\n Captopril 6.25 Po TID\n Senna\n PRN:\n Albuterol\n Bisacodyl\n Acetaminophen\n Changes to medical and family history: None\n Review of systems is unchanged from admission except as noted below\n Review of systems: Unchanged, intubated and deeply sedated\n Flowsheet Data as of 05:28 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.4\nC (97.5\n Tcurrent: 35.9\nC (96.6\n HR: 74 (54 - 101) bpm\n BP: 142/70(92) {117/57(76) - 155/75(98)} mmHg\n RR: 34 (30 - 34) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 76.3 kg (admission): 76.3 kg\n Height: 68 Inch\n CVP: 18 (15 - 41)mmHg\n CO/CI (CCO): (5.7 L/min) / (3.0 L/min/m2)\n SVV 12%\n SVR: 926\n Total In:\n 4,090 mL\n 1,462 mL\n PO:\n TF:\n 163 mL\n IVF:\n 3,555 mL\n 1,104 mL\n Blood products:\n Total out:\n 6,200 mL\n 820 mL\n Urine:\n 6,090 mL\n 820 mL\n NG:\n 110 mL\n Stool:\n Drains:\n Balance:\n -2,110 mL\n 642 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: PCV+Assist\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 260 (260 - 260) mL\n PC : 16 cmH2O\n PS : 5 cmH2O\n RR (Set): 34\n PEEP: 12 cmH2O\n FiO2: 50%\n PIP: 39 cmH2O\n Plateau: 30 cmH2O\n SpO2: 96%\n ABG: 7.39/40/113//0\n Ve: 15.4 L/min\n PaO2 / FiO2: 226\n Physical Examination\n General Appearance: Intubated, sedated\n Eyes / Conjunctiva: sclera anicteric, conjunctiva non-injected, PERRL\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, esophageal\n balloon, NGT\n Cardiovascular: (S1: Normal), (S2: Normal, Fixed), tachycardic. regular\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:\n Rhonchorous: ), coarse mechanical BS throughout all lung fields\n Abdominal: Soft, Non-tender, hypoactive bowel sounds\n Extremities: no edema, palpable distal pulses\n Skin: Warm and dry, evidence of cutaneous GVHD on abdomen with\n sclerodermal changes.\n Labs / Radiology\n 130 K/uL\n 98 mg/dL\n 1.0\n 24 mEq/L\n 4.2 mEq/L\n 22 mg/dL\n 113 mEq/L\n 145 mEq/L\n 31.8\n 13.5 K/uL\n [image002.jpg]\n Micro:\n Bcx x2 NGTD\n Ucx: No growth\n CXR : New area of heterogeneous coalescing opacification in the\n RLL partially obscuring R hemidiaphragm, concerning for aspiration or\n evolving infection. Persistent R pleural effusion. Feeding tube tip\n terminates just above the level of the diaphragm and could be advanced\n 12:20 AM\n 04:38 AM\n 05:01 AM\n 11:22 AM\n 12:10 PM\n 02:14 PM\n 08:25 PM\n 10:25 PM\n 03:04 AM\n 04:46 AM\n WBC\n 12.3\n Hct\n 33.6\n Plt\n 124\n Cr\n 1.1\n TCO2\n 22\n 23\n 23\n 23\n 22\n 23\n 24\n 26\n 25\n Glucose\n 99\n Other labs: PT / PTT / INR:14.5/28.7/1.3, CK / CKMB /\n Troponin-T:260/9/0.22, ALT / AST:94/64, Alk Phos / T Bili:84/0.3,\n Amylase / Lipase:53/22, Differential-Neuts:67.0 %, Band:2.0 %,\n Lymph:18.0 %, Mono:9.0 %, Eos:0.0 %, Lactic Acid:1.7 mmol/L,\n Albumin:2.7 g/dL, LDH:274 IU/L, Ca++:8.0 mg/dL, Mg++:2.3 mg/dL, PO4:2.5\n mg/dL\n Assessment and Plan\n 50M h/o metastatic renal CA s/p nephrectomy, IL-2, mini-allograft SCT,\n DLI x 2 last in , emphysema/pulmonary fibrosis on home 02\n presented to OSH with hypoxic respiratory failure, fevers and\n hypotension.\n # Sepsis: On presentation to OSH pt hypotensive, hypoxic with fevers\n and leukocytosis. On arrival to ICU was intubated due to hypoxic\n respiratory failure and hypotensive requiring pressors. Likely\n pneumonia given hypoxia and possible opacities on CXR, although\n difficult to read due to fibrosis. No other apparent localizing\n symptoms. Ruled-out for flu at OSH. At this point, WBC and fever curve\n decreasing. Covered on broad spectrum antibiotics.\n - Legionella urine ag negative, all other cultures no growth to date.\n - Vanc, zosyn, levofloxacin, bactrim IV for PCP, to cover\n broadly given critical illness. As patient was on bactrim prophylaxis\n for PCP as outpatient and not on steroids, risk for PCP very low;\n therefore, will dc high dose bactrim and restart ppx dose.\n - D/C \n - Also on IV steroids for PCP and adrenal insufficiency, see below\n - Glucan, galactomannan pending\n - Follow WBC count, fever curve, decreasing\n - PPD negative\n - Continue acyclovir ppx, vanc/zosyn/levoflox\n # Respiratory failure: Pneumonia in patient with poor pulmonary reserve\n due to emphysema, ?GVHD, fibrosis.\n Pt tolerated decrease in PEEP and Fi02 yesterday. Attempted to switch\n to A/C, however pt less sedated off pressors and pulling large TV\n (~1600), dysynchronous with vent.\n - Back on pressure control for now, based on transpulmonary pressure\n (10 and -2), will titrate down FiO2 as tolerated today. Can consider\n changing to PSV or SIMV with low set respiratory rate if tolerated.\n -Off cisatracurium since . Currently sedated on midazolam and\n fentanyl on maximal doses. Will try trial of methadone to help\n decrease versed/fentanyl doses today. Attempt wean as tolerated.\n # Cardiogenic shock: Patient found to have PAH and RV failure on ECHO.\n Started on dobutamine with improvement in CI as well as pressures.\n Also started on captopril for afterload reduction which enabled\n decrease in dobutamine with continued improvement in hemodynamics.\n - Wean dobutamine today\n - Continue to monitor UOP and CI. If UOP decreases, will consider lasix\n drip if patient becomes very positive\n # Hypotension: Improved. Likely a mixed picture. Initially pt\n presentation of acute hypoxia with leukocytosis and fevers with\n hypotension made a septic shock picture predominate, however after\n adequate fluid rescusitation pt continued to require 2 pressors. His\n TTE and vigileo monitoring were consistent with low cardiac output due\n to pt\ns severe pulmonary hypertension due to pulmonary fibrosis and\n subsequent RV hypokinesis, a non-fluid responsive state. Dobutamine\n challenge resulted in increased CO to normal range with ability to be\n weaned off both levophed and vasopressin and addition of captopril\n which led to decreased afterload allowed decrease in dobutamine. Also,\n initial concern for adrenal insufficiency as patient has one adrenal\n gland with a metastasis, though he does not clinically appear to be\n functionally adrenally insufficient at this point. UOP remains high at\n ~100-200cc/hour.\n - Continue dobutamine\n - Continue HD monitoring with Vigileo device\n - Treat broadly for infection per above\n - IV hydrocort Q6 for adrenal insufficiency, will start wean today with\n 50mg q12, and subsequent wean over next few days.\n - Initially concerned for PE, however have more likley explanations for\n hypotension as listed above, LENIs negative\n - Guaiac stools, HCT has been stable.\n # Cardiac: Patient with probable demand ischemia in setting of\n hypotension, tachycardia, and sepsis; less likely unstable plaque.\n - CE\ns trending down, have stopped following.\n - ASA\n - ACEI as above for afterload reduction\n - Consider diuresis if UOP tapers off to further decrease preload.\n # Metastatic renal CA: Recurrent disease s/p donor lymphocyte\n transplant .\n - BMT to follow\n - Continue acyclovir ppx for now, will discuss with BMT\n ICU Care\n Nutrition: TF not at goal due to high residuals, will reduce fentanyl,\n colace/senna, consider lactulose/oral naloxone if ileus persists. TPN\n for now.\n Glycemic Control: ISS prn\n Lines:\n 20 Gauge - 09:10 PM\n Multi Lumen - 11:24 PM\n Arterial Line - 12:14 AM\n Prophylaxis:\n DVT: Hep SC, pneumoboots\n Stress ulcer: Ranitidine\n VAP: Chlorhexidine\n Comments:\n Communication: Comments: wife, \n Code status: Full code, have d/w family.\n Disposition: ICU\n" }, { "category": "Physician ", "chartdate": "2120-04-19 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 323050, "text": "Chief Complaint: 50M h/o metastatic renal CA s/p nephrectomy, IL-2,\n mini-allograft SCT, DLI x 2 last in , emphysema/pulmonary fibrosis\n on home 02 presents with hypotension, fevers, hypoxemic respiratory\n failure.\n 24 Hour Events:\n -dysynchronous on vent after rounds when on SIMV, put back on pressure\n control with normalization of ABG. Did well for most of the day.\n Overnight had mucous plugging with suctioning of sm amount thick\n sputum, after which pt transiently became dyscynchronous requiring\n increased sedation. PEEP increased to 12 from 10, Fi02 increased from\n 40% to 50%, driving pressure increased from 13 to 16, although down\n from 24 yesterday am.\n -decreased SVR, increased CO/CI after initiating ACEI, trial of\n decreasing dobutamine.\n -great UOP 100-200 cc/hour, no lasix for now\n -KUB read, no SBO\n Allergies:\n Flagyl (Oral) (Metronidazole)\n Rash;\n Last dose of Antibiotics:\n Levofloxacin - 10:14 AM\n Acyclovir - 04:30 PM\n Vancomycin - 08:15 PM\n Piperacillin/Tazobactam (Zosyn) - 10:13 PM\n Bactrim (SMX/TMP) - 12:02 AM\n - 03:58 AM\n Infusions:\n Dobutamine - 1 mcg/Kg/min\n Midazolam (Versed) - 12 mg/hour\n Fentanyl - 500 mcg/hour\n Other ICU medications:\n Famotidine (Pepcid) - 07:43 PM\n Heparin Sodium (Prophylaxis) - 09:00 PM\n Other medications:\n ISS\n ASA 325mg daily\n Docusate\n Chlorhexidine\n Folic Acid\n Hydrocortisone 50mg IV Q6\n Captopril 6.25 Po TID\n Senna\n PRN:\n Albuterol\n Bisacodyl\n Acetaminophen\n Changes to medical and family history: None\n Review of systems is unchanged from admission except as noted below\n Review of systems: Unchanged, intubated and deeply sedated\n Flowsheet Data as of 05:28 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.4\nC (97.5\n Tcurrent: 35.9\nC (96.6\n HR: 74 (54 - 101) bpm\n BP: 142/70(92) {117/57(76) - 155/75(98)} mmHg\n RR: 34 (30 - 34) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 76.3 kg (admission): 76.3 kg\n Height: 68 Inch\n CVP: 18 (15 - 41)mmHg\n CO/CI (CCO): (5.7 L/min) / (3.0 L/min/m2)\n SVV 12%\n SVR: 926\n Total In:\n 4,090 mL\n 1,462 mL\n PO:\n TF:\n 163 mL\n IVF:\n 3,555 mL\n 1,104 mL\n Blood products:\n Total out:\n 6,200 mL\n 820 mL\n Urine:\n 6,090 mL\n 820 mL\n NG:\n 110 mL\n Stool:\n Drains:\n Balance:\n -2,110 mL\n 642 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: PCV+Assist\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 260 (260 - 260) mL\n PC : 16 cmH2O\n PS : 5 cmH2O\n RR (Set): 34\n PEEP: 12 cmH2O\n FiO2: 50%\n PIP: 39 cmH2O\n Plateau: 30 cmH2O\n SpO2: 96%\n ABG: 7.39/40/113//0\n Ve: 15.4 L/min\n PaO2 / FiO2: 226\n Physical Examination\n General Appearance: Intubated, sedated\n Eyes / Conjunctiva: sclera anicteric, conjunctiva non-injected, PERRL\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, esophageal\n balloon, NGT\n Cardiovascular: (S1: Normal), (S2: Normal, Fixed), tachycardic. regular\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:\n Rhonchorous: ), coarse mechanical BS throughout all lung fields\n Abdominal: Soft, Non-tender, hypoactive bowel sounds\n Extremities: no edema, palpable distal pulses\n Skin: Warm and dry, evidence of cutaneous GVHD on abdomen with\n sclerodermal changes.\n Labs / Radiology\n 130 K/uL\n 98 mg/dL\n 1.0\n 24 mEq/L\n 4.2 mEq/L\n 22 mg/dL\n 113 mEq/L\n 145 mEq/L\n 31.8\n 13.5 K/uL\n [image002.jpg]\n Micro:\n Bcx x2 NGTD\n Ucx: No growth\n CXR : New area of heterogeneous coalescing opacification in the\n RLL partially obscuring R hemidiaphragm, concerning for aspiration or\n evolving infection. Persistent R pleural effusion. Feeding tube tip\n terminates just above the level of the diaphragm and could be advanced\n 12:20 AM\n 04:38 AM\n 05:01 AM\n 11:22 AM\n 12:10 PM\n 02:14 PM\n 08:25 PM\n 10:25 PM\n 03:04 AM\n 04:46 AM\n WBC\n 12.3\n Hct\n 33.6\n Plt\n 124\n Cr\n 1.1\n TCO2\n 22\n 23\n 23\n 23\n 22\n 23\n 24\n 26\n 25\n Glucose\n 99\n Other labs: PT / PTT / INR:14.5/28.7/1.3, CK / CKMB /\n Troponin-T:260/9/0.22, ALT / AST:94/64, Alk Phos / T Bili:84/0.3,\n Amylase / Lipase:53/22, Differential-Neuts:67.0 %, Band:2.0 %,\n Lymph:18.0 %, Mono:9.0 %, Eos:0.0 %, Lactic Acid:1.7 mmol/L,\n Albumin:2.7 g/dL, LDH:274 IU/L, Ca++:8.0 mg/dL, Mg++:2.3 mg/dL, PO4:2.5\n mg/dL\n Assessment and Plan\n 50M h/o metastatic renal CA s/p nephrectomy, IL-2, mini-allograft SCT,\n DLI x 2 last in , emphysema/pulmonary fibrosis on home 02\n presented to OSH with hypoxic respiratory failure, fevers and\n hypotension.\n # Septic shock: On presentation to OSH pt hypotensive, hypoxic with\n fevers and leukocytosis. On arrival to ICU was intubated due to\n hypoxic respiratory failure and hypotensive requiring pressors. Likely\n pneumonia given hypoxia and possible opacities on CXR, although\n difficult to read due to fibrosis. No other apparent localizing\n symptoms. Ruled-out for flu at OSH. At this point, WBC and fever curve\n decreasing. Covered on broad spectrum antibiotics.\n - Legionella urine ag negative, all other cultures no growth to date.\n - Vanc, zosyn, levofloxacin, bactrim IV for PCP, to cover\n broadly given critical illness. As patient was on bactrim prophylaxis\n for PCP as outpatient and not on steroids, risk for PCP very low;\n therefore, will dc high dose bactrim and restart ppx dose.\n - D/C \n - Also on IV steroids for PCP and adrenal insufficiency, see below\n - Glucan, galactomannan pending\n - Follow WBC count, fever curve, decreasing\n - PPD negative\n - Continue acyclovir ppx, vanc/zosyn/levoflox\n # Respiratory failure: Pneumonia in patient with poor pulmonary reserve\n due to emphysema, ?GVHD, fibrosis.\n Pt tolerated decrease in PEEP and Fi02 yesterday. Attempted to switch\n to A/C, however pt less sedated off pressors and pulling large TV\n (~1600), dysynchronous with vent.\n - Back on pressure control for now, based on transpulmonary pressure\n (10 and -2), will titrate down FiO2 as tolerated today. Can consider\n changing to PSV or SIMV with low set respiratory rate if tolerated.\n -Off cisatracurium since . Currently sedated on midazolam and\n fentanyl on maximal doses. Will try trial of methadone to help\n decrease versed/fentanyl doses today. Attempt wean as tolerated. Can\n consider propofol in addition in order to lower doses of\n versed/fentanyl.\n # Cardiogenic shock: Patient found to have PAH and RV failure on ECHO.\n Started on dobutamine with improvement in CI as well as pressures.\n Also started on captopril for afterload reduction which enabled\n decrease in dobutamine with continued improvement in hemodynamics.\n - Wean dobutamine today\n - Continue to monitor UOP and CI. If UOP decreases, will consider lasix\n drip if patient becomes very positive\n # Hypotension: Improved. Likely a mixed picture. Initially pt\n presentation of acute hypoxia with leukocytosis and fevers with\n hypotension made a septic shock picture predominate, however after\n adequate fluid rescusitation pt continued to require 2 pressors. His\n TTE and vigileo monitoring were consistent with low cardiac output due\n to pt\ns severe pulmonary hypertension due to pulmonary fibrosis and\n subsequent RV hypokinesis, a non-fluid responsive state. Dobutamine\n challenge resulted in increased CO to normal range with ability to be\n weaned off both levophed and vasopressin and addition of captopril\n which led to decreased afterload allowed decrease in dobutamine. Also,\n initial concern for adrenal insufficiency as patient has one adrenal\n gland with a metastasis, though he does not clinically appear to be\n functionally adrenally insufficient at this point. UOP remains high at\n ~100-200cc/hour.\n - Continue dobutamine\n - Continue HD monitoring with Vigileo device\n - Treat broadly for infection per above\n - IV hydrocort Q6 for adrenal insufficiency, will start wean today with\n 50mg q12, and subsequent wean over next few days.\n - Initially concerned for PE, however have more likley explanations for\n hypotension as listed above, LENIs negative\n - Guaiac stools, HCT has been stable.\n # Cardiac: Patient with probable demand ischemia in setting of\n hypotension, tachycardia, and sepsis; less likely unstable plaque.\n - CE\ns trended down, have stopped following.\n - ASA\n - ACEI as above for afterload reduction\n - Consider diuresis if UOP tapers off to further decrease preload.\n # Metastatic renal CA: Recurrent disease s/p donor lymphocyte\n transplant .\n - BMT to follow\n - Continue acyclovir ppx for now, will discuss with BMT\n ICU Care\n Nutrition: TF not at goal due to high residuals, will reduce fentanyl,\n colace/senna, consider lactulose/oral naloxone if ileus persists. TPN\n for now.\n Glycemic Control: ISS prn\n Lines:\n 20 Gauge - 09:10 PM\n Multi Lumen - 11:24 PM\n Arterial Line - 12:14 AM\n Prophylaxis:\n DVT: Hep SC, pneumoboots\n Stress ulcer: Ranitidine\n VAP: Chlorhexidine\n Comments:\n Communication: Comments: wife, \n Code status: Full code, have d/w family.\n Disposition: ICU\n" }, { "category": "Nursing", "chartdate": "2120-04-20 00:00:00.000", "description": "Nursing Progress Note", "row_id": 323127, "text": "Heart failure, right, isolated (Cor Pulmonale)\n Assessment:\n SBP >130 and UO > 100cc/hr\n Action:\n Dobutamine weaning attempted @2300, Restarted @ 2330 0.3mcg/kg/min\n Response:\n Bradycardic to 45, CI <2.4 when dobutamine turned off\n Plan:\n Wean dobutamine, Goal CI >2.5, UO >40cc/hr\n Respiratory failure, acute (not ARDS/)\n Assessment:\n During personal care pt became awake moved UE and fighting on vent and\n desated to 80\n Action:\n Suctioned for thick yellow sec. Fio2 increased to 50%\n Response:\n Sats picked up to 92%\n Plan:\n Cont vent support and ABG in AM\n Pt is sedated on vent. Fentanyl wean to 400mcg/hr, versed cont as\n 10mg/hr. Pt awakened while doing personal care Open eyes but does not\n follow commands. Moved UE, No movements on LE noted. Fighting on vent\n and desated to 80\ns suctioned for yellow thick sec Fio2 increased to\n 50% and received fentanyl bolus w/ that ha calms down, sats improved to\n 92% . Tube feeding replete w/ fiber 10cc/hr started @ 0200.\n" }, { "category": "Nursing", "chartdate": "2120-04-22 00:00:00.000", "description": "Nursing Progress Note", "row_id": 323326, "text": "50 yo male with met renal cell CA admitted with severe resp\n failure/PNA, cardiogenic/septic shock. RV hypoplasia\n" }, { "category": "Nursing", "chartdate": "2120-04-22 00:00:00.000", "description": "Nursing Progress Note", "row_id": 323327, "text": "50 yo male with met renal cell CA admitted with severe resp\n failure/PNA, cardiogenic/septic shock. RV hypoplasia\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n Heart failure, right, isolated (Cor Pulmonale)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Physician ", "chartdate": "2120-04-17 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 322777, "text": "Chief Complaint:\n 24 Hour Events:\n ESOPHOGEAL BALLOON - At 10:18 AM\n TRANSTHORACIC ECHO - At 10:56 AM\n ULTRASOUND - At 02:00 PM\n Pt paralyzed to improve ventilation\n Family meeting with team members conveying gravity of pt's situation,\n DNR status discussed, pt remains full code.\n Pt weaned off levophed, remains on vasopressin\n Vigileo device applied for CO monitoring, have been ~\n LENIs negative\n TF started\n TTE showed EF>55%, mild LV diastolic dysfunction, RV with mild global\n free wall hypokinesis with RV pressure overload and moderate to severe\n \n Allergies:\n Flagyl (Oral) (Metronidazole)\n Rash;\n Last dose of Antibiotics:\n Levofloxacin - 09:00 AM\n Bactrim (SMX/TMP) - 12:12 AM\n Acyclovir - 12:13 AM\n Caspofungin - 04:08 AM\n Piperacillin/Tazobactam (Zosyn) - 06:00 AM\n Infusions:\n Vasopressin - 2.4 units/hour\n Cisatracurium - 0.1 mg/Kg/hour\n Midazolam (Versed) - 6 mg/hour\n Norepinephrine - 0.08 mcg/Kg/min\n Fentanyl - 350 mcg/hour\n Other ICU medications:\n Fentanyl - 08:30 AM\n Famotidine (Pepcid) - 08:00 PM\n Heparin Sodium (Prophylaxis) - 08:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:04 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.2\nC (100.8\n Tcurrent: 37\nC (98.6\n HR: 70 (70 - 102) bpm\n BP: 84/58(66) {78/53(63) - 142/86(95)} mmHg\n RR: 34 (10 - 34) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 76.3 kg (admission): 76.3 kg\n Height: 68 Inch\n CVP: 26 (15 - 355)mmHg\n CO/CI (CCO): (2.5 L/min) / (1.3 L/min/m2)\n Total In:\n 5,512 mL\n 2,061 mL\n PO:\n TF:\n 75 mL\n 190 mL\n IVF:\n 5,287 mL\n 1,522 mL\n Blood products:\n Total out:\n 832 mL\n 435 mL\n Urine:\n 832 mL\n 435 mL\n NG:\n Stool:\n Drains:\n Balance:\n 4,680 mL\n 1,626 mL\n Respiratory support\n Ventilator mode: PCV+Assist\n PC : 24 cmH2O\n RR (Set): 34\n PEEP: 16 cmH2O\n FiO2: 60%\n RSBI Deferred: PEEP > 10\n PIP: 40 cmH2O\n Plateau: 38 cmH2O\n SpO2: 96%\n ABG: 7.32/38/115/17/-5\n Ve: 15.2 L/min\n PaO2 / FiO2: 192\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 119 K/uL\n 11.7 g/dL\n 174 mg/dL\n 1.1 mg/dL\n 17 mEq/L\n 5.1 mEq/L\n 16 mg/dL\n 106 mEq/L\n 128 mEq/L\n 35.4 %\n 13.1 K/uL\n [image002.jpg]\n 09:49 AM\n 01:08 PM\n 01:38 PM\n 03:16 PM\n 04:51 PM\n 06:59 PM\n 09:54 PM\n 11:52 PM\n 04:37 AM\n 04:52 AM\n WBC\n 13.1\n Hct\n 35.4\n Plt\n 119\n Cr\n 1.1\n 1.1\n TCO2\n 23\n 22\n 22\n 20\n 23\n 21\n 21\n 20\n Glucose\n 74\n Other labs: PT / PTT / INR:15.9/28.7/1.4, CK / CKMB /\n Troponin-T:168/15/0.49, ALT / AST:61/96, Alk Phos / T Bili:78/0.6,\n Amylase / Lipase:53/22, Differential-Neuts:67.0 %, Band:2.0 %,\n Lymph:18.0 %, Mono:9.0 %, Eos:0.0 %, Lactic Acid:1.8 mmol/L,\n Albumin:2.7 g/dL, LDH:856 IU/L, Ca++:8.0 mg/dL, Mg++:1.9 mg/dL, PO4:2.3\n mg/dL\n Assessment and Plan\n ICU Care\n Nutrition:\n Replete (Full) - 06:20 AM 40 mL/hour\n Glycemic Control:\n Lines:\n 20 Gauge - 09:10 PM\n Multi Lumen - 11:24 PM\n Arterial Line - 12:14 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": "2120-04-17 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 322779, "text": "Chief Complaint: 50M h/o metastatic renal CA s/p nephrectomy, IL-2,\n mini-allograft SCT, DLI x 2 last in , emphysema/pulmonary fibrosis\n on home 02 presents with sepsis.\n 24 Hour Events:\n ESOPHOGEAL BALLOON - At 10:18 AM\n TRANSTHORACIC ECHO - At 10:56 AM\n ULTRASOUND - At 02:00 PM\n Pt paralyzed to improve ventilation\n Family meeting with team members conveying gravity of pt's situation,\n DNR status discussed, pt remains full code.\n Pt weaned off levophed, remains on vasopressin\n Vigileo device applied for CO monitoring, have been ~\n LENIs negative\n TF started\n TTE showed EF>55%, mild LV diastolic dysfunction, RV with mild global\n free wall hypokinesis with RV pressure overload and moderate to severe\n \n Allergies:\n Flagyl (Oral) (Metronidazole)\n Rash;\n Last dose of Antibiotics:\n Levofloxacin - 09:00 AM\n Bactrim (SMX/TMP) - 12:12 AM\n Acyclovir - 12:13 AM\n Caspofungin - 04:08 AM\n Piperacillin/Tazobactam (Zosyn) - 06:00 AM\n Infusions:\n Vasopressin - 2.4 units/hour\n Cisatracurium - 0.1 mg/Kg/hour\n Midazolam (Versed) - 6 mg/hour\n Norepinephrine - 0.08 mcg/Kg/min\n Fentanyl - 350 mcg/hour\n Other ICU medications:\n Fentanyl - 08:30 AM\n Famotidine (Pepcid) - 08:00 PM\n Heparin Sodium (Prophylaxis) - 08:00 PM\n Other medications:\n Hydrocortisone\n Acetaminophen\n Folic Acid\n Albuterol\n ASA\n Famotidine\n Hep Sc\n ISS\n Docusate\n Senna\n Bisacodyl\n Chlorhexidine\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:04 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.2\nC (100.8\n Tcurrent: 37\nC (98.6\n HR: 70 (70 - 102) bpm\n BP: 84/58(66) {78/53(63) - 142/86(95)} mmHg\n RR: 34 (10 - 34) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 76.3 kg (admission): 76.3 kg\n Height: 68 Inch\n CVP: 26 (15 - 355)mmHg\n CO/CI (CCO): (2.5 L/min) / (1.3 L/min/m2)\n Total In:\n 5,512 mL\n 2,061 mL\n PO:\n TF:\n 75 mL\n 190 mL\n IVF:\n 5,287 mL\n 1,522 mL\n Blood products:\n Total out:\n 832 mL\n 435 mL\n Urine:\n 832 mL\n 435 mL\n NG:\n Stool:\n Drains:\n Balance:\n 4,680 mL\n 1,626 mL\n Respiratory support\n Ventilator mode: PCV+Assist\n PC : 24 cmH2O\n RR (Set): 34\n PEEP: 16 cmH2O\n FiO2: 60%\n RSBI Deferred: PEEP > 10\n PIP: 40 cmH2O\n Plateau: 38 cmH2O\n SpO2: 96%\n ABG: 7.32/38/115/17/-5\n Ve: 15.2 L/min\n PaO2 / FiO2: 192\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 119 K/uL\n 11.7 g/dL\n 174 mg/dL\n 1.1 mg/dL\n 17 mEq/L\n 5.1 mEq/L\n 16 mg/dL\n 106 mEq/L\n 128 mEq/L\n 35.4 %\n 13.1 K/uL\n [image002.jpg]\n 09:49 AM\n 01:08 PM\n 01:38 PM\n 03:16 PM\n 04:51 PM\n 06:59 PM\n 09:54 PM\n 11:52 PM\n 04:37 AM\n 04:52 AM\n WBC\n 13.1\n Hct\n 35.4\n Plt\n 119\n Cr\n 1.1\n 1.1\n TCO2\n 23\n 22\n 22\n 20\n 23\n 21\n 21\n 20\n Glucose\n 74\n Other labs: PT / PTT / INR:15.9/28.7/1.4, CK / CKMB /\n Troponin-T:168/15/0.49, ALT / AST:61/96, Alk Phos / T Bili:78/0.6,\n Amylase / Lipase:53/22, Differential-Neuts:67.0 %, Band:2.0 %,\n Lymph:18.0 %, Mono:9.0 %, Eos:0.0 %, Lactic Acid:1.8 mmol/L,\n Albumin:2.7 g/dL, LDH:856 IU/L, Ca++:8.0 mg/dL, Mg++:1.9 mg/dL, PO4:2.3\n mg/dL\n Assessment and Plan\n 50M h/o metastatic renal CA s/p nephrectomy, IL-2, mini-allograft SCT,\n DLI x 2 last in , emphysema/pulmonary fibrosis on home 02 presents\n with sepsis.\n # Sepsis: Likely pneumonia given new opacities on CXR, although\n difficult to read due to fibrosis. No other apparent localizing\n symptoms. Ruled-out for flu at OSH. Urine, GI sources less probable.\n Given immunocompromise from malignancy, at risk for PCP, , etc.\n Progression of GVHD could be contributing.\n - IVF resuscitation for MAP>65, IVF aggressively then pressors if\n necessary\n - Vanc, zosyn, levofloxacin, bactrim, caspofungin to cover broadly for\n now given critical illness\n - Blood, urine, sputum cultures\n - Legionella antigen, glucan, galactomannan\n - CT chest and possible bronch when more stable\n - Follow WBC count, fever curve\n - PPD to be read \n # Respiratory failure: Pneumonia in patient with poor pulmonary reserve\n due to emphysema, GVHD, fibrosis. Avoid high pressures given fibrotic\n lungs, will attempt pressure control to limit.\n - Continue mechanical ventilatory support, wean as tolerated\n # Acidosis: Primary respiratory, non-gap, lactate normal. Increase\n minute ventilation. require paralysis for adequate ventilation.\n # Hypotension: Likely sepsis, although probably component of\n hypovolemia as well. At risk for PE given malignancy. GI bleed unlikely\n as Hct stable. Adrenal insufficiency possible.\n - Treat broadly per above\n - stim in AM, after high dose steroids from OSH are off.\n - LENIs for ? DVT. Don't want to empirically start heparin given RCC\n and risk to bleed.\n - Guaiac stools, HCT has been stable.\n # Cardiac: Patient with probable demand ischemia in setting of\n hypotension, tachycardia, and sepsis; less likely unstable plaque.\n - Continue to trend enzymes and treat underlying cause\n - ASA, hold on beta-blocker and statin\n - TTE to eval for wall motion abnormality\n - Repeat ECG in am\n # Metastatic renal CA: Recurrent disease s/p donor lymphocyte\n transplant .\n - BMT to follow\n - Avoid steroids given risk to graft\n - Continue acyclovir ppx for now, will discuss with BMT\n ICU Care\n Nutrition:\n Replete (Full) - 06:20 AM 40 mL/hour\n Glycemic Control:\n Lines:\n 20 Gauge - 09:10 PM\n Multi Lumen - 11:24 PM\n Arterial Line - 12:14 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": "2120-04-18 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 322957, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 4\n Ideal body weight: 69.9 None\n Ideal tidal volume: 279.6 / 419.4 / 559.2 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation:\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: 24 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: 20 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: /\n Sputum source/amount: /\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Underlying illness\n not resolved\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n Pt on the vent changes made tol fairly well. See respiratory page of\n medivision for more information.\n" }, { "category": "Physician ", "chartdate": "2120-04-18 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 322959, "text": "Chief Complaint: 50M h/o metastatic renal CA s/p nephrectomy, IL-2,\n mini-allograft SCT, DLI x 2 last in , emphysema/pulmonary fibrosis\n on home 02 presents with sepsis.\n 24 Hour Events:\n -Multiple family discussions, pt FULL CODE\n -Paralysis stopped\n -Started on Dobutamine infusion, MAP maintained at >65 after\n vasopressin stopped. Now off levophed\n -PEEP decreased to 14 from 16, Fi02 50% from 60%\n -UOP maintained >200cc/hr\n -TF held for high residuals. No BM.\n Allergies:\n Flagyl (Oral) (Metronidazole)\n Rash;\n Last dose of Antibiotics:\n Levofloxacin - 10:04 AM\n Vancomycin - 07:35 PM\n Bactrim (SMX/TMP) - 11:39 PM\n Acyclovir - 12:16 AM\n - 03:59 AM\n Piperacillin/Tazobactam (Zosyn) - 06:08 AM\n Infusions:\n Dobutamine - 1.5 mcg/Kg/min\n Midazolam (Versed) - 6 mg/hour\n Fentanyl - 400 mcg/hour\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 07:41 PM\n Famotidine (Pepcid) - 08:30 PM\n Other medications:\n Hydrocortisone 50mg IV Q6\n Acetaminophen prn\n Folic Acid\n Albuterol\n Asa\n ISS\n Docusate\n Senna\n Bisacodyl\n Chlorhexidine\n Changes to medical and family history: None\n Review of systems is unchanged from admission except as noted below\n Review of systems: Intubated, sedated\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: 36.6\nC (97.9\n Tcurrent: 36.1\nC (97\n HR: 67 (56 - 96) bpm\n BP: 117/60(76) {89/58(69) - 152/77(99)} mmHg\n RR: 34 (30 - 34) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 76.3 kg (admission): 76.3 kg\n Height: 68 Inch\n CVP: 17 (10 - 25)mmHg\n CO/CI (CCO): (4.7 L/min) / (2.5 L/min/m2)\n Total In:\n 6,194 mL\n 820 mL\n PO:\n TF:\n 890 mL\n 46 mL\n IVF:\n 4,814 mL\n 739 mL\n Blood products:\n Total out:\n 2,395 mL\n 2,690 mL\n Urine:\n 1,845 mL\n 2,580 mL\n NG:\n 550 mL\n 110 mL\n Stool:\n Drains:\n Balance:\n 3,799 mL\n -1,870 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: PCV+Assist\n PC : 24 cmH2O\n RR (Set): 34\n PEEP: 14 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10\n PIP: 38 cmH2O\n Plateau: 36 cmH2O\n SpO2: 96%\n ABG: 7.36/39/95./21/-2\n Ve: 15.9 L/min\n PaO2 / FiO2: 192\n Physical Examination\n General Appearance: Intubated, sedated\n Eyes / Conjunctiva: sclera anicteric, conjunctiva non-injected, PERRL\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, esophageal\n balloon, NGT\n Lymphatic: No(t) Cervical WNL, No(t) Supraclavicular WNL, No(t)\n Cervical adenopathy\n Cardiovascular: (S1: Normal), (S2: Normal, Fixed), tachycardic. regular\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:\n Rhonchorous: ), coarse mechanical BS throughout all lung fields\n Abdominal: Soft, Non-tender, hypoactive bowel sounds\n Extremities: no edema, palpable distal pulses\n Skin: Warm and dry, evidence of cutaneous GVHD on abdomen with\n sclerodermal changes.\n Neurologic: Intubated, sedated, opens eyes, tracks around room.\n Labs / Radiology\n 124 K/uL\n 11.3 g/dL\n 99 mg/dL\n 1.1 mg/dL\n 21 mEq/L\n 4.6 mEq/L\n 19 mg/dL\n 110 mEq/L\n 139 mEq/L\n 33.6 %\n 12.3 K/uL\n [image002.jpg]\n 06:59 PM\n 09:54 PM\n 11:52 PM\n 04:37 AM\n 04:52 AM\n 08:05 PM\n 10:19 PM\n 12:20 AM\n 04:38 AM\n 05:01 AM\n WBC\n 13.1\n 12.3\n Hct\n 35.4\n 33.6\n Plt\n 119\n 124\n Cr\n 1.1\n 1.1\n TropT\n 0.22\n TCO2\n 23\n 21\n 21\n 20\n 21\n 22\n 22\n 23\n Glucose\n 164\n 179\n 174\n 99\n Other labs: PT / PTT / INR:14.9/28.9/1.3, CK / CKMB /\n Troponin-T:260/9/0.22, ALT / AST:94/64, Alk Phos / T Bili:84/0.3,\n Amylase / Lipase:53/22, Differential-Neuts:67.0 %, Band:2.0 %,\n Lymph:18.0 %, Mono:9.0 %, Eos:0.0 %, Lactic Acid:1.7 mmol/L,\n Albumin:2.7 g/dL, LDH:274 IU/L, Ca++:8.1 mg/dL, Mg++:2.2 mg/dL, PO4:1.6\n mg/dL\n Micro:\n Urine legionella ag: Negative\n Blood and urine cx pending\n Assessment and Plan\n 50M h/o metastatic renal CA s/p nephrectomy, IL-2, mini-allograft SCT,\n DLI x 2 last in , emphysema/pulmonary fibrosis on home 02\n presented to OSH with hypoxic respiratory failure, fevers and\n hypotension.\n # Severe septic shock: On presentation to OSH pt hypotensive, hypoxic\n with fevers and leukocytosis. On arrival to ICU was intubated due\n to hypoxic respiratory failure and hypotensive requiring pressors.\n Likely pneumonia given hypoxia and possible opacities on CXR, although\n difficult to read due to fibrosis. No other apparent localizing\n symptoms. Ruled-out for flu at OSH. Urine, GI sources less probable.\n Given immunocompromise from malignancy, at risk for PCP, , etc.\n Progression of GVHD could be contributing.\n - Will attempt to obtain deep ET sputum for culture\n - legionella urine ag negative, all other cultures no growth to date.\n - Vanc, zosyn, levofloxacin, bactrim IV for PCP, to cover\n broadly for now given critical illness. Iv steroids for PCP and\n adrenal insufficiency as below.\n - glucan, galactomannan pending for ? PCP, \n Unclear benefit of bronch for BAL at this point given duration of\n antimicrobial treatment and pt\ns tenuous respiratory status, albeit\n improved from yesterday.\n - CT chest and possible bronch when more stable\n - Follow WBC count, fever curve, decreasing\n - PPD negative\n # Respiratory failure: Pneumonia in patient with poor pulmonary reserve\n due to emphysema, ?GVHD, fibrosis.\n Pt tolerated decrease in PEEP and Fi02 yesterday. Attempted to switch\n to A/C today, however pt less sedated off pressors and pulling large TV\n (~1600), dysynchronous with vent.\n -Switch back to pressure control for now, titrating down PEEP and Fi02\n as tolerated, attempt to wean sedation as much as possible.\n -Off cisatracurium since yesterday am. Currently sedated on midazolam\n and fentanyl.\n # Hypotension: Likely a mixed picture. Initially pt\ns presentation of\n acute hypoxia with leukocytosis and fevers with hypotension made a\n septic shock picture predominate, however after adequate fluid\n rescusitation pt continued to require 2 pressors. His TTE and vigileo\n monitoring were consistent with low cardiac output due to pt\ns severe\n pulmonary hypertension due to pulmonary fibrosis and subsequent RV\n hypokinesis with resultant LVOT, a non-fluid responsive state.\n Dobutamin challenge yesterday resulted in increased CO to normal range\n with ability to be weaned off both levophed and vasopressin. UOP\n remains high at ~200cc/hour.\n - Continue dobutamine\n - No prostacyclin/NO for now due to concern that may increase mismatch\n and worsen hypoxia.\n - Continue HD monitoring with Vigileo device\n - Treat broadly for infection per above\n - IV hydrocort Q6 for adrenal insufficiency, continue\n - Initially concerned for PE, however have more likley explanations for\n hypotension as listed above, LENIs negative\n - Start ACE low dose/short acting for afterload reduction.\n - Guaiac stools, HCT has been stable.\n # Cardiac: Patient with probable demand ischemia in setting of\n hypotension, tachycardia, and sepsis; less likely unstable plaque.\n - CE\ns trending down, have stopped following.\n - ASA\n - ACEI as above for afterload reduction\n - Consider diuresis if UOP tapers off to further decrease preload.\n # Metastatic renal CA: Recurrent disease s/p donor lymphocyte\n transplant .\n - BMT to follow\n - Continue acyclovir ppx for now, will discuss with BMT\n ICU Care\n ICU Care\n Nutrition: TF not at goal due to high residuals, will reduce fentanyl,\n colace/senna, consider lactulose/oral naloxone if ileus persists. TPN\n for now.\n Glycemic Control: ISS prn\n Lines:\n 20 Gauge - 09:10 PM\n Multi Lumen - 11:24 PM\n Arterial Line - 12:14 AM\n Prophylaxis:\n DVT: Hep SC, pneumoboots\n Stress ulcer: Ranitidine\n VAP: Chlorhexidine\n Comments:\n Communication: Comments: wife, \n Code status: Full code, have d/w family.\n Disposition: ICU\n" }, { "category": "Nursing", "chartdate": "2120-04-21 00:00:00.000", "description": "Nursing Progress Note", "row_id": 323303, "text": "50 yo male with met renal cell CA admitted with severe resp\n failure/PNA, cardiogenic/septic shock. RV hypoplasia Being covered on a\n number of broad coverage abx for PNA/sepsis.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Remains intubated with no changes to the vent made. Attempted a slight\n decrease in sedation to improve HR however pt. became too awake and\n uncomfortable.\n Action:\n Increased sedation back to AM dosing of fent 500 and versed 10mg/hr,\n Methadone 20mg IV q8h, PCV: RR 30,driving pressure 28,PEEP 12. Vent\n changes ordered: decrease driving pressures from 28 to 26, however\n waiting until patient is more consistently sedated before making change\n given his history.\n Response:\n Pt. still very sensitive to stimulation and activity while on high\n levels of sedation. Desats to high 80\ns with activity but has so far\n been able to settle self out when unstimulated. Suctioning minimal tan\n thick secretions.\n Plan:\n pt. before activity. Continue with sedation /vent\n? Weaning when\n possible.\n Heart failure, right, isolated (Cor Pulmonale)\n Assessment:\n Off dobu yesterday, SB-NSR with HR dipping into upper 30\ns this AM. SBP\n 120\ns-150\n Action:\n Monitoring CO & CI, HR. Captopril increased to 12.5 mg TID.\n Response:\n CO 4.3-5.0, HR increases with stimulation and/or activity.\n Plan:\n Continue Monitor CO thru vigileo monitor.\n Lasix gtt started this AM with goal of patient being 2 L negative.\n Currently at 4mg/hr. Pt. tolerating well.\n Continuing to wean steroids, IV dose changed to 60mg PO daily.\n Tube feeds at goal 70mL/hr. Bowel sounds present, low residuals. 2 BM\n today, bowel regimen held.\n ------ Protected Section ------\n Lasix gtt off\n pt. 2 L negative\n Driving pressure weaned to 26, ABG needed at 8PM.\n ------ Protected Section Addendum Entered By: , RN\n on: 18:58 ------\n" }, { "category": "General", "chartdate": "2120-04-23 00:00:00.000", "description": "ICU Event Note", "row_id": 323428, "text": "50 yo male with metastatic renal cell CA s/p allo-SCT, COPD/fibrosis\n admitted with resp failure/shock. Mixed septic/cardiogenic picture with\n resp failure related to probable infxn superimposed on RV failure/pHTN,\n severe chronic pulm ds\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "General", "chartdate": "2120-04-23 00:00:00.000", "description": "ICU Event Note", "row_id": 323430, "text": "50 yo male with metastatic renal cell CA s/p allo-SCT, COPD/fibrosis\n admitted with resp failure/shock. Mixed septic/cardiogenic picture with\n resp failure related to probable infxn superimposed on RV failure/pHTN,\n severe chronic pulm ds\n Respiratory failure, acute (not ARDS/)\n Assessment:\n PSV/50% FiO2/30/12 of PEEP, breathing in sync with vent. LS clear,\n diminished at bases. ABG 7.51/44/91/10/36. Small amt of blood tinged\n thick sputum suctioned from ETT.\n Action:\n Response:\n Plan:\n Bradycardia\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Physician ", "chartdate": "2120-04-18 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 322950, "text": "Chief Complaint: 50M h/o metastatic renal CA s/p nephrectomy, IL-2,\n mini-allograft SCT, DLI x 2 last in , emphysema/pulmonary fibrosis\n on home 02 presents with sepsis.\n 24 Hour Events:\n -Multiple family discussions, pt FULL CODE\n -Paralysis stopped\n -Started on Dobutamine infusion, MAP maintained at >65 after\n vasopressin stopped. Now off levophed\n -PEEP decreased to 14 from 16, Fi02 50% from 60%\n -UOP maintained >200cc/hr\n -TF held for high residuals. No BM.\n Allergies:\n Flagyl (Oral) (Metronidazole)\n Rash;\n Last dose of Antibiotics:\n Levofloxacin - 10:04 AM\n Vancomycin - 07:35 PM\n Bactrim (SMX/TMP) - 11:39 PM\n Acyclovir - 12:16 AM\n - 03:59 AM\n Piperacillin/Tazobactam (Zosyn) - 06:08 AM\n Infusions:\n Dobutamine - 1.5 mcg/Kg/min\n Midazolam (Versed) - 6 mg/hour\n Fentanyl - 400 mcg/hour\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 07:41 PM\n Famotidine (Pepcid) - 08:30 PM\n Other medications:\n Hydrocortisone 50mg IV Q6\n Acetaminophen prn\n Folic Acid\n Albuterol\n Asa\n ISS\n Docusate\n Senna\n Bisacodyl\n Chlorhexidine\n Changes to medical and family history: None\n Review of systems is unchanged from admission except as noted below\n Review of systems: Intubated, sedated\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: 36.6\nC (97.9\n Tcurrent: 36.1\nC (97\n HR: 67 (56 - 96) bpm\n BP: 117/60(76) {89/58(69) - 152/77(99)} mmHg\n RR: 34 (30 - 34) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 76.3 kg (admission): 76.3 kg\n Height: 68 Inch\n CVP: 17 (10 - 25)mmHg\n CO/CI (CCO): (4.7 L/min) / (2.5 L/min/m2)\n Total In:\n 6,194 mL\n 820 mL\n PO:\n TF:\n 890 mL\n 46 mL\n IVF:\n 4,814 mL\n 739 mL\n Blood products:\n Total out:\n 2,395 mL\n 2,690 mL\n Urine:\n 1,845 mL\n 2,580 mL\n NG:\n 550 mL\n 110 mL\n Stool:\n Drains:\n Balance:\n 3,799 mL\n -1,870 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: PCV+Assist\n PC : 24 cmH2O\n RR (Set): 34\n PEEP: 14 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10\n PIP: 38 cmH2O\n Plateau: 36 cmH2O\n SpO2: 96%\n ABG: 7.36/39/95./21/-2\n Ve: 15.9 L/min\n PaO2 / FiO2: 192\n Physical Examination\n General Appearance: Intubated, sedated\n Eyes / Conjunctiva: sclera anicteric, conjunctiva non-injected, PERRL\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, esophageal\n balloon, NGT\n Lymphatic: No(t) Cervical WNL, No(t) Supraclavicular WNL, No(t)\n Cervical adenopathy\n Cardiovascular: (S1: Normal), (S2: Normal, Fixed), tachycardic. regular\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:\n Rhonchorous: ), coarse mechanical BS throughout all lung fields\n Abdominal: Soft, Non-tender, hypoactive bowel sounds\n Extremities: no edema, palpable distal pulses\n Skin: Warm and dry, evidence of cutaneous GVHD on abdomen with\n sclerodermal changes.\n Neurologic: Intubated, sedated, opens eyes, tracks around room.\n Labs / Radiology\n 124 K/uL\n 11.3 g/dL\n 99 mg/dL\n 1.1 mg/dL\n 21 mEq/L\n 4.6 mEq/L\n 19 mg/dL\n 110 mEq/L\n 139 mEq/L\n 33.6 %\n 12.3 K/uL\n [image002.jpg]\n 06:59 PM\n 09:54 PM\n 11:52 PM\n 04:37 AM\n 04:52 AM\n 08:05 PM\n 10:19 PM\n 12:20 AM\n 04:38 AM\n 05:01 AM\n WBC\n 13.1\n 12.3\n Hct\n 35.4\n 33.6\n Plt\n 119\n 124\n Cr\n 1.1\n 1.1\n TropT\n 0.22\n TCO2\n 23\n 21\n 21\n 20\n 21\n 22\n 22\n 23\n Glucose\n 164\n 179\n 174\n 99\n Other labs: PT / PTT / INR:14.9/28.9/1.3, CK / CKMB /\n Troponin-T:260/9/0.22, ALT / AST:94/64, Alk Phos / T Bili:84/0.3,\n Amylase / Lipase:53/22, Differential-Neuts:67.0 %, Band:2.0 %,\n Lymph:18.0 %, Mono:9.0 %, Eos:0.0 %, Lactic Acid:1.7 mmol/L,\n Albumin:2.7 g/dL, LDH:274 IU/L, Ca++:8.1 mg/dL, Mg++:2.2 mg/dL, PO4:1.6\n mg/dL\n Micro:\n Urine legionella ag: Negative\n Blood and urine cx pending\n Assessment and Plan\n 50M h/o metastatic renal CA s/p nephrectomy, IL-2, mini-allograft SCT,\n DLI x 2 last in , emphysema/pulmonary fibrosis on home 02\n presented to OSH with hypoxic respiratory failure, fevers and\n hypotension.\n # Severe septic shock: On presentation to OSH pt hypotensive, hypoxic\n with fevers and leukocytosis. On arrival to ICU was intubated due\n to hypoxic respiratory failure and hypotensive requiring pressors.\n Likely pneumonia given hypoxia and possible opacities on CXR, although\n difficult to read due to fibrosis. No other apparent localizing\n symptoms. Ruled-out for flu at OSH. Urine, GI sources less probable.\n Given immunocompromise from malignancy, at risk for PCP, , etc.\n Progression of GVHD could be contributing. Given tenuous respiratory\n status and requirments for high levels of PEEP a bronchoscopy would be\n too high risk for BAL and culture data.\n - Will attempt to obtain deep ET sputum for culture\n - legionella urine ag negative, all other cultures no growth to date.\n - Vanc, zosyn, levofloxacin, bactrim IV for PCP, to cover\n broadly for now given critical illness. Iv steroids for PCP and\n adrenal insufficiency as below.\n - glucan, galactomannan pending\n - CT chest and possible bronch when more stable\n - Follow WBC count, fever curve\n - PPD to be read \n # Respiratory failure: Pneumonia in patient with poor pulmonary reserve\n due to emphysema, ?GVHD, fibrosis. Avoid high pressures given fibrotic\n lungs, using pressure control ventilation. Tolerated decrease in Fi02\n from 100% to 60% yesterday, oxygenating well.\n -continue to wean FI02\n -will d/c cisatracurium infusion and use boluses as needed for\n paralysis should pt be dysynchronous with ventilator, otherwise will\n continue to manage sedation/pain with fentanyl/versed, increasing gtt\n as needed.\n - Continue mechanical ventilatory support, wean as tolerated\n -No proning for now as pt oxygenating well.\n # Hypotension: Likely sepsis, although probably component of\n hypovolemia as well. At risk for PE given malignancy. GI bleed unlikely\n as Hct stable. Adrenal insufficiency possible given s/p adrenelectomy\n with mets in remaining adrenal. Pt has dysfunctional RV with severe\n likely contributing to low CO. Set up vigileo device yesterday\n for non-invasive hemodynamic monitoring. Initially CI was 2.8, this am\n 1.8, a concerning decrease. His SV variability is low, indicating\n minimal fluid responsiveness.\n - start dobutamine in an attempt to increase CO, titrate to goal CO >4,\n CI >2.5, maintain on vasopressin and levophed. Monitor pressors if\n becomes hypotensive due to vasodilitory effect will discontinue.\n - No prostacyclin/NO for now due to concern that may increase mismatch\n and worsen hypoxia.\n - Consider PA catheter placement for more accurate hemodynamic\n monitoring, will continue to use vigileo for now.\n - Treat broadly for infection per above\n - IV hydrocort Q6 for adrenal insufficiency\n - LENIs to look for DVT negative.\n - Guaiac stools, HCT has been stable.\n # Cardiac: Patient with probable demand ischemia in setting of\n hypotension, tachycardia, and sepsis; less likely unstable plaque.\n - CE\ns this am trending down\n - ASA, hold on beta-blocker and statin\n - Repeat ECG in am\n # Metastatic renal CA: Recurrent disease s/p donor lymphocyte\n transplant .\n - BMT to follow\n - Avoid steroids given risk to graft\n - Continue acyclovir ppx for now, will discuss with BMT\n ICU Care\n ICU Care\n Nutrition: TF, tolerating with low residuals.\n Replete (Full) - 06:20 AM 40 mL/hour, advance as tolerated\n to goal of 70mL /hour\n Glycemic Control: ISS prn\n Lines:\n 20 Gauge - 09:10 PM\n Multi Lumen - 11:24 PM\n Arterial Line - 12:14 AM\n Prophylaxis:\n DVT: Hep SC, pneumoboots\n Stress ulcer: Ranitidine\n VAP: Chlorhexidine\n Comments:\n Communication: Comments: wife, \n Code status: Full code, have d/w family, will continue to readdress\n today\n Disposition: ICU\n" }, { "category": "Physician ", "chartdate": "2120-04-18 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 322954, "text": "Chief Complaint: 50M h/o metastatic renal CA s/p nephrectomy, IL-2,\n mini-allograft SCT, DLI x 2 last in , emphysema/pulmonary fibrosis\n on home 02 presents with sepsis.\n 24 Hour Events:\n -Multiple family discussions, pt FULL CODE\n -Paralysis stopped\n -Started on Dobutamine infusion, MAP maintained at >65 after\n vasopressin stopped. Now off levophed\n -PEEP decreased to 14 from 16, Fi02 50% from 60%\n -UOP maintained >200cc/hr\n -TF held for high residuals. No BM.\n Allergies:\n Flagyl (Oral) (Metronidazole)\n Rash;\n Last dose of Antibiotics:\n Levofloxacin - 10:04 AM\n Vancomycin - 07:35 PM\n Bactrim (SMX/TMP) - 11:39 PM\n Acyclovir - 12:16 AM\n - 03:59 AM\n Piperacillin/Tazobactam (Zosyn) - 06:08 AM\n Infusions:\n Dobutamine - 1.5 mcg/Kg/min\n Midazolam (Versed) - 6 mg/hour\n Fentanyl - 400 mcg/hour\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 07:41 PM\n Famotidine (Pepcid) - 08:30 PM\n Other medications:\n Hydrocortisone 50mg IV Q6\n Acetaminophen prn\n Folic Acid\n Albuterol\n Asa\n ISS\n Docusate\n Senna\n Bisacodyl\n Chlorhexidine\n Changes to medical and family history: None\n Review of systems is unchanged from admission except as noted below\n Review of systems: Intubated, sedated\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: 36.6\nC (97.9\n Tcurrent: 36.1\nC (97\n HR: 67 (56 - 96) bpm\n BP: 117/60(76) {89/58(69) - 152/77(99)} mmHg\n RR: 34 (30 - 34) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 76.3 kg (admission): 76.3 kg\n Height: 68 Inch\n CVP: 17 (10 - 25)mmHg\n CO/CI (CCO): (4.7 L/min) / (2.5 L/min/m2)\n Total In:\n 6,194 mL\n 820 mL\n PO:\n TF:\n 890 mL\n 46 mL\n IVF:\n 4,814 mL\n 739 mL\n Blood products:\n Total out:\n 2,395 mL\n 2,690 mL\n Urine:\n 1,845 mL\n 2,580 mL\n NG:\n 550 mL\n 110 mL\n Stool:\n Drains:\n Balance:\n 3,799 mL\n -1,870 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: PCV+Assist\n PC : 24 cmH2O\n RR (Set): 34\n PEEP: 14 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10\n PIP: 38 cmH2O\n Plateau: 36 cmH2O\n SpO2: 96%\n ABG: 7.36/39/95./21/-2\n Ve: 15.9 L/min\n PaO2 / FiO2: 192\n Physical Examination\n General Appearance: Intubated, sedated\n Eyes / Conjunctiva: sclera anicteric, conjunctiva non-injected, PERRL\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, esophageal\n balloon, NGT\n Lymphatic: No(t) Cervical WNL, No(t) Supraclavicular WNL, No(t)\n Cervical adenopathy\n Cardiovascular: (S1: Normal), (S2: Normal, Fixed), tachycardic. regular\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:\n Rhonchorous: ), coarse mechanical BS throughout all lung fields\n Abdominal: Soft, Non-tender, hypoactive bowel sounds\n Extremities: no edema, palpable distal pulses\n Skin: Warm and dry, evidence of cutaneous GVHD on abdomen with\n sclerodermal changes.\n Neurologic: Intubated, sedated, opens eyes, tracks around room.\n Labs / Radiology\n 124 K/uL\n 11.3 g/dL\n 99 mg/dL\n 1.1 mg/dL\n 21 mEq/L\n 4.6 mEq/L\n 19 mg/dL\n 110 mEq/L\n 139 mEq/L\n 33.6 %\n 12.3 K/uL\n [image002.jpg]\n 06:59 PM\n 09:54 PM\n 11:52 PM\n 04:37 AM\n 04:52 AM\n 08:05 PM\n 10:19 PM\n 12:20 AM\n 04:38 AM\n 05:01 AM\n WBC\n 13.1\n 12.3\n Hct\n 35.4\n 33.6\n Plt\n 119\n 124\n Cr\n 1.1\n 1.1\n TropT\n 0.22\n TCO2\n 23\n 21\n 21\n 20\n 21\n 22\n 22\n 23\n Glucose\n 164\n 179\n 174\n 99\n Other labs: PT / PTT / INR:14.9/28.9/1.3, CK / CKMB /\n Troponin-T:260/9/0.22, ALT / AST:94/64, Alk Phos / T Bili:84/0.3,\n Amylase / Lipase:53/22, Differential-Neuts:67.0 %, Band:2.0 %,\n Lymph:18.0 %, Mono:9.0 %, Eos:0.0 %, Lactic Acid:1.7 mmol/L,\n Albumin:2.7 g/dL, LDH:274 IU/L, Ca++:8.1 mg/dL, Mg++:2.2 mg/dL, PO4:1.6\n mg/dL\n Micro:\n Urine legionella ag: Negative\n Blood and urine cx pending\n Assessment and Plan\n 50M h/o metastatic renal CA s/p nephrectomy, IL-2, mini-allograft SCT,\n DLI x 2 last in , emphysema/pulmonary fibrosis on home 02\n presented to OSH with hypoxic respiratory failure, fevers and\n hypotension.\n # Severe septic shock: On presentation to OSH pt hypotensive, hypoxic\n with fevers and leukocytosis. On arrival to ICU was intubated due\n to hypoxic respiratory failure and hypotensive requiring pressors.\n Likely pneumonia given hypoxia and possible opacities on CXR, although\n difficult to read due to fibrosis. No other apparent localizing\n symptoms. Ruled-out for flu at OSH. Urine, GI sources less probable.\n Given immunocompromise from malignancy, at risk for PCP, , etc.\n Progression of GVHD could be contributing.\n - Will attempt to obtain deep ET sputum for culture\n - legionella urine ag negative, all other cultures no growth to date.\n - Vanc, zosyn, levofloxacin, bactrim IV for PCP, to cover\n broadly for now given critical illness. Iv steroids for PCP and\n adrenal insufficiency as below.\n - glucan, galactomannan pending for ? PCP, \n Unclear benefit of bronch for BAL at this point given duration of\n antimicrobial treatment and pt\ns tenuous respiratory status, albeit\n improved from yesterday.\n - CT chest and possible bronch when more stable\n - Follow WBC count, fever curve, decreasing\n - PPD negative\n # Respiratory failure: Pneumonia in patient with poor pulmonary reserve\n due to emphysema, ?GVHD, fibrosis.\n Pt tolerated decrease in PEEP and Fi02 yesterday. Attempted to switch\n to A/C today, however pt less sedated off pressors and pulling large TV\n (~1600), dysynchronous with vent.\n -Switch back to pressure control for now, titrating down PEEP and Fi02\n as tolerated, attempt to wean sedation as much as possible.\n -Off cisatracurium since yesterday am. Currently sedated on midazolam\n and fentanyl\n # Hypotension: Likely a mixed picture. Initially pt\ns presentation of\n acute hypoxia with leukocytosis and fevers with hypotension made a\n septic shock picture predominate, however after adequate fluid\n rescusitation pt continue to require 2 pressors. His TTE and vigileo\n monitoring were consistent with\n - start dobutamine in an attempt to increase CO, titrate to goal CO >4,\n CI >2.5, maintain on vasopressin and levophed. Monitor pressors if\n becomes hypotensive due to vasodilitory effect will discontinue.\n - No prostacyclin/NO for now due to concern that may increase mismatch\n and worsen hypoxia.\n - Consider PA catheter placement for more accurate hemodynamic\n monitoring, will continue to use vigileo for now.\n - Treat broadly for infection per above\n - IV hydrocort Q6 for adrenal insufficiency\n - LENIs to look for DVT negative.\n - Guaiac stools, HCT has been stable.\n # Cardiac: Patient with probable demand ischemia in setting of\n hypotension, tachycardia, and sepsis; less likely unstable plaque.\n - CE\ns this am trending down\n - ASA, hold on beta-blocker and statin\n - Repeat ECG in am\n # Metastatic renal CA: Recurrent disease s/p donor lymphocyte\n transplant .\n - BMT to follow\n - Avoid steroids given risk to graft\n - Continue acyclovir ppx for now, will discuss with BMT\n ICU Care\n ICU Care\n Nutrition: TF, tolerating with low residuals.\n Replete (Full) - 06:20 AM 40 mL/hour, advance as tolerated\n to goal of 70mL /hour\n Glycemic Control: ISS prn\n Lines:\n 20 Gauge - 09:10 PM\n Multi Lumen - 11:24 PM\n Arterial Line - 12:14 AM\n Prophylaxis:\n DVT: Hep SC, pneumoboots\n Stress ulcer: Ranitidine\n VAP: Chlorhexidine\n Comments:\n Communication: Comments: wife, \n Code status: Full code, have d/w family, will continue to readdress\n today\n Disposition: ICU\n" }, { "category": "Nursing", "chartdate": "2120-04-20 00:00:00.000", "description": "Nursing Progress Note", "row_id": 323205, "text": "50 yo man with metastatic renal cell CA s/p allo- SCT with subsequent\n severe chronic resp failure thought to be emphysema and fibrosis of\n unclear etiology (CT from last spring demonstrates severe cystic and\n fibrotic changes with almost no normal appearing lung) presented with 2\n wk prodrome, now with catastrophic acute on chronic failure. CXR shows\n diffuse opacification. RV with global hypokinesis, dilated, mod-sev\n PAH. Trop peaked at 1.98 at OSH, highest here was 0.49. No longer\n thought to have PCP, Bactrim D/C\nd, back on prophylactic dose.\n Weaning steroids. Methadone 20 mg q8h started yesterday to supplement\n sedation. Pt. had three medium to large BM, would recommend holding PM\n bowel regimen.\n Heart failure, right, isolated (Cor Pulmonale)\n Assessment:\n Dobuta off at 8am. C.O. 4\ns-low 5\ns. C.I. 2.2-2.8\n Action:\n Captopril 6.25mg given.\n Response:\n SBP 110\ns-140\ns. Remains bradycardic with HR 40\ns-50\ns. UO continues\n to be acceptable.\n Plan:\n Con\nt to monitor C.I. and C.O. via Vigileo monitor. Continue to closely\n evaluate UO.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Upper lobes clear today with diminished lowers. Breathing in sync with\n vent. ABG on PCV RR 30/insp pressure 28/PEEP 12 was 7.40/38/89\n Action:\n Weaned to PCV RR 30/inspiratory pressure 24/PEEP 12. O2 sats 91-94% -\n breathing in sync with vent. ABG done. Fent 450, Versed 10, Methadone\n 20mg IV q8h\n Response:\n ABG: 7.38/38/109. Pt. does occasionally does not tolerate turns well\n and drop sats to high 80\ns but returns to low 90\ns with rest.\n Plan:\n Con\nt to monitor sats and ABG\ns. Wean vent as tolerated.\n" }, { "category": "Nursing", "chartdate": "2120-04-22 00:00:00.000", "description": "Nursing Progress Note", "row_id": 323419, "text": "50M h/o metastatic renal CA s/p nephrectomy, IL-2, mini-allograft SCT,\n DLI x 2 last in , emphysema/pulmonary fibrosis on home 02 presents\n with hypotension, fevers, hypoxemic respiratory failure.\n Sepsis, Severe (with organ dysfunction)\n Assessment:\n Continues with low grade temps; tmax 99-3 PO.\n Action:\n Pan cultured.\n Response:\n Plan:\n Continue with abx ; caspofungin per BMT.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Desats when agitiated.\n Action:\n Several sedation boluses throughout shift; Methadone dosing increased.\n Response:\n Short term resolution of agitation\n Plan:\n Propofol gtt initiated; will attempt to wean Fent/Versed.\n Difficult time sedating adequately with frequent in boluses and\n increase in rates of Fentanyl and Versed. Methadone increased in\n frequency in attempt to wean other sedation. Propofol gtt intiated\n with decrease in HR, BP and RR. HR has been in 40s-50s consistently\n with increase to 130s while agitated. PCV weaned down to 24 at 1830 as\n patient has been autodiuresing consistently entire shift.\n PLAN: Continue to wean vent, sedation as tolerated. Continue with abx .\n Follow elytes.\n" }, { "category": "Nursing", "chartdate": "2120-04-21 00:00:00.000", "description": "Nursing Progress Note", "row_id": 323219, "text": "50 yo male with met renal cell CA admitted with severe resp\n failure/PNA, cardiogenic/septic shock. RV hypoplasia\n" }, { "category": "Respiratory ", "chartdate": "2120-04-16 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 322655, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 2\n Ideal body weight: 69.9 None\n Ideal tidal volume: 279.6 / 419.4 / 559.2 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation:\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type: Standard\n Size: 7.5mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 20 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: Crackles\n Comments:\n Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount: Suctioned / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern:\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours:\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n ABG puncture ( @ 9PM)\n Comments: Pt received from OSH via intub with OETT and placed\n on mech vent as per Metavision. Lung sounds initial fine bibasilar\n rales and dim; presently fine rales persist; aeration improved; suct sm\n th off white sput. ABGs mixed acidosis with marginal oxygenation though\n gas exchange has slowly improved overnoc on PCV. Cont PCV.\n" }, { "category": "Physician ", "chartdate": "2120-04-19 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 323012, "text": "Chief Complaint: 50M h/o metastatic renal CA s/p nephrectomy, IL-2,\n mini-allograft SCT, DLI x 2 last in , emphysema/pulmonary fibrosis\n on home 02 presents with hypotension, fevers, hypoxemic respiratory\n failure.\n 24 Hour Events:\n -dysynchronous on vent after rounds when on SIMV, put back on pressure\n control with normalization of ABG. Did well for most of the day.\n Overnight had mucous plugging with suctioning of sm amount thick\n sputum, after which pt transiently became dyscynchronous requiring\n increased sedation. PEEP increased to 12 from 10, Fi02 increased from\n 40% to 50%, driving pressure increased from 13 to 16, although down\n from 24 yesterday am.\n -decreased SVR, increased CO/CI after initiating ACEI, trial of\n decreasing dobutamine.\n -great UOP 100-200 cc/hour, no lasix for now\n -KUB read, no SBO\n Allergies:\n Flagyl (Oral) (Metronidazole)\n Rash;\n Last dose of Antibiotics:\n Levofloxacin - 10:14 AM\n Acyclovir - 04:30 PM\n Vancomycin - 08:15 PM\n Piperacillin/Tazobactam (Zosyn) - 10:13 PM\n Bactrim (SMX/TMP) - 12:02 AM\n - 03:58 AM\n Infusions:\n Dobutamine - 1 mcg/Kg/min\n Midazolam (Versed) - 12 mg/hour\n Fentanyl - 500 mcg/hour\n Other ICU medications:\n Famotidine (Pepcid) - 07:43 PM\n Heparin Sodium (Prophylaxis) - 09:00 PM\n Other medications:\n ISS\n ASA 325mg daily\n Docusate\n Chlorhexidine\n Folic Acid\n Hydrocortisone 50mg IV Q6\n Captopril 6.25 Po TID\n Senna\n PRN:\n Albuterol\n Bisacodyl\n Acetaminophen\n Changes to medical and family history: None\n Review of systems is unchanged from admission except as noted below\n Review of systems: Unchanged, intubated and deeply sedated\n Flowsheet Data as of 05:28 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.4\nC (97.5\n Tcurrent: 35.9\nC (96.6\n HR: 74 (54 - 101) bpm\n BP: 142/70(92) {117/57(76) - 155/75(98)} mmHg\n RR: 34 (30 - 34) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 76.3 kg (admission): 76.3 kg\n Height: 68 Inch\n CVP: 18 (15 - 41)mmHg\n CO/CI (CCO): (5.7 L/min) / (3.0 L/min/m2)\n SVV 12%\n SVR: 926\n Total In:\n 4,090 mL\n 1,462 mL\n PO:\n TF:\n 163 mL\n IVF:\n 3,555 mL\n 1,104 mL\n Blood products:\n Total out:\n 6,200 mL\n 820 mL\n Urine:\n 6,090 mL\n 820 mL\n NG:\n 110 mL\n Stool:\n Drains:\n Balance:\n -2,110 mL\n 642 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: PCV+Assist\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 260 (260 - 260) mL\n PC : 16 cmH2O\n PS : 5 cmH2O\n RR (Set): 34\n PEEP: 12 cmH2O\n FiO2: 50%\n PIP: 39 cmH2O\n Plateau: 30 cmH2O\n SpO2: 96%\n ABG: 7.39/40/113//0\n Ve: 15.4 L/min\n PaO2 / FiO2: 226\n Physical Examination\n General Appearance: Intubated, sedated\n Eyes / Conjunctiva: sclera anicteric, conjunctiva non-injected, PERRL\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, esophageal\n balloon, NGT\n Cardiovascular: (S1: Normal), (S2: Normal, Fixed), tachycardic. regular\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:\n Rhonchorous: ), coarse mechanical BS throughout all lung fields\n Abdominal: Soft, Non-tender, hypoactive bowel sounds\n Extremities: no edema, palpable distal pulses\n Skin: Warm and dry, evidence of cutaneous GVHD on abdomen with\n sclerodermal changes.\n Labs / Radiology\n 130 K/uL\n 98 mg/dL\n 1.0\n 24 mEq/L\n 4.2 mEq/L\n 22 mg/dL\n 113 mEq/L\n 145 mEq/L\n 31.8\n 13.5 K/uL\n [image002.jpg]\n Micro:\n Bcx x2 NGTD\n Ucx: No growth\n CXR : New area of heterogeneous coalescing opacification in the\n RLL partially obscuring R hemidiaphragm, concerning for aspiration or\n evolving infection. Persistent R pleural effusion. Feeding tube tip\n terminates just above the level of the diaphragm and could be advanced\n 12:20 AM\n 04:38 AM\n 05:01 AM\n 11:22 AM\n 12:10 PM\n 02:14 PM\n 08:25 PM\n 10:25 PM\n 03:04 AM\n 04:46 AM\n WBC\n 12.3\n Hct\n 33.6\n Plt\n 124\n Cr\n 1.1\n TCO2\n 22\n 23\n 23\n 23\n 22\n 23\n 24\n 26\n 25\n Glucose\n 99\n Other labs: PT / PTT / INR:14.5/28.7/1.3, CK / CKMB /\n Troponin-T:260/9/0.22, ALT / AST:94/64, Alk Phos / T Bili:84/0.3,\n Amylase / Lipase:53/22, Differential-Neuts:67.0 %, Band:2.0 %,\n Lymph:18.0 %, Mono:9.0 %, Eos:0.0 %, Lactic Acid:1.7 mmol/L,\n Albumin:2.7 g/dL, LDH:274 IU/L, Ca++:8.0 mg/dL, Mg++:2.3 mg/dL, PO4:2.5\n mg/dL\n Assessment and Plan\n 50M h/o metastatic renal CA s/p nephrectomy, IL-2, mini-allograft SCT,\n DLI x 2 last in , emphysema/pulmonary fibrosis on home 02\n presented to OSH with hypoxic respiratory failure, fevers and\n hypotension.\n # Severe septic shock: On presentation to OSH pt hypotensive, hypoxic\n with fevers and leukocytosis. On arrival to BIMC ICU was intubated due\n to hypoxic respiratory failure and hypotensive requiring pressors.\n Likely pneumonia given hypoxia and possible opacities on CXR, although\n difficult to read due to fibrosis. No other apparent localizing\n symptoms. Ruled-out for flu at OSH. Urine, GI sources less probable.\n Given immunocompromise from malignancy, at risk for PCP, , etc.\n Progression of GVHD could be contributing.\n - Will attempt to obtain deep ET sputum for culture, possible \n when on lower vent settings\n - legionella urine ag negative, all other cultures no growth to date.\n - Vanc, zosyn, levofloxacin, bactrim IV for PCP, to cover\n broadly for now given critical illness. Iv steroids for PCP and\n adrenal insufficiency as below.\n - glucan, galactomannan pending for ? PCP, \n Unclear benefit of bronch for BAL at this point given duration of\n antimicrobial treatment and pt\ns tenuous respiratory status, albeit\n improved from yesterday.\n - CT chest and possible bronch when more stable\n - Follow WBC count, fever curve, decreasing\n - PPD negative\n # Respiratory failure: Pneumonia in patient with poor pulmonary reserve\n due to emphysema, ?GVHD, fibrosis.\n Pt tolerated decrease in PEEP and Fi02 yesterday. Attempted to switch\n to A/C, however pt less sedated off pressors and pulling large TV\n (~1600), dysynchronous with vent.\n - Back on pressure control for now, titrating down PEEP and Fi02 as\n tolerated, attempt to wean sedation as much as possible.\n -Off cisatracurium since . Currently sedated on midazolam and\n fentanyl.\n # Hypotension: Improved. Likely a mixed picture. Initially pt\n presentation of acute hypoxia with leukocytosis and fevers with\n hypotension made a septic shock picture predominate, however after\n adequate fluid rescusitation pt continued to require 2 pressors. His\n TTE and vigileo monitoring were consistent with low cardiac output due\n to pt\ns severe pulmonary hypertension due to pulmonary fibrosis and\n subsequent RV hypokinesis with resultant LVOT, a non-fluid responsive\n state. Dobutamine challenge resulted in increased CO to normal range\n with ability to be weaned off both levophed and vasopressin. UOP\n remains high at ~100-200cc/hour.\n - Continue dobutamine\n - No prostacyclin/NO for now due to concern that may increase mismatch\n and worsen hypoxia.\n - Continue HD monitoring with Vigileo device\n - Treat broadly for infection per above\n - IV hydrocort Q6 for adrenal insufficiency, continue\n - Initially concerned for PE, however have more likley explanations for\n hypotension as listed above, LENIs negative\n - Started ACE low dose/short acting for afterload reduction with\n improved SVR and increased CO/CI, able to decrease dobutamine as well.\n - Guaiac stools, HCT has been stable.\n # Cardiac: Patient with probable demand ischemia in setting of\n hypotension, tachycardia, and sepsis; less likely unstable plaque.\n - CE\ns trending down, have stopped following.\n - ASA\n - ACEI as above for afterload reduction\n - Consider diuresis if UOP tapers off to further decrease preload.\n # Metastatic renal CA: Recurrent disease s/p donor lymphocyte\n transplant .\n - BMT to follow\n - Continue acyclovir ppx for now, will discuss with BMT\n ICU Care\n Nutrition: TF not at goal due to high residuals, will reduce fentanyl,\n colace/senna, consider lactulose/oral naloxone if ileus persists. TPN\n for now.\n Glycemic Control: ISS prn\n Lines:\n 20 Gauge - 09:10 PM\n Multi Lumen - 11:24 PM\n Arterial Line - 12:14 AM\n Prophylaxis:\n DVT: Hep SC, pneumoboots\n Stress ulcer: Ranitidine\n VAP: Chlorhexidine\n Comments:\n Communication: Comments: wife, \n Code status: Full code, have d/w family.\n Disposition: ICU\n" }, { "category": "Nursing", "chartdate": "2120-04-20 00:00:00.000", "description": "Nursing Progress Note", "row_id": 323119, "text": "Heart failure, right, isolated (Cor Pulmonale)\n Assessment:\n SBP >130 and UO > 100cc/hr\n Action:\n Dobutamine weaning attempted @2300, Restarted @ 2330 0.3mcg/kg/min\n Response:\n Bradycardic to 45, CI <2.4 when dobutamine turned off\n Plan:\n Wean dobutamine, Goal CI >2.5, UO >40cc/hr\n Respiratory failure, acute (not ARDS/)\n Assessment:\n During personal care pt became awake moved UE and fighting on vent and\n desated to 80\n Action:\n Suctioned for thick yellow sec. Fio2 increased to 50%\n Response:\n Sats picked up to 92%\n Plan:\n Cont vent support and ABG in AM\n Pt is sedated on vent. Fentanyl wean to 400mcg/hr, versed cont as\n 10mg/hr. Pt awakened while doing personal care Open eyes but does not\n follow commands. Moved UE No movements on LE noted. Fighting on vent\n and desated to 80\ns suctioned for yellow thick sec and Fio2 increased\n to 50%\n" }, { "category": "Respiratory ", "chartdate": "2120-04-20 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 323203, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 6\n Ideal body weight: 69.9 None\n Ideal tidal volume: 279.6 / 419.4 / 559.2 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation:\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: 23 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Tan / Thick\n Sputum source/amount: Suctioned / Scant\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment: Not triggering\n Dysynchrony assessment:\n Comments: with stimulation will trigger dysynchronously\n Plan\n Next 24-48 hours:\n Reason for continuing current ventilatory support: Underlying illness\n not resolved\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Pleural pressure measurement (0900)\n Comments:\n" }, { "category": "Nursing", "chartdate": "2120-04-22 00:00:00.000", "description": "Nursing Progress Note", "row_id": 323416, "text": "50M h/o metastatic renal CA s/p nephrectomy, IL-2, mini-allograft SCT,\n DLI x 2 last in , emphysema/pulmonary fibrosis on home 02 presents\n with hypotension, fevers, hypoxemic respiratory failure.\n Sepsis, Severe (with organ dysfunction)\n Assessment:\n Continues with low grade temps; tmax 99-3 PO.\n Action:\n Pan cultured.\n Response:\n Plan:\n Continue with abx ; caspofungin per BMT.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Desats when agitiated.\n Action:\n Several sedation boluses throughout shift; Methadone dosing increased.\n Response:\n Short term resolution of agitation\n Plan:\n Propofol gtt initiated; will attempt to wean Fent/Versed.\n" }, { "category": "Nursing", "chartdate": "2120-04-17 00:00:00.000", "description": "Nursing Progress Note", "row_id": 322768, "text": "50M h/o metastatic renal CA s/p nephrectomy, s/p BMT (),\n mini-allograft , emphysema/pulmonary fibrosis on home 02 presents with\n sepsis. Started on NIPPV, hydrocortisone, broad spectrum abx at OSH,\n TTE at OSH EF 65-70, RV dilation. Admitted to for further\n management of Sepsis, PNA secondary to lung fibrosis.\n Sepsis, Severe (with organ dysfunction)\n Assessment:\n Pt is heavily sedated on Fentanyl 350 mcg/hr and versed 6 mg/hr as well\n as paralysed with cisatracurium 0.1 mg/kg/hr, unresponsive, MAP has\n been maintained above 65, HR 75-95 NSR, CO wa 5.5 at beginning of\n shift, decreased gradually to 2.8, HO (Dr. informed, CVP 20-37.\n UO 30-50 cc hr, L foot cooler than Rt, ultrasound yesterday showed no\n clots.\n Action:\n Maintained on Acyclovir, bactrim, caspofungin, vancomycin and zosyn,\n Levophed was weaned to OFF at 0500, still on Vasopresin drip, Vigileo\n monitoring attached to monitor C/O. T max 98.6, dopplerable peripheral\n pulses.\n Response:\n MAP maintained above the goal (65) on vasopressin. CVP above 20, U/O\n about 50 cc/hr, no fluid boluses needed, still receiving antibiotics\n and steroids.\n Plan:\n Monitor BP closely, follow UO and Vigileo monitoring for CO, continue\n steroids and antibiotics. Follow up on culture data and WBC, monitor\n for spikes of Temp, culture as needed. If hemodynamically stable and\n MAP above 65, try to stop vasopressin, monitor FS and cover per sliding\n scale, advance tube feeding to goal, replete lytes as needed.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Intubated on PCV, TV 450, PEEP 16, FiO2 received 100%, weaned down to\n 60% based on frequent ABG monitoring. Esophageal balloon was placed\n yesterday , Sat high 90s, LS were coarse, then CTA to diminished at\n bases. Heavily sedated and paralyzed TOF ; paralytic seems to\n be adequate.\n Action:\n ABGs monitored frequently, vent changes made accordingly, TTE done Q 4\n hrs.\n Response:\n Pt showed improvement in ABG\ns, FiO2 and PEEP weaned down, adequately\n paralyzed.\n Plan:\n Monitor ABGs frequently, wean FiO2 and PEEP as tolerated.\n Family meeting with ICU Dr. (resident), this RN, pt\ns wife,\n mother, brothers, and daughter. The pt\ns critical status was explained\n and the option of DNR was discussed considering lack of reversibility\n of any cause of cardiac arrest, all options discussed including Lung\n transplant for the fibrosis, all kept saying\nPt is a fighter\n. Pt\n remains full code at present, the plan well be re-discussed with family\n later on.\n" }, { "category": "Nursing", "chartdate": "2120-04-22 00:00:00.000", "description": "Nursing Progress Note", "row_id": 323411, "text": "Jhtyjhnythtyhny\n Sepsis, Severe (with organ dysfunction)\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": "2120-04-23 00:00:00.000", "description": "Nursing Progress Note", "row_id": 323522, "text": "Bradycardia\n Assessment:\n HR down to 40s intermittently throughout shift.\n Action:\n Weaned sedation slightly.\n Response:\n Minimal effect on HR.\n Plan:\n Continue to monitor.\n Heart failure, right, isolated (Cor Pulmonale)\n Assessment:\n Action:\n Response:\n Plan:\n Sepsis, Severe (with organ dysfunction)\n Assessment:\n T max 99 PO\n Action:\n Remains on abx.\n Response:\n Plan:\n Continue abx ; culture data from pnd. Send stool for C diff when\n able.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Aggressive suctioning by RT early in shift; sats remained stable on PCV\n 24/PEEP 12/50%\n Action:\n Weaned PEEP to 10 with reflective ABG: 7.49/42/103 so PEEP lowered to\n 8\n Response:\n Unable to tolerate PEEP 8 with increase in HR to 140s, sats 89,\n hypertensive.\n Plan:\n Maintain PEEP 10.\n Able to wean Fentanyl slightly to 125 mcg/hr and Propofol to 10mcg/hr;\n Versed remains at 4mg/hr. Methadone dosing increased to Q3 hrs.\n Intermittent periods of agitation and difficult to determine if related\n to sedation titration or pulmonary status.\n PLAN: Wean sedation and vent as tolerated; family in to visit and\n spouse updated by phone.\n" }, { "category": "Nursing", "chartdate": "2120-04-24 00:00:00.000", "description": "Nursing Progress Note", "row_id": 323541, "text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n PCV/10 PEEP/50%/30. Resp pattern regular, sync with vent. LS crackles\n with diminished bases. Clear thick sputum from ET suction. No\n distress noted. Sats 93-97%\n Action:\n No vent changes made\n Response:\n Pt stable on vent\n Plan:\n Con\nt to wean vent as tol. Monitor ABG\ns and resp status. Con\nt abx\n as ordered.\n" }, { "category": "Nursing", "chartdate": "2120-04-22 00:00:00.000", "description": "Nursing Progress Note", "row_id": 323413, "text": "50M h/o metastatic renal CA s/p nephrectomy, IL-2, mini-allograft SCT,\n DLI x 2 last in , emphysema/pulmonary fibrosis on home 02 presents\n with hypotension, fevers, hypoxemic respiratory failure.\n Sepsis, Severe (with organ dysfunction)\n Assessment:\n Continues with low grade temps; tmax 99-3 PO.\n Action:\n Pan cultured.\n Response:\n Plan:\n Continue with abx ; caspofungin per BMT.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Desats when agitiated.\n Action:\n Several sedation boluses throughout shift; Methadone dosing frequency\n increased.\n Response:\n Short term resolution of agitation\n Plan:\n Attempt to wean Fentanyl/Versed by increasing Methadone.\n" }, { "category": "General", "chartdate": "2120-04-23 00:00:00.000", "description": "ICU Attending Note", "row_id": 323511, "text": "Clinician: Attending\n 50 yo man with metastatic renal cell CA s/p allo- SCT with subsequent\n severe chronic resp failure thought to be emphysema and fibrosis of\n unclear etiology (CT from last spring demonstrates severe cystic and\n fibrotic changes with almost no normal appearing lung) presented with 2\n wk prodrome, now with catastrophic acute on chronic failure. CXR shows\n diffuse opacification. Severe shock, initially presumed septic but more\n predominantly cardiogenic. RV with global hypokinesis, dilated, mod-sev\n PAH. Responded well to dobutamine. Was on high dose steroids, tapering\n prednisone and now 40PO qd.\n Adjusting sedation: now on propofol 20/h, fentanyl 150/h, methadone 20q\n 4h IV, Versed 4/h. Pt seems highly sensitive to family and activity\n around him- became very agitated requiring marked increase in sedation\n doses yesterday after family visit.\n Events:\n PC 24/PEEP12/0.5/30/TV400s\n Exam sig for: arousable, reponds to voice and followed commands (moved\n toes bilat), no audible crackles, hypoactiveBS, abd soft, minimal\n peripheral edema, no rashes\n - Remains afebrile\n - autodiuresing\n - No new micro data- bglucan and galactomannan still pending\n H2blocker, hepsc, prednisone, aspirin\n Abx: Vanco/Levoflox/Zosyn/Acyclovir/Caspofungin\n Cardiogenic shock and severe acute on chronic respiratory failure.\n Sepsis.\n CARDIOGENIC SHOCK, PAH, RV FAILURE\n Stable on captopril for afterload reduction, now hypertensive.\n Autodiuresing.\n INFECTION\n No source identified for infection, may have been viral URI, but if he\n did have a component of septic shock, most likely source pneumonia. Was\n ruled out for influenza at OSH. Minimal respiratory secretions. Very\n broad coverage.\n Continue vanc/zosyn/levoflox and prophylactic bactrim and acyclovir.\n Pending beta-glucan and galactomannan with plan to d/c caspofungin if\n markers neg.\n RESP FAILURE\n Infection, sepsis, acute exacerbation of underlying severe chronic\n disease as well as cardiogenic shock, with severe PH and impaired LV\n filling and outflow.\n - Did NOT tolerate changing from PC to AC mode vent- appears\n much more comfortable on PCV- he became agitated on AC\n - Weaning PEEP\n - Will need to discuss trach/PEG with pt\ns wife as he is now\n in a safe PEEP for the procedure and will likely require very prolonged\n vent support wean.\n SEDATION\n Continue to wean fentanyl while on methadone. Then will wean versed,\n will be maintained on methadone and propfol. Bolus fentanyl as needed\n for agitation.\n NUTRITION\n Tolerating TF, on PO narcan.\n HepSC, ranitidine, oral care, pneumoboots\n other issues per Dr \ns note.\n Will meet with pt\ns wife, to update her on developments. Also\n discussed with Dr .\n Total time spent: 75 minutes\n Patient is critically ill.\n" }, { "category": "Nursing", "chartdate": "2120-04-23 00:00:00.000", "description": "Nursing Progress Note", "row_id": 323513, "text": "Bradycardia\n Assessment:\n HR down to 40s intermittently throughout shift.\n Action:\n Weaned sedation slightly.\n Response:\n Minimal effect on HR.\n Plan:\n Continue to monitor.\n Heart failure, right, isolated (Cor Pulmonale)\n Assessment:\n Action:\n Response:\n Plan:\n Sepsis, Severe (with organ dysfunction)\n Assessment:\n T max 99 PO\n Action:\n Remains on abx.\n Response:\n Plan:\n Continue abx ; culture data from pnd. Send stool for C diff when\n able.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Aggressive suctioning by RT early in shift; sats remained stable on PCV\n 24/PEEP 12/50%\n Action:\n Weaned PEEP to 10 with reflective ABG: 7.49/42/103 so PEEP lowered to\n 8\n Response:\n Unable to tolerate PEEP 8 with increase in HR to 140s, sats 89,\n hypertensive.\n Plan:\n Maintain PEEP 10.\n Able to wean Fentanyl slightly to 125 mcg/hr and Propofol to 10mcg/hr;\n Versed remains at 4mg/hr. Methadone dosing increased to Q3 hrs.\n Intermittent periods of agitation and difficult to determine if related\n to sedation titration or pulmonary status.\n PLAN: Wean sedation and vent as tolerated; family in to visit and\n spouse updated by phone.\n" }, { "category": "Physician ", "chartdate": "2120-04-18 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 322945, "text": "Chief Complaint: 50M h/o metastatic renal CA s/p nephrectomy, IL-2,\n mini-allograft SCT, DLI x 2 last in , emphysema/pulmonary fibrosis\n on home 02 presents with sepsis.\n 24 Hour Events:\n -Multiple family discussions, pt FULL CODE\n -Paralysis stopped\n -Started on Dobutamine infusion, MAP maintained at >65 after\n vasopressin stopped. Now off levophed\n -PEEP decreased to 14 from 16, Fi02 50% from 60%\n -UOP maintained >200cc/hr\n -TF held for high residuals. No BM.\n Allergies:\n Flagyl (Oral) (Metronidazole)\n Rash;\n Last dose of Antibiotics:\n Levofloxacin - 10:04 AM\n Vancomycin - 07:35 PM\n Bactrim (SMX/TMP) - 11:39 PM\n Acyclovir - 12:16 AM\n - 03:59 AM\n Piperacillin/Tazobactam (Zosyn) - 06:08 AM\n Infusions:\n Dobutamine - 1.5 mcg/Kg/min\n Midazolam (Versed) - 6 mg/hour\n Fentanyl - 400 mcg/hour\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 07:41 PM\n Famotidine (Pepcid) - 08:30 PM\n Other medications:\n Hydrocortisone 50mg IV Q6\n Acetaminophen prn\n Folic Acid\n Albuterol\n Asa\n ISS\n Docusate\n Senna\n Bisacodyl\n Chlorhexidine\n Changes to medical and family history: None\n Review of systems is unchanged from admission except as noted below\n Review of systems: Intubated, sedated\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: 36.6\nC (97.9\n Tcurrent: 36.1\nC (97\n HR: 67 (56 - 96) bpm\n BP: 117/60(76) {89/58(69) - 152/77(99)} mmHg\n RR: 34 (30 - 34) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 76.3 kg (admission): 76.3 kg\n Height: 68 Inch\n CVP: 17 (10 - 25)mmHg\n CO/CI (CCO): (4.7 L/min) / (2.5 L/min/m2)\n Total In:\n 6,194 mL\n 820 mL\n PO:\n TF:\n 890 mL\n 46 mL\n IVF:\n 4,814 mL\n 739 mL\n Blood products:\n Total out:\n 2,395 mL\n 2,690 mL\n Urine:\n 1,845 mL\n 2,580 mL\n NG:\n 550 mL\n 110 mL\n Stool:\n Drains:\n Balance:\n 3,799 mL\n -1,870 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: PCV+Assist\n PC : 24 cmH2O\n RR (Set): 34\n PEEP: 14 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10\n PIP: 38 cmH2O\n Plateau: 36 cmH2O\n SpO2: 96%\n ABG: 7.36/39/95./21/-2\n Ve: 15.9 L/min\n PaO2 / FiO2: 192\n Physical Examination\n General Appearance: Intubated, sedated\n Eyes / Conjunctiva: Pupils dilated\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube\n Lymphatic: No(t) Cervical WNL, No(t) Supraclavicular WNL, No(t)\n Cervical adenopathy\n Cardiovascular: (S1: Normal), (S2: Normal, Fixed), tachycardic. regular\n Peripheral Vascular: (Right radial pulse: Diminished), (Left radial\n pulse: Diminished), (Right DP pulse: Diminished), (Left DP pulse:\n Diminished)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Rhonchorous: ), coarse mechanical BS throughout all lung fields\n Abdominal: Soft, Non-tender, hypoactive bowel sounds\n Extremities: no edema, palpable distal pulses\n Skin: Not assessed\n Neurologic: Intubated, sedated, paralyzed\n Labs / Radiology\n 124 K/uL\n 11.3 g/dL\n 99 mg/dL\n 1.1 mg/dL\n 21 mEq/L\n 4.6 mEq/L\n 19 mg/dL\n 110 mEq/L\n 139 mEq/L\n 33.6 %\n 12.3 K/uL\n [image002.jpg]\n 06:59 PM\n 09:54 PM\n 11:52 PM\n 04:37 AM\n 04:52 AM\n 08:05 PM\n 10:19 PM\n 12:20 AM\n 04:38 AM\n 05:01 AM\n WBC\n 13.1\n 12.3\n Hct\n 35.4\n 33.6\n Plt\n 119\n 124\n Cr\n 1.1\n 1.1\n TropT\n 0.22\n TCO2\n 23\n 21\n 21\n 20\n 21\n 22\n 22\n 23\n Glucose\n 164\n 179\n 174\n 99\n Other labs: PT / PTT / INR:14.9/28.9/1.3, CK / CKMB /\n Troponin-T:260/9/0.22, ALT / AST:94/64, Alk Phos / T Bili:84/0.3,\n Amylase / Lipase:53/22, Differential-Neuts:67.0 %, Band:2.0 %,\n Lymph:18.0 %, Mono:9.0 %, Eos:0.0 %, Lactic Acid:1.7 mmol/L,\n Albumin:2.7 g/dL, LDH:274 IU/L, Ca++:8.1 mg/dL, Mg++:2.2 mg/dL, PO4:1.6\n mg/dL\n Assessment and Plan\n 50M h/o metastatic renal CA s/p nephrectomy, IL-2, mini-allograft SCT,\n DLI x 2 last in , emphysema/pulmonary fibrosis on home 02 presents\n with sepsis.\n # Sepsis: On presentation to OSH pt hypotensive, hypoxic with fevers\n and leukocytosis. Now with hypoxic respiratory failure, requiring\n pressors. Likely pneumonia given hypoxia and possible opacities on\n CXR, although difficult to read due to fibrosis. No other apparent\n localizing symptoms. Ruled-out for flu at OSH. Urine, GI sources less\n probable. Given immunocompromise from malignancy, at risk for PCP,\n , etc. Progression of GVHD could be contributing. Given tenuous\n respiratory status and requirments for high levels of PEEP a\n bronchoscopy would be too high risk for BAL and culture data.\n - Will attempt to obtain deep ET sputum for culture\n - legionella urine ag negative, all other cultures no growth to date.\n - Vanc, zosyn, levofloxacin, bactrim IV for PCP, to cover\n broadly for now given critical illness. Iv steroids for PCP and\n adrenal insufficiency as below.\n - glucan, galactomannan pending\n - CT chest and possible bronch when more stable\n - Follow WBC count, fever curve\n - PPD to be read \n # Respiratory failure: Pneumonia in patient with poor pulmonary reserve\n due to emphysema, ?GVHD, fibrosis. Avoid high pressures given fibrotic\n lungs, using pressure control ventilation. Tolerated decrease in Fi02\n from 100% to 60% yesterday, oxygenating well.\n -continue to wean FI02\n -will d/c cisatracurium infusion and use boluses as needed for\n paralysis should pt be dysynchronous with ventilator, otherwise will\n continue to manage sedation/pain with fentanyl/versed, increasing gtt\n as needed.\n - Continue mechanical ventilatory support, wean as tolerated\n -No proning for now as pt oxygenating well.\n # Hypotension: Likely sepsis, although probably component of\n hypovolemia as well. At risk for PE given malignancy. GI bleed unlikely\n as Hct stable. Adrenal insufficiency possible given s/p adrenelectomy\n with mets in remaining adrenal. Pt has dysfunctional RV with severe\n likely contributing to low CO. Set up vigileo device yesterday\n for non-invasive hemodynamic monitoring. Initially CI was 2.8, this am\n 1.8, a concerning decrease. His SV variability is low, indicating\n minimal fluid responsiveness.\n - start dobutamine in an attempt to increase CO, titrate to goal CO >4,\n CI >2.5, maintain on vasopressin and levophed. Monitor pressors if\n becomes hypotensive due to vasodilitory effect will discontinue.\n - No prostacyclin/NO for now due to concern that may increase mismatch\n and worsen hypoxia.\n - Consider PA catheter placement for more accurate hemodynamic\n monitoring, will continue to use vigileo for now.\n - Treat broadly for infection per above\n - IV hydrocort Q6 for adrenal insufficiency\n - LENIs to look for DVT negative.\n - Guaiac stools, HCT has been stable.\n # Cardiac: Patient with probable demand ischemia in setting of\n hypotension, tachycardia, and sepsis; less likely unstable plaque.\n - CE\ns this am trending down\n - ASA, hold on beta-blocker and statin\n - Repeat ECG in am\n # Metastatic renal CA: Recurrent disease s/p donor lymphocyte\n transplant .\n - BMT to follow\n - Avoid steroids given risk to graft\n - Continue acyclovir ppx for now, will discuss with BMT\n ICU Care\n ICU Care\n Nutrition: TF, tolerating with low residuals.\n Replete (Full) - 06:20 AM 40 mL/hour, advance as tolerated\n to goal of 70mL /hour\n Glycemic Control: ISS prn\n Lines:\n 20 Gauge - 09:10 PM\n Multi Lumen - 11:24 PM\n Arterial Line - 12:14 AM\n Prophylaxis:\n DVT: Hep SC, pneumoboots\n Stress ulcer: Ranitidine\n VAP: Chlorhexidine\n Comments:\n Communication: Comments: wife, \n Code status: Full code, have d/w family, will continue to readdress\n today\n Disposition: ICU\n" }, { "category": "Respiratory ", "chartdate": "2120-04-21 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 323293, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 7\n Ideal body weight: 69.9 None\n Ideal tidal volume: 279.6 / 419.4 / 559.2 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation:\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: 24 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Tan / Thick\n Sputum source/amount: Suctioned / Scant\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing;\n Comments: with sedation\n Assessment of breathing comfort: No response (sleeping / sedated)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment: Not triggering\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Adjust Min. ventilation to control pH; Comments:\n decrease driving pressure\n Reason for continuing current ventilatory support: Underlying illness\n not resolved\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n" }, { "category": "Respiratory ", "chartdate": "2120-04-22 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 323407, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 8\n Ideal body weight: 69.9 None\n Ideal tidal volume: 279.6 / 419.4 / 559.2 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation:\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type: Standard\n Size: 7.5mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Bronchial\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Bronchial\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: pt with periods of\n restlessness, esp. when stimulated\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Reduce PEEP as tolerated, Adjust Min. ventilation to\n control pH; Comments: sats improved over course of shift. Pt\n auto-diuresing, more sedated, less restless in afternoon\n Reason for continuing current ventilatory support: Underlying illness\n not resolved\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n Remains on PCV with driving pressure of 26. TV\ns of 450-470cc, minute\n volume 13-14L consistently. Improved sats in afternoon. Plan is for\n ABG, possibly lower peep level. Cont to receive Albuterol MDI Q vent\n check. Sputum specimen obtained.\n" }, { "category": "Respiratory ", "chartdate": "2120-04-23 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 323502, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 9\n Ideal body weight: 69.9 None\n Ideal tidal volume: 279.6 / 419.4 / 559.2 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation:\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type: Standard\n Size: 7.5mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Brown / Thick\n Sputum source/amount: Suctioned / Moderate\n Comments:\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern:\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Reduce PEEP as tolerated\n Reason for continuing current ventilatory support: Intolerant of\n weaning attempts\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n Esophageal balloon discontinued, pulled off. Around 1430.\n" }, { "category": "Physician ", "chartdate": "2120-04-25 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 323700, "text": "Chief Complaint: 50M h/o metastatic renal CA s/p nephrectomy, IL-2,\n mini-allograft SCT, DLI x 2 last in , emphysema/pulmonary fibrosis\n on home 02 presented to OSH with hypoxic respiratory failure, fevers\n and hypotension with sepsis, cardiogenic shock now unable to wean off\n ventilator.\n 24 Hour Events:\n -B-glucan and galactomannan still pending\n -Decreased Fi02 to 40%, hypoxic, increased back to 50% with good\n response\n -TF held at MN for trach/peg.\n -Increased captopril to 25\n Allergies:\n Flagyl (Oral) (Metronidazole)\n Rash;\n Last dose of Antibiotics:\n Levofloxacin - 09:10 AM\n Vancomycin - 08:26 PM\n Caspofungin - 09:28 PM\n Acyclovir - 12:20 AM\n Piperacillin/Tazobactam (Zosyn) - 06:24 AM\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 07:41 PM\n Heparin Sodium (Prophylaxis) - 07:41 PM\n Dextrose 50% - 06:35 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 12 AM\n Tmax: 37.3\nC (99.2\n Tcurrent: 36.8\nC (98.3\n HR: 48 (42 - 111) bpm\n BP: 108/56(73) {98/56(72) - 171/91(120)} mmHg\n RR: 30 (19 - 30) insp/min\n SpO2: 95%\n Heart rhythm: SB (Sinus Bradycardia)\n Wgt (current): 76.3 kg (admission): 76.3 kg\n Height: 68 Inch\n CVP: 13 (3 - 13)mmHg\n Total In:\n 3,526 mL\n 413 mL\n PO:\n TF:\n 1,308 mL\n 26 mL\n IVF:\n 1,738 mL\n 333 mL\n Blood products:\n Total out:\n 7,165 mL\n 730 mL\n Urine:\n 7,165 mL\n 730 mL\n NG:\n Stool:\n Drains:\n Balance:\n -3,639 mL\n -317 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: PCV+\n PC : 24 cmH2O\n RR (Set): 30\n PEEP: 10 cmH2O\n FiO2: 50%\n PIP: 34 cmH2O\n Plateau: 33 cmH2O\n SpO2: 95%\n ABG: 7.44/50/110/30/8\n Ve: 11.7 L/min\n PaO2 / FiO2: 220\n Physical Examination\n Gen: Sedated, localization to voice\n Heent: pupils equal. Trached.\n Cor: RRR, nls1s2 no mr\n Pul: CTA anteriorly- mechanical breath sounds\n Abd: moderately distended. Bowel sounds present, PEG in placed,\n dressed, no guarding, no tenderness\n Extreme: Warm, trace pitting edema to mid-thigh\n Labs / Radiology\n 149 K/uL\n 10.6 g/dL\n 70 mg/dL\n 1.0 mg/dL\n 30 mEq/L\n 3.8 mEq/L\n 19 mg/dL\n 105 mEq/L\n 141 mEq/L\n 31.6 %\n 13.6 K/uL\n [image002.jpg]\n 03:50 PM\n 07:18 PM\n 03:49 AM\n 04:48 AM\n 11:19 AM\n 01:45 PM\n 08:13 PM\n 10:07 PM\n 04:05 AM\n 04:29 AM\n WBC\n 13.9\n 13.6\n Hct\n 30.8\n 31.6\n Plt\n 144\n 149\n Cr\n 0.9\n 0.9\n 0.9\n 1.0\n TCO2\n 33\n 35\n 36\n 36\n 34\n 35\n Glucose\n 101\n 92\n 93\n 70\n Other labs: PT / PTT / INR:13.7/42.1/1.2, CK / CKMB /\n Troponin-T:260/9/0.22, ALT / AST:57/31, Alk Phos / T Bili:70/0.4,\n Amylase / Lipase:53/22, Differential-Neuts:67.0 %, Band:2.0 %,\n Lymph:18.0 %, Mono:9.0 %, Eos:0.0 %, Lactic Acid:2.0 mmol/L,\n Albumin:2.6 g/dL, LDH:272 IU/L, Ca++:8.2 mg/dL, Mg++:2.3 mg/dL, PO4:3.1\n mg/dL\n Imaging: CXR IMPRESSION:\n 1. Decrease in the bilateral pulmonary edema.\n 2. Chronic interstitial lung disease.\n 3. Lines and tubes are in satisfactory location.\n Microbiology: Sputum cx: Neg\n Bcx: NGTD\n Assessment and Plan\n 50M h/o metastatic renal CA s/p nephrectomy, IL-2, mini-allograft SCT,\n DLI x 2 last in , emphysema/pulmonary fibrosis on home 02\n presented to OSH with hypoxic respiratory failure, sepsis, cardiogenic\n shock, now improving but with difficulty weaning vent and s/p\n trach/PEG.\n # Respiratory failure: Pneumonia as likely source of resp failure and\n sepsis in patient with poor pulmonary reserve due to emphysema, ?GVHD,\n fibrosis. Patient is now s/p trach/PEG this morning.\n - PEEP decreased to 10 which patient tolerated well. Did not tolerated\n PEEP decrease to 8 (increased agitation). Will maintain current PEEP\n at 10\n - Would not change driving pressures either as patient now has\n compensatory respiratory acidosis for metabolic alkalosis likely\n secondary to auto-diuresis.\n - Attempt decrease in FiO2 today (50->40%) -> maintain PaO2 >60\n - Patient did tolerate AC during trach today when he was completely\n sedated, though he did not tolerate this prior. Once sedation is\n decreased, can consider changing to PSV. He will likely continue to\n require high PEEPs\n # Sedation: Goals of sedation have been clarified; being too light was\n causing problems w/ oxygenation. Pt also was requiring supra-normal\n levels of midaz/fentanyl. Started on propofol for worsening agitation\n causing desats\n - On methadone q4H, fentanyl and versed off. On propofol for sedation,\n currently at 45 mcg/kg/min. Off fent/versed drips.\n - Goal to wean propofol as tolerated today, will check triglycerides.\n - Bolus fentanyl/ativan prn agitation\n - When able, will decrease methadone to q6H then to q8H\n # Shock: Multifactorial\n ** Sepsis: Likely source pneumonia. On very broad coverage w/\n vancomycin, levofloxacin, zosyn, bactrim (now only ppx dosing),\n caspofungin. All other cultures pending. WBC and fever curve\n improving slightly.\n - D/C caspo when beta glucan / galactomannan negative per BMT\n - F/u cultures- cont to culture with spikes. Currently afebrile x >24H\n - PPD negative\n - Continue acyclovir ppx, vanc/zosyn/levoflox for 14 day course, today\n is day 7.\n **Cardiogenic\n ## Pump: Now improved BPs, off dobutamine. On captopril for afterload\n reduction. Dilated hypokinetic RV, likely causative in hypotension.\n Now hypertensive. Increased to 25mg TID.\n ## Rhythm: Sinus bradycardia likely secondary to sedatives; increases\n with agitation. Cont weaning sedation as tolerated. Continue to\n follow QTc for prolongation given methadone and levoflox, has been wnl\n **Endocrine\n - Cont w/ rapid PO pred taper, decrease to 10 today then off.\n # Metastatic renal CA: Recurrent disease s/p donor lymphocyte\n transplant .\n - BMT to follow\n - Continue acyclovir and bactrim ppx for now, will discuss with BMT\n ICU Care\n Nutrition:\n Holding TF for now, will restart via PEG in hours.\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Multi Lumen - 11:24 PM\n Arterial Line - 12:14 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP: HOB elevation, Mouth care\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:ICU\n" }, { "category": "Nursing", "chartdate": "2120-04-25 00:00:00.000", "description": "Nursing Progress Note", "row_id": 323713, "text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Trach and PEG placed this AM. Pt. tolerated well. PEG to gravity, able\n to give medications, hold TF until tomorrow. Trach PCV 24 Insp\n Pressure/30 RR/5 PEEP/50% FiO2\n Action:\n ABG done, Propofol decreased to 30 mcg/kg/min\n Response:\n ABG: , pt. more awake, moving extremeities on bed. Does not follow\n commands\n Plan:\n Continue to wean sedation to encourage pt. participation in weaning\n from ventilation. Continue Methadone 20mg q4h, fent and ativan boluses\n prn agitation.\n" }, { "category": "General", "chartdate": "2120-04-25 00:00:00.000", "description": "Generic Note", "row_id": 323714, "text": "TITLE: RESPIRATORY CARE: PT REMAINS ON PCV AS PER METAVISION W/ PEEP\n REDUCED TO 5 CM H2O DUE TO AIRLEAK AROUND NEW TRACH. 8.0 PORTEX TRACH\n PLACED TODAY BY IP\n AND THORACIC. SEEMS TO HAVE A PERSISTENT CUFF LEAK AND REQUIRING A\n LARGE VOLUME OF AIR IN CUFF. IP NOTIFIED AND WILL BE OVER TO EVALUATE.\n IN MEANTIME\n WILL REMAIN ON PCV AND TOLERATE A CUFF LEAK AS LONG AS VT\nS 350-450 CC\n AND CUFF PRESSURE 25-30 CM H2O.\n" }, { "category": "Nursing", "chartdate": "2120-04-20 00:00:00.000", "description": "Nursing Progress Note", "row_id": 323113, "text": "Heart failure, right, isolated (Cor Pulmonale)\n Assessment:\n SBP >130 and UO > 100cc/hr\n Action:\n Dobutamine weaning attempted @2300, Restarted @ 2330 0.3mcg/kg/min\n Response:\n Bradycardic to 45, CI <2.4 when dobutamine turned off\n Plan:\n Wean dobutamine, Goal CI >2.5, UO >40cc/hr\n Respiratory failure, acute (not ARDS/)\n Assessment:\n During personal care pt became awake moved UE and fighting on vent and\n desated to 80\n Action:\n Suctioned for thick yellow sec. Fio2 increased to 50%\n Response:\n Sats picked up to 92%\n Plan:\n Cont vent support and ABG in AM\n" }, { "category": "Physician ", "chartdate": "2120-04-23 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 323499, "text": "Chief Complaint: 50M h/o metastatic renal CA s/p nephrectomy, IL-2,\n mini-allograft SCT, DLI x 2 last in , emphysema/pulmonary fibrosis\n on home 02 presented to OSH with hypoxic respiratory failure, fevers\n and hypotension.\n 24 Hour Events:\n - Still agitated on high doses of fentanyl/versed/methadone; methadone\n increased to q6H (per pharm requested q4H but held off for now due to\n QTc and bradycardia)\n - Patient was very agitated on high doses of Fentanyl/Versed (525/12)\n and methadone q6H -> increased methadone to q4H per pharmacy recs and\n added propofol as patient very agitated...attempting to wean propofol\n and fent/midaz as methadone kicks in throughout the night.\n - Patient became very bradycardic into the 30s, propofol, fent and\n midaz all weaned down with improvement in rates to 40s and 50s with\n minimal to no agitation (though patient more alert)\n - Off lasix gtt but with significant autodiuresis (250-300 cc/hr)\n - Driving pressure decreased further to 24\n - Bcx, urine cx, sputum cx sent today as no micro since and still\n with high WBC and low grade fevers\n - BMT recs: no new\n Allergies:\n Flagyl (Oral) (Metronidazole)\n Rash;\n Last dose of Antibiotics:\n Acyclovir - 04:18 PM\n Levofloxacin - 09:41 AM\n Vancomycin - 08:20 PM\n Caspofungin - 09:22 PM\n Piperacillin/Tazobactam (Zosyn) - 06:01 AM\n Infusions:\n Propofol - 15 mcg/Kg/min\n Midazolam (Versed) - 4 mg/hour\n Fentanyl - 150 mcg/hour\n Other ICU medications:\n Famotidine (Pepcid) - 08:00 PM\n Heparin Sodium (Prophylaxis) - 08:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n 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: 37.4\nC (99.3\n Tcurrent: 36.7\nC (98.1\n HR: 41 (37 - 116) bpm\n BP: 133/60(82) {123/56(76) - 182/82(116)} mmHg\n RR: 27 (17 - 30) insp/min\n SpO2: 95%\n Heart rhythm: SB (Sinus Bradycardia)\n Wgt (current): 76.3 kg (admission): 76.3 kg\n Height: 68 Inch\n CVP: 10 (10 - 21)mmHg\n CO/CI (CCO): (4.4 L/min) / (2.3 L/min/m2)\n Total In:\n 5,866 mL\n 812 mL\n PO:\n TF:\n 1,724 mL\n 328 mL\n IVF:\n 3,392 mL\n 384 mL\n Blood products:\n Total out:\n 5,850 mL\n 1,540 mL\n Urine:\n 5,850 mL\n 1,540 mL\n NG:\n Stool:\n Drains:\n Balance:\n 16 mL\n -727 mL\n Respiratory support\n Ventilator mode: PCV+\n PC : 24 cmH2O\n RR (Set): 30\n PEEP: 12 cmH2O\n FiO2: 1%\n PIP: 36 cmH2O\n Plateau: 30 cmH2O\n SpO2: 95%\n ABG: 7.47/44/94./32/7\n Ve: 13.5 L/min\n PaO2 / FiO2: 18,800\n Physical Examination\n Gen: eyes open, follow commands to move toes, localization to voice\n Heent: pupils equal. Intubated, ng tube and esophageal balloon in\n place\n Cor: rrr, nls1s2 no mr\n Pul: cta anteriorly- mechanical breath sounds\n Abd: moderately distended. Bowel sounds present, no guarding, no\n tenderness\n Extreme: warm, trace pitting edema to mid-thigh\n Neuro: sedated, but responds to voice and follows some commands\n Labs / Radiology\n 174 K/uL\n 10.8 g/dL\n 115 mg/dL\n 0.8 mg/dL\n 32 mEq/L\n 3.3 mEq/L\n 19 mg/dL\n 106 mEq/L\n 144 mEq/L\n 32.5 %\n 12.9 K/uL\n [image002.jpg]\n 01:58 AM\n 04:48 AM\n 05:04 AM\n 08:15 PM\n 04:54 AM\n 05:34 AM\n 05:52 PM\n 08:48 PM\n 04:35 AM\n 04:49 AM\n WBC\n 12.1\n 12.5\n 12.9\n Hct\n 31.2\n 31.9\n 32.5\n Plt\n 120\n 135\n 174\n Cr\n 1.0\n 1.0\n 0.9\n 0.8\n TCO2\n 28\n 26\n 33\n 36\n 36\n 33\n Glucose\n 122\n 99\n 115\n Other labs: PT / PTT / INR:13.1/32.2/1.1, CK / CKMB /\n Troponin-T:260/9/0.22, ALT / AST:57/31, Alk Phos / T Bili:70/0.4,\n Amylase / Lipase:53/22, Differential-Neuts:67.0 %, Band:2.0 %,\n Lymph:18.0 %, Mono:9.0 %, Eos:0.0 %, Lactic Acid:2.0 mmol/L,\n Albumin:2.6 g/dL, LDH:272 IU/L, Ca++:7.8 mg/dL, Mg++:2.3 mg/dL, PO4:2.4\n mg/dL\n Assessment and Plan\n 50M h/o metastatic renal CA s/p nephrectomy, IL-2, mini-allograft SCT,\n DLI x 2 last in , emphysema/pulmonary fibrosis on home 02\n presented to OSH with hypoxic respiratory failure, fevers and\n hypotension.\n # Respiratory failure: Pneumonia as likely source of resp failure and\n sepsis in patient with poor pulmonary reserve due to emphysema, ?GVHD,\n fibrosis.\n - Had difficulty with agitation and dropping sats yesterday; had to\n initially increase fent/midaz despite methadone, was then started on\n profol, but has since been significantly weaned with good O2 sats and\n no agitation\n - Decrease PEEP to 10 to continuing weaning as tolerated; hold on\n driving pressures for now since patient has compensatory respiratory\n acidosis for metabolic alkalosis likely secondary to auto-diuresis.\n - No change to A/C as patient has been tolerating PCV well\n - remove esophageal balloon\n - call IP to discuss placing trach.\n # Sedation: Goals of sedation have been clarified; being too light was\n causing problems w/ oxygenation. Pt also was requiring supra-normal\n levels of midaz/fentanyl. Started on propofol for worsening agitation\n causing desats\n - goal for today to increase methadone to 20 mg Q3H, decrease fentanyl\n and propofol, but if agitation/desats occurs, can use fentanyl boluses\n rather than increasing gtt again\n # Shock: Multifactorial\n ** Sepsis: Likely source pneumonia. On very broad coverage w/\n vancomycin, levofloxacin, zosyn, bactrim (now only ppx dosing),\n caspofungin. All other cultures pending. WBC and fever curve\n improving slightly.\n - D/C caspo when beta glucan / galactomannan negative per BMT\n - F/u cultures- cont to culture with spikes. Currently afebrile x >24H\n - PPD negative\n - Continue acyclovir ppx, vanc/zosyn/levoflox for 14 day course.\n **Cardiogenic\n ## Pump: Now improved BPs, off dobutamine. dilated hypokinetic RV,\n likely causative in hypotension. Now BP recovering well.\n ## Rhythm: Sinus bradycardia likely secondary to sedatives; increases\n with agitation. Cont weaning sedation as tolerated. BP stable\n QTc: prolonged mimimally to 485. Cont check EKG w/ levofloxacin,\n methadone.\n **Endocrine\n - cont w/ rapid PO pred taper, decrease to 40->20->10 then off.\n # Metastatic renal CA: Recurrent disease s/p donor lymphocyte\n transplant .\n - BMT to follow\n - Continue acyclovir and bactrim ppx for now, will discuss with BMT\n ICU Care\n Nutrition: Tube feeds\n Glycemic Control: ISS\n Lines:\n Multi Lumen - 11:24 PM\n Arterial Line - 12:14 AM\n Prophylaxis:\n DVT: hep sc\n Stress ulcer: famotidine\n VAP: mouth care\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU level of care ; cont to wean sedation. d/w family re\n Trach\n" }, { "category": "Respiratory ", "chartdate": "2120-04-24 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 323616, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 10\n Ideal body weight: 69.9 None\n Ideal tidal volume: 279.6 / 419.4 / 559.2 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation:\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type: Standard\n Size: 7.5mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Tan / Thin\n Sputum source/amount: Suctioned / Moderate\n Comments:\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern:\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours:\n Reason for continuing current ventilatory support: Intolerant of\n weaning attempts\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n Plan is for patient to have bedside tracheostomy done either this\n evening or tomorrow.\n" }, { "category": "Nutrition", "chartdate": "2120-04-25 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 323681, "text": "Potential for nutrition risk. Patient being monitored. Current\n intervention if any, listed below:\n Comments:\n Patient requested to speak with Nutrition regarding his diet. Patient\n does not wish to be on a Diabetic diet at this time. Spoke with patient\n and explained the diabetic diet. He seems to understand, but does not\n want to be restricted. Would continue to allow patient to have Regular\n diet and monitor blood glucose. Patient requested to have no garnishes\n on trays, have entered this restriction into the system. Was concerned\n that kitchen would not know that he was on a regular diet, I assured\n him that they will allow him to order off the regular menu. Will follow\n and let him know that if he has any additional questions, I will come\n back and see him. Thanks.\n 09:27\n ------ Protected Section------\n Wrong patient, note is in Error.\n ------ Protected Section Error Entered By: , MS, RD, LDN,\n on: 09:28 ------\n 09:28\n" }, { "category": "Physician ", "chartdate": "2120-04-25 00:00:00.000", "description": "ICU Attending Note", "row_id": 323696, "text": "Clinician: Attending\n 50 yo man with metastatic renal cell CA s/p allo- SCT with subsequent\n severe chronic resp failure thought to be emphysema and fibrosis of\n unclear etiology (CT from last spring demonstrates severe cystic and\n fibrotic changes with almost no normal appearing lung) presented with 2\n wk prodrome, presented with catastrophic acute on chronic failure. CXR\n shows diffuse opacification c/w ARDS. Severe shock, initially presumed\n septic but more predominantly cardiogenic. RV with global hypokinesis,\n dilated, mod-sev PAH. Responded well to dobutamine. Was on high dose\n steroids, tapering prednisone and now 40PO qd.\n Events:\n Adjusting sedation: Fentanyl off! now on propofol 25/h,\n methadone 20q 4h IV, Versed 2/h\n PC 0.5/24/PEEP10/30/TV400s 7.44/50/110\n Exam sig for: Remains afebrile, autodiuresing, sedated from trach and\n less responsive currently, trach site clean with no oozing, loud upper\n airway noise, hypoactiveBS, abd soft, trach site looks good, minimal\n peripheral edema, no rashes\n - No new micro data- bglucan and galactomannan still pending\n H2blocker, hepsc, prednisone 20, aspirin\n Abx: Vanco/Levoflox/Zosyn/Caspofungin/bactrim and acyclovir\n prophylaxis\n Cardiogenic shock and severe acute on chronic respiratory failure.\n Sepsis.\n CARDIOGENIC SHOCK, PAH, RV FAILURE\n Stable on increased dose captopril for afterload reduction, mildly\n hypertensive.\n Autodiuresing.\n RESP FAILURE\n No sig changes on vent today, given s/p trach this morning and on PEEP\n 10.\n INFECTION\n D7 vanc/zosyn/levoflox/caspofungin and prophylactic bactrim and\n acyclovir.\n Pending beta-glucan and galactomannan with plan to d/c caspofungin if\n markers neg.\n SEDATION\n Off fentanyl and versed. Continues on propofol and methadone. Bolus\n fentanyl/ativan as needed for pain/agitation and try to wean propofol.\n Will decrease methadone to q6 then q8. QTc okay. D3 propofol, will\n check triglycerides.\n NUTRITION\n Held TF for PEG- will restart in 12h, on PO narcan.\n HepSC, ranitidine, oral care, pneumoboots, HOB up.\n other issues per Dr \ns note.\n Total time spent: 45 minutes\n Patient is critically ill.\n" }, { "category": "Nutrition", "chartdate": "2120-04-22 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 323387, "text": "Labs:\n Value\n Date\n Glucose\n 99 mg/dL\n 04:54 AM\n Glucose Finger Stick\n 102\n 06:00 AM\n BUN\n 24 mg/dL\n 04:54 AM\n Creatinine\n 1.0 mg/dL\n 04:54 AM\n Sodium\n 148 mEq/L\n 04:54 AM\n Potassium\n 2.8 mEq/L\n 04:54 AM\n Chloride\n 107 mEq/L\n 04:54 AM\n TCO2\n 33 mEq/L\n 04:54 AM\n PO2 (arterial)\n 98. mm Hg\n 05:34 AM\n PCO2 (arterial)\n 50 mm Hg\n 05:34 AM\n pH (arterial)\n 7.45 units\n 05:34 AM\n pH (urine)\n 6.0 units\n 04:47 AM\n CO2 (Calc) arterial\n 36 mEq/L\n 05:34 AM\n Albumin\n 2.6 g/dL\n 04:54 AM\n Calcium non-ionized\n 226.0\n 12:00 PM\n Phosphorus\n 2.6 mg/dL\n 04:54 AM\n Ionized Calcium\n 1.02 mmol/L\n 06:28 PM\n Magnesium\n 2.1 mg/dL\n 04:54 AM\n WBC\n 12.5 K/uL\n 04:54 AM\n Hgb\n 10.8 g/dL\n 04:54 AM\n Hematocrit\n 31.9 %\n 04:54 AM\n Current diet order / nutrition support: FS Replete w/ Fiber @70cc/hr\n GI: Abd soft/obese/NT/ND, +BS\n Assessment of Nutritional Status\n Intubated and sedated.\n Pt w/ met. Renal ca S/P nephrectomy p/w HoTN, fevers and resp failure,\n possibly PNA. Pt septic, pending cultures MD notes. Pt bradycardic\n and on diuresis. At goal TF, tol well w/ min. residuals.\n Medical Nutrition Therapy Plan - Recommend the Following\n 1. Continue w/ TF via OGT, FS Replte w/ Fiber@70cc/hr to provide\n 1680kcals and 104g prot/ day meeting 100% est needs.\n 2. Check residual q 4-6 hrs, hold TF if > 150cc\n 3. Monitor and replete lytes prn, low K today. Would benefit from\n IV repletions.\n 4. Monitor hydration status.\n 12:58\n" }, { "category": "Physician ", "chartdate": "2120-04-22 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 323391, "text": "Chief Complaint: shock/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 50 yo male with metastatic renal cell CA s/p allo-SCT, COPD/fibrosis\n admitted with resp failure/shock. Mixed septic/cardiogenic picture with\n resp failure related to probable infxn superimposed on RV failure/pHTN,\n severe chronic pulm ds\n 24 Hour Events:\n *Still bradycardic\n *Vent wean: Decreased to PC 24\n *Diuresed\n History obtained from Medical records\n Patient unable to provide history: Sedated\n Allergies:\n Flagyl (Oral) (Metronidazole)\n Rash;\n Last dose of Antibiotics:\n Acyclovir - 04:18 PM\n Caspofungin - 08:00 PM\n Piperacillin/Tazobactam (Zosyn) - 05:54 AM\n Vancomycin - 08:28 AM\n Levofloxacin - 09:41 AM\n Infusions:\n Midazolam (Versed) - 10 mg/hour\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:32 PM\n Famotidine (Pepcid) - 07:51 AM\n Other medications:\n ASA, folic acid, SSI, lactulose, captopril, prednisone 60mg 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 11:26 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 (99.3\n HR: 41 (41 - 60) bpm\n BP: 125/59(79) {119/50(69) - 159/69(93)} mmHg\n RR: 30 (21 - 30) insp/min\n SpO2: 94%\n Heart rhythm: SB (Sinus Bradycardia)\n Wgt (current): 76.3 kg (admission): 76.3 kg\n Height: 68 Inch\n CVP: 12 (6 - 18)mmHg\n CO/CI (CCO): (4.4 L/min) / (2.3 L/min/m2)\n Total In:\n 5,547 mL\n 2,454 mL\n PO:\n TF:\n 2,460 mL\n 818 mL\n IVF:\n 2,577 mL\n 1,236 mL\n Blood products:\n Total out:\n 7,120 mL\n 2,310 mL\n Urine:\n 7,120 mL\n 2,310 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,573 mL\n 144 mL\n Respiratory support\n Ventilator mode: PCV+\n PC : 26 cmH2O\n RR (Set): 30\n PEEP: 12 cmH2O\n FiO2: 50%\n PIP: 37 cmH2O\n Plateau: 25 cmH2O\n SpO2: 94%\n ABG: 7.45/50/98./33/8\n Ve: 13.9 L/min\n PaO2 / FiO2: 196\n Physical Examination\n General Appearance: Well nourished, No(t) No acute distress, Overweight\n / Obese, No(t) Thin\n Eyes / Conjunctiva: PERRL, No(t) Pupils dilated, No(t) Conjunctiva pale\n Head, Ears, Nose, Throat: Normocephalic, No(t) Poor dentition, No(t) NG\n tube, 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) S3, No(t) S4,\n No(t) Rub, (Murmur: No(t) Systolic, No(t) Diastolic)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Present), (Left DP pulse:\n Present)\n Respiratory / Chest: (Expansion: Symmetric, No(t) Paradoxical), (Breath\n Sounds: Clear : , No(t) Wheezes : , decreased at bases No(t)\n Rhonchorous: )\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended,\n No(t) Tender: , Obese\n Extremities: Right: Absent, Left: Absent, No(t) Cyanosis, No(t)\n Clubbing\n Musculoskeletal: No(t) Muscle wasting, No(t) Unable to stand\n Skin: Warm, No(t) Rash: , No(t) Jaundice\n Neurologic: No(t) Attentive, No(t) Follows simple commands, Responds\n to: Unresponsive, Movement: No spontaneous movement, Sedated, No(t)\n Paralyzed, Tone: Normal\n Labs / Radiology\n 10.8 g/dL\n 135 K/uL\n 99 mg/dL\n 1.0 mg/dL\n 33 mEq/L\n 2.8 mEq/L\n 24 mg/dL\n 107 mEq/L\n 148 mEq/L\n 31.9 %\n 12.5 K/uL\n [image002.jpg]\n 06:06 AM\n 02:28 PM\n 06:28 PM\n 09:12 PM\n 01:58 AM\n 04:48 AM\n 05:04 AM\n 08:15 PM\n 04:54 AM\n 05:34 AM\n WBC\n 12.1\n 12.5\n Hct\n 31.2\n 31.9\n Plt\n 120\n 135\n Cr\n 1.0\n 1.0\n TCO2\n 26\n 24\n 24\n 26\n 28\n 26\n 33\n 36\n Glucose\n 122\n 99\n Other labs: PT / PTT / INR:13.1/32.2/1.1, CK / CKMB /\n Troponin-T:260/9/0.22, ALT / AST:57/31, Alk Phos / T Bili:70/0.4,\n Amylase / Lipase:53/22, Differential-Neuts:67.0 %, Band:2.0 %,\n Lymph:18.0 %, Mono:9.0 %, Eos:0.0 %, Lactic Acid:1.3 mmol/L,\n Albumin:2.7 g/dL, LDH:272 IU/L, Ca++:7.5 mg/dL, Mg++:2.1 mg/dL, PO4:2.6\n mg/dL\n Imaging: CXR (reviewed): ETT properly positioned, continued diffuse\n infiltrates, left HD no longer visualized\n Assessment and Plan\n 50 yo male with metastatic renal cell CA s/p allo-SCT, COPD/fibrosis\n admitted with resp failure/shock. Mixed septic/cardiogenic picture with\n resp failure related to probable infxn superimposed on RV failure/pHTN,\n severe chronic pulm ds/COPD/fibrosis\n *Acute respiratory failure. Multifactorial - suspect acute infxn as\n inciting cause, but also COPD/fibrosis and pulm HTN/RV dysfunction\n contributing\n - Remains on high vent support, able to tolerate small decrease in\n driving pressure\n - No further diuresis today given development of metabolic alkalosis.\n Pt appears to be autodiuresing today.\n - Continue to wean vent: decrease driving pressure further. With\n continued diuresis, oxygenation may improve enough to permit decrease\n in PEEP. Once evidence of improved lung compliance (decreased need for\n PC, PEEP), will attempt switch to ACV\n -Sedation wean\n *Cardiogenic/septic shock\n - Hemodynamics unchanged, not requiring pressors or fluids\n - Tolerated ACE-I increase\n *Sepsis/PNA\n - No change in abx regimen\n - low grade fever- will pan culture\n - continue capsofungin until galactomanan returns\n *Bradycardia: sinus origin, BP tolerating. Continue to monitor.\n *Adrenal insufficiency: continue to taper steroids\n Pt\ns wife updated.\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 12:09 AM 70 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Multi Lumen - 11:24 PM\n Arterial Line - 12:14 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: 40 minutes\n Patient is critically ill\n" }, { "category": "Physician ", "chartdate": "2120-04-22 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 323398, "text": "Chief Complaint: 50M h/o metastatic renal CA s/p nephrectomy, IL-2,\n mini-allograft SCT, DLI x 2 last in , emphysema/pulmonary fibrosis\n on home 02 presents with hypotension, fevers, hypoxemic respiratory\n failure.\n 24 Hour Events:\n -Did not tolerate weaning sedation\n -Remains bradycardic in 40s\n -Decreased driving pressures throughout the day, now at 26\n -Got lasix gtt to which he responded, put out >2L in afternoon, was\n stopped, BP stable, now autodiuresing\n -Increased ACEI\n Allergies:\n Flagyl (Oral) (Metronidazole)\n Rash;\n Last dose of Antibiotics:\n Bactrim (SMX/TMP) - 09:00 AM\n Levofloxacin - 09:11 AM\n Acyclovir - 04:18 PM\n Caspofungin - 08:00 PM\n Vancomycin - 08:33 PM\n Piperacillin/Tazobactam (Zosyn) - 05:54 AM\n Infusions:\n Midazolam (Versed) - 10 mg/hour\n Fentanyl - 500 mcg/hour\n Other ICU medications:\n Furosemide (Lasix) - 11:00 AM\n Heparin Sodium (Prophylaxis) - 08:32 PM\n Famotidine (Pepcid) - 08:33 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:08 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.8\nC (100\n Tcurrent: 37.8\nC (100\n HR: 45 (41 - 60) bpm\n BP: 131/57(79) {119/50(69) - 159/69(94)} mmHg\n RR: 30 (21 - 30) insp/min\n SpO2: 94%\n Heart rhythm: SB (Sinus Bradycardia)\n Wgt (current): 76.3 kg (admission): 76.3 kg\n Height: 68 Inch\n CVP: 11 (6 - 20)mmHg\n CO/CI (CCO): (5.1 L/min) / (2.7 L/min/m2)\n Total In:\n 5,547 mL\n 1,369 mL\n PO:\n TF:\n 2,460 mL\n 539 mL\n IVF:\n 2,577 mL\n 580 mL\n Blood products:\n Total out:\n 7,120 mL\n 1,020 mL\n Urine:\n 7,120 mL\n 1,020 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,573 mL\n 349 mL\n Respiratory support\n Ventilator mode: PCV+\n PC : 26 cmH2O\n RR (Set): 30\n PEEP: 12 cmH2O\n FiO2: 50%\n PIP: 37 cmH2O\n SpO2: 94%\n ABG: 7.45/50/98./33/8\n Ve: 14 L/min\n PaO2 / FiO2: 196\n Physical Examination\n Gen: eyes open, not following commands, some localization to voice\n Heent: pupils equal. Intubated, ng tube and esophageal balloon in\n place\n Cor: rrr, nls1s2 no mr\n Pul: cta anteriorly\n Abd: moderately distended. Bowel sounds present, no guarding, no\n tenderness\n Extreme: warm, 2+ pitting edema to mid-thigh\n Neuro: sedated, not responding to commands\n Labs / Radiology\n 135 K/uL\n 10.8 g/dL\n 99 mg/dL\n 1.0 mg/dL\n 33 mEq/L\n 2.8 mEq/L\n 24 mg/dL\n 107 mEq/L\n 148 mEq/L\n 31.9 %\n 12.5 K/uL\n [image002.jpg]\n 06:06 AM\n 02:28 PM\n 06:28 PM\n 09:12 PM\n 01:58 AM\n 04:48 AM\n 05:04 AM\n 08:15 PM\n 04:54 AM\n 05:34 AM\n WBC\n 12.1\n 12.5\n Hct\n 31.2\n 31.9\n Plt\n 120\n 135\n Cr\n 1.0\n 1.0\n TCO2\n 26\n 24\n 24\n 26\n 28\n 26\n 33\n 36\n Glucose\n 122\n 99\n Other labs: PT / PTT / INR:13.1/32.2/1.1, CK / CKMB /\n Troponin-T:260/9/0.22, ALT / AST:57/31, Alk Phos / T Bili:70/0.4,\n Amylase / Lipase:53/22, Differential-Neuts:67.0 %, Band:2.0 %,\n Lymph:18.0 %, Mono:9.0 %, Eos:0.0 %, Lactic Acid:1.3 mmol/L,\n Albumin:2.7 g/dL, LDH:272 IU/L, Ca++:7.5 mg/dL, Mg++:2.1 mg/dL, PO4:2.6\n mg/dL\n Imaging: CXR : No interval change\n Microbiology: All micro negative to date\n Assessment and Plan\n 50M h/o metastatic renal CA s/p nephrectomy, IL-2, mini-allograft SCT,\n DLI x 2 last in , emphysema/pulmonary fibrosis on home 02\n presented to OSH with hypoxic respiratory failure, fevers and\n hypotension.\n # Respiratory failure: Pneumonia as likely source of resp failure and\n sepsis in patient with poor pulmonary reserve due to emphysema, ?GVHD,\n fibrosis. Overall not tolerating vent wean well. Driving pressures\n decreased over the day yesterday.\n Cont sedation w/ fent / midazolam / methadone; no urgency in relieving\n sedating w/ high vent needs.\n - Diuresed significantly on lasix gtt, now autodiuresising, goal I/O\n 500-1000mL neg to improve oxygenation now that BP / shock has resolved.\n Will continue to monitor\n - No changes to FiO2 / Peep until oxygenation improves\n - No change to A/C as patient has been tolerating PCV well\n - Decrease driving pressure again today and re-eval abg in attempt to\n reduce intrathoracic pressures and barotrauma\n # Shock: Multifactorial\n ** Sepsis: Likely source pneumonia. On very broad coverage w/\n vancomycin, levofloxacin, zosyn, bactrim (now only ppx dosing),\n caspofungin. All other cultures pending. WBC and fever curve\n improving slightly.\n - D/C caspo when beta glucan / galactomannan negative per BMT\n - F/u cultures, will pan-culture today as no micro since .\n - PPD negative\n - Continue acyclovir ppx, vanc/zosyn/levoflox for 14 day course, now\n \n **Cardiogenic\n ## Pump: Now improved BPs, off dobutamine. W/ dilated hypokinetic RV,\n likely causative in hypotension. Now BP recovering well. Increased\n ACEI yesterday for BP contol and afterload reduction which patient has\n tolerated well. No further change today\n ## Rhythm: Sinus bradycardia. ? med effect. Sustaining blood pressure\n well, no need for atropine.\n QTc: prolonged mimimally to 485. Cont check EKG w/ levofloxacin,\n methadone.\n **Endocrine\n ? absolute adrenal insufficiency, appears unlikely as patient was not\n on steroids at home. Pt w/ hx of adrenalectomy and adrenal gland w/\n mets.\n - 60 mg po prednisone today and cont w/ rapid PO pred taper, decrease\n to 40->20->10 then off.\n # Metastatic renal CA: Recurrent disease s/p donor lymphocyte\n transplant .\n - BMT to follow\n - Continue acyclovir and bactrim ppx for now, will discuss with BMT\n # Sedation: Goals of sedation have been clarified; being too light was\n causing problems w/ oxygenation. Pt also was requiring supra-normal\n levels of midaz/fentanyl. Now adequately sedated on midax / fent /\n methadone.\n - Cont current regimen for now. Will titrate sedation as tolerated\n trying to minimize agitation as this has been interfering with his\n ventilation.\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 12:09 AM 70 mL/hour\n Glycemic Control: ISS\n Lines:\n Multi Lumen - 11:24 PM\n Arterial Line - 12:14 AM\n Prophylaxis:\n DVT: SC heparin\n Stress ulcer: Famotidine \n VAP: VAP bundle\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n" }, { "category": "Nursing", "chartdate": "2120-04-22 00:00:00.000", "description": "Nursing Progress Note", "row_id": 323410, "text": "Jhtyjhnythtyhny\n Sepsis, Severe (with organ dysfunction)\n Assessment:\n Action:\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Physician ", "chartdate": "2120-04-25 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 323674, "text": "Chief Complaint:\n 24 Hour Events:\n -B-glucan and galactomannan still pending\n -Decreased Fi02 to 40%, hypoxic, increased back to 50% with good\n response\n -TF held at MN for trach/peg.\n -Increased captopril to 25\n Allergies:\n Flagyl (Oral) (Metronidazole)\n Rash;\n Last dose of Antibiotics:\n Levofloxacin - 09:10 AM\n Vancomycin - 08:26 PM\n Caspofungin - 09:28 PM\n Acyclovir - 12:20 AM\n Piperacillin/Tazobactam (Zosyn) - 06:24 AM\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 07:41 PM\n Heparin Sodium (Prophylaxis) - 07:41 PM\n Dextrose 50% - 06:35 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 12 AM\n Tmax: 37.3\nC (99.2\n Tcurrent: 36.8\nC (98.3\n HR: 48 (42 - 111) bpm\n BP: 108/56(73) {98/56(72) - 171/91(120)} mmHg\n RR: 30 (19 - 30) insp/min\n SpO2: 95%\n Heart rhythm: SB (Sinus Bradycardia)\n Wgt (current): 76.3 kg (admission): 76.3 kg\n Height: 68 Inch\n CVP: 13 (3 - 13)mmHg\n Total In:\n 3,526 mL\n 413 mL\n PO:\n TF:\n 1,308 mL\n 26 mL\n IVF:\n 1,738 mL\n 333 mL\n Blood products:\n Total out:\n 7,165 mL\n 730 mL\n Urine:\n 7,165 mL\n 730 mL\n NG:\n Stool:\n Drains:\n Balance:\n -3,639 mL\n -317 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: PCV+\n PC : 24 cmH2O\n RR (Set): 30\n PEEP: 10 cmH2O\n FiO2: 50%\n PIP: 34 cmH2O\n Plateau: 33 cmH2O\n SpO2: 95%\n ABG: 7.44/50/110/30/8\n Ve: 11.7 L/min\n PaO2 / FiO2: 220\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 149 K/uL\n 10.6 g/dL\n 70 mg/dL\n 1.0 mg/dL\n 30 mEq/L\n 3.8 mEq/L\n 19 mg/dL\n 105 mEq/L\n 141 mEq/L\n 31.6 %\n 13.6 K/uL\n [image002.jpg]\n 03:50 PM\n 07:18 PM\n 03:49 AM\n 04:48 AM\n 11:19 AM\n 01:45 PM\n 08:13 PM\n 10:07 PM\n 04:05 AM\n 04:29 AM\n WBC\n 13.9\n 13.6\n Hct\n 30.8\n 31.6\n Plt\n 144\n 149\n Cr\n 0.9\n 0.9\n 0.9\n 1.0\n TCO2\n 33\n 35\n 36\n 36\n 34\n 35\n Glucose\n 101\n 92\n 93\n 70\n Other labs: PT / PTT / INR:13.7/42.1/1.2, CK / CKMB /\n Troponin-T:260/9/0.22, ALT / AST:57/31, Alk Phos / T Bili:70/0.4,\n Amylase / Lipase:53/22, Differential-Neuts:67.0 %, Band:2.0 %,\n Lymph:18.0 %, Mono:9.0 %, Eos:0.0 %, Lactic Acid:2.0 mmol/L,\n Albumin:2.6 g/dL, LDH:272 IU/L, Ca++:8.2 mg/dL, Mg++:2.3 mg/dL, PO4:3.1\n mg/dL\n Imaging: CXR IMPRESSION:\n 1. Decrease in the bilateral pulmonary edema.\n 2. Chronic interstitial lung disease.\n 3. Lines and tubes are in satisfactory location.\n Microbiology: Sputum cx: Neg\n Bcx: NGTD\n Assessment and Plan\n 50M h/o metastatic renal CA s/p nephrectomy, IL-2, mini-allograft SCT,\n DLI x 2 last in , emphysema/pulmonary fibrosis on home 02\n presented to OSH with hypoxic respiratory failure, sepsis, cardiogenic\n shock, now improving but with difficulty weaning vent.\n # Respiratory failure: Pneumonia as likely source of resp failure and\n sepsis in patient with poor pulmonary reserve due to emphysema, ?GVHD,\n fibrosis.\n - PEEP decreased to 10 which patient tolerated well (PaO2 104). Did not\n tolerated PEEP decrease to 8 (increased agitation). PEEP increased\n back to 10 with good response.\n - Sedation on vent, see below\n - No change in PEEP today as did not tolerate, would not change driving\n pressures either as patient now has compensatory respiratory acidosis\n for metabolic alkalosis likely secondary to auto-diuresis.\n - Attempt decrease in FiO2 today (50->40%) as repeat gas this am showed\n 7.44/51/109\n - Plan for trach by IP today with anesthesia\n - No change to A/C as patient has been tolerating PCV well; once\n sedation is decreased/trach in place, can consider changing to PSV.\n Changing mode of ventilation would likely be next consideration as he\n will likely continue to require high PEEPs\n # Sedation: Goals of sedation have been clarified; being too light was\n causing problems w/ oxygenation. Pt also was requiring supra-normal\n levels of midaz/fentanyl. Started on propofol for worsening agitation\n causing desats\n - On methadone q4H, fentanyl and versed off. On propofol for sedation,\n currently at 45 mcg/kg/min.\n - Goal to wean propofol as tolerated today (though will await placement\n of trach before making sedation changes).\n # Shock: Multifactorial\n ** Sepsis: Likely source pneumonia. On very broad coverage w/\n vancomycin, levofloxacin, zosyn, bactrim (now only ppx dosing),\n caspofungin. All other cultures pending. WBC and fever curve\n improving slightly.\n - D/C caspo when beta glucan / galactomannan negative per BMT\n - F/u cultures- cont to culture with spikes. Currently afebrile x >24H\n - PPD negative\n - Continue acyclovir ppx, vanc/zosyn/levoflox for 14 day course, today\n is day 7.\n **Cardiogenic\n ## Pump: Now improved BPs, off dobutamine. On captopril for afterload\n reduction. Dilated hypokinetic RV, likely causative in hypotension.\n Now hypertensive. Increased to 25mg TID.\n ## Rhythm: Sinus bradycardia likely secondary to sedatives; increases\n with agitation. Cont weaning sedation as tolerated. Continue to\n follow QTc for prolongation given methadone and levoflox, has been wnl\n **Endocrine\n - Cont w/ rapid PO pred taper, decrease to 10 today then off.\n # Metastatic renal CA: Recurrent disease s/p donor lymphocyte\n transplant .\n - BMT to follow\n - Continue acyclovir and bactrim ppx for now, will discuss with BMT\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Multi Lumen - 11:24 PM\n Arterial Line - 12:14 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP: HOB elevation, Mouth care\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:ICU\n" }, { "category": "Physician ", "chartdate": "2120-04-25 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 323676, "text": "Chief Complaint: 50M h/o metastatic renal CA s/p nephrectomy, IL-2,\n mini-allograft SCT, DLI x 2 last in , emphysema/pulmonary fibrosis\n on home 02 presented to OSH with hypoxic respiratory failure, fevers\n and hypotension with sepsis, cardiogenic shock now unable to wean off\n ventilator.\n 24 Hour Events:\n -B-glucan and galactomannan still pending\n -Decreased Fi02 to 40%, hypoxic, increased back to 50% with good\n response\n -TF held at MN for trach/peg.\n -Increased captopril to 25\n Allergies:\n Flagyl (Oral) (Metronidazole)\n Rash;\n Last dose of Antibiotics:\n Levofloxacin - 09:10 AM\n Vancomycin - 08:26 PM\n Caspofungin - 09:28 PM\n Acyclovir - 12:20 AM\n Piperacillin/Tazobactam (Zosyn) - 06:24 AM\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 07:41 PM\n Heparin Sodium (Prophylaxis) - 07:41 PM\n Dextrose 50% - 06:35 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 12 AM\n Tmax: 37.3\nC (99.2\n Tcurrent: 36.8\nC (98.3\n HR: 48 (42 - 111) bpm\n BP: 108/56(73) {98/56(72) - 171/91(120)} mmHg\n RR: 30 (19 - 30) insp/min\n SpO2: 95%\n Heart rhythm: SB (Sinus Bradycardia)\n Wgt (current): 76.3 kg (admission): 76.3 kg\n Height: 68 Inch\n CVP: 13 (3 - 13)mmHg\n Total In:\n 3,526 mL\n 413 mL\n PO:\n TF:\n 1,308 mL\n 26 mL\n IVF:\n 1,738 mL\n 333 mL\n Blood products:\n Total out:\n 7,165 mL\n 730 mL\n Urine:\n 7,165 mL\n 730 mL\n NG:\n Stool:\n Drains:\n Balance:\n -3,639 mL\n -317 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: PCV+\n PC : 24 cmH2O\n RR (Set): 30\n PEEP: 10 cmH2O\n FiO2: 50%\n PIP: 34 cmH2O\n Plateau: 33 cmH2O\n SpO2: 95%\n ABG: 7.44/50/110/30/8\n Ve: 11.7 L/min\n PaO2 / FiO2: 220\n Physical Examination\n Gen: eyes open, follows commands to move toes, localization to voice\n Heent: pupils equal. Intubated\n Cor: rrr, nls1s2 no mr\n Pul: cta anteriorly- mechanical breath sounds\n Abd: moderately distended. Bowel sounds present, no guarding, no\n tenderness\n Extreme: warm, trace pitting edema to mid-thigh\n Neuro: sedated, but responds to voice and follows some commands\n Labs / Radiology\n 149 K/uL\n 10.6 g/dL\n 70 mg/dL\n 1.0 mg/dL\n 30 mEq/L\n 3.8 mEq/L\n 19 mg/dL\n 105 mEq/L\n 141 mEq/L\n 31.6 %\n 13.6 K/uL\n [image002.jpg]\n 03:50 PM\n 07:18 PM\n 03:49 AM\n 04:48 AM\n 11:19 AM\n 01:45 PM\n 08:13 PM\n 10:07 PM\n 04:05 AM\n 04:29 AM\n WBC\n 13.9\n 13.6\n Hct\n 30.8\n 31.6\n Plt\n 144\n 149\n Cr\n 0.9\n 0.9\n 0.9\n 1.0\n TCO2\n 33\n 35\n 36\n 36\n 34\n 35\n Glucose\n 101\n 92\n 93\n 70\n Other labs: PT / PTT / INR:13.7/42.1/1.2, CK / CKMB /\n Troponin-T:260/9/0.22, ALT / AST:57/31, Alk Phos / T Bili:70/0.4,\n Amylase / Lipase:53/22, Differential-Neuts:67.0 %, Band:2.0 %,\n Lymph:18.0 %, Mono:9.0 %, Eos:0.0 %, Lactic Acid:2.0 mmol/L,\n Albumin:2.6 g/dL, LDH:272 IU/L, Ca++:8.2 mg/dL, Mg++:2.3 mg/dL, PO4:3.1\n mg/dL\n Imaging: CXR IMPRESSION:\n 1. Decrease in the bilateral pulmonary edema.\n 2. Chronic interstitial lung disease.\n 3. Lines and tubes are in satisfactory location.\n Microbiology: Sputum cx: Neg\n Bcx: NGTD\n Assessment and Plan\n 50M h/o metastatic renal CA s/p nephrectomy, IL-2, mini-allograft SCT,\n DLI x 2 last in , emphysema/pulmonary fibrosis on home 02\n presented to OSH with hypoxic respiratory failure, sepsis, cardiogenic\n shock, now improving but with difficulty weaning vent.\n # Respiratory failure: Pneumonia as likely source of resp failure and\n sepsis in patient with poor pulmonary reserve due to emphysema, ?GVHD,\n fibrosis.\n - PEEP decreased to 10 which patient tolerated well (PaO2 104). Did not\n tolerated PEEP decrease to 8 (increased agitation). PEEP increased\n back to 10 with good response.\n - Sedation on vent, see below\n - No change in PEEP today as did not tolerate, would not change driving\n pressures either as patient now has compensatory respiratory acidosis\n for metabolic alkalosis likely secondary to auto-diuresis.\n - Attempt decrease in FiO2 today (50->40%) as repeat gas this am showed\n 7.44/51/109\n - Plan for trach by IP today with anesthesia\n - No change to A/C as patient has been tolerating PCV well; once\n sedation is decreased/trach in place, can consider changing to PSV.\n Changing mode of ventilation would likely be next consideration as he\n will likely continue to require high PEEPs\n # Sedation: Goals of sedation have been clarified; being too light was\n causing problems w/ oxygenation. Pt also was requiring supra-normal\n levels of midaz/fentanyl. Started on propofol for worsening agitation\n causing desats\n - On methadone q4H, fentanyl and versed off. On propofol for sedation,\n currently at 45 mcg/kg/min.\n - Goal to wean propofol as tolerated today (though will await placement\n of trach before making sedation changes).\n # Shock: Multifactorial\n ** Sepsis: Likely source pneumonia. On very broad coverage w/\n vancomycin, levofloxacin, zosyn, bactrim (now only ppx dosing),\n caspofungin. All other cultures pending. WBC and fever curve\n improving slightly.\n - D/C caspo when beta glucan / galactomannan negative per BMT\n - F/u cultures- cont to culture with spikes. Currently afebrile x >24H\n - PPD negative\n - Continue acyclovir ppx, vanc/zosyn/levoflox for 14 day course, today\n is day 7.\n **Cardiogenic\n ## Pump: Now improved BPs, off dobutamine. On captopril for afterload\n reduction. Dilated hypokinetic RV, likely causative in hypotension.\n Now hypertensive. Increased to 25mg TID.\n ## Rhythm: Sinus bradycardia likely secondary to sedatives; increases\n with agitation. Cont weaning sedation as tolerated. Continue to\n follow QTc for prolongation given methadone and levoflox, has been wnl\n **Endocrine\n - Cont w/ rapid PO pred taper, decrease to 10 today then off.\n # Metastatic renal CA: Recurrent disease s/p donor lymphocyte\n transplant .\n - BMT to follow\n - Continue acyclovir and bactrim ppx for now, will discuss with BMT\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Multi Lumen - 11:24 PM\n Arterial Line - 12:14 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP: HOB elevation, Mouth care\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:ICU\n" }, { "category": "Nutrition", "chartdate": "2120-04-25 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 323680, "text": "Potential for nutrition risk. Patient being monitored. Current\n intervention if any, listed below:\n Comments:\n Patient requested to speak with Nutrition regarding his diet. Patient\n does not wish to be on a Diabetic diet at this time. Spoke with patient\n and explained the diabetic diet. He seems to understand, but does not\n want to be restricted. Would continue to allow patient to have Regular\n diet and monitor blood glucose. Patient requested to have no garnishes\n on trays, have entered this restriction into the system. Was concerned\n that kitchen would not know that he was on a regular diet, I assured\n him that they will allow him to order off the regular menu. Will follow\n and let him know that if he has any additional questions, I will come\n back and see him. Thanks.\n 09:27\n" }, { "category": "Nursing", "chartdate": "2120-04-21 00:00:00.000", "description": "Nursing Progress Note", "row_id": 323290, "text": "50 yo male with met renal cell CA admitted with severe resp\n failure/PNA, cardiogenic/septic shock. RV hypoplasia Being covered on a\n number of broad coverage abx for PNA/sepsis.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Remains intubated with no changes to the vent made. Attempted a slight\n decrease in sedation to improve HR however pt. became too awake and\n uncomfortable.\n Action:\n Increased sedation back to AM dosing of fent 500 and versed 10mg/hr,\n Methadone 20mg IV q8h, PCV: RR 30,driving pressure 28,PEEP 12. Vent\n changes ordered: decrease driving pressures from 28 to 26, however\n waiting until patient is more consistently sedated before making change\n given his history.\n Response:\n Pt. still very sensitive to stimulation and activity while on high\n levels of sedation. Desats to high 80\ns with activity but has so far\n been able to settle self out when unstimulated. Suctioning minimal tan\n thick secretions.\n Plan:\n pt. before activity. Continue with sedation /vent\n? Weaning when\n possible.\n Heart failure, right, isolated (Cor Pulmonale)\n Assessment:\n Off dobu yesterday, SB-NSR with HR dipping into upper 30\ns this AM. SBP\n 120\ns-150\n Action:\n Monitoring CO & CI, HR. Captopril increased to 12.5 mg TID.\n Response:\n CO 4.3-5.0, HR increases with stimulation and/or activity.\n Plan:\n Continue Monitor CO thru vigileo monitor.\n Lasix gtt started this AM with goal of patient being 2 L negative.\n Currently at 4mg/hr. Pt. tolerating well.\n Continuing to wean steroids, IV dose changed to 60mg PO daily.\n Tube feeds at goal 70mL/hr. Bowel sounds present, low residuals. 2 BM\n today, bowel regimen held.\n" }, { "category": "Nursing", "chartdate": "2120-04-26 00:00:00.000", "description": "Nursing Progress Note", "row_id": 323782, "text": "Pt is a 50 yo M with metastatic renal cell CA s/p allo- SCT with\n subsequent severe chronic resp failure thought to be emphysema and\n fibrosis of unclear etiology (CT from last spring demonstrates severe\n cystic and fibrotic changes with almost no normal appearing lung).\n Admitted w/ catastrophic acute on chronic failure and severe shock,\n initially presumed septic but more predominantly cardiogenic. Was on\n high dose steroids, tapering prednisone and now 40PO qd.\n Pt rec\nd trach & PEG on ; cuff leak persistent, even w/ large\n volume inflation. IP due to change out today.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n LS clear to rhoncorous. Pressure control RR 30/Peep 5/FiO2 50%/insp\n P24cm\n Action:\n Subglottal sxn for mod amt bloody sputum x2, deep sxn for bloody plug\n x1 by RT, small amt bloody secretions x2\n Response:\n Remains comfortable w/ rate @30. Pulling volumes of 350-500 despite\n continuing cuff leak. Leak improves somewhat w/repositioning.\n Plan:\n IP to reassess today\n Note increasing WBC to 15 this am. Pt currently on Vanc, Zosyn,\n Levaquin, Acyclovir and qod Bactrim.\n" }, { "category": "Physician ", "chartdate": "2120-04-26 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 323789, "text": "Chief Complaint:\n 24 Hour Events:\n PEG INSERTION - At 09:45 AM\n PERCUTANEOUS TRACHEOSTOMY - At 10:10 AM\n - S/p trach and PEG\n - B glucan/galactomannan negative -> caspo discontinued\n - Trach with persistent air-leak, IP made aware by RT, plan to come by\n today to potentially change in am\n - Tolerating PEEP of 5 and maintaining sats >95% during the early\n afternoon\n Allergies:\n Flagyl (Oral) (Metronidazole)\n Rash;\n Last dose of Antibiotics:\n Caspofungin - 09:28 PM\n Levofloxacin - 10:30 AM\n Vancomycin - 08:45 PM\n Acyclovir - 12:00 AM\n Piperacillin/Tazobactam (Zosyn) - 05:30 AM\n Infusions:\n Propofol - 30 mcg/Kg/min\n Other ICU medications:\n Fentanyl - 10:00 AM\n Famotidine (Pepcid) - 08:00 PM\n Heparin Sodium (Prophylaxis) - 08:00 PM\n Lorazepam (Ativan) - 06:20 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 07:46 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: 36.6\nC (97.9\n HR: 91 (46 - 93) bpm\n BP: 130/69(89) {96/50(66) - 159/86(111)} mmHg\n RR: 29 (12 - 34) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 76.3 kg (admission): 76.3 kg\n Height: 68 Inch\n CVP: 8 (7 - 14)mmHg\n Total In:\n 2,694 mL\n 496 mL\n PO:\n TF:\n 26 mL\n IVF:\n 2,279 mL\n 381 mL\n Blood products:\n Total out:\n 4,950 mL\n 1,360 mL\n Urine:\n 4,950 mL\n 1,060 mL\n NG:\n 300 mL\n Stool:\n Drains:\n Balance:\n -2,256 mL\n -864 mL\n Respiratory support\n Ventilator mode: PCV+\n Vt (Set): 500 (500 - 500) mL\n PC : 24 cmH2O\n RR (Set): 30\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI Deferred: Unstable Airway\n PIP: 29 cmH2O\n Plateau: 25 cmH2O\n SpO2: 94%\n ABG: 7.49/34/127/26/3\n Ve: 13.9 L/min\n PaO2 / FiO2: 254\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 159 K/uL\n 11.4 g/dL\n 65 mg/dL\n 1.0 mg/dL\n 26 mEq/L\n 3.5 mEq/L\n 17 mg/dL\n 108 mEq/L\n 141 mEq/L\n 34.0 %\n 15.0 K/uL\n [image002.jpg]\n 04:48 AM\n 11:19 AM\n 01:45 PM\n 08:13 PM\n 10:07 PM\n 04:05 AM\n 04:29 AM\n 03:23 PM\n 06:00 PM\n 04:43 AM\n WBC\n 13.6\n 15.0\n Hct\n 31.6\n 34.0\n Plt\n 149\n 159\n Cr\n 0.9\n 1.0\n 1.0\n TCO2\n 35\n 36\n 36\n 34\n 35\n 27\n Glucose\n 93\n 70\n 76\n 65\n Other labs: PT / PTT / INR:13.7/42.1/1.2, CK / CKMB /\n Troponin-T:260/9/0.22, ALT / AST:57/31, Alk Phos / T Bili:70/0.4,\n Amylase / Lipase:53/22, Differential-Neuts:67.0 %, Band:2.0 %,\n Lymph:18.0 %, Mono:9.0 %, Eos:0.0 %, Lactic Acid:2.0 mmol/L,\n Albumin:2.6 g/dL, LDH:272 IU/L, Ca++:8.6 mg/dL, Mg++:2.2 mg/dL, PO4:2.6\n mg/dL\n Microbiology: C. Diff neg x1\n Assessment and Plan\n 50M h/o metastatic renal CA s/p nephrectomy, IL-2, mini-allograft SCT,\n DLI x 2 last in , emphysema/pulmonary fibrosis on home 02\n presented to OSH with hypoxic respiratory failure, sepsis, cardiogenic\n shock, now improving but with difficulty weaning vent and s/p\n trach/PEG.\n # Respiratory failure: Pneumonia as likely source of resp failure and\n sepsis in patient with poor pulmonary reserve due to emphysema, ?GVHD,\n fibrosis. Patient is now s/p trach/PEG.\n - PEEP decreased to 5 yesterday after trach which he has tolerated\n well. Last ABG 7.49/34/127.\n - Would not change driving pressures either as patient now has\n compensatory respiratory acidosis for metabolic alkalosis likely\n secondary to auto-diuresis.\n - Attempt decrease in FiO2 today (50->40%) -> maintain PaO2 >60.\n Patient's oxygenation has improved.\n - Will decrease RR today to see if patient can breath over the vent on\n his own. Then can consider decreased driving pressure.\n - Plan to replace trach today by IP given persistent air leak.\n # Sedation: Currently on methadone q4H, fentanyl and versed off. On\n propofol for sedation, currently at 30 down from 45 mcg/kg/min. Off\n fent/versed drips.\n - Goal to wean propofol as tolerated today, triglycerides mildly\n elevated at 182\n - Continue to check triglycerides twice weekly while on propofol.\n - Bolus fentanyl/ativan prn agitation\n - When able, will decrease methadone to q6H then to q8H\n # Shock: Multifactorial\n ** Sepsis: Likely source pneumonia. On very broad coverage w/\n vancomycin, levofloxacin, zosyn, bactrim (now only ppx dosing),\n caspofungin. All other cultures pending. WBC and fever curve\n improving slightly.\n - D/C'd caspo yesterday\n - F/u cultures - cont to culture with spikes. Currently afebrile x\n >24H\n - PPD negative\n - Continue acyclovir ppx, vanc/zosyn/levoflox for 14 day course, today\n is day 8.\n **Cardiogenic\n ## Pump: Now improved BPs, off dobutamine. On captopril for afterload\n reduction. Dilated hypokinetic RV, likely causative in hypotension.\n Now hypertensive. Increased to 25mg TID.\n ## Rhythm: Sinus bradycardia likely secondary to sedatives; increases\n with agitation. Cont weaning sedation as tolerated. Continue to\n follow QTc for prolongation given methadone and levoflox, has been wnl\n **Endocrine\n - Prednisone off today\n # Metastatic renal CA: Recurrent disease s/p donor lymphocyte\n transplant .\n - BMT to follow\n - Continue acyclovir and bactrim ppx\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 11:24 PM\n Arterial Line - 12:14 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n" }, { "category": "Physician ", "chartdate": "2120-04-26 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 323791, "text": "Chief Complaint: 50M h/o metastatic renal CA s/p nephrectomy, IL-2,\n mini-allograft SCT, DLI x 2 last in , emphysema/pulmonary fibrosis\n on home 02 presented to OSH with hypoxic respiratory failure, fevers\n and hypotension with sepsis, cardiogenic shock now unable to wean off\n ventilator\n 24 Hour Events:\n PEG INSERTION - At 09:45 AM\n PERCUTANEOUS TRACHEOSTOMY - At 10:10 AM\n - S/p trach and PEG\n - B glucan/galactomannan negative -> caspo discontinued\n - Trach with persistent air-leak, IP made aware by RT, plan to come by\n today to potentially change in am\n - Tolerating PEEP of 5 and maintaining sats >95% during the early\n afternoon\n Allergies:\n Flagyl (Oral) (Metronidazole)\n Rash;\n Last dose of Antibiotics:\n Caspofungin - 09:28 PM\n Levofloxacin - 10:30 AM\n Vancomycin - 08:45 PM\n Acyclovir - 12:00 AM\n Piperacillin/Tazobactam (Zosyn) - 05:30 AM\n Infusions:\n Propofol - 30 mcg/Kg/min\n Other ICU medications:\n Fentanyl - 10:00 AM\n Famotidine (Pepcid) - 08:00 PM\n Heparin Sodium (Prophylaxis) - 08:00 PM\n Lorazepam (Ativan) - 06:20 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 07:46 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: 36.6\nC (97.9\n HR: 91 (46 - 93) bpm\n BP: 130/69(89) {96/50(66) - 159/86(111)} mmHg\n RR: 29 (12 - 34) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 76.3 kg (admission): 76.3 kg\n Height: 68 Inch\n CVP: 8 (7 - 14)mmHg\n Total In:\n 2,694 mL\n 496 mL\n PO:\n TF:\n 26 mL\n IVF:\n 2,279 mL\n 381 mL\n Blood products:\n Total out:\n 4,950 mL\n 1,360 mL\n Urine:\n 4,950 mL\n 1,060 mL\n NG:\n 300 mL\n Stool:\n Drains:\n Balance:\n -2,256 mL\n -864 mL\n Respiratory support\n Ventilator mode: PCV+\n Vt (Set): 500 (500 - 500) mL\n PC : 24 cmH2O\n RR (Set): 30\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI Deferred: Unstable Airway\n PIP: 29 cmH2O\n Plateau: 25 cmH2O\n SpO2: 94%\n ABG: 7.49/34/127/26/3\n Ve: 13.9 L/min\n PaO2 / FiO2: 254\n Physical Examination\n Gen: Sedated, localization to voice\n Heent: pupils equal. Trached.\n Cor: RRR, nls1s2 no mr\n Pul: CTA anteriorly- mechanical breath sounds\n Abd: moderately distended. Bowel sounds present, PEG in placed,\n dressed, no guarding, no tenderness\n Extreme: Warm, trace pitting edema to mid-thigh\n Labs / Radiology\n 159 K/uL\n 11.4 g/dL\n 65 mg/dL\n 1.0 mg/dL\n 26 mEq/L\n 3.5 mEq/L\n 17 mg/dL\n 108 mEq/L\n 141 mEq/L\n 34.0 %\n 15.0 K/uL\n [image002.jpg]\n 04:48 AM\n 11:19 AM\n 01:45 PM\n 08:13 PM\n 10:07 PM\n 04:05 AM\n 04:29 AM\n 03:23 PM\n 06:00 PM\n 04:43 AM\n WBC\n 13.6\n 15.0\n Hct\n 31.6\n 34.0\n Plt\n 149\n 159\n Cr\n 0.9\n 1.0\n 1.0\n TCO2\n 35\n 36\n 36\n 34\n 35\n 27\n Glucose\n 93\n 70\n 76\n 65\n Other labs: PT / PTT / INR:13.7/42.1/1.2, CK / CKMB /\n Troponin-T:260/9/0.22, ALT / AST:57/31, Alk Phos / T Bili:70/0.4,\n Amylase / Lipase:53/22, Differential-Neuts:67.0 %, Band:2.0 %,\n Lymph:18.0 %, Mono:9.0 %, Eos:0.0 %, Lactic Acid:2.0 mmol/L,\n Albumin:2.6 g/dL, LDH:272 IU/L, Ca++:8.6 mg/dL, Mg++:2.2 mg/dL, PO4:2.6\n mg/dL\n Microbiology: C. Diff neg x1\n Assessment and Plan\n 50M h/o metastatic renal CA s/p nephrectomy, IL-2, mini-allograft SCT,\n DLI x 2 last in , emphysema/pulmonary fibrosis on home 02\n presented to OSH with hypoxic respiratory failure, sepsis, cardiogenic\n shock, now improving but with difficulty weaning vent and s/p\n trach/PEG.\n # Respiratory failure: Pneumonia as likely source of resp failure and\n sepsis in patient with poor pulmonary reserve due to emphysema, ?GVHD,\n fibrosis. Patient is now s/p trach/PEG.\n - PEEP decreased to 5 yesterday after trach which he has tolerated\n well. Last ABG 7.49/34/127.\n - Would not change driving pressures either as patient now has\n compensatory respiratory acidosis for metabolic alkalosis likely\n secondary to auto-diuresis.\n - Attempt decrease in FiO2 today (50->40%) -> maintain PaO2 >60.\n Patient's oxygenation has improved.\n - Will decrease RR today to see if patient can breath over the vent on\n his own. Then can consider decreased driving pressure.\n - Plan to replace trach today by IP given persistent air leak.\n # Sedation: Currently on methadone q4H, fentanyl and versed off. On\n propofol for sedation, currently at 30 down from 45 mcg/kg/min. Off\n fent/versed drips.\n - Goal to wean propofol as tolerated today, triglycerides mildly\n elevated at 182\n - Continue to check triglycerides twice weekly while on propofol.\n - Bolus fentanyl/ativan prn agitation\n - When able, will decrease methadone to q6H then to q8H\n # Shock: Multifactorial\n ** Sepsis: Likely source pneumonia. On very broad coverage w/\n vancomycin, levofloxacin, zosyn, bactrim (now only ppx dosing),\n caspofungin. All other cultures pending. WBC and fever curve\n improving slightly.\n - D/C'd caspo yesterday\n - F/u cultures - cont to culture with spikes. Currently afebrile x\n >24H\n - PPD negative\n - Continue acyclovir ppx, vanc/zosyn/levoflox for 14 day course, today\n is day 8.\n **Cardiogenic\n ## Pump: Now improved BPs, off dobutamine. On captopril for afterload\n reduction. Dilated hypokinetic RV, likely causative in hypotension.\n Now hypertensive. Increased to 25mg TID.\n ## Rhythm: Sinus bradycardia likely secondary to sedatives; increases\n with agitation. Cont weaning sedation as tolerated. Continue to\n follow QTc for prolongation given methadone and levoflox, has been wnl\n **Endocrine\n - Prednisone off today\n # Metastatic renal CA: Recurrent disease s/p donor lymphocyte\n transplant .\n - BMT to follow\n - Continue acyclovir and bactrim ppx\n ICU Care\n Nutrition:\n Restart TF 24 hours after PEG\n Glycemic Control:\n Lines:\n Multi Lumen - 11:24 PM\n Arterial Line - 12:14 AM\n Prophylaxis:\n DVT: Pneumoboots, SQ heparin\n Stress ulcer: H2 blocker\n VAP: HOB elevation, mouth care\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n" }, { "category": "Nursing", "chartdate": "2120-04-22 00:00:00.000", "description": "Nursing Progress Note", "row_id": 323347, "text": "50 yo male with met renal cell CA admitted with severe resp\n failure/PNA, cardiogenic/septic shock. RV hypoplasia\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Remains intubated, sedated with Fentanyl 500 mcg / versed 10mg/hr. on\n PCV ,no attempt to wean . still pt very awake with stimulation,but not\n desats like yesterday,sats maintained 93-94% even during turning.\n Action:\n Continued with same vent settings, Rate 30 / i:e ratio 1:1.7 / peep 12/\n Pinsp 38 /fio2 50%. Blood gas early shift 7.53/38/78/8. am labs\n pending.\n Response:\n Remained stable with sats and vitals.\n Plan:\n Continue wean vent /sedation when possible.\n Heart failure, right, isolated (Cor Pulmonale)\n Assessment:\n HR 40-50\ns, SB ,CO and CI monitoring through vigileo monitor.\n Action:\n CO 4.3-5.4 . No acute intervention for bradycardia now, may be its\n part of his high sedation,when pt awake HR 55-60\n Response:\n Plan:\n Continue monitor CI, CO, and vital signs.\n Off lasix drip from yesterday ,urine output adequate > 120cc\n /hr.maintained neg balance.\n No BM this shift, bowel regimen hold as he was having loose stool.\n Feed @ 70cc/hr @ goal rate. Tolerating well.residual 5-10cc.\n Bath given and positioned.\n Family visited early shift and updated .\n" }, { "category": "Physician ", "chartdate": "2120-04-22 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 323348, "text": "Chief Complaint: a\n 24 Hour Events:\n a\n Allergies:\n Flagyl (Oral) (Metronidazole)\n Rash;\n Last dose of Antibiotics:\n Bactrim (SMX/TMP) - 09:00 AM\n Levofloxacin - 09:11 AM\n Acyclovir - 04:18 PM\n Caspofungin - 08:00 PM\n Vancomycin - 08:33 PM\n Piperacillin/Tazobactam (Zosyn) - 05:54 AM\n Infusions:\n Midazolam (Versed) - 10 mg/hour\n Fentanyl - 500 mcg/hour\n Other ICU medications:\n Furosemide (Lasix) - 11:00 AM\n Heparin Sodium (Prophylaxis) - 08:32 PM\n Famotidine (Pepcid) - 08:33 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:08 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.8\nC (100\n Tcurrent: 37.8\nC (100\n HR: 45 (41 - 60) bpm\n BP: 131/57(79) {119/50(69) - 159/69(94)} mmHg\n RR: 30 (21 - 30) insp/min\n SpO2: 94%\n Heart rhythm: SB (Sinus Bradycardia)\n Wgt (current): 76.3 kg (admission): 76.3 kg\n Height: 68 Inch\n CVP: 11 (6 - 20)mmHg\n CO/CI (CCO): (5.1 L/min) / (2.7 L/min/m2)\n Total In:\n 5,547 mL\n 1,369 mL\n PO:\n TF:\n 2,460 mL\n 539 mL\n IVF:\n 2,577 mL\n 580 mL\n Blood products:\n Total out:\n 7,120 mL\n 1,020 mL\n Urine:\n 7,120 mL\n 1,020 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,573 mL\n 349 mL\n Respiratory support\n Ventilator mode: PCV+\n PC : 38 cmH2O\n RR (Set): 30\n PEEP: 12 cmH2O\n FiO2: 50%\n PIP: 37 cmH2O\n SpO2: 94%\n ABG: 7.45/50/98./33/8\n Ve: 14 L/min\n PaO2 / FiO2: 196\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 135 K/uL\n 10.8 g/dL\n 99 mg/dL\n 1.0 mg/dL\n 33 mEq/L\n 2.8 mEq/L\n 24 mg/dL\n 107 mEq/L\n 148 mEq/L\n 31.9 %\n 12.5 K/uL\n [image002.jpg]\n 06:06 AM\n 02:28 PM\n 06:28 PM\n 09:12 PM\n 01:58 AM\n 04:48 AM\n 05:04 AM\n 08:15 PM\n 04:54 AM\n 05:34 AM\n WBC\n 12.1\n 12.5\n Hct\n 31.2\n 31.9\n Plt\n 120\n 135\n Cr\n 1.0\n 1.0\n TCO2\n 26\n 24\n 24\n 26\n 28\n 26\n 33\n 36\n Glucose\n 122\n 99\n Other labs: PT / PTT / INR:13.1/32.2/1.1, CK / CKMB /\n Troponin-T:260/9/0.22, ALT / AST:57/31, Alk Phos / T Bili:70/0.4,\n Amylase / Lipase:53/22, Differential-Neuts:67.0 %, Band:2.0 %,\n Lymph:18.0 %, Mono:9.0 %, Eos:0.0 %, Lactic Acid:1.3 mmol/L,\n Albumin:2.7 g/dL, LDH:272 IU/L, Ca++:7.5 mg/dL, Mg++:2.1 mg/dL, PO4:2.6\n mg/dL\n Imaging: CXR : No interval cahnge\n Microbiology: All micro negative to date\n Assessment and Plan\n 50M h/o metastatic renal CA s/p nephrectomy, IL-2, mini-allograft SCT,\n DLI x 2 last in , emphysema/pulmonary fibrosis on home 02\n presented to OSH with hypoxic respiratory failure, fevers and\n hypotension.\n # Respiratory failure:\n Pneumonia as likely source of resp failure and sepsis in patient with\n poor pulmonary reserve due to emphysema, ?GVHD, fibrosis.\n Overnight w/ ? mucous plugging and decreased compliance. Overall not\n tolerating vent wean well.\n Cont sedation w/ fent / midazolam / methadone; no urgency in relieving\n sedating w/ high vent needs.\n - Diurese 500-1000mL in attempt improve oxygenation now that BP / shock\n has resolved\n - No changes to FiO2 / Peep until oxygenation improves\n - No change to A/C\n volume controlled setting\n - Decrease driving pressure and re-eval abg in attempt to reduce\n intrathoracic pressures and barotrauma\n # Shock:\n Multifactorial\n ** Sepsis: Likely source pneumonia. On very broad coverage w/\n vancomycin, levofloxacin, bactrim (now only ppx dosing), caspofungin.\n All other cultures pending. WBC and fever curve responding well.\n D/C caspo when beta glucan / galactomannan negative.\n - f/u cultures\n - Follow WBC count, fever curve, decreasing\n - PPD negative\n - Continue acyclovir ppx, vanc/zosyn/levoflox for 14 day course, now\n \n **Cardiogenic/\n ##Pump: Now improved BPs, off dobutamine. W/ dilated hypokinetic RV,\n likely causative in hypotension. Now BP recovering well.\n Will increase ace-I for BP contol and afterload reduction, and titrate\n to effect.\n ##Rhythm\n Sinus bradycardia. ? med effect. Sustaining blood pressure well, no\n need for atropine.\n QTc: prolonged mimimally to 485. Cont check EKG w/ levofloxacin,\n methadone.\n **Endocrine\n ? absolute adrenal insufficiency\n Pt w/ hx of adrenalectomy and adrenal gland w/ mets.\n - 60 mg po prednisone today and cont w/ rapid PO pred taper\n # Metastatic renal CA: Recurrent disease s/p donor lymphocyte\n transplant .\n - BMT to follow\n - Continue acyclovir ppx for now, will discuss with BMT\n # Sedation\n Goals of sedation have been clarified; being too light was causing\n problems w/ oxygenation. Pt also was requiring supra-normal levels of\n midaz/fentanyl. Now adequately sedated on midax / fent / methadone.\n Cont this regimen for now and hold off on further sedation wean until\n ventilatory needs decrease.\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 12:09 AM 70 mL/hour\n Glycemic Control:\n Lines:\n Multi Lumen - 11:24 PM\n Arterial Line - 12:14 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": "2120-04-22 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 323349, "text": "Chief Complaint: 50M h/o metastatic renal CA s/p nephrectomy, IL-2,\n mini-allograft SCT, DLI x 2 last in , emphysema/pulmonary fibrosis\n on home 02 presents with hypotension, fevers, hypoxemic respiratory\n failure.\n 24 Hour Events:\n -Did not tolerate weaning sedation\n -Remains bradycardic in 40s\n -Decreased driving pressures throughout the day, from 28 to 24(?)\n -Got lasix gttto which he -responded, put out >2L in afternoon, was\n stopped, BP stable\n -Increased ACEI\n Allergies:\n Flagyl (Oral) (Metronidazole)\n Rash;\n Last dose of Antibiotics:\n Bactrim (SMX/TMP) - 09:00 AM\n Levofloxacin - 09:11 AM\n Acyclovir - 04:18 PM\n Caspofungin - 08:00 PM\n Vancomycin - 08:33 PM\n Piperacillin/Tazobactam (Zosyn) - 05:54 AM\n Infusions:\n Midazolam (Versed) - 10 mg/hour\n Fentanyl - 500 mcg/hour\n Other ICU medications:\n Furosemide (Lasix) - 11:00 AM\n Heparin Sodium (Prophylaxis) - 08:32 PM\n Famotidine (Pepcid) - 08:33 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:08 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.8\nC (100\n Tcurrent: 37.8\nC (100\n HR: 45 (41 - 60) bpm\n BP: 131/57(79) {119/50(69) - 159/69(94)} mmHg\n RR: 30 (21 - 30) insp/min\n SpO2: 94%\n Heart rhythm: SB (Sinus Bradycardia)\n Wgt (current): 76.3 kg (admission): 76.3 kg\n Height: 68 Inch\n CVP: 11 (6 - 20)mmHg\n CO/CI (CCO): (5.1 L/min) / (2.7 L/min/m2)\n Total In:\n 5,547 mL\n 1,369 mL\n PO:\n TF:\n 2,460 mL\n 539 mL\n IVF:\n 2,577 mL\n 580 mL\n Blood products:\n Total out:\n 7,120 mL\n 1,020 mL\n Urine:\n 7,120 mL\n 1,020 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,573 mL\n 349 mL\n Respiratory support\n Ventilator mode: PCV+\n PC : 38 cmH2O\n RR (Set): 30\n PEEP: 12 cmH2O\n FiO2: 50%\n PIP: 37 cmH2O\n SpO2: 94%\n ABG: 7.45/50/98./33/8\n Ve: 14 L/min\n PaO2 / FiO2: 196\n Physical Examination\n Gen: eyes open, not following commands, some localization to voice\n Heent: pupils equal. Intubated, ng tube and esophageal balloon in\n place\n Cor: rrr, nls1s2 no mr, + S4 gallop\n Pul: cta anteriorly\n Abd: moderately distended. Bowel sounds present, no guarding, no\n tenderness\n Extreme: warm, 2+ pitting edema to mid-thigh\n Neuro: sedated, eyes open, not responding to commands,\n Labs / Radiology\n 135 K/uL\n 10.8 g/dL\n 99 mg/dL\n 1.0 mg/dL\n 33 mEq/L\n 2.8 mEq/L\n 24 mg/dL\n 107 mEq/L\n 148 mEq/L\n 31.9 %\n 12.5 K/uL\n [image002.jpg]\n 06:06 AM\n 02:28 PM\n 06:28 PM\n 09:12 PM\n 01:58 AM\n 04:48 AM\n 05:04 AM\n 08:15 PM\n 04:54 AM\n 05:34 AM\n WBC\n 12.1\n 12.5\n Hct\n 31.2\n 31.9\n Plt\n 120\n 135\n Cr\n 1.0\n 1.0\n TCO2\n 26\n 24\n 24\n 26\n 28\n 26\n 33\n 36\n Glucose\n 122\n 99\n Other labs: PT / PTT / INR:13.1/32.2/1.1, CK / CKMB /\n Troponin-T:260/9/0.22, ALT / AST:57/31, Alk Phos / T Bili:70/0.4,\n Amylase / Lipase:53/22, Differential-Neuts:67.0 %, Band:2.0 %,\n Lymph:18.0 %, Mono:9.0 %, Eos:0.0 %, Lactic Acid:1.3 mmol/L,\n Albumin:2.7 g/dL, LDH:272 IU/L, Ca++:7.5 mg/dL, Mg++:2.1 mg/dL, PO4:2.6\n mg/dL\n Imaging: CXR : No interval cahnge\n Microbiology: All micro negative to date\n Assessment and Plan\n 50M h/o metastatic renal CA s/p nephrectomy, IL-2, mini-allograft SCT,\n DLI x 2 last in , emphysema/pulmonary fibrosis on home 02\n presented to OSH with hypoxic respiratory failure, fevers and\n hypotension.\n # Respiratory failure:\n Pneumonia as likely source of resp failure and sepsis in patient with\n poor pulmonary reserve due to emphysema, ?GVHD, fibrosis.\n Overnight w/ ? mucous plugging and decreased compliance. Overall not\n tolerating vent wean well.\n Cont sedation w/ fent / midazolam / methadone; no urgency in relieving\n sedating w/ high vent needs.\n - Diurese 500-1000mL in attempt improve oxygenation now that BP / shock\n has resolved\n - No changes to FiO2 / Peep until oxygenation improves\n - No change to A/C\n volume controlled setting\n - Decrease driving pressure and re-eval abg in attempt to reduce\n intrathoracic pressures and barotrauma\n # Shock:\n Multifactorial\n ** Sepsis: Likely source pneumonia. On very broad coverage w/\n vancomycin, levofloxacin, bactrim (now only ppx dosing), caspofungin.\n All other cultures pending. WBC and fever curve responding well.\n D/C caspo when beta glucan / galactomannan negative.\n - f/u cultures\n - Follow WBC count, fever curve, decreasing\n - PPD negative\n - Continue acyclovir ppx, vanc/zosyn/levoflox for 14 day course, now\n \n **Cardiogenic/\n ##Pump: Now improved BPs, off dobutamine. W/ dilated hypokinetic RV,\n likely causative in hypotension. Now BP recovering well.\n Will increase ace-I for BP contol and afterload reduction, and titrate\n to effect.\n ##Rhythm\n Sinus bradycardia. ? med effect. Sustaining blood pressure well, no\n need for atropine.\n QTc: prolonged mimimally to 485. Cont check EKG w/ levofloxacin,\n methadone.\n **Endocrine\n ? absolute adrenal insufficiency\n Pt w/ hx of adrenalectomy and adrenal gland w/ mets.\n - 60 mg po prednisone today and cont w/ rapid PO pred taper\n # Metastatic renal CA: Recurrent disease s/p donor lymphocyte\n transplant .\n - BMT to follow\n - Continue acyclovir ppx for now, will discuss with BMT\n # Sedation\n Goals of sedation have been clarified; being too light was causing\n problems w/ oxygenation. Pt also was requiring supra-normal levels of\n midaz/fentanyl. Now adequately sedated on midax / fent / methadone.\n Cont this regimen for now and hold off on further sedation wean until\n ventilatory needs decrease.\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 12:09 AM 70 mL/hour\n Glycemic Control: ISS\n Lines:\n Multi Lumen - 11:24 PM\n Arterial Line - 12:14 AM\n Prophylaxis:\n DVT: SC heparin\n Stress ulcer: Famotidine \n VAP: VAP bundle\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n" }, { "category": "Physician ", "chartdate": "2120-04-22 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 323372, "text": "Chief Complaint: shock/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 50 yo male with metastatic renal cell CA s/p allo-SCT, COPD/fibrosis\n admitted with resp failure/shock. Mixed septic/cardiogenic picture with\n resp failure related to probable infxn superimposed on RV fialure/pHTN,\n severe chronic pulm ds\n 24 Hour Events:\n *Still bradycardic\n *Vent wean: Decrease to PC 24\n *Diuresed\n History obtained from Medical records\n Patient unable to provide history: Sedated\n Allergies:\n Flagyl (Oral) (Metronidazole)\n Rash;\n Last dose of Antibiotics:\n Acyclovir - 04:18 PM\n Caspofungin - 08:00 PM\n Piperacillin/Tazobactam (Zosyn) - 05:54 AM\n Vancomycin - 08:28 AM\n Levofloxacin - 09:41 AM\n Infusions:\n Midazolam (Versed) - 10 mg/hour\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:32 PM\n Famotidine (Pepcid) - 07:51 AM\n Other medications:\n ASA, folic acid, SSI, lactulose, captopril, prednisone 60mg 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 11:26 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 (99.3\n HR: 41 (41 - 60) bpm\n BP: 125/59(79) {119/50(69) - 159/69(93)} mmHg\n RR: 30 (21 - 30) insp/min\n SpO2: 94%\n Heart rhythm: SB (Sinus Bradycardia)\n Wgt (current): 76.3 kg (admission): 76.3 kg\n Height: 68 Inch\n CVP: 12 (6 - 18)mmHg\n CO/CI (CCO): (4.4 L/min) / (2.3 L/min/m2)\n Total In:\n 5,547 mL\n 2,454 mL\n PO:\n TF:\n 2,460 mL\n 818 mL\n IVF:\n 2,577 mL\n 1,236 mL\n Blood products:\n Total out:\n 7,120 mL\n 2,310 mL\n Urine:\n 7,120 mL\n 2,310 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,573 mL\n 144 mL\n Respiratory support\n Ventilator mode: PCV+\n PC : 26 cmH2O\n RR (Set): 30\n PEEP: 12 cmH2O\n FiO2: 50%\n PIP: 37 cmH2O\n Plateau: 25 cmH2O\n SpO2: 94%\n ABG: 7.45/50/98./33/8\n Ve: 13.9 L/min\n PaO2 / FiO2: 196\n Physical Examination\n General Appearance: Well nourished, No(t) No acute distress, Overweight\n / Obese, No(t) Thin\n Eyes / Conjunctiva: PERRL, No(t) Pupils dilated, No(t) Conjunctiva pale\n Head, Ears, Nose, Throat: Normocephalic, No(t) Poor dentition, No(t) NG\n tube, 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) S3, No(t) S4,\n No(t) Rub, (Murmur: No(t) Systolic, No(t) Diastolic)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Present), (Left DP pulse:\n Present)\n Respiratory / Chest: (Expansion: Symmetric, No(t) Paradoxical), (Breath\n Sounds: Clear : , No(t) Wheezes : , No(t) Absent : , No(t) Rhonchorous:\n )\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended,\n No(t) Tender: , Obese\n Extremities: Right: Absent, Left: Absent, No(t) Cyanosis, No(t)\n Clubbing\n Musculoskeletal: No(t) Muscle wasting, No(t) Unable to stand\n Skin: Warm, No(t) Rash: , No(t) Jaundice\n Neurologic: No(t) Attentive, No(t) Follows simple commands, Responds\n to: Unresponsive, Movement: No spontaneous movement, Sedated, No(t)\n Paralyzed, Tone: Normal\n Labs / Radiology\n 10.8 g/dL\n 135 K/uL\n 99 mg/dL\n 1.0 mg/dL\n 33 mEq/L\n 2.8 mEq/L\n 24 mg/dL\n 107 mEq/L\n 148 mEq/L\n 31.9 %\n 12.5 K/uL\n [image002.jpg]\n 06:06 AM\n 02:28 PM\n 06:28 PM\n 09:12 PM\n 01:58 AM\n 04:48 AM\n 05:04 AM\n 08:15 PM\n 04:54 AM\n 05:34 AM\n WBC\n 12.1\n 12.5\n Hct\n 31.2\n 31.9\n Plt\n 120\n 135\n Cr\n 1.0\n 1.0\n TCO2\n 26\n 24\n 24\n 26\n 28\n 26\n 33\n 36\n Glucose\n 122\n 99\n Other labs: PT / PTT / INR:13.1/32.2/1.1, CK / CKMB /\n Troponin-T:260/9/0.22, ALT / AST:57/31, Alk Phos / T Bili:70/0.4,\n Amylase / Lipase:53/22, Differential-Neuts:67.0 %, Band:2.0 %,\n Lymph:18.0 %, Mono:9.0 %, Eos:0.0 %, Lactic Acid:1.3 mmol/L,\n Albumin:2.7 g/dL, LDH:272 IU/L, Ca++:7.5 mg/dL, Mg++:2.1 mg/dL, PO4:2.6\n mg/dL\n Imaging: CXR (reviewed): ETT properly positioned, continued diffuse\n infiltrates, left HD no longer visualized\n Assessment and Plan\n 50 yo male with metastatic renal cell CA s/p allo-SCT, COPD/fibrosis\n admitted with resp failure/shock. Mixed septic/cardiogenic picture with\n resp failure related to probable infxn superimposed on RV fialure/pHTN,\n severe chronic pulm ds/COPD/fibrosis\n *Acute respiratory failure. Multifactorial with acute infxn\n - Remains on high vent support, able to tolerate small decrease in\n driving pressures\n -Now Auto-diuresing\n - Continue to wean vent as able: decrease driving pressure further\n *Cardiogenic/septic shock\n - Hemodynamics unchanged, not requiring pressors or fluids\n - Tolerated ACe-I increase\n *Sepsis/PNA\n - No change in abx regimen\n - low grade fever- will pan culture\n - continue capsofungin until galactomanan returns\n *Bradycardia: sinus origin, BP tolerating. Continue to monitor.\n *Adrenal insufficiency: continue to taper steroids\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 12:09 AM 70 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Multi Lumen - 11:24 PM\n Arterial Line - 12:14 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: 40 minutes\n Patient is critically ill\n" }, { "category": "Nursing", "chartdate": "2120-04-25 00:00:00.000", "description": "Nursing Progress Note", "row_id": 323667, "text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt on PCV/40%/10 PEEP/rate 30 at start of shift. Sats 94-97%. LS\n tubular. No apparent distress noted. Minimal secretions. Regular\n breathing pattern in sync with vent. Pt desated to 91-92% - ABG showed\n 7.49/43/65/8/34.\n Action:\n FiO2 up to 50%\n Response:\n Sats back up to 96-97% - pt appeares more comfortable. AM ABG\n 7.44/50/110/8/35\n Plan:\n Plan for trach and PEG today. TF off since MN. Wean vent as tol.\n Pt on Propofol and Methadone for sedation receiving Ativan and Fentanyl\n boluses. Only received 2mg Ativan IV x1 on shift. Plan to try and\n wean Propofol as tol during days.\n" }, { "category": "Social Work", "chartdate": "2120-04-16 00:00:00.000", "description": "Social Work Admission Note", "row_id": 322704, "text": "Family Information\n Next of : \n Health Care Proxy appointed: Yes - But NO copy of signed proxy form in\n medical record, HCP paperwork requested\n Family Spokesperson designated:\n Communication or visitation restriction:\n Patient Information:\n Previous living situation:\n Previous level of functioning: Independent\n Previous or other hospital admissions: patient has had previous\n admissions. See OMR notes by , NP.\n Past psychiatric history: not obtained during this admission\n Past addictions history: not obtained during this admission\n Employment status:\n Legal involvement:\n Mandated Reporting Information:\n Additional Information:\n Patient / Family Assessment: is a 50 yo man known to me from his\n BMT in . Not followed since then but met with wife today. and\n live in their own home in NH. they have a 12 yo daughter who is\n currently at home being cared for by mother while is\n here. Daughter was 4 old when her father got and is familiar\n with hospitals and illness. notes that they have always been\n honest with her and that she will be telling her how seriously ill her\n father is at this point. has several siblings and has called\n his two brothers who will be coming down tonight. Offered to help them\n find a place to stay but wants to wait until tomorrow to make a\n plan. She is very tearful and scared. Family meeting held with ICU\n Team and BMT Team and situation was carefully outlined fr her. She\n realizes how he is but keeps stating that he is a \"fighter\" and\n has been very before. She has requested the priest, and Father\n has visited and will follow up tomorrow. I will see her again\n tomorrow as well. suppport provided.\n Clergy Contact:\n Communication with Team:\n Plan / Follow up:\n Assess need for family meeting\n" }, { "category": "General", "chartdate": "2120-04-23 00:00:00.000", "description": "ICU Event Note", "row_id": 323481, "text": "Clinician: Attending\n 50 yo man with metastatic renal cell CA s/p allo- SCT with subsequent\n severe chronic resp failure thought to be emphysema and fibrosis of\n unclear etiology (CT from last spring demonstrates severe cystic and\n fibrotic changes with almost no normal appearing lung) presented with 2\n wk prodrome, now with catastrophic acute on chronic failure. CXR shows\n diffuse opacification. Severe septic shock. RV with global hypokinesis,\n dilated, mod-sev PAH. Responded well to dobutamine.\n Adjusting sedation: now on propofol 20/h, fentanyl 150/h, methadone 20q\n 4h IV, Versed 4/h.\n Events:\n Weaned down Dobutamine to 1.0, remains off levophed, vasopressin.\n Afebrile\n Did not bronch due to resp events and sense that yield would be quite\n low given risk of procedure\n PC 24/PEEP12/0.5/30/TV400s\n Exam sig for: arousable, reponds to voice with gaze despite fent\n 500/versed 12, no audible crackles, hypoactiveBS, abd soft, minimal\n peripheral edema, no rashes\n - Remains afebrile\n - autodiuresing\n - WBC remains stable\n - No new micro data- bglucan and galactomannan still pending\n Fent/Versed. H2blocker, hepsc, hydrocortisone 50mg q 6h, aspirin\n Abx: Vanco/Levoflox/Zosyn/Acyclovir/Caspofungin\n Cardiogenic shock and severe acute on chronic respiratory failure.\n CARDIOGENIC SHOCK, PAH, RV FAILURE\n Stable on captopril for afterload reduction, now hypertensive.\n SEPTIC SHOCK\n No source identified for infection, may have been viral URI, but if he\n did have a component of septic shock, most likely source pneumonia. Was\n ruled out for influenza at OSH. Minimal respiratory secretions. Very\n broad coverage.\n Continue vanc/zosyn/levoflox and prophylactic bactrim and acyclovir.\n Pending beta-glucan and galactomannan with plan to d/c caspofungin if\n markers neg.\n RESP FAILURE\n Infection, sepsis, acute exacerbation of underlying chronic disease as\n well as cardiogenic shock, with severe PH and impaired LV filling and\n outflow.\n - reduce FiO2\n - switch from PC to AC vent if possible\n HYPOTENSION: multifactorial shock- cardiogenic, septic, possibly\n adrenal insufficiency.\n Wean down steroids to prednisone 50 .\n SEDATION\n Try to wean off propofol and bolus\n NUTRITION\n Has bowel sounds. Reattempt TF.\n HepSC, ranitidine, oral care, pneumoboots\n other issues per Dr \ns note.\n Will meet with to update her on developments.\n Total time spent: 65 minutes\n Patient is critically ill.\n" }, { "category": "Physician ", "chartdate": "2120-04-24 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 323579, "text": "Chief Complaint:\n 24 Hour Events:\n - PEEP decreased to 10 and PaO2 104, then decreased to 8 but patient\n didn't tolerate; back up to 10. FiO2 still 50%\n - Plan for sedation is to change methadone back to q4h, decrease\n fentanyl, and use propofol as needed for sedation. then, once fentanyl\n off, preferentially wean versed and cont on propofol for sedation\n - IP called about trach, plan for Thurs\n Allergies:\n Flagyl (Oral) (Metronidazole)\n Rash;\n Last dose of Antibiotics:\n Acyclovir - 04:18 PM\n Levofloxacin - 08:21 AM\n Vancomycin - 08:27 PM\n Caspofungin - 09:28 PM\n Piperacillin/Tazobactam (Zosyn) - 05:50 AM\n Infusions:\n Fentanyl - 50 mcg/hour\n Midazolam (Versed) - 2 mg/hour\n Propofol - 25 mcg/Kg/min\n Other ICU medications:\n Fentanyl - 07:45 PM\n Heparin Sodium (Prophylaxis) - 07:57 PM\n Famotidine (Pepcid) - 08:05 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 07:36 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: 35.8\nC (96.5\n HR: 53 (50 - 110) bpm\n BP: 142/72(97) {130/68(88) - 182/99(127)} mmHg\n RR: 30 (21 - 3,024) insp/min\n SpO2: 94%\n Heart rhythm: SB (Sinus Bradycardia)\n Wgt (current): 76.3 kg (admission): 76.3 kg\n Height: 68 Inch\n CVP: 15 (10 - 21)mmHg\n Total In:\n 4,414 mL\n 1,155 mL\n PO:\n TF:\n 1,681 mL\n 513 mL\n IVF:\n 2,173 mL\n 362 mL\n Blood products:\n Total out:\n 6,805 mL\n 1,580 mL\n Urine:\n 6,805 mL\n 1,580 mL\n NG:\n Stool:\n Drains:\n Balance:\n -2,391 mL\n -425 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: PCV+\n PC : 24 cmH2O\n RR (Set): 30\n PEEP: 10 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10\n PIP: 34 cmH2O\n Plateau: 31 cmH2O\n SpO2: 94%\n ABG: 7.47/47/82./34/8\n Ve: 13 L/min\n PaO2 / FiO2: 166\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 144 K/uL\n 10.2 g/dL\n 92 mg/dL\n 0.9 mg/dL\n 34 mEq/L\n 3.8 mEq/L\n 17 mg/dL\n 105 mEq/L\n 144 mEq/L\n 30.8 %\n 13.9 K/uL\n [image002.jpg]\n 04:54 AM\n 05:34 AM\n 05:52 PM\n 08:48 PM\n 04:35 AM\n 04:49 AM\n 03:50 PM\n 07:18 PM\n 03:49 AM\n 04:48 AM\n WBC\n 12.5\n 12.9\n 13.9\n Hct\n 31.9\n 32.5\n 30.8\n Plt\n 135\n 174\n 144\n Cr\n 1.0\n 0.9\n 0.8\n 0.9\n 0.9\n TCO2\n 36\n 36\n 33\n 33\n 35\n Glucose\n 99\n 115\n 101\n 92\n Other labs: PT / PTT / INR:13.1/32.2/1.1, CK / CKMB /\n Troponin-T:260/9/0.22, ALT / AST:57/31, Alk Phos / T Bili:70/0.4,\n Amylase / Lipase:53/22, Differential-Neuts:67.0 %, Band:2.0 %,\n Lymph:18.0 %, Mono:9.0 %, Eos:0.0 %, Lactic Acid:2.0 mmol/L,\n Albumin:2.6 g/dL, LDH:272 IU/L, Ca++:8.0 mg/dL, Mg++:2.3 mg/dL, PO4:2.9\n mg/dL\n Imaging: CXR : Little overall change\n Microbiology: BCx x4: NGTD\n Sputum cx and gram stain : NG\n Assessment and Plan\n 50M h/o metastatic renal CA s/p nephrectomy, IL-2, mini-allograft SCT,\n DLI x 2 last in , emphysema/pulmonary fibrosis on home 02\n presented to OSH with hypoxic respiratory failure, fevers and\n hypotension.\n # Respiratory failure: Pneumonia as likely source of resp failure and\n sepsis in patient with poor pulmonary reserve due to emphysema, ?GVHD,\n fibrosis.\n - PEEP decreased to 10 which patient tolerated well (PaO2 104). Did not\n tolerated PEEP decrease to 8 (increased agitation). PEEP increased\n back to 10 with good response.\n - Sedation on vent, see below\n - No change in PEEP today as did not tolerate, would not change driving\n pressures either as patient now has compensatory respiratory acidosis\n for metabolic alkalosis likely secondary to auto-diuresis.\n - No change to A/C as patient has been tolerating PCV well\n - Esophageal balloon removed\n - Plan for trach by IP on Thursday\n # Sedation: Goals of sedation have been clarified; being too light was\n causing problems w/ oxygenation. Pt also was requiring supra-normal\n levels of midaz/fentanyl. Started on propofol for worsening agitation\n causing desats\n - Changed back to methadone q4H, decreasing fentanyl (now at\n 50mcg/hr). Also weaning versed (now at 2mg/hr) and preferentially\n using propofol for sedation (currently at 25).\n - Can still use fentanyl boluses prn if necessary for agitation\n # Shock: Multifactorial\n ** Sepsis: Likely source pneumonia. On very broad coverage w/\n vancomycin, levofloxacin, zosyn, bactrim (now only ppx dosing),\n caspofungin. All other cultures pending. WBC and fever curve\n improving slightly.\n - D/C caspo when beta glucan / galactomannan negative per BMT\n - F/u cultures- cont to culture with spikes. Currently afebrile x >24H\n - PPD negative\n - Continue acyclovir ppx, vanc/zosyn/levoflox for 14 day course, tdaoy\n is day 6.\n **Cardiogenic\n ## Pump: Now improved BPs, off dobutamine. On captopril for afterload\n reduction. Dilated hypokinetic RV, likely causative in hypotension.\n Now hypertensive. Can consider increasing to 25mg TID.\n ## Rhythm: Sinus bradycardia likely secondary to sedatives; increases\n with agitation. Cont weaning sedation as tolerated. Continue to\n follow QTc for prolongation given methadone and levoflox, has been wnl\n **Endocrine\n - Cont w/ rapid PO pred taper, decrease to 40->20->10 then off.\n # Metastatic renal CA: Recurrent disease s/p donor lymphocyte\n transplant .\n - BMT to follow\n - Continue acyclovir and bactrim ppx for now, will discuss with BMT\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 06:54 PM 70 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Multi Lumen - 11:24 PM\n Arterial Line - 12:14 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:ICU\n" }, { "category": "Physician ", "chartdate": "2120-04-24 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 323580, "text": "Chief Complaint: 50M h/o metastatic renal CA s/p nephrectomy, IL-2,\n mini-allograft SCT, DLI x 2 last in , emphysema/pulmonary fibrosis\n on home 02 presented to OSH with hypoxic respiratory failure, fevers\n and hypotension\n 24 Hour Events:\n - PEEP decreased to 10 and PaO2 104, then decreased to 8 but patient\n didn't tolerate; back up to 10. FiO2 still 50%\n - Plan for sedation is to change methadone back to q4h, decrease\n fentanyl, and use propofol as needed for sedation. then, once fentanyl\n off, preferentially wean versed and cont on propofol for sedation\n - IP called about trach, plan for Thurs\n Allergies:\n Flagyl (Oral) (Metronidazole)\n Rash;\n Last dose of Antibiotics:\n Acyclovir - 04:18 PM\n Levofloxacin - 08:21 AM\n Vancomycin - 08:27 PM\n Caspofungin - 09:28 PM\n Piperacillin/Tazobactam (Zosyn) - 05:50 AM\n Infusions:\n Fentanyl - 50 mcg/hour\n Midazolam (Versed) - 2 mg/hour\n Propofol - 25 mcg/Kg/min\n Other ICU medications:\n Fentanyl - 07:45 PM\n Heparin Sodium (Prophylaxis) - 07:57 PM\n Famotidine (Pepcid) - 08:05 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 07:36 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: 35.8\nC (96.5\n HR: 53 (50 - 110) bpm\n BP: 142/72(97) {130/68(88) - 182/99(127)} mmHg\n RR: 30 (21 - 3,024) insp/min\n SpO2: 94%\n Heart rhythm: SB (Sinus Bradycardia)\n Wgt (current): 76.3 kg (admission): 76.3 kg\n Height: 68 Inch\n CVP: 15 (10 - 21)mmHg\n Total In:\n 4,414 mL\n 1,155 mL\n PO:\n TF:\n 1,681 mL\n 513 mL\n IVF:\n 2,173 mL\n 362 mL\n Blood products:\n Total out:\n 6,805 mL\n 1,580 mL\n Urine:\n 6,805 mL\n 1,580 mL\n NG:\n Stool:\n Drains:\n Balance:\n -2,391 mL\n -425 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: PCV+\n PC : 24 cmH2O\n RR (Set): 30\n PEEP: 10 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10\n PIP: 34 cmH2O\n Plateau: 31 cmH2O\n SpO2: 94%\n ABG: 7.47/47/82./34/8\n Ve: 13 L/min\n PaO2 / FiO2: 166\n Physical Examination\n Gen: eyes open, follow commands to move toes, localization to voice\n Heent: pupils equal. Intubated, ng tube and esophageal balloon in\n place\n Cor: rrr, nls1s2 no mr\n Pul: cta anteriorly- mechanical breath sounds\n Abd: moderately distended. Bowel sounds present, no guarding, no\n tenderness\n Extreme: warm, trace pitting edema to mid-thigh\n Neuro: sedated, but responds to voice and follows some commands\n Labs / Radiology\n 144 K/uL\n 10.2 g/dL\n 92 mg/dL\n 0.9 mg/dL\n 34 mEq/L\n 3.8 mEq/L\n 17 mg/dL\n 105 mEq/L\n 144 mEq/L\n 30.8 %\n 13.9 K/uL\n [image002.jpg]\n 04:54 AM\n 05:34 AM\n 05:52 PM\n 08:48 PM\n 04:35 AM\n 04:49 AM\n 03:50 PM\n 07:18 PM\n 03:49 AM\n 04:48 AM\n WBC\n 12.5\n 12.9\n 13.9\n Hct\n 31.9\n 32.5\n 30.8\n Plt\n 135\n 174\n 144\n Cr\n 1.0\n 0.9\n 0.8\n 0.9\n 0.9\n TCO2\n 36\n 36\n 33\n 33\n 35\n Glucose\n 99\n 115\n 101\n 92\n Other labs: PT / PTT / INR:13.1/32.2/1.1, CK / CKMB /\n Troponin-T:260/9/0.22, ALT / AST:57/31, Alk Phos / T Bili:70/0.4,\n Amylase / Lipase:53/22, Differential-Neuts:67.0 %, Band:2.0 %,\n Lymph:18.0 %, Mono:9.0 %, Eos:0.0 %, Lactic Acid:2.0 mmol/L,\n Albumin:2.6 g/dL, LDH:272 IU/L, Ca++:8.0 mg/dL, Mg++:2.3 mg/dL, PO4:2.9\n mg/dL\n Imaging: CXR : Little overall change\n Microbiology: BCx x4: NGTD\n Sputum cx and gram stain : NG\n Assessment and Plan\n 50M h/o metastatic renal CA s/p nephrectomy, IL-2, mini-allograft SCT,\n DLI x 2 last in , emphysema/pulmonary fibrosis on home 02\n presented to OSH with hypoxic respiratory failure, fevers and\n hypotension.\n # Respiratory failure: Pneumonia as likely source of resp failure and\n sepsis in patient with poor pulmonary reserve due to emphysema, ?GVHD,\n fibrosis.\n - PEEP decreased to 10 which patient tolerated well (PaO2 104). Did not\n tolerated PEEP decrease to 8 (increased agitation). PEEP increased\n back to 10 with good response.\n - Sedation on vent, see below\n - No change in PEEP today as did not tolerate, would not change driving\n pressures either as patient now has compensatory respiratory acidosis\n for metabolic alkalosis likely secondary to auto-diuresis.\n - No change to A/C as patient has been tolerating PCV well\n - Esophageal balloon removed\n - Plan for trach by IP on Thursday\n # Sedation: Goals of sedation have been clarified; being too light was\n causing problems w/ oxygenation. Pt also was requiring supra-normal\n levels of midaz/fentanyl. Started on propofol for worsening agitation\n causing desats\n - Changed back to methadone q4H, decreasing fentanyl (now at\n 50mcg/hr). Also weaning versed (now at 2mg/hr) and preferentially\n using propofol for sedation (currently at 25).\n - Can still use fentanyl boluses prn if necessary for agitation\n # Shock: Multifactorial\n ** Sepsis: Likely source pneumonia. On very broad coverage w/\n vancomycin, levofloxacin, zosyn, bactrim (now only ppx dosing),\n caspofungin. All other cultures pending. WBC and fever curve\n improving slightly.\n - D/C caspo when beta glucan / galactomannan negative per BMT\n - F/u cultures- cont to culture with spikes. Currently afebrile x >24H\n - PPD negative\n - Continue acyclovir ppx, vanc/zosyn/levoflox for 14 day course, tdaoy\n is day 6.\n **Cardiogenic\n ## Pump: Now improved BPs, off dobutamine. On captopril for afterload\n reduction. Dilated hypokinetic RV, likely causative in hypotension.\n Now hypertensive. Can consider increasing to 25mg TID.\n ## Rhythm: Sinus bradycardia likely secondary to sedatives; increases\n with agitation. Cont weaning sedation as tolerated. Continue to\n follow QTc for prolongation given methadone and levoflox, has been wnl\n **Endocrine\n - Cont w/ rapid PO pred taper, decrease to 40->20->10 then off.\n # Metastatic renal CA: Recurrent disease s/p donor lymphocyte\n transplant .\n - BMT to follow\n - Continue acyclovir and bactrim ppx for now, will discuss with BMT\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 06:54 PM 70 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Multi Lumen - 11:24 PM\n Arterial Line - 12:14 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:ICU\n" }, { "category": "Nursing", "chartdate": "2120-04-26 00:00:00.000", "description": "Nursing Progress Note", "row_id": 323772, "text": "Pt is a 50 yo M with metastatic renal cell CA s/p allo- SCT with\n subsequent severe chronic resp failure thought to be emphysema and\n fibrosis of unclear etiology (CT from last spring demonstrates severe\n cystic and fibrotic changes with almost no normal appearing lung).\n Admitted w/ catastrophic acute on chronic failure and severe shock,\n initially presumed septic but more predominantly cardiogenic. Was on\n high dose steroids, tapering prednisone and now 40PO qd.\n Pt rec\nd trach & PEG on ; cuff leak persistent, even w/ large\n volume inflation. IP due to change out today.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n LS clear to rhoncorous. Pressure control RR 30/Peep 5/FiO2 50%/insp\n P24cm\n Action:\n Subglottal sxn for mod amt bloody sputum x2, deep sxn for bloody plug\n x1 by RT, small amt bloody secretions x2\n Response:\n Remains comfortable w/ rate @30. Pulling volumes of 350-500 despite\n continuing cuff leak. Leak improves somewhat w/repositioning.\n Plan:\n IP to reassess today\n Note increasing WBC to 15 this am. Pt currently on Vanc, Zosyn,\n Levaquin, Acyclovir and qod Bactrim.\n" }, { "category": "Case Management ", "chartdate": "2120-04-16 00:00:00.000", "description": "Case Managment Initial Patient Assessment", "row_id": 322683, "text": "Insurance information\n Primary insurance: MEDICARE A B (HOSP MED INS)\n Secondary insurance: OOS PPO\n Insurance reviewer::\n Free Care application: N/A\n Status:\n Medicaid application: N/A\n Pre-Hospitalization services: None prior to admission\n DME / Home O[2]: None prior to admission\n Functional Status / Home / Family Assessment:\n Pt. lives with wife in , .\n Primary Contact(s): : ; ;\n \n Health Care Proxy: Yes - But NO copy of signed proxy form in medical\n record. HCP paperwork requested\n Dialysis: Yes\n Referrals Recommended: Social Work, Physical Therapy\n Current plan: Undetermined\n Unclear what level of services will be required at discharge. Case\n Management will follow for DC needs.\n Patient (s) to Discharge:\n Patient discussed with multidisciplinary team: No\n" }, { "category": "Nursing", "chartdate": "2120-04-16 00:00:00.000", "description": "Nursing Progress Note", "row_id": 322692, "text": "50M h/o metastatic renal CA s/p nephrectomy, IL-2, mini-allograft , DLI\n x 2 last in , emphysema/pulmonary fibrosis on home 02 presents\n with sepsis. Started on NIPPV, hydrocortisone, broad spectrum abx at\n OSH yesterday. TTE at OSH EF 65-70, LVH, PASP 54, RV dilation.\n Intubated. On FiO2 100% 7.02/104/105. Had received vecuronium. ECG with\n deep TW inversions. Hypotensive here, received 4L NS. Vent transitioned\n to PCV. Started on norepinephrine and subsequently vasopressin.\n" }, { "category": "Nursing", "chartdate": "2120-04-16 00:00:00.000", "description": "Nursing Progress Note", "row_id": 322693, "text": "50M h/o metastatic renal CA s/p nephrectomy, IL-2, mini-allograft , DLI\n x 2 last in , emphysema/pulmonary fibrosis on home 02 presents\n with sepsis. Started on NIPPV, hydrocortisone, broad spectrum abx at\n OSH yesterday. TTE at OSH EF 65-70, LVH, PASP 54, RV dilation.\n Intubated. On FiO2 100% 7.02/104/105. Had received vecuronium. ECG with\n deep TW inversions. Hypotensive here, received 4L NS. Vent transitioned\n to PCV. Started on norepinephrine and subsequently vasopressin.\n Sepsis, Severe (with organ dysfunction)\n Assessment:\n SBP down to high 70\ns this AM\n Action:\n Levophed increased without adequate\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Physician ", "chartdate": "2120-04-17 00:00:00.000", "description": "ICU Attending Note", "row_id": 322826, "text": "Clinician: Attending\n 50 yo man with metastatic renal cell CA s/p allo- SCT with subsequent\n severe chronic resp failure thought to be emphysema and fibrosis and\n possible GVHD/BOOP (CT from last spring demonstrates severe cystic and\n fibrotic changes with almost no normal appearing lung) presented with 2\n wk prodrome, now with catastrophic acute on chronic failure. CXR shows\n diffuse opacification. Severe septic shock, now on 2 pressors. Not\n recently on corticosteroids.\n Overnight events:\n - weaned off levophed, but restarted\n - LENI negative\n - RV with global hypokinesis, dilated, mod-sev PAH.\n - Cardiac index decreased from 2.8 to 2.0, approximately\n - I/O 5.5/0.8\n - PCV FiO2 0.6/24/PEEP 16/ TV 450ish 7.32/38/115, (7/27/43/111\n when on 0.8)\n - Remains paralyzed on cisatracurium\n - No new culture data. Legionella urine Ag negative.\n - WBC 20\n - HCO3 22\n - LDH increased from 505\n 856\n Fent 350/Versed 6. H2blocker, hepsc, hydrocortisone 50mg q 6h.\n Abx: Vanco/Levoflox/Vanco/Acyclovir/Bactrim/Caspofungin\n SEPTIC SHOCK\n Most likely source pneumonia. R/O for influenza at OSH.\n Cx pending. Markers pending.\n Bronch will probably not allow us to change his management- given his\n >48 of broad spectrum abx the most likely organism we will be able to\n obtain (if present) is PCP. the severity of his presentation I am\n not sure we will be able to remove any of his antibiotics, as he is\n improved.\n RESP FAILURE\n Infection, sepsis, acute exacerbation of underlying chronic disease as\n well as cardiogenic shock, with severe PH and impaired LV filling and\n outflow.\n - oxygenation currently adequate on high PEEP, with improved FiO2\n - stop paralysis and redose with boluses as needed\n - rescue strategy in some patients includes inhaled prostacyclin or NO,\n though he given his underlying severe lung disease these agents will\n probably worsen his hypoxia via worsened V/Q mismatch/shunt. Not\n indicated in PAH caused by pulm fibrosis, which is probably the major\n etiology of his PH, compounded by ARDS.\n - will trial Dobutamine, willing to increase norepinephrine if\n necessary.\n - confusing volume issue- will titrate up Dobutamine and watch levophed\n requirement and urine output to decide fluid goal\n HYPOTENSION\n Septic and cardiogenic shock and RV failure. Has one adrenal gland with\n metastatic lesion.\n Fluid resuscitation. Received high dose steroids at OSH. Continuing\n high dose hydrocortisone.\n CARDIAC\n Severe PH with hypokinetic and dilated RV.\n Continue to check ECGs, cardiac enzymes.\n Aspirin.\n SEDATION with fent 350 /versed 6\n COLD FOOT- resolved- now warm bilaterally.\n other issues per Dr note.\n Total time spent: 100 minutes\n Patient is critically ill.\n" }, { "category": "Respiratory ", "chartdate": "2120-04-18 00:00:00.000", "description": "Generic Note", "row_id": 322887, "text": "TITLE:\n Respiratory Care:\n Pt remains intubated and vented on PCV. Peep decreased to 14, Fio2\n decreased to 50% with good abg results, see carevue. Opening eyes at\n times. Plan is to continue with support, and wean further as pt\n tolerates.\n" }, { "category": "Nursing", "chartdate": "2120-04-18 00:00:00.000", "description": "Nursing Progress Note", "row_id": 322888, "text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Current vent settings PCV/50%/34/14 PEEP. Scant secretions. Sats\n 94-97%. Synchronous with vent. Fent and Versed gtts. Pt deat to 89%\n when turned on left side\n recovered on own with no intervention\n needed.\n Action:\n Vent changes made\n FiO2 down to 50% from 60% and PEEP down to 14 from\n 16. ABG\ns followed.\n Response:\n Sats remain 95-97% on current settings. ABG\n Plan:\n Con\nt to wean vent settings as tol. Con\nt to monitor ABG\n Sepsis, Severe (with organ dysfunction)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2120-04-18 00:00:00.000", "description": "Nursing Progress Note", "row_id": 322891, "text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Current vent settings PCV/50%/34/14 PEEP. Scant secretions. Sats\n 94-97%. Synchronous with vent. Fent and Versed gtts. Pt deat to 89%\n when turned on left side\n recovered on own with no intervention\n needed. LS clear with diminished bases.\n Action:\n Vent changes made\n FiO2 down to 50% from 60% and PEEP down to 14 from\n 16. ABG\ns followed.\n Response:\n Sats remain 95-97% on current settings. ABG 7.36/39/96/-\n Plan:\n Con\nt to wean vent settings as tol. Con\nt to monitor ABG\n Heart failure, right, isolated (Cor Pulmonale)\n Assessment:\n C.I less than 2.5\n Action:\n Dobutamine gtt increased to 1.5 mcg/kg/min\n Response:\n C.I. up to 2.7-3.2\n Plan:\n Con\nt to monitor hemodynamics and titrate Dobuta as needed for goal of\n C.I. greater than 2.5\n" }, { "category": "Physician ", "chartdate": "2120-04-24 00:00:00.000", "description": "ICU Attending Note", "row_id": 323592, "text": "Clinician: Attending\n 50 yo man with metastatic renal cell CA s/p allo- SCT with subsequent\n severe chronic resp failure thought to be emphysema and fibrosis of\n unclear etiology (CT from last spring demonstrates severe cystic and\n fibrotic changes with almost no normal appearing lung) presented with 2\n wk prodrome, now with catastrophic acute on chronic failure. CXR shows\n diffuse opacification. Severe shock, initially presumed septic but more\n predominantly cardiogenic. RV with global hypokinesis, dilated, mod-sev\n PAH. Responded well to dobutamine. Was on high dose steroids, tapering\n prednisone and now 40PO qd.\n Events:\n Adjusting sedation: Fentanyl off! now on propofol 25/h,\n methadone 20q 4h IV, Versed 2/h\n PC 0.5/24/PEEP10/30/TV400s 7.44/51/109\n Exam sig for: Remains afebrile, autodiuresing, arousable, reponds to\n voice and followed commands (moved toes and hands bilat), no audible\n crackles, hypoactiveBS, abd soft, minimal peripheral edema, no rashes\n - No new micro data- bglucan and galactomannan still pending\n H2blocker, hepsc, prednisone 20, aspirin\n Abx: Vanco/Levoflox/Zosyn/Caspofungin/bactrim and acyclovir\n prophylaxis\n Cardiogenic shock and severe acute on chronic respiratory failure.\n Sepsis.\n CARDIOGENIC SHOCK, PAH, RV FAILURE\n Stable on captopril for afterload reduction, now hypertensive.\n Autodiuresing.\n INFECTION\n No source identified for infection, may have been viral URI, but if he\n did have a component of septic shock, most likely source pneumonia. Was\n ruled out for influenza at OSH. Minimal respiratory secretions. Very\n broad coverage.\n Continue vanc/zosyn/levoflox and prophylactic bactrim and acyclovir.\n Pending beta-glucan and galactomannan with plan to d/c caspofungin if\n markers neg.\n RESP FAILURE\n Infection, sepsis, acute exacerbation of underlying severe chronic\n disease (emphysema and fibrosis) as well as cardiogenic shock, with\n severe PH and impaired LV filling and outflow.\n - Did NOT tolerate changing from PC to AC mode vent- appears\n much more comfortable on PCV- he became agitated on AC.\n - Weaned PEEP to 10. Will not decrease at this point. Will\n decrease FiO2. Will trial PS when on less propofol.\n SEDATION\n Off fentanyl. Then will wean versed, will be maintained on methadone\n and propfol. Bolus fentanyl as needed for agitation. Will decrease\n methadone to q6 then q8. QTc okay.\n NUTRITION\n Tolerating TF, on PO narcan.\n HepSC, ranitidine, oral care, pneumoboots, HOB up.\n other issues per Dr \ns note.\n Will meet with pt\ns wife, to update her on developments and\n discuss trach/PEG. Also discussed with Dr .\n Total time spent: 40 minutes\n Patient is critically ill.\n" }, { "category": "Respiratory ", "chartdate": "2120-04-25 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 323663, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 11\n Ideal body weight: 69.9 None\n Ideal tidal volume: 279.6 / 419.4 / 559.2 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: 23 cm at teeth\n Route:\n Type: Standard\n Size: 7.5mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Tubular\n LUL Lung Sounds: Tubular\n LLL Lung Sounds: Clear\n Comments:\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / None\n Comments:\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern:\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment: Not triggering\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours:\n Reason for continuing current ventilatory support: Sedated / Paralyzed,\n Intolerant of weaning attempts, Pending procedure / OR\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n Pt to have trach. At bedside today\n" }, { "category": "Nursing", "chartdate": "2120-04-24 00:00:00.000", "description": "Nursing Progress Note", "row_id": 323601, "text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Received on PCV peep 10,rate 30,FiO2 50%,Desats to 88% when agitated.\n Action:\n ABG repeated X2 times,FiO2 down to 40%,ABG after one hr 7.46/49/78, no\n changes were made after that.Fentanyl successfully weaned off,Midazolam\n weaned to 1 mg,Propofol 25 mcg/kg/mt.Required bolus occasionally to\n keep him calm,Methadone dose titrated to 20 mg/IV Q4hr.\n Response:\n Pt was comfortable with above measures.\n Plan:\n Plan to continue PEEP@10,Once sedations are minimal can try to change\n mode of ventilation,Plan to do TRACHEOSTOMY at bedside today if\n possible.TF are off since 1130 for the same.\n **********autodiuresing 400 ml/hr team aware,lytes repeated WNL\n **********Captopril dose ^^ 25 mg\n ********** Pt\ns brother and sister visited,wife called X 2times and\n updated,like to be called before tracheostomy.\n **********Continue to wean sedations as tolerated.\n" }, { "category": "Physician ", "chartdate": "2120-04-24 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 323607, "text": "Chief Complaint: 50M h/o metastatic renal CA s/p nephrectomy, IL-2,\n mini-allograft SCT, DLI x 2 last in , emphysema/pulmonary fibrosis\n on home 02 presented to OSH with hypoxic respiratory failure, fevers\n and hypotension\n 24 Hour Events:\n - PEEP decreased to 10 and PaO2 104, then decreased to 8 but patient\n didn't tolerate; back up to 10. FiO2 still 50%\n - IP called about trach, plan for today or Thurs with anesthesia\n present\n Allergies:\n Flagyl (Oral) (Metronidazole)\n Rash;\n Last dose of Antibiotics:\n Acyclovir - 04:18 PM\n Levofloxacin - 08:21 AM\n Vancomycin - 08:27 PM\n Caspofungin - 09:28 PM\n Piperacillin/Tazobactam (Zosyn) - 05:50 AM\n Infusions:\n Fentanyl - 50 mcg/hour\n Midazolam (Versed) - 2 mg/hour\n Propofol - 25 mcg/Kg/min\n Other ICU medications:\n Fentanyl - 07:45 PM\n Heparin Sodium (Prophylaxis) - 07:57 PM\n Famotidine (Pepcid) - 08:05 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 07:36 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: 35.8\nC (96.5\n HR: 53 (50 - 110) bpm\n BP: 142/72(97) {130/68(88) - 182/99(127)} mmHg\n RR: 30 (21 - 30) insp/min\n SpO2: 94%\n Heart rhythm: SB (Sinus Bradycardia)\n Wgt (current): 76.3 kg (admission): 76.3 kg\n Height: 68 Inch\n CVP: 15 (10 - 21)mmHg\n Total In:\n 4,414 mL\n 1,155 mL\n PO:\n TF:\n 1,681 mL\n 513 mL\n IVF:\n 2,173 mL\n 362 mL\n Blood products:\n Total out:\n 6,805 mL\n 1,580 mL\n Urine:\n 6,805 mL\n 1,580 mL\n NG:\n Stool:\n Drains:\n Balance:\n -2,391 mL\n -425 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: PCV+\n PC : 24 cmH2O\n RR (Set): 30\n PEEP: 10 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10\n PIP: 34 cmH2O\n Plateau: 31 cmH2O\n SpO2: 94%\n ABG: 7.47/47/82./34/8\n Ve: 13 L/min\n PaO2 / FiO2: 166\n Physical Examination\n Gen: eyes open, follows commands to move toes, localization to voice\n Heent: pupils equal. Intubated\n Cor: rrr, nls1s2 no mr\n Pul: cta anteriorly- mechanical breath sounds\n Abd: moderately distended. Bowel sounds present, no guarding, no\n tenderness\n Extreme: warm, trace pitting edema to mid-thigh\n Neuro: sedated, but responds to voice and follows some commands\n Labs / Radiology\n 144 K/uL\n 10.2 g/dL\n 92 mg/dL\n 0.9 mg/dL\n 34 mEq/L\n 3.8 mEq/L\n 17 mg/dL\n 105 mEq/L\n 144 mEq/L\n 30.8 %\n 13.9 K/uL\n [image002.jpg]\n 04:54 AM\n 05:34 AM\n 05:52 PM\n 08:48 PM\n 04:35 AM\n 04:49 AM\n 03:50 PM\n 07:18 PM\n 03:49 AM\n 04:48 AM\n WBC\n 12.5\n 12.9\n 13.9\n Hct\n 31.9\n 32.5\n 30.8\n Plt\n 135\n 174\n 144\n Cr\n 1.0\n 0.9\n 0.8\n 0.9\n 0.9\n TCO2\n 36\n 36\n 33\n 33\n 35\n Glucose\n 99\n 115\n 101\n 92\n Other labs: PT / PTT / INR:13.1/32.2/1.1, CK / CKMB /\n Troponin-T:260/9/0.22, ALT / AST:57/31, Alk Phos / T Bili:70/0.4,\n Amylase / Lipase:53/22, Differential-Neuts:67.0 %, Band:2.0 %,\n Lymph:18.0 %, Mono:9.0 %, Eos:0.0 %, Lactic Acid:2.0 mmol/L,\n Albumin:2.6 g/dL, LDH:272 IU/L, Ca++:8.0 mg/dL, Mg++:2.3 mg/dL, PO4:2.9\n mg/dL\n Imaging: CXR : Little overall change\n Microbiology: BCx x4: NGTD\n Sputum cx and gram stain : NG\n Assessment and Plan\n 50M h/o metastatic renal CA s/p nephrectomy, IL-2, mini-allograft SCT,\n DLI x 2 last in , emphysema/pulmonary fibrosis on home 02\n presented to OSH with hypoxic respiratory failure, fevers and\n hypotension.\n # Respiratory failure: Pneumonia as likely source of resp failure and\n sepsis in patient with poor pulmonary reserve due to emphysema, ?GVHD,\n fibrosis.\n - PEEP decreased to 10 which patient tolerated well (PaO2 104). Did not\n tolerated PEEP decrease to 8 (increased agitation). PEEP increased\n back to 10 with good response.\n - Sedation on vent, see below\n - No change in PEEP today as did not tolerate, would not change driving\n pressures either as patient now has compensatory respiratory acidosis\n for metabolic alkalosis likely secondary to auto-diuresis.\n - Attempt decrease in FiO2 today (50->40%) as repeat gas this am showed\n 7.44/51/109\n - No change to A/C as patient has been tolerating PCV well; once\n sedation is decreased, can consider changing to PSV today. Changing\n mode of ventilation would likely be next consideration as he will\n likely continue to require high PEEPs\n - Esophageal balloon removed\n - Plan for trach by IP today with anesthesia\n # Sedation: Goals of sedation have been clarified; being too light was\n causing problems w/ oxygenation. Pt also was requiring supra-normal\n levels of midaz/fentanyl. Started on propofol for worsening agitation\n causing desats\n -Changed back to methadone q4H, decreasing fentanyl (now off this\n morning). Also weaning versed (now at 2mg/hr) and preferentially\n using propofol for sedation (currently at 25 requiring occasional\n boluses for agitation).\n - Goal to wean off versed today and keep patient comfortable, awake if\n possible and calm with sedation regimen.\n # Shock: Multifactorial\n ** Sepsis: Likely source pneumonia. On very broad coverage w/\n vancomycin, levofloxacin, zosyn, bactrim (now only ppx dosing),\n caspofungin. All other cultures pending. WBC and fever curve\n improving slightly.\n - D/C caspo when beta glucan / galactomannan negative per BMT\n - F/u cultures- cont to culture with spikes. Currently afebrile x >24H\n - PPD negative\n - Continue acyclovir ppx, vanc/zosyn/levoflox for 14 day course, today\n is day 6.\n **Cardiogenic\n ## Pump: Now improved BPs, off dobutamine. On captopril for afterload\n reduction. Dilated hypokinetic RV, likely causative in hypotension.\n Now hypertensive. Increasing to 25mg TID today.\n ## Rhythm: Sinus bradycardia likely secondary to sedatives; increases\n with agitation. Cont weaning sedation as tolerated. Continue to\n follow QTc for prolongation given methadone and levoflox, has been wnl\n **Endocrine\n - Cont w/ rapid PO pred taper, decrease to 10 tomorrow then off.\n # Metastatic renal CA: Recurrent disease s/p donor lymphocyte\n transplant .\n - BMT to follow\n - Continue acyclovir and bactrim ppx for now, will discuss with BMT\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 06:54 PM 70 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Multi Lumen - 11:24 PM\n Arterial Line - 12:14 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP: Mouth care, HOB elevation\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:ICU\n" }, { "category": "Physician ", "chartdate": "2120-04-16 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 322669, "text": "Chief Complaint: hypoxemic resp failure 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 50M h/o metastatic renal CA s/p nephrectomy, IL-2, mini-allograft SCT,\n DLI x 2 last in , emphysema/pulmonary fibrosis on home 02 presents\n with sepsis. Started on NIPPV, hydrocortisone, broad spectrum abx at\n OSH yesterday. TTE at OSH EF 65-70, LVH, PASP 54, RV dilation.\n Intubated en route. On FiO2 100% 7.02/104/105. Had received vecuronium.\n ECG with deep TW inversions. Hypotensive here, received 4L NS. Vent\n transitioned to PCV. Started on norepinephrine and subsequently\n vasopressin.\n 24 Hour Events:\n INVASIVE VENTILATION - START 09:10 PM\n EKG - At 10:53 PM\n MULTI LUMEN - START 11:24 PM\n ARTERIAL LINE - START 12:14 AM\n BLOOD CULTURED - At 01:32 AM\n URINE CULTURE - At 01:32 AM\n BLOOD CULTURED - At 05:00 AM\n FEVER - 101.1\nF - 06:00 AM\n Allergies:\n Flagyl (Oral) (Metronidazole)\n Rash;\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 04:11 AM\n Caspofungin - 04:45 AM\n Bactrim (SMX/TMP) - 06:00 AM\n Infusions:\n Fentanyl - 250 mcg/hour\n Midazolam (Versed) - 6 mg/hour\n Norepinephrine - 0.17 mcg/Kg/min\n Vasopressin - 1.2 units/hour\n Other ICU medications:\n Metoprolol - 10:30 PM\n Midazolam (Versed) - 11:22 PM\n Fentanyl - 11:51 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 09:33 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.4\nC (101.1\n Tcurrent: 38.2\nC (100.8\n HR: 101 (79 - 133) bpm\n BP: 105/67(82) {78/53(63) - 105/71(82)} mmHg\n RR: 19 (13 - 26) insp/min\n SpO2: 94%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 76.3 kg (admission): 76.3 kg\n Height: 68 Inch\n CVP: 16 (16 - 21)mmHg\n Total In:\n 3,511 mL\n 2,082 mL\n PO:\n TF:\n IVF:\n 2,011 mL\n 2,082 mL\n Blood products:\n Total out:\n 275 mL\n 182 mL\n Urine:\n 275 mL\n 182 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,236 mL\n 1,900 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: PCV+Assist\n Vt (Set): 450 (400 - 450) mL\n PC : 20 cmH2O\n RR (Set): 32\n PEEP: 18 cmH2O\n FiO2: 100%\n RSBI Deferred: PEEP > 10, FiO2 > 60%\n PIP: 40 cmH2O\n Plateau: 34 cmH2O\n SpO2: 94%\n ABG: 7.18/54/76 on PEEP 18, FiO2 100%\n Ve: 16 L/min\n PaO2 / FiO2: 76\n Physical Examination\n General Appearance: Well nourished\n Eyes / Conjunctiva: PERRL, Conjunctiva pale\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Rhonchorous: )\n Abdominal: Soft, Bowel sounds present, No(t) Distended\n Extremities: Right: Absent, Left: Absent, No(t) Cyanosis, No(t)\n Clubbing, left foot cold, right foot warm\n Musculoskeletal: No(t) Muscle wasting\n Skin: Warm, No(t) Rash: , No(t) Jaundice\n Neurologic: Responds to: Unresponsive, Movement: No spontaneous\n movement, Sedated, No(t) Paralyzed, Tone: Not assessed\n Labs / Radiology\n 13.3 g/dL\n 185 K/uL\n 109 mg/dL\n 0.8 mg/dL\n 22 mEq/L\n 5.0 mEq/L\n 11 mg/dL\n 118 mEq/L\n 145 mEq/L\n 41.8 %\n 20.7 K/uL\n [image002.jpg]\n 09:51 PM\n 11:55 PM\n 12:22 AM\n 01:31 AM\n 02:10 AM\n 04:13 AM\n 06:23 AM\n 08:00 AM\n WBC\n 20.8\n 20.7\n Hct\n 44\n 41.2\n 41.8\n Plt\n 185\n 185\n Cr\n 0.8\n TropT\n 0.34\n TCO2\n 29\n 22\n 21\n 22\n 21\n 21\n Glucose\n 109\n Other labs: PT / PTT / INR:16.0/28.8/1.4, CK / CKMB /\n Troponin-T:168/15/0.34, ALT / AST:44/52, Alk Phos / T Bili:95/0.9,\n Differential-Neuts:67.0 %, Band:2.0 %, Lymph:18.0 %, Mono:9.0 %,\n Eos:0.0 %, Lactic Acid:1.4 mmol/L, Albumin:2.6 g/dL, LDH:435 IU/L,\n Ca++:6.1 mg/dL, Mg++:2.0 mg/dL, PO4:4.3 mg/dL\n Assessment and Plan\n 50 yo man with metastatic renal cell CA s/p allo- SCT with subsequent\n severe chronic resp failure thought to be emphysema and fibrosis and\n possible GVHD/BOOP (CT from last spring demonstrates severe cystic and\n fibrotic changes with almost no normal appearing lung) presented with 2\n wk prodrome, now with catastrophic acute on chronic failure. CXR shows\n diffuse opacification. Severe septic shock, now on 2 pressors. Not\n recently on corticosteroids.\n SEPTIC SHOCK\n Most likely source pneumonia. R/O for influenza at OSH.\n Vanc/Zosyn/Levoflox/Bactrim/Caspofungin/acyclovir prophylaxis.\n Cx pending.\n Markers pending.\n Not safe for bronch.\n RESP FAILURE\n Infection, sepsis, acute exacerbation of underlying chronic disease as\n well as cardiac component with likely severe PH and also likely\n impaired LV filling and impaired LV outflow with subsequent CHF.\n - oxygenation currently adequate on high PEEP, max FiO2\n - consider paralysis if we are unable to decrease FiO2\n - rescue strategy may include inhaled prostacyclin or NO, though he may\n have severe F/Q mismatch/shunt given his underlying severe lung\n disease.\n HYPOTENSION\n Septic shock. Has one adrenal gland with metastatic lesion.\n Fluid resuscitation. Received high dose steroids at OSH. Add high dose\n hydrocortisone.\n CARDIAC\n Severe PH. New TW inversions, likely demand ischemia with tachy,\n hypotension.\n TTE.\n Aspirin.\n SEDATION with fent 350 /versed 6\n COLD FOOT- observe for now\n other issues per Dr note.\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 20 Gauge - 09:10 PM\n Multi Lumen - 11:24 PM\n Arterial Line - 12:14 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP: Mouth care\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 80 minutes\n Patient is critically ill\n" }, { "category": "Physician ", "chartdate": "2120-04-17 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 322816, "text": "Chief Complaint: 50M h/o metastatic renal CA s/p nephrectomy, IL-2,\n mini-allograft SCT, DLI x 2 last in , emphysema/pulmonary fibrosis\n on home 02 presents with sepsis.\n 24 Hour Events:\n ESOPHOGEAL BALLOON - At 10:18 AM\n TRANSTHORACIC ECHO - At 10:56 AM\n ULTRASOUND - At 02:00 PM\n Pt paralyzed to improve ventilation\n Family meeting with team members conveying gravity of pt's situation,\n DNR status discussed, pt remains full code.\n Pt weaned off levophed, remains on vasopressin\n Vigileo device applied for CO monitoring, have been ~\n LENIs negative\n TF started\n TTE showed EF>55%, mild LV diastolic dysfunction, RV with mild global\n free wall hypokinesis with RV pressure overload and moderate to severe\n \n Allergies:\n Flagyl (Oral) (Metronidazole)\n Rash;\n Last dose of Antibiotics:\n Levofloxacin - 09:00 AM\n Bactrim (SMX/TMP) - 12:12 AM\n Acyclovir - 12:13 AM\n - 04:08 AM\n Piperacillin/Tazobactam (Zosyn) - 06:00 AM\n Infusions:\n Vasopressin - 2.4 units/hour\n Cisatracurium - 0.1 mg/Kg/hour\n Midazolam (Versed) - 6 mg/hour\n Norepinephrine - 0.08 mcg/Kg/min\n Fentanyl - 350 mcg/hour\n Other ICU medications:\n Fentanyl - 08:30 AM\n Famotidine (Pepcid) - 08:00 PM\n Heparin Sodium (Prophylaxis) - 08:00 PM\n Other medications:\n Hydrocortisone\n Acetaminophen\n Folic Acid\n Albuterol\n ASA\n Famotidine\n Hep Sc\n ISS\n Docusate\n Senna\n Bisacodyl\n Chlorhexidine\n Changes to medical and family history: None\n Review of systems is unchanged from admission except as noted below\n Review of systems: intubated, sedated, paralysis\n Flowsheet Data as of 07:04 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.2\nC (100.8\n Tcurrent: 37\nC (98.6\n HR: 70 (70 - 102) bpm\n BP: 84/58(66) {78/53(63) - 142/86(95)} mmHg\n RR: 34 (10 - 34) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 76.3 kg (admission): 76.3 kg\n Height: 68 Inch\n CVP: 26 (15 - 355)mmHg\n CO/CI (CCO): (2.5 L/min) / (1.3 L/min/m2)\n Total In:\n 5,512 mL\n 2,061 mL\n PO:\n TF:\n 75 mL\n 190 mL\n IVF:\n 5,287 mL\n 1,522 mL\n Blood products:\n Total out:\n 832 mL\n 435 mL\n Urine:\n 832 mL\n 435 mL\n NG:\n Stool:\n Drains:\n Balance:\n 4,680 mL\n 1,626 mL\n Respiratory support\n Ventilator mode: PCV+Assist\n PC : 24 cmH2O\n RR (Set): 34\n PEEP: 16 cmH2O\n FiO2: 60%\n RSBI Deferred: PEEP > 10\n PIP: 40 cmH2O\n Plateau: 38 cmH2O\n SpO2: 96%\n ABG: 7.32/38/115/17/-5\n Ve: 15.2 L/min\n PaO2 / FiO2: 192\n Physical Examination\n General Appearance: Intubated, sedated\n Eyes / Conjunctiva: Pupils dilated\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube\n Lymphatic: No(t) Cervical WNL, No(t) Supraclavicular WNL, No(t)\n Cervical adenopathy\n Cardiovascular: (S1: Normal), (S2: Normal, Fixed), tachycardic. regular\n Peripheral Vascular: (Right radial pulse: Diminished), (Left radial\n pulse: Diminished), (Right DP pulse: Diminished), (Left DP pulse:\n Diminished)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Rhonchorous: ), coarse mechanical BS throughout all lung fields\n Abdominal: Soft, Non-tender, hypoactive bowel sounds\n Extremities: no edema, palpable distal pulses\n Skin: Not assessed\n Neurologic: Intubated, sedated, paralyzed\n Labs / Radiology\n 119 K/uL\n 11.7 g/dL\n 174 mg/dL\n 1.1 mg/dL\n 17 mEq/L\n 5.1 mEq/L\n 16 mg/dL\n 106 mEq/L\n 128 mEq/L\n 35.4 %\n 13.1 K/uL\n [image002.jpg]\n 09:49 AM\n 01:08 PM\n 01:38 PM\n 03:16 PM\n 04:51 PM\n 06:59 PM\n 09:54 PM\n 11:52 PM\n 04:37 AM\n 04:52 AM\n WBC\n 13.1\n Hct\n 35.4\n Plt\n 119\n Cr\n 1.1\n 1.1\n TCO2\n 23\n 22\n 22\n 20\n 23\n 21\n 21\n 20\n Glucose\n 74\n Other labs: PT / PTT / INR:15.9/28.7/1.4, CK / CKMB /\n Troponin-T:168/15/0.49, ALT / AST:61/96, Alk Phos / T Bili:78/0.6,\n Amylase / Lipase:53/22, Differential-Neuts:67.0 %, Band:2.0 %,\n Lymph:18.0 %, Mono:9.0 %, Eos:0.0 %, Lactic Acid:1.8 mmol/L,\n Albumin:2.7 g/dL, LDH:856 IU/L, Ca++:8.0 mg/dL, Mg++:1.9 mg/dL, PO4:2.3\n mg/dL\n Assessment and Plan\n 50M h/o metastatic renal CA s/p nephrectomy, IL-2, mini-allograft SCT,\n DLI x 2 last in , emphysema/pulmonary fibrosis on home 02 presents\n with sepsis.\n # Sepsis: On presentation to OSH pt hypotensive, hypoxic with fevers\n and leukocytosis. Now with hypoxic respiratory failure, requiring\n pressors. Likely pneumonia given hypoxia and possible opacities on\n CXR, although difficult to read due to fibrosis. No other apparent\n localizing symptoms. Ruled-out for flu at OSH. Urine, GI sources less\n probable. Given immunocompromise from malignancy, at risk for PCP,\n , etc. Progression of GVHD could be contributing. Given tenuous\n respiratory status and requirments for high levels of PEEP a\n bronchoscopy would be too high risk for BAL and culture data.\n - Will attempt to obtain deep ET sputum for culture\n - legionella urine ag negative, all other cultures no growth to date.\n - Vanc, zosyn, levofloxacin, bactrim IV for PCP, to cover\n broadly for now given critical illness. Iv steroids for PCP and\n adrenal insufficiency as below.\n - glucan, galactomannan pending\n - CT chest and possible bronch when more stable\n - Follow WBC count, fever curve\n - PPD to be read \n # Respiratory failure: Pneumonia in patient with poor pulmonary reserve\n due to emphysema, ?GVHD, fibrosis. Avoid high pressures given fibrotic\n lungs, using pressure control ventilation. Tolerated decrease in Fi02\n from 100% to 60% yesterday, oxygenating well.\n -continue to wean FI02\n -will d/c cisatracurium infusion and use boluses as needed for\n paralysis should pt be dysynchronous with ventilator, otherwise will\n continue to manage sedation/pain with fentanyl/versed, increasing gtt\n as needed.\n - Continue mechanical ventilatory support, wean as tolerated\n -No proning for now as pt oxygenating well.\n # Hypotension: Likely sepsis, although probably component of\n hypovolemia as well. At risk for PE given malignancy. GI bleed unlikely\n as Hct stable. Adrenal insufficiency possible given s/p adrenelectomy\n with mets in remaining adrenal. Pt has dysfunctional RV with severe\n likely contributing to low CO. Set up vigileo device yesterday\n for non-invasive hemodynamic monitoring. Initially CI was 2.8, this am\n 1.8, a concerning decrease. His SV variability is low, indicating\n minimal fluid responsiveness.\n - start dobutamine in an attempt to increase CO, titrate to goal CO >4,\n CI >2.5, maintain on vasopressin and levophed. Monitor pressors if\n becomes hypotensive due to vasodilitory effect will discontinue.\n - No prostacyclin/NO for now due to concern that may increase mismatch\n and worsen hypoxia.\n - Consider PA catheter placement for more accurate hemodynamic\n monitoring, will continue to use vigileo for now.\n - Treat broadly for infection per above\n - IV hydrocort Q6 for adrenal insufficiency\n - LENIs to look for DVT negative.\n - Guaiac stools, HCT has been stable.\n # Cardiac: Patient with probable demand ischemia in setting of\n hypotension, tachycardia, and sepsis; less likely unstable plaque.\n - CE\ns this am trending down\n - ASA, hold on beta-blocker and statin\n - Repeat ECG in am\n # Metastatic renal CA: Recurrent disease s/p donor lymphocyte\n transplant .\n - BMT to follow\n - Avoid steroids given risk to graft\n - Continue acyclovir ppx for now, will discuss with BMT\n ICU Care\n Nutrition: TF, tolerating with low residuals.\n Replete (Full) - 06:20 AM 40 mL/hour, advance as tolerated\n to goal of 70mL /hour\n Glycemic Control: ISS prn\n Lines:\n 20 Gauge - 09:10 PM\n Multi Lumen - 11:24 PM\n Arterial Line - 12:14 AM\n Prophylaxis:\n DVT: Hep SC, pneumoboots\n Stress ulcer: Ranitidine\n VAP: Chlorhexidine\n Comments:\n Communication: Comments: wife, \n Code status: Full code, have d/w family, will continue to readdress\n today\n Disposition: ICU\n" }, { "category": "Nursing", "chartdate": "2120-04-18 00:00:00.000", "description": "Nursing Progress Note", "row_id": 322889, "text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Current vent settings PCV/50%/34/14 PEEP. Scant secretions. Sats\n 94-97%. Synchronous with vent. Fent and Versed gtts. Pt deat to 89%\n when turned on left side\n recovered on own with no intervention\n needed. LS clear with diminished bases.\n Action:\n Vent changes made\n FiO2 down to 50% from 60% and PEEP down to 14 from\n 16. ABG\ns followed.\n Response:\n Sats remain 95-97% on current settings. ABG\n Plan:\n Con\nt to wean vent settings as tol. Con\nt to monitor ABG\n Sepsis, Severe (with organ dysfunction)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nutrition", "chartdate": "2120-04-26 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 323796, "text": "Subjective\n Patient s/p trach and PEG placement\n Objective\n Pertinent medications: RISS, folic acid, senna/colace, lactulose,\n prednisone\n Labs:\n Value\n Date\n Glucose\n 65 mg/dL\n 04:43 AM\n Glucose Finger Stick\n 80\n 06:00 AM\n BUN\n 17 mg/dL\n 04:43 AM\n Creatinine\n 1.0 mg/dL\n 04:43 AM\n Sodium\n 141 mEq/L\n 04:43 AM\n Potassium\n 3.5 mEq/L\n 04:43 AM\n Chloride\n 108 mEq/L\n 04:43 AM\n Albumin\n 2.6 g/dL\n 04:54 AM\n Calcium non-ionized\n 8.6 mg/dL\n 04:43 AM\n Phosphorus\n 2.6 mg/dL\n 04:43 AM\n Ionized Calcium\n 1.00 mmol/L\n 03:23 PM\n Magnesium\n 2.2 mg/dL\n 04:43 AM\n Current diet order / nutrition support: NPO\n GI: Abdomen soft/distended with hypoactive bowel sounds\n Assessment of Nutritional Status\n Specifics:\n 50 year old male with metastatic renal cell cancer s/p nephrectomy, s/p\n allo-SCT, with emphysema/pulmonary fibrosis on home O2 presenting with\n hypoxic respiratory failure, fever, sepsis. Patient was unable to be\n weaned from ventilator so now s/p trach and PEG placement .\n Patient\ns trach with cuff , replace today. Plan to restart tube\n feeding once PEG able to be used.\n Medical Nutrition Therapy Plan - Recommend the Following\n 1. Once medically possible, recommend restarting tube feeding of\n Replete with Fiber to goal rate of 65ml/hr. Will adjust goal rate based\n on propofol dosing if needed.\n 2. Monitor tolerance, check residuals q4H and hold if >150ml\n 3. Continue to monitor/replete lytes PRN\n 09:24\n" }, { "category": "Physician ", "chartdate": "2120-04-26 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 323802, "text": "Chief Complaint: hypoxemic resp failure\n HPI:\n 50 yo M with metastatic renal cell CA s/p allo- SCT with subsequent\n severe chronic resp failure thought to be emphysema and fibrosis of\n unclear etiology (CT from last spring demonstrates severe cystic and\n fibrotic changes with almost no normal appearing lung) presented with 2\n wk prodrome, presented with catastrophic acute on chronic failure. CXR\n shows diffuse opacification c/w ARDS. Severe shock, initially presumed\n septic but more predominantly cardiogenic. RV with global hypokinesis,\n dilated, mod-sev PAH. Responded well to dobutamine. Was on high dose\n steroids, tapering prednisone and now 40PO qd.\n 24 Hour Events:\n PEG INSERTION - At 09:45 AM\n PERCUTANEOUS TRACHEOSTOMY - At 10:10 AM\n s/p trach/PEG, trach w/persistent air leak- IP to change today\n beta glucan and galactomannan negative so caspo d/c'd\n tolerating peep 5\n PCV 20/5 x30 (breathes up to 40 when awake), FiO2 0.5\n propofol gtt 20 (HTN, tachy when propofol shut off this am)\n mehtadone 20mg q4hrs\n intermittent 1mg ativan boluses for agitation\n Allergies:\n Flagyl (Oral) (Metronidazole)\n Rash;\n Last dose of Antibiotics:\n Caspofungin - 09:28 PM\n Piperacillin/Tazobactam (Zosyn) - 05:30 AM\n Acyclovir - 08:15 AM\n Vancomycin - 08:16 AM\n Levofloxacin - 08:16 AM\n Bactrim (SMX/TMP) - 08:16 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:00 PM\n Lorazepam (Ativan) - 06:20 AM\n Famotidine (Pepcid) - 08:16 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 11:09 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.2\nC (100.8\n Tcurrent: 38.2\nC (100.8\n HR: 88 (48 - 117) bpm\n BP: 106/73(79) {106/72(50) - 164/94(111)} mmHg\n RR: 30 (12 - 34) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 76.3 kg (admission): 76.3 kg\n Height: 68 Inch\n CVP: 7 (7 - 14)mmHg\n Total In:\n 2,694 mL\n 1,017 mL\n PO:\n TF:\n 26 mL\n IVF:\n 2,279 mL\n 822 mL\n Blood products:\n Total out:\n 4,950 mL\n 1,765 mL\n Urine:\n 4,950 mL\n 1,465 mL\n NG:\n 300 mL\n Stool:\n Drains:\n Balance:\n -2,256 mL\n -748 mL\n Respiratory support\n Ventilator mode: PCV+\n Vt (Set): 500 (500 - 500) mL\n PC : 20 cmH2O\n RR (Set): 30\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI Deferred: Unstable Airway\n PIP: 25 cmH2O\n Plateau: 25 cmH2O\n SpO2: 94%\n ABG: 7.49/34/127/26/3\n Ve: 13.8 L/min\n PaO2 / FiO2: 254\n Physical Examination\n General Appearance: No acute distress\n Lymphatic: trach in place\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: Symmetric), coarse BS anteriorly b/l\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended,\n g-tube site ok\n Extremities: Right: Absent, Left: Absent\n Skin: Not assessed, No(t) Rash:\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed, opens eyes/orients to voice, does not follow commands\n Labs / Radiology\n 11.4 g/dL\n 159 K/uL\n 65 mg/dL\n 1.0 mg/dL\n 26 mEq/L\n 3.5 mEq/L\n 17 mg/dL\n 108 mEq/L\n 141 mEq/L\n 34.0 %\n 15.0 K/uL\n [image002.jpg]\n 04:48 AM\n 11:19 AM\n 01:45 PM\n 08:13 PM\n 10:07 PM\n 04:05 AM\n 04:29 AM\n 03:23 PM\n 06:00 PM\n 04:43 AM\n WBC\n 13.6\n 15.0\n Hct\n 31.6\n 34.0\n Plt\n 149\n 159\n Cr\n 0.9\n 1.0\n 1.0\n TCO2\n 35\n 36\n 36\n 34\n 35\n 27\n Glucose\n 93\n 70\n 76\n 65\n Other labs: PT / PTT / INR:13.7/42.1/1.2, CK / CKMB /\n Troponin-T:260/9/0.22, ALT / AST:57/31, Alk Phos / T Bili:70/0.4,\n Amylase / Lipase:53/22, Differential-Neuts:67.0 %, Band:2.0 %,\n Lymph:18.0 %, Mono:9.0 %, Eos:0.0 %, Lactic Acid:2.0 mmol/L,\n Albumin:2.6 g/dL, LDH:272 IU/L, Ca++:8.6 mg/dL, Mg++:2.2 mg/dL, PO4:2.6\n mg/dL\n Assessment and Plan\n 50 yo man with metastatic renal cell CA s/p allo- SCT with subsequent\n severe chronic resp failure thought to be emphysema and fibrosis of\n unclear etiology (CT from last spring demonstrates severe cystic and\n fibrotic changes with almost no normal appearing lung) presented with 2\n wk prodrome, presented with catastrophic acute on chronic failure. CXR\n shows diffuse opacification c/w ARDS. Severe shock, initially presumed\n septic but more predominantly cardiogenic. RV with global hypokinesis,\n dilated, mod-sev PAH. Responded well to dobutamine. Was on high dose\n steroids, now tappered off.\n Slowly improving.\n Abx: Vanco/Levoflox/Zosyn/bactrim and acyclovir prophylaxis\n #CARDIOGENIC SHOCK-resolved, PAH, RV FAILURE\n Stable on increased dose captopril for afterload reduction, mildly\n hypertensive. Autodiuresing. Rpt TTE in a couple of weeks.\n #Hypoxemic resp failure s/p trach, to be changed today given cuff\n leak. Tolerating wean of driving pressure and peep. PS trial post\n trach change today.\n No sig changes on vent today, given s/p trach this morning and on PEEP\n 10.\n #INFECTION\n D10/14 empiric vanc/zosyn/levoflox, also on prophylactic bactrim and\n acyclovir. Febrile this am- pan cx.\n #Sedation\n Off fentanyl and versed. Continues on propofol and methadone w/bolus\n ativan as needed for pain/agitation. Cont to wean propofol. Will\n decrease methadone to q6 then q8, after come down further on propofol.\n QTc okay. TG fine on propofol, check BIW.\n #NUTRITION\n Resume TF today\n HepSC, ranitidine, oral care, pneumoboots, HOB up.\n Patient is critically ill.\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Multi Lumen - 11:24 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP: HOB elevation\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :\n Total time spent:\n" }, { "category": "Physician ", "chartdate": "2120-04-26 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 323804, "text": "Chief Complaint: 50M h/o metastatic renal CA s/p nephrectomy, IL-2,\n mini-allograft SCT, DLI x 2 last in , emphysema/pulmonary fibrosis\n on home 02 presented to OSH with hypoxic respiratory failure, fevers\n and hypotension with sepsis, cardiogenic shock now weaning off\n ventilator\n 24 Hour Events:\n PEG INSERTION - At 09:45 AM\n PERCUTANEOUS TRACHEOSTOMY - At 10:10 AM\n - S/p trach and PEG\n - B glucan/galactomannan negative -> caspo discontinued\n - Trach with persistent air-leak, IP made aware by RT, plan to come by\n today to potentially change in am\n - Tolerating PEEP of 5 and maintaining sats >95% over the day yesterday\n Allergies:\n Flagyl (Oral) (Metronidazole)\n Rash;\n Last dose of Antibiotics:\n Caspofungin - 09:28 PM\n Levofloxacin - 10:30 AM\n Vancomycin - 08:45 PM\n Acyclovir - 12:00 AM\n Piperacillin/Tazobactam (Zosyn) - 05:30 AM\n Infusions:\n Propofol - 30 mcg/Kg/min\n Other ICU medications:\n Fentanyl - 10:00 AM\n Famotidine (Pepcid) - 08:00 PM\n Heparin Sodium (Prophylaxis) - 08:00 PM\n Lorazepam (Ativan) - 06:20 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 07:46 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: 36.6\nC (97.9\n HR: 91 (46 - 93) bpm\n BP: 130/69(89) {96/50(66) - 159/86(111)} mmHg\n RR: 29 (12 - 34) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 76.3 kg (admission): 76.3 kg\n Height: 68 Inch\n CVP: 8 (7 - 14)mmHg\n Total In:\n 2,694 mL\n 496 mL\n PO:\n TF:\n 26 mL\n IVF:\n 2,279 mL\n 381 mL\n Blood products:\n Total out:\n 4,950 mL\n 1,360 mL\n Urine:\n 4,950 mL\n 1,060 mL\n NG:\n 300 mL\n Stool:\n Drains:\n Balance:\n -2,256 mL\n -864 mL\n Respiratory support\n Ventilator mode: PCV+\n Vt (Set): 500 (500 - 500) mL\n PC : 24 cmH2O\n RR (Set): 30\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI Deferred: Unstable Airway\n PIP: 29 cmH2O\n Plateau: 25 cmH2O\n SpO2: 94%\n ABG: 7.49/34/127/26/3\n Ve: 13.9 L/min\n PaO2 / FiO2: 254\n Physical Examination\n Gen: Sedated, localization to voice\n Heent: pupils equal. Trached.\n Cor: RRR, nls1s2 no mr\n Pul: CTA anteriorly\n coarse, mechanical breath sounds\n Abd: moderately distended. Bowel sounds present, PEG in placed,\n dressed, no guarding, no tenderness\n Extreme: Warm, trace pitting edema to mid-thigh\n Labs / Radiology\n 159 K/uL\n 11.4 g/dL\n 65 mg/dL\n 1.0 mg/dL\n 26 mEq/L\n 3.5 mEq/L\n 17 mg/dL\n 108 mEq/L\n 141 mEq/L\n 34.0 %\n 15.0 K/uL\n [image002.jpg]\n 04:48 AM\n 11:19 AM\n 01:45 PM\n 08:13 PM\n 10:07 PM\n 04:05 AM\n 04:29 AM\n 03:23 PM\n 06:00 PM\n 04:43 AM\n WBC\n 13.6\n 15.0\n Hct\n 31.6\n 34.0\n Plt\n 149\n 159\n Cr\n 0.9\n 1.0\n 1.0\n TCO2\n 35\n 36\n 36\n 34\n 35\n 27\n Glucose\n 93\n 70\n 76\n 65\n Other labs: PT / PTT / INR:13.7/42.1/1.2, CK / CKMB /\n Troponin-T:260/9/0.22, ALT / AST:57/31, Alk Phos / T Bili:70/0.4,\n Amylase / Lipase:53/22, Differential-Neuts:67.0 %, Band:2.0 %,\n Lymph:18.0 %, Mono:9.0 %, Eos:0.0 %, Lactic Acid:2.0 mmol/L,\n Albumin:2.6 g/dL, LDH:272 IU/L, Ca++:8.6 mg/dL, Mg++:2.2 mg/dL, PO4:2.6\n mg/dL\n Microbiology: C. Diff neg x1\n Assessment and Plan\n 50M h/o metastatic renal CA s/p nephrectomy, IL-2, mini-allograft SCT,\n DLI x 2 last in , emphysema/pulmonary fibrosis on home 02\n presented to OSH with hypoxic respiratory failure, sepsis, cardiogenic\n shock, now improving but with difficulty weaning vent and s/p\n trach/PEG.\n # Respiratory failure: Pneumonia as likely source of resp failure and\n sepsis in patient with poor pulmonary reserve due to emphysema, ?GVHD,\n fibrosis. Patient is now s/p trach/PEG.\n - PEEP decreased to 5 yesterday after trach which he has tolerated\n well. Last ABG 7.49/34/127.\n - Driving pressures decreased this am from 24 to 20. Will check ABG on\n current settings.\n - Attempt decrease in FiO2 today (50->40%) -> maintain PaO2 >60.\n Patient's oxygenation has improved.\n - Can also attempt PSV trial today if able to adequately wean sedation\n without agitation.\n - Plan to replace trach today by IP given persistent air leak.\n # Sedation: Currently on methadone q4H, and propofol for sedation,\n currently at 20 mcg/kg/min. Off fent/versed drips.\n - Goal to wean propofol as tolerated today, triglycerides mildly\n elevated at 182\n - Continue to check triglycerides twice weekly while on propofol.\n - Bolus fentanyl/ativan prn agitation\n - When able, will decrease methadone to q6H then to q8H\n # Shock: Multifactorial, resolved.\n ** Sepsis: Likely source pneumonia. On very broad coverage w/\n vancomycin, levofloxacin, zosyn, bactrim (now only ppx dosing). All\n cultures pending or no growth. WBC stable. Patient with temp 100.8\n rectal this am during rounds. Blood cx/urine cx sent.\n - D/C'd caspo yesterday\n - F/u cultures - cont to culture with spikes.\n - Continue acyclovir and bactrim ppx, vanc/zosyn/levoflox for 14 day\n course, today is day 10.\n **Cardiogenic\n ## Pump: Now improved BPs, off dobutamine. On captopril for afterload\n reduction. Dilated hypokinetic RV, likely causative in hypotension.\n Now hypertensive. Increased to 25mg TID. Will likely need repeat ECHO\n once acute issues resolved to assess for resolution of RV dysfunction.\n ## Rhythm: Sinus bradycardia likely secondary to sedatives; increases\n with agitation. Cont weaning sedation as tolerated. Continue to\n follow QTc for prolongation given methadone and levoflox, has been wnl\n **Endocrine\n - Prednisone off today\n # Metastatic renal CA: Recurrent disease s/p donor lymphocyte\n transplant .\n - BMT to follow\n - Continue acyclovir and bactrim ppx\n ICU Care\n Nutrition:\n Restart TF 24 hours after PEG\n Glycemic Control:\n Lines:\n Multi Lumen - 11:24 PM\n Arterial Line - 12:14 AM\n Prophylaxis:\n DVT: Pneumoboots, SQ heparin\n Stress ulcer: H2 blocker\n VAP: HOB elevation, mouth care\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n" }, { "category": "Nursing", "chartdate": "2120-04-29 00:00:00.000", "description": "Nursing Progress Note", "row_id": 324052, "text": "This is 50M with h/o metastatic renal CA s/p\n nephrectomy,emphysema/pulmonary fibrosis on home 02 presented to OSH\n with hypoxic respiratory failure, fevers and hypotension with sepsis,\n cardiogenic shock was weaning off ventilator.Had trach and PEG on\n .Main issue with trach is that it has got air leak.IP was\n ,they will review the pt on .Pt failed PS on Friday. Was\n pan cultured on for temp of 101.4.\n Pt highly disynchronous with the vent and desaturating down to\n 75%.sedated on fent/versed and paralysed.pt hypotensive and started on\n neosynephrine.\n Hypotension (not Shock)\n Assessment:\n Pts BP down to map of 50 consistently.Tachycardic in 120\ns after\n starting on dopamine and persistently tachycardic even after dopamine\n changed to neosynephrine. On monitor to measure CI and SVV. SVV\n < 15. and CI .\n Action:\n Pt had 1000cc fluid bolus and started on dopamine but pt became\n tachycardic with that so switched to neo and is currently on neo\n 4.3mcg/kg/min.\n Response:\n BP at the time of report 75/51 with map 62.\n Plan:\n Monitor bp,aim for map >60. to switch to vasopressin if BP persistently\n low.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt highly disynchronous with the vent. Desaturating down to 70\ns. bld\n gases with po2 of 49. pco2 of 113.\n Action:\n Increased the o2 to 100% and increased peep to 18,increased the\n sedation and added fentanyl.Pt currently on fentanyl 225mcg/hr and\n versed 25mg/hr. Started on cisatracurium to paralyse the pt and is\n currently at a rate of .2mcg/kg/min.\n Response:\n Pt is saturating 100% now,bld gases are pco2 90, po2 91.LS clear.Peep\n reduced down to 10.\n Plan:\n Monitor resp status.Bld gases routinely.\n Heart failure, right, isolated (Cor Pulmonale)\n Assessment:\n Pt has got significant rt sided failure.CO 4.5 CI 2.7-4. SVV .\n Action:\n Started on lasix gtt and started on monitor.\n Response:\n UO 100cc/hr initially.stopped lasix as pressures dropped.\n Plan:\n Monitor CI and SVV and maintain .\n" }, { "category": "Nursing", "chartdate": "2120-04-27 00:00:00.000", "description": "Nursing Progress Note", "row_id": 323865, "text": "This is 50M with h/o metastatic renal CA s/p\n nephrectomy,emphysema/pulmonary fibrosis on home 02 presented to OSH\n with hypoxic respiratory failure, fevers and hypotension with sepsis,\n cardiogenic shock now weaning off ventilator.Had trach and PEG on\n .Mian issue with trach is that it has got air leak.IP was\n ,they will review the pt on .Pt was tried on PS\n yesterday lasting only 20 min.\n Hypotension (not Shock)\n Assessment:\n Action:\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n Heart failure, right, isolated (Cor Pulmonale)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2120-04-27 00:00:00.000", "description": "Nursing Progress Note", "row_id": 323867, "text": "This is 50M with h/o metastatic renal CA s/p\n nephrectomy,emphysema/pulmonary fibrosis on home 02 presented to OSH\n with hypoxic respiratory failure, fevers and hypotension with sepsis,\n cardiogenic shock now weaning off ventilator.Had trach and PEG on\n .Mian issue with trach is that it has got air leak.IP was\n ,they will review the pt on .Pt was tried on PS\n yesterday lasting only 20 min.Raised WCC yesterday and was cultured.\n There was a 6 point hct drop yesterday. Repeat hct stable.\n Hypotension (not Shock)\n Assessment:\n BP systolic in high 80\ns-110\ns.MAP 58-80.\n Action:\n Propofol weaned down to 15 but pt increasingly restless so put it back\n upto 25.omitted captopril.\n Response:\n BP increases when pt more awake.\n Plan:\n Titrate sedation for comfort and in according with the BP. Restart back\n on captopril when BP more stable.Aim MAP >60.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt mechanically ventilated through trach,on PCV 60%/.Failed PS\n yesterday.Has got huge cuff leak\n Action:\n No vent changes overnight.\n Response:\n Pt is saturating 95-98% on the current settings.Desaturates to low 90\n when turned.\n Plan:\n Try on ps today.\n" }, { "category": "Respiratory ", "chartdate": "2120-04-27 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 323869, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 13\n Ideal body weight: 69.9 None\n Ideal tidal volume: 279.6 / 419.4 / 559.2 mL/kg\n Tube Type\n Type:\n Tracheostomy tube:\n Type: Cuffed\n Manufacturer: Portex\n Size: 8.0mm\n PMV: No\n Cuff Management:\n Vol/Press:\n Cuff pressure: 50 cmH2O\n Cuff volume: mL /\n Airway problems: P > 30cm/H2O, Cuff / valve leak\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 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 Comments: Pt has a persistent cuff leak. Trachael cuff pressure=50.\n Intervention pulmonology is aware but not available until Monday . Pt\n is currently on pressure control ventilation with a rate of 30. Tidal\n volumes are between\n 380-450,varying with amount of leak. Pt does desaturate with position\n changes but comes back up quickly.\n" }, { "category": "Respiratory ", "chartdate": "2120-04-29 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 324044, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 15\n Ideal body weight: 69.9 None\n Ideal tidal volume: 279.6 / 419.4 / 559.2 mL/kg\n Tracheostomy tube:\n Type: Cuffed\n Manufacturer: Portex\n Size: 8.0mm\n PMV: No\n Cuff Management:\n Vol/Press:\n Cuff pressure: 50 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Clear\n Comments:\n Secretions\n Sputum color / consistency: White / Plug\n Sputum source/amount: Suctioned / Small\n Comments:\n Ventilation Assessment\n :\n Invasive ventilation assessment:\n Trigger work assessment: Not triggering\n Dysynchrony assessment:\n Comments: patient sedataed and paralysed\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: Esoh. balloon\n Recruitment Maneuvers Done\n CPAP pressure used: cm H2O\n Duration: sec\n Times per shift:\n Comments: Recruited on aprv x 3 without change\n Respiratory status deteriorated overnight with an acute drop in sats.\n Multiple changes made. Patient was put on paralytics\n And esophageal balloon placed. Transpulmonary pressure on\n inspiration=37. showing patient over distended . Ptp on exhalation =\n 1.7 on 18 of peep. At this time , patient was severely hypercarbic.\n Therefore, the peep was decreased to allow for higher tidal volumes.\n Oxygenation at this time has improved with Pao2 in 80s. Pco2 slowly\n returning down but still remains severely acidotic.\n" }, { "category": "Nursing", "chartdate": "2120-04-27 00:00:00.000", "description": "Nursing Progress Note", "row_id": 323938, "text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt trached and vented..on PSV 60%/5peep TV300-500 rr 16-22. am ABG\n done with po2 61/co2 47/ ph 7.36. Sats 89-94%..Having periods of\n agitation, pulling arms up towards face, moving legs around bed.\n Tachycardic with higher bp and lower sats. Periodiclly..still has cuff\n leak from trach. IP aware.\n Action:\n Pt more hypoxic with agitation. Per ho..worsening CXR.. Increased\n propofol to 30mic/kg/min, Given 1mgm ativan x2\n Response:\n More calm with increased meds..\n Plan:\n Aline placed for better monitoring of abgs\n Hypotension (not Shock)\n Assessment:\n BP running lower..maps 58-64..Has not received any fluid boluses today.\n HR 60-110sr/st\n Action:\n Decreased captopril dose..\n Response:\n Assessing\n Plan:\n New aline for bp monitoring..??use fluids if further hypotensive\n" }, { "category": "General", "chartdate": "2120-04-29 00:00:00.000", "description": "Generic Note", "row_id": 324108, "text": "TITLE:\n RESPIRATORY CARE: PT REMAINS W/ AN 8.0 PORTEX TRACH IN\n PLACE. BECAME HYPOXEMIC AND ACIDOTIC LAST NIGHT. ABG W/ SEVERE\n RESPIRATORY ACIDOSIS AND REQUIRING 100 % O2. CHANGED TO PRVC\n W/ VT 360 AND RR 42. ABG IMPROVED. VT DECREASED TO 340 AND FIO2 TO .70.\n MINI BAL DONE AND SENT TO MICROBIOLOGY LAB. TPp ON INSP HOLD NOW ABOUT\n 25-27 AND TPp ON EXP ABOUT + CMH2O. WILL C/W PRVC\n ON THE AC MODE AS TOLERATED.\n" }, { "category": "Nursing", "chartdate": "2120-04-29 00:00:00.000", "description": "Nursing Progress Note", "row_id": 324043, "text": "This is 50M with h/o metastatic renal CA s/p\n nephrectomy,emphysema/pulmonary fibrosis on home 02 presented to OSH\n with hypoxic respiratory failure, fevers and hypotension with sepsis,\n cardiogenic shock was weaning off ventilator.Had trach and PEG on\n .Main issue with trach is that it has got air leak.IP was\n ,they will review the pt on .Pt failed PS on Friday. Was\n pan cultured on for temp of 101.4.\n Pt highly disynchronous with the vent and desaturating down to\n 75%.sedated on fent/versed and paralysed.pt hypotensive and started on\n neosynephrine.\n Hypotension (not Shock)\n Assessment:\n Pts BP down to map of 50 consistently.Tachycardic in 120\ns after\n starting on dopamine and persistently tachycardic even after dopamine\n changed to neosynephrine. On monitor to measure CI and SVV. SVV\n < 15. and CI .\n Action:\n Pt had 1000cc fluid bolus and started on dopamine but pt became\n tachycardic with that so switched to neo and isc urrently on neo\n 4mcg/kg/min.\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n Heart failure, right, isolated (Cor Pulmonale)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2120-04-29 00:00:00.000", "description": "Nursing Progress Note", "row_id": 324113, "text": "Shock, septic\n Assessment:\n Pt had been demonstrating downward trending BP\ns over past several\n shifts, then with acute hypotension overnoc per report w/ SBP to 70\n T max 101.4 yesterday w/ repeat temp spike over noc per report. At\n start of shift Pt hypotensive w/ SBP to 70\ns, Temp 99.0 axillary.\n Action:\n Monitoring hemodynamic status closely w/ continuous ECG and BP\n monitoring. Pt received total 3L IVF this shift. Pt\n Response:\n Plan:\n Bradycardia\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": "2120-04-29 00:00:00.000", "description": "Nursing Progress Note", "row_id": 324116, "text": "Shock, septic\n Assessment:\n Pt had been demonstrating downward trending BP\ns over past several\n shifts, then with acute hypotension overnoc per report w/ SBP to 70\n T max 101.4 yesterday w/ repeat temp spike over noc per report. At\n start of shift Pt hypotensive w/ SBP to 70\ns, Temp 99.0 axillary.\n Action:\n Monitoring hemodynamic status closely w/ continuous ECG and BP\n monitoring. Pt received total 3L IVF this shift. Monitoring temp. ABX\n changed to Linezolid, meropenem, caspofungin, Tobramycin, vanc enema\n and flagyl. Dr. reports ok to give flagyl despite flagyl allergy\n given risk/benefit. Monitoring closely for s/s allergic reaction.\n During severe hypotension this am pt continued on neosynephrine at max\n dose, started on vasopressing, given IVF bolus and started on Levophed.\n Neo has since been titrated to off and levophed titrated to minimal\n dose. Despite triple pressors and IVF, BP continued to trend down this\n am and pt was given 1 amp sodium bicarb.\n Response:\n Pt responded well to sodium bicarb w/ SBP up to 150\ns. Allowing\n pressors to be weaned as above. Pt remains afebrile and MAP > 65.\n Plan:\n Continue to monitor hemodynamic status closely. Follow temps per\n policy. Continue abx as ordered. Wean pressors as able.\n Bradycardia\n Assessment:\n w/ episode of continued hypotension as above, HR decreased from low\n 100\ns to 60\ns. EKG confirmed junctional rhythm.\n Action:\n EKG obtained. Monitoring ECG and hemodynamic status. Pt also on heparin\n gtt for ?PE. Heparin held this am for line placement and restarted at\n 1730 s/p mini BAL.\n Response:\n Cardiac rhythm quickly returned to SR after receiving sodium bicarb as\n above.\n Plan:\n Continue to monitor ECG and hemodynamic status. Continue heparin gtt as\n ordered.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt remains trached and vented. Continues on fentanyl/versed and\n methadone for sedation w/ cisatracurium for NMB.\n Action:\n Vent settings changed to Volume control by RT as ordered. Vent settings\n weaned as respiratory status improved. Monitoring respiratory status\n closely. Following ABGs. Pt underwent mini BAL this afternoon. Pt\n transferred to triadyne bed for continuous kinetic therapy.\n Response:\n ABG markedly improved\n see flowsheet. Vent settings weaned to volume\n control 340/9 X 42 FiO2 70%. Pt tolerating kinetic therapy well.\n Plan:\n Continue to monitor respiratory status closely. Continue kinetic\n therapy via triadyne bed. Continue current vent settings.\n" }, { "category": "General", "chartdate": "2120-04-29 00:00:00.000", "description": "ICU Event Note", "row_id": 324120, "text": "12:30pm\n Clinician: Attending\n Along with patient's primary oncologist (Dr. and other\n members of the oncology team, I met with Mr. wife, mother,\n and sister. We reviewed his current extremetly grave status (3-pressor\n shock, severe respiratory failure, severe acidosis, etc.) We discussed\n our substantial diagnostic uncertainty, and that he was too sick to get\n many of the diagnostic tests we might normally perform. Our leading\n suspicions are perforated bowel, ischemic bowel, and massive pulmonary\n embolism. Therapuetic options are extremely limited, although if this\n is a PE there is some finite chance of survival. We discussed that CPR\n in this situation in usually not effective, and that the chances of\n survival to discharge are very low if he detiorates to the point of\n requiring CPR, while the risk of discomfort (e.g. rib fx) is fairly\n high. They do not wish for him to have resuscitative efforts (CPR or\n shocks) in the event of an arrest. We will otherwise pursue full\n care. All questions answered. At their request, we will also ask a\n priest to come by.\n Total time spent: 40 minutes\n Patient is critically ill.\n" }, { "category": "Physician ", "chartdate": "2120-04-29 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 324121, "text": "Chief Complaint: shock, 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 24 Hour Events:\n Worsened substantially over the last 24 hours -- hypotension --> shock\n --> pressors, much worse hypoxemia with increasing dead space -->\n paralysis and heparinization. Esophageal balloon placed. Oral\n vancomycin started (has rash to Flagyl) for empiric rx of C diff.\n BLOOD CULTURED - At 12:44 PM\n URINE CULTURE - At 12:44 PM\n PICC LINE - START 04:30 PM\n MULTI LUMEN - STOP 07:52 PM\n ARTERIAL LINE - STOP 07:57 PM\n SPUTUM CULTURE - At 08:24 PM\n ULTRASOUND - At 11:16 PM\n EKG - At 03:00 AM\n ARTERIAL LINE - START 04:30 AM\n FEVER - 101.4\nF - 03:00 AM\n History obtained from Medical records, ICU team\n Patient unable to provide history: Sedated\n Allergies:\n Flagyl (Oral) (Metronidazole)\n Rash;\n Last dose of Antibiotics:\n Acyclovir - 04:00 PM\n Levofloxacin - 08:00 AM\n Piperacillin/Tazobactam (Zosyn) - 06:32 AM\n Vancomycin - 08:00 AM\n Infusions:\n Fentanyl - 225 mcg/hour\n Heparin Sodium - 1,050 units/hour\n Cisatracurium - 0.2 mg/Kg/hour\n Phenylephrine - 4.3 mcg/Kg/min\n Vasopressin - 2.4 units/hour\n Midazolam (Versed) - 25 mg/hour\n Norepinephrine - 0.08 mcg/Kg/min\n Other ICU medications:\n Midazolam (Versed) - 05:30 PM\n Heparin Sodium (Prophylaxis) - 08:25 PM\n Furosemide (Lasix) - 01:45 AM\n Other medications:\n vanco, bactrim mwf, zosyn, acyclovir 400 q 8, CHG, colace, ASA, folate,\n SQI, methadone, PPI, captopril (held), levoflox 750 oral, reglan,\n versed, fentanyl, neosynephrine, cistra, heparin, vasporessin,\n hydrocort (ordered, pending), levophed\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 08:44 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.6\nC (101.4\n Tcurrent: 37.2\nC (99\n HR: 67 (67 - 128) bpm\n BP: 124/75(87) {74/45(53) - 124/78(87)} mmHg\n RR: 18 (0 - 36) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 76.3 kg (admission): 76.3 kg\n Height: 68 Inch\n CVP:\n Total In:\n 5,318 mL\n 1,457 mL\n PO:\n TF:\n 164 mL\n IVF:\n 5,054 mL\n 1,457 mL\n Blood products:\n Total out:\n 1,630 mL\n 675 mL\n Urine:\n 1,630 mL\n 675 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,688 mL\n 782 mL\n Respiratory support\n Ventilator mode: PCV+\n PC : 26 cmH2O\n PS : 10 cmH2O\n RR (Set): 30\n RR (Spontaneous): 38\n PEEP: 10 cmH2O\n FiO2: 100%\n SpO2: 100%\n ABG: 7.05/88/132/26/-8\n Physical Examination\n General Appearance: Well nourished\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Diminished), (Left DP pulse: Diminished)\n Respiratory / Chest: (Breath Sounds: Crackles : )\n Abdominal: Soft, No(t) Bowel sounds present\n Extremities: Right: 1+, Left: 1+\n Skin: Cool\n Neurologic: Responds to: Unresponsive, Movement: No spontaneous\n movement, Tone: Decreased\n Labs / Radiology\n 10.7 g/dL\n 195 K/uL\n 114 mg/dL\n 1.3 mg/dL\n 26 mEq/L\n 4.6 mEq/L\n 14 mg/dL\n 110 mEq/L\n 141 mEq/L\n 34.2 %\n 22.4 K/uL\n [image002.jpg]\n 12:14 PM\n 03:59 AM\n 04:26 AM\n 09:26 PM\n 12:22 AM\n 03:34 AM\n 03:52 AM\n 04:29 AM\n 05:30 AM\n 07:55 AM\n WBC\n 12.5\n 22.4\n Hct\n 29.9\n 34.2\n Plt\n 166\n 195\n Cr\n 0.9\n 1.3\n TCO2\n 28\n 30\n 29\n 29\n 31\n 31\n 29\n 26\n Glucose\n 82\n 114\n Other labs: PT / PTT / INR:13.7/42.1/1.2, CK / CKMB /\n Troponin-T:260/9/0.22, ALT / AST:35/49, Alk Phos / T Bili:178/1.6,\n Amylase / Lipase:50/19, Differential-Neuts:85.4 %, Band:0.0 %,\n Lymph:8.8 %, Mono:4.1 %, Eos:1.4 %, Lactic Acid:5.1 mmol/L, Albumin:2.6\n g/dL, LDH:473 IU/L, Ca++:7.3 mg/dL, Mg++:2.0 mg/dL, PO4:4.9 mg/dL\n Assessment and Plan\n 50-year-old man with recrudescent severe shock and respiratory failure,\n on a background of renal cell CA .\n Shock\n Etiology here is uncertain. Sepsis is most likely, but PE\n For sepsis\n cover MRSA and VRE, cover ESBL and other resistant GNR\n (change to meropenem and IV quinolone), and for C diff (oral vanco;\n discuss his Flagyl allergy with his prior providers). Will discuss\n antifungal coverage with BMT. Check other cultures. (CMV,\n galactomannan, etc.) Consult ID for advice on antibiotics.\n Check KUB and upright CXR to exclude free air. He is too sick for\n travel and for operation.\n Treat empirically for adrenal insufficiency. Add on cortisol to\n morning labs.\n Check echo. Check EKG since heart rate is relatively low.\n Follow and replete ionized calcium.\n Heparinize empirically for PE. Discuss with BMT whether he would be a\n candidate for lytics if we documented PE (his metastatic disease in the\n spine makes it unlikely).\n Place central line after heparin is held for an hour.\n Respiratory failure\n Esophageal-balloon guided settings for PEEP and driving pressure.\n Has marked respiratory acidosis that seems to be mostly related to high\n dead-space fraction.\n Will try to increase respiratory rate and watch for autoPEEP.\n Bradycardia\n Appears to be a junctional rhythm. Will replete all lytes including\n calcium, etc.\n Try to swap to Levophed for\n Acute renal failure\n Secondary to hemodynamics. Follow for now.\n Acidosis\n Mostly related to respiratory acidosis, although his bicarb has fallen\n over the past days as well.\n Since he has a lactic (and respiratory) acidosis, will hold off on\n bicarbonate for now.\n ICU Care\n Nutrition: NPO\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Will place CVL today\n 20 Gauge - 02:03 PM\n 18 Gauge - 02:03 PM\n PICC Line - 04:30 PM\n Arterial Line - 04:30 AM\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: Heparin gtt)\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care\n Comments: Wakeup and RSBI are contraindicated.\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Team has called wife, who is coming in this morning, and has talked to\n BMT.\n Code status: Full code\n Disposition :ICU\n Total time spent: 65 minutes\n Patient is critically ill\n ------ Protected Section ------\n CRITICAL CARE STAFF ADDENDUM\n 7pm addendum\n Major events today:\n (1) pressor requirement improved\n (2) central line placed without incident. CVP was only 7\n (3) Respiratory acidosis improved more than expected based on\n ventilator manipulations\n (4) Family meeting at 12:30\n (5) Echo shows no tamponade; RV is perhaps larger than prior echo\n (6) LENIs (-)\n (7) Formal jugular doppler confirmed our findings of RIJ DVT\n (8) Episode of coffee grounds\n Overall, although he remains tremendously ill he has improved\n substantially compared with earlier today. This (along with the IJ\n DVT) suggests that the primary mechanism here may have been a PE in a\n patient with an already compromised RV and pulmonary status\n and that\n he may now be having some auto-lysis of the clot. His coffee grounds\n (in addition to his malignancy) means that TPA is contraindicated at\n present. We will do our best to continue heparin and support with\n transfusions as needed.\n 50 minutes\n ------ Protected Section Addendum Entered By: , MD\n on: 19:51 ------\n" }, { "category": "Nursing", "chartdate": "2120-05-01 00:00:00.000", "description": "Nursing Progress Note", "row_id": 324314, "text": "Pt became increasing difficult to ventilate, his BP cont to drop\n .Wife made the decision for CMO. Pt passed peacefully @ 1030 w/ his\n family at the bedside.\n" }, { "category": "Physician ", "chartdate": "2120-05-01 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 324318, "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 24 Hour Events:\n 24 hour events\n Significant decompensation oevrnight with profound resp acidosis,\n family meeting with Dr with plan not to escalate care and\n consider transition to CMO as family comes in\n Allergies:\n Flagyl (Oral) (Metronidazole)\n Rash;\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 06:32 AM\n Vancomycin - 08:00 AM\n Ciprofloxacin - 11:00 AM\n Metronidazole - 04:20 PM\n Caspofungin - 07:57 PM\n Linezolid - 03:58 AM\n Meropenem - 04:06 AM\n Infusions:\n Norepinephrine - 0.05 mcg/Kg/min\n Fentanyl (Concentrate) - 300 mcg/hour\n Midazolam (Versed) - 25 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 Constitutional: Fever\n Respiratory: Dyspnea\n Gastrointestinal: melena\n Genitourinary: Foley\n Heme / Lymph: Anemia\n Flowsheet Data as of 08:45 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: 36.6\nC (97.9\n HR: 105 (69 - 130) bpm\n BP: 68/44(54) {68/44(54) - 130/68(89)} mmHg\n RR: 40 (38 - 44) insp/min\n SpO2: 79%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 76.3 kg (admission): 76.3 kg\n Height: 68 Inch\n CVP: 15 (11 - 21)mmHg\n Total In:\n 6,543 mL\n 1,470 mL\n PO:\n TF:\n IVF:\n 5,793 mL\n 1,271 mL\n Blood products:\n 750 mL\n 199 mL\n Total out:\n 2,055 mL\n 250 mL\n Urine:\n 2,055 mL\n 250 mL\n NG:\n Stool:\n Drains:\n Balance:\n 4,488 mL\n 1,220 mL\n Respiratory support\n Ventilator mode: PCV+Assist\n Vt (Set): 400 (340 - 400) mL\n PC : 38 cmH2O\n RR (Set): 40\n PEEP: 6 cmH2O\n FiO2: 100%\n PIP: 40 cmH2O\n Plateau: 37 cmH2O\n Compliance: 14.3 cmH2O/mL\n SpO2: 79%\n ABG: 7.04/95./52/24/-8\n Ve: 16.6 L/min\n PaO2 / FiO2: 52\n Physical Examination\n Lying in bed, sedated\n RR\n Diminished BS\n Labs / Radiology\n 12.0 g/dL\n 117 K/uL\n 158 mg/dL\n 2.0 mg/dL\n 24 mEq/L\n 5.1 mEq/L\n 35 mg/dL\n 104 mEq/L\n 133 mEq/L\n 37.0 %\n 13.4 K/uL\n [image002.jpg]\n 04:44 AM\n 11:01 AM\n 05:44 PM\n 07:36 PM\n 09:00 PM\n 09:36 PM\n 10:37 PM\n 11:48 PM\n 03:24 AM\n 03:40 AM\n WBC\n 12.0\n 13.4\n Hct\n 36.4\n 37.0\n Plt\n 60\n 117\n Cr\n 1.8\n 2.0\n TCO2\n 30\n 28\n 27\n 29\n 29\n 26\n 28\n 28\n Glucose\n 116\n 158\n Other labs: PT / PTT / INR:17.0/37.6/1.5, CK / CKMB /\n Troponin-T:260/9/0.22, ALT / AST:2554/2595, Alk Phos / T Bili:188/1.5,\n Amylase / Lipase:50/19, Differential-Neuts:84.7 %, Band:2.0 %,\n Lymph:11.2 %, Mono:0.0 %, Eos:0.0 %, Fibrinogen:688 mg/dL, Lactic\n Acid:1.4 mmol/L, Albumin:2.8 g/dL, LDH:1159 IU/L, Ca++:7.6 mg/dL,\n Mg++:3.3 mg/dL, PO4:5.8 mg/dL\n Assessment and Plan\n Extremely sad case of 50 yr old male with met RCC now in refractory\n hypoxemic and hypercarbic resp failure. After many meeting in [ast 48\n hours and much effort , family has decided to pursue comfort care.\n Clergy has been to bedside\n Primary Oncologist Dr aware.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 02:03 PM\n 18 Gauge - 02:03 PM\n PICC Line - 04:30 PM\n Arterial Line - 04:30 AM\n Multi Lumen - 12:05 PM\n Prophylaxis:\n Communication: wife\n status: CMO\n Disposition : CMO\n Total time spent: 30\n" }, { "category": "Nursing", "chartdate": "2120-04-27 00:00:00.000", "description": "Nursing Progress Note", "row_id": 323882, "text": "This is 50M with h/o metastatic renal CA s/p\n nephrectomy,emphysema/pulmonary fibrosis on home 02 presented to OSH\n with hypoxic respiratory failure, fevers and hypotension with sepsis,\n cardiogenic shock now weaning off ventilator.Had trach and PEG on\n .Mian issue with trach is that it has got air leak.IP was\n ,they will review the pt on .Pt was tried on PS\n yesterday lasting only 20 min.Raised WCC yesterday and was cultured.\n There was a 6 point hct drop yesterday. Repeat hct stable.\n Hypotension (not Shock)\n Assessment:\n BP systolic in high 80\ns-110\ns.MAP 58-80.\n Action:\n Propofol weaned down to 15 but pt increasingly restless so put it back\n upto 25.omitted captopril.\n Response:\n BP increases when pt more awake.\n Plan:\n Titrate sedation for comfort and in according with the BP. Restart back\n on captopril when BP more stable.Aim MAP >60.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt mechanically ventilated through trach,on PCV 60%/.Failed PS\n yesterday.Has got huge cuff leak\n Action:\n No vent changes overnight.\n Response:\n Pt is saturating 95-98% on the current settings.Desaturates to low 90\n when turned.\n Plan:\n Try on ps today.\n" }, { "category": "Physician ", "chartdate": "2120-04-28 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 324000, "text": "Chief Complaint: Sepsis\n Respiratory Failure\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n ARTERIAL LINE - START 08:13 PM\n History obtained from Patient\n Allergies:\n Flagyl (Oral) (Metronidazole)\n Rash;\n Last dose of Antibiotics:\n Bactrim (SMX/TMP) - 08:16 AM\n Acyclovir - 04:00 PM\n Piperacillin/Tazobactam (Zosyn) - 06:06 AM\n Vancomycin - 08:00 AM\n Levofloxacin - 08:00 AM\n Infusions:\n Other ICU medications:\n Lansoprazole (Prevacid) - 08:00 AM\n Heparin Sodium (Prophylaxis) - 08:00 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 Flowsheet Data as of 11:45 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.2\nC (98.9\n Tcurrent: 37.2\nC (98.9\n HR: 82 (62 - 87) bpm\n BP: 91/54(67) {84/40(48) - 106/60(75)} mmHg\n RR: 25 (15 - 30) insp/min\n SpO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 76.3 kg (admission): 76.3 kg\n Height: 68 Inch\n CVP: 19 (9 - 300)mmHg\n Total In:\n 3,124 mL\n 834 mL\n PO:\n TF:\n 750 mL\n 157 mL\n IVF:\n 1,733 mL\n 577 mL\n Blood products:\n Total out:\n 2,900 mL\n 930 mL\n Urine:\n 2,900 mL\n 930 mL\n NG:\n Stool:\n Drains:\n Balance:\n 224 mL\n -96 mL\n Respiratory support\n Ventilator mode: PCV+\n PC : 24 cmH2O\n RR (Set): 30\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 60%\n RSBI Deferred: No Spon Resp\n PIP: 29 cmH2O\n Plateau: 26 cmH2O\n SpO2: 93%\n ABG: 7.36/51/105/25/1\n Ve: 12.4 L/min\n PaO2 / FiO2: 175\n Physical Examination\n General Appearance: Well nourished\n Head, Ears, Nose, Throat: Normocephalic, Trachesostomy Tube\n Lymphatic: Persistent significant cuff leak\n Cardiovascular: (S1: Normal), (S2: Distant)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Dullness : ),\n (Breath Sounds: Crackles : , Bronchial: )\n Extremities: Right: 1+, Left: 1+\n Musculoskeletal: Unable to stand\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Sedated,\n Tone: Not assessed\n Labs / Radiology\n 10.0 g/dL\n 166 K/uL\n 82 mg/dL\n 0.9 mg/dL\n 25 mEq/L\n 4.3 mEq/L\n 12 mg/dL\n 110 mEq/L\n 142 mEq/L\n 29.9 %\n 12.5 K/uL\n [image002.jpg]\n 03:23 PM\n 06:00 PM\n 04:43 AM\n 02:25 PM\n 05:37 PM\n 09:20 PM\n 04:49 AM\n 12:14 PM\n 03:59 AM\n 04:26 AM\n WBC\n 15.0\n 11.1\n 12.5\n Hct\n 34.0\n 28.1\n 31.5\n 29.2\n 29.9\n Plt\n 159\n 145\n 166\n Cr\n 1.0\n 1.0\n 0.9\n TCO2\n 27\n 30\n 28\n 30\n Glucose\n 76\n 65\n 80\n 82\n Other labs: PT / PTT / INR:13.7/42.1/1.2, CK / CKMB /\n Troponin-T:260/9/0.22, ALT / AST:57/31, Alk Phos / T Bili:70/0.4,\n Amylase / Lipase:53/22, Differential-Neuts:67.0 %, Band:2.0 %,\n Lymph:18.0 %, Mono:9.0 %, Eos:0.0 %, Lactic Acid:2.0 mmol/L,\n Albumin:2.6 g/dL, LDH:272 IU/L, Ca++:8.1 mg/dL, Mg++:2.2 mg/dL, PO4:2.4\n mg/dL\n Fluid analysis / Other labs: 7.36/51/105\n Imaging: --mild improvement in diffuse infiltrates\n Microbiology: No new cultures to date\n Assessment and Plan\n 50 yo male with metastatic renal cell ca and pulmonary fibrosis and now\n with prolonged ventilator weaning secondary to persistent hypercarbic\n compromise.\n 1)Respiratory Failure-Patient with multiple challenges most prominently\n pulmonary fibrosis and modest pulmonary edema in addition making\n oxygenation a primary challenge. In addition the destructive lung\n disease makes progress a challenge. He will need continued high levels\n of support until oxygenation can be stabilized.\n -PCV to continue\n -Will consider trach change to minimize cuff leak when stable\n -Wean O2 and move to keep SaO2 >90% and move to 0.5 for FIO2\n -Will move to PSV trial when effective Ve requirement is understood.\n 2)Pneumonia\ncontinue ABX for 14 day course\n 3)Altered Mental Status-\n -Will move to Propofol wean if possible\n -Hope to be able to tolerate wean with better defined ventilator\n support\n -Continue trials of weaning\n 4)Sepsis-\n Hemodynamically improved\n Cardiogenic contribution will be managed with efforts at afterload\n reduction if BP tolerates\n Continue with Abx\n Could consider ECHO to eval current function\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 02:13 AM 20 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Multi Lumen - 11:24 PM\nWill need to consider D/C and given\n longer term ABX may be appropriate for PICC\n Arterial Line - 08:13 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP: Following pathway\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 45 minutes\n" }, { "category": "Physician ", "chartdate": "2120-04-28 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 324001, "text": "Chief Complaint: 50M h/o metastatic renal CA s/p nephrectomy, IL-2,\n mini-allograft SCT, DLI x 2 last in , emphysema/pulmonary fibrosis\n on home 02 presented to OSH with hypoxic respiratory failure, sepsis,\n cardiogenic shock, now improving but with difficulty weaning vent and\n s/p trach/PEG\n 24 Hour Events:\n ARTERIAL LINE - START 08:13 PM\n - replaced a-line\n -kept on 5 PEEP due to concern for increased leak around cuff\n -in PM, 02 sats improved, less agitated.\n Allergies:\n Flagyl (Oral) (Metronidazole)\n Rash;\n Last dose of Antibiotics:\n Bactrim (SMX/TMP) - 08:16 AM\n Levofloxacin - 09:00 AM\n Acyclovir - 04:00 PM\n Vancomycin - 08:08 PM\n Piperacillin/Tazobactam (Zosyn) - 06:06 AM\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 08:00 AM\n Lorazepam (Ativan) - 11:09 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:52 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.2\nC (98.9\n Tcurrent: 37.2\nC (98.9\n HR: 73 (60 - 99) bpm\n BP: 100/54(71) {84/40(48) - 106/60(75)} mmHg\n RR: 30 (0 - 30) insp/min\n SpO2: 91%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 76.3 kg (admission): 76.3 kg\n Height: 68 Inch\n CVP: 10 (8 - 310)mmHg\n Total In:\n 3,124 mL\n 464 mL\n PO:\n TF:\n 750 mL\n 77 mL\n IVF:\n 1,733 mL\n 287 mL\n Blood products:\n Total out:\n 2,900 mL\n 530 mL\n Urine:\n 2,900 mL\n 530 mL\n NG:\n Stool:\n Drains:\n Balance:\n 224 mL\n -66 mL\n Respiratory support\n Ventilator mode: PCV+\n PC : 24 cmH2O\n RR (Set): 30\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 60%\n RSBI Deferred: No Spon Resp\n PIP: 29 cmH2O\n Plateau: 26 cmH2O\n SpO2: 91%\n ABG: 7.36/51/105/25/1\n Ve: 10.2 L/min\n PaO2 / FiO2: 175\n Physical Examination\n Gen: Sedated, opens eyes to voice, no purposeful movements\n Heent: pupils equal. Trached.\n Cor: RRR, nls1s2 no mr\n Pul: CTA anteriorly\n coarse, mechanical breath sounds\n Abd: moderately distended. Bowel sounds present, PEG in placed,\n dressed, no guarding, no tenderness\n Extreme: Warm, trace pitting edema to mid-thigh\n Labs / Radiology\n 166 K/uL\n 10.0 g/dL\n 82 mg/dL\n 0.9 mg/dL\n 25 mEq/L\n 4.3 mEq/L\n 12 mg/dL\n 110 mEq/L\n 142 mEq/L\n 29.9 %\n 12.5 K/uL\n [image002.jpg]\n 03:23 PM\n 06:00 PM\n 04:43 AM\n 02:25 PM\n 05:37 PM\n 09:20 PM\n 04:49 AM\n 12:14 PM\n 03:59 AM\n 04:26 AM\n WBC\n 15.0\n 11.1\n 12.5\n Hct\n 34.0\n 28.1\n 31.5\n 29.2\n 29.9\n Plt\n 159\n 145\n 166\n Cr\n 1.0\n 1.0\n 0.9\n TCO2\n 27\n 30\n 28\n 30\n Glucose\n 76\n 65\n 80\n 82\n Other labs: PT / PTT / INR:13.7/42.1/1.2, CK / CKMB /\n Troponin-T:260/9/0.22, ALT / AST:57/31, Alk Phos / T Bili:70/0.4,\n Amylase / Lipase:53/22, Differential-Neuts:67.0 %, Band:2.0 %,\n Lymph:18.0 %, Mono:9.0 %, Eos:0.0 %, Lactic Acid:2.0 mmol/L,\n Albumin:2.6 g/dL, LDH:272 IU/L, Ca++:8.1 mg/dL, Mg++:2.2 mg/dL, PO4:2.4\n mg/dL\n Imaging: CXR : IMPRESSION: 1. The acute changes noted in both\n lungs favor edema, although aspiration cannot be completely excluded.\n 2. Chronic interstitial lung fibrotic disease.\n Microbiology: All micro NGTD\n Assessment and Plan\n 50M h/o metastatic renal CA s/p nephrectomy, IL-2, mini-allograft SCT,\n DLI x 2 last in , emphysema/pulmonary fibrosis on home 02\n presented to OSH with hypoxic respiratory failure, sepsis, cardiogenic\n shock, now improving but with difficulty weaning vent and s/p\n trach/PEG.\n # Respiratory failure: Pneumonia as likely source of resp failure and\n sepsis in patient with poor pulmonary reserve due to emphysema, ?GVHD,\n fibrosis. Patient is now s/p trach/PEG on . PEEP decreased to 5\n after trach placement which patient has been tolerating. He does,\n however, have a trach leak, hard to quantify amount of leak. IP has\n evaluated and would like to wait until track is more healed prior to\n changing trach. Has increasing Fi02 requirement from 40% up to 60%\n since yesterday.\n - Continue PEEP of 5 on PCV given concern over cuff leak by RT, plan\n for replacement of cuff by IP after a few days when trach is not so\n new\n - Driving pressures maintained at 24. FiO2 at 60% now with sats in the\n low 90s. Last gas 7.36/51/105. Will attempt decrease in FiO2 to 50%\n this morning.\n - Can attempt PS trial later if sedation weaned and patient alert\n enough to tolerate.\n - Treat PNA for planned 14 day course. See below. B-glucan,\n galactomannan negative, caspogungin d/c\n # Sedation: Currently on methadone q4H, and propofol for sedation,\n currently at 35 mcg/kg/min. Off fent/versed drips, using fentanyl and\n lorazepam boluses for agitation.\n - Goal to wean propofol as tolerated today, triglycerides mildly\n elevated at 182\n - Continue to check triglycerides twice weekly while on propofol. Last\n checked \n - Will bolus with versed/fentanyl prn agitation in an attempt to wean\n down level of propofol.\n - Continue to check daily ECG for QTc prolongation on methadone.\n - When able, will decrease methadone to q6H then to q8H\n # Shock: Multifactorial, improved.\n ** Sepsis: Likely source pneumonia. On very broad coverage w/\n vancomycin, levofloxacin, zosyn, bactrim (now only ppx dosing) and\n acyclovir ppx. All cultures pending or no growth. WBC stable.\n - D/C'd caspo\n - F/u cultures - cont to culture with spikes.\n - Continue acyclovir and bactrim ppx, vanc/zosyn/levoflox for 14 day\n course, today is day 12.\n **Cardiogenic\n ## Pump: Had improved BPs off dobutamine. On captopril for afterload\n reduction. Dilated hypokinetic RV, likely causative in hypotension.\n Currently on captopril 12.5mg TID decreased yesterday in the setting of\n hypotension requiring a fluid bolus. Patient has not been receiving\n captopril given BPs in the high 80s and 90s.\n - Will get repeat ECHO now to evaluate pump function as patient had\n been hypertensive, now hypotensive. ?decreased forward flow poor\n pump function vs. intravascular volume depletion as partially\n responsive to fluids.\n - Continue to monitor BP for now, prn IVFto maintain MAPs >65.\n ## Rhythm: Sinus bradycardia likely secondary to sedatives, largely\n resolved; increases with agitation. Cont weaning sedation as\n tolerated. Continue to follow QTc for prolongation given methadone and\n levoflox, has been wnl\n **Endocrine: relative adrenal \n - Prednisone off\n # Metastatic renal CA: Recurrent disease s/p donor lymphocyte\n transplant .\n - BMT to follow\n - Continue acyclovir and bactrim ppx\n # Access: Multilumen has been in place sinc ethe 14^th. Will request\n PICC for now, pull line once PICC in place. Will also get PIV access\n today.\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 02:13 AM 20 mL/hour, holding TF\n for now due to high residuals\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Multi Lumen - 11:24 PM\n Arterial Line - 08:13 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:ICU\n" }, { "category": "Physician ", "chartdate": "2120-05-01 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 324275, "text": "Chief Complaint: 50 y/o M w/ metastatic renal cell Ca involving the\n adrenals s/p nephrectomy, IL-2, mini-SCT, DLIx2 in , pulmonary\n fibrosis on home O2 now admitted with hypoxic respiratory failure,\n sepsis, no trach/peg and w/ difficulty ventilating last 24 hours due to\n increasing acidemia and increasing transpulmonary pressures.\n 24 Hour Events:\n URINE CULTURE - At 10:56 AM\n Allergies:\n Flagyl (Oral) (Metronidazole)\n Rash;\n Last dose of Antibiotics:\n Levofloxacin - 08:00 AM\n Piperacillin/Tazobactam (Zosyn) - 06:32 AM\n Vancomycin - 08:00 AM\n Ciprofloxacin - 11:00 AM\n Metronidazole - 04:20 PM\n Caspofungin - 07:57 PM\n Linezolid - 03:58 AM\n Meropenem - 04:06 AM\n Infusions:\n Norepinephrine - 0.05 mcg/Kg/min\n Fentanyl (Concentrate) - 300 mcg/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 07:30 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 HR: 113 (69 - 130) bpm\n BP: 75/48(58) {75/48(58) - 130/68(89)} mmHg\n RR: 40 (38 - 44) insp/min\n SpO2: 78%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 76.3 kg (admission): 76.3 kg\n Height: 68 Inch\n CVP: 16 (11 - 21)mmHg\n Total In:\n 6,543 mL\n 1,139 mL\n PO:\n TF:\n IVF:\n 5,793 mL\n 940 mL\n Blood products:\n 750 mL\n 199 mL\n Total out:\n 2,055 mL\n 150 mL\n Urine:\n 2,055 mL\n 150 mL\n NG:\n Stool:\n Drains:\n Balance:\n 4,488 mL\n 989 mL\n Respiratory support\n Ventilator mode: PRVC/AC\n Vt (Set): 400 (340 - 400) mL\n PC : 38 cmH2O\n RR (Set): 40\n PEEP: 6 cmH2O\n FiO2: 100%\n PIP: 46 cmH2O\n Plateau: 37 cmH2O\n Compliance: 14.3 cmH2O/mL\n SpO2: 78%\n ABG: 7.04/95./52/24/-8\n Ve: 16 L/min\n PaO2 / FiO2: 52\n Physical Examination\n General Appearance: Well nourished\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal), No(t) S3, No(t) S4, No(t)\n Rub, (Murmur: No(t) Systolic, No(t) Diastolic)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear :\n lower lung zones, Wheezes : expiratory wheeze at apices ?mechanical)\n Abdominal: Soft, Bowel sounds present\n Extremities: Right: Trace, Left: Trace\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Sedated,\n Paralyzed, Tone: Not assessed\n Labs / Radiology\n 117 K/uL\n 12.0 g/dL\n 158 mg/dL\n 2.0 mg/dL\n 24 mEq/L\n 5.1 mEq/L\n 35 mg/dL\n 104 mEq/L\n 133 mEq/L\n 37.0 %\n 13.4 K/uL\n [image002.jpg]\n 04:44 AM\n 11:01 AM\n 05:44 PM\n 07:36 PM\n 09:00 PM\n 09:36 PM\n 10:37 PM\n 11:48 PM\n 03:24 AM\n 03:40 AM\n WBC\n 12.0\n 13.4\n Hct\n 36.4\n 37.0\n Plt\n 60\n 117\n Cr\n 1.8\n 2.0\n TCO2\n 30\n 28\n 27\n 29\n 29\n 26\n 28\n 28\n Glucose\n 116\n 158\n Other labs: PT / PTT / INR:17.0/37.6/1.5, CK / CKMB /\n Troponin-T:260/9/0.22, ALT / AST:2554/2595, Alk Phos / T Bili:188/1.5,\n Amylase / Lipase:50/19, Differential-Neuts:84.7 %, Band:2.0 %,\n Lymph:11.2 %, Mono:0.0 %, Eos:0.0 %, Fibrinogen:688 mg/dL, Lactic\n Acid:1.4 mmol/L, Albumin:2.8 g/dL, LDH:1159 IU/L, Ca++:7.6 mg/dL,\n Mg++:3.3 mg/dL, PO4:5.8 mg/dL\n Imaging: CXR: In comparison with the study of , there is little\n overall\n change. There is persistent diffuse prominence of interstitial markings\n consistent with the clinical diagnosis of severe interstitial fibrosis.\n No\n definite acute focal infiltrate is appreciated. Tubes remain in place.\n Renal USD:\n IMPRESSION:\n 1. Normal examination of the right kidney. In particular, no evidence\n for\n renal vein thrombosis.\n 2. Status post left nephrectomy.\n 3. Small amount of ascites in the pelvis.\n Microbiology: C. Diff negative x1\n Mini-BAL: NGTD\n Blood Culture: NGTD\n Urine: NGTD\n Assessment and Plan\n SHOCK, SEPTIC\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 02:03 PM\n 18 Gauge - 02:03 PM\n PICC Line - 04:30 PM\n Arterial Line - 04:30 AM\n Multi Lumen - 12:05 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": "2120-05-01 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 324276, "text": "Chief Complaint: 50 y/o M w/ metastatic renal cell Ca involving the\n adrenals s/p nephrectomy, IL-2, mini-SCT, DLIx2 in , pulmonary\n fibrosis on home O2 now admitted with hypoxic respiratory failure,\n sepsis, no trach/peg and w/ difficulty ventilating last 24 hours due to\n increasing acidemia and increasing transpulmonary pressures.\n 24 Hour Events:\n URINE CULTURE - At 10:56 AM\n -Became progressively more acidotic and hypercarbic despite increases\n in tidal volume. The family was notified that the patient was likely\n dying, and that further options to treat respiratory failure were\n limited. They are currently at the bedside deciding how to proceed in\n terms of weaning the paralytic and making the patient comfortable.\n -Urine lytes wnl, renal ultrasound done, preliminary read is wnl\n -Methadone discontinued\n -Acyclovir and meropenam switched to q12h dosing for renal\n insufficiency\n -ID recommedations to discontinue C. diff coverage (IV flagyl and po\n vanco), and to hold tobramycin unless sputum cultures grow out GNR's\n -Had a transient episode of ventricular bigeminy in the setting of\n acidosis, empirically given magnesium. Lytes otherwise unremarkable.\n .\n Allergies:\n Flagyl (Oral) (Metronidazole)\n Rash;\n Last dose of Antibiotics:\n Levofloxacin - 08:00 AM\n Piperacillin/Tazobactam (Zosyn) - 06:32 AM\n Vancomycin - 08:00 AM\n Ciprofloxacin - 11:00 AM\n Metronidazole - 04:20 PM\n Caspofungin - 07:57 PM\n Linezolid - 03:58 AM\n Meropenem - 04:06 AM\n Infusions:\n Norepinephrine - 0.05 mcg/Kg/min\n Fentanyl (Concentrate) - 300 mcg/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 07:30 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 HR: 113 (69 - 130) bpm\n BP: 75/48(58) {75/48(58) - 130/68(89)} mmHg\n RR: 40 (38 - 44) insp/min\n SpO2: 78%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 76.3 kg (admission): 76.3 kg\n Height: 68 Inch\n CVP: 16 (11 - 21)mmHg\n Total In:\n 6,543 mL\n 1,139 mL\n PO:\n TF:\n IVF:\n 5,793 mL\n 940 mL\n Blood products:\n 750 mL\n 199 mL\n Total out:\n 2,055 mL\n 150 mL\n Urine:\n 2,055 mL\n 150 mL\n NG:\n Stool:\n Drains:\n Balance:\n 4,488 mL\n 989 mL\n Respiratory support\n Ventilator mode: PRVC/AC\n Vt (Set): 400 (340 - 400) mL\n PC : 38 cmH2O\n RR (Set): 40\n PEEP: 6 cmH2O\n FiO2: 100%\n PIP: 46 cmH2O\n Plateau: 37 cmH2O\n Compliance: 14.3 cmH2O/mL\n SpO2: 78%\n ABG: 7.04/95./52/24/-8\n Ve: 16 L/min\n PaO2 / FiO2: 52\n Physical Examination\n General Appearance: Well nourished\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal), No(t) S3, No(t) S4, No(t)\n Rub, (Murmur: No(t) Systolic, No(t) Diastolic)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear :\n lower lung zones, Wheezes : expiratory wheeze at apices ?mechanical)\n Abdominal: Soft, Bowel sounds present\n Extremities: Right: Trace, Left: Trace\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Sedated,\n Paralyzed, Tone: Not assessed\n Labs / Radiology\n 117 K/uL\n 12.0 g/dL\n 158 mg/dL\n 2.0 mg/dL\n 24 mEq/L\n 5.1 mEq/L\n 35 mg/dL\n 104 mEq/L\n 133 mEq/L\n 37.0 %\n 13.4 K/uL\n [image002.jpg]\n 04:44 AM\n 11:01 AM\n 05:44 PM\n 07:36 PM\n 09:00 PM\n 09:36 PM\n 10:37 PM\n 11:48 PM\n 03:24 AM\n 03:40 AM\n WBC\n 12.0\n 13.4\n Hct\n 36.4\n 37.0\n Plt\n 60\n 117\n Cr\n 1.8\n 2.0\n TCO2\n 30\n 28\n 27\n 29\n 29\n 26\n 28\n 28\n Glucose\n 116\n 158\n Other labs: PT / PTT / INR:17.0/37.6/1.5, CK / CKMB /\n Troponin-T:260/9/0.22, ALT / AST:2554/2595, Alk Phos / T Bili:188/1.5,\n Amylase / Lipase:50/19, Differential-Neuts:84.7 %, Band:2.0 %,\n Lymph:11.2 %, Mono:0.0 %, Eos:0.0 %, Fibrinogen:688 mg/dL, Lactic\n Acid:1.4 mmol/L, Albumin:2.8 g/dL, LDH:1159 IU/L, Ca++:7.6 mg/dL,\n Mg++:3.3 mg/dL, PO4:5.8 mg/dL\n Imaging: CXR: In comparison with the study of , there is little\n overall\n change. There is persistent diffuse prominence of interstitial markings\n consistent with the clinical diagnosis of severe interstitial fibrosis.\n No\n definite acute focal infiltrate is appreciated. Tubes remain in place.\n Renal USD:\n IMPRESSION:\n 1. Normal examination of the right kidney. In particular, no evidence\n for\n renal vein thrombosis.\n 2. Status post left nephrectomy.\n 3. Small amount of ascites in the pelvis.\n Microbiology: C. Diff negative x1\n Mini-BAL: NGTD\n Blood Culture: NGTD\n Urine: NGTD\n Assessment and Plan\n SHOCK, SEPTIC\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 02:03 PM\n 18 Gauge - 02:03 PM\n PICC Line - 04:30 PM\n Arterial Line - 04:30 AM\n Multi Lumen - 12:05 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": "2120-04-28 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 323979, "text": "Chief Complaint: 50M h/o metastatic renal CA s/p nephrectomy, IL-2,\n mini-allograft SCT, DLI x 2 last in , emphysema/pulmonary fibrosis\n on home 02 presented to OSH with hypoxic respiratory failure, sepsis,\n cardiogenic shock, now improving but with difficulty weaning vent and\n s/p trach/PEG\n 24 Hour Events:\n ARTERIAL LINE - START 08:13 PM\n - replaced a-line\n -kept on 5 PEEP due to concern for increased leak around cuff\n -in PM, 02 sats improved, less agitated.\n Allergies:\n Flagyl (Oral) (Metronidazole)\n Rash;\n Last dose of Antibiotics:\n Bactrim (SMX/TMP) - 08:16 AM\n Levofloxacin - 09:00 AM\n Acyclovir - 04:00 PM\n Vancomycin - 08:08 PM\n Piperacillin/Tazobactam (Zosyn) - 06:06 AM\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 08:00 AM\n Lorazepam (Ativan) - 11:09 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:52 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.2\nC (98.9\n Tcurrent: 37.2\nC (98.9\n HR: 73 (60 - 99) bpm\n BP: 100/54(71) {84/40(48) - 106/60(75)} mmHg\n RR: 30 (0 - 30) insp/min\n SpO2: 91%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 76.3 kg (admission): 76.3 kg\n Height: 68 Inch\n CVP: 10 (8 - 310)mmHg\n Total In:\n 3,124 mL\n 464 mL\n PO:\n TF:\n 750 mL\n 77 mL\n IVF:\n 1,733 mL\n 287 mL\n Blood products:\n Total out:\n 2,900 mL\n 530 mL\n Urine:\n 2,900 mL\n 530 mL\n NG:\n Stool:\n Drains:\n Balance:\n 224 mL\n -66 mL\n Respiratory support\n Ventilator mode: PCV+\n PC : 24 cmH2O\n RR (Set): 30\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 60%\n RSBI Deferred: No Spon Resp\n PIP: 29 cmH2O\n Plateau: 26 cmH2O\n SpO2: 91%\n ABG: 7.36/51/105/25/1\n Ve: 10.2 L/min\n PaO2 / FiO2: 175\n Physical Examination\n Gen: Sedated, opens eyes to voice, no purposeful movements, mildly\n agitated\n Heent: pupils equal. Trached.\n Cor: RRR, nls1s2 no mr\n Pul: CTA anteriorly\n coarse, mechanical breath sounds\n Abd: moderately distended. Bowel sounds present, PEG in placed,\n dressed, no guarding, no tenderness\n Extreme: Warm, trace pitting edema to mid-thigh\n Labs / Radiology\n 166 K/uL\n 10.0 g/dL\n 82 mg/dL\n 0.9 mg/dL\n 25 mEq/L\n 4.3 mEq/L\n 12 mg/dL\n 110 mEq/L\n 142 mEq/L\n 29.9 %\n 12.5 K/uL\n [image002.jpg]\n 03:23 PM\n 06:00 PM\n 04:43 AM\n 02:25 PM\n 05:37 PM\n 09:20 PM\n 04:49 AM\n 12:14 PM\n 03:59 AM\n 04:26 AM\n WBC\n 15.0\n 11.1\n 12.5\n Hct\n 34.0\n 28.1\n 31.5\n 29.2\n 29.9\n Plt\n 159\n 145\n 166\n Cr\n 1.0\n 1.0\n 0.9\n TCO2\n 27\n 30\n 28\n 30\n Glucose\n 76\n 65\n 80\n 82\n Other labs: PT / PTT / INR:13.7/42.1/1.2, CK / CKMB /\n Troponin-T:260/9/0.22, ALT / AST:57/31, Alk Phos / T Bili:70/0.4,\n Amylase / Lipase:53/22, Differential-Neuts:67.0 %, Band:2.0 %,\n Lymph:18.0 %, Mono:9.0 %, Eos:0.0 %, Lactic Acid:2.0 mmol/L,\n Albumin:2.6 g/dL, LDH:272 IU/L, Ca++:8.1 mg/dL, Mg++:2.2 mg/dL, PO4:2.4\n mg/dL\n Imaging: CXR : IMPRESSION: 1. The acute changes noted in both\n lungs favor edema, although aspiration cannot be completely excluded.\n 2. Chronic interstitial lung fibrotic disease.\n Microbiology: All micro NGTD\n Assessment and Plan\n 50M h/o metastatic renal CA s/p nephrectomy, IL-2, mini-allograft SCT,\n DLI x 2 last in , emphysema/pulmonary fibrosis on home 02\n presented to OSH with hypoxic respiratory failure, sepsis, cardiogenic\n shock, now improving but with difficulty weaning vent and s/p\n trach/PEG.\n # Respiratory failure: Pneumonia as likely source of resp failure and\n sepsis in patient with poor pulmonary reserve due to emphysema, ?GVHD,\n fibrosis. Patient is now s/p trach/PEG on . PEEP yesterday\n decreased to 5 yesterday after trach placement. Pt has small cuff\n leak. IP had evaluated this am and wanted to continue to monitor for\n now. This am pt agitated, low 02 sats. Has increasing Fi02\n requirement from 40% now up to 60%.\n - Continue PEEP of 5 on PCV given concern over cuff leak by RT, plan\n for replacement of cuff by IP after a few days when trach is not so\n new\n - Driving pressures maintained at 24. FiO2 at 60% now with sats in the\n low 90s. Last gas 7.36/51/105. Can consider decreasing FiO2 to 50%\n this morning.\n - Can attempt PS trial today if sedation weaned and patient alert\n enough to tolerate.\n - Treat PNA for planned 14 day course. B-glucan, galactomannan\n negative, caspogungin d/c\n # Sedation: Currently on methadone q4H, and propofol for sedation,\n currently at 35 mcg/kg/min. Off fent/versed drips, using fentanyl and\n lorazepam boluses for agitation.\n - Goal to wean propofol as tolerated today, triglycerides mildly\n elevated at 182\n - Continue to check triglycerides twice weekly while on propofol. Last\n checked \n - When able, will decrease methadone to q6H then to q8H\n # Shock: Multifactorial, resolved.\n ** Sepsis: Likely source pneumonia. On very broad coverage w/\n vancomycin, levofloxacin, zosyn, bactrim (now only ppx dosing). All\n cultures pending or no growth. WBC stable.\n - D/C'd caspo\n - F/u cultures - cont to culture with spikes.\n - Continue acyclovir and bactrim ppx, vanc/zosyn/levoflox for 14 day\n course, today is day 12.\n **Cardiogenic\n ## Pump: Now improved BPs, off dobutamine. On captopril for afterload\n reduction. Dilated hypokinetic RV, likely causative in hypotension.\n Currently on captopril 12.5mg TID decreased yesterday in the setting of\n hypotension requiring a fluid bolus. Will likely need repeat ECHO once\n acute issues resolved to assess for resolution of RV dysfunction.\n - Continue to monitor BP, can consider repeat ECHO to evaluate pump\n function.\n ## Rhythm: Sinus bradycardia likely secondary to sedatives; increases\n with agitation. Cont weaning sedation as tolerated. Continue to\n follow QTc for prolongation given methadone and levoflox, has been wnl\n **Endocrine: relative adrenal \n - Prednisone off\n # Metastatic renal CA: Recurrent disease s/p donor lymphocyte\n transplant .\n - BMT to follow\n - Continue acyclovir and bactrim ppx\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 02:13 AM 20 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Multi Lumen - 11:24 PM\n Arterial Line - 08:13 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:ICU\n" }, { "category": "Respiratory ", "chartdate": "2120-04-20 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 323134, "text": "Demographics\n Day of mechanical ventilation: 6\n Ideal body weight: 69.9 None\n Ideal tidal volume: 279.6 / 419.4 / 559.2 mL/kg\n Airway\n Tube Type\n ETT:\n Position: 25 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Cuff pressure: 20 cmH2O\n Lung sounds\n RLL Lung Sounds: Crackles\n RUL Lung Sounds: Tubular\n LUL Lung Sounds: Tubular\n LLL Lung Sounds: Crackles\n Comments:\n Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount: Suctioned / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n :\n Trigger work assessment: Not triggering\n Plan\n Next 24-48 hours: Utilize ARDSnet protocol, Maintain PEEP at current\n level and reduce FiO2 as tolerated\n Reason for continuing current ventilatory support: Sedated / Paralyzed,\n Underlying illness not resolved\n No RSBI due to PEEP level Esophageal balloon in place. No measurements\n this shift. Abgs reveal resp alkalosis, oxygenation improving.\n" }, { "category": "Nursing", "chartdate": "2120-04-20 00:00:00.000", "description": "Nursing Progress Note", "row_id": 323135, "text": "Heart failure, right, isolated (Cor Pulmonale)\n Assessment:\n SBP >130 and UO > 100cc/hr\n Action:\n Dobutamine weaning attempted @2300, Restarted @ 2330 0.3mcg/kg/min\n Response:\n Bradycardic to 45, CI <2.4 when dobutamine turned off\n Plan:\n Wean dobutamine, Goal CI >2.5, UO >40cc/hr\n Respiratory failure, acute (not ARDS/)\n Assessment:\n During personal care pt became awake moved UE and fighting on vent and\n desated to 80\n Action:\n Suctioned for thick yellow sec. Fio2 increased to 50%\n Response:\n Sats picked up to 92%\n Plan:\n Cont vent support and ABG in AM\n Pt is sedated on vent. Fentanyl wean to 400mcg/hr, versed cont as\n 10mg/hr. Pt awakened while doing personal care Open eyes but does not\n follow commands. Moved UE, No movements on LE noted. Fighting on vent\n and desated to 80\ns suctioned for yellow thick sec Fio2 increased to\n 50% and received fentanyl bolus w/ that ha calms down, sats improved to\n 92% . Tube feeding replete w/ fiber 10cc/hr started @ 0200 minimal\n residual. ABG @ 0600 7.46/36/88/1\n" }, { "category": "Nursing", "chartdate": "2120-04-21 00:00:00.000", "description": "Nursing Progress Note", "row_id": 323220, "text": "50 yo male with met renal cell CA admitted with severe resp\n failure/PNA, cardiogenic/septic shock. RV hypoplasia\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n Sepsis, Severe (with organ dysfunction)\n Assessment:\n Action:\n Response:\n Plan:\n Heart failure, right, isolated (Cor Pulmonale)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2120-04-28 00:00:00.000", "description": "Nursing Progress Note", "row_id": 323968, "text": "This is 50M with h/o metastatic renal CA s/p\n nephrectomy,emphysema/pulmonary fibrosis on home 02 presented to OSH\n with hypoxic respiratory failure, fevers and hypotension with sepsis,\n cardiogenic shock now weaning off ventilator.Had trach and PEG on\n .Main issue with trach is that it has got air leak.IP was\n ,they will review the pt on .Pt failed PS on Friday. Was\n pan cultured on Friday for raised wcc.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n No vent changes overnight. Remains on pcv 60%/peep 5/rate 30. pt still\n has got cuff leak but not as bad as it was yesterday. Pt was\n overbreathing on the vent at the start of the shift.\n Action:\n Bld gases within acceptable limits.Propofol increased from 30 to 35\n mcg/kg/min for pt comfort.\n Response:\n Pt is saturating 93-98%. Saturating well when no air leak.\n Plan:\n To try on PS this am.\n Hypotension (not Shock)\n Assessment:\n BP systolic 80-110.MAP >60.\n Action:\n No interventions overnight.\n Response:\n Plan:\n To keep MAP>60.\n" }, { "category": "Nursing", "chartdate": "2120-05-01 00:00:00.000", "description": "Nursing Progress Note", "row_id": 324269, "text": "Pt continues to have worsening respiratory status. Unable to ventilate.\n Adjustment made on the vent with no change in the saturation. Pt\n continues to have worsening bld gases and worsening acidemia. On max\n settings on the vent. Family called and updated regarding the worsening\n scenario. Family at the bedside all night. Not escalating on the\n pressors. Paged priest with no response.\n" }, { "category": "General", "chartdate": "2120-04-23 00:00:00.000", "description": "ICU Event Note", "row_id": 323440, "text": "50 yo male with metastatic renal cell CA s/p allo-SCT, COPD/fibrosis\n admitted with resp failure/shock. Mixed septic/cardiogenic picture with\n resp failure related to probable infxn superimposed on RV failure/pHTN,\n severe chronic pulm ds\n Respiratory failure, acute (not ARDS/)\n Assessment:\n PSV/50% FiO2/30/12 of PEEP, breathing in sync with vent. LS clear,\n diminished at bases. ABG 7.51/44/91/10/36. Small amt of blood tinged\n thick sputum suctioned from ETT. Sats 93-97%\n Action:\n Con\nt to administer abx for ? PCP. vent changes made.\n Response:\n Pt stable on current vent settings. Remains afebrile.\n Plan:\n Con\nt to monitor resp status and make appropriate vent changes.\n Bradycardia\n Assessment:\n HR consistently in sinus brady at 36-51bmp.\n Action:\n Propofol and Fentanyl weaned down throughout night to stimulate pt and\n raise HR.\n Response:\n HR up to 50\ns when awake, however became too agitated. Propofol\n currently at 10mcg/kg/min and Fentanyl at 150 mcg/hr. MD aware of HR\n and updated throughout night.\n Plan:\n Con\nt to monitor HR and titrate sedation as tolerated. ?longer acting\n benzo and d/c versed in AM\n" }, { "category": "Respiratory ", "chartdate": "2120-04-23 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 323441, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 9\n Ideal body weight: 69.9 None\n Ideal tidal volume: 279.6 / 419.4 / 559.2 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation:\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: 23 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Blood Tinged / Thick\n Sputum source/amount: Suctioned / Scant\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing;\n Comments: Episodes of dysncrony and desats when pt reposition.\n Assessment of breathing comfort: No response (sleeping / sedated)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Maintain PEEP at current level and reduce FiO2 as\n tolerated, 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 Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n" }, { "category": "Nursing", "chartdate": "2120-04-26 00:00:00.000", "description": "Nursing Progress Note", "row_id": 323750, "text": "Pt is a 50 yo M with metastatic renal cell CA s/p allo- SCT with\n subsequent severe chronic resp failure thought to be emphysema and\n fibrosis of unclear etiology (CT from last spring demonstrates severe\n cystic and fibrotic changes with almost no normal appearing lung).\n Admitted w/ catastrophic acute on chronic failure and severe shock,\n initially presumed septic but more predominantly cardiogenic. Was on\n high dose steroids, tapering prednisone and now 40PO qd.\n Pt rec\nd trach & PEG on ; cuff leak persistent, even w/ large\n volume inflation. IP due to change out today.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nutrition", "chartdate": "2120-04-29 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 324058, "text": "Subjective\n Patient with trach\n Objective\n Pertinent medications: fentanyl, versed, vasopressin, norepinephrine\n Labs:\n Value\n Date\n Glucose\n 114 mg/dL\n 03:34 AM\n Glucose Finger Stick\n 82\n 12:00 AM\n BUN\n 14 mg/dL\n 03:34 AM\n Creatinine\n 1.3 mg/dL\n 03:34 AM\n Sodium\n 141 mEq/L\n 03:34 AM\n Potassium\n 4.6 mEq/L\n 03:34 AM\n Chloride\n 110 mEq/L\n 03:34 AM\n Albumin\n 2.6 g/dL\n 07:59 PM\n Calcium non-ionized\n 7.3 mg/dL\n 03:34 AM\n Phosphorus\n 4.9 mg/dL\n 03:34 AM\n Ionized Calcium\n 1.00 mmol/L\n 03:23 PM\n Magnesium\n 2.0 mg/dL\n 03:34 AM\n Current diet order / nutrition support: NPO\n GI: Abdomen soft/distended with hypoactive bowel sounds\n Assessment of Nutritional Status\n Specifics:\n 50 year old male with metastatic renal cell cancer s/p nephrectomy, s/p\n allo SCT presenting with respiratory failure, fevers, sepsis now s/p\n trach and PEG placement. Patient was started on tube feedings, but now\n on hold d/t high residuals. Event of last 24 hours noted, patient NPO\n at this time. Once patient more stable, can retry tube feedings of\n Replete with Fiber to goal rate of 70ml/hr.\n Medical Nutrition Therapy Plan - Recommend the Following\n 1. Keep NPO for now, once more stable, can restart Replete with\n Fiber at 20ml/hr, advance by 20ml q6H to goal rate of 70ml/hr x 24\n hours\n 2. Monitor/replete lytes\n 3. Will follow for plan of care closely.\n 09:43\n" }, { "category": "Physician ", "chartdate": "2120-04-30 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 324177, "text": "Chief Complaint: shock, respiratory failure\n HPI:\n 24 Hour Events:\n EKG - At 09:00 AM\n TRANSTHORACIC ECHO - At 10:17 AM\n MULTI LUMEN - START 12:05 PM\n ULTRASOUND - At 02:29 PM\n Eventful day yesterday; see my evening addendum:\n 1) pressor requirement improved\n (2) central line placed without incident. CVP was only 7\n (3) Respiratory acidosis improved more than expected based on\n ventilator manipulations\n (4) Family meeting at 12:30\n (5) Echo shows no tamponade; RV is perhaps larger than prior echo\n (6) LENIs (-)\n (7) Formal jugular doppler confirmed our findings of RIJ DVT\n (8) Episode of coffee grounds\n Overnight, had some additional progress in terms of hemodynamics.\n Allergies:\n Flagyl (Oral) (Metronidazole)\n Rash;\n Last dose of Antibiotics:\n Acyclovir - 04:00 PM\n Levofloxacin - 08:00 AM\n Piperacillin/Tazobactam (Zosyn) - 06:32 AM\n Vancomycin - 08:00 AM\n Ciprofloxacin - 11:00 AM\n Metronidazole - 04:00 PM\n Linezolid - 05:14 AM\n Meropenem - 08:13 AM\n Infusions:\n Fentanyl (Concentrate) - 300 mcg/hour\n Cisatracurium - 0.1 mg/Kg/hour\n Heparin Sodium - 1,200 units/hour\n Norepinephrine - 0.05 mcg/Kg/min\n Other ICU medications:\n Pantoprazole (Protonix) - 08:00 PM\n Other medications:\n colace, SQI, ASA, acyclovir, folate, Bactrim MWF, nystatin, methadone,\n Reglan, phenylephrine, cisatra, vanco oral, levophed, midaz, fentanyl,\n meropenem, linezolid, PPI, caspofungin, flagyl, heparin IV, IVIG, CHG,\n PPI IV q12\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 09:51 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: 34\nC (93.2\n HR: 73 (64 - 104) bpm\n BP: 120/60(78) {79/41(59) - 175/87(183)} mmHg\n RR: 39 (0 - 42) insp/min\n SpO2: 90%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 76.3 kg (admission): 76.3 kg\n Height: 68 Inch\n CVP: 12 mmHg\n Total In:\n 9,039 mL\n 3,530 mL\n PO:\n TF:\n IVF:\n 9,039 mL\n 3,530 mL\n Blood products:\n Total out:\n 3,595 mL\n 570 mL\n Urine:\n 3,295 mL\n 570 mL\n NG:\n 300 mL\n Stool:\n Drains:\n Balance:\n 5,444 mL\n 2,960 mL\n Respiratory support\n Ventilator mode: PRVC/AC\n Vt (Set): 340 (340 - 360) mL\n PC : 38 cmH2O\n PS : 32 cmH2O\n PEEP: 6 cmH2O\n FiO2: 70%\n RSBI Deferred: FiO2 > 60%\n PIP: 38 cmH2O\n Plateau: 30 cmH2O\n Compliance: 17.9 cmH2O/mL\n SpO2: 90%\n ABG: 7.21/70/104/26/-1\n Ve: 15 L/min\n PaO2 / FiO2: 149\n Physical Examination\n General Appearance: Well nourished\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n Respiratory / Chest: (Breath Sounds: Clear : anteriorly)\n Abdominal: Soft, Non-tender\n Extremities: Right: Trace, Left: Trace\n Skin: Warm\n Neurologic: Responds to: Unresponsive, Movement: No spontaneous\n movement, Sedated, Paralyzed, Tone: Decreased\n Labs / Radiology\n 8.1 g/dL\n 88 K/uL\n 253 mg/dL\n 1.9 mg/dL\n 26 mEq/L\n 4.4 mEq/L\n 28 mg/dL\n 108 mEq/L\n 136 mEq/L\n 25.4 %\n 11.3 K/uL\n [image002.jpg]\n 03:11 PM\n 05:58 PM\n 08:48 PM\n 09:33 PM\n 01:17 AM\n 01:43 AM\n 01:59 AM\n 03:07 AM\n 04:27 AM\n 04:44 AM\n WBC\n 11.3\n Hct\n 30.4\n 27.6\n 25.4\n Plt\n 88\n Cr\n 1.9\n TCO2\n 28\n 29\n 30\n 28\n 30\n 29\n 30\n Glucose\n 253\n Other labs: PT / PTT / INR:19.2/77.9/1.8, CK / CKMB /\n Troponin-T:260/9/0.22, ALT / AST:2542/3606, Alk Phos / T Bili:146/0.9,\n Amylase / Lipase:50/19, Differential-Neuts:85.4 %, Band:0.0 %,\n Lymph:8.8 %, Mono:4.1 %, Eos:1.4 %, Lactic Acid:1.9 mmol/L, Albumin:2.7\n g/dL, LDH:1697 IU/L, Ca++:7.0 mg/dL, Mg++:2.0 mg/dL, PO4:4.7 mg/dL\n Microbiology: No new growth\n Assessment and Plan\n 50-year-old man with metastatic renal cell cancer s/p BMT now with\n multiple organ failure of uncertain etiology.\n recrudescent severe shock\n Main differential here is pulmonary embolism (with\n pre-existing severe pulmonary parenchymal and vascular disease and RV\n dysfunction) and sepsis.\n Continue ABX as directed by ID\n Heparinize\n Keep CVP >12 (higher, if his oxygenation and ventilation\n will tolerate). Vasopressor support as needed.\n Transfuse today given ongoing bleeding, anemia, and relative\n hypovolemia\n recrudescent severe respiratory failure with a very high dead space\n fraction\n Heparinze for suspected PE (+ RIJ DVT)\n Esophageal-pressure-targeted ventilation. Keep\n transpulmonary pressure as low as possible while keeping pH > 7.20. If\n TPP goes up and acidemic, would consider bicarbonate\n acute hepatitis (likely ischemic/shock liver)\n Review meds with ID and pharmacy to avoid hepatotoxicity\n Expect bilirubin to come up in next day or so.\n GI bleed\n IV PPI twice a day\n Will try to keep heparinized for now, given high risk of death if RIJ\n clot embolized\n acute renal failure (likely ischemic, althoug postrenal is not fully\n excluded)\n acidosis\n thrombocytopenia\n HIT seems unlikely given ongoing prior exposure\n TTP seems unlikely given timing\n Medications (ABX, ??IVIG) certainly possible\n Follow platelets again today. If continues to fall, hold heparin.\n Will discuss with heme/onc and ID today\n Shock\n Etiology here is uncertain. Sepsis is most likely, but PE\n For sepsis\n cover MRSA and VRE, cover ESBL and other resistant GNR\n (change to meropenem and IV quinolone), and for C diff (oral vanco;\n discuss his Flagyl allergy with his prior providers). Will discuss\n antifungal coverage with BMT. Check other cultures. (CMV,\n galactomannan, etc.) Consult ID for advice on antibiotics.\n Check KUB and upright CXR to exclude free air. He is too sick for\n travel and for operation.\n Treat empirically for adrenal insufficiency. Add on cortisol to morning\n labs.\n Check echo. Check EKG since heart rate is relatively low.\n Follow and replete ionized calcium.\n Heparinize empirically for PE. Discuss with BMT whether he would be a\n candidate for lytics if we documented PE (his metastatic disease in the\n spine makes it unlikely).\n Place central line after heparin is held for an hour.\n Respiratory failure\n Esophageal-balloon guided settings for PEEP and driving pressure.\n Has marked respiratory acidosis that seems to be mostly related to high\n dead-space fraction.\n Will try to increase respiratory rate and watch for autoPEEP.\n Bradycardia\n Appears to be a junctional rhythm. Will replete all lytes including\n calcium, etc.\n Try to swap to Levophed for\n Acute renal failure\n Secondary to hemodynamics. Follow for now.\n Acidosis\n Mostly related to respiratory acidosis, although his bicarb has fallen\n over the past days as well.\n Since he has a lactic (and respiratory) acidosis, will hold off on\n bicarbonate for now.\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 20 Gauge - 02:03 PM\n 18 Gauge - 02:03 PM\n PICC Line - 04:30 PM\n Arterial Line - 04:30 AM\n Multi Lumen - 12:05 PM\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: Heparin gtt)\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 :\n Total time spent:\n" }, { "category": "Physician ", "chartdate": "2120-04-30 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 324178, "text": "Chief Complaint: shock, respiratory failure\n HPI:\n 24 Hour Events:\n EKG - At 09:00 AM\n TRANSTHORACIC ECHO - At 10:17 AM\n MULTI LUMEN - START 12:05 PM\n ULTRASOUND - At 02:29 PM\n Eventful day yesterday; see my evening addendum:\n 1) pressor requirement improved\n (2) central line placed without incident. CVP was only 7\n (3) Respiratory acidosis improved more than expected based on\n ventilator manipulations\n (4) Family meeting at 12:30\n (5) Echo shows no tamponade; RV is perhaps larger than prior echo\n (6) LENIs (-)\n (7) Formal jugular doppler confirmed our findings of RIJ DVT\n (8) Episode of coffee grounds\n Overnight, had some additional progress in terms of hemodynamics.\n Allergies:\n Flagyl (Oral) (Metronidazole)\n Rash;\n Last dose of Antibiotics:\n Acyclovir - 04:00 PM\n Levofloxacin - 08:00 AM\n Piperacillin/Tazobactam (Zosyn) - 06:32 AM\n Vancomycin - 08:00 AM\n Ciprofloxacin - 11:00 AM\n Metronidazole - 04:00 PM\n Linezolid - 05:14 AM\n Meropenem - 08:13 AM\n Infusions:\n Fentanyl (Concentrate) - 300 mcg/hour\n Cisatracurium - 0.1 mg/Kg/hour\n Heparin Sodium - 1,200 units/hour\n Norepinephrine - 0.05 mcg/Kg/min\n Other ICU medications:\n Pantoprazole (Protonix) - 08:00 PM\n Other medications:\n colace, SQI, ASA, acyclovir, folate, Bactrim MWF, nystatin, methadone,\n Reglan, phenylephrine, cisatra, vanco oral, levophed, midaz, fentanyl,\n meropenem, linezolid, PPI, caspofungin, flagyl, heparin IV, IVIG, CHG,\n PPI IV q12\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 09:51 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: 34\nC (93.2\n HR: 73 (64 - 104) bpm\n BP: 120/60(78) {79/41(59) - 175/87(183)} mmHg\n RR: 39 (0 - 42) insp/min\n SpO2: 90%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 76.3 kg (admission): 76.3 kg\n Height: 68 Inch\n CVP: 12 mmHg\n Total In:\n 9,039 mL\n 3,530 mL\n PO:\n TF:\n IVF:\n 9,039 mL\n 3,530 mL\n Blood products:\n Total out:\n 3,595 mL\n 570 mL\n Urine:\n 3,295 mL\n 570 mL\n NG:\n 300 mL\n Stool:\n Drains:\n Balance:\n 5,444 mL\n 2,960 mL\n Respiratory support\n Ventilator mode: PRVC/AC\n Vt (Set): 340 (340 - 360) mL\n PC : 38 cmH2O\n PS : 32 cmH2O\n PEEP: 6 cmH2O\n FiO2: 70%\n RSBI Deferred: FiO2 > 60%\n PIP: 38 cmH2O\n Plateau: 30 cmH2O\n Compliance: 17.9 cmH2O/mL\n SpO2: 90%\n ABG: 7.21/70/104/26/-1\n Ve: 15 L/min\n PaO2 / FiO2: 149\n Physical Examination\n General Appearance: Well nourished\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n Respiratory / Chest: (Breath Sounds: Clear : anteriorly)\n Abdominal: Soft, Non-tender\n Extremities: Right: Trace, Left: Trace\n Skin: Warm\n Neurologic: Responds to: Unresponsive, Movement: No spontaneous\n movement, Sedated, Paralyzed, Tone: Decreased\n Labs / Radiology\n 8.1 g/dL\n 88 K/uL\n 253 mg/dL\n 1.9 mg/dL\n 26 mEq/L\n 4.4 mEq/L\n 28 mg/dL\n 108 mEq/L\n 136 mEq/L\n 25.4 %\n 11.3 K/uL\n [image002.jpg]\n 03:11 PM\n 05:58 PM\n 08:48 PM\n 09:33 PM\n 01:17 AM\n 01:43 AM\n 01:59 AM\n 03:07 AM\n 04:27 AM\n 04:44 AM\n WBC\n 11.3\n Hct\n 30.4\n 27.6\n 25.4\n Plt\n 88\n Cr\n 1.9\n TCO2\n 28\n 29\n 30\n 28\n 30\n 29\n 30\n Glucose\n 253\n Other labs: PT / PTT / INR:19.2/77.9/1.8, CK / CKMB /\n Troponin-T:260/9/0.22, ALT / AST:2542/3606, Alk Phos / T Bili:146/0.9,\n Amylase / Lipase:50/19, Differential-Neuts:85.4 %, Band:0.0 %,\n Lymph:8.8 %, Mono:4.1 %, Eos:1.4 %, Lactic Acid:1.9 mmol/L, Albumin:2.7\n g/dL, LDH:1697 IU/L, Ca++:7.0 mg/dL, Mg++:2.0 mg/dL, PO4:4.7 mg/dL\n Microbiology: No new growth\n Assessment and Plan\n 50-year-old man with metastatic renal cell cancer s/p BMT now with\n multiple organ failure: respiratory failure, shock, acute renal\n failure, shock liver, thrombocytopenia and ?hemolysis.\n recrudescent severe shock\n Main differential here is pulmonary embolism (with\n pre-existing severe pulmonary parenchymal and vascular disease and RV\n dysfunction) and sepsis.\n Continue ABX as directed by ID\n Heparinize\n Keep CVP >12 (higher, if his oxygenation and ventilation\n will tolerate). Vasopressor support as needed.\n Transfuse today given ongoing bleeding, anemia, and relative\n hypovolemia\n recrudescent severe respiratory failure with a very high dead space\n fraction\n Heparinze for suspected PE (+ RIJ DVT)\n Esophageal-pressure-targeted ventilation. Keep\n transpulmonary pressure as low as possible while keeping pH > 7.20. If\n TPP goes up and acidemic, would consider bicarbonate\n acute hepatitis (likely ischemic/shock liver)\n Review meds with ID and pharmacy to avoid hepatotoxicity\n Expect bilirubin to come up in next day or so.\n GI bleed\n suspect stress ulceration\n IV PPI twice a day\n Will try to keep heparinized for now, given high risk of\n death if RIJ clot embolized\n acute renal failure (likely ischemic, althoug postrenal is not fully\n excluded)\n Check renal ultrasound\n Check sediment and lytes\n acidosis\n Lactate has improved\n Respiratory component is limited both by high Vd/Vt and\n pulmonary compliance/transpulmonary pressures\n thrombocytopenia\n HIT seems unlikely given ongoing prior exposure\n TTP seems unlikely given timing\n DIC certainly possible\n Medications (ABX, ??IVIG) certainly possible\n Follow platelets again today. If continues to fall, hold\n heparin.\n Will discuss with heme/onc and ID today\n Accelerated junctional rhythm\n Resolved\n ICU Care\n Nutrition: Nutrition consult\n would consider trophic tube feeds\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 20 Gauge - 02:03 PM\n 18 Gauge - 02:03 PM\n PICC Line - 04:30 PM\n Arterial Line - 04:30 AM\n Multi Lumen - 12:05 PM\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: Heparin gtt)\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Comments:\n Code status: DNR (no resuscitation for pulseless arrest)\n Disposition : ICU\n Total time spent: 45 minutes\n" }, { "category": "General", "chartdate": "2120-04-30 00:00:00.000", "description": "Generic Note", "row_id": 324187, "text": "TITLE:\n RESPIRATORY CARE: PT REMAINS W/ AN 8.0 PORTEX TRACH IN\n PLACE. REMAINS ON PRVC RR 42 VT 340 FIO2 .70 PEEP 6 AND PARALYZED AND\n SEDATED. ABG C/W A RESPIRATORY ACIDOSIS AND MODERATE TO SEVERE\n HYPOXEMIA. TPp INSP PLATEAU = 26 AND TPp EXP PLATEAU = 3. SPO2 MONITOR\n 90-93 % THIS SHIFT W/ OCCASIONAL DESATURATION UPON TURNING. SX FOR\n SMALL AMTS THICK YELLOW SPUTUM. BAL SENT TO LAB\n YESTERDAY. ALBUTEROL MDI GIVEN . GOAL ARE TO KEEP PH . 7.20, SPO2 >\n 90-92 %, TPp INSP < OR =\n" }, { "category": "Nursing", "chartdate": "2120-04-22 00:00:00.000", "description": "Nursing Progress Note", "row_id": 323332, "text": "50 yo male with met renal cell CA admitted with severe resp\n failure/PNA, cardiogenic/septic shock. RV hypoplasia\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Remains intubated, sedated with Fentanyl 500 mcg / versed 10mg/hr. on\n PCV ,no attempt to wean . still pt very awake with stimulation,but not\n desats like yesterday,sats maintained 93-94% even during turning.\n Action:\n Continued with same vent settings, Rate 30 / i:e ratio 1:1.7 / peep 12/\n Pinsp 38 /fio2 50%. Blood gas early shift 7.53/38/78/8. am labs\n pending.\n Response:\n Remained stable with sats and vitals.\n Plan:\n Continue wean vent /sedation when possible.\n Heart failure, right, isolated (Cor Pulmonale)\n Assessment:\n HR 40-50\ns, SB ,CO and CI monitoring through vigileo monitor.\n Action:\n CO 4.3-5.4 . No acute intervention for bradycardia now, may be its\n part of his high sedation,when pt awake HR 55-60\n Response:\n Plan:\n Continue monitor CI, CO, and vital signs.\n Off lasix drip from yesterday ,urine output adequate > 120cc\n /hr.maintained neg balance.\n No BM this shift, bowel regimen hold as he was having loose stool.\n Feed @ 70cc/hr @ goal rate. Tolerating well.residual 5-10cc.\n Bath given and positioned.\n Family visited early shift and updated .\n" }, { "category": "General", "chartdate": "2120-04-23 00:00:00.000", "description": "ICU Event Note", "row_id": 323433, "text": "50 yo male with metastatic renal cell CA s/p allo-SCT, COPD/fibrosis\n admitted with resp failure/shock. Mixed septic/cardiogenic picture with\n resp failure related to probable infxn superimposed on RV failure/pHTN,\n severe chronic pulm ds\n Respiratory failure, acute (not ARDS/)\n Assessment:\n PSV/50% FiO2/30/12 of PEEP, breathing in sync with vent. LS clear,\n diminished at bases. ABG 7.51/44/91/10/36. Small amt of blood tinged\n thick sputum suctioned from ETT. Sats 93-97%\n Action:\n Con\nt to administer abx for ? PCP. vent changes made.\n Response:\n Pt stable on current vent settings. Remains afebrile.\n Plan:\n Con\nt to monitor resp status and make appropriate vent changes.\n Bradycardia\n Assessment:\n HR consistently in sinus brady at 36-51bmp.\n Action:\n Propofol and Fentanyl weaned down throughout night to stimulate pt and\n raise HR.\n Response:\n HR up to 50\ns when awake, however became too agitated. Propofol\n currently at 10mcg/kg/min and Fentanyl at 150 mcg/hr. MD aware of HR\n and updated throughout night.\n Plan:\n Con\nt to monitor HR and titrate sedation as tolerated. ?longer acting\n benzo and d/c versed in AM\n" }, { "category": "Respiratory ", "chartdate": "2120-04-24 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 323548, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 10\n Ideal body weight: 69.9 None\n Ideal tidal volume: 279.6 / 419.4 / 559.2 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation:\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type: Standard\n Size: 7.5mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Clear\n Comments:\n Secretions\n Sputum color / consistency: Blood Tinged / Thick\n Sputum source/amount: Suctioned / Moderate\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing;\n Comments: epidoes of dysyncrony with reposition.\n Assessment of breathing comfort: No response (sleeping / sedated)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Maintain PEEP at current level and reduce FiO2 as\n tolerated, Reduce PEEP as tolerated, Adjust Min. ventilation to control\n pH\n Reason for continuing current ventilatory support: Sedated / Paralyzed,\n Hemodynimic instability, Underlying illness not resolved\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n Mdis given as ordered. Will continue to monitor.\n" }, { "category": "Nursing", "chartdate": "2120-04-24 00:00:00.000", "description": "Nursing Progress Note", "row_id": 323549, "text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n PCV/10 PEEP/50%/30. Resp pattern regular, sync with vent. LS crackles\n with diminished bases. Clear thick sputum from ET suction. No\n distress noted. Sats 93-97%\n Action:\n No vent changes made\n Response:\n Pt stable on vent\n Plan:\n Con\nt to wean vent as tol. Monitor ABG\ns and resp status. Con\nt abx\n as ordered.\n Plan to wean pt off of Fentanyl and Versed. Currently on 2mg/hr Versed\n and 50mcg/hr of Fentanyl. Goal is to keep pt on Propofol and\n Methadone. ? PO Ativan.\n Plan for possible trach on Thursday.\n" }, { "category": "Nursing", "chartdate": "2120-04-25 00:00:00.000", "description": "Nursing Progress Note", "row_id": 323654, "text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt on PCV/40%/10 PEEP/rate 30 at start of shift. Sats 94-97%. LS\n tubular. No apparent distress noted. Minimal secretions. Regular\n breathing pattern in sync with vent. Pt desated to 91-92% - ABG showed\n 7.49/43/65/8/34.\n Action:\n FiO2 up to 50%\n Response:\n Sats back up to 96-97% - pt appeares more comfortable. AM ABG\n 7.44/50/110/8/35\n Plan:\n Plan for trach today. TF off since MN. Wean vent as tol.\n Pt on Propofol and Methadone for sedation receiving Ativan and Fentanyl\n boluses. Only received 2mg Ativan IV x1 on shift. Plan to try and\n wean Propofol as tol during days.\n" }, { "category": "Nursing", "chartdate": "2120-04-26 00:00:00.000", "description": "Nursing Progress Note", "row_id": 323747, "text": "Pt is a 50 yo M with metastatic renal cell CA s/p allo- SCT with\n subsequent severe chronic resp failure thought to be emphysema and\n fibrosis of unclear etiology (CT from last spring demonstrates severe\n cystic and fibrotic changes with almost no normal appearing lung).\n Admitted 2 wk prodrome, presented with catastrophic acute on chronic\n failure. CXR showed diffuse opacification c/w ARDS. Severe shock,\n initially presumed septic but more predominantly cardiogenic. RV with\n global hypokinesis, dilated, mod-sev PAH. Responded well to dobutamine.\n Was on high dose steroids, tapering prednisone and now 40PO qd. Pt\n rec\nd trach & PEG on ; cuff leak\n" }, { "category": "Respiratory ", "chartdate": "2120-04-28 00:00:00.000", "description": "Generic Note", "row_id": 323963, "text": "TITLE:\n Resp. Care Note Patient remains ventilated on pressure control.\n Trached with # 8 Portex trach tube. Cuff leak remains an issue with a\n sometimes audible air leak. Plan is for trach change possibly Monday\n or Tuesday of this week.\n" }, { "category": "Nursing", "chartdate": "2120-05-01 00:00:00.000", "description": "Nursing Progress Note", "row_id": 324265, "text": "Pt continues to have worsening respiratory status. Unable to ventilate.\n Adjustment made on the vent with no change in the saturation. Pt\n continues to have worsening bld gases and worsening acidemia. On max\n settings on the vent. Family called and updated regarding the worsening\n scenario. Family at the bedside all night. Not escalating on the\n pressors. Paged priest with no response.\n" }, { "category": "Physician ", "chartdate": "2120-04-25 00:00:00.000", "description": "ICU Attending Note", "row_id": 323735, "text": "Clinician: Attending\n 50 yo man with metastatic renal cell CA s/p allo- SCT with subsequent\n severe chronic resp failure thought to be emphysema and fibrosis of\n unclear etiology (CT from last spring demonstrates severe cystic and\n fibrotic changes with almost no normal appearing lung) presented with 2\n wk prodrome, presented with catastrophic acute on chronic failure. CXR\n shows diffuse opacification c/w ARDS. Severe shock, initially presumed\n septic but more predominantly cardiogenic. RV with global hypokinesis,\n dilated, mod-sev PAH. Responded well to dobutamine. Was on high dose\n steroids, tapering prednisone and now 40PO qd.\n Events:\n Adjusting sedation: Fentanyl off! now on propofol 25/h,\n methadone 20q 4h IV, Versed 2/h\n PC 0.5/24/PEEP10/30/TV400s 7.44/50/110\n Exam sig for: Remains afebrile, autodiuresing, sedated from trach and\n less responsive currently, trach site clean with no oozing, loud upper\n airway noise, hypoactiveBS, abd soft, trach site looks good, minimal\n peripheral edema, no rashes\n - No new micro data- bglucan and galactomannan still pending\n H2blocker, hepsc, prednisone 20, aspirin\n Abx: Vanco/Levoflox/Zosyn/Caspofungin/bactrim and acyclovir\n prophylaxis\n Cardiogenic shock and severe acute on chronic respiratory failure.\n Sepsis.\n CARDIOGENIC SHOCK, PAH, RV FAILURE\n Stable on increased dose captopril for afterload reduction, mildly\n hypertensive.\n Autodiuresing.\n RESP FAILURE\n No sig changes on vent today, given s/p trach this morning and on PEEP\n 10.\n INFECTION\n D7 vanc/zosyn/levoflox/caspofungin and prophylactic bactrim and\n acyclovir.\n Pending beta-glucan and galactomannan with plan to d/c caspofungin if\n markers neg.\n SEDATION\n Off fentanyl and versed. Continues on propofol and methadone. Bolus\n fentanyl/ativan as needed for pain/agitation and try to wean propofol.\n Will decrease methadone to q6 then q8. QTc okay. D3 propofol, will\n check triglycerides.\n NUTRITION\n Held TF for PEG- will restart in 12h, on PO narcan.\n HepSC, ranitidine, oral care, pneumoboots, HOB up.\n other issues per Dr \ns note.\n Total time spent: 45 minutes\n Patient is critically ill.\n ------ Protected Section ------\n Met with pt\ns wife, , and her daughter, mother, and mother-in-law.\n Discussed progress on vent, developments with sedation, trach/peg, new\n laboratory data, likely clinical course particularly dealing with\n respiratory recovery and neurologic response to changes with sedating\n meds.\n Answered all questions.\n Time: 40 minutes.\n ------ Protected Section Addendum Entered By: , MD\n on: 21:19 ------\n" }, { "category": "Nursing", "chartdate": "2120-04-26 00:00:00.000", "description": "Nursing Progress Note", "row_id": 323748, "text": "Pt is a 50 yo M with metastatic renal cell CA s/p allo- SCT with\n subsequent severe chronic resp failure thought to be emphysema and\n fibrosis of unclear etiology (CT from last spring demonstrates severe\n cystic and fibrotic changes with almost no normal appearing lung).\n Admitted 2 wk prodrome, presented with catastrophic acute on chronic\n failure. CXR showed diffuse opacification c/w ARDS. Severe shock,\n initially presumed septic but more predominantly cardiogenic. RV with\n global hypokinesis, dilated, mod-sev PAH. Responded well to dobutamine.\n Was on high dose steroids, tapering prednisone and now 40PO qd. Pt\n rec\nd trach & PEG on ; cuff leak persistant, even w/ large volume\n inflation. IP due to change out today.\n" }, { "category": "Nursing", "chartdate": "2120-04-28 00:00:00.000", "description": "Nursing Progress Note", "row_id": 323961, "text": "This is 50M with h/o metastatic renal CA s/p\n nephrectomy,emphysema/pulmonary fibrosis on home 02 presented to OSH\n with hypoxic respiratory failure, fevers and hypotension with sepsis,\n cardiogenic shock now weaning off ventilator.Had trach and PEG on\n .Main issue with trach is that it has got air leak.IP was\n ,they will review the pt on .Pt failed PS on Friday. Was\n pan cultured on Friday for raised wcc.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n No vent changes overnight. Remains on pcv 60%/peep 5/rate 30. pt still\n has got cuff leak but not as bad as it was yesterday. Pt was\n overbreathing on the vent at the start of the shift.\n Action:\n Bld gases within acceptable limits.Propofol increased from 30 to 35\n mcg/kg/min for pt comfort.\n Response:\n Pt is saturating 93-98%. Saturating well when no air leak.\n Plan:\n To try on PS this am.\n Hypotension (not Shock)\n Assessment:\n BP systolic 80-110.MAP >60.\n Action:\n No interventions overnight.\n Response:\n Plan:\n To keep MAP>60.\n" }, { "category": "Physician ", "chartdate": "2120-04-29 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 324055, "text": "Chief Complaint: shock, 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 24 Hour Events:\n Worsened substantially over the last 24 hours -- hypotension --> shock\n --> pressors, much worse hypoxemia with increasing dead space -->\n paralysis and heparinization. Esophageal balloon placed. Oral\n vancomycin started (has rash to Flagyl) for empiric rx of C diff.\n BLOOD CULTURED - At 12:44 PM\n URINE CULTURE - At 12:44 PM\n PICC LINE - START 04:30 PM\n MULTI LUMEN - STOP 07:52 PM\n ARTERIAL LINE - STOP 07:57 PM\n SPUTUM CULTURE - At 08:24 PM\n ULTRASOUND - At 11:16 PM\n EKG - At 03:00 AM\n ARTERIAL LINE - START 04:30 AM\n FEVER - 101.4\nF - 03:00 AM\n History obtained from Medical records, ICU team\n Patient unable to provide history: Sedated\n Allergies:\n Flagyl (Oral) (Metronidazole)\n Rash;\n Last dose of Antibiotics:\n Acyclovir - 04:00 PM\n Levofloxacin - 08:00 AM\n Piperacillin/Tazobactam (Zosyn) - 06:32 AM\n Vancomycin - 08:00 AM\n Infusions:\n Fentanyl - 225 mcg/hour\n Heparin Sodium - 1,050 units/hour\n Cisatracurium - 0.2 mg/Kg/hour\n Phenylephrine - 4.3 mcg/Kg/min\n Vasopressin - 2.4 units/hour\n Midazolam (Versed) - 25 mg/hour\n Norepinephrine - 0.08 mcg/Kg/min\n Other ICU medications:\n Midazolam (Versed) - 05:30 PM\n Heparin Sodium (Prophylaxis) - 08:25 PM\n Furosemide (Lasix) - 01:45 AM\n Other medications:\n vanco, bactrim mwf, zosyn, acyclovir 400 q 8, CHG, colace, ASA, folate,\n SQI, methadone, PPI, captopril (held), levoflox 750 oral, reglan,\n versed, fentanyl, neosynephrine, cistra, heparin, vasporessin,\n hydrocort (ordered, pending), levophed\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 08:44 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.6\nC (101.4\n Tcurrent: 37.2\nC (99\n HR: 67 (67 - 128) bpm\n BP: 124/75(87) {74/45(53) - 124/78(87)} mmHg\n RR: 18 (0 - 36) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 76.3 kg (admission): 76.3 kg\n Height: 68 Inch\n CVP:\n Total In:\n 5,318 mL\n 1,457 mL\n PO:\n TF:\n 164 mL\n IVF:\n 5,054 mL\n 1,457 mL\n Blood products:\n Total out:\n 1,630 mL\n 675 mL\n Urine:\n 1,630 mL\n 675 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,688 mL\n 782 mL\n Respiratory support\n Ventilator mode: PCV+\n PC : 26 cmH2O\n PS : 10 cmH2O\n RR (Set): 30\n RR (Spontaneous): 38\n PEEP: 10 cmH2O\n FiO2: 100%\n SpO2: 100%\n ABG: 7.05/88/132/26/-8\n Physical Examination\n General Appearance: Well nourished\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Diminished), (Left DP pulse: Diminished)\n Respiratory / Chest: (Breath Sounds: Crackles : )\n Abdominal: Soft, No(t) Bowel sounds present\n Extremities: Right: 1+, Left: 1+\n Skin: Cool\n Neurologic: Responds to: Unresponsive, Movement: No spontaneous\n movement, Tone: Decreased\n Labs / Radiology\n 10.7 g/dL\n 195 K/uL\n 114 mg/dL\n 1.3 mg/dL\n 26 mEq/L\n 4.6 mEq/L\n 14 mg/dL\n 110 mEq/L\n 141 mEq/L\n 34.2 %\n 22.4 K/uL\n [image002.jpg]\n 12:14 PM\n 03:59 AM\n 04:26 AM\n 09:26 PM\n 12:22 AM\n 03:34 AM\n 03:52 AM\n 04:29 AM\n 05:30 AM\n 07:55 AM\n WBC\n 12.5\n 22.4\n Hct\n 29.9\n 34.2\n Plt\n 166\n 195\n Cr\n 0.9\n 1.3\n TCO2\n 28\n 30\n 29\n 29\n 31\n 31\n 29\n 26\n Glucose\n 82\n 114\n Other labs: PT / PTT / INR:13.7/42.1/1.2, CK / CKMB /\n Troponin-T:260/9/0.22, ALT / AST:35/49, Alk Phos / T Bili:178/1.6,\n Amylase / Lipase:50/19, Differential-Neuts:85.4 %, Band:0.0 %,\n Lymph:8.8 %, Mono:4.1 %, Eos:1.4 %, Lactic Acid:5.1 mmol/L, Albumin:2.6\n g/dL, LDH:473 IU/L, Ca++:7.3 mg/dL, Mg++:2.0 mg/dL, PO4:4.9 mg/dL\n Assessment and Plan\n 50-year-old man with recrudescent severe shock and respiratory failure,\n on a background of renal cell CA .\n Shock\n Etiology here is uncertain. Sepsis is most likely, but PE\n For sepsis\n cover MRSA and VRE, cover ESBL and other resistant GNR\n (change to meropenem and IV quinolone), and for C diff (oral vanco;\n discuss his Flagyl allergy with his prior providers). Will discuss\n antifungal coverage with BMT. Check other cultures. (CMV,\n galactomannan, etc.) Consult ID for advice on antibiotics.\n Check KUB and upright CXR to exclude free air. He is too sick for\n travel and for operation.\n Treat empirically for adrenal insufficiency. Add on cortisol to\n morning labs.\n Check echo. Check EKG since heart rate is relatively low.\n Follow and replete ionized calcium.\n Heparinize empirically for PE. Discuss with BMT whether he would be a\n candidate for lytics if we documented PE (his metastatic disease in the\n spine makes it unlikely).\n Place central line after heparin is held for an hour.\n Respiratory failure\n Esophageal-balloon guided settings for PEEP and driving pressure.\n Has marked respiratory acidosis that seems to be mostly related to high\n dead-space fraction.\n Will try to increase respiratory rate and watch for autoPEEP.\n Bradycardia\n Appears to be a junctional rhythm. Will replete all lytes including\n calcium, etc.\n Try to swap to Levophed for\n Acute renal failure\n Secondary to hemodynamics. Follow for now.\n Acidosis\n Mostly related to respiratory acidosis, although his bicarb has fallen\n over the past days as well.\n Since he has a lactic (and respiratory) acidosis, will hold off on\n bicarbonate for now.\n ICU Care\n Nutrition: NPO\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Will place CVL today\n 20 Gauge - 02:03 PM\n 18 Gauge - 02:03 PM\n PICC Line - 04:30 PM\n Arterial Line - 04:30 AM\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: Heparin gtt)\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care\n Comments: Wakeup and RSBI are contraindicated.\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Team has called wife, who is coming in this morning, and has talked to\n BMT.\n Code status: Full code\n Disposition :ICU\n Total time spent: 65 minutes\n Patient is critically ill\n" }, { "category": "Nursing", "chartdate": "2120-04-30 00:00:00.000", "description": "Nursing Progress Note", "row_id": 324147, "text": "This is 50M with h/o metastatic renal CA s/p\n nephrectomy,emphysema/pulmonary fibrosis on home 02 presented to OSH\n with hypoxic respiratory failure, fevers and hypotension with sepsis,\n cardiogenic shock was weaning off ventilator.Had trach and PEG on \n Acute decompensation in the respiratory status on , suspecting and\n being treated for PE. Not able to scan as pt unstable.\n ?sepsis as became hypotensive and spiked temp.Pan cultured and is now\n on prophylactic antibiotics including c-diff precaution.\n Liver usg done to r/o cholecystitis.USG to extremities to r/o DVTs,had\n cardiac echo.\n Pt highly disynchronous with the vent and desaturating down to\n 75%.sedated on fent/versed and paralysed.pt hypotensive and started on\n neosynephrine,levophed and vasopressin.Pt is now on high dose of\n sedation and paralysed.\n Heart failure, right, isolated (Cor Pulmonale)\n Assessment:\n Pts cvp b/w .CI 3.5-5. SVV below 12.\n Action:\n Had 1lit fluid bolus to keep cvp >10.Had CXR to r/o pulmonary edema.\n Response:\n CVP upto 13 and is sustaining there.CXR shows no change from the\n previous one\n Plan:\n Keep cvp>10.FB as needed.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt continues to be vented through trach.Was on volume controlled with\n peep of 9 and RR 42 on 70%.started to have high peak pressures in\n 50\ns.Changed to pressure controlled and decreased the peep to 6.On\n versed 25,fentanyl 225 and cisatracurium 0.2.\n Action:\n Increased fentanyl to 300 and cisatracurium to0.25.Following ABG\ns.Pt\n continues to be on triadyne.On heparin gtt for ?PE.\n Response:\n ABG improved with change in the above mentioned settings.Pt not\n tolerating triadyne on Rt side so stopped rotating and will start later\n on during the day.\n Plan:\n Monitor respiratory status and follow bld gases,cont on the current\n vent settings and aim to keep ph >7.2.\n Shock, septic\n Assessment:\n BP has been improving as the shift progressed.Has been afebrile.Lactate\n trending down with the latest being 2.0.Hct trending down.\n Action:\n Levophed weaned off and remains off at the time of report.Vasopressin\n turned off at 6 am.ABX given as prescribed.Had 1lit Fb for low cvp.On\n c-diff precaution.On IVIG once a day.\n Response:\n BP stable with pressors off.Remains afebrile.WCC down to 11.4.\n Plan:\n Cont ABX.hemodynamic monitoring.Follow hct.\n" }, { "category": "Respiratory ", "chartdate": "2120-04-30 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 324143, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 16\n Ideal body weight: 69.9 None\n Ideal tidal volume: 279.6 / 419.4 / 559.2 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation:\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type:\n Size:\n Tracheostomy tube:\n Type: Cuffed\n Manufacturer: Portex\n Size: 8.0mm\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 50 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Bronchial\n RUL Lung Sounds: Crackles\n LUL Lung Sounds: Bronchial\n LLL Lung Sounds: Crackles\n Comments:\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Small\n Comments: Pt was sx for small to mod amt x1\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Difficult night with increasing\n ventilating pressures, rising Pco2, decreased pH and sometimes falling\n Spo2.\n Assessment of breathing comfort: No response (sleeping / sedated)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments: High pressure limit, occasional low min vol\n Plan\n Next 24-48 hours: Adjust Min. ventilation to control pH; Comments:\n Balancing between high pressures, auto peep, hypercapnea/pH, hypoxemia\n Reason for continuing current ventilatory support: Sedated / Paralyzed,\n Intolerant of weaning attempts, Cannot protect airway\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n Pt has esophageal balloon in place. Teso 0-2, T I 33. Pco2 has been\n between 70 and 80 with pH between 7.12 and 7.21\n" }, { "category": "Physician ", "chartdate": "2120-04-30 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 324167, "text": "Chief Complaint:\n HPI:\n 24 Hour Events:\n EKG - At 09:00 AM\n TRANSTHORACIC ECHO - At 10:17 AM\n MULTI LUMEN - START 12:05 PM\n ULTRASOUND - At 02:29 PM\n Eventful day yesterday; see my evening addendum:\n 1) pressor requirement improved\n (2) central line placed without incident. CVP was only 7\n (3) Respiratory acidosis improved more than expected based on\n ventilator manipulations\n (4) Family meeting at 12:30\n (5) Echo shows no tamponade; RV is perhaps larger than prior echo\n (6) LENIs (-)\n (7) Formal jugular doppler confirmed our findings of RIJ DVT\n (8) Episode of coffee grounds\n Overnight, had some additional progress in terms of hemodynamics.\n Allergies:\n Flagyl (Oral) (Metronidazole)\n Rash;\n Last dose of Antibiotics:\n Acyclovir - 04:00 PM\n Levofloxacin - 08:00 AM\n Piperacillin/Tazobactam (Zosyn) - 06:32 AM\n Vancomycin - 08:00 AM\n Ciprofloxacin - 11:00 AM\n Metronidazole - 04:00 PM\n Linezolid - 05:14 AM\n Meropenem - 08:13 AM\n Infusions:\n Fentanyl (Concentrate) - 300 mcg/hour\n Cisatracurium - 0.1 mg/Kg/hour\n Heparin Sodium - 1,200 units/hour\n Norepinephrine - 0.05 mcg/Kg/min\n Other ICU medications:\n Pantoprazole (Protonix) - 08:00 PM\n Other medications:\n colace, SQI, ASA, acyclovir, folate, Bactrim MWF, nystatin, methadone,\n Reglan, phenylephrine, cisatra, vanco oral, levophed, midaz, fentanyl,\n meropenem, linezolid, PPI, caspofungin, flagyl, heparin IV, IVIG, CHG,\n PPI IV q12\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 09:51 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: 34\nC (93.2\n HR: 73 (64 - 104) bpm\n BP: 120/60(78) {79/41(59) - 175/87(183)} mmHg\n RR: 39 (0 - 42) insp/min\n SpO2: 90%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 76.3 kg (admission): 76.3 kg\n Height: 68 Inch\n CVP: 12 (-3 - 335)mmHg\n Total In:\n 9,039 mL\n 3,530 mL\n PO:\n TF:\n IVF:\n 9,039 mL\n 3,530 mL\n Blood products:\n Total out:\n 3,595 mL\n 570 mL\n Urine:\n 3,295 mL\n 570 mL\n NG:\n 300 mL\n Stool:\n Drains:\n Balance:\n 5,444 mL\n 2,960 mL\n Respiratory support\n Ventilator mode: PRVC/AC\n Vt (Set): 340 (340 - 360) mL\n PC : 38 cmH2O\n PS : 32 cmH2O\n PEEP: 6 cmH2O\n FiO2: 70%\n RSBI Deferred: FiO2 > 60%\n PIP: 38 cmH2O\n Plateau: 30 cmH2O\n Compliance: 17.9 cmH2O/mL\n SpO2: 90%\n ABG: 7.21/70/104/26/-1\n Ve: 15 L/min\n PaO2 / FiO2: 149\n Physical Examination\n General Appearance: Well nourished\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n Respiratory / Chest: (Breath Sounds: Clear : anteriorly)\n Abdominal: Soft, Non-tender\n Extremities: Right: Trace, Left: Trace\n Skin: Warm\n Neurologic: Responds to: Unresponsive, Movement: No spontaneous\n movement, Sedated, Paralyzed, Tone: Decreased\n Labs / Radiology\n 8.1 g/dL\n 88 K/uL\n 253 mg/dL\n 1.9 mg/dL\n 26 mEq/L\n 4.4 mEq/L\n 28 mg/dL\n 108 mEq/L\n 136 mEq/L\n 25.4 %\n 11.3 K/uL\n [image002.jpg]\n 03:11 PM\n 05:58 PM\n 08:48 PM\n 09:33 PM\n 01:17 AM\n 01:43 AM\n 01:59 AM\n 03:07 AM\n 04:27 AM\n 04:44 AM\n WBC\n 11.3\n Hct\n 30.4\n 27.6\n 25.4\n Plt\n 88\n Cr\n 1.9\n TCO2\n 28\n 29\n 30\n 28\n 30\n 29\n 30\n Glucose\n 253\n Other labs: PT / PTT / INR:19.2/77.9/1.8, CK / CKMB /\n Troponin-T:260/9/0.22, ALT / AST:2542/3606, Alk Phos / T Bili:146/0.9,\n Amylase / Lipase:50/19, Differential-Neuts:85.4 %, Band:0.0 %,\n Lymph:8.8 %, Mono:4.1 %, Eos:1.4 %, Lactic Acid:1.9 mmol/L, Albumin:2.7\n g/dL, LDH:1697 IU/L, Ca++:7.0 mg/dL, Mg++:2.0 mg/dL, PO4:4.7 mg/dL\n Microbiology: No new growth\n Assessment and Plan\n 50-year-old man with metastatic renal cell cancer s/p BMT now with\n multiple organ failure\n recrudescent severe shock\n Main differential here is pulmonary embolism (with\n pre-existing severe pulmonary parenchymal and vascular disease and RV\n dysfunction) and sepsis.\n Continue ABX as directed by ID\n Transfuse today given ongoin bleeding, anemia, and relative\n hypovolemia\n recrudescent severe respiratory failure with a very high dead space\n fraction\n Heparinze for\n acute hepatitis (likely ischemic/shock liver)\n Review meds with ID and pharmacy\n GI bleed\n IV PPI twice a day\n Will try to keep heparinized for now, given high risk of death if RIJ\n clot embolized\n acute renal failure (likely ischemic, althoug postrenal is not fully\n excluded)\n acidosis\n thrombocytopenia\n HIT seems unlikely given ongoing prior exposure\n TTP seems unlikely given timing\n Medications (ABX, ??IVIG) certainly possible\n Follow platelets again today. If continues to fall, hold heparin.\n Will discuss with heme/onc and ID today\n Shock\n Etiology here is uncertain. Sepsis is most likely, but PE\n For sepsis\n cover MRSA and VRE, cover ESBL and other resistant GNR\n (change to meropenem and IV quinolone), and for C diff (oral vanco;\n discuss his Flagyl allergy with his prior providers). Will discuss\n antifungal coverage with BMT. Check other cultures. (CMV,\n galactomannan, etc.) Consult ID for advice on antibiotics.\n Check KUB and upright CXR to exclude free air. He is too sick for\n travel and for operation.\n Treat empirically for adrenal insufficiency. Add on cortisol to morning\n labs.\n Check echo. Check EKG since heart rate is relatively low.\n Follow and replete ionized calcium.\n Heparinize empirically for PE. Discuss with BMT whether he would be a\n candidate for lytics if we documented PE (his metastatic disease in the\n spine makes it unlikely).\n Place central line after heparin is held for an hour.\n Respiratory failure\n Esophageal-balloon guided settings for PEEP and driving pressure.\n Has marked respiratory acidosis that seems to be mostly related to high\n dead-space fraction.\n Will try to increase respiratory rate and watch for autoPEEP.\n Bradycardia\n Appears to be a junctional rhythm. Will replete all lytes including\n calcium, etc.\n Try to swap to Levophed for\n Acute renal failure\n Secondary to hemodynamics. Follow for now.\n Acidosis\n Mostly related to respiratory acidosis, although his bicarb has fallen\n over the past days as well.\n Since he has a lactic (and respiratory) acidosis, will hold off on\n bicarbonate for now.\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 20 Gauge - 02:03 PM\n 18 Gauge - 02:03 PM\n PICC Line - 04:30 PM\n Arterial Line - 04:30 AM\n Multi Lumen - 12:05 PM\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: Heparin gtt)\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 :\n Total time spent:\n" }, { "category": "Respiratory ", "chartdate": "2120-05-01 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 324261, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 17\n Ideal body weight: 69.9 None\n Ideal tidal volume: 279.6 / 419.4 / 559.2 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Unknown\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type:\n Size:\n Tracheostomy tube:\n Type: Cuffed\n Manufacturer: Portex\n Size: 8.0mm\n PMV:\n Management:\n Vol/Press:\n pressure: 50 cmH2O\n volume: mL /\n Airway problems: / valve leak\n Comments:\n Lung sounds\n RLL Lung Sounds: Crackles\n RUL Lung Sounds: Crackles\n LUL Lung Sounds: Crackles\n LLL Lung Sounds: Crackles\n Comments:\n Secretions\n Sputum color / consistency: /\n Sputum source/amount: / Scant\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Tachypneic (RR> 35 b/min), High\n flow demand; Comments: Pt is hypoxic on 100% and 6 peep, Pco2 is >85\n and climbing,pH ~ 7-7.1, rr 40, Ptp insp 27-30.\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment: Possible air trapping\n Comments:\n Plan\n Next 24-48 hours: Keep pt as comfortable as possible. Family at bedside\n Reason for continuing current ventilatory support: Intolerant of\n weaning attempts\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n" }, { "category": "Nursing", "chartdate": "2120-04-25 00:00:00.000", "description": "Nursing Progress Note", "row_id": 323730, "text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Trach and PEG placed this AM. Pt. tolerated well. PEG to gravity, able\n to give medications, hold TF until tomorrow. Trach PCV 24 Insp\n Pressure/30 RR/5 PEEP/50% FiO2\n Pt has persistent air leak, and will be re-assessed tomorrow by IP\n Action:\n ABG done, Propofol decreased to 30 mcg/kg/min\n Response:\n ABG: 7.49/34/127, pt. more awake, moving extremeities on bed. Does not\n follow commands\n Plan:\n Continue to wean sedation to encourage pt. participation in weaning\n from ventilation. Continue Methadone 20mg q4h, fent and ativan boluses\n prn agitation.\n" }, { "category": "Nursing", "chartdate": "2120-04-16 00:00:00.000", "description": "Nursing Progress Note", "row_id": 322643, "text": "Pt w/ hx of Renal Ca, and Pulmonary Fibrosis on home 02 (see FHP for\n further PMH) experienced worsening of chronic dyspnea for past \n weeks. Over past several days self treated with inhalers with no\n relief. Brought himself to OSH ER and was admitted. Became hypotensive\n and hypoxic. Initially supported with NIMV and levophed gtt. Pt\n transferred to per pts request via . Pt was electively\n intubated, and levophed gtt d/c\nd prior to transport and received 1.5 L\n IVF en route for hypotension.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Currently on PCV, rate 32, PEEP 18 100% FiO2. Frequent ABG\ns being\n drawn. LS = crackles, diminished at bases. Pt appears comfortable\n with regular breathing pattern. Sats 90-95%.\n Sedated on fent/midaz gtt\n Action:\n Mult vent changes and ABG\ns drawn.\n Response:\n Most recent ABG 7.17/55/78/- on above settings\n Plan:\n Con\nt to monitor ABG\ns and resp status and wean vent as tolerated.\n Sepsis, Severe (with organ dysfunction)\n Assessment:\n Pt arrived with sbp 120\ns, HR 120\ns. Afebrile. WBC 20.8\n Action:\n Lopressor 5mg IV given MD order and sbp down to 70\ns, HR down to\n 70\ns-80\ns in NSR. Urine legionella sent, urine cx sent, blood cx\n sent. Pt bloused with total of 3L NS in addition to the 1.5L received\n at OSH.\n Response:\n BP up to 80\ns but back down to high 70\ns so started on Levo IV. SBP up\n to 100\ns on 0.08mcg/kg/min.\n Plan:\n Con\nt to monitor BP and maintain MAP >65\n" }, { "category": "Nursing", "chartdate": "2120-04-16 00:00:00.000", "description": "Nursing Progress Note", "row_id": 322644, "text": "Pt w/ hx of Renal Ca, and Pulmonary Fibrosis on home 02 (see FHP for\n further PMH) experienced worsening of chronic dyspnea for past \n weeks. Over past several days self treated with inhalers with no\n relief. Brought himself to OSH ER and was admitted. Became hypotensive\n and hypoxic. Initially supported with NIMV and levophed gtt. Pt\n transferred to per pts request via . Pt was electively\n intubated, and levophed gtt d/c\nd prior to transport and received 1.5 L\n IVF en route for hypotension.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Currently on PCV, rate 32, PEEP 18 100% FiO2. Frequent ABG\ns being\n drawn. LS = crackles, diminished at bases. Pt appears comfortable\n with regular breathing pattern. Sats 90-95%.\n Sedated on fent/midaz gtt\n Action:\n Mult vent changes and ABG\ns drawn.\n Response:\n Most recent ABG 7.17/55/78/- on above settings\n Plan:\n Con\nt to monitor ABG\ns and resp status and wean vent as tolerated.\n Sepsis, Severe (with organ dysfunction)\n Assessment:\n Pt arrived with sbp 120\ns, HR 120\ns. Afebrile. WBC 20.8\n Action:\n Lopressor 5mg IV given MD order and sbp down to 70\ns, HR down to\n 70\ns-80\ns in NSR. Urine legionella sent, urine cx sent, blood cx\n sent. Pt bolused with total of 3L NS in addition to the 1.5L received\n at OSH.\n Central line and aline placed overnight.\n Response:\n BP up to 80\ns but back down to high 70\ns so started on Levo IV. SBP up\n to 100\ns on 0.08mcg/kg/min.\n Plan:\n Con\nt to monitor BP and maintain MAP >65\n" }, { "category": "General", "chartdate": "2120-04-17 00:00:00.000", "description": "Generic Note", "row_id": 322751, "text": "TITLE:Resp Care Note, Pt remains on current vent settings. See vent\n flow sheet for details. Paralyzed and sedated with fentanyl and\n midazolam.Unable to do RSBI due to high vent settings.Will cont to\n monitor resp status\n" }, { "category": "Nursing", "chartdate": "2120-04-26 00:00:00.000", "description": "Nursing Progress Note", "row_id": 323849, "text": "Pt is a 50 yo M with metastatic renal cell CA s/p allo- SCT with\n subsequent severe chronic resp failure thought to be emphysema and\n fibrosis of unclear etiology (CT from last spring demonstrates severe\n cystic and fibrotic changes with almost no normal appearing lung).\n Admitted w/ catastrophic acute on chronic failure and severe shock,\n initially presumed septic but more predominantly cardiogenic. Was on\n high dose steroids, tapering prednisone and now off.\n Arterial line inadvertently pulled out this AM. Team did not want to\n replace, will draw ABGs prn.\n Pt rec\nd trach & PEG on ; cuff leak persistent, even w/ large\n volume inflation. IP aware, will reassess on Monday. Note increasing\n WBC to 15 this am. Pt currently on Vanc, Zosyn, Levaquin, Acyclovir\n and qod Bactrim. Blood, urine, sputum cultures sent.\n TF restarted at noon, increased to 30mL/hr at 1600. Goal 65 mL/hr.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n LS clear to rhoncorous. Pressure control RR 30/Peep 5/FiO2 50%/insp\n P24cm, Propofol reduced to 20mcg/kg/min\n Action:\n Trial of PS, 10 PS/5 PEEP, pt tolerated well for 20 minutes, propofol\n shut off, pt became increasingly uncomfortable and agitated, desats\n into low 80\ns with coughing. Subglottal sxn and deep suction by RN and\n RT multiple times for small amount of thick bloody secretions. ABG:\n 7.38/49/67\n Response:\n Put back on PCV RR 30/PEEP 5/ FiO2 50%/ insp P 24, Propofol increased\n to 30mcg/kg/min. Sats 88-90%, increased FiO2 to 60%, sats increased to\n 94%.\n Plan:\n Continue to wean from vent as tolerated. Consider another trial of PS\n when patient is able to tolerate being more awake.\n Hypotension (not Shock)\n Assessment:\n During trial of PS patient became hypotensive SBP 77-83, note: pt.\n fluid negative for past few days\n Action:\n 2.5 L NS given over 2 hrs.\n Response:\n Good response SBP increased to 95-117. SBP dropped again to 83 at 1700,\n 500 mL NS given, SBP 102, MAP 73\n Plan:\n Team aware, will follow closely. If BP falls again, will bolus with\n fluid. Follow I/O closely, assess for intravascular dryness. Goal mean\n >65\n" }, { "category": "Nursing", "chartdate": "2120-04-28 00:00:00.000", "description": "Nursing Progress Note", "row_id": 324028, "text": "Hypotension (not Shock)\n Assessment:\n Pt continues w;/ borderline BP this shift. Continues on vanc, zosyn and\n levofloxacin. Pt has remained afebrile overnoc per report.\n Action:\n Monitoring hemodynamic status closely w/ continuous BP via a-line.\n Monitoring temp. Administering abx as ordered.\n Response:\n SBP 85-90\ns, trending down to 77-85. Pt given total 2L NS bolus w/\n moderate response. Pt continues w/ increased agitation and becomes\n significantly dysynchronous w/ vent when propofol dose titrated down.\n SBP now remains 85-95. Team aware. Tmax 101.4 this shift. RIJ was D/C\n and tip sent for culture. Blood and urine samples also sent for\n culture.\n Plan:\n Continue to monitor hemodynamic status closely. Continue to monitor\n temp and administer abx as ordered. Propofol has now been changed to\n versed gtt. Pt has also been given additional NS 500ml bolus. Plan to\n titrate versed to achieve adequate sedation as BP allows. Anticipate\n need for pressors if pt remains hypotensive.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt remains vented on Pressure control 24/5 X 30 FiO2 60%. Per report pt\n has failed previous PS trials.\n Action:\n No change in vent settings this shift. SpO2 remains stable 90-92% when\n pt adequately sedated. Titrating sedation according to hemodynamic\n status and level of sedation. Monitor respiratory status closely.\n Response:\n BBS tubular to course t/o. Occasional snx for only small amounts of\n thick white secretions. Pt has had a substantial amount of subglotic\n secretions and has been receiving frequent subglotal snx. Pt has also\n had high gastric residuals and TF have been held through most of shift.\n Bowel sounds initially hypoactive, and now normoactive. Pt continues on\n reglan as ordered.\n Plan:\n Continue to follow respiratory assessment closely. Plan for IP to\n further eval cuff leak tomorrow w/ possible plan to change trach.\n Continue pulmonary toilet. Propofol changed to versed as above. Titrate\n sedation to facilitate ventilation. If pt remains hypoxic anticipate\n chest CT to r/o PE.\n" }, { "category": "Nursing", "chartdate": "2120-04-16 00:00:00.000", "description": "Nursing Progress Note", "row_id": 322641, "text": "Pt experienced worsening of chronic dyspnea X 2-3 weeks. Over past \n days self treated with inhalers with no relief. Brought himself to OSH\n ER. Hypotensive and hypoxic at OSH. Started on Levo. Arrived from\n OSH with Levo off and intubated. BP stable.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Currently on PCV, rate 32, PEEP 18 100% FiO2. Frequent ABG\ns being\n drawn. LS = crackles, diminished at bases. Pt appears comfortable\n with regular breathing pattern. Sats 90-95%.\n Action:\n Mult vent changes and ABG\ns drawn.\n Response:\n Most recent ABG 7.17/55/78/- on above settings\n Plan:\n Con\nt to monitor ABG\ns and resp status and wean vent as tolerated.\n Sepsis, Severe (with organ dysfunction)\n Assessment:\n Pt arrived with sbp 120\ns, HR 120\ns. Afebrile. WBC 20.8\n Action:\n Lopressor 5mg IV given MD order and sbp down to 70\ns, HR down to\n 70\ns-80\ns in NSR. Urine legionella sent, urine cx sent, blood cx\n sent. Pt bloused with total of 3L NS in addition to the 1.5L received\n at OSH.\n Response:\n BP up to 80\ns but back down to high 70\ns so started on Levo IV. SBP up\n to 100\ns on 0.08mcg/kg/min.\n Plan:\n Con\nt to monitor BP and maintain MAP >65\n" }, { "category": "Physician ", "chartdate": "2120-04-18 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 322914, "text": "Chief Complaint:\n 24 Hour Events:\n Allergies:\n Flagyl (Oral) (Metronidazole)\n Rash;\n Last dose of Antibiotics:\n Levofloxacin - 10:04 AM\n Vancomycin - 07:35 PM\n Bactrim (SMX/TMP) - 11:39 PM\n Acyclovir - 12:16 AM\n - 03:59 AM\n Piperacillin/Tazobactam (Zosyn) - 06:08 AM\n Infusions:\n Dobutamine - 1.5 mcg/Kg/min\n Midazolam (Versed) - 6 mg/hour\n Fentanyl - 400 mcg/hour\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 07:41 PM\n Famotidine (Pepcid) - 08:30 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:23 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.9\n Tcurrent: 36.1\nC (97\n HR: 67 (56 - 96) bpm\n BP: 117/60(76) {89/58(69) - 152/77(99)} mmHg\n RR: 34 (30 - 34) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 76.3 kg (admission): 76.3 kg\n Height: 68 Inch\n CVP: 17 (10 - 25)mmHg\n CO/CI (CCO): (4.7 L/min) / (2.5 L/min/m2)\n Total In:\n 6,194 mL\n 820 mL\n PO:\n TF:\n 890 mL\n 46 mL\n IVF:\n 4,814 mL\n 739 mL\n Blood products:\n Total out:\n 2,395 mL\n 2,690 mL\n Urine:\n 1,845 mL\n 2,580 mL\n NG:\n 550 mL\n 110 mL\n Stool:\n Drains:\n Balance:\n 3,799 mL\n -1,870 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: PCV+Assist\n PC : 24 cmH2O\n RR (Set): 34\n PEEP: 14 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10\n PIP: 38 cmH2O\n Plateau: 36 cmH2O\n SpO2: 96%\n ABG: 7.36/39/95./21/-2\n Ve: 15.9 L/min\n PaO2 / FiO2: 192\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 124 K/uL\n 11.3 g/dL\n 99 mg/dL\n 1.1 mg/dL\n 21 mEq/L\n 4.6 mEq/L\n 19 mg/dL\n 110 mEq/L\n 139 mEq/L\n 33.6 %\n 12.3 K/uL\n [image002.jpg]\n 06:59 PM\n 09:54 PM\n 11:52 PM\n 04:37 AM\n 04:52 AM\n 08:05 PM\n 10:19 PM\n 12:20 AM\n 04:38 AM\n 05:01 AM\n WBC\n 13.1\n 12.3\n Hct\n 35.4\n 33.6\n Plt\n 119\n 124\n Cr\n 1.1\n 1.1\n TropT\n 0.22\n TCO2\n 23\n 21\n 21\n 20\n 21\n 22\n 22\n 23\n Glucose\n 164\n 179\n 174\n 99\n Other labs: PT / PTT / INR:14.9/28.9/1.3, CK / CKMB /\n Troponin-T:260/9/0.22, ALT / AST:94/64, Alk Phos / T Bili:84/0.3,\n Amylase / Lipase:53/22, Differential-Neuts:67.0 %, Band:2.0 %,\n Lymph:18.0 %, Mono:9.0 %, Eos:0.0 %, Lactic Acid:1.7 mmol/L,\n Albumin:2.7 g/dL, LDH:274 IU/L, Ca++:8.1 mg/dL, Mg++:2.2 mg/dL, PO4:1.6\n mg/dL\n Assessment and Plan\n 50M h/o metastatic renal CA s/p nephrectomy, IL-2, mini-allograft SCT,\n DLI x 2 last in , emphysema/pulmonary fibrosis on home 02 presents\n with sepsis.\n # Sepsis: On presentation to OSH pt hypotensive, hypoxic with fevers\n and leukocytosis. Now with hypoxic respiratory failure, requiring\n pressors. Likely pneumonia given hypoxia and possible opacities on\n CXR, although difficult to read due to fibrosis. No other apparent\n localizing symptoms. Ruled-out for flu at OSH. Urine, GI sources less\n probable. Given immunocompromise from malignancy, at risk for PCP,\n , etc. Progression of GVHD could be contributing. Given tenuous\n respiratory status and requirments for high levels of PEEP a\n bronchoscopy would be too high risk for BAL and culture data.\n - Will attempt to obtain deep ET sputum for culture\n - legionella urine ag negative, all other cultures no growth to date.\n - Vanc, zosyn, levofloxacin, bactrim IV for PCP, to cover\n broadly for now given critical illness. Iv steroids for PCP and\n adrenal insufficiency as below.\n - glucan, galactomannan pending\n - CT chest and possible bronch when more stable\n - Follow WBC count, fever curve\n - PPD to be read \n # Respiratory failure: Pneumonia in patient with poor pulmonary reserve\n due to emphysema, ?GVHD, fibrosis. Avoid high pressures given fibrotic\n lungs, using pressure control ventilation. Tolerated decrease in Fi02\n from 100% to 60% yesterday, oxygenating well.\n -continue to wean FI02\n -will d/c cisatracurium infusion and use boluses as needed for\n paralysis should pt be dysynchronous with ventilator, otherwise will\n continue to manage sedation/pain with fentanyl/versed, increasing gtt\n as needed.\n - Continue mechanical ventilatory support, wean as tolerated\n -No proning for now as pt oxygenating well.\n # Hypotension: Likely sepsis, although probably component of\n hypovolemia as well. At risk for PE given malignancy. GI bleed unlikely\n as Hct stable. Adrenal insufficiency possible given s/p adrenelectomy\n with mets in remaining adrenal. Pt has dysfunctional RV with severe\n likely contributing to low CO. Set up vigileo device yesterday\n for non-invasive hemodynamic monitoring. Initially CI was 2.8, this am\n 1.8, a concerning decrease. His SV variability is low, indicating\n minimal fluid responsiveness.\n - start dobutamine in an attempt to increase CO, titrate to goal CO >4,\n CI >2.5, maintain on vasopressin and levophed. Monitor pressors if\n becomes hypotensive due to vasodilitory effect will discontinue.\n - No prostacyclin/NO for now due to concern that may increase mismatch\n and worsen hypoxia.\n - Consider PA catheter placement for more accurate hemodynamic\n monitoring, will continue to use vigileo for now.\n - Treat broadly for infection per above\n - IV hydrocort Q6 for adrenal insufficiency\n - LENIs to look for DVT negative.\n - Guaiac stools, HCT has been stable.\n # Cardiac: Patient with probable demand ischemia in setting of\n hypotension, tachycardia, and sepsis; less likely unstable plaque.\n - CE\ns this am trending down\n - ASA, hold on beta-blocker and statin\n - Repeat ECG in am\n # Metastatic renal CA: Recurrent disease s/p donor lymphocyte\n transplant .\n - BMT to follow\n - Avoid steroids given risk to graft\n - Continue acyclovir ppx for now, will discuss with BMT\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 11:24 PM\n Arterial Line - 12:14 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": "2120-04-26 00:00:00.000", "description": "Nursing Progress Note", "row_id": 323829, "text": "Pt is a 50 yo M with metastatic renal cell CA s/p allo- SCT with\n subsequent severe chronic resp failure thought to be emphysema and\n fibrosis of unclear etiology (CT from last spring demonstrates severe\n cystic and fibrotic changes with almost no normal appearing lung).\n Admitted w/ catastrophic acute on chronic failure and severe shock,\n initially presumed septic but more predominantly cardiogenic. Was on\n high dose steroids, tapering prednisone and now off.\n Arterial line inadvertently pulled out this AM. Team did not want to\n replace, will draw ABGs prn.\n Pt rec\nd trach & PEG on ; cuff leak persistent, even w/ large\n volume inflation. IP aware, will reassess on Monday. Note increasing\n WBC to 15 this am. Pt currently on Vanc, Zosyn, Levaquin, Acyclovir\n and qod Bactrim. Blood, urine, sputum cultures sent.\n TF restarted at noon, increased to 30mL/hr at 1600. Goal 65 mL/hr.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n LS clear to rhoncorous. Pressure control RR 30/Peep 5/FiO2 50%/insp\n P24cm, Propofol reduced to 20mcg/kg/min\n Action:\n Trial of PS, 10 PS/5 PEEP, pt tolerated well for 20 minutes, propofol\n shut off, pt became increasingly uncomfortable and agitated, desats\n into low 80\ns with coughing. Subglottal sxn and deep suction by RN and\n RT multiple times for small amount of thick bloody secretions. ABG:\n 7.38/49/67\n Response:\n Put back on PCV RR 30/PEEP 5/ FiO2 50%/ insp P 24, Propofol increased\n to 30mcg/kg/min. Sats 88-90%, increased FiO2 to 60%, sats increased to\n 94%\n Plan:\n Continue to wean from vent as tolerated. Consider another trial of PS\n when patient is able to tolerate being more awake.\n Hypotension (not Shock)\n Assessment:\n During trial of PS patient became hypotensive SBP 77-83, note: pt.\n fluid negative for past few days\n Action:\n 2.5 L NS given over 2 hrs.\n Response:\n Good response SBP increased to 95-117\n Plan:\n Follow I/O closely, assess for intravascular dryness. Goal mean >75\n" }, { "category": "Physician ", "chartdate": "2120-04-26 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 323831, "text": "Chief Complaint: hypoxemic resp failure\n HPI:\n 50 yo M with metastatic renal cell CA s/p allo- SCT with subsequent\n severe chronic resp failure thought to be emphysema and fibrosis of\n unclear etiology (CT from last spring demonstrates severe cystic and\n fibrotic changes with almost no normal appearing lung) presented with 2\n wk prodrome, presented with catastrophic acute on chronic failure. CXR\n shows diffuse opacification c/w ARDS. Severe shock, initially presumed\n septic but more predominantly cardiogenic. RV with global hypokinesis,\n dilated, mod-sev PAH. Responded well to dobutamine. Was on high dose\n steroids, tapering prednisone and now 40PO qd.\n 24 Hour Events:\n PEG INSERTION - At 09:45 AM\n PERCUTANEOUS TRACHEOSTOMY - At 10:10 AM\n s/p trach/PEG, trach w/persistent air leak- IP to change today\n beta glucan and galactomannan negative so caspo d/c'd\n tolerating peep 5\n PCV 20/5 x30 (breathes up to 40 when awake), FiO2 0.5\n propofol gtt 20 (HTN, tachy when propofol shut off this am)\n mehtadone 20mg q4hrs\n intermittent 1mg ativan boluses for agitation\n Allergies:\n Flagyl (Oral) (Metronidazole)\n Rash;\n Last dose of Antibiotics:\n Caspofungin - 09:28 PM\n Piperacillin/Tazobactam (Zosyn) - 05:30 AM\n Acyclovir - 08:15 AM\n Vancomycin - 08:16 AM\n Levofloxacin - 08:16 AM\n Bactrim (SMX/TMP) - 08:16 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:00 PM\n Lorazepam (Ativan) - 06:20 AM\n Famotidine (Pepcid) - 08:16 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 11:09 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.2\nC (100.8\n Tcurrent: 38.2\nC (100.8\n HR: 88 (48 - 117) bpm\n BP: 106/73(79) {106/72(50) - 164/94(111)} mmHg\n RR: 30 (12 - 34) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 76.3 kg (admission): 76.3 kg\n Height: 68 Inch\n CVP: 7 (7 - 14)mmHg\n Total In:\n 2,694 mL\n 1,017 mL\n PO:\n TF:\n 26 mL\n IVF:\n 2,279 mL\n 822 mL\n Blood products:\n Total out:\n 4,950 mL\n 1,765 mL\n Urine:\n 4,950 mL\n 1,465 mL\n NG:\n 300 mL\n Stool:\n Drains:\n Balance:\n -2,256 mL\n -748 mL\n Respiratory support\n Ventilator mode: PCV+\n Vt (Set): 500 (500 - 500) mL\n PC : 20 cmH2O\n RR (Set): 30\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI Deferred: Unstable Airway\n PIP: 25 cmH2O\n Plateau: 25 cmH2O\n SpO2: 94%\n ABG: 7.49/34/127/26/3\n Ve: 13.8 L/min\n PaO2 / FiO2: 254\n Physical Examination\n General Appearance: No acute distress\n Lymphatic: trach in place\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: Symmetric), coarse BS anteriorly b/l\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended,\n g-tube site ok\n Extremities: Right: Absent, Left: Absent\n Skin: Not assessed, No(t) Rash:\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed, opens eyes/orients to voice, does not follow commands\n Labs / Radiology\n 11.4 g/dL\n 159 K/uL\n 65 mg/dL\n 1.0 mg/dL\n 26 mEq/L\n 3.5 mEq/L\n 17 mg/dL\n 108 mEq/L\n 141 mEq/L\n 34.0 %\n 15.0 K/uL\n [image002.jpg]\n 04:48 AM\n 11:19 AM\n 01:45 PM\n 08:13 PM\n 10:07 PM\n 04:05 AM\n 04:29 AM\n 03:23 PM\n 06:00 PM\n 04:43 AM\n WBC\n 13.6\n 15.0\n Hct\n 31.6\n 34.0\n Plt\n 149\n 159\n Cr\n 0.9\n 1.0\n 1.0\n TCO2\n 35\n 36\n 36\n 34\n 35\n 27\n Glucose\n 93\n 70\n 76\n 65\n Other labs: PT / PTT / INR:13.7/42.1/1.2, CK / CKMB /\n Troponin-T:260/9/0.22, ALT / AST:57/31, Alk Phos / T Bili:70/0.4,\n Amylase / Lipase:53/22, Differential-Neuts:67.0 %, Band:2.0 %,\n Lymph:18.0 %, Mono:9.0 %, Eos:0.0 %, Lactic Acid:2.0 mmol/L,\n Albumin:2.6 g/dL, LDH:272 IU/L, Ca++:8.6 mg/dL, Mg++:2.2 mg/dL, PO4:2.6\n mg/dL\n Assessment and Plan\n 50 yo man with metastatic renal cell CA s/p allo- SCT with subsequent\n severe chronic resp failure thought to be emphysema and fibrosis of\n unclear etiology (CT from last spring demonstrates severe cystic and\n fibrotic changes with almost no normal appearing lung) presented with 2\n wk prodrome, presented with catastrophic acute on chronic failure. CXR\n shows diffuse opacification c/w ARDS. Severe shock, initially presumed\n septic but more predominantly cardiogenic. RV with global hypokinesis,\n dilated, mod-sev PAH. Responded well to dobutamine. Was on high dose\n steroids, now tappered off.\n Slowly improving.\n Abx: Vanco/Levoflox/Zosyn/bactrim and acyclovir prophylaxis\n #CARDIOGENIC SHOCK-resolved, PAH, RV FAILURE\n Stable on increased dose captopril for afterload reduction, mildly\n hypertensive. Autodiuresing. Rpt TTE in a couple of weeks.\n #Hypoxemic resp failure s/p trach, to be changed today given cuff\n leak. Tolerating wean of driving pressure and peep. PS trial post\n trach change today.\n No sig changes on vent today, given s/p trach this morning and on PEEP\n 10.\n #INFECTION\n D10/14 empiric vanc/zosyn/levoflox, also on prophylactic bactrim and\n acyclovir. Febrile this am- pan cx.\n #Sedation\n Off fentanyl and versed. Continues on propofol and methadone w/bolus\n ativan as needed for pain/agitation. Cont to wean propofol. Will\n decrease methadone to q6 then q8, after come down further on propofol.\n QTc okay. TG fine on propofol, check BIW.\n #NUTRITION\n Resume TF today\n HepSC, ranitidine, oral care, pneumoboots, HOB up.\n Patient is critically ill.\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Multi Lumen - 11:24 PM\n Prophylaxis:\n DVT: SQ UF Heparin\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\n" }, { "category": "Nursing", "chartdate": "2120-04-26 00:00:00.000", "description": "Nursing Progress Note", "row_id": 323837, "text": "Pt is a 50 yo M with metastatic renal cell CA s/p allo- SCT with\n subsequent severe chronic resp failure thought to be emphysema and\n fibrosis of unclear etiology (CT from last spring demonstrates severe\n cystic and fibrotic changes with almost no normal appearing lung).\n Admitted w/ catastrophic acute on chronic failure and severe shock,\n initially presumed septic but more predominantly cardiogenic. Was on\n high dose steroids, tapering prednisone and now off.\n Arterial line inadvertently pulled out this AM. Team did not want to\n replace, will draw ABGs prn.\n Pt rec\nd trach & PEG on ; cuff leak persistent, even w/ large\n volume inflation. IP aware, will reassess on Monday. Note increasing\n WBC to 15 this am. Pt currently on Vanc, Zosyn, Levaquin, Acyclovir\n and qod Bactrim. Blood, urine, sputum cultures sent.\n TF restarted at noon, increased to 30mL/hr at 1600. Goal 65 mL/hr.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n LS clear to rhoncorous. Pressure control RR 30/Peep 5/FiO2 50%/insp\n P24cm, Propofol reduced to 20mcg/kg/min\n Action:\n Trial of PS, 10 PS/5 PEEP, pt tolerated well for 20 minutes, propofol\n shut off, pt became increasingly uncomfortable and agitated, desats\n into low 80\ns with coughing. Subglottal sxn and deep suction by RN and\n RT multiple times for small amount of thick bloody secretions. ABG:\n 7.38/49/67\n Response:\n Put back on PCV RR 30/PEEP 5/ FiO2 50%/ insp P 24, Propofol increased\n to 30mcg/kg/min. Sats 88-90%, increased FiO2 to 60%, sats increased to\n 94%\n Plan:\n Continue to wean from vent as tolerated. Consider another trial of PS\n when patient is able to tolerate being more awake.\n Hypotension (not Shock)\n Assessment:\n During trial of PS patient became hypotensive SBP 77-83, note: pt.\n fluid negative for past few days\n Action:\n 2.5 L NS given over 2 hrs.\n Response:\n Good response SBP increased to 95-117. SBP dropped again to 83 at 1700,\n 500 mL NS given\n Plan:\n Follow I/O closely, assess for intravascular dryness. Goal mean >75\n" }, { "category": "Respiratory ", "chartdate": "2120-04-26 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 323845, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 12\n Ideal body weight: 69.9 None\n Ideal tidal volume: 279.6 / 419.4 / 559.2 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation:\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type:\n Size:\n Tracheostomy tube:\n Type: Standard\n Manufacturer: Portex\n Size: 8.0mm\n PMV: No\n Management:\n Vol/Press:\n pressure: 50 cmH2O\n volume: mL /\n Airway problems: / valve leak\n Comments:\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Crackles\n LUL Lung Sounds: Crackles\n LLL Lung Sounds: Clear\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: when sedated\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: When sedated, pt is synchronous. When awake pt is anxious,\n tachypnaic and tachycardic.\n Plan\n Next 24-48 hours: Plan is to keep pt stabalized until trach can be\n changed to address leak.\n Reason for continuing current ventilatory support: Intolerant of\n weaning attempts\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n PSV was attempted, but pt had episodes of desat. Pt returned to PCV\n and FiO2 raised to 60%.\n" }, { "category": "General", "chartdate": "2120-04-16 00:00:00.000", "description": "ICU Event Note", "row_id": 322732, "text": "Clinician: Attending\n Met again with pt's wife, , in presence of pulm fellow Dr \n . Discussed our continued aggressive support and his critical\n though currently stable status. Discussed appropriateness of DNR given\n the lack of reversibility of any cause of cardiac arrest or lethal\n arrhythmia, including pneumothorax or PEA from hypoxemia. I also\n discussed this with Dr , who told me to tell that\n he agreed that DNR was appropriate.\n Total time spent: 30 minutes\n Patient is critically ill.\n" }, { "category": "Physician ", "chartdate": "2120-04-18 00:00:00.000", "description": "ICU Attending Note", "row_id": 322926, "text": "Clinician: Attending\n Clinician: Attending\n 50 yo man with metastatic renal cell CA s/p allo- SCT with subsequent\n severe chronic resp failure thought to be emphysema and fibrosis of\n unclear etiology (CT from last spring demonstrates severe cystic and\n fibrotic changes with almost no normal appearing lung) presented with 2\n wk prodrome, now with catastrophic acute on chronic failure. CXR shows\n diffuse opacification. Severe septic shock. RV with global hypokinesis,\n dilated, mod-sev PAH. Trop peaked at 1.98 at OSH, highest here was\n 0.49.\n Events:\n PEEP decreased from 16 to 14 and FiO2 decreased to 0.5.\n Stopped paralysis yest morning.\n Started Dobutamine and able to wean off levophed and vasopressin. Good\n urine output, > 200cc/h.\n Esoph balloon indicates transpulm pressure 15 and 4 mmHg, then dropped\n PEEP from 21 to 10 and end exp transpulm pressure approx 1mmHg.\n - Cardiac index 2.5, approximately, based on vigileo, on\n Dobutamine 1.5 mcg/kg/min\n - Remains afebrile\n - Stroke volume variability approx 10%, indicating adequately\n volume repleted (and possibly overloaded)\n - I/O 6L/2.3L (3.8+)\n - PCV FiO2 0.5/24/PEEP 14/RR 34/ TV 550ish 7.36/39/96\n - WBC 20\n - HCO3 22\n - LDH from \n Fent/Versed. H2blocker, hepsc, hydrocortisone 50mg q 6h, aspirin\n Abx: Vanco/Levoflox/Vanco/Acyclovir/Bactrim/Caspofungin\n Admitted with what appeared to be septic picture, but now cardiogenic\n shock predominates.\n SEPTIC SHOCK\n Most likely source pneumonia. R/O for influenza at OSH.\n Cx pending. Markers pending.\n Very broad coverage. Bronch will allow us to d/c PCP coverage if neg.\n Bronch today to r/o PCP and will stop Bactrim if bronch and beta-glucan\n are neg.\n If beta-glucan and galactomannan are neg will plan to d/c caspofungin.\n RESP FAILURE\n Infection, sepsis, acute exacerbation of underlying chronic disease as\n well as cardiogenic shock, with severe PH and impaired LV filling and\n outflow.\n - reduce PEEP\n - switch from PC to AC vent if possible\n HYPOTENSION\n Septic and cardiogenic shock and RV failure. Has one adrenal gland with\n metastatic lesion.\n Fluid resuscitation. Received high dose steroids at OSH. Continuing\n high dose hydrocortisone for adrenal insufficiency (and for PCP\n ).\n CARDIAC\n Severe PH with hypokinetic and dilated RV.\n Will continue Dobutamine, adding ACE for afterload reduction. Urine\n output is high at the moment, but if net +++ will consider adding Lasix\n gtt.\n Aspirin.\n SEDATION with fent 400 /versed 6. Will try to taper after transition\n from PCV to AC.\n other issues per Dr note.\n Will meet with to update her on developments.\n Total time spent: 50 minutes\n Patient is critically ill.\n" }, { "category": "Physician ", "chartdate": "2120-04-19 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 322998, "text": "Chief Complaint:\n 24 Hour Events:\n -dysynchronous on vent after rounds when on SIMV, put back on pressure\n control with normalization of ABG. Did well for most of the day.\n Overnight had mucous plugging with suctioning of sm amount thick\n sputum, after which pt transiently became dyscynchronous requiring\n increased sedation. PEEP increased to 12 from 10, Fi02 increased from\n 40% to 50%, driving pressure increased from 13 to 16, although down\n from 24 yesterday am.\n -decreased SVR, increased CO/CI after initiating ACEI, trial of\n decreasing dobutamine.\n -great UOP 100-200 cc/hour, no lasix for now\n -KUB read, no SBO\n Allergies:\n Flagyl (Oral) (Metronidazole)\n Rash;\n Last dose of Antibiotics:\n Levofloxacin - 10:14 AM\n Acyclovir - 04:30 PM\n Vancomycin - 08:15 PM\n Piperacillin/Tazobactam (Zosyn) - 10:13 PM\n Bactrim (SMX/TMP) - 12:02 AM\n - 03:58 AM\n Infusions:\n Dobutamine - 1 mcg/Kg/min\n Midazolam (Versed) - 12 mg/hour\n Fentanyl - 500 mcg/hour\n Other ICU medications:\n Famotidine (Pepcid) - 07:43 PM\n Heparin Sodium (Prophylaxis) - 09:00 PM\n Other medications:\n ISS\n ASA 325mg daily\n Docusate\n Chlorhexidine\n Folic Acid\n Hydrocortisone 50mg IV Q6\n Captopril 6.25 Po TID\n Senna\n PRN:\n Albuterol\n Bisacodyl\n Acetaminophen\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:28 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.4\nC (97.5\n Tcurrent: 35.9\nC (96.6\n HR: 74 (54 - 101) bpm\n BP: 142/70(92) {117/57(76) - 155/75(98)} mmHg\n RR: 34 (30 - 34) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 76.3 kg (admission): 76.3 kg\n Height: 68 Inch\n CVP: 18 (15 - 41)mmHg\n CO/CI (CCO): (6.8 L/min) / (3.6 L/min/m2)\n Total In:\n 4,090 mL\n 1,462 mL\n PO:\n TF:\n 163 mL\n IVF:\n 3,555 mL\n 1,104 mL\n Blood products:\n Total out:\n 6,200 mL\n 820 mL\n Urine:\n 6,090 mL\n 820 mL\n NG:\n 110 mL\n Stool:\n Drains:\n Balance:\n -2,110 mL\n 642 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: PCV+Assist\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 260 (260 - 260) mL\n PC : 16 cmH2O\n PS : 5 cmH2O\n RR (Set): 34\n PEEP: 12 cmH2O\n FiO2: 50%\n PIP: 39 cmH2O\n Plateau: 30 cmH2O\n SpO2: 96%\n ABG: 7.39/40/113//0\n Ve: 15.4 L/min\n PaO2 / FiO2: 226\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 124 K/uL\n 11.3 g/dL\n 99 mg/dL\n 1.1 mg/dL\n 21 mEq/L\n 4.6 mEq/L\n 19 mg/dL\n 110 mEq/L\n 139 mEq/L\n 33.6 %\n 12.3 K/uL\n [image002.jpg]\n 12:20 AM\n 04:38 AM\n 05:01 AM\n 11:22 AM\n 12:10 PM\n 02:14 PM\n 08:25 PM\n 10:25 PM\n 03:04 AM\n 04:46 AM\n WBC\n 12.3\n Hct\n 33.6\n Plt\n 124\n Cr\n 1.1\n TCO2\n 22\n 23\n 23\n 23\n 22\n 23\n 24\n 26\n 25\n Glucose\n 99\n Other labs: PT / PTT / INR:14.9/28.9/1.3, CK / CKMB /\n Troponin-T:260/9/0.22, ALT / AST:94/64, Alk Phos / T Bili:84/0.3,\n Amylase / Lipase:53/22, Differential-Neuts:67.0 %, Band:2.0 %,\n Lymph:18.0 %, Mono:9.0 %, Eos:0.0 %, Lactic Acid:1.7 mmol/L,\n Albumin:2.7 g/dL, LDH:274 IU/L, Ca++:8.1 mg/dL, Mg++:2.2 mg/dL, PO4:1.6\n mg/dL\n Assessment and Plan\n 50M h/o metastatic renal CA s/p nephrectomy, IL-2, mini-allograft SCT,\n DLI x 2 last in , emphysema/pulmonary fibrosis on home 02\n presented to OSH with hypoxic respiratory failure, fevers and\n hypotension.\n # Severe septic shock: On presentation to OSH pt hypotensive, hypoxic\n with fevers and leukocytosis. On arrival to ICU was intubated due\n to hypoxic respiratory failure and hypotensive requiring pressors.\n Likely pneumonia given hypoxia and possible opacities on CXR, although\n difficult to read due to fibrosis. No other apparent localizing\n symptoms. Ruled-out for flu at OSH. Urine, GI sources less probable.\n Given immunocompromise from malignancy, at risk for PCP, , etc.\n Progression of GVHD could be contributing.\n - Will attempt to obtain deep ET sputum for culture\n - legionella urine ag negative, all other cultures no growth to date.\n - Vanc, zosyn, levofloxacin, bactrim IV for PCP, to cover\n broadly for now given critical illness. Iv steroids for PCP and\n adrenal insufficiency as below.\n - glucan, galactomannan pending for ? PCP, \n Unclear benefit of bronch for BAL at this point given duration of\n antimicrobial treatment and pt\ns tenuous respiratory status, albeit\n improved from yesterday.\n - CT chest and possible bronch when more stable\n - Follow WBC count, fever curve, decreasing\n - PPD negative\n # Respiratory failure: Pneumonia in patient with poor pulmonary reserve\n due to emphysema, ?GVHD, fibrosis.\n Pt tolerated decrease in PEEP and Fi02 yesterday. Attempted to switch\n to A/C today, however pt less sedated off pressors and pulling large TV\n (~1600), dysynchronous with vent.\n -Switch back to pressure control for now, titrating down PEEP and Fi02\n as tolerated, attempt to wean sedation as much as possible.\n -Off cisatracurium since yesterday am. Currently sedated on midazolam\n and fentanyl.\n # Hypotension: Likely a mixed picture. Initially pt\ns presentation of\n acute hypoxia with leukocytosis and fevers with hypotension made a\n septic shock picture predominate, however after adequate fluid\n rescusitation pt continued to require 2 pressors. His TTE and vigileo\n monitoring were consistent with low cardiac output due to pt\ns severe\n pulmonary hypertension due to pulmonary fibrosis and subsequent RV\n hypokinesis with resultant LVOT, a non-fluid responsive state.\n Dobutamin challenge yesterday resulted in increased CO to normal range\n with ability to be weaned off both levophed and vasopressin. UOP\n remains high at ~200cc/hour.\n - Continue dobutamine\n - No prostacyclin/NO for now due to concern that may increase mismatch\n and worsen hypoxia.\n - Continue HD monitoring with Vigileo device\n - Treat broadly for infection per above\n - IV hydrocort Q6 for adrenal insufficiency, continue\n - Initially concerned for PE, however have more likley explanations for\n hypotension as listed above, LENIs negative\n - Start ACE low dose/short acting for afterload reduction.\n - Guaiac stools, HCT has been stable.\n # Cardiac: Patient with probable demand ischemia in setting of\n hypotension, tachycardia, and sepsis; less likely unstable plaque.\n - CE\ns trending down, have stopped following.\n - ASA\n - ACEI as above for afterload reduction\n - Consider diuresis if UOP tapers off to further decrease preload.\n # Metastatic renal CA: Recurrent disease s/p donor lymphocyte\n transplant .\n - BMT to follow\n - Continue acyclovir ppx for now, will discuss with BMT\n ICU Care\n Nutrition:\n TPN without Lipids - 08:51 PM 42. mL/hour\n Glycemic Control:\n Lines:\n Multi Lumen - 11:24 PM\n Arterial Line - 12:14 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": "2120-04-19 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 322999, "text": "Chief Complaint: 50M h/o metastatic renal CA s/p nephrectomy, IL-2,\n mini-allograft SCT, DLI x 2 last in , emphysema/pulmonary fibrosis\n on home 02 presents with hypotension, fevers, hypoxemic respiratory\n failure.\n 24 Hour Events:\n -dysynchronous on vent after rounds when on SIMV, put back on pressure\n control with normalization of ABG. Did well for most of the day.\n Overnight had mucous plugging with suctioning of sm amount thick\n sputum, after which pt transiently became dyscynchronous requiring\n increased sedation. PEEP increased to 12 from 10, Fi02 increased from\n 40% to 50%, driving pressure increased from 13 to 16, although down\n from 24 yesterday am.\n -decreased SVR, increased CO/CI after initiating ACEI, trial of\n decreasing dobutamine.\n -great UOP 100-200 cc/hour, no lasix for now\n -KUB read, no SBO\n Allergies:\n Flagyl (Oral) (Metronidazole)\n Rash;\n Last dose of Antibiotics:\n Levofloxacin - 10:14 AM\n Acyclovir - 04:30 PM\n Vancomycin - 08:15 PM\n Piperacillin/Tazobactam (Zosyn) - 10:13 PM\n Bactrim (SMX/TMP) - 12:02 AM\n - 03:58 AM\n Infusions:\n Dobutamine - 1 mcg/Kg/min\n Midazolam (Versed) - 12 mg/hour\n Fentanyl - 500 mcg/hour\n Other ICU medications:\n Famotidine (Pepcid) - 07:43 PM\n Heparin Sodium (Prophylaxis) - 09:00 PM\n Other medications:\n ISS\n ASA 325mg daily\n Docusate\n Chlorhexidine\n Folic Acid\n Hydrocortisone 50mg IV Q6\n Captopril 6.25 Po TID\n Senna\n PRN:\n Albuterol\n Bisacodyl\n Acetaminophen\n Changes to medical and family history: None\n Review of systems is unchanged from admission except as noted below\n Review of systems: Unchanged, intubated and deeply sedated\n Flowsheet Data as of 05:28 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.4\nC (97.5\n Tcurrent: 35.9\nC (96.6\n HR: 74 (54 - 101) bpm\n BP: 142/70(92) {117/57(76) - 155/75(98)} mmHg\n RR: 34 (30 - 34) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 76.3 kg (admission): 76.3 kg\n Height: 68 Inch\n CVP: 18 (15 - 41)mmHg\n CO/CI (CCO): (6.8 L/min) / (3.6 L/min/m2)\n SVV 12%\n Total In:\n 4,090 mL\n 1,462 mL\n PO:\n TF:\n 163 mL\n IVF:\n 3,555 mL\n 1,104 mL\n Blood products:\n Total out:\n 6,200 mL\n 820 mL\n Urine:\n 6,090 mL\n 820 mL\n NG:\n 110 mL\n Stool:\n Drains:\n Balance:\n -2,110 mL\n 642 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: PCV+Assist\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 260 (260 - 260) mL\n PC : 16 cmH2O\n PS : 5 cmH2O\n RR (Set): 34\n PEEP: 12 cmH2O\n FiO2: 50%\n PIP: 39 cmH2O\n Plateau: 30 cmH2O\n SpO2: 96%\n ABG: 7.39/40/113//0\n Ve: 15.4 L/min\n PaO2 / FiO2: 226\n Physical Examination\n General Appearance: Intubated, sedated\n Eyes / Conjunctiva: sclera anicteric, conjunctiva non-injected, PERRL\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, esophageal\n balloon, NGT\n Lymphatic: No(t) Cervical WNL, No(t) Supraclavicular WNL, No(t)\n Cervical adenopathy\n Cardiovascular: (S1: Normal), (S2: Normal, Fixed), tachycardic. regular\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:\n Rhonchorous: ), coarse mechanical BS throughout all lung fields\n Abdominal: Soft, Non-tender, hypoactive bowel sounds\n Extremities: no edema, palpable distal pulses\n Skin: Warm and dry, evidence of cutaneous GVHD on abdomen with\n sclerodermal changes.\n Neurologic: Intubated, sedated, opens eyes, tracks around room.\n Labs / Radiology\n 124 K/uL\n 11.3 g/dL\n 99 mg/dL\n 1.1 mg/dL\n 21 mEq/L\n 4.6 mEq/L\n 19 mg/dL\n 110 mEq/L\n 139 mEq/L\n 33.6 %\n 12.3 K/uL\n [image002.jpg]\n 12:20 AM\n 04:38 AM\n 05:01 AM\n 11:22 AM\n 12:10 PM\n 02:14 PM\n 08:25 PM\n 10:25 PM\n 03:04 AM\n 04:46 AM\n WBC\n 12.3\n Hct\n 33.6\n Plt\n 124\n Cr\n 1.1\n TCO2\n 22\n 23\n 23\n 23\n 22\n 23\n 24\n 26\n 25\n Glucose\n 99\n Other labs: PT / PTT / INR:14.9/28.9/1.3, CK / CKMB /\n Troponin-T:260/9/0.22, ALT / AST:94/64, Alk Phos / T Bili:84/0.3,\n Amylase / Lipase:53/22, Differential-Neuts:67.0 %, Band:2.0 %,\n Lymph:18.0 %, Mono:9.0 %, Eos:0.0 %, Lactic Acid:1.7 mmol/L,\n Albumin:2.7 g/dL, LDH:274 IU/L, Ca++:8.1 mg/dL, Mg++:2.2 mg/dL, PO4:1.6\n mg/dL\n Assessment and Plan\n 50M h/o metastatic renal CA s/p nephrectomy, IL-2, mini-allograft SCT,\n DLI x 2 last in , emphysema/pulmonary fibrosis on home 02\n presented to OSH with hypoxic respiratory failure, fevers and\n hypotension.\n # Severe septic shock: On presentation to OSH pt hypotensive, hypoxic\n with fevers and leukocytosis. On arrival to ICU was intubated due\n to hypoxic respiratory failure and hypotensive requiring pressors.\n Likely pneumonia given hypoxia and possible opacities on CXR, although\n difficult to read due to fibrosis. No other apparent localizing\n symptoms. Ruled-out for flu at OSH. Urine, GI sources less probable.\n Given immunocompromise from malignancy, at risk for PCP, , etc.\n Progression of GVHD could be contributing.\n - Will attempt to obtain deep ET sputum for culture\n - legionella urine ag negative, all other cultures no growth to date.\n - Vanc, zosyn, levofloxacin, bactrim IV for PCP, to cover\n broadly for now given critical illness. Iv steroids for PCP and\n adrenal insufficiency as below.\n - glucan, galactomannan pending for ? PCP, \n Unclear benefit of bronch for BAL at this point given duration of\n antimicrobial treatment and pt\ns tenuous respiratory status, albeit\n improved from yesterday.\n - CT chest and possible bronch when more stable\n - Follow WBC count, fever curve, decreasing\n - PPD negative\n # Respiratory failure: Pneumonia in patient with poor pulmonary reserve\n due to emphysema, ?GVHD, fibrosis.\n Pt tolerated decrease in PEEP and Fi02 yesterday. Attempted to switch\n to A/C today, however pt less sedated off pressors and pulling large TV\n (~1600), dysynchronous with vent.\n -Switch back to pressure control for now, titrating down PEEP and Fi02\n as tolerated, attempt to wean sedation as much as possible.\n -Off cisatracurium since yesterday am. Currently sedated on midazolam\n and fentanyl.\n # Hypotension: Likely a mixed picture. Initially pt\ns presentation of\n acute hypoxia with leukocytosis and fevers with hypotension made a\n septic shock picture predominate, however after adequate fluid\n rescusitation pt continued to require 2 pressors. His TTE and vigileo\n monitoring were consistent with low cardiac output due to pt\ns severe\n pulmonary hypertension due to pulmonary fibrosis and subsequent RV\n hypokinesis with resultant LVOT, a non-fluid responsive state.\n Dobutamin challenge yesterday resulted in increased CO to normal range\n with ability to be weaned off both levophed and vasopressin. UOP\n remains high at ~200cc/hour.\n - Continue dobutamine\n - No prostacyclin/NO for now due to concern that may increase mismatch\n and worsen hypoxia.\n - Continue HD monitoring with Vigileo device\n - Treat broadly for infection per above\n - IV hydrocort Q6 for adrenal insufficiency, continue\n - Initially concerned for PE, however have more likley explanations for\n hypotension as listed above, LENIs negative\n - Start ACE low dose/short acting for afterload reduction.\n - Guaiac stools, HCT has been stable.\n # Cardiac: Patient with probable demand ischemia in setting of\n hypotension, tachycardia, and sepsis; less likely unstable plaque.\n - CE\ns trending down, have stopped following.\n - ASA\n - ACEI as above for afterload reduction\n - Consider diuresis if UOP tapers off to further decrease preload.\n # Metastatic renal CA: Recurrent disease s/p donor lymphocyte\n transplant .\n - BMT to follow\n - Continue acyclovir ppx for now, will discuss with BMT\n ICU Care\n Nutrition: TF not at goal due to high residuals, will reduce fentanyl,\n colace/senna, consider lactulose/oral naloxone if ileus persists. TPN\n for now.\n Glycemic Control: ISS prn\n Lines:\n 20 Gauge - 09:10 PM\n Multi Lumen - 11:24 PM\n Arterial Line - 12:14 AM\n Prophylaxis:\n DVT: Hep SC, pneumoboots\n Stress ulcer: Ranitidine\n VAP: Chlorhexidine\n Comments:\n Communication: Comments: wife, \n Code status: Full code, have d/w family.\n Disposition: ICU\n" }, { "category": "Physician ", "chartdate": "2120-04-16 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 322629, "text": "Chief Complaint: SOB\n HPI:\n Pt is a 50M with PMH of metastatic RCC s/p nephrectomy, IL-2,\n mini-allograft SCT, DLI x 2 last in , emphysema/pulmonary fibrosis\n on home 02 who presented to OSH after 2 weeks of worsening dyspnea.\n Per OSH records pt had chronic worsening of dyspnea x 2-3 weeks with\n acute worsening over 2-3 days. Had been self medicating with increased\n home 02 and inhalers to which he stopped responding. He had myalgias\n and headaches at home. Mild purulent sputum production.\n At OSH he was hypoxic to 60% 02, hypotensive to 80s, febrile to 102.\n His CXR per report showed evidence of pulmonary fibrosis but no clear\n infiltrate. Pt was given IVF, empirically started on zosyn and levaquin\n for PNA, given IV hydrocortisone 75mg Q8 and started on levophed. His\n systolic pressures responded to 120s. He was placed on NIPPV with fi02\n 70% with 02 sats maintained in 90%s.\n PPD planted at OSH on left arm.\n WBC 17, repeat 20. 79-80% PMN, no bands. Cr 1.1. mets to adrenal,\n pelvis, mediastinal nodes, spine. Some elevations on CEs, continuing\n to rise. TTE with RV dysfunction, septal deviation, PA pressure 50-60.\n EF 70%. Platelets ok.\n Ruled out for flu\n Seen at by OSH ID consult: Recommended empiric coverage for CAP as well\n as for OIs with Zosyn, Levaquin, Bactrim IV, caspogungin, and\n acyclovir as well as discontinuing steroids.\n He requested transfer to where he receives his cancer care.\n Upon arrival pt is intubated and sedated. Had been off pressors for\n duration of transport.\n Overnight events: Initially he is normotensive and tachycardic.\n Initial ABG: pH7.02 pCO2104 pO2105 HCO329 BaseXS-7\n Given asa and 5mg IV lopressor. Hypotensive to 70s.\n Central line and arterial line placed, pt switched to pressure control\n with interval improvement in acidosis and hypercarbia.\n Pt started on broad coverage abx and aggressively fluid resuscitated\n with ~3-4L IVF\n Allergies:\n Flagyl (Oral) (Metronidazole)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Fentanyl - 100 mcg/hour\n Midazolam (Versed) - 6 mg/hour\n Norepinephrine - 0.1 mcg/Kg/min\n Other ICU medications:\n Metoprolol - 10:30 PM\n Midazolam (Versed) - 11:22 PM\n Fentanyl - 11:51 PM\n Other medications:\n (home) (from OMR updated )\n Acyclovir 400mg PO TID\n Albuterol prn\n Dexamethasone S&S TID\n Folate\n Duonebs\n Oxycodone 5mg Q4 prn\n Oxycontin 10mg PO Q12\n Spiriva 1 INH daily\n Bactrim DS 1 tab PO MWF\n Augmentin 500mg PO daily\n MVI\n Omeprazole 20mg daily\n eye gtts\n (on transfer)\n Colace\n Lovenox 40mg Sc daily\n Insulin sliding scale\n Pantoprazole 40mg IV daily\n Augmentin 500mg PO daily\n Oxycontin 10mg \n MVI\n Acyclovir 400mg PO TID\n Folate\n Zosyn 3.375g IV Q6\n Levaquin 750mg IV daily\n Bactrim 380mg IV Q8 hours\n Caspofungin 50mg IV daily\n MOM\n Maalox\n Oxycodone prn\n Ativan prn\n levophed (off on arrival)\n Duonebs\n Albuterol\n Past medical history:\n Family history:\n Social History:\n Metastatic RCC\n -diagnosed in , s/p left nephrectomy. Mets to spine, adrenals,\n right kidney, pelvis, mediastinal LN.\n -s/p IL-2 and allogeneic non-myeloablative peripheral stem cell\n transplant from sibling donor in \n -s/p 2 rounds DLI, also from sibling donor last in \n GVHD, affecting liver\n Emphysema - followed by Dr. , attributes lung disease to\n emphysema with some fibrosis possibly due to radiation vs oxygen\n tocixity. So far no evidence for GVHD\n Recurrent bronchitis\n Hx repaired varicocele\n The patient's mother passed away from colon cancer. The\n patient's father passed away from pancreatic cancer.\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: (Pt unable to give, obtained from prior records) The patient\n lives in , NH, with his wife. reports smoking ppd x many\n years, stopped several years ago. Reports drinking four times per\n year, and not to excess, though he says he did drink more considerable\n amounts in his younger years.\n Review of systems:\n Flowsheet Data as of 03:20 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: 95 (79 - 133) bpm\n BP: 79/59(66) {79/59(66) - 91/67(76)} mmHg\n RR: 17 (15 - 26) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 76.3 kg (admission): 76.3 kg\n Height: 68 Inch\n CVP: 21 (17 - 21)mmHg\n Total In:\n 3,511 mL\n 1,055 mL\n PO:\n TF:\n IVF:\n 2,011 mL\n 1,055 mL\n Blood products:\n Total out:\n 275 mL\n 65 mL\n Urine:\n 275 mL\n 65 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,236 mL\n 990 mL\n Respiratory\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: PCV+Assist\n Vt (Set): 450 (400 - 450) mL\n PC : 35 cmH2O\n RR (Set): 32\n PEEP: 18 cmH2O\n FiO2: 100%\n PIP: 41 cmH2O\n Plateau: 34 cmH2O\n SpO2: 95%\n ABG: 7.14/60/68/22/-9\n Ve: 17.9 L/min\n PaO2 / FiO2: 68\n Physical Examination\n General Appearance: Intubated, sedated\n Eyes / Conjunctiva: Pupils dilated\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube\n Lymphatic: No(t) Cervical WNL, No(t) Supraclavicular WNL, No(t)\n Cervical adenopathy\n Cardiovascular: (S1: Normal), (S2: Normal, Fixed), tachycardic. regular\n Peripheral Vascular: (Right radial pulse: Diminished), (Left radial\n pulse: Diminished), (Right DP pulse: Diminished), (Left DP pulse:\n Diminished)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Rhonchorous: ), coarse mechanical BS throughout all lung fields\n Abdominal: Soft, Non-tender, hypoactive bowel sounds\n Extremities: Right: Absent, Left: Absent\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Sedated,\n Tone: Not assessed\n Labs / Radiology\n 185 K/uL\n 13.0 g/dL\n 109 mg/dL\n 0.8 mg/dL\n 11 mg/dL\n 22 mEq/L\n 118 mEq/L\n 5.0 mEq/L\n 145 mEq/L\n 41.2 %\n [image002.jpg]\n \n 2:33 A4/14/ 09:51 PM\n \n 10:20 P4/14/ 11:55 PM\n \n 1:20 P4/15/ 12:22 AM\n \n 11:50 P4/15/ 01:31 AM\n \n 1:20 A4/15/ 02:10 AM\n \n 7:20 P\n 1//11/006\n 1:23 P\n \n 1:20 P\n \n 11:20 P\n \n 4:20 P\n Hct\n 44\n 41.2\n Plt\n 185\n Cr\n 0.8\n TropT\n 0.34\n TC02\n 29\n 22\n 21\n 22\n Glucose\n 109\n Other labs: PT / PTT / INR:16.0/28.8/1.4, CK / CKMB /\n Troponin-T:144/14/0.34, ALT / AST:44/52, Alk Phos / T Bili:95/0.9,\n Lactic Acid:1.1 mmol/L, Albumin:2.6 g/dL, LDH:435 IU/L, Ca++:6.1 mg/dL,\n Mg++:2.0 mg/dL, PO4:4.3 mg/dL\n Fluid analysis / Other labs:\n Labs:\n (OSH)\n Cr 1.4 --->1.1\n LFTs WNL\n WBC 17.4, no bands\n Hct 46.8 Plt 258\n BNP 642\n Influenza A&B negative\n trop (T?) 0.5, 1.78, 1.98\n CK 106, 116, 150 MB 2.5, 6.6, 10.8\n coags WNL\n CRP 142\n ESR 42\n Blood Cx sent\n ABG 7.36/34/68 on 60% Fi02\n Imaging: OSH CXR : chronic pulmonary fibrosis, cannot rule out\n acute change\n TTE : EF 65-70%, concentric LVH, grade I diastolic dysfunction,\n moderate RV dilitation, PASP 54. No effusion\n EKG: tachy, regular, sinus, S1Q3T3, new deep TWIs in V2-V4, poor r wave\n progression. TWIs new from .\n Assessment and Plan\n Assessment/Plan:\n 50M h/o metastatic renal CA s/p nephrectomy, IL-2, mini-allograft SCT,\n DLI x 2 last in , emphysema/pulmonary fibrosis on home 02 presents\n with sepsis.\n # Sepsis: Likely pneumonia given new opacities on CXR, although\n difficult to read due to fibrosis. No other apparent localizing\n symptoms. Ruled-out for flu at OSH. Urine, GI sources less probable.\n Given immunocompromise from malignancy, at risk for PCP, , etc.\n Progression of GVHD could be contributing.\n - IVF resuscitation for MAP>65, IVF aggressively then pressors if\n necessary\n - Vanc, zosyn, levofloxacin, bactrim, caspofungin to cover broadly for\n now given critical illness\n - Blood, urine, sputum cultures\n - Legionella antigen, glucan, galactomannan\n - CT chest and possible bronch when more stable\n - Follow WBC count, fever curve\n - PPD to be read \n # Respiratory failure: Pneumonia in patient with poor pulmonary reserve\n due to emphysema, GVHD, fibrosis. Avoid high pressures given fibrotic\n lungs, will attempt pressure control to limit.\n - Continue mechanical ventilatory support, wean as tolerated\n # Acidosis: Primary respiratory, non-gap, lactate normal. Increase\n minute ventilation. require paralysis for adequate ventilation.\n # Hypotension: Likely sepsis, although probably component of\n hypovolemia as well. At risk for PE given malignancy. GI bleed unlikely\n as Hct stable. Adrenal insufficiency possible.\n - Treat broadly per above\n - stim in AM, after high dose steroids from OSH are off.\n - LENIs for ? DVT. Don't want to empirically start heparin given RCC\n and risk to bleed.\n - Guaiac stools, HCT has been stable.\n # Cardiac: Patient with probable demand ischemia in setting of\n hypotension, tachycardia, and sepsis; less likely unstable plaque.\n - Continue to trend enzymes and treat underlying cause\n - ASA, hold on beta-blocker and statin\n - TTE to eval for wall motion abnormality\n - Repeat ECG in am\n # Metastatic renal CA: Recurrent disease s/p donor lymphocyte\n transplant .\n - BMT to follow\n - Avoid steroids given risk to graft\n - Continue acyclovir ppx for now, will discuss with BMT\n ICU Care\n Nutrition: NPO for now, consider starting trophic feeds in am, hold now\n for poss bronch\n Glycemic Control: ISS\n Lines:\n 20 Gauge - 09:10 PM\n Multi Lumen - 11:24 PM\n Arterial Line - 12:14 AM\n Prophylaxis:\n DVT: Hep SC, pneumoboots\n Stress ulcer: Ranitidine\n VAP: Chlorhexidine\n Comments:\n Communication: Comments: Attending spoke with brother, wife still in\n \n Code status: Full code\n Disposition: ICU\n" }, { "category": "Nursing", "chartdate": "2120-04-16 00:00:00.000", "description": "Nursing Progress Note", "row_id": 322718, "text": "50M h/o metastatic renal CA s/p nephrectomy, IL-2, mini-allograft , DLI\n x 2 last in , emphysema/pulmonary fibrosis on home 02 presents\n with sepsis. Started on NIPPV, hydrocortisone, broad spectrum abx at\n OSH yesterday. TTE at OSH EF 65-70, LVH, PASP 54, RV dilation.\n Intubated. On FiO2 100% 7.02/104/105. Had received vecuronium. ECG with\n deep TW inversions. Hypotensive here, received 4L NS. Vent transitioned\n to PCV.\n Sepsis, Severe (with organ dysfunction)\n Assessment:\n SBP down to high 70\ns (confirmed with doppler, NBP)on levo. CVP 15. UO\n 40-50 cc hr. L foot cooler than R.\n Action:\n Levophed increased without adequate response. Vasopresin added with\n good effect. CVP 15 Given LR 1 liter bolus. Vigileo monitoring\n initiated. CO 5.0-5.5, SVV initially 15. T max 100.8 PO. On mult\n antibx.\n Able to doppler DP & PT pulses. LENI\ns done.\n Response:\n BP stable on levo, vaso. CVP 25 and SVV after fld bolus. Steroids\n started.\n Plan:\n Titrate levo as tol. Follow UO, Vigileo monitoring. Cont antibx. Follow\n culture data, WBC\n Respiratory failure, acute (not ARDS/)\n Assessment:\n ABG with persistent acidosis, discoordinate breathing pattern despite\n versed gtt & escalating fentanyl gtt. Esophageal balloon placed. On\n PCV with Fio2 100%, PEEP 18, IP 22, 34 breaths. ABG 7.19/51/120/-.\n BS coarse, diminished at bases. TOF but appears adequately\n paralyzed\n Action:\n Cisatracuruim added. TTE done\n Response:\n Some improvement in ABG\n Plan:\n Decrease PEEP to 16 & cont to drop peep as tol.\n Family meeting with ICU team, Dr. (Onc), ID MD & \n ( BMT Social Worker), Pt\ns wife & this RN. Explained to wife\n pt\ns critical status. Wife phoning relative\ns to come to hospital. Pt\n remains full code at present. Priest in to see pt at wife\ns request.\n L NGT replaced. Placement confirmed by CXR. Team requests TF started\n despite no BS heard. No stool.\n" }, { "category": "Respiratory ", "chartdate": "2120-04-17 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 322849, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 3\n Ideal body weight: 69.9 None\n Ideal tidal volume: 279.6 / 419.4 / 559.2 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation:\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: 22 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n 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 invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Plan\n Next 24-48 hours:\n Reason for continuing current ventilatory support: Underlying illness\n not resolved\n Comments: Pt received on PCV as noted with no vent changes this shift.\n Paralytic weaned off today. Pt seems to be tolerating well with no\n dysychrony. Plan to continue on PCV settings at this time and wean\n settings as pt improves.\n" }, { "category": "Nursing", "chartdate": "2120-04-19 00:00:00.000", "description": "Nursing Progress Note", "row_id": 322990, "text": "50 yo man with metastatic renal cell CA s/p allo- SCT with subsequent\n severe chronic resp failure thought to be emphysema and fibrosis of\n unclear etiology (CT from last spring demonstrates severe cystic and\n fibrotic changes with almost no normal appearing lung) presented with 2\n wk prodrome, now with catastrophic acute on chronic failure. CXR shows\n diffuse opacification. Severe septic shock. RV with global hypokinesis,\n dilated, mod-sev PAH. Trop peaked at 1.98 at OSH, highest here was\n 0.49.\n Heart failure, right, isolated (Cor Pulmonale)\n Assessment:\n Currently on Dobuta at 1.2 mcg/kg/min. C.O. 4\ns-5. C.I. 2.6-3.4\n edema noted\n Action:\n No changes made to dobuta. Captopril 6.25mg given.\n Response:\n SBP 120\ns-140\ns. HR high 50\nhigh 90\n Plan:\n Con\nt to monitor C.I. and C.O. via Vigileo monitor. Con\nt to titrate\n dobuta for C.I. >2.5\n Respiratory failure, acute (not ARDS/)\n Assessment:\n L.S clear. Vent settings on PCV/50% fio2/34/12 PEEP. O2 sats 93-97% -\n breathing in sync with vent\n Action:\n Fio2 lowered to 40%. ABG done. Suctioned for small amt brown think\n sputum\n Response:\n After suctioning sats dropped to 86%. FiO2 increased to 50% and sats\n back up to 94-95%. ABG 7.34/46/109/-. Pt became more\n dysynchronous with vent.\n Plan:\n ? paralytics. Con\nt to monitor sats and ABG\ns. ? bronch when more\n stable\n" }, { "category": "Respiratory ", "chartdate": "2120-04-19 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 322995, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 5\n Ideal body weight: 69.9 None\n Ideal tidal volume: 279.6 / 419.4 / 559.2 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation:\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type: Standard\n Size: 7.5mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 20 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Crackles\n LUL Lung Sounds: Crackles\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Brown / Thick\n Sputum source/amount: Suctioned / Moderate\n Comments:\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern:\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours:\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments: Pt cont intub with OETT and on mech vent as per Metavision.\n Lung sounds bilat rales; suct sm th brn plugs. ABGs stable @ present\n once DP increased. Cont PCV.\n" }, { "category": "General", "chartdate": "2120-04-27 00:00:00.000", "description": "Generic Note", "row_id": 323923, "text": "TITLE:\n RESPIRATORY CARE: PT REMAINS W/ AN 8.0 PORTEX TRACH IN PLACE AND ON\n PRESSURE TARGETED VENTILATION IN THE AC MODE AS PER METAVISION. CUFF\n LEAK PERSISTS. IP CAME BY TO SEE PATIENT\n AND THEY WOULD PREFER TO WAIT 2-3 DAYS PRIOR TO CHANGING TRACH TO A\n . WILL TOLERATE\n A LLEAK IN MEANTIME.\n" }, { "category": "Case Management ", "chartdate": "2120-05-01 00:00:00.000", "description": "Case Management Continued Stay Review", "row_id": 324304, "text": "Planned Discharge Date: \n Insurance Update\n Primary insurance / reviewer:\n Hospital days authorized to:\n Current Discharge Plan: Undetermined\n Barrier(s) To Discharge:\n Family Meeting: Yes\n Referrals:\n Narrative / Plan:\n Mr. overall status, and particular, his respiratory status\n has declined significantly over the last 4 days. He is is on maximum\n ventilatory support with continued deterioration of his status. Family\n aware and at bedside. I will follow for an assistance and or\n questions.\n" }, { "category": "Respiratory ", "chartdate": "2120-04-16 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 322719, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 1\n Ideal body weight: 69.9 None\n Ideal tidal volume: 279.6 / 419.4 / 559.2 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation:\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type: Standard\n Size: 7.5mm\n Lung sounds\n RLL Lung Sounds: Crackles\n RUL Lung Sounds: Crackles\n LUL Lung Sounds: Diminished\n LLL Lung Sounds: Crackles\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Gasping efforts; Comments: Pt\n dysynchronous with vent secondary to gasping breaths. Pt sedated and\n paralyzed.\n Plan\n Next 24-48 hours:\n Reason for continuing current ventilatory support: Sedated / Paralyzed,\n Hemodynimic instability, Underlying illness not resolved\n Respiratory Care Shift Procedures\n Bedside Procedures:\n Comments: Pt received on PCV as noted. Vent changed from to\n Avea secondary to Esophageal balloon placement this morning. Procedure\n was without incident. Vent rate increased from 32 to 34 and driving\n pressure increased from 17 to 22cm throughout shift secondary to ABG\n PEEP weaned from 18 to 16cm secondary to PaO2 of 120. Plan to continue\n to adjust vent settings as needed and monitor ABG\ns closely.\n" }, { "category": "Physician ", "chartdate": "2120-04-16 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 322725, "text": "Chief Complaint: hypoxemic resp failure 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 50M h/o metastatic renal CA s/p nephrectomy, IL-2, mini-allograft SCT,\n DLI x 2 last in , emphysema/pulmonary fibrosis on home 02 presents\n with sepsis. Started on NIPPV, hydrocortisone, broad spectrum abx at\n OSH yesterday. TTE at OSH EF 65-70, LVH, PASP 54, RV dilation.\n Intubated en route. On FiO2 100% 7.02/104/105. Had received vecuronium.\n ECG with deep TW inversions. Hypotensive here, received 4L NS. Vent\n transitioned to PCV. Started on norepinephrine and subsequently\n vasopressin.\n 24 Hour Events:\n INVASIVE VENTILATION - START 09:10 PM\n EKG - At 10:53 PM\n MULTI LUMEN - START 11:24 PM\n ARTERIAL LINE - START 12:14 AM\n BLOOD CULTURED - At 01:32 AM\n URINE CULTURE - At 01:32 AM\n BLOOD CULTURED - At 05:00 AM\n FEVER - 101.1\nF - 06:00 AM\n Allergies:\n Flagyl (Oral) (Metronidazole)\n Rash;\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 04:11 AM\n Caspofungin - 04:45 AM\n Bactrim (SMX/TMP) - 06:00 AM\n Infusions:\n Fentanyl - 250 mcg/hour\n Midazolam (Versed) - 6 mg/hour\n Norepinephrine - 0.17 mcg/Kg/min\n Vasopressin - 1.2 units/hour\n Other ICU medications:\n Metoprolol - 10:30 PM\n Midazolam (Versed) - 11:22 PM\n Fentanyl - 11:51 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 09:33 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.4\nC (101.1\n Tcurrent: 38.2\nC (100.8\n HR: 101 (79 - 133) bpm\n BP: 105/67(82) {78/53(63) - 105/71(82)} mmHg\n RR: 19 (13 - 26) insp/min\n SpO2: 94%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 76.3 kg (admission): 76.3 kg\n Height: 68 Inch\n CVP: 16 (16 - 21)mmHg\n Total In:\n 3,511 mL\n 2,082 mL\n PO:\n TF:\n IVF:\n 2,011 mL\n 2,082 mL\n Blood products:\n Total out:\n 275 mL\n 182 mL\n Urine:\n 275 mL\n 182 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,236 mL\n 1,900 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: PCV+Assist\n Vt (Set): 450 (400 - 450) mL\n PC : 20 cmH2O\n RR (Set): 32\n PEEP: 18 cmH2O\n FiO2: 100%\n RSBI Deferred: PEEP > 10, FiO2 > 60%\n PIP: 40 cmH2O\n Plateau: 34 cmH2O\n SpO2: 94%\n ABG: 7.18/54/76 on PEEP 18, FiO2 100%\n Ve: 16 L/min\n PaO2 / FiO2: 76\n Physical Examination\n General Appearance: Well nourished\n Eyes / Conjunctiva: PERRL, Conjunctiva pale\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Rhonchorous: )\n Abdominal: Soft, Bowel sounds present, No(t) Distended\n Extremities: Right: Absent, Left: Absent, No(t) Cyanosis, No(t)\n Clubbing, left foot cold, right foot warm\n Musculoskeletal: No(t) Muscle wasting\n Skin: Warm, No(t) Rash: , No(t) Jaundice\n Neurologic: Responds to: Unresponsive, Movement: No spontaneous\n movement, Sedated, No(t) Paralyzed, Tone: Not assessed\n Labs / Radiology\n 13.3 g/dL\n 185 K/uL\n 109 mg/dL\n 0.8 mg/dL\n 22 mEq/L\n 5.0 mEq/L\n 11 mg/dL\n 118 mEq/L\n 145 mEq/L\n 41.8 %\n 20.7 K/uL\n [image002.jpg]\n 09:51 PM\n 11:55 PM\n 12:22 AM\n 01:31 AM\n 02:10 AM\n 04:13 AM\n 06:23 AM\n 08:00 AM\n WBC\n 20.8\n 20.7\n Hct\n 44\n 41.2\n 41.8\n Plt\n 185\n 185\n Cr\n 0.8\n TropT\n 0.34\n TCO2\n 29\n 22\n 21\n 22\n 21\n 21\n Glucose\n 109\n Other labs: PT / PTT / INR:16.0/28.8/1.4, CK / CKMB /\n Troponin-T:168/15/0.34, ALT / AST:44/52, Alk Phos / T Bili:95/0.9,\n Differential-Neuts:67.0 %, Band:2.0 %, Lymph:18.0 %, Mono:9.0 %,\n Eos:0.0 %, Lactic Acid:1.4 mmol/L, Albumin:2.6 g/dL, LDH:435 IU/L,\n Ca++:6.1 mg/dL, Mg++:2.0 mg/dL, PO4:4.3 mg/dL\n Assessment and Plan\n 50 yo man with metastatic renal cell CA s/p allo- SCT with subsequent\n severe chronic resp failure thought to be emphysema and fibrosis and\n possible GVHD/BOOP (CT from last spring demonstrates severe cystic and\n fibrotic changes with almost no normal appearing lung) presented with 2\n wk prodrome, now with catastrophic acute on chronic failure. CXR shows\n diffuse opacification. Severe septic shock, now on 2 pressors. Not\n recently on corticosteroids.\n SEPTIC SHOCK\n Most likely source pneumonia. R/O for influenza at OSH.\n Vanc/Zosyn/Levoflox/Bactrim/Caspofungin/acyclovir prophylaxis.\n Cx pending.\n Markers pending.\n Not safe for bronch.\n RESP FAILURE\n Infection, sepsis, acute exacerbation of underlying chronic disease as\n well as cardiac component with likely severe PH and also likely\n impaired LV filling and impaired LV outflow with subsequent CHF.\n - oxygenation currently adequate on high PEEP, max FiO2\n - consider paralysis if we are unable to decrease FiO2\n - rescue strategy may include inhaled prostacyclin or NO, though he may\n have severe F/Q mismatch/shunt given his underlying severe lung\n disease.\n HYPOTENSION\n Septic shock. Has one adrenal gland with metastatic lesion.\n Fluid resuscitation. Received high dose steroids at OSH. Add high dose\n hydrocortisone.\n CARDIAC\n Severe PH. New TW inversions, likely demand ischemia with tachy,\n hypotension.\n TTE.\n Aspirin.\n SEDATION with fent 350 /versed 6\n COLD FOOT- observe for now\n other issues per Dr note.\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 20 Gauge - 09:10 PM\n Multi Lumen - 11:24 PM\n Arterial Line - 12:14 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP: Mouth care\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 80 minutes\n Patient is critically ill\n ------ Protected Section ------\n Met with pt\ns wife, , and explained septic shock, cardiogenic\n shock with severe PH, RV failure. Described the echocardiogram\n findings. Explained severity of his condition, on maximal vent support\n and high doses of 2 pressor agents, as well as receiving very broad\n antimicrobial coverage. Answered questions.\n 30 minutes.\n ------ Protected Section Addendum Entered By: , MD\n on: 19:00 ------\n" }, { "category": "Nursing", "chartdate": "2120-04-16 00:00:00.000", "description": "Nursing Progress Note", "row_id": 322731, "text": "50M h/o metastatic renal CA s/p nephrectomy, IL-2, mini-allograft , DLI\n x 2 last in , emphysema/pulmonary fibrosis on home 02 presents\n with sepsis. Started on NIPPV, hydrocortisone, broad spectrum abx at\n OSH yesterday. TTE at OSH EF 65-70, LVH, PASP 54, RV dilation.\n Intubated. On FiO2 100% 7.02/104/105. Had received vecuronium. ECG with\n deep TW inversions. Hypotensive here, received 4L NS. Vent transitioned\n to PCV.\n Sepsis, Severe (with organ dysfunction)\n Assessment:\n SBP down to high 70\ns (confirmed with doppler, NBP)on levo. CVP 15. UO\n 40-50 cc hr. L foot cooler than R.\n Action:\n Levophed increased without adequate response. Vasopresin added with\n good effect. CVP 15 Given LR 1 liter bolus. Vigileo monitoring\n initiated. CO 5.0-5.5, SVV initially 15. T max 100.8 PO. On mult\n antibx.\n Able to doppler DP & PT pulses. LENI\ns done.\n Response:\n BP stable on levo, vaso. CVP 25 and SVV after fld bolus. Steroids\n started.\n Plan:\n Titrate levo as tol. Follow UO, Vigileo monitoring. Cont antibx. Follow\n culture data, WBC\n Respiratory failure, acute (not ARDS/)\n Assessment:\n ABG with persistent acidosis, discoordinate breathing pattern despite\n versed gtt & escalating fentanyl gtt. Esophageal balloon placed. On\n PCV with Fio2 100%, PEEP 18, IP 22, 34 breaths. ABG 7.19/51/120/-.\n BS coarse, diminished at bases. TOF but appears adequately\n paralyzed\n Action:\n Cisatracuruim added. TTE done\n Response:\n Some improvement in ABG\n Plan:\n Decrease PEEP to 16 & cont to drop peep as tol.\n Family meeting with ICU team, Dr. (Onc), ID MD & \n ( BMT Social Worker), Pt\ns wife & this RN. Explained to wife\n pt\ns critical status. Wife phoning relative\ns to come to hospital. Pt\n remains full code at present. Priest in to see pt at wife\ns request.\n L NGT replaced. Placement confirmed by CXR. Team requests TF started\n despite no BS heard. No stool.\n On SS insulin coverage.\n" }, { "category": "Nursing", "chartdate": "2120-04-19 00:00:00.000", "description": "Nursing Progress Note", "row_id": 323073, "text": "50 yo man with metastatic renal cell CA s/p allo- SCT with subsequent\n severe chronic resp failure thought to be emphysema and fibrosis of\n unclear etiology (CT from last spring demonstrates severe cystic and\n fibrotic changes with almost no normal appearing lung) presented with 2\n wk prodrome, now with catastrophic acute on chronic failure. CXR shows\n diffuse opacification. Severe septic shock. RV with global hypokinesis,\n dilated, mod-sev PAH. Trop peaked at 1.98 at OSH, highest here was\n 0.49. No longer thought to have PCP, Bactrim D/C\nd, back on\n prophylactic dose. Weaning steroids.\n Heart failure, right, isolated (Cor Pulmonale)\n Assessment:\n Currently weaned to Dobuta at 0.5 mcg/kg/min. C.O. 4\ns-6. C.I.\n 2.6-3.4\n no edema noted\n Action:\n Captopril 6.25mg given.\n Response:\n SBP 110\ns-140\ns. HR low 50\n110. CI 2.8\n Plan:\n Con\nt to monitor C.I. and C.O. via Vigileo monitor. Con\nt to titrate\n dobuta for C.I. >2.5\n Respiratory failure, acute (not ARDS/)\n Assessment:\n L.S course with diminished bases. Vent settings on PCV/40% fio2/34/12\n PEEP. O2 sats 91-94% - breathing in sync with vent.\n Action:\n Fio2 lowered to 40% from 50%. ABG done. Suctioned for small amt brown\n think sputum. Subglottal suctioning garnered large amounts of thick tan\n secretions. Methadone 20mg/hr q4h started to help with sedation and\n encourage synchronisity with the vent. HR lowered to low 50\n Response:\n ABG: 7.45/36/77 Pt. appears more comfortable and tolerates turns\n better. Fent weaned to 450, Versed to 10\n Plan:\n Con\nt to monitor sats and ABG\ns. Wean vent as tolerated.\n" }, { "category": "Nursing", "chartdate": "2120-04-19 00:00:00.000", "description": "Nursing Progress Note", "row_id": 323075, "text": "50 yo man with metastatic renal cell CA s/p allo- SCT with subsequent\n severe chronic resp failure thought to be emphysema and fibrosis of\n unclear etiology (CT from last spring demonstrates severe cystic and\n fibrotic changes with almost no normal appearing lung) presented with 2\n wk prodrome, now with catastrophic acute on chronic failure. CXR shows\n diffuse opacification. Severe septic shock. RV with global hypokinesis,\n dilated, mod-sev PAH. Trop peaked at 1.98 at OSH, highest here was\n 0.49. No longer thought to have PCP, Bactrim D/C\nd, back on\n prophylactic dose. Weaning steroids.\n Heart failure, right, isolated (Cor Pulmonale)\n Assessment:\n Currently weaned to Dobuta at 0.5 mcg/kg/min. C.O. 4\ns-6. C.I.\n 2.6-3.4\n no edema noted\n Action:\n Captopril 6.25mg given.\n Response:\n SBP 110\ns-140\ns. HR low 50\n110. CI 2.8\n Plan:\n Con\nt to monitor C.I. and C.O. via Vigileo monitor. Con\nt to titrate\n dobuta for C.I. >2.5\n Respiratory failure, acute (not ARDS/)\n Assessment:\n L.S course with diminished bases. Vent settings on PCV/40% fio2/34/12\n PEEP. O2 sats 91-94% - breathing in sync with vent.\n Action:\n Fio2 lowered to 40% from 50%. ABG done. Suctioned for small amt brown\n think sputum. Subglottal suctioning garnered large amounts of thick tan\n secretions. Methadone 20mg/hr q4h started to help with sedation and\n encourage synchronisity with the vent. HR lowered to low 50\n Response:\n ABG: 7.45/36/77 Pt. appears more comfortable and tolerates turns\n better. Fent weaned to 450, Versed to 10\n Plan:\n Con\nt to monitor sats and ABG\ns. Wean vent as tolerated.\n" }, { "category": "Nursing", "chartdate": "2120-04-20 00:00:00.000", "description": "Nursing Progress Note", "row_id": 323194, "text": "50 yo man with metastatic renal cell CA s/p allo- SCT with subsequent\n severe chronic resp failure thought to be emphysema and fibrosis of\n unclear etiology (CT from last spring demonstrates severe cystic and\n fibrotic changes with almost no normal appearing lung) presented with 2\n wk prodrome, now with catastrophic acute on chronic failure. CXR shows\n diffuse opacification. RV with global hypokinesis, dilated, mod-sev\n PAH. Trop peaked at 1.98 at OSH, highest here was 0.49. No longer\n thought to have PCP, Bactrim D/C\nd, back on prophylactic dose.\n Weaning steroids. Methadone 20 mg q8h started yesterday to supplement\n sedation. Pt. had three medium to large BM, would recommend holding PM\n bowel regimen.\n Heart failure, right, isolated (Cor Pulmonale)\n Assessment:\n Dobuta off at 8am. C.O. 4\ns-low 5\ns. C.I. 2.2-2.8\n Action:\n Captopril 6.25mg given.\n Response:\n SBP 110\ns-140\ns. Remains bradycardic with HR 40\ns-50\ns. UO continues\n to be acceptable.\n Plan:\n Con\nt to monitor C.I. and C.O. via Vigileo monitor. Continue to closely\n evaluate UO.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Upper lobes clear today with diminished lowers. Breathing in sync with\n vent. ABG on PCV RR 30/insp pressure 28/PEEP 12 was 7.40/38/89\n Action:\n Weaned to PCV RR 30/inspiratory pressure 24/PEEP 12. O2 sats 91-94% -\n breathing in sync with vent. ABG done. Fent 450, Versed 10, Methadone\n 20mg IV q8h\n Response:\n ABG:\n Plan:\n Con\nt to monitor sats and ABG\ns. Wean vent as tolerated.\n" }, { "category": "Physician ", "chartdate": "2120-04-21 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 323244, "text": "Chief Complaint:\n 24 Hour Events:\n EKG - At 06:04 PM\n Vent changes:\n Decreased rr to 30 from 36, driving pressure to 26 from 28: 7.4/38/89\n Rate decreased to 26 from 30, patient\nagitated\n and , \n increased rr to 30 and temp 100% fio2.\n Overnight dropped tidal volumes, and change in compliance, was\n suctioned, ? mucous plug. Cxr obtained, w/ ? new L mid lung / lingula\n opacification.\n Driving pressure increased back to 28 in light of this.\n TV improved back to normal.\n TUBE feed rate increased\n Allergies:\n Flagyl (Oral) (Metronidazole)\n Rash;\n Last dose of Antibiotics:\n Bactrim (SMX/TMP) - 09:00 AM\n Levofloxacin - 09:11 AM\n Vancomycin - 08:00 PM\n Caspofungin - 08:23 PM\n Acyclovir - 12:17 AM\n Piperacillin/Tazobactam (Zosyn) - 05:15 AM\n Infusions:\n Fentanyl - 500 mcg/hour\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:22 PM\n Famotidine (Pepcid) - 08:23 PM\n Midazolam (Versed) - 01:15 AM\n Fentanyl - 01:15 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:07 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.3\nC (99.2\n Tcurrent: 37.2\nC (99\n HR: 48 (45 - 67) bpm\n BP: 114/51(69) {114/51(69) - 144/73(97)} mmHg\n RR: 30 (23 - 30) insp/min\n SpO2: 92%\n Heart rhythm: SB (Sinus Bradycardia)\n Wgt (current): 76.3 kg (admission): 76.3 kg\n Height: 68 Inch\n CVP: 15 (12 - 314)mmHg\n CO/CI (CCO): (4.5 L/min) / (2.4 L/min/m2)\n Total In:\n 3,451 mL\n 1,236 mL\n PO:\n TF:\n 485 mL\n 458 mL\n IVF:\n 2,506 mL\n 528 mL\n Blood products:\n Total out:\n 1,805 mL\n 600 mL\n Urine:\n 1,805 mL\n 600 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,646 mL\n 636 mL\n Respiratory support\n Ventilator mode: PCV+\n PC : 28 cmH2O\n RR (Set): 30\n PEEP: 12 cmH2O\n FiO2: 1%\n RSBI Deferred: PEEP > 10\n PIP: 39 cmH2O\n SpO2: 92%\n ABG: 7.41/40/85./26/0\n Ve: 15 L/min\n PaO2 / FiO2: 17,000\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 120 K/uL\n 10.3 g/dL\n 122 mg/dL\n 1.0 mg/dL\n 26 mEq/L\n 3.9 mEq/L\n 26 mg/dL\n 110 mEq/L\n 142 mEq/L\n 31.2 %\n 12.1 K/uL\n [image002.jpg]\n 04:46 AM\n 04:59 PM\n 03:12 AM\n 06:06 AM\n 02:28 PM\n 06:28 PM\n 09:12 PM\n 01:58 AM\n 04:48 AM\n 05:04 AM\n WBC\n 10.2\n 12.1\n Hct\n 31.7\n 31.2\n Plt\n 136\n 120\n Cr\n 1.1\n 1.0\n TCO2\n 25\n 26\n 26\n 24\n 24\n 26\n 28\n 26\n Glucose\n 91\n 122\n Other labs: PT / PTT / INR:13.5/29.8/1.2, CK / CKMB /\n Troponin-T:260/9/0.22, ALT / AST:57/31, Alk Phos / T Bili:70/0.4,\n Amylase / Lipase:53/22, Differential-Neuts:67.0 %, Band:2.0 %,\n Lymph:18.0 %, Mono:9.0 %, Eos:0.0 %, Lactic Acid:1.3 mmol/L,\n Albumin:2.7 g/dL, LDH:272 IU/L, Ca++:7.5 mg/dL, Mg++:2.2 mg/dL, PO4:3.1\n mg/dL\n Assessment and Plan\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 05:04 AM 70 mL/hour\n Glycemic Control:\n Lines:\n Multi Lumen - 11:24 PM\n Arterial Line - 12:14 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": "2120-04-21 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 323245, "text": "Chief Complaint:\n 24 Hour Events:\n EKG - At 06:04 PM\n Vent changes:\n Decreased rr to 30 from 36, driving pressure to 26 from 28: 7.4/38/89\n Rate decreased to 26 from 30, patient\nagitated\n and , \n increased rr to 30 and temp 100% fio2.\n Overnight dropped tidal volumes, and change in compliance, was\n suctioned, ? mucous plug. Cxr obtained, w/ ? new L mid lung / lingula\n opacification.\n Driving pressure increased back to 28 in light of this.\n TV improved back to normal.\n TUBE feed rate increased\n Allergies:\n Flagyl (Oral) (Metronidazole)\n Rash;\n Last dose of Antibiotics:\n Bactrim (SMX/TMP) - 09:00 AM\n Levofloxacin - 09:11 AM\n Vancomycin - 08:00 PM\n Caspofungin - 08:23 PM\n Acyclovir - 12:17 AM\n Piperacillin/Tazobactam (Zosyn) - 05:15 AM\n Infusions:\n Fentanyl - 500 mcg/hour\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:22 PM\n Famotidine (Pepcid) - 08:23 PM\n Midazolam (Versed) - 01:15 AM\n Fentanyl - 01:15 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:07 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.3\nC (99.2\n Tcurrent: 37.2\nC (99\n HR: 48 (45 - 67) bpm\n BP: 114/51(69) {114/51(69) - 144/73(97)} mmHg\n RR: 30 (23 - 30) insp/min\n SpO2: 92%\n Heart rhythm: SB (Sinus Bradycardia)\n Wgt (current): 76.3 kg (admission): 76.3 kg\n Height: 68 Inch\n CVP: 15 (12 - 314)mmHg\n CO/CI (CCO): (4.5 L/min) / (2.4 L/min/m2)\n Total In:\n 3,451 mL\n 1,236 mL\n PO:\n TF:\n 485 mL\n 458 mL\n IVF:\n 2,506 mL\n 528 mL\n Blood products:\n Total out:\n 1,805 mL\n 600 mL\n Urine:\n 1,805 mL\n 600 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,646 mL\n 636 mL\n Respiratory support\n Ventilator mode: PCV+\n PC : 28 cmH2O\n RR (Set): 30\n PEEP: 12 cmH2O\n FiO2: 1%\n RSBI Deferred: PEEP > 10\n PIP: 39 cmH2O\n SpO2: 92%\n ABG: 7.41/40/85./26/0\n Ve: 15 L/min\n PaO2 / FiO2: 17,000\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 120 K/uL\n 10.3 g/dL\n 122 mg/dL\n 1.0 mg/dL\n 26 mEq/L\n 3.9 mEq/L\n 26 mg/dL\n 110 mEq/L\n 142 mEq/L\n 31.2 %\n 12.1 K/uL\n [image002.jpg]\n 04:46 AM\n 04:59 PM\n 03:12 AM\n 06:06 AM\n 02:28 PM\n 06:28 PM\n 09:12 PM\n 01:58 AM\n 04:48 AM\n 05:04 AM\n WBC\n 10.2\n 12.1\n Hct\n 31.7\n 31.2\n Plt\n 136\n 120\n Cr\n 1.1\n 1.0\n TCO2\n 25\n 26\n 26\n 24\n 24\n 26\n 28\n 26\n Glucose\n 91\n 122\n Other labs: PT / PTT / INR:13.5/29.8/1.2, CK / CKMB /\n Troponin-T:260/9/0.22, ALT / AST:57/31, Alk Phos / T Bili:70/0.4,\n Amylase / Lipase:53/22, Differential-Neuts:67.0 %, Band:2.0 %,\n Lymph:18.0 %, Mono:9.0 %, Eos:0.0 %, Lactic Acid:1.3 mmol/L,\n Albumin:2.7 g/dL, LDH:272 IU/L, Ca++:7.5 mg/dL, Mg++:2.2 mg/dL, PO4:3.1\n mg/dL\n Assessment and Plan\n 50M h/o metastatic renal CA s/p nephrectomy, IL-2, mini-allograft SCT,\n DLI x 2 last in , emphysema/pulmonary fibrosis on home 02\n presented to OSH with hypoxic respiratory failure, fevers and\n hypotension.\n # Respiratory failure:\n Pneumonia as likely source of resp failure and sepsis in patient with\n poor pulmonary reserve due to emphysema, ?GVHD, fibrosis.\n Pt was dysynchronous w/ vent yesterday w/ decreasing sedation of fent /\n midazolam although methadone was added; oxygenation seems to worsen\n when patient is dysynchronous / less sedated.\n Sats decreased overnight and placed back on 50% FiO2.\n Had air trapping w/ high RR; will decrease RR and driving pressure if\n tolerates.\n Cont sedation w/ fent / midazolam / methadone; no urgency in relieving\n sedating w/ high vent needs.\n # Septic shock:\n **Likely source pneumonia. On very broad coverage w/ vancomycin,\n levofloxacin, bactrim (now only ppx dosing), caspofungin.\n All other cultures pending. WBC and fever curve responding well. Will\n cont broad coverage for now; consider d/c caspofungin tomorrow if\n cultures negative, since this is unlikely acute fungal pneumonia, and\n more likely bacterial.\n Since responding no need for CT chest currently.\n Also, won\nt tolerate bronch at this point, plus diagnostic studies\n probably no longer useful (culture).\n - f/u cultures\n - Legionella urine ag negative, all other cultures no growth to date.\n - D/C caspofungin sun if cultures negative\n - Glucan, galactomannan pending\n - Follow WBC count, fever curve, decreasing\n - PPD negative\n - Continue acyclovir ppx, vanc/zosyn/levoflox\n **Hypotension\n Now improved BPs, off dobutamine.\n Shock likely mix of septic, cardiogenic, and metabolic (absolute\n adrenal insufficiency). CVP goal > 8, and meeting that criteria. From\n cardiac perspective, RV hypokinesis and dysfunction though to be \n high intrapulmonary pressures (hypoxia, pulmonary fibrosis). Now able\n to maintain BP off dobutamine. Although CI decreased, will cont to\n follow urine output and MAP trend.\n For endocrine, pt w/ hx of adrenalectomy and adrenal gland w/ mets.\n - cont IV hydrocortisone taerp.\n # Metastatic renal CA: Recurrent disease s/p donor lymphocyte\n transplant .\n - BMT to follow\n - Continue acyclovir ppx for now, will discuss with BMT\n # Sedation\n Goals of sedation have been clarified; being too light was causing\n problems w/ oxygenation. Pt also was requiring supra-normal levels of\n midaz/fentanyl. Now adequately sedated on midax / fent / methadone.\n Cont this regimen for now and hold off on further sedation until\n ventilatory needs decrease.\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 05:04 AM 70 mL/hour\n Glycemic Control:\n Lines:\n Multi Lumen - 11:24 PM\n Arterial Line - 12:14 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": "2120-04-21 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 323246, "text": "Chief Complaint:\n 24 Hour Events:\n EKG - At 06:04 PM\n Vent changes:\n Decreased rr to 30 from 36, driving pressure to 26 from 28: 7.4/38/89\n Rate decreased to 26 from 30, patient\nagitated\n and , \n increased rr to 30 and temp 100% fio2.\n Overnight dropped tidal volumes, and change in compliance, was\n suctioned, ? mucous plug. Cxr obtained, w/ ? new L mid lung / lingula\n opacification.\n Driving pressure increased back to 28 in light of this.\n TV improved back to normal.\n TUBE feed rate increased\n Allergies:\n Flagyl (Oral) (Metronidazole)\n Rash;\n Last dose of Antibiotics:\n Bactrim (SMX/TMP) - 09:00 AM\n Levofloxacin - 09:11 AM\n Vancomycin - 08:00 PM\n Caspofungin - 08:23 PM\n Acyclovir - 12:17 AM\n Piperacillin/Tazobactam (Zosyn) - 05:15 AM\n Infusions:\n Fentanyl - 500 mcg/hour\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:22 PM\n Famotidine (Pepcid) - 08:23 PM\n Midazolam (Versed) - 01:15 AM\n Fentanyl - 01:15 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:07 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.3\nC (99.2\n Tcurrent: 37.2\nC (99\n HR: 48 (45 - 67) bpm\n BP: 114/51(69) {114/51(69) - 144/73(97)} mmHg\n RR: 30 (23 - 30) insp/min\n SpO2: 92%\n Heart rhythm: SB (Sinus Bradycardia)\n Wgt (current): 76.3 kg (admission): 76.3 kg\n Height: 68 Inch\n CVP: 15 (12 - 314)mmHg\n CO/CI (CCO): (4.5 L/min) / (2.4 L/min/m2)\n Total In:\n 3,451 mL\n 1,236 mL\n PO:\n TF:\n 485 mL\n 458 mL\n IVF:\n 2,506 mL\n 528 mL\n Blood products:\n Total out:\n 1,805 mL\n 600 mL\n Urine:\n 1,805 mL\n 600 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,646 mL\n 636 mL\n Respiratory support\n Ventilator mode: PCV+\n PC : 28 cmH2O\n RR (Set): 30\n PEEP: 12 cmH2O\n FiO2: 1%\n RSBI Deferred: PEEP > 10\n PIP: 39 cmH2O\n SpO2: 92%\n ABG: 7.41/40/85./26/0\n Ve: 15 L/min\n PaO2 / FiO2: 17,000\n Physical Examination\n Gen: eyes open, not following commands, some evidence of localization\n side to side when calling name\n Heent: pupils equal. Intubated, ng tube and esophageal balloon in\n place\n Cor: rrr, nls1s2 no mrg\n Pul: cta anteriorly\n Abd: moderately distended. Bowel sounds present, no guarding, no\n tenderness / facial grimacing w/ palpation, no masses\n Extreme: warm, 2+ pitting edema to mid-thigh\n Neuro: sedated, eyes open, not responding to commands,\n Labs / Radiology\n 120 K/uL\n 10.3 g/dL\n 122 mg/dL\n 1.0 mg/dL\n 26 mEq/L\n 3.9 mEq/L\n 26 mg/dL\n 110 mEq/L\n 142 mEq/L\n 31.2 %\n 12.1 K/uL\n [image002.jpg]\n 04:46 AM\n 04:59 PM\n 03:12 AM\n 06:06 AM\n 02:28 PM\n 06:28 PM\n 09:12 PM\n 01:58 AM\n 04:48 AM\n 05:04 AM\n WBC\n 10.2\n 12.1\n Hct\n 31.7\n 31.2\n Plt\n 136\n 120\n Cr\n 1.1\n 1.0\n TCO2\n 25\n 26\n 26\n 24\n 24\n 26\n 28\n 26\n Glucose\n 91\n 122\n Other labs: PT / PTT / INR:13.5/29.8/1.2, CK / CKMB /\n Troponin-T:260/9/0.22, ALT / AST:57/31, Alk Phos / T Bili:70/0.4,\n Amylase / Lipase:53/22, Differential-Neuts:67.0 %, Band:2.0 %,\n Lymph:18.0 %, Mono:9.0 %, Eos:0.0 %, Lactic Acid:1.3 mmol/L,\n Albumin:2.7 g/dL, LDH:272 IU/L, Ca++:7.5 mg/dL, Mg++:2.2 mg/dL, PO4:3.1\n mg/dL\n Assessment and Plan\n 50M h/o metastatic renal CA s/p nephrectomy, IL-2, mini-allograft SCT,\n DLI x 2 last in , emphysema/pulmonary fibrosis on home 02\n presented to OSH with hypoxic respiratory failure, fevers and\n hypotension.\n # Respiratory failure:\n Pneumonia as likely source of resp failure and sepsis in patient with\n poor pulmonary reserve due to emphysema, ?GVHD, fibrosis.\n Pt was dysynchronous w/ vent yesterday w/ decreasing sedation of fent /\n midazolam although methadone was added; oxygenation seems to worsen\n when patient is dysynchronous / less sedated.\n Sats decreased overnight and placed back on 50% FiO2.\n Had air trapping w/ high RR; will decrease RR and driving pressure if\n tolerates.\n Cont sedation w/ fent / midazolam / methadone; no urgency in relieving\n sedating w/ high vent needs.\n # Septic shock:\n **Likely source pneumonia. On very broad coverage w/ vancomycin,\n levofloxacin, bactrim (now only ppx dosing), caspofungin.\n All other cultures pending. WBC and fever curve responding well. Will\n cont broad coverage for now; consider d/c caspofungin tomorrow if\n cultures negative, since this is unlikely acute fungal pneumonia, and\n more likely bacterial.\n Since responding no need for CT chest currently.\n Also, won\nt tolerate bronch at this point, plus diagnostic studies\n probably no longer useful (culture).\n - f/u cultures\n - Legionella urine ag negative, all other cultures no growth to date.\n - D/C caspofungin sun if cultures negative\n - Glucan, galactomannan pending\n - Follow WBC count, fever curve, decreasing\n - PPD negative\n - Continue acyclovir ppx, vanc/zosyn/levoflox\n **Hypotension\n Now improved BPs, off dobutamine.\n Shock likely mix of septic, cardiogenic, and metabolic (absolute\n adrenal insufficiency). CVP goal > 8, and meeting that criteria. From\n cardiac perspective, RV hypokinesis and dysfunction though to be \n high intrapulmonary pressures (hypoxia, pulmonary fibrosis). Now able\n to maintain BP off dobutamine. Although CI decreased, will cont to\n follow urine output and MAP trend.\n For endocrine, pt w/ hx of adrenalectomy and adrenal gland w/ mets.\n - cont IV hydrocortisone taerp.\n # Metastatic renal CA: Recurrent disease s/p donor lymphocyte\n transplant .\n - BMT to follow\n - Continue acyclovir ppx for now, will discuss with BMT\n # Sedation\n Goals of sedation have been clarified; being too light was causing\n problems w/ oxygenation. Pt also was requiring supra-normal levels of\n midaz/fentanyl. Now adequately sedated on midax / fent / methadone.\n Cont this regimen for now and hold off on further sedation until\n ventilatory needs decrease.\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 05:04 AM 70 mL/hour\n Glycemic Control:\n Lines:\n Multi Lumen - 11:24 PM\n Arterial Line - 12:14 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": "2120-04-21 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 323249, "text": "Chief Complaint:\n 24 Hour Events:\n EKG - At 06:04 PM\n Vent changes:\n Decreased rr to 30 from 36, driving pressure to 26 from 28: 7.4/38/89\n Rate decreased to 26 from 30, patient\nagitated\n and , \n increased rr to 30 and temp 100% fio2.\n Overnight dropped tidal volumes, and change in compliance, was\n suctioned, ? mucous plug. Cxr obtained, w/ ? new L mid lung / lingula\n opacification.\n Driving pressure increased back to 28 in light of this.\n TV improved back to normal.\n TUBE feed rate increased\n Allergies:\n Flagyl (Oral) (Metronidazole)\n Rash;\n Last dose of Antibiotics:\n Bactrim (SMX/TMP) - 09:00 AM\n Levofloxacin - 09:11 AM\n Vancomycin - 08:00 PM\n Caspofungin - 08:23 PM\n Acyclovir - 12:17 AM\n Piperacillin/Tazobactam (Zosyn) - 05:15 AM\n Infusions:\n Fentanyl - 500 mcg/hour\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:22 PM\n Famotidine (Pepcid) - 08:23 PM\n Midazolam (Versed) - 01:15 AM\n Fentanyl - 01:15 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:07 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.3\nC (99.2\n Tcurrent: 37.2\nC (99\n HR: 48 (45 - 67) bpm\n BP: 114/51(69) {114/51(69) - 144/73(97)} mmHg\n RR: 30 (23 - 30) insp/min\n SpO2: 92%\n Heart rhythm: SB (Sinus Bradycardia)\n Wgt (current): 76.3 kg (admission): 76.3 kg\n Height: 68 Inch\n CVP: 15 (12 - 314)mmHg\n CO/CI (CCO): (4.5 L/min) / (2.4 L/min/m2)\n Total In:\n 3,451 mL\n 1,236 mL\n PO:\n TF:\n 485 mL\n 458 mL\n IVF:\n 2,506 mL\n 528 mL\n Blood products:\n Total out:\n 1,805 mL\n 600 mL\n Urine:\n 1,805 mL\n 600 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,646 mL\n 636 mL\n Respiratory support\n Ventilator mode: PCV+\n PC : 28 cmH2O\n RR (Set): 30\n PEEP: 12 cmH2O\n FiO2: 1%\n RSBI Deferred: PEEP > 10\n PIP: 39 cmH2O\n SpO2: 92%\n ABG: 7.41/40/85./26/0\n Ve: 15 L/min\n PaO2 / FiO2: 17,000\n Physical Examination\n Gen: eyes open, not following commands, some evidence of localization\n side to side when calling name\n Heent: pupils equal. Intubated, ng tube and esophageal balloon in\n place\n Cor: rrr, nls1s2 no mrg\n Pul: cta anteriorly\n Abd: moderately distended. Bowel sounds present, no guarding, no\n tenderness / facial grimacing w/ palpation, no masses\n Extreme: warm, 2+ pitting edema to mid-thigh\n Neuro: sedated, eyes open, not responding to commands,\n Labs / Radiology\n 120 K/uL\n 10.3 g/dL\n 122 mg/dL\n 1.0 mg/dL\n 26 mEq/L\n 3.9 mEq/L\n 26 mg/dL\n 110 mEq/L\n 142 mEq/L\n 31.2 %\n 12.1 K/uL\n [image002.jpg]\n 04:46 AM\n 04:59 PM\n 03:12 AM\n 06:06 AM\n 02:28 PM\n 06:28 PM\n 09:12 PM\n 01:58 AM\n 04:48 AM\n 05:04 AM\n WBC\n 10.2\n 12.1\n Hct\n 31.7\n 31.2\n Plt\n 136\n 120\n Cr\n 1.1\n 1.0\n TCO2\n 25\n 26\n 26\n 24\n 24\n 26\n 28\n 26\n Glucose\n 91\n 122\n Other labs: PT / PTT / INR:13.5/29.8/1.2, CK / CKMB /\n Troponin-T:260/9/0.22, ALT / AST:57/31, Alk Phos / T Bili:70/0.4,\n Amylase / Lipase:53/22, Differential-Neuts:67.0 %, Band:2.0 %,\n Lymph:18.0 %, Mono:9.0 %, Eos:0.0 %, Lactic Acid:1.3 mmol/L,\n Albumin:2.7 g/dL, LDH:272 IU/L, Ca++:7.5 mg/dL, Mg++:2.2 mg/dL, PO4:3.1\n mg/dL\n Micro\n Blood culture 4/15+ pending\n Urine culture final negative\n Legionella negative\n RADS\n \n Cxr\n Persistent abnormal interstitial pattern. Diagnostic considerations\n include\n pulmonary fibrosis.\n Support lines unchanged, allowing for differences in patient\n positioning. The\n feeding tube is again noted to terminate at the GE junction. The\n feeding tube\n should be advanced.\n **the\n feeding tube\n is actually the esophageal balloon in correct\n position. Ng tube is seen below diaphragm.\n Assessment and Plan\n 50M h/o metastatic renal CA s/p nephrectomy, IL-2, mini-allograft SCT,\n DLI x 2 last in , emphysema/pulmonary fibrosis on home 02\n presented to OSH with hypoxic respiratory failure, fevers and\n hypotension.\n # Respiratory failure:\n Pneumonia as likely source of resp failure and sepsis in patient with\n poor pulmonary reserve due to emphysema, ?GVHD, fibrosis.\n Pt was dysynchronous w/ vent yesterday w/ decreasing sedation of fent /\n midazolam although methadone was added; oxygenation seems to worsen\n when patient is dysynchronous / less sedated.\n Sats decreased overnight and placed back on 50% FiO2.\n Had air trapping w/ high RR; will decrease RR and driving pressure if\n tolerates.\n Cont sedation w/ fent / midazolam / methadone; no urgency in relieving\n sedating w/ high vent needs.\n # Septic shock:\n **Likely source pneumonia. On very broad coverage w/ vancomycin,\n levofloxacin, bactrim (now only ppx dosing), caspofungin.\n All other cultures pending. WBC and fever curve responding well. Will\n cont broad coverage for now; consider d/c caspofungin tomorrow if\n cultures negative, since this is unlikely acute fungal pneumonia, and\n more likely bacterial.\n Since responding no need for CT chest currently.\n Also, won\nt tolerate bronch at this point, plus diagnostic studies\n probably no longer useful (culture).\n - f/u cultures\n - Legionella urine ag negative, all other cultures no growth to date.\n - D/C caspofungin sun if cultures negative\n - Glucan, galactomannan pending\n - Follow WBC count, fever curve, decreasing\n - PPD negative\n - Continue acyclovir ppx, vanc/zosyn/levoflox\n **Hypotension\n Now improved BPs, off dobutamine.\n Shock likely mix of septic, cardiogenic, and metabolic (absolute\n adrenal insufficiency). CVP goal > 8, and meeting that criteria. From\n cardiac perspective, RV hypokinesis and dysfunction though to be \n high intrapulmonary pressures (hypoxia, pulmonary fibrosis). Now able\n to maintain BP off dobutamine. Although CI decreased, will cont to\n follow urine output and MAP trend.\n For endocrine, pt w/ hx of adrenalectomy and adrenal gland w/ mets.\n - cont IV hydrocortisone taerp.\n # Metastatic renal CA: Recurrent disease s/p donor lymphocyte\n transplant .\n - BMT to follow\n - Continue acyclovir ppx for now, will discuss with BMT\n # Sedation\n Goals of sedation have been clarified; being too light was causing\n problems w/ oxygenation. Pt also was requiring supra-normal levels of\n midaz/fentanyl. Now adequately sedated on midax / fent / methadone.\n Cont this regimen for now and hold off on further sedation until\n ventilatory needs decrease.\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 05:04 AM 70 mL/hour\n Glycemic Control: ssi\n Lines:\n Multi Lumen - 11:24 PM\n Arterial Line - 12:14 AM\n Prophylaxis:\n DVT: sq heparin\n Stress ulcer: famotidine\n VAP: vap bundle\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: icu\n" }, { "category": "Physician ", "chartdate": "2120-04-27 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 323913, "text": "Chief Complaint: 50M h/o metastatic renal CA s/p nephrectomy, IL-2,\n mini-allograft SCT, DLI x 2 last in , emphysema/pulmonary fibrosis\n on home 02 presented to OSH with hypoxic respiratory failure, sepsis,\n cardiogenic shock, now improving but with difficulty weaning vent and\n s/p trach/PEG.\n 24 Hour Events:\n ARTERIAL LINE - STOP 08:00 AM\n - hypotensive to the 70s after trial of PS. Unclear why, but thought\n that maybe preload dependancy and increased PEEP, and\n intravascularly volume deplete from all of the auto-diuresis\n - given 3L NS with improvement in his BP to the 90s\n - IP felt that cuff leak not significant enough to do anything about\n right now; will re-evaluate in a few days when tract is more matured\n Allergies:\n Flagyl (Oral) (Metronidazole)\n Rash;\n Last dose of Antibiotics:\n Caspofungin - 09:28 PM\n Levofloxacin - 08:16 AM\n Bactrim (SMX/TMP) - 08:16 AM\n Vancomycin - 08:03 PM\n Acyclovir - 12:17 AM\n Piperacillin/Tazobactam (Zosyn) - 06:02 AM\n Infusions:\n Propofol - 25 mcg/Kg/min\n Other ICU medications:\n Lorazepam (Ativan) - 12:45 PM\n Heparin Sodium (Prophylaxis) - 08:00 PM\n Famotidine (Pepcid) - 09:58 PM\n Other medications:\n Senna prn\n Artificial tears prn\n Captopril 25mg TID\n Methadone 20mg Q4\n Nystatin\n Bactrim\n Acetaminophen prn\n Folic acid\n Albuterol prn\n Acyclovir\n Asa\n ISS\n Docusate prn\n Bisacodyl prn\n Chlorhexidine\n Changes to medical and family history: None\n Review of systems is unchanged from admission except as noted below\n Review of systems: Intubated\n Flowsheet Data as of 08:23 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.2\nC (100.8\n Tcurrent: 36.9\nC (98.4\n HR: 67 (61 - 138) bpm\n BP: 116/67(79) {81/49(50) - 130/94(102)} mmHg\n RR: 18 (13 - 30) insp/min\n SpO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 76.3 kg (admission): 76.3 kg\n Height: 68 Inch\n CVP: 10 (5 - 17)mmHg\n Total In:\n 5,572 mL\n 963 mL\n PO:\n TF:\n 311 mL\n 439 mL\n IVF:\n 4,766 mL\n 274 mL\n Blood products:\n Total out:\n 3,713 mL\n 860 mL\n Urine:\n 3,113 mL\n 860 mL\n NG:\n 600 mL\n Stool:\n Drains:\n Balance:\n 1,859 mL\n 103 mL\n Respiratory support\n Ventilator mode: PCV+\n Vt (Spontaneous): 470 (470 - 740) mL\n PC : 24 cmH2O\n PS : 20 cmH2O\n RR (Set): 30\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 60%\n PIP: 29 cmH2O\n SpO2: 93%\n ABG: 7.38/49/67/23/2\n Ve: 11.7 L/min\n PaO2 / FiO2: 112\n Physical Examination\n Gen: Sedated, opens eyes to voice, no purposeful movements, mildly\n agitated, moving legs in bed.\n Heent: pupils equal. Trached.\n Cor: RRR, nls1s2 no mr\n Pul: CTA anteriorly\n coarse, mechanical breath sounds\n Abd: moderately distended. Bowel sounds present, PEG in placed,\n dressed, no guarding, no tenderness\n Extreme: Warm, trace pitting edema to mid-thigh\n Labs / Radiology\n 145 K/uL\n 9.6 g/dL\n 80 mg/dL\n 1.0 mg/dL\n 23 mEq/L\n 4.0 mEq/L\n 15 mg/dL\n 110 mEq/L\n 141 mEq/L\n 29.2 %\n 11.1 K/uL\n [image002.jpg]\n 10:07 PM\n 04:05 AM\n 04:29 AM\n 03:23 PM\n 06:00 PM\n 04:43 AM\n 02:25 PM\n 05:37 PM\n 09:20 PM\n 04:49 AM\n WBC\n 13.6\n 15.0\n 11.1\n Hct\n 31.6\n 34.0\n 28.1\n 31.5\n 29.2\n Plt\n 149\n 159\n 145\n Cr\n 1.0\n 1.0\n 1.0\n TCO2\n 34\n 35\n 27\n 30\n Glucose\n 70\n 76\n 65\n 80\n Other labs: PT / PTT / INR:13.7/42.1/1.2, CK / CKMB /\n Troponin-T:260/9/0.22, ALT / AST:57/31, Alk Phos / T Bili:70/0.4,\n Amylase / Lipase:53/22, Differential-Neuts:67.0 %, Band:2.0 %,\n Lymph:18.0 %, Mono:9.0 %, Eos:0.0 %, Lactic Acid:2.0 mmol/L,\n Albumin:2.6 g/dL, LDH:272 IU/L, Ca++:7.6 mg/dL, Mg++:2.2 mg/dL, PO4:2.4\n mg/dL\n Micro: Blood cultures from , , and : no growth to\n date\n Sputum: : No growth\n : OP contamination, test cancelled\n Urine culture: , , , : no growth\n c. diff : negative\n b-glucan and galactomannan negative\n CXR :\n FINDINGS:\n On today's examination, there is worsening opacification seen in both\n lungs,\n predominantly in the mid and lower regions. The chronic interstitial\n lung\n disease is stable. The heart size is within normal limits. Minimal\n present\n pleural effusion is again noted with no change. The ET tube is 4.6 cm\n from\n the carina.\n IMPRESSION:\n 1. The acute changes noted in both lungs favor edema, although\n aspiration\n cannot be completely excluded.\n 2. Chronic interstitial lung fibrotic disease.\n Assessment and Plan\n 50M h/o metastatic renal CA s/p nephrectomy, IL-2, mini-allograft SCT,\n DLI x 2 last in , emphysema/pulmonary fibrosis on home 02\n presented to OSH with hypoxic respiratory failure, sepsis, cardiogenic\n shock, now improving but with difficulty weaning vent and s/p\n trach/PEG.\n # Respiratory failure: Pneumonia as likely source of resp failure and\n sepsis in patient with poor pulmonary reserve due to emphysema, ?GVHD,\n fibrosis. Patient is now s/p trach/PEG on . PEEP yesterday\n decreased to 5 yesterday after trach placement. Pt has small cuff\n leak. IP had evaluated this am and wanted to continue to monitor for\n now. This am pt agitated, low 02 sats. Has increasing Fi02\n requirement from 40% now up to 60%.\n -increase PEEP to 8, temporarily switch to volume control to ensure\n adequate tidal volumes on increased PEEP in setting of cuff leak.\n - Driving pressures decreased this am from 24 to 20. Will check ABG on\n current settings.\n - Attempt decrease in FiO2 today (50->40%) -> maintain PaO2 >60.\n Patient's oxygenation has improved.\n - Can also attempt PSV trial today if able to adequately wean sedation\n without agitation.\n - Plan to replace trach today by IP given persistent air leak.\n # Sedation: Currently on methadone q4H, and propofol for sedation,\n currently at 20 mcg/kg/min. Off fent/versed drips.\n - Goal to wean propofol as tolerated today, triglycerides mildly\n elevated at 182\n - Continue to check triglycerides twice weekly while on propofol.\n - Bolus fentanyl/ativan prn agitation\n - When able, will decrease methadone to q6H then to q8H\n # Shock: Multifactorial, resolved.\n ** Sepsis: Likely source pneumonia. On very broad coverage w/\n vancomycin, levofloxacin, zosyn, bactrim (now only ppx dosing). All\n cultures pending or no growth. WBC stable. Patient with temp 100.8\n rectal this am during rounds. Blood cx/urine cx sent.\n - D/C'd caspo yesterday\n - F/u cultures - cont to culture with spikes.\n - Continue acyclovir and bactrim ppx, vanc/zosyn/levoflox for 14 day\n course, today is day 10.\n **Cardiogenic\n ## Pump: Now improved BPs, off dobutamine. On captopril for afterload\n reduction. Dilated hypokinetic RV, likely causative in hypotension.\n Now hypertensive. Increased to 25mg TID. Will likely need repeat ECHO\n once acute issues resolved to assess for resolution of RV dysfunction.\n ## Rhythm: Sinus bradycardia likely secondary to sedatives; increases\n with agitation. Cont weaning sedation as tolerated. Continue to\n follow QTc for prolongation given methadone and levoflox, has been wnl\n **Endocrine\n - Prednisone off today\n # Metastatic renal CA: Recurrent disease s/p donor lymphocyte\n transplant .\n - BMT to follow\n - Continue acyclovir and bactrim ppx\n ICU Care\n Nutrition:\n Restart TF 24 hours after PEG\n Glycemic Control:\n Lines:\n Multi Lumen - 11:24 PM\n Arterial Line - 12:14 AM\n Prophylaxis:\n DVT: Pneumoboots, SQ heparin\n Stress ulcer: H2 blocker\n VAP: HOB elevation, mouth care\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n" }, { "category": "Physician ", "chartdate": "2120-04-27 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 323914, "text": "Chief Complaint: 50M h/o metastatic renal CA s/p nephrectomy, IL-2,\n mini-allograft SCT, DLI x 2 last in , emphysema/pulmonary fibrosis\n on home 02 presented to OSH with hypoxic respiratory failure, sepsis,\n cardiogenic shock, now improving but with difficulty weaning vent and\n s/p trach/PEG.\n 24 Hour Events:\n ARTERIAL LINE - STOP 08:00 AM\n - hypotensive to the 70s after trial of PS. Unclear why, but thought\n that maybe preload dependancy and increased PEEP, and\n intravascularly volume deplete from all of the auto-diuresis\n - given 3L NS with improvement in his BP to the 90s\n - IP felt that cuff leak not significant enough to do anything about\n right now; will re-evaluate in a few days when tract is more matured\n Allergies:\n Flagyl (Oral) (Metronidazole)\n Rash;\n Last dose of Antibiotics:\n Caspofungin - 09:28 PM\n Levofloxacin - 08:16 AM\n Bactrim (SMX/TMP) - 08:16 AM\n Vancomycin - 08:03 PM\n Acyclovir - 12:17 AM\n Piperacillin/Tazobactam (Zosyn) - 06:02 AM\n Infusions:\n Propofol - 25 mcg/Kg/min\n Other ICU medications:\n Lorazepam (Ativan) - 12:45 PM\n Heparin Sodium (Prophylaxis) - 08:00 PM\n Famotidine (Pepcid) - 09:58 PM\n Other medications:\n Senna prn\n Artificial tears prn\n Captopril 25mg TID\n Methadone 20mg Q4\n Nystatin\n Bactrim\n Acetaminophen prn\n Folic acid\n Albuterol prn\n Acyclovir\n Asa\n ISS\n Docusate prn\n Bisacodyl prn\n Chlorhexidine\n Changes to medical and family history: None\n Review of systems is unchanged from admission except as noted below\n Review of systems: Intubated\n Flowsheet Data as of 08:23 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.2\nC (100.8\n Tcurrent: 36.9\nC (98.4\n HR: 67 (61 - 138) bpm\n BP: 116/67(79) {81/49(50) - 130/94(102)} mmHg\n RR: 18 (13 - 30) insp/min\n SpO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 76.3 kg (admission): 76.3 kg\n Height: 68 Inch\n CVP: 10 (5 - 17)mmHg\n Total In:\n 5,572 mL\n 963 mL\n PO:\n TF:\n 311 mL\n 439 mL\n IVF:\n 4,766 mL\n 274 mL\n Blood products:\n Total out:\n 3,713 mL\n 860 mL\n Urine:\n 3,113 mL\n 860 mL\n NG:\n 600 mL\n Stool:\n Drains:\n Balance:\n 1,859 mL\n 103 mL\n Respiratory support\n Ventilator mode: PCV+\n Vt (Spontaneous): 470 (470 - 740) mL\n PC : 24 cmH2O\n PS : 20 cmH2O\n RR (Set): 30\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 60%\n PIP: 29 cmH2O\n SpO2: 93%\n ABG: 7.38/49/67/23/2\n Ve: 11.7 L/min\n PaO2 / FiO2: 112\n Physical Examination\n Gen: Sedated, opens eyes to voice, no purposeful movements, mildly\n agitated, moving legs in bed.\n Heent: pupils equal. Trached.\n Cor: RRR, nls1s2 no mr\n Pul: CTA anteriorly\n coarse, mechanical breath sounds\n Abd: moderately distended. Bowel sounds present, PEG in placed,\n dressed, no guarding, no tenderness\n Extreme: Warm, trace pitting edema to mid-thigh\n Labs / Radiology\n 145 K/uL\n 9.6 g/dL\n 80 mg/dL\n 1.0 mg/dL\n 23 mEq/L\n 4.0 mEq/L\n 15 mg/dL\n 110 mEq/L\n 141 mEq/L\n 29.2 %\n 11.1 K/uL\n [image002.jpg]\n 10:07 PM\n 04:05 AM\n 04:29 AM\n 03:23 PM\n 06:00 PM\n 04:43 AM\n 02:25 PM\n 05:37 PM\n 09:20 PM\n 04:49 AM\n WBC\n 13.6\n 15.0\n 11.1\n Hct\n 31.6\n 34.0\n 28.1\n 31.5\n 29.2\n Plt\n 149\n 159\n 145\n Cr\n 1.0\n 1.0\n 1.0\n TCO2\n 34\n 35\n 27\n 30\n Glucose\n 70\n 76\n 65\n 80\n Other labs: PT / PTT / INR:13.7/42.1/1.2, CK / CKMB /\n Troponin-T:260/9/0.22, ALT / AST:57/31, Alk Phos / T Bili:70/0.4,\n Amylase / Lipase:53/22, Differential-Neuts:67.0 %, Band:2.0 %,\n Lymph:18.0 %, Mono:9.0 %, Eos:0.0 %, Lactic Acid:2.0 mmol/L,\n Albumin:2.6 g/dL, LDH:272 IU/L, Ca++:7.6 mg/dL, Mg++:2.2 mg/dL, PO4:2.4\n mg/dL\n Micro: Blood cultures from , , and : no growth to\n date\n Sputum: : No growth\n : OP contamination, test cancelled\n Urine culture: , , , : no growth\n c. diff : negative\n b-glucan and galactomannan negative\n CXR :\n FINDINGS:\n On today's examination, there is worsening opacification seen in both\n lungs,\n predominantly in the mid and lower regions. The chronic interstitial\n lung\n disease is stable. The heart size is within normal limits. Minimal\n present\n pleural effusion is again noted with no change. The ET tube is 4.6 cm\n from\n the carina.\n IMPRESSION:\n 1. The acute changes noted in both lungs favor edema, although\n aspiration\n cannot be completely excluded.\n 2. Chronic interstitial lung fibrotic disease.\n Assessment and Plan\n 50M h/o metastatic renal CA s/p nephrectomy, IL-2, mini-allograft SCT,\n DLI x 2 last in , emphysema/pulmonary fibrosis on home 02\n presented to OSH with hypoxic respiratory failure, sepsis, cardiogenic\n shock, now improving but with difficulty weaning vent and s/p\n trach/PEG.\n # Respiratory failure: Pneumonia as likely source of resp failure and\n sepsis in patient with poor pulmonary reserve due to emphysema, ?GVHD,\n fibrosis. Patient is now s/p trach/PEG on . PEEP yesterday\n decreased to 5 yesterday after trach placement. Pt has small cuff\n leak. IP had evaluated this am and wanted to continue to monitor for\n now. This am pt agitated, low 02 sats. Has increasing Fi02\n requirement from 40% now up to 60%.\n -increase PEEP to 8, temporarily switch to volume control to ensure\n adequate tidal volumes on increased PEEP in setting of cuff leak.\n - Driving pressures decreased yesterday from 24 to 20. Continue to\n monitor patient if persistent breathing over vent consider resuming\n prior pressures.\n -attempted PS yesterday, pt became hypotensive. Now on pressure\n control.\n -treat PNA for planned 14 day course. B-glucan, galactomannan\n negative, caspogungin d/c\n # Sedation: Currently on methadone q4H, and propofol for sedation,\n currently at 20 mcg/kg/min. Off fent/versed drips, using fentanyl and\n lorazepam boluses for agitation.\n - Goal to wean propofol as tolerated today, triglycerides mildly\n elevated at 182\n - Continue to check triglycerides twice weekly while on propofol. Last\n checked \n - When able, will decrease methadone to q6H then to q8H\n # Shock: Multifactorial, resolved.\n ** Sepsis: Likely source pneumonia. On very broad coverage w/\n vancomycin, levofloxacin, zosyn, bactrim (now only ppx dosing). All\n cultures pending or no growth. WBC stable.\n - D/C'd caspo yesterday\n - F/u cultures - cont to culture with spikes.\n - Continue acyclovir and bactrim ppx, vanc/zosyn/levoflox for 14 day\n course, today is day 10.\n **Cardiogenic\n ## Pump: Now improved BPs, off dobutamine. On captopril for afterload\n reduction. Dilated hypokinetic RV, likely causative in hypotension.\n Now hypertensive. Increased to 25mg TID . Will likely need repeat\n ECHO once acute issues resolved to assess for resolution of RV\n dysfunction.\n -will decrease captopril to 12.5 TID in setting of hypotension\n yesterday.\n ## Rhythm: Sinus bradycardia likely secondary to sedatives; increases\n with agitation. Cont weaning sedation as tolerated. Continue to\n follow QTc for prolongation given methadone and levoflox, has been wnl\n **Endocrine: relative adrenal \n - Prednisone off today\n # Metastatic renal CA: Recurrent disease s/p donor lymphocyte\n transplant .\n - BMT to follow\n - Continue acyclovir and bactrim ppx\n ICU Care\n Nutrition:\n Restart TF 24 hours after PEG, this pm at 3\n Glycemic Control:\n Lines:\n Multi Lumen - 11:24 PM\n Arterial Line - 12:14 AM, needs to be replaced\n Prophylaxis:\n DVT: Pneumoboots, SQ heparin\n Stress ulcer: H2 blocker\n VAP: HOB elevation, mouth care\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n" }, { "category": "Nursing", "chartdate": "2120-04-28 00:00:00.000", "description": "Nursing Progress Note", "row_id": 324018, "text": "Hypotension (not Shock)\n Assessment:\n Pt continues w;/ borderline BP this shift. Continues on vanc, zosyn and\n levofloxacin. Pt has remained afebrile overnoc per report.\n Action:\n Monitoring hemodynamic status closely w/ continuous BP via a-line.\n Monitoring temp. Administering abx as ordered.\n Response:\n SBP 85-90\ns, trending down to 77-85. Pt given total 2L NS bolus w/\n moderate response. Pt continues w/ increased agitation and becomes\n significantly dysynchronous w/ vent when propofol dose titrated down.\n SBP now remains 85-95. Team aware. Tmax 101.4 this shift. RIJ was D/C\n and tip sent for culture. Blood and urine samples also sent for\n culture.\n Plan:\n Continue to monitor hemodynamic status closely. Continue to monitor\n temp and administer abx as ordered.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt remains vented on Pressure control 24/5 X 30 FiO2 60%. Per report pt\n has failed previous PS trials.\n Action:\n No change in vent settings this shift. SpO2 remains stable 90-92% when\n pt adequately sedated. Titrating sedation according to hemodynamic\n status and level of sedation. Monitor respiratory status closely.\n Response:\n BBS tubular to course t/o. Occasional snx for only small amounts of\n thick white secretions. Pt has had a substantial amount of subglotic\n secretions and has been receiving frequent subglotal snx. Pt has also\n had high gastric residuals and TF have been held through most of shift.\n Bowel sounds initially hypoactive, and now normoactive. Pt continues on\n reglan as ordered.\n Plan:\n Continue to follow respiratory assessment closely. Plan for IP to\n further eval cuff leak tomorrow w/ possible plan to change trach.\n Continue pulmonary toilet. Wean sedation as able and wean vent settings\n as pt tolerates.\n" }, { "category": "General", "chartdate": "2120-04-30 00:00:00.000", "description": "Generic Note", "row_id": 324212, "text": "TITLE:\n RESPIRATORY CARE: PT REMAINS W/ AN 8.0 PORTEX TRACH IN\n PLACE. REMAINS ON PRVC RR 42 VT 340 FIO2 .70 PEEP 6 AND PARALYZED AND\n SEDATED. ABG C/W A RESPIRATORY ACIDOSIS AND MODERATE TO SEVERE\n HYPOXEMIA. TPp INSP PLATEAU = 26 AND TPp EXP PLATEAU = 3. SPO2 MONITOR\n 90-93 % THIS SHIFT W/ OCCASIONAL DESATURATION UPON TURNING. SX FOR\n SMALL AMTS THICK YELLOW SPUTUM. BAL SENT TO LAB\n YESTERDAY. ALBUTEROL MDI GIVEN . GOAL ARE TO KEEP PH . 7.20, SPO2 >\n 90-92 %, TPp INSP < OR =\n" }, { "category": "Respiratory ", "chartdate": "2120-05-01 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 324306, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 17\n Ideal body weight: 69.9 None\n Ideal tidal volume: 279.6 / 419.4 / 559.2 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation:\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type:\n Size:\n Tracheostomy tube:\n Type: Cuffed\n Manufacturer: Portex\n Size: 8.0mm\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 50 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: Crackles\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: Comfort measures only\n Reason for continuing current ventilatory support: Underlying illness\n not resolved\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n Pt was taken off the vent at 10:30 am; pt expired at 10:30 am\n" }, { "category": "Nursing", "chartdate": "2120-04-17 00:00:00.000", "description": "Nursing Progress Note", "row_id": 322840, "text": "Sepsis, Severe (with organ dysfunction)\n Assessment:\n Decreasing Ci, on levo and vasopressin.\n Action:\n Decreased levo to off, started dobutamine\n Response:\n Bp improved , CI increased to 2.4\n Plan:\n Cont to monitor hemodynamics, cont mech vent support\n" }, { "category": "Respiratory ", "chartdate": "2120-04-19 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 323074, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 5\n Ideal body weight: 69.9 None\n Ideal tidal volume: 279.6 / 419.4 / 559.2 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation:\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type: Standard\n Size: 7.5mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 20 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Bronchial\n LUL Lung Sounds: Bronchial\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Tan / Thick\n Sputum source/amount: Suctioned / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing;\n Comments: With periods of dysynchrony\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: Utilize ARDSnet protocol\n Reason for continuing current ventilatory support: Sedated / Paralyzed,\n Intolerant of weaning attempts, Underlying illness not resolved\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n" }, { "category": "Physician ", "chartdate": "2120-04-21 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 323279, "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 met renal CA with PNA/mixed cardiogenic shock\n 24 Hour Events:\n Vent: decreased rate/pressure on PC ventilation. Then, got agitated\n with desats-->R back up to 30. Improved with suctioning. ? new lingular\n process on CXR\n TF increased\n Allergies:\n Flagyl (Oral) (Metronidazole)\n Rash;\n Last dose of Antibiotics:\n Bactrim (SMX/TMP) - 09:00 AM\n Levofloxacin - 09:11 AM\n Caspofungin - 08:23 PM\n Piperacillin/Tazobactam (Zosyn) - 05:15 AM\n Acyclovir - 08:03 AM\n Vancomycin - 08:04 AM\n Infusions:\n Midazolam (Versed) - 10 mg/hour\n Fentanyl - 500 mcg/hour\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:22 PM\n Midazolam (Versed) - 01:15 AM\n Fentanyl - 01:15 AM\n Famotidine (Pepcid) - 08:03 AM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 10:52 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.4\nC (99.3\n Tcurrent: 37.4\nC (99.3\n HR: 43 (43 - 63) bpm\n BP: 136/64(84) {114/51(69) - 144/73(97)} mmHg\n RR: 30 (23 - 30) insp/min\n SpO2: 93%\n Heart rhythm: SB (Sinus Bradycardia)\n Wgt (current): 76.3 kg (admission): 76.3 kg\n Height: 68 Inch\n CVP: 20 (12 - 24)mmHg\n CO/CI (CCO): (4.5 L/min) / (2.4 L/min/m2)\n Total In:\n 3,451 mL\n 2,065 mL\n PO:\n TF:\n 485 mL\n 696 mL\n IVF:\n 2,506 mL\n 1,039 mL\n Blood products:\n Total out:\n 1,805 mL\n 1,100 mL\n Urine:\n 1,805 mL\n 1,100 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,646 mL\n 965 mL\n Respiratory support\n Ventilator mode: PCV+\n PC : 28 cmH2O\n RR (Set): 30\n PEEP: 12 cmH2O\n FiO2: 50%\n PIP: 39 cmH2O\n SpO2: 93%\n ABG: 7.41/40/85./26/0\n Ve: 12.7 L/min\n PaO2 / FiO2: 170\n Physical Examination\n General Appearance: No acute distress, Overweight / Obese, 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: Endotracheal tube, No(t) NG tube, OG tube\n Cardiovascular: (S1: Normal), (S2: Normal), No(t) S3, No(t) S4,\n (Murmur: No(t) Systolic, No(t) Diastolic)\n Peripheral Vascular: (Bilateral radial pulse:\n Respiratory / Chest: (Expansion: Symmetric, No(t) Paradoxical), (Breath\n Sounds: Clear : )\n Abdominal: Soft, No(t) Non-tender, Bowel sounds present, Distended,\n No(t) Tender:\n Extremities: Right: Trace, Left: Trace, No(t) Cyanosis, No(t) Clubbing\n Musculoskeletal: No(t) Muscle wasting, No(t) Unable to stand\n Skin: Warm, No(t) Rash: , No(t) Jaundice\n Neurologic: Responds to: Tactile stimuli, Movement: No spontaneous\n movement, Sedated, Tone: Normal\n Labs / Radiology\n 10.3 g/dL\n 120 K/uL\n 122 mg/dL\n 1.0 mg/dL\n 26 mEq/L\n 3.9 mEq/L\n 26 mg/dL\n 110 mEq/L\n 142 mEq/L\n 31.2 %\n 12.1 K/uL\n [image002.jpg]\n 04:46 AM\n 04:59 PM\n 03:12 AM\n 06:06 AM\n 02:28 PM\n 06:28 PM\n 09:12 PM\n 01:58 AM\n 04:48 AM\n 05:04 AM\n WBC\n 10.2\n 12.1\n Hct\n 31.7\n 31.2\n Plt\n 136\n 120\n Cr\n 1.1\n 1.0\n TCO2\n 25\n 26\n 26\n 24\n 24\n 26\n 28\n 26\n Glucose\n 91\n 122\n Other labs: PT / PTT / INR:13.5/29.8/1.2, CK / CKMB /\n Troponin-T:260/9/0.22, ALT / AST:57/31, Alk Phos / T Bili:70/0.4,\n Amylase / Lipase:53/22, Differential-Neuts:67.0 %, Band:2.0 %,\n Lymph:18.0 %, Mono:9.0 %, Eos:0.0 %, Lactic Acid:1.3 mmol/L,\n Albumin:2.7 g/dL, LDH:272 IU/L, Ca++:7.5 mg/dL, Mg++:2.2 mg/dL, PO4:3.1\n mg/dL\n Imaging: CXR: bilteral infiltrates, possible increase lingular/r base\n Microbiology: galactomanan pending\n Assessment and Plan\n 50 year old male with hypoxic resp failure/PNA, COPD/pulm fibrosis, dil\n RV\n #Acute resp failure: Mixed picture with sepsis, cardiogenic.\n Minimal progress made on ventilator yesterday. Attempt diuresis.\n Will try decreasing driving pressure, no change in PEEP/FiO2\n #Sedation: under reasonable limits per nursing. Continue\n versed/fentanyl/methadone\n #Sepsis: No recent fevers. Continue LVQ/vanc/zosyn for day\n course. Continue caspofungin\n Wean steroids (stress-dose + presumptive PCP)\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 07:51 AM 70 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Multi Lumen - 11:24 PM\n Arterial Line - 12:14 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 45 minutes\n Patient is critically ill\n" }, { "category": "General", "chartdate": "2120-04-28 00:00:00.000", "description": "Generic Note", "row_id": 324013, "text": "TITLE:\n RESPIRATORY CARE: PT REMAINS W/ AN 8.0 PORTEX TRACH IN PLACE AND ON PCV\n IN AC MODE AS PER METAVISION. CUFF LEAK PERSISTS. IP TO CHANGE TO A\n TRACH ON MONDAY OR TUESDAY. WILL\n C/W PCV AS TOLERATED.\n" }, { "category": "Physician ", "chartdate": "2120-04-29 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 324088, "text": "Chief Complaint: 50 y/o M w. metastatic renal cell cancer s/p\n nephrectomy, IL-2, mini-SCT, DLI 2x in , emphysema/pulmonary\n fibrosis on home O2 presented to OSH with hypoxic respiratory failure,\n sepsis, cardiogenic shock now with difficulty weaning vent and s/p\n trach/peg\n 24 Hour Events:\n BLOOD CULTURED - At 12:44 PM\n URINE CULTURE - At 12:44 PM\n PICC LINE - START 04:30 PM\n MULTI LUMEN - STOP 07:52 PM\n ARTERIAL LINE - STOP 07:57 PM\n SPUTUM CULTURE - At 08:24 PM\n ULTRASOUND - At 11:16 PM\n EKG - At 03:00 AM\n ARTERIAL LINE - START 04:30 AM\n FEVER - 101.4\nF - 03:00 AM\n - Overnight, patient with increasing hypoxia and respiratory distress.\n Increasing PCO2 c/w dead space fraction. Patient improved transiently\n with diuresis and briefly on lasix gtt overnight. Later started on\n heparin gtt for ? PE in setting of hypoxia/hypotension. Overnight\n patient had to be resedated and reparalyzed because was fighting the\n vent. Also with increasing LFT's so RUQ USD obtained for ?\n cholecystitis but w/o e/o CBD on imaging. This morning is on three\n pressors to maintain MAP > 60.\n Allergies:\n Flagyl (Oral) (Metronidazole)\n Rash;\n Last dose of Antibiotics:\n Acyclovir - 04:00 PM\n Levofloxacin - 08:00 AM\n Piperacillin/Tazobactam (Zosyn) - 06:32 AM\n Vancomycin - 08:00 AM\n Infusions:\n Vasopressin - 2.4 units/hour\n Cisatracurium - 0.2 mg/Kg/hour\n Midazolam (Versed) - 25 mg/hour\n Norepinephrine - 0.05 mcg/Kg/min\n Other ICU medications:\n Midazolam (Versed) - 05:30 PM\n Heparin Sodium (Prophylaxis) - 08:25 PM\n Furosemide (Lasix) - 01:45 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 03:23 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.6\nC (101.4\n Tcurrent: 37.2\nC (99\n HR: 80 (64 - 128) bpm\n BP: 104/64(80) {66/41(52) - 175/87(100)} mmHg\n RR: 42 (0 - 42) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 76.3 kg (admission): 76.3 kg\n Height: 68 Inch\n CVP: 3 (3 - 7)mmHg\n Total In:\n 5,318 mL\n 2,490 mL\n PO:\n TF:\n 164 mL\n IVF:\n 5,054 mL\n 2,490 mL\n Blood products:\n Total out:\n 1,630 mL\n 2,095 mL\n Urine:\n 1,630 mL\n 1,795 mL\n NG:\n 300 mL\n Stool:\n Drains:\n Balance:\n 3,688 mL\n 395 mL\n Respiratory support\n Ventilator mode: PRVC/AC\n Vt (Set): 360 (360 - 360) mL\n PC : 24 cmH2O\n PS : 10 cmH2O\n RR (Set): 30\n PEEP: 9 cmH2O\n FiO2: 100%\n PIP: 37 cmH2O\n Plateau: 33 cmH2O\n Compliance: 18 cmH2O/mL\n SpO2: 99%\n ABG: 7.25/60/201/26/-1\n Ve: 15.7 L/min\n PaO2 / FiO2: 201\n Physical Examination\n General Appearance: Well nourished, sedated\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, trach\n Cardiovascular: (S1: Normal), (S2: Normal), No(t) S3, No(t) S4, No(t)\n Rub\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear :\n coarse), mechanical breath sounds\n Extremities: warm, with trace b/l LE edema\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 195 K/uL\n 10.7 g/dL\n 114 mg/dL\n 1.3 mg/dL\n 26 mEq/L\n 4.6 mEq/L\n 14 mg/dL\n 110 mEq/L\n 141 mEq/L\n 34.3 %\n 22.4 K/uL\n [image002.jpg]\n 04:26 AM\n 09:26 PM\n 12:22 AM\n 03:34 AM\n 03:52 AM\n 04:29 AM\n 05:30 AM\n 07:55 AM\n 10:02 AM\n 03:11 PM\n WBC\n 22.4\n Hct\n 34.2\n 34.3\n Plt\n 195\n Cr\n 1.3\n TCO2\n 30\n 29\n 29\n 31\n 31\n 29\n 26\n 28\n Glucose\n 114\n Other labs: PT / PTT / INR:13.7/104.5/1.2, CK / CKMB /\n Troponin-T:260/9/0.22, ALT / AST:35/49, Alk Phos / T Bili:178/1.6,\n Amylase / Lipase:50/19, Differential-Neuts:85.4 %, Band:0.0 %,\n Lymph:8.8 %, Mono:4.1 %, Eos:1.4 %, Lactic Acid:2.8 mmol/L, Albumin:2.6\n g/dL, LDH:473 IU/L, Ca++:7.3 mg/dL, Mg++:2.0 mg/dL, PO4:4.9 mg/dL\n Assessment and Plan\n SHOCK, SEPTIC\n 50 y/o M w. metastatic renal cell cancer s/p nephrectomy, IL-2,\n mini-SCT, DLI 2x in , emphysema/pulmonary fibrosis on home O2\n presented to OSH with hypoxic respiratory failure, sepsis, cardiogenic\n shock now with difficulty weaning vent and s/p trach/peg\n .\n #Hypotension: At this time impression is most consistent with septic\n shock given fevers, elevated lactate, leukocytosis. also be\n cardiogenic/obstructive shock from a PE or from pericardial tamponade.\n Has RV dysfunction at baseline. At this time will continue\n - Possible Sepsis: Given fevers on broad antibiotics will\n broaden to cover ESBL-GNR\ns and VRE. Change vancomycin to linezolid\n given need to cover pulmonary source in this hypoxic patient. Will\n also change zosyn to meropenem for above. Will hold on fungal coverage\n given not neutropenic and fungal studies have been negative.\n Tobramycin for resistant GNR\ns. Consider broadening PRN.\n - Rising WBC count also concerning for C. Diff infection.\n Started on PO vanco overnight. Change to IV flagyl this AM and PR\n vanco given high residuals and lack of absorption.\n - ID consult today -> ? IV Ig.\n - Cardiogenic Shock: Unclear what component may be related to\n obstructive shock from PE, EKG this AM with junctional rhythm with no\n clear P-waves. Do not believe this is ischemic, but will obtain TTE\n today for ? effusion/tamponade/thrombus.\n - Hypovolemic Shock: Less likely. With bloody NG lavage today\n after starting heparin. Q6h HCT and stop heparin gtt only for\n significant GI bleed.\n - Adrenal: Has adrenal involvement from renal cell carcinoma.\n Will check AM cortisol today. Given hydrocortisone x1.\n - Continue pressors with vasopressin,and uptitrate levophed\n and down titrate neosynephrine. Check ionized calcium this AM and\n ensure replete.\n - Continue acyclovir and bactrim PPx.\n .\n # Respiratory failure: Pneumonia as likely source of resp failure and\n sepsis in patient with poor pulmonary reserve due to emphysema, ?GVHD,\n fibrosis. However, increasing CO2 requirement concerning for PE and\n will continue heparin gtt today given clinical improvement since\n starting. No trach leak on exam this AM as per respiratory. Now on\n 100% FIO2. Patient is now s/p trach/PEG on . CXR this AM with\n increasing opacities c/w pneumonia/edema.\n - continue heparin gtt at this time.\n - will not diurese given hypotension\n - Continue on current vent setting for now.\n - Driving pressures maintained at 24. FiO2 at 100% now with sats in the\n low 90s. Last gas7.05/88/132/26/-8.\n - Treat PNA for planned 14 day course. See below. B-glucan,\n galactomannan negative, caspogungin d/c\n # Sedation: continue fentanyl, cisatracurium, midazolam.\n - Goal to wean propofol as tolerated today, triglycerides mildly\n elevated at 182\n - Continue to check triglycerides twice weekly while on propofol. Last\n checked \n - Will bolus with versed/fentanyl prn agitation in an attempt to wean\n down level of propofol.\n - Continue to check daily ECG for QTc prolongation on methadone.\n - When able, will decrease methadone to q6H then to q8H\n .\n #GI Bleeding: IV PPI while on heparin gtt given black on lavage.\n Will follow and hold heparin for GI bleed. Q6H hematocrit for now.\n - continue to follow.\n .\n # Pump: As above. TTE today, hold captopril.\n .\n # Rhythm: Sinus at times with junction rhythm on occasion. Continue to\n monitor. Telemetry/TTE.\n # Metastatic renal CA: Recurrent disease s/p donor lymphocyte\n transplant .\n - BMT to follow -> to give input on code status and discussions with\n family regarding severity of illness at this time.\n - Continue acyclovir and bactrim ppx\n # Access: Central line today, with upper extremity ultrasound\n guidance. PIV. A-Line.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 02:03 PM\n 18 Gauge - 02:03 PM\n PICC Line - 04:30 PM\n Arterial Line - 04:30 AM\n Multi Lumen - 12:05 PM\n Prophylaxis:\n DVT: Heparin GTT\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2120-04-30 00:00:00.000", "description": "Nursing Progress Note", "row_id": 324194, "text": "Anemia, other\n Assessment:\n Pt w/ slowly falling hct , down 10pts from yesterday, suspected bleed\n vs TTP\n Action:\n Transfused 1 units PRBC 2^nd unit infusing\n Response:\n Post HCT 2 hr after PRBC finished\n Plan:\n Cont to monitor for s/s active bleed\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt on A/C mech vent support. Attempted wean\n Action:\n Decreased PEEP , multiple vent setting changes, now back to original\n settings at start of shift a/c 340 x42 ,PEEP 6 /70%.\n Response:\n Unable to tolerate turn in bed , desat to high 80\ns min reserve\n Plan:\n Turn only as necessary, cont mech vent support wean as tol\n" }, { "category": "General", "chartdate": "2120-04-30 00:00:00.000", "description": "Generic Note", "row_id": 324213, "text": "TITLE:\n RESPIRATORY CARE: PT REMAINS W/ AN 8.0 PORTEX TRACH IN\n PLACE. REMAINS ON PRVC RR 42 VT 340 FIO2 .70 PEEP 6 AND PARALYZED AND\n SEDATED. ABG C/W A RESPIRATORY ACIDOSIS AND MODERATE TO SEVERE\n HYPOXEMIA. TPp INSP PLATEAU = 26 AND TPp EXP PLATEAU = 3. SPO2 MONITOR\n 90-93 % THIS SHIFT W/ OCCASIONAL DESATURATION UPON TURNING. SX FOR\n SMALL AMTS THICK YELLOW SPUTUM. BAL SENT TO LAB\n YESTERDAY. ALBUTEROL MDI GIVEN . GOAL ARE TO KEEP PH . 7.20, SPO2 >\n 90-92 %, TPp INSP < 26 and TPp EXP > 0.\n WILL C/W PRVC AS TOLERATED.\n" }, { "category": "Physician ", "chartdate": "2120-04-30 00:00:00.000", "description": "Critical Care Attending", "row_id": 324225, "text": "CRITICAL CARE STAFF ADDENDUM\n 8:35pm\n CC: respiratory failure\n Mr. \ns respiratory status has worsened. He has had some\n ventricular bigeminy. His most recent ABG is 7.05 / 95 / 69. He is on\n pressure-targeted volume control with RR 44, Vt 340, PEEP 6, FiO2 0.8\n 1.0. Plateau is ~35; end-inspiratory transpulmonary pressure is ~27\n and end-expiratory is ~ 0.\n On exam he is compliant with the ventilator but has four twitches on\n nerve stimulation. His CVP tracing shows substantial v waves.\n On my ultrasound exam of the right IJ, his DVT is still present and\n looks a similar size as yesterday.\n Lytes and CBC are pending.\n Assessment and Plan\n He has had a marked worsening of VQ matching, with a substantial rise\n in pCO2 in spite of essentially constant minute volume. This suggests\n worsened Vd/Vt. His CVP tracing suggests that there is substantial TR\n at present, and that there may be more pulmonary hypertension than\n previously. His ultrasound exam suggests that his right IJ clot has\n not embolized. It is possible that this represents a reaction to his\n transfusion, but there are no other corroborating signs.\n We have increased his tidal volume to 400cc and decreased his RR to\n 40. With this, his minute volume increased from ~15\n ~17. His Pplat\n is 37; his end-inspiratory TPP is 30. These are tolerable numbers. We\n have also rebolused and increased his cisatracurium.\n Will check ABG in 15 - 30 minutes. If we do not see substantial\n improvement in pCO2 will discuss further with his wife and family.\n They have gone home for the first time in days to try to get some\n rest. In addition, will consider (1) further ventilator maneuvers\n (although he is near-maximal safe support); (2) bicarbonate (although\n just a temporizing measure); (3) trial of inotropes to try to increase\n CO2 elimination (although substantial risk of SVT); and (4) nitric\n oxide (although not clear where this would bridge toward).\n CC time: 50 minutes\n" }, { "category": "Physician ", "chartdate": "2120-04-20 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 323139, "text": "Chief Complaint:\n 24 Hour Events:\n Allergies:\n Flagyl (Oral) (Metronidazole)\n Rash;\n Last dose of Antibiotics:\n Acyclovir - 04:30 PM\n Bactrim (SMX/TMP) - 09:00 AM\n Levofloxacin - 10:30 AM\n Vancomycin - 08:00 PM\n Caspofungin - 08:00 PM\n Piperacillin/Tazobactam (Zosyn) - 10:00 PM\n Infusions:\n Dobutamine - 0.3 mcg/Kg/min\n Midazolam (Versed) - 10 mg/hour\n Other ICU medications:\n Famotidine (Pepcid) - 08:14 PM\n Heparin Sodium (Prophylaxis) - 08:15 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:56 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: 36.7\nC (98.1\n HR: 52 (47 - 91) bpm\n BP: 119/51(71) {110/42(61) - 148/65(90)} mmHg\n RR: 34 (28 - 35) insp/min\n SpO2: 93%\n Heart rhythm: SB (Sinus Bradycardia)\n Wgt (current): 76.3 kg (admission): 76.3 kg\n Height: 68 Inch\n CVP: 7 (6 - 17)mmHg\n CO/CI (CCO): (5.1 L/min) / (2.7 L/min/m2)\n Total In:\n 5,654 mL\n 590 mL\n PO:\n TF:\n 59 mL\n IVF:\n 4,015 mL\n 402 mL\n Blood products:\n Total out:\n 3,280 mL\n 585 mL\n Urine:\n 3,280 mL\n 585 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,374 mL\n 5 mL\n Respiratory support\n Ventilator mode: PCV+\n PC : 28 cmH2O\n RR (Set): 24\n PEEP: 12 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10\n PIP: 39 cmH2O\n Plateau: 34 cmH2O\n SpO2: 93%\n ABG: 7.46/36/87./24/1\n Ve: 16.9 L/min\n PaO2 / FiO2: 176\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 10.4 g/dL\n 91 mg/dL\n 1.1 mg/dL\n 24 mEq/L\n 4.0 mEq/L\n 26 mg/dL\n 112 mEq/L\n 145 mEq/L\n 31.7 %\n 10.2 K/uL\n [image002.jpg]\n 12:10 PM\n 02:14 PM\n 08:25 PM\n 10:25 PM\n 03:04 AM\n 04:30 AM\n 04:46 AM\n 04:59 PM\n 03:12 AM\n 06:06 AM\n WBC\n 13.5\n 10.2\n Hct\n 31.8\n 31.7\n Plt\n 130\n 136\n Cr\n 1.0\n 1.1\n TCO2\n 23\n 22\n 23\n 24\n 26\n 25\n 26\n 26\n Glucose\n 98\n 91\n Other labs: PT / PTT / INR:14.6/29.1/1.3, CK / CKMB /\n Troponin-T:260/9/0.22, ALT / AST:57/31, Alk Phos / T Bili:70/0.4,\n Amylase / Lipase:53/22, Differential-Neuts:67.0 %, Band:2.0 %,\n Lymph:18.0 %, Mono:9.0 %, Eos:0.0 %, Lactic Acid:1.7 mmol/L,\n Albumin:2.7 g/dL, LDH:272 IU/L, Ca++:8.3 mg/dL, Mg++:2.3 mg/dL, PO4:2.8\n mg/dL\n Assessment and Plan\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 02:00 AM 20 mL/hour\n Glycemic Control:\n Lines:\n Multi Lumen - 11:24 PM\n Arterial Line - 12:14 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": "2120-04-20 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 323143, "text": "Chief Complaint:\n 24 Hour Events:\n + bactrim d/c\n Beta glucan and galactomannan pending\n But\n BMT wanted to gold onto , will d/c sun if still no\n positive fungal cultures by then\n Hydrocortisone weaned to 50mg iv bid from qid\n Dobutamine weaned off, but C.I. dropped to 2.8 (from 3.5), so restarted\n overnight\n IV methadone started to wean fent / midaz; ECG without QTc prolongation\n Did NOT start propofol gtts (not close to extubation)\n FiO2 increased to 50% (from 40%) after sats fell (paO2 78 @ 9pm)\n Bradycardic overnight in 50\n increase to 90s w/ stimulation (bathing)\n Lactulose added to bowel regimen\n Allergies:\n Flagyl (Oral) (Metronidazole)\n Rash;\n Last dose of Antibiotics:\n Acyclovir - 04:30 PM\n Bactrim (SMX/TMP) - 09:00 AM\n Levofloxacin - 10:30 AM\n Vancomycin - 08:00 PM\n - 08:00 PM\n Piperacillin/Tazobactam (Zosyn) - 10:00 PM\n Infusions:\n Dobutamine - 0.3 mcg/Kg/min\n Midazolam (Versed) - 10 mg/hour\n Other ICU medications:\n Famotidine (Pepcid) - 08:14 PM\n Heparin Sodium (Prophylaxis) - 08:15 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:56 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: 36.7\nC (98.1\n HR: 52 (47 - 91) bpm\n BP: 119/51(71) {110/42(61) - 148/65(90)} mmHg\n RR: 34 (28 - 35) insp/min\n SpO2: 93%\n Heart rhythm: SB (Sinus Bradycardia)\n Wgt (current): 76.3 kg (admission): 76.3 kg\n Height: 68 Inch\n CVP: 7 (6 - 17)mmHg\n CO/CI (CCO): (5.1 L/min) / (2.7 L/min/m2)\n Total In:\n 5,654 mL\n 590 mL\n PO:\n TF:\n 59 mL\n IVF:\n 4,015 mL\n 402 mL\n Blood products:\n Total out:\n 3,280 mL\n 585 mL\n Urine:\n 3,280 mL\n 585 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,374 mL\n 5 mL\n Respiratory support\n Ventilator mode: PCV+\n PC : 28 cmH2O\n RR (Set): 24\n PEEP: 12 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10\n PIP: 39 cmH2O\n Plateau: 34 cmH2O\n SpO2: 93%\n ABG: 7.46/36/87./24/1\n Ve: 16.9 L/min\n PaO2 / FiO2: 176\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 10.4 g/dL\n 91 mg/dL\n 1.1 mg/dL\n 24 mEq/L\n 4.0 mEq/L\n 26 mg/dL\n 112 mEq/L\n 145 mEq/L\n 31.7 %\n 10.2 K/uL\n [image002.jpg]\n 12:10 PM\n 02:14 PM\n 08:25 PM\n 10:25 PM\n 03:04 AM\n 04:30 AM\n 04:46 AM\n 04:59 PM\n 03:12 AM\n 06:06 AM\n WBC\n 13.5\n 10.2\n Hct\n 31.8\n 31.7\n Plt\n 130\n 136\n Cr\n 1.0\n 1.1\n TCO2\n 23\n 22\n 23\n 24\n 26\n 25\n 26\n 26\n Glucose\n 98\n 91\n Other labs: PT / PTT / INR:14.6/29.1/1.3, CK / CKMB /\n Troponin-T:260/9/0.22, ALT / AST:57/31, Alk Phos / T Bili:70/0.4,\n Amylase / Lipase:53/22, Differential-Neuts:67.0 %, Band:2.0 %,\n Lymph:18.0 %, Mono:9.0 %, Eos:0.0 %, Lactic Acid:1.7 mmol/L,\n Albumin:2.7 g/dL, LDH:272 IU/L, Ca++:8.3 mg/dL, Mg++:2.3 mg/dL, PO4:2.8\n mg/dL\n Micro\n Bl cx 4/14+ pending\n Negative legionella\n Rads\n Cxr \n SINGLE SEMI-UPRIGHT VIEW OF THE CHEST AT APPROXIMATELY 7 a.m.: This\n exam is\n largely unchanged from the prior exam. Endotracheal tube, nasogastric\n tube,\n feeding tube, and right internal jugular catheter are all in unchanged\n positions. Again, the feeding tube terminates above the GE junction.\n Lung volumes remain low and widespread interstitial thickening is\n consistent\n with diffuse fibrosis. A slight relative increase in air space opacity\n at the\n right lung base (most evident when in comparison to the scout film from\n the CT\n torso of ) is largely unchanged, as is a small right pleural\n effusion.\n Assessment and Plan\n 50M h/o metastatic renal CA s/p nephrectomy, IL-2, mini-allograft SCT,\n DLI x 2 last in , emphysema/pulmonary fibrosis on home 02\n presented to OSH with hypoxic respiratory failure, fevers and\n hypotension.\n # Septic shock: On presentation to OSH pt hypotensive, hypoxic with\n fevers and leukocytosis. On arrival to ICU was intubated due to\n hypoxic respiratory failure and hypotensive requiring pressors. Likely\n pneumonia given hypoxia and possible opacities on CXR, although\n difficult to read due to fibrosis. No other apparent localizing\n symptoms. Ruled-out for flu at OSH. At this point, WBC and fever curve\n decreasing. Covered on broad spectrum antibiotics.\n - Legionella urine ag negative, all other cultures no growth to date.\n - Vanc, zosyn, levofloxacin, bactrim IV for PCP, to cover\n broadly given critical illness. As patient was on bactrim prophylaxis\n for PCP as outpatient and not on steroids, risk for PCP very low;\n therefore, will dc high dose bactrim and restart ppx dose.\n - D/C sun if cultures negative\n - Also on IV steroids for PCP and adrenal insufficiency, see below\n - Glucan, galactomannan pending\n - Follow WBC count, fever curve, decreasing\n - PPD negative\n - Continue acyclovir ppx, vanc/zosyn/levoflox\n # Respiratory failure: Pneumonia in patient with poor pulmonary reserve\n due to emphysema, ?GVHD, fibrosis.\n Pt tolerated decrease in PEEP and Fi02 yesterday. Attempted to switch\n to A/C, however pt less sedated off pressors and pulling large TV\n (~1600), dysynchronous with vent.\n - Back on pressure control for now, based on transpulmonary pressure\n (10 and -2), will titrate down FiO2 as tolerated today. Can consider\n changing to PSV or SIMV with low set respiratory rate if tolerated.\n -Off cisatracurium since . Currently sedated on midazolam and\n fentanyl on maximal doses. Will try trial of methadone to help\n decrease versed/fentanyl doses today. Attempt wean as tolerated. Can\n consider propofol in addition in order to lower doses of\n versed/fentanyl.\n # Cardiogenic shock: Patient found to have PAH and RV failure on ECHO.\n Started on dobutamine with improvement in CI as well as pressures.\n Also started on captopril for afterload reduction which enabled\n decrease in dobutamine with continued improvement in hemodynamics.\n - Wean dobutamine today\n - Continue to monitor UOP and CI. If UOP decreases, will consider lasix\n drip if patient becomes very positive\n # Cardiac: Patient with probable demand ischemia in setting of\n hypotension, tachycardia, and sepsis; less likely unstable plaque.\n - CE\ns trended down, have stopped following.\n - ASA\n - ACEI as above for afterload reduction\n - Consider diuresis if UOP tapers off to further decrease preload.\n # Hypotension: Improved. Likely a mixed picture. Initially pt\n presentation of acute hypoxia with leukocytosis and fevers with\n hypotension made a septic shock picture predominate, however after\n adequate fluid rescusitation pt continued to require 2 pressors. His\n TTE and vigileo monitoring were consistent with low cardiac output due\n to pt\ns severe pulmonary hypertension due to pulmonary fibrosis and\n subsequent RV hypokinesis, a non-fluid responsive state. Dobutamine\n challenge resulted in increased CO to normal range with ability to be\n weaned off both levophed and vasopressin and addition of captopril\n which led to decreased afterload allowed decrease in dobutamine. Also,\n initial concern for adrenal insufficiency as patient has one adrenal\n gland with a metastasis, though he does not clinically appear to be\n functionally adrenally insufficient at this point. UOP remains high at\n ~100-200cc/hour.\n - Continue dobutamine\n - Continue HD monitoring with Vigileo device\n - Treat broadly for infection per above\n - IV hydrocort Q6 for adrenal insufficiency, will start wean today with\n 50mg q12, and subsequent wean over next few days.\n - Initially concerned for PE, however have more likley explanations for\n hypotension as listed above, LENIs negative\n - Guaiac stools, HCT has been stable.\n # Metastatic renal CA: Recurrent disease s/p donor lymphocyte\n transplant .\n - BMT to follow\n - Continue acyclovir ppx for now, will discuss with BMT\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 02:00 AM 20 mL/hour\n Glycemic Control: ssi\n Lines:\n Multi Lumen - 11:24 PM\n Arterial Line - 12:14 AM\n Prophylaxis:\n DVT: sq heparin\n Stress ulcer: famotidine \n VAP: chlorhexidine\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: icu\n" }, { "category": "Physician ", "chartdate": "2120-04-20 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 323150, "text": "Chief Complaint:\n 24 Hour Events:\n + bactrim d/c\n Beta glucan and galactomannan pending\n But\n BMT wanted to gold onto , will d/c sun if still no\n positive fungal cultures by then\n Hydrocortisone weaned to 50mg iv bid from qid\n Dobutamine weaned off, but C.I. dropped to 2.8 (from 3.5), so restarted\n overnight\n IV methadone started to wean fent / midaz; ECG without QTc prolongation\n Did NOT start propofol gtts (not close to extubation)\n FiO2 increased to 50% (from 40%) after sats fell (paO2 78 @ 9pm)\n Bradycardic overnight in 50\n increase to 90s w/ stimulation (bathing)\n Lactulose added to bowel regimen\n Allergies:\n Flagyl (Oral) (Metronidazole)\n Rash;\n Last dose of Antibiotics:\n Acyclovir - 04:30 PM\n Bactrim (SMX/TMP) - 09:00 AM\n Levofloxacin - 10:30 AM\n Vancomycin - 08:00 PM\n - 08:00 PM\n Piperacillin/Tazobactam (Zosyn) - 10:00 PM\n Infusions:\n Dobutamine - 0.3 mcg/Kg/min\n Midazolam (Versed) - 10 mg/hour\n Other ICU medications:\n Famotidine (Pepcid) - 08:14 PM\n Heparin Sodium (Prophylaxis) - 08:15 PM\n Other medications:\n Lactulose / docusate / bisacodyl\n Captopril\n Tylenol prn\n Folic acid\n Albuterol\n Asa\n chlorhexidine\n Changes to medical 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: 37.3\nC (99.1\n Tcurrent: 36.7\nC (98.1\n HR: 52 (47 - 91) bpm\n BP: 119/51(71) {110/42(61) - 148/65(90)} mmHg\n RR: 34 (28 - 35) insp/min\n SpO2: 93%\n Heart rhythm: SB (Sinus Bradycardia)\n Wgt (current): 76.3 kg (admission): 76.3 kg\n Height: 68 Inch\n CVP: 7 (6 - 17)mmHg\n CO/CI (CCO): (5.1 L/min) / (2.7 L/min/m2)\n Total In:\n 5,654 mL\n 590 mL\n PO:\n TF:\n 59 mL\n IVF:\n 4,015 mL\n 402 mL\n Blood products:\n Total out:\n 3,280 mL\n 585 mL\n Urine:\n 3,280 mL\n 585 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,374 mL\n 5 mL\n Respiratory support\n Ventilator mode: PCV+\n PC : 28 cmH2O\n RR (Set): 24\n PEEP: 12 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10\n PIP: 39 cmH2O\n Plateau: 34 cmH2O\n SpO2: 93%\n ABG: 7.46/36/87./24/1\n Ve: 16.9 L/min\n PaO2 / FiO2: 176\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 10.4 g/dL\n 91 mg/dL\n 1.1 mg/dL\n 24 mEq/L\n 4.0 mEq/L\n 26 mg/dL\n 112 mEq/L\n 145 mEq/L\n 31.7 %\n 10.2 K/uL\n [image002.jpg]\n 12:10 PM\n 02:14 PM\n 08:25 PM\n 10:25 PM\n 03:04 AM\n 04:30 AM\n 04:46 AM\n 04:59 PM\n 03:12 AM\n 06:06 AM\n WBC\n 13.5\n 10.2\n Hct\n 31.8\n 31.7\n Plt\n 130\n 136\n Cr\n 1.0\n 1.1\n TCO2\n 23\n 22\n 23\n 24\n 26\n 25\n 26\n 26\n Glucose\n 98\n 91\n Other labs: PT / PTT / INR:14.6/29.1/1.3, CK / CKMB /\n Troponin-T:260/9/0.22, ALT / AST:57/31, Alk Phos / T Bili:70/0.4,\n Amylase / Lipase:53/22, Differential-Neuts:67.0 %, Band:2.0 %,\n Lymph:18.0 %, Mono:9.0 %, Eos:0.0 %, Lactic Acid:1.7 mmol/L,\n Albumin:2.7 g/dL, LDH:272 IU/L, Ca++:8.3 mg/dL, Mg++:2.3 mg/dL, PO4:2.8\n mg/dL\n Micro\n Bl cx 4/14+ pending\n Negative legionella\n Rads\n Cxr \n SINGLE SEMI-UPRIGHT VIEW OF THE CHEST AT APPROXIMATELY 7 a.m.: This\n exam is\n largely unchanged from the prior exam. Endotracheal tube, nasogastric\n tube,\n feeding tube, and right internal jugular catheter are all in unchanged\n positions. Again, the feeding tube terminates above the GE junction.\n Lung volumes remain low and widespread interstitial thickening is\n consistent\n with diffuse fibrosis. A slight relative increase in air space opacity\n at the\n right lung base (most evident when in comparison to the scout film from\n the CT\n torso of ) is largely unchanged, as is a small right pleural\n effusion.\n Assessment and Plan\n 50M h/o metastatic renal CA s/p nephrectomy, IL-2, mini-allograft SCT,\n DLI x 2 last in , emphysema/pulmonary fibrosis on home 02\n presented to OSH with hypoxic respiratory failure, fevers and\n hypotension.\n # Septic shock: On presentation to OSH pt hypotensive, hypoxic with\n fevers and leukocytosis. On arrival to ICU was intubated due to\n hypoxic respiratory failure and hypotensive requiring pressors. Likely\n pneumonia given hypoxia and possible opacities on CXR, although\n difficult to read due to fibrosis. No other apparent localizing\n symptoms. Ruled-out for flu at OSH. At this point, WBC and fever curve\n decreasing. Covered on broad spectrum antibiotics.\n - Legionella urine ag negative, all other cultures no growth to date.\n - Vanc, zosyn, levofloxacin, bactrim IV for PCP, to cover\n broadly given critical illness. As patient was on bactrim prophylaxis\n for PCP as outpatient and not on steroids, risk for PCP very low;\n therefore, will dc high dose bactrim and restart ppx dose.\n - D/C sun if cultures negative\n - Also on IV steroids for PCP and adrenal insufficiency, see below\n - Glucan, galactomannan pending\n - Follow WBC count, fever curve, decreasing\n - PPD negative\n - Continue acyclovir ppx, vanc/zosyn/levoflox\n # Respiratory failure: Pneumonia in patient with poor pulmonary reserve\n due to emphysema, ?GVHD, fibrosis.\n Pt tolerated decrease in PEEP and Fi02 yesterday. Attempted to switch\n to A/C, however pt less sedated off pressors and pulling large TV\n (~1600), dysynchronous with vent.\n - Back on pressure control for now, based on transpulmonary pressure\n (10 and -2), will titrate down FiO2 as tolerated today. Can consider\n changing to PSV or SIMV with low set respiratory rate if tolerated.\n -Off cisatracurium since . Currently sedated on midazolam and\n fentanyl on maximal doses. Will try trial of methadone to help\n decrease versed/fentanyl doses today. Attempt wean as tolerated. Can\n consider propofol in addition in order to lower doses of\n versed/fentanyl.\n # Cardiogenic shock: Patient found to have PAH and RV failure on ECHO.\n Started on dobutamine with improvement in CI as well as pressures.\n Also started on captopril for afterload reduction which enabled\n decrease in dobutamine with continued improvement in hemodynamics.\n - Wean dobutamine today\n - Continue to monitor UOP and CI. If UOP decreases, will consider lasix\n drip if patient becomes very positive\n # Cardiac: Patient with probable demand ischemia in setting of\n hypotension, tachycardia, and sepsis; less likely unstable plaque.\n - CE\ns trended down, have stopped following.\n - ASA\n - ACEI as above for afterload reduction\n - Consider diuresis if UOP tapers off to further decrease preload.\n # Hypotension: Improved. Likely a mixed picture. Initially pt\n presentation of acute hypoxia with leukocytosis and fevers with\n hypotension made a septic shock picture predominate, however after\n adequate fluid rescusitation pt continued to require 2 pressors. His\n TTE and vigileo monitoring were consistent with low cardiac output due\n to pt\ns severe pulmonary hypertension due to pulmonary fibrosis and\n subsequent RV hypokinesis, a non-fluid responsive state. Dobutamine\n challenge resulted in increased CO to normal range with ability to be\n weaned off both levophed and vasopressin and addition of captopril\n which led to decreased afterload allowed decrease in dobutamine. Also,\n initial concern for adrenal insufficiency as patient has one adrenal\n gland with a metastasis, though he does not clinically appear to be\n functionally adrenally insufficient at this point. UOP remains high at\n ~100-200cc/hour.\n - Continue dobutamine\n - Continue HD monitoring with Vigileo device\n - Treat broadly for infection per above\n - IV hydrocort Q6 for adrenal insufficiency, will start wean today with\n 50mg q12, and subsequent wean over next few days.\n - Initially concerned for PE, however have more likley explanations for\n hypotension as listed above, LENIs negative\n - Guaiac stools, HCT has been stable.\n # Metastatic renal CA: Recurrent disease s/p donor lymphocyte\n transplant .\n - BMT to follow\n - Continue acyclovir ppx for now, will discuss with BMT\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 02:00 AM 20 mL/hour\n Glycemic Control: ssi\n Lines:\n Multi Lumen - 11:24 PM\n Arterial Line - 12:14 AM\n Prophylaxis:\n DVT: sq heparin\n Stress ulcer: famotidine \n VAP: chlorhexidine\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: icu\n" }, { "category": "Nursing", "chartdate": "2120-04-21 00:00:00.000", "description": "Nursing Progress Note", "row_id": 323232, "text": "50 yo male with met renal cell CA admitted with severe resp\n failure/PNA, cardiogenic/septic shock. RV hypoplasia\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Remained intubated and vented, unable to wean off from sedation / vent,\n tried to change RR ,desats .pt very sensitive to stimulation,easily\n desats and takes time to maintain sats after that. Tried to wean at\n 200hrs ,sats 88-90%,back to same settings and again at MN tried, sats\n remained on 80\ns for long time,pt needed more bolus doses fent/versed\n to settle down,\n Action:\n Continued with fent 500 and versed 10mg/hr,both at maximum dose, Blood\n gas done x3 , at present on PCV, RR 30,I:E 1:1.7,PEEP 12,PCV 24 TO 28.\n bolus sedations PRN. CXR done in the MN .\n Response:\n Blood gas borderline, PO2 low in am.\n Plan:\n Continue with sedation /vent\n? Weaning when possible.\n Sepsis, Severe (with organ dysfunction)\n Assessment:\n Multi organ failure,off dobu yesterday. Urine output adequate.\n Action:\n Continued with antibiotics, vanco/ zosyn/ acyclovir/ capsofungin/\n levoflox.\n Response:\n Afebrile.\n Plan:\n Continue with antbx,\n Heart failure, right, isolated (Cor Pulmonale)\n Assessment:\n Off dobu yesterday, SB-NSR.\n Action:\n Monitoring CO & CI.\n Response:\n CO 4.3-5.0, HR 46-50\ns when deeply sedated.\n Plan:\n Continue Monitor CO thru vigileo monitor.\n Feed tolerating well ,residual 5-10cc, feed increased gradually to\n 70cc/hr @ goal rate now.\n Bath given and positioned.\n Family visited and updated.brother stayed in the family room.\n" }, { "category": "Physician ", "chartdate": "2120-04-27 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 323896, "text": "Chief Complaint: 50M h/o metastatic renal CA s/p nephrectomy, IL-2,\n mini-allograft SCT, DLI x 2 last in , emphysema/pulmonary fibrosis\n on home 02 presented to OSH with hypoxic respiratory failure, sepsis,\n cardiogenic shock, now improving but with difficulty weaning vent and\n s/p trach/PEG.\n 24 Hour Events:\n ARTERIAL LINE - STOP 08:00 AM\n - hypotensive to the 70s after trial of PS. Unclear why, but thought\n that maybe preload dependancy and increased PEEP, and\n intravascularly volume deplete from all of the auto-diuresis\n - given 3L NS with improvement in his BP to the 90s\n - IP felt that cuff leak not significant enough to do anything about\n right now; will re-evaluate in a few days when tract is more matured\n Allergies:\n Flagyl (Oral) (Metronidazole)\n Rash;\n Last dose of Antibiotics:\n Caspofungin - 09:28 PM\n Levofloxacin - 08:16 AM\n Bactrim (SMX/TMP) - 08:16 AM\n Vancomycin - 08:03 PM\n Acyclovir - 12:17 AM\n Piperacillin/Tazobactam (Zosyn) - 06:02 AM\n Infusions:\n Propofol - 25 mcg/Kg/min\n Other ICU medications:\n Lorazepam (Ativan) - 12:45 PM\n Heparin Sodium (Prophylaxis) - 08:00 PM\n Famotidine (Pepcid) - 09:58 PM\n Other medications:\n Senna prn\n Artificial tears prn\n Captopril 25mg TID\n Methadone 20mg Q4\n Nystatin\n Bactrim\n Acetaminophen prn\n Folic acid\n Albuterol prn\n Acyclovir\n Asa\n ISS\n Docusate prn\n Bisacodyl prn\n Chlorhexidine\n Changes to medical and family history: None\n Review of systems is unchanged from admission except as noted below\n Review of systems: Intubated\n Flowsheet Data as of 08:23 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.2\nC (100.8\n Tcurrent: 36.9\nC (98.4\n HR: 67 (61 - 138) bpm\n BP: 116/67(79) {81/49(50) - 130/94(102)} mmHg\n RR: 18 (13 - 30) insp/min\n SpO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 76.3 kg (admission): 76.3 kg\n Height: 68 Inch\n CVP: 10 (5 - 17)mmHg\n Total In:\n 5,572 mL\n 963 mL\n PO:\n TF:\n 311 mL\n 439 mL\n IVF:\n 4,766 mL\n 274 mL\n Blood products:\n Total out:\n 3,713 mL\n 860 mL\n Urine:\n 3,113 mL\n 860 mL\n NG:\n 600 mL\n Stool:\n Drains:\n Balance:\n 1,859 mL\n 103 mL\n Respiratory support\n Ventilator mode: PCV+\n Vt (Spontaneous): 470 (470 - 740) mL\n PC : 24 cmH2O\n PS : 20 cmH2O\n RR (Set): 30\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 60%\n PIP: 29 cmH2O\n SpO2: 93%\n ABG: 7.38/49/67/23/2\n Ve: 11.7 L/min\n PaO2 / FiO2: 112\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 145 K/uL\n 9.6 g/dL\n 80 mg/dL\n 1.0 mg/dL\n 23 mEq/L\n 4.0 mEq/L\n 15 mg/dL\n 110 mEq/L\n 141 mEq/L\n 29.2 %\n 11.1 K/uL\n [image002.jpg]\n 10:07 PM\n 04:05 AM\n 04:29 AM\n 03:23 PM\n 06:00 PM\n 04:43 AM\n 02:25 PM\n 05:37 PM\n 09:20 PM\n 04:49 AM\n WBC\n 13.6\n 15.0\n 11.1\n Hct\n 31.6\n 34.0\n 28.1\n 31.5\n 29.2\n Plt\n 149\n 159\n 145\n Cr\n 1.0\n 1.0\n 1.0\n TCO2\n 34\n 35\n 27\n 30\n Glucose\n 70\n 76\n 65\n 80\n Other labs: PT / PTT / INR:13.7/42.1/1.2, CK / CKMB /\n Troponin-T:260/9/0.22, ALT / AST:57/31, Alk Phos / T Bili:70/0.4,\n Amylase / Lipase:53/22, Differential-Neuts:67.0 %, Band:2.0 %,\n Lymph:18.0 %, Mono:9.0 %, Eos:0.0 %, Lactic Acid:2.0 mmol/L,\n Albumin:2.6 g/dL, LDH:272 IU/L, Ca++:7.6 mg/dL, Mg++:2.2 mg/dL, PO4:2.4\n mg/dL\n Assessment and Plan\n 50M h/o metastatic renal CA s/p nephrectomy, IL-2, mini-allograft SCT,\n DLI x 2 last in , emphysema/pulmonary fibrosis on home 02\n presented to OSH with hypoxic respiratory failure, sepsis, cardiogenic\n shock, now improving but with difficulty weaning vent and s/p\n trach/PEG.\n # Respiratory failure: Pneumonia as likely source of resp failure and\n sepsis in patient with poor pulmonary reserve due to emphysema, ?GVHD,\n fibrosis. Patient is now s/p trach/PEG.\n - PEEP decreased to 5 yesterday after trach which he has tolerated\n well. Last ABG 7.49/34/127.\n - Driving pressures decreased this am from 24 to 20. Will check ABG on\n current settings.\n - Attempt decrease in FiO2 today (50->40%) -> maintain PaO2 >60.\n Patient's oxygenation has improved.\n - Can also attempt PSV trial today if able to adequately wean sedation\n without agitation.\n - Plan to replace trach today by IP given persistent air leak.\n # Sedation: Currently on methadone q4H, and propofol for sedation,\n currently at 20 mcg/kg/min. Off fent/versed drips.\n - Goal to wean propofol as tolerated today, triglycerides mildly\n elevated at 182\n - Continue to check triglycerides twice weekly while on propofol.\n - Bolus fentanyl/ativan prn agitation\n - When able, will decrease methadone to q6H then to q8H\n # Shock: Multifactorial, resolved.\n ** Sepsis: Likely source pneumonia. On very broad coverage w/\n vancomycin, levofloxacin, zosyn, bactrim (now only ppx dosing). All\n cultures pending or no growth. WBC stable. Patient with temp 100.8\n rectal this am during rounds. Blood cx/urine cx sent.\n - D/C'd caspo yesterday\n - F/u cultures - cont to culture with spikes.\n - Continue acyclovir and bactrim ppx, vanc/zosyn/levoflox for 14 day\n course, today is day 10.\n **Cardiogenic\n ## Pump: Now improved BPs, off dobutamine. On captopril for afterload\n reduction. Dilated hypokinetic RV, likely causative in hypotension.\n Now hypertensive. Increased to 25mg TID. Will likely need repeat ECHO\n once acute issues resolved to assess for resolution of RV dysfunction.\n ## Rhythm: Sinus bradycardia likely secondary to sedatives; increases\n with agitation. Cont weaning sedation as tolerated. Continue to\n follow QTc for prolongation given methadone and levoflox, has been wnl\n **Endocrine\n - Prednisone off today\n # Metastatic renal CA: Recurrent disease s/p donor lymphocyte\n transplant .\n - BMT to follow\n - Continue acyclovir and bactrim ppx\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 03:48 AM 60 mL/hour\n Glycemic Control:\n Lines:\n Multi Lumen - 11:24 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": "2120-04-27 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 323897, "text": "Chief Complaint: 50M h/o metastatic renal CA s/p nephrectomy, IL-2,\n mini-allograft SCT, DLI x 2 last in , emphysema/pulmonary fibrosis\n on home 02 presented to OSH with hypoxic respiratory failure, sepsis,\n cardiogenic shock, now improving but with difficulty weaning vent and\n s/p trach/PEG.\n 24 Hour Events:\n ARTERIAL LINE - STOP 08:00 AM\n - hypotensive to the 70s after trial of PS. Unclear why, but thought\n that maybe preload dependancy and increased PEEP, and\n intravascularly volume deplete from all of the auto-diuresis\n - given 3L NS with improvement in his BP to the 90s\n - IP felt that cuff leak not significant enough to do anything about\n right now; will re-evaluate in a few days when tract is more matured\n Allergies:\n Flagyl (Oral) (Metronidazole)\n Rash;\n Last dose of Antibiotics:\n Caspofungin - 09:28 PM\n Levofloxacin - 08:16 AM\n Bactrim (SMX/TMP) - 08:16 AM\n Vancomycin - 08:03 PM\n Acyclovir - 12:17 AM\n Piperacillin/Tazobactam (Zosyn) - 06:02 AM\n Infusions:\n Propofol - 25 mcg/Kg/min\n Other ICU medications:\n Lorazepam (Ativan) - 12:45 PM\n Heparin Sodium (Prophylaxis) - 08:00 PM\n Famotidine (Pepcid) - 09:58 PM\n Other medications:\n Senna prn\n Artificial tears prn\n Captopril 25mg TID\n Methadone 20mg Q4\n Nystatin\n Bactrim\n Acetaminophen prn\n Folic acid\n Albuterol prn\n Acyclovir\n Asa\n ISS\n Docusate prn\n Bisacodyl prn\n Chlorhexidine\n Changes to medical and family history: None\n Review of systems is unchanged from admission except as noted below\n Review of systems: Intubated\n Flowsheet Data as of 08:23 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.2\nC (100.8\n Tcurrent: 36.9\nC (98.4\n HR: 67 (61 - 138) bpm\n BP: 116/67(79) {81/49(50) - 130/94(102)} mmHg\n RR: 18 (13 - 30) insp/min\n SpO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 76.3 kg (admission): 76.3 kg\n Height: 68 Inch\n CVP: 10 (5 - 17)mmHg\n Total In:\n 5,572 mL\n 963 mL\n PO:\n TF:\n 311 mL\n 439 mL\n IVF:\n 4,766 mL\n 274 mL\n Blood products:\n Total out:\n 3,713 mL\n 860 mL\n Urine:\n 3,113 mL\n 860 mL\n NG:\n 600 mL\n Stool:\n Drains:\n Balance:\n 1,859 mL\n 103 mL\n Respiratory support\n Ventilator mode: PCV+\n Vt (Spontaneous): 470 (470 - 740) mL\n PC : 24 cmH2O\n PS : 20 cmH2O\n RR (Set): 30\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 60%\n PIP: 29 cmH2O\n SpO2: 93%\n ABG: 7.38/49/67/23/2\n Ve: 11.7 L/min\n PaO2 / FiO2: 112\n Physical Examination\n Gen: Sedated, localization to voice\n Heent: pupils equal. Trached.\n Cor: RRR, nls1s2 no mr\n Pul: CTA anteriorly\n coarse, mechanical breath sounds\n Abd: moderately distended. Bowel sounds present, PEG in placed,\n dressed, no guarding, no tenderness\n Extreme: Warm, trace pitting edema to mid-thigh\n Labs / Radiology\n 145 K/uL\n 9.6 g/dL\n 80 mg/dL\n 1.0 mg/dL\n 23 mEq/L\n 4.0 mEq/L\n 15 mg/dL\n 110 mEq/L\n 141 mEq/L\n 29.2 %\n 11.1 K/uL\n [image002.jpg]\n 10:07 PM\n 04:05 AM\n 04:29 AM\n 03:23 PM\n 06:00 PM\n 04:43 AM\n 02:25 PM\n 05:37 PM\n 09:20 PM\n 04:49 AM\n WBC\n 13.6\n 15.0\n 11.1\n Hct\n 31.6\n 34.0\n 28.1\n 31.5\n 29.2\n Plt\n 149\n 159\n 145\n Cr\n 1.0\n 1.0\n 1.0\n TCO2\n 34\n 35\n 27\n 30\n Glucose\n 70\n 76\n 65\n 80\n Other labs: PT / PTT / INR:13.7/42.1/1.2, CK / CKMB /\n Troponin-T:260/9/0.22, ALT / AST:57/31, Alk Phos / T Bili:70/0.4,\n Amylase / Lipase:53/22, Differential-Neuts:67.0 %, Band:2.0 %,\n Lymph:18.0 %, Mono:9.0 %, Eos:0.0 %, Lactic Acid:2.0 mmol/L,\n Albumin:2.6 g/dL, LDH:272 IU/L, Ca++:7.6 mg/dL, Mg++:2.2 mg/dL, PO4:2.4\n mg/dL\n Assessment and Plan\n 50M h/o metastatic renal CA s/p nephrectomy, IL-2, mini-allograft SCT,\n DLI x 2 last in , emphysema/pulmonary fibrosis on home 02\n presented to OSH with hypoxic respiratory failure, sepsis, cardiogenic\n shock, now improving but with difficulty weaning vent and s/p\n trach/PEG.\n # Respiratory failure: Pneumonia as likely source of resp failure and\n sepsis in patient with poor pulmonary reserve due to emphysema, ?GVHD,\n fibrosis. Patient is now s/p trach/PEG.\n - PEEP decreased to 5 yesterday after trach which he has tolerated\n well. Last ABG 7.49/34/127.\n - Driving pressures decreased this am from 24 to 20. Will check ABG on\n current settings.\n - Attempt decrease in FiO2 today (50->40%) -> maintain PaO2 >60.\n Patient's oxygenation has improved.\n - Can also attempt PSV trial today if able to adequately wean sedation\n without agitation.\n - Plan to replace trach today by IP given persistent air leak.\n # Sedation: Currently on methadone q4H, and propofol for sedation,\n currently at 20 mcg/kg/min. Off fent/versed drips.\n - Goal to wean propofol as tolerated today, triglycerides mildly\n elevated at 182\n - Continue to check triglycerides twice weekly while on propofol.\n - Bolus fentanyl/ativan prn agitation\n - When able, will decrease methadone to q6H then to q8H\n # Shock: Multifactorial, resolved.\n ** Sepsis: Likely source pneumonia. On very broad coverage w/\n vancomycin, levofloxacin, zosyn, bactrim (now only ppx dosing). All\n cultures pending or no growth. WBC stable. Patient with temp 100.8\n rectal this am during rounds. Blood cx/urine cx sent.\n - D/C'd caspo yesterday\n - F/u cultures - cont to culture with spikes.\n - Continue acyclovir and bactrim ppx, vanc/zosyn/levoflox for 14 day\n course, today is day 10.\n **Cardiogenic\n ## Pump: Now improved BPs, off dobutamine. On captopril for afterload\n reduction. Dilated hypokinetic RV, likely causative in hypotension.\n Now hypertensive. Increased to 25mg TID. Will likely need repeat ECHO\n once acute issues resolved to assess for resolution of RV dysfunction.\n ## Rhythm: Sinus bradycardia likely secondary to sedatives; increases\n with agitation. Cont weaning sedation as tolerated. Continue to\n follow QTc for prolongation given methadone and levoflox, has been wnl\n **Endocrine\n - Prednisone off today\n # Metastatic renal CA: Recurrent disease s/p donor lymphocyte\n transplant .\n - BMT to follow\n - Continue acyclovir and bactrim ppx\n ICU Care\n Nutrition:\n Restart TF 24 hours after PEG\n Glycemic Control:\n Lines:\n Multi Lumen - 11:24 PM\n Arterial Line - 12:14 AM\n Prophylaxis:\n DVT: Pneumoboots, SQ heparin\n Stress ulcer: H2 blocker\n VAP: HOB elevation, mouth care\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n" }, { "category": "Physician ", "chartdate": "2120-04-29 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 324081, "text": "Chief Complaint: 50 y/o M w. metastatic renal cell cancer s/p\n nephrectomy, IL-2, mini-SCT, DLI 2x in , emphysema/pulmonary\n fibrosis on home O2 presented to OSH with hypoxic respiratory failure,\n sepsis, cardiogenic shock now with difficulty weaning vent and s/p\n trach/peg\n 24 Hour Events:\n BLOOD CULTURED - At 12:44 PM\n URINE CULTURE - At 12:44 PM\n PICC LINE - START 04:30 PM\n MULTI LUMEN - STOP 07:52 PM\n ARTERIAL LINE - STOP 07:57 PM\n SPUTUM CULTURE - At 08:24 PM\n ULTRASOUND - At 11:16 PM\n EKG - At 03:00 AM\n ARTERIAL LINE - START 04:30 AM\n FEVER - 101.4\nF - 03:00 AM\n - Overnight, patient with increasing hypoxia and respiratory distress.\n Increasing PCO2 c/w dead space fraction. Patient improved transiently\n with diuresis and briefly on lasix gtt overnight. Later started on\n heparin gtt for ? PE in setting of hypoxia/hypotension. Overnight\n patient had to be resedated and reparalyzed because was fighting the\n vent. Also with increasing LFT's so RUQ USD obtained for ?\n cholecystitis but w/o e/o CBD on imaging. This morning is on three\n pressors to maintain MAP > 60.\n Allergies:\n Flagyl (Oral) (Metronidazole)\n Rash;\n Last dose of Antibiotics:\n Acyclovir - 04:00 PM\n Levofloxacin - 08:00 AM\n Piperacillin/Tazobactam (Zosyn) - 06:32 AM\n Vancomycin - 08:00 AM\n Infusions:\n Vasopressin - 2.4 units/hour\n Cisatracurium - 0.2 mg/Kg/hour\n Midazolam (Versed) - 25 mg/hour\n Norepinephrine - 0.05 mcg/Kg/min\n Other ICU medications:\n Midazolam (Versed) - 05:30 PM\n Heparin Sodium (Prophylaxis) - 08:25 PM\n Furosemide (Lasix) - 01:45 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 03:23 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.6\nC (101.4\n Tcurrent: 37.2\nC (99\n HR: 80 (64 - 128) bpm\n BP: 104/64(80) {66/41(52) - 175/87(100)} mmHg\n RR: 42 (0 - 42) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 76.3 kg (admission): 76.3 kg\n Height: 68 Inch\n CVP: 3 (3 - 7)mmHg\n Total In:\n 5,318 mL\n 2,490 mL\n PO:\n TF:\n 164 mL\n IVF:\n 5,054 mL\n 2,490 mL\n Blood products:\n Total out:\n 1,630 mL\n 2,095 mL\n Urine:\n 1,630 mL\n 1,795 mL\n NG:\n 300 mL\n Stool:\n Drains:\n Balance:\n 3,688 mL\n 395 mL\n Respiratory support\n Ventilator mode: PRVC/AC\n Vt (Set): 360 (360 - 360) mL\n PC : 24 cmH2O\n PS : 10 cmH2O\n RR (Set): 30\n PEEP: 9 cmH2O\n FiO2: 100%\n PIP: 37 cmH2O\n Plateau: 33 cmH2O\n Compliance: 18 cmH2O/mL\n SpO2: 99%\n ABG: 7.25/60/201/26/-1\n Ve: 15.7 L/min\n PaO2 / FiO2: 201\n Physical Examination\n General Appearance: Well nourished, sedated\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, trach\n Cardiovascular: (S1: Normal), (S2: Normal), No(t) S3, No(t) S4, No(t)\n Rub\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear :\n coarse), mechanical breath sounds\n Extremities: warm, with trace b/l LE edema\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 195 K/uL\n 10.7 g/dL\n 114 mg/dL\n 1.3 mg/dL\n 26 mEq/L\n 4.6 mEq/L\n 14 mg/dL\n 110 mEq/L\n 141 mEq/L\n 34.3 %\n 22.4 K/uL\n [image002.jpg]\n 04:26 AM\n 09:26 PM\n 12:22 AM\n 03:34 AM\n 03:52 AM\n 04:29 AM\n 05:30 AM\n 07:55 AM\n 10:02 AM\n 03:11 PM\n WBC\n 22.4\n Hct\n 34.2\n 34.3\n Plt\n 195\n Cr\n 1.3\n TCO2\n 30\n 29\n 29\n 31\n 31\n 29\n 26\n 28\n Glucose\n 114\n Other labs: PT / PTT / INR:13.7/104.5/1.2, CK / CKMB /\n Troponin-T:260/9/0.22, ALT / AST:35/49, Alk Phos / T Bili:178/1.6,\n Amylase / Lipase:50/19, Differential-Neuts:85.4 %, Band:0.0 %,\n Lymph:8.8 %, Mono:4.1 %, Eos:1.4 %, Lactic Acid:2.8 mmol/L, Albumin:2.6\n g/dL, LDH:473 IU/L, Ca++:7.3 mg/dL, Mg++:2.0 mg/dL, PO4:4.9 mg/dL\n Assessment and Plan\n SHOCK, SEPTIC\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 02:03 PM\n 18 Gauge - 02:03 PM\n PICC Line - 04:30 PM\n Arterial Line - 04:30 AM\n Multi Lumen - 12:05 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": "2120-05-01 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 324286, "text": "Subjective\n Patient with trach and PEG\n Objective\n Pertinent medications: RISS, folic acid, reglan, norepinephrine, versed\n Labs:\n Value\n Date\n Glucose\n 158 mg/dL\n 03:24 AM\n Glucose Finger Stick\n 124\n 06:00 PM\n BUN\n 35 mg/dL\n 03:24 AM\n Creatinine\n 2.0 mg/dL\n 03:24 AM\n Sodium\n 133 mEq/L\n 03:24 AM\n Potassium\n 5.1 mEq/L\n 03:24 AM\n Chloride\n 104 mEq/L\n 03:24 AM\n Albumin\n 2.8 g/dL\n 03:24 AM\n Calcium non-ionized\n 7.6 mg/dL\n 03:24 AM\n Phosphorus\n 5.8 mg/dL\n 03:24 AM\n Ionized Calcium\n 1.18 mmol/L\n 03:40 AM\n Magnesium\n 3.3 mg/dL\n 03:24 AM\n Current diet order / nutrition support: NPO\n GI: Abdomen soft/distended with absent bowel sounds\n Assessment of Nutritional Status\n Specifics:\n 50 year old male with metastatic renal cell cancer s/p nephrectomy,\n mini-SCT admitted with hypoxic respiratory failure, sepsis, s/p trach\n and PEG now with worsening respiratory status. Patient has been NPO d/t\n tenuous status. Would continue as patient is unstable. Once able, if\n medically possible, would recommend considering trophic tube feedings\n of Replete with Fiber at 10ml/hr. If tolerated, can advance by 10ml q6H\n to goal rate of 70ml/hr. Will follow for plan of care and patient\n status.\n Medical Nutrition Therapy Plan - Recommend the Following\n 1. Will follow for plan of care, if possible can consider\n starting trophic tube feedings of Replete with Fiber at 10ml/hr when\n medically possible\n 08:45\n" }, { "category": "Physician ", "chartdate": "2120-05-01 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 324287, "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 24 Hour Events:\n 24 hour events\n Significant decompensation oevrnight with profound resp acidosis,\n family meeting with Dr with plan not to escalate care and\n consider transition to CMO as family comes in\n Allergies:\n Flagyl (Oral) (Metronidazole)\n Rash;\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 06:32 AM\n Vancomycin - 08:00 AM\n Ciprofloxacin - 11:00 AM\n Metronidazole - 04:20 PM\n Caspofungin - 07:57 PM\n Linezolid - 03:58 AM\n Meropenem - 04:06 AM\n Infusions:\n Norepinephrine - 0.05 mcg/Kg/min\n Fentanyl (Concentrate) - 300 mcg/hour\n Midazolam (Versed) - 25 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 Constitutional: Fever\n Respiratory: Dyspnea\n Gastrointestinal: melena\n Genitourinary: Foley\n Heme / Lymph: Anemia\n Flowsheet Data as of 08:45 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: 36.6\nC (97.9\n HR: 105 (69 - 130) bpm\n BP: 68/44(54) {68/44(54) - 130/68(89)} mmHg\n RR: 40 (38 - 44) insp/min\n SpO2: 79%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 76.3 kg (admission): 76.3 kg\n Height: 68 Inch\n CVP: 15 (11 - 21)mmHg\n Total In:\n 6,543 mL\n 1,470 mL\n PO:\n TF:\n IVF:\n 5,793 mL\n 1,271 mL\n Blood products:\n 750 mL\n 199 mL\n Total out:\n 2,055 mL\n 250 mL\n Urine:\n 2,055 mL\n 250 mL\n NG:\n Stool:\n Drains:\n Balance:\n 4,488 mL\n 1,220 mL\n Respiratory support\n Ventilator mode: PCV+Assist\n Vt (Set): 400 (340 - 400) mL\n PC : 38 cmH2O\n RR (Set): 40\n PEEP: 6 cmH2O\n FiO2: 100%\n PIP: 40 cmH2O\n Plateau: 37 cmH2O\n Compliance: 14.3 cmH2O/mL\n SpO2: 79%\n ABG: 7.04/95./52/24/-8\n Ve: 16.6 L/min\n PaO2 / FiO2: 52\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 12.0 g/dL\n 117 K/uL\n 158 mg/dL\n 2.0 mg/dL\n 24 mEq/L\n 5.1 mEq/L\n 35 mg/dL\n 104 mEq/L\n 133 mEq/L\n 37.0 %\n 13.4 K/uL\n [image002.jpg]\n 04:44 AM\n 11:01 AM\n 05:44 PM\n 07:36 PM\n 09:00 PM\n 09:36 PM\n 10:37 PM\n 11:48 PM\n 03:24 AM\n 03:40 AM\n WBC\n 12.0\n 13.4\n Hct\n 36.4\n 37.0\n Plt\n 60\n 117\n Cr\n 1.8\n 2.0\n TCO2\n 30\n 28\n 27\n 29\n 29\n 26\n 28\n 28\n Glucose\n 116\n 158\n Other labs: PT / PTT / INR:17.0/37.6/1.5, CK / CKMB /\n Troponin-T:260/9/0.22, ALT / AST:2554/2595, Alk Phos / T Bili:188/1.5,\n Amylase / Lipase:50/19, Differential-Neuts:84.7 %, Band:2.0 %,\n Lymph:11.2 %, Mono:0.0 %, Eos:0.0 %, Fibrinogen:688 mg/dL, Lactic\n Acid:1.4 mmol/L, Albumin:2.8 g/dL, LDH:1159 IU/L, Ca++:7.6 mg/dL,\n Mg++:3.3 mg/dL, PO4:5.8 mg/dL\n Assessment and Plan\n SHOCK, SEPTIC\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 02:03 PM\n 18 Gauge - 02:03 PM\n PICC Line - 04:30 PM\n Arterial Line - 04:30 AM\n Multi Lumen - 12:05 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": "2120-04-21 00:00:00.000", "description": "Nursing Progress Note", "row_id": 323222, "text": "50 yo male with met renal cell CA admitted with severe resp\n failure/PNA, cardiogenic/septic shock. RV hypoplasia\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n Sepsis, Severe (with organ dysfunction)\n Assessment:\n Action:\n Response:\n Plan:\n Heart failure, right, isolated (Cor Pulmonale)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Physician ", "chartdate": "2120-04-20 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 323178, "text": "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 50 yo male with met renal cell CA admitted with severe resp\n failure/PNA, cardiogenic/septic shock. RV hypoplasia\n 24 Hour Events:\n #Weaned abx: Bactrim to prophylaxis doses\n #Weaned stress dose steroids\n #Wean off dobutamine (has RV hypoplasia in the setting of\n COPD/hypoxia/pulmonary fibrosis)\n #Sedation: IV methadone added\n #Lactulose added : BM this am\n History obtained from Medical records. Pt\n Unable to provide due to being sedated and intubated\n Allergies:\n Flagyl (Oral) (Metronidazole)\n Rash;\n Last dose of Antibiotics:\n Acyclovir - 04:30 PM\n Bactrim (SMX/TMP) - 09:00 AM\n Caspofungin - 08:00 PM\n Piperacillin/Tazobactam (Zosyn) - 10:00 PM\n Vancomycin - 08:05 AM\n Levofloxacin - 09:11 AM\n Infusions:\n Midazolam (Versed) - 10 mg/hour\n Fentanyl - 400 mcg/hour\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:15 PM\n Famotidine (Pepcid) - 08:06 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 10:50 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.3\nC (99.1\n Tcurrent: 37.1\nC (98.8\n HR: 67 (47 - 91) bpm\n BP: 133/60(83) {110/42(61) - 148/65(90)} mmHg\n RR: 26 (26 - 34) insp/min\n SpO2: 92%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 76.3 kg (admission): 76.3 kg\n Height: 68 Inch\n CVP: 314 (6 - 314)mmHg\n CO/CI (CCO): (4.3 L/min) / (2.3 L/min/m2)\n Total In:\n 5,654 mL\n 1,347 mL\n PO:\n TF:\n 128 mL\n IVF:\n 4,015 mL\n 939 mL\n Blood products:\n Total out:\n 3,280 mL\n 765 mL\n Urine:\n 3,280 mL\n 765 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,374 mL\n 582 mL\n Respiratory support\n Ventilator mode: PCV+\n PC : 28 cmH2O\n RR (Set): 30\n PEEP: 12 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10\n PIP: 39 cmH2O\n Plateau: 34 cmH2O\n SpO2: 92%\n ABG: 7.46/36/87./24/1\n Ve: 16.7 L/min\n PaO2 / FiO2: 176\n Physical Examination\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube,, OG tube\n Lungs: clear anteriorly, no rales/wheezes\n CV: tachycardic, RR\n Abd: soft, nontender\n Neurologic: Sedated\n Labs / Radiology\n 10.4 g/dL\n 136 K/uL\n 91 mg/dL\n 1.1 mg/dL\n 24 mEq/L\n 4.0 mEq/L\n 26 mg/dL\n 112 mEq/L\n 145 mEq/L\n 31.7 %\n 10.2 K/uL\n [image002.jpg]\n 12:10 PM\n 02:14 PM\n 08:25 PM\n 10:25 PM\n 03:04 AM\n 04:30 AM\n 04:46 AM\n 04:59 PM\n 03:12 AM\n 06:06 AM\n WBC\n 13.5\n 10.2\n Hct\n 31.8\n 31.7\n Plt\n 130\n 136\n Cr\n 1.0\n 1.1\n TCO2\n 23\n 22\n 23\n 24\n 26\n 25\n 26\n 26\n Glucose\n 98\n 91\n Other labs: PT / PTT / INR:14.6/29.1/1.3, CK / CKMB /\n Troponin-T:260/9/0.22, ALT / AST:57/31, Alk Phos / T Bili:70/0.4,\n Amylase / Lipase:53/22, Differential-Neuts:67.0 %, Band:2.0 %,\n Lymph:18.0 %, Mono:9.0 %, Eos:0.0 %, Lactic Acid:1.7 mmol/L,\n Albumin:2.7 g/dL, LDH:272 IU/L, Ca++:8.3 mg/dL, Mg++:2.3 mg/dL, PO4:2.8\n mg/dL\n Imaging: : continued bilateral infiltrates\n Microbiology: BdCx NGTD\n Assessment and Plan\n #Respiratory failure/ARDS: Remains vent-dependent on pressure control\n ventilation: Recheck ABG after decreasing vent rate. Want to decrease\n borderline transpulm pressure- will further reduce PC\n #ID: Causs of sepsis unclear. Continue antibiotics, f/u cultures.\n #Septic/cardiogenic shock:Off dobutamine. CI lower, but maintaining BP.\n Continue to monitor. Continue afterload reduction with Ace inhibitor\n #Sedation: On Methadone, versed/fentanyl. Current level of sedation\n adequate. Will consider further wean once vent requirements have\n improved.\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 02:00 AM 20 mL/hour\n Comments: Had high residuals yesterday but improving; advance to goal\n as tolerated\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Multi Lumen - 11:24 PM\n Arterial Line - 12:14 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP: HOB elevation, Mouth care\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": "2120-04-20 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 323181, "text": "Chief Complaint:\n 24 Hour Events:\n + bactrim d/c\n Beta glucan and galactomannan pending\n But\n BMT wanted to gold onto , will d/c sun if still no\n positive fungal cultures by then\n Hydrocortisone weaned to 50mg iv bid from qid\n Dobutamine weaned off, but C.I. dropped to 2.8 (from 3.5), so restarted\n overnight\n IV methadone started to wean fent / midaz; ECG without QTc prolongation\n Did NOT start propofol gtts (not close to extubation)\n FiO2 increased to 50% (from 40%) after sats fell (paO2 78 @ 9pm)\n Bradycardic overnight in 50\n increase to 90s w/ stimulation (bathing)\n Lactulose added to bowel regimen -> had bowel movement this morning per\n nursing\n Allergies:\n Flagyl (Oral) (Metronidazole)\n Rash;\n Last dose of Antibiotics:\n Acyclovir - 04:30 PM\n Bactrim (SMX/TMP) - 09:00 AM\n Levofloxacin - 10:30 AM\n Vancomycin - 08:00 PM\n Caspofungin - 08:00 PM\n Piperacillin/Tazobactam (Zosyn) - 10:00 PM\n Infusions:\n Dobutamine - 0.3 mcg/Kg/min\n Midazolam (Versed) - 10 mg/hour\n Other ICU medications:\n Famotidine (Pepcid) - 08:14 PM\n Heparin Sodium (Prophylaxis) - 08:15 PM\n Other medications:\n Lactulose / docusate / bisacodyl\n Captopril\n Tylenol prn\n Folic acid\n Albuterol\n Asa\n chlorhexidine\n Changes to medical 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: 37.3\nC (99.1\n Tcurrent: 36.7\nC (98.1\n HR: 52 (47 - 91) bpm\n BP: 119/51(71) {110/42(61) - 148/65(90)} mmHg\n RR: 34 (28 - 35) insp/min\n SpO2: 93%\n Heart rhythm: SB (Sinus Bradycardia)\n Wgt (current): 76.3 kg (admission): 76.3 kg\n Height: 68 Inch\n CVP: 7 (6 - 17)mmHg\n CO/CI (CCO): (5.1 L/min) / (2.7 L/min/m2)\n Total In:\n 5,654 mL\n 590 mL\n PO:\n TF:\n 59 mL\n IVF:\n 4,015 mL\n 402 mL\n Blood products:\n Total out:\n 3,280 mL\n 585 mL\n Urine:\n 3,280 mL\n 585 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,374 mL\n 5 mL\n Respiratory support\n Ventilator mode: PCV+\n PC : 28 cmH2O\n RR (Set): 24\n PEEP: 12 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10\n PIP: 39 cmH2O\n Plateau: 34 cmH2O\n SpO2: 93%\n ABG: 7.46/36/87./24/1\n Ve: 16.9 L/min\n PaO2 / FiO2: 176\n Physical Examination\n Gen: eyes open, not following commands, some evidence of localization\n side to side when calling name\n Heent: pupils equal. Intubated, ng tube and esophageal balloon in\n place\n Cor: rrr, nls1s2 no mrg\n Pul: cta anteriorly\n Abd: moderately distended. Bowel sounds present, no guarding, no\n tenderness / facial grimacing w/ palpation, no masses\n Extreme: warm, 2+ pitting edema to mid-thigh\n Neuro: sedated, eyes open, not responding to commands,\n Labs / Radiology\n 136 K/uL\n 10.4 g/dL\n 91 mg/dL\n 1.1 mg/dL\n 24 mEq/L\n 4.0 mEq/L\n 26 mg/dL\n 112 mEq/L\n 145 mEq/L\n 31.7 %\n 10.2 K/uL\n [image002.jpg]\n 12:10 PM\n 02:14 PM\n 08:25 PM\n 10:25 PM\n 03:04 AM\n 04:30 AM\n 04:46 AM\n 04:59 PM\n 03:12 AM\n 06:06 AM\n WBC\n 13.5\n 10.2\n Hct\n 31.8\n 31.7\n Plt\n 130\n 136\n Cr\n 1.0\n 1.1\n TCO2\n 23\n 22\n 23\n 24\n 26\n 25\n 26\n 26\n Glucose\n 98\n 91\n Other labs: PT / PTT / INR:14.6/29.1/1.3, CK / CKMB /\n Troponin-T:260/9/0.22, ALT / AST:57/31, Alk Phos / T Bili:70/0.4,\n Amylase / Lipase:53/22, Differential-Neuts:67.0 %, Band:2.0 %,\n Lymph:18.0 %, Mono:9.0 %, Eos:0.0 %, Lactic Acid:1.7 mmol/L,\n Albumin:2.7 g/dL, LDH:272 IU/L, Ca++:8.3 mg/dL, Mg++:2.3 mg/dL, PO4:2.8\n mg/dL\n Micro\n Bl cx 4/14+ pending\n Negative legionella\n Rads\n Cxr \n SINGLE SEMI-UPRIGHT VIEW OF THE CHEST AT APPROXIMATELY 7 a.m.: This\n exam is\n largely unchanged from the prior exam. Endotracheal tube, nasogastric\n tube,\n feeding tube, and right internal jugular catheter are all in unchanged\n positions. Again, the feeding tube terminates above the GE junction.\n Lung volumes remain low and widespread interstitial thickening is\n consistent\n with diffuse fibrosis. A slight relative increase in air space opacity\n at the\n right lung base (most evident when in comparison to the scout film from\n the CT\n torso of ) is largely unchanged, as is a small right pleural\n effusion.\n Assessment and Plan\n 50M h/o metastatic renal CA s/p nephrectomy, IL-2, mini-allograft SCT,\n DLI x 2 last in , emphysema/pulmonary fibrosis on home 02\n presented to OSH with hypoxic respiratory failure, fevers and\n hypotension.\n # Respiratory failure:\n Pneumonia as likely source of resp failure and sepsis in patient with\n poor pulmonary reserve due to emphysema, ?GVHD, fibrosis.\n Pt was dysynchronous w/ vent yesterday w/ decreasing sedation of fent /\n midazolam although methadone was added; oxygenation seems to worsen\n when patient is dysynchronous / less sedated.\n Sats decreased overnight and placed back on 50% FiO2.\n Had air trapping w/ high RR; will decrease RR and driving pressure if\n tolerates.\n Cont sedation w/ fent / midazolam / methadone; no urgency in relieving\n sedating w/ high vent needs.\n # Septic shock:\n **Likely source pneumonia. On very broad coverage w/ vancomycin,\n levofloxacin, bactrim (now only ppx dosing), caspofungin.\n All other cultures pending. WBC and fever curve responding well. Will\n cont broad coverage for now; consider d/c caspofungin tomorrow if\n cultures negative, since this is unlikely acute fungal pneumonia, and\n more likely bacterial.\n Since responding no need for CT chest currently.\n Also, won\nt tolerate bronch at this point, plus diagnostic studies\n probably no longer useful (culture).\n - f/u cultures\n - Legionella urine ag negative, all other cultures no growth to date.\n - D/C caspofungin sun if cultures negative\n - Glucan, galactomannan pending\n - Follow WBC count, fever curve, decreasing\n - PPD negative\n - Continue acyclovir ppx, vanc/zosyn/levoflox\n **Hypotension\n Now improved BPs, off dobutamine.\n Shock likely mix of septic, cardiogenic, and metabolic (absolute\n adrenal insufficiency). CVP goal > 8, and meeting that criteria. From\n cardiac perspective, RV hypokinesis and dysfunction though to be \n high intrapulmonary pressures (hypoxia, pulmonary fibrosis). Now able\n to maintain BP off dobutamine. Although CI decreased, will cont to\n follow urine output and MAP trend.\n For endocrine, pt w/ hx of adrenalectomy and adrenal gland w/ mets.\n - cont IV hydrocortisone taerp.\n # Metastatic renal CA: Recurrent disease s/p donor lymphocyte\n transplant .\n - BMT to follow\n - Continue acyclovir ppx for now, will discuss with BMT\n # Sedation\n Goals of sedation have been clarified; being too light was causing\n problems w/ oxygenation. Pt also was requiring supra-normal levels of\n midaz/fentanyl. Now adequately sedated on midax / fent / methadone.\n Cont this regimen for now and hold off on further sedation until\n ventilatory needs decrease.\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 02:00 AM 20 mL/hour\n Glycemic Control: ssi\n Lines:\n Multi Lumen - 11:24 PM\n Arterial Line - 12:14 AM\n Prophylaxis:\n DVT: sq heparin\n Stress ulcer: famotidine \n VAP: chlorhexidine\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: icu\n" }, { "category": "Respiratory ", "chartdate": "2120-04-21 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 323230, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 7\n Ideal body weight: 69.9 None\n Ideal tidal volume: 279.6 / 419.4 / 559.2 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation:\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: 23 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Tan / Thick\n Sputum source/amount: Suctioned / Moderate\n Comments: At times pluggy, Volumes improving after deep suctioning\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Frequent desaturation episodes,\n Tachypneic (RR> 35 b/min), Gasping efforts; Comments: Episodes of\n discomfort, forced exhalation and long sighs with desatuaration.\n Improving with proper sedation\n Assessment of breathing comfort: No response (sleeping / sedated)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment: Not triggering, Abnormal trigger efforts\n (efforts during inspiratory)\n Dysynchrony assessment: Erratic exhaled Tidal Volumes, Frequent alarms\n (Low min. ventilation)\n Comments: A long episode of trending down of minute volume and tidal\n volumes. Requiring frequent suctioning and mdi treatments. Forced\n exhalation and sighs. Improving after deep suctioning and sedation.\n Plan\n Next 24-48 hours: Maintain PEEP at current level and reduce FiO2 as\n tolerated, Adjust Min. ventilation to control pH\n Reason for continuing current ventilatory support: Sedated / Paralyzed,\n Intolerant of weaning attempts; Comments: When attempting to wean rr\n early in shift, desat to low 90s without improvement. Returned to\n original settings\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n" }, { "category": "Nursing", "chartdate": "2120-04-21 00:00:00.000", "description": "Nursing Progress Note", "row_id": 323233, "text": "50 yo male with met renal cell CA admitted with severe resp\n failure/PNA, cardiogenic/septic shock. RV hypoplasia\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Remained intubated and vented, unable to wean off from sedation / vent,\n tried to change RR ,desats .pt very sensitive to stimulation,easily\n desats and takes time to maintain sats after that. Tried to wean at\n 200hrs ,sats 88-90%,back to same settings and again at MN tried, sats\n remained on 80\ns for long time,pt needed more bolus doses fent/versed\n to settle down,\n Action:\n Continued with fent 500 and versed 10mg/hr,both at maximum dose, Blood\n gas done x3 , at present on PCV, RR 30,I:E 1:1.7,PEEP 12,PCV 24 TO 28.\n bolus sedations PRN. CXR done in the MN .\n Response:\n Blood gas borderline, PO2 low in am.\n Plan:\n Continue with sedation /vent\n? Weaning when possible.\n Sepsis, Severe (with organ dysfunction)\n Assessment:\n Multi organ failure,off dobu yesterday. Urine output adequate.\n Action:\n Continued with antibiotics, vanco/ zosyn/ acyclovir/ capsofungin/\n levoflox.\n Response:\n Afebrile.\n Plan:\n Continue with antbx,\n Heart failure, right, isolated (Cor Pulmonale)\n Assessment:\n Off dobu yesterday, SB-NSR.\n Action:\n Monitoring CO & CI.\n Response:\n CO 4.3-5.0, HR 46-50\ns when deeply sedated.\n Plan:\n Continue Monitor CO thru vigileo monitor.\n Feed tolerating well ,residual 5-10cc, feed increased gradually to\n 70cc/hr @ goal rate now.\n Bath given and positioned.\n Family visited and updated.brother stayed in the family room.\n" }, { "category": "Respiratory ", "chartdate": "2120-04-22 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 323339, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 8\n Ideal body weight: 69.9 None\n Ideal tidal volume: 279.6 / 419.4 / 559.2 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation:\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: 24 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: 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 Comments: pt sedated well and calm on vent, some moments of dyscroncrny\n Assessment of breathing comfort: No response (sleeping / sedated)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Maintain PEEP at current level and reduce FiO2 as\n tolerated, 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, Cannot protect airway, Cannot manage\n secretions, Hemodynimic instability, Underlying illness not resolved\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n" }, { "category": "Physician ", "chartdate": "2120-04-23 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 323455, "text": "Chief Complaint: 50M h/o metastatic renal CA s/p nephrectomy, IL-2,\n mini-allograft SCT, DLI x 2 last in , emphysema/pulmonary fibrosis\n on home 02 presented to OSH with hypoxic respiratory failure, fevers\n and hypotension.\n 24 Hour Events:\n - Still agitated on high doses of fentanyl/versed/methadone; methadone\n increased to q6H (per pharm requested q4H but held off for now due to\n QTc and bradycardia)\n - Patient was very agitated on high doses of Fentanyl/Versed (525/12)\n and methadone q6H -> increased methadone to q4H per pharmacy recs and\n added propofol as patient very agitated...attempting to wean propofol\n and fent/midaz as methadone kicks in throughout the night.\n - Patient became very bradycardic into the 30s, propofol, fent and\n midaz all weaned down with improvement in rates to 40s and 50s with\n minimal to no agitation (though patient more alert)\n - Off lasix gtt but with significant autodiuresis (250-300 cc/hr)\n - 6pm lytes: K 3.4, Mag 2.2, BUN 20, Cr 0.9, repleted K\n - Driving pressure decreased further to 24\n - Glucan/galactomannan still pending, awaiting results to dc caspo\n - Bcx, urine cx, sputum cx sent today as no micro since and still\n with high WBC and low grade fevers\n - Rapid prednisone taper (60 today, then 40->20->10 then off)\n - BMT recs: no new\n Allergies:\n Flagyl (Oral) (Metronidazole)\n Rash;\n Last dose of Antibiotics:\n Acyclovir - 04:18 PM\n Levofloxacin - 09:41 AM\n Vancomycin - 08:20 PM\n Caspofungin - 09:22 PM\n Piperacillin/Tazobactam (Zosyn) - 06:01 AM\n Infusions:\n Propofol - 15 mcg/Kg/min\n Midazolam (Versed) - 4 mg/hour\n Fentanyl - 150 mcg/hour\n Other ICU medications:\n Famotidine (Pepcid) - 08:00 PM\n Heparin Sodium (Prophylaxis) - 08:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n 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: 37.4\nC (99.3\n Tcurrent: 36.7\nC (98.1\n HR: 41 (37 - 116) bpm\n BP: 133/60(82) {123/56(76) - 182/82(116)} mmHg\n RR: 27 (17 - 30) insp/min\n SpO2: 95%\n Heart rhythm: SB (Sinus Bradycardia)\n Wgt (current): 76.3 kg (admission): 76.3 kg\n Height: 68 Inch\n CVP: 10 (10 - 21)mmHg\n CO/CI (CCO): (4.4 L/min) / (2.3 L/min/m2)\n Total In:\n 5,866 mL\n 812 mL\n PO:\n TF:\n 1,724 mL\n 328 mL\n IVF:\n 3,392 mL\n 384 mL\n Blood products:\n Total out:\n 5,850 mL\n 1,540 mL\n Urine:\n 5,850 mL\n 1,540 mL\n NG:\n Stool:\n Drains:\n Balance:\n 16 mL\n -727 mL\n Respiratory support\n Ventilator mode: PCV+\n PC : 24 cmH2O\n RR (Set): 30\n PEEP: 12 cmH2O\n FiO2: 1%\n PIP: 36 cmH2O\n Plateau: 30 cmH2O\n SpO2: 95%\n ABG: 7.47/44/94./32/7\n Ve: 13.5 L/min\n PaO2 / FiO2: 18,800\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 174 K/uL\n 10.8 g/dL\n 115 mg/dL\n 0.8 mg/dL\n 32 mEq/L\n 3.3 mEq/L\n 19 mg/dL\n 106 mEq/L\n 144 mEq/L\n 32.5 %\n 12.9 K/uL\n [image002.jpg]\n 01:58 AM\n 04:48 AM\n 05:04 AM\n 08:15 PM\n 04:54 AM\n 05:34 AM\n 05:52 PM\n 08:48 PM\n 04:35 AM\n 04:49 AM\n WBC\n 12.1\n 12.5\n 12.9\n Hct\n 31.2\n 31.9\n 32.5\n Plt\n 120\n 135\n 174\n Cr\n 1.0\n 1.0\n 0.9\n 0.8\n TCO2\n 28\n 26\n 33\n 36\n 36\n 33\n Glucose\n 122\n 99\n 115\n Other labs: PT / PTT / INR:13.1/32.2/1.1, CK / CKMB /\n Troponin-T:260/9/0.22, ALT / AST:57/31, Alk Phos / T Bili:70/0.4,\n Amylase / Lipase:53/22, Differential-Neuts:67.0 %, Band:2.0 %,\n Lymph:18.0 %, Mono:9.0 %, Eos:0.0 %, Lactic Acid:2.0 mmol/L,\n Albumin:2.6 g/dL, LDH:272 IU/L, Ca++:7.8 mg/dL, Mg++:2.3 mg/dL, PO4:2.4\n mg/dL\n Assessment and Plan\n 50M h/o metastatic renal CA s/p nephrectomy, IL-2, mini-allograft SCT,\n DLI x 2 last in , emphysema/pulmonary fibrosis on home 02\n presented to OSH with hypoxic respiratory failure, fevers and\n hypotension.\n # Respiratory failure: Pneumonia as likely source of resp failure and\n sepsis in patient with poor pulmonary reserve due to emphysema, ?GVHD,\n fibrosis. Overall not tolerating vent wean well. Driving pressures\n decreased over the day yesterday.\n Cont sedation w/ fent / midazolam / methadone; no urgency in relieving\n sedating w/ high vent needs.\n - Diuresed significantly on lasix gtt, now autodiuresising, goal I/O\n 500-1000mL neg to improve oxygenation now that BP / shock has resolved.\n Will continue to monitor\n - No changes to FiO2 / Peep until oxygenation improves\n - No change to A/C as patient has been tolerating PCV well\n - Decrease driving pressure again today and re-eval abg in attempt to\n reduce intrathoracic pressures and barotrauma\n # Shock: Multifactorial\n ** Sepsis: Likely source pneumonia. On very broad coverage w/\n vancomycin, levofloxacin, zosyn, bactrim (now only ppx dosing),\n caspofungin. All other cultures pending. WBC and fever curve\n improving slightly.\n - D/C caspo when beta glucan / galactomannan negative per BMT\n - F/u cultures, will pan-culture today as no micro since .\n - PPD negative\n - Continue acyclovir ppx, vanc/zosyn/levoflox for 14 day course, now\n \n **Cardiogenic\n ## Pump: Now improved BPs, off dobutamine. W/ dilated hypokinetic RV,\n likely causative in hypotension. Now BP recovering well. Increased\n ACEI yesterday for BP contol and afterload reduction which patient has\n tolerated well. No further change today\n ## Rhythm: Sinus bradycardia. ? med effect. Sustaining blood pressure\n well, no need for atropine.\n QTc: prolonged mimimally to 485. Cont check EKG w/ levofloxacin,\n methadone.\n **Endocrine\n ? absolute adrenal insufficiency, appears unlikely as patient was not\n on steroids at home. Pt w/ hx of adrenalectomy and adrenal gland w/\n mets.\n - 60 mg po prednisone today and cont w/ rapid PO pred taper, decrease\n to 40->20->10 then off.\n # Metastatic renal CA: Recurrent disease s/p donor lymphocyte\n transplant .\n - BMT to follow\n - Continue acyclovir and bactrim ppx for now, will discuss with BMT\n # Sedation: Goals of sedation have been clarified; being too light was\n causing problems w/ oxygenation. Pt also was requiring supra-normal\n levels of midaz/fentanyl. Now adequately sedated on midax / fent /\n methadone.\n - Cont current regimen for now. Will titrate sedation as tolerated\n trying to minimize agitation as this has been interfering with his\n ventilation.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 11:24 PM\n Arterial Line - 12:14 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": "2120-04-23 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 323456, "text": "Chief Complaint: 50M h/o metastatic renal CA s/p nephrectomy, IL-2,\n mini-allograft SCT, DLI x 2 last in , emphysema/pulmonary fibrosis\n on home 02 presented to OSH with hypoxic respiratory failure, fevers\n and hypotension.\n 24 Hour Events:\n - Still agitated on high doses of fentanyl/versed/methadone; methadone\n increased to q6H (per pharm requested q4H but held off for now due to\n QTc and bradycardia)\n - Patient was very agitated on high doses of Fentanyl/Versed (525/12)\n and methadone q6H -> increased methadone to q4H per pharmacy recs and\n added propofol as patient very agitated...attempting to wean propofol\n and fent/midaz as methadone kicks in throughout the night.\n - Patient became very bradycardic into the 30s, propofol, fent and\n midaz all weaned down with improvement in rates to 40s and 50s with\n minimal to no agitation (though patient more alert)\n - Off lasix gtt but with significant autodiuresis (250-300 cc/hr)\n - 6pm lytes: K 3.4, Mag 2.2, BUN 20, Cr 0.9, repleted K\n - Driving pressure decreased further to 24\n - Glucan/galactomannan still pending, awaiting results to dc caspo\n - Bcx, urine cx, sputum cx sent today as no micro since and still\n with high WBC and low grade fevers\n - Rapid prednisone taper (60 today, then 40->20->10 then off)\n - BMT recs: no new\n Allergies:\n Flagyl (Oral) (Metronidazole)\n Rash;\n Last dose of Antibiotics:\n Acyclovir - 04:18 PM\n Levofloxacin - 09:41 AM\n Vancomycin - 08:20 PM\n Caspofungin - 09:22 PM\n Piperacillin/Tazobactam (Zosyn) - 06:01 AM\n Infusions:\n Propofol - 15 mcg/Kg/min\n Midazolam (Versed) - 4 mg/hour\n Fentanyl - 150 mcg/hour\n Other ICU medications:\n Famotidine (Pepcid) - 08:00 PM\n Heparin Sodium (Prophylaxis) - 08:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n 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: 37.4\nC (99.3\n Tcurrent: 36.7\nC (98.1\n HR: 41 (37 - 116) bpm\n BP: 133/60(82) {123/56(76) - 182/82(116)} mmHg\n RR: 27 (17 - 30) insp/min\n SpO2: 95%\n Heart rhythm: SB (Sinus Bradycardia)\n Wgt (current): 76.3 kg (admission): 76.3 kg\n Height: 68 Inch\n CVP: 10 (10 - 21)mmHg\n CO/CI (CCO): (4.4 L/min) / (2.3 L/min/m2)\n Total In:\n 5,866 mL\n 812 mL\n PO:\n TF:\n 1,724 mL\n 328 mL\n IVF:\n 3,392 mL\n 384 mL\n Blood products:\n Total out:\n 5,850 mL\n 1,540 mL\n Urine:\n 5,850 mL\n 1,540 mL\n NG:\n Stool:\n Drains:\n Balance:\n 16 mL\n -727 mL\n Respiratory support\n Ventilator mode: PCV+\n PC : 24 cmH2O\n RR (Set): 30\n PEEP: 12 cmH2O\n FiO2: 1%\n PIP: 36 cmH2O\n Plateau: 30 cmH2O\n SpO2: 95%\n ABG: 7.47/44/94./32/7\n Ve: 13.5 L/min\n PaO2 / FiO2: 18,800\n Physical Examination\n Gen: eyes open, not following commands, some localization to voice\n Heent: pupils equal. Intubated, ng tube and esophageal balloon in\n place\n Cor: rrr, nls1s2 no mr\n Pul: cta anteriorly\n Abd: moderately distended. Bowel sounds present, no guarding, no\n tenderness\n Extreme: warm, 2+ pitting edema to mid-thigh\n Neuro: sedated, not responding to commands\n Labs / Radiology\n 174 K/uL\n 10.8 g/dL\n 115 mg/dL\n 0.8 mg/dL\n 32 mEq/L\n 3.3 mEq/L\n 19 mg/dL\n 106 mEq/L\n 144 mEq/L\n 32.5 %\n 12.9 K/uL\n [image002.jpg]\n 01:58 AM\n 04:48 AM\n 05:04 AM\n 08:15 PM\n 04:54 AM\n 05:34 AM\n 05:52 PM\n 08:48 PM\n 04:35 AM\n 04:49 AM\n WBC\n 12.1\n 12.5\n 12.9\n Hct\n 31.2\n 31.9\n 32.5\n Plt\n 120\n 135\n 174\n Cr\n 1.0\n 1.0\n 0.9\n 0.8\n TCO2\n 28\n 26\n 33\n 36\n 36\n 33\n Glucose\n 122\n 99\n 115\n Other labs: PT / PTT / INR:13.1/32.2/1.1, CK / CKMB /\n Troponin-T:260/9/0.22, ALT / AST:57/31, Alk Phos / T Bili:70/0.4,\n Amylase / Lipase:53/22, Differential-Neuts:67.0 %, Band:2.0 %,\n Lymph:18.0 %, Mono:9.0 %, Eos:0.0 %, Lactic Acid:2.0 mmol/L,\n Albumin:2.6 g/dL, LDH:272 IU/L, Ca++:7.8 mg/dL, Mg++:2.3 mg/dL, PO4:2.4\n mg/dL\n Assessment and Plan\n 50M h/o metastatic renal CA s/p nephrectomy, IL-2, mini-allograft SCT,\n DLI x 2 last in , emphysema/pulmonary fibrosis on home 02\n presented to OSH with hypoxic respiratory failure, fevers and\n hypotension.\n # Respiratory failure: Pneumonia as likely source of resp failure and\n sepsis in patient with poor pulmonary reserve due to emphysema, ?GVHD,\n fibrosis. Overall not tolerating vent wean well. Driving pressures\n decreased over the day yesterday.\n Cont sedation w/ fent / midazolam / methadone; no urgency in relieving\n sedating w/ high vent needs.\n - Diuresed significantly on lasix gtt, now autodiuresising, goal I/O\n 500-1000mL neg to improve oxygenation now that BP / shock has resolved.\n Will continue to monitor\n - No changes to FiO2 / Peep until oxygenation improves\n - No change to A/C as patient has been tolerating PCV well\n - Decrease driving pressure again today and re-eval abg in attempt to\n reduce intrathoracic pressures and barotrauma\n # Shock: Multifactorial\n ** Sepsis: Likely source pneumonia. On very broad coverage w/\n vancomycin, levofloxacin, zosyn, bactrim (now only ppx dosing),\n caspofungin. All other cultures pending. WBC and fever curve\n improving slightly.\n - D/C caspo when beta glucan / galactomannan negative per BMT\n - F/u cultures, will pan-culture today as no micro since .\n - PPD negative\n - Continue acyclovir ppx, vanc/zosyn/levoflox for 14 day course, now\n \n **Cardiogenic\n ## Pump: Now improved BPs, off dobutamine. W/ dilated hypokinetic RV,\n likely causative in hypotension. Now BP recovering well. Increased\n ACEI yesterday for BP contol and afterload reduction which patient has\n tolerated well. No further change today\n ## Rhythm: Sinus bradycardia. ? med effect. Sustaining blood pressure\n well, no need for atropine.\n QTc: prolonged mimimally to 485. Cont check EKG w/ levofloxacin,\n methadone.\n **Endocrine\n ? absolute adrenal insufficiency, appears unlikely as patient was not\n on steroids at home. Pt w/ hx of adrenalectomy and adrenal gland w/\n mets.\n - 60 mg po prednisone today and cont w/ rapid PO pred taper, decrease\n to 40->20->10 then off.\n # Metastatic renal CA: Recurrent disease s/p donor lymphocyte\n transplant .\n - BMT to follow\n - Continue acyclovir and bactrim ppx for now, will discuss with BMT\n # Sedation: Goals of sedation have been clarified; being too light was\n causing problems w/ oxygenation. Pt also was requiring supra-normal\n levels of midaz/fentanyl. Now adequately sedated on midax / fent /\n methadone.\n - Cont current regimen for now. Will titrate sedation as tolerated\n trying to minimize agitation as this has been interfering with his\n ventilation.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 11:24 PM\n Arterial Line - 12:14 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": "2162-09-01 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 341344, "text": "Chief Complaint:\n 24 Hour Events:\n -one episode of nausea overnight with transient SBP in 80s and HR in\n 60s - gave 500cc bolus NS and ondansetron IV with resolution of her\n symptoms.\n Allergies:\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:18 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.9\n Tcurrent: 36.4\nC (97.6\n HR: 64 (63 - 87) bpm\n BP: 96/53(63) {85/43(52) - 163/81(101)} mmHg\n RR: 14 (13 - 20) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 58 Inch\n Total In:\n 2,781 mL\n PO:\n TF:\n IVF:\n 500 mL\n Blood products:\n 281 mL\n Total out:\n 0 mL\n 100 mL\n Urine:\n 100 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 2,681 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 3.4 mEq/L\n 29.3 %\n [image002.jpg]\n 02:04 AM\n Hct\n 29.3\n Assessment and Plan\n 78 year old woman with history of hypertension and hyperlipidemia\n presenting with acute GI bleed.\n 1) Acute blood loss anemia secondary to GI bleed: likely source of\n bleeding upper given pink NG lavage however bright red blood per rectum\n either suggests lower bleed instead or brisk upper source. upper source\n would be likely PUD, AVM, mass; lower source diverticulosis, AVM or\n mass - unlikely infectious colitis. Currently appears hemodynamically\n stable with HR<SBP and visable neck veins when sitting upright although\n HR increase from 70->85 on change of position suggesting volume\n depletion (but not marked). Would anticipate that upper bleeding has\n stopped at this point, but would need to monitor closely should she\n rebleed.\n - serial Hct q4hrs for now\n - T&S\n - GI consult for likely endoscopy +/- colonoscopy\n - PPI IV BID\n - 2PIV (18g or larger)\n - NPO except meds and ice chips\n 2) Hypertension: elevated blood pressure not associated with acute\n end-organ damage. and given that patient recently/actively bleeding\n would opt to hold on treating hypertension for now. plan to resume home\n medication once bleeding stabilized.\n - monitor\n ICU Care\n Nutrition:\n Comments: NPO for now excepts meds and ice chips\n Glycemic Control: Blood sugar well controlled\n Lines:\n 20 Gauge - 12:36 AM\n 18 Gauge - 12:41 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Family meeting held , ICU consent signed Comments: Son\n is first contact cell : (\n Code status: Full code\n Disposition: ICU\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 12:36 AM\n 18 Gauge - 12:41 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": "2162-09-01 00:00:00.000", "description": "Nursing Progress Note", "row_id": 341461, "text": "The patient is a 78 year old woman with history of hypertension and\n hyperlipidemia who presented to her community health center ( Community Health Center) after developing ~6 marroon stools\n while at home. She went to her CHC and she was referred to the ER.\n She denies vomiting or abdominal pain but did have some nausea. Pt\n denies dizziness, chest pain, SOB. She is a lifelong non-drinker,takes\n prn tylenol for osteoarthritis pains and only rarely takes NSAIDs. She\n has never had a colonoscopy. She had no pain passing the bloody\n stools.\n Upon arrival to the ED her initial vital signs were 98.1 94 192/93\n 18 99%RA. Bright red blood was seen on rectal exam. NG tube lavage\n was initially light pink but cleared rapidly. PIV were placed (18 and\n 20g). She received 2L of IVF and had ~700cc of bright red blood per\n rectum. Pt transferred to MICU for further monitoring. She is A&O x 3,\n MAE, denies any pain. Pt lives independently, son and present at\n bedside.\n Gastrointestinal bleed, other (GI Bleed, GIB)\n Assessment:\n A&O x 3. MAE. HR 80s, pt hasn\nt had bloody BM since Admission to\n MICU.HCT stayed stable\n Action:\n Checking hct Q4H.GI consulted today ,planning to do colonoscopy\n tomorrow.\n Response:\n HCt syayed stable with previous ones.las t one 28.5 At 1400( 28.5 at\n 1000).will start prep at 1700 for colonoscopy with mag citrate.\n Plan:\n Q 4 hr Hcts. Monitor for S/S GIB. Colonoscopy tomorrow.\n" }, { "category": "Nursing", "chartdate": "2162-09-01 00:00:00.000", "description": "Nursing Progress Note", "row_id": 341310, "text": "The patient is a 78 year old woman with history of hypertension and\n hyperlipidemia who presented to her community health center ( Community Health Center) after developing ~6 marroon stools\n while at home. She went to her CHC and she was referred to the ER.\n She denies vomiting or abdominal pain but did have some nausea. Pt\n denies dizziness, chest pain, SOB. She is a lifelong non-drinker,takes\n prn tylenol for osteoarthritis pains and only rarely takes NSAIDs. She\n has never had a colonoscopy. She had no pain passing the bloody\n stools.\n Upon arrival to the ED her initial vital signs were 98.1 94 192/93\n 18 99%RA. Bright red blood was seen on rectal exam. NG tube lavage\n was initially light pink but cleared rapidly. PIV were placed (18 and\n 20g). She received 2L of IVF and had ~700cc of bright red blood per\n rectum. Pt transferred to MICU for further monitoring. She is A&O x 3,\n MAE, denies any pain. Pt lives independently, son and present at\n bedside.\n Gastrointestinal bleed, other (GI Bleed, GIB)\n Assessment:\n A&O x 3. MAE. HR 80s, NBP 170s on arrival to MICU. C/O nausea x 1, felt\n like she needed to move her bowels. Dry heaving clear sputum, no BM,\n however HR decreased to 60, BP 85/53. Color .\n Action:\n Fluid bloused 500cc, zofran 4 mg x 1. EKG done. Hct sent 30\n prior to ?\n vagal episode. Transfused 1 uPRBC for Hct 29 (from 35)\n Response:\n Zofran effective for nausea. BP improved to 110s. HR 60s-70s. No\n further N/V. No stool.\n Plan:\n Q 4 hr Hcts. Monitor for S/S GIB. GI consult today, probable EGD, +/-\n colonoscopy. NPO except PO meds and ice chips. Zofran for nausea.\n Protonix . Hold antihypertensive meds in setting of GIB.\n" }, { "category": "Nursing", "chartdate": "2162-09-01 00:00:00.000", "description": "Nursing Progress Note", "row_id": 341303, "text": "The patient is a 78 year old woman with history of hypertension and\n hyperlipidemia who presented to her community health center ( Community Health Center) after developing ~6 marroon stools\n while at home. She went to her CHC and she was referred to the ER.\n She denies vomiting or abdominal pain but did have some nausea. Pt\n denies dizziness, chest pain, SOB. She is a lifelong non-drinker,takes\n prn tylenol for osteoarthritis pains and only rarely takes NSAIDs. She\n has never had a colonoscopy. She had no pain passing the bloody\n stools.\n Upon arrival to the ED her initial vital signs were 98.1 94 192/93\n 18 99%RA. Bright red blood was seen on rectal exam. NG tube lavage\n was initially light pink but cleared rapidly. PIV were placed (18 and\n 20g). She received 2L of IVF and had ~700cc of bright red blood per\n rectum. Pt transferred to MICU for further monitoring. She is A&O x 3,\n MAE, denies any pain. Pt lives independently, son and present at\n bedside.\n Gastrointestinal bleed, other (GI Bleed, GIB)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Physician ", "chartdate": "2162-09-01 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 341389, "text": "Chief Complaint: Gi bleed\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 to MICU\n Transfused for Hct 5 --> 28.\n Apparent vagal episodes while trying to move bowels\n Allergies:\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n PPI IV q12; Zofran 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 Constitutional: Fatigue\n Gastrointestinal: BRBPR\n Pain: No pain / appears comfortable\n Flowsheet Data as of 08:48 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.9\n Tcurrent: 36.4\nC (97.6\n HR: 73 (62 - 87) bpm\n BP: 119/90(98) {85/43(52) - 163/90(101)} mmHg\n RR: 17 (13 - 20) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 58 Inch\n Total In:\n 2,797 mL\n PO:\n TF:\n IVF:\n 516 mL\n Blood products:\n 281 mL\n Total out:\n 0 mL\n 200 mL\n Urine:\n 200 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 2,597 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 100%\n ABG: ///25/\n Physical Examination\n General Appearance: Thin\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal), S4, (Murmur: Systolic),\n very soft systolic murmur\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Breath Sounds: Clear : , No(t) Crackles : )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Absent, Left: Absent\n Skin: Warm\n Neurologic: Attentive, Responds to: Verbal stimuli, Movement:\n Purposeful, Tone: Normal\n Labs / Radiology\n 9.7 g/dL\n 258 K/uL\n 98 mg/dL\n 0.6 mg/dL\n 25 mEq/L\n 3.7 mEq/L\n 12 mg/dL\n 107 mEq/L\n 138 mEq/L\n 28.5 %\n 7.9 K/uL\n [image002.jpg]\n 02:04 AM\n 05:46 AM\n WBC\n 7.9\n Hct\n 29.3\n 28.5\n Plt\n 258\n Cr\n 0.6\n Glucose\n 98\n ECG: NSR @ 70; small Qs in I,L, II. Precordial TWF.\n Assessment and Plan\n 78-year-old woman with GI bleed of uncertain etiology. Most likely is\n a lower or small bowel source, although we cannot fully exclude an\n upper source. Today, we will plan:\n GI consult for possible EGD and colonoscopy\n Maintain IV access (currently two 18 and one 20, which is\n adequate at present)\n Intravenous PPI\n Serial Hcts and transfusion support for anemia (2ndary to\n blood loss) as needed\n Maintain NPO for possible procedures\n For hypertension, we are holding medications during the acute phase of\n her bleeding.\n ICU Care\n Nutrition: NPO for now\n Glycemic Control: well-controlled\n Lines:\n 20 Gauge - 12:36 AM\n 18 Gauge - 12:41 AM x 2\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition : ICU\n Total time spent: 35 minutes\n" }, { "category": "Physician ", "chartdate": "2162-09-01 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 341403, "text": "Chief Complaint:\n 24 Hour Events:\n -one episode of nausea overnight with transient SBP in 80s and HR in\n 60s - gave 500cc bolus NS and ondansetron IV with resolution of her\n symptoms.\n -1u pRBCs o/n completed at 6am (right before 6am Hct drawn --- 28.5\n therefore not reflective of transfusion)\n Allergies:\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:18 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.9\n Tcurrent: 36.4\nC (97.6\n HR: 64 (63 - 87) bpm\n BP: 96/53(63) {85/43(52) - 163/81(101)} mmHg\n RR: 14 (13 - 20) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 58 Inch\n Total In:\n 2,781 mL\n PO:\n TF:\n IVF:\n 500 mL\n Blood products:\n 281 mL\n Total out:\n 0 mL\n 100 mL\n Urine:\n 100 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 2,681 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 99% on RA\n Physical Examination\n Gen: Pleasant, NAD. Resting comfortably in bed.\n CV: RRR no MRG, enlarged, sustained PMI in MCL\n Lungs: CTA b/l\n Abd: NT/ND, + BS\n Ext: no CCE\n Labs / Radiology\n 28.5 %\n 258\n 9.7\n 98\n 0.6\n 25\n 3.7 mEq/L\n 12\n 107\n 138\n 7.9\n [image002.jpg]\n 02:04 AM\n Hct\n 29.3\n Assessment and Plan\n 78 year old woman with history of hypertension and hyperlipidemia\n presenting with acute GI bleed.\n 1) Acute blood loss anemia secondary to GI bleed: likely lower GI\n bleed with nasopharyngeal trauma NG tube lavage. upper source would\n be likely PUD, AVM, mass; lower source diverticulosis, AVM or mass -\n unlikely infectious colitis. Currently appears hemodynamically stable\n with HR<SBP and visable neck veins. Without BM since arrival to the\n floor, it is difficult to determine if the patient continues to bleed\n aside from following Hcts.\n - serial Hct q4hrs for now --- Hct at 1200\n if <30 or patient is\n symptomatic, will transfuse\n - T&S\n - GI consult for likely endoscopy +/- colonoscopy\n - PPI IV BID\n - maintain at least 2 PIVs (large bore)\n - NPO except meds and ice chips\n 2) Hypertension: elevated blood pressure not associated with acute\n end-organ damage. and given that patient recently/actively bleeding\n would opt to hold on treating hypertension for now. plan to resume home\n medication once bleeding stabilized.\n - monitor\n ICU Care\n Nutrition:\n Comments: NPO for now excepts meds and ice chips\n Glycemic Control: Blood sugar well controlled\n Lines:\n 20 Gauge - 12:36 AM\n 18 Gauge - 12:41 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Family meeting held , ICU consent signed Comments: Son\n is first contact cell : (\n Code status: Full code\n Disposition: ICU\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 12:36 AM\n 18 Gauge - 12:41 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": "2162-09-01 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 341298, "text": "TITLE: PGY3 MICU Admission Note\n Chief Complaint: blood stools\n HPI:\n The patient is a 78 year old woman with history of hypertension and\n hyperlipidemia who presented to her community health center ( Community Health Center) after developing ~6 marroon stools\n while at home the first of which was at ~4pm. She went to her CHC and\n she was referred to the ER. She denies vomiting or abdominal pain but\n did have some nausea. She states that she has not been dizzy or\n lightheaded during this time. She denies chest pain or shortness of\n breath. She is a lifelong non-drinker. She takes prn tylenol for\n osteoarthritis pains and only rarely takes NSAIDs. She has never had a\n colonoscopy. She had no pain passing the bloody stools.\n Upon arrival to the ED her initial vital signs were 98.1 94 192/93\n 18 99%RA. Bright red blood was seen on rectal exam. NG tube lavage\n was initially light pink but cleared rapidly. PIV were placed (18 and\n 20g). She received 2L of IVF and had ~700cc of bright red blood per\n rectum.\n ROS: no nausea. no dysuria. no weight loss. normally can walk miles\n at a time without assist of cane or walker. independent of ADLs.\n Patient admitted from: ER\n History obtained from Patient, Family / Friend\n Allergies:\n dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n simvastatin 20 mg daily\n lisinopril/HCTZ 10 mg/12.5mg daily\n Past medical history:\n Family history:\n Social History:\n hypertension\n hyperlipidemia\n osteoarthritis\n PSurgH:\n TAH for fibroids\n no bleeding disorders. no GI bleeding no GI cancers.\n Occupation: retired\n Drugs: none\n Tobacco: only as teenager\n Alcohol: life-long non-drinker\n Other: lives alone. independent of ADLs. 1 son is BPD and active in her\n care. she is regularly involved in her church (Greater Love Tabernacle\n in )\n Review of systems:\n Constitutional: No(t) Weight loss\n Ear, Nose, Throat: No(t) Dry mouth\n Cardiovascular: No(t) Chest pain, No(t) Tachycardia, No(t) Orthopnea\n Respiratory: No(t) Dyspnea, No(t) Tachypnea\n Gastrointestinal: No(t) Abdominal pain, Nausea, Diarrhea\n Genitourinary: No(t) Dysuria\n Heme / Lymph: Anemia\n Neurologic: No(t) Headache\n Pain: No pain / appears comfortable\n Flowsheet Data as of 01:44 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.9\n Tcurrent: 36.6\nC (97.9\n HR: 87 (78 - 87) bpm\n BP: 158/79(97) {158/79(97) - 163/81(101)} mmHg\n RR: 16 (16 - 18) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 58 Inch\n Total In:\n 2,000 mL\n PO:\n TF:\n IVF:\n Blood products:\n Total out:\n 0 mL\n 100 mL\n Urine:\n 100 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 1,900 mL\n Respiratory\n O2 Delivery Device: None\n SpO2: 100%\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, Poor dentition\n Cardiovascular: (S1: Normal), (S2: Normal, Loud), (Murmur: No(t)\n Systolic, No(t) Diastolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ),\n (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present, no cutaneous sign of\n liver disease\n Extremities: Right: Absent, Left: Absent\n Skin: Warm, No(t) Jaundice\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): x3, Movement: Purposeful, Tone: Not assessed,\n CN II-XII intact. tone/bulk normal throughout. moving all 4\n extremities symmetrically. light touch intact to face/hands/feet\n Labs / Radiology\n 3.4 mEq/L\n [image002.jpg]\n Fluid analysis / Other labs: 10:04pm\n Na 132 Cl 101 BUN 12 Gluc 101 AGap=16\n K 7.5 CO2 23 Cr 0.7\n Comments: K: Hemolysis Falsely Elevates K\n CK: 152 MB: 3 Trop-T: <0.01\n WBC 7.3 Hb 11.2 Hct 35.4 Plt 321 MCV 84 RDW 13.8\n N:49.6 L:44.9 M:3.7 E:1.4 Bas:0.4\n PT: 12.5 PTT: 24.5 INR: 1.1\n Imaging: none\n Microbiology: none\n ECG: sinus @ 79 nl axis and intervals. LAE, LVH. no ischemic changes\n <1mm ST depression in V5-6\n Assessment and Plan\n 78 year old woman with history of hypertension and hyperlipidemia\n presenting with acute GI bleed.\n 1) Acute blood loss anemia secondary to GI bleed: likely source of\n bleeding upper given pink NG lavage however bright red blood per rectum\n either suggests lower bleed instead or brisk upper source. upper source\n would be likely PUD, AVM, mass; lower source diverticulosis, AVM or\n mass - unlikely infectious colitis. Currently appears hemodynamically\n stable with HR<SBP and visable neck veins when sitting upright although\n HR increase from 70->85 on change of position suggesting volume\n depletion (but not marked). Would anticipate that upper bleeding has\n stopped at this point, but would need to monitor closely should she\n rebleed.\n - serial Hct q4hrs for now\n - T&S\n - GI consult for likely endoscopy +/- colonoscopy\n - PPI IV BID\n - 2PIV (18g or larger)\n - NPO except meds and ice chips\n 2) Hypertension: elevated blood pressure not associated with acute\n end-organ damage. and given that patient recently/actively bleeding\n would opt to hold on treating hypertension for now. plan to resume home\n medication once bleeding stabilized.\n - monitor\n ICU Care\n Nutrition:\n Comments: NPO for now excepts meds and ice chips\n Glycemic Control: Blood sugar well controlled\n Lines:\n 20 Gauge - 12:36 AM\n 18 Gauge - 12:41 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Family meeting held , ICU consent signed Comments: Son\n is first contact cell : (\n Code status: Full code\n Disposition: ICU\n" }, { "category": "Nursing", "chartdate": "2162-09-01 00:00:00.000", "description": "Nursing Progress Note", "row_id": 341299, "text": "The patient is a 78 year old woman with history of hypertension and\n hyperlipidemia who presented to her community health center ( Community Health Center) after developing ~6 marroon stools\n while at home. She went to her CHC and she was referred to the ER.\n She denies vomiting or abdominal pain but did have some nausea. Pt\n denies dizziness, chest pain, SOB. She is a lifelong non-drinker,takes\n prn tylenol for osteoarthritis pains and only rarely takes NSAIDs. She\n has never had a colonoscopy. She had no pain passing the bloody\n stools.\n Upon arrival to the ED her initial vital signs were 98.1 94 192/93\n 18 99%RA. Bright red blood was seen on rectal exam. NG tube lavage\n was initially light pink but cleared rapidly. PIV were placed (18 and\n 20g). She received 2L of IVF and had ~700cc of bright red blood per\n rectum. Pt transferred to MICU for further monitoring. She is A&O x 3,\n MAE, denies any pain.\n Gastrointestinal bleed, other (GI Bleed, GIB)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2162-09-01 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 341503, "text": "Pt is 78 yr old with PMH: HTN, hyperlipedemia. Full code, NKMA. Pt to\n have colonoscopy tomorrow, pt currently drinking mag. Citrate. Pt went\n to her community health center after having 6 marroon stools at home.\n Pt has not vomited and has not complained of nausea. Pt did pass 700ml\n of bright red blood while in the ED but none since then. Now that pt\n is drinking mag citrate she has had 3 bowel movements of maroon liquid\n blood, about 450ml total. Blood appears to be old blood that is\n clearing with the mag. Citrate, not bright red blood has been passed\n since the ED episode. Pt is alert/orient x3 and very pleasant. Hct\n level has been stable all day 28-29. will draw another Hct before pt\n leaves Micu.\n Gastrointestinal bleed, other (GI Bleed, GIB)\n Assessment:\n Pt drinking mag citrate for colonoscopy tomorrow. She needs to drink\n 900ml. pt has passed 3 liquid marroon bloody stools. No bright red\n blood noted since the ED episode.\n Action:\n Cont to have pt drink mag citrate. Monitor stools for bright red blood\n as that could mean she is actively bleeding.\n Response:\n Pt cont to stool with mag citrate.\n Plan:\n Cont to make sure pt is clearing her colon with mag citrate, finish\n 900ml, cont to monitor Hct.\n Demographics\n Attending MD:\n D.\n Admit diagnosis:\n GASTROINTESTINAL BLEED\n Code status:\n Full code\n Height:\n 58 Inch\n Admission weight:\n 49.3 kg\n Daily weight:\n Allergies/Reactions:\n No Known Drug Allergies\n Unknown;\n Precautions:\n PMH:\n CV-PMH: Hypertension\n Additional history: high cholesterol\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:152\n D:73\n Temperature:\n 98.9\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 22 insp/min\n Heart Rate:\n 71 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n None\n O2 saturation:\n 99% %\n O2 flow:\n FiO2 set:\n 24h total in:\n 3,786 mL\n 24h total out:\n 1,150 mL\n Pertinent Lab Results:\n Sodium:\n 138 mEq/L\n 05:46 AM\n Potassium:\n 3.7 mEq/L\n 05:46 AM\n Chloride:\n 107 mEq/L\n 05:46 AM\n CO2:\n 25 mEq/L\n 05:46 AM\n BUN:\n 12 mg/dL\n 05:46 AM\n Creatinine:\n 0.6 mg/dL\n 05:46 AM\n Glucose:\n 98 mg/dL\n 05:46 AM\n Hematocrit:\n 29.7 %\n 06:14 PM\n Finger Stick Glucose:\n 116\n 05:00 AM\n Valuables / Signature\n Patient valuables:\n Other valuables:\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: Micu 6\n Transferred to: 2\n Date & time of Transfer:\n" }, { "category": "Physician ", "chartdate": "2162-09-01 00:00:00.000", "description": "Physician Resident / Attending Admission Note - MI", "row_id": 341327, "text": "TITLE: PGY3 MICU Admission Note\n Chief Complaint: blood stools\n HPI:\n The patient is a 78 year old woman with history of hypertension and\n hyperlipidemia who presented to her community health center ( Community Health Center) after developing ~6 marroon stools\n while at home the first of which was at ~4pm. She went to her CHC and\n she was referred to the ER. She denies vomiting or abdominal pain but\n did have some nausea. She states that she has not been dizzy or\n lightheaded during this time. She denies chest pain or shortness of\n breath. She is a lifelong non-drinker. She takes prn tylenol for\n osteoarthritis pains and only rarely takes NSAIDs. She has never had a\n colonoscopy. She had no pain passing the bloody stools.\n Upon arrival to the ED her initial vital signs were 98.1 94 192/93\n 18 99%RA. Bright red blood was seen on rectal exam. NG tube lavage\n was initially light pink but cleared rapidly. PIV were placed (18 and\n 20g). She received 2L of IVF and had ~700cc of bright red blood per\n rectum.\n ROS: no nausea. no dysuria. no weight loss. normally can walk miles\n at a time without assist of cane or walker. independent of ADLs.\n Patient admitted from: ER\n History obtained from Patient, Family / Friend\n Allergies:\n dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n simvastatin 20 mg daily\n lisinopril/HCTZ 10 mg/12.5mg daily\n Past medical history:\n Family history:\n Social History:\n hypertension\n hyperlipidemia\n osteoarthritis\n PSurgH:\n TAH for fibroids\n no bleeding disorders. no GI bleeding no GI cancers.\n Occupation: retired\n Drugs: none\n Tobacco: only as teenager\n Alcohol: life-long non-drinker\n Other: lives alone. independent of ADLs. 1 son is BPD and active in her\n care. she is regularly involved in her church (Greater Love Tabernacle\n in )\n Review of systems:\n Constitutional: No(t) Weight loss\n Ear, Nose, Throat: No(t) Dry mouth\n Cardiovascular: No(t) Chest pain, No(t) Tachycardia, No(t) Orthopnea\n Respiratory: No(t) Dyspnea, No(t) Tachypnea\n Gastrointestinal: No(t) Abdominal pain, Nausea, Diarrhea\n Genitourinary: No(t) Dysuria\n Heme / Lymph: Anemia\n Neurologic: No(t) Headache\n Pain: No pain / appears comfortable\n Flowsheet Data as of 01:44 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.9\n Tcurrent: 36.6\nC (97.9\n HR: 87 (78 - 87) bpm\n BP: 158/79(97) {158/79(97) - 163/81(101)} mmHg\n RR: 16 (16 - 18) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 58 Inch\n Total In:\n 2,000 mL\n PO:\n TF:\n IVF:\n Blood products:\n Total out:\n 0 mL\n 100 mL\n Urine:\n 100 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 1,900 mL\n Respiratory\n O2 Delivery Device: None\n SpO2: 100%\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, Poor dentition\n Cardiovascular: (S1: Normal), (S2: Normal, Loud), (Murmur: No(t)\n Systolic, No(t) Diastolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ),\n (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present, no cutaneous sign of\n liver disease\n Extremities: Right: Absent, Left: Absent\n Skin: Warm, No(t) Jaundice\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): x3, Movement: Purposeful, Tone: Not assessed,\n CN II-XII intact. tone/bulk normal throughout. moving all 4\n extremities symmetrically. light touch intact to face/hands/feet\n Labs / Radiology\n 3.4 mEq/L\n [image002.jpg]\n Fluid analysis / Other labs: 10:04pm\n Na 132 Cl 101 BUN 12 Gluc 101 AGap=16\n K 7.5 CO2 23 Cr 0.7\n Comments: K: Hemolysis Falsely Elevates K\n CK: 152 MB: 3 Trop-T: <0.01\n WBC 7.3 Hb 11.2 Hct 35.4 Plt 321 MCV 84 RDW 13.8\n N:49.6 L:44.9 M:3.7 E:1.4 Bas:0.4\n PT: 12.5 PTT: 24.5 INR: 1.1\n Imaging: none\n Microbiology: none\n ECG: sinus @ 79 nl axis and intervals. LAE, LVH. no ischemic changes\n <1mm ST depression in V5-6\n Assessment and Plan\n 78 year old woman with history of hypertension and hyperlipidemia\n presenting with acute GI bleed.\n 1) Acute blood loss anemia secondary to GI bleed: likely source of\n bleeding upper given pink NG lavage however bright red blood per rectum\n either suggests lower bleed instead or brisk upper source. upper source\n would be likely PUD, AVM, mass; lower source diverticulosis, AVM or\n mass - unlikely infectious colitis. Currently appears hemodynamically\n stable with HR<SBP and visable neck veins when sitting upright although\n HR increase from 70->85 on change of position suggesting volume\n depletion (but not marked). Would anticipate that upper bleeding has\n stopped at this point, but would need to monitor closely should she\n rebleed.\n - serial Hct q4hrs for now\n - T&S\n - GI consult for likely endoscopy +/- colonoscopy\n - PPI IV BID\n - 2PIV (18g or larger)\n - NPO except meds and ice chips\n 2) Hypertension: elevated blood pressure not associated with acute\n end-organ damage. and given that patient recently/actively bleeding\n would opt to hold on treating hypertension for now. plan to resume home\n medication once bleeding stabilized.\n - monitor\n ICU Care\n Nutrition:\n Comments: NPO for now excepts meds and ice chips\n Glycemic Control: Blood sugar well controlled\n Lines:\n 20 Gauge - 12:36 AM\n 18 Gauge - 12:41 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Family meeting held , ICU consent signed Comments: Son\n is first contact cell : (\n Code status: Full code\n Disposition: ICU\n ------ Protected Section ------\n MICU ATTENDING ADDENDUM\n I saw and examined the patient, and was physically present with the ICU\n team for the key portions of the services provided. I agree with the\n note above, including the assessment and plan. I would emphasize and\n add the following points: 78F hypertension and hyperlipidemia p/w \n episodes of maroon stools / BRBPR over the past 18 hours. Rare NSAIDs,\n no history of EtOH or liver disease. Hypertensive on presentation, NGL\n notable for pink fluid, which cleared with lavage. Continued to pass\n BRBPR in ED, treated with IV PPI and 2L IVF and sent to MICU after\n discussion with GI team.\n Exam notable for Tm 97.9 BP 158/78 HR 87 RR 14 with sat 99% on RA. Well\n nourished, CTA, RRR S1S2S4 with soft SM at base. Abd soft, NT\n hyperactive BS no rebound. No edema, neurologically intact. Labs\n notable for WBC 7K, HCT 35 to 28 c 2L NS, K+ 3.4, Cr 0.8. EKG NSR @78,\n LVH.\n Agree with plan to transfuse one unit PRBCs, continue IV PPI and keep\n NPO while monitoring serial HCT. Currently has adequate PIV access.\n Will discuss timing of endoscopy with GI team in AM; from the history\n this presentation is most consistent with a lower bleeding source,\n though report of NGL raises the possibility of a brisk UGI bleed that\n has subsided. Will continue to hold antihypertensives for now;\n remainder of plan as outlined above.\n Patient is critically ill.\n Total time: 40 min\n ------ Protected Section Addendum Entered By: , MD\n on: 05:23 ------\n" }, { "category": "Nursing", "chartdate": "2162-09-01 00:00:00.000", "description": "Nursing Progress Note", "row_id": 341492, "text": "The patient is a 78 year old woman with history of hypertension and\n hyperlipidemia who presented to her community health center ( Community Health Center) after developing ~6 marroon stools\n while at home. She went to her CHC and she was referred to the ER.\n She denies vomiting or abdominal pain but did have some nausea. Pt\n denies dizziness, chest pain, SOB. She is a lifelong non-drinker,takes\n prn tylenol for osteoarthritis pains and only rarely takes NSAIDs. She\n has never had a colonoscopy. She had no pain passing the bloody\n stools.\n Upon arrival to the ED her initial vital signs were 98.1 94 192/93\n 18 99%RA. Bright red blood was seen on rectal exam. NG tube lavage\n was initially light pink but cleared rapidly. PIV were placed (18 and\n 20g). She received 2L of IVF and had ~700cc of bright red blood per\n rectum. Pt transferred to MICU for further monitoring. She is A&O x 3,\n MAE, denies any pain. Pt lives independently, son and present at\n bedside.\n Gastrointestinal bleed, other (GI Bleed, GIB)\n Assessment:\n A&O x 3. MAE. HR 80s, pt hasn\nt had bloody BM since Admission to\n MICU.HCT stayed stable\n Action:\n Checking hct Q4H.GI consulted today ,planning to do colonoscopy\n tomorrow.Started on colonoscopy prep,drink 300ml,600ml left\n Response:\n HCt syayed stable with previous ones.las t one 28.5 At 1400( 28.5 at\n 1000).will start prep at 1700 for colonoscopy with mag citrate.\n Plan:\n Q 4 hr Hcts. Monitor for S/S GIB. Colonoscopy tomorrow.\n" }, { "category": "ECG", "chartdate": "2162-08-31 00:00:00.000", "description": "Report", "row_id": 223364, "text": "Sinus rhythm. Lateral precordial ST segment depression. T wave flattening\nin lead aVL. No previous tracing available for comparison.\n\n" } ]

[ { "category": "ECG", "chartdate": "2121-05-04 00:00:00.000", "description": "Report", "row_id": 161327, "text": "Sinus rhythm\n*** arm lead reversal - only aVF, V1 - V6 analyzed ***\nNormal ECG\nSince previous tracing, lead reversed\n\n" }, { "category": "ECG", "chartdate": "2121-05-03 00:00:00.000", "description": "Report", "row_id": 161328, "text": "Sinus arrhythmia with rate 70-55. Inverted P waves V1 indicating left atrial\nabnormality. INT: Sinus arrhythmia with bradycardia at times. No previous\ntracing available for comparison.\n\n" }, { "category": "Radiology", "chartdate": "2121-05-03 00:00:00.000", "description": "CT C-SPINE W/O CONTRAST", "row_id": 756871, "text": " 5:15 PM\n CT C-SPINE W/O CONTRAST; CT RECONSTRUCTION Clip # \n Reason: prevertebral soft tissue swelling on plain film, s/p unrestr\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old man with\n REASON FOR THIS EXAMINATION:\n prevertebral soft tissue swelling on plain film, s/p unrestrained driver w/\n facial injuries. thanks.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Question of prevertebral soft tissue swelling on plain film in\n unrestrained driver with facial injuries.\n\n TECHNIQUE: Axial non-contrast images are obtained from the skull base through\n the thoracic inlet.\n\n There is no significant prevertebral soft tissue swelling. There is normal\n alignment of the cervical vertebral bodies and disc spaces. No fractures are\n identified. High attenuation fluid (approximately 50-55 ) is detected,\n layering along the posterior aspect of the inferior oropharynx. The skull\n base and mastoid air cells are unremarkable.\n\n The reformatted sagittal and coronal images again confirm the above findings.\n\n IMPRESSION:\n 1) No evidence of fracture or mal-alignment.\n 2) The previously described soft tissue within the oropharynx likely\n represents sanguinous fluid related to the facial trauma.\n\n" }, { "category": "Radiology", "chartdate": "2121-05-03 00:00:00.000", "description": "C-SPINE, TRAUMA", "row_id": 756875, "text": " 5:55 PM\n C-SPINE, TRAUMA Clip # \n Reason: S/P MVA ?FX\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Status post motor vehicle accident. Completion of C-spine series.\n\n AP AND OPEN-MOUTH VIEWS OF THE CERVICAL SPINE: These two views show no\n evidence of acute fractures or malalignment. The open-mouth view shows a\n noraml C1-C2 relationship. No odontoid fracture.\n\n IMPRESSION: Completion C-spine series. No acute fractures or malalignment.\n\n" }, { "category": "Radiology", "chartdate": "2121-05-05 00:00:00.000", "description": "MR THORACIC SPINE", "row_id": 756960, "text": " 9:55 AM\n MR THORACIC SPINE Clip # \n Reason: s/p mvc w/ tenderness of T3-4 region on exam. plain films n\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50 year old man with\n REASON FOR THIS EXAMINATION:\n s/p mvc w/ tenderness of T3-4 region on exam. plain films negative but\n limited. please page w/ questions/results. thanks.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY:\n Motor vehicle accident. Tenderness of T3-4 region. Plain films showed no\n abnormalities.\n\n TECHNIQUE:\n Sagittal and T1- and T2-weighted thoracic spine images were obtained with\n axial T1-weighted scans of the T1-2 and T4-5 interspaces.\n\n FINDINGS:\n This examination is within normal limits. There is no sign of abnormal signal\n within or abnormal alignment of the component vertebrae. No obvious fracture\n is seen. However, MRI scanning is inferior to CT scanning in the detection of\n fractures, particularly those that are nondisplaced. No abnormalities of the\n surrounding paraspinal soft tissues are defined either.\n\n CONCLUSION:\n Normal study (see above report).\n\n" }, { "category": "Radiology", "chartdate": "2121-05-03 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 756884, "text": " 9:54 PM\n CHEST (PORTABLE AP) Clip # \n Reason: S/P MVC w/ small L PTX on ct. please perform follow-up film\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50 year old man with\n REASON FOR THIS EXAMINATION:\n S/P MVC w/ small L PTX on ct. please perform follow-up film at 10pm to eval\n for expansion. Please place pt in reverse trendelenberg to obtain semi-upright\n film. page w/ questions/results. thanks.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Left pneumothorax followup.\n\n PORTABLE CHEST: Comparison is made to earlier film from 4:40 PM the same day.\n The patient's known multiple left rib fractures are again identified. There is\n a very tiny left pneumothorax seen on today's film. The lungs appear clear.\n Cardiac and mediastinal contours are stable.\n\n IMPRESSION: 1. Tiny left apical pneumothorax.\n 2. Multiple left rib fractures.\n\n" }, { "category": "Radiology", "chartdate": "2121-05-03 00:00:00.000", "description": "R HAND (AP, LAT & OBLIQUE) RIGHT", "row_id": 756863, "text": " 4:35 PM\n HAND (AP, LAT & OBLIQUE) RIGHT Clip # \n Reason: s/p mva\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old man with\n REASON FOR THIS EXAMINATION:\n s/p mva\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Status post motor vehicle accident, pain.\n\n THREE VIEWS OF THE RIGHT HAND: No evidence of acute fractures, dislocations\n or areas of bone destruction. The soft tissues are grossly normal. Note that\n the distal phalanx of the second digit is obscured by an overlying pulse\n oximeter.\n\n IMPRESSION: No fractures or dislocations.\n\n" }, { "category": "Radiology", "chartdate": "2121-05-04 00:00:00.000", "description": "T-SPINE", "row_id": 756909, "text": " 11:17 AM\n T-SPINE; LUMBO-SACRAL SPINE (AP & LAT) Clip # \n Reason: s/p mvc w/ T3 tenderness on exam. , s/p mvc w/ T3 tendernes\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50 year old man with\n REASON FOR THIS EXAMINATION:\n s/p mvc w/ T3 tenderness on exam.\n ______________________________________________________________________________\n FINAL REPORT\n TWO VIEWS T-SPINE, TWO VIEWS L-SPINE\n\n INDICATION: Pain after MVA.\n\n THORACIC SPINE: The frontal view again demonstrates fractures of the lateral\n aspects of left ribs two through six. A tiny left apical pneumothorax is\n again visualized.\n\n On the lateral thoracic spine film, note is made of a displaced fracture\n through the sternum inferiorly.\n\n The film does not allow confident evaluation of T12 to precisely locate T3,\n which may be suboptimally imaged. Grossly, the T3 vertebral body as well as\n remaining thoracic vertebral body heights are maintained and the vertebral\n bodies are well aligned.\n\n LUMBAR SPINE: There are five non-rib bearing lumbar vertebral bodies.\n Vertebral body heights and disk space heights are maintained and the vertebral\n bodies are well aligned. There is no evidence of lumbar spine fracture or\n dislocation. Minimal degenerative change is seen.\n\n IMPRESSION: 1) Fractures of left ribs two through six again identified.\n\n 2) Tiny residual left apical pneumothorax.\n\n 3) Displaced fracture of the lower sternum. This finding was telephoned to\n the house staff caring for this patient.\n\n 4) No definite thoracic spine fracture. If there is persistent pain referable\n to this area, MR may be useful for further evaluation.\n\n 5) No evidence of lumbar spine fracture.\n\n\n" }, { "category": "Radiology", "chartdate": "2121-05-03 00:00:00.000", "description": "CT EMERGENCY HEAD W/O CONTRAST", "row_id": 756864, "text": " 4:48 PM\n CT EMERGENCY HEAD W/O CONTRAST Clip # \n Reason: s/p mva, *please obtain fine facial cuts*\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old man with\n REASON FOR THIS EXAMINATION:\n s/p mva\n *please obtain fine facial cuts*\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Motor vehicle accident.\n\n TECHNIQUE: Noncontrast head CT.\n\n FINDINGS: There is no intra or extra-axial hemorrhage. There is no shift of\n normally midline structures. The ventricles, sulci, and cisterns are normal.\n The -white matter differentiation is preserved. No major vascular\n territorial infarctions are identified. The visualized paranasal sinuses are\n normal. The mastoid air cells are well pneumatized.\n\n IMPRESSION: No evidence of acute intracranial hemorrhage. No fractures on\n this head CT.\n\n" }, { "category": "Radiology", "chartdate": "2121-05-03 00:00:00.000", "description": "CTA ABD W&W/O C & RECONS", "row_id": 756865, "text": " 4:49 PM\n CTA ABD W&W/O C & RECONS; CTA CHEST W&W/O C &RECONS Clip # \n CT 150CC NONIONIC CONTRAST; CT PELVIS W/CONTRAST\n Reason: s/p mva\n Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old man with\n REASON FOR THIS EXAMINATION:\n s/p mva\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: MVA.\n\n TECHNIQUE: Noncontrast and post contrast images of the chest, abdomen and\n pelvis were performed.\n\n CONTRAST: 150 cc of Optiray was administered.\n\n CHEST CT WITHOUT AND WITH INTRAVENOUS CONTRAST: The soft tissue windows\n reveal no significant axillary, mediastinal or hilar lymph node enlargement.\n The heart, pericardium and great vessels are normal in appearance. There is\n mild atelectasis at the lung bases bilaterally. There is a small rounded area\n of hypodensity within the left midlung zone with a small area of surrounding\n ground glass opacity. This appears adjacent to the left subsegmental\n bronchus. The remainder of the lung demonstrates no other focal\n abnormalities. There is a trace pneumothorax noted at the left apex adjacent\n to the esophagus.\n Bone windows demonstrate four fractures involving the left lateral ribs\n involving the ribs off of T3,T4, T5 and T6. There is a solitary fracture\n involving a superior right rib. The thoracic spine is normal.\n\n CT OF THE ABDOMEN WITHOUT AND WITH INTRAVENOUS CONTRAST: The liver, spleen,\n adrenal glands, kidneys, pancreas, gallbladder, large and small bowel are\n normal. There is no evidence of intra-abdominal free fluid or free air. No\n mesenteric or retroperitoneal lymphadenopathy is identified.\n\n CT OF THE PELVIS WITH INTRAVENOUS CONTRAST: The large and small bowel are\n unremarkable. The bladder and distal ureters are normal. There is no\n significant pelvic or inguinal lymphadenopathy.\n\n Osseous structures within the abdomen and pelvis are unremarkable. No\n fractures are identified.\n\n IMPRESSION:\n 1. Minimal left pneumothorax.\n 2. Rounded area of low density within the left midlung zone most likely\n represents a pneumatocele with adjacent lung contusion. However, an\n infectious process creating a cavitation cannot entirely be excluded. This is\n an unlikely area for tuberculosis. Focal bronchiectasis is an additional\n possibility. Recommend repeat Chest CT in 3 months for follow up.\n 3. Four left rib fractures involving the ribs off of T3, T4, T5 and T6. One\n rib fracture involving the right hemithorax. The thoracic and lumbar spine\n (Over)\n\n 4:49 PM\n CTA ABD W&W/O C & RECONS; CTA CHEST W&W/O C &RECONS Clip # \n CT 150CC NONIONIC CONTRAST; CT PELVIS W/CONTRAST\n Reason: s/p mva\n Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n are unremarkable.\n 4. The abdomen and pelvis are unremarkable.\n 5. No thoracid or lumbar spinal fractures are identified.\n\n" }, { "category": "Radiology", "chartdate": "2121-05-03 00:00:00.000", "description": "CT SINUS/MAXLIOFACIAL W/O CONTRAST", "row_id": 756866, "text": " 4:54 PM\n CT SINUS/MAXLIOFACIAL W/O CONTRAST; CT RECONSTRUCTION Clip # \n Reason: TRAUMA\n ______________________________________________________________________________\n FINAL REPORT\n CT SINUS/MAXILLOFACIAL:\n\n TECHNIQUE: Thin axial images were obtained through the sinuses to the level\n of the mandible.\n\n FINDINGS: The frontal, maxillary, ethmoid and sphenoid sinuses are normal.\n The orbits appear normal. The maxilla is normal. Note is made of posterior\n displacement of the four anterior mandibular teeth. There is minor\n discontinuity of the superior anterior cortex of the mandible. More\n inferiorly, the mandible appears intact. There is no evidence of\n malialignment. The temporotemporal mandibular joint is not included in this\n series.\n\n IMPRESSION: Probable small fracture involving the superior aspect of the\n mandible adjacent to the anterior teeth.\n Frontal, maxillary, ethmoid and sphenoid sinuses are normal.\n\n\n" }, { "category": "Radiology", "chartdate": "2121-05-03 00:00:00.000", "description": "P TRAUMA SERIES (LAT C-SPINE, AP CXR, AP PELVIS PORT) PORT", "row_id": 756862, "text": " 4:34 PM\n TRAUMA SERIES (LAT C-SPINE, AP CXR, AP PELVIS PORT) PORT Clip # \n Reason: s/p trauma\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old man with\n REASON FOR THIS EXAMINATION:\n s/p trauma\n ______________________________________________________________________________\n FINAL REPORT (REVISED)\n INDICATION: Status post motor vehicle accident with trauma to chest and face\n and persistent chest pain.\n\n TRAUMA SERIES\n\n CERVICAL SPINE, SINGLE VIEW: The vertebral bodies C1 through C7 are normal in\n alignment and demonstrate normal mineralization. There is normal vertebral\n body and disc height. No fractures are identified.\n\n CHEST, SINGLE VIEW: Allowing for AP supine technique, the cardiac,\n mediastinal and hilar contours are within normal limits. The pulmonary\n vasculature is unremarkable. The lungs are clear. There is a small left apical\n pneumothorax. Fractures are noted through the lateral aspects of the left 3rd,\n 4th and 5th ribs.\n\n PELVIS, AP VIEW: There is normal mineralization and alignment. No fracture or\n dislocation is noted. The SI joints and pubic symphysis are unremarkable.\n Nonspecific calcifications are noted in the region overlying the superior\n pubic ramus.\n\n IMPRESSION:\n 1. No evidence of cervical spine fracture.\n 2. Multiple left rib fractures, with an associated small left apical\n pneumothorax.\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2121-05-05 00:00:00.000", "description": "MANDIBLE SERIES INCLUD PANOREX", "row_id": 756973, "text": " 2:56 PM\n MANDIBLE SERIES INCLUD PANOREX Clip # \n Reason: s/p mvc w/ inf alveolar ridge injury, pain at L ear, poor vi\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50 year old man with\n REASON FOR THIS EXAMINATION:\n s/p mvc w/ inf alveolar ridge injury, pain at L ear, poor visualization of\n mandible on ct. pt cannot stand until MR of thoracic spine is cleared. page\n w/ questions. thanks.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: Pain.\n\n FOUR VIEWS INCLUDING PANOREX: No fractures.\n\n" }, { "category": "Radiology", "chartdate": "2121-05-05 00:00:00.000", "description": "R SHOULDER (AP, NEUTRAL & AXILLARY) TRAUMA RIGHT", "row_id": 757017, "text": " 5:44 PM\n SHOULDER (AP, NEUTRAL & AXILLARY) TRAUMA RIGHT Clip # \n Reason: s/p MVC now w/ R shoulder pain, limited motion, please eval\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50 year old man with\n REASON FOR THIS EXAMINATION:\n s/p MVC now w/ R shoulder pain, limited motion, please eval for fx/dislocation.\n thanks.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: History of pain and limited motion.\n\n RIGHT SHOULDER, THREE VIEWS: No fracture or dislocation. No calcification in\n the rotator cuff. The acromioclavicular and glenohumeral joints are\n unremarkable.\n\n IMPRESSION: No significant abnormalities.\n\n" }, { "category": "Nursing/other", "chartdate": "2121-05-04 00:00:00.000", "description": "Report", "row_id": 1453394, "text": "TSICU NPN\nO: ROS\nNEURO: PT REMAINS A&O X3 (INTERPRETER PRESENT FOR NEURO EXAMS) MAE AND FOLLOWS COMMANDS. C SPINE CLEARED AND COLLAR REMOVED. PT HAS PAIN OVER TLS SPINE ON PALPATION. TLS FILMS DONE AND RESULTS PND. REMAINS ON LOGROLL PRECAUTIONS. PCA MS04 W/ GD EFFECT.\n\nCV: HR 70-80 NSR, NO ECTOPY. STABLE BP. REPEAT EKG DONE. CK'S AND TROPONIN NEGATIVE.\n\nRESP: STABLE 02SATS 0N RM AIR. LS CLEAR. PAIN ON INSPIRATION ?D/T FX RIBS. AERATION IN ALL LOBES. SM STABLE PTX ON CXR. SRR 16.\n\nGI: REMAINS NPO, NO N/V, NO BM.\n\nRENAL: ADEQUATE U/O VIA FOLEY. IVF AT 100CC/HR.\n\nHEME: STABLE\n\nID: LOW GRADE TEMP 100>1. CONT ON CLINDA.\n\nSKIN: R HAND SUTURES W/ SM AMT BLOODY DNGE. DSG CHANGED X1, D&I. BACITRACIN APPLIED TO ABRASIONS, R HAND AND LIP LAC. BACKSIDE INTCT.\n\nSOCIAL: FAMILY IN THIS AFTERNOON. PT IN GD SPIRITS.\n\nA: HEMODYNAMICALLY AND NEUROLOGICALLY STABLE.\n\nP: AWAIT RESULTS OF TLS FILMS. ?ADVANCE DIET AND ACTIVITY ONCE CLEARED. PT IS READY FOR TRANSFER AWAITING A BED.\n" }, { "category": "Nursing/other", "chartdate": "2121-05-04 00:00:00.000", "description": "Report", "row_id": 1453393, "text": "TRAUMA SICU NURSING ADMISSION/TRANSFER NOTE\n\nTHIS 50YO GENTLEMAN WAS INVOLVED IN AN UNRESTRAINED HIGH SPEED CAR VRS POLE MVA LAST EVE, WHILE TRYING TO AVOID HITTING A CAR THAT APPARENTLLY PULLED OUT IN FRONT OF HIM. GCS 15, NO LOC AT SCENE PER WITNESSES AND TO VIA AMBULANCE D/T MECHANISM OF INJURY (CHEST IN STEERING WHEEL). PT RECEIVED FULL TRAUMA W/U IN ED , RECEIVED TETNUS SHOT, CLINDA, HAD LACS SUTURED, AND WAS TO THE TSICU AT 9PM TO BE MONITORED.\n\nPMHX: WIFE REPORTS PT HAS HAD 2 EPISODE OF \"CHEST DISCOMFORT\" WHILE LIFTING HEAVY OBJECTS IN THE PAST MONTH. THIS WAS SELF LIMITING AND PT DID NOT SEEK MEDICAL CARE AT EITHER TIME. NO OTHER PMHX NOTED.\n\nPREADM MEDS: NONE\n\nSOC-> PT MARRIED WITH ONE 2YO DAUGHTER. IS TODAY. WORKS FULL TIME. LRG SUPPORTIVE FAMILY.\n\nINJURIES: LT 4,5,6 FX RIBS\n RT 4TH RIB FX\n LAC BOTTOM LIP-SUTURED IN ED\n LAC RT HAND-SUTURED IN ED\n LOSS OF 2BOTTOM FRONT TEETH\n SM HEAD ABRASION OTA\n\nCTSCANS: -HEAD, -ABD, -CHEST, CSPINE TO C7 NEGATIVE, XRAY RT HAND NEG\n\n**CURRENT REVIEW OF SYSTEMS**\n\nNEURO-> A/O X3, MAE WITH STRENGTH AND EQUALITY. PCA MSO4 1MG Q6MIN, LOCKOUT 10MG IV WITH GOOD EFFECT. PT SPANISH SPEAKING ONLY. TRANSLATOR CONFIRMING NEURO EXAM. PERRLA, +GAG,COUGH. CCOLLAR ON, TLS NOT CLEARED YET, LOG ROLL PRECAUTIONS MAINTAINED.\n\nCV-> HR SR 70-80 BP 130-150/60. PALP PULSES. EXT WARM TO TOUCH. R/O CPKS, TROPONIN NEGATIVE, CK ELEVATED WITH NEG MBS. EKGS NORMAL.\n\nRESP-> NC 2LO2 POX 100% RR 12-16. LS CTA. ENC TO DB AND USE I/S-Q1-2HR WITH VOLUMES UP TO 550-700. CXR 10PM LAST EVE.\n\nRENAL-> IVF LR 100CCHR. LYTES WNL. RENAL PROFILE NORMAL. U/O ADEQUATE.\n\nGI-> NPO OVERNGIHT. +BS. NO N/V. ZANTAC ATC.\n\nHEME-> HCT STABLE. INR 1.2. PNEUMOBOOTS.\n\nENDO-> BS 110\n\nID-> LOW GRADE TEMPS. CLINDAMYCIN ATC. WBC 9.\n\nSKIN-> HEAD ABRASION CLEANSED WITH NS. CHIN ABRASION AND LIP LAC CLEANSED AND TX WITH BACITRACIN OINT. RT ELBOW LAC AND SUTURED HAND LAC CLEANSED WITH NS AND TX WITH BACITRACIN OINT. BACK INTACT. LEGS INTACT. COLLAR ON, COLLAR CARE QSHIFT\n\nSOC-> WIFE AND SISTER IN LAW IN LAST EVE. SISTER IN LAW TRANSLATING. SUPPORT PROVIDED, ASKING APPROPRIATE QUESTIONS.\n\nSTATUS-> FULL CODE.\n\n\nA: PT /NEURODYN STABLE HD 2 S/P MVA\nP: FULL SUPPORT, REPEAT TLS FILMS, CLEAR NECK, ADVANCE ACTIVITY AND DIET AND TRANSFER TO FLOOR WHEN ABLE. SUPPORT PT/FAM AT THIS TIME. MSO4 PCA FOR PAIN MGT.\n" } ]

[ { "category": "Radiology", "chartdate": "2177-06-08 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 966741, "text": " 7:39 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please evaluate for acute cardiopulm process\n Admitting Diagnosis: IMI\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 86 year old man s/p inferior STEMI\n REASON FOR THIS EXAMINATION:\n please evaluate for acute cardiopulm process\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST OF \n\n INDICATION: Myocardial infarction.\n\n Lung volumes are low. Heart size is normal. Aorta is mildly tortuous and\n pulmonary vascularity is normal. Bibasilar discoid atelectasis is present.\n No pleural effusions are identified on this single portable projection.\n\n\n" }, { "category": "Radiology", "chartdate": "2177-06-10 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 966982, "text": " 7:39 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please assess for interval change\n Admitting Diagnosis: IMI\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 86 year old man s/p inferior STEMI\n\n REASON FOR THIS EXAMINATION:\n please assess for interval change\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 86-year-old man status post inferior myocardial infarction.\n\n COMPARISON: .\n\n CHEST AP: Cardiac, mediastinal, and hilar contours are stable. Pulmonary\n vasculature is unremarkable. There are low lung volumes on the exam which\n results in mild compressive atelectasis. The lungs are otherwise clear.\n There are no pleural effusions. Osseous and soft tissue structures are\n unchanged.\n\n IMPRESSION: No acute cardiopulmonary process.\n\n\n" }, { "category": "Echo", "chartdate": "2177-06-09 00:00:00.000", "description": "Report", "row_id": 83606, "text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. Myocardial infarction.\nHeight: (in) 66\nWeight (lb): 168\nBSA (m2): 1.86 m2\nBP (mm Hg): 123/71\nHR (bpm): 60\nStatus: Inpatient\nDate/Time: at 10:13\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Normal LA size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.\n\nLEFT VENTRICLE: Normal LV wall thicknesses and cavity size. Mild regional LV\nsystolic dysfunction. No resting LVOT gradient.\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: basal inferior\n- akinetic; remaining LV segments contract normally.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Mildly dilated aortic sinus. Focal calcifications in aortic root.\nMildly dilated ascending aorta.\n\nAORTIC VALVE: Moderately thickened aortic valve leaflets. Mild AS (AoVA\n1.2-1.9cm2). Mild (1+) AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. Mild mitral\nannular calcification. Mild (1+) MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Normal PA\nsystolic pressure.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor subcostal views.\n\nConclusions:\nThe left atrium is normal in size. Left ventricular wall thicknesses and\ncavity size are normal. There is mild regional left ventricular systolic\ndysfunction with focal akinesis of the basal inferior wall. The remaining left\nventricular segments contract normally. Right ventricular chamber size and\nfree wall motion are normal. The aortic root is mildly dilated at the sinus\nlevel. The ascending aorta is mildly dilated. The aortic valve leaflets are\nmoderately thickened. There is mild aortic valve stenosis (area 1.2cm2). Mild\n(1+) aortic regurgitation is seen. The mitral valve leaflets are mildly\nthickened. There is no mitral valve prolapse. Mild (1+) mitral regurgitation\nis seen. The estimated pulmonary artery systolic pressure is normal. There is\nno pericardial effusion.\n\nIMPRESSION: Mild regional left ventricular systolic dysfunction c/w CAD. Mild\naortic stenosis. Mild aortic regurgitation. Mild mitral regurgitation.\n\nCLINICAL IMPLICATIONS:\nBased on AHA endocarditis prophylaxis recommendations, the echo findings\nindicate prophylaxis is NOT recommended. Clinical decisions regarding the need\nfor prophylaxis should be based on clinical and echocardiographic data.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2177-06-08 00:00:00.000", "description": "Report", "row_id": 1664865, "text": "CCU NSG PROGRESS NOTE 7:30P-7A/ S/P RCA STENT/R/I MI\n\nS- \" SO LOOKS LIKE I HAD A HEART ATTACK...\"\n\nO- SEE FLOWSHEET FOR OBJECTIVE DATA\n\n PT ARRIVED FROM CATH LAB, CP FREE, VSS- S/P STENT X 3 TO RCA.\nSHEATHS IN PLACE RT GROIN- D/C BY CV FELLOW 8:15- HELD PRESSURE X 1/2 HOUR. NO OOZE, GROIN STABLE, PULSES PRESENT.\nHCT -41.5 ON ARRIVAL, 36 THIS AM. SLIGHT PINK/HEMATURIA SINCE ARRIVAL BUT NO EVIDENCE ACUTE BLEEDING.\nDENIES PAIN- ON STRICT BEDREST S/P SHEATH REMOVAL- CURRENTLY LESS RESTRICTED.\nHR- 70'S SR, STARTED 12.5 MG LOPRESSOR- RATE DOWN TO 55-60 SR AFTER DOSE, TOLERATED FINE. SOME AIVR/REPERFUSION VEA. K- 3.9- GIVEN 40 PO, THIS AM-K-3.6 GIVEN 40 KCL AGAIN.\nTO START CAPTOPRIL AS WELL. ON INTEGRILLEN 2MCG/KG X 18 HOUR AND S/P CATH IVF 150/HOUR.\nBP- 134/67-116/50.\n\nRESP- DENIES SOB- COMFORTABLE LAYING FLAT ON 2 L NP.\nCLEAR TO AUSC LING SOUNDS.\n\nID- AFEBRILE\n\nGU- ARRIVED WITH FOLEY CATH IN PLACE- LIGHT LIGHT PINK INITIALLY, NOW DARKER PINK IN COLOR BUT NO FRANK BLOOD/CLOTS.\nLARGE DIURESIS ON ARRIVAL WITH IVF GTT AND S/P BOLUS AT OSH. 1200CC OUT IN 1ST 4 HOUR ARRIVAL TO CCU.\nCURRENTLY 40-60CC/HOUR.\n\n PT EATING TOAST/ICE CREAM/TAKING PILLS WITHOUT ISSUE.\nTO START ON CV DIET TODAY.\n(+) BOWEL SOUNDS.\n\nLINES- 3 PIV.\nVENOUS AND ARTERIAL SHEATH D/C RT GROIN- SEE ABOVE.\n\n PT ALERT/ORIENTED X 3, AWARE OF PLAN OF CARE, MED TEACHING AND TEACHING RE: MI.\nDAUGHTERS PRESENT TO VISIT- GIVEN PHONE NUMBER AND INSTRUCTIONS RE: PLAN OF CARE/VISIT HOURS - ALL APPEAR TO UNDERSTAND.\n\nPT SLEEPING ALL NITE WELL, NO PAIN.\n\nA/ PT S/P MI/SYNCOPE CURRENTLY DOING WELL S/P RCA STENT X 3.\nAWAIT INTERVENTION ON LAD EARLY NEXT WEEK.\n\nCONTINUE TO TITRATE UP ACE/B BLOCKER- CONTINUE 2B3A AS ORDERED.\nIVF X 2 LITERS.\nWATCH URINE FOR ANY CHANGE IN COLOR/MORE BLOODY LOOK- CHECK HCT/LYTES AS NEEDED- CYCLE CPK'S.\nKEEP PT COMFORTABLE, FREE OF PAIN/ANXIETY, KEEP PT AND FAMILY AWARE OF PLAN OF CARE.\nC/O TO 6 ONCE MEDICALLY APPROPRIATE TO AWAIT PTCA/STENT PART 2.\nAM EKG.\n" }, { "category": "Nursing/other", "chartdate": "2177-06-08 00:00:00.000", "description": "Report", "row_id": 1664866, "text": "86 y/o male w/ IMI s/p PCI, 3 BMS to RCA/PL.\n\ns/o: pt denies cp/sob\nCV: SB hr of 56. BP 117/53 (70) on low dose captopril and lopressor. Captopril changed to Lisinopril.\nCk's trending down 837 mb 110. Integrilin off this am d/t hx of head bleed after fall in /.\nResp: ls clear, diminished at bases. o2 sat 98% on 2lnc.\nGI/GU: tolerating po's, on colace. Foley d/c'd at 1500. creat .9 Hematuria rosolving. DTV 2100-2300.\n\nA/P: stable post pci to rca post r/i imi. plan to return to cath lab on tuesday for intervention to lad.\n" }, { "category": "Nursing/other", "chartdate": "2177-06-09 00:00:00.000", "description": "Report", "row_id": 1664867, "text": "CCU NSG PROGRESS NOTE 7P-7A/ S/P IMI; STENT RCA\n\nS- DENIES PAIN, SLEEPING WELL\n\nO- SEE FLOWSHEET FOR OBJECTIVE DATA\n\n PT WITH STABLE VS- HR- 55-68 SR, REMAINS ON LOPRESSOR 12.5 , TO START LISINOPRIL THIS AM. BP- 100-120/50-60'S VIA NBP.\nNO CP, GROIN SITE STABLE AS WELL AS PULSES.\nAWAITING CATH TUES? PERHAPS ON STANDBY TODAY TO INTERVENE ON 95% LAD.\n\nRESP- CLEAR TO SM CX DEPENDANTLY- BETTER WITH DEEP BREATHE/COUGHING.\n02 SATS 97-99%- ON 2-3L NP.\n\nID- AFEBRILE\n\nGU- FOLEY DC/- VOIDED 600CC THIS SHIFT, CLEAR AMBER URINE.\nOFF ALL IVF INFUSIONS.\n\nGI- TAKING MEDS/LIX WITHOUT ISSUE.NO FOOD THIS SHIFT- SLEEPING.\n\nLINES- 2 PIV- PATENT.\n\nSKIN- DRY/INTACT- COMPRESSION SLEEVES ON BILATERALLY.\nOOB TO CHAIR YESTERDAY BY REPORT.\n\nSOCIAL- DAUGHTERS/WIFE- NEXT OF /PROXY- NO CALLS LAST NITE- DID HAVE VISIT FROM DAUGHTER YESTERDAY BY REPORT.\n\nA/ PT S/P IMI AND STENT X 3 TO RCA,\nCURRENTLY HEMODYNAMICALLY STABLE, AWAITING FURTHER PCI TO LAD.\n\nCONTINUE TO CONTROL RATE/PRESSURE PRODUCT- LISINOPRIL/LOPRESSOR.\nMODEST INCREASE OF ACTIVITY UNTIL LAD INTERVENED UPON.\nCONTINUE TEACHING, SUPPORT, ENCOURAGE DEEP BREATHE/COUGH TO PREVENT ATECLECTASIS R/T BEDREST.\nKEEP PT AND FAMILY AWARE OF PLAN OF CARE. ? C/O TO 6 OR STAY IN CCU UNTIL REPEAT CATH/STENTS.\n" }, { "category": "Nursing/other", "chartdate": "2177-06-09 00:00:00.000", "description": "Report", "row_id": 1664868, "text": "CCU NPN: please see flowsheet for objective data\n\nCardiac: HR 53-60 SB-NSR BP 94-123/43-71 on lisinopril 2.5,lopressor 12.5mg both K and mag repleted\n\nResp: on 1l NP,lungs clear,using the incentive spirometry\n\nGU: voiding using urinal\n\nGI: good appetite,had medium brown formed stool,OB-\n\nNeuro: alert and oriented x3,spoke on phone with several family members\n\nHeme: HCT 31.8 this am repeat at 4pm 35.9\n\nActivity: OOB to chair for lunch\n\nA:s/p three stents to RCA and to have LAD intervention tomorrow\ncont with current medical plan,emotional support\n" }, { "category": "Nursing/other", "chartdate": "2177-06-10 00:00:00.000", "description": "Report", "row_id": 1664869, "text": "ccu nsg progress note.\no:cv=pf. hemodynamically stable. tolerating cardiac meds.\n gi=npo after mn for ?2nd/3rd case cath lab.\n gu=adeq uo.\n id=afebrile.\n\na:stable throughout night. awaiting cath lab.\n\np:contin present management. support pt/family as indicated.\n" }, { "category": "Nursing/other", "chartdate": "2177-06-10 00:00:00.000", "description": "Report", "row_id": 1664870, "text": "Nursing Note 7a-7p\nNeuro- A+Ox3, cooperative. No c/o sob, c-pain. Assisted oob->chair, pt very weak. PT consulted, will follow-up p cath.\nCV- Tele SB, rare PVCs. Hr 48-62, NBPs 96-110/40-53. Conts on BB/ACE, on SC heparin & P-boots on in bed. R groin site cd+i, all pulses by doppler.\nResp- LSC, cxr shows a slight LL atelectasis. Using IS @ bedside. Conts on 2L nc sats >95%.\nGI/GU- Was NPO for planned recath this AM. Postponed d/t rising Cre 1.4 (1.1). U/A sent off, started on D5.45ns x 1L. Restarted on diet, tol well. Voiding qs cyu using urinal. Balance +1200 LOS.\nSkin- Intact, no issues.\nA/P- 86yo male s/p IMI w/ 3 bms to RCA. Also has 90% LAD occlusion. Scheduled for re-cath today, postponed d/t contrast dye induced ATN. Call-out to 6 while awaiting cath. Cont monitoring vs, Cre, i+o's.\n" }, { "category": "ECG", "chartdate": "2177-06-10 00:00:00.000", "description": "Report", "row_id": 228312, "text": "Sinus rhythm, rate 52. Since tracing of no definite changes are seen.\n\n" }, { "category": "ECG", "chartdate": "2177-06-09 00:00:00.000", "description": "Report", "row_id": 228313, "text": "Sinus bradycardia. Compared to tracing #1 premature ventricular complex is no\nlonger present. The QTc interval is also shorter.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2177-06-07 00:00:00.000", "description": "Report", "row_id": 228314, "text": "Sinus rhythm with premature ventricular complex. Possible inferior wall\nmyocardial infarction of indeterminate age. Non-specific anterolateral\nST-T wave changes. Mildly prolonged QTc interval. No previous tracing available\nfor comparison.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2177-06-12 00:00:00.000", "description": "Report", "row_id": 228310, "text": "Sinus rhythm, rate 63. Since the previous tracing the technical artifacts are\nsomewhat improved. No other changes have occurred.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2177-06-11 00:00:00.000", "description": "Report", "row_id": 228311, "text": "Sinus rhythm, rate 59. Since tracing of some technical artifacts are\npresent. More flattening of the T wave is seen over the lateral precordium.\nTRACING #1\n\n" }, { "category": "Radiology", "chartdate": "2177-06-09 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 966830, "text": " 8:22 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please assess for interval change\n Admitting Diagnosis: IMI\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 86 year old man s/p inferior STEMI\n\n REASON FOR THIS EXAMINATION:\n please assess for interval change\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST of \n\n COMPARISON: .\n\n INDICATION: Microinfarction.\n\n Low lung volumes accentuate the cardiac and mediastinal contours. Worsening\n bibasilar opacities are attributed to atelectasis. No pleural effusions or\n pneumothoraces are evident.\n\n\n" } ]

[ { "category": "Nursing/other", "chartdate": "2100-12-17 00:00:00.000", "description": "Report", "row_id": 1328337, "text": "CCU Nursing Progress note 7am-11am\nS: I feel like I can't breathe!\n\nO: pt alert and oriented, answering questions. Initial assessment begun. Posterior resp assessment performed with by this nurse and resp therapist. Pt then c/o being unable to breathe. HR gradually dropped from 80's nsr to CHB with no vent escape. Pt unresponsive and o2 placed at 100%. CPR initiated, and NSR as well as responsiveness resumed. This incident occurred another 2 times within the hour, each time proceeded by movement of the patient. Pt placed on portable defib in pacing mode with MA off. Atropine at .\n\nCV - HR 80's nsr with freq pvc's. BP 90-110/50-60. Heparin had been infusing at 1030u/hr, but was dc/d at 9am in preparation for EP.\n\nResp - ls are diminished at bases. O2 on 4ln/p with sats 95-97%. Rec'd neb by resp therapy.\n\nGU - foley draining clear amber urine.\n\nGI - abd is soft with +bs. No stool this shift.\n\nID - Afebrile. Cont on Nafcillin 2Gm q4hrs. Orders POE'd for blood cultures, unable to obtain. Requested that EP lab nurses obtain cultures during pacemaker placement.\n\nSkin - Pt has + edema on all extremities. R LE ace bandage re-wrapped to include hand. Multiple open areas noted on abdomen, chest presumably from elastoplast tape. L chest tube site d/i with steri's. 3 dsgs on back, including thoracotomy steri strips, are d/i. Were to be changed by surgeon, but d/t tenous cv status, dsg changed was deferred. L fem elastoplast dsg intact with no ooze noted. Air bed ordered.\n\n Pt c/o mid chest soreness, presumably d/t cpr. Morphine 2mg IV given with intermittent relief.\n\nSocial - Daughter and Son are present, have spoken with MD's and are aware of POC.\n\nA: 3 episodes of witnessed CHB with no vent escape requiring cpr.\n\nP: To EP for temp pmr placement.\n" }, { "category": "Nursing/other", "chartdate": "2100-12-17 00:00:00.000", "description": "Report", "row_id": 1328338, "text": "CCU Nursing Progress Note 2pm-7pm\nS: I'm just so scared after what happened today.\n\nO: CV - pt awake and alert after temp screw in r pacemaker placement. VVI placed with rate set at 50. BP 150/50 during case with HR 80's. Rec'd 50mcgs Fentanyl for pain. Dsg is d/i. sling in room, but is not in place as pt is not moving around in bed. Since pmr placement, pt has had no episodes of CHB. HR cont 70-80's nsr with occ pvc's. BP 110-140/60's. Heparin not resumed post pmr.\n\nResp - ls are diminished. o2 on 4ln/p with sats 96-98%.\n\nPain - rec'd fentanyl in cath lab. Rec'd dilaudid 4mg po x1 this afternoon to reestablish po med regime.\n\nGU - u/o via foley cath is clear amber 30-50cc/hr\n\nGI - abd is soft with +bs. No stool today. Refusing bowel meds as he has had diarrhea up until .\n\nAccess - PIV r hand has infiltrated and was dc'd. Single lumen PICC inserted and has been pulled out approx 5cm. IV team up to assess. Multiple cxr done to confirm placement, which was confirmed. Utilized at this point as only access.\nNBP is on l arm (with PICC), as r arm has dvt. Awaiting ultrasound of bilat le to r/o dvt so BP's can be performed on legs.\n\nID - afebrile. Cont on Nafcillin q4hrs. 1 set bc drawn at time of pmr placement. Will draw from PICC if unable to perform venipuncture.\n\nSkin - + edema with some areas that ooze, esp r forearm. Dsgs on back are d/i. L fem pressure dsg dc/d and bandaid applied. Open areas on abd and chest washed with soap and water and are open to air. Pt is on air bed.\n\nA: No evidence of chb once pmr inserted.\n\nP: Cont close monitoring of cv status, restart Heparin at 8pm at 1000u/hr. Monitor resp status and administer nebs prn as well as encourage c/db, Ultrasound 8pm in ED to r/o dvt le then utilize le for bp's, turn and position as necessary, medicate with dilaudid q4hs, then Morphine for breakthrough pain, monitor and change back dsgs prn, increase activity with sling on r arm for pmr. Pt may only be oob with back brace in place. Keep pt and family informed of poc per multidisiciplinary rounds.\n\n" }, { "category": "Nursing/other", "chartdate": "2100-12-18 00:00:00.000", "description": "Report", "row_id": 1328339, "text": "Resp. care\nBS clear upon evaluation @ during the shift at which time he denied any SOB. I reminded the patiant that if he should become SOB he could request a tx. I checked on him casualy during the shift never noticing any resp. distress & never hearing a complaint of SOB. No tx given by RT.\n" }, { "category": "Nursing/other", "chartdate": "2100-12-18 00:00:00.000", "description": "Report", "row_id": 1328340, "text": "0550 Resp. care\ntx requested & given with 0.5mg atrovent & 2.5mg albuterol as per order. Pt found wheezing (mostly from upper airwayor vocal cord tightness) with slightly forced rather then passive exhalations.\nBS unchanged post tx\n" }, { "category": "Nursing/other", "chartdate": "2100-12-10 00:00:00.000", "description": "Report", "row_id": 1328332, "text": " 2324\n NEURO AWAKE ALERT X 2 UNDERSTANDS AND TRIES TO HELP WITH CARE MEDICATED FOR LOW BACK PAIN MAE MD FOR EXAM\n HEART S1S2 NSR TO MD MADE AWARE LOPRESSOR NOW IV UNTIL TAKING PO PULSES POS 3 THRU OUT NO ISSUES\n RESP CLEAR 4L NP SAO2 100 CPT\n ABD POS B/S NOTED SOFT NPO UNTIL AM OR FULLY AWAKE\n PLAN SUPPORTIVE OOB WITH BRACE\n" }, { "category": "Nursing/other", "chartdate": "2100-12-14 00:00:00.000", "description": "Report", "row_id": 1328333, "text": "Post op fusion T3-T10 with instrumentation\nPlease see careview for details.\n\nNeuro: intact, follows commands, moves all extremities. back incision and rt iliac crest dressed with elastoplast, appears clean and dry. Morphine PCA used by pt as needed.\n\nCV: sinus tachy with occ pac's to nsr rate 90's. bp stable. hct 25, transfused 2 u pc, repeat hct pending. right radial aline upon arrival to sicu, rt hand cool and dusky. aline d/c'd. hand remains cool, but color is improved, pulses present with doppler. no c/o pain in hand.\n\nPulm: bs fairly clear, left side. cxr done post op for removal of chest tube on left. np at 5 l, sats 96-100. IS done, but pt has difficult time executing.\n\ngi: taking po water. no flatus yet.\n\ngu: u/o low, fluid bolus given with increase in u/o to 30-40/hr.\n\nSkin: pt has cellulitis of rt lower arm into antecubital space, it is outlines in black, warm and edematous, treated with warm packs, elevated on pillow. coccyx has small broken area, treated with turning and double guard cream. abdomen is reddened bilaterally from prone oposition on OR table, small blister on left side of abdomen.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2100-12-14 00:00:00.000", "description": "Report", "row_id": 1328334, "text": "NPN 7a-7p\nSee carevue for specifics:\nAt change of shift pt noted to be ST high 90s-low 100s, u/o marginal, SBP 130s, LR 1000cc bolus given, pt tol well, u/o increased, 2nd LR 1000cc bolus given 900cc infused and pt became ST 110-120s, Spo2 decreased to 93% on 5L, & pt c/o chest pain. SICU team at BS, Nitro 0.4mg SL x1 given, morphine sulfate via PCA given, non-rebreather placed, EKG & CXR done, labs drawn, ASA 81mg given, nitro gtt started & L foot aline placed. EKG showed ST depressions ? inferior wall infact. CK 802, CKMB 12, & tropinin 0.17, Per cardiology consult most likely demand ischemic event (rate rated) vs MI. Mg repleted.\n\nNeruo-A&Ox3, PERRLA at 4mm with Brisk reaction, MAEs, Follows commands consistantly. Tmax 99.5 c/o back pain morphine sulfate PCA providing adequate pain relief. Dr. to speak with Dr regarding activiy restrictions in bed for the current time Keep HOB>30. TLSO brace lost within hospital travels PT to order new one.\nCV-HR 70s-80s NSR with occas PVCs & missed beats, weaning Nitro gtt, lopressor IV PRN for HR >77. PO lopressor increased to 37.4mg . SBP 110s-140s, (+)Pulses all extremetries via Dopper. RUE US showed cephalic vein occulsion with fluid collection. CKs cycled. HMV x2 intact with sero-sang drng, (+)generalized edema all extremeties.\nRESP-Spo2 95-100% on 5L, LS RLL crackles, L side diminished. CXR showed no change from previous L sided pleural effusion with associated atelectasis, pt cought up lg amt bloody/brown sputum, CX sent.\nGI-Clears advanced to solids, NPO most of am d/t above epsisode, then advanced. ABD softly distended, NT, (+)BSx4, denies N/V.\nGU-foley with borderline u/o\nSkin-Lg back dsg intact, L thoracotomy site with steri-strips, no drng noted. Coccxy with sm open area T/P freq, awaiting Dr. OK to use Kinair bed (? provides enough support).\nSocial-Daughter at BS most of afternoon, spoke with both SICU & cardiology resident.\nA/P-Stable, monitor hemodynamics, cycle cks, wean from nitro gtt, HOB >30 while in bed, await TLSO brace, HMVx2, monitor labs. T/P freq, assess skin integrity, pulmonary toileting.\n" }, { "category": "Nursing/other", "chartdate": "2100-12-15 00:00:00.000", "description": "Report", "row_id": 1328335, "text": "Nursing progress note\nPleases see careview for details\nneuro: intact. slightly confused at times, though oriented x 3., not sleeping well, using MS .\ncv: extra dose of lopressor 5 mg iv for hr 78. slightly elevated bp.\nPulm: np at 5 l. sats good, coughing not raising, bs dim throughout.\ngi: taking po, passing small amts stool, lactulose held. bowel sounds active.\ngu: u/o better at 30-50/hr.\nincisions c+d, original elastoplast dsgs remain intact. pain controlled with ms .\n" }, { "category": "Nursing/other", "chartdate": "2100-12-17 00:00:00.000", "description": "Report", "row_id": 1328336, "text": "CCU NPN 2200-0700\nS: \"Now I remember where I am...\"\nO: please see carevue flowsheet for complete assessment data\nArrived from 5 @ ~ 2200 after ? PEA arrest HD stable, on NRB w/ SpO2 100% and alert but confused, (on 5 pt unresponsive upon transfer from bed to stretcher (off tele) unable to find fem pulse, CPR started, when lifepack applied revealed sinus brady 40s, ^ to 60s w/o med intervention, when BP obtained reportedly 120s/xx, never apenic/hypoxic).\n\nNEURO: no focal neuro deficits noted, PERRL 4mm/brisk, MS clearing throughout night, now A&Ox3, pleasant and cooperative w nsg care. C/o pain in L chest, described as incisional/sharp. ECG w/ no evidence of ischemia. Admin 2mg morphine w/o improvement, 4mg dilauded w/o improvement, awaiting further recs from CCU team.\n\nCV: has remained HD stable, MAP >65. HR NSR w/ occas PVCs, 60s-80s. admission labs: (Hct down 28 from 34, repete pending, K 3.2 repleted w/ total of 60meq KCl PO). Initial Ctnt up to 0.20, CK pending, MB 3. Distal pulses by dop, RUE w/ DVT, raised on pillows, ace bandage and hot pack applied. Heparin gtt started at 1300u/hr, PTT pending. Pressure dsg applied after brisk bleed from L fem code line site, no further ooze noted. TTE w/ basal-mid inf/lat AK, LVEF 50% (overall unchanged from study )\n\nRESP: LSCTA, intermittent ex wheezes and pt concurrently c/o dyspnea, relieved w/ alb/atr neb. SpO2 >95% on 2l NC. No cough. CXR revealed edema, opacities and effusion in L lung. CTA r/o PE\n\nGI: Abd soft, nontender, nondistended. +BS/-BM/+RF. Tol PO meds w/ sips water.\n\nGU: foley draining adequate amts CYU.\n\nENDO: no issues\n\nID: afebrile, cont nafacillin for MSSA osteo. WBC ^ but stable\n\nSKIN: L fem code line site, initially w/ bleed, now stable w/ pressure dsg, + edema/anasarca throughout. See carevue for detailed skin/incision assessment.\n\nSOC: no calls/visitors\n\nA: 71yo admitted for dx epidural abcess discovered on biopsy to be osteomyelitis, underwent spinal fusion/corpectemy on , intermittent CP/ischemia post-op. S/p ? vagal/?PEA arrest on floor. Currently HD/Resp stable.\nP: cont present ICU management f/u am labs, cont to monitor for pain. Monitor hemodynamics. Cont heparin gtt for R arm DVT and ? ACS, NPO since MN for ? cath. Cont support to pt as indicated.\n" }, { "category": "Nursing/other", "chartdate": "2100-12-10 00:00:00.000", "description": "Report", "row_id": 1328331, "text": "NPN 7a-7p\nSee carevue for specifics:\nBriefly 71yr male with PMH MIx2-3 with ballon plasty 92', EF 40-45%, HTN, RBBB, gout, ? cataracts-reparired R eye & coccygeal fx. Received from OR s/p t7-t8 corpectomy & t6-t9 fusion with L thoracomtomy apporoach, paralyzed & reversed in OR, extubated prior to arrival. Sleepy but easily arousable, PERRLA 2mm with brisk reaction, follows simple commands inconsistantly, MAEs, L hand grasp weaker than R, will wiggle R toes upon command, withdraws to pain LLE. Became very agitated, restless & combative, unable to redirect, ativan 1mg IV given with good effect. Afeb, c/o back pain medicated with Dilaudid by anesthesia upon arrival to unit no further pain meds given. HR 90s-low 100s NSR, SBP 90s-130s, aline dampened & very positional not correlating with NBP, HCT stable, Mg+ sulfate repleted. LR bolus 500cc x1 for decreased SBP, ST & low u/o with good response. BLEs mottled appearance in color Dr. aware. L CT intact, no leak or crepitus noted (to wall sxn with sang drng). LS Clear with ? crackles LLL, spo2 95-100% on FT at 10L desats to 80s when removed. ABG paCo2 54/56 team aware. NPO until fully awake, ABD softly distended, tender to palp, (+)BSx4. Foley with adequate u/o 25-60cc/hr. L thoracotomy/CT site intact with occlusive dsg.\n PLAN: -Continue to monitor hemodynamics neuro & resp status closely. -CT to wall sxn.\n -Fluid resusitation\n -Cont IV fluids, NPO until fully awake than adv as tol\n -HOB 30 degress or less while in bed, OOB with TLSO AATs\n -Monitor Labs\n -Assess pain level offer PRNS, PCA when more alert/awake\n -To floor in am if stable (per ortho)\n" }, { "category": "Nursing/other", "chartdate": "2100-12-19 00:00:00.000", "description": "Report", "row_id": 1328344, "text": "NURSING PROGRESS NOTE 7P-7A\nS: \"I DON'T KNOW WHY I TOOK IT OUT, I JUST DID\"\n\nO: NEURO: PT. CONFUSED AND AT TIMES COMBATIVE AND VERBALLY ABUSIVE TO STAFF. DIIFICULT TO REORIENT TO SURROUNDING. CONFUSED TO PERSON, PLACE AND TIME. WRIST RESTRAINTS ON FOR PT. SAFETY ALTHOUGH MANAGED TO PULL OUT FEMORAL CENTRAL LINE DESPITE WRIST RESTRAINTS. COOPERATIVE WITH TAKING PO MEDS. ABLE TO RECALL NAMES OF CHILDREN. MOVING EXTREMITIES ON BED. SLEPT IN SHORT NAPS OVERNIGHT.\n\nCV: HR 78 SR WITH OCCASIONAL PVC'S. K+ LAST EVE 3.2 GIVEN 40 MEQ KCL IVPB AND 40 MEQ PO. LOPRESSOR INCREASED TO 75 MG PO TID. SCREW PACER INTACT IN RSC. NO BRADYCARDIC EVENTS.\n\nRESP: O2 5L VIA NC, O2 SATS 96- 100%. UPPER AIRWAY CONGESTION NOTED. NT SUCTIONED X2 FOR THICK TAN SPUTUM. SPUTUM CULTURE SENT. OCC EXP WHEEZE NOTED.\n\nGU: FOLEY DRAINING LIGHT YELLOW URINE U/O 200-400 CC/HR. URINE CULTURE OBTAINED AND SENT.\n\nGI: INC X3 LARGE AMT OF LIQUID BROWN STOOL. FIB IN PLACE THIS AM FOR STOOL MANAGEMENT. TAKING SIPS OF WATER AND JUICE WITH MEDS. STATES HE DOES NOT FEEL HUNGRY. ? NUTRITION CONSULT FOR INCREASED CALORIC INTAKE, LOW ALBUMIN LEVELS.\n\nID: FEBRILE 101.2, STARTED ON LEVAQUIN AND FLAGYL PO. GIVEN TYLENOL 650 MG PO, TEMP NOW 99.8 (R). URINE, SPUTUM AND BC X1 (FROM CENTRAL LINE) OBTAINED AND SENT.\n\nSKIN: DRESSINGS ON BACK CHANGED. ALL INCISIONS C&D, SMALL AMT OF DRAINAGE NOTED ON LOWER LUMBAR DRESSING. LEFT THORACOTOMY INCISION INTACT. OPEN TO AIR WITH STERI-STRIPS. COCCYX RED WITH BREAKDOWN THROUGH DERMIS. CLEANSED WITH WOUND CLEANER AND DUODERM APPLIED.\n\nA: BRADYCARDIA/ASYSTOLIC EVENT REQUIRING TEMP PACEMAKER, S/P T7-T8 CORPECTOMY AND T6-T9 FUSION. CONFUSION ? ETIOLOGY.\n\nP: NEEDS CENTRAL LINE PLACEMENT. LABS WHEN LINE PLACED AS PT. HAS POOR ACCESS AND DIFFICULT BLOOD DRAW. FOLLOW LYTES AND REPLETE AS NEEDED. WRIST RESTRAINTS FOR SAFETY. UPDATE PT. AND FAMLY ON PLAN OF CARE PER CCU TEAM.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2100-12-19 00:00:00.000", "description": "Report", "row_id": 1328345, "text": "CCU Progress note 0700-1900\nADDENDUM:- SKIN;- Continues to be gernerally oedematus, and continus to ooze from lt forearm, absiorbant pad insitu.\n" }, { "category": "Nursing/other", "chartdate": "2100-12-19 00:00:00.000", "description": "Report", "row_id": 1328346, "text": "CCU Progress note 0700-1900\nADDENDUM:- SKIN;- Continues to be gernerally oedematus, and continus to ooze from lt forearm, absiorbant pad insitu.\n" }, { "category": "Nursing/other", "chartdate": "2100-12-19 00:00:00.000", "description": "Report", "row_id": 1328347, "text": "CCU Progress note 0700-1900\nRESP:- Remains on N/C at 5 litres, Sa02 96-100%, RR 28-28 and regular. Occationally complains not being able to breath, even though Sa02 100%, given nebulizer treatments with good results, bilateral air entry heard to all lungfields but diminished at the bases. Coughing but not expectorating sputum.\n\nCV:- monitored in NSR 80-90 bpm, with occational ectopics. SBP 93-160, Given po metoprolol but held captopril all day as SBP belwo parameters, Drs . Peripherally cool to touch at times, feet pale and slightly mottled, pulses dopplerable. Unable to obtain labs until late afternoon as no access, now has central line in place. to have 1 unit of blood this evening.\n\nNEURO:- Initally agiataed this morning, but settled and became A&Ox and has been apprpriate most of the day. This morning was low in mood, staing that he did not want line placed and that he just \"had enough\", disscussion with house staff regarding this, family called and visited they all spoke and they were able to pursuade him to have the line placed and give the anti-biotics ago to see if they help, which he agreed to. Now much happier and glad he changed his mind. Code staus has however changed and he is now DNR/DNI. Wrist restraints off during the day as more orientated and family present.\n\nGU:- Foley catheer draining good amounts of clear yellow urine.\n\nGI:- Feacal bag insitu and draining small amounts of stool, is now aware when he needs to stool, but has agreed to keep bag on overnight. Abdoman soft and non tender, faint bowel sounds hear x4. Has taken 2x pudding during the day and good amounts of fluid.\n\nACCESS:- Had no access until 1600, awaiting XCR confirmation, but line patent.\n\nSKIN:- Refused to lay on side during the day, even though I stated that he is at risk of deveopling pressure damage, lotion applied to back. Nursed on Kinair bed. Barrier cream applied to el;bows and heels. Freshen up wash given this morning, declined full bed bath. Surgical dressing clean and intact.\n\nID:-Afebrile during the day, missed x2 dose of antibiotics as no acces. Awaitng culture data. No other signs of infection. Coughing but no expctorating sputum.\n\nENDO:- Not on sliding scale insluin as not diabetic or steroids.\n\nFAMILY:- Family visited spoken with mediacal and nusring satff about plan of care. Aware of DNR/DNI status.\n\nPLAN:- To continue with antibiotics and await culture data. Monitor neuro status and orientation level. Contiune to liase with ortho regarding surgery. To cntinue to give full explination of care to patient and family.\n" }, { "category": "Nursing/other", "chartdate": "2100-12-20 00:00:00.000", "description": "Report", "row_id": 1328348, "text": "S:\"I don't want to get blood and I don't want to take those pills right now, I'll take them later. My life is in God's hands now, if comes to me in my dreams and tells me to take the blood then I will change my mind.\"\"I want to just go home alone and if I die then it what wants.\"\n\nO:please see flowsheet for full details.\n\nCV:NSR/ST HR 77, pt has transvenous VVI set at a rate of 50 temp pacer in place. BP 115/54. K was 3.2 and was repleated with 3x 20meq potassium IV. Right arm DVT. feet aple and slightly mottled with 3+ edema to lower extremities. Hct 21.5. pt has refused blood transfusion several times throughout day and night. Rn explained to pt importance of receiving blood and taking medication pt continues to refuse.\n\nneuro: pt has been consulted by psych. They think pt is capable of accepting treatment and accepting a blood transfusion but they do not think he is alright to refuse a blood transfusion. that requires more of a different kind of thinking. we will continue to watch and monitor pt for s/s of bleeding. pt is alert and oriented x3.\n\nResp:lung sounds are clear with diminished bases.pt is currently on 3l nc. pt refused to deep breath and cough.\n\nGI:pt has rectum bag in place, draining loose stool. pt vomited after eatting a few small bites this afternoon.\n\nGU:pt urin output is 30cc/hr. +100cc for last 24hrs.\n\nID:tmax 100.1 pt received tylenol 650mg po with good effect. pt c/o less pain also. pt has been c/o chest pain from where the cpr was performed. On antibiotics.\n\nskin: pt 's suture dressings on his back are intact and dry and clean. pt has a duoderm in place and intact on coccyx. right arm has a blister and it is seeping small amount of yellow fluid. lower extremity edema present +2. Pt continues to let rn turn pt. pt c/o feeling like he is in too much pain to turn and he is too cold to move also. rn explained to patient that he could keep his covers on while he turned and also rn explained to pt the importance of turning to prevent skin damage. pt continued to refuse.\n\nA:pt refusing most of medication and blood transfusion and treatment. pt being evaluated by psych.\n\nP:encourage turning pt and encourage pt to take medication. follow up status of psych consult. continue to assess mental status. change dressngs as needed. continue to encourage deep cough and breathing. continue to follow lytes and hct. contiue to encourage eatting.\n" }, { "category": "Nursing/other", "chartdate": "2100-12-20 00:00:00.000", "description": "Report", "row_id": 1328349, "text": "Nursing Progress Note 0700-1900\nS: \"I know that the blood will help me, but I just want to die..I am so sorry (to daughter), but I just don't want to live\"\n\nO: Please see carevue for complete objective data\n\nNeuro: Pleasant and cooperative, thankful for care. A&O x 3, confused @ times explaining visual hallucinations (i.e. the floating file cabinets in his room and person lying next to him in bed.) Admits confusion and is re-oriented. Pt refused blood transfusion and oral meds overnight, despite the medical necessity and urgency. Psych consult determined he has the ?capacity to accept care but not to refuse it. Ethics/legal consulted. MD's spoke c daughter (spokesperson) and informed her of options-she will speak to brother and make a decision.\n\nCV: NSR, 70-80's, no ectopy. During turning/ AM cares, pt on side and c/o trouble breathing, monitor showed pt to be sat'ing 100 c RR-19, but pt was paced @ 50 bpm. Once pt sat upright, returned to NSR c rate in 80's. Pulses Dopp. R arm DVT-elevate and hot pack applied for 30 mins, Q3-4H. pneumo boots and stockings on. Tolerating po Lopressor. HCT down to 21.6, refusing blood transfusion. Awaiting family's decision to treat.\n\nResp: on 3L nc, lungs clr c dim bases. Sats 95-100. Weak non productive cough.\n\nGI/GU: pt appetite fair, FIB replaced, guaiac negative liquid stool. Foley draining clr yellow urine. ~ even for day, +10L LOS.\n\nAccess/Skin: RIJ trip lumen. R arm swollen from DVT, elevate and hot pack. Back incisions, sutured, DSD CD&I, no drainage. Coccyx, Stage 2 pressure ulcer, pink wound base. Allevyn changed today. BLE +3 edema.\n\nA: s/p asystole arrest requiring pacer placement. Confused @ times and now refusing care/transfusions, evaluated by psyche-no capacity to refuse care, Awaiting family's decision to continue care. DNR/DNI.\n\nP: Transfuse if family consents, serial crits. Continue to monitor hemodynamics and response to meds. Enc diet and activity. Emotionally support pt and family. Keep updated on plan.\n" }, { "category": "Nursing/other", "chartdate": "2100-12-18 00:00:00.000", "description": "Report", "row_id": 1328341, "text": "NURSING PROGRESS NOTE 7P-7A\nS: \"I DON'T THINK I'LL BE GOING TO WORK TODAY\"\n\nO: NEURO; PT. ALERT AND ORIENTED X3 EARLIER IN EVENING. CONVERSING APPROPRIATELY, MOVING ALL EXTREMITIES. FOLLOWING COMMANDS. DURING NOC. PT. BECOMING MORE AGITATED AND CONFUSED. PULLED OUT PICC LINE, ECG LEADS, GAZE UP AT CEILING, PUPILS REACTIVE TO LIGHT. GIVEN OLANZAPINE SL FOR AGITATION WITH GOOD EFFECT. SLEPT FOR SHORT TIME. ACCESS TEAM IN TO SEE PT., #22G PIV IN LEFT HAND. PT. AGAIN BECOMING MORE AGITATED AND CONFUSED X3, PULLED OUT PIV. HO AWARE OF PT. CONDITION. BP UP TO 225/100, HR 103. GIVEN LOPRESSOR PO TAKES PO MEDS WILLINGLY.\n\nCV: BP NOW 137/69 AFTER RECEIVING LOPRESSOR PO 50 MG. HR 82 WITH OCC PVC. PACER INTACT IN RIGHT SC. DRESSING INTACT. WILL OCC DROP HR TO 52 (PACER RATE 50). RIGHT ARM DVT, RIGHT ARM COOL, ACE WRAP REMOVED BY VASCULAR MD. UNABLE TO DRAW AM LABS DUE TO POOR ACCESS. +, GENERALIZED PITTING EDEMA NOTED.\n\nRESP: O2 ON 4L VIA NC. O2 SAT 97%. LUNGS SOUNDS WITH I/E WHEEZE THIS AM. GIVEN ALB/ATR NEBS BY RESP. NO CHANGE IN BREATH SOUNDS.\n\nGU: FOLEY DRAINING AMBER COLORED URINE IN FAIR AMTS. SEE FLOWSHEET FOR DATA.\n\nGI: TAKING SIPS OF WATER AND JUICE WITHOUT DIFFICULTY. ABD SOFT, + BOWEL SOUNDS. NO BM OVERNIGHT.\n\nSKIN: SEVERAL ABRASIONS NOTED ON LEFT SIDE OF ABD AND SIDE (? FROM ADHESIVE TAPE). SEVERAL BLISTERS ALSO NOTED, BLISTER INTACT. BACK DRESSING INTACT. L THORACOTOMY DRESSING INTACT.\n\nA: S/P AYSTOLIC ARREST WHILE TURNING IN BED. SCREW PACER INSERTED. RIGHT ARM DVT.\n\nP: NEEDS IV ACCESS, ? LEFT EJ. CHECK RESULTS OF US, REORIENT TO SURROUNDINGS. FOLLOW LABS, I/O. UPDATE PT. AND FAMILY ON PLAN OF CARE PER CCU TEAM.\n" }, { "category": "Nursing/other", "chartdate": "2100-12-18 00:00:00.000", "description": "Report", "row_id": 1328342, "text": "CCU NURSING 0700-1900\nS. \"WHERE ARE MY KIDS - THEY'RE GOING TO BRING ME HOME TODAY.\"\n \"WHAT ARE THEY DOING TO ME - STAY AWAY FROM ME OR I'LL CALL THE COPS!\"\n\nO. NEURO/MS: PT ALERT AND ORIENTED X2 THIS AM BUT W/PERIODS DELIRIUM, PARANOID IDEATIONS; , , NO FOCAL DEFICITS NOTED, RECEIVED ZYPREXA X1 AFTER TEAM ROUNDED THIS AM, ALSO RECEIVED DILUDID 4MG PO X1 FOR C/O BACK PAIN; PT W/ACUTE AGITATION AND UNABLE TO BE COOPERATIVE WITH CENTRAL LINE PLACEMENT, THEREFORE RECEIVED ATIVAN 2MG PO @1030, HALDOL 5MG PO AT 1045; PT EVENTUALLY BECAME SEDATED, RIGHT FEMORAL TLC PLACED W/O DIFFICULTY; PT CONTINUED MOST OF DAY, WHEN AWAKENED PT RESTLESS, PICKING AT LEADS, PULLING OFF GOWN, FAMILY IN TO VISIT, RECOGNIZED FAMILY BUT CONTINUED RESTLESS, PT BACK TO SLEEP WHEN LEFT ALONE, NO FURTHER MEDS GIVEN\n\nCV: HR 80-100'S SR-ST W/OCCAS PVC'S, RSC SCREW-IN TEMP WIRE IN PLACED, TESTED BY EP, SET AT 50 VVI, NO EPISODES BRADY TODAY; LOPRESSOR DOSE DUE 12PM, UNABLE TO GIVE SECONDARY TO SEDATION, BP 100-170'S/50-80'S BP INCREASED WHEN AGITATED, SIGNIFICANTLY LOWER WITH SEDATION, CAPTOPRIL GIVEN AT 0800, HELD AT 1600 SEC TO SOMNULENCE, CPK'S SENT 12PM WNL; RUE DVT - DECREASED REDDNESS PER TEAM, PULSE TR TO DOP X4, RECEIVING LOVENOX\n\nRESP: O2 5L NC W/SATS 98-100%, LUNGS CRACKLES W/2 EPISODES AUDIBLE EXP WHEEZES TODAY - RECEIVED ALB/ATR NEBS WITH RELIEF, ALSO RECEIVED 80MG PO LASIX THIS AM W/ > 2LITER URINE OUTPUT THUS FAR AND CONTINUING TO DIURESE >200CC PER HOUR, K= REPLACED W/20 PO THEN 40 IV FOR K+ 3.2, REPEAT LYTES PENDING; CXR PLEURAL EFFUSIONS > LEFT SIDE\n\nID: REFUSING TO COOPERATE W/PO/RECTAL TEMPS AX TEMP 99.1 MAX, RECEIVED TYLENOL X1, WBC'S DOWN TO 8 FROM 14 YESTERDAY, MISSED NAFCILLIN DOSES X2 SECONDARY TO NO IV ACCESS, RESUMED Q4HR DOSES AT 1200 PM, BC X1SENT TODAY, 1 STOOL SENT FOR C-DIFF\n\nGI: TAKING PO LIQUIDS/MEDS WELL PRIOR TO RECEIVING SEDATION, , PT UNABLE TO TAKE SIPS H2O, UNABLE TO SWALLOW PILLS, TEAM AWARE PT AS MEDS\n\nGU: FOLEY IN PLACE, DRAINING LG AMTS CLEAR URINE\n\nSKIN: SURGICAL DSGS CHANGED BY ORTHO THIS AM, SITES C+D, DSD , RN'S TO CHANGE DSG QD AND PRN W/DSD, MULTIPLE SKIN TEARS, OPEN TO AIR, MULTIPLE NEEDLE STICK SITES OOZING CLEAR FLUID FROM THIRD SPACE, PT REMAINS W/ + EDEMA IN ALL EXTREMITIES, SCROTAL AREA, BED SHEETS, GOWN CHANGED MULTIPLE TIMES SEC TO BEING SOAKED W/FLUID\n\nSOCIAL: DAUGHTER AM, VISITING IN PM W/HUSBAND, SON FROM ARRIVED AND VISITING, ALL 3 UPDATED BY CCU TEAM MEMBERS AND RN, FAMILY LEFT FOR EVENING, WILL CALL FOR UPDATES, WANT TO BE CALLED WITH ACUTE CHANGES\n\nA: ACUTE CONFUSION OF UNKNOWN ETILOGY C/B SOMNULENCE FROM SEDATION\n NO FURTHER BRADY/ASYSTOLE\n DIURESING WELL; ^^^INSENSIBLE LOSS FROM THIRD SPACE\n\nP: MONITOR I/O'S - REPLACE ELECTROLYTES AS NEEDED AND MONITOR CLOSELY; ASSESS MENTAL STATUS, RESUME PO MEDS AS NEEDED IF MENTAL STATUS CLEARS, ASSESS PMR INTEGRITY, MONITOR HR/RHYTHM, BP, FOLLOW TEMPS/WBC, CONT ANTIBX; EMOTIONAL SUPPORT FOR PT/FAMILY, KEEP FAM\n" }, { "category": "Nursing/other", "chartdate": "2100-12-18 00:00:00.000", "description": "Report", "row_id": 1328343, "text": "CCU NURSING 0700-1900\n(Continued)\nILY INFORMED OF PT CONDITION, PLAN OF CARE, PAIN MEDS, FURTHER SEDATION WITH CAUTION; CONT LOVENOX FOR RUE DVT, ASSESS R FEM TLC SITE; R ARM IN SLING IF PT BEGINS MOVING ARM, BACK BRACE WHEN PT BEGINS TO GET OOB.\n\n" }, { "category": "Nursing/other", "chartdate": "2100-12-23 00:00:00.000", "description": "Report", "row_id": 1328356, "text": "CCU Nursing Progress Note 7pm-7am\nS: Now it's time to just leave\n\nO: Neuro - Pt alert and oriented early in shift. At approx midnight, pt found attempting to get oob, pulling at leads and disoriented. Reoriented, but at this time is untrusting of staff. Olanzapine with poor effect. Bilat wrist restraints placed for line safety. Pt slept in short naps through night.\n\nCV - HR 80-100's nsr with rare pvc. Occ bursts of v paced complexes noted. BP 110-150/80's. Pt had 1 c/o cp with the above episode of confusion. Medicated with 4mg IVP Morphine and 2 sl ntg with relief.\n\nResp - o2 on 2lnp with o2 sats 98-100%. ls are diminished with rales at bases and exp wheeze. Nebs x1.\n\nGI - Flexiseal system inplace and draining brown liquid stool. Tolerated supper without difficulty.\n\nID - Cont on Nafcillin q4hs.\n\nGU - u/o 30-50cc/hr clear yellow urine\n\nSkin - Peri area excoriated. Washed with soap and water, pat dried and covered with aloe vesta and doubleguard.\n\nSocial - Daughter called.\n\nA: 71yom cont to experience confusion and delerium at night. Stable cv status\n\nP: cont maintain safety with wrist restraints, all side rails up and frequent reorientation, monitor cv status for further cp, vigilent skin care, check pnd am labs, keep family informed of pt status and plan per multidisiciplinary rounds.\n" }, { "category": "Nursing/other", "chartdate": "2100-12-23 00:00:00.000", "description": "Report", "row_id": 1328357, "text": "Nursing Progress Note 0700-1100\nS: \"Get the hell out of my face!!\"\n\nO: Please see carevue for complete objective data.\n\nNeuro: Pt awoke from sleep A&O x 1, person. Believed he was in a bus station, visual hallucinations of people standing in the room including the queen of . Agitated, removing hosp gown and bedding, throwing legs over the side rails, requiring co-worker to sit with pt to maintain pt safety and integrity of lines and pacemaker. Occassionally swearing at staff. Daughter called and was updated by RN on pt condition. Psych RN notified and will consult.\n\nCV: NSR, Vpaced occassionally when vagal episodes occur. SBP 110-150's, tolerating lopressor. AM crit-30.6, post 3 units of PRBC's.\n\nResp: Sats 96-100 on 2L nc, Removes O2 and maintains sats.\n\nGI/GU: Flexiseal rectal collecting guaiac positive brown liquid stool. Foley draining clr yellow urine.\n\nAccess/Skin: Mult lumen RIJ. Pt bottom red and excoriated, applying creams and protectants.\n\nP: Monitor pt's MS. Follow up c psych nurse. Call out to floor c sitter. Emotionally support pt and fam.\n" }, { "category": "Nursing/other", "chartdate": "2100-12-26 00:00:00.000", "description": "Report", "row_id": 1328364, "text": "NURSING PROGRESS NOTE 11P-7A\nS: \"I DON'T HAVE TO DO ANYTHING THE DOCTORS \"\n\nO: NEURO: PT. CONFUSED TO TIME AND PLACE LAST EVENING. ATTEMPTING TO GET OOB, SITTING UP IN BED AND SWINGING LEGS OVER SIDE RAILS. UNABLE TO STATE SONS NAMES CALLING THEM HARPO AND GROUCHO. WAS COOPERATIVE WITH CARE LAST EVENING, TAKING PO MEDS WITHOUT DIFFICULTY. NOW REFUSING RESP TREATMENT AND AM PO MEDS. CONFUSED TO PERSON, PLACE AND TIME. GIVEN HALDOL 2 MG IVP LAST NOC FOR AGITATION AND SLEPT MOST OF NOC. AWOKE THIS AM PLEASANT, NOW REFUSING ALL CARE.\n\nCV: HR 60-80 NSR WITH OCC VPACED RHYTHM AND RARE PVC. RECEIVED ADDITIONAL DOSE OF 20 MEQ KCL IVPB LAST EVE. BP 104-124/56.\n\nRESP: LUNGS COARSE, REFUSING RESP TREATMENTS THIS AM. O2 AT 2L VIA NC. O2 SAT 98%.\n\nGI: FLEXISEAL FECAL COLLECTION SYSTEM INTACT. DRAINED 200 CC GREENISH-BROWN STOOL. ABD SOFT, TAKING SIPS OF WATER. POOR APPETITE.\n\nGU: FOLEY DRAINING CLEAR YELLOW URINE IN FAIR AMTS. I/O EVEN THIS AM.\n\nC/O HEADACHE LAST NOC, GIVEN TYLENOL WITH GOOD RELIEF FROM PAIN.\n\nA: MENTAL STATUS CHANGES, ? ETIOLOGY. PACER FOR SYMPTOMATIC BRADYCARDIA, S/P T7-78 CORPECTOMY, T6-T9 FUSION WITH LEFT THORACOTOMY.\n\nP: CONT TO FOLLOW LABS, ESP K+ AND MG++. REPLETE AS NEEDED. ENCOURAGE PO INTAKE. TRANSFER TO 3 THIS AM WITH 1:1 SITTER WHEN ON FLOOR. UPDATE PT. AND FAMILY ON PLAN OF CARE PER CCU TEAM.\n" }, { "category": "Nursing/other", "chartdate": "2100-12-25 00:00:00.000", "description": "Report", "row_id": 1328362, "text": "NURSING PROGRESS NOTE 7P-7A\nS: \"I PROMISE I WILL BE GOOD TONIGHT\"\n\nO: NEURO: PT. ALERT AND ORIENTED X3 EARLIER IN EVENING. NOW APPEARS MORE CONFUSED TO TIME AND PLACE. HE IS NOW CONFUSED TO TIME AND PLACE, CARRYING ON CONVERSATIONS WITH FRIENDS AND FAMILY AND EXPERIENCING VISUAL HALLUCINATIIONS (SEEING PICTURES ON THE CEILING OF HIS SON). PLEASANT AND COOPERATIVE WITH CARE. TAKING PO MEDS WITHOUT DIFFICULTY. GIVEN HALDOL AS ORDERED AT BEDTIME AND ALSO GIVEN EXTRA DOSE OF HALDOL AT FOR BREAKTHROUGH AGITATION.\n\nCV: HR 75-80 WITH OCCASIONAL V-PACING. BP 140-152/67. DENIES C/O PAIN. PACER SITE C&D, DRESSING D&I.\n\nRESP: O2 VIA NC AT 2L. O2 SAT 99%. CRACKLES AT BASES. COUGHING AND RAISING THICKK WHITE SPUTUM. I/E WHEEZES NOTED THIS AM, GIVEN ATR/ALB NEB BY RESP THERAPY. WHEEZES NOW DIMINISHED AND PT. STATES HE CAN \"BREATHE BETTER\"\n\nGI: FLEXISEAL INTACT. DRAINING DARK BROWN LIQUID STOOL. DRAINED 500 CC. ABD SOFT. + BOWEL SOUNDS. TAKING SIPS OF WATER WITH MEDS.\n\nGU: FOLEY DRAINING CLEAR YELLOW URINE. I/O (-) 1200 CC AT MIDNOC.\n\nSKIN: COCCYX RED, PT. C/O \"SORENESS\". BARRIER CREAM APPLIED. BACK INCISIONS C%D, STABLES INTACT.\n\nID: CONT ON NAFCILLIN IV, TEMP 98.5 PO.\n\nA: S/P PERM. PACER, WAITING FOR REHAB PLACEMENT.\n\nP: CONT TO FOLLOW I/O, LABS, REPLETE LYTES AS NEEDED. REORIENT TO SURROUNDING PRN, UPDATE PT. AND FAMILY ON PLAN OF CARE PER CCU TEAM.\n" }, { "category": "Nursing/other", "chartdate": "2100-12-25 00:00:00.000", "description": "Report", "row_id": 1328363, "text": "CCU Nursing Progress Note 7am-7pm\nS: I'm at the meat market in \n\nO: Mental Status - Pt initially oriented to person only. Was pleasant and cooperative. Reoriented easily and pt was contrite regarding his behavior. Realized he was confused and asking as to why this was happening to him. Gradually over the day, pt became increasingly confused, angry and hallucinating. Angry and hostile at daughter and nursing staff. Pt required haldol 2mg po without effect. Found pt had taken off dsg to screwed in pacemaker. House staff informed and redressed pacemaker. Iv haldol 2mg given with fair effect. Pt continues to attempt to get oob, swing legs over rail, takes O2 off as well as bp cuff, pulled out flexiseal stool collecting system. Required bilat wrist restraints and now has nursing sitter.\n\nCV - HR 70-100's nsr with occ vea, paced rhythm. BP 120-150/60's. cont on lopressor and captopril.\n\nResp - ls are coarse throughout. No cough. o2 on 2ln/p with sats 98-100%, down to 88% on RA.\n\nGI - Flexiseal intact at present time, draining greenish liquid stool. Poor appetite today.\n\nGu - diuresed with 40mg ivp lasix with 1liter out.\n\nLytes - K+ remains low 3.5 this am. Pt refused po KCl tabs and was changed over to IV KCl.\n\nActivity - OOB to chair x1 hr with 3 nurse assist. Pt has brace on with transfer and finds it very uncomfortable.\n\nSurgical incisions - Staples on r lower back as well as mid back are intact and clean. Sternotomy steris d/i.\n\nA: cont with acute delerium, hallucinating and pulling at lines.\n\nP: cont haldol and safety measures, monitor cv status, encourage oob as tolerated, keep family informed of poc\n" }, { "category": "Nursing/other", "chartdate": "2100-12-22 00:00:00.000", "description": "Report", "row_id": 1328352, "text": "CCU NPN 1900-0700\nS: \"I had a much better day today.\"\nO: please see carevue for complete assessment data\nNo Events\nNEURO: A&OX3, sleeping through night, awoked by pacing @ 0300 anxious and dyspneic->easily re-assured/settled. MAE, assists w/ turning. denies pain. Pre-med for sundowning/delerium w/ 5mg olanzapine w/ effect.\n\nCV: Remains HD stable, pm Hct down slightly but stable, no source of bleeding identified. HR NSR/ST w/ rare PVCs noted on tele and occasional v-pacing @ 50 (assoc w/ anxiety and dyspnea).\n\nRESP: LSCTA, increasingly coarse/rhonchorus throughout night, enc CDB, nebs for occas wheezing. Non-productive congested cough. Cont 2l NC w/ SpO2 >94%.\n\nGI: abd soft, nontender, nondistended. +BS/multiple loose OB (-) BM.\n\nGU: foley draining adequate amts CYU.\n\nENDO: no issues\n\nID: low grade, tmax 99.8, cont nafcillin\n\nSKIN: unchanged, excoriated area around rectum improving.\n\nSOC: no calls/visits onoc.\n\nA: HD stable awaiting perm PCM placement after complete course abx\nP: cont present ICU management, anticipate c/o to floor when bed available. Cont to encourage CDB, ^ diet and activity as tolerated. Support to pt/family as indicated.\n" }, { "category": "Nursing/other", "chartdate": "2100-12-22 00:00:00.000", "description": "Report", "row_id": 1328353, "text": "CCU NPN 1900-0700\nADDENDUM: Am HCt 20.5, awaiting to speak to family re: blood consent, remains HD stable. K 2.9->ordered 80meq KCl IVPB.\n" }, { "category": "Nursing/other", "chartdate": "2100-12-22 00:00:00.000", "description": "Report", "row_id": 1328354, "text": "CCU NPN 1900-0700\nADDENDUM: Am HCt 20.5, awaiting to speak to family re: blood consent, remains HD stable. K 2.9->ordered 80meq KCl IVPB.\n" }, { "category": "Nursing/other", "chartdate": "2100-12-22 00:00:00.000", "description": "Report", "row_id": 1328355, "text": "Nursing Progress Note 0700-1900\nS: \"How do you pronounce the name of this place?\"\n\nO: Please see carevue for complete objective data.\n\nNeuro: A&O x 2, person and time. Has trouble remembering where he is and trys to ask you for the answer in a subtle way. Does well after re-orientation. becomes frustrated with care and wants to be left alone. Encouraging him that care and meds are beneficial. Feels like everything is going wrong. OOb c PT , will see him again . MAE, helps c turning.\n\nCV: NSR, 70-80's, ocas PVC's. Several vagal episodes during activity requiring pacing @ 50 bpm. pt becomes anxious and dyspneic. EP consulted and increased rate to 60. SBP 119-160, on lopressor po. AM crit 20.6. Transfused x 2 units, bump to 27.3. Transfused x 1 more unit, hanging now. had ultrasound on upper R arm to locate DVT. Results pnding. pneumo boots on. Repleted pm calcium and potassium.\n\nRESP: Sats 95-100, lungs coarse c dim bases. weak productive cough. Becomes dyspneic during vagal/pacing episodes.\n\nGI/GU: Appetite fair. Refusing ensure supplement drinks. Multiple liquid guaiac pos stools. Inserted Flexiseal rectal tube, draining well. Extra bags in room. Foley draining Clr yel urine, rec'd lasix 20mg IV @ 1500.\n\nSKIN/ID: Incisions on back, sutured, DSD, not draining. R arm swollen, heat pack and elevation. Coccyx, perianal area, and scrotal area reddened and excoriated from numerous stools. Applied A&D ointment, antifungal and aloe vesta cream to area. Would benefit from desitin cream. MSSA osteomyelitis, treated c Naficillin Q4h. Afebrile.\n\nA: 71 yo male s/p fusion thoracotomy c/b asystole cardiac arrest requiring temp pacemaker. R arm DVT, low crit, and MS changes.\n\nP: Follow labs and replete lytes as necessary. Enc diet monitor UO. Skin care to coccyx area. Emotionally support pt and keep updated. Called out to floor.\n" }, { "category": "Nursing/other", "chartdate": "2100-12-21 00:00:00.000", "description": "Report", "row_id": 1328350, "text": "CCU NPN 1900-0700\nS: \"I'm just sick of all this, why does every complication have to happen to me?\"\nO: please see carevue for complete assessment data\nNo Events\nNEURO: initially A&Ox3, pleasant and cooperative w/ NSG care. Denies pain. @ 0200 pt awoke, completely disoriented/delerius, unable to re-orient, SWR applied to protect integrity of invasive lines (pt never became combative). 5mg orally disintegrating zyprexa admin w/ effect. Completely re-oriented again by 0400. MAE, assists w/ turning, PERRL 4mm/brisk.\n\nCV: Remains HD stable, MAP >65, tolerating lopressor, HR ranging 70s-90s NSR w/ occas PVCs, rare instances of v-pacing noted on tele, most often association w/ repositioning. Screwed in temp transvenous line intact. Denies CP. Distal pulses all by dop, cont grossly edematous.\n\nRESP: LSCTA, coarse/dim @ bases w/ rare int. ex wheeses improved w/ alb/atr neb. SpO2 wnl on 2l NC. Intermittent non-productive cough.\n\nGI: abd soft, nontender, nondistended. +BS, multiple loose stools, attempted FIB w/ no success, now w/ frequent checks d/t alt skin integrity, multiple abrasions in perianal area.\n\nGU: foley draining adequate amts CYU.\n\nID: afebrile, cont nafcillin q4hr for osteo.\n\nSKIN: unchanged.\n\nSOC: no calls/visitors, house staff unable to reach pts dtr re: transfusion, goals of care, SW to attempt family meeting today.\n\nA: s/p brady arrest w/ temp wire placement; anemic, but HD/resp stable.\nP: cont present ICU management per mulitdiciplinary rounds. Encourage ^ nutrition as pts albumin very low on admit and he cont w/ gross peripheral edema. Family meeting to discuss goals of care.\n" }, { "category": "Nursing/other", "chartdate": "2100-12-21 00:00:00.000", "description": "Report", "row_id": 1328351, "text": "S:\"I am actually hungry this morning.\"\n\nO:please see careview.\n\nOrtho: back incision looks clean and dry intact. skin staples intact.\npt used back brace today for ambulating to chair. pt was able to stand up straight and pivot to chair he did mention that he felt very weak while standing.\n\nID:MSSA from spinal wound cx on day 5 of nafcillin. temp 98.6 po. Pt will have perm pace maker placed once his infection is gone.\n\nCV:NSR HR 80-90's. BP 161/85-112/69.Pt has had several episodeds of v-pacing while being turned or getting up to move to chair and while sitting in chair.pt will get very nervouse and sob. towards end of day pt stated that it is not so bad now that he is getting use to what to expect when his hr drops. temp pacer screwed in and intact.Family meeting today pt does have hcp now his daughter and his son as backup if needed. pt did agree he will get blood transfusion and take meds.pt continues to be dnr/dni.left arm less swollen r/t cephalic vein thrombosis.\n\nneuro; pt a+ox3, calm, cooperative.\n\nskin: skin care consult today, use foam cushion when sitting in chair, limit time to one hour at a time. cleans perianal and coccyx skin with gentle foam cleanser pat dry apply antifungal powder apply double guard and aloe vesta cream repeat after each BM, also elevat scrotum with towel folded in thirds apply aloe vesta moisture barrier . Pt can also be on a 1st step select mattress outside of ccu setting.\n\nGI: pt ate all of breakfast and lunch. appetite much more improved. guaic positive stool. loose brown bm x1 + BS.\n\nGU: CYU _200cc for last 24hours.\n\nA: low albumin, poor appetite.\n\nP:encourage food consumption, encourage pt to turn q 2 hrs, continue to assess mental status. skin care as needed.\n" }, { "category": "Nursing/other", "chartdate": "2100-12-23 00:00:00.000", "description": "Report", "row_id": 1328358, "text": "CCU Progress note 1130-1900\nRESP:- Remains on intermittent N/C at 3 litres, when agaitated take it off, Sa02 on room air 95-96%, 98-100% on 3 litres. Bilateral air entry haerd to all lungfields, but diminished at the bases. Coughing occationally but not expectorating. RR 20-30 and regualr, ^ when agaitaed.\n\nCV:- Moniotored in NSR 80-90bpm and sinus tachycardia when agaited, up to 120s'. K+ replaetd, as having freequent PVCs, improved with 40meq IV. SBP 120-170s', more hypertensive when agaitaed. Peripherally cool to touch at times, pedal pules dopplerable. Hct 30, post transfusion yesturday.\n\nNEURO:- At lunctime intially A&O x3, but at 1700 became very agiated and during psych visit, he recommended haloperidol, gave 2mg PO halperidol with good response, as currently sleeping and settled. When agaitaed pulling at leads and N/C, not able to calm down by talking to him. earlier stated that he was aware that he was confused earlier, and that scared him.\n\nGI:- Not eaten at all during the day, refused all meals. Flexi-seal had to be resited as leaked, clogged, unblocked and re-inserted. Abdomen soft and nontender, faint bowel sounds heard.\n\nGU:- Foley catheter draining good amounts of clear yellow urine.\n\nACCESS:- Cenbtral line inplace, lumen patent, dressing changed this morning, No new problems noted.\n\nSKIN:- Nursed on Kinair bed, and alternate sides during the afternoon. Barrier cream allpied to sacral area and areas. stockings taken off at pT request.\n\nENDO:- Blood suagrs within normal limits not requring RISS.\n\nID:- Afebrile during the afternoon, antibiotics given as per chart.\n\nFAMILY:- Daughter called and updated on plan of care, informed of change in mental status this afternoon, she was very concerned, told that we were able to keep him calm with mediacation and were seeking other teams advice on how best to manage him, she also asked whether he wouold be moving to another floor tonight, I said that he would be staying here overnight.\n\nPLAN:- To continue to monitor mental staus changes and give mediaction as oredered. Monitor response to cardiac meds. Follow ID status and continue with antibiotics. To continue to give full explination of care to aptient and family.\n\n" }, { "category": "Nursing/other", "chartdate": "2100-12-24 00:00:00.000", "description": "Report", "row_id": 1328359, "text": "CCU NPN 1900-0700\nS: \"Get out of here...\"\nO: please see carevue for complete assessment data\nNo Events\nNEURO: Pt A&Ox1-2, restless moving about in bed all night despite position changes and intermittently verbally abusive to staff. pm olanzapine changed to 2mg haldol po w/ little effect, pt finally settling briefly ~0300. Denies pain.\n\nCV: Remains HD stable, intermittently v-pacing in 80s otherwise NSR 70s-90s w/ occas PVCs. Am labs pending. BP ^ 150s-160s, started captopril 25mg tid and ^'d lopressor to 50mg . Tolerating well thus far.\n\nRESP: LS coarse, intermittent ex wheezes tx'd w/ nebs. Atrovent d/c'd for ? of cholinergic effect exacerbating dementia.\n\nGI/GU/ENDO: unchanged, cont w/ loose brown/green stool via flexi-seal. Foley draining adequate amts CYU. BG wnl.\n\nID: afebrile, cont nafcillin\n\nSOC: no calls/visitors\n\nSKIN: unchanged, abrasions in perirectal area slightly improved.\n\nA: CV/resp stable w/ cont/worsending delerium/dementia.\nP: anticipate c/o to floor when bed and sitter are available, cont to monitor CV sts w/ titration of ACE-I and BB. Encourage ^ activity and PO intake.\n" }, { "category": "Nursing/other", "chartdate": "2100-12-24 00:00:00.000", "description": "Report", "row_id": 1328360, "text": "S: I'm ready to leave.\n\nO:please see careview.\n\nCV: HR 80's nsr v-paced many time throughout day. pt gets very sob and nervous when hr drops and he starts to vpaced. bp 1168/68-111/74.\n\nresp:coarse ls. 2liters o2 sat.\n\nGI: flexiseal in place brown liquid stool pt eatting well pt ate all breakfast and lunch.\n\nGU: -1050cc for day via foley cath.\n\naccess: pt was ready to leave to be dc/d to rehab. that plan was dc'd r/t picc line placement was not in correct place. Pt had to go to IR for line placement. still waiting for picc line confirmation placement. md will follow up.\n\nneuro: a+ox3\n\nskin: very raw reddened coccxys and buttocks double guard/aloe vesta applied.\n\na:pt access needed for rehab p[lacement for antibiotics.\n\nP: pt c/o to floor. pt needes to take potassium tabs once he eats dinner.\n" }, { "category": "Nursing/other", "chartdate": "2100-12-25 00:00:00.000", "description": "Report", "row_id": 1328361, "text": "Respiratory Care:\nPatient audibly wheezing, requiring nebulizer treatment with ud albuterol and atrovent. BS much improved with the treatment. Patient in no visible distress post Rx.\n" }, { "category": "Echo", "chartdate": "2100-12-17 00:00:00.000", "description": "Report", "row_id": 81938, "text": "PATIENT/TEST INFORMATION:\nIndication: s/p ?PEA arrest with h/o recent NSTEMI, assess LV fxn/wall motion\nHeight: (in) 70\nWeight (lb): 180\nBSA (m2): 2.00 m2\nBP (mm Hg): 150/90\nHR (bpm): 76\nStatus: Inpatient\nDate/Time: at 01:47\nTest: TTE (Focused views)\nDoppler: Limited Doppler and color Doppler\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nVery limited study. LV function appears mildly depressed with EF of 50%. There\nis basal-mid inferior/inferior lateral akinesis. Compared to prior study in\n, LV function or wall motion does not appear substantially changed. There\nis no pericardial effusion.\nThis study was compared to the prior study of .\n\n\nLEFT ATRIUM: Normal LA size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.\n\nLEFT VENTRICLE: Mildly dilated LV cavity. Mildly depressed LVEF.\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.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows. Emergency\nstudy performed by the cardiology fellow on call.\n\nConclusions:\n1. The left ventricular cavity is mildly dilated. Overall left ventricular\nsystolic function is mildly depressed. Lateral and inferior hypokinesis is\npresent.\n2. The aortic valve leaflets are mildly thickened.\n3. The mitral valve leaflets are mildly thickened.\n4. Compared with the prior study (images reviewed) of , there is no\nsignificant change.\n\n\n" }, { "category": "Echo", "chartdate": "2100-12-14 00:00:00.000", "description": "Report", "row_id": 81939, "text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function.\nHeight: (in) 69\nWeight (lb): 163\nBSA (m2): 1.90 m2\nBP (mm Hg): 129/49\nHR (bpm): 95\nStatus: Inpatient\nDate/Time: at 11:54\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT ATRIUM: Normal LA size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.\n\nLEFT VENTRICLE: Mildly dilated LV cavity. Mildly depressed LVEF.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic root diameter.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Mild mitral annular\ncalcification. Mild thickening of mitral valve chordae. Calcified tips of\npapillary muscles. Trivial MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.\n\nPERICARDIUM: No pericardial effusion.\n\nConclusions:\n1. The left ventricular cavity is mildly dilated. Overall left ventricular\nsystolic function is mildly depressed. Inferiolateral and inferior hypokinesis\nis present.\n2. The aortic valve leaflets (3) are mildly thickened.\n3. The mitral valve leaflets are mildly thickened. Trivial mitral\nregurgitation is seen.\n3. Compared with the prior study (images reviewed) of , there is no\nsignificant change.\n\n\n" }, { "category": "Echo", "chartdate": "2100-12-06 00:00:00.000", "description": "Report", "row_id": 81873, "text": "PATIENT/TEST INFORMATION:\nIndication: Endocarditis. Murmur.\nHeight: (in) 70\nWeight (lb): 160\nBSA (m2): 1.90 m2\nBP (mm Hg): 140/64\nHR (bpm): 70\nStatus: Inpatient\nDate/Time: at 13:46\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. The IVC is normal in diameter\nwith >50% decrease collapse during respiration (estimated RAP 5-10 mmHg).\n\nLEFT VENTRICLE: Normal LV wall thickness. Mildly dilated LV cavity. Mild\nregional LV systolic dysfunction. Transmitral Doppler and TVI c/w Grade I\n(mild) LV diastolic dysfunction. No resting LVOT gradient.\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: basal inferior\n- hypo; mid inferior - hypo; basal inferolateral - hypo; mid inferolateral -\nhypo;\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic root diameter. Focal calcifications in aortic root.\nNormal ascending aorta diameter.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. No mass or\nvegetation on mitral valve. Mild mitral annular calcification. Mild thickening\nof mitral valve chordae. Calcified tips of papillary muscles. Mild (1+) MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Normal PA\nsystolic pressure.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with\nphysiologic PR.\n\nPERICARDIUM: No pericardial effusion.\n\nConclusions:\nThe left atrium is normal in size. Left ventricular wall thicknesses are\nnormal. The left ventricular cavity is mildly dilated with focal near akinesis\nof the basal half of the inferolateral wall. The remaining segments contract\nwell. Transmitral Doppler and tissue velocity imaging are consistent with\nGrade I (mild) LV diastolic dysfunction. Right ventricular cavity size and\nfree wall motion are normal. The aortic valve leaflets (3) are mildly\nthickened. There is no aortic valve stenosis. No aortic regurgitation is seen.\nThe mitral valve leaflets are mildly thickened. No systolic prolapse is seen.\nNo mass or vegetation is seen on the mitral valve. Mild (1+) mitral\nregurgitation is seen. The estimated pulmonary artery systolic pressure is top\nnormal. There is no pericardial effusion.\n\nIMPRESSION: Regional left ventricular systolic dysfunction c/w CAD. Mild\nmitral regurgitation with mild leaflet thickening. No discrete vegetation\nidentified (does not exclude endocarditis if clinically suggested).\n\n\n" }, { "category": "ECG", "chartdate": "2101-01-02 00:00:00.000", "description": "Report", "row_id": 208275, "text": "Sinus rhythm. Consider left atrial abnormality. Modest non-specific\nintraventricular conduction delay. Probable left ventricular hypertrophy.\nConsider also biventricular hypertrophy. Non-specific ST-T wave abnormalities.\nSince the previous tracing of atrial pacing is not evident.\n\n" }, { "category": "ECG", "chartdate": "2101-01-01 00:00:00.000", "description": "Report", "row_id": 208276, "text": "Atrial paced rhythm. Inferior myocardial infarction, age undetermined.\nAnterolateral ST-T wave changes may be due to myocardial ischemia. Since the\nprevious tracing of atrial pacing is present.\n\n" }, { "category": "ECG", "chartdate": "2100-12-30 00:00:00.000", "description": "Report", "row_id": 208277, "text": "Baseline artifact. Sinus rhythm. Since the previous tracing of the\nventricular premature beat is not seen. ST-T wave abnormalities in the lateral\nprecordial leads are more marked.\n\n" }, { "category": "ECG", "chartdate": "2100-12-24 00:00:00.000", "description": "Report", "row_id": 208278, "text": "Sinus rhythm with occasional ventricular premature beats. Intraventricular\nconduction delay. Non-specific inferolateral ST-T wave abnormalities. Compared\nto the previous tracing of , except for ventricular premature beats,\nthere is no significant diagnostic change.\n\n" }, { "category": "ECG", "chartdate": "2100-12-23 00:00:00.000", "description": "Report", "row_id": 208279, "text": "Sinus rhythm. Intraventricular conduction delay may be incomplete left\nbundle-branch block. ST-T wave abnormalities could be due to intraventricular\nconduction delay and are non-specific. Since the previous tracing of \nventricular ectopy is absent and the ST-T wave changes appear less prominent.\n\n" }, { "category": "ECG", "chartdate": "2100-12-21 00:00:00.000", "description": "Report", "row_id": 208280, "text": "Sinus rhythm\nPremature contraction\nIntraventricular conduction defect\nExtensive ST-T changes\nSince previous tracing, QRS width prolonged\n\n" }, { "category": "ECG", "chartdate": "2100-12-20 00:00:00.000", "description": "Report", "row_id": 208281, "text": "Sinus rhythm. Premature contractions. Extensive ST-T wave changes. Compared to\nthe previous tracing no significant change.\n\n" }, { "category": "ECG", "chartdate": "2100-12-17 00:00:00.000", "description": "Report", "row_id": 208282, "text": "Sinus rhythm with occasional ventricular premature beats. Anterolateral\nST-T wave changes. Cannot rule out myocardial ischemia. Compared to the\nprevious tracing of anterolateral ST-T wave changes are modestly more\nprominent. Clinical correlation is suggested.\n\n" }, { "category": "ECG", "chartdate": "2100-12-17 00:00:00.000", "description": "Report", "row_id": 208502, "text": "Sinus rhythm with two premature beats. Since the previous tracing of \nprobably no significant change in previously noted findings.\nTRACING #3\n\n" }, { "category": "ECG", "chartdate": "2100-12-16 00:00:00.000", "description": "Report", "row_id": 208503, "text": "Baseline artifact. Probable sinus rhythm with a single wide complex beat.\nIntraventricular conduction delay. Since the previous tracing of the\npremature beat is new. Other features are probably unchanged. Clinical\ncorrelation is suggested.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2100-12-16 00:00:00.000", "description": "Report", "row_id": 208504, "text": "Baseline artifact. Probable sinus rhythm. Mild P-R interval prolongation.\nBorderline intraventricular conduction delay, Since the previous tracing\nof the QRS interval is wider. The Q wave in lead aVF is not as\napparent. Clinical correlation is suggested.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2100-12-14 00:00:00.000", "description": "Report", "row_id": 208505, "text": "Sinus rhythm. Left atrial abnormality. Prior inferior wall myocardial\ninfarction. Delayed precordial R wave progression. Compared to the previous\ntracing of the rate has slowed. Otherwise, no diagnostic interim\nchange.\n\n" }, { "category": "ECG", "chartdate": "2100-12-14 00:00:00.000", "description": "Report", "row_id": 208506, "text": "Sinus tachycardia\nConsider prior inferior myocardial infarction\nNonspecific ST-T abnormalities\nSince previous tracing of , sinus tachycardia present\n\n" }, { "category": "ECG", "chartdate": "2100-12-12 00:00:00.000", "description": "Report", "row_id": 208507, "text": "Sinus rhythm. Compared to the previous tracing of there are\ninferolateral ST segment abnormalities. The limb lead voltage has diminished\nmarkedly. Prior inferior wall myocardial infarction. Clinical correlation is\nsuggested.\n\n" }, { "category": "ECG", "chartdate": "2100-11-29 00:00:00.000", "description": "Report", "row_id": 208508, "text": "Sinus rhythm. Tall voltage. T wave inversion in lead aVL. QR complexes in\nlead III. Tall R waves in lead V2. Rare ventricular premature beat. Prominent\nU waves in leads V2-V3 suggesting possibility of hypokalemia. Transmural\ninferior wall myocardial infarction of undetermined age because of ST segment\nelevations in these leads. Clinical correlation is required.\n\n" }, { "category": "Radiology", "chartdate": "2100-12-19 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 938495, "text": " 3:32 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: eval lines, r/o pneumothorax\n Admitting Diagnosis: SPINAL MASS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man with spinal mass and profound bradycardia, w/ temp pacer now\n s/p RIJ TLC placement\n REASON FOR THIS EXAMINATION:\n eval lines, r/o pneumothorax\n ______________________________________________________________________________\n FINAL REPORT\n CHEST PORTABLE\n\n HISTORY: Spinal mass, bradycardia, fever, placement of central line. Evaluate\n for pneumothorax.\n\n Three AP views. Comparison with the previous study done . There is\n continued evidence of a large amount left pleural effusion which is at least\n partially loculated. There is also a small right pleural effusion as\n demonstrated before. The retrocardiac area remains dense. The patient is\n status post spinal fusion surgery, hardware and post-surgical changes are\n present in the spine. Mediastinal structures are unchanged. A transvenous\n pacemaker remains in place. A right internal jugular catheter has been\n inserted and terminates just below the level of the thoracic inlet, apparently\n in central position. There is no evidence of a pneumothorax and no other\n significant change.\n\n IMPRESSION: Right internal jugular line in central position. No other\n significant change.\n\n" }, { "category": "Radiology", "chartdate": "2100-12-06 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 936757, "text": " 1:42 PM\n CHEST (PA & LAT) Clip # \n Reason: rule out infection, prior TB\n Admitting Diagnosis: SPINAL MASS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man with epidural mass, now with leukocytosis\n REASON FOR THIS EXAMINATION:\n rule out infection, prior TB\n ______________________________________________________________________________\n FINAL REPORT\n CHEST TWO VIEWS, PA AND LATERAL\n\n History of epidural mass with leukocytosis.\n\n Heart size is within normal limits. There is tortuosity of the thoracic\n aorta. There is mild blunting of both costophrenic sulci consistent with small\n bilateral pleural effusions. small rounded density right lung base unchanged\n when compared with prior outside film of . No pulmonary\n consolidation. The pulmonary vasculature is unremarkable.\n\n IMPRESSION: No evidence for pneumonia. Small bilateral pleural effusions but\n no evidence for CHF. Small well defined nodular density right lung base.\n Correlate with prior outside films if available . Further evaluation, either\n by follow up plain radiographs in approx 3 months or by CT is suggested.\n (Discussed by telephone with ordering physician )\n\n" }, { "category": "Radiology", "chartdate": "2100-12-29 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 939833, "text": " 5:12 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for reexpansion, pneumothorax\n Admitting Diagnosis: SPINAL MASS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man s/p verterbral fusion after spinal abscess, hx loculated L\n effusion, s/p thoracentesis.\n REASON FOR THIS EXAMINATION:\n eval for reexpansion, pneumothorax\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: Single portable AP chest radiograph.\n\n INDICATION: 71-year-old male status post thoracentesis, rule out\n pneumothorax.\n\n COMPARISON: AP chest radiograph .\n\n FINDINGS: Decrease in diffuse hazy opacity within the left lower lung field\n consistent with interval removal of left-sided pleural fluid. No pneumothorax\n identified. Mild blunting of the left costophrenic angle likely represents\n small residual pleural fluid. No pleural effusion on the right. The\n cardiomediastinal silhouette is generally unchanged in appearance. A\n horizontal linear opacity is identified in the left mid hemithorax likely\n representing discoid atelectasis vs scar. Lateral to this abnormality is a\n vertically oriented linear lucency which may represent a tiny amount of\n loculated pleural air.\n\n Posterior osseous metallic fusion device from T1-T11 is generally unchanged in\n appearance.\n\n IMPRESSION:\n 1. Interval removal of left pleural effusion with small amount of pleural\n fluid remaining.\n\n 2. Left middle lung field discoid atelectasis vs scar with possible adjacent\n tiny pleural air collection. Recommend follow up radiographs to resolution.\n\n\n" }, { "category": "Radiology", "chartdate": "2100-12-20 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 938575, "text": " 9:44 AM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o infiltrate, assess left-sided pleural effusion progressi\n Admitting Diagnosis: SPINAL MASS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man with spinal mass and profound bradycardia, w/ temp pacer now\n s/p RIJ TLC placement, falling hematocrit.\n REASON FOR THIS EXAMINATION:\n r/o infiltrate, assess left-sided pleural effusion progression, other site of\n bleeding.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 71-year-old with spinal mass and bradycardia as well as falling\n hematocrit.\n\n Portable semi-upright frontal radiograph. Comparison is made to one day\n earlier.\n\n FINDINGS: Allowing for positional differences, there is no change in\n appearance of bilateral pleural effusions, left greater than right. The left\n effusion may be partially loculated. Associated bibasilar atelectatic changes\n are also stable. There is a left retrocardiac opacity, also unchanged. There\n is decreased gastric distention compared to the most recent examinations.\n Spinal fusion hardware, overlying skin staples, and a right single-lead\n pacemaker are unchanged. A right IJ center venous catheter also remains in\n place, though the tip of the catheter is obscured by overlying spinal fusion\n hardware.\n\n IMPRESSION: No significant change in bilateral pleural effusions and\n associated atelectasis.\n\n\n" }, { "category": "Radiology", "chartdate": "2100-12-17 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 938318, "text": " 4:04 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: Need to assess for PICC line positioning, need 2 views, 1 a\n Admitting Diagnosis: SPINAL MASS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man with spinal mass and profound bradycardia, s/p placement of\n temporary screw-in pacemaker lead via right subclavian.\n REASON FOR THIS EXAMINATION:\n Need to assess for PICC line positioning, need 2 views, 1 a left\n obligque-anterior view and 1 right-oblique anterior view. Thank you.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Check left-sided PICC line position.\n\n COMPARISON: CXR, .\n\n FINDINGS: Two oblique films are obtained. Left-sided PICC line is identified\n and appears to terminate with its tip either in the upper SVC or at the\n cephalic junction. However, on the film in which this is most evident, the\n course of the PICC line is cut off in the upper aspect of the film limiting\n complete evaluation. Spinal fusion hardware is unchanged. A single lead\n pacemaker is unchanged in position. Left retrocardiac density is also\n unchanged. Left-sided loculated pleural effusion seems unchanged in size\n compared to a few hours prior.\n\n IMPRESSION: PICC line with its tip most likely located at the cephalic\n junction or within the proximal SVC. Stable left retrocardiac density and\n left-sided loculated pleural effusion.\n\n\n" }, { "category": "Radiology", "chartdate": "2100-12-17 00:00:00.000", "description": "BILAT LOWER EXT VEINS", "row_id": 938342, "text": " 8:03 PM\n BILAT LOWER EXT VEINS Clip # \n Reason: rule out DVTs\n Admitting Diagnosis: SPINAL MASS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man with s/p spinal surgery with right cephalic vein DVT\n REASON FOR THIS EXAMINATION:\n rule out DVTs\n ______________________________________________________________________________\n WET READ: MMBn FRI 9:43 PM\n Non occlusive, old thrombus in the right greater saphenous vein. No acute\n thrombus is seen\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 71-year-old man, status post spinal surgery with right cephalic\n vein DVT. Evaluate for additional DVTs.\n\n BILATERAL LOWER EXTREMITY ULTRASOUND WITH DOPPLER EXAMINATION: Grayscale,\n color flow, and Doppler ultrasound of bilateral common femoral, superficial\n femoral, and popliteal veins were performed. Normal flow, augmentation,\n compressibility, and waveforms were demonstrated. No intraluminal thrombus\n was seen.\n\n IMPRESSION: Negative bilateral lower extremity DVT study.\n\n\n" }, { "category": "Radiology", "chartdate": "2100-12-26 00:00:00.000", "description": "T-SPINE", "row_id": 939409, "text": " 1:11 PM\n T-SPINE Clip # \n Reason: confirm hardware alignment\n Admitting Diagnosis: SPINAL MASS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man s/p thoracic fusion--eval hardware placement\n REASON FOR THIS EXAMINATION:\n confirm hardware alignment\n ______________________________________________________________________________\n FINAL REPORT\n CHEST, TWO VIEWS ON \n\n HISTORY: Status post thoracic fusion, check hardware.\n\n FINDINGS: Films were limited by the patient's inability to move on the x-ray\n table. Spinal fixation devices are present spanning the entire thoracic\n spine. There is a left subclavian line with the tip not definitively\n visualized but likely in the superior vena cava. There is a right-sided\n pacemaker with the tip poorly seen due to motion but likely projecting over\n the right ventricle. There is retrocardiac opacity that could represent\n volume loss. The stomach is grossly distended.\n\n\n" }, { "category": "Radiology", "chartdate": "2100-12-02 00:00:00.000", "description": "CT ABDOMEN W/CONTRAST", "row_id": 936216, "text": " 4:08 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: please perform CT-guided biopsy\n Admitting Diagnosis: SPINAL MASS\n Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man with epidural mass and back pain\n REASON FOR THIS EXAMINATION:\n please perform CT-guided biopsy\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 71-year-old male with epidural mass and back pain. Rule out\n primary.\n\n COMPARISONS: Comparison is made to outside chest CT performed on .\n\n No abdomens are available for comparison.\n\n TECHNIQUE: CT of the abdomen with IV contrast only. 130 cc of Optiray 350\n were administered. Nonionic IV contrast was used due to the rapid bolus\n necessary for this study.\n\n CT ABDOMEN: The gallbladder is distended likely due to fasting. However,\n clinical correlation is recommended. The liver, spleen, and pancreas are\n unremarkable. The small 11-mm left adrenal gland nodule is not well\n characterized in this study. The right adrenal gland is normal. Small\n hypodense area at the interpolar region of the right kidney is too small to be\n characterized. Small and large bowel are grossly unremarkable. There is a\n moderate amount of stool within the colon. The appendix is within normal\n limits. Severe calcifications of the aorta. All the major branches are\n patent. No free fluid or retroperitoneal lymphadenopathy.\n\n CT PELVIS: Urinary bladder, distal ureters are unremarkable. No free fluid\n or free air in the pelvis. Calcifications within the prostate. Small segment\n of chronic dissection involving both proximal common ilia\n arteries.\n\n BONE WINDOWS: There are degenerative changes of the lumbar spine. The\n paraspinal mass at the level of T7/T8 was not completely imaged in this study.\n The destruction of the bone can be appreciated in the scout.\n\n IMPRESSION:\n 1. The paraspinal mass with bone destruction at the level of T7/T8 was not\n completely imaged in this study and can be seen on the scout.\n\n 2. Small left adrenal nodule was incompletely characterized in this study. It\n could represent a small adrenal adenoma but possibility of metastasis cannot\n be excluded.\n\n 3. Small hypodense area in the interpolar region of the right kidney is too\n (Over)\n\n 4:08 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: please perform CT-guided biopsy\n Admitting Diagnosis: SPINAL MASS\n Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n small to be characterized.\n\n 4. Small segment of chronic dissection involving both proximal common iliac\n arteries.\n\n" }, { "category": "Radiology", "chartdate": "2100-12-24 00:00:00.000", "description": "PERIPHERAL W/O PORT", "row_id": 939233, "text": " 2:51 PM\n PICC LINE PLACMENT SCH Clip # \n Reason: please reposition Left PICC line into proper location.\n Admitting Diagnosis: SPINAL MASS\n ********************************* CPT Codes ********************************\n * PERIPHERAL W/O FLUOR GUID PLCT/REPLCT/REMOVE *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71M Epidural abscess, new temp wire placed on R SCL, needs 6 weeks nafcillin\n for abscess.\n REASON FOR THIS EXAMINATION:\n please reposition Left PICC line into proper location.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 71-year-old male with epidural abscess, s/p recent bedside left-\n sided PICC line, with the tip in the left IJ, for repositioning.\n\n PROCEDURE: The procedure was performed by Drs. and .\n Dr. , the attending radiologist, was present and supervising throughout\n the procedure.\n\n PROCEDURE AND FINDINGS: Prior to initiation of the procedure, a preprocedure\n timeout was performed, the patient was placed supine on the angiographic\n table. A fluoroscopic spot image was obtained demonstrating the left PICC\n line with the tip in the left IJ. A 0.018 guidewire was advanced through the\n PICC line, which was then removed over the wire. The wire was then positioned\n within the mid SVC using flouroscopic guidance. A 4.5-French micropuncture\n sheath was advanced over the guidewire. The central dilator was exchanged for\n the double lumen PICC, with the tip positioned in the mid SVC. The guidewire\n and sheath were removed. A fluoroscopic spot image showed final position of\n the tip in the SVC. Patient tolerated the procedure well, without immediate\n complication.\n\n IMPRESSION: Successful repositioning of a left PICC, with the tip positioned\n in the mid SVC, measuring 45 cm in length. The line is ready for use.\n\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2100-12-30 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 940031, "text": " 7:45 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for pneumothorax\n Admitting Diagnosis: SPINAL MASS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man s/p verterbral fusion after spinal abscess, hx loculated L\n effusion, s/p thoracentesis. Now with chest pain.\n REASON FOR THIS EXAMINATION:\n eval for pneumothorax\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 71-year-old man status post vertebral fusion after spinal\n abscess. History of loculated left effusion post-thoracentesis, now with\n chest pain. Evaluate for pneumothorax.\n\n Spinal rods are in place with associated screws and vertebral body spacer. The\n heart size is normal. There is a somewhat tortuous aorta. The mediastinal\n contours are otherwise unremarkable. There are some interstitial opacities\n predominantly within the lung bases along with small bilateral pleural\n effusions. A right-sided pacemaker with single lead is present extending into\n the right ventricle. The previously placed left-sided PICC line has been\n pulled back and now is seen with tip overlying the axillary region.\n\n IMPRESSION:\n 1. No evidence of pneumothorax.\n 2. Interval retraction of PICC line now overlying the axillary region. Note\n shoud be made that this location is intentional per recommendation for PICC\n line retraction secondary to cardiac pacer procedure to be performed.\n 3. Otherwise stable chest radiograph.\n\n" }, { "category": "Radiology", "chartdate": "2100-12-22 00:00:00.000", "description": "R UNILAT UP EXT VEINS US RIGHT", "row_id": 938905, "text": " 1:00 PM\n UNILAT UP EXT VEINS US RIGHT Clip # \n Reason: R UE: evaluation for propagation of clot.\n Admitting Diagnosis: SPINAL MASS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man with erythematous right extremity, past thrmobus, new IJ\n placed.\n REASON FOR THIS EXAMINATION:\n R UE: evaluation for propagation of clot.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Right extremity erythema, prior clot in cephalic vein. Evaluate\n for propagation.\n\n RIGHT UPPER EXTREMITY VENOUS ULTRASOUND: Grayscale and Doppler son of\n the right internal jugular vein, subclavian, axillary, brachial, and cephalic\n veins were performed. A persistent occlusive thrombus is visualized in the\n cephalic vein. A central venous catheter is present in the right internal\n jugular and the proximal subclavian. Focal area of recanalized brachial vein\n is seen within eccentric chronic thrombus adherent to the wall\n circumferentially with passage of good flow through that point.\n\n IMPRESSION: Unchanged appearance of cephalic clot without extension to the\n other deep veins.\n\n" }, { "category": "Radiology", "chartdate": "2100-12-18 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 938381, "text": " 8:22 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval increasing effusion, lead placement\n Admitting Diagnosis: SPINAL MASS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man with spinal mass and profound bradycardia, s/p placement of\n temporary screw-in pacemaker lead via right subclavian, also, concerning for\n increasing L pleural effusion s/p thoracic vertebral corpectomy.\n REASON FOR THIS EXAMINATION:\n eval increasing effusion, lead placement\n ______________________________________________________________________________\n FINAL REPORT\n CHEST\n\n HISTORY: Left pleural effusion.\n\n Two views. Comparison with . Positioning is suboptimal. There is\n continued evidence of a large left pleural effusion, which is at least\n partially loculated. There is now increased density at the right lung base\n and along the lateral aspect of the right lung consistent with accumulation of\n pleural fluid on that side. The retrocardiac area is dense and the left lung\n base is obscured, as before. The heart and mediastinal structures are\n unchanged. The patient is status post spinal fusion. Hardware and post\n surgical changes are demonstrated in the thoracic spine. A left PICC line has\n been withdrawn. A transvenous pacemaker lead remains in place.\n\n IMPRESSION: Peristent left pleural effusion and retrocardiac/left basilar\n density. Development of increased density in the right chest consistent with\n pleural fluid. Left PICC line withdrawn. No other significant change.\n\n\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2100-12-30 00:00:00.000", "description": "CT CHEST W/O CONTRAST", "row_id": 939986, "text": " 2:31 PM\n CT CHEST W/O CONTRAST Clip # \n Reason: Please eval for effusions, ? loculated\n Admitting Diagnosis: SPINAL MASS\n Field of view: 36\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man s/p spinal surgery who had thorocentesis yesterday\n REASON FOR THIS EXAMINATION:\n Please eval for effusions, ? loculated\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post spinal surgery with recent thoracentesis. Evaluate\n effusions.\n\n COMPARISON: CTA chest from .\n\n TECHNIQUE: MDCT axial images of the chest were obtained without intravenous\n contrast secondary to poor IV access. Images are presented for display in the\n axial plane at 5-mm and 1.25-mm collimation.\n\n NONCONTRAST CHEST CT: A tiny loculated hydropneumothorax along the lateral\n left hemithorax at the level of the carina is likely secondary to recent\n thoracentesis (series 3, image 29). A dependent low attenuation right pleural\n effusion is slightly smaller over the interval, now moderate in size. A\n moderate left effusion with loculated components involving the posteromedial\n upper hemithorax and along the major fissure demonstrates interval decrease\n following thoracentesis. High-density fluid located in the upper hemithorax\n loculation suggests prior hemothorax and is without change from the prior\n study. There is no evidence of active hemorrhage. Lung windows demonstrate\n ground-glass opacity with septal thickening at the left lung base, suggestive\n of reexpansion edema. No pulmonary nodules are identified. Mediastinal\n structures are midline.\n\n The heart size is normal. Coronary artery calcifications are again noted.\n Pacer wires are unchanged in standard positions. There is no pericardial\n effusion. Soft tissue and fluid density surrounding the anterior vertebral\n spacer cage in the mid thoracic spine are slightly less prominent. Multiple\n subcentimeter lymph nodes in the right paratracheal, subcarinal, and\n prevascular stations are stable.\n\n In the imaged upper abdomen, the visualized liver dome is unremarkable.\n No osseous findings suspicious for malignancy are identified. Postoperative\n change in the mid thoracic spine, including multiple pedicle screws and rods\n as well as an intervertebral body cage is stable.\n\n IMPRESSION:\n\n 1. Decrease in size of a moderate left pleural effusion with loculated\n components. High attenuation within a loculated fluid collection in the left\n upper hemithorax suggests component of possible hemothorax and is unchanged.\n No evidence of new or active extravasation.\n (Over)\n\n 2:31 PM\n CT CHEST W/O CONTRAST Clip # \n Reason: Please eval for effusions, ? loculated\n Admitting Diagnosis: SPINAL MASS\n Field of view: 36\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n 2. Ground-glass opacity at the left base consistent with reexpansion edema in\n the setting of recent thoracentesis. Bibasilar hydrostatic interstitial edema.\n 3. Stable appearance of postoperative change within the mid thoracic spine as\n above.\n 4. Tiny left hydropneumothorax, likely secondary to recent thoracentesis.\n\n\n" }, { "category": "Radiology", "chartdate": "2100-12-27 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 939529, "text": " 2:03 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Please eval for infiltrate\n Admitting Diagnosis: SPINAL MASS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man s/p verterbral fusion after spinal abscess. Now with\n leukocytosis.\n REASON FOR THIS EXAMINATION:\n Please eval for infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n CHEST, SINGLE AP FILM\n\n History of spinal fusion with leukocytosis.\n\n Status post bone cage and spinal fusion with posterior instrumentation\n extending from T1-T11. Heart size is normal. There is tortuosity of the\n thoracic aorta. There is a left-sided pleural effusion, increased in size\n since the previous film of and in addition, there is a new area\n of pulmonary consolidation in the left lower zone with obscuration of both the\n left heart and diaphragm consistent with consolidation in the lingula and left\n lower lobe. The right lung remains clear. Left PICC line overlies proximal\n SVC. Left-sided pacemaker with single lead in region of RV apex in this\n single view. No pneumothorax. The right lung remains clear.\n\n IMPRESSION: Increase in size of left pleural effusion and new relatively\n large area of consolidation in lingula and left lower lobe since prior study\n of . Findings discussed by telephone with Dr. .\n\n\n" }, { "category": "Radiology", "chartdate": "2100-12-11 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 937421, "text": " 8:03 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? resolution of ptx\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man with spinal mass\n\n REASON FOR THIS EXAMINATION:\n ? resolution of ptx\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Spinal mass status post surgery.\n\n CHEST: Since the prior chest x-ray of , increased opacities in the\n left lower lobe are present probably due to consolidation in the left lower\n lobe. A new left effusion is now present.\n\n No pneumothorax is now seen. The right lung remains clear.\n\n IMPRESSION: New consolidation in the left lower lobe, left effusion.\n\n\n" }, { "category": "Radiology", "chartdate": "2100-12-03 00:00:00.000", "description": "CT MUSCLE (SOFT TISSUE) BX", "row_id": 936325, "text": " 11:30 AM\n CT MUSCLE (SOFT TISSUE) BX; CT GUIDED NEEDLE PLACTMENT Clip # \n Reason: EPIDURAL MASS\n Admitting Diagnosis: SPINAL MASS\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 71-year-old man with epidural mass as well as a paraspinal mass. For\n biopsy of the paraspinal mass at the level of T7/8.\n\n PROCEDURE: The risks and benefits of the procedure were explained to the\n patient, and written informed consent was obtained. A preprocedure timeout\n using two patient identifiers was performed. The patient was placed prone on\n the CT table, and a preprocedure CT was obtained. The area was prepped and\n draped in a sterile fashion. Under CT fluoroscopic guidance, an 18-gauge\n needle was inserted into the right paraspinal mass at the level of T7/8. Using\n a coaxial core biopsy system, two samples were obtained. Samples were sent\n for cytology, pathology, as well as for Gram stain and culture including AFB.\n The patient tolerated the procedure well, and there were no immediate post-\n procedure complications. Dr. , the attending radiologist, was\n present throughout and performed the procedure.\n\n PREPROCEDURE CT: Few limited images of the chest demonstrate coronary artery\n calcifications in the left anterior descending and left circumflex arteries.\n There is a right-sided paraspinal mass at the level of T7/T8 with destruction\n of the inferior endplate of T7 and superior endplate of T8. The visualized\n lung fields demonstrate minimal dependent atelectasis.\n\n IMPRESSION: Technically successful CT-guided biopsy of right thoracic\n paraspinal mass.\n\n" }, { "category": "Radiology", "chartdate": "2100-12-16 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 938133, "text": " 12:40 PM\n CHEST (PA & LAT) Clip # \n Reason: r/o pleural effusion\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man with epidural mass, now with leukocytosis\n\n REASON FOR THIS EXAMINATION:\n r/o pleural effusion\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Epidural mass now has leukocytosis, evaluate for pleural\n effusion.\n\n CHEST: Extensive spinal hardware is seen within the thoracic region unchanged\n in position. Left effusion is present, little changed from the prior chest\n x-ray of . The left IJ line has been removed. Atelectasis is\n present on both sides.\n\n IMPRESSION: Decrease in size of left effusion.\n\n\n" }, { "category": "Radiology", "chartdate": "2100-11-29 00:00:00.000", "description": "MR L-SPINE W & W/O CONTRAST", "row_id": 935731, "text": " 8:34 PM\n MR W& W/O CONTRAST; MR W &W/O CONTRAST Clip # \n MR W & W/O CONTRAST\n Reason: eval for mass\n Contrast: MAGNEVIST Amt: 20\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man with CT scan with paraspinal t7-8 abscess.\n REASON FOR THIS EXAMINATION:\n eval for mass\n ______________________________________________________________________________\n WET READ: DJD TUE 1:40 AM\n C-SPINE:\n Multilevel disc protrusions, esp C5-6, C6-7.\n No acute abnormality\n\n T-SPINE:\n POSITIVE for abnormal signal and partial collapse of T7\n Abnormal signal of T8\n Epidural mass emanating from T7-8 causing cord compression.\n Althogh in fection is possible (two contiguous vertebrae), there is also\n anterior spinal mass and possibly mediastinal adenopathy, favoring neoplasm.\n Also, there is no disk edema. However, both neoplasm and infection need to be\n considered.\n On-call rad. resident made aware of findings by phone\n\n L-SPINE:\n . changes. including mild L5 on S1 anterolisthesis w/possible\n spondylolysis. No acute abnormality\n\n MD\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INFORMATION: CT scan with paraspinal left T7-T8 abscess.\n\n MRI OF THE CERVICAL SPINE WITH GADOLINIUM:\n\n There is no evidence of disc infection. There is degenerative disc disease at\n multiple levels.\n\n At C4-C5, there is a small central disc protrusion without evidence of canal\n or foraminal stenosis.\n\n At C5-C6, there is a broad-based disc-osteophyte bar producing moderate canal\n and moderate bilateral foraminal stenosis.\n\n At C6-C7, there is mild retrolisthesis producing moderate canal and moderate\n bilateral foraminal stenosis. There is no evidence of abnormal cord signal or\n abnormal cord enhancement.\n\n IMPRESSION: Multilevel degenerative disease as described.\n\n MRI OF THE THORACIC SPINE WITH GADOLINIUM:\n (Over)\n\n 8:34 PM\n MR W& W/O CONTRAST; MR W &W/O CONTRAST Clip # \n MR W & W/O CONTRAST\n Reason: eval for mass\n Contrast: MAGNEVIST Amt: 20\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n Paraspinal mass, more on the right than on the left, at T7-T8 is noted with\n abnormal signal within the T7 and T8 vertebral bodies and an epidural mass\n producing moderate cord compression. On the T2-weighted sequence, the signal\n is not especially bright within this lesion, and in particular, there is no\n increased signal within the disc space. The lesion does enhance with contrast\n material, as do the vertebral bodies. The disc enhances, but less so. The\n subchondral cortex appears to be somewhat preserved. There is an area within\n the enhancement in the epidural region with lesser enhancement, but this area\n does not have increased signal on the T2-weighted sequence. On the STIR\n sequence, there is some abnormal signal posteriorly at the level of the T7-T8\n paraspinous region suggesting some extension of the abnormal process into the\n posterior elements. There is no evidence of cord compromise at any additional\n level nor definite evidence of abnormal disc signal at any additional level to\n suggest the presence of disc infection.\n\n IMPRESSION: Paraspinal mass with vertebral body involvement at T7-T8. There\n is involvement of the disc, and there is an epidural mass. The features in\n general suggest that this may be a malignant process rather than an active\n infection, although granulomatous disease would be an additional\n consideration. The findings are a bit unusual for bacterial abscess, but this\n is not entirely excluded.\n\n MRI OF THE LUMBAR SPINE:\n\n There is first degree spondylolisthesis at L5-S1 with bilateral spondylosis.\n There is no evidence of focal disc protrusion. There is no evidence of a\n destructive process or disc infection in the lumbar region. There is no\n evidence of paraspinal mass or abscess. There is mild generalized disc\n bulging at L2-L3, and . There is no definite evidence of canal or\n foraminal stenosis.\n\n IMPRESSION: First degree spondylolisthesis at L5-S1. Mild disc bulging. No\n evidence of focal disc protrusion. No evidence of a destructive mass or\n abscess in the lumbar region.\n\n" }, { "category": "Radiology", "chartdate": "2100-12-17 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 938234, "text": " 8:27 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Please evaluate for interval change.\n Admitting Diagnosis: SPINAL MASS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man with spinal mass POD 1 s/p T7-T8 s/p CPR and 30 second run of\n asystole.\n REASON FOR THIS EXAMINATION:\n Please evaluate for interval change.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Spinal mass, postoperative day #1, status post 30-second asystole\n and CPR.\n\n COMPARISON: CXR, and multiple priors.\n\n FINDINGS: Portable radiograph of the chest. Spinal fusion hardware is again\n identified in similar position. The PICC line is again identified and appears\n to be unchanged in position, but the exact location of the tip is difficult to\n locate on this film. Stable moderate left-sided pleural effusion, partially\n loculated, is again identified. Persistent left lower lobe opacity\n representing atelectasis versus airspace disease is again seen. Previously\n described asymmetric edema appears relatively stable.\n\n IMPRESSION:\n 1. Persistent moderate left-sided partially loculated pleural effusion.\n Underlying empyema cannot be excluded based on these radiographic findings.\n 2. Stable appearance of asymmetric edema in left lung. Stable left\n retrocardiac density representing atelectasis versus airspace disease.\n\n\n" }, { "category": "Radiology", "chartdate": "2100-12-07 00:00:00.000", "description": "CT CHEST W/O CONTRAST", "row_id": 936955, "text": " 3:14 PM\n CT CHEST W/O CONTRAST Clip # \n Reason: please perform high res CT to evaluate nodule seen on recent\n Admitting Diagnosis: SPINAL MASS\n Contrast: OPTIRAY Amt: 65\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man with nodule at right lung base on CXR and epidural mass\n REASON FOR THIS EXAMINATION:\n please perform high res CT to evaluate nodule seen on recent CXR. ? granuloma\n vs. malignancy\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Evaluation of pulmonary nodules in a patient with\n prevertebral abscess.\n\n COMPARISON: Chest CT from .\n\n TECHNIQUE: MDCT of the chest from thoracic inlet to upper abdomen was\n obtained after injection of IV contrast with subsequent 1.25 and 5 mm\n collimation axial images reviewed.\n\n FINDINGS:\n\n There is a large paraspinal mass with destruction of the inferior one-half of\n T7 and superior endplate of T8 is again demonstrated with small epidural mass\n component, involving also the T7-T8 intervertebral disc. The multiple\n mediastinal lymph nodes are subcentimeter ranging up to 9 mm in the right\n paratracheal, 8 mm in the outer pulmonary, and 1 cm in subcarinal are. There\n is no hilar or axillary lymphadenopathy. The aorta is calcified with\n relatively thick mural plaques ranging up to 4 mm, some of them ulcerated, for\n example in the proximal distending thoracic aorta, series 2, image 26, 27; at\n the level of the aortic arch, series 2, image 21; in the distending aorta,\n series 2, image 31. The extensive mural thickening also involve the origin of\n the left subclavian and left carotid and innominate arteries.\n\n The left PICC line terminates in the superior SVC. The narrowing of left\n subclavian vein is demonstrated between the right clavicle and first rib,\n series 2, image 10, with a wide network of collaterals.\n\n The airways are patent to the level of segmental bronchi.\n\n The assessment of the lung parenchyma demonstrate mild centrilobular emphysema\n involving predominantly the upper lobes. A focal thickening of the left\n fissure is 4.3 mm in length. The bilateral pleural effusion is small with\n adjacent lung atelectasis. Additional area of focal pleural thickening is in\n the right upper lobe, series 4, image 45. No other lung nodules or masses are\n identified. The images of the upper abdomen demonstrate normal liver, spleen,\n adrenals, pancreas and kidneys. The gallbladder is markedly distended\n measuring up to 6 cm in diameter with some high-attenuation of the posterior\n portion suggesting vicarious excretion.\n\n (Over)\n\n 3:14 PM\n CT CHEST W/O CONTRAST Clip # \n Reason: please perform high res CT to evaluate nodule seen on recent\n Admitting Diagnosis: SPINAL MASS\n Contrast: OPTIRAY Amt: 65\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n IMPRESSION:\n\n Focal pleural thickening in the major fissure on the left. The most likely\n benign finding should be followed in three to six months to exclude the\n possibility of lung nodule. No other nodules or masses are demonstrated. If\n the report of the previous CT study done in the other hospital would be\n available, an addendum shall be added comparing the previously mentioned\n granuloma.\n\n\n" }, { "category": "Radiology", "chartdate": "2100-12-16 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 938190, "text": " 6:45 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: Check PICC placement for use\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man with spinal mass POD 1 s/p T7-T8 with new PICC line\n placement.\n REASON FOR THIS EXAMINATION:\n Check PICC placement for use\n ______________________________________________________________________________\n FINAL REPORT (REVISED)\n INDICATIONS: 71-year-old man with spinal mass at T7-T8, one day\n postoperative. Evaluate for PICC line placement.\n\n CHEST, SEMIUPRIGHT AP VIEW: There is spinal fusion hardware in a similar\n position. The PICC line terminates in the upper superior vena cava, about 3\n cm above the cavoatrial junction. There is persistent left lower lobe opacity\n and discoid atelectasis in the left mid lung. There is also a left-sided\n pleural effusion. There is increased asymmetric edema in the left lung since\n the prior study.\n\n IMPRESSION:\n 1. Tip of PICC line in upper superior vena cava.\n\n 2. Persistent opacities in the left lung with left effusion.\n\n 3. Evidence of asymmetric increased edema in the left lung.\n\n" }, { "category": "Radiology", "chartdate": "2100-12-17 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 938287, "text": " 1:17 PM\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \n Reason: r/o pneumothorax\n Admitting Diagnosis: SPINAL MASS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man with spinal mass and profound bradycardia, s/p placement of\n temporary screw-in pacemaker lead via right subclavian.\n REASON FOR THIS EXAMINATION:\n r/o pneumothorax\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post pacemaker placement. Rule out pneumothorax.\n\n COMPARISON: CXR, and multiple priors.\n\n FINDINGS: Portable semi-upright radiograph of the chest. The lateral left\n hemithorax is cut off on this film. Spinal fusion hardware is again\n identified and unchanged. Left-sided PICC line in the visualized in the mid\n mediastinum; however, exact location of the tip is limited due to overlying\n hardware. Single lead pacemaker overlying the right hemithorax is identified\n with its tip likely within the mid portion of the right ventricle. Left\n retrocardiac density appears unchanged. Although evaluation of the left\n hemithorax is severely limited on this film, there does appear to be increase\n in size of loculated pleural effusion. No new consolidation in the right\n lung. No pneumothorax.\n\n IMPRESSION:\n 1. Single lead pacemaker with tip of lead in mid portion of right ventricle.\n No pneumothorax.\n 2. Cannot precisely locate the tip of the left-sided PICC line. Oblique\n views may be more helpful in identifying its location.\n 3. Apparent worsening of left-sided loculated pleural effusion but limited\n evaluation on this exam. This may be better evaluated with repeat AP film.\n\n These findings were discussed with at the time of this dictation.\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2100-12-13 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 937774, "text": " 8:50 PM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p removal of chest tube from left side; eval for pneumotho\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man with spinal mass\n\n REASON FOR THIS EXAMINATION:\n s/p removal of chest tube from left side; eval for pneumothorax\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 71-year-old with spinal mass. Status post left sided chest tube\n removal.\n\n COMPARISON: Chest radiograph from and multiple priors.\n\n TECHNIQUE AND FINDINGS: Portable upright radiograph of the chest.\n\n There appears to be a new right-sided internal jugular line with its tip\n terminating in the region of the right brachiocephalic vein. A left-sided\n chest tube has been removed. New spinal orthopedic hardware has been\n positioned. No pneumothorax is identified. Left lower lobe retrocardiac\n density representing atelectasis versus airspace disease is again seen. There\n appears to be worsening of a moderate left-sided pleural effusion. No right-\n sided pleural effusion is seen. Right lung is unchanged.\n\n IMPRESSION: No pneumothorax status post removal of left-sided chest tube.\n Left bibasilar atelectasis versus airspace disease with worsening of left-\n sided moderate pleural effusion.\n\n" }, { "category": "Radiology", "chartdate": "2100-12-16 00:00:00.000", "description": "T-SPINE", "row_id": 938134, "text": " 12:41 PM\n T-SPINE Clip # \n Reason: s/p posterior fusion\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man s/p fusion\n\n REASON FOR THIS EXAMINATION:\n s/p posterior fusion\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Fusion.\n\n Three radiographs of the thoracic spine demonstrate the patient to be status\n post posterior spinal fusion and T7 and T8 corpectomy, new when compared to\n the CT exam of . No hardware loosening. A left-sided PICC line is\n present with its tip at the atriocaval junction. Pulmonary parenchyma is\n incompletely assessed given respiratory motion. Multiple staples are present\n within the midline skin of the posterior thorax.\n\n\n" }, { "category": "Radiology", "chartdate": "2100-11-30 00:00:00.000", "description": "CT T-SPINE W/O CONTRAST", "row_id": 935878, "text": " 4:44 PM\n CT T-SPINE W/O CONTRAST Clip # \n Reason: Please perform 3mm thin cuts with and without contrast\n Admitting Diagnosis: SPINAL MASS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man with worsening back pain and epidural mass at T7.\n REASON FOR THIS EXAMINATION:\n Please perform 3mm thin cuts with and without contrast\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 71-year-old man with worsening back pain and epidural mass at T7.\n\n COMPARISON: spine MRI.\n\n TECHNIQUE: Multidetector axial images of the thoracic spine were obtained\n without contrast. Coronal and sagittal reformatted images were obtained.\n\n FINDINGS: Again seen is destruction of the inferior one-half of T7 and\n superior endplate of T8 with a large associated paraspinal mass. There is a\n small epidural component as well as retropulsion of bone fragments into the\n ventral part of the spinal canal. The degree of cord compression is better\n evaluated on the previous day's MRI. Again noted is kyphotic angulation of\n the thoracic spine at this locale. No new abnormalities are identified. There\n are emphysematous changes in the lungs. Aortic calcifications are identified.\n\n IMPRESSION: Redemonstration of paraspinal and epidural mass with involvement\n of the T7 and T8 vertebral bodies as well as the T7-8 disc. The appearance is\n similar to the prior day's MRI and evaluation for the degree of cord\n compression is better evaluated on the MRI.\n\n" }, { "category": "Radiology", "chartdate": "2100-12-10 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 937340, "text": " 1:49 PM\n CHEST (PORTABLE AP) Clip # \n Reason: ?proper positioning of CT\n Admitting Diagnosis: SPINAL MASS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man with spinal mass\n\n REASON FOR THIS EXAMINATION:\n ?proper positioning of CT\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST X-RAY \n\n COMPARISON: .\n\n INDICATION: Chest tube placement.\n\n A left-sided chest tube is present, coursing superiorly along the lateral\n aspect of the left hemithorax, terminating at the left apex. Hyperlucency in\n the left lung base is suggestive of a basilar pneumothorax on nonfully upright\n chest radiograph exam. Additionally, a small apical component is present.\n\n There has been interval spinal surgery with spinal hardware in the mid\n thoracic spine. New compared to the preoperative radiograph is a sharply\n emarginated homogeneous opacity in the left apex medially, extending from the\n apex to the superior aspect of the aortic knob.\n\n Assessment of the lungs is remarkable for new discoid atelectasis in the right\n lower lung region and new ill-defined opacities along the peribronchovascular\n structures in the left hilar and lower lobe regions. Finally, there is new\n subcutaneous emphysema in the left chest wall.\n\n IMPRESSION:\n 1. Left pneumothorax with basilar and apical components, with chest tube in\n place.\n\n 2. Homogeneous well-marginated opacity medially in upper left hemithorax,\n likely pleural (loculated pleural fluid) or mediastinal (postoperative\n hematoma), and less likely lung parenchymal.\n\n 3. Peribronchiolar opacities in the left perihilar and basilar regions, which\n may represent asymmetric edema or aspiration.\n\n Findings communicated by telephone on with Dr. .\n\n\n" }, { "category": "Radiology", "chartdate": "2100-12-16 00:00:00.000", "description": "CTA CHEST W&W/O C &RECONS", "row_id": 938206, "text": " 10:36 PM\n CTA CHEST W&W/O C &RECONS Clip # \n Reason: rule out PE\n Admitting Diagnosis: SPINAL MASS\n Field of view: 40 Contrast: OPTIRAY Amt: 95\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man s/p spinal surgery with DVT in right cephalic vein now with\n shortness of breath and cp\n REASON FOR THIS EXAMINATION:\n rule out PE\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CTA OF THE CHEST\n\n INDICATION: 71-year-old male status post spinal surgery with DVT in right\n cephalic vein, now with shortness of breath and chest pain. Please evaluate\n for pulmonary embolism.\n\n COMPARISON: CT study from and MRI from .\n\n TECHNIQUE: Continuous MDCT acquired axial images were obtained from the\n thoracic inlet to the mid upper abdomen before and after the administration of\n Optiray intravenous contrast via bolus CTA protocol. Multiplanar reformatted\n images were obtained and reviewed.\n\n CTA CHEST: The heart, pericardium, and great vessels are unremarkable. There\n is no evidence of pericardial effusion. Bilateral loculated pleural effusions\n greater on the left ,are seen, with associated compressive atelectasis. There\n is no evidence of pulmonary embolism. The patient is status post thoracic\n spinal surgery, and multiple rods and screws as well as a vertebral body cage\n is seen. There is subcutaneous emphysema in the soft tissues of the right\n posterior back, most consistent with recent surgical intervention. The\n central airways are patent bilaterally. Multiple prominent mediastinal lymph\n nodes are noted, not significantly changed from previous study. The largest\n is a pretracheal node measuring 12 mm in short axis, meeting CT criteria for\n pathologic enlargement. Atherosclerotic disease with calcification is noted\n throughout the thoracic aorta, without evidence of dissection or dilatation.\n\n Osseous structures are remarkable for postoperative change in the thoracic\n spine as described above. Limited views of the upper abdomen are notable for\n a mildly distended gallbladder, but no secondary signs of cholecystitis.\n\n IMPRESSION:\n\n 1. No evidence of pulmonary embolism.\n\n 2. Bilateral predominantly leftsided loculated pleural effusions with\n associated compressive atelectasis.\n\n 3. Status post thoracic spinal surgery, with evidence of postoperative\n change, spinal hardware, and subcutaneous air.\n (Over)\n\n 10:36 PM\n CTA CHEST W&W/O C &RECONS Clip # \n Reason: rule out PE\n Admitting Diagnosis: SPINAL MASS\n Field of view: 40 Contrast: OPTIRAY Amt: 95\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n 4. Mild gallbladder distention, incompletely evaluated on this CTA of the\n chest.\n\n\n" }, { "category": "Radiology", "chartdate": "2100-12-16 00:00:00.000", "description": "T-SPINE", "row_id": 938208, "text": " 10:51 PM\n T-SPINE; -77 BY DIFFERENT PHYSICIAN # \n Reason: AP & Lateral\n Admitting Diagnosis: SPINAL MASS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man s/p thoracic fusion--eval hardware placement (s/p CPR tonight)\n REASON FOR THIS EXAMINATION:\n AP & Lateral\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: AP and lateral views of the thoracic spine.\n\n INDICATION: 70-year-old male status post thoracic fusion and CPR.\n\n FINDINGS: Study is unchanged from previous of the same date. Patient is\n status post posterior metallic spinal fusion and T7 and T8 corpectomy. No\n hardware related complications identified. Skin staples are unchanged. No\n fracture or dislocation.\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2100-12-14 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 937812, "text": " 8:47 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? PTX vs pulm edema\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man with spinal mass POD 1 s/p T7-T8 corpectomy, chest pain\n with recent CT removal\n REASON FOR THIS EXAMINATION:\n ? PTX vs pulm edema\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 71-year-old man with spinal mass, postop day 1 status post T7-T8\n carpectomy, now with chest pain after chest tube removal.\n\n COMPARISON: and .\n\n SUPINE FRONTAL CHEST: Extensive thoracic spinal hardware is in unchanged\n position. A right internal jugular central venous catheter tip overlies the\n superior vena cava. Again seen is diffusely increased opacity in the left\n hemithorax likely secondary to a layering, partially loculated pleural\n effusion, which is unchanged in size since the prior study. There is\n associated compressive atelectasis. No pneumothorax is clearly identified.\n The right lung appears clear.\n\n IMPRESSION: Essentially stable appearance of the chest since the prior study.\n Moderate left-sided pleural effusion with associated atelectasis.\n\n" }, { "category": "Radiology", "chartdate": "2100-12-14 00:00:00.000", "description": "RP UNILAT UP EXT VEINS US RIGHT PORT", "row_id": 937821, "text": " 9:27 AM\n UNILAT UP EXT VEINS US RIGHT PORT Clip # \n Reason: r/o abscessDVT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man with erythematous right extremity\n REASON FOR THIS EXAMINATION:\n r/o abscessDVT\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 71-year-old man with right extremity swelling, evaluate for abscess\n or DVT.\n\n PORTABLE RIGHT UPPER EXTREMITY VENOUS ULTRASOUND STUDY: The right internal\n jugular vein is patent. There is normal compressibility of the right\n subclavian, brachial, and basilic veins. Normal waveforms and appropriate\n directionality of flow is seen in these veins. However, there is non-\n compressibility of the right cephalic vein without flow demonstrated in it.\n Furthermore, separate from the brachial vein, in the distal right arm\n medially, there is a septated fluid collection. This measures approximately\n 1.4 x 1.4 cm in size.\n\n Findings were discussed with Dr. . Kverage on .\n\n IMPRESSION:\n 1. Right cephalic vein DVT.\n 2. Small septated collection in the medial upper arm, separate from the\n brachial vein and artery. This could represent a small abscess or a hematoma.\n Clinical correlation is recommended.\n\n" }, { "category": "Radiology", "chartdate": "2100-12-10 00:00:00.000", "description": "O T-SPINE IN O.R.", "row_id": 937315, "text": " 10:42 AM\n T-SPINE IN O.R. Clip # \n Reason: T6-9 FUSIUON, FX,\n Admitting Diagnosis: SPINAL MASS\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: Thoracic spine two, views, .\n\n HISTORY: T6 and T9 fusion for vertebral abscess.\n\n FINDINGS: There has been corpectomy and placement of an interbody cage device\n in T7-T8. There is a left lateral fusion with screws in the T6 and T9\n vertebral bodies bridging the corpectomy. The alignment is grossly preserved.\n Please refer to the operative note for further details.\n\n The tip of the endotracheal tube is in the left mainstem bronchus and there is\n hyperinflation of the left and underinflation of the right lung. This\n finding has been discussed with Dr. who has given the findings to the\n operating room staff.\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2100-12-06 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 936786, "text": " 3:22 PM\n CHEST PORT. LINE PLACEMENT; -59 DISTINCT PROCEDURAL SERVICE Clip # \n Reason: L picc\n Admitting Diagnosis: SPINAL MASS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man with spinal mass\n REASON FOR THIS EXAMINATION:\n L picc\n ______________________________________________________________________________\n FINAL REPORT\n CHEST, SINGLE AP FILM\n\n PICC line placement.\n\n Tip of the PICC line is in mid SVC. There is minimal blunting of both\n costophrenic sulci. The lungs are clear. No pneumothorax.\n\n\n" }, { "category": "Radiology", "chartdate": "2100-12-13 00:00:00.000", "description": "OP T-SPINE IN O.R. PORT", "row_id": 937769, "text": " 7:24 PM\n T-SPINE IN O.R. PORT; SPINAL FLUORO WITHOUT RADIOLOGIST IN O.R. PORTClip # \n Reason: FUSION POST THORACIC T3-10\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Fusion posterior thoracic spine T3-T10.\n\n Multiple spot views obtained intraoperatively are submitted. Comparison is\n made to prior study of .\n\n The patient had previously undergone placement of an interbody cage at T7 and\n 8. Left lateral fusion has been performed with screws in the T6 and T9\n vertebral bodies. rods have been placed during today's procedure.\n The inferior screws of the rods are within the T10 and T11\n vertebral bodies assuming that the lateral fusion screws were in the T6 and T9\n vertebral bodies. The cephalad location of the hooks of the rod\n appear at the T5, T4 and likely T2 levels. Exact location of the hardware is\n somewhat limited due to the lack of availability of a complete AP and lateral\n view of the thoracic spine.\n\n IMPRESSION: Intraoperative hardware as described above.\n\n\n" }, { "category": "Radiology", "chartdate": "2100-12-24 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 939213, "text": " 1:04 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: Pt had a left sided picc line placed and needs tip confirmat\n Admitting Diagnosis: SPINAL MASS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man with spinal mass who needs picc for IV antibiotics.\n REASON FOR THIS EXAMINATION:\n Pt had a left sided picc line placed and needs tip confirmation please page\n at with wet read,thanks.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 71-year-old with spinal mass post-PICC placement, assess\n position.\n\n Portable semiupright frontal radiograph. Comparison .\n\n There is a new left-sided PICC which is malpositioned with its tip going into\n the left internal jugular vein, and off the edge of the film. A right-sided\n IJ central venous catheter remains in place. Bilateral pleural effusions and\n atelectasis/consolidation in the left retrocardiac region with obscuration of\n the hemidiaphragm are unchanged. There has been no other change in the\n appearance of the lung fields.\n\n\n" }, { "category": "Radiology", "chartdate": "2101-01-01 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 940209, "text": " 10:41 AM\n CHEST (PA & LAT) Clip # \n Reason: Lead placement\n Admitting Diagnosis: SPINAL MASS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man with spinal mass and profound bradycardia, s/p placement of\n permanent pacemaker leads via right subclavian \n REASON FOR THIS EXAMINATION:\n Lead placement\n ______________________________________________________________________________\n FINAL REPORT\n AP AND LATERAL CHEST ON .\n\n HISTORY: Spinal mass and bradycardia. Placed pacemaker leads.\n\n IMPRESSION: PA and lateral chest compared to :\n\n Transvenous right atrial and right ventricular pacemaker leads are continuous\n from the left axillary pacemaker. Small bilateral pleural effusions are\n slightly larger today. There is no pneumothorax. Heart size normal although\n shifted to the left by virtue of worsening left lower lobe atelectasis. Spinal\n stabilization hardware grossly unchanged in position.\n\n" }, { "category": "Radiology", "chartdate": "2100-12-22 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 938878, "text": " 11:27 AM\n CHEST (PORTABLE AP) Clip # \n Reason: R/o infiltrate, assess progression of pleural effusions.\n Admitting Diagnosis: SPINAL MASS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man with spinal mass and profound bradycardia, w/ temp pacer now\n s/p RIJ TLC placement, falling hematocrit.\n REASON FOR THIS EXAMINATION:\n R/o infiltrate, assess progression of pleural effusions.\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 11:38 A.M, .\n\n HISTORY: Spinal mass and bradycardia.\n\n COMPARISON: AP chest compared to and 4:\n\n Small-to-moderate left pleural effusion has decreased in volume. Small right\n pleural effusion unchanged. Mild left basal atelectasis unchanged. Mild\n pulmonary vascular congestion is stable. The heart is normal size.\n Mediastinum is stable. Tip of the transsubclavian right ventricular pacer\n lead unchanged in position. Tip of the right jugular line projects over the\n upper SVC. No pneumothorax.\n\n\n" }, { "category": "Radiology", "chartdate": "2100-12-24 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 939260, "text": " 6:34 PM\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \n Reason: please assess for pICC line placement\n Admitting Diagnosis: SPINAL MASS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man with spinal mass who needs picc for IV antibiotics and\n PICC was repositioned by radiology this afternoon.\n REASON FOR THIS EXAMINATION:\n please assess for pICC line placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 71-year-old man with spinal mass who needs PICC for IV\n antibiotics, and PICC was repositioned by Radiology this afternoon. Please\n assess for PICC line placement.\n\n COMPARISON: Five hours prior.\n\n SINGLE PORTABLE UPRIGHT CHEST RADIOGRAPH:\n\n The new position of the PICC line catheter is with tip overlying the mid SVC\n in the appropriate position. A right-sided internal jugular vein catheter has\n tip overlying the junction of the right brachiocephalic vein and SVC. The\n spinal hardware and lung fields are stable. There is no evidence of\n pneumothorax.\n\n IMPRESSION:\n\n PICC line catheter tip in appropriate position overlying the mid SVC.\n\n\n" } ]

[ { "category": "Radiology", "chartdate": "2145-02-12 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1176403, "text": " 10:01 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: Please eval for interval changes\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 22 year old woman with tbi and VPS\n REASON FOR THIS EXAMINATION:\n Please eval for interval changes\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n EXAM: CT of the head.\n\n CLINICAL INFORMATION: Patient with traumatic brain injury and VPS\n TECHNIQUE: Axial images of the head were obtained without contrast and\n compared with the prior CT of and .\n\n FINDINGS: Since the previous study, the swelling of the right cerebral\n hemisphere protruding through the craniectomy defect has decreased. There is\n encephalomalacia in the right temporal lobe. A Left-sided extra-axial\n hypodense fluid collection is again identified from frontal to parietal region\n with maximum width of 1.8 cm, slightly decreased from previous study. The\n ventricular size has decreased except for right temporal , which\n demonstrates ex vacuo dilatation. There is a left frontal\n ventriculoperitoneal shunt identified with the tip in the region of foramen of\n . No acute hemorrhage is identified.\n\n IMPRESSION: Since the previous study of , the right cerebral\n hemispheric swelling has decreased. Encephalomalacia in the right cerebral\n hemisphere again noted. The left-sided extra-axial collection has slightly\n decreased, but still measures 1.8 cm. The ventricular size has decreased. No\n new hemorrhage seen.\n\n" }, { "category": "Radiology", "chartdate": "2145-02-12 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1176490, "text": " 5:28 PM\n CT HEAD W/O CONTRAST; -76 BY SAME PHYSICIAN # \n Reason: Eval for post-op changes within 4 hrs\n Admitting Diagnosis: SUBDURAL HEMATOMA/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 23 year old woman with hx of TBI s/p craniectomy in , now s/p cranioplasty\n REASON FOR THIS EXAMINATION:\n Eval for post-op changes within 4 hrs\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: IPf 6:11 PM\n S/p cranioplasty with small foci of hemorrhage and pneumocephalus along right\n hemisphere.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 23-year-old woman with history of traumatic the brain injury and\n status post craniectomy in , now status post cranioplasty.\n\n TECHNIQUE: Contiguous axial images were obtained through the brain. No\n intravenous contrast was administrated.\n\n COMPARISON: CT head, at 10:26 a.m.\n\n FINDINGS: There is interval right cranioplasty, with post-surgical foci of\n pneumocephalus and a few hyperdense foci of blood products along the right\n parietal lobe (2:17 and 2:20, 21, 22). There is reexpansion of the right\n hemisphere along the new cranioplasty. There is stable encephalomalacia in\n the right temporal lobe. There is stable left-sided hypodense extra-axial\n fluid collection with maximum width of 1.8 cm. There is a stable appearance\n of the ventricles with ex vacuo dilatation of the right temporal . There\n is a VP shunt in place with tip at the third ventricle in region of the\n foramen of .\n\n There is no large acute hemorrhage or large acute territorial infarction.\n There is stable mild shift of midline structures. There is no hydrocephalus.\n There is mucosal thickening in the ethmoid air cells, and sphenoid sinus. The\n mastoid air cells are well pneumatized. There is no free fluid in the middle\n ear cavity bilaterally.\n\n IMPRESSION:\n\n 1. Status post interval cranioplasty with post-surgical changes along right\n convexity.\n\n 2. No large acute hemorrhage.\n\n 3. Stable encephalomalacia in the right temporal lobe and stable left-sided\n hypodense extra-axial fluid collection.\n\n 4. Similar ventricular size and configuration. No interval hydrocephalus.\n VP shunt in unchanged position.\n (Over)\n\n 5:28 PM\n CT HEAD W/O CONTRAST; -76 BY SAME PHYSICIAN # \n Reason: Eval for post-op changes within 4 hrs\n Admitting Diagnosis: SUBDURAL HEMATOMA/SDA\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2145-02-14 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1176681, "text": " 12:52 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: Post cranioplasty\n Admitting Diagnosis: SUBDURAL HEMATOMA/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 23 year old woman with elective cranioplasty, must eval\n REASON FOR THIS EXAMINATION:\n Post cranioplasty\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: ENYa SUN 2:08 PM\n 1. Interval decrease of the left frontal extra-axial hypodense collection. 3\n mm rightward shift, compared to 5 mm two days ago.\n 2. Otherwise, no signficant changes from the study two days ago. No new foci\n of hemorrhage.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 23-year-old woman, with elective cranioplasty on ,\n now assess for interval changes.\n\n COMPARISON: Multiple prior studies with the latest dated on .\n\n TECHNIQUE: Non-contrast CT images were acquired through the brain.\n\n FINDINGS: There is interval decrease of the left frontal hypodense\n extra-axial collection, with now 9-mm maximum thickness compared to 12-mm two\n days ago. There is a correspondent decreased mass effect, with a 3-mm\n rightward shift compared to 5-mm previously. The ventriculostomy drain with\n left transfrontal approach remains unchanged in position, terminating in the\n third ventricle. There is stable encephalomalacia in the right temporal lobe,\n with scattered pockets of pneumocephalus and small amoutn of subarachnoid\n hemorrhage layering along the sulci, unchanged.\n\n There is no evidence of new hemorrhage or infarction. No developing\n hydrocephalus is noted. No intraventricular hemorrhagic extension is seen.\n Aside from a small opacification in the right sphenoid sinus, the visualized\n paranasal sinuses are clear. The mastoid air cells are clear.\n\n The known bilateral Le Fort fractures are incompletely assessed in this study,\n but grossly similar in appearance.\n\n IMPRESSION:\n 1. Interval decrease of the left frontal hypodense extra-axial fluid\n collection, with mild decrease of mass effect as described above.\n 2. Otherwise, essentially unchanged postoperative and post-traumatic\n appearance from two days ago. No new foci of hemorrhage. No developing\n hydrocephalus.\n\n (Over)\n\n 12:52 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: Post cranioplasty\n Admitting Diagnosis: SUBDURAL HEMATOMA/SDA\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" } ]

[ { "category": "Radiology", "chartdate": "2129-12-13 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 813195, "text": " 9:18 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please eval effusions prior to ct removal\n Admitting Diagnosis: CONGESTIVE HEART FAILURE;CORONARY ARTERY DISEASE\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old man with CAD, cardiogenic shock, pre CABG.IABP in place. Now\n s/p CABG/MV repair.\n REASON FOR THIS EXAMINATION:\n please eval effusions prior to ct removal\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST: Compared to previous study of one day earlier.\n\n CLINICAL INDICATION: Cardiogenic shock.\n\n Comparison is made to previous chest radiograph dated one day earlier.\n\n An intra-aortic balloon pump remains in place with the tip terminating\n approximately 5.2 cm below the superior aspect of the aortic knob. A Swan-\n Ganz catheter terminates at the junction of the main and right pulmonary\n artery. Mediastinal drain remains in place as well as the left-sided chest\n tube. The cardiac and mediastinal contours are stable. There is persistent\n vascular engorgement and perihilar haziness with interval increase in degree\n of haziness as well as increased interstitial opacities within the lung\n parenchyma. There is a persistent moderate to large layering left pleural\n effusion with adjacent left retrocardiac opacity.\n\n IMPRESSION:\n\n 1) Intra-aortic balloon pump terminates slightly greater than 5 cm below the\n superior aspect of the aortic knob.\n\n 2) Worsening congestive heart failure pattern.\n\n 3) Persistent moderate to large left pleural effusion with adjacent\n atelectasis.\n\n" }, { "category": "Radiology", "chartdate": "2129-12-07 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 812581, "text": " 5:34 PM\n CHEST (PORTABLE AP) Clip # \n Reason: ?infiltrate, CHF\n Admitting Diagnosis: CONGESTIVE HEART FAILURE;CORONARY ARTERY DISEASE\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old man with CAD, cardiogenic shock, pre CABG.IABP in place\n REASON FOR THIS EXAMINATION:\n ?infiltrate, CHF\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Cardiogenic shock. Intra-aortic balloon pump in place.\n\n CHEST AP PORTABLE: The heart is slightly enlarged. Hilar and mediastinal\n contours appear stable. There is an intra-aortic balloon pump noted, with the\n distal tip about 1.7 cm below the aortic arch. Also noted is a femoral placed\n central line, with the tip in the main pulmonary trunk. The pulmonary\n vascularity appears prominent, with left lower lobe collapse/consolidation\n noted. Visualized osseous structures appear unremarkable.\n\n IMPRESSION: Findings are consistent with mild CHF. The distal tip of the\n intra-aortic balloon pump is less than 2 cm below the aortic arch.\n\n" }, { "category": "Radiology", "chartdate": "2129-12-09 00:00:00.000", "description": "ABDOMEN U.S. (PORTABLE)", "row_id": 812743, "text": " 8:07 AM\n ABDOMEN U.S. (PORTABLE) Clip # \n Reason: please evaluate for abdominal aortic aneurysm\n Admitting Diagnosis: CONGESTIVE HEART FAILURE;CORONARY ARTERY DISEASE\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67yo male with HTN, acute MI, cardiogenic shock, now with IABP, going for CABG\n in am.\n REASON FOR THIS EXAMINATION:\n please evaluate for abdominal aortic aneurysm\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 67 year old male with an intraaortic balloon pump following\n myocardial infarction. Evaluate for abdominal aortic aneurysm.\n\n FINDINGS: The liver is normal in echo texture without intrahepatic mass or\n ductal dilatation. The gallbladder contains sludge and multiple small stones,\n however there is no gallbladder wall thickening or pericholecystic fluid. The\n common bile duct measures less than 3 mm in maximum dimension. The right\n kidney measures 10 cm in length without hydronephrosis or mass. Hepatopetal\n flow is present. The spleen measures 9.7 cm in length and is normal in\n appearance. The left kidney measures 10.3 cm in length and is free of\n hydronephrosis. There is a 2 cm, rounded, slightly hyperechoic region in the\n midpole of the left kidney. This does not appear to be associated with\n increased vascular flow.\n\n The abdominal aorta contains an intraaortic balloon pump in the proximal\n portion and there is some resultant artifact. The abdominal aorta measures\n approximately 2.2 cm in maximum dimension proximally and contains no\n aneurysmal dilatation. There is extensive atherosclerotic disease. The\n origins of both renal arteries are visualized and are patent. The left and\n right common iliac arteries are also normal in size. There is no free fluid\n in the abdomen.\n\n IMPRESSION:\n\n 1. No evidence of abdominal aortic aneurysm in this patient with diffuse\n atherosclerotic disease.\n\n 2. The left kidney contains a 2 cm, rounded, slightly hyperechoic structure\n in the midpole. This could represent a small lesion vs. a pseudolesion, and a\n repeat ultrasound in six months is recommended for followup.\n\n" }, { "category": "Radiology", "chartdate": "2129-12-15 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 813438, "text": " 7:59 AM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p CABG-evaluate effusion\n Admitting Diagnosis: CONGESTIVE HEART FAILURE;CORONARY ARTERY DISEASE\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old man with CAD, cardiogenic shock, pre CABG.IABP in place. Now\n s/p CABG/MV repair.\n REASON FOR THIS EXAMINATION:\n s/p CABG-evaluate effusion\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 67 y/o man status post CABG. Evaluate pleural effusion.\n\n COMPARISONS: \n\n AP SEMI UPRIGHT CHEST RADIOGRAPH:\n There has been interval removal of the mediastinal drains and intra aortic\n balloon pump. The swan ganz catheter appears to terminate in the right\n pulmonary artery.\n\n There are again noted changes status post CABG with sternal wires and multiple\n surgical clips in the mediastinum. There is persistent vascular\n engorgement and hilar haziness. However, this is likely decreased compared to\n the previous study. There is a persistent moderate large layering left\n pleural effusion with adjacent retrocardiac opacity. This is minimally\n increased in size compared to the previous study.\n\n IMPRESSION:\n\n 1) Slight improvement in the heart failure pattern.\n 2) Persistent moderate to large pleural effusion with adjacent atelectasis.\n 3) Interval removal of intra aortic balloon pump and tubes as described above.\n\n" }, { "category": "Radiology", "chartdate": "2129-12-09 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 812833, "text": " 9:34 PM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o PTX/effusion/tamponade. Pt still in OR. PLease perform\n Admitting Diagnosis: CONGESTIVE HEART FAILURE;CORONARY ARTERY DISEASE\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old man with CAD, cardiogenic shock, pre CABG.IABP in place. Now s/p\n CABG/MV repair.\n REASON FOR THIS EXAMINATION:\n r/o PTX/effusion/tamponade. Pt still in OR. PLease perform CXR when pt\n arrives CSRU.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Check lines and tubes and evaluate for pneumothorax. Status post\n CABG and mitral valve repair.\n\n PORTABLE CHEST: Supine view is compared to . An endotracheal tube\n appears in good position with the tip 5.5 cm above the carina. The nasogastric\n tube courses below the view of the image. The tip of the swan ganz catheter\n is in the main pulmonary artery. The tip of the intra aortic balloon pump\n projects at the superior margin of the left 7th rib. The cardiac silhouette\n is within normal limits post surgery. There is minor atelectasis in the left\n lower lobe and mild pulmonary edema bilaterally. A thoracostomy tube projects\n over the left lung base. No pneumothorax or significant effusion is seen.\n\n IMPRESSION: Placement of lines and tubes and post surgical findings as\n described above. No pneumothorax.\n\n" }, { "category": "Radiology", "chartdate": "2129-12-22 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 814280, "text": " 3:58 PM\n CHEST (PA & LAT) Clip # \n Reason: r/o chf\n Admitting Diagnosis: CONGESTIVE HEART FAILURE;CORONARY ARTERY DISEASE\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old man with\n REASON FOR THIS EXAMINATION:\n r/o chf\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 67 y/o male with shortness of breath. R/O CHF.\n\n COMPARISON: .\n\n The most recent comparisons are not available due to PACS problem.\n\n CHEST PA & LATERAL VIEWS:\n\n There are postoperative changes of CABG with sternal wires and mediastinal\n clips. The heart is borderline in size. Pulmonary vascularity is within normal\n limits. There is no evidence of overt CHF. There is a large left pleural\n effusion with associated atelectasis of the left base. Otherwise, lung fields\n are clear.\n\n IMPRESSION:\n Large left pleural effusion with associated atelectasis.\n\n" }, { "category": "Radiology", "chartdate": "2129-12-07 00:00:00.000", "description": "P CAROTID SERIES COMPLETE PORT", "row_id": 812546, "text": " 2:00 PM\n CAROTID SERIES COMPLETE PORT Clip # \n Reason: HX CAROTID STENOSIS, PREOP CABG\n Admitting Diagnosis: CONGESTIVE HEART FAILURE;CORONARY ARTERY DISEASE\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old man with CAD, Pt. w/IABP, must be portable please\n REASON FOR THIS EXAMINATION:\n r/o stenosis, pre-op CABG\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Pre-operative evaluation before CABG in a 67-year-old man with\n coronary artery disease.\n\n COMPARISON: None available.\n\n TECHNIQUE AND FINDINGS: Duplex ultrasound evaluation was performed at the\n level of the cervical portions of the bilateral carotid and vertebral\n arteries. The intra-aortic balloon pressure pump (IABP) was switched from a\n 1:1 ratio to a 2:1 ratio temporarily so as to allow correct velocity\n measurements intermittently.\n\n Moderate plaque was seen at the origins of the bilateral internal and external\n carotid arteries. On the right side, the velocities in the internal, common\n and external carotid arteries were 197/46, 37/17, and 197 cm per second,\n respectively. This gives a peak systolic velocity ratio of 5.32 between the\n right internal and right common carotid arteries. On the left side, the\n velocities were 152/57, 57/13 and 112 cm per second in the left internal,\n common and external carotid arteries. This gives a peak systolic velocity\n ratio of 2.66 between the left internal and common carotid arteries.\n\n There was antegrade flow in the bilateral vertebral arteries.\n\n CONCLUSION:\n 1. Carotid evaluation performed while patient was on IABP at a 2:1 ratio.\n This showed stenoses evaluated between 60 and 69% in diameter reduction in the\n right and left internal carotid arteries.\n 2. Antegrade flow in the bilateral vertebral arteries.\n\n Dr. assisted in this procedure.\n\n" }, { "category": "Radiology", "chartdate": "2129-12-10 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 812863, "text": " 9:19 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please eval for effusion\n Admitting Diagnosis: CONGESTIVE HEART FAILURE;CORONARY ARTERY DISEASE\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old man with CAD, cardiogenic shock, pre CABG.IABP in place. Now s/p\n CABG/MV repair.\n REASON FOR THIS EXAMINATION:\n please eval for effusion\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 67 y/o man status post CABG and mitral valve repair. Evaluate for\n effusion.\n\n AP SUPINE PORTABLE CHEST at 10 A.M.\n\n Since prior study last nite, there appears to be a decrease in the size of the\n left pleural effusion. There is still left retrocardiac opacity which most\n likely reflects postoperative changes. The rest of the visualized lung fields\n are clear.\n\n IMPRESSION: Decreased left pleural effusion. Postoperative changes in the\n retrocardiac region. No acute infiltrate or failure seen.\n\n" }, { "category": "Radiology", "chartdate": "2129-12-09 00:00:00.000", "description": "P ART EXT SGL LEVEL PORT", "row_id": 812771, "text": " 10:42 AM\n ART EXT SGL LEVEL PORT Clip # \n Reason: evidence of PVD\n Admitting Diagnosis: CONGESTIVE HEART FAILURE;CORONARY ARTERY DISEASE\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old man with HTN, acute MI, cardiogenic shock, now on IABP, for CABG\n tomorrow.\n REASON FOR THIS EXAMINATION:\n evidence of PVD\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 67 year old male with hypertension, acute myocardial infarction,\n cardiogenic shock, pre-operative coronary artery bypass grafting. The patient\n is currently on an intraaortic balloon pump.\n\n The intraaortic balloon pump has been placed via the right common femoral\n artery, and the study is limited due to its presence.\n\n The right ankle-brachial index measures 0.41 and the left measures 0.74. Pulse\n volume recordings demonstrate significant dampening of the amplitude on the\n right (calf 5 mm, ankle 5 mm), which is most likely at least partially due to\n the presence of the balloon pump. On the left, amplitude measures 17 and 26\n mm at the calf and ankle, respectively.\n\n The segmental pressure waveforms on the left appear to have an upside-down\n normal pattern, again which may be due to the presence of the balloon pump. On\n the right, the waveforms are dampened and widened, suggesting the presence of\n significant disease.\n\n Given the medical history, as well as the findings on this study,\n bilateral superficial femoral arterial disease, right greater than left, is\n most likely present. This could be confirmed with magnetic resonance\n angiography or catheter angiography, if indicated.\n\n IMPRESSION: Limited study due to the presence of a right common femoral\n intraaortic balloon pump. Findings suggest the presence of bilateral\n superficial femoral artery disease, right greater than left.\n\n\n" }, { "category": "Radiology", "chartdate": "2129-12-23 00:00:00.000", "description": "CHEST (LAT DECUB ONLY)", "row_id": 814333, "text": " 10:22 AM\n CHEST (LAT DECUB ONLY) Clip # \n Reason: monitor effusion\n Admitting Diagnosis: CONGESTIVE HEART FAILURE;CORONARY ARTERY DISEASE\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old man with\n REASON FOR THIS EXAMINATION:\n monitor effusion\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Cardiogenic shock. Assess left effusion.\n\n This examination consists of 2 left lateral decubitus films. The moderate\n sized left effusion layers on this radiograph. There is probable atelectasis\n and possible associated loculated effusion in the obscured left lower thorax.\n No evidence of right effusion and right lung clear. Previous CABG.\n\n IMPRESSION: Predominantly non-loculated left effusion.\n\n" }, { "category": "Radiology", "chartdate": "2129-12-12 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 813055, "text": " 8:45 AM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o effusion\n Admitting Diagnosis: CONGESTIVE HEART FAILURE;CORONARY ARTERY DISEASE\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old man with CAD, cardiogenic shock, pre CABG.IABP in place. Now\n s/p CABG/MV repair.\n REASON FOR THIS EXAMINATION:\n r/o effusion\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Coronary artery disease, cardiogenic shock. Now has had CABG and\n MV repair surgery. Rule out effusion, check current status.\n\n FINDINGS: A single AP semi-upright view. Comparison study dated . Status post CABG and mitral valve replacement surgery noted. The heart\n shows moderate LV enlargement. There is slight residual upper zone\n redistribution, consistent with slight left heart failure. is worsening\n left lower lobe collapse/consolidation and increasing left pleural effusion\n since a prior study. The left diaphragm is further elevated. The ET tube has\n been removed. The SG catheter tip remains well positioned in the right\n pulmonary artery. A left chest tube remains positioned at the left base. An\n interaortic balloon pump is noted with its tip overlying the left \n interspace posteriorly.\n\n IMPRESSION:\n\n 1. Worsening left lower lobe and lingular atelectasis, associated with\n increasing left pleural effusion. Appearance is otherwise not significantly\n changed.\n\n" }, { "category": "Echo", "chartdate": "2129-12-07 00:00:00.000", "description": "Report", "row_id": 76571, "text": "PATIENT/TEST INFORMATION:\nIndication: Coronary artery disease. Preoperative assessment. Patient on IABP.\nHeight: (in) 71\nWeight (lb): 150\nBSA (m2): 1.87 m2\nBP (mm Hg): 152/83\nHR (bpm): 103\nStatus: Inpatient\nDate/Time: at 15:45\nTest: Portable TTE (Complete)\nDoppler: Complete pulse and color flow\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nPatient receiving IABP support during this study.\nLEFT ATRIUM: The left atrium is moderately 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: Overall left ventricular systolic function is severely\ndepressed.\n\nRIGHT VENTRICLE: The right ventricular cavity is mildly dilated. Right\nventricular systolic function appears depressed.\n\nAORTA: The aortic root is normal in diameter.\n\nAORTIC VALVE: The aortic valve leaflets are mildly thickened. Trace aortic\nregurgitation is seen.\n\nMITRAL VALVE: Moderate (2+) mitral regurgitation is seen.\n\nTRICUSPID VALVE: The tricuspid valve leaflets are mildly thickened. Mild\ntricuspid [1+] regurgitation is seen. There is borderline pulmonary artery\nsystolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: The pulmonic valve leaflets appear\nstructurally normal.\n\nPERICARDIUM: There is no pericardial effusion.\n\nGENERAL COMMENTS: A left pleural effusion is present.\n\nConclusions:\nThe left atrium is moderately dilated. Overall left ventricular systolic\nfunction is severely depressed. The right ventricular cavity is mildly\ndilated. Right ventricular systolic function appears depressed. The aortic\nvalve leaflets are mildly thickened. Trace aortic regurgitation is seen.\nModerate (2+) mitral regurgitation is seen. The tricuspid valve leaflets are\nmildly thickened. There is borderline pulmonary artery systolic hypertension.\nThere is no pericardial effusion.\n\n\n" }, { "category": "ECG", "chartdate": "2129-12-10 00:00:00.000", "description": "Report", "row_id": 196192, "text": "Sinus rhythm\nPossible old anteroseptal myocardial infarction\nLateral T wave changes may be due to myocardial ischemia\nThese lateral T wave changes are more pronounced than previous\n\n" }, { "category": "ECG", "chartdate": "2129-12-07 00:00:00.000", "description": "Report", "row_id": 196193, "text": "Sinus tachycardia with ventricular premature beats. Borderline right axis\ndeviation. Consider inferior myocardial infarction, age indeterminate. Poor\nR wave progression - is non-specific. Consider left ventricular hypertrophy.\nDiffuse ST-T wave abnormalities - could be due in part, to left ventricular\nhypertrophy but cannot exclude in part, ischemia. Clinical correlation is\nsuggested. No previous tracing available for comparison.\n\n" }, { "category": "Nursing/other", "chartdate": "2129-12-15 00:00:00.000", "description": "Report", "row_id": 1462926, "text": "7a-3p\nUpdate\n\nNEURO: Alert and oriented. MAE and follows commands. Received Percocet early this AM and having c/o feeling \"stupid\". No further c/o pain this shift. OOB to chair, some c/o dizziness.\n\nRESP: LS clear with dim bases. O2 sats 96-99%. Svo2 decrease to high 30's when ambulating OOB to chair. Returned to baseline after 10-15min. Chest xray this AM.\n\nCV: NSR, no ectopy noted. HR 70-80's. CCO swan in place. SVO2 decrease whrn ambulating team aware. CI>2.0. Epi gtt dc'd by this AM as ordered bu team. Continues on Milrinone gtt. SBP 105-115. Continues on PO Captopril (dose changed today) and Imdur.\n\nENDO: No coverage needed.\n\nGI/GU: BS+4. Abd soft. Tolerating po's, needs encouragement. C/O N/V after ambulating into chair, Zofran given x1 with good relief. Diuresing well from tid lasix. No BM this shift.\n\nPLAN: Awaiting heart failure team. ?dc CCO swan. Continues milrinone gtt. Monitor labs. Increase diet and activity as tolerated.\n\n" }, { "category": "Nursing/other", "chartdate": "2129-12-15 00:00:00.000", "description": "Report", "row_id": 1462927, "text": "NEURO: INTACT.\n\nCARDIAC: MP SR WITHOUT. SB/P DOWN AFTER PO CAPTOPRIEL AT 2200. CCO IN PLACE, RECALIBRATED. MILRANONE GTT CONTINUES.\n\nRESP: CS DIMINISHED IN BASES, DOING SPIROCARE WELL, STRONG PRODUCTIVE COUGH.\n\nGI: STATES THAT HE HAS POOR APPETITE ESP AFTER TAKING PERCOCET THIS AM.\n\nGU: FOLEY IN PLACE, ADEQUATE AMTS URINE.\n\nENDO: FOLLOWING PROTOCOL, TX AT .\n\nNO INTERACTION WITH FAMILY.\n" }, { "category": "Nursing/other", "chartdate": "2129-12-19 00:00:00.000", "description": "Report", "row_id": 1462935, "text": "7a-7p\nCV: NSR, rare PVCs. AFebrile. BP stable. A/V pacing wires, protected and secured to chest. Milrinone continues at .2mcg/kg/min per Dr. .\n\nPULM: Weaned O2 to off. Sats 97-100%. Strong cough, rarely raises clear, thin sputum. Lungs clear.\n\nNEURO: Alert, oriented. OOB to chair for several hours and ambulated twice, once with PT. Wife at bedside visiting. Denies pain except right leg pain while walking. Encouraged pt to take some form of pain meds before activity.\n\nGU: Foley, marginal UOP but pt negative for stay in ICU.\n\nGI: Active bowel sounds. Ate 75% of breakfast, 25% of lunch, eating dinner now with a better appetite. No BM today.\n\nSKIN: Incisions . Slight rash healing on back. Cordis d/c'd. Pt has two PIV.\n\nPLAN: Continue to slowly wean milrinone. Increase activity as tolerated by pt.\n" }, { "category": "Nursing/other", "chartdate": "2129-12-13 00:00:00.000", "description": "Report", "row_id": 1462920, "text": "CSRU NPN\n\nNeuro: Alert and oriented x 3. MAE with equal strength.\n\nCV: HR stable with rare PVC's. Milrinone, epi, and amiodarone cont without changes. MVO2's initially in high 50's but have since been in 60's during night with CI's > 2. IABP remains at 1:1 with good systolic and diastolic unloading. Site without hematoma. Able to locate right DP on more proximal area of right foot. Right toes slightly cool but with adequate cap refill. Hct stable. PLT's up to 83 from 73. Lytes repleted prn. CT's with minimal dng.\n\nResp: BS clear but diminished at lower lobes bilat. Needs encouragement to use IS which he can move 750cc with. Cough productive small yellow secretions.\n\nGi: Abd soft, BS noted. Denies nausea. Taking pills crushed in custard.\n\nGU: u/o dropping down to 15cc x 1 hr. Lasix dose given with good diuresis.\n\nEndo: SSRI per protocol.\n\nID: Afebrile.\n\nSkin: Buttocks reddened earlier on but much improved after lying on side. Sternal and leg incisions OTA, no dng.\n\nActivity/Comfort: Pt denying pain until attempted to cough-> pain score with coughing. Percocet given with some improvement after 2nd tablet. Sleeping x several hours during night.\n\nA: Improved MVO2's. CI stable. Right DP by doppler. Needs to do pulmonary hygiene more independently.\n\nP: Maintain gtts and IABP and wean per team. Monitor right leg perfusion. Pulmonary hygiene. Diuresis. Insulin protocol. Encourage use of pain med to allow for increased participation in coughing and deep breathing.\n" }, { "category": "Nursing/other", "chartdate": "2129-12-16 00:00:00.000", "description": "Report", "row_id": 1462928, "text": "Nursing Progress Note\n 2345->0745\n\nS/O\n\nNEURO: A&O x3. Denies pain of any kind. No issues overnoc.\n\nCV: NSR, SBP and PA pressures WNL. Captoril 12.5mg given @07:00a.m. with SBP 108. Pulses dopplerable, as noted in CareVue; right DP audible; pt states this pulse is typically absent -> distal portion occluded and pulse remained audible and steady.\n\nRESP: LS diminished at rest, clear to bases with DB.\n\nGI: BS positive; no nausea, no vomiting, no BM.\n\nFEN: BS 80's-100's overnoc without issue or intervention. KVO IVF off for CVP monitoring.\n\nGU: U/O qs via foley. Please refer to CareVue for details.\n\nHAEM: No current issues.\n\nID: Afebrile. NO current issues.\n\nA/P\n\nContinue interventions to promote cardiac wellness.\nTransfer pt out of PACU ASAP to promote restful sleep and privacy.\n" }, { "category": "Nursing/other", "chartdate": "2129-12-16 00:00:00.000", "description": "Report", "row_id": 1462929, "text": "A+Ox3, pleasant, cooperative. Denies pain. VSS. Aline at times positional. NBP wnl. Tolerating Captopril 12.5mg. Remains on .5 milrinone. D/c'd swann as ordered. Lungs are clear. L base diminished. SPO2>95% 2L. Low uop. See Careview. +Bs. Tolerating solids. Ate 75% breakfast. No c/o n/v. Ambulated w/ PT. Did well. See PT note. OOto chair w/o difficulty. A/P Stable. ? Attempt to wean milrinone. Increase activity as tol. Continue care as planned.\n" }, { "category": "Nursing/other", "chartdate": "2129-12-17 00:00:00.000", "description": "Report", "row_id": 1462930, "text": "Shift Note\nNeurologically pt is intact, MAE to command. Hemodynamically, milrinone continues. Lungs are CTA but diminished, encouraged to cough and deep breathe and to use the IS. U/O qs. See flowsheet for details.\n" }, { "category": "Nursing/other", "chartdate": "2129-12-20 00:00:00.000", "description": "Report", "row_id": 1462936, "text": "RN progress note\nNeuro: intact; slept poorly despite ativan @ HS.\n\nCV: NSR, no ectopy. Milrinone remains at 0.2mg\n\nPulm: BS CTAb; CDB, IS well w/ scant white secretions. RA sats > 95%\n\nGI: tol diet and fluids. No BM\n\nGU: UOP adequate, concentrated. F/C remains in place, POD 10\n\nMS/derm: wounds healed, C/D. Right leg remains swollen. Pacing wires in place, POD 10\n\nLabs: essentially WNL w/ cont rising platelets (600).\n\nP: wean and D/C milrinone; d/c F/C and pacing wires. rehab and D/C teaching. F/U platelets\n" }, { "category": "Nursing/other", "chartdate": "2129-12-20 00:00:00.000", "description": "Report", "row_id": 1462937, "text": "UPDATE\nCV: STABLE NSR AND BP. CONT ON CAPTOPRIL. MILRINONE @ .1MCG/KG/MIN. EPICARDIAL WIRES D/C'D THIS A.M. NO COMPLICS.\n\nRESP: DIMINISHED BS BILAT. I.S. ENCOURAGED. SPO2 HIGH 90'S ON RA.\n\nNEURO: PLEASANT BUT EAGER TO GET HOME. STATES R LEG INCISION STILL TENDER BUT OTHERWISE DENTIES PAIN AND STATES NO NEED FOR PAIN MED.\n\nG.I.: TAKING ADEQ PO'S. DOESN'T LIKE HOSPITAL FOOD TOO WELL. AWAITING FOR SOME HOME COOKED FOOD TO BE BROUGHT IN BY FAMILY. NO B.M. TODAY.\n\nG.U./RENAL: FOLEY D/C'D. HAS VOIDED X 1 SINCE SO FAR. LYTES WNL.\n\nACTIVITY: OOB TO CHAIR THIS A.M. AMBULATED LOOP AROUND UNIT PLUS LENGTH OF OUTER HALLWAY AND BACK. TOL WELL BUT TIRED AFTER.\n\nA/P: TOL MILRINONE WEAN. TOLERATING DIET AND ACTIVITY WELL. CONT TO MONITOR UO AND ENC PULM TOILET.\n" }, { "category": "Nursing/other", "chartdate": "2129-12-21 00:00:00.000", "description": "Report", "row_id": 1462938, "text": "RN progres note\n\nSlept well after benadryl and ativan. No deficits. NSR, no VEA. HD stable. BS CLTb, dim left base. Raising scant thick white sputum. Tol diet; no BM. UOP adequate. Rash on back resolving. Wounds C/D; right leg sore and edematous still. Milrinone off at 0400.\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2129-12-13 00:00:00.000", "description": "Report", "row_id": 1462921, "text": "CARDIAC~NSR 80'S. NO ECTOPY NOTED. 12NOON EPISODES OF HTN POST FEM CATH REMOVAL. STARTED ON NITRO @.25 UCG/KG/MIN TITRATING TO MAINTAIN MAPS~60-90, ALSO DROP IN SVO2 AND CARDIAC INDEX. GIVEN 2 MG MILNIRONE BOLUS AND MIL DRIP INCREASED TO .5 UCG/KG/MIN. MVO2 RECALIBRATED. LOW~46. EVENTUALLY RECOVERED TO ^ 50'S 60'S. EPI INCREASED TO .05 UCG/KG/MIN BRIEFLY. CURRENTLY @ .030 UCG/KG/MIN. AMIO @ .5 MG/MIN. DIFFICULT TO STOP R FEM SITE FROM BLEEDING. PRESSURE X 3.5 HRS PULSES CHECKED FREQUENTLY ALL POS EXCEPT DP W/ DOPPLER.\n\nNEURO~A&0 X3. FC. MAE. CALM. MED X 1 W/ PERCOCET FOR C/O SHOULDER DISCOMFORT. POST FEM SHEATH REMOVAL PT MED W/ MSO4 AND ATIVAN FOR AGITATION. EFFECTIVE.\n\nRESP~ON 3L NP. MAINTAINING SATS: 97%. LUNGS CLEAR UPPER DIM IN BASES.\nPRODUCTIVE COUGH. USING INS WELL.\n\nGI/GU~TOL PO FLUIDS AND FOOD WELL. GIVEN LASIX 20 MG IV THIS AM GOOD DIURESIS. + BS.\n\nA/P~LOW PLT COUNT. CLAMP TIME GREATER THAN 3 HOURS. TO REMAIN ON BED REST FOR SEVERAL HOURS DO NOT ALLOW PT TO MOVE RIGHT LEG.\n" }, { "category": "Nursing/other", "chartdate": "2129-12-13 00:00:00.000", "description": "Report", "row_id": 1462922, "text": "VSS. Remains on epi, milrinone, amio, ntg. R Groin pressure drsg . Unable to doppler R dp. R pt dopperable. Feet are cool and pink. Pt understands that he needs to remain flat w/o moving R leg. A+Ox3. Asleep and easily aroused.\n" }, { "category": "Nursing/other", "chartdate": "2129-12-14 00:00:00.000", "description": "Report", "row_id": 1462923, "text": "Pt. alert and pleasant. Slept for the earlier part of the night.\nIABP site with elastoplast pressure bandage; removed at 2100. site is c&d. leg is warm down to ankle and then foot is cool to touch. right 3 toes appear dusky in color. Left leg warm but foot cool; color wnl, All pulse by doppler except right DP which is absent.\nAll drips unchanged as noted on flow sheet. K+ repleted; Mg repleted. BS covered with SSRI.\nPLAN: attempt epi wean today. Maintain milrinone therapy. Get pt. oob to chair. progress diet.\n" }, { "category": "Nursing/other", "chartdate": "2129-12-14 00:00:00.000", "description": "Report", "row_id": 1462924, "text": "NEURO-A & O X3. PLEASANT,COOPERATIVE WITH CARE. NO DEFICIT.\n\nCV-NSR. NO ECTOPY.AMIO & NTG GTTS WEANED TO P.O.FORM. EPI WEANED TO 0.01MCGKGMIN WITH STABLE HEMODYNAMICS. CO/CI > 2.5 RLE COOL-> COLD WITH ABSENT DP,+ PT, + POPLITEAL. FOOT SLIGHTLY MOTTLED. SLUGGHISH CAP .NO C/O PAIN,PARATHESIS.LEFT FOOT COOL WITH DOPPLERABLE PULSES. RT GROIN C-D-I. TRANSPARNET DSG.\n\nRESP-3LNC-> 1LNC WITH SATS=97%. LS DIM THROUGHOUT. USING I.S. INDEPENDENTLY. CT DCD WITH COPIOUS AMT SEROUS FLUID LEAKING FROM SITE. DSG CHANGED X2.\n\nG.I.- ABD SOFT, + BS. TOLERATING FULL LIQUIDS.TAKING PILLS PO WITHOUT DIFFICULTY.\n\nG.U.- ADEQ HOURLY U/O VIA FOLEY. MODERATE DIURESIS WITH IV LASIX.\n\nLABS-NO LABS NEEDED TO RE-CHECKED.\n\nPAIN - 2 PERCOCET X1 FOR C/O STERNAL DISCOMFORT. RELIEF NOTED.\n\nPLAN-CONTINUE TO MONITOR HEMODYNAMICS,KEEP EPI AT 0.01MCGKGMIN TONOC.\nINC. DIET AS TOL. OOB AM.\n\n" }, { "category": "Nursing/other", "chartdate": "2129-12-15 00:00:00.000", "description": "Report", "row_id": 1462925, "text": "NEURO ALERT ORIENTED NO DEFECITS NOTED MOVES ALL EXTREMETIES FOLLOWS COMMANDS EASILY\n\nC/V NSR NO ECT CAPTOPRIL STARTED TOL WELL MILRINONE AND EPI MAINTAINED R FOOT COOLER THAN L UNABLE TO FEEL OR DOPPLER PULSE 12AM ABLE TO PALPATE AND HEAR BY DOPPLER PEDALS FEET COOL R TOES DUSKY CI REMAINS > 2 SVO2 60S DECREASE LOW 60S WITH EXERTION RETURN TO BASELINE WITH REST\n\nRESP NC 2L SATS 96-98% LUNGS DIMINISHED THROUGHOUT PRODUCTIVE SMALL AMT TAN SECRETIONS NO RESP DISTRESS OR SOB NOTED CHEST TUBE DSG SITES DRY AND INTACT\n\nGU/GI TOL LIQUIDS WELL ABD SOFT BOWEL SOUNDS HEARD ADEQUATE URINE OUT WITH IV LASIX TID\n\nPLAN WEAN MILRINONE AND EPI TODAY INCREASE CAPTOPRIL AS TOL MONITOR CI AND SVO2 WITH WEAN\n" }, { "category": "Nursing/other", "chartdate": "2129-12-17 00:00:00.000", "description": "Report", "row_id": 1462931, "text": "ALTERED CARDIAC STATUS\nS: \"IS EVERYTHING ALRIGHT?\"\nO: SR WITHOUT VEA, PACS. MAG REPLACED. SBP >90 RECIEVED CAPTOPRIL . DOPP PP. DSGS D+I. MILRINONE CONTINUES @ .4 MCQ WITHOUT CHANGE . EXTREMITIES WARM. OOB AMB AROUND UNIT TOLERATED WELL. 4CMX2CM OPEN AREA DRIED - PT C/O BEING VERY TENDER.\n BS DIMINISHED 1/2 UP BILATERALLY. COUGHING WITHOUT RAISING. IS Q2HOURS. O2 STA >95% ON 2 L NP.\n A+O, DENIES ANXIETY. MAE- C/O NUMBNESS TOP OF FOOT.FOLLOWING COMMANDS. PLEASANT. PERL.\n FAIR APPETITE, ABD SOFT. + BOWEL SOUNDS. MEDIUM SOFT BROWN STOOL- QUIAC NEGATIVE.\n DECREASED UO- SEE FLOW. DR, AND VIN AWARE NO TREATMENT AT THIS TIME.\n ENDO: HAS NOT REQUIRED ANY SLIDING SCALE INSULIN\n PAIN: REFUSES PAIN MED- DENIES PAIN EXCEPT FOR LEFT LEG OP SITE.\n ID; CLINDAMYCIN\n SOCIAL: WIFE AND FAMILY INTO VISIT TEACHING RE: DECREASED EF.\nA: STABLE AT PRESENT\nP: MONITOR COMFORT, HR AND RYTHYM, SBP, CONTINUE MILRINONE- ? WEAN IN AM, INCISIONS, PP, RESP STATUS-PULM TOILET, NEURO STATUS-ANXIETY, I+O--UO, LABS . AS PER ORDERS.\n" }, { "category": "Nursing/other", "chartdate": "2129-12-18 00:00:00.000", "description": "Report", "row_id": 1462932, "text": "Shift Note\nNeurologically pt is intact. Hemodynamically, milrinone weaned to 0.3mcg/kg/min. Lungs are CTA but diminished. U/O qs. +BS. Ativan given for sleep with good effect. See flowsheet for details.\n" }, { "category": "Nursing/other", "chartdate": "2129-12-18 00:00:00.000", "description": "Report", "row_id": 1462933, "text": "ALTERED CARDIAC STATUS\nS: \"WHY AM I GETTING SOB?\"\nO: CARDIAC ; SR WITH ISOLATED PVC-K3.7 RECIEVED 40 MEQ KCL X1. SBP >90 RECIEVED CAPTOPRIL AS PER ORDERS. MILRINONE CONTINUES @ .3MCQ. DOPP PP WITH RIGHT DSP FLEETING, FEET WARM TO TOUCH. MEDIASTINAL DSG TO BE CHANGED. CONTINUES TO C/O NUMBNESS OF TOP OF FOOT, AMB WITHOUT DIFFICULTY. MAG REPLACED X1. HCT 32.\n RESP: 2L NP WITH O2 SAT> 95%. IS. NOT COUGHING AND RAISING. BS DIMINISHED 1/2 UP BILATERALLY. RR HIGH TEENS. PT IS NOTING .\n GI: APPETITE GOOD. ABD SOFT NONTENDER, + BOWEL SOUNDS, NO STOOL TODAY. COLACE HELD THIS AM.\n GU: MARGINAL UO THROUGHOUT THE DAY.\n ENDO: SLIDING SCALE INSULIN X1.\n PAIN: DENIES\n ID: CLINDA CONTINUES\n TEACHING: PT BEGINNING TO UNDERSTAND CHANGES HE WILL NEED TO ADJUST TO.\n SOCIAL: FAMILY IN AND UPDATED, DAUGHTER SPOKE TO ME REGARDING HER CONCERNS FOR HER FATHER GETTING VERY DEPRESSED- TO SPEAK TO DR. REGARDING THIS.\nA: PT FEELS SLIGHTLY MORE , WEANING MILRINONE\nP: MONITOR COMFORT, HR AND RYTHYM, SBP, CONTINUE SLOW MILRINONE WEAN ? INCREASE CAPTOPRIL, PP, DSG, RESP STATUS-PULM TOILRT ?CXR, NEURO STATUS-ENCOURAGE VERBALIZATION, I+O-UO, LABS. AS PER ORDERS.\n" }, { "category": "Nursing/other", "chartdate": "2129-12-19 00:00:00.000", "description": "Report", "row_id": 1462934, "text": "CSRU UPDATE\nNEURO: INTACT. OOB TO CHAIR WITH ONE ASSIST. REFUSING PERCOCET.\nCV: SR. NO ECTOPY. SLOW WEAN ON MILRINONE. DECREASED TO .2 THIS AM. BP STABLE. TOLERATING CAPTOPRIL.\nPULM: DIM IN BASES. ENCOURAGE CDB AND IS. 2L NC WITH SATS >95%.\nGI: BENIGN. +BM THIS SHIFT.\nGU: LOW UO AROUND 30CC/HR. DR. AWARE. CONT TO MONITOR.\nPLAN: WEAN MILRINONE.\n" }, { "category": "Nursing/other", "chartdate": "2129-12-11 00:00:00.000", "description": "Report", "row_id": 1462917, "text": "RESP~EXTUBATED @ 1215. POST EXTUBATION ABGS EXCELLENT. WEANED FROM FM TO NP, CURRENTLY ON 3L NP, MAINTAINING SATS OF 97-98%. SVO2~68-70%. LUNGS CLEAR UPPER DIMINSIHED IN THE BASES. NON PRODUCTIVE COUGH.\n\nNEURO~A&OX3. FC. MAE. TURNED FREQUENTLY. MED W/MSO4 FOR C/O BACK DISCOMFORT. EFFECTIVE.\n\nCARDIAC~NSR 80'S RARE PVC NOTED. LEVOPHED WEANED TO OFF BY 1145 AM. CONT ON MIL @ .25UCG/KG/MIN, AMIODARONE @ .5 MG/MIN AND EPI @ .05 UCG/KG/MIN. BRIEFLY ON NEO @ .75UCG/KG/MIN FOR SBP~100. CURRENTLY OFF.\nIABP 1:1 W/ GOOD AUGUMENTATION. SITE C&D. RIGHT DP FLEETING TO ABSENT ALL OTHER PULSES POS W/ DOPPLER. FEET WARM W/ COOL TOES BILAT. + CAP REFILL <3 SEC. REPEAT PLT COUNT 83. WILL REPEAT AGAIN THIS EVENING CA++ AND MAG++ REPLACED.\n\nGI/GU~GIVEN REGLAN 10 MG X1 FOR C/O NAUSEA POST EXTUBATION. EFFECTIVE. TOL ICE CHIPS WELL. GIVEN 20 MG IV LASIX @ 0800, GOOD DIURESIS. NO FURTHER DIURETICS GIVEN DIURESISING WELL.\n\nENDO~TX BG W/ SS INSULIN PER CSRU PROTOCOL.\n\nA/P~LABILE BP. NEO AS NEEDED TO MAINTAIN SBP> 110. CONT ON MILNIRONE, AMIODARONE AND EPI THROUGHOUT THE NIGHT. IABP THROUGHOUT THE NIGHT, TO ATTEMPT WEAN IN AM. MED W/ MSO4 AS NEEDED FOR DISCOMFORT. TEAM AWARE OF DENTAL ISSUES, TO REQUEST CONSULT FOR PT.\n" }, { "category": "Nursing/other", "chartdate": "2129-12-12 00:00:00.000", "description": "Report", "row_id": 1462918, "text": "PT. SLEPT IN HOURLY NAPS. VERY PLEASANT ALTHOUGH QUESTIONING IF EVERYTHING IS GOING WELL. PT. REASSURED AS NEEDED.\nIABP @1:1 WITH GOOD AUGMENTATION AND SYST AND DIAST UNLOADING. NO ISSUES WITH ALARMS. RIGHT FEM SITE STABLE WITHOUT BLEEDING OR HEMATOMA. PEDAL PULSES BY DOPPLER AND RIGHT DP COMES AND GOES AS HAS BEEN DOCUMENTED. CONT. ON EPI, AMIO & MILR. STABLE HEMODYNAMICS.\nON 3L O2. LUNGS CLEAR AND SLIGHTLY DIM. @ BASES. HUO FALLING TO 25CC & 10/HR. RESPONDED WELL TO LASIX 20MG IVP. MG &K+ REPLETED . COAGS WNL, PLTS 78K.\nPLAN: ? WEAN IABP AND D/C. WEAN EPI, AMIO, MILR. AND START AMIO PO.\nRESP. CARE; DIURESE AS NEEDED.\n" }, { "category": "Nursing/other", "chartdate": "2129-12-12 00:00:00.000", "description": "Report", "row_id": 1462919, "text": "shift update:\n\nneuro: a&o x3. appears calm but when asked states he feels anxious. ativan given w/good effect. mae. turns in bed w/minimal assist. denies pain.\n\ncardiac: nsr. hr 70-80's. sbp stable. cont on amio & milrinone. attempted to wean epi & iabp->returned to prior settings. see flow sheet. iabp good augmentation. ct minimal drainage. dopp pp except for right dp=absent. k+ repleated.\n\nresp: lungs clear but diminished in bases. encouraged to cdb & use is. + thick yellow sputum after cpt. sat's>95% on 3l nc.\n\ngi/gu: +bs. tolerating liquids. refused solids. small liquid stool. started on lasix q8h. uop>50cc/hr.\n\nendo: fs tx'd w/ssri per protocol.\n\nsocial: family into visit. update given & questions answered.\n\nplan: cont current gtts & iabp settings. no changes to be made this pm. monitor hemodynamics, need for anxiety meds, pulmonary toilet. encourage po's->advance diet as tolerates.\n" }, { "category": "Nursing/other", "chartdate": "2129-12-09 00:00:00.000", "description": "Report", "row_id": 1462910, "text": "PRE-OP CABG\nNEURO: A&O X3. PLEASANT & COOPERATIVE WITH CARE. APPROPRIATELY ANXIOUS\n RE: SURGERY & OUTCOME. ATIVAN 1MG PO X1 AT HS WITH GOOD EFFECT.\nRESP: O2->2L NP. BS CLEAR BUT DIMINISHED AT BASES. RR 14-23. O2 SAT\n 95-98%. MVO2 65%.\nCARDIAC: HR 85-97 SR WITH OCC. PVC'S. BP 88-107/52-72. PAD 19-24, CO\n 4.4/CI 2.39. IABP 1:1 WITH GOOD AUGMENTATION. DOBUTAMINE IN-\n FUSING AT 3.5MCG/KG. HEPARIN INFUSING AT 950U/HR. PTT 45.7.\n HEPARIN GTT INCREASED T0 1100U/HR->REPEAT PTT 59.4. +PULSES\n BY DOPPLER BILATERALLY. R. GROIN SITE C&D. NO SIGNS BLEEDING\n OR HEMATOMA. K 4.3->3.8. TX WITH KCL 40MEQ PB X1.\nGI: ABD. SL. DISTENDED. BS+. APPETITE POOR. NPO AFTER MIDNOC->OR. NO\n STOOL.\nGU: VOIDING QS VIA CONDOM CATHETER, CLEAR YELLOW URINE.\nID: AFEBRILE.\nAM LABS: WBC 10.9, H/H 12.2/36.9, PLAT CT 175, PT 14.0, PTT 59.4, INR\n 1.3, BS 101, NA 138, K 3.8, CL 97, MG 1.9.\nPLAN: NPO->CABG & POSS. VALVE---2nd CASE.\n" }, { "category": "Nursing/other", "chartdate": "2129-12-10 00:00:00.000", "description": "Report", "row_id": 1462911, "text": "Neuro: Pt. arrived from O.R. on 10mcq Propofol. Titrated up as BP tol and as pt. showed signs of movement. Coughing on ETT and MAE with Sx stimulation. Eyes fluttering. PERL 2mm; brisk.\n\nCV~ Arrived on Milr, Levo, Amiod, Epi. Levo weaned quickly due to MAP's >95. NTG added to bring SBP to ~ 120 as stated parameter per Dr. . Weaned to off as BP drifted to <120. SVO2 's 69-79% after calibration. CI >3. Levo restarted when SBp ~103; MAP 70's. Discussed this with Dr. : all other hemodynamics stable. Will accept SBP between100-120 as long as CI & SVo2 stay stable. PAD ~ 22 with cvp 16-18.\nPedal pulses obtained by doppler although right foot pulses very difficult to find and fleeting. Right popliteal dopplerable. both feet cool to touch although right cooler from ankle to toes. Right foot also flushy pink in color. Left foot warm from ankle to top of foot. Toes cool. Ace wrap removed from right leg to rule out constriction. Able to doppler Right PT after this. Will leave off for now.\n" }, { "category": "Nursing/other", "chartdate": "2129-12-10 00:00:00.000", "description": "Report", "row_id": 1462915, "text": "ALTERED CARDIAC STATUS\nO: CARDIAC: SR 80'S WITH ISOLATED PVC'S AND PAC'S, 1- 4 BEAT RUN OF SVT NONE SINCE HO AWARE. K 4.2 TO RECIEVE 20 MEQKCL AND 2 GM MAG. SBP 110'S-120'S. EPI WEANED TO .05MCQ /DR. . MILRINONE TO .25MCQ, LEVO TRANSIENTLY TO .35 MCQ PRESENTLY @ .275 MCQ. AMIODARONE CONTINUES @ .5MG. SVO2 >68%, CI> 2.3. PADS LO 20'S. CVP 14-16. IABP WITH GOOD UNLOADING. RIGHT FEM SITE C+D , SOFT. RIGHT FOOT COLD THIS AM WITH ABSENT DP PRESENTLY WARM WITH FLEETING DP +DOPP L DP AND PTS. MINIMAL CT DRAINAGE. NO CHANGE IN DSG. REMAINS INTACT. RECIEVED 1 UPC # 2 UPC UP AND TO INFUSE OVER 4 HOURS.\n RESP: VENT SETTINGS UNCHANGED OTHER THAN DECREASE FIO2 TO 40% - IF CONTINUES TO PROGRESS OVERNIGHT WILL WAKE AND WORK BREATHING IN AM. SX FOR A SMALL AMOUNT OF THICK TAN TO WHITE SPUTUM. BS DIMINISHED BIBASILAR, CXR DONE. + CT LEAK.\n NEURO: EASILY AROUSABLE ON 35 MCQ OF PROPOFOL, FOLLOWS COMMANDS, MAE, PERL. CALM. APPARENTLY PT IS AN EXTREMELY ANXIOUS MAN. HAS REMAINED CALM ON PROPOFOL.\n GI: NPO, OGT + PLACEMENT DRAINED 200 ML GREEN BILIOUS DRAINAGE. HYPOACTIVE BOWEL SOUNDS. ABD SOFT.\n GU: GOOD UO UNTIL 1800 28 ML.\n ENDO: INSULIN GTT OFF\n PAIN: TORADOL 15 MG X 2 AND 2 MG MSO4 X2 WITH GOOD EFFECT.\n ID: VANCO @ 1600. WBC 16.\n SOCIAL: WIFE AND FAMILY INTO VISIT AND UPDATED\nA: SLOW WEAN WITH MEDS BEING TOLERATED THUS FAR.\nP: MONITOR COMFORT, HR AND RYTHYM, SBP GOAL TO KEEP SBP >120 -110 EXCEPTABLE, CONTINUE AMIO,MILRINONE,EPI @ PRESENT RATES,LEVO- WEAN AS TOLERATED,SVO2, CI, CT DRAINAGE, RESP STATUS- ? WAKE AND WEAN IF CONTINUES TO BE STABLE IN AM, NEURO STATUS- SLOW WEAN OF PROPOFOL IF TO WAKE AND WEAN, PP, CT DRAINAGE, CT LEAK, BS, I+O, # 2 UPC TO INFUSE OVER 4 HOURS. LABS. AS PER ORDERS.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2129-12-11 00:00:00.000", "description": "Report", "row_id": 1462916, "text": "Neuro~ Pt. arousable to voice commands. Nods head in response to questions. MAE.\n\nCV~ Remains on Milr, amio, epi & levo. Levo being weaned to keep SBP 110-120. Occ. PVC's with one burst of ST rate 113 lasting approx. 7 seconds. Electrolytes all WNL prior to event. Oxygenating well. Otherwise, HR stable in the 70's. Lower extr. warm down to metatarsal area and then toes cool bilat. Coloring equal with absent to fleeting DP in right foot. Good PT signal by doppler no other signs of vascular impairment. IABP without problems or alarms. Good augmentation and unloading. CI >2.1 throughout shift.\n\nPulm~ Great oxygenation on 40% PO2's >160. SX for thick white. BS more distant but IABP noise a factor. Crackles at left base. Diminished at right. No chest tube leak noted. Drainage minimal.\n\nGI~ No n/v. OGT drng bilious.\n\nGU~ adequate huo.\n\nEndocrine: SSRI for blood sugar management.\n\nHeme: Hct stable @ 31 after 2 units blood yesterday. Plts down to 78 today.\n\nplan: cont. to wean levo. Possibly wake to wean from vent today. Extubate if stable. Wean other drips as hemodynamics allow. Begin diuresis with Lasix.\n" }, { "category": "Nursing/other", "chartdate": "2129-12-10 00:00:00.000", "description": "Report", "row_id": 1462912, "text": "Continued Note from Above:\n\nPulm: Vent changes per resp. as determined by ABG results. Pt. has clear bilat. BS. Sx. for small amount blood streaked secretions. Chest tubes without airleak.\n\nGI: OGT to sx. pink tinged returns noted intermittently; pt. had intraop TEE. Carafate/Zantac for prophylaxis.\n\nGU: Adequate HUO.\n\nHeme: Hct stable. PT 17 slightly when rcvd from O.R. One FFP given; additional 1 FFP given for volume .PT corrected.\n\nEndo: Insulin drip started for BS > 200. titrated per protocol.\n\nCV/hemodynamics: IABP with good augmentation and good. syst & diast unloading. No issues with alarms. Baseline LFT's drawn while IABP tx in progress per Dr. .\n" }, { "category": "Nursing/other", "chartdate": "2129-12-10 00:00:00.000", "description": "Report", "row_id": 1462913, "text": "Resp care\nPt remains intubated & supported in SIMV/PS mode\nB/S clear, Sx scant amount of bloody secretions\nPlan: continue support, wean as tolerated\n" }, { "category": "Nursing/other", "chartdate": "2129-12-10 00:00:00.000", "description": "Report", "row_id": 1462914, "text": "Resp. Care:\n Pt. remains on vent. support. able to decrease fio2 today, but without any further changes made. He cont.'s sedated on mult. drips and IABP 1:1.\n" }, { "category": "Nursing/other", "chartdate": "2129-12-07 00:00:00.000", "description": "Report", "row_id": 1462907, "text": "CCU NPN 1900-2300\nS/O:\n\nCV: PT WITHOUT CP/SOB TONIGHT. HEP CONT. DOBUT UNCHANGED WITH C/O INC TO 3.7 AND INDEX TO 2.0. IABP CONT 1:1 WITH GOOD AUGMENTATION BUT NO UNLOADING. RIGHT GROIN SITE D/I. DP PULSE ON RIGHT CONT ABSENT BUT PT STATES THE FOOT FEELS LESS NUMB AND WARMER. FEET COOL BUT WITH NL COLOR. IVF CONT AT 75CC/HR, D/C AFTER 750CC. GOOD DIURESIS TO LASIX IN CATH LAB.\n\nRESP: TOL 2LNP WITH SATS IN HIGH 90'S.\n\nID: AFEB.\n\nGI: NO DESIRE TO EAT ALTHOUGH NO NAUSEA AFTER ZOFRAN. DRINKING GINGER ALE AND JUICE. POS BS, NO STOOL.\n\nGU: COMDOM CATH DRAINING CLEAR URINE.\n\nMS: PT QUIET BUT ADMITS TO ANXIETY. WIFE STATES HE ALWAYS HAS TROUBLE SLEEPING AND HAS \"NPT SLEPT FOR A MONTH\". STATES AMBIEN AND VALIUM WAS TRIED AT . PT ASKING APPROPRIATE QUESTIONS, VISITED BY PRIEST AND HAS ROSARY BEADS AND HOLD WATER AT BEDSIDE. PT DENIES NICOTINE WITHDRAWAL AND SMOKING CESSATION/ UPCOMING SURGERY DISCUSSED AT LENGTH WITH PT AND FAMILY.\n\nA/P: CONT FOLLOW CARDIAC NUMBERS Q4H. ASSESS RIGHT GROIN SITE AND RIGHT FOOT Q1-2H. FOLLOW DIURESIS. ? TRY TRAZADONE OR SERAX TONIGHT.\nSURGERY SCHEDULED FOR FRIDAY FOR NOW.\n" }, { "category": "Nursing/other", "chartdate": "2129-12-08 00:00:00.000", "description": "Report", "row_id": 1462908, "text": "CCU Nursing Progress Note\nS: This all happened so fast\n\nO: Afebrile\n\nHR 90'2 NSR with rare single PVC's. cont on IABP 1:1 via right groin. with systolic unloading points and MAPs maintained between 74-81. PAD'S 19 down to 17 after 40mg lasix IV. MV sat improved to 70 from 64. Awaiting HGB to calc c.o and c.i. Dobutamine cont 7.6 mcgs/kg. Heparin maintained 800u/hr despite PTT 43.3 last PM. House staff aware. R DP pulse transiently present by doppler, PT is +. R groin d/I with knee immobilizer on r. C/o uncomfortable r ankle. Encouraged to do ROM on r foot/ankle\n\nResp - pt taking O2 off and on. O2 sat down to 92 % without O2, encouraged to keep np on. Decreased bs on r with occasional crackles on l base.\n\nu/o via condom cath qs clear amber urine\n\nGI - Abd soft with +bs\n\nA: improving c.o with IABP and Dobutamine\n\nP: Pre op teaching, Possible wean or decrease of dobutamine, encourage C &DB as well as change of position. Monitor lytes and replace as necessary\n" }, { "category": "Nursing/other", "chartdate": "2129-12-08 00:00:00.000", "description": "Report", "row_id": 1462909, "text": "AWAITING CABG POSSIBLE VALVE TOMRROW.NO CP,SOB. IABP 1TO 1.GOOD AUGMENTATION.NO BLEEDING FROM GROIN.DISTAL PULSES BY DOP.FEET WARM . CI 4.8,MVO2 76.DOBUTAMINE WEANED TO 3,5. MAPS 80S.PAD 22 TO 28 .AT TIMES FREQ PVCS ,MG,K REPLETED. HEPARIN 950U .\n\nSAT 97 RM AIR . BS DECREASED.\n\nTAKING FULL LIQUIDS POOR APPETITE\n\nURINE OUTPUT TAPERING OFF BUT MAINTAINING NEG 500CC BALANCE, NEED LASIX.\n\nGENERALIZED DISCOMFORT ,GIVEN TYLENOL,POSITION CHANGE C MOD RELEIF\nVISITING C WIFE .SEEN BY SX AND ANESTHESIA .\n\nREPEAT HEMODYNAMICS,K,PTT\nCHECK C HO 6PM FOR LASIX DOSE\n" }, { "category": "Nursing/other", "chartdate": "2129-12-07 00:00:00.000", "description": "Report", "row_id": 1462906, "text": "67 YR OLD SP MI,LM,3VD FOR CABG. EF 15% ,CI 1.4 .IABP PLACE3D ,DOBUTAMINE STARTED . PAIN FREE ,NO SOB ,SAT 97 ON RM AIR UPON ADMIT TO CCU\n\nSR,ST NO ECTOPY .IABP I TO I /GOOD AUGMENTATION . MAPS 90S . DOBUTAMINE 7.5 . HEPARIN 800U . NO R DP BY DOP SINCE PROCEDURE ,OTHER PULSES BY DOPPLER . R FOOT COOL, NUMBNESS PRESENT BUT IMPROVING P HEPARIN STARTED .PAD 28 HEPARIN GIVEN .\n\nSAT 98 RM AIR ,BUT 02 ADDED AT 2L NP.\n\nZOFRAN FOR NAUSEA .TAKING FLUIDS POS BS\n\n40 IV LASIX GIVEN ,CONDOM CATH IN PLACE\n\nALERT,ANXIOUS,REQUESTING SLLEP MED .SEEN BY PRIEST AND FAMILY\n\nLOW EF ,ELEVATED CREAT . PLAN TO OPTIMIZE HEMODYNAMICS PREOP\n\nRECHECK PA SAT\nWEAN DOBUTAMINE IF POSSIBLE\nEMOTIONAL SUPPORT TO FAMILY AND PT\n" } ]

[ { "category": "Radiology", "chartdate": "2128-04-18 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1234241, "text": " 3:17 PM\n CHEST (PA & LAT) Clip # \n Reason: Please schedule for 15:00. assess for interval change\n Admitting Diagnosis: GUN SHOT WOUND\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Please schedule for 15:00. 29 year old man s/p GSW to left chest now with chest\n tube removed\n REASON FOR THIS EXAMINATION:\n Please schedule for 15:00. assess for interval change\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Gunshot wounds to chest with tube removed.\n\n FINDINGS: In comparison with study of earlier in this date, the left chest\n tube has been removed. No evidence of pneumothorax. Left upper zone\n opacification persists, consistent with contusion or hemorrhage. Right lung\n is clear.\n\n\n" }, { "category": "Radiology", "chartdate": "2128-04-16 00:00:00.000", "description": "TRAUMA #3 (PORT CHEST ONLY)", "row_id": 1234067, "text": " 8:50 PM\n TRAUMA #3 (PORT CHEST ONLY) Clip # \n Reason: TRAUMA\n ______________________________________________________________________________\n FINAL REPORT\n EXAM: Chest, single supine AP portable view.\n\n CLINICAL INFORMATION: Trauma, gunshot wound.\n\n COMPARISON: None.\n\n FINDINGS: Single supine AP portable view of the chest was obtained.\n Endotracheal tube is malpositioned, terminating at the carina. Recommend\n withdrawal by approximately 3 cm. Nasogastric tube is seen coiling in the\n upper mediastinum. Recommend removal/repositioning. Presumably shrapnel is\n seen in the left axilla as well as projecting over the left upper mediastinum\n to the left of midline. There is left upper lobe opacification, which may\n represent underlying pulmonary hemorrhage/contusion and left apical\n pneumothorax. Left chest tube is seen, with tip at the left lung apex. Small\n amount of subcutaneous gas is seen overlying the left chest wall adjacent to\n this insertion site of the chest tube. No large pleural effusion is seen.\n The cardiac silhouette is top normal. The mediastinum does not appear\n widened. No displaced fracture is seen.\n\n IMPRESSION:\n 1. Endotracheal tube in inappropriate position, terminating at the level of\n the carina, recommend withdrawal by approximately 3 cm.\n 2. Nasogastric tube coiled in the upper mediastinum; recommend\n removal/repositioning.\n 3. Shrapnel from gunshot seen in the left axilla and left upper mediastinum\n to the left of midline.\n 4. Left upper lobe opacification may be due to pulmonary\n hemorrhage/contusion. Small left apical pneumothorax seen. Left chest tube\n is seen, terminating high in the left apex, may be withdrawn somewhat.\n\n Initial phone call to Dr. was placed Dr. at 9:15\n p.m. via telephone on and findings/recommendations discussed with\n Dr. at 9:32PM on .\n\n" }, { "category": "Radiology", "chartdate": "2128-04-16 00:00:00.000", "description": "CTA CHEST W&W/O C&RECONS, NON-CORONARY", "row_id": 1234069, "text": " 9:19 PM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY; CTA ABD & PELVIS Clip # \n Reason: injuries\n ______________________________________________________________________________\n MEDICAL CONDITION:\n History: 29M with GSW to L chest\n REASON FOR THIS EXAMINATION:\n injuries\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: YGd FRI 10:31 PM\n Small L ptx now w chest tube in place terminating apically with material in\n the distal tube, likely hemorrhage. Substantial subQ emphysema in the left\n anterior chest wall. Small vascular blush in posterior left pulmonary apex\n (300b, 40) active extravasation, into an area of LUL\n consolidation/contusion/hemorrhage. Bullet 1 in location of left T3\n vertebrocostal junction. Bullet 2 in left axilla. Significant streak\n artifacts, assessment subjacent to bullets. L anterior 1st rib fx'd, in path\n of bullet.\n\n WET READ VERSION #1\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 29-year-old male with gunshot wound to the left chest. Question\n injury.\n\n COMPARISON: None available.\n\n TECHNIQUE: MDCT images were acquired from the thoracic inlet through the\n pubic symphysis following administration of intravenous contrast with\n multiplanar reformations.\n\n CT CHEST: Patient is status post intubation with ET tube extending to 2.3 cm\n above the carina. An enteric tube extends to the level of stomach which\n appears distended and fluid filled.\n\n A anterior chest wall soft tissue defect (2, 57) likely represents at least\n one of the bullet entries. There is substantial underlying anterior chest\n wall subcutaneous emphysema, without definite underlying injury to the\n traversing subclavian vessels. There is mildly displaced anterior left first\n rib fracture in the path of the bullet trajectory.\n\n Two bullets are seen, one in the location of left T3 vertebrocostal junction,\n and the second in the left axilla. These generate substantial streak\n artifacts limiting assessment of subjacent structures. There is a small\n residual left apical pneumothorax. A chest tube is in place terminating\n apically with material in the distal tube likely representing hemorrhage.\n Mild left lateral chest wall subcutaneous emphysema is likely related to\n placement of the chest tube.\n\n Within the left posterior apical lung, there is a small vascular blush (300b,\n 40 and 2, 58), consistent with active extravasation likely from a distal\n pulmonary arterial branch, bleeding into an area of left upper lobe\n (Over)\n\n 9:19 PM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY; CTA ABD & PELVIS Clip # \n Reason: injuries\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n consolidation/contusion/hemorrhage. There are bibasilar dependent\n atelectasis, left greater than right. Supervening aspiration cannot be\n excluded on the left. Layering fluid is seen in the esophagus.\n\n The heart is normal in size without pericardial effusion. The aorta appears\n normal in caliber throughout without acute pathology.\n\n CT ABDOMEN: The liver appears intact. The gallbladder, spleen, splenules,\n and pancreas appear unremarkable. Bilateral adrenal glands are normal in\n morphology. Nephrograms are symmetric without hydronephrosis or hydroureter.\n Small and large bowel loops are normal in caliber. Great vessels are patent.\n There is no free air or free fluid within the abdomen.\n\n CT PELVIS: The bladder is decompressed by a Foley catheter. The rectum and\n prostate as well as seminal vesicles appear unremarkable. Inguinal and pelvic\n sidewall lymph nodes are subcentimeter in size. There is no free fluid in the\n pelvis.\n\n BONE WINDOW: No definite additional injury besides aforementioned left first\n rib fracture.\n\n IMPRESSION:\n 1. Two bullets, one in the location of left T3 costovertebral junction, the\n other in the left axilla. Assessment of subjacent structures highly limited\n due to streak artifact.\n 2. Left anterior chest wall subcutaneous emphysema and underlying left first\n rib fracture in the path of bullet with a small residual left apical\n pneumothorax status post chest tube placement. Note hyperdense material in\n the distal chest tube which likely represents hemorrhage.\n 3. Active extravasation from a distal pulmonary arterial branch in the\n posterior left pulmonary apex with bleeding into left upper lobe area of\n consolidation/hemorrhage/contusion.\n 4. No obvious injury to the left subclavian arterial vessels.\n 5. No intra-abdominal or intrapelvic visceral injury.\n\n" }, { "category": "Radiology", "chartdate": "2128-04-16 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1234070, "text": " 9:19 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: injuries\n ______________________________________________________________________________\n MEDICAL CONDITION:\n History: 29M with GSW to L chest\n REASON FOR THIS EXAMINATION:\n injuries\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: YGd FRI 9:55 PM\n No ICH. Paranasal sinus dz\n\n WET READ VERSION #1\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 29-year-old male with gunshot wound to the left chest.\n\n COMPARISON: None available.\n\n TECHNIQUE: Contiguous non-contrast axial images were acquired through the\n brain, with multiplanar reformations.\n\n FINDINGS: The head is mildly tilted. There is no intracranial hemorrhage,\n mass effect, edema, or shift of normally midline structures. The -white\n matter differentiation appears preserved. Ventricles and sulci are age\n appropriate. Suprasellar and basilar cisterns are patent.\n\n There is mucosal thickening in the left maxillary sinus and fluid layering in\n the right maxillary sinus as well as opacification of several mid-to-posterior\n ethmoidal air cells. Mastoid air cells appear well aerated. No definite\n skull base fracture is appreciated. Globes and orbits are unremarkable.\n There is fluid and aerosolized secretions in the nasal and oropharynx,\n compatible with recent intubation. No acute fracture is seen.\n\n IMPRESSION:\n 1. No acute intracranial process.\n\n\n" }, { "category": "Radiology", "chartdate": "2128-04-18 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1234191, "text": " 5:09 AM\n CHEST (PORTABLE AP); -59 DISTINCT PROCEDURAL SERVICE Clip # \n Reason: Interval change Please take on at 6:00 am. Thanks !\n Admitting Diagnosis: GUN SHOT WOUND\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 29M GSW to to the left chest and left shoulder complicated by left pneumothorax\n REASON FOR THIS EXAMINATION:\n Interval change Please take on at 6:00 am. Thanks !\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Gunshot to left chest and shoulder complicated by pneumothorax.\n\n FINDINGS: In comparison with the study of , the nasogastric tube has been\n removed. Endotracheal tube also is no longer present. Contrast fragments in\n the midline and axillary region are unchanged. Left upper zone opacification\n has slightly decreased. This suggests clearing pulmonary hemorrhage or\n contusion. A definite pneumothorax in the left apical region is not\n appreciated.\n\n Left chest tube remains in place.\n\n\n" } ]

[ { "category": "Nursing/other", "chartdate": "2127-09-27 00:00:00.000", "description": "Report", "row_id": 1578251, "text": "Resp Care\nPt remains on mech vent-parameters noted. No wean this shift. ABG within parameters. Team would like PaCO2 to remain within 35-40. Head CT today shows increase bleed in ventricles. Suction for small amt of thick whitish secretions. Will continue mech vent and wean as tol.\n" }, { "category": "Nursing/other", "chartdate": "2127-09-27 00:00:00.000", "description": "Report", "row_id": 1578252, "text": "focus update note\nplease see flowsheet for details\n\npt with large thalmic bleed with herniation, pupils now fixed and dilated,no corneal reflex, negative dolls eyes,no nystagmus to cold ice water in ear, no gag repeat stat head ct worsening of bleed, minimal breaths when pt taken off the ventilator. pt requiring neo gtt at 5 mcq/kg/min to keep sbp 110-140, total iv bolus given 2 liters, K 3.0 repleated with 40 kcl, urine output increased, sodium 157, free water bolus' 250cc q 6 hours ordered, pt temp range 92.7-101.4 pt on/off bair hugger/ cooling blanket. q 6 hours serum osmos, mannitol q 6 hours for serum osmo < 325.\n\npoor prognosis discussed multiple times with pt mother and father(health care proxy's) and family would like to have pt full code at this time. social work notified\n\nplan: continue with above mentioned plan of care, provide emotional support to family, continue to monitor neuro status closely.\n" }, { "category": "Nursing/other", "chartdate": "2127-09-27 00:00:00.000", "description": "Report", "row_id": 1578253, "text": " 19/07 SHIFT\n PT REMAINS IN COMA STATE NO DEEP TENDON NEG DOLLS NEG CORNEAL PUPILS FIX DIALATED\n RESP NO EFFORT CMV CLEAR FIELDS\n HEART S1S2 ST ON MAX NEO TO MAINTAIN BP 110 SYS PLEASE CAREVIEW FOR DETAILS\n GI NO B/S NOTED ABD DISTENDED N/G IN PLACE SUCTION IN PROGRESS\n SUPPORTIVE CARE MONITOR LYTES OSMO ABG S/S DI DDAVP IF NEEDED\n HELP FAMILY WITH SITUATION\n" }, { "category": "Nursing/other", "chartdate": "2127-09-28 00:00:00.000", "description": "Report", "row_id": 1578254, "text": "Respiratory Care:\nPatient remains on A/C ventilatory support. FIO2 decreased from 50% to 40%. Morning abg results on 50% revealed a normal acid-base balance with excellent oxygenation.\n\nNo RSBI determined at this time, due to patient's instability.\n" }, { "category": "Nursing/other", "chartdate": "2127-09-28 00:00:00.000", "description": "Report", "row_id": 1578255, "text": "Resp Care\nPt received on mech vent-parameters noted. Apnea test performed. Pt passed (no attempt at resp made, PaCO2 greater than 60). Per family's wishes, pt removed from mech vent. Extubated to room air.\n" }, { "category": "Nursing/other", "chartdate": "2127-09-28 00:00:00.000", "description": "Report", "row_id": 1578256, "text": "focus update: pt made care and comfort measures\nneuro status remains unchanged, pt requiring increased amounts of levophed and neo gtts to maintain blood pressure, brain death protocol performed by Dr attending neurologist, icu resident present , nursing and respiratory therapist at bedside, pt health care proxy (pt's mother) as well as her step father were present and social work. pt was declared brain dead. family meeting occured with attending neurologist following at which time the decision was made to make the pt care and comfort measures only. pt was extubated and levophed/neo gtts were discontinued at 1400, pt was pronounced dead at 1428. pts parents were in the pts room at the time. social work was notified to facilitate funeral arrangements and pts primary care physician was notified.\n" }, { "category": "Nursing/other", "chartdate": "2127-09-27 00:00:00.000", "description": "Report", "row_id": 1578250, "text": "NPN (NOC): PLEASE SEE FHPA AND FLOWSHEET FOR DETAILS OF PMHX, HPI AND ASSESSMENT. BRIEFLY, PT IS A 27 Y/O FEMALE W/ A PMHX OF SICKLE CELL ANEMIA S/P CVA X2 WHO HAD A GRAND MAL SZ AT HOME TODAY. HEAD CT AT OSH SHOWED LG THALAMIC BLEED W/ L> R SUBFALCINE HERNIATION AND INTRAVENTRICULAR BLEED W/ MARKED HYDROCEPHALUS. TRANS TO FOR FURTHER EVALUATION AND MANAGEMENT. RPT HEAD CT IS UNCHANGED, BUT SHE IS NOT A SURGICAL CANDIDATE. ADM TO SICU FOR FURTHER CONSERVATIVE CARE.\n\nROS: CV- HR 70'S, NSR W/O ECTOPY. LABETOLOL DRIP MAINTAINED TO KEEP SBP < 140.\n\nRESP: INTUBATED. CURRENT VENT SETTINGS AC 16X450X50%. NOT OVERBREATHING SET RATE. SATS 100%. BS'S CLEAR. SX'D X 1 FOR NO SECRETIONS. TMAX 100.\n\nNEURO: PT IS . PUPILS ARE NON EQUAL, L> R AND NON REACTIVE. SHE HAS A COUGH BUT POOR GAG AT BASELINE D/T PRIOR CVA. NO RESPONSE TO PAIN IN ANY EXTREMITIES EXCEPT TOES ARE SLIGHTLY UPGOING BILAT. NEURO MED IS AWARE. PT IS TO RECEIVE MANNITOL Q 6 HRS. LOADED W/ DILANTIN AT OSH. TO RECEIVE DIALTIN 100 IV TID. PAST SZ D/O WAS MAL SZ SINCE CHILDHOOD, NO NEED TO CONTINUE TRILEPTAL PER NEURO.\n\nGI: HAS J-TUBE. IS NPO FOR NOW BUT RECEIVES TF AT HOME.\n\nF/E: UO IS BRISK S/P MANNITOL. WILL CHECK 'LYTES AND OSOMS IN AM.\n\nSOCIAL: PT'S MO AND FA INTO VISIT. THEY HAVE SPOKEN TO NEURO MED AND NEURO . PT ALSO HAS A YOUNG SON WHO ALSO HAS SCD. PT'S MO TAKES CARE OF BOTH OF THEM (PT WAS APHASIC AND WHEELCHAIR BOUND PRIOR TO THIS CVA.)\n" }, { "category": "Radiology", "chartdate": "2127-09-26 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 886015, "text": " 9:17 PM\n CHEST (PORTABLE AP) Clip # \n Reason: ett placement\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 27 year old woman with sickle cell anemia\n REASON FOR THIS EXAMINATION:\n ett placement\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Sickle cell anemia and endotracheal tube placement.\n\n COMPARISON: .\n\n SUPINE AP VIEW OF THE CHEST: An endotracheal tube is demonstrated with tip at\n the carina. A nasogastric tube is seen with tip in the stomach. The heart\n appears mildly enlarged. The mediastinal contours are unchanged. Low lung\n volumes are present, likely accounting for the patchy perihilar parenchyma\n opacities. There are no effusions or pneumothorax noted. Clips are seen in the\n right upper quadrant consistent with prior cholecystectomy.\n\n IMPRESSION:\n 1. Endotracheal tube tip at the carina.\n 2. Low lung volumes.\n\n Dr. was informed of these findings at 12:30 a.m. on .\n DFDdp\n\n" }, { "category": "Radiology", "chartdate": "2127-09-26 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 886016, "text": " 9:20 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: UNRESPONSIVE. EVALUATE BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 27 year old woman with ich\n REASON FOR THIS EXAMINATION:\n please eval\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: DFDdp FRI 9:51 PM\n large left thalamic hemorrhage with intraventricular extension, left to right\n subfalcine herniation. appearances are not changed since outside study\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Intracranial hemorrhage.\n\n COMPARISON: Outside head CT from . Images are not available\n for review on PACS.\n\n TECHNIQUE: Non-contrast head CT.\n\n HEAD CT WITHOUT IV CONTRAST: There is a large intraparenchymal hemorrhage\n centered within the left thalamus with marked left to right subfalcine\n herniation and surrounding mass effect and edema. There is blood present\n within all the ventricles and there is marked dilatation of the ventricular\n system, which is stable since the prior examination. No new areas of\n intraparenchymal hemorrhage are demonstrated. There is also\n indistinctness of the and white matter within the left frontal lobe,\n likely secondary to surrounding mass effect from the large intraparenchymal\n hemorrhage. Visualized paranasal sinuses and mastoid air cells are clear.\n Surrounding osseous and soft tissue structures are unremarkable.\n\n IMPRESSION: Large left thalamic intraparenchymal hemorrhage with\n intraventricular extension and hydrocephalus. There is marked left to right\n subfalcine herniation, which appears stable in the interval.\n DFDdp\n\n" }, { "category": "Radiology", "chartdate": "2127-09-27 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 886079, "text": " 12:15 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: follow up\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 27 year old woman with head bleed\n REASON FOR THIS EXAMINATION:\n follow up\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Intracranial hemorrhage.\n\n COMPARISON: .\n\n TECHNIQUE: Non-contrast head CT.\n\n FINDINGS: The large left thalamic hemorrhage appears stable in size but\n slightly increased in density in its medial portion, which may be related to\n the technical differences between the two studies. Extensive mass effect with\n severe shift of the septum pellucidum and third ventricle to the right does\n not appear significantly changed. A large amount of blood remains present in\n the lateral ventricles, left greater than right, as well as in the third and\n fourth ventricles. The lateral ventricles remain dilated. Evaluation of the\n right frontal lobe is slightly limited by CT calibration artifact.\n Indistinctness of the /white matter interface is again noted in the left\n frontal lobe and possibly also in the right frontal lobe. The visualized\n osseous structures and paranasal sinuses appear unchanged.\n\n IMPRESSION:\n 1. Stable extent of left thalamic hemorrhage with large intraventricular\n component and severe associated mass effect.\n\n 2. Stable indistinct appearance of /white matter interface in both\n cerebral hemisphere could be related to old infarcts and periventricular\n edema.\n\n\n" } ]

[ { "category": "Nursing/other", "chartdate": "2180-02-11 00:00:00.000", "description": "Report", "row_id": 1329560, "text": "Nursing note:\n\nNEURO/COMFORT: Pt. abruptly awoke from anesthetics at and was very agitated, thrashing arms and banging on siderails, SBP elevated and HR in 130s. Drs. and at bedside to evaluate. Pt. c/o pain to abdomen and difficulty breathing. Sats 97-100%, good TVs and RR 16-24. ABGs cont. to reflect metabolic acidosis and decision made to keep pt. intubated and comfortable until am rounds. Pt. medicated w/2mg IV MS04 and 0.5mg IV Ativan w/effect on anxiety and pain. Pt. moving all extremities, following simple commands. PERRLA. Opens eyes spont and appears to understand when situation explained to her, calms somewhat to verbal reassurance.\n\nCV: Afebrile, ST to 130s early in shift, responded to Ativan/Morphine and Lopressor briefly, then crept back up to 120s. MD aware, given 2 500cc LR boluses and Albumin 5% x2 w/minimal response (Pt. thought to be dry. ) Increase in HR w/agitation. Pboots worn , on sq heparin. Mag. repleted and K+ repleted. SBP 100-120s.\n\nRESP: CPAP 40%, 5 IPS and 5 PEEP tolerated well overnight. RR 16-24 and TVs 450-500. ABGs improved this am. Sxn'd for thick yellow secretions infrequently. Lung sounds clear throughout.\n\nGI: Abdomen large, obese, soft. DSD intact, not changed MD. 4 JPs patent for serosang. drainage. J-tube to GD. NGT patent for small amount bilious drainage. -BS.\n\nGU: Foley patent borderline amounts clear yellow urine. 45cc/hr.\n\nSKIN: Intact, turned and repositioned q2hours.\n\nENDO: Insulin per SS.\n\nA/P: Stable, monitor HR and fluid status closely, frequent reassurance for anxiety. Medicate PRN pain. Extubate this am. Cont. current plan of care.\n" }, { "category": "Nursing/other", "chartdate": "2180-02-10 00:00:00.000", "description": "Report", "row_id": 1329559, "text": "NSG ADMIT NOTE\nPT RECEIVED FROM OR INTUBATED. LETHARGIC BUT EASILY AROUSABLE. PT IS A 70 YO FEMALE WITH HX OF MULTI COLOCUTANEOUS FISTULA'S. TODAY PT HAD EXP LAP, LOA, J TUBE PLACEMENT, RESECTION OF FISTULA AND COLOPROTECTOMY. JP X4. J TUBE CLAMPED. FOLEY TO GRAVITY. RIGHT SUBCLAV TLC. PIV X2. ALLERGIC TO ASA- HIVES-. OTHER PMH- MI, CAD, CVA IN PAST WITH RIGHT SIDED WEAKNESS, GERD, HYPERLIPIDEMIA, TYPE 2 DIABETES. PREVIOUS SURGERIES FOR FISTULLA'S AND LOA. PLAN TO EXTUBATE TONIGHT. CURRENT ABG ACIDOTIC- ? DRY. IVF LR 125/HR. CVP 13-17.\n" }, { "category": "ECG", "chartdate": "2180-02-16 00:00:00.000", "description": "Report", "row_id": 300471, "text": "Normal sinus rhythm. Tracing is within normal limits. Compared to the previous\ntracing of , no change.\n\n" } ]

[ { "category": "Radiology", "chartdate": "2198-09-20 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 981332, "text": " 2:27 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: s/p doboff re-placement\n Admitting Diagnosis: SEIZURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with cirrhosis, encephalopathy p/w seizures now with trach\n and low-grade fever\n REASON FOR THIS EXAMINATION:\n s/p doboff re-placement\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Low-grade fevers, evaluation of Dobbhoff placement.\n\n Portable AP chest radiograph compared to previous study obtained today at\n 10:18 a.m.\n\n The Dobbhoff tube tip is currently in the proximal stomach, advanced compared\n to the previous study although additional advancement for at least 20 cm is\n recommended. The tracheostomy tube is in unchanged standard position. The\n right PICC line is better visualized with its tip terminating at the level of\n cavoatrial junction. The TIPS catheter is demonstrated.\n There is improvement of aeration of the left lower lobe with otherwise\n unchanged mild pulmonary edema.\n\n" }, { "category": "Radiology", "chartdate": "2198-08-16 00:00:00.000", "description": "P LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT", "row_id": 976261, "text": " 2:14 PM\n LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT Clip # \n Reason: PERSISTEN FEVER AND LFTS\n Admitting Diagnosis: SEIZURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with seizures, sepsis, persistent fever and lfts\n REASON FOR THIS EXAMINATION:\n r/o cholecystitis\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Seizure, sepsis, persistent fevers and rising LFTs, rule out\n cholecystitis. Additional information reveals that the patient has cirrhosis\n and TIPS and HCC.\n\n FINDINGS: Comparison is made to abdominal ultrasound , and\n abdominal CT . The liver is small, and echogenic consistent with\n cirrhosis. There is small ascites about the liver. The gallbladder is\n moderately distended but otherwise appears normal without shadowing stones,\n gallbladder wall thickening, or pericholecystic fluid. There is a right\n pleural effusion. The common bile duct measures 5 mm. The pancreas is not\n visualized. The TIPS was not formally evaluated but color flow demonstrates\n patency.\n\n IMPRESSION:\n 1. Moderately distended gallbladder, but otherwise normal.\n 2. Small ascites.\n 3. Right pleural effusion.\n\n\n" }, { "category": "Radiology", "chartdate": "2198-08-23 00:00:00.000", "description": "P ABDOMEN (SUPINE & ERECT) PORT", "row_id": 977233, "text": " 11:16 AM\n ABDOMEN (SUPINE & ERECT) PORT Clip # \n Reason: abdominal obstruction\n Admitting Diagnosis: SEIZURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with hx of liver cirrhosis and distended abdomen\n REASON FOR THIS EXAMINATION:\n abdominal obstruction\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE ABDOMEN\n\n HISTORY: 63-year-old male with history of liver cirrhosis and distended\n abdomen. Evaluate for abdominal obstruction.\n\n COMPARISON: Abdomen portable plain film .\n\n ABDOMEN, SUPINE AND UPRIGHT: NG tube with tip within stomach. Metal stent\n overlies the right upper quadrant. Air and feces is seen within the colon.\n However, no dilated loops of small or large bowel are seen. No evidence of\n free intraperitoneal air.\n\n IMPRESSION: No evidence of obstruction.\n\n\n" }, { "category": "Radiology", "chartdate": "2198-08-28 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 977998, "text": " 3:03 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: evaluation of dobhoff\n Admitting Diagnosis: SEIZURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with cirrhosis, encephalopathy p/w seizures s/p\n intubation for airway protection. Now w/ dobhoff placed\n REASON FOR THIS EXAMINATION:\n evaluation of dobhoff\n ______________________________________________________________________________\n FINAL REPORT\n TYPE OF EXAMINATION: Chest, AP portable, single view.\n\n INDICATION: Liver cirrhosis, encephalopathy, now with seizures. Status post\n intubation for airway protection. Dobbhoff line placement. Evaluate\n position.\n\n FINDINGS: AP single view of the chest has been obtained with patient in\n semi-upright position and analysis is performed in direct comparison with a\n preceding similar study obtained 4 hours earlier during the same date.\n Tracheostomy remains in place. A Dobbhoff line has been placed seen to\n terminate in the stomach. The distal looped portion has passed the hiatal\n area. There is no pneumothorax or any other placement-related complication.\n The previously described diffuse basal densities indicative of pleural\n effusions remain.\n\n IMPRESSION: Successful placement of Dobbhoff line.\n\n\n" }, { "category": "Radiology", "chartdate": "2198-08-26 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 977724, "text": " 7:48 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Source of fever?\n Admitting Diagnosis: SEIZURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with cirrhosis, encephalopathy p/w seizures s/p\n intubation for airway protection. Now w/ fevers.\n REASON FOR THIS EXAMINATION:\n Source of fever?\n ______________________________________________________________________________\n FINAL REPORT\n Portable chest of with comparison to .\n\n INDICATION: Fever.\n\n Endotracheal tube terminates 6 cm above the carina and could be advanced 1 to\n 2 cm for standard positioning. Left subclavian catheter remains in standard\n position as well as a nasogastric tube. Heart is enlarged, and there is\n worsening pulmonary vascular congestion with associated mild perihilar edema.\n Bilateral small-to-moderate pleural effusions and adjacent basilar atelectasis\n are significantly changed. Underlying pneumonia in the lung bases is not\n excluded. No new areas of consolidation or atelectasis are evident.\n\n\n" }, { "category": "Radiology", "chartdate": "2198-08-14 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 975896, "text": " 11:27 AM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: s/p line placement\n Admitting Diagnosis: SEIZURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with cirrhosis, encephalopathy p/w seizures now s/p\n intubation for airway protection. Now w/ fevers.\n REASON FOR THIS EXAMINATION:\n s/p line placement\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Line placement in 63 y/o man with fevers and known cirrhosis.\n\n SEMI-UPRIGHT PORTABLE CHEST RADIOGRAPH:\n\n Comparison is made to film and CT.\n\n There has been interval placement of a left subclavian central venous catheter\n terminating within the distal SVC without evidence of pneumothorax. There is\n increased hazy opacities projecting over both lung fields and worsening\n probable compression atelectasis of the right and left lower lobes. No new\n infiltrates or pulmonary edema is identified. Endotracheal tube terminates\n approximately 8.4 cm from the carina and is above the thoracic inlet with\n nasogastric tube terminating within the gastric fundus. A right-sided central\n venous catheter is unchanged in position.\n\n TIPS stent is again noted projecting over the right upper quadrant.\n\n IMPRESSION:\n\n 1) Appropriate positioned new left central venous catheter without evidence\n of pneumothorax.\n\n 2) Worsening layering bilateral pleural effusions with probable adjacent\n compression atelectasis/consolidation of the right and left lower lobes.\n\n 3) Endotracheal tube approximately 8.4 cm above the carina would likely\n benefit from mild advancement.\n\n D/w Dr. at 1 p.m.\n\n" }, { "category": "Radiology", "chartdate": "2198-08-15 00:00:00.000", "description": "MR HEAD W & W/O CONTRAST", "row_id": 976033, "text": " 10:21 AM\n MR HEAD W & W/O CONTRAST Clip # \n Reason: Please assess for mets to brain and other possible causes of\n Admitting Diagnosis: SEIZURE\n Contrast: MAGNEVIST Amt: 20\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with end stage liver disease, hepatocellular carcinoma and\n seizure disorder. In persistent status when not sedated.\n REASON FOR THIS EXAMINATION:\n Please assess for mets to brain and other possible causes of seizure activity.\n ______________________________________________________________________________\n FINAL REPORT\n MR SCAN OF THE BRAIN WITH GADOLINIUM ENHANCEMENT\n\n HISTORY: Please assess for metastases to the brain or other possible causes\n of seizure activity. The patient has known end-stage liver disease,\n hepatocellular cancer and seizure disorder.\n\n TECHNIQUE: Multiplanar T1- and T2-weighted pre- and post-gadolinium enhanced\n images of the brain were obtained.\n\n COMPARISON STUDY: examination, interpreted by Drs. and\n as revealing \"resolution of extensive cortical and white matter signal\n abnormality since . Findings are most likely related to seizures and\n hepatic encephalopathy, rather than anoxic injury.\" They also reported \"high\n T1 signal in the lentiform nucleus and posterior thalami bilaterally, likely\n related to hepatic encephalopathy.\"\n\n FINDINGS: Compared to the prior study of , there is negligible change\n in the distribution and extent of multiple areas of FLAIR hyperintensity\n within the white matter of both cerebral hemispheres. As before, these\n findings are non-specific in etiology, and could represent either sequelae of\n chronic small vessel infarctions or post-inflammatory residua, including\n demyelination. There are no areas of pathological enhancement seen within the\n brain. It should be mentioned that there are bilaterally symmetric\n curvilinear areas of apparent contrast enhancement seen within the corona\n radiata bilaterally on axial images, which are not confirmed on either the\n sagittal or coronal post-contrast images. Consequently, they are likely\n pulsation artifacts. There are no areas of abnormal susceptibility seen within\n the brain. The principal vascular flow patterns are identified. There is no\n evident shift of normally midline structures. Ventricular and cerebral sulcal\n size are unchanged from the prior examination. Diffusion-weighted images are\n within normal limits.\n\n CONCLUSION: Negligible interval change in the appearance of the brain\n compared to the prior study. Particularly in view of the history of status\n epilepticus, it is of some interest that the present diffusion scan is normal,\n whereas as a diffusion imaging study from , showed very\n extensive areas of signal abnormality. The reason for this discrepancy is not\n clear.\n\n ADDENDUM: Multiple paranasal sinuses exhibit mucosal thickening, and likely\n (Over)\n\n 10:21 AM\n MR HEAD W & W/O CONTRAST Clip # \n Reason: Please assess for mets to brain and other possible causes of\n Admitting Diagnosis: SEIZURE\n Contrast: MAGNEVIST Amt: 20\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n fluid as well within the mastoid sinuses. Presumably, these findings relate\n to the intubated status of the patient.\n\n\n" }, { "category": "Radiology", "chartdate": "2198-08-15 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 976080, "text": " 2:16 PM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p OGT tube placement\n Admitting Diagnosis: SEIZURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with cirrhosis, encephalopathy p/w seizures now s/p\n intubation for airway protection. Now w/ fevers.\n REASON FOR THIS EXAMINATION:\n s/p OGT tube placement\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Cirrhosis, encephalopathy and fever.\n\n SINGLE AP BEDSIDE CHEST RADIOGRAPH\n Large bilateral pleural effusions are greater in the right side and associated\n with bibasilar atelectasis. ET tube is in standard position. Left subclavian\n vein catheter tip is in the distal SVC. NG tube tip is present to the right\n of the midline most likely in the duodenum.\n\n IMPRESSION: No short interval change from prior examination performed a day\n earlier with bilateral pleural effusions, atelectasis. Pneumonic\n consolidation cannot be completely excluded.\n\n\n" }, { "category": "Radiology", "chartdate": "2198-08-28 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 977940, "text": " 11:01 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluation of trach\n Admitting Diagnosis: SEIZURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with cirrhosis, encephalopathy p/w seizures s/p\n intubation for airway protection. Now w/ trach\n REASON FOR THIS EXAMINATION:\n evaluation of trach\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: A 63-year-old male with cirrhosis, encephalopathy and seizures\n status post tracheostomy for airway protection. Evaluate tracheostomy.\n\n COMPARISON: Radiographs .\n\n A single portable supine view of the chest. As previously demonstrated, there\n is pulmonary vascular congestion with associated perihilar edema. There are\n bilateral moderate pleural effusions and bibasilar atelectasis. The\n tracheostomy tube is approximately 6.0 cm above the carina in an acceptable\n position. There has been no interval change in the position of the left\n subclavian catheter. There is evidence of a previous TIPS procedure. No\n pneumothorax is identified.\n\n IMPRESSION:\n 1. Acceptable position of tracheostomy tube.Otherwise no significant change\n as above.\n\n" }, { "category": "Radiology", "chartdate": "2198-08-07 00:00:00.000", "description": "PORTABLE ABDOMEN", "row_id": 974925, "text": " 11:14 AM\n PORTABLE ABDOMEN Clip # \n Reason: KUB to eval for obstruction\n Admitting Diagnosis: SEIZURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with seizures. Stool decreased and high tube feed residuals\n REASON FOR THIS EXAMINATION:\n KUB to eval for obstruction\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 62-year-old man with seizure and high tube-feed residuals, please\n evaluate for obstruction.\n\n Comparison is made to the prior study done on .\n\n One supine radiograph of the abdomen was obtained. This study is somewhat\n limited as upper abdomen and part of the right lower quadrant are not included\n in the radiograph. However, no concerning bowel gas pattern is noted. No\n supine evidence of free intraperitoneal air is visualized. The bony markings\n are normal.\n\n IMPRESSION: Limited study but no evidence of bowel obstruction.\n\n" }, { "category": "Radiology", "chartdate": "2198-08-07 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 974926, "text": " 11:16 AM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o PNA\n Admitting Diagnosis: SEIZURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with cirrhosis, encephalopathy p/w seizures now s/p\n intubation for airway protection. Now w/ fevers.\n REASON FOR THIS EXAMINATION:\n r/o PNA\n ______________________________________________________________________________\n FINAL REPORT\n TYPE OF EXAMINATION: Chest AP portable single view.\n\n INDICATION: Cirrhosis, encephalopathy, now with seizures. Status post\n intubation for airway protection. Now with fevers. Evaluate for possible\n pneumonia.\n\n FINDINGS: AP single view of the chest has been obtained with the patient in\n supine position. Analysis is performed in direct comparison with a preceding\n similar study dated . The patient remains intubated, the ETT\n terminating the trachea at the level of the sternoclavicular junction. NG\n tube remains and still reaches far below diaphragm. Right subclavian approach\n central venous line in unchanged appropriate position. No pneumothorax. There\n is now evidence of bilateral diffuse densities partially concealing the\n diaphragmatic contours. This is in strong contrast to the next previous\n examination of when both diaphragms, where clearly identified as\n being free. Noteworthy is, however, that the preceding examination has been\n performed in upright position, which differs from the present supine portable\n chest examination. Most likely explanation is that bilateral pleural\n effusions exist which now layer out in the posterior dependent pleural spaces.\n When comparison is made with the chest examination of at which time\n the patient was in semi-erect position a similar left-sided basal density was\n already present.\n\n The most likely explanation is that the patient developed increased bilateral\n pleural effusions. To evaluate the possibility of coexisting lower lobe\n parenchymal infiltrates a lateral chest view could be helpful to identify the\n pleural effusion in the posterior position. If bases cannot be penetrated\n enough one may have to resort to a chest CT.\n\n IMPRESSION: Bilateral basal densities most likely representing pleural\n effusions layering posteriorly in supine position.\n\n" }, { "category": "Radiology", "chartdate": "2198-08-05 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 974614, "text": " 10:29 AM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: right SC CVL placed\n Admitting Diagnosis: SEIZURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with cirrhosis, encephalopathy p/w seizures now s/p\n intubation for airway protection\n REASON FOR THIS EXAMINATION:\n right SC CVL placed\n ______________________________________________________________________________\n FINAL REPORT\n EXAMINATION: Chest x-ray.\n\n CLINICAL INDICATION: Status post right subclavian line placed.\n\n FINDINGS: A single portable image of the chest is compared to the prior\n examination dated . In the interim since the prior examination, a\n right subclavian central venous catheter has been placed that terminates\n within the expected region of the SVC/RA junction. A feeding catheter has\n been placed as well that terminates below the gastroesophageal junction with\n its tip at the expected region of the gastric fundus. The endotracheal tube\n is stable in position terminating approximately 6 cm above the carina. There\n are stable left basilar streaky opacities likely reflects underlying\n atelectasis. There is improved aeration of the left lung. The\n cardiomediastinal silhouette is within normal limits. No pneumothorax is\n seen.\n\n IMPRESSION:\n 1. New right-sided subclavian line in grossly satisfactory position.\n\n 2. Improved aeration of the left lung.\n\n\n" }, { "category": "Radiology", "chartdate": "2198-08-02 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 974228, "text": " 11:31 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: eval for bleed\n Admitting Diagnosis: SEIZURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with seizures, s/p fall out of bed, hit head\n REASON FOR THIS EXAMINATION:\n eval for bleed\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CT OF THE HEAD WITHOUT CONTRAST PERFORMED ON \n\n HISTORY: A 53-year-old male with seizures, status post fall out of bed,\n hitting his head. Concern for intracranial hemorrhage.\n\n TECHNIQUE: Contiguous 2.5 mm thick axial images were obtained through the\n brain. No IV contrast was administered.\n\n COMPARISON: CT of the head without contrast performed on .\n\n FINDINGS: There is no evidence of hemorrhage, edema, masses, mass effect or\n large vascular territory infarction. The ventricles and sulci are normal in\n caliber and configuration. No fractures are seen.\n\n Compared to the prior study, there is increased opacification of the ethmoid\n air cells, particularly posteriorly. There is opacification of the right\n maxillary sinus, which was previously seen in the MRI of the head found on\n . There is a central region of hyperintensity within this\n opacified sinus. This may represent chronic sinusitis changes, however, these\n findings may also be consistent with fungal infection; further workup would be\n recommended if clinically warranted. The left maxillary sinus also has\n posterior mucosal thickening. There is fluid or mucosal thickening in the left\n frontal sinus as well. There is also right nasoseptal deviation with a small\n right-sided spur.\n\n IMPRESSION:\n 1. There is no evidence of intracranial hemorrhage, mass effect, or large\n vascular territory infarct. There is no evidence of fracture.\n 2. There is increase in opacification of the ethmoid air cells. Again seen\n is opacification of the right maxillary sinus with central hyperintensity.\n This is likely due to chronic sinusitis changes, however, would recommend work\n up to rule out fungal infection if clinically warranted. There is no change\n to the appearance of this sinus compared to prior studies. A left maxillary\n sinus also has mucosal thickening posteriorly, and there is fluid or mucosal\n thickening in the left frontal sinus as well.\n\n" }, { "category": "Radiology", "chartdate": "2198-08-07 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 975013, "text": " 10:43 PM\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \n Reason: s/p Left IJ dialysis catheter\n Admitting Diagnosis: SEIZURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with cirrhosis, encephalopathy p/w seizures now s/p\n intubation for airway protection. Now w/ fevers.\n REASON FOR THIS EXAMINATION:\n s/p Left IJ dialysis catheter\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 63-year-old man with cirrhosis, encephalopathy and seizures status\n post intubation with newly placed left internal jugular dialysis catheter.\n\n Comparison to prior radiograph and CT examinations dated .\n\n SUPINE PORTABLE CHEST RADIOGRAPH: There has been interval placement of a left\n internal jugular central venous catheter with its tip terminating within the\n brachiocephalic junction with no significant interval change other lines and\n tubes. Endotracheal tube which terminates 7 cm from the carina and right\n subclavian central venous catheter. Left lower lobe atelectasis has improved\n with residual air bronchogram density persisting with interval worsening of\n probable layering right pleural effusion and adjacent compression atelectasis.\n No evidence of pneumothorax. Heart size remains enlarged.\n\n IMPRESSION: New left internal jugular central venous catheter terminating\n within the brachiocephalic junction. No evidence of pneumothorax. Improvement\n to left lower lobe atelectasis with persistent air bronchogram containing\n opacity and slight worsening of layering right pleural effusion and adjacent\n compression atelectasis.\n\n 3. Endotracheal tube terminating 7 cm from the carina and above the thoracic\n inlet. Advancement is recommended.\n\n" }, { "category": "Radiology", "chartdate": "2198-08-02 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 974172, "text": " 3:52 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate for infiltrates\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with cirrhosis, encephalopathy p/w seizures\n REASON FOR THIS EXAMINATION:\n evaluate for infiltrates\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Cirrhosis and encephalopathy.\n\n FINDINGS: Single bedside chest radiograph is compared to .\n Evaluation is limited secondary to marked rotation and the apparent asymmetric\n opacification of the left hemithorax is likely secondary to overlying soft\n tissues. The lungs are clear. The costophrenic angles are sharp. The heart and\n mediastinal contours are difficult to evaluate, but likely likely unchanged,\n\n IMPRESSION: Limited, but no acute cardiopulmonary process.\n\n" }, { "category": "Radiology", "chartdate": "2198-08-03 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 974336, "text": " 4:33 AM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o PNA\n Admitting Diagnosis: SEIZURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with cirrhosis, encephalopathy p/w seizures\n\n REASON FOR THIS EXAMINATION:\n r/o PNA\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 60-year-old male with cirrhosis and encephalopathy with seizures.\n Evaluate for pneumonia.\n\n Comparison is made to prior radiograph dated and CT torso\n dated .\n\n UPRIGHT PORTABLE CHEST RADIOGRAPH\n\n The lungs are clear. Cardiomegaly is unchanged with mediastinal silhouette,\n hilar contours, and pleural surfaces appear unremarkable. There is no\n evidence of pulmonary edema or pneumothorax. TIPS stent projects over the\n liver.\n\n IMPRESSION:\n\n No acute cardiopulmonary process.\n\n" }, { "category": "Radiology", "chartdate": "2198-08-10 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 975416, "text": " 4:27 PM\n CHEST (PORTABLE AP) Clip # \n Reason: PNA?\n Admitting Diagnosis: SEIZURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with cirrhosis, encephalopathy p/w seizures now s/p\n intubation for airway protection. Now w/ fevers.\n REASON FOR THIS EXAMINATION:\n PNA?\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Cirrhosis and encephalopathy with seizures, patient\n intubated.\n\n CHEST:\n\n The endotracheal tube lies in the region of the thoracic inlet, unchanged\n since the prior chest x-ray. Position of the other various lines and tubes is\n also unaltered.\n\n There has been considerable clearing of the left lower lobe atelectasis and\n infiltrate. There is some infiltrate in the posterior portion of the left\n lower lobe still probably present. Some fluid is still probably present on\n the right side, but the size of the right pleural effusion has improved since\n the prior chest x-ray.\n\n IMPRESSION: Overall, improvement on both the right and left sides of the\n chest.\n\n\n" }, { "category": "Radiology", "chartdate": "2198-08-04 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 974518, "text": " 1:44 PM\n CHEST (PORTABLE AP) Clip # \n Reason: ET tube placement\n Admitting Diagnosis: SEIZURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with cirrhosis, encephalopathy p/w seizures now s/p\n intubation for airway protection\n REASON FOR THIS EXAMINATION:\n ET tube placement\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST X-RAY.\n\n CLINICAL HISTORY: Patient with encephalopathy and seizures status post\n endotracheal tube placement.\n\n FINDINGS: A single portable image of the chest was obtained and compared to\n the prior examination dated . In the interim, an endotracheal tube\n has been placed that terminates approximately 5.2 cm above the carina. There\n is a new left basilar hazy opacity, likely reflects underlying effusion. The\n right costophrenic angle is not included on this film. The right lung is\n otherwise clear. The mild cardiomegaly is unchanged as is the mediastinal\n contour.\n\n IMPRESSION:\n\n 1. Endotracheal tube in grossly satisfactory position.\n\n 2. New left basilar hazy opacity likely reflects underlying effusion, cannot\n exclude associated atelectasis and/or pneumonia.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2198-09-24 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 981752, "text": " 9:24 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval pna\n Admitting Diagnosis: SEIZURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with cirrhosis, encephalopathy p/w seizures now with\n trach and low-grade fever\n REASON FOR THIS EXAMINATION:\n eval pna\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Cirrhosis, encephalopathy with seizures, now with fever.\n\n CHEST\n\n Comparison is made with the prior chest x-ray of . Left lower lobe\n consolidation is again noted with air bronchograms. Some opacification is\n present in the right lower lung, which may represent either an effusion or\n possibly early infiltrate. Perihilar edema present on the prior chest x-ray\n of is no longer present.\n\n The position of the various lines and tubes remains unchanged.\n\n IMPRESSION: Left lower lobe consolidation, new opacification in right lower\n lobe.\n\n\n" }, { "category": "Radiology", "chartdate": "2198-09-20 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 981278, "text": " 9:44 AM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p doboff advancement\n Admitting Diagnosis: SEIZURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with\n REASON FOR THIS EXAMINATION:\n s/p doboff advancement\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE AP PORTABLE VIEW OF THE CHEST\n\n REASON FOR EXAM: Assess Dobbhoff placement.\n\n Comparison is made with prior study dated .\n\n Tracheostomy tube remains in place. Dobbhoff tube tip is in the lower\n esophagus. Left lower lobe retrocardiac atelectasis is persistent. There is\n small left pleural effusion. Mild cardiomegaly is unchanged. There is no\n pneumothorax.\n\n Findings were discussed with Dr. at the time of interpretation\n of the study.\n\n\n DR. \n" }, { "category": "Radiology", "chartdate": "2198-08-07 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 975000, "text": " 7:56 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: Septic, Status epilepticus\n Admitting Diagnosis: SEIZURE\n ______________________________________________________________________________\n FINAL ADDENDUM\n ADDENDUM: Please note, there is no gross midline shift.\n\n DR. \n\n 7:56 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: Septic, Status epilepticus\n Admitting Diagnosis: SEIZURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with NASH cirrhosis, HTN , status epilepticus\n REASON FOR THIS EXAMINATION:\n Septic, Status epilepticus\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CT OF THE HEAD WITHOUT CONTRAST.\n\n INDICATION: 63-year-old male with NASH cirrhosis, hypertension, status post\n status epilepticus. Patient also with sepsis.\n\n COMPARISONS: .\n\n TECHNIQUE: Non-contrast head CT.\n\n FINDINGS: Detailed evaluation is significantly limited by streak artifact\n from multiple overlying metallic markers surrounding the outside of the head\n at multiple planes. Within these limitations, no focal intracranial\n hemorrhage, shift of normally midline structures, hydrocephalus or major\n vascular territorial infarction is present. Dense material is again noted\n within the right maxillary sinus. A small amount of dense material is also\n noted within the left maxillary sinus. There is diffuse opacification of the\n ethmoid sinuses. A small amount of high-density material is also located\n within the left frontal sinus. The soft tissues and osseous structures are\n unremarkable.\n\n IMPRESSION: Limited evaluation secondary to artifact from overlying metallic\n devices. No gross acute intracranial hemorrhage. Unchanged multifocal sinus\n disease as described on .\n\n NOTE ON ATTENDING REVIEW:\n\n The study is markedly limited for the evaluation of brain parencyma due to\n streak artifacts from the several external metallic objects. There is gross\n midline shift. Other than this, it is extremely difficult to assess the\n intracranial structures for abnormality.\n\n There is new moderate opacification of the sphenoid sinus and the left side\n of frontal sinus and the marked opacification of ethmoid air cells is\n worsened.\n\n The nasopharynx is opaciifed with a tube, likely nasogastric tube within. This\n appearance is new.\n\n Dr. reviewed the study and edited the report.\n\n\n (Over)\n\n 7:56 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: Septic, Status epilepticus\n Admitting Diagnosis: SEIZURE\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2198-08-07 00:00:00.000", "description": "CT CHEST W/O CONTRAST", "row_id": 975001, "text": " 7:57 PM\n CT CHEST W/O CONTRAST; CT ABDOMEN W/O CONTRAST Clip # \n CT PELVIS W/O CONTRAST\n Reason: elevating lactic acid, acidiotic, any abdominal processes?PO\n Admitting Diagnosis: SEIZURE\n Field of view: 44\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with HTN, NASH cirrhosis, admitted for status epilepticus,\n currently comaosed,\n REASON FOR THIS EXAMINATION:\n elevating lactic acid, acidiotic, any abdominal processes?PO CONTRAST\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: CT of the chest, abdomen and pelvis.\n\n INDICATION: 63-year-old male with a history of cirrhosis admitted for status\n epilepticus presenting with elevated lactic acid and comatose. Assess for\n abdominal process.\n\n COMPARISONS: .\n\n TECHNIQUE: Non-contrast MDCT axial images were acquired from the thoracic\n inlet to the pubic symphysis. Coronal and sagittal reformatted images were\n then obtained.\n\n CT OF THE CHEST WITHOUT IV CONTRAST: Mild-to-moderate calcific\n atherosclerotic disease of the left anterior descending, left circumflex, and\n right coronary artery is noted. The heart is moderately enlarged in size.\n There is no pericardial effusion. Please note, detailed evaluation of the\n intrathoracic organs is limited secondary to lack of intravenous contrast\n administration. No pathologically enlarged mediastinal, hilar or axillary\n lymph nodes are present. There is bilateral partial collapse of the lower\n lobes, right greater than left. There is a small right pleural effusion as\n well. A focal opacity present at the left lung base measuring 14 x 11 mm in\n size is suspicious for aspiration. Otherwise, the lungs are clear.\n\n CT OF THE ABDOMEN WITHOUT IV CONTRAST: Please note, detailed evaluation of\n the intra-abdominal organs is limited secondary to lack of intravenous\n contrast administration. The silhouette of a TIPS shunt can be seen within\n the right lobe of the liver. The gallbladder is minimally distended but there\n is no wall edema. The pancreas, adrenal glands, right kidney, and spleen are\n unremarkable. A low-attenuation area within the lower pole of the left kidney\n measuring 1.4 cm, most likely represents a simple renal cyst (2:70). A small\n amount of fluid is noted around the spleen. Multiple diverticula of the colon\n are present. The ascending colon is noted to be filled with liquid material.\n No significant mesenteric or retroperitoneal lymphadenopathy is present.\n\n CT OF THE PELVIS WITHOUT IV CONTRAST: A rectal tube is present. Multiple\n diverticula of the sigmoid colon are present. A Foley balloon is present\n within a decompressed bladder. There is no free fluid in the pelvis. No\n pathologically enlarged inguinal or pelvic lymph nodes present.\n (Over)\n\n 7:57 PM\n CT CHEST W/O CONTRAST; CT ABDOMEN W/O CONTRAST Clip # \n CT PELVIS W/O CONTRAST\n Reason: elevating lactic acid, acidiotic, any abdominal processes?PO\n Admitting Diagnosis: SEIZURE\n Field of view: 44\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n BONE WINDOWS: Mild degenerative changes are noted at the L5-S1 level.\n\n IMPRESSION:\n\n 1. Limited evaluation secondary to lack of intravenous contrast\n administration. New right and left lower lobe collapse compared to .\n New small right pleural effusion. Patchy appearance of left lung base raises\n the suspicion for component of aspiration. Overall findings suspicious for\n pneumonia. Clinical correlation is recommended. Endotracheal tube and\n nasogastric tube remain in good position.\n\n 2. Small amount of perihepatic fluid. TIPS shunt. No significant amount of\n abdominal ascites. No evidence of acute abdominal or pelvic pathology within\n the limitations described.\n\n Findings were discussed with Dr. by Dr. over the\n telephone at 9:30 p.m. on .\n\n" }, { "category": "Radiology", "chartdate": "2198-09-16 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 980730, "text": " 10:24 AM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: please check picc tip position. #5f, dl, 45cm v-cath picc fo\n Admitting Diagnosis: SEIZURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with cirrhosis, encephalopathy p/w seizures now with trach\n and low-grade fever\n REASON FOR THIS EXAMINATION:\n please check picc tip position. #5f, dl, 45cm v-cath picc for hydration and\n meds. thanks.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 63-year-old man with cirrhosis and encephalopathy, now with\n seizures. Evaluate PICC placement.\n\n COMPARISON: .\n\n SINGLE AP SUPINE BEDSIDE CHEST RADIOGRAPH: Right PICC has been placed,\n terminating deep in the right atrium, approximately 6.2 cm below the tip of\n the left subclavian catheter which terminates at the cavo-atrial junction.\n Weighted feeding tube tip terminates in the stomach. Tracheostomy tube and\n multiple EKG leads are noted. The appearance of the lungs is unchanged, with\n persistent moderate bilateral pleural effusions and bibasilar\n atelectasis/airspace consolidation. A TIPS stent is noted in the right\n upper quadrant. There is no pneumothorax.\n\n IMPRESSION:\n\n Newly introduced right PICC terminates in the right atrium and should be\n repositioned. Pulmonary findings are unchanged. Findings were discussed with\n the IV access team at the time of the exam.\n\n\n" }, { "category": "Radiology", "chartdate": "2198-09-16 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 980752, "text": " 2:26 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: new picc\n Admitting Diagnosis: SEIZURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with cirrhosis, encephalopathy p/w seizures now with trach\n and low-grade fever\n REASON FOR THIS EXAMINATION:\n new picc\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: AP chest, .\n\n HISTORY: 63-year-old male with cirrhosis and encephalopathy. New PICC line.\n\n FINDINGS: Comparison is made to previous study from at\n 10:52 a.m.\n\n There is a right-sided PICC line whose distal tip is in the distal SVC and has\n been pulled back since the previous study. The left-sided PICC line has been\n removed. There is a feeding tube whose distal tip is within the body of the\n stomach. TIPS is seen. There is a left retrocardiac opacity and pleural\n effusions, left side worse than right. There is crowding in the pulmonary\n vascular markings due to poor inspiratory effort.\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2198-10-24 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 985670, "text": " 7:20 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Tip of Dobhoff in stomach or post-pyloric?\n Admitting Diagnosis: SEIZURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with encephalopathy, s/p Dobhoff adjustment.\n REASON FOR THIS EXAMINATION:\n Tip of Dobhoff in stomach or post-pyloric?\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 63-year-old male with encephalopathy, status post Dobbhoff\n adjustment.\n\n COMPARISON: Chest radiograph of .\n\n AP UPRIGHT PORTABLE CHEST X-RAY: A Dobbhoff tube is again seen, further into\n the stomach. Tracheostomy tube, right PICC and TIPS are again seen, in\n unchanged positions. The heart size is in the upper limits of normal. The\n mediastinal contour is unchanged. No pneumothorax or pleural effusions are\n present. Again seen is right mid lung and left basal atelectasis, unchanged\n from the prior exam.\n\n IMPRESSION: Dobhoff terminates in the stomach. Unchanged atelectasis.\n\n" }, { "category": "Radiology", "chartdate": "2198-09-18 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 980964, "text": " 9:37 AM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: Picc location\n Admitting Diagnosis: SEIZURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with cirrhosis, encephalopathy p/w seizures now with trach\n and low-grade fever\n REASON FOR THIS EXAMINATION:\n Picc location\n ______________________________________________________________________________\n FINAL REPORT\n\n INDICATION: 53-year-old man with cirrhosis, encephalopathy and tracheostomy;\n low-grade fever; assess PICC location.\n\n COMPARISON: Chest radiograph dated .\n\n FINDINGS: A single AP view of the chest and upper abdomen was obtained. The\n left costophrenic angle is excluded from the study. A tracheostomy tube\n terminates approximately 4 cm above the carina. A right-sided PIC catheter\n terminates in the mid superior vena cava. A feeding tube situated in the\n stomach. A TIPS stent is seen in the right upper abdomen.\n\n There is a stable retrocardiac opacity with associated air bronchograms. Lung\n volumes are low and opacity in the medial right lower lung may represent\n vessel crowding. There is no pneumothorax or pulmonary vascular congestion.\n The cardiac silhouette is stable.\n\n IMPRESSION:\n\n 1. Stable retrocardiac opacity, which could represent a combination of\n pneumonia, atelectasis and effusion.\n\n 2. Right PICC line terminating in the mid superior vena cava.\n\n RLE\n\n" }, { "category": "Radiology", "chartdate": "2198-10-22 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 985348, "text": " 8:53 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Placement of NG tube tip?\n Admitting Diagnosis: SEIZURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 yo man s/p Dobhoff placement, moved in 30 cm further after last CXR\n\n REASON FOR THIS EXAMINATION:\n Placement of NG tube tip?\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Dobbhoff replacement, evaluate.\n\n COMPARISON: .\n\n FINDINGS: The single upright portable chest radiograph performed at 9:15 a.m.\n shows Dobbhoff tube terminating in the stomach. There is no pleural effusion\n or pneumothorax. Right mid lung and left basal atelectasis are unchanged. No\n other change compared to prior study.\n\n IMPRESSION: Dobbhoff tube terminates in the stomach.\n\n The results were discussed with Dr. at 10:20 a.m. on , .\n\n\n" }, { "category": "Radiology", "chartdate": "2198-09-14 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 980494, "text": " 1:54 PM\n CHEST (PORTABLE AP) Clip # \n Reason: pneumonia/atx\n Admitting Diagnosis: SEIZURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with cirrhosis, encephalopathy p/w seizures now with trach and\n low-grade fever\n REASON FOR THIS EXAMINATION:\n pneumonia/atx\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Cirrhosis, encephalopathy, and fever.\n\n FINDINGS: In comparison with the study of , the left hemidiaphragm is\n sharper consistent with some decrease in effusion and atelectasis on that\n side. The opacifications on the right are essentially unchanged, as is the\n position of the various tubes.\n\n\n" }, { "category": "Radiology", "chartdate": "2198-09-02 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 978683, "text": " 7:45 AM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o acute pulmonary process\n Admitting Diagnosis: SEIZURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with cirrhosis, encephalopathy p/w seizures s/p\n intubation for airway protection now desating\n REASON FOR THIS EXAMINATION:\n r/o acute pulmonary process\n ______________________________________________________________________________\n FINAL REPORT\n EXAMINATION: AP chest.\n\n INDICATION: Intubated. Hypoxia.\n\n Single AP view of the chest was obtained at 0748 hours and compared\n with the prior radiograph performed at 1520 hours. Patient remains\n with the tracheostomy tube with the tip approximately 3.6 cm above the carina.\n Increased retrocardiac density in the left side consistent with\n atelectasis/airspace disease/fluid is essentially unchanged since the prior\n examination. Right costophrenic angle is not included and therefore I cannot\n comment on a right pleural effusion. Dobbhoff tube is within the gastric\n fundus. A left-sided subclavian line is present with its tip projecting over\n the distal SVC.\n\n IMPRESSION:\n\n Stable appearances to the chest with persistent atelectasis/airspace\n disease/effusion on the left side.\n\n" }, { "category": "Radiology", "chartdate": "2198-10-21 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 985298, "text": " 10:21 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Line position?\n Admitting Diagnosis: SEIZURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with Dobhoff placed\n REASON FOR THIS EXAMINATION:\n Line position?\n ______________________________________________________________________________\n FINAL REPORT\n COMPARISON: .\n\n FINDINGS: Single semi-upright portable chest radiograph performed at 10:30\n p.m. demonstrates Dobbhoff tube terminating in the upper to mid thoracic\n esophagus. Tracheostomy tube is unchanged and terminates about 3.4 cm above\n carina. Right mid lung and left basal atelectasis are present. There is no\n pneumothorax or pleural effusion.\n\n IMPRESSION: The Dobbhoff tube terminates in the mid thoracic esophagus and\n needs to be replaced.\n\n\n" }, { "category": "Radiology", "chartdate": "2198-10-22 00:00:00.000", "description": "US ABD LIMIT, SINGLE ORGAN", "row_id": 985390, "text": " 12:47 PM\n US ABD LIMIT, SINGLE ORGAN Clip # \n Reason: Ascitis?\n Admitting Diagnosis: SEIZURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with NASH and HCC, liver failure and s/p status epilepticus, in\n need for PEG for Persistent Vegetative State. *** Patient will be seen by\n GI/Liver on Monday , if possible please perform study before then.\n Thanks ***\n REASON FOR THIS EXAMINATION:\n Ascitis?\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 63-year-old man with NASH and hepatitis C. Evaluate for ascites.\n\n COMPARISON: .\n\n LIMITED ABDOMINAL ULTRASOUND: Limited views were obtained in the right upper,\n right lower, left upper, and left lower quadrants. There is no intra-\n abdominal ascites.\n\n IMPRESSION:\n\n 1. No intra-abdominal ascites.\n\n" }, { "category": "Radiology", "chartdate": "2198-09-06 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 979354, "text": " 11:50 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Please assess for consolidation or edema.\n Admitting Diagnosis: SEIZURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with cirrhosis, encephalopathy p/w seizures now with trach and\n poor lung sounds.\n REASON FOR THIS EXAMINATION:\n Please assess for consolidation or edema.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: A 53-year-old man with cirrhosis, encephalopathy, seizures, now\n with poor lung sounds.\n\n COMPARISON: AP semiupright portable chest x-ray dated .\n\n AP UPRIGHT PORTABLE CHEST X-RAY: Tracheostomy tube is in place, unchanged.\n The Dobbhoff catheter descends below the diaphragm with the tip in area of the\n stomach body. A left subclavian central venous catheter terminates in the\n proximal SVC. The patient is status post TIPS. Pulmonary vasculature is not\n engorged. The lung volumes are low, and bilateral pleural effusions have\n increased.\n\n IMPRESSION: Worsening pleural effusions.\n\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2198-10-24 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 985777, "text": " 7:48 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: Position of Dobhoff tip?\n Admitting Diagnosis: SEIZURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with Dobhoff, recently manipulated\n REASON FOR THIS EXAMINATION:\n Position of Dobhoff tip?\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE AP PORTABLE VIEW OF THE CHEST.\n\n REASON FOR EXAM: Assess NG tube.\n\n Comparison is made with prior study performed the same day earlier in the\n morning.\n\n Tracheostomy tube remains in standard position. NG tube (Dobbhoff) tip is to\n the right of midline probable in the first portion of the duodenum.\n Cardiomediastinal contour is unchanged. Discoid atelectasis in the right\n parahilar region is stable as is left lower lobe discoid atelectasis. There\n are no new lung opacities. Right PICC remains in place. There is no\n pneumothorax or sizable pleural effusion.\n\n\n DR. \n" }, { "category": "Radiology", "chartdate": "2198-10-24 00:00:00.000", "description": "CT CHEST W/CONTRAST", "row_id": 985751, "text": " 3:15 PM\n CT CHEST W/CONTRAST; CT ABD W&W/O C Clip # \n CT PELVIS W/CONTRAST\n Reason: Lung metastasis?\n Admitting Diagnosis: SEIZURE\n Contrast: OPTIRAY Amt: 150\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n\n INDICATION: 63-year-old man with NASH, cirrhosis, post RF ablation of liver\n lesions, question lung metastasis.\n\n TECHNIQUE: Contiguous axial CT images of the chest, abdomen, and pelvis are\n obtained with the administration of intravenous contrast , using\n multiphasic technique.\n\n Multiplanar reformation images are reconstructed.\n\n COMPARISON: Multiple prior CT studies, including the recent CT torso study\n dated .\n\n FINDINGS:\n\n CHEST: The patient is status post tracheostomy tube placement, with the tip\n terminating at the level of thoracic inlet. There are small mediastinal lymph\n nodes; however, there is no significant lymphadenopathy. Coronary arteries\n are calcified. There is no pericardial effusion. Small pericardial nodes are\n noted; however, measure less than 5 mm. There is trace pleural effusion\n bilaterally. In the lung window, again note is made of patchy opacities in\n the dependent portion of lower lobes, decreased since prior study, likely\n representing residual atelectasis. Somewhat confluent area in the left lower\n lobe is noted, likely due to a part of resolving atelectasis; however, the\n attention should be paid to this location at the time of next follow up. There\n is no endobronchial lesion.\n\n ABDOMEN: The patient is status post RF ablation of two lesions in the right\n lobe of the liver, which demonstrate hypoattenuation relative to liver\n parenchyma on all the phases. The patient is status post TIPS placement. The\n visualized portion of portal vein is patent. There is no new focal arterial\n enhancement. Again, note is made of splenomegaly. Gallbladder is\n unremarkable without evidence of calcification. Pancreas is somewhat\n atrophic, without ductal dilatation or focal solid lesion. There is fat\n replacement of the pancreatic head. There is unchanged fat stranding\n surrounding the celiac trunk with small nodes. There are enlarged\n peripancreatic and porta hepatis nodes measuring up to 1.4 cm in short axis,\n unchanged since prior study. There is no significant ascites. The adrenal\n glands are within normal limits. The visualized portion of large and small\n intestines are within normal limits. Bilateral kidneys have surrounding fat\n stranding with unchanged small hypoattenuating lesion, likely representing\n cyst, unchanged since prior studies. There is no hydronephrosis. The\n evaluation of the posterior portion of the abdomen is somewhat limited due to\n artifact from the arms.\n (Over)\n\n 3:15 PM\n CT CHEST W/CONTRAST; CT ABD W&W/O C Clip # \n CT PELVIS W/CONTRAST\n Reason: Lung metastasis?\n Admitting Diagnosis: SEIZURE\n Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n PELVIS: There is colonic diverticulosis without evidence of diverticulitis.\n Note is made of residual fluid in the somewhat dilated rectum. Foley catheter\n is noted in the urinary bladder. The visualized portions of small intestines\n are within normal limits, without ascites or lymphadenopathy.\n\n There are degenerative changes of thoracolumbar spine; however, there is no\n suspicious lytic or blastic lesion in skeletal structures. Atherosclerotic\n changes of the vascular structures are again noted.\n\n IMPRESSION:\n 1. Decreased parenchymal opacities in both lower lobes with residual\n atelectasis and effusion. Somewhat confluent area near the left lower lobe,\n likely a part of resolving atelectasis. Attention should be paid to this\n location at the time of next followup.\n 2. Post RF ablation of two liver lesions without new arterial enhancement,\n with severe cirrhosis and splenomegaly.\n 3. Enlarged porta hepatis and peripancreatic nodes, unchanged.\n 4. Diverticulosis.\n\n\n" }, { "category": "Radiology", "chartdate": "2198-10-12 00:00:00.000", "description": "MR HEAD W & W/O CONTRAST", "row_id": 984063, "text": " 3:03 AM\n MR HEAD W & W/O CONTRAST Clip # \n Reason: Please eval for interval change since last MRI. Since then,\n Admitting Diagnosis: SEIZURE\n Contrast: MAGNEVIST Amt: 17\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with epilepsy\n REASON FOR THIS EXAMINATION:\n Please eval for interval change since last MRI. Since then, he has been in\n status epilepticus, drug-induced coma and neurologic examination has been\n difficult to obtain. Looking for any evidence of anoxic-ischemic brain injury.\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INDICATION: Evaluate for interval changes in a patient with status\n epilepticus and drug-induced coma.\n\n TECHNIQUE: Multiplanar T1- and T2-weighted pre- and post-gadolinium enhanced\n images of the brain were obtained. Diffusion-weighted imaging was also\n reviewed.\n\n COMPARISON: .\n\n FINDINGS: There is no interval change in the distribution and extent of\n multiple areas of FLAIR hyperintensity within the white matter of both\n cerebral hemispheres. These are nonspecific in etiology and could represent\n sequelae of chronic small vessel infarctions or post-inflammatory residual.\n There are no areas of pathological enhancement. There are no areas of\n restricted diffusion. There is no shift of normally midline structures. The\n ventricular and cerebral sulcal size is unchanged. The right maxillary sinus\n demonstrates an air-fluid level. There is a smaller air-fluid level in the\n sphenoid sinus. The posterior ethmoid sinuses are prominent.\n\n IMPRESSION:\n 1. No acute intracranial process.\n\n 2. Multiple paranasal sinuses exhibit mucosal thickening and some demonstrate\n air-fluid levels. This may represent sinusitis or post intubation changes.\n\n\n" }, { "category": "Radiology", "chartdate": "2198-10-24 00:00:00.000", "description": "BONE SCAN", "row_id": 985686, "text": "BONE SCAN Clip # \n Reason: SEE REQ\n ______________________________________________________________________________\n FINAL REPORT\n\n RADIOPHARMECEUTICAL DATA:\n 25.3 mCi Tc-m MDP ();\n HISTORY:63 year old male with NASH and HCC. Evaluate for metastatic disease.\n\n INTERPRETATION: Whole body images of the skeleton were obtained in anterior\n and posterior projections. Multifocal periarticular MDP uptake in the\n shoulders, right elbow, wrists, hand, knees, ankles and feet are essentially\n unchanged and most likely related to degenerative change. Foley catheter is\n present. No new focus of abnormal MDP uptake.\n\n The kidneys and urinary bladder are visualized, the normal route of tracer\n excretion.\n\n IMPRESSION: No change from . Specifically, no evidence of MDP avid\n osseous metastases.\n\n\n , M.D.\n , M.D. Approved: MON 4:01 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": "Echo", "chartdate": "2198-08-10 00:00:00.000", "description": "Report", "row_id": 81883, "text": "PATIENT/TEST INFORMATION:\nIndication: assess for wall motion abnormality\nHeight: (in) 68\nWeight (lb): 170\nBSA (m2): 1.91 m2\nBP (mm Hg): 110/60\nHR (bpm): 110\nStatus: Inpatient\nDate/Time: at 01:39\nTest: 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 ATRIUM: Mild LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.\n\nLEFT VENTRICLE: Normal LV wall thickness and cavity size. Mild regional LV\nsystolic dysfunction. Mildly depressed LVEF.\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: basal\nanteroseptal - hypo; mid anteroseptal - hypo; basal inferoseptal - akinetic;\nmid inferoseptal - akinetic; basal inferior - akinetic; mid inferior - hypo;\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTIC VALVE: No AR.\n\nMITRAL VALVE: Mild (1+) MR.\n\nTRICUSPID VALVE: Physiologic TR. Indeterminate PA systolic pressure.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Emergency study performed by the cardiology fellow on call.\n\nConclusions:\nThe left atrium is mildly dilated. Left ventricular wall thicknesses and\ncavity size are normal. There is mild regional left ventricular systolic\ndysfunction with hypokinesis of the anterior septum, akinesis of the inferior\nseptum, and severe hypokinesis of the inferior wall (c/w multivessel CAD). The\nremaining segments contract normally (LVEF = 40%). Right ventricular chamber\nsize and free wall motion are normal. No aortic regurgitation is seen. Mild\n(1+) mitral regurgitation is seen. The pulmonary artery systolic pressure\ncould not be determined. There is no pericardial effusion.\n\nIMPRESSION: Mild regional left ventricular systolic dysfunction, c/w CAD. Mild\nmitral regurgitation.\n\nCompared with the prior study (images reviewed) of , regional LV wall\nmotion abnormalities are new, and consequently, LV systolic function is now\ndepressed.\n\nDr. was informed of the findings at 0750 hours on \n\n\n" }, { "category": "Nursing/other", "chartdate": "2198-09-19 00:00:00.000", "description": "Report", "row_id": 1265483, "text": "condition update\nPlease see carevue for specifics.\nNeuro: Alert, opens eyes spontanteously, does not track. Pt will withdrawl very slightly in all extremities to noxious stimuli. Cont. eeg continues.\nCV: iv lopressor changed to po\nResp: suctioned for large amts. thick tan/blood tinged sputum, pt also able to expectorate sputum.\nGI: Flexiseal d/c'd as there has been no stool for several days and stool had become soft (from liquid). Shortly after flexiseal, pt was incontinent x's 2 of copious amts. soft golden brown stool - turning to liquid stool. New flexiseal placed at this time. Abd. is less distended. TF continue at goal.\nGU: foley draining clear yellow urine at times, intermittently bloody with clots. Sicu team is aware, and urology team has evaluated. u/a and culture sent. Foley required irrigation x's 2 to clear clots. No new orders at this time.\nEndo: bs elevated, lantus dose increased.\nIV: Unable to flush 1 lumen of picc after dilantin dose, though attempted flush immediately after dose completed. IV rn notfied who suggested sodium bicarbonate. Sicu ho notified and sodium bicarb. tried without effect. Will cont. to try to flush with na bicarb, and change over wire in am if unsuccessful.\nPlan: continue neuro checks, eeg, pulmonary toileting, cont. to monitor urine, irrigate as necessary.\n" }, { "category": "Nursing/other", "chartdate": "2198-09-20 00:00:00.000", "description": "Report", "row_id": 1265484, "text": "Respiratory Care:\nPt remains with #8 portex. On 35% trach mask. Suctioning thick tan secretions. No changes.\n" }, { "category": "Nursing/other", "chartdate": "2198-09-20 00:00:00.000", "description": "Report", "row_id": 1265485, "text": "Condition update\nSee careview for objective data/trends:\n\nAlert, opens eyes, does not track. Withdraws LUE to nailbed, grimice to RUE nailbed, no movement noted to BLE. Pupils equal and briskly reactive. Appears comfortable. Low grade temp this , 100.1, down to 98.6 without intervention. HR 80-90, NSR no ectopy. BP stable. Lungs coarse, requires suctioning for thick tan blood tinged secreations. Sats >96% on 35% trach mask. Abd soft, flexiseal in place with large amt liquid stool. Tolerating tube feeds at goal. Foley with yello-pink urine with some clots, irrigated x 1 with good effect, currently urine is clear. K 3.4 this , repleated with 60meq, 3.1 this am, repleating with additional 60 meq. PICC line port remains unable to flush. IV RN to change PICC over wire today. See careview for skin assessment. Plan to cont on eeg, wean seizure medication as tolerated, monitor resp status and hemodynamics. Cont to monitor urine for clots, per urology recs hand irrigate q4hrs. Monitor and repleate lytes prn.\n" }, { "category": "Nursing/other", "chartdate": "2198-09-03 00:00:00.000", "description": "Report", "row_id": 1265424, "text": "Status Update\nSee carevue for vital signs and assessment\nNeuro: Opening eyes sporadically not always to noxious stimuli, pupils 2 and reactive no movement of extremities to any stimuli. Remains on continuous EEG monitoring, no seizure activity observed. Dilantin increased to 300 mg Q8h to maintain current level.\nResp: O2 sats 100 on SIMV so vent weaned to CPAP with 8 PS tolerated well to placed on 50% trach collar with O2 sats 97-100. Suctioned twice for thick tan sputum. Patient with minimal cough and no gag.\nGI: Tube feeds of Nutren Pulm with protein at goal of 50cc/hr. Flexiseal in place to manage liquid stool.\nInteg: Small stage 2 decub on coccyx 1cm by 0.7cm. seen by skin care RN and Allevyn reapplied, also 2 areas on penis and 1 on scrotum evaluated and wound gel and adaptic placed on the areas.\nPlan: Neuro med resident spoke with wife today and update give. Meeting scheduled for tomorrow afternoon to review status. Maintain on trach collar as ,wean Ativan per orders, monitor for seizure activity.\n\n" }, { "category": "Nursing/other", "chartdate": "2198-09-03 00:00:00.000", "description": "Report", "row_id": 1265425, "text": "Resp Care\n\nPt weaned to 50% trach collar. Spo2 100%; rr lower 20's. BS are generally clear. Suctioning small to moderate thick tan yellow sputum.\n" }, { "category": "Nursing/other", "chartdate": "2198-08-03 00:00:00.000", "description": "Report", "row_id": 1265308, "text": "Nursing Progress Note:\nEVENTS: pt called out to floor awaiting bed for VRE/contact precautions and needs sitter on floor; EEG yesterday negative for seizure; during day pt confused and attempted to get OOB, found down on floor with hematoma on head and knee abrasion; head CT negative\n\nNKDA\n\nFULL CODE\n\nCONTACT PRECAUTIONS\n\nNEURO: pt sleeping intermittantly; pt confused and encephalopathic; mental status waxing and , oriented to person and place, at times only to person; difficulty with word finding and has garbled speech; sometimes follows commands; moves all extremities; PERL, pupils 3mm and brisk bilaterally; cont on lactulose regimen 5x day, now alert enough to take PO's safely; denies pain; cont on keppra IV, takes PO at home; bed low and locked, waist restraint in place\n\nCV: SBP stable 97-132; HR NSR in 60's rare PVC's; no CP; +radial/pedal pulses to palpation; no S+S bleeding; no edema\n\nGI: +BS, +flatus, looose to liquid brown stools; mushroom cath placed and d/c'd; abd soft non-tender, non-distended; diet with fair PO intake\n\nGU: foley in place, draining large amt clear yellow urine\n\nSKIN: hametoma at forehead; right knee abrasion\n\nACCESS: 20G PIV x2 left forearm\n\n: cont neuro checks; cont lactulose regimen; called out to floor and awaiting bed; maintain safety, waist restraint\n" }, { "category": "Nursing/other", "chartdate": "2198-08-03 00:00:00.000", "description": "Report", "row_id": 1265309, "text": "MICU7 RN Note 0700-1900\n\nCalled out to Neuro Med Room assigned 5 awaiting for confirmation on Sitter. High risk to fall. See transfer note\n\nNeuro: Awake alert oriented x1 responds verabally has difficulty finding words expressive aphasia. @ times becomes frustrated trying to express what he wants. Pupils 3mm equal react brisk. MAE random and inconsistently to command. Denies pain. No siezures/tremors. recieved lactalose q4hrs BM x1 At start of shift. No stool attempts on Bedpan.\n\nCV: NSR 68-80 NBP 124-156/60-70. Peripheral pulses 3+ DP/DT neg edema.\nResp: RR 20-24 O2 2L/min NC Sats 100% Lungs clear.\n\nGU: foley u/o >50cc/hr\n GI: abd soft sidtended +BS lg soft stool x 1 recieved lactalose q4hrs.\n\nSocial: Full code status. Wife visited for day. Waist restraint removed while wife @ bedside.\n" }, { "category": "Nursing/other", "chartdate": "2198-08-19 00:00:00.000", "description": "Report", "row_id": 1265369, "text": "Resp Care\n\nPt remains intubated and on full vent support. Mv is being maintained in the 14-15L range. Spo2 96-98%. BS are diminished and suctioning small amts of thick white sputum.\n" }, { "category": "Nursing/other", "chartdate": "2198-08-20 00:00:00.000", "description": "Report", "row_id": 1265370, "text": "NSG.PROGRESS NOTES:\nSEE FLOW SHEET FOR SPECIFIC;\n\nNEURO:STILL ON MIDAZ GTT AT 3.5MG/HR,PERL,NO MOVEMENT OF EXTRIMITIES NOTES,NO REACTION TO NAIL BED PRESSURE,CONT WITH EEG,NO SZ ACTIVITIES NOTED,OPENS EYES SPONT OCCATINALY AND TO PAIN,NOT FOLLOWING ANY COMMANDS.\nCV:NSR, HR:80-95,NO ECTOPY NOTED,SBP 120-140 IV LOPRESSOR 10MG Q6H,++PP,++ GEN.EDEMA,NS AT 75ML/HR,FLUID BALANCE OF +990ML BY MN,2GM MAG REPLACED FOR +MG 1.7 WITH GOOD EFFECT.\n\nRESP:REMAINS ON VENT,NO VENT CAHNGES OVERNIGHT,LS COARSE ALL OVER,SXN YELLOW_ BLD TINGED SXN,O2 SAT 96-98%IMPAIRED COUGH, AND NO GAG NOTED.\n\nGI: ABD W/ASCITIS,+ BS,NO BM THIS SHIFT,TF AT GOAL,TOLERATED.\n\nENDO: BLD SUG Q2H ON INSULIN GTT.\n\nID: AFEBRILE,ON ANBX.\n\nACT: TURNED AND POSITION CHANGED,CCCYX W/ALLEVYN DRESSING,SCROTUM GROSSLY EDEMATOUS AND W/SKIN PEEL.\n\nSOCIAL: VISITED BY WIFE EARLY SHIFT,AWARE OF THE PLAN.\n\nPLAN: CONT MONITORING,PULM HYGIENE,WATCH FOR SZ,?TAPER OFF SZ MEDICATION.? TRACH LATER,SUPPORT TO FAMILY.\n" }, { "category": "Nursing/other", "chartdate": "2198-08-07 00:00:00.000", "description": "Report", "row_id": 1265321, "text": "Resp Care\n\npt remains intubated and on full vent support. MV being maintained in the 10-12L range. ABG with met acidosis. BS are generally clear and suctioning scant yellow sputum\n" }, { "category": "Nursing/other", "chartdate": "2198-08-07 00:00:00.000", "description": "Report", "row_id": 1265322, "text": "Nursing Progress Note\n Please see carevue for details of care. Remains sedated on pentobarbital gtt to keep burst episodes Q 6-10 seconds. Bursts averaging 12-18 seconds apart. Epilepsy team aware and pentobarb titrated down to 1mg/kg/hr. Bursts avg Q 10-12 seconds this pm.\n Insulin gtt titrated down to 6 units/hr this shift. BS Q 2hr to goal 100-150, BS at 1800 121.\n ABD remains soft, no BOS, po meds held due to high kresiduals after am meds, gastric contents colored of lactulose.\n BP remains labile this am, levo cont at 0.45 mcg. Titrated up to p0.5mcg this pm, epi gtt added to maint MAP about 60, infusing at 0.024 mcg this pm, MAP 55-65 range.\n ABG remains acidotic this pm in spite of IVP bicarb and bicarb gtt infusing at 150cc/hr. K repleted with po, IV and Kphos this pm after episode of 30 beat run of V tach.\n Foley draining yellow urine 100-140/hr this am, eventually u/o decreased to zero/hr.\n\nPLAN: Cont to monitor VS and support BP to acceptable range, titrate pentobarb to bursts Q 6-10 seconds, support to wife and son.\n" }, { "category": "Nursing/other", "chartdate": "2198-08-08 00:00:00.000", "description": "Report", "row_id": 1265323, "text": "Resp Care Note, Pt remains on current vent settings. See vent flow sheet for details. Suctioned for mod amts thick tan secretions.Started on CVVHD for poor U.O.Getting epinephrine,levophed,and insulin. To CT head and abd no conclusive results.Will cont to monitor reswp status.\n" }, { "category": "Nursing/other", "chartdate": "2198-08-08 00:00:00.000", "description": "Report", "row_id": 1265324, "text": "SICU Nursing Note\n\nEvents: R Fem arterial line placed, L Rad arterial line DC'ed, CT scan of head/chest/abd/pelvis done w/o contrast, LIJ Quinton cath placed, CXR done, CRRT (in CVVHDF mode) started. Xigris criteria met, and was started at 0100. Of note, patient's APACHE II score is 25.\n\nNeuro: Unresponsive, not on Pentobarbitol gtt since , continues to have supressed EEG activity w/o medication. Pupils sluggish/non-reactive. Flaccid extremities.\nCV: SR w/ PAC's, HR slowing throughout night in spite of Epi/Norepi gtts. SBP maintained without changes in gtt rates, but did drop when pt was turned for bedbath. SBP maintained with CRRT.\nResp: LS coarse throughout. Some vent changes made for poor ABG's, see CareVue for specifics of these changes.\nGI: TF's remain on hold, passing stool through Flexiseal. Absent BS, abd soft. Of note, no free air on CT scan. In spite of patent NGT, passing dark fluid by mouth, no source of which could be identified.\nGU: Oliguric, with dark urine passing through foley. Able to remove up to 300cc of fluid per hour at the time of writing this note.\nEndo: Poor control of blood glucose in spite of increasing insulin gtt nearly every hour.\nSkin: Intact, unable to turn for pressure relief due to illness.\nSocial: Family in to visit in early evening and asking appropriate questions, aware of the gravity of the patient's illness.\nPlan: Attempt to increase fluid removal with CRRT, wean pressors carefully. Update family.\n" }, { "category": "Nursing/other", "chartdate": "2198-08-13 00:00:00.000", "description": "Report", "row_id": 1265343, "text": "NURSING UPDATE\nCV: HR NSR, NO ECTOPY, BP WITHIN ACCEPTABLE RANGE. PEDAL PULSES PALP @ DP, DOPPLERABLE @ PT.\n\nID: AFEBRILE. CONTACT PRECAUTIONS MAINTAINED. DR REPORTS ACTUAL NEUTROPHIL COUNT 1300, NEED TO START NEUTROPENIC PRECAUTIONS IF LEVEL FALLS<1000 PER ID PROTOCOL.\n\nNEURO: NO CHANGE IN STATUS. MIDAZOLAM GTTS INCREASED FOR SUPPRESSION OF EEG WAVE BURSTS, MONITORED CLOSELY BY NEURO TEAM. NO PHYSICAL SEIZURE ACTIVITY SEEN. EEG CONTINUOUS.\n\nRESP: BREATH SOUNDS COARSE AT TIMES BUT CLEAR AFTER SUCTION FOR THICK YELLOW SECRETIONS. SATS 94-98%. ABG WITHIN NORMAL RANGE.\n\nGI: ABDOMEN SOFT, BOWEL SOUNDS MORE HYPACTIVE THAN YESTERDAY, STOOL OUTPUT SLOWED AND GASTRIC RESIDUAL INCREASED. METOCLOPRAMIDE RESUMED (HELD X1 YESTERDAY), AND LACTULOSE CONTINUED. FLEXISEAL APPLIANCE IN PLACE. STOOL LIQUID BROWN GUAIAC NEG.\n\nGU: HOURLY URINE OUTPUT IMPROVED, URINE CLEARER AND PALER.\n\nENDO: INSULIN GTTS TITRATED PROTOCOL ACCORDING TO FINGERSTICK GLUCOSE.\n\nPLAN: COLLECT STOOL FOR OVA&PARASITES AND C.DIFF AND .\nDECREASE MIDAZ SEDATION WHEN EEG ADEQUATELY SUPPRESSED WITH PHENOBARB AT THERAPEUTIC LEVEL.\nMONITOR ANC, APPLY NEUTROPENIC PRECAUTIONS IF LEVEL<1000.\n\nPT MONITORED CONTINUOUSLY.\nDR IN CLOSE ICU ATTENDANCE.\nSEE CAREVUE FLOWSHEETS FOR DETAILED DATA.\n" }, { "category": "Nursing/other", "chartdate": "2198-08-20 00:00:00.000", "description": "Report", "row_id": 1265371, "text": "Resp: pt on a/c 16/600/+5/40%. BS are coarse bilaterally. Suctioned for moderate amounts of thick yellow secretions. No changes noc. AM ABG 7.44/33/101/23. RSBI=exempt as md.\n" }, { "category": "Nursing/other", "chartdate": "2198-08-20 00:00:00.000", "description": "Report", "row_id": 1265372, "text": "Resp Care\n\nPt remains intubated and on full vent support. MV being maintained in the 12-16L range. Spo2 96-98%. Bs with occ upper lobe rhonchi and suctioning small thick yellow sputum.\n" }, { "category": "Nursing/other", "chartdate": "2198-08-20 00:00:00.000", "description": "Report", "row_id": 1265373, "text": "NURSING NOTE\nPLEASE SEE CAREVUE FOR DETAILS\nNEURO: PT REMAINS ON VERSED DRIP AT 3MG/HR. PT NOT TO NOXIOUS STIMULI, DOES NOT WITHDRAW TO NAILBED PRESSURE. OPENS EYES TO NAILBED PRESSURE/WITH REPOSITION AT TIMES, PERRL 2-3MM, BRISK. VERY MIN GAG/COUGH. REMAINS ON CONT EEG, NEEDS DILANTIN LOAD, CONT PHENOBARBITAL.\n\nCVS: HR 80S-90S, NSR W/FEW PVC'S, SBP 120S-150S, LOPRESSOR IV GIVEN AS ORDERED. iCA THIS EVE 1.08, 40MG LASIX GIVEN W/VERY LGE DIURESIS, FLUID BAL -550CC/24HR, CONT GEN EDEMA, LGE SCROTAL EDEMA. Tm 99.5 RECTAL.\n\nRESP: NO VENT CHANGES MADE, CONT 600X16/40%/5, BREATHING 4-8BPM OVER SETTINGS AT TIMES. SUCTIONED FOR SM AMTS THICK TAN/YELLOW SECRETIONS. LUNGS COARSE, DIMINISHED AT BASES.\n\nGI/GU: CONT LGE ABD ASCITES, HYPO+BS, MIN GOLDEN, LOOSE STOOL NOTED VIA FLEXI-SEAL. REPLETE W/FIB CONT AT GOAL, MIN RESIDUALS. LGE AMT HUO VIA FOLEY CATH.\n\nENDO: INSULIN DRIP CONT 4-5MG/HR\n\nINTEG: COCCYX WND COVERED W/ALLEVYN INTACT. RIGHT GROIN BURST BLISTER SITES COVERED W/ALLEVYN. PT TURNED FREQUENTLY, NO NEW AREAS OF BREAKDOWN NOTED.\n\nPLAN: CONT HEMODYNAMIC MONITORING, ?NEG FLUID BAL GOAL, DIURETICS AS ORDERED. MONITOR FOR SEIZURE ACT, DILANTIN LOAD. RESP SUPPORT, VERSED DRIP FOR COMFORT, REPLETE LYTES AS NEEDED. FAMILY SUPPORT, CONT ICU PLAN OF CARE.\n" }, { "category": "Nursing/other", "chartdate": "2198-09-10 00:00:00.000", "description": "Report", "row_id": 1265449, "text": "NURSING NOTE\nASSESSMENT:\n NEURO EXAM UNCHANGED, SEE FLOWSHEET FOR DETAILS. REMAINS ON CONTINUOUS EEG. PM PHENOBARB DOSE BEING HELD AS ORDERED BY SICU TEAM (AFTER DISCUSSED WITH NEUROLOGY). HEART RATE MOSTLY 80'S NORMAL SINUS, SBP RANGING 100-110. AFEBRILE. AM LASIX HELD DUE TO CVP OF AND PATIENT ALREADY NEGATIVE 750 CC (SICU TEAM AND DR , SICU FELLOW, NOTIFIED). WEIGHT CONTINUES TO DECREASE AND EDEMA IMPROVING.\n TOLERATING TRACH COLLAR 50%. RESP RATE NORMAL AND SP02 99-100%. LUNG SOUNDS CLEAR. PATIENT HAS COUGH AND OCCASIONALLY ABLE TO RAISE SECRETIONS, SPUTUM THICK TAN.\n ABDOMEN SOFT, NONDISTENDED. TOLERATING NUTREN WITH BENEPRO THRU DOBHOFF. REMAINS ON LACTULOSE & REGULARLY WITH FLEXI-SEAL IN PLACE. INSULIN GIVEN FOR ELEVATED BLOOD GLUCOSE.\nPLAN:\n HOLD PHENOBARB DOSE THIS EVENING, FOLLOW CONTINUOUS EEG CLOSELY. ? FURTHER DECREASE ATIVAN DOSE TOMORROW. PROVIDE SUPPORT TO FAMILY.\n" }, { "category": "Nursing/other", "chartdate": "2198-09-10 00:00:00.000", "description": "Report", "row_id": 1265450, "text": "Respiratory Care:\nPt seen for routine airway check. Pt on 50% cool aerosol. Lung sounds diminished. Suctioned for copious/moderate thick yellow secretions. Emmergency equipment at , follow.\n" }, { "category": "Nursing/other", "chartdate": "2198-09-11 00:00:00.000", "description": "Report", "row_id": 1265451, "text": "Respiratory Care:\nPt seen for airway checks this shift. Remains trached #8 per-fit. Suctioning thick tan/blood tinged secretions. Wearing 50% aerosol mask.\n" }, { "category": "Nursing/other", "chartdate": "2198-08-24 00:00:00.000", "description": "Report", "row_id": 1265387, "text": "NURSING NOTE\nPLEASE SEE CAREVUE FOR DETAILS\nNEURO: PT NOT RESPONSIVE TO ANY NOXIOUS STIMULI. NO SPONTANEOUS MVMT NOTED, SPONTANEOUSLY OPENING EYES, BUT NOT TRACKING. PERRL, 2-3MM, BRISK. CONT EEG, REMAINS ON DILANTIN/PHENOBARB/KEPPRA, ATIVAN WEAN, NO SEIZURE ACT NOTED.\n\nCVS: HR 70S-80S, NSR, SBP 90S-130S, CVP 8-13. BOLUSED 500CC NS FOR SBP DROP TO 80S THIS EVE W/SBP INCREASE TO 110S. GOAL FLUID BAL 1L NEG, PRESENTLY NEG ~1L/24HR. LASIX GIVEN W/LGE DIURESIS. CONT GEN EDEMA, DIFFICULT BUT PALP PP R/T ++EDEMA. AFEBRILE.\n\nRESP: NO VENT CHANGES MADE, 02 SATS 98-100%. SUCTIONED FOR MOD AMTS THICK, YELLOW/TAN SECRETIONS, LUNGS COARSE, IMPAIRED GAG/COUGH. ?TRACH ON MON.\n\nGI/GU: TF AT GOAL, MIN RESIDUALS. CONT LGE ABD ASCITES, FLEETS ENEMA GIVEN, MED FORMED STOOL X2. LGE HUO VIA FOLEY CATH.\n\nENDO: INSULIN DRIP WEANED OFF, NPH 20 UNITS GIVEN\n\nINTEG: COCCYX ALLEVYN C/D/I, RIGHT GROIN BLISTERS W/SM SEROUS DRNG. CONT GROSS SCROTAL W/SEV PRESSURE SORES COVERED W/ADAPTIC.\n\nPLAN: CONT HEMODYNAMIC MONITORING, DIURETICS FOR GOAL NEG FLUID BAL, VENT SUPPORT. MONITOR SEIZURE ACT, WEAN INSULIN DRIP TO OFF, WMD/SKIN CARE. REPLETE LYTES AS NEEDED, FAMILY SUPPORT.\n" }, { "category": "Nursing/other", "chartdate": "2198-08-25 00:00:00.000", "description": "Report", "row_id": 1265388, "text": "Focus: Status Update\nData:\nPatient continues sedated, Ativan and Phenobarbital weaned daily. He opens eyes spontaneously, non-related to stimuli. He does not withdraw to nailbed pressure or sternal rub. He does not move spontaneously with any extremity. Pupils are equal and briskly reactive at 2mm. Continues with cont. EEG monitoring.\n\nLungs bilaterally clear, no vent changes overnight, continues on AC vent. Minimal tan secretions suctioned from ETT.\n\nAbdomen distended but soft d/t ascites. No stool overnight. Continues on goal tube feeds without residuals. Positive anasarca. Diuresing well to meet 1L negative goal. Lytes repleted as needed.\n\nCoccyx PU healing well with Allevyn dressing. Area is pink and 1cmx1cm. Blisters and broken down areas on penis and scrotum are red with adaptic to protect. Scrotal edema very slightly improved.\n\nPlan;\nContinue to monitor neurological status closely. Trach/Peg planned for Monday.\n" }, { "category": "Nursing/other", "chartdate": "2198-08-25 00:00:00.000", "description": "Report", "row_id": 1265389, "text": "Resp: pt on a/c 16/600/+5/40%. Ett #8, taped @ 22 lip. Bilateral clear bs. Suctioned small amount of tan secretions. No changes noc. AM ABG 7.49/40/114/31. Exempt from RSBI protocol.\n" }, { "category": "Nursing/other", "chartdate": "2198-09-17 00:00:00.000", "description": "Report", "row_id": 1265475, "text": "NPN\n to stimuli, opens eyes. Continues with facial grimacing to nailbed pressure of BUE. PERRL 3-4 mm briskly reactive. Continues ativan and phenobarb wean. BLS clear at apices, diminished at bases. Copious amounts of thick yellow blood tinged sputum. Able to expectorate some secretions as well. + BS x4 abd soft nt/nd. Flexiseal in place with decreased amount of liquid stool. TF at goal through Dobhoff. Foley draining adequate urine, pink tinged with occasional clots. Team aware. U/a sent. R PICC clotted off. tpa attempted in both ports unsuccessfully. SICU HO aware. L PIV in place. Plan for IV to rewire PICC tomorrow. Coccyx decub dsg changed today. Decreased amount of drainage and perimeter of wound intact. FS elevated- in 200s. Pboots on. Heparin SQ. HR 80s SBP 100-120s. PLAN: Continue to wean phenobarb and ativan as ordered and closely monitor neuro status, respiratory status, maintain skin integrity. provide comfort and support.\n" }, { "category": "Nursing/other", "chartdate": "2198-08-13 00:00:00.000", "description": "Report", "row_id": 1265344, "text": "Resp Care\nPT remains intubated on full vent support. No vent changes made this shift. BS coarse bilaterally, but remain mostly clear post suctioning. Pt suctioned for small to moderate amounts of thick yellow secretions. ABG WNL. Pt currently exempt from weaning protocol, therefore RSBI not completed. See CareVue and orders for details and specifics.\nPlan: Maintain vent support, currently being medicated with phenobarb.\n" }, { "category": "Nursing/other", "chartdate": "2198-08-13 00:00:00.000", "description": "Report", "row_id": 1265345, "text": "SICU NN: SEE CAREVUE FOR SPECIFICS. PATIENT REMAINS IN BURST SUPPRESSION AS PER NEURO. BUSTS Q3-5SEC. VERSED DRIP AT 6 MG/HR, NOT TITRATING AS PER NEURO. ON PHENOBARB , EXTRA ONE TIME DOSE GIVEN AS NEURO MD ORDER. PT UNRESPONSIVE SECONDARY TO DRUG INDUCED COMA. SEE ASSESSMENT. ET TO VENT, CMV, NO RESP ISSUES. RSR/ST. BP WNL. TEMP 101, MD NOTIFIED, PAN CULTURED AS ORDERED. DIALYSIS CATH DC'D BY SICU MD SENT FOR CULTURE. QUESTIONED NEED TO CHANGE CENTRAL LINE. ALINE INTACT. DOPPLER PEDAL PULSES. TOLERATING TUBE FEEDS VIA NGT. FLEXISEAL WITH LG AMT LIQUID BROWN STOOL, SENT FOR CDIFF, CULTURE AND O AND P AS ORDERED. ABD SOFT WITH BOWEL SOUNDS PRESENT. FOLEY WITH ADEQUATE CLEAR YELLOW URINE. ORDER TO CHANGE FOLEY DC'D SECONDARY TO FOLEY BEING CHANGED ON AND 4+EDEMA OF SCROTUM AND PENIS. ALLEVYN TO SACCRUM INTACT. INSULIN DRIP FOR GLUCOSE CONTROL. NO SIGNS/SYMPTOMS OF PAIN. NO RESTRAINTS NECESSARY AT THIS TIME. WIFE AND FAMILY AT BEDSIDE, UPDATED BY MD. PLAN: PT IN BURST SUPPRESSION AS PER NEURO TEAM, VAP PREVENTION, VENTILATORY SUPPORT, FOLLOW CULTURE DATA, NUTRITIONAL SUPPORT WITH TUBE FEEDS, SKIN CARE, EMOTIONAL SUPPORT.\n" }, { "category": "Nursing/other", "chartdate": "2198-08-13 00:00:00.000", "description": "Report", "row_id": 1265346, "text": "pt remained on full vent support through shift. sx'd for minimal secretions. pt still having seizure activity and remains sedated.plan to be re evaluated in am.\n" }, { "category": "Nursing/other", "chartdate": "2198-08-31 00:00:00.000", "description": "Report", "row_id": 1265412, "text": "Respiratory Care\nPatient remains on trach collar as documented on Carevue. Breath sounds diminished throughout. Suctioned for small amount of pale tan secreations.\n" }, { "category": "Nursing/other", "chartdate": "2198-08-31 00:00:00.000", "description": "Report", "row_id": 1265413, "text": "condition update\nPlease see carevue for specifics.\nNeuro: Will open eyes spontaneously at times, does not track. Does not follow commands, withdraws left upper extremity to noxious stimuli only. Pupils equal and briskly reactive. Eeg continues.\nCV: NSR 70's-80's, no ectopy. Sbp 90's-100's, lopressor held - sicu team aware. Lasix dose decreased to 60mg, + diuresis.\nResp: Remains on trach. collar. LS coarse/diminished, suctioned for small amts. thick yellow sputum. 02 sat 96-99%.\nGI: Abd soft, +bs, flexiseal drained about 200cc's liquid golden-brown stool. Lactulose continues.\nGU: foley draining adequate amts. clear yellow urine.\nEndo: nph and ssri\nskin: wound care rn consulted d/t penile and testicular abrasions/ulcerations.\nsocial: wife/son at bedside, updated by rn. Plan for family meeting on Monday, social work aware.\nPlan: bowel regime, continue pulmonary toileting, neuro checks, continuous eeg, family meeeting monday.\n" }, { "category": "Nursing/other", "chartdate": "2198-09-11 00:00:00.000", "description": "Report", "row_id": 1265452, "text": "Nursing Progress Note\nPlease see carvue for specifics:\nNo changes in neuro status. phenobarb given this am. Level after holding of evening dose 53 neuro aware into eval EEG no noted spikes no sz activity. Plan: cont with current plan of care. Supportive care to family. Cont to monitor neuro status as pheno level decreases.\n" }, { "category": "Nursing/other", "chartdate": "2198-09-11 00:00:00.000", "description": "Report", "row_id": 1265453, "text": "respiratory care\npt on his 50% trach well. see respiratory page of carevue for more information.\n" }, { "category": "Nursing/other", "chartdate": "2198-09-11 00:00:00.000", "description": "Report", "row_id": 1265454, "text": "NURSING NOTE\nASSESSMENT:\n PATIENT STILL , NEURO EXAM UNCHANGED (SEE FLOWSHEET FOR DETAILS). PHENOBARB DOSE DECREASED, PATIENT REMAINS ON ATIVAN AS ORDERED. CONTINUOUS EEG IN PLACE. HEART RATE AND BLOOD PRESSURE WITHIN NORMAL RANGE. EDEMA IMPROVING, PATIENT WEIGHT ONLY SLIGHTLY INCREASED FROM BASELINE WEIGHT (APPROX 3 KGS). LASIX CHANGED TO ONCE DAILY AND PATIENT CONTINUES TO DIURESE ADEQUATE AMOUNTS. AFEBRILE. TOLERATING TRACH COLLAR @ 50% WITH RESP RATE IN TEENS. EXPECTORATING LARGE AMOUNTS TAN/BLOOD TINGED SPUTUM. LUNG SOUNDS OTHERWISE CLEAR. ABDOMEN SOFT, NONDISTENDED. REMAINS ON LACTULOSE, IN FLEXI-SEAL. TOLERATING NUTREN WITH BENEPRO @ GOAL RATE.\nPLAN:\n CONTINUE WITH ICU MONITORING AND TREATMENT. PROVIDE SUPPORT TO FAMILY.\n" }, { "category": "Nursing/other", "chartdate": "2198-09-12 00:00:00.000", "description": "Report", "row_id": 1265455, "text": "Resp Care Note\nPt remains on 50% cool aerosol trach mask. Trach is patent with inner cannula inline. RN sx'd pt t/o shift. Breath sounds clear during both rounds. Ambu bag and mask at bedside.\nWill cont to follow.\n" }, { "category": "Nursing/other", "chartdate": "2198-09-18 00:00:00.000", "description": "Report", "row_id": 1265476, "text": "Nursing progress note\nSee Carevue for specifics\n\nNEURO: unchanged. Periods of alertness with eyes open spontaneously and blinking but does not track or follow any commands. Occasionally moves lower extremeties non-purposefully. Grimaces to nail bed pressure. PERRL.\n\nCV: NSR. SBP 90s-120s. Lopressor dose held. A.M. lytes pending.\n\nRESP: Cont on trache mask. Expectorates thick blood-tinged secretions. LS coarse/diminished.\n\nGI: TF to goal. Flexi-seal intact and draining golden liquid stool. +BS.\n\nGU: Foley draining large amounts of heavily blood-tinged urine.\n\nSKIN: Allevyn intact. Abrasion on scrotum tx'd with wound gel.\n\nPLAN: Cont monitor neuro status and wean from anti-convulsants.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2198-09-18 00:00:00.000", "description": "Report", "row_id": 1265477, "text": "Resp Care\nPt is with # 8 portex, inner cannula in, cuff inflated. Cuff with 5 cc air with 26cm pressure. Suctioned for small amounts of thick tan sputum;pt expecorating the same on his own. Wearing 35% trach collar.\n" }, { "category": "Nursing/other", "chartdate": "2198-09-18 00:00:00.000", "description": "Report", "row_id": 1265478, "text": "Respiratory Care\nPt reamins (#8 Portex Per-fit) and on trach collar. Pt remained on trach collar t/o shift. Trach site remains stable, no redness or swelling. Pt suctioned for thk tan secretions. Pt has been able to clear secretions all day. Sutures remain in place, MD aware. Cuff is inflated to 25 cmH2O. Care plan is to continue to follow pt and clean trach and suction prn.\n" }, { "category": "Nursing/other", "chartdate": "2198-09-18 00:00:00.000", "description": "Report", "row_id": 1265479, "text": "NPN\nPlease see carevue for further details\nNo changes in neuro assessment. Continues with Phenobarb and Ativan wean. Continuous EEG. PICC rewired by IVRN. No changes hemodynamically. Urology in to eval hematuria. Irrigates clear. Flexiseal intact. Stool soft- frequently irrigate to prevent occlusion of flexiseal. Dilantin changed PO. Expectorates large amounts of thick blood tinged sputum. Continue slow wean and closely monitor neuro, respiratory status. Family updated. provide comfort adn support.\n" }, { "category": "Nursing/other", "chartdate": "2198-09-19 00:00:00.000", "description": "Report", "row_id": 1265480, "text": "Nursing progress note\nSee Carevue for specifics\n\nNeuro status unchanged. Cont EEG. No seizure activity noted. Cont wean from anticonvulsants. NSR, SBP 110s-120s. Cont on trache mask. LS coarse/diminished, expectorates/sxn'd large thick blood-tinged secretions. TF to goal, abd more distended, +BS, no stool, colace given. Foley draining blood-tinged urine, 40 Lasix given, K 3.5 & currently being repleted.\n\nPlan: cont with slow wean from anticonvulsants, cont diuresis.\n" }, { "category": "Nursing/other", "chartdate": "2198-08-31 00:00:00.000", "description": "Report", "row_id": 1265414, "text": " 1900\n NEURO PT REMAINS IN COMA LIKE STATE OCC OPEN EYES TO STIMULUS DOES NOT FOLLOW ANY COMANDS PLEASE SEE CAREVIEW FOR DETAILS REGARDING NEURO CONDITION ON GOING EEG IN PROGRESS SEDATE WAVE FORM OCC SPIKES NOTED\n RESP CLEAR T/C IN PLACE THICK SPUTUM NOTED CLEARS AFTER SUCTIONING YELLOW IN COLOR\n HEART S1S2 M POOR DISTAL PULSES NOTED EDEMA REMAINS NSR TO ST PR .16 QRS .08 QT WNL VSS LOW BP\n GI POS B/S NOTED QS DISTENTION REMAINS U/O QS\n PLAN SUPPORTIVE IN NATURE FAMILY SUPPORT DURING THIS PERIOD MONITOR B/P CLOSLY\n" }, { "category": "Nursing/other", "chartdate": "2198-09-01 00:00:00.000", "description": "Report", "row_id": 1265415, "text": "Respiratory Care:\n\nPt remain on Cool mist TC @ 50% FI02. Bs are fiar bil. We are sxtn small amt of thick yellowish from Trach. Plan: keep confortable.\n" }, { "category": "Nursing/other", "chartdate": "2198-09-01 00:00:00.000", "description": "Report", "row_id": 1265416, "text": "Respiratory Care\nPatient remains on trach collar, suction for small amount of pale tan secreations.\n" }, { "category": "Nursing/other", "chartdate": "2198-09-01 00:00:00.000", "description": "Report", "row_id": 1265417, "text": "status\nD: LOW GRADE TEMP..NEURO ESSENTIALLY UNCHANGED REMAINS ON CONT. EEG\nNO SEIZURES NOTED\nA: UNCHANGED..OPENS EYES TO NOXIOUS STIMULI..REMAINS SEDATED..LGE AMT LIQ BROWN STOOL..ADQUATE HUO.. TF'S WELL..ON TRACH COLLAR WITH GOOD SAT'S >95%..SUCTIONED FOR MOD AMT THICK TAN/BLD TINGED SPUTUM\nR: UNCHANGED\nP: FAMILY MEETING MONDAY..KEEP COMF\n" }, { "category": "Nursing/other", "chartdate": "2198-09-01 00:00:00.000", "description": "Report", "row_id": 1265418, "text": " \n NEURO PT IN UNRESPONDIVE STATE PLEASE SEE CAREVIEW FOR DETAILS SOME DEEP TENDON ON MD AWARE OF SITUATION\n HEART S1S2 NSR TO ST M PULSES POS 2 THRU OUT PR .16 QRS .08 QT WNL VSS BP WNL\n RESP CLEAR RHONCHI CLEARS AFTER COUGHING T/C WELL SA02 WNL\n GI POS B/S T/F WELL\n PLAN SUPPORTIVE MEETING ON MONDAY TO BRING TOGETHER CARE FOR T/P CPT ROM\n" }, { "category": "Nursing/other", "chartdate": "2198-09-02 00:00:00.000", "description": "Report", "row_id": 1265419, "text": "Resp: Pt rec'd on 50% t/c. No changes noc or abg's. Plan keep pt comfortable with family meeting on monday.\n" }, { "category": "Nursing/other", "chartdate": "2198-08-02 00:00:00.000", "description": "Report", "row_id": 1265303, "text": "Nursing Admission Note:\nPlease see Admission history/FHP.\n\nNKDA\n\nFULL CODE\n\nCONTACT PRECAUTIONS for VRE\n\npt arrived obtunded, not answering questions, responding to voice, and sternal rub, speaking in garbled voice, pupils unequal, left 3mm and right 2mm, brisk bilaterally, trauma sicu MD aware; currently recieving keppra IV, finished dilantin gtt, due for level at 08a; EEG today; LSCTA, on 3LNC, sats 100%; SBP 90's to 100's, HR NSR no ectopy 60's, NS @ 75cc continuous; +BS, no stools, rec'd lactulose at OSH, to recieve PR q4h, abd soft non-tender non-distended; foley in place draining adequate amt clear yellow urine; skin intact; left 20G x2 WNL; wife at bedside\n" }, { "category": "Nursing/other", "chartdate": "2198-08-02 00:00:00.000", "description": "Report", "row_id": 1265304, "text": "MICU 7 RN Note:\n\nEvents: Hepatic encephalopathy, head CT, EEG, diet dv.\n\nNeuro: recieved pt sommulant w/eyes closed responding to painful stimulation withdraws. By 0900 opeing eyes to verbal command gazed star unable to track. by 12n opening eyes spont will focus cont not to tracking will turn head in direction of request. Pupils initally unequal 2/3mm now equal 3mm react brisk. responds verbally has some expressive aphasia/confusion and difficult word finding. Oriented x1 knows place/wife/children confused about date and time. Encephalopathic recieved lactalose enema x1 w/multiple loose stools. MAE random Inconsistent movent on command. Hand grasp equal strong. No siezures/ tremors. Dilantin level 9.8 recieved Dilanatin/ keppra per routine. @ 1015 pt got OOB and found on floor. noted R forehead hematoma and abrasion R knee. No LOC pt attempted to get OOB to bathroom. Stats haed CT neg findings. throughout day cont to be confused was belt placed and alarm on for safety. family @ bedside. EEG @ 1700 result pending.\n\nCV: HR 70-80 NSR recieved Propranolol per parameters. BP 120-146/70 MAPS>60. Peripheral pulses 3+ dP/DT neg edema. K+ 3.9 repeted 10meq per sliding scale. Phos 2.9 repleted Kphos 15mmol over 6hrs. IV access 2PIV. NS changed to 40cc/hr.\n Pt/PTT 13.9/30.1 INR 1.2\n\nResp: RR 12-20 reg O2 3l/min NC Sats 98-100%. Lungs Clear. HOB 30 degrees.\n\nGI: abd soft nontender + BS recieved Lactalose enema @ 1000 w/ multiple loose brown stool. Npo until 12n now taking PO no difficulty swallowing. Diet and to reg /cardiac.\n\nLiver : Liver team following Ammonia level 56 from 138\n\nGU: foley u/o 50-200cc/hr\n\nDerm: Impaired. Rforehead Hematoma, DSD, R Knee abrasion clean.\n\nSocial: Full code status. Wife and son visited updated on plan of care.\n\nPLan: NVS monitor q1-2hrs monitor foe siezures.\n call out to Neuro stepdown if EEG neg for siezures.\n sitter needed for safety\n" }, { "category": "Nursing/other", "chartdate": "2198-08-29 00:00:00.000", "description": "Report", "row_id": 1265403, "text": "Resp Care\nPt remains on vent. Trached with #8 per-fit. Suctioned for mod amt of blood-tinged to yellow secretions. Abgs WNL. Rsbi 80.9. Cont. EEG. Will continue tp monitor.\n" }, { "category": "Nursing/other", "chartdate": "2198-08-29 00:00:00.000", "description": "Report", "row_id": 1265404, "text": "CONDITION UPDATE\nSEE CAREVIEW FOR OBJECTIVE DATA\n\nOPENS EYES SPONTANOUSLY ALTHOUGH NOT REACTING TO STIMULI. NO MOVEMENT NOTED, DOES NOT WITHDRAW TO PAIN. PUPILS EQUAL AND BRISKLY REACTIVE. EEG LEADS INTACT, NMED INTO ASSESS FOR SEIZURE ACTIVYTY THIS EVENING. NO ACTIVITY NOTED. APPEARS COMFORTABLE. TMAX 99.7. SR HR 80'S, NO ECTOPY NOTED. BP 110-130'S/50-70'S. HCT STABLE. LUNGS COARSE AND DIMINISHED. NO VENT CHANGES, ABG WNL. SECREATIONS BLOOD TINGED, MINIMAL SECREATIONS NOTED. TRACH SITE CDI. ABD WITH +ASCITIES, TUBEFEEDS AT GOAL VIA DOBHOFF. GIVEN MAG CITRATE AND DUCOLAX SUPPOS D/T NO BM FOR SEVERAL DAYS. MED SOFT BM. BOWEL SOUNDS HYPERACTIVE. FOLEY WITH CYU, GOOD URINE OUTPUT AFTER AFTERNOON LASIX, ~1L NEG AT MIDNIGHT. GENERALIZED EDEMA, SCROTOM/PENIS VERY EDEMEDOUS. 3 ULCERS TO SCROTUM, COVERED WITH ADAPTIC AND GAUZE. MULTIPLE SMALL ULCERS ON PENIS AROUND CATHETER, COVERED WITH DUODERM GELL. ALLEVYN DSG TO COCCYX CHANGED. NO FURTHER BREAKDOWN NOTED. ICA 1.01, GIVEN 2 GRAMS CAGLUCONATE. K4.0, MAG 2.1. REMAINS ON RISS WITH NPH . PLAN TO CONT ON EEG MONITORING AND WEAN ANTI SEIZURE MEDS AS TOLERATED, FREQUENT NEURO CHECKS, MONITOR RESP/HEMODYNAMICS. PLAN FOR FLOURO IN AM TO ADV DOBHOFF TUBE. PROVIDE SUPPORT TO FAMILY.\n" }, { "category": "Nursing/other", "chartdate": "2198-08-29 00:00:00.000", "description": "Report", "row_id": 1265405, "text": "Resp Care\n\nPt remains trached with #8 portex and currently vented on PSV 5/5 well with stable VS on present settings. Vt ranged from 400-500cc with MV 8-9L. BS clear to course sxing for small amts of thick yellow secretions. WIll cont with vent support and wean on trach collar tomorrow when ready.\n" }, { "category": "Nursing/other", "chartdate": "2198-08-29 00:00:00.000", "description": "Report", "row_id": 1265406, "text": "condition update\nPlease see carevue for specifics.\nNeuro: Arouses to noxious stimuli, does not follow commands, no spontaneous movements noted. Very slight withdrawl with right upper extremity to nailbed pressure. Pupils are equal and briskly reactive. Continuous eeg in place. Keppra dosing schedule changed so as to stagger with phenobarbitol as per neuro med team.\nCV: NSR 70's-80's, no ectopy. sbp >100. Laxix 80mg given with + diuresis.\nResp: LS coarse diminished. Vent. weaned to cpap 5/5, tolerated well, abg's acceptable. Suctioned for small amts. thick yellow sputum.\nGI: Very small/smudge bm today,- discussed with sicu team. Colace, senna, mag. citrate given. Will follow mag. citrate with enema. Abd. softly distended, +bs, +flatus.\nGU: Foley draining adequate amts. clear yellow urine.\nEndo: nph dose increased, ssri\nPlan: continue bowel reg., neuro checks, eeg, emotional support for family.\n" }, { "category": "Nursing/other", "chartdate": "2198-08-03 00:00:00.000", "description": "Report", "row_id": 1265305, "text": "Nursing Progress Note:\nplease disregard above note, written on wrong pt\n" }, { "category": "Nursing/other", "chartdate": "2198-08-03 00:00:00.000", "description": "Report", "row_id": 1265306, "text": "Nursing Progress Note:\nEVENTS: pt called out to floor awaiting bed for VRE/contact precautions and needs sitter on floor; EEG yesterday negative for seizure; during day, pt confused and attempted to get OOB, found on floor with hematoma on forehead and knee abrasion, head CT negative\n\nNDKA\n\nFULL CODE\n\nCONTACT PRECAUTIONS\n\nNEURO: pt sleeping intermittantly; pt confused and encephalopathic, difficulty with word finding and has garbled speech; sometimes follos commands; moves all extremities; PERL, pupils 3mm and brisk bilaterally; cont on lactulose regimen 5x day; now alert enough to take PO's safely; denies pain; cont keppra IV, takes PO form at home; last dilantin level 9.8\n\nCV: SBP stable 97-132; HR NSR with rare PVC's; no edema noted; no CP; +pedal/radial pulses to palpation; no S+S bleeding; currently on NS at 50 for 500cc; given insulin/D50/albterol for K+ 5.4, am pending; BS on arrival to MICU 64, rec'd 1 amp D50\n\nRESP: LSCTA bilaterally; on 2L NC overnight for desat x1 while sleeping to 83%; no crackles/wheezing/SOB\n\nGI: +BS, sm amt liquid to loose golden brown stools; mushroom cath placed and later d/'d; abd soft non-tender non-distended; tolerating diet with fair PO intake; +nausea, no vomiting, rec'd zofran x1 with good effect; refusing to take Kayexalate\n\nGU: foley in place; pt anuric, very small amt of clear amber urine; will send ua and culture if able to obtain enough urine\n\nACCESS: PIV 20G x2\n\nSKIN: WNL\n\n: plan to take pt to CT of abd and liver US in am; keep NPO for US; cont to monitor and treat K+\n" }, { "category": "Nursing/other", "chartdate": "2198-08-03 00:00:00.000", "description": "Report", "row_id": 1265307, "text": "Nursing Progress Note:\nplease disregard above note, written on wrong pt\n" }, { "category": "Nursing/other", "chartdate": "2198-08-19 00:00:00.000", "description": "Report", "row_id": 1265367, "text": "conditon update\nD: pt is sedated and opens eyes to painful stimuli. no movement of extremities. pupils are equal and reactive to light. pt remains on continuous eeg monitor. neuro resident up once to exam monitor after being called for ? spikes on monitor. no concern per resident minimal spikes. parameter reviewed with md . pt continues on dilantin, levitractum and phenobarbital. levels are pending.\ncardiac: pt in nsr rate 80's pt continues on lopressor 10 mg q6.\nresp: abd is unchanged. pt suctioned for thick white sputum. breath sounds are clear and diminished in the bases. no change in vent settings at this time.\ngi: pt tolerating tube feeds at goal with minimal residuals. flexiseal in with minimal stool.\ngu: foley patent draining good amts of clear yellow urine fluid balance positive 1 liter.\nskin: pt with generalized edema and scrotal edema present with several open areas.\na: continue to monitor neuro status. wean versed at tolerated.\nr: no obvious seizure activity. pt still remains sedated.\n" }, { "category": "Nursing/other", "chartdate": "2198-08-06 00:00:00.000", "description": "Report", "row_id": 1265317, "text": "Nursing Progress Note\n Please see carevue for details of care. Remains heavily sedated on propofol 160mcg/kg/min. Bursts consistently 6-10 seconds apart w/occasional increased frequency for isolated bursts. Epilepsy fellow aware this am and propofol rate has not been changed.\n Remains intubated on CPAP 40% 5/5, A-line inserted late am and ABG reveals gross acidosis. Vent settings changed to AC 600x12x50%+ 5PEEP. ABG repeated and improving. RR increased to 20, ABG repeated and improving to more acceptable level. BS dim t/o w/rare wheeze audible, suctions for scant white. Sats 96-99%.\n Neo cont at 2mcg/kg/min this am to maint MAP 60-70 range. MAP down this pm to 50 in spite of titrating Neo up to 3.5mcg. Neo D/C'd and Levo gtt started and quickly titrated up to 0.2mcg to keep MAP in 60's and SBP 100. Fluid bolus NS 500ml x3 as well this pm per SICU team. CVP 6-11 today. U/o remains 40-60/hr, up slightly after fluid bolus. Remains in NSR w/o ectopy.\n TF cont at 30 ml/hr (goal). Flexiseal draining liquid golden brown stool. Remains on lactulose Q4hr. BS elevated to 200 range this am, Q1hr BS and RISS coverage x 3hrs this am w/little change in BS. Insulin gtt started at 1300, titrated up to 10 units/hr and BS slowly responding. Will continue to monitor.\n Family in the pm, updated by SICU and nuero teams.\n\nPLAN: Cont sedation to maintain \"bursts\" Q 6-10 seconds or less; monitor HD status, titrate levo to MAP >60; wean vent as ; Q1hr BS and titrate insulin gtt to desired goal, monitor and replete as ordered, support to family.\n" }, { "category": "Nursing/other", "chartdate": "2198-08-06 00:00:00.000", "description": "Report", "row_id": 1265318, "text": "Respiratory care\nPt recieved on cpap/psv 5/5 abg obtained 700/97/121, pt switched to a/c 600 x 20 5 peep 50% abg's with a metabolic acidosis. Plan to continue support as ordered.\n" }, { "category": "Nursing/other", "chartdate": "2198-08-07 00:00:00.000", "description": "Report", "row_id": 1265319, "text": "NURSING UPDATE\nCV: NSR NO ECTOPY, K+ AND PHOS LOW, EKG->NO CHANGES, KPHOS ADMINISTERED IV AND NEURAPHOS VIA NGT. PLATELETS DOWN TO 78, HIT PANEL SENT AND HEPARIN DISCONTINUED. LEVOPHED GTTS TITRATED TO MAINTAIN MAP>60. LACTATE 5.7 THIS AM.\n\nID: TMAX 100.3. ABX CONT, CX PENDING.\n\nENDO: INSULIN GTTS UP TO 18UNITS/H TO KEEP GLUCOSE 100-150.\n\nNEURO: PROPOFOL INFUSING THROUGH PM AT EXCESSIVE DOSE IN ATTEMPT TO SUPPRESS EEG WAVEFORM. AT 0130, PENTOBARIBITOL 400MG IV BOLUS GIVEN AND PROPOFOL STOPPED, PENTOBARB GTTS CONTINUE @ 3MG/KG/HR IN ATTEMPT TO MAINTAIN EEG BURSTS Q6-10 SECONDS ONLY.\n\nRESP: BREATH SOUNDS CLEAR, DIMINISHED @ BASES. SXN 0-SCANT THICK YELLOW. SATS 97-98%, NO VENT CHANGES OVERNOC.\n\nGI: NGT FEEDS STOPPED DUE TO RESIDUAL 150CC. ALSO WHEN TURNING, PT SPITTING UP SMALL AMOUNT THICK FLUID RESEMBLING GASTRIC ASPIRATE. ABDOMEN SOFT, BOWEL SOUNDS HYPOACTIVE, FLEXISEAL DEVICE COLLECTING LIQUID BROWN STOOL. LACTULOSE REGIMEN CONT. AMMONIA LEVEL PENDING.\n\nGU: URINE CLEAR, GREEN TINGED DUE TO HIGH DOSE PROPOFOL. HUO 80-250CC.\n\nGOAL: MAINTAIN MAP>60.\nCONTROL EEG BURSTS TO 1 EVERY 6-10 SECONDS.\n\nPT MONITORED .\nDR AND (NEURO) IN CLOSE ICU ATTENDANCE.\nSEE CAREVUE FLOWSHEETS FOR DETAILED DATA.\n" }, { "category": "Nursing/other", "chartdate": "2198-08-07 00:00:00.000", "description": "Report", "row_id": 1265320, "text": "Resp Care Note,Pt remains on current vent settings.See vent flow sheet for details.Suctioned for mod amts thick yellow secretions.RSBI done on 0 pee/5 ips 149.Getting levophed and pentabarb.Temp 100.3.Will cont to monitor resp status.\n" }, { "category": "Nursing/other", "chartdate": "2198-08-19 00:00:00.000", "description": "Report", "row_id": 1265368, "text": "Nursing Progress Note\nSee Carevue for details\n\nNeuro: Pt more alert this shift. Opens eyes to voice intermittently. +corneal reflexes. PERRL 2 mm bil. No gag. Impaired cough. No spontaneous movements. Does not withdraw to nailbed pressure. Remains on continuous EEG in burst suppression. Versed gtt decreased to 3.5 mg/hr per Dr. . Phenobarb dose increased. Dilantin dose increased and 500 mg bolus given. ?interaction between the two drugs resulting in decreased Dilantin level. Discussed with Dr. .\n\nCV: NSR. No ectopy noted. BP 110's/50's. Continues on Lopressor. CVP 7-14. Generalized edema. Given Albumin 5% followed by Lasix.\n\nResp: Vented. No changes made. VT 600 x 16. 40% FIO2. Sats 97-98%. Suctioned for small amts thick white sputum. LS clear at apices, diminished at bases.\n\nGI: +BS. Abdomen firm, distended. Appears larger ?increase in fluid. Primary team and SICU team aware. Will try diuresis to decrease edema/ascites. TF's at goal with minimal residuals. Flexiseal intact. Scant stool output. Reglan IV restarted.\n\nGU: Foley draining lge amts CYU.\n\nID: AFebrile. Continues on Vancomycin and Rifaximin.\n\nEndo: FBS well-controlled with insulin gtt at 4 units/hr.\n\nSkin: Scrotum very edematous with open areas. Barrier cream applied. Fluocinolone applied to psoriatic areas bil. ears.\n\nPlan: ?wean off anticonvulsants, continue monitor neuro status/seizure activity, fluid status, lytes, CK's. Continue provide support to pt and family.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2198-09-08 00:00:00.000", "description": "Report", "row_id": 1265443, "text": "Condition Update\nPlease see carevue for specifics.\n\nPt remains unresponsive. Neuro exam unchanged. Pt remains on the continuous EEG monitor. Ativan dose weaned from 2.25mg Q6 to 2mg Q6. TMAX 99.1 SR. No ectopy noted. CVP 3-8. Pt remains on trach collar. fi02 50% sats 98-100% Sxn'd for moderate to copious amts of thick, bld tinged sputum. LS are clear to coarse. TF infusing @ goal via dobhoff. Foley patent and draining adequate amts of clear urine. Flexiseal intact. Lactulose Q 6 for encephalopathy. Pt continues to have moderate amts of brown liquid stools. Intact allevyn dressing on coccyx.\n\nPlan: continue w/ current plan of care per sicu/ nmed teams. Continue the continuous EEG monitoring. Continue phenobarb/ dilantin, wean ativan. RISS + NPH for bs coverage. Pulmonary toilet.\n" }, { "category": "Nursing/other", "chartdate": "2198-09-09 00:00:00.000", "description": "Report", "row_id": 1265444, "text": "nursing progress note\nNo changes over noc. Pt remains hemodynamically stable. Neuro status unchanged no notable sz activity. Remain unresponsive. ? possible trnf to stepdown or floor today. cont with current plan of care.\n" }, { "category": "Nursing/other", "chartdate": "2198-09-09 00:00:00.000", "description": "Report", "row_id": 1265445, "text": "Condition Update\nPlease see carevue for specifics.\n\nNo neuro changes noted. IV Phenobarbitol dose decreased to 250mg down from 275mg . continuous eeg monitoring continues. tmax 100.3 SR. no ectopy. Sxn'd several times for moderate to copious amts of bld tinged to yellow secretions. Pt still on trach collar fi02 50% 02 sats 98-99% TF infusing via dobhoff at goal. foley patent. Diuresed w/ lasix and aldactone. Goal u/o 1L/ day. Flexiseal intact. riss and nph for bs coverage.\n\nplan: continue continuous eeg monitoring in the icu per nmed team. Continue to slowly wean phenobarbitol and ativan. pulmonary toilet.\n" }, { "category": "Nursing/other", "chartdate": "2198-08-23 00:00:00.000", "description": "Report", "row_id": 1265382, "text": "NURSING NOTE\nPLEASE SEE CAREVUE FOR DETAILS\nNEURO: PT REMAINS UNRESPONSIVE TO ALL NOXIOUS STIM, NO SPONT MVMT NOTED. OPENS EYES SPONT& AT TIMES WHEN TURNED BUT DOES NOT TRACK. PERRL 1-3MM, BRISKLY REACTIVE. NO SEIZURE ACT NOTED VIA CONT EEG, CONT ATIVAN/PHENOBARB/KEPPRA/DILANTIN.\n\nCVS: HR 80S-90S, NSR, SBP 100S-130S, CVP 12-16, AFEBRILE. CA REPLETED FOR iCA 1.06, HCT 24.1, AM PENDING. FLUID BAL +200/24HR PRESENTLY W/CONT GEN/LGE SCROTAL/PEDAL EDEMA, PALP PP DESPITE EXCESS FLUID.\n\nRESP: NO VENT CHANGES MADE, 600X16/40%/5, ABG 7.47/37/121/28. O2 SATS 98-100%, LNGS CLR, SUCTIONED FOR SM AMTS THICK YELLOW-TAN SECRETIONS.\n\nGI/GU: CONT LGE ABD ASCITES,+BS, NO BM, LACTULOSE GIVEN AS ORDERED. TF AT GOAL, MIN RESIDUALS. PT DIURESING WELL, HUO 30-500CC, C/Y/U.\n\nENDO: CONT INSULIN DRIP 5-6MG/HR, 10MG NPH GIVEN\n\nINTEG: COCCYX ALLEVYN C/D/I, MULTI RIGHT GROIN BLISTER SITE W/MOD AMT SEROUS DRNG, COVERED W/AQUACEL, INTACT. SM PRESS SORE SITES NOTED TO VARIOUS AREAS OF PENIS/SCROTUM.\n\nSOCIAL: PT FAMILY IN TO VISIT X SEV HRS, VERY SUPPORTIVE.\n\nPLAN: CONT HEMODYNAMIC MONITORING, SEIZURE ACTIVITY/FREQUENT NEUROS. RESP SUPPORT, ?TRACH . CONT DIURETICS FOR NEG FLUID BAL GOAL, LYTE REPLETION. WND/SKIN CARE, FAMILY SUPPORT.\n" }, { "category": "Nursing/other", "chartdate": "2198-08-23 00:00:00.000", "description": "Report", "row_id": 1265383, "text": "resp care\nPt remained on a/c 600x16 40% 5peep with peak/plat 45/22.Over breathing 2-4 breaths. BS essent clear bil.Suct for sml amt of thick tan. RSBI held at this time.Will cont to followand wean when ready.\n" }, { "category": "Nursing/other", "chartdate": "2198-08-23 00:00:00.000", "description": "Report", "row_id": 1265384, "text": "Respiratory Care:\nPt still on A/C 600 x 16 .4 5peep and has had his medications lightened and has been a little more awake overbreathing the vent by 2-4 bpm still Sx'd for tan secretions mod amount. Trach and peg was mentioned at rounds this AM. See Carevue for more details.\n" }, { "category": "Nursing/other", "chartdate": "2198-08-23 00:00:00.000", "description": "Report", "row_id": 1265385, "text": "Focus: Status Update\nData:\nPatient continues sedated on scheduled dosing of intermittent Ativan and Phenobarbital. Ativan dose reduced again today by Neurology service and pt. does open eyes spontaneously but not moving any extremities or responding to stimuli. He does not follow commands. Positive impaired gag and cough. Pupils equal and briskly reactive at 2mm. Positive corneals. Continous EEG monitoring-no evidence of seizure activity per Neurology.\n\nLungs clear bilaterally. Continues on AC vent without changes today. Suctioned for minimal amount of tan secretions. Afebrile.\n\nAbdomen more distended today with hypoactive bowel sounds. Dulcolax, Fleets enema x2 and Lactulose give with good large solid bowel movement resulting. KUB done which showed impacted stool. Continues on tube feeds at goal with no residuals.\n\nDiuresing well with Lasix daily. Lytes monitored and repleted as needed. Continues with anasarca particularly scrotal area.\n\nContinues on Insulin drip with stable glucoses. NPH dosing increased with minimal effect.\n\nPlan:\nContinue to monitor neurological status closely. Trach/Peg to be evaluated on Monday.\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2198-08-24 00:00:00.000", "description": "Report", "row_id": 1265386, "text": "Resp Care\nPt remains intubated. Current vent settings: A/C 600 x 16 5P 40%. No current ABG's. No other changes noted.\n" }, { "category": "Nursing/other", "chartdate": "2198-09-09 00:00:00.000", "description": "Report", "row_id": 1265446, "text": "resp care\nremains with 8.0 perfit portex trach,cuff inflated at 25 cmh20. appropriate equipment at bedside. inner cannula changed. expectorating and for bld tinged thick dark green sputum.\n" }, { "category": "Nursing/other", "chartdate": "2198-09-10 00:00:00.000", "description": "Report", "row_id": 1265447, "text": "Nursing Progress Note\nPlease see carvue for specifics:\nNo neuro changes. Cont to wean phentobarb. Level this am still high at 57. Pt sxn for copious amts of tan/bloodtinged secretions. Pt did desat to 86% X1 ambu and sxn for mult med thick plugs. Lungs sounds coarse, diminished at the bases. Pt also with + hematuria. Foley irrigated X2. No noted clots or sediment noted. MD aware. Pt remains afebrile with normal WBC's. Plan: Cont with current plan of care\n" }, { "category": "Nursing/other", "chartdate": "2198-09-10 00:00:00.000", "description": "Report", "row_id": 1265448, "text": "Resp Care: Pt continues trached #8 portex inflated to ~24 cm with 6 ml, on 50% cool mist to trach reqiuring freq sxn for thick tan blood tinged secretions, will follow for airway care.\n" }, { "category": "Nursing/other", "chartdate": "2198-09-15 00:00:00.000", "description": "Report", "row_id": 1265469, "text": "CONDITION UPDATE\nNO NEURO CHANGES. APPEARS COMFORTABLE. TMAX 99.4, HR 70 NSR, BP STABLE. LUNGS COARSE, CLEARS WITH SUCTION. REQUIRES FREQUENT SUCTIONING, SECREATIONS BLOOD TINGED AND THICK. REMAINS ON TRACH MASK AT 50%. ABD SOFT, FLEXI SEAL IN PLACE. TUBEFEEDS REMAIN AT GOAL. FOLEY WITH BLOOD TINGED URINE, U/A AND CX SENT. SKIN CARE PER RECOMONDATIONS. NO MED CHANGES TODAY, PER NMED NO SEIZURE ACTIVITY ON EEG.\n" }, { "category": "Nursing/other", "chartdate": "2198-09-15 00:00:00.000", "description": "Report", "row_id": 1265470, "text": " \n NEURO REMAINS IN LETHARGIC STATE SOME MOTION WITH PAIN AS STIMULENT PLEASE SEE CAREVIEW FOR DETAILS\n RESP RHONCHI CLEARS AFTER SUCTIONING T/C .50 WELL YELLOW SPUTUM\n HEART NSR VSS PULSES DOPPLER EDEMA REMAINS\n EEG IN PROGRESS GENERLIZED MOTION IN ALL WAVES NO ACUTE BURSTS\n PLAN SUPPORTIVE WEAN SUPPRESSANTS ALLOW PT TO WAKE FAMILY SUPPORT\n" }, { "category": "Nursing/other", "chartdate": "2198-09-16 00:00:00.000", "description": "Report", "row_id": 1265471, "text": "Resp Care,\nPt. has #8 portex cuff inflated 5cc cuff pressure 25cm. Suctioned for thick bloody sputum. 50% cool mist. Continue to monitor respiratory status.\n" }, { "category": "Nursing/other", "chartdate": "2198-09-16 00:00:00.000", "description": "Report", "row_id": 1265472, "text": "CONDITION UPDATE\nMORE ALERT, DOES NOT TRACK. SPONT MOVEMENT TO LLE AND RUE. APPEARS COMFORTABLE. LOW GRADE TEMP 99.8. SR-ST HR 70-90 NO ECTOPY. BP STABLE. LUNGS COARSE, LARGE AMT THICK SECREATIONS, STARTED ON NAFFICILIN FOR +SPUTUM CX. SATS 98-100% ON 35% TRACH MASK. REQUIRES FREQUENT SUCTIONING. ABD SOFT, FLEXISEAL IN PLACE, TUBE FEEDS AT GOAL. FOLEY WITH YELLOW-RED URINE WITH CLOTS, ADEQUETE URINE OUTPUT. ALLEVYN DSG INTACT. PHENOBARB AND ATIVAN DECREASED, ZONOGRAM INCREASED PER RECS. NO SZ NOTED ON EEG PER NEURO. CONT TO WEAN MEDS AS TOLERATED AND MONITOR RESP STATUS.\n" }, { "category": "Nursing/other", "chartdate": "2198-09-17 00:00:00.000", "description": "Report", "row_id": 1265473, "text": "Resp Care,\nPt. seen for trach chaeck, 35% cool mist #8 Portex inflated 5cc cuff pressure 25 cm. Suctioned by RN for large amounts thick tan sputum. O2 Sat 100%.\n" }, { "category": "Nursing/other", "chartdate": "2198-09-17 00:00:00.000", "description": "Report", "row_id": 1265474, "text": "focus hemodynmics\ndata: neuro: does not respond to verbal stimuli. opens eyes at times but will not open to command. no movement in both arms or legs. pupils react briskly and even in size. eeg being done continous. iv dilantin given. phenobaribital iv given. ativan iv as ordered given.\n\nresp: suctioned for thick blood tinge sputum. on trach collar and well. o2sat 100%. trach done x3/\n\ncardiac: remains in nsr. no ectopy seen. bp 10o-150 syst. on lopressor 10mg iv.\n\ngu: foley patent and draining yellow to amber colored urine.\n\ngI abd soft. and flexiseal patent. tube fdgs intact.\n\naction: as orderd but results quite elevated and redrawn. results still pending. dilantin, phenobarbial and ativan iv. tube fdgs at 80cc/hr. suctioned prn. continous eeg. no seizure activity. update\n\n to wife.\n\nresponse: monitor closely\n" }, { "category": "Nursing/other", "chartdate": "2198-08-18 00:00:00.000", "description": "Report", "row_id": 1265363, "text": "Condition Update B:\nPLease refer to careview and remarks for detials.\n\nPt remains sedated on versed gtt. Pt only opening ou and blinking with stimulation. No movement from extremities to painful stimuli. Absent gag, impaired cough. PERL 2mm/2mm brisk. Eye gtts and ointment applied to ou. Cont EEG at bedside. Dilatin 2.5 Phenobarbital 26.4. Tmax 100.2 (R). HR 80-90's with PVC's. SBP 130-140/60's. This morning PVC's increasing and SBP ^ 170's. Lopressor 5mg IVadmin with fair effect. Repeat potassium sent, 0600 mannitol dose held. Pt wt up 0.8kg. Pt continues with generalized pit edema. Pt positive 1.3L at mn. BUN and Cr continue to improve. Discussed with Dr. . , lasix 20mg IV admin with effect. Electrolytes repleted per PRN orders. Titrating insulin gtt to keep glucose levels 100-150. No vent changes over night. Breathing over the ventilator. Suctioned for no to small thick yellow secretions.\n\nPLAN: Neuro exam every 2 hours. EEG continues. Monitror electrolytes and replete per PRN orders. Monitor I/O, BUN/Cr. Assess and treat skin. Flexiseal inplace. Possible extra dose dilatin today. Continue with current care.\n" }, { "category": "Nursing/other", "chartdate": "2198-08-18 00:00:00.000", "description": "Report", "row_id": 1265364, "text": "Resp Care\n\nPt remains intubated and on full vent support. MV is being maintained in the 12-15L range. Spo2 98%. Bs are coarse apically when suctioning is required. Suctioning small thick white in small amts.\n" }, { "category": "Nursing/other", "chartdate": "2198-08-18 00:00:00.000", "description": "Report", "row_id": 1265365, "text": "Nursing Progress Note\nSee Carevue for details\n\nNeuro: Obtunded. Continues on Versed gtt at 4 mg/hr. Intermittently opens eyes, blinks (not to threat) and yawns. PERRL 2mm. +corneal reflexes. Does not follow commands. No spontaneous movements. No response to painful stimuli. Continuous EEG-remains in burst suppression. 500 mg Dilantin bolus given. Re-check level in am. Phenobarbital dose increased to 350 mg q 12 hours.\n\nID: Afebrile. Rectal probe in place. Continues on Vanco and Rifaximin.\n\nCV: NSR. HR 80's. Lopressor dose increased to 10 mg IV q 6 hours with effect. BP 120's/60's. Edematous extremities and scrotum. +PP. CVP 5-7.\n\nResp: ETT to vent. VT 600 x 16. 40% FIO2. Sats 98%. LS clear to coarse (worse left side) upper airways. Diminished at bases. Suctioned for small amts thick white secretions.\n\nGI: +BS. Abdomen soft, distended. +ascites. TF's at goal with minimal residuals. Flexiseal intact draining moderate amts loose golden stool.\n\nGU: Foley draining adequate amts CYU.\n\nEndo: FBS well-controlled with insulin gtt. Goal FBS 100-150.\n\nSkin: Fluocinolone cream applied to psoriatic areas both ears. Barrier cream applied to scrotal area. Allevyn to coccyx intact.\n\n: CK's 1037 down from 1278.\n\nPlan: Continue monitor neuro status, seizure activity, EEG, continue monitor fluid status, resp status, .\n\n\n" }, { "category": "Nursing/other", "chartdate": "2198-08-19 00:00:00.000", "description": "Report", "row_id": 1265366, "text": "RESP CARE: Pt remains intubated/on vent on settings per carevue. No changes overnight. SXd thick yellow sputum. Exempt from weaning protocol MD order.\n" }, { "category": "Nursing/other", "chartdate": "2198-09-07 00:00:00.000", "description": "Report", "row_id": 1265436, "text": "NPN (SEE CAREVUE FOR SPECIFICS)\n PT REMAINS UNRESPONSIVE, OPENS EYES SPONTANEOUSLY. DOES NOT FOLLOW COMMANDS OR TRACK. PUPILS REACTIVE, NO MOVEMENT FROM EXT. NO SEIZURE ACTIVITY NOTED, CONTINUOUS EEG TO BE REVIEWED BY TEAM\nCV- BP AND HR STABLE, NSR WITHOUT ECTOPY.\nRESP- LUNGS CLEAR WITH DIM BASES. SUCTIONED EVERY FEW HOURS FOR THICK YELLOWISH SPUTUM, PT HAS A WEAK COUGH. O2 SATS 99-100% ON 50% TRACH MASK.\nGI/GU- ABD SOFT, LOOSE STOOL CONTINUES VIA FLEXI SEAL. TOLERATING TF AT GOAL. UOP ADEQUATE, CLEAR YELLOW URINE.\nID- AFEBRILE\nPLAN- CONTINUE GRADUAL DECREASE IN ATIVAN, CONTINUED EMOTIONAL SUPPORT FOR FAMILY.\n" }, { "category": "Nursing/other", "chartdate": "2198-09-07 00:00:00.000", "description": "Report", "row_id": 1265437, "text": "Resp Care Note\nPt remains on 50% CATC with sats >97%. Breath sounds diminished but clear. # 8.0 portex patent with inner cannula in place. RN suctioned multiple times. Cuff pressure WNL (25cmh20). ambu bag and mask at bedside. Will cont to follow\n" }, { "category": "Nursing/other", "chartdate": "2198-09-07 00:00:00.000", "description": "Report", "row_id": 1265438, "text": "resp care\nremains with #8.0 perfit portex in place. cuff inflated with 8 cc's to cuff pressure 25 cmh20. by rn. on 50% humidified tc. appropriate equipment at bedside.\n" }, { "category": "Nursing/other", "chartdate": "2198-09-07 00:00:00.000", "description": "Report", "row_id": 1265439, "text": "NURSING NOTE\nASSESSMENT:\n PATIENT'S NEURO EXAM UNCHANGED, REMAINS UNRESPONSIVE. CONTINUOUS EEG STILL IN PLACE, ATIVAN SLOWLY BEING WEANED. PHENOBARB LEVEL HIGH THIS AM, NO CHANGE IN DOSE PER NEURO. HEART RATE AND BLOOD PRESSURE STABLE, AFEBRILE, SEE FLOWSHEET FOR DETAILS. PATIENT STILL EDEMATOUS, DIURESING WITH LASIX (INCREASED TO TWICE DAILY) WITH GOOD EFFECT.\n LUNG SOUNDS MOSTLY CLEAR. REQUIRED MINIMAL SUCTIONING FOR THICK TAN SPUTUM. TOLERATING TRACH COLLAR 50%, RESP RATE 16-20. ABDOMEN SOFT, NONDISTENDED. TOLERATING NUTREN PULM WITH BENEPRO @ GOAL RATE THRU DOBHOFF. LOOSE STOOL THRU FLEXI-SEAL (RECEIVING LACTULOSE). BLOOD GLUCOSE CONSISTENTLY 160-200, NPH & SLIDING SCALE REG INSULIN INCREASED.\nPLAN:\n CONTINUE WITH CURRENT MONITORING AND TREATMENT. SLOW WEAN OFF ATIVAN. PROVIDE SUPPORT TO FAMILY.\n" }, { "category": "Nursing/other", "chartdate": "2198-09-08 00:00:00.000", "description": "Report", "row_id": 1265440, "text": "7PM-7AM Nursing Note\nSee CareVue for objective data and trends:\nNEURO: Pt unresponsive to stimuli. No movement noted in exremities, pupils at 3mm and are reactive to light. No visible seizure activity noted-pt. remains on continuos EEG monitoring.\nRESP: pt with trach intact, suctioned periodically for large to copious amounts of thick, yellow, slightly blood tinged sputum. Pox 97-98% on 50% Trach mask. LS clear to coarse and diminished at bases.\nCV: HR 80s-90s, NSR. BP 90s-110s/0s-60s.\nGI: Pt with post pylorc NGT in place. Tolerating TF at goal. Abdomen is soft with positive bowel sounds. Pt continues to have large amounts of liquid brown stool-flexi-seal intact.\nGU: Foley intact, putting out adequate amounts of clear,yellow urine.\nPLAN: Monitor neuro status for any changes. Continue to taper ativan as per neuro recommendations.\n" }, { "category": "Nursing/other", "chartdate": "2198-09-08 00:00:00.000", "description": "Report", "row_id": 1265441, "text": "Resp Care\nPt remains trached with # 8 per-fit, inner cannula in, cuff inflated to 25cm pressure. Wearing 50% aerosol collar, O2 sats 98-100%.\n" }, { "category": "Nursing/other", "chartdate": "2198-09-08 00:00:00.000", "description": "Report", "row_id": 1265442, "text": "resp care\nremains with #8 perfit portex trach. cuff inflated to 25 cmh20. by rn. appropriate equipment at bedside.\n" }, { "category": "Nursing/other", "chartdate": "2198-08-05 00:00:00.000", "description": "Report", "row_id": 1265314, "text": "SICU NN: SEE CAREVUE FOR SPECIFICS. PATIENT SEDATED ON PROPOFOL, USING HIGH DOSES TO TITRATE TO BURST SUPPRESSION. TITRATING TO ACHIEVE BURSTS Q10SEC. BURSTS LAST 20-30SEC, OK AS PER NEURO ATTENDING, DR. . ON DILANTIN, KEPPRA, AND NEURONTIN. WILL ATTEMPT TO WEAN PROPFOL TOMORROW AS PER NEURO TEAM. SEE CAREVUE FOR FULL NEURO ASSESSMENT. ET TO CPAP, WELL, MINIMAL TO NO SECRETIONS. LUNGS CLEAR TO DIM IN BASES. RSR/SB. TITRATING NEOSYNEPHRINE FOR BP CONTROL. AFEBRILE. PALP PEDALS. CENTRAL LINE INSERTED TODAY, CXR READ BY DR. , OK TO USE LINE. THREE PIV'S INTACT. TUBE FEEDS AT 30CC/HR. ABD SOFT WITH BOWEL SOUNDS PRESENT. LIQUID GOLDEN STOOL. FLEXISEAL INSERTED. FOLEY WITH ADEQUATE HOURLY URINE OUTPUT. SKIN INTACT. NO SIGNS OR SYMPTOMS OF PAIN. RISS. HEP SQ, PROTONIX, PBOOTS PROPHYLAXIS. PLAN: CONT TITRATION OF PROPOFOL FOR BURST SUPRESSION, NEURO CHECKS Q2H, VENTILATORY SUPPORT, VAP PREVENTION, HEMODYNAMIC SUPPORT WITH NEOSYNEPHRINE, TF FOR NUTRITION, SKIN CARE, EMOTIONAL SUPPORT.\n" }, { "category": "Nursing/other", "chartdate": "2198-08-06 00:00:00.000", "description": "Report", "row_id": 1265315, "text": "Resp Care Note, Pt remains on current vent setttings. See vent flow sheet for details. Suctioned for mod amts thick white secretions.Sedated with propofol. Getting neosynephrine. No spont resp,Will cont to monitor resp status.\n" }, { "category": "Nursing/other", "chartdate": "2198-08-10 00:00:00.000", "description": "Report", "row_id": 1265333, "text": "Nursing Progress Note\n Please see carevue for details of care. Remains off all sedation this am, unresponsive to external stimuli. PERL @ 2mm. Overbreathing ventilator 3-4 breaths per minute. No cough/gag noted. Epilepsy team in this am to review EEG, tracings reveal more normal activity slowly returning. No evidence of acute seizure activity present.\n Remains on vent support CMV 600x16x40%+10PEEP. ABG acceptable, BS coarse, dim in bases, sats 96-99%. Suctions for small amounts thjick yellow secretions.\n Levo off this am, MAP 60-64, occas dips to 56-60 range briefly but returns to 60's. Levo has not needed to be restarted. No episodes of tacky arrythmias noted today, K+ level remains 5. Foley draining clear amber urine 30-40 ml/hr.\n Xigris gtt cont as ordered, Insulin gtt cont a 2 units/hr, BS maint 80-120 range this am an 2 unit infusion.\n NGT to suction this am draining scant thick bilious secretions. Sm amt tan gelatinous stool noted. Lactulose given via NGT and clamped. ABD remains soft, no BOS audible. No residual noted when checked at 4pm. Meds given via NGT and clamped. Small soft brown BM this pm.\n Bicarb gtt started this pm due to rising CPK and renal function studies. Insulin gtt also increased to 4 units/hr due to consistent K+ level of 5 and BS 148. Will continue to monitor\n\nPLAN: Cont to monitor , bicarb gtt, insulin gtt and need for pressors. Xigris gtt until @ 0130. Monitor NGT residuals after meds, note stools and presence of bowel sounds, plan to start TF if ABD asses unchanged overnight. Support to family.\n" }, { "category": "Nursing/other", "chartdate": "2198-08-10 00:00:00.000", "description": "Report", "row_id": 1265334, "text": "Respiratory Care\nPt remains intubated (#8.0 ETT 22 @lip) and on vent support. No vent changes were made t/o shift. Lung sounds were course t/o. Last ABG was borderline normal with good oxygenation. Care plan is to continue current therapy and follow ABG's. Will continue to follow pt.\n" }, { "category": "Nursing/other", "chartdate": "2198-08-11 00:00:00.000", "description": "Report", "row_id": 1265335, "text": "Respiratory Care:\nPatient remains on A/C ventilatory support with no parameter changes made throughout the night. Latest abg results determined a metabolic alkalemia with very good oxygenation on the current settings. HCO3 drip stopped.\n\nNo RSBI measured due to the level of PEEP currently required.\n" }, { "category": "Nursing/other", "chartdate": "2198-08-11 00:00:00.000", "description": "Report", "row_id": 1265336, "text": "NURSING UPDATE\nCV/HEME: NSR, NO ECTOPY, BP MARGINAL AT TIMES BUT PRESSORS REMAIN OFF. CVP 18-20. CPK ELEVATED TO 6900 @ 0130, AM LEVEL PENDING. ICA+ REPLETED. HCT 20 AND PLTS 84, DR AWARE OF DOWNWARD TREND, NO NEW ORDERS AT THIS TIME.\n\nID: TEMP RANGE 100->97.6. XIGRIS GTTS AND ABX REGIMEN CONT. WBC CONTACT PRECAUTIONS MAINTAINED. WBC 3.0. VANCO TROUGH PENDING.\n\nNEURO: REMAINS UNRESPONSIVE, CONTINUOUS EEG IN PROGRESS.\n\nRESP: BREATH SOUNDS DIMINISHED @ BASES, SXN SMALL-MOD THICK YELLOW. NO VENT CHANGES. SATS 98-100%. METABOLIC ALKALOSIS THIS AM, PH 7.52, BICARB GTTS STOPPED.\n\nENDO: INSULIN GTTS TITRATED PER FINGERSTICK GLUCOSE.\n\nGI: NGT ASPIRATED X3, RESIDUAL MINIMAL, MEDS GIVEN. ABDOMEN SOFT, BOWEL SOUNDS HYPO, LG LIQUID (700CC OVERNOC), FIB APPLIED.\n\nGU: HOURLY URINE OUTPUT 30-40CC BROWN CLEAR.\n\nPT MONITORED .\nDR IN CLOSE ICU ATTENDANCE.\nSEE CAREVUE FLOWSHEETS FOR DETAILED DATA.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2198-08-28 00:00:00.000", "description": "Report", "row_id": 1265401, "text": "focus hemocdynmics\ndata: neuro: unresponsive. no movement. pupils #2 and sluggish to reaact. on iv keppra and iv ativan and phenobarbital. . eeg continous. seen by neuro med. no gag reflex.\n\nresp: rremains vented. on assist control. to have trach today. o2sats 96-100%. this am o2sat dropping to 88-90. suctioned and lavaged. lg plug obtained. o2sat back up to 97-100%. mouth care q4hrs done as per protocol.\n\ncardiac: remins in nsr. bp > 100syst. hct 25. k 4.2 mgnesium 2.1. lopressor 10mg iv q6hrs.\n\ngu: foley patent and draining yelllow urine. scrotum edematous and open area noted on penis and scrotum . adaptic dsg applied on open sores.\n\ngI abd distended. very small amt of stool tonite despite laxatives and enema. tube fdgs infusing tll0600am pt is now npo for trach today.\n\naction: as ordered. suctioned prn. on iv ativan q6hrs. onkeppra and phenobarital iv. continous eeg. head leads intact. neuro signs monitored closely. to have trach today. wife updated.\n\nresponse: monitor neuro status closely. provide emottional support to family.\n" }, { "category": "Nursing/other", "chartdate": "2198-08-28 00:00:00.000", "description": "Report", "row_id": 1265402, "text": "condition update\nPlease see carevue for specifics.\nNeuro: No sez. activity noted, continoius eeg in place. Phenobarb, ativan, keppra, dilantin continue. Pupils 2-3mm, and briskly reactive. Pt opens his eyes to noxious stimuli, does not follow commands, does not withdraw any extremities to nailbed pressure, no spontaneous movement. -gage, + cough.\nResp: Percutaneous trach. done at bedside per Dr. , pt recieved 7mg vec., 8 ativan, and 100 fent, briefly on neo gtt, tolerated procedure well. Ls coarse diminished, suctioned for thick blood tinged sputum, trach. site intact.\nCV: NSR 70's-80's, no ecotpy. Sbp mainly 100's-110's. Peripheral pulses palpable.\nGI: Abd soft distended, +bs. No bm - discussed with sicu, will administer mag. citrate when available from pharmacy. Dobhoff placed at bedside per sicu ho, verified by chest x-ray (advanced 3cm after chest x-ray as per sicu ho). TF restarted at 80cc/hr.\nGU: Foley draining adequate amts. clear yellow urine.\nEndo: Pt recieved NPH dose this am as he was NPO for trach. , afternoon bs 99 - no treatment.\nSocial: Wife/son at bedside this afternoon, updated by this rn\nPlan: To fluoro tomorrow for post-pyloric dobhoff , neuro checks, mag. citrate, trach. care.\n" }, { "category": "Nursing/other", "chartdate": "2198-08-06 00:00:00.000", "description": "Report", "row_id": 1265316, "text": "NPN (NOC):\n\nNEURO: PT REMAINS HEAVILY SEDATED ON PROPOFOL, CURRENTLY AT 160 MCG'S/KG/MIN. RATE NEEDED TO BE INCREASED TO TO CONSISTENT BURSTS Q 4 SECS. BURSTS ARE NOW (6:30 AM) COMING Q 6-10 SECS WHICH IS GOAL. NO OVERT SZ ACTIVITY NOTED.\n\nRESP: REMAINS INTUBATED. CURRENT VENT SETTINGS: \"5&5\" X 40%. RR LOW TEENS, VT'S 400'S TO 500'S, SATS HIGH 90'S. BS'S W/ SLIGHT I/E COURSE WHEEZES THROUGHOUT. SX'D FOR MINIMAL SECRETIONS. AFEBRILE.\n\nCV: PHENYLEPHRINE CURRENTLY AT 2.0 MCG'S/KG/MIN W/ SBP'S IN LOW 100'S. PT IS IN NSR W/O ECTOPY.\n\nGI: TF AT 30 ML PER HR (GOAL) WELL. FLEXISEAL DRAINED SM AMT OF LIQ BROWN STOOL. LACTULOSE CONTINUES.\n\nF/E: UO IS GOOD. CVP'S IN LOW TEENS. AM PND.\n" }, { "category": "Nursing/other", "chartdate": "2198-08-22 00:00:00.000", "description": "Report", "row_id": 1265378, "text": "NSG.PROGRESS NOTES:\nSEE FLOW SHEET FOR SPECIFIC:\n\nNEURO:PATIENT IS STILL ON ATIVAN 9MG Q6H,KEPPRA AND PHNO,OPENS EYES TO PAIN SOMETIMES,NOT CONSISTENTLY,NO MOVEMENT TO NOXIOUS STIMULI,PERL.NO SZ ACTIVITIES NOTED.\n\nCV: NSR,HR: 80'S SBP: 107-130,IVF KVO ONLY,++GEN EDEMA,- 1.5 L BY MN,WEAK PP,(DIFFICULT TO PALPATE DUE TO EDEMA).K 3.8 REPLACED WITH 40 MMOL KCL AND I CA 1.09 WITH AM LAB 2GM CALCIUM GLUC GIVEN.\n\nRESP: REMAINS ON VENT,NO VENT CHANGES OVERNIGHT.LS CLEAR,SXN MINIMAL ONLY.O2 SAT 98- 100%,\n\nGI;ABD W/ASCITIS,HYPOACTIVE BS,FLEXISEAL REMOVED AS NOT DRAINING ANY MORE,NO BM TODAY.TR AT GOAL.TOLERATING.\n\nGU: FOLEY CATH PATENT WITH YELLOW CLEAR URINE ADQ AMT.\n\nID: AFEBRILE,NO ANBX.\n\nENDO: BLD SUG Q2H,ON IONSULIN GTT.\n\nSOCIAL: VISITED BY WIFE AND SON EARLY SHIFT,AWARE OF THE .\n\nACT; TURNED AND POSITION CHANGED,COCCYX W/ALLEVYN DRESSING,RT GROIN AND SCROTUM SKIN PEEL DREESING DONE WITH AQUACEL..\n\nPLAN: CONT MONITORING,PULM HYGIENE,MONITOR NEURO AND WATCH FOR ANY SZ,CHECK LYTES AND REPLACE ACCORDINGLY.SUPPORT TO PATIENT AND FAMILY. ? TRACH AT LATER TIME .\n" }, { "category": "Nursing/other", "chartdate": "2198-08-22 00:00:00.000", "description": "Report", "row_id": 1265379, "text": "Respiratory therapy\nPt remains orally intubated on full ventilatory support, and EEG monitoring. BS clear bilaterally Sx scant secretions. CXR from revealed lge bilateral pl effusions with bibasilar atelectasis.\n" }, { "category": "Nursing/other", "chartdate": "2198-08-22 00:00:00.000", "description": "Report", "row_id": 1265380, "text": "Resp. Care Note\nPt remains intubated and vented on AC settings per resp. flowsheet. No vent changes made this shift. BS decreased to bases, sxn for thick yellow secretions. Occas, assisting above vent set rate. Cont current support.\n" }, { "category": "Nursing/other", "chartdate": "2198-08-22 00:00:00.000", "description": "Report", "row_id": 1265381, "text": "Focus: Status Update\nData:\nPlease see carevue flowsheet for details of care.\n\nPatient continues sedated, Ativan reduced to 8mg QID today per Neurology. Continuous EEG monitoring without eveidence of seizure activity by Neurology rounds this am. Grimacing slightly, weak cough and attempting to open eyes while turning. Pupils are equal at 1.5mm and briskly reactive. No response with sternal rub or nailbed pressure. No spontaneous movement.\n\nLungs bilaterally clear, continues on AC vent with no changes this shift. Sats 96-100%.\n\nAbdomen very distended, likely secodanry to ascites. Lactulose without response. No BM documented x3days. Positive bowel sounds, abd soft and continues on tube feeds at goal rate of 80ml/hr with minimal residuals.\n\nLasix continues with good diuresing. Goal 1Liter negative. Lytes repleted as needed.\n\nStarted NPH insulin today, weaning insulin drip with stable glucoses.\n\nPlan;\nContinue current plan of care.\n" }, { "category": "Nursing/other", "chartdate": "2198-09-14 00:00:00.000", "description": "Report", "row_id": 1265462, "text": "Nursing progress note\nSee Carevue for specifics\n\nNEURO: Mostly unresponsive but at times eyelids flutter/open to voice or pain. Does not follow commands or move extremeties. Occasional grimace to nailbed pain. PERRL. EEG cont.\n\nCV: NSR in 70s-80s. Became hypotensive s/p lopressor and ativan doses. Gave 250 NS bolus resulting in slight improvement. Current SBP in 90s. MD aware. Latest hct 25.\n\nRESP: LS clear, expectorating/suctioning thick blood tinged secretions/plugs.\n\nGI: TF to goal, +BS, flexi-seal intact and draining minimal amounts of liquid golden stool.\n\nGU: Foley draining increasingly blood-tinged urine. Urine cx sent.\n\nSKIN: Allevyn on coccyx intact. Pink abrasions on scrotum, penis and R upper thigh - ?psoriasis. Transferred to Kinair bed.\n\nPLAN: Cont weaning of anti-seizures and sedatives.\n" }, { "category": "Nursing/other", "chartdate": "2198-09-14 00:00:00.000", "description": "Report", "row_id": 1265463, "text": "Resp Care\nPt remains trached on 50% trach mask. BS mostly clear bilaterally, suctioning for moderate amounts of thick blood tinged secretions. Cuff inflated with 6cc air, to achieve 25cmh20. See CareVue for details and specifics.\nPlan: Continue to follow for trach monitoring.\n" }, { "category": "Nursing/other", "chartdate": "2198-09-14 00:00:00.000", "description": "Report", "row_id": 1265464, "text": "NPN\nPlease see carevue for further details. Increasingly more to voice and stimuli. Opens eyes to command and slight facial grimacing to nailbed pressure in BUE. Slow phenobarb and ativan wean. Kinair bed on. Criticaid applied to scrotum/penis abrasions. Allevyn on coccyx appears intact. HR 80s SBP 130-140s. sats 98-100 on 50% trach mask. BLS clear, diminished at bases. CXR done this afternoon. sputum spec sent. suctioned for thick blood tinged sputum. Foley with pinkish urine adq amounts. EEG monitoring continues. Continue slow phenobarb and ativan wean, closely monitor neuro status. continue with current plan of care. provide comfort and support.\n" }, { "category": "Nursing/other", "chartdate": "2198-09-14 00:00:00.000", "description": "Report", "row_id": 1265465, "text": "Resp. Care Note\nPt followed for airway checks this shift. Pt with #8 perc. portex in place. Cuff with 5cc's for 25cm H2O, inner cannula in place, inspected and clear. 50% aerosol trache mask in place.Nebulizer filled and tubing drained of water. Sxn for thick old blood tinged secretions.\n" }, { "category": "Nursing/other", "chartdate": "2198-09-14 00:00:00.000", "description": "Report", "row_id": 1265466, "text": " 2035\n NEURO PT REMAINS IN DEEP LETHARGIC STATE STARTING TO WAKE AS NARCOTICS LOWERED PLEASE SEE CAREVIEW FOR DETAILS NOTE UNEVENTFUL EEG\n RESP REMAINS T/C ON .50 WELL SAO2 100 THICK SPUTUM YELLOW IN COLOR\n HEART S1S2 NSR TO ST PR .16 QRS .08 QT WNL PULSES POS 2 THRU OUT VSS M \n GI POS BS THRU OUT T/F WELL SOFT LG ABD\n PLAN SUPPORTIVE IN NATURE ROM T/P CPT FAMILY SUPPORT\n" }, { "category": "Nursing/other", "chartdate": "2198-09-15 00:00:00.000", "description": "Report", "row_id": 1265467, "text": "RESP CARE: PT REMAINS /8.0 PORTEX PERC TRACH TUBE IN PLACE/CUFF INFLATED WITH 5CC TO MAINTAIN CUFF PRESSURE OF 25CMH20. ON50% TC. SXD THICK BLOODY SECRETIONS. CONTINUE TO MONITOR PER RESP PROTOCOL.\n" }, { "category": "Nursing/other", "chartdate": "2198-09-15 00:00:00.000", "description": "Report", "row_id": 1265468, "text": "Respiratory Care\n\n Pt continues with a #8.0 portex sx'ing large amounts of thick bloody secretions. Will continue to follow.\n" }, { "category": "Nursing/other", "chartdate": "2198-08-09 00:00:00.000", "description": "Report", "row_id": 1265329, "text": "NURSING NOTE\nASSESSMENT:\n PATIENT REMAINS OFF ALL SEDATION, DOES NOT OPEN EYES OR MOVE ANY EXTREMITIES. PUPILS EQUAL & BRISKLY REACTIVE. REMAINS ON EEG MONITOR, NEUROLOGY CHECKING THROUGHOUT THE DAY. EEG MOSTLY SUPPRESSED OCCASIONAL BURSTS, OKAY PER NEURO RESIDENT. REMAINS ON DILANTIN & KEPPRA.\n HEART RATE 80-110 SINUS TACH. MAP > 60, PATIENT WEANED OFF EPI GTT & LEVOPHED REQUIREMENTS DECREASING SLOWLY. PATIENT HYPOTENSIVE WITH SYSTOLIC 80-90 AFTER TURNING, RESOLVED WITHOUT INTERVENTION. AFEBRILE, WBC COUNT NORMAL. CVP 15-20, PATIENT NOW MAKING 40-100 CC URINE HOURLY. ABGS NORMAL/ACIDOSIS RESOLVED, PATIENT CURRENTLY OFF CRRT (PER DR. AND RENAL TEAM). BICARB GTT STOPPED THIS AM. REPLETING ALL ELECTROLYTES THROUGHOUT THE DAY. SURVEILLANCE BLOOD & URINE CULTURES SENT. XIGRIS CONTINUES.\n LUNG SOUNDS CLEAR, MINIMAL SUCTIONING REQUIRED. PATIENT ON ASSIST CONTROL, NOT BREATHING OVER VENT. RESP RATE DECREASED IN AFTERNOON FOR PAC02 32, WILL REPEAT ABG. PATIENT STILL CONTINUES TO HAVE GREY ORAL SECRETIONS, TEAM AWARE.\n ABDOMEN SOFT, NONDISTENDED. MEDS ORDERED PER NGT HELD DUE TO ? ABSORBTION, TEAM AWARE. FLEETS ENEMA AND DUCOLAX SUPP GIVEN, AWAITING EFFECT. BLOOD GLUCOSE 70-120, CURRENTLY OFF INSULIN GTT.\nPLAN:\n ? MRI AND/OR CT SCAN TOMORROW. ? ATTEMPT TUBE FEEDS IF PATIENT STOOLS OVERNIGHT. RESTART CRRT IF NEEDED.\n" }, { "category": "Nursing/other", "chartdate": "2198-08-09 00:00:00.000", "description": "Report", "row_id": 1265330, "text": "Respiratory Care\nPt remains intubated (#8.0 ETT 22@lip) and on vent support. Vent changes were RR dropped from 20 to 16, ABG to follow. Lung sounds were cleart/o. Suctioned for scant thk tan secretions. Last ABG showed acute resp alk with good oxygenation. Care plan is to continue to follow ABG's and adjust vent as needed. Will continue to follow pt.\n" }, { "category": "Nursing/other", "chartdate": "2198-08-10 00:00:00.000", "description": "Report", "row_id": 1265331, "text": "Respiratory Care:\nPatient remains on A/C ventilatory support with no parameter changes made throughout the night. Latest abg results determined a minor respiratory alkalemia with very good oxygenation.\n\nNo RSBI measured due to the level of PEEp currently required.\n" }, { "category": "Nursing/other", "chartdate": "2198-08-10 00:00:00.000", "description": "Report", "row_id": 1265332, "text": "nursing note\nNeuro: pt remains unresponsive, pupils equal. remains on cont. EEG. No response to stimuli. no gag or cough.\nCV:Wide complex tachycardia in early evening wtih rate up to 130's, sent, K 5.4. MD in to awssess, mulitple EKG's done. EP up to consult, mag, Calcium, dextrose/insulin given as ordered. Repeat K's trending down. One episode of brady to 20's that resolved without intervention. Wide complex tahcy subsided with correction of K. EKG repated at 12a and faxed to EP MD.\nRESP:LS clear to coarse, thick yellow secretions on deep ET suction. no vent changes overnight.\nGI:abs soft,distended. NGT remains with minimal bilious output. no stool cont. md aware. no kayexalate md secondary to ? ischemia.\nGU:foley patent amber urine adeq amounts.\nEndo: on insulin gtt at 2units/hour.\nsoical:family at bedside during tachycardia and bradycardia and updated by RN and MD multiple times. pt remains full code.\n\nPLAN: cont to monitor lytes and abg cont. ? restart CVVHDF today secondary to rising K. await EP/cards input. xigris to ccont through tonight. wean levo as tolerated.\n" }, { "category": "Nursing/other", "chartdate": "2198-08-16 00:00:00.000", "description": "Report", "row_id": 1265356, "text": "RESP CARE\nPt remained on a/c 600x16 40% 5peep with peak/plat 22/18. BS essent clear. Suct for scant amt of thick yellow.RSBI held per order.ABG acceptable. Will cont to follow.\n" }, { "category": "Nursing/other", "chartdate": "2198-08-16 00:00:00.000", "description": "Report", "row_id": 1265357, "text": "Resp Care\n\nPt remains intubated and on full vent support. Mv is being maintained in the 12-14L range. ABG 7.39/40/125/25. BS are clear and suctioning small amats of white sputum.\n" }, { "category": "Nursing/other", "chartdate": "2198-08-16 00:00:00.000", "description": "Report", "row_id": 1265358, "text": "Nursing Progress Note:\nPlease refer to CareVue for details.\n Neuro exam q2hr. Midazolam gtt decreased to 5mg/hr per team and Dr. . Pt does not open eyes to painful stimulus. No movement noted on extremities. PERRLA (2mm bilat; briskly reactive). Gag reflex absent. Impaired cough/corneal reflex. No seizures noted. Continuous EEG. Tmax 38.4C (rectal); Dr. aware (no new interventions/meds ordered). Per Dr. , notify HO if temp >/= 38.5C. HR 80-100s (NSR/sinus tach; rare to frequent PVCs). Lytes sent in afternoon. PVCs less frequent after calcium and potassium repleted. Magnesium repleted this morning. ABP 100-130s/50s-60s. CVP 8-14. BUE/ BLE with +2 edema. +4 scrotal edema; elevated in bed. Venodyne boots on BLE. DP pulses palpable; PT pulses dopplerable. CPK 4419. US of liver/gallbladder done to r/o cholecystitis. Lungs clear. +rhonchi on upper lobes this afternoon. No vent change made this shift. ABG WNL. Pt suctioned for thick/thin white secretions. O2 sat >/= 96%. RN and RT moved ETT to right side of mouth. Mouth care performed per VAP prevention protocol. Abdomen softly distended with hypoactive bowel sounds. Replete with fiber @ 80cc/hr via OGT (goal rate); minimal residual noted. Flexi-seal intact; liquid golden stool noted in bag. Insulin gtt continued; following insulin scale with target BG 101-150. Foley intact with clear, yellow urine. Diuresed with furosemide 20mg IV BID; diuresing well. UO >/= 80cc/hr. Allevyn on coccyx intact; no drainage noted. Left and right ears with abrasions (pink; open to air); no drainage noted. Pt turned and repositioned q2hr to maintain skin integrity. wife called x2; updated by RN on pt's condition and on plan of care. wife will visit this evening.\n Plan: Monitor VS, I's and O's, . Monitor neuro and respiratory status. Neuro exam q2hr. Continue midazolam gtt; keep midazolam gtt @ 5mg/hr per team. Monitor for seizures. Continuous EEG. Monitor ABG. Follow up result of gallbladder/liver US. Notify HO if temp >/= 38.5C. Continue TF at goal rate via OGT; check for residuals q4hr. FS q1hr while on insulin gtt. Update pt and family on plan of care; provide emotional support. Continue ICU care and treatment.\n" }, { "category": "Nursing/other", "chartdate": "2198-08-17 00:00:00.000", "description": "Report", "row_id": 1265359, "text": "NURSING UPDATE\n TEMP MAX 100.8, HR SINUS RHYTHM WITH OCCASIONAL->FREQUENT PVC'S. CALCIUM REPLETED. RESPONDED VERY WELL TO LASIX.\n BREATH SOUNDS CLEAR AFTER SUCTIONED FOR THICK WHITE SECRETIONS, SATS 97-98%, ABG WITHIN NORMAL RANGE.\n GLUCOSE WELL CONTROLLED WITH TITRATION OF INSULIN GTTS PER FINGER STICK AND LAB GLUCOSE.\n EYES FLICKERING AND MOUTH MOVING AT TIMES, 2 EPISODES OF IRREGULAR ACTIVITY ON EEG WAVEFORM MARKED FOR EXAMINATION - NOTIFIED OF THESE EVENTS. NO OTHER NEUROLOGICAL CHANGES. SEDATED ON MIDAZOLAM GTTS.\n TUBE FEED TOLERATED AT GOAL WITH MINIMAL-ZERO GASTRIC RESIDUALS. STOOL OUTPUT REMAINS SLOW, BOWEL SOUNDS ACTIVE, ABDOMEN DISTENDED & SOFT.\n\nPT MONITORED CLOSELY.\nDR ON ICU SERVICE OVERNOC.\nSEE CAREVUE FLOWSHEETS FOR DETAILED DATA.\n\n" }, { "category": "Nursing/other", "chartdate": "2198-08-17 00:00:00.000", "description": "Report", "row_id": 1265360, "text": "Resp Care\nPt remains on vent. Intubated with #8 ett @ 22, patent and secure. No changes made. ABGs WNL. Will continue to monitor.\n" }, { "category": "Nursing/other", "chartdate": "2198-08-17 00:00:00.000", "description": "Report", "row_id": 1265361, "text": "FOCUS: CONDITION UPDATE\nD: SEE CAREVUE FOR SPECIFIC VITAL SIGNS//ASSESSMENTS\nNEURO--REMAINS ON VERSED GTT, DECREASED TO 4 MG/HR. IMPAIRED COUGH, NO GAG, WINCES TO STERNAL PINCHING. OTHERWISE NO MOVEMENT. PUPIL 2 AND BRISK TO SLUGGISHLY REACTIVE. CONTINUOUS EEG. PHENOBARB DOSE INCREASED.\nGI--TUBE FEEDS AT GOAL. BELLY SOFT AND DISTENDED, LARGE AMOUNTS OF BROWN GOLDEN STOOL. FLEXISEAL INTACT.\nGU--FOLEY INTACT. LASIX CHANGED TO MANNITOL/ALDACTONE FOR DIURESIS. STILL POSITIVE TODAY, HO AWARE, NO FURTHER DIURETICS ORDERED. K/CA REPLACED AS ORDERED.\nENDO--BLOOD SUGARS WELL CONTROLLED ON INSULIN GTT.\nCV--STABLE. AFEBRILE.\nSOCIAL--FAMILY IN, VERY SUPPORTIVE. ENCOURAGED BY PATIENT'S SLOW PROGRESS.\nPLAN: CONTINUE ON 4 MG VERSED TODAY.\n NEURO CHECKS\n CONTINUOUS EEG\n FREQUENT LYTE CHECKS, REPLACE AS ORDERED.\nCALL HO WITH ANY CHANGES.\n" }, { "category": "Nursing/other", "chartdate": "2198-08-26 00:00:00.000", "description": "Report", "row_id": 1265395, "text": "NURSING NOTE\nPLEASE SEE CAREVUE FOR DETAILS\nNEURO: PT REMAINS UNRESPONSIVE TO ALL NOXIOUS STIM, MIN OPENS EYES SPONT, UNABLE TO TRACK. PERRL 2-3MM, BRISK, IMPAIRED CORNEAL REFLEXES.\nCONT EEG, NO SEIZURE ACT NOTED, ATIVAN WEANED TO 4MG, CONT KEPPRA/PHENOBARB/DILANTIN. IMPAIRED GAG/COUGH.\n\nCVS: HR 80S-90S, SBP 90S-140S, CVP 8-12, LOPRESSOR HELD, MAP MAINTAINED>60 PER DR.. LASIX 40MG GIVEN X1 W/LGE DIURESIS. GOAL NEG 1L, PRESENTLY NEG~275CC/24HR. CONT GEN EDEMA, DIFFICULT BUT PALP PP R/T GROSS GEN EDEMA. PM LYTES WNL.\n\nRESP: NO VENT CHANGES MADE, 600X16/40%/5, MIN OVERBREATHING VENT. LUNGS CLEAR-COARSE, SUCTIONED FOR SM AMTS YELLOW-TAN THICK SECRETIONS, O2 SATS 96-99%.\n\nGI/GU: REPLETE W/FIBER CONT AT GOAL, MIN RESIDUALS. CONT ABD ASCITES, +BS, NO BM, DULCOLAX SUPP GIVEN. ADEQUATE AMT HUO, GOOD RESPONSE TO LASIX.\n\nINTEG: COCCYX ALLEVYN C/D/I. RIGHT GROIN BLISTERS W/SM SEROSANG DRNG, COVERED W/AQUACEL, INTACT. CONT GROSS SCROTAL EDEMA, SM AREA OF BREAKDOWN TO INFERIOR ASPECT OF SCOTUM W/SM AMT SEROUS DRNG, COVERED W/ADAPTIC. PENIS W/SEV BLISTERS/AREAS OF BREAKDOWN W/SM AMT SEROUS DRNG COVERED W/ADAPTIC.\n\nENDO: INSULIN DRIP REMAINS OFF, BS COVERED W/RISS, NPH STANDING DOSE.\n\nSOCIAL: PT FAMILY IN TO VISIT, VERY SUPPORTIVE/INVOLVED.\n\nPLAN: CONT HEMODYNAMIC MONITORING, DIURESIS FOR NEG 1L FLUID BAL GOAL, REPLETE LYTES. CONT EEG, MONITOR FOR SEIZURE ACT, FREQUENT NEURO CHECKS. RESP SUPPORT, WND/SKIN CARE. FAMILY SUPPORT, CONT PLAN OF CARE.\n" }, { "category": "Nursing/other", "chartdate": "2198-08-27 00:00:00.000", "description": "Report", "row_id": 1265396, "text": "Resp: pt on 16/600/+5/40%. Ett 8.0, rotated, retaped and secured @22 lip. BS are clear bilaterally. No changes noc. AM ABG 7.51/39/155/32. Pt continues to be exempt from weaning protocol. Plan to remain on present settings.\n" }, { "category": "Nursing/other", "chartdate": "2198-08-27 00:00:00.000", "description": "Report", "row_id": 1265397, "text": "FOCUSED NURSING NOTE\nPLease see carevue flowsheet for further details\n\nNEURO: Pt s/p pentobarb coma and aggressive anti-sz regimen for status epilepticus. Remains unresponsive, no spontaneous movement on current med regimen of phenobarb 350mg , keppra , dilantin TID and Ativan taper (4mg QID). Gag absent, cough impaired, corneals present but poor reflex. Pupils 2mm, reactive. Dilantin level 10.8, pentobarb level 45.1. No sz activity noted, EEG continuous recording in room.\n\nRESP: Trach and ventilated by CMV 600/16, 5, 40%. Breathing over vent with RR 18-22. ABG= metabolic alkalosis, good oxygentation. Lungs are clear, diminished t/o. Freq cuff leak noted. CXR obtained for fever, report pending. Secretions infrequent, tan. No vent wean at this time secondary to LOC.\n\nHEMODYNAMICS: Stable. BP trending up o/n 140-150s intermittently accompanied by ST 100-103 in setting of low-grade fever. Lopressor given as scheduled. Pt anasarcous. Wt slowly declining. Diuresing well, -1100ml at midnight. No sx bleeeding.\n\nID: Tmax 100.5- CVL site benign. Urine clear/yellow. Pancx, results pending.\n\nGI/METABOLIC: NPO. TF at goal rate, no residuals. Abd large/distended, ?ascites vs air/stool. Pos flatus, poor bs. Minimal stool outputs despite lactulose TID and colace/dulcolax suppos. Resident notified.\nGlucoses 150-185, covered with NPH/RISS.\n\nSKIN INTEGRITY: score 12. ulcerations base of penis and scrotum secondary to gross edema- sites appear clean, stable. Treated with adaptic and cleansing. Allevyne to coccyx left intact. No further developments of skin breakdown. Triadyne bed reccomended.\n\nPLAN OF CARE: Cont to monitor neurological status closely, anti-sz meds as ordered and benzodiazepine taper continued. Monitor fluid balance, discuss diuresis goals with team. Plan for trach/peg today or tomorrow, TF suspended at 0600. Aggressive skin care, pulmonary hygiene. Nutrition, glycemic control. Emotional support to pts family, updated on plan of care daily.\n" }, { "category": "Nursing/other", "chartdate": "2198-08-27 00:00:00.000", "description": "Report", "row_id": 1265398, "text": "Condition Update\nD: See carevue flowsheet for specifics\n Patient afebrile tmax 100.6. HR 80's NSR, BP tolerating lopressor dose. No hemodynamic issues.\n No neuro changes noted. Phenobarb dose decreased. Pt unresponsive and not moving any extremeties no corneals. Continuous EEG with no seizure activity noted.\n No vent changes made today. No significant secretions noted. TF resumed d/t not planning to trach until tomorrow. Multiple laxatives given today, senna, colace, (scheduled lactulose), dulcolax suppository, and enema-with small hard results.\n Wife called in am for update.\nPLAN:\n Cont to wean benzos as tolerated\n Cont EEG\n neuro checks\n Trach tomorrow.\n Notify H.O. with any changes\n" }, { "category": "Nursing/other", "chartdate": "2198-08-27 00:00:00.000", "description": "Report", "row_id": 1265399, "text": "Resp care\nPt remains intubated. Current vent settings: A/C 600 x 16 5P 40%. Plan is for trach. No other changes noted.\n" }, { "category": "Nursing/other", "chartdate": "2198-08-28 00:00:00.000", "description": "Report", "row_id": 1265400, "text": "Resp: pt on a/c 18/600/5+/40%. BS are clear with diminished bases. Suctioned for small amounts of thick white secretions. No changes or abg's this shift. Exempt per weaning protocol. Plan to trach/peg today.\n" }, { "category": "Nursing/other", "chartdate": "2198-08-18 00:00:00.000", "description": "Report", "row_id": 1265362, "text": "Respiratory Care:\n\nPt remain orally intubated & sedated on full/assist ventilation. No vent changees done. We are sxtn for scant amt of thick yellow secretions from ETT. Plan: Continua present ICU monitoring. Will follow.\n" }, { "category": "Nursing/other", "chartdate": "2198-09-05 00:00:00.000", "description": "Report", "row_id": 1265430, "text": "Nursing note:\nSee Carevue for details:\n Neuro essentially unchanged, unresponsive to stim. Opens eyes spont. but not to command. Blinking but not tracking. Slow Ativan wean continues. Cont. EEG running, no overt s/sx seizure activity. Tmax 99.9, SR, no ectopy. SBP 90s-120s. +PP, +2 edema to LEs. Lung sounds clear, dim to bases. Sats 100% on 50% trach collar. Suctioned q2-3 hours for thick tan -yellow secretions. -cough/gag noted. +BS, abdomen soft, flexi-seal in place for large amounts brown liquid stool. Foley patent adequate amount amber urine. Glucose levels somewhat elevated, SSRI/NPH given a/o. Allevyn intact to coccyx, adaptic/wound gel to reddened areas on scrotum.\n\nA/P: Stable, marginally less sedated today - remains on Ativan ATC for seizure suppression. EEG @ bedside, no seizure activity. Continue neuro exams, resp. care, Ativan wean to continue, support to pt. and family.\n" }, { "category": "Nursing/other", "chartdate": "2198-09-05 00:00:00.000", "description": "Report", "row_id": 1265431, "text": "REspiratory Care:\nPt seen for routine airway check. Pt on 50% cool aerosol via trach mask. Lung sounds coarse. Suctioned for copious thick bloody/tanish secretions. Inner cannual claer and patent, cuff up. Emmergency equipment at HOB. Will follow.\n" }, { "category": "Nursing/other", "chartdate": "2198-09-06 00:00:00.000", "description": "Report", "row_id": 1265432, "text": "Respiratory Care:\n\nPatient trached with 8.0 Portex. Cuff pressure 25cm/H20 with 6cc of air in cuff. Inner cannula patent. BS clear bilaterally. Sxing not indicated at this time. 50% Trach mask in use. Nebulizer full. RR 18, O2 sat 99%. Ambu bag, sxing equipment at bedside. Pt. appears comfortable at rest.\nPlan: Will continue to follow for trach management.\n" }, { "category": "Nursing/other", "chartdate": "2198-09-06 00:00:00.000", "description": "Report", "row_id": 1265433, "text": "NPN (SEE CAREVUE FOR SPECIFICS)\n PT REMAINS UNRESPONSIVE, OPENING EYES TO STERNAL RUB. NOT MOVING EXTREMITIES TO PAIN. PERRL. NO SEIZURE ACTIVITY NOTED.\nCV- BP AND HR STABLE. HR 80'S, NSR WITHOUT ECTOPY. AM PENDING.\nRESP- TOLERATING TRACH MASK AT 50% WITH SATS 100%. ABLE TO COUGH AND RAISE SPUTUM.\nGI/GU- ABD SOFT, + BS. LOOSE STOOL CONTINUES VIA FLEXI SEAL. UOP ADEQUATE.\nID- TMAX 99.9\n" }, { "category": "Nursing/other", "chartdate": "2198-09-06 00:00:00.000", "description": "Report", "row_id": 1265434, "text": "7am-7pm Nursing Note\nSee CareVue for objective data and trends:\nNEURO: Pt unresponsive to stimuli. Pt noted to occasionally open eyes, however the eye opening did not correlate with stimulation or appear to be purposeful. Pt does not respond to painful stimuli. Pupils reactive to light. No outward signs of seizure activity and pt remains on continuous EEG monitoring. Tapering Ativan slowly.\nCV: Pt HR 90s and in NSR. BP 90s-120/50-60s.\nRESP: Pt with trach and on 50% O2 via trach mask. Pt suctioned for large amounts of thick, yellow sputum. Pt cough is weak and generally non-productive. Pox 96-99%.\nGI: Pt with post pyloric NGT intact-tolerating tube feeds at 50cc/hour. Pt remains on standing lactulose dosing for elevated ammonia and is moderate to large amounts of liquid brown stool. abdomen is soft with positive bowel sounds.\nGU: Foley catheter intact, putting out adequate amounts of clear, yellow urine.\nID: Tmax 100.8 today.\nPLAN: Monitor neuro signs and assess for seizure activity. Taper ativan slowly as patient tolerates. Monitor temps. Assess skin closely for breakdown.\n" }, { "category": "Nursing/other", "chartdate": "2198-08-04 00:00:00.000", "description": "Report", "row_id": 1265310, "text": "SICU NN: SEE FHP FOR HISTORY AND PHYSICAL. PATIENT TRANSFERRED TO SICU FROM 5 S/P CODE BLUE. PATIENT APNEIC AND WITHOUT PULSE ON 5, PATIENT RESUMED BREATHING AND PULSE SPONTANEOUSLY, INTUBATED PRIOR TO ARRIVAL. CXR DONE AND ET POSITION CHECKED BY DR. . SENT. EEG OBTAINED. EEG CONTINUOUS AND TO REMAIN OVERNIGHT. PATIENT NOTED TO BE IN STATUS EPILEPTICUS. DR. NOTIFIED, ATIVAN GIVEN AND PROPOFOL INFUSION RESTARTED AS REQUESTED AND AS MD ORDER. BURST SUPPRESSION ACHIEVED, TRACING SHOWN TO DR. FROM NEURO. FAMILY UPDATED. PERRL 3 AND BRISK. PATIENT WITH SOME SPONTANEOUS MOVEMENT ALTHOUGH NON PURPOSEFUL. PATIENT OPENS EYES TO STIMULI OFF SEDATION. WITHDRAWS ALL EXTREMITES TO PAIN. DOES NOT FOLLOW COMMANDS. EYES DEVIATE TO RIGHT WHEN OPEN. ET TO VENT, CPAP, TOLERATING. GAG AND COUGH PRESENT. MINIMAL CLEAR/WHITE SECRETIONS. LUNGS CLEAR. RSR. BP WNL. AFEBRILE. PALP PEDALS. PIV X 3. BLOOD CULTURES SENT AS ORDERED. NGT CLAMPED, USE FOR MEDS. LACTULOSE Q4H FOR HIGH AMMONIA LEVELS. ABD SOFT, BOWEL SOUNDS PRESENT. PROTONIX FOR PROPHYLAXIS. FOLEY URINE OUTPUT LOW ON ARRIVAL 250CC FLUID BOLUS GIVEN WITH IMPROVEMENT NOTED. UA AND URINE CULTURE SENT AS ORDERED DUE TO CLOUDINESS. SKIN INTACT. PATIENT WITHOUT SIGNS AND SYMPTOMS OF PAIN. RESTRAINTS IN PLACE TO MAINTAIN SAFETY SECONDARY TO ET TUBE. FINGERSTICKS Q4H. HEP SQ AND PBOOTS FOR DVT PROPHYLAXIS. FAMILY AT BEDSIDE SPOKE WITH SICU MD AND NEURO MD. PLAN: ATIVAN AND PROPOFOL FOR BURST SUPRESSION, NEURO CHECKS Q2H, CONTINUOUS EEG, HEMODYNAMIC SUPPORT, MECH VENTILATION, VAP PREVENTION, SKIN CARE, EMOTIONAL SUPPORT.\n" }, { "category": "Nursing/other", "chartdate": "2198-08-05 00:00:00.000", "description": "Report", "row_id": 1265311, "text": "Resp Care Note, Pt remains on current vent settings. See vent flow sheet for details.RSBI done on 0 peep/5 ips 18.6.Sedated with propofol. Getting neosynephrine. Will cont to monitor resp status.\n" }, { "category": "Nursing/other", "chartdate": "2198-08-05 00:00:00.000", "description": "Report", "row_id": 1265312, "text": "NPN (NOC):\n\nNEURO: PT CONTINUES ON PROPOFOL, CURRENTLY AT 165 MCG'S/KG/MIN. GOAL IS TO KEEP BURSTS Q 6-10 SECS. ON LARGER DOSES OF PROPOFOL, BURSTS COME Q 30 TO 60 SECS WHICH IS NOT DESIRABLE PER N-MED. HENCE MEDS ADJUSTED DOWNWARD. BURSTS LAST 16 TO 30 SECS, N-MED IS AWARE. NO OUTWARD SIGN OF SZ ACTIVITY NOTED AND PT IS VERY HEAVILY SEDATED. ATIVAN 2 MG'S IV GIVEN X1, DIALNTIN AND KEPPRA GIVEN. AM DILANTIN LEVEL PND.\n\nCV: SBP'S DROPPED TO LOW 80'S ON LARGE DOSES OF PROPOFOL. PHENYLEPHRINE BEGUN AND IS NOW AT 1 MCG/KG/MIN W/ SBP'S IN LOW 100'S, MAPS HIGH 50'S TO LOW 60'S.\n\nRESP: REMAINS INTUBATED. CURRENT VENT SETTINGS: \"5&5\" X 40%. RR LOW TEENS, VT'S 400'S TO 500'S. SATS HIGH 90'S. LUNGS CLEAR. AM RSBI = 18.\n\nGI: NGT CLAMPED EXCEPT FOR MEDS. HAS RECEIVED 3 DOSES OF LACTULOSE AND STILL HAS NOT STOOLED. ABD IS SOFT W/ + BS'S.\n\nF/E: UO WAS AS LOW AS 0 FOR ONE HR. WHEN SBP'S WERE LOWER. GIVEN NS 250 CC'S BOLUSE X 3. ALSO HAS NS RUNNING AT 75/ HR. WITH SBP'S IN LOW 100'S., UO IS NOW 100/HR. AM LYTES OKAY.\n" }, { "category": "Nursing/other", "chartdate": "2198-08-05 00:00:00.000", "description": "Report", "row_id": 1265313, "text": "Resp. care note - Pt. remaines intubated and vented, no vent changes made at this time.\n" }, { "category": "Nursing/other", "chartdate": "2198-08-08 00:00:00.000", "description": "Report", "row_id": 1265325, "text": "Respiratory Care Note\nPt received on AC as noted with no vent changes this shift. BS are coarse bilaterally which clears with suctioning. Pt suctioned for copious amt of thick, tan secretions x 1. ABG 7.34/38/119/21/-4. ETT repositioned and retaped without incident. Pt remains on CVVHD. Plan to continue on current settings at this time.\n" }, { "category": "Nursing/other", "chartdate": "2198-08-15 00:00:00.000", "description": "Report", "row_id": 1265351, "text": "SICU NPN:\nS:Sedated and intubated\n\nSEE CAREVUE FOR ALL OBJECTIVE DATA AND TRENDS IN FLOWSHEET.\n\nO:Continues on Midazolam infusion at 6mg/hr. No change in neuro exam. EEG in progress. VSS. Respiratory status unchanged. HUO adequate. CVP 12-14. Appearing fluid overloaded. TFs at GR, tolerating. Flexiseal in tact, passing liquid brown stools. Lactulose and Regland continuing to give. Pancytopenia improving. CPKs on the rise, MBs flat. Low grade temps.\n\nA/P:\nQuestion gently diureses\nContinue to monitor\n" }, { "category": "Nursing/other", "chartdate": "2198-08-15 00:00:00.000", "description": "Report", "row_id": 1265352, "text": "Resp Care\nPt remains intubated and sedated on full vent support. No vent changes made this shift. BS coarse bilaterally and diminished at lung bases. Pt currently exempt from weaning protocol due to sedation and cont EEG monitoring, therefore RSBI not completed. See CareVue for details and specifics.\nPlan: Continue vent support.\n" }, { "category": "Nursing/other", "chartdate": "2198-08-15 00:00:00.000", "description": "Report", "row_id": 1265353, "text": "Resp. Care Note\nPt remains intubated and vented on AC settings as charted on resp flowsheet. No vent changes made this shift. Pt transported to MRI today on portable MRI vent without incident. Plan to cont current vent settings, exempt from weaning protocol at this time.\n" }, { "category": "Nursing/other", "chartdate": "2198-08-15 00:00:00.000", "description": "Report", "row_id": 1265354, "text": "SICU NN: SEE CAREVUE FOR ASSESSMENT. MRI HEAD W AND W/O CONTRAST DONE TODAY. CONTINUOUS EEG CONTINUES TRACING APPEARS MORE SUPPRESSED, SHOWN TO MD ATTENDING. SEDATED ON VERSED AT 6MG PER HOUR AS PER NOT TO BE TITRATED AND PHENOBARBITOL EXTRA DOSE GIVEN AS ORDERED AND DOSE INCREASED. DILANTIN AND KEPPRA CONTINUE. SEE NEURO ASSESSMENT. ET TO VENT, CMV, NO RESPIRATORY ISSUES AT THIS TIME. RSR. STANDING LOPRESSOR. BP WNL. TEMPS IMPROVED. DOPPLER PULSES. IVF INCREASED TO 150CC/HR AND LASIX ADDED SECONDARY TO INCREASING CPK'S. CENTRAL LINE AND ALINE INTACT. TOLERATING TUBE FEEDS AT GOAL, NGT DC'D CHANGED TO OGT SECONDARY TO SINUSITUS SEEN ON MRI, POSITION CHECKED BY XRAY. FLEXISEAL WITH LIQUID BROWN STOOL, LACTULOSE AND RIFAXIMIN CONTINUE. FOLEY WITH ADEQUATE OUTPUT, RESPONDED WELL TO LASIX. SACCRUM WITH ALLEVYN. INSULIN GTT FOR GLUCOSE CONTROL. NO RESTRAINTS NECESSARY AT THIS TIME. NO SIGNS OR SYMPTOMS OF PAIN. FAMILY AT BEDSIDE UPDATED BY TEAM. PLAN: GOAL PHENOBARB LEVEL >30, WEAN DOWN VERSED WHEN OK BY TO ASSESS FOR STATUS, NEURO CHECKS, VENTILATORY SUPPORT, VAP PREVENTION, NUTRITIONAL SUPPORT WITH TUBE FEEDS, IVF AND DIURETICS FOR KIDNEY PROTECTION DUE TO RISING CPKS, SKIN CARE, EMOTIONAL SUPPORT.\n" }, { "category": "Nursing/other", "chartdate": "2198-08-16 00:00:00.000", "description": "Report", "row_id": 1265355, "text": "NURSING UPDATE\nCV: HR SR W/RARE->FREQUENT PVC'S. NORMOTENSIVE, LOPRESSOR EFFECTED HR AND BP MINIMALLY. HEME'S IMPROVING...HCT 29, PLTS 100, CPK ON DECLINE.\n\nNEURO: CONT EEG..WAVEFORM ADEQUATELY SUPPRESSED. CONT MIDAZ GTTS. NO SEIZURE ACTIVITY OBSERVED.\n\nID: TEMP SLOWLY ESCALATING. WBC 5.1, ABX AS ORDERED, CONTACT .\n\nENDO: INSULIN GTTS TITRATED PER FS GLUCOSE.\n\nRESP: BS COARSE, SXN SMALL THICK YELLOW, ABG WITHIN ACCEPTABLE RANGE. SATS 98-99%, NO VENT CHANGES.\n\nGI: TUBE FEED TOLERATE @ GOAL, RESIDUAL MIN->0. ABDOMEN MORE DISTENDED AND LESS SOFT. LG GOLDEN BROWN LIQUID, GUAIAC NEGATIVE.\n\nGU/RENAL: RESPONDED WELL TO IV LASIX. HUO 130-820CC CLEAR YELLOW. BUN/CREAT...28/0.8 @ 2300, AM CHEMS PENDING AT THIS TIME.\n\nPT MONITORED CLOSELY.\nSEE CAREVUE FLOWSHEET FOR DETAILED DATA.\n" }, { "category": "Nursing/other", "chartdate": "2198-09-06 00:00:00.000", "description": "Report", "row_id": 1265435, "text": "resp care\n#8.0 perfit portex trach in place. sxned for thick yellow sputum, inner cannula changed x1. remains on humidifed trach mask with stable spo2. cuff pressure sealed at 25 cmH20. nard. appropriate equipment at bedside.\n" }, { "category": "Nursing/other", "chartdate": "2198-08-21 00:00:00.000", "description": "Report", "row_id": 1265374, "text": "NSG.PROGRESS NOTES:\nSEE FLOW SHEET FOR SPEICIFIC:\n\nNEURO:STILL ON VERSED GTT AT 3MG/HR,NO SZ ACTIVITIES NOTED,PERL.NO RESPONSE TO NAIL BED PRESSURE,OPENS EYES SPONT AT TIMES AND SOMETIMES TO STIMULI.CONT WITH KEPPRA AND PHNO,DILANTIN 1000MG GIVEN AT 1900 STILL THE LEVEL IS 9.1.\nCV: NSR,HR: 80-90.NO ECTOPY NOTED,SBP 100-135.LOPRESSOR HELD AS SBP LOW,PALPABLE PP,++GEN EDEMA,FLUID BALANCE OF -30ML BY MN,SCROTUM GROSSLY EDEMATOUS AND WITH SKIN PEEL WBC 3.9.TODAY,IVF NS AT 50ML/HR/CVP 10-12CM.\n\nRESP;REMAINSON VENT, NO VENT CHANGES TODAY,SXN THICK YELLOW SECRETION MOD AMT,LS COARSE - CLEAR.IMPAIRED COUGH AND GAG.ABG ACCEPTABLE.\n\nGI: TF AT GOAL,TOLERATING WELL,ABD W/ASCITIS,HYPOACTIVE BS,NO BM.\n\nGU: FOLEY CATH PATENT WITH YELLOW CLEAR URINE ADQ AMT.\n\nENDO: ON INSULIN GTT,BLD SUG Q2H.\n\nID: AFEBRILE,ON ANBX.\n\nACT: TURNED AND POSITION CAHNGED,SKIN PEEL AT SCROTUM AND GROIN AQUACEL APPLIED.BACK INTACT.\n\nPLAN: CONT MONITORING,PULM HYGIENE,NEURO CHECKS,MONITOR FOR SZ,SKIN CARE REFERRAL,WEAN OFF MIDAZ,SUPPORT TO FAMILY.\n" }, { "category": "Nursing/other", "chartdate": "2198-08-21 00:00:00.000", "description": "Report", "row_id": 1265375, "text": "Respiratory Therapy\nPt remains orally intubated on full ventilatory support. BS clear bilaterally. Sx sml amts thick yellow secretions. No vent changes made overnight. Continue to follow, wean as rolerated.\n" }, { "category": "Nursing/other", "chartdate": "2198-08-21 00:00:00.000", "description": "Report", "row_id": 1265376, "text": "Resp Care\n\nPt remains intubated and on full vent support. Mv being maintained in the 12-15L range. ABG 7.45/31/117/22. BS are coarse and suctioning thick yellow sputum.\n" }, { "category": "Nursing/other", "chartdate": "2198-08-21 00:00:00.000", "description": "Report", "row_id": 1265377, "text": "NURSING NOTE\nPLEASE SEE CAREUVE FOR DETAILS\nNEURO: PT CONT TO ANY NOXIOUS STIM, NO SPONT MVMT NOTED, NOT ABLE TO FOLLOW COMMANDS. OPENS EYES SPONTANEOUSLY, BUT NOT ABLE TO TRACK, PERRL 2-3MM, BRISK. VERSED DRIP D/C'D, STARTED ON ATIVAN. NO SEIZURE ACT NOTED ON CONT EEG, CONT ON PHENOBARB, DILANTIN.\n\nCVS: HR 70S-90S, NSR W/FEW PVC'S. SBP 100S-140S, DOWN TO 90S AFTER 9MG ATIVAN SLOW IVP GIVEN. CONT GROSS GEN EDEMA, VERY LGE SCROTAL EDEMA PALP PP. 80MG LASIX W/VERY LGE DIURESIS, GOAL FLUID BAL 1L NEG, PRESENTLY NEG~1500CC/24HR. CA REPLETED FOR 1.05\n\nRESP: NO VENT CHANGES MADE, 600X16/40%/5, ABG 7.45/31/117/22. LUNGS CLEAR TO COARSE, SUCTIONED FOR SM-MOD AMT THICK YELLOW SECRETIONS. IMPAIRED GAG/COUGH.\n\nGI/GU: CONT ABD ASCITES, +BS, FLEXI-SEAL INTACT W/SM AMT GOLDEN LOOSE STOOL DESPITE GIVEN LACTULOSE. REPLETE W/FIBER CONT AT GOAL, MIN RESIDUALS. LGE AMT HUO VIA FOLEY CATH, SOME SEDIMENT NOTED, DR. AWARE.\n\nENDO: CONT INSULIN DRIP AT 5-6MG/HR\n\nINTEG: COCCYX WND COVERED W/ALLEVYN C/D/I. RIGHT GROIN SKIN TEARS W/SM AMT SEROUS-SEROSANG DRNG COVERED W/AQUALCEL INTACT. SCROTAL EDEMA W/MOD AMT SEROUS DRNG.\n\nPLAN: CONT HEMODYNAMIC MONITORING, NEURO CHECKS. MONITOR FOR SEIZURE ACT/CONT EEG, GOAL 1L NEG FLUID BAL. RESP SUPPORT, ?TRACH IN NEAR FUTURE. FAMILY SUPPORT, CONT ICU PLAN OF CARE.\n" }, { "category": "Nursing/other", "chartdate": "2198-08-08 00:00:00.000", "description": "Report", "row_id": 1265326, "text": "NURSING NOTE\nASSESSMENT:\n PATIENT REMAINS OFF ALL SEDATION & ON CONTINOUS EEG. NO SEIZURE ACTIVITY NOTED, EEG WITH OCCASIONAL BURSTS (OKAY PER NEUROLOGY). PATIENT DOES NOT WITHDRAW TO PAIN OR OPEN EYES AT ALL. CONTINUES ON KEPPRA & DILANTIN.\n HEART RATE 80'S NORMAL SINUS & MAP 55-60. PATIENT REMAINS ON EPI GTT & LEVO GTT, UNABLE TO WEAN. SLIGHTLY HYPOTHERMIC (ON CRRT), BAIR HUGGER IN PLACE. PATIENT ONLY MAKING SCANT URINE. CVVHDF AND BICARB GTT CONTINUES, ACIDOSIS IMPROVING (BICARB 18-20). XIGRIS GTT PER PROTOCOL. CBC & COAGS STABLE, SEE FLOWSHEET.\n PATIENT ON ASSIST CONTROL, NO VENT CHANGES MADE TODAY. PATIENT NOT BREATHING OVER VENT. SUCTIONED BY RESP THERAPY FOR THICK, TAN SPUTUM.\n ABDOMEN SOFT, NONDISTENDED, NO BOWEL SOUNDS. PATIENT CONTINUES TO RECEIVE LACTULOSE, ? ABSORBTION. WHEN NGT TO SUCTION, MODERATE AMOUNT OUTPUT THAT APPEARS TO BE MEDS. INSULIN GTT INCREASED THROUGHOUT THE AM, BLOOD GLUCOSE NOW < 150. NO NUTRITION.\n FAMILY VISITING THROUGHOUT THE DAY, GIVEN UPDATE BY DR. & NEURO. APPEAR TO BE COPING WELL.\nPLAN:\n CONTINUE WITH CVVHDF OVERNIGHT, FOLLOW EVERY 6 HOURS. PROVIDE SUPPORT TO FAMILY. XIGRIS GTT FOR 96 HOURS FROM START.\n" }, { "category": "Nursing/other", "chartdate": "2198-08-09 00:00:00.000", "description": "Report", "row_id": 1265327, "text": "SICU Nursing Note, B Shift\n\nNeuro: Increased seizure activity noted on continous EEG, Neurology resident notified. A one time dose of pentobarb is being ordered. No changes in objective assessment.\nCV: SR at beginning of shift, with increasing tachycardia as the night progressed. One episode of vent. bigeminy at about 0300 after bedbath, which lasted about 30 seconds. At the time of this note, able to decrease Epi gtt to decrease by half, and slightly the norepi gtt without compromising SBP or MAP.\nResp: Remarkable improvement in ABG, FiO2 was able to be decreased. LS coarse.\nGI: Meds given down NGT are clearly not being absorbed. 0400 Lactulose dose held for this. Absent BS, passing scant brown stool through Flexiseal.\nRenal: CRRT running in CVVHDF mode, required another 4g of calcium beyond the continuous gtt, due to a sustained calcium level of 1.08, twice. Running even presently. Passing increasing amounts of CYU throughout shift.\nSkin: Intact, one area of breakdown (stage II) noted on right buttock. Diffuse macular rash in R axilla and onto R flank, looks like yeast, antifungal ointment applied.\nSocial: Family in earlier in shift, asking appropriate questions, pleasantly involved in care.\nPlan: Continue CRRT, attempt to wean vasopressors and insulin gtt.\n" }, { "category": "Nursing/other", "chartdate": "2198-08-09 00:00:00.000", "description": "Report", "row_id": 1265328, "text": "resp care\nPt remained on a/c 600x20 40% 10peep with peak/plat 28/25.Fio2 weaned to 40% with acceptable abg.Rsbi held due to peep level.Bs coarse-suct for scant amt of sput. Will cont to follow and wean as tolerated.\n" }, { "category": "Nursing/other", "chartdate": "2198-08-14 00:00:00.000", "description": "Report", "row_id": 1265347, "text": "SICU NPN\nS-Sedated and intubated.\n\nSEE CAREVUE FOR OBJECTIVE DATA AND TRENDS IN FLOWSHEET.\n\nO-Remains on Midazolam infusion with unchanged rate at 6mg/hr. Continious EEG remains in progresss. No seizure activity noted by RN. Non-arousable to deep stimuli. PERL, pinpoint, brisk. Unable to stimulate gag or cough. VSS. Tachycardic, when febrile, with some PVC and later runs couplets and bigemeny. Lytes checked and repleted. Respiratory stable. No issues. HUO adequate. Maitenance fluid continues in additional to TFs hourly. Addressed with Dr. and wanting to continue. Pt hourly intacke 230cc/hr. TFs at GR and tolerating. Continuing Lactulose and Reglan depsite loose stool. Flexiseal intact. Tm 101.7 and Tc 99.9. Pan cultured on prior shift. Dr. made aware. Cooling blanket in place. Dosing Vanco PRN for prior renal functions. Renal function since has normalized. AM level pending. Still with pancytopenia. PLTs 50s and WBC 2s. CVL site reddened at insertion. SICU team aware from prior shift. Insulin infusion continues, rate 8-10 units/hour over night. Fingerstick glucoses 80-90. Wife and son visiting into evening, updated by RN.\n\nA/P:63 year old male ESLD c/b septicemia and continued seizures despite induced Propfol and Pentobarb coma. Continue to monitor with continious EEG.\n\nQuestion fluid status, euvolemic vs. hypovolemic\nQuestion source of pancytopenia, ?hem/onc c/s ? HIT (+)\nFollow temp curve, treat accordingly with cooling blanket\nContinue to follow lytes\nContinue to monitor\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2198-08-14 00:00:00.000", "description": "Report", "row_id": 1265348, "text": "Resp Care\nPt remains intubated on full vent support. No vent changes made this shift. BS clear bilaterally and diminished at lung bases. Pt suctioned for small amounts of thick tan secretions. Pt on Phenobarb and currently exempt from weaning protocol, therefore RSBI not completed at this time. See CareVue for details and specifics.\nPlan: Maintain vent support.\n" }, { "category": "Nursing/other", "chartdate": "2198-08-14 00:00:00.000", "description": "Report", "row_id": 1265349, "text": "the pt remained stable throughout the shift .No vent settings changes.\nbs:coarse ,suctionned minimal white thin secretions.\n" }, { "category": "Nursing/other", "chartdate": "2198-09-04 00:00:00.000", "description": "Report", "row_id": 1265426, "text": "NPN\nNeuro:Pt unresposive to painful stimulus, pupils unequal x 1 rt<Lt 2mm and 3mm. Pt opens eyes spontaneously but not to command. Continuous EEG continues. Ativan 3.25mg q 6hrs tolerated.\nCV:SBP stable tonight, no drops in SBP around ativan doses. CVP 10.\nResp:PT tolerated 50% trach mask all night. Thick tan secretions continue from trach. Vent at bedside for back-up.\nGI:Pt tolerating goal TFs, continues to have diarrhea, flexiseal in place.\nGU:u/o adequate.\nSkin:No new breakdowns. see carevue assessment.\nFamily:Wife at bedside talking about pt as a good father and husband, she saw him pull through severe illness 9 mos ago and hopes the same will happen this time. She realizes pt is much sicker than last time but still has hope.\nPlan:Continue to suction trach q3-4 hrs.\nemotional supporet for family members.\nContinue plan of care.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2198-09-04 00:00:00.000", "description": "Report", "row_id": 1265427, "text": "Resp: Pt rec'd on 50% t/c and tolerated well all night. Suctioned for thick to thin yellow/tan secretions. Family meeting again today. Pt is full code. Will continue to follow.\n" }, { "category": "Nursing/other", "chartdate": "2198-09-04 00:00:00.000", "description": "Report", "row_id": 1265428, "text": "Nursing note:\nSee Carevue for specifics:\nNEURO: Remains sedated on ATC Ativan, weaning dose slightly. Unresponsive, does not open eyes, withdraw or follow commands. PERRLA 2-3mm and brisk. Continuous EEG in place, no seizure activity noted. No s/sx pain.\nRESP: Lung sounds clear, dim to bases. Suctioned frequently for thick tan-yellow secretions. Remains on trach collar, 50%.\nCV: Tmax 99.9, SR in 80s, no ectopy. SBP 100-120s. +PP. +2 edema to extremities.\nGI: Abdomen soft, +BS, tolerating TFs at goal. Flexi-seal intact for large amounts brown liquid stool.\nGU: Foley patent adequate amount amber urine.\nENDO: Glucose stable, SSRI/NPH given per parameters.\nSKIN: Scrotum edematous, abrasion noted. Adaptic in place. Coccyx reddened w/small open area noted, Allevyn in place.\nFamily meeting held today w/neuro-med, no real change in plan.\n\nA/P: Hemodynamically stable, no seizure activity noted. Continue w/slow Ativan wean, monitor closely.\n" }, { "category": "Nursing/other", "chartdate": "2198-09-05 00:00:00.000", "description": "Report", "row_id": 1265429, "text": "NPN\nNeuro:unchanged, pt opens eyes spontaneously otherwise no purposeful movement. Continuous EEG in progress, no overt seizure activity noted.\nCV:Afeb, SR, no ectopics, BP fairly stable.\nResp:Trach to .50 trach mask suctioned for thick blood tinged tan secretions. trach care given. Pt does desat if o2 off for trach care.\nGI:Tolerating FS neutren pulm with adds (in refrigerator). Pt continues to have diarrheal stool.\nGU:u/o adeq.\nSkin:allevyn on coccx to prevent skin breakdown.\nEndocrine:Blood sugars treated per sliding scale.\nFamily: wife and son at bedside.\nPlan of care\nComplete care\nContinue plan of care\n" }, { "category": "Nursing/other", "chartdate": "2198-09-12 00:00:00.000", "description": "Report", "row_id": 1265456, "text": "NURSING PROGRESS NOTE\nPLEASE SEE CARVUE FOR SPECIFICS:\nCONT TO WEAN PHENOBARB. PT APPEARING MORE \"AWAKE\" AT TIMES. PT WITH NOTABLE INCREASED BLINKING AND SMALL LIP MOVEMENT AT TIMES TO VOICE/STIMULI. STILL DOES NOT WITHDRAW TO PAIN NOR FOLLOW COMMAND. HR AND SBP NOTEABLY INCREASED FROM PREVIOUS ? \"WAKING UP.\" OTHERWISE AFEBRILE. HR-NSR NO NOTED ECTOPY. TRACHED SXN FOR MODERATE AMTS TAN/BLD TNG SECRETIONS. FOLEY PATENT DRNG CLEAR YELLOW URINE. PLAN: CONT TO CLOSELY ASSES NEURO STATUS DURING WEANING PROCESS. CONT TO MONITOR HEMODYNAMICS/RESP STATUS. EMOTIONAL SUPPORT TO PT AND FAMILY. CONT WITH CURRENT PLAN OF CARE.\n" }, { "category": "Nursing/other", "chartdate": "2198-09-12 00:00:00.000", "description": "Report", "row_id": 1265457, "text": "NPN\nPlease see carevue for further details and specifics.\n, on continuous EEG. No response to nailbed pressure. PERRL 3 mm, briskly reactive. continues slow wean of phenobarb and ativan. On trach mask, suctioned for thick yellow/blood tinged sputum moderate amounts. sats 98-100%. RR 18-22. BLS clear at apices, diminished at bases. + BS x4 abd soft nt/nd. TF switched to replete with fiber, goal rate of 80. Currently at 60. Flexiseal intact with large amounts of golden liquid stool. Lactulose TID. Foley draining clear yellow urine adq amounts. Allevyn intact to sacrum. Small abrasions to scrotum and penis. criticaid clear applied. PLAN: Continue to closely monitor neuro status, respiratory status, hemodynamics. PRovide comfort and support.\n" }, { "category": "Nursing/other", "chartdate": "2198-09-12 00:00:00.000", "description": "Report", "row_id": 1265458, "text": "RESPIRATORY CARE\nPt remains on cool aerosol via trach mask. 7cc in balloon to generate 25cmh20 in cuff. Suctioning yellow and bloody secrections from trach. Aerosol filled and drained.\n" }, { "category": "Nursing/other", "chartdate": "2198-09-13 00:00:00.000", "description": "Report", "row_id": 1265459, "text": "NURSING NOTE\n NEURO EXAM UNCHANGED, REMAINS ON CONTINUOUS EEG MONITORING. PHENOBARB & ATIVAN CONTINUE. ALL VITALS STABLE, SEE FLOWSHEET FOR DETAILS. TOLERATING TRACH COLLAR 50% AND EXPECTORATING TAN/BLOOD TINGED SPUTUM. ABDOMEN SOFT, REPLETE WITH FIBER @ GOAL RATE. LOOSE STOOL, CONTINUES ON LACTULOSE. BLOOD GLUCOSE STILL HIGH, COVERED WITH INSULIN AS ORDERED (NPH INCREASED YESTERDAY). MAKING ADEQUATE URINE, PATIENT ALMOST RETURNED TO BASELINE WEIGHT. PLAN TO CONTINUE WITH CURRENT MONITORING AND TREATMENT.\n" }, { "category": "Nursing/other", "chartdate": "2198-09-13 00:00:00.000", "description": "Report", "row_id": 1265460, "text": "Resp Care Note\nPt remains on 50% cool aerosol trach mask. Breath sounds diminished but clear. Suctioned moderate amts of thick bloody/tan secretions. Trach is secure and inner cannula in place. Ambu bag and mask at bedside. Will cont to follow.\n\n" }, { "category": "Nursing/other", "chartdate": "2198-09-13 00:00:00.000", "description": "Report", "row_id": 1265461, "text": "NPN\nPlease see carevue for further details\nNeuro exam unchanged. Continues with bedside EEG monitoring. PERRL 2-3 mm. Phenobarb and ativan cont. Tolerating trach collar well at 50%. suctioned for mod amounts of thick blood tinged sputum. Abd soft + BSx 4 nt/nd. Loose stool continues. flexiseal in place. Lactulose TID. Replete with fiber at goal. HR 80s NSR. SBP wnl. FOley with adq amounts of clear urine, blood tinged. ? positional trauma. team aware. Coccyx decubitus- ? increasing in size. Wound care RN in to assess. Larger allevyn in place over duoderm. Kinair bed ordered- awaiting arrival. FS 140s. PROM to all extremities. Continue to closely monitor hemodynamics, respiratory status, neuro status, and maintain skin integrity.\n" }, { "category": "Nursing/other", "chartdate": "2198-08-25 00:00:00.000", "description": "Report", "row_id": 1265390, "text": "NURSING NOTE\nPLEASE SEE CAREUVUE FOR DETAILS\nNEURO: PT NOT RESPONSIVE TO ANY NOXIOUS STIM, NO SPONT MVMT NOTED. OPENS EYES SPONT, NOT TRACKING, PERRL 2-3MM, BRISK. CONT EEG, NO SEIZURE ACT NOTED, CONT DILANTIN/PHENOBARB/KEPPRA, ATIVAN WEANED TO 5MG.\n\nCVS: HR 70S-90S, NSR, SBP 90S-120S, CVP 7-13. LASIX 40MG GIVEN X1 W/LGE DIURESIS, ALBUMIN GIVEN X1 FOR SBP DOWN TO 88 THIS EVE. GOAL NEG FLUID BAL, PRESENTLY NEG ~600CC/24HR. CONT GEN EDEMA, PALP PP DESPITE SIG PEDAL EDEMA. Tm 99.6\n\nRESP: NO VENT CHANGES MADE, 600X16/40%/5, SUCTIONED FOR MOD AMTS THICK YELLOW-TAN SECRETIONS. LUNGS COARSE, CLEAR AT TIMES, ABSENT GAG, +COUGH. O2 SATS 98-99%.\n\nGI/GU: TF REPLETE W/FIB AT GOAL, MIN RESIDUALS. CONT LGE ABD ASCITES, SM SOFT FORMED BM X2, DULCOLAX SUPP X1, HYPO+BS. LGE AMT HUO-GOOD RESPONSE TO DIURETICS.\n\nINTEG: COCCYX WND COVERED W/ALLEVYN C/D/I. RIGHT GROIN BLISTERS AQUACEL DSGS W/SM AMT SEROSANG DRNG, INTACT. PENIS W/SEVERAL BLISTERS TO SUPERIOR/INFERIOR ASPECT W/SM AMT SEROUS DRNG, COVERED W/ADAPTIC. CONT GROSS SCROTAL EDEMA, BLISTER TO UNDER SIDE OF SCROTUM COVERED W/ADAPTIC.\n\nENDO: INSULIN DRIP REMAINS OFF, BS COVERED PER RISS/NPH\n\nPLAN: CONT HEMODYNAMIC MONITORING, FLUID BOLUS/ALBUMIN FOR LOW SBP. FREQUENT NEUROS, RESP SUPPORT, MONITOR FOR SEIZURE ACT. ?CONT DIURESIS FOR FLUID GOALS. FAMILY SUPPORT, CONT ICU PLAN OF CARE.\n" }, { "category": "Nursing/other", "chartdate": "2198-08-25 00:00:00.000", "description": "Report", "row_id": 1265391, "text": "Resp Care\nPt remains intubated. Current vent settings: A/C 600 x 16 5P 40%. Pt remains on EEG. No other changes noted.\n" }, { "category": "Nursing/other", "chartdate": "2198-08-26 00:00:00.000", "description": "Report", "row_id": 1265392, "text": "Resp: Pt rec'd on a/c 16/600/+5/40%. BS are coarse to clear. Suctioned for small to moderate amounts of thick tan secretion. No changes noc. AM ABG 7.48/41/145/31. Exempt from RSBI. Plan to maintain present settings.\n" }, { "category": "Nursing/other", "chartdate": "2198-08-26 00:00:00.000", "description": "Report", "row_id": 1265393, "text": "NURSING NOTE\n?NPO/hold TF after MN for planned Trach . Pt Tm 100.3 this eve, Dr. aware, pan cultures ordered.\n" }, { "category": "Nursing/other", "chartdate": "2198-08-26 00:00:00.000", "description": "Report", "row_id": 1265394, "text": "NURSING NOTE\n?NPO/hold TF after MN for planned Trach . Pt Tm 100.3 this eve, Dr. aware, pan cultures ordered.\n" }, { "category": "Nursing/other", "chartdate": "2198-09-19 00:00:00.000", "description": "Report", "row_id": 1265481, "text": "resp care\nPt remained on a 35% trach collar. #8portex,cuff inflated/cuff pressure 28.BS coarse bil. Suct for sml amt of thick tan.Will cont to follow for routine airway assessment.\n" }, { "category": "Nursing/other", "chartdate": "2198-09-19 00:00:00.000", "description": "Report", "row_id": 1265482, "text": "Respiratory Care\n\n Pt continues on .35% t-collar. B/S sl coarse sx'd for sm/mod thick blood tinged secretions. cuff pressure now 26 cmH20. Will continue to follow for routine airway checks.\n" }, { "category": "Nursing/other", "chartdate": "2198-08-11 00:00:00.000", "description": "Report", "row_id": 1265337, "text": "Nursing Progress Note\n Please see carevue for details of care. Remains off all sedation but enresponsive to external stimuli. PERL @ 2mm. Continues to overbreath vent 2-4 BPM at times this am, no cough/gag.\n Remains on vent support CMV 600x16x40%+10PEEP, ABG less acidotic this am after bicarb d/c'd. BS remain clear to coarse, dim in bases. Suctions for thick yellow secretions.\n Remains off pressors this am, MAP >60 w/rare dip to high 50's which recovers to 60's quickly w/o intervention. No evidence of arrythmia today. 2 units RBC's transfused for HCT=20, repeat hct 25 after transfusion. K+ within range, level 3.8 this pm, repletion held after discussion with SICU resident pending repeat early this pm.\n Xigris infusion cont as ordered, insulin gtt titrated down to maint BS 80-120 after dextrose discontinued in IVF this am.\n NGT remains clamped w/no residual noted after meds. TF restarted full strength replete w/fiber at 10 ml/hr, rate increased to 20 after no residual at 1600, goal=80 ml/hr. ABD remains soft, BOS faint. Liquid brown stool via FIB. Changed to flexiseal this pm due to leakage. Criticaid clear cream to perianal area and reddened scrotum. Scrotum/penis remain edematous, elevated for comfort. Alevyn dressing applied to coccyx d/t scant serous drainage from superficial 2x5mm open area.\n Phenobarb bolus started this pm after epilepsy team in to exam patient and stated that status epilepticus can be seen on EEG monitor. Meds as ordered, no visual symptoms of seizures noted.\n Wife in this pm, updated re: pt. conditon and changes in .\n\nPLAN: Continue to monitor , insulin gtt and need for pressors. Xigris gtt until at 0130 then d/c. Monitor TF tolerance and advance as ordered. Note stools and amount, support to family.\n\n" }, { "category": "Nursing/other", "chartdate": "2198-08-11 00:00:00.000", "description": "Report", "row_id": 1265338, "text": "pt remains on full vent support for airway protection during seizures. sx'd for minimal secretions. ABG showed improvement in oxygenation, therefore PEEP decreased. plan to re evaluate in AM for potential to wean.\n" }, { "category": "Nursing/other", "chartdate": "2198-08-12 00:00:00.000", "description": "Report", "row_id": 1265339, "text": "NURSING UPDATE\nCV: HR NSR, NO ECTOPY. BP WITHIN ACCEPTABLE PARAMETERS. HCT 23 @ , AM PENDING.\n\nRESP: BREATH SOUNDS DIMINSHEDD @ BASES, SXN THICK YELLOW SECRETIONS, SATS 99-100%, NO VENT CHANGES.\n\nID: AFEBRILE. XIGRIS RX COMPLETED @ 0130. CONTACT PRECAUTIONS MAINTAINED.\n\nNEURO: NO PHYSICAL SEIZURE ACTIVITY OBSERVED. NEURO STATUS UNCHANGED. PHENOBARBITOL 200MG IV X1 IN PM (ADDITIONAL DOSE). S/B DR IN PM, VERSED GTTS ORDERED TO BE TITRATED TO SUPPRESS EEG BURSTS, DR EXPRESSED THAT EEG MONITORING BE PERFORMED ONLY BY NEURO RESIDENT. THEREFORE AS ORDERED, GTTS STARTED @ 2230 AT 1MG/H, EEG REVIEWED BY NEURO HO @ MN AND DOSE INCREASED TO 2MG/H AS REQUESTED AT THAT TIME. FROM MN UNTIL THIS TIME, PT AND EEG WAVEFORM HAS NOT BEEN REVIEWED BY NEURO, VERSED CONTINUES AT 2MG/H.\n\nENDO: INSULIN GTTS TITRATED PER FS GLUCOSE.\n\nGI: TUBE FEED ADVANCED TO 50CC/H, TOLERATING WELL WITH LOW GASTRIC RESIDUALS. ABDOMEN SOFT, BOWEL SOUNDS PRESENT. LG AMOUNTS LIQUID GUAIAC NEGATIVE STOOL PASSED VIA FLEXISEAL COLLECTION SYSTEM.\n\nGU: HUO REMAINS MARGINAL, BROWN, CLEAR.\n\nPT MONITORED BY NURSING.\nDR IN CLOSE ICU ATTENDANCE.\nSEE CAREVUE FLOWSHEETS FOR DETAILED DATA.\n" }, { "category": "Nursing/other", "chartdate": "2198-08-14 00:00:00.000", "description": "Report", "row_id": 1265350, "text": "SICU NN: SEE CAREVUE FOR SPECIFICS. NEURO UNCHANGED. REMAINS ON CONTINUOUS EEG. BURSTS Q5SEC. CONTINUES ON PHENOBARB, VERSED GTT, DILANTIN, AND KEPPRA. SEE ASSESSMENT. ET TO VENT, CMV, NO ISSUES AT THIS TIME. RSR/ST WITH PVCS MD NOTIFIED. LOPRESSOR ADDED TODAY. BP WNL. TEMPS 100 MD NOTIFIED. CENTRAL LINE RESITED. CXR DONE POST INSERTION, OK USE LINE AS SICU MD. OLD LINE CULTURED. IVF KVO'D. DOPPLER PEDAL PULSES. TOLERATING TUBE FEEDS VIA NGT. FLEXISEAL WITH LG AMTS LIQUID BROWN STOOL ON LACTULOSE ATC. ABD SOFTLY DISTENDED WITH BOWEL SOUNDS PRESENT. FOLEY WITH GOOD URINE OUTPUT. ALLEVYN TO SACCRUM. INSULIN DRIP FOR GLUCOSE CONTROL. NO SIGNS OR SYMPTOMS OF PAIN. NO RESTRAINTS NECESSARY AT THIS TIME. PROPHYLAXIS HEP SQ, H2 BLOCKER, PBOOTS. WIFE UPDATED BY MD TODAY. PLAN: CONTINUOUS EEG MONITOR, ANTISEIZURE MEDS, VENTILATORY SUPPORT, VAP PREVENTION, BETA BLOCKADE, NUTRITIONAL SUPPORT WITH TUBE FEEDS, DVT PREVENTION, SKIN CARE, EMOTIONAL SUPPORT, ELECTROLYTE REPLETION AS ORDERED.\n" }, { "category": "Nursing/other", "chartdate": "2198-09-02 00:00:00.000", "description": "Report", "row_id": 1265420, "text": "Respiratory Care\nPatient placed on ventilatory support secondary to hypoventilation. All settings documented in Carevue. Breath sounds diminished throughout with scattered rhonchi. Suction for small amounts of thick tan secreations.\n" }, { "category": "Nursing/other", "chartdate": "2198-09-02 00:00:00.000", "description": "Report", "row_id": 1265421, "text": "STATUS\nD: DROPPING SAT'S 80'S..FEBRILE..NEURO UNCHANGED\nA: AMBUED/LAVAGED/SUCTIONED WITH IMPROVED SAT'S FOR ONLY A SHORT TIME PLACED BACK ON VENT @ 60% FIO2..SAT'S NOW >97%..CONTINUES TO BE SUCTIONED FOR THICK TAN..TEMP TO 101.5..CULTURE OF SPUTUM/URINE..BLD CULT FROM CVP & PERI..STOOL C-DIFF SENT..TEMP COMING DOWN ON OWN.. CONTINUES WITH MOD AMT LOOSE BROWN STOOL..GOOD HUO'S.. TF'S WELL\nR: ? FEVER DUE TO PULMONARY\nP: CONTINUE WITH GOOD PULMONARY TOILET..WEAN TO TRACH COLLAR IF \n? FAMILY MEETING MONDAY\n" }, { "category": "Nursing/other", "chartdate": "2198-09-03 00:00:00.000", "description": "Report", "row_id": 1265422, "text": "Resp: pt on simv 12/600/8/+5/60%. Pt has #8 portex trach. BS are coarse bilaterally and suctioned for moderate amounts of thick tan secretions/some bloody tinged. No changes noc. No rsbi eu to ^ fio2. Family meeting this am to discuss cmo status.\n" }, { "category": "Nursing/other", "chartdate": "2198-09-03 00:00:00.000", "description": "Report", "row_id": 1265423, "text": "NPN\nsee carevue for asessment and details\nNeuro:unchanged, continuous EEG in progress, no overt seizures noted. ho at bedside this am.\nCV:hypotensive SBP 89, no tachycardia not related to around ativan dose. treated with albumin per Dr .\nResp:Remains on vent/wean to cpap today.\nGI:tolerating TFs at goal rate 50ml/hr. Diarrhea-using flexiseal for stool mgt.\nGU:foley adeq u/o.\nPlan:Family meeting after 5pm today.\ncontinue plan of care as directed by .\n\n" }, { "category": "ECG", "chartdate": "2198-08-10 00:00:00.000", "description": "Report", "row_id": 206066, "text": "Sinus rhythm. Compared to previous tracing left bundle-branch block is no\nlonger present.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2198-08-09 00:00:00.000", "description": "Report", "row_id": 206067, "text": "Sinus tachycardia. Left bundle-branch block. First degree atrio-ventricular\nconduction delay. Compared to previous tracing of left bundle-branch\nblock is now present.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2198-08-07 00:00:00.000", "description": "Report", "row_id": 206068, "text": "Sinus rhythm. Compared to the prior tracing of there is new\nST segment depression in leads V2-V6 consistent with anterolateral ischemic\nprocess. There is Q-T interval prolongation. Followup and clinical correlation\nare suggested.\n\n" }, { "category": "ECG", "chartdate": "2198-08-02 00:00:00.000", "description": "Report", "row_id": 206069, "text": "Sinus rhythm and occasional ventricular ectopy. Prior inferior myocardial\ninfarction. Compared to the prior tracing of no diagnostic interim\nchange.\n\n" }, { "category": "Nursing/other", "chartdate": "2198-08-12 00:00:00.000", "description": "Report", "row_id": 1265340, "text": "Resp Care\nPT remains intubated on full vent support. No vent changes made this shift. BS clear bilaterally and diminished at lung bases. Suctioning for moderate amounts of thick yellow secretions. ABG show slight metabolic alkalosis with good oxygenation. See CareVue for details and specifics.\nPlan: Wean Peep as tolerated by ABG's\n" }, { "category": "Nursing/other", "chartdate": "2198-08-12 00:00:00.000", "description": "Report", "row_id": 1265341, "text": "pt remained on full vent support and sedation through shift. sx'd for moderat amount of secretions. oxygenation improving slowly as shown in ABG analysis. plan is to keep pt fully supported as his seizures are addressed.\n" }, { "category": "Nursing/other", "chartdate": "2198-08-12 00:00:00.000", "description": "Report", "row_id": 1265342, "text": "Nursing Progress Note\n Please see carevue for details of care. Remains on versed gtt for seizure supression per epilepsy team. Unresponsive to external stimuli. PERL sluggishly at 2mm. Not overbreathing vent this am. No cough/gag. Remains on CMV 600x16x40%+5PEEP w/acceptable ABG. BS remain clear this am w/few scattered fine insp wheeze. Suctions for scant thick yellow secretions.\n Remains off all pressors this shift, SBP consistently 90-110, MAPS 65-70's. HR 70's-80's, no evidence of arrythmias. 1300 K+ level 3.8, K Phos infusing, repleted w/20 meq KCL after discussed w/SICU resident . Repeat due at .\n TF cont to infuse w/minimal residuals. Infusing at goal at 1600. ABD remains soft, BOS hypoactive. Lg amt liquid brown stool via flexiseal, 1 liter discarded at 1400. Stool c diff, O&P and Cx to lab. Lactulose dose decreased to 15ml Q4hr and reglan to be held for large amt stool; dose held at 1200 and 1800. Barrier cream to perianal area for scant drainage around flexiseal, Alevyn DSD dry and intact on coccyx. Scrotum and penis remain edematous, elevated and supported, general edema persists.\n Wife in this pm, condition updated by RN and also spoke w/SICU resident this pm\n\nPLAN: Continue to monitor and replete as ordered and adjust insulin gtt per protocol, monitor TF residuals, monitor stools and hold reglan as appropriate, support to family.\n\n" }, { "category": "Nursing/other", "chartdate": "2198-08-30 00:00:00.000", "description": "Report", "row_id": 1265407, "text": "CONDITION UPDATE\nSEE CAREVIEW FOR OBJECTIVE DATA/TRENDS:\n\nAT TIMES OPENS EYES SPONT BUT DOES NOT TRACK. DOES NOT CONSISTANTLY OPEN EYES TO PAINFUL STIMULI. DOES NOT WITHDRAWL TO PAIN BUT DOES GRIMICE TO NAILBED PRESSURE BUE. PUPILS EQUAL AND BRISKLY REACTIVE. APPEARS COMFORTABLE. CONT ON EEG MONITORING, NMED INTO ASSESS AT 0400, NO SEIZURE ACTIVITY PER DR . TMAX 99.3. SR HR 70S, NO ECTOPY. BP STABLE. LUNGS COARSE #8 PERFIT TRACH REMAINS ON CPAP+PS 5PEEP 5PS 40% FIO2. ABG WNL. MINIMAL SECREATIONS. ABD SLIGHTLY DISTENDED +ACSITIES. GIVEN ADDITIONAL BOTTLE MAG CITTRATE AND CURRENTLY PUTTING OUT LARGE AMT LIQUID STOOL. HAS PUT OUT ~2.5LITERS MUSHROOM CATH PLACED. DR AWARE. FOLEY WITH ADEQUATE URINE OUTPUT. FREQUENT SKIN CARE D/T LARGE AMT STOOL. ALLEVYN DSG TO COCCYX CHANGED. MULT DSG CHANGES TO WOUNDS ON PENIS+SCROTUM. K3.2 ON ABG 60MEQ. IONIZED CA 1.03 GIVEN @ GRAMS CAL GLUCONATE. HCT AND WBC STABLE. AMMONIA DOWN TO 50 FROM 110> PLAN TO CONT TO MONITOR NEURO STATUS WEAN SEIZURE MEDS AS TOLERATED MONITOR HEMODYNAMICS MAINTAIN SKIN INTEGRITY.\n" }, { "category": "Nursing/other", "chartdate": "2198-08-30 00:00:00.000", "description": "Report", "row_id": 1265408, "text": "Resp Care\nPt remains on vent. No changes made. Suctioned for mod amt of blood-tinged secretions. Pt abgs acceptable. Rsbi 38. Will continue to monitor.\n" }, { "category": "Nursing/other", "chartdate": "2198-08-30 00:00:00.000", "description": "Report", "row_id": 1265409, "text": "condition update\nPlease see carevue for specifics.\nNeuro: Occasionally opens eyes spontaneously, does not track. Withdraws left upper extremity to nailbed pressure, no spontaneous movements. Pupils equal and briskly reactive. EEG in place. Dilantin level 10 this afternoon, dose increased to 300mg, keppra increased to 2250mg.\nCV: NSR 70's-80's, no ectopy. Sbp dipped to high 80's this afternoon during/after phenobarb. dose, discussed with sicu fellow, no intervention at this time, will continue to follow. Diuresed well post aldactone/lasix. K+/mag+ repleted this afternoon.\nResp: Trach. collar all day, tolerating well. ABg' acceptable, rr 20, 02 sat 99% on 50% fio2. Suctioned for yellow or blood tinged sputum. Ls coarse/diminished.\nGI: Flexiseal placed - drained about 400cc liquid golden stool this shift, guiac negative. TF continue at goal.\nGu: foley draining adequate amts. clear yellow urine.\nEndo: nph and ssri\nPlan: continue neuro checks, trach. collar, pulmonary toileting.\n" }, { "category": "Nursing/other", "chartdate": "2198-08-30 00:00:00.000", "description": "Report", "row_id": 1265410, "text": " 2045\n NEURO REMAINS IN COMA STATE SOME MOTION WITH PAINFUL STIMULI PERL LEFT EYE DEVIATION NOTED MD AWARE PLEASE SEE CAREVIEW FOR DETAILS ONGOING EEG FINE MOTION ALL LEADS NO DEEP SPIKES OR RAPID EVENTS AT THIS TIME\n RESP CLEAR T/C .50 FI02 WELL SCANT SPUTUM NO SOB NOTED\n HEART S1S2 NSR TO ST PR .16 QRS .08 QT WNL M SL NVD PULSES POS 1 EDEMA 3 PLUS THRU OUT VSS NO TEMP\n GI POS B/S T/F WELL FIRM ABD\n PLAN SUPPORTIVE MONITOR NEURO STATUS CLOSLY DILANTIN LEVEL T/P CPT\n" }, { "category": "Nursing/other", "chartdate": "2198-08-31 00:00:00.000", "description": "Report", "row_id": 1265411, "text": "Resp: Pt rec'd on 50% t/c. BS are clear with diminished bases. Suctioned for scant amount of yellow secretions. Pt tolerated t/c over night. Fio2 weaned to 40%, 02 sats @ 98%. Vent pulled.\n" } ]

[ { "category": "Nursing/other", "chartdate": "2196-09-02 00:00:00.000", "description": "Report", "row_id": 1323192, "text": "Nursing Note: 1900-0700\n67 yo female s/p ureteral stent replacement on without complications. Sent home and returned to ED c/o flank pain, temp 101.7, hypotensive, decreased sats, lactate 7.3. Sepsis protocol intiated; intubated and arrived to MICU on sepsis protocol. PMH significant for: DM, breast Ca, thyroid Ca, HTN, renal calculi.\n\n\nSignificant events:\n\nLevophed weaned to off by 0430 but BP decreased to 80s/50s from 100s/60s, therefore, Levophed reinitiated after 15 min.\n\nAble to wean FiO2 to 50%\n\nOne liter LR for decreased urine output.\n\n\nNEURO: Lightly sedated on Fentanyl gtt @ 25mcg/hr and Versed gtt @ 2mg/hr. Easily arousable to voice; following commands; MAE. Denies pain. Cough/gag intact. Decreased safety awareness requiring use of bilat soft wrist restraints to maintain integrity of lines.\n\nRESP: Current setting: A/C 450X28/8/50% Able to wean FiO2 and rate maintaining sats high 90s-100 based on ABGs. LS coarse throughout. Not overbreathing vent.\n\nC/V: HR 58-70s, SR; ABP very responsive to changes in Levophed gtt rate. Attempting to wean off. Remains on Vasopressin @ 2.4 units/hr for ABP 88-110s/50s-60s. CVPs 13-19; SvO2 70s.\n\nGI/GU: TF Promote with fiber via OGT held for high residuals of 90cc; unable to advance beyond 10cc/hr; goal rate 70cc/hr. Abdomen soft, med OB neg. loose stool this shift. U/O generally ~ 40cc/hr but low of 15; received 1L of LR for decreased output.\n\nID: Tmax 99.6 start of shift; bld cx sent previous shift for persistent low grade temps. Receiving Linezolid, Meropenem for septic shock. Lactate 3.4.\n\nENDO: Insulin gtt titrated protocol.\n\nDISPO: Full code; micu ; family in and updated previous shift; no contact overnight.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2196-09-04 00:00:00.000", "description": "Report", "row_id": 1323199, "text": "NPN-MICU\nMRS HAS BEEN RESTLESS ALL SHIFT.\nNeuro: pt has been restless in bed all shift. She has been flipping back and forth, side to side and up and down in the bed. She has been unable to get comfortable even when I postition her exactly as she says. She says she is achy all over but no pain. She is awake but only oriented to person and place. She is able to follow all directions but still asks for the same thing over, with no STM.She wants to get up to go to the bathroom (remind her of foley but she does not understand). SHE HAS PULLED Out ALINE AND KEEPS TAKING O2 OFF. She has not slept a wink. Dr pt at 2am and ?withdrawal so she was given .5mg IVP ativan x2 which did little. She did settle down for about 15 min 2-3 times since but she cont to be restless and grabbing for everything.\n\nResp:she is now tolerating 2L NPO2, when she keeps it on her O2 sats are 95-97%, if she takes it off, the O2 sats are 89-90%, Her lungs are clr but she now has a very dry cough and airway (she keeps the mask on even less). She is intermittenly snoring and grunting. She denies any SOB and RR is in the 20's.\n\nCV: pt has been mainting a BP 110-150's/60-90's on her and her HR has been in the 90-110's range with her agitation. Aline failed after she pulled on it so it was d/c'd.\n\nGU: pt cont to have a brisk u/o 100-200cc/hr:foley and 50-75cc/hr (nephrostomy). She is very dry and thirsty now. labsl pnd. Left nephrostomy site intact and now draining clr urine\n\nGI:pt able to swallow without difficulty, She pulled out mushroom cath but is passing sm amts of liq stool. She said she constantly had to go to the bathroom with the mushroom in soooo... She was OB-. No appetite only water. Her blood sugars are in the 90's, no coverage needed as yet.\n\nID:pt cont to be afebrile on IVAB. She has x1 +BC from adm. BC and stool cx resesnt.\n\nA/P:Will cont to asses mental staus for improvemnts. Will try to avoid further drugs as she may still have some on board and this is what is contributing to her agitation.\nREorient as needed\n Will cont to follow renal function and asses need for cont diuresis\n Support/replace lytes as needed. Monitor BP for changes\n Asses for appetite, note stool amt\n Await cx results, cont IVAB\n Follow O2 sats and asses resp status\n" }, { "category": "Nursing/other", "chartdate": "2196-09-04 00:00:00.000", "description": "Report", "row_id": 1323200, "text": "Nursing note 0700-1900\n\nCODE STATUS: FULL CODE\nALLERGIES:VANCO AND DERIVATIVES, TETRACYCLINES, PCN,SULFONAMIDES\nPRECAUTIONS:CONTACT AND FALL\n\n67 YO F WITH UROSEPSIS,ACUTE RENAL FAILURE IN THE SETTING OF SEVERE HYPOTENSION. PATIENT WAS CALM AND COOPERATIVE IN THE MORNING. SHE BECAME RESTLESS AND AGITATED THIS AFTERNOON. PT. DENIED PAIN ALL MORNING AND REPORTED SUDDEN PAIN IN LUQ (NEPHROSTOMY SITE)IN AFTERNOON.\nDR. NOTIFIED. RENAL NOTIFIED. GU NOTIFIED. IR NOTIFIED.\n1 MG OF MORPHINE ADMINISTERED FOR EXTEME PAIN.\n\nNEURO:A&OX3,PATIENT ANSWERS QUESTIONS APPROPRIATELY. PT EXTREMELY , OFTEN TOO TIRED TO ANSWER QUESTIONS. PT C/O PAIN IN AFTERNOON. 1 MG MORPHINE ADMIN WITH SOME RELIEF. PT OOB TO CHAIR WITH 3 ASSISTS.TOLERATED WELL. VERY RESTLESS IN THE AFTERNOON.\nPT C/O CONSTANT URGE TO URINATE. PT WAS RESTRAINED WITH SOFT LIMB RESTAINTS ON BOTH ARMS FOR ONE HOUR D/T PT PULLING AT LINES.\nRESTRAINTS REMOVED WHEN PATIENT CALMED A BIT. PERRL.\n\nRESP:SATS 91-98%, VERY LABORED BREATHING, DR. NOTIFIED.RR 19-35.\nLUNG SOUNDS CLEAR TO RHONCHEROUS AND DIMINISHED. PT HAS A VERY DRY NONPRODUCTIVE COUGH. RECIEVED PT ON 2L NC AND INCREASED TO 4L NC AT 1700 DUE TO LABORED BREATHING.\n\nCARDIAC:HR 85-100 NSR, SBP 129-157,K 3.2,HCT 33.3,PRESEPT CATH DISCONTINUED.CVP 4-21\n\nGU/GI:PT HAS ULCER SORES IN ORAL CAVITY. SWALLOWING SMALL AMOUNTS OF LIQUID IN AM...BY AFTERNOON UNABLE TO SWALLOW LIQUIDS. TONGUE HAS THICKENED. NUTRITION NEEDS TO BE ADDRESSED AGAIN. PT VERY THIRSTY. SWABBING MOUTH HOURLY. PATENT FOLEY DRAINING CLEAR YELLOW URINE. NEPHROSTOMY SITE IS PATENT AND INTACT HOWEVER, VERY TENDER TO PALPATION.TENDER. DR. NOTIFIED. INTERVENTIONAL RADIOLOGY NOTIFIED AND ASSESSED PT. PT INCONTINENT OF MODERATE AMOUNTS OF BROWN LOOSE STOOL X 3. GUAIC NEGATIVE.\n\nID:TMAX 97.8, IVAB, WBC DECREASED TO 33 FROM 38\n\nENDO:INSULIN SS PROTOCOL.\n\nPLAN:MONITOR RESP.STATUS AND MENTAL STATUS CLOSELY.\nREORIENT PATIENT PRN. MONITOR PT FOR AGITATION.\nASSESS RENAL FUNCTION;BUN/CREA.ASSESS FOR CONT. DIURESIS.\nMONITOR LABS AND LYTES AND BLOOD GLUCOSE.\nMONITOR NEPHROSTOMY OUTPUT AND SITE.\n\n" }, { "category": "Nursing/other", "chartdate": "2196-09-05 00:00:00.000", "description": "Report", "row_id": 1323201, "text": "NPN-MICU\nMrs cont to be restless with no specific c/o.\nNeuro: pt has become more confused and restless thru night. She had been oriented to place but by 1am she thought she was in Palm Beach. She has constantly been on the move in the bed, rolling from side to side,up and down and throwing her leg over the siderail. She has not c/o any pain but occas she will shout out OUCH!!! She has slept maybe 10-15 min x2 but not much more. MAE, follows all commands, but she is just not hersel. She has no STM and continues to take O2 off even thought she says she understands me when I tell her to leave it on. She has no idea what to do for herself.\n\nResp:pt cont on O2 now at 3l NP will not keep it on ans she desats to 88% in min. Her lungs sound clr but she has this junky cough that because she is so dry she is non productive of much. She also has increase sores on lips, under nose and on tongue ?herpes. Nystatin S&S tried and bacitracin applied.\n\nCV: pt cont to maintain BP 120-160/90's HR in the 90-110 SR/ST. K+ replaced.\n\nGU:pt denies any pain but says OUCH when site of left nephrostomy tube is touched. Pt had CT scan to it. Both foley and Nephrostomy tube are draining clr urine. Her u/o is 10cc foley and 75cc:nephrostomy. She is very thirsty and has dry MM, Her I&O was neg and she has made some headway in Making her LOS I&O down to only 7 l from 11 of yesterday!.\n\nGI: she has been able to have several drinks of water with min trouble. She was able to swallow pills. She is still passing sm amts of stool and has lots of flatus. Her blood sugars are all over the place, covered by SS insulin. Hct and coags remain stable, am labs pnd\nHer tongue does not appear swollen at present\n\nID: pt still afebrile and IV AB cont, still ?oral herpes.\n\nSocial:daughter spokes person for today, called for update.\n\nA/P:Will cont to follow mental status, asses for focal signs, avoid meds unless she becomes unsafe.\n Cont to asses need for O2, follow lung exam and sats\n Await cx results and CT scan results for for kidneys, check am labs for cont renal fx\n Try and get some food into her, note stool amt\n Cont IVAB and ? lip cx herpes.\n\n" }, { "category": "Nursing/other", "chartdate": "2196-09-05 00:00:00.000", "description": "Report", "row_id": 1323202, "text": "Micu Nursing note \n\nNeuro Pt is awake and alert x1 does not know month or yr and intermittent knows the place, pt reorientated, but remains restlessm with only napping for 15-20 min durring the day, pt follows commands, pupils PLus 3 pearl, pt oob with 2 assist to chair following commands well, but was only able to be in chair for 2 hrs and became more restless. sitting up so was placed back to bed for safty reasons, durring this time I spoke to house staff about pt's worsening mental status and restlessness, pt did c.o of pain durring the morning and was med with 2 mg morphine and again at 11 am c/o pain but she is not consistant and will call out ouch and then when asked denies pain, she recieved a repeat dose of morphine with moderate effect. pt 13:00 pt med with ativan 1 mg iv for resltessness, she seems more quiet and less tossing and turning in the bed, pt has napped in bed for shirt period.\nFamily very concerned about mental status, plan will be to do Lp this afternoon.\n\nCv Pt hemodynamically stable, pulses palp.\nResp pt remians on 4L n/c sats 94-97% lungs cta, pt has a cough which is non productive,\n\nGi abd soft distended, Bs x4 , no stool, pt now npo except for meds, attempted to give pt water this am and pt was ? asperating water, she was given meds in applesausce and tol well.\n\nGU pt has foley which is draining yellow urine 40-60 cc/hr, pt also has neph tube in place and draining yellow urine.\nId pt a febrile\nA/P will follow mental status, prn ativan for restlessness, and LP for this afternoon, If pt contniues to be very respless they will add haldol tonight.\n" }, { "category": "Nursing/other", "chartdate": "2196-09-06 00:00:00.000", "description": "Report", "row_id": 1323203, "text": "Nursing Note: 1900-0700\n67 yo female s/p ureteral stent replacement on returned to hospital with dx septic shock. Placed on sepsis protocol requiring 3 pressors, intubation, ards protocol. Extubated on with complications post extubation: tongue swelling requiring Benadryl, steriods, and becoming minimally responsive. Received Narcan with improvement in mental status at that point but has become increasingly more confused.\n\n\nSignificant events this shift:\n\nVery agitated for most of shift requiring total of Ativan 4mg and Haldol total of 4mg.\n\n\nNEURO: Agitated/confused as described but able to follow most directions. Calling out at times and inconsistently c/o pain but unable to articulate. Continuous restlessness with no safety awareness requiring bilat wrist restraints to maintain integrity of lines; bed alarm on. Family stating no prior episodes of confusion or extreme mental status change. LP planned to rule out infective process.\n\nRESP: Cool neb at 40% O2 maintaining sats mid to high 90s. LS clr/diminished at bases. Nonproductive cough at times. RR mid 20s. Reflective abg: 7.48/26/96.\n\nC/V: HR 100s, ST, no ectopy. NBP 120s-160s/70s-80s. Pulses palpable.\n\nGI/GU: NPO awaiting speech and swallow ordered as choking noted previous shift. Abdomen obese, soft, hypoactive sounds, no BM. U/O via Foley wnl and adequate amt from left nephrostomy tube.\n\nID: Tmax 99.1 start of shift. Covered with Meropenem for bacteremia.\n\nENDO: Covered with SS insulin.\n\nACCESS: Right IJ precept catheter.\n\nDISPO: Full code; micu ; ? LP to rule out infection; may require 1:1 observer to maintain safety.\n" }, { "category": "Nursing/other", "chartdate": "2196-09-06 00:00:00.000", "description": "Report", "row_id": 1323204, "text": "Nursing Addendum: 0630\nNa 154 - hung D5W @ 100cc/hr for 2400cc.\n\nK 2.8 - ordered for 40Meq IV and PO; hung 20Meq IV.\n" }, { "category": "Echo", "chartdate": "2196-09-01 00:00:00.000", "description": "Report", "row_id": 96677, "text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function.\nHeight: (in) 63\nWeight (lb): 242\nBSA (m2): 2.10 m2\nBP (mm Hg): 105/54\nHR (bpm): 96\nStatus: Inpatient\nDate/Time: at 09:25\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Moderate LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA.\n\nLEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size. Overall\nnormal LVEF (>55%).\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic root diameter. Mildly dilated ascending aorta.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets. No valvular AS. The\nincreased transaortic gradient related to high cardiac output. No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with\nphysiologic PR.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - ventilator.\n\nConclusions:\nThe left atrium is moderately dilated. Left ventricular wall thicknesses are\nnormal. The left ventricular cavity size is normal. Overall left ventricular\nsystolic function is normal (LVEF>55%). Right ventricular chamber size and\nfree wall motion are normal. The ascending aorta is mildly dilated. The aortic\nvalve leaflets are mildly thickened. There is no valvular aortic stenosis. The\nincreased transaortic gradient is likely related to high cardiac output. No\naortic regurgitation is seen. The mitral valve leaflets are mildly thickened.\nNo mitral regurgitation is seen. There is no pericardial effusion.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2196-09-06 00:00:00.000", "description": "Report", "row_id": 1323205, "text": "NURSING NOTE 7A-7P REVIEW OF SYSTEMS:\nNEURO: AWAKE AND ALERT AT TIMES ORIENTED TO PERSON AND PLACE DISORIENTED TO TIME. UNABLE TO STATE YEAR, YET ABLE TO SAY AT HOSPITAL. , MAEW, BILATERIAL SOFT WRIST RESTRAINTS REMAIN ON. MEDICATED WITH TOTAL OF 4MG HALDOL IN AM FOR AGIATION. ALSO MEDICATED WTIH ATIVAN TOTAL OF 4MG GIVEN PRIOR TO AND DURING LP. LP DONE AND SAMPLES SENT AFTER SEVERAL ATTEMPTS. (PATIENT UNABLE TO REMAIN STILL DURING PROCEDURE.\nC/V: HR 92-112, NO ECTOPY. BP 123-154/76-87. POTASSIUM REPLETED WITH 80MEQ IN AM FOR K-2.8, REPEAT K=3.1 AND REPLETED WITH 40MEQ KCL.\nRESP: CONTINUES ON 40% COOL NEB TOLERATED WELL, MOUTH AND NOSE REMAINS VERY DRY DESPITE FREQUENT CLEANSING. LUNG SOUNDS CLEAR WITH COARSE BASES. PRODUCTIVE COUGH RAISING THICK BROWN SECRETIONS. O2 SAT 96-100%\nGI: ABD SOFT HYPOACTIVE BOWEL SOUNDS, SPEECH AND SWALLOW INTO EVALUATE PATIENT YET PATIENT MEDICATED FOR LP AND UNABLE TO COOPERATE. NO STOOLS THIS SHIFT.\nGU: FOLEY PATENT DRIAING CLEAR YELLOW URINE,LEFT NEPHROSTOMY TUBE PATENT AND DRAINING YELLOW URINE WITH SM AMOUNTS BLOODY STRINGS,\nID: CONTINUES ON MEROPENUM, LP SAMPLES SENT REULST PENDING. PATIENT PLACED ON CONTACT PRECAUTIONS AS POSITIVE CULTURES FOR RESISTENT ECOLI IN URINE AND BLOOD FROM .\nACCESS: RIGHT IJ PRECEPT CATHETER INTACT.\nSOCIAL: PATENTS DAUGHTERS INTO VISIT AND UPDATED BY NURSE .\nPLAN: LP RESULTS PENDING, CONTINUE TO MONITOR FOR AGIATAION AND SAFTY.\n" }, { "category": "Nursing/other", "chartdate": "2196-09-07 00:00:00.000", "description": "Report", "row_id": 1323206, "text": "NPN-MICU\nMrs. has been able to rest and sleep some tonight finally!\n\nNEURO:Pt has been quiet and resting overnight after she recieved meds yesterday for her LP procedure. She got 1mg of IV ativan at 8pm to cont to help her rest. She will now only get IV haldol prn agitation as she has no h/o ETOH use. She cont to rsp to name and follows all commands. Her and MAE. Pt still restrained for safety of lines and herself. Her prelim LP results are neg for infections (family informed) but need to await final cx results.\n\nRESP:pt has cont on 40% FT with O2 sats of >96%. She has a non prod cough but she sounds like she is clearing her airway. Her RR has been in the 20's no SOB noted. Mouht still dry despite oral care, Acyclovir cream applied to mouth sores.\n\nCV: pt has been maintaining good BP 120-160's/80's, Hr if sleeping has been down to 80's, if awake 90-106 ST, K+ replaced.\n\nGI: pt not awake enough to take any po's so S&S delayed. She has not passes any stool as yet + BS. Her blood sugars are high on D5 but she is on SS insuin.\n\nGU: She cont on IVF and her u/o is about 10cc/hr. she has made great headway into her I&O, she is only3.5L + for LOS, she is much less puffy. Her nephrostomy urine si still blood tinged but foley urine is clr. am Lytes are pnd,\n\nID: pt still afebrile and on IVAB, cx pnd from LP\n\nSocial:pt's family made aware of prelim LP results by Dr. .\n\nA/P:Will cont to follow pt for MS changes. Avoid any further benzos and stick with Haldol as needed.\n Await S&S before pushing nutrition but if pt still not participating ? use of PPN for now. Note stool amts\n Cont to renal function and asses diursis. Replaced lytes as needed.\n Cont to monitor BP for changes and need for her usual BP meds, If unable to take po's ? IV synthroid\n Encourage C&DB and try to keep neb on for humidity\n Await cx results and cont IVAB\n" }, { "category": "Nursing/other", "chartdate": "2196-09-01 00:00:00.000", "description": "Report", "row_id": 1323189, "text": "Nursing Note: 1900-0700\nSignificant events:\n\nHypotensive after Fentanyl bolus SBP 104 down to 76: received fluid bolus with desired effect.\n\nDobutamine started and Dopamine weaned off.\n\n\n\nNEURO: Alert, following commands and mouthing words, denies pain. MAE. Restless at times; pulled out OGT; able to initiate Fentanyl and Versed gtts 25mcg and 1mg respectively and remains lightly sedated. Requiring use of bilat, soft wrist restraints to maintain safety and integrity of lines.\n\nRESP: Remains on A/C but several changes in rate to compensate for increased Co2 and acidosis. Current settings: 450X30/8/70% Unable to wean FiO2 below 70% as sats dropped to 93% LS coarse, RR 30 and overbreathing few breaths especially when stimulated.\n\nC/V: Hypotensive episode as noted; able to wean Dopamine off but started Dobutamine @ 2.5mcg/kg/min to increase cardiac output. HR 80s-90s, SR. ABP essentially 90s-120s on pressors. CVP 21-15. Levophed wean in progress and remains on Vasopressin. Elytes repleted; Na Bicarb gtt continues at 100ml/hr; lactate increased slightly then decreased. Continues on sepsis protocol with SvO2 in 80s.\n\nENDO: Insulin gtt titrated protocol.\n\nGI/GU: OGT replaced and now to LIWS for bilious material. Placement checked by auscultation but awaiting CXR to confirm. Hypoactive bowel sounds; no BM. U/O 80-100cc/hr.\n\nID: Tmax 99.4 PO; received Meropenem and Linezolid on sched and one time dose of Tobramycin. Lactate checked Q 4hrs per protocol.\n\nDISPO: Full code; micu ; sepsis protocol.\n\n" }, { "category": "Nursing/other", "chartdate": "2196-09-01 00:00:00.000", "description": "Report", "row_id": 1323190, "text": "Respiratory Care:\nPatient remains on A/C ventilatory support. FIO2 titrated down to 70% and the RR was increased to 30 BPM. Last abg results determined a partially compensated metabolic acidemia with good oxygenation on the current settings.\n\nNo RSBI measured due to the high FIO2 currently required.\n" }, { "category": "Nursing/other", "chartdate": "2196-09-02 00:00:00.000", "description": "Report", "row_id": 1323193, "text": "RESP CARE: Pt remains intubated/on vent per carevue. FI02 weaned to .50. ABG pending. RR decreased to 28/Pt well sedated. Lungs coarse, sxd thick white sputum. No RSBI due to unstable hemodynamics. Continue to wean set rate, improving met acidosis.\n" }, { "category": "Nursing/other", "chartdate": "2196-09-07 00:00:00.000", "description": "Report", "row_id": 1323207, "text": "MICU NURSING PROGRESS NOTE 0700-1900\nNeuro consult in. They will not MRI today as pt is improving and is axo x2-3. Remains somnelent.\n" }, { "category": "Nursing/other", "chartdate": "2196-09-08 00:00:00.000", "description": "Report", "row_id": 1323210, "text": "0700-1900 NPN:\n\nPLEASE SEE CAREVUE FLOWSHEET AND TRANSFER NOTE FOR OBJECTIVE DATA AND FURTHER SHIFT DOCUMENTATION. PT ALERT AND ORIENTED X3, FOLLOWING COMMANDS, MAE, PERLA. NO ATTEMPTS OOB, NO ATTEMPTS TO PULL AT TUBES/LINES. RESTRAINTS OFF X 24HRS. PT SEEN BY NEURO AND RENAL TEAMS THIS SHIFT. PT READY TO TRANSFER TO FLOOR, AWAIT AVAILABLE BED. PT . LS= CLEAR/DIM. 02 SAT 93-98% ON 2L N/C TO RA. RR= . PT DENIES SOB, BUT DOES REQUEST 02 N/C AT TIMES. PT TO 88% LAST HS WHILE ASLEEP. ABD SOFT/ DISTENDED. PRESENT BS. FREQ LOOSE DARK BROWN STOOL THIS SHIFT, SENT FOR CDIFF. FOLEY CATH DRAINING CLOUDY YELLOW URINE 40-300CC/HR. LEFT NEPHROSTOMY TUBE PLACED IN IR, DRAINING APPROX 500CC Q24HR. SKIN INTACT, BARRIER CREAM APPLIED TO COCCYX. FS QID ON S/S COVERAGE. NPO STATUS MAINTAINED, PT FAILED SWALLOW AGAIN TODAY. PT CONTINUES W/ SLIGHTLY EDEMATOUS TONGUE AND CAN BE LETHARGIC AT TIMES. PT REQUESTS FLUIDS FREQ, MOUTH CARE PROVIDED. MICU TEAM AWARE PT FAILED SWALLOW , PLAN TO PLACE NGT BUT PT . FAMILY AWARE AND AGREE, WILL READRESS NUTRITION ON DAILY BASIS. ACYCLOVIR D/C'D TODAY. PT CONTINUES ON IV MEROPENEM. CONTACT PRECAUTIONS MAINTAINED FOR OPEN SORES ON LIPS R/O HSV. FULL CODE. PT'S DAUGHTERS VISITED AND UPDATED ON CONDITION, AWARE OF POSSIBLE TRANSFER OUT OF MICU TO FLOOR TONIGHT.\n\nPLAN- CALLED OUT TO FLOOR, AWAITING AVAILABLE BED, REQUIRES PRIVATE ROOM FOR CONTACT PRECAUTIONS. ASSESS MENTAL STATUS CLOSELY. NO ANXIETY/SEDATIVE MEDS TO BE GIVEN PER NEURO TEAM. PLEASE FOLLOW UP ON CDIFF RESULTS. REASSESS SWALLOW FUNCTION WHEN TONGUE EDEMA RESOLVED. CONTINUE ICU SUPPORTIVE CARE.\n" }, { "category": "Nursing/other", "chartdate": "2196-09-09 00:00:00.000", "description": "Report", "row_id": 1323211, "text": "Nursing Note: 1900-0700\nNo significant events this shift.\n\nNEURO: A&O X 3; pleasant & . Able to make needs known. MAE. Denies pain. Neuro consult but will not intervene as mental status much improved.\n\nRESP: O2@2L n/c intermittently throughout shift. Desats to high 80s at times when asleep. LS clr/diminished at bases.\n\nC/V: HR 60s, SR, with occasional drop into 50s. NBP 110s-150s. Pulses palpable. No appreciable edema. AM labs pnd.\n\nGI/GU: NPO continues secondary to tongue swelling. Abdomen obese, present sounds; several episodes of loose stool throughout shift. U/O wnl via Foley; left nephrostomy draining ~ 300cc q4-6 hrs.\n\nID: Afebrile; continues with Meropenem for sepsis.\n\nENDO: Covered with SS Humalog.\n\nDISPO: Full code; micu ; called out to floor.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2196-09-02 00:00:00.000", "description": "Report", "row_id": 1323194, "text": "npn 0700-1900\n\n\nWBC continues to climb, as does creatinine. Urology was consulted today and has recommended that patient have a left nephrostomy tube placed. This procedure will be done in IR. Currently the physicians are arranging a time; ? this evening.\n\nneuro: Pt is sedated on fentanyl @ 25 mcg/h and versed @ 2 mg/h. She is lightly sedated, following commands and attempts to communicate with her family members. . Pt is not in pain per the grimace scale and assessment of VS.\n\nresp: AC 400/20/40% PEEP 8. LS coarse.\n\ncv: SR in the 60's today without ectopy. Remains on levophed at .02 mcg/kg/min and vasopressin 2.4 units/h. Maintaining a MAP > 60.\n\naccess: RIJ tlc and 1 piv. R radial aline.\n\ngi/gu: Abdomen is obese and soft with hypoactive BS. TF has been increased to 30 cc/h without residuals. Urine output 30 cc/h.\n\nskin: Skin is intact; no areas of breakdown noted.\n\nendo: Insulin gtt has been titrated protocol.\n\nsocial: 3 daughter and 1 son was in to visit today and were updated by this RN.\n\nPlan: Wean pressors as tolerated. Decrease vent settings as tolerated with a RISBI in the morning.\nContinue to increase tube feedings to a goal of 40cc/h. monitor BS and titrate insulin gtt.\n\nTo IR this evening for placement of L sided nephrostomy tube.\n" }, { "category": "Nursing/other", "chartdate": "2196-09-02 00:00:00.000", "description": "Report", "row_id": 1323195, "text": "Respiratory Care\nPt reemains on a/c vent weaned support to 400 x 20 last abg 733/28/103/15/-. Plan to go to IR for stent placement.\n" }, { "category": "Nursing/other", "chartdate": "2196-09-03 00:00:00.000", "description": "Report", "row_id": 1323196, "text": "NPN-MICU\nMrs. cont to make slow pregress.\nResp:Pt cont on A/C 50% 400 x20 with PEEP 8. She has min secretions but sputum spec sent. Her O2 sats are good, >98%\n\nNeuro: Pt cont on fentanyl and versed. She was on propofol for the procedure in IR and it was weaned off upon arrival back to unit. Her Fentanyl was at 75mcg in IR and that too has been weaned back to 30mcg/hr by 6am. She opens eyes to name, follows simple commands bu is still very lethargic.\n\nCV: pt's BP has continued to be supported by Vasopressin and Levophed. BP had been drifting down throuth the night on increased sedation so Levo was increased sl to keep MAP >60, but with weaning of sedation, BP is improving and I have been able to slowly wean the Levo back to preprocedure levels. Her HR cont to be 58-60 SB->SR. Her CVP is \nHer SvO2 cont to be in the 80's\n\nGU: pt had left Nephrostomy tube placed in IR. She initially did not tol being proned for the procedure and needed propofol and increased sedation to get her through it. She than did well. She was noted to have a very mild obstriction and urine sent to cx. Her u/o so far has been 20-40cc/hr vial foley and 15-20cc/hr vial Nephrostomy. am labs pnd\n\nGI:TF restarted at 12mn. She is on promote with fiber at 30cc/hr. She has some residuals but is passing sm amts of liq stool, Mushroom cath in place. She has drecreased bowel sounds. Her BS have increased so her Insulin drip was restarted at 4U/hr so far and BS are dropping nicely.\n\nHeme: her hct is stable at 28 and no obvious bleeding noted.\n\nID: she remains afebrile, am WBC ct pnd. IVAB renal dosed for now\n\nA/P: Will cont to wean Levo as able to keep MAP >60.\n Will get sedation back to a lower dose and keep her comfortable\n Follow u/o from both sites, note kidney function labs\n Cont and asses tolerance to TF,adv to goal of 70cc/hr Note stool amt, adjust Insulin drip as needed\n Follow hct and coag to asses for pot of bleeding and resolution of sepsis\n Await final cx and follow fever curve and WBC ct\n" }, { "category": "Nursing/other", "chartdate": "2196-09-03 00:00:00.000", "description": "Report", "row_id": 1323197, "text": "Resp Care\nRemains intubated and ventilated on a/c 400 x 20 40% +8 peep. O2 sats 99-100%. Suctioning minimal secretions. RSBI this morning = 67 on 0/5\n" }, { "category": "Nursing/other", "chartdate": "2196-09-03 00:00:00.000", "description": "Report", "row_id": 1323198, "text": "npn 0700-1900\n\nPressors and sedation weaned this am.\n\nPt has had a very good day. Started weaning ventilator at 10 am. Pt was successfully extubated at 1230pm. At 1305 nurse was called into the room because pt was \"groaning loudly\".\nHer tongue was visibly swollen and she was having difficulty speaking. note: At the time of extubation she was able to speak clearly, but quietly. Hydrocort, benedryl given and Dr was at the bedside. While we were in the room, she became unresponsive to sternal rub and corneal reflex also absent. VS reamined stable. narcan given along with the reversal for versed. It worked immediately and pt was axox3.\n\nneuro: AXOX3, follows commands and is able to verbalize needs. @ 2mm. No c/o pain, although she has required frequent turning and repostioning.\n\nresp: Sats 94-96% with LS clear.\n\ncv: SR in the 80's, no ectopy. BP with MAP in the 80's.\n\naccess: R radail aline which does not draw back. RIJ tlc.\n\ngi/gu: Currently NPO s/p extubation. No PO meds as of yet, but she will most likely tolerate. Mushroom cath in place and she Patent foley; has started auto-diuresing 200-300 cc/h. Total of 500 cc clear yellow urine via L nephrostomy tube.\n\nskin: Intact.\n\nendo: Insulin gtt is off now that TF dc'd. Please follow q6h.\n\nplan: Continue to monitor respiratory status. ? source of WBC, possible call out tommorrow??\n\n\n" }, { "category": "Nursing/other", "chartdate": "2196-09-07 00:00:00.000", "description": "Report", "row_id": 1323208, "text": "MICU NURSING PROGRESS NOTE 0700-1900\nNEURO--MS HAS SLOWLY BEEN INCREASING WAKEFULNESS SINCE THIS AM. HER SPEECH WAS SLURRED EARLIER BUT NOW SHE IS COMPLETING FULL SENTENCES ASKING FOR WATER AND THE BATHROOM. PEARL 3-4 MM. SHE IS ALERT TO PERSON, NOT TO PLACE OR TIME. MAE SPONT AND INCONSISTENTLY FOLLOWS COMMANDS. NEUROLOGY IS BEING CONSULTED. PT HAS NOT RECIEVED ANY HALDOL TODAY AS OF THIS TIME.\n\nCARDIAC--SBP AND HR WNL IN SR WITHOUT OBSERVED ECTOPY. MG++ AND K++ HAVE BEEN REPLETED. PT REMAINS ON IVF AT 150CC HR.\n\nRESP--O2 DECREASED TO 4L NC WITH SPONT RESP . SAO2 >96%. WEAK PRODUCTIVE COUGH. LUNGS CLEAR BUT DIMINISHED IN BASES.\n\nGI--REQUESTING WATER AND TOLERATING IT WELL WITHOUT ASPIRATION. SPEECH AND SWALLOW IN THIS AM BUT PT WAS TOO OBTUNDED. BE IN THIS AFTERNOON TO NOW THAT PT IS MORE AWAKE. NO STOOL. +BS.\n\nGU--FOLEY CATH DRAINING >50 CCHR OF CLOUDY URINE. L NEPHROSTOMY TUBE DRAINING THE SAME CLOUDY URINE~100 CC Q2 HR.\n\nENDO--BS COVERED WITH SSRI. LYTES CHECKED AT 1500.\n\nSKIN--ORAL CAVITY IS VERY DRY. LIPS ARE CAKED WITH BLOOD DESPITE NUMEROUS ATTEMPTS TO CLEAN THEY REBLEED FROM ORAL LESIONS. ATTEMPTED TO OBTAIN MOUTH CX FOR HSV BUT LAB HAS RUN OUT OF SPECIAL SWABS. WILL ATTEMPT TO GET SWABS FROM . BUTTOCKS AND BACK WITHOUT BREAKDOWN. SEVERAL AREAS OF ECCYMOISIS ON ARMS AND TORSO. AT LP SITE THERE IS A HEMATOMA.\n\nID--AFEBRILE. REMAINS ON ABX. CX REMAIN NEG SO FAR.\n\nPAIN- DENIES PAIN WHEN ASKED.\n\nCOPING--BROTHER IN TO VISIT. DAUGHTER HAS PHONED AND HAS BEEN UPDATED REGARDING PT'S CONDITION AND PLAN FOR NEUROLOGY TO COME AND ASSESS.\n\nA--MS IMPROVING AS DAY GOES BY, REQUESTING WATER. NEUROLOGY NOT IN AS OF THIS TIME.\n\nP--CON'T TO REDIRECT AND REORIENT AS NEEDED. CHECK LYTES. OFFER SUPPORT TO PT AND FAMILY.\n" }, { "category": "Nursing/other", "chartdate": "2196-09-08 00:00:00.000", "description": "Report", "row_id": 1323209, "text": "NURSING MICU NOTE 7P-7A\n\nPT MORE CLEAR THIS EVENING. NO PRN MEDS GIVEN FOR ANXIETY OR SEDATION. AROUND 2300 PT C/O DIFFICULTY SWALLOWING, THICK \"FAT\" TOUNGE. PT SATS LOW 90'S. AT THIS TIME PT DROPPING HR TO LOW 40'S FROM 90'S. DR. IN TO EVALUATE PT. EKG DONE. PLAN TO CONT TO MONITOR PT AND KEEP HER NPO.\n\nNEURO: PT SLEPT ON AND OFF. WHEN AWAKE PT ALERT OX2. ASKING FOR WATER WANTING TO GO HOME. PT . RESTRAINES REMOVED.\n\nRESP: PT REMAINS ON 3L NC. O2 SATS 96-100%. FOR BRIEF TIME O2 SATS HOVERING 88-93%. LS DIMINSHED.\n\nCV: HR 42-100. SBP 130'S. PT AFEBRILE. WHEN PT IS SLEEPING HR 59-60'S. DURING THE EPISODE AT 2300 HR AS LOW AS 42 X2. IVF CONT D5W 20KCL AT 150CC/HR.\n\nGI/GU: EARLY IN SHIFT PT TAKING WATER WITHOUT ANY DIFFICULTY. PT STARTED TO C/O TROUBLE SWOLLOWING AND NOT BEING ABLE TO CLEAR HER THROAT. AT 1AM PT STATED SHE FELT BETTER AND WANTED WATER. PT WITH 1 ICE CHIP AND STARTED TO COUGH. PT IS NOW NPO. FOLEY INTACT DRAINING YELLOW URINE W/SEDIENT. PT STOOL X1.\n\nDISPO: PLAN IS TO CONT TO MONITOR MENTAL STATUS. AVOID SEDATION MEDS IF POSSIBLE. NEURO TO RECONSULT TODAY. SPEACH AND SWALLOW TO PT TODAY. PT IS A FULL CODE.\n" }, { "category": "Nursing/other", "chartdate": "2196-08-31 00:00:00.000", "description": "Report", "row_id": 1323187, "text": "Resp. care note - pt. intubated in ER, transsfered to CT and then to MICU7, without incident, placed on the venet at this time.\n" }, { "category": "Nursing/other", "chartdate": "2196-08-31 00:00:00.000", "description": "Report", "row_id": 1323188, "text": "MICU NURSING ADMIT NOTE:\n Pt is a 67 yr old female with PMH pancreatitis, kidney stones, s/p lithotripsy/L ureteral stent removal and replacement who presented ambulatory to EW today with fever, hematuria, tachypnea, SOB, L flank pain. Lactate was 7.0, wbc 19.4. In EW, her sbp was 50, sats 84% RA, temp 102. Code sepsis called, pt received 7L IVF/ eventually required 3 vasopressors, was intubated, received abx, tylenol, Decadron. Blood and urine cx sent. CXr showed bilateral infiltrates. Ab CT showed ? hemoperitoneum. Ct repeated, await official read. Pt was transferred to MICU for further care.\nREVIEW of SYSTEMS:\nALLERGIES: Vanco and derivatives, PCN, Sulfa, tetracyclines\nNuero: Pt opens eyes to voice, following commands, MAE, calm after 1mg iv versed. Await fentanyl/versed gtts to start at low doses.\nCV: Initially on Dopamine/Levo/Neo.. Vasopressin added and Neo dc'd. CVP 17-18. MAP's >60 since admit. HR 80's nsr. pt on continual mixed venous sat montoring, Mixed venous sat 80's.\nID: lactate now 2.7. wbc up to 24.7. stim test completed, await results. afebrile. received 2 units prbc's total (first up in ew). pt to starte on tobramycin, meropenum, and linezolid. ID consult following. received Levaquin and flagyl in ew.\nRESP: abg on arrival: 7.18/35/134/14 Pt to receive lung protective ventilatory settings d/t ARDS picture. Settings changed to 450 x 25/peep 8. FIO2 remains at 1.0. no secretions as of yet. LS bronchial R base, crackles throughout.\nFE: insulin gtt started for fsbs consistently in 200's. currently infusing at 2unit/hr. Ionized calcium .89 and magnesium 1.0.. treated with 4amps magnesium and 2 amps calcium gluconate.\nGU: foley intact, urine tea colored, with sediment. 30-60cc's/hr out.\nGI: ab obese, distended, absent bs. ogt advanced and 150cc's bile out. tube to lis.\nSocial: dtr at bedside, and is HCP.. form in chart.\nInteg: intact.\nAccess: 2 piv's, RIJ presept catheter, aline.\nA/P: pt with sepsis likely r/t renal issues. to start new abx regime, follow sepsis labs. follow abgs, wean fio2 as able. follow cx. f/u results of stim test. titrate insulin gtt prn. f/u results CT.\n" }, { "category": "Nursing/other", "chartdate": "2196-09-01 00:00:00.000", "description": "Report", "row_id": 1323191, "text": "NPN 7a-7P:\n Nuero: pt remains lightly sedated on Fentanyl 25mcg/hr and versed increased to 2mg/hr. opens eyes to voice follows commands, resting comfortably unless disturbed. MAE, assists to turn. Perrl.\n RESP: remains vented A/C 450 x 30 peep8/fio2 .60. abg: 7.38/26/132/16. LS bronchial bases, course upper. sx q 4 hrs for small amts white, then pale yellow secretions.\n CV: HR 70's-80's nsr. MAP's >60 on vasopressin, levophed. Dobutamine weaned off after Cardiac echo showed normal LV function. CVP 13-16. Remains on hydrocortisone and fludrocortisone for adrenal insufficiencyl.\n ID: remains on meropenum and linezolid. low grade temps. cx pending, ngtd. wbc 24.5. Lactate up to 4.6 at 10 am, down to 3.3 this afternoon (? r/t being on Dobutamine, as other factors appear unchanged). SVO2 80's.\n FE: repleated 4 amps calcium gluconate this am, pm ionized calcium wnl. remains on insulin gtt 1.5-3units/hr. Insulin gtt was held x 2 hrs for fsbs 58.. pt received 1 amp D50 with fsbs >100 since.\n GU: UO 40cc's/hr this afternoon, was 80-100cc's'/hr while pt was on dobutamine.\n GI: ab soft, bs hypo. Ogt placement confirmed by xray. on pantoprazole. stool x 2, loose, brown.\n Integ: intact.\n Access: piv x 1, presept catheter to RIJ, aline intact.\n Social: pt's dtr (HCP) updated by Dr. . pt's other dtr and son also into visit and were updated.\n A/P: 67 yr old female admit with sepsis/ARDS s/p lithotripsy/L ureteral stent removal/replacement on . Continue abx, follow cx, titrate vasopressors as able. continue lung protective vent strategy for ARDS. Cont support to pt/family.\n" }, { "category": "ECG", "chartdate": "2196-09-08 00:00:00.000", "description": "Report", "row_id": 264652, "text": "Sinus rhythm\nLeft axis deviation\nNonspecific ST-T wave changes\nSince previous tracing, no significant change\n\n" }, { "category": "ECG", "chartdate": "2196-09-07 00:00:00.000", "description": "Report", "row_id": 264653, "text": "Sinus rhythm\nLeft axis deviation\nPoor R wave progression - probable normal variant\nNonspecific ST-T changes\nSince previous tracing, no significant change\n\n" }, { "category": "ECG", "chartdate": "2196-08-31 00:00:00.000", "description": "Report", "row_id": 264654, "text": "Sinus rhythm\nLeft axis deviation\nLeft anterior fascicular block\nAnterior T wave changes are nonspecific\nSince previous tracing, T wave flattening in leads V2-V3, sinus bradycardia\nabsent\n\n" }, { "category": "ECG", "chartdate": "2196-08-31 00:00:00.000", "description": "Report", "row_id": 264655, "text": "Sinus tachycardia\nPossible left anterior fascicular block\nNonspecific T wave changes\nSince previous tracing, sinus tachycardia present\n\n" } ]

[ { "category": "Echo", "chartdate": "2201-04-09 00:00:00.000", "description": "Report", "row_id": 69701, "text": "PATIENT/TEST INFORMATION:\nIndication: H/O cardiac surgery. Recent AVR. Now with chest pain and SOB\nHeight: (in) 68\nWeight (lb): 165\nBSA (m2): 1.89 m2\nBP (mm Hg): 161/77\nHR (bpm): 94\nStatus: Inpatient\nDate/Time: at 16:31\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Dilated LA.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. Dynamic interatrial\nseptum. No ASD by 2D or color Doppler. The IVC is normal in diameter with\nappropriate phasic respirator variation.\n\nLEFT VENTRICLE: Mild symmetric LVH. Normal LV cavity size. Overall normal LVEF\n(>55%). No resting LVOT gradient. No LV mass/thrombus. No VSD.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Moderately dilated aortic root. Moderately dilated ascending aorta.\nMildly dilated aortic arch.\n\nAORTIC VALVE: Bioprosthetic aortic valve prosthesis (AVR). AVR well seated,\nnormal leaflet/disc motion and transvalvular gradients. No masses or\nvegetations on aortic valve. No AR.\n\nMITRAL VALVE: Normal mitral valve leaflets with trivial MR. No MVP. Normal\nmitral valve supporting structures. Normal LV inflow pattern for age.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Normal\ntricuspid valve supporting structures. Moderate PA systolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with\nphysiologic PR. Normal main PA. No Doppler evidence for PDA\n\nPERICARDIUM: Small pericardial effusion. No echocardiographic signs of\ntamponade.\n\nConclusions:\nThe left atrium is dilated. No atrial septal defect is seen by 2D or color\nDoppler. There is mild symmetric left ventricular hypertrophy. The left\nventricular cavity size is normal. Overall left ventricular systolic function\nis normal (LVEF 60%). No masses or thrombi are seen in the left ventricle.\nThere is no ventricular septal defect. Right ventricular chamber size and free\nwall motion are normal. The aortic root is moderately dilated. The ascending\naorta is moderately dilated. The aortic arch is mildly dilated. A\nbioprosthetic aortic valve prosthesis is present. The aortic prosthesis\nappears well seated, with normal leaflet/disc motion and transvalvular\ngradients. No masses or vegetations are seen on the aortic valve. No aortic\nregurgitation is seen. The mitral valve appears structurally normal with\ntrivial mitral regurgitation. There is no mitral valve prolapse. There is\nmoderate pulmonary artery systolic hypertension. There is a small\nposterolateral pericardial effusion. There are no echocardiographic signs of\ntamponade.\n\nCompared with the findings of the prior study (images reviewed) of , the aortic valve has been replaced. A small pericardial effusion is now\npresent.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2201-04-09 00:00:00.000", "description": "Report", "row_id": 1323110, "text": "ADMISSION NOTE\nNEURO ARRIVED FROM MRI ALERT MOVING ALL EXTREMETIES EQUAL STRENGTHS ORIENTED X1 ONLY TO PERSON, UNAWARE OF TIME OR PLACE REORIENTED FREQ TO PRESENT SITUATION AND UNABLE TO REPEAT INFO AFTER ONLY MINUTES, PULILS EQUAL AND REACTIVE\n\nC/V NSR WITH SOME ST ELEVATION NOTED IN LEAD 2 12LEAD EKG DONE B/P 138/70 PALP PULSES EXTREMETIES WARM PALP BILATERAL RADIAL AND BRACHIAL PULSES PALP HANDS WARM\n\nRESP NC 3L SATS 97% LUNGS CLEAR NO SOB OR RESP DISTRESS\n\nGU/GI ABD SOFT VOIDED 850CC URINE\n\nPLAN CONTINUE TO CLOSELY MONITOR NEURO STATUS\n" }, { "category": "Nursing/other", "chartdate": "2201-04-10 00:00:00.000", "description": "Report", "row_id": 1323111, "text": "SEE CAREVUE FOR Q1H VS, NEURO CHECKS AND ALL OTHER OBJECTIVE DATA.\n\nNEURO: \"I SUPPOSE I'M STILL IN THE HOSPITAL.\" MEMORY IMPROVING OVER SHIFT. NOW KNOWS HE IS AT THE \"\" IN \", \", YEAR IS \"\", MONTH IS \"PROBABLY BY NOW.\" IDENTIFIES \" \" AS HIS HEART SURGEON. NO RECALL OF EVENTS OF . MAE, EQUAL STRENGTH, PEARL ALL SHIFT.\n\nPULM: LUNGS DIMINSIHED R BASE. SATS 94% ON R/A, 98% ON 4L N/C. DENIES RESPIRATORY DISTRESS.\n\nCV: NSR WITHOUT ECTOPY. PALPABLE PEDAL PULSES, PALPABLE ULNAR AND RADIAL PULSES BILATERALLY, R BRACHIAL. PULSE FAINTLY PLAPATED. TO US FOR BILATERAL LE STUDIES. ON HEPARIN GTT BUT PLATELET COUNT DROPPED SIGNIFICANTLY, HEPARIN DC'D, ARGATROBAN GTT STARTED AT 0530 AT 2MCG/KG/MIN. PTT AT 0730.\n\nENDO: 8 UNITS REGULAR INSULIN SC AT 2200 FOR BS 193.\n\nGI: ABDOMEN SOFT, + BS. NPO.\n\nGU: USING URINAL FOR QS AMTS YELLOW URINE.\n\nSOCIAL: SO, , VISITED UNTIL 2130.\n\nPLAN: NEURO CHECKS Q1H. REORIENT AS NEEDED. ? EEG THIS AM. NEUROLOGY TO FOLLOW. TITRATE ARGATROBAN PER PTT SLIDING SCALE, GOAL 60-80. RESUME MEDS THIS AM, ? ADVANCE DIET. ? OOB TO CHAIR.\n" }, { "category": "ECG", "chartdate": "2201-04-09 00:00:00.000", "description": "Report", "row_id": 164468, "text": "Sinus rhythm. The QTc interval is mildly prolonged. There is non-specific\njunctional ST segmenmt depression in the inferior leads with minimal ST segment\nelevation in the remaining leads. Compared to the previous tracing the findings\nare similar.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2201-04-09 00:00:00.000", "description": "Report", "row_id": 164469, "text": "Sinus rhythm. First degree A-V conduction delay. Left atrial abnormality.\nDiffuse ST segment elevation most consistent with early repolarization,\nalthough ischemia or infarction cannot be excluded. Compared to the previous\ntracing these ST segment changes are new.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2201-04-11 00:00:00.000", "description": "Report", "row_id": 164466, "text": "Baseline artifact\nLead V3 absent\nSinus rhythm\nProminent QRS voltage - possible left ventricular hypertrophy\nDiffuse ST-T wave changes with ST segment elevation - clinical correlation is\nsuggested for possible injury/pericarditis\nSince previous tracing of , rate slower and further ST-T wave changes\npresent\n\n" }, { "category": "ECG", "chartdate": "2201-04-09 00:00:00.000", "description": "Report", "row_id": 164467, "text": "Sinus rhythm. Left atrial abnormality. Diffuse non-specific ST-T wave changes.\nCompared to the previous tracing of no definite change.\n\n" }, { "category": "Radiology", "chartdate": "2201-04-09 00:00:00.000", "description": "CTA CHEST W&W/O C &RECONS", "row_id": 913431, "text": " 1:34 PM\n CTA CHEST W&W/O C &RECONS; CT 100CC NON IONIC CONTRAST Clip # \n Reason: PE\n Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 54 year old man with known DVT in right UE and R neck, now w/ bilateral\n pleuritic CP.\n REASON FOR THIS EXAMINATION:\n PE\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: 3:56 PM\n 1. Several segmental pulmonary embolism in the ligula and left lower lobe.\n 2. Right pleural effusion and bilateral atelectasis.\n 3. Pneumopericardium probably due to recent operation.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 54-year-old male with DVT in the right upper extremity, bilateral\n chest pain.\n\n TECHNIQUE: Contiguous axial CT images of the chest were obtained with and\n without the administration of IV contrast . Multiplanar reformation\n images are reconstructed.\n\n COMPARISON: No comparison.\n\n FINDINGS: Note is made of several small filling defects in segmental arteries\n in the lingula and left lower lobe, suggestive of pulmonary embolism. Note is\n made of pneumopericardium, most likely due to recent operation. The patient\n is status post median sternotomy. Coronary arteries are calcified. The\n patient is status post aortic valve replacement. Moderate right pleural\n effusion is noted. Bibasilar atelectasis is noted. No other suspicious mass\n or nodule is noted.\n\n In the visualized portion of the upper abdomen, no gross abnormalities are\n noted. Small hiatal hernia is noted.\n\n There is no suspicious lytic or blastic lesion in skeletal structures.\n\n IMPRESSION:\n 1. Several small filling defects in the segmental arteries of the lingula and\n left lower lobe, suggestive of pulmonary embolism.\n 2. Moderate right pleural effusion with bibasilar atelectasis.\n 3. Small pneumopericardium in this patient with recent aortic valve\n replacement with median sternotomy. Coronary artery calcification and\n pericardial effusion.\n\n The information was communicated to the referring physician, . by\n telephone at the time of examination, and also sent to ED dash board.\n (Over)\n\n 1:34 PM\n CTA CHEST W&W/O C &RECONS; CT 100CC NON IONIC CONTRAST Clip # \n Reason: PE\n Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2201-04-09 00:00:00.000", "description": "MR HEAD W/O CONTRAST", "row_id": 913470, "text": " 5:30 PM\n MR HEAD W/O CONTRAST; MRA BRAIN W/O CONTRAST Clip # \n Reason: R/O Stroke\n Admitting Diagnosis: PULMONARY EMBOLI\n Contrast: MAGNEVIST Amt: 15\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 54 year old man with mental status changes. Onset 1 hour ago, s/p cardiac\n surgery\n REASON FOR THIS EXAMINATION:\n R/O Stroke\n ______________________________________________________________________________\n WET READ: 7:40 PM\n NAD\n MRA wnl also\n ______________________________________________________________________________\n FINAL REPORT\n MRI OF THE BRAIN WITH AND WITHOUT CONTRAST\n\n CLINICAL HISTORY: Mental status changes after cardiac surgery.\n\n TECHNIQUE: Multiplanar pre- and post-contrast T1-weighted images, axial T2-\n weighted, susceptibility, FLAIR, and diffusion-weighted images were obtained.\n\n FINDINGS:\n\n No prior MRI studies are available. Comparison is made to the CT of the same\n day.\n\n No area of restricted diffusion is seen to suggest a recent infarct. The\n brain parenchyma appears normal. The pattern of enhancement is normal. Note\n is made of a normal CSF intensity perivascular space at the base of the left\n lentiform nucleus. There is no evidence of a hemorrhage or an abnormal extra-\n axial collection. The CSF spaces are normal in size as seen on the recent CT.\n\n IMPRESSION: Normal MRI of the brain.\n\n MRA OF THE HEAD\n\n TECHNIQUE: A 3D time-of-flight study was derived from overlapping axial slabs\n through the inferior cranium.\n\n FINDINGS:\n\n The distal internal carotid arteries, the distal vertebral arteries, and the\n basilar artery are widely patent. The major branches of the cerebral arteries\n are normal. There is much more venous visualization than typical, suggesting\n of the study was performed after the contrast was given.\n\n IMPRESSION: Normal MRA of the skull base/circle of levels.\n\n (Over)\n\n 5:30 PM\n MR HEAD W/O CONTRAST; MRA BRAIN W/O CONTRAST Clip # \n Reason: R/O Stroke\n Admitting Diagnosis: PULMONARY EMBOLI\n Contrast: MAGNEVIST Amt: 15\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2201-04-11 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 913738, "text": " 8:09 PM\n CHEST (PA & LAT) Clip # \n Reason: eval for interval change.\n Admitting Diagnosis: PULMONARY EMBOLI\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 54 year old man a/w PE, extensive RUE DVT, s/p recent AVR. now with transient\n chest tightness\n REASON FOR THIS EXAMINATION:\n eval for interval change.\n ______________________________________________________________________________\n FINAL REPORT\n PA AND LATERAL CHEST:\n\n HISTORY: Extensive right upper extremity DVT. Now chest tightness.\n\n IMPRESSION: PA and lateral chest compared to chest radiographs since , most recently :\n\n Aside from minimal subsegmental atelectasis at the right lung base, lungs are\n clear. Small right pleural effusion is decreasing. Mediastinum has a normal\n postoperative appearance with top normal heart size comparable to the\n preoperative size. No pneumothorax.\n\n\n" }, { "category": "Radiology", "chartdate": "2201-04-09 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 913451, "text": " 3:18 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: bleed?\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 54 year old man with AMS, now resolving. Was AAO upon presentation and non\n focal neuro, then had unresponsiveness, now back to nonfocal neurologic exam\n though still confused. Heparin was bolused intially and pt premedicated with\n solumedrol and pepcid and benadryl.\n REASON FOR THIS EXAMINATION:\n bleed?\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: 4:23 PM\n no bleed\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Altered mental status.\n\n COMPARISON: None.\n\n TECHNIQUE: Non-contrast axial head CT.\n\n FINDINGS: There is no evidence for hemorrhage. There is no mass effect or\n shift of normally midline structures. The ventricles, cisterns, and sulci\n appear normal. The osseous structures are unremarkable, and the visualized\n paranasal sinuses are clear. The mastoid air cells are well pneumatized.\n\n IMPRESSION: No evidence for hemorrhage.\n\n\n" }, { "category": "Radiology", "chartdate": "2201-04-09 00:00:00.000", "description": "BILAT LOWER EXT VEINS", "row_id": 913493, "text": " 9:12 PM\n BILAT LOWER EXT VEINS Clip # \n Reason: PE UE DVT\n Admitting Diagnosis: PULMONARY EMBOLI\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 54 year old man s/p AVR w/ PE.\n REASON FOR THIS EXAMINATION:\n R/O DVT, has RUE DVT. Please do bil. LE and UE.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 54-year-old male status post AVR with pulmonary embolism, concern\n for DVT.\n\n BILATERAL LOWER EXTREMITY ULTRASOUND: scale and Doppler son of the\n bilateral common femoral, superficial femoral, deep femoral, greater saphenous\n and popliteal veins were performed. There is normal compressibility,\n waveform, augmentation and flow. No intraluminal echogenic material is\n identified.\n\n IMPRESSION: No evidence of DVT in the bilateral lower extremities.\n\n\n" }, { "category": "Radiology", "chartdate": "2201-04-10 00:00:00.000", "description": "VEN DUP EXTEXT BIL (MAP/DVT)", "row_id": 913581, "text": " 1:33 PM\n DUP EXTEXT BIL (MAP/DVT) Clip # \n Reason: assess Upper extrem for dvt\n Admitting Diagnosis: PULMONARY EMBOLI\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 54 year old man s/p AVR w/ PE.\n\n REASON FOR THIS EXAMINATION:\n assess Upper extrem for dvt\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 54-year-old male status post aortic valve replacement presenting\n with pulmonary embolism.\n\n COMPARISONS: No comparisons are available.\n\n TECHNIQUE: scale and Doppler son of the bilateral internal jugular\n veins, subclavian veins, axillary veins, cephalic veins, brachial veins, and\n basilic veins were performed.\n\n FINDINGS: There is completely occluded thrombosis of the right internal\n jugular vein, right subclavian vein, right axillary vein, right brachial veins\n and the right basilic vein. The only vein fully patent on the right arm is\n the right cephalic vein.\n\n On the left arm, there is thrombosis of the left cephalic vein. All the other\n vessels appear to be patent including the left IJ, subclavian, axillary, and\n brachial veins. There is a line within the left basilic vein.\n\n IMPRESSION:\n 1. Positive study for DVT involving the right internal jugular vein and right\n upper extremity.\n 2. Thrombophlebitis involving the left cephalic vein.\n\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2201-04-09 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 913445, "text": " 2:47 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for PTX, CHF, PNA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 54 year old man with AI s/p AVR.\n\n REASON FOR THIS EXAMINATION:\n eval for PTX, CHF, PNA\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 54-year-old male with status post AVR. Assess for pneumothorax,\n CHF, pneumonia.\n\n TECHNIQUE: Portable AP chest radiograph.\n\n COMPARISON: Chest radiograph dated .\n\n FINDINGS: The patient is status post aortic valve replacement with median\n sternotomy. The cardiac and mediastinal contours are unchanged. Again note\n is made of bibasilar opacities with small layering effusion, unchanged\n compared to the prior study. Small pneumopericardium is seen. No new\n consolidation is noted. No evidence of CHF.\n\n IMPRESSION: Unchanged appearance of the chest with bibasilar opacities with\n effusion, most likely representing atelectasis. Small\n amount of pneumopericardium.\n\n" } ]

[ { "category": "Radiology", "chartdate": "2140-10-18 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 982781, "text": " 1:05 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: ptx\n Admitting Diagnosis: AORTIC STENOSIS;CORONARY ARTERY DISEASE\\AORTIC VALVE REPLACEMENT, ? CORONARY ARTERY BYPASS GRAFT /SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old woman aortic stenosis s/p AVR(tissue)\n REASON FOR THIS EXAMINATION:\n ptx\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Aortic stenosis status post aortic valve replacement.\n\n The chest dated is compared to the prior PA and lateral chest\n radiograph of . The patient is intubated and the endotracheal tube\n terminates 3.4 cm above the carina. Pacemaker is placed over the right upper\n chest with the leads terminating in the right atrium and right ventricle. A\n nasogastric tube tip terminates below the diaphragm. A right internal jugular\n Swan-Ganz catheter terminates in the area overlying the right border of the\n mediastinum. Multiple mediastinal drainage tubes are identified. Median\n sternotomy wires are intact. Staples overlie the mid chest. The heart is\n enlarged. The mediastinal contour are stable. The lung fields continue to\n show diffuse lung parenchymal abnormality consistent with pulmonary fibrosis.\n There is a hazy opacity at the right lung base suggesting a pleural effusion.\n A retrocardiac opacity suggests consolidation versus atelectasis.\n\n IMPRESSION:\n 1. Lines and tubes as described above. No evidence for pneumothorax.\n 2. Increased retrocardiac opacity which may represent atelectasis versus\n consolidation. Probable bilateral pleural effusions.\n\n\n" }, { "category": "Radiology", "chartdate": "2140-10-24 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 983556, "text": " 12:31 PM\n CHEST (PA & LAT) Clip # \n Reason: evaluate effusion please do at 1200\n Admitting Diagnosis: AORTIC STENOSIS;CORONARY ARTERY DISEASE\\AORTIC VALVE REPLACEMENT, ? CORONARY ARTERY BYPASS GRAFT /SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old woman s/p avr\n REASON FOR THIS EXAMINATION:\n evaluate effusion please do at 1200\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post aortic valve replacement.\n\n PA and lateral chest radiographs dated is compared to the prior chest\n CT of and portable chest radiographs of and 18, .\n\n PA AND LATERAL CHEST: A right-sided pacemaker is again seen with leads\n terminating in the right atrium and right ventricle. Median sternotomy wires\n and CABG clips are in stable position. There is stable cardiomegaly. There\n has been interval improvement in the degree of pulmonary vascular engorgement\n consistent with improved CHF. There is an unchanged underlying mild chronic\n subpleural interstitial abnormality. Chronic left apical fibrotic changes are\n stable. Small bilateral pleural effusions have decreased in size. The\n surrounding osseous and soft tissue structures are otherwise unremarkable.\n\n IMPRESSION: Cardiomegaly with improved congestive heart failure with smaller\n bilateral pleural effusions. Unchanged mild chronic background interstitial\n abnormality.\n\n\n" }, { "category": "Radiology", "chartdate": "2140-10-19 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 982966, "text": " 3:25 PM\n CHEST (PORTABLE AP) Clip # \n Reason: ? ptx s/p ct removal\n Admitting Diagnosis: AORTIC STENOSIS;CORONARY ARTERY DISEASE\\AORTIC VALVE REPLACEMENT, ? CORONARY ARTERY BYPASS GRAFT /SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old woman aortic stenosis s/p AVR(tissue)\n\n REASON FOR THIS EXAMINATION:\n ? ptx s/p ct removal\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Aortic valve replacement; assess changes in postoperative status.\n\n FINDINGS: In comparison with the study of , the patient has taken a poor\n inspiration. The endotracheal tube, Swan-Ganz catheter, and nasogastric tube\n have been removed. The left chest tube has been removed and there is no\n evidence of pneumothorax. Mediastinal tubes have been removed. Pacemaker\n remains in place. Some atelectatic changes persist at the left base.\n\n IMPRESSION: Removal of tubes as described above with expected postoperative\n appearance.\n\n\n" }, { "category": "Radiology", "chartdate": "2140-10-20 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 983047, "text": " 8:10 AM\n CHEST (PORTABLE AP) Clip # \n Reason: R/O effusion\n Admitting Diagnosis: AORTIC STENOSIS;CORONARY ARTERY DISEASE\\AORTIC VALVE REPLACEMENT, ? CORONARY ARTERY BYPASS GRAFT /SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old woman aortic stenosis s/p AVR(tissue)\n\n REASON FOR THIS EXAMINATION:\n R/O effusion\n ______________________________________________________________________________\n FINAL REPORT\n Post-operative portable chest film to rule out effusion. Pacemaker, sternal\n sutures and skin sutures are again noted. Patient takes a poor inspiratory\n effort and the left hemidiaphragm is obscured suggesting some atelectasis or\n effusion on that side. I cannot exclude an effusion on the right side and\n suspect there may be a small one. The pulmonary vascularity is normal with no\n evidence of infiltrate.\n\n CONCLUSION: It is my impression that there are bilateral effusions left\n larger than the right. For further evaluation lateral film if feasible or CT\n study would be necessary.\n\n" }, { "category": "Nursing/other", "chartdate": "2140-10-18 00:00:00.000", "description": "Report", "row_id": 1648294, "text": "1130-1900:\ns/p avr tissue. stable or course. ez intubation. received on neo and propofol gtts.\n\nneuro: sedated on propofol gtts. reversed per orders and pt following all commands although remains lethargic. perrl. morphine prn pain with good effect, denies pain at present.\n\ncv: v paced via internal , paced at times for hemodynamic support with atrial pacing from epicardial wires. thermodilution ci < 2, pt with tr. ci via fick > 2, with drop in mixed venous to 50's. 3l lr given with improved svo2 > 60. pad 14-19, cvp 5-13. ct oozy, inr 1.7. if remains greater than 90 cc/hr will treat with ffp. hct 27. easily palpable pedal pulses bilaterally. np aware.\n\nresp: lungs coarse at times, suctioned for small amounts thick tan secretions. ct to 20 cm sxn, no airleak. weaned to cpap 40% 5/10 with good abg. o2 sat 100%. cxr done.\n\ngi/gu: abd soft, nd. bs positive. ogt to lws, draining bilious drainage. foley to gravity, huo 90-100 cc. cr wnl.\n\nendo: fs 72-99, will treat per orders as needed.\n\nplan: wean vent as tolerates. monitor hemodynamics.\n" }, { "category": "Nursing/other", "chartdate": "2140-10-18 00:00:00.000", "description": "Report", "row_id": 1648295, "text": "Respiratory Care Note\nPt recieved from OR intubated and placed on SIMV as noted. BS are clear and equal. Pt weaned according to ABG's to PSV 15/5 - tolerated well. Pt then weaned to PS 10 - PaCO2 increased from 38 to 49 with a pH of 7.28. PS subsequently increased back to 15cm. Plan to wean toward extubation as tolerated by pt.\n" }, { "category": "Nursing/other", "chartdate": "2140-10-18 00:00:00.000", "description": "Report", "row_id": 1648292, "text": "1130-1900:\npt with improved abg on cpap 40% 5/15. remains labile with pt with respiratory acidosis on cpap 40% 5/10, placed on 15 drops of svo2 to 49, volume given. np aware. svo2pressure support and will redraw abg. will place on rate if increased to 62. pt remains acidotic. see carevue.\n" }, { "category": "Nursing/other", "chartdate": "2140-10-18 00:00:00.000", "description": "Report", "row_id": 1648293, "text": "1130-1900:\npt with improved abg on cpap 40% 5/15. remains labile with pt with respiratory acidosis on cpap 40% 5/10, placed on 15 drops of svo2 to 49, volume given. np aware. svo2pressure support and will redraw abg. will place on rate if increased to 62. pt remains acidotic. see carevue.\n" }, { "category": "Nursing/other", "chartdate": "2140-10-19 00:00:00.000", "description": "Report", "row_id": 1648296, "text": "Nursing Progress Note\nNeuro: alert, following commands. Nods yes/no to pain, Nods yes to questions \"do you want the breathing tube out?\" Perla 3 brisk, Gag and cough intact. Mae, generalized weak. Bilateral soft wrist restraints to protect lines from interference.\n\nCVS: temp 99.7, hr 88 v paced (internal ) no ectopy noted, bp 113/53, pa 36/22, cvp 12, mvo2 72, co 7.0, ci 3.91 (fick). 2 a and 2 v epicardial wires, off to not compete with internal. Pulses palp x 4 extremities, skin pale warm and dry. Right ij cordis with cco swan and right radial a line transduced. Right ac piv patent. Sternal and mediastinal dressings with scant serosang staining. Chest tube with scant loose serosang output.\n\nResp: ls coarse in upper lobes diminished at bilateral bases. Intubated, on vent cpap+ps .40/342/28/5/10 abg 7.36/41/155/24/-1/98%\nSuctioned for thick tan to rusty pluggy secretions. Oral yellow secretions.\n\nGI: abdomen soft, obese, bs hypo x 4 quadrants. OGT draining scant bilious secretions to LCS.\n\nGU: Foley cath with less than 30 cc hour of urine, yellow/brown sedimented. PA aware, fluid bolus not improving UOP, flushed for patency.\n\nEndo: fs bs covered q 1 hour with iv insulin scale.\n\nPain: Nods head no to question \"Are you in any pain?\"\n\nHeme: transfused 1 unit prbc, no s/s of transfusion reaction.\n\nSocial: no calls or family contact this shift.\n\nPlan continue vent wean as tolerated.\n\nSee carevue flowsheet and for further details and values.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2140-10-19 00:00:00.000", "description": "Report", "row_id": 1648297, "text": "Resp Care\nRemains intubated and ventilated on cpap/psv with no remarkable changes overnight.Breath sounds coarse suctioned for small amounts of thick yellow sputum. ABGS within normal limits with good oxygenation. RSBI = 118.\n" }, { "category": "Nursing/other", "chartdate": "2140-10-19 00:00:00.000", "description": "Report", "row_id": 1648299, "text": "npn 0700-1500\n\nneuro ;aoox2-3 mae to command perla answering appropriately in oob to chair denies pain and is no longer splinting after mso4 1 mgsi.v at 9am.\n\nresp; extubated with good at 10am weaned to 4l n/c.rr 18-24 strong productive cough of thick pink tinged secretions.encouraged to cd/b.\n\ncvs; tmax 38 core swan d/c this am. bp 130-140 on nitro to 1mcg/kgmin aware po lopressor increased and norvasc added.\n\ngu; passing mod amounts clear urine with sed via foley after lasix 20 mgs i.v at 6am\n\ngi; belly soft pos bs insulin drip off at 1430 taking small amounts of\nfood denies nausea\n\nct drained mod amounts of serosanguinous draininge d/c at 2pm cxr done awaiting read.\n\nskin intact;\n\nsoc; family called for up dates on pt conditions and plan of care.\n\na/p ; stable improved bp control with oral meds wean ntg and poss rtrans fer to floor in am.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2140-10-20 00:00:00.000", "description": "Report", "row_id": 1648300, "text": "cvicu update\nneuro/pain: slept much of shift. confused. follows commands. maew in bed. denies pain. perl.\n\ncv: vs as per flowsheet. A sensing/ V paced by perm . A & V epicardial wires present though not checked r/t perm . rt hand cool, other extrems warm. rt rad art line d/c w/out issue. nbp 120-130's. Hct 22 (rechecked) team aware.\n\nresp: o2 sats high 90's on 2 l n/c. lungs w/ crackles bilat. RR 20's, denies sob. am lasix 20 mg iv just given.\n\ngi/gu: abd soft. bsp. only clears w/ meds tonoc.\n\nsocial: family in to visit last pm. pt somewhat confused at that time.\n\nassess: vss w/ hct down to 22.3\n\nplan: ? transfuse, ? cxr, increase lasix. pulm hygiene. ? transfer to if remains stable.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2140-10-20 00:00:00.000", "description": "Report", "row_id": 1648301, "text": "Neuro: alert and oriented x 3 does at times become confused to place, mae, oob to chair is steady on feet, following commands correctly, denies pain.\n\nCardiac: 100% v paced with internal , sbp's are wnl's, palpible pedial pulses, afebrile, +3 edema in extremities, did get 2 units of prbc's for low hct and are awaiting repete hct to come back from lab.\n\nResp: lungs dim in bases with scattered crackles, on 2 liters satting at 97%, is using is but only able to get up to 300, is deep breathing and coughing.\n\nSkin: chest with dsd that is cdi, old ct dsds are cdi.\n\nGi/gu: tolerating po's, abd soft round and nontender with good bowel sounds poor appetite needs encouragment to eat, on riss, making good u/o is on lasix and did get extra dose with blood.\n\nSocial: son into visit and updated, no beds on .\n\nPlan: d/c cordis post lab draws in am, f2 in am did do transfer note will need to be updated in am.\n" }, { "category": "Nursing/other", "chartdate": "2140-10-19 00:00:00.000", "description": "Report", "row_id": 1648298, "text": "Respiratory Care Note\nPt received on PSV 8/5 and weaned to at start of shift. BS coarse bilaterally. Pt tolerating PSV 5/5 well with good follow up ABG. ABG within normal limits with good oxygenation. Subglottic suctioning done prior to extubation and cuff leak test. Pt has a postive cuff leak test. Pt extubated to cool aerosol without incident.\n" }, { "category": "Nursing/other", "chartdate": "2140-10-21 00:00:00.000", "description": "Report", "row_id": 1648302, "text": "csru update\nslept much of shift. disoriented last pm. now oriented to place/year. cooperative to care. cont to doze freq. vss. additional lasix 20 mg iv for crackles full up bilat w/ good responce. epicardial wires d/c by team w/ out incident. resting at present.\nassess: stable pm. confused at times\nplan: transfer to 2.\n\n\n\n\n" }, { "category": "Echo", "chartdate": "2140-10-18 00:00:00.000", "description": "Report", "row_id": 85631, "text": "PATIENT/TEST INFORMATION:\nIndication: Abnormal ECG. Aortic valve disease. Left ventricular function. Mitral valve disease. Right ventricular function. Valvular heart disease.\nStatus: Inpatient\nDate/Time: at 10:01\nTest: TEE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Mild LA enlargement. No spontaneous echo contrast or thrombus in\nthe body of the LAA. All four pulmonary veins identified and enter the\nleft atrium.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. A catheter or pacing wire is\nseen in the RA. A catheter or pacing wire is seen in the RA and extending into\nthe RV. No ASD by 2D or color Doppler.\n\nLEFT VENTRICLE: Wall thickness and cavity dimensions were obtained from 2D\nimages. Severe symmetric LVH. Normal LV cavity size. Low normal LVEF.\n\nLV WALL MOTION: basal anterior - normal; mid anterior - normal; basal\nanteroseptal - normal; mid anteroseptal - normal; basal inferoseptal - normal;\nmid inferoseptal - normal; basal inferior - normal; mid inferior - normal;\nbasal inferolateral - normal; mid inferolateral - normal; basal anterolateral\n- normal; mid anterolateral - normal; anterior apex - normal; septal apex -\nnormal; inferior apex - normal; lateral apex - normal; apex - normal;\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal ascending aorta diameter. Simple atheroma in ascending aorta.\nNormal descending aorta diameter. Simple atheroma in descending aorta.\n\nAORTIC VALVE: Severely thickened/deformed aortic valve leaflets. Severe AS\n(AoVA <0.8cm2). Trace AR.\n\nMITRAL VALVE: Moderately thickened mitral valve leaflets. Moderate thickening\nof mitral valve chordae. Moderate (2+) MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with\nphysiologic PR.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: A TEE was performed in the location listed above. I certify\nI was present in compliance with HCFA regulations. The TEE probe was passed\nwith assistance from the anesthesioology staff using a laryngoscope. No TEE\nrelated complications.\n\nConclusions:\nPRE-BYPASS: The left atrium is mildly dilated. No spontaneous echo contrast or\nthrombus is seen in the body of the left atrium or left atrial appendage. No\natrial septal defect is seen by 2D or color Doppler. There is severe symmetric\nleft ventricular hypertrophy. The left ventricular cavity size is normal.\nOverall left ventricular systolic function is low normal (LVEF 50-55%). Right\nventricular chamber size and free wall motion are normal. There are simple\natheroma in the ascending aorta. There are simple atheroma in the descending\nthoracic aorta. The aortic valve leaflets are severely thickened/deformed.\nThere is severe aortic valve stenosis (area <0.8cm2). Trace aortic\nregurgitation is seen. The mitral valve leaflets are moderately thickened.\nThere is moderate thickening of the mitral valve chordae. Moderate (2+) mitral\nregurgitation is seen. There is no pericardial effusion.\n\nPOST CPB:\nPreserved -ventricular systolic function.\nBioprosthesis (Tr-Leaflet) in the aortic position. Well seated and\nmechanically stable, with good leaflet excursion. There is trace perivalvular\nregurgitation. Unabel to obtain a satisfactoy deep transgastric window to\nevaluate the PG across the bioprosthesis.\nNo other change.\n\n\n" }, { "category": "ECG", "chartdate": "2140-10-18 00:00:00.000", "description": "Report", "row_id": 220679, "text": "Atrial sensed and ventricular paced rhythm. All ventricular complexes are\npaced in a left bundle-branch block and left axis deviation pattern with\nvoltage for left ventricular hypertrophy. Compared to the previous tracing\nof no significant change. Lead V3 has a mini-deflection of a possible\natrial pacemaker.\n\n" } ]

[ { "category": "Nursing", "chartdate": "2152-07-08 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 683995, "text": "HPI:Ms. is a 70-year-old woman who is now 3 years\n status post right breast lumpectomy and sentinel node biopsy for\n Stage I breast cancer in . She was also treated with Femara\n and with whole breast radiation therapy which was completed in\n . During her fu/surveillance CT chest she was found to\n have LUL leision which has been increased in size upto from 10\n to 13 cms. Mediastinoscopy was done taht showed no malignancy. PET scan\n had no SUV. Therefore, she had VATS/wedge resection today histo path\n was performed that showed fibrotic and lymhoid element, no evidence of\n malignancy per prelim path. pt with LVEF=20% has been on Cardiac meds\n and lasix at home. Pt was extubated in PACU but hypotensive and\n oliguric.\n .\n PMH:\n Asthma, Diabetes, HTN, Nonischemic\n cardiomyopathy, Breast Cancer, COPD, unstable angina, right\n shoulder pain, EF 20%\n .\n PSH:Right arthroscopic shoulder surgery,\n right breast lumpectomy and sentinel lymph node biopsy.\n .\n EVENTS:\n : Admitted to SICU for post op monitoring due to hypotension and\n poor UO. Tolerating nasal cannula. Received albumin overnight and UO\n improved.\n .\n Lobectomy or wedge resection\n Assessment:\n Post-op day #1..c/o\n pain from CT inscision site. Wearing 3l\n nc..sats 95-98% rr20-30. CT changed to water seal..Draining\n serosanquinous fluid. DSD..\n Action:\n After multiple position changes, pt became very uncomfortable. Started\n morphine PCA..after 4hrs (total 5mgm) pt very sleepy, says her eyes\n are going\nbuggy\n in her head, has funny feeling iin head. Dc\nd PCA\n and changed her to percocett..states she has had this before. I\n Response:\n Pt less sleepy without the morphine. Pain is controlled at this time.\n Rr 20\ns..stable sats\n Is tolerating po liqs and solids. Urine output is good.\n Plan:\n Pt is ready for transfer to floor. Possible dc of CT tomorrow per\n thoracics team. Encourge po, monitor u/o.\n" }, { "category": "Nursing", "chartdate": "2152-07-08 00:00:00.000", "description": "Nursing Progress Note", "row_id": 683996, "text": "Pt ready for transfer to floor: See transfer note\n" }, { "category": "Nursing", "chartdate": "2152-07-08 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 684054, "text": "HPI:Ms. is a 70-year-old woman who is now 3 years\n status post right breast lumpectomy and sentinel node biopsy for\n Stage I breast cancer in . She was also treated with Femara\n and with whole breast radiation therapy which was completed in\n . During her fu/surveillance CT chest she was found to\n have LUL leision which has been increased in size upto from 10\n to 13 cms. Mediastinoscopy was done taht showed no malignancy. PET scan\n had no SUV. Therefore, she had VATS/wedge resection today histo path\n was performed that showed fibrotic and lymhoid element, no evidence of\n malignancy per prelim path. pt with LVEF=20% has been on Cardiac meds\n and lasix at home. Pt was extubated in PACU but hypotensive and\n oliguric.\n .\n PMH:\n Asthma, Diabetes, HTN, Nonischemic\n cardiomyopathy, Breast Cancer, COPD, unstable angina, right\n shoulder pain, EF 20%\n .\n PSH:Right arthroscopic shoulder surgery,\n right breast lumpectomy and sentinel lymph node biopsy.\n .\n EVENTS:\n : Admitted to SICU for post op monitoring due to hypotension and\n poor UO. Tolerating nasal cannula. Received albumin overnight and UO\n improved.\n .\n Lobectomy or wedge resection\n Assessment:\n Post-op day #1..c/o\n pain from CT inscision site. Wearing 3l\n nc..sats 95-98% rr20-30. CT changed to water seal..Draining\n serosanquinous fluid. DSD..\n Action:\n After multiple position changes, pt became very uncomfortable. Started\n morphine PCA..after 4hrs (total 5mgm) pt very sleepy, says her eyes\n are going\nbuggy\n in her head, has funny feeling iin head. Dc\nd PCA\n and changed her to percocett..states she has had this before. Given 1\n pill 1700\n Response:\n Pt less sleepy without the morphine. Pain is controlled at this time.\n Rr 20\ns..stable sats\n Is tolerating po liqs and solids. Urine output is good.\n Plan:\n Pt is ready for transfer to floor. Possible dc of CT tomorrow per\n thoracics team. Needs reminder to use spirometer. Encourge po,\n monitor u/o.\n Splint pillow given to pt to assist with c/db. IS encouraged. VSS.\n Ready for transfer to floor.\n Demographics\n Attending MD:\n S.\n Admit diagnosis:\n LUNG NODULE/SDA\n Code status:\n Height:\n Admission weight:\n 74.9 kg\n Daily weight:\n Allergies/Reactions:\n Ampicillin\n Rash;\n Precautions:\n PMH: Asthma, COPD, Diabetes - Insulin\n CV-PMH: Angina, Hypertension\n Additional history: left bundle branch block, obesity, reflux,\n cardiomyopathy,\n Surgery / Procedure and date: s/p VATS/lobectomy .\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:102\n D:71\n Temperature:\n 99.5\n Arterial BP:\n S:103\n D:39\n Respiratory rate:\n 15 insp/min\n Heart Rate:\n 96 bpm\n Heart rhythm:\n LBBB (Left Bundle Branch Block)\n O2 delivery device:\n Nasal cannula\n O2 saturation:\n 99% %\n O2 flow:\n 3 L/min\n FiO2 set:\n 24h total in:\n 5,130 mL\n 24h total out:\n 1,393 mL\n Pertinent Lab Results:\n Sodium:\n 137 mEq/L\n 02:58 PM\n Potassium:\n 4.3 mEq/L\n 02:58 PM\n Chloride:\n 102 mEq/L\n 02:58 PM\n CO2:\n 24 mEq/L\n 02:58 PM\n BUN:\n 18 mg/dL\n 02:58 PM\n Creatinine:\n 1.3 mg/dL\n 02:58 PM\n Glucose:\n 112 mg/dL\n 02:58 PM\n Hematocrit:\n 31.5 %\n 11:28 PM\n Finger Stick Glucose:\n 153\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: SICU A\n Transferred to: 907\n Date & time of Transfer: 12:00 AM\n" }, { "category": "Physician ", "chartdate": "2152-07-08 00:00:00.000", "description": "Intensivist Note", "row_id": 683900, "text": "SICU\n HPI:\n Date HD1 POD1\n AB:Clindamycin 600 mg IV q 12 x 24 hrs\n PPX:heparin sq 5000 u , famotidine\n .\n CC: .\n HPI:Ms. is a 70-year-old woman who is now 3 years\n status post right breast lumpectomy and sentinel node biopsy for\n Stage I breast cancer in . She was also treated with Femara\n and with whole breast radiation therapy which was completed in\n . During her fu/surveillance CT chest she was found to\n have LUL leision which has been increased in size upto from 10\n to 13 cms. Mediastinoscopy was done taht showed no malignancy. PET scan\n had no SUV. Therefore, she had VATS/wedge resection today histo path\n was performed that showed fibrotic and lymhoid element, no evidence of\n malignancy per prelim path. pt with LVEF=20% has been on Cardiac meds\n and lasix at home. Pt was extubated in PACU but hypotensive and\n oliguric. Preop Clinda IV and intrathecal Astro morph was given.\n .\n PMH:\n Asthma, Diabetes, HTN, Nonischemic\n cardiomyopathy, Breast Cancer, COPD, unstable angina, right\n shoulder pain, EF 20%\n .\n PSH:Right arthroscopic shoulder surgery,\n right breast lumpectomy and sentinel lymph node biopsy.\n .\n EVENTS:\n : Admitted to SICU for post op monitoring due to hypotension and\n poor UO. Tolerating nasal cannula. Unable to resite positional A line.\n Using vigileo. Received albumin overnight and UO improved.\n .\n MICRO:\n None pending.\n .\n IMAGING:\n : large loculated pneumothorax in the lower left lung as\n well as a large amount of subcutaneous emphysema within the adjacent\n left chest wall.\n Current medications:\n Metoprolol Tartrate 12.5 mg PO BID, Aspirin 81 mg PO DAILY, Morphine\n Sulfate 0.5 mg IT ONCE Montelukast Sodium 10 mg PO DAILY, Clindamycin\n 600 mg IV Q12H, Promethazine HCl 6.25-12.5 mg IV MRX1:PRN\n nausea/vomiting, Ranitidine 150 mg PO BID, Insulin SC Sliding Scale,\n Valsartan 80 mg PO DAILY\n 24 Hour Events:\n ARTERIAL LINE - START 11:00 PM\n EKG - At 12:03 AM\n Allergies:\n Ampicillin\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Flowsheet Data as of 06:31 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.7\nC (99.8\n T current: 37.3\nC (99.2\n HR: 95 (82 - 95) bpm\n BP: 76/59(65) {59/44(52) - 124/92(101)} mmHg\n RR: 9 (9 - 13) insp/min\n SPO2: 100%\n Heart rhythm: LBBB (Left Bundle Branch Block)\n Total In:\n 3,935 mL\n PO:\n 720 mL\n Tube feeding:\n IV Fluid:\n 2,715 mL\n Blood products:\n 500 mL\n Total out:\n 0 mL\n 748 mL\n Urine:\n 190 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 3,187 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SPO2: 100%\n ABG: 7.31/52/158/26/0\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Left Extremities: (Edema: Absent)\n Right Extremities: (Edema: Absent)\n Neurologic: Follows simple commands, Moves all extremities\n Labs / Radiology\n 286 K/uL\n 10.2 g/dL\n 174 mg/dL\n 1.5 mg/dL\n 26 mEq/L\n 4.4 mEq/L\n 19 mg/dL\n 105 mEq/L\n 141 mEq/L\n 31.5 %\n 17.1 K/uL\n [image002.jpg]\n 10:28 PM\n 11:28 PM\n 11:33 PM\n 02:43 AM\n WBC\n 15.5\n 17.1\n Hct\n 30.8\n 31.5\n Plt\n 262\n 286\n Creatinine\n 1.7\n 1.5\n Troponin T\n <0.01\n TCO2\n 28\n 27\n Glucose\n 185\n 172\n 168\n 174\n Other labs: CK / CK-MB / Troponin T:989/5/<0.01, Lactic Acid:1.9\n mmol/L, Ca:8.1 mg/dL, Mg:1.7 mg/dL, PO4:5.3 mg/dL\n Assessment and Plan\n LOBECTOMY OR WEDGE RESECTION, CARDIOMYOPATHY, OTHER\n Assessment and Plan:\n PLAN: 70 yr female with EF 20% cardiomyopathy DM CHF COPD on lasix 40\n at home,h/o Breast Ca and leisions in LUL, had VATS/ Lobectomy on\n .\n Neuro: Normal neuro exam. Intrathecal Morphine placed at 0728AM on\n . Chronic pain service following.\n CVS: Using vigileo to monitor hemodynamics but A-line very positional.\n Albumin 5% 250 bolus given.\n Pulm: Tolerating nasal cannula. CT on suction -20 cm of H20 ( air leak\n present). Monitor pneumothorax with daily CXR.\n GI: NPO\n FEN: LR at 50 cc/hr\n Renal: Monitor UO. Cr improving.\n Heme: Monitor HCT\n Endo: RISS, keep BS < 150\n ID: no active issues\n TLD: PIV, a line, L chest drain.\n Wounds: L chest\n Imaging: CXR reviewed\n Prophylaxis: boots, famotidine\n Consults: Thoracics\n Code: Full- needs consent\n Disposition:SICU\n Billing Diagnosis: Other: s/p L VATS surgery\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Arterial Line - 11:00 PM\n 18 Gauge - 11:00 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: ICU\n Total time spent: 35\n" }, { "category": "Nursing", "chartdate": "2152-07-08 00:00:00.000", "description": "Nursing Progress Note", "row_id": 683835, "text": "70 y.o woman s/p left VATS and lobectomy. Hx of cardiomyopathy,\n diabetes- insulin dependent, EF approx 20%,\n" }, { "category": "Physician ", "chartdate": "2152-07-08 00:00:00.000", "description": "Intensivist Note", "row_id": 683888, "text": "SICU\n HPI:\n Date HD1 POD1\n AB:Clindamycin 600 mg IV q 12 x 24 hrs\n PPX:heparin sq 5000 u , famotidine\n .\n CC: .\n HPI:Ms. is a 70-year-old woman who is now 3 years\n status post right breast lumpectomy and sentinel node biopsy for\n Stage I breast cancer in . She was also treated with Femara\n and with whole breast radiation therapy which was completed in\n . During her fu/surveillance CT chest she was found to\n have LUL leision which has been increased in size upto from 10\n to 13 cms. Mediastinoscopy was done taht showed no malignancy. PET scan\n had no SUV. Therefore, she had VATS/wedge resection today histo path\n was performed that showed fibrotic and lymhoid element, no evidence of\n malignancy per prelim path. pt with LVEF=20% has been on Cardiac meds\n and lasix at home. Pt was extubated in PACU but hypotensive and\n oliguric. Preop Clinda IV and intrathecal Astro morph was given.\n .\n PMH:\n Asthma, Diabetes, HTN, Nonischemic\n cardiomyopathy, Breast Cancer, COPD, unstable angina, right\n shoulder pain, EF 20%\n .\n PSH:Right arthroscopic shoulder surgery,\n right breast lumpectomy and sentinel lymph node biopsy.\n .\n CURRENT MEDS:\n Metoprolol Tartrate 12.5 mg PO BID, Aspirin 81 mg PO DAILY, Morphine\n Sulfate 0.5 mg IT ONCE Montelukast Sodium 10 mg PO DAILY, Clindamycin\n 600 mg IV Q12H, Promethazine HCl 6.25-12.5 mg IV MRX1:PRN\n nausea/vomiting, Ranitidine 150 mg PO BID, Insulin SC Sliding Scale,\n Valsartan 80 mg PO DAILY\n .\n EVENTS:\n : Admitted to SICU for post op monitoring due to hypotension and\n poor UO. Tolerating nasal cannula. Unable to resite positional A line.\n Using vigileo. Received albumin overnight and UO improved.\n .\n MICRO:\n None pending.\n .\n IMAGING:\n : large loculated pneumothorax in the lower left lung as\n well as a large amount of subcutaneous emphysema within the adjacent\n left chest wall.\n .\n PLAN: 70 yr female with EF 20% cardiomyopathy DM CHF COPD on lasix 40\n at home,h/o Breast Ca and leisions in LUL, had VATS/Lobectomy on\n .\n .\n Neuro: Normal neuro exam. Intrathecal Morphine placed at 0728AM on\n . Chronic pain service following.\n CVS: Using vigileo to monitor hemodynamics but A-line very positional.\n Albumin 5% 250 bolus given.\n Pulm: Tolerating nasal cannula. CT on suction -20 cm of H2o ( air leak\n present). Monitor pneumothorax with daily CXR.\n GI: NPO\n FEN: LR at 50 cc/hr\n Renal: Monitor UO. Cr improving.\n Heme: Monitor HCT\n Endo: RISS, keep BS < 150\n ID: no active issues\n TLD: PIV, a line, L chest drain\n Wounds: L chest\n Imaging: CXR\n Prophylaxis: boots, famotidine\n Consults: Thoracics\n Code: Full- needs consent\n Disposition:SICU\n Chief complaint:\n PMHx:\n Current medications:\n 24 Hour Events:\n ARTERIAL LINE - START 11:00 PM\n EKG - At 12:03 AM\n Allergies:\n Ampicillin\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Flowsheet Data as of 06:31 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.7\nC (99.8\n T current: 37.3\nC (99.2\n HR: 95 (82 - 95) bpm\n BP: 76/59(65) {59/44(52) - 124/92(101)} mmHg\n RR: 9 (9 - 13) insp/min\n SPO2: 100%\n Heart rhythm: LBBB (Left Bundle Branch Block)\n Total In:\n 3,935 mL\n PO:\n 720 mL\n Tube feeding:\n IV Fluid:\n 2,715 mL\n Blood products:\n 500 mL\n Total out:\n 0 mL\n 748 mL\n Urine:\n 190 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 3,187 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SPO2: 100%\n ABG: 7.31/52/158/26/0\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Left Extremities: (Edema: Absent)\n Right Extremities: (Edema: Absent)\n Neurologic: Follows simple commands, Moves all extremities\n Labs / Radiology\n 286 K/uL\n 10.2 g/dL\n 174 mg/dL\n 1.5 mg/dL\n 26 mEq/L\n 4.4 mEq/L\n 19 mg/dL\n 105 mEq/L\n 141 mEq/L\n 31.5 %\n 17.1 K/uL\n [image002.jpg]\n 10:28 PM\n 11:28 PM\n 11:33 PM\n 02:43 AM\n WBC\n 15.5\n 17.1\n Hct\n 30.8\n 31.5\n Plt\n 262\n 286\n Creatinine\n 1.7\n 1.5\n Troponin T\n <0.01\n TCO2\n 28\n 27\n Glucose\n 185\n 172\n 168\n 174\n Other labs: CK / CK-MB / Troponin T:989/5/<0.01, Lactic Acid:1.9\n mmol/L, Ca:8.1 mg/dL, Mg:1.7 mg/dL, PO4:5.3 mg/dL\n Assessment and Plan\n LOBECTOMY OR WEDGE RESECTION, CARDIOMYOPATHY, OTHER\n Assessment and Plan:\n Neurologic:\n Cardiovascular:\n Pulmonary:\n Gastrointestinal / Abdomen:\n Nutrition:\n Renal:\n Hematology:\n Endocrine:\n Infectious Disease:\n Lines / Tubes / Drains:\n Wounds:\n Imaging:\n Fluids:\n Consults:\n Billing Diagnosis: Other: s/p L VATS surgery\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Arterial Line - 11:00 PM\n 18 Gauge - 11:00 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: ICU\n Total time spent:\n" }, { "category": "Nursing", "chartdate": "2152-07-08 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 684031, "text": "HPI:Ms. is a 70-year-old woman who is now 3 years\n status post right breast lumpectomy and sentinel node biopsy for\n Stage I breast cancer in . She was also treated with Femara\n and with whole breast radiation therapy which was completed in\n . During her fu/surveillance CT chest she was found to\n have LUL leision which has been increased in size upto from 10\n to 13 cms. Mediastinoscopy was done taht showed no malignancy. PET scan\n had no SUV. Therefore, she had VATS/wedge resection today histo path\n was performed that showed fibrotic and lymhoid element, no evidence of\n malignancy per prelim path. pt with LVEF=20% has been on Cardiac meds\n and lasix at home. Pt was extubated in PACU but hypotensive and\n oliguric.\n .\n PMH:\n Asthma, Diabetes, HTN, Nonischemic\n cardiomyopathy, Breast Cancer, COPD, unstable angina, right\n shoulder pain, EF 20%\n .\n PSH:Right arthroscopic shoulder surgery,\n right breast lumpectomy and sentinel lymph node biopsy.\n .\n EVENTS:\n : Admitted to SICU for post op monitoring due to hypotension and\n poor UO. Tolerating nasal cannula. Received albumin overnight and UO\n improved.\n .\n Lobectomy or wedge resection\n Assessment:\n Post-op day #1..c/o\n pain from CT inscision site. Wearing 3l\n nc..sats 95-98% rr20-30. CT changed to water seal..Draining\n serosanquinous fluid. DSD..\n Action:\n After multiple position changes, pt became very uncomfortable. Started\n morphine PCA..after 4hrs (total 5mgm) pt very sleepy, says her eyes\n are going\nbuggy\n in her head, has funny feeling iin head. Dc\nd PCA\n and changed her to percocett..states she has had this before. Given 1\n pill 1700\n Response:\n Pt less sleepy without the morphine. Pain is controlled at this time.\n Rr 20\ns..stable sats\n Is tolerating po liqs and solids. Urine output is good.\n Plan:\n Pt is ready for transfer to floor. Possible dc of CT tomorrow per\n thoracics team. Needs reminder to use spirometer. Encourge po,\n monitor u/o.\n" }, { "category": "Nursing", "chartdate": "2152-07-08 00:00:00.000", "description": "Nursing Progress Note", "row_id": 683876, "text": "70 y.o woman s/p left VATS and lobectomy. Hx of cardiomyopathy,\n diabetes- insulin dependent, EF approx 20%. In PACU, urine output\n decreased, Cr with slight bump 1.2. pCO2 ellevated post extubation in\n PACU. On CPAP briefly which decreased CO2 to around 50s. Then\n transferred to SICU for fluid status & respiratory management.\n Lobectomy or wedge resection\n Assessment:\n arrived from , alert, oriented. On 4L n.c. sats 98-100.\n CT to 20 cm dry wall suction. + fluctuation, + slight leak and negative\n crepitus.\n Dsg c/d/i. serosang output.\n LS rhoncherous, dim at bases.\n Action:\n close monitoring of respiratory status.\n IS use encouraged.\n unable to turn pt to left side d/t pain when lying on CT site.\n Response:\n CT site c/d/i. sats remain 98-100. nonproductive cough.\n Plan:\n Continue to closely monitor respiratory status. OOB to chair. D/w team\n ? transfer to floor.\n Cardiomyopathy, Other\n Assessment:\n LBBB, SBP 100-120s.\n min urine output most of the shift.\n Action:\n EKG done upon arrival from PACU. Enzymes sent.\n vigileo monitor attached, CO approx 4 and SVV with good aline\n tracing. A line very positional and not representing accurate CO/SVV\n numbers d/t very dampened waveform. Dr. at beside-\n attempted another a line unsuccessfully.\n Albumin given. Encouraged PO intake.\n Response:\n Pt\ns u/o increased to approx 25 ccs per hour after Albumin given.\n Plan:\n D/w team ? discontinuing of A line.\n Follow urine output. Encourage POs. provide comfort and support.\n" }, { "category": "Nursing", "chartdate": "2152-07-08 00:00:00.000", "description": "Nursing Progress Note", "row_id": 683866, "text": "70 y.o woman s/p left VATS and lobectomy. Hx of cardiomyopathy,\n diabetes- insulin dependent, EF approx 20%. In PACU, urine output\n decreased, Cr with slight bump 1.2. Transferred to SICU for fluid\n status management.\n" }, { "category": "ECG", "chartdate": "2152-07-06 00:00:00.000", "description": "Report", "row_id": 275034, "text": "Normal sinus rhythm. Left bundle-branch block. Compared to the previous\ntracing of no diagnostic interval change.\n\n" }, { "category": "ECG", "chartdate": "2152-07-05 00:00:00.000", "description": "Report", "row_id": 275273, "text": "Sinus rhythm. Left bundle-branch block. Since the previous tracing\nof there is no significant change.\n\n" }, { "category": "Radiology", "chartdate": "2152-07-10 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1086171, "text": " 3:40 PM\n CHEST (PA & LAT) Clip # \n Reason: chest tube removal assess for ptx\n Admitting Diagnosis: LUNG NODULE/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old woman s/p vats/wedge left\n REASON FOR THIS EXAMINATION:\n chest tube removal assess for ptx\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 70-year-old female, status post VATS. Chest tube removal, assess\n for pneumothorax.\n\n Single AP chest radiograph compared to shows removal of left\n apical chest tube with increased left upper lobe volume loss and new left-\n sided pneumothorax with apical and medial components. There is a small left-\n sided loculated pleural effusion. The heart remains moderately enlarged,\n unchanged. The mediastinal and hilar contours are normal. Extensive left\n chest subcutaneous emphysema is unchanged.\n\n IMPRESSION: Left upper lobe volume loss and new left-sided pneumothorax with\n apical and mediastinal component, status post removal of chest tube.\n\n" }, { "category": "Radiology", "chartdate": "2152-07-08 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1085872, "text": " 4:02 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for effusion/ptx\n Admitting Diagnosis: LUNG NODULE/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old woman s/p left vats and wedge resection, ct on sxn\n REASON FOR THIS EXAMINATION:\n eval for effusion/ptx\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 70-year-old woman with history of left VATS wedge resection.\n Chest tube on waterseal.\n\n CHEST, UPRIGHT AP: Comparison to the prior day. A left-sided chest tube is\n in unchanged position. Pneumothorax has essentially resolved, although there\n is persistent subcutaneous emphysema. There is no pleural effusion. Opacity\n projecting over the left heart border probably signifies minor residual\n atelectasis.\n\n" }, { "category": "Radiology", "chartdate": "2152-07-09 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1085993, "text": " 7:07 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please eval for interval prog. Please take film at 5am\n Admitting Diagnosis: LUNG NODULE/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old woman with h/o VATS, ptx.\n REASON FOR THIS EXAMINATION:\n please eval for interval prog. Please take film at 5am\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: AP chest, .\n\n HISTORY: 70-year-old woman with history of VATS procedure and possible\n pneumothorax.\n\n FINDINGS: Comparison is made to prior study from .\n\n There is again seen a left-sided chest tube. No pneumothorax is appreciated.\n There is a prominent amount of subcutaneous emphysema within the left chest\n wall. Lungs are grossly clear. Overall, there has been no change.\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2152-07-11 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1086239, "text": " 8:07 AM\n CHEST (PORTABLE AP) Clip # \n Reason: F/u PTX. Please take in AM .\n Admitting Diagnosis: LUNG NODULE/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old woman with post-pull ptx.\n REASON FOR THIS EXAMINATION:\n F/u PTX. Please take in AM .\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Followup of pneumothorax.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, the extent of the\n pre-existing pneumothorax on the left has not substantially changed. Also\n unchanged is the soft tissue air collection on the left. Minimal retrocardiac\n atelectasis, no signs indicative of tension, no newly appeared focal\n parenchymal opacities indicating pneumonia.\n\n\n" }, { "category": "Radiology", "chartdate": "2152-07-08 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1085929, "text": " 3:39 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: interval changes\n Admitting Diagnosis: LUNG NODULE/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old woman with chest tube\n REASON FOR THIS EXAMINATION:\n interval changes\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Chest tube.\n\n A single portable radiograph of the chest again demonstrates a left-sided\n chest tube, unchanged from the radiograph obtained 10 hours prior. Extensive\n subcutaneous emphysema predominantly over the left hemithorax is unchanged as\n well. Mild blunting of the left costophrenic angle persists. No pneumothorax\n is detected. The right lung is clear. The cardiomediastinal contours are\n unchanged. Overall, there is little interval change.\n\n\n" }, { "category": "Radiology", "chartdate": "2152-07-07 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1085748, "text": " 12:01 PM\n CHEST (PORTABLE AP) Clip # \n Reason: post op unexpected changes\n Admitting Diagnosis: LUNG NODULE/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old woman with sp VATS LUL wedge resection post op cxr\n REASON FOR THIS EXAMINATION:\n post op unexpected changes\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST RADIOGRAPH, \n\n COMPARISON: Radiograph of .\n\n INDICATION: Status post wedge resection procedure.\n\n FINDINGS: A left-sided chest tube terminates at the left lung apex, and a\n moderate to large loculated pneumothorax is present in the lower left lung as\n well as a large amount of subcutaneous emphysema within the adjacent left\n chest wall. Parenchymal opacification within the left upper and mid lung\n regions is probably related to recent VATS procedure. The heart remains\n enlarged. The right lung is clear.\n\n Presence of pneumothorax has been communicated by phone with Dr. .\n\n" } ]

[ { "category": "Radiology", "chartdate": "2128-04-22 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1181654, "text": " 3:18 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: FAST TRACK EXTUBATION CARDIAC SURGERY, ?line placement, r/o\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\CORONARY ARTERY BYPASS GRAFT: ? AVR /SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 49 year old woman s/p CABG x 3/MVR. Please at with\n abnormalities.\n REASON FOR THIS EXAMINATION:\n FAST TRACK EXTUBATION CARDIAC SURGERY, ?line placement, r/o PTX/Effuxion\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 49-year-old woman status post CABG and mitral valve replacement.\n Assess for pneumothorax and line placement.\n\n COMPARISON: Pre-operative chest radiograph on .\n\n SINGLE SUPINE PORTABLE CHEST RADIOGRAPH: The endotracheal tube terminates 3.7\n cm above the carina. The Swan-Ganz catheter via right IJ approach terminates\n in the right main pulmonary artery. A left-sided chest tube terminates in the\n lateral base. NG tube is seen in the stomach with the tip excluded from the\n radiograph. Two mediastinal drains terminate in the mid thoracic level.\n External cardiac pacers are noted in the left upper abdomen.\n\n The lungs are symmetric in volumes, but with mild hazy opacities, compatible\n with non-full expansion and/or mild pulmonary edema. There is no mediastinal\n shift, pneumothorax, pleural effusion or focal air-space consolidation.\n Multilevel median sternotomy wires are intact.\n\n IMPRESSION: No pneumothorax, pleural effusions, or acute surgical\n complications. Support devices in standard positions.\n\n" }, { "category": "Radiology", "chartdate": "2128-04-24 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1181891, "text": " 12:41 PM\n CHEST (PORTABLE AP) Clip # \n Reason: line\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\CORONARY ARTERY BYPASS GRAFT: ? AVR /SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 49 year old woman with assess line placement\n REASON FOR THIS EXAMINATION:\n line\n ______________________________________________________________________________\n FINAL REPORT\n CHEST X-RAY\n\n HISTORY: Line placement.\n\n One portable view. Comparison with the previous study done .\n Prominent interstitial markings consistent with mild edema persist. There is\n evidence of a right pleural effusion which may have increased. There is new\n subsegmental atelectasis at the left base. The patient is status post median\n sternotomy, CABG and MVR as before. Mediastinal structures are unchanged. An\n endotracheal tube, nasogastric tube, left chest tube, mediastinal drains and\n Swan-Ganz catheter have been withdrawn. A right internal jugular line has\n been placed, terminating at the cavoatrial junction.\n\n IMPRESSION: Line placement as described.\n\n\n" }, { "category": "Echo", "chartdate": "2128-04-22 00:00:00.000", "description": "Report", "row_id": 65735, "text": "PATIENT/TEST INFORMATION:\nIndication: coronary artery bypass grafting, mitral regurgitation\nHeight: (in) 65\nWeight (lb): 121\nBSA (m2): 1.60 m2\nBP (mm Hg): 140/70\nHR (bpm): 70\nStatus: Inpatient\nDate/Time: at 12:09\nTest: TEE (Congenital)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Dilated LA. No spontaneous echo contrast or thrombus in the\nLA/LAA or the RA/RAA.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. PFO is present. Left-to-right\nshunt across the interatrial septum at rest.\n\nLEFT VENTRICLE: Normal LV wall thickness and cavity size. Moderate-severe\nregional left ventricular systolic dysfunction. Moderately depressed LVEF.\nChordal remnants are present.\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: basal\ninferoseptal - akinetic; mid inferoseptal - hypo; basal inferior - hypo; mid\ninferior - hypo; inferior apex - hypo;\n\nRIGHT VENTRICLE: Dilated RV cavity. Mild global RV free wall hypokinesis.\n\nAORTA: Focal calcifications in aortic root. Normal ascending aorta diameter.\nSimple atheroma in ascending aorta. Normal aortic arch diameter. Normal\ndescending aorta diameter. Simple atheroma 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 to severe (3+)\nMR.\n\nTRICUSPID VALVE: Mild [1+] TR.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS.\nPhysiologic PR.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: A TEE was performed in the location listed above. I certify\nI was present in compliance with HCFA regulations. The patient was under\ngeneral anesthesia throughout the procedure. No TEE related complications. The\npatient appears to be in sinus rhythm. Results were personally reviewed with\nthe MD caring for the patient. See Conclusions for post-bypass data\n\nConclusions:\nPRE-BYPASS:\nThe left atrium is dilated. No spontaneous echo contrast or thrombus is seen\nin the body of the left atrium/left atrial appendage or the body of the right\natrium/right atrial appendage. A patent foramen ovale is present. A\nleft-to-right shunt across the interatrial septum is seen at rest.\nLeft ventricular wall thicknesses and cavity size are normal. There is\nmoderate to severe regional left ventricular systolic dysfunction with\nakinetic/aneurysmal basal inferior and basal inferoseptal walls. The mid and\napical inferior, inferoseptal walls are severe. Overall left ventricular\nsystolic function is moderately depressed (LVEF= 35% %).\n\nThe right ventricular cavity is dilated with mild global free wall\nhypokinesis.\n\nThere are simple atheroma in the ascending aorta. There is a ridge of\ncalcium/tissue in the ST junction, with a small mobile atheroma. This point\nseems to be cause of increased transaortic velocity of 1.7 m/sec, The velocity\nat the aortic valve seems normal. There are simple atheroma in the descending\nthoracic aorta.\n\nThe aortic valve leaflets (3) are mildly thickened but aortic stenosis is not\npresent. No aortic regurgitation is seen.\n\nThe mitral valve leaflets are mildly thickened. Moderate to severe (3+) mitral\ncentral regurgitation is seen. There is no prolapse or flail mitral leaflets.\nThe vena contract measures upto 6mm.\n\nThere is no pericardial effusion.\n\nDr. was notified in person of the results on before\nsurgical incision.\n\nPOST-BYPASS:\nPatient is on milrinone 0.25 mcg/kg/min and levophed 0.1 mcg/kg/min.\nMild global RV systolic function.\nThere is a mechanical prosthesis in the mitral position with gradients\nconsistent with the prosthesis and usual washing jets.\nMild TR.\nThe thoracic aorta is intact.\nOverall LVEF 35%.\n\n\n" }, { "category": "ECG", "chartdate": "2128-04-22 00:00:00.000", "description": "Report", "row_id": 139327, "text": "Sinus rhythm. Borderline low voltage in the limb leads. Delayed precordial\nR wave transition with possible old anterior myocardial infarction.\nIntraventricular conduction delay. Compared to the previous tracing of \nno change.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2128-04-27 00:00:00.000", "description": "Report", "row_id": 139325, "text": "Sinus rhythm. Atrial ectopy. Left bundle-branch block. Low voltage in the\nlimb leads. Compared to the previous tracing of atrial ectopy is new.\n\n" }, { "category": "ECG", "chartdate": "2128-04-22 00:00:00.000", "description": "Report", "row_id": 139326, "text": "Sinus rhythm. Intraventricular conduction delay. Possible old anterior\nmyocardial infarction. Borderline prolonged Q-T interval. Compared to the\nprevious tracing no definite change.\nTRACING #2\n\n" } ]

[ { "category": "Echo", "chartdate": "2146-10-07 00:00:00.000", "description": "Report", "row_id": 88541, "text": "PATIENT/TEST INFORMATION:\nIndication: Worsening shortness of breath. Metastatic melanoma and dyspnea.\nHeight: (in) 62\nWeight (lb): 150\nBSA (m2): 1.69 m2\nBP (mm Hg): 109/47\nHR (bpm): 82\nStatus: Outpatient\nDate/Time: at 14:53\nTest: TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Mild LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.\n\nLEFT VENTRICLE: Normal LV wall thickness, cavity size and regional/global\nsystolic function (LVEF >55%). TDI E/e' >15, suggesting PCWP>18mmHg. No\nresting LVOT gradient.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic diameter at the sinus level. Normal ascending aorta\ndiameter.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. Trace AR.\n\nMITRAL VALVE: Moderately thickened mitral valve leaflets. Mild mitral annular\ncalcification. Trivial MR.\n\nTRICUSPID VALVE: Mild [1+] TR. Mild PA systolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS.\nPhysiologic PR.\n\nPERICARDIUM: No pericardial effusion.\n\nConclusions:\nThe left atrium is mildly dilated. Left ventricular wall thickness, cavity\nsize and regional/global systolic function are normal (LVEF >55%). Tissue\nDoppler imaging suggests an increased left ventricular filling pressure\n(PCWP>18mmHg). Right ventricular chamber size and free wall motion are normal.\nThe aortic valve leaflets (3) are mildly thickened but aortic stenosis is not\npresent. Trace aortic regurgitation is seen. The mitral valve leaflets are\nmoderately thickened. Trivial mitral regurgitation is seen. There is mild\npulmonary artery systolic hypertension. There is no pericardial effusion.\n\nIMPRESSION: Normal global and regional biventricular systolic function.\nElevated LV filling pressures and mild pulmonary hypertension.\n\n\n" }, { "category": "Radiology", "chartdate": "2146-10-06 00:00:00.000", "description": "CTA CHEST W&W/O C&RECONS, NON-CORONARY", "row_id": 1207449, "text": " 9:56 PM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \n Reason: eval for PE\n Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old woman with metastatic melanoma with dyspnea, tachycardia,\n tachypneia, fevers\n REASON FOR THIS EXAMINATION:\n eval for PE\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: 11:15 PM\n 1. no PE or acute aortic syndrome.\n 2. clear lungs.\n 3. no pericardial/pleural effusion.\n 4. multiple hepatic mets and 3.5 x 2.5 cm L adrenal met.\n WET READ VERSION #1\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 78-year-old female with metastatic melanoma, now with dyspnea,\n tachycardia and tachypnea.\n\n STUDY: Chest CT; MDCT images were generated through the chest without IV\n contrast. Subsequent MDCT images were generated through the chest after\n administration of 100 mL of Optiray intravenous contrast without adverse\n reaction or complication in the pulmonary arterial phase. Coronal, sagittal,\n and right and left oblique reformatted images were also generated.\n\n COMPARISON: PET-CT from .\n\n FINDINGS: The visualized portion of the thyroid appears unremarkable.\n Prominent lymph nodes are seen in the axilla bilaterally measuring 9 mm in the\n right axilla (3:17) and 8 mm in the left axilla (3:31). The previously\n described paratracheal lymph nodes are not well visualized on this exam.\n\n The aorta is of a normal caliber along its course without evidence of\n dissection or intramural hematoma. Calcified atherosclerotic disease is seen\n in scattered areas along the arch and descending aorta. The pulmonary\n arterial trunk is of normal caliber. There are no filling defects down the\n subsegmental level. Evaluation of the lungs is somewhat suboptimal due to\n motion artifact. An area of linear scarring and nodularity along the\n perifissural aspect of the right pleura may represent an area of scarring.\n Otherwise, the lungs are clear. There is no pleural or pericardial effusion.\n\n Below the diaphragm, multiple hepatic hypodensities are compatible with\n metastases. Additionally, the left adrenal gland shows a 39 x 28 mm mass,\n which in the setting of melanoma also likely represents metastatic lesion.\n\n No aggressive-appearing osseous lesion is seen.\n\n IMPRESSION:\n 1. No evidence of PE or acute aortic syndrome.\n (Over)\n\n 9:56 PM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \n Reason: eval for PE\n Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n 2. No pulmonary consolidation with scarring along the right lateral lung.\n 3. No pericardial or pleural effusion.\n 4. Metastatic disease of the liver and left adrenal gland as described above.\n\n\n" }, { "category": "Radiology", "chartdate": "2146-10-06 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1207444, "text": " 8:45 PM\n CHEST (PORTABLE AP) Clip # \n Reason: pls eval ro acute process\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old woman with shortness of breath\n REASON FOR THIS EXAMINATION:\n pls eval ro acute process\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 78-year-old female with shortness of breath.\n\n STUDY: Portable AP upright chest radiograph.\n\n COMPARISON: None.\n\n FINDINGS: The heart size is within normal limits. The mediastinal contours\n demonstrate calcified atherosclerotic disease of the aortic knob and\n descending aorta. The lungs appear clear without evidence of lobar\n consolidation, masses, or edema. There is no large pleural effusion or\n pneumothorax. Bony irregularity of the left humeral head likely reflects\n sequela of prior trauma.\n\n IMPRESSION: No acute cardiopulmonary process.\n SESHa\n\n" }, { "category": "Radiology", "chartdate": "2146-10-08 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1207634, "text": " 5:05 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for acute process\n Admitting Diagnosis: URINARY TRACT INFECTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old woman with MDS and dyspnea\n REASON FOR THIS EXAMINATION:\n eval for acute process\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Dyspnea, myelodysplastic syndrome.\n\n CHEST:\n\n Comparison is made with the prior chest x-ray of . New opacities\n are seen in the left lower lobe with a left effusion. This was not present on\n the previous chest x-ray or the CT of and represents a new\n finding. This may represent an area of aspiration pneumonia.\n\n There appears to be some perihilar edema and some mild failure may also be\n present.\n\n IMPRESSION: New onset left lower lobe opacities with effusion. Possible\n aspiration pneumonia.\n\n\n" }, { "category": "ECG", "chartdate": "2146-10-07 00:00:00.000", "description": "Report", "row_id": 230960, "text": "Sinus rhythm. Short P-R interval without other signs of pre-excitation.\nLow QRS voltage in the precordial leads. Compared to the previous tracing\nof sinus tachycardia is absent.\n\n" }, { "category": "ECG", "chartdate": "2146-10-06 00:00:00.000", "description": "Report", "row_id": 230961, "text": "Sinus tachycardia. Otherwise, normal tracing. No previous tracing available\nfor comparison.\n\n" } ]

[ { "category": "Radiology", "chartdate": "2125-07-19 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1195327, "text": " 2:43 PM\n CHEST (PORTABLE AP) Clip # \n Reason: please eval for infiltrate/effusion\n Admitting Diagnosis: COLITIS;BILE LEAK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 41 year old woman with h/o cholecystitis s/p ERCP, w/ tachypnea, fevers\n REASON FOR THIS EXAMINATION:\n please eval for infiltrate/effusion\n ______________________________________________________________________________\n FINAL REPORT\n TYPE OF EXAMINATION: Chest AP portable single view.\n\n INDICATION: 41-year-old female patient with history of cholecystitis status\n post ERCP, now with tachypnea, and fevers. Evaluate for infiltrate or\n effusion.\n\n FINDINGS: AP single view of the chest was obtained with patient in sitting\n semi-upright position. The heart size is at the upper limit of normal\n variation. No typical configurational abnormalities identified, however,\n prominence of the left upper cardiac contour is suggestive of distention of\n the main pulmonary artery. The pulmonary vasculature is plethoric but there\n is no evidence of interstitial or alveolar edema. The lateral pleural sinus\n remained free. No conclusive evidence for acute parenchymal infiltrates. Our\n records do not include a previous chest examination available for comparison.\n\n IMPRESSION: The radiographically seen increased pulmonary vascular pattern is\n compatible with perioperative fluid overload. No evidence of acute venous\n congestion or pleural effusion and no pneumothorax. NG tube is seen to reach\n far below the diaphragm with its tip pointing into the region of the duodenum.\n\n A right internal jugular central venous line terminates overlying the\n right-sided mediastinum terminating just above the expected entrance into the\n right atrium.\n\n IMPRESSION: Increased pulmonary vascular pattern most likely representing\n perioperative fluid overload.As no previous chest examination is available for\n comparison, consider followup examination within a few days.\n\n" }, { "category": "Radiology", "chartdate": "2125-07-19 00:00:00.000", "description": "PORTABLE ABDOMEN", "row_id": 1195328, "text": " 2:43 PM\n PORTABLE ABDOMEN Clip # \n Reason: please eval for acute abdominal process\n Admitting Diagnosis: COLITIS;BILE LEAK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 41 year old woman with h/o cholecystitis s/p ERCP, w/ tachypnea, fevers, abd\n distention\n REASON FOR THIS EXAMINATION:\n please eval for acute abdominal process\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): 4:41 PM\n Non-obstructive bowel gas pattern.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 41-year-old woman with history of cholecystitis, status post\n ERCP, with tachypnea, fevers, and abdominal distention.\n\n COMPARISON: None.\n\n PORTABLE ABDOMINAL RADIOGRAPH: Single frontal view of the abdomen\n demonstrates nonobstructive bowel gas . Cholecystectomy clips are seen\n in the right upper quadrant. A feeding tube is noted with tip in the expected\n region of the stomach. A biliary stent is noted.\n\n IMPRESSION: Non-obstructive bowel gas pattern.\n\n" }, { "category": "Radiology", "chartdate": "2125-07-20 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1195403, "text": " 7:56 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? venous congestion\n Admitting Diagnosis: COLITIS;BILE LEAK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 41 year old woman with worsening hypoxia\n REASON FOR THIS EXAMINATION:\n ? venous congestion\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 41-year-old female with worsening hypoxia. Evaluate for venous\n congestion.\n\n COMPARISON: .\n\n AP UPRIGHT VIEW OF THE CHEST: Right-sided central venous catheter follows a\n normal course terminating in the distal SVC. Increased pulmonary vascular\n congestion and interstitial opacity suggest worsening edema. However, new\n confluent opacity in the right mid lung suggests concurrent developing\n infection. No large effusion or pneumothorax is present. The\n cardiomediastinal silhouette is stable.\n\n IMPRESSION: Increased pulmonary edema with developing opacity in the right mid\n lung suggests concurrent infection.\n\n Findings discussed with Dr. by phone at 10:45 am on .\n\n" }, { "category": "Radiology", "chartdate": "2125-07-19 00:00:00.000", "description": "PORTABLE ABDOMEN", "row_id": 1195329, "text": ", J. SICU-B 2:43 PM\n PORTABLE ABDOMEN Clip # \n Reason: please eval for acute abdominal process\n Admitting Diagnosis: COLITIS;BILE LEAK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 41 year old woman with h/o cholecystitis s/p ERCP, w/ tachypnea, fevers, abd\n distention\n REASON FOR THIS EXAMINATION:\n please eval for acute abdominal process\n ______________________________________________________________________________\n PFI REPORT\n Non-obstructive bowel gas pattern.\n\n" }, { "category": "Radiology", "chartdate": "2125-07-20 00:00:00.000", "description": "ABDOMEN U.S. (COMPLETE STUDY)", "row_id": 1195419, "text": " 9:18 AM\n ABDOMEN U.S. (COMPLETE STUDY) Clip # \n Reason: Suspected peri-colic gutter bile leak.\n Admitting Diagnosis: COLITIS;BILE LEAK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 41 year old woman s/p cholecystectomy with fevers and RUQ pain.\n REASON FOR THIS EXAMINATION:\n Suspected peri-colic gutter bile leak.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 41-year-old status post cholecystectomy on with fever and\n right upper quadrant pain. Suspect paracolic bile leak.\n\n COMPARISON: CT of abdomen, .\n\n ABDOMINAL ULTRASOUND: The liver is normal in echotexture. There are no focal\n hepatic lesions. No biliary dilation. The common duct measures 6 mm. The\n portal vein is patent with antegrade flow. The gallbladder has been removed\n and there is a small oblong collection within the gallbladder fossa which has\n decreased in size compared to ultrasound from , now measures 2.7\n x 1.6 x 1.3 cm, previously 5.1 x 1.2 x 1.5 cm. There is no additional free\n fluid seen in the lower quadrants. There are bilateral pleural effusions,\n right greater than left. The spleen is mildly enlarged measuring 12.8 cm.\n The right kidney measures 12.7 cm and left kidney measures 12.4 cm, with no\n hydronephrosis, masses or stones. The pancreatic head and body are normal,\n though the tail is not visualized due to overlying bowel gas.\n\n IMPRESSION:\n 1. Small collection in the gallbladder fossa, which has decreased in size\n compared to ultrasound . No free fluid within the abdomen.\n\n 2. Moderate pleural effusions, right greater than left.\n\n" }, { "category": "ECG", "chartdate": "2125-07-19 00:00:00.000", "description": "Report", "row_id": 249669, "text": "Baseline artifact. Supraventricular tachycardia, possibly sinus or atrial\nflutter with 2:1 block. Non-diagnostic inferior and lateral precordial\nQ waves. ST-T wave abnormalities. No previous tracing available for\ncomparison. Clinical correlation and repeat tracing are suggested.\n\n" } ]

[ { "category": "Radiology", "chartdate": "2153-10-19 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1207613, "text": " 9:18 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: concern for evolution of left sdh\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 87 year old woman with syncopal episode resulting in diffuse SAH, new left SDH\n noted on CT \n REASON FOR THIS EXAMINATION:\n concern for evolution of left sdh\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): AJy FRI 11:52 PM\n PFI: No change in intracranial hemorrhage. In particular, the thin left\n subdural hematoma newly noted on prior study is stable. Hyperdense\n opacification of the right maxillary sinus, suggesting hemorrhage, with\n suspected associated fracture is unchanged.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 87-year-old female with intracranial hemorrhage. Prior CT\n demonstrated a new left subdural hematoma. Evaluate for interval change.\n\n COMPARISON: Multiple prior studies, most recently CT of the head , at 1202.\n\n NON-CONTRAST HEAD CT:\n\n Multifocal, multicompartment intracranial hemorrhage is redemonstrated. Right\n frontal and left temporoparietal intraparenchymal hematomas, with associated\n vasogenic edema and local mass effect, are unchanged. Similarly, diffuse\n scattered subarachnoid hemorrhage seen over the bilateral cerebral convexities\n and within the right posterior fossa are unchanged in extent and distribution.\n Lastly, the thin left-sided subdural hematoma newly noted on the prior\n examination is unchanged, again measuring no more than 3 mm from the inner\n table.\n\n There is no new focus of intracranial hemorrhage identified. Basal cisterns\n remain patent, and there is again no shift of the midline structures. The\n ventricles are unchanged in size, with no hydrocephalus. There is no CT\n evidence of territorial infarct. Cavernous carotid and verterbal vascular\n calcifications are redemonstrated.\n\n Hyperdense opacification of the right maxillary sinus, likely hemorrhage, with\n suspected associated fracture is again noted, incompletely imaged. The\n remainder of the paranasal sinuses and mastoid air cells remain clear.\n\n IMPRESSION:\n\n 1. No interval change in multifocal multicompartment intracranial hemorrhage\n compared to . In particular, a diffuse though thin left\n subdural hematoma newly noted on the prior study is stable.\n\n 2. Redemonstration of hyperdense opacification of the right maxillary sinus,\n (Over)\n\n 9:18 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: concern for evolution of left sdh\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n with suspected associated fracture, incompletely imaged. D/w K.\n Neurosurgery NP on by Dr..\n\n" }, { "category": "Radiology", "chartdate": "2153-10-19 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1207614, "text": ", M. NSURG FA11 9:18 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: concern for evolution of left sdh\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 87 year old woman with syncopal episode resulting in diffuse SAH, new left SDH\n noted on CT \n REASON FOR THIS EXAMINATION:\n concern for evolution of left sdh\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n PFI: No change in intracranial hemorrhage. In particular, the thin left\n subdural hematoma newly noted on prior study is stable. Hyperdense\n opacification of the right maxillary sinus, suggesting hemorrhage, with\n suspected associated fracture is unchanged.\n\n" }, { "category": "Radiology", "chartdate": "2153-10-16 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1207053, "text": " 10:52 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: 87 year old woman with traumatic SAH and IPH on coumadin, af\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 87 year old woman with traumatic SAH and IPH on coumadin, after syncopal\n episode. Eval for interval changes\n REASON FOR THIS EXAMINATION:\n 87 year old woman with traumatic SAH and IPH on coumadin, after syncopal\n episode. Eval for interval changes\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: AJy WED 12:41 AM\n Interval increase in size of left frontal intraparenchymal hematoma with\n increase in associated edema and local mass effect. Small right\n temporoparietal intraparenchymal hematoma is newly noted. Subarachnoid blood\n is little changed. No evidence of herniation.\n\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 87 year old woman with traumatic SAH and IPH on coumadin, after\n syncopal episode. Eval for interval changes.\n\n COMPARISON: NECT ( hrs, ), roughly\n 4.5 hours earlier.\n\n NON-CONTRAST HEAD CT:\n\n There is multicompartmental intracranial hemorrhage, as before. A left\n frontal parechymal hematoma measures 2.1 x 3.4 cm, increased from prior study\n when it measured 1.6 x 2.3 cm. There is also increased adjacent vasogenic\n edema. There is local mass effect upon the overlying sulci but no shift of\n midline structures or central herniation. A second focus of intraparenchymal\n blood in the right temporoparietal region overlying the tentorium is also\n larger, with more surrounding edema (2:11). Scattered multifocal subarachnoid\n hemorrhage, bilaterally, including the posterior fossa, is little changed.\n There is no epidural or subdural collection. A 10 mm calcified dural-based\n extraaxial lesion in the right frontal region likely represents a meningioma.\n There is no CT evidence of acute territorial infarct. Carotid vascular\n calcifications are noted. The paranasal sinuses and mastoid air cells are\n clear. There is no fracture.\n\n IMPRESSION:\n\n Interval increase in size of left frontal parenchymal hematoma with increase\n in associated edema and local mass effect. Small right temporoparietal\n intraparenchymal hematoma is also larger, while diffuse multifocal\n subarachnoid blood is little changed. No evidence of central herniation.\n\n\n\n (Over)\n\n 10:52 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: 87 year old woman with traumatic SAH and IPH on coumadin, af\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2153-10-17 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1207226, "text": " 8:32 PM\n CT HEAD W/O CONTRAST; -77 BY DIFFERENT PHYSICIAN # \n Reason: repeat CT at for ? worsening SAH.\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 87yoF s/p SAH while on Coumadin with INR 3.3.\n REASON FOR THIS EXAMINATION:\n repeat CT at for ? worsening SAH.\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): AJy WED 10:26 PM\n PFI: No change from 0519 hours. No new or increased intracranial hemorrhage.\n Stable associated edema and local mass effect. No midline shift or central\n herniation.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Evaluate for interval change in subarachnoid hemorrhage. The\n patient is on Coumadin with INR of 3.3.\n\n COMPARISON: at 0519 hours.\n\n NON-CONTRAST HEAD CT: Left frontalmoderate sized and right temporoparietal\n small intraparenchymal hematomas are unchanged in size compared to prior\n study. Associated vasogenic edema is also little changed. There is resultant\n local mass effect, without midline shift or evidence of central herniation.\n\n Volume and distribution of subarachnoid hemorrhage, seen diffusely over both\n the right and left hemispheres as well as in the posterior fossa, is also\n essentially unchanged from prior study. Areas of subdural hemorrhage along\n the right side of the posterior fossa are unchanged. There is no new\n intracranial hemorrhage identified.\n\n Ventricles remain unchanged in size, the basal cisterns are patent. There are\n no new extra-axial fluid collections. Visualized paranasal sinuses and\n mastoids remain well aerated. Cavernous carotid and vertebral artery vascular\n calcifications are noted. A slightly dense focus in the antero-inferior pons\n is of equivocal significance. ( se 2, im 5)\n S/p ocular surgery- bil.\n\n IMPRESSION: No change from study performed earlier the same day. No new or\n increase in the previously existent multicompartmental intracranial\n hemorrhage. Followup as clinically indicated.\n\n" }, { "category": "Radiology", "chartdate": "2153-10-17 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1207227, "text": ", M. NSURG FA11 8:32 PM\n CT HEAD W/O CONTRAST; -77 BY DIFFERENT PHYSICIAN # \n Reason: repeat CT at for ? worsening SAH.\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 87yoF s/p SAH while on Coumadin with INR 3.3.\n REASON FOR THIS EXAMINATION:\n repeat CT at for ? worsening SAH.\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n PFI: No change from 0519 hours. No new or increased intracranial hemorrhage.\n Stable associated edema and local mass effect. No midline shift or central\n herniation.\n\n" }, { "category": "Echo", "chartdate": "2153-10-18 00:00:00.000", "description": "Report", "row_id": 91583, "text": "PATIENT/TEST INFORMATION:\nIndication: Atrial fibrillation. Cerebrovascular event/TIA.\nHeight: (in) 63\nWeight (lb): 183\nBSA (m2): 1.86 m2\nBP (mm Hg): 147/47\nHR (bpm): 89\nStatus: Inpatient\nDate/Time: at 10:47\nTest: TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Elongated LA.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA.\n\nLEFT VENTRICLE: Mild symmetric LVH with normal cavity size and regional/global\nsystolic function (LVEF>55%).\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic diameter at the sinus level. Normal ascending aorta\ndiameter.\n\nAORTIC VALVE: Three aortic valve leaflets. Moderately thickened aortic valve\nleaflets. Mild AS (area 1.2-1.9cm2). Trace AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. Calcified tips\nof papillary muscles. Trivial MR.\n\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Physiologic TR.\nMild PA systolic hypertension.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows. Suboptimal\nimage quality as the patient was difficult to position. Suboptimal image\nquality - patient unable to cooperate. The patient appears to be in sinus\nrhythm.\n\nConclusions:\nThe left atrium is elongated. There is mild symmetric left ventricular\nhypertrophy with normal cavity size and regional/global systolic function\n(LVEF>55%). Right ventricular chamber size and free wall motion are normal.\nThere are three aortic valve leaflets. The aortic valve leaflets are\nmoderately thickened. There is mild aortic valve stenosis (valve area\n1.2-1.9cm2). Trace aortic regurgitation is seen. The mitral valve leaflets are\nmildly thickened. There is no mitral valve prolapse. Trivial mitral\nregurgitation is seen. The tricuspid valve leaflets are mildly thickened.\nThere is mild pulmonary artery systolic hypertension. There is no pericardial\neffusion.\n\nIMPRESSION: Mild symmetric left ventricular hypertrophy with preserved global\nand regional biventricular systolic function. Mild calcific aortic stenosis.\nMild pulmonary artery systolic hypertension.\n\n\n" }, { "category": "Radiology", "chartdate": "2153-10-17 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1207081, "text": " 5:19 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: interval change\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 87 year old woman with SAH/L front contusion\n REASON FOR THIS EXAMINATION:\n interval change\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: PBec WED 8:00 AM\n stable exam. pbishop\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Patient with known subarachnoid hemorrhage, left frontal\n contusion. Please evaluate for interval change.\n\n COMPARISON: Comparison is made to head CT performed , some\n 6 hrs earlier.\n\n TECHNIQUE: Non-contrast axial images were obtained through the brain.\n Coronal and sagittal reformations were provided.\n\n FINDINGS: Overall the exam is stable. The left frontal parenchymal\n hemorrhage with associated edema and local mass effect is unchanged in size\n and configuration. The small right temporoparietal parenchymal hemorrhage is\n also stable. The volume and distribution of the subarachnoid hemorrhage\n overlying the right cerebral convexity, the left frontal lobe and the right\n cerebellar hemisphere are unchanged. The ventricles and quadrigeminal cistern\n are unremarkable. There is slight stable effacement of the right suprasellar\n cistern. No fracture is identified. The mastoid air cells, middle ear\n cavities and paranasal sinuses are clear. No significant soft tissue swelling\n noted.\n\n IMPRESSION: Stable examination, with no new hemorrhage, edema or central\n herniation.\n\n" }, { "category": "Radiology", "chartdate": "2153-10-17 00:00:00.000", "description": "CAROTID SERIES COMPLETE", "row_id": 1207120, "text": " 10:22 AM\n CAROTID SERIES COMPLETE Clip # \n Reason: 87yo woman with PMH afib who presented with SDH after syncop\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 87yo woman with PMH afib who presented with SDH after syncopal episode. eval\n for abnormality\n REASON FOR THIS EXAMINATION:\n 87yo woman with PMH afib who presented with SDH after syncopal episode. eval\n for abnormality\n ______________________________________________________________________________\n FINAL REPORT\n\n Standard Report Carotid US\n\n Study: Carotid Series Complete\n\n Reason: 87 year old woman with SDH after syncopal episode.\n\n Findings: Duplex evaluation was performed of bilateral carotid arteries. On\n the right there is mild heterogeneous plaque in the ICA. On the left there is\n a tiny heterogeneous plaque seen in the ICA.\n\n On the right systolic/end diastolic velocities of the ICA proximal, mid and\n distal respectively are 80/19, 90/24, 105/25, cm/sec. CCA peak systolic\n velocity is 92 cm/sec. ECA peak systolic velocity is 134 cm/sec. The ICA/CCA\n ratio is 1.1. These findings are consistent with <40% stenosis.\n\n On the left systolic/end diastolic velocities of the ICA proximal, mid and\n distal respectively are 94/16, 93/20, 88/20, cm/sec. CCA peak systolic\n velocity is 95 cm/sec. ECA peak systolic velocity is 185 cm/sec. The ICA/CCA\n ratio is .98 . These findings are consistent with no stenosis.\n\n Right antegrade vertebral artery flow.\n Left antegrade vertebral artery flow.\n\n Impression: Right ICA <40% stenosis.\n Left ICA no stenosis.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2153-10-18 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1207323, "text": " 11:22 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: Patient with known IPH and SAH s/p fall off comode striking\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 87 year old woman with left frontal IPH and SAH\n REASON FOR THIS EXAMINATION:\n Patient with known IPH and SAH s/p fall off comode striking head\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): 6:05 PM\n PFI:\n\n 1. New small left occipital subdural hematoma.\n\n 2. No change in intraparenchymal hematomas and scattered subarachnoid\n hemorrhages.\n\n These findings were discussed with Dr. at 1500 on by\n telephone.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Left frontal intraparenchymal and subarachnoid hemorrhages, status\n post fall off of commode and head trauma.\n\n COMPARISONS: CT of the head without contrast from at 2036\n hours.\n\n TECHNIQUE: Contiguous axial sections of the brain without IV contrast.\n\n FINDINGS: There is a new left sided subdural hematoma, which measures 3.1 mm\n in greatest depth in the frontal, parietal and occipital regions. There is\n only local sulcal effacement. Again seen is a moderate-sized left frontal and\n small right temporoparietal intraparenchymal hematomas which are unchanged in\n size compared to prior. Distribution of the multiple foci of subarachnoid\n hemorrhages throughout the right and left hemispheres is unchanged. There is\n no shift of midline structures and the basilar cisterns are not compressed.\n There is dense opacification of the right maxillary sinus, not seen on the\n prior study; a small fracture fragment is noted involving the anterior\n portion of the right maxilla, incompletely imaged. Again noted are carotid\n and vertebral artery calcifications.\n\n IMPRESSION:\n\n 1. New left sided subdural hematoma along the convexity and left occipital\n region.\n\n 2. No change in intraparenchymal hematomas and scattered subarachnoid\n hemorrhages.\n These findings were discussed with Dr. at 1500 on by\n telephone.\n\n (Over)\n\n 11:22 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: Patient with known IPH and SAH s/p fall off comode striking\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n 3. Small amount of dense material in the right maxillary sinus likely from\n hemorrhage, not seen on prior studies; a small fracture fragment in the\n anterior aspect of maxilla- needs dedicated imaging with CT Sinus/facial\n bones. Pending d/w the req. doctor.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2153-10-18 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1207324, "text": ", M. NSURG FA11 11:22 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: Patient with known IPH and SAH s/p fall off comode striking\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 87 year old woman with left frontal IPH and SAH\n REASON FOR THIS EXAMINATION:\n Patient with known IPH and SAH s/p fall off comode striking head\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n PFI:\n\n 1. New small left occipital subdural hematoma.\n\n 2. No change in intraparenchymal hematomas and scattered subarachnoid\n hemorrhages.\n\n These findings were discussed with Dr. at 1500 on by\n telephone.\n\n" }, { "category": "ECG", "chartdate": "2153-10-19 00:00:00.000", "description": "Report", "row_id": 248591, "text": "Artifact is present. Sinus rhythm. Non-specific ST-T wave changes. Compared to\nthe previous tracing of inferior Q waves are less apparent.\n\n" }, { "category": "ECG", "chartdate": "2153-10-16 00:00:00.000", "description": "Report", "row_id": 248592, "text": "Normal sinus rhythm. Q wave in leads III and aVF. Mild baseline artifact.\nSlight non-specific ST segment changes. No previous tracing available for\ncomparison.\n\n" } ]

[ { "category": "Radiology", "chartdate": "2185-03-08 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 999830, "text": " 6:48 PM\n CHEST (PA & LAT) Clip # \n Reason: eval for CHF\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 25 year old man with hx IVDU, p/w new cardiomyopathy\n REASON FOR THIS EXAMINATION:\n eval for CHF\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 25-year-old man with history of IV drug use, presents with new\n cardiomyopathy. Evaluate for CHF.\n\n COMPARISON: None.\n\n FRONTAL AND LATERAL CHEST RADIOGRAPHS: Cardiac silhouette appears slightly\n enlarged. Mediastinal contour is unremarkable. Diffuse increased\n interstitial pattern is seen throughout the lungs bilaterally, consistent with\n CHF. There are small bilateral pleural effusions. No definite focal\n consolidation identified.\n\n IMPRESSION: Findings most consistent with cardiomegaly and CHF; however,\n followup imaging following diuresis is recommended to exclude underlying\n infectious process.\n\n" }, { "category": "Radiology", "chartdate": "2185-03-10 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1000029, "text": " 12:20 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ?fever; pls page with wet read\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 25 year old man with endocarditis, new fever\n REASON FOR THIS EXAMINATION:\n ?fever; pls page with wet read\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: 25-year-old man with endocarditis and new fever.\n\n CHEST, AP UPRIGHT: Comparison is made to two days earlier. The cardiac and\n mediastinal contours are unchanged with borderline cardiomegaly again noted.\n There has been marked interval improvement in pulmonary edema, leaving only\n mild residual interstitial edema. There is no focal consolidation. Small\n bilateral pleural effusions are again present.\n\n IMPRESSION: Resolving pulmonary edema. No evidence of pneumonia.\n\n\n" }, { "category": "Radiology", "chartdate": "2185-03-13 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1000573, "text": " 4:16 PM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate for RUL collapse, infiltrate\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 25 year old man pod 1 s/p aortic homograft and arch replacement\n REASON FOR THIS EXAMINATION:\n evaluate for RUL collapse, infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE AP PORTABLE VIEW OF THE CHEST.\n\n REASON FOR EXAM: SP aortic on the left and arch replacement.\n\n Comparison is made with the prior study performed a day earlier.\n\n The patient has been extubated. There are low lung volumes, which account for\n the increase in the cardiac silhouette, which is mildly enlarged. Right\n transvenous pacemaker lead terminating in the standard position in the right\n ventricle. Right IJ catheter sheath tip is in the proximal SVC. There is no\n pneumothorax. Right pleural effusion is small. Bilateral bibasilar\n atelectases are unchanged. Right upper lobe ill-defined opacity described in\n prior study is less conspicuous. There is no right upper lobe collapse. There\n has been resolution of mild interstitial pulmonary edema. No other interval\n changes.\n\n DR. \n" }, { "category": "Radiology", "chartdate": "2185-03-15 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1000787, "text": " 12:30 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: please check placementl ceph picc (51 cm) call beeper \n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 25 year old man with\n REASON FOR THIS EXAMINATION:\n please check placementl ceph picc (51 cm) call beeper with read asap\n thanks\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post PICC.\n\n COMPARISON: Multiple priors, most recent from .\n\n AP PORTABLE CHEST: The tip of a left PICC terminates at the cavoatrial\n junction. There is a right chest wall pacemaker generator with a single\n intact lead projecting over the right atrium. Median sternotomy wires and\n epicardial pacer leads are unchanged in position. Mild cardiomegaly is\n stable. Pneumopericardium is again noted. A tiny right apical pneumothorax\n persists. There is improving left retrocardiac opacity consistent with\n resolving atelectasis. Right lower lobe atelectasis remains stable. Small\n bilateral pleural effusions, greater on the right, are without change.\n\n IMPRESSION: Improving left basilar atelectasis. Otherwise no significant\n interval change.\n\n\n DL\n\n" }, { "category": "Radiology", "chartdate": "2185-03-14 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1000643, "text": " 11:28 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for pneumo\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 25M s/p AVR/ascending aortic homograft for endocarditis s/p CT removal\n REASON FOR THIS EXAMINATION:\n eval for pneumo\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE AP PORTABLE VIEW OF THE CHEST\n\n REASON FOR EXAM: Evaluate for pneumothorax, patient S/P AVR ascending aortic\n homograft and chest tube removal.\n\n Comparison is made with prior study performed a day earlier.\n\n There is a tiny right apical pneumothorax. Pneumopericardium is again noted.\n Cardiomegaly is stable. Small bilateral pleural effusions, greater on the\n right side, are unchanged. The left lower lobe retrocardiac opacity is\n persistent consistent with atelectasis. Improved fluid overload. Right lower\n lobe atelectasis has worsened from , stable from . There\n are no other changes.\n\n jr\n\n DR. \n" }, { "category": "Radiology", "chartdate": "2185-03-11 00:00:00.000", "description": "CTA ABD W&W/O C & RECONS", "row_id": 1000296, "text": " 10:31 AM\n CTA ABD W&W/O C & RECONS; CTA PELVIS W&W/O C & RECONS Clip # \n Reason: Please assess for emboli\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 25 year old man with 25 year old man hx IV drug use with new endocarditis,\n aortic valve vegetations, profound aortic insufficiency.\n REASON FOR THIS EXAMINATION:\n Please assess for emboli\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: History of IV drug use with new endocarditis, and aortic valve\n vegetation. Assess for emboli.\n\n There are no prior studies for comparison.\n\n TECHNIQUE: Contiguous axial images through the abdomen and pelvis were\n obtained without IV contrast. Subsequently, following the administration of\n 150 cc of Optiray, contiguous axial images through the abdomen and pelvis were\n obtained during arterial and portal venous phase. Coronal and sagittal\n reformatted images were generated.\n\n CTA OF THE ABDOMEN: The abdominal aorta is normal in caliber, and the\n proximal celiac, SMA, renal arteries, and are patent. Two left renal\n arteries arise from the aorta.\n\n CT OF THE ABDOMEN WITHOUT AND WITH CONTRAST: There is a small right pleural\n effusion, simple in attenuation and trace left pleural fluid, also simple in\n the attenuation. There is a moderate pericardial effusion which is simple in\n attenuation as well. Patchy atelectasis is seen at the lung bases. There is\n smooth intralobular septal thickening, with the pleural effusions,\n suggestive of fluid overload. No nodules are seen.\n\n Near the dome of the liver, there is a punctate focus of enhancement which may\n represent a tiny flash filling hemangioma (3B:175). A subcentimeter\n subcapsular focus of hyperattenuation on the same phase may represent a\n transient hepatic arterial defect (). The gallbladder, pancreas, and\n adrenal glands are normal. There is a peripheral wedge-shaped hypodensity in\n the spleen which is consistent with a small infarct. The infarct measures up\n to 1.8 cm in diameter. There is a second tiny peripheral hypodensity more\n superiorly in the spleen, which may represent a second tiny infarct. A couple\n of splenules are unremarkable. The kidneys enhance symmetrically and excrete\n normally. There are a couple of small rounded hypodensities in the kidneys,\n including one at the right upper pole measuring 12 mm and one at the left\n lower pole measuring 18 mm, most likely representing renal cysts. There is a\n 6-mm calculus in the lower pole of the right kidney. The stomach, small and\n large bowel are normal. There is no free air or free fluid in the abdomen. No\n pathologically enlarged mesenteric or retroperitoneal lymph nodes.\n\n CT OF THE PELVIS WITHOUT AND WITH CONTRAST: The bladder, seminal vesicles,\n prostate, rectum, and sigmoid are normal. There is a small amount of free\n (Over)\n\n 10:31 AM\n CTA ABD W&W/O C & RECONS; CTA PELVIS W&W/O C & RECONS Clip # \n Reason: Please assess for emboli\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n pelvic fluid, simple in attenuation. No pathologically enlarged pelvic or\n inguinal lymph nodes.\n\n BONE WINDOWS: There is a sizable sclerotic focus in the lesser trochanter of\n the proximal left femur, which is partially imaged (2:86) measuring 12 mm.\n This could represent a bone island, though the entire extent of the lesion is\n not evaluated on this study. There are small bone islands in the\n intertrochanteric region of each femur. No lytic osseous lesions are seen.\n\n Multiplanar reformatted images were essential in delineating the anatomy and\n pathology in this case.\n\n IMPRESSION:\n 1. A wedge-shaped hypodensity in the lower portion of the spleen measuring up\n to 1.8 cm likely represents a small infarct. A second punctate area of\n hypodensity in the spleen may represent a second tiny infarct. No other\n infarcts are seen in the abdomen.\n\n 2. Small right pleural effusion, trace left pleural effusion, moderate\n pericardial effusion, and small amount of free fluid in the pelvis.\n Interlobular septal thickening in the lung bases raises concern for fluid\n overload.\n\n 3. 6-mm nonobstructing calculus at the lower pole of the right kidney.\n\n 4. Rounded hypodensities in kidneys are not fully characterized, though are\n most compatible with cysts.\n\n 5. Sclerotic focus in the proximal left femur as described. It is not\n completely visualized on this study, and plain radiographs of the left femur\n are recommended for further evaluation.\n\n" }, { "category": "Nursing/other", "chartdate": "2185-03-14 00:00:00.000", "description": "Report", "row_id": 1612956, "text": "ROS:\n\nNeuro: A+O x's 3. MAE x's 4 to command. PERRLA. Steady on feet and transfers w/minimal assist. Pain mngt greatly improved w/the addition of methadone. Morphine PCA w/basal rate of 4 mg/hr w/minimal uses. No doses of ativan given yet in this shift. Dilaudid 2 mg given prior to removal of chest tubes.\n\nCV: Regular rhythm w/1st degree AV block. No ectoy noted. Occasional dropped beat. Has right subclavian transvenous pacing wire capped and secured. Has 2 A and 2 V epicardial pacing wires which both sense and capture. No pacing requirements this shift. Chest tubes dc'd. RIJ cordis dc'd. ABP line dc'd. Large bore IVs dc'd and new peripheral IVs placed. Mediastinal drsg /removal of CT. Sternal drst w/scant old dry serosang drng. Generalized edema. Neo remains off as VSS.\n\nResp: Breath sounds clear. O2 2 L/ NP on/off (patient keeps taking off to blow nose and doesn't replace it). Sats 92-100%. No resp distress noted, = rise and fall of chest.\n\nGI: Abd soft taking general soft diet w/o c/o n/v. H2 blocker for GI prophylaxis. Reports a stitch broke loose in mouth, Dr. .\n\nGU: Foley dc'd at 11:00. DTV b/t 1900 and 2100 hrs this evening.\n\nEndo: FSG covered w/RSSI.\n\nSocial: Mom at bedside @ noon, supportive.\n\nPlan: Decrease basal rate of morphine to 2 mg and then off 2 hrs later. Pulmonary toilet, mobilize. Monitor, tx, support, and comfrort. Floor bed tomorrow. ? psych and addiction nurse consults.\n" }, { "category": "Nursing/other", "chartdate": "2185-03-15 00:00:00.000", "description": "Report", "row_id": 1612957, "text": "7pm-7am update\nneuro: pt alert and orieantated x3. MAE and able to follow commands.\n\nCV: pt remains in 1st degree AV block, no ectopy noted. HR 70-80's. BP 90-110's/40-60's. HCT 22.3 - team aware - no treatment. + pp. pt with epicardial wires on VVI at 50. pt also has right subclavian transvenous wire -> capped and covered with DSD.\n\nresp: LS clear with dim bases bil. pt placed on 2 L NC while sleeping, o2 sats 95-100%. pt with strong productive cough. Using IS\n\nGi/gu: pt with + bs. no stool. pt voiding in urinal clear yellow urine. UO adequate.\n\nendo: elvated bs treated with ss reg insulin per protocol\n\nactivity/comfort: pt ambulated x 1 last night. pt OOb to chiar this am with minimal assist. pt recieving methadone TID and morphine PCA for pain control. Morphine PCA with no basal rate, dose of 2 mg and 6 lockout. pt reports that his pain is well controled.\n\nmouth: pt with teeth extractions prior to surgery. pt reports the feeling that 2 stitches have \"popped\" in his mouth. team notified. no bleeding noted\n\nplan: pulm toleit, pain control, advance activity as tolerated, transfer to 6\nplan: pain control, pulm toliet,\n" }, { "category": "Nursing/other", "chartdate": "2185-03-13 00:00:00.000", "description": "Report", "row_id": 1612954, "text": "ROS: A+O x's 4. MAE x's 4 to command. Steady on feet when out of bed. Transfers w/ease. Sudden acute onsets of pain x's 3 today. Becomes tachypnic, more tachycardic, with extream diaphoresis and tears. Morphine PCA started. W/second episode of acute onset of pain basal rate of morphine added at 2 mg/hr. W/third episode of acute pain basal rate ^ to 4 mg/hr. Multiple doses of dilaudid given w/these acute pain attacks. PERRLA.\n\nCV: RSR/ST w/1st degree AV block. Neo on for BP support. PA line dc'd cordis left in place. Has left radial ABP line.Sternal drsg w/scant serosang drsg. Has 2 mediastinal and one pleural chest tubes. Generalized edema. HAs 2 A and 2 V epicardial pacing wires, no pacing requirements. Has right subclavian transvenous pacing wire, caped and secured. Peripheral pulses palpable w/ease.\n\nResp: Breath sounds clear and diminished. O2 weaned off to room air w/sats maintaining 92%. W/this less episode of acute pain Sats drop to 89% o2 added 3/l NP and sats up to 97%. Pleural chest tube as noted above.\n\nGI: Taking diet w/o c/o n/v or difficulties swallowing. Abd soft w/hypoactive BS.\n\nID: On ceftriaxone, gent, and cipro. Tmax 100.5\n\nEndo: FSG covered w/RSSI sq.\n\nHct: 22.9 21 Hct pending.\n\nSocial: Mother at bedside late this afternoon. Supportive.\n\nPlan: Pain mngt. Pulmonary toilet. Mobilize. Monitor, tx, support, and comfort. Dc transvenous pacing wires in AM. Titrate neo as BP alows\n" }, { "category": "Nursing/other", "chartdate": "2185-03-14 00:00:00.000", "description": "Report", "row_id": 1612955, "text": "CVICUB NPN\nO: ROS\n\nNeuro: C/O acute pain, unable to move, diaphoretic and anxious. PCA morphine w/ basal rate increased to 4mg and prn dilaudid for breakthrough pain. Improved w/ conversation and w/ increased basal rate. Pt given 2mg dilaudid x1 w/ returning to bed. Using pca appropriately abt 6-12mg/hr. Pt anxious again after returning to bed and given 1mg ativan iv w/ gd effect. Resting and calm but not sleeping or calling out. Able to stand easily w/ steady gait but slow to walk in room or move. Sl paranoid and concerned initially abt people judging him and switching medications behind his back. This improved w/ trust and improved pain control.\n\nCV: HR 120's-110 once more comfortable. Cont in first degree avb, no ectopy. epicardial wires and transvenous wire remain in place. Neo weaned off w/ map >60 consistently. Palpable pedal pulses.\n\nResp: Alternating between 2lnp and rm air w/ stable 02sats. Able to CDB and produce sm amt sputum independently. LS clear. SRR 20-32. Shallow pattern w/ anxiety.\n\nRenal: Adequate u/o. Body balance sl negative at mn. Lytes wnl.\n\nGI/Endo: No insulin requirement overnoc. BS 110. Tol cl w/ no difficulty. Denies nausea. Abd soft.\n\nHeme: Hct 25.5 - 21.5 this am. INR 1.5. Stable serosang ct dnge.\n\nID: WBC 10.0 (12.9) Tmax 101.2. Cont on cipro, gent and ceftriaxone.\n\nSkin: Intact.\n\nSH: mom in the room all evening and calming, assisting pt. Enc to leave the room and sleep after 0100. Pt able to sleep once mom stepped out.\n\nA: Hemodynamically stable off neo this am. Pain control improved.\n\nP: Cont to monitor and support systems. Transfuse as needed if hemodynics indicate. Pain control w/ pca. Pt may benefit from ATC po ativan. Change to po dilaudid for breakthrough pain. Cont abx. Deline and ready pt for transfer. Increase activity. Cont w/ pain service and ?consult addiction RN for recommendations prior to and for discharge.\n" }, { "category": "Nursing/other", "chartdate": "2185-03-12 00:00:00.000", "description": "Report", "row_id": 1612951, "text": "Admission note:\n\nPOST OP Homograrft bentall. CPBT 163\", XCT 139\" no problems on/off pump. Out on neo and propofol. 2500 cc/Crystaloids. 30% EF pre/post.\n\nROS:\n\nNeuro:Sedated on propofol, no reversals given. Left pupil > then right pupil x's 1 mm. Pain mngt w/fentanyl gtt.\n\nCV: 1st degree AV block rate 90's. Has 2 A and 2V epicardial pacing wires, both sense and pace. Peripheral pulses palpable w/ease. Has RIJ CCO swan via cordis. SVO2 72, CO 4.5-5.0 w/CI 2.0 or >. Has right radial ABP line. Has 2 Mediastinal CT draining serosang drng. Sternal and mediastinal drsg . No edema.\n\nResp: Intubated and on vent. Breath sounds coarse, unable to obtain any secreations w/sx. No resp distress noted, = rise and fall of chest.\n\nGI: Oral gastic tube to LCS placement varified to be correct via insertion and auscultation of air bolus and CXR. Carafate for GI prophylaxis. No Bowel sounds.\n\nGU: Foley patent draining clear yellow urine in QS.\n\nLabs: Hct 27. lytes stable.\n\nSocial: No family available. Dr. left voice message on contact persons phone #,\n\nPlan: Leave intubated overnoc, wake, wean and extubate in AM. Neo/ntg for BP mngt. Monitor and support SVO2 and CI. Pulmonary toilet. Mobilize. Monitor, tx, support, and comfort.\n" }, { "category": "Nursing/other", "chartdate": "2185-03-13 00:00:00.000", "description": "Report", "row_id": 1612952, "text": "Resp Care Note:\n\nPt cont intub with OETT, sedated and on mech vent as per Carevue. Lung sounds ess clear after suct sm th white sput. ABGs stable able to wean FIO2 overnoc. Cont mech vent and wean to extub this AM.\n" }, { "category": "Nursing/other", "chartdate": "2185-03-13 00:00:00.000", "description": "Report", "row_id": 1612953, "text": "CVICU NPN\nO: ROS\n\nNeuro: Sedated on fentanyl and propofol overnoc. Woke up calm on medication nodding appropriately, MAE and follows commands. Able to communicate when in pain. Propofol weaned down slightly and pt woke up thrashing and mouthing \"I can't breathe\". Unable to calm w/ reassurance. Hemodynamic compromise w/ agitation. Resedated w/ increased propofol and fentanyl.\n\nCV: Hypotensive and required 2.5 liters fluid for MAP < 60 and low FP. FP stable and pt cont on neo titrated to maintain MAP > 60. CO/CI stable w/ CI > 2.5, sv02 65-75%. Pedal pulses easily palpable. HR remains 70-80 nsr w/ 1st degree avb. PR interval .32-.34. Rare pvc's noted. Pacer wires attatched and both a and v wires capture. No pacing required.\n\nResp: Fully vented overnoc as planned on simv w/ stable abg and 02sats. Sxned for thick white secretions. LS coarse, clearing w/ sxning.\n\nRenal: Brisk u/o. 2.5 liters fluid given and body balance +2650 at mn.\nLytes wnl. Lactate 1.4 (2.7)\n\nGI: NPO w/ ogt-lcs, bilious dnge. Abd soft, BS absent.\n\nEndo: No insulin requirement overnoc.\n\nHeme: Hct 24.9 (27.0) MCT output serosang w/ total ct output 160cc since mn.\n\nID: Tmax 100.2 core temp. Cont on cipro, gent and ceftriaxone. WBC 10.3 (22.3).\n\nSkin: Sternal and mediastinal dsgs D&I. No skin breakdown.\n\nSH: mom and sister in to visit. V appropriate and asking appropriate questions. Expressing pt's and their concern re: addiction and cont wean protocol he was on preop. mom spoke to Dr. and family went home for the night.\n\nA: Hemodynamically stable overnoc.\n\nP: Cont to monitor and support systems. Wean neo as tol. Cont pulm toilet. Wake, wean and extubate in am as tolerated. Cont abx. OOB-Chair in am and ready pt for transfer. Contact addiction RN to follow pt post-op. Cont pt and family support.\n" }, { "category": "Nursing/other", "chartdate": "2185-03-11 00:00:00.000", "description": "Report", "row_id": 1612947, "text": "Nursing Note 7p-7a\nThis is a 25yo male w/ Hx of IV heroin abuse. Admit to hosp on for tx suspected PNA. Persistent sob/ doe, orthopenea showing s/s of fluid overload. TEE showed severe aortic regurgitation w/ a concern for vegetation on aortic valve. Tnsf'd to on . Pt tx'd for heart failure-> successfully diuresed w/ improvements in orhopenea. BC grew high-grade strep Viridans bacteremia. Dx w/ strep viridans endocarditis, presumed from IVDA. TEE revealed a bicuspid aortic valve, lg aortic valve vegetation & severe (+4) AI. Also a sm pericardial effusion seen w/ slight R atrial diastolic colaps. ID & CT were both consulted. Pt also c/o mouth pain, had dental panorax which showed sig oral infection. ? poss source of endocarditis. Will prob have teeth extraction, ? date. Currently Tx strep infection w/ iv ceftriaxone & gentamycin synergy. Over the past 36hrs on 7, EKGs showed PR interval w/ cont'd prolongation. Increasing from 180ms on admission to 360ms on . Pt was tnsf to CCU closer monitoring. EP made aware, in case pt goes into a junctional escape rhythm, for need of temp pacing wire.\n\nNeuro- A+Ox3, cooperative w/ care. MAE in bed, no c/o c-pain/sob. Pending brain MRI/A to eval for mycotic anurism. Also needs CT of abd/ pelvis to eval for septic emboli.\nCV- Tele SR/ST w/ 1st degree AVB, (PR .27-.30) no vea. HR 90-100, NBPs by auscultation 104-96/70s-60s. Life-pac @ bedside.\nResp- LSC, sats >95% r/a. RR 30s-40, NPO p MN.\nGI/GU- Abd soft +bs, no bm. Tol diet, voiding qs cyu using urinal.\nID- Tmax 100.9po, conts on Ancef & Genta for +strep. Pending BC x2, Genta trough w/ AM labs. HIV-, HB serology pending.\nSkin- Intact, no issues.\nA/P- Stable, cont to monitor tele rhythm & PR interval. Q6 EKGs. If develops CHB prob temp pacer placement by EP. NPO for MRI/A & abd/ pelvic CT today. Cont abx's, qd BC. Monitor s/s pulmonary edema. Needs teeth extraction ? today prior to pending AVR.\n\n" }, { "category": "Nursing/other", "chartdate": "2185-03-11 00:00:00.000", "description": "Report", "row_id": 1612948, "text": "Nursing Progress Note\n\nO: Please see flow sheet for objective data. Tele conts to have prolonged pr this am .30. EP up to see pt decision made to place temp wire. To cath lab. set at back up rate of 60. Dressing over site is intact wit sm amt of bld. Dressing to remain intact per EP. Pt denies chest pain. TTE from does show abcess on aotic valve. Seen by CT surgery for AVR in am. Seen by oral surgeon. To have teeth extracted later this pm.\n\nResp: Lungs CTA o2 sats 95-99%. Pt denies shortness of breath.\n\nNeuro: Pt is alert and oriented x's 3. Cooperative with expressing a great deal of concern regarding post op pain d/t ho drug abuse. Seen by pain service. Recommends MSO4 via PCA. Buprenorphine-Naloxone dc'd. Head CT done.\n\nGI/GU: Pt NPO throughout the day. Ab is soft with bowel sounds present. No BM. CT done.Voiding CYU.\n\nID: TM 99.1. Conts on Gentamycin and Cefriaxone. Bld cultures done this am.\n\nSocial: Mother and fiance in to visit and spoke with all MD's aware of POC. Mother is planning on spending the nite.\n\nA&P: 25 yo with aortic vegatation and abcess with h/o heroin abuse and poor dentition. Hemodynamically stable conts with prolonged PR temp pacer at rate of 60. For dental extraction later today then AVR in am.\n\nA&P:\n" }, { "category": "Nursing/other", "chartdate": "2185-03-12 00:00:00.000", "description": "Report", "row_id": 1612949, "text": "NPN 7 PM-- 7 AM\n\nS: \" I feel Ok, Just scared that the pian meds won't work sfter surgery tomorrow\"\n\no: Please see careview for vitals and other objective data\n\n25 year old male with hx of IVDU, reformed x 6 months but does report snorting on superbowl sunday, went to on with SOB, dx with PNA and CHF, but TEE showed large aotic vegitaion, pt transferred here. He C/o Mouth pain and was found to have carries and impacted molars possible source of infection, organism strep Viradans from BC,\nsent to OR last night at ten and had morals extracted along with infected tooth. Did well post OP back here stable and awake, started\nPCA morphine for pain, with good effect. Mouth with gauze packing x 2 hours post op, no bleeding. pt swish and spit with chlorohexidine .\n Contines on gentamycin and ceftriaxone, Afebrile, BC to be sent with AM labs. Cardaic wise pt had screw in pacer Placed yesterday, as PR is prolonged 0.28-0.30 and we are following that, pt has not required any pacing, HR 75-90 SR, BP has been stable 98/50--112/59. O2 sats 97-98 on room air, lungs clear. TEE on confirmed large aortic Veg with 4+ aortic insufficiency. Pt has been NPO and is planned for AVR today\nhe is second case.\nSocial : Mother has been staying with PT, Pt states he was afraid, almost panicked around extubation but responded to reassurance. Otherwise he is a nice pleasant kid, states \" I know I cant use any more, it will kill me. \" He states that he was worried that his med Bupremorphine/Naloxone would block his pain receptors but is reassured\nnow that morphine worked, responded to 2 MG doses.\n\nA: Pt with aortic valve vegitation, sp temp pacer and tooth extraction yesterday and now NPO for AVR on saturday. Responding to antibiotics, afebrile. Appears well. has developed long PR but no heart block.\n\nP: NPO for OR, mouth rinse, examine oral cavity for bleeding, monitor PR, ekg, survelance cultures, reassure pt and family, keep them updated on CCU rounds.\n" }, { "category": "Nursing/other", "chartdate": "2185-03-12 00:00:00.000", "description": "Report", "row_id": 1612950, "text": "resp care\nreceived from o.r. intubated,on simv. will wean per cardiac surgery fast track protocol when appropriate. +bbs. pips/plat within normal limits.\n" }, { "category": "Echo", "chartdate": "2185-03-12 00:00:00.000", "description": "Report", "row_id": 85417, "text": "PATIENT/TEST INFORMATION:\nIndication: Aortic valve disease. Endocarditis. Left ventricular function. Preoperative assessment.\nStatus: Inpatient\nDate/Time: at 13:38\nTest: TEE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: No ASD by 2D or color Doppler.\n\nLEFT VENTRICLE: Severely dilated LV cavity. Moderately depressed LVEF.\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: basal anterior\n- hypo; mid anterior - hypo; basal anteroseptal - hypo; mid anteroseptal -\nhypo; basal inferoseptal - hypo; mid inferoseptal - hypo; basal inferior -\nhypo; mid inferior - hypo; basal inferolateral - hypo; mid inferolateral -\nhypo; basal anterolateral - hypo; mid anterolateral - hypo; anterior apex -\nhypo; septal apex - hypo; inferior apex - hypo; lateral apex - hypo; apex -\nhypo;\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal ascending, transverse and descending thoracic aorta with no\natherosclerotic plaque.\n\nAORTIC VALVE: Bicuspid aortic valve. Large vegetation on aortic valve. Severe\n(4+) AR.\n\nMITRAL VALVE: Normal mitral valve leaflets. Trivial MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets.\n\nPERICARDIUM: Moderate pericardial effusion. Sustained RA diastolic collapse,\nc/w low filling pressures or early tamponade.\n\nGENERAL COMMENTS: A TEE was performed in the location listed above. I certify\nI was present in compliance with HCFA regulations. The patient was under\ngeneral anesthesia throughout the procedure. No TEE related complications.\n\nConclusions:\nPREBYPASS\nNo atrial septal defect is seen by 2D or color Doppler. The left ventricular\ncavity is severely dilated. Overall left ventricular systolic function is\nmoderately depressed (LVEF= 25-35 %). Right ventricular chamber size and free\nwall motion are normal. The ascending, transverse and descending thoracic\naorta are normal in diameter and free of atherosclerotic plaque. The aortic\nvalve is bicuspid. There is a large vegetation on the aortic valve. Severe\n(4+) aortic regurgitation is seen. No perivalvular abcess is visualized. The\nmitral valve leaflets are structurally normal. Trivial mitral regurgitation is\nseen. There is a moderate sized pericardial effusion. There is sustained right\natrial collapse, consistent with low filling pressures or early tamponade.\n\nPOSTBYPASS\nThe LV remains dilated with moderate to severe global hypokinesis.\nLVEF~25-30%. The AV is now tricuspid and competent. No AI is visualized. This\nis consistent with aortic homograft placement. The remaining study is\nunchanged from prebypass.\n\n\n" }, { "category": "Echo", "chartdate": "2185-03-10 00:00:00.000", "description": "Report", "row_id": 85418, "text": "PATIENT/TEST INFORMATION:\nIndication: Aortic valve disease. Congestive heart failure. Endocarditis. Mitral valve disease.\nHeight: (in) 70\nWeight (lb): 147\nBSA (m2): 1.83 m2\nBP (mm Hg): 99/32\nHR (bpm): 94\nStatus: Inpatient\nDate/Time: at 14:49\nTest: TEE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: No spontaneous echo contrast or thrombus in the LA/LAA or the\nRA/RAA.\n\nLEFT VENTRICLE: Dilated LV cavity. Mildly depressed LVEF.\n\nRIGHT VENTRICLE: Normal RV systolic function.\n\nAORTA: Normal ascending, transverse and descending thoracic aorta with no\natherosclerotic plaque.\n\nAORTIC VALVE: Bicuspid aortic valve. Mildly thickened aortic valve leaflets.\nModerate-sized vegetation on aortic valve. No aortic valve abscess. Severe\n(4+) AR.\n\nMITRAL VALVE: Normal mitral valve leaflets. No mass or vegetation on mitral\nvalve. Mild (1+) MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. No mass or\nvegetation on tricuspid valve.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets.\n\nPERICARDIUM: Small pericardial effusion. No RV diastolic collapse. Brief RA\ndiastolic collapse.\n\nGENERAL COMMENTS: A TEE was performed in the location listed above. I certify\nI was present in compliance with HCFA regulations. The patient was monitored\nby a nurse throughout the procedure. The patient was monitored\nby a nurse throughout the procedure. Local anesthesia was\nprovided by benzocaine topical spray. The patient was sedated for the TEE.\nMedications and dosages are listed above (see Test Information section). The\nposterior pharynx was anesthetized with 2% viscous lidocaine. 0.1 mg of IV\nglycopyrrolate was given as an antisialogogue prior to TEE probe insertion. No\nTEE related complications. Results were reviewed with the Cardiology Fellow\ninvolved with the patient's care.\n\nConclusions:\nNo spontaneous echo contrast or thrombus is seen in the body of the left\natrium/left atrial appendage or the body of the right atrium/right atrial\nappendage. The left ventricular cavity is dilated. LV systolic function\nappears mildly depressed. Right ventricular function is normal with normal\nfree wall contractility. The ascending, transverse and descending thoracic\naorta are normal in diameter and free of atherosclerotic plaque to 40 cm from\nthe incisors. The aortic valve is functionally bicuspid (with fusion of the\nleft and right coronary cusps). The aortic valve leaflets are mildly\nthickened. There is a moderate-sized vegetation (1.2 x 1.1 cm) on the\nposterior leaflet of the aortic valve; this leaflet is flail. No aortic valve\nabscess is seen. There is edema of the fibrous trigone of the anterior mitral\nvalve leaflet and arotic root. Severe (4+) aortic regurgitation is seen. The\nmitral valve leaflets are structurally normal. No mass or vegetation is seen\non the mitral valve. Mild (1+) mitral regurgitation is seen. There is a small\npericardial effusion. No right ventricular diastolic collapse is seen. There\nis brief right atrial diastolic collapse.\n\nIMPRESSION: definite moderate-sized vegetation on the posterior leaftlet of\nthe bicuspid aortic valve with flail and severe aortic regurgitation. Edema of\nthe intervalvar fibrosa at the confluence of the anterior mitral leaflet and\naortic root with no discrete perivalvular abcess identified. Dilated left\nventricular cavity with mildly depressed left ventricular systolic function.\nSmall pericardial effusion with brief right atrial collapse.\n\nPhysician. . was notified in person of the results on\n at 10:10AM.\n\n\n" }, { "category": "Radiology", "chartdate": "2185-03-12 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1000470, "text": " 5:44 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: postop film-contact MD # if abnormal\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 25 year old s/p Bentall procedure with homograft\n REASON FOR THIS EXAMINATION:\n postop film-contact MD # if abnormal\n ______________________________________________________________________________\n WET READ: MPtb SAT 8:23 PM\n ETT & NGT in satisfactory position. Tip of Swann-ganz catheter probably in\n main PA. Single lead pacer/ICD unchanged. No PTX or pleural effusion.\n MPOWELL\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE AP PORTABLE VIEW OF THE CHEST.\n\n REASON FOR EXAM: Assess Swan-Ganz catheter.\n\n Comparison is made with prior study performed a day earlier.\n\n ET tube tip is 5 cm above the carina. Swan-Ganz catheter tip is in the main\n pulmonary artery. Single transvenous pacemaker lead terminates in a standard\n position in the right ventricle. NG tube tip is in the stomach. There is no\n pneumothorax or pleural effusion. Cardiac size is normal. There is\n postoperative pneumomediastinum. There is atelectasis in the left base. Ill-\n defined opacity in the right upper lobe is worrisome for aspiration. Mild\n interstitial pulmonary edema is improving. Mediastinal chest tubes are in\n place.\n\n Findings were discussed with Dr. at the time of the\n interpretation of the study.\n\n" }, { "category": "Radiology", "chartdate": "2185-03-11 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1000315, "text": " 12:52 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: assess for lead position and pneumothorax\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 25 year old man with new temporary pacemaker via right subclavian vein\n REASON FOR THIS EXAMINATION:\n assess for lead position and pneumothorax\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: New temporary pacemaker.\n\n CHEST, ONE VIEW: Comparison with . New right-sided pacer\n with single lead overlying the right ventricle, in standard position.\n Cardiomegaly is unchanged. Hilar and mediastinal contours are also unchanged.\n There are bilateral small pleural effusions and associated atelectasis. No\n pneumothorax. Osseous structures are unchanged.\n\n IMPRESSION:\n 1. No pneumothorax after right pacemaker placement.\n 2. Persistent small bilateral pleural effusions and associated atelectasis.\n\n\n jr\n\n" }, { "category": "ECG", "chartdate": "2185-03-10 00:00:00.000", "description": "Report", "row_id": 215698, "text": "Sinus rhythm. The P-R interval is prolonged at 320 milliseconds. Non-specific\nanterior ST-T wave changes. Compared to the previous tracing there is no\nsignificant change.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2185-03-10 00:00:00.000", "description": "Report", "row_id": 215699, "text": "Sinus rhythm. The P-R interval is prolonged. Non-specific anterior ST-T wave\nchanges. Compared to the previous tracing there is no significant change.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2185-03-10 00:00:00.000", "description": "Report", "row_id": 215700, "text": "Sinus rhythm. First degree A-V block. P-R interval is about 380 milliseconds.\nAnterior T wave changes which are non-specific. Compared to the previous\ntracing of P-R interval prolongation has significantly increased.\nClinical correlation is suggested.\n\n" }, { "category": "ECG", "chartdate": "2185-03-09 00:00:00.000", "description": "Report", "row_id": 215701, "text": "Sinus tachycardia. Prolonged P-R interval. Compared to the previous tracing\nthe P-R interval is slightly longer.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2185-03-08 00:00:00.000", "description": "Report", "row_id": 215702, "text": "Sinus tachycardia. No previous tracing available for comparison.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2185-03-12 00:00:00.000", "description": "Report", "row_id": 215694, "text": "Sinus rhythm with marked P-R interval prolongation. Compared to the previous\ntracing of the heart rate is minimally faster with more leftward\nQRS axis consistent with left anterior fascicular block. T waves are more\npeaked raising consideration of hyperkalemia. Other abnormalities are as\nreported. The QTc interval is also relatively longer. Clinical correlation is\nsuggested.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2185-03-12 00:00:00.000", "description": "Report", "row_id": 215695, "text": "Sinus rhythm with marked P-R interval prolongation at about 314 milliseconds.\nLeft axis deviation. Left atrial abnormality. Marked left ventricular\nhypertrophy. Non-specific ST-T wave changes consistent with left ventricular\nhypertrophy, ischemia, etc. Q-T interval at the upper limits of normal.\nCompared to the previous tracing of no diagnostic change. Clinical\ncorrelation is suggested.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2185-03-11 00:00:00.000", "description": "Report", "row_id": 215696, "text": "Sinus rhythm. The P-R interval is prolonged at 320 milliseconds. Left\naxis deviation. Probable left anterior fascicular block. Compared to the\nprevious tracing anterolateral ST segment depression has resolved.\nTRACING #4\n\n" }, { "category": "ECG", "chartdate": "2185-03-11 00:00:00.000", "description": "Report", "row_id": 215697, "text": "Sinus rhythm. The P-R interval is prolonged at 320 milliseconds. Left axis\ndeviation. Probable left anterior fascicular block. Non-specific\nanterolateral ST segment depression. Compared to the previous tracing left\naxis deviation and ST segment depression are new.\nTRACING #3\n\n" } ]

[ { "category": "Radiology", "chartdate": "2170-07-28 00:00:00.000", "description": "TRAUMA #3 (PORT CHEST ONLY)", "row_id": 1193324, "text": " 5:06 AM\n TRAUMA #3 (PORT CHEST ONLY) Clip # \n Reason: FALL TRAUMA\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INFORMATION: 73-year-old female with fall.\n\n FINDINGS: Portable supine chest radiograph is read in conjunction with a CT\n of the chest, abdomen, and pelvis. Multiple rib fractures and scapular\n fracture are not as well appreciated on the portable trauma radiograph.\n Similarly, the small right pneumothorax is not well seen. Please see separate\n report for those details.\n\n IMPRESSION: Limited trauma radiograph, does not demonstrate injuries as seen\n on CT.\n\n\n" }, { "category": "Radiology", "chartdate": "2170-07-28 00:00:00.000", "description": "CT C-SPINE W/O CONTRAST", "row_id": 1193330, "text": " 5:27 AM\n CT C-SPINE W/O CONTRAST; OUTSIDE FILMS READ ONLY Clip # \n Reason: second-read CT c-spine\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old woman with s/p fall\n REASON FOR THIS EXAMINATION:\n second-read CT c-spine\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: NATg SAT 5:36 AM\n No fracture or subluxation\n Right small pneumothorax.\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INFORMATION: 73-year-old female status post fall.\n\n TECHNIQUE: Images were loaded into PACS performed at Caritas for second opinion read including axial images of the spine with\n coronal and sagittal reformations without contrast.\n\n FINDINGS: There is no fracture or subluxation of the cervical spine. The\n prevertebral soft tissues are normal in appearance.\n\n C2-3: No canal or foraminal narrowing.\n\n C3-4: Moderate bilateral neural foraminal narrowing without significant canal\n narrowing.\n\n C4-5: Severe bilateral neural foraminal narrowing. There is mild canal\n narrowing.\n\n C5-6: Severe bilateral neural foraminal narrowing. There is mild canal\n narrowing.\n\n C6-7: Moderate left neural foraminal narrowing.\n\n There is a small right apical pneumothorax. The lungs are otherwise\n unremarkable.\n\n IMPRESSION:\n 1. No fracture or subluxation of the cervical spine, with multilevel\n degenerative change. If there is concern for cord injury, MRI is more\n sensitive for this.\n\n 2. Small right apical pneumothorax.\n\n Findings were discussed by phone with Dr. of the ED.\n (Over)\n\n 5:27 AM\n CT C-SPINE W/O CONTRAST; OUTSIDE FILMS READ ONLY Clip # \n Reason: second-read CT c-spine\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2170-07-30 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1193671, "text": " 11:37 AM\n CHEST (PA & LAT) Clip # \n Reason: r/o pneumonia or other processes\n Admitting Diagnosis: POLYTRAUMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old woman s/p fall with rib fractures, desats with ambulation to mid\n 80's, new oxygen requirement.\n REASON FOR THIS EXAMINATION:\n r/o pneumonia or other processes\n ______________________________________________________________________________\n FINAL REPORT\n PA AND LATERAL CHEST, \n\n HISTORY: 73-year-old woman with rib fractures. Hypoxic.\n\n IMPRESSION: PA and lateral chest compared to :\n\n Small bilateral pleural effusion is new. Lungs are severely hyperinflated,\n due to COPD, but clear of any focal abnormality, specifically edema or\n pneumonia. Heart is borderline enlarged. No pneumothorax.\n\n\n" }, { "category": "Radiology", "chartdate": "2170-07-28 00:00:00.000", "description": "CT CHEST W/CONTRAST", "row_id": 1193328, "text": " 5:26 AM\n CT CHEST W/CONTRAST; OUTSIDE FILMS READ ONLY Clip # \n CT ABD & PELVIS WITH CONTRAST; OUTSIDE FILMS READ ONLY\n Reason: second-read CT torso\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old woman with s/p fall\n REASON FOR THIS EXAMINATION:\n second-read CT torso\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: NATg SAT 5:59 AM\n small right pneumothorax\n 8-11th posterior rib fractures, acutely angled ribs anteriorly span 3rd-9th\n levels, may be nondisplaced fxs.\n Right vertically oriented scapular fracture displaced 5mm\n No intrabdominal injury\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INFORMATION: 73-year-old female status post fall.\n\n COMPARISON: None.\n\n TECHNIQUE: Images were loaded into PACS performed at Caritas for a second opinion read including images of the chest, abdomen,\n and pelvis with coronal and sagittal reformations following the administration\n of intravenous contrast.\n\n FINDINGS:\n\n CHEST: The heart and great vessels are normal in size and configuration.\n There is no acute aortic injury. There is no mediastinal, hilar, or axillary\n lymphadenopathy. There is a small right pneumothorax seen anteriorly. The\n lungs are clear, with note made only of bibasilar atelectasis.\n\n ABDOMEN: The liver, spleen, pancreas, adrenals, and gallbladder are normal.\n The kidneys demonstrate symmetric contrast enhancement without acute injury\n seen. Stomach is collapsed and not well evaluated. Loops of bowel are normal\n in caliber and enhancement. There is no intraperitoneal free fluid or free\n air.\n\n PELVIS: The rectosigmoid is unremarkable. The bladder is normal in\n appearance. The uterus and adnexa are notable for bilateral adnexal cysts,\n measuring 2.0 cm on the left and 2.4 cm on the right. There is no pathologic\n lymphadenopathy.\n\n BONES: There are rib fractures of the posterior eighth, ninth, tenth, and\n eleventh ribs. The right ribs are also acutely angulated anteriorly from the\n third through ninth levels, which may represent nondisplaced fracture. There\n is a right vertically oriented scapular fracture which is displaced by 5 mm\n inferiorly. There are no concerning lytic or blastic osseous lesions.\n Vertebral body height and alignment are maintained. The pelvis appears\n intact.\n (Over)\n\n 5:26 AM\n CT CHEST W/CONTRAST; OUTSIDE FILMS READ ONLY Clip # \n CT ABD & PELVIS WITH CONTRAST; OUTSIDE FILMS READ ONLY\n Reason: second-read CT torso\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n IMPRESSION:\n\n 1. Small right pneumothorax.\n\n 2. Multiple rib fractures, and right scapular fracture.\n\n 3. Bilateral adnexal cysts, which are abnormal for a woman of this age.\n Recommend further evaluation with pelvic ultrasound on an outpatient basis.\n\n Findings were discussed with Dr. of the emergency department at 6 a.m.\n\n\n" }, { "category": "Radiology", "chartdate": "2170-07-31 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1193892, "text": " 3:09 PM\n CHEST (PA & LAT) Clip # \n Reason: eval pleural effusions\n Admitting Diagnosis: POLYTRAUMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73F fell backwards down 12 stairs, R scapular fx, small R PTX, 6 rib fxs on\n right\n REASON FOR THIS EXAMINATION:\n eval pleural effusions\n ______________________________________________________________________________\n FINAL REPORT\n TYPE OF EXAMINATION: Chest PA and lateral.\n\n INDICATION: 73-year-old female patient fell backwards down 12 stairs, right\n scapula fracture and small right-sided pneumothorax, six rib fractures on the\n right side, evaluate for pleural effusion.\n\n FINDINGS: PA and lateral chest views were obtained with patient in upright\n position. Comparison is made with the next preceding PA and lateral chest\n examination of . Again noted is moderate cardiac enlargement.\n There is no significant congestive pattern in the pulmonary circulation. The\n latter, however, shows typical changes for COPD with irregular peripheral\n vascular distribution and low positioned diaphragms. There is evidence of\n mild blunting of the right lateral pleural sinus extending slightly into the\n posterior sinus as seen on the lateral view. There is no significant interval\n change in comparison with yesterday's examination (). Again, the known\n scapula and multiple rib fractures are poorly identified on the routine chest\n examination. In comparison with the single view chest examination of , it can be stated that the right-sided pleural effusion did not exist at\n that time and thus is new and probably related to the trauma.\n\n IMPRESSION: Stable chest findings in comparison with yesterday's examination.\n\n\n" }, { "category": "Radiology", "chartdate": "2170-07-28 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1193325, "text": " 5:23 AM\n CT HEAD W/O CONTRAST; OUTSIDE FILMS READ ONLY Clip # \n Reason: please second-read CT head from OSH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old woman with s/p fall\n REASON FOR THIS EXAMINATION:\n please second-read CT head from OSH\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: NATg SAT 6:00 AM\n axial images of the head demonstrate no intracranial injury\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INFORMATION: 73-year-old female status post fall.\n\n TECHNIQUE: Images performed at Caritas were uploaded\n into PACS for a second opinion read comprising axial images of the head\n without contrast.\n\n FINDINGS: Limited axial evaluation of the head demonstrates no acute\n intracranial hemorrhage, extraaxial collection, or mass effect. The\n ventricles are normal in size. The sulci are mildly prominent, consistent\n with age-appropriate atrophy. matter/white matter differentiation is\n preserved throughout.\n\n The orbits and soft tissues appear normal. The mastoid air cells and\n visualized portions of the paranasal sinuses are clear.\n\n IMPRESSION: No acute intracranial injury.\n\n\n" }, { "category": "ECG", "chartdate": "2170-07-28 00:00:00.000", "description": "Report", "row_id": 249883, "text": "Sinus rhythm with ventricular premature beats. Left axis deviation. Left\nbundle-branch block. No previous tracing available for comparison.\n\n" } ]

[ { "category": "Echo", "chartdate": "2113-08-08 00:00:00.000", "description": "Report", "row_id": 79652, "text": "PATIENT/TEST INFORMATION:\nIndication: Myocardial infarction. Left ventricular function.\nHeight: (in) 72\nWeight (lb): 279\nBSA (m2): 2.46 m2\nBP (mm Hg): 103/63\nHR (bpm): 75\nStatus: Inpatient\nDate/Time: at 10:10\nTest: Portable TTE (Complete)\nDoppler: Full doppler and color doppler\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Elongated LA.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.\n\nLEFT VENTRICLE: Normal LV wall thicknesses and cavity size. Moderate regional\nLV systolic dysfunction.\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: mid anterior -\nhypo; mid anteroseptal - hypo; anterior apex - hypo; septal apex - hypo;\ninferior apex - hypo; apex - akinetic;\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic root diameter.\n\nAORTIC VALVE: Normal aortic valve leaflets. No AR.\n\nMITRAL VALVE: Normal mitral valve leaflets. Mild (1+) MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.\nIndeterminate PA systolic pressure.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows. Based on \nAHA endocarditis prophylaxis recommendations, the echo findings indicate a low\nrisk (prophylaxis not recommended). Clinical decisions regarding the need for\nprophylaxis should be based on clinical and echocardiographic data.\n\nConclusions:\nThe left atrium is mildly elongated. Left ventricular wall thicknesses and\ncavity size are normal. There is moderate regional left ventricular systolic\ndysfunction with hypokinesis of the disal half of the anterior septum and\nanterior walls and of the distal anterior and inferior walls. The apex is near\nakinetic. The remaining segments contract well. No intraventricular thrombus\nis seen and the apex is not focally aneurysmal. Right ventricular chamber size\nand free wall motion are normal. The aortic valve leaflets appear structurally\nnormal with good leaflet excursion. No aortic regurgitation is seen. The\nmitral valve leaflets are structurally normal. Mild (1+) mitral regurgitation\nis seen. The pulmonary artery systolic pressure could not be determined. There\nis no pericardial effusion.\n\nIMPRESSION: Regional left ventricular systolic dysfunction c/w CAD (mid-LAD\nlesion). Mild mitral regurgitation.\n\nBased on AHA endocarditis prophylaxis recommendations, the echo findings\nindicate a low risk (prophylaxis not recommended). Clinical decisions\nregarding the need for prophylaxis should be based on clinical and\nechocardiographic data.\n\n\n" }, { "category": "Radiology", "chartdate": "2113-08-08 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 872485, "text": " 7:09 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Pt with leukocytosis\n Admitting Diagnosis: ACUTE MYOCARDIAL INFARCTION\\CARDIAC CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 43 year old man with CAD s/p anterior STEMI\n REASON FOR THIS EXAMINATION:\n Pt with leukocytosis\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 42-year-old male with CAD status post anterior ST MI. The\n patient has leukocytosis. Rule out pneumonia.\n\n COMPARISONS: No comparisons are available.\n\n TECHNIQUE: AP supine single view of the chest.\n\n FINDINGS: The cardiac silhouette is in the upper limits of normal for\n technique. The pulmonary vasculature is normal without evidence of CHF. Lung\n fields are grossly clear without evidence of pneumonia. There is no evidence\n of pneumothorax. There are no obvious pleural effusions. Skeletal structures\n are grossly unremarkable.\n\n IMPRESSION: No evidence of pneumonia.\n\n" }, { "category": "ECG", "chartdate": "2113-08-08 00:00:00.000", "description": "Report", "row_id": 210012, "text": "Sinus rhythm. Compared to tracing #1 acute anterolateral ST segment elevations\nconsistent with acute myocardial infarction persist.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2113-08-07 00:00:00.000", "description": "Report", "row_id": 210013, "text": "Sinus rhythm. There are Q waves in leads VI-V2 with ST segment elevations of\none to two millimeters in leads I, aVL and VI-V5 consistent with acute\nextensive anterolateral myocardial infarction. Generalized low QRS voltage.\nST segment depression in leads III and aVF with inverted T waves consistent\nwith reciprocal changes. No previous tracing available for comparison. Clinical\ncorrelation is suggested.\nTRACING #1\n\n" }, { "category": "Nursing/other", "chartdate": "2113-08-09 00:00:00.000", "description": "Report", "row_id": 1492017, "text": "CCU NSG PROGRESS NOTE 7P-7A/ S/P MI\n\nS- \" HOW LONG DO I HAVE TO STAY HERE...\"\n\nO- SEE FLOWSHEET FOR OBJECTIVE DATA\n\n PT REMAINS FREE OF CHEST PAIN, JAW PAIN OR ARRYTHMIA S/P MI/ STENT TO LAD.\nHR- 70-80'S SR, BP- 98/63-128/74- REMAINS ON LOPRESSOR 25 TID, LISINOPRIL 2.5 QD AS WELL AS ASA, PLAVIX, HEPARIN GTT. INCREASED HEPARIN GTT FROM U FOR PTT 27. TO RECHECK 6:30 AM.\nSTARTED COUMADIN LOAD 5 MG FOR EF- 35-40%.\nREMAINS ON BEDREST, TURNING SELF IN BED, USING URINAL.\nASKING APPROPRIATE QUESTIONS RE: PLAN OF CARE, CV MEDS.\nDECLINING INITIATION OF NICOTINE PATCH CURRENTLY.\n\nRESP- CLEAR LUNGS- DIM AT BASE- O2 SATS- 98-95% ON ROOM AIR.\nDENIES SOB.\nNO FURTHER LASIX- I/O (+)1100 CC AS OF 12 AM.\n\nID- AFEBRILE\n\nGU- USING URINAL- FOLEY D/C ON EVES-\nNO ISSUES CURRENTLY\n\nMS- A AND O X 3- ANXIOUS TO GET MOVING, GET OOB, GET HOME.\nTEACHING/SUPPORT.\nASKING QUESTIONS ABOUT PLAN OF CARE\nATIVAN 0.5 FOR SLEEP.\nRESTING CURRENTLY.\n\nLINES- 3 PERIPHERALS- ALL (+) FUNCTIONING, CHANGED DSG.\n\nA/ PT S/P LARGE AMI AND STENT TO LAD WITH 3 VD CURRENTLY TOLERATING MED REGIMEN, WITHOUT CP/ISCHEMIA.\n\nCONTINUE TO MAXIMIZE RATE/PRESSURE WITH CV MEDS.\nCOUMADIN LOAD- CHECK AM PTT- GET HEPARIN AT THERAPEUTIC DOSE.\nGRADUALLY INCREASE ACTIVITY AS TOLERATED S/P R/I MI\nC/O TO FLOOR ONCE MEDICALLY APPROPRIATE.\nTEACHING, SUPPORT- BENZO/NICOTINE PATCH AS NEEDED FOR TOBACCO WITHDRAWAL SYMPTOMS\nKEEP PT AND FAMILY AWARE OF PLAN OF CARE.\n" }, { "category": "Nursing/other", "chartdate": "2113-08-08 00:00:00.000", "description": "Report", "row_id": 1492015, "text": "CCU NSG PROGRESS NOTE- 9:30P-7A/ R/I AMI\n(Continued)\n FOR AM ECHO-\n\n? D/C RT FEMORAL PA LINE TO MAKE PT MORE COMFORTABLE AND EASIER TO SIT UPRIGHT FOR MORE COMFORTABLE BREATHING .\n\nDIURESIS AS CLINICAL NECESSARY- CONTINUE TO CLOSELY CHECK RESP STATUS AND AM CXR AS WELL AS PA # FOR EVIDENCE OF MORE CHF.\n\nASSESS HEMODYNAMICS- ADD ACE AND INCREASE B BLOCKER AS TOLERATED.\n\nPAIN/ANXIETY MANAGEMENT- CIWA SCALE FOR R/O WITHDRAWAL WITH H/O TOB AND ETOH USE.\nFREQ CHANGE IN POSITION AS TOLERATED\nFOR PT COMFORT.\n\nKEEP PT AND FAMILY/GIRLFRIEND AWARE OF PLAN OF CARE.\n\nIVF X 2 LITER AT 50CC/HOUR.\n\nCHECK WITH TEAM ABOUT ? D/C INTEGRILEN VS RESUME HEPARIN.\n\n" }, { "category": "Nursing/other", "chartdate": "2113-08-08 00:00:00.000", "description": "Report", "row_id": 1492016, "text": "CCU Nursing Progress Note\nS-\"My back raelly hurts from lying in bed all night.\"\nO-Neuro alert and oriented x3, very pleasant and cooperative. c/o generalized back ache received percocett 2 tabs x2 with good relief of pain. No c/o anxiety from not smoking. CIWA scale 4-5 not requiring ativan. Family concerned that pt will continue to deny problem. Because 7 years ago pt had a heart attack/stent but continued to smoke and deny he ever had any \"damage to his heart\". HO aware.\nCV-VSS HR 78-88 NSR with frequent runs of AIVR, tolerating lorpessor 12.5mg po TID. Amioderone infusion d/c'd at 1400. SBP 100-120's/80 PAP 38/18 with CO/CI 6.3/2.4 at 1200. Second CPK at 0 mb, third CPK pnd from 1300. Integrelin d/c'd at 1230. Right fem venous sheath removed by cardiology fellow. Pedal pulses intact 3+/3+ right and 1+/1+ left. No further c/o chest pain or SOB.\nResp-LS diminished at bases, RA O2 sat 97%.\nID afebrile with elevated WBC 19.0 pnd urine culture sent. No cough.\nGU-BUN/Cr 14/.9 foley draining 40-50cc/hr post cath IVF at 50cc/hr.\nGI-Oral cavity cleansed with old blood, no active bleeding noted with gums/teeth. +BS x4. Appetite good no n/v.\nActivity-Bedrest maintained until 1900pm. HOB elevated at 1600 2hrs post venous sheath pull.\nSocial-Brother calling/spokesperson. Girlfriend and father into visit. Asking appropriate questions and concerned about pt quiting smoking, received CAD teaching material including smoking cessation programs.\nAccess-3 PIV.\nCode Status- Full\nA/P-RI STEMI ant/septal s/p VF arrest, 3VD with LAD stent.\nCheck results of CPK at 1400, serial CPK until peak CPK obtained.\nClosely monitor for chest pain or SOB. Medicate for further pain prn.\nIVF post cath 50cc/hr for 2 liters. Monitor K+ level and replete prn goal K> 4.0. Monitor arrhythmia.\nContinue to explain procedures/POC as discussed in multi disciplanary rounds.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2113-08-08 00:00:00.000", "description": "Report", "row_id": 1492014, "text": "CCU NSG PROGRESS NOTE- 9:30P-7A/ R/I AMI\n\nS- \" MY BACK IS REALLY HURTING...\"\n\nO- SEE FLOWSHEET FOR OBJECTIVE DATA AND CCU FHPA FOR CURRENT HPI/PMH\n\n PT ADMITTED FROM CATH LAB S/P LAD STENT WITH RT GROIN PA AND ALINE, VSS. UPON ARRIVAL, ACT CHECKED AND LESS THAN 180 SO ARTERIAL SHEATHS D/C WITHOUT INCIDENT - FINISHED CLAMP PRESSURE 10:40 PM. NO OOZE OR GROIN BLEED, PULSES ALL (+). HR- 70-80'S SR, STARTED LOPRESSOR 12.5 TID AND TOLERATING IT. ARRIVED ON AMIODORONE 1 MG AND DROPPED TO 0.5 MG AT 12:30 AM AS SCHEDULED, ORDERED. ALSO ON INTEGRILEN 2MCG/KG FOR 18 HOUR- TO D/C 12:30 PM TODAY. RECEIVED ASA AND BOLUS DOSE PLAVIX IN CATH LAB. PLAN FOR FURTHER WORK ON LCX AND RCA AND PT AWARE OF PLAN OF CARE. DENIES CP OR JAW PAIN OR INDIGESTION. CYCLING CPK, TROPONIN AND CPK GREATLY (+) AT 12AM CHECK OF LABS. PA SAT CHECKED ON ARRIVAL- CI- 2.14. MV SAT- LOW 60'S.\n\nISSUES THIS SHIFT WITH VT/RUNS- IN SETTING OF R/I MI IN SPITE OF AMIO GTT AND WITH K- 4.0/ MG- 1.8 IN SETTING OF LARGE DIURESIS.\nPT REPLETED WITH 40 KCL AND 2 AMPS MGSO4 AND BY 3AM, MUCH LESS FREQUENCY OF VEA. NO SUSTAINED RUNS- HOUSE STAFF AWARE.\nPLAN FOR STARTING ACE TODAY AND INCREASE LOPRESSOR AS WELL AS AM ECHO.\n\nRESP- PAD LOW 20'S, HIGH TEENS AT TIMES- DIURESED TO 20 LASIX IN CATH LAB AND NO FURTHER DIURESIS THIS SHIFT.\n\nINITIALLY O2 SATS OFF 02- 88-86% WITH MUCH TALKING TO STAFF AND FAMILY- ADDED FACE TENT- 100-60% AND ONCE ASLEEP AND LESS ENERGY / PT SATS COMING UP TO 96-97%. TILTED UP 15 DEGREES ONCE SHEATHS OUT AS WELL FOR BETTER RESP EFFORT.\nCOMFORTABLE CURRENTLY.\n\nGU- 200CC/HOUR UPON ARRIVAL AND (-)750CC WITH GOAL APPROX (-) 1 LITER - CURRENTLY 60-100CC/HOUR WITHOUT FURTHER LASIX DOSES.\nFOLEY CATH IN PLACE- CLEAR YELLOW URINE.\n\nGI- NPO BUT FOR MEDS AND LIX SIPS- ASKING FOR MUCH ICE AND DRINKS BUT LIMITING WITH NEED FOR BEING STRAIGHT AND STILL WITH RT LEG IMMOBILIZED AND WITH NEED FOR SHEATHS OUT/PRESSURE HELD ETC.\nTAKING PILLS AND GINGER ALE WITHOUT PROBLEM BUT FOR FLEETING NAUSEA FEELING AFTER DRINKING.\nPROTONIX FOR GI PROTECTION.\n(+) BOWEL SOUNDS.\n\n PT ANXIOUS AND UNCOMFORTABLE OVERALL WITH NEED FOR LEG IMMOBILITY AND BEDREST. MUCH CHANGE OF POSITION FROM RT TO LEFT, LOGROLLING.\nBACKRUBS, SUPPORT.\nTYLENOL AND ATIVAN 0.5 X 2 DOSES THIS SHIFT.\nONCE ASLEEP ON SIDE, MORE COMFORTABLE AND LESS ANXIOUS.\nBROTHER IN TO VISIT AS WELL AS GIRLFRIEND- ALL APPEAR TO UNDERSTAND PLAN OF CARE. PT DENIES ANY PAIN BUT FOR NEED TO ROLL AND TURN FREQUENTLY FOR BACK TIGHTENING UP WITH PROLONGED BEDREST.\n\nLINES- RT VENOUS SIDEARM/PA LINE FEMORAL\nLEFT - 2 PERIPHERAL #20'S/ RIGHT-\n1 PERIPHERAL #20.\n\nSKIN- NO ISSUES- S/P CYST REMOVAL MID BACK- SMALL BANDAID PRESENT.\n\nA/ PT S/P LARGE AMI/VF ARREST ADMITTED TO CCU S/P LAD STENT- DOING WELL BUT FOR RUNS OF VT NONSUSTAINED IN SETTING OF LOW NORMAL K/MG AND R/I FOR MI\n\nCONTINUE TO CLOSELY CHECK LYTES/CYCLE CPK/FOLLOW HCT/PLT ON INTEGRILEN.\n\nD/C INTEG 12:30 PM- ? RESUME HEPARIN WHILE AWAITING INTERVENTION ON 2 OTHER DISEASED ARTERIES.\n\nCYCLE CPK'S/CHECK LYTES AND REPLETE AS NEEDED.\n\nP\n" } ]

[ { "category": "Nursing/other", "chartdate": "2112-04-23 00:00:00.000", "description": "Report", "row_id": 1562701, "text": "ccu npn\no- id- t max 99.8po. bld c+s sent x2, 1 stick, 1 iv, urine c+s sent also. started on abx x2.\ncv- hr max 128, mainly 80-90s sr, no vea. bp 84-106/. aline inserted by ho r radial. repeat labs about 1pm, k 5.0, creat up to 1.5, hct down 40 from 43, inr down 1.2. wbc down about 19. treponin .17. mg 2.0, ion. ca 1.15. aicd checked by ep. no hx of vt detected.\nresp- intubated on a/c, initial trial psv tol ok, then after about 1/2hr, pt became more anxious, slightly diaphoretic, sob and sat down to 90, back to a/c and on 40%o2, rate 24, tv 600 with 8peep. abg 88,35,7.44,25,0. sx'd per rt for scant brn via ett. l/s dim, few cxs bases. cxr showed mod. chf, l retrocardiac ?atelectasis vs consolidation. u/o adeq, diuresed x2 with 40mg ivp lasix with fair effect, i+o neg about 150cc at 1600.\ngi- abd soft w/bowel sounds. ngt with about 20cc dk blood, lavaged by ho to coffee grnds. started on iv protonix . meds given later day with scant brn aspirate. pt had r tendernesss w/palpation on rounds. lfts done wnl except alk phos amylase sl. elevated. no bm.\nbs 188-216, on sc insulin.\nms- alert and awake on admit. anxious when awake. sedated w/propofol drip, gradually increased w/fair effect (dozes off/on but wakes to slightest touch/care given and looks uncomfortable most time). fentanyl drip added with better effect, still easily wakes w/care given. central line insertion being done- pt moving drips up to 50mic fent. and propofol 25mic so far with bolus propofol x1- 20mg. followed commands when awake.\nskin- has small old callous r heel and old scabbed abrasions r shin, otherwise skin inatct, repo from side to back w/skin care.\naccess- 2 peripherals, 3rd in. aline in, tlc line being inserted now.\nsocial- no relatives nearby friend, ?girlfriend visited, updated on pt ststus, plan.\na- intubated chf, ?pneumonia\np-follow temp, c+s results, need sputum. follow low bp, rising creat, diuresis. check 3rd ck this eve. cont. vent a/c and sedation overnoct.\n\n" }, { "category": "Nursing/other", "chartdate": "2112-04-25 00:00:00.000", "description": "Report", "row_id": 1562706, "text": "CCU NPN: please see flowsheet for objective data\n\nCardiac: HR 70-90's NSR,no VEA. on amiodorone. BP 90-126/ received 25mg po lopressor this am and then to receive again at 8pm,tomorrow to start metoprolol XL. both K and mag repleted this am,repeat labs sent this evening\n\nResp: 2l NP to RA sats good.lungs clear,diminished at bases\n\nGU: foley d/ced this am,has voided 250cc since then,-1 liter for the day\n\nGI: good appetite\n\nEndocrine: covered with insulin at 12 and 6pm per SScale\n\nID: abx d/ced. afebrile. WBC 15.7 this am.\n\nNeuro: alert and oriented x3,paxil restarted this evening\n\nA/P: to go to 6 when bed available.\n check results of labs\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2112-04-24 00:00:00.000", "description": "Report", "row_id": 1562702, "text": "CCU progress note 7p-7a\n\nNEURO: sedated on Propofol @ 35mcg/k/min + Fentanyl @ 35mcg/hr. Lightly sedated, will nod head appropriately.\n\nID: pan cultured yesterday. Tmax 99.9. WBC 25.7 yesterday, am labs pnd. no abx.\n\nRESP: weaned from AC to PS 10/5 40% this evening - RR 10-15 Sats 97%. Abg: 7.30/49/127. To continue to wean this morning ?extubation mid morning. RSBI due this morning. LS clear, dim. diuresed overnite x1.\n\nCARDIAC: SR 80-90s. SBP 100s-140s. Started on lopressor 12.5mg - ?increase next dose? R radial Aline. RIJ TLC. 3PIV. cycling CKs - peak 115. Trop 0.24. HCT 40.9. monitor K + Mg w/ diuresis. no ectopy noted - pt has AICD.\n\nGI/GU: foley patent. diuresed w/ 40mg Lasix @ 2200hrs w/ some effect. abd soft +BS. NGT - sl coffee ground residual. HCT stable. NPO. no BM. RISS. FS QID.\n\nPLAN: extubated this morning. RSBI + con't vent wean. monitor temp. re-culture for T>101.\n" }, { "category": "Nursing/other", "chartdate": "2112-04-24 00:00:00.000", "description": "Report", "row_id": 1562703, "text": "CCU progress note 7p-7a\n\nPt agitated at 7am. Team in to see pt. Sedation shut off + pt extubated by respiratory. doing well.\n" }, { "category": "Nursing/other", "chartdate": "2112-04-24 00:00:00.000", "description": "Report", "row_id": 1562704, "text": "ccu npn\no- id- t max 99.5, c+s pnd. cont. abx.\ncv- hr 90s to 79 sr, rare pvc. bp 90s-113/. k 4.1, creat 1.4, po4 5.2, treponin down to .21, hct down to 35. lopressor increased to 25mg , tol well. restarted on po amiodarone.\nresp- on 50% face tent after extubation. abg repeated post extubation 69,44,7.40 with finger sat 94, increased to 70% face tent with sats up to 99. later day, weaned to n/c 3l to eat with sats 90s to 100. l/s clear upper, coarse cxs bases with scat rhonchi thruout. productive strong cough of bloody sputum in am, less this pm. diuresed in early am after lasix 40mg iv. i+o neg. about 900cc at 1800, goal liter for day.\ngi- abd soft w/bowel sounds. took ice/meds/water well in am, ngt with no aspirate. ngt d/c'd. asking for lot ice/water, explained chf/lasix/limiting fluids, understands but states is always dry. atempted bm on commode, did not go. down for liver, gallbladder ultrasound this pm. npo in am pre us, diet this pm, taking pudding, then ate light dinner, tol well. teaching done w/pt and friend regarding 2gm diet. also pt states he is a diabetic, diet controlled, but has been cheating lately.\nms- a+ox3. cooperative.\nskin- no change, prefers to stay on his back in bed. activity- oob to chair, tol well for about 1.5hrs, then tired and back to bed. pivoted well w/asisst.\nsocial- friend and some of her fx visited, supportive to pt.\nbelongings- pt states missing gold wire glasses. called ambulance company- did not have and called and they are in the ew there. asked friend to pick them up.\na- s/p extubation for chf, pneumonia, r/i mi\np- follow resp status, would tolerate lower sats w/hx copd. diurese prn. follow hct in am. increase activity as tolerated. ?c.cath here or at per team. cont. cardiac teaching.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2112-04-25 00:00:00.000", "description": "Report", "row_id": 1562705, "text": "CCU progress note 7p-7a\n\nUneventful pm. Slept well overnite. VSS. Rec'd lasix 40mg IVP overnite w/ fair diuresis via foley. Extubated yesterday am -LS clear, dim. on 2L n/c. sats >94%. monitor HCT (dropped yesterday w/ no evidence of bleed). taking po well.\n\nPLAN: possible cardiac cath when ?GIB issue clear. ?transfer to floor.\n" }, { "category": "Echo", "chartdate": "2112-04-23 00:00:00.000", "description": "Report", "row_id": 78824, "text": "PATIENT/TEST INFORMATION:\nIndication: Congestive heart failure. Left ventricular function. Myocardial infarction.\nHeight: (in) 71\nWeight (lb): 188\nBSA (m2): 2.06 m2\nBP (mm Hg): 100/80\nHR (bpm): 100\nStatus: Inpatient\nDate/Time: at 08:01\nTest: Portable TTE (Complete)\nDoppler: Full doppler and color doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Normal LA size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. A catheter or pacing wire is\nseen in the RA and extending into the RV.\n\nLEFT VENTRICLE: Normal LV wall thickness. Mildly dilated LV cavity. Severe\nglobal LV hypokinesis. Severely depressed LVEF.\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). Trace AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Mild (1+) MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.\n\nPERICARDIUM: Trivial/physiologic pericardial effusion.\n\nConclusions:\n1. The left ventricular cavity is mildly dilated. There is severe global left\nventricular hypokinesis to akinesis with some preservation of basal wall\nmotion. Overall left ventricular systolic function is severely depressed.\n2. The aortic valve leaflets (3) are mildly thickened. Trace aortic\nregurgitation is seen.\n3. The mitral valve leaflets are mildly thickened. Mild (1+) mitral\nregurgitation is seen.\n4. There is a trivial/physiologic pericardial effusion.\n\n\n" }, { "category": "Radiology", "chartdate": "2112-04-23 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 866305, "text": " 6:22 PM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate line placement and CHF\n Admitting Diagnosis: CONGESTIVE HEART FAILURE-RESPIRATORY FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old man with CHF s/p R internal jugular line placement\n REASON FOR THIS EXAMINATION:\n evaluate line placement and CHF\n ______________________________________________________________________________\n FINAL REPORT\n Portable chest on at 18:50.\n\n INDICATION: Line placement.\n\n COMPARISON: at 05:17.\n\n FINDINGS:\n\n A right CVL has been placed with the tip in the SVC and no PTX. There is some\n clearing of the left upper lung zone with residual increased interstitial\n markings apparent. The right lateral costophrenic sulcus is cut off from\n view. Pacemaker hardware and wires intact for the visualized portion, the\n distalmost aspect of the right ventricular wires was cut off from view. There\n are no new consolidations.\n\n IMPRESSION:\n\n CVL placement with no PTX. Improvement in CHF with residual features of this\n condition.\n\n\n" }, { "category": "Radiology", "chartdate": "2112-04-24 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 866342, "text": " 8:30 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for chf/ptx\n Admitting Diagnosis: CONGESTIVE HEART FAILURE-RESPIRATORY FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old man with CHF Q\n REASON FOR THIS EXAMINATION:\n eval for chf/ptx\n ______________________________________________________________________________\n FINAL REPORT\n COMPARISON: .\n\n INDICATION: CHF.\n\n FINDINGS:\n\n Compared to the prior study, there is continued improvement of CHF features,\n now better delineation of the left hemidiaphragm. Previously seen lines\n remain in place. There are no new consolidations.\n\n IMPRESSION:\n\n Continued improvement in fluid status.\n\n\n" }, { "category": "Radiology", "chartdate": "2112-04-23 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 866226, "text": " 5:19 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval forCHF\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old man with intubation\n REASON FOR THIS EXAMINATION:\n eval forCHF\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: History of intubation, evaluate for CHF.\n\n COMPARISON: None.\n\n PORTABLE AP CHEST RADIOGRAPH: An ET tube is seen, with the tip positioned\n approximately 6.5 cm above the carina. An NG tube is seen with the tip\n positioned within the stomach. A pacemaker is overlying the left hemithorax\n with the ventricular leads overlying the cardiac shadow. There are increased\n pulmonary vasculature markings diffusely, with blunting of the costophrenic\n angles, consistent with pulmonary edema or CHF. There is left retrocardiac\n opacity, which may represent atelectasis or consolidation. The heart size is\n enlarged. The mediastinal contours are within normal limits. The soft tissue\n and osseous structures are normal.\n\n IMPRESSION:\n 1) ET tube with tip positioned approximately 6.5 cm above the carina.\n 2) Diffusely increased pulmonary vasculature markings with small bilateral\n pleural effusions, consistent with pulmonary edema/CHF.\n 3) Left retrocardiac opacity, which may represent atelectasis or\n consolidation.\n\n" }, { "category": "Radiology", "chartdate": "2112-04-24 00:00:00.000", "description": "ABDOMEN U.S. (COMPLETE STUDY)", "row_id": 866371, "text": " 1:12 PM\n ABDOMEN U.S. (COMPLETE STUDY) Clip # \n Reason: eval for cirrhosis/ascities/biliary tract dz\n Admitting Diagnosis: CONGESTIVE HEART FAILURE-RESPIRATORY FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old man with CHF and possible cirrhosis/SBP\n REASON FOR THIS EXAMINATION:\n eval for cirrhosis/ascities/biliary tract dz\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: History of CHF and possible cirrhosis.\n\n No studies available for comparison.\n\n Transabdominal ultrasound examination was performed. The liver demonstrates\n no focal lesion. There are several calcified gallstones without evidence of\n acute cholecystitis. Flow in the portal vein is anterograde. There is no\n demonstrable ascites. There is no intra or extrahepatic biliary ductal\n dilatation. The left kidney measures 10.6 cm. The right kidney measures 9.95\n cm. There are no stones, masses, or evidence of hydronephrosis affecting\n either kidney. The spleen measures 10.6 cm without focal abnormality. The\n imaged portions of the pancreas are unremarkable. The tail is poorly\n visualized.\n\n IMPRESSION:\n 1) Possibly coarsened liver architecture, without focal lesion.\n 2) Cholelithiasis without evidence of cholecystitis.\n\n\n" }, { "category": "Radiology", "chartdate": "2112-04-25 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 866510, "text": " 3:21 PM\n CHEST (PA & LAT) Clip # \n Reason: eval for evidence of PNA\n Admitting Diagnosis: CONGESTIVE HEART FAILURE-RESPIRATORY FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57M ischemic CM, CHF, ? PNA\n REASON FOR THIS EXAMINATION:\n eval for evidence of PNA\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Ischemic cardiomyopathy, CHF. Question of pneumonia.\n\n TECHNIQUE: PA and lateral views of the chest were obtained, compared with the\n examination performed yesterday.\n\n FINDINGS: Cardiac and mediastinal silhouettes remain stable. Left-sided AICD\n is again seen, and placement of right-sided IJ central venous catheter\n remaining stable, with the tip in the mid SVC. There are no focal pulmonary\n opacities or evidence of pneumothorax. There is a small right-sided pleural\n effusion. No evidence of congestive failure.\n\n IMPRESSION:\n 1. No evidence of failure.\n\n 2. Small right-sided pleural effusion.\n\n" }, { "category": "ECG", "chartdate": "2112-04-26 00:00:00.000", "description": "Report", "row_id": 211851, "text": "Sinus rhythm\nMarked left axis deviation - left anterior fascicular block\nIntraventricular conduction defect\nLeft atrial abnormality\nPoor R wave progression - anteroseptal infarct\nInferior ST-T changes are nonspecific\nSince previous tracing of , no significant change\n\n" }, { "category": "ECG", "chartdate": "2112-04-23 00:00:00.000", "description": "Report", "row_id": 211852, "text": "Sinus rhythm. Left axis deviation. Left anterior fascicular block. Q waves in\nthe anterior, anterolateral and lateral leads consistent with prior extensive\nanterior and anterolateral infarction. Non-specific inferior T wave changes.\nCompared to the previous tracing of the rate is slower and the\nT wave changes are new.\nTRACING #3\n\n" }, { "category": "ECG", "chartdate": "2112-04-23 00:00:00.000", "description": "Report", "row_id": 211853, "text": "Sinus tachycardia. Left axis deviation. Left anterior fascicular block. Left\natrial abnormality. Q waves in the anterior, anterolateral and lateral leads\nconsistent with prior extensive anterior and anterolateral infarction. Compared\nto the previous tracing of no diagnostic change.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2112-04-23 00:00:00.000", "description": "Report", "row_id": 211854, "text": "Sinus tachycardia. Left axis deviation. Left anterior fascicular block. Left\natrial abnormality. Q waves in the lateral, anterior and anterolateral leads\nwith a late transition consistent with extensive prior anterior and\nanterolateral myocardial infarction. No previous tracing available for\ncomparison.\nTRACING #1\n\n" } ]

[ { "category": "Echo", "chartdate": "2201-01-12 00:00:00.000", "description": "Report", "row_id": 80363, "text": "PATIENT/TEST INFORMATION:\nIndication: Pericardial effusion.\nHeight: (in) 69\nWeight (lb): 175\nBSA (m2): 1.95 m2\nBP (mm Hg): 140/80\nHR (bpm): 140\nStatus: Inpatient\nDate/Time: at 19:36\nTest: Portable TTE (Focused views)\nDoppler: Limited Doppler and no color Doppler\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT VENTRICLE: Normal LV cavity size.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets.\n\nPERICARDIUM: Small pericardial effusion. Effusion echo dense, c/w blood,\ninflammation or other cellular elements.\n\nGENERAL COMMENTS: Emergency study performed by the cardiology fellow on call.\n\nConclusions:\nThe left ventricular cavity size is normal. The aortic valve leaflets are\nmildly thickened. There is a small circumferential partially echofilled\npericardial effusion. No definite right atrial collapse is identified.\n\n\n" }, { "category": "ECG", "chartdate": "2201-01-13 00:00:00.000", "description": "Report", "row_id": 204619, "text": "Normal sinus rhythm. Borderline A-V conduction delay. ST segment elevations in\nleads V2-V6 suggestive of possible anterior ischemia/infarction. Compared to\nthe previous tracing of the ST segment elevations in the anterior leads\nare more prominent.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2201-01-12 00:00:00.000", "description": "Report", "row_id": 204620, "text": "Atrial fibrillation with a rapid ventricular response. Non-specific ST-T wave\nabnormalities. Probable old inferior myocardial infarction. Compared to the\nprevious tracing of atrial fibrillation is new.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2201-01-11 00:00:00.000", "description": "Report", "row_id": 204621, "text": "Sinus rhythm\nFirst degree A-V delay\nConsider left atrial abnormality\nInferior infarct, age indeterminate - possible acute\nST segment elevation is diffuse - clinical correlation is suggested for\npossible in part pericarditis\nSince previous tracing of , diffuse ST segment elevation present\n\n" }, { "category": "ECG", "chartdate": "2201-01-09 00:00:00.000", "description": "Report", "row_id": 204622, "text": "Sinus rhythm\n - first degree A-V block\nInferior infarct - age undetermined\n Anterolateral T wave changes may be due to myocardial ischemia\nSince last ECG, anterolateral T wave abnormalities more pronounced\n\n" }, { "category": "ECG", "chartdate": "2201-01-06 00:00:00.000", "description": "Report", "row_id": 204623, "text": "Sinus arrhythmia with 1st degree A-V block.\nLeft axis deviation\nLateral T wave changes are nonspecific\nNo previous tracing available for comparison\n\n" }, { "category": "Radiology", "chartdate": "2201-01-07 00:00:00.000", "description": "CTA CHEST W&W/O C &RECONS", "row_id": 900008, "text": " 1:28 PM\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: r/o aortic dilitation\n Admitting Diagnosis: CHEST PAIN;+ETT\\CATH\n Field of view: 40 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old man with CAD\n REASON FOR THIS EXAMINATION:\n r/o aortic dilitation\n CONTRAINDICATIONS for IV CONTRAST:\n Creat 1.4\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 64-year-old male with coronary artery disease. Rule out aortic\n dilatation.\n\n TECHNIQUE: Contiguous axial CT images of the chest and upper abdomen are\n obtained with and without the administration of IV contrast , 100 cc of\n Optiray. Multiplanar reformation images are reconstructed.\n\n COMPARISON: Chest x-ray dated .\n\n FINDINGS: Note is made of calcification along the aortic wall, however, the\n aorta is normal in caliber throughout, and there is no evidence of dilatation,\n and no evidence of dissection. Coronary arteries are calcified, in this\n patient with history of coronary artery disease. The heart is normal in size,\n and there is no evidence of pericardial or pleural effusion. There is no\n significant mediastinal or hilar lymphadenopathy.\n\n In the lung windows, bilateral lungs are clear. Note is made of noncalcified\n pulmonary nodule measuring 3 mm in left lower lobe. The central airways are\n patent.\n\n ABDOMEN: There is 5 mm focal calcification in the segment VIII of the liver\n just below the diaphragm. Otherwise, there is no evidence of focal liver\n lesion. There is no evidence of intrahepatic duct dilatation. Gallbladder is\n unremarkable without evidence of calcification. Spleen, pancreas, adrenal\n glands, and the visualized portions of large and small intestines are within\n normal limits. No significant lymphadenopathy. No ascites. Note is made of\n hypodense cystic lesion in the right lower pole of the kidney, probably\n representing cyst. Note is made of nonspecific fat stranding around bilateral\n kidneys. However, there is no evidence of hydronephrosis or renal mass.\n\n Abdominal aorta is normal in caliber throughout without evidence of aneurysm\n or dissection, and note is made of calcification along the wall.\n\n BONE WINDOWS: There is no suspicious lytic or blastic lesion in skeletal\n structures.\n\n IMPRESSION:\n 1. No evidence of aortic dilatation.\n (Over)\n\n 1:28 PM\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: r/o aortic dilitation\n Admitting Diagnosis: CHEST PAIN;+ETT\\CATH\n Field of view: 40 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n 2. 3-mm noncalcified pulmonary nodule in the left lower lobe. Please follow\n in one year if this patient has no history of malignancy.\n 3. Right renal cyst.\n 4. Focal calcification in the segment VIII of the liver.\n 5. Coronary artery calcification.\n The multiplanar reformation images confirm the above findings.\n\n\n" }, { "category": "Radiology", "chartdate": "2201-01-10 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 900455, "text": " 4:32 PM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o ptx s/p ct's removed\n Admitting Diagnosis: CHEST PAIN;+ETT\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old man with CAD s/p CABG. Call ordering PA with any abnormality.\n\n REASON FOR THIS EXAMINATION:\n r/o ptx s/p ct's removed\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST ON AT 17:06.\n\n INDICATION: Chest tube removal.\n\n COMPARISON: .\n\n FINDINGS:\n\n ETT, right CVL and left chest tube were removed. There is no pneumothorax. A\n shallow level of inspiration is observed, limiting the assessment of the heart\n and mediastinum. Some left pleural fluid is seen on the current study, which\n appears more prominent than prior. Persistent left basilar atelectasis is\n noted as well.\n\n IMPRESSION:\n\n No PTX after multiple tube removals and slight increase in left pleural fluid.\n\n" }, { "category": "Radiology", "chartdate": "2201-01-12 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 900629, "text": " 2:04 PM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p CABG w/lo Sat-r/o PTX\n Admitting Diagnosis: CHEST PAIN;+ETT\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old man with CAD s/p CABG. Call ordering PA with any abnormality.\n\n REASON FOR THIS EXAMINATION:\n s/p CABG w/lo Sat-r/o PTX\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Status post CABG with hypoxia.\n\n COMPARISON: .\n\n CHEST: AP upright portable view. Lung volumes are low. There is a\n persistent opacity in the left lower lobe, consistent with either atelectasis\n or pneumonia. Small bilateral pleural effusions are unchanged. Evidence of\n CABG is again seen. There is no pulmonary edema. Dilated bowel loops are\n noted in the upper abdomen.\n\n IMPRESSION:\n 1. Persistent left lower lobe atelectasis or pneumonia.\n 2. Unchanged small bilateral pleural effusions.\n 3. Dilated bowel loops in the upper abdomen. Clinical correlation is\n suggested.\n DFDkq\n\n" }, { "category": "Radiology", "chartdate": "2201-01-13 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 900726, "text": " 8:18 AM\n CHEST (PORTABLE AP) Clip # \n Reason: postop\n Admitting Diagnosis: CHEST PAIN;+ETT\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old man with CAD s/p CABG. Call ordering PA with any abnormality.\n\n REASON FOR THIS EXAMINATION:\n postop\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 8:52 A.M., \n\n HISTORY: Coronary artery disease.\n\n IMPRESSION: AP chest compared to and 13:\n\n Although lung volumes have improved since , left lower lobe\n collapse has not cleared. Small bilateral pleural effusions remain.\n Postoperative widening of the cardiomediastinal silhouette improved between\n and 13 and is subsequently unchanged. There is no pneumothorax or\n pulmonary edema.\n\n\n" }, { "category": "Radiology", "chartdate": "2201-01-09 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 900333, "text": " 2:53 PM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o PTX/Effusion/Tamponade\n Admitting Diagnosis: CHEST PAIN;+ETT\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old man with CAD s/p CABG. Call ordering PA with any abnormality.\n REASON FOR THIS EXAMINATION:\n r/o PTX/Effusion/Tamponade\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Evaluation for pneumothorax or effusion.\n\n Portable AP chest x-ray was done and compared to previous study from .\n\n The patient is status post recent median sternotomy and CABG. The\n endotracheal tube tip is in the good position, at least, 3 cm above the\n carina. The right internal jugular Swan-Ganz catheter is seen with the tip\n presenting over the region of main pulmonary trunk.\n\n Left side chest tube is seen. The nasogastric tube is inserted with its tip\n projecting over the region of left upper abdomen.\n\n There is no evidence of pneumothorax. The heart size is enlarged and the\n mediastinum is widened most probably due to postsurgical hematoma. The lungs\n are clear. There is no evidence of pulmonary edema.\n\n IMPRESSION:\n\n 1. No evidence of pneumothorax in the patient status post recent sternotomy\n and CABG.\n\n 2. Tubes and lines remain in place.\n\n 3. No evidence of congestive heart failure.\n\n\n" }, { "category": "Radiology", "chartdate": "2201-01-06 00:00:00.000", "description": "CHEST (PRE-OP PA & LAT)", "row_id": 899915, "text": " 6:23 PM\n CHEST (PRE-OP PA & LAT) Clip # \n Reason: routine pre-procedure\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old man with 3 vessel CAD on cath today now referred for CABG, pt. on\n bedrest until 5:30 PM\n REASON FOR THIS EXAMINATION:\n routine pre-procedure\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Preoperative CABG.\n\n COMPARISON: None.\n\n PA AND LATERAL VIEWS OF THE CHEST: Heart size is within normal limits. Aorta\n is tortuous. There is prominence of the right mid mediastinal border. Lungs\n are clear. No pleural effusion. No evidence of pneumothorax. There are\n degenerative changes of the spine.\n\n IMPRESSION:\n 1. No evidence of acute cardiopulmonary process.\n 2. Prominence of the right mid mediastinal contour that may represent a\n dilated ascending aortic contour. Correlation with other studies including\n echocardiography if already available is recommended. If further evaluation\n is required, CT scan may be considered.\n\n The above was discussed with , physician assistant covering for\n cardiothoracic surgery.\n\n" }, { "category": "Nursing/other", "chartdate": "2201-01-12 00:00:00.000", "description": "Report", "row_id": 1410786, "text": "SOB/TRANSFER BACK FROM 2 POD #3 CABG X 3\nPT RECEIVED BACK FROM 2 ABOUT 19/HR TONIGHT WITH AFIB/FLUTTER RATE ~ 148 NOTED ON BEDSIDE MONITOR. NRB ON WITH SPO2 ~ 99%. PT CONVERSE AND ORIENTED ON ARRIVAL. METOPROLOL 5MG GIVEN BY DR. . AFIB/FLUTTER W/^ RATE CONTINUED. AMIODARONE BOLUS OF 150MG STARTED AT AND FOLLOWED BY 1MG/MIN GTT. HR DOWN TO ABOUT 100 AFTER GTT STARTED. CONVERTED TO ACCERRATED JUNCTIONAL RHYTHM ABOUT 22/HR AND NSR @ 2215. NBP BY R CUFF WNL. BEDSIDE ECHO REPORTED TO R/O CARDIAC TAMPONADE (AFTER EPICARDIAL WIRES REMOVED THIS AFTERNOON). 12 LEAD EKG DONE. ST ELEVATION IN V2-3 REPORTED TO DR. .\n\nBREATHSOUNDS DIMINISHED AT BASES. NRB CONTINUED W/SPO2 ~ 100%. CONSULTED W/DR. AND RESPIRATORY THERAPY. PT CHANGED TO HIGH FLOW NEB AND WEANED FROM 100% TO 60% AT CURRENT. HCT ~ 26. PRBC STARTED AND TO INFUSE OVER 4HRS W/ADDITIONAL LASIX TO BE GIVEN. BASED ON 2/CSRU I & O PT ~ 1LITER FOR 24/HR FLUID BALANCE. CXR REPORTED TO BE NORMAL.\n\nNPO EXCEPT FOR SIPS OF WATER FOR PILLS. +BOWEL SOUNDS. NO STOOL.\n\nFOLEY CATH REMAINS IN AND PATENT.\n\nONLY 2 #20 ANGIOCATHS IN PLACE. NO CENTRAL ACCESS AT THIS TIME.\n\nDENIES HAVING ANY PAIN.\n\nPT STARING AT THE CEILING. PT ASKED IF HE WAS OKAY AND HE REPORTED THAT \"HE WAS AFRAID OF WHAT WAS HAPPENING\". PT TOLD THAT HIS VITAL SIGNS HAD IMPROVED SINCE HIS TRANSFER FROM 2.\n\nDR. REPORTED SPEAKING WITH PATIENT FAMILY REGARDING MR. TRANSFER TO CSRU. PT BELONGINGS IN ROOM.\n\nPLAN TO MONITOR CLOSELY. PLAN TO LOWER AMNIODARONE DOSE @ 0240. PLAN TO GIVE ADDITIONAL LASIX W/BLOOD TRANSFUSION. ROUTINE EVENING METOPROLOL HELD TO REEVALUATE NEED W/DROPPING HR/BP. EXTERNAL PACING PADS REMAIN IN PLACE AS A PRECAUTION.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2201-01-13 00:00:00.000", "description": "Report", "row_id": 1410787, "text": "1900-0700\n\nNeuro: Pt awake, alert, oriented x3. Anxious at times but cooperative and wasy to calm. Follows commands well. MAEs. No neuro deficits noted.\n\nResp: Pt changed to 60% face tent-tolerating well but remains very dependent on O2. Pt will desaturate quickly w/o O2. Lungs clear/dimininshed at the bedside. 02sat stable 95-100%. Deep breathing and coughing encouraged. IS used at bedside.\n\nCV: NSR without ectopy. 2mm ST elevation noted: EKG done on addmission to unit HO aware-pt denies CP, SOB, diaphoresis. HR 70-80s, SBP 100s, afebrile. C/o of pain X1 medicated at 0400. Amiodarone drip @.5. Recieved 1 unit of PRBCs. HCT:27.3, WBC:16.7. Sternal dsg D+I. + pulses to lower ext. PIV X2.\n\nGI/GU: Abd soft, + BS, NPO. Foley to BSD draining clear yellow urine. CR:1.7, BUN:28.\n\nPlan: Supportive care, resp support-face tent.\n" }, { "category": "Radiology", "chartdate": "2201-01-19 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 901489, "text": " 11:16 AM\n CHEST (PA & LAT) Clip # \n Reason: eval post op\n Admitting Diagnosis: CHEST PAIN;+ETT\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old man s/p CABG\n REASON FOR THIS EXAMINATION:\n eval post op\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post CABG. Postop followup.\n\n COMPARISON: .\n\n TECHNIQUE: PA and lateral chest.\n\n FINDINGS: Since the examination of , the postoperative widening of\n the cardiomediastinal silhouette appears unchanged. Left lower lobe\n atelectasis appears mildly improved and there is new plate-like atelectasis at\n the right base. Small left pleural effusion appears approximately unchanged.\n No pneumothorax.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2201-01-09 00:00:00.000", "description": "Report", "row_id": 1410783, "text": "~1325 PATIENT ADMITTED S/P CABD X 3 FROM OR. PATIENT INTUBATED AND SEDATED WITH IV PROPOFOL. IV NEO ^. PATIENT BEING APACED WITH RATE UNDER 60'S SR. OG IN PLACE, PLACEMENT CHECKED, PATENT FOR SMALL AMT BILIOUS. CT'S PATENT FOR SMALL AMT SERO-SANG DRAINAGE. FOLEY IN PLACE, PATENT FOR CLEAR YELLOW URINE. DOPPLERABLE PULSES. FAMILY IN.\n\nPATIENT REVERSED, WOKE IMMEDIATELY. C/O INCISIONAL PAIN, MEDICATED WITH IV MS WITH EFFECT.\n" }, { "category": "Nursing/other", "chartdate": "2201-01-09 00:00:00.000", "description": "Report", "row_id": 1410784, "text": "NEURO: APPEARS INTACT, ORIENTED X 3, MAE, FOLLOWING COMMANDS.\n\nCARDAIC: PACER WILL NOT A PACE, BOX CHANGED, NEW BATTERY TRIED, POLARITY CHANGED WITH NO EFFECT. V DEMAND 50 SET. CO/CI ACCEPTABLE. TITRATING IV NEO TO KEEP SB/P ^ 100-120. PATIENT LIKED PAD IN 20 RANGE PER ANESTHESIA. CT'S PATENT FOR SMALL AMT SERO-SANG DRAINAGE. DOPPLERABLE PULSES.\n\nRESP: CS DIMINISHED IN BASES. EXTUBATED AT 1710, PHH AT 50% CHANGED TO NP'S 3 L. INSTRUCTED IN SPIROCARE. TV 500-700. POOR COUGH NOT RAISING.\n\nGI: OG DC'D WITH EXTUBATION. WILL ADVANCE DIET AS TOLERATED.\n\nGU: FOLEY IN PLACE, PATENT FOR CLEAR YELLOW URINE.\n\nENDO: INSULIN GTT ^, FOLLOWING PROTOCOL.\n\nPAIN: MEDICATED WITH IV MS X 3 WITH EFFECT.\n\nFAMILY: WIFE AND DAUGHTERS IN, AWARE OF EVENTS.\n\nPLAN: MONITOR HEMODYNAMICS, TITRATE IV NEO AS NEEDED FOR S B/P SUPPORT. FOLLOW INSULIN PROTOCOL. ADVANCCE DIET AS TOLERATED. ? OOB IN AM AND TRANSFER TO F2 IF OFF GTTS. ENCOURAGE PATIENT TO TAKE DEEP BREATHS AND COUGH. TURN Q2-3. MEDICATE WITH IV MS AS NEEDED.\n\n" }, { "category": "Nursing/other", "chartdate": "2201-01-10 00:00:00.000", "description": "Report", "row_id": 1410785, "text": "SEE CAREVUE FOR Q1H VS & I&0, OBJECTIVE DATA.\n\nNEURO: A&O X 3. MAE. NO DEFICITS. MORPHINE IV FOR PAIN CONTROL, PERCOCET 2 PO STARTED AT 0430.\n\nPULM: NEEDS ENCOURAGEMENT WITH COUGHING, USE OF IS. SPLINTS RESPIRATIONS D/T PAIN. SATS > 95% UNTIL ~ 0400 WHEN DROPPED TO 90% WHEN HR UP TO 128, N/C INCREASED TO 6L 70% FM ADDED. REMAINS ON FM AND N/C WITH SATS ~ 95% AFTER HR SLOWED TO 80'S. LUNGS DIMINISHED IN BASES. CT TO PLEUROVAC SX WITH MINIMAL SEROSANGUINOUS DRAINAGE, NO AIR LEAK, NO CREPITUS. T MAX 37.2 CORE, WBC UP TO 27K.\n\nCV: RIJ PA LINE. NSR 88-95 UNTIL ~ 0400 WHEN HR UP TO 128, SINUS WITH OCC PAC'S. DESATURATION TO 90% WITH SINUS TACH. CO 6.4/CI 2.98 WITH HR 120'S. LOPRESSOR 5MG IV X 1 WITH HR DROP TO 80'S SINUS. NEO TIRTATED TO KEEP SBP 100-110. MAG AND CA REPLETED. PALPABLE PEDAL PULSES.\n\nENDO: LOW DOSE INSULIN GTT WITH Q1H BS.\n\nGI: ABDOMEN SOFT, + BS. TAKING ICE CHIPS.\n\nGU: FOLEY TO CD WITH QS AMTS YELLOW URINE.\n\nSOCIAL: NO VISITORS OR PHONE INQUIRIES.\n\nPLAN: WEAN OFF NEO GTT. WEAN OFF OXYGEN. AGGRESSIVE PULM HYGIENE. DC ALINE TODAY ONCE NEO OFF, DC PA LINE. START PO LOPRESSOR. DC INSULIN GTT AT 0600 PER PROTOCOL. QID FSBS WITH SSRI COVERAGE. ADVANCE DIET. INCREASE ACTIVITY.\n\n\n" } ]

[ { "category": "Nursing/other", "chartdate": "2196-11-20 00:00:00.000", "description": "Report", "row_id": 1325437, "text": "pmicu nursing progress 7a-2p\nreview of systems\nCV-bp was high this am, was briefly on nipride before dialysis began, once dialysis started his bp was significantly lower and nipride was d/cd.now is 105-120/. receiving po hydralazine, labetolol.hr has been in the 80's nsr.\nRESp-wearing o2 2l with o2 sats 100%. rr has been 15-25, regular.lungs are improved from admission as per resident.no c/o SOB when o2 on.\nID-afebrile. wbc=3.3.on po azithromycin q sunday.\nGI-abd is soft with positive bowel sounds. eating well. no stool today. on ppi\nF/E-was dialysed for 2.7 L today and tolerated well. has facial edema but no peripheral edema noted.please see labs as listed in carevue.\nHEME-on heparin for a recent DVT (noncompliant with coumadin at home)heparin infusing at 1300u/hr- PTT at 12n was >150, and so heparin was held x 1 hour then restarted at 1000u/hr.\nSKIN- is intact, has a red streak on R arm from iv site where Ca had been infusing. heplock removed.\nNEURO- a+o x 3, cooperative.had arm pain at IV site, and was tx with 1000 mgs tylenol with good results.also had some restlessness, acting twitchy- no seizure activity noted.twitchiness resolved with dialysis. then slept in naps.\nENDO-have been checking periodic fingersticks have been stable.\nIV ACCESS-has a #20 heplock in R EJ. a-line removed.\nSOCIAL-no phone calls or visitors today.\na- pt called out s/p hemodialysis\np-to CC7. plan to dialyse tommorrow as per renal team.needs social work consult.\n" }, { "category": "Nursing/other", "chartdate": "2196-11-20 00:00:00.000", "description": "Report", "row_id": 1325436, "text": "NURSING PROGRESS NOTE 0200-0700\nREPORT RECIEVED FROM ER. PT ARRIVED VIA STRETCHER AND TX TO CC772 WITH NO UNTOWARD INCIDENT. ALL ALARMS ON MONITOR ARE FUNCTIONING PROPERLY. PT'S ENVIRONMENT SECURED FOR SAFETY.\n\nTHIS IS A 39 Y/O M WITH ESRD, DVT,HEP-C, HIV, HTN, IVDA, POLYSUBSTANCE ABUSE-TOBACCO AND ETOH THAT PRESENTED TO THE ER TODAY C/O SOB WITH WALKING FOR THE PAST TWO WEEKS. PT KNOWN TO BE MEDICALLY NON-COMPLIANT- HAS MISSED DIALYSIS FOR 1 WEEK. MS CHANGES IN ER- LETHARGIC. IN PT FOUND TO BE HYPERKALEMIC AND HYPOGLYCEMIC WITH A BLOOD SUGAR OF 5- SUBSEQUENTLY, PT HAD SEIZURE R/T TO BLOOD GLUCOSE LEVEL. TREATED WITH DEXTROSE, KAYEXALATE. PT KNOWN TO HAVE A BASELINE OF SBP IN THE 180'S. IN ER, SBP 200'S. PT HAD EMERGENT DIALYSIS- REMOVAL OF 2.4 L. TX TO MICU FOR BP CONTROL. UPON ARRIVAL HERE TO PT SBP IN THE 230'S. TARGET GOAL IS SBP 160-180'S. PT IS TO RECEIVE DIALYSIS THIS AM AS WELL.\n\nNEURO: PT IS SLEEPY BUT AWAKENS WITH VERBAL STIMULI AND IS THEN ALERT AND ORIENTED. PT ABLE TO MOVE AND REPOSITION HIMSELF WITHOUT DIFFICULTY. SPEECH CLEAR. PERRLA, 3/BRISK. LOW GRADE TEMP OF 99. NO SEIZURE ACTIVITY. MAE X 4 WITHOUT DIFFICULTY. EQUAL STRENGTH NOTED TO BILATERAL UPPER AND LOWER EXTREMITIES.\n\nRR: BBS= ESSENTIALLY COARSE TO BILATERAL UPPER LOBES AND DIMINISHED TO BILATERAL LOWER LOBES. PT HAS STRONG COUGH EFFORT- PRODUCTIVE FOR CLEAR SECRETIONS. RR 15-20 AND UNLABORED, NO C/O SOB OR DIFFICULTY BREATHING, NO INCREASED WOB NOTED. SP02 > OR = TO 95 ON RA. BILATERAL CHEST EXPANSION NOTED.\n\nCV: NSR-ST WITH HR 80-100'S. NO SIGNS OF ECTOPY. SBP VERY LABILE- HTN AT 230'S UPON ARRIVAL- CURRENTLY BETWEEN 160-180 RANGE. RECEIVED TOTAL OF 80MG HYDRALIZINE IV. STARTING ON ORAL REGIMEN OF LABETALOL AND HYRDRALIZINE. IF BP IS UNMANAGEABLE- START NIPRIDE GTT- HAS NOT NEEDED SO FAR. PALPABLE PULSES NOTED TO BILATERAL DORSALIS AND RADIALS. LT RADIAL ALINE IS SECURE AND PATENT. REZEROED AND RECALIBRATED DURING THE SHIFT. CURRENTLY ON HEPARIN GTT AT 1300U- FOR PTT 60-80. PENDING PTT LEVEL. PT WAS ALSO ON CAGLUC GTT FOR INITIAL CA OF .89. HAS BEEN WEANED OFF AS PER SLIDING SCALE PARAMETERS.\n\nGI: ABD IS SOFT, NON-DISTENDED AND NON-TENDER TO PALPATION. PT STATES THAT HE IS HUNGRY- TOLERATING PO'S WELL. BS X 4 QUADRANTS. PASSING FLATUS. NO BM THIS SHIFT.\n\nGU: PT DOES NOT MAKE URINE. SCHEDULED FOR DIALYSIS SOMETIME THIS AM.\n\nINTEG: NO SIGNS OF BREAKDOWN NOTED TO BACK OR BUTTOCKS.\n\nACCESS: PT IS A VERY DIFFICULT STICK. #20 TO RT WRIST AND # 20 TO RT EJ.\n\nSOCIAL: NO CONTACT WITH FAMILY THIS AM.\n\nPLAN: SBP 160-180. DIALYSIS THIS AM. BE POSSIBLE C/O TO FLOOR. THANK YOU.\n\n\n" }, { "category": "Radiology", "chartdate": "2196-11-20 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 841360, "text": " 4:22 AM\n CHEST (PORTABLE AP) Clip # \n Reason: L INFILTRATE?\n Admitting Diagnosis: HYPERKALEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 38 year old man with renal faliure and mild sob; s/p quinton catheter\n placement\n REASON FOR THIS EXAMINATION:\n L INFILTRATE?\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 38-year-old man with renal failure and mild shortness of breath.\n Status post Quinton catheter placement, ?infiltrate.\n\n AP supine portable chest at 4:00 a.m.: The examination is limited\n due to patient rotation. No significant change when compared to prior study\n 12 hours earlier. No acute infiltrates are seen. No change in the position\n of the catheter.\n\n" }, { "category": "Radiology", "chartdate": "2196-11-19 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 841333, "text": " 5:38 PM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o infiltrate\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 38 year old man with renal faliure and mild sob; s/p quinton catheter\n placement\n REASON FOR THIS EXAMINATION:\n r/o infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: 38-year-old male with renal failure and shortness of\n breath.\n\n TECHNIQUE: Portable AP chest.\n\n COMPARISON: Please note that the prior study is not currently available for\n comparison.\n\n FINDINGS: A hemodialysis catheter terminates within the proximal right\n atrium. The heart is enlarged with a left ventricular configuration. There\n is vascular fullness, consistent with mild volume overload. There is a hazy\n parenchymal opacity at the right lung base, concerning for early pneumonia.\n The lungs otherwise appear clear. There are no pleural effusions. The\n visualized osseous structures are within normal limits.\n\n IMPRESSION: Findings concerning for early right lower lobe pneumonia.\n Mild volume overload.\n\n" }, { "category": "ECG", "chartdate": "2196-11-19 00:00:00.000", "description": "Report", "row_id": 183695, "text": "Normal sinus rhythm\nNonspecific ST-T wave changes\nSince pervious tracing, no significant change\n\n" } ]

[ { "category": "Radiology", "chartdate": "2121-10-30 00:00:00.000", "description": "BY DIFFERENT PHYSICIAN", "row_id": 1045674, "text": " 1:26 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: ETT position\n Admitting Diagnosis: AIRWAY OBSTRUCTION/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man with TBM s/p rigid bronch with stent removal, now with new ETT\n REASON FOR THIS EXAMINATION:\n ETT position\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): 7:45 PM\n Endotracheal tube approximately 2.5 cm from carina. Distortion of the trachea\n suggests possible hyperinflation of the endotracheal balloon. Recommend\n checking cuff pressure.\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE AP CHEST RADIOGRAPH\n\n HISTORY: 53-year-old man with TBM. Status post rigid bronchoscopy with stent\n removal. Now with new endotracheal tube. Evaluate for endotracheal tube\n position.\n\n COMPARISON: Chest radiographs from and .\n\n FINDINGS: There is an endotracheal tube whose tip terminates approximately\n 2.6 cm from the carina. The carina is somewhat difficult to identify due to\n enlarged trachea and bronchi. There is slight enlargement of the mid trachea,\n which could be related to prior intervention, but may be also due to\n hyperinflation of the endotracheal balloon cuff and would recommend checking\n balloon cuff pressure. There is a right-sided central line in unchanged\n position. There is a nasogastric tube which courses through the esophagus.\n There are spinal stimulator devices in unchanged position. There is no\n pneumothorax. There is minimal plate-like atelectasis at the left base. There\n are no areas of consolidation, and there are no pleural effusions. The\n cardiac silhouette is normal in size. The aorta is mildly tortuous, but\n unchanged. The remainder of the hilar and mediastinal contours appear\n unremarkable.\n\n IMPRESSION:\n 1. Endotracheal tube with tip approximately 2.5 cm from carina.\n 2. Dilated contour of the trachea suggests possible overinflation of\n endotracheal balloon cuff and would recommend checking balloon cuff pressure.\n 3. Otherwise, unchanged chest radiograph.\n\n\n" }, { "category": "Radiology", "chartdate": "2121-10-30 00:00:00.000", "description": "BY DIFFERENT PHYSICIAN", "row_id": 1045675, "text": ", TSURG TSICU 1:26 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: ETT position\n Admitting Diagnosis: AIRWAY OBSTRUCTION/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man with TBM s/p rigid bronch with stent removal, now with new ETT\n REASON FOR THIS EXAMINATION:\n ETT position\n ______________________________________________________________________________\n PFI REPORT\n Endotracheal tube approximately 2.5 cm from carina. Distortion of the trachea\n suggests possible hyperinflation of the endotracheal balloon. Recommend\n checking cuff pressure.\n\n" }, { "category": "ECG", "chartdate": "2121-10-28 00:00:00.000", "description": "Report", "row_id": 180293, "text": "Sinus rhythm. RSR' pattern in leads V1-V2. Non-diagnostic inferior Q waves -\nconsider inferior myocardial infarction. No previous tracing available for\ncomparison.\n\n" }, { "category": "ECG", "chartdate": "2121-11-05 00:00:00.000", "description": "Report", "row_id": 180292, "text": "Technically difficult study\nSinus bradycardia\nrsr' in lead V1\nNondiagnostic inferior Q wave are noted\nNormal ECG except for rate\nSince previous tracing of , no significant change\n\n" }, { "category": "Respiratory ", "chartdate": "2121-10-28 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 644296, "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: OR\n Reason:\n Tube Type\n ETT:\n Position: 21 cm at teeth\n Route: Oral\n Type: Standard\n Size: 8mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Clear / Frothy\n Sputum source/amount: Suctioned / Scant\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing;\n Comments: pt remains intuabted s/p rigid bronch for removal of stents\n Assessment of breathing comfort: No response (sleeping / sedated)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours:\n Reason for continuing current ventilatory support: Cannot protect\n airway; Comments: pt airway very unstable due to tracheo-bronch malasia\n plan to return to OR for placement of stents\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n Pt has fragments of metal stent below and possible above ETT cuff, if\n balloon appears to not be holding air IP must be called for possible\n tube exchange. Plan to remain intubated at this time\n" }, { "category": "Nursing", "chartdate": "2121-11-07 00:00:00.000", "description": "Nursing Progress Note", "row_id": 645901, "text": "HPI:\n A 53-year-old gentleman sent from for evaluation of\n tracheobronchiomalacia, s/p multiple metal stents, now with stent\n fracture. Currently with 3 Polyflex stents, trachea and bilateral main\n stem. Walked in for elective procedure, on 3 L O2 baseline at home.\n Pt taken to bronch by IP for plan to remove old stents and place Y\n stent. There was multiple fractured pieces noted, the old plastic\n stents were removed. Airway collapse noted, and plan is to keep\n intubated for repeat procedures for removal, and thoracic c/s for\n tracheal reconstruction/plasty. s/p rigid bronch with removal of stents\n .\n Chief complaint:\n SOB, airway obstruction\n PMHx:\n DM II, CAD, L CVA 8 years ago, asthma, OSA, emphysema,\n tracheobroncheomalacia c/b multiple pneumonias and s/p stents both\n metal and plastic, ? Mounre-Kuhu syndrome (tracheomegaly), spinal\n fusion L3-4 w/ chronic lbp\n Tracheobronchomalacia (tracheomalacia, bronchomalacia)\n Assessment:\n Sent to OR at 1100 for tracheostomy. Returned at 1300 with in\n place.\n Action:\n Weaned quickly to trach mask with cuff down as per interventional\n pulmonary service. NGT placed.\n Response:\n Lungs rhonchorous -> clear with coughing and deep breathing.\n Expectorates thick blood tinged sputum in small amounts. SPO2 97-100%\n on 50% FiO2.\n Plan:\n Pulmonary toileting, continue to mobilze out of bed. Speech & swallow\n for PMV and eating in am.\n Pain control (acute pain, chronic pain)\n Assessment:\n Complains of neck/right chest pain, pain consistent with ongoing\n symptoms.\n Action:\n Dilaudid PCA started at 0.12, now up to 0.25/6/2.5mg.\n Response:\n Pain management currently not optimized.\n Plan:\n Continue to instruct patient on PCA use, assess need for larger doses\n of analgesics.\n" }, { "category": "Nutrition", "chartdate": "2121-11-04 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 645439, "text": "Objective\n Pertinent medications: NPH, RISS, SS lytes, heparin, pepcid, others\n noted\n Labs:\n Value\n Date\n Glucose\n 213 mg/dL\n 02:31 AM\n Glucose Finger Stick\n 165\n 10:00 AM\n BUN\n 24 mg/dL\n 02:16 AM\n Creatinine\n 0.7 mg/dL\n 02:16 AM\n Sodium\n 135 mEq/L\n 02:31 AM\n Potassium\n 4.3 mEq/L\n 02:31 AM\n Chloride\n 96 mEq/L\n 02:31 AM\n TCO2\n 26 mEq/L\n 02:16 AM\n PO2 (arterial)\n 86. mm Hg\n 09:19 AM\n PCO2 (arterial)\n 34 mm Hg\n 09:19 AM\n pH (arterial)\n 7.46 units\n 09:19 AM\n CO2 (Calc) arterial\n 25 mEq/L\n 09:19 AM\n Calcium non-ionized\n 8.1 mg/dL\n 02:51 PM\n Phosphorus\n 4.4 mg/dL\n 02:51 PM\n Ionized Calcium\n 1.16 mmol/L\n 02:31 AM\n Magnesium\n 2.2 mg/dL\n 02:51 PM\n Current diet order / nutrition support: Nutren Pulmonary @50mL/hr (1800\n kcals/82 gr aa)\n GI: Abd soft/dist/+bs\n Assessment of Nutritional Status\n Estimation of current intake: Adequate\n Specifics:\n Pt s/p flex bronch yesterday to remove remaining fragments of stents.\n Pt was tolerating TF\ns a/ s/ problems, and they were resumed post-op.\n Currently infusing @ goal, meeting 100% estimated nutrition needs.\n BG\ns remain elevated despite low formula. Insulin regimen being\n adjusted daily prn. Noted plan for trach tomorrow.\n Medical Nutrition Therapy Plan - Recommend the Following\n Multivitamin / Mineral supplement: via TF\n Tube feeding recommendations: Continue c/ TF's as ordered\n Continue to adjust insulin regimen prn\n Lyte management as you are\n Please page c/ ?\ns #\n" }, { "category": "Nursing", "chartdate": "2121-11-07 00:00:00.000", "description": "Nursing Progress Note", "row_id": 645902, "text": "HPI:\n A 53-year-old gentleman sent from for evaluation of\n tracheobronchiomalacia, s/p multiple metal stents, now with stent\n fracture. Currently with 3 Polyflex stents, trachea and bilateral main\n stem. Walked in for elective procedure, on 3 L O2 baseline at home.\n Pt taken to bronch by IP for plan to remove old stents and place Y\n stent. There was multiple fractured pieces noted, the old plastic\n stents were removed. Airway collapse noted, and plan is to keep\n intubated for repeat procedures for removal, and thoracic c/s for\n tracheal reconstruction/plasty. s/p rigid bronch with removal of stents\n .\n Chief complaint:\n SOB, airway obstruction\n PMHx:\n DM II, CAD, L CVA 8 years ago, asthma, OSA, emphysema,\n tracheobroncheomalacia c/b multiple pneumonias and s/p stents both\n metal and plastic, ? Mounre-Kuhu syndrome (tracheomegaly), spinal\n fusion L3-4 w/ chronic lbp\n Tracheobronchomalacia (tracheomalacia, bronchomalacia)\n Assessment:\n Sent to OR at 1100 for tracheostomy. Returned at 1300 with in\n place.\n Action:\n Weaned quickly to trach mask with cuff down as per interventional\n pulmonary service. NGT placed.\n Response:\n Lungs rhonchorous -> clear with coughing and deep breathing.\n Expectorates thick blood tinged sputum in small amounts. SPO2 97-100%\n on 50% FiO2.\n Plan:\n Pulmonary toileting, continue to mobilze out of bed. Speech & swallow\n for PMV and eating in am.\n Pain control (acute pain, chronic pain)\n Assessment:\n Complains of neck/right chest pain, pain consistent with ongoing\n symptoms.\n Action:\n Dilaudid PCA started at 0.12, now up to 0.25/6/2.5mg.\n Response:\n Pain management currently not optimized.\n Plan:\n Continue to instruct patient on PCA use, assess need for larger doses\n of analgesics.\n Anxiety\n Assessment:\n Pt is anxious about surgery. Pt states he has not slept in two days.\n Action:\n Ativan given PRN for anxiety.\n Ambien given x1\n Response:\n Pt appears to be sleeping most of shift. Ambien w/ +effect.\n Does wake shortly approx q2hrs & c/o pain.\n Plan:\n Continue to give emotional support, ativan as needed.\n ?Ambien qhs?\n" }, { "category": "Nursing", "chartdate": "2121-11-07 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 646015, "text": "A 53-year-old gentleman sent from for evaluation of\n tracheobronchomalacia, status post multiple metal stents, now with\n stent fracture. Currently with 3 Polyflex stents, trachea and bilateral\n main stem. Walked in for elective procedure, on 3 L O2 baseline at\n home. Pt taken to bronch by IP for plan to remove old stents and place\n Y stent. There was multiple fractured pieces noted, the old plastic\n stents were removed. Airway collapse noted, remained intubated until\n , when he was taken to the OR for trach placement.\n PMHx:\n DM II, CAD, L CVA 8 years ago, asthma, OSA, emphysema,\n tracheobroncheomalacia c/b multiple pneumonias and s/p stents both\n metal and plastic, ? Mounre-Kuhu syndrome (tracheomegaly), spinal\n fusion L3-4 w/ chronic lbp\n Current medications:\n Acetaminophen, Clonidine, Famotidine, Furosemide, Dilaudid, Heparin,\n Insulin, Lorazepam, Methadone, Piperacillin-Tazobactam, Prednisone,\n Simvastatin\n Tracheobronchomalacia (tracheomalacia, bronchomalacia)\n Assessment:\n tracheostomy secured 11cm at the flange with the cuff deflated.\n Lung sounds coarse/rhonchi with intermittent wheezes. SPO2 >97% on\n humidified trach mask and 4L nasal cannula. Pt primarily inspires air\n through his mouth / nose. Strong cough but no secretions raised, and no\n secretions are suctioned manually. Trach incision site has old dried\n blood with some serosanguenous oozing.\n Action:\n Nasal cannula for oxygenation as trach mask does not increase SpO2.\n Pulmonary toileting, out of bed to chair.\n Response:\n Adequate oxygenation with resolution of prior complaints of shortness\n of breath.\n Plan:\n Continue pulmonary toileting and wean oxygen as tolerated.\n Pain control (acute pain, chronic pain)\n Assessment:\n Complained of pain on first exam this morning. Poor compliance\n with PCA. States he has a high tolerance and requirement for pain\n medication.\n Action:\n Changed to 2mg dilaudid q2 hrs and increased methadone dose.\n Response:\n Pain now , which he states is\ngood\n and tolerable.\n Plan:\n Continue dilaudid 2mg iv q2hrs, hold for rr<10 or other signs of over\n sedation / respiratory depression.\n Alteration in Nutrition\n Assessment:\n Tube feeds replete with fiber @30mL/hr with residuals equal to several\n hours of feeding this am. Pt then self-d/c\nd ng tube while feeds were\n being advanced. Failed speech and swallow.\n Action:\n NGT replaced and tube feeds restarted at 10mL/ hr. Added hand mitts to\n protect tube.\n Response:\n Pt reports comfort with hand mitts, does not want to need tube replaced\n again.\n Plan:\n Advance tube feeds to goal of 80mL/hr as tolerated. Reglan and\n erythromycin for motility.\n Demographics\n Attending MD:\n \n Admit diagnosis:\n AIRWAY OBSTRUCTION/SDA\n Code status:\n Full code\n Height:\n Admission weight:\n 92.7 kg\n Daily weight:\n 87 kg\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions: No Additional Precautions\n PMH: Asthma, Diabetes - Insulin, Smoker\n CV-PMH: CAD, CVA\n Additional history: Mounic- syndrome, LBP, obstructive sleep apnea,\n Left CVA (8years ago), emphysema, tracheomegaly, spinal fusion L3-L4,\n multiple tracheal/broncheal stents, tracheostomy x8 mos, removed 6yrs\n ago.\n Surgery / Procedure and date: : Flexible and rigid bronchoscopy\n with stent removal-left intubated airway collapse and stent\n removed.\n 11/17flex bronch with stent removal some fragments are imbeded and were\n to difficult to remove.\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:133\n D:80\n Temperature:\n 97.2\n Arterial BP:\n S:113\n D:57\n Respiratory rate:\n 17 insp/min\n Heart Rate:\n 73 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n Nasal cannula, Trach mask\n O2 saturation:\n 99% %\n O2 flow:\n 12 L/min\n FiO2 set:\n 40% %\n 24h total in:\n 1,902 mL\n 24h total out:\n 1,795 mL\n Pertinent Lab Results:\n Sodium:\n 136 mEq/L\n 01:35 AM\n Potassium:\n 4.0 mEq/L\n 01:35 AM\n Chloride:\n 98 mEq/L\n 01:35 AM\n CO2:\n 25 mEq/L\n 01:35 AM\n BUN:\n 10 mg/dL\n 01:35 AM\n Creatinine:\n 0.7 mg/dL\n 01:35 AM\n Glucose:\n 95 mg/dL\n 01:35 AM\n Hematocrit:\n 37.8 %\n 01:35 AM\n Finger Stick Glucose:\n 178\n 04:00 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: T/\n Transferred to: 7\n Date & time of Transfer: 12:00 AM\n" }, { "category": "Nursing", "chartdate": "2121-11-05 00:00:00.000", "description": "Nursing Progress Note", "row_id": 645485, "text": "HPI:\n A 53-year-old gentleman sent from for evaluation of\n tracheobronchomalacia, status post multiple metal stents, now with\n stent fracture. Currently with 3 Polyflex stents, trachea and bilateral\n main stem. Walked in for elective procedure, on 3 L O2 baseline at\n home.\n Pt taken to bronch by IP for plan to remove old stents and place Y\n stent. There was multiple fractured pieces noted, the old plastic\n stents were removed. Airway collapse noted, and plan is to keep\n intubated for repeat procedures for removal, and thoracic c/s for\n tracheal reconstruction/plasty. s/p rigid bronch with removal of stents\n .\n Chief complaint:\n SOB, airway obstruction\n PMHx:\n DM II, CAD, L CVA 8 years ago, asthma, OSA, emphysema,\n tracheobroncheomalacia c/b multiple pneumonias and s/p stents both\n metal and plastic, ? Mounre-Kuhu syndrome (tracheomegaly), spinal\n fusion L3-4 w/ chronic lbp\n Plan: Plan for trach in am .\n" }, { "category": "Respiratory ", "chartdate": "2121-11-06 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 645718, "text": "Demographics\n Day of intubation: 10\n Day of mechanical ventilation: 10\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: Intubated for airway protection\n d/t trach.-bronch. malacia.\n Tube Type\n ETT:\n Position: 24 cm at teeth\n Route: Oral\n Type: Standard\n Size: 8mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Cuff volume: 7 mL / Air\n Lung sounds\n RLL Lung Sounds: Rhonchi\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Rhonchi\n Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount: Suctioned / Small\n Ventilation Assessment\n Level of breathing assistance: Intermittent invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No 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 Tracheostomy planned; Comments: Plan for OR for trach today.\n Reason for continuing current ventilatory support: Pending procedure /\n OR, Cannot protect airway\n" }, { "category": "Nursing", "chartdate": "2121-11-06 00:00:00.000", "description": "Nursing Progress Note", "row_id": 645711, "text": "HPI:\n A 53-year-old gentleman sent from for evaluation of\n tracheobronchiomalacia, s/p multiple metal stents, now with stent\n fracture. Currently with 3 Polyflex stents, trachea and bilateral main\n stem. Walked in for elective procedure, on 3 L O2 baseline at home.\n Pt taken to bronch by IP for plan to remove old stents and place Y\n stent. There was multiple fractured pieces noted, the old plastic\n stents were removed. Airway collapse noted, and plan is to keep\n intubated for repeat procedures for removal, and thoracic c/s for\n tracheal reconstruction/plasty. s/p rigid bronch with removal of stents\n .\n Chief complaint:\n SOB, airway obstruction\n PMHx:\n DM II, CAD, L CVA 8 years ago, asthma, OSA, emphysema,\n tracheobroncheomalacia c/b multiple pneumonias and s/p stents both\n metal and plastic, ? Mounre-Kuhu syndrome (tracheomegaly), spinal\n fusion L3-4 w/ chronic lbp\n Trach planned for today, . Pt is an add-on.\n Airway, Inability to Protect (Risk for Aspiration, Altered Gag, Airway\n Clearance, Cough)\n Assessment:\n -Pt remains intubated, SATS WNL, no respiratory distress noted.\n -OR (trach) cancelled for today\n Action:\n -PS decreased to 5\n -respiratory status monitored, suctioned PRN for thick white\n secretions.\n Response:\n SATS WNL. ABG pending at this time.\n Plan:\n Continue to monitor resp status, plan for trach tomorrow.\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt c/o right ear and throat chest pain.\n Action:\n -TSICU team and IP team into assess pt\ns pain, feel pain is related to\n prior procedures and ETT tube. Ear pain assessed with otoscope, no\n infection present per resident.\n -Dilaudid ordered and given frequently for throat/chest pain\n -Pseudoephedrine given for ear pain.\n Response:\n Pt still has pain present.\n Plan:\n Continue to assess pain. Plan for sleeping med overnight to provide\n sleep.\n Anxiety\n Assessment:\n Pt is anxious about surgery, increased after finding out OR case was\n cancelled for day. Pt states he has not slept in two days.\n Action:\n Ativan given PRN for anxiety.\n Response:\n Pt remains alert, yet able to doze off at times.\n Plan:\n Continue to give emotional support, ativan as needed.\n" }, { "category": "Nursing", "chartdate": "2121-11-06 00:00:00.000", "description": "Nursing Progress Note", "row_id": 645713, "text": "HPI:\n A 53-year-old gentleman sent from for evaluation of\n tracheobronchiomalacia, s/p multiple metal stents, now with stent\n fracture. Currently with 3 Polyflex stents, trachea and bilateral main\n stem. Walked in for elective procedure, on 3 L O2 baseline at home.\n Pt taken to bronch by IP for plan to remove old stents and place Y\n stent. There was multiple fractured pieces noted, the old plastic\n stents were removed. Airway collapse noted, and plan is to keep\n intubated for repeat procedures for removal, and thoracic c/s for\n tracheal reconstruction/plasty. s/p rigid bronch with removal of stents\n .\n Chief complaint:\n SOB, airway obstruction\n PMHx:\n DM II, CAD, L CVA 8 years ago, asthma, OSA, emphysema,\n tracheobroncheomalacia c/b multiple pneumonias and s/p stents both\n metal and plastic, ? Mounre-Kuhu syndrome (tracheomegaly), spinal\n fusion L3-4 w/ chronic lbp\n Trach planned for today, . Pt is an add-on.\n Airway, Inability to Protect (Risk for Aspiration, Altered Gag, Airway\n Clearance, Cough)\n Assessment:\n Pt remains intubated, SATS WNL, no respiratory distress noted. No vent\n changes made.\n Action:\n Respiratory status monitored, suctioned PRN for thick white\n secretions.\n ABG obtained\n Oral care provided per VAP protocol\n Response:\n SATS, ABG WNL. Pt continues to appear comfortable on the\n vent.\n Plan:\n Continue to monitor resp status, suction PRN, frequent oral\n care.\n Plan for trach today.\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt c/o throat/chest pain. C/o ear pain minimal.\n Action:\n TSICU team and IP team into assess pt\ns pain, feel pain is\n related to prior procedures and ETT tube. Ear pain assessed with\n otoscope, no infection present per resident--- assessed 11/19 days.\n PRN Fentanyl & Dilaudid given for pain\n PRN Pseudophedrine available for persistent ear pain\n Response:\n Pain meds w/ immediate, but short lasting effects. Pt\n resting comfortably approx 2hrs then will wake & c/o pain. ?relation to\n anxiety?\n Plan:\n Continue to assess pain. Maintain pts comfort\n Anxiety\n Assessment:\n Pt is anxious about surgery. Pt states he has not slept in two days.\n Action:\n Ativan given PRN for anxiety.\n Ambien given x1\n Response:\n Pt appears to be sleeping most of shift. Ambien w/ +effect.\n Does wake shortly approx q2hrs & c/o pain.\n Plan:\n Continue to give emotional support, ativan as needed.\n ?Ambien qhs?\n" }, { "category": "Nursing", "chartdate": "2121-11-06 00:00:00.000", "description": "Nursing Progress Note", "row_id": 645714, "text": "HPI:\n A 53-year-old gentleman sent from for evaluation of\n tracheobronchiomalacia, s/p multiple metal stents, now with stent\n fracture. Currently with 3 Polyflex stents, trachea and bilateral main\n stem. Walked in for elective procedure, on 3 L O2 baseline at home.\n Pt taken to bronch by IP for plan to remove old stents and place Y\n stent. There was multiple fractured pieces noted, the old plastic\n stents were removed. Airway collapse noted, and plan is to keep\n intubated for repeat procedures for removal, and thoracic c/s for\n tracheal reconstruction/plasty. s/p rigid bronch with removal of stents\n .\n Chief complaint:\n SOB, airway obstruction\n PMHx:\n DM II, CAD, L CVA 8 years ago, asthma, OSA, emphysema,\n tracheobroncheomalacia c/b multiple pneumonias and s/p stents both\n metal and plastic, ? Mounre-Kuhu syndrome (tracheomegaly), spinal\n fusion L3-4 w/ chronic lbp\n Trach planned for today, . Pt is an add-on.\n Airway, Inability to Protect (Risk for Aspiration, Altered Gag, Airway\n Clearance, Cough)\n Assessment:\n Pt remains intubated, SATS WNL, no respiratory distress noted. No vent\n changes made.\n Action:\n Respiratory status monitored, suctioned PRN for thick white\n secretions.\n ABG obtained\n Oral care provided per VAP protocol\n Response:\n SATS, ABG WNL. Pt continues to appear comfortable on the\n vent.\n Plan:\n Continue to monitor resp status, suction PRN, frequent oral\n care.\n Plan for trach today.\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt c/o throat/chest pain. C/o ear pain minimal.\n Action:\n TSICU team and IP team into assess pt\ns pain, feel pain is\n related to prior procedures and ETT tube. Ear pain assessed with\n otoscope, no infection present per resident--- assessed 11/19 days.\n PRN Fentanyl & Dilaudid given for pain\n PRN Pseudophedrine available for persistent ear pain\n Response:\n Pain meds w/ immediate, but short lasting effects. Pt\n resting comfortably approx 2hrs then will wake & c/o pain. ?relation to\n anxiety?\n Plan:\n Continue to assess pain. Maintain pts comfort\n Anxiety\n Assessment:\n Pt is anxious about surgery. Pt states he has not slept in two days.\n Action:\n Ativan given PRN for anxiety.\n Ambien given x1\n Response:\n Pt appears to be sleeping most of shift. Ambien w/ +effect.\n Does wake shortly approx q2hrs & c/o pain.\n Plan:\n Continue to give emotional support, ativan as needed.\n ?Ambien qhs?\n" }, { "category": "Nursing", "chartdate": "2121-11-07 00:00:00.000", "description": "Nursing Progress Note", "row_id": 645900, "text": "Tracheobronchomalacia (tracheomalacia, bronchomalacia)\n Assessment:\n Sent to OR at 1100 for tracheostomy. Returned at 1300 with in\n place.\n Action:\n Weaned quickly to trach mask with cuff down as per interventional\n pulmonary service. NGT placed.\n Response:\n Lungs rhonchorous -> clear with coughing and deep breathing.\n Expectorates thick blood tinged sputum in small amounts. SPO2 97-100%\n on 50% FiO2.\n Plan:\n Pulmonary toileting, continue to mobilze out of bed. Speech & swallow\n for PMV and eating in am.\n Pain control (acute pain, chronic pain)\n Assessment:\n Complains of neck/right chest pain, pain consistent with ongoing\n symptoms.\n Action:\n Dilaudid PCA started at 0.12, now up to 0.25/6/2.5mg.\n Response:\n Pain management currently not optimized.\n Plan:\n Continue to instruct patient on PCA use, assess need for larger doses\n of analgesics.\n" }, { "category": "Nursing", "chartdate": "2121-11-05 00:00:00.000", "description": "Nursing Progress Note", "row_id": 645486, "text": "HPI:\n A 53-year-old gentleman sent from for evaluation of\n tracheobronchomalacia, status post multiple metal stents, now with\n stent fracture. Currently with 3 Polyflex stents, trachea and bilateral\n main stem. Walked in for elective procedure, on 3 L O2 baseline at\n home.\n Pt taken to bronch by IP for plan to remove old stents and place Y\n stent. There was multiple fractured pieces noted, the old plastic\n stents were removed. Airway collapse noted, and plan is to keep\n intubated for repeat procedures for removal, and thoracic c/s for\n tracheal reconstruction/plasty. s/p rigid bronch with removal of stents\n .\n Chief complaint:\n SOB, airway obstruction\n PMHx:\n DM II, CAD, L CVA 8 years ago, asthma, OSA, emphysema,\n tracheobroncheomalacia c/b multiple pneumonias and s/p stents both\n metal and plastic, ? Mounre-Kuhu syndrome (tracheomegaly), spinal\n fusion L3-4 w/ chronic lbp\n Plan: Plan for trach in am .\n Airway, Inability to Protect (Risk for Aspiration, Altered Gag, Airway\n Clearance, Cough)\n Assessment:\n Pt remains intubated, sxn\ns for thick yellow secretions. Able to also\n cough up and sxn himself orally. Sats WNL dipped to 90% but increased\n to 99% after sxn\nd. Pt difficult intubation plan for trach in am. Also\n c/o OGT coming out at times when coughing- advanced and rechecked for\n placement.\n Action:\n OGT clamped for OR in am. TF held at this time. Currently NPO except\n meds.\n Response:\n SaO2 remain above 97%\n Plan:\n Continue to monitor sats and sxn prn.\n" }, { "category": "Nursing", "chartdate": "2121-11-07 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 645996, "text": "A 53-year-old gentleman sent from for evaluation of\n tracheobronchomalacia, status post multiple metal stents, now with\n stent fracture. Currently with 3 Polyflex stents, trachea and bilateral\n main stem. Walked in for elective procedure, on 3 L O2 baseline at\n home. Pt taken to bronch by IP for plan to remove old stents and place\n Y stent. There was multiple fractured pieces noted, the old plastic\n stents were removed. Airway collapse noted, remained intubated until\n , when he was taken to the OR for trach placement.\n PMHx:\n DM II, CAD, L CVA 8 years ago, asthma, OSA, emphysema,\n tracheobroncheomalacia c/b multiple pneumonias and s/p stents both\n metal and plastic, ? Mounre-Kuhu syndrome (tracheomegaly), spinal\n fusion L3-4 w/ chronic lbp\n Current medications:\n Acetaminophen, Clonidine, Famotidine, Furosemide, Dilaudid, Heparin,\n Insulin, Lorazepam, Methadone, Piperacillin-Tazobactam, Prednisone,\n Simvastatin\n Tracheobronchomalacia (tracheomalacia, bronchomalacia)\n Assessment:\n tracheostomy\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": "2121-11-07 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 645997, "text": "A 53-year-old gentleman sent from for evaluation of\n tracheobronchomalacia, status post multiple metal stents, now with\n stent fracture. Currently with 3 Polyflex stents, trachea and bilateral\n main stem. Walked in for elective procedure, on 3 L O2 baseline at\n home. Pt taken to bronch by IP for plan to remove old stents and place\n Y stent. There was multiple fractured pieces noted, the old plastic\n stents were removed. Airway collapse noted, remained intubated until\n , when he was taken to the OR for trach placement.\n PMHx:\n DM II, CAD, L CVA 8 years ago, asthma, OSA, emphysema,\n tracheobroncheomalacia c/b multiple pneumonias and s/p stents both\n metal and plastic, ? Mounre-Kuhu syndrome (tracheomegaly), spinal\n fusion L3-4 w/ chronic lbp\n Current medications:\n Acetaminophen, Clonidine, Famotidine, Furosemide, Dilaudid, Heparin,\n Insulin, Lorazepam, Methadone, Piperacillin-Tazobactam, Prednisone,\n Simvastatin\n Tracheobronchomalacia (tracheomalacia, bronchomalacia)\n Assessment:\n tracheostomy secured 11cm at the flange with the cuff deflated.\n Lung sounds coarse/rhonchi with intermittent wheezes. SPO2 >97% on\n humidified trach mask and 4L nasal cannula. Pt primarily inspires air\n through his mouth / nose. Strong cough but no secretions raised, and no\n secretions are suctioned manually. Trach incision site has old dried\n blood with some serosanguenous oozing.\n Action:\n Nasal cannula for oxygenation as trach mask does not increase SpO2.\n Pulmonary toileting, out of bed to chair.\n Response:\n Adequate oxygenation with resolution of prior complaints of shortness\n of breath.\n Plan:\n Continue pulmonary toileting and wean oxygen as tolerated.\n Pain control (acute pain, chronic pain)\n Assessment:\n Complained of pain on first exam this morning. Poor compliance\n with PCA. States he has a high tolerance and requirement for pain\n medication.\n Action:\n Changed to 2mg dilaudid q2 hrs and increased methadone dose.\n Response:\n Pain now , which he states is\ngood\n and tolerable.\n Plan:\n Continue dilaudid 2mg iv q2hrs, hold for rr<10 or other signs of over\n sedation / respiratory depression.\n" }, { "category": "Nursing", "chartdate": "2121-11-07 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 645999, "text": "A 53-year-old gentleman sent from for evaluation of\n tracheobronchomalacia, status post multiple metal stents, now with\n stent fracture. Currently with 3 Polyflex stents, trachea and bilateral\n main stem. Walked in for elective procedure, on 3 L O2 baseline at\n home. Pt taken to bronch by IP for plan to remove old stents and place\n Y stent. There was multiple fractured pieces noted, the old plastic\n stents were removed. Airway collapse noted, remained intubated until\n , when he was taken to the OR for trach placement.\n PMHx:\n DM II, CAD, L CVA 8 years ago, asthma, OSA, emphysema,\n tracheobroncheomalacia c/b multiple pneumonias and s/p stents both\n metal and plastic, ? Mounre-Kuhu syndrome (tracheomegaly), spinal\n fusion L3-4 w/ chronic lbp\n Current medications:\n Acetaminophen, Clonidine, Famotidine, Furosemide, Dilaudid, Heparin,\n Insulin, Lorazepam, Methadone, Piperacillin-Tazobactam, Prednisone,\n Simvastatin\n Tracheobronchomalacia (tracheomalacia, bronchomalacia)\n Assessment:\n tracheostomy secured 11cm at the flange with the cuff deflated.\n Lung sounds coarse/rhonchi with intermittent wheezes. SPO2 >97% on\n humidified trach mask and 4L nasal cannula. Pt primarily inspires air\n through his mouth / nose. Strong cough but no secretions raised, and no\n secretions are suctioned manually. Trach incision site has old dried\n blood with some serosanguenous oozing.\n Action:\n Nasal cannula for oxygenation as trach mask does not increase SpO2.\n Pulmonary toileting, out of bed to chair.\n Response:\n Adequate oxygenation with resolution of prior complaints of shortness\n of breath.\n Plan:\n Continue pulmonary toileting and wean oxygen as tolerated.\n Pain control (acute pain, chronic pain)\n Assessment:\n Complained of pain on first exam this morning. Poor compliance\n with PCA. States he has a high tolerance and requirement for pain\n medication.\n Action:\n Changed to 2mg dilaudid q2 hrs and increased methadone dose.\n Response:\n Pain now , which he states is\ngood\n and tolerable.\n Plan:\n Continue dilaudid 2mg iv q2hrs, hold for rr<10 or other signs of over\n sedation / respiratory depression.\n Alteration in Nutrition\n Assessment:\n Tube feeds replete with fiber @30mL/hr with residuals equal to several\n hours of feeding this am. Pt then self-d/c\nd ng tube while feeds were\n being advanced. Failed speech and swallow.\n Action:\n NGT replaced and tube feeds restarted at 10mL/ hr. Added hand mitts to\n protect tube.\n Response:\n Pt reports comfort with hand mitts, does not want to need tube replaced\n again.\n Plan:\n Advance tube feeds to goal of 80mL/hr as tolerated. Reglan and\n erythromycin for motility.\n" }, { "category": "Respiratory ", "chartdate": "2121-11-06 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 645825, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 10\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Yes\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type: Not applicable\n Size: Not applicable\n Tracheostomy tube:\n Type: Cuffed, Adjustable Neck Flange\n Manufacturer: \n Size: 8.0mm\n PMV: No\n Cuff Management:\n Vol/Press:\n Cuff pressure: 26 cmH2O\n Cuff volume: 8 mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Blood Tinged / Thin\n Sputum source/amount: Suctioned / None\n Comments:\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern:\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours:\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n Patient extubated had tracheostomy done xlong was inserted, is\n 10 at the flange, patient now weaned to trach mask with cool mist 40%,\n eupneic breath sounds diminished and rhoncherous, small amounts of\n thin bloody secretions suctioned , has been treated with Albuterol\n inhaler, will continues to be followed, while vent is on Stand By at\n bedside.\n" }, { "category": "Nursing", "chartdate": "2121-11-04 00:00:00.000", "description": "Nursing Progress Note", "row_id": 645374, "text": "53 year old male with hx of mounic- syndrome. S/p multiple metallic\n stents. Admitted to for SOB and productive cough and sensation\n of stent irritating trachea.\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt c/o right ear ache. MD in to assess. Slight swelling noted to\n inner cannula. No discharge noted\n Action:\n Fentanyl given ivpush q 2hours for discomfort. Pseudoephedrine given po\n q 6hours prn for discomfort with little effect.\n Response:\n Pt continues to c/o of right earache.\n Plan:\n Continue with pseudoephedrine prn for discomfort. Questionable requires\n antibiotic therapy for possible ear infection.\n Airway, Inability to Protect (Risk for Aspiration, Altered Gag, Airway\n Clearance, Cough)\n Assessment:\n Pt remains intubated. Arterial blood gases remain within normal range.\n Action:\n Fio2 weaned down to50% peep 10.\n Response:\n SaO2 remain above 97%\n Plan:\n Continue to wean down fio2 as tolerated. Monitor arterial blood gases.\n" }, { "category": "Respiratory ", "chartdate": "2121-11-05 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 645513, "text": "Demographics\n Day of intubation: 9\n Day of mechanical ventilation: 9\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: Elective; Comments: for airway protection\n Tube Type\n ETT:\n Position: 24 cm at teeth\n Route: Oral\n Type: Standard\n Size: 8mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 26 cmH2O\n Cuff volume: 7 mL / Air\n Lung sounds\n RLL Lung Sounds: Rhonchi\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Rhonchi\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Expectorated / Moderate\n Ventilation Assessment\n Level of breathing assistance: Intermittent invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n 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: Tracheostomy planned; Comments: Plan for\n tracheoplasty in OR today.\n Reason for continuing current ventilatory support: Pending procedure /\n OR\n" }, { "category": "Nursing", "chartdate": "2121-10-29 00:00:00.000", "description": "Nursing Progress Note", "row_id": 644516, "text": "53 yo male with hx of tracheobronchomalacia and Mounic- syndrome\n s/p multiple metallic stents (tracheal and bronchial), now with stent\n fracture. Pt originally from , being treated in \n but transferred here by MD for further care. Pt presented to \n on with SOB, + productive cough, sensation of stent wires\n irritating trachea. Pt taken to OR on for flexible and rigid\n bronchoscopy with 3 stents removed. Per anesthesia, fragments still\n remain in trachea. Pt is planned to have additional bronch and stent\n replacement within 24-48 hours, will remain intubated and in TSICU for\n several days.pt with very difficult airway. Please note do not advance\n or with draw ETT without having ip at bedside as pt still has stent\n fragments that could puncture balloon of ett and as he extremely\n swollen reintubation would be very difficult.\n Airway obstruction, Central / Upper\n Assessment:\n Pt with ETT , LS clear bilat and throughout, no wheezing auscultated,\n RR and 02 sats stable until 1730 when pt dropped sats to 89 suctioned\n for large amounts thick secretions returned to 96-98% sat. again\n dropped sats aabout 10 mins later suctioned and lavaged for thick tan\n plugs fio2 increased by resp to 60%\n Action:\n Sxn as needed, assessed for any obstruction\n Increased anxiety noted given fentanyl 50 mcgsi.v and propofol\n increased from 40 mcgsto 50 mcgs\n Response:\n Pt maintained a patent air way with intermittent plugging team aware\n Plan:\n Remain intubated until IR team completely remove fractured stents.\n And pt has good cuff leak prior to extubation.\n Tracheobronchomalacia (tracheomalacia, bronchomalacia)\n Assessment:\n Pt intubated and sedated ,ventilating well until 1730 when desatted see\n above.\n Action:\n No vent changes until 1700 when fip2 increased to 60%.suctioned for\n copius amounts of thick tan pink tinged secretions.\n Response:\n Pt intermittently desatting\n Plan:\n Procedure cancelled today as pt has no cuff leak and will assess for\n procedure as in am.\n" }, { "category": "Respiratory ", "chartdate": "2121-10-30 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 644563, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 3\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Yes\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type: Standard\n Size: 8mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Rhonchi\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Rhonchi\n Comments:\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Moderate\n Comments:\n Comments:\n Plan\n Next 24-48 hours:\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments: Pt remains on current vent settings. See vent flow sheet for\n details. Suctioned for mod amts thick tan secretions this AM.\n Occasional cuff leak. Cough very strong . Sedated with propofol and\n fentanyl.MDI\nS given.Pt may go to the OR today . Will cont to monitor\n resp status.\n" }, { "category": "Nursing", "chartdate": "2121-10-31 00:00:00.000", "description": "Nursing Progress Note", "row_id": 644883, "text": "Tracheobronchomalacia (tracheomalacia, bronchomalacia)\n Assessment:\n CPAP 5 pressure support and 10 cm H20 PEEP, # 7.5 ETT, + cuff leak with\n cuff pressure > than 25 mmHg, copious secretions.\n Action:\n Subglottal suctioning q 2 hrs, changed ETT to # 8.0, - cuff leak with\n cuff inflated to 20 mmHg, bronchoscopy for copious secretions.\n Response:\n Less secretions, improved ETT seal, improved tidal volumes.\n Plan:\n Continue to monitor and assess as ordered, remain intubated over the\n weekend, to OR on Monday .\n Assessment: Green/Yellow urine, on propofol for sedation/\n Action: Switched to lorazepam IVP.\n Response: Appropriate sedation with lorazepam.\n Plan: Continue to assess for elevated anxiety and treat with anxiolytic\n as ordered.\n" }, { "category": "Nursing", "chartdate": "2121-11-01 00:00:00.000", "description": "Nursing Progress Note", "row_id": 645024, "text": "Airway, Inability to Protect (Risk for Aspiration, Altered Gag, Airway\n Clearance, Cough)\n Assessment:\n Remains on CPAP and 50% with appropriate tidal volumes and\n respiratory rates.\n Action:\n Frequent suctioning required for thick copious yellow and white\n secretions, VAP care q 2 hrs, frequent cuff pressure checks with\n respiratory therapy, sedation and pain mgmt prn.\n Response:\n Remains lightly sedated and intubated.\n Plan:\n Prepare for OR on Monday.\n" }, { "category": "Physician ", "chartdate": "2121-11-02 00:00:00.000", "description": "Intensivist Note", "row_id": 645106, "text": "TSICU\n HPI:\n A 53-year-old gentleman sent from for evaluation of\n tracheobronchomalacia, status post multiple metal stents, now with\n stent fracture. Currently with 3 Polyflex stents, trachea and bilateral\n main stem. Walked in for elective procedure, on 3 L O2 baseline at\n home.\n Pt taken to bronch by IP for plan to remove old stents and place Y\n stent. There was multiple fractured pieces noted, the old plastic\n stents were removed. Airway collapse noted, and plan is to keep\n intubated for repeat procedures for removal, and thoracic c/s for\n tracheal reconstruction/plasty. s/p rigid bronch with removal of stents\n .\n Chief complaint:\n SOB, airway obstruction\n PMHx:\n DM II, CAD, L CVA 8 years ago, asthma, OSA, emphysema,\n tracheobroncheomalacia c/b multiple pneumonias and s/p stents both\n metal and plastic, ? Mounre-Kuhu syndrome (tracheomegaly), spinal\n fusion L3-4 w/ chronic lbp\n Current medications:\n Aspirin, Dexamethasone 4mg IV Q8, Fentanyl Citrate prn, morphine prn,\n Furosemide 20mg PO daily, Heparin 5000sc TID, RISS, Lorazepam,\n Methadone, famotidine, Propofol, Simvastatin\n 24 Hour Events:\n BRONCHOSCOPY - At 12:33 PM\n s/p ETT replacement from 7.5 to 8.0 ETT\n Post operative day:\n POD#5 - flex and rigid bronch removal of tracheal stents x3\n POD#3 - bronchoscopy with rigid bronch, removal of old stent wires, ETT\n changed over a cooks catheter now 7.5\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 02:00 AM\n Methadone Hydrochloride - 08:45 AM\n Fentanyl - 11:07 PM\n Lorazepam (Ativan) - 11:07 PM\n Heparin Sodium (Prophylaxis) - 12:47 AM\n Other medications:\n Flowsheet Data as of 01:43 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.7\nC (99.8\n T current: 37.7\nC (99.8\n HR: 75 (65 - 85) bpm\n BP: 139/66(88) {126/62(82) - 174/86(116)} mmHg\n RR: 17 (12 - 20) insp/min\n SPO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 92.1 kg (admission): 92.7 kg\n Total In:\n 1,511 mL\n 89 mL\n PO:\n 10 mL\n Tube feeding:\n 1,171 mL\n 81 mL\n IV Fluid:\n 180 mL\n 8 mL\n Blood products:\n Total out:\n 2,385 mL\n 100 mL\n Urine:\n 2,385 mL\n 100 mL\n NG:\n Stool:\n Drains:\n Balance:\n -875 mL\n -11 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 761 (511 - 761) mL\n PS : 5 cmH2O\n RR (Spontaneous): 21\n PEEP: 10 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10\n PIP: 16 cmH2O\n SPO2: 94%\n ABG: 7.46/44/80./29/6\n Ve: 12.6 L/min\n PaO2 / FiO2: 160\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Non-distended, Bowel sounds present\n Left Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n Moves all extremities\n Labs / Radiology\n 259 K/uL\n 11.7 g/dL\n 218 mg/dL\n 0.7 mg/dL\n 29 mEq/L\n 4.0 mEq/L\n 17 mg/dL\n 104 mEq/L\n 142 mEq/L\n 33.9 %\n 15.8 K/uL\n [image002.jpg]\n 08:00 AM\n 09:27 AM\n 01:48 PM\n 02:00 PM\n 03:14 PM\n 09:01 PM\n 09:39 PM\n 01:52 AM\n 02:51 AM\n 03:24 AM\n WBC\n 17.1\n 15.8\n Hct\n 33.6\n 33.9\n Plt\n 278\n 259\n Creatinine\n 0.6\n 0.7\n TCO2\n 31\n 31\n 29\n 27\n 28\n 32\n Glucose\n 35\n 218\n Other labs: PT / PTT / INR:14.1/27.7/1.2, Albumin:3.6 g/dL, Ca:8.6\n mg/dL, Mg:2.1 mg/dL, PO4:2.9 mg/dL\n Assessment and Plan\n TRACHEOBRONCHOMALACIA (TRACHEOMALACIA, BRONCHOMALACIA), AIRWAY,\n INABILITY TO PROTECT (RISK FOR ASPIRATION, ALTERED GAG, AIRWAY\n CLEARANCE, COUGH), AIRWAY OBSTRUCTION, CENTRAL / UPPER\n Assessment and Plan: 53M w/ tracheobronchomalacia s/p multiple tracheal\n stents presenting with stent fractures and SOB\n Neurologic: Pain controlled. Add clonidine for agitation, anxiety.\n Cardiovascular: Aspirin, Statins, cont home dose lasix\n Pulmonary: Cont ETT, (Ventilator mode: CPAP + PS), cont decadron for\n airway edema, plan for OR \n Gastrointestinal / Abdomen:\n Nutrition: Tube feeding\n Renal: Foley, Adequate UO, cont home dose lasix\n Hematology:\n Endocrine: RISS\n Infectious Disease:\n Lines / Tubes / Drains: Foley, OGT, ETT\n Wounds:\n Imaging:\n Fluids: KVO\n Consults: CT surgery, Interventional Pulmonology\n Billing Diagnosis: (Respiratory distress: Failure)\n ICU Care\n Nutrition:\n Nutren Pulmonary (Full) - 02:21 PM 50 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Indwelling Port (PortaCath) - 01:30 PM\n Arterial Line - 03:15 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: Patient discussed on interdisciplinary rounds Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 35 minutes\n" }, { "category": "Physician ", "chartdate": "2121-10-29 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 644402, "text": "Chief Complaint: SOB, airway obstruction\n 24 Hour Events:\n INDWELLING PORT (PORTACATH) - START 01:30 PM\n accessed by OR RNs.\n INVASIVE VENTILATION - START 01:30 PM\n OR RECEIVED - At 01:36 PM\n ARTERIAL LINE - START 03:15 PM\n placed by HO in room\n Pt came from OR as described above, remained sedated and intubated, RN\n noted high NG output, no blood and belly benign.\n History obtained from Medical records\n Patient unable to provide history: Sedated\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Propofol - 50 mcg/Kg/min\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 12:05 AM\n Fentanyl - 06:18 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Ear, Nose, Throat: OG / NG tube\n Respiratory: Dyspnea\n Genitourinary: Foley\n Pain: No pain / appears comfortable\n Flowsheet Data as of 07:06 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: 35.9\nC (96.7\n HR: 54 (52 - 98) bpm\n BP: 108/56(75) {94/54(68) - 133/67(90)} mmHg\n RR: 21 (15 - 49) insp/min\n SpO2: 96%\n Heart rhythm: SB (Sinus Bradycardia)\n Wgt (current): 92 kg (admission): 92.7 kg\n Total In:\n 1,028 mL\n 869 mL\n PO:\n TF:\n IVF:\n 1,028 mL\n 869 mL\n Blood products:\n Total out:\n 790 mL\n 1,060 mL\n Urine:\n 690 mL\n 460 mL\n NG:\n 100 mL\n 600 mL\n Stool:\n Drains:\n Balance:\n 238 mL\n -191 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 16\n RR (Spontaneous): 0\n PEEP: 10 cmH2O\n FiO2: 50%\n RSBI Deferred: Agitated\n PIP: 21 cmH2O\n Plateau: 19 cmH2O\n Compliance: 55.6 cmH2O/mL\n SpO2: 96%\n ABG: 7.42/50/90./30/6\n Ve: 7.5 L/min\n PaO2 / FiO2: 180\n Physical Examination\n General Appearance: Well nourished\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: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Bronchial:\n , Rhonchorous: )\n Abdominal: Soft, Bowel sounds present\n Extremities: Right: Absent, Left: Absent\n Skin: Warm\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Sedated,\n Tone: Not assessed\n Labs / Radiology\n 287 K/uL\n 12.0 g/dL\n 148 mg/dL\n 0.7 mg/dL\n 30 mEq/L\n 4.3 mEq/L\n 13 mg/dL\n 101 mEq/L\n 140 mEq/L\n 34.4 %\n 9.6 K/uL\n [image002.jpg]\n 03:43 PM\n 04:17 PM\n 01:48 AM\n 02:11 AM\n WBC\n 10.9\n 9.6\n Hct\n 34.8\n 34.4\n Plt\n 297\n 287\n Cr\n 0.8\n 0.7\n TCO2\n 32\n 34\n Glucose\n 185\n 148\n Other labs: PT / PTT / INR:14.1/27.7/1.2, Albumin:3.6 g/dL, Ca++:8.5\n mg/dL, Mg++:2.0 mg/dL, PO4:3.9 mg/dL\n Assessment and Plan\n TRACHEOBRONCHOMALACIA (TRACHEOMALACIA, BRONCHOMALACIA)\n AIRWAY, INABILITY TO PROTECT (RISK FOR ASPIRATION, ALTERED GAG,\n AIRWAY CLEARANCE, COUGH)\n AIRWAY OBSTRUCTION, CENTRAL / UPPER\n ASSESSMENT AND PLAN: 53 yo M, long hx of tracheobronchiomalacia w/\n multiple stents placed s/p stent fractures. Currently intubated for\n airway collapse and plan to go back to OR for stent removal and for\n thoracic c/s for tracheal reconstruction/plasty\n NEUROLOGIC: intubated/sedated\n sedation: propofol, ativan prn\n pain: methadone, fentanyl\n CARDIOVASCULAR: BP stable, was low on prop so minimal sedation,\n anesthesia using precedex to min prop. will con't asa/statin for CAD\n PULMONARY: vented, poor pulm tree but oxygenating/ventilating\n appropriately, plan to OR tmw for more stent fragment removal, thoracic\n c/s for recon/plasty. IP anticipates tracheostomy need. will check\n post-proc CXR and f/u BAL. will con't steroids w/ hydrocort given long\n term prednisone use.\n GI / ABD: NPO for now, place OGT and feed within next 24 hours\n NUTRITION: will start TF tmw after procedure\n RENAL: no issues\n HEMATOLOGY: no issues\n ENDOCRINE: SSI\n ID: no ABx for now, will f/u BAL\n LINES/TUBES/DRAINS: ETT, OGT, R portacath, PIV, foley\n WOUNDS: none\n IMAGING: CXR\n FLUIDS: LR @ 100\n CONSULTS: primary is , c/s\n BILLING DIAGNOSIS:\n ICU CARE:\n GLYCEMIC CONTROL: ssi\n PROPHYLAXIS: PPI, SCH, boots, VAP bundle\n COMMUNICATIONS: wife\n ICU Consent: pending wife\n CODE STATUS: presumed full\n DISPOSITION: ICU\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale, Blood sugar well\n controlled\n Lines:\n Indwelling Port (PortaCath) - 01:30 PM\n Arterial Line - 03:15 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care\n Need for restraints reviewed\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:ICU\n" }, { "category": "Nursing", "chartdate": "2121-11-05 00:00:00.000", "description": "Nursing Progress Note", "row_id": 645500, "text": "HPI:\n A 53-year-old gentleman sent from for evaluation of\n tracheobronchomalacia, status post multiple metal stents, now with\n stent fracture. Currently with 3 Polyflex stents, trachea and bilateral\n main stem. Walked in for elective procedure, on 3 L O2 baseline at\n home.\n Pt taken to bronch by IP for plan to remove old stents and place Y\n stent. There was multiple fractured pieces noted, the old plastic\n stents were removed. Airway collapse noted, and plan is to keep\n intubated for repeat procedures for removal, and thoracic c/s for\n tracheal reconstruction/plasty. s/p rigid bronch with removal of stents\n .\n Chief complaint:\n SOB, airway obstruction\n PMHx:\n DM II, CAD, L CVA 8 years ago, asthma, OSA, emphysema,\n tracheobroncheomalacia c/b multiple pneumonias and s/p stents both\n metal and plastic, ? Mounre-Kuhu syndrome (tracheomegaly), spinal\n fusion L3-4 w/ chronic lbp\n Plan: Plan for trach in am .\n Airway, Inability to Protect (Risk for Aspiration, Altered Gag, Airway\n Clearance, Cough)\n Assessment:\n Pt remains intubated, sxn\ns for thick yellow secretions. Able to also\n cough up and sxn himself orally. Sats WNL dipped to 90% but increased\n to 99% after sxn\nd. Pt difficult intubation plan for trach in am. Also\n c/o OGT coming out at times when coughing- advanced and rechecked for\n placement.\n Action:\n OGT clamped for OR in am. TF held at this time. Currently NPO except\n meds.\n Response:\n SaO2 remain above 97%\n Plan:\n Continue to monitor sats and sxn prn.\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt c/o right ear pain and also chest pain at times and discomfort from\n OGT\n Action:\n Fentanyl given prn and also Pseudoephedrine given po for ear pain.\n Response:\n Pt still states that he is having pain in ear- asked if he wanted hot\n compress pt refuses at this time.\n Plan:\n Continue to assess pain. Methadone dose in the am. Continue to provide\n reassurance.\n" }, { "category": "Social Work", "chartdate": "2121-11-05 00:00:00.000", "description": "Social Work Progress Note", "row_id": 645609, "text": "social work f/up\nsocial work f/up with transportation assistance for pt's wife who\nis staying at hospitality home from out of town. The plan\narranged w/ is that pt is to get T Pass to get to &\nfrom hospital. Tonight RN's requested that wife get cab voucher\nto get back to hospital early in the morning before pt's surgery\ntomorrow, which may be as early at 7am. Wife wanted to stay the\nnight in the but she is sick with pnemonia & there are many\nvisitors on tonight. RN staff felt it would be best if she\nreturn to hospitality home tonight for rest. SW provided her with\ncab voucher for tomorrow morning, dated tomorrow in the\nmorning. SW explained that this was to be used only tomorrow\nmorning b/c of the urgency to get her to hospital prior to\nsurgery. wife states she understands the terms & that in the\nfuture, only t passes will be given.\n Epperhart, LICSW\nPager \n" }, { "category": "Nutrition", "chartdate": "2121-11-07 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 645989, "text": "Objective\n Pertinent medications: SS lytes, pepcid, predisone, NPH, RISS, lasix,\n reglan, erythromycin, others noted\n Labs:\n Value\n Date\n Glucose\n 95 mg/dL\n 01:35 AM\n Glucose Finger Stick\n 158\n 10:00 AM\n BUN\n 10 mg/dL\n 01:35 AM\n Creatinine\n 0.7 mg/dL\n 01:35 AM\n Sodium\n 136 mEq/L\n 01:35 AM\n Potassium\n 4.0 mEq/L\n 01:35 AM\n Chloride\n 98 mEq/L\n 01:35 AM\n TCO2\n 25 mEq/L\n 01:35 AM\n PO2 (arterial)\n 80. mm Hg\n 01:45 AM\n PCO2 (arterial)\n 38 mm Hg\n 01:45 AM\n pH (arterial)\n 7.46 units\n 01:45 AM\n CO2 (Calc) arterial\n 28 mEq/L\n 01:45 AM\n Albumin\n 3.6 g/dL\n 01:48 AM\n Calcium non-ionized\n 8.5 mg/dL\n 01:35 AM\n Phosphorus\n 3.3 mg/dL\n 01:35 AM\n Ionized Calcium\n 1.13 mmol/L\n 01:45 AM\n Magnesium\n 2.0 mg/dL\n 01:35 AM\n Current diet order / nutrition support: Replete c/ Fiber @ 80mL/hr\n ( kcals/119 gr aa)\n GI: Abd: soft/dist/+bs\n Assessment of Nutritional Status\n Specifics:\n Pt now s/p trach. TF\ns resumed via NGT and advancing towards goal. Of\n note, team changed TF Rx-new Rx will meet 100% estimated nutrition\n needs. Would however, consider changing back to a volume restricted\n formula given pt receiving daily lasix and Na trending down. Pt failed\n swallow eval earlier today, SP to f/u early next week.\n Medical Nutrition Therapy Plan - Recommend the Following\n Multivitamin / Mineral supplement: via TF\n Consider changing TF to Nutren Pulmonary @ 55mL/hr ( kcals/90 gr\n aa)\n BG and lyte management as you are\n Repeat swallow study per SLP\n Please page c/?'s #\n" }, { "category": "Respiratory ", "chartdate": "2121-11-03 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 645296, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 7\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Yes\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: 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: 8 mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Moderate\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Tracheostomy planned\n Reason for continuing current ventilatory support: Underlying illness\n not resolved\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n Pt to Or for Flex bronch. Unable to remove some stents. Peep to 12\n after procedure. Later returned to 10.\n" }, { "category": "Nursing", "chartdate": "2121-11-07 00:00:00.000", "description": "Nursing Progress Note", "row_id": 645935, "text": "HPI:\n A 53-year-old gentleman sent from for evaluation of\n tracheobronchiomalacia, s/p multiple metal stents, now with stent\n fracture. Currently with 3 Polyflex stents, trachea and bilateral main\n stem. Walked in for elective procedure, on 3 L O2 baseline at home.\n Pt taken to bronch by IP for plan to remove old stents and place Y\n stent. There was multiple fractured pieces noted, the old plastic\n stents were removed. Airway collapse noted, and plan is to keep\n intubated for repeat procedures for removal, and thoracic c/s for\n tracheal reconstruction/plasty. s/p rigid bronch with removal of stents\n .\n Chief complaint:\n SOB, airway obstruction\n PMHx:\n DM II, CAD, L CVA 8 years ago, asthma, OSA, emphysema,\n tracheobroncheomalacia c/b multiple pneumonias and s/p stents both\n metal and plastic, ? Mounre-Kuhu syndrome (tracheomegaly), spinal\n fusion L3-4 w/ chronic lbp\n" }, { "category": "Physician ", "chartdate": "2121-10-31 00:00:00.000", "description": "Intensivist Note", "row_id": 644785, "text": "TSICU\n HPI:\n A 53-year-old gentleman sent from for evaluation of\n tracheobronchomalacia, status post multiple metal stents, now with\n stent fracture. Currently with 3 Polyflex stents, trachea and bilateral\n main stem. Walked in for elective procedure, on 3 L O2 baseline at\n home.\n Pt taken to bronch by IP for plan to remove old stents and place Y\n stent. There was multiple fractured pieces noted, the old plastic\n stents were removed. Airway collapse noted, and plan is to keep\n intubated for repeat procedures for removal, and thoracic c/s for\n tracheal reconstruction/plasty. s/p rigid bronch with removal of stents\n .\n Chief complaint:\n SOB, airway obstruction\n PMHx:\n DM II, CAD, L CVA 8 years ago, asthma, OSA, emphysema,\n tracheobroncheomalacia c/b multiple pneumonias and s/p stents both\n metal and plastic, ? Mounre-Kuhu syndrome (tracheomegaly), spinal\n fusion L3-4 w/ chronic lbp\n Current medications:\n Aspirin, Dexamethasone 4mg IV Q8, Fentanyl Citrate, Furosemide 20mg PO\n daily, Heparin 5000sc TID, RISS, Lorazepam, Methadone, Pantoprazole,\n Propofol, Simvastatin\n 24 Hour Events:\n OR SENT - At 10:55 AM\n EXTUBATION - At 12:45 PM\n IN OR\n INTUBATION - At 12:45 PM\n In OR\n BAL FLUID CULTURE - At 12:45 PM\n In OR\n OR RECEIVED - At 12:45 PM\n Taken to OR for stent removal, most of the stent were able to be\n removed, however one small fragment remained secondary to granulation.\n Tube feeds started.\n Post operative day:\n POD#3 - flex and rigid bronch removal of tracheal stents x3\n POD#1 - bronchoscopy with rigid bronch, removal of old stent wires, ETT\n changed over a cooks catheter now 7.5\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Propofol - 60 mcg/Kg/min\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 12:00 AM\n Fentanyl - 01:30 AM\n Pantoprazole (Protonix) - 02:02 AM\n Other medications:\n Flowsheet Data as of 04:35 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 36.6\nC (97.8\n T current: 36.2\nC (97.2\n HR: 61 (58 - 96) bpm\n BP: 130/61(85) {105/51(70) - 165/82(107)} mmHg\n RR: 12 (12 - 44) insp/min\n SPO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 92 kg (admission): 92.7 kg\n Total In:\n 2,852 mL\n 609 mL\n PO:\n Tube feeding:\n 4 mL\n 47 mL\n IV Fluid:\n 2,728 mL\n 542 mL\n Blood products:\n Total out:\n 3,755 mL\n 565 mL\n Urine:\n 2,905 mL\n 565 mL\n NG:\n 300 mL\n Stool:\n Drains:\n 500 mL\n Balance:\n -903 mL\n 44 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 600 (600 - 600) mL\n Vt (Spontaneous): 527 (527 - 588) mL\n PS : 5 cmH2O\n RR (Set): 16\n RR (Spontaneous): 16\n PEEP: 10 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10\n PIP: 16 cmH2O\n Plateau: 18 cmH2O\n Compliance: 75 cmH2O/mL\n SPO2: 96%\n ABG: 7.43/41/101/28/2\n Ve: 7.5 L/min\n PaO2 / FiO2: 202\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : ), (Sternum: Stable )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Neurologic: Moves all extremities, Sedated\n Labs / Radiology\n 278 K/uL\n 11.6 g/dL\n 220 mg/dL\n 0.6 mg/dL\n 28 mEq/L\n 3.5 mEq/L\n 9 mg/dL\n 105 mEq/L\n 140 mEq/L\n 33.6 %\n 17.1 K/uL\n [image002.jpg]\n 02:26 AM\n 06:35 AM\n 08:00 AM\n 09:27 AM\n 01:48 PM\n 02:00 PM\n 03:14 PM\n 09:01 PM\n 09:39 PM\n 01:52 AM\n WBC\n 12.7\n 17.1\n Hct\n 34.6\n 33.6\n Plt\n 248\n 278\n Creatinine\n 0.7\n 0.6\n TCO2\n 30\n 31\n 31\n 29\n 27\n 28\n Glucose\n 20\n Other labs: PT / PTT / INR:14.1/27.7/1.2, Albumin:3.6 g/dL, Ca:8.6\n mg/dL, Mg:2.1 mg/dL, PO4:2.7 mg/dL\n Assessment and Plan\n TRACHEOBRONCHOMALACIA (TRACHEOMALACIA, BRONCHOMALACIA), AIRWAY,\n INABILITY TO PROTECT (RISK FOR ASPIRATION, ALTERED GAG, AIRWAY\n CLEARANCE, COUGH), AIRWAY OBSTRUCTION, CENTRAL / UPPER\n Assessment and Plan: 53 yo M, long hx of tracheobronchiomalacia w/\n multiple stents placed s/p stent fractures. Currently intubated for\n airway collapse and plan to go back to OR for stent removal and for\n thoracic c/s for tracheal reconstruction/plasty\n Neurologic: Pain controlled, Sedated with propofol, ativan.\n pain: methadone, fentanyl\n Cardiovascular: Aspirin, Statins, HD stable, cont asa, statin, lasix\n Pulmonary: Cont ETT, (Ventilator mode: CPAP + PS), vented, poor pulm\n tree but oxygenating/ventilating appropriately, plan for OR Monday for\n T-tube placement, thoracic c/s for recon/plasty. cont steroids for\n airway edema\n Gastrointestinal / Abdomen: OGT in place, abdomen benign\n Nutrition: Tube feeding, Cont to advance TF to goal\n Renal: Foley, Adequate UO, Stable, Cr 0.6, UOP stable\n Hematology: Stable, Hct 33.6\n Endocrine: RISS\n Infectious Disease: Check cultures, Afebrile, WBC 17 (12), no ABx for\n now, will f/u BAL\n : bronchial wash: >100K Moraxella Cat, GNR's\n : BAL - 3+ PMN, 2+ muliple organisms, 1+ epi's\n Lines / Tubes / Drains: Foley, OGT, ETT\n Wounds:\n Imaging:\n Fluids: D5 1/2 NS, D5 1/2NS 75cc/hr\n Consults: CT surgery, Pulmonology\n Billing Diagnosis:\n ICU Care\n Nutrition:\n Nutren Pulmonary (Full) - 11:34 PM 20 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Indwelling Port (PortaCath) - 01:30 PM\n Arterial Line - 03:15 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: ICU\n Total time spent: 35 minutes\n Patient is critically ill\n" }, { "category": "Respiratory ", "chartdate": "2121-11-03 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 645209, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 7\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Yes\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type: Standard\n Size: 8mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 28 cmH2O\n Cuff volume: 8 mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount: Suctioned / Moderate\n Comments:\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern:\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours:\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments: Pt remains on mechanical ventilation, PSV 5/10. will\n continue to wean support as tolerated.\n" }, { "category": "Respiratory ", "chartdate": "2121-11-04 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 645348, "text": "Demographics\n Day of intubation: 8\n Day of mechanical ventilation: 8\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 Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Cuff volume: 7 mL /\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: Yellow / 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:\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 Tracheostomy planned\n Reason for continuing current ventilatory support: Pending procedure /\n OR; Comments: Patient plan for trach in OR.\n" }, { "category": "Physician ", "chartdate": "2121-10-30 00:00:00.000", "description": "Intensivist Note", "row_id": 644546, "text": "TSICU\n HPI:\n A 53-year-old gentleman sent from for evaluation of\n tracheobronchomalacia, status post multiple\n metal stents, now with stent fracture. Currently with 3 Polyflex\n stents, trachea and bilateral main stem. Walked in for elective\n procedure, on 3 L O2 baseline at home.\n Chief complaint:\n SOB, airway obstruction\n PMHx:\n DM II, CAD, L CVA 8 years ago, asthma, OSA, emphysema,\n tracheobroncheomalacia c/b multiple pneumonias and s/p stents both\n metal and plastic, ? Mounre-Kuhu syndrome (tracheomegaly), spinal\n fusion L3-4 w/ chronic lbp\n Current medications:\n Aspirin, Dexamethasone 4mg IV Q8, Fentanyl Citrate, Furosemide 20mg PO\n daily, Heparin 5000sc TID, RISS, Lorazepam, Methadone, Pantoprazole,\n Propofol, Simvastatin\n 24 Hour Events:\n INDWELLING PORT (PORTACATH) - START 01:30 PM\n accessed by OR RNs.\n INVASIVE VENTILATION - START 01:30 PM\n OR RECEIVED - At 01:36 PM\n ARTERIAL LINE - START 03:15 PM\n placed by HO in room\n Post operative day:\n POD#2 - flex and rigid bronch removal of tracheal stents x3\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Propofol - 40 mcg/Kg/min\n Other ICU medications:\n Pantoprazole (Protonix) - 08:16 AM\n Fentanyl - 10:00 PM\n Heparin Sodium (Prophylaxis) - 12:00 AM\n Other medications:\n Flowsheet Data as of 03:07 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.1\nC (98.8\n T current: 36.5\nC (97.7\n HR: 62 (51 - 71) bpm\n BP: 130/63(87) {100/53(69) - 137/73(96)} mmHg\n RR: 32 (15 - 41) insp/min\n SPO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 92 kg (admission): 92.7 kg\n Total In:\n 2,910 mL\n 300 mL\n PO:\n Tube feeding:\n IV Fluid:\n 2,850 mL\n 300 mL\n Blood products:\n Total out:\n 3,140 mL\n 380 mL\n Urine:\n 2,140 mL\n 380 mL\n NG:\n 1,000 mL\n Stool:\n Drains:\n Balance:\n -230 mL\n -80 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST\n Vt (Set): 600 (500 - 600) mL\n RR (Set): 16\n RR (Spontaneous): 0\n PEEP: 10 cmH2O\n FiO2: 60%\n RSBI Deferred: Agitated\n PIP: 30 cmH2O\n Plateau: 22 cmH2O\n Compliance: 50 cmH2O/mL\n SPO2: 97%\n ABG: 7.46/42/122//6\n Ve: 9.5 L/min\n PaO2 / FiO2: 203\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Non-distended, Bowel sounds present\n Left Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n Moves all extremities, Sedated\n Labs / Radiology\n 248 K/uL\n 12.1 g/dL\n 148 mg/dL\n 0.7 mg/dL\n 30 mEq/L\n 3.4 mEq/L\n 13 mg/dL\n 101 mEq/L\n 140 mEq/L\n 34.6 %\n 12.7 K/uL\n [image002.jpg]\n 03:43 PM\n 04:17 PM\n 01:48 AM\n 02:11 AM\n 04:20 PM\n 06:39 PM\n 09:29 PM\n 02:26 AM\n WBC\n 10.9\n 9.6\n 12.7\n Hct\n 34.8\n 34.4\n 33.3\n 34.6\n Plt\n 297\n 287\n 248\n Creatinine\n 0.8\n 0.7\n TCO2\n 32\n 34\n 34\n 31\n Glucose\n 185\n 148\n Other labs: PT / PTT / INR:14.1/27.7/1.2, Albumin:3.6 g/dL, Ca:8.5\n mg/dL, Mg:2.0 mg/dL, PO4:3.9 mg/dL\n Assessment and Plan\n TRACHEOBRONCHOMALACIA (TRACHEOMALACIA, BRONCHOMALACIA), AIRWAY,\n INABILITY TO PROTECT (RISK FOR ASPIRATION, ALTERED GAG, AIRWAY\n CLEARANCE, COUGH), AIRWAY OBSTRUCTION, CENTRAL / UPPER\n Assessment and Plan: 53M tracheobronchomalacia, status post multiple\n metal stents, now with stent fracture\n Neurologic: Pain controlled, cont methadone, fent\n Cardiovascular: Aspirin, Statins, lasix daily home dose\n Pulmonary: Cont ETT, OR today to remove fractured stents, cont decadron\n to minimize airway edema\n Gastrointestinal / Abdomen:\n Nutrition: Tube feeding, to initiate when returns from OR\n Renal: Foley, Adequate UO\n Hematology:\n Endocrine: RISS\n Infectious Disease:\n Lines / Tubes / Drains: Foley, OGT, ETT\n Wounds:\n Imaging: CXR today\n Fluids: D5 1/2 NS\n Consults: CT surgery, Interventional pulmonology\n Billing Diagnosis: (Respiratory distress: Failure)\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Indwelling Port (PortaCath) - 01:30 PM\n Arterial Line - 03:15 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 35 minutes\n" }, { "category": "Nursing", "chartdate": "2121-11-07 00:00:00.000", "description": "Nursing Progress Note", "row_id": 645936, "text": "HPI:\n A 53-year-old gentleman sent from for evaluation of\n tracheobronchiomalacia, s/p multiple metal stents, now with stent\n fracture. Currently with 3 Polyflex stents, trachea and bilateral main\n stem. Walked in for elective procedure, on 3 L O2 baseline at home.\n Pt taken to bronch by IP for plan to remove old stents and place Y\n stent. There was multiple fractured pieces noted, the old plastic\n stents were removed. Airway collapse noted, and plan is to keep\n intubated for repeat procedures for removal, and thoracic c/s for\n tracheal reconstruction/plasty. s/p rigid bronch with removal of stents\n .\n Chief complaint:\n SOB, airway obstruction\n PMHx:\n DM II, CAD, L CVA 8 years ago, asthma, OSA, emphysema,\n tracheobroncheomalacia c/b multiple pneumonias and s/p stents both\n metal and plastic, ? Mounre-Kuhu syndrome (tracheomegaly), spinal\n fusion L3-4 w/ chronic lbp\n Tracheobronchomalacia (tracheomalacia, bronchomalacia)\n Assessment:\n Sent to OR at 1100 for tracheostomy. Returned at 1300 with in\n place.\n Action:\n Weaned quickly to trach mask with cuff down as per interventional\n pulmonary service. NGT placed.\n Response:\n Lungs rhonchorous -> clear with coughing and deep breathing.\n Expectorates thick blood tinged sputum in small amounts. SPO2 97-100%\n on 50% FiO2.\n Plan:\n Pulmonary toileting, continue to mobilze out of bed. Speech & swallow\n for PMV and eating in am.\n Pain control (acute pain, chronic pain)\n Assessment:\n Complains of neck/right chest pain, pain consistent with ongoing\n symptoms.\n Action:\n Dilaudid PCA started at 0.12, now up to 0.25/6/2.5mg.\n Response:\n Pain management currently not optimized.\n Plan:\n Continue to instruct patient on PCA use, assess need for larger doses\n of analgesics.\n" }, { "category": "Respiratory ", "chartdate": "2121-11-01 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 644927, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 5\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 Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type: Standard\n Size: 8mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Cuff volume: 10 mL /\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 Comments:\n Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount: Suctioned / Copious\n Comments:\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern: Normal quiet breathing\n :\n Trigger work assessment: Triggering synchronously\n Plan: Patient intubated on PSV. Current vent settings PSV10, Peep 5,\n Fio2 50%. Spont vols 600-700\ns with RR 11- to high teens. Patient\n desating x 1 to 90%. ? Secondary to secretions. Sx\nd for moderate\n amounts of secretions and copious amount x 1. BS with few expiratory\n wheezes L upper lung fields, R clear. O2 sats increasing back to 95%\n post sxing and Albuterol MDI RX. Albuterol MDI given Q4hr. Tolerated\n well. No further changes made. Increased secretions over the course of\n the shift. Strong cough effort.\n Plan: Continue with mechanical support. Wean Fio2 as tolerated.\n" }, { "category": "Nursing", "chartdate": "2121-11-02 00:00:00.000", "description": "Nursing Progress Note", "row_id": 645074, "text": "Airway, Inability to Protect (Risk for Aspiration, Altered Gag, Airway\n Clearance, Cough)\n Assessment:\n Remains intubated, no change in vent settings overnight, copious thick\n white secretions\n Action:\n Gas @ 0600, frequent sx. and mouth care, Fentanyl and ativan given ~ q2\n for pt. comfort\n Response:\n Continues with copious secretions, able to rest for short periods with\n Fent/ativan\n Plan:\n OR Mon., maintain pt. safety and comfort\n" }, { "category": "Nursing", "chartdate": "2121-10-30 00:00:00.000", "description": "Nursing Progress Note", "row_id": 644592, "text": "Tracheobronchomalacia (tracheomalacia, bronchomalacia)\n Assessment:\n Tracheal /bronchomalacia\n Action:\n Decadron Iv as ordered\n Response:\n +cuff leak\n Plan:\n To OR today for trach revision, new stent\n Airway, Inability to Protect (Risk for Aspiration, Altered Gag, Airway\n Clearance, Cough)\n Assessment:\n Ls clear /rhonchorous, strong productive cough,\n Action:\n Suctioned prn, sedated with propofol to prevent self extubation\n Response:\n Patent airway\n Plan:\n Maintain intubated post op until edema subsides\n" }, { "category": "Nursing", "chartdate": "2121-11-06 00:00:00.000", "description": "Nursing Progress Note", "row_id": 645832, "text": "Tracheobronchomalacia (tracheomalacia, bronchomalacia)\n Assessment:\n Sent to OR at 1100 for tracheostomy. Returned at 1300 with in\n place.\n Action:\n Weaned quickly to trach mask with cuff down as per interventional\n pulmonary service. NGT placed.\n Response:\n Lungs rhonchorous -> clear with coughing and deep breathing.\n Expectorates thick blood tinged sputum in small amounts. SPO2 97-100%\n on 50% FiO2.\n Plan:\n Pulmonary toileting, continue to mobilze out of bed. Speech & swallow\n for PMV and eating in am.\n Pain control (acute pain, chronic pain)\n Assessment:\n Complains of neck/right chest pain, pain consistent with ongoing\n symptoms.\n Action:\n Dilaudid PCA started at 0.12, now up to 0.25/6/2.5mg.\n Response:\n Pain management currently not optimized.\n Plan:\n Continue to instruct patient on PCA use, assess need for larger doses\n of analgesics.\n" }, { "category": "Respiratory ", "chartdate": "2121-11-07 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 645927, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 11\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 Tube Type\n Tracheostomy tube:\n Type: Cuffed done \n Manufacturer: \n Size: 7.0mm\n PMV: No\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Cuff volume: 8 mL /\n Airway problems:\n Comments: ( Cuff) Xlong @ ~10cmm at flange.\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: Blood Tinged / Thick\n Sputum source/amount: Suctioned / Scant\n Comments: minimal oral secretions, able to clear throat.\n Ventilation Assessment\n Level of breathing assistance: Unassisted spontaneous breathing on TC\n ~50%.\n Visual assessment of breathing pattern: Normal\n Assessment of breathing comfort: No claim of dyspnea)\n Plan\n Next 24-48 hours: Pt received on TC/ vent on St/by overnight.\n Reason for continuing current ventilatory support:\n" }, { "category": "Nursing", "chartdate": "2121-11-04 00:00:00.000", "description": "Nursing Progress Note", "row_id": 645459, "text": "A 53-year-old gentleman sent from for evaluation of\n tracheobronchomalacia, status post multiple metal stents, now with\n stent fracture. Currently with 3 Polyflex stents, trachea and bilateral\n main stem. Walked in for elective procedure, on 3 L O2 baseline at\n home.\n Pt taken to bronch by IP for plan to remove old stents and place Y\n stent. There was multiple fractured pieces noted, the old plastic\n stents were removed. Airway collapse noted, and plan is to keep\n intubated for repeat procedures for removal, and thoracic c/s for\n tracheal reconstruction/plasty. s/p rigid bronch with removal of stents\n .\n Plan for OR tomorrow. Turn off Tube Feeds at MN and start half NS at\n 75cc/hr.\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt C/o pain back and R ear. VSS.\n Action:\n Pt given fentanyl for pain per orders. Pt OOB to chair today for 1.5\n hrs. Pseudoephedrine given po\n Response:\n Pain more tolerable. Pt stated being OOB made the pain more tolerable.\n Plan:\n Continue to turn and provide meds as needed for pain control.\n Airway, Inability to Protect (Risk for Aspiration, Altered Gag, Airway\n Clearance, Cough)\n Assessment:\n Pt remains intubated. Arterial blood gases remain within normal range.\n O2 sat 96-98%. PCXR ordered. Pt c/o feeling the OGT move after\n coughing. Thick yellow/tan secretions suctioned from the ETT and pt\n mouth.\n Action:\n CXR done. OGT needs to be advanced 4in. Did get back GI secretions and\n tube feeds from OGT.\n Response:\n SaO2 remain above 97% Pt tolerated\n Plan:\n Continue to monitor pt and provide treatment as needed. Frequent\n suction. Check ABG in am. Plan for OR tomorrow for trach placement.\n" }, { "category": "Respiratory ", "chartdate": "2121-11-01 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 645009, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 5\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Yes\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route: 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: 24 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Clear\n Comments:\n Secretions\n Sputum color / consistency: 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 Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours:\n Reason for continuing current ventilatory support: Pending procedure /\n OR\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n" }, { "category": "Respiratory ", "chartdate": "2121-11-02 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 645068, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 6\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Yes\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type: Standard\n Size: 8mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 24 cmH2O\n Cuff volume: 10 mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Clear\n Comments:\n Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount: Suctioned / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern:\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments: Pt currently on PSV 5/10. Pt suctioned for moderate to\n copious white secretions. Pt requires frequent suctioning. Albuterol\n MDI given as ordered with good results.\n" }, { "category": "Nursing", "chartdate": "2121-11-05 00:00:00.000", "description": "Nursing Progress Note", "row_id": 645506, "text": "HPI:\n A 53-year-old gentleman sent from for evaluation of\n tracheobronchomalacia, status post multiple metal stents, now with\n stent fracture. Currently with 3 Polyflex stents, trachea and bilateral\n main stem. Walked in for elective procedure, on 3 L O2 baseline at\n home.\n Pt taken to bronch by IP for plan to remove old stents and place Y\n stent. There was multiple fractured pieces noted, the old plastic\n stents were removed. Airway collapse noted, and plan is to keep\n intubated for repeat procedures for removal, and thoracic c/s for\n tracheal reconstruction/plasty. s/p rigid bronch with removal of stents\n .\n Chief complaint:\n SOB, airway obstruction\n PMHx:\n DM II, CAD, L CVA 8 years ago, asthma, OSA, emphysema,\n tracheobroncheomalacia c/b multiple pneumonias and s/p stents both\n metal and plastic, ? Mounre-Kuhu syndrome (tracheomegaly), spinal\n fusion L3-4 w/ chronic lbp\n Plan: Plan for trach in am .\n Airway, Inability to Protect (Risk for Aspiration, Altered Gag, Airway\n Clearance, Cough)\n Assessment:\n Pt remains intubated, sxn\ns for thick yellow secretions. Able to also\n cough up and sxn himself orally. Sats WNL dipped to 90% but increased\n to 99% after sxn\nd. Pt difficult intubation plan for trach in am. Also\n c/o OGT coming out at times when coughing- advanced and rechecked for\n placement.\n Action:\n OGT clamped for OR in am. TF held at this time. Currently NPO except\n meds.\n Response:\n SaO2 remain above 97%\n Plan:\n Continue to monitor sats and sxn prn.\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt c/o right ear pain and also chest pain at times and discomfort from\n OGT\n Action:\n Fentanyl given prn and also Pseudoephedrine given po for ear pain.\n Response:\n Pt still states that he is having pain in ear- asked if he wanted hot\n compress pt refuses at this time.\n Plan:\n Continue to assess pain. Methadone dose in the am. Continue to provide\n reassurance.\n" }, { "category": "Nursing", "chartdate": "2121-10-31 00:00:00.000", "description": "Nursing Progress Note", "row_id": 644748, "text": "A 53-year-old gentleman sent from for evaluation of\n tracheobronchomalacia, status post multiple metal stents.\n : Pt taken to bronch by IP for plan to remove old stents and place\n Y stent. There was multiple fractured pieces noted, the old plastic\n stents were removed.\n : Rigid Bronch performed and removal of the remainder of the\n stents\n Airway, Inability to Protect (Risk for Aspiration, Altered Gag, Airway\n Clearance, Cough)\n Assessment:\n Pt had tracheobronchomalacia, ? syndrome. Pt a+ox3. LS\n rhoncherous. Lots of blood tinged secretions. Pt on CPAP with wnl ABG.\n Pt in a lot of pain.\n Action:\n Pt given IV Dexamethasone. Pt suctioned frequently. VAP care q2hr for\n positional cuff leak with induced coughing. Pt given prn Fentanyl\n frequently. ICU resident ordered Morphine prn as well.\n Response:\n With suctioning LS become clear. Pt pain decreased with pain\n management.\n Plan:\n Pt to be taken to OR on Monday to have a T tube trach placed and the\n removal of the last small agranulated stent. Keep intubated for airway\n protection over the weekend. Continue Pulmonary Toileting. Monitor\n pain and give prn fentanyl or morphine. Continue q2hr VAP care for cuff\n leak.\n Pt wife called last night and will be visit in the morning.\n" }, { "category": "Nursing", "chartdate": "2121-11-01 00:00:00.000", "description": "Nursing Progress Note", "row_id": 644960, "text": "Airway, Inability to Protect (Risk for Aspiration, Altered Gag, Airway\n Clearance, Cough)\n Assessment:\n Tracheobronchomalasia. Intubated on PS 5/PEEP 10/O2 50%. #8ETT. Breath\n sounds coarse bilaterally, moderate to large amts thick white sputum.\n Resp rate regular, nonlabored. Episode of desat to 90% last evening.\n Neurologically intact.\n Action:\n VAP bundle components/protocol maintained including frequent oral care\n per protocol. Fentanyl boluses for pain management. Ativan IV boluses\n for sedation. Frequent suctioning. Pt desat to 90% last evening,\n responded to suctioning.\n Response:\n Patient hemodynamically stable. Respiratory status stable, Patient\n airway, maintaining adequate oxygenation and ventilation.\n Plan:\n Continue hemodynamic, respiratory monitoring. Continue VAP bundle\n complinance including frequent oral care, subglottal suction. To remain\n intubated ventilated next few days, return to OR for trach on Monday.\n Continue to provide patient/family information, emotional support.\n" }, { "category": "Physician ", "chartdate": "2121-11-01 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 644963, "text": "Chief Complaint: SOB, airway obstruction\n 24 Hour Events:\n BRONCHOSCOPY - At 12:33 PM\n s/p ETT replacement from 7.5 to 8.0 ETT\n d/c prop, sed w/ ativan/fentanyl, inc nutrition goal at 50, kvo ivf,\n inc secretions but clear. gas PaO2 80. no changes in vent made.\n History obtained from Family / Medical records\n Patient unable to provide history: Sedated\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Methadone Hydrochloride - 08:00 AM\n Heparin Sodium (Prophylaxis) - 01:00 AM\n Pantoprazole (Protonix) - 02:00 AM\n Lorazepam (Ativan) - 03:50 AM\n Fentanyl - 03:50 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Ear, Nose, Throat: OG / NG tube\n Nutritional Support: Tube feeds\n Respiratory: inc secretions, clear\n Genitourinary: Foley\n Pain: No pain / appears comfortable\n Flowsheet Data as of 04:13 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.2\nC (99\n Tcurrent: 37.2\nC (98.9\n HR: 74 (59 - 104) bpm\n BP: 142/65(90) {103/50(67) - 181/82(116)} mmHg\n RR: 15 (12 - 27) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 92.4 kg (admission): 92.7 kg\n Total In:\n 2,020 mL\n 206 mL\n PO:\n TF:\n 547 mL\n 176 mL\n IVF:\n 1,353 mL\n 31 mL\n Blood products:\n Total out:\n 2,445 mL\n 340 mL\n Urine:\n 2,445 mL\n 340 mL\n NG:\n Stool:\n Drains:\n Balance:\n -425 mL\n -134 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 600 (213 - 787) mL\n PS : 5 cmH2O\n RR (Spontaneous): 16\n PEEP: 10 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10\n PIP: 16 cmH2O\n SpO2: 95%\n ABG: 7.46/44/80.//6\n Ve: 9.4 L/min\n PaO2 / FiO2: 160\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, OG tube\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Rhonchorous: mild, grossly)\n Abdominal: Soft, Bowel sounds present\n Extremities: Right: Absent, Left: Absent\n Skin: Warm\n Neurologic: Follows simple commands, Responds to: Verbal stimuli,\n Movement: Purposeful, Sedated, Tone: Normal\n Labs / Radiology\n 259 K/uL\n 11.7 g/dL\n 218 mg/dL\n 0.6 mg/dL\n 28 mEq/L\n 3.5 mEq/L\n 9 mg/dL\n 105 mEq/L\n 140 mEq/L\n 33.9 %\n 15.8 K/uL\n [image002.jpg]\n 08:00 AM\n 09:27 AM\n 01:48 PM\n 02:00 PM\n 03:14 PM\n 09:01 PM\n 09:39 PM\n 01:52 AM\n 02:51 AM\n 03:24 AM\n WBC\n 17.1\n 15.8\n Hct\n 33.6\n 33.9\n Plt\n 278\n 259\n Cr\n 0.6\n TCO2\n 31\n 31\n 29\n 27\n 28\n 32\n Glucose\n 18\n Other labs: PT / PTT / INR:14.1/27.7/1.2, Albumin:3.6 g/dL, Ca++:8.6\n mg/dL, Mg++:2.1 mg/dL, PO4:2.7 mg/dL\n Assessment and Plan\n TRACHEOBRONCHOMALACIA (TRACHEOMALACIA, BRONCHOMALACIA)\n AIRWAY, INABILITY TO PROTECT (RISK FOR ASPIRATION, ALTERED GAG,\n AIRWAY CLEARANCE, COUGH)\n AIRWAY OBSTRUCTION, CENTRAL / UPPER\n ASSESSMENT AND PLAN: 53 yo M, long hx of tracheobronchiomalacia w/\n multiple stents placed s/p stent fractures. Currently intubated for\n airway collapse and plan to go back to OR for stent removal and for\n thoracic c/s for tracheal reconstruction/plasty\n NEUROLOGIC: intubated/sedated\n sedation: daily wake ups, ativan/fentanyl\n pain: methadone, fentanyl\n CARDIOVASCULAR: HD stable, cont asa, statin, lasix\n PULMONARY: vented, poor pulm tree but oxygenating/ventilating\n appropriately, plan for OR Monday for T-tube placement, thoracic \n c/s for recon/plasty. cont steroids for airway edema\n GI / ABD: NPO for now, OGT in place\n NUTRITION: TF\n RENAL: Stable, Cr 0.6, UOP stable\n HEMATOLOGY: Stable, Hct 33.6\n ENDOCRINE: SSI, sugars high, tighten ssi consider adding baseline\n coverage\n ID: Afebrile, WBC 17 (12), no ABx for now, will f/u BAL. Abx if more\n secretions, fever, or increase in WBC\n LINES/TUBES/DRAINS: ETT, OGT, R portacath, PIV, foley\n WOUNDS: none\n IMAGING: none\n FLUIDS: kvo\n CONSULTS: primary is , c/s\n BILLING DIAGNOSIS:\n ICU CARE:\n GLYCEMIC CONTROL: ssi\n PROPHYLAXIS: PPI, SCH, boots, VAP bundle\n COMMUNICATIONS: wife\n ICU Consent: obtained\n CODE STATUS: full\n DISPOSITION: ICU\n ICU Care\n Nutrition:\n Nutren Pulmonary (Full) - 03:00 PM 50 mL/hour\n Glycemic Control: Regular insulin sliding scale, Comments: BS high,\n 200's\n Lines:\n Indwelling Port (PortaCath) - 01:30 PM\n Arterial Line - 03:15 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Family meeting held , ICU consent signed Comments:\n Code status: Full code\n Disposition:ICU\n" }, { "category": "Respiratory ", "chartdate": "2121-11-05 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 645665, "text": "TITLE:\n Demographics\n Day of intubation:\n Day of mechanical ventilation: 9\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Yes\n Procedure location:\n Reason: Elective\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: 8 mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Rhonchi\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Rhonchi\n Comments:\n Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount: Suctioned / Moderate\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No claim of dyspnea)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Cannot protect\n airway, Underlying illness not resolved; Comments: awaiting trach\n and/or trachoeplasty\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": "2121-11-06 00:00:00.000", "description": "Intensivist Note", "row_id": 645767, "text": "TSICU\n HPI:\n A 53-year-old gentleman sent from for evaluation of\n tracheobronchomalacia, status post multiple metal stents, now with\n stent fracture. Currently with 3 Polyflex stents, trachea and bilateral\n main stem. Walked in for elective procedure, on 3 L O2 baseline at\n home. Pt taken to bronch by IP for plan to remove old stents and place\n Y stent. There was multiple fractured pieces noted, the old plastic\n stents were removed. Airway collapse noted, and plan is to keep\n intubated for repeat procedures for removal, and thoracic c/s for\n tracheal reconstruction/plasty. s/p rigid bronch with removal of stents\n .\n Chief complaint:\n SOB, airway obstruction\n PMHx:\n DM II, CAD, L CVA 8 years ago, asthma, OSA, emphysema,\n tracheobroncheomalacia c/b multiple pneumonias and s/p stents both\n metal and plastic, ? Mounre-Kuhu syndrome (tracheomegaly), spinal\n fusion L3-4 w/ chronic lbp\n Current medications:\n Albuterol, Aspirin, Fentanyl Citrate prn, Furosemide 20mg PO daily,\n Heparin 5000sc TID, RISS, Lorazepam prn, Methadone, famotidine,\n Simvastatin, clonidine, prednisone 5mg daily, zosyn\n 24 Hour Events:\n Post operative day:\n POD#9 - flex and rigid bronch removal of tracheal stents x3\n POD#7 - bronchoscopy with rigid bronch, removal of old stent wires, ETT\n changed over a cooks catheter now 7.5\n POD#3 - s/p flex bronch\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 06:00 AM\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 09:00 PM\n Fentanyl - 02:30 AM\n Heparin Sodium (Prophylaxis) - 08:00 AM\n Lorazepam (Ativan) - 08:00 AM\n Hydromorphone (Dilaudid) - 08:00 AM\n Other medications:\n Flowsheet Data as of 08:47 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.4\nC (99.4\n T current: 36.3\nC (97.4\n HR: 61 (52 - 73) bpm\n BP: 88/49(63) {85/49(63) - 136/81(100)} mmHg\n RR: 20 (11 - 20) insp/min\n SPO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 92.1 kg (admission): 92.7 kg\n Total In:\n 2,290 mL\n 918 mL\n PO:\n Tube feeding:\n IV Fluid:\n 2,160 mL\n 803 mL\n Blood products:\n Total out:\n 1,315 mL\n 790 mL\n Urine:\n 1,315 mL\n 790 mL\n NG:\n Stool:\n Drains:\n Balance:\n 975 mL\n 128 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 535 (367 - 963) mL\n PS : 5 cmH2O\n RR (Spontaneous): 18\n PEEP: 10 cmH2O\n FiO2: 40%\n RSBI: 48\n PIP: 15 cmH2O\n SPO2: 94%\n ABG: 7.44/42/81./28/3\n Ve: 10.6 L/min\n PaO2 / FiO2: 205\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Non-distended\n Left Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n Moves all extremities\n Labs / Radiology\n 312 K/uL\n 12.4 g/dL\n 126 mg/dL\n 0.7 mg/dL\n 28 mEq/L\n 3.8 mEq/L\n 13 mg/dL\n 100 mEq/L\n 137 mEq/L\n 35.2 %\n 12.0 K/uL\n [image002.jpg]\n 02:51 PM\n 03:02 PM\n 02:16 AM\n 02:31 AM\n 09:19 AM\n 01:35 AM\n 01:49 AM\n 06:36 PM\n 02:20 AM\n 02:34 AM\n WBC\n 17.9\n 13.7\n 12.0\n Hct\n 36.4\n 35.7\n 35.2\n Plt\n \n Creatinine\n 0.7\n 0.7\n 0.7\n TCO2\n 31\n 27\n 25\n 32\n 26\n 29\n Glucose\n 227\n 237\n 213\n 129\n 126\n Other labs: PT / PTT / INR:14.2/30.3/1.2, Lactic Acid:1.0 mmol/L,\n Albumin:3.6 g/dL, Ca:8.2 mg/dL, Mg:2.2 mg/dL, PO4:3.8 mg/dL\n Assessment and Plan\n ANXIETY, PROBLEM - ENTER DESCRIPTION IN COMMENTS\n ear pain, PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN),\n TRACHEOBRONCHOMALACIA (TRACHEOMALACIA, BRONCHOMALACIA), AIRWAY,\n INABILITY TO PROTECT (RISK FOR ASPIRATION, ALTERED GAG, AIRWAY\n CLEARANCE, COUGH), AIRWAY OBSTRUCTION, CENTRAL / UPPER\n Assessment and Plan: 53M tracheobronchomalacia s/p trach stent fracture\n awaiting trach today\n Neurologic: Pain controlled\n Cardiovascular: Aspirin, Statins, HD stable, cont home lasix dose\n Pulmonary: Cont ETT, (Ventilator mode: CPAP + PS), OR today for trach\n Gastrointestinal / Abdomen:\n Nutrition: NPO, resume TF's postop\n Renal: Foley, Adequate UO\n Hematology:\n Endocrine: RISS\n Infectious Disease: cont zosyn\n Lines / Tubes / Drains: Foley, OGT, ETT\n Wounds:\n Imaging:\n Fluids: Other, 1/2NS 75cc/hr\n Consults: CT surgery, interventional pulmonology\n Billing Diagnosis: (Respiratory distress: Failure)\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Indwelling Port (PortaCath) - 01:30 PM\n Arterial Line - 03:15 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: Patient discussed on interdisciplinary rounds Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 35 minutes\n" }, { "category": "Physician ", "chartdate": "2121-11-06 00:00:00.000", "description": "Intensivist Note", "row_id": 645770, "text": "TSICU\n HPI:\n A 53-year-old gentleman sent from for evaluation of\n tracheobronchomalacia, status post multiple metal stents, now with\n stent fracture. Currently with 3 Polyflex stents, trachea and bilateral\n main stem. Walked in for elective procedure, on 3 L O2 baseline at\n home. Pt taken to bronch by IP for plan to remove old stents and place\n Y stent. There was multiple fractured pieces noted, the old plastic\n stents were removed. Airway collapse noted, and plan is to keep\n intubated for repeat procedures for removal, and thoracic c/s for\n tracheal reconstruction/plasty. s/p rigid bronch with removal of stents\n .\n Chief complaint:\n SOB, airway obstruction\n PMHx:\n DM II, CAD, L CVA 8 years ago, asthma, OSA, emphysema,\n tracheobroncheomalacia c/b multiple pneumonias and s/p stents both\n metal and plastic, ? Mounre-Kuhu syndrome (tracheomegaly), spinal\n fusion L3-4 w/ chronic lbp\n Current medications:\n Albuterol, Aspirin, Fentanyl Citrate prn, Furosemide 20mg PO daily,\n Heparin 5000sc TID, RISS, Lorazepam prn, Methadone, famotidine,\n Simvastatin, clonidine, prednisone 5mg daily, zosyn\n 24 Hour Events:\n Post operative day:\n POD#9 - flex and rigid bronch removal of tracheal stents x3\n POD#7 - bronchoscopy with rigid bronch, removal of old stent wires, ETT\n changed over a cooks catheter now 7.5\n POD#3 - s/p flex bronch\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 06:00 AM\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 09:00 PM\n Fentanyl - 02:30 AM\n Heparin Sodium (Prophylaxis) - 08:00 AM\n Lorazepam (Ativan) - 08:00 AM\n Hydromorphone (Dilaudid) - 08:00 AM\n Other medications:\n Flowsheet Data as of 08:47 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.4\nC (99.4\n T current: 36.3\nC (97.4\n HR: 61 (52 - 73) bpm\n BP: 88/49(63) {85/49(63) - 136/81(100)} mmHg\n RR: 20 (11 - 20) insp/min\n SPO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 92.1 kg (admission): 92.7 kg\n Total In:\n 2,290 mL\n 918 mL\n PO:\n Tube feeding:\n IV Fluid:\n 2,160 mL\n 803 mL\n Blood products:\n Total out:\n 1,315 mL\n 790 mL\n Urine:\n 1,315 mL\n 790 mL\n NG:\n Stool:\n Drains:\n Balance:\n 975 mL\n 128 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 535 (367 - 963) mL\n PS : 5 cmH2O\n RR (Spontaneous): 18\n PEEP: 10 cmH2O\n FiO2: 40%\n RSBI: 48\n PIP: 15 cmH2O\n SPO2: 94%\n ABG: 7.44/42/81./28/3\n Ve: 10.6 L/min\n PaO2 / FiO2: 205\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Non-distended\n Left Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n Moves all extremities\n Labs / Radiology\n 312 K/uL\n 12.4 g/dL\n 126 mg/dL\n 0.7 mg/dL\n 28 mEq/L\n 3.8 mEq/L\n 13 mg/dL\n 100 mEq/L\n 137 mEq/L\n 35.2 %\n 12.0 K/uL\n [image002.jpg]\n 02:51 PM\n 03:02 PM\n 02:16 AM\n 02:31 AM\n 09:19 AM\n 01:35 AM\n 01:49 AM\n 06:36 PM\n 02:20 AM\n 02:34 AM\n WBC\n 17.9\n 13.7\n 12.0\n Hct\n 36.4\n 35.7\n 35.2\n Plt\n \n Creatinine\n 0.7\n 0.7\n 0.7\n TCO2\n 31\n 27\n 25\n 32\n 26\n 29\n Glucose\n 227\n 237\n 213\n 129\n 126\n Other labs: PT / PTT / INR:14.2/30.3/1.2, Lactic Acid:1.0 mmol/L,\n Albumin:3.6 g/dL, Ca:8.2 mg/dL, Mg:2.2 mg/dL, PO4:3.8 mg/dL\n Assessment and Plan\n ANXIETY, PROBLEM - ENTER DESCRIPTION IN COMMENTS\n ear pain, PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN),\n TRACHEOBRONCHOMALACIA (TRACHEOMALACIA, BRONCHOMALACIA), AIRWAY,\n INABILITY TO PROTECT (RISK FOR ASPIRATION, ALTERED GAG, AIRWAY\n CLEARANCE, COUGH), AIRWAY OBSTRUCTION, CENTRAL / UPPER\n Assessment and Plan: 53M tracheobronchomalacia s/p trach stent fracture\n awaiting trach today\n Neurologic: Pain controlled\n Cardiovascular: Aspirin, Statins, HD stable, cont home lasix dose\n Pulmonary: Cont ETT, (Ventilator mode: CPAP + PS), OR today for trach\n Gastrointestinal / Abdomen:\n Nutrition: NPO, resume TF's postop\n Renal: Foley, Adequate UO\n Hematology:\n Endocrine: RISS\n Infectious Disease: cont zosyn\n Lines / Tubes / Drains: Foley, OGT, ETT\n Wounds:\n Imaging:\n Fluids: Other, 1/2NS 75cc/hr\n Consults: CT surgery, interventional pulmonology\n Billing Diagnosis: (Respiratory distress: Failure)\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Indwelling Port (PortaCath) - 01:30 PM\n Arterial Line - 03:15 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: Patient discussed on interdisciplinary rounds Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 35 minutes\n" }, { "category": "Nursing", "chartdate": "2121-11-03 00:00:00.000", "description": "Nursing Progress Note", "row_id": 645282, "text": "Events; to or at 1240 for flex bronch unable to remove some stents as\n imbedded in tissue ett is at 24 at teeth inflated with 8cc.\n Returned from or at 1345 on propofol 40 mcgs/kg/min as paralytic not\n reversed awake and moving everything to command by 15 15. did drop sats\n to 85% suctioned for scant amounts of thick secretions . continues to\n desat peep increased to 12 fio2 increased to 100% po2 80 on abg sent\n on 50% at .lllung sounds clear upper diminished at bases.no wheeze\n or broncospam noted.\n Airway, Inability to Protect (Risk for Aspiration, Altered Gag, Airway\n Clearance, Cough)\n Assessment:\n Pt.on cmv on return from or changed to cpap with 12 of peep once awaken\n Action:\n FiO2 increased to .60, pt. sx for thick white secretions, albuterol q4.\n Response:\n O2 sats variable since return\n Plan:\n Check repeat abg on current settings.\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt. c/o abd. No stool bs present soft distended abdomen\n Action:\n Fentanyl given PRN, pt. started on Clonidine yest. with good effect,\n CXR yest benign\n Colace and senna po ducolax x1pr.\n Response:\n Ptc/o of pain no bm large amount of flatus\n Plan:\n Fentanyl PRN, continue to monitor for bm .\n" }, { "category": "Nursing", "chartdate": "2121-11-04 00:00:00.000", "description": "Nursing Progress Note", "row_id": 645332, "text": "53 year old male with hx of mounic- syndrome. S/p multiple metallic\n stents. Admitted to for SOB and productive cough and sensation\n of stent irritating trachea.\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt c/o right ear ache. MD in to assess. Slight swelling noted to\n inner cannula. No discharge noted\n Action:\n Fentanyl given ivpush q 2hours for discomfort. Pseudoephedrine given po\n q 6hours prn for discomfort with little effect.\n Response:\n Pt continues to c/o of right earache.\n Plan:\n Continue with pseudoephedrine prn for discomfort.\n Airway, Inability to Protect (Risk for Aspiration, Altered Gag, Airway\n Clearance, Cough)\n Assessment:\n Pt remains intubated. Arterial blood gases remain within normal range.\n Action:\n Fio2 weaned down to50% peep 10.\n Response:\n SaO2 remain above 97%\n Plan:\n Continue to wean down fio2 as tolerated. Monitor arterial blood gases.\n" }, { "category": "Physician ", "chartdate": "2121-11-05 00:00:00.000", "description": "Intensivist Note", "row_id": 645568, "text": "SICU\n HPI:\n A 53-year-old gentleman sent from for evaluation of\n tracheobronchomalacia, status post multiple metal stents, now with\n stent fracture. Currently with 3 Polyflex stents, trachea and bilateral\n main stem. Walked in for elective procedure, on 3 L O2 baseline at\n home. Pt taken to bronch by IP for plan to remove old stents and place\n Y stent. There was multiple fractured pieces noted, the old plastic\n stents were removed. Airway collapse noted, and plan is to keep\n intubated for repeat procedures for removal, and thoracic c/s for\n tracheal reconstruction/plasty. s/p rigid bronch with removal of stents\n .\n Chief complaint:\n SOB, airway obstruction\n PMHx:\n DM II, CAD, L CVA 8 years ago, asthma, OSA, emphysema,\n tracheobroncheomalacia c/b multiple pneumonias and s/p stents both\n metal and plastic, ? Mounre-Kuhu syndrome (tracheomegaly), spinal\n fusion L3-4 w/ chronic lbp\n Current medications:\n Albuterol, Aspirin, Fentanyl Citrate prn, morphine prn, Furosemide 20mg\n PO daily, Heparin 5000sc TID, RISS, Lorazepam prn, Methadone,\n famotidine, Propofol, Simvastatin, clonidine, prednisone 5mg daily,\n zosyn\n 24 Hour Events:\n EKG - At 06:16 AM\n NPH dosing changed to 15am and 15pm, TF held after MN and maintenance\n IVF started at MN for OR .\n Post operative day:\n POD#8 - flex and rigid bronch removal of tracheal stents x3\n POD#6 - bronchoscopy with rigid bronch, removal of old stent wires, ETT\n changed over a cooks catheter now 7.5\n POD#2 - s/p flex bronch\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 06:13 AM\n Infusions:\n Other ICU medications:\n Fentanyl - 07:57 AM\n Heparin Sodium (Prophylaxis) - 08:30 AM\n Famotidine (Pepcid) - 08:31 AM\n Other medications:\n Flowsheet Data as of 09:58 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.1\nC (98.8\n T current: 37.1\nC (98.7\n HR: 52 (51 - 68) bpm\n BP: 116/61(81) {96/47(63) - 146/73(97)} mmHg\n RR: 12 (7 - 18) insp/min\n SPO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 92.1 kg (admission): 92.7 kg\n Total In:\n 2,722 mL\n 982 mL\n PO:\n Tube feeding:\n 1,206 mL\n IV Fluid:\n 1,256 mL\n 892 mL\n Blood products:\n Total out:\n 1,670 mL\n 405 mL\n Urine:\n 1,670 mL\n 405 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,052 mL\n 577 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 718 (560 - 1,073) mL\n PS : 10 cmH2O\n RR (Spontaneous): 11\n PEEP: 10 cmH2O\n FiO2: 40%\n PIP: 20 cmH2O\n SPO2: 97%\n ABG: 7.47/43/73./28/6\n Ve: 8.6 L/min\n PaO2 / FiO2: 183\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL, EOMI\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Rhonchorous : )\n Abdominal: Soft, Non-distended, Non-tender\n Left Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Neurologic: Follows simple commands, Moves all extremities\n Labs / Radiology\n 304 K/uL\n 12.5 g/dL\n 129 mg/dL\n 0.7 mg/dL\n 28 mEq/L\n 3.5 mEq/L\n 21 mg/dL\n 101 mEq/L\n 137 mEq/L\n 35.7 %\n 13.7 K/uL\n [image002.jpg]\n 06:41 AM\n 02:15 AM\n 09:42 AM\n 02:51 PM\n 03:02 PM\n 02:16 AM\n 02:31 AM\n 09:19 AM\n 01:35 AM\n 01:49 AM\n WBC\n 18.9\n 17.9\n 13.7\n Hct\n 38.3\n 36.4\n 35.7\n Plt\n 297\n 306\n 304\n Creatinine\n 0.7\n 0.7\n 0.7\n TCO2\n 31\n 28\n 31\n 27\n 25\n 32\n Glucose\n 232\n 189\n 227\n 237\n 213\n 129\n Other labs: PT / PTT / INR:13.8/33.7/1.2, Lactic Acid:1.0 mmol/L,\n Albumin:3.6 g/dL, Ca:8.2 mg/dL, Mg:2.0 mg/dL, PO4:4.2 mg/dL\n Assessment and Plan\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN), TRACHEOBRONCHOMALACIA\n (TRACHEOMALACIA, BRONCHOMALACIA), AIRWAY, INABILITY TO PROTECT (RISK\n FOR ASPIRATION, ALTERED GAG, AIRWAY CLEARANCE, COUGH), AIRWAY\n OBSTRUCTION, CENTRAL / UPPER\n Assessment and Plan: 53 yo M, long hx of tracheobronchiomalacia w/\n multiple stents placed s/p stent fractures. Remains intubated \n collapsed airways, ultimate plan for tracheoplasty.\n Neurologic: intubated/sedated\n sedation: daily wake ups, will d/c propofol and minimize sedation w/\n ativan/fentanyl\n pain: methadone, fentanyl PRN\n Cardiovascular: Aspirin, Statins, HD stable, cont asa, statin, lasix\n Pulmonary: Cont ETT, stable on vent, minimize settings, plan for OR Wed\n for trach, thoracic c/s for recon/plasty. cont home dose\n prednisone\n Gastrointestinal / Abdomen:\n Nutrition:\n Renal:\n Hematology:\n Endocrine:\n Infectious Disease:\n Lines / Tubes / Drains:\n Wounds:\n Imaging:\n Fluids:\n Consults:\n Billing Diagnosis:\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Indwelling Port (PortaCath) - 01:30 PM\n Arterial Line - 03:15 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP bundle:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n Total time spent:\n" }, { "category": "Physician ", "chartdate": "2121-11-05 00:00:00.000", "description": "Intensivist Note", "row_id": 645569, "text": "SICU\n HPI:\n A 53-year-old gentleman sent from for evaluation of\n tracheobronchomalacia, status post multiple metal stents, now with\n stent fracture. Currently with 3 Polyflex stents, trachea and bilateral\n main stem. Walked in for elective procedure, on 3 L O2 baseline at\n home. Pt taken to bronch by IP for plan to remove old stents and place\n Y stent. There was multiple fractured pieces noted, the old plastic\n stents were removed. Airway collapse noted, and plan is to keep\n intubated for repeat procedures for removal, and thoracic c/s for\n tracheal reconstruction/plasty. s/p rigid bronch with removal of stents\n .\n Chief complaint:\n SOB, airway obstruction\n PMHx:\n DM II, CAD, L CVA 8 years ago, asthma, OSA, emphysema,\n tracheobroncheomalacia c/b multiple pneumonias and s/p stents both\n metal and plastic, ? Mounre-Kuhu syndrome (tracheomegaly), spinal\n fusion L3-4 w/ chronic lbp\n Current medications:\n Albuterol, Aspirin, Fentanyl Citrate prn, morphine prn, Furosemide 20mg\n PO daily, Heparin 5000sc TID, RISS, Lorazepam prn, Methadone,\n famotidine, Propofol, Simvastatin, clonidine, prednisone 5mg daily,\n zosyn\n 24 Hour Events:\n EKG - At 06:16 AM\n NPH dosing changed to 15am and 15pm, TF held after MN and maintenance\n IVF started at MN for OR .\n Post operative day:\n POD#8 - flex and rigid bronch removal of tracheal stents x3\n POD#6 - bronchoscopy with rigid bronch, removal of old stent wires, ETT\n changed over a cooks catheter now 7.5\n POD#2 - s/p flex bronch\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 06:13 AM\n Infusions:\n Other ICU medications:\n Fentanyl - 07:57 AM\n Heparin Sodium (Prophylaxis) - 08:30 AM\n Famotidine (Pepcid) - 08:31 AM\n Other medications:\n Flowsheet Data as of 09:58 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.1\nC (98.8\n T current: 37.1\nC (98.7\n HR: 52 (51 - 68) bpm\n BP: 116/61(81) {96/47(63) - 146/73(97)} mmHg\n RR: 12 (7 - 18) insp/min\n SPO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 92.1 kg (admission): 92.7 kg\n Total In:\n 2,722 mL\n 982 mL\n PO:\n Tube feeding:\n 1,206 mL\n IV Fluid:\n 1,256 mL\n 892 mL\n Blood products:\n Total out:\n 1,670 mL\n 405 mL\n Urine:\n 1,670 mL\n 405 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,052 mL\n 577 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 718 (560 - 1,073) mL\n PS : 10 cmH2O\n RR (Spontaneous): 11\n PEEP: 10 cmH2O\n FiO2: 40%\n PIP: 20 cmH2O\n SPO2: 97%\n ABG: 7.47/43/73./28/6\n Ve: 8.6 L/min\n PaO2 / FiO2: 183\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL, EOMI\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Rhonchorous : )\n Abdominal: Soft, Non-distended, Non-tender\n Left Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Neurologic: Follows simple commands, Moves all extremities\n Labs / Radiology\n 304 K/uL\n 12.5 g/dL\n 129 mg/dL\n 0.7 mg/dL\n 28 mEq/L\n 3.5 mEq/L\n 21 mg/dL\n 101 mEq/L\n 137 mEq/L\n 35.7 %\n 13.7 K/uL\n [image002.jpg]\n 06:41 AM\n 02:15 AM\n 09:42 AM\n 02:51 PM\n 03:02 PM\n 02:16 AM\n 02:31 AM\n 09:19 AM\n 01:35 AM\n 01:49 AM\n WBC\n 18.9\n 17.9\n 13.7\n Hct\n 38.3\n 36.4\n 35.7\n Plt\n 297\n 306\n 304\n Creatinine\n 0.7\n 0.7\n 0.7\n TCO2\n 31\n 28\n 31\n 27\n 25\n 32\n Glucose\n 232\n 189\n 227\n 237\n 213\n 129\n Other labs: PT / PTT / INR:13.8/33.7/1.2, Lactic Acid:1.0 mmol/L,\n Albumin:3.6 g/dL, Ca:8.2 mg/dL, Mg:2.0 mg/dL, PO4:4.2 mg/dL\n Assessment and Plan\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN), TRACHEOBRONCHOMALACIA\n (TRACHEOMALACIA, BRONCHOMALACIA), AIRWAY, INABILITY TO PROTECT (RISK\n FOR ASPIRATION, ALTERED GAG, AIRWAY CLEARANCE, COUGH), AIRWAY\n OBSTRUCTION, CENTRAL / UPPER\n Assessment and Plan: 53 yo M, long hx of tracheobronchiomalacia w/\n multiple stents placed s/p stent fractures. Remains intubated \n collapsed airways, ultimate plan for tracheoplasty.\n Neurologic: intubated/sedated\n sedation: daily wake ups, will d/c propofol and minimize sedation w/\n ativan/fentanyl\n pain: methadone, fentanyl PRN\n Cardiovascular: Aspirin, Statins, HD stable, cont asa, statin, lasix\n Pulmonary: Cont ETT, stable on vent, minimize settings, plan for OR Wed\n for trach, thoracic c/s for recon/plasty. cont home dose\n prednisone\n Gastrointestinal / Abdomen:\n Nutrition: NPO\n Renal: Adequate U/O\n Hematology:\n Endocrine:\n Infectious Disease: Ear pain but no evidence of otitis\n Lines / Tubes / Drains:\n Wounds:\n Imaging:\n Fluids:\n Consults:\n Billing Diagnosis:\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Indwelling Port (PortaCath) - 01:30 PM\n Arterial Line - 03:15 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP bundle:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n Total time spent:\n" }, { "category": "Social Work", "chartdate": "2121-11-03 00:00:00.000", "description": "Social Work Progress Note", "row_id": 645274, "text": "Social Work:\n Follow-up SW meeting with pt\ns wife, , who reports she is well\n overall, but is having problems with transportation. She reports that\n she called a cab last week and driver did not know how to get to where\n she was staying and was charged $65. She states that the people with\n whom she is staying are going to call the cab co and complain with goal\n of getting her money back. She also states that they have told her she\n and pt can stay there after he is \nd since he has to return to\n in 6 weeks to reverse trach.\n Regarding transportation, is staying in home on the 65 bus route\n and although she has issues about reliability of bus, we can only offer\n 3 more cards to assist with cost which is big issue for her.\n She is informed that if she has an emergency, she can contact SW for\n assessment for a cab voucher, but these are not available on regular\n basis. seemed accepting of this.\n She reports that she has good support from her family with whom she is\n in contact daily and is coping well with overall situation. SW provided\n emotional support & contact info. Remain available as needed. Please\n page PRN.\n , LICSW\n #\n" }, { "category": "Nursing", "chartdate": "2121-10-30 00:00:00.000", "description": "Nursing Progress Note", "row_id": 644682, "text": "HPI:\n A 53-year-old gentleman sent from for evaluation of\n tracheobronchomalacia, status post multiple\n metal stents, now with stent fracture. 3 Polyflex stents, trachea and\n bilateral main stem. Walked in for elective procedure, on 3 L O2\n baseline at home.\n Chief complaint:\n SOB, airway obstruction\n PMHx:\n DM II, CAD, L CVA 8 years ago, asthma, OSA, emphysema,\n tracheobroncheomalacia c/b multiple pneumonias and s/p stents both\n metal and plastic, ? Mounre-Kuhu syndrome (tracheomegaly), spinal\n fusion L3-4 w/ chronic lbp\n Airway, Inability to Protect (Risk for Aspiration, Altered Gag, Airway\n Clearance, Cough)\n Assessment:\n Lung sounds clear, thin secretions, strong productive cough, ABG\n 7.43/45/117/5/31 on CPAP50% 10 PEEP 5 PS. Positive cuff leak. ETT 8\n Action:\n Suctioned frequently, IV decadron, pulmonary toilet, taken to OR for\n rigid bronchoscopy today with stent removal, ETT changed over a cooks\n catheter.\n Response:\n Lung sounds clear, thin secretions, some blood in oral airway, airway\n patent, positive cuff leak, ETT 7.5, ABG 7.44/42/107/3/29.\n Plan:\n Continue pulmonary toileting, anti-Vap care, oral care Q2 hours,\n monitor respiratory status, wean from vent, plan for OR next Monday for\n follow up bronch.\n" }, { "category": "Respiratory ", "chartdate": "2121-10-31 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 644847, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 4\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: Re-intubation; Comments: ETT changed to larger size\n Tube Type\n ETT:\n Position: 24 cm at teeth\n Route: Oral\n Type: Standard\n Size: 8mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Cuff volume: 7 mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount: Suctioned / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No claim of dyspnea)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Maintain PEEP at current level and reduce FiO2 as\n tolerated\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Bronchoscopy (1230)\n Comments:\n" }, { "category": "Nursing", "chartdate": "2121-11-01 00:00:00.000", "description": "Nursing Progress Note", "row_id": 644957, "text": "Airway, Inability to Protect (Risk for Aspiration, Altered Gag, Airway\n Clearance, Cough)\n Assessment:\n Tracheobronchomalasia. Intubated on PS 5/PEEP 10/O2 50%. #8ETT. Breath\n sounds coarse bilaterally, moderate to large amts thick white sputum.\n Resp rate regular, nonlabored. Episode of desat to 90% last evening.\n Neurologically intact.\n Action:\n VAP bundle components/protocol maintained including frequent oral care\n per protocol. Fentanyl boluses for pain management. Ativan IV boluses\n for sedation. Frequent suctioning. Pt desat to 90% last evening,\n responded to suctioning.\n Response:\n Patient hemodynamically stable. Respiratory status stable, Patient\n airway, maintaining adequate oxygenation and ventilation.\n Plan:\n Continue hemodynamic, respiratory monitoring. Continue VAP bundle\n complinance including frequent oral care, subglottal suction. To remain\n intubated ventilated next few days, return to OR for trach on Monday.\n Continue to provide patient/family information, emotional support.\n" }, { "category": "Nursing", "chartdate": "2121-11-05 00:00:00.000", "description": "Nursing Progress Note", "row_id": 645661, "text": "HPI:\n A 53-year-old gentleman sent from for evaluation of\n tracheobronchomalacia, status post multiple metal stents, now with\n stent fracture. Currently with 3 Polyflex stents, trachea and bilateral\n main stem. Walked in for elective procedure, on 3 L O2 baseline at\n home.\n Pt taken to bronch by IP for plan to remove old stents and place Y\n stent. There was multiple fractured pieces noted, the old plastic\n stents were removed. Airway collapse noted, and plan is to keep\n intubated for repeat procedures for removal, and thoracic c/s for\n tracheal reconstruction/plasty. s/p rigid bronch with removal of stents\n .\n Chief complaint:\n SOB, airway obstruction\n PMHx:\n DM II, CAD, L CVA 8 years ago, asthma, OSA, emphysema,\n tracheobroncheomalacia c/b multiple pneumonias and s/p stents both\n metal and plastic, ? Mounre-Kuhu syndrome (tracheomegaly), spinal\n fusion L3-4 w/ chronic lbp\n Trach was planned for today, but has been cancelled. Plan for tomorrow,\n \n Airway, Inability to Protect (Risk for Aspiration, Altered Gag, Airway\n Clearance, Cough)\n Assessment:\n -Pt remains intubated, SATS WNL, no respiratory distress noted.\n -OR (trach) cancelled for today\n Action:\n -PS decreased to 5\n -respiratory status monitored, suctioned PRN for thick white\n secretions.\n Response:\n SATS WNL. ABG pending at this time.\n Plan:\n Continue to monitor resp status, plan for trach tomorrow.\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt c/o right ear and throat chest pain.\n Action:\n -TSICU team and IP team into assess pt\ns pain, feel pain is related to\n prior procedures and ETT tube. Ear pain assessed with otoscope, no\n infection present per resident.\n -Dilaudid ordered and given frequently for throat/chest pain\n -Pseudoephedrine given for ear pain.\n Response:\n Pt still has pain present.\n Plan:\n Continue to assess pain. Plan for sleeping med overnight to provide\n sleep.\n Anxiety\n Assessment:\n Pt is anxious about surgery, increased after finding out OR case was\n cancelled for day. Pt states he has not slept in two days.\n Action:\n Ativan given PRN for anxiety.\n Response:\n Pt remains alert, yet able to doze off at times.\n Plan:\n Continue to give emotional support, ativan as needed.\n" }, { "category": "Nursing", "chartdate": "2121-11-05 00:00:00.000", "description": "Nursing Progress Note", "row_id": 645662, "text": "HPI:\n A 53-year-old gentleman sent from for evaluation of\n tracheobronchomalacia, status post multiple metal stents, now with\n stent fracture. Currently with 3 Polyflex stents, trachea and bilateral\n main stem. Walked in for elective procedure, on 3 L O2 baseline at\n home.\n Pt taken to bronch by IP for plan to remove old stents and place Y\n stent. There was multiple fractured pieces noted, the old plastic\n stents were removed. Airway collapse noted, and plan is to keep\n intubated for repeat procedures for removal, and thoracic c/s for\n tracheal reconstruction/plasty. s/p rigid bronch with removal of stents\n .\n Chief complaint:\n SOB, airway obstruction\n PMHx:\n DM II, CAD, L CVA 8 years ago, asthma, OSA, emphysema,\n tracheobroncheomalacia c/b multiple pneumonias and s/p stents both\n metal and plastic, ? Mounre-Kuhu syndrome (tracheomegaly), spinal\n fusion L3-4 w/ chronic lbp\n Trach was planned for today, but has been cancelled. Plan for tomorrow,\n \n Airway, Inability to Protect (Risk for Aspiration, Altered Gag, Airway\n Clearance, Cough)\n Assessment:\n -Pt remains intubated, SATS WNL, no respiratory distress noted.\n -OR (trach) cancelled for today\n Action:\n -PS decreased to 5\n -respiratory status monitored, suctioned PRN for thick white\n secretions.\n Response:\n SATS WNL. ABG pending at this time.\n Plan:\n Continue to monitor resp status, plan for trach tomorrow.\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt c/o right ear and throat chest pain.\n Action:\n -TSICU team and IP team into assess pt\ns pain, feel pain is related to\n prior procedures and ETT tube. Ear pain assessed with otoscope, no\n infection present per resident.\n -Dilaudid ordered and given frequently for throat/chest pain\n -Pseudoephedrine given for ear pain.\n Response:\n Pt still has pain present.\n Plan:\n Continue to assess pain. Plan for sleeping med overnight to provide\n sleep.\n Anxiety\n Assessment:\n Pt is anxious about surgery, increased after finding out OR case was\n cancelled for day. Pt states he has not slept in two days.\n Action:\n Ativan given PRN for anxiety.\n Response:\n Pt remains alert, yet able to doze off at times.\n Plan:\n Continue to give emotional support, ativan as needed.\n" }, { "category": "Nursing", "chartdate": "2121-11-07 00:00:00.000", "description": "Nursing Progress Note", "row_id": 645937, "text": "HPI:\n A 53-year-old gentleman sent from for evaluation of\n tracheobronchiomalacia, s/p multiple metal stents, now with stent\n fracture. Currently with 3 Polyflex stents, trachea and bilateral main\n stem. Walked in for elective procedure, on 3 L O2 baseline at home.\n Pt taken to bronch by IP for plan to remove old stents and place Y\n stent. There was multiple fractured pieces noted, the old plastic\n stents were removed. Airway collapse noted, and plan is to keep\n intubated for repeat procedures for removal, and thoracic c/s for\n tracheal reconstruction/plasty. s/p rigid bronch with removal of stents\n .\n Chief complaint:\n SOB, airway obstruction\n PMHx:\n DM II, CAD, L CVA 8 years ago, asthma, OSA, emphysema,\n tracheobroncheomalacia c/b multiple pneumonias and s/p stents both\n metal and plastic, ? Mounre-Kuhu syndrome (tracheomegaly), spinal\n fusion L3-4 w/ chronic lbp\n : Tracheostomy placed, \n Tracheobronchomalacia (tracheomalacia, bronchomalacia)\n Assessment:\n Trach placed . Pt remains on trach collar, currently @ 60%FiO2.\n Respirations & SpO2 remain WNL. LS rhonchorous w/ dim bases\n bilaterally.\n Action:\n Weaned quickly to trach mask with cuff down as per interventional\n pulmonary service. NGT placed.\n Response:\n Lungs rhonchorous -> clear with coughing and deep breathing.\n Expectorates thick blood tinged sputum in small amounts. SPO2 97-100%\n on 50% FiO2.\n Plan:\n Pulmonary toileting, continue to mobilze out of bed. Speech & swallow\n for PMV and eating in am.\n Pain control (acute pain, chronic pain)\n Assessment:\n Complains of neck/right chest pain, pain consistent with ongoing\n symptoms.\n Action:\n Dilaudid PCA started at 0.12, now up to 0.25/6/2.5mg.\n Response:\n Pain management currently not optimized.\n Plan:\n Continue to instruct patient on PCA use, assess need for larger doses\n of analgesics.\n Anxiety\n Assessment:\n Pt is anxious about surgery. Pt states he has not slept in two days.\n Action:\n Ativan given PRN for anxiety.\n Ambien given x1\n Response:\n Pt appears to be sleeping most of shift. Ambien w/ +effect.\n Does wake shortly approx q2hrs & c/o pain.\n Plan:\n Continue to give emotional support, ativan as needed.\n ?Ambien qhs?\n" }, { "category": "Physician ", "chartdate": "2121-11-07 00:00:00.000", "description": "Intensivist Note", "row_id": 645977, "text": "SICU\n HPI:\n A 53-year-old gentleman sent from for evaluation of\n tracheobronchomalacia, status post multiple metal stents, now with\n stent fracture. Currently with 3 Polyflex stents, trachea and bilateral\n main stem. Walked in for elective procedure, on 3 L O2 baseline at\n home. Pt taken to bronch by IP for plan to remove old stents and place\n Y stent. There was multiple fractured pieces noted, the old plastic\n stents were removed. Airway collapse noted, and plan is to keep\n intubated for repeat procedures for removal, and thoracic c/s for\n tracheal reconstruction/plasty. s/p rigid bronch with removal of stents\n .\n Chief complaint:\n SOB, airway obstruction\n PMHx:\n DM II, CAD, L CVA 8 years ago, asthma, OSA, emphysema,\n tracheobroncheomalacia c/b multiple pneumonias and s/p stents both\n metal and plastic, ? Mounre-Kuhu syndrome (tracheomegaly), spinal\n fusion L3-4 w/ chronic lbp\n Current medications:\n Acetaminophen, Clonidine, Famotidine, Furosemide, Dilaudid, Heparin,\n Insulin, Lorazepam, Methadone, Piperacillin-Tazobactam, Prednisone,\n Simvastatin, Zolpidem\n 24 Hour Events:\n OR SENT - At 10:45 AM\n OR RECEIVED - At 01:00 PM\n Pt had tracheostomy no complications, is off vent on trach collar.\n dilauded pca, ngt and TF restarted w/ replete w/ fiber. Pain control\n has been an issue\n Post operative day:\n POD#10 - flex and rigid bronch removal of tracheal stents x3\n POD#8 - bronchoscopy with rigid bronch, removal of old stent wires, ETT\n changed over a cooks catheter now 7.5\n POD#4 - s/p flex bronch\n POD#1 - tracheostomy\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 06:00 AM\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 07:40 PM\n Heparin Sodium (Prophylaxis) - 12:06 AM\n Hydromorphone (Dilaudid) - 12:08 AM\n Lorazepam (Ativan) - 03:00 AM\n Other medications:\n Flowsheet Data as of 07:31 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 36.9\nC (98.4\n T current: 36.9\nC (98.4\n HR: 67 (56 - 93) bpm\n BP: 115/60(78) {88/49(63) - 134/83(101)} mmHg\n RR: 22 (11 - 29) insp/min\n SPO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 87 kg (admission): 92.7 kg\n Total In:\n 3,169 mL\n 869 mL\n PO:\n Tube feeding:\n 57 mL\n 161 mL\n IV Fluid:\n 2,907 mL\n 618 mL\n Blood products:\n Total out:\n 3,200 mL\n 1,030 mL\n Urine:\n 3,200 mL\n 1,030 mL\n NG:\n Stool:\n Drains:\n Balance:\n -31 mL\n -161 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 491 (491 - 491) mL\n PS : 5 cmH2O\n RR (Spontaneous): 24\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 11 cmH2O\n SPO2: 95%\n ABG: 7.46/38/80./25/2\n Ve: 10.9 L/min\n PaO2 / FiO2: 200\n Physical Examination\n General Appearance: Anxious, Well nourished\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : ), (Sternum: Stable ), trach c/d/i\n Abdominal: Soft, Non-distended, Non-tender\n Left Extremities: (Edema: Absent), (Temperature: Warm)\n Right Extremities: (Edema: Absent), (Temperature: Warm)\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n Moves all extremities\n Labs / Radiology\n 301 K/uL\n 13.3 g/dL\n 95 mg/dL\n 0.7 mg/dL\n 25 mEq/L\n 4.0 mEq/L\n 10 mg/dL\n 98 mEq/L\n 136 mEq/L\n 37.8 %\n 14.3 K/uL\n [image002.jpg]\n 09:19 AM\n 01:35 AM\n 01:49 AM\n 06:36 PM\n 02:20 AM\n 02:34 AM\n 02:22 PM\n 02:28 PM\n 01:35 AM\n 01:45 AM\n WBC\n 13.7\n 12.0\n 14.4\n 14.3\n Hct\n 35.7\n 35.2\n 35.6\n 37.8\n Plt\n 01\n Creatinine\n 0.7\n 0.7\n 0.7\n 0.7\n TCO2\n 25\n 32\n 26\n 29\n 27\n 28\n Glucose\n 129\n 126\n 154\n 95\n Other labs: PT / PTT / INR:14.2/30.3/1.2, Lactic Acid:1.0 mmol/L,\n Albumin:3.6 g/dL, Ca:8.5 mg/dL, Mg:2.0 mg/dL, PO4:3.3 mg/dL\n Assessment and Plan\n ANXIETY, PROBLEM - ENTER DESCRIPTION IN COMMENTS\n ear pain, PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN),\n TRACHEOBRONCHOMALACIA (TRACHEOMALACIA, BRONCHOMALACIA), AIRWAY,\n INABILITY TO PROTECT (RISK FOR ASPIRATION, ALTERED GAG, AIRWAY\n CLEARANCE, COUGH), AIRWAY OBSTRUCTION, CENTRAL / UPPER\n Assessment and Plan: 53 yo M, long hx of tracheobronchiomalacia w/\n multiple stents placed s/p stent fractures. On trach collar, ultimate\n plan for tracheoplasty.\n Neurologic: A/O, follow commands, continues to have intermittant\n episodes of anxiety and continues to complain of pain. pt communicates\n that he is fed up with it and want to go home, social c/s and ? psych\n Cardiovascular: Aspirin, Statins, HD stable, cont asa, statin, lasix\n Pulmonary: Trach, stable on trach collar. thoracic c/s for\n recon/plasty. cont home dose prednisone\n Gastrointestinal / Abdomen: NGT in place\n Nutrition: Tube feeding, resumed TF\n Renal: Foley, Stable Cr, UOP stable, cont home dose lasix\n Hematology: Stable, Hct 35\n Endocrine: RISS, RISS, NPH 15am/15pm\n Infectious Disease: Afebrile, cont. zosyn for moraxella and psuedomonas\n Lines / Tubes / Drains: Foley, NGT, Trach, trach, NGT, R portacath,\n PIV, foley\n Wounds:\n Imaging:\n Fluids: 1/2 NS\n Consults: CT surgery, IP\n Billing Diagnosis: Other: tracheobronchomalasia\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 06:16 PM 30 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Indwelling Port (PortaCath) - 01:30 PM\n Arterial Line - 03:15 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: Transfer to floor\n Total time spent: 31 minutes\n" }, { "category": "Respiratory ", "chartdate": "2121-10-29 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 644479, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 2\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Yes\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: 21 cm at teeth\n Route: Oral\n Type: Standard\n Size: 8mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount: Suctioned / Moderate\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing;\n Comments: pt remains on ac no changes made this shift tolerating\n well\n Assessment of breathing comfort: No claim of dyspnea)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours:\n Reason for continuing current ventilatory support: Pending procedure /\n OR; Comments: plan for pt to return to OR for removal of more airway\n stents\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n" }, { "category": "Nursing", "chartdate": "2121-10-30 00:00:00.000", "description": "Nursing Progress Note", "row_id": 644679, "text": "HPI:\n A 53-year-old gentleman sent from for evaluation of\n tracheobronchomalacia, status post multiple\n metal stents, now with stent fracture. 3 Polyflex stents, trachea and\n bilateral main stem. Walked in for elective procedure, on 3 L O2\n baseline at home.\n Chief complaint:\n SOB, airway obstruction\n PMHx:\n DM II, CAD, L CVA 8 years ago, asthma, OSA, emphysema,\n tracheobroncheomalacia c/b multiple pneumonias and s/p stents both\n metal and plastic, ? Mounre-Kuhu syndrome (tracheomegaly), spinal\n fusion L3-4 w/ chronic lbp\n Airway, Inability to Protect (Risk for Aspiration, Altered Gag, Airway\n Clearance, Cough)\n Assessment:\n Lung sounds clear, thin secretions, strong productive cough, ABG\n 7.43/45/117/5/31 on CPAP50% 10 PEEP 5 PS. Positive cuff leak. ETT 8\n Action:\n Suctioned frequently, IV decadron, pulmonary toilet, taken to OR for\n rigid bronchoscopy today with stent removal, ETT changed over a cooks\n catheter.\n Response:\n Lung sounds clear, thin secretions, some blood in oral airway.\n Plan:\n" }, { "category": "Nursing", "chartdate": "2121-11-07 00:00:00.000", "description": "Nursing Progress Note", "row_id": 645944, "text": "HPI:\n A 53-year-old gentleman sent from for evaluation of\n tracheobronchiomalacia, s/p multiple metal stents, now with stent\n fracture. Currently with 3 Polyflex stents, trachea and bilateral main\n stem. Walked in for elective procedure, on 3 L O2 baseline at home.\n Pt taken to bronch by IP for plan to remove old stents and place Y\n stent. There was multiple fractured pieces noted, the old plastic\n stents were removed. Airway collapse noted, and plan is to keep\n intubated for repeat procedures for removal, and thoracic c/s for\n tracheal reconstruction/plasty. s/p rigid bronch with removal of stents\n .\n Chief complaint:\n SOB, airway obstruction\n PMHx:\n DM II, CAD, L CVA 8 years ago, asthma, OSA, emphysema,\n tracheobroncheomalacia c/b multiple pneumonias and s/p stents both\n metal and plastic, ? Mounre-Kuhu syndrome (tracheomegaly), spinal\n fusion L3-4 w/ chronic lbp\n : Tracheostomy placed, \n Tracheobronchomalacia (tracheomalacia, bronchomalacia)\n Assessment:\n Trach placed . Pt remains on trach collar, currently @ 60%FiO2.\n Respirations & SpO2 remain WNL. LS rhonchorous w/ dim bases\n bilaterally. Pt mobilizing secretions, minimal amt thick bld tinged.\n Action:\n ABG obtained\n Pt repositioned frequently, pulmonary toileting\n Response:\n Exam unchanged, baseline ABG. SPO2 95-99%.\n Plan:\n Cont aggressive Pulmonary toileting\n Continue to mobilze out of bed.\n Speech & swallow for PMV and eating in am.\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt on Dilaudid PCA for pain control. Complains of neck/right\n chest pain & back pain. Minimal pain relief-- ?r/t anxiety?\n Action:\n IV Dilaudid given x1\n Emotional support given\n Pt encouraged to use PCA\n Response:\n Pt conts to appear anxious w/ periods of intermittent pain\n Plan:\n Continue to instruct patient on PCA use,\n ?Reassess effectiveness of pain meds\n Anxiety\n Assessment:\n Pt anxious overnight, minimal sleep. Pt stated\nIts just one thing\n after another. I just want to go home\n RE his medical condition.\n Action:\n Ativan given PRN for anxiety.\n Ambien ordered qhs PRN\n Emotional support given\n Response:\n PRN meds w/ minimal to no effect. Pt w/ increased anxiety &\n restlessness throughout shift.\n Plan:\n Continue to give emotional support, ativan, ambient as\n needed.\n ?SW, Psych consult?\n" }, { "category": "Physician ", "chartdate": "2121-11-07 00:00:00.000", "description": "Intensivist Note", "row_id": 645945, "text": "SICU\n HPI:\n A 53-year-old gentleman sent from for evaluation of\n tracheobronchomalacia, status post multiple metal stents, now with\n stent fracture. Currently with 3 Polyflex stents, trachea and bilateral\n main stem. Walked in for elective procedure, on 3 L O2 baseline at\n home. Pt taken to bronch by IP for plan to remove old stents and place\n Y stent. There was multiple fractured pieces noted, the old plastic\n stents were removed. Airway collapse noted, and plan is to keep\n intubated for repeat procedures for removal, and thoracic c/s for\n tracheal reconstruction/plasty. s/p rigid bronch with removal of stents\n .\n Chief complaint:\n SOB, airway obstruction\n PMHx:\n DM II, CAD, L CVA 8 years ago, asthma, OSA, emphysema,\n tracheobroncheomalacia c/b multiple pneumonias and s/p stents both\n metal and plastic, ? Mounre-Kuhu syndrome (tracheomegaly), spinal\n fusion L3-4 w/ chronic lbp\n Current medications:\n Acetaminophen, Clonidine, Famotidine, Furosemide, Dilaudid, Heparin,\n Insulin, Lorazepam, Methadone, Piperacillin-Tazobactam, Prednisone,\n Simvastatin, Zolpidem\n 24 Hour Events:\n OR SENT - At 10:45 AM\n OR RECEIVED - At 01:00 PM\n Pt had tracheostomy no complications, is off vent on trach collar.\n dilauded pca, ngt and TF restarted w/ replete w/ fiber. Pain control\n has been an issue\n Post operative day:\n POD#10 - flex and rigid bronch removal of tracheal stents x3\n POD#8 - bronchoscopy with rigid bronch, removal of old stent wires, ETT\n changed over a cooks catheter now 7.5\n POD#4 - s/p flex bronch\n POD#1 - tracheostomy\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 06:00 AM\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 07:40 PM\n Heparin Sodium (Prophylaxis) - 12:06 AM\n Hydromorphone (Dilaudid) - 12:08 AM\n Lorazepam (Ativan) - 03:00 AM\n Other medications:\n Flowsheet Data as of 07:31 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 36.9\nC (98.4\n T current: 36.9\nC (98.4\n HR: 67 (56 - 93) bpm\n BP: 115/60(78) {88/49(63) - 134/83(101)} mmHg\n RR: 22 (11 - 29) insp/min\n SPO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 87 kg (admission): 92.7 kg\n Total In:\n 3,169 mL\n 869 mL\n PO:\n Tube feeding:\n 57 mL\n 161 mL\n IV Fluid:\n 2,907 mL\n 618 mL\n Blood products:\n Total out:\n 3,200 mL\n 1,030 mL\n Urine:\n 3,200 mL\n 1,030 mL\n NG:\n Stool:\n Drains:\n Balance:\n -31 mL\n -161 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 491 (491 - 491) mL\n PS : 5 cmH2O\n RR (Spontaneous): 24\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 11 cmH2O\n SPO2: 95%\n ABG: 7.46/38/80./25/2\n Ve: 10.9 L/min\n PaO2 / FiO2: 200\n Physical Examination\n General Appearance: Anxious, Well nourished\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : ), (Sternum: Stable ), trach c/d/i\n Abdominal: Soft, Non-distended, Non-tender\n Left Extremities: (Edema: Absent), (Temperature: Warm)\n Right Extremities: (Edema: Absent), (Temperature: Warm)\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n Moves all extremities\n Labs / Radiology\n 301 K/uL\n 13.3 g/dL\n 95 mg/dL\n 0.7 mg/dL\n 25 mEq/L\n 4.0 mEq/L\n 10 mg/dL\n 98 mEq/L\n 136 mEq/L\n 37.8 %\n 14.3 K/uL\n [image002.jpg]\n 09:19 AM\n 01:35 AM\n 01:49 AM\n 06:36 PM\n 02:20 AM\n 02:34 AM\n 02:22 PM\n 02:28 PM\n 01:35 AM\n 01:45 AM\n WBC\n 13.7\n 12.0\n 14.4\n 14.3\n Hct\n 35.7\n 35.2\n 35.6\n 37.8\n Plt\n 01\n Creatinine\n 0.7\n 0.7\n 0.7\n 0.7\n TCO2\n 25\n 32\n 26\n 29\n 27\n 28\n Glucose\n 129\n 126\n 154\n 95\n Other labs: PT / PTT / INR:14.2/30.3/1.2, Lactic Acid:1.0 mmol/L,\n Albumin:3.6 g/dL, Ca:8.5 mg/dL, Mg:2.0 mg/dL, PO4:3.3 mg/dL\n Assessment and Plan\n ANXIETY, PROBLEM - ENTER DESCRIPTION IN COMMENTS\n ear pain, PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN),\n TRACHEOBRONCHOMALACIA (TRACHEOMALACIA, BRONCHOMALACIA), AIRWAY,\n INABILITY TO PROTECT (RISK FOR ASPIRATION, ALTERED GAG, AIRWAY\n CLEARANCE, COUGH), AIRWAY OBSTRUCTION, CENTRAL / UPPER\n Assessment and Plan: 53 yo M, long hx of tracheobronchiomalacia w/\n multiple stents placed s/p stent fractures. On trach collar, ultimate\n plan for tracheoplasty.\n Neurologic: A/O, follow commands, continues to have intermittant\n episodes of anxiety and continues to complain of pain. pt communicates\n that he is fed up with it and want to go home, social c/s and ? psych\n Cardiovascular: Aspirin, Statins, HD stable, cont asa, statin, lasix\n Pulmonary: Trach, stable on trach collar. thoracic c/s for\n recon/plasty. cont home dose prednisone\n Gastrointestinal / Abdomen: NGT in place\n Nutrition: Tube feeding, resumed TF\n Renal: Foley, Stable Cr, UOP stable, cont home dose lasix\n Hematology: Stable, Hct 35\n Endocrine: RISS, RISS, NPH 15am/15pm\n Infectious Disease: Afebrile, cont. zosyn for moraxella and psuedomonas\n Lines / Tubes / Drains: Foley, NGT, Trach, trach, NGT, R portacath,\n PIV, foley\n Wounds:\n Imaging:\n Fluids: 1/2 NS\n Consults: CT surgery, IP\n Billing Diagnosis: Other: tracheobronchomalasia\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 06:16 PM 30 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Indwelling Port (PortaCath) - 01:30 PM\n Arterial Line - 03:15 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: Transfer to floor\n Total time spent:\n" }, { "category": "Nursing", "chartdate": "2121-10-29 00:00:00.000", "description": "Nursing Progress Note", "row_id": 644525, "text": "53 yo male with hx of tracheobronchomalacia and Mounic- syndrome\n s/p multiple metallic stents (tracheal and bronchial), now with stent\n fracture. Pt originally from , being treated in \n but transferred here by MD for further care. Pt presented to \n on with SOB, + productive cough, sensation of stent wires\n irritating trachea. Pt taken to OR on for flexible and rigid\n bronchoscopy with 3 stents removed. Per anesthesia, fragments still\n remain in trachea. Pt is planned to have additional bronch and stent\n replacement within 24-48 hours, will remain intubated and in TSICU for\n several days.pt with very difficult airway. Please note do not advance\n or with draw ETT without having ip at bedside as pt still has stent\n fragments that could puncture balloon of ett and as he extremely\n swollen reintubation would be very difficult.\n Airway obstruction, Central / Upper\n Assessment:\n Pt with ETT , LS clear bilat and throughout, no wheezing auscultated,\n RR and 02 sats stable until 1730 when pt dropped sats to 89 suctioned\n for large amounts thick secretions returned to 96-98% sat. again\n dropped sats aabout 10 mins later suctioned and lavaged for thick tan\n plugs fio2 increased by resp to 60%\n Action:\n Sxn as needed, assessed for any obstruction\n Increased anxiety noted given fentanyl 50 mcgs i.v and propofol\n increased from 40 mcgs to 50 mcgs/kg/min.\n Response:\n Pt maintained a patent air way with intermittent plugging team aware\n Plan:\n Remain intubated until IR team completely remove fractured stents.\n And pt has good cuff leak prior to extubation.\n Check abg on 60%.\n Tracheobronchomalacia (tracheomalacia, bronchomalacia)\n Assessment:\n Pt intubated and sedated ,ventilating well until 1730 when desatted see\n above.\n Action:\n No vent changes until 1700 when fip2 increased to 60%.suctioned for\n copius amounts of thick tan pink tinged secretions.\n Response:\n Pt intermittently desatting\n Plan:\n Procedure cancelled today as pt has no cuff leak and will assess for\n procedure in am.\n" }, { "category": "Nursing", "chartdate": "2121-10-29 00:00:00.000", "description": "Nursing Progress Note", "row_id": 644526, "text": "53 yo male with hx of tracheobronchomalacia and Mounic- syndrome\n s/p multiple metallic stents (tracheal and bronchial), now with stent\n fracture. Pt originally from , being treated in \n but transferred here by MD for further care. Pt presented to \n on with SOB, + productive cough, sensation of stent wires\n irritating trachea. Pt taken to OR on for flexible and rigid\n bronchoscopy with 3 stents removed. Per anesthesia, fragments still\n remain in trachea. Pt is planned to have additional bronch and stent\n replacement within 24-48 hours, will remain intubated and in TSICU for\n several days.pt with very difficult airway. Please note do not advance\n or with draw ETT without having IP at bedside as pt still has stent\n fragments that could puncture balloon of ett and as he extremely\n swollen reintubation would be very difficult.\n Airway obstruction, Central / Upper\n Assessment:\n Pt with ETT , LS clear bilat and throughout, no wheezing auscultated,\n RR and 02 sats stable until 1730 when pt dropped sats to 89 suctioned\n for large amounts thick secretions returned to 96-98% sat. again\n dropped sats aabout 10 mins later suctioned and lavaged for thick tan\n plugs fio2 increased by resp to 60%\n Action:\n Sxn as needed, assessed for any obstruction\n Increased anxiety noted given fentanyl 50 mcgs i.v and propofol\n increased from 40 mcgs to 50 mcgs/kg/min.\n Response:\n Pt maintained a patent air way with intermittent plugging team aware\n Plan:\n Remain intubated until IP team completely remove fractured stents.\n And pt has good cuff leak prior to extubation.\n Check abg on 60%.\n Tracheobronchomalacia (tracheomalacia, bronchomalacia)\n Assessment:\n Pt intubated and sedated ,ventilating well until 1730 when desatted see\n above.\n Action:\n No vent changes until 1700 when fip2 increased to 60%.suctioned for\n copius amounts of thick tan pink tinged secretions.\n Response:\n Pt intermittently desatting\n Plan:\n Procedure cancelled today as pt has no cuff leak and will assess for\n procedure in am.\n Continues to drain coffee grounds from ogt. Both IP and tsicu aware hct\n at 1500 stable pt c/o of feeling bloated belly soft pos bs no stool no\n flatus. Bs covered on riss.\n" }, { "category": "Nursing", "chartdate": "2121-11-04 00:00:00.000", "description": "Nursing Progress Note", "row_id": 645454, "text": "A 53-year-old gentleman sent from for evaluation of\n tracheobronchomalacia, status post multiple metal stents, now with\n stent fracture. Currently with 3 Polyflex stents, trachea and bilateral\n main stem. Walked in for elective procedure, on 3 L O2 baseline at\n home.\n Pt taken to bronch by IP for plan to remove old stents and place Y\n stent. There was multiple fractured pieces noted, the old plastic\n stents were removed. Airway collapse noted, and plan is to keep\n intubated for repeat procedures for removal, and thoracic c/s for\n tracheal reconstruction/plasty. s/p rigid bronch with removal of stents\n .\n Pain control (acute pain, chronic pain)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nutrition", "chartdate": "2121-10-30 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 644672, "text": "Subjective\n Pt intubated/sedated\n Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 68\" cm\n 89.8 kg\n 92 kg ( 03:00 AM)\n 30.2\n Ideal body weight\n % Ideal body weight\n Adjusted weight\n Usual body weight\n % Usual body weight\n 70\n 128%\n 75\n Diagnosis: Airway Obstruction\n PMH : DM II, CAD, L CVA 8 years ago, asthma, OSA, emphysema,\n tracheobroncheomalacia c/b multiple pneumonias and s/p stents both\n metal and plastic, ? Mounre-Kuhu syndrome (tracheomegaly), spinal\n fusion L3-4 w/ chronic lbp\n Food allergies and intolerances: NKFA\n Pertinent medications: Heparin, SS lytes, lasix, protonix, RISS,\n dexamethasone, propofol gtt, others noted\n Labs:\n Value\n Date\n Glucose\n 221\n 02:00 PM\n Glucose Finger Stick\n 187\n 03:00 PM\n BUN\n 12 mg/dL\n 02:26 AM\n Creatinine\n 0.7 mg/dL\n 02:26 AM\n Sodium\n 138 mEq/L\n 02:26 AM\n Potassium\n 4.4 mEq/L\n 02:26 AM\n Chloride\n 102 mEq/L\n 02:26 AM\n TCO2\n 29 mEq/L\n 02:26 AM\n PO2 (arterial)\n 107 mm Hg\n 03:14 PM\n PCO2 (arterial)\n 42 mm Hg\n 03:14 PM\n pH (arterial)\n 7.44 units\n 03:14 PM\n CO2 (Calc) arterial\n 29 mEq/L\n 03:14 PM\n Albumin\n 3.6 g/dL\n 01:48 AM\n Calcium non-ionized\n 8.6 mg/dL\n 02:26 AM\n Phosphorus\n 2.7 mg/dL\n 02:26 AM\n Ionized Calcium\n 1.15 mmol/L\n 06:35 AM\n Magnesium\n 2.1 mg/dL\n 02:26 AM\n Current diet order / nutrition support: NPO\n GI: Abd: soft/hypo bs/OGT to sxn\n Assessment of Nutritional Status\n Adequately nourished, but At risk for malnutrition\n Pt at risk due to: NPO / hypocaloric diet\n Estimated Nutritional Needs\n Calories: 1875-2100 (BEE x or / 25-28 cal/kg)\n Protein: 83-105 (1.1-1.4 g/kg)\n Fluid: per team\n Estimation of current intake: Inadequate NPO\n Specifics:\n 53 y/o male c/ tracheobroncheomalacia s/p multiple stents, both metal\n and plastic, now c/ fractured stent. Pt s/p flex and rigid c/\n removal of stents , c/ return to OR today for further removal of\n stent fragments. Will likely need to return again, per chart, plan for\n Monday. Pt currently c/ OGT to sxn per d/w RN, but plan to begin TF\n once pt tolerates clamping trials. Would use low , volume\n restricted feed to aid in BG control and diuresis respectively. Pt\n currently receiving ~600 kcals/day from propofol, therefore TF goal\n rate will be decreased until propofol weaned off.\n Medical Nutrition Therapy Plan - Recommend the Following\n Multivitamin / Mineral supplement: via TF\n Tube feeding recommendations: Once able to begin TFs, rec Nutren\n Pulmonary @10 mL/hr to increase 10mL q 4 hr to goal of 40mL/hr (c/\n propofol) (1440 kcals/65 gr aa)\n Once off propofol, can increase goal rate of TF to 55mL/hr ( kcals/\n 90 gr aa)\n Residual checks q4 hr, hold if >200mL\n BG and lyte management as you are\n Please page c/ ?'s #\n" }, { "category": "Nursing", "chartdate": "2121-11-02 00:00:00.000", "description": "Nursing Progress Note", "row_id": 645171, "text": "Tracheobronchomalacia (tracheomalacia, bronchomalacia)\n Assessment:\n Remains intubated and continues on decadron\n Action:\n Maintain pt on cpap. Decadron decreased to q12 today\n Response:\n Tol cpap well. Sats 90-95%\n Plan:\n Or tomorrow for tracheoplasty\n Airway, Inability to Protect (Risk for Aspiration, Altered Gag, Airway\n Clearance, Cough)\n Assessment:\n Pt with scatter rhonchi and exp wheezes. Secretions are thick tan and\n in mod amts\n Action:\n Cont with albuterol q4. cont aggressive pulmonary toilet.\n Response:\n Pt with decreasing amts of secretions as shift progresses.\n Plan:\n Pulmonary toilet.\n Airway obstruction, Central / Upper\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2121-11-04 00:00:00.000", "description": "Nursing Progress Note", "row_id": 645456, "text": "A 53-year-old gentleman sent from for evaluation of\n tracheobronchomalacia, status post multiple metal stents, now with\n stent fracture. Currently with 3 Polyflex stents, trachea and bilateral\n main stem. Walked in for elective procedure, on 3 L O2 baseline at\n home.\n Pt taken to bronch by IP for plan to remove old stents and place Y\n stent. There was multiple fractured pieces noted, the old plastic\n stents were removed. Airway collapse noted, and plan is to keep\n intubated for repeat procedures for removal, and thoracic c/s for\n tracheal reconstruction/plasty. s/p rigid bronch with removal of stents\n .\n Plan for OR tomorrow. Turn off Tube Feeds at MN and start half NS at\n 75cc/hr.\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt C/o pain back and R ear. VSS.\n Action:\n Pt given fentanyl for pain per orders. Pt OOB to chair today for 1.5\n hrs.\n Response:\n Pain more tolerable. Pt stated being OOB made the pain more tolerable.\n Plan:\n Continue to turn and provide meds as needed for pain control.\n Airway, Inability to Protect (Risk for Aspiration, Altered Gag, Airway\n Clearance, Cough)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Respiratory ", "chartdate": "2121-10-30 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 644675, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 3\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Yes\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at lip 25\n Route:\n Type: Standard\n Size: 7.5mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 50 cmH2O\n Cuff volume: 9 mL /\n Airway problems:\n Comments: IP md aware of cuff pressure\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Clear\n Comments:\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Moderate\n Comments:\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Bronchoscopy (1400)\n Comments: BAL done in OR\n" }, { "category": "Physician ", "chartdate": "2121-10-31 00:00:00.000", "description": "Intensivist Note", "row_id": 644737, "text": "TSICU\n HPI:\n A 53-year-old gentleman sent from for evaluation of\n tracheobronchomalacia, status post multiple metal stents, now with\n stent fracture. Currently with 3 Polyflex stents, trachea and bilateral\n main stem. Walked in for elective procedure, on 3 L O2 baseline at\n home.\n Pt taken to bronch by IP for plan to remove old stents and place Y\n stent. There was multiple fractured pieces noted, the old plastic\n stents were removed. Airway collapse noted, and plan is to keep\n intubated for repeat procedures for removal, and thoracic c/s for\n tracheal reconstruction/plasty. s/p rigid bronch with removal of stents\n .\n Chief complaint:\n SOB, airway obstruction\n PMHx:\n DM II, CAD, L CVA 8 years ago, asthma, OSA, emphysema,\n tracheobroncheomalacia c/b multiple pneumonias and s/p stents both\n metal and plastic, ? Mounre-Kuhu syndrome (tracheomegaly), spinal\n fusion L3-4 w/ chronic lbp\n Current medications:\n Aspirin, Dexamethasone 4mg IV Q8, Fentanyl Citrate, Furosemide 20mg PO\n daily, Heparin 5000sc TID, RISS, Lorazepam, Methadone, Pantoprazole,\n Propofol, Simvastatin\n 24 Hour Events:\n OR SENT - At 10:55 AM\n EXTUBATION - At 12:45 PM\n IN OR\n INTUBATION - At 12:45 PM\n In OR\n BAL FLUID CULTURE - At 12:45 PM\n In OR\n OR RECEIVED - At 12:45 PM\n Taken to OR for stent removal, most of the stent were able to be\n removed, however one small fragment remained secondary to granulation.\n Tube feeds started.\n Post operative day:\n POD#3 - flex and rigid bronch removal of tracheal stents x3\n POD#1 - bronchoscopy with rigid bronch, removal of old stent wires, ETT\n changed over a cooks catheter now 7.5\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Propofol - 60 mcg/Kg/min\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 12:00 AM\n Fentanyl - 01:30 AM\n Pantoprazole (Protonix) - 02:02 AM\n Other medications:\n Flowsheet Data as of 04:35 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 36.6\nC (97.8\n T current: 36.2\nC (97.2\n HR: 61 (58 - 96) bpm\n BP: 130/61(85) {105/51(70) - 165/82(107)} mmHg\n RR: 12 (12 - 44) insp/min\n SPO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 92 kg (admission): 92.7 kg\n Total In:\n 2,852 mL\n 609 mL\n PO:\n Tube feeding:\n 4 mL\n 47 mL\n IV Fluid:\n 2,728 mL\n 542 mL\n Blood products:\n Total out:\n 3,755 mL\n 565 mL\n Urine:\n 2,905 mL\n 565 mL\n NG:\n 300 mL\n Stool:\n Drains:\n 500 mL\n Balance:\n -903 mL\n 44 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 600 (600 - 600) mL\n Vt (Spontaneous): 527 (527 - 588) mL\n PS : 5 cmH2O\n RR (Set): 16\n RR (Spontaneous): 16\n PEEP: 10 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10\n PIP: 16 cmH2O\n Plateau: 18 cmH2O\n Compliance: 75 cmH2O/mL\n SPO2: 96%\n ABG: 7.43/41/101/28/2\n Ve: 7.5 L/min\n PaO2 / FiO2: 202\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : ), (Sternum: Stable )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Neurologic: Moves all extremities, Sedated\n Labs / Radiology\n 278 K/uL\n 11.6 g/dL\n 220 mg/dL\n 0.6 mg/dL\n 28 mEq/L\n 3.5 mEq/L\n 9 mg/dL\n 105 mEq/L\n 140 mEq/L\n 33.6 %\n 17.1 K/uL\n [image002.jpg]\n 02:26 AM\n 06:35 AM\n 08:00 AM\n 09:27 AM\n 01:48 PM\n 02:00 PM\n 03:14 PM\n 09:01 PM\n 09:39 PM\n 01:52 AM\n WBC\n 12.7\n 17.1\n Hct\n 34.6\n 33.6\n Plt\n 248\n 278\n Creatinine\n 0.7\n 0.6\n TCO2\n 30\n 31\n 31\n 29\n 27\n 28\n Glucose\n 20\n Other labs: PT / PTT / INR:14.1/27.7/1.2, Albumin:3.6 g/dL, Ca:8.6\n mg/dL, Mg:2.1 mg/dL, PO4:2.7 mg/dL\n Assessment and Plan\n TRACHEOBRONCHOMALACIA (TRACHEOMALACIA, BRONCHOMALACIA), AIRWAY,\n INABILITY TO PROTECT (RISK FOR ASPIRATION, ALTERED GAG, AIRWAY\n CLEARANCE, COUGH), AIRWAY OBSTRUCTION, CENTRAL / UPPER\n Assessment and Plan: 53 yo M, long hx of tracheobronchiomalacia w/\n multiple stents placed s/p stent fractures. Currently intubated for\n airway collapse and plan to go back to OR for stent removal and for\n thoracic c/s for tracheal reconstruction/plasty\n Neurologic: Pain controlled, Sedated with propofol, ativan.\n pain: methadone, fentanyl\n Cardiovascular: Aspirin, Statins, HD stable, cont asa, statin, lasix\n Pulmonary: Cont ETT, (Ventilator mode: CPAP + PS), vented, poor pulm\n tree but oxygenating/ventilating appropriately, plan for OR Monday for\n T-tube placement, thoracic c/s for recon/plasty. cont steroids for\n airway edema\n Gastrointestinal / Abdomen: OGT in place, abdomen benign\n Nutrition: Tube feeding, Cont to advance TF to goal\n Renal: Foley, Adequate UO, Stable, Cr 0.6, UOP stable\n Hematology: Stable, Hct 33.6\n Endocrine: RISS\n Infectious Disease: Check cultures, Afebrile, WBC 17 (12), no ABx for\n now, will f/u BAL\n : bronchial wash: >100K Moraxella Cat, GNR's\n : BAL - 3+ PMN, 2+ muliple organisms, 1+ epi's\n Lines / Tubes / Drains: Foley, OGT, ETT\n Wounds:\n Imaging:\n Fluids: D5 1/2 NS, D5 1/2NS 75cc/hr\n Consults: CT surgery, Pulmonology\n Billing Diagnosis:\n ICU Care\n Nutrition:\n Nutren Pulmonary (Full) - 11:34 PM 20 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Indwelling Port (PortaCath) - 01:30 PM\n Arterial Line - 03:15 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: ICU\n Total time spent: 35 minutes\n Patient is critically ill\n" }, { "category": "Physician ", "chartdate": "2121-11-03 00:00:00.000", "description": "Intensivist Note", "row_id": 645227, "text": "TSICU\n HPI:\n A 53-year-old gentleman sent from for evaluation of\n tracheobronchomalacia, status post multiple metal stents, now with\n stent fracture. Currently with 3 Polyflex stents, trachea and bilateral\n main stem. Walked in for elective procedure, on 3 L O2 baseline at\n home.\n Pt taken to bronch by IP for plan to remove old stents and place Y\n stent. There was multiple fractured pieces noted, the old plastic\n stents were removed. Airway collapse noted, and plan is to keep\n intubated for repeat procedures for removal, and thoracic c/s for\n tracheal reconstruction/plasty. s/p rigid bronch with removal of stents\n .\n Chief complaint:\n SOB, airway obstruction\n PMHx:\n DM II, CAD, L CVA 8 years ago, asthma, OSA, emphysema,\n tracheobroncheomalacia c/b multiple pneumonias and s/p stents both\n metal and plastic, ? Mounre-Kuhu syndrome (tracheomegaly), spinal\n fusion L3-4 w/ chronic lbp\n Current medications:\n Aspirin, Dexamethasone 4mg IV Q8, Fentanyl Citrate prn, morphine prn,\n Furosemide 20mg PO daily, Heparin 5000sc TID, RISS, Lorazepam,\n Methadone, famotidine, Propofol, Simvastatin\n 24 Hour Events:\n Post operative day:\n POD#6 - flex and rigid bronch removal of tracheal stents x3\n POD#4 - bronchoscopy with rigid bronch, removal of old stent wires, ETT\n changed over a cooks catheter now 7.5\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Lorazepam (Ativan) - 04:00 PM\n Heparin Sodium (Prophylaxis) - 01:16 AM\n Fentanyl - 06:37 AM\n Other medications:\n Flowsheet Data as of 07:58 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.7\nC (99.8\n T current: 36.8\nC (98.3\n HR: 57 (57 - 87) bpm\n BP: 141/75(98) {118/61(79) - 141/75(98)} mmHg\n RR: 14 (13 - 19) insp/min\n SPO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 92.1 kg (admission): 92.7 kg\n Total In:\n 1,370 mL\n 231 mL\n PO:\n Tube feeding:\n 1,201 mL\n 30 mL\n IV Fluid:\n 118 mL\n 201 mL\n Blood products:\n Total out:\n 1,655 mL\n 460 mL\n Urine:\n 1,655 mL\n 460 mL\n NG:\n Stool:\n Drains:\n Balance:\n -285 mL\n -229 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 626 (562 - 990) mL\n PS : 5 cmH2O\n RR (Spontaneous): 16\n PEEP: 10 cmH2O\n FiO2: 60%\n RSBI Deferred: PEEP > 10\n PIP: 16 cmH2O\n SPO2: 97%\n ABG: ///27/\n Ve: 9.2 L/min\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Non-distended\n Left Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n Moves all extremities\n Labs / Radiology\n 297 K/uL\n 13.3 g/dL\n 232 mg/dL\n 0.7 mg/dL\n 27 mEq/L\n 4.2 mEq/L\n 25 mg/dL\n 102 mEq/L\n 137 mEq/L\n 38.3 %\n 18.9 K/uL\n [image002.jpg]\n 02:00 PM\n 03:14 PM\n 09:01 PM\n 09:39 PM\n 01:52 AM\n 02:51 AM\n 03:24 AM\n 02:11 AM\n 06:41 AM\n 02:15 AM\n WBC\n 17.1\n 15.8\n 15.8\n 18.9\n Hct\n 33.6\n 33.9\n 36.2\n 38.3\n Plt\n 97\n Creatinine\n 0.6\n 0.7\n 0.7\n 0.7\n TCO2\n 29\n 27\n 28\n 32\n 31\n Glucose\n 221\n 220\n 235\n \n Other labs: PT / PTT / INR:13.3/25.4/1.1, Albumin:3.6 g/dL, Ca:8.7\n mg/dL, Mg:2.2 mg/dL, PO4:3.8 mg/dL\n Assessment and Plan\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN), TRACHEOBRONCHOMALACIA\n (TRACHEOMALACIA, BRONCHOMALACIA), AIRWAY, INABILITY TO PROTECT (RISK\n FOR ASPIRATION, ALTERED GAG, AIRWAY CLEARANCE, COUGH), AIRWAY\n OBSTRUCTION, CENTRAL / UPPER\n Assessment and Plan: 53M w/ tracheobronchomalacia s/p multiple tracheal\n stents c/b stent fractures\n Neurologic: Pain controlled\n Cardiovascular: Aspirin, Statins, home lasix dose\n Pulmonary: Cont ETT, OR today for ? T-tube vs attempt to remove stent\n fragments, decadron to minimize upper airway edema\n Gastrointestinal / Abdomen:\n Nutrition: Tube feeding, held since MN for OR today\n Renal: Foley, Adequate UO\n Hematology:\n Endocrine: RISS\n Infectious Disease: will start empiric coverage for PNA given increased\n WBC's, secretions\n Lines / Tubes / Drains: Foley, OGT, ETT\n Wounds:\n Imaging:\n Fluids: KVO\n Consults: CT surgery, interventional pulmonology\n Billing Diagnosis: (Respiratory distress: Failure)\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Indwelling Port (PortaCath) - 01:30 PM\n Arterial Line - 03:15 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: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: ICU\n Total time spent: 35 minutes\n" }, { "category": "Physician ", "chartdate": "2121-11-03 00:00:00.000", "description": "Intensivist Note", "row_id": 645228, "text": "TSICU\n HPI:\n A 53-year-old gentleman sent from for evaluation of\n tracheobronchomalacia, status post multiple metal stents, now with\n stent fracture. Currently with 3 Polyflex stents, trachea and bilateral\n main stem. Walked in for elective procedure, on 3 L O2 baseline at\n home.\n Pt taken to bronch by IP for plan to remove old stents and place Y\n stent. There was multiple fractured pieces noted, the old plastic\n stents were removed. Airway collapse noted, and plan is to keep\n intubated for repeat procedures for removal, and thoracic c/s for\n tracheal reconstruction/plasty. s/p rigid bronch with removal of stents\n .\n Chief complaint:\n SOB, airway obstruction\n PMHx:\n DM II, CAD, L CVA 8 years ago, asthma, OSA, emphysema,\n tracheobroncheomalacia c/b multiple pneumonias and s/p stents both\n metal and plastic, ? Mounre-Kuhu syndrome (tracheomegaly), spinal\n fusion L3-4 w/ chronic lbp\n Current medications:\n Aspirin, Dexamethasone 4mg IV Q8, Fentanyl Citrate prn, morphine prn,\n Furosemide 20mg PO daily, Heparin 5000sc TID, RISS, Lorazepam,\n Methadone, famotidine, Propofol, Simvastatin\n 24 Hour Events:\n Post operative day:\n POD#6 - flex and rigid bronch removal of tracheal stents x3\n POD#4 - bronchoscopy with rigid bronch, removal of old stent wires, ETT\n changed over a cooks catheter now 7.5\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Lorazepam (Ativan) - 04:00 PM\n Heparin Sodium (Prophylaxis) - 01:16 AM\n Fentanyl - 06:37 AM\n Other medications:\n Flowsheet Data as of 07:58 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.7\nC (99.8\n T current: 36.8\nC (98.3\n HR: 57 (57 - 87) bpm\n BP: 141/75(98) {118/61(79) - 141/75(98)} mmHg\n RR: 14 (13 - 19) insp/min\n SPO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 92.1 kg (admission): 92.7 kg\n Total In:\n 1,370 mL\n 231 mL\n PO:\n Tube feeding:\n 1,201 mL\n 30 mL\n IV Fluid:\n 118 mL\n 201 mL\n Blood products:\n Total out:\n 1,655 mL\n 460 mL\n Urine:\n 1,655 mL\n 460 mL\n NG:\n Stool:\n Drains:\n Balance:\n -285 mL\n -229 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 626 (562 - 990) mL\n PS : 5 cmH2O\n RR (Spontaneous): 16\n PEEP: 10 cmH2O\n FiO2: 60%\n RSBI Deferred: PEEP > 10\n PIP: 16 cmH2O\n SPO2: 97%\n ABG: ///27/\n Ve: 9.2 L/min\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Non-distended\n Left Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n Moves all extremities\n Labs / Radiology\n 297 K/uL\n 13.3 g/dL\n 232 mg/dL\n 0.7 mg/dL\n 27 mEq/L\n 4.2 mEq/L\n 25 mg/dL\n 102 mEq/L\n 137 mEq/L\n 38.3 %\n 18.9 K/uL\n [image002.jpg]\n 02:00 PM\n 03:14 PM\n 09:01 PM\n 09:39 PM\n 01:52 AM\n 02:51 AM\n 03:24 AM\n 02:11 AM\n 06:41 AM\n 02:15 AM\n WBC\n 17.1\n 15.8\n 15.8\n 18.9\n Hct\n 33.6\n 33.9\n 36.2\n 38.3\n Plt\n 97\n Creatinine\n 0.6\n 0.7\n 0.7\n 0.7\n TCO2\n 29\n 27\n 28\n 32\n 31\n Glucose\n 221\n 220\n 235\n \n Other labs: PT / PTT / INR:13.3/25.4/1.1, Albumin:3.6 g/dL, Ca:8.7\n mg/dL, Mg:2.2 mg/dL, PO4:3.8 mg/dL\n Assessment and Plan\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN), TRACHEOBRONCHOMALACIA\n (TRACHEOMALACIA, BRONCHOMALACIA), AIRWAY, INABILITY TO PROTECT (RISK\n FOR ASPIRATION, ALTERED GAG, AIRWAY CLEARANCE, COUGH), AIRWAY\n OBSTRUCTION, CENTRAL / UPPER\n Assessment and Plan: 53M w/ tracheobronchomalacia s/p multiple tracheal\n stents c/b stent fractures\n Neurologic: Pain controlled\n Cardiovascular: Aspirin, Statins, home lasix dose\n Pulmonary: Cont ETT, OR today for ? T-tube vs attempt to remove stent\n fragments, decadron to minimize upper airway edema\n Gastrointestinal / Abdomen:\n Nutrition: Tube feeding, held since MN for OR today\n Renal: Foley, Adequate UO\n Hematology:\n Endocrine: RISS\n Infectious Disease: Will start empiric coverage for PNA given increased\n WBC's, secretions\n Lines / Tubes / Drains: Foley, OGT, ETT\n Wounds:\n Imaging:\n Fluids: KVO\n Consults: CT surgery, interventional pulmonology\n Billing Diagnosis: (Respiratory distress: Failure)\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Indwelling Port (PortaCath) - 01:30 PM\n Arterial Line - 03:15 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: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: ICU\n Total time spent: 35 minutes\n" }, { "category": "Physician ", "chartdate": "2121-11-04 00:00:00.000", "description": "Intensivist Note", "row_id": 645400, "text": "TSICU\n HPI:\n A 53-year-old gentleman sent from for evaluation of\n tracheobronchomalacia, status post multiple metal stents, now with\n stent fracture. Currently with 3 Polyflex stents, trachea and bilateral\n main stem. Walked in for elective procedure, on 3 L O2 baseline at\n home.\n Pt taken to bronch by IP for plan to remove old stents and place Y\n stent. There was multiple fractured pieces noted, the old plastic\n stents were removed. Airway collapse noted, and plan is to keep\n intubated for repeat procedures for removal, and thoracic c/s for\n tracheal reconstruction/plasty. s/p rigid bronch with removal of stents\n .\n Chief complaint:\n SOB, airway obstruction\n PMHx:\n DM II, CAD, L CVA 8 years ago, asthma, OSA, emphysema,\n tracheobroncheomalacia c/b multiple pneumonias and s/p stents both\n metal and plastic, ? Mounre-Kuhu syndrome (tracheomegaly), spinal\n fusion L3-4 w/ chronic lbp\n Current medications:\n Aspirin, Dexamethasone 4mg IV Q8, Fentanyl Citrate prn, morphine prn,\n Furosemide 20mg PO daily, Heparin 5000sc TID, RISS, Lorazepam,\n Methadone, famotidine, Propofol, Simvastatin\n 24 Hour Events:\n OR SENT - At 12:16 PM\n OR RECEIVED - At 01:45 PM\n started Zosyn. Inc SSI for poor sugars. Went to OR, failed removal of\n last part of fragmented stent. Had one episode of sats to mid 80's,\n suction and recruitment maneuvers helped resolve this. BS still running\n high, UOP better w/ maintenance fluid\n Post operative day:\n POD#7 - flex and rigid bronch removal of tracheal stents x3\n POD#5 - bronchoscopy with rigid bronch, removal of old stent wires, ETT\n changed over a cooks catheter now 7.5\n POD#1 - s/p flex bronch\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 05:30 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 12:00 AM\n Lorazepam (Ativan) - 12:00 AM\n Fentanyl - 06:00 AM\n Other medications:\n Flowsheet Data as of 09:19 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.2\nC (99\n T current: 37.2\nC (98.9\n HR: 52 (52 - 68) bpm\n BP: 116/51(72) {102/51(70) - 142/75(98)} mmHg\n RR: 11 (8 - 17) insp/min\n SPO2: 99%\n Heart rhythm: SB (Sinus Bradycardia)\n Wgt (current): 92.1 kg (admission): 92.7 kg\n Total In:\n 1,533 mL\n 1,406 mL\n PO:\n Tube feeding:\n 380 mL\n 463 mL\n IV Fluid:\n 1,027 mL\n 762 mL\n Blood products:\n Total out:\n 1,550 mL\n 595 mL\n Urine:\n 1,550 mL\n 595 mL\n NG:\n Stool:\n Drains:\n Balance:\n -17 mL\n 811 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 931 (560 - 931) mL\n PS : 5 cmH2O\n RR (Spontaneous): 16\n PEEP: 10 cmH2O\n FiO2: 40%\n RSBI Deferred: PEEP > 10\n PIP: 16 cmH2O\n SPO2: 99%\n ABG: 7.47/36/124/26/3\n Ve: 12.4 L/min\n PaO2 / FiO2: 310\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: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Neurologic: Follows simple commands, Moves all extremities\n Labs / Radiology\n 306 K/uL\n 12.7 g/dL\n 213 mg/dL\n 0.7 mg/dL\n 26 mEq/L\n 4.3 mEq/L\n 24 mg/dL\n 96 mEq/L\n 135 mEq/L\n 36.4 %\n 17.9 K/uL\n [image002.jpg]\n 02:51 AM\n 03:24 AM\n 02:11 AM\n 06:41 AM\n 02:15 AM\n 09:42 AM\n 02:51 PM\n 03:02 PM\n 02:16 AM\n 02:31 AM\n WBC\n 15.8\n 15.8\n 18.9\n 17.9\n Hct\n 33.9\n 36.2\n 38.3\n 36.4\n Plt\n 259\n 287\n 297\n 306\n Creatinine\n 0.7\n 0.7\n 0.7\n 0.7\n TCO2\n 32\n 31\n 28\n 31\n 27\n Glucose\n 235\n 218\n 265\n 232\n 189\n 227\n 237\n 213\n Other labs: PT / PTT / INR:13.3/25.4/1.1, Lactic Acid:1.0 mmol/L,\n Albumin:3.6 g/dL, Ca:8.1 mg/dL, Mg:2.2 mg/dL, PO4:4.4 mg/dL\n Assessment and Plan\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN), TRACHEOBRONCHOMALACIA\n (TRACHEOMALACIA, BRONCHOMALACIA), AIRWAY, INABILITY TO PROTECT (RISK\n FOR ASPIRATION, ALTERED GAG, AIRWAY CLEARANCE, COUGH), AIRWAY\n OBSTRUCTION, CENTRAL / UPPER\n Assessment and Plan: 53 yo M, long hx of tracheobronchiomalacia w/\n multiple stents placed s/p stent fractures. Remains intubated \n collapsed airways, ultimate plan for tracheoplasty.\n Neurologic: Pain controlled, intubated/sedated\n sedation: daily wake ups, will d/c propofol and minimize sedation w/\n ativan/fentanyl\n pain: methadone, fentanyl PRN\n Cardiovascular: Aspirin, Statins, HD stable, cont asa, statin, lasix\n Pulmonary: Cont ETT, stable on vent, minimize settings, plan for OR Wed\n for trach, thoracic c/s for recon/plasty. change steroids to\n prednisone home dose\n Gastrointestinal / Abdomen: OGT in place\n Nutrition: Tube feeding\n Renal: Foley, Adequate UO, Stable Cr, UOP stable\n Hematology: Stable\n Endocrine: RISS\n Infectious Disease: Check cultures, Afebrile, started zosyn to cover\n moraxella and psuedomonas\n Lines / Tubes / Drains: Foley, OGT, ETT, ETT, OGT, R portacath, PIV,\n foley\n Wounds:\n Imaging: CXR today\n Fluids: KVO\n Consults: CT surgery, Pulmonology\n Billing Diagnosis: (Respiratory distress)\n ICU Care\n Nutrition:\n Nutren Pulmonary (Full) - 02:56 AM 50 mL/hour\n Glycemic Control:\n Lines:\n Indwelling Port (PortaCath) - 01:30 PM\n Arterial Line - 03:15 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: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: ICU\n Total time spent: 35 minutes\n" }, { "category": "Physician ", "chartdate": "2121-10-29 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 644423, "text": "Chief Complaint: SOB, airway obstruction\n 24 Hour Events:\n INDWELLING PORT (PORTACATH) - START 01:30 PM\n accessed by OR RNs.\n INVASIVE VENTILATION - START 01:30 PM\n OR RECEIVED - At 01:36 PM\n ARTERIAL LINE - START 03:15 PM\n placed by HO in room\n Pt came from OR as described above, remained sedated and intubated, RN\n noted high NG output, no blood and belly benign.\n History obtained from Medical records\n Patient unable to provide history: Sedated\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Propofol - 50 mcg/Kg/min\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 12:05 AM\n Fentanyl - 06:18 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Ear, Nose, Throat: OG / NG tube\n Respiratory: Dyspnea\n Genitourinary: Foley\n Pain: No pain / appears comfortable\n Flowsheet Data as of 07:06 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: 35.9\nC (96.7\n HR: 54 (52 - 98) bpm\n BP: 108/56(75) {94/54(68) - 133/67(90)} mmHg\n RR: 21 (15 - 49) insp/min\n SpO2: 96%\n Heart rhythm: SB (Sinus Bradycardia)\n Wgt (current): 92 kg (admission): 92.7 kg\n Total In:\n 1,028 mL\n 869 mL\n PO:\n TF:\n IVF:\n 1,028 mL\n 869 mL\n Blood products:\n Total out:\n 790 mL\n 1,060 mL\n Urine:\n 690 mL\n 460 mL\n NG:\n 100 mL\n 600 mL\n Stool:\n Drains:\n Balance:\n 238 mL\n -191 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 16\n RR (Spontaneous): 0\n PEEP: 10 cmH2O\n FiO2: 50%\n RSBI Deferred: Agitated\n PIP: 21 cmH2O\n Plateau: 19 cmH2O\n Compliance: 55.6 cmH2O/mL\n SpO2: 96%\n ABG: 7.42/50/90./30/6\n Ve: 7.5 L/min\n PaO2 / FiO2: 180\n Physical Examination\n General Appearance: Well nourished\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, OG tube\n with some old blood\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Bronchial:\n , Rhonchorous: )\n Abdominal: Soft, Bowel sounds present\n Extremities: Right: Absent, Left: Absent\n Skin: Warm\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Sedated,\n Tone: Not assessed\n Labs / Radiology\n 287 K/uL\n 12.0 g/dL\n 148 mg/dL\n 0.7 mg/dL\n 30 mEq/L\n 4.3 mEq/L\n 13 mg/dL\n 101 mEq/L\n 140 mEq/L\n 34.4 %\n 9.6 K/uL\n [image002.jpg]\n 03:43 PM\n 04:17 PM\n 01:48 AM\n 02:11 AM\n WBC\n 10.9\n 9.6\n Hct\n 34.8\n 34.4\n Plt\n 297\n 287\n Cr\n 0.8\n 0.7\n TCO2\n 32\n 34\n Glucose\n 185\n 148\n Other labs: PT / PTT / INR:14.1/27.7/1.2, Albumin:3.6 g/dL, Ca++:8.5\n mg/dL, Mg++:2.0 mg/dL, PO4:3.9 mg/dL\n Assessment and Plan\n TRACHEOBRONCHOMALACIA (TRACHEOMALACIA, BRONCHOMALACIA)\n AIRWAY, INABILITY TO PROTECT (RISK FOR ASPIRATION, ALTERED GAG,\n AIRWAY CLEARANCE, COUGH)\n AIRWAY OBSTRUCTION, CENTRAL / UPPER\n ASSESSMENT AND PLAN: 53 yo M, long hx of tracheobronchiomalacia w/\n multiple stents placed s/p stent fractures. Currently intubated for\n airway collapse and plan to go back to OR for stent removal and for\n thoracic c/s for tracheal reconstruction/plasty\n NEUROLOGIC: intubated/sedated\n sedation: propofol, ativan prn\n pain: methadone, fentanyl\n CARDIOVASCULAR: BP stable, was low on prop so minimal sedation,\n anesthesia using precedex to min prop. will con't asa/statin for CAD\n PULMONARY: vented, poor pulm tree but oxygenating/ventilating\n appropriately, plan to OR tmw for more stent fragment removal, thoracic\n c/s for recon/plasty. IP anticipates tracheostomy need. will check\n post-proc CXR and f/u BAL. will con't steroids w/ hydrocort given long\n term prednisone use.\n GI / ABD: NPO for now, place OGT and feed within next 24 hours\n NUTRITION: will start TF tmw after procedure Add glucose to IV fluids\n RENAL: no issues\n HEMATOLOGY: no issues\n ENDOCRINE: SSI Decrease steroids to 7.5mg q 6h\n ID: no ABx for now, will f/u BAL\n LINES/TUBES/DRAINS: ETT, OGT, R portacath, PIV, foley\n WOUNDS: none\n IMAGING: CXR\n FLUIDS: LR @ 100\n CONSULTS: primary is , c/s\n BILLING DIAGNOSIS: RESPIRATORY FAILURE\n ICU CARE:\n GLYCEMIC CONTROL: ssi\n PROPHYLAXIS: PPI, SCH, boots, VAP bundle\n COMMUNICATIONS: wife\n ICU Consent: pending wife\n CODE STATUS: presumed full\n DISPOSITION: ICU\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale, Blood sugar well\n controlled\n Lines:\n Indwelling Port (PortaCath) - 01:30 PM\n Arterial Line - 03:15 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care\n Need for restraints reviewed\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:ICU 31 minutes spent\n" }, { "category": "Physician ", "chartdate": "2121-10-30 00:00:00.000", "description": "Intensivist Note", "row_id": 644608, "text": "TSICU\n HPI:\n A 53-year-old gentleman sent from for evaluation of\n tracheobronchomalacia, status post multiple\n metal stents, now with stent fracture. Currently with 3 Polyflex\n stents, trachea and bilateral main stem. Walked in for elective\n procedure, on 3 L O2 baseline at home.\n Chief complaint:\n SOB, airway obstruction\n PMHx:\n DM II, CAD, L CVA 8 years ago, asthma, OSA, emphysema,\n tracheobroncheomalacia c/b multiple pneumonias and s/p stents both\n metal and plastic, ? Mounre-Kuhu syndrome (tracheomegaly), spinal\n fusion L3-4 w/ chronic lbp\n Current medications:\n Aspirin, Dexamethasone 4mg IV Q8, Fentanyl Citrate, Furosemide 20mg PO\n daily, Heparin 5000sc TID, RISS, Lorazepam, Methadone, Pantoprazole,\n Propofol, Simvastatin\n 24 Hour Events:\n INDWELLING PORT (PORTACATH) - START 01:30 PM\n accessed by OR RNs.\n INVASIVE VENTILATION - START 01:30 PM\n OR RECEIVED - At 01:36 PM\n ARTERIAL LINE - START 03:15 PM\n placed by HO in room\n Post operative day:\n POD#2 - flex and rigid bronch removal of tracheal stents x3\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Propofol - 40 mcg/Kg/min\n Other ICU medications:\n Pantoprazole (Protonix) - 08:16 AM\n Fentanyl - 10:00 PM\n Heparin Sodium (Prophylaxis) - 12:00 AM\n Other medications:\n Flowsheet Data as of 03:07 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.1\nC (98.8\n T current: 36.5\nC (97.7\n HR: 62 (51 - 71) bpm\n BP: 130/63(87) {100/53(69) - 137/73(96)} mmHg\n RR: 32 (15 - 41) insp/min\n SPO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 92 kg (admission): 92.7 kg\n Total In:\n 2,910 mL\n 300 mL\n PO:\n Tube feeding:\n IV Fluid:\n 2,850 mL\n 300 mL\n Blood products:\n Total out:\n 3,140 mL\n 380 mL\n Urine:\n 2,140 mL\n 380 mL\n NG:\n 1,000 mL\n Stool:\n Drains:\n Balance:\n -230 mL\n -80 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST\n Vt (Set): 600 (500 - 600) mL\n RR (Set): 16\n RR (Spontaneous): 0\n PEEP: 10 cmH2O\n FiO2: 60%\n RSBI Deferred: Agitated\n PIP: 30 cmH2O\n Plateau: 22 cmH2O\n Compliance: 50 cmH2O/mL\n SPO2: 97%\n ABG: 7.46/42/122//6\n Ve: 9.5 L/min\n PaO2 / FiO2: 203\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Non-distended, Bowel sounds present\n Left Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n Moves all extremities, Sedated\n Labs / Radiology\n 248 K/uL\n 12.1 g/dL\n 148 mg/dL\n 0.7 mg/dL\n 30 mEq/L\n 3.4 mEq/L\n 13 mg/dL\n 101 mEq/L\n 140 mEq/L\n 34.6 %\n 12.7 K/uL\n [image002.jpg]\n 03:43 PM\n 04:17 PM\n 01:48 AM\n 02:11 AM\n 04:20 PM\n 06:39 PM\n 09:29 PM\n 02:26 AM\n WBC\n 10.9\n 9.6\n 12.7\n Hct\n 34.8\n 34.4\n 33.3\n 34.6\n Plt\n 297\n 287\n 248\n Creatinine\n 0.8\n 0.7\n TCO2\n 32\n 34\n 34\n 31\n Glucose\n 185\n 148\n Other labs: PT / PTT / INR:14.1/27.7/1.2, Albumin:3.6 g/dL, Ca:8.5\n mg/dL, Mg:2.0 mg/dL, PO4:3.9 mg/dL\n Assessment and Plan\n TRACHEOBRONCHOMALACIA (TRACHEOMALACIA, BRONCHOMALACIA), AIRWAY,\n INABILITY TO PROTECT (RISK FOR ASPIRATION, ALTERED GAG, AIRWAY\n CLEARANCE, COUGH), AIRWAY OBSTRUCTION, CENTRAL / UPPER\n Assessment and Plan: 53M tracheobronchomalacia, status post multiple\n metal stents, now with stent fracture\n Neurologic: Pain controlled, cont methadone, fent\n Cardiovascular: Aspirin, Statins, lasix daily home dose\n Pulmonary: Cont ETT, OR today to remove fractured stents, cont decadron\n to minimize airway edema. Decrease FIO2. Change to PSV.\n Gastrointestinal / Abdomen:\n Nutrition: Tube feeding, to initiate when returns from OR\n Renal: Foley, Adequate UO\n Hematology:\n Endocrine: RISS\n Infectious Disease: Check sputum culture\n Lines / Tubes / Drains: Foley, OGT, ETT\n Wounds:\n Imaging: CXR today\n Fluids: D5 1/2 NS\n Consults: CT surgery, Interventional pulmonology\n Billing Diagnosis: (Respiratory distress: Failure)\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Indwelling Port (PortaCath) - 01:30 PM\n Arterial Line - 03:15 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 35 minutes\n" }, { "category": "Respiratory ", "chartdate": "2121-10-31 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 644763, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 4\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 Tube Type\n ETT:\n Position: 25 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 53 cmH2O\n Cuff volume: 9 mL /\n Airway problems: P > 30cm/H2O, Positional leak around\n cuff\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: Blood Tinged / Thick\n Sputum source/amount: Suctioned / Moderate\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours:\n Reason for continuing current ventilatory support: Underlying illness\n not resolved\n" }, { "category": "Nursing", "chartdate": "2121-10-31 00:00:00.000", "description": "Nursing Progress Note", "row_id": 644762, "text": "A 53-year-old gentleman sent from for evaluation of\n tracheobronchomalacia, status post multiple metal stents.\n : Pt taken to bronch by IP for plan to remove old stents and place\n Y stent. There was multiple fractured pieces noted, the old plastic\n stents were removed.\n : Rigid Bronch performed and removal of the remainder of the\n stents\n Airway, Inability to Protect (Risk for Aspiration, Altered Gag, Airway\n Clearance, Cough)\n Assessment:\n Pt has tracheobronchomalacia, ? syndrome. Remains\n Intubated. Pt follows commands, moves all extremities. LS rhoncherous.\n No tachypnea, tachycardia. Lots of blood-tinged secretions. Pt on CPAP\n with wnl ABG. Pt in a lot of pain. Afebrile.\n Action:\n Pt given IV Dexamethasone. Pt suctioned frequently. VAP care q2hr for\n positional cuff leak with induced coughing. Albuterol given. Propofol\n gtt for comfort. Pt given prn Fentanyl frequently.\n Response:\n With suctioning LS become clear. Pt pain decreased with pain\n management. Still has a fair amt of secretions.\n Plan:\n Pt to be taken to OR on Monday to have a T tube trach placed and the\n removal of the last small agranulated stent. Keep intubated for airway\n protection over the weekend. Continue Pulmonary Toileting. Monitor\n pain and give prn fentanyl or morphine. Continue q2hr VAP care for cuff\n leak.\n Pt wife called last night and will be visit in the morning.\n" }, { "category": "Physician ", "chartdate": "2121-11-01 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 644905, "text": "Chief Complaint: SOB, airway obstruction\n 24 Hour Events:\n BRONCHOSCOPY - At 12:33 PM\n s/p ETT replacement from 7.5 to 8.0 ETT\n d/c prop, sed w/ ativan/fentanyl, inc nutrition goal at 50, kvo ivf,\n inc secretions but clear. gas PaO2 80. no changes in vent made.\n History obtained from Family / Medical records\n Patient unable to provide history: Sedated\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Methadone Hydrochloride - 08:00 AM\n Heparin Sodium (Prophylaxis) - 01:00 AM\n Pantoprazole (Protonix) - 02:00 AM\n Lorazepam (Ativan) - 03:50 AM\n Fentanyl - 03:50 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Ear, Nose, Throat: OG / NG tube\n Nutritional Support: Tube feeds\n Respiratory: inc secretions, clear\n Genitourinary: Foley\n Pain: No pain / appears comfortable\n Flowsheet Data as of 04:13 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.2\nC (99\n Tcurrent: 37.2\nC (98.9\n HR: 74 (59 - 104) bpm\n BP: 142/65(90) {103/50(67) - 181/82(116)} mmHg\n RR: 15 (12 - 27) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 92.4 kg (admission): 92.7 kg\n Total In:\n 2,020 mL\n 206 mL\n PO:\n TF:\n 547 mL\n 176 mL\n IVF:\n 1,353 mL\n 31 mL\n Blood products:\n Total out:\n 2,445 mL\n 340 mL\n Urine:\n 2,445 mL\n 340 mL\n NG:\n Stool:\n Drains:\n Balance:\n -425 mL\n -134 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 600 (213 - 787) mL\n PS : 5 cmH2O\n RR (Spontaneous): 16\n PEEP: 10 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10\n PIP: 16 cmH2O\n SpO2: 95%\n ABG: 7.46/44/80.//6\n Ve: 9.4 L/min\n PaO2 / FiO2: 160\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, OG tube\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Rhonchorous: mild, grossly)\n Abdominal: Soft, Bowel sounds present\n Extremities: Right: Absent, Left: Absent\n Skin: Warm\n Neurologic: Follows simple commands, Responds to: Verbal stimuli,\n Movement: Purposeful, Sedated, Tone: Normal\n Labs / Radiology\n 259 K/uL\n 11.7 g/dL\n 218 mg/dL\n 0.6 mg/dL\n 28 mEq/L\n 3.5 mEq/L\n 9 mg/dL\n 105 mEq/L\n 140 mEq/L\n 33.9 %\n 15.8 K/uL\n [image002.jpg]\n 08:00 AM\n 09:27 AM\n 01:48 PM\n 02:00 PM\n 03:14 PM\n 09:01 PM\n 09:39 PM\n 01:52 AM\n 02:51 AM\n 03:24 AM\n WBC\n 17.1\n 15.8\n Hct\n 33.6\n 33.9\n Plt\n 278\n 259\n Cr\n 0.6\n TCO2\n 31\n 31\n 29\n 27\n 28\n 32\n Glucose\n 18\n Other labs: PT / PTT / INR:14.1/27.7/1.2, Albumin:3.6 g/dL, Ca++:8.6\n mg/dL, Mg++:2.1 mg/dL, PO4:2.7 mg/dL\n Assessment and Plan\n TRACHEOBRONCHOMALACIA (TRACHEOMALACIA, BRONCHOMALACIA)\n AIRWAY, INABILITY TO PROTECT (RISK FOR ASPIRATION, ALTERED GAG,\n AIRWAY CLEARANCE, COUGH)\n AIRWAY OBSTRUCTION, CENTRAL / UPPER\n ASSESSMENT AND PLAN: 53 yo M, long hx of tracheobronchiomalacia w/\n multiple stents placed s/p stent fractures. Currently intubated for\n airway collapse and plan to go back to OR for stent removal and for\n thoracic c/s for tracheal reconstruction/plasty\n NEUROLOGIC: intubated/sedated\n sedation: daily wake ups, ativan/fentanyl\n pain: methadone, fentanyl\n CARDIOVASCULAR: HD stable, cont asa, statin, lasix\n PULMONARY: vented, poor pulm tree but oxygenating/ventilating\n appropriately, plan for OR Monday for T-tube placement, thoracic \n c/s for recon/plasty. cont steroids for airway edema\n GI / ABD: NPO for now, OGT in place\n NUTRITION: TF\n RENAL: Stable, Cr 0.6, UOP stable\n HEMATOLOGY: Stable, Hct 33.6\n ENDOCRINE: SSI, sugars high, tighten ssi consider adding baseline\n coverage\n ID: Afebrile, WBC 17 (12), no ABx for now, will f/u BAL\n LINES/TUBES/DRAINS: ETT, OGT, R portacath, PIV, foley\n WOUNDS: none\n IMAGING: none\n FLUIDS: kvo\n CONSULTS: primary is , c/s\n BILLING DIAGNOSIS:\n ICU CARE:\n GLYCEMIC CONTROL: ssi\n PROPHYLAXIS: PPI, SCH, boots, VAP bundle\n COMMUNICATIONS: wife\n ICU Consent: obtained\n CODE STATUS: full\n DISPOSITION: ICU\n ICU Care\n Nutrition:\n Nutren Pulmonary (Full) - 03:00 PM 50 mL/hour\n Glycemic Control: Regular insulin sliding scale, Comments: BS high,\n 200's\n Lines:\n Indwelling Port (PortaCath) - 01:30 PM\n Arterial Line - 03:15 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Family meeting held , ICU consent signed Comments:\n Code status: Full code\n Disposition:ICU\n" }, { "category": "Physician ", "chartdate": "2121-11-02 00:00:00.000", "description": "Intensivist Note", "row_id": 645049, "text": "TSICU\n HPI:\n A 53-year-old gentleman sent from for evaluation of\n tracheobronchomalacia, status post multiple metal stents, now with\n stent fracture. Currently with 3 Polyflex stents, trachea and bilateral\n main stem. Walked in for elective procedure, on 3 L O2 baseline at\n home.\n Pt taken to bronch by IP for plan to remove old stents and place Y\n stent. There was multiple fractured pieces noted, the old plastic\n stents were removed. Airway collapse noted, and plan is to keep\n intubated for repeat procedures for removal, and thoracic c/s for\n tracheal reconstruction/plasty. s/p rigid bronch with removal of stents\n .\n Chief complaint:\n SOB, airway obstruction\n PMHx:\n DM II, CAD, L CVA 8 years ago, asthma, OSA, emphysema,\n tracheobroncheomalacia c/b multiple pneumonias and s/p stents both\n metal and plastic, ? Mounre-Kuhu syndrome (tracheomegaly), spinal\n fusion L3-4 w/ chronic lbp\n Current medications:\n Aspirin, Dexamethasone 4mg IV Q8, Fentanyl Citrate prn, morphine prn,\n Furosemide 20mg PO daily, Heparin 5000sc TID, RISS, Lorazepam,\n Methadone, famotidine, Propofol, Simvastatin\n 24 Hour Events:\n BRONCHOSCOPY - At 12:33 PM\n s/p ETT replacement from 7.5 to 8.0 ETT\n Post operative day:\n POD#5 - flex and rigid bronch removal of tracheal stents x3\n POD#3 - bronchoscopy with rigid bronch, removal of old stent wires, ETT\n changed over a cooks catheter now 7.5\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 02:00 AM\n Methadone Hydrochloride - 08:45 AM\n Fentanyl - 11:07 PM\n Lorazepam (Ativan) - 11:07 PM\n Heparin Sodium (Prophylaxis) - 12:47 AM\n Other medications:\n Flowsheet Data as of 01:43 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.7\nC (99.8\n T current: 37.7\nC (99.8\n HR: 75 (65 - 85) bpm\n BP: 139/66(88) {126/62(82) - 174/86(116)} mmHg\n RR: 17 (12 - 20) insp/min\n SPO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 92.1 kg (admission): 92.7 kg\n Total In:\n 1,511 mL\n 89 mL\n PO:\n 10 mL\n Tube feeding:\n 1,171 mL\n 81 mL\n IV Fluid:\n 180 mL\n 8 mL\n Blood products:\n Total out:\n 2,385 mL\n 100 mL\n Urine:\n 2,385 mL\n 100 mL\n NG:\n Stool:\n Drains:\n Balance:\n -875 mL\n -11 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 761 (511 - 761) mL\n PS : 5 cmH2O\n RR (Spontaneous): 21\n PEEP: 10 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10\n PIP: 16 cmH2O\n SPO2: 94%\n ABG: 7.46/44/80./29/6\n Ve: 12.6 L/min\n PaO2 / FiO2: 160\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Non-distended, Bowel sounds present\n Left Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n Moves all extremities\n Labs / Radiology\n 259 K/uL\n 11.7 g/dL\n 218 mg/dL\n 0.7 mg/dL\n 29 mEq/L\n 4.0 mEq/L\n 17 mg/dL\n 104 mEq/L\n 142 mEq/L\n 33.9 %\n 15.8 K/uL\n [image002.jpg]\n 08:00 AM\n 09:27 AM\n 01:48 PM\n 02:00 PM\n 03:14 PM\n 09:01 PM\n 09:39 PM\n 01:52 AM\n 02:51 AM\n 03:24 AM\n WBC\n 17.1\n 15.8\n Hct\n 33.6\n 33.9\n Plt\n 278\n 259\n Creatinine\n 0.6\n 0.7\n TCO2\n 31\n 31\n 29\n 27\n 28\n 32\n Glucose\n 35\n 218\n Other labs: PT / PTT / INR:14.1/27.7/1.2, Albumin:3.6 g/dL, Ca:8.6\n mg/dL, Mg:2.1 mg/dL, PO4:2.9 mg/dL\n Assessment and Plan\n TRACHEOBRONCHOMALACIA (TRACHEOMALACIA, BRONCHOMALACIA), AIRWAY,\n INABILITY TO PROTECT (RISK FOR ASPIRATION, ALTERED GAG, AIRWAY\n CLEARANCE, COUGH), AIRWAY OBSTRUCTION, CENTRAL / UPPER\n Assessment and Plan: 53M w/ tracheobronchomalacia s/p multiple tracheal\n stents presenting with stent fractures and SOB\n Neurologic: Pain controlled\n Cardiovascular: Aspirin, Statins, cont home dose lasix\n Pulmonary: Cont ETT, (Ventilator mode: CPAP + PS), cont decadron for\n airway edema, plan for OR \n Gastrointestinal / Abdomen:\n Nutrition: Tube feeding\n Renal: Foley, Adequate UO, cont home dose lasix\n Hematology:\n Endocrine: RISS\n Infectious Disease:\n Lines / Tubes / Drains: Foley, OGT, ETT\n Wounds:\n Imaging:\n Fluids: KVO\n Consults: CT surgery, Interventional Pulmonology\n Billing Diagnosis: (Respiratory distress: Failure)\n ICU Care\n Nutrition:\n Nutren Pulmonary (Full) - 02:21 PM 50 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Indwelling Port (PortaCath) - 01:30 PM\n Arterial Line - 03:15 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: Patient discussed on interdisciplinary rounds Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 35 minutes\n" }, { "category": "Respiratory ", "chartdate": "2121-11-01 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 644903, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 5\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 Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type: Standard\n Size: 8mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Cuff volume: 10 mL /\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 Comments:\n Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount: Suctioned / Copious\n Comments:\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern: Normal quiet breathing\n :\n Trigger work assessment: Triggering synchronously\n Plan: Patient intubated on PSV. Current vent settings PSV10, Peep 5,\n Fio2 50%. Spont vols 600-700\ns with RR 11- to high teens. Patient\n desating x 1 to 90%. ? Secondary to secretions. Sx\nd for moderate\n amounts of secretions and copious amount x 1. BS with few expiratory\n wheezes L upper lung fields, R clear. O2 sats increasing back to 95%\n post sxing and Albuterol MDI RX. Albuterol MDI given Q4hr. Tolerated\n well. No further changes made. Increased secretions over the course of\n the shift. Strong cough effort.\n Plan: Continue with mechanical support. Wean Fio2 as tolerated.\n" }, { "category": "Nursing", "chartdate": "2121-11-03 00:00:00.000", "description": "Nursing Progress Note", "row_id": 645186, "text": "Airway, Inability to Protect (Risk for Aspiration, Altered Gag, Airway\n Clearance, Cough)\n Assessment:\n Pt. remains on CPAP 10/5 overnight, pt. desating to 89 last evening, LS\n rhochi with occasional wheezing, secretions decreased from last evening\n Action:\n FiO2 increased to .60, pt. sx for thick white secretions, albuterol q4.\n Response:\n O2 sats increasing, >95% this am\n Plan:\n OR this am, albuterol q4, sx. as needed\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt. c/o abd. Pain overnight\n Action:\n Fentanyl given PRN, pt. started on Clonidine yest. with good effect,\n CXR yest benign\n Response:\n Pt. resting well overnight, minimal c/o pain\n Plan:\n Fentanyl PRN, Ativan PRN for sedation\n" }, { "category": "Respiratory ", "chartdate": "2121-11-02 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 645144, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 6\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Yes\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route: Oral\n Type: Standard\n Size: 8mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 28 cmH2O\n Cuff volume: 8 mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Exp Wheeze\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Exp Wheeze\n Comments:\n Secretions\n Sputum color / consistency: Tan / Thick\n Sputum source/amount: Suctioned / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern:\n Assessment of breathing comfort: Pt acknowledges dyspnea\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Tracheostomy planned\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n" }, { "category": "Nursing", "chartdate": "2121-11-03 00:00:00.000", "description": "Nursing Progress Note", "row_id": 645185, "text": "Airway, Inability to Protect (Risk for Aspiration, Altered Gag, Airway\n Clearance, Cough)\n Assessment:\n Pt. remains on CPAP 10/5 overnight, pt. desating to 89 last evening, LS\n rhochi with occasional wheezing, secretions decreased from last evening\n Action:\n FiO2 increased to .60, pt. sx for thick white secretions, albuterol q4.\n Response:\n O2 sats increasing, >95% this am\n Plan:\n OR this am, albuterol q4, sx. as needed\n" }, { "category": "Physician ", "chartdate": "2121-11-04 00:00:00.000", "description": "Intensivist Note", "row_id": 645402, "text": "TSICU\n HPI:\n A 53-year-old gentleman sent from for evaluation of\n tracheobronchomalacia, status post multiple metal stents, now with\n stent fracture. Currently with 3 Polyflex stents, trachea and bilateral\n main stem. Walked in for elective procedure, on 3 L O2 baseline at\n home.\n Pt taken to bronch by IP for plan to remove old stents and place Y\n stent. There was multiple fractured pieces noted, the old plastic\n stents were removed. Airway collapse noted, and plan is to keep\n intubated for repeat procedures for removal, and thoracic c/s for\n tracheal reconstruction/plasty. s/p rigid bronch with removal of stents\n .\n Chief complaint:\n SOB, airway obstruction\n PMHx:\n DM II, CAD, L CVA 8 years ago, asthma, OSA, emphysema,\n tracheobroncheomalacia c/b multiple pneumonias and s/p stents both\n metal and plastic, ? Mounre-Kuhu syndrome (tracheomegaly), spinal\n fusion L3-4 w/ chronic lbp\n Current medications:\n Aspirin, Dexamethasone 4mg IV Q8, Fentanyl Citrate prn, morphine prn,\n Furosemide 20mg PO daily, Heparin 5000sc TID, RISS, Lorazepam,\n Methadone, famotidine, Propofol, Simvastatin\n 24 Hour Events:\n OR SENT - At 12:16 PM\n OR RECEIVED - At 01:45 PM\n started Zosyn. Inc SSI for poor sugars. Went to OR, failed removal of\n last part of fragmented stent. Had one episode of sats to mid 80's,\n suction and recruitment maneuvers helped resolve this. BS still running\n high, UOP better w/ maintenance fluid\n Post operative day:\n POD#7 - flex and rigid bronch removal of tracheal stents x3\n POD#5 - bronchoscopy with rigid bronch, removal of old stent wires, ETT\n changed over a cooks catheter now 7.5\n POD#1 - s/p flex bronch\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 05:30 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 12:00 AM\n Lorazepam (Ativan) - 12:00 AM\n Fentanyl - 06:00 AM\n Other medications:\n Flowsheet Data as of 09:19 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.2\nC (99\n T current: 37.2\nC (98.9\n HR: 52 (52 - 68) bpm\n BP: 116/51(72) {102/51(70) - 142/75(98)} mmHg\n RR: 11 (8 - 17) insp/min\n SPO2: 99%\n Heart rhythm: SB (Sinus Bradycardia)\n Wgt (current): 92.1 kg (admission): 92.7 kg\n Total In:\n 1,533 mL\n 1,406 mL\n PO:\n Tube feeding:\n 380 mL\n 463 mL\n IV Fluid:\n 1,027 mL\n 762 mL\n Blood products:\n Total out:\n 1,550 mL\n 595 mL\n Urine:\n 1,550 mL\n 595 mL\n NG:\n Stool:\n Drains:\n Balance:\n -17 mL\n 811 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 931 (560 - 931) mL\n PS : 5 cmH2O\n RR (Spontaneous): 16\n PEEP: 10 cmH2O\n FiO2: 40%\n RSBI Deferred: PEEP > 10\n PIP: 16 cmH2O\n SPO2: 99%\n ABG: 7.47/36/124/26/3\n Ve: 12.4 L/min\n PaO2 / FiO2: 310\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: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Neurologic: Follows simple commands, Moves all extremities\n Labs / Radiology\n 306 K/uL\n 12.7 g/dL\n 213 mg/dL\n 0.7 mg/dL\n 26 mEq/L\n 4.3 mEq/L\n 24 mg/dL\n 96 mEq/L\n 135 mEq/L\n 36.4 %\n 17.9 K/uL\n [image002.jpg]\n 02:51 AM\n 03:24 AM\n 02:11 AM\n 06:41 AM\n 02:15 AM\n 09:42 AM\n 02:51 PM\n 03:02 PM\n 02:16 AM\n 02:31 AM\n WBC\n 15.8\n 15.8\n 18.9\n 17.9\n Hct\n 33.9\n 36.2\n 38.3\n 36.4\n Plt\n 259\n 287\n 297\n 306\n Creatinine\n 0.7\n 0.7\n 0.7\n 0.7\n TCO2\n 32\n 31\n 28\n 31\n 27\n Glucose\n 235\n 218\n 265\n 232\n 189\n 227\n 237\n 213\n Other labs: PT / PTT / INR:13.3/25.4/1.1, Lactic Acid:1.0 mmol/L,\n Albumin:3.6 g/dL, Ca:8.1 mg/dL, Mg:2.2 mg/dL, PO4:4.4 mg/dL\n Assessment and Plan\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN), TRACHEOBRONCHOMALACIA\n (TRACHEOMALACIA, BRONCHOMALACIA), AIRWAY, INABILITY TO PROTECT (RISK\n FOR ASPIRATION, ALTERED GAG, AIRWAY CLEARANCE, COUGH), AIRWAY\n OBSTRUCTION, CENTRAL / UPPER\n Assessment and Plan: 53 yo M, long hx of tracheobronchiomalacia w/\n multiple stents placed s/p stent fractures. Remains intubated \n collapsed airways, ultimate plan for tracheoplasty.\n Neurologic: Pain controlled, intubated/sedated\n sedation: daily wake ups, will d/c propofol and minimize sedation w/\n ativan/fentanyl\n pain: methadone, fentanyl PRN\n Cardiovascular: Aspirin, Statins, HD stable, cont asa, statin, lasix\n Pulmonary: Cont ETT, stable on vent, minimize settings, plan for OR Wed\n for trach, thoracic c/s for recon/plasty. change steroids to\n prednisone home dose\n Gastrointestinal / Abdomen: OGT in place\n Nutrition: Tube feeding\n Renal: Foley, Adequate UO, Stable Cr, UOP stable\n Hematology: Stable\n Endocrine: RISS\n Infectious Disease: Check cultures, Afebrile, started zosyn to cover\n moraxella and psuedomonas\n Lines / Tubes / Drains: Foley, OGT, ETT, ETT, OGT, R portacath, PIV,\n foley\n Wounds:\n Imaging: CXR today\n Fluids: KVO\n Consults: CT surgery, Pulmonology\n Billing Diagnosis: (Respiratory distress)\n ICU Care\n Nutrition:\n Nutren Pulmonary (Full) - 02:56 AM 50 mL/hour\n Glycemic Control:\n Lines:\n Indwelling Port (PortaCath) - 01:30 PM\n Arterial Line - 03:15 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: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: ICU\n Total time spent: 35 minutes\n" }, { "category": "Nursing", "chartdate": "2121-10-28 00:00:00.000", "description": "Nursing Progress Note", "row_id": 644302, "text": "53 yo male with hx of tracheobronchomalacia and Mounic- syndrome\n s/p multiple metallic stents (tracheal and bronchial), now with stent\n fracture. Pt originally from , being treated in \n but transferred here by MD for further care. Pt presented to \n on with SOB, + productive cough, sensation of stent wires\n irritating trachea. Pt taken to OR on for flexible and rigid\n bronchoscopy with 3 stents removed. Per anesthesia, fragments still\n remain in trachea. Pt is planned to have additional bronch and stent\n replacement within 24-48 hours, will remain intubated and in TSICU for\n several days.\n Tracheobronchomalacia (tracheomalacia, bronchomalacia)\n Assessment:\n Pt has history of tracheobronchomalacia, present to with SOB,\n productive cough, sensation of stent wires irritating trachea. Pt to\n OR for removal of 3 stents, fragments remain, recovering in TSICU. Pt\n denying pain. Suctioned for scant tan, frothy secretions. Pt has strong\n cough.\n Action:\n Pt remains intubated on CMV for respiratory support, suctioned as\n needed, provided emotional support. Pt sedated on 30mcg/kg/min\n propofol gtt.\n Response:\n Pt appears comfortable, lightly sedated, BP WNL, easily arousable, pt\n interacting appropriately. Pt not agitated by ET tube. Pt and wife\n coping well, in touch with social worker and family.\n Plan:\n Continue to support pt and family. Wean vent as tolerated. Plan for\n future procedure(s) within 24-48 hrs to remove metal fragments and\n replace stent.\n Airway, Inability to Protect (Risk for Aspiration, Altered Gag, Airway\n Clearance, Cough)\n Assessment:\n Per anesthesia, pt has very swollen airway from procedure today, must\n remain intubated at this time.\n Action:\n Pt intubated, vent being weaned as tolerated. Pt sedated lightly on\n propofol for comfort ET tube. Pt and wife provided with comfort and\n support.\n Response:\n Pt tolerating ET tube well, no issues, minimal secretions, no pain.\n Plan:\n Continue to wean vent as tolerated. Continue to support pt and\n family. Plan for pt to have additional procedures within 24-48hrs.\n" }, { "category": "Respiratory ", "chartdate": "2121-10-29 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 644355, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 2\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Yes\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type: Standard\n Size: 8mm\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Clear\n Comments:\n Secretions\n Sputum color / consistency: Blood Tinged / Thick\n Sputum source/amount: Suctioned / Small\n Comments:\n Ventilation Assessment\n Plan\n Next 24-48 hours:\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments: Pt remains on current vent settings. See vent flow sheet for\n details. Pt sedated with propofol awke and alert to what is going on.\n Unable to tol RSBI at this time bites on ETT and gets agitated.Will\n cont to monitor resp status.\n" }, { "category": "Nursing", "chartdate": "2121-10-29 00:00:00.000", "description": "Nursing Progress Note", "row_id": 644356, "text": "53 yo male with hx of tracheobronchomalacia and Mounic- syndrome\n s/p multiple metallic stents (tracheal and bronchial), now with stent\n fracture. Pt originally from , being treated in \n but transferred here by MD for further care. Pt presented to \n on with SOB, + productive cough, sensation of stent wires\n irritating trachea. Pt taken to OR on for flexible and rigid\n bronchoscopy with 3 stents removed. Per anesthesia, fragments still\n remain in trachea. Pt is planned to have additional bronch and stent\n replacement within 24-48 hours, will remain intubated and in TSICU for\n several days.\n Airway obstruction, Central / Upper\n Assessment:\n Pt with ETT , LS clear bilat and throughout, no wheezing auscultated,\n RR and psox are wnl,tongue is swollen\n Action:\n Sxn as needed, assessed for any obstruction\n Response:\n Pt maintained a patent airway all night\n Plan:\n Check for airleak before attempting extubation,cont to assess for s/s\n of resp distress\n Tracheobronchomalacia (tracheomalacia, bronchomalacia)\n Assessment:\n Pt intubated and sedated,ventilating well\n Action:\n Remained on CMV throughout night\n Response:\n Resp status stable all night\n Plan:\n Remain intubated for bronch today, ? placement of stents\n" } ]

[ { "category": "Echo", "chartdate": "2159-01-09 00:00:00.000", "description": "Report", "row_id": 103058, "text": "PATIENT/TEST INFORMATION:\nIndication: Post-liver transplant.\nHeight: (in) 70\nWeight (lb): 235\nBSA (m2): 2.24 m2\nBP (mm Hg): 85/49\nHR (bpm): 111\nStatus: Inpatient\nDate/Time: at 14:47\nTest: TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Normal LA size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in the RA.\n\nLEFT VENTRICLE: Normal LV wall thickness, cavity size, and systolic function\n(LVEF>55%). Suboptimal technical quality, a focal LV wall motion abnormality\ncannot be fully excluded. No resting LVOT gradient.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Normal mitral valve leaflets with trivial MR.\n\nTRICUSPID VALVE: Normal PA systolic pressure.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Research echocardiogram. Suboptimal image quality - poor\necho windows.\n\nConclusions:\nThe left atrium is normal in size. Left ventricular wall thickness, cavity\nsize, and systolic function are normal (LVEF>55%). Due to suboptimal technical\nquality, a focal wall motion abnormality cannot be fully excluded. 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 regurgitation is seen. The mitral valve appears structurally normal\nwith trivial mitral regurgitation. The estimated pulmonary artery systolic\npressure is normal. There is no pericardial effusion.\n\nIMPRESSION: Preserved global biventricular systolic function.\n\n\n" }, { "category": "Echo", "chartdate": "2158-11-21 00:00:00.000", "description": "Report", "row_id": 103059, "text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. Pulmonary hypertension. Right ventricular function. Pre liver transplant.\nHeight: (in) 70\nWeight (lb): 235\nBSA (m2): 2.24 m2\nBP (mm Hg): 120/69\nHR (bpm): 75\nStatus: Inpatient\nDate/Time: at 14:30\nTest: TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Mild LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA.\n\nLEFT VENTRICLE: Normal LV wall thickness, cavity size, and systolic function\n(LVEF>55%). Normal regional LV systolic function.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic root diameter.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3).\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Mild (1+) MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Left pleural effusion. Ascites.\n\nConclusions:\n1. The left atrium is mildly dilated.\n2. Left ventricular wall thickness, cavity size, and systolic function are\nnormal (LVEF>55%). Regional left ventricular wall motion is normal.\n3. The aortic valve leaflets (3) are mildly thickened.\n4. The mitral valve leaflets are mildly thickened. Mild (1+) mitral\nregurgitation is seen.\n\n\n" }, { "category": "Echo", "chartdate": "2159-01-10 00:00:00.000", "description": "Report", "row_id": 103038, "text": "PATIENT/TEST INFORMATION:\nIndication: Hypertension.\nHeight: (in) 70\nWeight (lb): 235\nBSA (m2): 2.24 m2\nBP (mm Hg): 147/69\nHR (bpm): 110\nStatus: Inpatient\nDate/Time: at 18:00\nTest: TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nResearch echo\nThis study was compared to the prior study of .\n\n\nLEFT ATRIUM: Normal LA size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in the RA\nand extending into the RV.\n\nLEFT VENTRICLE: Mild regional LV systolic dysfunction. Overall normal LVEF\n(>55%). No resting LVOT gradient.\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: basal inferior\n- hypo; remaining LV segments contract normally.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic root diameter.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Normal mitral valve leaflets. Mild (1+) MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.\nIndeterminate PA systolic pressure.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with\nphysiologic PR.\n\nPERICARDIUM: Trivial/physiologic pericardial effusion.\n\nGENERAL COMMENTS: Research echocardiogram. The patient appears to be in sinus\nrhythm. Resting tachycardia (HR>100bpm).\n\nConclusions:\nThe left atrium is normal in size. There is mild regional left ventricular\nsystolic dysfunction with focal hypokinesis of the basal inferior wall. The\nremaining left ventricular segments contract normally and overall systolic\nfunction is preserved. Right ventricular chamber size and free wall motion are\nnormal. The aortic valve leaflets (3) appear structurally normal with good\nleaflet excursion and no aortic regurgitation. The mitral valve leaflets are\nstructurally normal. Mild (1+) mitral regurgitation is seen. The pulmonary\nartery systolic pressure could not be determined. There is a\ntrivial/physiologic pericardial effusion.\n\nIMPRESSION: Very mild regional left ventricular systolic function with\npreserved global function.. Mild mitral regurgitation. The findings are new as\ncompared with the prior study (images reviewed) of .\n\n\n" }, { "category": "Nursing/other", "chartdate": "2159-01-01 00:00:00.000", "description": "Report", "row_id": 1382922, "text": "ADMISSION NOTE, CONDITION UPDATE:\nD/A: PT @ 1715 FROM 5 WITH ONE UNIT PRBC INFUSING. PT A+OX3, MAE, AWARE OF SITUATION. NEEDING URGENT ENDOSCOPY TO R/O BLEEDING.\n\nNEURO: A+OX3, MAE, ABLE TO MOVE TRANSFER BETWEEN BEDS WITH MINIMAL ASSISTANCE. TALKING APPROPRIATELY WITH STAFF.\n\nCV: HR 80'S NSR. NBP ~ 150/70. + GENERALIZED EDEMA. INR PER REPORT FROM 10 3.6. ONE UNIT PRBC FINISHED, 2 UNITS FFP AND 1 UNIT CRYO GIVEN. LABS DUE @ .\n\nRESP: LS CLEAR, NO SOB, OCCASSIONAL COUGH. ON O2 FOR ENDOSCOPY, NOW 96 % ON ROOM AIR.\n\nGI: ENDOSCOPY PERFORMED. NO ACTIVE BLEEDING. PT TOLERATED PROCEDURE WELL. RECOVERING WITHOUT INCIDENT. NPO. OCTREOTIDE GTT STARTED.\n\nGU: PT VOIDS.\n\nSX: WIFE .\n\nR: ENDOSCOPY DONE, NO ACTIVE BLEEDING.\n\nP: OCTREOTIDE GTT X 24 HOURS. NPO. CONTINUE TO CLOSELY MONITOR VITALS, LABS, S+S OF BLEEDING. TO RETURN TO 10 IN AM IF NO S+S OF BLEEDING RE-OCCUR. PT AND FAMILY SUPPORT. FULL CODE.\n" }, { "category": "Nursing/other", "chartdate": "2159-01-02 00:00:00.000", "description": "Report", "row_id": 1382923, "text": "data: vss. afrebile. no c/o pain. no stool during the night\nc/o being hungry but pt npo o/n-ice chips only-tolerating w/ no nausea.\nslept in long naps. abd. very softly distended w/ ascitic fliud.\ncs-clear in bases. 02sat 94-97 on room air.\nhct 22.2 stable (baseline). continues on octreotide 50mcg/hr gtt.\n\n" }, { "category": "Nursing/other", "chartdate": "2159-01-12 00:00:00.000", "description": "Report", "row_id": 1382932, "text": "condition update\nplease see carevue for specifics;\nneuro: alert and oriented x's 3, moves all extremities to command. Pt denies pain at rest and describes pain with movement as 'tolerable' and declines pain medication. Pt reports he feels mildly anxious, emotional support offered.\ncv: hr noted to be sinus arrhythmia, no ectopy, ekg obtained and revied by sicu ho and dr. . abp 140's-170's with ? fling, nbp lower - 110's-130's - dr. aware. JP output replacement 1cc/cc + 50cc/hr of NS changed to 1/2cc/cc + 20cc/hr NS. Will receive 1 unit prbc for hct 24.4 this am.\nresp: ls clear, coughing and raising small amts. thick white/clear sputum. Using i/s. 02 titrated down to 2l n.c., 02 sat 97-99%.\ngi: abd. soft, +bs, + flatus, pt reports feeling hungry, tolerating clear liquids. JP output decreasing overnight, ok to monitor q 2hrs per Dr. .\ngu: foley draining adequate amts. clear yellow urine.\nendo: ssri\nskin: area on cocyx appears to be abrasion, cleaned with wound cleansor, aquacel and allevyn applied.\nsocial: brother/sister-in-law at bedside early in evening.\nactivity: oob to chair for 2hrs, with 2 assist, tolerated well.\nPlan: monitor jp output, q 8 hr labs, oob to chair, offer emotional support, ? transfer to 10.\n" }, { "category": "Nursing/other", "chartdate": "2159-01-12 00:00:00.000", "description": "Report", "row_id": 1382933, "text": " 1726\n NEURO A/O IN GOOD SPIRITS MAE STANDS WITH LIMITATION\n RESP CLEAR SAO2 100 ON ROOM AIR\n HEART S1S2 NSR TO SB PR .18 QRS .10 QTC WNL VSS NO FEVER\n GI PO WELL LG STOOL THIS PM TOL WELL JP X \n PLAN A/LINE REMOVED READY FOR TRANSFER TO 10 REPORT TO BE GIVEN FAMILY SUPPORT\n" }, { "category": "Nursing/other", "chartdate": "2159-01-11 00:00:00.000", "description": "Report", "row_id": 1382930, "text": "FULL CODE Universal Precautions\nAllergies: Bactrim, Flexeril\n\n\nNeuro: AAOx3, MEAx4, assists to turn self in bed.\n\nCV: HR=90s, NSR, no ectopy. BP=140-160/60s. +periph pulses, extrems warm, sl edema. CCO swan and CO=14-18, SVR 450, CVP 9-12.\n\nResp: Was on 40% face tent at beginning of shift - changed to 6l n/p w/ 02sat maintained at 97-98%. Lungs clear bilat, occ cough, using yankar to clear small amt white secretions. RR=.\n\nGI/GU: abd softly distended, +BS, no BM. Taking sips H20 and ice chips. Foley cath w/ clear yellow urine. Pt received 60mg Lasix IV at 8pm and had diuresed between 60-160cc/hr up until time of note.\n\nSkin: Abd incision intact/staples - clean and dry. There was mod amt serosang drainage when it was changed. Abd JPs intact - sites ok. Medial JP w/ small amt drainage. Lat JP has so far drained 875cc. Coccyx abraision beefy red w/ mod amt serous drainage. Cleansed w/ wound cleanser, aquacel placed on wound w/ allevyn over that. Psoriasis.\n\nAccess: PIVx3, RIJ swan, RIJ CL\n\nPain: Med w/ Morphine 2mg x2 for discomfort when turning/nursing care.\n\nSocial: Brother and sister-in-law for visit at beginning of shift. Wife also called in for update.\n\nLabs: Hct trending down to 27.2, plt at 77 - given one unit platelets and repeat plt count 88 - no additonal plt given.\n\nPlan: Continue to monitor labs/lytes. Monitor neuro/cardiac/resp status. Increase diet, increase activity. Monitor lat jp output.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2159-01-11 00:00:00.000", "description": "Report", "row_id": 1382931, "text": "7am-7pm Nursing Note\nSee CareVue for objective data and trends:\n\nNEURO: Pt alert and oriented X 3. PERRL, following commands and MAE.\n\nRESP: Pt's LS are clear but dim at bases. RR even and non-labored and pt. remains on 6Liter NC. Pt's o2 sats will drop to 90% without O2 on. Pt woth occasional productive cough for small to moderate amts of sputum.\n\nCV: Pt HR ranging 58-70s in NSR. BP 150s-170s/70s-80s. CVP 12-19. Pt with minimal peripheral edema present and positive peripheral pulses. PA line changed to TLCL over guide wire today and pt. tolerated well. Pt given a total 2 units of platlets for low PLT levels today, next level to be drawn at 7PM.\n\nGI/GU: Pt abdomen is soft and tender to palpate secondary to surgical site. BS present and pt reporting positive flatus. Pt advanced to clear fluids today and is tolerating well. JP bulbs continue to put out moderate to large amts of serosanquinous fluid, new orders to replace JP output cc/cc with NS Q hour with goal to keep pt negative 1 liter. Pt voiding 100-140cc every hour.\n\nSOCIAL: wife and multiple other family members in to visit throughout day. Wife updated on pt's condition and plan of care. Support offered.\n\nSKIN: Skin RN up to assess pt's coccyx wound which is 6 X 5 cm in dimension. Wound is very superficial, bed is red and surrounding skin is WNL. Aquacel applied covered by Allevyn dressing.\n\nPLAN: Goal to keep pt 1 liter negative, continue to replace JP output cc per cc. Follow labs, I/Os. Goal to get pt. OOB tomorrow and PT consult ordered as well ? D/C to floor if stable.\n\nPLAN: Plan\n" }, { "category": "Nursing/other", "chartdate": "2159-01-10 00:00:00.000", "description": "Report", "row_id": 1382926, "text": "CONDITION UPDATE\nD: PLEASE SEE CAREVUE FOR SPECIFICS. ON EXAM, PT NOTED TO HAVE BRB IN LAT JP, WITHIN 1 HR, PT PUT OUT 1 LITER VIA JP, TRANSPLANT TEAM AWARE, PT TRANSFUSED WITH 4 UNITS PC AND 2 UNITS FFP. VSS AT THIS TIME, PT CONT TO PUT OUT AN ADDITIONAL 650CC BLOODY DRAINAGE FROM JP. TAKEN TO OR AT 1145 BY DR . RETURNED AT 0145- S/P EXP LAP FOR INTRA ABD BLEEDING. EBL 2 LITERS, TRANSFUSED WITH 1 UNIT PC AND PLTS DURING OR. PT HAS CONTINUED TO PUT OUT LARGE AMTS BLOODY DRAINAGE FROM LAT JP (950CC). DR IN, PT TRANSFUSED WITH AN ADDITIONAL 2 UNITS PC AND PLTS.\nNEURO: SEDATED ON PROPOFOL GTT, AROUSABLE TO NAME AND FOLLOWED SIMPLE COMMANDS PRE-OP, AROUSABLE TO STIMULI POST-OP.\nCV: AFEBRILE. HR 80-100 NSR-ST. SBP 100-150. CO .\nRESP: BS CLEAR BUT DIMINSHED IN BASES. SX FOR SM AMTS WHITE SECRETIONS. REMAINS ON CMV WITH RATE OF 18, TV 600 AND FIO2 40%\nGI: ABD SOFT AND MUCH FLATTER POST-OP. BS ABSENT. NGT PATENT AND DRAINING BILIOUS. NO STOOL\nGU: HUO , DR AWARE. CR 3.1\nENDO: BS REMAIN ELEVATED 180-240, TX'D WITH SLIDING SCALE.\nWOUND: ABD DRESSING HAS MOD AMT SEROSANG DRAINAGE PRESENT. DUODERM ON COCCYX COVERED IN BLOOD, UPON REMOVAL- MOD AMT SKIN ON BACK OF DUODERM, WOUND BLEEDING AT THIS TIME, ALLEVYN DRESSING APPLIED, PT PLACED ON AIRBED IN OR\nA/P: CONT TO MONITOR HEMODYNAMICS AND LABS, MONITOR JP OUTPUT CLOSELY, TRANSFUSE AS ORDERED,\n" }, { "category": "Nursing/other", "chartdate": "2159-01-10 00:00:00.000", "description": "Report", "row_id": 1382927, "text": "rsep care note\n\nNo change=s in AC ventilation last night. Pt was re-sedated and went back to OR for abd bleeding, few litres fluid were drained. try to wean later today.\n" }, { "category": "Nursing/other", "chartdate": "2159-01-10 00:00:00.000", "description": "Report", "row_id": 1382928, "text": "Respiratory Care:\nPt. successfully extubated to a 40% cool neb. seems to be OK.\nRR = 11 hr = 94 BP = 152/72 O2Sat = 97%.\n" }, { "category": "Nursing/other", "chartdate": "2159-01-10 00:00:00.000", "description": "Report", "row_id": 1382929, "text": "nsg note\nSEE FLOWSHEET FOR SPECIFICS.\n\nNEURO-PROP GTT OFF. PT A+OX3. MAE. FOLLOWS COMMANDS. PERRL.\n\nCV-HR 80-90'S, NSR. SBP STABLE. REMAINS HYPERDYNAMIC. CVP 8-12. HCT STABLE. PLTS LOW, 2 BAGS GIVEN. SKIN W+D. +PP. PBOOTS ON. + EDEMA.\n\nRESP-WEANED AND EXTUBATED TODAY. TOL WELL THUS FAR. RR WNL. O2 SAT 97%. ABG ACCEPTABLE. LS COARSE. USING YANKEAR FOR SM AMT THICK TAN SPUTUM. C+DB ENC.\n\nGI-ABD SOFT, HYPO BS. OGT D/C'D WHEN EXTUBATED. PRIMARY DSG INTACT WITH OLD STAINING. JP LAT WITH LG AMT BLOODY DRG. TEAM AWARE. WILL FOLLOW. JP MED WITH SEROUSSANG DRG WITH SOME CLOTS.\n\nGU-VOIDING VIA FOLEY AMBER URINE WITH SEDIMENT. U/O LOW THROUGHOUT DAY, BUT NOW INCREASING SOMEWHAT. WILL FOLLOW.\n\nACT-REPOSITIONED AS TOL.\n\nCOMFORT-MSO4 PRN FOR ABD PAIN WITH GOOD EFFECT.\n\nENDO-SSRI.\n\nID-AFEB. ON ABX AND IMMUNOSUPPRESSANTS.\n\nSKIN-HAS MULTI AREAS OF PSORIASIS. HAS STAGE 2 DECUB IN COCCYX. AREA RED WITH SEROUSSANG DRG. ALLYVEN DSG ON. ON AIR MATTRESS.\n\nP-CON'T WITH CURRENT PLAN. MONITOR FOR CHANGES. ASSESS PAIN. FOLLOW LABS. SKIN CARE. PULM HYGIENE.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2159-01-09 00:00:00.000", "description": "Report", "row_id": 1382924, "text": "NPN\nPlease see carevue for further details.\n\nPt arrived from OR @ 0930 s/p liver transplant.\n\nN: Sedated-currently on Propofol gtt. Awoken this afternoon- Arousable to voice, opens eyes spontaneously. MAE. Follows commands inconsistently. PERRL 4 mm.\n\nR: BLSCTA, 02 sats 98-100 ABGs acidotic this a.m-vent changes made accordingly. now on 40% fi02, 600x 20 PEEP 5\n\nC: Hypotensive and tachycardic, sinus, no ectopy. SBP 80-90s, MAP 58-65. cvp down to 8. co/ci adeq. responds well to blood products and boluses. hct down to 21. Received 3 units of PRBcs and 1 unit of PLTs thus far. pap 20's/10's. Attempted wedge-does not wedge. skin w+d +pp. pboots on.\n\nGI: hypoactive BSx4, abdomen soft. OGT -placement verified via CXR and auscultation. OGT to wall suction draining bilious fluid mod amts. Abdominal dsg with mod amounts of serosang drainage, dsg intact. Transplant team notified. LFTs trending down. medial and lateral jp's draining mod amts bloody drg with clots. team aware. will monitor.\n\nGU: Foley draining amber urine with sediment. u/o decreased this afternoon. Team aware. Boluses given.\n\nENDO: elevated FS, SSRI a/o.\n\nPAIN: Prop gtt turned off this am, pt in discomfort. 2mg IV morphine given with good relief.\n\nID: T 99-100.2 Continues with postop IV ABX and immunosuppressants.\n\nSKIN: pt has multi areas of psoriasis. Noted to have stage 2 pressure sore on coccyx. duoderm applied. turned as tol. air mattress ordered.\n\nFAMILY: Wife will be spokesperson. Brothers and extended family involved in care.\n\nPLAN: Monitor VS, labs and assess need for products and/or fluids, u/o, incision/dsg & JP drainage, FS, pain. support.\n" }, { "category": "Nursing/other", "chartdate": "2159-01-09 00:00:00.000", "description": "Report", "row_id": 1382925, "text": "Respiratory Care:\n\nPt is a liver transplant of today. Came to us from the OR intubated W/\n#8.0 OET secured @ 24cms. He has a Hx of Choley in the past and a Hernia repair in the past: also Is HEP C + as well as HIV +.\nPresently on A/C 40% 600 16 5peep and had not been overbreathing as yet. He was initially acidotic but we've been working on this since\narrival. See CareVue for details and serial ABG's.\n" }, { "category": "ECG", "chartdate": "2159-01-11 00:00:00.000", "description": "Report", "row_id": 312620, "text": "Sinus rhythm with occasional atrial premature beats. Compared to the previous\ntracing of heart rate is significantly slower and frequent atrial\npremature beats are new. Modest inferolateral ST-T wave changes have resolved.\nNo diagnostic change is suggested.\n\n" }, { "category": "ECG", "chartdate": "2159-01-09 00:00:00.000", "description": "Report", "row_id": 312621, "text": "Sinus tachycardia. Compared to the previous tracing of no significant\ndiagnostic change.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2159-01-09 00:00:00.000", "description": "Report", "row_id": 312622, "text": "Sinus tachycardia. Diffuse non-specific inferolateral ST-T wave changes.\nCompared to the previous tracing of rate is faster. Otherwise, no\nsignificant diagnostic change.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2159-01-08 00:00:00.000", "description": "Report", "row_id": 312623, "text": "Sinus rhythm. RSR' pattern in lead V1, probably normal variant. Low QRS voltage\nin the precordial leads. Diffuse non-specific T wave flattening. Compared to\nthe previous tracing of no significant diagnostic change.\n\n" }, { "category": "ECG", "chartdate": "2158-12-24 00:00:00.000", "description": "Report", "row_id": 312624, "text": "Sinus rhythm\nModest nonspecific ST-T wave changes\nSince previous tracing of , modest ST-T wave changes present\n\n" }, { "category": "ECG", "chartdate": "2158-11-18 00:00:00.000", "description": "Report", "row_id": 312625, "text": "Sinus rhythm. Normal ECG. Compared to the previous tracing of no\nchange.\n\n" }, { "category": "ECG", "chartdate": "2159-01-25 00:00:00.000", "description": "Report", "row_id": 312617, "text": "Sinus rhythm. Left atrial abnormality. Right ventricular conduction delay.\nSince the previous tracing of no change.\n\n" }, { "category": "ECG", "chartdate": "2159-01-22 00:00:00.000", "description": "Report", "row_id": 312618, "text": "Sinus rhythm\nrSr'(V1) - probable normal variant\nNormal ECG\nSince previous tracing of , no significant change\n\n" }, { "category": "ECG", "chartdate": "2159-01-16 00:00:00.000", "description": "Report", "row_id": 312619, "text": "Sinus rhythm, rate 55. Since the previous tracing of no atrial\npremature beats are present. No other changes have occurred.\n\n" }, { "category": "Radiology", "chartdate": "2158-11-18 00:00:00.000", "description": "DISTINCT PROCEDURAL SERVICE", "row_id": 932494, "text": " 12:02 PM\n CHEST (PORTABLE AP); -59 DISTINCT PROCEDURAL SERVICE Clip # \n Reason: check NG tube placement\n Admitting Diagnosis: HEPATIC ENCEPHALOPATHY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 46 year old man with encephalitis, NG tube placed\n REASON FOR THIS EXAMINATION:\n check NG tube placement\n ______________________________________________________________________________\n FINAL REPORT\n AP PORTABLE CHEST, AT 12:31 P.M.\n\n HISTORY: Encephalitis with NG tube placement.\n\n COMPARISON: Earlier same day.\n\n FINDINGS: Again noted are markedly diminished lung volumes with resultant\n bronchovascular crowding. There is a relative clearing of the previously\n noted hydrostatic edema. Please note the extreme right costophrenic angle has\n been excluded. A nasogastric tube has been introduced with the distal tip and\n side hole within the gastric body.\n\n IMPRESSION: New NG tube as above. Decreasing hydrostatic edema. Limited\n study.\n\n\n" }, { "category": "Radiology", "chartdate": "2159-01-15 00:00:00.000", "description": "1SR ORDER BRANCH VENOUS SYSTEM", "row_id": 940421, "text": " 9:01 AM\n TRANSJUG LIVER BX Clip # \n Reason: Need Transjugular biopsy of liver\n Admitting Diagnosis: HEPATIC ENCEPHALOPATHY\n ********************************* CPT Codes ********************************\n * TRANSCATHETER BIOPSY 1SR ORDER BRANCH VENOUS SYSTEM *\n * -51 MULTI-PROCEDURE SAME DAY TRANSCATHETER BIOPSY *\n * MOD SEDATION, FIRST 30 MIN. MOD SEDATION, EACH ADDL 15 MIN *\n * MOD SEDATION, EACH ADDL 15 MIN *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 47 year old man s/p liver transplant now with elevated T Bili and Alk\n phos\n REASON FOR THIS EXAMINATION:\n Need Transjugular biopsy of liver\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 47-year-old man status post liver transplant, , now with\n elevated bilirubin and alkaline phosphatase. Please perform transjugular\n biopsy of the liver secondary to low platelets.\n\n RADIOLOGISTS: Doctors , , and . Dr. , the attending\n radiologist was present and supervising throughout the procedure.\n\n TECHNIQUE/FINDINGS: Following explanation of the potential risks and benefits\n of the procedure, written informed consent was obtained. Preprocedure timeout\n was performed to confirm patient identity and proposed procedure. The patient\n was placed supine on the angiographic table and the right neck was prepped and\n draped in standard sterile fashion.\n\n Right internal jugular central line was exchanged over a wire for\n micropuncture sheath. A 0.035 wire was advanced through the\n micropuncture sheath, which was then exchanged for 7 French bright tip sheath.\n A 5 French Kumpe catheter was advanced through the sheath over the wire, and\n the wire and Kumpe catheter were used to gain access to the right hepatic\n vein. The bright tip sheath was then advanced into the right hepatic vein and\n the wire and Kumpe catheter were removed. Subsequently, two passes of core\n biopsy needle were performed, and the samples were placed in formalin. The\n sheath was removed and a three lumen central venous line was placed in the\n right internal jugular vein. Patient tolerated the procedure well with no\n evidence of immediate complication.\n\n MODERATE SEDATION was provided by administering divided doses of 75 mcg of\n Fentanyl and 1 mg of Versed throughout the intraservice time of 70 minutes\n during which the patient's hemodynamic parameters were continuously monitored.\n\n IMPRESSION: Successful transjugular biopsy of the right lobe of the liver.\n Two core biopsy needle samples were obtained and sent to pathology.\n\n\n\n (Over)\n\n 9:01 AM\n TRANSJUG LIVER BX Clip # \n Reason: Need Transjugular biopsy of liver\n Admitting Diagnosis: HEPATIC ENCEPHALOPATHY\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2158-12-29 00:00:00.000", "description": "DUPLEX DOPP ABD/PEL", "row_id": 938316, "text": " 3:48 PM\n LIVER OR GALLBLADDER US (SINGLE ORGAN); DUPLEX DOPP ABD/PEL Clip # \n Reason: EVALUATE PORTAL VEIN WITH DOPPLERS, please mark for tap\n Admitting Diagnosis: HEPATIC ENCEPHALOPATHY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 46 year old man with cirrhosis, ascites, worsening LFTs and ascites\n REASON FOR THIS EXAMINATION:\n EVALUATE PORTAL VEIN WITH DOPPLERS, please mark for tap\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 47-year-old man with cirrhosis, ascites, and worsening LFTs. For\n evaluation of the portal vein with Doppler, and to mark a spot on the abdomen\n for paracentesis.\n\n ABDOMINAL ULTRASOUND WITH DOPPLER: A large amount of ascites is present, and\n a suitable spot was marked in the right lower quadrant for paracentesis to be\n performed by the clinical service.\n\n The liver has a shrunken nodular appearance consistent with the given history\n of cirrhosis. No liver masses are present. There is no intrahepatic biliary\n ductal dilatation. Doppler evaluation demonstrates patent left, middle, and\n right hepatic veins. Appropriate directionality and patency is demonstrated\n in the left, anterior and posterior branches of the right portal vein. The\n IVC is patent. Normal arterial waveforms of the left and right hepatic\n arteries are present.\n\n IMPRESSION:\n 1. Normal liver Doppler ultrasound study. No focal liver masses.\n 2. Large amount of ascites, and a suitable spot was marked in the right lower\n quadrant for paracentesis to be performed by the clinical service.\n\n\n" }, { "category": "Radiology", "chartdate": "2159-01-10 00:00:00.000", "description": "LIVER OR GALLBLADDER US (SINGLE ORGAN)", "row_id": 939753, "text": " 7:15 AM\n DUPLEX DOPP ABD/PEL PORT; LIVER OR GALLBLADDER US (SINGLE ORGAN)Clip # \n Reason: please assess transplant liver for patent vasculature\n Admitting Diagnosis: HEPATIC ENCEPHALOPATHY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 46 year old man s/p liver transplant\n REASON FOR THIS EXAMINATION:\n please assess transplant liver for patent vasculature\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 47-year-old man postop day #1 with liver transplant for Doppler\n evaluation.\n\n FINDINGS: Both -scale and color Doppler ultrasound examination was\n performed. The left, middle, and right hepatic veins, and IVC are patent with\n normal waveforms. The anterior right, posterior right portal veins are patent\n with appropriate directionality. The main portal vein is patent with\n appropriate directionality. However, its velocities range from 40 cm before\n the anastomotic site and increased to 120 cm/sec distal to the anastomosis.\n The left, right, and middle hepatic arteries are patent however, the waveforms\n are spiky with no diastolic flow.\n\n There is no intrahepatic biliary ductal dilatation. A subhepatic hematoma is\n seen measuring 8 x 4 x 8 cm. There is right lung base atelectasis present.\n There is no ascites.\n Findings were discussed with the Liver Transplant Fellow on .\n\n IMPRESSION:\n 1. Increased main portal vein velocities across the anastomosis. Patent\n right, left, and main hepatic arteries, however without diastolic flow. Both\n these findings need to be followed in the short-term.\n 2. Subhepatic hematoma as described above.\n\n" }, { "category": "Radiology", "chartdate": "2158-11-22 00:00:00.000", "description": "GUIDANCE FOR THORA/ABD/PARA CENTESIS US", "row_id": 933038, "text": " 2:02 PM\n PARACENTESIS DIAG. OR THERAPEUTIC; GUIDANCE FOR /ABD/PARA CENTESIS USClip # \n Reason: Please perform 3 to 4L therapeutic paracentesis under ultras\n Admitting Diagnosis: HEPATIC ENCEPHALOPATHY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 47 year old man with HIV, Hep C cirrhosis presents with worsening\n encephalopathy\n REASON FOR THIS EXAMINATION:\n Please perform 3 to 4L therapeutic paracentesis under ultrasound guidance.\n Attempted x 2 on floor without success. Please do NOT remove more than 4L given\n ongoing Hepatorenal syndrome. *\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 47-year-old man with HIV, hepatitis C, cirrhosis, worsening\n encephalopathy. Please perform therapeutic paracentesis, status post failed\n attempts before. Please do not remove more than 4 liters.\n\n ULTRASOUND-GUIDED PARACENTESIS:\n\n Following discussion of the risks and benefits of the procedure, informed\n written consent was obtained. Preprocedure timeout was performed confirming\n patient identity and procedure to be performed. A spot was marked under\n ultrasound guidance on the right lower quadrant, under which moderate-to-\n large amount of ascites was identified. The patient was prepped and draped in\n the usual sterile fashion. Local anesthesia was achieved with approximately 5\n cc of 1% lidocaine bicarbonate solution. 19-gauge catheter was inserted\n into the right lower quadrant and 4 liters of clear yellow fluid was drained.\n Patient tolerated the procedure well without evidence of immediate\n complication. The patient left the department in stable condition.\n\n The attending radiologist, Dr. , was present and supervised\n the procedure.\n\n IMPRESSION: Successful paracentesis in the right lower quadrant, with\n drainage of 4 liters of clear yellow fluid.\n\n" }, { "category": "Radiology", "chartdate": "2158-11-25 00:00:00.000", "description": "PORTABLE ABDOMEN", "row_id": 933444, "text": " 8:40 AM\n CHEST (PORTABLE AP); PORTABLE ABDOMEN Clip # \n Reason: Please perform upright film, evaluate for free air under dia\n Admitting Diagnosis: HEPATIC ENCEPHALOPATHY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 46 year old man with cirrhosis with ascites and recent colonoscopy, now\n reporting abdominal pain\n REASON FOR THIS EXAMINATION:\n Please perform upright film, evaluate for free air under diaphragm as possible\n given ascites\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST\n\n HISTORY: Abdominal pain post-colonoscopy.\n\n One portable view at 08:30. Comparison with a previous study done .\n There is new streaky density bilaterally consistent with subsegmental\n atelectasis. The lungs are otherwise clear. The heart and mediastinal\n structures are unremarkable. The bony thorax is grossly intact.\n\n Compared with the previous study, a nasogastric tube has been withdrawn.\n Subsegmental atelectasis is new. No free air is identified.\n\n IMPRESSION: Bilateral subsegmental atelectasis.\n\n\n" }, { "category": "Radiology", "chartdate": "2158-11-25 00:00:00.000", "description": "REDUCED SERVICES", "row_id": 933479, "text": " 1:46 PM\n MRI ABDOMEN W/O CONTRAST; -52 REDUCED SERVICES Clip # \n Reason: assess vessels patency, r/o focal lesions and assess liver v\n Admitting Diagnosis: HEPATIC ENCEPHALOPATHY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 46 year old man with hep c cirrhosis.\n REASON FOR THIS EXAMINATION:\n assess vessels patency, r/o focal lesions and assess liver volume.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Hepatitis C and cirrhosis.\n\n TECHNIQUE:\n\n This study is limited due to the patient's inability to cooperate. Breath-hold\n independent techniques were attempted but the patient had severe back pain\n during the course of the exam with shifting positions throughout. This exam is\n of limited value.\n\n Breath-hold independent T1 and T2-weighted imaging was performed. Gadolinium\n was not administered as monitoring of the case during the course of the exam\n was showing too limited a quality of image and artifacts precluding further\n imaging.\n\n FINDINGS:\n\n Copious ascites is evident. Large drops in signal preclude assessment in\n ruling out of liver masses. The spleen is prominent in its AP dimension. The\n visualized pancreas shows normal signal intensity and morphology on the T1-\n weighted images, however, some of the gland is not seen, due to artifacts.\n There is no evidence for hydronephrosis.\n\n IMPRESSION:\n\n Insufficient image quality for diagnostic purposes. Copious ascites and\n splenomegaly is present.\n\n\n Liver volume was calculated to be 1650 cc's.\n\n\n\n\n\n\n\n\n\n\n\n\n\n (Over)\n\n 1:46 PM\n MRI ABDOMEN W/O CONTRAST; -52 REDUCED SERVICES Clip # \n Reason: assess vessels patency, r/o focal lesions and assess liver v\n Admitting Diagnosis: HEPATIC ENCEPHALOPATHY\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n\n\n" }, { "category": "Radiology", "chartdate": "2158-11-28 00:00:00.000", "description": "MR 3D RENDERING W/POST PROCESSING ON INDEPENDENT WS", "row_id": 933871, "text": " 11:38 AM\n MRI ABDOMEN W/O & W/CONTRAST; MR 3D RENDERING W/POST PROCESSING ON INDEPENDENT WSClip # \n Reason: eval for vessel patency as part of pre-liver transplant w/u\n Admitting Diagnosis: HEPATIC ENCEPHALOPATHY\n Contrast: MAGNEVIST Amt: 20\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 47 year old man with HCV cirrosis, renal failure\n REASON FOR THIS EXAMINATION:\n eval for vessel patency as part of pre-liver transplant w/u\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 47-year-old man with hepatitis C cirrhosis and renal failure.\n Evaluate for vessel patency as part of pre-liver transplant workup.\n\n COMPARISON: MRI abdomen dated . This study was incomplete secondary\n to patient's inability to comply.\n\n TECHNIQUE: Multiplanar T1- and T2-weighted images were acquired on a 1.5-\n Tesla magnet including dynamic 3D imaging, obtained prior to, during, and\n after the uneventful intravenous administration of 0.1 mmol/kg of gadolinium-\n DTPA.\n\n FINDINGS: The study is extremely limited secondary to patient's body habitus,\n large intra-abdominal ascites, and resulting dielectric effect. Allowing for\n this, the liver parenchyma is diffusely nodular, consistent with cirrhosis.\n The portal vein is patent with hepatopetal flow. There is a recanalized\n umbilical vein. The spleen is enlarged measuring up to 20 cm, with multiple\n Gamna-Gandy bodies. Again, there is a large amount of intra-abdominal\n ascites. The adrenal glands and bilateral kidneys are grossly unremarkable.\n The pancreas is poorly visualized. The splenic vein is patent. The superior\n mesenteric vein is not seen. The celiac axis and proximal superior mesenteric\n artery are patent.\n\n The bone marrow signal is unremarkable.\n\n Multiplanar 2D and 3D reformations provided multiple perspectives for the\n dynamic series.\n\n IMPRESSION: Extremely limited study secondary to a large volume intra-\n abdominal ascites, patient's body habitus, and artifacts.\n\n Findings consistent with cirrhosis include a nodular liver contour,\n splenomegaly, and large volume ascites. The portal vein and splenic vein are\n patent with appropriate direction of flow. The celiac axis and superior\n mesenteric artery are patent.\n\n\n" }, { "category": "Radiology", "chartdate": "2159-01-11 00:00:00.000", "description": "P US ABD LIMIT, SINGLE ORGAN PORT", "row_id": 939893, "text": " 8:05 AM\n DUPLEX DOPP ABD/PEL; US ABD LIMIT, SINGLE ORGAN PORT Clip # \n -59 DISTINCT PROCEDURAL SERVICE\n Reason: vascular flow\n Admitting Diagnosis: HEPATIC ENCEPHALOPATHY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 46 year old man s/p liver transplant\n\n REASON FOR THIS EXAMINATION:\n vascular flow\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 47-year-old man post-op day #2 with liver transplant for followup of\n Doppler evaluation.\n\n FINDINGS: Both grayscale and color Doppler ultrasound examination was\n performed. There is no intrahepatic biliary ductal dilatation. Previously\n seen subhepatic hematoma is slightly decreased in the interval, now measuring\n 7.0 x 3.7 x 6.7 cm. There is no ascites.\n\n Doppler ultrasound examination demonstrates patent anterior right, posterior\n right portal veins with appropriate directionality. The main portal vein is\n patent with hepatopetal flow. The velocities across the anastomotic site\n range from 80-120 cm/sec (compared to 40-120 cm/sec on the prior study). The\n left, right, and middle hepatic arteries are patent, but these waveforms\n remain spiky with no diastolic flow.\n\n IMPRESSION:\n 1. Continued increased main portal vein velocities across the anastomosis\n measuring 80-120 cm/sec (compared to 42-120 cm/sec one day prior).\n 2. Patent hepatic arteries, however, without diastolic flow.\n 3. Subhepatic hematoma slightly decreased in size from one day prior.\n\n\n" }, { "category": "Radiology", "chartdate": "2159-01-17 00:00:00.000", "description": "CT ABDOMEN W/CONTRAST", "row_id": 940745, "text": " 11:26 AM\n CTA ABD W&W/O C & RECONS; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: please do hepatic CTA with recons to assess for portal vein\n Admitting Diagnosis: HEPATIC ENCEPHALOPATHY\n Field of view: 43 Contrast: OPTIRAY Amt: 200\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 47 year old man s/p liver transplant with rising alk phos. u/s concerning for\n portal vein stenosis\n REASON FOR THIS EXAMINATION:\n please do hepatic CTA with recons to assess for portal vein stenosis\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post liver transplant on with increased flow\n velocity across the portal venous anastomosis demonstrated by ultrasound.\n Evaluate for portal vein stenosis.\n\n COMPARISON: No previous post-transplant CT. Liver transplant ultrasound of\n , and are available for correlation.\n\n TECHNIQUE: Axial multidetector CT images of the abdomen were obtained without\n contrast, and then with 200 cc of intravenous Optiray in arterial, portal\n venous, and delayed phases. Delayed images of the pelvis were also obtained.\n 2-dimensional and 3-dimensional reformatted images were performed.\n\n ABDOMINAL CT ANGIOGRAM: The main, right, and left hepatic arteries are widely\n patent. The main, right, and left portal veins are patent with a change in\n caliber noted at the anastomosis. The donor main portal vein is smaller in\n diameter, then the recipient main portal vein. However, there is no evidence\n of superimposed stenosis in the portal vein. The right, middle and left\n hepatic veins are patent. There is an apparent narrowing in the donor\n inferior vena cava just distal to the confluence of the three hepatic veins,\n best seen on the 2-dimensional coronal reformatted images (image 500B:33).\n\n A linear hypodensity at the liver dome, best seen in portal venous phase, may\n be related to surgical instrumentation. Several subserosal hypodensities in\n the liver dome, measuring up to 1.5 cm (image 500B:38) in the portal venous\n phase may represent small infarcts. The remainder of the liver parenchyma\n enhances homogeneously. There is no biliary ductal dilatation. The spleen is\n mildly enlarged. The pancreas, adrenal glands, and kidneys appear\n unremarkable. A large amount of ascites is present. There is a 10 x 4 cm\n hematoma inferior to the right hepatic lobe. A surgical drain is present,\n terminating below the right hepatic lobe. Bowel loops, which are not\n opacified with oral contrast, appear unremarkable.\n\n There are bilateral pleural effusions at the imaged lung bases, right greater\n than left, with associated atelectasis in the right lower lobe.\n\n PELVIS CT WITH INTRAVENOUS CONTRAST: The bladder, prostate, seminal vesicles,\n and rectum appear unremarkable. Ascites is present. Evidence of previous\n left inguinal hernia repair is noted.\n (Over)\n\n 11:26 AM\n CTA ABD W&W/O C & RECONS; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: please do hepatic CTA with recons to assess for portal vein\n Admitting Diagnosis: HEPATIC ENCEPHALOPATHY\n Field of view: 43 Contrast: OPTIRAY Amt: 200\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n BONE WINDOWS: There are no lytic or sclerotic bone lesions suspicious for\n malignancy. Mild degenerative changes are noted in the spine.\n\n CT RECONSTRUCTIONS: 2-dimensional and 3-dimensional reformatted images were\n essential in evaluating hepatic arteries, portal veins, and hepatic veins.\n\n IMPRESSION:\n\n 1. Change in caliber at the portal venous anastomosis, with the donor main\n portal vein being smaller than the recipient main portal vein, without\n evidence of any superimposed stenosis.\n\n 2. Apparent narrowing of the recipient inferior vena cava just distal to the\n confluence of the hepatic veins, which are patent. Correlation with\n intraoperative findings may be helpful.\n\n 3. Few peripheral hypoenhancing areas in the liver dome, measuring up to 1.5\n cm, may represent small infarcts.\n\n 4. Large amount of ascites.\n\n 5. A 10 x 4 cm infrahepatic hematoma.\n\n 6. Bilateral pleural effusions, right greater than left.\n\n\n" } ]